Association between Myometrial Thickness and Assisted Reproductive Technologies Outcomes: A Prospective Cohort Study.

BACKGROUND: Myometrial thickness has been expected to be a prognosticator for lower uterine segment function. An abnormal function of the uterine muscle layer can cause common and important reproductive problems. This study aimed to evaluate the relationship between baseline myometrial thickness and assisted reproductive technologies (ART) outcomes. MATERIALS AND METHODS: In this prospective cohort study, 453 infertile women undergoing ART cycles without any obvious uterine pathology, participated in this prospective cohort study from February 2013 to May 2015. In order to measure the myometrial thickness in the anterior and posterior of the uterine, trans-vaginal ultrasounds were conducted on days 2-4 of the cycle (menstrual phase) preceding ovarian stimulation and the day of human chorionic gonadotropin (hCG) injection. We defined three groups based on the baseline myometrial thickness in the anterior and posterior, including (A) <25 mm, (B) 25-29.9 mm and (C) ≥30 mm. Ovarian stimulation, oocyte retrieval and luteal phase support were performed in accordance with the standard long protocol. Two weeks after embryo transfer, the patients underwent a pregnancy test by checking their serum ß-hCG levels. The primary outcome measure was clinical pregnancy rate. Secondary outcome measures were, implantation rate, abortion rate and live birth rate. RESULTS: The clinical pregnancy (P=0.013) and implantation (P=0.003) rates were significantly lower in group A than in two other groups. Although the live birth rate was lower in group A than two other groups, this decrease was not statistically significant (P=0.058). CONCLUSION: The findings may be a way for clinicians to draw focus on providing therapeutic strategies and a specific supportive care for women with a baseline myometrial thickness <25 mm in order to improve the reproductive outcome of in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI).

Verification Bias Correction in Endometrial Abnormalities in Infertile Women Referred to Royan Institute Using Statistical Methods.

Background: Verification bias is a common bias in the diagnostic accuracy of diagnostic tests and occurs when a number of individuals do not perform the gold standard test. In this study, we review the correcting methods of verification bias. Methods: In a cross-sectional study in 2020, 567 infertile women who were referred to Royan Research Institute were evaluated. The ultrasound is the performed test and the gold standard are hysteroscopy for some, and pathology for other abnormalities. For correcting verification bias conventional, Begg and Greens, Zhou, and logistic regression methods were used. Results: In the gold standard hysteroscopy test, the sensitivity (SEN) and specificity (SPEC) obtained in conventional, Begg and Greens, Zhou, and logistics Regression methods were (50%, 90.3%), (48%, 96%), (22%, 77%), (50%, 90%), and (72.8, 77) respectively. Furthermore, the area under the curve (AUC) index and kappa statistics were calculated as 70.2%, and 43.6% respectively. In the pathology gold standard test, the SEN and SPEC for the conventional methods, Begg and Greens, Zhou and logistics regression were (67.7%, 86.7%), (66%, 88%), (29%, 70%), (66.9%, 87.6%), and (73%, 83.9%) respectively. Also, the AUC index and kappa statistics were 77%, and 55% respectively. Conclusion: In the study on endometrial abnormalities in infertile women, assuming that the missing data mechanism is random, the amount of bias in calculating SEN and SPEC is very low in the diagnostic tests calculated before and after correction, using Begg and Greens and logistic regression method. But Zhou's method gives rather large biased estimates.

Hysterosalpingography in the assessment of proximal tubal pathology: a review of congenital and acquired abnormalities.

Tubal and peritoneal disease are the main causes of infertility. Tubal pathology can be either congenital malformation or acquired, proximal or distal, unilateral or bilateral and transient or permanent. Several imaging methods such as laparoscopy, fluoroscopy, saline infusion sonography, and hysterosalpingography (HSG) have been used in the assessment of tubal and peritoneal pathology. Although laparoscopy is the modality of choice for investigating tubal patency and pelvic structure in many infertility centers, HSG is usually the initial diagnostic method for infertility workup because of its ease of performance, accuracy, and minimal risk of complications. This method provides useful information about size, contour, and anatomy of the inner surface of the fallopian tubes and is the gold standard for evaluation of tubal lumen. Tubal and peritubal pathology show various imaging manifestations on HSG. This review illustrates the radiographic features of congenital and acquired structural abnormalities of the proximal tubal pathology and along with etiology of proximal obstruction or occlusion will be described.

