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6 PCOS
101
literature could be explained by the different
study designs, selection of controls, criteria used
for the denition of PCOS, the lack of hormonal
assessments, the variety in ultrasound equipment
and settings, and, nally, the arbitrary selection
of vessels in 2D ultrasound [93, 116].
2D ultrasound assessment of blood ow could
be subjective through color Doppler maps that are
no longer used or objective by measuring ow
velocity and resistance with pulsed-wave Doppler
(PWD). PWD is used to depict the ow velocity
waveform from the vessel of interest. Angle correction is applied whenever necessary to t the incident
beam. The waveforms are then analyzed manually
(at least three optimal waveforms in a row) or automatically to calculate peak systolic velocity (PSV),
end-diastolic velocity (EDV), resistance index (RI),
pulsatility index (PI), and, lately, capacitance index
(CI), which is the area under the curve for the diastolic part of the waveform, and S/D ratio that is the
ratio of the PSV divided by the EDV [93, 116]. A
strong correlation was reported between stromal PI
and LH/FSH [118].
Three-dimensional ultrasound assessment of
blood ow is easy to perform. When the power
Doppler signal is optimal, the 3D volume box is
opened, and a 3D sweep scan is performed. Then
the VOCAL program quanties the information
using the histogram facility, and the blood ow
indices are calculated automatically (see
Fig.6.5). Vascularization index (VI) represents
the ratio of color voxels within the total dataset
relative to both color and gray information, providing, thus, an indication of the number and/or
size of the vessels lying in the area of interest
and, therefore, the degree of vascularity. VI is
expressed as a percentage of the ovarian volume.
Flow index (FI) is the mean power Doppler
intensity, and as the intensity of the signal is
dependent on the number of erythrocytes within
a given volume at any time, this index is considered reective of the average intensity of ow
inside the ovary. Vascularization ow index
(VFI) represents the ratio of the weighted color
voxels to total voxels. VFI is calculated by multiplying VI and FI and gives a unied value for
both vascularity and volume ow reecting the
tissue perfusion [119].
These indices are all signicantly affected by
volume ow, attenuation, vessel number, and
erythrocyte density, but in different ways. The VI
and VFI seem to have a more predictable relationship, whereas the FI often demonstrates a
more complex cubic relationship that is not
always logical. Further work is required before a
better understanding of 3D power Doppler ultrasound imaging is achieved [120]. However, the
ndings are controversial even with 3D power
Doppler.
Some studies showed increased vascularity
and blood ow in the ovaries of women with
PCOS [107, 121–123] explained possibly by the
higher vascular endothelial growth factor
(VEGF), while others did not report any signicant difference [85, 93, 94, 106, 107]. Higher
ovarian VFI was correlated with lower BMI,
hyperandrogenism, greater LH/FSH values, ovarian volumes, and follicle numbers [93, 94, 123].
The 3D ultrasound approach is preferable because
it provides the possibility to examine the blood
ow and vascularization in the whole ovary,
avoiding the arbitrary selection of a single vessel,
or even to dene a region and calculate separately
the ow within and around this region [87, 124].
The basal stromal ow measurement is considered to have no predictive value in PCOS with
regard to pregnancy, since the ow indices
between conception and non-conception cycles
in women with PCOS undergoing IVF are similar
[116, 149]. Nevertheless, the stromal blood perfusion has been proven the most relevant predictor of ovarian response to controlled ovarian
stimulation compared to ovarian or stromal volume [92, 149]. Jarvela etal. compared the vascularization per follicle between women with PCOS
and controls, after pituitary suppression during
IVF.Women with PCOS had lower ovarian vascularization per follicle and demanded lower
doses of FSH to achieve a similar level of vascularization after stimulation with FSH and hCG
administration [106]. Moreover, there was a signicant positive correlation between the number
of retrieved oocytes and vascularized ovarian volume after stimulation. Still, the calculation of
ovarian vascularization per follicle was ambiguous, and there was no report to clinical outcome.
102
A. M. Monzo et al.
Role ofUltrasound inMonitoring
theEects ofLaparoscopic Ovarian
Drilling
Laparoscopic ovarian drilling (LOD) is an effective, although interventional, therapy of anovulatory infertility in women with PCOS. LOD is
considered by the ESHRE/ASRM PCOS consensus workshop the second-line intervention in the
clomiphene citrate-resistant PCOS patients
[125]. Usually, ovarian cortex is drilled in three
to six points per ovary with a bipolar electrosurgical probe, unipolar needle electrode, or laser
[126–129].
The success of LOD could be estimated with
ultrasound given that the ovarian volume reduces
3weeks after intervention [147] and also the stromal blood ow in the early follicular phase of the
rst postoperative cycle or 3months after drilling
[121, 122, 148]. The 3D Doppler assessment
showed signicantly higher ovarian stromal VI,
FI, and VFI coexisting with higher AMH levels in
PCOS compared to controls before drilling and
decreased ovarian blood ow, AFC, and AMH
concentrations after drilling [121, 122, 130]. The
same results were observed after a 6-month follow- up of PCOS patients undergoing ovarian
drilling by transvaginal hydrolaparoscopy [128].
There was no difference in stromal blood perfusion between responders (spontaneous ovulation
after LOD) and nonresponders with PCOS [122]
and any clinical outcome report. However,
decreased AMH levels and AFC after LOD may
indicate a possible diminished ovarian reserve,
and this surgical treatment must be carefully indicated [160].
Uterine Size andPerfusion
Literature references upon uterine ultrasound
characteristics in PCOS are scarce. The uterine
volume has been found either smaller [131, 132]
or bigger [19, 133] in women with PCOS and
lower in 40% of adolescent with the syndrome
[134] and also in correlation with LH [133]. In
few studies, a new criterion was suggested, the
ratio of ovarian to uterine volume with an upper
limit of 1.0 which was doubted and abandoned
[132, 135]. Endometrial thickness was diverse in
women and adolescents with PCOS [134, 136,
137] without correlation with the time interval
since the last period [134]. Nevertheless, in a
more recent study, there was no difference in
endometrial thickness and volume between
women with PCOS and controls [138].
