Pregnancy outcome of in vitro fertilization after Essure and laparoscopic management of hydrosalpinx: a systematic review and meta-analysis

Reproductive surgery remains an essential element of reproductive medicine

Background

Reproductive surgery has long been neglected and is perceived to be simple surgery that can be undertaken by all gynaecologists. However, given the ever-expanding knowledge in the field, reproductive surgery now comprises surgical interventions on female reproductive organs that need to be carefully planned and executed with consideration given to the individuals symptoms, function of the organ and fertility concerns.

Objectives

To discuss the different perspectives of reproductive surgeons and other gynaecological surgeons, e.g., gynaecological oncologists, and advanced minimally invasive surgeons, regarding diagnosis and management of pelvic pathology that affects reproductive potential. Furthermore, to highlight the gaps in knowledge and numerous controversies surrounding reproductive surgery, while summarising the current opinion on management.

Materials and Methods

Narrative review based on literature and the cumulative experience of the authors.

Main outcome measures

The paper does not address specific research questions.

Conclusions

Reproductive surgery encompasses all reproductive organs with the aim of alleviating symptoms whilst restoring and preserving function with careful consideration given to alternatives such as expectant management, medical treatments, and assisted reproductive techniques. It necessitates utmost technical expertise and sufficient knowledge of the female genital anatomy and physiology, together with a thorough understanding of and respect to of ovarian reserve, tubal function, and integrity of the uterine anatomy, as well as an up-to-date knowledge of alternatives, mainly assisted reproductive technology.

What is new?

A holistic approach to infertile women is only possible by focusing on the field of reproductive medicine and surgery, which is unattainable while practicing in multiple fields.

Prognostic value of hysterosalpingography after salpingostomy in patients with hydrosalpinx

To assess whether post-hysterosalpingography evaluation was associated with pregnancy rate and to identify independent risk factors for pregnancy success after salpingostomy in patients with hydrosalpinx. A retrospective analysis was conducted on the clinical data of 47 patients diagnosed with hydrosalpingography (HSG) in our hospital from 2015 to 2018. These patients received laparoscopic surgery and another salpingography within 2 months after surgery. According to the fallopian tube conditions evaluated by HSG before and after surgery, the patients could be divided into two groups. According to the pregnancy rate and postoperative HSG of patients with hydrosalpinx after laparoscopy, the total pregnancy rate of the tubal improved group was 65.62%, while that of the non-improved group was 20%, with statistical significance (p < 0.05). We found that hysterosalpingography after salpingostomy in patients with hydrosalpinx can provide reference for clinical treatment and improve the prognosis of patients.

Comparisons of different treatment outcomes in IVF/ET patients with hydrosalpinx: a retrospective study

AIMS

To explore suggestions for clinicians on the most effective treatment for hydrosalpinx undergoing IVF-ET.

MATERIALS AND METHODS

We reviewed 936 women with hydrosalpinx and 6715 tubal infertile women without hydrosalpinx who underwent IVF/ICSI between January 2014 and August 2019 in our center. Hydrosalpinx patients received different treatments including laparoscopic surgery (only salpingectomy and proximal tubal occlusion/ligation were included), ultrasonic-guided aspiration and hysteroscopic tubal occlusion. Outcomes were analyzed by One-way ANOVA, Chi-Square test and logistic regression.

RESULTS

The live birth rate (LBR) of laparoscopic surgery was significantly higher compared with hydrosalpinx aspiration (48.3% vs 39.6%, p = .024). The cumulative live birth rate (CLBR) of subsequent laparoscopic surgery was significantly higher compared with subsequent hysteroscopic occlusion (65.1% vs 34.1%, p = .001) and no subsequent treatment (65.1% vs 44.9%, p  <  .005). Subsequent laparoscopic surgery significantly improved the CLBR of hydrosalpinx patients who received ultrasonic-guided aspiration and didn't get clinical pregnancy in fresh cycles (Odds Ratio (OR) =1.875; 95%CI = 1.041-3.378, p = .036).

CONCLUSIONS

Laparoscopic surgery leads to significantly higher LBR than ultrasonic-guided aspiration and significantly higher CLBR than hysteroscopic occlusion and no treatment.

