Intraobserver and interobserver reproducibility of ovarian volume, antral follicle count, and vascularity indices obtained with transvaginal 3-dimensional ultrasonography, power Doppler angiography, and the virtual organ computer-aided analysis imaging program

Cut-off value for anti-Müllerian hormone in the diagnostic criteria for polycystic ovary syndrome in the Japanese population

AIM

To establish cut-off values for anti-Müllerian hormone (AMH) and antral follicle count (AFC) in the diagnostic criteria for polycystic ovary syndrome (PCOS) applicable to the Japan Society of Obstetrics and Gynecology (JSOG) 2024 criteria and the Rotterdam/International Evidence-Based Guideline for the assessment and management of PCOS (IEBG) 2023 criteria based on a nationwide survey, respectively, taking into account age, assays, and structure of the diagnostic criteria.

METHODS

Data were collected for 986 PCOS cases and 965 control cases using a national survey in Japan and used to establish cut-off values for AMH and AFC.

RESULTS

Serum AMH levels were significantly higher in the PCOS group compared to the control group. Serum AMH showed a significant negative correlation with age and significant positive correlation with AFC in both groups. In multiple regression analysis, serum AMH level was independently affected by AFC and total testosterone. AMH cut-off values suitable for the JSOG 2024 criteria and the Rotterdam/IEBG 2023 criteria were separately established for the 20-29 and 30-39 years of age groups, respectively, and for Access, Lumipulse and Elecsys/ECLusys, respectively. AFC cut-off values suitable for the JSOG 2024 criteria and Rotterdam/IEBG 2023 criteria were also established separately. AFC exhibited statistically greater variability than AMH.

CONCLUSION

The serum AMH level is the biochemical representation of ovarian findings in PCOS and considered objective and highly reliable. Therefore, it could serve as a surrogate for AFC as a marker of polycystic ovarian morphology in diagnostic criteria.

Ultrasonographic criteria in the diagnosis of polycystic ovary syndrome: a systematic review and diagnostic meta-analysis

BACKGROUND

Polycystic ovary morphology (PCOM) on ultrasonography is considered as a cardinal feature of polycystic ovarian syndrome (PCOS). Its relevance as a diagnostic criterion for PCOS was reaffirmed in the most recent International Evidence-Based Guideline for the Assessment and Management of PCOS. However, there remains a lack of clarity regarding the best practices and specific ultrasonographic markers to define PCOM.

OBJECTIVE AND RATIONALE

The aim of this systematic review and diagnostic meta-analysis was to assess the diagnostic accuracy of various ultrasonographic features of ovarian morphology in the diagnosis of PCOS.

SEARCH METHODS

Relevant studies published from 1 January 1990 to 12 June 2023 were identified by a systematic search in PubMed, Web of Science, Scopus, CINAHL, and CENTRAL. Studies that generated diagnostic accuracy measures (e.g. proposed thresholds, sensitivity, specificity) for PCOS using the following ultrasonographic markers met criteria for inclusion: follicle number per ovary (FNPO) or per single cross-section (FNPS), ovarian volume (OV), and stromal features. Studies on pregnant or post-menopausal women were excluded. Risk of bias and applicability assessment for diagnostic test accuracy studies were determined using the QUADAS-2 and QUADAS-C tool for a single index test or between multiple index tests, respectively. Diagnostic meta-analysis was conducted using a bivariate model of pooled sensitivity and specificity, and visualized using forest plots and summary receiver-operating characteristic (SROC) curves.

OUTCOMES

From a total of 2197 records initially identified, 31 studies were included. Data from five and two studies were excluded from the meta-analysis due to duplicate study populations or limited data for the index test, leaving 24 studies. Pooled results of 20 adult studies consisted of 3883 control participants and 3859 individuals with PCOS. FNPO was the most accurate diagnostic marker (sensitivity: 84%, CI: 81-87%; specificity: 91%, CI: 86-94%; AUC: 0.905) in adult women. OV and FNPS had similar pooled sensitivities (OV: 81%, CI: 76-86%; FNPS: 81%, CI: 70-89%) but inferior pooled specificities (OV: 81%, CI: 75-86%; FNPS: 83%, CI: 75-88%) and AUCs (OV: 0.856; FNPS: 0.870) compared to FNPO. Pooled results from four adolescent studies consisting of 210 control participants and 268 girls with PCOS suggested that OV may be a robust ultrasonographic marker for PCOS diagnosis albeit the current evidence remains limited. The majority of the studies had high risk of bias for the patient selection (e.g. lack of randomized/consecutive patient selection) and index test (e.g. lack of pre-proposed thresholds for comparison) domains across all ultrasonographic markers. As such, diagnostic meta-analysis was unable to determine the most accurate cutoff for ultrasonographic markers to diagnose PCOS. Subgroup analysis suggested that stratification based on previously proposed diagnostic thresholds, age, BMI, or technology did not account for the heterogeneity in diagnostic accuracy observed across the studies. Studies that diagnosed PCOS using the Rotterdam criteria had improved sensitivity for FNPO. Studies from North America had lower diagnostic accuracy when compared to Asian studies (FNPO: sensitivity) and European studies (OV: specificity, diagnostic odds ratio and positive likelihood ratio). Geographic differences in diagnostic accuracy may potentially be due to differences in age, BMI, and diagnostic criteria of the PCOS group across regions.

WIDER IMPLICATIONS

This diagnostic meta-analysis supports the use of FNPO as the gold standard in the ultrasonographic diagnosis of PCOS in adult women. OV and FNPS provide alternatives if total antral follicle counts cannot be accurately obtained. Our findings support the potential for ultrasonographic evidence of PCOM in adolescents as more data becomes available. Subgroup analysis suggests the need to investigate any relative contributions of geographical differences on PCOS phenotypes. These findings may provide the basis for the development of strategies and best practices toward a standardized definition of PCOM and a more accurate ultrasonographic evaluation of PCOS.

Antral follicle count and anti-Müllerian hormone to classify low-prognosis women under the POSEIDON criteria: a classification agreement study of over 9000 patients

STUDY QUESTION

What is the agreement between antral follicle count (AFC) and anti-Müllerian hormone (AMH) levels when used to patient classification according to the Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number (POSEIDON) criteria?

SUMMARY ANSWER

Our study indicates a strong agreement between the AFC and the AMH levels in classifying POSEIDON patients; thus, either can be used for this purpose, although one in four women will have discordant values when both biomarkers are used.

WHAT IS KNOWN ALREADY

According to the POSEIDON criteria, both AFC and AMH may be used to classify low-prognosis patients. Proposed AFC and AMH thresholds of 5 and 1.2 ng/ml, respectively, have their basis in published literature; however, no study has yet determined the reproducibility of patient classification in comparing one biomarker with the other, nor have their thresholds ever been validated within this patient population.

STUDY DESIGN, SIZE, DURATION

A population-based cohort study involving 9484 consecutive patients treated in three fertility clinics in Brazil, Turkey and Vietnam between 2015 and 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were infertile women between 22 and 46 years old in their first in vitro fertilization/intracytoplasmic sperm injection cycle of standard ovarian stimulation with exogenous gonadotropins whose baseline ovarian reserves had been assessed by both AFC and AMH. Details of pre- and post-treatment findings were input into a coded research file. Two indicators of interest were created to classify patients according to the POSEIDON criteria based upon AFC and AMH values. Patients who did not fit any of the four POSEIDON groups were classified as non-POSEIDON. AFC was determined in the early follicular phase using two-dimensional (2D) transvaginal ultrasonography, whereas AMH values were based on the modified Beckman Coulter generation II enzyme-linked immunosorbent assay. Agreement rates were computed between AFC and AMH to classify patients using Cohen's kappa statistics. Logistic regression analyzes were carried out to examine the association between ovarian markers and low (<4) and suboptimal (4-9) oocyte yield.