Two leading international congresses in Iran in the era of COVID-19: 21st royan international twin congress, 4th international and 16th Iranian genetics congress.

In this report, we look at the challenges posed by the outbreak of COVID-19 and how the Executive Board of these two congresses succeeded in overcoming those challenges and holding two congresses. The approach for a large festival with different virtual setting components provided a suitable solution that led to exemplary achievements and created an appropriate model for future virtual or combined virtual and face-to-face events. These events proved that pandemic problems could not limit the organizers, pushing them to make better use of the facilities and turning this threat into an opportunity.

Hysterosalpingography findings of leiomyomas and how they look in artistic eyes: new diagnostic signs.

Leiomyomas are benign lesions of the uterine smooth muscles that contain various amounts of fibrous connective tissue. Hystrosalpingography is not a method of diagnosing uterine fibroids, and other methods such as ultrasound and MRI are preferred, but during hystrosalpingography, especially in infertile females, uterine fibroids may be seen frequently. Leiomyomas have a wide range of appearances depending on their number, size and location. Leiomyomas may enlarge, elongate, displace, distort or rotate the uterine cavity and can be detected by such changes showing in hysterosalpingograms. These changes may be symmetric or asymmetric. Leiomyomas may result in uterine atony which can be locolized or generalized. Leiomyomas also may appear as one or multiple filling defects in different sizes which can be smooth or irregular. Some of the noted findings may create similar and frequent appearances looking like some patterns in nature and can be considered "excellent signs" for better detecting and enabling differential diagnosis. This study aims to improve the process of training on the diagnostic appearances of leiomyomas in hysterosalpingography by aligning the images with patterns found in nature that can be easily remembered by radiologists.

Predictive Value of Endometrial Length Measurement by Transvaginal Ultrasound and IVF/ICSI Outcomes.

BACKGROUND: The purpose of this study to determine the relationship between endometrial length and positive pregnancy test in patients who underwent assisted reproductive technology (ART). MATERIALS AND METHODS: This cross-sectional study included patients who were referred for in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) therapy from 2013 to 2016. All nulliparous women who met the inclusion criteria were between 20-38 years of age and presented for ultrasound measurements prior to fresh embryo transfer (ET). Endometrial length was measured by transvaginal ultrasound (TVS) with a Medison Accuvix device on the day of human chorionic gonadotropin (hCG) administration. The relationship between endometrial length and treatment success was assessed. The independent sample t test, receiver operating characteristic (ROC) curve and the area under the curve (AUC) index and chi-square test were used for data analysis. P<0.05 were statistically significant. RESULTS: There was a significant relationship between endometrial length (41.5%) and treatment success (P<0.05). The endometrial length of 41.5(mm) with a sensitivity of 66.7%, specificity of 50.6%, positive predictive value of 46.8%, negative predictive value of 69.4%, and efficiency of 56.62% can be used as a proper cut-off point with an AUC of 0.63. CONCLUSION: The value of 41.5(mm) for endometrial length can be used as a proper cut-off point for prediction of a higher ART success rate. We recommend TVS as the first step for assessment of uterine and endometrium receptivity in the ART cycle.

Pain Perception and Side Effects During Saline Infusion Sonohysterography With a Balloon Catheter: A Randomized Comparative Study of Cervical Versus Intrauterine Catheter Placement.

