Hydrosalpinx and infertility: what about conservative surgical management?

Hysteroscopic tubal electrocoagulation versus laparoscopic tubal disconnection for the management of hydrosalpinx and subsequent pregnancy outcomes: A randomized clinical trial

Objective

Hydrosalpinx impairs the success of in vitro fertilization (IVF) embryo transfer. Various surgical approaches, such as fluid aspiration or isolation of the affected fallopian tubes, have been used to enhance the outcome. This study was conducted to evaluate and compare the efficacy of laparoscopic tubal disconnection (LTD) and hydroscopic tubal electrocoagulation (HTE) for hydrosalpinx before IVF.

Materials and Methods

After obtaining ethical committee approval, we assessed 112 women who were subfertile due to hydrosalpinx to check their adherence to our selection criteria. Eligible patients were allocated into two groups (LTD vs. HTE). Both groups underwent extensive assessment before the operative procedure. IVF and subsequent embryo transfers were performed in both groups. Live birth and pregnancy rates were evaluated.

Results

Patients who underwent LTD prior to IVF embryo transfer had significantly higher live birth (41%), clinical pregnancy (57%), and chemical pregnancy (61%) rates in the LTD group than in the HTE group (12%, 35%, 41%, respectively). However, we could not find a significant difference between the two groups regarding the miscarriage (17% vs. 28%, p=0.33) and multiple pregnancy (14% vs. 12%, p=0.79) rates. No major complications with HTE were observed, except for a case of uterine perforation, whereas two cases of surgical complications occurred in the LTD group. Additionally, we found a significantly shorter operative time and hospital stay (0.5±0.7 days, p=0.012) in the HTE group.

Conclusion

LTD may be a more effective approach compared with hysteroscopic tubal electrocoagulation for improving birth and pregnancy rates in patients with IVF and hydrosalpinx.

IFTT in children and adolescents-single-center experience and systematic review of literature

PURPOSE

Isolated fallopian tube torsion (IFTT) is defined by rotation of the fallopian tube around itself without involving the ipsilateral ovary. It is a rare cause of acute lower abdominal pain in (adolescent) girls, but is commonly overlooked. Due to its rarity, literature is still scarce. Currently there is no generally accepted management and treatment.

METHODS

A retrospective analysis of all IFTT cases treated in our institution was performed. In addition, a systematic literature research on pediatric IFTT was carried out on Medline/ PubMed database according to PRISMA principles using predefined search terms and inclusion criteria. Patient characteristics regarding age, clinical symptoms, diagnostic methods, treatment, and follow-up were analyzed.

RESULTS

Three of our patients and fifty-nine reports totaling one hundred seventy girls were included in the analysis. Mean age was 13.0 years. Left tube was slightly more often affected (52.9%). Abdominal pain was present in 99.4% of cases accompanied with nausea in 57.1%. In only 16.4%, correct preoperative diagnosis was made. Salpingectomy was the most common treatment in 111 (66.9%) cases, 55 (33.1%) patients were treated with detorsion of the tube (organ-sparing management). Girls with symptoms longer than 1 day had a significant higher rate of salpingectomy (95% CI, P = 0.0323).

CONCLUSION

When IFTT is suspected, emergency laparoscopy should be performed to possibly preserve future reproductive potential. In case of detorsion and reinstated blood supply, organ-preserving management should be performed with simultaneous addressment of concomitant pathology if possible. Sufficient long-term follow-up must be assured to get significant results to introduce guidelines for children and adolescents.

Tubal Pathologies and Fertility Outcomes: A Review

Anomalies of the fallopian tubes represent one of the most significant elements that might contribute to reproductive issues. They can be inherited or acquired; they are among the most important problems of the profession. Although there is much discussion regarding which therapies for each tubal disease are the most effective and result in the best long-term reproductive outcomes. During the evaluation of an infertile couple, certain anomalies of the fallopian tubes are frequently discovered. These abnormalities were thought, for a long time, to not have an influence on fertility; however, in recent years, researchers have discovered that they seem to play a crucial role in fertility problems. Couples in industrialized countries are postponing childbearing, which raises the risk of women developing tubal diseases before they are ready to become pregnant. These disorders may have a negative impact on a woman's ability to get pregnant. The goals of this study are to conduct research to gain a deeper understanding of the recent advancements that have been made in the field of tubal diseases and to carry out an evaluation of the medical conducts that have the best fertility outcomes. We searched both Medline and PubMed, paying special attention to the most relevant articles that have been added to either database over the course of the last six years.

