Intracycle variation in number of antral follicles stratified by size and in endocrine markers of ovarian reserve in women with normal ovulatory menstrual cycles.

OBJECTIVE: To quantify the intracycle variation in markers of ovarian reserve measured by antral follicle counts stratified by size using three-dimensional (3D) ultrasound and anti-Müllerian hormone (AMH) in women with normal menstrual cycles. METHODS: Healthy volunteers with normal menstrual cycles were prospectively recruited. Three-dimensional (3D) ultrasound examination and blood test were performed in early (F1) and mid-follicular (F2) phases and in periovulatory (PO) and luteal (LU) phases of one menstrual cycle. Antral follicles were measured using 'sonography-based automated volume calculation' with post processing (SonoAVC) and ovarian volume was measured using Virtual Organ Computer-aided AnaLysis (VOCAL). Blood serum was processed for hormonal assays including AMH, follicle stimulating hormone (FSH), luteinizing hormone (LH) and estradiol. Repeated-measures analysis was used to examine the variance in markers of ovarian reserve in different phases of one menstrual cycle. RESULTS: A total of 36 volunteers were included in the final analysis, of whom 34 attended all four visits. Repeated-measures analysis showed a significant variation in total antral follicle count (AFC) (P < 0.001). However, on stratifying the antral follicles according to size using SonoAVC, a non-significant variation (P = 0.382) was seen in small AFC (≤ 6.0 mm) and a significant variation (P < 0.001) was seen in large AFC (> 6.0 mm). The ovarian volume showed a significant intracycle variation (P < 0.001). A small but significant intracycle variation was noted in AMH (P = 0.041) and a significant variation was seen in levels of serum FSH, LH and estradiol (P < 0.05). CONCLUSION: Small antral follicles (≤ 6.0 mm) measured using 3D ultrasound and AMH show little intracycle variation and perhaps should be evaluated when predicting ovarian reserve independent of menstrual cycle.

Quantifying effect of combined oral contraceptive pill on functional ovarian reserve as measured by serum anti-Müllerian hormone and small antral follicle count using three-dimensional ultrasound.

OBJECTIVES: Oral contraceptive pills suppress the hypothalomo-pituitary axis, which can affect the ultrasound and endocrine markers used to examine ovarian reserve. The objective of this study was to quantify the ultrasound and endocrine markers of functional ovarian reserve in women using a combined oral contraceptive pill (COCP) for more than a year. METHODS: This was a prospective case-control study involving healthy volunteers: 34 women using for more than a year a COCP with hormone-free interval (HFI) were compared to 36 normo-ovulatory, age-matched controls who had not used hormonal contraception within the last year. Volunteers using a COCP underwent a 3D ultrasound examination and had a blood sample taken within the first 4 days of active pill ingestion and those in the control group had the scan and blood test in the early follicular phase (days 2-5) of menstrual cycle. The main outcome measure was the difference in antral follicle counts stratified according to size and anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E2) levels. RESULTS: There were no significant differences in the number of small antral follicles measuring 2-6 mm. The COCP group had significantly fewer antral follicles measuring ≥ 6 mm (P < 0.001) and had significantly smaller ovaries (P < 0.001), which also had lower vascular indices than the control group (P < 0.05). While serum FSH, LH and E2 levels were significantly lower in the COCP group (P < 0.05), there was no significant difference in serum AMH levels between the two groups. CONCLUSIONS: Prolonged use of COCP suppressed pituitary gonadotropins and antral follicle development beyond 6 mm, but had no effect on levels of serum AMH and number of small antral follicles.

Embryo volume measurement: an intraobserver, intermethod comparative study of semiautomated and manual three-dimensional ultrasound techniques.

