Ultrasound in the evaluation of normal and induced ovulation

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.

Sporadic anovulation is not an important determinant of becoming pregnant and time to pregnancy among eumenorrheic women: A simulation study

BACKGROUND

Attaining pregnancy is conditional upon a series of complex processes, including adequately timed intercourse, ovulation, fertilisation, and implantation. Anovulation is a first-line treatment target for couples with difficulty conceiving and is frequently examined in studies of fecundability.

OBJECTIVES

To identify whether sporadic anovulation is an important determinant of cumulative pregnancy rates and time to pregnancy among fertile women with regular menstrual cycles.

METHODS

We simulated cumulative pregnancy rates and time to pregnancy for 12 consecutive menstrual cycles among 100 000 women based on data-driven probabilities of implantation, fertilisation, ovulation, and intercourse occurring in the fertile window. We assumed anovulation probabilities of 1%, 8%, or 14.5% and intercourse averaging once per week, every other day, or daily. The model incorporated reductions in implantation and fertilisation rates for successive cycles of non-pregnancy.

RESULTS

After 12 cycles, a reduction in the per cycle incidence of anovulation from 14.5% to 1% resulted in a 4.0% higher cumulative pregnancy rate (86.7% vs 90.7%) and similar time to pregnancy (1-cycle median difference). In contrast, increasing mean unscheduled sexual intercourse frequency from weekly to every other day was associated with a 5-cycle median reduction in time to pregnancy (weekly: 7 cycles; every other day or daily: 2 cycles) and a 28.9% increase in the cumulative pregnancy rate (weekly: 59.9%, every other day: 88.8%; daily: 91.6%).

CONCLUSIONS

In presumed fertile women with regular menstrual cycles, routine investigation of anovulation may not be an informative outcome in studies of fecundability, and routine testing to ensure ovulation and treatment of anovulation are unlikely to be medically necessary. While biomarkers or cervical fluid may help time intercourse to the fertile window, time to pregnancy can also be improved through increasing the frequency of unscheduled intercourse. These findings need corroboration in large preconception time to pregnancy studies.

Three-Dimensional Automated Volume Calculation (Sonography-Based Automated Volume Count) versus Two-Dimensional Manual Ultrasonography for Follicular Tracking and Oocyte Retrieval in Women Undergoing in vitro Fertilization-Embryo Transfer: A Randomized Controlled Trial

Aim:

To compare the oocyte yield using three-dimensional (3D) automated and two-dimensional (2D) ultrasound-based follicle tracking in women undergoing in vitro fertilization-embryo transfer (IVF-ET).

Settings and Design:

A randomized controlled trial was conducted in the Reproductive Medicine Unit of a teaching medical institute from January 2017 to December 2018.

Materials and Methods:

A total of 130 patients undergoing IVF-ET were enrolled and randomized into two groups (65 patients in each group). In Group A, follicular tracking during controlled ovarian stimulation (COS) was done using 3D Sonography- based Automated Volume Count (SonoAVC), whereas in Group B, follicular tracking was done by manual ultrasonography (2D USG). The primary outcome measures were the number of oocytes retrieved (the total number and the number of mature oocytes). Secondary outcomes were fertilization rate, cleavage rate, total number of embryos and time taken to perform scans. Other outcome measures were clinical pregnancy rate, miscarriage rate and live birth rate (LBR).

Statistical Analysis Used:

Chi-square test, Student's t-test, Z-test, Wilcoxon rank-sum test, Bland–Altman's plot.

Results:

The two groups were comparable with regard to assisted reproductive technology (ART) outcomes. Group B required more time for performing the scan (P < 0.01).

Conclusion:

Automated SonoAVC ultrasound can be used interchangeably with manual 2D USG for follicle tracking during COS giving comparable ART outcomes with the added advantage of saving time. Our study implies the promising results of applying artificial intelligence in follicular tracking during COS.

Assessment of ovarian follicular dynamics and folliculogenesis associated endocrine profiles following gonadotropin stimulation in the bonnet monkey

We evaluated ovarian follicular dynamics in bonnet monkeys by employing trans-abdominal ultrasonography. Following the administration of human follicle stimulating hormone (hFSH) and/or human menopausal gonadotropin (hMG), multiple follicular development was assessed and their numbers, size and growth profiles were monitored. The ultrasonograms showed that the follicular antrum appeared distinctly anechoic with well-defined hyperechoic borders. Depending on the type, quantity (12.5-25IU), and duration (6-9days) of hormones administered, the number of developing follicles was 2-12 per ovary with their lowest diameter being 2mm. With continued hormone administration, their numbers and diameters increased; which were more pronounced in animals administered with hFSH than with hMG, with follicles of 6-8mm. Interestingly, human chorionic gonadotropin (hCG) injection (2000-3000IU), when follicles acquiring >6-8mm sizes, induced the maximum expansion of antral follicles with sizes reaching up to 14mm. On days 3-5 post-hCG, the ultrasonograms showed loosely demarcated multiple hypoechoic structures and well-demarcated hyperechoic structures with anechoic/hypoechoic cores corresponding to unruptured luteinized follicles and corpora lutea, respectively. On day 4 post-hCG, there was a substantial reduction in the number of antral follicles. In stimulated animals, follicular growth, ovulation, and formation of luteal structures were accompanied by corresponding physiological changes in the serum estradiol and progesterone profiles. These findings, for the first time, showed that ultrasonographic imaging approach is useful for precise monitoring of temporal changes in follicular developmental dynamics and to time the hCG induced ovulation in the bonnet monkey.

Does optimal follicular size in IUI cycles vary between clomiphene citrate and gonadotrophins treatments?

