Estrogens are involved in the modulation of the cardiovascular system, yet their effects in young women remains largely unknown. Women who undergo ovulation induction treatments attain extremely high estrogen concentrations during a very short time period. The aim of the present study was to evaluate the effects of an acute increase in estrogens on the autonomic nervous system modulation of heart rate variability (HRV). A total of 27 women undergoing ovulation induction and 14 normally menstruating women were prospectively studied. HRV was assessed during nadir and peak estrogen using time domain and power spectral density analyses. A significant increase in high-frequency spectral power (243 ± 77 vs. 188 ± 73 ms2/Hz, P < 0.01) with a significant decrease in the ratio of low to high-frequency power was observed during estrogen peak in women undergoing induction of ovulation. The acute increase in estrogen in women undergoing ovulation induction was associated with vagal activation and altered sympathovagal balance.

Endometrial vascularization parameters generated by a new image processing program were assessed in correlation with standard monitoring along IVF cycles. Forty two IVF patients having normal uterus and uterine cavity were studied at 5 sessions in their treatment cycles. Ovarian stimulation was achieved by long protocol. The study was conducted under standard B-mode and power Doppler presets in the mid-sagittal and axial uterine planes at peak systolic vascular filling. A region of interest (ROI) was defined in 2D power Doppler images of the endometrium. Absolute vascular area (AVA) within the ROI, mean color intensity (MCI), vascular area ratio (VAR) to the total ROI area were calculated by the computer program. These parameters were correlated with the day of ovulatory cycle, endometrial thickness and E2 level. AVA was positively correlated with the day of cycle (r = 0.31p < 0.05), whereas VAR had negative correlation (r = − 0.27p < 0.05) with cycle day. AVA was positively correlated with endometrial thickness (r = 0.42, p < 0.05), but VAR showed strong negative correlation with the thickness of the endometrium (r = − 0.85p < 0.05). E2 was found to be significantly correlated with AVA (r = 0.63p < 0.05), VAR (r = 0.37p < 0.05) and MCI (r = 0.44p < 0.05). Endometrial vascularization shows significant development along IVF cycles. Probably, the vascular endometrial proliferation is less prominent compared to the stromal and glandular growth of the endometrium. This may explain negative VAR correlation with the day of the cycle and the thickness of the endometrium. Our parameters can provide data concerning endometrial dating in ovulatory cycles.

The influence of blood flow impedance in subendometrial arteries on embryo implantation rate was investigated by transvaginal sonographic examination in in vitro fertilization (IVF) cycles. A total of 39 women undergoing IVF treatment were evaluated along the treatment cycle. Power and spectral Doppler studies of subendometrial arteries were performed to calculate the pulsatility index (PI), resistance index (RI) and systolic:diastolic ratio (S:D). The correlation between these parameters and pregnancy achievement was analyzed. Patients were grouped according to whether pregnancy was achieved or not. RI and S:D did not differ between the groups along the course of treatment. In pregnant patients, the PI was significantly lower in the beginning of the cycle than on the preovulation day and ovum pickup day. PI in the beginning of the treatment was significantly lower in pregnancy cycles than in nonpregnancy ones. A lower PI on day 1 was correlated with a better chance for pregnancy.

Pregnancy rate of IVF treated patients was studied in view of the parameters of endometrial vascularization provided by new image processing program. Forty seven patients undergoing IVF-ET cycles were recruited prospectively. All had normal uterine cavity and were treated by long stimulation protocol. The studies of the endometrial vascularization were conducted under standard B-mode and power Doppler presets in the mid-sagittal and axial uterine planes at peak systolic vascular filling. A region of interest (ROI) was defined in 2D power Doppler images of the endometrium. Absolute vascular area (AVA) within the ROI, mean color intensity (MCI), vascular area ratio (VAR) to the total ROI area were calculated by the computer program. Studies were performed on the following days: fifth day of ovarian stimulation, day of hCG administration and day of oocyte retrieval. Patients were grouped according to whether pregnancy was achieved or not. AVA, MCI, VAR were compared between the groups. The groups had similar demographic and IVF-ET treatment variables. AVA, MCI, VAR did not differ significantly between the groups along the treatment cycle. On ROC curve analysis, higher AVA values were associated with significantly better pregnancy rates (p = 0.014) on the fifth day, whereas higher AVA and MCI values showed opposite trend on the hCG day and the day of oocyte retrieval. Pregnancy rate in IVF-ET cycles showed complex dependence on the studied endometrial vascularization parameters. Appropriate vascularity in the different stages of the developing endometrium may contribute to the optimal endometrial receptivity.