MAIN RESULTS AND THE ROLE OF CHANCE

The degree of agreement in classifying patients according to POSEIDON groups was strong overall (kappa = 0.802; 95% CI: 0.792-0.811). A total of 73.8% of individuals were classified under the same group using both biomarkers. The disagreement rates were ∼26% and did not diverge when AFC or AMH was used as the primary biomarker criterion. Significant regression equations were found between ovarian markers and oocyte yield (P < 0.0001). For low oocyte yield, the optimal AFC and AMH cutoff values were 5 and 1.27 ng/ml with sensitivities of 0.61 and 0.66, specificities of 0.81 and 0.72, and AUC receiver operating characteristics of 0.791 and 0.751, respectively. For suboptimal oocyte yield respective AFC and AMH cutoffs were 12 and 2.97 ng/ml with sensitivities of 0.74 and 0.69, specificities of 0.76 and 0.66 and AUCs of 0.81 and 0.80.

LIMITATIONS, REASONS FOR CAUTION

Our study relied on 2D transvaginal sonography to quantify the AFC and manual Gen II assay for AMH determination and classification of patients. AMH data must be interpreted in an assay-specific manner. Treatment protocols varied across centers potentially affecting patient classification.

WIDER IMPLICATIONS OF THE FINDINGS

Three of four patients will be classified the same using either AFC or AMH values. Both biomarkers provide acceptable and equivalent accuracy in predicting oocyte yield further supporting their use and proposed thresholds in daily clinical practice for patient classification according to the POSEIDON criteria. However, the sensitivity of POSEIDON thresholds in predicting low oocyte yield is low. Clinicians should adopt the biomarker that may best reflect their clinical setting.

STUDY FUNDING/COMPETING INTEREST(S)

Unrestricted investigator-sponsored study grant (MS200059_0013) from Merck KGaA, Darmstadt, Germany. The funder had no role in study design, data collection, analysis, decision to publish or manuscript preparation. S.C.E. declares receipt of unrestricted research grants from Merck and lecture fees from Merck and Med.E.A. H.Y. declares receipt of payment for lectures from Merck and Ferring. L.N.V. receives speaker fees and conferences from Merck, Merck Sharp and Dohme (MSD) and Ferring and research grants from MSD and Ferring. T.M.H. received speaker fees and conferences from Merck, MSD and Ferring. The remaining authors have nothing to disclose.

TRIAL REGISTRATION NUMBER

not applicable.

The effect of melatonin on ultrasound markers of follicular development: A double-blind placebo-controlled randomised trial

BACKGROUND

Melatonin is a potent oxygen scavenger and is capable of altering blood flow in various vascular beds.

AIMS

We aimed to determine the effect of melatonin on ovarian vascular indices during ovarian stimulation for in vitro fertilisation (IVF).

MATERIALS AND METHODS

This is a pilot double-blind placebo-controlled randomised trial. Sixty-nine women (mean age 35.8 ± 4.3 years) undergoing their first cycle of IVF were randomised to receive either placebo, 2, 4 or 8 mg of melatonin, twice a day. Each participant underwent a transvaginal ultrasound at days 6-10 assessing follicular number and size. The vascularisation index (VI), flow index (FI) and vascularisation-flow index (VFI) were measured. These indices were then correlated with embryological outcomes. Informed consent was obtained from participants. This trial was registered with the Australia New Zealand Clinical Trials Registry (ACTRN12613001317785).

RESULTS

The number of follicles did not differ between groups (P = 0.4). There were no differences in the VI (P = 0.4), FI (P = 0.1) or VFI (P = 0.3) in the right ovary or the FI (P = 0.3) or VFI (P = 0.3) in the left ovary between groups. When comparing placebo to any dose of melatonin, there were no differences in any measured parameter. While there was correlation between the number of follicles on ultrasound and all measured embryological outcomes, there was no correlation between ovarian vascular indices and these important clinical outcomes.

CONCLUSIONS

Melatonin does not appear to change ovarian vascular indices during ovarian stimulation. In addition, such vascular indices cannot predict the number or quality of oocytes or embryos obtained in an IVF cycle. These findings require confirmation in future larger studies.

Recommendation Patterns among Gynaecologists and Radiologists for Adnexal Masses on Ultrasound

OBJECTIVE

Ultrasound is the primary modality used to evaluate adnexal lesions. Follow-up recommendations for ovarian cysts remain controversial between gynaecologists and radiologists. The objective of this study was to compare practice patterns for adnexal masses described on ultrasound on the basis of the interpreter's field of specialty.

METHODS

This study was conducted within the McGill University Hospital Network at two hospitals that differ in the department of interpretation of pelvic ultrasounds. In one hospital, all studies are reported by gynaecologists, and in the other, by radiologists. The study investigators collected data from pelvic ultrasounds of newly diagnosed ovarian lesions performed from May to June 2014. Multivariate logistic regression analyses were used to compare recommendation patterns between the two groups.

RESULTS

A total of 201 of 1110 pelvic ultrasound studies performed met our inclusion criteria. Gynaecologists interpreted 69 (34%) pelvic ultrasounds, and radiologists reported on 132 (66%). Reported adnexal mass types were not significantly different between the two groups. As compared with gynaecologists, radiologists were more likely to recommend MRI or CT scans (OR 11.76; 95% CI 1.17-117.78), as well as follow-up ultrasound studies (OR 4.67; 95% CI 1.66-13.1), and they were less likely to recommend no further imaging (OR 0.18; 95% CI 0.07-0.45). Groups did not differ in recommendation patterns for referral to a specialist.

CONCLUSION

There are significant differences in recommendation patterns between gynaecologists and radiologists in evaluating new adnexal masses on ultrasound. This difference can have important effects on resource use and patients' concerns.

Imaging the ovary

During each reproductive cycle, the ovary exhibits tissue remodelling and cyclic vasculature changes associated with hormonally regulated folliculogenesis, follicle rupture, luteal formation and regression. However, the relationships among different types of follicles and corpora lutea are unclear, and the role of ovarian vasculature in folliculogenesis and luteal dynamics has not been extensively investigated. Understanding of ovarian physiology and pathophysiology relies upon elucidation of ovarian morphology and architecture. This paper summarizes the literature on traditional approaches to the imaging of ovarian structures and discusses recent advances in ovarian imaging. Traditional in-vivo ultrasound, together with histological and electron microscopic approaches provide detailed views of the ovary at organ, tissue and molecular levels. However, in-vivo imaging is limited to antral and larger follicles whereas histological imaging is mainly two-dimensional in nature. Also discussed are emerging approaches in the use of near-infrared fluorophores to image follicles in live animals to detect preantral follicles as well as visualizing ovarian structures using CLARITY in fixed whole ovaries to elucidate three-dimensional interrelationships among follicles, corpora lutea and ovarian vasculature. Advances in ovarian imaging techniques provide new understanding of ovarian physiology and allow for the development of better tools to diagnose ovarian pathophysiology.

