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OPEN An extended machine learning

technique for polycystic ovary
syndrome detection using ovary
ultrasound image
Sayma Alam Suha & Muhammad Nazrul Islam*
Polycystic ovary syndrome (PCOS) is the most prevalent endocrinological abnormality and one of
the primary causes of anovulatory infertility in women globally. The detection of multiple cysts using
ovary ultrasonograpgy (USG) scans is one of the most reliable approach for making an accurate
diagnosis of PCOS and creating an appropriate treatment plan to heal the patients with this
syndrome. Instead of depending on error-prone manual identification, an intelligent computer-aided
cyst detection system can be a viable approach. Therefore, in this research, an extended machine
learning classification technique for PCOS prediction has been proposed, trained and tested over 594
ovary USG images; where the Convolutional Neural Network (CNN) incorporating different state-of-
the-art techniques and transfer learning has been employed for feature extraction from the images;
and then stacking ensemble machine learning technique using conventional models as base learners
and bagging or boosting ensemble model as meta-learner have been used on that reduced feature
set to classify between PCOS and non-PCOS ovaries. The proposed technique significantly enhances
the accuracy while also reducing training execution time comparing with the other existing ML
based techniques. Again, following the proposed extended technique, the best performing results
are obtained by incorporating the “VGGNet16” pre-trained model with CNN architecture as feature
extractor and then stacking ensemble model with the meta-learner being “XGBoost” model as image
classifier with an accuracy of 99.89% for classification.

Polycystic ovary syndrome (PCOS) is one of the most widespread endocrinological anomalies affecting one out
of every ten pre-menopausal reproductive women worldwide. PCOS is associated with excessive rise in male
androgen hormone in the female body, which causes a persistent disruption in hormonal levels and as a conse-
quence, adversely affects normal ovarian functions, resulting in the growth of numerous cysts inside the o ­ vary1.
PCOS has been recognized as the leading cause of anovulatory infertility as well as being related to a range of
metabolic and psychological disorders; including irregular menstrual periods, hirsutism, abrupt obesity, type 2
diabetes, thyroid abnormalities, increased depression, sexual dissatisfaction, etc. lowering the quality of a healthy
way of ­life2,3. Multiple studies have also revealed that, women having PCOS are at higher risk of suffering from
endometrial and ovarian cancer which can lead to death if not detected e­ arly4,5. However, accumulating evidence
suggests that if a well-standardized diagnostic approach can be used to identify PCOS in a timely manner, the
condition can be recovered by appropriate, symptom-oriented, long-term and dynamic ­treatments6.
The Rotterdam criteria for polycystic ovarian syndrome (PCOS) are three criteria that are commonly used to
diagnose PCOS by a wide spectrum of medical practitioners; those are: hyperandrogenism, menstrual irregula-
tions and existance of multiple cysts in ovary u ­ ltrasonography7. Among these, the identification of numerous
cysts using ultrasound scanning is the most reliable method of detecting P ­ COS8. But, because of the reliance on
the observer and the presence of significant noise in these images, medical analysis can be time-consuming and
difficult, with the risk of human mistake. In addition, in least developed and underdeveloped countries, there
is a scarcity of experienced radiologists who can appropriately diagnose ovarian ultrasound. As a result, many
young women who are suffering from this serious condition go undetected and untreated for long periods of
time. Therefore, researchers worldwide are now working to develop effective PCOS detection approach that
would employ a variety of modern computational techniques.

Military Institute of Science and Technology, Department of Computer Science and Technology, Dhaka 1216,
Bangladesh. *email: [email protected]

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However, the typical methodologies applied for detecting PCOS using computational approaches rely on
several image processing techniques for feature extraction and then traditional machine learning strategies
for image classification which is a tedious process with relatively lower performances. Again, some researchers
also performed deep learning approaches to detect PCOS from ultrasound images using Convolutional Neural
Network(CNN). Though deep learning algorithms typically attain a high level of accuracy in categorizing images,
they have the limitation of consuming a lot of computing complexity and time to execute which becomes a barrier
to utilize them in practical a­ pplications9. As such, an integrated or extended ML based approach may enhance
the prediction performance and reduce the computational complexity to predict PCOS using image data.
Therefore, the objective of this research is to propose an extended machine learning classification technique
for PCOS prediction using ovary USG images. The significant contributions that has been conducted to achieve
the goal of this study are listed below.

• A deep learning method incorporating different state-of-the-art techniques like transfer learning with several
pre-trained models in a CNN architecture has been utilized for feature extraction from the input ultrasound
ovary images. And then a stacking ensemble machine learning model employing five traditional models as
base learners with one boosting or bagging ensemble model as meta-learner, have been employed on that
reduced feature set to classify them into PCOS or non-PCOS criterion.
• For inspecting the performance of the proposed methodology, four different types of machine learning
techniques have been trained and tested with same dataset for PCOS detection, including the conventional
machine learning technique; conventional machine learning technique with feature reduction; deep learning
technique, and the proposed extended technique.
• Multiple ablation studies have been conducted to analyze the impact of different stages of machine learn-
ing such as image pre-processing in case of performing conventional machine learning technique; transfer
learning in case of executing deep learning technique. Furthermore, the outcomes of various approaches
employing several types of machine learning models are examined through relevant performance metrics
in order to determine the optimal strategy for PCOS ultrasound image categorization.

The rest of the paper is organized as follows: the related works are presented in “Related works” section; and
the methodology applied in this study is discussed in “Methodology” section; “Exploring machine learning
techniques” section represents the result analysis with comparative findings; and finally, “Result analysis” sec-
tion includes discussion and conclusion that summarizes the key findings, limitations, and future plan for the
research.

