Ultrasound imaging--2000: assessment of utero-ovarian blood flow with transvaginal color Doppler sonography; potential clinical applications in infertility

Going, gonad, gone. Gender inequalities in the management of gonadal torsion: a cohort study

Gonadal torsion (when the gonad twists on its ligamentous supports) is a surgical emergency in both men and women. Prompt management is essential to preserve gonadal function. Our aim was to compare the timeliness with which men and women who underwent surgery for suspected gonadal torsion are managed. All adult patients who underwent surgery for suspected gonadal torsion between 1/4/16 and 31/3/18 were reviewed and the following times recorded: symptom onset; hospital presentation; gynaecological/surgical review; decision for theatre; and knife-to-skin (KTS). The surgical procedure(s) and intra-operative findings were also documented. In total, 31 women (mean age 29.4 ± 7.1yrs) and 49 men (mean age 23.2 ± 7.0yrs) were identified. Women waited significantly longer than men at every stage (p < 0.01). Time intervals between hospital presentation and review, review and decision for theatre, and decision and KTS were 1.6 (1.2-2.6 hrs), 0.3 (0.0-0.9 hrs) and 1.7 (1.5-2.5 hrs) for men and 4.3 (3.1-15.3 hrs), 10.3 hrs (2.4-20.7 hrs) and 4.7 (2.3-9.3 hrs) for women, respectively. Torsion was confirmed in 20 (64.5%) women and 25 (51.0%) men. Intraoperatively, 13(65%) ovaries were reportedly necrotic compared to only 6 (24%) testes (p = 0.0076). All necrotic gonads were removed despite conservative surgery being recommended practice during the study period. Women with suspected gonadal torsion received suboptimal care compared to their male counterparts, which has potentially catastrophic consequences for the subsequent fertility of this predominantly young population.

Relationship of vascular perfusion of the wall of the preovulatory follicle to in vitro fertilisation and embryo development in heifers

The effect of the extent of vascular perfusion of the wall of the preovulatory follicle on in vitro cleavage rate of the recovered oocyte and embryo development to >8 cells was studied in 52 heifers. Heifers received a luteolytic dose of prostaglandin F2α (PGF2α) when the largest follicle was ≥11 mm. An ovulation-inducing injection of GnRH was given 36 h later (hour 0), and collection of follicular fluid and the oocyte was done at hour 26. Vascular perfusion of the follicular wall was assessed by colour Doppler ultrasonography at hours 0 and 26. Each of the recovered oocytes (41/52; 79%) was mature (extruded polar body). Cleavage and embryo development were assessed at 48 h and 120 h respectively, after in vitro fertilisation (IVF). The percentage of cleaved oocytes and >8 cell embryos was 80% (31/39) and 55% (17/31) respectively. Vascular perfusion of the follicular wall was greater (lower pulsatility index; P<0.001) for follicles that produced cleaved versus non-cleaved oocytes and greater (P<0.04) for follicles that produced >8 cell versus ≤8 cell embryos. Percentage of follicular wall with Doppler signals of blood flow was greater (P<0.001) for >8 cell versus ≤8 cell embryos. Follicular-fluid concentration of free IGF1 was lower for cleaved oocytes (P<0.001) and >8 cell embryos (P<0.05), and oestradiol was lower (P<0.05) for >8 cell embryos. Results supported the hypothesis that greater vascular perfusion of the wall of the preovulatory follicle was positively associated with IVF and embryo development.

Prevention of recurrent adnexal torsion

OBJECTIVE

To report a case of adnexal torsion after in vitro fertilization (IVF) with two subsequent episodes of contralateral adnexal torsion and a novel approach for reducing the risk of recurrence.

DESIGN

Case report.

SETTING

University-based IVF program.

PATIENT(S)

A 32-year-old woman who conceived with IVF and experienced sequential bilateral adnexal torsion. Left adnexal torsion was diagnosed with laparoscopic detorsion performed 2 days after embryo transfer. At 7 weeks' gestation, right adnexal torsion occurred and was managed with laparoscopic detorsion. Subsequently, right adnexal torsion recurred at 10 weeks' gestation, and laparoscopic detorsion with shortening of the uteroovarian ligament was performed.

INTERVENTION(S)

Gonadotropin ovulation induction, IVF, and laparoscopic detorsion of both right and left adnexa with shortening of the right uteroovarian ligament.

