Ultrasound and the receptivity of the endometrium

Treatment effects of laparoscopy versus laparotomy on heterotopic pregnancy after in vitro fertilization and embryo transfer

OBJECTIVE

To compare the treatment effects of laparoscopy versus laparotomy on heterotopic pregnancy (HP) after in vitro fertilization-embryo transfer (IVF-ET).

METHODS

The retrospective case-control study enrolled 109 patients diagnosed with HP after IVF-ET treatment in our hospital from January 2009 to March 2020. All patients received surgical treatment by either laparoscopy or laparotomy. Data for general characteristics, diagnostic features, surgical parameters, as well as perinatal and neonatal outcomes were collected.

RESULTS

Sixty-two patients received laparoscopy and 47 received laparotomy. Significantly lower percentage of large hemoperitoneum (P = 0.001), shorter surgery duration (P < 0.001), less intraoperative blood loss (P = 0.001), higher rates of general anesthesia (P < 0.001), and lower cesarean section rates for singletons (P = 0.003) were found in the laparoscopy group. The perinatal and neonatal outcomes were comparable between the two groups. When interstitial pregnancy was considered alone, the surgical blood loss was significantly reduced in the laparoscopy group (P = 0.021), but there was no significant difference in hemoperitoneum, surgery duration, or perinatal and neonatal outcomes in singletons.

CONCLUSION

Both laparoscopy and laparotomy are effective surgical treatments for HP after IVF-ET. Laparoscopy is minimally invasive but laparotomy can be an alternative in emergency situations.

Differences in Ectopic Pregnancy Rates between Fresh and Frozen Embryo Transfer after In Vitro Fertilization: A Large Retrospective Study

Ectopic pregnancy (EP) is increasingly found in women treated with in vitro fertilization and embryo transfer (IVF−ET). With the development of the freeze-all policy in reproductive medicine, it is controversial whether frozen embryo transfer (FET) could reduce the rate of EP. In this single-center, large-sample retrospective study, we analyzed 16,048 human chorionic gonadotrophin (hCG)-positive patients who underwent fresh embryo transfer (ET) or FET cycles between January 2013 and March 2022. Throughout the study, the total EP rate was 2.09% (336/16,048), 2.16% (82/3803) in the ET group, and 2.07% (254/12,245) in the FET group. After adjustment for age, infertility causes, and other confounding factors, logistic regression results showed no statistical difference in EP rates between FET and ET groups (odds ratio (OR) 0.93 (0.71−1.22), p > 0.05). However, among the 3808 patients who underwent fresh ET cycles, the OR for EP was significantly lower in the long agonist protocol group than in the gonadotropin-releasing hormone antagonist (GnRH-ant) protocol group (OR 0.45 (0.22−0.93), p < 0.05). Through a large retrospective study, we demonstrated a slightly lower EP rate in FET cycles than in fresh ET cycles, but there was no significant difference. The long agonist protocol in ET cycles had a significantly lower risk of EP than the GnRH-ant protocol.

Heterotopic cervical pregnancy: Case report and literature review

Cervical pregnancy (CP) is a rare form of ectopic pregnancy (EP) in which the embryo implants and grows inside the endocervical canal. Heterotopic cervical pregnancy is an even rare form of EP, in which at least two embryos are simultaneously implanted in different sites and only one in the uterine cavity. Although many treatment approaches are available, the ideal management remains unclear. Here, we describe two cases of CP caused by assisted reproductive technologies (ART). One case underwent fertilization with intracytoplasmic sperm injection (ICSI) for male factor infertility, and the other was frozen–thawed embryo transfer (FET) following conventional in vitro fertilization (IVF). Both cases were successfully treated with ultrasound‐guided cervical pregnancy aspiration, and intrauterine pregnancies were effectively protected. To the best of our knowledge, these two were rare case reports use aspiration without additional methods and intrauterine pregnancy achieved live birth.