OBJECTIVE

To evaluate pregnancy-related leading follicles during ovulation induction and superovulation with clomiphene citrate (CC) or gonadotropin.

DESIGN

Retrospective cohort.

PATIENTS

Five hundred and forty-two women who underwent a total of 615 treatment cycles with CC or gonadotropin.

INTERVENTION

We evaluated the effects of CC and gonadotropin on the leading follicles, clinical pregnancy rates and miscarriage rate.

RESULTS

The number of follicles larger than 15 mm in the different protocols was comparable. In those treated with CC, the diameter of the dominant follicles before human chorionic gonadotropins (hCG) trigger in the conception cycles (20.4 ± 1.2 mm) was significantly larger than in the non-conception cycles (18.8 ± 1.9 mm). In women treated with gonadotropin, the diameter of the leading follicle in the conception cycles (18.5 ± 1.7 mm) was comparable to that in the non-conception cycles (18.2 ± 1.7 mm). The pregnancy-related diameter of the leading follicle in CC cycles (20.4 ± 1.2 mm) was significantly larger than that in gonadotropin cycles (18.8 ± 1.9 mm; p = 0.001; 95% CI, -2.2 to -0.9).

CONCLUSION

Pregnancy-related diameter of the leading follicle in CC cycles is significantly larger than that in gonadotropin cycles and the best time for hCG trigger in the CC cycle is when the leading follicle reaches 20 mm.

Evaluation of ultrasonography for monitoring follicular growth in rhesus monkeys

The purpose of this study was to determine if the ovaries and uterus of rhesus monkeys could be visualized by ultrasonography and to detect changes associated with follicular growth and ovulation. Animals were examined during 15 menstrual cycles, for an average of nine consecutive days. Ultrasonic recordings were correlated with hormonal parameters (estradiol 17beta, E(2); luteinizing hormone, LH; and progesterone, P) and laparoscopic findings. The uterus and both ovaries were observed in more than 90% of the examinations. A dominant follicle (DF) was identified during all ovulatory cycles, on average 1 d preceding the E(2) peak. The maximal diameter of the DF ranged from 3 to 7 mm. Laparoscopic examinations to determine the site of the DF confirmed ultrasonic findings in 10 of 14 cycles (P < 0.1). There was no significant difference in the size of the dominant and contralateral ovaries; however, more follicles with a diameter of 2 to 7 mm were found on the dominant ovary (P < 0.05). Two animals stimulated with exogenous gonadotropins showed a linear increase in ovarian size for 6 d prior to oocyte recovery (P < 0.05), reflecting an increase in the number of developing follicles. Ultrasonography can be used to identify the DF during spontaneous cycles in rhesus monkeys and to monitor the response of monkeys to exogenous gonadotropins.

Comparison of automated and manual follicle monitoring in an unrestricted population of 100 women undergoing controlled ovarian stimulation for IVF

BACKGROUND

Ovarian response to gonadotrophin stimulation is monitored with serial ultrasound (US) examinations. Sonography-based Automated Volume Count (SonoAVC) is a relatively new three-dimensional (3D) US technology, which automatically generates a set of measurements including the mean follicular diameter (MFD) and a volume-based diameter (d(V)) for each follicle in the ovaries. The present study aimed to assess the applicability and reproducibility of this automated follicle measurement method in an IVF programme.

METHODS

For this prospective method comparison study, 100 women undergoing US monitoring of a controlled ovarian stimulation cycle were recruited. Each follicle was manually measured by taking the mean of maximal diameters on three orthogonal planes with two-dimensional (2D) US. A 3D volume of each ovary was then captured. The ovarian volumes were later analysed using SonoAVC. The agreement between the two methods for the numbers of follicles and the size of the leading follicle was assessed with the Bland-Altman method. The reproducibility of SonoAVC measurements was assessed with the intraclass correlation coefficient (ICC).

RESULTS

Both SonoAVC-generated MFD and d(V)-based follicle counts, as well as the leading follicle diameter, had good agreement with conventional 2D US measurements. SonoAVC measurements had very good reproducibility, with ICC ≥0.8 for most evaluations.

CONCLUSIONS

Automated follicle monitoring with SonoAVC can replace or be used interchangeably with conventional 2D measurements. Automated follicle monitoring can save time, provide a method of quality control and create opportunities for developing HCG criteria based on follicular volume or for monitoring patients from a distance.

Changes in ultrasound morphology of the uterus and ovaries during the menopausal transition and early postmenopause: a 4-year longitudinal study

OBJECTIVES

To describe changes in uterine and ovarian size and morphology as determined by ultrasonography from 2 years before to 2 years after menopause.

METHODS

Twenty 50-year-old women with fairly regular vaginal bleeding at the start of the study underwent transvaginal ultrasound examination every 3 months until 12 months postmenopause, then every 6 months until 24 months postmenopause. The results are presented from 2 years before to 2 years after the menopause.

RESULTS

In the 2 years preceding menopause all the women were in menopausal transition. From 2 years before to 2 years after menopause uterine anteroposterior diameter decreased by 22% (mean) and left and right ovarian volumes by 45 and 20% (median), respectively. At 2 years before the menopause the total number of intraovarian follicle-like cystic structures varied from 0 to 5, at the menopause from 0 to 7, and at 1 and 2 years after the menopause from 0 to 4 and from 0 to 2, respectively. Premenopause, the most common finding was that of ovaries containing either no follicles or a few follicles with at least one measuring >/= 11 mm and simultaneously a hyperechogenic endometrium of varying thickness and not manifesting any midline echo or triple-layer appearance. Images compatible with the late follicular phase were found in 6% (9/150) of examinations ('cycle day' 8-196) and images compatible with the luteal phase in 7% (10/150) ('cycle day' 11-56). Intraovarian cystic structures (3-25 mm) were seen in 14 women after the menopause.

