Laparoscopic salpingectomy for women with hydrosalpinges enhances the success of IVF: a Cochrane review

Risk factor for interstitial pregnancy following ipsilateral salpingectomy? A retrospective matched case control study

BACKGROUND

Interstitial pregnancy may still happen even after ipsilateral salpingectomy, resulting in massive hemorrhage. Therefore, the purpose of the study is to identify risk factors associated with interstitial pregnancy following ipsilateral salpingectomy and discuss possible prevention.

METHODS

We conducted a retrospective cohort study in a single, large, university-affiliated hospital. Data of 29 patients diagnosed with interstitial pregnancy following ipsilateral salpingectomy from January 2011 to November 2020 were assigned into the case group (IP group). Whereas there were 6151 patients with intrauterine pregnancy after unilateral salpingectomy in the same period. A sample size of 87 control patients was calculated to achieve statistical power (99.9%) and an α of 0.05. The age, BMI and previous salpingectomy side between the two group were adjusted with PSM at a ratio of 1:3. After PSM, 87 intrauterine pregnancy patients were successfully matched to 29 IP patients.

RESULTS

After PSM, parous women were more common and intrauterine operation was more frequent in the IP group compared with control group (P<0.05). There was only one patient undergoing IVF-ET in the IP group as compared with 29 cases in the control group (3.4% vs. 33.3%, P<0.05). Salpingectomy was performed on 5 patients in the IP group and 4 patients in the control group due to hydrosalpinx (P<0.05). Logistic regression indicated that hydrosalpinx was the high risk factor of interstitial pregnancy following ipsilateral salpingectomy (OR = 8.175).

CONCLUSIONS

Hydrosalpinx appears to be an independent factor contributing to interstitial pregnancy following ipsilateral salpingectomy in subsequent pregnancy.

Ovarian Follicular Response Is Altered by Salpingectomy in Assisted Reproductive Technology: A Pre- and Postoperative Case-Control Study

Objectives: The goal of this study was to assess the effect of unilateral salpingectomy on the number of mature follicles in the ipsilateral ovary during an assisted reproductive technology (ART) stimulation cycle, as compared to the contralateral ovary. Methods: This was a retrospective, single-center, case-control cohort study conducted from 2017 to 2022. Patients from 18 to 43 years old who underwent at least one ART cycle before and after a unilateral salpingectomy were included. The number of recruited follicles, including mature (≥16 mm) and intermediate follicles (13-15.5 mm), on the salpingectomy side (case) were compared to those present on the contralateral ovary (control) during an ART attempt. To take into account the inter-ovarian variability, the comparison was performed on two ART cycles, performed before then after the salpingectomy. Results: Overall, 24 patients were included in our study. While the number of mature follicles was similar in both ovaries before surgery, the mean number of mature follicles was significantly reduced after salpingectomy in the operated side, as compared to the control side, being, respectively 3.00 vs. 5.08 (p = 0.048). There was no significant difference between the intermediate and total recruited follicles. Conclusions: Our study suggests that salpingectomy may impact the follicle recruitment on the ipsilateral side by altering the vascularization during mesosalpinx coagulation. Gynecologists should be mindful of this concept and accurately set surgical indications. Beyond the indication, this emphasizes the critical role of having infertility surgeons sensitive to fertility preservation for optimal management of ART patients. Further studies with larger patient populations are required to confirm these results.

Extended doxycycline treatment versus salpingectomy in the management of patients with hydrosalpinx undergoing IVF-ET

Background

The aim of this study was to determine whether the treatment with doxycycline before and after oocyte retrieval is as effective as salpingectomy in minimizing the detrimental effect of hydrosalpinx on the outcomes of IVF-ET.

Methods

A retrospective analysis was done for the outcomes of the IVF-ET cycles of patients with hydrosalpinx who underwent laparoscopic salpingectomy prior to IVF cycle (n = 260) or were treated with extended doxycycline treatment during the IVF cycle (n = 45). In doxycycline group, doxycycline (100 mg twice daily) was started 1 week before anticipated oocyte retrieval and was continued for 1 week after oocyte retrieval. In salpingectomy group, the mesosalpinx was coagulated as close as possible to the fallopian tube.

Results

The implantation, clinical pregnancy, ongoing pregnancy and live birth rates were significantly higher in the salpingectomy group (20.87% Vs. 9.91%, P value =0.007, 44.62% Vs. 20%, P value = 0.002, 39.62% Vs. 17.78%, P value = 0.005 and 37.31% Vs. 15.56%, P value = 0.005 respectively).

