Preovulatory follicular size: a comparison of ultrasound and laparoscopic measurements

Normal and Abnormal Appearances of the Ovaries during Assisted Reproduction: Multimodality Imaging Review

Infertility is a common diagnosis that prompts many couples and individuals to seek assisted reproductive technology (ART) for assistance with conception. These technologies have become increasingly used in the United States in the past several decades, with 326 468 ART cycles performed in 2020, resulting in 75 023 live births. This ubiquity of ART also increases the likelihood that radiologists will encounter both normal and abnormal imaging findings associated with these treatments. Thus, radiologists of all subspecialties should be familiar with the multimodality appearance of the ovaries and pelvis in patients undergoing ART treatments. Furthermore, it is imperative that radiologists understand the appearance expected during different stages of the ART process. During stimulated ovulatory cycles, it is normal and expected for the ovaries to appear enlarged and to contain numerous cystic follicles, often with a small to moderate volume of pelvic free fluid. After oocyte retrieval, hemorrhagic ovarian follicles and a small to moderate volume of blood products in the cul-de-sac can be expected to be seen. Multiple nonemergency and emergency complications are related to ART, many of which can be seen at imaging. The most encountered emergency complications of ART include ovarian hyperstimulation syndrome, ectopic pregnancy, heterotopic pregnancy, multiple gestations, ovarian torsion, and procedural complications related to oocyte retrieval. These complications have important clinical implications, thus necessitating accurate and timely detection by the radiologist and the clinical team. ©RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Timed intercourse for couples trying to conceive

BACKGROUND

Many factors influence fertility, one being the timing of intercourse. The 'fertile window' describes a stage in the cycle when conception can occur and is approximately five days before to several hours after ovulation. 'Timed intercourse' is the practice of prospectively identifying ovulation and, thus, the fertile window to increase the likelihood of conception. Methods of predicting ovulation include urinary hormone measurement (luteinising hormone (LH) and oestrogen), fertility awareness-based methods (FABM) (including tracking basal body temperatures, cervical mucus monitoring, calendar charting/tracking apps), and ultrasonography. However, there are potentially negative aspects associated with ovulation prediction, including stress, time consumption, and cost implications of purchasing ovulation kits and app subscriptions. This review considered the evidence from randomised controlled trials (RCTs) evaluating the use of timed intercourse (using ovulation prediction) on pregnancy outcomes.

OBJECTIVES

To evaluate the benefits and risks of ovulation prediction methods for timing intercourse on conception in couples trying to conceive.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group Specialised Register, CENTRAL, MEDLINE, and Embase in January 2023. We also checked the reference lists of relevant studies and searched trial registries for any additional trials.

SELECTION CRITERIA

We included RCTs that compared methods of timed intercourse using ovulation prediction to other forms of ovulation prediction or intercourse without ovulation prediction in couples trying to conceive.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane to select and analyse studies in this review. The primary review outcomes were live birth and adverse events (such as depression and stress). Secondary outcomes were clinical pregnancy, pregnancy (clinical or positive urinary pregnancy test not yet confirmed by ultrasound), time to pregnancy, and quality of life. We assessed the overall quality of the evidence for the main comparisons using GRADE methods.

MAIN RESULTS

This review update included seven RCTs involving 2464 women or couples. Four of the five studies from the previous review were included in this update, and three new studies were added. We assessed the quality of the evidence as moderate to very low, the main limitations being imprecision, indirectness, and risk of bias. Urinary ovulation tests versus intercourse without ovulation prediction Compared to intercourse without ovulation prediction, urinary ovulation detection probably increases the chance of live birth in couples trying to conceive (risk ratio (RR) 1.36, 95% confidence interval (CI) 1.02 to 1.81, 1 RCT, n = 844, moderate-quality evidence). This suggests that if the chance of a live birth without urine ovulation prediction is 16%, the chance of a live birth with urine ovulation prediction is 16% to 28%. However, we are uncertain whether timed intercourse using urinary ovulation detection resulted in a difference in stress (mean difference (MD) 1.98, 95% CI -0.87 to 4.83, I² = 0%, P = 0.17, 1 RCT, n = 77, very low-quality evidence) or clinical pregnancy (RR 1.09, 95% CI 0.51 to 2.31, I² = 0%, 1 RCT, n = 148, low-quality evidence). Similar to the live birth result, timed intercourse using urinary ovulation detection probably increases the chances of clinical pregnancy or positive urine pregnancy test (RR 1.28, 95% CI 1.09 to 1.50, I² = 0, 4 RCTs, n = 2202, moderate-quality evidence). This suggests that if the chance of a clinical pregnancy or positive urine pregnancy test without ovulation prediction is assumed to be 18%, the chance following timed intercourse with urinary ovulation detection would be 20% to 28%. Evidence was insufficient to determine the effect of urine ovulation tests on time to pregnancy or quality of life. Fertility awareness-based methods (FABM) versus intercourse without ovulation prediction Due to insufficient evidence, we are uncertain whether timed intercourse using FABM resulted in a difference in live birth rate compared to intercourse without ovulation prediction (RR 0.95, 95% CI 0.76 to 1.20, I² = 0%, 2 RCTs, n = 157, low-quality evidence). We are also uncertain whether FABM affects stress (MD -1.10, 95% CI -3.88 to 1.68, 1 RCT, n = 183, very low-quality evidence). Similarly, we are uncertain of the effect of timed intercourse using FABM on anxiety (MD 0.5, 95% CI -0.52 to 1.52, P = 0.33, 1 RCT, n = 183, very low-quality evidence); depression (MD 0.4, 95% CI -0.28 to 1.08, P = 0.25, 1 RCT, n = 183, very low-quality evidence); or erectile dysfunction (MD 1.2, 95% CI -0.38 to 2.78, P = 0.14, 1 RCT, n = 183, very low-quality evidence). Evidence was insufficient to detect a benefit of timed intercourse using FABM on clinical pregnancy (RR 1.13, 95% CI 0.31 to 4.07, 1 RCT, n = 17, very low-quality evidence) or clinical or positive pregnancy test rates (RR 1.08, 95% CI 0.89 to 1.30, 3 RCTs, n = 262, very low-quality evidence). Finally, we are uncertain whether timed intercourse using FABM affects the time to pregnancy (hazard ratio 0.86, 95% CI 0.53 to 1.38, 1 RCT, n = 140, low-quality evidence) or quality of life. No studies assessed the use of timed intercourse with pelvic ultrasonography.

