Associations between ultrasound indices of follicular blood flow, oocyte recovery and preimplantation embryo quality

Effect of Coenzyme Q10 and transcutaneous electrical acupoint stimulation in assisted reproductive technology: a retrospective controlled study

PURPOSE

To investigate the effects of coenzyme Q10 (CoQ10) and transcutaneous electrical acupoint stimulation (TEAS) pretreatment on pregnancy in patients with poor ovarian response (POR).

METHODS

A total of 330 POR patients who were pretreated with CoQ10 or CoQ10 combined with TEAS before their in vitro fertilization/intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET) cycles and who were not pretreated were selected and divided into CoQ10 group (group A, n = 110), CoQ10 + TEAS group (group B, n = 110) and control group (group C, n = 110). For patients with 2 or more transfer cycles, only the information of the first cycle was included. Ovarian function, response to gonadotropin (Gn) stimulation, and pregnancy outcomes of the three groups were compared in the IVF/ICSI-ET cycles.

RESULTS

After pretreatment, basal FSH, total Gn dosage and duration were comparable among the three groups (all p-value > 0.05), basal E2 in group B decreased significantly compared with the control group (p = 0.022). Endometrial thickness on the human chorionic gonadotropin (hCG) day, antral follicle counts (AFC), the numbers of oocytes, metaphase II (MII) eggs and excellent embryos in the two pretreatment groups were significantly increased compared with group C (all p-value < 0.001), but the rates of MII oocytes, fertilization and excellent embryos had no apparent change. The endometrial thickness on the day of hCG, the numbers of MII eggs and excellent embryos in group B were higher than those in group A (p < 0.001; p = 0.020; p = 0.027; respectively). The embryo implantation rate (IR), clinical pregnancy rate (CPR) and live birth rate (LBR) in group B were significantly higher than those in group C (p = 0.022; p = 0.010; p = 0.019; respectively), but not significantly different from group A.

CONCLUSION

CoQ10 alone or in combination with TEAS are effective methods for IVF/ICSI-ET adjuvant therapy, which can significantly improve ovarian reactivity, increase the numbers of retrieved eggs and superior embryos, and improve endometrial receptivity. Adjuvant TEAS on the basis of CoQ10 can significantly enhance pregnancy rates, but CoQ10 alone failed to present such an obvious effect.

Time Series Ovarian Transcriptome Analyses of the Porcine Estrous Cycle Reveals Gene Expression Changes during Steroid Metabolism and Corpus Luteum Development

Simple Summary

The estrous cycle, which is divided into follicular and luteal phases based on ovulation, is influenced by reproductive hormones which affect reproduction and cause changes in the reproductive system of the pig. As the main reproductive organ, the ovary is involved in ovulation and changes in the corpus luteum. We aimed to identify dynamic changes in gene expression through differentially expressed gene profiling and to provide a comprehensive understanding of the molecular mechanisms that occur in the pig ovary during the estrous cycle. The transcriptome analysis revealed that the dynamic change in gene expression was more activated in the luteal phase than in the follicular phase. Functional analysis revealed that the metestrus and diestrus periods are important in preparation for pregnancy or the next estrous cycle after ovulation.

Abstract

The porcine estrous cycle is influenced by reproductive hormones, which affect porcine reproduction and result in physiological changes in the reproductive organs. The ovary is involved in ovulation, luteinization, corpus luteum development, and luteolysis. Here, we aimed to provide a comprehensive understanding of the gene expression patterns in porcine ovarian transcriptomes during the estrous cycle through differentially expressed genes profiling and description of molecular mechanisms. The transcriptomes of porcine ovary were obtained during the estrous cycle at three-day intervals from day 0 to day 18 using RNA-seq. At seven time points of the estrous cycle, 4414 DEG were identified; these were classified into three clusters according to their expression patterns. During the late metestrus and diestrus periods, the expression in cluster 1 increased rapidly, and steroid biosynthesis was significant in the pathway. Cluster 2 gene expression patterns represented the cytokine–cytokine receptor interaction in significant pathways. In cluster 3, the hedgehog signaling pathway was selected as the significant pathway. Our study exhibited dynamic gene expression changes with these three different patterns of cluster 1, 2, and 3. The results helped identify the functions and related significant genes especially during the late metestrus and diestrus periods in the estrous cycle.

ICSI does not improve reproductive outcomes in autologous ovarian response cycles with non-male factor subfertility

STUDY QUESTION

Does the method of fertilisation improve reproductive outcomes in poor ovarian response (POR) cycles when compared to all other ovarian response categories in the absence of male factor subfertility?

SUMMARY ANSWER

ICSI does not confer any benefit in improving the clinical pregnancy or live birth (LB) outcome in autologous ovarian response cycles in the absence of male factor subfertility when compared to IVF.

WHAT IS KNOWN ALREADY

ICSI is associated with an improved outcome when compared to IVF in patients with severe male factor subfertility.

STUDY DESIGN, SIZE, DURATION

A retrospective study involving 1 376 454 ART cycles, of which 569 605 (41.4%) cycles fulfilled the inclusion and exclusion criteria for all autologous ovarian response categories: 272 433 (47.8%) IVF cycles and 297 172 (52.2%) ICSI cycles. Of these, the POR cohort represented 62 641 stimulated fresh cycles (11.0%): 33 436 (53.4%) IVF cycles and 29 205 (46.6%) ICSI cycles.

PARTICIPANTS/MATERIALS, SETTING, METHOD

All cycles recorded on the anonymised Human Fertilisation and Embryology Authority (HFEA) registry database between 1991 and 2016 were analysed. All fresh cycles with normal sperm parameters, performed after 1998 were included: frozen cycles, donor oocyte and sperm usage, intrauterine insemination cycles, preimplantation genetic testing (PGT) for aneuploidies (PGT-A), PGT for monogenic/single gene defects (PGT-M), PGT for chromosomal structural arrangements (PGT-SR) cycles, where the reason for stimulation was for storage and unstimulated cycles were excluded.

