Sonographic appearance of the endometrium: the predictive value for the outcome of in-vitro fertilization in stimulated cycles

Intrauterine administration of platelet-rich plasma improves embryo implantation by increasing the endometrial thickness in women with repeated implantation failure: A single-arm self-controlled trial

Purpose

The purpose of this study was to investigate the effectiveness of intrauterine administration of platelet‐rich plasma (PRP) in frozen embryo transfer (FET) cycle in Japanese patients with a thin endometrium.

Method

A prospective single‐arm self‐controlled trial was conducted in Japan. PRP administration was performed in 36 of the 39 eligible patients with a thin endometrium (≤7 mm). Hormone replacement therapy (HRT) with estrogen was performed for 2 menstrual cycles, and PRP was administrated on the 10th and 12th days of the second HRT cycle. The endometrial thickness was evaluated on transvaginal ultrasonography by two physicians at every visit, one an attending physician and the other a specialist physician blinded to the date and timing of the sonography. FET was performed during the second HRT cycle after PRP administration.

Results

After PRP administration, the mean (SD) endometrial thickness on the 14th day was significantly increased by 1.27 mm (P < .001) and 0.72 mm (P = .001) on the basis of the unblinded and blinded measurements, respectively. Of the 36 patients, 32 (88.9%) underwent FET. The clinical pregnancy rate was 15.6%. No adverse events occurred.

Conclusions

PRP therapy was safe and effective in increasing endometrial thickness improving possibly pregnancy rate.

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.

Value of endometrial echo pattern transformation after hCG trigger in predicting IVF pregnancy outcome: a prospective cohort study

BACKGROUND

There is much value in identifying non-invasive ways of measuring endometrial receptivity, as it has the potential to improve outcomes following in vitro fertilization (IVF). It has been suggested that endometrial echogenicity on the day of hCG administration was a good marker of endometrial receptivity. In the daily practice, we notice that patients with non-homogeneous hyperechoic endometrium on the embryo transfer day usually have lower pregnancy rates. We therefore extended the research onward transformation of echo pattern after hCG trigger to analyze the relationship between endometrial echogenicity transformation and IVF outcomes.

METHODS

A total of 146 infertile women undergoing their first IVF cycle were recruited in the prospective cohort study from August 2017 through August 2018. A series of endometrial echo pattern monitoring was carried out in these patients after hCG trigger: hCG day, from 1 through 3 days after ovum pick-up (OPU + 1, OPU + 2, OPU + 3).

RESULTS

The endometrial echogenicity value was calculated as the ratio of the hyperechogenic endometrial area over the whole endometrial area. Clinical pregnancy rate and embryo implantation rate had positive relationship with echogenicity value. The ROC curve analysis of endometrial echogenicity showed the area under curve was greatest on the second day after oocyte retrieval (OPU + 1, 2, 3 were 0.738, 0.765, 0.714 respectively) versus pregnancy. Endometrial echogenicity value on OPU + 2 had a higher predictive efficiency, and the cutoff value was 76.5%. The sensitivity was 61.3% and specificity was 82.0%. When putting the cut-off at <60%, the sensitivity was 93.8% and the specificity was 23.1%.

CONCLUSIONS

The endometrial echogenicity value on OPU + 2 was recommended to evaluate endometrial receptivity. It seemed appropriate for clinicians to provide a 'freeze all' IVF cycle and transfer in a subsequent frozen-thawed embryos cycle when echogenicity value <60% on OPU + 2.

TRIAL REGISTRATION

The registration number was ChiCTR-OOC-17012214 and the registration date was August 1st, 2017.

Improved in vitro fertilization success and pregnancy outcome with autologous platelet-rich plasma treatment in unexplained infertility patients that had repeated implantation failure history

Repeated implantation failure (RIF) due to suboptimal endometrial lining is a major challenge in reproductive medicine. The study aims to evaluate effect of intrauterine platelet-rich plasma (PRP) treatment on frozen-thawed embryo transfer (FET) cycles in patients whose endometrium was unable to achieve optimal lining in unexplained infertility patients with history of RIF. We retrospectively analyzed the charts of a total of 302 cycles performed in 273 patients attending Diyar Life ART Centre between January 2014 and January 2017. After excluding 232 cycles, we compared pregnancy outcomes of 34 patients who had suboptimal endometrial lining and underwent PRP + FET and 36 patients who had optimal endometrial lining and underwent only FET. We observed that, endometrial thickness was higher after 48 hours from PRP when compared to endometrial thickness before PRP (10 mm vs. 6.25 mm, p < .001). Clinical pregnancy rate, and importantly live birth rate were also significantly higher in PRP group than the control group. Based on this information, we showed that intrauterine autologous PRP infusion is a safe, inexpensive adjuvant treatment for optimizing endometrium especially in patients with RIF history and intrauterine PRP infusion improved not only endometrial lining but also in vitro fertilization success and pregnancy outcome.

Investigation of platelet-rich plasma in increasing proliferation and migration of endometrial mesenchymal stem cells and improving pregnancy outcome of patients with thin endometrium

BACKGROUND

Platelet-rich plasma (PRP) contains abundant growth factors and is gradually used in the field of reproduction. A thin endometrium is recognized as a critical factor in embryo implantation failure. Endometrial mesenchymal stem cells (EnMSCs), which were isolated from human menstrual blood, are highly proliferative and show multiple differentiation capacity. The current study was to investigate the effect of PRP on the proliferation and migration of EnMSCs, and the effectiveness of PRP in the treatment of patients with thin endometrium.

MATERIALS AND METHODS

EnMSCs were treated with PRP in vitro, followed by measuring cell proliferation, migration, and adhesion by using CCK8, scratch, and adhesion test, respectively. Twenty patients undergoing in vitro fertilization (IVF) with refractory thin endometrium history were given PRP by infusion into the uterine cavity after the treatment of hormone replacement therapy (HRT).

RESULTS

All components of PRP significantly stimulated the growth, migration, and adhesion of EnMSCs when compared with the negative control. Cell proliferation and migration were induced by PRP in a dose-dependent manner with maximum proliferation at a 2% PRP dose. The clinical data showed that successful endometrial expansion and pregnancy were discovered in 12 patients after PRP infusion, and the pregnancy rate increased to 60%.

CONCLUSION

Intrauterine PRP infusion represents a new way for female patients with thin endometrium with poor response. This study lays the foundations for the potential treatment of thin endometrium with PRP in vivo.

