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Resume L’imagerie de la femme et en particulier l’echographie pelvienne jouent un role majeur dans l’evaluation et le diagnostic d’anomalies de la reserve ovarienne, que ce soit dans les situations d’exces folliculaire tel que le syndrome des ovaires polykystiques, ou dans la situation inverse, c’est-a-dire les baisses de reserve ovarienne, pouvant amener a proposer aux femmes une preservation de la fertilite.

Resume La necessite d’une imagerie calibree pour les ovaires polykystiques s’est renforcee depuis la conference de consensus qui s’est tenue a Rotterdam en mai 2003. Cependant l’imagerie des ovaires polykystiques est une procedure difficile qui requiert une technique precise et des connaissances medicales. L’echographie bidimensionnelle reste l’examen de choix pour visualiser les OPK et le consensus de Rotterdam privilegie cette technique en retenant comme criteres au moins 12 follicules mesurant 2 a 9 mm de diametre et/ou un volume ovarien superieur a 10 cm3. Les autres techniques telles que le Doppler, l’echographie 3D et l’imagerie par resonance magnetique peuvent aider au diagnostic mais ne seront utilises qu’en seconde intention.

Resume L’hysterographie constituait la methode de reference pour l’exploration des malformations uterines. Elle est invasive et irradiante; elle montre bien la cavite, mais le diagnostic entre uterus bicorne et cloisonne demandait souvent un complement cœlioscopique. L’echographie seule, puis couplee au Doppler permet une excellente analyse de la cavite et du myometre dans le meme temps. Cependant, l’examen reste operateur dependant et les cliches sont d’interpretation difficile pour un tiers dans ce cas precis. L’IRM et l’echographie 3D/4D, procurant au clinicien des coupes frontales de la cavite se sont imposees dans l’exploration de cette pathologie.

Objective To extend our previous findings on the diagnostic validity of ovarian stroma hypertrophy in women with hyperandrogenic and/or menstrual disorders. Design Transvaginal ultrasonography was performed in 69 patients complaining of hyperandrogenism and/or menstrual disorders and in 48 normal ovulatory women in early follicular phase. To check the validity of stroma assessment by visual analysis, we used computer-assisted analysis, which allowed selective measurement of the stromal area on a longitudinal ovarian cut. Sensitivity and specificity of each method were estimated by using the normative data from the control group. Results Stromal area was considered to be increased using visual analysis and computer-assisted analysis in 74% and 61% patients, respectively. Specificity of this sign was 84% and 96% by visual analysis and computer-assisted analysis, respectively. In patients, the increase in stromal area correlated very significantly with the one of total ovarian area, whose upper normal limit was 5.5 cm 2 per ovary. Conclusion Visual assessment of stroma may be misleading in some cases, with the risk of overestimating its hypertrophy. An increased total ovarian area >5.5 cm 2 (which can easily be detected by carefully shaping a strict longitudinal ovarian cut) has the same diagnostic value as an increased stromal area by computerized measurement.

In order to compare the diagnostic significance of hormonal and ultrasonic criteria of polycystic ovarian syndrome (PCOS), the presence or the absence of ultrasonographic and hormonal features of PCOS were recorded in a heterogeneous population of 90 women presenting with hyperandrogenism and/or menstrual disorders. On clinical and hormonal grounds exclusively, these patients could be separated into five diagnostic subgroups: presumed cases of PCOS (n = 21), idiopathic hirsutism (IH) (n = 26), hypothalamic anovulation (HA) (n = 11), hyperprolactinemia (HPRL) (n = 9), and miscellaneous or undetermined diagnosis (n = 23). By the means of a computed automatic classification of patients (cluster analysis) using five hormonal and ultrasonic criteria of PCOS, four homogeneous clusters of patients were obtained. Cluster #1 (25 patients) had the most characteristic profile of PCOS. It included 15 cases of PCOS and 7 cases of IH. Cluster #4 (47 patients) had the less characteristic profile of PCOS. It included the majority of patients with HA and HPRL and the half of the patients with IH. Cluster #2 included only two hyperandrogenic patients, who were massively obese and in whom ultrasonography may have failed to detect PCOS. Cluster #3 (16 patients) included patients from each diagnostic group, who were gathered together because ultrasonographic and hormonal features were, respectively, present and absent in nearly all of them. With the same analysis, the criteria of PCOS could be graded according to their grouping potential. The presence of an abnormal ovarian stroma by ultrasonography appeared as the most potent criterion. Elevated serum testosterone and androstenedione levels and the polyfollicular pattern of ovaries gave intermediate results, while elevated basal LH level was a much weaker grouping parameter. In conclusion, the automatic classification of patients by cluster analysis using both hormonal and ultrasonographic criteria revealed that the classical diagnostic classification, relying upon hormonal data exclusively, may arbitrarily separate patients having the same disease; and that ultrasonography affords pertinent information that should help provide a better diagnostic definition of PCOS.

The need for a calibrated imaging of polycystic ovaries (PCO) is now stronger than ever since the recent consensus conference held in Rotterdam, May 1–3, 2003. However, imaging PCO is not an easy procedure, and it requires a thorough technical and medical background. The two-dimensional (2-D) ultrasonography (U/S) remains the standard for imaging PCO and the current consensus definition of PCO determined at the joint ASRM/ESHRE consensus meeting on PCOS rests on this technique: either 12 or more follicles measuring 2–9 mm in diameter and/or increased ovarian volume (>10 cm3). The other techniques such as Doppler, 3-D U/S, and magnetic resonance imaging (MRI) can help for the diagnosis but are so far only second-line techniques.

