Ovarian stroma flow intensity decreases by age: a three-dimensional power doppler ultrasonographic study

The stromal microenvironment and ovarian aging: mechanisms and therapeutic opportunities

For decades, most studies of ovarian aging have focused on its functional units, known as follicles, which include oocytes and granulosa cells. However, in the ovarian stroma, there are a variety of somatic components that bridge the gap between general aging and ovarian senescence. Physiologically, general cell types, microvascular structures, extracellular matrix, and intercellular molecules affect folliculogenesis and corpus luteum physiology alongside the ovarian cycle. As a result of damage caused by age-related metabolite accumulation and external insults, the microenvironment of stromal cells is progressively remodeled, thus inevitably perturbing ovarian physiology. With the established platforms for follicle cryopreservation and in vitro maturation and the development of organoid research, it is desirable to develop strategies to improve the microenvironment of the follicle by targeting the perifollicular environment. In this review, we summarize the role of stromal components in ovarian aging, describing their age-related alterations and associated effects. Moreover, we list some potential techniques that may mitigate ovarian aging based on their effect on the stromal microenvironment.

Ovarian Changes After Abdominal Hysterectomy for Benign Conditions

OBJECTIVES

To investigate any change in the ovaries, including early follicular serum follicle-stimulating hormone (FSH) level, total ovarian volume, total antral follicle count, and ovarian stromal blood flow, in patients who had undergone abdominal hysterectomy for benign conditions.

METHODS

Fifteen women with abdominal hysterectomy and conservation of ovaries for benign conditions and who were between 29 and 44 years old were recruited to undergo three-dimensional ultrasound examination with power Doppler to assess total ovarian volume, total antral follicle count, and vascularization index (VI), flow index (FI), and vascularization flow index (VFI) of ovarian stromal blood flow. Serum FSH, estradiol, and progesterone levels were checked on the same day. The results of the assessments were considered taken during the early follicular phase if the estradiol and progesterone levels were basal. Fifteen age-matched healthy women underwent the same assessments on the second day of menstruation.

RESULTS

Women with hysterectomy had significantly elevated serum FSH level and lower ovarian stromal blood flow indices, including VI, FI, and VFI, as compared with healthy women. The total antral follicle count and the total ovarian volume were similar between the two groups.

CONCLUSION

These changes may suggest altered ovarian function after hysterectomy.

Change in the ovarian environment after hysterectomy with bilateral salpingectomy: is it the technique or surgery itself?

OBJECTIVE

To compare the effects of total laparoscopic hysterectomy with bilateral salpingectomy (TLH-BS) and total abdominal hysterectomy with bilateral salpingectomy (TAH-BS) on ovarian function among women of reproductive age.

STUDY DESIGN

One hundred and three patients with a diagnosis of benign uterine disorder were divided into two groups in this prospective longitudinal study. Patients who had never had sexual intercourse and patients with uterovaginal disproportion underwent TAH-BS (n=57), and the remaining patients (n=46) underwent TLH-BS. Ovarian function was assessed before and 6 months after surgery; ovarian volume was assessed by gray-scale ultrasonography, and levels of serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), oestradiol (E2), anti-Mullerian hormone (AMH) and inhibin B were measured.

RESULTS

Postoperative serum FSH, LH and inhibin B decreased significantly in both groups. Postoperative serum E2 did not change significantly. Postoperative serum AMH and ovarian volume decreased significantly in the TAH-BS group (p=0.016 and p<0.001, respectively), but not in the TLH-BS group. Significant differences were observed between the TLH-BS and TAH-BS groups with respect to change in FSH (p=0.012) and ovarian volume (p=0.001); between-group differences were not significant for changes in AMH and inhibin B.

CONCLUSIONS

Although serum AMH did not change significantly in patients who underwent TLH-BS, ovarian aging commenced following both surgical procedures.

Endocrinology of the Menopause

In women, age-related changes in ovarian function begin in the mid-30s with decreased fertility and compensatory hormonal changes in the hypothalamus-pituitary-gonadal axis that maintain follicle development and estrogen secretion in the face of a waning pool of ovarian follicles. The menopause transition is characterized by marked variability in follicle development, ovulation, bleeding patterns, and symptoms of hyper- and hypoestrogenism. The menopause, which is clinically defined by the last menstrual period, is followed by the consistent absence of ovarian secretion of estradiol.

