Tubal sterilization during cesarean section or as an elective procedure? Effect on the ovarian reserve

Proximal tubal occlusion first or oocyte retrieval first for patients with hydrosalpinx?

PURPOSE

Our study aimed to investigate the best time to manage hydrosalpinx to improve pregnancy outcomes during in vitro fertilization-embryo transfer (IVF-ET).

METHODS

Patients with hydrosalpinx who received IVF treatment were analyzed retrospectively. And two groups were included to compare the effects of different timing treatment of hydrosalpinx on IVF pregnancy outcomes, "Proximal Tubal Occlusion First Group" (Group Ligation-COH) and "Oocyte Retrieval First Group" (Group COH-Ligation). The main outcome measures included: ovarian response indexes, laboratory indexes and clinical pregnancy outcomes. Univariate and multivariate Logistic regression analysis was performed for outcome indicators, and the odds ratios (OR) and 95% confidence interval (CI) were used.

RESULTS

A total of 1490 patients were included (n = 976 Ligation-COH and n = 514 COH-Ligation). The Gn starting dose and MII rate in group Ligation-COH were significantly higher than those in group COH-Ligation (203.33 ± 58.20 vs. 203.33 ± 58.20, 81.58% vs. 80.28%, P < 0.05). The number of oocytes obtained and the number of available D3 embryos in group COH-Ligation were higher than those in group Ligation-COH (15.10 ± 7.58 vs. 13.45 ± 6.42, 10.92 ± 5.81 vs. 9.94 ± 5.15, P < 0.05). Although the number of ET cycles per IVF cycle in group COH-Ligation was higher than that in group Ligation-COH (1.88 ± 1.00 vs. 1.48 ± 0.70, P < 0.05), the biochemical pregnancy rate, clinical pregnancy rate, multiple pregnancy rate, live birth rate and cumulative live birth rate in group Ligation-COH were significantly higher than those in group COH-Ligation (60.83% vs. 46.27% for biochemical pregnancy, 55.69% vs. 38.5% for clinical pregnancy, 26.18% vs. 17.74% for multiple pregnancy, 47.08% vs. 25.26% for live birth, 69.47% vs. 47.47% for cumulative live birth, P < 0.05), and the miscarriage rate in group Ligation-COH was lower than that in group COH-Ligation (10.47% vs. 17.20 for early abortion, 4.49% vs. 15.86% for late abortion, P < 0.05). In logistic regression analysis, after adjustment for age and multiple factors, the above results were still statistically significant differences (P < 0.001). For elderly patients, the clinical pregnancy rate, multiple birth rate and live birth rate in group Ligation-COH were also higher than those in group COH-Ligation (P < 0.001). No significant differences were detected for patients with diminished ovarian reserve.

CONCLUSIONS

For the choice of ligation operation time, we recommend that patients choose tubal ligation first and then ovulation induction and oocyte retrieval treatment.

Association of oral contraceptives and tubal ligation with antimüllerian hormone

OBJECTIVE

Oral contraceptives (OCs) and tubal ligation are commonly used methods of contraception that may impact ovarian function. Few studies have examined the association of these factors with antimüllerian hormone (AMH), a marker of ovarian aging.

METHODS

We examined the association of OC use and tubal ligation with AMH in the Nurses' Health Study II prospective cohort among a subset of 1,420 premenopausal participants who provided a blood sample in 1996-1999. History of OC use and tubal ligation were reported in 1989 and updated every 2 years until blood collection. We utilized generalized linear models to assess whether mean AMH levels varied by duration of and age at first use of OCs and history, age, and type of tubal ligation.

RESULTS

In multivariable models adjusted for smoking, reproductive events, and other lifestyle factors, we observed a significant, inverse association between duration of OC use and mean AMH levels (P for trend = 0.036). Compared to women without a tubal ligation, AMH levels were significantly lower when the procedure included a clip, ring, or band (1.04 ng/ml vs 1.72 ng/ml, P < 0.01). AMH levels were not associated with age at first use of OCs or age at tubal ligation.

CONCLUSIONS

Our analysis found an association between duration of OC use and certain types of tubal ligation with mean AMH levels. Further research is warranted to confirm the long-term association of these widely used contraceptive methods with AMH.