Counting ovarian antral follicles by ultrasound: a practical guide

This Consensus Opinion summarizes the main aspects of several techniques for performing ovarian antral follicle count (AFC), proposes a standardized report and provides recommendations for future research. AFC should be performed using a transvaginal ultrasound (US) probe with frequency ≥ 7 MHz. For training, we suggest a minimum of 20-40 supervised examinations. The operator should be able to adjust the machine settings in order to achieve the best contrast between follicular fluid and ovarian stroma. AFC may be evaluated using real-time two-dimensional (2D) US, stored 2D-US cine-loops and stored three-dimensional (3D) US datasets. Real-time 2D-US has the advantage of permitting additional maneuvers to determine whether an anechoic structure is a follicle, but may require a longer scanning time, particularly when there is a large number of follicles, resulting in more discomfort to the patient. 2D-US cine-loops have the advantages of reduced scanning time and the possibility for other observers to perform the count. The 3D-US technique requires US machines with 3D capability and the operators to receive additional training for acquisition/analysis, but has the same advantages as cine-loop and also allows application of different imaging techniques, such as volume contrast imaging, inversion mode and semi-automated techniques such as sonography-based automated volume calculation. In this Consensus Opinion, we make certain recommendations based on the available evidence. However, there is no strong evidence that any one method is better than another; the operator should choose the best method for counting ovarian follicles based on availability of resources and on their own preference and skill. More studies evaluating how to improve the reliability of AFC should be encouraged. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

True Reproducibility of UltraSound Techniques (TRUST): systematic review of reliability studies in obstetrics and gynecology

OBJECTIVES

To examine the quality of methods used and the accuracy of the interpretation of agreement in existing studies that examine the reliability of ultrasound measurements and judgments in obstetrics and gynecology.

METHODS

A systematic search of MEDLINE was performed on 25 March 2014, looking for studies that examined the reliability of ultrasound measurements and judgments in obstetrics and gynecology with evaluation of concordance (CCC) or intraclass (ICC) correlation coefficients or kappa as a main objective.

RESULTS

Seven hundred and thirty-three records were examined on the basis of their title and abstract, of which 141 full-text articles were examined completely for eligibility. We excluded 29 studies because they did not report CCC/ICC/kappa, leaving 112 studies that were included in our analysis. Two studies reported both ICC and kappa and were counted twice, therefore, the number used as the denominator in the analyses was 114. Only 16/114 (14.0%) studies were considered to be well designed (independent acquisition and blinded analysis) and to have interpreted the results properly. Most errors occurring in the studies are likely to overestimate the reliability of the method examined.

CONCLUSIONS

The vast majority of published studies examined had important flaws in design, interpretation and/or reporting. Such limitations are important to identify as they might create false confidence in the existing measurements and judgments, jeopardizing clinical practice and future research. Specific guidelines aimed at improving the quality of reproducibility studies that examine ultrasound methods should be encouraged.

Technical and performance characteristics of anti-Müllerian hormone and antral follicle count as biomarkers of ovarian response

BACKGROUND

Stratified (individualized) medicine has been recognized as a key priority for policy makers and healthcare providers. The main principle of individualized care depends on utilizing patients' characteristics and biomarkers to predict prognosis, tailor intended treatment and predict treatment outcomes. In reproductive medicine a wide variety of biomarkers have been proposed as predictors of ovarian response; of these, anti-Müllerian hormone (AMH) and antral follicle count (AFC) are purported as exhibiting the most favourable analytical and performance characteristics. Previously AFC and AMH have been considered essentially interchangeable; however, recent trial data have questioned this postulation. The aim of this review is to present an analysis of the strengths and weaknesses of these biomarkers as predictors of ovarian response, using both physiological and technical perspectives.

METHODS

We have conducted a systematic search of the most recent (to May 2014) relevant literature and summarized the existing evidence. Articles written in a language other than English without an available English translation were excluded.

RESULTS

Both AMH values and AFC can be influenced by comparable technical, physiological and exogenous factors. AMH displays some variation within and between cycles, consistent with its physiological role in follicle development, and there are growing data on the impact of pharmacological treatments and pathological conditions but cycle-independent measurement is appropriate for clinical purposes. A range of issues with manual AMH assays may be resolving with the development of fully automated assays. Despite described standardization of its measurement technique, AFC is subject to marked inter- and intra-operator variability and the effects of external influences are likely to be comparable. Outwith some highly specialist centres, the intracyclic variation in AFC requires its measurement between Day 2 and 4 of the cycle. Observational studies suggest comparable performance characteristics for AMH and AFC in predicting poor and high ovarian response, but recent RCTs suggest markedly better performance for AMH.

CONCLUSIONS

The performance characteristics of both AMH and AFC for the prediction of ovarian response to exogenous gonadotrophins have been inflated by single site observational cohorts, resulting in the viewpoint that AMH and AFC exhibit equivalent performance characteristics. Large scale multicentre RCTs, with centralized assay performance, have demonstrated that AMH is substantially the more accurate and robust biomarker, probably reflecting difficulties with standardization of AFC determination. While AFC retains some advantages, particularly immediacy and accessibility, international standardization of AMH combined with a stable automated assay is likely to enhance its performance as the biomarker of choice in predicting the ovarian response in assisted conception.

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.

Assessment of ovarian stromal blood flow after metformin treatment in women with polycystic ovary syndrome

PURPOSE

To authenticate the effect of metformin treatment on ovarian stromal blood flow in women with polycystic ovary syndrome (PCOS) using 3-dimensional (3D) power Doppler.

METHODS

The current case-control study was conducted at Ain Shams University Maternity Hospital. A total of 60 women diagnosed to have PCOS were included as group 1. Another 40 fertile women who were recruited from outpatient clinic for contraception without PCOS with regular menstrual cycles were included as control group (group 2). All women underwent 3D power Doppler evaluations of ovarian stroma. Anthropometric, hormonal and biochemical criteria were also measured. All women in group 1 received metformin hydrochloride 500 mg tablets, which were started in a step-up maneuver every 5 days, from one to three tablets per day. The same parameters were also measured after the 3 months duration of treatment.

RESULTS

A total of 100 women were finally analyzed. At the start of the study, there were no statistically significant differences between group 1 and group 2 and regarding age and body mass index, but the waist/hip ratio and Ferriman-Gallwey scoring were statistically different between the 2 groups. The mean ovarian volume and stromal volume were significantly larger in group 1. 3D power Doppler indices [the vascularization index (VI), the flow index (FI) and the (VFI) vascularization-flow index] were much higher in group 1 than in group 2 (1.38 ± 0.76 vs. 4.69 ± 1.37, P < 0.05, 26.59 ± 2.26 vs. 32.66 ± 4.37, P < 0.05, and 0.76 ± 0.39 vs. 1.54 ± 0.69, P < 0.05, respectively). After 3 months of using metformin in normal weight PCO women, there was a statistically significant improvement in group 1 regarding, hirsutism, most of hormonal measurements. Also 3 months metformin treatment significantly reduce VI, FI and VFI (4.69 ± 1.37 vs. 2.95 ± 1.52, P < 0.05, 32.66 ± 4.37 vs. 29.48 ± 4.98, P < 0.05 and 1.54 ± 0.69 vs. 1.21 ± 0.7 P < 0.05, respectively). Using Receiver operator characteristic, there was no cut-off value of VI, FI or VFI to detect ovulation in women of PCOS.

CONCLUSIONS

Metformin seems to have a beneficial effect in normal weight PCO women via correcting ovarian stromal blood flow and hormonal profiles.

Testing and interpreting measures of ovarian reserve: a committee opinion

Currently, there is no uniformly accepted definition of decreased ovarian reserve (DOR), as the term may refer to three related but distinctly different outcomes: oocyte quality, oocyte quantity, or reproductive potential. Available evidence concerning the performance of ovarian reserve tests is limited by small sample sizes, heterogeneity among study design, analyses and outcomes, and the lack of validated outcome measures.

Ovarian stromal vessels assessed by spatiotemporal image correlation-high definition flow in women with polycystic ovary syndrome: a case-control study

OBJECTIVE

To compare spatiotemporal image correlation-high definition flow (STIC-HDF) indices from spherical samples of ovary between women with polycystic ovary syndrome (PCOS) and normal women.

