Pregnancy outcome in patients with early recurrent abortion following laparoscopic tubal corneal interruption of a fallopian tube with hydrosalpinx

S100A8 expression in oviduct mucosal epithelial cells is regulated by estrogen and affects mucosal immune homeostasis

Chronic inflammation can cause oviduct mucosal damage and immune dysfunction, leading to infertility, early pregnancy loss, ectopic pregnancy, tumors, and a decrease in reproductive capacities in female animals. Estrogen can suppress immune responses in different tissues and oviducts, and regulate the oviduct immune balance; however, the underlying mechanisms remain unclear. The objective of this study was to explore the mechanism of estrogen-regulated oviduct mucosal immunity and discover new estrogen targets for regulating oviduct mucosal immune homeostasis. Sheep oviduct epithelial cells (SOECs) were treated with 17-β estradiol (E2). Transcriptome sequencing and analysis showed differentially expressed S100 calcium-binding protein A (S100A) genes that may participate in the oviduct mucosa immunoregulation of estrogen. Quantitative polymerase chain reaction and immunocytochemistry analysis showed that S100A8 expression changed dynamically in E2-treated SOECs and peaked after 7 h of treatment. Estrogen nuclear receptors and G protein-coupled membrane receptors promoted E2-dependent S100A8 upregulation. The S100A8 gene was disrupted using the clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9 method. Levels of inflammatory factors interleukin (IL)-1β and IL-4 were significantly upregulated in S100A8-knockdown SOECs, whereas those of the anti-inflammatory factor IL-10 was downregulated. Following S100A8 knockdown in SOECs treated with E2 for 7 h, IL-10 levels increased significantly. Estrogen affected oviduct mucosa immune function and dynamically regulated S100A8 in SOECs. S100A8 knockdown caused an excessive immune response, indicating that S100A8 is beneficial for maintaining immune homeostasis in the oviduct mucosa. Moreover, estrogen can compensate for the effect of S100A8 knockdown by upregulating IL-10.

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.

Surgery for tubal infertility

BACKGROUND

Surgery remains an acceptable treatment modality for tubal infertility despite the rise in usage of in vitro fertilisation (IVF). Estimated livebirth rates after surgery range from 9% for women with severe tubal disease to 69% for those with mild disease; however, the effectiveness of surgery has not been rigorously evaluated in comparison with other treatments such as IVF and expectant management (no treatment). Livebirth rates have not been adequately assessed in relation to the severity of tubal damage. It is important to determine the effectiveness of surgery against other treatment options in women with tubal infertility because of concerns about adverse outcomes, intraoperative complications and costs associated with tubal surgery, as well as alternative treatments, mainly IVF.

OBJECTIVES

The aim of this review was to determine the effectiveness and safety of surgery compared with expectant management or IVF in improving the probability of livebirth in the context of tubal infertility (regardless of grade of severity).

SEARCH METHODS

We searched the following databases in October 2016: the Cochrane Gynaecology and Fertility (CGF) Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO; as well as clinical trials registries, sources of unpublished literature and reference lists of included trials and related systematic reviews.

SELECTION CRITERIA

We considered only randomised controlled trials to be eligible for inclusion, with livebirth rate per participant as the primary outcome of interest.

DATA COLLECTION AND ANALYSIS

We planned that two review authors would independently assess trial eligibility and risk of bias and would extract study data. The primary review outcome was cumulative livebirth rate. Pregnancy rate and adverse outcomes, including miscarriage rate, rate of ectopic pregnancy and rate of procedure-related complications, were secondary outcomes. We planned to combine data to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). We planned to assess statistical heterogeneity using the I2 statistic and to assess the overall quality of evidence for the main comparisons using GRADE methods.

MAIN RESULTS

We identified no suitable randomised controlled trials.

AUTHORS' CONCLUSIONS

The effectiveness of tubal surgery relative to expectant management and IVF in terms of livebirth rates for women with tubal infertility remains unknown. Large trials with adequate power are warranted to establish the effectiveness of surgery in these women. Future trials should not only report livebirth rates per patient but should compare adverse effects and costs of treatment over a longer time. Factors that have a major effect on these outcomes, such as fertility treatment, female partner's age, duration of infertility and previous pregnancy history, should be considered. Researchers should report livebirth rates in relation to severity of tubal damage and different techniques used for tubal repair, including microsurgery and laparoscopic methods.

