my key note address at AICOG 2013.....for all who missed this one and on request of many who were present and wanted a copy...... if you copy these please do but please acknowledge.....

1. ultrasound in reproductive
endocriology in women
narendra malhotra
jaideep malhotra
neharika malhotra bora
rishabh bora
Inputs from
ashok khurana,sonal panchal,asim kurjak,sakshi tomar

2. Greetings from agra

3. female reproductive physiology a
well orchestrated
neuro-endocrinological process
Parts of the system
Gonads
􀂄 Ovaries
Internal genitalia
􀂄 Uterine tubes
􀂄 Uterus
􀂄 Vagina
External genitalia

4. Female endocrinology
• 1.Functional anatomy
• 2.Overview hormones
• 3.gametogenesis and folliculogenesis
• 4.puberty and adolescence
• 5.regulation of menstrual cycle &
problems
• 6.infertility
• 7.pregnancy
• 8.contraception
• 9.menopause

6. advantages of 3D ultrasound
1. Surface rendering
2. Multi-planar imaging
3. Exact volume measurement
4. Power Doppler quantification
5. Inversion mode
6. Automation
7. Virtual scan
Automatic Volume Scan
Multiplanar Volume Analysis

7. I. Functional anatomy

8. characteristics
􀂄 Ovaries function until
menopause ↔ testes function
until
old age (only slight decline)
􀂄 Periodic preparation for
fertilization and pregnancy
and
intermittent release of ova ↔
continuous production of
spermatozoa
Fundamental reproductive unit = single ovarian
follicle, composed of one germ cell (oocyte), surrounded
by endocrine cells

9. Ovary
Two roles
􀂄 gametogenic
􀂄 endocrine
􀂄 The gametogenic
potential is established
early in the
fetus
􀂄 Endocrine role of the
ovary is not realized until
puberty

10. HORMONE: Estrogen (female)
Secretory gland: Ovaries
Secretory cell: Granulosa (thecal cells as well)
Chemical class: Steroid hormone
Stimulus for release FSH (granulosa) and LH (thecal)
Inhibitors of release None direct
Transport in blood: Bound to plasma proteins
Removal from blood: Liver, results excreted by
kidneys
Mechanism of Cytosolic & nuclear receptors;
action: alters synth. & activity of
enzymes
Biological Necessary for ovulation;
response(s) produces 2nd sex
characteristics
2

11. HORMONE: Progesterone
Secretory gland: Adrenal cortex, ovaries,
placenta
Secretory cell: Granulosa cells of corpus
luteum
Chemical class: Steroid hormone
Stimulus for release
Inhibitors of release
Transport in blood: Bound to plasma proteins
Removal from blood:
Mechanism of Nuclear (& possibly non-
action: nuclear) mobile receptors
Biological Alterations to uterus and
response(s) breasts

12. HORMONE: Inhibin (male and female)
Secretory gland: Testes and ovaries
Secretory cell: Sertoli (m) & Granulosa cells (f)
Chemical class: Glycoprotein
Stimulus for release FSH
Inhibitors of release
Transport in blood: In solution
Removal from blood:
Mechanism of Fixed receptor system
action:
Biological Inhibits release of FSH from ant.
response(s) pituitary

13. II. Overview
Function of the reproductive system
• Oogenesis
• Puberty and menstruation
• Conception - reception of sperm and
transport of sperm and ovum
• Gestation - maintenance of the fetus
• Parturition
• Lactation
• Contraception
• menopause
ULTRASOUND HELPS IN ASSESSING ALL THESE ENDOCRINOLOGICALFUNCTIONS

14. Ovary
Cortex
􀂄 Contains follicles
in different stages of
development
􀂄 Medulla
􀂄 Interstitial, steroid
producing cells
􀂄 Stromal cells
(connective tissue)

15. cellular components of the
ovary
The ovary consists of epithelial
and mesenchymal
components
􀂄 Mesenchymal tissue
differentiates into interstitial tissue
􀂄 This tissue is the primary
source of hormones
􀂄 Also associated with
germinal elements of the ovary
􀂄 Provides nutritive
environment for the oocytes
􀂄 Epithelial tissue differentiates
into granulosa cells

16. III. Gameto- & folliculogenesis

17. follicle
􀂄 Each contains an
oocyte
􀂄 Concentric layers of
cells
􀂄 Granulosa cells
􀂄 Thecal cells
􀂄 There is a basal
membrane between
granulosa and thecal
cells
􀂄 Follicle is embedded
in stroma

