Ovarian Volume Assessment By Vaginal Three Dimensional Ultrasound Biology Essay

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There was a significant difference between observers in mean ovarian volume calculated by the prolate ellipsoid formula, which proved to be a significantly less reproducible technique than 3-D rotational volume calculation with VOCAL (virtual organ computer aided analysis). Rotational measurement of ovarian volume from 3D-US data is significantly more reliable between observers than volume estimation from 2-D parameters using the prolate ellipsoid formula.

Transvaginal ultrasound for each patient was carried out to exclude any genital or pelvic pathology, assess the ovarian morphology regarding the stromal echogenicity and determine the number, diameter and the distribution of the microcytes. Also, it was used to measure each ovarian dimensions to calculate the ovarian volume. Measuring the endometrial thickness and the uterine diameters for calculation of the uterine volume was done. Exclusion of ovulation was confirmed by extended ovarian folliculometry or by measuring the midluteal serum progstrone (ï‚£3 ng/ml).

Results: The patients mean age was 27.04.54 years, their mean body mass index was 33.65.40 kg/m2. Infertility was the main presenting symptom, while (51.7%) presented with hirsutism.

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It was found that there is a statistically significant difference between ovarian volume measured by 2 dimensional transvaginal ultrasound and 3 dimensional transvaginal ultrasound.

There was a positive significant correlation between body mass index and free-testosterone, and there was a negative significant correlation between body mass Index and LH. No significant difference in total testosterone levels, E2 , prolactin hormone, FSH was found between obese and lean PCOS women.

There was a positive significant correlation between ovarian volume (measured by 3D-US) and E2, total testosterone hormone. But no significant correlation between the ovarian volume and prolactin hormone, f-testosterone hormone, LH, FSH.

No, statistically significant correlation was found between BMI and ovarian volume measured by 3D-US, androgenic manifestations (hirsutism, acne) and BMI, and between androgenic manifestations and ovarian volume.

Conclusions: The mean ovarian volume measured by 3D ultrasound in PCO is significantly higher than ovarian volume measured by 2D ultrasound. There was a statistically positive significant correlation between ovarian volume measured by 3D-US and E2, total testosterone hormones. While no statistically significant difference between ovarian volume and prolactin, f-testosterone hormone, LH, FSH. Body mass index (BMI) had positive significant correlation with free-testosterone hormones, and a negative significant correlation with LH.

Keywords: Ovarian volume, addressed by 2 & 3 dimensional ultrasonography, hormonal status and PCOD.

INTRODUCTION

Clinically, PCOS is associated with short -

and long - term consequences. The short-term consequences include three groups of disorder: hyperandrogenic, reproductive and metabolic. These manifestations co-exist in variable combinations in different women with PCOS. The long - term sequelae include diabetes mellitus, dyslipidaemia, hypertension, cardiovascular disease and endometrial carcinoma. The reproductive problems associated with PCOS related to anovulatory subfertility and early pregnancy loss.(1)

ISSN 1110-0834Women with PCOS are at an increased risk of an adverse cardiovascular effects. In women with PCOS, elevated androgen and insulin levels are associated with an unfavourable lipid profile, an increase in LDL, a decrease in HDL and increases

in total cholesterol and triglyceride levels. Women with PCOS are at a 2.5-fold increased risk

of coronary atherosclerosis (as assessed by computerized tomography or angiography), carotid artery atherosclerosis and arterial stiffness compared to controls.(2)

A retrospective long-term study suggests that postmenopausal women with a history of premenopausal polycystic ovary syndrome do have a greater rate of hypertension (39%) than do control subjects (11%).(3)

In a population of women with PCOS, approximately 30% will have impaired glucose tolerance (IGT) and up to 10% will have diabetes.(4)

Miscarriage rates have been reported to be between 30 and 50% of all conceptions in women with PCOS. In addition, over 30% of women with recurrent miscarriages are reported to have PCOS. Several conditions exist in women with unexplained recurrent pregnancy loss (without PCOS), including high circulating levels of LH and free testosterone, low luteal progesterone, and delayed endometrial development.(5)

