The Medical and Surgical Practice of NaProTECHNOLOGY, 259-268, 2004
Chapter 20: Disorders of Human Ovulation: Sonographic Classification System
Thomas W Hilgers
Author affiliations
Pope Paul VI Institute for the Study of Human Reproduction, Omaha, Nebraska.ROR
Abstract
Serial transvaginal ultrasound monitoring of follicular dynamics -- growth, rupture, corpus luteum formation, and free fluid -- forms the basis of a systematic classification of human ovulation disorders, including anovulation, luteinized unruptured follicle (LUF), follicular arrest, premature luteinization, and PCOS-type patterns. Anchoring sonographic findings to the CrMS Peak day allows precise correlation between ultrasound events and cervical mucus biomarkers, creating a reproducible diagnostic taxonomy that drives targeted medical and surgical treatment within the NaProTECHNOLOGY framework.
how is ovulation evaluated by ultrasound, what is a luteinized unruptured follicle, what is empty follicle syndrome, can you ovulate without releasing an egg with regular periods, types of ovulation disorders diagnosed by ultrasound, serial follicular ultrasound monitoring for infertility, cumulus oophorus on ultrasound meaning, is my ovulation normal if my cycles are regular
Hilgers et al. 2004, Hilgers 2004
Cite this article
Hilgers, T. W. (2004). Chapter 20: Disorders of Human Ovulation: Sonographic Classification System. The Medical and Surgical Practice of NaProTECHNOLOGY, 259-268.
Hilgers TW. Chapter 20: Disorders of Human Ovulation: Sonographic Classification System. The Medical and Surgical Practice of NaProTECHNOLOGY. 2004:259-268.
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Ovulatory disorders are common causes of amenorrhea, abnormal uterine bleeding and infertility and are frequent manifestations of polycystic ovary syndrome (PCOS). There are many potential causes and contributors to ovulatory dysfunction that challenge clinicians, trainees, educators, and those who perform basic, translational, clinical and epidemiological research. Similarly, therapeutic approaches to ovulatory dysfunction potentially involve a spectrum of lifestyle, psychological, medical and procedural interventions. Collaborative research, effective education and consistent clinical care remain challenged by the absence of a consensus comprehensive system for classification of these disorders. The existing and complex system, attributed to the World Health Organization (WHO), was developed more than three decades ago and did not consider more than 30 years of research into these disorders in addition to technical advances in imaging and endocrinology. This article describes the development of a new classification of ovulatory disorders performed under the aegis of the International Federation of Gynecology and Obstetrics (FIGO) and conducted using a rigorously applied Delphi process. The stakeholder organizations and individuals who participated in this process comprised specialty journals, experts at large, national, specialty obstetrical and gynecological societies, and informed lay representatives. After two face-to-face meetings and five Delphi rounds, the result is a three-level multi-tiered system. The system is applied after a preliminary assessment identifies the presence of an ovulatory disorder. The primary level of the system is based on an anatomic model (Hypothalamus, Pituitary, Ovary) that is completed with a separate category for PCOS. This core component of the system is easily remembered using the acronym HyPO-P. Each anatomic category is stratified in the second layer of the system to provide granularity for investigators, clinicians and trainees using the GAIN-FIT-PIE mnemonic (Genetic, Autoimmune, Iatrogenic, Neoplasm; Functional, Infectious and Inflammatory, Trauma and Vascular; Physiological, Idiopathic, Endocrine). The tertiary level allows for specific diagnostic entities. It is anticipated that, if widely adopted, this system will facilitate education, clinical care and the design and interpretation of research in a fashion that better informs progress in this field. Integral to the deployment of this system is a periodic process of reevaluation and appropriate revision, reflecting an improved understanding of this collection of disorders.
To assess prospectively luteinized unruptured follicle (LUF) syndrome in juvenile idiopathic arthritis (JIA) patients with and without non-steroidal anti-inflammatory drugs (NSAIDs) and healthy controls. Twenty-three adolescent and young adult female JIA patients (ILAR criteria) and 11 female healthy subjects were studied by pelvic ultrasound monitoring for follicular development and ovulation in one menstrual cycle. LUF syndrome was prospectively investigated by pelvic ultrasound with a dominant ovarian follicle without signs of follicular rupture, with elevation of serum progesterone in the luteal phase of the menstrual cycle and luteinizing hormone (LH) detected in the urine. Comparison between JIA patients with (n = 8) vs. without NSAIDs (n = 15) and healthy controls (n = 11) revealed that LUF syndrome was significantly higher in the former group (2 (25%) vs. 0% vs. 0%, p = 0.049). These two patients with LUF syndrome had normal menstrual cycles without reduced ovarian reserve, and they were under naproxen 500 mg bid during the menstrual cycle. Disease duration was comparable in JIA with and without NSAIDs [19.8 (4.4-25) vs. 13 (3.1-33) years, p = 0.232]. Further comparison between JIA patients with and without NSAIDs and healthy controls showed similar mean anti-Müllerian hormone levels (p = 0.909), estradiol (p = 0.436), FSH (p = 0.662), LH (p = 0.686), and mean antral follicle count (p = 0.240) and ovarian volume (p = 0.363). No differences were evidenced in three groups regarding Caucasian race, body mass index, duration, and length of menstrual cycles (p > 0.05). This is the first study to identify that JIA patients have a high frequency of LUF without impaired ovarian reserve. Future prospective studies are necessary to determine if chronic/continuous use of NSAIDs in JIA will have an impact in these patients' fertility.
Hilgers TW, 2004·The Medical and Surgical Practice of NaProTECHNOLOGY·
Ovarian cysts in NaProTECHNOLOGY are classified as functional (follicular cysts, luteinized unruptured follicle, corpus luteum cysts) or pathological (endometriomas, neoplasms) through serial cycle-timed transvaginal ultrasound correlated with CrMS Peak day observations and post-Peak progesterone and estradiol profiles. Management of functional cysts uses cooperative progesterone replacement and targeted HCG injections to normalize corpus luteum function and reduce cyst recurrence without contraceptive suppression, while pathological or persistent cysts are addressed through fertility-sparing laparoscopic surgery with anti-adhesion technique.
The empty follicle syndrome was assessed using transvaginal ultrasonography in a group of 152 consecutive women with unmedicated menstrual cycles being studied because of primary or secondary infertility or repetitive miscarriage. The overall frequency of the empty follicle syndrome was found to be 43.4%. The frequency increased with age but was independent of gravidity. The empty follicle syndrome may be a significant etiologic factor in infertility or other reproductive abnormalities, and transvaginal ultrasound represents a good, non-invasive means of evaluating it.