The predictive value of uterine artery blood flow measurements for uterine receptivity in an intracytoplasmic sperm injection program

General anesthesia with propofol during oocyte retrieval and in vitro fertilization outcomes: retrospective cohort study

General anesthesia is frequently administered during oocyte retrieval. Its effects on the outcomes of IVF cycles are uncertain. This study investigated whether administration of general anesthesia (specifically propofol) during oocyte retrieval affects IVF outcomes. A total of 245 women undergoing IVF cycles were included in this retrospective cohort study. IVF outcomes of 129 women who underwent oocyte retrieval under propofol anesthesia and 116 without anesthesia were compared. Data were adjusted for age, BMI, estradiol on triggering day and total gonadotropin dose. The primary outcomes were fertilization, pregnancy and live birth rates. A secondary outcome was the efficiency of follicle retrieval associated with the use of anesthesia. Fertilization rate was lower in retrievals under anesthesia compared to without (53.4% ± 34.8 vs. 63.7% ± 33.6, respectively; p = 0.02). There was no significant difference in the ratio of expected to retrieved oocytes between retrievals with and without anesthesia (0.8 ± 0.4 vs. 0.8 ± 0.8, respectively, p = 0.96). The differences in pregnancy and live birth rates between the groups were not statistically significant. General anesthesia administered during oocyte retrieval may have adverse effects on the fertilization potential of oocytes. This impact on the developmental potential of oocytes may lead to negative IVF outcomes and should be investigated further.

Prospective observational comparison of arteria uterina blood flow between two frozen embryo transfer cycle regimens: natural cycle versus hormonal replacement cycle

PURPOSE

Is there a difference in the blood flow of the Arteria uterina in frozen embryo transfer (FET) cycles between a Natural Cycle (NC) and a Hormonal Replacement Therapy (HRT) cycle?

METHODS

Prospective observational study with measurement of the pulsatility index (PI) and resistance index (RI) throughout the ovarian stimulation cycle for IVF/ICSI, the FET cycle and at 12 weeks of gestation.

RESULTS

A total of 124 ovarian stimulation cycles with preimplantation genetic testing for aneuploidy (PGT-A) and "freeze-all" strategy due to PGT-A were included. Mean patient's age was 31.4 years, mean BMI 26.47 kg/m2, mean AMH 3.62 ng/ml and a mean AFC of 13. FET cycles were performed in 77 patients (NC protocol: 37.7%, HRT protocol: 62.2%). The overall pregnancy rate was 75%, (NC group: 79%, HRT-group 73%; not significant). No significant change of PI and RI was seen during hormonal stimulation. In FET cycles, there was a significant increase between cycle day 2/3 and ovulation/P4-start in the HRT-cycle, followed by a significant decrease until 12 weeks of gestation. The slope of the decrease in patients with a pregnancy in an HRT-approach was a bit steeper than in the NC-approach for both PI and RI, however, without a significant difference.

CONCLUSIONS

Early measurements of the blood flow parameters during the FET cycle do not reveal a difference between the NC- and the HRT-approach for FET, which could be predictive for development of pre-eclampsia.

Mid-luteal uterine artery Doppler indices in the prediction of pregnancy outcome in nulliparous women undergoing assisted reproduction

Traditionally, the assessment of endometrial receptivity at transvaginal ultrasound scan has been based on the thickness and the morphological appearance of the endometrium. The objective of this study was to prospectively evaluate endometrial thickness (ET), endometrial morphology and uterine artery Doppler parameters prior to assisted reproduction treatment (ART) in the prediction of pregnancy outcome. This was a prospective cohort study. ET, morphology and uterine artery Doppler (UtAD) pulsatility index (PI) and resistance index (RI) were measured in the mid-luteal stage of the menstrual cycle ultrasonographically, timed with urinary luteinizing hormone testing. A total of 50 women were included in the analysis. The clinical pregnancy rate (CPR) per embryo transfer was 42.0% (n = 21/50). Twenty nine women (58.0%) had an unsuccessful outcome. There were no differences in mean ± SD endometrial thickness (ET) (10.0 ± 1.8 mm vs. 10.5 ± 2.4; p = 0.43), or endometrial morphology (100% (n = 21) vs 100% (n = 29); p = 1.00) between the pregnant and not pregnant groups. Similarly, there were no differences in mean ± SD UtAD PI (2.17 ± 0.83 vs. 2.07 ± 0.81; p = 0.67 or mean ± SD UtAD RI (0.84 ± 0.10 vs. 0.81 ± 0.10; p = 0.30). Ultrasonographic endometrial assessment did not differentiate between those who would have a subsequent clinical pregnancy.