A comprehensive analysis of miRNA/isomiRs profile of hydrosalpinx patients with interventional ultrasound sclerotherapy

Hydrosalpinx is a chronic inflammatory condition with high recurrence rate, and it is reported among female population having fallopian tubal factor infertility. Previously, we have reported that interventional ultrasound sclerotherapy improves endometrial receptivity and pregnancy rate with negligible adverse effects in patients suffering from hydrosalpinx. During present investigation, we have used next generation sequencing (NGS) to characterize the isomiR profiles from the endometrium of patients suffering from hydrosalpinx before and after interventional ultrasound sclerotherapy. Our results indicated that miRNA arm shift and switch remained unaffected when compared in patients before and after interventional ultrasound sclerotherapy. We observed that isomiRs with trimming at 3’ and isomiRs with canonical sequences were lower in post-treatment than in pre-treatment group. Gene ontology (GO) annotation and KEGG pathway analysis revealed that the expression of mature mir-30 was significantly lower in the pre-treatment as compared to post treatment group while the expression of mir-30 isomiR was 4.26-fold higher in pre-treatment when compared with the post-treatment group. These different expression patterns of mir-30 mature miRNA and mir-30 isomiRs in two groups are affecting the physiological function of the endometrium. Our results suggested that differential isomiR distribution in hydrosalpinx patients before and after treatment plays an important role in hydrosalpinx incidence and can help in designing novel strategy for the treatment of hydrosalpinx in female population.

Hysteroscopic versus laparoscopic management in patients with communicating hydrosalpinx and planning for IVF: a randomized controlled trial

Background

Hydrosalpinx is considered one of the obstacles that could hinder the success of IVF techniques due to the toxic effect of the hydrosalpinx fluid pouring into the uterine cavity. Tubal disconnection by either hysteroscopic or laparoscopic approaches is considered the standard in the operative management of hydrosalpinx prior to IVF cycles. The aim of the current study was to compare the success rate of hysteroscopic tubal occlusion using electro-coagulation with laparoscopic tubal disconnection in cases of hydrosalpinx prior to in vitro fertilization (IVF).

Methods

A total of 108 women with unilateral or bilateral hydrosalpinx, who were candidates for tubal occlusion before IVF, were equally randomized into two groups. Group A (n = 54) underwent hysteroscopic tubal occlusion using the roller-ball electro-coagulation of the interstitial part of the tube and the uterine cornual area, and group B (n = 54) underwent laparoscopic tubal disconnection using bipolar coagulation and a proximal tubal cut. Operative time, complications, postoperative pain measured by the visual analogue score (VAS score), and postoperative hospital stay were recorded for both groups. The success rate of tubal occlusion was assessed 1 month later using a post-menstrual hysterosalpingogram (HSG).

Results

Laparoscopic tubal disconnection was more successful than the hysteroscopic approach regarding tubal occlusion rate (96.15% vs. 86.67% respectively, p = 0.044). The operative time and postoperative pain VAS scores in the hysteroscopy group (3.65 ± 1.03 min and 1.81 ± 1.35, respectively) were significantly lower than that in the laparoscopy group (17.48 ± 4.70 min and 4.06 ± 1.65, respectively) with p < 0.001.

Conclusion

Although laparoscopic tubal disconnection is more successful, the hysteroscopic approach is an alternative which has its own limitations that can be assessed by hysterosalpingogram, especially when laparoscopy is contraindicated, technically difficult, or refused by the patient.

Trial registration

It was first registered at ClinicalTrials.gov on 30/07/2019 with registration number NCT04037813.

ART Outcomes After Hysteroscopic Proximal Tubal Occlusion Versus Laparoscopic Salpingectomy for Hydrosalpinx Management in Endometriosis Patients

The objective of this paper is to compare assisted reproductive technology (ART) cumulative live birth rates after hysteroscopic proximal tubal occlusion and laparoscopic salpingectomy in endometriosis patients, for management of hydrosalpinx. This is an observational cohort study at a university hospital, including all endometriosis patients with hydrosalpinges undergoing ART, between January 2013 and December 2018. The patients underwent either laparoscopic salpingectomy or hysteroscopic proximal tubal occlusion with Essure® when laparoscopy was not an option (extensive pelvic adhesions at exploratory laparoscopy or a history of multiple abdominal surgeries with frozen pelvis). The diagnosis of endometriosis was based on published imaging criteria using transvaginal sonography (TVUS) and magnetic resonance imaging (MRI). Endometriosis patients with hydrosalpinges diagnosed by hysterosalpingography and/or TVUS and/or MRI were included. The primary outcome was the cumulative live birth rate. A total of 104 patients were included in the study; 74 underwent laparoscopic salpingectomy and 30 underwent proximal tubal occlusion with Essure®. The Essure® group had longer infertility durations (58.9 ± 30.0 months vs. 39.5 ± 19.1 months, p = 0.002) and a higher incidence of associated adenomyosis (76.7% vs. 39.1%, p < 0.001) than the salpingectomy group. The cumulative live birth rate was 56.6% after 44 ART cycles in the Essure® group and 40.5% after 99 ART cycles in the salpingectomy group (p = 0.13). In a population of endometriosis patients undergoing ART, women treated by Essure® for management of hydrosalpinx have similar cumulative live birth rates as women treated by laparoscopic salpingectomy.

