Endometrial vascularity by three-dimensional power Doppler ultrasound and cytokines: a complementary approach to assess uterine receptivity.

INTRODUCTION: Uterine receptivity was assessed simultaneously by measurement of vasoactive cytokines possibly involved in development of spiral arteries and by assessment of endometrial and uterine arterial blood flow. The objective was to explore the relationship between cytokine-related dysregulation and endometrial vascularisation in women with repeated implantation failures after in vitro fertilisation embryo transfer (IVF-ET). MATERIALS AND METHODS: We studied 40 women with recurrent IVF/ICSI-ET failures, despite replacement of more than 10 embryos of 'good quality', and 8 fertile controls. Three-dimensional ultrasound with power angiography was performed to record the sub-endometrial vascular flow index (VFI) and uterine artery pulsatility index prior to endometrial biopsy at day 21-23 of a monitored natural cycle. Endometrial IL-18, IL-18BP and IL-15 mRNA expression was assessed by real-time PCR, and the number of CD56(+) cells determined by immunochemistry. RESULTS: IL-18 and IL-15 mRNA expression was significantly different between the two groups. The range of variation in vascular imaging data was increased in the implantation failure (IF) group. The mRNA ratio for IL-15, but not the other cytokines, correlated with sub-endometrial vascular flow (r=0.65; p<0.001). This ratio correlated also with the mean number of CD56(+) cells per high-power field (r=0.41; p=0.005). Both IL-18 and IL-18BP mRNA expression was significantly negatively correlated with mean uterine artery pulsatility index (r=-0.37 and -0.43; p=0.02 and 0.01, respectively). CONCLUSION: Comprehensive ultrasonographic indicators appear to be related to various mechanisms, including insufficient or excessive uterine NK cell recruitment and inadequate endothelial vascular remodelling. New molecular tools may be useful in providing greater precision of uterine receptivity than ultrasonic indicators alone.

Novel application of polypropylene sling: transvaginal cervicoisthmic cerclage in women with high risk of preterm delivery.

STUDY OBJECTIVE: To describe a novel technique of transvaginal cervicoisthmic cerclage with a polypropylene sling in prevention of preterm labor in pregnant women at high risk. DESIGN: Retrospective study (Canadian Task Force classification: III). SETTING: University hospital (department of obstetrics and gynecology). PATIENTS: Twenty-one women showing symptoms of high risk of preterm delivery: histories of pregnancy losses in the second trimester and prior failure of MacDonald's cerclage or absent portio vaginalis of the cervix. The median age of the patients was 32.8 years (range 22-39 years). INTERVENTIONS: Cerclage was performed between 12 and 16 weeks' gestation. A polypropylene tape was placed at the cervicoisthmic junction by vaginal route. Caesarean delivery was systematically performed in all patients because the cerclage was considered to be definitive. MEASUREMENTS AND MAIN RESULTS: No intraoperative complications occurred. The mean operating time was 36 +/- 6 minutes (range 30-45 minutes). The mean length of stay was 1.4 +/- 0.5 days. Mean gestational age and birth weight at delivery were respectively 37.1 +/- 1.8 weeks (CI 95%: 36.4-37.9) and 2850 +/- 745 g (CI 95%: 2531-3168). The preterm birth rate was 19% (4/21). One neonatal death occurred after amniotic fluid infection at 34 weeks. Birth at less than 32 weeks occurred in one patient (4%). CONCLUSION: Transvaginal cervicoisthmic cerclage with polypropylene sling may be considered as an effective and minimally invasive alternative to the transabdominal cervicoisthmic cerclage in women presenting with high risk of preterm delivery.

Dynamics of serum anti-Müllerian hormone levels during the luteal phase of controlled ovarian hyperstimulation.

BACKGROUND: To investigate the dynamics of serum anti-Müllerian hormone (AMH) levels during the luteal phase of controlled ovarian hyperstimulation (COH) and its possible association with follicle development. METHODS: We prospectively studied 34 women undergoing COH with GnRH agonist and FSH. On the day of hCG (dhCG), serum AMH, estradiol (E2), progesterone and hCG levels were measured, and ovarian follicles were sorted into three size classes: <12, 12-15 and 16-22 mm. Hormonal measurements were repeated 4 days (hCG + 4) and 7 days (hCG + 7) after hCG. RESULTS: From dhCG to hCG + 4, we observed a decline in serum AMH levels (-64 +/- 3%; P < 0.0001), which paralleled that of E2 levels. From hCG + 4 to hCG + 7, an increase in AMH levels occurred (82 +/- 28%; P < 0.02), whose magnitude was correlated with the number of < 12 mm follicles (r = 0.68; P < 0.0001) but not with other follicle size classes nor with the remaining hormone levels. CONCLUSIONS: After hCG, AMH levels initially decline, presumably as an effect of follicle luteinization, then increase during the mid-luteal phase. Although the mechanisms implicated in the mid-luteal AMH increase are unclear, its positive association with small follicle count, but not with luteal progesterone and E2 levels, supports the hypothesis that AMH levels might reflect luteal follicle development.

Per-follicle measurements indicate that anti-müllerian hormone secretion is modulated by the extent of follicular development and luteinization and may reflect qualitatively the ovarian follicular status.

OBJECTIVE: To investigate the possible influence of follicular maturation and luteinization on anti-müllerian hormone (AMH) secretion and the relationship between per-follicle AMH levels, ovarian follicular status, and responsiveness to controlled ovarian hyperstimulation (COH). DESIGN: Prospective study. SETTING: University hospital in France. PATIENT(S): Thirty seven in vitro fertilization/embryo transfer candidates undergoing COH. INTERVENTION(S): On the day of oocyte retrieval, serum samples and follicular fluids from two small (8-12 mm in diameter) and two large (16-20 mm in diameter) follicles were collected for AMH, E2, and progesterone (P4) measurements. MAIN OUTCOME MEASURE(S): Per-follicle AMH levels. RESULT(S): Small follicles secreted AMH levels that were approximately three times as high as large follicles. Follicular fluid AMH and P4 levels were negatively correlated to each other both in small and large follicles. Per-follicle AMH levels in both follicular classes were positively correlated with antral follicle count on cycle day 3 before COH and with growing follicle (> or =12 mm) count and oocytes retrieved, but negatively correlated with FSH requirement. CONCLUSION(S): Both final follicular maturation and luteinization interfere with granulosa cell AMH production. The relationship between intrafollicular AMH content, the surrounding follicular status, and ovarian response to COH indicates that peripheral AMH levels reflect not only follicle count but also per-follicle AMH production.