Temporal Analysis in Outcomes of Long-Term Mechanical Circulatory Support: Retrospective Study

BACKGROUND

 Mechanical assist device indications have changed in recent years. Reduced incidence of complications, better survival, and the third generation of mechanical support devices contributed to this change. In this single-center study, we focused on two time periods that are characterized by the use of different types of mechanical support devices, different patient characteristics, and change in the indications.

METHODS

 The data were processed from the European Registry for Patients with Mechanical Circulatory Support (EUROMACS). We retrospectively defined two time intervals to reflect changes in ventricular assist device technology (period 1: 2007-2015; period 2: 2016-20222). A total of 181 patients underwent left ventricular assist device implantation. Device utilization was the following: HeartMate II = 52 (76.4%) and HeartWare = 16 (23.6%) in period 1 and HeartMate II = 2 (1.8%), HeartMate 3 = 70 (61:9%), HeartWare = 29 (25.7%), SynCardia TAH = 10 (8.8%), and BerlinHeart EXCOR = 2 (1.8%) in period 2. The outcomes of the time intervals were analyzed and evaluated.

RESULTS

 Survival was significantly higher during the second time period. Multivariate analysis revealed that age and bypass pump time are independent predictors of mortality. Idiopathic cardiomyopathy, bypass time, and the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) score are independent predictors of adverse events. Furthermore, the first period was noted to be at an increased risk of the following adverse events: pump thrombosis, gastrointestinal bleeding, and bleeding events.

CONCLUSION

 Despite the higher risk profile of the patients and persistent challenges, during the second period, there was a significant decrease in mortality and morbidity. The use of the HeartMate 3 device may have contributed to this result.

Genomic Adaptations to an Endoparasitic Lifestyle in the Morphologically Atypical Crustacean Sacculina carcini (Cirripedia: Rhizocephala)

The endoparasitic crustacean Sacculina carcini (Cirripedia: Rhizocephala) has a much simpler morphology than conventional filter-feeding barnacles, reflecting its parasitic lifestyle. To investigate the molecular basis of its refined developmental program, we produced a draft genome sequence for comparison with the genomes of nonparasitic barnacles and characterized the transcriptomes of internal and external tissues. The comparison of clusters of orthologous genes revealed the depletion of multiple gene families but also several unanticipated expansions compared to non-parasitic crustaceans. Transcriptomic analyses comparing interna and externa tissues revealed an unexpected variation of gene expression between rootlets sampled around host midgut and thoracic ganglia. Genes associated with lipid uptake were strongly expressed by the internal tissues. We identified candidate genes probably involved in host manipulation (suppression of ecdysis and gonad development) including those encoding crustacean neurohormones and the juvenile hormone binding protein. The evolution of Rhizocephala therefore appears to have involved a rapid turnover of genes (losses and expansions) as well as the fine tuning of gene expression.

Single centre 12 year experience with durable mechanical circulatory support: comparison with the EUROMACS registry

OBJECTIVES

Mechanical circulatory support is an established therapy in end-stage heart failure. The EUROMACS registry was created to promote research in these patients. The aim of this report was to present our 12 year experience with the durable mechanical circulatory support devices and compare it with the EUROMACS registry.

METHODS

Data from the entire EUROMACS registry from January 2011 to April 2019 were included (4704 implantations in 4410 patients). During the 12 years of our experience, until April 2019,125 mechanical support devices were implanted, in 122 patients. We compare patients´ characteristics, operative data and results with the EUROMACS registry and we report the major complications during the observational period.

RESULTS

Primary end-point (death) occurred in 40 (32.8 %) patients in our cohort during the follow-up period, representing the survival rate 75 %, 68 %, and 58 % for 6, 12, 24 months respectively, which compares favourably with the data, reported by the EUROMACS registry, the survival 66 % and 53 % after 1 and 2 years respectively. Cerebrovascular accident occurred in 7 %, a bleeding event in 32 %, significant infection (driveline) in 78 % and a device malfunction in 13 % of the patients. Forty- three patients underwent a heart transplant with hospital and long-term mortality of 11.6 % and 14 % respectively.

CONCLUSION

Mechanical circulatory support is a valuable therapeutic option with excellent survival rates, nevertheless it is associated with clinically significant complications rates. The direct comparison between our cohort and the EUROMACS registry showed that early implantation strategy and mini invasive approach may improve survival rates and decrease postoperative complications (Tab. 3, Fig. 3, Ref. 16).

