Theriogenology 95 (2017) 171e177

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Theriogenology
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Two-dimensional sonographic and Doppler changes in the uteri of

bitches according to breed, estrus cycle phase, parity, and fertility
Luana Azevedo Freitas*, Gustavo Lobato Mota, Herlon Victor Rodrigues Silva,
Lúcia Daniel Machado Silva
Laboratory of Carnivore Reproduction, Veterinary School, State University of Ceara, Fortaleza, CE, Brazil

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

Article history: This study aimed to evaluate the two-dimensional and Doppler ultrasonographic features of bitches'
Received 23 August 2016 uteri according to breed, cycle phase, parity and fertility during the follicular and early diestrus phases.
Received in revised form Thirty-nine pubertal bitches were divided into groups according to breed, parity, and fertility. Sono-
6 March 2017
graphic assessments started from the first day of vaginal bleeding and were performed weekly for a
Accepted 14 March 2017
Available online 15 March 2017
month. The diameter of the uterine body was measured longitudinally and the uterine characteristics
observed sonographically were evaluated. The resistivity index (RI) and pulsatility index (PI) of the
uterine artery were calculated and the spectral morphology analyzed subjectively. The uterine diameter
Keywords:
Doppler
increased from proestrus to the diestrus regardless of the breed or parity. Multiparous bitches of both
Blood vessel breeds had higher uterine diameters than nulliparous bitches, except Fila Brasileiro bitches in estrus. In
Fertility diestrus and proestrus, the uterine diameters were significantly the largest for multiparous bitches,
Pregnancy followed by the primiparous bitches and smallest for nulliparous bitches. The uterine diameter was
Breed larger in Fila Brasileiro females than in French Bulldogs during estrus and diestrus. The RI did not differ
during the different phases of the cycle for the same breed. However, the RI was higher in nulliparous
and primiparous Fila Brasileiro females compared to French Bulldog females. Within Fila Brasileiro,
multiparous bitches showed lower RI than nulliparous and primiparous bitches. Higher PI values were
found during proestrus. All multiparous French Bulldog bitches had greater PI than nulliparous bitches,
while multiparous Fila bitches had lower PI. Nulliparous and primiparous Fila bitches had larger PI larger
than bitches with the same reproductive status of the breed French Bulldog. Infertile bitches had higher
RI and PI than bitches considered fertile during the initial estrus and diestrus. Triphasic and types A, C,
and D spectral morphologies were found in females who did not gestate; while pregnant females showed
spectral morphologies of type B, C and D. Hence, it was concluded that the breed, the phase of estrus
cycle and pregnancy history should be considered when studies the uterine artery flow during estrus and
early diestrus using investigations such as Doppler assessment, which can be an important tool in
diagnosing fertility in dogs.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction
Ultrasound examination of the uteri of bitches is an investiga-
tion routinely solicited for clinical reproductive evaluation [1,2].
Such exams permit the evaluation of size, echogenicity character-
istics, contour of the uterine walls, and presence of luminal content.
The size of the uterus varies depending on the animal's size,
number of previous pregnancies, disease or wellness conditions,
* Corresponding author.
E-mail address: lualaf@hotmail.com (L.A. Freitas).
phase of the estrus cycle and pregnancy status [1,3]. However, few
studies have considered and addressed these factors and applied
them have considered to ultrasound images in dogs [4,5].
Doppler ultrasound has found application as a non-invasive
method in the assessment of uterine vasculature in different spe-
cies [5e8]. Studies suggest that uterine perfusion regulates endo-
metrial receptivity and influences successful implantation and
maintenance of early pregnancy. Thus, good uterine blood supply
preceding conception directly relates to fertility [9,10].
Flow in the uterine artery is evaluated quantitatively by
measuring the velocities, namely, peak systolic velocity (PSV), end
diastolic velocity (EDV) and mean velocity (MV); this is followed by