Impact of Curcumin on Ovarian Reserve After Tubal Ligation: an Experimental Study

The aim of this study was to evaluate the effects of tubal ligation (TL) via modified Pomeroy method on ovarian reserve and to determine the role of curcumin (Curcuma longa [Indian saffron]) against ovarian reserve decrement after TL. Forty-eight albino Wistar rats were randomly divided into four groups: (1) Control group: a sham operation was performed (n = 12), (2) Tubal ligation group: TL was performed (n = 12), (3) TL+DMSO group: 1 mL/day dimethyl sulfoxide was used for 50 days after TL, (4) TL+Curc group: 100 mg/kg/day curcumin dissolved in DMSO was administrated for 50 days after TL. Pre-operatively and on post-operative day 50, blood samples were collected for AMH evaluation, and oophorectomy was performed for histological and immunohistochemical examinations of ovaries in all groups. No difference in the basal AMH levels was found among the groups (p = 0.249). Compared to the basal, AMH levels were lower in the control, TL, and TL+DMSO groups (p = 0.003, p = 0.004, and p < 0.001, respectively) but not different in the TL+Curc group (p = 0.503) on post-operative day 50. No significant differences in the number of primary, preantral, antral, atretic follicles, and corpus luteum among the groups (p > 0.05) were found. The percentage of granulosa cells stained for caspase-3 in antral follicles and the corpus luteum was higher in the TL+Curc group than in the control and TL groups ([antral follicles; p < 0.01 for both groups], [corpus leteum; p = 0.009 and 0.002 for the control and TL groups, respectively]). It seems that TL does not decrease ovarian reserve and curcumin might have a positive effect on ovarian reserve in the setting of TL.

Association of oral contraceptives and tubal ligation with risk of early natural menopause

STUDY QUESTION

What is the association of oral contraceptives (OCs) and tubal ligation (TL) with early natural menopause?

SUMMARY ANSWER

We did not observe an association of OC use with risk of early natural menopause; however, TL was associated with a modestly higher risk.

WHAT IS KNOWN ALREADY

OCs manipulate hormone levels, prevent ovulation, and may modify the rate of follicular atresia, while TL may disrupt the blood supply to the ovaries. These mechanisms may be associated with risk of early menopause, a condition associated with increased risk of cardiovascular disease and other adverse health outcomes.

STUDY DESIGN, SIZE, DURATION

We examined the association of OC use and TL with natural menopause before the age of 45 years in a population-based study within the prospective Nurses' Health Study II (NHSII) cohort. Participants were followed from 1989 to 2017 and response rates were 85-90% for each cycle.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants included 106 633 NHSII members who were premenopausal and aged 25-42 years at baseline. Use, duration and type of OC, and TL were measured at baseline and every 2 years. Menopause status and age were assessed every 2 years. Follow-up continued until early menopause, age 45 years, hysterectomy, oophorectomy, death, cancer diagnosis, or loss to follow-up. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% CIs adjusted for lifestyle, dietary, and reproductive factors.

MAIN RESULTS AND THE ROLE OF CHANCE

Over 1.6 million person-years, 2579 members of the analytic cohort experienced early natural menopause. In multivariable models, the duration, timing, and type of OC use were not associated with risk of early menopause. For example, compared with women who never used OCs, those reporting 120+ months of OC use had an HR for early menopause of 1.01 (95% CI, 0.87-1.17; P for trend=0.71). TL was associated with increased risk of early menopause (HR = 1.17, 95% CI, 1.06-1.28).

LIMITATIONS, REASONS FOR CAUTION

Our study population is homogenous with respect to race and ethnicity. Additional evaluation of these relations in more diverse populations is important.

WIDER IMPLICATIONS OF THE FINDINGS

To our knowledge, this is the largest study examining the association of OC use and TL with early natural menopause to date. While TL was associated with a modest higher risk of early menopause, our findings do not support any material hazard or benefit for the use of OCs.

STUDY FUNDING/COMPETING INTEREST(S)

The study was sponsored by UO1CA176726 and R01HD078517 from the National Institutes of Health and Department of Health and Human Services. The work was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The authors have no competing interests to report.

TRIAL REGISTRATION NUMBER

N/A.

Longitudinal assessment of anti-Müllerian hormone after cesarean section and influence of bilateral salpingectomy on ovarian reserve

OBJECTIVE

This study aimed to compare longitudinal changes in ovarian reserve markers after cesarean section (CS) with and without bilateral salpingectomy (BS).