ENDOMETRIAL RECEPTIVITY AS THE KEY TO THE SUCCESS OF ART PROGRAMS: A LITERATURE REVIEW

Relevance: To date, the success of in vitro fertilization (IVF) programs in Kazakhstan is 38%. The purpose of the study was to evaluate the mechanisms of influence of various risk factors on endometrial receptivity in women in IVF programs. Materials and Methods: This review was based on a search conducted for domestic and foreign publications available in Russian and international search systems (PubMed, eLibrary) for the past 25 years. Results: Chronic endometritis is a verified cause of impaired receptivity. Many studies have proven the beneficial effect of complex empirical treatment using antibacterial, anti-inflammatory, hormonal therapy with transdermal forms of estrogens and vitamin therapy on the outcome of IVF. Conclusion: The problem of recurrent implantation disorders in IVF programs is multifactorial. Women with unrealized reproductive function require rehabilitation after an unsuccessful fertilization attempt to prevent disorders of homeostasis and ensure adequate pain relief during transvaginal puncture of ovarian follicles. In addition to hormone therapy with transdermal forms of estradiol, complex rehabilitation measures shall include immunomodulatory therapy, psychotherapy, and vitamin therapy.

An investigation of the time trends, risk factors, role of ultrasonic preoperative diagnosis of 79 ovarian pregnancy

BACKGROUND

Ovarian pregnancy (OP) is a rare form of ectopic pregnancy and is still a medical challenge. Therefore, more studies about the time trends, risk factors and diagnostic measurements are needed for the efficient treatment of OP.

METHODS

The datum of OP patients who were treated at the Second Hospital of Hebei Medical University from 2003 to 2018 was collected and a retrospective cohort study was preformed between OP and tubal pregnancy.

RESULTS

79 of all 6943 ectopic pregnancy (1.14%) were OP. The prevalence of OP following assisted reproductive technology showed an increasing trend over time, from 8.33% to 15.22%. Previous abdominal surgery was one of the risk factors of OP (OR 0.41, 95% CI 0.18-0.95, p = 0.04). Merely 2 (2.53%) patients were sonographically diagnosed as OP accorded with their discharge diagnosis. However, 56 (80.0%) accumulation of blood in the pelvis formed echo free areas could be clearly found by ultrasonography. A significant difference was found in serum β-hCG level among OP patients and tubal pregnancy patients (2762.73 ± 1915.24 mmol/L vs 1034.20 ± 915.32 mmol/L, p < 0.001).

CONCLUSIONS

The prevalence of OP following assisted reproductive technology is on the rise. History of abdominal surgery may be a high risk factor for OP patients who have the tendency of high β-hCG levels. The ultrasonic preoperative diagnosis is conductive to the early diagnosis of OP though the diagnosis accuracy is low.

Does the ultrasound appearance of the endometrium during treatment with assisted reproductive technologies influence pregnancy outcomes?

We evaluated endometrial pattern, defined as the relative echogenicity of the endometrium on a longitudinal uterine ultrasonic section, as a surrogate for endometrial receptivity in an attempt to evaluate the association between endometrial pattern and pregnancy outcome in women who underwent ART treatment. The primary outcome was live birth and secondary outcomes were clinical intrauterine pregnancy and miscarriage. Potential associations were evaluated using cluster-weighted generalized estimating equations to account for within-couple correlation among repeated ART cycles while adjusting for potentially confounding variables. There were 1034 ART cycles with embryo transfer (778 fresh, 256 frozen) among 695 women (median age: 31.0 (6.0) years). The average number of embryos transferred per cycle was 2.1. The clinical intrauterine pregnancy rate per transfer was 56.0% for fresh and 54.3% for frozen cycles. The overall live birth rate per embryo transfer was 48.4%. Live birth rates were unchanged when the endometrium was semi-trilinear (RR:0.91 CI:0.74,1.12) or unilinear (RR:1.15 CI:0.89,1.49) in comparison to trilinear endometrium after controlling for potentially confounding variables. Results were similar when analysed separately for fresh and frozen cycles and when evaluating associations with clinical intrauterine pregnancy and miscarriage rates. It appears that endometrial pattern does not significantly affect live birth in ART and our data do not support cancelling an ART cycle if the endometrium is less than trilinear.