MAIN OUTCOME MEASURE(S)

Preservation of adnexa after torsion and successful pregnancy.

RESULT(S)

Successful pregnancy and birth; resolution of torsion, prevention of recurrence with viable bilateral adnexa after detorsion and shortening of the utero-ovarian ligament with novel use of laparoscopic Endoloop.

CONCLUSION(S)

This is a unique case of multiple episodes of adnexal torsion following IVF with a new form of treatment using the laparoscopic Endoloop. Management of the infertility patient should be conservative and warrants ovarian preservation whenever possible. Multiple sequential episodes of adnexal torsion during a single pregnancy are a rare complication of IVF. Shortening of the utero-ovarian ligament is an alternative to oophoropexy to prevent recurrence.

Successful pregnancy complicated by early and late adnexal torsion after in vitro fertilization

OBJECTIVE

To report a case of unilateral adnexal torsion and subsequent contralateral adnexal torsion after in vitro fertilization.

DESIGN

Case report and literature review.

SETTING

Academic fertility center; university hospital.

PATIENT(S)

A 28-year-old woman with tubal factor infertility conceived with IVF and experienced mild-to-moderate ovarian hyperstimulation syndrome. Right adnexal torsion occurred at 7 weeks of gestation, and laparoscopic detorsion was performed. Subsequent contralateral adnexal torsion occurred at 19 weeks and was managed with laparotomy and salpingo-oophorectomy.

INTERVENTION(S)

Laparoscopic right adnexal detorsion and laparotomy with salpingo-oophorectomy for left adnexal torsion.

MAIN OUTCOME MEASURE(S)

Preservation of torsed adnexa and successful pregnancy.

RESULT(S)

Successful pregnancy and birth complicated by two episodes of adnexal torsion after IVF, and viable right adnexa after laparoscopic detorsion.

CONCLUSION(S)

Subsequent contralateral adnexal torsion is a rare complication of IVF and can occur in the second trimester. Data support preservation of the torsed adnexa despite the ovary's appearance.

Follicular vascularity is not predictive of pregnancy outcome in mild controlled ovarian stimulation and IUI cycles

BACKGROUND

Although follicular vascularity has been shown to be a good indicator of oocyte quality in IVF, scant evidence is currently available on the predictive value of this variable in terms of pregnancy rate during controlled ovarian stimulation (COS) and intrauterine insemination (IUI) cycles.

METHODS

Three-hundred and eighteen patients who had received mild COS underwent transvaginal ultrasound scan before performing the IUI. Using power Doppler imaging, vascularity of follicles with a mean diameter > or =16 mm was graded into a three grades according to the circumference of the follicle in which flow was identified. When more than one follicle was observed, grading was performed for all of them, and the highest vascularity grade was recorded.

RESULTS

Clinical pregnancy rate (number/total) in the low-, medium- and high-grade vascularity groups was 14.1% (14/99), 10.0% (10/100) and 11.8% (14/119), respectively (P = 0.66). Similar results were observed when only monofollicular cycles were considered.

CONCLUSIONS

Follicular vascularity does not predict the chance of pregnancy in women undergoing mild COS and IUI cycles.

Assessment of Uterine Wall Thickness and Position of the Vascular Plexus in the Deep Myometrium: Implications for the Measurement of Depth of Myometrial Invasion of Endometrial Carcinomas

Accurate discrimination between FIGO stages IB and IC endometrial carcinomas has important prognostic and therapeutic implications, but depth of invasion as a percentage of myometrial thickness can be difficult to ascertain. In such cases, pathologists often presume that infiltration that reaches the arcuate vascular plexus (AVP) in the myometrium indicates >50% myoinvasion. The further assumption is sometimes made that the anterior and posterior uterine walls are of the same thickness. To our knowledge, neither supposition is based on published data. We performed a prospective study of myometrial thickness and the position of the AVP in 50 normal uteruses from patients aged 27 to 84 years. Myometrial thickness varied inversely with age (p < 0.0001); however, anterior and posterior wall myometrial thickness did not differ significantly in the cohort as a whole (p = 0.059) and in individual cases was highly correlated (p < 0.0001). The position of the AVP was variable. On average, its inner limit was situated at a depth of 47.3% of the thickness of the myometrium in both uterine walls, but the position varied between individuals and sometimes differed considerably between the anterior and posterior walls of the same uterus. The position of the AVP did not differ significantly with age. We conclude that carcinomatous infiltration well into or through the AVP usually signifies >50% myoinvasion; however, if infiltration barely extends into the AVP, the depth of invasion should be calculated with reference to the thickness of the myometrium in the opposite uterine wall.

