Transvaginal color flow Doppler in the assessment of ovarian and uterine blood flow in infertile women

Changes in uterine and ovarian arterial impedance during the periovulatory period in conception and nonconception cycles

OBJECTIVE

To evaluate whether the Doppler velocimetry of uterine and ovarian arteries during the periovulatory period in conception cycles differs from that in nonconception cycles.

DESIGN

Transvaginal color Doppler sonography was used to assess uterine and ovarian perfusion in 63 infertile women during the periovulatory period.

RESULTS

In the conception cycles (n = 16), the PI values of uterine arteries at the day of ovulation were significantly less than those in nonconception cycles (n = 47). There were no significant differences in the PI values of ovarian arteries between the conception and nonconception cycles.

CONCLUSIONS

In the present study, the conception cycles showed lower vascular impedance in the uterine during the periovulatory period than did the nonconception cycles. This endometrial perfusion presents an accurate noninvasive assay of uterine receptivity that can be used to predict the successful outcome of implantation and to reveal unexplained infertility problems.

Angiogenesis in ovarian follicular and luteal development

Angiogenesis is the process of new capillary formation from previously existing mature vessels. The adult ovary exhibits dramatic growth and regression of capillary networks on a cyclic basis. Ovarian follicles and the corpus luteum contain and produce endothelial cell-specific factors, which may act alone or in concert to regulate the process of angiogenesis. These factors are ultimately controlled by endocrine, paracrine and autocrine regulation, as well as by metabolic cellular signals such as intracellular oxygen content and ageing. Aberrant production of these angiogenic factors may be the cause of vascular dysfunction and the development of ovarian disorders. Recent technological advances for monitoring blood flow and measuring angiogenic factors could assist in accurately diagnosing ovarian disorders. Further elucidation of specific physiological role(s) of factors involved in angiogenesis of the pre-ovulatory follicle and developing corpus luteum may be useful in addressing issues of infertility in women.

Recombinant luteinizing hormone in ovarian hyperstimulation after stimulation failure in normogonadotropic women

The aim of this study was to examine the effect of an additional administration of recombinant luteinizing hormone (r-LH) to a gonadotropin-releasing hormone agonist (GnRHa) long protocol using recombinant follicle-stimulating hormone (r-FSH). In particular we determined whether such a stimulation protocol would be more effective in women (1) who respond poorly to stimulation with GnRHa long protocol using r-FSH only, and (2) whose LH concentrations after down-regulation in the cancelled cycle were low but above the values reported in the literature to be sufficient for folliculogenesis. After GnRHa desensitization 150 IU r-FSH and 75 IU r-LH were administered subcutaneously daily to six normogonadotropic women with low response to ovarian hyperstimulation using a GnRHa long protocol with r-FSH and low LH concentrations after down-regulation in the cancelled cycle. All six women had an oocyte retrieval and an embryo transfer after follicular stimulation. One women conceived but had a miscarriage in the eleventh week of gestation. Our results suggest that women with low response to a GnRHa long protocol with r-FSH, and whose LH concentration after down-regulation in the cancelled cycles were low, benefit from the additional administration of r-LH in a GnRHa long protocol using r-FSH. It seems that due to the additional administration of r-LH the LH concentration in the follicular phase is sufficient to support folliculogenesis.

Comparison of resistive index versus pulsatility index in assessing the benign etiology of adnexal masses

Retrospective analysis of pelvic sonograms with colorguided spectral Doppler evaluation of 189 adnexal masses yielded four malignancies, 20 benign neoplasms, 32 cysts, and 14 endometriomas. Fifty-eight masses were presumed benign on additional imaging. Pulsatility index (PI) < 1.0 was seen in 70% neoplasms, 63% benign cysts and 50% endometriomas. Thirteen percent of benign cysts and no neoplasms had resistive index (RI) < 0.4. Fifty percent malignancies had PI < 1.0. None had RI < 0.4. Both thresholds lack sufficient sensitivity and specificity for distinguishing benign and malignant lesions.

Female "varicocele": two cases diagnosed by labeled red blood cell angioscintigraphy and treated by percutaneous phlebography and embolization

Varicocele, a varicosity of the gonadal venous plexus, is a well-recognized disorder occurring in up to 10% of men. In women, an analogous varicosity of the salpingo-ovarian plexus is rare. This may be explained, in part, by the lack of obvious findings on clinical examination in women compared with men and the need, until recently, to use invasive venographic methods to confirm the diagnosis. Two cases of "female varicocele" diagnosed by means of echo Doppler and Tc-99m red blood cell scintigraphy and their cure by percutaneous phlebographic occlusion of the ovarian venous varicosity are described.