STUDY DESIGN

We prospectively enrolled women >35 weeks' gestation scheduled for CS alone or CS + BS and obtained blood samples for anti-Müllerian hormone prior to surgery and at 3 and 6 months after surgery. At the 3-month visit, we similarly performed transvaginal ultrasound for antral follicle count.

RESULTS

We enrolled 50 women; 30 underwent CS only and 20 underwent CS + BS. Although anti-Müllerian hormone level increased over 6 months of follow-up in both groups, no clinically important differences in the geometric mean (interquartile range) (ng/mL) were observed at any timepoint (baseline [0.69 {0.36-1.21} {CS only} vs 0.49 {0.32-2.10} {CS + BS}, p = 0.64]; 3 months [1.35 {0.58-3.13} vs 1.45 {1.04-2.25}, p = 0.79]; and 6 months [1.74 {0.93-4.45} vs 2.60 {1.41-5.10}, p =0.27]). Similarly, we detected no difference in antral follicle count.

CONCLUSION

BS at the time of CS does not have a negative impact on ovarian reserve 6 months after surgery.

IMPLICATION

While our results provide reassuring data that bilateral salpingectomy for permanent contraception at the time of cesarean section does not impact ovarian reserve, longer adequately powered studies are needed.

Management of Hydrosalpinx in the Era of Assisted Reproductive Technology: A Systematic Review and Meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis evaluating the effect of hydrosalpinx on pregnancy outcomes, to compare different types of management of hydrosalpinx and their impact on pregnancy rates as well as on the ovarian reserve.

DATA SOURCES

Electronic search using Pubmed, EMBASE, Ovid MEDLINE, Google Scholar, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials and including all published studies that examined tubal infertility and its management (assisted reproductive technology or surgery) as well as the effects on ovarian reserve. The following medical subject headings (Mesh) terms combinations were used: "fallopian tube disease," hydrosalpinx," "tubal or salpinx occlusion or obstruction," "in vitro fertilization," "fallopian tube surgery," "salpingectomy," "salpingostomy," "infertility," "subfertility," "sterility" and "ovarian reserve."

METHODS OF STUDY SELECTION

All randomized trials, cohort, and case controls studies were included. We excluded review articles, meeting abstracts, case series and case reports, and abstracts without access to full texts. The search was limited to trials in humans and published in English.

TABULATION, INTEGRATION, AND RESULTS

Our electronic search initially retrieved 6354 articles. Finally, 19 studies were included in the quantitative evaluation of the effects of hydrosalpinx: 23 in the qualitative evaluation and 5 in the quantitative evaluation of different types of hydrosalpinx treatments; and 17 in the quantitative evaluation of ovarian reserve. The presence of a hydrosalpinx was associated with decreased rates of implantation and clinical pregnancy, and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx with salpingectomy, tubal occlusion, or hydrosalpinx aspiration led to better in vitro fertilization pregnancy rates. We found no difference in ovarian response to stimulation after salpingectomy except a decrease in antimüllerian hormone compared to no surgery.

CONCLUSIONS

The presence of hydrosalpinx is associated with decreased pregnancy rate and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx, regardless of the type of treatment, leads to an increased chance of pregnancy.

Can delivery mode influence future ovarian reserve? Anti-Mullerian hormone levels and antral follicle count following cesarean section: a prospective cohort study

Background

The incidence of Cesarean has increased in recent years. The purpose of this study is to evaluate the effect of cesarean section on ovarian reserve.

This is a prospective cohort study from January 2016 to November 2017. Inclusion criteria included singleton primigravid pregnant women whose gestational age was above 37 weeks. Exclusion criteria included history of infertility, pelvic surgery, underlying chronic diseases, any adverse pregnancy outcome and postpartum complication in current pregnancy and hormonal medication within six months of delivery. Anti-Mullerian hormone was measured at the admission time for delivery. The type of delivery was determined based on obstetrics indications. Six months after delivery, antral follicle count was performed and anti-Mullerian hormone was measured again.