CONCLUSION

We have described sonographic changes in the uterus and ovaries occurring during the transition from premenopause to postmenopause.

The effects of GnRH antagonist on the endometrium of normally menstruating women

PURPOSE

To study the effects of GnRH antagonist (ganirelix-Orgalutran) on the endometrium of regularly menstruating women.

MATERIALS AND METHODS

Prospective, self-controlled study. The thirty-five volunteers were studied for two cycles: one as a control and the other, GnRH antagonist-treated cycles in which ganirelix 0.25 mg/d was given daily for 3 days, starting when the largest follicle reached 15 mm. In both cycles, serum estradiol, LH and endometrial thickness were measured when the largest follicle was > or =18 mm. Endometrial biopsy was performed on day 6 after ovulation for histological dating and morphometric study.

RESULTS

No statistical differences between histological dating and the endometrial thickness in the control and GnRH antagonist-treated cycles. All morphometric parameters were also not different. Serum estradiol and LH levels were significantly lower in GnRH antagonist-treated cycles.

CONCLUSION

GnRH antagonist has no effect on the endometrium of regularly menstruating women as assessed by either histological dating or morphometric analysis.

Estimation of the follicle-stimulating hormone (FSH) threshold for initiating the final stages of follicular development in women with elevated FSH levels in the early follicular phase

OBJECTIVE

To test the hypothesis that the follicle-stimulating hormone (FSH) threshold in patients with elevated FSH levels in the early follicular phase (EFP) is higher than in controls.

DESIGN

Pilot study.

SETTING

Academic hospital.

PATIENT(S)

Six patients with elevated EFP FSH (>10 IU/L) and 13 controls.

INTERVENTION(S)

Treatment with a GnRH agonist in the midluteal phase before IV administration of recombinant FSH was started in an ultra-low-dose step-up protocol. The FSH threshold was determined by the mean of FSH levels of the above threshold value and the below threshold value.

MAIN OUTCOME MEASURE(S)

Follicle-stimulating hormone threshold, FSH screening value, E(2), number of follicles.

RESULT(S)

The FSH threshold in the elevated EFP FSH group was 6.75 IU/L and was significantly higher than the FSH threshold of the controls (4.65 IU/L). The FSH screening value on day 3 was 12.0 IU/L in the patient group and 5.0 IU/L in the controls. Estradiol was significantly lower on the day that the largest follicle was 18 mm in the elevated EFP FSH group compared with controls (277 vs. 491 pmol/L, respectively). On the day of hCG administration, the number of smaller (10-13 mm) follicles was equal but the number of larger (>14 mm) follicles was higher in the control group compared with the elevated FSH group. In the control group, the basal FSH levels correlated highly with the FSH threshold levels (r = 0.8), but in the patients with elevated EFP FSH this correlation was absent.

CONCLUSION(S)

In normal women, basal FSH day 3 values represent the ovarian threshold for FSH. In women with elevated day 3 FSH, the FSH threshold is higher but not as high as basal FSH values. We postulate that the FSH threshold in patients with elevated EFP FSH is higher because of intraovarian factors. Basal FSH overshoots the threshold, probably because of the limited feedback by the ovary.

One versus two inseminations per cycle in intrauterine insemination with sperm from patients' husbands: a systematic review of the literature

OBJECTIVE

To study the efficacy of performing two inseminations per cycle in IUI with husband's sperm compared with one insemination per cycle.

DESIGN

Meta-analysis.

SETTING

Randomized and prospective trials comparing two inseminations vs. one insemination per cycle in IUI with husband's sperm, retrieved by MEDLINE and Cochrane Library searches (1966-2001) and a manual search of the abstracts of the European Society of Human Reproduction and Embryology and American Society for Reproductive Medicine annual meetings (1990-2001).

PATIENT(S)

A total of 865 patients underwent 1156 cycles of IUI with husband's sperm.

INTERVENTION(S)

After different ovarian stimulation protocols, one or two inseminations were performed.

MAIN OUTCOME MEASURE(S)

Pregnancy rate per cycle. Detected studies were tested for homogeneity. Because heterogeneity was observed, DerSimonian-Laird relative risk with alleatory effects was used.

RESULT(S)

Six randomized and prospective trials involving 865 patients and 1156 cycles were identified. There was remarkable heterogeneity among the different studies concerning methodology, especially regarding ovarian cycle management and the timing of inseminations. Although the pregnancy rate per cycle was somewhat higher in the two-inseminations-per-cycle group (14.9% vs. 11.4%), there were no statistically significant differences (relative risk = 1.34; 95% confidence interval 0.90-1.99).

CONCLUSION(S)

No significant differences were observed when two inseminations per cycle were performed, compared with one insemination. There was great heterogeneity concerning ovarian management and insemination timing. This heterogeneity hampered the analysis. We detected a better pregnancy rate with two inseminations vs. one insemination when clomiphene citrate with or without gonadotropins and 5000 IU of hCG were used. More studies are necessary to ascertain whether this is true or merely an artifact from the multiple subgroups analysis.