METHODS

This was a prospective case-control study of premenopausal women with a diagnosis of PCOS according to the Rotterdam criteria and of healthy, regularly menstruating, premenopausal women (controls) matched for age (< 35 years) and body mass index. Women were assessed in the follicular phase of the menstrual cycle by 4D STIC-HDF transvaginal ultrasound. Based on 1-cm(3) spherical sampling, we calculated for each woman the vascularization index (VI) for the most vascularized part of the ovarian stroma in all three-dimensional volumes of the 4D STIC-HDF sequence. The maximum (VI(sys)) and minimum (VI(diast)) values were assumed to represent systole and diastole, respectively, and the mean VI for all frames from one cardiac cycle was calculated. Based on these three VI values, we calculated the following indices: volumetric systolic/diastolic ratio (vS/D), volumetric resistance index (vRI) and volumetric pulsatility index (vPI), and compared them between study and control groups.

RESULTS

The study included 32 PCOS women (mean age, 29.6 years) and 32 controls (mean age, 30.4 years). Mean VI(sys) (26.246% vs 8.136%, P < 0.0001) and mean VI(diast) (22.242% vs 5.997%, P < 0.0001) were significantly higher in PCOS women compared with controls. Median vS/D (1.15 vs 1.33, P < 0.001), mean vRI (0.17 vs 0.30, P < 0.001) and median vPI (0.14 vs 0.28, P < 0.001) were significantly lower in PCOS women compared with controls.

CONCLUSION

4D STIC-HDF indices from 1-cm(3) spherical samples of the ovaries were different between PCOS women and controls, suggesting lower impedance to flow in ovarian stromal vessels in PCOS women.

A nationwide study on reproductive function, ovarian reserve, and risk of premature menopause in female survivors of childhood cancer: design and methodological challenges

BACKGROUND

Advances in childhood cancer treatment over the past decades have significantly improved survival, resulting in a rapidly growing group of survivors. However, both chemo- and radiotherapy may adversely affect reproductive function. This paper describes the design and encountered methodological challenges of a nationwide study in the Netherlands investigating the effects of treatment on reproductive function, ovarian reserve, premature menopause and pregnancy outcomes in female childhood cancer survivors (CCS), the DCOG LATER-VEVO study.

METHODS

The study is a retrospective cohort study consisting of two parts: a questionnaire assessing medical, menstrual, and obstetric history, and a clinical assessment evaluating ovarian and uterine function by hormonal analyses and transvaginal ultrasound measurements. The eligible study population consists of adult female 5-year survivors of childhood cancer treated in the Netherlands, whereas the control group consists of age-matched sisters of the participating CCS. To date, study invitations have been sent to 1611 CCS and 429 sister controls, of which 1215 (75%) and 333 (78%) have responded so far. Of these responders, the majority consented to participate in both parts of the study (53% vs. 65% for CCS and sister controls respectively). Several challenges were encountered involving the study population: dealing with bias due to the differences in characteristics of several types of (non-) participants and finding an adequately sized and well-matched control group. Moreover, the challenges related to the data collection process included: differences in response rates between web-based and paper-based questionnaires, validity of self-reported outcomes, interpretation of clinical measurements of women using hormonal contraceptives, and inter- and intra-observer variation of the ultrasound measurements.

DISCUSSION

The DCOG LATER-VEVO study will provide valuable information about the reproductive potential of paediatric cancer patients as well as long-term survivors of childhood cancer. Other investigators planning to conduct large cohort studies on late effects may encounter similar challenges as those encountered during this study. The solutions to these challenges described in this paper may be useful to these investigators.

TRIAL REGISTRATION

NTR2922; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2922

Two- and three-dimensional sonographic and color Doppler techniques for diagnosis of polycystic ovary syndrome. The stromal/ovarian volume ratio as a new diagnostic criterion

OBJECTIVES

The purpose of this work was to study the role of 2-dimensional (2D) and 3-dimensional (3D) sonographic and Doppler techniques in the diagnosis of polycystic ovary syndrome.

METHODS

A total of 112 young adult lean women with polycystic ovary syndrome and 52 healthy volunteers with regular ovulatory cycles, matched for age and body mass index, underwent a detailed history, medical examination, hormonal assay, and 2D and 3D sonographic and Doppler flow ovarian evaluation during the early follicular phase.

RESULTS

The Ferriman-Gallwey score, circulating androgen levels, ovarian volume, and mean number of small subcapsular follicles on 2D and 3D sonography were significantly higher in the patients with polycystic ovary syndrome than the controls (P < .001). A stromal score of 1 or 2 was found in all of the patients but none of the controls. The ovarian stromal/total area ratio was 0.32 or higher in 104 of 112 of the patients (93%), which was significantly higher than in the controls (P < .001). On Doppler analysis, the lowest ovarian stromal resistance levels were found in the patients. On 3D sonography, the total ovarian stromal volume, ovarian stroma/total ovarian volume ratio, and stromal mean grayness were significantly higher in the patients than the controls. With 3D power Doppler imaging, ovarian vascularization measurements were significantly lower in the controls than the patients. The ovarian stroma/total ovarian volume ratio was the most accurate predictor of both hyperandrogenemia (area under the curve, 0.915; P < .0001) and hirsutism (area under the curve, 0.891; P < .0001).

CONCLUSIONS

Our data strongly support the use of 3D sonography with analysis of stromal volume and vascularization in the diagnosis of polycystic ovary syndrome.

Three-dimensional ultrasound as a predictor of pregnancy in patients undergoing ART

Different ultrasound parameters have been used to assess endometrial receptivity during ART treatment, including endometrial thickness, endometrial pattern, endometrial volume, Doppler of uterine arteries and endometrial blood flow. However, conflicting results have been reported with regard to their role in the prediction of pregnancy in ART treatment. The 3D ultrasound with power Doppler provides a unique tool with which to examine the blood supply of the whole endometrium and subendometrial region. Volume assessment can also be precisely performed by 3D ultrasound. Based on a med-line research and on our experience, the clinical use of 3D ultrasound is discussed in this review article.

Periovulatory follicular volume and vascularization determined by 3D and power Doppler sonography as pregnancy predictors in intrauterine insemination cycles

PURPOSE

To evaluate the relationship between volume and vascularization of the periovulatory follicle and subfollicular area measured by three-dimensional power Doppler ultrasound (US), and ovulation and pregnancy in patients undergoing intrauterine insemination (IUI).

METHODS

We studied 79 consecutive cycles of IUI on hCG administration day. We measured the periovulatory follicle and subfollicular area by means of three-dimensional power Doppler US. The stored volumes were processed with the VOCAL image processing software to calculate the volume of the follicle and the following vascular indices: vascularization index (VI), flow index (FI), and vascularization flow index (VFI).

RESULTS

The follicular volume was higher in anovulatory cycles (7.7 ± 3.7 cubic centimeters (CC) versus 4.1 ± 2.0 CC; p < 0.001). There was no difference between the follicular volumes in cycles with or without subsequent pregnancy. The vascular indices of the follicle did not differ significantly between ovulatory and anovulatory cycles, and between cycles that did and did not achieve pregnancy. Periovulatory subfollicular VI and VFI were lower in women who became pregnant (VI: 2.9 ± 2.3% versus 5.6 ± 4.6%; p < 0.05, and VFI: 1.1 ± 0.8 versus 2.2 ± 2.2; p < 0.01).

CONCLUSIONS

High values of follicular volume were associated with anovulatory cycles. Subfollicular VI and VFI might be used as markers of follicular quality and pregnancy predictors.

The interovarian variation in three-dimensional ultrasound markers of ovarian reserve in women undergoing baseline investigation for subfertility

OBJECTIVE

To evaluate differences in the three-dimensional (3D) ultrasound markers of ovarian reserve between the ovaries within an individual undergoing investigation for subfertility.

