Polycystic ovary syndrome ( PCOS ) is the most common hormone upset that affects adult females pre-menopausal. ( Speca, Napolitano and Tagliaferri, 2007 ; Balen, 1999 ) . Assorted surveies have been carried out to seek and measure the prevalence of PCOS in the population and figures range from 17-22 % , with 22 % being the most common. ( Hart, Hickey and Franks, 2004 ) .
There is no known cause of the syndrome and its pathogenesis varies from literature to literature, therefore the deficiency of international definition. ( Speca et al. , 2007 ) . Until 2004, the most recognized definition of PCOS came from the National Institutes of Health ( NIH ) 1990 standard for PCOS, and this described that patients who had PCOS had to hold: hyperandrogenism and/or hyperandrogenemia, oligoovulation, and the exclusion of any other related upsets. ( Azziz, 2006 ) .
As these standards did non include the diagnosing of polycystic ovaries utilizing echography, it was thought to be controversial, hence in 2003, a meeting between the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine produced new standards for the definition of PCOS, which was called the Rotterdam 2003 Criteria. It had been clear for some clip that PCOS had a broad scope of symptoms and the new standards is thought to embrace more fluctuations of the syndrome. Patients diagnosed with the old NIH standards would besides run into the new Rotterdam 2003 standard. Azziz, 2006 ).
Symptoms in PCOS can include oligoovulation, anovulation, marks of hyperandrogenism which can be hirsuteness, acne, seborrhoea, alopecia and fleshiness, and polycystic ovaries. ( Speca, 2007 ) . The new definition would first except any other upsets that may show in a similar manner to PCOS and so the patient would anticipate to hold two out of three of the undermentioned characteristics: oligoovulation or anovulation ; clinical and/or biochemical marks of hyperandrogenism ; or polycystic ovaries.
Rotterdam ESHRE/ASRM Sponsored PCOS Consensus Workshop Group, 2004 ) . Transvaginal ( TVS ) echography has long been the mode of pick to image the ovaries and womb and allows a non invasive appraisal of the country. In scanning for PCOS, the sonographer harmonizing to the Rotterdam 2003 Criteria should stay by the rigorous guidelines before doing a diagnosing. The polycystic ovary should hold 12 or more follicles present mensurating 2-9mm in diameter or for at least one of the ovaries to hold a volume of 10cm3. ( Balen, Laven, Tan and Dewailly, 2003).
The usage of three dimensional ( 3D ) ultrasound in this country has grown chiefly due to the desire to hike success rates in IVF processs. ( Timor-Tritsch and Monteagudo, 2007 ) . The involvement in analyzing PCO and PCOS entirely has increased over the last few old ages and assorted surveies have been carried out depicting the characteristics of PCO on three dimensional ultrasound. Ovarian volume is more accurately measured in 3D echography as it is more consistent. ( Raine-Fenning, Campbell, Clewes, Kendall and Johnson, 2003 ) . Figure 1, illustrates the difference in size of a normal ovary compared to one which is polycystic.
The debut of 3D power Doppler has enabled the entire flow of blood to the ovaries to be measured instead than merely single blood vass. The volumes are so analysed utilizing Virtual Organ Computer-Aided Analysis ( VOCAL ) package which produces blood flow indices. ( Pan et al. , 2002 ) . These indices are vascularisation index ( VI ) which is the grade of vascularity ; volume flow rate ( FI ) the signal strength ; vascularization flow index ( VFI ) an merger of VI and FI ; and intend gray ( MG ) which measures the echogenicity of the tissue.
Lam, Johnson and Raine-Fenning, 2007 ) . These measurings have shown the most differences in patients with PCOS and are a valid tool in the diagnosing of PCOS. Kyei-Mensah, Tan, Zaide and Jacobs ( 1998 ) were among the first to utilize 3D echography in measuring patients with PCOS. In their survey they measured stromal volume ( entire ovarian volume minus follicular volumes ) , ovarian and follicular volumes. Measurements were taken in the early follicular stage as many patients were due for intervention in the ulterior follicular stage.
The patients that showed PCO on ultrasound were divided into two groups – group 1 with PCO and group 2 with PCOS. Both the ovarian and stromal volumes were significantly higher than the control group ( P & lt ; 0. 05 ) in both the PCO and PCOS groups – 15. 8mls and 14. 5mls ( mean of PCO and PCOS groups ) versus 9. 6mls and 8. 6mls severally. The grade of hyperandrogenism was non assessed which in later surveies have proved to be of import. All the adult females in the survey had complained of sterility antecedently and hence were self-selected for the survey.
This takes off the credibleness of the survey as the consequences were predictable. Dolz et Al. ( 1999 ) conducted a survey of 65 adult females with PCOS demoing marks of oligoovulation, clinical grounds of acne, alopecia or hirsuteness and elevated endocrine degrees. Patients had to show with one unnatural clinical characteristic and one unnatural endocrine degree to be included in the survey. The control group had 25 adult females with a normal catamenial rhythm, a BMI & lt ; 25kg/m2 and no medical, gynecological or hormonal abnormalcies.
