HDLive ultrasound images of ovarian dermoid cysts: diagnostic accuracy.

OBJECTIVE: To demonstrate that the use of 3D/4D HDLive increases the image quality in the diagnosis of benign cystic ovarian teratomas. MATERIALS AND METHODS: 3D/HDLive ultrasound (US) was used in 31 cases of suspected ovarian cystic teratoma using vaginal 2D US. The following pathognomonic images of mature cystic teratomas were considered for diagnosis: 1) a cystic, unilocular lesion with a densely echogenic tubercle (Rokitansky nodule); 2) a diffuse or partially echogenic mass usually demonstrating sound attenuation; 3) fluid-fluid/fat-fluid levels; 4) dermoid mesh with hyperechogenic calcifications indicating the presence of bone, teeth, or other ectodermally-derived structure; 5) multiple mobile spherical structures (fat globules). RESULTS: Dermoids present a wide spectrum of images depending on the predominant tissue type. In the vast majority of cases there are dense echogenic structures that correspond to complex masses of fatty tissue, sebum, hair, epithelial remnants, along with cartilage or bone. If we catalogue all the images together, the pathognomonic of dermoid are: 1) cystic or solid cystic lesions with a Rokitansky nodule, with bone, teeth or cartilage (six cases, 22.2%); 2) a solid mass with or without attenuation that corresponds with pure sebum (five cases, 18.5%); 3) a diffuse mass with fine bands that correspond with hair inside sebum (four cases, 12.9%) and that may form meshes or plugs corresponding with a mixture of fat, sebum, and hair (three cases, 11.5%). CONCLUSIONS: HDLive U.S. provides some images of exceptional quality that enhance the definition of the structures of these tumors (fat, hair, cartilage, bone, etc.) compared to 2D/3D/4D.

Semi-automatic Sono T measurement of nuchal translucency.

A prospective study of 63 singleton pregnancies between 11 + 0 and 13 + 6 weeks gestation underwent semi-automatic nuchal translucency (NT) measurement and were compared with two-dimensional ultrasonography (2D US). Inter-observer variation and the repeatability were evaluated. Sono T automatically achieves mid-sagittal plane views and measures the maximum NT thickness. Measurements have less inter-observer variation (CI = -0.13, -0.04) when compared with 2D measurements (CI = -0.45, 0.28). It is reproducible and comparable to conventional 2D US technique for NT measurement. However, incorporating Sono T into routine practice requires further program refinements in order to reduce erroneous NT measurements.

Triggering with GnRH agonist in oocyte-donation cycles: oestradiol monitoring is not necessary during ovarian stimulation.

This prospective observational study evaluated the efficacy and safety of oocyte-donation cycles triggered with a gonadotrophin-releasing hormone (GnRH) agonist without monitoring oestradiol concentrations during ovarian stimulation. A total of 97 oocyte donors received recombinant FSH (150-225/day) and GnRH antagonists (0.25mg/day). Oocyte maturation was triggered with 0.2mg triptorelin s.c. Donors aged 25.4 ± 4.1 years were stimulated for 8.8 ± 0.9 days and underwent 2.9 ± 0.5 (2-4) ultrasound assessments. Total FSH dose was 1703.4 ± 304.7IU, antagonists were administered for 4.3 ± 1.0 days, 14.7 ± 8.8 oocytes were retrieved and there were no cases of ovarian hyperstimulation syndrome. Recipients (n=123) aged 40.3 ± 3.4 years received 10.9 ± 4.3 oocytes, 88.7% of which were metaphase II. Intracytoplasmic sperm injection fertilization rate was 79% and 2.18 ± 0.6 (1-3) embryos were transferred. The pregnancy, clinical pregnancy and twin pregnancy rates were 64.2%, 57.7% and 19.7%, respectively. In conclusion, given the high efficacy and safety of the GnRH-antagonist protocol triggered with a GnRH agonist, the monitoring of oestradiol concentrations is not necessary. Ultrasound monitoring is enough for an adequate follow up of the stimulation cycle in oocyte donors.

Predicting ovarian reserve and reproductive outcome using antimüllerian hormone (AMH) and antral follicle count (AFC) in patients with previous assisted reproduction technique (ART) failure.

