1. Rifat GÜRSOY, M.D. GAZİ UNIVERSITY SCHOOL OF MEDICINE DEPARTMENT OF GYNECOLOGY AND OBSTETRICS REPRODCTIVE ENDOCRINOLOGY AND INFERTILITY DIVISION GÜVEN HOSPITAL ASSISTED REPRODUDTIVE TECHNOLOGIES CENTER IVF UNIT A N K A R A

2. The Role of Endometrium on ART Success 2nd.Congress of Reproductive Endocrinology, Reproductive Endocrinology, Assisted Reproductive Technologies And 1st Congress of Repoductive Medicine Society (ÜTD)

3. Implantation Complex series of interactions between heterogenous cell types of the uterus and the blastocyst

4. Implantation Apposition Apposition Adhesion Adhesion Invasion Invasion

5. Implantation Window 1234567891011121314 Ovulation 1 2 3 4 5 9 10 11 12 13 Cycle Days 20-24

6. Natural and Stimulated Cycles

7. Endometrial Biopsy In-Phase In-Phase Ful secretory transformation Ful secretory transformation Receptive endometrium Receptive endometrium Out-of-Phase Out-of-Phase Incomplete or absent secretory tranformation Incomplete or absent secretory tranformation Noyes et al

8. Implantation Window If blastocysts transfer to uterus before decidualization,they can wait until decidualization before implantation If blastocysts transfer to uterus before decidualization,they can wait until decidualization before implantation If early stage embriyos transfer to decidualized endometrium,they can not reach to blastocyst stage so successfully If early stage embriyos transfer to decidualized endometrium,they can not reach to blastocyst stage so successfully

9. Time of natual implantation and loss of pregnancy Wilcox et al

10. Spandorfer et al

11. Spandofer et al

12. Spandorfer et al

13. Hysteroscopy Hysteroscopic appearance of mid-secretory endometrium in releation to early phase pregnancy outcome has been found to be better prognostic factor than any hormonal data investigated at this stage of menstruel cycle Hysteroscopic appearance of mid-secretory endometrium in releation to early phase pregnancy outcome has been found to be better prognostic factor than any hormonal data investigated at this stage of menstruel cycle

14. Kanazawa

15. Good hysteroscopic appearance

16. Poor hysteroscopic appearance

17. Ongoing Pregnancy Rates

18. Microarchitecture by scanning electron microscope

19. Sonography High resolution ultrasonography serves as a non-invasive alternative method using endometrial pattern and thickness to assess endometrial receptivity High resolution ultrasonography serves as a non-invasive alternative method using endometrial pattern and thickness to assess endometrial receptivity Endometrial pattern Endometrial pattern Endometrial thickness Endometrial thickness

20. Sonography

21. Sonography Hypoechoic texture:Central echogenic line during proliferative phase Hypoechoic texture:Central echogenic line during proliferative phase Hyperechogenic texture:Lacking central echogenic line during secretory phase Hyperechogenic texture:Lacking central echogenic line during secretory phase

22. Sonography Lack of homogenous hyperechogenic pattern in COH+IVF Lack of homogenous hyperechogenic pattern in COH+IVF DECREASED FECUNDITY COH may have an adverse effect on implantation COH may have an adverse effect on implantation

23. Check et al

24. Check et al (fresh embryo)

25. Check et al (frozen embryo)

26. Premature hyperechogenic pattern of endometrium

27. Fanchin et al

30. Endometrial thichness Considerable contraversy concern Considerable contraversy concern Predictive value for treatment outcome Predictive value for treatment outcome In younger patients In younger patients Who require prolonged gonadotrophin stimulation Who require prolonged gonadotrophin stimulation Those who have poor quality embryos Those who have poor quality embryos

31. Endometrial Thickness

32. Zhang et al

35. Endometrial voulme by 3D

36. Zollner et al

37. 3D Power Doppler Sonography

38. Jinno etal

39. Subendometrial Blood Flow by 3D Power Doppler

40. Wu et al (vascularization flow index)

41. MAJOR TAKE HOME POINTS Implantation rates in ART have not improved during last decade Implantation rates in ART have not improved during last decade Implantation is still an enigma Implantation is still an enigma Endometrial thickness and pattern are still the most Endometrial thickness and pattern are still the most reliable (!) criteria about endometrial receptivity in ART practice We do need to know more about microarchitecture,biochemical and molecular markers We do need to know more about microarchitecture,biochemical and molecular markers