Relationship between bovine endometrial thickness and plasma progesterone and estradiol concentrations in natural and induced estrus

The objective of this study was to investigate cyclical changes in endometrial thickness in relation to progesterone (P₄) and estradiol-17β (E₂) concentrations during natural and induced estrus in 15 cows. In the prostaglandin (PG) F_2α-induced estrus group, ultrasonography (USG) at 6-h intervals was used to determine endometrial thickness 48-24 h before the PGF_2α treatment until 24 h after ovulation (ovulation = Day 0). In the natural estrus group, USG was performed every 48 h from Day 3 to Days 15-18 after the first ovulation, and then every 6 h until 24 h after ovulation. Endometrial thickness was standardized using Day 13 as a reference day. Blood was collected during every USG examination and plasma P₄ and E₂ concentrations were determined. Endometrial thickness of the induced estrus group (n = 11) was greater than that of the natural estrus group (n = 9) between 60 and 12 h before ovulation (P < 0.05). In the natural estrus group, prior to an increase in endometrial thickness, a decrease in P₄ and an increase in E₂ were detected. In the induced estrus group, based on the time of ovulation, an increase in endometrial thickness was detected at the same time of a decrease in P₄ before an increase in E₂. These results suggest that decreases in P₄ concentrations may be a cue to changes in endometrial thickness, while increases in E₂ concentrations appear to sustain and/or enhance these changes.

Endometrial thickness influences neonatal birth weight in pregnancies with obstetric complications achieved after fresh IVF-ICSI cycles

PURPOSE

Pregnancy-associated complications, duration of gestation and parity are well-known predictors of neonatal birth weight. Assisted reproductive technology (ART) affects neonatal birth weight as well. Endometrial thickness as measured on the day of HCG triggering may therefore impact on the neonatal birth weight.

METHODS

The data of 764 singleton deliveries achieved after fresh transfer between November 1997 and 2014 were collected retrospectively with the intention to analyze the relationship of maternal and neonatal characteristics with endometrial thickness and the possible predictive value of endometrial thickness on neonatal birth weight.

RESULTS

Higher maternal age (p < 0.001), diminished ovarian reserve (p < 0.001), endometriosis (p = 0.008) and hypogonadotropic hypogonadism (p < 0.001) predicted thin endometrium. Neonatal birth weight (p = 0.004), longer duration of pregnancy (p = 0.008), parity (p = 0.026) and higher maternal BMI (p = 0.003) were correlated significantly with the degree of endometrial proliferation. Endometrial thickness strongly predicted neonatal birth weight (p = 0.004). After adjusting regression analysis for maternal age and BMI, parity, neonatal gender and pregnancy duration, endometrial thickness remained predictive for neonatal birth weight in pregnancies with obstetric complications (p = 0.017). In uneventful pregnancies duration and parity are determinants of neonatal birth weight.

CONCLUSIONS

Our findings suggest that endometrial thickness is an additional ART-related factor influencing neonatal birth weight. This finding should be confirmed in large cohort studies.

What is the contribution of embryo-endometrial asynchrony to implantation failure?

PURPOSE

The synchronized development of a viable embryo and a receptive endometrium is critical for successful implantation to take place. The aim of this paper is to review current thinking about the importance of embryo-endometrial synchrony in in vitro fertilization (IVF).

METHODS

Detailed review of the literature on embryo-endometrial synchrony.

RESULTS

By convention, the time when the blastocyst first attaches and starts to invade into the endometrium has been defined as the 'window of implantation'. The term window of implantation can be misleading when it is used to imply that there is a single critical window in time that determines whether implantation will be successful or not. Embryo maturation and endometrial development are two independent continuous processes. Implantation occurs when the two tissues fuse and pregnancy is established. A key concept in understanding this event is developmental 'synchrony', defined as when the early embryo and the uterus are both developing at the same rate such that they will be ready to commence and successfully continue implantation at the same time. Many different events, including controlled ovarian hyperstimulation as routinely used in IVF, can potentially disrupt embryo-endometrial synchrony. There is some evidence in humans that implantation rates are significantly reduced when embryo-endometrial development asynchrony is greater than 3 days (±1.5 days).

CONCLUSIONS

Embryo-endometrial synchrony is critical for successful implantation. There is an unmet need for improved precision in the evaluation of endometrial development to permit better synchronization of the embryo and the endometrium prior to implantation.

Endometrial pattern, thickness and growth in predicting pregnancy outcome following 3319 IVF cycle

A retrospective study of 3319 women was conducted to assess predictive ability of endometrial characteristics for outcomes of IVF and embryo transfer. Endometrial thickness, growth and pattern were assessed at two time points (day 3 of gonadotrophin stimulation and day of HCG administration). Endometrial patterns were classified as pattern A: triple-line pattern comprising a central hyperechoic line surrounded by two hypoechoic layers; pattern B: an intermediate isoechogenic pattern with the same reflectivity as the surrounding myometrium and poorly defined central echogenic line; and pattern C: homogenous, hyperechogenic endometrium. The endometrium of pregnant women was thinner on day 3 of stimulation, thicker on the day of HCG administration, and showed greater growth in thickness compared with non-pregnant women. Clinical pregnancy rates differed according to endometrial pattern on the day of HCG administration (55.2%, 50.9% and 37.4% for patterns A, B and C, respectively). A positive linear relationship was found between endometrial thickness on the day of HCG administration and clinical pregnancy rate. Endometrial thickness, change and pattern were independent factors affecting outcome. Receiver operator characteristic curves showed that endometrial pattern, thickness and changes were not good predictors of clinical pregnancy. Discriminant analysis indicated that 58.7% of original grouped cases were correctly classified. Although endometrium with triple-line or increased thickness may favour pregnancy, combined endometrial characteristics do not predict outcomes.

Treating patients with "thin" endometrium - an ongoing challenge

OBJECTIVE

To review the literature regarding inadequate growth ("thin") of the endometrium and to present the hitherto published methods aimed to improve endometrial thickness and the consequent endometrial receptivity.

MATERIALS AND METHODS

A literature review was conducted for all relevant articles assessing the effect of various treatment modalities on "thin" endometrium and the consequent reproductive outcome.

RESULTS

Several treatment modalities have been offered to patients with "thin" endometrium, including hysteroscopic adhesiolysis, hormonal manipulation by estrogen and GnRH-agonist, vasoactive measures such as aspirin, vitamin E, pentoxifylline, l-arginine or sildenafil, intra-uterine infusion of growth factor such as G-CSF and the recent application of regenerative medicine. In spite of the vast diversity of treatment, most of the options accomplish only minor change in the endometrium thickness and subsequent pregnancy rate, and when they fail, patients are usually referred to surrogacy.