Guideline No. 435: Minimally Invasive Surgery in Fertility Therapy

OBJECTIVE

To evaluate the benefits and risks of minimally invasive procedures in the management of patients with infertility and provide guidance to gynaecologists who manage common conditions in these patients.

TARGET POPULATION

Patients with infertility (inability to conceive after 12 months of unprotected intercourse) undergoing investigation and treatment.

BENEFITS, HARMS, AND COSTS

Minimally invasive reproductive surgery can be used to treat infertility, improve fertility treatment outcomes, or preserve fertility. All surgery has risks and associated complications. Reproductive surgery may not improve fertility outcomes and may, in some instances, damage ovarian reserve. All procedures have costs, which are borne either by the patient or their health insurance provider.

EVIDENCE

We searched English-language articles from January 2010 to May 2021 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library (see Appendix A for MeSH search terms).

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix B (Tables B1 for definitions and B2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Gynaecologists who manage common conditions in patients with infertility.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Directive clinique no 435 : Chirurgie minimalement invasive dans les traitements de fertilité

OBJECTIF

Évaluer les risques et bénéfices de la chirurgie minimalement invasive dans la prise en charge des patientes atteintes d'infertilité et fournir des conseils aux gynécologues qui prennent en charge les problèmes les plus fréquents chez ces patientes.

POPULATION CIBLE

Patientes atteintes d'infertilité (incapacité à concevoir après 12 mois de rapports sexuels non protégés) en processus diagnostique ou sous traitement. BéNéFICES, RISQUES ET COûTS: On peut recourir à la chirurgie de la reproduction minimalement invasive pour traiter l'infertilité, améliorer les résultats des traitements de fertilité ou préserver la fertilité. Toutes les interventions chirurgicales comportent des risques et des complications associées. La chirurgie de la reproduction n'améliore pas toujours la fertilité et peut, dans certains cas, compromettre la réserve ovarienne. Toutes les interventions entraînent des coûts, lesquels sont assumés par la patiente ou son assureur. DONNéES PROBANTES: Des recherches ont été faites dans les bases de données PubMed-Medline, Embase, Science Direct, Scopus et Cochrane Library pour répertorier les articles publiés en anglais dans la période de janvier 2010 à mai 2021 (voir les termes de recherche MeSH à l'annexe A). MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe B en ligne (tableau B1 pour les définitions et tableau B2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Gynécologues qui prennent en charge les affections courantes chez les patientes atteintes d'infertilité. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Which patients with hydrosalpinx will benefit more from reproductive surgery to improve natural pregnancy outcomes?: A systematic review and meta-analysis

BACKGROUND

The most common tubal disease leading to infertility occurs in the distal region, manifesting as hydrosalpinx. Tubal surgery is an effective alternative treatment. However, subpopulations that benefit the most from tubal repair surgery remain unclear. The objective of this study was to investigate the natural pregnancy outcomes of patients with hydrosalpinx after reproductive surgery and those with different grades of hydrosalpinx.

METHODS

We searched the major online databases (PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials) to collect observational studies on patients with hydrosalpinx who underwent surgeries to preserve natural fertility from January 2000 to August 2022. The outcome indicators were natural intrauterine pregnancy (IUP) and ectopic pregnancy (EP) rates. Studies on patients with hydrosalpinx who underwent laparoscopic surgeries and those who intended to be conceived naturally were included. Studies on patients with non-hydrosalpinx diseases, those who underwent open surgery, and those who intended to undergo assisted conception were excluded. The Newcastle-Ottawa scale for observational studies was used for quality evaluation. Meta-analysis of a single rate was performed using RevMan5.3 software.

RESULTS

A total of 10 articles were included in this study, including 1317 patients with hydrosalpinx. Seven studies were retrospective and 3 were prospective. It was found that after surgery for preserving natural fertility function, the IUP and EP rates of patients with hydrosalpinx were 27% (95% confidence interval [CI]: 22-32%) and 4.8% (95% CI: 2.91-8.26%), respectively. In addition, the IUP and EP rates in patients with mild (n = 254), moderate (n = 252), and severe (n = 473) hydrosalpinx were 50.5% (95% CI: 38.65-61.97%), 32.9% (95% CI: 21.88-46.24%), 10.7% (95% CI: 4.76-21.88%), and 7.4% (95% CI: 2.91-19.35%), 9.09% (95% CI: 6.54-13.79%), 8.3%, 8.26% (95% CI: 3.85-18.03%), respectively.

