B. Campbell

Which follicles make the most anti-Mullerian hormone in humans? Evidence for an abrupt decline in AMH production at the time of follicle selection.

Anti-Müllerian hormone (AMH) is exclusively produced by granulosa cells (GC) of the developing pre-antral and antral follicles, and AMH is increasingly used to assess ovarian function. It is unclear which size follicles make the most AMH (total content) and are the main contributors to circulating AMH concentrations. To determine AMH gene expression in GC (q-RT-PCR) and follicular AMH production (Elisa and RIA) in relation to follicular development, 87 follicles (3-13 mm diameter) including both GC and the corresponding follicular fluid (FF) were collected in connection with fertility preservation of human ovaries. Further, follicle number and diameter, graded in 1 mm increments, were determined by 3D ultrasound in 113 women in their natural menstrual cycle to determine follicle number and diameter in relation to circulating AMH levels. This study demonstrates for the first time a positive association between AMH gene expression in human and both total follicular fluid AMH (P < 0.02) and follicular fluid AMH concentration (P < 0.01). AMH gene expression and total AMH protein increased until a follicular diameter of 8 mm, after which a sharp decline occurred. In vivo modelling confirmed that 5-8 mm follicles make the greatest contribution to serum AMH, estimated for the first time in human to be 60% of the circulating concentration. Significant positive associations between gene expression of AMH and FSHR, AR and AMHR2 expression (P < 0.00001 for all three) and significant negative association between follicular fluid AMH concentration and CYP19a1 expression were found (P < 0.0001). Both AMH gene expression (P < 0.02) and follicular fluid concentration of AMH (P < 0.00001) correlated negatively with estradiol concentration.

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

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.

Embryo volume measurement: an intraobserver, intermethod comparative study of semiautomated and manual three-dimensional ultrasound techniques.

To compare the reliability of our recently introduced technique for first‐trimester embryo volume measurement, the ‘semiautomated technique’ using both Virtual Organ Computer‐aided AnaLysis (VOCAL™) and Sonography‐based Automated Volume Count (SonoAVC) with a manual technique using VOCAL alone.

Use of double decidual sac sign to confirm intrauterine pregnancy location prior to sonographic visualization of embryonic contents

To determine the diagnostic accuracy of the double decidual sac sign (DDSS) for predicting an intrauterine pregnancy (IUP) prior to visualization of embryonic contents, using modern high‐resolution transvaginal sonography (TVS).

OC04.01: Endometrial biopsy prior to IVF impacts on the ultrasound appearance of the endometrium at oocyte retrieval

Objectives: The objectives of this study were to identify sonographic changes of the endometrium following endometrial biopsy (EB) and correlate these with IVF pregnancy outcomes. Methods: In this prospective controlled study, unselected infertile women were randomised to undergo a Pipelle endometrial biopsy or no procedure during the mid-luteal phase of the cycle directly preceding IVF. Following EB, all participants underwent IVF using standard local protocols. A transvaginal ultrasound scan (TVUS) was performed at oocyte retrieval (OR) and embryo transfer (ET). 2D, 3D and Doppler ultrasound data were acquired (Voluson E8, GE Healthcare). Clinical pregnancy rates were the primary outcome. Student’s t-test and Chi2 statistics were used as appropriate. Research Ethics Committee approval was obtained. Results: A total of 151 women were recruited and randomised: 76 to the biopsy group and 75 to the control group. TVUS data of adequate quality were available for 49 and 50 of these women respectively. Mean age was 33.7±4.0 and 32.8±4.3 years in the treatment and control group, respectively (P=0.21). Both clinical groups were matched for duration of infertility, BMI, AMH, and cycle number (P<0.05). At OR, 19/49 (38.8%) women in the biopsy group and 10/50 (20.0%) control subjects had a triple endometrial pattern (P=0.04). There were no statistically significant differences in other TVUS markers (P>0.05). The clinical pregnancy rates were 31/49(63.3%) and 27/50(54.0%) in the treatment and control group, respectively (P=0.35). Women whom achieved pregnancy were more likely to have a triple pattern endometrium at OR (P=0.035). There were no statistically significant differences in other TVUS markers at ET. Conclusions: In conclusion, a mid-luteal EB may influence endometrial response during the peri-ovulatory phase of a subsequent cycle, as evident by an ultrasound appearance of a triple pattern at the time of OR. Molecular and histological studies are required to provide clues to the underlying mechanisms.