MAIN RESULTS AND THE ROLE OF CHANCE

ICSI did not confer any benefit in improving the LB outcome when compared to conventional IVF per treatment cycle (PTC), when adjusted for female age, number of previous ART treatment cycles, number of previous live births through ART, oocyte yield, stage of transfer, method of fertilisation and number of embryos transferred in the POR cohort (adjusted odds ratio [a OR] 1.03, 99.5% confidence interval [CI] 0.96–1.11, P = 0.261) and all autologous ovarian response categories (aOR 1.00, 99.5% CI 0.98–1.02, P = 0.900). The mean fertilisation rate was statistically lower for IVF treatment cycles (64.7%) when compared to ICSI treatment cycles (67.2%) in the POR cohort (mean difference −2.5%, 99.5% CI −3.3 to −1.6, P &lt; 0.001). The failed fertilisation rate was marginally higher in IVF treatment cycles (17.3%, 95% binomial exact 16.9 to 17.7%) when compared to ICSI treatment cycles (17.0%, 95% binomial exact 16.6 to 17.4%); however, this did not reach statistical significance (P = 0.199). The results followed a similar trend when analysed for all autologous ovarian response categories with a higher rate of failed fertilisation in IVF treatment cycles (4.8%, 95% binomial exact 4.7 to 4.9%) when compared to ICSI treatment cycles (3.2%, 95% binomial exact 3.1 to 3.3%) (P &lt; 0.001).

LIMITATIONS, REASONS FOR CAUTION

The quality of data is reliant on the reporting system. Furthermore, success rates through ART have improved since 1991, with an increased number of blastocyst-stage embryo transfers. The inability to link the treatment cycle to the individual patient meant that we were unable to calculate the cumulative LB outcome per patient.

WIDER IMPLICATIONS OF THE FINDINGS

This is the largest study to date which evaluates the impact of method of fertilisation in the POR patient and compares this to all autologous ovarian response categories. The results demonstrate that ICSI does not confer any benefit in improving reproductive outcomes in the absence of male factor subfertility, with no improvement seen in the clinical pregnancy or LB outcomes following a fresh treatment cycle.

STUDY FUNDING/COMPETING INTEREST(S)

The study received no funding. C.M.B. is a member of the independent data monitoring group for a clinical endometriosis trial by ObsEva. He is on the scientific advisory board for Myovant and medical advisory board for Flo Health. He has received research grants from Bayer AG, MDNA Life Sciences, Volition Rx and Roche Diagnostics as well as from Wellbeing of Women, Medical Research Council UK, the NIH, the UK National Institute for Health Research and the European Union. He is the current Chair of the Endometriosis Guideline Development Group for ESHRE and was a co-opted member of the Endometriosis Guideline Group by the UK National Institute for Health and Care Excellence (NICE). I.G. has received research grants from Bayer AG, Wellbeing of Women, the European Union and Finox.

TRIAL REGISTRATION NUMBER

Not applicable.

The effect of melatonin on ultrasound markers of follicular development: A double-blind placebo-controlled randomised trial

BACKGROUND

Melatonin is a potent oxygen scavenger and is capable of altering blood flow in various vascular beds.

AIMS

We aimed to determine the effect of melatonin on ovarian vascular indices during ovarian stimulation for in vitro fertilisation (IVF).

MATERIALS AND METHODS

This is a pilot double-blind placebo-controlled randomised trial. Sixty-nine women (mean age 35.8 ± 4.3 years) undergoing their first cycle of IVF were randomised to receive either placebo, 2, 4 or 8 mg of melatonin, twice a day. Each participant underwent a transvaginal ultrasound at days 6-10 assessing follicular number and size. The vascularisation index (VI), flow index (FI) and vascularisation-flow index (VFI) were measured. These indices were then correlated with embryological outcomes. Informed consent was obtained from participants. This trial was registered with the Australia New Zealand Clinical Trials Registry (ACTRN12613001317785).

RESULTS

The number of follicles did not differ between groups (P = 0.4). There were no differences in the VI (P = 0.4), FI (P = 0.1) or VFI (P = 0.3) in the right ovary or the FI (P = 0.3) or VFI (P = 0.3) in the left ovary between groups. When comparing placebo to any dose of melatonin, there were no differences in any measured parameter. While there was correlation between the number of follicles on ultrasound and all measured embryological outcomes, there was no correlation between ovarian vascular indices and these important clinical outcomes.

CONCLUSIONS

Melatonin does not appear to change ovarian vascular indices during ovarian stimulation. In addition, such vascular indices cannot predict the number or quality of oocytes or embryos obtained in an IVF cycle. These findings require confirmation in future larger studies.

An objective volumetric method for assessment of ovarian follicular and luteal vascular flow using colour Doppler ultrasonography

Our goal was to develop an objective computer-assisted volumetric method of assessing vascular flow from colour Doppler ultrasound data of ovarian structures recorded by free-hand movement. We hypothesized that a vascularity index (ratio of the region of blood flood to the region of ovarian structure) obtained from the three-dimensional volumetric analysis would be more precise (less variable) than conventional two-dimensional analysis of single images in estimating the functional status of the preovulatory follicles and corpus luteum. Doppler ultrasound cineloops of water buffaloes (Bubalus bubalis; n = 22) ovaries were recorded daily from 12 h before GnRH treatment to four days after ovulation. Cineloops were processed using Fiji and Imaris software packages for segmenting the area (two-dimensional analysis) and the volume (three-dimensional analysis) occupied by the blood-flow and associated tissue to calculate the vascularity index. For volumetric measurement, all images in a cineloop were used (i.e., no a-priori selection of images) while for two-dimensional analysis, three images from the region with apparent maximum vascularity were selected. The volumetric method was verified with theoretical ellipsoidal volume of the follicle (r = 0.96 P < 0.01) or corpus luteum (r = 0.58 P = 0.02). The variability in the follicular vascularity index among animals was lower using the volumetric method than two-dimensional analysis (0.018 ± 0.002 vs 0.030 ± 0.005, P < 0.01), while the variability for CL vascularity was similar between methods (P = 0.23). An increase in the follicular vascularity index was detected at 12 h after GnRH treatment using both methods (two-dimensional: 0.030 ± 0.008, P < 0.01; three-dimensional: 0.016 ± 0.006, P < 0.02). Buffaloes that ovulated tended to have a greater increase in 3D vascularity index than non-responding buffaloes (P = 0.06); the two-dimensional method was not able to detect these changes. Using the three-dimensional method, a moderate positive correlation (r = 0.59; P = 0.02) was evident between the follicular vascularity index at 14-16 h after GnRH treatment and follicular diameter. In conclusion, an objective volumetric method for assessing relative ovarian blood flow changes was developed using Doppler ultrasound cineloops recorded by free-hand movement. The 3-dimensional method eliminates the need for a-priori selection of images and is more precise as a result of decreased technical variability.

