Middle East Fertility Society Journal 23 (2018) 324–330

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Original Article

Evaluation of endometrial and subendometrial vascularity in obese

women with polycystic ovarian disease
Essam R. Othman, Karim S. Abdullah, Ahmed M. Abbas ⇑, Mostafa Hussein, Elwany Elsnosy,
Ihab H. El-Nashar
Department of Obstetrics & Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The study aims to evaluate the effect of obesity on the endometrium in women with poly-
Received 6 February 2018 cystic ovarian disease (PCOD) through evaluation of endometrial and subendometrial vascularity by two-
Revised 4 April 2018 dimensional (2D) ultrasound, Doppler and three dimensional power Doppler (3DPD).
Accepted 17 April 2018
Methods: A prospective case-control study, conducted in a tertiary University hospital between February
Available online 27 April 2018
2016 and December 2016. The study included 50 women with PCOD and 50 fertile regular menstruating
women divided according to their body mass index (BMI) into normal weight and overweight/obese
Keywords:
groups. Endometrial thickness and pattern combined with Doppler examination of the uterine vessels
Obesity
Polycystic ovarian disease
for measurement of Resistance index (RI) and pulsatility index (PI) were assessed. Evaluation of endome-
Endometrium trial and subendometrial blood flow was performed by 3DPD using Virtual organ computer-aided anal-
Doppler ysis program.
VOCAL Results: No significant difference in the endometrial pattern or thickness between all study groups.
Infertility Endometrial volume was significantly lower in the overweight/obese PCOD women and overall in the
PCOD women compared to the control group (p < 0.01). Uterine artery RI was significantly higher in
the PCOD women compared to the control group (p = 0.004), but no difference in uterine PI. Vascular
indices of endometrial and subendometrial blood flow were significantly lower in the overweight/obese
PCOD women than the normal weight PCOD women.
Conclusions: The endometrium is negatively affected by obesity in women with PCOD. Additionally,
PCOD women had lower endometrial and subendometrial blood flow than non-PCOD women.
Therefore, overweight/obese PCOD women should be encouraged to reduce their body weight in order
to improve the endometrial receptivity.
Ó 2018 Middle East Fertility Society. Production and hosting by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction 38–66% of women with PCOD are commonly overweight or obese

Obesity, defined as a body mass index (BMI) more than 30 kg/
m2, is an increasingly prevalent health problem in modern society.
It has been linked to a variety of chronic diseases, that becoming
one of the leading causes of mortality in the USA [1]. The majority
of obese women are not infertile; however, the effects of obesity on
infertility have been well documented. Obese women are more
likely to suffer infertility than women with a normal BMI [2].
Polycystic ovarian disease (PCOD), a common endocrine disor-
der with multisystem affection, is the most common cause of
anovulatory infertility [3]. PCOD has been linked to obesity as
Peer review under responsibility of Middle East Fertility Society.
⇑ Corresponding author at: Department of Obstetrics and Gynecology, Assiut
University, Women Health Hospital, 71511 Assiut, Egypt.
E-mail address: ahmedabbas@aun.edu.eg (A.M. Abbas).
[4].
A healthy endometrium is essential for reception of the fertil-
ized blastocyst. An adequate endometrial blood supply is a crucial
requirement for implantation [5]. Endocrinologic and metabolic
abnormalities in PCOD patients may pose complex effects on the
endometrium, contributing to the infertility and endometrial dis-
orders observed in those women [6].
The effect of PCOD with or without obesity has received a few
attentions. Whether BMI affects the endometrial blood flow, which
is necessary for implantation, or not is still questionable. Bellver
et al. stated that the ovary is not the solitary factor in charge for
the poor reproductive outcome in obese patients, but the endome-
trium also shares in this outcome. Therefore, being overweight
exerts an inferior reproductive prognosis [7].
Zeng et al. concluded that isolated obesity had a negative effect
on the endometrial and subendometrial blood flow. However, the