P11.02: How does IVF treatment affect uterine artery pulsed wave Doppler indices

Objectives: In severe anomalies requiring early intervention in utero, ultrasound diagnosis may be beneficial facilitating neonatal care. The aim of this study is to determine the correlation of ultrasound findings in congenital fetal heart disease and neonatal diagnosis. Methods: A retrospective study of all patients with singleton pregnancy between 2010–2011 was performed. The data collected included patient age, gestational age, cardiac diagnosis, extracardiac anomalies, prenatal and postnatal management and outcome. Results: Out of 4749 patients admitted in our hospital 23 were CHDs (congenital heart defects), 18 living newborns, 3 stillbirths and 2 misscariages. Mean age was 24 (range 16–40) and mean gestational age 31 weeks (range 24–40). Ultrasound was the most relevant diagnosis tool in all CHDs cases for both in utero and postpartum diagnosis. We recorded VSD (ventricular septal defect) in 10 cases, ASD (atrial septal defect) in 8 cases, TGA (transposition of great arteries) 4 cases, common arterial trunk 1 case, coarctation of aortic artery 1 case, TOF (tetralogy of Fallot) 1 case and HLHS (hypoplastic left heart syndrome) 1 case. In utero ultrasound findings were VSD (10 cases), ASD (8 cases), TGA (4 cases), common arterial trunk 1 case, coarctation of aortic artery 1 case, TOF 1 case and HLHS 1 case. We recorded 8 cases of extracardiac anomalies (hydrocephalia, keiloskisis, esophagus athresia, abdominal situs inversus and encephalocele). We had 3 stillbirth cases with mean gestational age 35 weeks and 2 misscariages at 24 and 22 weeks with complex CHDs associated with extracardiac anomalies. Conclusions: In our study the most common CHDs was VSD. The correlation rate between prenatal and postnatal ultrasound findings was more than 90%. Although the sensitivity of routine ultrasound remains low there is no doubt that an increasing number of fetal diagnosis are being made and sonografic diagnosis of CHDs is feasible from early gestation.

P11.01: How does IVF affect the endometrium and is this predictive of conception?

Objectives: In severe anomalies requiring early intervention in utero, ultrasound diagnosis may be beneficial facilitating neonatal care. The aim of this study is to determine the correlation of ultrasound findings in congenital fetal heart disease and neonatal diagnosis. Methods: A retrospective study of all patients with singleton pregnancy between 2010–2011 was performed. The data collected included patient age, gestational age, cardiac diagnosis, extracardiac anomalies, prenatal and postnatal management and outcome. Results: Out of 4749 patients admitted in our hospital 23 were CHDs (congenital heart defects), 18 living newborns, 3 stillbirths and 2 misscariages. Mean age was 24 (range 16–40) and mean gestational age 31 weeks (range 24–40). Ultrasound was the most relevant diagnosis tool in all CHDs cases for both in utero and postpartum diagnosis. We recorded VSD (ventricular septal defect) in 10 cases, ASD (atrial septal defect) in 8 cases, TGA (transposition of great arteries) 4 cases, common arterial trunk 1 case, coarctation of aortic artery 1 case, TOF (tetralogy of Fallot) 1 case and HLHS (hypoplastic left heart syndrome) 1 case. In utero ultrasound findings were VSD (10 cases), ASD (8 cases), TGA (4 cases), common arterial trunk 1 case, coarctation of aortic artery 1 case, TOF 1 case and HLHS 1 case. We recorded 8 cases of extracardiac anomalies (hydrocephalia, keiloskisis, esophagus athresia, abdominal situs inversus and encephalocele). We had 3 stillbirth cases with mean gestational age 35 weeks and 2 misscariages at 24 and 22 weeks with complex CHDs associated with extracardiac anomalies. Conclusions: In our study the most common CHDs was VSD. The correlation rate between prenatal and postnatal ultrasound findings was more than 90%. Although the sensitivity of routine ultrasound remains low there is no doubt that an increasing number of fetal diagnosis are being made and sonografic diagnosis of CHDs is feasible from early gestation.

