Subendometrial Blood Flow Research Articles

Ultrasound Markers of Implantation

ABSTRACT Endometrial 3D power Doppler indices change significantly during the normal menstrual cycle. Vascularity indices of the endometrial and subendometrial vessels increase throughout the proliferative phase of the menstrual cycle, reaching a maximum value 2 to 3 days prior to ovulation. From this peak, vascularity indices decrease and reach a nadir 2 to 5 days after ovulation. Reduced endometrial perfusion assessed by 3D power Doppler ultrasound is most likely related to increased uterine contractility. If prolonged, it may cause endometrial hypoxia, leading to detrimental effect on implantation potential. In normal spontaneous menstrual cycles, endometrial vascular indices increase progressively during the course of the luteal phase. Endometrial and subendometrial perfusion is negatively affected by serum estradiol concentrations, which can explain why patients with hyperstimulation have lower endometrial and subendometrial blood flow during the early luteal phase. Our results indicate that 3D power Doppler implantation markers are crucial for planning a single embryo transfer in order to select the most suitable cycle for transfer of a single cryopreserved embryo. How to cite this article Mercé LT, Barco MJ, Kurjak A. Ultrasound Markers of Implantation. Donald School J Ultrasound Obstet Gynecol 2012;6(1):14-26.

OC01.03: How does the IVF treatment protocol affect subendometrial blood flow prior to ovulation?

Objectives: To compare subendometrial blood flow prior to ovulation in the natural menstrual cycle with blood flow prior to HCG administration in the IVF treatment cycle in subfertile women. Hypothesis: IVF treatment causes an increase in blood flow, and women who subsequently conceive have higher endometrial blood flows pre HCG. Methods: 118 women with regular menstrual cycles were prospectively recruited. TV US in the late follicular phase (ovuln1to-2) of the natural cycle and in the morning prior to HCG administration in IVF cycle. A 3D dataset of the uterus was acquired using power Doppler angiography. Using VOCAL (9◦) the endometrial volume was measured using 9 degree rotation steps. 3, 5 and 7 mm shells were selected to represent the subendometrium. The standardised vascularity indices were measured as described previously. The Wilcoxon signed ranks test was used to analyse data. Results: 105 women were included. 13 women excluded due to cycle cancellation or non attendance. None of the indices were normally distributed. 50 (48%) women subsequently had a positive pregnancy test. All sub endometrial blood flow indices were significantly higher in the treatment cycle eg: pre ovulatory 3 mm subendometrial sVI in IVF cycle 24.5 ± 7.3% compared with 12.7 ± 5.5% in natural cycle (P < 0.01). Women who subsequently conceived did not demonstrate significantly higher vascular indices than women who did not conceive for any of the subendometrial parameters studied. We therefore accepted the hypothesis that IVF treatment is associated with an increase in subendometrial vascularity, but rejected the hypothesis that there was a difference in these indices between women who conceive and those who do not. Conclusions: IVF treatment is associated with an increase in subendometrial vascularity. We have shown that there is no difference in these indices between women who conceive and those who do not. Further studies are in progress to assess whether these indices fall at the time of embryo transfer as we have shown in the mid luteal phase, and whether this fall is predictive of pregnancy.

Uterine artery Doppler and subendometrial blood flow in patients with unexplained recurrent miscarriage

