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Huang Q, Mo L, Wang J, Qin A. Oil-soluble contrast medium bathing attenuated endometrial inflammation and improved endometrial receptivity in women with recurrent implantation failure: a descriptive study. BMC Womens Health 2024; 24:326. [PMID: 38840118 PMCID: PMC11151508 DOI: 10.1186/s12905-024-03160-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 05/27/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND The oil-soluble contrast medium used in hysterosalpingography has been shown to have a fertility-enhancing effect, but the underlying mechanism is unclear, especially regarding the role of window of implantation (WOI). This study aimed to assess the endometrial immunological impact of the WOI before and after bathing with the oil-soluble contrast medium in women with recurrent implantation failure (RIF). METHODS This descriptive study involved two medical centers between December 18, 2019, and December 30, 2020. We included infertile women who underwent three or more transfer cycles, cumulative transplantation of at least four high-quality cleavage-stage embryos or three high-quality blastocysts without clinical pregnancy, and high-quality frozen embryos that were still available for implantation. Patients received 5 ml of ethiodized poppyseed oil bathing, endometrial biopsy around bathing, and frozen-thawed embryo transfer (FET) within four menstrual cycles after bathing. Patients were excluded if failure to complete anyone. Data on the baseline characteristics and clinical data of the FET cycles were collected, and endometrial biopsy specimens were collected in the luteal phase before and after bathing and subjected to immunohistochemistry. The number of CD56 and CD138 positive cells and H-score of expression of ανβ-3 and HOXA10 in endometrium were collected. RESULTS Thirty-four patients were initially enrolled in the study; ultimately, twelve patients with a median age of 32.5 years (range 27-40 years) completed the research. The median number of embryo transfer cycles was three (range 3-8). A total of 4 of 12 women (33.33%) were diagnosed with chronic endometritis before oil-soluble contrast bathing. After bathing, the median numbers of CD138-positive cells in endometrium decreased from 0.75 (range 0-13.5) to 0.65 (range 0-6), P = 0.035; additionally, the H-score of expression of ανβ-3 in endometrium increased from 148.50 ± 31.63 to 175.58 ± 31.83, P < 0.001. The thickness of the endometrium also significantly increased (8.90 ± 1.45 mm vs.10.11 ± 1.98 mm, P = 0.005). However, no consistent changes were found in the expression of CD56 and HOXA10 in the endometrium. Five patients experienced biochemical pregnancies (41.67%), four had clinical pregnancies (33.33%), and three achieved live births following oil-soluble contrast bathing (25%). CONCLUSIONS These results suggest that oil-soluble contrast medium bathing decreased CD138-positive cells and upregulated expression of ανβ-3 during WOI in patients with RIF. This histological impact of endometrium may result in enhanced fertility during FET cycles. Investigating the ability of intrauterine bathing with lower-dosage oil-soluble contrast to improve pregnancy in the RIF population is warranted.
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Affiliation(s)
- Qiuyan Huang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, Guangzhou, 510632, Guangdong, China
- Key Laboratory of Metabolic Diseases of Baise, Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, 533000, Guangxi, China
- The First Affiliated Hospital of Guangxi Medical University, Nanning, 530022, Guangxi, China
| | - LinIing Mo
- Maternal and Child Health Hospital of the Guangxi Zhuang Autonomous Region, Nanning, 530028, Guangxi, China
| | - Junli Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, Guangzhou, 510632, Guangdong, China.
- Youjiang Medical University for Nationalities, Baise, 533000, Guangxi, China.
| | - Aiping Qin
- The First Affiliated Hospital of Guangxi Medical University, Nanning, 530022, Guangxi, China.
