1 Women's General Hospital, IVF Unit, Lederergasse 47 and 2 University of Linz, Department for Statistics, Altenbergstr. 69, A-4040 Linz, Austria
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Abstract |
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Key words: 3D ultrasound/down-regulation/endometrial volume/hormones/IVF
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Introduction |
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The relationship between oestradiol status and endometrial thickness has been proven (Nakamura et al., 1996). An endometrial thickness of 6 mm or more was selected to predict the occurrence of withdrawal bleeding after progesterone administration with an accuracy of 95.5%. Furthermore, endometrial thickness was superior to serum oestradiol concentration in predicting withdrawal bleeding (Nakamura et al., 1996
).
Only one study was available reporting on two-dimensional (2D) endometrial thickness measurement in down-regulated patients (Barash et al., 1998). No published data exist on endometrial volume changes measured by transvaginal three-dimensional (3D) ultrasound in patients undergoing pituitary down-regulation for subsequent IVFembryo transfer. The aim of this study was to document the role of 3D endometrial volume estimation in predicting pituitary down-regulation.
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Materials and methods |
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Equipment
All ultrasound scans (2D and 3D) were obtained using the Voluson 530 system (Kretztechnik AG, Zipf, Austria) with transvaginal 57.5 MHz volume transducer. First, the uterus was visualized in B mode. Then the system was switched to `volume mode'. After targeting of the endometrium in a vertical plane by the volume box, the slow volume acquisition setting was activated. Volume data were captured by holding the transducer stationary while its crystal electronically swept up to 95° for ~23 s. All scanned volumes were stored on a 540 MB hard disk with integrated magneto-optical drive for later measurements and analysis.
The full-planar (contour) method was used for volume measurements. The examinations were done by two observers (C.Y. and M.S.) experienced in pelvic ultrasonography. The measurements were done by only one observer (C.Y.). The volume was computed from several parallel cross-sections from the fundal part of the endometrium to the concentration of the internal os.
Statistical analysis
Receiver operating characteristic (ROC) curve analysis was used. The ROC curve represents the probability of true positive results (sensitivity) as a function of the probability of false positive results (1specificity).
For this reason, the decision criterion (cut-off point) has to be set at each different point of the decision axis and the sensitivity and specificity for these points have to be calculated. The possible combinations of sensitivity and specificity obtained when varying the cut-off point are combined into the area under the curve (AUC). The AUC (sensitivity/1 specificity) measures how good (AUC close to 1) or how poor (AUC close to 0.5) a test is.
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Results |
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Discussion |
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Two methods are available for 3D volume calculation, the three-distance and the full-planar (contour) method. In a previous study we found good reproducibility for both methods, though the reproducibility for the full-planar method was slightly higher (Yaman et al., 1999). With full-planar mode, organs can be visualized in several 2D viewing planes, but in contrast to 2D ultrasound more than one plane can be studied simultaneously. By using this method, the endometrium was investigated by stepping through the volume data in small units.
The assumption that 3D ultrasound can serve as a useful clinical marker for diagnosis of pathologies has been confirmed (Gruobeck et al., 1996). In that study, the diagnostic value of endometrial thickness and volume measurements by 3D ultrasound were tested in patients with postmenopausal bleeding. 3D volume was superior to 2D endometrial thickness in predicting endometrial cancer.
The main clinical finding of this study was that the state of relative hypo-oestrogenism after pituitary down-regulation can be diagnosed by 3D ultrasound with a high sensitivity and specificity if an endometrial volume cut-off value from 1.9 ml was used. Conversely, the endometrial thickness measurement by 2D ultrasound was also able to confirm the down-regulation with a high sensitivity if the cut-off value from 5.8 mm endometrial thickness was used.
The predictive value of ultrasound was poor if strong down-regulation or absolute hypo-oestrogenism defined as oestradiol <40 pg/ml was to be achieved.
The question of the proper criteria for the degree of down-regulation of the pituitaryovarian axis has not yet been answered. It has been reported (Jenkins et al., 1992) that oestradiol <55 pg/ml was the 95th percentile established for 727 IVFembryo transfer cycles without ovarian cysts. However, the optimum value for oestradiol concentration before commencing ovarian stimulation has not been defined, and criteria may vary from oestradiol <2080 pg/ml among different groups (Sampaio et al., 1991
; Golan et al., 1994
; Calhaz-Jorge et al., 1995
; Dantas et al., 1996
).
The data of 570 consecutive IVFembryo transfer cycles in which down-regulation with GnRH analogue long protocol was performed revealed no significant difference in fertilization rates of patients with oestradiol <50 or oestradiol >50 and <100 pg/ml (Calhaz-Jorge et al., 1995).
Based on this report and on the results of the present study, it may be assumed that pituitary down-regulation after GnRH analogue administration can be diagnosed by 3D volume calculation. Furthermore, the study documented that diagnosis of pituitary down-regulation can also be performed by 2D endometrial thickness measurements. Similarly, it has been reported (Barash et al., 1998) that the state of relative hypo-oestrogenism can be predicted by transvaginal ultrasonographic measurement of endometrial thickness with a positive predictive value of 95.9%. Therefore, routine testing for serum oestradiol concentration seems not to be necessary for diagnosis of down-regulation in patients undergoing IVFembryo transfer.
The ability to quantify accurately the endometrial volume using 3D ultrasound did not help us to predict the oestrogen status with a higher value than 2D ultrasound. We suggest that endometrial volume calculation by 3D ultrasound provides more accuracy than 2D ultrasound in measurement of asymmetrical organs. After down-regulation, the endometrium is a thin symmetrical structure (Figure 1), which may be quantified by 2D ultrasound as well as by 3D ultrasound.
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Notes |
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References |
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Submitted on February 22, 2000; accepted on May 2, 2000.