Reduced FSH and LH action: implications for medically assisted reproduction

Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) play complementary roles in follicle development and ovulation via a complex interaction in the hypothalamus, anterior pituitary gland, reproductive organs, and oocytes. Impairment of the production or action of gonadotropins causes relative or absolute LH and FSH deficiency that compromises gametogenesis and gonadal steroid production, thereby reducing fertility. In women, LH and FSH deficiency is a spectrum of conditions with different functional or organic causes that are characterized by low or normal gonadotropin levels and low oestradiol levels. While the causes and effects of reduced LH and FSH production are very well known, the notion of reduced action has received less attention by researchers. Recent evidence shows that molecular characteristics, signalling as well as ageing, and some polymorphisms negatively affect gonadotropin action. These findings have important clinical implications, in particular for medically assisted reproduction in which diminished action determined by the afore-mentioned factors, combined with reduced endogenous gonadotropin production caused by GnRH analogue protocols, may lead to resistance to gonadotropins and, thus, to an unexpected hypo-response to ovarian stimulation. Indeed, the importance of LH and FSH action has been highlighted by the International Committee for Monitoring Assisted Reproduction Technologies (ICMART) in their definition of hypogonadotropic hypogonadism as gonadal failure associated with reduced gametogenesis and gonadal steroid production due to reduced gonadotropin production or action. The aim of this review is to provide an overview of determinants of reduced FSH and LH action that are associated with a reduced response to ovarian stimulation.

A qualitative study of the impact of endometriosis on male partners

STUDY QUESTION

What is the impact of endometriosis on male partners of women with the condition?

SUMMARY ANSWER

Endometriosis significantly impacts men across several life domains and can negatively impact emotional well-being.

WHAT IS KNOWN ALREADY

Endometriosis has been shown to negatively impact women's quality of life and may strain intimate relationships. Little is known about the impact on male partners.

STUDY DESIGN, SIZE, DURATION

The ENDOPART study was a cross-sectional, qualitative study of 22 women with endometriosis and their male partners (n = 44) in the UK (2012–2013).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Inclusion criteria: laparoscopic diagnosis of endometriosis; the presence of symptoms for at least a year; partners living together. Data were collected via face to face, semi structured interviews with partners interviewed separately. Data were analysed thematically, assisted by NVivo 10.

MAIN RESULTS AND THE ROLE OF CHANCE

Men reported that endometriosis affected many life domains including sex and intimacy, planning for and having children, working lives and household income. It also required them to take on additional support tasks and roles. Endometriosis also had an impact on men's emotions, with responses including helplessness, frustration, worry and anger. The absence of professional or wider societal recognition of the impact on male partners, and a lack of support available to men, results in male partners having a marginalized status in endometriosis care.

LIMITATIONS REASONS FOR CAUTION

Self-selection of participants may have resulted in a sample representing those with more severe symptoms. Couples included are in effect ‘survivors’ in relationship terms, therefore, findings may underestimate the contribution of endometriosis to relationship breakdown.

WIDER IMPLICATIONS OF THE FINDINGS

The study extends knowledge about the impact of endometriosis on relationships, which thus far has been drawn largely from studies with women, by providing new insights about how this condition affects male partners. Healthcare practitioners need to take a more couple-centred, biopsychosocial approach toward the treatment of endometriosis, inclusive of partners and relationship issues. The findings demonstrate a need for information and support resources aimed at partners and couples.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Economic and Social Research Council (reference ES/J003662/1). The authors have no conflicts of interest.

Anxiety associated with diagnostic uncertainty in early pregnancy

OBJECTIVES

To determine anxiety levels of women presenting to an early pregnancy assessment unit (EPAU) with abdominal pain and/or vaginal bleeding and to assess how these levels change over time and according to ultrasonographic diagnosis.

METHODS

We undertook a prospective cohort study in an EPAU in a large UK teaching hospital. Women with abdominal pain and/or vaginal bleeding in early pregnancy (< 12 weeks' gestation) presenting for the first time were eligible for inclusion in the study. State anxiety levels were assessed using the standardized short form of Spielberger's state-trait anxiety inventory (STAI) on three occasions (before, immediately after and 48-72 hours after an ultrasound scan). Scores were correlated with ultrasonographic diagnosis. The diagnosis was either certain or uncertain. Certain diagnoses were either positive, i.e. a viable intrauterine pregnancy (IUP), or negative, i.e. a non-viable IUP or ectopic pregnancy. Uncertain diagnoses included pregnancy of unknown location and pregnancy of uncertain viability. Statistical analysis involved mixed ANOVAs and the post-hoc Tukey-Kramer test.