PURPOSE OF INVESTIGATION: The main objective of our prospective, observational, analytical research work was to determine whether Anti-Müllerian hormone (AMH) and antral follicle count (AFC) could be effectively used as predictors of ovarian reserve and, possibly, of reproductive outcome with ART. METHODS: We studied 143 IVF/ET cycles in patients with a previous history of ART failure, all of them supposed to be of poor prognosis, who had agreed to another ART attempt after knowing their AMH, AFC, and base hormone (FSH, LH, 17 beta-estradiol) levels. RESULTS: AMH and AFC showed a positive correlation with the number of oocytes retrieved (p = 0.0016) and (p < 0.0001), respectively and with percentage of MII oocytes, (p = 0.00756) and (p < 0.001). The combined use of these markers showed an area under the curve of 82.2% for oocytes retrieved. Our results shows a very high cancelation (22% of started cycles) and very low pregnancy rates (6.7% and 9.8%) in low and normoresponders, respectively. CONCLUSIONS: AMH levels and AFC are reliable indicators of ovarian reserve. Patients with ovarian reserve levels that predict a very low probability of success should be informed that the poor prognosis associated with these values may not justify the expense of IVF/ET.

Cycles triggered with GnRH agonist: exploring low-dose HCG for luteal support.

The aim of this study in patients at risk of ovarian hyperstimulation syndrome (OHSS) was to determine the efficacy and safety of luteal support using human chorionic gonadotrophin (HCG) after triggering ovulation with gonadotrophin-releasing hormone (GnRH) agonist in IVF/intracytoplasmic sperm injection antagonist cycles. A total of 192 OHSS-risk patients, following a GnRH antagonist protocol (0.25mg/day cetrorelix) during recombinant FSH stimulation, were triggered with 1.5mg s.c. leuproreline for ovulation. A total of three boluses of HCG were used for luteal support, 1000IU (group A, n=44), 500IU (group B, n=115) or 250IU (group C, n=33) every third day, starting the day after oocyte retrieval. For the reproductive outcome, main variables were biochemical and clinical pregnancy rates, and for OHSS, the variables were the numbers of moderate and severe OHSS cases. Overall pregnancy rate was 51.8% and clinical pregnancy rate was 43.4%. This study observed eight cases of moderate (4.2%) and seven of severe OHSS (3.6%). Six out of the seven (85.7%) severe cases were late-onset OHSS, related to pregnancy. In conclusion, GnRH agonist single dose for triggering ovulation and low doses of HCG used as luteal-phase support seem to secure a normal pregnancy outcome without increasing the OHSS risk.

High doses of GnRH antagonists are efficient in the management of severe ovarian hyperstimulation syndrome.

OBJECTIVE: To determine whether treatment of severe ovarian hyperstimulation syndrome (OHSS) with high-dose gonadotropin-releasing hormone (GnRH) antagonist, due to its luteolytic effect, is an effective method of management. METHODS: Six infertile patients who had been scheduled for embryo transfer and developed early-onset severe OHSS with ascites and hemoconcentration were chosen for treatment with 3.0 mg of a GnRH antagonist (Cetrotide; Cetrorelix, Serono, Madrid, Spain). The response of these patients was compared with five patients with severe early-onset OHSS who received support therapy alone. All patients were evaluated clinically, echographically, and hematologically. RESULTS: Estradiol (E2) levels dropped significantly a few days after treatment. Peritoneal fluid regression measured by ultrasound was faster on the study group compared with controls. Hematocrit remained comparable in both groups during follow-up. In two cases a second bolus of GnRH-antagonist was used due to clinical and biochemical findings during the four days of observation following the initial dose. None of the patients treated with GnRH antagonists required paracentesis. CONCLUSIONS: Treatment with high doses of GnRH antagonists seems to be effective in the management of severe OHSS.

The role of gonadotropin-releasing hormone in murine preimplantation embryonic development.