The uterine and endometrial blood ow was
found lower in women with PCOS [110, 111,
123, 134, 139–143] with the exemption of one
study [138]. The lower uterine and endometrial
blood perfusion is reected in higher values of
Doppler indices as PI and RI in PCOS and is correlated with obesity and hyperandrogenemia
(higher levels of androstenedione, DHEAS, and
LH/FSH) [110, 111, 142, 143]. Furthermore,
uterine perfusion increases with exogenous estrogen and progesterone as well as antiandrogen
administration [139, 144], while there is a signicant negative correlation between estrogens and
uterine PI [145]. This impaired uterine perfusion
was associated with metabolic disorders and risk
factors for cardiovascular events [140, 141]. The
only study to investigate the endometrial blood
ow with 3D Doppler did not reveal any signicant difference between PCOS and controls in
2D pulsed-wave (uterine arteries) and 3D power
Doppler (endometrial and subendometrial blood
ow) indices, apart from signicantly disturbed
endometrial perfusion in women with PCOS and
clinical signs of hyperandrogenemia diagnosed
only by 3D Doppler [138]. On the other hand,
6months of metformin treatment in obese PCOS
women showed a signicant increase in the endometrial thickness, endometrial volume, and endometrial and subendometrial vascularity indices
(VI, FI, VFI). No change in the RI and PI of the
uterine artery in both periovulatory and midluteal
phases was seen. Measures were also performed
using 3D Doppler sonography. These results suggest that metabolic, endocrine, vascular, and antiinammatory effects of metformin improve
markers of endometrial receptivity [146].
PCOS is also associated with recurrent miscarriages [150]. Likewise, hyperandrogenemia has
been reported as a serious etiology of recurrent
pregnancy loss, regardless of PCOS, possibly due
6 PCOS
103
to lower endometrial and subendometrial blood
perfusion secondary to elevated uterine arterial
resistance [151–158]. Altogether, higher uterine
resistance and lower ovarian stromal resistance,
as reported in women with PCOS due to hyperandrogenemia and unopposed estrogens, are indicative of failure of conception in IVF and recurrent
miscarriage. Recent evidence conclude that PCOS
according to the Rotterdam Criteria increase the
risk of miscarriage in lean women undergoing
pre-implantation genetic diagnosis, and transfer
of a single euploid blastocyst transfer [159]. Thus,
further research and maybe threshold value establishment, especially, in 3D power Doppler could
contribute to a prognosis algorithm of failed
implantation and miscarriage in women with
PCOS undergoing assisted reproduction.
Future Points
PCOS is a persistent challenge to the clinician, as
the phenotype of the syndrome can vary widely
from puberty to postmenopause, and diagnostic
criteria must be assessed taking into account the
broad and heterogeneous spectrum, even in the
same patient throughout her life. Ultrasound
examination has an outstanding position in the
diagnosis and management of women with
PCOS.However, there is still place for improvement and many matters that should be addressed.
The research regarding the ultrasound evaluation
and the diagnostic and prognostic markers of
PCOS is insufcient. The methodology and
mainly the diagnostic criteria applied in existing
studies are not unanimous and widely accepted.
The heterogenous phenotypic spectrum of the
syndrome renders necessary the clustered investigation both of clinical and ultrasound indices as
well as the correlation of hormonal ndings with
the clinical practice. Finally, the application of
3D ultrasound seems promising, at least in
research level, as it provides better spatial awareness, more objective volumetric and vascularization assessment, reduced scanning time, and
better intra- and interobserver variability, despite
the higher cost and training requirements.
Nevertheless, 3D ultrasound does not seem to
add much in clinical practice for the present.
References
1. Franks S. Polycystic ovary syndrome. N Engl J
Med. 1995;333:853–61. Erratum in: N Engl J Med.
1995;333:1435.
2. Diamanti-Kandarakis E, Kouli CR, Bergiele AT,
Filandra FA, Tsianateli TC, Spina GG, Zapanti ED,
Bartzis MI.A survey of the polycystic ovary syndrome
in the Greek island of Lesbos: hormonal and metabolic
prole. J Clin Endocrinol Metab. 1999;84:4006–11.
3. Azziz R, Woods KS, Reyna R, Key TJ, Knochenhauer
ES, Yildiz BO. The prevalence and features of the
polycystic ovary syndrome in an unselected popula-
tion. J Clin Endocrinol Metab. 2004;89:2745–9.
4. Zawadzki JA, Dunaif A.Diagnostic criteria for poly-
cystic ovary syndrome: towards a rational approach.
In: Dunaif A, Givens JR, Haseltine FP, Merriam GR,
editors. Polycystic ovary syndrome. Boston: Blackwell
Scientic; 1992. p.377–84.
5. The Rotterdam ESHRE/ASRM-Sponsored PCOS
Consensus Workshop Group. Revised 2003 consen-
sus on diagnostic criteria and long-term health risks
related to polycystic ovary syndrome (PCOS). Hum
Reprod. 2004;19:41–7.
6. The Rotterdam ESHRE/ASRM-Sponsored PCOS
Consensus Workshop Group. Revised 2003 consen-
sus on diagnostic criteria and long-term health risks
related to polycystic ovary syndrome (PCOS). Fertil
Steril. 2004;81:19–25.
7. Asuncion M, Calvo RM, San Millan JL, Sancho J,
Avila S, Escobar-Morreale HF.A prospective study
of the prevalence of the polycystic ovary syndrome
in unselected Caucasian women from Spain. J Clin
Endocrinol Metab. 2000;85:2434–8.
8. March WA, Moore VM, Willson KJ, Phillips DI,
Norman RJ, Davies MJ.The prevalence of polycys-
tic ovary syndrome in a community sample assessed
under contrasting diagnostic criteria. Hum Reprod.
2010;25:544–51.
9. Karkanaki A, Piouka A, Katsikis I, Farmakiotis D,
Macut D, Panidis D. Adiponectin levels reect the
different phenotypes of polycystic ovary syndrome:
study in normal weight, normoinsulinemic patients.
Fertil Steril. 2009;92:2078–81.
10. Diamanti-Kandarakis E, Panidis D. Unraveling the
phenotyping map of polycystic ovary syndrome
(PCOS): a prospective study of 634 women with
PCOS.Clin Endocrinol. 2007;67:735–42.
11. Polson DW, Adams J, Wadsworth J, Franks
S. Polycystic ovaries-a common nding in normal
women. Lancet. 1988;1:870–2.
12. Clayton RN, Ogden V, Hodgkinson J, Worswick L,
Rodin DA, Dyer S, etal. How common are polycystic
ovaries in normal women and what is their signicance
for the fertility of the population? Clin Endocrinol.
1992;37:127–34.