Hormonal and ultrasound characteristics of menstrual function during chronic hemodialysis and after successful renal transplantation

The cycles of 11 renal transplant recipients (RTR), at least 24 months after stabilization of graft function and four hemodialyzed (HD) patients, menstruating regularly, were evaluated by concurrent and systematic determinations throughout the cycle of LH, FSH, estradiol, progesterone, testosterone, prolactin and SHBG and in the case of RTR also by ultrasound follow-up. Biphasic estradiol secretion, midcycle LH and FSH surge, duration of luteal phase, midluteal progesterone values and in the case of RTR, ultrasonic parameters were consistent with: (1) normal ovulatory cycles in five RTR; (2) ovulatory cycles with luteal phase deficiency in five RTR and two HD patients; (3) anovulatory cycles in one RTR and two HD patients. Thus, in HD patients only abnormal cycles of central etiology were found, while in RTR, luteal phase deficiency was a very common syndrome, in equal percentage with normal ovulatory cycles.

Delayed first injection of the once-a-month injectable contraceptive containing 25 mg of medroxyprogesterone acetate and 5 mg of E(2)-cypionate: effects on ovarian function

OBJECTIVE

To assess whether women who were administered the first injection of DMPA+E(2)C on day 7 of their menstrual cycle (delayed injection) exhibit the same degree of ovarian suppression as women who receive it on day 5 of their menstrual cycle.

DESIGN

Multicenter, randomized controlled trial.

SETTING

Reproductive health clinics.

PATIENT(S)

Women aged between 18 and 38 years (inclusive) willing to use DMPA+E(2)C as their method of contraception.

INTERVENTION(S)

Participants received a DMPA+E(2)C injection on day 5 (control group, n = 41) or day 7 (delayed-injection group, n = 117) of their menstrual cycle.

MAIN OUTCOME MEASURE(S)

Ovarian activity and follicular development determined by serial serum progesterone levels and vaginal ultrasound.

RESULT(S)

Participants who received DMPA+E(2)C on day 5 of their menstrual cycle (control group) exhibited no more than limited follicular growth (no follicle >16 mm). Of those women who received DMPA+E(2)C on day 7 of their menstrual cycle (delayed-injection group), 21 (18%) showed some follicular growth, of whom 4 (3%) ovulated.

CONCLUSION(S)

The first injection of DMPA+E(2)C given on day 7 of a menstrual cycle does not provide the same inhibition of ovarian activity as that observed when it is administered on day 5 of the menstrual cycle.

Ultrasonographic assessment of endocervix and cervical mucus in ovulatory menstrual cycles

OBJECTIVE

In addition to the routinely used methods to evaluate the menstrual cycle, a new method will be described, assessing the aspect of the endocervix and the presence of cervical mucus by transvaginal ultrasonography.

STUDY DESIGN

36 healthy female volunteers with regular menstrual cycles participated in the study. Transvaginal ultrasonography was performed every other day until ovulation was observed, assessing the diameter of the largest ovarian follicle, endometrial thickness, the aspect of the endocervix, and the presence of cervical mucus. On the same days serum hormone concentrations were determined.

RESULTS

Changes in the echodensity of the endocervix were observed in 35 volunteers, from 7 (1-19) (median and range) days before ovulation onwards. The presence of cervical mucus could clearly be observed in the preovulatory phase in 25 volunteers, from 3 (1-7) days before ovulation onwards.

CONCLUSION

Preovulatory changes in the aspect of the endocervix and cervical mucus can be observed by transvaginal ultrasonography. Ultrasonography of the cervix may offer an additive diagnostic tool in fertility disorders and will, in many cases, make visual inspection of the cervix unnecessary.

Timing of onset of contraceptive effectiveness in Depo-Provera users. II. Effects on ovarian function

OBJECTIVE

To determine the timing of onset of contraceptive effectiveness after the first injection of 150 mg of depot medroxyprogesterone acetate (DMPA) administered between days 8 and 13 of the menstrual cycle.

DESIGN

Descriptive, prospective study.

SETTING

A tertiary university referral center.

PATIENT(S)

Thirty healthy women between 18 and 40 years of age.

INTERVENTION

Volunteers were injected with DMPA between days 8 and 13 (5 women on each day) of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Ovarian function determined by serum levels of E2 and progesterone and follicular development evaluated by vaginal ultrasound.

RESULT(S)

In nine (30%) of 30 women studied, DMPA did not prevent ovulation. All ovulations occurred in women receiving DMPA between days 10 and 13 of the cycle. No woman who received injections on day 8 or 9 ovulated. Ovulation suppression was more effective in women with low ovarian activity. All ovulation occurred within 3 days after the injection.

CONCLUSION

A back-up contraceptive method, used after the 7th day of the menstrual cycle, is recommended for up to 7 days after the first injection of DMPA.

Cohort size rather than follicle-stimulating hormone threshold level determines ovarian sensitivity in polycystic ovary syndrome

The aim of the presented study was to compare FSH threshold levels and ovarian response to stimulation with one of two standard increments of exogenous FSH above the threshold in patients with polycystic ovary syndrome (PCOS) (n = 12) and eumenorrheic women (n = 11). The individual FSH threshold was determined by treatment according to a low-dose, step-up protocol with urinary FSH (Metrodin; Ares Serono, Geneva, Switzerland). In a subsequent treatment cycle, six PCOS patients and six eumenorrheic women were randomly assigned to double-blind treatment with the threshold dose plus 1/2 ampoule; the other six PCOS patients and five eumenorrheic women were treated with 1 ampoule above the threshold dose. Determination of threshold levels showed no significant differences in median and range between PCOS patients and eumenorrheic women. The number of follicles on the day of human chorionic gonadotropin administration showed no significant correlation with the increase in FSH level above the threshold level. Irrespective of the dose given, the number of follicles in the PCOS group was significantly higher than in eumenorrheic women. The higher sensitivity for gonadotropin stimulation in patients with PCOS compared with women with regular menstrual cycles therefore appears not to be dependent on differences in FSH threshold level, but rather on the larger size of the FSH sensitive cohort of small antral follicles.