Abstract Objective To evaluate uterine artery blood flow and subendometrial blood flow in women with unexplained recurrent miscarriage (RM) compared to normal fertile women. Design Case control study. Settings Departments of Obstetrics and Gynaecology, Cairo university and, Beni Souif University, Cairo, Egypt. Patients and methods Women were divided into two groups: those with history of unexplained recurrent miscarriage (study group, no. = 40), and those with no history of miscarriage and at least one child born at term (control group, no. = 40), transvaginal 3D power Doppler ultrasonography was performed to all patients in the second phase of non-pregnant unstimulated cycle to detect uterine artery pulsatility index (UAPI) and subendometrial area to detect subendometrial blood flow presented by the indices vascularisation index (VI), flow index (FI), and vascular flow index (VFI). The indices between the two groups were compared. Results UAPI was significantly higher in the study group ( p = 0.000), on the other hand VI ( p = 0.000), FI ( p = 0.000), VFI ( p = 0.000) were significantly lower in the study group. A significant positive correlation was found between UAPI and recurrent miscarriage in the study group ( r = 0.8, p = 0.00), whereas a significant negative correlation was found between VI ( r = −0.56, p = 0.00), and FI ( r = −0.79, p = 0.00) and recurrent miscarriage in the study group, but no significant correlation was found between endometrial thickness and endometrial volume between the two groups. However the application of binary logistic regression analysis model found that adding variables has not significantly increased the ability to predict the occurrence of miscarriage. Conclusion The presence of good uterine and endometrial blood flow is an important prerequisite for successful implantation and continuation of pregnancy as shown by higher uterine artery blood flow resistance and lower endometrial blood flow in recurrent miscarriage cases and those patients with unexplained RPL may have abnormalities in the uterine and endometrial blood flow. Despite these findings we could not find any cut off values that could predict the occurrence of miscarriage which may be attributed to small sample size and short period of follow up so larger prospective studies are needed aiming to confirm such results and reaching values that can accurately predict the occurrence of miscarriage.

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Predictive value of endometrial thickness, pattern and sub-endometrial blood flows on the day of hCG by 2D doppler in in-vitro fertilization cycles: A prospective clinical study from a tertiary care unit.

AIMS AND OBJECTIVES:To evaluate the role of endometrial thickness, pattern and sub-endometrial blood flows measured by 2D power Doppler ultrasound to predict pregnancy during in-vitro fertilization (IVF) treatment.STUDY DESIGN:Prospective, non-randomized clinical study.MATERIALS AND METHODS:This was a prospective observational study. A total of 101 infertile women were recruited from our IVF-ET program from January to December, 2009. Women with tubal factor, male factor and unexplained infertility were included in the study.RESULTS:The mean age was 35 years and mean duration of infertility was 8 years. Seventy five (74.25%) patients had primary infertility and 26 (25.74%) had secondary infertility. The mean endometrial thickness was 8.1 mm and endometrial blood flow was in Zone I in 18 patients, 28 patients had blood flow in Zone II and 54 had in Zone III. Overall, 27 (26.73%) patients conceived and in these women the endometrial thickness was between 6 and 12 mm.CONCLUSIONS:With a thin endometrium (≤7 mm) and no-triple-line endometrial pattern coexisting in an in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) candidate, cryopreservation should be recommended. With a thin endometrium and a good texture (triple-line), other prognostic factors, such as embryo quality, should be taken into account. The endometrial vascularity has a useful predictive value on the implantation rate in IVF cycles irrespective of the morphological appearance of the endometrium. However, further study is needed to make a definitive conclusion.

Role of endometrial and subendometrial blood flows measured by three-dimensional power Doppler ultrasound in the prediction of endometrial receptivity during IVF-ET treatment

Objective To investigate the role of endometrial and subendometrial blood flows measured by transvaginal three-dimensional(3D) power Doppler ultrasound in the prediction of endometrial receptivity during in vitro fertilization-embryo transfer (IVF-ET) cycles. Methods One hundred and twenty patients undergoing IVF-ET cycles were enrolled in this study. Transvaginal 3D power Doppler ultrasound examination was performed on the day of human chorionic gonadotropin injection to determine endometrial thickness,endometrial volume, vascularization index(VI), flow index(FI) and vascularization flow index (VFI) of endometrial and subendometrial regions by experienced sonograpbers. The patients were divided into pregnant group and non-pregnant group according to pregnant outcome. The data between the two groups were compared and analysed. Results There were no significant differences( P ＞0.05) between the pregnant group and non-pregnant group in endometrial thickness, endometrial volume. Endometrial and subendometrial VI,FI, VFI were higher in the pregnant group than those in the non-pregnant group, and statistical comparison had significant difference( P ＜0.05). Conclusions Endometrial and subendometrial blood flows measured by transvaginal 3D power Doppler ultrasound can be as a reliable indicator to assess endometrial receptivity and to predict the pregnancy outcome. Key words: Endosonography; Endometrium; Fertilization in vitro; Embryo transfer

