Optimal timing of ultrasonographic and Doppler evaluation of uterine receptivity to implantation

doi:10.1016/S1472-6483(10)60598-6

Reproductive BioMedicine Online

Volume 16, Issue 3, 2008, Pages 368-375

https://doi.org/10.1016/S1472-6483(10)60598-6 Get rights and content

Abstract

In IVF programmes, transvaginal ultrasonography is used as a non-invasive method to evaluate uterine receptivity. The aim of this study was to determine when to perform this investigation in order to optimize prediction of the likelihood of pregnancy. Over 9 months, 124 patients undergoing IVF or intracytoplasmic sperm injection were studied. The ultrasonographic evaluation included endometrial thickness, endometrial pattern, uterine artery pulsatility index, protodiastolic notch, end-diastolic blood flow, and endometrial–subendometrial blood flow distribution pattern. All patients underwent ultrasonographic investigation on the days of human chorionic gonadotrophin (HCG) administration, oocyte retrieval, and embryo transfer. Statistical analysis was done using recursive-partitioning analysis. The pregnancy and implantation rates per transfer were 33 and 19.8% respectively. In terms of single parameters, women with an end-diastolic blood flow, an endometrial–subendometrial blood flow and a multilayered endometrium were more likely to be pregnant than women without one or more of these signs. The most effective combination for evaluation of uterine receptivity was end-diastolic blood flow, endometrial pattern and endometrial thickness. Sensitivity and specificity of this combination were around 81%, positive predictive value was 68.2%, and negative predictive value 89.7%. The best sensitivity and specificity were obtained on the day of HCG administration: respectively 81.1 and 81.3%.

Section snippets

Herve Dechaud received his MD degree in 1996 (Obstetrics and Gynaecology). He completed his PhD at Montpellier I University (France) (tubal infertility and impairment of embryo implantation). He then attended the University of Texas, Health Science Center at San Antonio, Texas, USA as research fellow in 1999. His research interests include endometrium and embryo implantation, infertility related to endometriosis, and ovarian stimulation protocols for assisted reproduction cycles. At the present

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Cited by (46)