CONCLUSIONS

"Thin" endometrium is known to adversely affect reproductive performance. Treatment of "thin endometrium" remains a challenge and future large researches are required to further elucidate and optimal management of patients with "thin" endometrium.

Assessment and treatment of repeated implantation failure (RIF)

Repeated implantation failure (RIF) is determined when embryos of good quality fail to implant following several in vitro fertilization (IVF) treatment cycles. Implantation failure is related to either maternal factors or embryonic causes. Maternal factors include uterine anatomic abnormalities, thrombophilia, non-receptive endometrium and immunological factors. Failure of implantation due to embryonic causes is associated with either genetic abnormalities or other factors intrinsic to the embryo that impair its ability to develop in utero, to hatch and to implant. New methods of time-lapse imaging of embryos and assessment of their metabolic functions may improve selection of embryos for transfer, and subsequent outcomes for IVF patients, as well as for those diagnosed with RIF. This review discusses the various causes associated with RIF and addresses appropriate treatments.

A meta-analysis of the relationship between endometrial thickness and outcome of in vitro fertilization cycles

OBJECTIVE:

The objective was to evaluate the relationship between endometrial thickness on the day of human chorionic gonadotropin administration and pregnancy outcome in in vitro fertilization cycles.

DESIGN:

This was a systematic review and meta-analysis.

MATERIALS AND METHODS:

We identified 484 articles using Cochrane library, PubMed, Web of Science, and Embase searches with various key words including endometrial thickness, pregnancy, assisted reproductive technology, endometrial pattern, and in vitro fertilization. A total of 14 studies with data on endometrial thickness and outcome were selected, representing 4922 cycles (2204 pregnant and 2718 nonpregnant). The meta-analysis with a random effects model was performed using comprehensive meta-analysis software. We calculated the standardized mean difference, odds ratio (OR), and 95% confidence intervals (CIs).

RESULTS:

There was a significant difference in the mean endometrial thickness between pregnant and nonpregnant groups (P<0.001), with a standardized mean difference of 0.4 mm (95% CI 0.22–0.58). The OR for pregnancy was 1.40 (95% CI 1.24–1.58).

CONCLUSIONS:

The mean endometrial thickness was significantly higher in pregnant women compared to nonpregnant. The mean difference between two groups was <1 mm which may not be clinically meaningful. Although there may be a relationship between endometrial thickness and pregnancy, implantation potential is probably more complex than a single ultrasound measurement can determine.

Ultrasound assessment of the peri-implantation uterus: a review

Emerging evidence suggests that early embryo implantation is a more active maternal process than hitherto appreciated, involving active encapsulation of the implanting blastocyst by maternal decidual cells and coordinated changes in the underlying inner myometrium, known as the junctional zone. These concepts raise the possibility that early ultrasound markers predictive of adverse pregnancy outcome could be identified. In this review we assess the role of ultrasound in predicting the likelihood of different pregnancy outcomes and highlight potential novel markers that could be tested.

Repeated implantation failure: clinical approach

Successful embryo implantation depends on a well-functioning endometrium as well as a normal healthy embryo. This process might be hampered if either of these variables is defective. Repeated implantation failure (RIF) is diagnosed when good-quality embryos repeatedly fail to implant after transfer in several IVF treatment cycles. The causes of RIF originate with either the mother or the embryo. The authors discuss factors that are associated with RIF and address various treatment options.

[Pregnancy predictive factors in case of double embryo transfer during "Top Quality" attempts]

OBJECTIVES

To identify IVF±ICSI pregnancy predictive factors during "Top Quality" attempts in case of double embryo transfer.

PATIENTS AND METHODS

Three years retrospective study (2007, 2008 and 2009) on parameters and results obtained during IVF±ICSI defined as "Top Quality" attempts: first or second attempts on less than 35years old women (age inferior or equal to) with one or two "Top Quality" embryo transfer.

RESULTS

In case of double embryo transfer, pregnancy predictive factors are (OR [IC 95%], P): average endometrial thickness on start (4.6 [2.9-5.5], P<0.01), women smoking (4.2 [3.5-4.9], P<0.01), average stimulation duration (3.4 [2.7-3.9], P<0.01), average men age (2.2 [1.7-2.5], P<0.05), gonadotrophins total dose (2.1 [1.1-3.2], P<0.05) and first rank's attempts (1.6 [1.2-2.5], P<0.05).

DISCUSSION AND CONCLUSION

Age patient, rank attempts and quality embryo are criteria, which used to guide to a single embryo transfer. Our results incite us to consider other parameters, in particular men age and women smoking status.

Implantation Failure, Etiology, Diagnosis and Treatment

Embryonic implantation is a complex interaction between the embryo and the endometrium. Despite great investigative effort this process is still obscure. Contrary to the great advancement in patient care, follicular recruitment, oocyte quality and aspiration, embryo quality, culture and cryopreservation, our understanding of the implantation process did not enhance as much, and the tools to intervene within this process are limited. The implantation of the transferred embryos still remains the major limiting factor in IVF. Here we will review the current literature on the maternal (uterine, hematologic, immunologic and others) and embryonic factors that are associated with repeated implantation failure (RIF) and describe the various therapeutic approaches to cope with them. In addition, we will present our conclusive recommendations on how to investigate and manage RIF based on the literature and our own experience.

Thin unresponsive endometrium--a possible complication of surgical curettage compromising ART outcome

PURPOSE

Endometrial thickness is important for implantation. Little data addresses the etiology of persistently thin endometrium. We present a patient cohort in order to define common features and draw conclusions.

METHODS

Thirteen out of 1,405 IVF patients repeatedly had thin unresponsive endometrium (<7 mm). Age, history, uterine cavity status, treatment type and outcome were examined.

RESULTS

Patient age was 35.9 +/- 5.7 years. Ten patients had a curettage performed previously. Nine patients had normal cavity and endometrium, and in four adhesions were diagnosed and removed. Out of 99 cycles performed afterwards, endometrial thickness increased in 22. ETs were performed in 49 cycles resulting in 11 pregnancies. Their outcome was eight miscarriages, two terminations due to malformations, and one live birth.

CONCLUSIONS

Thin unresponsive endometrium was associated with curettage, not necessarily with intrauterine adhesions. Even if adequate thickening eventually occurred, the reproductive outcome was still very poor. Therefore other alternatives should be sought for these patients.

Outcome of in vitro fertilization treatment in infertile women conservatively treated for endometrial adenocarcinoma

OBJECTIVE

To evaluate IVF characteristics and outcome of infertile women conservatively treated for well-differentiated endometrial adenocarcinoma.

DESIGN

Observational case series study.