Related works
The most prominent practice used by physicians to accurately diagnose PCOS is to examine ultrasound images
of the ovaries to examine for the existence of multiple follicular cysts and hence determine whether or not the
patient has P­ COS10. Ultrasound imaging is a well-known diagnostic technology that uses ultrasound waves
generated by a transducer to create images of human body parts that provide real-time, precise anatomical and
physiological ­information11. In the case of ovarian ultrasound imaging, the ultrasonographers or radiologists
visually assess the obtained ultrasound pictures for any abnormalities in the ovaries, and if several cysts with
higher measurements of diameters are observed, then PCOS is ­diagnosed12. Despite the fact that this is the
most usual method to diagnose ovarian abnormality, the correctness and reliability of visual interpretations are
frequently dependent on the observer’s expertise and also several types of noises have an impact on ultrasound
imaging making it harder for observers to ­diagnose13. Therefore, to replace this arduous, error-prone, and time-
consuming manual method of PCOS diagnosis; several researchers worldwide are exploring computer-assisted
techniques of follicle identification and diagnosis of PCOS, which provide significant benefits such as rapid ultra-
sound image processing in the quickest time frame with reduced diagnostic mistake and human ­involvement14.
For developing computer-aided PCOS follicle detection system, the implementation of various forms of
digital image processing techniques is the most frequently utilized strategy. For example, Mandal et al.15 sug-
gested a technique to diagnose PCOS by automatically segmenting cysts and follicle regions from ultrasound
images; for which they employed multiple digital image processing steps such as histogram equalization, K-means
clustering, median filtering, and morphological erosion on 19 ultrasound pictures. Yilmaz et al.16 tested and
compared two methods of follicle detection using image processing techniques to diagnose PCOS; where the
first approach includes noise reduction (Median, Average, Gaussian, and Wiener Filters), contrast modification
(histogram equalization and adaptive thresholding), binarization, and morphological procedures.; and the second
approach comprises of noise reduction (Gaussian Filter and Wavelet Transform), k-means clustering, hole fill-
ing and morphological operations. Further, they compared the analysis results using two performance metrics :
False Acceptance Rate (FAR) and False Rejection Rate (FRR). Gopalakrishnan et al.17 have suggested an image
processing-based strategy for PCOS detection utilizing the combination of modified Otsu method with active
contour to determine the precise quantity of cysts from the ultrasound ovary image; their proposed method
contains mainly two parts that is image pre-processing and follicle identification. In pre-processing stage they
performed Region of Interest (ROI) extraction, speckle noise reduction using various strategies; then explor-
ing the best performing filter technique they used the modified Otsu approach with active contour method to
accomplish the second phase of follicle identification, which included image segmentation and feature extrac-
tion. Setiawati et al.18 suggested a clustering approach that can be utilized for PCOS detection employing Particle
Swarm Optimization (PSO) technique with a non-parametric fitness function to create more compacted and
converging clusters for follicular segmentation.Sitheswaran et al.19 used object growing methodology to detect
PCOS in two stages; where first step pre-processing comprised median filtering, local maximum extraction with

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ROI selection, and the second stage of follicle detection included cost map development, which finally provided a
convex hull of probable follicles to decide object growing. Mehrotra et al.20 proposed another method where the
input ultrasound picture would be preprocessed for noise reduction and contrast enhancement using a multi-
scale morphological technique and then the follicles would be segmented using scanline thresholding; they also
conducted a comparative analysis of the manual result with the acquired result to assess its effectiveness. Again,
Deng et al.21 suggested another automated scheme in which an adaptive morphological filter was used to filter
the input ovary ultrasound picture, then for contour extraction a modified labeled watershed algorithm was
employed and lastly, to detect PCOS, a clustering algorithm was used to locate anticipated follicular cysts. Thus,
these investigations mostly used image processing to locate follicles in ovarian USG pictures, but they seldom
classified the images into PCOS or non-PCOS criteria.
Several researchers combined machine learning models with digital image processing techniques to develop
an automated machine learning based PCOS detection system which will not only detect follicles but also will
classify them into PCOS or non-PCOS classes. For example, Rachana et al.22 performed image enhancement,
histogram equalization, Otsu thresholding, binarization, noise reduction, segmentation, feature extraction, and
other relevant phases of image processing; and after that they used the KNN machine learning classification algo-
rithm to categorize 50 USG photos. Nilofer et al.23 proposed a method where the images were first preprocessed
using noise removal with median filter, segmentation using k-means clustering algorithm, feature extraction
using GLCM method; and then a hybrid technique with artificial neural network (ANN) incorporating Improved
Fruit Fly Optimization (IFFOA) was utilized to classify the images. On 65 ovary USG images, Gopalakrishnan
et al.24 employed multiple conventional image processing approaches, including image enhancement, thresh-
olding, noise reduction, Canny edge detection method to detect the follicle edge, and Scale-Invariant Feature
Transform method to extract essential features; and furthermore they were classified using the Support Vector
Machine (SVM), Decision Tree, and Naive Bayes classification algorithms, with SVM outperforming other
models with 94.40% accuracy. Purnama et al.25 suggested another approach for PCOS identification, in which
USG images are first preprocessed through various phases to create binary images, which are then segmented
using edge detection, labeling, and cropping; later, based on the feature vectors resulted from feature extraction
step using Gabor wavelet, 3 types of classification algorithm was implemented with SVM-RBF kernel classifica-
tion method achieving the highest accuracy of 82.55%. Deshpande et al.26 suggested another strategy, in which
they used image processing techniques like contrast enhancement, filtering, feature extraction using Multiscale
morphological approach and segmentation to determine the number of follicles in ovarian ultrasound pictures;
following that, integrating the number of follicles acquired from the image processing stage with other features
of that patient such as body mass index (BMI), hormone levels etc. they applied Support Vector Machine clas-
sification algorithm to detect PCOS.
Furthermor, Deep learning (DL) strategies have nowadays gained a lot of momentum in clinical diagnosis
using medical images since they have the advantages over conventional machine learning approaches to bypass
the feature extraction and traditional image processing steps as the neural network itself conduct these ­tasks27–29.
A few researchers recently have also utilized deep learning methods for PCOS detection. For example, Vikas
et al.30 proposed a deep learning method for detecting PCOS, in which they initially implemented a three-layer
Convolutional Neural Network (CNN) for detecting PCOS, then enhanced the model’s accuracy by incorporating
data augmentation method, and finally obtained the best accuracy by using transfer learning (VGG16 pretrained
model) with fine-tuning. Cahyono et al.31 suggested a Convolutional Neural Network (CNN) having 6 layers to
classify 40 PCOS and 14 non-PCOS USG images, with the feature extraction phase done automatically using
deep learning.; they employed the softmax activation function and tested the model’s performance using several
alternative dropout and learning rates, with the best F1-score on test data being 76.36%.
Therefore, according to the previous studies PCOS and non-PCOS usg image identification has been so far
conducted in two different ways: one group used image processing techniques to perform picture segmentation
with feature extraction, and then a machine learning model to categorize the pre-processed images ; another
group had applied deep learning methods to detect PCOS from USG images avoiding the image processing
steps. Even though the PCOS detection had been conducted employing these techniques, but The follicular seg-
mentation utilizing digital image processing requires cautious execution of several image processing stages. In
addition, the extraction method using digital image processing techniques need to be very carefully tuned based
on the varied picture quality and formats, which may need extra computing complexity and time, and thus each
step becomes quite laborious. Also, it has been observed that employing digital image processing technique for
feature extraction and then using conventional machine learning classifiers comparatively provides less accuracy
in comparison to the deep learning methodologies. Also, a relatively small number of studies that used solely
deep learning to diagnose PCOS encountered other difficulties, such as the prolonged processing times and high
computational power necessary to handle the enormous amount of pictures needed to detect PCOS and thus it
may become quite challenging to implement a practically usable interface for patients or medical professional
using these deep learning approaches.
However, from the earlier studies it can be observed that, though there are number of contributions sug-
gested from researchers across the world where several machine learning stretegies had been applied to detect
PCOS; rarely has any researcher investigated the possibilities and efficacy of employing several types of ensemble
machine learning techniques (bagging, boosting, and stacking) in this context. Ensemble techniques are a poten-
tial state-of-the-art solution for various machine learning difficulties, since they may considerably enhance a
single model’s forecasting performance by training multiple models and integrating their ­predictions32. Recently,
several researchers have successfully employed ensemble machine learning strategies in other fields of healthcare
predictions. For example, Jabbar et al.33 proposed an ensemble learning strategy to solve the challenge of breast
cancer data categorization; Kaur et al.34 applied stacking ensemble machine learning technique with an aim to
identify brain tumor using Magnetic Resonance Imaging(MRI) of brain etc. Also, in a few recent research of