Early life exposure to undernutrition induces ER stress, apoptosis, and reduced vascularization in ovaries of adult rat offspring

Maternal nutritional restriction has been shown to induce impairments in a number of organ systems including the ovary. We have previously shown that maternal undernutrition induces fetal growth restriction and low birth weight, and results in an offspring ovarian phenotype characteristic of premature ovarian aging with reduced ovarian reserve. In the present study, we set out to investigate the underlying mechanisms that lead offspring of undernourished mothers to premature ovarian aging. Pregnant dams were randomized to 1) a standard diet throughout pregnancy and lactation (control), 2) a calorie-restricted (50% of control) diet during pregnancy, 3) a calorie-restricted (50% of control) diet during pregnancy and lactation, or 4) a calorie-restricted (50% of control) diet during lactation alone. The present study shows that early life undernutrition-induced reduction of adult ovarian follicles may be mediated by increased ovarian endoplasmic reticulum stress in a manner that increased follicular apoptosis but not autophagy. These changes were associated with a loss of ovarian vessel density and are consistent with an accelerated ovarian aging phenotype. Whether these changes are mediated specifically by a reduction in the local antioxidant environment is unclear, although our data suggest the possibility that ovarian melatonin may play a part in early life nutritional undernutrition and impaired offspring folliculogenesis.

Ovarian ultrasonography in the mare

Ultrasonography has become indispensable in the control of equine reproduction. Mare ovary layers are inverted with respect to other species, with the follicles and corpus luteum found inside the ovary; only large follicles protrude from the organ's surface. This renders the making of diagnoses via rectal palpation of the ovaries very difficult. Ultrasound imaging, however, provides another avenue of examination. Since its first use in 1980, the diagnostic potential of ultrasonography has greatly improved. Colour Doppler ultrasonography can even asses blood flow, allowing for much better monitoring of ovarian activity. This study discusses the use of ultrasound, and in particular colour Doppler ultrasonography, in the monitoring of mare ovarian function and disease.

Doppler imaging in the diagnosis of ovarian disease

INTRODUCTION

Pelvic ultrasonography remains the non-invasive imaging modality of choice for detecting and characterising adnexal masses. The use of Doppler ultrasound has improved the differential diagnosis of ovarian disease and helped to widen the understanding of the aetiology and possible pathophysiology of the various underlying conditions with an aim of improved diagnosis and management.

AREAS COVERED

This review describes the basis of different Doppler techniques and their application in ovarian disease. The present evidence is critically analysed in an attempt to define the current role of Doppler ultrasound of the ovaries. The technique holds promise in certain ovarian diseases but remains controversial in others.

EXPERT OPINION

Doppler ultrasound has a role in both the clinical and research settings. Clinically, it can be used to differentiate benign and malignant disease and help confirm diagnoses suggested on grey-scale imaging giving the user more confidence. Its use here, however, is generally restricted to a subjective impression of colour flow rather than a quantitative analysis of vascularity or blood flow velocity. These measures are more relevant in the research setting where quantitative Doppler is being used to clarify the possible underlying aetiology of various ovarian diseases such as polycystic ovarian syndrome and benign cysts. Doppler ultrasound has also been used in various models to evaluate the response to ovarian stimulation and the effect of surgery on the ovary.

Assessment of nuchal translucency thickness and the fetal anatomy in the first trimester of pregnancy by two- and three-dimensional ultrasonography: a pilot study

AIM

To evaluate the use of three-dimensional ultrasonography (3D) as an alternative for examining fetal anatomy and nuchal translucency (NT) in the 1(st) trimester of pregnancy.

METHOD

Prospective study of 199 low risk pregnant women undergoing 1(st) trimester ultrasound scan for fetal anomalies. The NT and fetal anatomy were evaluated by three-dimensional (3D) ultrasonography after the standard two-dimensional (2D) examination. The gold standard in this study was the 2D ultrasonography.

RESULTS

In some of the evaluated parameters the 3D method approaches the conventional 2D results. These parameters are the crown-rump length (CRL), the skull - brain anatomy (93.5%), the spine (85.4%), the upper (88.4%) and lower limbs (87.9%) and the examination of the fetal abdomen (98.5%). Some of the anatomic parameters under evaluation revealed a statistically significant difference in favor of the 2D examination. During the 3D examination the nasal bone was identified in 62.1% of the cases, the stomach in 85.9%, and the urinary bladder in 57.3% of the cases. The NT was assessed accurately in half of the cases compared to 2D examination.

CONCLUSION

The 3D ultrasound is insufficient for the detailed fetal anatomy examination during the 1(st) trimester of pregnancy. Nevertheless, the method might be improved in order to be considered as a screening method.

First trimester 3D volumetry. Association of the gestational volumes with the birth weight

OBJECTIVE

To evaluate the three dimensional ultrasound (3D) in the volume assessment of the gestational contents during the 1st trimester of pregnancy. Our aim was to correlate the embryo, gestational sac, and placenta volume with the birth weight. To monitor the increase of these volumes according to the gestational age.

METHOD

Prospective study of 199 singleton low risk pregnant women undergoing the 1st trimester ultrasound for fetal anomalies. In these women, gestational volumetry was performed and it was compared with the crown-rump length (CRL). Regression models were computed in order to analyze the dependence of birth weight with the volumes.

