Ultrasound imaging in reproductive medicine

One in six couples seeks help for infertility during their reproductive years. Subfertility investigations should be performed without delays (because female fertility decreases with age) and should be as noninvasive as possible. Many fertility clinics use diagnostic hysteroscopy to assess the uterine cavity and evaluate the tubal ostia. Laparoscopy is also often used to examine internal pelvic organs and to assess tubal patency. However, both hysteroscopy and laparoscopy are invasive and expensive tests which could be replaced by transvaginal ultrasound examination. Simplified ultrasound-based infertility investigation protocols have been described. The concept of a ‘pivotal’ pelvic ultrasound examination includes an examination of the uterus and uterine cavity, endometrium, ovarian morphology and follicular size, blood flow in the uterus and ovaries and hystero-contrast sonography (HyCoSy) to check tubal patency, all performed at the same examination. The late preovulatory phase of the menstrual cycle (days 8–12) is usually suggested as the optimal time to perform these examinations. Most studies involving the ultrasound techniques referred to in this chapter are classified as evidence grade B. The aim of the pivotal scan is to assess the uterus, endometrium, fallopian tubes and ovaries. Ultrasound examination is as effective a diagnostic test as hysteroscopy or laparoscopy for the diagnosis of uterine abnormalities. Normal findings at ultrasound examination of the uterus and endometrium are described in Chapter 2. Uterine size and shape may be affected by ade-nomyosis or fibroids. The shape of the uterus can be also be distorted by congenital uterine anomalies

Inter-observer agreement in describing the ultrasound appearance of adnexal masses and in calculating the risk of malignancy using logistic regression models.

Purpose: To estimate inter-observer agreement with regard to describing adnexal masses using the International Ovarian Tumor Analysis (IOTA) terminology and the risk of malignancy calculated using IOTA logistic regression models LR1 and LR2, and to elucidate what explained the largest inter-observer differences in calculated risk of malignancy. Experimental Design: 117 women with adnexal masses were examined with transvaginal gray scale and power Doppler ultrasound by two independent experienced sonologists who described the masses using IOTA terminology. The risk of malignancy was calculated using LR1 and LR2. A predetermined risk of malignancy cutoff of 10% indicated malignancy. Results: There were 94 benign, four borderline and 19 invasively malignant tumors. There was substantial variability between the two sonologists in measurement results and some variability in assessment of categorical variables (agreement 40-98%, Kappa 0.30-0.91). Inter-observer agreement when classifying tumors as benign or malignant was 84% (98/117), Kappa 0.68 for LR1, and for LR2 85% (99/117), Kappa 0.68. When using LR1 and LR2 the inter-observer difference in calculated risk was >25 percentage units in 9% (11/117) and 12% (14/117) of tumors, respectively. Differences in assessment of wall irregularity, acoustic shadowing, color score and color flow in papillary projections explained most of these largest differences. Conclusions: Inter-observer agreement in classifying tumors as benign or malignant using the risk of malignancy cut off of 10% for LR1 and LR2 was good. However, because risks estimates may differ substantially between sonologists one should be cautious with using the risk value for counseling patients about their individual risk

Interobserver agreement in the results of Doppler examinations of extrauterine pelvic tumors

The aim of this study was to evaluate interobserver agreement in the results of Doppler measurements of peak systolic velocity (PSV), time-averaged maximum velocity (TAMXV) and the color content of tumor scans in extrauterine pelvic tumors. The results of transvaginal color and spectral Doppler examinations of 66 extrauterine pelvic masses obtained by two observers experienced in ultrasonography were compared. Each observer aimed to obtain the highest possible Doppler shift from arteries in the wall, septa and solid parts of each tumor. Tumor vascularization was assessed in terms of the 'tumor color score', i.e. the color content of the Doppler scan as rated for the tumor as a whole by each observer on a visual analog scale. The tumors were classified according to arbitrarily chosen cut-off limits for the tumor color score, the highest tumor TAMXV and the highest tumor PSV. Inter-class correlation coefficient values for TAMXV and PSV were < or = 0.75, whereas that for tumor color score was 0.89. Interobserver agreement was complete for the detection of color in tumors (Kappa value 1.0), excellent for the recording of arterial Doppler shift spectra from tumors (Kappa value 0.82), and moderate or good for classifying tumors based on cut-off limits for TAMXV, PSV (Kappa values ranging from 0.44 to 0.67) and tumor color score (Kappa values ranging from 0.59 to 0.66).(ABSTRACT TRUNCATED AT 250 WORDS