Transrectal color Doppler sonography of the A. uterina in cyclic mares

Color Doppler ultrasound was used transrectally in 6 mares to locate both the left and right Aa. uterinae and to obtain flow velocity waveforms at defined times (Days 0, 5, 10, 15 and 20) during 4 estrous cycles. Blood flow reflected by the resistance index (RI) was determined for both arteries on 120 occasions. As there was no significant difference and a high correlation in the RI values between the left and right arteries (paired Student's t-test, correlation coefficient r > 0.94; P < 0.05), the average RI value was used for subsequent analyses. There were correlations between RI values, mares and day of estrous cycle (P < 0.0001). The mean RI was higher (P < 0.05) in the 2 multiparous mares (age, 12 to 13 yr) than in the 4 younger maiden mares (age, 6 to 10 yr). During the estrous cycle mean RI values on Day 0 (day of ovulation) and Day 10 were higher (P < 0.05) than on Days 5, 15 and 20, whereas between estrous cycles within mares no differences (P > 0.05) could be measured. The results suggest that transrectal Color Doppler sonography is a noninvasive method for examining differences in impedance to uterine blood flow between different mares and cycle periods.

Evidence of interplay between plasma endothelin-1 and 17 beta-estradiol in regulation of uterine blood flow and endometrial growth in infertile women

OBJECTIVE

To determine the effects of gonadotropin-induced ovarian stimulation on the plasma levels of endothelin-1 as well as on uterine blood flow and endometrial thickness.

DESIGN

Controlled cross-over clinical study.

SETTING

Academic research environment.

PATIENT(S)

Eighteen volunteer infertile women (31.4 +/- 2.5 years, mean +/- SE) participating in an IVF-ET program.

INTERVENTION(S)

Transvaginal Doppler ultrasound was performed and blood samples were collected 4 days after the LH surge in a spontaneous cycle and 4 days after hCG administration in a subsequent gonadotropin-stimulated cycle.

MAIN OUTCOME MEASURE(S)

Plasma levels of E2, P, and endothelin-1; uterine artery pulsatility index; and endometrial thickness.

RESULT(S)

Stimulated cycles were associated with significantly higher E2 levels (101.0 +/- 10.2 versus 723.5 +/- 57.3 pg/mL [conversion Factor to SI unit, 3.671]; spontaneous versus stimulated), thicker endometrium (9.2 +/- 2.5 versus 11.4 +/- 2.9 mm), and lower endothelin-1 levels (2.5 +/- 0.1 versus 2.1 +/- 0.1 pg/mL [conversion factor to SI unit, 0.4]) and pulsatility index (3.22 +/- 0.12 versus 2.63 +/- 0.08) than spontaneous cycles. Endothelin-1 correlated negatively with E2 (r = -0.38), but not with P or pulsatility index. Differences in endothelin-1 and endometrial thickness between spontaneous and stimulated cycles correlated negatively (r = -0.56) with each other.

CONCLUSION

Our results suggest an inhibitory role for E2 in the release of endothelin-1, which could be a factor in the regulation of uterine and endometrial blood flow.

The assessment of normal and abnormal luteal function by transvaginal color Doppler sonography

OBJECTIVE

To evaluate intraovarian resistance index (RI) in 47 healthy fertile volunteers with ovulatory cycles, 28 patients with luteal phase defect (LPD) and four patients with luteinized unruptured follicle (LUF Sy).

STUDY DESIGN

Transvaginal color Doppler assessment of the follicular and corpus luteum blood flow and plasma progesterone (P) levels were obtained in each patient.

RESULTS

Significantly higher intraovarian artery RI (< 0.001) was obtained for LPD group than for controls during the luteal phase. In the control group both follicular and corpus luteum RI were significantly lower (P < 0.001) on the dominant side, while in LPD group no difference (P > 0.05) between the sides occurred. Mean P levels were significantly lower (P < 0.001) in the LPD group (6.9 +/- 2.3 ng/ml) than in controls (24.1 +/- 11.4 ng/ml). In all the LPD patients histopathology revealed delayed endometrial pattern, while normal endometrial dating was found in all the evaluated patients form the control group (n = 15). In the patients with LUF Sy (n = 4) similar RI values were obtained in the follicular and corpus luteum phase. There was no difference between the sides in terms of the intraovarian RI, while subnormal values of P were obtained in all the examined patients (14.1 +/- 6.2 ng/ml).

