专家介绍：Nicholas Raine Fenning是诺丁汉女王医学中心的妇科顾问、生殖医学和外科的副教授，特长是良性妇科疾病和不孕症，包括IVF的治疗，是辅助生殖研究（NURTURE：诺丁汉大学辅助生殖研究和治疗中心）的主管，致力于学术性的成像研究。除了是国际妇产超声协会的委员，Nick也是妇女健康研究咨询委员会的成员，PREPARE（早孕期和生殖患者参与的研究）的领导者，创立于2011年由患者参与的组织，旨在更好地鼓励参与研究的患者。所属的ISUOG委员会和工作组包括：UOG的副主编，临床标准委员会，教育委员会，网络编辑委员会，3D技术小组，患者联络小组.

Nicholas Raine Fenning 



1.In IVF area , what is the request for ultrasound equipment ?

在辅助生殖医学领域,对于使用的超声机器是否有一定的要求?


All Units need ultrasound and realistically a minimum of two systems. Can be different or the same. Some like one larger 'high end' system like an E8 and then use a smaller system like Voluson-I or S series for other work (e.g. Follicle tracking, procedures – egg collection, embryo transfer)  

We need machines for the following: 

Pretreatment assessment / exclusion of pathology that: 

oAffects implantation and possibly miscarriage eg polyps, fibroids, uterine anomalies, hydrosalpinges   

oMakes egg collection difficult e.g. Cysts  

oAffects fertility in several ways e.g endometriosis  

Ovarian reserve assessment – antral follicle counts (AFC) although more and more using AMH 

Tubal patency testing (HyCoSy or HyFoSy – the F = foam which most of us now use) – not for all and some Units focus only on IVF but those that do general assessment and other treatments (e.g. IUI – insemination or clomid – ovulation induction) this is important  

Follicle tracking – essential! For both IVF and also IUI an clomid etc. 

Guiding procedures eg cyst drainage (preIVF), egg collection, embryo transfer 

Assessment of endometrial receptivity – thickness, blood flow etc  

Early pregnancy assessment – position and viability 

Early pregnancy reassurance – not done enough but these patients like to see and know baby ok  


And for me the two big ones everyone forgets: 

Data archiving (for research, audit, quality assurance etc) 

Research and teaching 


    所有的辅助生殖机构都需要超声,而且实际上最好需要两台超声机器，机器可以不同或者相同. 有些人喜欢一台是大的高端机器，如E8，另一台是小些的机器，如Voluson-I 或者 S系列用于卵泡监测，取卵及胚胎移植。

    我们需要机器用于以下方面：

预评估/排除疾病

影响植入并可能导致流产，如息肉、子宫肌瘤、子宫畸形，积水等

影响取卵，如囊肿

影响生育率，如子宫内膜异位症

** 评估卵巢储备功能-窦卵泡计数(AFC)，尽管更多的是使用卵巢库存量测试(AMH)**

输卵管通畅性评估(输卵管超声造影或输卵管泡沫造影-F=泡沫，现在我们使用得越来越多)-有些机构只注重IVF，但应该做全面的评估和治疗方法的确定（如人工授精-授精或克罗米芬促排卵），这很重要.

* 卵泡监测-这是基本的，包括IVF，人工授精及克罗米芬促排卵等*

穿刺引导，如囊肿引流术(IVF之前)，取卵，胚胎移植

评估内膜容受性-厚度，血流状态等

早孕期评估-位置和活力

早孕确认-做的不多，但这些患者希望知道baby是好的。

    对我而言，有两大点需要提醒注意：

数据存储（科研，审查，确保质量等）

科研和教育 




2.In his routine work , what kind of technology (esp 3D tech)should he used for better diagnose ? Ultrasound has widespread application in IVF field, does 3D ultrasound has advantage for tubal patency analyze , assessment of ovarian function and endometria? 

在平常工作中，使用什么技术（如3D技术）可以更好地帮助诊断？超声在IVF领域有着广泛的应用，3D超声在输卵管通畅性、卵巢和内膜功能的评估方面是否有优势？


Key areas are:  

Archiving – for me 3D is the gold standard as can interact with data 

Research – for same reason as above  

Uterine anomalies – the gold standard test

Pathology – not for all but does improve diagnostic confidence in many (tubal, uterine etc) and makes the diagnosis in some 

Automation – sonoAVC for both antral follicle counts and follicle tracking 

HD live to show baby – maybe not essential but very good and patients love it!  