Role of endometrial blood flow assessment with color Doppler energy in predicting pregnancy outcome of IVF-ET cycles

This is a prospective study of 182 women (38 yrs or younger) undergoing IVF-ET. Endometrial thickness, echo pattern and blood flow on transvaginal ultrasonography were recorded eight hours prior to hCG administration. The patients were divided into three groups: A (n = 10) with undetectable endometrial blood flow; B (n = 82) with sub-endometrial blood flow; C (n = 90) with both endometrial and sub-endometrial blood flow. According to IVF-ET outcomes, all patients were re-divided into three groups: 1 non-pregnancy (n = 92); 2 intrauterine pregnancy with live fetus (n = 70); 3 others (n = 20 including biochemical pregnancy, embryonic diapause, ectopic pregnancy and miscarriage). Intrauterine pregnancy with live fetus in Group C (62.2%) was much higher than that in Group A and B (0% and 17.1%, p less than or equal to 0.001). The implantation rate (33.2%) was much higher than that in Group A and B (0% and 19.90%, p less than or equal to 0.001). The pulsatility index, resistance index, and S/D of endometrial spiral arteries were 0.1 +/- 0.2, 0.6 +/- 0.1 and 2.5 +/- 0.4 in Group 2, which were much lower than those in Group 1 and Group 3 (p1-2 less than 0.001, p2-3 less than 0.05). The patients with detectable endometrial blood flow had higher clinical pregnancy rates and implantation rates.

OC13.03: Assessment of endometrial and subendometrial blood flow in women undergoing frozen embryo replacement and its relationship to conception

OC13.03: Assessment of endometrial and subendometrial blood flow in women undergoing frozen embryo replacement and its relationship to conception

Endometrial/subendometrial blood flow indexes measured by 3D power Doppler angiography and inherited thrombophilia and in vitro fertilization outcome

OBJECTIVE: Endometrial and subendometrial blood flow is involved in embryo implantation.We have investigated the role of inherited thrombophilia in impairing endometrial and subendometrial blood flows during IVF. DESIGN: Prospective, nonrandomized clinical study. MATERIALS AND METHODS: 85 thrombophilic and 50 non-thrombophilic women were included and tested for inherited thrombophilia,including:FV Leiden,MTHFR–CT/-AC, PAI1,HPA1,FII,FXIII, FBG,APOE, PROTEIN C,PROTEIN S.Serial 3D ultrasound scans and power Doppler angiography (PDA) were performed during controlled ovarian hyperstimulation (COH) to measure endometrial and subendometrial blood flow transvaginally monitored by a GE 730Voluson machine.The stored volumes were off line analyzed considering as region of interest the 2mm uterine tissue surrounding endometrium.Endometrial pattern,thickness ,and volume,and PDA indexes of vascularization were calculated on the day of HCG administartion.These measurements were related to embryo implantation.COH was induced by long or short protocol + rFSH.Statistical analysis was performed using the SPSS® software package(SPSS Inc., Chicago, Il, USA). RESULTS: Women affected by inherited thrombophilia showed a marked reduction in vascularization flow indexes compared to the normal ones. In the non-thrombophilic group the all PDA parameters were statistically significantly higher. The number of high grade transferred embryos did not affected implantation/pregnancy rates.Blood flow restrictions appeared to be mostly related to some mutations.Homozigous state worsened the situation.In such women we obtained a very low implantation rate 15% vs 32.8%. CONCLUSION: Endometrial and subendometrial blood flow by 3D power Doppler is a useful tool to evaluate angiogenesis during COH and has been related to IVF outcome.To the best of our knowledge this is the first report regarding inherited thrombophilia and endometrial and subendometrial blood flow indexes.Endometrial and subendometrial blood flow seems to be related to implantation/pregnancy rates.

