The effect of unilateral tubal block diagnosed by hysterosalpingogram on clinical pregnancy rate in intrauterine insemination cycles: systematic review and meta‐analysis

Factors Influencing the Visualization of Fallopian Tubes in Hysterosalpingo-Contrast Sonography (HyCoSy)-The Value of Multimodal HyCoSy in Visualizing the Fallopian Tubes

BACKGROUND

Four-dimensional hysterosalpingo-contrast sonography (4D-HyCoSy) can non-invasively evaluate the patency of the fallopian tubes and is increasingly used in clinical practice. However, some factors may lead to false-positive diagnoses. This study aims to analyze the factors affecting clear imaging of the fallopian tubes in 4D-HyCoSy and explore methods to improve the quality of fallopian tube imaging.

METHODS

A total of 118 patients were enrolled in this retrospective study. After injecting the SonoVue into the uterine cavity, three modes of HyCoSy were completed in sequence: 4D-HyCoSy, 2D-HyCoSy, and second harmonic imaging (SHI). Participants were divided into two groups: the easy visualization group (fallopian tubes could be visualized using only 4D-HyCoSy) and the difficult visualization group (a multimodal combination was required for visualization). The position of the uterus, the relationship between the ovaries and the uterus, endometrial thickness, time of catheterization in the uterine cavity, presence or absence of lesions in the uterine cavity, whether intestinal gas covers the fallopian tubes and the imaging effect of different modes on the fallopian tubes was analyzed, to determine the key factors affecting the clear imaging of the fallopian tubes.

RESULTS

The positional relationship between the ovary and the uterus (OR = 4.711, 95% CI: 1.322-19.77, P = 0.023), the positioning of the uterus (OR = 3.843, 95% CI: 1.129-15.26, P = 0.04), endometrial thickness (OR = 3.985, 95% CI: 1.168-15.99, P = 0.036), and the duration of intrauterine catheter placement (OR = 3.547, 95% CI: 1.042-13.52, P = 0.05) were independent factors that affecting difficulty in visualizing the fallopian tubes.

CONCLUSION

Uterine position, the positional relationship between the ovary and the uterus, endometrial thickness, and the time of catheter insertion are factors that affect visualizing the fallopian tubes during 4D-HyCoSy. The combination of multimodal imaging, especially the combination of 4D-HyCoSy with SHI mode, can help improve the quality of fallopian tube visualization.

Incidence and Causes of Tubal Occlusion in Infertility: A Retrospective Cohort Study

Background and Objectives: Fallopian tubal pathology is a primary risk factor for female infertility, with simple proximal disease and proximal disease extending more distally being more common than pure distal occlusion. Proximal tubal occlusion is often attributed to ascending events, such as pelvic inflammatory disease. Conversely, while distal occlusion can also be attributable to ascending pelvic inflammatory disease, it can also have a pelvic origin, such as through endometriosis and ruptured appendicitis. The aim of this study was to identify certain causes of infertility and their association with tubal occlusion. The focus was on the location of tubal occlusion, uni- versus bilateral occlusion, and other causes of infertility, including male factors. Methods: In a retrospective study cohort study, 373 women aged between 18 and 40 years, treated from 1 January 2017 to 31 December 2022, were included. Fallopian tube patency was tested using either hysterosalpingography, hysterosalpingo-contrast sonography, or laparoscopic chromopertubation. Results: In total, 95 of 373 women (25.5%) revealed at least one occluded tube, with unilateral occlusion being more common than bilateral occlusion (60/95, 63.2% vs. 35/95, 36.8%). The majority of tubal occlusions occurred proximally (86.2%). According to the adjusted multivariate regression models, the presence of hydrosalpinx (odds ratio, OR, 13.323, 95% confidence interval, CI: 2.679-66.253, p = 0.002), myomas (OR 2.108, 95%CI: 1.008-4.409; p = 0.048), and an abnormal sperm test result of the male partner (OR 2.105, 95%CI: 1.156-3.833; p = 0.015) were statistically significant associated factors for tubal occlusion. Conclusions: Fallopian tube patency testing is still of major relevance in fertility evaluation. The presence of uterine myomas, hydrosalpinges, and a male factor significantly increase the risk.

