Dating sonographic endometrial images in the normal ovulatory cycle

Endometrial pattern, but not endometrial thickness, affects implantation rates in euploid embryo transfers

OBJECTIVE

To evaluate the relationship of endometrial thickness (EnT) and endometrial pattern (EnP) to euploid embryo transfer (ET) outcomes.

DESIGN

Retrospective cohort.

SETTING

Private academic clinic.

PATIENT(S)

Patients (n = 277; age 36.1 ± 4.0 years) whose embryos (n = 476) underwent aneuploidy screening with fresh (n = 176) or frozen (n = 180) ET from July 2010 to March 2014.

INTERVENTION(S)

The EnT and EnP were measured on trigger day and at ET. Patients were stratified by age and cycle type (fresh or frozen). Cycle data were combined at trigger day, but separated at ET day.

MAIN OUTCOME MEASURE(S)

Outcome measures were implantation rate, pregnancy rate, and clinical pregnancy rate. Analysis was conducted using χ(2) analysis and Fisher's exact test.

RESULT(S)

A total of 234 gestational sacs, 251 pregnancies, and 202 clinical pregnancies resulted from 356 cycles. The EnT (9.6 ± 1.8 mm; range: 5-15 mm) at trigger day (n = 241 cycles), as a continuous or categorical variable (≤8 vs. >8 mm), was not associated with implantation rate, pregnancy rate, or clinical pregnancy rate. The EnT at day of fresh ET (9.7 ± 2.2 mm; range: 4.4-17.9 mm) (n = 176 cycles) or frozen ET (9.1 ± 2.1 mm; range: 4.2-17.7 mm) (n = 180 cycles) was not associated with implantation rate, pregnancy rate, or clinical pregnancy rate. Type 3 EnP at trigger day was associated with increased serum progesterone at trigger and a decreased implantation rate, compared with type 2 EnP. The EnP at fresh or frozen ET was not associated with implantation rate, pregnancy rate, or clinical pregnancy rate.

CONCLUSION(S)

Within the study population, EnT was not significantly associated with clinical outcomes of euploid ETs. A type 3 EnP at trigger day suggests a prematurely closed window of implantation.

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

OBJECTIVE

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

DESIGN

Observational study.

SETTING

Outpatient infertility clinic of a University Medical Center.

PATIENT(S)

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

INTERVENTION(S)

Midluteal phase sonographic endometrial evaluation.

MAIN OUTCOME MEASURE(S)

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

RESULT(S)

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

CONCLUSION(S)

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

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.

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.

Computerized assessment of endometrial echogenicity: clues to the endometrial effects of premature progesterone elevation

OBJECTIVE

To determine whether premature progesterone elevation affects the timing of hyperechogenic transformation of the endometrium during the early luteal phase of controlled ovarian hyperstimulation (COH) cycles.

DESIGN

Prospective analysis.

SETTING

Assisted Reproduction Unit, Hôpital Antoine Béclère, Clamart, France.

PATIENT(S)

Fifty-nine women undergoing 59 IVF-ET cycles.

INTERVENTION(S)

Patients underwent COH with a GnRH agonist and hMG. Endometrial echogenicity was assessed on the days of hCG administration, oocyte retrieval, and ET. Results are expressed as the extent of submyometrial hyperechogenic area in relation to the total endometrial surface as determined by a computer-assisted analysis system. Patients were sorted according to whether their plasma progesterone level exceeded 0.9 ng/mL (n = 26) or not (n = 33) on the day of hCG administration.

MAIN OUTCOME MEASURE(S)

Endometrial echogenicity.

RESULT(S)

On the day of hCG administration, the degree of endometrial echogenicity was similar in both groups (41% vs. 40%), but after hCG administration, it increased significantly faster in the high progesterone group than in the low progesterone group (70% vs. 63% at oocyte retrieval and 90% vs. 79% at ET, respectively).

CONCLUSION(S)

End-follicular phase elevation in plasma progesterone (>0.9 ng/mL on the day of hCG administration) was associated with a faster increase in endometrial echogenicity during the early luteal phase of COH cycles. This observation is consistent with the hypothesis that premature progesterone elevation hastens the secretory transformation of the endometrium.

Lack of correlation between ultrasonography and histologic staging of the endometrium in in vitro fertilization (IVF) patients

In 53 patients of an in vitro fertilization (IVF) program with unsuccessful fertilization of oocytes, an endometrial biopsy was carried out on the day of the intended embryo transfer. The results were compared with the thickness (assessed on the very same day by means of ultrasonography) and the echo pattern of the endometrium, which was classified into four grades (A to D). We found grade A in 16 cases (30%), grade B in 22 cases (41.5%) and grade C in 15 cases (28.5%); no endometrium was assessed as grade D. The distribution of histologic findings was not significantly skewed within the respective grading categories (only 37.5% of grade A endometria, 63.5% of grade B endometria and 66.5% of grade C endometria were in phase with the menses). The in-phase and out-of-phase endometria did not display significant differences in endometrial thickness (8.8 +/- 0.29 mm vs. 9.13 +/- 0.4mm). Neither the sonographically measured endometrial thickness nor the echo pattern correlated with the histologic findings, suggesting that ultrasonography is inadequate for drawing reliable conclusions about endometrial receptivity in an IVF program.

