Left-right differences in ovarian volume and antral follicle count in 1423 women of reproductive age

Ovarian volume partially explains associations of phthalate biomarkers with anti-Müllerian hormone and estradiol in midlife women

BACKGROUND/OBJECTIVES

Women are ubiquitously exposed to endocrine disruptors, including phthalates. Ovarian follicles undergoing folliculogenesis (indirectly measured by ovarian volume) produce anti-Müllerian hormone (AMH) and estradiol (E2). We evaluated associations of phthalates with ovarian volume to assess whether this explained prior positive associations of phthalates with AMH and E2.

METHODS

Women ages 45-54 years (n = 614) had transvaginal ultrasounds of right/left ovaries to calculate mean ovarian volume. Women provided up-to-four urine and blood samples for quantifying AMH (first serum sample), E2 (all serum samples), and nine phthalate metabolites (from pooled urine, representing six parent phthalates). Multivariable linear or logistic regression models (for individual phthalate biomarkers), as well as weighted quantile sum (WQS) regression (for mixture analyses) evaluated associations of phthalate biomarkers with ovarian volume. Using cross-sectional mediation analysis, we assessed whether associations of phthalates with ovarian volume partially explained those of phthalates with AMH or E2.

RESULTS

Most women were non-Hispanic White (68%) and pre-menopausal (67%) with higher urinary phthalate metabolite concentrations than U.S. women. In single-pollutant models, 10% increases in mono(3-carboxypropyl) phthalate (MCPP) and monobenzyl phthalate (MBzP) were associated with 0.44% (95% CI: -0.02%, 0.91%) and 0.62% (95% CI: 0.02%, 1.23%) larger ovarian volumes, respectively. As a cumulative mixture, 10% increases in the phthalate mixture were associated with 2.89% larger ovarian volume (95%CI: 0.27, 5.59) with MCPP (35%) and MBzP (41%) identified as major contributors. Higher ovarian volume due to a 10% increase in MBzP (indirect effect OR: 1.004; 95% CI: 1.00, 1.01) explained 16% of the positive association between MBzP and higher AMH, whereas higher ovarian volume due to a 10% increase in MCPP (indirect effect %Δ: 0.11; 95% CI: -0.01, 0.22) explained 23% of the positive association between MCPP and E2.

CONCLUSION

In this cross-sectional study, phthalates were associated with increased ovarian volume, with implications for midlife hormone production.

Ovarian Morphometric and Histologic Characteristics and Correlation with Clinical Factors: A Cross-Sectional Study

Reproductive lifespan is determined by the reserve of ovarian follicles; their quality and quality determine the fertility potential at a given point in time for a particular individual. Inter-individual variations related to morphometry, laterality, medical history, demographic characteristics and ethnicity may impact ovarian histology, which however, has not been extensively studied or documented. The present cross-sectional study aims to investigate the potential association of clinical factors (age, medical and obstetric history) with ovarian morphometry and histology in females of reproductive age in the local population. The sample included 31 specimens of whole human ovaries, obtained from surgical/autopsy procedures in reproductive-aged women, processed at the Pathology Department. Morphometric characteristics were assessed, including shape, color, length, width, thickness and gross ovarian pathology. Random samples of specific dimensions were histologically examined to determine follicular counts. The results were analyzed statistically in correlation to morphometric characteristics and medical history. The majority of the patients had oval-shaped ovaries (77.8% right; 92.3% left; p = 0.368) of whitish color (38.9% right; 46.2% left; p > 0.999). Right ovaries had significantly greater length, width and volume (p-values 0.018, 0.040 and 0.050, respectively). Thickness was equivalent, as well as follicular distribution of all classes. Age correlated inversely with ovarian volume and primordial/primary follicular count on histology. Women with a caesarian-section history yielded significantly lower primordial/primary follicular counts. As estimated by ovarian histology, macroscopic and clinical factors may be significantly associated with actual ovarian reserve.

