Treatment of hydrosalpinx in the patient undergoing assisted reproduction

Comparison of salpingectomy and tubal occlusion for hydrosalpinx in in-vitro fertilization outcome

The occurrence of hydrosalpinx can reduce the success rate of assisted reproductive technology. The laparoscopic salpingectomy and tubal occlusion have been shown to improve in-vitro fertilization (IVF) outcomes in this disease. The primary goal of this review was to assess and compare the IVF outcome following salpingectomy or tubal occlusion in the published literature. The authors included studies with at least one of the following outcomes: days of controlled ovarian hyperstimulation, retrieved oocyte number, fertilization rates, clinical pregnancy rate, miscarriage rate, or ectopic pregnancy rate. In conclusion, proximal tubal occlusion outperforms salpingectomy in terms of fertilization rate while offering no evident advantages in terms of days of controlled ovarian hyperstimulation, retrieved oocytes number, IVF results, or problems in treating hydrosalpinx patients prior to IVF. These data may help clinicians choose the best therapy for patients with hydrosalpinx prior to IVF.

The role of IL-6/JAK/STAT signal in female infertility caused by hydrosalpinx

INTRODUCTION

To explore the role of IL-6/JAK/STAT signaling in tubal infertility.

METHODS

The fimbriae tissues of 14 patients with a history of infertility and hydrosalpinx and 14 patients with no history of infertility and no fallopian tube disease were collected. The tissues were then divided into hydrosalpinx group and control group followed by analysis of the protein expression of key factors in the IL-6/JAK/STAT signaling by immunohistochemistry and Western blot.

RESULTS

Immunohistochemical staining showed significantly higher level of IL-6, JAK1, p-JAK1, JAK2, p-JAK2, STAT1, p-STAT1, STAT3, and p-STAT3 in hydrosalpinx group than those in control group with IL-6 being mainly located in the cytoplasm and p-JAK2, STAT1, p-STAT1, STAT3, and p-STAT3 in the cytoplasm and nucleus. JAK1 and p-JAK1 was mainly located in the cytoplasm and JAK2 is in the cytoplasm and nucleus without difference of their expression between two groups. Consistently, hydrosalpinx group presented significantly higher protein levels of IL-6, JAK1, p-JAK1, JAK2, p-JAK2, STAT1, p-STAT1, STAT3, and p-STAT3 than control group without difference of JAK1, p-JAK1, JAK2 level.

CONCLUSION

The activation of IL-6/JAK2/STAT1 and STAT3 signaling pathways are found in the hydrosalpinx in infertile patients, indicating that they might be involved in the pathogenesis of hydrosalpinx.

Ovarian Response, Pregnancy Outcomes, and Complications Between Salpingectomy and Proximal Tubal Occlusion in Hydrosalpinx Patients Before in vitro Fertilization: A Meta-Analysis

Objectives

Contradictory findings exist in studies comparing salpingectomy and proximal tubal occlusion (PTO) in treating hydrosalpinx patients before in vitro fertilization (IVF). Therefore, this meta-analysis aimed to comprehensively compare ovarian response, pregnancy outcomes, and complications between salpingectomy and PTO in treating these patients.

Methods

Embase, PubMed, and Web of Science were searched to identify relevant articles published from 1980 to August 31, 2020. Eight studies that involve 716 hydrosalpinx patients before IVF were included, among whom 408 patients received salpingectomy and 308 patients received PTO. The data were pooled; the standardized mean difference (SMD) or odds ratio (OR) was calculated.

Results

Proximal tubal occlusion-treated patients had higher fertilization rate (SMD = 0.35, 95% CI: 0.11–0.59), while similar days of controlled ovarian hyperstimulation (COH) (SMD: 0.15, 95% CI: −0.36–0.67) and number of retrieved oocytes (SMD = −0.22, 95% CI: −0.54–0.10) compared with salpingectomy-treated patients. Furthermore, no difference of implantation rate (OR = 1.17, 95% CI: 0.62–2.20), clinical pregnancy rate (OR = 0.82, 95% CI: 0.59–1.15), ongoing pregnancy rate (OR = 0.64, 95% CI: 0.36–1.13), or live birth rate (OR = 0.67, 95% CI: 0.16–2.72) was shown between salpingectomy-treated patients and PTO-treated patients. Additionally, ectopic pregnancy rate (OR = 1.13, 95% CI: 0.21–5.92) and miscarriage rate (OR = 0.88, 95% CI: 0.31–2.48) were similar between salpingectomy-treated patients and PTO-treated patients.