Endometrial and subendometrial perfusion are impaired in women with unexplained subfertility

BACKGROUND

We used three-dimensional power Doppler angiography (3D-PDA) to examine the periodic changes in endometrial development and subendometrial vascularity during the normal menstrual cycle in 29 women with unexplained subfertility and 19 controls.

METHODS

3D-PDA was performed on alternate days from day 3 of the cycle until ovulation and then every 4 days until menses. VOCAL (Virtual Organ Computer-aided AnaLysis) and shell-imaging were used to define and to quantify the power Doppler signal within the endometrial and subendometrial regions producing indices of their relative vascularity.

RESULTS

Women with unexplained subfertility demonstrated significant changes with time (P<0.001) in the indices of vascularity within the endometrium and subendometrium during the menstrual cycle characterized by a pre-ovulatory peak and post-ovulatory fall. These changes mirrored those observed in the control group but were significantly reduced in the endometrium and subendometrium during the mid-late follicular phase and early luteal phase. There were no differences in endometrial thickness or volume between the groups or in the plasma concentrations of estradiol or progesterone.

CONCLUSIONS

Endometrial and subendometrial vascularity are significantly reduced in women with unexplained subfertility during the mid-late follicular phase irrespective of estradiol or progesterone concentrations and endometrial morphometry.

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

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

Uterine restoration by radiation sequelae regression with combined pentoxifylline-tocopherol: a phase II study

OBJECTIVE

To determine whether combined pentoxifylline (PTX) and tocopherol (vitamin E) treatment can improve uterine radiation-induced sequelae, resulting in an improved embryo implantation rate.

DESIGN

Retrospective phase II clinical trial.

SETTING

Volunteers in an oocyte donation program in a public hospital.

PATIENT(S)

Six women aged 31 +/- 4 years, who were irradiated 25 years previously for childhood cancer with 20 to 40 Gy including the pelvic area.

INTERVENTION(S)

Four women had taken hormone replacement therapy for primary amenorrhea, and two had retained their natural cycle. Treatment consisted of at least 12 months of pentoxifylline at 800 mg/day combined with 1000 IU/day of tocopherol.

MAIN OUTCOME MEASURE(S)

Endometrial thickness, uterine volume, and uterine artery blood flow were assessed by ultrasonography before and after pentoxifylline-tocopherol treatment, under usual estrogen-progesterone (OP) administration.

RESULT(S)

This treatment was well tolerated. All six patients improved significantly in endometrial thickness (6.2 +/- 0.6 vs. 3.2 +/- 1.1 mm), myometrial dimensions (44 [+/- 5] x 30 [+/- 3] x 20 [+/- 2] vs. 30 [+/- 7] x 22 [+/- 3] x 16 [+/- 2] mm), and diastolic uterine artery flow.

CONCLUSION(S)

In young women who want to bear children, the combination of pentoxifylline and vitamin E can reduce fibroatrophic uterine lesions after childhood irradiation.

Reduction of ovarian torsion 1 week after embryo transfer in a patient with bilateral hyperstimulated ovaries

OBJECTIVE

To report a rare case of unilateral ovarian torsion 1 week after embryo transfer in a patient with bilateral hyperstimulated ovaries.

DESIGN

Case report and literature review.

SETTING

Reproductive Endocrine division in a university teaching hospital.

PATIENT(S)

Infertility patients undergoing IVF-ET.

INTERVENTION(S)

Laparoscopic reduction of adnexa 1 week after ET.

MAIN OUTCOME MEASURE(S)

Successful preservation of the affected adnexa.

RESULT(S)

Delivery of 3.324 kg male infant with preservation of the affected ovary.

CONCLUSION(S)

Untwisting of the affected ovary at laparoscopy without aspiration reduction of cystic masses is appropriate. The outcome of the pregnancy (even very early) in patients with torsion of the adnexa may be favorable after a laparoscopic unwinding of the affected adnexa.