18. cellular layers of the follicle

19. oogenesis – before birth
􀂄 Oogonia (6-7 million)
􀂄 Undifferentiated stem
cells in the fetus
􀂄 During the prenatal
period, oogonia develop
into primary
oocytes
􀂄 At birth only primary
oocytes are present

20. oogenesis - at birth
􀂄 Primary oocytes
(2 million at birth)
􀂄 Primary oocyte is
covered by
single-layer of
flattened
granulosa cells =
primary
follicle a.k.a
primordial follicle

21. primordial follicles
Lie in the periphery (cortex) of the
ovary
􀂄 They are separated from each other
by stromal and
interstitial tissues
􀂄 Majority of primary follicles remain
arrested in
development state
􀂄 A small population of primary
follicles starts developing
towards more differentiated form:
secondary follicle
􀂄 Still in embryonic ovary, primordial
follicles begin
reduction division of meiosis

22. what happens to the primary
follicles
Before puberty: the developing population of
primary
follicles degenerates before reaching the secondary
follicle stage (atresia)
􀂄 After puberty: one of the simultaneously
differentiating
primary follicles will reach the fully mature form in
every
28 days (→ ovulation), the other simultaneously
maturing primary follicles will degenerate
By menopause: no primary follicle is left
(400 have
reached the fully mature stage, the rest
has
degenerated)

23. Secondary oocytes
(secondary follicles) →mature ovum

24. secondary follicle
After puberty, in every ovulatory cycle 6-12 primary
follicles are selected for development of secondary
follicles
􀂄 Increase in oocyte size and in granulosa cell layers
around each oocyte
􀂄 Granulosa cells secrete mucoid material that forms the
zona pellucida around each oocyte
Usually only one will develop into a mature follicle
􀂄 The rest will become atretic and disappear
􀂄 The follicle that is selected for maturation is thought to
be the one whose granulosa cells acquire high levels of
aromatase and LH receptor

25. purposes of ovarian follicle
Preserve resident oocyte
􀂄 Mature oocyte at the right
time
􀂄 Produce best surrounding
for development of healthy
oocyte
􀂄 Release oocyte at right
time
􀂄 Produce quality corpus
luteum after implantation
􀂄 Preserve hormonal
conditions for gestation

26. ovarian reserve assesment
ANTRAL FOLLICLE COUNT
• Goal: To determine the functional
capacity of the ovary. Specifically
the quantity and quality of oocytes
remaining.
Direct measures
AFC/ovarian volume
Anti-mullerian Hormone
(AMH)
Inhibin B
Indirect measures
FSH

27. cyclic behavior of female
reproductive
system
The cause of cyclicity –
hypothalamus Periodic
changes in the frequency of
GnRH bursts
􀂄 Ovarian cycle
􀂄 Uterine (menstrual cycle)

28. Periodic changes in the frequency of
GnRH bursts from the hypothalamus
Periodic changes in FSH and LH release
from pituitary
Periodic changes in ovarian function
(ovarian cycle)
periodic release of ovum periodic changes in the secretion of
estrogens and progesterone
- periodic changes in the uterus
(uterine cycle, a.k.a. menstrual
Periodicity in the cycle)
possibility of - periodic changes in the cervix
fertilization and - periodic changes in the vagina
implantation - periodic changes in the breasts

30. Uterus:Three-dimensional transvaginal ultrasound can
depict a coronal section of the uterus
1. Endometrial receptivity
2. Cavity problems : Fibroid and polyps
3. Congenital uterine abnormalities
4. Endometrial assessment in
endometrial carcinoma

31. sagittal section
A single coronal
section of the
uterus cannot
demonstrate the
whole uterine
cavity
(endometrium)
when the uterine
cavity curved too
much.
coronal section

32. Three-dimensional images of the endometrial
cavity or the endometrium - extraction of the
endometrial cavity and volume measurement.

33. uterine vascularity and wall
Layers of the uterus wall
􀂄 Endometrium (with
uterine glands)
􀂄 Myometrium
􀂄 Perimetrium
􀂄 The thickness of the
endometrium changes
during the menstrual cycle

34. Three-dimensional images of the endometrial
cavity or the endometrium - 3D images of the
endometrial cavity

35. ovarian cycle or follicular
maturation
Primary oocyte (meiotic
arrest, diploid)
􀂄 During each ovarian
cycle, primary oocytes
complete
first meiotic division
􀂄 First meiotic division is
completed shortly before
ovulation
􀂄 Followed by extrusion of
the first polar body and
formation of the secondary
oocyte

37. SonoAVC
Sonography-based Automated Volume Count
Automatically calculates the number and volume of
hypoechoic structures in a volume dataset.
Can significantly reduce time for assessment and reporting.
From the calculated volume an average diameter can be calculated.
It also lists the objects according to their size.

