Shilpa Deb

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

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.

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

OBJECTIVE To evaluate the relationship between serum anti-Müllerian hormone (AMH) and antral follicle size, and to ascertain which cohort of antral follicles is most predictive of the response to controlled ovarian stimulation during assisted reproduction treatment (ART). DESIGN Prospective study. SETTING University-based Assisted Conception Unit. PATIENT(S) One hundred thirteen women undergoing first cycle of ART. INTERVENTION(S) Transvaginal 3D-ultrasound assessment and venipuncture in the early-follicular phase of the menstrual cycle. MAIN OUTCOME MEASURE(S) Serum AMH levels, number of mature oocytes retrieved and poor ovarian response. RESULT(S) The antral follicle cohorts measuring 2 to 3 mm, >3 to 4 mm, >4 to 5 mm, and >5 to 6 mm were most significantly correlated with AMH (r = .30, .27, .30, and .41, respectively) and the number of mature oocytes retrieved (r = .28, .23, .29, and .34, respectively). Although these follicle cohorts of 2-6 mm were significant predictors of the number of mature oocytes retrieved on regression analysis, their discriminative ability (area under the curve [AUC]: 0.829) for the prediction of poor ovarian response was similar to total counts made using cohorts of 2 to 4 mm, 2 to 5 mm, 2 to 8 mm, and 2 to 10 mm (AUCs: 0.794, 0.812, 0.852, and 0.826, respectively). CONCLUSION(S) The number of antral follicles measuring 2 to 6 mm is most reflective of the quantitative ovarian reserve. However, the ability of this group of antral follicles to predict poor ovarian response appears similar to that of the follicular cohorts of 2 to 4 mm, 2 to 5 mm, 2 to 8 mm, and 2 to 10 mm.

Quantitative analysis of antral follicle number and size: a comparison of two‐dimensional and automated three‐dimensional ultrasound techniques

To compare two‐dimensional (2D) ultrasound imaging with automated three‐dimensional (3D) ultrasound imaging for the measurement of antral follicle number and size.

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.

PREVALENCE OF UTERINE ANOMALIES AND THEIR IMPACT ON EARLY PREGNANCY IN WOMEN CONCEIVING AFTER ASSISTED REPRODUCTION TREATMENT

To estimate the prevalence of congenital uterine anomalies in subfertile women and to evaluate their influence on early pregnancy following assisted reproduction treatment (ART).

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

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

Timing of oocyte maturation and egg collection during controlled ovarian stimulation: a randomized controlled trial evaluating manual and automated measurements of follicle diameter

OBJECTIVE To evaluate the effect of a new automated technique of follicle measurement (Sono automated volume calculation [SonoAVC]) on the timing of oocyte maturation and subsequent oocyte retrieval. DESIGN Prospective randomized controlled trial. SETTING University-based Assisted Conception Unit. PATIENT(S) Seventy-two women undergoing their first cycle of assisted reproduction treatment. INTERVENTION(S) The timing of final follicle maturation and oocyte retrieval based on follicle tracking with use of either conventional two-dimensional (2D) ultrasound or SonoAVC. MAIN OUTCOME MEASURE(S) The number of mature oocytes retrieved and clinical pregnancy rate. RESULT(S) The number of the mature oocytes collected (10.70 +/- 6.08 vs. 11.43 +/- 6.17), the number of fertilized oocytes (7.27 +/- 4.78 vs. 7.97 +/- 5.25), and the clinical pregnancy rates (42% vs. 43%) were similar with both 2D ultrasound and SonoAVC methods. CONCLUSION(S) Automated follicle tracking using SonoAVC identifies a comparable number of follicles to real-time 2D ultrasound in this preliminary study. Timing final follicle maturation and egg retrieval on the basis of these automated measures does not appear to improve the clinical outcome of assisted reproduction treatment.

The management of Cesarean scar ectopic pregnancy following treatment with methotrexate--a clinical challenge.

We present a case of Cesarean scar ectopic pregnancy, complicated by the persistence of clinical symptoms despite a rapid and complete biochemical response to a single systemic injection of methotrexate. A 34‐year‐old woman with three previous Cesarean sections was diagnosed with a Cesarean scar ectopic pregnancy following @ in‐vitro fertilization treatment. The diagnosis was suggested by three‐dimensional (3D) ultrasound scan and confirmed with magnetic resonance imaging (MRI). Management involved administration of a single systemic injection of methotrexate and follow‐up with serial ultrasound assessments and serum beta‐human chorionic gonadotropin (β‐hCG) measurements. The main challenge was the persistence of clinical symptoms despite adequate medical treatment, as judged by complete resolution of biochemical trophoblastic activity, which resulted in repeated admissions to the hospital. Serial transvaginal ultrasound scans showed an initial increase in the size of the mass, which led to increasing anxiety in the couple. Eventually, 15 weeks after the administration of methotrexate, the couple requested surgical intervention. An uneventful surgical resection of the abnormal area, which showed appearances suggestive of trophoblastic tissue, was undertaken to good effect. In summary, despite a rapid normalization of serum β‐hCG following the administration of methotrexate, the patient remained symptomatic and had ultrasound appearances suggestive of incomplete resorption of trophoblast, necessitating surgical intervention. Copyright