Transrectal Doppler sonography of uterine blood flow

Transrectal Doppler ultrasound was used for the noninvasive investigation of uterine blood flow in cows. Both the left and right Aa. uterinae were scanned to obtain blood flow velocity waveforms over 2 consecutive estrous cycles. Blood flow was reflected by the resistance index (RI) and the time-averaged maximum velocity (TAMV). Intra-observer reproducibility of Doppler measurements was evaluated. The intra-class correlation coefficient (Intra-CC) was 0.97 for the RI and 0.95 for TAMV. While RI values did not differ between the left and right A. uterina (P > 0.05), differences in TAMV occurred between both vessels in 2 cows. These differences were not related to the ovary bearing the dominant follicle or to the corpus luteum (P < 0.001). As in all cows, changes of RI and TAMV values between the left and right artery during the estrous cycle were correlated (correlation coefficient r > 0.72; P < 0.0001); the mean values of both sides were used for subsequent analyses. Variance component estimates for the effect of cow on RI and TAMV were 8 and 13% and for the influence of day of estrous cycle they were 70 and 47%, respectively (P <0.0001). Between estrous cycles no significant differences could be measured within cows (P > 0.05). The highest RI and lowest TAMV values occurred on Day 0 (= day of ovulation) and Day 1, while the lowest RI and highest TAMV values were measured between Days -3 and -1 of the estrous cycle, respectively. There was a positive correlation between TAMV and estrogen concentrations and a negative correlation between RI and plasma estrogen levels. Plasma progesterone levels and TAMV were negatively correlated, but no correlation could be measured (P > 0.05) between RI values and plasma progesterone concentrations. While there were no differences in plasma concentrations of estrogens and progesterone between estrous cycles within cows, the levels of these hormones differed between cows. The results show that transrectal Doppler sonography is a useful, noninvasive method for examining uterine blood flows in cows. If there is an influence of uterine perfusion on fertility in cows its role needs further investigation.

Fetal middle-cerebral and umbilical artery flow assessments after glucose challenge test

OBJECTIVE

To determine whether a change occurs in fetal middle-cerebral and umbilical artery flow after glucose challenge testing.

METHOD

Fetal middle-cerebral and umbilical artery flow was assessed by Color Dopppler technology in 21 pregnant patients before and after the 50-g glucose challenge test. The resistance index (IR) was evaluated separately for each vessel. Statistical significance was determined by Chi-square test and repeated measurement analysis with two co-variates.

RESULTS

After glucose ingestion the RI was significantly decreased in the middle-cerebral artery, but not in the umbilical artery. A significant increase in RI was recorded in the umbilical artery when maternal plasma glucose level exceeded 102 mg%.

CONCLUSION

Maternal ingestion of glucose significantly alters blood flow velocimetry in the fetal middle-cerebral and umbilical arteries. These changes may lead to the misinterpretation of normal results. It is therefore recommended that sonographic flow velocimetry assessment not be performed early after concentrated glucose ingestion.

Age does not affect uterine resistance to vascular flow in patients undergoing oocyte donation

OBJECTIVE

To determine whether uterine vasculature is affected by age using oocyte donation as an in vivo model.

DESIGN

Prospective longitudinal study in which recipients were grouped according to age. They underwent a successful oocyte donation cycle, and single pregnancies were followed during the first trimester by color Doppler ultrasound in uterine arteries.

SETTING

Oocyte donation and IVF program at the Instituto Valenciano de Infertilidad.

INTERVENTIONS

Serum E2, P, and hCG levels in single ovum donation pregnancies; pulsatility and resistance indexes in uterine arteries during initial pregnancy.

RESULTS

Similar serum levels of E2, P, and hCG in both groups of patients were observed. There was no difference between groups regarding the flow indexes analyzed.

CONCLUSIONS

The increased incidence of early pregnancy losses observed in patients > 40 years cannot be attributed to defective response of uterine vasculature to exogenous hormone replacement. Thus, uterine aging does not appear to be a factor influencing the poor reproductive performance of women with advancing age.

Is median thoracic artery a target organ artery for estradiol and progesterone? A comparison with uterine artery

PURPOSE

The aim of this study was to show the parallel evolution of the pulsatility index of the uterine artery and the one of the median thoracic artery.