Pregnancy rates using CC/hMG or hMG alone

OBJECTIVE

The purpose of our study was to determine which of the two drug regimens is more successful in achieving conception in the infertile couple.

SUBJECTS

One hundred and sixty women with primary infertility were included in this study. Group A, consisted of 102 patients were treated with clomiphene citrate (CC) and human menopausal gonadotrophin (hMG). Group B, consisted of 58 patients were treated with hMG alone.

METHODS

This retrospective study was performed between April 1993 and March 1996, to compare the pregnancy rates in women using two drug regimens with ultrasound scan and serum E2 to monitor ovulation induction.

RESULTS

The pregnancy rate per patient in Group A was significantly higher than in Group B (46% vs 25.9%) as was the pregnancy rate per treatment cycle (31.3% vs 15.8%) pregnancy loss was lower in Group A than in Group B (17% vs 33.3%). The incidence of multiple pregnancy was 8.5% in Group A, and 13.3% in Group B. While the incidence of ovarian hyperstimulation syndrome was 3% in Group A, and 6.9% in Group B.

CONCLUSIONS

We concluded that the use of CC + hMG in an assisted conception programme gives a better pregnancy rate 46% than in the hMG alone 25.9%. These data with the use of U/S scan and serum E2 clearly showed that the use of CC + hMG is a successful and safe method for the treatment of infertile patients.

The importance of endogenous feedback for monofollicular growth in low-dose step-up ovulation induction with follicle-stimulating hormone in polycystic ovary syndrome: a randomized study

OBJECTIVE

To evaluate the role of endogenous feedback in monofollicular growth during low-dose gonadotrophin therapy in polycystic ovary syndrome (PCOS) by measuring FSH levels in a group of patients cotreated with a GnRH agonist (GnRH-a) (group B) compared with patients not cotreated with an agonist (group A).

DESIGN

Prospective randomized study.

SETTING

University tertiary care Reproductive Endocrinology Unit.

PATIENTS

Women with clomiphene citrate-resistant PCOS.

MAIN OUTCOME MEASURES

Follicle-stimulating hormone, E2, and inhibin levels, follicular growth.

RESULTS

In group A, FSH levels decreased significantly from 7.3 mIU/mL (conversion factor to SI unit, 1.00) at day -5 to 5.9 mIU/mL at day 0 (day that hCG was administered) despite a constant dose, whereas they remained at a level of 7.4 mIU/mL in group B. The rate of monofollicular growth was significantly higher in group A (80%) than in group B (22%). No significant differences in E2 levels or inhibin levels were found between the groups.

CONCLUSIONS

The absence of a decrease of FSH during GnRH-a treatment in association with a lower rate of monofollicular growth suggests that endogenous feedback during low-dose step-up ovulation induction in PCOS plays an important role. The absence of this feedback mechanism in the presence of normal inhibin levels suggests that negative feedback control by inhibin during follicular stimulation is minimal.

Developmental failure in preimplantation human conceptuses

The majority of human conceptuses fertilized normally in vitro fail to establish a pregnancy following their replacement in utero. However, since conceptuses are usually transferred after only one or two cell divisions, their developmental outcome is not known. It has been found that a significant number of human oocytes which can be fertilized carry chromosomal abnormalities, even in the absence of ovarian stimulation. After fertilization, preimplantation-stage conceptuses developing in vitro display a high incidence of cellular abnormalities. Similar disruptions of cellular organization have also been noted in conceptuses fertilized in vivo. Thus, developmental abnormalities and the demise of the conceptus prior to the stage of implantation may stem from the poor quality of the oocyte. The conditions encountered in vitro have also been proposed to cause or contribute to the early demise of human conceptuses.

The relationship between follicle-stimulating hormone dose and level and its relevance for ovulation induction with adjuvant gonadotropin-releasing hormone-agonist treatment

OBJECTIVE

To investigate the effect of a GnRH agonist (GnRH-a) on the FSH threshold level and the relationship between the FSH dose and the FSH level of patients suffering from polycystic ovarian syndrome (PCOS).

DESIGN

The stimulation with low-dose FSH in PCOS (group 1) was compared with the subsequently performed stimulation with low-dose FSH combined with GnRH-a in another group of patients suffering from the same syndrome (group 2).

SETTING

Specialist Reproductive Endocrine Unit.

PATIENTS

Suffering from clomiphene citrate-resistant PCOS.

MAIN OUTCOME MEASURES

The FSH threshold level for ongoing follicular growth and the relationship between dose and level of FSH.

RESULTS

In 15 patients in group 1 and in 13 patients in group 2, respectively, 39 and 32 stimulation cycles were performed. Below and above threshold values of FSH of group 1 and 2 did not differ significantly. For the equation stable level of FSH (Y mIU/mL) = A X infusion rate of FSH (X IU/24 h) + basal level of FSH (B mIU/mL), the median A of group 1 was 0.027 and A of group 2 was 0.055 (significant difference).

CONCLUSIONS

In PCOS, a change of the FSH threshold level for ongoing follicular growth induced by the GnRH-a could neither be proven nor ruled out. The use of a GnRH-a resulted in larger FSH level increases per IU/24 h of FSH administered and might therefore interfere with the effect of low-dose FSH treatment.