Diagnosis and management of infertility: NICE-adapted guidelines from the Italian Society of Human Reproduction

In Italy the fertility rate is very low, and an increasing number of patients are infertile and require treatments. The Italian Law concerning the safety of patient care, and the professional liability of health professionals, indicates that health professionals must comply with the recommendations set out in the guidelines developed by public and private bodies and institutions, as well as scientific societies and technical-scientific associations of the health professions, except for specific cases. Unfortunately, no guideline for the diagnosis and the management of infertility is currently available in Italy. In 2019, the Italian Society of Human Reproduction pointed out the need to produce Italian guidelines and subsequently approved the establishment of a multidisciplinary and multiprofessional working group (MMWG) to develop such a guideline. The MMWG was representative of 5 scientific societies, one national federation of professional orders, 3 citizens' and patients' associations, 5 professions (including lawyer, biologist, doctor, midwife, and psychologist), and 3 medical specialties (including medical genetics, obstetrics and gynecology, and urology). The MMWG chose to adapt a high-quality guideline to the Italian context instead of developing one from scratch. Using the Italian version of the Appraisal of Guidelines for Research and Evaluation II scoring system, the National Institute of Clinical Excellence guidelines were selected and adapted to the Italian context. The document was improved upon by incorporating comments and suggestions where needed. This study presents the process of adaptation and discusses the pros and cons of the often-neglected choice of adapting rather than developing new guidelines.

Hysterosalpingography: a step up for dose reduction

AIM

To evaluate the efficiency of last image capture in interpreting a hysterosalpingogram (HSG) when compared to conventional spot views; to confirm its validity in showing pathology; to establish its use as the preferred method; and to decrease the radiation dose to the patient.

MATERIALS AND METHODS

The study population consisted of women aged ≥18 years. A standard technique was performed including additional five last image capture after each spot view. Every patient had two stacks of images, one with the exposure film and one with the last image capture. The images were interpreted separately (high-dose versus low-dose) and blindly by two radiologists with different levels of training assessing for uterine abnormalities, fallopian tube abnormalities, peritoneal spillage, and incidental findings. Inter-reading variability was calculated using Kohen's kappa.

RESULTS

Discrepancies between exposure film and last image capture were detected in only a minority of cases for all variables. Except for the presence of strictures, there was at least substantial agreement between the readers and almost perfect agreement regarding peritoneal spillage and fallopian tube patency, both on exposure film and last image capture.

CONCLUSION

Reduction in radiation dose without compromising the diagnostic efficacy of HSG is mandatory. If the study is of sufficient quality and deemed negative on last image capture, conventional spot view can be avoided. If further detail is required, standard spot views can still be obtained. Using last image capture instead of spot films has the potential to reduce the overall radiation dose by up to 78%.

Optimizing intrauterine insemination and spontaneous conception in women with unilateral hydrosalpinx or tubal pathology: A systematic review and narrative synthesis

BACKGROUND

Tubal surgery's role in infertile women with unilateral tubal pathology (e.g. hydrosalpinx, tubal occlusion) who desire spontaneous or intrauterine insemination (IUI) conception where in-vitro fertilisation is infeasible remains unclear.

OBJECTIVE

To conduct a systematic review on fertility outcomes in women with unilateral tubal pathology desiring to conceive spontaneously or via IUI and to find guidance to support therapeutic tubal procedures to help these women conceive.

SEARCH STRATEGY

Using a protocol registered on PROSPERO (ID CRD42021248720), we searched PubMed, EMBASE, CINAHL, and Cochrane Library from inception until June 2022. Bibliographies were reviewed to identify other relevant articles.