https://doi.org/10.1016/j.mefs.2018.04.006
1110-5690/Ó 2018 Middle East Fertility Society. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 E.R. Othman et al. / Middle East Fertility Society Journal 23 (2018) 324–330
clinical pregnancy and miscarriage rates were comparable
between all BMI subgroups [5].
Ultrasonographic findings indicating changed endometrial
receptivity have not yet been agreed. The different ultrasound
parameters of endometrial receptivity include endometrial thick-
ness, endometrial pattern, endometrial volume and Doppler stud-
ies of uterine vessels and the endometrium. Three-dimensional
Power Doppler (3DPD) assessment is applied for the study of dif-
ferent variables endometrial-subendometrial perfusion that is also
used as receptivity markers [8].
The current study aims to determine the effect of obesity on the
endometrium in women with PCOD, and compare them to the
endometrium of fertile regular menstruating women as controls,
using ultrasonographic endometrial and subendometrial vascular-
ity parameters.
2. Materials and methods
2.1. Study type, setting and duration
The study was a prospective pilot case-control study conducted
in a tertiary University hospital between February and December
2016. The study was registered at Clinical Trials. Gov
(NCT02694419).
2.2. Study population
All infertile women attended the infertility clinic in the afore-
mentioned hospital during the study period were clinically evalu-
ated, and those who were diagnosed as PCOD according to
Rotterdam criteria (presence of two out of the following three cri-
teria: oligomenorrhea (absence of menses for 35–182 days) or
amenorrhea (absence of menses for >182 days), signs or symptoms
of hyperandrogenism (acne, hirsutism), ultrasound showing poly-
cystic ovaries) [9] were invited to participate in the study. The
study was approved from the Assiut Medical School Ethical Review
Board and a written informed consent was obtained from all study
participants.
All included women were between 18 and 40 years old with
basal serum follicle stimulating hormone (FSH < 10 mIU/mL) level
tested on day 3 of a spontaneous or induced cycle. We excluded
women known to have Diabetes mellitus, hypertension, cardiovas-
cular diseases, women used ovulation induction drugs or hormonal
contraception in the preceded 3 months, those had previous
laparoscopic ovarian drilling and women with any uterine abnor-
malities as congenital anomalies, endometrial lesions, adeno-
myosis, fibroids and intrauterine adhesions. Moreover, women
refused to participate in the study were also excluded.
Age matched fertile women with regular menstruation and at
least previous one spontaneous pregnancy had approached to par-
ticipate in the study as a control group at the time of recruitment.
2.3. Intervention
The following data were collected at inclusion; age, duration of
infertility, previous infertility treatment, any used medication and
previous operations. Menstrual history was taken including the
regularity of the cycle, and the date of first day of last menstrual
period. Body weight and height of each woman was obtained to
calculate the BMI before allocation.
One-hundred participants had stratified into four groups (25
women in each group) depending upon their BMI and the presence
or absence of PCOD. BMI was measured in kg/m2 and categorized
according to WHO categories; 18.5 to <25 as normal weight, 25
to <30 as overweight, and 30 as obese [10].
325
Group A: Women with PCOD who are overweight/obese with
BMI  25 kg/m2.
Group B: Women with PCOD who are normal weight with BMI
< 25 kg/m2.
Group C: Fertile regularly menstruating women who are over-
weight/obese with BMI  25 kg/m2.
Group D: Fertile regularly menstruating women who are nor-
mal weight with BMI < 25 kg/m2.
The participants were scheduled to be evaluated on two visits
after the onset of spontaneous or progesterone-induced menses.
The first one was dated to be between the 12th–14th days (preovu-
latory), while the second was between the 20th–22nd days (mid-
luteal). All participants were examined by the same sonographer,
who had no clinical information about the patients, using a
SonoAce X8 machine (Medison, Korea) with transvaginal volumet-
ric probe with 4–8 MHz frequency (using an average 6.5 MHz).
At each visit, after asking the patients for emptying their blad-
der, preliminary transvaginal sonography (TVS) was done for eval-
uation of endometrial thickness and pattern. Endometrial
thickness was measured as the distance between the echogenic
interfaces of the endometrium and the myometrium through the
central longitudinal axis of the uterine body, at the junction
between the upper one-third and lower two-thirds of the endome-
trial cavity. The endometrial pattern was classified to a triple or
non-triple layer. A triple layer endometrium appears as a hypere-
chogenic outer lines and central hyperechogenic line with a hypoe-
chogenic region between them. A non-triple layer appears as
homogenous endometrial pattern characterized by either hypere-
chogenic or isoechogenic endometrium.
Then, Color Doppler ultrasound was used to demonstrate the
main ascending branches of left and right uterine arteries as they
cross over the hypogastric vessels just before they enter the uterus
at the uterine-cervical junction. These vessels were then examined
by pulsed-wave Doppler, which used to generate a consistent
waveform over five consecutive cardiac cycles. The wave forms
were analyzed to obtain the resistance index (RI) and the pulsatil-
ity index (PI) from three similar consecutive waveforms. The for-