RESULTS

A total of 160 women were included in the study. Anxiety levels decreased over time for women with a certain diagnosis (n = 128), even when negative (n = 64), and increased over time for women with an uncertain diagnosis (n = 32). Before the ultrasound examination, anxiety levels were high (STAI value, 21.96 ± 1.11) and there was no significant difference between the five groups. Immediately after the ultrasound examination, anxiety levels were lower in the viable IUP group (n = 64; 7.75 ± 1.13) than in any other group. The difference between the five groups was significant (P < 0.005). After 48-72 hours, women with a certain diagnosis had significantly lower anxiety levels than had those with an uncertain diagnosis (10.77 ± 4.30 vs 22.94 ± 1.65; P < 0.005).

CONCLUSIONS

The experience of abdominal pain and/or vaginal bleeding in early pregnancy is highly anxiogenic. Following an ultrasound examination, the certainty of the diagnosis affects anxiety levels more than does the positive or negative connotations associated with the diagnosis per se. Healthcare providers should be aware of this when communicating uncertain diagnoses. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Use of double decidual sac sign to confirm intrauterine pregnancy location prior to sonographic visualization of embryonic contents

OBJECTIVES

To determine the diagnostic accuracy of the double decidual sac sign (DDSS) for predicting an intrauterine pregnancy (IUP) prior to visualization of embryonic contents, using modern high-resolution transvaginal sonography (TVS).

METHODS

The study was conducted following STARD guidelines and participants were recruited prospectively from Nurture Fertility, Nottingham, UK, following in-vitro fertilization/intracytoplasmic sperm injection treatment between 1 January 2015 and 31 October 2015. Women were excluded if there was no evidence of intrauterine fluid collection during the index test, a yolk sac or fetal pole was visible during the index test, no outcome data were available or pregnancy location could not be determined by the reference standard. The index test consisted of TVS at 32-34 days' gestation using a high-frequency transvaginal probe. Reference standard was TVS at 7 weeks' gestation. The outcome of interest was an IUP.

RESULTS

A total of 67 intrauterine fluid collections were observed and included in the analysis, of which 61 exhibited the DDSS and 65 were proven to be IUPs. Two ectopic pregnancies were included, neither of which demonstrated the DDSS. The DDSS therefore had a sensitivity of 93.9% (95% CI, 85.0-98.3%), specificity of 100% (95% CI, 15.8-100%) and overall diagnostic accuracy of 94.0% (95% CI, 88.3-99.7%) for predicting an IUP. The negative likelihood ratio and positive and negative predictive values were 0.06 (95% CI, 0.02-0.16), 100% (95% CI, 94.1-100%) and 33.3% (95% CI, 4.3-77.7%), respectively.

CONCLUSION

With modern high-resolution TVS, presence of the DDSS can be used to confirm accurately IUP location prior to sonographic visualization of embryonic contents, and therefore to exclude effectively ectopic pregnancy. Absence of the DDSS, however, does not preclude an IUP. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Strategies for improving outcome of assisted reproduction in women with polycystic ovary syndrome: systematic review and meta-analysis

OBJECTIVES

To identify, appraise and summarize the current evidence regarding the efficacy of strategies aimed at improving assisted reproductive techniques in women with polycystic ovary syndrome (PCOS).

METHODS

A comprehensive literature search of the standard medical databases was performed. The last electronic search was run in July 2015. The primary outcome measures were live birth/ongoing pregnancy and ovarian hyperstimulation syndrome (OHSS). The secondary outcome measures were clinical pregnancy and miscarriage.