Studies have shown a clear relationship between the raised serum LH level often found in women with PCOS and early pregnancy loss.(6)

An association between PCOS and endometrial carcinoma was first suggested in 1949.(7) The mechanism which is generally assumed to be responsible for any increased risk of endometrial carcinoma in women with PCOS relates to prolonged anovulation with consequent continued secretion of oestrogen unopposed by progesterone.(8)

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Endometrial growth and differentiation in women with PCOS are influenced by androgens, insulin, and unopposed estrogens. In the absence of ovulation and the regulatory effects of progesterone, the endometrium does not undergo secretory trans-formation and is continuously exposed to the stimulatory and mitogenic effects of E2 that can lead to endometrial overgrowth, unpredictable bleeding patterns, hyperplasia, and cancer.(9)

Insulin receptors are present in normal endometrium and in endometrial cancers, suggesting the potential role of hyperinsulinemia in the growth and development of endometrial cancer. Endometrial cancer represents 8% of all cancers occurring in women, and those at highest risk are women who are obese, have type II diabetes, and PCOS, all of which may be associated with hyperinsulinemia.(5)

Because PCOS has profound implications for the woman in the short term with regard to reproductive function and also in the long-term with regard to chronic illness, PCOS therefore presents a major economic burden upon health resources. An estimate of the impact upon the health system in the USA suggested that this amounted to $4.36 billion.(10)

Traditionally, management of PCOS includes mainly ovulation induction, treatment of acne and hirsutism, and prevention of endometrial cancer. This can no longer be a sole focus, but women with PCOS should undergo comprehensive evaluation for diabetes and recognized cardiovascular risk factors and receive appropriate treatment as needed for prevention of these long-term health problems. PCO may arguably be one of the most serious and prevalent general health concerns of young women, given that an estimated 6 million women of child- bearing age in the United States only may have PCOS.(11)

So, generally there are four issues in the management of PCOS patients: regulation of menses, control of hirsutism, fertility issues, and the management of the insulin resistance IR syndrome and its associated risks (type 2 diabetes mellitus, dyslipidemia, and cardiovascular disease).(12)

Transabdominal (TA) and / or transvaginal ultrasound (TVU) have become the most

commonly used diagnostic methods for the identification of polycystic ovaries. With

advances in technology, in particular that of TVU, ultrasound has replaced laparoscopy and X-ray pelvic pneumogynaecography in the diagnosis of PCO.(13,14,15)

Transabdominal ultrasound has been largely superseded by transvaginal scanning because of greater resolution and in many cases patients preference, as the need for a full bladder is avoided which saves time and may be more comfortable.(16) Also transvaginal approach provides a more accurate view of the internal structure of the ovaries, avoiding apparently homogenous ovaries as described

with transabdominal scans, particularly in obese patients.(15)

The introduction of TVS and its high resolution technique allows visualization of follicles less

than 5 mm in diameter as well as echogenic stroma which corresponds closely to the characteristic histopathological changes.(16)

The recent innovation of three-dimensional (3-D) ultrasound, may further enhance the detection of polycystic ovaries, and may be more commonly employed in time.(17,18) Although 3-D ultrasound requires a longer time for storage and data analysis, increased training and more expensive equipment, good correlations were found between 2-D and 3-D ultrasound measurements of ovarian volume and polycystic ovary morphology.(19)

Three-dimensional (3-D) ultrasound scanning permits visualization of the coronal plane of the pelvis and more accurate measurement of the total ovarian volume and stromal volume. The precision and high degree of reproducibility of ovarian volume and endometrial volume measurements obtained using this technique have been reported and compared with conventional two-dimensional (2D) ultrasound volume measurements.(18,20) The advantage of using a 3D ultrasound system lies in its ability to prove follicular measurements which can be subtracted from the total volume to give a more accurate estimation of stromal volume. Several investigators have carried out similar studies using conventional ultrasound but were limited to measurement of total ovarian volume only.(21) This is because 2D ultrasound has no facility for the visualization of follicles simultaneously in three planes which is essential if duplication of follicle numbers and measurements is to be avoided. For the first time, 3D ultrasound permits the relative contributions of follicles and stroma to the total volume to be estimated and correlation with various endocrine parameters should provide a sound basis for comparative studies and may improve the understanding of the underlying pathophysiological mechanisms in PCOS.(22)