Conclusion

Salpingectomy is more effective than extended doxycycline treatment in improving the outcomes of IVF-ET in patients with hydrosalpinx undergoing IVF-ET. Further, larger well designed randomized controlled trials should be conducted to confirm the findings of this study.

In vivo oxygen, temperature and pH dynamics in the female reproductive tract and their importance in human conception: a systematic review

BACKGROUND

Despite advances in ART, implantation and pregnancy rates per embryo transfer still remain low. IVF laboratories strive to ensure that the process of handling gametes in vitro closely mimics the in vivo environment. However, there remains a lack of knowledge regarding the in vivo regulation and dynamic variation in biophysical parameters such as oxygen concentration, pH and temperature within the reproductive tract.

OBJECTIVE AND RATIONALE

To undertake a systematic review of the current understanding of the physico-chemical parameters of oxygen tension (pO2), pH and temperature within the female reproductive tract, and their potential implications in clinical and pathological processes related to fertility and those pertaining to limited reproductive capacity.

SEARCH METHODS

A comprehensive literature search was performed using electronic databases including Medline, Embase, Cochrane Library and Pubmed to identify original and review articles addressing the biophysical parameters (pO2, pH and temperature) in the female reproductive tract of any species. The search included all studies published between 1946 and November 2015. Search terms included 'oxygen', 'pH', 'hydrogen ion concentration', 'acid base' and others terms. We also used special features and truncations to identify synonyms and broaden the search. Studies were excluded if they only assessed embryo culture conditions, fetal acid-base status, oxidative stress, outcomes of pregnancy and measurements of these parameters in non-reproductive organs.

OUTCOMES

Our search generated 18 685 records and 60 articles were included. pO2 within the female reproductive tract shows cyclical variation and minute-to-minute oscillations, which may be influenced by uterine contractility, hormones, the autonomic system, cardiac pulsatility, and myometrial and smooth muscle integrity. Fine balanced control of pO2 and avoidance of overwhelming oxidative stress is crucial for embryogenesis and implantation. The pH in the female reproductive tract is graduated, with lowest pH in the vagina (~pH 4.42) increasing toward the Fallopian tubes (FTs) (~pH 7.94), reflecting variation in the site-specific microbiome and acid-base buffering at the tissue/cellular level. The temperature variation in humans is cyclical by day and month. In humans, it is biphasic, increasing in the luteal phase; with the caudal region of the oviduct 1-2 degrees cooler than the cranial portion. Temperature variation is influenced by hormones, density of pelvic/uterine vascular beds and effectiveness of heat exchange locally, crucial for sperm motility and embryo development. We have identified significant deficiencies and inconsistencies in the methods used to assess these biophysical factors within the reproductive tract. We have suggested that the technological solutions including the development of methods and models for real time, in vivo recordings of biophysical parameters.

WIDER IMPLICATIONS

The notion of 'back to nature' in assisted conception suggested 20 years ago has yet to be translated into clinical practice. While the findings from this systematic review do not provide evidence to change current in vitro protocols, it highlights our current inability to assess the in vivo reproductive tract environment in real time. Data made available through future development of sensing technology in utero may help to provide new insights into how best to optimize the in vitro embryo environment and allow for more precise and personalized fertility treatment.

Cornual Suture at the Time of Laparoscopic Salpingectomy Reduces the Incidence of Interstitial Pregnancy after In Vitro Fertilization

STUDY OBJECTIVE

To investigate the effect of cornual suture at the time of laparoscopic salpingectomy on the incidence of interstitial pregnancy (IP) after in vitro fertilization (IVF).

DESIGN

Single-center, retrospective review (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

Patients with hydrosalpinx who were treated with salpingectomy before IVF-embryo transfer and managed in our center were included in this study.

INTERVENTIONS

A total of 542 patients who underwent laparoscopic salpingectomy from April 2011 to March 2014 comprised group A. A total of 502 patients who underwent cornual suture at the time of laparoscopic salpingectomy from April 2014 to February 2016 comprised group B.

MEASUREMENTS AND MAIN RESULTS

The overall IP rate was significantly lower in group B (7/293, 2.39%) than in group A (27/373, 7.24%; p < .05). The intrauterine pregnancy and ongoing pregnancy/live birth rates were significantly higher in group B than in group A (both p < .05). All 34 patients with IP underwent laparoscopic cornuostomy and cornual repair. Seven of 11 patients with combined interstitial and intrauterine pregnancies carried the intrauterine pregnancy to term and delivered via cesarean section, whereas 4 patients underwent inevitable miscarriage. IP rupture occurred in 8 of 34 patients at a mean of 23.43 ± 2.77 days after embryo transfer. The earliest time of rupture was on day 20 after embryo transfer.