OC06.04: How does IVF affect cyclical changes in subendometrial vascularity

Methods: Stored 4D STIC-HDF volume data from ovaries from 34 women diagnosed as having PCOS and evaluated by transvaginal ultrasound were assessed retrospectively. The first step in calculations for every STIC record was to move the region of the highest signal within the ovarian volume to the center of the screen. Then we activated STIC loop in order to work with a chain of 3D volumes. Calculations were performed in two ways: in the first one all 3D volumes from the chain were consecutively activated and the center of a 1-cc virtual sphere was placed in the center of the displayed picture. Histograms were automatically calculated for each 3D volume of the complete STIC chain. We calculated the mean VI and mean FI values based on the results from all chain volumes. In the second way, the examiner subjectively selected the two volumes with the highest and lowest color signals, respectively. Then, instead of using the mean VI and mean FI values from all 3D volumes, we just averaged VI maximum and VI minimum. The same was done with FI calculations. A single expert examiner performed all calculations. Agreement of measurements was estimated by calculating the intra-class correlation coefficient (ICC). Results: ICC for VI was 0.999 (95% CI: 0.999–1.000). Mean difference was −0.09. Limits of agreement: −0.620 to 0.800. ICC for FI was 0.998 (95% CI: 0.997–0.999). Mean difference was −0.170. Limits of agreement: −0.780 to 0.440. Mean time consumed for calculating mean VI and mean FI using the whole STCI chain was significantly longer than using average values from the volumes selected by operator (20 minutes versus 4 minutes). Conclusions: There is a significant agreement between both methods. Using average VI and FI from maximum and minimum values found is less time consuming that using mean VI and FI from the whole STIC chain.

OP11.03: How early can conception be accurately diagnosed following embryo transfer in IVF treatment?

Methods: A web-based survey of fellows and trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Results: Three hundred and sixty-six (28%) responses included about 50% of Fetal Medicine and Obstetric Ultrasound subspecialists. Just over /4 (76.1%) of practices report or receive reports as a systolic:diastolic ratio (SD), just under 1/3 (31.6%) as pulsatility index (PI) and over 1/3 (36.4%) as resistance index (RI) with 22% declining to nominate a preferred umbilical artery Doppler index. 57% did not know the reference source used in their practice and more than 30% cited unpublished, local reference ranges. Many respondents were well aware of the limitations of umbilical artery Doppler. Survey participants requested 1. consistency 2. gestational age specific reference ranges 3. guidance in interpretation. Conclusions: Regarding Doppler indices, SD remains popular. RI advocates note its straightforward interpretation. PI is favoured by subspecialists, those following international research and those using ratios (e.g. cerebro-placental ratio). Until one index becomes universal, co-reporting of all indices is prudent. Concerning reference chart choice, local, unpublished charts remain popular: their concordance requires investigation. Generally, ideal reference chart are 1. Drawn from a representative population 2. not drawn from a referred population (biased toward abnormality) 3. not subject to retrospective exclusions (biased to ‘‘super-normality’’) 4. Developed using valid statistics, especially to estimate extreme values 5. Use optimal information about gestation 6. Use a good sample size. Ideally usable charts should be subject to peer review and publication, ASUM and RANZCOG endorsement, be readily accessible on ultrasound machines, reporting packages, smart phone applications and the world wide web

OP02.08: Linear and volumetric ultrasound measures of embryo growth and their predictive value for first trimester miscarriage

pregnancy of uncertain viability (IPUVI) after a single visit at the primary transvaginal scan (TVS). Methods: Prospective observational study. Between Nov 2006 and Jan 2010, all pregnant women presenting to the EPU underwent a TVS. Data was collected from women with an IPUVI at primary TVS. These women were followed up until the outcome (viable or non-viable pregnancy at the end of the first trimester) was established. More than 40 historical, clinical and ultrasonographic (US) end points were recorded for analysis, at which US data included the crown–rump length (CRL) as well as gestational sac (GS) and yolk sac (YS) measurements in 3 planes. Variables for preliminary model development were determined by stepwise logistic regression. Results: 2048 pregnant women underwent TVS, out of which 268 (13.1%) were classified with an IPUVI. 237 women with an IPUVI on primary TVS (84%) returned for follow up until the outcome was established (52.3% viable, 47.7% non-viable). 185 of these data sets have been used for model building. The variables used in the model were maternal age, gestational age in days by LMP, CRL in mm, mean GS size in mm, and previous normal vaginal delivery. The predictive ability of our model was measured with an AUC of 0.91 and its sensitivity and specificity for viable was shown to be 81.1% and 85.3% respectively. Conclusions: We have developed a valid model to predict the likelihood of a viable pregnancy at the end of the first trimester in women, who present with an IPUVI on primary ultrasound. This may help to counsel women with this common condition. We aim to test this model prospectively to evaluate its performance.