Conclusion

Proximal tubal occlusion exhibits a higher fertilization rate but no obvious benefits on days of COH, number of retrieved oocytes, pregnancy outcomes, and complications over salpingectomy in hydrosalpinx patients before IVF.

ACR Appropriateness Criteria® Female Infertility

The most common known causes of female infertility are male factor (26%), ovulatory failure (21%), and tubal damage (14%), while in 28% a couple's infertility remains unexplained. Female-specific causes of infertility include deterioration of oocyte quality with increasing maternal age; ovulatory disorders, most notably polycystic ovarian syndrome; history of salpingitis such as that caused by chlamydia infection; endometriosis; and uterine cavity abnormalities interfering with implantation causing inability to become pregnant or causing recurrent pregnancy loss. These potential causes of female infertility are discussed in this document and the appropriate imaging recommendations for each variant are provided. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Uterine peristalsis and fertility: current knowledge and future perspectives: a review and meta-analysis

Although uterine contractions in the non-pregnant uterus have been studied extensively, the knowledge gained has not been used in general fertility treatment work-up. In this review paper, we provide an overview of the current knowledge on uterine peristalsis (UP), based on the available literature. This literature shows that UP influences pregnancy chances in both natural and artificial cycles. Although the physiological background of these contractions is not completely clear, we know that several factors can be of influence, like uterine pathologies and hormones. Several options to alter pregnancy outcome by interfering with uterine contractions have been studied. Our meta-analysis on therapeutic options shows positive results of progesterone at time of embryo transfer in IVF cycles or prostaglandins at time of intrauterine insemination, although the quality of evidence is low. These therapies are probably most beneficial in selected groups of patients with abnormal contraction patterns. The introduction of an objective and user-friendly UP measuring tool suitable for use in daily practice would make it possible to identify and monitor these patients. We suggest that future research should focus on the physiology of initiation of UP and on the development of an effective standard measuring tool.

A Decade of Pelvic Pain and Infertility: A Case Report of an Unexpected Intraoperative Discovery

Introduction

Retained surgical objects can impact quality of life as it relates to chronic pelvic pain and reproductive health.

Case report

A 39-year-old G1P0010 with chronic pelvic pain and infertility attributed to pelvic adhesions and bilateral hydrosalpinx caused by an 18-cm surgical drain left 10 years prior.

Conclusions

Our case highlights the significance of thoughtful perioperative care as well as special considerations when approaching patients with pelvic pain and infertility with histories of abdominopelvic surgery.

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.

Excessive intrauterine fluid cause aberrant implantation and pregnancy outcome in mice

The normal intrauterine fluid environment is essential for embryo implantation. In hydrosalpinx patients, the implantation and pregnancy rates are markedly decreased after IVF-embryo transfer, while salpingectomy could significantly improve the pregnancy rates. The leakage of hydrosalpinx fluid into the endometrial cavity was supposed to be the major cause for impaired fertility. However, the underlying mechanisms of hydrosalpinx fluids on implantation and ongoing pregnancy were not fully understood and remain controversial regarding its toxicity. In present study, by infusing different volume of non-toxic fluid (0.9% saline) into uterine lumen before embryo implantation in mice (Day4 08:30), we found that while the embryos were not "flushed out" from the uteri, the timing of implantation was deferred and normal intrauterine distribution (embryo spacing) was disrupted. The abnormal implantation at early pregnancy further lead to embryo growth retardation, miscarriage and increased pregnancy loss, which is similar to the adverse effects observed in hydrosalpinx patients undergoing IVF-ET. We further examined uterine receptivity related gene expression reported to be involved in human hydrosalpinx (Lif, Hoxa10, Integrin α(v) and β(3)). The results showed that expression of integrin α(v) and β(3) were increased in the fluid infused mouse uteri, implicating a compensatory effect to cope with the excessive fluid environment. Our data suggested that the adverse effects of excessive non-toxic luminal fluid on pregnancy are primarily due to the mechanical interference for normal timing and location of embryo apposition, which might be the major cause of decreased implantation rate in IVF-ET patients 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.