Ovarian country, follicle count and size, stromal echogenicity and thickness and vascular flow by electric resistance indices were recorded between yearss 8-10 of the catamenial rhythm. Increased ovarian country, stromal thickness and vascular electric resistance indices ( P & lt ; 0. 001 ) were observed. Similar to Jarvela et Al. ( 2002 ) scans were carried out in the late follicular stage which has been shown to change consequences. ( Balen et al. , 2003 ) . The methodological analysis that Dolz et Al. ( 1999 ) used was different to all the other surveies and does n’t let for comparing.
Carried out a survey affecting 14 patients with PCO instead than PCOS who were get downing IVF intervention. Patients did n’t run into either the NIH consensus 1990 or the Rotterdam Criteria 2003. Measurements were taken from yearss 8-16 of the catamenial rhythm which prevents the consequences from being compared to other surveies. Most other literature in this country, scans patients in the early follicular stage ( between yearss 2-5 ) . Scans were carried out later so that they could govern out any other pathology that would afterwards forestall the patients from holding successful IVF intervention.
Balen et Al. ( 2003 ) states that if follicles are & gt ; 10mm so the scan should be repeated when ovarian dormancy is happening, which is likely to be during the early follicular stage. Larger follicles are more common subsequently in the follicular stage and can give a false diagnosing of PCO. Jarvela et Al. ( 2002 ) demonstrated no difference between normal and PCO in VI, FI, VFI and MG but a important difference ( P & lt ; 0. 001 ) was seen in ovarian volume between the two groups. The average ovarian volume was 13. cm3 for PCO and 8. 5cm3 for the control group.
Unfortunately due to a questionable methodological analysis this survey is limited and has weakened any statements for successful diagnosing of PCOS with 3D ultrasound. Pan et Al. ( 2002 ) used 25 adult females to show PCO sonographically, who besides had a history of oligoovulation or amenorrhoea and showed grounds of hirsuteness, acne alopecia or fleshiness. The patients for this survey would hold all been included in the more recent definition of PCOS in the Rotterdam Criteria 2003. 4 adult females were recruited as the control group who all had normal ovaries, regular catamenial rhythms and were set abouting IVF for male or tubal factors.
Both groups had a transvaginal scan carried out between yearss 2-3 of the catamenial rhythm. The ovarian volume and vascular indices ( measured utilizing 3D power Doppler and VOCAL package ) were calculated. The consequences showed an increased ovarian volume, VI, VFI and FI were found in the PCOS patients ( P & lt ; 0. 05 ) . The age and BMI between the 2 groups besides showed a important difference ( P & lt ; 0. 5 ) demonstrating that these parametric quantities for both groups were n’t the same.
All the adult females were get downing IVF intervention and uncertainties may come within the control group as the patients may hold other ovarian pathologies that skew the consequences. Even though consequences were promoting they have to be regarded with cautiousness as the groups were non controlled sufficiently. Ng, Chan, Yeung and Ho ( 2005 ) saw the importance of BMI in PCOS patients and divided its 32 PCOS patients into 2 groups – one with normal weight and the other with fleshy ( BMI a‰? 25kg/m2 ) patients.
PCOS patients met the Rotterdam Criteria 2003 but all seemed to hold oligoovulation and polycystic ovaries – no reference of hyperandrogenism within this group of patients. This may hold been because the survey involved a Chinese population where the prevalence of hyperandrogenism is much lower than Caucasic adult females. ( Lam, Raine-Fenning, Cheung and Haines, 2009 ) . 107 fertile adult females were used in the control group who had regular catamenial rhythms and grounds of self-generated construct. A transvaginal scan was carried out between yearss 2 and 4 of the catamenial rhythm.
Ovarian and stromal volume, antral follicle counts ( AFC ) and vascular indices were measured. Increased ovarian volume and AFC were seen in the PCOS group ( P ; lt ; 0. 001 ) . Normal weight PCOS adult females had much higher vascular indices ( VI, FI and VFI ) so the fleshy PCOS adult females. This demonstrates that within PCOS there are a assortment of subcategories were ovarian vascularity may differ. ( Aleem and Predonic, 1996 ) .
These subcategories have to be considered when construing consequences and the future consideration of these subcategories may help in the diagnosing of PCOS. Lam et Al. 2007 ) used 80 Caucasic adult females, 40 adult females had been diagnosed with PCOS utilizing the Rotterdam Criteria 2003 and the other 40 were undergoing birthrate intervention due to male factor or unexplained sterility and had no sonographic grounds of PCO. The grade of hirsuteness and acne were measured on a 4 point graduated table – ( 0 ) no clinical grounds to ( 3 ) terrible grounds on the PCOS patients. All patients had a transvaginal scan between yearss 3 and 5 of the catamenial rhythm, to mensurate for ovarian and stromal volumes, AFC and vascular indices.
