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The antral follicle count (AFC) correlates with metaphase II oocytes and ART cycle outcome: an update
Materials/Methods: Lesions resected from women participating in an IRB- approved clinical trial of a new treatment for endometriosis were formalin fixed, paraffin embedded, cut and evaluated by H&E staining. We evaluated CD10 IHC in 22 women [aged 20 – 45 years (38 ⫾ 8 years: means ⫾ SD)] with 44 lesions that were negative and 32 that were positive on H&E. We included a disproportionately higher number of negative specimens to test whether CD10 might improve diagnostic sensitivity. CD10 IHC was performed on paraffin-fixed sections using a monoclonal anti-CD10 (Novacastra, clone 56C6) at 1:20 dilution, with a streptavidinbased detection system (Ventana). For each woman, an endometrial biopsy obtained at the same surgery served as a positive control. When CD10 IHC was positive, a pathologist examined the corresponding H&E staining to determine if the initial diagnosis was correct. We used Fishers exact test with Statview software to compare the number of lesions considered positive for endometriosis by each method. Two-tailed p ⬍0.05 was considered significant. Sample size was determined by study interval and sample availability, and not by power analysis. Results: The addition of CD10 IHC detected more positive endometriosis lesions than H&E staining alone (54% vs 42%, p ⬍0.0001). Of 44 specimens judged negative by H&E staining, CD10 staining was diagnostic of endometriosis in 9 and suggestive in 3 cases that could not be confirmed because of the presence of inflammation. CD10 and H&E staining were concordant in the remaining 32 negative and 32 positive specimens. CD10 was present in the stroma of all endometrial biopsies. 16 women had a pathologic diagnosis of endometriosis by H&E staining. The stage of disease by inspection at surgery was minimal (n ⫽ 10), mild (n ⫽ 4), moderate (n⫽1) and severe (n ⫽ 2) using the revised ASRM (American Society of Reproductive Medicine) classification. (One woman had two procedures.) Six women with negative H&E results had no (n ⫽ 2) or minimal (n ⫽ 4) endometriosis at surgery; two of those with minimal disease had positive CD10 IHC. Conclusions: This study shows that the adjunctive use of CD10 improves diagnostic sensitivity compared to H&E alone. However, since the positive diagnoses from H&E staining were unchanged, perhaps CD10 should be used only to verify negative results, so as to minimize additional expense. In this setting it may improve diagnostic accuracy for women with minimal endometriosis, which is essential for determining proper treatment. Supported by: Division of Intramural Research, NICHD, NIH.
IMAGING IN REPRODUCTIVE MEDICINE SPECIAL INTEREST GROUP Wednesday, October 16, 2002 2:00 P.M. O-235 The antral follicle count (AFC) correlates with metaphase II oocytes and ART cycle outcome: An update. Jeffrey D. Fisch, G. Sher. Sher Institute for Reproductive Medicine, Las Vegas, NV; Sher Institute for Reproductive Medicine, and Dept of Ob/Gyn, Univ of Nevada Sch of Medicine, Las Vegas, NV. Objective: We reported the antral follicles count (AFC) correlated with Metaphase II (MII) oocytes obtained in that cycle among an initial cohort of 80 patients. Since then, we have accumulated data on an additional 120 patients. This update correlated the AFC with MII oocytes recovered in that cycle and with the cycle outcome among a large cohort. Design: Prospective, observational study in a private practice setting. Materials/Methods: Infertile couples undergoing treatment with ART (n ⫽ 200) had a baseline ultrasound evaluation prior to ovarian stimulation to exclude cyst formation. Recombinant gonadotropins were used for ovarian stimulation after pituitary desensitization with a GnRHa in a long protocol. Ovulation was triggered with hCG when 2 follicles measured ⱖ18mm in diameter and half the remainder were ⱖ15mm. Oocytes were recovered transvaginally under ultrasound guidance 34 –35 hours later. Antral follicles visualized at baseline evaluation were counted and correlated with the MII oocytes retrieved in that cycle using a Pearson coefficient. Differences in rates were analyzed using Chi-square tests. Significance was set at p ⬍0.5. Results: The mean patient age was 32 years (range: 19 – 44). Mean cycle day 3 FSH level was 6.8mIU/ml (range: 1.7–18). The number of antral follicles seen on baseline ultrasound (mean: 15; range: 4 –35) correlated
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strongly with the number of MII oocytes recovered in that cycle (mean: 14; range: 2– 47)(r ⫽ 0.80; p ⬍0.001), while other predictors of response to stimulation, (such as follicles number ⱖ15mm in diameter or peak Estradiol level), were less predictive of response. Overall pregnancy and implantation rates were 41% and 24%, respectively. Patients with an AFC ⱖ20 had significantly higher pregnancy and implantation rates (67% and 32%) than patients with an AFC ⬍10 (24% and 18%) or AFC⫽10 –19 (36 and 22%). Conclusions: Assessment of antral follicle number on baseline ultrasound prior to ovarian stimulation for ART is easy to perform and correlates well with the number of mature oocytes that will be recovered in that cycle. The AFC may be a better predictor of ovarian response than traditional indicators of ovarian reserve, and could be used alone or in conjunction with these parameters to titrate medication dosages, and determine the optimal number of embryos to transfer. Many factors influence pregnancy beyond the number of mature oocytes. However, routinely canceling “poor responders” cannot be recommended, since 24% of patients with an AFC ⬍10 developed an ongoing gestation. Supported by: None.
