| Part I: A study on the prediction of reproductive outcomes in frozen embryo transfer cycles by calculating the volume of uterine junctional zone with three-dimensional ultrasoundObjectives: To prospectively study the influence of the volume of uterine junctional zone(JZ)as a novel predictor of reproductive outcomes in frozen embryo transfer cycles.Methods:Women underwent in vitro fertilization(IVF)in the reproductive center of our hospital were collected from January 2020 to January 2021.The criteria for inclusion were frozen embryo transfers,transplantation of more than one high-quality embryo,and clearly displayed endometrium on ultrasound examination.The exclusion criteria were uterine malformation,adenomyosis,endometriosis,uterine fibroids,hydrosalpinx,and intrauterine adhesions.Prospective patients were evaluated by ultrasound on the second day of menstruation to detect any exclusion criteria,and this examination was performed by an ultrasound expert who had practiced gynecological ultrasound for more than 15 years.The medical history of selected patients was recorded,including age,course of disease,type of infertility,cause of infertility,etc.First,30 patients who met the enrollment conditions were subjected to threedimensional ultrasound multiplanar display of the uterine junction zone(JZ),and the intra-and interobserver repeatability was evaluated and expressed as a coefficient of repeatability.At the same time,the consistency of volume of junctional zone(JZV)measurement was studied in the 30 patients whose JZ was optimal and satisfactory.These 30 patients were not included in the follow-up study.Then 158 patients eligible for inclusion were collected,ultrasound examination was performed on the day before transplantation to measure endometrial thickness(EMT),and 3D imaging function was activated to save 2-3 3D volume images.The optimal 3D volume images were selected for offline analysis of the patients undergoing next-day transplantation.The three-dimensional(3D)volume images were then analyzed to obtain the volume of endometrium(EV),average thickness of JZ on the coronal plane,and volume of JZ(JZV).JZV was then divided by EV.These parameters were compared with the outcomes of clinical pregnancy.Results: The 3D image showed that JZ achieved a good intra-and interobserver consistency(K = 0.862,K = 0.694).JZ volumes were measured in 28 cases.There were good intra-and interobserver consistency(ICC = 0.973,ICC = 0.898).The total clinical pregnancy rate was 47%.There was a highly significant difference between pregnant and non-pregnant women with respect to age(P < 0.001),JZV(P = 0.016),and JZV/EV(P < 0.001)on the day before transplantation.Age and JZV/EV were independent factors for predicting the success of IVF transplantation(P = 0.010,P = 0.016).The area under the ROC curve of JZV/EV in predicting clinical pregnancy was 0.688,cut-off value was 0.54,sensitivity was 83.8%,and specificity was 50.0%.Conclusions: Age and JZV/EV are independent factors for predicting the success of frozen embryo transfer cycles in IVF.Smaller JZV/EV was more beneficial for clinical pregnancy.Part II: Analysis of influencing factors of endometrial blood flow in multimodal ultrasound and its correlation with endometrial MVDObjectives: To investigate the influencing factors of multimodal ultrasound in evaluating endometrial blood flow and the correlation between endometrial MVD and ultrasonographic characteristics of uterus and endometrium.Methods: First,we retrospectively analyzed the results of multimodal ultrasound examination performed on 112 IVF patients in our reproductive center from January 2020 to August 2021 before transplantation.The criteria for inclusion were clearly displayed endometrium on ultrasound examination.The exclusion criteria were uterine polyp,uterine malformation,uterine fibroids,intrauterine adhesions,and the inevitable artifacts in 3D-PD acquisition.Two-dimensional ultrasound: EMT,uterine cavity distance from the probe;Doppler ultrasound: Endometrial blood flow grading,resistance Index(RI),peak systolic velocity/end Diastolic Velocity ratio(S/D),bilateral uterine artery pulse index(PI),RI and S/D;Three-dimensional ultrasound: EV;3D-PD mode: VI,FI,VFI.The effects of EMT,the distance between probe and uterine cavity,EV,endometrial blood flow grading,uterine spiral artery RI,S/D,bilateral uterine artery PI,RI,S/D on VI,FI and VFI were analyzed.Then 30 patients who underwent hysteroscopy from October 2021 to January 2022 were collected.The criteria for inclusion were clearly displayed endometrium on ultrasound examination.The exclusion criteria were uterine polyp,uterine malformation,uterine fibroids,intrauterine adhesions,and the inevitable artifacts in 3D-PD acquisition.Record the general information of the patient.Ultrasonography was performed on the day of hysteroscopy and before hysteroscopy.EMT and endometrial pattern were recorded by two-dimensional ultrasound,and the distance between the probe and the uterus was recorded at the same time;Endometrial blood flow grade,PI,RI,S/D,and uterine artery blood flow parameters PI,RI,S/D were recorded by Doppler ultrasound;3D ultrasound recorded EV;vascularization index(VI),flow index(FI),and vascularization flow index(VFI)in three-dimensional power Doppler(3D-PD).The appearance of endometrium was observed under hysteroscopy on the same day,the endometrial tissue was sampled,and the microvessel density(MVD)value was analyzed.To explore the correlation between ultrasonic parameters,hysteroscopy,and MVD value.Results: In 112 