Assessment of ovarian reserve using the inversion mode
2005; Wiley; Volume: 27; Issue: 1 Linguagem: Inglês
10.1002/uog.2683
ISSN1469-0705
AutoresN. J. Raine‐Fenning, P. M. Lam,
Tópico(s)Assisted Reproductive Technology and Twin Pregnancy
ResumoUltrasound in Obstetrics & GynecologyVolume 27, Issue 1 p. 104-106 Picture of the MonthFree Access Assessment of ovarian reserve using the inversion mode N. J. Raine-Fenning, Corresponding Author N. J. Raine-Fenning nick.fenning@nottingham.ac.uk Academic Division of Reproductive Medicine, University of Nottingham, Queens Medical Centre, Nottinghamshire, UKAcademic Division of Reproductive Medicine, University of Nottingham, NURTURE, B Floor, East Block, Queens Medical Centre, Nottinghamshire NG7 2UH, UKSearch for more papers by this authorP. M. Lam, P. M. Lam Academic Division of Reproductive Medicine, University of Nottingham, Queens Medical Centre, Nottinghamshire, UKSearch for more papers by this author N. J. Raine-Fenning, Corresponding Author N. J. Raine-Fenning nick.fenning@nottingham.ac.uk Academic Division of Reproductive Medicine, University of Nottingham, Queens Medical Centre, Nottinghamshire, UKAcademic Division of Reproductive Medicine, University of Nottingham, NURTURE, B Floor, East Block, Queens Medical Centre, Nottinghamshire NG7 2UH, UKSearch for more papers by this authorP. M. Lam, P. M. Lam Academic Division of Reproductive Medicine, University of Nottingham, Queens Medical Centre, Nottinghamshire, UKSearch for more papers by this author First published: 22 December 2005 https://doi.org/10.1002/uog.2683Citations: 12AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Accurate prediction of a woman's fertility potential ultimately involves an assessment of her ovarian reserve. Over the last two decades various clinical, endocrine and ultrasonographic markers have been tried and tested with varying degrees of success, but the majority of assisted conception units simply rely on age and a baseline follicle stimulating hormone (FSH) level measured in the early follicular phase of the menstrual cycle1. These tests have limited sensitivity and specificity and therefore their predictive value is not high, with many young women with reassuring FSH levels of less than 10 IU/L demonstrating poor responses to ovarian stimulation2. Equally many women unexpectedly over-respond to treatment and in a significant minority of cases develop ovarian hyperstimulation syndrome, which is associated with considerable morbidity and occasionally mortality3. There is a need therefore for a more accurate predictor of ovarian reserve so that those women demonstrating an abnormally poor or exaggerated response to ovarian stimulation can be appropriately counseled and monitored. While recent studies have demonstrated the value of anti-Müllerian hormone (AMH) and inhibin measurements, these tests are not part of routine practice, and hormonal assays are expensive4. Ultrasonography, however, is readily available and has been used to calculate ovarian volume and measure the number of small (2–8 mm), hormonally-responsive ‘antral’ follicles5. An ovarian volume < 3 cm3 and a total antral follicle number of six or less have been associated with a poor response to ovarian stimulation and a high risk of cycle cancelation6, 7. An ovarian volume > 10 cm3 and a total antral follicle number of more than 20 have been associated with an exaggerated response to treatment and a high risk of ovarian hyperstimulation, undoubtedly reflecting a population of patients with polycystic ovarian syndrome8, 9. However, these measures are not part of most fertility units' practice and were not recommended in the UK's recent National Institute for Clinical Excellence (NICE) Guideline on Fertility10. This may reflect concerns over the reliability of measures of antral follicle number and ovarian volume and the time taken to generate such extra parameters. The high reproducibility of ovarian volume and antral follicle count obtained with transvaginal three-dimensional ultrasonography has been demonstrated11. While it has been shown to be more reliable than two-dimensional ovarian volume measurement12, its advantages over two-dimensional antral follicle counting have not yet been proven13. However, a new software application, the ‘inversion mode’, may be about to change this. The inversion mode enables an automatic and immediate demonstration of the follicles within the volume acquired (Figure 1). If virtual organ computer-aided analysis (VOCAL®; GE Kretz, Zipf, Austria) is used to manually define the ovarian cortex in a series of planar rotations the surrounding tissue is removed and the follicles alone are displayed, facilitating an even quicker objective assessment of their number (Figure 2). These displays may be rotated, either manually by the user or automatically by using a cine loop