OBJECTIVE: To compare the reliability of our recently introduced technique for first-trimester embryo volume measurement, the 'semiautomated technique' using both Virtual Organ Computer-aided AnaLysis (VOCAL(™) ) and Sonography-based Automated Volume Count (SonoAVC) with a manual technique using VOCAL alone. METHODS: Seventy-four subjects with viable, singleton first-trimester in-vitro fertilization (IVF) pregnancies were recruited. Each subject underwent transvaginal sonography, at which a three-dimensional ultrasound dataset of the entire gestational sac was acquired. Each embryo volume was measured by two techniques, each performed twice. In the semiautomated technique VOCAL was used to calculate the volume of the gestational and yolk sacs, and SonoAVC was used to quantify the fluid volume within the amniotic and extra-amniotic cavities. Embryo volume was calculated by subtracting the sum of yolk sac, amniotic and extra-amniotic fluid volumes from gestational sac volume. In the manual technique, VOCAL was used to delineate the entire embryo using 9° rotations. Reliability was assessed using limits of agreement and intraclass correlation coefficient. RESULTS: Datasets were included from 52 eligible subjects. Median gestational age was 7 + 4 weeks; median crown-rump length (CRL) was 13 (range, 2-29) mm; and median embryo volume was 1.8 (range, 0.03-8.1) cm(3) using the semiautomated technique and 0.7 (range 0.009-3.6) cm(3) using the manual technique. There was a significant discrepancy in the volumes measured by the two different techniques. Assessment of the limits of agreement suggested that the semiautomated technique (-15.8% to 14.0% of the mean embryo volume) was more reliable than was the manual technique (-22.4% to 26.6%). CONCLUSION: The semiautomated technique is more reliable than is the manual technique for embryo volume measurement. However, the discrepancy in measurements between the two methods raises concerns over the validity of the semiautomated technique that require further investigation.

Prevalence of uterine anomalies and their impact on early pregnancy in women conceiving after assisted reproduction treatment.

OBJECTIVE: To estimate the prevalence of congenital uterine anomalies in subfertile women and to evaluate their influence on early pregnancy following assisted reproduction treatment (ART). METHODS: We prospectively recruited 1402 subjects undergoing ART over a period of 5 years from 2005 to 2009. Three-dimensional transvaginal sonography was performed in the early follicular phase of the menstrual cycle (days 2-5) and repeated in the late follicular phase (days 10-14) if the shape of the uterine cavity could not be assessed at the first scan. All subjects who conceived following ART were followed up to 12 weeks' gestation. Chi-square test was used to compare the pregnancy rates and miscarriage rates between women shown to have uterine anomalies and those with a normal uterus. RESULTS: One thousand three hundred and eighty-five subjects were included for final analysis after excluding 17 subjects in whom a definitive diagnosis could not be made. While 1201 (86.7%) subjects had a normal uterine cavity, uterine anomalies were demonstrated in 184 (13.3%) subjects. Arcuate uteri represented the commonest anomaly (n = 164 (11.8%)) followed by septate (n = 7 (0.5%)), unicornuate (n = 6 (0.4%)), subseptate (n = 5 (0.4%)), bicornuate (n = 1 (0.1%)) and T-shaped uteri (n = 1 (0.1%)). A total of 440 subjects who underwent ART were followed up. The pregnancy rates in women with arcuate uteri (36/66 (54.5%)) and major uterine anomalies (7/10 (70.0%)) were statistically similar (P = 0.09 and P = 0.11, respectively) to that of the matched controls with normal uteri (158/364 (43.4%)). While first-trimester miscarriage rates were similar (P = 0.81) between the control group (20/158 (12.7%)) and women with arcuate uteri (5/36 (13.9%)), women with major uterine anomalies experienced a higher miscarriage rate (3/7 (42.9%); P = 0.05). CONCLUSIONS: Women who are referred for ART have a high prevalence of congenital uterine anomalies, the most common anomaly being an arcuate uterus. These anomalies are not associated with a reduction in pregnancy rates following ART. However, while the arcuate uterus was not associated with an increase in first-trimester miscarriage, major uterine anomalies seemed to increase the risk of first-trimester miscarriage.

Quantitative analysis of antral follicle number and size: a comparison of two-dimensional and automated three-dimensional ultrasound techniques.