patients,the correlation analysis results of uterine cavity distance to probe,EMT,EV,endometrial blood flow RI,S/D and uterine artery PI,RI,S/D with VI,FI and VFI in 3D-PD showed that: The measurement values of VI,FI and VFI were negatively correlated with the distance between the probe and the uterine cavity(P = 0.001,P = 0.012,P = 0.002).EV was significantly negatively correlated with VI and VFI(P = 0.035,P = 0.023).EMT,endometrial blood flow RI,S/D and uterine artery blood flow PI,RI,S/D were not significantly correlated with VI,FI,VFI.Endometrial blood flow grading was significantly correlated with VI,FI and VFI in 3D-PD(P < 0.001,P = 0.001,P < 0.001).The results of multiple step by step linear regression showed that VI,FI and VFI values were correlated with endometrial blood flow grading(P < 0.05),there was no significant correlation between the distance between the probe and the uterine cavity and VI,FI and VFI(P = 0.071,P = 0.069,P = 0.079).Hysteroscopy was normal in 18 of 30 patients,and endometrial polyps were found in 12 of 30 patients.In the endometrial pattern,non-A endometrium was more likely to be associated with endometrial polyps under hysteroscopy(P = 0.024),while blood flow indexes RI,PI,S/D,VI,FI,and VFI were not related to endometrial polyps under hysteroscopy.The correlation analysis between endometrial blood flow parameters VI,FI,VFI,and endometrial MVD in 30 patients showed that MVD was significantly correlated with VI and VFI(P = 0.038,P = 0.048;r = 0.381,r = 0.364).There was no significant correlation between MVD and FI(P = 0.325).After excluding 12 patients with polyps found by hysteroscopy,the analysis showed that MVD was significantly correlated with VI,FI,and VFI in the remaining 18 patients(P = 0.002,P = 0.043,P = 0.002;r = 0.675,r = 0.482,r = 0.680).Endometrial blood flow PI,RI,S/D,and bilateral uterine artery mean PI,RI,S/D was not associated with endometrial MVD.Conclusions: The endometrial blood flow indexes VI,FI and VFI evaluated by 3DPD were correlated with the endometrial blood flow grading,and the measured values were affected by the distance between the uterine cavity and the probe.VI,FI,VFI were positively correlated with normal endometrial MVD.Endometrial polyps that cannot be identified by ultrasound would affect the estimation of endometrial blood flow by 3D-PD blood flow index.Part III: Multimodal Ultrasound assessment of endometrial and blood flow periodic change patterns to predict the outcome of frozen cycle embryo transferObjectives: To study the influence of change patterns in endometrial volume(EV)and endometrial blood flow by three-dimensional ultrasound in frozen embryo transfer cycles.Methods: Women who underwent IVF were enrolled between September 2020 and July 2021.The criteria for inclusion were frozen embryo transfers,transplantation of more than one high-quality embryo,and clearly displayed endometrium on ultrasound examination.The exclusion criteria were uterine malformation,adenomyosis,endometriosis,uterine fibroids,hydrosalpinx,and intrauterine adhesions.Prospective patients were evaluated by ultrasound on the second day of menstruation to detect any exclusion criteria,and this examination was performed by an ultrasound expert who had practiced gynecological ultrasound for more than 15 years.The medical history of selected patients was recorded,including age,course of disease,type of infertility,cause of infertility,etc.Ultrasound examinations were performed in patients on the day of transformation,the third day after transformation,and the day of embryo transplantation.Ultrasound examinations were performed at 7-9 am.Endometrial thickness(EMT),EV,and three-dimensional power Doppler have recorded the endometrial blood flow parameters,VI,FI,and VFI.The change patterns in three inspections of the EMT,EV,VI,FI,VFI,and two inspections of estrogen levels were expressed as “down” and “up”.The correlation between these change indicators and the IVF outcome was analyzed.Results: 133 patients were enrolled in this study,48 were excluded,and 85 were included in the statistical analysis.Among the 85 patients,61 were pregnant(71%(61/85)),47 had a clinical pregnancy(CP)(55%(47/85)),and 39 had an ongoing pregnancy(OP)(45%(39/85)).Univariate analysis was used to analyze the change patterns in the EMT,EV,VI,FI,and VFI,and in the E2 level.The results showed that for the outcome of pregnancy,none of the indicators analyzed were influencing factors.Two changes in the EV were indicators associated with the outcome of CP(P = 0.005,P = 0.021).For the outcome of OP,two changes in the EMT and EV were influencing factors(P = 0.048,P = 0.022;P = 0.001,P = 0.007).The factors with P < 0.1 in univariate analysis were included in the multivariate stepwise logistic regression based on the AIC in the subsequent multivariate analysis.After multivariate stepwise regression analysis,the results showed that if the first change in the EV was up,then the likelihood of CP was more unfavorable(P = 0.037).In the second change,the difference between up and down for CP was not significant(P = 0.076).Similarly,if the first change in the EV was up,then the likelihood of OP was unfavorable(P = 0.014);however,if the second change in the EV on day ET was up,the likelihood of OP was more favorable(P = 0.037).Conclusions: The changing patterns in EV were factors in predicting the IVF outcome.The decrease in EV after transformation and the increase before transplantation were favorable factors for IVF pregnancy outcome. |
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