The predictive value of the automated quantification of the number and size of small antral follicles in women undergoing ART

A follicular volume of >0.56 cm3 at trigger is the cutoff to predict oocyte maturity: a starting point for novel volume-based triggering criteria

OBJECTIVE

To determine the minimum follicular volume on the day of trigger that will correspond to a mature oocyte at egg retrieval by individualized follicular puncture and to calculate the mean follicular growth from ovulation induction to egg retrieval using SonoAVCfollicle.

DESIGN

A prospective observational study of 53 women undergoing in vitro fertilization, in which it was possible to identify unequivocally one or more follicles at trigger and egg retrieval using three-dimensional ultrasound.

SETTING

University-affiliated private in vitro fertilization center.

PATIENTS

The final sample included 206 follicles from 14 oocyte donors and 39 patients.

INTERVENTIONS

A three-dimensional ultrasound with SonoAVCfollicle was performed at trigger and egg retrieval. The same operator selected follicles that were identified easily on both scans and verified that they were apt to be aspirated individually. Follicles were punctured individually, recording the real aspirated volume and the maturity stage of the oocyte.

MAIN OUTCOME MEASURES

The primary outcome was the relationship between follicular volume on the day of the trigger and the oocyte maturity stage. The secondary outcome was the rate of follicular growth from the day of trigger to the day of oocyte retrieval, as measured using SonoAVCfollicle.

RESULTS

On the day of trigger 206, follicles were selected. Of these, 5 could not be identified on the day of oocyte retrieval, probably because of follicular rupture (mean volume: 4 cm3, range: 2-7 cm3), and in 48, an oocyte was not obtained. The relationship between follicular volume and oocyte maturity was studied in 153 follicles: 125 (82%) contained mature and 28 (18%) contained immature oocytes. Receiver operating characteristic curves showed an area under the curve value of 0.73 (95% confidence interval: 0.65-0.80). A follicular volume of >0.56 cm3 is the cutoff point, with the highest Youden index having a sensitivity of 85% and a specificity of 64% to predict oocyte maturity. The mean follicular growth from trigger to egg retrieval was 26%-50% in 53% of cases.

CONCLUSION

A follicular volume of >0.56 cm3 at trigger is the cutoff point with the optimal balance between sensitivity and specificity for oocyte maturity. Follicles of >2-3 cm3 may undergo spontaneous rupture before egg retrieval. Given these findings, we propose new volume-based criteria for trigger: 70% of follicles of >0.6 cm3 and dominant follicles between 2 and 3 cm3. These findings need validation by randomized controlled trials.

The carriers of the A/G-G/G allelic combination of the c.2039 A>G and c.-29 G>A FSH receptor polymorphisms retrieve the highest number of oocytes in IVF/ICSI cycles

PURPOSE

The objective of this study was the elucidation of the possible role of the single-nucleotide polymorphisms (SNP) at position -29 and 2039 of the FSH receptor gene (FSHR) as independent predictive markers of ovarian response. Indeed, the tailoring of reproductive treatments is crucial for both maximizing the success of IVF patients and obtaining a reduction in hypo- or hyper-response rates.

METHODS

This prospective, observational study analyzed the association of -29 and 2039 FSHR polymorphisms with the number of retrieved oocytes in 140 patients attending an IVF/ICSI cycle for severe male factors (≤5,000,000 spermatozoa/mL) or tubal factors at the ANDROS Day Surgery Clinic, Palermo, Italy.

RESULTS

The results of this study demonstrate that the genetic combination of A/G for polymorphism c.2039 A>G with G/G for polymorphism c.-29 G>A is significantly associated with the highest number of collected oocytes (p = 0.03). This association was significant even after controlling for the effect of other clinical variables.

CONCLUSIONS

The A/G-G/G allelic variant, identified as an independent variable, if confirmed in a larger number of patients, could be considered as a new genetic biomarker, which could increase the efficacy of prediction models for ovarian stimulation.

The Value of Automated Follicle Volume Measurements in IVF/ICSI

BACKGROUND/AIMS

The objective of this literature study is to investigate the place of recent software technology sonography-based automated volume count (SonoAVC) for the automatic measurement of follicular volumes in IVF/ICSI. Its advantages and disadvantages and potential future developments are evaluated.