RESULTS

We screened 1021 records and completely assessed 173, finally including 66 studies in the quantitative analysis. Many different interventions were assessed, however the overall quality of the studies was low. We observed moderate-quality evidence that there is no clinically relevant difference in live birth/ongoing pregnancy rates (relative risk (RR), 0.95 (95% CI, 0.84-1.08)), or clinical pregnancy (RR, 1.02 (95% CI, 0.91-1.15)) when comparing antagonist and agonist protocols for ovarian stimulation. Additionally, we found low-quality evidence that metformin improves live birth/ongoing pregnancy (RR, 1.28 (95% CI, 1.01-1.63)) and clinical pregnancy rates (RR, 1.26 (95% CI, 1.04-1.53)) when compared with placebo or no intervention. We further found low-quality evidence that there is no clinically relevant difference in live birth/ongoing pregnancy rates (RR, 1.03 (95% CI, 0.80-1.34)) and clinical pregnancy rates (RR, 0.99 (95% CI, 0.81-1.22)) when comparing human menopausal gonadotropin for inducing ovulation and artificial preparation with estradiol valerate for endometrial preparation for frozen embryo transfer (FET). Low-quality evidence suggests that mannitol compared with no intervention (RR, 0.54 (95% CI, 0.39-0.77)) and antagonist protocols compared with agonist protocols (RR, 0.63 (95% CI, 0.49-0.80)) reduce rates of OHSS.

CONCLUSION

There is low- to moderate-quality evidence suggesting that antagonist protocols are preferable to agonist ones, because they reduce the incidence of OHSS without interfering with clinical pregnancy and live birth for women with PCOS. Additionally there is low-quality evidence pointing to a benefit of metformin supplementation on clinical pregnancy and live birth; and that ovulation induction and administration of estradiol seem to be equally effective for endometrial preparation before FET for women with PCOS. For all other interventions, the evidence is of very low quality, not allowing any meaningful conclusions to be drawn. Estrategias para mejorar el resultado de la reproducción asistida en mujeres con síndrome de ovario poliquístico: revisión sistemática y metaanálisis RESUMEN OBJETIVOS: Identificar, evaluar y resumir la evidencia actual sobre la eficacia de las estrategias para mejorar las técnicas de reproducción asistida en mujeres con síndrome de ovario poliquístico (SOP). MÉTODOS: Se realizó una búsqueda exhaustiva de literatura en las bases de datos médicas estándar. La última búsqueda electrónica se realizó en julio de 2015. Las medidas de resultado primarias fueron los nacimientos vivos/embarazos en curso y el síndrome de hiperestimulación ovárica (SHO). Las medidas de resultado secundarias fueron el embarazo confirmado ecográficamente y el aborto.

RESULTADOS

Se cribaron 1021 registros, de los que se evaluaron por completo 173, para finalmente incluir 66 estudios en el análisis cuantitativo. Aunque se evaluaron muchas intervenciones diferentes, en general la calidad de los estudios fue baja. Se observó evidencia de calidad moderada de que no hay diferencias relevantes clínicamente en las tasas de nacimientos vivos/embarazos en curso (riesgo relativo (RR): 0,95 (IC 95%, 0,84-1,08)), o de embarazos confirmados ecográficamente (RR: 1,02 (IC 95%, 0,91-1,15)), cuando se comparan los protocolos de antagonistas y agonistas para la estimulación ovárica. Además, se encontró evidencia de baja calidad en que la metformina mejora las tasas de nacimientos vivos/embarazos en curso (RR: 1,28 (IC 95%, 1,01-1,63)) y de embarazos confirmados ecográficamente (RR: 1,26 (IC 95%, 1,04-1,53)) en comparación con un placebo o la no intervención. Se encontró también evidencia de baja calidad en que no hay diferencias relevantes clínicamente en las tasas de nacimientos vivos/embarazos en curso (RR: 1,03 (IC 95%, 0,80-1,34)) y las tasas de embarazos confirmados ecográficamente (RR: 0,99 (IC 95%, 0.81-1,22)) al comparar la gonadotropina menopáusica humana para la inducción de la ovulación y la preparación artificial con el valerato de estradiol para preparar el endometrio para la transferencia de embriones congelados (TEC). La baja calidad de la evidencia sugiere que el manitol, en comparación con la no intervención (RR: 0,54 (IC 95%, 0,39-0,77)), y los protocolos de antagonistas, en comparación con los protocolos de agonistas (RR: 0,63 (IC 95%, 0,49-0,80)), reducen las tasas de SHO. CONCLUSIÓN: Hay evidencia de calidad baja a moderada que sugiere que los protocolos de antagonistas son preferibles a los de agonistas, ya que reducen la tasa de SHO sin interferir con el embarazo confirmado ecográficamente y los nacimientos vivos en las mujeres con SOP. Además, existe evidencia de baja calidad que indica un beneficio del uso de metformina como aporte suplementario en embarazos confirmados ecográficamente y en nacimientos vivos; y que la inducción de la ovulación y la administración de estradiol parecen ser igualmente eficaces para la preparación del endometrio antes de la TEC en mujeres con SOP. Para el resto de procedimientos, la evidencia es de muy baja calidad, y por ello no permite extraer conclusiones importantes.