OBJECTIVES: To compare two-dimensional (2D) ultrasound imaging with automated three-dimensional (3D) ultrasound imaging for the measurement of antral follicle number and size. METHODS: Twenty-four subjects aged < 40 years underwent transvaginal ultrasound examination (Voluson E8) in the early follicular phase of the menstrual cycle. A 2D ultrasound scan of both ovaries was performed; each antral follicle was identified and then measured by taking the mean of two diameters. A 3D ultrasound dataset of both ovaries was then acquired and analyzed using Sonography-based Automated Volume Count (SonoAVC). The time taken to measure the size of all antral follicles in both ovaries was recorded in seconds for each technique. Antral follicle size was recorded to the nearest millimeter and counts for each 1-mm group were obtained. Antral follicle counts were also grouped according to five predefined size categories: 2.0-5.0 mm, 2.0-6.0 mm, 2.0-8.0 mm, 2.0-9.0 mm and 2.0-10.0 mm. Limits of agreement (LOA) and a paired t-test or Wilcoxon signed ranks test were used to analyze the data depending on their distribution. RESULTS: When antral follicle numbers were compared for each 1-mm follicle size group, 2D ultrasound imaging recorded more follicles measuring 3.0-3.99 mm (mean +/- SD, 4.11 +/- 3.70 vs. 2.63 +/- 2.31; P = 0.019) and 4.0-4.99 mm (mean +/- SD, 4.63 +/- 4.86 vs. 2.68 +/- 2.89; P = 0.013) than did SonoAVC. LOA were widest with follicles measuring 3.0-3.99 mm (LOA, 6.38 and -3.43) and 4.0-4.99 mm (LOA, 7.99 and -4.09). The antral follicle count in each of the five predefined size categories was significantly lower with SonoAVC than with 2D ultrasound imaging (P < 0.05). SonoAVC took significantly less time to measure the size and record the number of antral follicles than did 2D ultrasound imaging (mean +/- SD, 132.05 +/- 56.23 s vs. 324.47 +/- 162.22 s; P < 0.001). CONCLUSIONS: Fewer antral follicles are evident overall when SonoAVC is used to analyze 3D ultrasound data. The clinical significance of this remains to be determined but the automated technique is significantly quicker than is making measurements using 2D ultrasound imaging.

The predictive value of the automated quantification of the number and size of small antral follicles in women undergoing ART.

BACKGROUND: Sono-automatic volume calculation (SonoAVC) automatically identifies and measures the dimensions of hypoechogenic areas within datasets acquired using three-dimensional ultrasound. The objective of this study was to evaluate the predictive value of automated antral follicle counts according to their relative sizes in women undergoing assisted reproduction treatment (ART). METHODS: A total of 156 subjects aged < or =40 years with a baseline FSH < or =15 IU that undergo their first cycle of ART were prospectively recruited. SonoAVC was used to measure the datasets and record the number of antral follicles measuring < or =9 mm in diameter. These follicles were then grouped into subsets according to their relative sizes: < or =2.0, 2.1-4.0, 4.1-6.0, 6.1-8.0 and 8.1-9.0 mm. The primary outcome was viable pregnancy confirmed on ultrasound 5 weeks following embryo transfer. RESULTS: A total of 142 subjects were included for analysis of primary end-point. Those subjects who conceived had significantly more antral follicles measuring < or =2 (P = 0.041) and 2.1-4.0 mm (P < 0.001) than those who had unsuccessful treatment. There were no significant differences between the groups in the number of antral follicles measuring 4.1-6.0 (P = 0.191), 6.1-8.0 (P = 0.203) and 8.1-9.0 mm (P = 0.601). Multiple logistic regression showed that antral follicles measuring 2.1-4.0 mm were an independent predictor of pregnancy [Exp(B) = 1.234, 95% CI = 1.092-1.491; P = 0.004; AUC = 0.693]. CONCLUSION: SonoAVC provides automated measures of antral follicle number and size. Using this technique, the number of antral follicles measuring 2.1-4.0 mm in diameter is an independent, significant predictor of pregnancy following in vitro fertilization treatment.

Intraobserver and interobserver reliability of automated antral follicle counts made using three-dimensional ultrasound and SonoAVC.