AUTHORS' CONCLUSIONS

The new evidence presented in this review update shows that timed intercourse using urine ovulation tests probably improves live birth and pregnancy rates (clinical or positive urine pregnancy tests but not yet confirmed by ultrasound) in women under 40, trying to conceive for less than 12 months, compared to intercourse without ovulation prediction. However, there are insufficient data to determine the effects of urine ovulation tests on adverse events, clinical pregnancy, time to pregnancy, and quality of life. Similarly, due to limited data, we are uncertain of the effect of FABM on pregnancy outcomes, adverse effects, and quality of life. Further research is therefore required to fully understand the safety and effectiveness of timed intercourse for couples trying to conceive. This research should include studies reporting clinically relevant outcomes such as live birth and adverse effects in fertile and infertile couples and utilise various methods to determine ovulation. Only with a comprehensive understanding of the risks and benefits of timed intercourse can recommendations be made for all couples trying to conceive.

[Ovarian stimulation monitoring: past, present and perspectives]

Since the inception of Assisted Reproductive Technology (ART), knowing the moment of ovulation has always been a priority. Initially, the monitoring was accomplished by observing the luteinizing hormone (LH) surge just before ovulation. Currently, in all ART facilities, the monitoring of all stimulated ovulatory cycles is done by using the conventional two-dimensional (2D) ultrasound to measure follicle diameter and by drawing blood tests that measure estradiol, progesterone, and luteinizing hormone levels. These exams allow determination of the numbers and quality of growing ovarian follicles and evaluation of follicle maturity before choosing the appropriate time for ovulation triggering. The monitoring of ovulatory cycles has now become enhanced with the arrival of new software called SonoAVC. This software allows the utilization of 3D blocks to immediately calculate the total number and volume of the follicles inside the ovary. This automatic approach is faster, precise, and more efficient. It also has better reproducibility than the classical 2D diameters. Furthermore, certain ART professionals envision that by using the SonoVac technology, patients will no longer need to be monitored with regular ultrasounds and with systematic hormonal testing.

Women with ovulatory dysfunction undergoing ovarian stimulation with clomiphene citrate for intrauterine insemination may benefit from administration of human chorionic gonadotropin

OBJECTIVE

To investigate factors that may affect pregnancy outcome following ovarian stimulation with clomiphene citrate (CC) combined with intrauterine insemination (IUI).

DESIGN

Retrospective cohort study.

SETTING

University teaching hospital.

PATIENT(S)

Three hundred and twenty women who underwent 691 ovarian stimulation cycles with CC for IUI.

INTERVENTION(S)

Ovarian stimulation with CC followed by a single IUI either 24 hours after a spontaneous serum LH surge (>25 mIU/mL) or 36 hours after intramuscular human chorionic gonadotropin (hCG) administration (10,000 IU) when the largest follicle had reached a diameter of 17 mm.

MAIN OUTCOME MEASURE(S)

Clinical pregnancies.

RESULT(S)

Women with ovulatory dysfunction who received hCG had significantly higher pregnancy rates (24.6%) compared with women with other types of infertility. There were no differences in pregnancy rates between the LH surge group and the hCG group (14.3% vs 12.4%). A spontaneous LH surge was noted in a variety of follicular sizes (14 to 35 mm). There was no correlation for age, body mass index, follicular diameter, number of mature follicles, other sperm characteristics, and pregnancy outcome in either group.

CONCLUSION(S)

After ovarian stimulation with CC, IUI is equally effective 24 hours after a spontaneous LH surge or 36 hours after administration of hCG. Spontaneous LH surges were observed at a variety of follicular sizes with comparable pregnancy rates. In women with ovulatory dysfunction, hCG administration before insemination may be beneficial.

One, two or three: how many directions are useful in transvaginal ultrasound measurement of ovarian follicles?

OBJECTIVE

To investigate whether it is necessary to measure an ovarian follicle in three directions using transvaginal ultrasonography.