Conventional and modern markers of endometrial receptivity: a systematic review and meta-analysis

BACKGROUND

Early reproductive failure is the most common complication of pregnancy with only 30% of conceptions reaching live birth. Establishing a successful pregnancy depends upon implantation, a complex process involving interactions between the endometrium and the blastocyst. It is estimated that embryos account for one-third of implantation failures, while suboptimal endometrial receptivity and altered embryo-endometrial dialogue are responsible for the remaining two-thirds. Endometrial receptivity has been the focus of extensive research for over 80 years, leading to an indepth understanding of the processes associated with embryo-endometrial cross-talk and implantation. However, little progress has been achieved to translate this understanding into clinically meaningful prognostic tests and treatments for suboptimal endometrial receptivity.

OBJECTIVE AND RATIONALE

The objective of this systematic review was to examine the evidence from observational studies supporting the use of endometrial receptivity markers as prognostic factors for pregnancy outcome in women wishing to conceive, in order to aid clinicians in choosing the most useful marker in clinical practice and for informing further research.

SEARCH METHODS

The review protocol was registered with PROSPERO (CRD42017077891). MEDLINE and Embase were searched for observational studies published from inception until 26 February 2018. We included studies that measured potential markers of endometrial receptivity prior to pregnancy attempts and reported the subsequent pregnancy outcomes. We performed association and accuracy analyses using clinical pregnancy as an outcome to reflect the presence of receptive endometrium. The Newcastle-Ottawa scale for observational studies was employed to assess the quality of the included studies.

OUTCOMES

We included 163 studies (88 834 women) of moderate overall quality in the narrative synthesis, out of which 96 were included in the meta-analyses. Studies reported on various endometrial receptivity markers evaluated by ultrasound, endometrial biopsy, endometrial fluid aspirate and hysteroscopy in the context of natural conception, IUI and IVF. Associations were identified between clinical pregnancy and various endometrial receptivity markers (endometrial thickness, endometrial pattern, Doppler indices, endometrial wave-like activity and various molecules); however, their poor ability to predict clinical pregnancy prevents them from being used in clinical practice. Results from several modern molecular tests are promising and further data are awaited.

WIDER IMPLICATIONS

The post-test probabilities from our analyses may be used in clinical practice to manage couples' expectations during fertility treatments (IUI and IVF). Conventionally, endometrial receptivity is seen as a dichotomous outcome (present or absent), but we propose that various levels of endometrial receptivity exist within the window of implantation. For instance, different transcriptomic signatures could represent varying levels of endometrial receptivity, which can be linked to different pregnancy outcomes. Many studies reported the means of a particular biomarker in those who achieved a pregnancy compared with those who did not. However, extreme values of a biomarker (as opposite to the means) may have significant prognostic and diagnostic implications that are not captured in the means. Therefore, we suggest reporting the outcomes by categories of biomarker levels rather than reporting means of biomarker levels within clinical outcome groups.

Subendometrial blood flow changes by 3-dimensional power Doppler ultrasound after hysteroscopic lysis of severe intrauterine adhesions: preliminary study

OBJECTIVE

To evaluate the changes in subendometrial blood flow and endometrial volume after hysteroscopic lysis of severe intrauterine adhesions (IUAs).

DESIGN

A pilot observational study. Forty infertile women with severe IUAs served as their own controls and were included in this study only once, to avoid selection bias.

INTERVENTION

Three-dimensional power Doppler ultrasound was performed in all patients 1 day before hysteroscopic lysis of severe IUA, and repeated 1 month later, to assess subendometrial blood flow [as measured by vascularization index (VI), flow index (FI), and vascularization flow index (VFI)] and endometrial volume. Main outcome measures were subendometrial blood flow (VI, FI, VFI) and endometrial volume.

RESULTS

There were statistically significant postoperative increases in endometrial volume, VI, FI, and VFI. Subendometrial blood flow improved in 14 women (35%), and menstrual improvement occurred in 15 women (37.5%).

CONCLUSION

Hysteroscopic lysis of severe IUAs improves subendometrial blood flow, with subsequent increases in endometrial volume.