To avoid the difficulties in outlining or measuring ovarian size, 3D ultrasound has been proposed using a dedicated volumetric probe or a manual survey of the ovary. 3D ultrasound has been used to measure ovarian and stromal volumes, providing information that is not available from two-dimensional (2D) ultrasound. Data are transferred to a computer and can be analyzed later and the volume can be more accurately evaluated.(23)

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It is necessary to identify each ovary and measure the maximum diameter in each of three planes (longitudinal, anteroposterior and transverse). It is recognized that because of the irregular shape of the ovary, any calculation of the volume of a sphere or prolate ellipse is, at best an estimate. The left ovary may be more difficult to measure because of the overlying sigmoid colon. Modern ultrasound machine can calculate volume once the callipers have been used to measure the ovary and an ellipse is drawn around the outline of the ovary. The ultrasound software for this calculation appears to be accurate.(15)

Traditionally, the calculation of ovarian volume has been performed using the formula for a

prolate ellipsoid (/6 x maximal longitudinal,

anteroposterior and transverse diameters).(24,25)

As /6=0.5233, a simplified formula for a prolate ellipse is (0.5 x length x width x thickness).(25) In practice, this formula is both easy to use and of practical value.

A large number of different ultrasound formulae with different weightings for the different diameters were used to calculate ovarian volume, and the prolate spheroid formula (/6 x anteroposterior diameter2 x transverse diameter) was found to correlate well with ovarian volume as assessed by 3-D ultrasound.(26)

The association between the presence of typical ovarian morphology and clinical and biochemical indices of PCOS has been confirmed. Both serum LH and testosterone levels are elevated, with normal serum FSH levels.(27,28)

Although several ultrasound features such as total ovarian volume and stromal hypertrophy(29) and increased stromal blood flow(145) have been shown to correlate accurately with PCOS, a correlation between the degree of ultrasound morphology changes and the severity of the endocrinopathy in women with PCOS has not been extensively investigated.(31)

The ultrasound finding of polycystic ovaries in the general population is in the order of 17-22%(32) and in women with anovulation and idiopathic hirsutism is much higher at ~ 90.0%.(33)

The development of TVS has also identified

a small group of women with one polycystic ovary in whom the contralateral ovary can be clearly visualized and appears normal. It has been reported that the women with bilateral PCO had higher concentrations of androstenedione and LH to

FSH ratios than women with unilateral PCO.(34) Furthermore, in women with unilateral PCO, grey scale and doppler ultrasound showed different features in the affected and the unaffected ovary, similar to the appearance of the polycystic and

the normal ovary, respectively.(34) This study was conducted to compare between ovarian volume measured by two-dimensional and three-dimensional transvaginal ultrasound, also to correlate these measurements with some hormonal status of 30 selected polycystic ovarian syndrome (PCOS) patients.

METHODS

This study was carried out at El-Shatby Maternity University Hospital. The study included 30 women recruited from the out patient clinic from March 2005 till December 2006 and were diagnosed as having polycystic ovary syndrome according to the criteria of ASRM/ESHRE consensus meeting on PCO held in Rotterdam (2003).(35)

The definition required the presence of two from the following three criteria:

Oligo-and/or anovulation.

Hyperandrogenism (clinical and/or biochemical).

12 or more follicles measuring 2-9 mm in diameter or increased ovarian volume >10 cm3 on vaginal/abdominal ultrasound.