Assesment of changes in uterine and subendometrial blood flows: the use of prediction outcome in IVF cycles

OBJECTIVE: The aim of this study is to evaluate the relationship between uterine Doppler flow and endometrial and subendometrial blood flows and uterine receptivity during IVF cycles. DESIGN: This is a prospective observational study which is conducted at Zekai Tahir Burak Women's Health Research and Education Hospital, Reproductive Endocrinology Clinic. MATERIALS AND METHODS: Sixty-eight patients from our infertility programme were recruited for this prospective observational study, after giving informed consent. Eight of them were excluded because of total fertilization failure (5 patients) and no sperm extraction in TESE (3 patients). A color Doppler ultrasound examination performed on the day of hCG injection and midluteal phase. Pulsatility and resistance indices of uterine vessels, and vascularization and flow endometrial and subendometrial region were assumed. No Doppler study was done on the endometrium in midluteal phase. RESULTS: There were no significant differences in the age of patients, BMI of patients, duration of infertility,cycle lenght or total number of embryos transferred between women who became pregnant (n =16) and those who did not (n = 44). There were no difference in mean endometrial thickness between the two groups on hCG day and 5-6days after embryo transfer. Mean uterine arterial resistance index (RI) and Pulsatility Index (PI) values were not significantly different in both group on hCG day but both indices were significantly lower in the pregnant than in the non-pregnant group in mudluteal phase (p=0.05 and 0.016, respectively). Also no significant differences were found between the two groups in subendometrial blood flow. CONCLUSION: Patients undergoing IVF-ICSI and embryo transfer, Doppler ultrasound examination of the uterine artery and subendometrial blood flow on hCG day do not discriminate between cycles resulting in conceived and non-conceived but especially low mean PI of uterine artery in 5-6 days after ET can predict pregnancy.

Recurrent miscarriage associated with antiphospholipid antibodies: assessment of endometrial and subendometrial characteristics by three-dimensional ultrasonography and power doppler angiography

OBJECTIVE: The antiphospholipid antibodies (APA) are recognized being closely related to recurrent miscarriage (RM). The aim of this study was to evaluate endometrial and subendometrial parameters by three-dimensional ultrasonography and power Doppler angiography (3D-PDA) in primary RM patients with APA (aPL-RM). DESIGN: A prospective observational study of vaginal 3D-PDA assessment for endometrial-subendometrial area in mid-luteal phase. MATERIALS AND METHODS: Out of 1109 primary RM patients between August, 2007 and January, 2010, 107 non-pregnant patients with anticardiolipin antibodies and/or lupus anticoagulant (aPL-RM group) and 46 fertile Control women without APA who have had one or more live births and no history of spontaneous abortions were enrolled. All subjects underwent a screening protocol to exclude the common genetic, anatomical, endocrine, immunological, behavioral and infectious factors associated with RM. Uterine arteries flow indices and endometrial-subendometrial vascularity were measured on the 7th day after the ultrasonographically confirmed ovulation by GE Voluson i machine. Endometrial volume (EV), subendometrial volume (sEV), vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were calculated using the VOCAL (Virtual Organ Computer-aided AnaLysis) software. RESULTS: No significant differences were observed in EV,sEV, uterine arteries pulsatility index and resistive index between the two groups. aPL-RM patients had significantly lower subendometrial FI (P=.000), endometrial VI (P=.048) and FI (P=.000) as well as endometrial and subendometrial VFI (P=.000 and .011,respectively) than the Control group; but no significant difference in subendometrial VI (P=.260) could be detected between the two groups. CONCLUSION: A decrease in endometrial and subendometrial blood flows detected by 3D-PDA may demonstrate the impaired implantation environment in aPL-RM patients.

OP30.04: Comparison of endometrial thickness, uterine artery Doppler and subendometrial blood flow among users of different Progestin contraceptives

This report discusses the effect of Mirena intrauterine device (IUD) depot medroxyprogesterone acetate (Depo Provera) and Progestin only pills on endometrial thickness uterine artery Doppler and subendometrial blood flow.