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Image Acquisition &

Pre-processing

Image Augmentation

Exploring ML Techniques

Image Enhancement with

Histogram Equalization
Apply Digital Feature Reduction using Training with Feature Reduction
Image Processing PCA & Chi-Square Deep Learning from the Best Performing
Image Restoration with Techniques Techniques architecture DL architechture
Median Noise Filter

Training Traditional Training Traditional Training Stacking

Morphological Processing with Machine Learning Machine Learning Ensemble Machine
Erosion & Dilation Operation Models Models Learning Models
with reduced feature set with reduced feature set

Image Segmentation with

‘OTSU’ Thresholding Performance Performance
Performance Performance
Analysis Analysis Analysis Analysis
Feature Extraction with
‘ORB’ Method TECHNIQUE 2:
TECHNIQUE 1: Traditional Machine TECHNIQUE 3: TECHNIQUE 4:
Traditional Machine Learning Technique with Deep Learning Proposed
Learning Technique Feature Reduction Technique Technique

Figure 1.  Framework of research methodology.

other healthcare fields, the strengths of the CNN technique for feature extraction and the traditional machine
learning technique for classification have been coupled to categorize medical images. For example, Pang et al.35
developed a technique of protein subcellular localization for Alzheimer’s disease prediction by using CNN as a
feature extractor to automatically extract features from the original sequence data and XGBoost as a classifier
to determine the subcellular localization based on the CNN’s outcome. Such kind of hybrid approaches have
rarely been employed in case of the area of PCOS detection using USG images. Thus, this study has proposed
an extended and novel machine learning technique where CNN architecture has been employed as the feature
extractor and then stacking ensemble machine learning has been used for classification with an aim to categorize
PCOS and non-PCOS USG images.

Methodology
In this study, an extended machine learning classification technique has been proposed, trained and tested inte-
grating ensemble ML models with Convolutional Neural Network(CNN) architecture that aims to differentiate
between PCOS and non-PCOS ovaries. The ovary ultrasound images have been used as the input of the study
from which the suggested method would determine whether or not the image reveals PCOS. Along with the
proposed technique three other types of techniques have also been explored for classifying PCOS with an aim
to conduct a comparative performance analysis of the suggested technique. The framework of the methodology
used in this research is illustrated in Fig. 1. The phases involved in this research are described briefly below.

Image acquisition and pre‑processing. The images that have been utilized in this study as inputs are
ultrasonography images of the ovary. There are a total of 594 images among which 123 have been acquired from
various open sources from the internet and the rest of them are collected from two diagnostic centers and three
hospitals of Bangladesh including Combined Military Hospital (CMH), maintaining the ethical and privacy
concerns. After consulting with two radiology specialists from Mymensignh Medical College Hospital, Bangla-
desh and Combined Military Hospital (CMH), Bangladesh; the images have been categorized to label as PCOS
and Non-PCOS for using them as training dataset. Following the data labeling, it is observed that there are 306
photos with PCOS abnormality and 288 Non-PCOS images.
Because the images have been gathered from multiple sources, their formats and sizes differed, making
them unsuitable to use in predictive models. Therefore, after acquiring the images from the repository to the
implementation environment, they are converted to grayscale colorspace using an OpenCV python function
‘COLOR_BGR2GRAY’ and then all the images were resized to 224X224 size. Here, the Google Colaboratory
has been used as a platform for implementation incorporating mainly the python scikit-learn and TensorFlow
packages. At this stage, all of the images are stored in a 3D multichannel array with the shape (594, 224, 224, 3)
that contains information about the images’ plane, row, column, and channel. The labeling information or classes
of each images are also stored in another 1D array which will be used as the target variable in predictive models.

Image augmentation. Image augmentation is a powerful technique for reducing prediction error, which
entails producing manipulated copies of images from the original training samples and therefore, depicting a
more comprehensive set of potential data ­points36. In this research, some basic image manipulations have been
applied for image augmentation which includes geometric transformations like flipping, rotating and shifting;

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enhancing contrast; sharpening etc. Therefore, each of the input images have been augmented to three more
images at this phase.

Applying machine learning classification techniques. Now, to train the machine learning models for
classifying the images into PCOS and non-PCOS criteria; four types of technique have been conducted in this
research (see Fig. 1).The first technique involves the traditional approach of ML training where after applying
relevant digital image processing phases the images are trained with conventional machine learning models. In
the second technique the similar steps of the previous technique have been applied but with reduced set of fea-
tures extracted from the images using two types (Chi-square and PCA) of feature reduction technique. The third
technique has been to train the images with deep neural network (DNN) architecture where CNN technique
have been applied incorporating different types of pre-trained models for transfer learning from which the best
performing DNN architechture have been explored. Finally, the proposed technique have been applied where
the reduced and significant features of the images have been acquired from the best performing deep learning
architecture that has been explored from the previous technique and then using those reduced set of features
a stacking ensemble machine learning model have been trained to classify the PCOS and non-PCOS images.