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Kamphuis D, van Eekelen R, van Welie N, Dreyer K, van Rijswijk J, van Hooff MHA, de Bruin JP, Verhoeve HR, Mol F, van Baal WM, Traas MAF, van Peperstraten AM, Manger AP, Gianotten J, de Koning CH, Koning AMH, Bayram N, van der Ham DP, Vrouenraets FPJM, Kalafusova M, van de Laar BIG, Kaijser J, Lambeek AF, Meijer WJ, Broekmans FJM, Valkenburg O, van der Voet LF, van Disseldorp J, Lambers MJ, Tros R, Lambalk CB, Stoker J, van Wely M, Bossuyt PMM, Mol BWJ, Mijatovic V. Hysterosalpingo-foam sonography versus hysterosalpingography during fertility work-up: an economic evaluation alongside a randomized controlled trial. Hum Reprod 2024; 39:1222-1230. [PMID: 38600625 PMCID: PMC11144974 DOI: 10.1093/humrep/deae071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 01/29/2024] [Indexed: 04/12/2024] Open
Abstract
STUDY QUESTION What are the costs and effects of tubal patency testing by hysterosalpingo-foam sonography (HyFoSy) compared to hysterosalpingography (HSG) in infertile women during the fertility work-up? SUMMARY ANSWER During the fertility work-up, clinical management based on the test results of HyFoSy leads to slightly lower, though not statistically significant, live birth rates, at lower costs, compared to management based on HSG results. WHAT IS KNOWN ALREADY Traditionally, tubal patency testing during the fertility work-up is performed by HSG. The FOAM trial, formally a non-inferiority study, showed that management decisions based on the results of HyFoSy resulted in a comparable live birth rate at 12 months compared to HSG (46% versus 47%; difference -1.2%, 95% CI: -3.4% to 1.5%; P = 0.27). Compared to HSG, HyFoSy is associated with significantly less pain, it lacks ionizing radiation and exposure to iodinated contrast medium. Moreover, HyFoSy can be performed by a gynaecologist during a one-stop fertility work-up. To our knowledge, the costs of both strategies have never been compared. STUDY DESIGN, SIZE, DURATION We performed an economic evaluation alongside the FOAM trial, a randomized multicenter study conducted in the Netherlands. Participating infertile women underwent, both HyFoSy and HSG, in a randomized order. The results of both tests were compared and women with discordant test results were randomly allocated to management based on the results of one of the tests. The follow-up period was twelve months. PARTICIPANTS/MATERIALS, SETTING, METHODS We studied 1160 infertile women (18-41 years) scheduled for tubal patency testing. The primary outcome was ongoing pregnancy leading to live birth. The economic evaluation compared costs and effects of management based on either test within 12 months. We calculated incremental cost-effectiveness ratios (ICERs): the difference in total costs and chance of live birth. Data were analyzed using the intention to treat principle. MAIN RESULTS AND THE ROLE OF CHANCE Between May 2015 and January 2019, 1026 of the 1160 women underwent both tubal tests and had data available: 747 women with concordant results (48% live births), 136 with inconclusive results (40% live births), and 143 with discordant results (41% had a live birth after management based on HyFoSy results versus 49% with live birth after management based on HSG results). When comparing the two strategies-management based on HyfoSy results versus HSG results-the estimated chance of live birth was 46% after HyFoSy versus 47% after HSG (difference -1.2%; 95% CI: -3.4% to 1.5%). For the procedures itself, HyFoSy cost €136 and HSG €280. When costs of additional fertility treatments were incorporated, the mean total costs per couple were €3307 for the HyFoSy strategy and €3427 for the HSG strategy (mean difference €-119; 95% CI: €-125 to €-114). So, while HyFoSy led to lower costs per couple, live birth rates were also slightly lower. The ICER was €10 042, meaning that by using HyFoSy instead of HSG we would save €10 042 per each additional live birth lost. LIMITATIONS, REASONS FOR CAUTION When interpreting the results of this study, it needs to be considered that there was a considerable uncertainty around the ICER, and that the direct fertility enhancing effect of both tubal patency tests was not incorporated as women underwent both tubal patency tests in this study. WIDER IMPLICATION OF THE FINDINGS Compared to clinical management based on HSG results, management guided by HyFoSy leads to slightly lower live birth rates (though not statistically significant) at lower costs, less pain, without ionizing radiation and iodinated contrast exposure. Further research on the comparison of the direct fertility-enhancing effect of both tubal patency tests is needed. STUDY FUNDING/COMPETING INTEREST(S) FOAM trial was an investigator-initiated study, funded by ZonMw, a Dutch organization for Health Research and Development (project number 837001504). IQ Medical Ventures provided the ExEm®-FOAM kits free of charge. The funders had no role in study design, collection, analysis, and interpretation of the data. K.D. reports travel-and speakers fees from Guerbet and her department received research grants from Guerbet outside the submitted work. H.R.V. received consulting-and travel fee from Ferring. A.M.v.P. reports received consulting fee from DEKRA and fee for an expert meeting from Ferring, both outside the submitted work. C.H.d.K. received travel fee from Merck. F.J.M.B. received a grant from Merck and speakers fee from Besins Healthcare. F.J.M.B. is a member of the advisory board of Merck and Ferring. J.v.D. reported speakers fee from Ferring. J.S. reports a research agreement with Takeda and consultancy for Sanofi on MR of motility outside the submitted work. M.v.W. received a travel grant from Oxford Press in the role of deputy editor for Human Reproduction and participates in a DSMB as independent methodologist in obstetrics studies in which she has no other role. B.W.M. received an investigator grant from NHMRC GNT1176437. B.W.M. reports consultancy for ObsEva, Merck, Guerbet, iGenomix, and Merck KGaA and travel support from Merck KGaA. V.M. received research grants from Guerbet, Merck, and Ferring and travel and speakers fees from Guerbet. The other authors do not report conflicts of interest. TRIAL REGISTRATION NUMBER International Clinical Trials Registry Platform No. NTR4746.
