Relationship of ovarian stromal blood flow at the baseline ultrasound scan to subsequent follicular response in an in vitro fertilization program

OBJECTIVE

To assess whether Doppler indices of intraovarian blood flow are related to the subsequent follicular response in an in vitro fertilization (IVF) program.

METHODS

One hundred five women underwent ultrasonographic assessment of ovarian morphology, transvaginal color Doppler measurement of intraovarian blood flow and immunoassay of serum FSH during the early follicular phase of an IVF cycle. The subsequent follicular response was related to the Doppler data.

RESULTS

Mean ovarian stromal peak systolic blood flow velocity was significantly correlated with the follicular response (P = .001), even after adjusting for the age of patient, type of ovary (polycystic or normal), total number of human menopausal gonadotropin ampules used, and serum FSH. Mean ovarian stromal pulsatility index was not related to the follicular response. Mean ovarian stromal peak systolic blood flow velocity was significantly lower (P = .007) in the poor-response group. The adjusted odds of a poor response increased significantly by an estimated 22% per cm/second decrease in velocity (P = .02).

CONCLUSION

Ovarian stromal blood flow at the baseline ultrasound scan is correlated with subsequent follicular response and may be a new indicator for predicting ovarian responsiveness in an IVF program.

Transvaginal three-dimensional ultrasound: reproducibility of ovarian and endometrial volume measurements

OBJECTIVE

To assess the reproducibility of ovarian and endometrial volume measurements obtained using transvaginal three-dimensional (3D) ultrasound (US).

DESIGN

Prospective clinical study.

SETTING

A tertiary referral center for assisted reproduction.

PATIENTS

Forty women undergoing ovarian stimulation for IVF-ET using the long protocol of GnRH agonist.

INTERVENTION

Three observers independently measured 20 stored ovarian scanned volumes and 20 endometrial volumes. Also, ovarian volume was calculated from three diameters obtained by two-dimensional (2D) US.

MAIN OUTCOME MEASURE

Analysis of variance, the paired Student's t-test, and calculation of intraclass and interclass correlation coefficients were used for statistical analysis.

RESULTS

Three-dimensional ovarian volume measurements were not significantly different from ovarian volume calculated from three diameters (7.98 versus 7.58 mL). The mean endometrial volume measurement was 3.56 mL. The intraobserver coefficient of variation for both ovarian and endometrial volume was 8%. The interobserver coefficient of variation was 9% for ovarian volume and 11% for endometrial volume. Intraclass and interclass correlation coefficients were 0.95 and 0.95 for ovarian volume and 0.90 and 0.82, respectively, for endometrial volume.

CONCLUSION

Transvaginal 3D US produces highly reproducible ovarian and endometrial volume measurements.

Ultrasound diagnosis of polycystic ovary syndrome

The US diagnostic criteria of the PCO have been refined with each successive advance in US technology. Diagnostic accuracy has evolved from a mere appreciation of overall ovarian size to the recognition of characteristic follicular patterns of distribution and subtle textural changes in the ovarian stroma. The most consistent features are the presence of multiple small follicles arranged around, or scattered through, a dense echogenic ovarian stroma, although recognition of the latter is highly subjective. Sophisticated innovations such as 3D US, together with colour and pulsed Doppler US, should improve the objectivity of observations and allow quantitative analysis of the ovarian stroma, which is known to be the source of the characteristic hyperandrogenaemia in PCOS. Valid comparative studies of women with normal and polycystic ovaries should now be feasible and will hopefully bring us closer to understanding the pathogenesis of this fascinating condition.

Transvaginal three-dimensional ultrasound: accuracy of follicular volume measurements

OBJECTIVES

To evaluate the accuracy of three-dimensional (3-D) ultrasound (US) follicular volume measurements.

DESIGN

Prospective clinical study.

SETTING

A tertiary referral center for assisted reproduction.

PATIENTS

Twenty-five patients undergoing ovarian stimulation for IVF-ET using the long protocol of GnRH agonist.

INTERVENTION

Transvaginal two-dimensional (2-D) and 3-D ovarian scan performed immediately before US-directed follicle aspiration.