METHODS

In 36 healthy female volunteers transvaginal ultrasonography was performed every other day during a spontaneous menstrual cycle. The diameter of the largest follicle in each ovary was measured in two directions in the sagittal plane, and in two directions in the coronal plane. In total, 304 follicular measurements were performed. The largest follicular diameter was compared to the mean diameter of two and three directions, respectively. The mean diameter of two directions was compared to that of three directions.

RESULTS

The mean difference between measurement in one and two directions was 1.2 mm (standard deviation (S.D.) = 1.1 mm), between measurement in one and three directions 1.2 mm (S.D. = 1.0 mm), and between measurement in two and three directions -0.03 mm (S.D. = 0.3 mm). The mean difference and the standard deviation of the difference increased with the follicular diameter.

CONCLUSIONS

In non-stimulated menstrual cycles, follicle measurement in only one direction is less accurate than measurement in two and three directions, and may result in clinically relevant differences. However, measurement in three directions gives no additional information compared to measurement in two directions.

Diagnosis of subtle ovulation disorders in subfertile women with regular menstrual cycles: cost-effective clinical practice?

Serial monitoring by plasma progesterone measurement is advised in the literature for fertility work-up, to detect ovulation disturbances in women presenting with regular menstrual cycles. Three strategies to diagnose such 'subtle ovulation disorders' (SOD, defined as anovulation, inadequately timed ovulation or ovulation of a follicle of reduced size in regularly cycling women) were evaluated, in order to investigate costs of such a diagnosis. On the basis of a 'maximal', an 'ultrasound-only', and a 'preselection' strategy, total medical costs and costs including non-medical costs were calculated for each SOD diagnosis. A 'maximal' diagnostic strategy resulted in a total medical cost of ECU 9057 per diagnosis (including non-medical costs ECU 12,787); an 'ultrasound-only' strategy in ECU 4520 (ECU 6791) per diagnosis. By use of a 'preselection' strategy, 4.25% of the women were found to have an SOD, at a cost of ECU 3036 (ECU 6868) for each diagnosis. As the real significance of SOD diagnosis for the prognosis of the patient to become pregnant without treatment remains unclear, and as no randomized trials on treatment effectiveness have as yet been undertaken, it is questionable whether this approach is worthwhile.

Radiological evaluation of infertility

With unwanted infertility on the rise, the radiologist is becoming increasingly involved both in the diagnosis and treatment of these patients. Assessment of the six most common factors causing infertility should be performed during the initial clinical evaluation. These six factors include the cervical factor, endometrial-uterine factor, tubal factor, ovarian factor, peritoneal factor, and male factor. Each of these groups will be discussed in detail with special attention to optimal methods of diagnosis. Hysterosalpingography and ultrasound play the major roles in evaluation; however, there is an important emerging role for newer techniques such as MRI and selective fallopian tube catheterization.

Effect of follicular size on oocyte retrieval, fertilization, cleavage, and embryo quality in in vitro fertilization cycles: a 6-year data collection

OBJECTIVE

To determine the effect of follicular size, including the size of the leading follicle, on oocyte retrieval, fertilization, cleavage, and embryo quality in IVF cycles based on a large data collection.

DESIGN

Retrospective analysis of 1,109 IVF cycles between 1987 and 1993 at the Hospital of the University of Pennsylvania including 606 patients ranging in age from 23 to 49 years.

RESULTS

Follicles with a volume < or = 1 mL show a significantly lower oocyte recovery rate than follicles with a volume of > 1 mL. The highest recovery rate (83.5%) was found in follicles with a volume of 3 to 4 mL. Above a follicular volume of 7 mL, the oocyte recovery drops below that observed for follicles between 1 and 7 mL. Fertilization and cleavage rates were also higher in oocytes obtained from follicles > 1 mL compared with follicles < or = 1 mL. Although fertilization rates were fairly stable above volumes of 1 mL, cleavage rates continued to rise to a peak percentage of 92% with volumes between 6 and 7 mL. Leading follicle size did not have an effect on fertilization and cleavage rates of cohort oocytes. Embryo quality was not influenced significantly by follicular volume.

CONCLUSION

Based on this evaluation of a large number of follicles, follicular size is a useful indicator of oocyte recovery, fertilization, and cleavage in IVF cycles. For optimal results, the follicular fluid volume in gonadotropin- and hCG-stimulated cycles should be > 1 mL, which corresponds to a follicle diameter of > 12 mm, and not larger than 7 mL (24 mm). For timing of hCG administration, the number of adequate size follicles appears to be more important than the size of the leading follicle(s).

Low luteal phase serum progesterone levels in regularly cycling women are predictive of subtle ovulation disorders

Serial hormonal and ultrasound measurements were performed in a group of 50 infertile women with regular menstrual cycles of normal length, and evidence of luteinization by measurement of biphasic basal body temperature (BBT). The progesterone levels however, remained below a critical threshold of 32 nmol/l (1 nmol/l = 0.315 ng/ml) in two cycles. In 50 cycles, 25 showed definite abnormalities. In 16 other cycles, ovulation was observed, but relatively low luteal progesterone followed. Although pregnancy in these 16 cycles could be less likely, the real significance of this finding is questionable. The etiology of these 'subtle cycle anomalies' is not clear and may be multifactorial. For this reason, no therapy other than use of ovulation-inducing agents by trial and error is as yet available. Preliminary results indicate that cycle disturbances may persist under ovulation induction, even though progesterone levels are normalized.