Accuracy of first-trimester ultrasound in diagnosis of tubal ectopic pregnancy in the absence of an obvious extrauterine embryo: systematic review and meta-analysis

OBJECTIVES

To determine the accuracy of ultrasound in the diagnosis of a tubal ectopic pregnancy in the absence of an obvious extrauterine embryo.

METHODS

This was a systematic review conducted in accordance with the PRISMA statement and registered with PROSPERO. We searched MEDLINE, EMBASE and The Cochrane Library for relevant citations from database inception to July 2014. Studies were selected in a two-stage process and their data extracted by two reviewers. Accuracy measures were calculated for each ultrasound sign, i.e. empty uterus, pseudosac, adnexal mass and free fluid in the pouch of Douglas, alone and in various combinations. Individual study estimates were plotted in summary receiver-operating characteristics curves and forest plots for examination of heterogeneity. The quality of included studies was assessed.

RESULTS

Thirty-one studies including 5858 women were selected from 19,959 citations. Following meta-analysis, an empty uterus on ultrasound was found to predict an ectopic pregnancy with a sensitivity of 81.1% (95% CI, 42.1-96.2%) and specificity of 79.5% (95% CI, 68.9-87.1%). The corresponding performance of the pseudosac, adnexal mass and free fluid were: 5.5% (95% CI, 3.3-9.0%) and 94.2% (95% CI, 75.9-98.8%); 63.5% (95% CI, 48.5-76.3%) and 91.4% (95% CI, 83.6-95.7%); and 47.2% (95% CI, 33.2-61.7%) and 92.3% (95% CI, 85.6-96.0%), respectively.

CONCLUSION

Visualization of an empty uterus, adnexal mass, free fluid or a pseudosac has poor sensitivity for the diagnosis of a tubal pregnancy when an obvious extrauterine embryo is absent, but it has good specificity. We can therefore infer that ultrasound is more useful for 'ruling in' a tubal pregnancy than 'ruling out' one. However, the findings were limited by the poor quality of some included studies and heterogeneity in the index test and reference standard.

Accuracy of first-trimester ultrasound in diagnosis of intrauterine pregnancy prior to visualization of the yolk sac: a systematic review and meta-analysis

OBJECTIVES

To evaluate the diagnostic accuracy of ultrasound in predicting the location of an intrauterine pregnancy before visualization of the yolk sac is possible.

METHODS

This was a systematic review conducted in accordance with the PRISMA statement and registered with PROSPERO. We searched MEDLINE, EMBASE and The Cochrane Library for relevant citations. Studies were selected in a two-stage process and their data extracted by two reviewers. Accuracy measures were calculated for each ultrasound sign, i.e. gestational sac, double decidual sac sign, intradecidual sign, chorionic rim sign and yolk sac. Individual study estimates were plotted in summary receiver-operating characteristics curves and forest plots for examination of heterogeneity. The quality of included studies was assessed.

RESULTS

Seventeen studies including 2564 women were selected from 19 959 potential papers. Following meta-analysis, the presence of a gestational sac on ultrasound examination was found to predict an intrauterine pregnancy with a sensitivity of 52.8% (95% CI, 38.2-66.9%) and specificity of 97.6% (95% CI, 94.3-99.0%). The corresponding performance of the double decidual sac sign, intradecidual sign, chorionic rim sign and yolk sac were: 81.8% (95% CI, 68.1-90.4%) and 97.3% (95% CI, 76.1-99.8%); 66.1% (95% CI, 58.9-72.8%) and 100% (95% CI, 91.0-100%); 79.9% (95% CI, 73.0-85.7%) and 97.1% (95% CI, 89.9-99.6%); and 42.2% (95% CI, 27.7-57.9%) and 100% (95% CI, 54.1-100%), respectively.

