Low endometrial volume may predict early pregnancy loss in women undergoing in vitro fertilization

Two subtypes of surgery-categorized upper-lateral intracavitary pregnancy identified by MRI, a retrospective study

BACKGROUND

The pregnancy outcomes in women with surgery-categorized upper-lateral intracavitary pregnancy (ULIP), previously named angular pregnancy, demonstrate higher heterogeneity than in women with ultrasonography-categorized ULIP. We aimed to use preoperative MRI and correlated clinical characteristics to explore whether the surgery-categorized ULIP comprises obstetric conditions undefined by the current ultrasonography-based diagnostic criteria.

METHODS

This retrospective study involved 28 women with surgically and pathologically confirmed ULIP from January 2016 to July 2022. Two board-certified radiologists, blinded to the patients' information, independently reviewed the MRI images, and determined each MRI feature, including endometrial thickness (EMT) and peri-gestational sac (GS) endometrial interruption. Disagreements were resolved by discussion to achieve a consensus. Based on the cutoff value of EMT (11.5 mm), the patients were divided into above-cutoff EMT (n = 22) and below-cutoff EMT (n = 6) groups.

RESULTS

Two subtypes of surgery-categorized ULIP were identified. Type-I ULIP (n = 22; EMT ≥ 11.5 mm), when compared to the type-II ULIP (n = 6; EMT < 11.5 mm), demonstrated lower incidence of peri-GS endometrial interruption (2/22 [9.1%] vs 6/6 [100%]; P = 0.001), higher logarithmic ß-human chorionic gonadotropin (ß-hCG) concentration (4.7 ± 0.4 mIU/ml vs 4.2 ± 0.6 mIU/ml; P = 0.026), lower rate of repeated dilatation and curettage (1/22 [4.6%] vs 4/6 [66.7%]; P = 0.003), less intraoperative blood loss (10.1 ± 6.3 ml vs 28.3 ± 18.3 ml; P = 0.001), and shorter hospital stay (2.8 ± 1.7 days vs 7.5 ± 3.8 days; P = 0.001). The peri-GS endometrial interruption negatively correlated with EMT (Odds ratio [OR] = 0.55; P = 0.001) and logarithmic ß-hCG concentration (OR = 0.08; P = 0.045). The below-cutoff EMT negatively correlated with ß-hCG concentration (OR = 0.06; P = 0.021).

CONCLUSIONS

Surgery-categorized ULIP comprised two obstetric conditions among which the type-II ULIP, possessing unique imaging features undocumented in the literature, requires further attention during clinical practice.

The Endometrial Immune Profiling May Positively Affect the Management of Recurrent Pregnancy Loss

Introduction

The endometrial immune profiling is an innovative approach based on the analysis of the local immune reaction occurring in the endometrium at the time of the embryo implantation. By documenting the local immune activation during the period of uterine receptivity, we aim to detect and correct potential imbalances before and at the very beginning of placentation. The main objective of the study was to analyze in women with a history of repeated pregnancy loss (RPL) the association of personalized strategies based on immune dysregulations with live birth rates. The secondary objective was to highlight the main prognostic factors for live births.

Methods

This is an observational retrospective analysis of 104 patients with RPL, included between January 2012 and December 2019. Inclusion criteria included a spontaneous fertility with at least three miscarriages, an assessment including a three-dimension ultrasound scan, an endometrial biopsy for uterine immune profiling and a follow-up over at least 6 months with personalized care if indicated after the complete assessment. We defined as a success if the patients had a live birth after the suggested plan, as a failure if the patient either did not get pregnant or experienced a new miscarriage after the targeted therapies.

Results

Uterine immune profiling was the only exploration to be significantly associated with a higher live birth rate (LBR) if a dysregulation was identified and treated accordingly (55% vs 45%, p=0.01). On the contrary, an absence of local dysregulation (resulting in an apparently balanced immune environment) was associated with a higher risk of a new miscarriage, suggesting that the cause inducing RPL still needed to be identified. Independently of age and AMH level, dysregulated immune profile is significatively associated with 3 times higher LBR than a non-deregulated profile (OR=3.4 CI 95%1.27-9.84) or five times in case of an overactive profile treated by immunotherapy (OR=5 CI 95% 1.65-16.5). The usage of ART was significantly associated with lower LBR regardless of the presence of a subfertility factor (p=0.012). Personalization of medical care using natural cycle or simple hormonal stimulation is associated with a significantly higher LBR than personalization including ART treatments regardless of maternal age and AMH level (OR= 2.9 CI 95% 1.03-8.88).

