Assessment of uterine, subendometrial blood flows and endometrial gland vascular endothelial growth factor (EG-VEGF) in women with unexplained infertility

Comparative study of endometrial & subendometrial angiogenesis in unexplained infertile versus normal fertile women

Background & objectives:

Local angiogenesis in endometrium has been shown to be an essential pre-requisite for endometrial receptivity needed for implantation and gestation. Recently, numerous diagnostic gears have been projected to ‘measure’ or ‘estimate’ the endometrial receptivity relying upon angiogenic factors helping throughout implantation. This study evaluated the endometrial and subendometrial blood flow and the local endometrial gland vascular endothelial growth factor (EG-VEGF) expression as markers of local angiogenesis.

Methods:

The present study was done to give quantitative assessment of endometrial thickness (ET), endometrial blood flow and subendometrial blood flow colour Doppler indices with endometrial vascular zones. Endometrial biopsy was taken and with VEGF stained and scored with immunohistochemistry.

Results:

The mean ET for fertile women was 9.41 mm, while in unexplained infertile women it was around 7.90 mm. Upon comparison of ET with EG-VEGF which is considered as a gold standard with correlation coefficient, the present study suggested a positive correlation of EG-VEGF with ET, endometrial pulsatility index (PI), and subendometrial PI also the vascular zones were considered as significant. However, a strong negative correlation was seen with subendometrial resistivity index and PI.

Interpretation & conclusions:

The present study suggests that uterine ultrasound, uterine colour Doppler and EG-VEGF are parameters which can be used as markers of local angiogenesis for endometrial receptivity in the evaluation of women with unexplained infertility.

Impact of letrozole versus clomiphene citrate on endometrial receptivity in Iraqi women with polycystic ovarian syndrome

WHAT IS KNOWN AND OBJECTIVES

Letrozole is widely known for its use as an ovulation inductor. This study aims to investigate the effects of letrozole and clomiphene citrate in females with polycystic ovarian syndrome.

METHODS

This is a randomized non-blinded controlled trial study that included 80 infertile females with polycystic ovarian syndrome receiving a standard dose of either clomiphene citrate or letrozole on day 2 of the cycle. An ultrasound was done to examine growth of the follicle, endometrial thickness on days 12-13, and a Doppler study to measure resistance index (RI), pulsatility index and ratio of systolic/diastolic velocity.

RESULTS AND DISCUSSION

The mean levels of dominant follicle and oestradiol were significantly higher in the clomiphene citrate group than in the letrozole group. The letrozole group had a significantly greater endometrial thickness than the clomiphene citrate group. The resistance index and pulsatility index were lower in the letrozole group and in pregnant women than in the clomiphene citrate group and the non-pregnant group.

WHAT IS NEW AND CONCLUSION

The use of letrozole for ovulation induction in polycystic ovarian syndrome patients has a better effect on endometrial receptivity markers when compared to clomiphene citrate.

Transcutaneous electrical acupoint stimulation (TEAS) treatment improves pregnancy rate and implantation rate in patients with implantation failure

OBJECTIVE

Although major advances have greatly improved the outcomes of assisted reproductive technology in the last two cascades, there remains significant difficulty in achieving pregnancy for many patients even after repeated attempts of IVF. Interestingly, recent studies have shown that transcutaneous electrical acupoint stimulation (TEAS) can improve the reproductive outcomes of select IVF patients. To determine the utility of TEAS in improving IVF outcomes in patients with a history of implantation failure, we conducted a retrospective study of clinical outcomes of women, who had a prior history of unsuccessful pregnancy outcome after IVF-embryo transfer (IVF-ET), following TEAS treatment.

MATERIALS AND METHODS

A total of 25 patients, who had failed to conceive after multiple IVF cycles in which good embryos were transferred, received noninvasive low frequency TEAS treatment prior to and during an IVF-ET cycle. The clinical outcomes, including biochemical pregnancy rate, clinical pregnancy rate and implantation rate, were compared to those of prior cycles which received only standard IVF treatment.

RESULTS

Analysis of reproductive outcomes showed that implantation rate and clinical pregnancy rate increased significantly in IVF cycles that included the TEAS treatment when compared to prior cycles that received only the standard IVF treatment in this cohort of patients.