Effects of Hydrosalpinx on Endometrial Implantation Failures: Evaluating Salpingectomy in Women Undergoing in vitro fertilization

Hydrosalpinx is a disease characterized by the obstruction of the salpinx, with progressive accumulation in the shape of a fluid-filled sac at the distal part of the tuba uterina, and closed to the ovary. Women with hydrosalpinges have lower implantation and pregnancy rates due to a combination of mechanical and chemical factors thought to disrupt the endometrial environment. Evidence suggests that the presence of hydrosalpinx reduces the rate of pregnancy with assisted reproductive technology. The main aim of the present is review to make an overview of the possible effects of hydrosalpinx on in vitro fertilization (IVF). We conducted a literature search on the PubMed, Ovid MEDLINE, and Google Scholar data bases regarding hydrosalpinx and IVF outcomes. Hydrosalpinx probably has a direct toxic effect on sperm motility and on the embryos. In addition, the increasing liquid inside the salpinges could alter the mechanisms of endometrial receptivity. The window of endometrial receptivity is essential in the implantation of blastocysts, and it triggers multiple reactions arising from the endometrium as well as the blastocysts. Hydrosalpinx could influence the expression of homeobox A10 (HOXA10) gene, which plays an essential role in directing embryonic development and implantation. Salpingectomy restores the endometrial expression of HOXA10; therefore, it may be one mechanism by which tubal removal could result in improved implantation rates in IVF. In addition, salpingectomy does not affect the ovarian response, nor reduces the antral follicle count. Further studies are needed to establish the therapeutic value of fluid aspiration under ultrasonographic guidance, during or after oocyte retrieval, in terms of pregnancy rate and ongoing pregnancy.

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.

Effect comparison of salpingectomy versus proximal tubal occlusion on ovarian reserve: A meta-analysis

INTRODUCTION

The women with hydrosalpinx have lower pregnancy rates in assisted reproductive technology, and only laparoscopic salpingectomy and tubal occlusion has proven to be effective to improve the outcome of in vitro fertilization. The main objective of the present meta-analysis was to assess and compare the ovarian reserve after salpingectomy or proximal tubal occlusion (PTO) in the published literature.

MATERIAL AND METHODS

We considered all published cohort (retrospective and prospective) and cross-sectional studies as well as randomized controlled trials that investigated changes in serum anti-Müllerian hormone (AMH), follicle-stimulating hormone levels or antral follicle count (AFC) following salpingectomy or PTO. Two investigators (SW, QZ) independently screened the full text of all identified articles to assess relevance to our meta-analysis.

RESULTS

In total, 648 patients were included in 5 studies. In the analysis of comparative studies. In the analysis of comparative studies, the follicle-stimulating hormone of salpingectomy had no significant difference with that of PTO (WMD 0.46IU/L, 95% CI[-0.14,1.05]). The AMH and AFC of salpingectomy were significantly higher than that of PTO (AFC: WMD -0.80IU/L, 95% CI [-1.46, -0.14]; AMH: WMD -1.01IU/L, 95% CI [-1.28, -0.74]).

CONCLUSIONS

Salpingectomy did more harm to ovarian reserve than PTO in the short-term. However, the long-term effects on ovarian reserve remains uncertain.

Comparison of the efficacy between bilateral proximal tubal occlusion and total salpingectomy on ovarian reserve and the cholinergic system: an experimental study

Background and aim

To compare the effects of bilateral proximal tubal occlusion and bilateral total salpingectomy on ovarian reserve and the cholinergic system via rat experiment.