Understanding the Ovarian Interrelationship with Low Antral Follicle Counts (AFC) in the In Vivo Bos indicus Cow Model: Unilateral and Bilateral Main AFC as Possible Biomarkers of Ovarian Response to Hormonal Synchronisation

The antral follicle count (AFC) is a test in which the number of oocyte-containing follicles that are developing in both ovaries are visually counted. The count of these follicles strongly relates to the population of the growing follicle reserve on the ovaries. However, the importance of the main number of antral follicle populations (mAFC) in mono-ovulatory animal species has yet to be completely elucidated. Moreover, the investigation of the ovarian interrelationship with unilateral mAFC (main number of antral follicle populations appearing on only one side of the ovary) and bilateral mAFC (main number of antral follicle populations appearing in equivalent numbers on both sides of the ovary) and how understanding this interrelationship can offer possible indicators of ovarian response to hormonal induction have not yet been investigated in mono-ovulatory Bos indicus beef cows. The aim of this study is to investigate the different ovarian interrelationships of mAFC (unilateral and bilateral mAFC) at the time of exogenous hormonal stimulation on the total number of AFC (left and right ovaries) at the beginning of the hormonal protocol for ovarian stimulation and ovarian response at the completion of exogenous hormonal stimulation as well as their usefulness as possible biomarkers of successful hormonal stimulation in Bos indicus beef cattle. Beef cows (n = 104) with low total numbers of AFC (4.7 ± 2.4 follicles) were stimulated with a gonadotropin-releasing hormone-progesterone-prostaglandin F2α-based protocol. At the beginning of the hormonal protocol, ovarian ultrasound scans were performed to evaluate AFC from both ovaries of cows. Beef cows were divided into two groups, unilateral (n = 74) and bilateral mAFC (n = 30), according to the ovarian interrelationship. At the completion of the hormonal stimulation, ovarian ultrasound scans were performed to evaluate the dominant follicle (DF) and cows with DF > 8.5 mm in diameter emerging on their ovaries were defined as having experienced a response to hormonal stimuli. There was a difference of 19.1% between Bos indicus cows bearing unilateral mAFC that produced an increase in ovarian response (odds ratio = 2.717, p < 0.05) compared to the responsive rate of cows displaying bilateral mAFC (82.4% vs. 63.3%). In unilateral mAFC, cows bearing mAFC ipsilateral to the ovary of dominant follicle (DF) had a higher responsive rate than cows bearing mAFC contralateral to the DF ovary (50.0% vs. 32.4%, p < 0.05). In mAFC ipsilateral to the DF ovary, pregnancy rates were greatest in cows bearing mAFC and DF on the right ovary compared with cows bearing mAFC and DF on the left ovary (25.0% vs. 9.1%, p < 0.05). In primiparous and multiparous cows, unilateral mAFC occurs with a greater (p < 0.05) frequency than bilateral mAFC (69.0% and 72.0% vs. 31.0% and 28.0%, respectively). In unilateral mAFC, primiparous cows bearing mAFC ipsilateral to the DF ovary had a greater responsive rate than primiparous cows bearing mAFC contralateral to the DF ovary (55.0% vs. 20.0%, p < 0.05). In mAFC ipsilateral to the DF ovary, responsive and pregnancy rates were greatest (p < 0.05) in multiparous cows bearing mAFC and DF on the right ovary compared with multiparous cows bearing mAFC and DF on the left ovary (58.1% and 22.6% vs. 25.8% and 3.2%, respectively). Furthermore, there was a positive correlation between the mean diameter of AFC at the time of the exogenous hormonal trigger and the mean diameter of DF at the completion of hormonal synchronisation (p < 0.05). Our findings emphasise that the ovarian interrelationship with unilateral mAFC at the time of the hormonal trigger might be a promising biomarker for predicting success in ovarian response to hormonal stimulation of mono-ovulatory Bos indicus beef cows with low AFCs.

The value of transvaginal 4-dimensional hysterosalpingo-contrast sonography in predicting the necessity of assisted reproductive technology for women with tubal factor infertility

Background

More than 50 million women suffer from infertility worldwide, among whom 30% have associated fallopian tube pathology. Fortunately, the diagnostic accuracy of tubal patency has been enhanced with the consistent development of ultrasound imaging technology, especially the invention of transvaginal 4-dimensional hysterosalpingo-contrast sonography (TV 4D HyCoSy). However, detailed imaging data for evaluating the tubal condition for spontaneous conception and assessing the necessity of assisted reproductive technology (ART) have yet to be amassed.

Methods

Patients with tubal factor infertility (TFI) who received TV 4D HyCoSy were recruited for this study. They were divided into two groups according to the method of conception: the natural pregnancy group (patients who naturally conceived within 3 months after TV 4D HyCoSy) and the assisted reproduction group (patients who failed to conceive naturally within the 3 months but successfully conceived through ART). Logistic regression analysis was performed to examine the data obtained from participants' medical history and TV 4D HyCoSy investigation.