13. Azziz R, Carmina E, Dewailly D, Diamanti-
Kandarakis E, Escobar-Morreale HF, Futterweit
W, Janssen OE, Legro RS, Norman RJ, Taylor AE,
Witchel SF.Androgen Excess Society. Positions state-
ment: criteria for dening polycystic ovary syndrome
104
A. M. Monzo et al.
as a predominantly hyperandrogenic syndrome: an
Androgen Excess Society guideline. J Clin Endocrinol
Metab. 2006;91:4237–45.
14. Peña AS, Metz M. What is adolescent polycystic
ovary syndrome? J Paediartr Child Health. 2017;27.
https://doi.org/10.1111/jpc.13821.
15. Christensen JT, Boldsoen J, Westergaard JG.Ovarian
volume in gynecologically healthy women using contraception or using IUD.Acta Obstet Gynecol Scand.
1997;76:784–9.
16. Balen AH, Laven JSE, Tan SL, Dewailly D.Ultrasound
assessment of the polycystic ovary: international consensus denitions. Hum Reprod. 2003;9:505–14.
17. Zaidi J, Jurkovic D, Campbell S, Pitroff R, McGregor
A, Tan SL. Description of circadian rhythm in uterine artery blood ow indices during the peri- ovulatory
period. Hum Reprod. 1995;10:1642–6.
18. Zaidi J, Tan SL, Pitroff R, Campbell S, Collins
W.Blood ow changes in the intra-ovarian arteries during the peri-ovulatory period-relationship to the time
of day. Ultrasound Obstet Gynecol. 1996;7:135–40.
19. Adams J, Franks S, Polson DW, Mason HD,
Abdulwahid N, Tucker M, Morris DV, Price J, Jacobs
HS. Multifollicular ovaries: clinical and endocrine
features and response to pulsatile gonadotropin releasing hormone. Lancet. 1985;2:1375–9.
20. Jonard S, Robert Y, Cortet-Rudelli C, Pigny P,
Decanter C, Dewailly D.Ultrasound examination of
polycystic ovaries: is it worth counting the follicles?
Hum Reprod. 2003;18:598–603.
21. Jonard S, Dewailly D, Pigny P, Robert Y, Decanter
C. What are the determinants of the antral follicle
number at ovarian ultrasonography (U/S) in PCOS?
ESHRE Congress, Madrid, 29 June to 3 July 2003,
oral communication, 0–119. Hum Reprod. 2003;18
Suppl 1:42.
22. Peigné M, Catteau-Jonard S, Robin G, Dumont A,
Pigny P, Dewailly D.The numbers of 2–5 and 6–9mm
ovarian follicles are inversely correlated in both normal women and polycystic ovary syndrome patients:
what is the missing ling? Hum Reprod. 2018; https://
doi.org/10.1093/humrep/dey017.
23. Raine-Fenning N.What’s in a number? The polycystic
ovary revisited. Hum Reprod. 2011;11:3118–22.
24. Balen AH, Dunger D. Pubertal maturation of the
internal genitalia. Ultrasound Obstet Gynecol.
1995;6:164–5.
25. Johnstone EB, Rosen MP, Neril R, Trevithick D,
Sternfeld B, Murphy R, Addauan-Andersen C,
McConnell D, Pera RR, Cedars MI. The polycystic
ovary post-rotterdam: a common, age-dependent nding in ovulatory women without metabolic signicance. J Clin Endocrinol Metab. 2010;95:4965–72.
26. Azziz R, Carmina E, Dewailly D, DiamantiKandarakis E, Escobar-Morreale HF, Futterweit W,
Janssen OE, Legro RS, Norman RJ, Taylor AE, Witchel
SF. Task Force on the Phenotype of the Polycystic
Ovary Syndrome of The Androgen Excess and PCOS
Society. The Androgen Excess and PCOS Society cri-
teria for the polycystic ovary syndrome: the complete
task force report. Fertil Steril. 2009;91:456–88.
27. Adams JM, Taylor AE, Crowley WF Jr, Hall
JE.Polycystic ovarian morphology with regular ovulatory cycles: insights into the pathophysiology of polycystic ovarian syndrome. J Clin Endocrinol Metab.
2004;89:4343–50.
28. Kousta E, Cela E, Lawrence N, Penny A, Millauer B,
White D, etal. The prevalence of polycystic ovaries
in women with a history of gestational diabetes. Clin
Endocrinol. 2000;53:501–7.
29. Dewailly D. Diagnostic criteria for PCOS: Is there a
need for a rethink? Best Practice & Research Clinical
Obstetrics and Gynaecology. 2016;37:5–11.
30. Koivunen R, Laatikainen T, Tomas C, Huhtaniemi I,
Tapanainen J, Martikainen H.The prevalence of polycystic ovaries in healthy women. Acta Obstet Gynecol
Scand. 1999;78:137–41.
31. Swanton A, Storey L, McVeigh E, Child T.IVF outcome in women with PCOS, PCO and normal ovarian morphology. Eur J Obstet Gynecol Reprod Biol.
2010;149:68–71.
32. Esinler I, Bayar U, Bozdag G, Yarali H.Outcome of
intracytoplasmic sperm injection in patients with polycystic ovary syndrome or isolated polycystic ovaries.
Fertil Steril. 2005;84:932–7.
33. McDougall MJ, Tan SL, Jacobs HS. IVF and the
ovarian hyperstimulation syndrome. Hum Reprod.
1992;5:597–600.
34. Sahu B, Ozturk O, Ranierri M, Serhal P.Comparison
of oocyte quality and intracytoplasmic sperm injection
outcome in women with isolated polycystic ovaries or
polycystic ovarian syndrome. Arch Gynecol Obstet.
2008;277:239–44.
35. Elting MW, Kwee J, Schats R, Rekers-Mombarg LT,
Schoemaker J.The rise of estradiol and inhibin B after
acute stimulation with follicle-stimulating hormone
predict the follicle cohort size in women with polycystic ovary syndrome, regularly menstruating women
with polycystic ovaries, and regularly menstruating
women with normal ovaries. J Clin Endocrinol Metab.
2001;86:1589–95.
36. Catteau-Jonard S, Bancquart J, Poncelet E, LefebvreMaunoury C, Robin G, Dewailly D.Polycystic ovaries at ultrasound: normal variant or silent Polycystic
Ovary Syndrome? Ultrasound Obstet Gynecol.
