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

Endometrial echo patterns of embryo transfer day affect pregnancy outcomes in frozen embryo transfer cycles: a retrospective clinical study

BACKGROUND

The echo pattern constitutes an ultrasonic index that reflects the characteristics of the endometrium across various phases of the menstrual cycle. However, consensus of endometrial echo pattern and pregnancy outcomes is lacking in clinical application.

METHODS

The retrospective cohort study analyzed the data from the electronic records of women who underwent frozen embryo transfer (FET) with hormone replacement treatment (not only one cycle per patient) between July 2020 to August 2021 at Reproduction Medicine Center of Jbnminling Hospital of Medical College of Nanjing University. A total of 138 cleavage stage embryo transfer cycles and 561 blastocyst transfer cycles were analyzed in this study. Transvaginal ultrasound scans were performed on the embryo transfer day. The endometrial echo pattern was classified into four types: A, B, B-C and C. Pattern A was defined as trilinear type, Pattern B, B-C and C were defined as non-trilinear type. All scans were conducted by experienced clinicians, and the images were reviewed by the same two physicians. The outcomes measured included embryo implantation rate, clinical pregnancy rate, first trimester abortion rate, and live birth rate. For the data that conforms to a normal distribution, two independent sample t-tests are used for comparison between two groups, and one-way analysis of variance (ANOVA) is used for comparison among multiple groups. For the data that does not conform to a normal distribution, rank sum tests (Kruskal-Wallis test) are used for inter-group comparisons. Count data are analyzed using chi-square tests. Logistic regression models were applied for the analysis of clinical outcome.

RESULTS

The embryo implantation rate (p = 0.066), clinical pregnancy rate (p = 0.140), early abortion rate (p = 0.515) and live birth rate (p = 0.578) were similar between the 4 type of endometrial pattern groups in cleavage-stage embryo FET cycles. In blastocyst cycles, the implantation rate (p = 0.201) and clinical pregnancy rate (p = 0.555) did not differ between the four endometrial patterns. Patients with a Pattern A endometrium on blastocyst transfer day experienced a decreased live birth rate (19.05%) compared with Pattern B, Pattern B-C and Pattern C (p = 0.006. p = 0.008, p = 0.031 for Pattern A vs. Pattern B, Pattern A vs. Pattern B-C, Pattern A vs. Pattern C). The first trimester abortion rate of Pattern A is up to 40.00%, although there was no statistical difference (p = 0.118). In the cycles of non-trilinear type group, the early miscarriage rate (0.248 [95% CI, 0.067-0.914]; p = 0.036) was lower and the live birth rate (0.269 [95% CI, 0.089-0.810]; p = 0.020) was higher than trilinear type group.

CONCLUSIONS

Our retrospective study suggests that a trilinear pattern endometrium on blastocyst transfer was associated with a higher first trimester abortion rate and lower live birth rate.

Associations between Individual and Combined Polymorphisms of the TNF and VEGF Genes and the Embryo Implantation Rate in Patients Undergoing In Vitro Fertilization (IVF) Programs

BACKGROUND

A multiple pregnancy is now considered to be the most common adverse outcome associated with in vitro fertilization (IVF). As a consequence, the identification of women with the best chances of embryo implantation is a challenge in IVF program, in which the objective is to offer elective single-embryo transfer (eSET) without decreasing the pregnancy rate. To date, a range of hormonal and clinical parameters have been used to optimize eSET but none have significant predictive value. This variability could be due to genetic predispositions related to single-nucleotide polymorphisms (SNPs). Here, we assessed the individual and combined impacts of thirteen SNPs that reportedly influence the outcome of in vitro fertilisation (IVF) on the embryo implantation rate for patients undergoing intracytoplasmic sperm injection program (ICSI).

MATERIALS AND METHODS

A 13 gene polymorphisms: FSHR(Asn680Ser), p53(Arg72Pro), AMH(Ile49Ser), ESR2(+1730G>A), ESR1(-397T>C), BMP15(-9C>G), MTHFR1(677C>T), MTHFR2(1298A>C), HLA-G(-725C>G), VEGF(+405G>C), TNFα(-308A>G), AMHR(-482A>G), PAI-1(4G/5G), multiplex PCR assay was designed to genotype women undergoing ICSI program. We analyzed the total patients population (n = 428) and a subgroup with homogeneous characteristics (n = 112).

RESULTS

Only the VEGF(+405G>C) and TNFα(-308A>G) polymorphisms impacted fertilization, embryo implantation and pregnancy rates. Moreover, the combined VEGF+405.GG and TNFα-308.AG or AA genotype occurred significantly more frequently in women with high implantation potential. In contrast, the VEGF+405.CC and TNFα-308.GG combination was associated with a low implantation rate.

CONCLUSION

We identified associations between VEGF(+405G>C) and TNFα(-308A>G) polymorphisms (when considered singly or as combinations) and the embryo implantation rate. These associations may be predictive of embryo implantation and could help to define populations in which elective single-embryo transfer should be recommended (or, conversely, ruled out). However, the mechanism underlying the function of these polymorphisms in embryo implantation remains to be determined and the associations observed here must be confirmed in a larger, more heterogeneous cohort.

