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Antral Follicle Count As a Predictor of Ovarian Response

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Antral Follicle Count As a Predictor of Ovarian Response Original article Antral follicle count as a predictor of ovarian response N. Lonegroa, N. Napolia,*, R. Pesceb and C. Chacóna a Imaging Department, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina b Gynecology Department, Hospital Italiano de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina Received the 28th of June of 2016; accepted the 1st of October of 2016 *Corresponding author. E-mail: [email protected] (N. Napoli) Abstract Objective: To evaluate the relationship between the number of antral follicles at baseline and the number of oocytes retrieved after ovarian stimulation treatment, and to establish the role of antral count follicles by ultrasonography as a predictor of ovarian response. As a secondary objetive we assessed the correlation of antral follicle count with the age of patients and the success of treatment. Materials and methods: We retrospectively evaluated 40 women undergoing transvaginal ultrasonography guided follicular aspiration between January and March 2015. Transvaginal ultrasonography follicle count was performed prior to antral follicles stimulation, (only follicles measuring between 3 and 8 mm were considered). All patients received hormonal stimulation and were monitored with ultrasonography and hormonal blood tests until follicle aspiration. Results: A strong inverse correlation between patient age and antral follicle count and a very strong inverse correlation between age and oocyte retrieval was observed. A very strong positive correlation between the antral follicle count and the number of oocytes retrieved in the transvaginal aspiration was also observed. The small number of patients limited the analysis of treatment success. Conclusion: The antral follicle count had significant associations with ovarian response and the number of oocytes retrieved. The antral follicles count by ultrasonography should be considered the first choice for ovarian reserve testing because of its low cost, good performance and accessibility. © 2016 Published by Elsevier España, S.L.U. on behalf of Sociedad Argentina de Radiolog´ıa. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). Keywords: Ultrasonography; Fertility; Ovarian follicle; Ovarian reserve. Introduction cause of their small size, these follicles might only be assessed by histologic exploration4. The success of in vitro fertilization (IVF) and embryo transfer Primordial follicles initiate folliculogenesis in the ovary, pro- depends, among other factors, on the number of oocytes gressing to primary, secondary or preantral follicles, which retrieved after ovarian stimulation through various drugs (ex- cannot be identified on ultrasound examination. A propor- ogenous gonadotropins, gonadotropin-releasing hormone, tion of follicles develops into antral follicles, which are sensi- clomiphene citrate, etc.)1 In turn, the number of oocytes re- tive to follicle-stimulating hormone (FSH), can be identified trieved after ovarian stimulation is associated with the num- by ultrasound, and progressively reaches the preovulatory ber of oocytes available for ovulation in the ovary and with status. The number of these follicles can be quantified by the chronological age of the patient2,3. gonadotropins measurement (FSH, basal estradiol, luteinizing Women are born with a finite number of eggs, which are used hormone), especially by the anti-Mullerian hormone (AMH), throughout their reproductive life and decline in quality and together with the determination of the number of follicles quantity with age. The possibility of identifying the number of with developing antrum in the ovary by ultrasound. follicles available and measuring ovarian function would allow AMH is produced in the adult ovary by the granulosa cells of estimation of the patient’s reproductive potential. small (primordial, primary and secondary) follicles until the In this respect, the true ovarian reserve is represented by the preantral status. It has an inhibitory and protective effect in number of primordial or resting follicles in both ovaries. Be- folliculogenesis, but most of all, it reflects in a reliable man- 252 Rev. Argent. Radiol. 