Materials and methods

Twenty-one adult female rats were randomly divided into the following three groups:G1 (n = 7), sham group;G2 (n = 7), bilateral total salpingectomy group; and G3 (n = 7), bilateral proximal tubal occlusion group. Four weeks later, the abdomen of the rats was opened. The right ovarian tissues were stored in 10% formaldehyde, whereas the left ovarian tissues were stored at –80 °C in aluminum foil. Serum samples were evaluated for antimullerian hormone. The right ovary was used for histological and immunoreactive examination, and the left ovary was used for tissue MDA analysis. Tissue samples were analyzed for MDA levels with spectrophotometric measurement, apoptosis with TUNEL staining, fibrosis score with Mason trichrome staining, ovarian reserve with HE staining, and cholinergic receptor muscarinic 1 (CHRM1) level with immunoreactivity method.

Results

Compared to G1 and G3, the number of corpus luteum with secondary follicles was significantly lower in G2, whereas the number of ovarian cysts and fibrosis and apoptosis scores increased significantly. The CHRM1 immunoreactivity was significantly lower in G2 than in G1 and G3.

Conclusions

Compared to the bilateral proximal tubal occlusion performed by using bipolar cautery, bilateral total salpingectomy in rats leads to a significant damage in ovarian histopathology and the cholinergic system.

Hormonal Effects in Reproductive Technology with Focus on Diminished Ovarian Reserve

Modern use of reproductive technologies has revolutionized the treatment of infertile couples. Strategies to improve ovarian function in cases of diminished ovarian reserve are perhaps the least understood area in this field and will be the chief focus of this chapter.

Safety and Assisted Reproductive Technology Outcomes of Hysteroscopic Tubal Microinserts Versus Laparoscopic Proximal Tubal Occlusion or Salpingectomy for Hydrosalpinges Treatment

OBJECTIVE

This study sought to answer the following question: What are the complications and assisted reproductive technology outcomes among women with hydrosalpinges managed by hysteroscopic microinsert tubal occlusion compared with women with hydrosalpinges managed by laparoscopic proximal tubal occlusion or salpingectomy?

METHODS

This was a retrospective cohort study conducted from January 2009 to December 2014 at two academic, tertiary care, in vitro fertilization centres in Toronto, Ontario. All patients (n = 52) who underwent hysteroscopic tubal occlusion for hydrosalpinges were identified. Patients who proceeded with embryo transfer cycles after hysteroscopic microinsert (n = 33) were further age matched to a cohort of patients who underwent embryo transfer after laparoscopic proximal tubal occlusion or salpingectomy (n = 33). Main outcome measures were clinical pregnancy rate per patient and per embryo transfer cycle.

RESULTS

Among 33 patients, there were 39 fresh and 37 frozen embryo transfer cycles in the hysteroscopic group (group A); among 33 patients in the laparoscopic group (group B), there were 42 fresh and 29 frozen embryo transfer cycles. The cumulative clinical pregnancy rate in group A and group B was similar (66.7% vs. 69.7%, respectively; P = 0.8). The clinical pregnancy rate per embryo transfer cycle was also similar in both groups (28.9% in group A vs. 32.4% in group B; P = 0.6). There were two incidents of ectopic pregnancy in the laparoscopic group and no ectopic pregnancy in the hysteroscopic group. There were three major complications: tubo-ovarian abscess, distal migration of the coil after microinsert placement, and an acute abdomen following the hysteroscopic procedure.

CONCLUSION

Pregnancy outcomes after hysteroscopic placement of a microinsert for hydrosalpinx management before embryo transfer were comparable to those following laparoscopic proximal tubal occlusion or salpingectomy. However, caution is advised regarding microinsert placement for hydrosalpinges before proceeding with assisted reproductive technology.

Up-regulation of miR-145 may contribute to repeated implantation failure after IVF-embryo transfer by targeting PAI-1

RESEARCH QUESTION

Repeated implantation failure (RIF) is a major limiting factor in assisted reproductive technology. As miR-145 (also known as MIR145) is up-regulated in patients with RIF, this study asked, what is the molecular mechanism underlying the affect of miR-145 on embryo implantation in RIF?

DESIGN

Ishikawa cells were infected with lentivirus containing miR-145 and miR-145 NC. Massive transcriptome data analyses and bioinformatics analysis were used to search for a potential candidate target of miR-145. The expression of the potential candidate target was detected using quantitative reverse transcription PCR (qRT-PCR) and western blotting in the Ishikawa cells infected with lentivirus containing miR-145 or miR-145 NC. Subsequently, a dual luciferase reporter assay was performed to verify whether the potential candidate target was a novel direct target of miR-145. In addition, expression of PAI-1 (plasminogen activator inhibitor 1, also known as SERPINE1) in endometrial tissue from women with RIF and in control endometrial tissue was examined using qRT-PCR and immunohistochemistry.