Result(s)

First blood sample was taken from 730 women. After excluding 550 women, the second blood sample was taken from 180 participants. The mean of first anti-Mullerian hormone in women with cesarean and vaginal delivery were 1.01 ng/mL (95% CI 0.82 to 1.18) and 1.18 ng/mL (95% CI 0.96 to 1.40) respectively (P = 0.211). The mean of second anti-Mullerian hormone in women with cesarean and vaginal delivery were 4.77 ng/mL (95% CI:3.91 to 5.63) and 4.92 ng/mL (95% CI: 4.01 to 5.82) respectively (P = 0.818). No statistically significant difference existed in total AFC between cesarean and vaginal delivery groups (MD: 0.41, 95% CI: − 1.05 to 1.89, P = 0.576).

Conclusion

Antral follicle count and anti-Mullerian hormone, six month after delivery, are not affected by delivery mode even after adjusting for women’s age, baseline Anti-Mullerian hormone, body mass index, gestational age at delivery, breastfeeding, postpartum menstruation, neonatal sex and weight. Based on our best knowledge, this is the first report that investigates the effects of delivery mode on ovarian reserve. Decreased fertility following cesarean has been shown in some previous studies but most of them had assessed this association based on the incidence of subsequent pregnancy. Since subsequent pregnancy can be influenced by several confounding factors, we investigated the effect of cesarean on fertility using its impact on anti-Mullerian hormone levels and antral follicle count. We hope that this study will be a beginning of more detailed studies in this field. We believe that this link is yet to be studied.

Post-partum tubal ligation at time of cesarean delivery or via laparoscopy as an interval sterilization has similar effects on ovarian reserve

Objective:

To observe and compare the effect of postpartum tubal ligation (TL) procedures on ovarian reserve at women desiring TL as a contraceptive method at the end of pregnancy.

Material and Methods:

Eighty-one women were included in the prospective study. TL was performed at the time of cesarean delivery (CD) (n=49) and as an interval procedure by laparoscopy (LS) in the postpartum period (n=32). Anti-müllerian hormone (AMH) was used to determine ovarian reserve. Blood samples were taken twice from each subject; the first sample was taken before delivery from all subjects and the second sample was taken 4 months after sterilization. AMH level differences were compared in each group and between groups.

Results:

The preoperative AMH values of CD and LS groups were similar 2.30 (maximum: 5.20, minimum: 0.42) ng/mL and 1.80 (maximum: 3.50, minimum: 0.40) ng/mL, respectively (p=0.262). The postoperative AMH values of the CD and LS groups were 1.30 (maximum: 2.60, minimum: 0.30) ng/mL and 0.90 (maximum: 2.50, minimum: 0.20) ng/mL, respectively (p=0.284). When the preoperative and postoperative values of each group were compared the change was statistically significant for both groups p<0.001. The decrease in mean AMH values in the CD and LS groups were 37.83% and 44.15%, respectively. The percentage changes of AMH values were not statistically significant (p=0.286).

Conclusion:

TL at the time of CD and interval sterilization with LS have similar effects on ovarian reserve.

Unfavorable lipid profile and higher frequency of hot flashes during perimenopausal years after fallopian tube ligation

AIM

We sought to study the effect of tubal ligation on lipid profile, ovarian reserve and hot flashes during perimenopausal years.

METHODS

A total of 210 perimenopausal women complaining of abnormal vaginal bleeding were enrolled for the study. Subjects' menstrual, reproductive and medical histories were recorded. Serum FSH, LH and estradiol levels were screened in all women to determine menopausal status. In order to rule out any gynecologic pathology, all subjects underwent transvaginal sonography. Women were divided into two groups according to presence (study group, n = 68) or absence (control group, n = 142) of tubal ligation history. Lipid profiles and ovarian reserve tests were compared between groups.

RESULTS

Mean age, parity, serum hemoglobin (Hb), high density lipoprotein (HDL-C), triglyceride, estradiol levels, endometrial thickness and frequency of hot flashes were significantly different between groups (p < 0.05). Mean age was 42.8 ± 1.9 years in women with tubal ligation and 45.9 ± 3.5 years in control group. Mean serum estradiol level was lower in group with tubal ligation (41.4 versus 92.5 pg/ml). Mean endometrial thickness was higher in control group (10.2 versus 7.5 mm). Age-adjusted serum Hb, HDL-C, triglyceride, estradiol, FSH level, endometrial thickness and frequency of hot flashes remained significantly different between groups (p < 0.05).

CONCLUSION

Tubal ligation is associated with unfavorable lipid profile and higher frequency of hot flashes during perimenopausal years.