Scholarly article on topic 'Ultrasound in evaluating ovarian reserve, is it reliable?'

Ultrasound in evaluating ovarian reserve, is it reliable? Academic research paper on "Agriculture, forestry, and fisheries"

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Abstract of research paper on Agriculture, forestry, and fisheries, author of scientific article — Eman Ahmaed Shawky Sabek, Ola I. Saleh, Howida A. Ahmed

Abstract The objective of this study was to compare the diagnostic accuracy of transvaginal ultrasound (TVS), as a less invasive technique instead of hormonal assay to evaluate the ovarian reserve. This study included fifty-five females with breast cancer and we compared the ovarian reserve for these patients by hormonal assay through measuring the serum AntiMullerian Hormone (AMH) level and follicular stimulating hormone (FSH) level before and after chemotherapy, and by transvaginal ultrasound through the ovarian volume (OV) calculation and counting the Antral follicles (AFC) before and after chemotherapy treatment. There was decline in the AntiMullerian Hormone level after chemotherapy by 27±11.19% and decrease in the Antral follicle counts by 21±13.43%. In conclusion there was strong relation between AMH level and AFC which makes the use of transvaginal ultrasound is a reliable alternative method to the hormonal assay to detect the ovarian reserve.

Academic research paper on topic "Ultrasound in evaluating ovarian reserve, is it reliable?"

The Egyptian Journal of Radiology and Nuclear Medicine (2015) 46, 1343-1348

Egyptian Society of Radiology and Nuclear Medicine The Egyptian Journal of Radiology and Nuclear Medicine

www.elsevier.com/locate/ejrnm www.sciencedirect.com

ORIGINAL ARTICLE

Ultrasound in evaluating ovarian reserve, is it c^Ma*

reliable?

Eman Ahmaed Shawky Sabeka, Ola I. Salehb'*, Howida A. Ahmedb

a Health Radiation Research Department, National Center of Research and Radiation Technology, Atomic Energy Authority, Egypt b Radiology Department, Faculty of Medicine, Al-Azhar University, Egypt

Received 15 July 2015; accepted 15 August 2015 Available online 8 September 2015

KEYWORDS

Ovarian reserve; Transvaginal ultrasound; Radiotherapy

Abstract The objective of this study was to compare the diagnostic accuracy of transvaginal ultrasound (TVS), as a less invasive technique instead of hormonal assay to evaluate the ovarian reserve. This study included fifty-five females with breast cancer and we compared the ovarian reserve for these patients by hormonal assay through measuring the serum AntiMullerian Hormone (AMH) level and follicular stimulating hormone (FSH) level before and after chemotherapy, and by transvaginal ultrasound through the ovarian volume (OV) calculation and counting the Antral follicles (AFC) before and after chemotherapy treatment. There was decline in the AntiMullerian Hormone level after chemotherapy by 27 ± 11.19% and decrease in the Antral follicle counts by 21 ± 13.43%. In conclusion there was strong relation between AMH level and AFC which makes the use of transvaginal ultrasound is a reliable alternative method to the hormonal assay to detect the ovarian reserve.

© 2015 The Authors. The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.

org/licenses/by-nc-nd/4.0/).

1. Introduction

Ovarian reserve tests (ORT) play important parts in detecting and treating infertility. They also play important parts in evaluation of women prior to in vitro fertilization (1). ORT has to be easy to perform, easy to be followed up and reliable enough for decision making (2). Many situations as old patients, or chronic illness patients seeking for pregnancy and preparation of woman to IVF are in need for accurate method to detect the response to treatment (3), also up to one third of the cancer survivals, undergo the fertility testing, place them into the cat-

* Corresponding author.

Peer review under responsibility of Egyptian Society of Radiology and Nuclear Medicine.

egory of suspected infertility, compared with an infertility rate of around 5% in the corresponding age segment of the general population. Ovarian aging, radiotherapy and chemotherapy are the most common causes for fertility loss in women. With increasing numbers of young female survivors following cyto-toxic cancer treatments, the issue of fertility preservation has assumed greater importance (4).

1.1. Aim of the work

The objective of this study was to assess the ability of ultrasound in evaluating ovarian reserve, and whether we can use ultrasound instead of hormones in decision making regarding ovulation induction and IVF.

http://dx.doi.org/10.1016/j.ejrnm.2015.08.008

0378-603X © 2015 The Authors. The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

2. Subjects and methods

This study was done at National center of radiation and research technology and Al-Zahraa University Hospital from September 2014 to January 2015.

Fifty-five females were subjected to treatments of breast cancer that include surgery, radiotherapy and chemotherapy are used to measure ovarian reserve before and after treatment. Serum Anti-Mullerian hormone (AMH) and Follicular stimulating hormone (FSH) were measured before and after treatment, and used as a reference for the fertility. Antral follicle count (AFC) and ovarian volume (OV) were measured before and after treatment by ultrasonography for all patients and compared with the hormonal assay to detect the reliability of this modality.