Ten-year survival and prognostic markers in one thousand patients with advanced heart failure. A single-centre analysis

AIM

Patients with advanced heart failure (HF) represent a pool of candidates for heart transplantation and long-term mechanical circulatory support devices. The aim of our study was to determine simple and reliable markers of one-year mortality for selection of the most suitable patients for heart replacement therapy.

METHODS AND RESULTS

One thousand consecutive patients with HF (mean age 49 ± 10.9 years; 86.8% males) referred to a single tertiary centre from January 1998 to January 2010 in order to assess the indication for heart transplantation were enrolled. Kaplan-Meier survival analysis was performed. Independent mortality predictors were established using logistic regression analysis. The mean follow-up was 4.3 ± 2.7 years (range 1-12 years). Cumulative survival was as follows: 1-year survival 83%, 3-year 63%, 5-year 50%, 7-year 39%, and 10-year 23%. Independent predictors of 1-year mortality included coronary artery disease, left ventricular diastolic diameter >79 mm, plasma sodium <135 mmol/L, the need for intravenous treatment at hospital admission (diuretics and/or inotropes), and furosemide dose at discharge >240 mg/day.

CONCLUSIONS

Short-term prognosis of HF patient can be estimated based on simple parameters. Patients with signs of poor prognosis should be referred to tertiary centres to be considered for heart replacement therapy.

The long-term response to treatment with calcium channel blockers in a patient with idiopathic pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a disease characterised by a gradual increase in resistance of pulmonary circulation leading to right ventricular failure and death. In only 10 % of cases, there is a response to acute vasoreactivity testing with a significant reduction in mean pulmonary artery pressure (PAP), while in this group of patients, less than one half of cases benefit from long-term treatment with calcium channel blockers (CCB). This paper describes a case report of a young patient with dyspnoea and suspicion of pulmonary hypertension who was referred to a specialised centre. The complex evaluation of her clinical state led to confirmed diagnosis of idiopathic pulmonary arterial hypertension (IPAH). Because there was a positive response to vasoreactivity testing, the treatment for IPAH was initiated with a high dose of CCB. This treatment markedly improved her clinical state as well as echocardiographic and hemodynamic findings.In this study, the authors present a diagnostic algorithm in pulmonary hypertension and emphasise the role of CCB in treatment of PAH in carefully selected patients (Tab. 1, Fig. 5, Ref. 7).

ECG signs of right ventricular hypertrophy may help distinguish pulmonary arterial hypertension and pulmonary hypertension due to left ventricular diastolic dysfunction

OBJECTIVES

Distinguishing pulmonary arterial hypertension (PAH) and pulmonary hypertension due to left ventricular diastolic dysfunction (PHLDD) is essential for the correct disease management. We compared the importance of electrocardiographic (ECG) signs of right ventricular hypertrophy (RVH) in patients with similar degree PAH and PHLDD.

METHODS

ECG analysis was retrospectively performed in 17 PHLDD and in 17 PAH patients with catheterization-confirmed moderate pulmonary hypertension. Sensitivity, specificity, and positive and negative predictive values for individual RVH signs were calculated.

RESULTS

The PAH group showed a higher prevalence of the following: R/S ratio > 1 in V1 (p < 0.001), R in V1 + S in V6 > 1.05 mV (p < 0.01), R wave peak time > 0.035 s (p < 0.05), right ventricular strain (p < 0.001), and A+R-PL parameter (i. e. R(V1) + S1 - S(V1)) = 0.07 mV (p < 0.05). The sensitivity and negative predictive value (NPV) of RVH signs for distinguishing PAH and PHLDD were low for all signs except right ventricular strain (sensitivity 71%, NPV 77%). The specificity and positive predictive value (PPV) of all six parameters were both 100%.

CONCLUSIONS

In patients with pulmonary hypertension detected using echocardiography, ECG presence of RVH/overload may exclude LV diastolic dysfunction as a cause of PH and suggests the diagnosis of PAH (Tab. 3, Ref. 19).

Changes of portal flow in heart failure patients with liver congestion

AIM

The goal of the study was to describe the changes of the portal vein (PV) flow in patients with an exacerbation of advanced chronic congestion heart failure (CHF) in relation to central hemodynamics and biochemical indicators of liver lesion.