Results

Of the initial 1,433 women, 348 were excluded due to exclusion criteria or lack of follow-up. A total of 1,085 TFI patients were finally included, with individuals in the natural pregnancy group accounting for 27.74% (n=301), and those in the ART group accounting for 37.33% (n=405). The age was younger and the duration of infertility was shorter in the group of women who conceive spontaneously after TV 4D HyCoSy (P<0.05). In terms of imaging data, their endometrial thickness was thinner, right fallopian tube wall was more intact, morphology of the right fallopian tube was smoother, and their ovarian motility (bilateral), fallopian tube visualization (bilateral) and overflow condition of the contrast agent from the fimbriae of fallopian tube (bilateral) were better. In addition, the resistance of the contrast agent injection was less likely to be persistent, reflux was less likely to happen and 0/1 dispersion of the contrast agent around the ovary (bilateral) were more likely to be annular (P<0.05).

Conclusions

The imaging data gathered from TV 4D HyCoSy in TFI patients were comprehensive, which suggested that TV 4D HyCoSy could have potential to be used to assess the necessity of post-HyCoSy ART intervention in patients with TFI. This could be of benefit in reducing the incidence of overtreatment and potential complications of ART.

Relation of Birthweight and Ovarian and Uterine Size Prior to Menarche

During pregnancy, supply of nutrients and exposure of the mother to environmental factors can influence fetus phenotype, possibly modifying growth of fetal tissues and organs. Few studies inconsistently reported that fetuses exposed to an insufficient energy supply, as those born small for gestational age, may have a reduced volume of uterus and ovaries. A retrospective analysis was performed on ultrasound data performed between 2012 and 2018 in 69 young premenarchal girls, 5 to 9 years of age, attending our endocrine-gynecologic clinic for a suspect of early puberty. Length of pregnancy and birthweight was also retrieved. When corrected for age, and presence of ovarian follicles, ovarian volume was positively (R² = 0.210; p = 0.001) related to percentiles of birthweight (beta coefficient 0.012; 95% CI, 0.002-0.021). Similarly, uterine volume was positively (R² = 0.237; p = 0.005) related to percentiles of birthweight (beta coefficient 0.067; 95% CI, 0.021-0.114). Ovarian (p = 0.034) and uterine (p = 0.014) volume was higher in the upper 3rd distribution of birthweight percentiles. In conclusion, development of ovarian and uterine volume increases progressively with the increase of birthweight percentiles. The data indicate an association between birthweight and the volume of uterus and ovary at 5-9 years of age.

Long-Term Ultrasound Follow-Up After Pediatric Adnexal Torsion

PURPOSE

 Conservative surgical management of adnexal torsion in pre- and post-menarchal girls by de-torsion and adnexal conservation is the current standard of care. The aim of this study is to investigate the long-term outcome of adnexal torsion in this population in terms of ultrasound appearance and ovarian volume.

METHODS

 Patients who were surgically treated for adnexal torsion and were < 18 years old at time of surgery were prospectively invited for ultrasound follow-up. The ultrasound exam included measurements of ovarian volume and grayscale appearance including identification of ovarian follicular activity.

RESULTS

 84 cases of torsion in this population were identified, and 37 of them were included in the study. Of those, the affected ovary could not be demonstrated on follow-up scan in six (16.2 %) cases. A difference of ≥ 2 cm³ in ovarian volume between the affected and non-affected ovaries was diagnosed in 12 (32.4 %) cases, but follicular activity was observed in 10 of those. Thus, possible ovarian injury (including cases of non-demonstrated ovary and volume difference of ≥ 2 cm³ between the affected and non-affected ovaries) was found in 18 (48.6 %) cases. Of the clinical and surgical parameters (including age at time of torsion, duration of pain prior to admission, cystectomy procedure and intraoperative "bluish" appearance of the ovary), only the presence of fever on admission was significantly associated with possible ovarian injury (p = 0.01).

CONCLUSION

 Long-term ultrasound follow-up of pre- and post-menarchal girls with a history of adnexal torsion may identify patients with adversely affected ovarian volume. The significance of this finding in terms of fertility is unknown.

Effects of uterine artery occlusion during myomectomy on ovarian reserve: Serial follow-up of sex hormone levels, ultrasound parameters and Doppler characteristics

AIM

To evaluate the influence of uterine artery occlusion at myomectomy (UAO + M) on ovarian reserve based on serum sex hormone levels, ultrasound and color Doppler examinations.

METHODS

In this cohort study, nine women with symptomatic uterine myomas underwent UAO + M were recruited. Each woman was assessed preoperatively and 3, 6 months postoperatively, through a serial of hormonal, ultrasound parameters and Doppler examination for ovarian stromal blood flow. The data were analyzed using generalized estimating equations.