38. SonoAVC follicle TM
New Graph & Graph with 2 lines
Exam Summary
Selection if >4
exams/cycle
SonoAVC
Index
Cut-off value set

39. Report page of Sono AVC

40. Other tools for volume calculation .....

42. Infolding of follicular wall

43. What is specific in PCO
morphology…
• Multiple antral follicles
• Distribution of antral follicles
• Stromal predominance
• Stromal vascularity

44. • Polycystic ovarian morphology has
been found to be a better
discriminator than ovarian volume
between polycystic ovarian syndrome
and control women.
Legro, et al, JCEM 90(5): 2571-79.

45. 3D 4 D PCOD

46. Threshold volume

47. • PCO shows multiple follicles and
therefore is likely to lead to errors when
counted manually.
• Therefore an automated volume
calculator is used : Sono AVC.

48. Stromal vascularity
• Even with same echogenecity, PCOS
has more stromal flow.

49. Volume histogram

50.  Women with PCOS had
 higher AFC(median 16.3 v/s 5.5 per ovary),
 ovarian volume ( 12.56 v/s 5.6ml)
 stromal volume ( 10.79 v/s 4.69ml)
 stromal vascularization (VI 3.85v/s 2.79%, VFI
1.27 v/s 0.85).
 Though 2Dpower Doppler indices were not
higher in PCOS than in controls. Lam PM, et al,
Hum Reprod 2007 Dec ; 22(12):3116-23

51. Deciding the stimulation
protocol
ASSESSING OVARIAN RESERVE
AND RESPONSE

52. Predictors of ovarian response are
enumerated as:
• Number of antral follicles
• Stromal flow: stromal FI
• Total ovarian stromal area
• Total ovarian volume
Kupesic S et al, Hum Reprod 2002; 17(4):950-55

53. • AFC is reported the
benefit to predict
ovarian response
and reduce
cancellation cycles.
Chang MY, et al. Fertil Steril
1998; 69:505-10

54. DECIDING THE TIME OF HCG

55. In spite of deciding the time of
hCG based on 2D and CD
assessment of the follicle, there
were lots of failures.
3D US was therefore tried for
follicular assessment with 3D PD.

56. Follicular Volume
 Follicular volumes of between 3 – 7 cc are
optimum for oocyte retrieval .
 The limits of agreement between the
volume of the follicular aspirate and 3D
volume of the follicle were + 0.96 to – 0.43
with 3D and + 3.47 to – 2.42 by 2D volume
estimation.

57. cumulus
On the day of HCG – If
cumulus like echoes is not seen in all
three planes in the follicle , it is less
likely to be mature fertilizable oocyte.

58. Perifollicular 3D PD

59. • Follicles with more uniform
perifollicular vascular network are
more likely to produce pregnancy.

60. Perifollicular 3DPD

61. SonoAVC for IVF pre hCG
Pre hCG OHSS prediction
Even when the age of the patient
and total number of follicles are
similar, the ovarian volume was
significantly higher in the patients
who developed OHSS ( 271+/- 87
v/s 157.30 +/- 54.20ml)

62. corpus luteum
􀂄 After release of ovum
it fills up with
blood:corpus
hemorrhagicum
􀂄 Granulosa cells
increase in number and
clotted blood is
absorbed
􀂄 Granulosa cells
accumulate a lot of
cholesterol
􀂄 Luteinization process
forms the corpus luteum

63. luteal phase
follicular remnant (mainly
outer
layer of granulosa cells)
↓
corpus hemorrhagicum
↓
c. luteum: secretes estrogen
and progesterone
survives for 14 days (in
pregnancy: for 12 weeks)
↓
c. albicans

64. ovarian hormones
Steroids
􀂄 Estrogens
􀂄 Androgens
􀂄 Progesterone
Peptides
Produced in both interstitial and follicular cells
Derivatives of cholesterol (coming from LDL-lipoproteins and de novo synthesis)

65. estrogens
• Development and maintenance of uterus, uterine
tubes,
• vagina, external genitalia and breasts
• Cyclic changes in the endometrium, cervix, vagina
• Growth of the ovarian follicles
• Motility of the uterine tubes ↑
• > Pregnancy: uterine muscle mass ↑, excitability ↑,
• breasts ↑
• Female secondary sex characteristics (fat
deposits, etc)
• Estrous behavior in animals, increased libido in
humans