mulas used for PI and RI were PI = (S D)/mean and RI = (S D)/
S respectively, when S is the peak Doppler frequency shift and D
is the minimum. The average value of the bilateral uterine arteries
is calculated for each index. Mean values of bilateral uterine RI and
PI were used for statistical analysis.
The US scanner was then switched to the 3DPD mode. The ultra-
sound probe was kept steady, and the patient was asked to lie sta-
tic on the bed during the volume acquisition. A three-dimensional
data set was acquired using the medium-speed sweep mode, and
the sweep angle was set to 90° to ensure that the complete
endometrial cavity is obtained.
The built-in VOCAL (virtual organ computer aided analysis)
imaging program for the 3DPD histogram analysis was used to cal-
culate the endometrial volume and vascularity indices within the
endometrium. VOCAL displays sequential parallel slices of 3D anat-
omy to facilitate more precise volume analysis of irregularly
shaped structures. During the analysis and calculations, the man-
ual mode of the VOCAL Contour Editor was used to cover the whole
three-dimensional volume of the endometrium with a 30° rotation
step. Hence, six contour planes were analyzed for the endome-
trium of each patient to cover 180°. The subendometrium was
set through the application of ‘‘shell-imaging”, which allows the
user to generate a variable contour that parallels the originally
defined contour (Fig. 1).
In the present study, the subendometrial region was considered
to be within 2 mm outside of the originally defined myometrial-
endometrial contour ‘outside shell’. There is no consensus
regarding what size of shell should be used, but blood flow and
326 E.R. Othman et al. / Middle East Fertility Society Journal 23 (2018) 324–330
Fig. 1. Measurement of endometrial volume using 3D-ultrasound.
vascularity within 2 mm of the myometrial-endometrial border
has been shown to be reduced in patients with PCOD [11].
The following indices were obtained: Vascularization index
(VI): the ratio of the number of color voxels to the number of all
the voxels represents the presence of blood vessels (vascularity)
in the endometrium and is expressed as a percentage of the
endometrial volume. Flow index (FI): the mean power Doppler sig-
nal intensity inside the endometrium is used to express the aver-
age intensity of flow. Vascularization flow index (VFI): calculated
by multiplying VI and FI, it reflects a combination of vascularity
and flow intensity (Fig. 2).
2.4. Statistical analysis
All data were analyzed using SPSS software Chicago, IL, USA,
version 21. Qualitative data were expressed as frequency and per-
centage. Fisher’s exact test was used to examine the relation
between qualitative variables. Quantitative data were presented
in terms of, mean and standard deviation. For quantitative data,
comparison between two groups was done using Mann-Whitney
test. Spearman correlation analysis between the ultrasonographic
and Doppler parameters with BMI was done. Level of significance
‘‘P” value was evaluated, where P value <0.05 is considered of sig-
nificant value.
3. Results
One hundred and seventy-nine infertile women were evaluated
during the study period, of them 66 (36.9%) women were diag-
nosed to have PCOD according to Rotterdam criteria. Sixteen
women were excluded for various exclusion criteria ends in 50
PCOD patients included in the study group (25 overweight/obese
women ‘Group A’, 25 normal weight women ‘Group B’). Fifty
fertile regularly menstruating women with matched age were
recruited as a control group (25 overweight/obese women ‘Group
C’, and 25 normal weight women ‘Group D’).
As regard to PCOD patients; the mean BMI for women in group
A was 30.42 ± 3.15 kg/m2, while the mean BMI for women in group
B was 23.35 ± 1.51 kg/m2. No statistical difference between both
groups as regards mean duration of infertility; 3.53 ± 2.74 years
for group A and 3.72 ± 3.53 years for group B (P = 0.796) (Table 1).
There was significant difference in the endometrial volume
between both groups both in the preovulatory and midluteal phase
(P = 0.001, 0.000 respectively). Additionally, 3DPD indices shown
significant difference between both groups regarding VI and FI in
both phases being higher in group B, while there was no significant
difference regarding VFI.
There was no statistical difference between the two groups
regarding endometrial thickness (8.06 ± 1.40 cm in group A versus
7.74 ± 1.76 cm in group B preovulatory and 9.16 ± 1.99 cm in group
A versus 9.26 ± 2.15 cm in group B midluteal), endometrial pattern
(triple layer in 76% of patients in group A versus 72% of patients in
group B preovulatory and 16% in group A versus 4% in group B mid-
luteal) and uterine artery Doppler indices (Table 2).
When comparing obese women in group A and C, we found that
the mean BMI for women in group C was 30.65 ± 3.47 kg/m2 with
no statistical difference between both groups. No statistical differ-
ence between both groups regarding endometrial (8.06 ± 1.40 cm
in group A versus 9.10 ± 2.33 cm in group B preovulatory and 9.1
6 ± 1.99 cm in group A versus 10.25 ± 4.07 cm in group B mid-
luteal), endometrial pattern (triple layer in 76% of patients in both
group A & C preovulatory and 16% in group A versus 8% in group B
midluteal).
There was a significant difference in the endometrial volume
between both groups both in the preovulatory and midluteal phase
(P = 0.002, 0.000 respectively) being more in fertile obese women.
 E.R. Othman et al. / Middle East Fertility Society Journal 23 (2018) 324–330 327

