Two-Dimensional and Three-Dimensional Doppler in Reproductive Medicine



Fig. 3.1
Right (a) and left (b) uterine blood flow measured by 2D Doppler ultrasound



Flow velocity waveforms are obtained from the ascending main branch of the uterine artery on the right and left side of the cervix in a longitudinal plane before it enters the uterus. The ‘gate’ of the Doppler is positioned when the vessel with good colour signals is identified on the screen. The PI and RI of the uterine arteries were calculated electronically when three similar, consecutive waveforms of good quality were obtained.

Good uterine blood flow as shown by low PI or RI is correlated with successful IVF outcomes [12, 13]. Steer et al. [12] classified PI measured on the day of ET as low, medium and high in the ranges of 0–1.99, 2.00–2.99 and ≥3.00, respectively, and reported a 35 % implantation failure when PI was >3.0. Using a PI upper limit of 3.0 [12] or 3.3 [13], the uterine Doppler flow indices have a high negative predictive value and sensitivity (in the ranges of 88–100 % and 96–100 %, respectively) and a relatively higher range of positive predictive value and specificity (44–56 % and 13–35 %, respectively) when compared with endometrial thickness and pattern [5].

Uterine artery Doppler study may not reflect the actual blood flow to the endometrium as the major compartment of the uterus is the myometrium and there is collateral circulation between uterine and ovarian vessels. I have shown 2D Doppler study of uterine vessels is a poor reflection of subendometrial blood flow by 3D power Doppler in both stimulated and natural cycles as endometrial and subendometrial 3D Doppler flow indices were similar among patients with averaged uterine PI <2.0, 2.0–2.99 and ≥3.0. [14].



Endometrial and Subendometrial Blood Flow by 2D Doppler


Endometrial and subendometrial blood flow examined by colour (Table 3.1) and power Doppler (Table 3.2) was correlated with implantation or pregnancy rates during IVF treatment. 2D Doppler flow indices of spiral arteries such as PI and PSV are not predictive of pregnancy [8, 19, 22], although Battaglia et al. [16] and Kupesic et al. [23] found significantly lower spiral artery PI in pregnant cycles than nonpregnant cycles.


Table 3.1
Summary of studies of endometrial blood flow by 2D colour Doppler











































Study

IVF cycles

USS parameters

USS day

Results

Popovic-Todorovic et al. [15]

96 cycles using a long protocol

Spiral PI and PSV

hCG

No difference in subendometrial PI and PSV between pregnant and nonpregnant cycles

Presence of endometrial and subendometrial flow

Absent subendometrial flow associated with no pregnancy

Battaglia et al. [16]

60 cycles

Uterine and spiral PI

OR

Uterine and spiral PI lower in pregnant than nonpregnant cycles

Presence of endometrial blood flow

Absent subendometrial flow associated with no pregnancy

Chien et al. [17]

623 cycles using ultrashort and ultralong protocols

Uterine and spiral PI and RI

ET

Significantly lower implantation and pregnancy rates in patients without endometrial/subendometrial flow

Presence of endometrial and subendometrial (<10 mm) blood flow

Presence of subendometrial flow 5.9 times to become pregnant than those with absent flow


USS ultrasound, PI pulsatility index, PSV peak systolic velocity, OR oocyte retrieval, ET embryo transfer



Table 3.2
Summary of studies of endometrial blood flow by 2D power Doppler



















































Study

IVF cycles

USS parameter

USS day

Results

Yang et al. [18]

95 cycles using long and short protocols

Intraendometrial power Doppler area (EDPA) <5 mm2; ≥5 mm2

OR

Higher EDPA in pregnant cycles

Endometrium ≥10 mm

Lower implantation and pregnancy rates when EDPA <5 mm2

Yuval et al. [19]

156 cycles using a long protocol

PI and RI

OR and ET

No difference in any USS parameters between pregnant and nonpregnant cycles

Contart et al. [20]

185 cycles using a long protocol

Fundal region along transverse plan; grades I, II, III and IV according to visualisation of power Doppler in the quadrants

hCG

Implantation and pregnancy rates similar in all grades of endometrial vascularity

Schild et al. [8]

135 cycles using a long protocol; first cycle only

PI and PSV of vessels in endometrium and subendometrial area (<5 mm)

OR

No difference in spiral artery PI and PSV between pregnant and nonpregnant cycles

Non-detectable spiral blood flow was not associated with a lower implantation rate

Maugey-Laulon et al. [21]

144 cycles using a long protocol

Presence of endometrial and subendometrial blood flow

ET

Absent endometrial and subendometrial flow associated with a lower pregnancy rate


USS ultrasound, PI pulsatility index, PSV peak systolic velocity, OR oocyte retrieval, ET embryo transfer

Yang et al. [18] used a computer software to measure the area and intensity of colour signals present in the endometrium in a longitudinal axis, i.e. intraendometrial power Doppler area (EDPA). Significantly higher EDPA was found in pregnant cycles than nonpregnant cycles (8.8 mm2 vs. 5.8 mm2 respectively). Patients with EDPA <5 mm2 had significantly lower pregnancy rate (23.5 % vs. 47.5 %; P = 0.021) and implantation rate (8.1 % vs. 20.2 %; P = 0.003) than those with ≥5 mm2. Contart et al. [20] graded endometrial blood flow by the visualisation of power Doppler in the quadrants in the fundal region of the transverse plane but could not demonstrate any predictive value of such grading system.