RESULTS

The embryo volume reveals the strongest association with the birth weight at delivery (β = 0.24), followed by the CRL (β = 0.20) and the gestational sac volume (β = 0.20). The placenta volume appears the weakest association with fetal weight at delivery (β = 0.16). All volumes increased significantly from 11(+0)-11(+6) to 13(+0)-13(+6) weeks of gestation (p < 0.001). Ten cubic millimeter increase in embryo volume corresponds to a mean birth weight increase of 75 g, while 1 mm increase in the CRL corresponds to a birth weight increase of 113 g.

CONCLUSION

Our results provide evidence that the embryo volume during the first trimester of pregnancy correlates better with birth weight than the CRL. This might assist in the identification of the high risk pregnancies caring macrosomic and low birth weight fetuses.

Soft-tissue tumor differentiation using 3D power Doppler ultrasonography with echo-contrast medium injection

BACKGROUND

We aimed to evaluate the ability of 3-dimensional power Doppler ultrasonography to differentiate soft-tissue masses from blood flow and vascularization with contrast medium.

METHODS

Twenty-five patients (mean age, 44.1 years; range, 12-77 years) with a palpable mass were enrolled in this study. Volume data were acquired using linear and convex 3-dimensional probes and contrast medium injected manually by bolus. Data were stored and traced slice by slice for 12 slices. All patients were scanned by the same senior sonologist. The vascular index (VI), flow index (FI), and vascular-flow index (VFI) were automatically calculated after the tumor was completely traced. All tumors were later confirmed by pathology.

RESULTS

The study included 8 benign (mean, 36.5 mL; range, 2.4-124 mL) and 17 malignant (mean, 319.4 mL; range, 9.9-1,179.6 mL) tumors. Before contrast medium injection, mean VI, FI and VFI were, respectively, 3.22, 32.26 and 1.07 in benign tumors, and 1.97, 29.33 and 0.67 in malignant tumors. After contrast medium injection, they were, respectively, 20.85, 37.33 and 8.52 in benign tumors, and 40.12, 41.21 and 17.77 in malignant tumors. The mean differences between with and without contrast injection for VI, FI and VFI were, respectively, 17.63, 5.07 and 7.45 in benign tumors, and 38.15, 11.88 and 16.55 in malignant tumors. Tumor volume, VI, FI and VFI were not significantly different between benign and malignant tumors before and after echo-contrast medium injection. However, VI, FI and VFI under self-differentiation (differences between with and without contrast injection) were significantly different between malignant and benign tumors.

CONCLUSION

Three-dimensional power Doppler ultrasound is a valuable tool for differential diagnosis of soft-tissue tumors, especially with the injection of an echo-contrast medium.

Role of the parathyroid gland vascularization index in predicting percutaneous ethanol injection efficacy in refractory uremic hyperparathyroidism

AIMS

To evaluate the role of the quantitative vascularization index (VI) as a measure of the completeness of percutaneous ethanol injection therapy (PEIT).

METHODS

A total of 37 dialysis patients with secondary hyperparathyroidism refractory to medical therapy received PEIT. We analyzed the role of a quantitative marker of parathyroid adenoma activity, i.e. VI, flow index and vascular flow index as measured by 3-dimensional Doppler ultrasound with a 3-dimensional histogram software, for all patients before treatment and at 1 month and 6 months after PEIT.

RESULTS

Serum intact parathyroid hormone (i-PTH) level showed a strong positive correlation with the VI both before (p < 0.001) and after (p < 0.001) PEIT. There was no correlation between i-PTH level and the volume of the gland either before (p = 0.697) or after (p = 0.564) PEIT. One month after PEIT, 20 patients (group 1) reached the target of i-PTH ≤ 300 pg/ml and 17 patients (group 2) did not. Group 2 patients had significantly greater VI and i-PTH prior to PEIT than group 1 patients (42.23 ± 8.38 vs. 14.95 ± 8.07, p <0.001 and 1,447 ± 243 vs. 859 ± 231, p < 0.001 respectively).

CONCLUSION

A higher VI indicates a higher i-PTH, and the VI may be a reliable predictor of the completeness of PEIT.

Three-dimensional power Doppler angiography of cyclic ovarian blood flow

OBJECTIVE

The purpose of this study was to assess the vascular indices generated by 3-dimensional (3D) power Doppler angiography by evaluating the cyclic changes in the vascularity of normal ovaries, including those that were ovulating, nonovulating, and hormonally suppressed.

METHODS

In this prospective longitudinal observational study, a cohort of premenopausal regularly menstruating women with no known ovarian disease underwent 3D power Doppler imaging every 2 to 3 days for the duration of 1 menstrual cycle. Four indices were generated: vascularization index (VI), flow index (FI), vascularization-flow index (VFI), and mean grayness. Comparisons of vascularity were made between ovulating, nonovulating, and hormonally suppressed ovaries. Normal ranges were established and graphed longitudinally.