CONCLUSION

Patients with mild to moderate hydrosalpinx will benefit more from reproductive surgery to improve natural pregnancy outcomes. However, the small sample size in our study needs to be further expanded, and the grouping needs to be more refined, such as grouping based on age. This may provide more guidance in clinical practice.

A review of the pathophysiology of recurrent implantation failure

Implantation is a critical step in human reproduction. The success of this step is dependent on a competent blastocyst, receptive endometrium, and successful cross talk between the embryonic and maternal interfaces. Recurrent implantation failure is the lack of implantation after the transfer of several embryo transfers. As the success of in vitro fertilization has increased and failures have become more unacceptable for patients and providers, the literature on recurrent implantation failure has increased. While this clinical phenomenon is often encountered, there is not a universally agreed-on definition-something addressed in an earlier portion of this Views and Reviews. Implantation failure can result from several different factors. In this review, we discuss factors including the maternal immune system, genetics of the embryo and parents, anatomic factors, hematologic factors, reproductive tract microbiome, and endocrine milieu, which factors into embryo and endometrial synchrony. These potential causes are at various stages of research and not all have clear implications or immediately apparent treatment.

Treatment of hydrosalpinx in relation to IVF outcome: a systematic review and meta-analysis

Salpingectomy is the most widely used treatment for hydrosalpinx. The effect of salpingectomy on the stimulation response during subsequent IVF treatment, however, remains unclear. The aim of this systematic review was to evaluate the ovarian response and pregnancy outcome of IVF treatment carried out after salpingectomy compared with other pre-IVF treatment options for hydrosalpinx. We conducted a literature search using PubMed, Ovid MEDLINE, Google Scholar, ClinicalTrials.gov and the Cochrane Central Register of Controlled Trials. Five randomized studies and nine observational studies were included in the systematic review and evaluated using Cochrane Collaboration's tool for randomized, Newcastle-Ottawa scale for observational studies and GRADE guidelines for certainty of evidence assessment. The mean number of retrieved oocytes was similar between the groups in randomized (mean difference [MD] = -0.03, 95% CI -0.75 to 0.70) and observational studies (MD = -0.15, 95% CI -2.32 to 2.02). Live birth (RR 1.59, 95% CI 1.17 to 2.16), clinical pregnancy (RR 1.27, 95% CI 1.02 to 1.57) and implantation rates (RR 1.55, 95% CI 1.16 to 2.08) were higher in the salpingectomy group in randomized studies. The present systematic review and meta-analysis showed that salpingectomy does not impair the ovarian response during subsequent IVF treatment.

Quadruple torsion of the fallopian tube in an 18-year-old virgin: a rare twist

In this report, we describe an 18-year-old nulliparous virgo, with no medical history, who presented herself at the emergency department with symptoms of lower abdominal pain and nausea with vomiting. On examination, an echogenic unilocular cyst with possible relation to the right ovary was found. The working diagnosis was an ovarian torsion. She underwent a diagnostic laparoscopy which revealed a quadruple torsion of the fallopian tube with hydrosalpinx. Detorsion of the tube was performed, and the tube was drained using diathermic incision. After the surgery, the patient recovered rapidly. Ultrasonic evaluation 38 days later showed an echogenic area measuring 2×3 cm suspected for persistent hydrosalpinx. Because of the asymptomatic postoperative period, the patient was treated conservatively, and no further treatment was performed.

Tubal restorative surgery for hydrosalpinges in women due to in vitro fertilization

OBJECTIVE

The study was carried out to clarify the IVF outcome after laparoscopic neosalpingostomy for infertile patients affected by hydrosalpinx stage III.

MATERIALS AND METHODS

From January 2010 to June 2015, 91 subjects of hydrosalpinx stage III were treated in out center by laparoscopic surgery before IVF cycle. 43 underwent neosalpingostomy (group 1) and the remaining 48 underwent salpingestomy (group 2). We compared these patients and their IVF outcomes after two different surgical techniques.