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Affiliation(s)
- Danah Kamphuis
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Rik van Eekelen
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Centre for Reproductive Medicine, Amsterdam UMC location Universitity of Amsterdam, Amsterdam, The Netherlands
| | - Nienke van Welie
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, OLVG, Amsterdam, The Netherlands
| | - Kim Dreyer
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Joukje van Rijswijk
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Machiel H A van Hooff
- Department of Obstetrics and Gynaecology, Franciscus Hospital, Rotterdam, The Netherlands
| | - Jan Peter de Bruin
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Harold R Verhoeve
- Department of Obstetrics and Gynaecology, OLVG, Amsterdam, The Netherlands
| | - Femke Mol
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Centre for Reproductive Medicine, Amsterdam UMC location Universitity of Amsterdam, Amsterdam, The Netherlands
| | | | - Maaike A F Traas
- Department of Obstetrics and Gynaecology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Arno M van Peperstraten
- Department of Obstetrics and Gynaecology, Rivierenland Hospital, Tiel, The Netherlands
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Arentje P Manger
- Department of Obstetrics and Gynaecology, Diakonessenhuis, Utrecht, The Netherlands
| | - Judith Gianotten
- Department of Obstetrics and Gynaecology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Cornelia H de Koning
- Department of Obstetrics and Gynaecology, Tergooi Medical Center, Hilversum, The Netherlands
| | - Aafke M H Koning
- Department of Obstetrics and Gynaecology, Amstelland Hospital, Amstelveen, The Netherlands
| | - Neriman Bayram
- Department of Obstetrics and Gynaecology, Zaans Medical Centre, Zaandam, The Netherlands
| | - David P van der Ham
- Department of Obstetrics and Gynaecology, Martini Hospital, Groningen, The Netherlands
| | | | - Michaela Kalafusova
- Department of Obstetrics and Gynaecology, Refaja Hospital, Stadskanaal, The Netherlands
| | | | - Jeroen Kaijser
- Department of Obstetrics and Gynaecology, Ikazia Medical Center, Rotterdam, The Netherlands
| | - Arjon F Lambeek
- Department of Obstetrics and Gynaecology, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - Wouter J Meijer
- Department of Obstetrics and Gynaecology, Gelre Hospitals, Zutphen, The Netherlands
| | - Frank J M Broekmans
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Obstetrics and Gynaecology, Dijklander Hospital, Hoorn, The Netherlands
| | - Olivier Valkenburg
- Department of Reproductive Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Lucy F van der Voet
- Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, The Netherlands
| | - Jeroen van Disseldorp
- Department of Obstetrics and Gynaecology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Marieke J Lambers
- Department of Obstetrics and Gynaecology, Dijklander Hospital, Hoorn, The Netherlands
| | - Rachel Tros
- Department of Obstetrics and Gynaecology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Cornelis B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Madelon van Wely
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Centre for Reproductive Medicine, Amsterdam UMC location Universitity of Amsterdam, Amsterdam, The Netherlands
- Department of Epidemiology & Data Science, Amsterdam Public Health, Amsterdam UMC, Amsterdam, The Netherlands
| | - Patrick M M Bossuyt
- Department of Epidemiology & Data Science, Amsterdam Public Health, Amsterdam UMC, Amsterdam, The Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
- Aberdeen Centre for Women’s Health Research, University of Aberdeen, King’s College, Aberdeen, UK
| | - Velja Mijatovic
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
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Van Muylder A, D'Hooghe T, Luyten J. Economic Evaluation of Medically Assisted Reproduction: A Methodological Systematic Review. Med Decis Making 2023; 43:973-991. [PMID: 37621143 DOI: 10.1177/0272989x231188129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Medically assisted reproduction (MAR) is a challenging application area for health economic evaluations, entailing a broad range of costs and outcomes, stretching out long-term and accruing to several parties. PURPOSE To systematically review which costs and outcomes are included in published economic evaluations of MAR and to compare these with health technology assessment (HTA) prescriptions about which cost and outcomes should be considered for different evaluation objectives. DATA SOURCES HTA guidelines and systematic searches of PubMed Central, Embase, WOS CC, CINAHL, Cochrane (CENTRAL), HTA, and NHS EED. STUDY SELECTION All economic evaluations of MAR published from 2010 to 2022. DATA EXTRACTION A predetermined data collection form summarized