DATA COLLECTION AND ANALYSIS

Two authors independently selected and extracted data. Disagreements were resolved by a third author. Studies presenting fertility outcome data in infertile women with unilateral tubal pathologies desiring spontaneous or IUI conception were included. Methodologic quality was assessed using a modified Newcastle Ottawa Scale for observational studies and the Institute of Health Economics Quality Appraisal Checklist for case series. Primary outcomes collated included cumulative pregnancy rate (CPR) and pregnancy rate per cycle (PR/cycle). Secondary outcomes such as ectopic pregnancy, birth outcomes, and pelvic inflammatory disease were collated. These were stratified by the types of unilateral tubal occlusion (UTO) i.e. hydrosalpinx, proximal tubal occlusion (PTO), or distal tubal occlusion (DTO) MAIN RESULTS: Two studies reported spontaneous or IUI pregnancies after treatment of unilateral hydrosalpinx with one reporting a pregnancy rate of 88% within 5.6 months on average. Thirteen studies compared IUI outcomes between women with UTO vs unexplained infertility and bilateral tubal patency (controls). Almost all were retrospective cohort studies and identified UTO by hysterosalpingography. In general, PTOs had no difference in PR/cycle and CPR compared to controls and significantly higher PR/cycle to DTOs. Women with DTOs had minimal incremental CPR benefit with each additional IUI cycle.

CONCLUSIONS

Therapeutic salpingectomy or tubal occlusion improve IUI or spontaneous conception in women with hydrosalpinx, although more prospective studies are needed. While significant study heterogeneity hampered assessment of fertility outcomes, overall, infertile women with PTOs had similar IUI pregnancy outcomes to those with bilateral tubal patency while DTOs had inferior PR/cycle. This review highlights significant deficiencies in the evidence guiding management for this group of patients.

Diagnostic laparoscopy prior to IVF cycle improves outcome in patients with unilateral distal tubal occlusion

OBJECTIVE

To assess the impact of laparoscopy before in vitro fertilization (IVF) treatment on live birth rates in patients with distal unilateral tubal obstruction (UTO).

METHODS

Retrospective cohort study which was conducted in tertiary ART center in Ankara University Hospital between January 2008- January 2019. Inclusion criteria were distal UTO at HSG, patients who were 18-40 years age and baseline serum FSH levels between 3-15 IU/ml. Exclusion criteria were patients who had previous tubal surgery and, hormonal dysfunction such as hyperprolactinemia or hypothyroidism at the time of the IVF cycle.

RESULTS

49 patients who underwent 117 IVF treatment cycles were included in the final analysis. Among those 17 patients (34 IVF cycles) in the study group who underwent laparoscopy prior to IVF cycles, and 32 patients (83 IVF cycles) in the control group who directly underwent IVF cycle with no prior laparoscopy. Eleven pathologies (64.7%) were detected and treated at laparoscopies of 17 patients with distal UTO. Both the clinical pregnancy and the live birth rates were also significantly higher in the study group when compared to the control group (29.4% vs. 12%, P=.031; 26.5% vs. 9.6%, respectively; P=.039).

CONCLUSIONS

Patients with distal UTO generally have a pelvic pathology and laparoscopy prior to IVF cycles can improve the treatment outcome.

Association of adverse birth outcomes with in vitro fertilization after controlling infertility factors based on a singleton live birth cohort