A randomized trial comparing the endometrial effects of daily subcutaneous administration of 25 mg and 50 mg progesterone in aqueous preparation

OBJECTIVE

To study the efficacy of a new P preparation in aqueous solution for subcutaneous injection for inducing the predecidual transformation of the endometrium.

DESIGN

Prospective, single-blinded, randomized, parallel pilot trial.

SETTING

University-affiliated clinical research center.

PATIENT(S)

Twenty-five regularly cycling female volunteers.

INTERVENTION(S)

Volunteers, aged 18-45 years, body mass index 19-25 kg/m(2), whose ovaries were suppressed with a GnRH agonist were estrogenized for 14 or 21 days with the use of transdermal systems delivering 0.1 mg/d E₂. After confirming that the endometrial thickness was >7 mm, the women were randomized to 25 mg or 50 mg of subcutaneous P injections daily for 11 days, after which the endometrium was sampled with the use of a Pipelle device. The endometrial biopsies were evaluated by two independent pathologists. Adverse events and subjective tolerance were checked every day by the study investigator.

MAIN OUTCOME MEASURE(S)

Predecidual changes in endometrial biopsies obtained after 11 days of subcutaneous administration of P.

RESULT(S)

Of 24 biopsies performed (one dropout), 22 provided tissue for histologic analysis. Evidence of predecidual changes in the endometrial stroma was found in 100% of the cases, with no differences between the two studied doses.

CONCLUSION(S)

Both doses of the new aqueous P preparation available for subcutaneous administration demonstrated predecidual changes in 100% of the interpretable endometrial biopsies in total absence of endogenous P. This offers good prospect of efficacy in luteal phase support for the lowest dose tested, 25 mg/d, the physiologic amount produced daily by the ovary during the midluteal phase.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00377923.

Implantation failure: molecular mechanisms and clinical treatment

BACKGROUND

Implantation is a complex initial step in the establishment of a successful pregnancy. Although embryo quality is an important determinant of implantation, temporally coordinated differentiation of endometrial cells to attain uterine receptivity and a synchronized dialog between maternal and embryonic tissues are crucial. The exact mechanism of implantation failure is still poorly understood.

METHODS

This review summarizes the current knowledge about the proposed mechanisms of implantation failure in gynecological diseases, the evaluation of endometrial receptivity and the treatment methods to improve implantation.

RESULTS

The absence or suppression of molecules essential for endometrial receptivity results in decreased implantation rates in animal models and gynecological diseases, including endometriosis, hydrosalpinx, leiomyoma and polycystic ovarian syndrome. The mechanisms are diverse and include abnormal cytokine and hormonal signaling as well as epigenetic alterations.

CONCLUSIONS

Optimizing endometrial receptivity in fertility treatment will improve success rates. Evaluation of implantation markers may help to predict pregnancy outcome and detect occult implantation deficiency. Treating the underlying gynecological disease with medical or surgical interventions is the optimal current therapy. Manipulating the expression of key endometrial genes with gene or stem cell-based therapies may some day be used to further improve implantation rates.

Three-dimensional ultrasound assessment of endometrial receptivity: a review

Three-dimensional ultrasound (3D US) is a new imaging modality, which is being introduced into clinical practice. Although this technique will not probably replace two-dimensional ultrasound, it is being increasingly used. It has been reported that 3D US is a very high reproducible technique. The endometrium has been paid special attention when using this technique. The aim of this paper is to address some technical aspects of 3D US and to review critically its current status in evaluating endometrial function with special focus in its role in predicting pregnancy in assisted reproductive techniques. In spontaneous cycles endometrial volume grows during follicular phase remaining constant through the luteal phase. Endometrial vascularization increases during follicular phase peaking 2-3 days before ovulation, decreasing thereafter and increasing again during mid and late luteal phase. Data from studies analysing the role of 3D US for predicting IVF outcome are controversial. An explanation for these controversial findings might be different design of reported studies, specially the timing of ultrasound evaluation.

The human endometrium as a fertility-determining factor

Intensive research work has been performed to better understand the regulation of the endometrium and its clinical implications to improve implantation. Although many proteins and molecules may influence endometrial development, their co-ordinated contribution to the implantation process is still poorly understood and a translation into clinical use has not sufficiently been performed. Clinical evaluation of the endometrium by ultrasound and other techniques, like endometrial biopsy and analysis of uterine secretions, has been intensively studied and therapeutic options to improve endometrial function have been suggested and tested. Systemic treatment with heparin, aspirin or corticosteroids did not result in improved implantation rates. Gene therapy and cervical treatment, e.g. with seminal plasma, are still in the phase of clinical research. Therefore, this review focuses on different aspects of endometrial research, which all contribute to the diagnosis, evaluation and therapy of endometrial function and dysfunction. First, the endometrial development towards a receptive milieu is described. Second, the actual clinical evaluation of endometrial receptivity, possible therapeutic strategies and in particular, the evaluation of endometrial function in the non-natural situation of hormonal stimulation is critically evaluated. In conclusion, the endometrium shall be considered as an important fertility-determining factor and therapeutic options should be developed in near future.