CONCLUSION

An optimized salpingectomy technique plays an important role in pretreatment before embryo transfer in patients with hydrosalpinx. Cornual suture at the time of salpingectomy helps reduce the risk of IP.

Ovarian reserve after salpingectomy: a systematic review and meta-analysis

INTRODUCTION

Although there has been a growing concern over the possible damaging effect of salpingectomy on ovarian reserve, this issue remains uncertain. The purpose of this meta-analysis was to test the hypothesis that salpingectomy may compromise ovarian reserve.

MATERIAL AND METHODS

A detailed search was conducted using MEDLINE, Embase, Dynamed Plus, ScienceDirect, TRIP database and the Cochrane Library from January 2000 to November 2016. All cohort, cross-sectional and randomized controlled studies investigating changes in circulating anti-Müllerian hormone (AMH) after salpingectomy were considered. Thirty-seven studies were identified, of which eight were eligible. Data were extracted and entered into RevMan software for calculation of the weighted mean difference (WMD) and 95% CI. Two groups of studies were analyzed separately: group 1 (six studies, n = 464) comparing data before and after salpingectomy and group 2 (two studies) comparing data in women who have undergone salpingectomy (n = 169) vs. healthy controls (n = 154).

RESULTS

Pooled results of group 1 studies showed no statistically significant change in serum AMH concentration after salpingectomy (WMD, -0.10 ng/mL; 95% CI -0.19 to 0.00, I² = 0%). Similarly, meta-analysis of group 2 showed no statistically significant difference in serum AMH concentration between salpingectomy group and controls (WMD, -0.11 ng/mL; 95% CI -0.37 to 0.14, I² = 77%). Subgroup analyses based on laterality of surgery, type of AMH kit and participants' age (<40 years) still showed no statistically significant changes in circulating AMH.

CONCLUSION

Salpingectomy does not seem to compromise ovarian reserve in the short-term. However, the long-term effect of salpingectomy on ovarian reserve remains uncertain.

Ultrasound sclerotherapy pretreatment could obtain a similar effect to surgical intervention on improving the outcomes of in vitro fertilization for patients with hydrosalpinx

AIM

The aim of this study was to compare the clinical outcomes of in vitro fertilization (IVF) for patients with hydrosalpinx between ultrasound sclerotherapy and surgical intervention.

METHODS

The data of 482 IVF/intracytoplasmic sperm injection (ICSI) cycles were divided into three groups according to different intervention protocols before IVF/ICSI. Group A included 265 cycles in which ultrasound sclerotherapy pretreatment was carried out before controlled ovarian hyperstimulation. Group B included 109 cycles in which hydrosalpinx aspiration was carried out under ultrasound guidance on the day of oocyte retrieval. Croup C included 108 cycles in which bilateral salpingectomy was carried out before IVF/ICSI.

RESULTS

The rates of embryo implantation, biochemical pregnancy, clinical pregnancy, multiple pregnancy, and early abortion showed no significant differences between groups A and C (P > 0.05); whereas the rates of embryo implantation, biochemical pregnancy, and clinical pregnancy in group B were significantly lower than those in groups A and C (P < 0.05), and that of early abortion in group B was significantly higher than that in groups A and C (P < 0.05).

CONCLUSION

Ultrasound sclerotherapy on patients with hydrosalpinx before IVF-embryo transfer could obtain a similar clinical outcome to surgical intervention.

Influence of various tubal surgeries to serum antimullerian hormone level and outcome of the subsequent IVF-ET treatment

OBJECTIVE

To compare the influence of various tubal surgeries to ovarian reserve via serum level of antimullerian hormone (AMH) and the subsequent in vitro fertilization and embryo transplantation (IVF-ET) outcome in patients with simple tubal infertility.

STUDY DESIGN

A prospective cohort study was conducted on 134 IVF cycles undegone by 26 and 34 cases with bilateral and unilateral salpingectomy, respectively, 23 cases with bilateral oviducts interrupted in the proximal and 51 cases with bilateral oviducts obstruction without intervention as controls.

RESULTS

Serum AMH displayed its great superiority to traditional markers of ovarian reserve in correspondence with antral follicles count and decisive effect for the number of oocytes retrieved after stimulation in each group. No significant differences on ovarian reserve and responsiveness or IVF-ET outcome existed among four groups comparable on essential characteristics, except for numerically higher clinical pregnancy rate and live birth rate after various tubal surgeries versus no intervention for bilateral oviducts obstruction. Especially, bilateral salpingectomy precursed the statistically highest implantation rate (51.0% versus 28.0%, 39.1%, 30.4%) and numerically best IVF outcome.