http://dx.doi.org/10.1016/j.theriogenology.2017.03.012
0093-691X/© 2017 Elsevier Inc. All rights reserved.
172 L.A. Freitas et al. / Theriogenology 95 (2017) 171e177
derivation of the indices, namely, resistivity (RI) and pulsatility
index (PI). Qualitative evaluation is performed by assessing the
spectral morphology. While velocity evaluates the blood flow
behavior, these indices generate information on the impedance of
the vessel and thus characterizes the vascular supply of a given
organ [10]. Moreover, the study of flow by measuring the indices is
accurate and provides replicability, especially when the study tar-
gets are vessels with small diameters or highly convoluted vessels,
independent of the angle of sounding since they are based on the
ratio between the speeds [11,12]. Some authors have demonstrated
the relevance of spectral morphology evaluation to relate spectral
descriptive aspects to infertility in women [13]. Although this is a
subjective analysis for interpretation of flow, it permits evaluation
when there is a diastolic change. In such cases, quantitative analysis
does not provide precise flow information [9,12].
Many studies have focused on Doppler evaluation of uterine
arteries for a biological understanding of variations due to physi-
ological or pathological events in women [9,10,12e17]. In dogs,
studies have shown that there is a quantitative physiological vari-
ation in uterine flow during the estrus cycle [17,18], ovulation
[18,20], deposit of semen [21], pregnancy [22] and post-partum
[23], and in inflammatory processes [24]. Changes in the spectral
morphology of the canine uterine artery were described during
anestrus [19], and different wave patterns during the follicular and
early luteal phase were found in dogs that did not become pregnant
[20].
Factors such as age influence changes in the flow of canine
uterine artery and may have an impact on fertility [20]. The phase
of the estrus cycle can also influence the Doppler parameters [19].
However, factors influencing the size of the uterus and the uterine
artery, such as the animal [25] and the pregnancy history [3,25],
factors that lead to reduced fertility such as a history of recurrent
failures of pregnancies [15e17], uterine pathology [27], gestational
changes [14,26e28], and ovarian pathology [29], have not been
investigated to determine the influence of the canine uterine artery
Doppler parameters on them. In this setting, this study aimed to
evaluate the two-dimensional and Doppler ultrasonographic fea-
tures of bitches' uteri according to breed, cycle phase, parity and
fertility during the follicular and early diestrus phases.
2. Material and methods
2.1. Experimental animals
The experimental protocol (protocol number 5999508/2015)
was approved by the Ethics Committee in Animal Experimentation

in accordance with the guidelines
of the State University of Ceara
for the care and use of laboratory animals established by the Bra-
zilian College of Animal Experimentation. Thirty-nine pubertal
bitches were evaluated, consisting of the French Bulldog (n ¼ 24)
and Fila Brasileiro (n ¼ 15) breeds. All included animals were
healthy, with a body score of approximately 3.0, weighing between
10 and 75 kg, ages ranging from 8 months to 6 years, and belonging
to private kennels. The animals were fed granulated canine com-
mercial food and water ad libitum. Their reproductive history was
known and/or had normal standard clinical examinations (physical
inspection), laboratory (blood count) tests, and abdominal and
pelvic ultrasound evaluations. All animals tested negative for
brucellosis annually. The bitches were monitored using vaginal
cytology and clinically; they were inseminated either artificially or,
using known fertile males. The vaginal cytology was performed
once a week by a single observer, beginning on the first day of
bloody vaginal discharge until the identification of cytological
diestrus. The smears were stained by Diff-Quick. The phases of the
estrus cycle were defined based on the cytological characteristics
[25]. Intravaginal inseminations were performed after obtaining
the characteristic cytologic estrus on 3 alternate days using semen
from animals with proven fertility. For those that were naturally
mated, the male dog accompanied the bitch during the whole
estrus.
The animals were grouped according to categories: breed
(French Bulldog or Fila Brasileiro), parity (nulliparous, primiparous
or multiparous), and fertility history (fertile or infertile/sub-fertile).
Bitches that did not conceive for a year or more after mating, had
reproductive history of gestational failures, or had low prolificacy
or reproductive alterations during the experiment were considered
infertile or subfertile. A total of 21 French Bulldog bitches and 12
Fila Brasileiro bitches without clinical and historical anomalies of
previous reproductive changes were allocated according to the
order of parity into groups of 7 and 4 animals, respectively; for each
breed, the uterine diameter and Doppler indices were evaluated.
Six bitches (3 from each breed) were not included in this compar-
ison as they showed sonographic changes during the stages of the
evaluated cycle, endometritis and ovarian cyst, or a history of
gestational failures.
2.2. Technical examination
Sonographic examinations were performed in private kennels