RESULTS

There were no significant differences between the two groups, except a higher number of patients with bilaterial hydrosalpinges was noted in the neosalpingostomy group (79.1% vs. 56.3%, respectively). 25 patients with neosalpingostomy and 29 with salpingectomy achieved pregnancy by IVF. The ongoing pregnancy rate per cycle in group 1 and group 2 was 51.1 and 47.2%, respectively. Two cases of ampullary ectopic pregnancies were noted in group 1 and one case of right tube interstitial pregnancy in group 2. No significant difference was observed in live birth rate between the groups (48.9% vs. 45.3%, respectively).

CONCLUSIONS

The outcomes of IVF after neosalpingostomy were matchable with salpingectomy. For patients desire to preserve fallopian tubes, we recommend laparoscopic neosalpingostomy as an alternative choice to manage moderate hydrosalpinx before IVF.

Isolated fallopian tube torsion with hydrosalpinx: Review of a debated management in a pediatric population

PURPOSE

To quantify our experience with and assess the literature on diagnosis and management of isolated fallopian tube torsion (IFTT) with hydrosalpinx (HSX) in children.

METHODS

A PubMed search was performed on pediatric cases of IFTT with HSX to provide a comprehensive review analyzing details and management of this association, focusing on the problem of fertility preservation.

RESULTS

In addition to our 3 cases, 17 patients of pediatric IFTT associated with HSX were identified, for a total of 21 cases (median age 12.2 years). Menarchal status was present in 10/13 (76.9%); blood tests were reported in 9/20 (42%) showing leucocytosis in 7/9 (75%). Ultrasonography was performed in all cases except one. Laparoscopy was the surgical approach in 84.6% of the reported cases. The torsion was to the right in 36.8%, and to the left in 63.2% of the cases. In one case the torsion was bilateral and asynchronous. Performed procedures were salpingectomy (52.4%) and partial salpingectomy (14.3%); conservative management was reported in 33.3% of the cases.

CONCLUSIONS

The literature describes different management techniques. Salpingectomy is the most frequently performed procedure but recently conservative management seems to be increasingly applied. A long-term study is necessary to define the most effective treatment for the preservation of future fertility in pediatric patients.

TYPE OF STUDY

Treatment study (Retrospective Study): LEVEL IV.

A Decade of Pelvic Pain and Infertility: A Case Report of an Unexpected Intraoperative Discovery

Introduction

Retained surgical objects can impact quality of life as it relates to chronic pelvic pain and reproductive health.

Case report

A 39-year-old G1P0010 with chronic pelvic pain and infertility attributed to pelvic adhesions and bilateral hydrosalpinx caused by an 18-cm surgical drain left 10 years prior.

Conclusions

Our case highlights the significance of thoughtful perioperative care as well as special considerations when approaching patients with pelvic pain and infertility with histories of abdominopelvic surgery.

High miscarriage rate in women treated with Essure® for hydrosalpinx before embryo transfer: a systematic review and meta-analysis

OBJECTIVES

Essure® has been tested as an alternative treatment for hydrosalpinx before embryo transfer (ET) in women undergoing assisted reproduction techniques. However, the persistence of a foreign body inside the uterine cavity might have a negative impact on the outcome of pregnancy. The present systematic review aimed at identifying, appraising and summarizing the available evidence regarding the effectiveness and safety of using Essure prior to ET for women with hydrosalpinx.

METHODS

We searched for studies in PubMed, Scopus, CENTRAL, Web of Science and ClinicalTrials.gov and the reference lists of eligible studies. All studies including at least 10 women with hydrosalpinx who received Essure, any other intervention or no treatment prior to ET were considered eligible. Study selection, data extraction and evaluation of the risk of bias were performed independently by two authors. Study outcomes were miscarriage per clinical pregnancy, singleton preterm birth per singleton live birth and live birth/ongoing pregnancy and clinical pregnancy per ET. The pooled results for each outcome and intervention were summarized as proportions with their respective 95% CIs, using a random-effects model.

RESULTS

Our electronic search of databases was performed on 7 November 2015, and 26 studies with 43 study arms were considered eligible: eight study arms evaluating Essure; seven assessing tubal aspiration; seven appraising effects of no treatment; 12 evaluating salpingectomy; two assessing tubal division; and seven evaluating tubal occlusion. When compared with women who had no intervention, women with Essure had a higher clinical pregnancy rate per ET (36% (95% CI, 0-43%) vs 13% (95% CI, 9-17%)). When compared with women who had other interventions, women with Essure had a higher miscarriage rate per clinical pregnancy (38% (95% CI, 27-49%) vs 15% (95% CI, 10-19%)).