Growth hormone supplementation may improve the pregnancy rate and endometrial receptivity among women aged more than 40 years undergoing in vitro fertilization

Background

Growth hormone (GH) supplements have been shown to improve pregnancy and live-birth rates, suggesting that GH has a beneficial effect on oocyte quality. However, the effects of GH on implantation and receptivity remain unknown. This study evaluated the efficacy of GH in women aged more than 40 years participating in assisted reproductive technology (ART) programs.

Methods

Cycles of in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) in women aged more than 40 years (range, 40–43 years) between January 2009 and March 2014 at a university-based reproductive center were reviewed. Women were divided into two groups, those with and without GH co-stimulation. ART outcomes were evaluated.

Results

Supplement of GH significantly lowered cycle cancellation rate by increasing the per cycle rates of harvesting at least one oocyte and transferring at least one embryo (80.2% vs. 69.4%). GH increased the per cycle clinical pregnancy (15.9% vs. 6.8%) and favorable ultrasonic endometrial pattern (60.9% vs. 39.3%) rates. GH also increased the per transfer clinical pregnancy (19.9% vs. 9.9%) and implantation (11.2% vs. 5.2%) rates and the rate of a favorable ultrasonic endometrial pattern (65.1% vs. 45.0%).

Conclusion

GH supplementation reduces the cycle cancellation rate in women aged more than 40 years, and increases the favorable ultrasonic endometrial pattern, pregnancy, and implantation rates by its beneficial actions on embryo quality and endometrial receptivity.

Myomas and Adenomyosis: Impact on Reproductive Outcome

Among uterine structural abnormalities, myomas and adenomyosis represent two distinct, though frequently coexistent entities, with a remarkable prevalence in women of reproductive age. Various mechanisms have been proposed to explain the impact of each of them on reproductive outcome. In respect to myomas, current evidence implies that submucosal ones have an adverse effect on conception and early pregnancy. A similar effect yet is not quite clear and has been suggested for intramural myomas. Still, it seems reasonable that intramural myomas greater than 4 cm in diameter may negatively impair reproductive outcome. On the contrary, subserosal myomas do not seem to have a significant impact, if any, on reproduction. The presence of submucosal and/or large intramural myomas has also been linked to adverse pregnancy outcomes. In particular increased risk for miscarriage, fetal malpresentation, placenta previa, preterm birth, placenta abruption, postpartum hemorrhage, and cesarean section has been reported. With regard to adenomyosis, besides the tentative coexistence of adenomyosis and infertility, to date a causal relationship among these conditions has not been fully confirmed. Preterm birth and preterm premature rupture of membranes, uterine rupture, postpartum hemorrhage due to uterine atony, and ectopic pregnancy have all been reported in association with adenomyosis. Further research on the impact of adenomyosis on reproductive outcome is welcome.

Colony stimulating factor-1 and leukemia inhibitor factor expression from current-cycle cannula isolated endometrial cells are associated with increased endometrial receptivity and pregnancy

Background

Poor endometrial quality is associated with more than a third of embryo implantation failures. Current ultrasonography technology lacks the capacity to determine efficiently the endometrial receptivity during ongoing cycle transfers. We analyzed the relationship between the gene expression profile associated with implantation and clinical pregnancy from endometrial cells taken during embryo transfer.

Methods

Seventy-six patients submitted to a standard ovarian stimulation protocol, in vitro fertilization, and good quality embryos were collected (morphological assessment). Endometrial samples were taken with ultrasonography guidance and cells were Hematoxylin and Eosin stained for morphological identification. Total RNA was extracted and the expression of Mucin 1 (MUC1), Homeobox A10 (HOXA-10), Leukemia Inhibitor Factor (LIF), Colony Stimulating Factor-1 (CSF-1), and ribosomal 18 s (endogenous control) were analyzed using RT-qPCR. Presence of a gestational sac, β-hGC (≥10 mIU/mL on Day 20), and a fetal heartbeat were used to determine a positive embryo implantation and pregnancy.

Results

Samples collected from same cycle embryo transfer showed clear morphological staining for endometrial cells (80–90% of the cells). Cells in the sample were molecularly identified as the endometrium (HOXA-10 positive and MUC-1 negative). CSF-1 expression was 4.55-fold and LIF expression was 12.25-fold higher in patients who became pregnant. Both increases were statistically significant (p < 0.05).

