Evaluation of active and passive transport mechanisms in genital tracts of IUD-bearing women with radionuclide hysterosalpingoscintigraphy

Systematic Review of Postfertilization Effects and Potential for Embryo Formation and Loss during the Use of Intrauterine Devices

Objectives

This review sought to evaluate the evidence for embryo formation during intrauterine device (IUD) use, to articulate how often embryo loss occurs in well-designed studies, and to comment on other bodies of literature suggestive of postfertilization mechanisms of action of IUDs.

Methods

The MEDLINE, EMBASE, and Ovid databases were searched for English-language studies of markers of pregnancy in IUD users in May 2018. Studies of human chorionic gonadotropin (hCG) were subjected to quality assessment based on the US Preventive Services Task Force quality tool. Bias of studies assessing pregnancy in other ways was assessed on a study-to-study basis.

Results

In all, 1,073 studies were identified and 138 were read in detail. Twenty-three studies of β-hCG, 4 studies of direct observation of embryos in fallopian tubes, 2 studies of pregnancy-specific binding globulin (PSBG), and 1 study of heat-shock protein 10 (Hsp10) or chaperonin 10 were included. In all studies considered together, 7.3 percent of IUD users had evidence of fertilization and pregnancy failure. In good-quality studies, 4.5 percent had evidence of fertilization and pregnancy failure.

Discussion

There are no randomized trials of embryo formation and loss in IUD users compared with noncontracepting controls. Studies of β-hCG span a large spectrum of quality, but several good-quality studies exist, which support embryo formation and loss in IUD users. Evidence of embryos found in tubes is moderate and evidence of PSBG and Hsp10 elaboration was limited, but these are also concerning for embryo formation and loss.

Conclusion

There is good-quality evidence of embryo formation and loss in IUD users. Studies are inconsistent, and the stated conclusions of several papers inaccurately diminish postfertilization evidence of embryo formation. To better assess the rate of embryo loss in IUD users compared with non-users, future research should include well-designed prospective trials and less subjective assessments of embryos in fallopian tubes.

Summary

A systematic review was carried out examining the English-language literature in the MEDLINE, EMBASE, and Ovid databases for evidence of embryo formation and loss during IUD use. In all, 1,073 studies were identified and 138 were read. There are no randomized trials and evidence ranges in quality, but evidence for the embryo formation and loss in 4.5 percent of IUD users exists in good-quality research. Further research is needed to compare embryo loss in IUD users to loss in controls.

Novel approach for quality assessment and improving diagnostic accuracy in cell-based infection imaging using 99mTc-HMPAO labeled leukocytes

Background and aim: Labeled leukocytes with ^99mTc-HMPAO are routinely used for infection imaging. Although cell labeling with ^99mTc-HMPAO represents an imaging probe to detect infection sites, the diagnostic efficiency of the probe is largely influenced by cell manipulation, multidisciplinary interventions (i.e., biologist, technicians) and available technology (i.e., SPECT, SPECT/CT). The aim of the study was to assess in vitro and in vivo accuracy of a comprehensive approach for quality assessment (QA) of all steps of the procedure. Methods: Radiochemical purity (RCP), pH, labeling efficiency (LE) were measured in 320 procedures. White Cell Viability Factor (WVF) was determined in consecutive blood samples. Images (490 studies) were scored using a 5-point scale. Training program was evaluated using a Learning Questionnaire and a score system. Results: Pre/post-labelling WVF was 0.99% (max value 1%) in all blood samples. LE (mean value 72%) and RCP (>80% until 55 minutes) yielded considerably high values. The vast majority of images were scored as diagnostic by three independent observer (90% with score ≥4). Conclusions: This method appears highly reproducible and easy to use in clinical routine for leukocyte labeling, especially when standardized training and total QA system are implemented. (www.actabiomedica.it)

Chlamydia trachomatis, a hidden epidemic: effects on female reproduction and options for treatment

The number of genital tract Chlamydia trachomatis infections is steadily increasing worldwide, with approximately 50-70% of infections asymptomatic. There is currently no uniform screening practice, current antibiotic treatment has failed to prevent the increased incidence, and there is no vaccine available. We examined studies on the epidemiology of C. trachomatis infections, the effects infections have on the female reproductive tract and subsequent reproductive health and what measures are being taken to reduce these problems. Undetected or multiple infections in women can lead to the development of severe reproductive sequelae, including pelvic inflammatory disease and tubal infertility. There are two possible paradigms of chlamydial pathogenesis, the cellular and immunological paradigms. While many vaccine candidates are being extensively tested in animal models, they are still years from clinical trials. With no vaccine available and antibiotic treatment unable to halt the increased incidence, infection rates will continue to increase and cause a significant burden on health care systems.

Decreased endometrial HOXA10 expression associated with use of the copper intrauterine device

OBJECTIVE

To characterize human endometrial HOXA10 expression in patients using a copper intrauterine device (IUD).

DESIGN

Case-control study.

SETTING

Academic medical center.

PATIENT(S)

Women using copper IUDs.

