High-intensity focused ultrasound for potential treatment of polycystic ovary syndrome: toward a noninvasive surgery  Islam A. Shehata, M.D., M.Sc., John R. Ballard, Ph.D., Andrew J. Casper, Ph.D., Leah J. Hennings, D.V.M., Erik Cressman, M.D., Ph.D., Emad S. Ebbini, Ph.D.  Fertility and Sterility  Volume 101, Issue 2, Pages 545-551.e2 (February 2014) DOI: 10.1016/j.fertnstert.2013.10.023 Copyright © 2014 American Society for Reproductive Medicine Terms and Conditions

Figure 1 HIFU-induced tissue damage in canine ovaries. (A) The 2 seconds of sonication resulted in a zone of tissue damage (arrows) measuring about 6.7 × 4.8 mm. (B) The 1-second exposure resulted in a smaller zone of damage (arrows) measuring about 3.2 × 2.7 mm in maximum cross sections. Fertility and Sterility 2014 101, 545-551.e2DOI: (10.1016/j.fertnstert.2013.10.023) Copyright © 2014 American Society for Reproductive Medicine Terms and Conditions

Figure 2 DMUA monitoring of HIFU therapy. (A) DMUA imaging showing well-localized echogenic changes (arrows) that developed after a 750-ms sonication time. (B) Corresponding tissue slice showing localized damage (arrows) that correlated well with the echogenic changes detected by DMUA imaging. Note the high DMUA imaging resolution that showed the hypoechoic follicles (labeled F) with good correlation with the actual gross anatomy in panel B. Fertility and Sterility 2014 101, 545-551.e2DOI: (10.1016/j.fertnstert.2013.10.023) Copyright © 2014 American Society for Reproductive Medicine Terms and Conditions

Figure 3 Histology analysis of HIFU damage in bovine ovaries. (A) Ultrasound image showing the design of HIFU therapy in bovine ovary. Two sets of HIFU lesions (cigar shaped) were placed close to an ovarian follicle (labeled F) as a landmark. The arrow shows the direction of HIFU beam. (B) Echogenic changes (outlined) were seen by the end of sonication for set no. 2. (C) Hematoxylin and eosin staining of the treated ovary (×40 magnification) showing a rather ellipsoid area of tissue damage corresponding to one of the HIFU shots. (D) ×200 magnification of the damaged area (above the line) showing evidence of tissue ablation in the form of hypereosinophilia (coagulation), nuclear pyknosis, and tissue shrinkage. Fertility and Sterility 2014 101, 545-551.e2DOI: (10.1016/j.fertnstert.2013.10.023) Copyright © 2014 American Society for Reproductive Medicine Terms and Conditions

Figure 4 Ovarian surface before and after HIFU therapy. (A) Canine ovary fixed in gelatin before therapy. (B) The same ovary after HIFU therapy showing smooth surface with no evidence of damage, despite the damage induced within the ovarian stroma, shown in Figure 2. Fertility and Sterility 2014 101, 545-551.e2DOI: (10.1016/j.fertnstert.2013.10.023) Copyright © 2014 American Society for Reproductive Medicine Terms and Conditions

Supplemental Figure 1 The experimental setup. (A) Gelatin-fixed ovaries (labeled O) are placed within a tissue holder (labeled H) above a tank containing degassed water (labeled W) that serves as a coupling medium for ultrasound propagation. (B) The tissue holder is immersed in the degassed water in front of the integrated DMUA transducer (labeled T). The arrow shows the direction of the HIFU beam. Fertility and Sterility 2014 101, 545-551.e2DOI: (10.1016/j.fertnstert.2013.10.023) Copyright © 2014 American Society for Reproductive Medicine Terms and Conditions

Supplemental Figure 2 Correlation between conventional B-mode and DMUA imaging. (A) Conventional B-mode imaging obtained from the diagnostic transducer within the central fenestration of the integrated transducer showing a peripheral slightly hypoechoic ovarian cortex (labeled C) and a central relatively more echogenic medulla (labeled M). (B) Corresponding DMUA imaging showing the same corticomedullary differentiation as in panel A. Fertility and Sterility 2014 101, 545-551.e2DOI: (10.1016/j.fertnstert.2013.10.023) Copyright © 2014 American Society for Reproductive Medicine Terms and Conditions