Comparison of hCG versus GnRH analog for releasing oocytes following ultra low-dose gonadotropin stimulation

Previous data have suggested there is a higher incidence of luteinized unruptured follicle (LUF) syndrome (defined as failure to release any oocyte as determined by sonography) in gonadotropin-treated patients following human chorionic gonadotropin (hCG) versus the gonadotropin releasing hormone agonist (GnRH-a) leuprolide acetate. The present study was designed to determine if an ultra low-dose gonadotropin regimen, designed not to raise the serum estradiol level much above normal for non-stimulated cycles, might result in a decrease in LUF following hCG treatment, and even reduce the rate to that seen following leuprolide acetate. The hypothesis tested was that the higher estradiol levels might suppress the pre-ovulatory follicle stimulating hormone (FSH) surge which, in turn, would inhibit plasmin production, thus preventing detachment of the oocyte from the follicle. The data did show a reduced rate of LUF incidence with either hCG or leuprolide acetate in ultra low-dose human menopausal gonadotropin-(hMG-) treated patients compared to data from previous studies with conventional hMG/hCG therapy. Pregnancy rates were also similar following hCG or leuprolide acetate for release in low-dose hMG-treated patients. Preliminary data show that leuprolide acetate is superior to hCG for causing oocyte release when stimulation is with low-dose purified FSH, and possibly also that low-dose hMG is superior to low-dose purified FSH for producing superior pregnancy rates.

The origin of estrogens, progesterone, androgens and sex hormone binding globulin in peritoneal fluid in the immediate postovulatory period in normal ovulating women

In 20 women with proven fertility, one menstrual cycle was monitored by ovarian ultrasonography, laparoscopy and estimation of 17 beta-estradiol (E2), estrone (E1), progesterone, testosterone, androstenedione (Adion), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), and sex hormone binding globulin (SHBG) in serum and peritoneal fluid. Three groups were studied, in which the peritoneal fluid was collected within 1, 3 and 5 days after ovulation. E1, E2 and progesterone levels in peritoneal fluid were highest shortly after ovulation and decreased with time. Testosterone and Adion in peritoneal fluid showed no changes, but peritoneal fluid levels were always higher than serum levels. No differences were found between the peritoneal fluid and serum levels of DHEA and DHEAS. SHBG in serum was always higher than in peritoneal fluid. The results are compared with reported steroid levels in follicular fluid from the literature and factors complicating the interpretation of steroid levels in peritoneal fluid are discussed.

Physicochemical properties of follicular fluid and their relation to in vitro fertilization (IVF) outcome

Despite the limited data that are available concerning FF physicochemical properties, the following conclusions can be drawn. (1) FF temperature is lower than ovarian stroma and body temperatures. The physiological significance of this gradient is unknown. (2) Follicular size increases exponentially prior to ovulation. The relationship between FF volume and successful IVF outcome is well established. (3) A highly significant association exists between fertilization (but not embryo cleavage) and FF spectrophotometric absorbance at delta optic density of 455 nm. (4) FF behaves as a non-Newtonian fluid--its viscosity changes at different shear rates. Neither FF viscosity nor its refractive index was found to correlate with the presence of oocytes, their maturation grade, or their fertilizing capacity. (5) FF osmolarity is similar to that of the plasma. There is no information linking variations in FF osmolarity to IVF outcome. (6) FF pH is acidic, probably due to acid mucopolysaccharides. It appears that the intact follicle is capable of buffering any carbon dioxide which diffuses through its wall at the time of intraperitoneal insufflation. The transvaginal aspiration technique eliminates any possible effect of exogenous gas on FF pH. (7) Regarding the intact follicle, it was shown that (a) there is a small potential difference across the follicle wall, and (b) intrafollicular pressure remains steady prior to ovulation. This information may shed some light on mechanisms underlying FF formation and ovulation. No experiments relating these properties to IVF outcome have been performed.

Effects of gonadotropin-releasing hormone (GnRH) agonist on pituitary and ovarian responses to pulsatile GnRH therapy in polycystic ovarian disease

Nine clomiphene citrate-resistant polycystic ovarian disease (PCOD) patients received intravenous gonadotropin-releasing hormone (GnRH) pulses before and immediately after 1 month of GnRH agonist (GnRH-a) therapy. Circulating gonadotropin and ovarian steroid levels, as well as follicular development, were measured throughout therapy. Results were compared with those obtained from five hypogonadotropic patients treated with GnRH pulses only who ovulated during six of seven treatment cycles. Only two PCOD patients ovulated normally with GnRH pulses before GnRH-a therapy. Aberrant gonadotropin and ovarian steroid secretory patterns were noted in the others. After GnRH-a, gonadotropin and ovarian steroid hormone levels were similar to those of the hypogonadotropic patients. Subsequent secretory responses to GnRH pulses were partially normalized. However, only two additional PCOD patients ovulated.

