[Evaluation of a proximity training program of nuchal translucency measurements and of self-scoring]. / Evaluation d'une formation de proximité à la mesure de la clarté nucale et à l'autoévaluation des clichés.

OBJECTIVE: Improvement in prenatal diagnosis of Down syndrome imposes to sonographers to realize good quality nuchal translucency measurements, which can be used for assessment of combined risk. The aim of our study was to evaluate a training program of 109 sonographers for measuring nuchal translucency and scoring their own image. STUDY DESIGN: After a proximity training program, trainees submitted 20 images scored by themselves with Herman image-scoring method. All images were reviewed by two experts. RESULTS: One hundred and nine sonographers have accomplished the training program (87.3%), collecting 2162 images. After reviewing, the mean score was 6.8+/-1.8. The rate of inacceptable scan (score< or =3) was in 6.0%. On the other hand, 48.1% of scans were excellent (score> or =8). Only 6.5% of scores were discordant for at least three points between self-scoring and reviewing. After the fourth scan, there was no significant scoring difference between self-scoring and reviewing. Finally, 84% of trainees were very satisfied of this program. CONCLUSION: As part of HAS evaluation of practitioners practices, it is possible to realize proximity training program for measuring nuchal translucency. Learning curve seems to be fast. Good handling of Herman scoring method by sonographers allows their accreditation after this kind of training program.

[Contribution of ultrasonography in the diagnosis of ectopic pregnancy]. / Apport de l'échographie dans le diagnostic de la grossesse extra-utérine.

High-resolution endovaginal sonography has considerably improved ectopic pregnancy imaging. In conjunction with serum hCG measurements, it allows early detection of ectopic pregnancy (EP) and has significantly reduced the morbidity and the mortality of this disease. The major sonographic finding is the uterine vacuity, the diagnosis of ectopic pregnancy is quite sure in case of absence of intra-uterine pregnancy (IUP) associated with serum hCG above 1500 mUi/ml. Conversely, the presence of IUP excludes practically the diagnosis of EP, but IUP must be distinguished from a pseudosac. The visualization of an ectopic sac that contains an embryo or a yolk sac clearly allows the diagnosis of EP, but its sensitivity is only 25%. The most common sonographic finding is a hematosalpinx, which looks like an echogenic adnexal mass, next to the ovary containing the corpus luteum. Color Doppler is useful to enhance ectopic trophoblastic flow, but it is only a complementary technique of endovaginal sonography. Finally, if the first sonography is inconclusive, a follow-up examination must be performed 2 or 4 days later.

[Contribution of ovarian and uterine color Doppler in medically assisted reproduction techniques (ART)]. / Apport du Doppler couleur ovarien et utérin dans l'assistance médicale à la procréation (AMP).

Along the menstrual cycle and during pregnancy, small blood vessels proliferate within the uterus and the ovulating ovary. Angiogenic factors such as VEGF are involved in this phenomenon. In the ovulating ovary, neo-angiogenesis spreads progressively inside the dominant follicle wall and plays a role in the maintenance of the corpus luteum, under the influence of LH (or HCG during pregnancy). In ART, the measure of the blood flow is interesting since it correlates to the number and quality of harvested oocytes. Follicle hypoxia may impair chromosomal organization and separation within the oocyte. This neo-angiogenesis is also important in endometrium, in particular for embryo implantation. Ultrasounds with Doppler allow to estimate the endometrial receptivity, especially in IVF cycles. It is assumed that chance for ongoing pregnancy is almost zero if: endometrial thickness is < 8 mm; uterine pulsatility index (PI) is > 3. Doppler ultrasounds are a useful and even mandatory complement to standard vaginal ultrasonoghraphy in ART. It can be viewed as an indicator of the endometrial and follicular "well-being".

[Color echo-Doppler and endometrial receptivity in in vitro fertilization]. / Echo-Doppler couleur et réceptivité endométriale en FIV.

The chances of nidation after in vitro fertilization procedures are contingent upon the development potential of the transferred embryo(s), but they also depend on the receptivity of the endometrium and on the uterine vascular supply. It is generally accepted that the chances of pregnancy are practically nil: if the endometrium is less than 8 mm thick, and/or if the uterine pulsatility index (PI) is below 3. However, the predictive value of the Doppler evaluation alone is poor to the extent that other parameters require consideration, such as the aspect of the endometrium and/or the number of embryos transferred. This is why our group initiated a prospective study on 213 patients designed to validate a 10 point scale based on: -the PI of each uterine artery on the day of transfer; -the features of the protodiastolic notch (absent, moderate or clearcut); -the thickness of the endometrium; -the number of embryos transferred. Each parameter by itself had a poor predictive value: optimal values of endometrium thickness and pulsatility index (PI) predicted a 29% and 33% pregnancy rate, which is hardly higher than our overall pregnancy rate (24%). By contrast, a score that encompasses all these parameters increased predictive value, with a score > 9 the probability of pregnancy reach 53% and the one of multiple pregnancy 24%. Our results emphasize the usefulness of a score prior embryo transfer which should be used to adjust the number of embryos transferred. When the score is higher than 10 transferring 2 embryos will prevent the risk of multiple pregnancy. 3 embryos should be transferred when the score is between 7 and 10, and a bad score (< or = 6) should delay the transfer.