, over 1 year. The
located in the metropolitan area of Fortaleza, Ceara
equipment used was MyLab 30 Vet Gold (Esaote, Genova, Italy)
with a multi-frequency micro-convex probe of 5e10 MHz (LA523
reference-Esaote, Genova, Italy). All ultrasound evaluations were
performed by the same operator. The evaluations were carried out,
preferably in the morning, with the animals fasted for at least 8 h.
The bitches were placed in dorsal recumbency, without sedation.
The abdominal and pelvic areas were shaved and a water soluble
acoustic gel was applied.
2.3. Two-dimensional ultrasound evaluation
The bitches were evaluated once a week for 4 weeks. Assess-
ments commenced on the first day of serosanguinous vaginal
discharge (day 0), which marked the beginning of proestrus. The
period of the estrus cycle was confirmed based on to the clinical
signs, behavior, and vaginal cytology. The animals were grouped
according to the phase of the cycle, breed and parity. The uterus
was assessed for the presence or absence of intraluminal fluid. The
longitudinal uterine diameter was measured (cm) at the body of
the uterus. Ovaries were evaluated for the presence of cysts.
2.4. Doppler ultrasound evaluation
After obtaining the two-dimensional images, Doppler was used
to characterize the hemodynamics of the uterine artery on both
sides of the uterine body.
For color and spectral Doppler, we set and kept constant for all
evaluations the insonation angle at 0 , color gain at 64% and the
lowest wall filter to characterize the signal amplitude. For flow
evaluation, we used a color map with the depth adequate for
maximizing the frame rate, pulse repetition frequency of 9e18 Hz
and sample size constant at 18 mm. The vessel was visualized
longitudinally and the sample was measured in this plane.
After identification of the arteries by color mapping, electronic
markers (sample volume or gates) were placed in the central region
of the vessel and the spectral Doppler was started. For analysis and
to minimize data variability, 3 similar and consecutive waves were
recorded. Blood flow was measured automatically by the ultra-
sound system using RI (PSV-EDV/PSV) [30] and PI (PSV-EDV/MV)
[31] and by assessing the spectral morphology.
 L.A. Freitas et al. / Theriogenology 95 (2017) 171e177
The spectral morphology assessment was performed as follows
[12]: Type A, a systolic peak followed by absent early diastolic wave,
but with flow through the mid and late diastole until the next
systole; Type B, systolic peak followed by continuous diastole to
systole, absent late diastolic flow; Type C, the systolic peak followed
by diastole, extending throughout the cardiac cycle to subsequent
systole; Type D, systolic peak with absent early and late diastole,
but with the mean diastolic flow; Type O, the systolic flow alone is
identified, with characteristic high monophasic resistivity; Type N
(3 phases), systolic peak followed by reverse-diastolic and positive
flow.
2.5. Statistical analysis
The data addressing the sonographic parameters related to
uterine sonogram characteristics were described qualitatively and
quantitatively. The uterine diameter and the RI and PI were
expressed as a mean with standard deviations. The comparison of
uterine diameter, RI, and PI among the breeds, estrus cycle phase,
reproductive status and fertility was performed using SPSS 19.0
software (SPSS Inc. Chicago, IL, USA). The data were subjected to the
Shapiro-Wilk test for evaluation of normality and compared using
bivariate analysis by Student T test and Kruskal-Wallis considering
P values less than 0.05 as significant.
3. Results
All bitches had normal estrus cycle and were mated. The average
time of ultrasound assessment was 15 min, ranging from 10 to
20 min.
The uterus was located dorsal to the urinary bladder and ventral
to the colon. The uterine body was identified longitudinally as a