CONCLUSIONS

This surprising finding indicated that TEAS treatment is a promising technique to improve reproductive outcomes in difficult cases of IVF-ET. Because TEAS treatment is noninvasive and has high reproducibility, and can be applied with limited training, further refinement of this procedure would not only substantiate the beneficial effects of TEAS, but also allow the technique to be more effective and reproducible.

AlphaVBeta3 Integrin expression within uterine endometrium in unexplained infertility: a prospective cohort study

BACKGROUND

Implantation defect is one of these contributing factors for unexplained infertility. In the mid-luteal phase, when implantation is expected to happen, Integrins expression is remarkably increased. So, Integrins could potentially serve as markers for the frame of the window of implantation. αVβ3 integrin could have a role as a potential receptor for embryonic attachment. The aim of the current study is to investigate whether the women with unexplained infertility have a pattern of expression of endometrial αvβ3 integrin that could differ from those who have normal fertility or not.

METHOD

Two groups of women have been included in this study. The first group was the Unexplained Infertility Group. This group included women diagnosed with unexplained primary infertility. The second group was the fertile Group, which included fertile parous women presented to the family planning clinic seeking contraception. 2D transvaginal ultrasound scan (TVS) was performed six days after detecting urinary LH surge. (TVS) was used to measure endometrial thickness, and subendometrial blood flow color Doppler Resistance Index (RI). On the same day of transvaginal ultrasound, endometrial samples were taken using the Endocell® office suction sampler for Immunohistochemistry (IHC) study using monoclonal mouse IgG antibodies to detect endometrial αvβ3 integrin.

RESULTS

Thirty-five fertile women with a diagnosis of unexplained infertility were included as a group I [Unexplained infertility Group] along with an equal number of fertile women as group II [Fertile Group]. The group of women with a diagnosis of unexplained infertility had a significantly lower αvβ3 integrin score when compared to the fertile group (median score 0, range:0-2 and median score 1, range: 1-3 and for infertile and fertile groups respectively, P < 0.0001). In addition, the unexplained infertility group had significantly higher subendometrial flow RI and Significantly thinner endometrial thickness.

CONCLUSION

This study showed that Alpha v Beta 3 integrin is a significantly lower in endometrium in cases of unexplained infertility, which may suggest that underexpression of Alpha v Beta 3 integrin in human endometrium could be linked to defective uterine receptivity, and play a role as an unrecognized cause of infertility in this population of women. We need larger studies of adequate statistical power, ideally investigating more than one menstrual cycle in the same woman, to investigate the usefulness of using these molecular molecules in clinical practice.

Preimplantation 3D ultrasound: current uses and challenges

The preimplantation ultrasound (US) refers to targeted imaging of the uterus and adnexa prior to assisted reproductive techniques (ART) to optimize the infertility treatment outcomes. After a thorough evidence based literature review, we propose the use of transvaginal three-dimensional (3D) US during the early follicular phase. A systematic approach for 3D US examination consists of a detailed examination of the uterine shape, size and contour, evaluation of the endometrial thickness, volume, pattern and vascularity, and assessment of the junctional zone regularity, echogenicity and thickness. Uterine anatomy is explored in the coronal plane by simultaneous visualization of the uterine cavity, the external surface of the fundus and cervix. Saline infusion sonogram (SIS) is recommended for patients with increased endometrial volume, abnormal endometrial pattern and irregular uterine cavity shape suggestive of Müllerian duct anomalies or acquired intracavitary abnormalities. Myometrial lesions should be recognized and proper dimensions and locations should be ascertained. Ovarian dimensions and volume are measured and the antral follicle count is recorded. Adnexa are carefully assessed for masses, endometriosis and dilated tubes. Color power Doppler US may be applied to evaluate vascularity of the ovaries and pelvic lesions. Hysterosalpingo-contrast-sonography (Hy-Co-Sy) should be optimally utilized for assessment of tubal patency. Accessibility and mobility of the ovaries should be checked in real time for better planning of the ultrasound-guided oocyte retrieval. The cul-de-sac is assessed for the presence of free fluid or masses.