The impact of hydrosalpinx on successful pregnancy in tubal factor infertility treated by in vitro fertilization

Study on diagnosis and management strategies on heterotopic pregnancy: a retrospective study

Heterotopic pregnancy (HP) is a rare but potentially life-threatening event with a high risk of maternal death, which also jeopardise the coexisting intrauterine pregnancy (IUP), thus an early accurate diagnosis and prompt treatment can decrease adverse complications. We aimed to explore the early predictors for pregnancy outcomes of HP. We reviewed patients with HP following assisted reproductive technology in our institution between January 2013 and December 2020. The relationships between pregnancy outcomes and clinical features were analysed by logistic regression. We found that 29 patients (72.5%) of HP were accurately diagnosed by transvaginal ultrasonography (TVS). Eighteen patients in the surgery group had live births, three of whom delivered preterm. Additionally, the miscarriage rate was lower for patients with IUP cardiac activity than those without (16.7% vs. 90.0%, p < .001). Further by logistic regression analysis, an IUP with cardiac activity at HP diagnosis was identified as favourable independent predictor of live birth (p < .001). Therefore, early diagnosis and prompt surgical intervention are recommended to prevent the development of HP.Impact of statementWhat is already known on this subject? Heterotopic pregnancy (HP) has long been thought to be a rare but potentially life-threatening event with a high risk of complications. The early diagnosis of HP is challenging due to the co-existence of a viable intrauterine pregnancy (IUP) and the absence of typical clinical symptoms.What do the results of this study add? This stduy showed that symptoms combined with routine transvaginal ultrasonography (TVS) scans reduce the rates of misdiagnosis of HP and prompt surgical intervention after diagnosis may minimise the incidence of miscarriage of the IUP.What are the implications of these findings for clinical practice and/or further research? An IUP with cardiac activity at HP diagnosis is a predictor of a favourable prognosis of HP, and laparoscopy under general anaesthesia is effective and safe during the first trimester of pregnancy. Awareness, assessment and early interventions in view of symptoms combined with routine TVS is recommended to reduce the risk of miscarriage and ensure a favourable live birth rate.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Is There Still a Place for Reconstructive Surgery in Distal Tubal Disease?

Tubal diseases account for 25–40% of female factor infertility. Mainly, they involve the distal part of the fallopian tube, and hydrosalpinx is the most severe manifestation. Usually, the management decision is made between reconstructive surgery and ART, depending on the severity of the tubal damage, patient age, ovarian reserve, and seminogram, as well as financial, religious, ethical, and psychological factors. Estimated live-birth rates after corrective surgery range from 9% to 69%. The success rate of IVF is about 30% live-birth rate per cycle initiated in women across all ages with tubal factor infertility. Surgery offers a long-term cure and patients may attempt conception many times but are burdened with perioperative adverse events. IVF bypasses potential complications of operative treatment; however, this has its own unique risks. The effectiveness of reconstructive surgery versus ART has not been adequately evaluated. The success of fertility management depends on a thorough interpretation of existing data and careful patient selection. The presented review provides updates on the most recent progress in this area.

Role of ultrasonographic parameters for predicting tubal involvement in infertile patients affected by endometriosis: A retrospective cohort study

INTRODUCTION

Transvaginal ultrasound is fundamental for the mapping of endometriosis, and the imaging criteria have been clearly described for different organs study. However, no specific ultrasonographic signs of tubal endometriosis have been reported, with the exception of hydrosalpinx, which is the expression of an extreme tubal damage and obstruction. The detection of tubal pathology in infertile patients is fundamental, therefore the aim of the study was to evaluate incidence of tubal endometriosis in infertile patients, and to analyze ultrasonographic signs useful for detection of this condition.

MATERIAL AND METHODS

It is a single-center, retrospective cohort study. All 500 consecutive infertile women who underwent laparoscopic surgery for endometriosis were included. The preoperative workup included transvaginal ultrasound and was compared to intraoperative findings and histologic study.

RESULTS

The incidence of tubal endometriosis in our study was 8%. Using hydrosalpinx as the ultrasonographic marker for tubal involvement the overall pooled, sensitivity and specificity of TVU were 12% (95%CI, 5-23%) and 99% (95%CI, 98-100%), respectively. If at least one ultrasonographic parameter like hydrosalpinx, periadnexal adhesions or ovarian cyst was considered as a sign of tubal endometriosis, a sensitivity, VPN and specificity were 94% (95% IC, 85-98%), 97% (95%IC, 93-99%) and 31% (95%CI, 27-36%), respectively.

DISCUSSION

Hydrosalpinx as ultrasonographic sign alone is characterized by a high specificity but low sensitivity for detection of tubal endometriosis; its sensitivity can be improved by the addition of other markers such as endometrioma and/or periadnexal adhesions.

Management strategies of heterotopic pregnancy following in vitro fertilization-embryo transfer

OBJECTIVE

The purpose of this study was to evaluate the efficiency and safety of different treatment modalities for heterotopic pregnancy (HP) in vitro fertilization-embryo transfer (IVF-ET) cycles to avoid influence on intrauterine pregnancy (IUP).

MATERIALS AND METHODS

Cases of HP (n = 90) were from the IVF/ICSI registry database at the Reproductive Hospital Affiliated to Shandong University. An additional 360 women were randomly selected as controls. The primary outcome to examine the risk factors, diagnostic modalities and the impact of different treatment modalities for HP.

RESULTS

Our results showed that surgical treatment had a certain effect on improving the live-birth rate, although the effect was not statistically significant (87.9% vs. 70.8%, P = 0.055). The risk factors for HP included previous tubal surgery and hydrosalpinx. Fourteen days after embryo transfer, the serum levels of β-human chorionic gonadotropin (β-hCG) and estradiol (E2) were lower in the HP group than in the IUP group (P < 0.05). Furthermore, age and endometrial thickness showed a significant difference between the early abortion and the live-birth groups of HP.