Conclusions

Here, we provide evidence of a new method to assess endometrial receptivity. Furthermore, we demonstrate that the expression profile, based on LIF and CSF-1, showed a difference between a receptive and a non-receptive endometrium.

Biomechanics of the human uterus

The appropriate biomechanical function of the uterus is required for the execution of human reproduction. These functions range from aiding the transport of the embryo to the implantation site, to remodeling its tissue walls to host the placenta, to protecting the fetus during gestation, to contracting forcefully for a safe parturition and postpartum, to remodeling back to its nonpregnant condition to renew the cycle of menstruation. To serve these remarkably diverse functions, the uterus is optimally geared with evolving and contractile muscle and tissue layers that are cued by chemical, hormonal, electrical, and mechanical signals. The relationship between these highly active biological signaling mechanisms and uterine biomechanical function is not completely understood for normal reproductive processes and pathological conditions such as adenomyosis, endometriosis, infertility and preterm labor. Animal studies have illuminated the rich structural function of the uterus, particularly in pregnancy. In humans, medical imaging techniques in ultrasound and magnetic resonance have been combined with computational engineering techniques to characterize the uterus in vivo, and advanced experimental techniques have explored uterine function using ex vivo tissue samples. The collective evidence presented in this review gives an overall perspective on uterine biomechanics related to both its nonpregnant and pregnant function, highlighting open research topics in the field. Additionally, uterine disease and infertility are discussed in the context of tissue injury and repair processes and the role of computational modeling in uncovering etiologies of disease. WIREs Syst Biol Med 2017, 9:e1388. doi: 10.1002/wsbm.1388 For further resources related to this article, please visit the WIREs website.

The effect of fertility stress on endometrial and subendometrial blood flow among infertile women

BACKGROUND

To investigate the effect of fertility stress on endometrial and subendometrial blood flow among infertile women.

METHODS

This case-control study was conducted in The First Affiliated Hospital of Zhengzhou University. The fertility problem inventory (FPI) was adopted to evaluate fertility stress. Three-dimensional power Doppler ultrasonography (3D PD-US) was performed during the proliferative phase of the menstrual cycle (days 5-11) to measure endometrial thickness, pattern, endometrial and subendometrial volume (V), the vascularization index (VI), the flow index (FI) and the vascularization-FI (VFI) index. Then, 300 infertile women were separated into two groups (high-score group and low-score group) based on total FPI scores and 80 healthy women were selected as controls.

RESULTS

No differences were found among all three groups with regard to general characteristics, endometrial thickness, pattern, endometrial and subendometrial V, VI and VFI. The endometrial and subendometrial FIs associated with different stress levels significantly differed among the three groups (F = 33.95, P < 0.001; F = 44.79, P < 0.001, respectively). The endometrial and subendometrial FIs in the control group were significantly higher than those in the high-score group and low-score groups. The endometrial and subendometrial FIs in the low-score group were significantly higher than those in the high-score group. The total FPI score was closely related to the endometrial and subendometrial FIs (r = -0.304, P < 0.001; r = -0.407, P < 0.001, respectively).

CONCLUSION

Fertility stress was associated with endometrial and subendometrial flow index. Whether fertility stress might affect pregnancy outcome by reducing endometrial and subendometrial blood flow requires further research.

Trends in ectopic pregnancy rates following assisted reproductive technologies in the UK: a 12-year nationwide analysis including 160 000 pregnancies

STUDY QUESTION

Have the advancement of assisted reproductive technologies (ART) and changes in the incidence of specific causes of infertility-altered ectopic pregnancy (EP) rates following ART over time in the UK?

SUMMARY ANSWER

EP rates in the UK following IVF/ICSI have progressively decreased, and this appears to be associated with a reduction in the incidence of tubal factor infertility and the increased use of both a lower number of embryos transferred and extended embryo culture.

WHAT IS KNOWN ALREADY

Historically, EP rates following ART are known to have increased over time. However, the impact of progress in ART procedures and changes in both policy and the incidence of specific causes of infertility on the overall EP rate in the UK has yet to be studied.