Obstetrical outcome after B-Lynch sutures and ligation of uterine arteries: A case report
2021, Case Reports in Women's Health
To illustrate the obstetrical outcome after B-Lynch sutures and ligation of the uterine arteries.
A 26-year-old nulliparous woman. A caesarean section performed for obstructed labour was complicated by uterine atony. A B-Lynch uterine compression suture technique was used combined with ligation of the ascending branches of the uterine arteries. Before the subsequent fertility treatment, gel instillation sonography and power Doppler imaging showed a normal uterine cavity and restored myometrial vascularization. Subsequent caesarean section showed external adhesions on the anterior uterine serosa. A healthy baby of normal weight was delivered. There was focal placenta accreta; the underlying myometrium was strikingly thinner and prone to inversion.
After B-Lynch sutures and ligation of the ascending branches of the uterine arteries, the pregnancy was subsequently uncomplicated. The potential association between B-Lynch sutures and placenta accreta or uterine inversion in a subsequent pregnancy has to be assessed in further studies. This case report illustrates how 3D gel instillation sonography is a valuable tool to evaluate the integrity of the uterine cavity.
Endometrial thickness and IVF cycle outcomes: a meta-analysis
2020, Reproductive BioMedicine Online
Citation Excerpt :
Moreover, no evidence of publication bias was found for the risk of miscarriage (Supplementary Figure 7). The relationship between EMT and live birth or ongoing pregnancy rate was available in 11 studies (Richter et al., 2007; Dechaud et al., 2008; Kuc et al., 2011; Wu, 2014; Bu and Sun, 2015; Fang et al., 2016; Yuan et al., 2016; Liu et al., 2018; Ribeiro et al., 2018; Wang et al., 2018; Yang et al., 2018). Overall, lower versus higher EMT was associated with reduced incidence of live birth or ongoing pregnancy rate (OR 0.60; 95% CI 0.48 to 0.73; P < 0.001) (Figure 5), and significant heterogeneity was observed among the included studies (I2 = 78.7%%; P < 0.001).
In this meta-analysis, the association between endometrial thickness (EMT) and cycle outcomes after IVF is explored. Associations between EMT and cycle outcomes according to study and individual characteristics were also assessed.
Studies evaluating associations between EMT and pregnancy, implantation, miscarriage, live birth or ongoing pregnancy and ectopic pregnancy rates in individuals after IVF were identified on PubMed, Embase and the Cochrane Library (from their inception up to December 2018). Pooled odds ratios with 95% confidence intervals, calculated using the random-effects model, were used.
Nine prospective and 21 retrospective studies, including a total of 88,056 cycles, were retrieved. The summary odds ratios indicated that women with lower EMT were associated with lower pregnancy rates than those with higher EMT (n = 30, OR 0.61; 95% CI 0.52 to 0.70; P < 0.001). Moreover, the implantation rate in women with lower EMT was significantly reduced (n = 9, OR 0.49; 95% CI 0.32 to 0.74; P = 0.001). Furthermore, no significant association was found between EMT and the miscarriage rate (n = 12). In addition, women with lower EMT were associated with reduced live birth or ongoing pregnancy rate (11 studies, OR 0.60; 95% CI 0.48 to 0.73; P < 0.001). Finally, the incidence of ectopic pregnancy rate between lower and higher EMT showed no statistically significant association (n = 3).
Lower EMT was associated with lower pregnancy, implantation and live birth or ongoing pregnancy rates.
Modern management of thin lining
2017, Middle East Fertility Society Journal
Citation Excerpt :
Using receiver operating characteristics (ROC) area under the curve, a cutoff limit of endometrial thickness (on day of hCG trigger) above which implantation could be predicted was not detected by three reports, whereas two studies reported a threshold thickness of 8 mm (30–34). While several reports showed that endometrial thickness has a predictive value for successful pregnancies in ART, others have demonstrated the opposite (18,22,35–58). Moreover, most of the reports used a cutoff EMT of 7 mm while others used 6 mm, 8 mm, 9 mm, or 10 mm (18,32–34,38,40,44,46–52,56–60).
To define “thin” endometrium in fertility treatment, and to critically explore the available treatment options.
A review of the scientific literature.
N/A.
An electronic literature search pertaining to patients with “thin” endometrium undergoing fertility treatment was performed through April 2016.
Adequate endometrial growth is an integral step in endometrial receptivity and embryo implantation. Whether idiopathic or resulting from an underlying pathology, a thin endometrium of <7 mm is linked to a lower probability of pregnancy; however, no reported thickness excludes the occurrence of pregnancy. Several treatment modalities have been studied and include extended estrogen, gonadotropin therapy, low-dose hCG, tamoxifen, pentoxifylline, tocopherol, l-arginine, low-dose aspirin, vaginal sildenafil, acupuncture and neuromuscular electric stimulation, intrauterine G-CSF, and stem cell therapy. All treatment modalities except vaginal sildenafil, intrauterine GCF, and stem cell therapy were inconsistent in showing significant improvement in pregnancy rates. Early results of stem cell therapy trials seem promising.
EMT <7 mm is associated with lower probability of pregnancy in ART. Vaginal sildenafil appears to be a reasonable first line therapy option, and G-CSF appears to be a potential second option, while stem cell therapy seems to be a promising new treatment modality.
Ultrasound in assisted reproduction: a call to fill the endometrial gap
2016, Fertility and Sterility
Citation Excerpt :
Interestingly, attempts have been made to correlate sonographic patterns and molecular studies, testing for specific proteins known to be involved with endometrial receptivity and traditional histology (14). The results do not carry, at least at this point, clinical applicability, and it seems that different groups combine their own clinical results to establish their local policies, for example, one publication suggesting a protocol combining endometrial end-diastolic blood flow, endometrial thickness, and endometrial pattern as yielding the highest positive and negative predictive values for pregnancy when performed on the day of hCG administration (23). We support an ongoing testing of integrated endometrial scores incorporating the conservative endometrial measurements, endometrial-myometrial junction studies (Fig. 4), and endometrial contractility, as well as new concepts that are still to be evaluated, such as endometrial surface area and three-dimensional (3D) imaging (Figs. 5 and 6).
Ultrasound offers essential details and an overall view of the anatomic features of the reproductive organs, as well as physiologic assessment. There is still a great gap, however, in our understanding and interpretation of endometrial sonographic findings. Endometrial thickness, growth, and sonographic patterns have been repeatedly tested and compared with pregnancy rates in IVF cycles, yielding conflicting results. Generally, the data accrued so far suggest refraining from clinical decisions based solely on endometrial thickness. The three-layer ultrasound pattern reflects normal follicular/proliferative dynamics, and its presence in the pre-hCG period was reported to carry a better outcome: Significantly higher clinical pregnancy rates were found in patients with this pattern on the day of hCG administration among IVF cohorts. Subendometrial contractility (endometrial “waves”) offers a tool that can be used in cases of repeated implantation failure in patients reporting cramps around the planned time of embryo transfer, or as a reassuring modality to assess uterine quiescence during preparations for embryo transfer. We support the creation of an integrated endometrial score incorporating conservative endometrial measurements, endometrial-myometrial junction studies, and endometrial contractility, as well as new concepts that remain to be tested, such as endometrial surface area. Such scores may enable us to improve the effectiveness of endometrial ultrasound imaging in the clinical setting.
The effects of growth hormone on clinical outcomes after frozen-thawed embryo transfer
2016, International Journal of Gynecology and Obstetrics
To evaluate the effects of recombinant human growth hormone (rhGH) on clinical outcomes of frozen–thawed embryo transfer (FET).
A prospective study was conducted among 240 patients (aged ≤ 38 years) who underwent FET cycles at a center in Hefei, China, between November 2011 and October 2012. Patients were divided into three groups on the basis of visit order: those in group A received hormone-replacement therapy (HRT) for endometrial preparation, those in group B received HRT plus simultaneous rhGH, and those in group C received rhGH on day 8 of HRT.
Ten cycles were cancelled; 230 FET cycles were analyzed (77 in group A, 77 in group B, 76 in group C). The rates of clinical pregnancy, embryo implantation, and live birth were significantly higher in group B than in group A, as were the serum levels of estradiol and insulin-like growth factor-1 (P ≤ 0.033 for all comparisons). Endometrial thickness and serum levels of vascular endothelial growth factor were significantly higher in group B than in groups A and C, whereas pulsatility index, resistance index, and peak systolic velocity/end diastolic velocity of the uterine arcuate artery were significantly lower (P ≤ 0.017 for all comparisons).
Simultaneous administration of rhGH with HRT could improve clinical outcomes after FET by increasing endometrial blood perfusion and expression of cytokines related to endometrial receptivity.
The usefulness of endometrial thickness, morphology and vasculature by 2D Doppler ultrasound in prediction of pregnancy in IVF/ICSI cycles
2016, Egyptian Journal of Radiology and Nuclear Medicine
The aim of this study was to assess the predictive value of endometrial thickness, morphology and vasculature using two-dimensional (2D) Doppler ultrasound on the IVF/ICSI cycle outcome.
Endometrial thickness, morphology and subendometrial blood flow were assessed using transvaginal ultrasound on the day of hCG in 100 patients undergoing IVF/ICSI treatment in the period between June 2013 and January 2015. Statistical analysis was done.
There was no difference in the demographic features or details of ovarian stimulation between pregnant and non-pregnant women. Overall, 40 patients conceived; 23 (57.5%) of them had blood flow in zone III and 15 (37.5%) in zone II. All patients achieved pregnancy had endometrial thickness >8 mm. Using the ROC curve, the cutoff endometrial thickness for non-achieving pregnancy was 7 mm with a sensitivity and specificity of 100%. There was no significant difference in Doppler indices between pregnant and non-pregnant women.
When the endometrial thickness is <8 mm, and if there are non-triple endometrial line and non-favorable blood flow zone on day of hCG in IVF/ICSI cycles, pregnancy is unlikely and embryo transfer should be canceled with freezing of all embryos for future transfer to increase the success rate.