OBJECTIVE: To assess the reliability of automated measurements of the total antral follicle count (AFC) made using Sono-Automatic Volume Count (SonoAVC), and to compare these to two-dimensional (2D) and manual three-dimensional (3D) techniques. METHODS: Fifty-five subjects aged under 40 years who had 3D transvaginal ultrasound examination in the early follicular phase of their menstrual cycle were prospectively recruited. 3D datasets were acquired and subsequently analyzed. The total AFC (2-10 mm antral follicles) was calculated by two observers using three independent methods: 2D real-time equivalent (2D-RTE), 3D manual multiplanar view (3D-MPV), and SonoAVC. For measurements made using SonoAVC, the initial automated count (sAVC-AA) was recorded and postprocessing (sAVC-PP) then applied to identify follicles that had been missed or incorrectly included. Intraclass correlation and limits of agreement were used to evaluate the methods. RESULTS: The intra- and interobserver reliability of measurements of total AFC was best with SonoAVC with postprocessing followed by 3D-MPV and 2D-RTE. The initial count calculated by sAVC-AA missed follicles and this was reflected in the significantly lower mean total AFC (6.51 +/- 4.79) than that made after postprocessing techniques (sAVC-PP, 18.42 +/- 10.53, P < 0.001; 3D-MPV, 19.38 +/- 10.85, P < 0.001; and 2D-RTE, 19.26 +/- 10.55, P < 0.001). The mean total AFC became more comparable with postprocessing (sAVC-PP) but still remained significantly lower than counts made with 2D-RTE and 3D-MPV (P < 0.05). CONCLUSION: SonoAVC with postprocessing is a reliable method for measuring total AFC. It takes longer to perform, because of the need for postprocessing, and obtains values that are lower than those obtained by the 2D and 3D-MPV techniques. However, the AFC obtained by sAVC-PP is likely to be lower because this method measures and color codes each follicle preventing recounting.

Can quantitative three-dimensional power Doppler angiography be used to predict ovarian hyperstimulation syndrome?

OBJECTIVE: To test the hypothesis that ovarian vascularity is increased in women developing ovarian hyperstimulation syndrome (OHSS) and to assess its value as a predictor of OHSS during in-vitro fertilization (IVF). METHODS: 118 subjects undergoing their first cycle of IVF had a three-dimensional (3D) transvaginal ultrasound scan in the early follicular phase of the menstrual cycle preceding IVF treatment. 18 of them developed moderate or severe OHSS and 100 subjects had normal ovarian response. Antral follicle count, ovarian volume, and ovarian vascularity (vascularization index (VI), flow index (FI) and vascularization flow index (VFI)) were compared between OHSS and control groups. Multiple regression analysis was used to assess the predictive value of these variables against age, body mass index and basal follicle-stimulating hormone level for the development of OHSS. RESULTS: The ovarian blood flow indices VI (11.1 +/- 11.6 vs. 8.6 +/- 7.3%; P = 0.23), FI (38.0 +/- 4.8 vs. 38.0 +/- 5.5; P = 0.95) and VFI (4.2 +/- 3.3 vs. 3.5 +/- 3.1; P = 0.40) were similar in the OHSS group and the normal responders. While antral follicle count was significantly higher in women developing OHSS (33.0 +/- 15.1) than in the control group (19.2 +/- 9.9, P < 0.001), ovarian volume did not differ between the two groups (10.6 +/- 3.8 vs. 8.9 +/- 4.8 cm(3), respectively, P = 0.11). On multiple regression analysis, antral follicle count was the only significant predictor of OHSS (P < 0.01). CONCLUSIONS: Women developing OHSS during IVF do not demonstrate an increased ovarian blood flow as measured by 3D ultrasound but do have a significantly higher antral follicle count, which is the only significant predictor of OHSS.

Effect of pituitary desensitization on the early growing follicular cohort estimated using anti-Mullerian hormone.

BACKGROUND: This study evaluated the effect of pituitary desensitization on the early growing follicle population through assessment of serum anti-Mullerian hormone (AMH) concentration. Other markers of ovarian reserve, basal follicular stimulating hormone (FSH), luteinizing hormone (LH), estradiol, inhibin-B and three-dimensional ultrasound ovarian parameters were also assessed for comparison. METHODS: One hundred and two subjects aged <40 years with FSH levels <12 IU/l underwent venepuncture and transvaginal ultrasound in the early follicular phase of the menstrual cycle and after 14 days of down-regulation using gonadotrophin releasing hormone (GnRH) agonists. Serum levels of AMH and other markers of ovarian reserve measured during the early follicular phase were compared with those measured following down-regulation. RESULTS: While AMH levels increased significantly by approximately 32% (P < 0.01), there was a significant decline of approximately 40-50% (P < 0.01) in the levels of inhibin-B, FSH, LH and estradiol. Down-regulation treatment was also associated with a decrease (P < 0.01) in mean ovarian volume and in ovarian blood flow, but no difference was seen in the antral follicle count. CONCLUSIONS: Pituitary desensitization results in a significant increase in AMH levels, which implies that either the secretion of AMH by early growing follicles is enhanced or that the size of this follicle cohort is increased. The number of antral follicles visualized on ultrasound in the early follicular phase and at down-regulation appears unchanged, suggesting that any effect is restricted to the smaller selectable follicles. Our results may explain the enhanced ovarian response to conventional controlled ovarian stimulation and higher pregnancy rates when pretreatment with GnRH-agonists is employed.