CONCLUSIONS

In our retrospective study, we supported early surgical laparoscopic intervention to minimize the incidence of abortion of IUP, which resulted in a better live-birth rate. A history of ectopic pregnancy and previous tubal surgery may increase the risk of HP. Low levels of serum β-hCG and E2 on the 14th day after embryo transfer could indicate the incidence of HP.

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.

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.

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgical treatment for hydrosalpinx prior to in-vitro fertilization embryo transfer: a network meta-analysis

OBJECTIVE

The presence of hydrosalpinx impairs the outcome of in-vitro fertilization embryo transfer (IVF-ET). Surgical methods to either aspirate the fluid or isolate the affected Fallopian tubes have been attempted as a means of improving outcome. The aim of this network meta-analysis was to compare the effectiveness of surgical treatments for hydrosalpinx before IVF-ET.

METHODS

An electronic search of MEDLINE, Scopus, Cochrane Central Register of Controlled Trials (Central) and the US Registry of clinical trials for articles published from inception to July 2015 was performed. Eligibility criteria included randomized controlled trials of women with hydrosalpinx before IVF-ET comparing ultrasound-guided aspiration of the fluid, tubal occlusion, salpingectomy or no intervention. Ongoing pregnancy was the primary outcome and clinical pregnancy, ectopic pregnancy and miscarriage were secondary outcomes. A random-effects network meta-analysis synthesizing direct and indirect evidence from the included trials was carried out. We estimated the relative effect sizes as risk ratios (RRs) and obtained the relative ranking of the interventions using cumulative ranking curves. The quality of evidence according to GRADE guidelines, adapted for network meta-analysis, was assessed.

RESULTS

Proximal tubal occlusion (RR, 3.22 (95% CI, 1.27-8.14)) and salpingectomy (RR, 2.24 (95% CI, 1.27-3.95)) for treatment of hydrosalpinx were superior to no intervention for ongoing pregnancy. For an outcome of clinical pregnancy, all three interventions appeared to be superior to no intervention. No superiority could be ascertained between the three surgical methods for any of the outcomes. In terms of relative ranking, tubal occlusion was the best surgical treatment followed by salpingectomy for ongoing and clinical pregnancy rates. No significant statistical inconsistency was detected; however, the point estimates for some inconsistency factors and their CIs were relatively large. The small study number and sizes were the main limitations. The quality of evidence was commonly low/very low, especially when aspiration was involved, indicating that the results were not conclusive and should be interpreted with caution.

CONCLUSIONS

Proximal tubal occlusion, salpingectomy and aspiration for treatment of hydrosalpinx scored consistently better than did no intervention for the outcome of IVF-ET. In terms of relative ranking, proximal tubal occlusion appeared to be the most effective intervention, followed by salpingectomy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Risk Factors and Early Predictors for Heterotopic Pregnancy after In Vitro Fertilization

This study investigated the risk factors and early predictors for heterotopic pregnancy (HP) after in vitro fertilization and embryo transfer (IVF-ET). From January 2008 to January 2013, 41 cases of HP and 72 cases of intrauterine twin pregnancy after IVF-ET were recruited and retrospectively analyzed. Compared with intrauterine twin pregnancy group, the HP group had a lower basal luteinizing hormone (LH) level (P = 0.005) and more cases had a history of hydrosalpinx (P = 0.008). After 14 days of IVF-ET, the serum β-HCG (β-human chorionic gonadotropin), E2 (Estradiol) and P (Progesterone) levels were lower in HP group (P<0.001, respectively). Moreover, vaginal bleeding and abdominal pain were the significant features of HP before diagnosis (P<0.001, respectively). Further by logistic regression, serum β-hCG, P levels on the 14th day after ET, and vaginal bleeding were identified as the independent factors of HP. These results indicate that when two or more embryos transferred in IVF procedure, β-hCG, P levels on the 14th day after ET, and vaginal bleeding could be taken as predictors for HP.

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

STUDY QUESTION

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

SUMMARY ANSWER

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

WHAT IS KNOWN ALREADY

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

STUDY DESIGN, SIZE, DURATION

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

PARTICIPANTS/MATERIALS, SETTING, METHODS

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

MAIN RESULTS AND THE ROLE OF CHANCE

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

LIMITATIONS, REASONS FOR CAUTION

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

WIDER IMPLICATIONS OF THE FINDINGS

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

STUDY FUNDING/COMPETING INTERESTS

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

TRIAL REGISTRATION NUMBER

N/A.

State-mandated insurance coverage is associated with the approach to hydrosalpinges before IVF

The aim of this study was to determine whether practice in states with infertility insurance mandates is associated with physician-reported practice patterns regarding hydrosalpinx management in assisted reproduction clinics. A cross-sectional, internet-based survey of 442 members of Society for Reproductive Endocrinology and Infertility or Society of Reproductive Surgeons was performed. Physicians practising in states without infertility insurance mandates were more likely to report performing diagnostic surgery after an inconclusive hysterosalpingogram than physicians practising in states with mandates (RR 1.2, 95% CI 1.1-1.3, P < 0.01). Additionally, respondents in states without mandates were more likely to report that, due to lack of infertility insurance coverage, they did not perform salpingectomy (SPX) or proximal tubal occlusion (PTO) before assisted reproduction treatment (RR 1.4, 95% CI 1.1-1.8, P = 0.01). Finally, respondents in states without mandates were less likely to report that the presence of assisted reproduction treatment coverage determined the urgency with which they pursued SPX or PTO before treatment (RR 0.7, 95% CI 0.5-1.0, NS). These results persisted after controlling for physician years in practice, age and clinic volume. In conclusion, self-reported physician practice interventions for hydrosalpinges before assisted reproduction treatment may be associated with state-mandated infertility insurance. Fallopian tube dysfunction is a known cause of infertility and severe dysfunction is manifested by dilation and occlusion, known as hydrosalpinx. Outcomes with assisted reproductive techniques (ART) are lower when hydrosalpinges are present and while there are several theories for this, reproductive specialist recommend "neutralizing" the tube either by occlusion or removal in order to enhance pregnancy rates. In the United States, coverage for infertility services is not uniform with only 15 states having some legislation requiring infertility benefits. Some states where ART is covered liberally, physicians might have different practice patterns related to the neutralization of hydrosalpinges compared to those who are in non -mandated states. We utilized a survey of over 400 providers in the United States to examine their practice patterns as it relates to hydrosalpinges based on which state they practice in and whether or not that state has mandated coverage of not.