Previous studies have established the presence of an extrahypothalamic GnRH in a variety of tissues. GnRH receptor is known to be present in the placenta, which produces and secretes the decapeptide from the very early stages of placentation. We hypothesized that GnRH may play a role in the preimplantation development of embryos. To examine this hypothesis, we assessed GnRH and GnRH receptor messenger RNA (mRNA; RT-PCR) and protein expression (Immunohistochemistry) in preimplantation murine embryos at various developmental stages. Furthermore, preimplantation murine embryos were cultured with GnRH agonist and antagonist in vitro to assess the influence of GnRH analogs on embryo development. GnRH is expressed in the developing mouse embryo from morula to hatching blastocyst stages at the mRNA and protein levels. GnRH receptor mRNA is also present in the developing embryos studied. Preimplantation embryonic development was significantly enhanced by incubation with increasing concentrations of GnRH agonist and is significantly decreased by GnRH antagonist compared with that in the control group. Moreover, GnRH antagonist (5 and 10 microM) was able to completely block embryo development. The deleterious effect of GnRH antagonist on embryo development was reversed by increasing concentrations of the agonist, as determined by the number of embryos reaching the blastocyst stage.

Human oviductal gonadotropin-releasing hormone: possible implications in fertilization, early embryonic development, and implantation.

The oviduct is host to gametes and early embryos at a critical point in their lives. It is clear that the interactions of gametes/early embryo with the maternal oviduct in an autocrine and paracrine manner provide a microenvironment that enhances fertilization, early embryonic development, and implantation. Moreover, there is considerable evidence that an extrahypothalamic GnRH may play a substantial role as a molecular autocrine/paracrine regulator in these events. Gametes and preimplantation embryos express GnRH and GnRH receptor at both messenger ribonucleic acid (mRNA) and protein levels. However, whether GnRH is produced by the human oviduct has not yet been demonstrated. We used RT-PCR and immunohistochemical techniques to investigate GnRH mRNA and protein expression in human fallopian tubes throughout the menstrual cycle of premenopausal fertile patients. Our results, at both the mRNA and protein levels, revealed cycle-dependent production of an oviductal GnRH with expression during the luteal phase. Moreover, GnRH immunostaining was localized in the tubal epithelium during the luteal phase. On the basis of these data, we suggest that during reproductive life, oviductal GnRH may play a substantial paracrine/autocrine role in human fertilization, early embryonic development, and implantation.

Independent regulation of matrix metalloproteinase-9, tissue inhibitor of metalloproteinase-1 (TIMP-1), and TIMP-3 in human endometrial stromal cells by gonadotropin-releasing hormone: implications in early human implantation.

Early human trophoblast shows dramatic invasive properties during early pregnancy. The simultaneous synthesis of matrix metalloproteinases (MMPs) and their specific tissue inhibitors (TIMPs) in both human trophoblast and decidual membranes suggests that their controlled and balanced expression is crucial for the rapid matrix remodeling and controlled invasion during early pregnancy. Recently, we have described the presence of an extrahypothalamic GnRH immunologically, biologically and chemically identical to the hypothalamic hormone in periimplantation human embryos. Moreover, the production of this decapeptide by the human trophoblast during the early stages of placentation is well documented. TIMP-1 and -3 messenger ribonucleic acid (mRNA) expression in cultured stromal cells and protein secretion into the medium were significantly decreased by GnRH agonist compared to that in control groups. Moreover, expression of TIMP-1 was affected to a greater extent than that of TIMP-3. GnRH antagonist ablated the down-regulation of TIMPs by the GnRH agonist. MMP-9 mRNA expression was not detected in the control groups or in the groups treated with GnRH analogs. Our results provide evidence that trophoblastic GnRH may play an important role in placental tissue organization and in the early embryo-maternal dialogue by enhancing trophoblast invasion through the specific inhibition of TIMPs.

Congenital Müllerian anomalies: diagnostic accuracy of three-dimensional ultrasound.

OBJECTIVE: To determine whether it is possible to identify and diagnose accurately Müllerian anomalies with three-dimensional (3-D) ultrasound (US). DESIGN: Controlled blinded clinical study. SETTING: Normal human volunteers undergoing infertility evaluation in a university hospital. PATIENTS: Forty-two patients who underwent laparoscopy and hysterosalpingography as part of their work up for infertility and were found to have either a normal uterus (30 patients) or a Müllerian abnormality (12 patients) consented to be evaluated with 3-D US by sonographers who were unaware of their infertility history or of their laparoscopy and hysterosalpingography diagnoses. INTERVENTIONS: Transvaginal 3-D US evaluation over a 10- to 15-minute duration. MAIN OUTCOME MEASURES: Three-dimensional imaging was successful in all cases. RESULTS: Sonographers identified a Müllerian anomaly in all cases and came up with the correct classification in 11 of 12 cases. All patients with a normal uterus were identified correctly. CONCLUSIONS: In all patients with Müllerian anomalies, 3-D US examination of the endometrial cavity correlated with hysterosalpingography. In 91.6% of patients, 3-D US correlated with the external uterine configuration observed by laparoscopy. This technique may be used reliably in an office setting to diagnose and classify Müllerian anomalies.