PATIENTS AND METHODS

90 pts (76 males) aged 49.2 +/- 11.2 years admitted for an acute exacerbation of chronic heart failure based on severe left ventricular systolic dysfunction (LVEF 20 +/- 4.3%) were evaluated. The PV flow was sampled from the main portal vein using the intercostal approach. Systolic and diastolic flow velocities were measured and the the pulsatility index (PI, max - min/max PV flow velocity) was calculated.

RESULTS

The median of PI in all patients was 0.82 (0-2.0). PI > or = 0.5 was found in 77 (86%) of patients. There was a significant linear correlation of PI and right atrium pressure (RAP), pulmonary vascular resistance (PVR) and mean pulmonary artery pressure (mPAP) (p <0.01, r = 0.68, 0.51 and 0.49 resp). Out of 75 patients with RAP > or =8 mmHg, 67 (89%) had the pulsatility index > or = 0.5. The mean RAP was 7.2 +/- 3.1 mmHg in patients with continuous flow, 14.9 +/- 5.9 mmHg in the group with pulsatile flow pattern, and 20.1 +/- 6.3 and 21.1 +/- 6.5 mmHg in intermittent and alternating flow, respectively (p < 0.01).

CONCLUSION

The flow pulsatility increases with increasing right ventricular filling pressure so that an analysis of the PV flow can detect the elevation of right atrial pressure and allow a quantitative estimation of RAP. The finding of flat portal vein flow wave patterns in HF patients with signs of congestion draws the attention to concurrent primary liver disease. This information could be important in the risk stratification as well as in the therapeutic decision (Tab. 1, Fig. 6, Ref. 19).

Telmisartan and metabolic syndrome after heart transplantation

INTRODUCTION

Metabolic syndrome (MS) is a cardiovascular risk predictor. Prevalence of MS after heart transplantation (HTx) is high. Recent data suggest a positive metabolic effect of telmisartan.

AIM

To describe the influence of telmisartan on lipid and glycide metabolism in MS after HTx.

METHODS

Fifteen patients aged 55+/-12 yr, 88+/-25 months after HTx with MS receiving statins were followed. The reason for telmisartan administration was arterial hypertension with either drug intolerance or poor control. Body mass index (BMI), waist circumference, total cholesterol, low density lipoprotein LDL-cholesterol, high density lipoprotein-cholesterol, triglycerides, C-reactive protein (CRP), fasting glucose, immunoreactive insulin (IRI), C-peptide and the homeostasis model assessment (HOMA) index were determined. Ambulatory blood pressure monitoring was performed. After initial evaluation, telmisartan 80 mg was started. After 20 +/- 5 wk follow-up, identical parameters were measured. Statistical significance was evaluated using Student's t-test.

RESULTS

BMI, waist circumference, systolic and diastolic blood pressures, serum lipids and CRP remained unchanged after telmisartan. Significant reduction in fasting glucose (6.7 vs. 5.6 mmol/L, p < 0.02), IRI (8.8 vs. 8.5 U/mL p = 0.05), HOMA (7.3 vs. 5.8 mmol/L x muU/mL, p < 0.05) and C-peptide (4.0 vs. 3.3 ng/mL, p < 0.02) was found.

CONCLUSIONS

Telmisartan had a positive impact on insulin sensitivity parameters (fasting glucose, IRI, C-peptide and HOMA) in this population. No effect on obesity, serum lipids and systemic inflammation was observed.

A successful therapy of renovascular hypertension

Authors describe a rare cause, diagnostic difficulties and successful therapy of renovascular hypertension in a 12 year-old girl caused by anular stenosis of the intrarenal arterial branch. Activation of the system renin-angiotensin (RAS) is found in all forms of renovascular hypertension at the beginning. Etiologically, stenosis in childhood is caused mostly by renal artery dysplasia, affecting mostly media, and fibromuscular dysplasia. Fibromuscular dysplasia affects middle and distal third of renal artery in 60%, more frequently on right, only in 10% of cases affects segmental branches; one quarter of patients are affected bilaterally. This disease is found predominantly in young women. During clinical course, typical signs include sudden onset of severe and poorly controlled hypertension, renal insufficiency, proteinuria and hypertensive retinopathy. From non-invasive diagnostic approaches, color duplex ultrasound, NMR and CT angiography are important, from invasive ones, digital subtractive angiography and the measurement of plasma rennin activity in renal veins. In therapy, it is percutaneous transluminal renal angioplasty, associated with low mortality and morbidity. The net result of angioplasty is dilation of stenosis, complete restoration of artery lumen and flow and decrease of blood pressure. The best results can be achieved in young patients with fibromuscular dysplasia, more then half can recover completely. Using this method, also our patient has recovered (Tab. 2, Fig. 2, Ref. 7).