Influence of follicular fluid and cumulus cells on oocyte quality: clinical implications

An equilibrium needs to be established by the cellular and acellular components of the ovarian follicle if developmental competence is to be acquired by the oocyte. Both cumulus cells (CCs) and follicular fluid (FF) are critical determinants for oocyte quality. Understanding how CCs and FF influence oocyte quality in the presence of deleterious systemic or pelvic conditions may impact clinical decisions in the course of managing infertility. Given that the functional integrities of FF and CCs are susceptible to concurrent pathological conditions, it is important to understand how pathophysiological factors influence natural fertility and the outcomes of pregnancy arising from the use of assisted reproduction technologies (ARTs). Accordingly, this review discusses the roles of CCs and FF in ensuring oocyte competence and present new insights on pathological conditions that may interfere with oocyte quality by altering the intrafollicular environment.

Perifollicular blood flow and its relationship with endometrial vascularity, follicular fluid EG-VEGF, IGF-1, and inhibin-a levels and IVF outcomes

PURPOSE

The aim of this study is to investigate the association of perifollicular blood flow (PFBF) with follicular fluid EG-VEGF, inhibin-a, and insulin-like growth factor-1 (IGF-1) concentrations, endometrial vascularity, and IVF outcomes.

METHODS

Forty women with tubal factor infertility were included in a prospective cohort study. Each woman underwent IVF/ICSI procedure. Individual follicles of ≥16 mm (n = 156) were evaluated by power Doppler analysis and categorized as well-vascularized follicles (WVFs) or poorly vascularized follicles (PVFs). WVFs referred to those with perifollicular vascularity of 51-100 %. Each follicular fluid (FF) was individually aspirated and FF/serum EG-VEGF, inhibin-a, and FF IGF-1 levels were evaluated. Zones III-IV endometrial vascularity was classified as a well-vascularized endometrium (WVE). The presence of a WVE and mature oocytes, in addition to the embryo quality and clinical pregnancy rate (CPR), were recorded for each follicle. The main outcome measures were FF serum EG-VEGF, inhibin-a, IGF-1 levels, and WVE and IVF outcome per PFBF.

RESULTS

For WVFs, the level of FF EG-VEGF (p = 0.008), oocyte quality (p = 0.001), embryo quality (p = 0.002), a WVE (p = 0.001), and CPR (p = 0.04) increased significantly. The pregnant group was characterized by increased numbers of WVFs (p = 0.044), a WVE (p = 0.022), and increased levels of FF IGF-1 (p = 0.001) and serum EG-VEGF (p = 0.03). FF IGF-1 >50 ng/mL (AUC 0.72) had 75 % sensitivity and 64 % specificity for predicting CPR.

CONCLUSIONS

WVFs yield high-quality oocytes and embryos, a WVE, increased FF EG-VEGF levels, and increased CPRs.

Effect of hydrosalpinx on uterine and ovarian hemodynamics in women with tubal factor infertility

OBJECTIVE

To evaluate the effect of hydrosalpinx on uterine and ovarian blood flows in women with tubal factor infertility.

STUDY DESIGN

In a cross-sectional study at a university teaching hospital, 60 women with hydrosalpinx-related tubal infertility (hydrosalpinx group) were compared with 60 women with male or unexplained infertility (non-hydrosalpinx group). In the mid-luteal (peri-implantation) phase of the cycle, endometrial thickness, uterine and ovarian artery pulsatility index (PI) and resistance index (RI), and endometrial and ovarian volume and 3D power Doppler vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were measured in both groups.

RESULTS

The endometrial VI (p=0.002), FI (p=0.041), and VFI (p=0.018), and ovarian VI (p=0.011), and VFI (p=0.015) were significantly lower in the hydrosalpinx group than in the non-hydrosalpinx group. However, the endometrial thickness, uterine artery PI and RI, ovarian artery PI and RI, endometrial volume, and ovarian volume and FI were not significantly different between the two groups.

CONCLUSION

Hydrosalpinx is associated with impaired endometrial and ovarian blood flows which may adversely affect endometrial receptivity and oocyte quality.

Ovarian and uterine periovulatory Doppler ultrasonography in bitches

This paper aims to describe the uterine and ovarian ultrasonographic characteristics and Doppler velocimetric features of their arteries in bitches during the periovulatory period. Fifteen estrous cycles in 10 animals were evaluated. The ultrasonographic characteristics, resistance indices (RI) and pulsatility indices (PI) of the uterus and ovaries in each animal were recorded 5 days before and after ovulation (D0). The data were statistically analyzed, and the results were expressed as the mean ± standard error of mean (P<0.05). In results the ultrasonographic features of the uterus were the same on all of the cycles and evaluated days. The uterus had an average diameter of 0.85±0.02cm. An increase in the volume of the ovaries and the diameter of the ovarian follicles were measured. Ovaries had a volume of 0.64±0.06cm³, and the follicles cavities had a diameter of 0.46 ± 0.01 cm on the day of ovulation. After ovulation, it was observed that some follicles not collapse in some cycles. Two days prior to ovulation, the uterine blood perfusion decreased. This decrease remained unchanged until ovulation. Following ovulation, we measured a gradual increase in the uterine perfusion and in the ovarian artery. This artery directed blood flow to the ovaries and increased the intra-ovarian perfusion on the day after ovulation. In conclusion, specific features are observed in the uterus and ovarian ultrasound image and Doppler values of their arteries presented on the periovulatory days and when associated allow to estimate more accurately the date of ovulation.

Contrast imaging ultrasound detects abnormalities in the marmoset ovary

The development of a functional vascular tree within the primate ovary is critical for reproductive health. To determine the efficacy of contrast agents to image the microvascular environment within the primate ovary, contrast ultrasonography was performed in six reproductive-aged female common marmosets (Callithrix jacchus) during the late luteal phase of the cycle, following injection of Sonovue™. Regions of interest (ROIs), representing the corpus luteum (CL) and noncorpus luteum ovarian tissue (NCLOT), were selected during gray-scale B-mode ultrasound imaging. The magnitude of backscatter intensity of CL and NCLOT ROIs were calculated in XnView, post hoc: subsequent gamma-variate modeling was implemented in Matlab to determine perfusion parameters. Histological analysis of these ovaries revealed a total of 11 CL, nine of which were identified during contrast ultrasonography. The median enhancement ratio was significantly increased in the CL (5.54AU; 95% CI -2.21-68.71) compared to the NCLOT (2.82AU; 95% CI 2.73-15.06; P < 0.05). There was no difference in time parameters between the CL and NCLOT. An additional avascular ROI was identified in the ovary of Animal 5, both histologically and by ultrasonography. This cystic ROI displayed a markedly lower enhancement ratio (0.79AU) and higher time parameters than mean CL and NCLOT, including time to peak and time to wash out. These data demonstrate, for the first time, the ability of commercially available contrast agents, to differentiate structures within the nonhuman primate ovary. Contrast-enhanced ultrasonography has a promising future in reproductive medicine.