SETTING

The Department of Gynecology Oncology and IVF unit of Chaim Sheba Medical center, Tel-Hashomer, Israel.

PATIENT(S)

Eight women referred to IVF treatment because of failure of other fertility treatments after conservative treatment of endometrial adenocarcinoma. All women were selected carefully for conservative treatment at the Department of Gynecology Oncology of the Chaim Sheba Medical Center after a thorough metastatic workup.

INTERVENTION(S)

In vitro fertilization/intracytoplasmic sperm injection treatment.

MAIN OUTCOME MEASURE(S)

Serum E(2) levels at hCG administration, endometrial thickness, number of oocytes retrieved, fertilization rate, pregnancy and delivery rate.

RESULT(S)

All women were nulliparous before IVF treatment, and only one woman was older than 35 years. In four of them, endometrial adenocarcinoma was diagnosed during infertility workup or treatment. A total of 31 IVF cycles were performed. The mean number of oocytes retrieved was 9.4 (95% confidence interval, 5.1-13.6), and fertilization rate was 58.6%. Six women (75%) conceived, and four (50%) delivered six healthy offspring.

CONCLUSION(S)

In vitro fertilization treatment of infertile women conservatively treated for well-differentiated endometrial adenocarcinoma is highly successful and offers the opportunity to cryopreserve embryos for future use.

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.

Adjuvant therapy enhances endometrial receptivity in patients undergoing assisted reproduction

Adjuvant therapies are often used to enhance endometrial thickness during IVF. This retrospective cohort analysis investigated if women undergoing oocyte donation cycles with sonographic evidence of endometrial insufficiency benefit from adjuvant medicaltherapy. Infertile patients received 503 mock cycles followed by 503 anonymous oocyte donation cycles. One hundred and twenty-three patients received adjuvant therapy during a donor oocyte cycle. Patients who had a mock endometrial thickness > or = 8 mm experienced a significant decrease in endometrial thickness with the donor oocyte cycle regardless of the use of adjuvant therapy (P < 0.001). In contrast, those patients with a mock endometrial thickness < 8 mm experienced a significant increase in donor oocyte cycle endometrial thickness regardless of adjuvant therapy use (P < 0.001). The patients with a mock endometrial thickness < 8 mm experienced a significant improvement in pregnancy rates when taking adjuvant therapy (87.7 versus 73.5%, P < 0.05). Adjuvant therapy significantly improved both pregnancy (87.8 versus 76.8%, P < 0.01) and live birth rates (74.8 versus 63.7%, P < 0.05) in the entire patient population. While the use of adjuvant therapy did not significantly improve ultrasonographic endometrial thickness, it did improve outcome rates.

Cumulative embryo score, not endometrial thickness, is best for pregnancy prediction in IVF

PURPOSE

To assess the combined effect of endometrial thickness and cumulative embryo score (CES) on pregnancy rates in assisted reproduction cycles compared to the effect of each of these factors considered individually.

METHODS

Retrospective review of 2001 IVF pregnancy outcomes with respect to endometrial thickness and CES.

RESULTS

One hundred fifty-five IVF cycles were reviewed. Endometrial thickness ranged from 6.4 to 22 mm. CES ranged from 16 to 194. CES scores above 50 correlated with improved pregnancy rates (31%) over those less than 50 (12.5%). CES scores above 150 were correlated with a further doubling in pregnancy rates (66%). Endometrial thickness alone or in combination with cumulative embryo score did not improve the prediction of pregnancy.

CONCLUSIONS

CES alone, and not combined with endometrial thickness, is a statistically significant factor in pregnancy rates that may be clinically useful in decisions regarding number of embryos transferred to ensure a better pregnancy rate.

Endometrial evaluation in superovulation programs: relationship with successful outcome

It is well known that an adequate endometrial receptivity is required for successful implantation in both natural and assisted reproductive cycles. In particular, a brief "implantation window", during which endometrium undergoes anatomical and molecular changes necessary for embryo implantation, has been observed. The hormonal treatment applied to induce ovulation seems to be able to modify the normal development of the prenidatory endometrium, with possible negative effect on the implantation rate. For this reason, several attempts have been made to identify specific markers of endometrial receptivity, useful for predicting implantation outcome in clinical practice. Even if different histological, immunohistochemical, and ultrasonographic parameters are studied, none unfortunately has been univocally shown to be predictive of pregnancy outcome. Therefore, the evaluation of endometrial receptivity remains a challenge in clinical practice.

A suboptimal endometrial pattern is associated with a reduced likelihood of pregnancy after a day 5 embryo transfer

This retrospective study examined the association of endometrial pattern and pregnancy after a day 5 ET. The pregnancy rate of women with a triple-line ultrasound endometrial pattern on the day of hCG administration was significantly higher than the pregnancy rate of women with the other ultrasound patterns. This observation suggests that, in a subset of patients, a suboptimal endometrial lining may interfere with assisted reproductive technology success.

Endometrial development in association with ovarian follicular waves during the menstrual cycle

OBJECTIVES

Waves of ovarian follicular development during the menstrual cycle have recently been documented in our laboratory. The objective of this study was to test the hypothesis that ultrasonographically detectable changes in the endometrium during the menstrual cycle would differ between women with two vs. three waves of ovarian follicular development and among women with different major and minor wave patterns of follicle growth.

METHODS

Fifty women of reproductive age (mean age +/- SD, 28.0 +/- 6.9 years) underwent daily transvaginal ultrasonography for one interovulatory interval (IOI). Ultrasonographic images of the endometrium were obtained each day, and measurements of endometrial area and perimeter (based on the shape of an ellipse, in the transverse plane) and thickness and pattern (in the sagittal plane) were recorded. Endometrial area, perimeter, thickness and pattern were compared between women with two and three waves of follicle development and among women with different minor and major wave patterns of follicular growth during the IOI.

RESULTS

Endometrial area, perimeter, thickness and pattern increased earlier during the follicular phase in women with two vs. three waves of follicular development. In women with two follicle waves, endometrial area and perimeter increased earlier in those with major major vs. minor major follicle wave patterns.

CONCLUSIONS

Ultrasonographically detectable changes in the endometrium occurred in association with follicle wave dynamics in women. Earlier development of the endometrium during the follicular phase in women with two vs. three follicle waves was attributed to an earlier increase in dominant follicle estradiol production.

Factors associated with an optimal pregnancy outcome in an oocyte donation program

PURPOSE

To identify donor and recipient variables that may have a significant impact on pregnancy outcome in order to optimize results of an oocyte donation program.