CONCLUSION

Tubal surgical procedures have some beneficial effect for improving IVF outcome without significant impact on ovarian reserve or responsiveness. Bilateral salpingectomy appears to be an appropriate procedure before IVF treatment for bilateral salpingitis, especially hydrosalpinx.

Effect of ultrasound-guided aspiration of hydrosalpingeal fluid during oocyte retrieval on the outcomes of in vitro fertilisation-embryo transfer: a randomised controlled trial (NCT01040351)

OBJECTIVE

To determine whether the ultrasound-guided aspiration of hydrosalpingeal fluid at the time of oocyte retrieval can improve the outcomes of in vitro fertilisation-embryo transfer (IVF-ET).

PATIENTS

One hundred and ten women with ultrasound-visible hydrosalpinges were randomised to two groups based on computer generated randomisation list. Fifty-four women underwent ultrasound-guided aspiration of hydrosalpingeal fluid prior to IVF-ET and 53 women underwent IVF-ET without any prior intervention.

RESULTS

Patients who underwent aspiration of hydrosalpinges demonstrated a significantly increased implantation, clinical pregnancy rates. Among the patients in the aspiration group, the implantation rate and pregnancy rates were higher in the subgroup of patients with no reaccumulation of hydrosalpingeal fluid within the first 2 weeks after aspiration compared to patients with reaccumulation of hydrosalpingeal fluid within the first 2 weeks after aspiration, but this difference failed to reach statistical significance. Furthermore, no pregnancies occurred in the four patients with uterine fluid collection detected during IVF-ET cycles.

CONCLUSION

The aspiration of hydrosalpingeal fluid at the time of oocyte retrieval is simple, safe and effective procedure for treatment of patients with ultrasound-visible hydrosalpinges particularly those without rapid reaccumulation of hydrosalpingeal fluid after aspiration or uterine fluid collection during the IVF-ET cycles.

Three-dimensional ultrasound inversion rendering technique facilitates the diagnosis of hydrosalpinx

PURPOSE

To test the utility of three-dimensional (3D) ultrasound (US) inversion rendering technique in the evaluation of fluid-distended fallopian tubes.

METHODS

Fifty-two patients with fluid-filled adnexal masses suspected of being abnormal fallopian tubes were scanned by two-dimensional and 3D transvaginal ultrasound (TVUS). Six patients had bilateral disease. The acquired volumes were then "inverted" to display a cast-like appearance of the fluid-filled structures. The ipsilateral ovaries were identified in all patients. Five patients had acute tubal disease.

RESULTS

Fifty-two of the 58 inversion renderings yielded acceptable images of hydrosalpinges. Only in four patients were the two-dimensional images more informative than the 3D-rendered and inverted views. In nine patients adjacent corpora lutea, ovarian cysts, and follicles within normal ovaries were also identified, but appeared separate from the fluid-filled tubes. The tubes in the patients with acute disease were all successfully inverted.

CONCLUSIONS

The 3D inversion technique is a simple and effective way to render fluid-filled spaces, which may be tortuous and follow various directions. The rendered images increased the confidence in diagnosing hydrosalpinx.

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.

Effects of hydrosalpinx on pinopodes, leukaemia inhibitory factor, integrin beta3 and MUC1 expression in the peri-implantation endometrium

OBJECTIVES

To compare the expression of pinopodes, LIF, integrin beta(3) and MUC1 in the peri-implantation endometrium of women with and without hydrosalpinx.

STUDY DESIGN

A prospective observational study in an assisted reproductive unit in a university teaching hospital, including 20 women with hydrosalpinx and 21 women without hydrosalpinx. Endometrial biopsies were performed on day LH+7 or +8. The proportion and density of pinopodes were assessed by scanning electron microscopy. LIF, integrin beta3 and MUC1 were evaluated with immunohistochemical staining.

RESULTS

The proportion and the density of pinopodes were not significantly different between the hydrosalpinx and control groups. The LIF, integrin beta(3), and MUC1 expression were significantly reduced in both glandular epithelial cells and endometrial lumen of the hydrosalpinx group when compared with those of the control group. The expression of integrin beta(3) in stromal cells was also significantly lower in the hydrosalpinx group.

CONCLUSIONS

The proportion and the density of pinopodes in the peri-implantation endometrium were not affected by the presence of hydrosalpinx while LIF, integrin beta(3) and MUC1 were significantly reduced in patients with hydrosalpinx.