Development status and future prospects for a vaccine against Chlamydia trachomatis infection

Chlamydia trachomatis continues to be the most commonly reported sexually transmitted bacterial infection in many countries with more than 100 million new cases estimated annually. These acute infections translate into significant downstream health care costs, particularly for women, where complications can include pelvic inflammatory disease and other disease sequelae such as tubal factor infertility. Despite years of research, the immunological mechanisms responsible for protective immunity versus immunopathology are still not well understood, although it is widely accepted that T cell driven IFN-g and Th17 responses are critical for clearing infection. While antibodies are able to neutralize infections in vitro, alone they are not protective, indicating that any successful vaccine will need to elicit both arms of the immune response. In recent years, there has been an expansion in the number and types of antigens that have been evaluated as vaccines, and combined with the new array of mucosal adjuvants, this aspect of chlamydial vaccinology is showing promise. Most recently, the opportunities to develop successful vaccines have been given a significant boost with the development of a genetic transformation system for Chlamydia, as well as the identification of the key role of the chlamydial plasmid in virulence. While still remaining a major challenge, the development of a successful C. trachomatis vaccine is starting to look more likely.

Comparison of IVF-ET outcomes in patients with hydrosalpinx pretreated with either sclerotherapy or laparoscopic salpingectomy

Objective

Many studies have demonstrated that hydrosalpinx has a detrimental effect on the outcome of IVF. Treating hydrosalpinges prior to the IVF procedure in women with hydrosalpinges is thought to improve the likelihood of successful IVF outcome. Vaginal ultrasound-guided aspiration of hydrosalpinx fluid (HSF) with injection of the sclerosing agent in situ might be simpler than invasive procedures like salpingectomy. Therefore, we carried out a retrospective study on the effects of ultrasound-guided HSF aspiration and injection of the sclerosing agent of ultrasonically diagnosed hydrosalpinx on IVF outcome.

Methods

In our retrospective study, 97 tubal factor infertile female patients that underwent IVF treatment between January 2005 and December 2012 at the Reproductive Medicine Center of CHA Hospital were divided into two study groups. Fifty-six patients underwent interventional ultrasound sclerotherapy (group 1), and the remaining 41 patients received laparoscopic salpingectomy (group 2) before IVF. We compared the IVF outcomes of the two groups.

Results

The results showed that ultrasound-guided HSF aspiration and sclerotherapy have IVF outcomes comparable to laparoscopic salpingectomy.

Conclusion

Interventional ultrasound guided sclerotherapy before IVF is an effective and less invasive prophylactic intervention alternative to salpingectomy with hydrosalpinx.

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

OBJECTIVE

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

DESIGN

Cross-sectional survey of SREI/SRS members.

SETTING

Academic and private practice-based reproductive medicine physicians.

PARTICIPANT(S)

A total of 442 SREI and/or SRS members.

INTERVENTION(S)

Internet-based survey.

MAIN OUTCOME MEASURE(S)

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

RESULT(S)

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

CONCLUSION(S)

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

Implantation failure: molecular mechanisms and clinical treatment

BACKGROUND

Implantation is a complex initial step in the establishment of a successful pregnancy. Although embryo quality is an important determinant of implantation, temporally coordinated differentiation of endometrial cells to attain uterine receptivity and a synchronized dialog between maternal and embryonic tissues are crucial. The exact mechanism of implantation failure is still poorly understood.

METHODS

This review summarizes the current knowledge about the proposed mechanisms of implantation failure in gynecological diseases, the evaluation of endometrial receptivity and the treatment methods to improve implantation.

RESULTS

The absence or suppression of molecules essential for endometrial receptivity results in decreased implantation rates in animal models and gynecological diseases, including endometriosis, hydrosalpinx, leiomyoma and polycystic ovarian syndrome. The mechanisms are diverse and include abnormal cytokine and hormonal signaling as well as epigenetic alterations.

CONCLUSIONS

Optimizing endometrial receptivity in fertility treatment will improve success rates. Evaluation of implantation markers may help to predict pregnancy outcome and detect occult implantation deficiency. Treating the underlying gynecological disease with medical or surgical interventions is the optimal current therapy. Manipulating the expression of key endometrial genes with gene or stem cell-based therapies may some day be used to further improve implantation rates.

A prospective clinical study of interventional ultrasound sclerotherapy on women with hydrosalpinx before in vitro fertilization and embryo transfer

In this prospective clinical study, ultrasound-guided transvaginal aspiration and sclerotherapy with 98% ethanol was performed before the IVF cycle in 33 patients with hydrosalpinx. The results showed that ultrasound aspiration and sclerotherapy could improve the endometrial receptivity and outcomes of IVF, with no recurring sign of the hydrosalpinx and no adverse effect on ovarian reserve or responsiveness during the IVF procedure.

Laparoscopic proximal tubal division can preserve ovarian reserve for infertility patients with hydrosalpinges

AIM

To investigate whether laparoscopic proximal tubal division for the treatment of hydrosalpinges could preserve ovarian function.

METHODS

From June 2002 to October 2006, before assisted reproductive treatment (ART), a total of 17 infertile patients with bilateral hydrosalpinges were studied--11 patients underwent laparoscopic proximal tubal division (PTD group), and six underwent laparoscopic salpingectomy (salpingectomy group). In both groups, the basal follicle-stimulating hormone (FSH) values before and after surgery, the operation time and outcome of ART treatment were retrospectively evaluated.

RESULTS

The mean FSH value before laparoscopic PTD was similar to that after surgery. The FSH value before laparoscopic salpingectomy significantly increased after surgery (6.8 +/- 1.1 vs 14.1 +/- 9.3). The operation time in the PTD group was significantly shorter than in the salpingectomy group. The outcomes of ART were similar in both groups. The pregnancy rate per patient in the PTD and salpingectomy groups were 45.5% and 50%, respectively.