Reproducibility of Doppler measurements of blood flow velocity in the uterine and ovarian arteries in premenopausal women

Intra- and interobserver reproducibility of Doppler measurements of the pulsatility index (PI) and time-averaged maximum velocity (TAMXV) in the uterine and ovarian arteries were evaluated in examinations of healthy premenopausal women. Each woman underwent reproducibility measurements once in the late follicular phase and once in the midluteal phase. Intraobserver repeatability was assessed in examinations of 12 women, three replicate Doppler measurements being made by one observer in the same vessel. Interobserver agreement was assessed by comparing the results of Doppler measurements made by two investigators in 11 women. The intraclass correlation coefficient (Intra-CC) was 0.78 for the TAMXV in the dominant uterine artery in the follicular phase and 0.82 for the PI in the wall of the dominant follicle. For all other measurements the Intra-CC was 0.75 (0.79 to 0.88) for the PI and TAMXV in the dominant uterine artery in the follicular phase and for the PI of both uterine arteries in the luteal phase. For all other measurements the Inter-CC was < 0.75

Prospective validation of two mathematical models to calculate the risk of endometrial malignancy in patients with postmenopausal bleeding and sonographic endometrial thickness ≥4.5 mm

AIM: To prospectively validate two mathematical models for calculating the likelihood of endometrial malignancy in patients with postmenopausal bleeding (PMPB), sonographic endometrial thickness (ET) ≥4.5 mm and no fluid in the uterine cavity.METHODS: This is a prospective observational diagnostic validation study performed in a PMPB clinic in a university hospital. Of 860 consecutive patients, 350 fulfilled our inclusion criteria. A standardized history was taken, clinical and transvaginal grey scale and power Doppler ultrasound examinations were performed following a research protocol. The percentage vascularized area of the endometrium at power Doppler examination (VI) was calculated using computer software. The colour content of the endometrial scan was estimated subjectively on a visual analogue scale (VAS). Gold standard was the histological diagnosis of the endometrium. Main outcome measures were area under the receiver operating characteristic curve (AUC), sensitivity and specificity when using the cut-offs suggested in the original study, and calibration curves.RESULTS: Eighty (23%) patients had malignant endometrium. The performance of the models was similar to that in the original study. The model including patient's age, use of hormone therapy, ET and VAS performed best (AUC 0.91; 95% confidence interval [CI] 0.87-0.95; sensitivity 70%, specificity 93%). The model including ET, VI, patient's age and hormone therapy use had AUC 0.89 (95% CI 0.84-0.93; sensitivity 79%; specificity 81%). ET had AUC 0.83 (95% CI 0.78-0.88). The models were reasonably well calibrated.CONCLUSION: On prospective validation both models retained their diagnostic performance. This suggests that they are robust and potentially clinically useful for individualized patient management

Intra- and inter-observer agreement when describing adnexal masses using the International Ovarian Tumour Analysis (IOTA) terms and definitions: a study on three-dimensional (3D) ultrasound volumes.