How to deal with fluid in the endometrial cavity during assisted reproductive techniques

PURPOSE OF REVIEW

Patients with endometrial cavity fluid (ECF) in assisted reproductive techniques (ARTs) are poor in prognosis. This review presents the research development of ECF during ARTs, particularly in treatment.

RECENT FINDINGS

ECF patients with or without tubal infertility may represent a different clinical entity. ECF impairs the ART outcome in tubal factor, but not polycystic ovarian syndrome, patients. Actually, it was tubal infertility, not only hydrosalpinx, that was related to the development of ECF. Both appearance time and accumulation amount of ECF are critical in the impact of ECF on the ART outcome. Since excessive ECF (equal to or higher than 3.5 mm in the anterior-posterior diameter) usually had a negative impact on the ART outcome, postponing embryo transfer should be considered. A nonexcessive ECF usually disappeared by the time of embryo transfer. The routine embryo transfer in these ECF patients could yield the same ART outcome as in patients without ECF. If a nonexcessive ECF persisted until the day of embryo transfer, particularly in patients with nontube infertility, transvaginal sonographic aspiration could be an alternative of treatment.

SUMMARY

The treatment of ECF during ARTs should be individual according to the causes, appearance time and accumulation amount of ECF.

Management of 273 cases of recurrent implantation failure: results of a combined evidence-based protocol

This study evaluated the results of a management protocol combining a number of investigations and interventions, previously proven beneficial in randomized controlled trials in IVF/intracytoplasmic sperm injection (ICSI) patients with apparently unexplained recurrent implantation failure (defined as two or more previous failed cycles, during which at least six good-quality embryos were transferred). It was a prospective cohort study and included 273 couples with previous recurrent implantation failure. Each patient (all under 40) underwent a pre-treatment work-up, consisting of pelvic ultrasound scan for hydrosalpinx, hysteroscopy and screening for acquired and congenital thrombophilia. Detected abnormalities were dealt with accordingly: proximal occlusion for hydrosalpinx, hysteroscopic management for intrauterine pathology and thromboprophylaxis with daily low-molecular weight heparin from the day of embryo transfer for thrombophilia. The patients then underwent IVF/ICSI with laser-assisted hatching. 112 patients (41%; group 1) had abnormalities detected (17 hydrosalpinx, 11 intrauterine pathology, 63 congenital thrombophilia, 21 acquired thrombophilia) and the remaining 161 (59%; group 2) had normal work-up. The pregnancy rates per cycle started for all patients, group 1 and group 2 were 47%, 55% and 41%, respectively. This suggests that using the described management protocol in couples with previous recurrent implantation failure leads to a favourable chance of success.

Approaches to improve the diagnosis and management of infertility

BACKGROUND Recent advances in our understanding of the causes of infertility and of assisted reproductive technology (ART) have led to the development of complex diagnostic tools, prognostic models and treatment options. The Third Evian Annual Reproduction (EVAR) Workshop Meeting was held on 26-27 April 2008 to evaluate evidence supporting current approaches to the diagnosis and management of infertility and to identify areas for future research efforts. METHODS Specialist reproductive medicine clinicians and scientists delivered presentations based on published literature and ongoing research on patient work-up, ovarian stimulation and embryo quality assessment during ART. This report is based on the expert presentations and subsequent group discussions and was supplemented with publications from literature searches and the authors' knowledge. RESULTS It was agreed that single embryo transfer (SET) should be used with increasing frequency in cycles of ART. Continued improvements in cryopreservation techniques, which improve pregnancy rates using supernumerary frozen embryos, are expected to augment the global uptake of SET. Adaptation and personalization of fertility therapy may help to optimize efficacy and safety outcomes for individual patients. Prognostic modelling and personalized management strategies based on individual patient characteristics may prove to represent real progress towards improved treatment. However, at present, there is limited good-quality evidence to support the use of these individualized approaches. CONCLUSIONS Greater quality control and standardization of clinical and laboratory evaluations are required to optimize ART practices and improve individual patient outcomes. Well-designed, good-quality studies are required to drive improvements to the diagnosis and management of ART processes.