All patients recruited in the study signed a concent to participate after explaining the objectives of the research to them, they were all subjected to:

History taking:

Full name, age, marital status, telephone number and address. Past history of hypertension or diabetes mellitus, menstrual history including the age of menarche, menstrual pattern, dysmenorrhea and any related symptoms, family history of similar condition and/or diabetes, history of weight loss thorough medication or diet restriction and exercises and treatment of hirsutism by laser or by epillation.

Clinical examination:

General examination, vital signs, breast examination to exclude the presence of galactorrhea, abdominal examination, bimanual pelvic examination of both adnexa and uterus for detection of any abnormality in the female genital tract, measurement of weight (kgs), Height (mt) to calculate the Body mass index (BMI) using the metric formula and Hyperandrogenic manifestations e.g. hirsutism, acne and male baldness.

Investigations:

All patients were evaluated on the 3rd or 4th day of spontaneous menstruation or at any time if amenorrhea was present to get basal hormonal profile:

Hormonal analysis:

Serum FSH (follicular stimulating hormone) 3.3-11.3(mIU/ml), serum LH (lutinizing hormone) 1.6-10.1(mIU/ml), total serum testosterone 0.22-0.8(ng/ml), free serum testosterone 1.5 -6.5(pg/ml), estrogen (E2) Upto 178(pg/ml), serum prolactin 3.9-29.5(ng/ml) and mid-luteal serum progesterone (21st - 24th day) of the cycle or at any time if amenorrhea was present.

All hormones were analysed by using the electrochemiluminescence immunoassay "ECLIA", the assay was based on competitive test principle using a monoclonal antibody specifically directed against the hormone that was analysed.

Vaginal ultrasound:

Scanning was done using the sono Ace 9900 with a 6.5 MHz vaginal probe (Medison Co. LTD Seoul, Korea) for: Folliculometry, ovarian morphology and ovarian volume.

Statistical analysis:

The Data was collected and entered into the personal computer. Statistical analysis was done using Statistical Package for Social Sciences (SPSS/version 15) software.

The statistical tests were:

t-test was used for independent groups, Person correlation coefficient was used to detect the correlation between different variables. The level of significant was 0.05.

RESULTS

The study included 30 women recruited from the out patient clinic and were diagnosed as having polycystic ovary syndrome during the period from March 2005 till December 2006. One patient excluded from the study due to failure of follow up.

Table (1) shows the distribution of the cases according to their age and age of menarche. 21 women (72.4%) were in age group: 20-30 years, while 8 females (27.6%) were > 30-40 years. The age of the patients ranged from 20-39 years with a mean of 27.04.54 years.

Age of menarche was  14 years in 11 females (37.9%), while it was > 14 years in 18 females (62.1%). It ranged from 10-17 years with a mean of 13.71.44 years.

Table (II) demonstrats the distribution of the cases according to their body mass index. There was one female (3.4%) with normal body mass index (18.5-24.9kg/m2), 3 females (10.3%) were over weight (25-29.9 kg/m2), 11 females (37.9%) were obese (30-34.9 kg/m2), while 14 females (48.3%) had morbid obesity ( 35 kg/m2). The range of the body mass index was between 18.75-40.24 kg/m2with a mean of 33.65.40 kg/m2.

Table (III) represents the distribution of the

cases according to their metabolic changes and androgenic manifestations. In 24 females (82.8%) there were no metabolic changes, 2 females (6.9%) were hypertensive, and 3 females (10.3%) were diabetics. There were 14 females (48.3%) with no androgenic manifestations, 15 females (51.7%) with hirsutism and one female (3.5%) had both acne and hirsutism.

Table (IV) shows the distribution of the cases according to the type of infertility. There were 20 females (69.0%) with primary infertility, while 9 females (31.0%) had secondary infertility.

Table (V) shows the mean ovarian volume (using 2D and 3D- vaginal ultrasound methods), uterine volume and endometrial thickness in the studied patients. Mean ovarian volume using 3D-US ranged from 11-26.61cc with a mean of 16.44.21cc, while it was ranging from 6.2-28.3cc with a mean of 12.35.7cc using 2D-US, and the difference was statistically significant (p = 0.013). Uterine volume ranged from 34.67-136.03cc with a mean of 68.226.41cc, while endometrial thickness ranged from 3-15mm with a mean of 92.7 mm.