Objective. The purpose of this series is to present deciduosis (the formation of extrauterine decidua) as one of the differential diagnoses of a malignant tumor during pregnancy. Methods. Two cases are described in which pregnant patients had a pelvic tumor. The lesions, which were diagnosed in the early second trimester, consisted of complex masses with an extensive blood supply and had a sonographic appearance of a malignant tumor The high suspicion for malignancy necessitated surgical intervention. Results. During surgery, the lesions were observed to be of an ovarian origin with papillary excrescences covering their exterior The lesions were excised and sent for histologic examination. The results showed a markedly decidualized endometriotic cyst in both cases. Conclusions. This phenomenon is a diagnostic challenge and should be considered in the differential diagnosis of a malignant mass during pregnancy.

BACKGROUND In patients with transient azoospermia, few sperm may be found in the ejaculate. We investigated the outcome of ICSI in patients with transient azoospermia. METHODS Records of patients with transient azoospermia referred during a 42 month period were reviewed. If only immotile sperm were found, the sample was incubated with 30% human serum albumin (HSA) before motility re-assessment. If still immotile, mechanical assessment of sperm viability was utilized. Study groups were: (A) motile sperm; (B) motility achieved by HSA; (C) no motility, but viability assessed by a mechanical technique; and (D) control group with sperm counts from 1 to 5 x 10(6)/ml. There were 57 couples (cycles) in the study group and 43 couples (cycles) in the control group. RESULTS Age, days of stimulation and endometrial thickness were comparable among groups. In 29.8% of the cycles, only immotile sperm were found. Fertilization and cleavage rates were higher in groups A and D than in groups B and C. Clinical pregnancy rate/cycle and live birth rate/cycle were not different among groups. No congenital malformations were found in newborns. CONCLUSION Fertilization and cleavage rates were lower in patients with initially immotile sperm compared with those with initially motile sperm and oligoasthenoteratozoospermia patients. Clinical pregnancy and viable pregnancy rates were not statistically different among groups, although when only immotile sperm were present both clinical pregnancy and live birth rate were lower in comparison with cycles with motile sperm.

Primary ovarian ectopic pregnancy is an uncommon ectopic gestation. It accounts for 0.5% to 1% of all ectopic gestations, and its incidence ranges from 1 in 7000 to 1 in 40,000 deliveries. 1 , 2 The clinical appearance varies. It is known to mimic an ovarian tumor or a tubal ectopic pregnancy 3 - 8 but to be misdiagnosed as an asymptomatic 8-week missed abortion is uncommon and makes this an interesting case. In the literature, there have been sparse case reports of primary ovarian ectopic pregnancy mistaken for intrauterine gestation, some of which progressed to the third trimester. 9 - 1 2 We present this case as an example of a misdiagnosed missed abortion and discuss sonographic examination methods to diagnose ovarian ectopic pregnancy.

The influence of blood flow impedance in subendometrial arteries on embryo implantation rate was investigated by transvaginal Doppler study before embryo transfer. A total of 36 women undergoing in vitro fertilization procedures were evaluated 3 times during the treatment cycle: upon completion of pituitary desensitization (Day 1), on the day of hCG administration and on the day of oocyte pick-up (OPU day) The patients had no uterine abnormality and no uterine surgery. Power and spectral flow imaging of subendometrial arteries was obtained to calculate PI, RI and S/D ratio. These indices were longitudinally assessed according to the examination day. The correlation between the Doppler parameters, endometrial thickness and pregnancy achievement was analyzed. Patients were grouped according to whether pregnancy was achieved (group A—13 cases) or not (group B—26 cases). No significant difference was found between the two groups in mean age, days of gonadotropin stimulation, peak serum estradiol level, endometrial thickness and number of embryos transferred. Doppler measurements of RI and S/D did not differ between group A and B on any of the days on which the studies were done. In patients who have conceived, PI was significantly lower on Day 1 (1.09 ± 0.17) compared to hCG day (1.25 ± 0.15) and OPU day (1.32 ± 0.21) (p < 0.02). PI measurements obtained on Day 1in group A (1.09 ± 0.17) were significantly lower compared to group B (1.29 ± 0.34) (P = 0.019). Lower PI measurements in subendometrial arteries on Day 1 were correlated with a better chance for pregnancy.