STUDY DESIGN, SIZE, DURATION

A population-based retrospective analysis was carried out on all pregnancies following ART cycles carried out in the UK between 2000 and 2012 included in the anonymized database of the Human Fertilisation and Embryology Authority.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Overall, 161 967 treatment cycles resulting in a pregnancy were included in the analysis. Among them, 8852 pregnancies occurred after intrauterine insemination (IUI) and 153 115 following IVF/ICSI.

MAIN RESULTS AND THE ROLE OF CHANCE

During this period of 12 years, ∼1.4% (n = 2244) of all pregnancies following ART were an EP. Crude EP rates were significantly higher after IVF/ICSI when compared with following IUI (1.4 versus 1.1%, P = 0.043). The incidence of EP decreased significantly over time for IVF/ICSI cycles [incidence rate ratios (IRR) 0.96 per year, 95% confidence interval (CI) 0.94-0.97], but not after IUI (IRR 0.96 per year, 95% CI 0.91-1.03).Among pregnancies resulting from IVF/ICSI, multivariable logistic regression analysis demonstrated that the major risk factor for EP was the presence of tubal infertility [adjusted odds ratio (aOR) 2.23, 95% CI 1.93-2.58), followed by the increased number of embryos transferred (aOR 1.29 for 2 versus 1 embryo transferred, 95% CI 1.11-1.49; aOR 1.69 for 3 or more versus 1 embryo transferred, 95% CI 1.35-2.11). The use of extended embryo culture to Days 3-4 or 5-7 significantly reduced the risk of EP, when compared with the transfer of early cleavage (Days 1-2) embryos (respectively, aOR 0.85, 95% CI 0.76-0.94; and aOR 0.73, 95% CI 0.63-0.84). Finally, frozen embryo transfer (ET) had no effect on the risk of EP following IVF/ICSI (aOR 0.92, 95% CI 0.76-1.11).

LIMITATIONS, REASONS FOR CAUTION

Owing to the use of this particular registry data, well-established risk factors of EP, such as smoking habits or uterine surgery, could not be assessed.

WIDER IMPLICATIONS OF THE FINDINGS

Our results provide the first evidence of a potential benefit-in terms of the reduction in EP rates-of the implementation of national programmes aiming to reduce the incidence of tubal infertility, such as the National Chlamydia Screening Programme. In addition, campaigns for the widespread introduction of single ET may not only reduce the incidence of multiple pregnancies but also the incidence of EP following IVF/ICSI.

STUDY FUNDING/COMPETING INTERESTS

No funding was obtained for this study, and there are no conflicts of interest to declare.

A novel approach to normal responder patient with repeated implantation failures--a case report

We describe a case of normal responder patients with repeated implantation failure who was offered the combination of the ultrashort GnRH-ag/ GnRH-ant COH protocol, followed by endometrial injury and a subsequent natural cycle frozen-thawed embryos transfer. The patient conceived following the natural FET cycle that was supported by luteal daily progesterone, with the additional single injection of HCG and GnRH-agonist, on day of ET and 4 days later, respectively. This combined approach seems to be a valuable tool in the armamentarium for treating normal responder patients with repeated implantation failures and should be further examined in large randomized controlled trials.

Do Endometrial Movements Affect The Achievement of Pregnancy during Intrauterine Insemination?

Background

This study was aimed to assess the effect of endometrial movements on pregnancy achievement in intrauterine insemination (IUI) cycles.

Materials and Methods

The population of this observational study was composed of unexplained infertility couples undergoing first-time IUI with clomiphene citrate between September 2010 and October 2011. Not only endometrial movements, but also thickness, volume, pattern, and echogenic change of endometrium were analyzed prospectively in prediction of pregnancy.

Results

The total number of 241 cycles of IUI with 49 intrauterine pregnancies (20.3%) was analyzed. Pregnancy was not related to endometrial thickness and endometrial volume, but significantly related to endometrial movements associated with the number of contraction, strong movement, cervicofundal direction, and hyperechoic change (p<0.05). Pregnant group showed higher cervicofundal movement rate (89.8 vs. 75.5%).