Fig. 2. 3-Dimensional power Doppler histogram showing endometrial and subendometrial vascularity with measurement of vascular indices.

Table 1
The basal criteria of the study participants.
# § $
Group A Group B P-value Group C P-value Group D P-value
(n = 25) (n = 25) (n = 25) (n = 25)
Age, years 26.24 ± 1.78 25.08 ± 2.16 0.146 25.48 ± 2.32 0.074 25.52 ± 1.15 0.573
BMI, kg/m2 30.42 ± 3.15 23.35 ± 1.51 0.000* 30.65 ± 3.47 0.823 23.02 ± 2.66 0.274
Nullipara 12 (48%) 10 (40) 0.325 – – – –
Type of infertility: Primary 12 (48%) 10 (40) 0.325 – – – –
Secondary 13 (52%) 15 (60)
Duration of infertility 3.53 ± 2.74 3.72 ± 3.53 0.796 – – – –
History of oligomenorrhea 25 (100%) 24 (96%) 0.312 – – – –
History of hirsutism 9 (36%) 8 (32%) 0.765 – – – –

All values are expressed as mean ± SD or number (%).

BMI, body mass index.
*
Statistical significant difference.
#
P-value between group A and group B.
§
P-value between group A and group C.
$
P-value between group B and group D.

There was a significant difference between both groups regarding
the uterine artery RI being higher in PCOD obese women than fer-
tile obese women, while PI didn’t show significant difference.
Moreover, all 3DPD indices were significantly higher in fertile
obese women than PCOD obese women in both preovulatory and
midluteal phase except VFI in the midluteal phase (P = 0.123)
(Table 2).
Both fertile groups (C&D) showed no significant difference in
any of the ultrasonographic or Doppler endometrial parameters
in either preovulatory or midluteal phases of the menstrual cycle.
Additionally, no significant difference between normal weight
women; whether they were fertile or PCOD (group B&D) in any
ultrasonographic or Doppler endometrial parameters except RI in
the midluteal phase (P = 0.001).
The results of Spearman correlation analysis between BMI and
different ultrasonographic and Doppler parameters were shown
in Table 3. There was a significant strong negative correlation
between endometrial thickness and BMI in both preovulatory
(r = 0.762, P = 0.000) and midluteal phases (r = 0.737,
P = 0.000) (Fig. 3). Also, there was a significant mild negative
correlation between VFI of the endometrium and subendometrial
and BMI in the midluteal phase (r = 0.260, P = 0.009) (Fig. 4).
328 E.R. Othman et al. / Middle East Fertility Society Journal 23 (2018) 324–330

Table 2
Ultrasonographic and Doppler endometrial characteristics in the study groups.
# § $
Group A Group B P-value Group C P-value Group D P-value
(n = 25) (n = 25) (n = 25) (n = 25)
Endometrial thickness, mm
Preovulatory 8.06 ± 1.40 7.74 ± 1.76 0.299 9.10 ± 2.33 0.053 8.38 ± 1.15 0.055
Midluteal 9.16 ± 1.99 9.26 ± 2.15 0.734 10.25 ± 4.07 0.19 9.12 ± 1.30 0.768