Three-dimensional ultrasound improves the interobserver reliability of antral follicle counts and facilitates increased clinical work flow.

OBJECTIVES: To compare the interobserver reliability of antral follicle counts made using real-time two-dimensional (2D) ultrasound with offline counts made from stored three-dimensional (3D) data and to assess the time required for such counts. METHODS: Two observers conducted transvaginal ultrasound examinations in 45 subfertile women in the early follicular phase of the menstrual cycle. Antral follicles were counted using real-time 2D ultrasound and the time taken was recorded. A 3D volume was then acquired from each ovary and stored for subsequent offline analysis using the multiplanar view. The time taken for each step was recorded and the total time was calculated. Intraclass correlation coefficients (ICC) and limits of agreement were used to assess reliability. RESULTS: There was no difference in the mean antral follicle counts using real-time 2D (16.51 +/- 11.51) and 3D (16.33 +/- 12.13) ultrasound. According to ICCs, there was a significantly higher interobserver reliability for counts made using 3D (mean, 0.992; 95% CI, 0.986-0.996) compared with real-time 2D (mean, 0.961; 95% CI, 0.940-0.977) (P < 0.01) ultrasound. 3D ultrasound was also associated with narrower limits of agreement (-2.7 to + 3.1) than was 2D ultrasound (-6.9 to + 6.4). Whilst the total time taken was significantly longer for the 3D technique (239.3 +/- 71.4 s vs. 103.1 +/- 28.6 s, P < 0.001), the time required for the actual ultrasound examination was significantly less (46.4 +/- 7.4 s vs. 103.1 +/- 28.6 s, P < 0.001). CONCLUSIONS: 3D ultrasound significantly improves the interobserver reliability of antral follicle counts. While this is at the expense of time overall, the duration of the actual ultrasound examination and patient exposure is significantly reduced using 3D compared with real-time 2D ultrasound.

Evaluation of the effect of machine settings on quantitative three-dimensional power Doppler angiography: an in-vitro flow phantom experiment.

OBJECTIVES: Three-dimensional (3D) ultrasound is being used increasingly to acquire and subsequently quantify power Doppler data within the clinical setting. One proprietary software package calculates three 3D vascular indices: the vascularization index (VI), the flow index (FI), and the vascularization flow index (VFI). Our aim was to evaluate how different settings affect the Doppler signal in terms of its quantification by these three indices within a 3D dataset. METHODS: A computer-driven 'flow phantom' was used to continuously pump a nylon particle-based blood mimic (Orgasol(trade mark)) around a closed system through a C-flex(trade mark) tube embedded in an agar-based tissue mimic. The test tanks were insonated with a modified 3D transvaginal 4-8-MHz ultrasound transducer (V530D) and power Doppler data were acquired over a series of different settings. Each experiment involved the manipulation of just one Doppler setting in order to study it in isolation. RESULTS: As expected, all of the power Doppler settings, when altered, were found to effect significant changes (P < 0.05) in the VI, FI and VFI. The gain and signal power had the greatest effect, producing no Doppler signals at the lowest settings and the highest recordable indices at the maximum settings. The pulse repetition frequency (PRF) was the next most influential setting but a Doppler signal was seen and measurable at all of the different settings. The other Doppler settings had a much less profound effect on the vascular indices, with subtle but significantly different measures across the full range of settings. The speed of data acquisition was also found to affect the vascular indices, all of which were reduced when the fast mode was used although the only significant effect was on the VFI. CONCLUSIONS: The VI, FI and VFI are all affected significantly by variations in power Doppler settings and by the speed of acquisition. The gain and signal power have the greatest effect on the power Doppler signal, followed closely by the PRF. The other settings and speed of acquisition also influence the signal, but to a much lesser degree. It is essential to maintain Doppler settings if any meaningful comparisons are to be made within and between subjects.