CONCLUSIONS

The available evidence suggests that, although Essure prior to ET in women with hydrosalpinx improves the chance of achieving a clinical pregnancy compared with no intervention, it is associated with a higher rate of miscarriage when compared with the other interventions. Although this evidence is based on observational studies, we believe that salpingectomy should be the first option for women who are eligible for videolaparoscopy. However, it is still premature to make recommendations for women who are not eligible for surgery, and randomized controlled trials are needed to clarify which is the best treatment alternative in such a scenario. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Essure a novel option for the treatment of hydrosalpinx: a case series and literature review

OBJECTIVE

The aim of this study is to evaluate the use of hysteroscopic Essure device placement for the treatment of hydrosalpinx (HS)-related infertility in patients with laparoscopic contraindications and compared their pregnancy outcomes following IVF-ICSI treatment with those patients having had laparoscopic tubal occlusion (LTO).

PATIENTS

From 2008 to 2014 a total of 50 patients were diagnosed with unilateral or bilateral hydrosalpinges: 29 patients had laparoscopic contraindications and were treated hysteroscopically and 21 patients were treated with laparoscopical salpingectomy.

RESULTS

Of the 29 patients who underwent treatment with Essure(®), 21 began a cycle of in vitro fertilization (IVF), and 13 finished in embryo transfer that resulted in seven clinical pregnancies. Furthermore, in the group of women treated with salpingectomy, 17 started an IVF cycle that resulted in 12 clinical pregnancies. The clinical pregnancy rate per patient with an IVF cycle started was 33.3% and 70.6%, the live-birth rate per patient was 14.3% and 52.9%, the miscarriage rate was 57.1% and 18.2%, and the implantation rate was 16.3% and 34.1% for hysteroscopy and laparoscopy, respectively.

CONCLUSION

Essure(®) placement is an alternative method for occlusion of hydrosalpinges before IVF. Monitoring the live-birth rate confirms that this option may be considered when laparoscopy is impossible or contraindicated.

Salpingostomy in the treatment of hydrosalpinx: a systematic review and meta-analysis

STUDY QUESTION

What is the chance of natural conception when salpingostomy is used to treat hydrosalpinx?.

SUMMARY ANSWER

The natural clinical pregnancy rate following salpingostomy is 27%, in the hands of experienced surgeons who publish their results.

WHAT IS KNOWN ALREADY

Tubal surgery is not commonly offered for women with hydrosalpinges since the advent of assisted conception treatment. This is the first systematic review to investigate natural conception rates following salpingostomy in the treatment of hydrosalpinx.

STUDY DESIGN, SIZE, DURATION

A systematic review and meta-analysis of 22 observational studies encompasses 2810 patients undergoing salpingostomy and attempting natural conception.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Literature searches were conducted to retrieve observational studies which reported salpingostomy for hydrosalpinx. Databases searched included MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINAHL, with no language restriction. Only studies that focused on salpingostomy (rather than other tubal conserving surgeries) for the treatment of hydrosalpinx were included. A total of 22 studies matched the inclusion criteria.

MAIN RESULTS AND THE ROLE OF CHANCE

The pooled natural clinical pregnancy rate from the 22 observational studies (including 2810 patients) was 27% (95% confidence interval (CI): 25-29%) after salpingostomy was performed for hydrosalpinx. The cumulative clinical pregnancy rates were 8.7% (95% CI: 6.6-11.5%) at 6 months, 13.3% (95% CI: 10.6-16.7%) at 9 months, 20.0% (95% CI: 17.5-22.8%) at 12 months, 21.2% (95% CI: 18.6-24.1%) at 18 months and 25.5% (95% CI: 22.2-29.4%) at 24 months after salpingostomy. The pooled live birth rate (10 studies, 1469 patients) was 25% (95% CI: 22-28%) after salpingostomy was performed for hydrosalpinx. The pooled ectopic pregnancy rate (19 studies, 2662 patients) was 10% (95% CI: 9-11%). The pooled miscarriage rate (seven studies, 924 patients) was 7% (95% CI: 6-9%). The included studies scored well on the Newcastle Ottawa quality assessment scale.