2012;40(2):223–9. https://doi.org/10.1002/uog.11202.
37. Eldar-Geva T, Margalioth EJ, Gal M, Ben-Chetrit A,
Algur N, Zylber-Haran E, Brooks B, Huerta M, Spitz
IM.Serum anti-Mullerian hormone levels during controlled ovarian hyperstimulation in women with polycystic ovaries with and without hyperandrogenism.
Hum Reprod. 2005;20:1814–9.
38. Engmann L, DiLuigi A, Schmidt D, Nulsen J, Maier
D, Benadiva C. The use of gonadotropin-releasing
hormone (GnRH) agonist to induce oocyte maturation
after cotreatment with GnRH antagonist in high-risk
patients undergoing invitro fertilization prevents the
risk of ovarian hyperstimulation syndrome: a pro-
6 PCOS
105
spective randomized controlled study. Fertil Steril.
2008;89:84–91.
39. Son WY, Tan SL. Laboratory and embryological
aspects of hCG-primed invitro maturation cycles for
patients with polycystic ovaries. Hum Reprod Update.
2010;16:675–89.
40. Nardo LG, Gelbaya TA.Evidence-based approach for
the use of ultrasound in the management of polycystic
ovary syndrome. Minerva Ginecol. 2008;60:83–9.
41. Broekmans FJ, Kwee J, Hendriks DJ, Mol BW,
Lambalk CB. A systematic review of tests predicting ovarian reserve and IVF outcome. Hum Reprod
Update. 2006;12:685–718.
42. Scheffer GJ, Broekmans FJ, Dorland M, Habbema
JD, Looman CW, te Velde ER.Antral follicle counts
by transvaginal ultrasonography are related to age
in women with proven natural fertility. Fertil Steril.
1999;72:845–51.
43. Kline J, Kinney A, Kelly A, Reuss ML, Levin
B.Predictors of antral follicle count during the reproductive years. Hum Reprod. 2005;20:2179–89.
44. Broer SL, Mol BW, Hendriks D, Broekmans FJ.The
role of antimüllerian hormone in prediction of outcome after IVF: comparison with the antral follicle
count. Fertil Steril. 2009;91:705–14.
45. Broekmans FJM, de Ziegler D, Howles CM, Gougeon
A, Trew G, Olivennes F. The antral follicle count:
practical recommendations for better standardization.
Fertil Steril. 2010;94:1044–51.
46. Craig J, Orisaka M, Wang H, Orisaka S, Thompson
W, Zhu C, etal. Gonadotropin and intra-ovarian signals regulating follicle development and atresia: the
delicate balance between life and death. Front Biosci.
2007;12:3628–39.
47. Charleston JS, Hansen KR, Thyer AC, Charleston LB,
Gougeon A, Siebert JR, etal. Estimating human ovarian non-growing follicle number: the application of
modern stereology techniques to an old problem. Hum
Reprod. 2007;22:2103–10.
48. Gougeon A. Human ovarian follicular development:
from activation of resting follicles to preovulatory
maturation. Ann Endocrinol (Paris). 2010;71:132–43.
49. Gougeon A.Regulation of ovarian follicular development in primates: facts and hypotheses. Endocr Rev.
1996;17:121–55.
50. Broekmans FJ, Faddy MJ, Scheffer G, te Velde
ER.Antral follicle counts are related to age at natural fertility loss and age at menopause. Menopause.
2004;11:607–14.
51. Gougeon A. Ovarian follicular growth in humans:
ovarian ageing and population of growing follicles.
Maturitas. 1998;30:137–42.
52. Deb S, Campbell BK, Clewes JS, Raine-Fenning
NJ.Quantitative analysis of antral follicle number and
size: a comparison of two-dimension and automated
three-dimension ultrasound techniques. Ultrasound
Obstet Gynecol. 2010;35:354–60.
53. Dewailly D, Andersen CY, Balen A, Broekmans F,
Dilaver N, Fanchin R, Griesinger G, Kelsey TW, La
Marca A, Lambalk C, etal. The physiology and clinical utility of anti-Mullerian hormone in women. Hum
Reprod Update. 2014;20:370–85.
54. Pellatt L, Hanna L, Brincat M, Galea R, Brain H,
Whitehead S, etal. Granulosa cell production of antiMullerian hormone is increased in polycystic ovaries.
J Clin Endocrinol Metab. 2007;92:240–5.
55. Franks S, Stark J, Hardy K. Follicle dynamics and
anovulation in polycystic ovary syndrome. Hum
Reprod Update. 2008;14:367–78.
56. Lebbe M, Woodruff TK. Involvement of androgens
in ovarian health and disease. Mol Hum Reprod.
2013;19:828–37.
57. Webber LJ, Stubbs S, Stark J, Trew GH, Margara
R, Hardy K, Franks S. Formation and early development of follicles in the polycystic ovary. Lancet.
2003;362:1017–21.
58. Dewailly D, Catteau-Jonard S, Reyss AC, MaunouryLefebvre C, Poncelet E, Pigny P. The excess in
2–5 mm follicles seen at ovarian ultrasonography is
tightly associated to the follicular arrest of the polycystic ovary syndrome. Hum Reprod. 2007;22:1562–6.
59. Raine-Fenning N, Jayaprakasan K, Clewes
J.Automated follicle tracking facilitates standardization and may improve work ow. Ultrasound Obstet
Gynecol. 2007;30:1015–8.
60. Raine-Fenning N, Jayaprakasan K, Clewes J, Joergner
I, Bonaki SD, Chamberlain S, Devlin L, Priddle H,
Johnson I. SonoAVC: a novel method of automatic
volume calculation. Ultrasound Obstet Gynecol.
2008;31:691–6.
61. Dewailly D, Lujan ME, Carmina E, Cedars MI, Laven
J, Norman RJ, Escobar-Morreale HF. Denition and
signicance of polycystic ovarian morphology: a task
force report from the Androgen Excess and Polycystic
Ovary Syndrome Society. Hum Reprod Update.
2014;20:334–52.
62. Lujan ME, Jarrett BY, Brooks ED, Reines JK, Peppin
AK, Muhn N, et al. Updated ultrasound criteria for
polycystic ovary syndrome: reliable thresholds for
elevated follicle population and ovarian volume. Hum
Reprod. 2013;28:1361–8.
63. Kim HJ, Adams JM, Gudmundsson JA, Arason
G, Pau CT, Welt CK. Polycystic ovary morphology: age-based ultrasound criteria. Fertil Steril.