CONCLUSIONS

Laparoscopic proximal tubal division preserved ovarian function and was an optimal operation method for infertility patients with hydrosalpinges. The basal FSH values after laparoscopic proximal tubal division were comparable to those before surgery.

Involvement of cystic fibrosis transmembrane conductance regulator (CFTR) in the pathogenesis of hydrosalpinx induced by Chlamydia trachomatis infection

BACKGROUND

Genital Chlamydia (C) trachomatis infection has been recognized as the single most common cause of pelvic inflammatory disease leading to severe tubal damage, ectopic pregnancy, infertility and hydrosalpinx. However, the mechanism underlying the formation of hydrosalpinx induced by C. trachomatis infection remains largely unknown. We performed this study to determine the involvement of cystic fibrosis transmembrane conductance regulator (CFTR), a cAMP-activated chloride channel that regulates epithelial electrolyte and fluid secretion, in hydrosalpinx fluid formation.

METHODS

Western blot analysis was used to determine CFTR expression in the hydrosalpinges that were seen on the ultrasound scans of infertile assisted reproduction treatment patients. Correlation with C. trachomatis infection was done by testing patients' sera for C. trachomatis immunoglobulin G antibody titer using a Capita enzyme-linked immunosorbent assay based kit. CFTR involvement was further verified in a rat C. trachomatis infection model and confirmed using CFTR mutant (CFTR(tm1Unc)) mice.

RESULTS

Here we report on the up-regulated expression of CFTR in the hydrosalpinx tissues of infertile patients with detectable serum levels of C. trachomatis antibody (immunoglobulin G). In a rat model, increased CFTR expression and fluid accumulation could be observed in the uterine horns infected with C. trachomatis elementary bodies, which was reversed by antibiotics treatment. In C. trachomatis-infected CFTR(tm1Unc) mice, however, no detectable fluid accumulation was observed.

CONCLUSION

These findings suggest the involvement of CFTR in the pathogenesis of hydrosalpinx fluid formation and may provide grounds for a better treatment strategy to improve assisted reproduction treatment outcome in infertile patients with hydrosalpinx.

Mild ovarian stimulation

PURPOSE

To evaluate the efficacy of using only mild ovarian stimulation protocols for in vitro fertilization. Both groups with decreased and normal ovarian reserve were evaluated.

METHODS

Three different mild stimulation protocols were evaluated: natural with no exogenous follicle stimulation hormone (FSH) drugs at all, natural with a boost of low dose FSH to complete follicular maturation, and minimal stimulation with low dose (75-150IU) FSH from day 3-5 of the menstrual cycle. Ethinyl estradiol was sometimes used to lower high day 3 serum FSH.

RESULTS

Good pregnancy and implantation rates were found even in those women with elevated serum FSH that could only generate one follicle.

CONCLUSIONS

Mild ovarian stimulation seems preferable to high dose FSH regimens in women with elevated day 3 serum FSH based on previous poor reported pregnancy rates with the latter protocols. Comparable pregnancy rates to high dose regimen were seen in women with normal egg reserve at much lower risk and cost.

Heterotopic pregnancy after bilateral salpingectomy resulting in near-term delivery of a healthy infant

OBJECTIVE

To describe an unusual case of heterotopic pregnancy.

DESIGN

Case report.

SETTING

Division of Reproductive Medicine and Infertility, Women & Infants' Hospital of Rhode Island, Brown Medical School. Providence, Rhode Island.

PATIENT(S)

A woman with an unusual heterotopic pregnancy who had had prior bilateral salpingectomies, but delivered a healthy female infant near term after requiring laparotomy for a ruptured left cornual pregnancy 28 days after embryo transfer.

INTERVENTION(S)

IVF, laparotomy with wedge resection of the left tubal cornu, and near-term cesarean section.

MAIN OUTCOME MEASURE(S)

Excision of ectopic pregnancy with preservation of intrauterine pregnancy.

RESULT(S)

Delivery of a 2920 gram (6 lb, 7 oz) female infant.

CONCLUSION(S)

Heterotopic pregnancy may occur after bilateral salpingectomy, but a satisfactory outcome can be obtained in such circumstances after surgical excision of the ectopic gestation and preservation of the intrauterine pregnancy.

Hydrosalpinx and IVF: assessment of treatments implemented prior to IVF

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

Proximal tubal occlusion and salpingectomy result in similar improvement in in vitro fertilization outcome in patients with hydrosalpinx

OBJECTIVE

To evaluate and compare the clinical impact of proximal tubal occlusion and salpingectomy when performed before IVF in patients with hydrosalpinges.

DESIGN

Prospective randomized study.

SETTING

Assisted reproduction unit in an obstetrics and gynecology department in a university hospital in Greece as well as assisted reproduction unit in an urban clinic in a major city in Greece.

PATIENT(S)

One hundred fifteen patients with unilateral or bilateral hydrosalpinges who were candidates for IVF treatment.

INTERVENTION(S)

Laparoscopic proximal tubal occlusion, laparoscopic salpingectomy, controlled ovarian hyperstimulation, IVF, and embryo transfer.

MAIN OUTCOME MEASURE(S)

Implantation rate, clinical-pregnancy rate, ongoing-pregnancy rate, abortion rate, and ectopic-pregnancy rate.

RESULT(S)

Patients who underwent proximal tubal occlusion before IVF demonstrated significantly increased implantation, clinical-pregnancy, and ongoing-pregnancy rates compared with those with no surgical intervention and demonstrated implantation, clinical-pregnancy, and ongoing-pregnancy rates comparable to those who underwent salpingectomy.

CONCLUSION(S)

Proximal tubal occlusion, when performed in women with unilateral or bilateral hydrosalpinges before their IVF treatment, represents a potentially beneficial surgical procedure, increasing significantly the chances for successful implantation and for clinical and ongoing pregnancy. Proximal tubal occlusion may be viewed as a valid alternative when salpingectomy is technically difficult or not feasible.

The management of hydrosalpinges: tubal surgery or salpingectomy?