The value of transabdominal pelvic ultrasonography in monitoring of ovulation induction with gonadotropins

Seventy-five patients with a total of 306 human menopausal gonadotropin treatment cycles over the period 1984-1989 were analysed retrospectively to evaluate the value of transabdominal pelvic ultrasonography in prevention of complications arising from ovulation induction with human menopausal gonadotropins. There were 60 pregnancies giving a pregnancy rate of 19.6% per cycle. There was positive correlation between the number of follicles > or = 14 mm in mean diameter and the incidence and degree of hyperstimulation (p < 0.005) as well as the incidence of multiple pregnancies (p < 0.01). Ultrasonography is a useful adjunct for monitoring in such a program.

The reliability, acceptability and applications of basal body temperature (BBT) records in the diagnosis and treatment of infertility

The possibilities and limitations of basal body temperature (BBT) records as an adjunct in the management of infertility were re-evaluated. To assess its accuracy as an index of ovulation, 172 charts were analyzed by three different physicians. While the average true positive rate was 90%, the false negative rate was only 2%. The remaining graphs (8%) were classified as non-interpretable, probably reflecting measurement problems. Retrospective assessment of 210 biphasic records showed the thermal nadir to occur within 1 day of the urinary luteinizing hormone (LH) surge in 75% of the cases, and in 90% when 2 days where considered. This confirms BBT as a relatively accurate guide for retrospective identification of the periovulatory period. Moreover, results of a study conducted to investigate how patients experienced daily recording of BBT graphs suggest that the method is well accepted by a high proportion of women. From all these it appears that there are many indications where BBT graphs can still be applied. Development of new electronic devices may further improve the reliability, acceptability and applications of the BBT records in the fertility investigation.

Vaginal ultrasound in assisted reproduction

Vaginal scanning of the ovaries and the uterus is a diagnostic and monitoring tool of utmost importance in assisted conception. Although the value of ultrasound for monitoring follicular growth has been questioned, few groups working on assisted conception do not use it. Follicle aspiration under the guidance of vaginal sonography is the method of choice. With such a simple and safe technique available, using laparoscopy for retrieving oocytes for assisted conception cannot be justified. The introduction of ultrasound-guided transvaginal retrograde tubal catheterization has meant that laparoscopic GIFT and ZIFT procedures will probably soon be unnecessary. Vaginal sonography is one of the most clinically important diagnostic instruments in assisted conception.

Transvaginal color flow Doppler in the assessment of ovarian and uterine blood flow in infertile women

OBJECTIVE

To measure the flow velocity of the uterine and ovarian arteries through the menstrual cycle to determine there are changes.

DESIGN

Serial measurements throughout the menstrual cycle in women attending an infertility clinic, compared with volunteers coming for annual examinations. Transvaginal ultrasound-color flow Doppler was the investigative tool.

SETTING

A University Hospital ambulatory care center.

PATIENTS

One hundred infertile women compared with 150 women attending the clinic for annual checkups.

MAIN OUTCOME MEASURES

Changes in the resistance index of flow velocity waveforms of the uterine and ovarian arteries.

RESULTS

Uterine flow velocity has a resistance index of 0.88 +/- 0.04 (2 SE) in the proliferative phase and starts to decrease the day before ovulation. A nadir of 0.84 +/- 0.04 is reached on day 18 and remains at that level for the rest of the cycle. In anovulatory cycles, these changes do not occur. A subgroup of 12 women who lacked end diastolic flow in the uterine arteries during the secretory phase were identified. Eleven of these women were infertile, 8 of whom with primary infertility. Ovarian artery flow velocity is usually detected when the dominant follicle reaches 12 to 15 mm. The resistance index is 0.54 +/- 0.04 and also declines on the day before ovulation. A nadir of 0.44 +/- 0.04 is reached 4 to 5 days later and slowly rises to 0.050 +/- 0.04 before menstruation.

CONCLUSIONS

There are changes in the flow velocity patterns of the uterine and ovarian arteries during the normal ovulatory menstrual cycle. Because these changes in flow velocity begin before ovulation, it can be suspected that they may involve angiogenesis as well as hormonal factors. The changes noted in these studies are statistically significant but may be too small to be used as a diagnostic tool in the study of infertility problems.

Follicular size at the time of human chorionic gonadotropin administration predicts ovulation outcome in human menopausal gonadotropin-stimulated cycles

OBJECTIVE

The objectives of this study were: (1) to correlate follicle size by transvaginal sonography with ovulation outcome in cycles of controlled ovarian hyperstimulation with human menopausal gonadotropins; (2) to determine if follicular size on the day of human chorionic gonadotropin (hCG) administration predicts the incidence of ovulation; and, if so, (3) to derive a mathematical model that predicts the number of expected ovulations in any given cycle of controlled ovarian hyperstimulation.

DESIGN

A retrospective analysis.

PARTICIPANTS

Forty-nine consecutive patients undergoing 122 cycles of controlled ovarian hyperstimulation were studied in a tertiary care setting.

MAIN OUTCOME MEASURES

Follicular size and evidence of ovulation were determined sonographically. The main outcome measure was the rate of ovulation per follicle size.

RESULTS

The percentages of follicles measuring less than or equal to 14 mm, 15 to 16 mm, 17 to 18 mm, 19 to 20 mm, and greater than 20 mm on the day of hCG administration that subsequently ovulated were 0.5%, 37.4%, 72.5%, 81.2%, and 95.5%, respectively.

CONCLUSIONS

(1) Follicular size on the day of hCG administration correlates with the incidence of ovulation. (2) The expected number of ovulations in any given controlled ovarian hyperstimulation cycle can be predicted with 95% confidence using the accompanying equation.