CONCLUSIONS

Transvaginal color Doppler may predict the function capacity of the corpus luteum.

The assessment of uterine and ovarian perfusion in infertile patients

OBJECTIVE

To evaluate ovarian and uterine perfusion in 790 infertile patients.

STUDY DESIGN

Transvaginal color Doppler assessment of the ovarian and uterine circulation in infertile patients with benign pelvic lesions, uterine anomalies and ovarian or uterine dysfunction.

RESULTS

Uterine anomalies were detected in 146 patients: 135 septate and 11 bicornute uteri. No alteration, in terms of resistance index (RI), was detected for main uterine arteries in patients with duplication anomalies of the uterus. Submucous fibroids were identified in 25 patients, while subserous leiomyoma were diagnosed in five patients. The mean RI for these lesions covered the value of 0.55 +/- 0.09. Endometrial polyps altered the endometrial perfusion in 26 infertile patients (RI = 0.48 +/- 0.06), while 11 avascular intrauterine synechiae were identified. Functional ovarian cysts were transitory present in 59 patients. The RI varied from 0.52 +/- 0.06 for follicular and 0.46 +/- 0.08 for corpus luteum cysts. Ovarian endometrioma were visualized in 78 infertile patients. Forty eight of them were vascularized at the level of the hilus, while 16 showed pericistic vascular location (RI ranged from 0.40 to 0.59). Dermoid cysts (n = 12) were mostly avascularized (75%), while polycystic ovaries demonstrated increased intraovarian vascularity in all the examined cases. The mean RI detected within the ovarian stroma was 0.52 +/- 0.06. In 11 patients premature menopause was predicted due to low volume of the ovary (< 2 cm3) and absence of the intraovarian vascularity. Hydrosalpynx or sactosalpynx were imaged in 154 patients. The RI varied from 0.44 in acute to 0.74 in chronic stage of the disease.

CONCLUSION

Transvaginal color Doppler allows precise estimation of the functional state of the reproductive organs in infertile patients.

Hemodynamic assessment in pelvic inflammatory disease by transvaginal color Doppler ultrasonography

One of the major signs of inflammation is a change in vascular flow and caliber. It is possible to detect these changes with the help of transvaginal color Doppler velocitometry. The purpose of this study was to evaluate the changes in pelvic circulation in cases with pelvic infection and to correlate these findings with other infectious parameters. The study group consisted of 20 cases who had the diagnosis of pelvic inflammatory disease (PID). Resistance index (RI) and pulsatility index (PI) were measured with transvaginal color Doppler ultrasonography in the uterine and ovarian arteries as well as at the tubouterine junction three times in a one-month period. At the same time the body temperature, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and leukocyte counts were recorded. Infectious parameters declined to normal values, following a pattern parallel to clinical improvement from the first until day 30. Infectious parameters revealed significant differences between days 1-7, 1-30 and 7-30. On the other hand, low resistance in all three measurement points exhibited a rapid increase on the day 7 day and plateaued until the day 30 day. Color Doppler velocitometry measurements revealed significant differences between days 1-7 and 1-30 but not between days 7-30. These findings demonstrate that as the infection subsides, the changes in vascular flow return to normal before infectious parameters do. In conclusion, it is possible to detect decreased vascular resistance in acute infection with the help of transvaginal color Doppler ultrasonography. Furthermore, color Doppler ultrasonography can accurately detect regression of the infectious process before body temperature and acute phase reactants do.

Female Reproductive Arterial Blood Flow and Its Relation to Infertility

Transvaginal color Doppler offers a closer look at blood flow within the reproductive organs. Recent literature using this technique demonstrates that 1) blood flow in the uterine and ovarian arteries is related inversely to estrogen levels, 2) no significant difference is seen between right and left uterine arteries among fertile and infertile patients, and 3) high resistance in uterine and ovarian arteries is correlated directly with poor pregnancy outcome. The question remains: Is there an resistive index or pulsatility index value, representing a cut-off point, for predicting successful outcome in the patient undergoing in vitro fertilization?

Blood flow changes in the ovarian and uterine arteries during the normal menstrual cycle

OBJECTIVE

Our purpose was to study the hemodynamic changes in the uterine and intraovarian vessels during the normal menstrual cycle and to relate the vascular changes to hormonal index values.