tubular structure that could be visualized as a slight thickening
with hypoechoic (edema) uterine walls during all stages. The layers
of the uterus could be distinguished on the cross-section images
due to reduced central echogenicity corresponding to the endo-
metrium and a peripheral hyperechogenicity corresponding to the
perimetrium (Fig. 1). The uterine horns were identified as thin
hypoechoic tubular structures in the lateral abdomen continuing
along the line of the ovaries.
A discrete amount of anechoic intraluminal content was visible
during estrus in 18 dogs of both breeds. However, only 1 French
Bulldog bitch was diagnosed with endometritis; the presenting
sonogram image was characterized by increased uterine wall con-
tour irregularity, accompanied by a moderate amount of anechoic
Fig. 1. (A). Two-dimensional ultrasound image showing a longitudinal section of the uterine body of a bitch in proestrus (B) Uterine layers identified in transverse section (C)
Doppler with color mapping showing the uterine artery bordering the uterine body in a bitch in estrus.
173
intraluminal fluid content. Two French Bulldog bitches presented
with multiple ovarian cysts that visually manifested as multiple
circular hypoechoic structures in the ovarian cortex measuring
more than 3 mm in diameter.
The uterine diameter increased from proestrus to diestrus
regardless of the breed or parity. Multiparous bitches of both
breeds had higher uterine diameters than nulliparous bitches,
except for Fila Brasileiro bitches in estrus. In proestrus and diestrus,
the uterine diameters of multiparous bitches were significantly
greater than in primiparous females, which in turn was greater than
in nulliparous females. In estrus, the uterine diameter of primipa-
rous and multiparous Bulldogs did not differ and were significantly
larger than in nulliparous females. For the Fila Brasileiro bitches in
estrus, there was no difference in the uterine diameter based on
parity. The uterine diameter was higher in Fila females than French
Bulldog during estrus and diestrus, regardless of the parity
(Table 1).
The uterine arteries were identified in all bitches (Fig. 1). No
differences were found between the flow of the uterine artery on
the right and left, based on grouped data. The RI of the uterine
arteries did not differ between the phases of the cycle for either
breed. The RI of the French Bulldog uterine artery did not differ in
proestrus and estrus independent of the parity. However, the RI
was significantly higher in diestrus in multiparous females
compared to nulliparous and primiparous females. In Fila Brasileiro
bitches, the RI during different phases of the cycle were similar in
nulliparous and primiparous and significantly lower in multiparous
females bitches. On comparing the breeds, it was observed that the
RI in nulliparous and primiparous French Bulldog bitches were
significantly lower than in the Fila Brasileiro bitches, while the RI of
multiparous French Bulldog bitches did not differ from the RI of
multiparous Fila Brasileiro bitches (Table 2).
Larger PI values were notes during proestrus. All multiparous
French Bulldog bitches registered PI greater than nulliparous
bitches, while multiparous Fila Brasileiro bitches had lower IP.
Nulliparous and primiparous Fila Brasileiro bitches registered
greater PI than French Bulldog bitches with the same reproductive
status (Table 3).
The RI of fertile female dogs did not differ between the phases of
the cycle. In infertile bitches, the RI in diestrus and estrus were
significantly higher than in proestrus. The PI increased from pro-
estrus to estrus and decreased from estrus to diestrus, both in
fertile bitches as in those infertile. The RI and PI did not differ in
proestrus between fertile and infertile bitches; however, they were
significantly higher in infertile bitches during estrus and diestrus
174 L.A. Freitas et al. / Theriogenology 95 (2017) 171e177

