3D and 4D studies from human reproduction to perinatal medicine.

Three-dimensional ultrasound (3D US) is a modality of choice for prenatal diagnosis of congenital malformations. But 3D-four-dimensional US(4D US) is of utmost importance also to achieve pregnancy. 3D US plays an important role for diagnosis of PCO, to assess ovarian reserve and response and thus to decide optimum stimulation protocols. It adds to the information on follicular maturity and endometrial receptivity, thus improving the chances to achieve pregnancy for patients under treatment for fertility. 3D hystero-contrast-salpingography (HyCoSy) has also proved itself to be one of the best modalities for assessment of tubal patency. In this article, the role of 3D and 4D US is discussed for the following. I. Pretreatment assessment of the females desiring fertility which includes assessment of uterus and fallopian tubes. II. Monitoring of infertile females undergoing treatment. III. Assessment of very early pregnancy - especially in abnormal locations.

Imaging techniques for assessment of tubal status.

Fallopian tubes make a vital portal for transfer of gametes and embryo. Tubal factor is responsible for infertility in 25-35% of cases. Hysterosalpingography (HSG) has been used to evaluate the uterine cavity and the tubal status since decades. It uses iodinated contrast and X-rays and is painful and inconvenient for patient. Laparoscopy is considered to be the gold standard for tubal evaluation, but is an operative procedure and needs anesthesia. Though ultrasound is a modality of choice for assessment of uterus and ovaries, it does not allow assessment of the fallopian tube unless there is any fluid surrounding it or inside the lumen. This fluid interface can be created artificially by introducing saline in the uterine cavity and fallopian tubes and scanning simultaneously. The procedure is named Saline infusion HSG. Saline infusion sonohysterosalpingography (SIS) can be done with B mode US and Doppler. SIS can demonstrate a patent tube but if blocked, the site of block cannot be demonstrated. Ultrasound contrast agents can be used for tubal assessment using contrast mode on the scanners. This procedure is known as hystero-contrast sonography (HyCoSy). This actually shows the passage of hyperechoic contrast agent through tubal lumen and delineates it and locates the site of block. Using the volume ultrasound may even make the demonstration of tubal status and fimbriae better. Results of HyCoSy have been found to correlate well with laparoscopic findings, which are a gold standard. It is recommended by National Institute for Health and Clinical Excellence as a primary investigation for tubal assessment in patients without any positive history of tubal damage and also can replace a second look laparoscopy.

Comparison of anti-mullerian hormone and antral follicle count for assessment of ovarian reserve.

AIM: This study aims to compare the efficacy of AFC and AMH, as markers for ovarian reserve. MATERIALS AND METHODS: 75 patients with PCO (polycystic ovaries) undergoing IVF were randomized with 75 non-PCO patients. On day 3, volume of ovary was acquired, ovarian volume was defined by VOCAL, and Sono AVC was used to count the number of antral follicles. Sum total of antral follicles in both ovaries was taken as total antral follicle count (AFC). AMH was measured on the same day. Long agonist protocol with recombinant FSH (rFSH) was used for IVF stimulation till at least two follicles of 18 mm were seen. hCG 10,000 iu was given and ovum pick up was done after 34-35 h. Primary end point was number of follicles >12 mm seen on day of hCG. Final end point was number of ova retrieved on ovum pick up. Correlation of AFC and AMH was checked for both end points and with each other. RESULTS: Correlation of AFC and follicles >12 mm on day of hCG in PCO group is 0.56 and non-PCO group is 0.63,(1) and for AMH and follicles >12 mm on day of hCG in PCO group is 0.42 and non-PCO group is 0.47. Correlation of AFC with number of ova retrieved on OPU in PCO group is 0.44 and for non-PCO group is 0.50. The value for AMH is 0.39 in PCO and 0.43 for non-PCO group. Comparing correlation of AFC and AMH for primary end point in PCO group has 'z' value 1.11(onetailed significance 0.1335, twotailed significance 0.267) and in non-PCO group comparison shows a 'z' value of 1.39 (one tailed significance 0.0823, two-tailed significance 0.1645). Therefore in both groups, AFC and AMH correlates with total number of follicles >12 mm on day of hCG, but both AFC and AMH have independent significance. Comparing correlation of AFC and AMH with number of ova retrieved on OPU, in non-PCO group has 'z' value of 0.54(one tailed 0.2946, two-tailed 0. 5892). In PCO group, this comparison shows, 'z' value of 0.36(one tailed 0.3594, two tailed 0.7188). CONCLUSION: AFC and AMH correlate with each other but have independent significance for estimating follicles >12 mm on day of hCG. For ova retrieved on OPU, in PCO group, AMH and AFC have similar significance. In non-PCO, AMH may increase accuracy of estimation of number of ova retrieved on OPU over AFC, but difference is not significant. AFC only may suffice for estimation of number of ova retrieved on OPU for all practical purposes.

Endometrial regeneration using autologous adult stem cells followed by conception by in vitro fertilization in a patient of severe Asherman's syndrome.

In a woman with severe Asherman's syndrome, curettage followed by placement of intrauterine contraceptive device (IUCD) (IUCD with cyclical hormonal therapy) was tried for 6 months, for development of the endometrium. When this failed, autologous stem cells were tried as an alternative therapy. From adult autologous stem cells isolated from patient's own bone marrow, endometrial angiogenic stem cells were separated using immunomagnetic isolation. These cells were placed in the endometrial cavity under ultrasound guidance after curettage. Patient was then given cyclical hormonal therapy. Endometrium was assessed intermittently on ultrasound. On development of endometrium with a thickness of 8 mm and good vascularity, in vitro fertilization and embryo transfer was done. This resulted in positive biochemical pregnancy followed by confirmation of gestational sac, yolk sac, and embryonic pole with cardiac activity on ultrasound. Endometrial angiogenic stem cells isolated from autologous adult stem cells could regenerate injured endometrium not responding to conventional treatment for Asherman's syndrome.