Failed in vitro fertilization of human oocytes: a cytogenetic analysis.

OBJECTIVE: To investigate possible causes of in vitro fertilization (IVF) failure. DESIGN: A retrospective cytogenetic study of human oocytes divided into four groups or, alternatively, into two groups according to fertilization rates and whether the patients became pregnant or not. Two additional groups included oocytes in which there was no or only partial fertilization. SETTING: Primary treatment of infertility in an institutional practice. PATIENTS, PARTICIPANTS: Two hundred fifty-three inseminated-unfertilized oocytes from 87 women entering the IVF program because of tubal, unknown, and male infertility. Immunological infertility was excluded. INTERVENTIONS: Ultrasound-guided transvaginal follicular aspiration. MAIN OUTCOME MEASURE(S): Planned after data collection. RESULTS: The rate of chromosome anomalies did not show any significant difference among the four groups established according to the fertilization rate and between pregnant and nonpregnant patients. Independently, our data identified male factor as responsible for 41%, chromosome anomalies 19.3%, oocyte immaturity 11.8%, and unknown etiology 41% of fertilization failures (based on analysis of 161 oocytes). CONCLUSIONS: Fertilization rate and pregnancy outcome after IVF are not related to the incidence of oocyte chromosome anomalies.

In vitro fertilization as a diagnostic and therapeutic tool in a patient with partial 17,20-desmolase deficiency.

OBJECTIVE: To present a case with 17,20-desmolase activity deficiency in which in vitro fertilization (IVF) served not only as a therapeutic approach but also as a diagnostic tool for the specificity of the enzymatic deficiency. DESIGN: IVF in the patient under study compared with a control group. All women treated with pure follicle-stimulating hormone (FSH). SETTING: IVF program at the Instituto Valenciano de Infertilidad. PATIENTS, PARTICIPANTS: A patient with primary amenorrhea, who was the subject under study, and seven normally cycling control patients undergoing IVF in the same series. INTERVENTIONS: IVF, steroidogenesis in vitro of granulosa-luteal cell obtained at ovum pick-up. MAIN OUTCOME MEASURE(S): Oocyte fertilization and embryo cleavage. Serum and follicular fluid (FF) levels of estradiol (E2), progesterone (P), testosterone (T), androstendione (A), 17 alpha-hydroxyprogesterone (17-OHP). In vitro accumulation of E2 and P. RESULTS: Ovulation induction with FSH was successful in achieving follicular development despite low circulating E2. Fertilization and cleavage rates were similar to the control subjects. The patient developed ovarian hyperstimulation. The lack of 17,20-desmolase activity was detected by normal P levels in serum and FF, high 17-OHP, and low T, A, and E2 levels in serum and FF. Granulosaluteal cell cultures in the presence of T restored normal E2 and P production in response to gonadotropins. CONCLUSIONS: In patients with 17,20-desmolase deficiency, follicular development, oocyte maturation, and fertilization can take place in a low estrogenic environment.

Evaluation of the ovarian reserve in young low responders with normal basal levels of follicle-stimulating hormone using three-dimensional ultrasonography.

OBJECTIVE: To assess the ovarian content of selectable (2-5 mm) follicles using three-dimensional ultrasonography in low responders to ovarian stimulation for IVF. DESIGN: Prospective case-control study. SETTING: IVF program at the Instituto Valenciano de Infertilidad. PATIENT(S): Ten low responders < or =35 years of age with normal basal serum FSH and eight control patients with normal response in a previous cycle. INTERVENTION(S): Blood was drawn under basal (day 3) conditions. Three-dimensional ultrasound was performed in both ovaries using a vaginal probe. MAIN OUTCOME MEASURE(S): Basal serum E2 and FSH measurements. The ovarian volume and the number of follicles > or =2 mm in each ovary were recorded and compared between the groups. RESULT(S): Low-responder women had significantly higher serum FSH levels than controls despite having FSH values within the normal range. The number of selectable follicles and the total number of follicles with an antrum were significantly decreased in low responders as compared with normal responders. Ovarian volume did not differ between the groups. CONCLUSION(S): This study introduces three-dimensional ultrasound as a novel method for the evaluation of low responders. The results show that the most plausible explanation for low response in young women with normal serum FSH is diminished ovarian reserve.