Table (VI) represents the basal hormonal profile levels of the studied cases. E2 ranged from 29.4-78.4 pg / ml with a mean of 53.814.43pg/ml, prolactin ranged from 5.6-18.5 ng/ml with a mean of 11.232.83ng/ml, F-testosterone ranged from 1.63-13.8pg/ml with a mean of 5.63.14pg/ml, T-testosterone ranged from 0.24-1.71ng/ml with a mean of 0.70.39ng/ml, LH ranged from 4.8-19.7mIU with a mean of 13.05.11mIU, while FSH ranged from 3.7-8.61mIU with a mean of 5.81.46 mIU.

Table (VII) represents the percentage of normal and abnormal finding of the studied hormones. There was no abnormal finding regarding the prolactin, E2 and FSH. 15 cases (51.7%) had abnormal f-testosterone values, 14 cases (48.3%) had abnormal t-testosterone values while 8 cases (27.6%) had abnormal LH values.

Table (VIII) represents the correlation between BMI and the studied hormones. There was a positive significant correlation between body mass index (BMI) and f-testosterone hormone (p= 0.042), and a negative significant correlation between BMI and luteinizing hormone (p= 0.04). While there were no significant correlation between BMI and E2 (p= 0.486), prolactin (p= 0.511), t-testosterone (p= 0.91), FSH (p= 0.351).

Table (IX) represents the correlation between ovarian volume measured by 3D-US and the

studied hormones. There was a positive significant correlation between ovarian volume and E2 (p= 0.012), t-testosterone (p= 0.029). While there was no statistically significant correlation between ovarian volume and prolactin (p= 0.51), f-testosterone (p= 0.61), LH (p= 0.061), FSH (p= 0.061).

Correlation between body mass index and ovarian volume was presented in table (16). There was no significant correlation between body mass index and ovarian volume (P=0. 35).

Table (X) shows the body mass index and

ovarian volume of the cases with and without androgenic manifestations. In patients where androgenic manifestations were positive (n=15), the body mass index ranged from 26.85-40.24 kg/m2 with a mean of 34.76.11kg/m2, while in those with no androgenic manifestations (n=14) the body mass index ranged from 18.75-39.44 kg/m2 with a mean

of 32.14.65 kg/m2. There was no significant difference in body mass index between those

with and those without androgenic manifestations (P=0.128).

In patients with positive androgenic manifestations (n=15), ovarian volume ranged from 11.73-27.34cc with a mean of 16.724.24cc, while in those with no androgenic manifestations, the ovarian volume ranged from 12.1-22.73cc with a mean of 17.254.12cc. There was no significant difference in ovarian volume between those with and those without androgenic manifestations. (P=0.073).

Table I: Distribution of the cases according

to their age and age of menarche.

Frequency

No =29

%

Age group

20-30 years

> 30-40 years

21

8

72.4

27.6

Range

MeanS.D.

20 - 39

27.04.54

Age of menarche

ï‚£ 14 years

> 14 years

11

18

37.9

62.1

Range

MeanS.D.

10 - 17

13.71.44

Table II: Distribution of the cases according

to their body mass index.

Frequency

No =29

%

Body Mass index

Normal wt (18.5-24.9)

Over wt.(25-29.9)

Obese (30-34.9)

Morbidly obese ( 35)

1

3

11

14

3.4

10.3

37.9

48.3

Range

MeanS.D.

18.75 - 40.24

33.65.40

Table III: Distribution of the cases according to their metabolic

changes and androgenic manifestations.

Frequency

No =29

%

Metabolic changes

No Hypertension or Diabetes

Hypertension

Diabetes mellitus

24

2

3

82.8

6.9

10.3

Androgenic manifestations

No

Hirsutism

14

15

48.3

51.7

Table IV: Distribution of the cases according

to their type of infertility.