OBJECTIVES: This study aimed to evaluate whether the site of the balloon placement into either the uterine cavity or cervical canal can affect the intensity of pain during sonohysterography. METHODS: In this randomized clinical trial, women who underwent saline infusion sonohysterography (SIS) were randomized to intracervical or intrauterine balloon placement between May 2012 and May 2014. The examination was scheduled at the early follicular phase of the menstrual cycle. The primary outcome measures included the degree of pain after inflation and then after deflation of the balloon catheter. Data were analyzed on the basis of the intention-to-treat principle for each woman who underwent SIS. RESULTS: A total of 300 infertile women were assigned to the treatment groups. There were no significant differences in inflation and deflation pain and the total procedure time between the 2 groups. The total volume of required saline for adequate distention of the cavity was significantly lower in the cervical group than the intrauterine group (p = .015). Nulliparous women had insignificantly more pain after the initial inflation of the balloon compared with multiparous women (p = .069). The pain score was not associated with patients' age, the volume of the saline infused, the presence of intrauterine abnormality, and the procedure time. CONCLUSIONS: Intracervical catheter placement did not reduce pain during or after SIS. However, intracervical balloon insertion requires a less-significant volume of saline compared with intrauterine placement, leading to a reduced risk of intrauterine infection and the spread of malignant endometrial cells into the peritoneal cavity at the time of the procedure.

The Effect of Vaginal Sildenafil on The Outcome of Assisted Reproductive Technology Cycles in Patients with Repeated Implantation Failures: A Randomized Placebo-Controlled Trial.

BACKGROUND: The aim of this study was to investigate the effects of vaginal sildenafil on the outcome of patients with at least two unsuccessful in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) attempts. MATERIALS AND METHODS: In this randomized placebo-controlled trial study, a total of 66 infertile women aged ≤38 years, with a history of normal ovarian reserve, two prior consecutive failed IVF/ICSI attempts, human chorionic gonadotropin (hCG) day endometrial thickness <7 mm in all prior IVF/ICSI cycles, normal endometrial appearance by either hysteroscopy, hysterosonography, or hysterosalpingography enrolled in this study. The conventional gonadotropin-releasing hormone (GnRH) protocol was used for ovarian stimulation. The patients were randomly divided into three groups: vaginal sildenafil (suppository-100 mg/daily), vaginal placebo/sildenafil (suppository-100 mg/daily), and vaginal placebo (suppository). Each patient underwent colour Doppler ultrasound on day 14 of their previous cycle to investigate any abnormalities in the uterus and adnexa. Endometrial thickness, echo pattern, uterine artery resistance, and pulsatility indices were recorded pre- and post-treatment. The primary outcome measures were implantation, chemical and clinical pregnancy rates. For data analysis, SPSS version 20 software was used. In all tests, the significance level was considered less than 0.05. RESULTS: There was no significant difference between three groups in endometrial thickness on the hCG injection day. The chemical pregnancy in women who received sildenafil (alone or in combination with placebo) showed a two-fold increase in comparison to the placebo group. This increase was clinically meaningful, but according to sample size, it was statistically non-significant. The results of our study showed that the implantation was higher in women who received placebo/sildenafil compared to the other groups. The abortion rate was not statistically significant among the groups. CONCLUSION: Vaginal sildenafil may conceivably improve chemical pregnancy rates in repeated IVF failure patients. Further randomized clinical trials using oral or vaginal sildenafil with higher sample size are recommended (Registration number: NCT03192709).

Ultrasound Evaluation of Visceral Fat Thickness for Prediction of Metabolic Syndrome in the First Trimester of Pregnancy in a Sample of Non-obese Iranian Women.

OBJECTIVES: Ultrasonography is a noninvasive and safe modality for assessing body fat and is routinely performed in developed countries. Although pregnant women with obesity are at risk for many unfavorable outcomes, the relationship between abdominal fat distribution and metabolic syndrome (MS) is evident in some studies. Therefore, it is important to evaluate fat thickness in non-obese women and predict MS using fat thickness measurement. METHODS: A total of 132 pregnant women completed anthropometric and demographic questionnaires. All women were scanned for visceral fat thickness (VFT) via ultrasound at 11-14 weeks gestation. Body mass index (BMI) and waist circumference (WC) were calculated at the first prenatal visit. MS components were also measured in the same weeks. RESULTS: MS was detected in seven (5.3%) women. There was a statistically significant difference between women with and without MS for weight, WC, anterior and posterior VFT, insulin, lipid profile (total cholesterol, high-density lipoprotein cholesterol, and triglyceride), and systolic and diastolic blood pressure (p < 0.050). The optimal cut-off points determined for predicting MS disorder were an anterior VFT of 43.83 mm and a posterior VFT of 32.50 mm. CONCLUSIONS: Fat thickness measurement in the first trimester is a good predictor for MS even in women with a normal BMI. Ultrasonography as a safe, simple, and cost-effective modality can be used to assess fat thickness besides the other screening evaluations in the first trimester of pregnancy.