Ultrasonic assessment of ovulation in cyclofenil induced ovulatory cycles

Graafian follicle growth was studied by ultrasound scanning during the peri-ovulatory period in 64 ovulatory cycles in 32 infertile patients on cyclofenil treatment, and compared with a control group of 32 patients with confirmed ovulatory cycles assessed on the basis of serum progesterone levels in the middle of the second half of the cycle. The mean maximum diameters of the leading follicles before ovulation were 21.9 +/- 0.6 (S.E.) mm and 24.4 +/- 0.5 (S.E.) mm, respectively for the cyclofenil group and the normal control group (P greater than 0.05). In 79% of the cyclofenil stimulated group and 83% of the spontaneous ovulation group, ultrasonic evidence of ovulation was present between 12 and 36 h after the initial increase in urine LH levels. Ultrasound scanning was found to be simple, and a quick method of monitoring graafian follicle development and ovulation on cyclofenil therapy and the cycles were comparable to the spontaneous ovulatory cycles as assessed on the basis of graafian follicle diameter, and the time of ovulation. Cervical score was not found to be useful to assess ovulation time in the cyclofenil treated group since 31.3% achieved a score of 10 or more on day -4, 93.8% within 24 h of ovulation and 24% on day 3 following the ovulation.

Comparison of the results of vaginal and abdominal follicle scans

The hormonal profile and sonographical assessing of the number and size of the follicles are important in hyperstimulated cycles. Follicular imaging obtained by abdominal scanning may be distorted by echoes from the intestine or by unfavourable location of the ovaries and patients must have a full bladder. We compared the number and size of the follicles at abdominal sonography with the results obtained by vaginal sonography in 37 patients. Vaginal sonography showed more follicles than abdominal sonography because of improved imaging of small follicles on early days of cycle. This might help one to tailor the hyperstimulation to an individual's endocrine response.

Characteristics of ovarian follicles in spontaneous and stimulated cycles in which there was an endogenous luteinizing hormone surge

The growth of ovarian follicles was assessed with the use of ultrasound in spontaneous cycles and in cycles stimulated with clomiphene citrate (CC) alone, CC plus pulsatile human menopausal gonadotropin, and CC plus pulsatile follicle-stimulating hormone (FSH). At the time of the onset of the luteinizing hormone surge (LH), the size of the leading follicle did not differ significantly between the spontaneous and the stimulated cycles, although it was larger in the CC/FSH cycles. During the two days before the LH surge onset, the growth rate was faster in the stimulated than the spontaneous cycles. It is suggested that despite the provocation of extremely high plasma-estradiol levels and multiple follicular development, the leading follicle in stimulated cycles ovulated at a size equal to or greater than that in spontaneous cycles. The reason for the higher follicle size in the CC/FSH cycles is, as yet, unclear.

Follicular growth and endocrine profiles in spontaneous and induced conception cycles

Twenty conception cycles were tracked with ultrasound ovarian scanning from the midfollicular to midluteal phase, and simultaneous hormone profiles were obtained in 18 of the cycles. Twelve cycles were spontaneous and 8 were induced with a variety of regimens. Two of the spontaneous cycles did not have endocrine data, and in one other no follicular growth was observed, despite repeated scanning. The induced cycles did not differ significantly from the spontaneous ones in any respect except the number of follicles and the consequent estradiol (E2) levels. E2 levels per unit total follicular surface area, however, were similar in both groups and remained relatively constant throughout the late follicular phase.

Ultrasonic and endocrinologic investigation of ovarian follicle and free fluid in cul-de-sac for monitoring follicular development and ovulation

The accuracy of ultrasound as a means of monitoring follicular development and ovulation detection was studied in 31 infertile women. The follicular diameter measured by ultrasound correlated well actual diameter found during laparotomy (r = 0.88), and estradiol-17 beta (E2) and progesterone in follicular fluid aspirated from large follicles (greater than or equal to 16 mm) indicated high levels. Furthermore, in 23 out of the 55 cycles, ultrasound examinations demonstrated free fluid in cul-de-sac at ovulation, and concentrations of E2 and progesterone (P) in peritoneal fluid by the puncture of cul-de-sac dramatically increased after ovulation. We suggested that ultrasound monitoring provided a reliable measure of follicular growth and prediction of ovulation, and a combined use of ultrasound and puncture of cul-de-sac could be developed into a new tool for the study of the mechanism of human ovulation.

Urinary oestrogen levels and follicle ultrasound measurements in clomiphene induced cycles with an endogenous luteinizing hormone surge

Total oestrogen in urine and the ultrasonic size of the follicles were measured in relation to the onset of the endogenous luteinizing hormone (LH) surge (day 0) in 18 cycles induced with clomiphene citrate in an in-vitro fertilization programme. Oestrogen values in urine (microgram/24 h) increased progressively during the late follicular phase up to the day of the onset of the surge. The mean maximum follicle diameter (22.3, SD 4.7 mm) estimated by ultrasound was measured on day 0. At the onset of the LH surge, the values of urinary total oestrogen showed a better relation with the total volume of the first three follicles in order estimated by ultrasound (r = 0.71) than with the mean ultrasonic diameter of the leading follicle (r = 0.56). A wide range of individual values for both urinary oestrogen and follicle size was found. In another group of 32 women treated with clomiphene for recovery of oocytes used for research purposes, a good correlation was found between the mean ultrasonic follicle diameter 16 h before the laparoscopy and the follicle diameter calculated from the fluid volume at aspiration (r = 0.80). These results suggest that the decision when to give human chorionic gonadotrophin (hCG) in an in-vitro fertilization programme remains arbitrary in many individual cases. Apart from the oestrogen levels, the calculation of the size of all follicles, instead of only the leading one, may give further help in timing the hCG.