Performance analysis. The predictive models’ performances for each type of method are assessed on test
data using several performance measures such as the Accuracy, Precision, Sensitivity (recall), Specificity, F1
score, execution time and AUC-ROC curve. Here, the execution time represents the computational time that is
required for the algorithm to be trained. Other performance metrics are mainly based on the the comparative
analysis of predicted values and true values of the training dataset which can be divided into four categories :
true positive where the true value is positive and the predicted value is also positive; true Negative where the
original value is negative, and also the predicted value has been negative; false positive in which the observation
is negative, but the predicted value from the training has resulted to be positive and finally false negative that is
the true value is positive, but is predicted to be negative. Basing on these evaluation the performance metrics can
be written as following:
TruePositive + TrueNegative
Accuracy = (1)
TruePositive + TrueNegative + FalsePositive + FalseNegative

TruePositive
Precision = (2)
TruePositive + FalsePositive

TruePositive
Sensitivity (Recall) = (3)
TruePositive + FalseNegative

TrueNegative
Specificity = (4)
TrueNegative + FalsePositive

2 ∗ (Precision ∗ Sensitivity)
F-measure (F1score) = (5)
Precision + Sensitivity
Another evaluation metrics that has been employed in this study for assessing the performances of the models
is the AUC (Area Under The Curve)- ROC (Receiver Operating Characteristics) curve. It is a familiar indicator
of performance for classification methods at different threshold levels where AUC stands for the level or meas-
urement of separability, and ROC is a probability curve. The curve is typically generated based on True Positive
Rate (TPR). The higher the AUC, the more the model is effective at differentiating between patients with the
condition and those who do not have. d False Positive Rate(FPR).

Ethics approval and informed consent. No human participants, human data, human tissue or any clini-
cal data were collected for this study. However, we confirm that this research uses ultrasonography images of
the ovary collected from internet and from two diagnostic centers and three hospitals of Bangladesh, maintain-
ing the ethical and privacy concerns. Formal approval has been taken for this research work from the ethical
committee (IRB) headed by the Research & Development Wing of Military Institute of Science and Technology
(MIST), Bangladesh.

Exploring machine learning techniques

The four different techniques that have been used in this study for classifying PCOS and Non-PCOS USG images
are discussed hereafter.

Technique 1: traditional machine learning technique. In this technique, after performing the digital
image processing operations to the images, they were fed into several conventional machine learning models to
classify them. The procedure is briefly discussed below:

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Performing digital image processing steps. For identifying the significant areas from the images to detect the
follicles, the conventional digital image processing stages have been applied to the ovary USG images (see Fig. 1:
Image Processing Steps).

• The first phase is image enhancement, which is accomplished here using the histogram equalization method
that improves the appearance and perception of information in pictures by providing a more consistently
distributed grayscale histogram, resulting in a clearer image for v­ iewers37.
• The high impulsive noises in ultrasound images create severe uncertainty causing a detrimental impact on
image interpretation for clinical ­diagnosis38. Thus, here a median filter technique is used as an image restora-
tion step for noise reduction; which is a widely utilized nonlinear filter having outstanding edge preserving
qualities with ability to reduce impulsive ­noise39.
• After that, the required amount of morphological erosion and dilation has been done where dilation increases
and erosion reduces the number of pixels on the edges of objects.
• The next phase is image segmentation to locate and highlight the follicles in the images for which the OTSU
thresholding method has been emoloyed here. The OTSU technique is one of the most efficient automatic
optimum global thresholding methods, which chooses a threshold value that maximizes the difference
between pixel class variance and so divides the image into brighter and darker a­ reas40,41.
• Finally, from the segmented images the key regions were extracted using Oriented FAST and Rotated BRIEF
(ORB) feature extraction technique which is a faster and effective method for feature extraction to detect key
points from the figure with enhanced computing efficiency as well as real-time ­benefits42 and therefore the
important areas are marked in the original images.

Splitting into train and test data. After performing the above mentioned image processing steps the set of
processed images each having size 224x224 are converted into a single dimension of using an OpenCV python
function ‘FLATTEN’. The two dimentional array now contains the pixel values of 594 images where each row
indicates an input image with 224 ∗ 224 = 50176 columns or features containing the pixel values of that image.
This array is then splitted into 70% train data and 30% test data to be utilized in the machine learning models.

Training traditional machine learning models. Ten different machine learning models have been applied to
the train and test image dataset. The prediction type here is classification since the forecasting is a binary out-
come to determine whether an USG image has PCOS or not. The seven models can be categorised as classical
machine learning classification ­models43 that includes Naive Bayes model, Decision Tree model, Support Vec-
tor Machine(SVM), K Nearest Neighbour(KNN) model, Naive Bayes (NB) model; bagging ensemble machine
learning ­models44 including Random Forest Classifier and boosting ensemble machine learning including gradi-
ent boosting, eXtreme Gradient Boosting (XGBoost) model, Adaptive Boosting(AdaBoost) classifier and Cat-
egorical Boosting(CATBoost).

Ablation experiment. In machine learning, ablation commonly implies the absence of a certain element or task
from an AI system. Ablation studies shed light on the relative contributions of various structural and regulariza-
tion elements to the efficiency of machine learning models. An ablation experiment examines the performance
of an AI system by eliminating specific components in order to determine how those components affect the
system as a ­whole45. In this case, in order to assess the relative significance of image processing approaches, an
ablation study has been carried out by eliminating the image pre-processing stages and running the machine
learning models on the raw images.

Technique 2: traditional machine learning technique with feature reduction. In the previous
technique, it has been observed that, the input image array size was 594X50176 which means each row of image
consists of 50176 features containing pixel values. Such enormous amount of features may cause an over-fitting
problem, lowering the models’ prediction performance. In that circumstance, feature selection strategies can
reduce the number of features from the dataset by selecting the most significant ones, thereby avoiding the curse
of ­dimensionality46. Therefore, the second technique that has been performed in this study applied two types
of feature selection approaches to find out the optimal and reduced set of features from the image dataset after
conducting the image processing steps. And then those two types of dataset with reduced features are fed to the
traditional machine learning models.

Feature reduction using PCA and Chi‑square technique. The chi-square feature selection strategy, which is one
of the most common and useful feature selection techniques used in machine learning, is the first feature reduc-
tion method employed here. It is a numerical analysis that estimates departure from the expected distribution
and prioritizes features by studying the connection between t­ hem47. Another technique used for feature reduc-
tion in this study is the Principal component analysis (PCA) method, which is an efficient dimension reduction
tool for feature prioritizing via quantitative ­simulation48. To achieve the feature reduction goal, PCA maps and
reconstructs the original n-dimensional features to the needed k-dimensional features, where the k-dimensional
features are new orthogonal features referred to as principal ­components49. Each of these strategies selected the
most significant 25000 features from the 50176 features using their own methodology, resulting in two sets of
datasets with reduced features at this step.