STUDY DESIGN

Seven women who had bilateral tubal patency, a normal pelvis on laparoscopy, and regular ovulatory cycles underwent serial transvaginal ultrasonography on menstrual cycle day 2, daily from estimated day of ovulation-6, hourly from estimated day of ovulation-2, or when the mean follicular diameter was > 16 mm (whichever was earlier) until 6 hours after follicular rupture and once 7 days after follicular rupture. At each scan uterine and intraovarian blood flow was assessed with transvaginal color Doppler ultrasonography and serum concentrations of follicle-stimulating hormone, luteinizing hormone, estradiol, and progesterone assessed by fluoroimmunoassay.

RESULTS

In one case there was evidence of a luteinized unruptured follicle and the patient was therefore excluded from analysis. In the other six women there was spontaneous ovulation at a mean of 39 hours after the onset of the luteinizing hormone surge. On the side with the dominant follicle, follicular and ovarian stromal peak systolic blood flow velocity rose significantly during the menstrual cycle with no significant change in pulsatility index. The changes in blood flow velocity correlated significantly with changes in serum follicle-stimulating hormone, luteinizing hormone and progesterone concentrations. There were no significant changes in either blood flow velocity or pulsatility index in the contralateral ovary. Uterine artery time-averaged maximum velocity on the side of the developing ovarian follicle increased during the menstrual cycle with no significant change in the contralateral vessel. Uterine artery pulsatility index on the side of the developing follicle declined during the midluteal phase and was significantly lower than on the contralateral side. The changes in time-averaged maximum velocity correlated with the changes in serum estradiol and progesterone concentrations.

CONCLUSION

The vascular changes in the wall of the dominant ovarian follicle and ovarian stroma during the menstrual cycle are consistent with activity of angiogenic-like factors. The decline in uterine artery resistance during the midluteal phase may reflect optimal vascularity for implantation of the blastocyst.

Transvaginal Doppler study of uterine artery blood flow in in vitro fertilization-embryo transfer cycles

OBJECTIVE

To verify whether uterine artery impedance, measured as pulsatility index and resistance index is related to the outcome of in IVF-ET cycles.

DESIGN

Prospective study of infertile women participating in an IVF-ET program.

SETTING

University Hospital.

PATIENTS

Two hundred women (24 to 40 years of age), who had one to three good quality embryos transferred to the uterus after a standardized IVF cycle.

INTERVENTION

Transvaginal color Doppler and a blood sample on the day of ET.

MAIN OUTCOME MEASURES

Uterine artery pulsatility index and resistance index, endometrial thickness, serum E2 and P concentrations, clinical pregnancy rate (PR).

RESULTS

Pulsatility indices and resistance indices were lower in conception (2.45 +/- 0.54 and 0.85 +/- 0.04, respectively) than in nonconception cycles (2.66 +/- 0.39 and 0.87 +/- 0.04, respectively), although the overlap of the values is considerable. Overall PR was 35% per ET, and it decreased significantly when pulsatility index was > 3.0 (15%) and resistance index > 0.92 (13%), being lowest when pulsatility index was > 3.3 and resistance index > 0.95 (10%). Such a high impedance was detected in 9% of nonconception cycles.

CONCLUSION

In IVF-ET cycles the uterus is likely to be unreceptive when uterine artery pulsatility index is > 3.3 and resistance index > 0.95 before ET, but this occurs only in 9% of the cycles.

Transvaginal color Doppler determination of the ovarian and uterine blood flow characteristics in polycystic ovary disease

OBJECTIVE

To determine blood flow characteristics of ovarian and uterine arteries in patients with endocrinologically and clinically confirmed polycystic ovary disease (PCOD) in comparison with blood flow parameters observed in patients with spontaneous ovulatory cycles.

DESIGN

Controlled clinical study.

SETTING

Patients from Infertility Service in a tertiary care institution.

PATIENTS

Forty patients with confirmed PCOD and 50 control patients in various phases of spontaneous menstrual cycles.

MAIN OUTCOME MEASURE

Using transvaginal color Doppler sonography to determine ovarian morphology, ovarian blood vessel visualization rates, and ovarian and uterine arteries blood flow parameters (resistance index, pulsatility index, and maximal peak velocity). These parameters were correlated with serum hormone levels.

RESULTS

Polycystic ovaries showed typical vascular pattern: increased stromal vascularity, a positive correlation between increased blood velocities and serum LH levels, and a trend toward lower resistance index and pulsatility index values, whereas uterine arteries revealed significantly increased resistance index and pulsatility index values.