DESIGN

Prospective observational study.

SETTING

University-based assisted conception unit.

PATIENT(S)

Two hundred seventy women undergoing baseline early follicular phase ultrasound as an investigation for subfertility.

INTERVENTION(S)

Three-dimensional ultrasound scan in early follicular phase between days 2 and 5 of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Variations in 3D ultrasound markers of ovarian reserve between the two ovaries within same individual.

RESULT(S)

Two hundred fifteen subjects were analyzed for ovarian volume and antral follicle count, and 205 subjects for 3D power Doppler indices. Significant differences were noted (median, range) in the number of antral follicles measuring >6.0 mm and ovarian volume. Significant correlation was noted between the two ovaries in antral follicles measuring 6.0 mm or less, ovarian volume, and 3D power Doppler indices. On stratifying the antral follicles according to size using sonography-based automated volume calculation with postprocessing, maximum variation was seen in follicles measuring more than 6.0 mm as measured using limits of agreement.

CONCLUSION(S)

There are significant differences in the antral follicles measuring >6.0 mm and ovarian volume, as measured using 3D ultrasound, that require consideration when comparing the two ovaries within an individual.

Ultrasound tests of ovarian reserve; a systematic review of accuracy in predicting fertility outcomes

We conducted a systematic review of studies evaluating the diagnostic accuracy of all the ultrasound based tests of ovarian reserve, including antral follicle count (AFC), ovarian volume and stromal blood flow in predicting fertility outcomes and, where appropriate, performed a meta-analysis to determine the predictive_value at each cut-off value described in the literature. Included in the analysis were 17 studies for AFC, six studies for ovarian volume and six studies for stromal blood flow. Meta-analyses showed that women with AFC less than four were 8.7 times more likely not to get pregnant after IVF (two studies; 95% CI, 2.4-31.7) than women with AFC four or more. The sensitivity and specificity of AFC to predict cycle cancellation was 66.7% and 94.7%, respectively. Women with an AFC of less than four were 37 times (two studies; 95% CI, 13.68-100.45) more likely to have their cycle cancelled than women with AFC of four o r more. Ovarian volume measurement, at a cut off value of 3 cm3, showed specificity for prediction of cycle cancellation and non-pregnancy of 92% (three studies, 95% CI, 89-94) and 93% (three studies, 95% CI, 87-97), respectively. The clinical value of Doppler studies for ovarian stromal blood flow was unclear.

Comparison of 3- and 2-dimensional sonographic techniques for counting ovarian follicles

OBJECTIVE

The purpose of this study was to compare 3-dimensional (3D) and 2-dimensional (2D) ovarian follicle counts and 3D counts using stored volumes between experienced and inexperienced operators.

METHODS

Follicles larger than 5 mm were counted on 1 randomly selected ovary. Two-dimensional follicle counts were compared with stored 3D volumes by the same experienced operator (registered diagnostic medical sonographer [RDMS]). Counts using 3D stored data were compared between the experienced operator and inexperienced operator (principal investigator [PI]). The mean difference in follicle counts was computed, and a 1-sample Student t test was performed to test the hypothesis that the mean of the differences was 0. Comparison of the 2 methods and observers by Bland-Altman plots was used to determine any systematic differences based on the total number of follicles per selected ovary.

RESULTS

Mean differences differed from 0 (P < .005) for all 3 comparisons: 2D RDMS versus 3D RDMS, 2D RDMS versus 3D PI, and 3D RDMS versus 3D PI. For the comparison of 2D versus 3D counts done by the RDMS, 5 ovaries (10%) had a difference of more than 5 follicles counted; for the 2D RDMS versus 3D PI, 11 ovaries (22%) had a difference of more than 5 follicles; for the 3D RDMS versus 3D PI, 8 ovaries (16%) had a difference of more than 5 follicles. Mean differences in counts ranged 0.29 to 1.04 for ovaries with 10 or fewer follicles compared with 3.94 to 9.00 for ovaries with more than 10 follicles.

CONCLUSIONS

Follicle counts using 3D volumes were similar to 2D counts, and 3D follicle counts done by an inexperienced operator were similar to counts done by an experienced sonographer.

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.

Testing ovarian reserve to predict age at menopause

In modern society with women delaying pregnancy, predicting the age of the natural menopause with its preceding infertility will allow making informed choices about when to try starting to have children. Also if premature menopause could be predicted in young women, strategies could be instigated to reduce the long term health risks of early estrogen deficiency. This review examines the physiology of ovarian ageing, with the menopause being the final outcome. Long and short term predictive markers of the age of the menopause and the preceding natural infertility are evaluated. Many subtle changes in the endocrine regulation of ovarian function with advancing age may seem interesting but currently are not clinically useful as a predictive test. Examples are changes in concentrations of estradiol, progesterone, luteinizing hormone (LH) and activin, as well as follicle dynamics. Other features hold more promise. Among these are chronological age, family history, anti-Müllerian hormone (AMH), poor response to in vitro fertilization (IVF), basal follicle-stimulating hormone (FSH) and the antral follicle count for long term prediction. For short term prediction, cycle shortening and occurrence of vasomotor symptoms may prove useful. To date, none of these markers has been found to have sufficient predictive accuracy in individual women. Results of new and ongoing longitudinal studies may provide better predictive models. In particular, use of genetic profiles may add to the accuracy of currently known markers.

The antral follicle count: practical recommendations for better standardization

OBJECTIVE

To provide recommendations for the standardized use of the Antral follicle count (AFC) which is used to predict ovarian response to gonadotrophin stimulation during assisted reproductive technology treatment. However, the nature of the follicles that are visualized by ultrasound and the competence of the oocytes held within are largely unknown. In addition, there is considerable variability in the clinical definitions and technical methods used to count and measure antral follicles in both published studies and clinical practice.

DESIGN AND SETTING

In December 2007, specialist reproductive medicine clinicians and scientists attended a workshop in an effort to address these issues. Literature concerning the physiology and measurement of ovarian antral follicles was reviewed, clinical and technical considerations regarding antral follicle measurement were discussed, and an operational definition of AFC was developed.

PATIENT(S)

None.

INTERVENTION(S)

None.

OUTCOME MEASURES

Simple recommendations were established for the standardization of AFC assessment in routine clinical practice. The basic clinical and technical requirements required for AFC evaluation were agreed upon, and a systematic method of measuring and counting antral follicles in routine practice was proposed.

CONCLUSION(S)

The use of a standardized approach according to the practical recommendations for antral follicle counting as presented is encouraged in future clinical trials and routine practice. The authors also advocate a systematic evaluation of these recommendations as standardized study data become available.

Assessment of ultrasonographic features of polycystic ovaries is associated with modest levels of inter-observer agreement

Background

There is growing acceptance that polycystic ovaries are an important marker of polycystic ovary syndrome (PCOS) despite significant variability when making the ultrasound diagnosis. To better understand the nature of this variability, we proposed to evaluate the level of inter-observer agreement when identifying and quantifying individual ultrasonographic features of polycystic ovaries.

Methods

Digital recordings of transvaginal ultrasound scans performed in thirty women with PCOS were assessed by four observers with training in Radiology or Reproductive Endocrinology. Observers evaluated the scans for: 1) number of follicles ≥ 2 mm per ovary, 2) largest follicle diameter, 3) ovarian volume, 4) follicle distribution pattern and 5) presence of a corpus luteum (CL). Lin's concordance correlation coefficients and kappa statistics for multiple raters were used to assess inter-observer agreement.