RESULTS

Based on massive transcriptome data analyses and bioinformatics analysis, PAI-1 was regarded as a potential candidate target of miR-145. miR-145 overexpression was achieved in Ishikawa cells. PAI-1 was confirmed as a direct target of miR-145 by bioinformatic analysis, qRT-PCR, western blotting and dual luciferase reporter assay. Further, results from the clinical sample indicated that at both the mRNA and protein levels, PAI-1 expression was down-regulated in endometrial tissues from women with RIF compared with control group women, and this was negatively related to miR-145 expression.

CONCLUSIONS

The study results suggests that miR-145 may target and down-regulate PAI-1 expression and influence embryo implantation in women with RIF who are undergoing IVF.

Proximal Fallopian Tubal Embolization by Interventional Radiology prior to Embryo Transfer in Infertile Patients with Hydrosalpinx: A Prospective Study of an Off-label Treatment

STUDY OBJECTIVE

To evaluate in vitro fertilization (IVF) outcomes of proximal fallopian tube embolization by interventional radiology compared with laparoscopic salpingectomy before embryo transfer (ET) in patients with hydrosalpinx.

DESIGN

A single-center, off-label, nonrandomized prospective study.

SETTING

Academic university hospital.

PATIENTS

One hundred fifty-five patients with hydrosalpinx were identified on ultrasound or hysterosalpingography desiring IVF between April 2016 and December 2017.

INTERVENTIONS

Radiologically guided tubal occlusion with embolization microcoils (RTO-EM) and laparoscopic salpingectomy.

MEASUREMENTS AND MAIN RESULTS

Of the 155 analyzed patients, 42 were treated with RTO-EM and 113 with laparoscopic salpingectomy. The subsequent IVF outcomes, including implantation, clinical pregnancy, miscarriage, ectopic pregnancy, and ongoing pregnancy (i.e., a fetal heartbeat on ultrasound beyond 10 weeks) were compared between the 2 groups. Implantation and clinical pregnancy per ET cycle in the RTO-EM group were similar to that of the salpingectomy group (26.7% vs 30.2% [p = .51] and 39.0% vs 45.3% [p = .40], respectively), with a similar miscarriage rate. There was no statistically significant difference in ectopic pregnancies between the 2 groups. Moreover, no difference was detected in ongoing pregnancy per cycle between the 2 groups (33.9% vs 41.2%; p = .32). The ongoing-pregnancy rate per patient following RTO-EM was 47.6% (20 of 42) compared with 61.9% (70 of 113) following salpingectomy (odds ratio, 0.56; 95% confidence interval, 0.27-1.14; p = .11).

CONCLUSION

Pregnancy in the RTO-EM group was comparable to the salpingectomy group in patients with hydrosalpinx before ET treatment. RTO-EMs may be an alternative to salpingectomy for patients with hydrosalpinx planning for IVF-ET.

Characterization of Microbiota in Endometrial Fluid and Vaginal Secretions in Infertile Women with Repeated Implantation Failure

Studies suggest that persisting intrauterine bacterial infectious conditions such as chronic endometritis potentially impair the embryo implantation process. The microbial environment in the female reproductive tract, however, remains largely undetermined in infertile patients with a history of repeated implantation failure (RIF). Using next-generation sequencing, we aimed to characterize the microbiota in the endometrial fluid (EF) and vaginal secretions (VS) in women with RIF. Twenty-eight infertile women with a history of RIF and eighteen infertile women undergoing the first in vitro fertilization-embryo transfer attempt (the control group) were enrolled in the study. On days 6-8 in the luteal phase of the natural, oocyte-pickup, or hormone replacement cycle, the paired EF and VS samples were obtained separately. Extracted genomic DNA was pyrosequenced for the V4 region of 16S ribosomal RNA using a next-generation sequencer. The EF microbiota had higher α-diversity and broader bacterial species than the VS microbiota both in the RIF and control groups. The analysis of the UniFrac distance matrices between EF and VS also revealed significantly different clustering. Additionally, the EF microbiota, but not the VS microbiota, showed significant variation in community composition between the RIF group and the control group. Burkholderia species were not detected in the EF microbiota of any samples in the control group but were detectable in a quarter of the RIF group. To our best knowledge, this is the first study investigating the microbiota in the paired EF and VS samples in infertile women with RIF.