LIMITATIONS, REASONS FOR CAUTION

Strict inclusion criteria were used in the conduct of the systematic review. However, the studies included are clinically heterogeneous in many aspects including patient characteristics, surgical technique and duration of follow-up after salpingostomy.

WIDER IMPLICATIONS OF THE FINDINGS

The findings of this systematic review suggest that salpingostomy is an alternative treatment strategy to tubal clipping or salpingectomy in patients presenting to fertility services with hydrosalpinx. Further prospective, large and high quality studies are needed to identify the subpopulation that would most benefit from tube conserving surgery.

STUDY FUNDING/COMPETING INTERESTS

No external funding was either sought or obtained for this study. The authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Isolated fallopian tube torsion with partial hydrosalpinx in a premenarcheal girl: a case report

INTRODUCTION

Isolated fallopian tube torsion as a complication of a preexisting hydrosalpinx is a rare finding in pediatric patients. The obvious rarity of this condition, its subtle diagnostic features and dissonant previous reporting about the appropriate therapeutic approach according to age, future conception capacity and potential complications of possible pregnancies make the decision about which surgical approach to use very difficult. In this report, we describe the case of a patient with such a presentation and review the literature. Very few similar reports of neosalpingostomy in pediatric patients have been published to date.

CASE PRESENTATION

In our present report, we describe the case of an 11-year-old Caucasian prepubertal girl who presented to our hospital with complaints of abdominal pain in the right lower quadrant, nausea and vomiting. The diagnostic workup led us to conclude that she had a torsion of the right ovary, which was cystically altered. Exploratory surgery revealed a partial hydrosalpinx and consecutive isolated torsion of the fimbrial part. The proximal isthmic part of the fallopian tube was intact and vital. Restorative surgery was performed to create a neosalpingostomy on the viable isthmic part of the tube and remove the cystic and twisted fimbrial and infundibular parts.

CONCLUSION

The surgical procedure described in this report is technically simple and feasible, but leaves doubts about the final outcome.

Lack of long-lasting hydrosalpinx in A/J mice correlates with rapid but transient chlamydial ascension and neutrophil recruitment in the oviduct following intravaginal inoculation with Chlamydia muridarum

Lower genital tract infection with Chlamydia trachomatis and C. muridarum can induce long-lasting hydrosalpinx in the upper genital tract of women and female mice, respectively. However, A/J mice were highly resistant to induction of long-lasting hydrosalpinx by C. muridarum. We further compared host inflammatory responses and chlamydial infection courses between the hydrosalpinx-resistant A/J mice and CBA/J mice known to be susceptible to hydrosalpinx induction. Both mouse strains developed robust pyosalpinx during the acute phase followed by hydrosalpinx during the chronic phase. However, the hydrosalpinges disappeared in A/J mice by day 60 after infection, suggesting that some early hydrosalpinges are reversible. Although the overall inflammatory responses were indistinguishable between CBA/J and A/J mice, we found significantly more neutrophils in oviduct lumen of A/J mice on days 7 and 10, which correlated with a rapid but transient oviduct invasion by C. muridarum with a peak infection on day 7. In contrast, CBA/J mice developed a delayed and extensive oviduct infection. These comparisons have revealed an important role of the interactions of oviduct infection with inflammatory responses in chlamydial induction of long-lasting hydrosalpinx, suggesting that a rapid but transient invasion of oviduct by chlamydial organisms can prevent the development of the long-lasting hydrosalpinges.

Factors related to clinical pregnancy after vitrified-warmed embryo transfer: a retrospective and multivariate logistic regression analysis of 2313 transfer cycles

STUDY QUESTION

What factors does multivariate logistic regression show to be significantly associated with the likelihood of clinical pregnancy in vitrified-warmed embryo transfer (VET) cycles?

SUMMARY ANSWER

Assisted hatching (AH) and if the reason to freeze embryos was to avoid the risk of ovarian hyperstimulation syndrome (OHSS) were significantly positively associated with a greater likelihood of clinical pregnancy.

WHAT IS KNOWN ALREADY

Single factor analysis has shown AH, number of embryos transferred and the reason of freezing for OHSS to be positively and damaged blastomere to be negatively significantly associated with the chance of clinical pregnancy after VET. It remains unclear what factors would be significant after multivariate analysis.