Determining the relationship between three-dimensional power Doppler data and true blood flow characteristics: an in-vitro flow phantom experiment.

OBJECTIVES: Three-dimensional (3D) ultrasound can be used to acquire power Doppler data which can be quantified to give an objective impression about blood flow within a tissue or organ. Proprietary software can be used to calculate three indices of vascularity: vascularization index (VI), flow index (FI) and vascularization flow index (VFI). Although these indices appear to have a predictive value in the clinical setting and can be shown to vary between different patient populations and over time within the same population, their relationship with true in-vivo blood flow characteristics has not been established. The objective was to examine the effect of flow rate, vessel number, attenuation and erythrocyte density on these indices. METHODS: A computer-driven flow phantom was used to continuously pump a nylon particle-based blood mimic (Orgasol(trade mark)) around a closed system through three different ultrasound test tanks. These tanks were designed specifically for these experiments and contained C-Flex(trade mark) tubing, in a variety of arrangements, encased in an agar-based tissue mimic. The test tanks were insonated with a modified 3D transvaginal 4-8-MHz ultrasound transducer and 3D power Doppler data were then acquired over a graduated series of flow rates, depths and blood mimic concentrations. Regression analysis was used to determine the resulting relationships. RESULTS: The VI increased linearly with an increase in flow rate (P < 0.05), whereas the FI increased in a cubic manner with a more rapid initial increase (P < 0.05). The VI demonstrated a similar linear increase with an increase in the erythrocyte mimic density (P < 0.05), whereas the FI increased markedly with a small change in erythrocyte mimic density and then plateaued (P < 0.01). There was a significant reduction in each index as the distance between the transducer and vessel increased (P < 0.05). Patterns similar to those seen in relation to the change in flow rate were evident, with a more linear relationship between depth and the VI and VFI than between depth and the FI, although the FI remained relatively constant and was not significantly affected by distance from the transducer until a depth of 55 mm was reached. Although a positive linear relationship was seen between vessel number and VI and VFI (P < 0.05) the FI demonstrated a very different and complex, cubic relationship (P < 0.001), increasing linearly until a maximum of three vessels were present when it decreased, and no overall correlation was seen (P > 0.05). CONCLUSIONS: The VI, FI and VFI are all significantly affected by volume flow, attenuation, vessel number and erythrocyte density, but in different ways. The VI and VFI seem to have a more predictable relationship, whereas the FI often demonstrates a more complex cubic relationship that is not always logical. Further work is required to establish the effect of other confounding parameters before valid conclusions may be made and a better understanding of 3D power Doppler ultrasound imaging achieved.

The interobserver reliability of ovarian volume measurement is improved with three-dimensional ultrasound, but dependent upon technique.

The effect of measurement technique on the interobserver reliability of ovarian volume calculation from three-dimensional (3-D) ultrasound (US) data was investigated. Ovarian volume was calculated in 20 patients by two observers using both the "prolate ellipsoid formula" and a new 3-D rotational technique (VOCAL). There was a significant difference between observers in mean ovarian volume calculated by the prolate ellipsoid formula (31.54 mL vs. 26.54 mL: p < 0.05), which proved to be a significantly less reliable technique than 3-D rotational volume calculation with VOCAL. Image quality was significantly better (p < 0.001) and measurements were significantly more reliable (p < 0.05) in the B-plane than in the C- plane of the multiplanar display. Rotational measurement of ovarian volume from 3-D US data is significantly more reliable between observers than volume estimation from 2-D parameters using the prolate ellipsoid formula, but is dependent upon image quality, which is significantly better in the B-plane than in the C-plane.

The interobserver reliability of off-line antral follicle counts made from stored three-dimensional ultrasound data: a comparative study of different measurement techniques.