Conclusion

For IUI cycles stimulated by clomiphene citrate in unexplained infertility women, endometrial movements on the day of IUI could be a predictor of pregnancy.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Should zygote intrafallopian transfer be offered to all patients with unexplained repeated in-vitro fertilization cycle failures?

BACKGROUND

One of the suggest strategy for patients with repeated implantation failure (RIF) is zygote intrafallopian transfer (ZIFT). However, no data exist regarding to the issue of when and under which circumstances should ZIFT be offered to patients with RIF? We therefore aimed to examine whether repeated implantation failure (RIF) patients characteristics or their previous controlled ovarian hyperstimulation (COH) variables may differentiate between those who will conceive following a ZIFT cycle and those who will not.

METHODS

Forty seven consecutive women admitted to our IVF unit during a 7 year period, who underwent ZIFT for RIF, were included. Ovarian stimulation characteristics, number of oocytes retrieved and number and quality of zygotes/embryos transferred were assessed and compared between the ZIFT cycle and the previous IVF/ICSI cycle and between those who conceived following the ZIFT cycle and those who did not.

RESULTS

Twelve clinical pregnancies (clinical pregnancy rate- 25.5%) were recorded following the ZIFT cycle. Those who benefit from ZIFT were young patients (≤31 yrs), who underwent ≤6 cycle attempts, yielding over eight 2PN embryos with low (≤0.4) ratio of number of top-quality embryos to total 2PN embryos. Moreover, in those destined for a ZIFT cycle, only those with >7 2PN embryo should undergo a transfer of at least five 2PN embryos.

CONCLUSIONS

Further large prospective studies are needed to identify the specific characteristics of RIF women who may benefit from ZIFT.

GnRH-agonist ovulation trigger in patients undergoing controlled ovarian hyperstimulation for IVF with ultrashort flare GnRH-agonist combined with multidose GnRH-antagonist protocol

OBJECTIVE

To evaluate, whether Gonadotropin-releasing hormone-agonist (GnRH-agonist or GnRH-ag) trigger in patients undergoing the ultrashort GnRH-ag/GnRH-antagonist (GnRH-ant) protocol is as effective as in patients at high risk to develop severe ovarian hyperstimulation syndrome (OHSS), who undergo the multidose GnRH-ant protocol.

DESIGN

Cohort study.

SETTING

University hospital.

PATIENTS

All consecutive women aged ≤35 years admitted to our IVF unit from January 2011 to October 2011 who reached the ovum pick-up stage.

INTERVENTIONS

Triggering final oocytes maturation by GnRH-ag instead of hCG, in high-responder patients undergoing either the ultrashort GnRH-ag/GnRH-ant or the multidose GnRH-antagonist controlled ovarian hyperstimulation (COH) protocols.

MAIN OUTCOME MEASURES

Ovarian stimulation characteristics, percentage of mature oocytes, fertilization and pregnancy rates.

RESULTS

No inbetween groups differences were observed in ovarian-stimulation related variable, percentage of mature oocytes, fertilization or pregnancy rates. No case of moderate-severe OHSS was reported in the study, or the control groups.

CONCLUSIONS

Three consecutive doses of daily GnRH-ag administration at the beginning of ultrashort flare GnRH-ag/GnRH-ant COH protocol, did not interfere with the ability of the GnRH-ag to trigger final oocytes maturation at the end of the COH cycle.

Expression of PRB, FKBP52 and HB-EGF relating with ultrasonic evaluation of endometrial receptivity

BACKGROUND

To explore the molecular basis of the different ultrasonic patterns of the human endometrium, and the molecular marker basis of local injury.

METHODOLOGY/PRINCIPAL FINDINGS

The mRNA and protein expression of FKBP52, progesterone receptor A (PRA), progesterone receptor B (PRB), and HB-EGF were detected in different patterns of the endometrium by real-time RTPCR and immunohistochemistry. There were differences in the mRNA and protein expression of FKBP52, PRB, and HB-EGF in the triple line (Pattern A) and homogeneous (Pattern C) endometrium in the window of implantation. No difference was detected in PRA expression. After local injury, the mRNA expression of HB-EGF significantly increased. In contrast, there was no difference in the mRNA expression of FKBP52, PRB, or PRA. The protein expression of FKBP52, PRB, and HB-EGF increased after local injury. There was no difference in the PRA expression after local injury.