STUDY DESIGN

The study involved seven volunteer women, below 38, suffering from premature ovarian failure, who received E2 and progesterone replacement therapy. Plasma levels of E2, progesterone, follicle stimulating hormone and luteinizing hormone were measured and PI were studied and compared before treatment and on Days 13, 27 and 41.

RESULTS

Before treatment, a high-resistance vascular for both arteries is uniformly found. The curves show with the increasing of the E2 plasma levels, a decrease in the PI of UA and MTA with a fall at Day 13. We compared the mean values in MTA and UA PI. No statistical difference between the three mean values in PI obtained at Day -1, Day 13 and Day 41 was demonstrated.

CONCLUSION

The results suggest that median thoracic artery is a target organ artery. Such as the UA, the MTA vascular resistance is according to the variations of plasma levels of E2. In consideration of it rectilinear and superficial type, this led us to study this artery when we use different sorts of replacement therapy, and particularly in the oocyte donation program.

Endometrial blood flow response to hormone replacement therapy in women with premature ovarian failure: a transvaginal Doppler study

OBJECTIVE

To evaluate the endometrial blood flow response to hormone replacement therapy (HRT) in women with premature ovarian failure who plan to enter an oocyte donation program.

DESIGN

Transvaginal color Doppler ultrasound examinations were performed in women with ovarian failure before and during a cycle of standard HRT and in those with normal menstrual cycles. Blood flow response was assessed by visualization of arterial wave forms in the endometrial region. The transvaginal color flow mapping system was used. Resistance indexes were calculated for analysis and correlated with plasma E2 and P concentrations.

PATIENTS

Eighteen women with ovarian failure (study group), and 12 volunteers with normal ovarian cycles (control group).

RESULTS

Data for resistance indexes were divided into five phases according to the day of hormonal cycle: 0, pretreatment phase; I, early follicular phase (days 5 to 7); II, late follicular phase (days 11 to 13); III, early luteal phase (days 17 to 21); and IV, late luteal phase (days 23 to 25). All women with ovarian failure demonstrated continuous forward end-diastolic flow velocities at phase I, whereas none showed this pattern during the pretreatment period (phase 0). Women with ovarian failure in the early follicular phase had a significantly higher resistance index (0.85 +/- 0.1; mean +/- SD) than that in the late follicular phase (0.57 +/- 0.1), and the resistance index in the early luteal phase (0.67 +/- 0.1) was significantly higher than that of the late follicular phase. There was no difference in the resistance index between early and late luteal phases. A similar pattern of lower resistance index around midcycle was observed in the control group. However, a comparison of the resistance indexes between ovarian failure and control patients revealed a significant difference between values in the early follicular phase only (0.85 +/- 0.1 versus 0.68 +/- 0.1). In the late follicular phase and during the entire luteal phase, the mean resistance index did not differ between the study and control groups.

CONCLUSIONS

The observed data suggest that standard HRT in women with premature ovarian failure enables restoration of endometrial blood flow to normal. This may imply uterine receptivity for oocyte donation.

Color Doppler imaging of the ocular vessels

BACKGROUND

Color Doppler imaging allows for simultaneous two-dimensional anatomical imaging and Doppler evaluation of blood flow velocity.

METHODS

We examined 40 normal eyes (17 males and 23 females, aged 16 to 57 years) with this technique. The color Doppler unit used in this study had a 5.0-MHz PLF-503 ST phased-array scanning head. Each vessel examination was repeated 10 times during a single session.

RESULTS

The following peak flow velocities were found: central retinal artery, 12.5 +/- 2.4 cm/s; central retinal vein, 4.4 +/- 0.49 cm/s; posterior ciliary arteries, 14.4 +/- 2.6 cm/s; vorticose veins, 5.5 +/- 1.0 cm/s; ophthamic artery, 36.9 +/- 7.0 cm/s. Ophthalmic artery systolic and end-diastolic velocities declined as a function of age; however, these changes were not significant (systolic: r = -0.24; diastolic, r = -0.22).

CONCLUSION

This noninvasive technique allows quantitative assessment of blood flow velocity in these vessels.

Sonographic uterine predictors of pregnancy in women undergoing ovulation induction for assisted reproductive treatments

OBJECTIVE

To determine preovulatory uterine sonographic predictors of pregnancy in women undergoing ovulation induction for assisted reproductive treatments.