PURPOSE OF REVIEW

The clinical management of hydrosalpinges in infertile patients remains a contentious issue. This review aims to provide a critical analysis on the available treatments for hydrosalpinges, which have recently created a fierce debate between the promoters of salpingectomy and in-vitro fertilization and those who endorse tubal surgery.

RECENT FINDINGS

Hydrosalpinges have a detrimental effect on the outcome of in-vitro fertilization yet their mechanism is still unclear. Salpingectomy prior to in-vitro fertilization restores the likelihood of a successful outcome in a well defined group of patients with ultrasound-visible hydrosalpinges. However, not every woman with large hydrosalpinges should undergo salpingectomy as some fallopian tubes may be amenable to surgical repair. Preserved tubal mucosa indicates a good prognosis for tubal surgery, therefore an appropriate mucosal assessment should be routine prior to deciding upon further management.

SUMMARY

As salpingectomy is a definitive procedure it should be performed when the hydrosalpinges are beyond repair or in cases of in-vitro fertilization failure. Tubal surgery should be preferred to salpingectomy in mild to moderate tubal disease. A comparative study of restorative tubal surgery versus salpingectomy and in-vitro fertilization in selected women with hydrosalpinges is needed and will significantly help this debate. Prophylactic salpingectomy prior to in-vitro fertilization and tubal surgery is not competing but complementary in the treatment of hydrosalpinges-related infertility.

Ovarian response to gonadotropins after laparoscopic salpingectomy or the division of fallopian tubes for hydrosalpinges

OBJECTIVE

To compare the effect of prophylactic laparoscopic salpingectomy versus division of the fallopian tubes on ovarian response to gonadotropins in women undergoing IVF.

DESIGN

Retrospective study.

SETTING

National Health Service-based tertiary referral center for reproductive medicine.

PATIENT(S)

One hundred sixty-eight women with tubal factor infertility. Sixty-five women with hydrosalpinges had either salpingectomy (n = 40, group A) or proximal tubal division (n = 25, group B), while the remaining women with tubal disease but without hydrosalpinges acted as the control group (n = 103, group C).

INTERVENTION(S)

Prophylactic laparoscopic salpingectomy or proximal division of the fallopian tubes and ovarian stimulation with gonadotropins for IVF.

MAIN OUTCOME MEASURE(S)

Day 2 serum FSH levels before surgery and 3 months after surgery but before ovarian stimulation, ovarian response assessed as total dose of hMG administered, serum E2 concentrations on day 3 and day 8 of stimulation and on the day of hCG injection, number of follicles, and number of oocytes retrieved and fertilized.

RESULT(S)

In group A, baseline FSH levels were significantly raised after surgery compared with before surgery. Postsurgery FSH concentrations were significantly higher in group A compared with group B. The number of follicles (15-20 mm) was significantly lower in group A compared with group B and group C. The serum E2 levels on day 8 of stimulation were lower in group A compared with group B, and on the day of hCG injection it was significantly reduced in group A compared with groups B and C. The number of oocytes retrieved per cycle was significantly lower in group A compared with group B. There were no significant differences in pregnancy rates and miscarriage rates among the three groups.

CONCLUSION(S)

These findings suggest that prophylactic salpingectomy in women with hydrosalpinx may compromise ovarian response to stimulation without affecting pregnancy rates. A randomized control trial is recommended to determine the most appropriate laparoscopic procedure in the management of hydrosalpinx before IVF.

Estimating causal effects from multiple cycle data in studies of in vitro fertilization

Prospective studies of reproductive outcomes frequently record data at multiple cycles. For example, studies of in vitro fertilization and embryo transfer (IVF-ET) follow women or couples for possibly several IVF cycles and record outcomes such as pregnancy status and embryo implantation. Several time-varying covariates, such as age and diagnostic markers, typically are available as well. When attention is focused on measurement of exposure effects, the use of multiple cycle data poses several complications. If the study is observational, the exposure probability may depend on subject characteristics. Moreover, attrition rates in IVF-ET can be substantial, and the attrition process can be expected to depend heavily on prior outcome. In fact, both success (pregnancy) and failure (lack of embryo implantations) can be prognostic of dropout. In this paper, we illustrate the use of causal modeling for multiple cycle data. Key assumptions are reviewed, and inference based on weighted estimating equations is described in detail. The methods are applied to a study of the effects of hydrosalpinx among women with tubal disease undergoing IVF-ET.

Comparison of endometrial and subendometrial blood flows among patients with and without hydrosalpinx shown on scanning during in vitro fertilization treatment

OBJECTIVE

To compare endometrial and subendometrial blood flows among patients with and without hydrosalpinx (HSP) during in vitro fertilization treatment as measured by a three-dimensional power Doppler ultrasound.

DESIGN

A prospective observational study.

SETTING

A tertiary assisted-reproduction unit.

PATIENT(S)

Twenty-one patients with HSP were compared with 42 matched controls without HSP.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Endometrial thickness, endometrial pattern, endometrial volume, pulsatility index (PI) and resistance index (RI) of uterine vessels, and the vascularization index (VI), flow index (FI), and vascularization flow index (VFI) of endometrial and subendometrial regions were measured on the day of oocyte retrieval.

RESULT(S)

The proportion of the non-multilayered endometrial pattern was significantly higher in the HSP group than in the non-HSP group. Patients in the HSP group had significantly lower endometrial and subendometrial VI and VFI. Endometrial thickness, endometrial volume, uterine PI, uterine RI, and endometrial and subendometrial FI were similar between the two groups. No significant differences were observed in endometrial and subendometrial VI, FI, and VFI among patients with unilateral and bilateral HSP.

CONCLUSION(S)

A change in endometrial pattern and a decrease in endometrial and subendometrial blood flows may be the reasons for impaired implantation in patients with HSP.

Increased cystic fibrosis transmembrane conductance regulator (CFTR) expression in the human hydrosalpinx

BACKGROUND

Hydrosalpinx (HSP), characterized by abnormal fluid accumulation in the Fallopian tube, is one of the main causes of infertility in women; however, the mechanism underlying the formation of hydrosalpinx fluid (HF) remains elusive. The present study investigated the possible involvement of cystic fibrosis transmembrane conductance regulator (CFTR), a cAMP-dependent chloride channel, in the pathogenesis of hydrosalpinx.