Does low-dose aspirin improve pregnancy rate in women undergoing frozen-thawed embryo transfer cycle? A pilot double-blind, randomized placebo-controlled trial.

AIM: To evaluate the effect of adjuvant low-dose aspirin therapy on clinical pregnancy rate and uterine perfusion in women undergoing frozen-thawed embryo transfer (FET) cycles. METHODS: This study was performed as a pilot randomized, double-blind placebo-controlled trial, from May 2012 to February 2015. Overall, 60 available eligible women who were candidates for FET were randomly assigned to two groups receiving either 100 mg oral aspirin (n =30) or placebo (n =30). The primary outcome measure was clinical pregnancy rate. Secondary outcome measures were pulsatility index (PI), resistance index (RI), implantation rate, live birth rate and miscarriage rate. RESULTS: There was no significant difference in endometrial thickness, PI and RI. However, the study group had higher rates of clinical pregnancy, implantation, live birth (P = 0.042, P = 0.031 and P = 0.007, respectively) and lower rate of miscarriage (P = 0.020) as compared to the control group. Twin birth rate was comparable between the two groups. CONCLUSION: Our pilot study demonstrated that administration of low-dose aspirin in FET cycles results in better pregnancy, implantation and live birth rates without changing the uterine hemodynamics or endometrial thickness. However, further randomized clinical studies in larger populations are needed to confirm these findings.

Interstitial ectopic pregnancy diagnosis by three-dimensional ultrasound and its laparoscopic management: A case report.

BACKGROUND: Interstitial Ectopic Pregnancy (IEP) is an uncommon type of ectopic pregnancy with the risk of rupturing and bleeding. The incidence of IEP is about 2-4% of all EPs. The diagnosis and management are challenging. We present a well-timed and managed case of IEP. CASE: The case was a 37-yr-old woman presented at the Royan Institute with a chief complain of sudden onset of pelvic pain and moderate vaginal bleeding, three weeks after her positive pregnancy test. She had got pregnant with in-vitro fertilization procedure. She was admitted for a two-dimensional ultrasound (2DUS). The 2DUS findings showed a gestational sac with live embryo and yolk sac which was located high in the fundus and eccentric to the endometrium. The suspicion of IEP rose after the 2DUS findings, the confirmation of further diagnosis was then done by three-dimensional ultrasound, and the treatment was done by laparoscopy. The patient underwent laparoscopic left corneal resection. She was discharged after two days and her ß-hCG achieved complete resolution ( < 5 mIU/mL) after two weeks' follow-up. CONCLUSION: According to the life-threatening complications that are associated with IEP, acquaintance and suspicion about IEP is important. Specified information that obtained by three-dimensional ultrasound could be useful for exact locating and detection.

A case report of Ggeneralized uterine arteriovenous malformation after molar pregnancy in an infertile woman.

BACKGROUND: Uterine arteriovenous malformation (UAVM) is a rare vascular condition in reproductive age presented mostly with bleeding. Although this malformation is infrequent, it is potentially life-threatening. Transvaginal Doppler ultrasonography is a widely available, noninvasive and excellent diagnostic method. CASE: The case is a 30-yr-old woman with a history of eight-yr infertility.following intrauterine insemination treatment, she had a molar pregnancy. Despite methotrexate treatment, there was persistent vaginal bleeding. Assessment of this patient was done with transvaginal sonography and color Doppler. According to suspicious appearances, angiography was planned for confirmation of UAVM. CONCLUSION: UAVM is one of the molar pregnancy complications. The first step for diagnosis of UAVM is transvaginal ultrasonography and color Doppler assessment. Embolization is the best treatment for women who intend to preserve fertility.