The follicular and endocrine environment in women with endometriosis: local and systemic cytokine production.

OBJECTIVE: To assess the endocrine, paracrine, and autocrine milieu in patients with endometriosis on the basis of the measurement of several cytokines in serum and follicular fluid (FF) and in vitro culture of granulosa luteal cells. DESIGN: Case-control study. SETTING: In vitro fertilization program at the Instituto Valenciano de Infertilidad. PATIENT(S): Twenty patients with laparoscopically documented endometriosis and 18 controls. Fifteen subjects were studied in a natural cycle and 23 were investigated in a stimulated cycle while undergoing IVF. INTERVENTION(S): Individual follicle aspiration, oocyte isolation, FF storage, and preparation of luteinized granulosa cell cultures. Diagnostic laparoscopy in natural cycles. MAIN OUTCOME MEASURE(S): Serum (day of ovum pick-up or laparoscopy) and FF measurement of interleukin (IL)-1beta, IL-6, and vascular endothelial growth factor (VEGF). Secretion of IL-1beta, IL-6, and VEGF in the cell-conditioned medium. Results were compared between patients with endometriosis and controls. RESULT(S): Interleukin-6 levels in serum were increased in the natural cycles of patients with endometriosis and modulated by ovarian stimulation, showing a significant decrease in hMG- and FSH-stimulated cycles and a significant increase after hCG administration. In addition, IL-6 levels were increased in the FF of patients with endometriosis and released in higher amounts by their granulosa luteal cells. Vascular endothelial growth factor was accumulated in lesser concentrations in the FF of patients with endometriosis. Interleukin-1beta levels did not show significant changes. Implantation rates were decreased significantly in patients with endometriosis who were undergoing IVF. CONCLUSION(S): The data demonstrate that cytokines are regulated differently in patients with endometriosis, who have increased IL-6 production, and suggest that fine hormonal modulation of this cytokine occurs at the systemic and local (ovarian) levels. These changes show that the endocrine, paracrine, and autocrine milieu is different in patients with endometriosis and may be related to their lower implantation rates.

The follicular endocrine environment in stimulated cycles of women with endometriosis: steroid levels and embryo quality.

OBJECTIVE: To assess the endocrine milieu in follicles of stimulated cycles comparing women with and without endometriosis. Steroids were measured in follicular fluid (FF) and in in vitro culture of granulosa-luteal cells, and this status was related to the quality of the embryos obtained after IVF. DESIGN: Case-control study. SETTING: IVF program at the Instituto Valenciano de Infertilidad. PATIENT(S): Twenty-four women with laparoscopically documented endometriosis and 26 controls undergoing IVF. INTERVENTION(S): Individual follicular aspiration, oocyte isolation, FF storage, and preparation of luteinized granulosa cells for culture; oocyte insemination and embryo cleavage in standard IVF. MAIN OUTCOME MEASURE(S): Serum (day of ovum pickup) and FF measurements of estradiol, progesterone, testosterone, and androstenedione. Secretion of progesterone was measured in the cell-conditioned medium. Results were compared between patients with endometriosis and controls, as well as between oocytes that yielded embryos of different quality. RESULT(S): Levels of progesterone in the FF increased with the severity of the disease, whereas testosterone accumulation in the FF decreased with the severity of the disease. An increase in progesterone accumulation in vitro was observed in basal and hCG-induced granulosa cell cultures. No difference was observed in terms of embryo quality, and no steroid marker was able to identify follicles with oocytes that displayed embryos of good or bad quality under the inverted microscope. CONCLUSION(S): The data show differences in the steroidogenesis of follicles from stimulated women with and without endometriosis. These changes indicate good endocrine health but are not predictive of embryo quality.