2017;108:548–53.
64. Christiansen SC, Eilertsen TB, Vanky E, Carlsen
SM. Does AMH reect follicle number similarly in
women with and without PCOS? PLoS One. 2016;
https://doi.org/10.1371/journal.pone.0146739.
65. Iliodromiti S, Kelsey TW, Anderson RA, Nelson
SM.Can anti-Mullerian hormone predict the diagnosis of polycystic ovary syndrome? A systematic review
and meta-analysis of extracted data. J Clin Endocrinol
Metab. 2013;98:3332–40.
66. Carmina E, Campagna AM, Fruzzetti F, Lobo
RA.AMH measurement versus ovarian ultrasound in
the diagnosis of polycystic ovary syndrome in different phenotypes. Endocr Pract. 2016;22:287–93.
106
A. M. Monzo et al.
67. Wittmaack FM, Kreger DO, Blasco L, Tureck RW,
Mastroianni L Jr, Lessey BA.Effect of follicular size
on oocyte retrieval, fertilization, cleavage, and embryo
quality in in vitro fertilization cycles: a 6-year data
collection. Fertil Steril. 1994;62:1205–10.
68. Amer A, Hammadeh ME, Kolkailah M, Ghandour
AA.Three-dimensional versus two-dimensional ultrasound measurement of follicular volume: are they
comparable? Arch Gynecol Obstet. 2003;268:155–7.
69. Penzias AS, Emmi AM, Dubey AK, Layman LC,
DeCherney AH, Reindollar RH. Ultrasound prediction of follicle volume: is the mean diameter reective? Fertil Steril. 1994;62:1274–6.
70. Ata B, Tulandi T.Ultrasound automated volume calculation in reproduction and in pregnancy. Fertil Steril.
2011;95:2163–70.
71. Jayaprakasan K, Hilwah N, Kendall NR, Hopkisson JF,
Campbell BK, Johnson IR, Raine-Fenning NJ.Does
3D ultrasound offer any advantage in the pretreatment assessment of ovarian reserve and prediction of
outcome after assisted reproduction treatment? Hum
Reprod. 2007;22:1932–41.
72. Deb S, Jayaprakasan K, Campbell BK, Clewes JS,
Johnson IR, Raine-Fenning NJ. Intraobserver and
interobserver reliability of automated antral follicle counts made using three-dimensional ultrasound and SonoAVC. Ultrasound Obstet Gynecol.
2009;33:477–83.
73. Nylander M, Frøssing S, Bjerre AH, Chabanova E,
Clausen HV, Faber J, Skouby SO. Ovarian morphology in polycystic ovary syndrome: estimates from 2D
and 3D ultrasound and magnetic resonance imaging
and their correlation to anti-Müllerian hormone. Acta
Radiol. 2017;58:997–1004.
74. Van Santbrink EJ, Hop WC, Fauser BC.Classication
of normogonadotropin infertility: polycystic ovaries
diagnosed by ultrasound versus endocrine characteristics of PCOS.Fertil Steril. 1997;67:452–8.
75. Pache TD, Hop WC, Wladimiroff JW, Schipper J,
Fauser BC.How to discriminate between normal and
polycystic ovaries. Radiology. 1992;17:589–93.
76. Erdem A, Erdem M, Biberoglu K, Hayit O, Arslan
M, Gursoy R. Age-related changes in ovarian volume, antral follicle counts and basal FSH in women
with normal reproductive health. J Reprod Med.
2002;47:835–9.
77. Alsamarai S, Adams JM, Murphy MK, Post MD,
Hayden DL, Hall JE, Welt CK. Criteria for polycystic ovarian morphology in polycystic ovary syndrome as a function of age. J Clin Endocrinol Metab.
2009;94:4961–70.
78. Kyei-Mensah A, Tan SL, Zaidi J, Jacobs
HS.Relationship of ovarian stromal volume to serum
androgen concentrations in patients with polycystic
ovary syndrome. Hum Reprod. 1998;13:1437–41.
79. Haadsma ML, Bukman A, Groen H, Roeloffzen EM,
Groenewoud ER, Heineman MJ, etal. The number of
small antral follicles (2-6mm) determines the outcome
of endocrine ovarian reserve tests in a subfertile population. Hum Reprod. 2007;22:1925–31.
80. Allemand MC, Tummon IS, Phy JL, Foong SC,
Dumesic DA, Session DR. Diagnosis of polycystic
ovaries by three-dimensional transvaginal ultrasound.
Fertil Steril. 2006;85:214–9.
81. Dewailly D, Gronier H, Poncelet E, Robin G, Leroy
M, Pigny P, Duhamel A, Catteau-Jonard S.Diagnosis
of polycystic ovary syndrome (PCOS): revisiting the
threshold values of follicle count on ultrasound and of
the serum AMH level for the denition of polycystic
ovaries. Hum Reprod. 2011;26:3123–9.
82. Jayaprakasan K, Campbell BK, Clewes JS, Johnson
IR, Raine-Fenning NJ.Three-dimensional ultrasound
improves the interobserver reliability of antral follicle
counts and facilitates increased clinical work ow.
Ultrasound Obstet Gynecol. 2008;31:439–44.
83. Raine-Fenning NJ, Campbell BK, Clewes JS, Johnson
IR. The interobserver reliability of ovarian volume
measurement is improved with three- dimensional
ultrasound, but dependent upon technique. Ultrasound
Med Biol. 2003;29:1685–90.
84. Kyei-Mensah A, Maconochie N, Zaidi J, Pittrof R,
Campbell S, Tan SL.Transvaginal three- dimensional
ultrasound: accuracy of ovarian follicular volume
measurements. Fertil Steril. 1996;65:371–6.
85. Ng EH, Chan CC, Yeung WS, Ho PC.Comparison
of ovarian stromal blood ow between fertile
women with normal ovaries and infertile women
with polycystic ovary syndrome. Hum Reprod.
2005;20:1881–6.
86. Pan HA, Wu MH, Cheng YC, Li CH, Chang
FM. Quantication of Doppler signal in polycystic
ovarian syndrome using 3D power Doppler ultrasonography. Hum Reprod. 2002;17:2484–8.
87. Lam PM, Raine-Fenning NJ. The role of threedimensional ultrasonography in polycystic ovary syndrome. Hum Reprod. 2006;21:2209–15.