Hydrosalpinx functional surgery or salpingectomy? The importance of hydrosalpinx fluid in assisted reproductive technologies

The first IVF baby, Louise Brown, was born in a natural cycle IVF of a woman who had bilateral tubal block making IVF the only option for having a child. The last 3 decades has seen astounding progress in the field of ART. Today thanks to ART, tubal disease and tubal factor infertility is easily overcome. The accepted theory today is that the hydrosalpinx fluid plays a causative role in the reduced pregnancy rate with ART. It is well known that the success of ART for patients with tubal disease with hydrosalpinx is reduced by half compared with patients without hydrosalpinx. Ideal would be removal of a hydrosalpinx by laparoscopic salpingectomy to improve pregnancy rates. However in some cases this is not feasible due to dense pelvic adhesions making access difficult. In such cases it is recommended that even de-linking the tube from the uterus would help in improving the ART outcome. There is suggestion that sonographically visible hydrosalpinges and those affected bilaterally have a poorer prognosis than those seen incidentally at laparoscopy. While there is clinical evidence supporting the causative role of the fluid itself, there is a lack of knowledge as to how the fluid exerts its negative effects. It is generally believed that the fluid holds a key position in impairing implantation potential. The aim of this review is to highlight the importance of identifying hydrosalpinges and its association with reduced fertility outcome using assisted reproductive technologies. Here we have discussed the different options available for the same, and highlighted the current modes of treatment.

Ultrasound-guided hydrosalpinx aspiration during oocyte collection improves pregnancy outcome in IVF: a randomized controlled trial

BACKGROUND

Hydrosalpinges have adverse effects on IVF outcomes. Salpingectomy is effective in improving outcomes, but it is not always practical or safe. Ultrasound-guided aspiration of hydrosalpinges at oocyte collection is an option for those who develop hydrosalpinges during controlled ovarian stimulation; however, there is no randomized evidence to show whether this practice is effective.

METHODS

Between October 1999 and June 2003, consenting women of age <or=39 years with an ultrasound diagnosis of hydrosalpinx were randomized before oocyte collection to transvaginal aspiration of hydrosalpinx under antibiotics cover or no aspiration. Third-party randomization was performed using a computer algorithm, and allocation concealment was achieved with opaque sealed envelopes. Outcomes were biochemical and clinical pregnancies, implantation, spontaneous abortion, ectopic pregnancy and pelvic infection rates. Analysis was by intention to treat.

RESULTS

Sixty-six women were recruited to the trial, 32 to the aspiration group and 34 to the no-aspiration group. Aspiration resulted in a greater biochemical pregnancy rate [14/32 (43.8%) versus 7/34 (20.6%), relative risk (RR) = 2.1 (1.02, 4.6), P = 0.04]. Clinical pregnancy rates for aspiration versus control groups were 31.3% (10/32) and 17.6% (6/34), respectively [RR = 1.8 (0.8, 4.3), P = 0.20]. There were no changes in implantation rate or spontaneous abortion risk with aspiration and no differences between the groups in infection or ectopic pregnancy rates.

CONCLUSIONS

In women who are identified to have hydrosalpinges during controlled ovarian stimulation during IVF, aspiration of hydrosalpinges during oocyte collection may be effective in improving pregnancy rates (Trial Registration Number: NCT00566956).

Infertility treatment: the viability of the laparoscopic view

Assisted reproductive technology (ART) and laparoscopy are not mutually exclusive, but coexisting and potentially complimentary treatments. For disease conditions contributing to infertility in addition to other concomitant or potential morbidity, laparoscopy represents a more comprehensive approach.

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.

Salpingectomy increases peri-implantation endometrial HOXA10 expression in women with hydrosalpinx

OBJECTIVE

To determine whether women with hydrosalpinx would have diminished endometrial HOXA10 expression and whether salpingectomy would reverse HOXA10 suppression. The homeobox gene HOXA10 is a transcription factor that is necessary for embryo implantation; its expression in human endometrium correlates with receptivity and implantation. Increased endometrial HOXA10 expression may be one mechanism by which salpingectomy results in increased implantation rates in IVF.

DESIGN

Prospective clinical trial.

SETTING

Academic medical center.

PATIENT(S)

Women with unilateral or bilateral hydrosalpinx.

INTERVENTION(S)

Expression of HOXA10 was examined prospectively during the midluteal phase in endometrium obtained from infertile women (n = 9) with hydrosalpinges before and after salpingectomy, as well as from fertile controls (n = 6). Quantitative HOXA10 mRNA expression was determined by real-time reverse-transcription polymerase chain reaction, and HOXA10 protein expression was determined by immunohistochemistry.

MAIN OUTCOME MEASURE(S)

Expression of HOXA10 mRNA and protein.

