Salpingectomy and Proximal Tubal Occlusion for Hydrosalpinx Prior to In Vitro Fertilization

Prior salpingectomy impairs the retrieved oocyte number in in vitro fertilization cycles of women under 35 years old without optimal ovarian reserve

STUDY OBJECTIVE

The impairment of the ovarian response in in vitro fertilization (IVF) cycles after salpingectomy remains contentious. Therefore, we investigated whether a history of salpingectomy affects the number of oocytes retrieved in women undergoing IVF in comparison with the number in women without underlying tubal disease.

DESIGN

Case-control study (Canadian Task Force Classification II-2).

SETTING

A tertiary hospital-affiliated fertility center.

PATIENTS

Fifty-four women aged <35 years with a history of salpingectomy and 59 age-matched women without tubal disease.

INTERVENTIONS

Gonadotropin-releasing hormone antagonist protocol for controlled ovarian stimulation and transvaginal oocyte retrieval.

MEASUREMENTS AND MAIN RESULTS

The antral follicle count (AFC), anti-Müllerian hormone (AMH) levels, and the number of retrieved oocytes were significantly lower in women with prior salpingectomy than in women without tubal disease. Day-3 follicle-stimulating hormone (FSH) levels, total gonadotropin dosage, and stimulation days did not significantly differ between the groups. The indications of salpingectomy (i.e., hydrosalpinx and ectopic pregnancy) did not differ significantly in terms of ovarian response or reserve among women with salpingectomy history. A history of salpingectomy and other factors related to ovarian response in IVF, such as age, AMH, AFC, day-3 FSH, and total gonadotropin dose, were significantly correlated with the number of oocytes retrieved by univariate regression analysis. In the multivariate-adjusted model after controlling all the above-mentioned variables, only AFC and AMH levels continued to exhibit significant associations with the number of retrieved oocytes. In a subgroup analysis, the negative impact of prior salpingectomy on the number of retrieved oocytes was especially significant in women with suboptimal ovarian reserves (defined as AMH < 4 ng/mL), regardless of the indication of salpingectomy or whether salpingectomy was bilateral or unilateral.

CONCLUSION

A negative effect on the number of retrieved oocytes in the subsequent IVF cycle after salpingectomy is more likely in women aged <35 years with suboptimal ovarian reserve. Nevertheless, postsurgical AMH and AFC levels still possess a more direct predictive value on ovarian response than the history of salpingectomy.

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.

State of the art and emerging drug therapies for female infertility

At present, infertility is a key-issue. When applicable, in vitro fertilization (IVF) has become the standard approach to treat this condition but a thorough investigation and, whenever possible, the individual diagnosis of the underlying causes of infertility are required. For many female causes, indeed, efficient medical therapies are available to achieve a fast solution of the problem. This review is based on the relevant literature indexed in PubMed and SCOPUS and is focused on the most recent clinical literature on the treatment of women (and couples) affected from infertility. The reduction in IVF treatment burden and risks are now considered pivotal to set 'patient-friendly' therapies and represent crucial issues for both patients and physicians. To this end, the researchers are now focusing their attention on old drugs with new indications and new compounds with more appropriate functions, to improve the compliance of the women and reduce the burden of infertility, a condition that is becoming an important issue in the modern world, also for the Public Health System.

Hysteroscopic Placement of Platinum Microinsert in Patients With Hydrosalpinx Before In Vitro Fertilization and Embryo Transfer

OBJECTIVE

To investigate the effectiveness of Tornado and Hilal (Cook Medical, Bloomington, IN) hysteroscopic proximal tubal occlusion (HPTO) for hydrosalpinx (HX) treatment before in vitro fertilization (IVF) and embryo transfer (ET) in patients with dense pelvic adhesions or low ovarian reserve.

DESIGN

A retrospective study of patients treated between May 2014 and May 2016 (Canadian Task Force classification III).

SETTING

A university-affiliated center.

PATIENTS

One hundred fifty women with unilateral or bilateral HX who were not candidates for laparoscopic surgery.

INTERVENTION

Tornado or Hilal HPTO before IVF-ET and/or frozen ET.

MEASUREMENTS AND MAIN RESULTS

The main outcome was the cumulative live birth rate. Tornado or Hilal placement was successful for 143 (95.3%) patients. Of the 132 patients who underwent 204 ET cycles, 86 (65.2%) conceived, and 78 (59.1%) resulted in live births. The overall early and late miscarriage rates per clinical pregnancy were 12.8% and 1.1%, respectively. The ectopic pregnancy rate was 2.3%. No major complications occurred.

CONCLUSION

Tornado or Hilal HPTO is an effective alternative for treating HX before IVF-ET/frozen ET in patients with dense pelvic adhesions or low ovarian reserve.

Fibered platinum coil: A novel option for the patients of hydrosalpinx with laparoscopic contradiction

OBJECTIVE

To investigate the feasibility of proximal tubal occlusion with fibered platinum coils in subfertile women with hydrosalpinx, and to observe the clinical outcomes of subsequent treatment with in vitro fertilization and embryo transfer (IVF-ET).

STUDY DESIGN

A prospective study was carried out in a university-affiliated teaching hospital. 56 women with uni- or bilateral hydrosalpinx received fibered platinum coil placement before IVF-ET. The clinical pregnancy rate and live birth rate was evaluated. Data analysis was performed with SPSS version 22.0 (SPSS, Inc., Chicago, IL, USA), using two-sided test, and a p value < 0.05 was considered statistically significant. The study has been registered in the ClinicalTrials. gov with the number of NCT03395301.

