Association between ultrasonographic parameters of Cesarean scar defect and outcome of early termination of pregnancy.

OBJECTIVE: To determine whether Cesarean scar defect (CSD) parameters assessed by transvaginal sonography (TVS) might affect the outcome of early termination of pregnancy (TOP) with mifepristone-misoprostol. METHODS: This was a retrospective review of 183 women with previous Cesarean delivery who received oral mifepristone and misoprostol for TOP. A successful TOP was defined by the absence of an intrauterine gestational sac, with no need for surgical intervention. CSD was diagnosed by TVS in the presence of a hypoechogenic indentation within the myometrium of the lower uterine segment at the site of a previous Cesarean incision. Women were analyzed in three subgroups according to size of defect (ratio of residual myometrial thickness over the defect to adjacent myometrial thickness < 30%, 30%-70% and > 70%). RESULTS: Of the 183 women, 43 (23.5%) had failure of TOP. Fifty-nine (32.2%) had CSD detectable at TVS, and these women had a higher failure rate of TOP than did those without CSD (38.9% vs 16.1%; P = 0.001). CSD was associated significantly with failure of TOP (odds ratio, 3.32 (95% CI, 1.64-6.75)). The TOP failure rates in relation to defect size in the myometrial thickness ratio < 30%, 30%-70% and > 70% subgroups were 57.1%, 25.0% and 18.2%, respectively. There was a linear trend in failure rate across these ratios (Cochran-Armitage trend test; P = 0.015). CONCLUSIONS: Women with CSD are at increased risk of failed TOP. Women with a defect in which the residual myometrial thickness was < 30% of the adjacent myometrial thickness tended to have a greater chance of failed TOP. CSD detected at TVS is of clinical relevance in counseling women with a history of Cesarean delivery who are considering TOP. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Assessment of changes in utero-ovarian arterial impedance during the peri-implantation period by Doppler sonography in women undergoing assisted reproduction.

OBJECTIVE: To investigate changes in utero-ovarian blood flow during the peri-implantation period and their significance in successful embryo implantation. METHODS: A prospective longitudinal study was conducted in 317 women undergoing in-vitro fertilization-embryo transfer (IVF-ET) treatment. All of them had at least one good-quality embryo for transfer on the second or third day after oocyte retrieval. Measurement of endometrial thickness and color flow imaging with pulsed waveform analysis of uterine and ovarian arteries were performed before ET and 5-6 days after ET. RESULTS: There were no significant differences in the age of patients, duration of infertility or number of embryos transferred between women who became pregnant (n = 91) and those who did not (n = 226). There was no difference in mean endometrial thickness between the two groups before ET, while a thicker endometrium was found in women who had conceived compared with those who had not 5-6 days after ET (P = 0.02). Mean uterine arterial resistance index (RI) and pulsatility index (PI) values were significantly lower in the pregnant than in the non-pregnant group before ET (P = 0.04 and P = 0.003, respectively), but no significant differences were found between the two groups 5-6 days after ET. In contrast, the mean ovarian arterial RI and PI values were similar between the two groups before ET, yet the pregnant group showed significantly lower RI and PI values compared with the non-pregnant group 5-6 days after ET (P = 0.002 and P = 0.01, respectively). A significantly higher peak systolic velocity (PSV) of intraovarian vessels was also noted in the pregnant group 5-6 days after ET. CONCLUSION: Different utero-ovarian blood flow changes during the peri-implantation period occur in conception and non-conception cycles in women following IVF. Doppler assessment of uterine arterial resistance can help to determine a time interval within the menstrual cycle that is of optimal endometrial status for embryo implantation in assisted conception programs. Delay in achieving adequate uterine perfusion during the temporal window of embryo implantation may have an impact on endometrial receptivity.

Pregnancy following in vitro fertilization and embryo transfer by microsurgical epididymal sperm aspiration from a patient with congenital absence of the vas deferens: a case report.