STUDY DESIGN, SIZE, DURATION

The study was a retrospective analysis of 2313 VET cycles from 1481 patients performed between January 2008 and April 2012. A multivariate logistic regression analysis was performed to identify the factors to affect clinical pregnancy outcome of VET.

PARTICIPANTS/MATERIALS, SETTING, METHODS

There were 22 candidate variables selected based on clinical experiences and the literature. With the thresholds of α entry = α removal= 0.05 for both variable entry and variable removal, eight variables were chosen to contribute the multivariable model by the bootstrap stepwise variable selection algorithm (n = 1000). Eight variables were age at controlled ovarian hyperstimulation (COH), reason for freezing, AH, endometrial thickness, damaged blastomere, number of embryos transferred, number of good-quality embryos, and blood presence on transfer catheter. A descriptive comparison of the relative importance was accomplished by the proportion of explained variation (PEV).

MAIN RESULTS AND THE ROLE OF CHANCE

Among the reasons for freezing, the OHSS group showed a higher OR than the surplus embryo group when compared with other reasons for VET groups (OHSS versus Other, OR: 2.145; CI: 1.4-3.286; Surplus embryos versus Other, OR: 1.152; CI: 0.761-1.743) and high PEV (marginal 2.77%, P = 0.2911; partial 1.68%; CI of area under receptor operator characteristic curve (ROC): 0.5576-0.6000). AH also showed a high OR (OR: 2.105, CI: 1.554-2.85) and high PEV (marginal 1.97%; partial 1.02%; CI of area under ROC: 0.5344-0.5647). The number of good-quality embryos showed the highest marginal PEV and partial PEV (marginal 3.91%, partial 2.28%; CI of area under ROC: 0.5886-0.6343).

LIMITATIONS, REASONS FOR CAUTION

This was a retrospective multivariate analysis of the data obtained in 5 years from a single IVF center. Repeated cycles in the same woman were treated as independent observations, which could introduce bias. Results are based on clinical pregnancy and not live births. Prospective analysis of a larger data set from a multicenter study based on live births is necessary to confirm the findings.

WIDER IMPLICATIONS OF THE FINDINGS

Paying attention to the quality of embryos, the number of good embryos, AH and the reasons for freezing that are associated with clinical pregnancy after VET will assist the improvement of success rates.

How members of the Society for Reproductive Endocrinology and Infertility and Society of Reproductive Surgeons evaluate, define, and manage hydrosalpinges

OBJECTIVE

To describe the management of hydrosalpinges among Society for Reproduction Endocrinology and Infertility (SREI)/Society of Reproductive Surgeons (SRS) members.

DESIGN

Cross-sectional survey of SREI/SRS members.

SETTING

Academic and private practice-based reproductive medicine physicians.

PARTICIPANT(S)

A total of 442 SREI and/or SRS members.

INTERVENTION(S)

Internet-based survey.

MAIN OUTCOME MEASURE(S)

To understand how respondents evaluate, define, and manage hydrosalpinges.

RESULT(S)

Of 1,070 SREI and SRS members surveyed, 442 responded to all items, for a 41% response rate. Respondents represented both academic and private practice settings, and differences existed in the evaluation and management of hydrosalpinges. More than one-half (57%) perform their own hysterosalpingograms (HSGs), and 54.5% involve radiologists in their interpretation of tubal disease. Most respondents thought that a clinically significant hydrosalpinx on HSG is one that is distally occluded (80.4%) or visible on ultrasound (60%). Approximately one in four respondents remove a unilateral hydrosalpinx before controlled ovarian hyperstimulation (COH)/intrauterine insemination (IUI) and clomiphene citrate (CC)/IUI (29.3% and 22.8%, respectively), and physicians in private practice were more likely to intervene (COH: risk ratio [RR] 1.81, 95% confidence interval [CI] 1.31-2.51; CC: RR 1.98, 95% CI 1.33-2.95). Although laparoscopic salpingectomy was the preferred method of surgical management, nearly one-half responded that hysteroscopic tubal occlusion should have a role as a primary method of intervention.

CONCLUSION(S)

SREI/SRS members define a "clinically significant hydrosalpinx" consistently, and actual practice among members reflects American Society for Reproductive Medicine/SRS recommendations, with variation attributed to individual patient needs. Additionally, one in four members intervene before other infertility treatments when there is a unilateral hydrosalpinx present.