METHODS

A total of 74 articles were read via a PubMed literature study. The literature study included 53 articles, 32 of which for the systematic review.

RESULTS

The SonoAVC software shows excellent accuracy. Comparing the technology with the "golden standard" two-dimensional (2D) manual follicle measurements, SonoAVC leads to a significantly lower intra- and inter-observer variability. However, there is no significant difference in clinical outcome (pregnancy rate). We noted a significant advantage in the time gained, both for doctor and patient. By storing the images, the technology offers the possibility of including a quality control and continuous training and further standardization of follicular monitoring can be expected. Ovarian reserve testing by measuring the antral follicle count with SonoAVC is highly reliable.

CONCLUSION

This overview of previously published literature shows how SonoAVC offers advantages for clinical practice, without losing any accuracy or reliability. Doctors should be motivated to the general use of follicular volumes instead of follicular diameters.

The ovarian reserve of primordial follicles and the dynamic reserve of antral growing follicles: what is the link?

The growing follicles develop from a reserve of primordial follicles constituted early in life. From this pre-established reserve, a second ovarian reserve is formed, which consists of gonadotropin-responsive small antral growing follicles and is a dynamic reserve for ovulation. Its size, evaluated by direct antral follicular count or endocrine markers, determines the success of assisted reproductive technologies in humans and embryo production biotechnologies in animals. Strong evidence indicates that these two reserves are functionally related. The size of both reserves appears to be highly variable between individuals of similar age, but the equilibrium size of the dynamic reserve in adults seems to be specific to each individual. The dynamics of both follicular reserves appears to result from the fine tuning of regulations involving two main pathways, the phosphatase and tensin homolog (PTEN)/phosphatidylinositol-3 kinase (PI3K)/3-phosphoinositide-dependent protein kinase-1 (PDPK1)/v-akt murine thymoma viral oncogene homolog 1 (AKT1) and the bone morphogenetic protein (BMP)/anti-Müllerian hormone (AMH)/SMAD signaling pathways. Mutations in genes encoding the ligands, receptors, or signaling effectors of these pathways can accelerate or modulate the exhaustion rate of the ovarian reserves, causing premature ovarian insufficiency (POI) or increase in reproductive longevity, respectively. With female aging, the decline in primordial follicle numbers parallels the decrease in the size of the dynamic reserve of small antral follicles and the deterioration of oocyte quality. Recent progress in our knowledge of signaling pathways and their environmental and hormonal control during adult and fetal life opens new perspectives to improve the management of the ovarian reserves.

Intracycle variation in number of antral follicles stratified by size and in endocrine markers of ovarian reserve in women with normal ovulatory menstrual cycles

OBJECTIVE

To quantify the intracycle variation in markers of ovarian reserve measured by antral follicle counts stratified by size using three-dimensional (3D) ultrasound and anti-Müllerian hormone (AMH) in women with normal menstrual cycles.

METHODS

Healthy volunteers with normal menstrual cycles were prospectively recruited. Three-dimensional (3D) ultrasound examination and blood test were performed in early (F1) and mid-follicular (F2) phases and in periovulatory (PO) and luteal (LU) phases of one menstrual cycle. Antral follicles were measured using 'sonography-based automated volume calculation' with post processing (SonoAVC) and ovarian volume was measured using Virtual Organ Computer-aided AnaLysis (VOCAL). Blood serum was processed for hormonal assays including AMH, follicle stimulating hormone (FSH), luteinizing hormone (LH) and estradiol. Repeated-measures analysis was used to examine the variance in markers of ovarian reserve in different phases of one menstrual cycle.

RESULTS

A total of 36 volunteers were included in the final analysis, of whom 34 attended all four visits. Repeated-measures analysis showed a significant variation in total antral follicle count (AFC) (P < 0.001). However, on stratifying the antral follicles according to size using SonoAVC, a non-significant variation (P = 0.382) was seen in small AFC (≤ 6.0 mm) and a significant variation (P < 0.001) was seen in large AFC (> 6.0 mm). The ovarian volume showed a significant intracycle variation (P < 0.001). A small but significant intracycle variation was noted in AMH (P = 0.041) and a significant variation was seen in levels of serum FSH, LH and estradiol (P < 0.05).