Transmyometrial embryo transfer and junctional zone contractions

BACKGROUND

Embryo transfer is a crucial step in IVF-embryo transfer cycles. Several studies have explored transmyometrial embryo transfer, but although this procedure has several favourable characteristics, its role in assisted reproduction has not yet been established. Junctional zone (JZ) contractions during embryo transfer are associated with a negative outcome and factors which increase JZ contractions should be avoided.

METHODS

In this study, we have investigated the effect of transmyometrial embryo transfer on JZ contractions. Ten patients with a previously difficult embryo transfer, or a difficult mock embryo transfer, underwent transmyometrial embryo transfer. Before and after this procedure a transvaginal ultrasound scan was performed and this was recorded on videotape for 5 min. The recordings were digitized and then analysed for JZ contractions.

RESULTS

Transmyometrial embryo transfer causes a significant increase in JZ contractions.

CONCLUSION

The increase in JZ contractions after transmyometrial embryo transfer forms a theoretical objection to this procedure. However, its alternative, a difficult transcervical embryo transfer, is also associated with an increase in JZ contractions. We therefore suggest a large prospective study to investigate the most effective method of embryo transfer in cases where a difficult transcervical embryo transfer is anticipated due to cervical factors.

[Physical training in the treatment of heart failure]

Exercise training leads to an increase in functional capacity and reduction of symptoms in patients with chronic heart failure. The benefit of training is explained particularly by its impacts on peripheral blood flow and metabolism of skeletal muscle. The appropriate exercise training as to its form and intensity is safe in patients with severe left ventricular dysfunction.

[Arterial hypertension after heart transplantation]

Arterial hypertension after HTx is almost a universal finding. The combined antihypertensive treatment achieves normotension in 34% of patients with arterial hypertension. Calcium blocators are the drugs of first choice.

Junctional zone contractions and embryo transfer: is it safe to use a tenaculum?

Applying a tenaculum to the cervix is a common practice when the correction of uterine position prior to embryo transfer is required. Our study was designed to assess junctional zone contractility before and after this procedure in 20 patients at the time of mock embryo transfer (mid-luteal phase, at commencement of down-regulation). Real-time transvaginal ultrasound and computer technology was used to evaluate the contraction pattern and frequency. When a tenaculum was applied, the total number of contractions, the number of cervico-fundal, random and opposing contractions all increased significantly (P values 0.0003, 0.005, 0. 001 and 0.007 respectively). Eleven women displayed cervico-fundal contractions, prominent opposing and random contractions were observed in all 20 patients and four patients generated fundo-cervical waves not seen in any case before stimulation with the instrument. In conclusion, manipulation with a tenaculum in the cervical area stimulates junctional zone contractions and is best avoided at the time of embryo transfer.

Transcervical embryo transfer as a risk factor for ectopic pregnancy

OBJECTIVE

To evaluate the ease and timing of transcervical ET as risk factors for ectopic pregnancy (EP) after IVF.

DESIGN

Retrospective study.

SETTING

University-based IVF program in the United Kingdom.

PATIENT(S)

Eighteen consecutively seen patients with an EP after IVF and 314 patients with an intrauterine pregnancy after transcervical ET performed during the same period.

INTERVENTION(S)

Additional manipulation with a transfer catheter or the use of other instruments to assist transfer. Embryo transfer on day 2 or 3 after oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Risk factors for EP (day 2 ET, difficult transfer overall and on days 2 and 3, history of tubal subfertility, and previous EP) presented as odds ratios with 95% confidence intervals.

RESULT(S)

The risk of EP was 2.26 (0.64-8.01) after day 2 ET, 3.91 (1.49-10.23) after difficult ET, 3.88 (1.34-11.24) after difficult ET on day 2, 2.7 (0.20-13.99) after difficult ET on day 3, 5.73 (1.99-16.62) when there was a history of tubal subfertility, and 5.41 (1.96-14.91) when there was a previous EP.

CONCLUSION(S)

A difficult ET significantly increases the risk of an EP. The risk is particularly high when the patient has a history of tubal damage or previous EP. The timing of ET is important only if the ET is difficult.