RESULT(S)

Expression of HOXA10 mRNA was significantly lower in infertile women with hydrosalpinges, compared with the case of fertile controls. Salpingectomy resulted in a statistically significant, 15-fold increase in endometrial HOXA10 expression. Immunohistochemical analysis confirmed the quantitative real-time reverse-transcription polymerase chain reaction findings. Increased HOXA10 expression was evident in both glandular epithelial cells and endometrial stroma.

CONCLUSION(S)

HOXA10 is necessary for implantation. Here, we demonstrate decreased HOXA10 expression in response to hydrosalpinx fluid as a potential molecular mechanism for diminished implantation rates. Salpingectomy restores endometrial HOXA10 expression. This may be one mechanism by which salpingectomy results in augmented implantation rates in IVF.

Laparoscopic Management of Hydrosalpinx

Hydrosalpinx is a common cause of female infertility. Lower implantation and pregnancy rates have been reported in women with hydrosalpinges. How hydrosalpinx exerts its negative effect on the implantation process is not clearly understood. Mechanical factors, toxicity of the hydrosalpingeal fluid, and receptivity dysfunction may explain the impaired IVF outcome in the presence of hydrosalpinx. Laparoscopic surgery has a place in the diagnosis and management of hydrosalpinx. Analysis of the results of laparoscopic management of hydrosalpinx underscores the positive role of laparoscopy in fertility outcomes in women with this pathological tubal disease. Laparoscopic salpingectomy should be offered in those women who have bilateral disease or in cases where hydrosalpinges are large enough to be visible on ultrasound. Further randomized trials are required to assess other surgical treatment options for hydrosalpinx, such as laparoscopic salpingostomy, laparoscopic or hysteroscopic tubal occlusion, and drainage of hydrosalpinx before or during oocyte retrieval.

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.

Ectopic pregnancy in a preexisting hydrosalpinx during a spontaneous pregnancy

OBJECTIVE

To discuss the possible role of abnormal embryo migration as a cause of ectopic pregnancy during IVF with hydrosalpinges.

DESIGN

Case report.

SETTING

University-based reproductive endocrinology and fertility clinic.

PATIENT(S)

A patient presenting with a tubal ectopic pregnancy after spontaneous conception in a preexisting hydrosalpinx.

INTERVENTION(S)

Laparoscopic salpingectomy.

MAIN OUTCOME MEASURE(S)

Ultrasound and operative findings.

RESULT(S)

Case demonstration of abnormal embryo migration into a surgically documented preexisting hydrosalpinx during a spontaneous conception.

CONCLUSION(S)

The mechanism of increased tubal ectopic pregnancy rates during IVF with hydrosalpinges remains unexplained. This case supports abnormal embryo migration due to the hydrosalpinx as a contributing factor.

Expression of alpha 1 and beta 3 integrins subunits in the endometrium of patients with tubal phimosis or hydrosalpinx

OBJECTIVE

To determine the expression of alpha1 and beta3 integrin subunit on the endometrium of infertile patients with hydrosalpinx and infertile patients with tubal phimosis.

DESIGN

Case-control study.

SETTING

Tertiary medical center.

PATIENT(S)

Infertile patients with radiologic or laparoscopic diagnosis of hydrosalpinx (n = 11) or tubal phimosis (n = 12) as the only cause of infertility, and fertile controls (n = 17).

INTERVENTION(S)

Immunohistochemical analysis of alpha1 and beta3 integrin subunits was performed on endometrial biopsies obtained during the implantation window.

MAIN OUTCOME MEASURE(S)

Histologic score (HSCORE) on luminal and glandular endometrium of the patients with hydrosalpinx or tubal phimosis and the normal fertile controls.

RESULT(S)

The median (+/-SEM) HSCORE for beta3 subunit expression in endometrial glands was 0.39 +/- 0.23 and 0.42 +/- 0.18 for tubal phimosis and hydrosalpinx, respectively, and 1.74 +/- 0.26 for fertile controls. The median HSCORE for beta3 subunit expression in luminal epithelium for tubal phimosis, hydrosalpinx, and fertile controls was 0.07 +/- 0.06, 0.21 +/- 0.18, and 1.03 +/- 0.31, respectively. No statistical difference was observed on the expression of alpha1 integrin subunit expression between the three groups.

CONCLUSION(S)

The endometrial expression of beta3 integrin subunit is reduced in the presence of tubal phimosis or hydrosalpinx, during the window of implantation.

Should endometriomas be treated before IVF–ICSI cycles?