The pathogenesis of ovarian hyperstimulation syndrome: in vivo studies investigating the role of interleukin-1beta, interleukin-6, and vascular endothelial growth factor.

OBJECTIVE: To evaluate systemic and ovarian changes in levels of interleukin (IL)-1beta, IL-6, and vascular endothelial growth factor (VEGF) in response to hCG administration to determine which may be the potential initiator of vascular effects and to identify the main source of the substance; to evaluate serum and follicular fluid levels of these cytokines as markers of ovarian hyperstimulation syndrome (OHSS), and to compare levels of these cytokines under basal conditions in women with normal ovulation and those with polycystic ovary syndrome (PCOS). DESIGN: Prospective controlled study. SETTING: In vitro fertilization program at the Instituto Valenciano de Infertilidad, Valencia, Spain. PATIENT(S): Women undergoing IVF, in whom the first two study objectives were analyzed, and women with normal ovulation and patients with PCOS undergoing retrieval of immature oocytes in natural cycles or cycles stimulated for IUI but cancelled during induction of ovulation, in whom the third study objective was analyzed. INTERVENTION(S): Serum was collected before and after hCG administration, and follicular fluid was collected at ovum pick-up. MAIN OUTCOME MEASURE(S): Serum and follicular fluid levels of IL-1beta, IL-6, and VEGF. RESULT(S): There was a significant increase in serum VEGF levels after hCG administration in patients who were at risk for OHSS compared with those who were not at risk for OHSS. Significantly lower VEGF levels were found in the follicular fluid of patients who were at risk; this decrease was the only useful marker to discriminate between the two groups. Moreover, both groups had similar cytokine production under basal conditions. An increase in serum E2 occurred coincident with a decrease in IL-1beta, IL-6, and VEGF in patients with PCOS. CONCLUSION(S): Vascular endothelial growth factor seems to be the mediator of hCG on the vascular tree. There was an early systemic increase in VEGF that may have significance in the development of OHSS. A decrease in the follicular fluid VEGF concentration is a valid marker to identify women in whom OHSS will develop. The pattern of cytokine release in patients with PCOS under basal conditions was not different from that in women with normal ovulation.

Role of color flow Doppler ultrasonography in diagnosing velamentous insertion of the umbilical cord and vasa previa. A report of two cases.

BACKGROUND: Prenatal diagnosis of velamentous insertion of the umbilical cord is of practical importance since unsupported vessels in the amnion may be lacerated at the time of membrane rupture. Failure to diagnose ruptured vessels may lead to fetal death. The incidence of velamentous insertion of the umbilical cord is about 1% in singleton pregnancies. This mode of insertion occurs much more frequently with multifetal pregnancies. CASES: Two cases of velamentous insertion of the umbilical cord unrelated to vasa previa were diagnosed prenatally with color Doppler ultrasound in women with twin gestations. Both women delivered uneventfully by cesarean section. The velamentous insertion diagnosis was confirmed postnatally in both cases. CONCLUSION: Color flow Doppler ultrasonography can be used in the second and third trimesters of pregnancy to identify potentially lethal structural abnormalities of the umbilical cord.

Color flow Doppler: a useful instrument in the diagnosis of funic presentation.

Color Doppler sonography offers the opportunity to evaluate the umbilical cord and to study blood velocity wave forms within the cord. Funic (cord) presentation can be diagnosed unequivocally with color Doppler sonography. Because funic presentation is likely to be the harbinger of cord prolapse, the morbidity and mortality associated with cord prolapse can be prevented if funic presentation is diagnosed before membrane rupture. This article describes the first case in the obstetric literature of funic presentation diagnosed with color Doppler sonography. The potential complications associated with cord prolapse were avoided with a cesarean section.

Subchorionic placental cyst: a cause of fetal growth retardation--ultrasound and color-flow Doppler diagnosis and follow-up.

Subchorionic placental cysts are ominous findings. When attached near the umbilical cord insertion, the risk of umbilical cord constriction is increased. This may cause fetal growth retardation and intrauterine asphyxia. This article reports a case of subchorionic placental cyst diagnosed in the first trimester by transvaginal ultrasound. Color Doppler ultrasound demonstrated a reduction of the umbilical cord bloodstream as the cyst increased in size. Fetal growth retardation was evident in the third trimester.