CONCLUSIONS

The observed specific intraovarian and uterine vascular pattern in PCOD patients may provide additional data for conventional endocrinologic and ultrasonic diagnostic methods for PCOD.

The first three weeks assessed by transvaginal color Doppler

Transvaginal color Doppler has made possible to study ovarian and uterine perfusion in non-pregnant and pregnant patients, thus advancing the understanding of the early human development. RI of follicular blood flow starts decreasing prior to ovulation reaching its nadir at ovulation. It is considered that apart from hormonal factors the angiogenesis is also involved. The mature corpus luteum shows increased blood flow velocity in relation to preovulatory follicle. Comparing RI values of luteal blood flow of normal and ectopic pregnancy no difference was found. But in threatened, incomplete and missed abortions the resistance and pulsatility indices were significantly higher than in normal pregnancy. The follow up of the luteal flow might have a prognostic value in a group of patients with threatened abortion. In women with spontaneous cycles the day preceding the ovulation impedance to uterine flow velocity starts decreasing. Alterations in flow velocity patterns of the radial and spiral arteries in spontaneous ovulatory cycles are paralleling blood flow dynamics of the uterine arteries. In stimulated cycles RI increases the day before ovulation in both the uterine arteries and their branches. It seems that endometrial perfusion presents more accurate noninvasive assay of uterine receptivity than uterine artery perfusion alone. Endometrial receptivity is maximum during the time of peak luteal function during which implantation is most likely to occur. During the pregnancy impedance to blood flow decrease from the main uterine to the spiral arteries as well as with the advancing gestational age. The spiral arteries in pregnancy become the vessels with completely different haemodynamic characteristics in relation to other arteries of uteroplacental circulation. Color Doppler adds new information on perfusion and pathophysiological changes connected with the ectopic trophoblast implantation.

Does ovarian stimulation affect uterine artery impedance?

PURPOSE

We evaluated the effect of induction of ovulation on uterine perfusion.

METHODS

In 42 infertile women transvaginal color Doppler was performed at days 16-21 of a spontaneous ovulatory cycle and prior to embryo transfer in an in vitro fertilization (IVF) cycle. Indication for treatment was mainly tubal or unexplained infertility.

RESULTS

Uterine artery pulsatility index was significantly (P < 0.001) lower in IVF than in natural cycles, 3.24 +/- 0.72 2.64 +/- 0.53 (mean +/- SD), with a mean reduction of 18%. The reduction was higher, although not significantly, in the women who conceived (20%) than in those who did not (15%), and in those with a basal PI > 3.0 (20%) as opposed to those with normal values (16%). The percentage reduction correlated with patient age and with estradiol concentration, number of follicles, and oocytes recruited.

CONCLUSIONS

Induction of superovulation reduces impedance to flow in the uterine circulation. The amplitude of this effect appears to be regulated partially by patient age and by effectiveness of ovarian stimulation.

Ovarian senescence and its significance on uterine and ovarian perfusion

OBJECTIVE

To measure the flow velocity of the ovarian, uterine, radial, and spiral arteries in different age groups.

DESIGN

Serial measurements throughout the menstrual cycle in normal cycling women with documented fertility were compared with those in postmenopausal patients with and without hormone replacement therapy (HRT).

SETTING

Department of Obstetrics and Gynecology, University of Zagreb, Sveti Duh Hospital, Zagreb, Croatia.

PATIENTS

Two hundred fifty patients were analyzed: 120 healthy fertile women, 85 postmenopausal patients, and 45 postmenopausal patients receiving HRT.

INTERVENTIONS

All patients were examined by transvaginal color and pulsed Doppler.

MAIN OUTCOME MEASURE

Changes in the resistance index of flow velocity waveforms of the ovarian, uterine, radial, and spiral arteries.

RESULTS

Ovarian artery Doppler measurements in postmenopausal patients showed a significant difference when compared with the ovarian artery on the side containing dominant follicle or corpus luteum in healthy fertile group. Uterine and radial artery flow velocity analyses demonstrated significant positive correlations between the resistance index and years of menopause. In patients receiving HRT, a lowering effect occurred in the resistance index of the main uterine artery and its intramyometrial branches. Visualization of clear Doppler signals from the spiral arteries was possible in 30% of women who were menopausal for < 5 years. Increased vascular impedance was the typical finding in this vessel for this group of patients. The addition of HRT resulted in higher visualization rates of the spiral arteries and lowered resistance index values.