Application of Doppler Ultrasonography in Cattle Reproduction

The development of Doppler processing extended the scope of sonographic imaging from an anatomical to a physiological basis. This technique became established as a clinical tool in human gynaecology. For example, it has been discussed that the implantation of an embryo is influenced by the uterine blood flow. In cows, this uterine blood flow was investigated, using surgically implanted Doppler ultrasonic or electromagnetic blood flow probes prior to the introduction of colour Doppler sonography in bovine medicine. Therefore, the aims of our studies were to use transrectal Doppler sonography for the non-invasive measurement of uterine and ovarian blood flow in cows and to determine changes in genital perfusion during the oestrous cycle, pregnancy and puerperium, respectively. The results of our studies show that transrectal flow imaging can be used to obtain blood flow velocity waveforms from the uterine arteries at any time during the oestrous cycle, pregnancy and puerperium. During all these phases, characteristic changes in the uterine blood flow could be observed. This uterine blood flow was low during diestrus and high during proestrus and oestrus. During pregnancy, an exponential rise in uterine blood supply could be detected. There was a positive relationship between the uterine blood flow volume (BFV) at the end of gestation and the birth weight of calves. During puerperium, the uterine BFV declined tremendously, especially during the first week after birth. In cows, with pathological disturbances of the pueperium a delayed decrease in the uterine BFV was observed. Characteristic alterations occurred also in the luteal blood flow during the oestrous cycle, which were highly related to those of the progesterone levels. Furthermore, it has been detected by the colour Doppler technique that there is no decrease, but an increase of the luteal blood flow at the beginning of luteolysis in cows. Another group has found that there are close relationships between the LH-surge and the follicular blood flow before ovulation. In conclusion, these studies show that transrectal colour Doppler sonography is a useful technique for the investigation of the genital blood flow and provides new information about physiological changes of the genital organs during, all reproductive phases. The influence of the genital blood flow on fertility in cows needs to be examined further in future studies.

The 3D vascular status of the follicle after HCG administration is qualitatively rather than quantitatively associated with its reproductive competence

BACKGROUND

The objective of this study was to determine whether the vascular status of a single pre-ovulatory follicle is associated quantitatively and/or qualitatively with its reproductive competence.

METHODS

We studied 61 monofollicular IVF-embryo transfer cycles. Just before single oocyte retrieval, follicle vascularization was detected by transvaginal power-Doppler, 3-dimensionally reconstructed, and analysed quantitatively by coloured/gray voxel ratio [vascularization index (VI)] and qualitatively by blood cell displacement [flow index (FI)] calculation. Cycles were sorted in two sets of two groups: low VI (<or=8%, n = 44) and high VI (>8%, n = 17); low FI (<or=30, n = 22) and high FI (>30, n = 39).

RESULTS

Patients' characteristics, fertilization rates, and embryo morphology were comparable in all groups. In contrast, clinical pregnancy rates/oocyte retrieval (4% versus 33%, P < 0.009) and implantation rates (11% versus 50%, P < 0.04) were markedly poorer in the low as compared to the high FI groups, respectively, but remained similar between the low and the high VI groups (22% versus 23% and 38% versus 44%, respectively).

CONCLUSIONS

A qualitative (FI) rather than quantitative (VI) relationship exists between vascular status and functional quality of the follicle after HCG administration.

Power doppler ultrasound assessment of the relationship between age and ovarian perifollicular blood flow in women undergoing in vitro fertilization treatment

PURPOSE

To examine the relationship between age and ovarian perifollicular blood flow (PFBF) in women undergoing IVF.

METHODS

Serial transvaginal power Doppler ultrasound (PDU) scans to assess ovarian PFBF were performed prospectively throughout the follicular phase of ovarian stimulation in women undergoing IVF. The ultrasound assessment days were categorized according to day of hCG trigger.

RESULTS

A total of 1050 ovarian follicles from 34 women undergoing one IVF treatment cycle were used for data analysis. The median age of the women was 38.5 years, ranging from 28 years to 44 years. There was a significant negative correlation between age and ovarian PFBF on the day of hCG trigger or trigger day minus 1, but not beforehand during the follicular phase.

CONCLUSIONS

There was a significant negative correlation between age and ovarian PFBF in women undergoing IVF which was only observed very late in the follicular phase of ovarian stimulation.

Clinical use of the perifollicular vascularity assessment in IVF cycles: a pilot study

BACKGROUND

In Italy, a recent law has imposed a ban on the fertilization of more than three oocytes at one time, and all resulting embryos produced must be transferred simultaneously. The aim of the present controlled study was to assess the clinical feasibility and efficacy of the perifollicular vascularity assessment for oocyte selection in IVF cycles.

METHODS

Fifty-four young primary infertile non-obese women (27 cases and 27 age- and BMI-matched controls) underwent IVF cycles. The choice of the oocytes to fertilize was performed according to perifollicular vascularization in the experimental group, whereas in the control group, the standard morphologic criteria alone were used. The dose of gonadotrophins used, the dominant follicles obtained, the duration of the ovarian stimulation, the number of oocytes retrieved, the number/quality of oocytes fertilized and of cleaved embryos, cycle cancellation, implantation, clinical pregnancy, ongoing pregnancy, multiple pregnancies and ovarian hyperstimulation syndrome rates were assessed in each group.

RESULTS

The assessment of perifollicular vascularity was feasible in 88.9% of cases. No difference between groups was detected in any parameter evaluated.

CONCLUSION

Power Doppler assessment of perifollicular vascularity seems to have no clinical utility for oocyte selection in IVF cycles for young infertile women.

Perifollicular vascularity in poor ovarian responders during IVF

BACKGROUND

Normal ovarian responders who have follicles with good vascularity shown by power Doppler scanning are associated with a better pregnancy rate following IVF treatment. This study evaluated the significance of perifollicular vascularity and follicular fluid hormonal profile in poor responders who developed < or = 3 dominant follicles.

METHODS

Before oocyte retrieval, they underwent power Doppler examination for perifollicular vascularity. Patients who had all follicles with low-grade vascularity were classified as Group A, whereas those with at least one follicle with high-grade vascularity were Group B. Their follicular fluid concentrations of estradiol (E2), progesterone, HCG, vascular endothelial growth factor (VEGF) and inhibin B were measured.

RESULTS

A total of 58 consecutive patients were recruited: 38 in Group A and 20 in Group B. Implantation rate, clinical pregnancy rate and follicular fluid hormonal concentrations were comparable for Groups A and B. Multiple pregnancy and live birth rates appeared higher, whereas miscarriage rate were lower in Group B than Group A, but these differences did not reach statistical significance.