Wednesday, October 16, 2002 2:15 P.M. O-236 Transcervical tubal catheterization (TTC) is the treatment of choice for infertile women with proximal tubal obstruction: An experience with 1010 fallopian tubes. Ilan Tur-Kaspa, Oana Moscovici, Simon Meltzer, Ronit Peled, Jacob Rabinson, Shmuel Segal. IVF Unit, Dept of Ob/Gyn, Barzilai Medical Ctr, Ben-Gurion Univ, Ashkelon, Israel; Dept of Radiology, Barzilai Medical Ctr, Ben-Gurion Univ, Ashkelon, Israel; Epidemiology Research Institute, Barzilai Medical Ctr, Ben-Gurion Univ, Ashkelon, Israel; Dept of Ob/Gyn, Barzilai Medical Ctr, Ben-Gurion Univ, Ashkelon, Israel. Objective: To prospectively evaluate the impact of transcervical tubal catheterization (TTC) procedures, as new medical technology, on patient counseling and management, in a large cohort of infertile women with proximal tubal obstruction (PTO). Design: Prospective observational study. Materials/Methods: 625 infertile women with bilateral (61.6%) or unilateral (38.4%) PTO underwent TTC. Patients with 3.7 (1–22) years of primary (23%) or secondary (77%) infertility were referred from all over the country (the author, from the Barzilai Medical Center, performed the TTC procedures at the Barzilai, Sheba, and Assuta Medical Centers, Israel). TTC is an ambulatory procedure performed under fluoroscopic observation. A coaxial catheters system (Cook Ob/Gyn) was used to perform an hysterosalpingogram and selective salpingography, before and after tubal catheterization with a soft tip guide-wire. Results: In 86% of the patients, at least one obstructed fallopian tube was successfully recanalized by TTC. Out of 1010 proximally obstructed fallopian tubes, 82% were successfully recanalized. Five cases (0.8%) were treated later for suspected PID, while one of them conceived spontaneously the following month. Because of the TTC results, 86% of patients was recommended to try to conceive naturally. 330 consecutive patients were followed after the procedure, by a telephone questioner, for a follow-up of 1719 women’s months. They obtained a 41% of intrauterine pregnancy rate (with only 1.4% of ectopic pregnancy rate). The cumulative pregnancy rates were 71% for women aged 20 –29 years, 52% for age 30 –39, and 18.5% for women aged ⱖ40 (p ⫽ 0.03; p ⫽ 0.0002 for trend). Conclusions: TTC has a major impact on the management and counseling of infertile women with PTO. After TTC, 86% of patients are recommended to try to conceive naturally, instead of being referred for laparoscopy or ART. TTC is a safe and cost effective procedure. TTC should be recommended as first choice for further diagnosis and treatment to all infertile women with bilateral or unilateral PTO. Supported by: No support.