Frequency

No =29

%

Type of infertility

Primary

Secondary

20

9

69.0

31.0

Table V: Mean ovarian volume, uterine volume and endometrial thickness in the studied patients.

Range

Mean ± S.D.

t

p

Ovarian volume (cc) by 3D-US

11-26.61

16.4±4.21

2.59

0.013*

Ovarian volume (cc) by 2D-US

6.2-28.3

12.3±5.7

Uterine volume (cc) by 2D-US

34.67-136.03

68.2±26.41

Endometrial thickness (mm) by 2D-US

3-15

9±2.7

* P is significant if ï‚£ 0.05

Table VI: Basal hormonal profile levels of the studied cases.

Patients range

Mean ± S.D.

E2 (pg/ml)

29.4 - 78.4

53.814.43

Prolactin (ng/ml)

5.6 - 18.5

11.23 2.83

F-testosterone (pg/ml)

1.63 - 13.8

5.6 3.14

T- testosterone (ng/ml)

0.24 - 1.71

0.7 0.39

LH (mIU/ml)

4.8 - 19.7

13.0 5.11

FSH (mIU/ml)

3.7 - 8.61

5.8 1.46

The normal values of the different measured hormones are

E2 (pg/ml)

Upto 178

Prolactin (ng/ml)

3.9-29.5

F-testosterone (pg/ml)

1.5 -6.5

T- testosterone (ng/ml)

0.22-0.8

LH (mIU/ml)

1.6-10.1

FSH (mIU/ml)

3.3-11.3

Table VII: Percentage of normal and abnormal finding

of the studied hormones

Hormone

Normal

finding

Abnormal

finding

No.

%

No.

%

E2 (pg/ml)

29

100

0

0.0

Prolactin (ng/ml)

29

100

0

0.0

F-testosterone (pg/ml)

14

48.3

15

51.7

T- testosterone (ng/ml)

15

51.7

14

48.3

LH (mIU/ml)

21

72.4

8

27.6

FSH (mIU/ml)

29

100

0

0.0

Table VIII: Correlation between body mass index

and different hormonal levels.

Body mass index #

r

p

E2 (pg)

-0.07

0.486

Prolactin (ng)

0.086

0.511

F-testosterone (pg)

0.45

0.042*

T- testosterone (ng)

0.007

0.91

LH (mIU)

-0.45

0.04*

FSH (mIU)

-0.22

0.351

* P is significant if ï‚£ 0.05

Table IX: Correlation between ovarian volume (measured by

using 3D-US) and different hormonal levels.

Ovarian volume #

r

p

E2 (pg)

0.606

0.012*

Prolactin (ng)

0.146

0.511

F-testosterone (pg)

0.074

0.61

T- testosterone (ng)

0.45

0.029*

LH (mIU)

0.318

0.061

FSH (mIU)

-0.334

0.061

* P is significant if ï‚£ 0.05

Table X: Body mass index and ovarian volume in cases with

and without androgenic manifestations.

Androgenic manifestations

p

Positive

n=15

Negative

n=14

Body mass index

Range

Mean S.D.

26.85-40.24

34.76.11

18.75-39.44

32.14.65

0.128

Ovarian volume

Range

Mean S.D.

11-26.61

16.724.24

12.1-22.73

17.254.12

0.073

* P is significant if ï‚£ 0.05

DISCUSSION

In the present study the distribution of PCOS study group according to their BMI was: 1 woman normal weight (3.4%), 3 women over weight (10.3%), 11 women obese (37.0%) and 14 of them had evident clinical and morbid obesity (48.3%).

In accordance with our results, Hoeger,(36)

stated that the prevalence of obesity in PCOS is at least (50.0%) in most studies, although in some reported studies estimates are closer to (70.0%). Sikka et al, (37) had similar results.

Considering the metabolic changes among our studied patients, 24 women (82.8%) were free, 3 women (10.3%) were diagnosed as diabetics, while 2 women (6.9%) were hypertensive, their mean age was 30 years and their mean body mass index was 34 kg/m2.