Correlation of follicular fluid volume with oocyte morphology from follicles stimulated by human menopausal gonadotropin

The maturity of human oocytes was correlated with corresponding follicular fluid volumes in 547 cycles stimulated with human menopausal gonadotropin, with or without the supplementation of follicle-stimulating hormone. Mature oocytes were found to be associated with larger follicles (average volume, 2.7 ml). Immature or degenerating oocytes were found to be associated with smaller follicles (average volume, 1.0 and 0.8 ml, respectively). Follicles without oocytes were generally quite small (average volume, 1.0 ml). We studied follicular fluid volumes associated with mature oocytes that were responsible for the establishment of pregnancy after single conceptus transfer. Analysis of these data demonstrated that the rate of spontaneous abortion was very high with conceptuses derived from smaller follicles, suggesting that oocytes from larger follicles may be of better quality.

Gynaecological history, complaints and examinations in a middle-aged population

A sample of women aged 40-56 years (n = 1349) was selected at random from the Census Register of Göteborg, Sweden. Altogether, 1095 (81%) filled out a questionnaire concerning gynaecological data. A control group (n = 170) was established and 135 women from this group (79%) underwent an extensive personal interview and pelvic examination. One aim was to investigate the representativity of the control group for the initial random sample and to compare the information obtained from the questionnaire with the information acquired by personal interview. An additional aim was to obtain information related to pelvic examination and FSH concentrations in the serum of middle-aged women. In general there was a good agreement between information from questionnaires and from personal interviews. The pelvic examination revealed that 53% of the post-menopausal women showed signs of genital atrophy and this condition was more common in sexually inactive than active women. Weakness of the pelvic floor was encountered in 16%. The uterus was of normal size in 94%, anteflexed in 76%, mid-positioned in 8% and retroflexed in 16%. There was a positive correlation between a pathological smear and cervical ectopy. Serum FSH values in menstruating women ranged from 6.4 to 47 IU/l. A cut-off value of 50 IU/l gave a complete separation between menstruating and post-menopausal subjects.

Ultrasound in the evaluation of normal and induced ovulation

In the past several years sonography has become an invaluable research tool for the investigation of spontaneous and induced ovulation and has added to the understanding of folliculogenesis and reproductive endocrinology. In practical terms, in ovulation induction sonography assists in the evaluation of the number and distribution of follicles, necessary for adequate interpretation of estrogen levels. Although there is no ideal size when it can be assumed that a follicle is mature, estimation of follicle size is of value and is a good guide to the timing of hCG administration. If the follicles are extremely small or there is evidence of hyperstimulation, these observations, together with the E2 levels, may be used to decide whether a further ultrasonic examination is warranted for the assessment of follicular growth or whether the treatment cycle should be abandoned. Provided follicular size is within normal limits, the diameter of the largest follicle may also be used in IVF programs to determine when the patient should be admitted to the hospital for more intensive monitoring of follicular development and the administration of hCG. Ultrasound is also valuable in patients with only one ovary accessible to laparoscopy. Even if the largest follicle is in the inaccessible ovary, the treatment cycle does not have to be abandoned, provided that several follicles are developing in the contralateral ovary. If neither ovary is accessible laparoscopically, percutaneous oocyte aspiration offers the patient the opportunity of IVF and embryo transfer.

Laparoscopic or ultrasonically guided follicle aspiration for in vitro fertilization?

Ultrasonically guided follicular aspiration is presented as an alternative method to laparoscopy for oocyte harvesting. The method is described in detail and compared to laparoscopic oocyte pickup. The success rate of this technique reached in 1984 compared to that of laparoscopic oocyte pickup was the same: the oocyte recovery rate was 93%, the fertilization rate was 58%, and the pregnancy rate was 13% (normal ongoing pregnancies per treatment cycle). Ultrasonically guided follicular aspiration is shown to be superior to laparoscopic oocyte recovery as far as ovarian accessibility and complication rate are concerned.

Hormonal and ultrasonic characteristics of 23 clomiphene citrate stimulated cycles resulting in pregnancies after in vitro fertilization and embryo transfer

In vitro fertilization (IVF) and embryo transfer (ET) were successful in 24 clomiphene citrate stimulated cycles in 22 patients. Ovarian follicular growth was monitored by ultrasound (US) and serum estradiol (E2) concentrations in order to determine the most favorable time for the induction of ovulation by administration of human chorionic gonadotropin (hCG). The day of the hCG injection was considered day 0. After an almost linear growth the mean diameter of the dominant follicle reached 19.3 +/- 2 mm on day 0. Serum E2 concentrations also increased in almost linear fashion up to a maximum of 1,037 +/- 322 pg/ml on day +1. On day 0 the mean serum E2 concentration was 862 +/- 279 pg/ml. A mean serum E2 concentration per dominant and codominant follicle of 328 +/- 100 pg/ml was found on day 0. There was no linear correlation between the follicular diameters and the serum E2-values on the same day. The time of ovum recovery was often different to the time at which ovulation would have been expected in a normal cycle.