CONCLUSION

Visualization of a gestational sac, double decidual sac sign, intradecidual sign or chorionic rim sign increases the probability of an intrauterine pregnancy but is not as accurate for diagnosis as the detection of the yolk sac. However, the findings were limited by the small number and poor quality of the studies included and heterogeneity in the index test and reference standard.

Maternal and neonatal outcomes in pregnant women with PCOS: comparison of different diagnostic definitions

STUDY QUESTION

Does the prevalence of adverse maternal and neonatal outcomes vary in women diagnosed with polycystic ovary syndrome (PCOS) according to different definitions?

SUMMARY ANSWER

A comparison of different criteria revealed that there is a substantial risk for perinatal complications in PCOS women, regardless of the used definition.

WHAT IS KNOWN ALREADY

Pregnant women with PCOS are susceptible to perinatal complications. At present, there are three main definitions for PCOS. So far, we are aware of only one study, which found that the elevated risk for complications varied widely depending on the different phenotypes and features but only considered a relatively small sample size for some of the phenotypes.

STUDY DESIGN, SIZE, DURATION

Retrospective matched cohort study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data of primiparous women with PCOS according to ESHRE/ASRM 2003 criteria and healthy controls giving birth to neonates ≥500 g were included. A total of 885 women were analysed: out of 177 women with PCOS, 85 (48.0%) met the National Institutes of Health (NIH) 1990 criteria, another 14 (7.9%) featured the additional phenotypes defined by The Androgen Excess and PCOS Society (AE-PCOS) 2006 criteria, 78 (44.1%) were classified as PCOS exclusively by the ESHRE/ASRM 2003 definition, and 708 represented the control group.

MAIN RESULTS AND THE ROLE OF CHANCE

The prevalence of adverse maternal (49.4 versus 64.3 versus 60.3%, P = 0.313) and neonatal (27.1 versus 35.7 versus 23.1%, P = 0.615) outcomes did not differ within the three PCOS groups (ESHRE/ASRM, NIH, AE-PCOS, respectively). Compared with healthy controls, the risk for maternal complications was increased in PCOS patients [odds ratio (OR) 2.57; 95% confidence interval (CI) 1.82-3.64; P < 0.001] while there was no difference in neonatal complications (OR 0.83; 95% CI 0.56-1.21; P = 0.343).

LIMITATIONS, REASONS FOR CAUTION

A limitation of our study is its retrospective design and the relatively small sample size, particularly in the AE-PCOS subgroup.

WIDER IMPLICATIONS OF THE FINDINGS

Since women with PCOS have, regardless of the used definition, a high risk of maternal and neonatal complications they should be informed and advised to follow regular checks in units where problems can be detected early to allow specialized care.

STUDY FUNDING/COMPETING INTERESTS

Marietta Blau Grant (Austrian Agency for International Cooperation in Education and Research; OeAD-GmbH) and mobility scholarship (Medical University of Graz).

Time-lapse embryo imaging for improving reproductive outcomes: systematic review and meta-analysis

OBJECTIVE

To identify, appraise and summarize the available evidence regarding the effectiveness and safety of time-lapse embryo monitoring on the main outcomes of assisted reproductive techniques.

METHODS

In this systematic review and meta-analysis, we included only randomized controlled trials (RCTs) comparing time-lapse embryo imaging with standard embryo monitoring. Our primary outcomes were live births (efficacy) and congenital abnormalities (safety). The secondary outcomes were clinical pregnancy, ongoing pregnancy and miscarriage.