CONCLUSIONS

PRB, FKBP52, and HB-EGF may be the molecular basis for the classification of the ultrasonic patterns. HB-EGF may be the molecular basis of local injury. Ultrasonic evaluation on the day of ovulation can be effective in predicting the outcome of implantation.

Combined analysis of endometrial thickness and pattern in predicting outcome of in vitro fertilization and embryo transfer: a retrospective cohort study

OBJECTIVE

To evaluate the combined effect of endometrial thickness and pattern on clinical outcome in patients undergoing in vitro fertilization/intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET).

METHODS

Cycles of IVF/ICSI-ET conducted between January 2003 and December 2008 at a university-based reproductive center were reviewed retrospectively. Endometrial ultrasonographic characteristics were recorded on the day of hCG administration. In the combined analysis, endometrial thickness groups (group 1: equal or <7 mm; group 2: 7-14 mm; group 3: >14 mm) were subdivided into two endometrial patterns (pattern A: triple-line; pattern B: no-triple line). Clinical pregnancy rate (CPR) and early miscarriage rate in different groups were analyzed.

RESULTS

A total of 2896 cycles were reviewed. Clinical pregnancy rate (CPR) was 24.4% in group 1-A. There were no second trimester pregnancies in group 1-B. Miscarriage rate in group 2-A was significantly lower compared to group 2-B (P < 0.01), although CPR did not show any significant differences between the groups. A no-triple line endometrial pattern with moderate endometrial thickness (7-14 mm) had a detrimental effect on pregnancy outcome, but not the occurrence of pregnancy. In group 3, there was no difference in CPR and miscarriage rates between the two patterns; adequate endometrial thickness (>14 mm) seemed to mitigate the detrimental impact (high miscarriage rate) of pattern B.

CONCLUSION

Combined analysis of endometrial thickness and pattern on the day of hCG administration was a better predictor of the outcome of IVF/ICSI-ET and may be more helpful for patient counseling than the separate analyses.

Assessment of endometrial and ovarian characteristics using three dimensional power Doppler ultrasound to predict response in frozen embryo transfer cycles

OBJECTIVE

To evaluate whether endometrial or ovarian parameters as measured using 3D power Doppler ultrasound would predict the outcome in frozen embryo transfer (FET) cycles.

METHODS

Thirty women with no known gynecological pathology undergoing FET were recruited. The FET was carried out in the natural menstrual cycle 3-4 days after the first positive LH test result. Blood samples for hormonal analysis were collected, and three-dimensional (3D) ultrasonographic examination was performed on the day of the FET and repeated with analysis of the total hCG one week later.

RESULTS

The demographic, clinical, and embryological characteristics were similar between the pregnant (15/30) and nonpregnant groups (15/30). There were no differences between the groups in endometrial/subendometrial thickness, volume, or vascularization index (VI). The endometrial triple-line pattern was more often present in the pregnant group on the day of the FET (93.3% vs. 40.0%, 95% CI 25.5-81.2%). No differences in the ovaries were observed on the day of the FET. At the second visit, the triple-line pattern was still more often present in those patients who had conceived (91.7% vs. 42.9%, 95% CI 18.5-79.1%), and their corpus luteum was more active as judged by the rise in 17-hydroxyprogesterone and estradiol levels. No differences were observed in the dominant ovarian vasculature.

CONCLUSIONS

According to our results, measurement of power Doppler indices using 3D ultrasound on the day of the FET does not provide any additional information concerning the outcome of the cycle. The existence of the triple-line pattern on the day of the FET seems to be a prognostic sign of a prosperous outcome after FET. The dominant ovary in the pregnant group seems to be already activated one week after the FET.