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Fully Connected
Layer

ImageNet
Pre-trained Model
Data

Transfer Learning

Input: Ovary
USG Images Fully Connected
Layer

Output:
PCOS /
No PCOS

Convolution Max Pooling Convolution Max Pooling Dropout

Fine Tuning
with 4X4 with 4X4
Padding Padding
Deep Learning & Striding
& Striding Flatten Layer
Technique

Classification
Input: Ovary
USG Images
Model 1: LR P1
Feature
Meta- Output:
Extraction Model 2: SVM P2
Learner PCOS /
through Best
Model No PCOS
Performing Model 3: DT P3
CNN
Architecture Model 4: KNN P4

Model 4: NB P5
Proposed Base Models Initial
Technique Predictions
Stacking Ensemble Model

Figure 2.  Architecture of deep learning technique and proposed technique.

Training traditional machine learning models with reduced feature sets. The ten machine learning models speci-
fied in the first technique are trained again here with the dataset that have been divided into 70% train and 30%
test data; where this time the models have utilized the two kinds of dataset with reduced set of features obtained
by PCA and the Chi-Square feature selection techniques.

Technique 3: deep learning technique. After completing the image acquisition and augmentation
phases, the third method performed in this study is the deep learning technique with Convolutional Neural
Networks(CNN). Figure 2 depicts the deep learning architecture used here.
In this study, a modified CNN model containing multiple layers with fine-tuning have been employed to clas-
sify the USG images. The techniques used in the multiple layers of the architecture have been described hereafter.

• Fine Tuning Layer: The initial layer of the architecture is based on transfer learning with fine tuning that is
a promising technique of machine learning which seeks to improve target learners’ performance on target
domains by transferring knowledge from different but relevant domains via pre-trained ­models50. This study
employs four types of best performing and popular pre-trained models, excluding their dense or fully con-
nected layers for transfer learning; and then examines the combination of which pre-trained model in the
CNN architecture can provide the best performance in case of this research. The pre-trained models that has
been ulilized in this study are :
– VGGNet16 ­model51,52 with 16 layers, 144M parameters and the best accuracy being 90.1% with Imagenet
Data;
– Xception ­model53 with 36 layers, 22M parameters and the best accuracy being 94.5% with Imagenet
Data;
– InceptionV3 ­model54 with 48 layers, 24M parameters and the best accuracy being 93.7% with Imagenet
Data;
– MobileNet ­model55 with 28 layers, 4.2M parameters and the best accuracy being 89.5% with Imagenet
Data;
  However, here an ablation experiment has been conducted in this technique to assess the relative impor-
tance of transfer learning with pre-trained model for which the CNN model has been trained and tested
eliminating this fine tuning layer.
• Convolution Layer: The following layer is a “Convolution layer” which is the CNN’s core foundational
component having a set of filters or kernels with typically a smaller size than the training image, whose
parameters must be trained over time and convolve with the actual i­ mage56. In this case, the kernel size has

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been considered to be 7X7. The convolution layer here uses padding and striding techniques to provide a
more accurate result, with padding providing one extra layer to the outer picture and striding handling the
space between two successive kernel positions c. In this CNN architecture the value of padding is ’same’ which
implies padding the input image with zeros uniformly to the outer side; and stride is 1 which means after the
convolution using the kernel the output size will be same as the input size. Now, in deep neural network, an
activation function is being utilized to feed a weighted sum of input signals through, and the outcome from it
is used as an input towards the following layer. In this case, ’Sigmoid’ activation function has been used which
provides an output between 0 and 1 representing the probability classification outcome. The mathematical
representation of the sigmoid function has been shown below:
1
Sigmoid Activation Function, f (x) = (6)
1 + e−(x)
Similar kind of convolution operation has been conducted again in this CNN architecture after performing
the following ’Pooling’ operation.
• Pooing Layer: The pooling layer is the next layer in the CNN architecture in this study which gradually
reduces the spatial size of the image keeping the significant information in order to minimize the number of
parameters and computations in the neural ­network57. A “Max Pooling” operation has been performed here,
which yields the maximal value for each patch of the feature space with a pooling window size being 4x4.
Similar kind of max-pooling operation has been conducted again after the second convolution operation in
the architecture.
• Dropout Layer: The next layer is the “Dropour Layer” which helps to minimize overfitting problem as well
as accelerate the training process as it changes input values to 0 randomly with a fixed frequency rate at every
step throughout training ­phase58. In this CNN model, the dropout rate has been considered to be 0.5 to avoid
the overfitting problem.
• Flatten Layer The “Flatten layer” is the subsequent layer, which turns the previous layer’s multi-dimensional
output into a single dimension. A one-dimensional array is formed as a result of this layer’s output, which aids
in the construction of the classifying neural network’s input layer, where the elements of the array is supplied
towards each neuron. However, after performing all the previous CNN operations, the one dimensional array
that has been generated in this phase possesses the most significant and reduced set of attributes from the
input images. Thus, from the “Fine tuning layer” to the “Flatten layer” is considered to be the feature extrac-
tion segment of this deep learning technique.
• Fully Connected Layer: The “Fully Connected Layer” or “Dense Layer” is the last layer of the CNN design,
which serves as the classifier layer in this technique. This layer, which is a sort of feed-forward artificial neural
network, is placed at the bottom of the CNN model and within this layer, every neuron is linked to all neu-
rons of the preceding layer, following the fundamental approach of the traditional multiple-layer perceptron
neural ­network59.

As the problem in this study is a binary classification task, the CNN model has been compiled utilizing the ’binary
cross-entropy’ loss function and ‘adam’ optimizer with considering ‘accuracy’ as the core evaluation metrics for
each classifiers per epoch. Therefore, employing the above mentioned CNN architecture the machine learning
has been executed in 30 epochs in order to train the model using the input images and provide the categoriza-
tion output. However, in deep learning method there is little necessity of processing the images before training,
because the internal neural network processes the image to extract prominent features for classification.

Technique 4: proposed extended technique. This proposed technique is the combination of both deep
learning approach and stacking ensemble machine learning models; where the dominant features from the input
dataset have been extracted using deep learning technique’s feature extraction segment and then the stacking
ensemble machine learning models are incorporated to perform the classification phase utilizing that dataset
containing reduced features. The block diagram of the proposed technique has been illustrated in Fig. 2.

Feature extraction from best performing DL model. The internal neural networks of the deep learning archi-
tecture extract significant features from the images and the “Flattten layer” generates a single feature vector,
accumulating the output of the previous layers. Therefore, after training the deep learning model with the input
image dataset, the outcome obtained from flatten layer with a one dimensional array will represent the reduced
set of dataset containing the vital features. As one of the core benefits of CNN architecture is that it automatically
detects significant attributes from the input image performing various layer of operations without the need for
human intervention or image processing; thus, the proposed technique has extracted the reduced and optimal
set of features from the best performing CNN model explored from the previously explained deep learning tech-
nique in “Technique 3: deep learning technique” section.

