The aim of this prospective study was to investigate the ability of transvaginal power Doppler ultrasonography to assess the relationship between follicular vascularity and outcome in women undergoing in-vitro fertilization. Each of 38 subjects underwent a single transvaginal power Doppler ultrasound scan on the day of oocyte collection, where the vascularity of individual ovarian follicles was assessed, using a subjective system, and graded 1 to 4. In addition, conventional pulsatility indices (PI) of the uterine and intra-ovarian (stromal) arteries were calculated, which showed no significant differences between the pregnant and non-pregnant groups. Using power Doppler ultrasonography, a total of 188 follicles was studied. The follicular vascularity grade was found to be independent of follicular size and there was no significant difference in fertilization rates with different degrees of vascularity, although there was a trend towards higher fertilization rates with higher grade vascularity. There were 10 pregnancies, giving a pregnancy rate of 26.3% per embryo transfer. Pregnancies were confined to those women whose embryos were derived from follicles with grade 3 and 4 vascularity (pregnancy rates per embryo transfer of 12.5 and 61.5% respectively), with only those from grade 4 follicles resulting in livebirths. This preliminary study suggested that high grade follicular vascularity is associated with increased pregnancy rate and that there is a possible link between follicular vascularity and implantation potential.
The aim of this prospective study of the use of transvaginal power Doppler ultrasound was to assess the subjectivity of the grading system and to elucidate, on a much larger series (200) of treatment cycles, the findings of previous authors. Vascular perfusion was studied using a grading system based on the percentage of follicular circumference (grade 1 < 25%, grade 2 < 50%, grade 3 < 75% and grade 4 > 75%) that depicted an echo signal. Interobserver variation was low (k = 0.81 + 0.08). A total of 1285 follicles were studied, of which 64% were of high (grades 3 or 4) and 36% were of low (grades 1 or 2) grade vascularity. Mean follicular diameter, oocyte retrieval rate, number of mature oocytes recovered and fertilization rates were all significantly higher (P < 0.05) and triploidy rate significantly lower (P < 0.05) from the cohort of follicles with high grade vascularity. There was no correlation between embryo morphology and vascularity grade. The pregnancy rate for cycles where the embryos transferred were derived from follicles with uniformly high grade (3 or 4 only) vascularity was significantly higher than for those cycles where the embryos transferred were derived from mixed (1 to 4) or low (1 or 2 only) grade follicles [24/72 (34.7%) versus 22/122 (18%); P < 0.05]. There were no significant differences in uterine artery or intraovarian pulsatility index values between the pregnant and non-pregnant treatment cycles. This study suggests that follicles with high grade vascularity are associated with better outcome variables. Thus, follicular assessment may be used prospectively to improve the outcome in in-vitro fertilization treatment cycles.
We have recently demonstrated the efficacy of paracervical block (PCB) used in conjunction with conscious sedation during egg collection. The dosage of lignocaine used in various studies ranges from 50 mg to 200 mg. There are, however, no studies evaluating the efficacy of different doses of local anaesthetic agents used in PCB. In this prospective, double-blind and placebo-controlled study, 150 women undergoing egg collection in their first IVF cycle were randomized to receive 200 mg and 150 mg lignocaine in PCB. No differences were seen in the demographic data, the ovarian responses, the duration of egg collection and the number of follicles punctured. The fertilization, implantation and pregnancy rates were similar when either 150 mg or 200 mg lignocaine was employed. The median pain levels during vaginal punctures were 14.0 (2.5th-97.5th centiles: 0-75.4) and 14.0 (2.5th-97.5th centiles: 0-86.5) in patients receiving 200 mg and 150 mg lignocaine respectively, whereas the corresponding median abdominal pain levels were 14.0 (2.5th-97.5th centiles: 0-85.6) and 14.0 (2.5th-97.5th centiles: 0-99.1). These pain levels during egg collection were not significantly different between the two groups. The use of 200 mg lignocaine in PCB is not justified, even in the absence of toxic effects.
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