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.

MTHFR C677T polymorphism is associated with follicle-stimulating hormone levels and controlled ovarian hyperstimulation response: a retrospective study from the clinical database

OBJECTIVE

To evaluate the impact of methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism with clinical data analysis in controlled ovarian hyperstimulation (COH) of infertile women in the Intravenous Infusion Safety Evaluation Center of Hunan Province, People's Republic of China.

DESIGN

Genetic Association Study.

SETTING

Reproductive medicine clinical.

PATIENT(S)

This genetic association study included 722 infertile women who received the standard long treatment protocol with accessible and complete electronic medical records.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The clinical parameters were obtained from the Intravenous Infusion Safety Evaluation center.

RESULT(S)

Basal FSH levels in the TT group were significantly higher than those of the CC group. The FSH levels after down-regulation in the TT group were higher than those of CC/CT genotypes. The TT genotype patients received significantly higher total doses of GnRH agonist and FSH compared with CC/CT genotypes, whereas the total dose of hCG was higher in the CT genotypes compared with the CC/TT genotypes. Further association analysis between hormone levels and COH outcomes indicated significantly negative correlation of basal FSH levels with antral follicle count and number of oocytes as well as the down-regulation FSH levels with the number of metaphase II oocytes and oocytes.

CONCLUSION(S)

The MTHFR C677T polymorphism was associated with high doses of ovarian stimulation medications, as well as higher FSH levels. The negative correlation between FSH levels and the number of oocytes suggested that C677T polymorphism may play a role in the poor prognosis of COH oocytes. This needs to be studied in future prospective studies with longer follow-up.

Hydrosalpinx - Salpingostomy, salpingectomy or tubal occlusion

Tubal factors account for approximately 25% of cases of infertility, and the most severe manifestation of tubal disease is hydrosalpinx, accounting for 10-30% of tubal diseases. Hydrosalpinx is a distension or dilatation of the fallopian tube in the presence of a distal tubal occlusion, and the most common cause is pelvic inflammatory disease. Women with hydrosalpinges have lower implantation and pregnancy rates in assisted reproductive technology (ART), due to a combination of mechanical and chemical factors thought to disrupt the endometrial environment. Current guidance is removal of the tube by salpingectomy (preferably laparoscopically) before IVF treatment. Salpingostomy, or distal tubal plastic surgery in the management of hydrosalpinx, is an alternative for women desiring natural conception, although ectopic pregnancy rates as high as 10% have been reported. Proximal tubal occlusion with Essure^® devices placed hysteroscopically can be considered particularly in cases of distorted pelvic anatomy or pelvic adhesions making abdominal surgery complex. However, low clinical pregnancy and live birth rates have been reported with the use of these devices before IVF. In this review, we discuss salpingostomy, salpingectomy and tubal occlusion as possible management options for the reproductive women with hydrosalpinx.

Hysteroscopic Placement of Platinum Microinsert in Patients With Hydrosalpinx Before In Vitro Fertilization and Embryo Transfer

OBJECTIVE

To investigate the effectiveness of Tornado and Hilal (Cook Medical, Bloomington, IN) hysteroscopic proximal tubal occlusion (HPTO) for hydrosalpinx (HX) treatment before in vitro fertilization (IVF) and embryo transfer (ET) in patients with dense pelvic adhesions or low ovarian reserve.

DESIGN

A retrospective study of patients treated between May 2014 and May 2016 (Canadian Task Force classification III).

SETTING

A university-affiliated center.

PATIENTS

One hundred fifty women with unilateral or bilateral HX who were not candidates for laparoscopic surgery.

INTERVENTION

Tornado or Hilal HPTO before IVF-ET and/or frozen ET.

MEASUREMENTS AND MAIN RESULTS

The main outcome was the cumulative live birth rate. Tornado or Hilal placement was successful for 143 (95.3%) patients. Of the 132 patients who underwent 204 ET cycles, 86 (65.2%) conceived, and 78 (59.1%) resulted in live births. The overall early and late miscarriage rates per clinical pregnancy were 12.8% and 1.1%, respectively. The ectopic pregnancy rate was 2.3%. No major complications occurred.

CONCLUSION

Tornado or Hilal HPTO is an effective alternative for treating HX before IVF-ET/frozen ET in patients with dense pelvic adhesions or low ovarian reserve.