Training stacked ensemble machine learning models with reduced feature set. A stacking ensemble based ML
classification approach has been applied here for classifying the PCOS or non-PCOS criteria in this proposed
technique that offers several advantageous perspectives, such as: (a) it analyzes heterogeneous weak classifiers
as well as learns them in parallel; (b) aggregates base classifiers by training a meta-learner to produce a stronger
prediction based on the forecasts of the individual weak learners; and (c) thus, it minimizes variance and also
enhances predictive force of the learning process. The stacking ensemble machine learning model has been
utilized as the classifier phase in this proposed technique to replace the fully connected layer in the deep learn-

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Without image pre-processing With image pre-processing

ML models Accu. Prec Rec. Spec F1-s Time Accu. Prec. Rec. Spec F1-s Time
Logistic regression 0.739 0.739 0.74 0.73 0.74 5.85 0.756 0.754 0.76 0.74 0.76 4.3
SVM 0.762 0.762 0.76 0.76 0.74 370.7 0.807 0.808 0.81 0.79 0.80 268.2
Decision tree 0.714 0.715 0.72 0.71 0.71 24.8 0.737 0.773 0.73 0.74 0.75 10.4
KNN 0.718 0.719 0.72 0.69 0.72 13.9 0.849 0.870 0.85 0.84 0.85 9.1
Naive Bayes 0.714 0.716 0.71 0.70 0.72 6.3 0.760 0.761 0.77 0.76 0.76 4.2
Random forest 0.778 0.779 0.77 0.74 0.77 8.2 0.883 0.883 0.88 0.87 0.88 5.8
Gradient boosting 0.791 0.792 0.80 0.79 0.82 44.3 0.855 0.856 0.86 0.86 0.85 31.8
Adaptive boosting 0.718 0.716 0.71 0.72 0.71 272.2 0.815 0.813 0.82 0.81 0.81 218.9
XG boosting 0.806 0.810 0.80 0.79 0.81 172.2 0.856 0.855 0.85 0.86 0.86 150.1
CATBoost 0.712 0.710 0.72 0.71 0.70 72.2 0.790 0.792 0.79 0.78 0.79 74.1

Table 1.  Performance analysis of test data using traditional machine learning technique with and without
image pre-processing (Technique 1).

ing technique. From the best performing CNN model, the reduced set of features has been explored and then
utilized as the input training data for the stacked machine learning classifiers.
Here, in the proposed stacked ensemble model, the dataset with reduced feature set is initially sent to the base
learners. At this phase, the five types of widely utilized traditional machine learning classifiers have been consid-
ered to be the weak learners or base classifiers at level 0 of the stacked model, which are: Logistic Regression(LR),
Support Vector Machine(SVM), Decision Tree(DT), K-Nearest Neighbour(KNN) and Gaussian Naive Bayes(NB)
classifiers. Each of these base models gets trained independently using their respective prediction algorithms,
resulting in forecasts symbolized p1, p2, p3, p4, and p5 in Fig. 2. Following that, the predictions acquired from
the level 0 models are fed into level 1 where a single classification model, or meta-learner, learns to generate
final prediction from it. The meta-learner has been created at level 1 employing one stronger machine learning
classifier. Here, while keeping the same base models at level 0, five types of classifiers have been explored as meta
learners in level 1 which resulted in five varieties of the proposed architecture with an aim to explore the best
performing one. The meta learner that has been used here is one of the five types of bagging or boosting classi-
fiers ( Random Forest, Adaptive Boosting, Gradient Boosting, CAT Boosting and XGBoosting) that is ultimately
trained on top of level 0 to generate the final output based on the predictions returned by the base models. Thus,
an extended stacked ensemble ML classifier has been proposed, trained and evaluated incorporating five types
of traditional classifiers as base models and one boosting or bagging type of classifier as meta learner with an
aim to differentiate between PCOS and non PCOS patient ovary USG images. The pseudocode of the proposed
technique for PCOS detection has been shown in Algorithm 1.

Result analysis
The following sections have been organized to present the findings from the interpretation of research results.

Findings from machine learning techniques. Employing technique 1, the performances of the ten
types of traditional machine learning models using several performance metrices and their execution times have
been illustrated in Table 1. In this technique, after image acquisition and augmentation phases, all the images
are being processed using image processing techniques. The examples of USG scan with image processing tech-
nique is shown in Fig. 3. The figure makes it apparent that image pre-processing steps change the original images
substantially clearer while also allowing for the identification of the ovarian cysts that were barely apparent in
the original image in the impacted locations. The models are then trained using the enhanced pictures with fea-

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A. Original Image B. Image C. Noise Reduction D. Morphological E. Image Segmentation F. Feature Extraction
Enhancement Processing (OTSU) (ORB)
EXAMPLE 1

A. Original Image B. Image C. Noise Reduction D. Morphological E. Image Segmentation F. Feature Extraction
Enhancement Processing (OTSU) (ORB)
EXAMPLE 2

Figure 3.  USG scans with image processing steps.

Using Chi-square feature set Using PCA feature set

ML models Accu. Prec Rec. Spec F1-s Time Accu. Prec. Rec. Spec F1-s Time
Logistic Regression 0.768 0.769 0.76 0.77 0.77 3.7 0.760 0.761 0.76 0.76 0.76 3.9
SVM 0.823 0.820 0.82 0.82 0.82 111.9 0.776 0.770 0.77 0.77 0.77 113.9
Decision Tree 0.639 0.647 0.64 0.69 0.63 14.6 0.637 0.673 0.63 0.54 0.65 10.2
KNN 0.778 0.822 0.73 0.67 0.72 6.3 0.782 0.819 0.77 0.72 0.77 7.6
Naive Bayes 0.698 0.699 0.69 0.69 0.69 2.75 0.697 0.664 0.67 0.65 0.66 3.3
Random Forest 0.888 0.886 0.89 0.89 0.88 4.3 0.793 0.781 0.72 0.70 0.72 4.8
Gradient Boosting 0.853 0.859 0.86 0.86 0.85 35.2 0.805 0.809 0.81 0.81 0.80 36.8
Adaptive Boosting 0.773 0.789 0.77 0.75 0.77 177.2 0.790 0.792 0.79 0.78 0.79 104.1
XG Boosting 0.783 0.779 0.77 0.74 0.77 75.2 0.765 0.769 0.76 0.74 0.76 86.8
CAT Boost 0.811 0.813 0.81 0.80 0.81 48.3 0.799 0.795 0.79 0.79 0.80 50.5