2.1. Technique of imaging

All patients undergo GE machine Logic P6 pro and My LabTM50 - Esaote.

Transvaginal sonography that was described about two decades ago is more precise because it provides better resolution and hence more morphological details of the ovaries 5. The patient was in the supine position using the vaginal probe for better detection of Antral follicles and determination of ovarian volume 6. The scan starts by viewing the uterus both longitudinal and cross-sectional and measuring the endome-trium, after that both ovaries both longitudinal and cross-sectional (Fig. 1) are scanned to assess volume and the Antral follicles are counted ranging from 3 to 10 mm. Then, blood sample was taken and used to detect the level of Anti-Mullerian Hormone (AMH) and follicle stimulating hormone (FSH). The AMH level was analyzed by the competitive enzyme immunoassay technique, and the FSH by Enzyme-Linked Immuno Sorbent Assay (ELISA) (see Fig. 2).

2.2. Statistical analysis

Data were analyzed using Statistical Package for Social Science (SPSS) version 21.0. Quantitative data were expressed as mean and standard deviation (SD). Paired-samples t-test of significance was used for calculating the mean differences between measurements of the three hormones and ovarian volume size before and after treatment. P-value <0.05 was considered significant and P-value <0.01 was considered highly significant. Confidence intervals were calculated with the software Confidence Interval Analysis (CIA) for windows, developed using Borland Delphi v 4.0 (Inprise Corporation) and ForHelp (ForeFront Technologies.)

3. Results

This study was conducted to evaluate whether ultrasound is an effective modality to measure ovarian reserve by measuring Antral follicle count and ovarian volume of patients who are subjected to cancer treatment. This study contains 55 patients with mean age of 32.5 and standard deviation of 4.9 ranging from 22 to 40 years. Statistical analysis of the measurements before and after treatment is shown in Table 1. The mean differences in measurements before and after treatment with their confidence intervals are shown in Table 2, the p values were all below 0.0001 indicating a high significant difference in the measurements before and after treatment in the 4 items measured. The negative sign in the FSH values is due to the increase in measurements after treatment in contrary to the other three items which show drop in measurements. Statistical analysis of the percentage of changes in measurements before and after treatment is described in Table 3. The median, range and the quartiles values of the percentage change of AMH, AFC, OV and FSH are shown in Figs. 3-6 respectively.

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Fig. 1 Transvaginal examination showing ovarian volume technique.

Fig. 2 Transvaginal US showing Antral follicle counts and ovarian volume.

Table 1 Descriptive analysis of the measurements before and after treatment.

Mean N Std. deviation Std. error mean

Pair 1 AMH before 3.4600 55 .73273 .09880

AMH after 2.4982 55 .63377 .08546

Pair 2 FSH before 21.0000 55 7.21375 .97270

FSH after 31.0873 55 8.26044 1.11384

Pair 3 AFC before 6.9455 55 1.90922 .25744

AFC after 5.3273 55 1.24803 .16828

Pair 4 Ovarian volume before 6.0309 55 2.42501 .32699

Ovarian volume after 4.7891 55 1.79719 .24233

Table 2 Mean differences between measurements before and after treatment.

Paired differences TP value < 0.0001 in all

Mean Std. deviation Std. error mean 95% Confidence interval of the

difference

Lower Upper

AMH before - AMH after 0.96182 0.48819 0.06583 0.82984 1.09379 14.611

FSH before - FSH after -10.08727 5.2333 0.70566 -11.50203 -8.67251 -14.295

AFC before - AFC after 1.61818 1.14651 0.15459 1.30824 1.92813 10.467

OV before - OV after 1.24182 1.20226 0.16211 0.9168 1.56684 7.66

4. Discussion

Ovarian reserve is very crucial part in predicting assisted reproductive treatment, a combination of clinical endocrinal and ultrasonic measures is used for this (5), and our study was designed to see whether or not ultrasound can replace the endocrinal ways in follow-up. In our study there was

marked decrease in ovarian reserve reflected on both hormonal and ultrasonic measurements, this goes with who reported decrease in ovarian Antral follicle count after cancer therapies (6,7). Cancer itself can impair ovarian reserve. Hormone and ultrasound measures of ovarian reserve suggest decreased underlying ovarian reserve comparing before and after therapy (8). So we used this decline in function to measure the

Table 3 Mean percentage changes in measurements before

and after treatment.

Percentage of Paired differences

change in

measurements

before and

after treatment

Mean Std. Std. 95% Confidence

deviation error interval of the

mean difference

Lower Upper

AMH 27.3739 11.1914 1.50905 24.3485 30.3994

FSH 55.2227 35.6944 4.81304 45.5732 64.8723

AFC 21.3848 13.4395 1.81218 17.7516 25.018

OV 18.7308 12.0968 1.63113 15.4606 22.001

percentage of change and whether this decline reflected on ultrasound parameter as well as hormones in the same percentage.