study characteristics. Essential costs and outcomes of MAR were listed based on HTA and treatment guidelines for different evaluation objectives. For each study, included costs and outcomes were reviewed. DATA SYNTHESIS The review identified 93 cost-effectiveness estimates, of which 57% were expressed as cost-per-(healthy)-live-birth, 19% as cost-per-pregnancy, and 47% adopted a clinic perspective. Few adopted societal perspectives and only 2% used quality-adjusted life-years (QALYs). Broader evaluations omitted various relevant costs and outcomes related to MAR. There are several cost and outcome categories for which available HTA guidelines do not provide conclusive directions regarding inclusion or exclusion. LIMITATIONS Studies published before 2010 and of interventions not clearly labeled as MAR were excluded. We focus on methods rather than which MAR treatments are cost-effective. CONCLUSIONS Economic evaluations of MAR typically calculate a short-term cost-per-live-birth from a clinic perspective. Broader analyses, using cost-per-QALY or BCRs from societal perspectives, considering the full scope of reproduction-related costs and outcomes, are scarce and often incomplete. We provide a summary of costs and outcomes for future research guidance and identify areas requiring HTA methodological development. HIGHLIGHTS The cost-effectiveness of MAR procedures can be exceptionally complex to estimate as there is a broad range of costs and outcomes involved, in principle stretching out over multiple generations and over many stakeholders.We list 21 key areas of costs and outcomes of MAR. Which of these needs to be accounted for alters for different evaluation objectives (determined by the type of economic evaluation, time horizon considered, and perspective).Published studies mostly investigate cost-effectiveness in the very short-term, from a clinic perspective, expressed as cost-per-live-birth. There is a lack of comprehensive economic evaluations that adopt a broader perspective with a longer time horizon. The broader the evaluation objective, the more relevant costs and outcomes were excluded.For several costs and outcomes, particularly those relevant for broader, societal evaluations of MAR, the inclusion or exclusion is theoretically ambiguous, and HTA guidelines do not offer sufficient guidance.
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Affiliation(s)
- Astrid Van Muylder
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
| | - Thomas D'Hooghe
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
| | - Jeroen Luyten
- Department Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium (AVM, JL); Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium (TD); Department of Obstetrics, Gynecology and Reproductive Sciences Yale School of Medicine, New Haven, CT, USA (TD); Global Medical Affairs Fertility, Research and Development, Merck Healthcare KGaA, Darmstadt, Germany (TD). The review was written at the Leuven Institute for Healthcare Policy. It was presented at the ESHRE 38th Annual Meeting (Milan 2022). The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Astrid Van Muylder and Jeroen Luyten have no conflicting interests to declare. The participation of Thomas D'Hooghe to this publication is part of his academic work; he does not see a conflict of interest as Merck KGaA was not involved in writing this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We acknowledge an internal funding from KU Leuven for this study. The funding agreement ensured the authors' independence in designing the study, interpreting the data, writing, and publishing the report. The following authors are employed by the sponsor: Astrid Van Muylder and Jeroen Luyten
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Wessel JA, Hunt S, van Wely M, Mol F, Wang R. Alternatives to in vitro fertilization. Fertil Steril 2023; 120:483-493. [PMID: 36642301 DOI: 10.1016/j.fertnstert.2023.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/07/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
There have been concerns on the potential overuse of in vitro fertilization (IVF) in view of the lack of evidence on effectiveness in certain populations, potential short and long-term safety risks, and economic considerations. On the other hand, the use of alternatives to IVF seems to be underappreciated in clinical practice as well as research. In this review, we summarized the up-to-date evidence on the effectiveness, safety as well as cost-effectiveness of different alternatives to IVF, including expectant management, intrauterine insemination, tubal flushing, in vitro maturation as well as intravaginal culture. We also discussed the trend of IVF use over the last decade and the available tiers of service because of intravaginal culture, and revisited the roles of different alternatives to IVF in modern reproductive medicine from both clinical and research perspectives.