setting of varying angle and speed, to provide a virtual real-time examination of the follicles (Videoclip S1). Figure 1Open in figure viewerPowerPoint Application of the inversion mode to a routinely acquired three-dimensional ultrasonographic dataset allows the immediate demonstration of all of the antral follicles within an ovary and its surrounding tissue. The internal iliac vein can be seen as a cylindrical structure evident in the lower right of the image. Figure 2Open in figure viewerPowerPoint In this image the surrounding ovarian tissue has been removed, following the delineation of the ovarian cortex with virtual organ computer-aided analysis (VOCAL®), revealing a normal number of antral follicles; while 16 follicles can be counted only eight of these are more than 5 mm in diameter. By using the inversion mode and VOCAL to perform antral follicle counts we have, within 6 weeks of introducing this technique to our baseline ultrasound assessment of a subject, been able to improve our ability to predict a patient's ovarian reserve and greatly enhance our detection of low responders (Figure 3) and those at risk of ovarian hyperstimulation with undiagnosed polycystic ovaries (Figure 4). While previous methods, including both two-dimensional and three-dimensional ultrasonography, provided reliable estimates of the number of mature oocytes recovered following controlled ovarian stimulation and oocyte retrieval in 364 women undergoing assisted reproduction treatment (R2 = 0.84), the new method performed in 100 consecutive women (so far) has significantly increased the reliability (R2 = 0.94; P < 0.05) (unpubl. observ.). Figure 3Open in figure viewerPowerPoint Rendered image from a young (aged 28 years) woman with a normal FSH level (7.3 IU/L) and ovarian volume (6.21 cm3) who would be expected to respond well to ovarian stimulation using current methods of assessment of ovarian reserve. The inversion mode shows the presence of only three antral follicles, however, and the patient subsequently responded poorly to controlled ovarian stimulation during an in-vitro fertilization cycle and was canceled prior to oocyte retrieval. Figure 4Open in figure viewerPowerPoint Rendered image of a polycystic ovary, showing multiple antral follicles of variable size and shape. Note the close proximity and irregular outline of these follicles in comparison to those seen in Figure 2. We are currently testing the predictive value of antral follicle counts made with the inversion mode in a prospective study and investigating its diagnostic role for the identification and classification of pathological processes that are associated with hypoechogenic fluid-filled areas such as hydrosalpinges and ovarian cysts. Supplementary Material on the Internet The following material is available from the Journal homepage: http://www.interscience.wiley.com/jpages/0960-7692/suppmat (restricted access) Videoclip S1 Three-dimensional cine loop using the inversion mode demonstrating a virtual real-time examination of antral follicles. Supporting Information This article contains supplementary material available via the Internet from the Journal http://www.interscience.wiley.com/jpages/0960-7692/suppmat (restricted access) Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. References 1Weghofer A, Margreiter M, Fauster Y, Schaetz T, Brandstetter A, Boehm D, Feichtinger W. Age-specific FSH levels as a tool for appropriate patient counselling in assisted reproduction. Hum Reprod 2005; 20: 2248– 2252. CrossrefWeb of Science®Google Scholar 2Pellicer A, Ardiles G, Neuspiller F, Remohi J, Simon C, Bonilla-Musoles F. Evaluation of the ovarian reserve in young low responders with normal basal levels of follicle-stimulating hormone using three-dimensional ultrasonography. Fertil Steril 1998; 70: 671– 675. 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Fertility: Assessment and Treatment for People with Fertility Problems. Commissioned by the National Institute for Clinical Excellence. RCOG Press: London, 2004. Google Scholar 11Merce LT, Gomez B, Engels V, Bau S, Bajo JM. Intraobserver and interobserver reproducibility of ovarian volume, antral follicle count, and vascularity indices obtained with transvaginal 3-dimensional ultrasonography, power Doppler angiography, and the virtual organ computer-aided analysis imaging program. J Ultrasound Med 2005; 24: 1279– 1287. Wiley Online LibraryPubMedWeb of Science®Google Scholar 12Raine-Fenning NJ, Campbell BK, Clewes JS, Johnson IR. The interobserver reliability of ovarian volume measurement is improved with three-dimensional ultrasound, but dependent upon technique. Ultrasound Med Biol 2003; 29: 1685– 1690. CrossrefCASPubMedWeb of Science®Google Scholar 13Scheffer GJ, Broekmans FJ, Bancsi LF, Habbema JD, Looman CW, Te Velde ER. 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