Anti-Mullerian Hormone (AMH) is a very sensitive indicator of the ovarian follicular content. Mullerian hormone is the most informative serum marker of ovarian reserve currently available and should be considered an important part of any contemporary reproductive medicine practice. It is more convenient and informative than basal FSH and can be assessed at any point in the cycle. It is the most useful serum method of determining ovarian reserve, which guides pretreatment counseling, choice of infertility treatment, and avoidance of ovarian hyperstimulation (9).

So we started by comparing both AFC and OV with the AMH. In our study there is a strong relation between AFC and AMH as both of them show decrease after cancer therapy, the former by 27 ± 11.19% and AFC by 21 ± 13.43%. This goes with Fanchin et al. (10) who correlated between AFC and the level of AMH as the AMH shown to be produced by the Antral follicle. Lan et al. (11) assess the use of AFC and AMH in the treatment of infertility, both of them shown to have the same predictive value regarding ovarian reserve. Verhagen et al. (12) stated that AFC is as accurate as the multivariate model and there are no benefits of using various

Fig. 4 Percentage of decrease in AFC with a mean of 21.38%.

Fig. 5 Percentage of decrease in OV with a mean of 18.73%.

Fig. 3 Percentage of decrease in AMH with a mean of 27.37%.

models over using AFC alone. Bansci et al. showed that AFC as a single variable was the best predictor of poor response with sensitivity and specificity of 62% and 88% respectively (9,13). Transvaginal ultrasound estimation of Antral follicle counts (AFCs) is a useful indicator of ovarian function and reserve (14).

Some authors such as Mutiu et al. (15) show that AFC determines poor ovarian response more than AMH. Various studies mentioned the proper size of Antral follicle, Mutiu et al. (15) used a range from 2 to 10 mm, and in our study we used Antral follicle ranging from 3 to 10 mm. Others such as Jayaprakasan et al. (5) mention the 2-6 mm is the proper size who also stated that there is no any correlation between hormonal markers and AFC. As the ultrasonography is operator dependent manufacturer made a software for easier automatic analysis of Antral follicle, in this software each follicle is given a special color, also these follicles are subdivided into cohorts according to their mean diameter calculated automatically into groups according to size by sono AFC. Manual

Fig. 6 Percentage of increase in FSH with a mean of 55.22%.

inclusion of missed follicle is also available by clicking over them for more accuracy (Fig. 7) (5).

Ovarian volume increases exponentially from birth to pubertal ages and are believed tope at a maximum shortly after puberty (16). It can be measured by using the formula (D1 x D2 x D3 x 0.523), and the mean volume is the average of the two ovaries in the same person (17). Ovarian volume is important for accurate evaluation and management of ovarian disorders (18). Some authors questioned the role of ovarian volume in the assessment of ovarian reserve and showed that it remains uncertain, with some studies suggesting that a reduced volume is a good predictor of poor outcome for assisted conception (19,20). Several studies showed that low ovarian volume <3 ml is predictor for poor response to ovarian stimulation (21). In this study ovarian volume decreased by 18.7 ± 12.09% from the former ovarian volume. It was the least one to be affected but is very close to AFC and AMH, ovaries with nonfunctional cysts are followed up until disappearance of the cyst so as to avoid false increase in size, and modern machines using 3-D technique

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reduce inter-observer variability but this needs specialized equipment.

Basal FSH level increases at day 2-3-4 of the cycle it also has significant intra-cycle and inter-cycle variability that limits their reliability, and also the absolute value can differ from one to another. But the overall correlation between values is shown to have significance (22). Despite this limitation FSH commonly used as a measurement for ovarian reserve and high value are associated with poor ovarian stimulation and inability to conceive. In our study there was high significant increase in serum level of FSH with the mean value reaching 55.2% after treatment which put them in postmenopausal level. These results corroborate findings of study by Gracia et al. (2012), who reported increased FSH levels in patients after cancer therapy. The future role of basal FSH testing is in doubt (9). There is evidence that Anti-Mullerian Hormone (AMH) and follicular stimulating hormone (FSH) levels may correlate well with Antral follicle counts and may be more consistent markers of ovarian reserve (23).

The use of wide range of tests suggests that no single test provides a sufficiently accurate result. But the simultaneous evaluation of a combination of tests could be used as a marker of diminished ovarian reserve and a sensitive predictor of response to ovarian stimulation in patients undergoing in vitro fertilization treatment (24). In our study there is evidence that Anti-Mullerian Hormone (AMH), Antral follicle count (AFC) and ovarian volume (OV) levels correlate well with each other more consistent markers of ovarian reserve. Regarding FSH there was marked increase reaching up to 55.2% which was more than the percentage of decrease of other markers.

5. Conclusion

The use of ultrasound in detecting ovarian reserve by detection of Antral follicle counts is very easy, minimal invasive, inexpensive and has good predictive value. It can be used instead of hormones on the basis of follow-up to detect either increase or decrease of ovarian function.

Conflict of interest

The authors declare that there are no conflict of interests. References

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