A important addition ( P ; lt ; 0. 01 ) is seen in AFC, ovarian and stromal volumes, VI, and VFI in the PCOS patients. Lam et Al. ( 2007 ) considered different phenotypic manifestations of PCOS and divided the PCOS patients into subgroups. This showed differences ( P ; lt ; 0. 05 ) between the normal and corpulent PCOS patients and the normo-androgenic and hairy PCOS patients showing that MG, FI and VFI were higher in the normal weight patients which agrees with Ng et Al. ( 2005 ) . Hirsute PCOS patients besides had increased stromal volume and FI compared to the normo-androgenic PCOS patients ( P ; lt ; 0. 05 ) .
Lam et Al. ( 2007 ) complements this work with farther survey – Lam, Raine-Fenning, Cheung and Haines ( 2009 ) enrolling 80 Chinese adult females. A similar methodological analysis was used in this survey but merely normal weight PCOS patients had an increased VI and VFI. This correlates with Ng et Al. ( 2005 ) who besides showed increased VI and VFI in normal weight PCOS adult females. Other consequences were similar within the two cultural groups. In Lam et Al. ( 2009 ) no important differences were found within the non-hirsute and hairy PCOS patients which contradicts Lam et Al. 2007 ) , this once more demonstrates that the Chinese population have a lower prevalence of hyperandrogenism. ( Lam et al. , 2009 ) .
Both surveies reveal the importance of the subgroups within the PCOS patient. Pascual et Al. ( 2008 ) scanned 83 adult females, 38 with PCOS as defined by the Rotterdam Criteria 2003 and 45 adult females with normal catamenial rhythms and sonographic ovarian form. Within the PCOS group the Ferriman-Gallwey mark was used for hirsuteness. This scores hair growing, in nine different parts of the organic structure, on a graduated table of 0 ( no hair growing ) to 4 ( complete and heavy screen ) .
Ultrasound scrutinies were carried out in the early follicular stage ( yearss 3-5 ) with ovarian volume and the vascular indices measured. The PCOS group were significantly younger ( P ; lt ; 0. 001 ) than the control group uncovering that the features of the adult females were different and could skew the reading of the concluding consequences. Merely ovarian volume showed an addition ( P ; lt ; 0. 001 ) in the PCOS adult females compared to the control group. These consequences correlate with Jarvela et Al. ( 2002 ) although testing was done at different phases of the follicular stage.
Even though BMI, ovulation and hirsuteness measurings were taken, they were non taken into consideration when analyzing the consequences doing this survey potentially uncomplete. Mala, Ghosh and Tripathi ( 2009 ) used a similar methodological analysis as Pascual et Al. ( 2008 ) but used 25 PCOS patients and 25 fertile adult females for the control group. The same measurings were taken around the same clip in the catamenial rhythm ( yearss 2-5 ) . Results showed that there was an increased ovarian volume, VI and VFI ( P ; lt ; 0. 001 ) in PCOS patients.
These consequences contradict Pascual et Al. ( 2008 ) when no clear differences are demonstrated in their methodological analysiss apart from Pascual et Al. ( 2008 ) used a larger group of adult females. Mala et Al. ( 2009 ) did non subgroup the PCOS patients either, which Lam et Al. ( 2007 ) and Lam et Al. ( 2009 ) had shown is of important importance in construing consequences. The consequences from Dolz et Al. ( 1999 ) and Jarvela et Al. ( 2002 ) show the demand for scans to be performed early on in the follicular stage as stated by Balen et Al. ( 2003 ) .
Besides used patients with PCO instead than PCOS which all the other patients in other surveies had. Kyei-Mensah et Al. ( 1998 ) did non mensurate vascular indices hence excepting Kyei-Mensah et Al. ( 1998 ) , Dolz et Al. ( 1999 ) and Jarvela et Al. ( 2002 ) from the consequences, all other surveies apart from Pascual et Al. ( 2008 ) showed some signifier of addition in the vascular indices. Normal weight PCOS patients seem to increase VI and VFI, which accounts for corpulent patients holding lower endocrine degrees and deficiency of hyperandrogenism ( Dolz et al. , 1999 ) .
This may explicate why the surveies affecting Chinese patients all demonstrated important differences in vascular indices, ( Pan et al. , 2002 ; Ng et al. , 2005 ; Lam et al. , 2009 ) due to Chinese adult females holding a lower prevalence of hyperandrogenism. ( Lam et al. , 2009 ) . Lam et Al. ( 2007 ) , Lam et Al. ( 2009 ) and Ng et Al. ( 2005 ) indicted a demand for different phenotypic manifestations within PCOS. ( A sum-up of the consequences from all the surveies can be found in Appendix D ) . All surveies demonstrated an addition in ovarian volume in the PCOS patient which was to be expected.
A polycystic ovary by definition is considered polycystic if ; lt ; 10cm3. ( Balen et al. , 2003 ) . In decision these nine surveies all provided interesting consequences but were hard to compare due to dissimilar methodological analysiss and different patient features. Further larger graduated table surveies need to be carried out to give definite parametric quantities for vascular indices, which can include the appraisal of BMI, ovulation and hirsuteness on the PCOS patient in 3D ultrasound. This will “ help in specifying the badness, patterned advance or arrested development of the disease. ” ( Mala et al. , 2009, 38 ) .