RESULTS

Two RCTs were considered eligible, and their data were extracted and included in a meta-analysis. In both studies embryos were transferred at the blastocyst stage. No studies reported rates of live birth or congenital abnormalities. Our estimates were not sufficiently precise to identify whether time-lapse monitoring provided a small benefit, no effect or minor harm on rates of clinical pregnancy (relative risk (RR), 1.05 (95% CI, 0.80-1.38)) or ongoing pregnancy (RR, 1.05 (95% CI, 0.76-1.45)), based on two studies involving 138 women with moderate-quality evidence. Considering the available data, we were unable to determine whether the intervention poses substantial benefit, no effect or substantial harm in the risk of miscarriage (RR, 0.95 (95% CI, 0.30-2.99)), based on two studies involving 76 clinical pregnancies with low-quality evidence.

CONCLUSIONS

Time-lapse embryo imaging is unlikely to have a large effect on the chance of achieving clinical and/or ongoing pregnancy when transferring embryos at the blastocyst stage. More studies are required to improve the quality of the current evidence and also to examine whether this intervention is useful when transferring embryos at the cleavage stage.

Endometrial scratching performed in the non-transfer cycle and outcome of assisted reproduction: a randomized controlled trial

OBJECTIVES

To investigate the effect of endometrial scratching, performed during oral contraceptive pill (OCP) pretreatment, on reproductive outcome and on ultrasound markers of endometrial receptivity, and to assess the pain involved in the procedure, in unselected women undergoing assisted reproductive techniques (ART).

METHODS

Women undergoing ART were randomly allocated to undergo either endometrial scratching with a pipelle de Cornier or a sham procedure, 7-14 days before starting controlled ovarian stimulation (COS). We evaluated subsequent rates of clinical pregnancy, live birth, implantation, miscarriage and multiple pregnancy. Pain during the procedure was evaluated using a 10-cm visual analog scale. Endometrial thickness and volume and three-dimensional power Doppler (3D-PD) indices (vascularization index (VI), flow index (FI) and vascularization flow index (VFI)) were assessed during COS when there was at least one follicle ≥ 17 mm in diameter.

RESULTS

We included 158 women. Endometrial scratching was associated with higher rates of live birth (41.8% vs 22.8%, P = 0.01) and clinical pregnancy (49.4% vs 29.1%, P = 0.01) and higher pain score (6.42 ± 2.35 cm vs 1.82 ± 1.52 cm, P < 0.001), endometrial VI (3.71 ± 1.77 vs 2.95 ± 1.56, P < 0.01) and VFI (0.97 ± 0.51 vs 0.76 ± 0.40, P < 0.01). There was no significant effect of endometrial scratching on rate of miscarriage (15.4% vs 21.7%, P = 0.53) or multiple pregnancy (22.5% vs 25.0%, P = 0.79), or on endometrial thickness (10.12 ± 1.55 mm vs 9.98 ± 1.62 mm, P = 0.59), endometrial volume (6.18 ± 1.63 cm(3) vs 6.01 ± 1.48 cm(3) , P = 0.51) or FI (26.12 ± 2.82 vs 25.91 ± 2.72, P = 0.65).

CONCLUSIONS

Endometrial scratching performed once, during OCP pretreatment 7-14 days before starting COS, increases the chance of live birth and clinical pregnancy, but might cause considerable pain.

Measurement of fetal fat in utero in normal and diabetic pregnancies using magnetic resonance imaging

OBJECTIVES

To assess the reliability of magnetic resonance imaging (MRI) to measure fetal fat volume in utero, and to study fetal growth in women with and without diabetes in view of the increased prevalence of macrosomia in the former.

METHODS

We studied 26 pregnant women, 14 with pre-gestational diabetes and 12 non-diabetic controls. Fetal assessment took place at 24 weeks' gestation and again at 34 weeks by standard ultrasound biometry followed by MRI at 1.5 T. Fetal fat volume was determined from T1-weighted water-suppressed images using a semi-automated approach based on pixel intensity and taking into account partial volume effects. Fetal volume was also determined from the MRI images. Fetal weight was calculated using published fat and lean tissue densities.

RESULTS

There was little fetal fat at 24 weeks' gestation, but at 34 weeks the fetal fat content was considerably higher in the women with diabetes, with a mean fat content of 1090 ± 417 cm(3) compared with 541 ± 348 cm(3) in the controls (P = 0.006). Measurements of fetal fat volume showed low intra- and interobserver variability at 34 weeks, with intraclass correlation coefficients consistently above 0.99. Birth-weight centile correlated with fetal fat volume (R(2)  = 0.496, P < 0.001), percentage of fetal fat (R(2)  = 0.362, P = 0.008) and calculated fetal weight (R(2)  = 0.492, P < 0.001) at 34 weeks.

