Sanja Kupesic

Assessment of endometrial receptivity by transvaginal color Doppler and three-dimensional power Doppler ultrasonography in patients undergoing in vitro fertilization procedures.

The objective of this study was to investigate the usefulness of transvaginal color Doppler and three‐dimensional power Doppler ultrasonography for the assessment of endometrial receptivity. A total of 89 patients undergoing in vitro fertilization procedures were evaluated for endometrial thickness and volume, endometrial morphology, and subendometrial perfusion on the day of embryo transfer. Neither the volume nor the thickness of the endometrium on the day of embryo transfer had a predictive value for conception during in vitro fertilization cycles (P > .05). Patients who became pregnant were characterized by a significantly lower resistance index, obtained from subendometrial vessels by transvaginal color Doppler ultrasonography (resistance index = 0.53 +/‐ 0.04 versus 0.64 +/‐ 0.04, pregnant versus not pregnant, respectively; P < .05), and a significantly higher flow index (13.2 +/‐ 2.2 versus 11.9 +/‐ 2.4; P < .05), as measured by a three‐dimensional power Doppler histogram. No difference was found in the predictive value of scoring systems analyzing endometrial thickness and volume, endometrial morphology, and subendometrial perfusion by color Doppler and three‐dimensional power Doppler ultrasonography. The high degree of endometrial perfusion shown by color Doppler ultrasonography and on three‐dimensional power Doppler histograms on the day of embryo transfer can indicate a more favorable endometrial milieu for successful in vitro fertilization.

Three-dimensional ultrasonographic ovarian measurements and in vitro fertilization outcome are related to age

OBJECTIVE To evaluate whether the number of ovarian antral follicles, ovarian volume, and ovarian stromal blood flow change with age and to prospectively analyze whether three-dimensional ultrasonographic measurements predict ovarian response and IVF outcome. DESIGN Prospective analysis. SETTING Assisted reproductive unit. PATIENT(S) Fifty-six consecutive women 22 to 43 years of age with normal basal serum FSH concentrations who were undergoing their first IVF cycle. MAIN OUTCOME MEASURE(S) Number of ovarian antral follicles, ovarian volume, and ovarian stromal flow index were determined by three-dimensional and power Doppler ultrasonography. Pretreatment measurements were compared with number of recovered oocytes, fertilization rates, and pregnancy rates. RESULT(S) As patient age increased, significant trends in ovarian volume, number of follicles, and stromal vascularity decreased. Three-dimensional ovarian measurements and fertilization rates differed significantly among age groups. For each age group, a higher number of antral follicles, greater ovarian volume, and favorable ovarian stromal vascularity was associated with higher number of retrieved oocytes and increased pregnancy rates. CONCLUSION(S) Increasing patient age is associated with poor ovarian response, as represented by smaller ovarian volume, lower antral follicle count, and poor stromal vascularity. Three-dimensional power Doppler ultrasonography can help to individualize IVF in patients regardless of age.

Fetal hand movements and facial expression in normal pregnancy studied by four-dimensional sonography

Abstract Aim: To evaluate the developmental pattern of fetal hand movements and facial activity and expression during the second and third trimester of pregnancy by four-dimensional ultrasound (4D-US). Subjects and methods: A total of 25 fetuses in uncomplicated pregnancies were analyzed; 15 fetuses at 13 to 16 weeks and 10 fetuses at 30 to 33 weeks of gestation were studied with abdominal 4D-US. After standard assessment in two dimensional (2D) real-time B mode, a 4D mode was switched on. Further examination lasted a maximum of 15 minutes. Results: Isolated hand movement and subtypes of hand movements were easily recognized by 4D-US. The subtypes of hand to head movement are: hand to head, hand to mouth, hand near mouth, hand to face, hand near face, hand to eye and hand to ear. All subtypes of hand to head movement can be seen from 13 weeks of gestation, with fluctuating incidence. Facial activities and different forms of expression are easily recognized by 4D-US. Among these, two types can be easily differentiated: smiling and scowling. Conclusions: 4D-US is superior over real-time two-dimensional ultrasound (2D-US) for qualitative, but inferior for quantitative analysis of hand movements. Thus 4D-US makes it possible to determine exactly the direction of the fetal hand, but the exact number of each type of hand movements can still not be determined. 4D-US is superior over two- and three-dimensional sonography in the evaluation of complex facial activity and expression. Among facial activities observed by 4D-US, simultaneous eyelid and mouthing movements dominate between 30 and 33 weeks of gestation. Pure mouth movements such as mouth opening, tongue expulsion, yawning and pouting are present, but at a significantly lower incidence. Facial expressions such as smiling and scowling can be precisely observed using 4D-US.