BackgroundTransvaginal sonography (TVS) enables a close imaging of the pelvic organs providing a clear imaging of the pelvic vessels. To the best of our knowledge – this is the first report of the diagnosis of uterine venous plexus thrombosis using this technique.Case reports 1st case: 38‐year‐old patient diagnosed as having a left tubal ectopic pregnancy in the 7th week of gestation. On TVS examination the ipsilateral uterine plexus thrombosis was found. The blood clots were demonstrated as elongated echogenic structures within the dilated veins. The thrombi showed swinging movements caused by the surrounding blood flow. This effect could also be provoked by gentle transducer pressure. On the transverse view of the affected veins the thrombi appeared as free round structures in the lumen. The blood flow around the thrombi was seen on color Doppler. 2nd case: 36‐year‐old patient with fetal death in the 19th week of gestation. Two days after the induced labor the patient experienced excessive vaginal bleeding. A placental residue was confirmed by TVS. Upon examination the engorged uterine venous plexuses were seen with a thrombus on the right side. The sonographic description of the clot was as in the first case.There were no signs of thromboembolic disease in both cases. The deep leg veins and iliac veins were studied and found to be normal. The uterine plexus thrombi could not be detected by transabdominal sonography and were only seen by TVS. Over 3 months of anticoagulation therapy the clots gradually disappeared in both cases.ConclusionsIn both patients the transvaginal sonographic diagnosis of uterine venous plexus thrombosis was accidental. There is not enough data in the medical literature to determine the evidence based approach to such cases. Nevertheless, focusing on the pelvic veins may reveal important findings with significant clinical implications.

OBJECTIVE:To evaluate the outcome of in vitro fertilization (IVF) treatment in relation to the sonographic parameters of the endometrium. DESIGN AND METHODS:Seventy-five patients with no uterine pathology (age 31.1 +/- 5.4 years) treated in our IVF clinic for various indications were assessed during 75 cycles in which good-quality (grades 1 and 2) embryos were transferred. Controlled ovarian stimulation was achieved by the long protocol (gonadotropin releasing hormone agonist and gonadotropins). The bilayered endometrial thickness (BET), estradiol, luteinizing hormone and progesterone serum levels were measured in 272 tests. A special computer program was used to measure endometrial echogenicity relative to myometrial echogenicity. The gray-level data were analyzed on the basis of the midsagittal sonographic uterine image. Endometrium-myometrium relative echogenicity coefficient (E/M REC) values were computed and displayed graphically along the anteroposterior axis of the endometrial layers in the upper part of the uterine cavity. The area under the E/M REC curve within the BET limits was defined as the relative echogenicity area (REA) and was used as a measure of endometrial echogenicity. Each cycle was sampled in six time segments representing desensitization, follicular and luteal phases. Assigning the day of ovum pick-up as day 0, the time segments of each cycle were: first, day -20 to day -11; second, day -10 to day -6; third, day -5 to day -2; fourth, day 0; fifth, day +7 to day +14; sixth, day +15 to day +21. RESULTS:A total of 276 embryos were transferred (3.68 +/- 1.01 per cycle), of which 223 were of good quality (2.97 +/- 1.51 per cycle). An intrauterine pregnancy was diagnosed in 29 patients. All patients in this study had a BET of > 5 mm in the third and the fourth time segments. There was no significant difference in BET and REA between pregnant and non-pregnant patients tested in the first to the fifth time segments of the IVF cycles. Both BET and REA measured in the sixth time segment were significantly higher in pregnant compared to non-pregnant patients. CONCLUSIONS:Our results suggest that the proposed sonographic assessment of the endometrium shows no benefit in characterization of uterine receptivity in IVF patients with a reactive endometrium. High BET and REA values can indicate pregnancy during the sixth time segment, when the decidualization of the endometrium is well established.

