4D ultrasound as a method to assess uterine peristalsis

Abstract

Objective: To study uterine peristalsis using step-by-step 4-dimensional (4D) ultrasound assessment video, explore its relationship with progesterone levels in a select in vitro fertilization population, and assess the reproducibility of the technique. Design: Four-dimensional uterine ultrasound and a retrospective analysis of outcomes in relation with progesterone levels. The videos were also analyzed by a senior doctor, junior doctor, and a nurse for their reproducibility. Setting: Instituto Bernabeu of Alicante is a private clinic. Patient(s):The study included 197 consecutive patients undergoing in vitro fertilization (from 2018 to 2019) with a history of recurrent implantation failure (defined as unsuccessful implantation of a total number of R3 blastocysts originated from oocyte donation cycles). Because it is known that most failures are attributed to the quality of the embryo, we deemed it important to explore the potential uterine factors explaining the failures in oocyte donation cycles, the use of which decreases the probability of embryo-related factors influencing it. Intervention(s): The participants were evaluated for uterine contractions and serum progesterone levels (10-30 minutes before the embryo transfer procedure). Uterine contractility (UC) was assessed by recording a 6-minute-long video using a 4D mode (Voluson E10; General Electric, Boston, MA), which was performed by a single operator (B.M.). Main Outcomes Measure(s): The contractions were seen like waves going through the endometrial cavity. They were counted on a Â15 accelerated recording video. To define high-frequency UC, we separated uterine peristalsis (contractions per minute [cpm]) into quartiles. The highest quartile defined the hypercontractility group (>1.51 cpm; n ¼ 41), considering the remaining quartiles as the normal contractility group (%1.51 cpm; n ¼ 156). The Mann-Whitney U test was performed. The intraclass correlation coefficient was used to validate variability. P < .05 was considered significant. SPSS version 21.0 was used for the statistical analysis. The institutional review board's approval was obtained. Result(s): Overall, an average of 1.1 cpm was found in the study population. There were no differences between the groups (hypercontractility vs. normal contractility) in terms of patient age and the presence of any uterine factor (adenomyosis, myomas, adhesions, or polyps). An inverse association was observed between UC and progesterone levels. Low progesterone levels (15.9 vs. 19.5 ng/mL; P ¼ .027) were observed in the HUP and NUP group, respectively. The intraclass correlation coefficient to evaluate the interobserver variability was 0.75 (0.63-0.85; P ¼ .000). Conclusion(s):Four-dimensional ultrasound assessment provides a dynamic view of uterine contractions, including their directionality and frequency. Even though recurrent implantation failure is yet a title of obscure definition and probably associated with multiple factors, a subgroup of patients with elevated UC associated with ''low'' progesterone leve...

An Appraisal of the Tissue Injury and Repair (TIAR) Theory on the Pathogenesis of Endometriosis and Adenomyosis

“…Interestingly, uterine contractions were not reduced at the time of peak progesterone level in the mid-luteal phase compared to the early or mid-follicular phase. This is at variance with a more recent study of uterine peristalsis, which employed 4D ultrasound technology and showed reduced uterine contractility at the time of implantation, perhaps aimed at aiding implantation through quiescence [ 84 ].…”

“…In addition, the study by Moliner et al [ 84 ] showed no difference between subjects considered with hypercontractility [>1.51 contractions per minute (cpm)] and those with normal contractility (≤1.51 cpm) in terms of patient’s age and the presence of adenomyosis, fibroids, adhesions, or polyps. However, there was an inverse association between contractility and progesterone levels due possibly to the suppression of myometrial NF-κB and COX-2 by progesterone receptors [ 85 ].…”

“…It is also important to note that the technique of assessing uterine contractility using ultrasound is not fully validated. Moliner et al [ 84 ] reported moderate inter-observer variability when using 4D ultrasound, but no assessment was made by Leyendecker et al [ 62 ]. To date, no other publications have independently confirmed the presence of dysperistalsis in endometriosis.…”

The effect of frozen embryo transfer regimen on the association between serum progesterone and live birth: a multicentre prospective cohort study (ProFET)

“…In the uterus, progesterone has been shown to facilitate decidualisation and embryo implantation by inducing an optimum immune-endocrine milieu within the endometrial lining ( Shah et al , 2019 ; Pereira et al , 2021 ). Progesterone also acts upon the myometrium, reducing its contractility and therefore leading to a state of mechanical quiescence which is additionally thought to aid early placentation ( Mueller et al , 2006 ; Moliner et al , 2021 ; Pereira et al , 2021 ). Systemically, progesterone exerts a regulatory role upon the innate and acquired immune responses, resulting in an inhibition of cytotoxicity and the induction of immune tolerance required for successful implantation ( Szekeres-Bartho, 2018 ; Shah et al , 2019 ).…”

Image_1.TIF

“…Figure 1B(ii) shows the time course of changes in the size of a uterine slice. Given the mouse uterus is a tube structure, and coordinated uterine circular smooth muscle contractions traveling through the tube constitute peristalsis (van Gestel et al, 2003;Kissler et al, 2004;Lesny and Killick, 2004;Fanchin and Ayoubi, 2009;Moliner et al, 2021), it is arguable that rhythmic contractions and relaxations in uterine slices reflect uterine peristalsis in vivo. Significantly, the peristalsis frequency of uterine slices (see below) is close to that of the whole uterus in vivo (Crane and Martin, 1991;Meirzon et al, 2011;Zhang et al, 2019).…”