Conclusion

Our study suggests that some endometrial immune profiles with targeted management of RPL are associated with a higher rate of LBR. ART may be negatively associated with LBR.

Efficacy of tocopherol and pentoxifylline combined therapy for women undergoing assisted reproductive treatment with poor endometrial development: a retrospective cohort study on 143 patients

Poor endometrial development during in vitro fertilization remains challenging. Indeed, no broadly accepted definition of poor endometrial development exists, and no treatment has shown any improvement in the condition. The aim of this study was to analyze whether treatment with a combination of pentoxifylline and tocopherol increases endometrial volume. This monocentric and retrospective study includes patients with previous miscarriages, in vitro fertilization failure, or poor endometrial development. The patients had an ultrasonography during the mid-luteal phase to assess both endometrial thickness and endometrial volume (EV). If the volume was less than 2 mL, they were given pentoxifylline (PTX) and tocopherol for at least 2 months before a second ultrasound assessment. One hundred and forty-four patients were analyzed. The mean duration of treatment was 132 days. The combination of tocopherol and PTX significantly increased the EV by 0.47 mL (p < 0.0001; 95% CI 0.38-0.57). The mean ± SD EV was 1.34 ± 0.38 mL and 1.82 ± 0.63 mL before and after the treatment respectively. No data concerning pregnancy rates were interpretable. We showed an improvement of poor endometrial proliferation with a treatment including PTX and tocopherol. These promising results should be followed up by a prospective study.

Risk of miscarriage in women conceiving after medically assisted reproduction with an ultrasound-verified viable pregnancy at 6-8 weeks' gestation

RESEARCH QUESTION

What is the risk of miscarriage after a viable fetus verified on ultrasound at 6-8 weeks' gestation among women who conceive with medically assisted reproduction (MAR), stratified by type of fertility treatment?

DESIGN

A nationwide register-based cohort study of women identified in the Danish ART-Registry with a viable singleton pregnancy at 6-8 weeks' gestation between 2007 and 2010 (n = 10,011). Women were identified from The Danish Fetal Medicine Database (DFMD), which holds information on early (between 6-8 and 11-14 weeks) and late (between 11-14 and 22 weeks) miscarriages. The late miscarriage rate was compared with a control group of naturally conceived pregnancies with a viable fetus at 11-14 weeks' gestation from 2008 to 2010, identified in the DFMD (n = 146,932).

RESULTS

In the MAR1 cohort, the overall miscarriage rate was 11.8% (1091/9261) after an ultrasound verified viable pregnancy at 6-8 weeks' gestation. Most miscarriages occurred before the 11-14-week scan (1035/1091 [94.9%]). The early miscarriage rate was slightly higher in women who conceived with frozen embryo transfer compared with intrauterine insemination (IUI), corresponding to an adjusted OR of 1.31 (1.02 to 1.68). We found no significant risk associated with IVF and intracytoplasmic sperm injection compared with IUI pregnancies. The late miscarriage rate was 0.8% in women conceiving with MAR and 0.6% among controls (P = 0.013).

CONCLUSIONS

After adjustment for maternal characteristics, none of the fertility treatment types were associated with an increased risk of miscarriage compared with naturally conceiving women.

Endometrial blood flow is impaired in women with polycystic ovarian syndrome who are clinically hyperandrogenic

OBJECTIVES

To quantify endometrial and subendometrial blood flow in Caucasian women with polycystic ovarian syndrome (PCOS) and to determine whether these values differ according to the phenotypic expression of PCOS.

METHODS

Transvaginal pelvic ultrasound was performed on the 3(rd)-5(th) day of the menstrual cycle in 36 women with PCOS and 36 controls to examine the endometrial and subendometrial vascularity. The subendometrial and endometrial blood flow indices (vascularizaton index (VI), flow index (FI) and vascularization flow index (VFI)) were measured using three-dimensional power Doppler angiography. Uterine artery blood flow was assessed through analysis of two-dimensional (2D) pulsed-wave Doppler waveforms. Analysis was performed to compare PCOS with non-PCOS women, and subgroup analysis was performed of the PCOS women categorized according to their phenotypic manifestation.