MAIN OUTCOME MEASURES

The volume of follicular fluid aspirated was compared with the corresponding volume of the follicle measured by 3-D US and with the conventional 2-D US volume measurement calculated using the formula pi/6 (D1 x D2 x D3). Limits of agreement and 95% confidence intervals were calculated and systematic bias between the methods was analyzed.

RESULTS

The limits of agreement between the volume of follicular aspirate and follicular volume determined by US were +0.96 to -0.43 mL for 3-D measurements and +3.47 to -2.42 mL for 2-D measurements.

CONCLUSIONS

The true volume of ovarian follicles, within the clinically useful range for IVF-ET cycles, is measured more accurately by a 3-D US system than by 2-D US techniques.

Assessment of uterine artery blood flow on the day of human chorionic gonadotropin administration by transvaginal color Doppler ultrasound in an in vitro fertilization program

OBJECTIVE

To assess whether measurement of uterine artery blood flow impedance (the pulsatility index) as determined by transvaginal color Doppler ultrasound on the day of hCG administration in patients undergoing IVF can predict pregnancy and implantation rates.

DESIGN

Prospective observational study of women undergoing IVF.

SETTING

A tertiary referral center for assisted reproduction.

PATIENTS

One hundred thirty-five patients undergoing 139 IVF cycles.

INTERVENTION

Transvaginal color Doppler assessment of uterine artery pulsatility index on the day of administration of hCG.

MAIN OUTCOME MEASURES

Mean pulsatility index of the left and right uterine arteries, pregnancy rate, and embryo implantation rate.

RESULTS

The patients were grouped into pregnant and nonpregnant groups and according to whether the pulsatility index was low (1.00 to 1.99), medium (2.00 to 2.99), or high (> or = 3.00). The pregnancy rates were 13.8%, 34.7%, and 14.3% for the low, medium, and high pulsatility index groups, respectively, and were not significantly different. The implantation rates for the same groups were 10.7%, 16.3%, and 5.4%, respectively. The implantation rate for all the patients with pulsatility index < 3.00 (and especially 2.00 to 2.99) was significantly higher than the high pulsatility index group.

CONCLUSIONS

The study suggests that the measurement of uterine artery pulsatility index on the day of hCG predicts subsequent implantation rates. It may allow the administration of hCG to be deferred until uterine artery pulsatility index falls to < 3.00, which may result in improved implantation rates.

Administration of progestogens to hasten pituitary desensitization after the use of gonadotropin-releasing hormone agonist in in vitro fertilization--a prospective randomized study

OBJECTIVE

To assess the effect of administration of adjuvant IM progestogen to patients undergoing IVF who were not pituitary desensitized after 14 days of GnRH agonist (GnRH-a) administration.

DESIGN

Prospective randomized study.

SETTING

A tertiary referral center for assisted conception.

PATIENTS

Forty-nine patients undergoing 51 IVF treatment cycles.

INTERVENTION

Patients in whom the endometrial thickness was > 5 mm or who had an ovarian cyst > 15 mm after 14 days of GnRH-a administration were recruited if the serum E2 concentration was > 27.24 pg/mL (> 100 pmol/L). Patients in group 1 (n = 22) received a single IM injection of 100 mg P whereas patients in group 2 (n = 29) did not. Patients in both groups continued to receive SC GnRH-a 500 micrograms/d and had serum E2 levels measured every 3 days until the concentrations were < or = 100 pmol/L.

MAIN OUTCOME MEASURES

The number of days of GnRH-a administration from recruitment until serum E2 concentration measured < or = 100 pmol/L, number of cycles with withdrawal bleeding, number of days from recruitment to withdrawal bleeding, total dose of hMG used, number of follicles > 14 mm, number of oocytes, number of embryos, and pregnancy rates per cycle commenced and per ET.

RESULTS

There were no significant differences in all the above parameters except in the mean number of days from recruitment to onset of withdrawal bleeding, which were 5.33 +/- 0.7 (mean +/- SEM) and 8.62 +/- 1.26 days in groups 1 and 2, respectively. The pregnancy rate per ET was higher in group 1 (38.88%) when compared with group 2 (19.04%). However, this difference was not statistically significant.