The laparoscopic excision of ovarian endometriomas appears to increase the chances of spontaneous conception, but the value of this treatment in women selected for IVF-ICSI cycles is debated. Studies recruiting women with unilateral disease and comparing ovarian responsiveness in the affected and contralateral intact gonads indicate that excision of endometriomas is associated with a quantitative damage to ovarian reserve. There are no randomized trials comparing laparoscopic excision to expectant management before IVF-ICSI cycles. The idea that surgery increases IVF pregnancy rates is not supported by the available evidence. However, the chance of conception is not the only issue that has to be considered. Some potential drawbacks are associated with both therapeutical strategies. Specifically, costs and hazard of surgical complications support expectant management whereas oocyte retrieval risks, the possibility of missing occult malignancy and endometriosis progression due to ovarian stimulation would favour surgical treatment. Alternative therapeutical options include medical treatment and ultrasound-guided aspiration. Whereas prolonged GnRH agonist down-regulation may be beneficial, data on ultrasound aspiration are more controversial.

Removal of hydrosalpinges increases endometrial leukaemia inhibitory factor (LIF) expression at the time of the implantation window

BACKGROUND

The presence of hydrosalpinges is associated with lower implantation and pregnancy rates in women undergoing IVF-embryo transfer, while salpingectomy improves these parameters. Although the mechanism by which hydrosalpinges affects fertility is not entirely understood, an adverse effect on endometrial receptivity has been postulated. In this study, we hypothesized that the adverse effects of hydrosalpinges on fertility may be in part mediated by inappropriate endometrial expression of leukaemia inhibitory factor (LIF), a cytokine implicated in implantation.

METHODS

In order to test our hypothesis, we prospectively examined the expression of LIF during the window of implantation in the endometrium of infertile women (n = 10) with hydrosalpinges prior to and following salpingectomy and of fertile controls (n = 10) by Western blotting and immunohistochemistry.

RESULTS

LIF expression was significantly lower in infertile women with hydrosalpinges compared with fertile controls (P < 0.05). Salpingectomy resulted in an increase in LIF expression in eight out of 10 women with hydrosalpinges. LIF levels were increased by 231 +/-49% (mean +/- SEM) following salpingectomy. Immunohistochemical analysis confirmed the Western blot findings. The increased LIF immunoreactivity was predominantly localized to luminal and glandular epithelial cells.

CONCLUSIONS

Our findings suggest that observed benefit from salpingectomy in infertile women with hydrosalpinges may be in part mediated by the up-regulation of endometrial LIF expression.

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.

Effects of subfertility cause, smoking and body weight on the success rate of IVF

BACKGROUND

We investigated the separate and combined effects of smoking and body mass index (BMI) on the success rate of IVF for couples with different causes of subfertility.

METHODS

The success rate of IVF was examined in 8457 women. Detailed information on reproduction and lifestyle factors was combined with medical record data on IVF treatment. All IVF clinics in The Netherlands participated in this study. The main outcome measures were live birth rate per first cycle of IVF differentiated for the major predictive factors.

RESULTS

For male subfertility the delivery rate per cycle was significantly lower than unexplained subfertility, OR of 0.70 (95% CI 0.57-0.86); for tubal pathology, the delivery rate was slightly lower, OR = 0.86 (95% CI 0.70-1.01). Smoking was associated with a significantly lower delivery rate was slightly lower; for OR = 0.72 (95% CI 0.61-0.84) and a significantly higher abortion rate compared to non-smoking delivery rates of 21.4% and 16.4%, respectively (P=0.02). Women with a BMI of > or = 27 kg/m2 had a significantly lower delivery rate, with an OR of 0.67 (95% CI 0.48-0.94), compared with normal weight women (BMI > or = 20 and <27 kg/m2).

CONCLUSIONS

Both smoking and overweight unfavourably affect the live birth rate after IVF. The devastating impact of smoking on the live birth rate in IVF treatment is comparable with an increase in female age of >10 years from age 20 to 30 years. Subfertile couples may improve the outcome of IVF treatment by lifestyle changes.

Recurrent implantation failure in assisted reproduction: how to counsel and manage. A. General considerations and treatment options that may benefit the couple

Recurrent implantation failure is a distressing phenomenon, both for the infertile couple and for the physician responsible for their treatment. Aetiology is often not clear and treatment options are vague. Particularly when transferred embryos are of good quality, recurrent implantation failure may be attributed to less than optimal embryo transfer technique, pathological lesions of the uterine cavity, the presence of hydrosalpinges, fibroids and endometriosis. Poor embryo quality, especially when repetitive, is a major impediment to successful implantation and cannot be corrected at the present time. Molecular abnormalities at the endometrial level and abnormal embryo-endometrium dialogue may be responsible for some cases of recurrent implantation failure. Furthermore, there may be over- or under-expressed genes that may be related to successful implantation. At the present time, the physician confronted with a couple presenting with recurrent implantation failure should discuss openly the potential causes of this phenomenon, with special emphasis on correctable causes, and offer remedies that are evidence based.