Results

Agreement between observers ranged from 0.08 to 0.63 for follicle counts, 0.27 to 0.88 for largest follicle diameter, 0.63 to 0.86 for ovarian volume, 0.51 to 0.76 for follicle distribution pattern and 0.76 to 0.90 for presence of a CL. Overall, reproductive endocrinologists demonstrated better agreement when evaluating ultrasonographic features of polycystic ovaries compared to radiologists (0.71 versus 0.53; p = 0.04).

Conclusion

Inter-observer agreement for assessing ultrasonographic features of polycystic ovaries was moderate to poor. These findings support the need for standardized training modules to characterize polycystic ovarian morphology on ultrasonography.

Individual ovarian volumes obtained from 2-dimensional and 3-dimensional ultrasound lack precision

Measuring ovarian volume has been suggested as a possible screening test to assess a woman's ovarian reserve. For such a screening tool to be clinically useful, knowledge of its precision and reproducibility is essential. Recent advances in ultrasound scanning techniques allow the measurement of volumes in three dimensions rather than the traditional estimation from two dimensions. Transvaginal 2-dimensional (2D) and 3-dimensional (3D) ultrasound examinations were performed on 49 women attending a tertiary centre for investigation or treatment for subfertility between January and May 2006. Two observers calculated ovarian volume using both 2D (prolate ellipsoid formula) and 3D techniques [virtual organ computer-aided analysis (VOCAL)] with rotation steps of 30 degrees (3D-30). For the four comparisons (inter- and intra-observer; 2D and 3D-30) intraclass coefficients of 0.97 to 0.98, and standard errors ranging from 17% to 14% (for inter-observer 2D and intra-observer 3D, respectively) were obtained. The corresponding coefficients of repeatability ranged from 33% to 28%. These results suggest that measurement of transvaginal ovarian volumes using both 2D and 3D ultrasound is imprecise for individuals. The imprecision is greater for lower ovarian volumes, which may be important in clinical practice. The average of two or more measurements is likely to be more accurate than a single measurement.

[The role of ultrasound examination to evaluate ovarian reserve of infertile patients]

The accurate assessment of ovarian reserve is an essential step before the treatment of infertile couples. Ovarian reserve could either be evaluated through clinical or biological parameters, but ultrasound plays a remarkable role, since it permits the direct visualization and count of ovarian antral follicles. Nevertheless, the available literature data are conflicting about the real sensibility and specificity of this method to predict the exact number of retrieved oocytes or the occurrence of pregnancy after a procedure for medical assisted reproduction. New technologies have been developed, as the 3D-ultrasound, who does not ameliorate ultrasound accuracy, but permits the reduction of the time necessary for patient's examination and virtually eliminates inter- and intra-observer bias. The place of the ovarian artery flow evaluation by Doppler remains unclear and need more studies.

Intraobserver and interobserver reliability of automated antral follicle counts made using three-dimensional ultrasound and SonoAVC

OBJECTIVE

To assess the reliability of automated measurements of the total antral follicle count (AFC) made using Sono-Automatic Volume Count (SonoAVC), and to compare these to two-dimensional (2D) and manual three-dimensional (3D) techniques.

METHODS

Fifty-five subjects aged under 40 years who had 3D transvaginal ultrasound examination in the early follicular phase of their menstrual cycle were prospectively recruited. 3D datasets were acquired and subsequently analyzed. The total AFC (2-10 mm antral follicles) was calculated by two observers using three independent methods: 2D real-time equivalent (2D-RTE), 3D manual multiplanar view (3D-MPV), and SonoAVC. For measurements made using SonoAVC, the initial automated count (sAVC-AA) was recorded and postprocessing (sAVC-PP) then applied to identify follicles that had been missed or incorrectly included. Intraclass correlation and limits of agreement were used to evaluate the methods.

RESULTS

The intra- and interobserver reliability of measurements of total AFC was best with SonoAVC with postprocessing followed by 3D-MPV and 2D-RTE. The initial count calculated by sAVC-AA missed follicles and this was reflected in the significantly lower mean total AFC (6.51 +/- 4.79) than that made after postprocessing techniques (sAVC-PP, 18.42 +/- 10.53, P < 0.001; 3D-MPV, 19.38 +/- 10.85, P < 0.001; and 2D-RTE, 19.26 +/- 10.55, P < 0.001). The mean total AFC became more comparable with postprocessing (sAVC-PP) but still remained significantly lower than counts made with 2D-RTE and 3D-MPV (P < 0.05).

CONCLUSION

SonoAVC with postprocessing is a reliable method for measuring total AFC. It takes longer to perform, because of the need for postprocessing, and obtains values that are lower than those obtained by the 2D and 3D-MPV techniques. However, the AFC obtained by sAVC-PP is likely to be lower because this method measures and color codes each follicle preventing recounting.

Intervillous and uteroplacental circulation in normal early pregnancy and early pregnancy loss assessed by 3-dimensional power Doppler angiography

OBJECTIVE

To assess intervillous and uteroplacental circulation in early normal pregnancies and miscarriages.

STUDY DESIGN

One hundred normal pregnancies and 46 delayed miscarriages were evaluated by 3-dimensional vaginal ultrasound and power Doppler angiography. Volumes of the early placenta and the subplacental area were obtained between 5 and 12.6 weeks' gestation. The placental volume, vascularization index, flow index, and vascularization flow index was calculated.

RESULTS

Intraclass correlation coefficients ranged from 0.961 for placental volume to 0.885 for intervillous flow index. Intervillous power Doppler signals were not detected before the sixth week. Placental volume (R(2) = 0.68), intervillous vascularization index (R(2) = 0.30), flow index (R(2) = 0.33) and vascularization flow index (R(2) = 0.35), uteroplacental flow index (R(2) = 0.34), and vascularization flow index (R(2) = 0.17) increase significantly (P < .001) throughout the first trimester of normal pregnancies. Uteroplacental vascularization index was not significantly related to gestational age. Intervillous vasculariztion index, flow index, and vascularization flow index were significantly raised in miscarriages, but there were no significant differences for uteroplacental vascularization index, flow index, or vascularization flow index.

CONCLUSION

Intervillous and uteroplacental blood flow increases throughout the first trimester of normal pregnancies. Intervillous circulation is abnormally increased when a miscarriage is diagnosed.

The reproducibility of the virtual organ computer-aided analysis program for evaluating 3-dimensional power Doppler ultrasonography of diffuse thyroid disorders

AIM

The aim of this study was to evaluate the intra- observer and inter-observer reproducibility of 3-dimensional (3D) power Doppler ultrasonography with the virtual organ computer-aided analysis (VOCAL) program for measuring thyroid volume and vascular indices in patients with diffuse thyroid disorders.

MATERIALS AND METHODS

Patients with diffuse goiters were examined by 3D ultrasonography from August 2005 to July 2006. The parameters for vascular assessment included the vascularization index (VI), flow index (FI), vascularization-flow index (VFI), and thyroid size, and were obtained using the VOCAL program. This program used plane A and a 30 degrees rotational step. Intra-observer and inter-observer repeatability are presented as intra-class correlation coefficient (intra-CC) and inter-class correlation coefficient (inter-CC), with values >0.70 being acceptable.

RESULTS

Sixty-three patients in total were enrolled for this study, including 19 patients with simple goiter and 44 patients with autoimmune thyroid disease (AITD) (23 Graves' disease, 21 Hashimoto's thyroiditis). Thyroid volume and 3 vascular indices showed excellent reproducibility in the AITD group (intra- CC>0.9373 and inter-CC>0.8763) and its subgroups. The VI had excellent consistent reproducibility in the simple goiter group (intra-CC>0.8987 and inter-CC>0.8881), but the other parameters did not.

CONCLUSIONS

Based on this study, 3D power Doppler ultrasonography with the VOCAL program is a reliable tool for evaluating diffuse thyroid disorders due to an autoimmune process. The VI is the most reliable parameter.

