الفهرس 
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Abstract
The ultimate goal of induction of ovulation or more sophisticated technologies of assisted reproduction is a healthy newborn after a smooth uncomplicated pregnancy.
Angiogenesis plays a critical role in various female reproductive processes such as development of a dominant follicle, formation of a corpus luteum, growth of endometrium, implantation and development of the placenta.
Successful implantation depends on a close interaction between the blastocyst and the receptive endometrium. Ultrasound examination of the endometrium allows a noninvasive evaluation of endometrial receptivity. Different ultrasound parameters have been used in evaluation, including endometrial thickness, endometrial pattern, and endometrial volume. A good blood supply towards the endometrium is usually considered as an essential requirement for implantation. It is assessed by Doppler ultrasound. Also Ovarian Peri-follicular blood flow assessment using Doppler ultrasound has been demonstrated to be a good marker of oocyte competence and subsequent implantation.
Several drugs have been proved to help in ovulation induction but they have been proved to have different effects on uterine endometrium characteristics and also ovarian response. Clomiphene citrate an antiestrogenic drug (CC) is the most commonly prescribed agent for ovulation induction and could be used as a super ovulation regimen when favorably combined with exogenous gonadotropin or alone. The antiestrogenic mechanism of action of cc which involves lasting estrogen receptor (ER) depletion and this may have a negative effect on the quality and quantity of cervical mucus, endometrial development, which may result in implantation failure and luteal phase defects.
Gonadotrophin products utilized in ovarian stimulation are derived from urinary or recombinant sources. Urinary products include human menopausal Gonadotrophin (hMG, highly purified [HP-hMG]), urinary follicle stimulating hormone (u-FSH) and human Chorionic Gonadotrophin (HCG). The recombinant gonadotropin products are recombinant human follicle stimulating hormone (r-hFSH), recombinant human luteinizing hormone (r-hLH) and recombinant human Chorionic Gonadotrophin (r-hCG). In terms of its primary constituents, hMG contains both FSH and LH activity
The current study included 180 patients in 3 equal groups according to the treatment protocol used. The patients were divided into three groups.
1st 60: received Clomiphene 50mg twice per day from day 3 for 5 days.
2nd 60: received HMG every other day starting from the 3rd day of the cycle.
3nd 60: received Clomiphene 50mg twice per day from 3 day for 5 days and HMG daily starting from the 6th day of the cycle.
Participants were chosen being below 35 years old, with a moderate duration of infertility ranging between 1.5 and 4 years. In the current study, we used Transvaginal Doppler for assessment of sub-endometrial blood flow as an indicator of endometrial receptivity in addition to assessment of peri-follicular. A secondary outcome was correlating the above with pregnancy outcome.
We followed up with endometrial thickness, follicular size and at follicular maturity (follicle size above 18mm) we started using the color Doppler and sometimes the power Doppler to detect presence and absence of blood flow in the sub-endometrial area and peri follicular area followed by using the pulsed Doppler to measure resistivity index (RI) and pulsatility index (PI) if flow is present.
In the whole group (n = 180), 21 patients got pregnant following treatment (a success rate of 11.7%). Pregnancy rate was higher in hMG and combined groups compared to clomiphene group. However the difference was not statistically significant (p = 0.191). To assess factors affecting outcome, we compared the total number of pregnancies in the whole group due to the relatively small number of pregnant cases.
Sub-endometrial blood flow was only detected in 65% of cases. In the current study, sub-endometrial RI was not significantly different between pregnant and non-pregnant groups (p = 0.208). While, sub-endometrial PI was significantly higher in the pregnant group (p = 0.017). In the current study, presence of sub-endometrial flow was not associated with pregnancy (p = 0.469).
Previous studies suggest a better role of 3D power Doppler study of sub-endometrial vessels to more accurately assess vascularity and hence, predict endometrial receptivity. The use of pulsed Doppler to study sub-endometrial vascularity is limited in that it is hard to accurately assess blood flow in the spiral arteries because of their sinuosity and low flow velocity. And This is an important technical limitation of our study.
In the ovary, power Doppler has been able to confirm data detected by pulsed Doppler in much greater detail. The mean ovarian RI was significantly lower in the pregnant group (p = 0.033), while PI was not significantly different between the two groups (p = 0.547). This was similar to findings in the right ovarian RI (p = 0.049) and PI (p = 0.733). However, left ovarian values were not significantly different. This proves better peri-follicular vascularity in women who got pregnant.
A further finding of the current study is the difference between the three treatment modalities. Sub-endometrial PI was significantly lowermost in the combined group compared to clomiphene and hMG groups. Also sub-endometrial RI was significantly higher in the clomiphene group compared to hMG (p = 0.001) and combined group (p = 0.002). Ovarian RI and PI were significantly different between the three studied groups. When we consider the mean value of RI and PI of both ovaries, the two indices were lowermost in the combined group while it was highest in the clomiphene group (p = 0.001).