66. progesterone
• 􀂄 The most distinctive hormone
between males and
• females
• 􀂄 Chemical structure: C21
• 􀂄 Source:
• 􀂄 c. luteum
• 􀂄 placenta
• 􀂄 follicles (small amount)
• 􀂄 adrenal cortex

67. physiological role of
progesterone
• 􀂄 Cyclic changes in the endometrium, cervix, and vagina
• 􀂄 Myometrium excitability ↓ ↓ (smooth muscle
• contractility ↓ in general → constipation, venous
• varicosities)
• 􀂄 Estrogen receptor number ↓ in endometrium
• 􀂄 Breasts: supports the secretory function during lactation
• 􀂄 Thermogenesis ↑
• Inhibits LH secretion
• 􀂄 Sodium excretion↑ (inhibits aldosterone receptors) →
• followed by compensatory increases in aldosterone
• secretion (→ mild water retention)
• 􀂄 Precursor for steroids in all steroid-producing tissues
• Progesterone is the ovarian hormone of pregnancy
It is responsible for preparing the reproductive tract for implantation
and the maintenance of pregnancy

68. peptide hormones of the ovary
Relaxin
• 􀂄 Relaxes pelvic joints
• 􀂄 Softens and dilates cervix
• 􀂄 Sperm mobility - in males
Inhibin
• 􀂄 Selective inhibitory control of FSH
Activin
• 􀂄 Selective stimulaton of FSH
• 􀂄 Cell differentiation
Follistatins
• 􀂄 Inhibit FSH secretion
Gonadotropin surge attenuating factor
• 􀂄 Prevents premature LH surge
POMC hormones
Vasopressin and oxytocin (in luteal cells)

69. hormonal control of ovulation

70. proliferative phase

71. secretary phase

72. 6mm
HIGH NEGATIVE PREDICTIVE VALUE
IN CASES WITH MINIMAL ENDOMETRIAL
THICKNESS !!!
CUT OFF VALUE
Gonan et al., Ultrasound Obstet Gynecol 1991 6 mm
Khalifa et al., Hum Reprod 1992
7 mm

73. Relative echogenicity of the
endometrium and adjacent
myometrium as demonstrated on
a longitudinal US scan

74. SPIRAL ARTERY
BLOOD FLOW
ENDOMETRIAL
PERFUSION
UTERINE
RECEPTIVITY
IMPLANTATION
RATE

75. Spiral artery perfusion
4 TYPES OF COLOR MAPS
ZONE 1 ZONE 3
ZONE 2 ZONE 4

76. VASCULARISATION

77. SUBENDOMETRIAL
ZONE
PR = 26.7 %
P < 0.05
OUTER
HYPERECHOGENIC
ZONE
PR = 36.4 %
INNER
HYPOECHOGENIC P > 0.05
ZONE
PR = 37.9 %
Zaidi et al., Ultrasound Obstet Gynecol 1995

78. CUT-OFF VALUE OF UTERINE PI & RI
PI = 3 - 4
RI = 0.93 - 0.95
• LOW UTERINE RECEPTIVITY
• VERY UNLIKELY IMPLANTATION
Steer et al., Fertil Steril 1992

79. 3D POWER DOPPLER
RENDERING AND QUANTIFICATION

80. VI NEW PARAMETERS
FI FOR PREDICTION OF
VFI IVF OUTCOME
Kupesic et al, J Ultrasound Med 2001

81. IV. Regulation: the menstrual cycle

82. Menstrual cycle – controlled by gonadotropins,
gonadal hormones
Ovarian cycle –
follicular phase – avg 15 d (range, 9-23 days)
ovulation
luteal phase – 13-14 d – less variable than follicular
Endometrial cycle – menstruation, proliferative and
secretory phases

83. 28 day cycle
Cycling begins at puberty
Fig. 5

84. Phases of Endometrial Cycle
Figure 81-7; Guyton & Hall

85. Ovarian
Cycle: follicular phase FSH and LH in the
ovulation Follicular phase
LH
surge
LH surge lasts 48 h
Inc
GnRH
bursts
FSH
LH
1 4 14
Endometrial proliferative phase secretory phase (12d) 28
Cycle: menstrual (11 d)
Copyright © 2006 by Elsevier, Inc.