Endometrial blood flow measured using three-dimensional power Doppler ultrasound may be a predictor of pregnancy in women undergoing intrauterine insemination

OBJECTIVE: This study was aimed to investigate whether endometrial and subendometrial blood flow parameters measured using three-dimensional power Doppler ultrasound (3D PD-US) can predict pregnancy following intrauterine insemination (IUI).

Endometrial blood flow is impaired in women with polycystic ovarian syndrome who are clinically hyperandrogenic

To quantify endometrial and subendometrial blood flow in Caucasian women with polycystic ovarian syndrome (PCOS) and to determine whether these values differ according to the phenotypic expression of PCOS. Transvaginal pelvic ultrasound was performed on the 3(rd)-5(th) day of the menstrual cycle in 36 women with PCOS and 36 controls to examine the endometrial and subendometrial vascularity. The subendometrial and endometrial blood flow indices (vascularizaton index (VI), flow index (FI) and vascularization flow index (VFI)) were measured using three-dimensional power Doppler angiography. Uterine artery blood flow was assessed through analysis of two-dimensional (2D) pulsed-wave Doppler waveforms. Analysis was performed to compare PCOS with non-PCOS women, and subgroup analysis was performed of the PCOS women categorized according to their phenotypic manifestation. There were no significant differences in endometrial volume, subendometrial vascularity and uterine artery blood flow between women with PCOS and controls after controlling for body mass index (BMI). On subgroup analysis, compared with anovulatory but clinically normoandrogenic women with polycystic ovaries (PCO) and with controls, women with PCO who were both clinically hyperandrogenic and anovulatory had significantly lower endometrial (VI: 0.57% vs. 1.11% and 0.86%, respectively, both P = 0.01; VFI: 0.14 vs. 0.42 and 0.28, respectively, both P = 0.02) and subendometrial (VI: 1.59% vs. 3.17% and 2.47%, P = 0.01 and 0.02, respectively; VFI: 0.50 vs. 1.67 and 0.96, P = 0.01 and 0.02, respectively) blood flow. Moreover, clinically hyperandrogenic but ovulatory women with PCO also had significantly lower endometrial blood flow (VI: 0.52% vs. 1.11%, P = 0.04) than did anovulatory but clinically normoandrogenic women with PCO. There were no differences in any of the 2D pulsed-wave Doppler measures of blood flow between the subgroups. Subendometrial and endometrial blood flow is significantly impaired in women with PCOS who have clinical signs of hyperandrogenism.

Relationship between endometrial and subendometrial blood flow measured by three-dimensional power Doppler ultrasound and pregnancy after intrauterine insemination

To evaluate whether endometrial and subendometrial blood flow parameters measured using three-dimensional power Doppler ultrasound (3D PD-US) can predict pregnancy after IUI. Prospective clinical study. Infertility center in a referral hospital. One hundred six women who underwent ovulation induction and IUI. A color Doppler ultrasound and a 3D PD-US examination were performed on the day of IUI. Pulsatility index (PI), resistance index (RI), and systolic/diastolic (S/D) ratio of uterine artery, and vascularization index (VI), flow index (FI), and vascularization flow index (VFI) of the endometrium as well as those of subendometrial region. These measurements were analyzed in relation to IUI outcome (pregnant vs. nonpregnant). The pregnant group had higher endometrium VI, FI, and VFI scores than the nonpregnant group. In contrast, the subendometrial region VI, FI, and VFI scores did not differ between the groups, nor did the uterine artery PI, RI, and S/D. Pregnancies did not occur when endometrial blood flow had not been detected. Three-dimensional PD-US was useful for evaluating endometrial and subendometrial neovascularization in IUI cycles. Endometrial blood flow parameters may be useful predictors for pregnancy.

Comparison of the effects of the levonorgestrel-releasing intrauterine system (Mirena®) and depot-medroxyprogesterone acetate (Depo-Provera®) on subendometrial microvascularisation and uterine artery blood flow

Objective To compare the effects of the levonorgestrel-intrauterine system (LNG-IUS) and depot-medroxyprogesterone acetate (DMPA) on subendometrial vascularisation and uterine artery blood flow.Study design The trial compared 25 patients wearing a LNG-IUS and 25 patients receiving DMPA. The subendometrial blood flow was evaluated using power Doppler analysis; the pulsatility index (PI) and resistance index (RI) in the uterine artery and spiral arteries were evaluated with spectral Doppler.Results The PI and RI of the uterine artery and endometrial thickness did not differ significantly between the two groups. The subendometrial vascularisation was lower and the PI in the spiral arteries was higher in DMPA-users.Conclusion In spite of a similar prevalence of bleeding disturbances, the effects of DMPA and the LNG-IUS on the subendometrial microvascularisation differ.