Presence of endometrial and subendometrial blood flow can be identified easily in 2D Doppler ultrasound. Absent endometrial and subendometrial blood flow has been shown to be associated with no pregnancy [16, 22] or a significantly lower pregnancy rate [17, 21].


Endometrial and Subendometrial Blood Flow by 3D Doppler


3D power Doppler ultrasound with the aid of the VOCAL® (Virtual Organ Computer-Aided Analysis) imaging program for the 3D power Doppler histogram can be used to measure the endometrial volume and indices of blood flow within the endometrium (Fig. 3.2). Vascularisation index (VI), which measures the ratio of the number of colour voxels to the number of all the voxels, is thought to represent the presence of blood vessels (vascularity) in the endometrium, and this was expressed as a percentage (%) of the endometrial volume. Flow index (FI), the mean power Doppler signal intensity inside the endometrium, is thought to express the average intensity of flow. Vascularisation flow index (VFI) is a combination of vascularity and flow intensity [24].

A300568_1_En_3_Fig2_HTML.jpg


Fig. 3.2
Endometrial volume (a) and blood flow (b) measured by 3D Doppler ultrasound

The subendometrium can be examined through the application of ‘shell imaging’ which allows the user to generate a variable contour that parallels the originally defined surface contour. The VI, FI and VFI of the subendometrial region are obtained accordingly (Fig. 3.3). The intra-observer reliability and interobserver reliability of endometrial and subendometrial blood flow by 3D power Doppler have been confirmed to be high with all measurements obtaining an intra-class correlation of above 0.9 [25, 26].

A300568_1_En_3_Fig3_HTML.jpg


Fig. 3.3
Subendometrial volume (a) and blood flow (b) measured by 3D Doppler ultrasound

Studies addressing the role of endometrial and subendometrial blood flow measured by 3D Doppler in IVF treatment are summarised in Table 3.3. Schild et al. [27] measured the subendometrial blood flow after pituitary downregulation but prior to ovarian stimulation and showed that subendometrial VI, FI and VFI were significantly lower in pregnant cycles than nonpregnant ones. Logistic regression analysis found that the subendometrial FI was the strongest predictive factor for the pregnancy outcome among other 3D Doppler flow indices.


Table 3.3
Summary of studies of endometrial and subendometrial blood flow by 3D power Doppler ultrasound



























































































































Study

IVF cycles

Inclusion/exclusion criteria

USS day

Results

Schild et al. [27]

75 cycles using a long protocol

Inclusion criteria

Before stimulation

Subendometrial VI, FI and VFI lower in pregnant than nonpregnant cycles

ET 2 days after TUGOR

 Downregulation confirmed (endometrium <5 mm, no ovarian cyst of >2.5 cm, serum oestradiol <60 pg/mL)

Subendometrial FI is the strongest predictive factor for IVF in logistic regression analysis

Kupesic et al. [23]

89 cycles using a long protocol

Inclusion criteria

ET (hCG +7)

Higher subendometrial FI in pregnant cycles

Blastocyst transfer 5 days after TUGOR

 Serum FSH < 10 IU/L

 No fibroid, ovarian cysts and ovarian endometriosis

Wu et al. [28]

54 cycles; first cycle only (details of ovarian stimulation and ET not given)

Inclusion criteria

hCG

Subendometrial VFI higher in pregnant cycles

 Age <38 years

 Normal uterine cavity

 Serum FSH <15 IU/L

 ≥2 good quality embryos

Dorn et al. [29]

42 cycles using a long protocol

Exclusion criteria

OR

No difference in subendometrial VI, FI and VFI between pregnant and nonpregnant cycles

 Polycystic ovary syndrome

 Endometrium <6 mm

 Gynaecological surgery

Järvelä et al. [30]

35 cycles using a long protocol

Exclusion criteria

After stimulation and OR

No difference in endometrial and subendometrial VI between pregnant and nonpregnant cycles on both days

ET 2 days after TUGOR

 Uterine fibroids

 Endometriosis

 Single ovary

 Previous operation on uterus or salpingectomy

Ng et al. [31]

451 cycles using a long protocol; first cycle only

Inclusion criteria

OR

Endometrial VI and VFI lower in pregnant cycles

ET 2 days after TUGOR

 Normal uterine cavity on scanning

Ng et al. [32]

193 cycles

Inclusion criteria

LH + 1

No difference in endometrial and subendometrial 3D Doppler flow indices between pregnant and nonpregnant cycles

Frozen-thawed embryo transfer cycles

 Normal uterine cavity

Mercè et al. [33]

80 cycles using a long protocol

Inclusion criteria

hCG

Higher endometrial VI, FI and VFI in pregnant cycles

 First cycle

 Normal uterine cavity

 Serum FSH <10 IU/L

 Regular cycles

 Non-smokers

Ng et al. [34]

293 cycles using a long protocol

Inclusion criteria

OR and ET

No difference in endometrial and subendometrial 3D Doppler flow indices on the 2 days and changes in these indices between pregnant and nonpregnant cycles

ET 2 days after OR

 First cycle

 Normal uterine cavity


USS ultrasound, VI vascularisation index, FI flow index, VFI vascularisation flow index, OR oocyte retrieval, ET embryo transfer

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Mar 15, 2016 | Posted by in ULTRASONOGRAPHY | Comments Off on Two-Dimensional and Three-Dimensional Doppler in Reproductive Medicine
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