CONCLUSION

There were no significant differences in the implantation, clinical pregnancy and live birth rates among poor responders with and without high-grade perifollicular vascularity.

Assessment of the ovarian volume, number and volume of follicles and ovarian vascularity by three-dimensional ultrasonography and power Doppler angiography on the HCG day to predict the outcome in IVF/ICSI cycles

OBJECTIVE

The aim of this prospective study was to investigate whether ovarian blood flow is related to embryological parameters and whether it could be a predictor of outcomes of IVF/ICSI.

METHODS

Eighty infertile women underwent ovarian stimulation with gonadotrophins after a long protocol with GnRH agonists. The ovarian volume (OV), number of follicles (NF) and follicular volume (FV) of all follicles >10 mm and vascularization index (VI), flow index (FI) and vascularization-flow index (VFI) were obtained by three-dimensional (3D) ultrasonography and power Doppler angiography (PDA) on the day of HCG administration. These parameters were tested for their relation with IVF laboratory parameters.

RESULTS

The OV, FV, VI, FI and VFI were significantly greater in the pregnant group. The NF and FV were the only independent predictors of the number of oocytes retrieved, mature and fertilized, and the number of embryos developed and their cumulative embryo score. Nevertheless, the number of grade 1 embryos depends on the NF and the VI. The ovarian FI and the number of transferred grade 1 embryos can predict gestation in 76% of IVF patients. A low FI and non-grade 1 embryo transferred are also associated with an increased pregnancy loss.

CONCLUSION

3D ultrasonography and PDA allow for an easier ovarian assessment in IVF cycles. The predictive value of IVF outcome suggests a high clinical usefulness of this new technique.

Power Doppler ultrasound assessment of ovarian perifollicular blood flow in women with polycystic ovaries and normal ovaries during in vitro fertilization treatment

OBJECTIVE

To evaluate whether ovarian perifollicular blood flow (PFBF) varies by ultrasound among women with polycystic and normal ovaries undergoing in vitro fertilization (IVF).

DESIGN

Prospective observational cohort study of women undergoing IVF treatment.

SETTING

Department of reproductive medicine at a university teaching hospital.

PATIENT(S)

Thirty four women with regular spontaneous ovulatory menstrual cycles undergoing IVF divided into two groups according to findings on a baseline transvaginal ultrasound scan: group 1 consisted of 20 women with ultrasound-evident normal ovaries (USNO group), and group 2 consisted of 14 women with ultrasound-evident polycystic ovaries (USPCO group).

INTERVENTION(S)

Serial transvaginal power Doppler ultrasound assessments throughout the follicular phase of ovarian stimulation.

MAIN OUTCOME MEASURE(S)

Ovarian PFBF and ovarian stromal artery pulsatility index.

RESULT(S)

Women with USPCO had a significantly lower ovarian stromal artery pulsatility index at the time of the first ultrasound assessment before starting the FSH injections compared with USNO women. However, there was no difference in ovarian PFBF between women with USPCO and USNO during the follicular phase of ovarian stimulation for IVF.

CONCLUSION(S)

There is no difference in ovarian follicular vascularity between women with polycystic and normal ovaries during ovarian stimulation at IVF treatment.

Comparison of follicular vascularization in normal versus polycystic ovaries during in vitro fertilization as measured using 3-dimensional power Doppler ultrasonography

OBJECTIVE

The growth of the follicles induced by gonadotropins during IVF treatment is accompanied by physiologic angiogenesis, which is essential for the maturation of the oocytes. We describe the IVF-induced changes in the vascularization and compare normal with polycystic ovaries (PCOs).

DESIGN

Prospective study.

SETTING

Assisted reproductive unit at a university hospital.

PATIENT(S)

Sixty women who underwent IVF cycles.

INTERVENTION(S)

The ovarian vascularization was measured after pituitary down-regulation, FSH stimulation, and hCG-injection using three-dimensional power Doppler ultrasonography.

MAIN OUTCOME MEASURE(S)

The total ovarian vascularization was divided by the number of follicles.

RESULT(S)

After pituitary suppression, the ovarian vascularization/follicle was lower in polycystic ovary (PCO) patients. During ovarian stimulation, follicles in PCOs required a lesser amount of FSH to acquire the same level of vascularization than the follicles in normal ovaries. In addition, hCG induced an increase in the follicular vascularization in both normal and PCOs. The follicle count correlated with the total vascularized volume in the ovaries throughout the IVF cycle.

CONCLUSION(S)

Follicles in PCOs seem to be less vascularized than the follicles in normal ovaries after GnRH treatment but not after gonadotropin stimulation. It is possible that restricted blood supply to the follicles in PCO might be associated with the follicular arrest that is observed. We could confirm that follicles in PCO are more sensitive to gonadotropin stimulation than follicles in normal ovaries.

Follicular blood flow is a better predictor of the outcome of in vitro fertilization-embryo transfer than follicular fluid vascular endothelial growth factor and nitric oxide concentrations

OBJECTIVE

To investigate the relationship between follicular blood flow and the follicular fluid vascular endothelial growth factor (VEGF) and nitric oxide (NO) concentrations and to determine which factor might be a better predictor of the outcome of IVF-ET.

DESIGN

Prospective study.

SETTING

Academic research laboratory.

PATIENT(S)

Forty-seven cycles of IVF (tubal factor, 25 cycles; male factor, 22 cycles) at the infertility clinic of Pusan National University Hospital from February 2002 to June 2002.

INTERVENTION(S)

Follicular blood flow was estimated on the day of hCG administration. Each follicular fluid sample was collected at oocyte retrieval, and follicular fluid VEGF and NO concentrations were assessed.

MAIN OUTCOME MEASURE(S)

Follicular blood flow and follicular fluid VEGF and NO concentrations according to the age of patients, the cause of infertility, and pregnancy rate.

RESULT(S)

Of 47 cycles, 18 (38.3%) cycles resulted in a pregnancy. Follicular blood flow was significantly higher in the pregnant group compared with the nonpregnant group, but there was no statistically significant difference in age and infertility cause. Follicular fluid concentrations of VEGF and NO did not show statistically significant differences in age, infertility cause, or pregnancy outcome. As the follicle size increases, the follicular blood flow and follicular fluid VEGF concentrations increased significantly but the follicular fluid NO concentrations decreased. There was no correlation between VEGF and NO concentrations in the follicular fluid by linear regression analysis.

CONCLUSION(S)

Our study showed that follicular blood flow was positively associated with the outcome of pregnancy. This is the first study to investigate the direct association of the follicular blood flow with pregnancy outcome after IVF-ET. These results suggest that follicular blood flow might be a more effective prognostic marker of the pregnancy outcome of IVF than follicular fluid VEGF or NO concentrations.