CONCLUSION

Small antral follicles (≤ 6.0 mm) measured using 3D ultrasound and AMH show little intracycle variation and perhaps should be evaluated when predicting ovarian reserve independent of menstrual cycle.

Quantifying effect of combined oral contraceptive pill on functional ovarian reserve as measured by serum anti-Müllerian hormone and small antral follicle count using three-dimensional ultrasound

OBJECTIVES

Oral contraceptive pills suppress the hypothalomo-pituitary axis, which can affect the ultrasound and endocrine markers used to examine ovarian reserve. The objective of this study was to quantify the ultrasound and endocrine markers of functional ovarian reserve in women using a combined oral contraceptive pill (COCP) for more than a year.

METHODS

This was a prospective case-control study involving healthy volunteers: 34 women using for more than a year a COCP with hormone-free interval (HFI) were compared to 36 normo-ovulatory, age-matched controls who had not used hormonal contraception within the last year. Volunteers using a COCP underwent a 3D ultrasound examination and had a blood sample taken within the first 4 days of active pill ingestion and those in the control group had the scan and blood test in the early follicular phase (days 2-5) of menstrual cycle. The main outcome measure was the difference in antral follicle counts stratified according to size and anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E2) levels.

RESULTS

There were no significant differences in the number of small antral follicles measuring 2-6 mm. The COCP group had significantly fewer antral follicles measuring ≥ 6 mm (P < 0.001) and had significantly smaller ovaries (P < 0.001), which also had lower vascular indices than the control group (P < 0.05). While serum FSH, LH and E2 levels were significantly lower in the COCP group (P < 0.05), there was no significant difference in serum AMH levels between the two groups.

CONCLUSIONS

Prolonged use of COCP suppressed pituitary gonadotropins and antral follicle development beyond 6 mm, but had no effect on levels of serum AMH and number of small antral follicles.

Follicle stimulating hormone and anti-Müllerian hormone per oocyte in predicting in vitro fertilization pregnancy in high responders: a cohort study

Background

Follicle stimulating hormone (FSH) and Anti-Müllerian hormone (AMH) are utilized to differentiate between good and poor response to controlled ovarian hyperstimulation. Their respective roles in defining functional ovarian reserve remain, however, to be elucidated. To better understand those we investigated AMH and FSH per oocyte retrieved (AMHo and FSHo).

Methodology/Principal Findings

Three-hundred and ninety-six women, undergoing first in vitro fertilization cycles, were retrospectively evaluated. Women with oocyte yields >75^th percentile for their age group were identified as high responders. In a series of logistic regression analyses, AMHo and FSHo levels were then evaluated as predictive factors for pregnancy potential in high responders. Patients presented with a mean age of 38.0±5.0 years, mean baseline FSH of 11.8±8.7 mIU/mL and mean AMH of 1.6±2.1 ng/mL. Those 88 women, who qualified as high responders, showed mean FSH of 9.7±6.5 mIU/mL, AMH of 3.1±3.1 ng/mL and oocyte yields of 15.8±7.1. Baseline FSH and AMH did not predict pregnancy in high responders. However, a statistically significant association between FSHo and pregnancy was observed in high responders, both after univariate regression (p = 0.02) and when adjusted for age, percentage of usable embryos, and number of embryos transferred (p = 0.03). Rate of useable embryos also significantly affected pregnancy outcome independently of FSHo (p = 0.01). AMHo was also associated with clinical pregnancy chances in high responders (p = 0.03) and remained significant when adjusted for usable embryos and number of embryos transferred (p = 0.04).

Conclusions

AMHo and FSHo are predictive of pregnancy potential in high responders, but likely reflect different responsibilities in recruitment and maturation of growing follicle cohorts.