METHOD

Retrospective analysis through a Generalized Estimating Equation (GEE) approach to clustered and binary clustered data, linear mixed effects model, scatter plot smoothing functions, and receiving operator characteristics (ROC) curves.

SETTING

University-based center.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURES

Pregnancy and implantation rates.

PATIENTS

257 donation and transfer cycles.

RESULT(S)

Overall results were as follows: clinical pregnancy rate, 47%; implantation rate, 22%; abortion rate, 19%; and overall multiple pregnancy rate, 35%. The total reproductive potential was 60%. Implantation and pregnancy rates were not significantly related to any variable from donors or recipients. Abortion rate increased significantly with donors' increased basal serum LH. Pregnancy rate was significantly enhanced with improved embryo quality. In donors stimulated more than once, the pregnancy rate was 84%.

CONCLUSION(S)

Although no single or combined donor or recipient variable(s) could be identified as predictor(s) of pregnancy, the data suggest that donors < or = 33 years of age with basal cycle day 3 serum levels of FSH 4-8 IU/L, LH < 8 IU/L, and E2 < 70 pg/mL had an optimal outcome. Transfer of two selected embryos on day 3 yields a favorable pregnancy outcome while significantly decreasing the occurrence of multiple pregnancies. These policies, in addition to embryo cryopreservation, were associated with optimal pregnancy outcome in oocyte donation.

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.

[Contribution of ovarian and uterine color Doppler in medically assisted reproduction techniques (ART)]

Along the menstrual cycle and during pregnancy, small blood vessels proliferate within the uterus and the ovulating ovary. Angiogenic factors such as VEGF are involved in this phenomenon. In the ovulating ovary, neo-angiogenesis spreads progressively inside the dominant follicle wall and plays a role in the maintenance of the corpus luteum, under the influence of LH (or HCG during pregnancy). In ART, the measure of the blood flow is interesting since it correlates to the number and quality of harvested oocytes. Follicle hypoxia may impair chromosomal organization and separation within the oocyte. This neo-angiogenesis is also important in endometrium, in particular for embryo implantation. Ultrasounds with Doppler allow to estimate the endometrial receptivity, especially in IVF cycles. It is assumed that chance for ongoing pregnancy is almost zero if: endometrial thickness is < 8 mm; uterine pulsatility index (PI) is > 3. Doppler ultrasounds are a useful and even mandatory complement to standard vaginal ultrasonoghraphy in ART. It can be viewed as an indicator of the endometrial and follicular "well-being".

Assessing uterine receptivity in 2001: ultrasonographic glances at the new millennium

The understanding and control of embryo implantation represents the major challenge for assisted reproductive technologies. Along with developments in basic research and efforts to optimize embryo quality, the improvement of noninvasive and reliable methods to assess uterine receptivity constitutes an important step toward meeting such a challenge. Today, ultrasound-based approaches to evaluate endometrial echogenicity and uterine perfusion and contractility are available for practical use. Increasing evidence indicates that echogenic patterns of the endometrium reflect histologic processes that are involved in the establishment of receptivity. This constitutes a possible explanation for the reported association between premature hyperechogenic patterns of the endometrium and poor implantation rates. Nevertheless, additional studies aiming at correlating further morpho-biochemical events in the endometrium with its echogenicity patterns are needed. Further, developments in vascular assessment by Doppler, Doppler-related, and vascular detection technologies will also be instrumental in monitoring and improving vascular changes that lead to uterine receptivity. Finally, data supporting the hypothesis that uterine contractility, as visualized by ultrasound, influences in vitro fertilization-embryo transfer (IVF-ET) pregnancy rates encourage further investigation on both the regulation and control of uterine contractions. This article discusses some of the advantages and limitations of ultrasonographic assessments of uterine receptivity in the perspective of the new millennium.

Subendometrial contractility is not predictive for in vitro fertilization (IVF) outcome

OBJECTIVES

The aim of the study was to investigate whether endometrial thickness, endometrial pattern, endometrial movement and serum estradiol and progesterone affect the outcome of in vitro fertilization.

METHODS

Prospectively collected data of endometrial thickness, endometrial pattern and subendometrial activity were analyzed in 122 consecutive in vitro fertilization cycles. All measurements were made on the day of hCG administration (day -2), day of embryo transfer (day +2), day +6 and day +12.

RESULTS

It would appear that pregnant women tend to have a thicker endometrium on day +12 than non-pregnant women. There appears to be no appreciable difference between pregnant and non-pregnant women in endometrial movement and thickness, nor in serum estradiol and progesterone on day +2 and day +6. In combining three echographic variables (thickness, pattern and movement) and hormone level (estradiol and progesterone), only progesterone on day +12 could be used to predict the outcome.

CONCLUSIONS

Subendometrial contractility plays no important role in implantation on the day of embryo transfer or 4 days later.

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.

New look at endometrial echogenicity: objective computer-assisted measurements predict endometrial receptivity in in vitro fertilization-embryo transfer

OBJECTIVE

To determine whether endometrial echogenicity, assessed objectively by a computer-assisted system on the day of hCG administration, predicts endometrial receptivity in controlled ovarian hyperstimulation (COH) cycles for IVF-ET.

DESIGN

Prospective analysis.

SETTING

Assisted reproduction unit, Clamart, France.

PATIENT(S)

Two hundred twenty-one women (aged <38 years with a normal uterus and >/=2 grade A or B embryos transferred) undergoing 228 GnRH agonist and FSH/hCG cycles for IVF-ET.

INTERVENTION(S)

On the day of hCG administration, uterine ultrasound scans were digitized with an image analysis system. Endometrial echogenicity was assessed as the ratio of the extent of the hyperechogenic transformation over the whole endometrial thickness. According to this, cycles were sorted arbitrarily into six groups: <30% (n = 34), 31%-40% (n = 37), 41%-50% (n = 37), 51%-60% (n = 55), 61%-70% (n = 37), and >70% (n = 28).

MAIN OUTCOME MEASURE(S)

Pregnancy and implantation rates.

RESULT(S)

The groups were similar in regard to population characteristics, ovarian response to COH, and embryology data. Pregnancy rates (59%, 57%, 35%, 20%, 16%, and 11%, respectively) and implantation rates (35%, 23%, 17%, 6%, 7%, and 3%, respectively) fell progressively and significantly from the low-echogenicity group to the high-echogenicity group.

CONCLUSION(S)

The present results confirm and extend previous observations that advanced hyperechogenic transformation of the endometrium is associated with poor IVF-ET outcome.

Prospective evaluation of the ultrasound appearance of the endometrium in a cohort of 1,186 infertile women

OBJECTIVE

To investigate the effect of differences in endometrial thickness and pattern as visualized with present-day high-resolution transvaginal ultrasound equipment on the outcome of assisted reproductive treatment.