DESIGN

Prospective evaluation of uterine sonographic and vascular flow profiles in women stimulated with leuprolide acetate and hMG.

SETTING

Private fertility center and tertiary-care academic center.

PATIENTS

Ninety-six women underwent 102 cycles of ovulation induction for IVF (46), GIFT (20), and zygote intrafallopian transfer (36).

MAIN OUTCOME MEASURES

Endometrial texture, thickness, resistance index at the first branch of uterine artery, diastolic blood flow, and pregnancy outcome (no conception, spontaneous abortion, and delivery).

RESULTS

Triple-lined pattern was predominant in women who delivered liveborn infants (P < 0.005). Endometrial pattern and diastolic blood flow were the only predictive markers of term pregnancy (P < 0.001 and P < 0.05, respectively).

CONCLUSION

Preovulatory triple-lined sonographic endometrial texture and the presence of end diastole blood velocities at the first branch of uterine artery are the most important uterine predictors of conception.

Uterine and ovarian perfusion during the periovulatory period assessed by transvaginal color Doppler

OBJECTIVE

To measure the flow velocity of the uterine, radial, spiral, and ovarian arteries during the periovulatory period in spontaneous and induced ovarian cycles with confirmed ovulation.

DESIGN

Daily measurements during the periovulatory period in 78 patients attending an infertility clinic because of the male factor in infertility.

RESULTS

Uterine flow velocity in spontaneous cycles has a pulsatility index (PI) of 3.16 2 days before ovulation and starts to decrease the day before ovulation (PI = 2.22). In stimulated cycles these changes do not occur, and mean PI of 3.06 remains at that level during the periovulatory period. Clear flow velocity waveforms are obtained from the endometrium and myometrium around the time of ovulation. Data obtained from the radial arteries suggest better myometrial perfusion in patients with natural cycles. Spiral artery flow velocity in spontaneous cycles has a PI of 1.13 the day before ovulation and a nadir of 0.72 is reached the day after ovulation. On the contrary, the mean PI of the spiral artery blood flow in the group with ovulation induction rises during the day before ovulation (PI = 2.32) and reaches a nadir of 1.09 the day after ovulation.

CONCLUSIONS

These data suggest the presence of better uterine receptivity during the periovulatory phase of natural cycles compared with induced ovarian cycles. Endometrial perfusion presents accurate noninvasive assay of uterine receptivity that may be used to predict implantation success rate, to reveal unexplained infertility problems, and to select patients for correction of endometrial perfusion abnormalities by an appropriate treatment.

Assessment of ovarian and uterine blood flow by transvaginal color Doppler in ovarian-stimulated women: correlation with the number of follicles and steroid hormone levels

OBJECTIVE

To study the changes that occur in vascular resistance to flow in the utero-ovarian circulation and their correlation with the number of follicles and steroid hormone levels in patients undergoing ovarian stimulation with gonadotropin.

DESIGN

In a prospective study, the impedance to flow in the intraovarian and uterine vessels was measured by means of transvaginal color flow Doppler imaging throughout the cycle.

SETTING

University-based IVF program.

PATIENTS

Eleven infertile patients undergoing ovarian stimulation with gonadotropin in preparation for IVF and ET.

MAIN OUTCOME MEASURES

Intraovarian, uterine, and arcuate artery blood flow velocity waveforms, follicular growth, and serum E2 and P concentrations throughout the cycle.

RESULTS

Pulsatility index (PI) of the intraovarian blood vessels and uterine artery decreased gradually during the follicular and luteal phase. The PI of the arcuate artery did not change significantly. The PI of the intraovarian blood vessels correlated with the number of follicles (> 15 mm; day of hCG). Serum E2 concentrations but not P demonstrated negative linear correlation with the PI of the intraovarian vessels and uterine artery.

CONCLUSIONS

Induced cycles are associated with decreased impedance to blood flow in the utero-ovarian circulation. Intraovarian PI correlates negatively at each stage of the cycle with the eventual number of preovulatory follicles. Little or no changes are observed when the response to ovarian stimulation is poor.