RESULTS

Eighteen participants (36 ovaries) ages 28 to 45 years underwent an average of 10 examinations, yielding 368 acquired ovarian volumes for analysis. Seven participants used hormonal contraception. The VI, FI, and VFI were closely correlated (Pearson product moment correlation coefficients, 0.52-0.95). The vascular indices of ovulating ovaries were significantly higher than those of nonovulating ovaries (VI, FI, and VFI, all P < .001), with the largest discrepancies during the luteal phase. Hormonally suppressed ovaries had significantly lower vascularity throughout the cycle (VI, P < .002; FI, P < .001; VFI, P < .007). The vascular indices of all groups appeared to drop during the late follicular period and then rise again.

CONCLUSIONS

The VI would suffice as the principal vascular parameter for 3D power Doppler analysis. Preovulatory scans may be more useful for distinguishing pathologic vascularization. Hormonally suppressed ovaries have significantly lower vascularity throughout the cycle. Normal-appearing ovaries with vascular indices above the normal ranges established by these data may warrant further investigation.

Changes in ultrasound morphology of the uterus and ovaries during the menopausal transition and early postmenopause: a 4-year longitudinal study

OBJECTIVES

To describe changes in uterine and ovarian size and morphology as determined by ultrasonography from 2 years before to 2 years after menopause.

METHODS

Twenty 50-year-old women with fairly regular vaginal bleeding at the start of the study underwent transvaginal ultrasound examination every 3 months until 12 months postmenopause, then every 6 months until 24 months postmenopause. The results are presented from 2 years before to 2 years after the menopause.

RESULTS

In the 2 years preceding menopause all the women were in menopausal transition. From 2 years before to 2 years after menopause uterine anteroposterior diameter decreased by 22% (mean) and left and right ovarian volumes by 45 and 20% (median), respectively. At 2 years before the menopause the total number of intraovarian follicle-like cystic structures varied from 0 to 5, at the menopause from 0 to 7, and at 1 and 2 years after the menopause from 0 to 4 and from 0 to 2, respectively. Premenopause, the most common finding was that of ovaries containing either no follicles or a few follicles with at least one measuring >/= 11 mm and simultaneously a hyperechogenic endometrium of varying thickness and not manifesting any midline echo or triple-layer appearance. Images compatible with the late follicular phase were found in 6% (9/150) of examinations ('cycle day' 8-196) and images compatible with the luteal phase in 7% (10/150) ('cycle day' 11-56). Intraovarian cystic structures (3-25 mm) were seen in 14 women after the menopause.

CONCLUSION

We have described sonographic changes in the uterus and ovaries occurring during the transition from premenopause to postmenopause.

Assessment of three-dimensional sonographic features of polycystic ovaries after laparoscopic ovarian electrocautery

BACKGROUND

Treatment of polycystic ovary syndrome-related infertility includes laparoscopic ovarian electrocautery. Three-dimensional (3-D) sonographic characterization of polycystic ovaries has been performed recently, including the study of the effect of laparoscopic ovarian drilling on ovarian volume. The impact of laparoscopic treatment on ovarian volume and vascular flow-patterns assessed by 3-D color power angiography (CPA), however, has not yet been elucidated.

OBJECTIVE

To measure ovarian volume, to evaluate and quantify intraovarian blood flow with 3-D CPA histogram analysis before and after laparoscopic ovarian electrocautery, and to compare the hormonal effects of surgery with 3-D sonographic findings.

SETTING

University hospital.

PATIENT(S)

Ten patients, aged 18-34 years, with polycystic ovary syndrome.

INTERVENTION(S)

Evaluation of serum and urinary hormone profiles as well as transvaginal 3-D ultrasonography were performed before and after laparoscopic ovarian surgery.

RESULT(S)

Ovarian volume decreased, and 3-D CPA showed increased intraovarian flow intensity after laparoscopic electrocautery. Serum LH and T levels, ratios of urinary steroids reflecting 5 alpha-reductase enzyme activity, and androgen to cortisol metabolites decreased; serum FSH levels increased 1 week after laparoscopy and correlated well with changes of 3-D sonographic features. Seven patients ovulated regularly after surgery, and five pregnancies were conceived within 1 year.

CONCLUSION(S)

Three-dimensional ultrasonography may be a useful adjunct and noninvasive method for correlating clinical parameters with the blood flow alterations in polycystic ovary syndrome patients.

Power doppler ultrasound assessment of the relationship between age and ovarian perifollicular blood flow in women undergoing in vitro fertilization treatment

PURPOSE

To examine the relationship between age and ovarian perifollicular blood flow (PFBF) in women undergoing IVF.

METHODS

Serial transvaginal power Doppler ultrasound (PDU) scans to assess ovarian PFBF were performed prospectively throughout the follicular phase of ovarian stimulation in women undergoing IVF. The ultrasound assessment days were categorized according to day of hCG trigger.

RESULTS

A total of 1050 ovarian follicles from 34 women undergoing one IVF treatment cycle were used for data analysis. The median age of the women was 38.5 years, ranging from 28 years to 44 years. There was a significant negative correlation between age and ovarian PFBF on the day of hCG trigger or trigger day minus 1, but not beforehand during the follicular phase.