The origin of pre-eclampsia: from decidual "hyperoxia" to late hypoxia

Normal gestation implants on a relatively hypoxic deciduas so that trophoblast deeply invades endometrium and angiogenesis seeks for oxygen supply. If implantation occurs before those hypoxic conditions occur, trophoblast invasion is defective, due to the relatively high oxygen tension in the decidual environment, laying the foundations for subsequent pre-eclampsia.

Relationship between the length of the uterine cavity and clinical pregnancy rates after in vitro fertilization or intracytoplasmic sperm injection

In this prospective clinical study involving 354 IVF-intracytoplasmic sperm injection cycles, we determined the influence of the length of the uterine cavity on clinical pregnancy rates. Our data showed that clinical pregnancy and implantation rates are associated positively with an increased length of the uterine cavity.

Three-dimensional power Doppler sonography of the (sub)endometrium and angiogenic cytokine concentrations

The aim of this study was to determine the correlation between three-dimensional power Doppler sonography (3D-PDS) of the (sub)endometrium and concentrations of angiogenic cytokines in patients attending an IVF programme. A total of 42 patients was included in a prospective, non-randomized clinical study. 3D-PDS of the (sub)endometrium was performed on the day of oocyte aspiration, with and without contrast agent. Quantitative assessment included the following 3D Doppler parameters: vascularization index, flow intensity, and vascularization flow index. On the same day, concentrations of oestradiol (serum only), vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF) 1, IGF-binding protein 3 (IGFBP-3) and leptin were determined in the serum and in the follicular fluid. All 3D-PDS indices were significantly higher with contrast enhancement (P < 0.05). Follicular fluid concentrations of VEGF and IGFBP-3, as well as serum concentrations of leptin, showed significant P-values when correlated with (sub)endometrial Doppler indices. A weak linear dependency appeared between flow intensity and VEGF and leptin. Furthermore, weak dependencies were apparent between 3D Doppler parameters and high follicular fluid concentrations of VEGF and IGFBP-3. It is concluded that there is only little evidence for an association between (sub)endometrial Doppler indices as assessed by 3D-PDS and concentrations of angiogenic cytokines.

Aspirin in women undergoing in vitro fertilization treatment: a systematic review and meta-analysis

OBJECTIVE

Many trials have evaluated the effects of aspirin in women undergoing IVF or intracytoplasmic sperm injection (ICSI) treatment. These trials have generally shown inconclusive or inconsistent findings. We conducted a systematic review of trials of aspirin during IVF or ICSI treatment to generate more precise estimates of effects and attempt to explore the reasons for the inconsistencies.

DESIGN

A systematic review and meta-analysis.

SETTING

Assisted conception units in different countries.

PATIENT(S)

Seven trials including 1,241 women undergoing controlled ovarian hyperstimulation (COH), IVF, or ICSI and day 3 embryo transfer.

INTERVENTION(S)

Low-dose aspirin supplementation versus placebo or no supplementation.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy and live birth.

RESULT(S)

Searches were conducted in MEDLINE, EMBASE, Cochrane Library, ISI Proceedings, and SCISEARCH, and all randomized controlled trials that evaluated the effectiveness of aspirin compared to placebo or no treatment in women undergoing IVF-ICSI treatment were included. Study selection, quality appraisal, and data extractions were performed independently and in duplicate. Seven relevant trials were identified. Meta-analysis of these studies did not show a significant benefit of aspirin therapy in improving clinical pregnancy rate (relative risk [RR] 1.11, 95% confidence interval [CI] 0.95, 1.31) or live birth rate (RR 0.94, 95% CI 0.64, 1.39). There was no significant difference in miscarriage rate (RR 1.06, 95% CI 0.53, 2.11) or ectopic pregnancy rate (RR 2.24, 95% CI 0.70, 7.24). An improvement was noted in uterine artery pulsatility index (weighted mean difference: -0.78, 95% CI -0.87, -0.69) in women taking low-dose aspirin. The evidence regarding other outcomes was either not significant or contradictory.

CONCLUSION(S)

Currently available evidence does not support the use of aspirin in IVF or ICSI treatment. However, the noted trend of improvement in clinical pregnancy, and the lack of power even when the studies were pooled highlight the need for a definitive trial.

Ultrasound and the receptivity of the endometrium

Ultrasound imaging can be used to assess the endometrium in a number of ways. In particular, time-lapse video recordings can show that the lining of the uterus undergoes rhythmical contractions that vary in strength and intensity throughout the ovarian cycle. These contractions appear to assist in sperm transport at the time of ovulation, but can decrease the chances of a fertilized egg implanting in the uterus if they persist later in the cycle. They are also the cause of ectopic pregnancies occurring in IVF treatment cycles. In order to reduce these uterine contractions and therefore increase the chances of a successful uterine pregnancy, IVF treatment cycles should incorporate minimal stimulation so as to make them as close to natural cycles as possible.