88. Raine-Fenning NJ, Clewes JS, Kendall NR, Bunkheila
AK, Campbell BK, Johnson IR. The interobserver
reliability and validity of volume calculation from
three-dimensional ultrasound datasets in the in vitro
setting. Ultrasound Obstet Gynecol. 2003;21:283–91.
89. Lam PM, Johnson IR, Raine-Fenning NJ. Threedimensional ultrasound features of the polycystic ovary and the effect of different phenotypic
expressions on these parameters. Hum Reprod.
2007;22:3116–23.
90. Dewailly D, Robert Y, Helin I, Ardaens Y, ThomasDesrousseaux P, Lemaitre L, Fossati P.Ovarian stromal hypertrophy in hyperandrogenic women. Clin
Endocrinol. 1994;41:557–62.
91. Buckett WM, Bouzayen R, Watkin KL, Tulandi T,
Tan SL. Ovarian stromal echogenicity in women
with normal and polycystic ovaries. Hum Reprod.
1999;14:618–21.
92. Yoo RY, Sirlin CB, Gottschalk M, Chang RJ.Ovarian
imaging by magnetic resonance in obese adolescent
girls with polycystic ovary syndrome: a pilot study.
Fertil Steril. 2005;84:985–95.
93. Lam P, Raine-Fenning NJ, Cheung L, Haines
C. Three-dimensional ultrasound features of the
6 PCOS
107
polycystic ovary in Chinese women. Ultrasound
Obstet Gynecol. 2009;34:196–200.
94. Fulghesu AM, Ciampelli M, Belosi C, Apa R,
Pavone V, Lanzone A. A new ultrasound criterion
for the diagnosis of polycystic ovary syndrome:
the ovarian stroma/total area ratio. Fertil Steril.
2001;76:326–31.
95. Pache TD, de Jong FH, Hop WC, Fauser
BCJM. Association between ovarian changes
assessed by transvaginal sonography and clinical
and endocrine signs of the polycystic ovary syndrome. Fertil Steril. 1993;59:544–9.
96. Lam PM, Raine-Fenning N. Polycystic ovarian
syndrome: a misnomer for an enigmatic disease.
Ultrasound Obstet Gynecol. 2009;33:621–7.
97. Fulghesu A, Angioni S, Frau E, Belosi C, Apa
R, Mioni R, Xamin N, Capobianco GP, Dessole
S, Fruzzetti F, Lazzarini V, Minerba L, Melis
GB, Lanzone A. Ultrasound in polycystic ovary
syndrome- the measuring of ovarian stroma and relationship with circulating androgens: results of a multicentric study. Hum Reprod. 2007;22:2501–8.
98. Belosi C, Selvaggi L, Apa R, Guido M, Romualdi
D, Fulghesu AM, Lanzone A.Is the PCOS diagnosis
solved by ESHRE/ASRM 2003 consensus or could
it include ultrasound examination of the ovarian
stroma? Hum Reprod. 2006;21:3108–15.
99. Ardaens Y, Robert Y, Lemaitre L, Fossati P, Dewailly
D.Polycystic ovarian disease: contribution of vaginal endosonography and reassessment of ultrasonic
diagnosis. Fertil Steril. 1991;55:1062–8.
100. Alviggi C, Conforti A, De Rosa P, Strina I, Palomba
S, Vallone R, etal. The Distribution of stroma and
antral Follicles Differs between insulin-resistance
and hyperandrogenism-related Polycystic Ovarian
syndrome. Front Endocrinol. 2017; https://doi.
org/10.3389/fendo.2017.00117.
101. Fedorcsak P, Dale PO, Storeng R, Tambo T, Abyholm
T.The impact of obesity and insulin resistance on the
outcome of IVF or ICSI in women with polycystic
ovarian syndrome. Hum Reprod. 2001;16:1086–91.
102. Amer S, Li TC, Samuelson C, Ledger W.The impact
of insulin resistance on the outcome of laparoscopic ovarian diathermy in women with polycystic ovarian syndrome. Acta Obstet Gynecol Scand.
2011;9(0):338–43.
103. Pache TD, Hop WC, Wladimiroff JW, Schipper J,
Fauser BCJM.Transvaginal sonography and abnormal ovarian appearance in menstrual cycle disturbances. Ultrasound Med Biol. 1991;17:589–93.
104. Al-Took S, Watkin K, Tulandi T, Tan SL. Ovarian
stromal echogenicity in women with clomiphene citrate-sensitive and clomiphene citrateresistant polycystic ovary syndrome. Fertil Steril.
1999;71:952–4.
105. Jarvela IY, Mason HD, Sladkevicius P, Kelly S, Ojha
K, Campbell S, Nargund G.Characterization of normal and polycystic ovaries using three-dimensional
power Doppler ultrasonography. J Assist Reprod
Genet. 2002;19:582–90.
106. Pascual MA, Graupera B, Hereter L, Tresserra F,
Rodriguez I, Alcazar JL. Assessment of ovarian
vascularization in the polycystic ovary by threedimensional power Doppler ultrasonography.
Gynecol Endocrinol. 2008;24:631–6.
107. Agrawal R, Sladkevicius P, Engmann L, Conway
GS, Payne NN, Bekis J, Tan SL, Campbell S, Jacobs
HS.Serum vascular endothelial growth factor concentrations and ovarian stromal blood ow are
increased in women with polycystic ovaries. Hum
Reprod. 1998;13:651–5.
108. Deb S, Jayaprakasan K, Campbell BK, Clewes JS,
Raine-Fenning NJ. The interovarian variation in
three-dimensional ultrasound markers of ovarian
reserve in women undergoing baseline investigation
for subfertility. Fertil Steril. 2011;95:667–72.
109. Aleem FA, Predanic M.Transvaginal color Doppler
determination of the ovarian and uterine blood ow
characteristics in polycystic ovary disease. Fertil
Steril. 1996;65:510–6.
110. Ozkan S, Vural B, Caliskan E, Bodur H, Turkoz
E, Vural F.Color Doppler sonographic analysis of
uterine and ovarian artery blood ow in women
with polycystic ovary syndrome. J Clin Ultrasound.
2007;35:305–13.
111. Loverro G, Vicino M, Lorusso F, Vimercati A, Greco
P, Selvaggi L.Polycystic ovary syndrome: relationship between insulin sensitivity, sex hormone levels
and ovarian stromal blood ow. Gynecol Endocrinol.