DESIGN

Prospective cohort study.

SETTING

Two large infertility units in university hospitals.

PATIENT(S)

The endometrial characteristics of 981 patients during 1,600 assisted reproductive treatment cycles were compared with those of 205 untreated women. In addition, abnormal echogenic patterns of the endometrium were characterized histologically in 44 patients.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Pregnancy rates.

RESULT(S)

The endometrium was significantly thinner in untreated women and women treated with IUI than in women treated with IVF or intracytoplasmic sperm injection. The exponential proliferation of the endometrium was similar in conception and nonconception cycles. The odds for a successful pregnancy were significantly lower in the presence of a thin endometrium in women treated with IUI but not in women treated with the long stimulation protocol for IVF or intracytoplasmic sperm injection. Singleton pregnancies were more common than multiple pregnancies in patients with thin endometria.

CONCLUSION(S)

The pregnancy rates of assisted reproductive procedures are influenced only marginally by the degree of endometrial proliferation, and treatment should not be canceled because of inadequate endometrial thickness.

Endometrial pattern on the day of oocyte retrieval is more predictive of implantation success than the pattern or thickness on the day of hCG administration

PURPOSE

Multiple studies have confirmed a lower implantation (IR) and pregnancy rate (PR) in women who exhibit a homogeneous pattern (pattern II) of the endometrium compared to a triple-line pattern (pattern I) on the day of hCG administration. However, no data are available to evaluate if patients alter their endometrial thickness and pattern between the day of hCG administration (DhCG) and the day of oocyte retrieval (DRET) and whether these changes adversely affect endometrial receptivity.

METHODS

We prospectively evaluated 86 women (mean age, 32.9 +/- 3.8 years; range, 24-40 years) undergoing 103 IVF/ET cycles.

RESULTS

Pattern II was noted in 7 cycles (6.8%) on DhCG, compared to 96 cycles with pattern I (93.2%). However, 20 cycles (19.4%) had pattern II on DRET. The ongoing IR was 13.0% (3/23) in the pattern II group compared to 20.8% (76/365) in the pattern I group on DhCG (P = NS). However, a significant decrease in the ongoing IR, to 9.9% (7/71), was noted in pattern II, compared to 23.3% (71/305) in pattern I, on DRET (P = 0.019). There was no difference in age, basal FSH, peak E2, P4 on the day of hCG, number of oocytes, number of ET, or endometrial thickness between pregnant and nonpregnant patients, or between patients with pattern I and those with pattern II. A trend toward higher progesterone levels on DhCG was noted in women with pattern II (P = 0.078).

CONCLUSIONS

Endometrial pattern, rather than thickness, on the day of oocyte retrieval appears to be an important prognosticator of endometrial receptivity.

Saline infusion contrast intrauterine sonographic assessment of the endometrium with high-frequency, real-time miniature transducer in normal menstrual cycle: a preliminary report

Normal endometrial texture was visualized using saline infusion contrast intrauterine sonography with a specially developed 20 MHz flexible catheter-based high-resolution, real-time miniature (2.4 mm outer diameter) ultrasound transducer in primary infertile women (n = 15) with a normal menstrual cycle. All the women had <2 years infertility duration and were studied in proliferative, and early or mid-secretory phases. Before intrauterine sonography, transvaginal sonographic assessment of the endometrium was conducted. The overall image clarity was subjectively compared between intrauterine and transvaginal sonography. Most endometrial textures in both proliferative and secretory phases were viewed more easily with intrauterine rather than transvaginal sonography, and this was especially true with an intrauterine saline infusion technique. Moreover, it was possible to obtain finer image quality of very small endometrial interfacial and internal textures with intrauterine sonography. However, the depth of penetration of the ultrasound beam is only approximately 2 cm, therefore examination of larger pathological endometrial lesions is markedly limited because of the shallow scanning range of the high-frequency transducer. Intrauterine sonography may be a valuable tool in imaging endometrial texture in normal menstrual cycle, and possibly in infertility practice, complementing and not replacing transvaginal sonography.

Adjuvant L-arginine treatment for in-vitro fertilization in poor responder patients

The objective of the present study was prospectively and randomly to evaluate the role of L-arginine in improving uterine and follicular Doppler flow and in improving ovarian response to gonadotrophin in poor responder women. A total of 34 patients undergoing assisted reproduction was divided in two groups according to different ovarian stimulation protocols: (i) flare-up gonadotrophin-releasing hormone analogue (GnRHa) plus elevated pure follicle stimulating hormone (pFSH) (n = 17); and (ii) flare-up GnRHa plus elevated pFSH plus oral L-arginine (n = 17). During the ovarian stimulation regimen, the patients were submitted to hormonal (oestradiol and growth hormone), ultrasonographic (follicular number and diameter, endometrial thickness) and Doppler (uterine and perifollicular arteries) evaluations. Furthermore, the plasma and follicular fluid concentrations of arginine, citrulline, nitrite/nitrate (NO2-/NO3-), and insulin-like growth factor-1 (IGF-1) were assayed. All 34 patients completed the study. In the L-arginine treated group a lower cancellation rate, an increased number of oocytes collected, and embryos transferred were observed. In the same group, increased plasma and follicular fluid concentrations of arginine, citrulline, NO2-/NO3-, and IGF-1 was observed. Significant Doppler flow improvement was obtained in the L-arginine supplemented group. Three pregnancies were registered in these patients. No pregnancies were observed in the other group. It was concluded that oral L-arginine supplementation in poor responder patients may improve ovarian response, endometrial receptivity and pregnancy rate.

Association of endometrial blood flow as determined by a modified colour Doppler technique with subsequent outcome of in-vitro fertilization

An endometrial thickness of 10 mm or more has been reported to be favourable for embryo implantation. Nevertheless, many women participating in in-vitro fertilization (IVF) programmes have adequate endometrial thickness but do not achieve satisfactory implantation. With the aid of power Doppler sonography, we examined the association between intra-endometrial vascularity and reproductive outcome. For this study, we enrolled only women with endometrial thickness >/=ISOdia>/=10 mm and excluded those with apparent endometrial pathologies. Of 95 women undergoing IVF cycles, there resulted 37 intrauterine pregnancies. The women were of similar age, body mass index, peak oestradiol concentration and endometrial thickness, and a similar number of embryos were transferred. Those women with an intra-endometrial power Doppler area (EPDA) <5 mm2 achieved a significantly lower pregnancy rate (23. 5 versus 47.5%, P = 0.021) and implantation rate (8.1 versus 20.2%, P = 0.003) than those with an EPDA >/=ISOdia>/=5 mm2. We conclude that, in addition to endometrial thickness, EPDA may serve as a factor indicative of endometrial receptivity. Women with adequate endometrial thickness but a small EPDA tended to have an unfavourable reproductive outcome.