Automated follicle tracking improves measurement reliability in patients undergoing ovarian stimulation

This study tested the hypothesis that the automated assessment of a stimulated ovary, using 3D ultrasound and sono-AVC (automatic volume calculation), provides quicker analysis of follicular number and size than conventional 2D ultrasound, without any loss in measurement validity. Transvaginal ultrasound was performed on day 10 of stimulation in 89 prospectively recruited subjects undergoing IVF treatment. The number and mean diameter of follicles present in both ovaries was measured manually using 2D ultrasound. 3D data were then acquired and analysed using sono-AVC. Outcome measures included the number of follicles with a mean diameter >9 mm, >13 mm and >17 mm. The time taken for measurements and data acquisition was recorded. The two methods were compared using a paired t-test or the Wilcoxon signed rank test. Complete data were available for 82 subjects. There was no significant difference in the number of follicles with mean diameters >9 mm, >13 mm and >17 mm measured by either method. The total time taken for follicular measurements was significantly less (P < 0.01) for the automated 3D method (180.5 +/- 63.6 versus 236.1 +/- 57.1 s) which was associated with significantly less exposure to ultrasound (39.0 +/- 6.0 versus 236.10 +/- 57.1 s; P < 0.001). Automated 3D follicular measurements using sono-AVC provide a comparable but quicker assessment of follicle number and size.

Three‐dimensional ultrasonographic characteristics of endometriomata

Endometriosis is a common condition, affecting somewhere between 5% and 60% of women of reproductive age and approximately 2 million women in the UK. The exact prevalence is difficult to ascertain and varies according to diagnostic criteria used and the populations studied, varying from 2 to 50% in women without symptoms, 40 to 60% in women with dysmenorrhea, and 20 to 30% in women with subfertility1,2. The etiology is unknown, but the disease is characterized by the objective demonstration of endometrial-like tissue outside the uterus. The condition is seen predominantly in women of reproductive age, and it occurs in all ethnic and social groups. Whilst extrapelvic disease can occur, endometriosis typically affects the pelvic organs and peritoneum. Disease severity is assessed semi-quantitatively at laparoscopy or laparotomy and is scored according to the American Society for Reproductive Medicine3, but is a poor predictor of the patient’s symptoms in many cases. The extent of the disease varies considerably; it may involve small areas of the peritoneum alone, or be associated with significant fibrosis, adhesions and nodular infiltration, in different individuals with the same symptoms1. The ovary may be involved only superficially or can contain a cyst lined with endometrial-like tissue known as an ‘endometrioma’. Endometriotic cysts have always been a controversial entity. There is no consensus as to the pathological processes which define their development or to their management in terms of the timing, type and effects of surgery. Opinion is divided as to whether these cysts arise from progressive invagination of endometriotic deposits on the ovarian cortex4,5, from metaplasia of epithelial inclusions in the ovary5,6 or because of secondary involvement of functional ovarian cysts in the endometriotic process7. The invagination theory is accepted by most, but there is no agreement as to whether the endometrial cells are superficial ovarian implants of endometriosis or they are derived through metaplastic transformation of normal ovarian cortical tissue. The invagination theory is supported by histological studies, which consistently show that these cysts are pseudocysts, with no real plane of cleavage between the endometrialtype stroma and the ovarian cortex, containing an obliterated, mostly endometrial-gland, lining8. The walls of an endometrioma are initially thin, but subsequently become fibrotic and thickened, and can give the cyst an irregular external border. Endometriomata are typically small, with 81% measuring between 30 and 59 mm in diameter9, although they can reach 15–20 cm in diameter. Is an isolated endometrioma a different disease from peritoneal endometriosis? Many women are found to have an endometrioma without evidence of peritoneal disease, and the pathophysiological mechanisms that determine how the disease is expressed remain unclear. Women with peritoneal endometriosis are thought to have reduced fertility, and surgical treatment may improve fecundity in those with minimal to mild disease10. Just how endometriosis affects fertility is unknown, but any effect probably relates to anatomical distortion and immobilization of the pelvic organs through adhesion formation and organ infiltration and/or a change in the peritoneal environment to one that is less favorable for fertilization and embryo implantation. The effect of an isolated endometrioma on fertility is less clear, and there is no definitive evidence that fertility is impaired. However, surgical intervention is often recommended when an endometrioma measures more than 3–4 cm in diameter11 and so, unsurprisingly, endometriomata represent the most frequently reported histological subtype following operative laparoscopy for the excision of ovarian cysts12. Preoperative detection of endometriomata is therefore important, and ultrasound is the investigative tool of choice in most cases. Conventional two-dimensional ultrasound has an established role in the detection of adnexal masses and in their differentiation through pattern recognition of characteristic morphological patterns13. Most studies use transvaginal rather than transabdominal ultrasound, as this approach allows a closer approximation of the probe to the ovary and the use of higher frequencies, which provide better resolution. However, transvaginal