Temporal relationship between Uniplant insertion and changes in cervical mucus

This study was undertaken to determine the time required by a single implant containing nomegestrol acetate to affect cervical mucus production and sperm penetration in women. All subjects were investigated and, if necessary, treated for any kind of cervicitis or vaginitis prior to starting cervical mucus study. The subjects had not used hormonal contraception for at least three months prior to investigation. They were counseled to use condoms during this study and also to refrain from intercourse during the period of cervical mucus sampling. Follicular development and endometrial thickness were analyzed by transvaginal sonography. Cervical mucus examination, sperm penetration test, and transvaginal sonography were performed during the control cycle and during the first cycle of Uniplant use. Blood samples were taken for the measurement of estradiol, LH, and progesterone. Cervical mucus and sperm penetration tests were evaluated according to the World Health Organization (WHO) criteria. In the treated cycle, when cervical mucus reached a score of 8-10, Uniplant was inserted, independent of the day of the cycle. Cervical mucus was then collected at 0, 4, 8, 12, 24, 48, and 96 h later until a marked change in volume, consistency, ferning spinnbarkheit, and cellularity was observed. All samples were also used for sperm penetration test. Preovulatory estradiol and LH peak decreased significantly compared to pre-implant insertion. Progesterone levels were within the normal limit. Cervical mucus and sperm penetration tests were not affected by Uniplant in the first 12 h. Twenty-four hours after Uniplant insertion, cervical mucus and sperm penetration tests were affected in 70.6% of the women. Forty-eight hours after implant insertion, the women were affected. Follicular rupture occurred in the majority of the women 48 h after implant insertion. Based on these results, it is possible to conclude that Uniplant can affect estradiol and LH preovulatory peaks and disrupt the process of cervical mucus production and sperm penetration, but it was unable to prevent ovulation when inserted in the preovulatory phase.

Effects of a single contraceptive Silastic implant containing nomegestrol acetate on ovarian function and cervical mucus production during 2 years

OBJECTIVE

To study the mechanism of action of Uniplant (South to South Corporation in Reproductive Health, Salvador, Brazil), a single Silastic capsule containing nomegestrol acetate (Lutenyl, Theramex, France) in women during 2 years.

DESIGN

Comparison between the hormonal levels, follicular development, cervical mucus (CM) production, and endometrial thickness in the menstrual cycle before implant insertion and at 1, 6, 12, 18, and 24 months after implant insertion.

PARTICIPANTS

A total of 15 women of reproductive age were enrolled for the 1st year of use. Twelve of these women continued for a 2nd year of Uniplant use.

MAIN OUTCOME MEASURES

Hormonal plasma levels were measured in control cycles and at 1, 6, 12, 18, and 24 months of Uniplant use. Cervical mucus, follicular development, and endometrial thickness also were evaluated.

RESULTS

In this study, Uniplant blocks ovulation in 86 percent of cycles studied. Disturbances in follicular growth were observed also. Cervical mucus was scanty and viscous in all women during this study. Endometrial thickness was <8 mm in all cycles studied.

CONCLUSION

This study shows that Uniplant is a long-acting contraceptive that probably acts at the hypothalamic-pituitary levels, on the ovary, on CM production, and on the endometrium. These properties suggest the use of Uniplant as a contraceptive agent, especially if one considers the lack of androgenic and metabolic effects and the maintenance of periodic bleeding similar to menstruation.

The uterus and endometrium

Transvaginal sonography is useful for the identification of physiologic and pathologic changes within the myometrium and endometrium. Endometrial ultrasonography is simple to learn because of the reliable identification of the uterus. It is useful for monitoring fertility treatment, evaluation of abnormal bleeding and monitoring patients in the menopause.

Immunohistochemical markers of uterine receptivity in the human endometrium

The factors responsible for the initial interaction between maternal and fetal epithelium leading to the establishment of pregnancy remain poorly understood. Temporal and spatial expression of specific endometrial peptides in response to ovarian steroids is thought to contribute to the development of a period of uterine receptivity, whereby the endometrium becomes hospitable to the implanting blastocyst. The failure to establish receptivity may account for a significant percentage of the cases of infertility in the female, especially affecting women with luteal phase deficiency, leiomyomata uteri, endometriosis, habitual abortion, and unexplained infertility. In addition, despite increasing global experience with advanced reproductive technologies, the majority of In Vitro Fertilization (IVF) attempts remain unsuccessful, most likely on the basis of implantation failure. In this article, we review the concepts involved in the study of uterine receptivity in the human, highlight potential immunohistochemical (IHC) markers that have recently been discovered, and discuss how IHC assessment of the endometrium is a potentially valuable method for the evaluation of the receptive endometrial state. Using this approach we have examined several new potential markers of uterine receptivity. Endometrial progesterone receptors and one of the integrin cell adhesion molecules appear to undergo changes in expression around the time of implantation, and may be sensitive indicators of the receptive state. Further, these markers are delayed in women with infertility and luteal phase deficiency. These studies illustrate the utility of IHC diagnosis for the evaluation of endometrial function.