Prospective cohort study of three- versus two-dimensional ultrasound for prediction of oocyte maturity

OBJECTIVE

To determine whether three-dimensional follicular ultrasound (3-D) measurements are better predictors of optimal timing of hCG administration than two-dimensional (2-D) images, the current standard.

DESIGN

Prospective, cohort study.

SETTING

Tertiary referral center.

PATIENT(S)

Seventy-six patients undergoing IVF.

INTERVENTION(S)

Seventy-six consecutive patients undergoing serial follicular monitoring during IVF had an additional daily 3-D volume scan of their ovaries once lead follicles had reached 16 mm diameter.

MAIN OUTCOME MEASURE(S)

Number of mature oocytes retrieved.

RESULT(S)

The 2-D follicular diameter measurements predicted 25.4% of the observed variance in the number of mature oocytes retrieved. The 3-D follicular volume measurements were more predictive of outcome, accounting for 29.2% of the observed variance in number of mature oocytes retrieved. Follicles >22 mm diameter and 5 mL volume were associated with fewer mature oocytes reflecting an undesired postmature state. Follicles measuring 11 to 15 mm had a 50% chance of yielding a mature oocyte.

CONCLUSION(S)

Three-dimensional follicular volume measurements have a stronger correlation with the number of mature oocytes retrieved than 2-D measurements. As 3-D technology improves, this parameter may replace 2-D measurements in the optimal timing of hCG before oocyte retrieval.

Importância da ecogenicidade da tireóide no diagnóstico da tireoidite crônica auto-imune

A tireoidite crônica auto-imune é, atualmente, a principal causa de hipotireoidismo e seu diagnóstico baseia-se nas manifestações clínico-laboratoriais. O marcador laboratorial mais importante é a presença de anticorpos antitireoglobulina e antiperoxidase, sendo este último o teste mais sensível. A biópsia aspirativa apresenta alta sensibilidade e especificidade, porém, é um método invasivo e, por isso, reservado para quando há presença de nódulo ou bócio de crescimento rápido. A cintilografia é desnecessária para o diagnóstico, já que apresenta baixa sensibilidade e especificidade. A ultra-sonografia, tanto ao modo B como ao dúplex-Doppler colorido, evoluiu de forma muito rápida e tornou-se um método simples, não-invasivo, reprodutível e com alta sensibilidade para o diagnóstico da tireoidite crônica auto-imune. Ao modo B, a ecogenicidade é um parâmetro de extrema importância, já que, além de apresentar alta correlação com o quadro citopatológico, também apresenta alta sensibilidade para o diagnóstico da tireoidite crônica auto-imune. Embora este parâmetro não seja específico da tireoidite crônica auto-imune, pois também pode estar presente na doença de Graves, na tireoidite pós-parto e na tireoidite subaguda, tais desordens podem ser facilmente diferenciadas tanto pelo quadro clínico-laboratorial quanto pelo dúplex-Doppler colorido. Assim, este artigo tem o objetivo de revisar a importância do estudo da ecogenicidade no diagnóstico da tireoidite crônica auto-imune.

Assessment of ovarian vascularization in the polycystic ovary by three-dimensional power Doppler ultrasonography

OBJECTIVE

To assess whether there are differences in ovarian echogenicity and vascularization as assessed by three-dimensional power Doppler angiography (3D-PDA) between women with polycystic ovaries (PCO) and women with normal ovaries (NO).

METHODS

Eighty-three women were classified into two groups according to the 2003 Rotterdam consensus criteria. The NO group comprised women (n = 45) with regular menstrual cycles and proven fertility, whereas the PCO group comprised women (n = 38) with oligo-anovulation, clinical and/or biochemical features of hyperandrogenism, and polycystic ovary morphology at two-dimensional ultrasound. All women were evaluated by means of 3D-PDA. The parameters studied in both groups were follicle number per ovary (FNPO), ovarian volume (OV), mean gray value (MG) and three vascular indices: vascularization index (VI), flow index (FI) and vascularization flow index (VFI).

RESULTS

The PCO group showed a higher mean OV as well as FNPO. No differences in MG, VI, FI and VFI were found between the groups.

CONCLUSIONS

3D-PDA indices are not useful for discriminating between normal and polycystic ovaries.

3D Ultrasound in Gynecology and Reproductive Medicine

With advances occurring in medicine on a daily basis, it was only a matter of time before essential gynecological investigations, such as ultrasound, were modified. Many clinicians remain unconvinced by its reputed advantages and 3D ultrasound is not without disadvantages. These mainly relate to the cost implications and training requirements. 3D ultrasound imaging is still at a relatively early stage in terms of its role as a day-to-day imaging modality in gynecology and reproductive medicine. 3D imaging has several obvious benefits that relate to an improved spatial orientation and the demonstration of multiplanar views, of which the coronal plane is particularly useful. It offers a more objective and reproducible measurement of volume and vascularity of the region of interest, and an improved assessment of normal and pathological pelvic organs through further postprocessing modalities, including tomographic ultrasound imaging and various rendering modalities. It also has the benefit of offering reduced scanning time, the option of teleconsultation and storage of images for re-evaluation. However, other than its application in the assessment and differentiation of uterine anomalies, there is very little evidence demonstrating that 3D ultrasound results in a clinically relevant benefit or negates the need for further investigation. Future work should ensure that 3D ultrasound is compared with conventional imaging in randomized trials where the observer is blind to the outcome, only after which will we truly be able to evaluate its role in an evidence-based manner.

Improving inter-observer variability in the evaluation of ultrasonographic features of polycystic ovaries

BACKGROUND

We recently reported poor inter-observer agreement in identifying and quantifying individual ultrasonographic features of polycystic ovaries. Our objective was to determine the effect of a training workshop on reducing inter-observer variation in the ultrasonographic evaluation of polycystic ovaries.

METHODS

Transvaginal ultrasound recordings from thirty women with polycystic ovary syndrome (PCOS) were evaluated by three radiologists and three reproductive endocrinologists both before and after an ultrasound workshop. The following endpoints were assessed: 1) follicle number per ovary (FNPO), 2) follicle number per single cross-section (FNPS), 3) largest follicle diameter, 4) ovarian volume, 5) follicle distribution pattern and 6) presence of a corpus luteum (CL). Lin's concordance correlation coefficients (rho) and kappa statistics for multiple raters (kappa) were used to assess level of inter-observer agreement (>0.80 good, 0.60 - 0.80 moderate/fair, <0.60 poor).

RESULTS

Following the workshop, inter-observer agreement improved for the evaluation of FNPS (rho = 0.70, delta rho = +0.11), largest follicle diameter (rho = 0.77, delta rho = +0.10), ovarian volume (rho = 0.84, delta rho = +0.12), follicle distribution pattern (kappa = 0.80, delta kappa = +0.21) and presence of a CL (kappa = 0.87, delta kappa = +0.05). No improvement was evident for FNPO (rho = 0.54, delta rho = -0.01). Both radiologists and reproductive endocrinologists demonstrated improvement in scores (p < 0.001).

CONCLUSION

Reliability in evaluating ultrasonographic features of polycystic ovaries can be significantly improved following participation in a training workshop. If ultrasonographic evidence of polycystic ovaries is to be used as an objective measure in the diagnosis of PCOS, then standardized training modules should be implemented to unify the approach to evaluating polycystic ovarian morphology.