Endometrial and subendometrial vascularity are significantly lower in patients with endometrial volume 2.5 ml or less

Endometrial development is largely dependent on a good blood supply to the basal endometrium. This study evaluated the endometrial and subendometrial vascularity in patients with thin (<or=8 mm) endometrium and in those with low volume (<or=2.5 ml) endometrium. Patients undergoing their first IVF cycle were recruited and all followed a standard ovarian stimulation regimen. Three-dimensional (3D) ultrasound examination with power Doppler was performed on the day of oocyte retrieval to determine endometrial thickness, endometrial pattern, Doppler flow indices of uterine vessels, endometrial volume and 3D power Doppler flow indices of endometrial and subendometrial regions. It was found that 3D power Doppler flow indices of the endometrial and subendometrial regions were significantly lower in patients with low volume endometrium compared with those with normal volume endometrium. The 3D power Doppler indices of the endometrial and subendometrial regions were comparable for patients with thin and normal endometrium. In conclusion, endometrial and subendometrial vascularity measured by 3D power Doppler ultrasound was significantly lower (P <or= 0.003) in patients with low volume endometrium, but not in those with thin endometrium.

Adenomyosis: New Knowledge is Generating New Treatment Strategies

In the early days, all mucosal invasions of abdominal organs were considered to be one pathological condition of uncertain origin, termed adenomyoma. It was only in the 1920s that endometriosis and adenomyosis were clearly separated and it took approximately 80 years to put forward a new theory reunifying their pathogenesis. Today, identification of adenomyosis is carried out exclusively through vaginal ultrasonography and MRI. These techniques have made a careful evaluation of a distinct anatomical structure and the inner myometrial layers underlying the endometrium, termed the junctional zone, possible. Adenomyosis is characterized by a homogeneous thickening of this portion of the myometrium. When this hyperplasia is associated to an alteration of spiral arterioles' angiogenesis, then both adenomyosis and endometriosis may develop. Evidence is being accumulated that pre-eclampsia, fetal growth restriction and premature delivery may be linked, together representing a new, major obstetrical syndrome characterized by a modified uterine environment around the time of nidation. A dozen different medical or surgical techniques are utilized for the treatment of adenomyosis and novel approaches are being tested. These include use of inhibitors of angiogenesis that have been shown to cause reduced neo-angiogenesis, a significant modification of gene expression and a decrease in the percentage of active lesions. Encouraging results have also been obtained with the levonorgestrel-releasing intrauterine system.

Characterization of endometrial growth in proliferative and early luteal phase in IVF cycles

Human endometrium has a definite role in implantation, although knowledge about its modifications in the course of IVF cycles is still limited. This study was performed to characterize endometrial growth throughout stimulation treatment in women undergoing IVF cycles, regardless of clinical outcomes. Endometrial growth was longitudinally evaluated by ultrasonography in the first induced ovarian stimulation cycle (717 patients). Acceleration and length of significant growth were used to assess the slope of the growth curve mathematically. Endometrial growth showed a parabolic trend and final thickness was significantly affected by age (P < 0.01). Endometria that tended to overgrowth had a more rapid and longer growth during the whole phase. A similar stimulation treatment was repeated within 6 months of the first one and a second evaluation was carried out to verify whether similar growth occurred. Similar growth was observed in 76% of the patients, with an absolute difference between the two cycles of <4 mm in 84% of cases. The endometrium seems to have an individual intrinsic potential that can be expressed regardless of the stimulation protocol. This supports the hypothesis that individual factors (intrinsic properties of the endometrium) significantly affect endometrial growth.

Mild IVF using GnRH agonist long protocol is possible: comparing stimulations with 100 IU vs. 150 IU recombinant FSH as starting dose

PURPOSE

To test the possibility of stimulating ovaries with a mild IVF approach using a GnRH agonist long protocol.

METHODS

Retrospective study of 142 first IVF cycles of women aged 30 to 35 who had undergone stimulation with 100 IU or 150 IU of rFSH.

RESULTS

The mean dose of rFSH used was smaller in the low dose compared with the high dose group (999 vs. 1343 IU; p<0.001), obtaining comparable numbers of mature oocytes in both groups. Additionally, reducing the mean number of embryos transferred from 1.8 to 1.5 significantly decreased the twin rate in the low dose group while maintaining similar pregnancy rates in both groups.

CONCLUSIONS

It is possible to develop mild IVF using GnRH agonist long protocol in women with good prognosis. A reduced amount of rFSH and fewer transferred embryos allow for lower costs and risks of IVF without compromising the pregnancy rate.