I've starred a few things above ** / *   

关键之处在于：

存储——对我而言，3D是金标准，可以对数据进行再处理

科研——和第一个是同样的原因

子宫畸形——是金标准的检查

病变——不是所有的，但可以在许多方面（如输卵管、子宫等）提高诊断的信心，为诊断带来价值

** 自动技术——卵泡体积自动测量(sonoAVC)用于窦卵泡计数和卵泡监测**

高分辨率容积成像(HD live)显示胎儿——可能不是必须的，但非常好，而且患者很喜欢

以上** / *是我已经有了一些成果




3.Sono AVC can access the stimulated follicle, what is the advantage? How to ensure the accuracy of the measurement, could you share some experience for it?  

卵泡体积自动测量可以评估受刺激卵巢，这个技术有什么优势？如何确保自动测量的准确性，您可否分享一些经验？


I really think we should push sonoAVC this far an try to take the ovarian reserve test market back from AMH by using for AFC ** – I've mailed Karl Heinz re this. I'be been approached by Merk Serono and they are losing confidence in AMH and like scanning. They worry re the reliability though. We can convince them sonoAVC is the right tool I am sure. Needs a relaunch and some very strong post-marketing / sales support. Happy to help and lead on this clinically. All the top pharm companies in IVF are pushing for 'personalised' IVF now and it all starts with the follicle count. I think we can take market if we get some consistency and then develop our own algorithms – think we could do a joint grant / study with Merck on this. That is what I want to do.  

    我认为我们应该拓展窦卵泡计数的应用，通过卵泡体积自动测量技术(sonoAVC)在卵巢储备功能评估的市场中走得更远**- 我已经发邮件给Karl Heinz(GE Voluson产品全球总经理)，Merk Serono和我联系过，他们在卵巢库存量测试(AMH)中已经失去信心，而更喜欢手动扫描，他们担心测量可靠性问题，我们可以说服他们确信卵泡体积自动测量技术(sonoAVC)会是一个正确的工具。需要重新启动市场和销售的强大支持，很荣幸能够帮助和引领这个技术在临床的推广应用。所有大的IVF制药公司都在推进“个体化”的治疗方案，所有这些方案的实施都起步于卵泡计数，我相信我们可以引领这个市场，如果我们可以获得一致性并开发我们自己的算法，相信我们会和Merck有很好的合作研究。这也是我想做的。   


We also need to look at why more people are not using for follicle tracking * as also works well and gives more reliable results between users. I think fear of use and new technology is the issue here which can only be overcome through teaching and support. They also need to know sonoAVC is not perfect in picking up all follicles (small astral and large stimulated) or in the measurement. I have a few papers we need to publish to show it under measures which we know but at least it does this systematically so we can account for that.  

    我们也需要关注为何更多的人不用这个技术进行卵泡监测*，尽管自动测量的技术工作很好，而且在不同操作者之间会获得更可靠的结果。我认为对新技术和使用的担忧是主要原因，只有教育培训和更多的技术支持才可以解决。同时，他们也需要知道卵泡体积自动测量技术(sonoAVC)并不能用于所有卵泡的监测和测量(特别是小的窦卵泡和过大的受刺激卵泡)， 在这方面的介绍，我有些文章，我们可以出版并告诉更多的人。对于卵泡体积自动测量的技术，至少获得的测量结果是机器自动得到的，我们可以定量的分析评估。


Aside from under measuring size (both volume and diameter) the problems with accuracy depend on what you are using it for are as follows: 

Antral / small follicles and volumes: it misses up to 50-60%. Not a problem as can manually add most 

Larger follicles / volumes: you get errors and either different areas are joined (need to split) or identified as different when one (need to merge). You also get 'bleeding'; where overlaps and get ugly mess. Best here is to delete and manually measure. It would be great if manual measures could be added to the automated ones in same report (both on machine and viewpoint) 

    另外，对于测量（包括体积和径线）的准确性还起决于你如何使用它：

    窦卵泡/小卵泡和体积：可能有50-60%无法测量到，不过没有关系，我们可以手动添加，并获得更多的测量结果。

    大的受刺激卵泡/体积：你可能会得到错误的结果，或者不同的区域会合并进来（需要手动分割），有时同一个会被标记成不同的区域（需要手动合并）。对于遮盖和得到不好边界的区域，你可能会非常纠结，最好的方法就是删除并手动测量。以后如果能在机器和 viewpoint上将手动测量添加到自动测量软件中，这会是非常大的进步。


SonoAVC, when calculate small follicles under blur image , cannot calculate accurately , does this have some influence to the treatment ?  卵泡体积自动测量(SonoAVC)，当测量小卵泡或边界不清楚的图像时，无法获得准确的结果，这种情况对于治疗会有影响吗？


Yes – set machine up correctly. No one does this as well as they should include the experts! Need to look at every part (probe, frequency, harmonics, gain, angle, zoom/ HD zoom etc. then need to look at SRI and dyamic range. Not a fan of CRI but think may help? Key most get wrong is magnification and then keep settings same. Need to scan dynamically and change for each patient, each ovary – work with machine. They are not getting best 2D image and so 3D spoilt or less good. Also acquisition can be improved – right angle and right speed which must be slowest. I have never seen anyone do this well or perfectly.  