Ultrasound evaluation of the uterine zonal anatomy during in-vitro fertilization and embryo transfer

This study was designed to establish if ultrasound could detect differences in uterine zonal anatomy between conception and non-conception in-vitro fertilization (IVF)/embryo transfer cycles. A transvaginal ultrasound scan was performed on the day of down regulation (D0), on day 8 of ovulation induction (D8), on the day of human chorionic gonadotrophin (HCG) injection, at the time of oocyte retrieval, and at embryo transfer. Thicknesses of endometrium, junctional zone, myometrium and full thickness of the uterus were recorded for every patient and comparisons made at all the assessment points. Differences between measurements on D0 and all other measurements (temporal changes) and between every subsequent measurement (dynamic changes) were also compared. There were no statistically significant differences in endometrial thickness between pregnant and non-pregnant groups at any time. The diameter of the uterus increased during therapy and was significantly greater in the pregnant subset at the time of HCG injection, oocyte retrieval and embryo transfer (P < 0.02, 0.03 and 0.02 respectively). The myometrium was significantly thicker in the pregnant group on D0, on D8 and at HCG administration (P < 0.03, 0.004 and 0.02). There was a decrease in junctional zone thickness in both groups during the first week of ovulation induction, and on D8 the junctional zone in pregnant patients was significantly thinner (P < 0.04). The junctional zone became significantly thicker at embryo transfer in the pregnant group (P < 0.01). This was confirmed by significant temporal and dynamic changes at the time of oocyte retrieval and embryo transfer (P < 0.01, 0.0001 and P < 0.05, 0.01 respectively). In the patients who did not conceive, changes in the junctional zone were less pronounced. In conclusion, it was not possible to predict the likelihood of pregnancy from endometrial thickness at any time during the IVF cycle, but changes occurred in other uterine layers that were more pronounced in conception cycles. The responsiveness of the junctional zone seems to be associated with implantation, and its measurements at the time of downregulation and embryo transfer can be used to predict treatment outcome.

The hormonal control of endometrial receptivity: estrogen (E2) and progesterone

While the number of identified substances produced by the ovary increases steadily, it remains remarkable that the sole use of exogenous estrogen (E2) and progesterone (P) can prime optimal endometrial receptivity in women whose ovaries have failed or are absent. Early work showed that a marked leeway existed in the acceptable duration of the E2-only phase of endometrial priming. Subsequently, a sequence of transformations are induced by exogenous progesterone that reproduces classical findings made in the menstrual cycle. Secretory changes in endometrial glands are best seen between the 4th and 6th day of progesterone administration (day 18-20 of an ideal cycle where progesterone exposure starts on day 15). Predecidual changes of the endometrial stroma are apparent starting on the 10th day of progesterone exposure (day 24). Contrary to earlier belief, even maximal alterations in the plasma E2 to progesterone ratio fails to alter the endometrial morphology of either glands or stroma. More recently it has been recognized that E2 and progesterone also affect uterine contractility. It has been postulated that excessively high levels of E2 may increase uterine contractility and adversely affect implantation rates in in-vitro fertilization (IVF). Exogenous progesterone has been shown to exert utero-relaxing effects and it has been hypothesised that progesterone supplementation before embryo transfer (ET) may improve receptivity in IVF.

Relation between endometrial wavelike activity and fecundability in spontaneous cycles

OBJECTIVE

To determine whether endometrial activity is related to the occurrence of pregnancy in spontaneous menstrual cycles.

DESIGN

Prospective observational ultrasound evaluation of endometrial activity during fertility screening cycles.

SETTING

University hospital-based infertility clinic.

PATIENT(S)

Fifty-nine fertility screening cycles (ultrasound monitoring of follicle growth and ovulation, postcoital test, semen analysis, midluteal P, Chlamydia antibody determination, and tubal patency testing) were performed in 47 couples complaining of infertility. In 33 couples (37 cycles), no fertility impairing factors were found. Endometrial activity was analyzed in these cycles.

INTERVENTION(S)

Ultrasound examination was performed transvaginally throughout the cycle.

MAIN OUTCOME MEASURE(S)

Endometrial activity, wave pattern, pregnancy.

RESULTS(S)

Nine women conceived within the cycle studied. Conception cycles showed less-activity compared with nonconception cycles. Endometrial wavelike activity increased throughout the follicular phase and decreased after ovulation in conception and nonconception cycles.

CONCLUSION(S)

Endometrial activity is related to fecundability in a spontaneous cycle.

The predictive value of an initial serum beta human chorionic gonadotropin level for pregnancy outcome following in vitro fertilization

PURPOSE

Our purpose was to assess the predictive value for pregnancy outcome of an initial serum quantitative beta-hCG measurement obtained 11 or 12 days after embryo transfer in an in vitro fertilization program.

METHODS

A prospective, descriptive study of 153 pregnancies achieved via in vitro fertilization-embryo transfer was performed. Initial beta-hCG levels and subsequent pregnancy outcomes were compared.

RESULTS

The overall mean initial beta-hCG level was 91 +/- 85.8 mIU/ml for normal (singleton, multiple-gestation) pregnancies and 29 +/- 24.9 mIU/ml for abnormal (miscarriage, ectopic) pregnancies (P < 0.01; power, > 80%). While 93.9% of patients with initial beta-hCG levels > or = 42 mIU/ml had normal pregnancies, 56.4% of those with initial levels < 42 mIU/ml experienced abnormal outcomes. With 42 mIU/ml as the cutoff level for predicting a normal pregnancy, this screening test yielded a sensitivity of 79.3% and a specificity of 83.8%.

CONCLUSIONS

Initial serum beta-hCG levels obtained 11 or 12 days after embryo transfer may be predictive of pregnancy outcome in an in vitro fertilization program.

Endometrial thickness is a valid monitoring parameter in cycles of ovulation induction with menotropins alone

OBJECTIVE

To evaluate the ability of an ultrasound (US)-measured periovulatory endometrial thickness to predict conception in hMG-stimulated cycles.

DESIGN

Retrospective.

SETTING

A university-based tertiary practice.

PATIENTS

One hundred twelve patients undergoing 292 cycles of ovulation induction with hMG alone.