CONCLUSIONS

There are changes in the flow velocity patterns of the ovarian, uterine, radial, and spiral arteries with age. The fact that the uterine artery resistance index does not change significantly in the first postmenopausal years strongly supports the thesis that the aging process initially affects the uterus less than the ovary. Furthermore, the uterine environment can be manipulated more easily during the menopausal years by proper hormonal stimulation.

The role of color Doppler imaging in the diagnosis of polycystic ovary syndrome

OBJECTIVE

Our purpose was to evaluate whether intraovarian and uterine blood flow variations are associated with clinical, ultrasonographic, and endocrine polycystic ovary syndrome findings.

STUDY DESIGN

Thirty-two hirsute, oligomenorrheic patients and 18 volunteer women underwent in the early follicular phase ultrasonographic evaluation of ovarian volume, echodensity, and follicle number; transvaginal color Doppler measurement of the uterine and intraovarian vessel variations; and radioimmunologic dosage of luteinizing hormone, follicle-stimulating hormone, estradiol, progesterone, testosterone, androstenedione, and other hormonal compartments.

RESULTS

In the patients with polycystic ovary syndrome (increased luteinizing hormone/follicle-stimulating hormone ratio, elevated androstenedione levels, high number of subcapsular follicles by ultrasonography-augmented ovarian volume and echodensity) (n = 22) we observed, at Doppler analysis, significantly elevated uterine artery pulsatility index values associated with a typical low resistance index of stromal ovary vascularization. The pulsatility index was positively correlated with the luteinizing hormone/follicle-stimulating hormone ratio, and the resistance index was negatively correlated. The elevated uterine artery resistance was correlated with androstenedione levels.

CONCLUSION

Doppler analysis can be a valuable additional tool for the diagnosis of polycystic ovary syndrome.

Reproducibility of Doppler measurements of blood flow velocity in the uterine and ovarian arteries in premenopausal women

Intra- and interobserver reproducibility of Doppler measurements of the pulsatility index (PI) and time-averaged maximum velocity (TAMXV) in the uterine and ovarian arteries were evaluated in examinations of healthy premenopausal women. Each woman underwent reproducibility measurements once in the late follicular phase and once in the midluteal phase. Intraobserver repeatability was assessed in examinations of 12 women, three replicate Doppler measurements being made by one observer in the same vessel. Interobserver agreement was assessed by comparing the results of Doppler measurements made by two investigators in 11 women. The intraclass correlation coefficient (Intra-CC) was 0.78 for the TAMXV in the dominant uterine artery in the follicular phase and 0.82 for the PI in the wall of the dominant follicle. For all other measurements the Intra-CC was < 0.75, indicating poor reproducibility. The interclass correlation coefficient (Inter-CC) was > 0.75 (0.79 to 0.88) for the PI and TAMXV in the dominant uterine artery in the follicular phase and for the PI of both uterine arteries in the luteal phase. For all other measurements the Inter-CC was < 0.75.

The value of transvaginal color Doppler in the assessment of pelvic inflammatory disease

This study compares transvaginal color and pulsed Doppler (TVCD), laparoscopic and clinical findings in 102 women with proven pelvic inflammatory disease (PID). Seventy-two (72) of them had acute symptoms, 11 presented with chronic pelvic pain and 19 patients were infertility cases suspected of tubal etiology. Uterine sonographic findings were demonstrated in 72 patients (70.6%). Free fluid in the cul-de-sac was demonstrated in 39 (38.2%) patients. Ovarian enlargement as the only finding was demonstrated in 6 (5.9%) patients, 22 (21.6%) presented with tubular adnexal structure, while in 74 (72.5%) patients it was of a complex nature. Color flow was obtained in all 6 patients presenting with ovarian enlargement, in 12 (54.5%) of those presenting with tubular adnexal structure, and in 56 (75.7%) of those with complex adnexal mass. Ovarian morphology was clearly delineated from adnexal mass in 59 patients (55.9%). The ipsilateral ovarian flow was altered in 50 of them (84.7%). The mean resistance index (RI) in patients with acute symptoms was 0.53 +/- 0.09 (+/-SD). It significantly differed from those obtained in patients with chronic pelvic pain (RI = 0.71 +/- 0.07) and infertility cases (RI = 0.73 +/- 0.09). We concluded that transvaginal color Doppler is useful additional tool in diagnosis and treatment monitoring in patients with PID.