Observations on intrauterine oxygen tension measured by fibre-optic microsensors

Understanding the biology of reproductive organs is essential for the development of assisted reproductive techniques. There is at present no direct evidence for either the concentration and dynamics of intrauterine oxygen tension at the endometrial surface, nor its importance for the receptiveness of the endometrium. In this study a new method measured mid-cycle (ranging from day 12-18) endometrial surface oxygen tension in 21 patients referred to intrauterine insemination (IUI). Time series was measured online for a period of 5-10 min. The (mean) individual oxygen tension among patients varied from 4 to 27% air saturation. Overall mean oxygen tension among all patients was 11.8% air saturation. Within the same patient, considerable time-related variations were observed. Some patients exhibited rhythmic oscillations with a frequency in the order of 1 min, whereas others did not show any regular patterns. A good description of endometrial surface oxygen concentration and dynamics was thus obtained, but given the relatively small number of participants, an association with pregnancy following insemination could not be established. Further studies using this new method could elucidate the association between individual intrauterine activity, embryo implantation and endometrial surface oxygen tension.

Is there a role for preparatory cycle in ovum donation recipients?

PURPOSE OF REVIEW

In ovum donation cycles, the role of preparatory cycles to ensure proper endometrial development in the recipient remains controversial. As evidenced in the literature, endometrial receptivity is critical in conception. Therefore, endometrial preparation with exogenous hormones in addition to synchronization of the recipient and donor are essential in achieving a successful outcome.

RECENT FINDINGS

There are very limited data specifically examining the benefit of recipients undergoing preparatory cycles prior to their actual egg donation cycle. One study concluded that trial hormone replacement treatment cycles with endometrial biopsies may be useful in older reproductive-age women but not in younger women. Another study showed no difference in pregnancy rates between those who did and did not undergo preparatory cycles.

SUMMARY

Since one of the integral elements of preparatory cycles is determining endometrial dating, with relatively conflicting data, these mock cycles may not be as beneficial as expected. Therefore, for those who routinely use preparatory cycles, the potential risks, benefits, and costs of these cycles, increased hormonal exposure, the relatively invasive nature of the procedure, and time prior to performing them must be considered.

Subendometrial arterial spectral doppler assessment during IVF cycles and its correlation with treatment outcome

The influence of blood flow impedance in subendometrial arteries on embryo implantation rate was investigated by transvaginal sonographic examination in in vitro fertilization (IVF) cycles. A total of 39 women undergoing IVF treatment were evaluated along the treatment cycle. Power and spectral Doppler studies of subendometrial arteries were performed to calculate the pulsatility index (PI), resistance index (RI) and systolic:diastolic ratio (S:D). The correlation between these parameters and pregnancy achievement was analyzed. Patients were grouped according to whether pregnancy was achieved or not. RI and S:D did not differ between the groups along the course of treatment. In pregnant patients, the PI was significantly lower in the beginning of the cycle than on the preovulation day and ovum pickup day. PI in the beginning of the treatment was significantly lower in pregnancy cycles than in nonpregnancy ones. A lower PI on day 1 was correlated with a better chance for pregnancy.

Circadian changes in uterine artery and ovarian stromal blood flow after pituitary down-regulation

OBJECTIVE

To investigate changes in the uterine artery and ovarian stromal blood flow in relation to the time of the day after pituitary down-regulation during in vitro fertilization treatment.

METHODS

Thirteen women were recruited. The uterine artery blood flow was studied using pulsed color Doppler ultrasonography and the ovarian stromal blood flow was measured using three-dimensional power Doppler ultrasonography. Ultrasound scan examinations and blood pressure measurements were performed in the morning and evening.

RESULTS

The diastolic and the mean arterial pressures were significantly higher in the evening. An increase in the uterine artery pulsatility index and resistance index in the evening was observed. The ovarian vascularization index, vascularization flow index, and right ovarian flow index were significantly lower in the evening.

CONCLUSIONS

Despite the small sample size, we have demonstrated the presence of a diurnal change in uterine artery and ovarian stromal blood flow after pituitary down-regulation. Such changes may be related to the systemic change in the sympathetic system and hence vascular resistance. Future study regarding ovarian stromal blood flow should take into account the effect of the time of the day on the readings in order to avoid misleading interpretation of data.