CONCLUSIONS

MRI appears to be a promising tool for the determination of fetal fat, body composition and weight in utero during the third trimester of pregnancy.

Ultrasound assessment of the peri-implantation uterus: a review

Emerging evidence suggests that early embryo implantation is a more active maternal process than hitherto appreciated, involving active encapsulation of the implanting blastocyst by maternal decidual cells and coordinated changes in the underlying inner myometrium, known as the junctional zone. These concepts raise the possibility that early ultrasound markers predictive of adverse pregnancy outcome could be identified. In this review we assess the role of ultrasound in predicting the likelihood of different pregnancy outcomes and highlight potential novel markers that could be tested.

The prevalence of congenital uterine anomalies in unselected and high-risk populations: a systematic review

BACKGROUND

The prevalence of congenital uterine anomalies in high-risk women is unclear, as several different diagnostic approaches have been applied to different groups of patients. This review aims to evaluate the prevalence of such anomalies in unselected populations and in women with infertility, including those undergoing IVF treatment, women with a history of miscarriage, women with infertility and recurrent miscarriage combined, and women with a history of preterm delivery.

METHODS

Searches of MEDLINE, EMBASE, Web of Science and the Cochrane register were performed. Study selection and data extraction were conducted independently by two reviewers. Studies were grouped into those that used ‘optimal’ and ‘suboptimal’ tests for uterine anomalies. Meta-analyses were performed to establish the prevalence of uterine anomalies and their subtypes within the various populations.

RESULTS

We identified 94 observational studies comprising 89 861 women. The prevalence of uterine anomalies diagnosed by optimal tests was 5.5% [95% confidence interval (CI), 3.5–8.5] in the unselected population, 8.0% (95% CI, 5.3–12) in infertile women, 13.3% (95% CI, 8.9–20.0) in those with a history of miscarriage and 24.5% (95% CI, 18.3–32.8) in those with miscarriage and infertility. Arcuate uterus is most common in the unselected population (3.9%; 95% CI, 2.1–7.1), and its prevalence is not increased in high-risk groups. In contrast, septate uterus is the most common anomaly in high-risk populations.

CONCLUSIONS

Women with a history of miscarriage or miscarriage and infertility have higher prevalence of congenital uterine anomalies compared with the unselected population.

A randomised controlled trial of 300 versus 225 IU recombinant FSH for ovarian stimulation in predicted normal responders by antral follicle count

OBJECTIVE

To test the hypothesis that among women predicted to have a normal ovarian response, ovarian stimulation using 300 IU follicle-stimulating hormone (FSH) results in the retrieval of more mature oocytes than 225 IU during in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) treatment.

DESIGN

Prospective randomised controlled study.

SETTING

University-based assisted conception unit.

POPULATION

A cohort of 131 women predicted to have a normal ovarian response to gonadotrophin stimulation, based on antral follicle count.

METHODS

Subjects undergoing their first cycle of IVF/ICSI were randomised to receive a fixed daily dose of 300 (experimental arm) or 225 IU (control arm) of recombinant FSH (Gonal-F).

MAIN OUTCOME MEASURES

Number of mature oocytes retrieved and live birth rates.

RESULTS

The number (mean +/- standard deviation) of mature oocytes retrieved (8.2 +/- 5.0 versus 9.0 +/- 4.8, for 300 and 225 IU, respectively; P = 0.34) was similar in each group. There were no differences between the 300- and 225 IU arms in live birth rates (31 versus 41%, respectively; P = 0.25), cycle cancellations resulting from insufficient ovarian response (0 versus 6.1%, respectively; P = 0.12), and prevalence of moderate (3.1 versus 3.0, respectively; P = 1.0) and severe (0 versus 1.5%, respectively; P = 1.0) ovarian hyperstimulation syndrome.

CONCLUSIONS

The use of a higher daily dose of 300 IU of recombinant FSH for ovarian stimulation does not improve the number of mature oocytes retrieved, or live birth rates, among women with a predicted normal response during conventional IVF/ICSI.

