**6. Conclusion**

*Innovations in Assisted Reproduction Technology*

cycle cancelation was 66.7 and 94.7%, respectively [21].

The volume of the ovaries is calculated by imaging and callipering the ovary

in three perpendicular planes with using the formula of ellipsoid volume as (L1 × L2 × L3 × π/6). An alternative automatic method is calculation of Ovarian volume through "virtual organ computer-aided analysis" or VOCAL. The predictive performance of ovarian volume toward poor response is clearly inferior compared with that of AFC. Therefore, the AFC may be considered the test of first choice when estimating quantitative ovarian reserve before IVF. Total Basal Ovarian Volume (BOV) is obtained by adding the volumes of both. The ovarian volume is constant till the perimenopausal period and the measurement does not increase the

*Doppler ovarian stromal vascularity measurements with 2D doppler calculation of pulsatility index and* 

**5.2 Ovarian volume**

in the early menstrual cycle, the AFC is believed to correlate strongly with the number of primordial follicles present in the ovary and, thus, the ovarian reserve. Antral Follicles are routinely measured by 2 D transvaginal ultrasonography in the early follicular phase, by taking the mean of two perpendicular measurements. Inversion made is useful for counting multiple follicles. The numbers of follicles in both ovaries are added for the total Antral Follicle count. (AFC). AFC has been predominantly used as a marker of ovarian reserve over a period of time. A count of 8–10 is taken as a normal response of ovaries. Different diameters are used to define antral follicles of varying sizes as those measuring 2–6 and 7–10 mm. There is no clear consensus regarding the size of antral follicles, which truly represent ovarian reserve. The number of small antral follicles (2–6 mm) is significantly related to age and also to all endocrine ORTs tested, suggesting the number of small antral follicles represents the functional ovarian reserve. It is seen that the number of antral follicles of 2–6 mm in size decreases with age and correlates with other markers such as serum basal FSH and CCCT whereas follicles of size 7–10 mm remains constant and thus, the former appears to be a more reliable marker of ovarian reserve. Measurements taken repeatedly of the antral follicles have shown that there is only a limited intercycle variability. 3D ultrasound imaging also does not carry any better advantage in comparison to 2D ultrasound for the detection of functional ovarian reserve [22–25]. Meta-analyses showed that women with AFC less than four were 8.7 times more likely not to get pregnant after IVF (two studies; 95% CI,) than women with AFC four or more. The sensitivity and specificity of AFC to predict

**70**

**Figure 5.**

*resistivity index.*

Ovarian pathophysiology is complex. Ovarian folliculogenesis follicular rupture and luteal transition should be studied elaborately. Endometrial evaluation should be also done in a nonstimulated cycle. Serum hormone values should be measured in normal non-induced menstrual cycle to study the ovarian reserve and detect any undiagnosed synchronizing defects in embryo invasion and endometrial implantation window. Sonoendocrinology is a new imaging science deciphers the hormonal action on target organs. Antral follicle count, at a cut off value of less than four, had high specificity for the prediction of cycle cancelation in assisted reproduction. Ovarian volume, at a cut-off value 3 mL3 , had high specificity for the prediction of non-pregnancy and cycle cancelation in assisted reproduction. Doppler studies of ovarian stromal blood flow are promising, but more research is needed. AFC and ovarian volume provide direct measurements of ovarian response, while AMH, Inhibin B and estradiol are released from the growing follicles and so they reflect the follicular cohort that has been selected from the follicular pool.