[Cancellation of IVF-ET cycles: poor prognosis, poor responder, or variability of the response to controlled ovarian hyperstimulation? An analysis of 142 cancellations]

INTRODUCTION

This retrospective study aimed at analyzing IVF-ET management and outcome after cancellation of a first cycle for poor response.

PATIENTS AND METHOD

One hundred and forty-two infertile patients were included in this observational study. After an overall analysis on the outcome of the second IVF-ET attempt, a sub-analysis was performed according to the presence or the absence of poor prognostic criteria defined as mentioned: patient age superior to 38 years old, antral follicle count (3-9 mm in diameter) inferior to 10 on cycle day 3 and day 3 serum AMH and FSH levels less than 1 ng/mL and more than 10 IU/mL, respectively. Main outcome measures were the cancellation rates, pregnancy and live birth rates.

RESULTS

When a controlled ovarian stimulation was performed, patients with poor prognosis had higher cancellation rates (37.8% vs. 13.3%, P<0.004) and lower pregnancy and live birth rates (22.2% vs. 35.0%, P<0.05 and 11.1% vs. 26.1%, P<0.05, respectively) as compared to good prognosis women.

CONCLUSION

The relatively high cancellation rate in patients with poor prognosis raises the question of the use of IVF modified natural cycle in this group.

Ultrasound automated volume calculation in reproduction and in pregnancy

OBJECTIVE

To review studies assessing the application of ultrasound automated volume calculation in reproductive medicine.

DESIGN

We performed a literature search using the keywords "SonoAVC, sonography-based automated volume calculation, automated ultrasound, 3D ultrasound, antral follicle, follicle volume, follicle monitoring, follicle tracking, in vitro fertilization, controlled ovarian hyperstimulation, embryo volume, embryonic volume, gestational sac, and fetal volume" and conducted the search in PubMed, Medline, EMBASE, and the Cochrane Database of Systematic Reviews. Reference lists of identified reports were manually searched for other relevant publications.

RESULT(S)

Automated volume measurements are in very good agreement with actual volumes of the assessed structures or with other validated measurement methods. The technique seems to provide reliable and highly reproducible results under a variety of conditions. Automated measurements take less time than manual measurements.

CONCLUSION(S)

Ultrasound automated volume calculation is a promising new technology which is already used in daily practice especially for assisted reproduction. Improvements to the technology will undoubtedly render it more effective and increase its use.

The cohort of antral follicles measuring 2-6 mm reflects the quantitative status of ovarian reserve as assessed by serum levels of anti-Müllerian hormone and response to controlled ovarian stimulation

OBJECTIVE

To evaluate the relationship between serum anti-Müllerian hormone (AMH) and antral follicle size, and to ascertain which cohort of antral follicles is most predictive of the response to controlled ovarian stimulation during assisted reproduction treatment (ART).

DESIGN

Prospective study.

SETTING

University-based Assisted Conception Unit.

PATIENT(S)

One hundred thirteen women undergoing first cycle of ART.

INTERVENTION(S)

Transvaginal 3D-ultrasound assessment and venipuncture in the early-follicular phase of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Serum AMH levels, number of mature oocytes retrieved and poor ovarian response.

RESULT(S)

The antral follicle cohorts measuring 2 to 3 mm, >3 to 4 mm, >4 to 5 mm, and >5 to 6 mm were most significantly correlated with AMH (r = .30, .27, .30, and .41, respectively) and the number of mature oocytes retrieved (r = .28, .23, .29, and .34, respectively). Although these follicle cohorts of 2-6 mm were significant predictors of the number of mature oocytes retrieved on regression analysis, their discriminative ability (area under the curve [AUC]: 0.829) for the prediction of poor ovarian response was similar to total counts made using cohorts of 2 to 4 mm, 2 to 5 mm, 2 to 8 mm, and 2 to 10 mm (AUCs: 0.794, 0.812, 0.852, and 0.826, respectively).

CONCLUSION(S)

The number of antral follicles measuring 2 to 6 mm is most reflective of the quantitative ovarian reserve. However, the ability of this group of antral follicles to predict poor ovarian response appears similar to that of the follicular cohorts of 2 to 4 mm, 2 to 5 mm, 2 to 8 mm, and 2 to 10 mm.