Endometrial pattern
Triple-layer (n, %)
Preovulatory 19 (76%) 18 (72%) 0.747 19 (76%) – 19 (76%) 0.747
Midluteal 4 (16%) 1 (4%) 0.346 2 (8%) 0.663 3 (12%) 0.602

Endometrial volume, cm3

Preovulatory 3.95 ± 0.71 4.83 ± 0.92 0.001* 4.71 ± 0.84 0.002* 4.71 ± 0.84 0.594
Midluteal 4.1 ± 0.75 5.1 ± 0.85 0.000* 5.23 ± 0.78 0.000* 4.98 ± 0.88 0.541

Uterine arteries Doppler

Mean RI
Preovulatory 0.87 ± 0.06 0.86 ± 0.07 0.247 0.80 ± 0.10 0.004* 0.81 ± 0.08 0.059
Midluteal 0.86 ± 0.09 0.86 ± 0.06 0.553 0.81 ± 0.08 0.007* 0.80 ± 0.07 0.001*
Mean PI
Preovulatory 2.26 ± 0.92 2.23 ± 0.72 0.808 1.97 ± 0.47 0.332 1.96 ± 0.59 0.197
Midluteal 2.32 ± 0.74 2.27 ± 0.69 0.854 2.15 ± 0.64 0.541 2.17 ± 0.56 0.443

Endometrial and subendometrial vascularity

VI
Preovulatory 3.54 ± 2.21 5.32 ± 2.39 0.010* 5.15 ± 2.52 0.032* 5.08 ± 2.27 0.786
Midluteal 3.93 ± 2.30 5.36 ± 2.43 0.034* 5.16 ± 2.60 0.015* 4.91 ± 2.22 0.421
FI
Preovulatory 0.001* 16.24 ± 5.88 0.018* 15.10 ± 5.91 0.064
Midluteal 12.35 ± 5.3114.04 ± 5.48 18.14 ± 5.1918.78 ± 5.44 0.005* 18.32 ± 5.74 0.014* 14.98 ± 5.30 0.057
VFI
Preovulatory 0.85 ± 0.61 1.08 ± 0.59 0.236 1.33 ± 0.62 0.012* 1.37 ± 0.49 0.071
Midluteal 0.92 ± 0.69 1.25 ± 0.61 0.095 1.18 ± 0.67 0.123 1.43 ± 0.55 0.260

All values are expressed as mean ± SD, RI; resistance index, PI; pulsatility index, VI; vascularization index, FI; flow index, VFI; vascularization flow index.
*
Statistical significant difference.
#
P-value between group A and group B.
§
P-value between group A and group C.
$
P-value between group B and group D.

Table 3
Correlation analysis between ultrasonographic and Doppler endometrial parameters
4. Discussion
with BMI of the study participants.

BMI The current study was designed to determine the effect of

r-value P-value obesity on the endometrium in patients with PCOD using ultra-
Endometrial thickness sound and Doppler parameters. To our knowledge, this is the
Preovulatory 0.762 0.000 first study performed to evaluate the effect of BMI on endome-
Midluteal 0.737 0.000 trial and subendometrial blood flow specifically in women with
PCOD.
Endometrial volume
Preovulatory 0.174 0.084 Women with PCOD are commonly overweight or obese; how-
Midluteal 0.089 0.376 ever, obesity does not considered one of the diagnostic criteria
for PCOD [4]. Obesity has an intense effect upon the symptoms that
Uterine arteries Doppler woman with PCOD presents; obese women with PCOD have a more
Mean RI
severe phenotype [12].
Preovulatory 0.099 0.327
Midluteal 0.055 0.588 The histopathological and molecular effect of obesity upon the
endometrium is not fully explained. The change in endometrial
Mean PI
Preovulatory 0.064 0.528 perfusion from the late follicular phase to the early luteal phase
Midluteal 0.013 0.897 has been suggested as an important determinant of endometrial
receptivity [13,14].
Endometrial and subendometrial vascularity
The condition of relative hyperestrogenaemia in the obese
VI
Preovulatory 0.190 0.058
women may have a negative impact on the endometrial recep-
Midluteal 0.192 0.055 tivity [15]. Additionally, obese women have insulin resistance
FI
and hyperinsulinemia that could decrease the glycodelin levels.
Preovulatory 0.184 0.067 Low glycodelin levels have been associated with recurrent mis-
Midluteal 0.079 0.435 carriage [16]. So, disturbed glycodelin levels could reduce the
VFI fertility at the endometrial level [17]. On the opposite, the
Preovulatory 0.114 0.257 high levels of acute phase proteins and pro-inflammatory
Midluteal 0.260 0.009 cytokines (as IL6, PAI1 and TNF) in obese women may have
RI; resistance index, PI; pulsatility index, VI; vascularization index, FI; flow index, a negative effect upon implantation and early embryonic
VFI; vascularization flow index, BMI; body mass index. growth [17,18].
 E.R. Othman et al. / Middle East Fertility Society Journal 23 (2018) 324–330 329