An ultrasound-based approach to the assessment of infertility, including the evaluation of tubal patency

An optimal initial infertility investigation protocol would be a process that is diagnostically accurate, expeditious, cost-effective, reliable and as minimally invasive as possible. In addition, the investigation should provide the clinician with useful prognostic information regarding possible future treatment. At present, extensive use of invasive procedures such as diagnostic hysteroscopy and laparoscopy is the standard at many fertility centres. Recent advances in gynaecological ultrasonography have shown that ultrasound can replace routine invasive investigative procedures. An ultrasound-based approach would make the basic infertility investigation less time-consuming and less expensive, but at the same time more acceptable to the majority of patients. This chapter describes an ultrasound-based approach to the assessment of infertility. In addition, the role of ultrasonography for assessment of the pelvic organs as a basic part of the initial investigation of an infertile couple is discussed and compared to more traditional invasive methods.

Perifollicular vascularity monitoring and scoring: a clinical tool for selecting the best oocyte

The aim of our study was to assess relationship between perifollicular vascularity and outcome of in vitro fertilization (IVF) cycles. In our study, women who received embryos originating from oocytes developed in well vascularized follicles had a statistically higher pregnancy rate than women who received embryos chosen without considering follicles of origin.

Measurement of perifollicular blood flow of the dominant preovulatory follicle using three-dimensional power Doppler

OBJECTIVE

To establish whether we might predict the outcome of unstimulated in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles with quantitative indices of perifollicular blood flow assessed with three-dimensional (3D) reconstruction of power Doppler images.

METHODS

This prospective study included an analysis of 52 unstimulated cycles. Color and power Doppler ultrasound examinations of a single dominant preovulatory follicle were performed on the day of oocyte pick-up. With 3D reconstruction and processing, quantitative indices were obtained i.e. the percentage of volume showing a flow signal (VFS) inside a 5-mm capsule of perifollicular tissue and the percentage of VFS of each of the three largest vessels in this capsule. These indices as well as pulsed Doppler indices were compared between the groups of cycles with different outcomes using a one-way ANOVA test.

RESULTS

In nine cycles no oocyte was retrieved (Group A), in seven cycles no fertilization occurred (Group B) and in 30 cycles no implantation occurred (Group C). Six cycles resulted in pregnancy (Group D). There were no statistically significant differences in pulsed and power Doppler indices between these groups. However, the percentage of VFS in the capsule was higher than average in cycles with implantation (19.22 +/- 16.82 vs. 12.42 +/- 8.89, NS) and the percentage of VFS in the main vessel exhibited lower than average values in cycles with implantation (20.66 +/- 10.05 vs. 39.84 +/- 20.15), but only reached borderline statistical significance (F = 2.457, P = 0.074).

CONCLUSION

It can be hypothesized that the follicles containing oocytes able to produce a pregnancy have a distinctive and more uniform perifollicular vascular network.

Promise of new imaging technologies for assessing ovarian function

Advancements in imaging technologies over the last two decades have ushered a quiet revolution in research approaches to the study of ovarian structure and function. The most significant changes in our understanding of the ovary have resulted from the use of ultrasonography which has enabled sequential analyses in live animals. Computer-assisted image analysis and mathematical modeling of the dynamic changes within the ovary has permitted exciting new avenues of research with readily quantifiable endpoints. Spectral, color-flow and power Doppler imaging now facilitate physiologic interpretations of vascular dynamics over time. Similarly, magnetic resonance imaging (MRI) is emerging as a research tool in ovarian imaging. New technologies, such as three-dimensional ultrasonography and MRI, ultrasound-based biomicroscopy and synchrotron-based techniques each have the potential to enhance our real-time picture of ovarian function to the near-cellular level. Collectively, information available in ultrasonography, MRI, computer-assisted image analysis and mathematical modeling heralds a new era in our understanding of the basic processes of female and male reproduction.

Pronuclear scoring as a predictor of embryo development

Many strategies have been proposed for the selection of viable embryos for transfer in human assisted reproduction. These have included morphological scoring criteria for day 1, 2, 3 and 5 embryos or combinations of these. Other strategies have used predictors such as timing of certain key events, as with early cleavage to the 2-cell, development to the 8-cell stage or patterns of fragmentation. All have shown some correlations with implantation. However, the overall success of these methods is still limited, with over 50% of all transferred embryos failing to implant. The use of pronuclear oocyte morphology has shown correlations with implantation and development to the blastocyst stage. The key aspects of pronuclear scoring, namely the presence of a cytoplasmic halo, the orientation of the nuclei in relation to the polar bodies and the size, number and pattern of distribution of nucleolar precursor bodies (NPB) in the nuclei were related to day 2,3 and 5 development, rate of development and day 3 and 5 morphology in a retrospective study. The pattern of the NPB or Z-score and the presence/absence of a halo had a significant effect on the rate of development on day 3 and day 5 and on the overall embryo morphology score. Low Z-score resulted in slow development, poor blastocyst formation and low morphology scores. The absence of a halo also resulted in slow and poor development, poor morphology, increased fragmentation and increased numbers of poor Z-scored embryos. The use of PN scoring can help predict embryos that have poor developmental potential, aid in early selection and may indicate the health of the oocyte.

Side of ovulation and its effects on uterine and ovarian stromal blood flow and reproductive hormones

OBJECTIVE

Effect of the side of ovulation on uterine, ovarian, and follicular blood flow parameters and various hormone levels.

DESIGN

Prospective, observational study.

SETTING

Fertility Clinic, St. George's Hospital.

PATIENT(S)

Nineteen women with regular menstrual cycles. Pulsed Doppler measurements and serum hormonal concentrations during midfollicular, periovulatory, and midluteal phase for three successive cycles.

MAIN OUTCOME MEASURE(S)

Doppler blood flow and serum hormones.

RESULT(S)

Doppler blood flow of the ovarian stroma and follicular and uterine arteries showed no differences in the three phases between the right and left sides. Left-side uterine peak systolic velocity (PSV) (right-side PSV, 31.51cm/s; left-side PSV, 37.38 cm/s) during the periovulatory phase tended to be higher in the nondominant ovary; however, this was not quite significant. The serum hormone concentration showed no significant differences.

CONCLUSION(S)

The side of ovulation did not influence the Doppler blood flow to the ovarian stroma or follicular and uterine arteries. The side of ovulation had no effect on serum FSH, LH, 17beta-estradiol, P, inhibin A, or inhibin B levels.