Role of utero–ovarian vascular impedance: predictor of ongoing pregnancy in an IVF–embryo transfer programme

The objective of this study was to evaluate the role of uterine, endometrial and follicular blood flow in prediction of ongoing pregnancy after assisted conception. A prospective observational study was conducted on 53 women undergoing IVF treatment. Transvaginal colour and pulsed Doppler measurements were performed on the day that pituitary suppression was confirmed, on day 10 of ovarian stimulation and on the day prior to human chorionic gonadotrophin injection. On the last day of ovarian stimulation, blood flow in the ascending uterine artery of the women who would conceive was characterized by significantly lower pulsatility index values. Sub-endometrial vascular impedance was comparable in the pregnant and non-pregnant groups. There were no differences in the perifollicular vascularity between pregnant and non-pregnant women. The chance of achieving pregnancy predicted by uterine artery Doppler and perifollicular blood flow in women whose PI values were higher than 3.26 and 1.08 was very low, with a sensitivity of 1.00 and specificity of 0.59 and 0.82 respectively. The data provide evidence for an association between utero-ovarian perfusion and reproductive outcome following IVF treatment. Uterine and ovarian vascular impedance values identify those women whose pregnancy chances are significantly limited. Measures to decrease vascular impedance in such women might enhance pregnancy rates by improving embryo quality and uterine receptivity for implantation.

[Towards a single embryo transfer: predictive value of uterine and embryological parameters in assisted reproduction outcome]

OBJECTIVE

The transfer of a single embryo would avoid obstetrical and neonatal complications due to multiple pregnancies. We studied the clinical value of both uterine and embryological parameters to define precise conditions allowing a single embryo transfer without decreasing pregnancy rates.

PATIENTS AND METHODS

Endometrial parameters expressed by a uterine score together with biological criteria of 131 in vitro fertilization or intracytoplasmic sperm injection attempts were retrospectively analysed.

RESULTS

Two hundred and sixty-two day-3 embryos were replaced through 131 transfers. Fifty-seven pregnancies were induced and 16 twins were obtained. The clinical pregnancy rate was 35.9% and the embryonic implantation rate 24.0%. After the transfer of two embryos, successful implantation was determined by the occurrence of top-quality embryos and simultaneously by a receptive endometrium. The uterine pulsatility index was significantly decreased for twin compared to singleton pregnancies.

DISCUSSION AND CONCLUSION

This study confirms that a uterine score constitutes a powerful tool for evaluating the uterine receptivity. This parameter has to be taken into account as well as the embryonic quality, in order to optimise the success rate. Young patients with at least two top-quality embryos available, a high uterine score and a low pulsatility index, have a high risk of multiple births and are suitable for a single-embryo transfer.

Réceptivité utérine et implantation embryonnaire : apport de l’échographie et du Doppler dans son évaluation en fécondation in vitro

Embryo implantation is a multifactorial event. Biochemical factors are implicated in the quality of the endometrium and in its vascularization. The non-invasive vaginal scan studies the endometrial morphology whereas color and power Doppler studies its vascularity. Through an analysis of the literature, we point out the interest of those techniques in ART.

Imaging the endometrium: are there predictors of uterine receptivity?

Ultrasound imaging technology brings new insight to cyclic changes in the endometrium and offers the potential to assess the probability of embryo implantation in natural and assisted reproduction cycles. However, the data reported are diverse and frequently conflict in their analysis and conclusions. This review examines imaging techniques used for endometrial evaluation, including grey-scale ultrasonography and colour-flow, power-flow, and spectral Doppler interrogation of the uterine vasculature. New techniques being used for uterine assessment, such as computer-assisted image analysis, three-dimensional ultrasonography, and magnetic resonance imaging, are also discussed. Each of these techniques is under active investigation and has the potential to provide rapid, noninvasive endometrial evaluation. Currently, there is reasonable certainty that women with heterogeneous endometrial linings of less than 6 mm will rarely conceive, and that endometrial contractions, or lack thereof, play some role in the successful establishment of pregnancy, even though this role has not yet been identified. Given the set of new imaging technologies available, it is feasible to expect that visual assessments will someday be used as predictors of uterine receptivity.

Role of acupuncture in the treatment of female infertility

OBJECTIVE

To review existing scientific rationale and clinical data in the utilization of acupuncture in the treatment of female infertility.