Fig. 3. Correlation between endometrial thickness and Body mass index.

In our study, the endometrial thickness and pattern have been
shown not to be affected by body weight in patients with PCOD.
This was consistent with the results reported by Zeng et al. [5], that
endometrial thickness and pattern had no significant difference
according to the BMI. However, our study showed that higher
BMI correlated negatively with the endometrial thickness
(r = 0.762).
Endometrial volume in our results was significantly lower with
higher BMI in women with PCOD (P = 0.000). Endometrial volume
was also significantly lower in the PCOD women compared to con-

Fig. 4. Correlation between Vascularization-flow index and Body mass index.

330 E.R. Othman et al. / Middle East Fertility Society Journal 23 (2018) 324–330
trol women (P = 0.000). This is consistent with the results of Moh-
sen et al. study [11] regarding endometrial volume, which was sig-
nificantly lower in the PCOD women than the control women who
were all overweight or obese.
In the current study, using the uterine artery Doppler, RI was
found to be increased in women with PCOD when compared to
the control group. However, the results showed that overweight/
obesity had no significant effect on RI in all groups. The increased
RI in PCOD women than in the control women was consistent with
the results of Mohsen et al. study [11].
There were no significant differences in PI among all the study
groups, which were inconsistent with previous studies, reported a
higher uterine artery PI in women with PCOD than in normal
women [11,19,20]. Chien et al. reported that the subendometrial
flow could affect the pregnancy and implantation, whereas there
was no relationship with uterine artery RI and PI [21]. This proba-
bly reflects the limitation of pulsed-wave Doppler analysis, which
selects a portion of the uterine artery, presuming it to reflect the
downstream endometrial blood flow.
Lam and coworkers were first to use quantitative 3DPD angiog-
raphy to evaluate endometrial and subendometrial blood flow in
women with PCOD as defined by Rotterdam criteria [22].
Assessment of the endometrial receptivity by 3DPD study of
subendometrial-endometrial blood flow is a simple, non-invasive
method especially if the primary ultrasound markers of endome-
trial receptivity are poor (ET < 7.0 mm, hyperechoic or presence
of subendometrial calcification) [8].
In the present study, endometrial and subendometrial blood
flow was studied by 3DPD. VI and FI were shown to be significantly
lower in overweight/obese PCOD women than normal weight
PCOD women, while VFI was not significantly different.
Also, our results showed that VI and FI were significantly lower
in the overweight/obese PCOD women than fertile overweight/
obese women. VFI was significantly lower in the PCOD over-
weight/obese women during the preovulatory phase than the over-
weight/obese fertile women. This was consistent with Mohsen
et al. results that stated significant lower values of VI, FI, and VFI
in overweight/obese PCOD women than fertile overweight/obese
women during both preovulatory and midluteal phases of men-
strual cycle [11].
Our results showed that there was no significant difference in
the endometrial and subendometrial blood flow parameters when
comparing normal weight PCOD women with fertile normal
weight women. Also there was no significant difference in all US
and Doppler endometrial parameters when comparing over-
weight/obese fertile women to normal weight fertile women.
In conclusion, the current study suggests that the endometrium
is negatively affected by the increased body weight and obesity in
PCOD women. Additionally, PCOD women had lower endometrial
and subendometrial blood flow than non-PCOD women. The
endometrial and subendometrial blood flow may be a cause of sub-
fertility and recurrent miscarriage in women with PCOD. So PCOD
women who are overweight or obese should be encouraged to
reduce their body weight in order to improve not only ovulation
but also endometrial receptivity.
Conflict of interest
The authors declare that they have no conflict of interest.
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