1. COMPARATIVE STUDY OF OVARIAN RESERVE BETWEEN THE USERS AND NON USERS OF ORAL CONTRACEPTIVES Abstract id: 1183

2. This study aims 1.To quantify and compare the sonographic ovarian reserve markers in the users and non users of oral contraceptives. 2.To show that sonographic ovarian reserve assessment still retains its efficacy as it is safer and cheaper than hormonal studies. AIMS AND OBJECTIVES

3. This study included 500 women aged between 18 – 45 years for a period of 12 months, of which - 260 were non users and - 240 were users (of which 30% were former pill users). Sonographic ovarian reserve includes ovarian volume and antral follicular count which were done using transvaginal ultrasound on day 2–5 of the menstrual cycle. MATERIALS AND METHOD

4. METHOD OF COLLECTION OF DATA A profoma was prepared for the study of all patients based on - regularity of mensuration, - use of oral contraceptives, - measurement of antral follicle count and - ovarian volume. Study type : Prospective study.

5. METHOD OF COLLECTION OF DATA INCLUSION CRITERIA: -Patients who are married and are in reproductive age group (18 to 45 years). -Patients willing to undergo transvaginal ultrasound. EXCLUSION CRITERIA: -Patients who refuse to undergo transvaginal ultrasound. -Patients who lost follow up.

6. INVESTIGATION DONE TRANSVAGINAL OVARIAN SONOGRAPHY

7. On day 2–5 of the menstrual cycle or during withdrawal bleeding, a transvaginal sonography was performed. Only those with both ovaries clearly visible on transvaginal sonography were included in the study. The number of antral follicles was counted and grouped according to three predefined size categories: -2–4 mm (small), -5–7 mm (intermediate) and -8–10 mm (large). TRANSVAGINAL OVARIAN SONOGRAPHY

8. Each ovary was measured in three planes and ovarian volume was calculated using the prolate ellipsoid formula V = D1 x D2 x D3 x 0.523 D1, D2 and D3 being the three maximal longitudinal, antero- posterior and transverse diameters respectively. Mean ovarian volume is the volume calculated as the mean value of the left and right ovary. TRANSVAGINAL OVARIAN SONOGRAPHY

9. RESULTS

11. Age group Total No of patients 500 Non users of OCP 260 Users 240 Current users Former OCP users 168 72 18 - 258342410 26 - 30172766531 31 - 35156615936 36 - 40615335 41 - 4528 00 Table 1: Number of patients involved in the study:

12. Antral follicle counts done between day 2 to 5 after menstruation were compared between the users and non users of oral contraceptive pills. Most of the users and former users had fewer than five follicles under 10 mm in diameter prior to the onset of therapy. The ovarian volume was believed to be dependent upon follicle number. The decline in antral follicle size and counts has been directly correlated with a decline in ovarian volume. Decreased ovarian volume and ovarian antral follicle count has been observed in users and former users of oral contraceptive pills. RESULTS

13. Ovary of non user: A dominant follicle is visualized in the central portion of the image and several subordinate follicles (2–5 mm) are observed in the left lateral aspect of the ovary. RESULTS

14. Ovary of OCP user: Only the stroma of the ovary is identified. A very few follicles of less than 1 mm diameter can be observed on the inferior aspect of the ovary. RESULTS

15. Ovary of non users

16. RESULTS Ovary of OCP users

17. When compared with non users, in oral contraceptive pill users, and former oral contraceptive pill users, the antral follicular counts were reduced by ~ 15 – 20 % and ovarian volume was reduced by ~ 25 – 30 %. When follicle size was further categorized into subclasses (small, intermediate and large), the number of antral follicles was significantly lower in all three antral follicle size categories in users compared with non-users of oral contraception. RESULTS

18. After discontinuation of oral contraceptive pills, - 20% of patients conceived after 1 month ( after 1 st cycle) - 75% of patients conceived in and after 1 year (after 4 - 12 cycles) RESULTS

20. Age group 30 % former pill user (72 patients) 20 % patient conceived ( 14) 75 % patient conceived within 1 year (55) 5 % patient did not conceive during study ( 3 ) 18 - 25000 26 - 3011200 31 - 353330 36 - 40023 41 - 45000 RESULTS