Table 1
Mean ± standard deviation of canine uterine body diameter (cm) in longitudinal section according to parity and breed during different phases of the estrus cycle.

Phases Uterine body diameter (cm)

French Bulldog (n ¼ 21) Fila Brasileiro (n ¼ 12)

Nulliparous Primiparous Multiparous Nulliparous Primiparous Multiparous

Poestrus 0.81 ± 0.07aA 0.94 ± 0.04aB 1.03 ± 0.04aC 0.80 ± 0.06aA 0.98 ± 0.03aB 1.06 ± 0.09aC
Estrus 0.91 ± 0.08bA* 1.10 ± 0.12bB* 1.17 ± 0.08bB* 1.33 ± 0.10bA* 1.30 ± 0.19bA* 1.33 ± 0.18bA*
Diestrus 1.12 ± 0.07cA* 1.29 ± 0.15cB* 1.53 ± 0.25cC* 1.66 ± 0.17cA* 1.84 ± 0.11cB* 1.99 ± 0.13cC*

Different superscript lower case letters in the same column indicate that there were differences among phases of the cycle in the same breed (P < 0.05).
Different superscript capital letters in the same line indicate that there were differences among reproductive status in the same breed (P < 0.05).
*
It refers to the difference between breeds.

Table 2
Mean ± standard deviation of resistivity index of the canine uterine artery according to parity and breed during different phases of the estrus cycle.

Phases Resistivity index

French Bulldog (n ¼ 21) Fila Brasileiro (n ¼ 12)

Nulliparous Primiparous Multiparous Nulliparous Primiparous Multiparous

Poestrus 0.80 ± 0.09aA* 0.85 ± 0.07aA* 0.87 ± 0.06aA 0.93 ± 0.03aA* 0.96 ± 0.02aA* 0.83 ± 0.03aB
Estrus 0.88 ± 0.06aA* 0.83 ± 0.03aA* 0.90 ± 0.04aA 0.98 ± 0.07aA* 0.94 ± 0.08aA* 0.83 ± 0.06aB
Diestrus 0.74 ± 0.14aA* 0.80 ± 0.04aA* 0.86 ± 0.09aB 0.97 ± 0.07aA* 0.91 ± 0.06aA* 0.81 ± 0.09aB

Different superscript lower case letters in the same column indicate that there were differences among phases of the cycle in the same breed (P < 0.05).
Different superscript capital letters in the same line indicate that there were differences among reproductive status in the same breed (P < 0.05).
*
It refers to the difference between breeds.

Table 3
Mean ± standard deviation of pulsatility index of the canine uterine artery according to parity and breed during different phases of the estrus cycle.

Phases Pulsatility index

French Bulldog (n ¼ 21) Fila Brasileiro (n ¼ 12)

Nulliparous Primiparous Multiparous Nulliparous Primiparous Multiparous

Poestrus 2.51 ± 0.21aA* 2.62 ± 0.26aA* 2.86 ± 0.24aB 3.46 ± 0.28aA* 3.85 ± 0.17aB* 2.56 ± 0.26aC
Estrus 1.98 ± 0.18bA* 2.39 ± 0.15bB* 2.64 ± 0.20bC 3.06 ± 0.19ab* 3.50 ± 0.26bB* 2.07 ± 0.21bC
Diestrus 2.01 ± 0.19bA* 2.29 ± 0.23bB* 2.43 ± 0.27bB 3.13 ± 0.21aA* 2.93 ± 0.22cB* 1.91 ± 0.29bC

Different superscript lower case letters in the same column indicate that there were differences among phases of the cycle in the same breed (P < 0.05).
Different superscript capital letters in the same line indicate that there were differences among reproductive status in the same breed (P < 0.05).
*
It refers to the difference between breeds.

(Table 4). Females with endometritis (RI proestrus: 0.85; RI estrus: characterizing the spectrum as monophasic with high resistivity
0.89 and RI diestrus: 0.86/PI proestrus: 2.63; PI estrus: 2.80 and PI (type O or type D). Primiparous bitches that did not give birth had
diestrus: 2.51) and ovarian cyst (RI proestrus: 0.88; RI estrus: 0.91 triphasic spectral morphologies that had a systolic peak, followed
and RI diestrus: 0.86/PI proestrus: 2.66 PI estrus: 2.88 and PI by reverse-diastolic and positive flow (type N). More details
diestrus: 2.45) did not differ from fertile bitches. regarding the types of spectral morphologies may be found in Fig. 2.
During this study, 26 dogs (66.66%) were diagnosed as pregnant,
17 being French Bulldogs and 9 Fila Brasileiro bitches. Most preg-
4. Discussion
nant bitches showed type C spectral morphology during proestrus,
estrus, and early diestrus. A Fila Brasileiro bitch that presented with
Factors that affect the uterine artery flow have already been
fetal death at 42 days of gestation exhibited Type D spectral
described in young and mature dogs [20], and after mating [21];
morphology. Spectral Type B were identified in a Fila Brasileiro
differences in the flow during different phases of the estrus cycle
bitch who had low prolificacy (2 pups) and multiple embryonic
have been identified [19]. However, this is the first description of
resorptions.
the uterine artery flow according to the breed, parity, and fertility in
Of the 7 Bulldog bitches that did not give birth, 1 had endo-
the period preceding conception, highlighting the importance of
metritis in the fourth week of evaluation, 2 had ovarian cysts, and 4
categorization of these factors in assessing the biological implica-
did not give birth because of a prior failure (history of gestational
tions of the uterine artery Doppler study in canine reproduction.
failures (2 nulliparous and 2 primiparous)). Of the 6 Fila Brasileiro
The uterine ultrasound description findings in this study agree
that did not give birth, 3 had gestational failures without prior
with previous reports in the literature [1,4,32]. However, the
history (nulliparous), while the other 3 had a known history of
presence of uterine intraluminal fluid during late estrus attributed
gestational failures.
to endometritis induced after mating [33] has not been related to
The spectral morphology of the bitch who had endometritis was
an adverse effect on the fertility; this was confirmed in females
similar to those that gave birth (Type C). Bitches that had ovarian
who had reached term and showed no changes during pregnancy
cysts had spectral morphologies C and A types during the weekly
or postpartum.
assessments. The nulliparous bitches that did not give birth showed
One of the factors related to the increase in uterine diameter,
a type of flow in which only the systolic flow was identified,
due to endometrial cyclic activity during proestrus, estrus and
 L.A. Freitas et al. / Theriogenology 95 (2017) 171e177 175