OBJECTIVE: To assess the interobserver reliability of antral follicle counts (AFCs) made from stored three-dimensional (3D) ultrasound data using conventional two-dimensional (2D) images, 3D multiplanar view and 3D-rendered 'inversion mode'. METHODS: 3D transvaginal ultrasound was performed in the early follicular phase (days 2-5) of the menstrual cycle in 41 subjects aged < 40 years, undergoing investigation for subfertility. From the stored 3D ultrasound datasets, the number of antral follicles of 2-10 mm in diameter in each ovary was independently measured, using all three methods by three investigators, each with a different level of experience. The image quality of each dataset was subjectively categorized into one of three groups, based on the proportion of the ovarian contour that could be seen clearly. RESULTS: There was no significant difference in the mean AFC between the observers for any of the three different techniques. The intraclass correlation coefficient (ICC) for the 2D-equivalent mode, the 3D multiplanar mode, and the 3D-rendered inversion mode were indicative of good interobserver reliability for each method. The interobserver reliability for the 3D-rendered inversion mode was better with Grade 1 image quality than with Grade 3 image quality. There were no equivalent differences, however, between the three different grades of image quality with the 2D-equivalent and 3D multiplanar modes. The time taken for AFC measurement using 3D-rendered inversion mode was significantly longer than with the 2D equivalent and 3D multiplanar methods. CONCLUSIONS: 3D image displays and rendering techniques do not appear to offer any advantage over a conventional 2D display in terms of AFC measurement reliability. AFC measurement using the 3D-rendered inversion mode has an adequate interobserver reproducibility but is dependent on image quality.

Quantifying the changes in endometrial vascularity throughout the normal menstrual cycle with three-dimensional power Doppler angiography.

BACKGROUND: We used three-dimensional power Doppler angiography (3D-PDA) to examine the periodic changes in endometrial and subendometrial vascularity during the normal menstrual cycle in 27 women without obvious menstrual dysfunction or subfertility. METHODS: 3D-PDA was performed on alternate days from day 3 of the cycle until ovulation and then every 4 days until menses. Virtual organ computer-aided analysis and shell-imaging were used to define and to quantify the power Doppler signal within the endometrial and subendometrial regions producing indices of their relative vascularity. RESULTS: Both the endometrial and subendometrial vascularization index (VI) and vascularization flow index (VFI) increased during the proliferative phase, peaking approximately 3 days prior to ovulation (P < 0.001) before decreasing to a nadir 5 days post-ovulation (P < 0.001). Thereafter, both vascular indices gradually increased during the transition from early to mid-secretory phase. The flow index (FI) showed a similar pattern but with a longer nadir post-ovulation. Smoking was associated with a significantly lower VI and VFI. The FI was significantly lower in women aged > or = 31 years and significantly higher in parous patients. CONCLUSIONS: Endometrial vascularity, as assessed by 3D-PDA, varies significantly during the menstrual cycle and is characterized by a pre-ovulatory peak and post-ovulatory nadir during the peri-implantation window.

Endometrial and subendometrial perfusion are impaired in women with unexplained subfertility.

BACKGROUND: We used three-dimensional power Doppler angiography (3D-PDA) to examine the periodic changes in endometrial development and subendometrial vascularity during the normal menstrual cycle in 29 women with unexplained subfertility and 19 controls. METHODS: 3D-PDA was performed on alternate days from day 3 of the cycle until ovulation and then every 4 days until menses. VOCAL (Virtual Organ Computer-aided AnaLysis) and shell-imaging were used to define and to quantify the power Doppler signal within the endometrial and subendometrial regions producing indices of their relative vascularity. RESULTS: Women with unexplained subfertility demonstrated significant changes with time (P<0.001) in the indices of vascularity within the endometrium and subendometrium during the menstrual cycle characterized by a pre-ovulatory peak and post-ovulatory fall. These changes mirrored those observed in the control group but were significantly reduced in the endometrium and subendometrium during the mid-late follicular phase and early luteal phase. There were no differences in endometrial thickness or volume between the groups or in the plasma concentrations of estradiol or progesterone. CONCLUSIONS: Endometrial and subendometrial vascularity are significantly reduced in women with unexplained subfertility during the mid-late follicular phase irrespective of estradiol or progesterone concentrations and endometrial morphometry.

The interobserver reliability of three-dimensional power Doppler data acquisition within the female pelvis.