Biomarkers of Ovarian Reserve

The primary function of the female ovary is the production of a mature and viable oocyte capable of fertilization and subsequent embryo development and implantation. At birth, the ovary contains a finite number of oocytes available for folliculogenesis. This finite number of available oocytes is termed "the ovarian reserve". The determination of ovarian reserve is important in the assessment and treatment of infertility. As the ovary ages, the ovarian reserve will decline. Infertility affects approximately 15%-20% of reproductive aged couples. The most commonly used biomarker assay to assess ovarian reserve is the measurement of follicle stimulating hormone (FSH) on day 3 of the menstrual cycle. However, anti-müllerian hormone and inhibin-B are other biomarkers of ovarian reserve that are gaining in popularity since they provide direct determination of ovarian status, whereas day 3 FSH is an indirect measurement. This review examines the physical tools and the hormone biomarkers used to evaluate ovarian reserve.

Potential use of biomarkers for analyzing interpopulation and cross-cultural variability in reproductive aging

OBJECTIVE

The aims of this study were (1) to document the extent of variability in physiological aspects of reproductive aging; (2) to outline those areas where more work is needed to expand our knowledge of this variability; (3) to outline available biomarkers that can be used to measure aspects of reproductive aging, such as ovarian reserve and declining hormone levels; and (4) to note potential problems with the use of these biomarkers in cross-cultural settings.

DESIGN

Literature review of English and French publications using PubMed with no date restrictions.

RESULTS

Substantial variability exists in both cultural and physiological aspects of reproductive aging and menopause. However, the extent of variability across populations for many areas of reproductive aging needs better documentation as well as explanation of sources of this variability. Several biomarkers exist for use in cross-cultural research, including ovarian characteristics such as ovarian volume, ovarian reserve, follicular development, and atresia, and levels of hormones such as follicle-stimulating hormone, inhibin B, and anti-mullerian hormone.

CONCLUSION

We urge that further work be undertaken to evaluate and describe variability in physiological aspects of reproductive aging in cross-cultural settings. Some problems exist in the use of biomarkers to record this variability, particularly in remote settings with few logistical resources.

Prediction of ovarian response and IVF/ICSI outcome by three-dimensional ultrasonography and power Doppler angiography

OBJECTIVE

The objective was to evaluate whether three-dimensional ultrasonography (3D-US) and power Doppler angiography (PDA) measurements can predict ovarian response and/or are associated with IVF/ICSI outcome.

STUDY DESIGN

A prospective clinical study in 65 women undergoing IVF cycles. Ovarian volume (OV), number of antral follicles > or =2mm (NAF) and PDA indices: vascularisation index (VI), flow index (FI), and vascularisation flow index (VFI) were evaluated by 3D-US and PDA on the day of pituitary suppression control. These measurements, age and BMI were correlated with the number of follicles>10mm on the hCG day and the number of oocytes retrieved.

RESULTS

Ovarian volume, NAF, VI, FI and FVI correlate significantly (P<0.01) with the number of follicles and oocytes recovered. Ovarian volume and the number of antral follicles predicted significantly the number of follicles (R=0.67; adjusted R(2)=0.43) and oocytes retrieved (R=0.63; adjusted R(2)=0.37). The oestradiol peak and the number of follicles, oocytes and Grade 1 embryos transferred were higher in the pregnant group.

CONCLUSIONS

Three-dimensional ultrasound and PDA make it easier to evaluate all the sonographic parameters implied in ovarian response. Ovarian volume and the number of antral follicles are the only independent predictors of the number of follicles developed and oocytes retrieved.

The interobserver reliability of off-line antral follicle counts made from stored three-dimensional ultrasound data: a comparative study of different measurement techniques

OBJECTIVE

To assess the interobserver reliability of antral follicle counts (AFCs) made from stored three-dimensional (3D) ultrasound data using conventional two-dimensional (2D) images, 3D multiplanar view and 3D-rendered 'inversion mode'.

METHODS

3D transvaginal ultrasound was performed in the early follicular phase (days 2-5) of the menstrual cycle in 41 subjects aged < 40 years, undergoing investigation for subfertility. From the stored 3D ultrasound datasets, the number of antral follicles of 2-10 mm in diameter in each ovary was independently measured, using all three methods by three investigators, each with a different level of experience. The image quality of each dataset was subjectively categorized into one of three groups, based on the proportion of the ovarian contour that could be seen clearly.

RESULTS

There was no significant difference in the mean AFC between the observers for any of the three different techniques. The intraclass correlation coefficient (ICC) for the 2D-equivalent mode, the 3D multiplanar mode, and the 3D-rendered inversion mode were indicative of good interobserver reliability for each method. The interobserver reliability for the 3D-rendered inversion mode was better with Grade 1 image quality than with Grade 3 image quality. There were no equivalent differences, however, between the three different grades of image quality with the 2D-equivalent and 3D multiplanar modes. The time taken for AFC measurement using 3D-rendered inversion mode was significantly longer than with the 2D equivalent and 3D multiplanar methods.

CONCLUSIONS

3D image displays and rendering techniques do not appear to offer any advantage over a conventional 2D display in terms of AFC measurement reliability. AFC measurement using the 3D-rendered inversion mode has an adequate interobserver reproducibility but is dependent on image quality.

The 3D vascular status of the follicle after HCG administration is qualitatively rather than quantitatively associated with its reproductive competence

BACKGROUND

The objective of this study was to determine whether the vascular status of a single pre-ovulatory follicle is associated quantitatively and/or qualitatively with its reproductive competence.

METHODS

We studied 61 monofollicular IVF-embryo transfer cycles. Just before single oocyte retrieval, follicle vascularization was detected by transvaginal power-Doppler, 3-dimensionally reconstructed, and analysed quantitatively by coloured/gray voxel ratio [vascularization index (VI)] and qualitatively by blood cell displacement [flow index (FI)] calculation. Cycles were sorted in two sets of two groups: low VI (<or=8%, n = 44) and high VI (>8%, n = 17); low FI (<or=30, n = 22) and high FI (>30, n = 39).

RESULTS

Patients' characteristics, fertilization rates, and embryo morphology were comparable in all groups. In contrast, clinical pregnancy rates/oocyte retrieval (4% versus 33%, P < 0.009) and implantation rates (11% versus 50%, P < 0.04) were markedly poorer in the low as compared to the high FI groups, respectively, but remained similar between the low and the high VI groups (22% versus 23% and 38% versus 44%, respectively).

CONCLUSIONS

A qualitative (FI) rather than quantitative (VI) relationship exists between vascular status and functional quality of the follicle after HCG administration.

Assessment of the ovarian volume, number and volume of follicles and ovarian vascularity by three-dimensional ultrasonography and power Doppler angiography on the HCG day to predict the outcome in IVF/ICSI cycles

OBJECTIVE

The aim of this prospective study was to investigate whether ovarian blood flow is related to embryological parameters and whether it could be a predictor of outcomes of IVF/ICSI.

METHODS

Eighty infertile women underwent ovarian stimulation with gonadotrophins after a long protocol with GnRH agonists. The ovarian volume (OV), number of follicles (NF) and follicular volume (FV) of all follicles >10 mm and vascularization index (VI), flow index (FI) and vascularization-flow index (VFI) were obtained by three-dimensional (3D) ultrasonography and power Doppler angiography (PDA) on the day of HCG administration. These parameters were tested for their relation with IVF laboratory parameters.

RESULTS

The OV, FV, VI, FI and VFI were significantly greater in the pregnant group. The NF and FV were the only independent predictors of the number of oocytes retrieved, mature and fertilized, and the number of embryos developed and their cumulative embryo score. Nevertheless, the number of grade 1 embryos depends on the NF and the VI. The ovarian FI and the number of transferred grade 1 embryos can predict gestation in 76% of IVF patients. A low FI and non-grade 1 embryo transferred are also associated with an increased pregnancy loss.

CONCLUSION

3D ultrasonography and PDA allow for an easier ovarian assessment in IVF cycles. The predictive value of IVF outcome suggests a high clinical usefulness of this new technique.