86. Ovarian
Cycle: follicular phase
ovulation
LH
surge Increase in estradiol to stimulate
LH surge. Then estradiol has
Negative feedback on GnRH to
reduce LH, FSH.
FSH
estradiol neg
LH feedback--GnRH
1 4 14 28
Endometrial Proliferative phase Secretory phase (12d)
Cycle: menstrual (11 d)
Copyright © 2006 by Elsevier, Inc.

87. reproductive endocrinology of
women
• Complicated
• Delicate interactions of
neural-hormonal-peripheral changes

88. The numbers game
• 7 million oogonia (by 20-24 weeks)
• 2 million oocytes at birth
• 100-400,000 oocytes at start of puberty
Pre-puberty, development of the oogonia
begins but can not be completed and the
cells die (atresia)

89. puberty an endocriological
event

90. Puberty and adolescence
• Precosious
• Delayed
• Primary gonadal failure
• A.U.B/D.U.B

91. ultrasound in puberty events
• Follicles and ovary
• Uterine growth
• Endometrium growth
All are in response to ovarian
steroidogenisis

92. hypthalamic-pitutary problems
• gonadotrophins and releasing hormones
• Prolactin
• thyroid hormones
PROBLEMS ARE
Amenorrhea
Precocious puberty/delayed puberty
Anovulatory DUB
Menstrual disorders

93. Primary gonadal failure
Pituitary
Insult
LH, FSH
Ovary/testis
Estrogen/
Testosterone
Clinical
hypogonadism

94. Secondary gonadal failure
Insult
Pituitary
LH, FSH
Ovary/testis
Estrogen/
Testosterone
Clinical
hypogonadism

95. Clinical features: Time of onset
• First trimester: female genitalia, ambiguous
genitalia, virilisation
• Third trimester: micropenis, cryptorchidism
• Childhood, adolescence: delayed puberty,
eunuchoid proportions ( long bone length)
• Adult
– Decreased libido, erectile dysfunction
– Fatigue
– Loss of muscle mass
– Reduced facial, body hair
– Loss of bone mass
– Gynaecomastia (1° > 2°)
– sperm count (1° > 2°)

96. Investigation
• LH, FSH – primary vs secondary
• Semen analysis
• Primary
– Karyotype
• Secondary
– Pituitary function
– MRI pituitary
– Prolactin
– Iron studies

97. Primary amenorrhoea
• Absence of menses by 15y in presence
of normal 2° sexual characteristics
• Causes
– Chromosomal
– Hypothalamic
– Anatomic
– Pituitary

98. Hypothalamic/pituitary
• Functional eg. anorexia
nervosa, exercise
• GnRH deficiency – eg Kallman
syndrome
• Constitutional delayed puberty
• Hyperprolactinaemia
• Pituitary lesions

99. Ovarian disease
• Turner syndrome commonest (45,X)
– Normal genital development until puberty
– Dysmorphic features
• Variants of gonadal dysgenesis: 45,X/46XX
mosaic, 46,XY
– 46,XY have high risk of gonadoblastoma or
dysgerminoma – removal required
• Fragile X
• Polycystic ovary syndrome

100. Secondary amenorrhoea
• Absence of ≥3 cycles or 6 months, if previous
menses
• Etiology
– Pregnancy
– Functional hypothalamic amenorrhoea
– Hypothalamic/pituitary disease
– Systemic disease
– Hyperprolactinaemia (GnRH suppression)
– Thyroid dysfunction
– Polycystic ovarian syndrome
– Premature ovarian failure
– Uterine disease

101. V. Hormones & contraception
• Combination contraceptives contain
– Estrogen
– Progesterone
• Inhibit ovulation by negative feedback
that reduces FSH and LH (no surge)
• Alters the production of cervical
mucus
• May alter the endometrium

102. VI. Menopause
• Permanent cessation of cycling
• Typically between 45-55 (35-65)
• Due to “ovarian failure”
– Responsiveness to LH/FSH reduced
– Therefore, less estrogen and progesterone
produced
• Adrenal cortex becomes the major
producer of sex hormones in post-
menopausal women

103. Newer machines and
technology has made it
possible to have usg as
an accurate tool for
complete reproductive
assesment…anatomical
and physiological
BT12 Enhancements
New clinical value for you
and your patients

106. MANAGING
INFERTILTY (AOFOG
BOOK)
dr jaideep malhotra

108. THANKYOU

109. THANK YOU
CONGRATULATIONS TO ALL ON
30YRS OF ART