Ultrasonic and endocrinologic aspects in gonadotropin releasing hormone induction of ovulation

Ovarian growth, follicular size, 17 beta-estradiol (E2), androstenedione (A) and testosterone (T) peripheral levels were evaluated in 12 hypogonadotropic patients during the follicular phase on 12 cycles of pulsatile GnRH iv administration. During GnRH therapy, significant correlations between E2 plasma levels and volume of the dominant follicle (p less than 0.001) as well as total follicular volume (p less than 0.001) and total ovarian volume (p less than 0.01) were found. Plasma A was significantly related to the ultrasonic changes of ovarian stroma and those follicles which usually fail to ovulate. Plasma T showed a significant correlation with ovarian stroma (p less than 0.05). Significant correlations of E2/A and E2/T peripheral ratios with volume of the dominant follicle (p less than 0.01) were also found. In spontaneous ovulatory cycles, similar correlations between endocrine and morphological parameters have been already published. The findings of the present investigation indicate that in spontaneous and GnRH-induced cycles the endocrine events associated to the follicular development are quite similar. In hypogonadotropic patients, a "normal" follicular maturation may be obtained by means of this therapy.

The role of superovulation with menotropins in ovulatory infertility: a review

The risks of menotropin therapy (ovarian hyperstimulation syndrome, multiple gestation, adnexal torsion) are well known and have been previously described. Superovulation should not be considered for the indications described herein until more traditional therapies for infertility have been tried and found unsuccessful and sufficient time has elapsed for conception to occur. The cost of superovulation is high: the medications are expensive, frequent E2 monitoring and US studies are costly, and pregnancy complications relating to the higher rate of pregnancy loss and multiple gestation may add substantially to the overall cost. Yet, compared with IVF and GIFT, superovulation cycles combined with IUI cost between one third to one sixth that of an IVF cycle. Protocols involving combined CC/hMG/hCG, which reduce the total number of ampules of Pergonal needed per cycle and still provide multiple follicular development, may further reduce costs. There is a growing consensus that superovulation-IUI protocols should be attempted before GIFT and IVF in couples with normal pelvic viscera. There is little doubt that IVF and GIFT cycles are more costly, stressful, and complex. No comparative data have clearly shown IVF and GIFT to be superior to superovulation protocols in ovulatory women with normal pelvic anatomy. In the only study examining this issue published to date, Kaplan et al. retrospectively analyzed all GIFT and superovulation/IUI cycles at a single university center and found GIFT to be three times more efficient. However, the inherent limitations of a nonrandomized, nonprospective study of this kind are obvious as these authors have suggested. Therefore, it may be wise to consider the use of superovulation before assisted reproductive technologies until this issue is settled. It would be interesting to determine if the high PRs reported for couples with unexplained infertility or mild endometriosis in IVF and GIFT cycles in some centers not incorporating superovulation/IUI protocols would hold up if such an approach was routinely followed. Despite the increasing acceptance of superovulation protocols, we must be aware that many of the studies suggesting a role of hMG in treating ovulatory infertile women with normal pelvic anatomy suffer from deficiencies in experimental design. In a payor-driven system, such as in the United States, the difficulties in designing and carrying out scientifically sound clinical studies examining infertility therapies are obvious. The lack of federal or outside funding for the study of infertility issues contributes to the problem. It is our hope that better designed studies examining the role of superovulation in the treatment of ovulatory infertile women with normal pelvic anatomy will be forthcoming.

Timing of ovulation in spontaneous and induced cycles

We studied 30 spontaneous cycles, 30 cycles induced with clomiphene citrate, and 30 cycles induced with human menopausal gonadotropin-human chorionic gonadotropin to evaluate the pattern of the following parameters and their predictive value in timing ovulation: basal body temperature; cervical mucus; mean follicular diameter; serum LH and 17-beta-estradiol; and urinary LH. Compared with the spontaneous cycles, in the cycles induced with clomiphene citrate the cervical score was significantly lower on the 4 days preceding ovulation, serum LH was higher in the early follicular phase, and serum 17-beta-estradiol was significantly higher in the pharmacologically treated cycles. The highest predictive values in all groups of cycles were obtained by considering the following combinations of parameters: serum 17-beta-estradiol and LH concentrations; mean follicular diameter as shown by ultrasonography and urinary LH as determined by a rapid method.

Intrauterine insemination does and clomiphene citrate does not improve fecundity in couples with infertility due to male or idiopathic factors: a prospective, randomized, controlled study

In the present prospective study we compared, in terms of pregnancy rates, the differences between intrauterine insemination (IUI) of in vitro capacitated husband's semen and timed natural intercourse in spontaneous or clomiphene citrate (CC) stimulated cycles. A rapid urinary luteinizing hormone peak detection test was used for timing of ovulation. Forty patients suffering from longstanding infertility of male (n = 17), cervical (n = 2), and idiopathic (n = 21) origin were randomly assigned into four distinct treatment modalities during 4 consecutive cycles. A total of 132 cycles were analyzed. In 35 cycles treated with CC plus IUI, five conceptions were achieved, whereas three pregnancies occurred in 32 inseminated spontaneous cycles. Only 1 patient conceived after timed intercourse in 31 CC stimulated cycles, and no pregnancy resulted from 34 spontaneous cycles combined with timed intercourse. There was a statistically significant higher conception rate in cycles in which IUI was performed, whereas the use of CC does not seem to improve the pregnancy rate. Analysis of results for other modifying factors did not substantially affect the relative risk (odds ratio) of pregnancy.

Enhanced pre-ovulatory progesterone levels in fertile cycles during clomiphene citrate treatment

We compared ovulatory changes in fertile and preceding infertile cycles in 21 patients with unexplained infertility conceiving after clomiphene citrate treatment. No significant differences were observed in follicular growth, cervical score and follicle stimulating hormone (FSH) levels. Progesterone was higher (P less than 0.05) in the 2 days preceding ovulation in fertile cycles, luteinizing hormone (LH) higher (P less than 0.05) the day before, and 17-beta-estradiol lower (P less than 0.05) 4 days before. Stimulating progesterone secretion by systematic LH administration before ovulation could improve secretory endometrial transformation and thus reproductive prognosis.