Congenital absence of the vas deferens (CAVD) has been considered a virtually untreatable cause of male infertility. Men with this condition have been shown on testicular biopsy to have adequate spermatogenesis, and are theoretically producing sperm capable of fertilizing an oocyte. Yet epididymal transit was thought to be essential for the maturation of spermatozoa and development of their fertilizing ability since the characteristics of sperm motility improve as the sperm passes through the cauda. However recent studies in man have shown that spermatozoa aspirated from the obstructed caput epididymis and ductuli efferentia are, in fact, capable of fertilization in vitro. Microsurgical epididymal sperm aspiration (MESA) from the proximal region (caput) of the epididymis, obtained 0.5 x 10(6) sperm per ml, following washing and direct swim-up. Twelve oocytes were inseminated and three embryos were generated for transfer. The patient conceived and delivered a healthy female baby weighting 2838 gm, on March 3, 1994. This is the first documentation in Taiwan of live birth resulting from MESA from a patient with CAVD combined with in vitro fertilization and embryo transfer.

The correlation of the embryo implantation rate with uterine arterial impedance in in vitro fertilization and embryo transfer.

The influence of uterine blood flow impedance on embryo implantation rate was investigated by transvaginal color Doppler sonography examination before embryo transfer. A total of 108 women undergoing in vitro fertilization (IVF) procedures and who had at least one good quality embryo for transfer to the uterus received Doppler evaluation before embryo transfer. Color flow imaging with blood flow waveform analysis from bilateral uterine arteries was obtained to calculate the mean pulsatility index (PI). The correlations between mean PI with the pregnancy rate and the embryo implantation rate (number of embryos implanted/number of embryos transferred) were analyzed. Patients were grouped according to the mean PI value, and the pregnancy rate and embryo implantation rate were 25% (5/20) and 10.7% (9/84), respectively, with a PI < 2.0 (n = 20); 27.5% (14/51) and 12.2% (12/109), respectively, with a PI = 2.00-2.49 (n = 51); 9.5% (2/21) and 3.5% (2/57), respectively, with a PI = 2.50-2.99 (n = 21); and 6.3% (1/16) and 4.3% (2/47), respectively, with a PI [symbol: see text] 3.0 (n = 16). There were no significant differences in either pregnancy rate or embryo implantation rate between the groups with mean PI values less than 2.00 and between 2.00 and 2.49. If a mean PI value of 2.50 was used as the cut-off value, both the pregnancy rate and embryo implantation rate were significantly higher in patients with a mean PI less than 2.50 (p < 0.05). The uterine arterial impedance measured by the Doppler sonographic examination is a non-invasive method for evaluating the endometrial response and a mean uterine PI value of 2.5 can be used as a cut-off value to identify optimal uterine receptivity before embryo transfer.

Effect of peritoneal fluid and serum from patients with endometriosis on mouse embryo in vitro development.

BACKGROUND: The adverse effects on early embryo development as caused by peritoneal fluid exudate and serum from endometriosis patients have been shown, but the underlying mechanism and clinical significance remain unknown. METHODS: Peritoneal fluid (PF) and serum (S) from patients with minimal to mild endometriosis (Group A, n = 12), moderate to severe endometriosis (Group B, n = 6), and others including tubal ligation and uterine myoma (Group C, controls n = 6) were obtained during laparoscopy. Two-cell mouse embryos were cultured at 37 degrees C in 5% CO2, 95% air with supplementation of 10%PF + 1%BSA, 10%S and 10%S + 10%PF in HTF medium. The percentage of progression to the blastocyst stage at 72 and 96 hours was observed and compared among the three groups. RESULTS: Serum and peritoneal fluid from infertile patients with moderate to severe endometriosis appeared to be embryotoxic to the in vitro development of two-cell mouse embryos, but no significant differences were found between minimal to mild endometriosis and group C patients. CONCLUSIONS: These data suggest that the production of embryotoxic factor(s) is related to the clinical stage, and may be derived from endometriotic implants. The correlation of the embryotoxic effect of the peritoneal fluid with that of the serum indicates that embryotoxic factor(s) may enter the systemic circulation and impede early embryogenesis in the reproductive tract. The nature and mechanism of this result demand further study.