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a Chapter 38 Three-Dimensional Doppler Ultrasound in Gynecology 561
during the transition from early to mid-secretory
phase. The FI showed a similar pattern but with a
longer nadir post-ovulation. Smoking was associated
with a significantly lower VI and VFI. The FI was significantly
lower in women aged ³31 years and significantly
higher in parous patients. The authors concluded
that endometrial vascularity, as assessed by
3D Doppler, varies significantly during the menstrual
cycle and is characterized by a pre-ovulatory peak
and post-ovulatory nadir during the peri-implantation
window.
Three-dimensional power Doppler has been largely
used for the subjective assessment of vascular patterns,
but semiquantification of the power Doppler signal is
now possible. Raine-Fenning et al. addressed the intraobserver
and interobserver error of the semiquantification
of pelvic blood flow using 3D Doppler, VOCAL,
and shell imaging [6]. The 3D Doppler was used to acquire
20 ovarian and 20 endometrial volumes from 40
different patients at various stages of in vitro fertilization
treatment. The VOCAL was then used to delineate
the 3D areas of interest and the ªhistogram facilityº
employed to generate three indices of vascularity: the
VI; the FI; and the VFI. Intraobserver and interobserver
reliability was assessed by two-way, mixed, intraclass
correlation coefficients (ICCs) and general linear
modeling was used to examine for differences in the
mean values between each observer. The intraobserver
reliability for both observers was extremely high and
there were no differences in reliability between the observers
for measurements of both volume and vascularity
within the ovary or endometrium and its shells.
With the exception of the outside sub-endometrial
shell volumes, there were no significant differences between
the two observers in the mean values obtained
for either endometrial or ovarian volume and vascularity
measurements. The interobserver reliability of measurements
was equally high throughout with all measurements
obtaining a mean ICC of above 0.985. They
concluded that 3D Doppler and shell imaging offer a
reliable, practical, and non-invasive method for the assessment
of ovarian, endometrial, and sub-endometrial
blood flow. Future work should concentrate upon confirming
the reliability of data acquisition and the validity
of the technique before its predictive value can be
truly tested in prospective clinical studies.
Vlaisavljevic et al. wanted to study whether they
might predict the outcome of unstimulated in vitro
fertilization/intracytoplasmic sperm injection (IVF/
ICSI) cycles with quantitative indices of perifollicular
blood flow assessed with 3D reconstruction of power
Doppler images [7]. This prospective study included
an analysis of 52 unstimulated cycles. Color and
power Doppler ultrasound examinations of a single
dominant preovulatory follicle were performed on the
day of oocyte pick-up. With 3D reconstruction and
processing, quantitative indices were obtained, i.e.,
the percentage of volume showing a flow signal (VFS)
inside a 5-mm capsule of perifollicular tissue and the
percentage of VFS of each of the three largest vessels
in this capsule. These indices as well as pulsed Doppler
indices were compared between the groups of
cycles with different outcomes using a one-way analysis
of variance test. In nine cycles no oocyte was retrieved
(group A), in seven cycles no fertilization occurred
(group B), and in 30 cycles no implantation
occurred (group C). Six cycles resulted in pregnancy
(group D). There were no statistically significant differences
in pulsed and power Doppler indices between
these groups; however, the percentage of VFS
in the capsule was higher than average in cycles with
implantation and the percentage of VFS in the main
vessel exhibited lower than average values in cycles
with implantation, but only reached borderline statistical
significance. It can be hypothesized that the follicles
containing oocytes able to produce a pregnancy
have a distinctive and more uniform perifollicular
vascular network.
Other authors also looked at 3D Doppler of the
ovary and relationship with hormonal status in IVF
patients. Wu et al. investigated, in a retrospective
study, whether the quantification of ovarian stromal
blood flow and/or leptin concentration are predictive
of IVF outcomes in women after laparoscopic ovarian
cystectomy for large endometriomas [8]. Twenty-two
women undergoing IVF after laparoscopic surgery for
ovarian endometriomas (> 6 cm) comprised the study
group. Twenty-six women with tubal factor infertility
constituted the control group. Ovarian stromal blood
flow was evaluated by 3D power Doppler ultrasound
imaging using VOCAL. Serum and follicular fluid
(FF) leptin concentrations were quantified using an
enzyme-linked immunosorbent assay kit. There were
significantly decreased ovarian stromal blood flow
parameters (including VI, FI, and VFI) in the endometriosis
group without an evident difference in total
ovarian volume on the day of human chorionic gonadotropin.
The value of FF leptin demonstrated a negative
correlation with ovarian stromal FI in the control
group, but there was a loss of this effect in the
endometriosis group. It appeared that the quantification
of ovarian stromal blood flow by 3D power Doppler
ultrasound in women with endometriosis may
provide an important prognostic indicator in those
undergoing IVF.
Kupesic and Kurjak designed the study to evaluate
whether ovarian antral follicle number, ovarian volume,
stromal area, and ovarian stromal blood flow
are predictive of ovarian response and IVF outcome
[9]. A total of 56 women with normal basal serum
FSH concentrations who had no history of ovarian
surgery and no ovarian and/or uterine pathology