DESIGN

A MEDLINE computer search was performed to identify relevant articles.

RESULTS

Although the understanding of acupuncture is based on ancient medical theory, studies have suggested that certain effects of acupuncture are mediated through endogenous opioid peptides in the central nervous system, particularly beta-endorphin. Because these neuropeptides influence gonadotropin secretion through their action on GnRH, it is logical to hypothesize that acupuncture may impact on the menstrual cycle through these neuropeptides. Although studies of adequate design, sample size, and appropriate control on the use of acupuncture on ovulation induction are lacking, there is only one prospective randomized controlled study examining the efficacy of acupuncture in patients undergoing IVF. Besides its central effect, the sympathoinhibitory effects of acupuncture may impact on uterine blood flow.

CONCLUSION

Although the definitive role of acupuncture in the treatment of female infertility is yet to be established, its potential impact centrally on the hypothalamic-pituitary-ovarian axis and peripherally on the uterus needs to be systemically examined. Prospective randomized controlled studies are needed to evaluate the efficacy of acupuncture in female fertility treatment.

Endometrial vascularity and ongoing pregnancy after IVF

BACKGROUND

Embryo transfer is prone to failure.

AIM

To investigate whether endometrial vascularity influences in vitro fertilization (IVF) outcome.

METHODS

Total 144 patients receiving IVF (conventional or microinjection) were assessed with color and power Doppler on the day of embryo transfer: age, IVF type, number and quality of embryos, endometrial thickness and aspect, mean uterine PI, uterine notch, type of endometrial vascularity (peripheral or sub- and intra-endometrial), and pregnancy involving second trimester were recorded.

RESULTS

27 (18.7%) pregnancies were obtained. By univariate analysis, two parameters were significant: high frequency of uterine notch (P = 0.03) and peri-endometrial vascularity (P = 0.012) in the group of failures. Multivariate analysis by logistic regression clearly showed that the absence of sub- and intra-endometrial color signal decreased the chances of pregnancy eight-fold odds ratio (OR) = 0.14 [CI: 0.029-0.68].

CONCLUSION

In this limited series, the presence of sub- and intra-endometrial vascularity on the day of transfer seemed to be mandatory for obtaining an ongoing pregnancy.

Measurement of endometrial tissue blood flow: a novel way to assess uterine receptivity for implantation

OBJECTIVE

To assess endometrial receptivity in terms of endometrial tissue blood flow (ETBF) measured hysterofiberscopically by laser blood-flowmetry, and to examine the technique's effectiveness in an in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) program.

DESIGN

A prospective clinical study.

SETTING(S)

IVF program in a university hospital.

PATIENT(S)

A total of 75 infertile women with normal menstrual cycles undergoing IVF/ICSI.

INTERVENTION(S)

ETBF, conventional ultrasonographic, endocrinologic, and histologic parameters for receptivity and immunoreactivity for vascular endothelial growth factor (VEGF) in endometrium were assessed between days 4 and 6 of the luteal phase in a spontaneous menstrual cycle. Then all patients underwent IVF/ICSI.

MAIN OUTCOME MEASURE(S)

Achievement of clinical pregnancy by IVF/ICSI.

RESULT(S)

ETBF, VEGF expression, and the number of embryos were significantly higher in the women who became pregnant than in those who did not. By stepwise multiple logistic regression, significant predictors of pregnancy were the number of embryos and ETBF but not conventional receptivity markers. The rate of pregnancy was significantly higher in women with ETBF values of at least 29 mL/min per 100 grams of tissue than in women with lower values (42 vs. 15% in 36 and 39 women, respectively). ETBF was significantly greater in morphologically normal than abnormal uteri. In normal uteri, ETBF was greatest in the fundus. Correspondingly, in normal uteri 85% of gestational sacs were implanted in the fundus.

CONCLUSION(S)

ETBF is superior to conventional parameters for determining endometrial receptivity for implantation.

Endometrial receptivity in an in vitro fertilization program as assessed by spiral artery blood flow, endometrial thickness, endometrial volume, and uterine artery blood flow

OBJECTIVE

To investigate the role of sonographic parameters in assessing endometrial receptivity in an in vitro fertilization (IVF) program.

DESIGN

Prospective clinical study.

SETTING

University setting.

PATIENT(S)

One hundred thirty-five patients in our IVF program, selected prospectively on the day of oocyte retrieval.