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Affiliation(s)
- Jennifer A Wessel
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development research institute, Amsterdam, the Netherlands
| | - Sarah Hunt
- Department of Obstetrics and Gynaecology, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Madelon van Wely
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development research institute, Amsterdam, the Netherlands
| | - Femke Mol
- Amsterdam UMC location University of Amsterdam, Department of Obstetrics and Gynecology, Amsterdam, the Netherlands; Amsterdam Reproduction and Development research institute, Amsterdam, the Netherlands
| | - Rui Wang
- Department of Obstetrics and Gynaecology, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia.
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Devine K, Dolitsky S, Ludwin I, Ludwin A. Modern assessment of the uterine cavity and fallopian tubes in the era of high-efficacy assisted reproductive technology. Fertil Steril 2022; 118:19-28. [PMID: 35725118 DOI: 10.1016/j.fertnstert.2022.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 11/28/2022]
Abstract
The high efficacy of modern assisted reproductive technology (ART) and increase in the number of noninfertile patients who are using ART for family building in the United States call into question the relevance of the standard, one-size-fits-all infertility evaluation. Here, we explore whether all patients presenting for ART need uterine cavity and tubal assessment and what tests are most appropriate, efficient, and cost-effective in current times.
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Affiliation(s)
- Kate Devine
- Division of Reproductive Endocrinology and Infertility, Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver NICHD, National Institutes of Health, Bethesda, Maryland; Shady Grove Fertility, Washington, D.C..
| | - Shelley Dolitsky
- Division of Reproductive Endocrinology and Infertility, Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver NICHD, National Institutes of Health, Bethesda, Maryland
| | - Inga Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland; Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - Artur Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland; Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
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6
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Rosielle K, Kamphuis D, van Welie N, Roest I, Mozes A, van Santbrink EJP, van de Laar T, Hooker AB, Huppelschoten AG, Li W, Bongers MY, Stoker J, van Wely M, Koks C, Lambalk CB, Hemingway A, Mol BWJ, Dreyer K, Mijatovic V. Oil-based versus water-based contrast media for hysterosalpingography in infertile women of advanced age, with ovulation disorders or a high risk for tubal pathology: study protocol of a randomized controlled trial (H2Oil2 study). BMC Womens Health 2022; 22:123. [PMID: 35436944 PMCID: PMC9016997 DOI: 10.1186/s12905-022-01707-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/07/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In women with unexplained infertility, tubal flushing with oil-based contrast during hysterosalpingography (HSG) increases ongoing pregnancy and subsequent live birth rates when compared to tubal flushing with water-based contrast. It is currently unclear whether an HSG with oil-based contrast also results in more ongoing pregnancies and live births in women of advanced age, women with ovulation disorders, and women with potential tubal pathology when compared to an HSG with water-based contrast. METHODS We plan an international, multicentre, open-label, randomized controlled trial (RCT) studying three groups of infertile women who have an indication for tubal patency testing according to their treating physician and additionally; (1) are 39 years of age or older, (2) have an ovulation disorder or (3) have a high risk for tubal pathology based on their medical history. Women with an allergy for iodinated contrast medium are excluded, as are women with diabetes, hyperprolactinemia or untreated hyper- or hypothyroidism, and women with a partner with severe male infertility. After informed consent, women will be randomly allocated to the intervention, tubal flushing with the use of oil-based contrast during HSG or the control group, tubal flushing with the use of water-based contrast during HSG in a 1:1 ratio by the web-based system Castor. The primary endpoint will be ongoing pregnancy leading to live birth with conception within six months after randomization. Secondary outcomes are other pregnancy outcomes, used fertility treatments, adverse events and cost-effectiveness. Based on the expected ongoing pregnancy rate of 17% in the control group and 27% in the intervention group, the sample size will be 930 women (465 per group). Study inclusion is expected to be complete in four years. DISCUSSION This multicentre RCT will establish whether, for women of advanced age, women with ovulatory disease, and women who have a high risk for tubal pathology, there is a fertility enhancing effect of tubal flushing with oil-based contrast during HSG and whether the use of this contrast medium is cost-effective. Trial Registration The study was prospectively registered in the Netherlands Trial Register on August 1st 2019 as 'H2Oil2' (reference number NL7925, https://www.trialregister.nl/trial/7925 ).