Endometrial blood flow is impaired in women with polycystic ovarian syndrome who are clinically hyperandrogenic

OBJECTIVES

To quantify endometrial and subendometrial blood flow in Caucasian women with polycystic ovarian syndrome (PCOS) and to determine whether these values differ according to the phenotypic expression of PCOS.

METHODS

Transvaginal pelvic ultrasound was performed on the 3(rd)-5(th) day of the menstrual cycle in 36 women with PCOS and 36 controls to examine the endometrial and subendometrial vascularity. The subendometrial and endometrial blood flow indices (vascularizaton index (VI), flow index (FI) and vascularization flow index (VFI)) were measured using three-dimensional power Doppler angiography. Uterine artery blood flow was assessed through analysis of two-dimensional (2D) pulsed-wave Doppler waveforms. Analysis was performed to compare PCOS with non-PCOS women, and subgroup analysis was performed of the PCOS women categorized according to their phenotypic manifestation.

RESULTS

There were no significant differences in endometrial volume, subendometrial vascularity and uterine artery blood flow between women with PCOS and controls after controlling for body mass index (BMI). On subgroup analysis, compared with anovulatory but clinically normoandrogenic women with polycystic ovaries (PCO) and with controls, women with PCO who were both clinically hyperandrogenic and anovulatory had significantly lower endometrial (VI: 0.57% vs. 1.11% and 0.86%, respectively, both P = 0.01; VFI: 0.14 vs. 0.42 and 0.28, respectively, both P = 0.02) and subendometrial (VI: 1.59% vs. 3.17% and 2.47%, P = 0.01 and 0.02, respectively; VFI: 0.50 vs. 1.67 and 0.96, P = 0.01 and 0.02, respectively) blood flow. Moreover, clinically hyperandrogenic but ovulatory women with PCO also had significantly lower endometrial blood flow (VI: 0.52% vs. 1.11%, P = 0.04) than did anovulatory but clinically normoandrogenic women with PCO. There were no differences in any of the 2D pulsed-wave Doppler measures of blood flow between the subgroups.

CONCLUSIONS

Subendometrial and endometrial blood flow is significantly impaired in women with PCOS who have clinical signs of hyperandrogenism.

Three-dimensional ultrasound features of the polycystic ovary in Chinese women

OBJECTIVES

To quantify the three-dimensional (3D) ultrasound characteristics of ovaries in Chinese women with polycystic ovarian syndrome (PCOS) and to compare these with previous data on a Caucasian cohort with PCOS.

METHODS

3D pelvic ultrasound was performed in 40 Chinese women with PCOS and 40 controls. Ovarian volume, stromal volume and echogenicity, and antral follicle count (AFC) were measured and ovarian blood flow was quantified using both 3D power Doppler and two-dimensional (2D) pulsed wave Doppler. These data were compared with previously published data on a Caucasian cohort with PCOS.

RESULTS

Compared with controls, women with PCOS had a higher AFC (median (range), 15 (11-30) vs. 5.5 (1-10) per ovary, P < 0.01), ovarian volume (12.32 (8.10-16.16) mL vs. 5.64 (2.62-8.81) mL, P < 0.01) and stromal volume (9.74 (6.44-13.56) mL vs. 4.07 (1.52-6.67) mL, P < 0.01) but were comparable in stromal echogenicity and ovarian blood flow as measured by 3D power Doppler or 2D pulsed wave Doppler indices. However, in comparison with a previously reported Caucasian cohort with PCOS, the ovaries of Chinese women with PCOS had a significantly smaller stromal volume (median (range), 9.74 (6.44-13.56) mL vs. 10.79 (5.65-17.12) mL, P < 0.05), were less echogenic as reflected in a lower mean gray value (22.43 (13.13-35.50) vs. 32.36 (19.35-53.71), P < 0.01), and had reduced ovarian blood flow as reflected in a lower flow index (30.19 (23.32-44.88) vs. 33.54 (21.88-51.65), P < 0.05).

CONCLUSION

Based on 3D ultrasound measurements, Chinese women with PCOS have an increased stromal volume compared with controls. However, their stromal volume, echogenicity and vascularity is significantly lower than that in Caucasian women with PCOS. The possible etiology for these differences is discussed.