INTERVENTION(S)

Transvaginal ultrasound examination was performed before oocyte collection.

MAIN OUTCOME MEASURE(S)

Association between implantation rate and spiral artery blood flow (primary outcome measure) and between implantation rate and endometrial measurements as well as uterine artery blood flow (secondary outcome measures).

RESULT(S)

Overall implantation rate was 23.7% per cycle. Subendometrial blood flow was detected in 113 (83.7%) cases, with pregnancy occurring in 21.2%. Mean spiral artery pulsatility index values were 1.12 +/- 0.28 and 1.21 +/- 0.27 for nonconception and conception cycles, respectively. Nondetectable spiral artery blood flow was not associated with a lower implantation rate. Neither endometrial thickness nor endometrial volume was correlated with the likelihood of successful implantation. Minimum endometrial thickness and volume associated with pregnancy were 6.9 mm and 1.59 mL, respectively.

CONCLUSION(S)

Neither Doppler sonography of the spiral or uterine arteries nor measurement of the endometrial thickness or volume allowed a reliable prediction of subsequent IVF outcome.

Low-dose aspirin does not increase implantation rates in patients undergoing intracytoplasmic sperm injection: a prospective randomized study

PURPOSE

The aim was to evaluate the effect of aspirin on pregnancy and implantation rates in an unselected group of patients undergoing intracytoplasmic sperm injection (ICSI).

METHODS

Two hundred and seventy-nine patients were randomized to receive 80 mg of aspirin (n = 139) or no treatment (r = 136) starting from the first day of controlled ovarian hyperstimulation.

RESULTS

Duration of stimulation, gonadotropin consumption, peak estradiol, number of oocytes retrieved, fertilization rate, cleavage rate, and number of embryos transferred were similar in the two groups. Implantation and clinical pregnancy rates were 15.6% and 39.6% versus 15.1% and 43.4% in aspirin treated and untreated groups, respectively (P > 0.05).

CONCLUSIONS

Low-dose aspirin administration does not improve implantation and pregnancy rates in an unselected group of patients undergoing ICSI.

Doppler evaluation of the uterine and spiral arteries from different sampling sites and phases of the menstrual cycle during controlled ovarian hyperstimulation

OBJECTIVE

To compare the pulsatility index (PI) and resistance index (RI) at different sampling sites of the uterine and spiral arteries in the early and mid-menstrual phases.

MATERIALS AND METHODS

The uterine and spiral arteries of 110 women undergoing similar ovarian hyperstimulation and intra-uterine insemination regimes were examined using transvaginal color Doppler ultrasound. The uterine artery was sampled at five sites: (1) ascending branch; (2) descending branch; (3) proximal, near branch division; (4) mid, 0.5 cm distal to the division; (5) lateral location, 1 cm distal to the division. The spiral artery was sampled at three sites: (a) anterior; (b) fundal; (c) posterior. The uterine and spiral arteries were examined twice, on days 2-3 and 14-16, respectively, of the menstrual cycle. The women were also grouped according to age at examination, < or = 30 years and > 30 years. The PI and RI values for different sites, menstrual phase, and age were compared.

RESULTS

The mean PI and RI values of the uterine artery were: (1) 2.86 +/- 1.20 and 0.92 +/- 0.13; (2) 2.66 +/- 1.15 and 0.89 +/- 0.12; (3) 2.88 +/- 1.26 and 0.90 +/- 0.15; (4) 3.03 +/- 1.02 and 0.91 +/- 0.07; (5) 3.23 +/- 1.38 and 0.89 +/- 0.12; and of the spiral artery were (a) 1.61 +/- 1.01 and 0.69 +/- 0.17; (b) 1.69 +/- 0.74 and 0.74 +/- 0.17; (c) 1.73 +/- 0.86 and 0.68 +/- 0.17. The PI values for uterine and spiral arteries at two phases of the menstrual cycle were 2.92 +/- 1.18 and 1.55 +/- 0.72 (days 2-3); 3.11 +/- 1.15 and 1.80 +/- 1.02 (days 14-16), respectively; for younger women (age < or = 30 years) these values were 2.83 +/- 1.22 and 1.6 +/- 0.85 and for older women (age > 30 years) 3.0 +/- 1.34 and 1.72 +/- 0.96, respectively.