Molecular profiling of human endometrium during the menstrual cycle

This summary of the findings of investigations of the changing transcriptional profile of human endometrium during the menstrual cycle shows that it is possible to classify the menstrual cycle based on the global gene expression profile, and identifies groups of known and novel genes that may be associated with different biological processes that occur in the endometrium such as implantation and menstruation.

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.

Molecular classification of human endometrial cycle stages by transcriptional profiling

Endometrium is a dynamic tissue that undergoes cyclic changes each month, under the overall control of estrogen and progesterone. The aims of this study were to investigate the changing global gene expression profile of human endometrium during the menstrual cycle using microarray technology and to determine the correlation between histopathological evaluation and molecular profile of the samples. Standard two-colour cDNA microarrays were performed on the 43 samples against a common reference, using a 10.5 K cDNA glass slide microarray. The results were validated using real-time PCR. Analysis of expression data was carried out using parametric analysis of variance with Benjamini-Hochberg correction. Hierarchical clustering reveals a strong relationship between histopathology and transcriptional profile of the samples. The study identified 1452 genes that showed significant changes in expression (P< or =0.05) across the menstrual cycle, with 425 genes having changes that are at least 2-fold. The data were also independently analysed by a CSIRO algorithm called GeneRaVE that identified a small subset of genes whose expression profiles could be used to classify nearly all the biopsies into their correct cycle stage. We also identified and validated three genes [(natural cytotoxicity triggering receptor (NCR)3, fucosyl transferase (FUT)4 and Fyn-binding protein (FYB)] that had not been shown to have significant cyclic changes in the human endometrium, previously. We have shown for the first time that endometrial cycle stage prediction is possible based on global gene expression profile.

Evaluation of a nonhomogeneous endometrial echo pattern in the midluteal phase as a potential factor associated with unexplained infertility

OBJECTIVE

To determine whether the failure to develop a homogeneous hyperechogenic pattern in the midluteal phase is associated with decreased fecundity in infertile women who are not receiving follicle-maturing drugs.

DESIGN

Observational study.

SETTING

Outpatient infertility clinic of a University Medical Center.

PATIENT(S)

Two hundred ninety-six infertile women (> or =6 months) with regular menses, normal fallopian tubes and uterine cavity, and absence of severe male factor on their initial investigation cycle for follicular dynamic studies.

INTERVENTION(S)

Midluteal phase sonographic endometrial evaluation.

MAIN OUTCOME MEASURE(S)

Viable pregnancy rates (live fetus at end of first trimester) according to endometrial echo pattern in the midluteal phase. Other variables considered were age of patient, endometrial thickness and serum E(2) levels at midcycle and midluteal phase, midcycle echo pattern, and P levels in the midluteal phase.

RESULT(S)

The viable pregnancy rate was significantly higher in those women who exhibited a homogeneous hyperechogenic pattern (8.5%) compared to those women whose endometrium was found to be nonhomogenous (2.2%). No other confounding variables were found that could explain this outcome.

CONCLUSION(S)

A nonhomogeneous hyperechogenic sonographic endometrial echo pattern predicts lower fertility potential in women who are not receiving follicle-maturing drugs.

A successful pregnancy following SEM fine tuning of hormonal priming

BACKGROUND: Manipulation of the uterine epithelium utilising standard dose exogenous oestrogen (E2) and progesterone (P4) has been shown to achieve a mature secretory morphological response. However, in an in vitro fertilisation (IVF) setting, frozen embryo transfer (ET) has had a low success rate. We propose that in patients with previously failed ET attempts, the uterine epithelium can be directly visualised by biopsy and Scanning Electron Microscopy (SEM) and that with an individualised fine tuning of the hormone supplementation regime, based on the SEM examination of sequential uterine biopsies, it is possible to provide a uterine environment conducive to successful ET. METHODS: A 47 year old women was chosen for endometrial biopsy, histopathological dating and endometrial observation utilising SEM to determine the integrity of her secretory uterine epithelium because of her age and several previously failed attempts at frozen ET. Exogenous E2 and P4 supplementation was administered in modified doses according to the SEM result, in consecutive cycles until the epithelial response appeared satisfactory for potential implantation. RESULTS: This case study demonstrates the dramatic change in epithelial characteristics that can be achieved as a response to these altered doses of E2 and P4. The uterine morphology changed from a hypotrophic to a mature, receptive epithelium such that ET resulted in the birth of healthy twin boys. CONCLUSION: The comparison between the consecutive biopsies in direct response to the SEM analysis and tailored modification of E2 and P4 dose clearly demonstrates, in this case, the effectiveness of individual morphological monitoring to maximise the successful outcome of ET.