Preovulatory serum estradiol-17 beta values and ultrasound scans in 17 pregnancies which followed in vitro fertilization and embryo transfer after treatment with clomiphene and hCG

17 patients whom we treated with clomiphene and hCG became pregnant after in vitro fertilization (IVF) and embryo transfer (ET). We now report on our experience with preovulatory estradiol 17 beta values and ultrasonography in determining the time of hCG administration in these patients. The mean estradiol value just before the hCG injection was 329 +/- 75 pg/ml/follicle. The mean follicle diameter on ultrasound was 23.4 +/- 1.5 mm on the same day. In four cases, we only used estradiol values and in one case only ultrasound for the timing of the hCG injection. Both methods of monitoring follicular growth are discussed.

The role of ultrasound in female infertility management

Ultrasound became an important help for the diagnosis of infertility by demonstration of the pelvic organs, of growing ovarian follicles, of intrafollicular structures and of cyclic uterine endometrial changes. Ultrasonic particularities of ovaries and their landmarks such as the ovarian artery, are described. Average ovarian blood flow can be measured. In hormone stimulated cycles, the ultrasonic examination is repeated through ovulation, induction and even afterward. The average diameter of the growing follicle is measured. The results of more than 8000 scans allowed the deduction that ovulation induction would be successful if the preovulatory follicular diameter was between 18 and 24 mm. Where two or more follicles of that diameter are present, multiple pregnancy occurs. The risk of overstimulation can be assessed. The importance of ultrasound is even higher than estradiol because it is impossible to differentiate between one big, some medium or many small follicles with hormone assays. It is possible to see the cumulus oöphorus, but not earlier than 1-2 days before ovulation. Following successful ovulation the mature follicle appears to have a more solid than cystic make-up. Signs of a failure of ovulation are given. Cyclic changes in the histology of the endometrium are described and make it possible to predict ovulation within 12 hr. Ultrasound is an important aid in predicting the time of ovulation more accurately than the basal body temperature and faster and cheaper than hormone profiles. Ultrasound plays a role in egg collection and replacement of the embryo. The detection of ovulation is very important in the treatment of infertility. This was only possible for a longtime by hormone profile. Nowadays ultrasound is an accepted method in the diagnostic procedures of this field. It permits the visualization of the position and size of the uterus, Fallopian tubes and ovaries, the exclusion of genital anomalies and the demonstration of physiological changes of these organs during the menstrual cycle. The main points of ultrasound in the diagnosis of infertility are as follows: Demonstration of the pelvic organs (uterus, Fallopian tube, ovary) and vascular structures. Demonstration of growing ovarian follicles (Measurement of their numbers and sizes). Demonstration of intrafollicular structures (Cumulus oöphorus, Corpus luteum). Demonstration of cyclic uterine endometrial changes. Most of the results were first obtained with high-resolution compound scanners, but the new generation of real-time scanners are equally capable. Sector scanners are superior to linear-array-parallel scanners, especially for the demonstration of specific structural ch

Diagnosis of luteinized unruptured follicle (LUF) syndrome by ultrasound

To evaluate the role of ultrasound in diagnosing luteinized unruptured follicle (LUF), 37 women with unexplained infertility were examined for two to three menstrual cycles. Laparoscopy or laparotomy was performed on days 16 to 18 of the third study cycle in 25 patients. The LUF syndrome was suspected at ultrasound examination in 57 of 100 cycles observed. In the remaining 43 cycles, follicular collapse was observed in 33, and 10 were diagnosed as anovulatory. At laparoscopy or laparotomy on 25 patients, 18 of the 21 patients diagnosed as having LUF by ultrasound had a corpus luteum without a stigma. The other three cases diagnosed as LUF by ultrasound had ovulation stigmata. Additional findings in the 25 patients who underwent laparotomy or laparoscopy were endometriosis in 7 (5 of whom had LUF as well), ovulation in 5, bilateral hydrosalpinx in 1, and inability to visualize the ovaries because of adhesions in 1. The LUF syndrome was not a consistent change in the ovulatory pattern of most of the patients. It occurred by ultrasound diagnosis in three consecutive cycles in only 34% of patients.

Assessment of follicular development in clomiphene induced cycles by means of ultrasound and laparoscopy: a comparative study

Fifty clomiphene/H.C.G. stimulated patients undergoing laparoscopy as part of their infertility work up consented to participate in a study on: the reproducibility of ultrasonic measurement of follicular size as expressed by the inter and intra observer variation; the accuracy of ultrasonic assessment of location, number and size of follicles and the growth rate of the Graafian follicle during the last 12 hr prior to oocyte collection. The inter and intra observer variation was moderate to good. Correct diagnosis of the dominant follicle was made in 73%, of the number of follicles in 72% and of follicular size (difference in size between ultrasound and laparoscopy less than 2 mm) in 48% of the material studied. There was a rather wide range in follicular growth rate values during the last 10-17 hr prior to laparoscopy.