INTERVENTION(S)

Immunohistochemical analysis of endometrial HOXA10 expression in biopsy samples obtained from 24 women using a copper Paraguard T380A as well as in samples obtained from 10 normal cycling women who were not using an IUD or hormonal contraceptives.

MAIN OUTCOME MEASURE(S)

Endometrial HOXA10 expression.

RESULT(S)

Endometrial HOXA10 expression was markedly decreased in the biopsy samples obtained from women using the IUD contraceptive when compared with controls. The mean H score for endometrial stromal cell HOXA10 expression in samples obtained from women using the Paraguard IUD was 0.21 compared with 2.2 in the control endometrial biopsy samples. Endometrial glandular expression of HOXA10 was absent in all IUD users.

CONCLUSION(S)

Decreased endometrial HOXA10 expression was apparent in women who use a copper IUD. Expression of HOXA10 is essential for endometrial receptivity. A novel mechanism of copper IUD action involves suppression of genes required for endometrial receptivity. The dramatic decrease of endometrial HOXA10 in response to IUD use may contribute to contraceptive efficacy.

Intrauterine devices and uterine peristalsis: evaluation with MRI

Intrauterine devices (IUDs) have been viewed as an effective form of contraception. However, the mechanism by which IUDs disturb fertility remains controversial. This study aimed to evaluate the effects of IUDs on uterine contractility using cine MR. Eleven healthy female volunteers of reproductive age bearing IUDs and 12 women not bearing IUDs were evaluated during the periovulatory phase. MR images were obtained with a 1.5-T magnet, acquiring 60 serial images every 3 s via half-Fourier acquisition single-shot turbo spin echo to be displayed on cine mode. Assessments were based on (a) the presence of peristaltic waves, (b) the frequency and direction of peristaltic waves and (c) the extent of peristaltic waves. Static images were evaluated for thickness of the junctional zone (JZ) and myometrium. A fundo-cervical (FC)-directed peristaltic wave was identified in 4 of 11 IUD-bearing subjects and in only 1 of 12 subjects from the control group. FC waves extended through more than half of the thickness of the myometrium. Peristaltic frequency in IUD users (5.0/3 min) was less than that of the control group (6.5/3 min). The JZ and myometrium were significantly thicker in IUD users. FC-directed waves were more often observed in IUD-bearing subjects, which might explain the inhibition of active sperm transport.

Labeling of autologous monocytes with 99mTc-HMPAO at very high specific radioactivity

Rheumatoid arthritis of joints involves the accumulation of monocyte-derived macrophages in the affected synovial tissue. This process of cell migration can be portrayed scintigraphically in order to monitor noninvasive effects of therapy on the progress of the disease. Scintigraphic detection of inflammation by means of technetium 99m-hexamethylpropylene amine oxime (99mTc-HMPAO)-labeled leukocytes provides a classic example. Present state-of-the-art methods in cell biology allow the isolation of cells like lymphocytes or monocytes, which are less abundant than main blood constituents but, instead, harbor particular functions like specific homing properties. To facilitate scintigraphic imaging of the cell functions involved, the relatively small population of cells must be labeled to radioactive yields as high as possible. We demonstrate that autologous monocytes isolated from 100 ml of peripheral blood can be radiolabeled to a yield of 10 (instead of 1) Bq per cell, allowing scintigraphic analysis of rheumatoid arthritis up to 20 h post injection of patients. The method is based on the instantaneous distribution of lipophilic 99mTc-HMPAO between the hydrophobic inside of cells and the hydrophilic (aqueous) surrounding of cells, followed by decomposition of the radiopharmaceutical into compounds that are unable to cross the cellular membrane. The procedure provides a method of choice for cell-mediated scintigraphy at low availability of cells with the correct homing properties.

Functional MR imaging of the female pelvis

Recent developments in MR techniques have magnified the roles and potential of MRI in the female pelvis. This article reviews the techniques and clinical applications of functional MRI (fMRI) of the female pelvis, including cine MRI, diffusion-weighted MRI (DWI), and dynamic contrast-enhanced (DCE)-MRI. Cine MRI is a useful tool for evaluating uterine contractility, including sustained contraction and peristalsis, in a variety of conditions and gynecologic disorders, and for evaluating pelvic-floor weakness. DWI can demonstrate abnormal signals in pathologic foci based on differences in molecular diffusion. It also enables the quantitative evaluation of the apparent diffusion coefficient (ADC), which may be useful for distinguishing malignant from benign tissues and monitoring therapeutic outcome. DCE-MRI has the potential to improve tumor detection and local staging, and can also provide quantitative information about perfusion of the tumor, which may be useful for both monitoring therapeutic effects and predicting therapeutic outcome. Understanding the roles played by functional MR techniques in the female pelvic region is beneficial not only for determining clinical applications, but also for developing further investigations with MRI.