Color Doppler assessment of folliculogenesis in in vitro fertilization patients

OBJECTIVES

To characterize hemodynamics of human ovarian follicles in the course of their development and to compare the results in relation to the age of patients, pregnancy, location of the ovary, and the quality of the oocytes.

DESIGN

Serial measurements of peak velocity and resistance index by color Doppler imaging.

SETTING

The In Vitro Fertilization Clinic, Success Through Assisted Reproductive Technologies, Inc., Toronto, Ontario, Canada.

PATIENTS

Fifty-two women undergoing hormonal stimulation for IVF.

MAIN OUTCOME MEASURES

The perifollicular peak velocity and resistance index values.

RESULTS

The perifollicular peak velocity values were gradually increasing with the increasing size of the follicles. Highly significant elevation of the peak velocity was observed especially after hCG injection. Such rapid rise of blood velocity was greater in the right ovary than in the left in the younger patients (mean age, 34 years) whereas in older patients (mean age, 41 years), the greater values were observed in the left ovary. There was no significant difference in peak velocity or resistance index between pregnant and nonpregnant patients.

CONCLUSIONS

There is a strong, positive correlation between the size of ovarian follicles and their peak velocity, which suggests an increase of blood flow around developing follicles in the course of the follicular phase. Human chorionic gonadotropin plays an important role in inducing influx of blood within follicles; however, the significance of this event remains obscure. It appears that the resistance index is not a useful parameter for characterization of the intrafollicular flow. Changes in peak velocity did not correlate with oocyte quality and may have no predictive value for IVF outcome.

Vascular resistance in uterine and ovarian arteries: its association with infertility and the prognosis of infertility

In this study we investigated the blood flow in uterine (u.a.) and ovarian arteries (o.a.) in healthy women and infertility patients and the relationship of vascular resistance to the etiology and the prognosis of infertility. A total of 101 consecutive infertility patients referred to hospital for investigations were studied by Doppler ultrasound. Couples with male infertility were excluded. The control group comprised 19 healthy women having regular menstrual cycle and no history of infertility. The pulsatility index (PI) in o.a. and u.a. was measured in pre- and post-ovulatory phase of the menstrual cycle. The PI values of the controls were compared with those of the patients with various infertility etiologies. The PI values of the infertility patients who subsequently delivered were compared with those of the patients failing to deliver. Infertility patients had high PI in o.a. and u.a. in the luteal phase more often than controls. High vascular resistance in u.a. and o.a. in the luteal phase reduce the take-baby-home rate.

Midluteal-phase vaginal color Doppler assessment of uterine artery impedance in a subfertile population

OBJECTIVE

To compare the midluteal uterine artery impedance to blood flow as measured by the pulsatility index in women with different causes of infertility with that of women with normal fertility and to correlate this with endometrial thickness.

DESIGN

A prospective study of normal women undergoing insemination with donor semen and subfertile women with tubal damage, endometriosis, premature ovarian failure, anovulation, or unexplained infertility.

SETTING

A tertiary infertility center.

PATIENTS

One-hundred sixty-one women (25 to 40 years of age) who were attending the clinic for subfertility treatment and 23 normal women who were having artificial insemination with donor sperm because their partners were azoospermic.

INTERVENTIONS

All women were examined by transvaginal ultrasonography, with color flow imaging and blood flow analysis, on day 21 of an unstimulated ovarian cycle.

MAIN OUTCOME MEASURES

The mean pulsatility index of the left and right uterine arteries and the endometrial thickness.

RESULTS

The patients were grouped according to the causes of infertility and compared with normal women. There were 23 women in the normal group (median pulsatility index, 1.91; range, 0.84 to 2.95), 35 with unexplained infertility (median pulsatility index, 2.45; range, 1.0 to 7.0), 91 with tubal damage (median pulsatility index, 2.65; range, 1.25 to 8.0), 8 with endometriosis (median pulsatility index, 2.32; range, 2.05 to 5.7), and 22 with anovulatory infertility (median pulsatility index, 3.03; range, 1.6 to 7.0). All the infertile groups had significantly different median pulsatility indexes when compared with the normal group, and the pulsatility indexes correlated with endometrial thickness.

CONCLUSIONS

The impedance to uterine artery blood flow is significantly different in women with different causes of infertility as compared with women of normal fertility. Increased resistance to uterine blood flow in the midluteal phase may be an important contributing factor to some causes of infertility and the cause of some previously "unexplained" infertility.