Objectives: To estimate intra-observer repeatability and inter-observer agreement in 1) describing adnexal masses using the International Ovarian Tumor Analysis (IOTA) terms and definitions, 2) the risk of malignancy calculated using IOTA logistic regression models LR1 and LR2, 3) the diagnosis made on the basis of subjective assessment of ultrasound images. Methods: One hundred and three adnexal masses were examined with transvaginal gray scale and power Doppler ultrasound using a GE Voluson 730 Expert system. Three-dimensional ultrasound volumes of the mass were saved. After 12-18 months the volumes were analyzed twice 1-6 months apart by each of two independent experienced sonologists who used the IOTA terms and definitions to describe the masses. The risk of malignancy was calculated using LR1 and LR2. The sonologists also classified the masses as benign or malignant using subjective assessment. Results: Eighty-four masses were benign, eight borderline and 11 invasively malignant. There was substantial variability within and between observers in the results of measurements included in LR1 and LR2 and some variability also when assessing categorical variables included in the models (agreement 51-100%, Kappa 0.42 -1.00). This resulted in substantial variability in the calculated risk of malignancy, the limits of agreement indicating that the calculated risk of malignancy could vary by a factor of five to twenty within and between observers. The reliability of the calculated risk of malignancy was moderate (LR1) or poor (LR2) when the calculated risk of malignancy was > 10% (intra-class correlation coefficients varying from 0.21 to 0.73). Inter-observer agreement when classifying tumors as benign or malignant using the predetermined risk of malignancy cut-off of 10% was fair to good (agreement 85%, Kappa 0.61 for LR1; agreement 81%, Kappa 0.52 for LR2). Intra- and inter-observer agreements for subjective assessment were 96%, 96% and 96% with Kappa values of 0.89, 0.87 and 0.88. Conclusions: Intra- and inter-observer agreement in classifying tumors as benign or malignant using the risk of malignancy cut off of 10% for LR1 and LR2 was fair or good, while the reproducibility of subjective assessment was excellent. The reliability of calculated risks > 10% was poor, and calculated risk > 10% cannot be used to discriminate between individuals at different risk. These results cannot be extrapolated to real-time ultrasound examinations. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd

Transvaginal ultrasound examination of the endometrium in postmenopausal women without vaginal bleeding.

To estimate in gynecologically asymptomatic postmenopausal women with and without hormone replacement therapy (HRT) the prevalence at transvaginal ultrasound examination of 1) endometrial thickness ≥5.0mm, 2) intrauterine focal lesions if endometrial thickness ≥5.0mm, and 3) premalignant and malignant changes in the endometrium if endometrial thickness is ≥5.0mm and intrauterine focal lesions are present

Blood flow velocity in the uterine and ovarian arteries during menstruation

Eleven healthy women with regular menstrual cycles were examined with a combination of two-dimensional real-time ultrasound and color and spectral Doppler techniques on the 7th day after follicular rupture, and on the 1st, 2nd, 3rd and 4th days of menstrual bleeding. Both uterine arteries, arteries in the stroma and hila of both ovaries, in the wall of the largest follicle of the non-dominant ovary and in the wall of the corpus luteum were examined with the Doppler technique. The pulsatility index (PI) and the time-averaged maximum velocity were calculated. In the uterine arteries, the PI was highest on the first day of menstrual bleeding (median PI 3.2 for the dominant and 3.0 for the non-dominant uterine artery), after which it decreased to its lowest values on the second day (median PI 2.1 and 1.8, respectively) and third day (median PI 2.2 and 2.1, respectively). The time-averaged maximum velocity reached its highest value on the second and third days of menstruation. The corpus luteum was still visible on the first day of menstrual bleeding in all women, and on the second day in five. It was indistinguishable on the third and fourth days of menstruation in all women. In the dominant ovary, the time-averaged maximum velocity of flow in the arteries in the ovarian hilum decreased during menstrual bleeding and was lower during menstruation than in the preceding luteal phase. In the non-dominant ovary, neither the PI nor the time-averaged maximum velocity manifested any consistent changes during the period studied. We conclude that substantial changes in PI and time-averaged maximum velocity occur in the uterine arteries and in the arteries of the dominant ovary during menstruation