2016;80(4): 252-257 N. Lonegro et al. ner the resting follicle pool. AMH is considered the marker of The risk of hyper-response is associated with over 10 antral choice of the follicle count. follicles in each ovary, while a poor response is associated Several authors agree that antral follicle count (AFC) by with an antral follicle count of less than 10 in total (poor transvaginal ultrasound before ovarian stimulation is the best ovarian reserve). Another ultrasound parameter is ovarian predictor of response to assisted reproduction treatment cy- volume measurement, although its usefulness remains con- cles3-9. Thus, AFC at the beginning of the ovarian cycle may troversial. This measurement is included in the initial evalua- provide information about the reserve, but also about the tion of the patient, with an ovarian volume of less than 3 cm3 type of response to ovarian stimulation. The ovarian reserve being associated with a high likelihood of failure in treatment is considered to be adequate when the number of antral response4. follicles (3-8 mm) identified in each ovary is greater than or Identifying women at a higher risk of poor ovarian response equal to 5. before treatment is useful for choosing an adequate thera- a b c d Figure 1 Transvaginal ultrasounds for antral follicle count: (a) ovary (arrows) with no antral follicle; (b) ovary with one antral follicle (arrow); (c) round anechoic images representing antral follicles; and (d) measurement of the internal diameter of the follicle (arrow). Rev. Argent. Radiol. 2016;80(4): 252-257 253 Antral follicle count as a predictor of ovarian response peutic management and adjusting the dose of medication, 1. Identify the ovary. thus optimizing ovarian response. Once treatment has been 2. Explore the dimensions in two planes. initiated, monitoring is performed by ultrasound to assess 3. Carefully examine the entire ovary in the anterior-posterior ovarian response to gonadotropin stimulation. This follow- and sagittal-parasagittal directions in order to count all vis- up is functionally supplemented with measurement of serum ible antral follicles. estradiol levels during stimulation, allowing identification of The number of follicles was quantitatively tabulated and pa- the type of response (poor or high) and of the associated risk tients were divided into four groups according to their antral of clinical complications1,5. follicle (AF) count, in a similar way to that reported by Huang The objective of this study was to evaluate the relationship et al.10: group A, less than 5 AFs; group B, 6- 10 AFs; group between the number of antral follicles at baseline and the C, 11-15 AFs, and group D, more than 16 AFs. number of oocytes retrieved after treatment, and to establish the role of AFC as a predictor of ovarian response. In addi- tion, we sought to determine if there is a correlation between Monitoring and follow-up AFC and the age of patients and treatment success. Following the baseline count of AFs, patients underwent stimulation with a flexible antagonist protocol. In the early follicular phase , patients received recombinant follicle-stim- Materials and methods ulating hormone (FSHr; Puregon, Organon Laboratory ) in individually adjusted doses, starting on day 2 of their cycle. Ethical considerations Follow-up ultrasound scans and estradiol measurements All study procedures were standard of care and all study data were performed during stimulation. With follicles larger than were blinded and managed with the highest level of con- 14 mm (average diameter) by ultrasound and a complemen- fidentiality, with access being restricted only to authorized tary correlation with plasma estradiol levels, daily administra- personnel for the purpose of the study in accordance with tion of gonadotropin-releasing hormone (GnRH; cetrorrelix the provisions of Personal Data Protection Act 25326/00 and 0.25 mg/ml, Orgalutran, Organon) antagonists was initiated, Act 26529/09 currently in force in Argentina. The final manu- in combination with 75 IU/day of human menopausal go- script was reviewed and approved by the Institutional Bioeth- nadotropin (HMG; Menopur, Ferring). ics Committee. With follicles larger than 17 mm in diameter on average, measured by ultrasound, ovulation trigger with human cho- rionic gonadotropin (hCG: 5000 to 10,000 IU) or GnRH ago- Study population and equipment nists (Triptorelin Acetate, Ferring) was scheduled with the aim In this cross-sectional retrospective study conducted in our of achieving the ovulatory changes required. institution, we evaluated candidates for follicular aspiration Follicle aspiration was scheduled 34 to 36 hours after trigger. who had had a transvaginal ultrasound performed for a base- The amount of oocytes retrieved in each patient was tabu- line antral follicle count before stimulation during the period lated and analyzed. The presence of pregnancy after transfer between January and March 2015. The age and reason for was recorded. ovarian stimulation were tabulated. Statistical analysis Study protocol The transvaginal ultrasounds of patients enrolled in this study Categorical variables were reported as proportions with con- were performed by four physicians specialized in radiology fidence intervals (CI), while continuous variables were report- with expertise
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