[Contribution of Doppler color ultrasonography to the screening and surveillance of ovarian hyperstimulation syndrome]. / Apport de l'échographie et du Doppler couleur dans le dépistage et la surveillance des hyperstimulations ovariennes (HSO).

Color and power Doppler producing ovarian vascular mapping allows to realize a new functional approach of ovarian hyperstimulation syndrome (OHS); local vascular factors (ovarian angiogenesis, increase in cappillary permeability) released by hCG injection (LH effect) have in fact an important part in this syndrome. Vaginal Doppler sonography allows: -before induction, to predict potential risk of hyperstimulation: polycystic ovaries, spontaneous stromal hypervascularization; -in monitoring of ovulation stimulation, to reduce risk of multiple pregnancy and to detect early hyperstimulation, decision of hCG injection depends on number of follicles able to be fertilized (> 15 mm) and luteinized (> 10 mm); -to assess severity of OHS and search complications: ascites, hydrothorax, ovarian torsion and deep venous thrombosis. So OHS prevention imposes a monitoring by Doppler sonography and estradiol assay of all cycles induced by gonadotropins.

Evaluation of destructive spondyloarthropathies in hemodialysis by computerized tomographic scan and magnetic resonance imaging.

OBJECTIVE: The incidence of destructive spondyloarthropathies (SpA) in hemodialysis can reach 50% after 10 years of treatment. Few studies have analyzed the magnetic resonance (MR) appearance of destructive SpA and data are controversial. Our objective was to evaluate the computerized tomographic (CT) scan and MR appearance of destructive SpA in comparison to infectious spondylodiscitis. METHODS: 23 destructive SpA were observed in 11 patients who had undergone hemodialysis [mean duration of treatment 12 years (89-228 mo)]: 17 SpA of the cervical spine, one of the dorsal, and 5 of the lumbar spine. CT scans at all levels demonstrating narrowing and discovertebral erosions were performed without injection. MRI was performed with T1 and T2* weighted spin echo sequences (0.5T) without gadolinium injection. Radiographs were analyzed by 2 independent examiners. The data concerning MRI of infectious spondylodiscitis were based on a study of 57 personal cases and literature reports. RESULTS: CT scan appearance was similar in all cases, especially showing multiple small well defined lucencies of the vertebral endplates. In 9 patients, MRI showed low signal intensity of the disk and the adjacent vertebral endplates on T1 and T2* sequences. In no case was discal or vertebral high signal intensity on T2* sequence noted. No periodontoidal pseudotumor was observed. CONCLUSION: CT scans and MRI of destructive SpA, even nonspecific, are different from those observed in infectious spondylodiscitis, particularly due to the absence of discal and vertebral hypersignal on T2* sequences.

Ultrasound assessment of ovarian stroma hypertrophy in hyperandrogenism and ovulation disorders: visual analysis versus computerized quantification.

OBJECTIVE: To extend our previous findings on the diagnostic validity of ovarian stroma hypertrophy in women with hyperandrogenic and/or menstrual disorders. DESIGN: Transvaginal ultrasonography was performed in 69 patients complaining of hyperandrogenism and/or menstrual disorders and in 48 normal ovulatory women in early follicular phase. To check the validity of stroma assessment by visual analysis, we used computer-assisted analysis, which allowed selective measurement of the stromal area on a longitudinal ovarian cut. Sensitivity and specificity of each method were estimated by using the normative data from the control group. RESULTS: Stromal area was considered to be increased using visual analysis and computer-assisted analysis in 74% and 61% patients, respectively. Specificity of this sign was 84% and 96% by visual analysis and computer-assisted analysis, respectively. In patients, the increase in stromal area correlated very significantly with the one of total ovarian area, whose upper normal limit was 5.5 cm2 per ovary. CONCLUSION: Visual assessment of stroma may be misleading in some cases, with the risk of overestimating its hypertrophy. An increased total ovarian area > 5.5 cm2 (which can easily be detected by carefully shaping a strict longitudinal ovarian cut) has the same diagnostic value as an increased stromal area by computerized measurement.