Prediction and self-prediction of ovulation in clomiphene citrate-treated patients

We studied 15 infertile patients for a total of 25 cycles in order to compare the predictive value of the following parameters in timing ovulation: basal body temperature (BBT), cervical mucus, serum E2 and LH, follicular growth as shown by ultrasonography, and urinary LH. The patients themselves tested urinary LH at home using Clearplan kits. BBT had low value as a predictive test for the time of ovulation, whereas ultrasonography had a predictive value of 9%, serum E2 50%, cervical mucus 59%, serum LH 63.6% and Clearplan kits 63.6%. The best predictive reliability in timing ovulation was obtained by considering both serum LH and E2 measurements. The Clearplan kits were as reliable as serum LH measurements and have greater practical advantages.

Ultrasonic and endocrinologic relationships in spontaneous and induced follicular phase

To correlate ovarian growth and follicular size with 17 beta-estradiol (E2) and androstenedione (A) peripheral levels, 20 induced cycles, 6 spontaneous ovulatory cycles and 6 spontaneous anovulatory cycles from 32 women during follicular phase were examined in order to obtain a better insight in the events involved in multiple folliculogenesis. In spontaneous ovulatory cycles, a significant correlation was obtained between E2 plasma levels and volume of the dominant follicle (p less than 0.05) as well as total follicular volume (p less than 0.01). Plasma A was significantly related with sonographic features likely related to ovarian stroma as well as preantral and antral subordinated follicles, which usually fail to ovulate. Significant correlation between E2/A peripheral ratio and volume of the dominant follicle(s) was also found (p less than 0.01). In anovulatory cycles, inverse significant correlation between E2 and sonographic aspects of degenerating antral follicles (p less than 0.001) was found, whereas a positive significant correlation between E2 and ovarian stroma was obtained (p less than 0.001). No correlation between peripheral A and any ovarian sonographic compartment was evident. However in the anovulatory cycles group a significant correlation between A v E2 peripheral levels was found, too. During HMG regimen, all the ovarian compartments seemed to be responsible for E2 peripheral levels. Ovarian stroma as well as preantral and multiple antral follicles were related to A levels. E2/A peripheral ratio did not result to be a good indicator of the large follicles. During "pure" FSH therapy, exclusive correlations between estrogen and large follicles as well as total follicular volume were found.(ABSTRACT TRUNCATED AT 250 WORDS)

The theory and practice of ovulation induction with gonadotropin-releasing hormone

Gonadotropin-releasing hormone therapy has undergone sufficient basic and clinical investigation as a tool for ovulation induction that it should now be considered a safe and effective infertility therapy for office practice. Nevertheless, there remains sufficient mystique about patient selection, optimal dosage and route of delivery, and apprehension on the part of both physicians and patients about cost and inconvenience of medication pumps that gonadotropin-releasing hormone therapy has not enjoyed the widespread acceptance it deserves. This article presents straightforward guidelines for therapy that are based on a detailed review of current literature, together with new information about evolving pump technologic characteristics, that should offer reassurance to the practitioner considering use of gonadotropin-releasing hormone therapy in her/his practice.

Linear regression analysis of ultrasound follicular growth series: evidence for an abnormality of follicular growth in endometriosis patients

Follicular diameter growth is a highly linear function of time. Recently, the potential utility of linear regression-derived parameters for describing and comparing cycles of follicular growth was described. The linearity of growth, growth rate constant (K), calculated date of growth onset (Do), total growth period (TGP), menstrual age at apparent ovulation (MAov), and peak follicular diameter (PFD) have been calculated from the follicular growth series of a group of patients with laparoscopically diagnosed endometriosis (n = 46). These parameters were compared with those of a group of normal volunteers (n = 18). The authors found significant differences between endometriosis patients and controls in follicular growth rate and total growth period. The effect of patients' clomiphene citrate usage on growth parameters in these patients was examined. Abnormalities in interrelationships between the growth parameters were detected, suggesting the possibility of subtle defects in the regulation of follicular growth in these patients.

The prediction of ovulation and monitoring of the fertile period

Simple and reliable methods have been sought for both predicting and confirming ovulation. Application of these methods could include management of infertile couples to aid in conception and for increasing the reliability of natural family planning (NFP) as a method of birth control. With the advent of specific hormone assays, serial measurements of estrogens, progesterone (and metabolites), and luteinizing hormone have been the gold standard of monitoring ovarian function in women. However, newer and simpler methodologies have been described and are currently either in use or being tested. These include the measurement of basal body temperature (BBT), the evaluation of the volume, consistency and electro-conductivity of cervicovaginal fluid, salivary steroid content and cellular enzymatic activity, the use of enzyme-linked immunosorbent assays applied to solid-phase formats, and the investigation of new hormonal molecules as markers of reproductive state and function. These new technologies are described herein and their potential for monitoring ovarian function is discussed.

Ultrasonically Guided Perurethral Transvesicle Aspiration of Follicles in an In Vitro Fertilization Program

Successful ova retrieval under ultrasound guidance using a transabdominal approach has been described in the literature. Perurethral transvesicle approach is a new method used for retrieving the ova. The patient's bladder is distended and used as a window for viewing the ovary and the needle. The needle is placed in the urethra and passed into the bladder. The needle is then aligned with the ovary, and the follicles are punctured. This procedure has initially proven very successful in retrieving the ova.