Miriam N. Baumgarten

Do dopamine agonists prevent or reduce the severity of ovarian hyperstimulation syndrome in women undergoing assisted reproduction? A systematic review and meta-analysis

Abstract Controlled ovarian stimulation is an integral part of assisted reproduction treatment. This can result in ovarian hyperstimulation syndrome (OHSS), which is associated with significant morbidity and potentially mortality. Recent approaches to ovarian stimulation have led to a reduction in the prevalence of OHSS but it still occurs. Dopamine agonists (DAs) have been used with some success during the ovarian stimulation phase when there are early signs of OHSS but there is no consensus on when to start and stop treatment or on the dose and specific agonist to use. EMBRASE, MEDLINE and Cochrane were searched using the following terms: ovarian hyperstimulation syndrome, controlled ovarian hyperstimulation, DAs, cabergoline, quinagolide, bromocriptide, pergolide, talipexole, ropinirole and pranipexole. The search yielded 20 publications. In total 1646 woman were included and 914 received a DA. In the treated group 86 (9.41%) developed OHSS, compared with 157 (21.45%) in the non-treated group. Nine studies were suitable for meta-analysis. This showed a benefit to the use of DAs (RR 0.51 [0.33, 0.78], Chi2 = 16.07). The use of DAs appears to be effective for the prevention of OHSS. DAs are useful but less effective for the treatment of OHSS. No conclusions can be made regarding the most effective drug, the optimal dose or the most appropriate drug regimen.

Influence of Gain Adjustment on 3-Dimensional Power Doppler Indices and on Spatiotemporal Image Correlation Volumetric Pulsatility Indices Using a Flow Phantom

Spatiotemporal image correlation can be used to acquire 3‐dimensional power Doppler information across a single cardiac cycle. Assessment and comparison of the systolic and diastolic components of the data sets allow measurement of the recently introduced “volumetric pulsatility index” (vPI) through algorithms comparable with those used in 2‐dimensional Doppler waveform analysis. The vPI could potentially overcome the dependency on certain machine settings, such as power, color gain, pulse repetition frequency, and attenuation, since these factors would affect the power Doppler signal equally throughout the cardiac cycle. The objective of this study was to compare the effect of color gain on the vascularization index (VI), vascularization‐flow index (VFI), and vPI using an in vitro flow phantom model. We separated gains into 3 bands: −8 to −1 (no noise), −1 to +5 (low noise), and +5 to +8 (obvious noise). The vPI was determined from the 3‐dimensional VI or VFI using the formula vPI = (maximum − minimum)/mean. Using no‐noise gains, we observed that although the VI and VFI increased linearly with gain, the vPI was substantially less dependent on this adjustment. The VI and VFI continued to increase linearly with gain, whereas the vPI decreased slightly using low‐noise gains. When gain was increased above the lower limit of obvious noise (+5), the VI and VFI increased noticeably, and there were marked reductions in both vPI values. We conclude that the vPI is less affected by changes in color gain than the VI and VFI at no‐noise gains.

4-D Assessment of Endometrial Vascularity Using Spatiotemporal Image Correlation: A Study Comparing Spherical Sampling and Whole-Tissue Analysis

Our aim in the study described here was to assess the feasibility of spatiotemporal image correlation power Doppler quantification of the endometrium with two techniques: spherical samples and whole tissue. We scanned 51 women in the midluteal phase of the menstrual cycle: STIC assessment of the whole endometrium was not possible in 10% of cases, whereas spherical analysis was possible in all. The time taken for data set analysis was much longer for the whole endometrium compared with spherical analysis (1478.9 ± 291 s vs. 266.8 ± 39.3 s, p < 0.05). Intra-class correlation coefficients for the vascularization flow index (VFI) were similar for both methods. Volumetric vascularity indices were higher when spherical sampling was conducted. Significant cycle-to-cycle variability in the vascularity indices was present, with coefficients of variation exceeding 20% for both techniques. We found that STIC power Doppler quantification of the whole endometrium is possible in the majority of cases, however, it is time consuming and limited by significant cycle-to-cycle variability.

Endometrial spatio-temporal image correlation (STIC) and prediction of outcome following assisted reproductive treatment

OBJECTIVE The aim of this study was to correlate manual and spherical endometrial spatio-temporal image correlation (STIC) vascularity indices with assisted reproductive treatment (ART) outcomes. STUDY DESIGN STIC ultrasound assessments of the endometrium were carried out at three time-points in 127 women in a prospective observational study. RESULTS Biochemical pregnancy rate was 69% (88/127), with a biochemical and clinical pregnancy loss of 17%. Endometrial STIC vascularity indices in the assessed time-points did not differ between subjects who achieved a clinical pregnancy and those who did not (P>0.05). For first trimester miscarriage, minimal manual vascularization index (VI) at oocyte collection (cut-off value ≥0.7; sensitivity 80.0% and specificity 68.1%) demonstrated the highest area under the curve (AUC) of 0.8. CONCLUSION In summary, STIC modality is not a useful tool to predict ART outcome, however manual STIC analysis of endometrial vascularity seems to be more accurate in predicting first trimester pregnancy loss.