21. Conception typically occurs at a rate of 20–22% per cycle in women who are less than 35 years of age. Approximately 50% of women not practicing contraception conceive within 3 months, others over a period of 6 months, 12 months, and within 18 months when no specific attention was paid to the time of optimal fertility. DISCUSSION

22. This study based on ovarian reserve parameters from the use of oral contraception in a population of healthy women. The ovarian reserve parameters AFC and ovarian volume were all comparatively lower in users than in non-users of oral contraception. Additionally, there was significant decrease in AFC and ovarian volume with increasing duration of oral contraception use in current users. DISCUSSION

23. Another ovarian reserve marker, serum Anti mullerian hormone concentration was not accounted in this study. However, the reductions in Antral follicle count and ovarian volume, which are probably temporary, should be taken into account when counselling women on their reproductive lifespan as these parameters might improve after termination of oral contraception use. DISCUSSION

24. ADVANTAGES OF SONOGRAPHIC OVARIAN RESERVE ASSESSMENT Sonographic ovarian reserve assessment is an - Safe, - Readily available, - Noninvasive technique, - Rapid diagnosis, - Cheaper and cost effective than Anti mullerian hormone (AMH) studies.

25. CONCLUSION This study indicates that sonographic ovarian reserve markers i.e. AFC and ovarian volume, are negatively affected by oral contraception, and are lower in women using oral contraceptive pills and suggests that reproductive life span may be temporarily affected in users of oral contraceptives. Sonographic ovarian reserve still retains its efficacy as it is safer and cheaper than hormonal studies

26. 1.Chizen, D. R. and R. A. Pierson (2004). Tranvaginal Ultrasonography at First Consultation Assists Management of Infertility. International Federation of Fertility Societies18th World Congress on Fertility and Sterility, Montreal, Quebec, IFFS 2004. 2.Timor-Tritsch, I. and S. Ruttem (1989). Transvaginal ultrasonography in the management of infertility. In: Kurjak A (ed) Ultrasound and Infertility.. Boca Raton, CRC Press. 3.Andersen, A.N., Witjes, H., Gordon, K., Mannaerts, B., 2011. Predictive factors of ovarian response and clinical outcome after IVF/ICSI following a rFSH/GnRH antagonist protocol with or without oral contraceptive pre-treatment. Hum. Reprod. 26, 3413–3423 4.Broekmans, F.J., Kwee, J., Hendriks, D.J., Mol, B.W., Lambalk, C.B., 2006. A systematic review of tests predicting ovarian reserve and IVF outcome. Hum. Reprod. Update 12, 685–718 5.Kelsey, T.W., Anderson, R.A., Wright, P., Nelson, S.M., Wallace, W.H., 2012. Data- driven assessment of the human ovarian reserve. Mol. Hum. Reprod. 18, 79–87 REFERENCES

27. 6. Chow, G. E., A. R. Criniti, et al. (2004). "Antral follicle count and serum follicle- stimulating hormone levels to assess functional ovarian age." Obstet Gynecol 104(4): 801-4. 7.Haadsma, M.L., Bukman, A., Groen, H., Roeloffzen, E.M., Groenewoud, E.R., Heineman, M.J., Hoek, A., 2007. The number of small antral follicles (2–6 mm) determines the outcome of endocrine ovarian reserve tests in a subfertile population. Hum. Reprod. 22, 1925–1931. 8.Rosen, M.P., Sternfeld, B., Schuh-Huerta, S.M., Reijo Pera, R.A., McCulloch, C.E., Cedars, M.I., 2010. Antral follicle count: absence of significant midlife decline. Fertil. Steril. 94, 2182–2185. 9.Gougeon, A., 1996. Regulation of ovarian follicular development in primates: facts and hypotheses. Endocr. Rev. 17, 121–155. 10.Gougeon, A. (1979). "Qualitative changes in medium and large antral follicles in the human ovary during the menstrual cycle." Annals Biol Anim Bioch Biophys 19(5): 1464-1468. REFERENCES