Ectopic pregnancy after transmyometrial embryo transfer: case report

OBJECTIVE

To report a case of ectopic pregnancy after transvaginal transmyometrial ET.

DESIGN

Case report.

SETTING

University-based IVF program.

PATIENT(S)

A woman with tubal subfertility and a history of difficult ETs.

INTERVENTION(S)

Transvaginal transmyometrial ET performed to avoid a difficult transcervical ET.

MAIN OUTCOME MEASURE(S)

Expected improvement in the pregnancy rate in a selected group of patients.

RESULT(S)

Tubal pregnancy.

CONCLUSION(S)

Transmyometrial ET is an attractive alternative to difficult transcervical ET but is not free of complications.

Ovarian hyperstimulation syndrome and benign intracranial hypertension in pregnancy after in-vitro fertilization and embryo transfer: case report

Ovarian hyperstimulation syndrome (OHSS) is a dangerous and sometimes life-threatening complication of ovulation induction with exogenous gonadotrophins. While many complications of severe OHSS are recognized we have only identified one review detailing neurological problems. This report concerns a 32-year-old patient with bilateral tubal blockage who achieved her first pregnancy following in-vitro fertilization (IVF) and embryo transfer. Shortly after embryo transfer she developed clinical signs of moderate OHSS with symptoms which were later diagnosed as benign intracranial hypertension (BIH). The BIH was treated effectively using repeated lumbar puncture and diuretics. Spontaneous labour and delivery occurred at 40 weeks' gestation. There was no neurological sequel and no recurrence of the BIH 2 years after the pregnancy. The possible link between OHSS and BIH is discussed as well as the risks of further pregnancy.

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.

90 years of Buerger's disease--what has changed?

Thromboangiitis obliterans or Winiwarter-Buerger's disease is a primary systemic vasculitis of an unknown etiology, which affects medium-sized arteries and veins mainly in the lower and upper extremities, causing multiple segmental arterial occlusions especially in young male smokers. The aim of our study is to compare the knowledge on the etiology, epidemiology, clinical presentation, diagnostic and therapeutic possibilities in the time of Leo Buerger (90 years ago) and now. Between 1994 and 1998, 26 patients (19 men and 7 women) were investigated with clinical suspicion for Winiwarter-Buerger's disease. Laboratory and arteriographic investigation revealed typical signs for this disease in 22 of them. To the most common clinical signs or symptoms belong smoking and the onset of the disease before the age of 50 years (in 95.5%), intermittent claudication (in 72.7%), rest pain and ischaemic ulcers or gangrenes in the fingers (in 68.2%). In slightly more than half of the patients migrating superficial thrombophlebitis was present and similarly in one half of the patients Raynaud's phenomenon was found. In conclusion--What has changed from the times of Leo Buerger? 1. Prevalence of TAO increased in women. 2. Older patients (more than 40 years old) are being diagnosed. 3. Upperextremity involvement is more frequently present. 4. Diagnosis of TAO is being more proper, especially due to up-to-date diagnostic methods, like digital subtraction angiography. 5. The treatment is more effective, amputation number is decreased. And what has not changed? Similarly like Leo Buerger we do not known the precise etiology of the disease. Ceasation of smoking has still the most important therapeutic procedure. The clinical course of the disease is individual and in spite of the treatment is the clinical course unpredictable. (Tab. 5, Ref. 47.)

A prospective clinical trial investigating the efficacy of a method of preparing subpopulations of antibody-free spermatozoa from the ejaculates of antibody-positive patients

Couples undergoing in vitro fertilization treatment (IVF) were invited to take part in a controlled prospective clinical trial. The aim was to determine the effect on the fertilization rate of a technique devised to obtain an antibody-free preparation of spermatozoa from an antibody-positive ejaculate. Oocytes collected during IVF were allocated into one of two groups, ensuring that quality and maturity were comparable in each. One group, the control, was inseminated with Percoll-processed spermatozoa. The experimental group was inseminated with identical numbers of Percoll-processed spermatozoa which had been treated to obtain an antibody-free preparation. The treatment was found to have no beneficial effect on the fertilization rate at IVF. Laboratory studies were also performed on the ejaculates of antibody-positive volunteers to determine whether this treatment led to any effects, whether beneficial or detrimental, on sperm function. Membrane integrity was found to be unaffected, as was the percentage of spermatozoa undergoing the spontaneous acrosome reaction following overnight incubation. The percentage of spermatozoa undergoing the ionophore-induced acrosome reaction following treatment, however, was higher than that of the controls. The results of sperm-zona pellucida binding studies were equivocal. The findings indicated that the treatment procedure could not be justified for use in IVF, but may be beneficial for intrauterine insemination.

