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29.07.2008
 
Newsletter No. 4/2008
 
  1. Decreased anti-Müllerian hormone and altered ovarian follicular cohort in infertile patients with mild/minimal endometriosis
  2. Quantification of the effect of pituitary down-regulation on 3D ultrasound predictors of ovarian response.
  3. Three-dimensional ultrasound improves the interobserver reliability of antral follicle counts and facilitates increased clinical work flow.
  4. Establishing the intercycle variability of three-dimensional ultrasonographic predictors of ovarian reserve.
  5. Intracytoplasmic morphologically selected sperm injection: a prospective randomized trial

1. Decreased anti-Müllerian hormone and altered ovarian follicular cohort in infertile patients with mild/minimal endometriosis.

OBJECTIVE: To evaluate the ovarian reserve and follicular cohort of infertile patients with minimal/mild endometriosis. DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): Patients were divided into two groups: group I, minimal/mild endometriosis and group II, tubal obstruction. The following exclusion criteria were established: [1] patients with previous endocrine disorders; and [2] cases in which the cause for infertility was other than endometriosis (except for patients with tubal obstruction, in the control group). INTERVENTION(S): Serum FSH and anti-Müllerian hormone were measured on day 3. On the same day all patients were submitted to transvaginal ultrasound to evaluate the antral follicular count and the ovarian follicular cohort. MAIN OUTCOME MEASURE(S): Serum FSH, anti-Müllerian hormone, and the follicular cohort with the respective antral follicular count. RESULT(S): Serum FSH were not different between the groups. However, infertile patients with endometriosis have a decreased serum anti-Müllerian hormone (1.26 +/- 0.7 ng/mL) compared to the control group (2.02 +/- 0.72 ng/mL). The analysis of follicular cohort showed that the number of selectable follicles were similar, but the follicular diameter was different. CONCLUSION(S): Minimal/mild endometriosis is associated with a decrease in the follicular ovarian reserve. In addition, the follicular cohort of these patients is more heterogeneous in comparison to the control group.

Reference

Lemos NA, Arbo E, Scalco R, Weiler E, Rosa V, Cunha-Filho JS. Decreased anti-Müllerian hormone and altered ovarian follicular cohort in infertile patients with mild/minimal endometriosis. Fertil Steril. 2008 May;89(5):1064-8. Epub 2007 Jul 10

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2. Quantification of the effect of pituitary down-regulation on 3D ultrasound predictors of ovarian response.

BACKGROUND: This study evaluated the effect of pituitary desensitization on ovarian volume, antral follicle count (AFC), and ovarian blood flow indices and their value as predictors of ovarian response during assisted reproduction treatment. METHODS: A total of 115 subjects aged <40 years with follicle-stimulating hormone (FSH) levels <12 IU/l underwent transvaginal ultrasound in the early follicular phase of the menstrual cycle and after 14 days of down-regulation using gonadotrophin-releasing hormone agonists. 3D power Doppler was used to quantify ovarian volume, AFC and ovarian blood flow. The relationship between these ultrasound variables and treatment outcome was evaluated using multiple regression analysis. RESULTS: Although a significant decrease in the ovarian volume (P < 0.05) and flow index (FI; P < 0.01) was demonstrated after pituitary desensitization, no differences were seen in the AFC. The total AFC, regardless of whether this was measured before or after down-regulation, was a significantly better predictor of the number of oocytes retrieved (P < 0.001) and poor ovarian response (P < 0.05) than age, FSH, ovarian volume and vascular indices although pre-treatment ovarian volume (P < 0.05) and FI (P < 0.05) were also predictive of the number of oocytes retrieved. CONCLUSIONS: Pituitary desensitization results in a significant reduction in ovarian volume and vascularity, but has no effect on the AFC. AFC is the single best predictor of ovarian response regardless of whether the assessment is performed before or after down-regulation.