CONCLUSIONS

Adjuvant administration of a single IM injection of progestogen hastens the onset of withdrawal bleeding in patients who are not pituitary desensitized after 2 weeks of administration of SC GnRH-a. It does not appear to affect the length of time the serum E2 concentrations take to reach basal levels or to alter the ovarian responsiveness to exogenous gonadotropins.

Ovarian stromal blood flow in women with polycystic ovaries--a possible new marker for diagnosis?

Blood flow changes in the ovarian stroma of women embarking on in-vitro fertilization treatment were assessed on day 2 or 3 of the menstrual cycle using colour and pulsed Doppler ultrasound. Women were divided into three groups: group 1, 63 women with regular, ovulatory menstrual cycles and normal ovaries on ultrasound scan; group 2, 13 women similar to group 1 but with polycystic ovaries (PCO) on ultrasound scan; and group 3, 12 women with biochemical evidence of previous anovulatory cycles and/or oligomenorrhoea and/or elevated serum luteinizing hormone concentrations (> 10 IU/l) in the early follicular phase together with PCO on ultrasound scan. A subjective assessment of the intensity and quantity of coloured areas in the ovarian stroma appeared to be greater in both groups 2 and 3 compared with group 1. Mean (SEM) ovarian stromal peak systolic blood flow velocity (Vmax) was 16.88 (1.79) and 16.89 (2.36) cm/s in groups 2 and 3 respectively. These velocities were significantly greater than the mean (SEM) ovarian stromal Vmax of group 1; 8.74 (0.68) cm/s (P < 0.001). Mean (SEM) ovarian stromal time averaged maximum velocity (TAMX) was 10.55 (0.91) and 10.89 (1.80) cm/s in groups 2 and 3 respectively, both significantly greater than mean ovarian stromal TAMX of group 1, (P < 0.001). There was no significant difference in pulsatility index (PI) between the three groups. There thus appears to be significantly greater ovarian stromal blood flow velocity in women with polycystic ovaries as detected by colour and pulsed Doppler ultrasound. Increased ovarian stromal blood velocity may be a new parameter to assist in the ultrasound diagnosis of PCO.(ABSTRACT TRUNCATED AT 250 WORDS)

Balancing the risk of recurrent thromboembolism and pre-existing osteoporosis in pregnancy

In summary, our 31-year-old patient with hypogonadotrophic hypogonadism has severe osteoporosis caused by chronic oestrogen deficiency. Her GnRH deficiency can be overcome using ovulation induction therapy. However, if she becomes pregnant there is a small risk of recurrent thromboembolism because of her previous cerebral thrombosis. This risk is hard to quantify but would undoubtedly increase if her mobility were impaired. The metabolic and mechanical alterations of pregnancy may compromise her weakened skeleton and increase the risk of a second major fracture. Her skeletal status precludes the use of standard heparin. Fractionated low molecular weight heparins would be the prophylactic agent of choice, possibly switching to low-dose warfarin for the second trimester. Alternative prophylaxis using low-dose aspirin may be suitable, although this is not proven. The difficulty in this case is that pregnancy and the prophylactic measures designed to protect the patient may prove to be detrimental. The case also highlights the vital role of prepregnancy counselling and interdisciplinary consultation between obstetrician, haematologist and endocrinologist in order to steer the safest course through this therapeutic minefield.

Acid-base changes after severe birth acidaemia

The aim of this study was to assess prospectively acid-base changes after severe birth acidaemia. Fourty-five term babies with severe acidaemia (median umbilical artery pH 6.99 [Range 6.74-7.05], mean base deficit 16.3 [SD 3.7] mmol/l) were prospectively identified. Pathological cardiotocographs were present in 32 (71%) prior to delivery and 39 (87%) were delivered operatively; 27 for fetal distress. Sixteen required intubation. At one hour of age, median pH was 7.29 [Range 7.04-7.45] and the change in pH correlated with one hour pCO2 (r = 0.62 p < 0.001). pH measurements were obtained in 11 of the 16 babies with a 1 hour pH < or = 7.25 and all values had recovered by this time. Five of this group were receiving oxygen. Of the 11 babies admitted to NICU, 1 died and 3 had evidence of encephalopathy, all of which were normal at follow-up [2-12 months]. Recovery of pH after severe birth acidaemia was evident at 1 hour of age and would appear to be complete by 4 hours.