Surgical treatment for tubal disease in women due to undergo in vitro fertilisation

BACKGROUND

Tubal disease, and particularly hydrosalpinx, has a detrimental effect on the outcome of in-vitro fertilisation (IVF). Performing a surgical intervention such as salpingectomy, tubal occlusion, aspiration of the hydrosalpinx fluid, or salpingostomy, prior to the IVF procedure in women with hydrosalpinges is thought improve the likelihood of successful outcome.

OBJECTIVES

To assess and compare the value of surgical treatments for tubal disease prior to IVF.

SEARCH STRATEGY

Trials were sought in the Cochrane Menstrual Disorders and Subfertility Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PSYCHMED and in Conference proceedings and reference lists up until Ocober 28 2009. Researchers in the field were contacted to reveal unpublished studies.

SELECTION CRITERIA

All trials comparing a surgical treatment for tubal disease with a control group generated by randomisation were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. The studied outcomes were live birth, ongoing pregnancy, viable-, clinical- and biochemical pregnancy, ectopic pregnancy, miscarriage, multiple pregnancy, ovarian function and complications.

MAIN RESULTS

Five randomised controlled trials involving 646 women were included in this review. Four studies assessed salpingectomy versus no treatment, two of which also included a tubal occlusion arm, and one trial assessed aspiration versus no treatment. No trials reported on the primary outcome: live birth. The odds of ongoing pregnancy (Peto OR 2.14, 95%CI 1.23 to 3.73) and of clinical pregnancy (Peto OR 2.31, 95%CI 1.48 to 3.62) however were increased with laparoscopic salpingectomy for hydrosalpinges prior to IVF. Laparoscopic occlusion of the fallopian tube versus no intervention did not increase the odds of ongoing pregnancy significantly (Peto OR 7.24, 95%CI 0.87 to 59.57) but the odds of clinical pregnancy (Peto OR 4.66, 95%CI 2.47 to 10.01) had sufficient power to show a significant increase. Comparison of tubal occlusion to salpingectomy did not show a significant advantage of either surgical procedure in terms of ongoing pregnancy (Peto OR: 1.65, 95%CI 0.74, 3.71) or clinical pregnancy (Peto OR 1.28, 95%CI 0,76 to 2.14). One RCT reported efficacy of ultrasound guided aspiration, however the odds of pregnancy did not show a significant increase in the odds of clinical pregnancy (Peto OR 1.97, 95%CI 0.62 to 6.29), and confidence intervals were wide. Throughout the different comparisons no significant differences were seen in adverse effects of surgical treatments.

AUTHORS' CONCLUSIONS

Surgical treatment should be considered for all women with hydrosalpinges prior to IVF treatment. Previous evidence supported only unilateral salpingectomy for a unilateral hydrosalpinx (bilateral salpingectomy for bilateral hydrosalpinges). This review now provides evidence that laparoscopic tubal occlusion is an alternative to laparoscopic salpingectomy in improving IVF pregnancy rates in women with hydrosalpinges. Further research is required to assess the value of aspiration of hydrosalpinges prior to or during IVF procedures and also the value of tubal restorative surgery as an alternative (or as a preliminary) to IVF.

Hydrosalpinx and IVF: assessment of treatments implemented prior to IVF

It is well known that the success of artificial reproductive techniques, especially IVF, for patients with tubal pathologies such as hydrosalpinx is reduced by half compared with patients without hydrosalpinx. Notably, there are also substantial increases in both early pregnancy loss and ectopic pregnancies. Alterations in the outcome of these patients generally reflect a detrimental effect of hydrosalpinx. However, although many theories have been published, a single explanation has not yet been found over a period of decades. Therefore, the negative effects of hydrosalpinx have generally been attributed largely to: (i) mechanical effects; (ii) embryo and gametotoxicity; (iii) alterations in endometrial receptivity markers; or dwindled cross talk between embryo-endometrium resulting in hindered implantation, and (iv) direct effect on endometrium, leading to intrauterine fluid formation. On the other hand, the most important question is selection of the preferred treatment option with either surgical or medical therapies. How should hydrosalpinx be managed? Does selection of the surgical method, either proximal obstruction or salpingectomy, depending on patients' clinical findings, differ in outcome, or is routine prophylactic salpingectomy needed? Additionally, the requirement for IVF or intracytoplasmic sperm injection is still controversial in patients with unilateral hydrosalpinx who have been treated with unilateral salpingectomy.