RESULT(S)

Successful placement was achieved in 106 fallopian tubes of 55 patients. The fibered platinum coils induced complete proximal occlusion in 52 out of 55 patients in the following 3-month HSG examination. In the 52 patients, 44 patients received following IVF-ET. The clinical pregnancy rate reached 60.5%(23/38)and live birth rate reached 60.87% (14/23) in patients less than 40 years old.

CONCLUSION(S)

Fibered platinum coil is a new, safe and valuable device for hysteroscopic tubal proximal occlusion in subfertile women with hydrosalpinx but with laparoscopic contradictions to improve the reproductive outcomes of IVF-ET. Capsule: Fibered platinum coil is a new, safe and valuable device for hysteroscopic tubal proximal occlusion in subfertile women with hydrosalpinx to improve the reproductive outcomes of in vitro fertilization and embryo transfer.

Effect of Surgical Adhesive on the Uterus of Rabbits Following Occlusion

Purpose/Aim of the Study: The present study investigated the effect of surgical adhesives on the uterus of rabbits and the histomorphology alterations following occlusion, to improve the clinical treatment of abnormal fallopian tube with surgical adhesives for in vitro fertilization and embryo transfer (IVF-ET). Materials and Methods: The experimental rabbits received laparotomy and occlusion of the uterus by surgical adhesive adjacent to the two fallopian tubes, while the control rabbits only received laparotomy. The body weight, hysterosalpingography, and histomorphology were measured to evaluate the uterine occlusion at 1 and 6 months after surgery. Results: There was no significant difference in the mortality rate or body weight between the experimental and control groups. In the experimental group, 38 uterine cavities were identified in 19 rabbits, of which 97.37% were occluded, with expanded uterine cavity and tissue oppression at 1 month after surgery. In total, 33 uterine cavities out of the 36 in the control group were occluded, with proliferation of new stratified epithelial cells observed at 6 months after surgery. In the control group, 20 uterine cavities of 10 rabbits were observed to be absent of occlusion at 1 month after surgery, while 18 uterine cavities in the remaining 9 rabbits were also absent of occlusion at 6 months after the surgery. Conclusion: Surgical adhesives are effective in occluding the uterus of rabbits without adverse effects, supporting their potential clinical use to treat the occlusion in abnormal fallopian tubes prior to IVF-ET.

Hydrosalpinx: Tubal surgery or in vitro fertilisation? An everlasting dilemma nowadays; a narrative review

The decision on how to treat tubal diseases, specifically hydrosalpinx, is a difficult one. Ιt involves surgical, medical, social, emotional and economic factors. This narrative review aims to increase awareness of tubal disease diagnosis and treatment, to compare between tubal surgery and in vitro fertilisation (IVF) for tubal factor infertility, and to investigate the effect of the combination of both. This way, we can be more effective, safe and provide our patients with better treatment results. The review analysed randomised studies, trials and meta-analysis, which give new aspects on the treatment methods for tubal pathology before IVF. Recent papers published in English have been studied, alongside guidelines and committee opinions from previous years. Tubal surgery and IVF aim to exploit a woman's reproductive potential. IVF and endoscopic tubal surgery must be thought of as complementary, rather than competing techniques in tubal disease cases, in order to improve fertility outcome. The first-line treatment for young women less than 35 years old with minor tubal pathology, is tubal surgery. IVF should be offered if there are other factors in a couple's subfertility, if the patient is >38 years old, if moderate to severe tubal disease is present, and if it has been more than 12 months post-surgery.

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.

3 to 5 Years Later: Long-term Effects of Prophylactic Bilateral Salpingectomy on Ovarian Function

STUDY OBJECTIVE

Preliminary data on the effects of prophylactic bilateral salpingectomy (PBS) show that postoperative ovarian function is preserved up to 3 months after surgery. The confirmation of PBS safety on ovarian function even many years after surgery is essential to reassure the medical community that this new strategy, recently proposed for the prevention of ovarian cancer, is at least able to avoid the risk of premature surgical menopause. We investigated whether the addition of PBS during total laparoscopic hysterectomy (TLH) causes long-term effects on ovarian function.

DESIGN

An observational study (Canadian Task Force classification II-3).

SETTING

Department of Obstetrics and Gynecology, "Magna Graecia" University, Catanzaro, Italy.

PATIENTS

Seventy-nine patients who underwent TLH plus salpingectomy between September 2010 and September 2012 at our institution have been recalled to be submitted to ovarian reserve evaluation in February 2015. Eight of 79 women refused to participate in this follow-up study.

INTERVENTIONS

The ovarian age of PBS patients has been determined through OvAge (OvAge sr., Catanzaro, Italy), a statistical model that combines antimüllerian hormone, follicle-stimulating hormone, 3-dimensional antral follicle count, vascular index, flow index, and vascular flow index values. The control group consisted of a large population of 652 healthy women (with intact uterus and adnexa) previously enrolled to build the OvAge model. Comparisons between ovarian ages of PBS patients and the control group have been assessed by analysis of covariance linear statistical modeling.

MEASUREMENTS AND MAIN RESULTS

The main outcome measurement was the differences in the behavior within OvAge/age relation between PBS and control women. Descriptive statistics of those 71 enrolled PBS patients are the following: age, 49.61 ± 2.15 years; OvAge, 49.22 ± 2.57 years; follicle-stimulating hormone, 43.02 ± 19.92 mU/mL; antimüllerian hormone, 0.12 ± 0.20 ng/mL; 3-dimensional antral follicle count, 1.91 ± 1.28; vascular index, 2.80% ± 5.32%; flow index, 19.37 ± 5.88; and vascular flow index, 0.56 ± 1.12. Analysis of covariance disclosed that PBS and control women do not exhibit different behaviors (p = .900) within OvAge/age relation.

CONCLUSION

According to our model, the addition of PBS to TLH in the late reproductive years does not modify the ovarian age of treated women up to 3 to 5 years after surgery.