2001;15:142–9.
112. Zaidi J, Campbell S, Pittrof R, Kyei-Mensah A,
Shaker A, Jacobs HS, Tan SL. Ovarian stromal
blood ow in women with polycystic ovaries-a
possible new marker for diagnosis? Hum Reprod.
1995;10:1992–6.
113. Dolz M, Osborne NG, Blanes J, Raga F, AbadVelasco L, Villalobos A, Pellicer A, BonillaMusoles F. Polycystic ovarian syndrome:
assessment with color Doppler angiography and
three- dimensional ultrasonography. J Ultrasound
Med. 1999;18:303–13.
114. Tugrul S, Oral O, Guclu M, Kutlu T, Uslu H, Pekin
O. Signicance of Doppler ultrasonography in the
diagnosis of polycystic ovary syndrome. Clin Exp
Obstet Gynecol. 2006;33:154–8.
115. Younis JS, Jadaon JE, Haddad S, Izhaki I, Ben-Ami
M.Prospective evaluation of basal stromal Doppler
studies in women with good ovarian reserve and
infertility undergoing in vitro fertilization-embryo
transfer treatment: patients with polycystic ovary
syndrome versus ovulatory patients. Fertil Steril.
2011;95:1754–8.
116. Battaglia C, Genazzani AD, Salvatori M, Giulini S,
Artini PG, Genazzani AR, Volpe A. Doppler, ultrasonographic and endocrinological environment with
regard to the number of small subcapsular follicles
in polycystic ovary syndrome. Gynecol Endocrinol.
1999;13:123–9.
117. Ozdemir O, Sari ME, Kalkan D, Koc EM, Ozdemir
S, Atalay CR.Comprasion of ovarian stromal blood
108
A. M. Monzo et al.
ow measured by color Doppler ultrasonography
in polycystic ovary syndrome patients and healthy
women with ultrasonographic evidence of polycystic. Gynecol Endocrinol. 2015;3:322–6.
118. Pairleitner H, Steiner H, Hasenoehrl G, Staudach
A. Three dimensional power Doppler sonography:
imaging and quantifying blood ow and vascularization. Ultrasound Obstet Gynecol. 1999;14:139–43.
119. Raine-Fenning NJ, Nordin NM, Ramnarine KV,
Campbell BK, Clewes JS, Perkins A, Johnson
IR. Determining the relationship between threedimensional power Doppler data and true blood ow
characteristics: an in-vitro ow phantom experiment. Ultrasound Obstet Gynecol. 2008;32:540–50.
120. El Behery MM, Diab AE, Mowafy H, Ebrahiem MA,
Shehata AE. Effect of laparoscopic ovarian drilling on vascular endothelial growth factor and ovarian stromal blood ow using 3-dimensional power
Doppler. Int J Gynaecol Obstet. 2011;112:119–21.
121. Elmashad AI. Impact of laparoscopic ovarian drilling on anti-Mullerian hormone levels and ovarian
stromal blood ow using three-dimensional power
Doppler in women with anovulatory polycystic
ovary syndrome. Fertil Steril. 2011;95:2342–6.
122. Mala YM, Ghosh SB, Tripathi R.Three-dimensional
power Doppler imaging in the diagnosis of polycystic ovary syndrome. Int J Gynaecol Obstet.
2009;105:36–8.
123. Raine-Fenning NJ, Campbell BK, Clewes JS,
Kendall NR, Johnson IR.The interobserver reliability of three-dimensional power Doppler data acquisition within the female pelvis. Ultrasound Obstet
Gynecol. 2004;23:501–8.
124. Hann LE, Hall DA, McArdle CR, Seibel
M. Polycystic ovarian disease: sonographic spectrum. Radiology. 1984;150:531–4.
125. ESHRE/ASRM-Sponsored PCOS Consensus
Workshop Group. Consensus on infertility treatment
related to polycystic ovary syndrome. Fertil Steril.
2008;89:505.
126. Farquhar C, Brown J, Marjoribanks J.Laparoscopic
drilling by diathermy or laser for ovulation induction
in anovulatory polycystic ovary syndrome. Cochrane
Database Syst Rev. 2012;(6):CD001122.
127. Hendriks ML, König T, Korsen T, Melgers I, Dekker
J, Mijatovic V, etal. Short-term changes in hormonal
proles after laparoscopic ovarian laser evaporation compared with diagnostic laparoscopy for
PCOS.Hum Reprod. 2014;29:2544–52.
128. Giampaolino P, Morra I, De Rosa N, Cagnacci A,
Pellicano M, Di Carlo C, etal. Impact of transvaginal hydrolaparoscopy ovarian drilling on ovarian
stromal blood ow and ovarian volume in clomiphene citrate-resistant PCOS patients: a case-control
study. Gynecol Endocrinol. 2017;33(9):690–3.
129. Seyam EM, Hefzi E.Laparoscopic ovarian drilling
versus GnRH antagonist combined with cabergoline
as a prophylaxis against the re-development of ovarian hyperstimulation syndrome. Ginecol Endocrinol.
2018;15:1–7.
130. Seyam EM, Mohamed TG, Hasan MM, Abd Al
Mawgood MH. Evaluation of ultrasonographic and
Anti-Mullerian Hormone (AMH) changes as predictors for ovarian reserve after laparoscopic ovarian
drilling for women with polycystic ovarian síndrome.
Middle East Fertility Society Journal. 2014;19:314–23.
131. Orsini LF, Venturoli S, Lorusso R, Pluchinotta V,
Paradisi R, Bovicelli L.Ultrasonic ndings in polycystic ovarian disease. Fertil Steril. 1985;43:709–14.
132. Balen AH, Conway GS, Kaltsas G, Techatrasak K,
Manning PJ, West C, Jacobs HS. Polycystic ovary
syndrome: the spectrum of the disorder in 1741
patients. Hum Reprod. 1995;10:2107–11.
133. Shah B, Parnell L, Milla S, Kessler M, David
R.Endometrial thickness, uterine, and ovarian ultrasonographic features in adolescents with polycystic
ovarian syndrome. J Pediatr Adolesc Gynecol.
2010;23:146–52.
134. Parisi L, Tramonti M, Casciano S, Zurli A, Gazzarini
O.The role of ultrasound in the study of polycystic
ovarian disease. J Clin Ultrasound. 1982;10:167–72.