METHODS

Masson's trichrome staining was used to characterize epithelial transformation in human HSP; RT-PCR, immunohistochemistry and immunofluorescence staining were used for CFTR expression and localization.

RESULTS

Masson's trichrome staining showed areas of epithelial transformation, focally attenuated and pseudostratified. Immunostaining showed enhanced CFTR immunoreactivity in the focally attenuated and pseudostratified areas of HSP epithelium. RT-PCR revealed that CFTR expression in HSP was significantly greater than that in normal Fallopian tubes.

CONCLUSIONS

These results indicate that HSP epithelium undergoes epithelial transformation with elevated CFTR expression, which may lead to increased transepithelial electrolyte and fluid secretion resulting in HF formation. The present findings may lead to the development of new treatment strategies for infertile patients with HSP.

Peritonitis after a ruptured left pyosalpinx in a patient undergoing in vitro fertilization

OBJECTIVE

To report acute abdomen in a young woman with infertility due to small asymptomatic bilateral hydrosalpinges who was on the 12th day of an IVF cycle.

DESIGN

Case report.

SETTING

Private IVF clinic.

PATIENT(S)

A 35-year-old woman with asymptomatic bilateral hydrosalpinges.

INTERVENTION(S)

Abdominal laparoscopy.

MAIN OUTCOME MEASURE(S)

Pus and a ruptured left pyosalpinx.

RESULTS

The patient suddenly developed acute abdomen while lifting a disabled person at a nursing home where she worked as a nurse. About 200 mL of pus was aspirated, and the patient had a ruptured left pyosalpinx. Bilateral salpingectomy was done by laparoscopy; the patient's postoperative recovery was uneventful.

CONCLUSION

We report a rare case of acute abdomen due to peritonitis after a ruptured pyosalpinx in an IVF patient who lifted a disabled person.

Effects of human hydrosalpinx fluid on in-vitro murine fertilization

Patients with hydrosalpinges show a decrease of both fertility and clinical outcome of IVF and embryo transfer treatment. Several reports have demonstrated the negative effects of hydrosalpinx fluid (HSF) on embryo development and implantation. The aim of this study was to determine whether human HSF, collected from infertile patients, might exhibit a deleterious effect on gametes and fertilization using a murine IVF system. Murine gametes were co-incubated during IVF until first cleavage with human HSF diluted to 50% from four patients (HSF1-4). It was demonstrated that HSF affected fertilization, as determined by the count of the 2-cell embryos. Pre-incubation of spermatozoa with HSF during capacitation significantly lowered the percentage of 2-cell embryos (P < 0.05). While HSF1-3 had no significant effect on motility and viability of spermatozoa, HSF4 almost completely affected their survival. In contrast, pre-incubation of ovulated oocytes surrounded by their cumulus cells with HSF before IVF did not impede first cleavage. Taken together, these results suggest that HSF has a cytotoxic effect on spermatozoa and/or impairs the fertilization process, probably by altering capacitation/acrosome reaction and/or ligand(s)-receptor(s) interactions. Hydrosalpinges may be partly associated with sterility through HSF inhibitory effects on fertilization.

Laparoscopic management of hydrosalpinges before in vitro fertilization-embryo transfer: salpingectomy versus proximal tubal occlusion

OBJECTIVE

To compare ovarian response and IVF-ET cycle outcome in patients with hydrosalpinges managed by either laparoscopic salpingectomy or proximal tubal occlusion.

DESIGN

Retrospective analysis.

SETTING

Tertiary-care assisted reproductive technology program.

PATIENT(S)

One hundred four consecutive fresh IVF-ET cycles in 94 patients with tubal-factor infertility.

INTERVENTION(S)

Laparoscopic salpingectomy (group 1: 35 cycles) or bipolar proximal tubal occlusion (group 2: 17 cycles), controlled ovarian hyperstimulation, and IVF-ET. Control groups consisted of both tubal-factor patients without hydrosalpinges (group 3: 37 cycles) and those with prior bilateral tubal ligation for sterilization (group 4: 15 cycles).

MAIN OUTCOME MEASURE(S)

Uterine artery Doppler flow, controlled ovarian hyperstimulation response, and implantation and clinical pregnancy rates.

RESULT(S)

There were no differences in mean uterine artery pulsatility indices or ovarian response among any of the groups. A trend toward a higher cycle cancellation rate in group 1 did not approach statistical significance. Clinical pregnancy and implantation rates were not significantly different between group 1 (57.1%, 29.2 +/- 5.9%, respectively) and group 2 (46.7%, 19.4 +/- 6.1%, respectively) or compared with those of controls.

CONCLUSION(S)

[1] Management of hydrosalpinges by laparoscopic salpingectomy or bipolar proximal tubal occlusion yielded statistically similar responses to controlled ovarian hyperstimulation and IVF-ET cycle outcome. [2] The latter approach may be preferable in patients who present with dense pelvic adhesions and easy access only to the proximal fallopian tube.

Controversies in the surgical management of hydrosalpinx

The surgical management of hydrosalpinges is a controversial subject. Chronic pathology of the fallopian tube with distal obstruction leads to the formation of a hydrosalpinx, and is associated with very poor pregnancy rates after surgery. In these cases, in-vitro fertilization has proved to be a much better alternative. However, several studies have shown that patients with hydrosalpinges have significantly lower pregnancy and implantation rates after in-vitro fertilization compared with patients with other forms of tubal damage. The exact mechanism by which the hydrosalpinx adversely affects in-vitro fertilization results is not yet fully understood. The value of performing a salpingectomy before in-vitro fertilization has been studied extensively. Currently, a clear benefit in salpingectomies has been proved for patients with ultrasonically visible hydrosalpinges.