Uterine and ovarian perfusion during the periovulatory period assessed by transvaginal color Doppler

OBJECTIVE To measure the flow velocity of the uterine, radial, spiral, and ovarian arteries during the periovulatory period in spontaneous and induced ovarian cycles with confirmed ovulation. DESIGN Daily measurements during the periovulatory period in 78 patients attending an infertility clinic because of the male factor in infertility. RESULTS Uterine flow velocity in spontaneous cycles has a pulsatility index (PI) of 3.16 2 days before ovulation and starts to decrease the day before ovulation (PI = 2.22). In stimulated cycles these changes do not occur, and mean PI of 3.06 remains at that level during the periovulatory period. Clear flow velocity waveforms are obtained from the endometrium and myometrium around the time of ovulation. Data obtained from the radial arteries suggest better myometrial perfusion in patients with natural cycles. Spiral artery flow velocity in spontaneous cycles has a PI of 1.13 the day before ovulation and a nadir of 0.72 is reached the day after ovulation. On the contrary, the mean PI of the spiral artery blood flow in the group with ovulation induction rises during the day before ovulation (PI = 2.32) and reaches a nadir of 1.09 the day after ovulation. CONCLUSIONS These data suggest the presence of better uterine receptivity during the periovulatory phase of natural cycles compared with induced ovarian cycles. Endometrial perfusion presents accurate noninvasive assay of uterine receptivity that may be used to predict implantation success rate, to reveal unexplained infertility problems, and to select patients for correction of endometrial perfusion abnormalities by an appropriate treatment.

Contrast-enhanced, three-dimensional power Doppler sonography for differentiation of adnexal masses

Objective To investigate the potential usefulness of contrast-enhanced, three-dimensional power Doppler sonography in the differentiation of benign and malignant adnexal lesions. Methods A total of 45 patients with complex adnexal lesions of uncertain malignancy at transvaginal B mode and/or color Doppler sonography were prospectively evaluated with three-dimensional power Doppler sonography before and after injection of contrast agent. Presence of a penetrating pattern and a mixed penetrating and peripheral pattern suggested adnexal malignancy. All the results were compared with histopathology. Results There were 12 cases of ovarian malignancy and 33 benign adnexal lesions. Of the 12 ovarian cancers, seven (58.3%) showed vascular distribution suggestive of malignancy at nonenhanced three-dimensional power Doppler sonography. After injection of contrast agent, a penetrating vascular pattern and/or a mixed penetrating and peripheral pattern were detected in all cases of ovarian malignancy. One cystadenofibroma demonstrated penetrating vessels at initial scan, whereas two benign lesions (fibroma and cystadenofibroma) were misdiagnosed as malignant at contrast-enhanced, three-dimensional power Doppler sonography. The use of a contrast agent with three-dimensional power Doppler sonography showed diagnostic efficiency (95.6%) that was superior to that of nonenhanced three-dimensional power Doppler sonography (86.7%). Conclusion Contrast-enhanced, three-dimensional power Doppler sonography provides better visualization of tumor vascularity in complex adnexal masses. If used together with three-dimensional morphologic ultrasound assessment, enhanced three-dimensional power Doppler imaging might precisely discriminate benign from malignant adnexal lesions.

Endometrial carcinoma in postmenopausal women: Evaluation by transvaginal color Doppler ultrasonography

OBJECTIVE This study was conducted to evaluate the role of transvaginal color Doppler ultrasonography in detecting endometrial carcinoma in postmenopausal women and in evaluating the depth of myometrial invasion and tumor staging. STUDY DESIGN A group of 750 postmenopausal women were examined by transvaginal color Doppler ultrasonography 1 day before the planned hysterectomy. Histopathologic and blood flow characteristics were evaluated. Analysis of variance was used to test the significance among the subgroups. RESULTS Thirty-five women had endometrial carcinoma; 32 (91.4%) cases were detected by transvaginal color Doppler ultrasonography. Visualization of abnormal blood flow within the endometrium was 100% in the diagnosed cases with resistance index near or < 0.40, which constituted a statistically significant difference compared with that of endometrial hyperplasia. No flow was detected in normal, atrophic, and in 92% of cases with hyperplastic endometria. The color Doppler ultrasonography depicted 18 of 19 histologically proved cases of myometrial invasion. Three asymptomatic cases were discovered on the basis of morphologic and blood flow patterns. CONCLUSION Transvaginal color Doppler ultrasonography can depict endometrial carcinoma, even in asymptomatic women, determine the depth of myometrial invasion, and help in tumor staging.

Septate uterus: detection and prediction of obstetrical complications by different forms of ultrasonography.