Ultrasound measurement of ovarian follicles stimulated by human gonadotropins for oocyte recovery and in vitro fertilization

Ultrasonic monitoring of ovarian follicles and estimation of serum estradiol (E2) were performed in 51 patients in whom oocyte aspiration for in vitro fertilization was planned. All patients received human menopausal gonadotropin and human chorionic gonadotropin. The daily growth rates of ovarian follicles were recorded ultrasonically for 6 days prior to aspiration. Serum plasma E2 was determined daily during the same period. Follicular dimensions based on the volume of aspirated fluid correlated very well with the ultrasonic measurements. Follicular growth was correlated with increasing peripheral blood E2 levels. The mean follicular diameter increased from 10.8 mm 6 days before aspiration to a maximum of 16.0 mm on the day of presumptive ovulation in a group of patients characterized as low E2 responders. In normal and high E2 responders, the values were from 9.7 mm and 10.5 mm to 16.9 mm and 17.6 mm, respectively. The mean sizes of the follicles by ultrasound 20 hours before laparoscopy were 16.0 mm for the right ovary, 16.6 mm for the left ovary, and 18.5 mm in patients with only one ovary. At laparoscopy the mean diameters calculated from the volume of the aspirated fluids were 17.5 mm, 17.4 mm, and 19.3 mm, respectively. Multiple follicles developed in all but 2 of the 51 patients.

Ultrasonic measurement of ovarian follicles during chronic LRH agonist treatment for contraception

Ultrasonic examinations of ovarian follicles were performed in seven healthy women on continuous luteinizing hormone-releasing hormone (LRH) agonist treatment for contraception. Four of the women had 1-4 uterine bleedings during the four-month study period and the remaining three women developed amenorrhea. The follicle diameter varied during LRH agonist treatment up to or above the preovulatory size of the normal menstrual cycle in the menstruating group of women. No ovulation occurred as judged by the low progesterone levels in serum. Slightly raised progesterone concentrations (mean 7.6 nmol/l) were observed during four treatment cycles with persistent follicles indicating luteinization of unruptured follicles. No or only small ovarian follicles (8-10 mm) were visualized by ultrasound in the amenorrheic group of women. This study further establish previous reports that chronic LRH agonist treatment effectively inhibits normal ovulation in regularly menstruating women.

Ultrasound monitoring of ovarian follicular development: a comparison real-time and static scanning techniques

Follicular growth was monitored in 19 patients during 20 spontaneous and induced cycles by different examiners in a blind trial using a real-time linear array, a mechanical sector scanner, and a gray scale compound scanner. This was done to compare the efficacy of different ultrasound equipment in the study of ovarian cycle. The mean maximum follicular diameter was calculated with each equipment and the quality of follicular images was classified as poor, sufficient, and good as defined in the study. The overall best results in ovary and follicle visualization were achieved with the real-time sector scanner. Measurements of the same dominant follicle using realtime and compound scanners were highly correlated (linear array/compound scanner: r = 0.894, p less than 0.001; sector/compound scanner: r = 0.928, p less than 0.001). Following ovulation, some unexpected differences in the distribution of the postovulatory patterns were noted with each instrument. Except in difficult patients, real-time examination, preferably performed using a sector scanner, appears to be the optimal first ultrasonic approach for monitoring follicular growth.

Correlation of ultrasonic measurement of ovarian follicle size and serum estradiol levels in ovulatory patients following clomiphene citrate for in vitro fertilization

Ovarian follicle development was investigated in 38 normally cycling women who received clomiphene citrate, 150 mg per day for 5 days, to maximize follicular development. Ultrasonic determination of follicle growth was performed on a daily basis with a real-time sector scanner and correlated with daily concentrations of estradiol (E2) in the peripheral serum as measured by rapid radioimmunoassay. Human Chorionic gonadotropin was given to induce ovulation, and the day of injection was considered day 0. Mean concentrations of E2 reached a maximum of 1,150 +/- 65 pg/ml on day 0. Mean diameter of the dominant follicle increased to 22.1 +/- 0.4 on day 0. When peripheral concentrations of E2 were correlated with diameter and total follicular volume it was found that plasma E2 levels varied, depending on the number of follicles seen on ultrasound examination, with a mean E2 value of 459 +/- 18.9 pg/ml per follicle per day. Multiple growth of follicles occur with artificial induction of ovulation; therefore, the use of ultrasound is an important parameter to assess follicular maturation and the timing of ovulation more precisely.

Premature ovulation after ovarian ultrasonography

Whereas follicle rupture never occurred before the 37th hour after an ovulatory stimulus (either the onset of the LH surge or hCG administration) in control patients, ovulation was observed at 26 to 36 h in women submitted to ultrasonography during the late follicular phase. Premature ovulation was observed in 5 out of 23 and 8 out of 19 cycles when ultrasonography occurred during the 3 days preceding or in the 36 h following ovulatory stimulus. This as yet unexplained observation leads us to reconsider the advisability of ovarian scan during the late follicular phase of the menstrual cycle.

Ultrasound observations in patients on gonadotrophin therapy

Twenty-four courses of ovulation induction with HMG-HCG were accompanied by ultrasound sector scanning. The results of cross-sectional studies did not deviate from those reported for normal cycles. Cross-sectional studies indicate smaller peak follicular volumes than repeated measurements of the same follicles. Results may, however, be influenced by frequency and time of measurements, as well as frequency and time of coitus for the patients. Peak-size follicular volumes in patients who became pregnant were relatively large. Peak volumes connected with subsequent pregnancies may therefore have another range of variation than follicles releasing oocytes which will remain unfertilized.