Transvaginal ultrasonography associated with colour Doppler energy in the diagnosis of hydrosalpinx

The aims of this prospective study were to investigate the accuracy of B-mode transvaginal ultrasonography alone, using the typical finding of the presence of an elongated shaped mass with incomplete septa, in the screening of hydrosalpinx in women undergoing surgery for gynaecological diseases, and to determine the predictive value of this method combined with colour Doppler energy (CDE) imaging evaluation and CA125 concentrations in differentiating hydrosalpinx from other adnexal masses. In the first part of the study, 378 consecutive pre-menopausal non-pregnant women were submitted to transvaginal ultrasonography alone before surgery. In the second part of the study, 256 adnexal masses underwent transvaginal ultrasonography combined with CDE imaging evaluation associated with spectral Doppler analysis and plasma concentrations of CA125. Sensitivity and specificity for the ultrasonographic screening were 84.6 and 99.7% respectively, calculated for each adnexum (n = 756) and 93.3 and 99.6% respectively, calculated for each mass, for differentiating hydrosalpinx from other adnexal masses. The CDE imaging and the evaluation of CA125 plasma concentrations do not seem to increase the accuracy of B-mode transvaginal ultrasonography. Inter- and intra-observer agreement, expressed in terms of k-values, was high (0.87 and 0.93 respectively). In conclusion, transvaginal ultrasonography alone is a useful method of detection of hydrosalpinx.

Salpingectomy for repeated embryo nonimplantation after in vitro fertilization in patients with severe tubal factor infertility

PURPOSE

To evaluate the impact of salpingectomy on the rates of embryo implantation and pregnancy in patients with severe, irreversible tubal factor sterility.

METHODS

A retrospective study of patients with repeated failure of in vitro fertilization due to nonimplantation of the embryo. Seventy-two patients with severe and irreversible tubal factor sterility were selected following repeated failure of in vitro fertilization (IVF) due to assumed nonimplantation of the embryo: 35 underwent a salpingectomy before continuing IVF cycles and 37 continued IVF cycles without salpingectomy.

RESULTS

After the first IVF cycle consecutive to diagnosis of embryo nonimplantation, the implantation rate was 10.2% in the salpingectomy group and 6.1% in the group without the procedure (P = 0.5). After all IVF cycles, the rate was, respectively, 6.9% and 4.5% (P = 0.2). Salpingectomy improved the pregnancy rate (PR) per transfer (23.5% vs. 9.9%; P = 0.01). The curves of the cumulative probability of becoming pregnant show that salpingectomy resulted in pregnancy more rapidly.

CONCLUSIONS

Salpingectomy improves the PR per transfer in patients with severe and irreversible tubal factor sterility who have experienced repeated failure of IVF due to embryo nonimplantation. This procedure also reduces the number of IVF attempts needed to obtain pregnancy.

Hierarchical logistic regression models for clustered binary outcomes in studies of IVF-ET

OBJECTIVE

To describe a hierarchical logistic regression model for clustered binary data, apply it to data from a study on the effect of hydrosalpinx on embryo implantation, and compare the results with analyses that do not account for clustering.

DESIGN

Observational study.

SETTING

Academic research environment.

PATIENT(S)

Women undergoing IVF-ET for tubal disease.

MAIN OUTCOME MEASURE(S)

Odds of per embryo implantation.

RESULT(S)

Although regression estimates are largely similar between the models, the hierarchical model properly reflects the added variation due to clustering. Standard errors are higher, confidence intervals are wider, and P values indicate fewer "statistically significant" effects.

CONCLUSION(S)

Ignoring important sources of variation in any analysis can lead to incorrect confidence intervals and P values. In studies of IVF-ET, where clustered data are common, unexplained heterogeneity can be substantial. In this setting, hierarchical logistic regression is an appropriate alternative to standard logistic regression.

Hydrosalpinx and IVF outcome: a prospective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF

Many retrospective studies have shown that hydrosalpinx is associated with poor in-vitro fertilization (IVF) outcome. The mechanism of the actual cause is not yet fully understood. A clinical practice of performing salpingectomy before IVF has developed, without any evidence from prospective trials. The aim of the present prospective randomized trial was to test if a salpingectomy prior to IVF was effective in terms of increased pregnancy rates. Patients with hydrosalpinx were randomized to either a laparoscopic salpingectomy or no intervention before IVF. A total of 204 patients was available for an intention-to-treat analysis and 192 actually started IVF. Clinical pregnancy rates per included patient were 36.6% in the salpingectomy group and 23.9% in the non-intervention group (not significant, P = 0.067) and the ensuing delivery rates were 28.6% and 16.3% (P = 0.045). The corresponding delivery rates per transfer cycle were 29.5% versus 17. 5% (not significant, P = 0.083). A subgroup analysis revealed significant differences in favour of salpingectomy, in implantation rates in patients with bilateral hydrosalpinges (25.6% versus 12.3%, P = 0.038) and in clinical pregnancy rates (45.7% versus 22.5%, P = 0.029) and delivery rates (40.0% versus 17.5%, P = 0.038) in patients with ultrasound visible hydrosalpinges. The delivery rate was increased 3.5-fold in patients with bilateral hydrosalpinges visible on ultrasound (P = 0.019).

Effects of hydrosalpingeal fluid on murine embryo development and implantation

PURPOSE

Our purpose was to evaluate the effects of various concentrations of hydrosalpingeal fluid (HSF) on the preimplantation development and implantation of murine embryos.

METHODS

One-cell mouse embryos were cultured in KSOM culture medium with 0.1, 1.0, 10, or 50% HSF, without and with lactate supplementation. Late-stage embryos were transferred into the uteri of pseudopregnant CD-1 females to determine implantation rates. The embryo transfer technique used was developed by our group and its effectiveness was evaluated during this experiment.

RESULTS

Blastocyst development in the 0.1, 1.0, 10, and 50% group was 45, 55.0, 12.5, and 17.5%, respectively, with lactate supplementation, and 35.0, 52.5, 12.5, and 5.0%, respectively, without lactate supplementation, while in the KSOM (control) group it was 63.8%. Blastocyst development was reduced compared to controls in the 10% HSF and 50% HSF groups. Implantation rates for the 0.1 and 1.0% groups with lactate supplementation were 43.0 and 25.0%, respectively, and those with lactate supplementation were 50.6 and 61.8%, respectively, while in the KSOM group the implantation rate was 65.5%. None of the implantation rates were significantly different.