Utility of color Doppler indices of dominant follicular blood flow for prediction of clinical factors in in vitro fertilization-embryo transfer cycles

OBJECTIVE

To investigate the relationship between color Doppler indices of dominant follicular blood flow and clinical factors in in vitro fertilization-embryo transfer cycles.

SUBJECTS AND METHODS

This was a prospective study involving 26 patients completing a total of 33 in vitro fertilization cycles. Dominant follicular blood flow indices, peak systolic velocities, the resistance index and the pulsatility index were evaluated using transvaginal color Doppler. The indices were compared to the clinical outcomes of in vitro fertilization-embryo transfer.

RESULTS

There was a significant correlation between dominant follicular peak systolic velocities and the number of oocytes retrieved, as well as the number of mature oocytes obtained. There was no significant correlation between dominant follicular resistance index or pulsatility index and the number of follicles > 10 mm in diameter, the number of oocytes retrieved or the number of mature oocytes. There were no significant differences between dominant follicular peak systolic velocities, resistance index or pulsatility index, and fertilization rate or the ratio of good quality embryos. However, significant differences were found between the number of oocytes retrieved, as well as the number of mature oocytes for those patients in which the peak systolic velocity was below 25 cm/s.

CONCLUSIONS

Doppler assessment of dominant follicle blood flow alone is useful for predicting the number of retrievable oocytes. However, morphological quality of the embryo produced or the pregnancy rate cannot be predicted by this method.

Three-dimensional sonographic and power Doppler characterization of ovaries in late follicular phase

OBJECTIVE

To determine ovarian blood flow characteristics using three-dimensional power Doppler ultrasound.

METHODS

We examined 30 patients (30 cycles) prior to the start of their in vitro fertilization treatment in the late follicular phase using three-dimensional power Doppler ultrasound. The volume, vascularization index, flow index, vascularization flow index, mean grayness and the presence of the dominant follicle were determined for each ovary separately.

RESULTS

The dominant follicle could be detected in 24 out of 30 cycles (80.0%). The volume of the dominant ovary was 9.9 (standard deviation, 4.0) cm3 and the volume of the non-dominant ovary 6.8 (standard deviation, 2.8) cm3 (P < 0.001). Mean grayness in the dominant ovary was 43.3 (standard deviation, 5.0) and in the non-dominant 47.2 (standard deviation, 4.0) (P < 0.001), but no other differences could be observed between dominant and non-dominant ovaries. The shell with a diameter of 2 mm surrounding the dominant follicle had a higher vascularization index (mean, 9.0; standard deviation, 5.9) and vascularization flow index (mean, 4.2; standard deviation, 2.8) than the whole dominant ovary (mean, 5.5; standard deviation, 2.5 and mean, 2.5; standard deviation, 1.3, respectively) (P = 0.003 and 0.002, respectively). In the cycles without a dominant follicle (n = 6), flow index (mean, 50.0; standard deviation, 5.9) and vascularization flow index (mean, 7.3; standard deviation, 6.2) on the left side were higher than on the right side (mean, 40.2; standard deviation, 3.1; mean, 1.5; standard deviation, 1.4; P-values 0.013 and 0.046, respectively).

CONCLUSION

In the dominant ovary, the volume was higher and mean grayness lower than in the non-dominant ovary. The vascularization index in the shell surrounding the dominant follicle was higher than the average vascularization index in the whole dominant ovary. In addition, there were differences in the vascularization and flow indices between right and left ovaries, which may be related to the anatomical difference in the venous drainage between right and left ovaries.

Day 5 inhibin B levels in a treatment cycle are predictive of IVF outcome

BACKGROUND

Day 5 serum inhibin B during IVF treatment has been investigated as a predictor of outcome.

METHODS

A total of 54 women (< or = 39 years, normal menses and endocrine profiles) were treated with urinary gonadotrophins or recombinant FSH following pituitary down-regulation. Serum day 3 FSH in a preceding cycle was <8.5 IU/l. Plasma inhibin B, inhibin A and estradiol were determined after 4 days of gonadotrophin administration (day 5).

RESULTS

Day 5 inhibin B was the most highly correlated with the number of mature follicles (>14 mm), oocytes retrieved and fertilized. Receiver operating characteristic analysis gave high accuracy for day 5 inhibin B in predicting ovarian response and indicated that a threshold of 400 pg/ml may be helpful in the decision as to whether to continue treatment. Women with <400 pg/ml (n = 16) had lower numbers of follicles, mature follicles, oocytes retrieved, fertilized and cleaved compared with those >400 pg/ml (n = 36) and this threshold gave a positive likelihood ratio of 30, 92.9% sensitivity, 95.0% specificity and 86.7% positive predictive value to detect poor ovarian response. Day 5 inhibin B was the best predictor of pregnancy (no live births and four cycles cancelled, low inhibin group; nine live births and no cancelled cycles, high inhibin group).

CONCLUSIONS

Normogonadotrophic, normogonadal women with day 5 inhibin B <400 pg/ml in down-regulated cycles have a poor response to ovarian stimulation and are less likely to conceive compared with women with higher day 5 inhibin B.

Investigation of the infertile couple: a one-stop ultrasound-based approach

The appropriateness of many investigations for subfertility will continue to be of debate for some time yet. Of most benefit to the concerned couple would be a process that is diagnostically accurate, expeditious and reliable. It should be performed with a minimum of invasion and provide both patient and clinician with useful prognostic information regarding possible future treatment. This article is intended to illustrate the advantages of an ultrasound-based process of subfertility investigation. Discussed is the role of ultrasound compared with more invasive investigative methods such as laparoscopy and hysteroscopy. In addition, the potential capacity of newer advanced ultrasound technologies is reviewed.

Perifollicular vascularity and its relationship with oocyte maturity and IVF outcome

New markers of embryo ability to implant are pursued continuously. Understanding whether an oocyte is really "mature," that is, ready to be fertilized, would be of great help in choosing an embryo that will implant. It is usual to pay attention to the phase of meiosis, considering the extrusion of the polar body (metaphase II) to be the only sign of the maturity of the oocytes. Nevertheless, understanding more about how the cytoplasm contributes to an oocyte's competency also shows promise as a method of predicting which embryos will implant. Some studies about perifollicular vascularity have demonstrated that embryos originating from oocytes developed in well-vascularized follicles have a higher implantation rate than those originating from oocytes developed in follicles with poor vascularization. Here, we report our results from a preliminary study in which embryos were transferred according to the degree of vascularization of the follicle. Women who received embryos originating from oocytes developed in well-vascularized follicles had a statistically higher pregnancy rate than women who received embryos deriving from oocytes grown in more poorly vascularized follicles (34% vs. 13.7%).