Complications of ART and Associated Early Pregnancy Problems

A healthy, term live birth following assisted reproduction in the most desired outcome. However, during the various phases of treatment, complications may arise. In this chapter, we present an up-to-date knowledge of ART associated complications, their prevalence and means of diagnosis. Described risks are related to ovarian stimulation, oocyte retrieval, as well as early pregnancy. Over-response and development of potentially life threatening ovarian hyperstimulation syndrome is related to ovarian stimulation with gonadotropins. Oocyte retrieval can be followed by bleeding and injury to the internal pelvic organs. Once pregnancy establishes, the risk of miscarriage and ectopic pregnancy occurs. ART complication associated with long term implications for the couple and the offspring is development of a multiple pregnancy. It is important to be aware of the potential serious complications that may arise during ART. These should be weighed against potential benefits and couples counselled accordingly.

OP36.07: Spatio‐temporal image correlation (STIC) of whole endometrium: evaluation of the intra and inter observer reliability of acquisition and measurement

measurements and significantly smaller for the CRL measurement (P = 0.041). Conclusions: Medaphor ScanTrainer distinguishes between gynaecologists of differing ultrasound expertise in terms of completing a comprehensive and systematic transvaginal scan and measurement accuracy. This system has sufficient construct validity to warrant further investigation into its use in gynaecological scan training and further research is ongoing.

OP03.07: Influence of gain adjustment on three‐dimensional power Doppler indices and on STIC volumetric pulsatility indices using an in vitro model

Objectives: The aim of the study was to evaluate uterine Cesarean scar 4–5 weeks after delivery using transvaginal ultrasound. Methods: The study group consisted of 65 women who underwent Cesarean section (CS) and reported for the transvaginal ultrasound examination 4–5 weeks after delivery. The lower uterine segment was assessed and the presence of the Cesarean scar, scar defect and defect’s dimensions were noted. The mean maternal age was 31.7 ± 4.5 years. There were 40 (61.5%) primiparas. 13 (20.0%) women had CS in the past. The mean gestational age at the delivery was 38.2 ± 2.5 weeks. Elective CS was performed in 30 (46.2%) cases. There were 27 (41.5%) operations done during delivery: 21 (32.3%) at the first stage and 6 (9.2%) at the second stage. All women had a one-layer closure of the uterine lower segment’s incison: 48 (73.8%) continous and 17 (26.2%) single sutures. Results: The scar was visible in all patients. The uterine scar defect was found in 29 (44.6%) women. In this group 5 had previous CS. The defect was present in 53.3% (16/30) of women who had elective CS compared to 37.1% (13/35) non elective CS. Continous suturing was related to the 35.3% (6/17) ratio of defects compared to 47.9% (23/48) of single sutures. The defect was found in 16/38 (55.2%) anteverted uteruses and in 13/27 (44.8%) retroverted. The uterine scar was localized ±3 mm to the level of internal os of the cervix in 26 (40%) cases, in 6 (9.2%) cases >3 mm below internal os and in 27 (41.5%) cases >3 mm above. The defect was present in 10/26 (38.5%) of scars at the level of internal os region, in 2/6 (33.3%) below internal os and in 15/27 (55.6%) above. The mean width of the defect was 8.2 ± 3.1 mm; depth 8.7 ± 4.0 mm; length 12.0 ± 5.0 mm; residual myometrial thickness was 9.8 ± 5.1 mm including 5 (7.7%) cases of RMT = 0. Conclusions: The proper healing of the uterine scar can be observed as early as 4 weeks after Cesarean section in half of women. Further research is needed to evaluate the significance of defects found in the other half of patients.

OP36.10: Spatio-Temporal Image Correlation (STIC) for analysis of whole ovarian blood flow

Objectives: Several 2 and 3-dimensional techniques have been used to asses ovarian blood flow and vascularity. All have their advantages and limitations. Spatio-temporal image correlation (STIC) is a 4D method that combines 2D velocity information with 3D vascular maps to provide pulsatile volumetric data across the cardiac cycle. This study was designed to see if this technique could be used to reliably acquire and measure 4D power Doppler data from the whole ovary. Methods: Ten consecutive patients in the early follicular phase of their menstrual cycle were scanned as part of their routine workup before starting fertility treatment (Voluson E8, GE Healthcare). STIC was used by two observers to acquire 4D data from the whole ovary using standardized settings. Each observer acquired two STIC datasets resulting in 4 STIC acquisitions for each ovary. From each acquisition a selected image was analyzed twice by both observers. VOCAL was used to define the ovarian cortex and the histogram applied to generate the vascularity index (VI), flow index (FI) and vascularity flow index (VFI). SPSS was used to calculate intraclass correlation coefficients (ICC) and their 95% confidence intervals. Results: The reliability analysis showed a high level of agreement between the two observers for both data acquisition and analysis for all three indices. The ICCs (95% CI) were indicative of a high degree (>0.9) of both inter and intra observer measurements. Conclusions: This is the first study to show that STIC can be reliably used to acquire and measure 4D power Doppler data from the whole ovary. Previous studies have been limited by the need to apply spherical sampling techniques which is associated with an obvious subjective selection bias. Further work is required to assess the clinical relevance of this technique but it offers a new way to assess whole organ flow in a standardized manner that is less dependent on machine settings and inter-subject variation.