CONCLUSIONS

Hydrosalpingeal fluid has a concentration-dependent inhibitory effect on in vitro murine embryo development, but it has minimal effects on implantation rates.

Controlled ovarian hyperstimulation adversely affects implantation following in vitro fertilization-embryo transfer

PURPOSE

Our purpose was to determine if controlled ovarian hyperstimulation adversely affects implantation.

METHODS

A retrospective comparison of pregnancy rates (PRs) and implantation rates was made between oocyte recipients versus their donors, who shared half of the retrieved oocytes, and regular patients undergoing in vitro fertilization-embryo transfer (IVF-ET) who were not sharing eggs.

RESULTS

Higher implantation rates (39.0 vs 22.5%; P < 0.05) were found in recipients compared to donors in the stimulated cycle. However, no differences were seen in PRs or implantation rates in frozen ET cycles. The data for standard IVF patients were almost-identical to those for donors.

CONCLUSIONS

Superior implantation rates and PRs in oocyte recipients versus donors were not related to better oocyte quality for recipients because of egg sharing or to a better uterine environment because of similar results with frozen ET in all three groups. An adverse effect of the hyperstimulation regimen best explains the difference.

The effect of hydrosalpinges on IVF-ET outcome

PURPOSE

Our purpose was to determine if the presence of a hydrosalpinx effects the outcome of in vitro fertilization (IVF)-embryo transfer.

METHODS

We performed a retrospective analysis of IVF cycle stimulation sheets.

RESULTS

A total of 1000 patients with tubal factor infertility was analyzed. There were 60 hydrosalpinx patients who underwent 116 initiated cycles with 106 embryo transfers, compared to 940 control patients undergoing 1428 initiated cycles with 1150 embryo transfers. Both groups had a similar response to ovarian stimulation, number of oocytes retrieved, and number of embryos transferred. The hydrosalpinx group had a significantly higher preclinical loss rate (22/59 = 37% vs 80/566 = 14%; P = 0.001), a significantly lower implantation rate (55/352 = 16% vs 795/3795 = 21%; P = 0.013), a trend toward a reduced delivery rate per transfer (28/106 = 26% vs 387/1150 = 34%; P = 0.066), a significantly higher ectopic pregnancy rate (5/59 = 8% vs 16/566 = 3%; P = 0.04), and a similar spontaneous abortion rate (9/37 = 24% vs 99/486 = 20%; P = 0.28) compared to the control tubal factor group.

CONCLUSIONS

This study demonstrates a decrease in implantation rates and an increase in preclinical miscarriages and ectopic pregnancies in patients with hydrosalpinges compared to tubal-factor patients without sonographic evidence of dilated fallopian tubes.

The embryo toxicity of hydrosalpinx fluid is only apparent at high concentrations: an in vitro model that stimulates in vivo events

OBJECTIVE

To simulate the in vivo model in studying the effect of hydrosalpinx fluid on embryonic development.

DESIGN

Controlled prospective study.

SETTING

Academic research center.

PATIENT(S)

Five hundred eighty-seven two-cell murine embryos.

INTERVENTION(S)

Embryos were grown under two sets of conditions. Half were cultured using 10% fetal calf serum in RPM1 medium in varying concentrations of hydrosalpinx fluid (0, 1%, 10%, 50%, 75%, and 100%). To more closely mimic the in vivo environment, the other half were grown in an endometrial coculture system with the same media and hydrosalpinx fluid concentrations.

MAIN OUTCOME MEASURE(S)

Embryonic development.

RESULT(S)

For each stage of embryogenesis, diminished development was noted with increasing concentrations of hydrosalpinx fluid. In the group of embryos grown without endometrial coculture, only at a minimum concentration of 50% hydrosalpinx fluid was diminished development noted for the blastocyst, hatching, and outgrowth stages. When an endometrial coculture system was used, development was not inhibited until exposure to a minimum of 75% hydrosalpinx fluid. Embryogenesis was enhanced when an endometrial coculture system was used for each concentration of hydrosalpinx fluid.

CONCLUSION(S)

When a model is used that more accurately mimics the in vivo conditions of IVF-ET in a patient with hydrosalpinges, it appears that high concentrations of hydrosalpinx fluid are required to signiticantly impede embryogenesis. The endometrium appears to help detoxify hydrosalpinx fluid.

Effect of salpingectomy on ovarian response to superovulation in an in vitro fertilization-embryo transfer program

OBJECTIVE

To investigate the effect of salpingectomy on the response of each ovary in patients undergoing an IVF-ET treatment cycle and to compare the results with those of patients who had not had surgery and were undergoing IVF-ET during the same period.

DESIGN

A prospective study.

SETTING

Tertiary referral academic IVF unit.

PATIENT(S)

Twenty-nine ET cycles were evaluated in 29 patients who previously had undergone unilateral salpingectomy because of ectopic pregnancy (study group). Seventy-three patients with unexplained or male factor infertility served as controls.

INTERVENTION(S)

Ovulation induction and IVF-ET.

MAIN OUTCOME MEASURE(S)

In the study group, mean ovarian volume, number of follicles, and number of oocytes recovered from each ovary were assessed and compared. The overall results, cycle characteristics, and pregnancy rates of the two groups were compared.

RESULT(S)

Among the patients who had undergone salpingectomy, significantly fewer follicles developed and consequently fewer oocytes were retrieved from the ovary on the operated side (4.4 versus 8.2 follicles and 3.8 versus 6.0 oocytes). There were no differences in the total numbers of follicles and oocytes recovered from both ovaries, the cycle characteristics, or the pregnancy rates between study and control groups.

CONCLUSION(S)

Salpingectomy has no detrimental effect on the total ovarian performance during IVF-ET treatment or on the outcome of IVF-ET. However, the ipsilateral ovary could be adversely affected. This could be detrimental in selected patients undergoing IVF-ET, in whom the second ovary already is compromised or missing.