CONCLUSIONS

There was a significant negative correlation between age and ovarian PFBF in women undergoing IVF which was only observed very late in the follicular phase of ovarian stimulation.

Assessment of changes in volume and vascularity of the ovaries during the normal menstrual cycle using three-dimensional power Doppler ultrasound

BACKGROUND

Our aim was to describe changes in the volume and vascularization of both ovaries, the dominant follicle and the corpus luteum during the normal menstrual cycle using three-dimensional (3D) power Doppler ultrasound.

METHODS

Fourteen healthy volunteers underwent serial transvaginal 3D ultrasound examinations of both ovaries on cycle day 2, 3 or 4, then daily from cycle day 9 until follicular rupture and 1, 2, 5, 7 and 12 days after follicular rupture. The volume and vascular indices of the ovaries, the dominant follicle and the corpus luteum were calculated off-line using virtual organ computer-aided analysis (VOCAL) software.

RESULTS

The volume of the dominant ovary increased during the follicular phase, decreased after follicular rupture and then increased again during the luteal phase. Vascular indices in the dominant ovary and the dominant follicle/corpus luteum increased during the follicular phase, the vascular flow index (VFI) in the dominant follicle being on average (median) 1.7 times higher on the day before ovulation than 4 days before ovulation (P=0.003). The vascular indices continued to rise after follicular rupture so that VFI in the corpus luteum was on average (median) 3.1 times higher 7 days after ovulation than in the follicle on the day before ovulation (P=0.0002). The volume and vascular indices in the non-dominant ovary manifested no unequivocal changes during the menstrual cycle.

CONCLUSIONS

Substantial changes occur in volume and vascularization of the dominant ovary during the normal menstrual cycle. 3D power Doppler ultrasound may become a useful tool for assessing pathological changes in the ovaries, for example, in subfertile patients.

Ovarian stromal vascularity is not predictive of ovarian response and pregnancy

The role of ovarian stromal vascularity in the prediction of the ovarian response and pregnancy in infertile women was evaluated by comparing age of women, body mass index (BMI), basal FSH concentration, antral follicle count (AFC) and ovarian stromal vascularity indices measured by three-dimensional power Doppler ultrasound. A total of 111 women in their first IVF cycle were analysed. They were aged <40 years with basal FSH concentration <10 IU/l on recruitment for IVF treatment. AFC, mean ovarian volume and mean ovarian 3D power Doppler flow indices were determined on day 2 of the treatment cycle prior to a standard regimen of ovarian stimulation. Ovarian response was represented by the number of oocytes, serum oestradiol, the duration and dosage of gonadotrophins. AFC achieved the best predictive value in relation to the number of oocytes obtained, followed by age of women and BMI. Basal FSH concentration was the only predictive factor for the duration and dosage of gonadotrophin used. Mean ovarian 3D power Doppler flow indices were not predictive of pregnancy in a multiple logistic regression analysis. Ovarian 3D power Doppler flow indices measured after pituitary down-regulation were not predictive of the ovarian response and pregnancy in the IVF treatment.

Biological aging and the etiology of aneuploidy

A prevalent hypothesis concerning the cause of the rise in aneuploid conceptions with maternal age is that the changes that accompany normal ovarian aging increase the rate of meiotic errors in the oocyte. Biological aging of the ovary is accompanied by a decline in both the total oocyte pool and the number of antral follicles maturing per cycle, as well as changes in the levels of circulating reproductive hormones. The biological aging hypothesis predicts that aneuploidy rates should be higher in women with a prematurely reduced oocyte pool, and that women with trisomic conceptions should show signs of earlier ovarian aging than women of the same chronological age without trisomic conceptions. Comprehensive studies of aneuploidy in groups of women with known causes of premature ovarian failure remain to be done, though anecdotal evidence does suggest increased rates of pregnancy loss and aneuploidy. Smoking, which is a well-documented cause of earlier ovarian aging, is not associated with an increase in aneuploid conceptions. Evidence from women with unilateral ovariectomies is inconsistent. Support for the biological aging hypothesis was provided by one study showing that menopause occurred about a year earlier in women with a trisomic spontaneous abortion compared to women with chromosomally normal conceptions. Associations between high FSH and pregnancies with Down syndrome and chromosomally abnormal spontaneous abortions have also been reported. However, the most direct test of the hypothesis, which compared antral follicle counts and hormonal levels in women with trisomic pregnancies and those with chromosomally normal pregnancies, failed to find a difference in the expected direction. A prospective study of FSH levels in women with subfertility also failed to find an association with the rate of pregnancy loss. The bulk of evidence thus suggests that, if the processes of biological aging are indeed related to aneuploidy, they probably involve factors other than those measured by oocyte or antral follicle pool size and reproductive hormone levels.