Hysterosalpingography in The Assessment of Congenital Cervical Anomalies.

Cervical abnormalities may be congenital or acquired. Congenital anomalies of the cervix are rarely isolated, and more commonly accompany other uterine anomalies. Various imaging tools have been used in the assessment of Müllerian duct anomalies (MDAs). Currently, magnetic resonance imaging (MRI) is the modality of choice for definitive diagnosis and classification of these MDAs. Hysterosalpingography is a basic tool for evaluation of infertility and allows us to detect a spectrum of anatomical malformations of the utero-cervix in the setting of MDAs. It provides good outlines of the uterine cavity and fallopian tubes, as well as the cervical canal and isthmus. However, hysterosalpingograms (HSG) cannot be performed in patients with isolated congenital maldevelopment (agenesis/disgenesis) of the cervix. This part of pictorial review illustrates the various radiographic appearances of congenital malformations of the utero-cervix with a brief overview of the embryologic features. Accurate diagnosis of such cases is considered essential for optimal treatment and categorization of each anomaly.

Value of Endometrial Echopattern at HCG Administration Day in Predicting IVF Outcome.

BACKGROUND: Assisted reproductive  treatment  (ART)  cycle  is an  expensive  procedure with low implantation and pregnancy rate; therefore, it is necessary to evaluate the predictors of success in these patients. OBJECTIVE: The relationship between endometrial echopattern and pregnancy rate was evaluated. METHODS: The endometrial  echopattern  was  analyzed  prospectively  on  the  day  of  human chorionic  gonadotropin  (HCG) administration  in  280  in  vitro  fertilization/intracytoplasmic  sperm  injection (IVF/ICSI) cycles with 8-14 mm endometrial thickness at Royan institute in 2013-2014. Based on echopattern, three groups were developed: pattern A (Triple line), pattern B (Heterogeneous-echogen) and pattern C (Homogeneous-echogen). Pregnancy rate (PR) was compared between all groups. Data was analyzed using SPSS (v.18, Chicago, IL, USA), and descriptive tests such as Chi-square and analytical tests like logistic regression, for controlling confounder variables like age. RESULTS: Among 280 patients finally evaluable, the distribution of endometrial echopattern on the day of HCG administration was 127 patients (45.4%) in group A, 98 patients (35%) in group B and 55 patients (19.6%) in group C. The highest PR per transfer pertained to group A (49.6%), and the lowest to group B (32.7%). CONCLUSION: The presence of pattern A (Triple line) appears more likely to favor pregnancy. Therefore, ultrasonographic evaluation of endometrial echopattern on the day of HCG administration has prognostic value in clinical settings for predicting implantation in ART cycle.

Adnexal masses or perineural (tarlov) cysts? Differentiation by imaging techniques: A case report.

BACKGROUND: Perineural cysts formed within the nerve-root sheath at the dorsal root ganglion. They are most commonly located in the arachnoid covering the junction of the dorsal ganglion and nerve root. They are usually asymptomatic, incidental findings, usually located in the lumbar and sacral region of the spinal canal. It is important to consolidate the imaging findings of this rare disease so clinicians can become more clinically relevant in the evaluation of these cysts. CASE: Herein we report a case of perineural cyst misdiagnosed with hydrosalpinx by pelvic ultrasonography and finally diagnosed with magnetic resonance image. CONCLUSION: Perineural cyst should be considered, in the presence of bilateral adnexal masses separated from the ovaries in pelvic sonography.

Imaging and Clinical Data of Placental Site Trophoblastic Tumor: A Case Report.

Placental site trophoblastic tumor (PSTT) is a very rare variant of gestational trophoblastic tumor. It can occur after normal termination of pregnancy or spontaneous abortion and ectopic or molar pregnancy. There is a wide range of clinical manifestations from a benign condition to an aggressive disease with fatal outcome. One of the most important characteristics of PSTT, unlike other forms of gestational trophoblastic diseases (GTD) is the presence of low beta-subunit of human chorionic gonadotropin (ß-hCG) levels because it is a neoplastic proliferation of intermediate trophoblastic cells. However, human placental lactogen (hPL) is increased on histologic section and in the serum of patients too. We present a case of PSTT and discuss the differential diagnosis in order to further familiarize physicians with the diagnosis and treatment of this disease. It has a varied clinical spectrum and usually presents with irregular vaginal bleeding or amenorrhea. Diagnosis is confirmed by dilatation and curettage (D and C) and hysterectomy. Because chemotherapy is not effective, surgery is the cornerstone of treatment. This case is presented because it is a rare neoplasm with different treatments and it should be differentiated from molar pregnancy.