Angiogenesis: a new diagnostic aspect of obstetric and gynecologic echography

An ultrasounds triplex system (pulsed Doppler, Color mode, B mode) has been employed to study ovarian and uterine circulatory changes in fertile, infertile and postmenopausal patients. PI and mean percentage variation of PI mean values have been used. No difference has been detected in uterine haemodynamics between fertile women and those infertile patients getting pregnant by IVF-ET procedure. Patients who did not obtain the pregnancy showed different uterine and endometrial Color Doppler patterns. Furthermore, a typical endometrial blood flow has been detected both in fertile patients and infertile patients who get pregnant. Color Doppler seems to be an useful tool in the monitoring of fibroids blood supply and the uterine blood supply, especially for the clinical monitoring of GnRH analogues therapies. The technique has been also employed for the study of ectopic pregnancy. The evaluation of both uterine and throphoblast haemodynamics has resulted in a good indicator of the pregnancy progression. Concerning the ovarian pathology the color Doppler evaluation has been useful to differentiate ovarian malignant cysts from inflammatory or disfunctional masses. Nevertheless, the most interesting results have been obtained from the study of endometrial and ovarian tumors. Indeed, in the most cases, a mass supply blood flow has been detected, although in some cases no angiogenetic color flow has been found. No difference has been found in uterine artery velocimetry between malign or benign pathologies. Furthermore, histological data supporting our findings are presented.

Fallopian tubes and ultrasonography: the Sion experience

OBJECTIVE

To compare the accuracy of three new ultrasonographic methods of detecting tubal patency and pathology with established methods like hysterosalpingography (HSG) and laparoscopy.

DESIGN

Sixty-seven cases were evaluated by performing the Sion test using endosonography to check for tubal patency. The Sion procedure includes filling up the pouch of Douglas with approximately 300 mL of sterile normal saline to elucidate not only the patency but visualize the motility, the fimbriae, and peritubal adhesions, if present. We have compared the accuracy of this procedure with HSG and laparoscopy in 24 infertile women. Color-coded duplex Doppler sonography was used in 38 patients to check for tubal patency.

RESULTS

Our experience at the Sion Hospital using the three new ultrasonographic techniques for evaluating the status of the fallopian tubes is very encouraging. The accuracy with the three modes shows agreement in > 90% of cases with established investigative modalities such as HSG and laparoscopy.

CONCLUSION

These three new investigative modalities are offered not as substitutes for HSG, laparoscopy, hysteroscopy, or salpingoscopy but as office-screening procedures that would be complementary to the armamentarium of infertility investigations already available.

Transvaginal color flow Doppler in the assessment of ovarian and uterine blood flow in infertile women

OBJECTIVE

To measure the flow velocity of the uterine and ovarian arteries through the menstrual cycle to determine there are changes.

DESIGN

Serial measurements throughout the menstrual cycle in women attending an infertility clinic, compared with volunteers coming for annual examinations. Transvaginal ultrasound-color flow Doppler was the investigative tool.

SETTING

A University Hospital ambulatory care center.

PATIENTS

One hundred infertile women compared with 150 women attending the clinic for annual checkups.

MAIN OUTCOME MEASURES

Changes in the resistance index of flow velocity waveforms of the uterine and ovarian arteries.

RESULTS

Uterine flow velocity has a resistance index of 0.88 +/- 0.04 (2 SE) in the proliferative phase and starts to decrease the day before ovulation. A nadir of 0.84 +/- 0.04 is reached on day 18 and remains at that level for the rest of the cycle. In anovulatory cycles, these changes do not occur. A subgroup of 12 women who lacked end diastolic flow in the uterine arteries during the secretory phase were identified. Eleven of these women were infertile, 8 of whom with primary infertility. Ovarian artery flow velocity is usually detected when the dominant follicle reaches 12 to 15 mm. The resistance index is 0.54 +/- 0.04 and also declines on the day before ovulation. A nadir of 0.44 +/- 0.04 is reached 4 to 5 days later and slowly rises to 0.050 +/- 0.04 before menstruation.

CONCLUSIONS

There are changes in the flow velocity patterns of the uterine and ovarian arteries during the normal ovulatory menstrual cycle. Because these changes in flow velocity begin before ovulation, it can be suspected that they may involve angiogenesis as well as hormonal factors. The changes noted in these studies are statistically significant but may be too small to be used as a diagnostic tool in the study of infertility problems.