The DICOM standard defines the application layer network protocol used to send and receive medical images. DICOM is defined on top of TCP. DICOM addresses many issues associated with medical image transmission; however, sending and receiving large studies is inefficient because they are transmitted one object at a time. The Multi-Series DICOM (MSD) format has been introduced as a solution to this problem. It can store an entire study in a single object. In addition, the metadata information in the MSD object is free of repetition. In this work, the performance of sending and receiving DICOM studies as MSD objects is investigated. A set of DICOM studies is stored in two formats, traditional Single-Frame DICOM (SFD) and MSD. The times required to send the studies in both formats synchronously and asynchronously are measured. The results show that there is a significant reduction in the time required to synchronously send the studies in the MSD format compared to the SFD format and a small improvement when sending asynchronously. Sending studies synchronously in the SFD format results in a delay waiting for the acknowledgement for each DICOM object sent before sending subsequent ones. With the asynchronous approach, the time reduction is a direct result of the difference in metadata size between the SFD and MSD formats and the lower number of acknowledgements sent back from the receiving application entity to the sender. The results show that it is more efficient to send DICOM studies as MSD objects whether synchronously or asynchronously.