Table 4 size of the animal [25] were also identified.

Mean ± standard deviation of resistivity and pulsatility index of the canine uterine Uterine artery flow characteristics during the follicular phase
artery of fertile (n ¼ 28) and infertile (n ¼ 11) bitches during different phases of the
estrus cycle.
have been reported in the past, exhibiting biphasic morphology
with spectral peak flow during estrus and early luteal phase; this
Phases Resistivity index Pulsatility index was identified in this study by evaluating the PI. Studies have
Fertile Infertile Fertile Infertile suggested that uterine flow is a dependent cycle in women [9],
Poestrus 0.88 ± 0.12aA 0.89 ± 0.14aA 2.66 ± 0.16aA 2.72 ± 0.21aA mares [5], and cows [6]; it is believed that cyclic variations in the
Estrus 0.93 ± 0.13aA 1.10 ± 0.16bB 2.87 ± 0.24bA 3.44 ± 0.19bB uterine artery flow are attributed to the concentration of proges-
Diestrus 0.85 ± 0.14aA 1.07 ± 0.18bB 2.51 ± 0.22cA 3.19 ± 0.31cB terone and estrogen principally, and other flow regulating factors
Different superscript lower case letters refer to the comparison of the RI or PI in the such as nitric oxide. However, in this study, even with an increase in
same reproductive status among the phases of cycle (P < 0.05). the uterine size over the phases studied, no RI differences were
Different superscript capital letters refer to the comparison between fertile and identified in both breeds, unlike PI, which showed higher values
infertile reproductive status in the same phase (P < 0.05).
during proestrus, the estrogen dominant phase. Based on these
findings, recent works in women have emphasized greater reli-
diestrus is hormonal influence. The uterine tissue undergoes a va- ability in the use of PI for the diagnosis of unexplained infertility
riety of adaptive reactions in response to hormonal changes that [17].
occur at different stages of the estrus cycle [25], through organizing Previous canine studies were suggestive of a fluctuation in the
events and stratification of endometrial stroma; growth and dif- uterine artery Doppler values during different stages of the estrus
ferentiation of the myometrium; and coordinated development of cycle [18e20]; this was not found in the current study due to the
the endometrial glands [34], apart from hormonal influence, the applied experimental design; hence, subtle differences that might
parity also determine the uterine size. A study of uterine have occurred daily were not identified weekly. Furthermore,
morphometry in multiparous bitches demonstrated an increase in another interesting aspect in the comparison of breeds and parity
the endometrium and especially the myometrium sizes with was that the RI and PI values of nulliparous and primiparous Fila
increasing number of pregnancies [3]. The increased thickness of Brasileiro bitches were higher than the French Bulldog bitches;
the uterine wall was subsequently confirmed by ultrasound [4]. As however, there were no differences between multiparous bitches.
this study evaluated bitches of different breeds and sizes, other This may be explained by assuming that parity and breed can in-
factors related to changes in the uterine size, such as the breed and fluence the Doppler indices; however, after successive pregnancies,
the influence of RI is lost.