Uterine Contractility Evaluated on Cine Magnetic Resonance Imaging

The inherent contractility of the uterus has attracted concern of researchers and exhibits two known patterns of contraction. One is focal and sporadic bulging of the myometrium, and the other is rhythmic and subtle stripping movement in the subendometrial myometrium, known as uterine peristalsis. Recent development in the ultrafast magnetic resonance imaging (MRI) techniques has enabled us to observe these uterine contractions directly and noninvasively. Although the mechanisms and relationship of these two kinds of myometrial contractions and their relations to age, pharmaceutical administration such as oral contraceptives (OCs), and a variety of gynecologic and obstetrical problems are still under debate, cine MRI can be applied for directly monitoring changes of the uterus related to important uterine functions such as fertility and menstrual problems.

Uterine contractility and directed sperm transport assessed by hysterosalpingoscintigraphy (HSSG) and intrauterine pressure (IUP) measurement

BACKGROUND

Uterine peristalsis sustains sperm transport and can be detected by hysterosalpingoscintigraphy (HSSG). This study is the first to be designed to investigate utero-tubal transport function by HSSG and uterine contractility by intrauterine pressure measurement (IUP) consecutively on the same day in the periovulatory phase.

METHODS

Twenty-one female subjects (mean age 28.4 years) without a gynecologic history were examined sequentially by HSSG and IUP on the same day to evaluate uterine contractility in relation to the utero-tubal transport function. In HSSG, intact transport function was visualized by the rapid uptake of 99m-technetium-marked albumin aggregates through the female genital tract. In IUP, the frequency of uterine contractions (UC/min), amplitude of uterine contractions and basal pressure tone were detected via a intrauterine catheter. HSSG and IUP were embedded in cycle monitoring with measurement of LH and estradiol.

RESULTS

In HSSG, a positive transport of inert particles was assessed in 20 of 21 subjects, in 76% to the side of the dominant follicle or on both sides of the oviduct, and in 19% a strict contralateral transport could be observed. In only one subject (5%), no transport was assessed. The mean value of uterine contractions was 3.4 UC/min (SD +/- 0.7), the mean amplitude was 12.0 mmHg (SD +/- 4.25 mmHg). Basal pressure tone was 70.7 mmHg. There was a statistically significant correlation with estradiol levels: none of the subjects with less than 3 UC/min showed an estradiol level higher than 100 pg/mL; nearly every patient (one exception) with more than 3 UC/min had an estradiol level higher than 100 pg/mL (p < 0.0001, Fisher's exact test).

CONCLUSIONS

Intact periovulatory utero-tubal transport function can be documented by HSSG and is caused by directed uterine contractility, measured consecutively by IUP. Uterine contractility is influenced by rising estradiol levels. Directed uterine contractility and intact utero-tubal transport function are considered necessary for intact sperm transport, mainly to the side bearing the dominant follicle to maximize fertility.

Determination of velocity of tubar transport with dynamic hysterosalpingoscintigraphy

Transport of 99mTc labelled albumin macroaggregates (MAA) can be used as a substitute for assessing transport of spermatozoa within the female genital tract. As yet, the velocity of tubar MAA transport has not been systematically studied in a large group. Dynamic hysterosalpingoscintigraphy (HSS) was performed after intrauterine instillation of 10-20 MBq 99mTc-MAA in 88 pre-ovulatory women suffering from infertility. They had to have anatomical patency of both tubes and at least one enlarged follicle. The direction and the latency of transport were evaluated. Forty-four per cent of patients exhibited MAA transport only to the dominant follicle, 31% to both ovaries and 16% to the contralateral ovary. In 9% no transport was visible. Fifty per cent of all patients studied exhibited MAA transport to the dominant follicle within 30 s, 75% within 20 min. Transport velocity in women having bilateral or ipsilateral transport did not differ significantly. There was no significant correlation between the size of the follicle and transport velocity. We conclude that in the majority of cases MAA transport occurs within 30 s after instillation. The variation in transport time between 30 s and 20 min suggests that dynamic scintigraphy is, in principle, better suited to a refined analysis of tubar function than static HSS.

[Degradation of copper IUDs in utero. The process of metallic corrosion. A scanning electron microscope study]

OBJECTIVE

The present investigation was carried out in order to study the process of metallic corrosion of copper IUD's in utero, to precise its dynamics and location along the IUD and to appraise the influence of eventual calcareous deposition.

MATERIAL AND METHODS

A total of 461 copper IUDs representing four standard models were screened by means of optical microscopy. Especially typical samples were studied at higher magnifications under the scanning electron microscope. The obtained data were considered in terms of statistics.

RESULTS

It was possible to demonstrate a preferential corrosive activity in the lower part of the IUD without significant variations between the models. It was also possible to precise the steps of the process, to describe its most characteristic aspects and to study the eventual effect of severe calcareous deposition on corroded copper.

DISCUSSION AND CONCLUSIONS

Intrauterine copper corrosion is a normal process which occurs preferentially in the cervical portion of an IUD and can lead to the total metal loss. Both its initiation and evolution are submitted to strong individual variations. Thick and compact vaterite deposits may thwart copper erosion in case of drastic and rapid deposition.