Regarding hypertension in PCOS women, there are some controversy as to whether PCOS perse is associated with hypertension. Many previous studies have found no difference in blood pressure between PCOS women and controls.(38-40)

In contrary to our results is that of Rabelo and Vick,(41) who reviewed 39 medical records of patients with PCOS, he found that hypertension was present in (36.0%) of them and diabetes mellitus type 2 was present in (37.0%). The mean age of those patients was 29.4 years and their body mass index was 36.0 kg/m2.

Focusing on diabetes mellitus type 2 in PCOS patients, it was found in some studies that

obese PCOS women had 10-fold increase in the development of insulin growth tolerance or diabetes, and over weight women had a 7-fold increase compared with normal weight PCOS women. This rate seems to be highly dependent on BMI.(36)

In this study 14 women (48.3%) were free from any androgenic manifestations such as hirsutism or acne but 15 women (51.7%) had hirsutism and 1 woman (3.5%) had both hirsutism and acne. This agreed with a study of Sikka et al,(37) which was conducted on 100 anovulatory infertile women with PCOS and (70%) of them were hirsute.

Almost the same percentage of hirsutism (66.9%) was found in a study of Gonzalez et al,(42) on 211 women with polycystic ovaries. (49.6%) hirsutism

in adult group  19 years and (64.7%) hirsutism

in adolescent group (ï‚£ 18 years) was found by Gulekli et al,(43) among patients with US diagnosed polycystic ovaries. In his study Meyer et al,(40)

found that subjects with PCOS had higher significant hirsutism score compared with controls (p < 0.05).

In this study 20 women (69.0%) were complaining from primary infertility, while 9 women (31.0%) were complaining from secondary infertility.

In a study conducted by Hemeida et al,(44) on forty patients with resistant polycystic ovary syndrome, the mean age of the patients was 29.5 ± 4.9 years. Primary infertility was the presenting symptom in 26 women (65.0%) while the remaining 14 (35.0%) had secondary infertility. Actually the patients of the secondary type of infertility are more likely to become pregnant while the reverse is true for primary infertility. Almost the same percentage was found by Abbasi et al,(45) where 11 patients (68.75%) had primary infertility and 5 patients (31.25%) had secondary infertility.

This study revealed that there was a statistically significant difference between the mean ovarian volume measured by using 2D-us conventional method and the mean ovarian volume measured

by using 3D-us VOCAL method "virtual organ computer aided analysis" imaging program. The mean ovarian volume obtained by 3D - US measurements was 16.4 ± 4.2 cc, while by 2D-US it was 12.3 ± 5.7 cc.

Similar results were reported from a study conducted by Nardo et al,(26) on 23 PCOS infertile women with CC (clomiphene citrate)-resistance [where the mean 3D total ovarian volume was 13.81.3 cm3, while the mean conventional elliptoid 2D total ovarian volume was 12.61.8 cm3]. A significant correlation between 3D and 2D-US measurements of ovarian volume was observed (p<0.001). Both 3D and 2D formulas produced high reproducibility in PCO morphology.

This also was consistent with the results concluded from a study done by Wu et al,(46) who stated that the volume of the ovary from 3D sonography correlates better with direct measurement of the surgical specimen than that from 2D-us and that the volume measurement in 3D-us is accurate and highly reproducible. The mean ovarian volume obtained by 3D-US was 11.3  3.5 cm3 in PCOS patients and was 5.41.3 cm3 in the normal controls (p<0.0001) i.e. the ovaries in PCOS patients were significantly increased compared with those of the normal controls.(46)

In this study, the endometrial thickness ranged from (3-15 mm) with a mean of (92.7 mm). In a study done by Iatrakis et al,(47) the mean thickness of the endometrium was statistically higher in PCOS group (11.16.0 mm) compared with the control group (6.22.9 mm).

In our study the correlation between body mass index and different hormones revealed that there was a positive significant correlation between body mass index (BMI) and free testosterone hormone, and a negative significant correlation between BMI and LH.