[Polycystic ovaries: an imprecise ultrasonographic definition]. / Les dystrophies ovariennes: une définition échographique imprécise.

In the absence of a precise definition, the terms "ovarian dystrophy" are often erroneously used. Therefore we propose a more modern terminology which allows to distinguish two types of ovarian follicle pathology: the microfollicular disease results from a follicular arrest of maturation, leading to an accumulation of immature microfollicles in the ovarian cortex. The clinical correlate is anovulation. This disease encompasses two aetiologic entities: polycystic ovarian disease (PCO) and the multifollicular ovaries (MFO), which were previously gathered under the label of "endocrinal ovarian dystrophy"; the macrofollicular disease results from the excessive growth of one or several follicles with or without luteinisation. Its clinical correlate is pelvic pain. It includes three main aetiologies: macropolycystic ovaries, functional cysts and LUF syndrome. These could also be termed "mechanical or local dystrophy". This new classification allows to consider two distinct anatomical entities which represent the whole of functional ovarian pathology.

Ovarian stromal hypertrophy in hyperandrogenic women.

OBJECTIVE: By using vaginal endosonography, ovarian stromal hypertrophy has been shown to be a strong diagnostic feature of polycystic ovarian syndrome and related states. However, this sign is difficult to quantify and to correlate with other findings because of its subjectivity. We have evaluated the use of computer assisted analysis of ultrasound scans to provide more objective measurements of ovarian structure and size. DESIGN: We used a computer assisted method for the reading of ultrasound scans. It allowed selective calculation of the stromal area by subtraction of the cyst area from the total ovarian area on a longitudinal ovarian section. PATIENTS: A consecutive series of 57 patients with hyperandrogenism (group 1), 17 patients with hypothalamic anovulation (group 2) and 20 normal women (group 3). RESULTS: By computerized measure, 75% patients from group 1 had a bilateral stromal area above the mean +2 SD (700 mm2) of women from group 3. All patients from group 2 were below this threshold. Serum LH level was above the normal range in 45% patients from group 1. The stromal area correlated positively with the serum delta 4-androstenedione (r = 0.47, P < 0.005) and 17 alpha-hydroxyprogesterone (r = 0.39, P < 0.005) levels, exclusively in group 1. It did not correlate with the basal serum testosterone, LH or insulin levels. The cyst area did not correlate with any hormonal parameter. CONCLUSION: Ovarian stromal hypertrophy is a frequent and specific feature of hyperandrogenism. It correlates with the ovarian androgenic dysfunction. Its presence is not always linked with elevated serum immunoreactive LH levels. Further data are needed to elucidate the role of insulin and ovarian growth factors.

Interrelationship between ultrasonography and biology in the diagnosis of polycystic ovarian syndrome.

In order to compare the diagnostic significance of hormonal and ultrasonic criteria of polycystic ovarian syndrome (PCOS), the presence or the absence of ultrasonographic and hormonal features of PCOS were recorded in a heterogeneous population of 90 women presenting with hyperandrogenism and/or menstrual disorders. On clinical and hormonal grounds exclusively, these patients could be separated into five diagnostic subgroups: presumed cases of PCOS (n = 21), idiopathic hirsutism (IH) (n = 26), hypothalamic anovulation (HA) (n = 11), hyperprolactinemia (HPRL) (n = 9), and miscellaneous or undetermined diagnosis (n = 23). By the means of a computed automatic classification of patients (cluster analysis) using five hormonal and ultrasonic criteria of PCOS, four homogeneous clusters of patients were obtained. Cluster #1 (25 patients) had the most characteristic profile of PCOS. It included 15 cases of PCOS and 7 cases of IH. Cluster #4 (47 patients) had the less characteristic profile of PCOS. It included the majority of patients with HA and HPRL and the half of the patients with IH. Cluster #2 included only two hyperandrogenic patients, who were massively obese and in whom ultrasonography may have failed to detect PCOS. Cluster #3 (16 patients) included patients from each diagnostic group, who were gathered together because ultrasonographic and hormonal features were, respectively, present and absent in nearly all of them. With the same analysis, the criteria of PCOS could be graded according to their grouping potential. The presence of an abnormal ovarian stroma by ultrasonography appeared as the most potent criterion. Elevated serum testosterone and androstenedione levels and the polyfollicular pattern of ovaries gave intermediate results, while elevated basal LH level was a much weaker grouping parameter. In conclusion, the automatic classification of patients by cluster analysis using both hormonal and ultrasonographic criteria revealed that the classical diagnostic classification, relying upon hormonal data exclusively, may arbitrarily separate patients having the same disease; and that ultrasonography affords pertinent information that should help provide a better diagnostic definition of PCOS.