The need for calibrated imaging of polycystic ovaries is now stronger than ever since the consensus conference held in Rotterdam in May 2003 to establish the diagnosis of the polycystic ovary syndrome. However, imaging polycystic ovaries is not an easy procedure, and it requires a thorough technical and medical background. Two-dimensional ultrasonography remains the standard for imaging polycystic ovaries, and the current consensus definition of polycystic ovaries determined at the joint Rotterdam meeting rests on this technique. The definition includes either 12 or more follicles measuring 2–9 mm in diameter and/or increased ovarian volume (>10 cm3) in at least one ovary. Other imaging techniques, such as Doppler and three-dimensional ultrasonography, can help in the diagnosis, but should be considered second-line techniques.

The need for a calibrated imaging of polycystic ovaries (PCO) is now stronger than ever since the recent consensus conference held in Rotterdam, May 1–3, 2003. However, imaging PCO is not an easy procedure and it requires a thorough technical and medical background. The two-dimensional ultrasonography remains the standard for imaging PCO and the current consensus definition of PCO determined at the joint American Society for Reproductive Medicine/European Society of Human Reproduction and Embryology (ASRM/ESHRE) consensus meeting on polycystic ovary syndrome rests on this technique: either 12 or more follicles measuring 2–9 mm in diameter and/or increased ovarian volume (>10 cm3). The other techniques, such as Doppler, three-dimensional, and magnetic resonance imaging, can help with the diagnosis, but are only second-line techniques.

Introduction The need for a calibrated imaging of polycystic ovaries (PCO) is now stronger than ever since the recent consensus conference held in Rotterdam in 2003. Indeed, the subjective criteria that were proposed 20 years ago and still used until recently by the vast majority of authors are now replaced by a stringent definition using objective criteria (Balen et al . 2003, The Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group 2004). Imaging PCO is not an easy procedure. It requires a thorough technical and medical background. The goal of this chapter is to provide the reader with the main issues ensuring a well-controlled imaging for the diagnosis of PCO. Two-dimensional (2D) ultrasonography will be first and extensively addressed since it remains the standard for imaging PCO. Other techniques such as Doppler, three-dimensional ultrasonography, and magnetic resonance imaging (MRI) will be then more briefly described. Two-dimensional (2D) ultrasonography: technical aspects and recommendations The transabdominal route should always be the first step of pelvic sonographic examination, followed by the transvaginal route, except in virgin or refusing patients. Of course, a full bladder is required for visualization of the ovaries. However, one should be cautious that an overfilled bladder can compress the ovaries, yielding a falsely increased length. The main advantage of the abdominal route is that it offers a panoramic view of the pelvic cavity. Therefore, it allows excluding associated uterine or ovarian abnormalities with an abdominal component. Indeed, lesions with cranial growth could be missed by using the transvaginal approach exclusively.

Summary OBJECTIVE By using vaginal endosonography, ovarian stromal hypertrophy has been shown to be a strong diagnostic feature of polycystic ovarian syndrome and related states. However, this sign is difficult to quantify and to correlate with other findings because of its subjectivity. We have evaluated the use of computer assisted analysis of ultrasound scans to provide more objective measurements of ovarian structure and size. DESIGN We used a computer assisted method for the reading of ultrasound scans. It allowed selective calculation of the stromal area by subtraction of the cyst area from the total ovarian area on a longitudinal ovarian section. PATIENTS A consecutive series of 57 patients with hyper-androgenism (group 1), 17 patients with hypothalamic anovulation (group 2) and 20 normal women (group 3). RESULTS By computerized measure, 75% patients from group 1 had a bilateral stromal area above the mean +2 SD (700 mm2) of women from group 3. All patients from group 2 were below this threshold. Serum LH level was above the normal range in 45% patients from group 1. The stromal area correlated positively with the serum A4-androstenedione (r= 047, P < 0.005) and 17α-hydroxy-progesterone (r= 039, P < 0.005) levels, exclusively in group 1. It did not correlate with the basal serum testosterone, LH or Insulin levels. The cyst area did not correlate with any hormonal parameter. CONCLUSION Ovarian stromal hypertrophy is a frequent and specific feature of hyperandrogenism. It correlates with the ovarian androgenic dysfunction. Its presence is not always linked with elevated serum Immunoreactive LH levels. Further data are needed to elucidate the role of insulin and ovarian growth factors.

We evaluated the superiority of vaginal ultrasonography (US) on the abdominal US for the diagnosis of polycystic ovarian disease (PCOD).The US pattern of ovaries was prospectively investigated by abdominal US and, whenever possible, by vaginal US.Primary care, institutional.One hundred forty-four women in whom PCOD was suspected on endocrine grounds and 62 other patients presenting with primary hyperprolactinemia (n = 23) or hypothalamic anovulation (n = 39).Vaginal US allowed a better analysis of the ovarian stroma.The external ovarian features of PCOD were observed by both routes in less than one third of the 144 patients with PCOD. The internal ovarian features of PCOD were much more frequently observed by vaginal US than by abdominal US (polycystic pattern: 66.7% versus 38.1%, P less than 0.05; increased ovarian stroma: 57.1% versus 4.8%, P less than 0.001). In the 62 patients without PCOD, US features of PCOD were observed in less than 10% of them, except for the uterine width/ovarian length ratio less than 1 and the polycystic pattern (abdominal US: 17% and 34%; vaginal US: 11% and 50%, respectively).An increased ovarian stroma seems to be the most sensitive and specific US sign of PCOD, providing that it can be investigated by vaginal US.