Low serum progesterone levels and tubal dysfunction--a possible cause of ectopic pregnancy

The association between polycystic ovary syndrome and ectopic pregnancy after in vitro fertilization and embryo transfer

OBJECTIVE

We sought to assess the association between polycystic ovary syndrome (PCOS) and ectopic pregnancy after in vitro fertilization-embryo transfer (ET).

STUDY DESIGN

In this retrospective cohort study, we included 5339 women who had clinical pregnancies after in vitro fertilization treatment (PCOS, 205 women; non-PCOS, 5134 women) at Nanjing Medical University (China) between 2007 and 2011. Fresh and cryo-thawed ET cycles were analyzed respectively. The primary outcome measure was the occurrence of ectopic pregnancy. Multivariate logistic regression analysis was used to adjust for important confounders.

RESULTS

In fresh ET cycles of women who were undergoing controlled ovarian hyperstimulation (COH; n = 3303), women with PCOS had 3.06 times higher risk of ectopic pregnancy compared with those without PCOS (7.0% vs 2.4%; adjusted odds ratio [aOR], 3.06; 95% confidence interval [CI], 1.34-6.96). In the stratified analysis, for women without PCOS, the high estradiol group (>4085 pg/mL) had higher ectopic pregnancy rates compared with the low estradiol group (≤4085 pg/mL; 3.4% vs 2.0%; aOR, 1.99; 95% CI, 1.19-3.35); however, for women with PCOS, both high and low estradiol groups had high ectopic pregnancy rates (5.6% vs 7.7%; aOR, 0.92; 95% CI, 0.15-5.67). In cryo-thawed ET cycles without COH (n = 2036), the ectopic rates between women with and without PCOS were similar (2.2% vs 2.0%; aOR, 0.94; 95% CI, 0.22-4.07).

CONCLUSION

PCOS was associated with an increased risk of ectopic pregnancy after COH in fresh ET cycles, but not in cryo-thawed ET cycles. A possible explanation is that, compared with women without PCOS, women with PCOS appear to hold a lower threshold of hyperphysiologic estradiol level that triggers the occurrence of ectopic pregnancy after COH.

Delayed ovulation and pregnancy outcome: effect of environmental toxicants on the neuroendocrine control of the ovary(1)

In the female rat, we have shown that a burst exposure to environmental toxicants known to alter noradrenergic function will block the ovulatory surge of LH when administered during a sensitive period on the day of vaginal proestrus. Such treatments will delay ovulation by 24 h and affect embryo survival. These results demonstrate clearly that brief, appropriately timed, toxicant exposure can initiate a cascade of changes that can alter reproductive outcome. However, we also found that continued exposure to the same compound is without an apparent influence on the reproductive capacity of the female, indicating that the female can become tolerant to such adverse reproductive effects. These observations raise a number of questions concerning the approaches currently used to examine potential reproductive toxicants. In this review, we describe the consequences of appropriately timed exposures to chlordimeform and dithiocarbamates on the timing of ovulation and subsequent alterations in pregnancy outcome. We also review the available literature on phenobarbital delays in ovulation and oocyte function in the rodent and the relevance to ovulatory delays in the human.

High progesterone levels and ciliary dysfunction--a possible cause of ectopic pregnancy

OBJECTIVES

To investigate the effects of different levels of hormones on the ciliary activity of human oviducts and, consequently, to assess their possible role in tubal implantation of the fertilized egg.

DESIGN

Fallopian tube epithelial samples were incubated in media with the addition of Estradiol (E2), progesterone (P), human menopausal gonadotropin (hMG), LH, or pure FSH (Metrodin) in different concentrations. The ciliary beat frequency (CBF) was measured after 24 h of incubation. Then the media were exchanged to media without the addition of hormones and the CBF was measured again 24 h later by using the photoelectric technique.

SETTING

University teaching hospital, IVF unit.

RESULTS

Twenty-four hr after the addition of P to the culture medium in concentrations of 0.5 or 1 ng/ml a significant decline of the CBF down to 63% of the control level was observed (P < 0.001) and with P in concentration of 2 ng/ml or greater, 50-70% of the cilia were paralyzed. These effects of P were found to be reversible. Incubation with E2 induced a slight increase of 4% in the mean CBF (P = 0.002). Twenty-four hr incubation with Metrodin, Pergonal, or LH did not affect ciliary motility.

CONCLUSIONS

Higher levels of progesterone cause ciliary dysfunction and subsequently may be a possible cause of ectopic pregnancy.

Endometrial cell dissemination at diagnostic hysteroscopy: a prospective randomized cross-over comparison of normal saline and carbon dioxide uterine distension

The incidence of pelvic spreading of endometrial cells at diagnostic hysteroscopy was studied comparing the two distension media carbon dioxide (CO(2)) and normal saline (N/Saline). Thirty patients requiring laparoscopy and hysteroscopy were included in this study, the main indication for surgery being subfertility. Hysteroscopy was performed using both CO(2) and N/Saline distension on each patient, the order of the distension media being randomly allocated. Samples of peritoneal fluid were aspirated from the pouch of Douglas before and after hysteroscopy with each distension medium, and the specimens were investigated cytologically for the presence of endometrial cells. Endometrium was present in 2/30 (6.7%) peritoneal aspirates before and in 15/60 (25%) collected after the hysteroscopies. There was no major difference between liquid or gaseous distension, transtubal reflux of endometrial cells occurring in 7/30 (23.3%) and in 8/30 (26.7%) hysteroscopies respectively. Positive peritoneal cytology was observed significantly more often in patients who were in the proliferative phase of the menstrual cycle [9/14 (64.3%) versus 0/11, P < 0.004]. In conclusion, transtubal dissemination of endometrium occurs in about one quarter of patients, irrespective whether N/Saline or CO(2) is used for uterine distension; there is no advantage to using gaseous distension for hysteroscopy when investigating high-risk cases for endometrial malignancy.

Vaginal progesterone after tubal pregnancy

We studied the effect of vaginal progesterone (P) treatment during the luteal phase of patients who had had a tubal pregnancy (TP) and were planning another, in a prospective, randomized, double-blind trial. The outpatient clinics of two University hospitals and three central hospitals had 135 patients treated for tubal pregnancy: 100 with grossly normal fallopian tubes (supposing an accidentally abnormal luteal phase as a possible etiology of their first TP) and 35 with signs of earlier pelvic inflammatory disease (PID etiology). They were treated with vaginal P (25 mg b.i.d.) or placebo during cycle days 16-24, for 10 months. Serum P levels after a single vaginal or oral dose were compared. The rates of conception, delivery, spontaneous abortion and recurrent TP were recorded, and fetal and placental weight measured. Both vaginal and oral formulas of P provoked a physiological (24-43 nmol/l) rise in serum concentrations. P and placebo-treated cycles resulted in a nearly equal number of pregnancies (33/37 resp.). Of the 55 infants born 53 were to mothers without signs of earlier PID (53/100); only 2 (2/35) to mothers in whom signs had been present. Recurrent TP occurred in 9% of all pregnancies. Four out of six recurrent TPs were patients with signs of PID (4/35), but two were without such signs (2/100): one occurred during placebo and one during P-treated cycle. Prophylactic P treatment of patients at risk of recurrent TP does not improve fertility or prevent recurrent TP. This indicates, that the functional etiology of recurrent TP, as compared to infection, is not important.