MAIN OUTCOME MEASURES

A periovulatory transvaginal US measurement of endometrial thickness was obtained during cycles of ovulation induction with hMG alone. Clinical pregnancy was defined by fetal cardiac activity. Sensitivity and false-positive rates for multiple discriminatory values of endometrial thickness were calculated and a relative operating characteristic (ROC) curve was constructed to evaluate the performance of this test as a predictor of pregnancy.

RESULTS

Thirty-eight of 292 cycles resulted in pregnancy. Conception and nonconception cycles showed similar demographics, diagnoses, peak E2, maximum number of follicles, midluteal P, and mean endometrial thickness. Ovulatory dysfunction was a more frequent diagnosis in the conception group. Relative operating characteristic analysis for endometrial thickness as a predictor of pregnancy yielded an area under the curve of 0.623 +/- 0.049 (mean +/- SD).

CONCLUSION

Endometrial thickness is a valid screening test for conception outcome in cycles stimulated with hMG. A periovulatory endometrial thickness > or = 10 mm defined 91% of conception cycles. No pregnancy occurred when the endometrium measured < 7 mm.

Ultrasonographic predictors of implantation after assisted reproduction

OBJECTIVE

To assess the utility of endometrial thickness, echogenic endometrial pattern, and uterine artery impedance measured as pulsativity index in predicting implantation.

DESIGN

Prospective case-controlled study of infertile patients undergoing assisted reproductive technologies (ARTs).

PATIENTS

Four hundred five women undergoing ARTs were studied: 100 women after ET of thawed embryos in natural cycles (frozen ET), 107 women after standardized IVF-ET, 99 women receiving donor oocytes after controlled endometrial development with estrogen and P, and 99 women undergoing IUI with various ovarian stimulation regimens (none, 16; GnRH, 7; clomiphene citrate [CC], 29; hMG, 47).

INTERVENTIONS

Transvaginal ultrasonographic examination performed on the day of hCG administration during stimulated cycles; on E2 day 15 during controlled endometrial cycles; and on the day of ovulation during natural, CC, and GnRH pump cycles.

MAIN OUTCOME MEASURE

The endometrial thickness, echogenic pattern, and pulsativity index results in 170 conception cycles were compared with 235 nonconception cycles.

RESULTS

When conception and nonconception cycles were compared, no difference in mean endometrial thickness and significant differences in the frequency of nonmultilayered pattern and pulsativity index > 3.3 were observed. Forty-seven percent of nonconception and 9% of conception cycles were associated with at least one of these factors.

CONCLUSION

Ultrasonic measurements of pulsativity index, resistance index, and echogenic pattern are useful in predicting implantation after assisted reproduction.

Cigarette smoking and the outcomes of in vitro fertilization: measurement of effect size and levels of action

OBJECTIVE

To assess whether cigarette smoking in women or men affects the outcomes of IVF-ET and at what functional levels smoking is active.

INTERVENTIONS

Demographic and smoking data were collected by questionnaire at the onset of consecutive treatment cycles (n = 462) and at the time of ET. In addition to routine endocrine and clinical data, circulating immunoreactive inhibin, follicular fluid E2 endometrial thickness, and morphology were assessed. Reported exposure to cigarettes was validated using a serum cotinine assay.

RESULTS

Serum cotinine level at the onset of treatment correlated strongly with the number of cigarettes reported (r = 0.68). The duration and dose of gonadotropin treatment was greater among active smokers than never smokers: 10.2 versus 9.2 days and 24.7 versus 19.8 ampules, respectively. Fertilization, pregnancy, and abortion rates were similar between groups. Multivariate analyses demonstrated negative correlation between female age, but no such effect was seen with female or male smoking. Sperm concentration was significantly reduced in male smokers (prewash: 108 versus 130 x 10(6); postwash: 17.1 versus 21.6 x 10(6)), although fertilization rate was unaffected (66% versus 62%). Follicular function, assessed using serum inhibin and E2, as well as follicular fluid E2 levels showed no significant difference between active smokers and never smokers. Endometrial thickness and morphology also were similar between groups.

CONCLUSIONS

These data suggest that among couples undergoing IVF neither female nor male smoking has a measurable deleterious effect on conception rate. Female age remains a far more potent prognostic factor in the current study. However, when all the published data are combined, a significant deleterious effect of smoking on conception is suggested, with a common odds ratio of 0.540 (95% confidence interval 0.385 to 0.757).

Relationship of the individual uterine size and the endometrial thickness in stimulated cycles

At present there is no agreement regarding the usefulness of monitoring the endometrial thickness in stimulated cycles. We tested prospectively the hypothesis of a linear relationship of the given individual uterine size and the endometrial thickness in stimulated cycles using a 240 degrees transvaginal sector scanner. There was a strong correlation of the uterine dimension with the endometrial thickness in the midfollicular and the early luteal phase. Our findings suggest that the endometrial thickness is determined by the individual uterine architecture and therefore not predictive of the likelihood of implantation.

Serum progesterone concentrations on the day after human chorionic gonadotropin administration and progesterone/oocyte ratios predict in vitro fertilization/embryo transfer outcome

PURPOSE

In gonadotropin-releasing hormone analogue-pretreated in vitro fertilization-embryo transfer cycles, pregnancy rates are inversely related to serum progesterone levels on the day of administration of human chorionic gonadotropin. The relationship of the progesterone concentration on other days in the periovulatory period to pregnancy rates in such cycles is little studied. We therefore retrospectively analyzed the relationship between progesterone concentrations on the day after human chorionic gonadotropin and pregnancy in 114 cycles, 28 and 23 of which produced clinical and ongoing/delivered pregnancies, respectively. To assess the effect of the extent of follicular luteinization on success, we also studied the relationship between the progesterone concentration per oocyte retrieved and pregnancy for the day of and day after human chorionic gonadotropin.

RESULTS

Progesterone concentrations on the day after human chorionic gonadotropin were inversely associated with clinical pregnancy by multiple logistic regression analysis (P < 0.05). Progesterone/oocyte ratios were inversely associated with clinical pregnancy (P < 0.05) and ongoing/delivered pregnancy (P < 0.02) for both the day of and the day after human chorionic gonadotropin.

CONCLUSION

The study results extend the window of time during which elevated progesterone concentration is associated with poor outcome to at least 2 days. This finding is consistent with hypothetical mechanisms attributing the link between progesterone concentration and outcome to either endometrial or follicle/oocyte events. The association of lack of follicular luteinization (low progesterone per oocyte ratios) and favorable outcome suggests a predominant effect of progesterone on follicle/oocyte quality. Further studies are needed to clarify the mechanisms underlying the association between progesterone and in vitro fertilization-embryo transfer outcome.