Thrombophilia was recently suggested as a possible factor in recurrent pregnancy losses. We studied prospectively 125 patients (mean age 31.4 +/- 5.6 years) with one or more first or second trimester pregnancy losses for the prevalence of activated protein C resistance (APCR). Proteins C and S antigens, antithrombin III, anticardiolipin, and lupus anti-coagulant were also evaluated. Patients with uterine malformations, hormonal abnormalities, chromosomal translocations and infectious causes were excluded. A control group of 125 women with no past fetal loss were matched with the study group. Whenever the APC-sensitivity ratio (APC-SR) was </=2.2, polymerase chain reaction for factor V mutation (Leiden) was performed. Heterozygosity for the mutation was found in 18 patients (14.4%) compared with seven heterozygous among 125 control group (5. 6%; P < 0.05). Acquired APCR (APC-SR 1.8 and Leiden negative) was revealed in seven patients (5.6%) in the study group and in three of the controls (2.4%; not significant). The rate of preclinical pregnancy losses (17/48) and second trimester miscarriages (10/48) in mutation carriers was significantly higher than in patients with no APCR (25/214) and (14/214) respectively (P < 0.001 and P < 0.01 respectively). Live birth rate was not different between the two groups. Occurrence of APCR with any kind of pregnancy loss calculated per patient, in our study group, was approximately 1/7, 1/4 and 1/5 with one, two and three or more pregnancy losses respectively. These findings suggest that assessment of APCR should be considered in a more extended evaluation of such patients.

A computer program was developed to assess the endometrial echogenicity relative to the myometrial one, based on the gray-level processing of the midsagittal uterine image. The endometrial region of interest was specified within the upper part of the uterine cavity. The adjacent area of the myometrium was used to determine the reference brightness. The endometrial region of interest was analyzed along the anteroposterior uterine axis, as a set of thin strips directed parallelly to the midcavitary line. The endometrial/myometrial relative echogenicity coefficient (E/M REC) was computed for each strip and displayed graphically as a function of the distance from the midcavitary line. The area under the E/M REC curve within the limits of the total endometrial width was defined as total area (TA) and was used as a measure of the endometrial echogenicity. This parameter was assessed in 9 patients during their normal ovulatory cycles and in 29 IVF-treated patients with mechanical infertility. TA has a significant linear increase during the days of the ovulatory cycles. TA was found in high correlation with log(estradiol). TA can be used reliably for sonographic endometrial dating in ovulatory cycles.

A computer program was developed to assess the endometrial echogenicity relative to the myometrial one, based on the gray-level processing of the midsagittal uterine image. The endometrial region of interest was specified within the upper part of the uterine cavity. The adjacent area of the myometrium was used to determine the reference brightness. The endometrial region of interest was analyzed along the anteroposterior uterine axis, as a set of thin strips directed parallelly to the midcavitary line. The endometrial/myometrial relative echogenicity coefficient (E/M REC) was computed for each strip and displayed graphically as a function of the distance from the midcavitary line. The area under the E/M REC curve within the limits of the total endometrial width was defined as total area (TA) and was used as a measure of the endometrial echogenicity. This parameter was assessed in 9 patients during their normal ovulatory cycles and in 29 IVF-treated patients with mechanical infertility. TA has a significant linear increase during the days of the ovulatory cycles. TA was found in high correlation with log(estradiol). TA can be used reliably for sonographic endometrial dating in ovulatory cycles.

The decision whether to perform uterine curettage for postabortal bleeding depends on the ability to demonstrate placental remnants in the uterine cavity. However, diagnosis of postabortal trophoblastic residua by conventional ultrasonography may be inconclusive. We report our experience with the use of combined sonohysterography and color Doppler to demonstrate a placental polyp after early pregnancy termination.