135. Peri N, Levine D. Sonographic evaluation of the
endometrium in patients with a history or an appearance of polycystic ovarian syndrome. J Ultrasound
Med. 2007;26:55–9.
136. Vanky E, Kjøtrød S, Salvesen KA, Romundstad P,
Moen MH, Carlsen SM. Clinical, biochemical and
ultrasonographic characteristics of Scandinavian
women with PCOS. Acta Obstet Gynecol Scand.
2004;83:482–6.
137. Lam P, Johnson I, Raine-Fenning N. Endometrial
blood ow is impaired in women with polycystic
ovarian syndrome who are clinically hyperandrogenic. Ultrasound Obstet Gynecol. 2009;34:326–34.
138. Ajossa S, Guerriero S, Paoletti AM, Orrù M, Melis
GB.The antiandrogenic effect of utamide improves
uterine perfusion in women with polycystic ovary
syndrome. Fertil Steril. 2002;77:1136–40.
139. Ajossa S, Guerriero S, Paoletti AM, Orrù M, Melis
GB. Hyperinsulinemia and uterine perfusion in
patients with polycystic ovary syndrome. Ultrasound
Obstet Gynecol. 2002;20:276–80.
140. Chekir C, Nakatsuka M, Kamada Y, Noguchi S,
Sasaki A, Hiramatsu Y. Impaired uterine perfusion
associated with metabolic disorders in women with
polycystic ovary syndrome. Acta Obstet Gynecol
Scand. 2005;84:189–95.
141. Battaglia C, Artini PG, Genazzani AD, Sgherzi MR,
Salvatori M, Giulini S, Volpe A. Color Doppler
analysis in lean and obese women with polycystic ovary syndrome. Ultrasound Obstet Gynecol.
1996;7:342–6.
142. Battaglia C, Artini PG, D’Ambrogio G, Genazzani
AD, Genazzani AR.The role of color Doppler imaging in the diagnosis of polycystic ovary syndrome.
Am J Obstet Gynecol. 1995;172:108–13.
143. de Ziegler D, Bessis R, Frydman R. Vascular
resistance of uterine arteries: physiological
effects of estradiol and progesterone. Fertil Steril.
1991;55:775–9.
6 PCOS
109
144. Killam AP, Rosenfeld CR, Battaglia FC, Makowski
EL, Meschia G. Effect of estrogens on the uterine
blood ow of oophorectomized ewes. Am J Obstet
Gynecol. 1973;115:1045–52.
145. Tulandi T, Watkin K, Tan SL.Reproductive performance and three dimensional ultrasound volume
determination of polycystic ovaries following laparoscopic ovarian drilling. Int J Fertil Womens Med.
1997;42:436–40.
146. Mohsen IA, Elkattan E, Nabil H, Khattab S.Effects
of metformin treatment on endometrial vascular
índices in anovulatory obese/overweight women
with polycystic ovarian síndrome using threedimensional power Doppler ultrasonography. Clin
Ultrasound. 2013;41:275–82.
147. Wu MH, Huang MF, Tsai SJ, Pan HA, Cheng
YC, Lin YS. Effects of laparoscopic ovarian drilling on young adult women with polycystic ovarian syndrome. J Am Assoc Gynecol Laparosc.
2004;11:184–90.
148. Engmann L, Sladkevicius P, Agrawal R, Bekir JS,
Campbell S, Tan SL.Value of ovarian stromal blood
ow velocity measurement after pituitary suppression in the prediction of ovarian responsiveness and
outcome of in vitro fertilization treatment. Fertil
Steril. 1999;71:22–9.
149. Cocksedge KA, Li TC, Saravelos SH, Metwally
M. A reappraisal of the role of polycystic ovary
syndrome in recurrent miscarriage. Reprod Biomed
Online. 2008;17:151–60.
150. Okon MA, Laird SM, Tuckerman EM, Li TC.Serum
androgen levels in women who have recurrent miscarriages and their correlation with markers of endometrial function. Fertil Steril. 1998;69:682–90.
151. Li TC, Spuijbroek MD, Tuckerman E, Anstie B,
Loxley M, Laird S. Endocrinological and endometrial factors in recurrent miscarriage. BJOG.
2000;107:1471–9.
152. Cocksedge KA, Saravelos SH, Wang Q, Tuckerman
E, Laird SM, Li TC.Does free androgen index predict
subsequent pregnancy outcome in women with recurrent miscarriage? Hum Reprod. 2008;23:797–802.
153. Ferreira AM, Pires CR, Moron AF, Araujo Júnior
E, Traina E, Mattar R.Doppler assessment of uterine blood ow in recurrent pregnancy loss. Int J
Gynaecol Obstet. 2007;98:115–9.
154. Nakatsuka M, Habara T, Noguchi S, Konishi H,
Kudo T. Impaired uterine arterial blood ow in
pregnant women with recurrent pregnancy loss. J
Ultrasound Med. 2003;22:27–31.
155. Habara T, Nakatsuka M, Konishi H, Asagiri K,
Noguchi S, Kudo T. Elevated blood ow resistance
in uterine arteries of women with unexplained recurrent pregnancy loss. Hum Reprod. 2002;17:190–4.
156. Ng EH, Chan CC, Tang OS, Yeung WS, Ho
PC. Endometrial and subendometrial vascularity is
higher in pregnant patients with livebirth following
ART than in those who suffer a miscarriage. Hum
Reprod. 2007;22:1134–41.
157. Mercé LT, Barco MJ, Bau S, Troyano J.Are endometrial parameters by three-dimensional ultrasound
and power Doppler angiography related to invitro
fertilization/embryo transfer outcome? Fertil Steril.
2008;89:111–7.
158. Zohav E, Orvieto R, Anteby EY, Segal O, Meltcer
S, Tur-Kaspa I. Low endometrial volume may
predict early pregnancy loss in women undergoing in vitro fertilization. J Assist Reprod Genet.
2007;24:259–61.
159. Luo L, Gu F, Jie H, Ding C, Zhao Q, Wang Q,
Zhou C. Early miscarriage rate in lean polycystic
ovary syndrome women after euploid embryo transfer– a matched-pair study. Reprod Biomed Online.
2017;35:576–82.
160. Amer SA, Shamy TTE, James C, Yosef AH,
Mohamed AA. The impact of laparoscopic ovarian drilling on AMH and ovarian reserve: a metaanalysis. Reproduction. 2017;154:R13–21.
Part IV
Ultrasound of the Uterus