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: Declaration: The authors report no financial or commercial conflicts of interest.

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ArticleOptimal timing of ultrasonographic and Doppler evaluation of uterine receptivity to implantation

Abstract

Section snippets

Gynecologie Obstetrique Fertilite

Fertility and Sterility

Fertility and Sterility

Fertility and Sterility

Fertility and Sterility

Fertility and Sterility

Gynecologie Obstetrique Fertilité

Reproductive BioMedicine Online

Reproductive BioMedicine Online

Fertility and Sterility

Fertility and Sterility

Fertility and Sterility

Fertility and Sterility

Fertility and Sterility

Reproductive BioMedicine Online

Reproductive BioMedicine Online

Fertility and Sterility

Fertility and Sterility

Fertility and Sterility

Assisted reproductive technology in Europe, 2001. Results generated from European registers by ESHRE

Human Reproduction

The uterine biophysical profile

Ultrasound Obstetrics Gynecology

[Color echo-Doppler and endometrial receptivity in in vitro fertilization]

Contraception Fertilité Sexualité

Evaluation of cycle-to-cycle variation of endometrial responsiveness using transvaginal sonography in women undergoing assisted reproduction

Ultrasound Obstetrics Gynecology

Changes in endometrial thickness, width, length and pattern in predicting pregnancy outcome during ovarian stimulation in in vitro fertilization

Ultrasound Obstetrics Gynecology

Article
Optimal timing of ultrasonographic and Doppler evaluation of uterine receptivity to implantation