RESULTS

There was no significant difference in serum anti-Müllerian hormone (AMH) or follicle-stimulating hormone (FSH) levels before and 3, 6 months after UAO + M. The ovarian volume, antral follicle count (AFC) and ovarian stromal blood flow had significant changes in the right ovary. Ovarian volume and AFC significantly reduced at 3 months and recovered at 6 months postoperatively (P = 0.046, P = 0.019, respectively). Peak systolic velocity and end diastolic velocity significantly decreased at 3 months and leveled off at 6 months (P < 0.001, P = 0.001, respectively). Resistance index significantly increased at 3 months and decreased at 6 months (P = 0.037). A similar trend in ultrasound and Doppler findings was observed in the left ovary, but no statistical significance was found.

CONCLUSION

UAO + M had no detrimental effect on ovarian reserve 6 months postoperatively based on AMH and FSH levels. AFC, ovarian volume and stromal blood flow were transiently decreased in 3 months and recovered in 6 months.

Impact of right-left differences in ovarian morphology on the ultrasound diagnosis of polycystic ovary syndrome

OBJECTIVE

To assess right-left differences in ultrasonographic markers of ovarian morphology and determine the impact on the diagnosis of polycystic ovarian morphology (PCOM).

DESIGN

A cross-sectional study of data collected from 2006 to 2018.

SETTING

Academic clinical research centers.

PATIENT(S)

Women with polycystic ovary syndrome (PCOS; n = 87) and controls (n = 67).

INTERVENTION(S)

None.

MAIN OUTCOMES MEASURE(S)

Follicle number per ovary (FNPO), follicle number per cross-section (FNPS), and ovarian volume (OV) were assessed in both ovaries using transvaginal ultrasonography. PCOM was identified based on recent international consensus guidelines or proposed diagnostic thresholds.

RESULT(S)

Overall, mean right-left differences were two follicles for FNPO, one follicle for FNPS, and 2 mL for OV. FNPO showed the strongest correlation between ovaries. Its assessment in a single ovary did not impact the diagnosis of PCOM in women with PCOS. However, there were differences in the probability of unilateral versus bilateral PCOM based on FNPS and OV in both groups.

CONCLUSION(S)

FNPO is the most reliable unilateral marker of PCOM in light of right-left differences in ovarian morphology. Use of FNPS or OV to define PCOM is discouraged when only one ovary is visualized.

Simplified 4-item criteria for polycystic ovary syndrome: A bridge too far?

OBJECTIVES

Although the Rotterdam 2003 polycystic ovarian syndrome (PCOS) diagnostic criteria is widely used, the need to consider multiple variables makes it unwieldy in clinical practice. We propose a simplified PCOS criteria wherein diagnosis is made if two of the following three items were present: (i) oligomenorrhoea, (ii) anti-mullerian hormone (AMH) above threshold and/or (iii) hyperandrogenism defined as either testosterone above threshold and/or the presence of hirsutism.

DESIGN SETTING AND PARTICIPANTS

This prospective cross-sectional study consists of healthy women (n = 157) recruited at an annual hospital health screen for staff and volunteers from the university community, and a patient cohort (n = 174) comprising women referred for suspected PCOS.

MAIN OUTCOME MEASURES

We used the healthy cohort to establish threshold values for serum testosterone, antral follicle counts (AFC), ovarian volume (OV) and AMH. Women from the patient cohort, classified as PCOS by simplified PCOS criteria, AMH alone and Rotterdam 2003, were compared with respect to prevalence of oligomenorrhoea, hyperandrogenism and metabolic indices.

RESULTS

In healthy women, testosterone ≥1.89 nmol/L, AFC ≥22 follicles and OV ≥8.44 mL, best predicted oligomenorrhoea and were used as threshold values for PCOS criteria. An AMH level ≥37.0 pmol/L best predicted polycystic ovarian morphology. AMH alone as a single biomarker demonstrated poor specificity (58.9%) for PCOS compared to Rotterdam 2003. In contrast, there was a 94% overlap in women selected as PCOS by the simplified PCOS criteria and Rotterdam 2003. The population characteristics of these two groups of PCOS women showed no significant mean differences in androgenic, ovarian, AMH and metabolic (BMI, HOMA-IR) variables.

CONCLUSIONS

Our data recommend the simplified PCOS criteria with population-specific thresholds for diagnosis of PCOS. Its ability to replace ovarian ultrasound biometry with the highly correlated variable AMH, and use of testosterone as a single marker for hyperandrogenaemia alongside the key symptoms of oligomenorrhoea and hirsutism confers significant clinical potential for the diagnosis of PCOS.