Uterine junctional zone contractions during assisted reproduction cycles

This study was designed to assess junctional zone contractions (JZ) during cycles of in-vitro fertilization (IVF) and embryo transfer in oocyte donors exposed to a long protocol regime for ovarian stimulation. Real-time transvaginal ultrasound and advanced audio-visual and computer technology were used to evaluate the contraction pattern, frequency and velocity. At the time of down-regulation JZ contractions were not observed. After 7 days of superovulation all patients displayed cervico-fundal, fundo-cervical and random contractions. Cervico-fundal waves dominated the picture at the time of human chorionic gonadotrophin injection. However, the activity was strongest on the day of oocyte retrieval. At that time the percentage of opposing waves increased and fundo-cervical waves disappeared. The highest wave frequency and velocity (4.29+/-0.68 waves/min and 2.73+/-0.54 mm/s respectively) were observed at the time of oocyte retrieval. All patients had some JZ activity on days 2, 3 and 4 after oocyte retrieval but regular wave-like contractility gradually decreased and only single random movements were seen on day 4 after oocyte retrieval. In conclusion, JZ activity throughout the IVF cycle is more exaggerated when compared to the results reported from observations of the natural cycle but follows a similar pattern. This fact can probably be explained by the vastly different hormone levels. Higher JZ activity and correspondingly increased mobility of the endometrium may impair its receptivity and affect implantation.

Embryo transfer--can we learn anything new from the observation of junctional zone contractions?

To assess whether embryo transfer can alter junctional zone contractility, we studied the effect of easy and difficult mock transfers in 14 oocyte donors during in-vitro fertilization (IVF) cycles. An Echovist bolus (30 microl) was used to represent embryos and transfer medium. An 'easy' transfer was judged to be an atraumatic insertion of the catheter without touching the uterine fundus. A 'difficult' embryo transfer was mimicked by deliberately touching the uterine fundus twice with the soft end of the cannula. Transvaginal scan images were recorded, digitized and converted into five times normal speed to allow us to evaluate junctional zone contractility. Easy mock embryo transfers did not change endometrial mechanical activity. Echovist remained in the upper part of the uterine cavity and was not dispersed after 45 min. A difficult procedure generated strong random waves in the fundal area and waves from fundus to cervix which relocated the Echovist in six out of seven cases. We observed movements of the transfer bolus from the upper part of the uterus towards the cervix (four cases) and into Fallopian tubes (two patients). Our study confirms that the mechanical activity of the uterus is capable of relocating intrauterine embryos and that this activity depends on physical stimulation. Junctional zone contractions can be implicated in cases of IVF/embryo transfer failure or ectopic gestation.

Assessment of uterine receptivity prior to embryo transfer: a review of currently available imaging modalities

This article aims to review in detail the current literature concerning the efficacy of, and problems associated with, the use of ultra-sonography and magnetic resonance imaging in predicting uterine receptivity and hence the outcome of assisted conception. Although the quality of the embryo and transportation to the uterine cavity are obvious requirements for in-vitro fertilization/embryo transfer treatment, attention has recently centred on the receptivity of the endometrium to the growing blastula. High resolution ultrasonography is currently the imaging modality of choice, but measurement of endometrial thickness is only associated with successful treatment outcome if ovarian stimulation includes clomiphene citrate. However, the ultrasonographic texture of the endometrium may have a greater prognostic value for implantation. The current literature is relatively unanimous that a 'triple' layered appearance of the uterus is associated with a 23-42% pregnancy rate and that endometrium is unreceptive when iso- or hyperechoic compared with myometrium. In an attempt to improve prediction rates, new techniques including magnetic resonance (MR) imaging are being used to determine uterine receptivity. Early results from MR imaging suggest that in patients treated with standard regimen of GnRHa, followed by human gonadotrophin (HMG), neither the endometrial thickness nor the volume is related to outcome. However, the relative signal intensity of the uterine layers provides good discrimination prior to embryo transfer, between pregnant and non-pregnant groups.