OBJECTIVES: To examine the interobserver reliability of three-dimensional (3D) power Doppler data acquisition from the uterus and ovary. METHODS: 3D power Doppler angiography was used to acquire endometrial data from 20 patients and ovarian data from a further 20 different patients at various stages of in vitro fertilization. Two different observers each acquired two datasets from all 40 patients resulting in 80 endometrial and 80 ovarian datasets in total. Virtual Organ Computer-aided AnaLysis was used to define the object of interest and semiquantify the power Doppler signal within it. The reliability of measurements of volume and vascularity was assessed by calculating interclass correlation coefficients (ICCs) and limits of agreement between the two observers. RESULTS: Whilst volumetric data proved more reliably acquirable than power Doppler data, the interobserver reliability of data acquisition was high overall for both the endometrium and ovary with all measurements obtaining a lower ICC of above 0.9. Limits of agreement revealed minimal disagreement between the two observers for measurements of volume and vascularity within both the ovary and endometrium. The 'indices of vascularity' within the endometrium were less than those derived from the ovary and subendometrium, which were comparable. CONCLUSIONS: 3D ultrasound can be reliably used between observers to acquire power Doppler information from the ovary and endometrium thus supporting the current use and further development of this technique in clinical practice.

The reliability of virtual organ computer-aided analysis (VOCAL) for the semiquantification of ovarian, endometrial and subendometrial perfusion.

OBJECTIVES: Three-dimensional power Doppler angiography (3D-PDA) has been largely used for the subjective assessment of vascular patterns but semiquantification of the power Doppler signal is now possible. We examined the intraobserver and interobserver reliability of the semiquantification of ovarian, endometrial and subendometrial blood flow using 3D-PDA, virtual organ computer-aided analysis (VOCAL) and shell-imaging. METHODS: 3D-PDA was used to acquire 20 ovarian and 20 endometrial volumes from 40 different patients at various stages of in vitro fertilization treatment. VOCAL was then used to delineate the 3D areas of interest and the 'histogram facility' employed to generate three indices of vascularity: the vascular index, the flow index and the vascularization flow index. Intraobserver and interobserver reliability was assessed by two-way, mixed, intraclass correlation coefficients (ICCs) and general linear modeling was used to examine for differences in the mean values between each observer. RESULTS: The intraobserver reliability for both observers was extremely high and there were no differences in reliability between the observers for measurements of both volume and vascularity within the ovary or endometrium and its shells. With the exception of the outside subendometrial shell volumes, there were no significant differences between the two observers in the mean values obtained for either endometrial or ovarian volume and vascularity measurements. The interobserver reliability of measurements was equally high throughout with all measurements obtaining a mean ICC of above 0.985. CONCLUSIONS: 3D-PDA and shell-imaging offer a reliable, practical and non-invasive method for the assessment of ovarian, endometrial and subendometrial blood flow. Future work should concentrate upon confirming the reliability of data acquisition and the validity of the technique before its predictive value can be truly tested in prospective clinical studies.

The interobserver reliability and validity of volume calculation from three-dimensional ultrasound datasets in the in vitro setting.

OBJECTIVES: The primary aim of this validation study was to determine the interobserver reliability and validity of measurements of phantom objects of known volume using conventional and rotational techniques of volume calculation according to measurement technique. METHODS: Two observers each acquired a single three-dimensional ultrasound dataset of three water-filled objects of different size and shape. The same two observers measured all six datasets using both the conventional technique and the newer rotational technique (Virtual Organ Computer-aided AnaLysis, VOCAL( trade mark )) of volume calculation. Reliability was assessed by calculating intraclass correlation coefficients (ICC) and validity by examining the percentage difference from the 'true' volume, as determined by a water displacement technique, by the limits of agreement method. RESULTS: All of the techniques were highly reliable (ICC: 0.9962-0.9997) and valid to within 4% of the 'true' volumes. There were no significant differences in reliability according to measurement plane or between observers. Measurements made with the 6 degrees rotation step were significantly more reliable than those made by all other techniques with the exception of the 9 degrees rotation step (P < 0.05) and significantly more valid than those made with the 30 degrees rotation step or conventional technique (P < 0.05). CONCLUSIONS: Volume calculation in the in vitro setting is both reliable and valid but is dependent upon the technique applied, with rotational measurements of volume proving superior to conventional techniques.