Wednesday, October 16, 2002 2:30 P.M. O-237 Endometrial sampling during sonohysterography (SHGes) in the management of abnormal uterine bleeding. Francesco Paolo Giuseppe Le-
Vol. 78, No. 3, Suppl. 1, September 2002
IMAGING IN REPRODUCTIVE MEDICINE SPECIAL INTEREST GROUP Wednesday, October 16, 2002 2:00 P.M. O-235 The antral follicle count (AFC) correlates with metaphase II oocytes and ART cycle outcome: An update. Jeffrey D. Fisch, G. Sher. Sher Institute for Reproductive Medicine, Las Vegas, NV; Sher Institute for Reproductive Medicine, and Dept of Ob/Gyn, Univ of Nevada Sch of Medicine, Las Vegas, NV. Objective: We reported the antral follicles count (AFC) correlated with Metaphase II (MII) oocytes obtained in that cycle among an initial cohort of 80 patients. Since then, we have accumulated data on an additional 120 patients. This update correlated the AFC with MII oocytes recovered in that cycle and with the cycle outcome among a large cohort. Design: Prospective, observational study in a private practice setting. Materials/Methods: Infertile couples undergoing treatment with ART (n ⫽ 200) had a baseline ultrasound evaluation prior to ovarian stimulation to exclude cyst formation. Recombinant gonadotropins were used for ovarian stimulation after pituitary desensitization with a GnRHa in a long protocol. Ovulation was triggered with hCG when 2 follicles measured ⱖ18mm in diameter and half the remainder were ⱖ15mm. Oocytes were recovered transvaginally under ultrasound guidance 34 –35 hours later. Antral follicles visualized at baseline evaluation were counted and correlated with the MII oocytes retrieved in that cycle using a Pearson coefficient. Differences in rates were analyzed using Chi-square tests. Significance was set at p ⬍0.5. Results: The mean patient age was 32 years (range: 19 – 44). Mean cycle day 3 FSH level was 6.8mIU/ml (range: 1.7–18). The number of antral follicles seen on baseline ultrasound (mean: 15; range: 4 –35) correlated
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Abstracts
strongly with the number of MII oocytes recovered in that cycle (mean: 14; range: 2– 47)(r ⫽ 0.80; p ⬍0.001), while other predictors of response to stimulation, (such as follicles number ⱖ15mm in diameter or peak Estradiol level), were less predictive of response. Overall pregnancy and implantation rates were 41% and 24%, respectively. Patients with an AFC ⱖ20 had significantly higher pregnancy and implantation rates (67% and 32%) than patients with an AFC ⬍10 (24% and 18%) or AFC⫽10 –19 (36 and 22%). Conclusions: Assessment of antral follicle number on baseline ultrasound prior to ovarian stimulation for ART is easy to perform and correlates well with the number of mature oocytes that will be recovered in that cycle. The AFC may be a better predictor of ovarian response than traditional indicators of ovarian reserve, and could be used alone or in conjunction with these parameters to titrate medication dosages, and determine the optimal number of embryos to transfer. Many factors influence pregnancy beyond the number of mature oocytes. However, routinely canceling “poor responders” cannot be recommended, since 24% of patients with an AFC ⬍10 developed an ongoing gestation. Supported by: None.
Wednesday, October 16, 2002 2:15 P.M. O-236 Transcervical tubal catheterization (TTC) is the treatment of choice for infertile women with proximal tubal obstruction: An experience with 1010 fallopian tubes. Ilan Tur-Kaspa, Oana Moscovici, Simon Meltzer, Ronit Peled, Jacob Rabinson, Shmuel Segal. IVF Unit, Dept of Ob/Gyn, Barzilai Medical Ctr, Ben-Gurion Univ, Ashkelon, Israel; Dept of Radiology, Barzilai Medical Ctr, Ben-Gurion Univ, Ashkelon, Israel; Epidemiology Research Institute, Barzilai Medical Ctr, Ben-Gurion Univ, Ashkelon, Israel; Dept of Ob/Gyn, Barzilai Medical Ctr, Ben-Gurion Univ, Ashkelon, Israel. Objective: To prospectively evaluate the impact of transcervical tubal catheterization (TTC) procedures, as new medical technology, on patient counseling and management, in a large cohort of infertile women with proximal tubal obstruction (PTO). Design: Prospective observational study. Materials/Methods: 625 infertile women with bilateral (61.6%) or unilateral (38.4%) PTO underwent TTC. Patients with 3.7 (1–22) years of primary (23%) or secondary (77%) infertility were referred from all over the country (the author, from the Barzilai Medical Center, performed the TTC procedures at the Barzilai, Sheba, and Assuta Medical Centers, Israel). TTC is an ambulatory procedure performed under fluoroscopic observation. A coaxial catheters system (Cook Ob/Gyn) was used to perform an hysterosalpingogram and selective salpingography, before and after tubal catheterization with a soft tip guide-wire. Results: In 86% of the patients, at least one obstructed fallopian tube was successfully recanalized by TTC. Out of 1010 proximally obstructed fallopian tubes, 82% were successfully recanalized. Five cases (0.8%) were treated later for suspected PID, while one of them conceived spontaneously the following month. Because of the TTC results, 86% of patients was recommended to try to conceive naturally. 330 consecutive patients were followed after the procedure, by a telephone questioner, for a follow-up of 1719 women’s months. They obtained a 41% of intrauterine pregnancy rate (with only 1.4% of ectopic pregnancy rate). The cumulative pregnancy rates were 71% for women aged 20 –29 years, 52% for age 30 –39, and 18.5% for women aged ⱖ40 (p ⫽ 0.03; p ⫽ 0.0002 for trend). Conclusions: TTC has a major impact on the management and counseling of infertile women with PTO. After TTC, 86% of patients are recommended to try to conceive naturally, instead of being referred for laparoscopy or ART. TTC is a safe and cost effective procedure. TTC should be recommended as first choice for further diagnosis and treatment to all infertile women with bilateral or unilateral PTO. Supported by: No support.
Wednesday, October 16, 2002 2:30 P.M. O-237 Endometrial sampling during sonohysterography (SHGes) in the management of abnormal uterine bleeding. Francesco Paolo Giuseppe Le-
Vol. 78, No. 3, Suppl. 1, September 2002