[Modern imaging of ovarian cysts]. / Imagerie moderne des kystes de l'ovaire.

Ultrasonography and specially vaginal endosonography is at present the technique of choice for the screening of ovary cysts. Nevertheless, the method have some limits in the study of solid lesions and big masses; that's where CT scan and MRI have good indications: CT is more reliable than US to detect fat in teratomas. CT and MRI are superior to US in determining big tumor extend because of their ability of multiplanar study. MRI permit a molecular characterisation of cystic lesions.

[Searching for prolactin microadenoma: scanner or MRI?]. / Recherche d'un microadénome à prolactine: scanner ou IRM?

Thirty three hyperprolactinemic women, aged 16-46 years, have been investigated by pituitary CT and MRI scans, searching for a microadenoma. The MRI scan with Gadolinium injection (MRI G+) appeared more efficient than the CT scan to detect a picture highly suggestive of a microprolactinoma (30/33 positive scans vs 21/33, respectively, p = 0.06). However, when the CT scan was performed optimaly (i.e. thin cuts, sequential imaging after iode injection, no artefact), its diagnostic potenty was close to the one of MRI G+, missing only 17.6% of lesions. All these were less than 5 mm in diameter. The indirect signs of microadenoma (focal convexity of the superior surface of pituitary, tilting of pituitary stalk, focal sella floor erosion or destruction) had a minimal value. Their sensitivity was 66.6% and 63.3 for convexity, and 63.3 and 46.6% for tilting of pituitary stalk, by MRI and CT scans, respectively. Therefore, they did not afford any help in our experience. Considering the cost and the limited accessibility of MRI, at least in our country, we advise to use CT scan as the primary morphologic means to detect a microadenoma.

Polycystic ovarian disease: contribution of vaginal endosonography and reassessment of ultrasonic diagnosis.

OBJECTIVE: We evaluated the superiority of vaginal ultrasonography (US) on the abdominal US for the diagnosis of polycystic ovarian disease (PCOD). DESIGN: The US pattern of ovaries was prospectively investigated by abdominal US and, whenever possible, by vaginal US. SETTING: Primary care, institutional. PATIENTS: One hundred forty-four women in whom PCOD was suspected on endocrine grounds and 62 other patients presenting with primary hyperprolactinemia (n = 23) or hypothalamic anovulation (n = 39). MAIN OUTCOME MEASURE: Vaginal US allowed a better analysis of the ovarian stroma. RESULTS: The external ovarian features of PCOD were observed by both routes in less than one third of the 144 patients with PCOD. The internal ovarian features of PCOD were much more frequently observed by vaginal US than by abdominal US (polycystic pattern: 66.7% versus 38.1%, P less than 0.05; increased ovarian stroma: 57.1% versus 4.8%, P less than 0.001). In the 62 patients without PCOD, US features of PCOD were observed in less than 10% of them, except for the uterine width/ovarian length ratio less than 1 and the polycystic pattern (abdominal US: 17% and 34%; vaginal US: 11% and 50%, respectively). CONCLUSIONS: An increased ovarian stroma seems to be the most sensitive and specific US sign of PCOD, providing that it can be investigated by vaginal US.

[Efficacy of modern imaging technics in the diagnosis of isolated angiomyolipoma of the kidney. Apropos of 11 cases]. / Efficacité de l'imagerie moderne dans le diagnostic des angiomyolipomes isolés du rein. A propos de 11 cas.

Ultrasound and computed tomography imaging techniques are very reliable methods of detection and diagnosis of renal angiomyolipoma not associated with the tuberous sclerosis of Bourneville's disease: results are considerably improved when compared with conventional investigations (IVU, arteriography). The series reported included 6 patients with large angiomyolipomas and 5 with lesions less than 2 cm in diameter discovered fortuitously on ultrasonography: all tumors were partially or totally hyperechogenic. The fatty tissue was detected in 9 of the 11 cases by computed tomography imaging.

[Pyelomanometry in obstructions of the upper urinary tract. Apropos of 26 cases]. / La pyélomanométrie dans les obstructions du tractus urinaire supérieur. A propos de vingt-six observations.

Pyelomanometry can be used in cases of ambiguous dilatation, to measure the pressure in the upper urinary tract during constant-flow perfusion through a percutaneous catheter (Whitaker's test). After recalling the principles of this method, and the technical procedure, the authors go on to discuss twenty six cases, analyzing the results, and comparing the advantages of this procedure with other methods of exploration.