Regarding the relation between BMI and serum free testosterone hormone, our results were in agreement with that of Kiddy et al,(48) who found that obese PCOS women had higher free testosterone concentration compared with normal weight PCOS women. Also, our results agreed with Hemeida et al,(44) study who found a strong positive correlation between BMI and free testosterone levels. The same found by Yoshino et al.(49)

Regarding the relation between BMI and LH,

in Rechkemmer et al,(50) study they found a statistically significant difference in LH values between lean and obese PCOS patients, where

there were lower LH levels in PCOS patients with

a BMI  25 kg/m2. The same was concluded from

a study done by Srouji et al,(51) who found that

there is an inverse relationship between LH and

BMI in his studied population. Also, the studies of Pagan et al.,(52) Li and Lin,(53) Dale et al,(54) and Tayler (55) found the same results.

In contrast to our study, is that of

Aboul Nasr et al,(56) who found that there is no significant difference in LH between obese and non-obese PCOS cases.

But in our study there was no statistically significant difference in total testosterone hormone levels, estradiole (E2), prolactin hormone, follicle stimulating hormone (FSH) between obese and lean PCOS women.

This agreed with Singh et al,(57) who evaluated

the hormonal profiles of 56 women with PCOS

and correlated them with obesity, they found that there were no statistically significant difference in the mean serum testosterone levels between obese and non-obese cases. This also agreed with a study done by Aboul Nasr et al,(56) Kiddy et al (48).Also Yoshino et al,(49) and Silfen et al,(58) found the same results, inspite of a significant decrease in serum hormone binding globulin (SHBG) was noted in obese adolescents.

In contrast to our results is that of Holte et al,(59) study where testosterone levels were positively associated with BMI in PCOS study group.

Regarding the relation between BMI and FSH similar to our results is what was reported by

Kiddy et al,(48) who found that there was an inverse relation between follicle stimulating hormone (FSH) and BMI, in obese PCOS women with BMI 25 kg/m2.

There are a lot of contradictory results about the most significant hormone correlated with the ovarian volume in PCOS women.

In this study there was a statistically significant correlation between the ovarian volume measured

by 3D-US and estradiol hormone (E2),

t-testosterone, while there was no statistically significant correlation between the ovarian volume and prolactin hormone, f-testosterone hormone, LH, FSH.

In agreement with our results Pache et al,(60)

found that only testosterone levels were statistically significant predictors of increase in follicle

number, ovarian volume and stroma amount. But, Gulekli et al,(43) reported that ovarian volume had a significant positive correlation with LH, total and free testosterone hormone in adolescent and adult PCOS groups.

Also, in a study conducted by Hahn et al,(61) on 133 untreated PCOS patients and 54 healthy control women, they found that all biochemical parameters of hyperandrogenism were significantly higher in PCOS patients than controls. Free testosterone correlated significantly with ovarian volume. Also, it was found that testosterone levels and the free androgen index (FAI) correlated significantly with ovarian volume, and that PCOS women with a combination of increased ovarian volume and follicle number had higher testosterone levels compared to women

with increased follicle count but normal ovarian volume.

In contrast to this study, Nardo et al,(62) found positive significant correlation between ovarian volume and LH concentration, but no significant correlation with testosterone hormone.

In this study there was no significant correlation between BMI and the mean ovarian volume. This agreed with the results of Aboul Nasr et al,(57) who found no statistically significant difference between obese and non-obese women in the study groups regarding the ovarian volume, although the mean ovarian volume in non-obese group was 11.21  2.23cc, while in the obese group is was 15.77  9.57 cc. Also the same was found by Sengos et al,(63) where the mean ovarian volume did not differ significantly between lean and obese PCOS women (12.5±3.7 vs 16.1±5.3 p < 0.05).

In contrast to our result was that of Sikka et al, (37) who found in their study that there was positive significant correlation between ovarian volume and body mass index and also in Bastos et al,(64) study the same was found.