Uterine and ovarian perfusion during the periovulatory period assessed by transvaginal color Doppler

OBJECTIVE

To measure the flow velocity of the uterine, radial, spiral, and ovarian arteries during the periovulatory period in spontaneous and induced ovarian cycles with confirmed ovulation.

DESIGN

Daily measurements during the periovulatory period in 78 patients attending an infertility clinic because of the male factor in infertility.

RESULTS

Uterine flow velocity in spontaneous cycles has a pulsatility index (PI) of 3.16 2 days before ovulation and starts to decrease the day before ovulation (PI = 2.22). In stimulated cycles these changes do not occur, and mean PI of 3.06 remains at that level during the periovulatory period. Clear flow velocity waveforms are obtained from the endometrium and myometrium around the time of ovulation. Data obtained from the radial arteries suggest better myometrial perfusion in patients with natural cycles. Spiral artery flow velocity in spontaneous cycles has a PI of 1.13 the day before ovulation and a nadir of 0.72 is reached the day after ovulation. On the contrary, the mean PI of the spiral artery blood flow in the group with ovulation induction rises during the day before ovulation (PI = 2.32) and reaches a nadir of 1.09 the day after ovulation.

CONCLUSIONS

These data suggest the presence of better uterine receptivity during the periovulatory phase of natural cycles compared with induced ovarian cycles. Endometrial perfusion presents accurate noninvasive assay of uterine receptivity that may be used to predict implantation success rate, to reveal unexplained infertility problems, and to select patients for correction of endometrial perfusion abnormalities by an appropriate treatment.

Early detection of endometrial cancer by transvaginal color Doppler

The present study aimed at evaluating the possibility of using transvaginal color Doppler sonography in early detection of endometrial cancer. This method was performed on 276 patients with uterine tumors before hysterectomy. Neovascularization was detected in 167 (67%) benign masses, while all malignant masses (26) were vascularised. The final diagnosis was made following pathological examination. Tumoral arterial blood flow was detected in all (26) patients with endometrial cancer. The blood flow analysis showed a significantly lower (P < 0.05) resistance index (RI = 0.37 +/- 0.07) in the cases of endometrial cancer than in patients with benign uterine lesions (0.54 +/- 0.09). Central vessels within endometrial carcinoma tended to have lower velocity and impedance compared to peripheral ones. Significant difference in the impedance of uterine artery blood flow, represented with RI between mentioned groups occurred (P < 0.05). There is a downward trend in the uterine artery RI in patients with endometrial cancer (mean RI = 0.64, ranged from 0.53 to 0.72) regarding benign lesions (mean RI 0.74, ranged from 0.64 to 0.82).

Fallopian tubes and ultrasonography: the Sion experience

OBJECTIVE

To compare the accuracy of three new ultrasonographic methods of detecting tubal patency and pathology with established methods like hysterosalpingography (HSG) and laparoscopy.

DESIGN

Sixty-seven cases were evaluated by performing the Sion test using endosonography to check for tubal patency. The Sion procedure includes filling up the pouch of Douglas with approximately 300 mL of sterile normal saline to elucidate not only the patency but visualize the motility, the fimbriae, and peritubal adhesions, if present. We have compared the accuracy of this procedure with HSG and laparoscopy in 24 infertile women. Color-coded duplex Doppler sonography was used in 38 patients to check for tubal patency.

RESULTS

Our experience at the Sion Hospital using the three new ultrasonographic techniques for evaluating the status of the fallopian tubes is very encouraging. The accuracy with the three modes shows agreement in > 90% of cases with established investigative modalities such as HSG and laparoscopy.

CONCLUSION

These three new investigative modalities are offered not as substitutes for HSG, laparoscopy, hysteroscopy, or salpingoscopy but as office-screening procedures that would be complementary to the armamentarium of infertility investigations already available.

Clinical value of the assessment of gynaecological tumour angiogenesis by transvaginal colour Doppler

Angiogenesis occurs in the body in only a few physiological conditions, but it regularly precedes carcinogenesis. Neovascularisation is a term well known to the pathologist, but with the advent of colour Doppler it is now of interest to those using ultrasonography. Since morphological criteria alone are insufficient to characterise space occupying lesions, visualisation of newly formed vessels and consequently, their blood flow characteristics, seems to provide a clearer distinction in vivo between benign and malignant gynaecological tumours. Very low resistance indices in newly formed vessels, as a predictor of malignancy, have already been established. The most recent area of investigation covering the differences between centrally and peripherally placed vessels offers additional criteria for diagnosing gynecological malignancy.