Evidence-based diagnosis and management of tubal factor infertility

PURPOSE OF REVIEW

The investigation for potential tubal disease is an essential step in the work-up of infertility. This review article provides an evidence-based overview of the diagnosis and management of tubal factor infertility.

RECENT FINDINGS

While laparoscopic chromopertubation remains the gold standard in the diagnosis of tubal disease and hysterosalpingography is still widely used, newer modalities offer some advantages. Sonohysterography with the use of contrast medium is superior to hysterosalpingography and comparable to laparoscopic chromotubation in diagnosing tubal blockage. Chlamydia serology is the most cost-effective and least invasive diagnostic test for tubal disease, and it is comparable to, if not better than, hysterosalpingography. Depending on the nature and degree of tubal dysfunction as well as the age and ovarian reserve of the patient, various treatments for tubal infertility are available. For proximal tubal obstruction, transcervical tubal cannulation with tubal flushing is a reasonable first approach. Surgical techniques for tubal repair, such as salpingostomy or fimbrioplasty for distal tubal obstruction, can provide good results. Still, tubal factor remains a major indication for in-vitro fertilization and embryo transfer, which bypasses the tubal problem altogether. In certain situations, such as the presence of hydrosalpinx, prophylactic surgery can be used in conjunction with in-vitro fertilization and embryo transfer.

SUMMARY

As with infertility in general, the diagnosis and management of tubal infertility should be tailored to the individual patient. Future studies should help to further clarify the role of the various diagnostic tests and therapeutic approaches for tubal infertility.

Rapid reaccumulation of hydrometra after drainage at embryo transfer in patients with hydrosalpinx

OBJECTIVE

To report the occurrence and management of hydrometra at the time of scheduled embryo transfer in two patients who underwent drainage of hydrosalpinges at oocyte retrieval.

DESIGN

Case report. University IVF clinic.

PATIENT(S)

Two patients with hydrosalpinges visible on ultrasonography who deferred tubal surgery. Although no fluid was seen at the time of oocyte retrieval, hydrometra was noticed and drained before planned embryo transfer (ET).

MAIN OUTCOME MEASURE(S)

Reoccurrence of hydrometra after drainage.

RESULT(S)

Rapid reaccumulation of hydrometra despite drainage was seen in both patients, one of whom had reoccurrence in 1 hour. Embryo transfer was deferred until after tubal surgery, and all embryos were cryopreserved.

CONCLUSION(S)

In patients with hydrosalpinges, ultrasonography before ET is useful to detect newly developed hydrometra. Aspiration of the uterine fluid is unlikely to help because of rapid reaccumulation of hydrometra. Cryopreservation of the embryos for future transfer after the hydrosalpinx is removed or ligated is recommended.

Semen polymorphonuclear neutrophil leukocyte elastase as a diagnostic and prognostic marker of genital tract inflammation--a review

Elastase is a protease released by polymorphonuclear neutrophils (PMN) during the inflammatory process. Since 1987, seminal elastase-inhibitor complex (Ela/alpha1-PI) has been proposed as a marker of male silent genital tract inflammation. Measured by immunoassay in seminal plasma, Ela/alpha1-PI at a cut-off level of > or = 230 microg/l, is useful in the detection of genital tract inflammation. The prevalence of increased seminal Ela/alpha1-PI in infertile men is significantly higher than that observed in fertile men. The Ela/alpha1-PI level is positively correlated with other seminal fluid markers of male genital tract inflammation: reduced semen volume, citric acid, fructose, and increased albumin, complement component C3, caeruloplasmin, immunoglobulins IgG and IgA, and cytokines interleukins-8 and -6. A higher seminal Ela/alpha1-PI level is significantly associated with tubal damage in female partners. After antibiotic therapy, a decrease of Ela/alpha1-PI level is observed. The presence of tubal damage in the partner may negatively affect the response to antibiotic treatment. A higher seminal Ela/alpha1-PI is associated with lower percentage of sperm with single-stranded deoxyribonucleic acid (DNA) and better fertilization rate in in vitro fertilization. Besides infertility, the determination of Ela/alpha1-PI is useful to confirm the presence of prostate and other male accessory gland bacterial inflammation. Screening for PMN Ela/alpha1-PI is easy to perform and reproducible and is a reliable quantitative test for diagnosis and prognosis of silent genital tract inflammation of couples. Moreover, sequential determinations allow the follow-up of inflammation during and after therapy.