The aims of the study were to compare the accuracy of transvaginal ultrasonography, transvaginal color Doppler sonography, hysterosonography, and three‐dimensional ultrasonography in detection of septate uterus and to evaluate the occurrence of obstetrical complications in relation to septal dimension and vascularity. Each patient underwent transvaginal ultrasonography and color Doppler examination, whereas hysterosonography and three‐dimensional ultrasonography were carried out in 76 and 86 patients, respectively. The sensitivity of different sonographic imaging modalities ranges between 95.21% and 99.29%. Color and pulsed Doppler sonographic studies of the septal area revealed vascularity in 71.22%. Patients with vascularized septa had a higher prevalence of obstetrical complications than those with avascularized septa (P < 0.05). Three‐dimensional ultrasonography and hysterosonography are highly accurate diagnostic tools for detection of uterine septa. We found no correlation between septal dimension and rate of obstetrical complications, although pregnancy loss was most likely to occur in patients with vascularized septa.

Ovarian senescence and its significance on uterine and ovarian perfusion

OBJECTIVE To measure the flow velocity of the ovarian, uterine, radial, and spiral arteries in different age groups. DESIGN Serial measurements throughout the menstrual cycle in normal cycling women with documented fertility were compared with those in postmenopausal patients with and without hormone replacement therapy (HRT). SETTING Department of Obstetrics and Gynecology, University of Zagreb, Sveti Duh Hospital, Zagreb, Croatia. PATIENTS Two hundred fifty patients were analyzed: 120 healthy fertile women, 85 postmenopausal patients, and 45 postmenopausal patients receiving HRT. INTERVENTIONS All patients were examined by transvaginal color and pulsed Doppler. MAIN OUTCOME MEASURE Changes in the resistance index of flow velocity waveforms of the ovarian, uterine, radial, and spiral arteries. RESULTS Ovarian artery Doppler measurements in postmenopausal patients showed a significant difference when compared with the ovarian artery on the side containing dominant follicle or corpus luteum in healthy fertile group. Uterine and radial artery flow velocity analyses demonstrated significant positive correlations between the resistance index and years of menopause. In patients receiving HRT, a lowering effect occurred in the resistance index of the main uterine artery and its intramyometrial branches. Visualization of clear Doppler signals from the spiral arteries was possible in 30% of women who were menopausal for < 5 years. Increased vascular impedance was the typical finding in this vessel for this group of patients. The addition of HRT resulted in higher visualization rates of the spiral arteries and lowered resistance index values. CONCLUSIONS There are changes in the flow velocity patterns of the ovarian, uterine, radial, and spiral arteries with age. The fact that the uterine artery resistance index does not change significantly in the first postmenopausal years strongly supports the thesis that the aging process initially affects the uterus less than the ovary. Furthermore, the uterine environment can be manipulated more easily during the menopausal years by proper hormonal stimulation.

An attempt to screen asymptomatic women for ovarian and endometrial cancer with transvaginal color and pulsed Doppler sonography.

Several screening procedures have been proposed to detect ovarian and endometrial cancer. However, none of them is sensitive and specific enough to be used in population‐based screening programs. During our 5 year long study, 5013 asymptomatic women (44% premenopausal and 56% postmenopausal women) were scanned by transvaginal color and pulsed Doppler ultrasonography in an attempt to detect malignancy. These women had 404 adnexal cysts; 70 had resolved spontaneously on follow‐up scans and 18 persisted. Another 316 sonographically benign cysts are still in the procedure of follow‐up second scans. Of 5013 women, four women had stage I ovarian carcinoma and six had stage I endometrial carcinoma. There was one false‐positive case encountered with an endometrioma. Only 14 women were subjected to major operative intervention; others underwent minor procedures based on the benign scan findings. No medical or surgical complications were reported. Transvaginal color Doppler ultrasonography, a noninvasive procedure, can detect ovarian and endometrial carcinoma in asymptomatic women and may be used as a screening procedure for these diseases.

Screening for uterine abnormalities by three-dimensional ultrasound improves perinatal outcome

Abstract The main goal of our study was to assess the true incidence of surgically correctable uterine abnormalities (congenital uterine anomalies, submucous leiomyoma, endometrial polyps and intrauterine synechiae) in the infertile population attending our tertiary infertility clinic. All of the infertile patients enrolled in the study were evaluated by three-dimensional ultrasound. Another objective was to assess pregnancy rates before and after operative hysteroscopy in patients affected by uterine causes of infertility. Good quality 3D images were obtained in all 3850 infertile patients, and in 23.2% of them 3D US revealed surgically correctable uterine abnormalities. The incidence of uterine septum in our general infertile population was 17.9 %. Uterine septum was the most common uterine abnormality accounting for 77.1% of the intracavitary lesions. Out of 310 patients that were followed-up, 225 (72.6%) patients achieved pregnancy. The rate of term deliveries after septal incision was 57.7%, while 15.4% of patients had preterm deliveries. The rate of spontaneous abortions dropped from 41.7% before, to 11.9% after hysteroscopic resection of the septum. Three-dimensional ultrasound can be used as a screening method for detection of uterine abnormalities in patients suffering from infertility. We found significant improvement in reproductive outcome after operative hysteroscopy in secondary infertile patients with septate uterus and/or other uterine abnormalities.