Summary and ConclusionThe first birth in July, 25, 1978 following IVF treatment by the British team of Steptoe and Edwards marked the beginning of a rapid expansion of the treatment modalities available to infertile couples as well as an improvement in success rates.Despite advances in in IVF techniques and ovarian stimulation regimens, pregnancy rates have not risen accordingly and implantation rates per embryo transferred still remain at a low 10-15%. This highlights the need to identify factors that are prognostic of outcome thus assisting in reducing the number of unsuccessful treatment cycles.Embryo quality and endometrial receptivity are two of the parameters which determine the reproductive outcome in IVF programmes.The introduction of high resolution ultrasound has allowed the development of uterine and ovarian sonographic markers that could be used to predict outcome in assisted reproduction treatment cycles.Many descriptive studies imply a role for immunology in reproductive success and failure, although the precise mechanisms by which such a role occurs remain ill-defined. The most substantive data to date suggest that autoantibodies to phospholipids cardiolipin are involved in reproductive failure.The aim of this study were to evaluate the relationship between anticardiolipin antibodies and uterine and ovarian hemodynamics, and the effects of these parameters, ACA; uterine and ovarian hemodynamics, on IVF outcome.This study was carried out in the assisted reproductive technologies unit, Zagazig University Hospitals during the period from May 2002 to April 2004.This study included a total of 120 infertile women of those attending the ART unit. They were scheduled to undergo ovarian stimulation and either IVF or ICSI therapy.All women subjected to full history taking, general examination, local examination and basal ultrasound examination, then ovarian hyperstimulation using long protocol GnRRH agonist and FSH (metrodin RS) and or hMG (pergonal) in appropriate doses. 10,000 IU of, HCG (pregnyl) were administered to induce final oocytes maturation and ovulation. Retrieval and incubation of the oocytes were done and according to planning procedures (IVF or ICSI) the oocytes were inseminated or injected.Embryos of good quality A and/ or B (stadessen classification) were transferred. Luteal phase support was provided by micronized progesterone either orally or vaginally. Pregnancy test (urine B.hCG test) was performed 14 days after ET. If positive luteal support was continued until ultrasonographic evidence of viable pregnancy.All patients on the day of hCG were examined for uterine (uterine and spiral artries PI) hemodynamics and ovarian (ovarian artery PI and perifollicular vascularity) hemodynamics.All patients were examined for ACA 2 weeks before IVF procedures and if positive (> 7.2 and 6.5 IU/ ml respectively for IgG and IgM ACA classes). The test repeated just before Doppler examination.The patients were classified according to pregnancy to pregnant (n = 22) and non pregnant (n = 98) groups.There were no significant differences between the pregnant and non pregnant groups for: the age of the patients, the number of hMG ampoules, the number of days of stimulation, the number of oocytes fertilized and quality of embryo transferred. The number of oocytes retrieved was significantly higher in the pregnant group (P = 0.03) (Table I).There was no significant difference in the uterine PI and the ovarian PI between pregnant and non-pregnant groups. The mean uterine pI was: 2.56 ± 0.53 and 2.75 ± 0.64 in the pregnant and non pregnant groups respectively. The mean ovarian PI was 2.2 ± 0.98 and 2.5 ± 1.2 in the pregnant and non pregnant groups respectively. The spiral artery blood flow was detected in 76 (63.3%) cases with pregnancy occurring in 17.1% of these cycles (13 of 76) and was absent in 44 patients with pregnancy occurring in 20.45 of these cycles (9 of 44). The mean spiral artery PI in the present group was 1.21 ± 0.27 and 1.12 ± 0.28 in the pregnant and non-pregnant groups respectively. The spiral artery blood flow did not correlate with pregnancy rate table 2.640 follicles were studied using color Doppler flow, 104 of them were grade F1, 156 were grade F2, 220 were grade F3 and 160 were grade F4 all pregnancies occurred in women with grade F3 (4 pregnancies) and grade F4 (18 pregnancies) follicular blood flow. Difference in pregnancy rate between F1 and F4 was significant (p = 0.03), F2 and F4 was highly significant (p = 0.000) and F3 and F4 was highly significant (p = 0.000) table 3.Of the studied patients, 28 tested persistently positive ACA.The mean age of those testing positive for ACA was 32.1 ± 5.6 and it did not differ significantly from that of the ACA negative groups. Therewas no significant difference comparing ACA status between patients grouped according to their cause of infertility, and the number of IVF trials table 4.There were 4 patients with positive pregnancy tests and 18 patients in ACA positive and negative groups respectively table 5. Only 2 cases and 11 had viable pregnancies later on table 6.The mean IgG and IgM in ACA positive group were 8.2 ± 5.4 and 7.5 ± 2.5 in uterine p = £ 3 and 9.1 ± 9.1 and 7.8 ± 3.0 in uterine PI > 3 respectively. in the ACA negative group IgG and IgM means were 6.5 ± 2.1 and 5.0 ± 1.99 in uterine PI £ 3 and 6.0 ± 1.9 and 4.6 ± 2.4 in uterine PI > 3 there was no significant relationship found between uterine PI and ACA IgG and IgM classes table 7.The mean IgG and IgM ACA positive group were 8.3 ± 4.1 and 7.4 ± 3.7 for uterine PI £ 3 and 8.9 ± 3.5 and 7.9 ± 4.5 in uterine PI > 3 respectively. In the ACA negative group IgG and IgM means were 4.1 ± 1.7 and 4.0 ± 2.5 in ovarian PI < 3.15 and 4.5 ± 2.3 and 3.5 ± 1.9 in ovarian PI > 3.15 respectively. There was no significant relationship between ovarian PI and ACA status table (8).As regard the relationship between micro vasculature (spiral and pen follicular) and ACA status the relationship was high but did not touch the significant level P value 0.09 and 0.06 for IgG and IgM ACA positive respectively for spiral artery blood flow table (9).The relationship between follicular vascularity and ACA positive IgG and IgM classes was high but non significant 0.06 and 0.08 respectively table (10).ConclusionOne may conclude from this study that:There is no relationship between uterine PI and IVF outcomeThere is no relationship between spiral blood flow and IVF outcomeThere is no relationship between ovarian PI and IVF outcomeThere is significant relationship between follicular vascularity and IVF outcome.There is no relationship between ACA and IVF outcomeThere is no relationship between uterine ovarian PI and ACAThe relationship between spiral, follicular blood flow and ACA was non significant but highRecommendationWe recommend for prospective clinical studies to elucidate the possible interaction between ACA and uterine and ovarian perfusion. Also we recommend prospective randomized controlled trial on large number of patient to elucidate the possible effects of antiphaspholipid antibodies on IVF outcome.