答案是肯定的。首先要将机器的状态调好，没人会比机器的专家更胜任这个工作了，需要检查每一个部分（探头，频率，谐波，增益，角度，放大/高清放大等等），还有需要检查SRI和动态范围， CRI的影响，如果考虑到会有助于图像的改善。关键是不能靠想象，并且全部用同样的模式，设置必须随图像和应用的要求进行合理的更改，动态扫描，随每个病人，每个卵巢而变化，主要是人掌握机器。他们没法得到好的2D图像，所有3D图像会有很多噪声，没有办法有好的表现。当然，3D的采集也很重要，正确的角度和速度会帮助获得好的3D图像。我还没有看到有人能做得很完美，这是必须要注意和追求的。



If you do all this and still blur then that can be bowel so wait, push, use hand etc etc. if still bad live with it! Cannot expect perfection. However with an E8 I pretty much get it most scans. The machine is just too good! I mean that.  

如果你做了这些，但仍然感到困惑，这需要等待、用心、实践，凡事无法完美。使用E8，我都尽量发挥机器的作用，而且也收获很多，我觉得这是一款好机器，关键在于如何更好地应用。


4.Could you introduce the latest technology and trend of development in IVF field? 您能介绍一下IVF领域的最新技术和发展趋势吗?

 

Not ultrasound?  

Key developments are: 

Personalised care – individual treatment (drug regime, protocols, timing etc) 

Endometrial scratching / biopsy – concept that a bit of damage preIVF good (we are dong UK trial – almost done – it works!) 

Antagonist cycles – different shorter protocol aimed at reducing risk of OHSS and making IVF more patient friendly and easier to do 

Egg collection – not flushing follicles 

Embryo choice – time lapse imaging 

Embryo transfer – most people agree need to scan but not all! Dummies :) 

Endometrial receptivity – people are looking at ways to see if right time (bloods, biopsy , genetics etc) and also if freezing all and then putting back in natural cycle better 

非超声方面的？

主要的发展方向是：

个性化的关怀——个体化治疗（药物方案，协议，时间等等）

内膜的活检/穿刺——IVF之前越小损失越好的概念（我们正在做英国的实验，已经基本完成，确定是可以做到的）

拮抗剂周期——不同的短协议旨在减少OHSS的风险，增加IVF的患者友好性，使流程更容易进行

取卵——不冲洗卵泡

* 胚胎选择——时差成像*

胚胎移植——大多数人都同意需要扫描，但不是所有的!很傻的想法:）

内膜容受性——人们寻找各种方法确定移植的正确时间（血流，穿刺，基因等等）， 或者冷冻然后放回到自然周期会更好。



Time lapse * probably the hottest topic at present – there are 3 (soon to be 5) systems that video (actually take lots of photos) or embryos and then use algorithms to say which will make blastocysts, which are best, which are abnormal etc. Lots of big claims but no hard evidence to show effective. Look up Embryoscope (market leader – incubator itself) and Eeva / primovision (go inside our incubators).    

时差*可能是现在最流行的话题-有3个（不久会5个）胚胎监测分析系统，有视频（事实上是很多照片），或者胚胎，然后运用算法来确定哪个会长成囊胚，哪个最好，哪个异常等等。有许多大的声明，但目前还没有确凿的证据证明其有效性，看胚胎镜（市场领导者-培养箱本身）和Eeva/ primo vision时差胚胎监测分析系统（进入我们的培养箱）


Any special concern from your side ? 

您在IVF领域有着很深的造诣，请问是否有一些想法或经验分享？


Only worry, which is good for you though, is sonoAVC is unique to you. People get put off that this limits their choice of systems. His may sound counterintuitive but people want and expect choice. We know others are developing automated systems.  

唯一担心的是你们虽然很好，而且卵泡体积自动测量技术(sonoAVC)也是独一无二的。但人们没有足够的重视，这限制了他们对于系统的选择，实际上，人们是需要和期待选择的。据我们所知，其它厂家也在开发自动化的系统。


My other concern is how many people invest in 3D but do not use or do bout use well or even correctly. This is volume acquisition and image display / analysis. Need more courses an hands on support. I run my own in Notts.  

我关心的是多少人对3D技术感兴趣，但不用或对正确使用存在疑惑，这关系到容积的采集和图像显示、分析，需要更多手把手的课程支持，我在诺茨郡就是这么做的。