Reference

Jayaprakasan K, Hopkisson JF, Campbell BK, Clewes J, Johnson IR, Raine-Fenning NJ. Quantification of the effect of pituitary down-regulation on 3D ultrasound predictors of ovarian response. Hum Reprod. 2008 Jul;23(7):1538-44. Epub 2008 May 2.

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3. 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. Copyright (c) 2008 ISUOG. Published by John Wiley & Sons, Ltd.

Reference

Jayaprakasan K, Campbell BK, Clewes JS, Johnson IR, Raine-Fenning NJ. Three-dimensional ultrasound improves the interobserver reliability of antral follicle counts and facilitates increased clinical work flow. Ultrasound Obstet Gynecol. 2008 Apr;31(4):439-44.

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4. Establishing the intercycle variability of three-dimensional ultrasonographic predictors of ovarian reserve.

OBJECTIVE: To estimate the intercycle variability of antral follicle counts (AFCs) and ovarian volume, as measured by using three-dimensional ultrasound, and to compare these to the variation in basal FSH levels. DESIGN: Prospective study. SETTING: University-based assisted conception unit. PATIENT(S): One hundred women undergoing two cycles of assisted reproductive technology. INTERVENTION(S): Transvaginal three-dimensional ultrasound assessment and venepuncture in the early follicular phase of the menstrual cycle, immediately before assisted reproductive technology. MAIN OUTCOME MEASURE(S): Intercycle variability of AFC, ovarian volume, and basal FSH. RESULT(S): The limits of agreement between cycles were +4.03 and -3.71 for AFC, +2.67 and -3.03 cm(3) for ovarian volume, and +4.36 and -4.52 IU/L for FSH levels. The AFC showed the least degree of variation, with a range of 0.48 times its own mean, in contrast to corresponding values of 0.73 and 1.29 for ovarian volume and basal FSH levels, respectively. The intraobserver variability for AFC and ovarian volume and the intraassay variability for FSH were 0.37, 0.17, and 0.42 times the mean of those respective variables. CONCLUSION(S): The AFC demonstrates a lower intercycle variability than do ovarian volume and basal FSH level. The observed intercycle variability of the AFC may primarily be caused by observer variability, and the true biological variation may be minimal.

Reference

Jayaprakasan K, Campbell B, Hopkisson J, Clewes J, Johnson I, Raine-Fenning N. Establishing the intercycle variability of three-dimensional ultrasonographic predictors of ovarian reserve. Fertil Steril. 2008 Jan 11. [Epub ahead of print]

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5. Intracytoplasmic morphologically selected sperm injection: a prospective randomized trial.

The aim of this prospective randomized study was to assess the advantages of a new modified intracytoplasmic sperm injection (ICSI) technique called intracytoplasmic morphologically selected sperm injection (IMSI) over the conventional ICSI procedure in the treatment of patients with severe oligoasthenoteratozoospermia. The new procedure consisted of IMSI based on a preliminary motile sperm organellar morphology examination under x6600 high magnification. A total of 446 couples with at least two previous diagnoses of severe oligoasthenoteratozoospermia, 3 years of primary infertility, the woman aged 35 years or younger, and an undetected female factor were randomized to IVF micro-insemination treatments: ICSI (n = 219; group 1) and IMSI (n = 227; group 2). A comparison between the two different techniques was made in terms of pregnancy, miscarriage and implantation rates. The data showed that IMSI resulted in a higher clinical pregnancy rate (39.2% versus 26.5%; P = 0.004) than ICSI when applied to severe male infertility cases. Despite their initial poor reproductive prognosis, patients with two or more previous failed attempts benefited the most from IMSI in terms of pregnancy (29.8% versus 12.9%; P = 0.017) and miscarriage rates (17.4% versus 37.5%). At present, 35 healthy babies have been born following the introduction of this promising technique in daily IVF practice.

Reference

Antinori M, Licata E, Dani G, Cerusico F, Versaci C, d’Angelo D, Antinori S Reprod Biomed Online. 2008 Jun;16(6):835-41PMID: 18549694 [PubMed - in process]

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Gerhard Leyendecker