Fertility in female cancer survivors: pathophysiology, preservation and the role of ovarian reserve testing

The improved long-term survival of adolescents and young women treated for cancer has resulted in an increased focus on the effects of chemotherapy on ovarian function and its preservation. These women may seek advice and treatment regarding their reproductive status, including ways of preserving their fertility and preventing a premature menopause--factors that can have a profound impact on their quality of life. This article comprehensively reviews ovarian reserve testing (ORT) in general. Special emphasis is placed on patients with cancer, including the pathophysiology of gonadal damage following chemotherapy, fertility preservation and the potential role of ORT. Baseline parameters of ovarian reserve [FSH LH, estradiol, inhibin B and anti-Mullerian hormone (AMH)] have not yet performed sufficiently well in predicting poor outcome in assisted reproduction, but biochemical markers of ovarian reserve appear to be better than chronological age. Inhibin B and AMH show potential for future use. Dynamic testing appears to show much promise, especially stimulated levels of inhibin B and estradiol. The most promising tests of ovarian reserve are the biophysical markers, where total antral follicle count was found to be most discriminatory followed by ovarian volume. Combination of biochemical, biophysical and clinical markers of ovarian reserve may also improve predictive capacity. However, there is a lack of data pertinent to ORT in cancer. As yet there is no single clinically useful test to predict ovarian reserve accurately. Patients with cancer represent a distinct cohort who have particular concerns about their future fertility and the possibility of a premature menopause, they can benefit greatly from knowledge of their functional ovarian reserve. Large, prospective, randomized, adequately controlled studies specific to different geographical areas are required in a control population of comparable reproductive age to determine the potential role of ORT in clinical practice.

Assessment of ovarian reserve

PURPOSE OF REVIEW

Various methods have been proposed and are currently used in the assessment of ovarian reserve in order to predict the outcome in assisted reproduction. This review focuses on the current information regarding the ovarian reserve markers and tests, an active area of research.

RECENT FINDINGS

Female age alone is a rough parameter for assessing ovarian reserve. The basal follicle stimulating hormone level is not adequately sensitive to predict poor outcome and the same is true for other basal parameters, including basal estradiol, the follicle stimulating hormone/luteinizing hormone ratio, and inhibin-B levels. The clomiphene citrate challenge test has a low sensitivity but this sensitivity is greater than that of basal follicle stimulating hormone. The value of other hormonal dynamic tests remains to be determined. Among the ultrasound markers the total antral follicle count seems to be promising. Ovarian biopsy in this assessment is controversial. History of poor response to ovarian stimulation is a strong indicator for declining ovarian function.

SUMMARY

There is currently no clinically useful predictive test sufficiently accurate and distinct in time from controlled ovarian stimulation to assess ovarian reserve accurately. Further research is warranted to validate the ovarian reserve tests in the general population and in populations with different causes of infertility.

Prenatal assessment of normal fetal humerus volume by three-dimensional ultrasound

Because fetal humerus dysplasia is associated with a variety of congenital syndromes, prenatal assessment of the fetal humerus growth is very important. The fetal humerus volume is one of the indexes in evaluating the humerus growth, but it has never been studied by 3-D ultrasound (US) in utero. To establish a normal reference chart of the fetal humerus volume for clinical use, we undertook a prospective and cross-sectional study using 3-D US to assess the fetal humerus volume in normal pregnancy. A total of 216 singleton fetuses that ranged between 20 and 40 weeks of gestation and fit the criteria of normal pregnancies were included in this study. Our results showed that the fetal humerus volume is highly correlated with the gestational age (GA). Using GA as the independent variable and the humerus volume as the dependent variable, the best-fit regression equation was humerus volume (mL) = 0.0044GA(2) - 0.0841GA + 0.6874 (r = 0.97, n = 216, p < 0.0001). For clinical use, a chart of normal growth centiles of the fetal humerus volume was then established based on this equation. In addition, the common indexes of fetal biometry, such as biparietal diameter, occipitofrontal diameter, head circumference, abdominal circumference, femur length and estimated fetal weight, were all highly correlated with the humerus volume (all p < 0.0001). In conclusion, our data of the fetal humerus volume assessed by 3-D US can serve as a useful reference in evaluating the fetal humerus growth during normal gestation.

Three-dimensional power Doppler ultrasound for the assessment of the fetal brain blood flow in normal gestation

Early identification of the abnormal fetal brain vascularization and blood flow is very important, because the deficient perfusion of the fetal brain may be related to a poor prognosis of the central nervous system (CNS) development. To assess the fetal brain vascularization and the blood flow in normal gestation, we measured the fetal brain vascularization and the brain blood flow in normal fetuses using three-dimensional (3-D) power Doppler ultrasound (US) and the quantitative 3-D power Doppler histogram analysis. This study was undertaken by a prospective and cross-sectional design. In total, 155 normal singletons with gestational age (GA) between 21 and 40 weeks were included. The 3-D power Doppler US and the quantitative 3-D histogram analyses were used to assess the fetal brain vascular indexes, i.e., vascularization index (VI), flow index (FI) and vascularization-flow index (VFI), in each case. Our results revealed that all the fetal brain VI, FI and VFI increased significantly with GA (all p<0.001). In addition, the fetal brain VI, FI and VFI were all significantly correlated with the common fetal growth indices, such as biparietal diameter, occipitofrontal diameter, head circumference, abdominal circumference, femur length and estimated fetal weight. Our study indicates that fetal brain vascularization and blood flow increase significantly with the advancement of GA as well as the fetal common growth indices during normal gestation. We believe our data may serve as a reference for further studies of the fetal brain blood flow in abnormal conditions.