Advanced ultrasound examination in the management of subfertility

The development of new ultrasound techniques such as colour power angiography (CPA) and three-dimensional ultrasound may expand the role of ultrasound in the management of the infertile couple. Measurements of follicular blood flow velocities appears to predict the development of a healthy oocyte while high ovarian stromal vascularity is associated with polycystic ovary and the risk of ovarian hyperstimulation syndrome. Three-dimensional ultrasound with CPA provides spatial evaluation of volume flow in pelvic organs which has been used to measure vascular changes in the endometrium and improve the evaluation of tubal patency.

Perifollicular blood flow Doppler indices, but not follicular pO2, pCO2, or pH, predict oocyte developmental competence in in vitro fertilization

OBJECTIVE

To assess the relationships among perifollicular blood flow; follicular fluid pO2, pCO2, and pH; oocyte developmental capacity; preimplantation embryo quality.

DESIGN

Prospective study.

SETTING

Academic, tertiary care institution.

PATIENT(S)

Unselected, gonadotropin-stimulated IVF cycles.

INTERVENTION(S)

Color, pulsed Doppler analysis of perifollicular blood flow, and follicular pO2, pCO2, and pH determinations of randomly designated, mapped ovarian follicles.

MAIN OUTCOME MEASURE(S)

Fertilization and day 3 embryo cleavage and morphology.

RESULT(S)

Perifollicular vascularity indices were significantly and negatively correlated with day 3 embryo cleavage. Pulsatility index and S-D ratio also were significantly and negatively correlated with follicular pO2. The same correlation was found between resistance index and the fertilization rate of preovulatory oocytes. No relationship existed between follicular metabolic analysis and fertilization or embryo quality. The resistance index had a sensitivity of 0.57 and a specificity of 0.71 for the prediction of advanced embryo cleavage status.

CONCLUSION(S)

Results confirm and extend previous reports demonstrating that color, pulsed Doppler ultrasound analysis of individual preovulatory follicles during IVF therapy may provide an indirect index of the developmental competence of the corresponding oocyte. Although these methods may provide means to select embryos for transfer with the highest implantation potential, the moderate predictive power showed so far may limit their clinical applicability.

Colour Doppler indices of follicular blood flow as predictors of pregnancy after in-vitro fertilization and embryo transfer

Peak systolic velocity (PSV) of individual follicles has been correlated with oocyte recovery, fertilization rate and embryo quality [in women undergoing in-vitro fertilization (IVF) and embryo transfer]. The present study assessed the role of quantitative and qualitative indices of follicular vascularity in predicting pregnancy after IVF and embryo transfer. A total of 106 women undergoing IVF treatment for infertility who were considered to be at risk of failure (>37 years of age, history of low response to gonadotrophin stimulation, or multiple failed IVF cycles) constituted the study group. PSV was measured from the three largest follicles on both the right and left ovaries on the day of human chorionic gonadotrophin (HCG) administration using an Acuson Sequoia with a 4-8 MHz transvaginal probe. The quality of follicular flow was graded from 1 to 4 according to the amount of visible colour flow around the follicle (grade 1 when one-quarter of the follicle, grade 2 when one-half, grade 3 when three-quarters, and grade 4 when the entire follicle was surrounded by colour). Clinical pregnancies resulted in 11 (10%) of the 106 high-risk women. Women who had PSV >/= 10 cm/s in at least one follicle on the day of HCG administration more often became pregnant than those with PSV <10 cm/s (P = 0.05). All pregnancies occurred in women with grade 3 or 4 follicular blood flow. Qualitative as well as quantitative measurements of follicular flow predict pregnancy after IVF and embryo transfer.

Epigenetic influences on oocyte developmental competence: perifollicular vascularity and intrafollicular oxygen

PURPOSE

Studies indicating that the developmental competence of the human oocyte is influenced by the level of intrafollicular oxygen are described.

METHODS

Perifollicular vascularity and dissolved oxygen content were determined by color Doppler ultrasonography and analysis of follicular fluid at ovum retrieval, respectively, in stimulated cycles for in vitro fertilization.

RESULTS

Differences in the degree of perifollicular vascularity correlate with differences in the dissolved oxygen content of the corresponding follicular fluid. Oocytes with cytoplasmic and chromosomal disorders and embryos with multinucleated blastomeres and limited developmental ability were derived predominantly from underoxygenated follicles. Findings from several studies indicate that embryos with the highest implantation potential originate from follicles that are well-vascularized and oxygenated.

CONCLUSIONS

Follicular vascularity and oxygen content appear to be important determinants of oocyte competence. Possible causes of differences in follicle-specific vascularity and the potential effects of severe hypoxia on the normality of molecular and cellular processes during follicle growth and preovulatory development are discussed.

Association of thymidine phosphorylase concentration with ultrasound-derived indices of blood flow in ovarian masses

BACKGROUND

The aim of this study was to determine the relationship between the concentration of thymidine phosphorylase (a known angiogenic factor) and indices of blood flow in physiologic ovarian tissues and overt (benign and malignant) tumors.

METHODS

The ovaries of all patients were examined by transvaginal ultrasonography, with color Doppler imaging and pulsed Doppler spectral analysis, within the 24 hours preceding laparotomy. Ovaries removed at surgery were dissected into their main components (follicles, corpus luteum, and tumor) and, where possible, into areas of high blood velocity according to the results of color Doppler imaging. The concentration of thymidine phosphorylase was measured by an enzyme-linked immunosorbent assay.

RESULTS

Thirty-eight tissue aliquots (16 from normal ovaries and 22 from ovarian tumors) were obtained from 33 patients. Twenty-nine tissue samples (76%) came from areas of measurable (high) blood velocity. The concentration of thymidine phosphorylase was significantly higher in tissue associated with high blood velocity (median 17.9, range 1.8-78.3 units per mg of protein vs. median 6.8, range 1.3-24.7 units per mg of protein, respectively; P < 0.05, Mann-Whitney U test). All of 8 corpora lutea, 12 of 14 benign tumors, and 7 of 7 malignant tumors had measurable blood velocity. There was a significant correlation between the concentration of thymidine phosphorylase and the peak systolic velocity in benign tumors (correlation coefficient [r] = 0.79, P < 0.01) and malignant tumors (r = 0.87, P < 0.05).

CONCLUSIONS

High intratumoral peak systolic velocity as determined by transvaginal color Doppler imaging and spectral analysis reflects high production of thymidine phosphorylase. This finding may aid the development of antivascular therapy for patients with ovarian carcinoma.