RESULTS

There were no significant differences in endometrial volume, subendometrial vascularity and uterine artery blood flow between women with PCOS and controls after controlling for body mass index (BMI). On subgroup analysis, compared with anovulatory but clinically normoandrogenic women with polycystic ovaries (PCO) and with controls, women with PCO who were both clinically hyperandrogenic and anovulatory had significantly lower endometrial (VI: 0.57% vs. 1.11% and 0.86%, respectively, both P = 0.01; VFI: 0.14 vs. 0.42 and 0.28, respectively, both P = 0.02) and subendometrial (VI: 1.59% vs. 3.17% and 2.47%, P = 0.01 and 0.02, respectively; VFI: 0.50 vs. 1.67 and 0.96, P = 0.01 and 0.02, respectively) blood flow. Moreover, clinically hyperandrogenic but ovulatory women with PCO also had significantly lower endometrial blood flow (VI: 0.52% vs. 1.11%, P = 0.04) than did anovulatory but clinically normoandrogenic women with PCO. There were no differences in any of the 2D pulsed-wave Doppler measures of blood flow between the subgroups.

CONCLUSIONS

Subendometrial and endometrial blood flow is significantly impaired in women with PCOS who have clinical signs of hyperandrogenism.

The effect of anti-thyroid antibodies on endometrial volume, embryo grade and IVF outcome

Thyroid auto-immunity (TAI) has been implicated as the most common cause of hypothyroidism in general population, especially in women. Many studies revealed that increased infertility incidences with TAI. The aim of the present article was to evaluate the effect of thyroid auto-antibody (TAA) positivity on embryological parameters, IVF-outcome and endometrial volume (EnV) in infertile patients who were applied for routine artificial reproductive technologies (ART) programme. This study included prospective, sequential, cross-sectional analyses of parameters obtained from 69 patients with unexplained infertility. It was the first ART application of patients. Patients were homogenous for age, body mass index, basal hormone measurements and underwent same ovulation induction protocol. They were evaluated for thyroid hormone profile and TAAs and divided into three groups; TAA negative group (n = 31), TAA positive group (n = 23) and TAA positive and euthyroid with medication group (n = 15). There were no differences among groups for the number of Grade-1 and Grade-2 embryos, distribution of embryo-grades, number of oocytes retrieved and fertilised, biochemical pregnancy ratios (PR), EnV and miscarriage ratio. However, the clinical PR was significantly lower in the TAA positive group (p = 0.024). In conclusion, the embryo grades and EnV did not differ among groups. But the clinical PR differs and the anti-thyroid peroxides positivity, above the cut-off point, affects the clinical PR.

Endometrial growth in early pregnancy after IVF/ET

PURPOSE

To detect the endometrial volume change in conception cycles. Additionally we measured endometrium in three planes, to see if the hypothesized endometrial volume differences will be detectable by this surrogate technique.

METHODS

Following the embryo transfer, a three-dimensional ultrasound exam was performed on average days 22 and 28 of the cycle.

RESULTS

Seventy-eight subjects signed the informed consent form, and 63 completed the study. A significant difference was observed between Visit 1 and Visit 2, for endometrial volume, thickness, length and width in the pregnant group, and for endometrial volume, thickness and width in the non-pregnant group.

CONCLUSIONS

In this study we have shown that in normal intrauterine pregnancy after IVF/ET, prominent endometrial volume growth can be detected by a three-dimensional ultrasound over the course of several days. Moreover, in patients who did not conceive in a particular cycle, a decrease in endometrial volume can be seen.

Predicting fertility

Various predictors of fertility have been described, suggesting that none are ideal. The literature on tests of ovarian reserve is largely limited to women undergoing in vitro fertilization, and is reliant on the use of surrogate markers, such as cycle cancellation and number of oocytes retrieved, as reference standards. Currently available prediction models are far from ideal; most are applicable only to subfertile women seeking assisted reproduction, and lack external validation. Systematic reviews and meta-analyses of predictors of fertility are limited by their heterogeneity in terms of the population sampled, predictors tested and reference standards used. There is an urgent need for consensus in the design of these studies, definition of abnormal tests, and, above all, a need to use robust outcomes such as live birth as the reference standard. There are no reliable predictors of fertility that can guide women as to how long childbearing can be deferred.