Quantification of ovarian stromal Doppler signals in postmenopausal women receiving hormone replacement therapy

OBJECTIVE

To investigate the effect of continuous-combined hormone replacement therapy (HRT) on ovarian circulation, we used three-dimensional power Doppler ultrasound to assess ovarian stromal blood flow in postmenopausal women.

DESIGN

Forty healthy, postmenopausal women were enrolled in this prospective, controlled study. They were divided into two groups: the control group (20 patients with no HRT treatment) and the HRT group [initially 20 patients, but later 15 patients who completed the study, using continuous-combined conjugated equine estrogen (0.625 mg/day) plus medroxyprogesterone (5 mg/day)]. All patients underwent transvaginal three-dimensional power Doppler ultrasonography at the time of recruitment and 3 months later. The ovarian stromal flow indices, including vascularization-flow index (VFI), flow index (FI), and vascularization index (VI), were measured. Blood withdrawals for serum follicle-stimulating hormone and estrogen level testing were obtained before and after 3 months of treatment.

RESULTS

All the variables in the hormone profile showed significant difference (P < 0.05) after 3 months of treatment in the HRT group. Of interest, the three-dimensional power Doppler indices of ovarian stromal flow, VFI (0.13 +/- 0.11 --> 0.59 +/- 0.49), FI (30.47 +/- 12.06 --> 38.41 +/- 10.21), and VI (0.31 +/- 0.27 --> 1.12 +/- 0.95) all showed significant increase (P < 0.05) after 3 months of HRT treatment.

CONCLUSIONS

There was a significant increase in ovarian stromal flow indices after 3 months of treatment in the HRT group, but not in the controls. Monitoring the ovarian flow changes by three-dimensional power Doppler may be of clinical importance when HRT is given.

Quantitative three-dimensional power Doppler sonography for assessment of the fetal renal blood flow in normal gestation

Renal blood flow is very important to fetal hemodynamics. To assess the development of fetal renal vascularization and blood flow in normal gestation, we measured the fetal renal vascularization and blood flow in healthy fetuses using three-dimensional (3-D) power Doppler sonography and quantitative 3-D power Doppler histogram analysis. This study was undertaken with a prospective, cross-sectional design. In total, 106 healthy singletons with gestational ages between 20 and 40 weeks were included. The 3-D power Doppler sonography and quantitative histogram analyses were used to assess the fetal renal vascularization index (VI), flow index (FI) and vascularization-flow index (VFI) in each case. Our results showed that all the VI, FI and VFI increased significantly with gestational age (GA). Using GA as the independent variable, the linear regression equations for fetal renal VI, FI and VFI were VI = 0.214 x GA - 3.5289 (r = 0.84, n = 106, p < 0.0001); FI = 0.3326 x GA + 35.224 (r = 0.33, n = 106, p < 0.001); and VFI = 0.1047 x GA - 1.8064 (r = 0.82, n = 106, p < 0.0001). Our study indicates that normal fetal renal vasculature and blood flow increase with the advancement of gestational age. In addition to our previous study for fetal renal volume using 3-D sonography, our data in this series may serve as a reference for further studies of fetal renal blood flow in abnormal conditions.

Quantification of ovarian Doppler signal in hyperresponders during in vitro fertilization treatment using three-dimensional power Doppler ultrasonography

To test the hypothesis that the increased ovarian sensitivity to gonadotropins observed in women embarking on an in vitro fertilization (IVF) treatment may be due to changes in ovarian stromal blood flow, we undertook this prospective comparative clinical study using three-dimensional (3-D) power Doppler ultrasound (US). The 3-D power Doppler ultrasonographic indexes were used to quantify ovarian stromal blood flow and vascularization in hyperresponders. A total of 58 patients undergoing an IVF cycle were recruited and divided into two groups, a hyperresponder group (n = 23) (peak estradiol > 3000 pg/mL or >/= 15 oocytes retrieved) and normal responders (n = 35), based on their response to a standard down-regulation protocol for controlled ovarian stimulation. During ovarian stimulation, on the day of human chorionic gonadotropin (HCG) administration, patients underwent hormonal (serum E2), ovarian volume and 3-D power Doppler (ovarian stroma flow) evaluation. The serum estradiol levels on the day of HCG administration, the number of oocytes retrieved and the ovarian volume were significantly higher in the hyperresponders than in the normal groups. The vascularization flow index (VFI), flow index (FI), and vascularization index (VI), were significantly higher (p < 0.05) in the hyperresponders (1.18 +/- 0.60, 50.23 +/- 2.81 and 2.27 +/- 1.08, respectively), compared to the women with a normal response (0.63 +/- 0.61, 43.19 +/- 7.81 and 1.25 +/- 1.18, respectively). Our study may help to explain the excessive response during gonadotropin administration in the hyperresponsive women.