CONCLUSIONS

There were no significant differences in PI and RI values of the uterine and spiral arteries at different sampling sites, phase of the menstrual cycle or age. The higher PI values tended to occur in the lateral uterine artery and posterior spiral artery, during the mid-menstrual phase and in the older age group. The PI and RI values of the mid-uterine and fundal spiral artery sampling sites are representative of the whole uterine artery and spiral artery, respectively.

Power Doppler endometrial evaluation as a method for the prognosis of embryo implantation in an ICSI program

PURPOSE

The objective of the present study was to evaluate power Doppler of the endometrium as a parameter for the prognosis of embryo implantation in patients who underwent intracytoplasmic sperm injection (ICSI).

METHODS

The power Doppler was performed on a transverse section at the level of the uterine fundus on the day of human chorionic gonadotropin in 185 patients who submitted to ovarian stimulation for ICSI. The endometrium was divided into four equal quadrants and classified as grade I, II, III, or IV according to the visualization of the power Doppler in the quadrants. The color Doppler signal was considered to be positive when it reached at least the basal layer of the endometrium.

RESULTS

Age, number of days of stimulation, number of follicles > or = 16 mm, number of oocytes in metaphase II retrieved, and fertilization rate did not differ patients with the four different types of endometrial grades. Endometrial thickness and the pulsatility index of uterine artery also were similar for the four grades. The rate of embryo implantation also did not differ significantly (P = 0.53) among groups: grade I = 10%; grade II = 11.6%; grade III = 15.4%; grade IV = 10.5%. The pregnancy rates were grade I = 25%; grade II = 29.7%; grade III = 37.5%; grade IV = 23.8% (P = 0.44).

CONCLUSIONS

Our data demonstrate that isolated evaluation of endometrial vascularization with power Doppler is not an important factor for the prediction of pregnancy in an ICSI program.

Predicting the histologic dating of an endometrial biopsy specimen with the use of Doppler ultrasonography and hormone measurements in patients undergoing spontaneous ovulatory cycles

OBJECTIVE

To examine the relation between uterine blood flow and endometrial thickness on transvaginal Doppler ultrasonography, serum E2 and progesterone levels, and the histologic dating of an endometrial biopsy specimen obtained in the midluteal phase of a spontaneous cycle.

DESIGN

Prospective clinical study.

SETTING

A tertiary care infertility center.

PATIENT(S)

One hundred fifty-nine patients with normal menstrual cycles.

INTERVENTION(S)

Transvaginal Doppler ultrasonographic evaluation of uterine blood flow and endometrial thickness, determination of serum concentrations of E2 and progesterone, and endometrial biopsy.

MAIN OUTCOME MEASURE(S)

Resistance index, pulsatility index, serum E2 and progesterone levels, endometrial thickness, and histologic dating of the endometrium.

RESULT(S)

One hundred thirteen (71%) of the endometrial biopsy specimens showed complete secretory transformation and thus were classified as "in phase," and 46 (29%) of the specimens lacked some or all of the criteria for secretory transformation and thus were classified as "out of phase." There was no statistically significant difference between the in phase and out of phase groups with regard to patient age, endometrial thickness, serum hormone levels, or resistance index. The pulsatility index was significantly higher in the in phase group. The overall predictive value of the studied parameters was only 64% (sensitivity, 57%; specificity, 66%).

CONCLUSION(S)

Doppler ultrasonographic evaluation of uterine blood flow and measurement of hormone concentrations cannot be used to predict the histologic dating of an endometrial biopsy specimen obtained in the midluteal phase of a spontaneous cycle.

Quantitative assessment of subendometrial blood flow by three-dimensional-ultrasound is an important predictive factor of implantation in an in-vitro fertilization programme

This study was designed to investigate the role of three-dimensional (3D) power Doppler sonography of the (sub-) endometrial area on the first day of ovarian stimulation in predicting the outcome of an in-vitro fertilization (IVF) programme. Among the 75 cycles analysed, the overall pregnancy rate was 20% (15/75) per cycle and 23.8% (15/63) per embryo transfer. Intra-observer variability of the colour histogram was checked in 14 patients with the results demonstrating a high level of agreement. Neither endometrial measurements nor uterine blood flow were correlated with the pregnancy rate. In contrast, all 3D indices were significantly lower in conception compared with non-conception cycles (P < 0.05). Logistic regression analysis found the subendometrial flow index to be the strongest predictive factor of IVF success among the tested sonographic parameters (P = 0.04). In conclusion, quantitative assessment of spiral artery blood flow may be of predictive value for implantation in IVF cycles even before ovarian stimulation therapy is started.