Table 2.  Performance analysis of test data using traditional machine learning technique with feature reduction
(Technique 2).

ture extraction containing 50176 features of pixel values, which have been collected at the completion of image
processing steps. Here, for conducting ablation study to analyze the relative importance of image processing
steps, the models have been trained and tested firstly without image pre-processing and then with image pre-
processing. From the performance analysis in Table 1, it can be observed that, for all the classifiers, the perfor-
mances significantly enhances after applying image-preprocessing steps. In case of training the models without
image pre-processing, the best performance has been acquired in XGBoosting model with 80.6% accuracy. On
the other hand, employing image pre-processing techniques, Random Forest classification model outperforms
all other classifiers in terms of performing with highest accuracy (88.3%) in less computation time (5.8 seconds)
whereas the Naive Bayes classifier provides the least accuracy (76.0%) and SVM classifier takes the highest
execution time (368.2 seconds). The AUC-ROC curve of the analysis without image pre-processing and with
image pre-processing has been shown in Fig. 6a,b. Thus, the performance analysis clearly reveals that, image pre-
processing techniques plays a significant role in acquiring good performances with machine learning classifiers.
In the second type of technique, the two datasets with reduced features of 25,000 pixel columns acquired
from the two types of feature reduction algorithms are applied to the traditional machine learning classifiers.
The performances and execution times of the ten types of traditional machine learning models with both type of
feature sets are shown in Table 2. From the table, it is apparent that after feature reduction the execution time for
each of the models reduces significantly. It can be also observed that, most of the models perform better when
employing chi-square feature sets than PCA technique. However, the Random Forest classifier outperforms
the others, with an accuracy of 88.8% using the chi-square approach and Gradient Boosting model performs
comparatively better using PCA feature set with 80.5% accuracy.
The 3rd technique has followed deep learning architecture in which a variety of pre-trained model has been
employed in the initial layer using the transfer learning (TL) approach. For analyzing the relative importance
of this transfer learning layer, an ablation study has also been conducted in this phase where the CNN model
has been trained and tested without the transfer learning layer. Each model has been trained using 30 epochs.
Table 3 shows the performances of the deep learning technique on a test dataset without transfer learning layer

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Deep learning models Accuracy Precision Recall Specificity F1-Score Time (s)
CNN without transfer learning 0.7479 0.75 0.78 0.74 0.75 45.9
CNN with VGGNet16 0.9780 0.97 0.96 0.96 0.97 82.6
CNN with Xception 0.9187 0.92 0.91 0.92 0.91 96.7
CNN with InceptionV3 0.7625 0.76 0.75 0.76 0.76 55.6
CNN with MobileNet 0.9162 0.91 0.92 0.91 0.91 70.8

Table 3.  Performance analysis of test data using deep learning technique (Technique 3).

Figure 4.  Accuracy and Loss per epoch for DNN models (technique 3) (a) CNN without transfer learning (b)
CNN with VGGNet16 for transfer learning (c) with InceptionV3 for transfer learning (d) with MobileNet for
transfer learning (e) with Xception for transfer learning.

as well as utilizing four different types of pre-trained models each one executing over 30 epochs. Figure 4 shows
the accuracy and loss per epoch for each type of the dnn techniques. Figure 6c illustrates the AUC-ROC curve
employing various forms of DNN technique. Here, from the performance analysis it is evident that all the deep
learning approaches have gained significantly higher accuracy with the “VGGNet16” pre-trained model surpass-
ing the others, obtaining 97.80% accuracy in 82.7 seconds execution time. It is also noticeable that, the CNN
model without transfer learning layer performs much worse with only 74.79% accuracy which is much lesser than
the models employing transfer learning. This analysis reveals that, transfer learning plays a key role in efficient
prediction of the classes. However, the performance analysis from 3 also shows that though the accuracy of the
models using this dnn technique is much higher but the execution time for prediction is also very high which
can be considered as a drawback of this technique.
Finally, in the proposed extended technique, the input dataset for the machine learning classifiers is the flat-
ten layer’s output feature vector from the deep learning architecture incorporating the best performing CNN
architecture with “VGGNet16” pre-trained model used for tranfer learning. The extracted dataset with reduced
features now contains only the 32 most significant attributes from the USG ovary images gained by the deep
learning method’s neural networks. This dataset with extracted features has been fed to the proposed stacking
machine learning classifiers where all the stacked ensemble model contains same base learners but five different
types of meta-learners and therefore their comparative predictive performances are analyzed using performance

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Base Models Meta-learner Accuracy Precision Recall Specificity F1-score Time (s)
Feature Extraction LR Random Forest 0.9844 0.98 0.98 0.97 0.98 0.09
with CNN SVM XGBoost 0.9989 0.99 1.00 1.00 0.99 0.05
& Classification DT AdaBoost 0.9959 0.99 0.98 0.99 0.99 1.07
with Stacking KNN GradBoost 0.9922 0.99 1.00 0.99 0.99 0.09
Ensemble Model NB CATBoost 0.9958 1.0 0.99 0.99 1.0 1.12

Table 4.  Performance analysis of test data using proposed technique (Technique 4).

Figure 5.  Comparative analysis of (a) accuracy and (b) execution time for ML models using different
techniques.

metrics, as shown in Table 4. The results reveal that, the performances of all of the models have improved dramati-
cally, with the XGBoost classification model as meta-learner achieving the greatest accuracy of 99.89% in just
0.05 seconds of execution time. Here, from this analysis it is apparent that, for all the varieties of the proposed
technique the accuracy is always more than at least 98% with comparatively very less execution times. The AUC-
ROC curve of the proposed technique has been shown in Fig. 6d, which also shows significantly efficient AUC
scores than the other types of predictive models.
However, here the best performing meta-learner “XGBoost” classifier is an efficient open-source boosting
type of ensemble machine learning model. The model is trained here by minimizing the loss of an ‘objective’
function against the dataset with an aim to minimize the error, where the appropriate choice of loss function
in XGBoost model is a critical hyperparameter to acquire desired performances. As the problem in this article
is a binary classification task with two class labels, thus in the proposed technique the loss function used for
predicting probabilities is ‘objective=binary:logistic’.