Fig. 2. Graph (x-axis, flow rate in meters and the y-axis, time in seconds) showing the uterine artery spectral morphologies of 39 bitches during proestrus, estrus, and diestrus. (A)
Type A, a systolic peak followed by absent early diastolic wave but with flow during mid and late diastole until the next systole. (B) Type B, systolic peak followed by continuous
diastole to systole, but absent late diastolic flow. (C) Type C, systolic peak is followed by diastolic, extending throughout the cardiac cycle to the subsequent systole. (D) Type D,
systolic peak with no early and late diastolic flow, but with the mean diastolic flow. (E) Type O, systolic flow alone is identified, with characteristic monophasic high resistivity. (F)
Type N (3 phases), systolic peak followed by reverse-diastolic and positive flow.
176 L.A. Freitas et al. / Theriogenology 95 (2017) 171e177
Bitches classified as infertile/subfertile had higher Doppler
indices during estrus and diestrus; they have maximum uterine
flow during these periods [12]. At this time, important physiolog-
ical events such as ovulation [18], sperm reception [21], and em-
bryo implantation [13,14] might occur; these require adequate
blood perfusion for successful reproduction.
Data shown in this work combined quantitative evaluation of
obtaining the indices and qualitative evaluation of analyzing the
spectral morphology. Thus, a high RI and change in spectral
morphology of the diastolic flow might indicate poor perfusion in
the vascular bed, which can in turn lead to failures in the design and
maintenance of the developing conceptus (change in placental
formation), as identified in Fila Brasileiro bitches with changes
during pregnancy [9,12,26,35]. Thus, our results demonstrate the
role of uterine vascularization, and the importance of Doppler
studies in pre-obstetric evaluation as a predictor of adversity before
and during pregnancy [11e16].
In a classification proposed by Dickey [35], there were 6 spectral
morphologies in the uterine artery flow: A, B, C, D, O, and N, related
to fertility and infertility. The triphasic flow was not reported with
regard to the flow of uterine artery, but was described with regard
to the ductus venous flow (transient vessel during fetal life)
[11,12,35]. It corresponds to the ventricular systole (1st wave), atrial
contraction (2nd wave-reverse peak), and ventricular diastole (3rd
wave), resulting in a pressure reduction, preceding the diastole,
which leads to distension of the contracted vessel, which in turn
leads to poor tissue perfusion [35]. In this study, bitches that had
this wave morphology had a history of recurrent pregnancy failures
and did not give birth.
In this work, nulliparous bitches that did not give birth showed
type O flow. This spectrum of the uterine artery flow patterns has
already been described in pre-pubertal children and individuals
[36], but it can also be identified in those with fertility problems
who undergo in vitro fertilization programs [12]. In this study, its
visualization was related to the early and reproductive immaturity
(first heat) or the presence of anovulatory cycles in these dogs,
mostly identified in the Fila Brasileiro, which is a giant breed,
consequently showing late puberty [25].
In many species, after the breeding, there is a transient in-
flammatory response to remove the excess sperm, bacteria, and
other contaminants from the uterus. Some dogs have increased
influx of neutrophils due to increased vascularization after mating,
reducing fertility and leading to endometritis induced by mating. It
has been reported in the literature that these females have a higher
RI after breeding than healthy females [24]. In this study, no
changes were noted in the RI of bitches that presented with
endometritis; this most likely was due to the evaluation not being
performed right after mating/insemination. Another factor related
to infertility is the presence of ovarian cysts. In women, ovarian
polycystic disease has been described as a cause of infertility, not
only due to hormonal changes, but also due to increased resistance
resulting from ovarian and uterine tissue vascularization [37]. In
this work, only two-dimensional changes could be identified by
inspection of intra-ovarian cysts and hence, no difference in the
flow was identified.
Thus, it is concluded that the flow of the normal uterine artery
differs depending on the breed, phase of the cycle, reproductive
status, and history. Moreover, Doppler studies during the follicular
and early luteal phase can be an important tool in the diagnosis of
infertility in dogs with unexplained causes of reproductive failure.
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