Changes in endometrial and subendometrial blood flow in IVF

A good blood supply to the endometrium is usually considered as an essential requirement for implantation. Endometrial and subendometrial blood flow was evaluated on the days of human chorionic gonadotrophin (HCG) administration and embryo transfer and the percentage change in endometrial and subendometrial blood flow between these 2 days was assessed as a predictor of pregnancy during IVF treatment. A three-dimensional (3D) ultrasound examination with power Doppler was performed in 293 patients undergoing the first IVF cycle to determine endometrial thickness, endometrial volume, vascularization index, flow index and vascularization flow index of endometrial and subendometrial regions on the days of HCG and embryo transfer. Patients in non-pregnant and pregnant groups had comparable endometrial thickness, endometrial volume and 3D power Doppler flow indices of endometrial and subendometrial regions measured on either day. Percentage changes in endometrial and subendometrial 3D power Doppler flow indices were also similar. In conclusion, endometrial and subendometrial blood flow on the days of HCG and embryo transfer and the percentage change in endometrial and subendometrial blood flows between these 2 days were not predictive of pregnancy in IVF treatment.

Qualité de la préparation endométriale

The gold standard in endometrial preparation remains what has been established for oocyte donation receivers. This preparation requires E2 for 14 days and then P4 in isolation. Endometrial thickness can now be evaluated with three-dimensional ultrasound or with the VOCAL system, which can evaluate endometrial volume: however, the mean thickness of the endometrium only has a predictive value for pregnancy at 6 mm, on day 6 or on the day that hCG is triggered. Despite the technical progress made, Doppler ultrasound, which can evaluate endometrial and subendometrial blood flow, does not contribute valid responses as to uterine receptivity and the chances for pregnancy. However, the level of uterine contractions at embryo transfer is recognized as a major factor of implantation and, to obtain faster uterine quiescence, it is recommended to begin progesterone before the transfer. The need for prolonged progesterone maintenance in case of pregnancy continues to be debated.

Endometrial thickness and pattern, uterine and sub-endometrial blood flow in women with unexplained infertility undergoing COH and IUI

OBJECTIVE: Poor receptivity of the endometrium during the peri-implantation period may be one of the potential causes in women with unexplained infertilty. The objective of the study was to assess endometrial thickness and pattern, uterine and sub-endometrial blood flow and their changes during peri-implantation period in predicting pregnancy rate in women with unexplained infertility undergoing COH with IUI.

Subendometrial microvascularization and uterine artery blood flow in IUD-induced side effects (levonorgestrel intrauterine system and copper intrauterine device)

Background A better understanding of the uterine and endometrial vascularization in intrauterine device (IUD)-induced side effects is clearly of paramount importance in terms of both physiological and pathophysiological changes and may permit assessment for future therapeutic treatments. The aim of the study was to quantify the subendometrial microvascularization and uterine artery blood flow in IUD-induced side effects using power Doppler analysis as well as pulsatility index (PI) and resistance index (RI) in the exact midluteal phase 3 months after IUD insertion. There were 27 patients using the levonorgestrel-releasing intrauterine system and 25 patients using TCu 380A. Study Design This study has a prospective clinical trial design. Results There is an increased subendometrial blood flow in patients with severe dysmenorrhea and/or bleeding, after controlling for IUD type, age and parity. Moreover, the PI and RI were not different in such women. Conclusion The results provide new data on the bleeding patterns related to these IUD types that may be relevant during contraception use. This method could be used as a prognostic factor to better evaluate women for the risk of developing dysmenorrhea and/or bleeding after IUD insertion.