Comparative analysis. The comparative performance analysis of the accuracy and execution times of vari-
ous machine learning models employing the four types of techniques in this study for PCOS detection are rep-
resented graphically in Fig. 5. Also, the AUC-ROC curve of the techniques have been illustrated in Fig. 6. The
comparative analysis of the four methods for detecting PCOS from ultrasound images using machine learning
techniques reveals that, the performances of the ten types of ML models employing traditional approach in
technique 1 with all input features from the images are much poorer in terms of all the performance metrics (see
Table 1). Though the performances of the models enhances after applying image pre-processing steps, but still
the highest performance can be achieved in this technique with an accuracy of 88.3% in 5.8sec execution time

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Figure 6.  AUC-ROC curve for ML models (a) without image pre-processing (technique 1) (b) with image pre-
processing (technique 1) (c) with deep learning (technique 3) (d) with proposed technique (technique 4).

employing Random Forest classifier. The performances of the models enhance a little bit when numerical feature
selection techniques like chi-aquare and PCA have been applied to the dataset in technique 2, where the highest
accuracy has been gained to be 88.8% with 4.3 sec execution time with Random Forest classifier trained with
reduced feature set of chi-square technique (see Table 2).
However, the performances of detecting the PCOS get much higher when deep learning model is utilized
for classification in technique 3 employing transfer learning technique, with an highest accuracy of 97.80% with
VGGNet16 used as the layer of transfer learning in the proposed CNN architecture (see Table 3). But, the limita-
tions of using deep learning models are that they are expensive to train and demand a lot of processing power and
time. Therefore, as compared to typical machine learning models the execution time is significantly longer in deep
learning models, which is evident in Table 3 (best performing model takes 82.6 sec execution time). To overcome
these drawbacks, this study have implemented a hybrid model in method 4, in which the feature extraction phase
from the images has be conducted by the best performing deep learning model and then the stacking ensemble
machine learning models are utilized to do the classification. This method yields substantially higher accuracy
in a short amount of time (see Table 4). It is noticeable that, for each of the ML model the accuracy increases and
execution time decreases dramatically with the proposed technique. For example, for Random Forest classifier
the best acquired accuracy with technique 1 is 88.3% and with technique 2 is 88.8%; which enhances significantly
providing 98.44% accuracy while employing as a meta-learner of the stacked ensemble model of the proposed
technique. Also, as the classifiers predicts the classes based on only 32 dominant features of the USG images,
the execution times are comparatively much lesser in the proposed technique. Therefore, the comparative per-
formance analysis reveals that, the proposed technique employing CNN with “VGGNet16” pre-trained model
used for transfer learning as the feature extractor and the stacking ensemble model with “XGBoost” classification
model used for meta-learner as the classifier of this problem can categorize PCOS and non-PCOS USG images
in not only with the best performances but also solve the problem in least execution time.

Discussion and conclusion

The presented work in this research can be a pioneer study in the domain of PCOS detection which has incor-
porated the advantages of both conventional and deep learning techniques. The findings of this study can be
significantly beneficial towards both patients and healthcare providers in identifying PCOS quickly and efficiently.

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The suggested hybrid method has combined transfer learning technique using powerful pre-trained models
in a CNN architecture to extract the most significant feature set from the images and then stacking ensemble
machine learning technique have been employed to classify the images. To analyze the efficacy of the model and
evaluate its performances, three types of other existing methodologies have also been performed in this study.
The first two existing techniques for PCOS detection from USG images using traditional ML algorithms have
appeared to be much inefficient as they provides significantly less accuracy as well necessitate tedious digital
image processing steps for feature extraction and also requires another feature selection method for the reduc-
tion of massive amount of image features. Also, the third existing technique with only deep learning technique
requires much higher computational space and time. Ultimately, after several analysis the experimental findings
reveal that, the proposed hybrid strategy of employing the “VGG16” pre-trained model for transfer learning in
the CNN architecture for feature extraction and then the “XGBoost” machine learning model as the meta-learner
of stacking ensemble model for image classification yields the maximum accuracy of 99.89% with a relatively
shortest execution time to detect PCOS from ultrasound images.
An effective machine learning approach to detect PCOS from ovarian ultrasound images is considered to
be a potentially valuable solution for recovering thousands of women’s reproductive health. Most of the stud-
ies that had been conducted in this field (for example the works conducted i­ n15–26) for PCOS detection are the
implementation of various forms of digital image processing techniques for follicle detection and then applying
conventional machine learning models for classification. Recently, a few researchers have also focused on apply-
ing deep neural network with CNN architecture to detect PCOS from medical images (for example the works
conducted ­in30,31). Yet, little or no research has been conducted in this area for PCOS diagnosis that uses both
traditional ML classifiers and deep neural networks together with transfer learning and fine tuning. Moreover,
even if some other research from different domains have adopted this type of integrated model (for e­ xample35),
but hardly any study has been found that combined the CNN techniques with stacked ensemble machine learning
classifiers with an aim to detect anomaly from medical images. Thus, to the best of our knowledge, the proposed
technique in this study, where CNN with transfer learning and fine tuning utilized as the feature extractor and
then stacked ensemble machine learning with the integration of classical and boosting ensemble models as the
classifier is a unique and novel solution in the domain of medical image analysis for disease identification.
The findings of this study will greatly benefit healthcare practitioners in identifying PCOS using ultrasound
images more quickly and accurately combining the advantages of both traditional machine learning and deep
learning approaches and thus it is anticipated to be widely used in the real-world scenario. However, one of the
study’s limitations was that, collecting medical images of the patients in the least developing country is quite
challenging and as a result the machine learning techniques have been applied on a limited number of images
(594 images) due to the lack of a dataset. Additionally, the proposed technique is based on deep learning feature
extraction and stacked ensemble machine learning classifier which is quite difficult to make explainable and thus
may seem like black box towards the physicians. Therefore, in the future, the researchers look forward to discover
more about PCOS identification employing larger datasets, incorporating the concepts of explainable AI (XAI)
and federated learning as well as use similar technique to detect other clinical disorders.

Data availibility
The dataset generated and analyzed during the current study are not publicly available due to the fact that we
are still using it for another publication, but are available from the corresponding author on reasonable request.

Received: 3 April 2022; Accepted: 30 September 2022

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Acknowledgements
The authors would like to thank the Information and Communication Technology (ICT) Division,Ministry of
Posts, Telecommunications and Information Technology, Bangladesh and the department of Computer Science
and Engineering, MIST for the continuous support and encouragement to pursue this research work.

Author contributions
The idea of this article was developed by S.A.S. and M.N.I. Literature review was conducted by M.N.I. The
framework was proposed by S.A.S. and M.N.I. The simulation was carried out by S.A.S. ALL authors took part
in interpreting the data. M.N.I. contributed toward rewriting the entire draft article to prepare it for publication.
All authors read, edited, and approved the final manuscript.

Competing interest
The authors declare no competing interests.

Additional information
Correspondence and requests for materials should be addressed to M.N.I.
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