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Affiliation(s)
- K Rosielle
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands.
| | - D Kamphuis
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - N van Welie
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - I Roest
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
- Grow Research School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
- Department of Obstetrics and Gynaecology, Máxima MC, De Run 4600, 5504 DB, Veldhoven, Eindhoven, The Netherlands
| | - A Mozes
- Department of Obstetrics and Gynaecology, Ziekenhuis Amstelland, Laan van de Helende Meesters 8, 1186 AM, Amstelveen, The Netherlands
| | - E J P van Santbrink
- Department of Reproductive Medicine, Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, The Netherlands
| | - T van de Laar
- Department of Obstetrics and Gynaecology, Elkerliek Ziekenhuis, Wesselmanlaan 25, 5707 HA, Helmond, The Netherlands
| | - A B Hooker
- Department of Obstetrics and Gynaecology, Zaans Medisch Centrum, Koningin Julianaplein 58, 1502 DV, Zaandam, The Netherlands
| | - A G Huppelschoten
- Department of Obstetrics and Gynaecology, Catharina Ziekenhuis, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - W Li
- Department of Obstetrics and Gynaecology, Monash University, 246 Clayton Rd, Clayton, VIC, 3168, Australia
| | - M Y Bongers
- Grow Research School for Oncology and Reproduction, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
- Department of Obstetrics and Gynaecology, Máxima MC, De Run 4600, 5504 DB, Veldhoven, Eindhoven, The Netherlands
| | - J Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M van Wely
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
- Centre for Reproductive Medicine, Amsterdam Reproduction and Development, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C Koks
- Department of Obstetrics and Gynaecology, Máxima MC, De Run 4600, 5504 DB, Veldhoven, Eindhoven, The Netherlands
| | - C B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - A Hemingway
- Department of Radiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, DuCane Road, London, W12 0HS, England
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, 246 Clayton Rd, Clayton, VIC, 3168, Australia
| | - K Dreyer
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - V Mijatovic
- Department of Reproductive Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
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7
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Grigovich M, Kacharia VS, Bharwani N, Hemingway A, Mijatovic V, Rodgers SK. Evaluating Fallopian Tube Patency: What the Radiologist Needs to Know. Radiographics 2021; 41:1876-18961. [PMID: 34597232 DOI: 10.1148/rg.2021210033] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Impaired tubal patency accounts for up to 35% of cases of subfertility and infertility. Hysterosalpingography (HSG) or hysterosalpingo-contrast sonography (HyCoSy) represents a first-line test in evaluating fallopian tube patency. Despite the association of HSG with ionizing radiation, HSG is a reference standard in assessing fallopian tube patency and tubal conditions such as tubal occlusion, salpingitis isthmica nodosa, and hydrosalpinx. HSG is widely available and utilizes either a water-soluble contrast medium (WSCM) or an oil-soluble contrast medium (OSCM). Compared with WSCM, HSG with OSCM results in a higher incidence of non-in vitro fertilization pregnancies and, therefore, may be preferred in women younger than 38 years with unexplained subfertility. HSG may also be helpful in assessment after sterilization or before fallopian tube recanalization. US-based tubal tests are free of ionizing radiation and include HyCoSy, with either air-saline or microbubble US contrast material, and hysterosalpingo-foam sonography (HyFoSy), a tubal patency test that utilizes a gel foam. A comprehensive US infertility evaluation of the pelvis and fallopian tubes can be achieved in one setting by adding coronal three-dimensional imaging of the uterus, saline infusion sonohysterography, and HyCoSy or HyFoSy to routine pelvic US. MR HSG and virtual CT HSG also depict tubal patency and uterine and adnexal pathologic conditions and may be considered in select patients. While laparoscopic chromopertubation remains the standard for tubal patency evaluation, its disadvantages are its invasiveness and cost. Knowledge of the different fallopian tube tests and radiologic appearance of normal and abnormal fallopian tubes results in fewer pitfalls, accurate interpretation, and optimal patient care. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Maria Grigovich
- From the Department of Diagnostic Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141-3098 (M.G., V.S.K., S.K.R.); Department of Radiology, Imperial College Healthcare NHS Trust, London, England (N.B., A.H.); and Endometriosis Center, Amsterdam, University Medical Center, Amsterdam, the Netherlands (V.M.)