Assessment of normal fetal liver blood flow using quantitative three-dimensional power Doppler ultrasound

Fetal liver blood flow is very important for fetal hemodynamics. To assess the development of fetal liver vascularization and blood flow in normal gestation, we measured the fetal liver vascularization and blood flow in normal fetuses using the three-dimensional (3-D) power Doppler ultrasound (US) and quantitative 3-D power Doppler histogram analysis. This study was undertaken with a prospective, cross-sectional design. In total, 196 normal singletons with gestational age between 20 and 40 weeks were included. The 3-D power Doppler US and the quantitative histogram analysis were used to assess the fetal liver vascularization index (VI), flow index (FI), vascularization-flow index (VFI) and mean greyness in each case. Our results showed that all the fetal liver VI, FI and VFI increased significantly with gestational age (GA), whereas, fetal liver mean greyness decreased with GA. Using GA as the independent variable, the linear regression equations for fetal liver VI, FI, VFI and mean greyness were VI = 0.5746 x GA - 5.8264 (r = 0.86, p < 0.0001), FI = 0.3291 x GA + 35.624 (r = 0.35, p < 0.001), VFI = 0.2905 x GA - 3.4871 (r = 0.82, p < 0.0001) and mean greyness = -0.2034 x GA + 42.315 (r = -0.20, p < 0.0001). In addition, fetal liver VI, FI, VFI and nean greyness were all significantly correlated with common fetal growth indexes, such as biparietal diameter, occipitofrontal diameter, head circumference, abdominal circumference, femur length and estimated fetal weight. Our study indicates that normal fetal liver vascularization and blood flow change significantly with the advancement of GA as well as fetal growth indexes. We believe our data may serve as a reference for further studies of fetal liver blood flow in abnormal conditions.

Three-dimensional power Doppler imaging of ovarian stromal blood flow in women with endometriosis undergoing in vitro fertilization

OBJECTIVE

The aims of this retrospective study were to investigate whether the quantification of ovarian stromal blood flow and/or leptin concentration are predictive of in vitro fertilization (IVF) outcomes in women after laparoscopic ovarian cystectomy for large endometriomas.

METHODS

Twenty-two women undergoing IVF after laparoscopic surgery for ovarian endometriomas (> 6 cm) comprised the study group. Twenty-six women with tubal factor infertility constituted the control group. Ovarian stromal blood flow was evaluated by three-dimensional (3D) power Doppler ultrasound imaging using virtual organ computer-aided analysis (VOCAL( trade mark )). Serum and follicular fluid (FF) leptin concentrations were quantified using an enzyme-linked immunosorbent assay kit.

RESULTS

There were significantly decreased ovarian stromal blood flow parameters (including vascularization index, flow index (FI), and vascularization flow index) in the endometriosis group without an evident difference in total ovarian volume on the day of human chorionic gonadotropin. The value of FF leptin demonstrated a negative correlation with ovarian stromal FI in the control group, but there was a loss of this effect in the endometriosis group.

CONCLUSIONS

Quantification of ovarian stromal blood flow by 3D power Doppler ultrasound in women with endometriosis may provide an important prognostic indicator in those undergoing IVF.

Assessment of placental fractional moving blood volume using quantitative three-dimensional power doppler ultrasound

To test the hypothesis that the placental fractional moving blood volume is different with advancing gestational age (GA), we assessed the vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) of the placenta in normal pregnancy by using three-dimensional (3-D) power Doppler ultrasound (US). We enrolled 100 healthy pregnant women with gestational age between 20 to 40 weeks for this study. Three-dimensional power Doppler ultrasonography was used to assess the VI, FI and VFI in each case. Our results showed that the linear regression equations for VI, FI and VFI, by using GA as the independent variable, were VI = 0.27107 x GA -4.02748 (r = 0.84, p < 0.0001), FI = 0.56115 x GA + 34.28945 (r = 0.49, p < 0.001), and VFI = 0.15663 x GA -2.53810 (r = 0.82, p < 0.0001), respectively. In addition, the VI, FI and VFI values of the placental flow were also positively correlated with the fetal growth indices, namely, biparietal diameter, occipitofrontal diameter, head circumference, abdominal circumference and estimated fetal weight (all p values < 0.001). In conclusion, our study illustrates that the fractional moving blood volume of the placenta is positively correlated with the increment of gestational age and the fetal growth indices. Our data may be used as a reference in the assessment of the placental fractional moving blood volume using the quantitative 3-D power Doppler US.