Outcome of isolated fetal choroid plexus cyst detected in prenatal sonography among infertile patients referred to Royan Institute: A 3-year study.

BACKGROUND: Several studies have assessed the correlation of fetal choroid plexus cyst (CPC) and the risk of congenital anomalies, but few ones have discussed isolated CPC (with no other abnormal sonographic finding). OBJECTIVE: The aim of this study was to determine the outcome of isolated fetal choroid plexus cyst and to specify its clinical significance. MATERIALS AND METHODS: This cross sectional study was carried out at Royan Institute in Tehran, Iran, between April 2009 and December 2012. All prenatal sonographies in this period of time were assessed using a computerized database and fetuses who had isolated CPC were recruited in the study. Sonography reports, mother serum screening test results, fetal echocardiography and amniocentesis were evaluated until birth. A follow-up phone call was made to all individuals to learn about the neonatal outcomes. RESULTS: Overall, 6240 prenatal sonographies were performed in this setting during this period. Isolated CPC was detected in 64 fetuses. The results of double test (N=30), triple test (N=5) and fetal echocardiography (N =24) were normal. Quadruple test result showed 3 abnormal out of 29 cases that all had normal karyotypes. Four samples were dropped out due to premature rupture of membranes (N=3) and intrauterine fetal death (N=1). It was found that the outcomes of all remaining fetuses (N=60) were normal and no anomaly ones were seen until birth. CONCLUSION: Isolated CPC is a benign regressive condition with no clinical significance.

A randomized controlled trial evaluating the effect of ethinyl estradiol during clomiphene citrate cycles among women with polycystic ovary syndrome.

OBJECTIVE: To investigate the effects of low-dose ethinyl estradiol (EE) on the clinical pregnancy rate among women with polycystic ovary syndrome (PCOS) undergoing ovulation induction with clomiphene citrate (CC). METHODS: Between March 12, 2011, and February 10, 2013, a randomized, double-blind, placebo-controlled trial was conducted at the Royan Institute Research Center, Tehran, Iran, among women with PCOS who were aged 25-30 years, were undergoing their first intrauterine insemination cycle, and had a history (≥2 years) of infertility, oligomenorrhea, or amenorrhea. Participants were randomly allocated to receive EE (0.05 mg daily for 5 days) or placebo, co-administered with CC cycles (100 mg daily for 5 days). The primary outcome was clinical pregnancy rate. Analyses were per protocol: patients who discontinued the intervention were excluded. RESULTS: Analyses included 45 women who received CC and EE, and 50 women who received CC and placebo. The number of women who achieved a clinical pregnancy was higher among participants who received CC and EE (13 [29%]) than among those in the control group (5 [10%]; P =0 .02). No adverse effects of EE were reported. CONCLUSION: The combination of CC and EE seems to increase the clinical pregnancy rate among women with PCOS undergoing intrauterine insemination. ClinicalTrials.gov:NCT01219101.

Endometrial Adenocarcinoma in A 31-Year Old Woman: A Case Report.

Endometrial adenocarcinoma (EC) usually occurs after menopause, whereas in 2-14% of cases, it occurs in young patients (less than 40 years old) who may desire to keep their fertility. It is of importance to evaluate women for EC when they develop polycystic ovarian syndrome and abnormal uterine bleeding. Its treatment includes hysterectomy, bilateral salpingo-oo- phorectomy and pelvic lymphadenectomy and in some cases, radiation therapy. We report a case of EC in a 31-year-old woman who presented to Royan Institute. She complained about oligomenorrhea with a 10-year history of primary infertility.