| | - Vidhi S Kacharia
- From the Department of Diagnostic Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141-3098 (M.G., V.S.K., S.K.R.); Department of Radiology, Imperial College Healthcare NHS Trust, London, England (N.B., A.H.); and Endometriosis Center, Amsterdam, University Medical Center, Amsterdam, the Netherlands (V.M.)
| | - Nishat Bharwani
- From the Department of Diagnostic Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141-3098 (M.G., V.S.K., S.K.R.); Department of Radiology, Imperial College Healthcare NHS Trust, London, England (N.B., A.H.); and Endometriosis Center, Amsterdam, University Medical Center, Amsterdam, the Netherlands (V.M.)
| | - Anne Hemingway
- From the Department of Diagnostic Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141-3098 (M.G., V.S.K., S.K.R.); Department of Radiology, Imperial College Healthcare NHS Trust, London, England (N.B., A.H.); and Endometriosis Center, Amsterdam, University Medical Center, Amsterdam, the Netherlands (V.M.)
| | - Velja Mijatovic
- From the Department of Diagnostic Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141-3098 (M.G., V.S.K., S.K.R.); Department of Radiology, Imperial College Healthcare NHS Trust, London, England (N.B., A.H.); and Endometriosis Center, Amsterdam, University Medical Center, Amsterdam, the Netherlands (V.M.)
| | - Shuchi K Rodgers
- From the Department of Diagnostic Radiology, Einstein Healthcare Network, 5501 Old York Rd, Philadelphia, PA 19141-3098 (M.G., V.S.K., S.K.R.); Department of Radiology, Imperial College Healthcare NHS Trust, London, England (N.B., A.H.); and Endometriosis Center, Amsterdam, University Medical Center, Amsterdam, the Netherlands (V.M.)
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8
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Pham C, Torre A, Mol B. Cost-effectiveness modelling of three different hysterosalpingography diagnostic strategies in addition to standard fertility management for couples with unexplained infertility in the United Kingdom. HUM FERTIL 2021:1-10. [PMID: 34348064 DOI: 10.1080/14647273.2021.1960435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Previous studies have demonstrated hysterosalpingography (HSG) in general, and specifically with an oil-soluble contrast medium, directly increases pregnancy rates. Decision modelling was performed to compare fertility management using three HSG diagnostic strategies: (i) water-soluble contrast medium (WSCM)-HSG; (ii) Lipiodol® Ultra Fluid (LUF)-HSG; and (iii) No HSG, for women aged ≤39 years with unexplained infertility. Four reimbursement scenarios were modelled to reflect the various funding arrangements across the regions of the United Kingdom. Compared with WSCM-HSG, the live birth rates after 24 months increased by 3.4% with LUF-HSG and decreased by 2.7% with no HSG. From a patient perspective, fertility management with LUF-HSG is the most cost-effective strategy with cost-savings ranging from £299 to £857 per patient depending on the funding arrangement for IVF. From an NHS perspective, fertility management with LUF-HSG is cost-effective when 2 or more IVF cycles are NHS-funded. If none of the IVF cycles are NHS-funded, fertility management with LUF-HSG can be considered cost-effective if society is willing to pay £8,353 for an additional live birth. The findings from this analysis suggest that fertility management with WSCM-HSG is cost-effective compared to no HSG and LUF-HSG is the most cost-effective with increased live birth rates after 24 months.
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Affiliation(s)
- Clarabelle Pham
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, Australia
| | - Antoine Torre
- Department of Obstetrics and Gynaecology, University of Nottingham, Nottingham, United Kingdom
| | - Ben Mol
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Monash Health and Monash University, Melbourne, Australia.,Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, United Kingdom
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