Infants conceived with in vitro fertilization (IVF) are exposed to underlying infertility and the IVF process. High risks of adverse birth outcomes (ABOs) were observed among these infants, including preterm birth, low birth weight, macrosomia, being large/small for gestational age (LGA/SGA). It is unclear whether the specific etiology of the rise of ABOs among IVF infants is IVF technology itself or underlying infertility. A total of 9,480 singletons conceived with IVF and 1,952,419 singletons from the general population were obtained in this study. Multivariable logistic regression model was used to assess variations in risk of ABOs according to causes of infertility. Poisson distributions were applied to calculate standardized risk ratios of IVF infants vs. general population after controlling the causes of infertility. Higher risk of preterm birth and low birth weight were observed among parents with polycystic ovary syndrome, endometriosis, uterine and semen abnormalities. Compared to the general population, after excluding the influence of infertility causes, singletons conceived with IVF were at higher risk of macrosomia (SRR = 1.28, 95% CI 1.14-1.44) and LGA (SRR = 1.25, 95% CI 1.15-1.35). The higher risk of ABOs in IVF was driven by both IVF treatments and infertility, which is important for improving IVF treatments and the managing pregnancies and child development.

OUP accepted manuscript

STUDY QUESTION

Does hysterosalpingo-foam sonography (HyFoSy) lead to similar pregnancy outcomes, compared with hysterosalpingography (HSG), as first-choice tubal patency test in infertile couples?

SUMMARY ANSWER

HyFoSy and HSG produce similar findings in a majority of patients and clinical management based on the results of either HyFoSy or HSG, leads to comparable pregnancy outcomes. HyFoSy is experienced as significantly less painful.

WHAT IS KNOWN ALREADY

Traditionally, tubal patency testing during fertility work-up is performed by HSG. HyFoSy is an alternative imaging technique lacking ionizing radiation and iodinated contrast medium exposure which is less expensive than HSG. Globally, there is a shift towards the use of office-based diagnostic methods, such as HyFoSy.

STUDY DESIGN, SIZE, DURATION

This multicentre, prospective, comparative study with a randomized design was conducted in 26 hospitals in The Netherlands. Participating women underwent both HyFoSy and HSG in randomized order. In case of discordant results, women were randomly allocated to either a management strategy based on HyFoSy or one based on HSG.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included infertile women between 18 and 41 years old who were scheduled for tubal patency testing during their fertility work-up. Women with anovulatory cycles not responding to ovulation induction, endometriosis, severe male infertility or a known iodine contrast allergy were excluded. The primary outcome for the comparison of the HyFoSy- and HSG-based strategies was ongoing pregnancy leading to live birth within 12 months after inclusion in an intention-to-treat analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Between May 2015 and January 2019, 1026 women underwent HyFoSy and HSG. HyFoSy was inconclusive in 97 of them (9.5%), HSG was inconclusive in 30 (2.9%) and both were inconclusive in 9 (0.9%). In 747 women (73%) conclusive tests results were concordant. Of the 143/1026 (14%) with discordant results, 105 were randomized to clinical management based on the results of either HyFoSy or HSG. In this group, 22 of the 54 women (41%) allocated to management based on HyFoSy and 25 of 51 women (49%) allocated to management based on HSG had an ongoing pregnancy leading to live birth (Difference −8%; 95% CI: −27% to 10%). In total, clinical management based on the results of HyFoSy was estimated to lead to a live birth in 474 of 1026 women (46%) versus 486 of 1026 (47%) for management based on HSG (Difference −1.2%; 95% CI: −3.4% to 1.5%). Given the pre-defined margin of −2%, statistically significant non-inferiority of HyFoSy relative to HSG could not be demonstrated (P = 0.27). The mean pain score for HyFoSy on the 1–10 Visual Analogue Scale (VAS) was 3.1 (SD 2.2) and the mean VAS pain score for HSG was 5.4 (SD 2.5; P for difference < 0.001).

LIMITATIONS, REASONS FOR CAUTION

Since all women underwent both tubal patency tests, no conclusions on a direct therapeutic effect of tubal flushing could be drawn.

WIDER IMPLICATIONS OF THE FINDINGS

HyFoSy or HSG produce similar tubal pathology findings in a majority of infertile couples and, where they differ, a difference in findings does not lead to substantial difference in pregnancy outcome, while HyFoSy is associated with significantly less pain.

STUDY FUNDING/COMPETING INTEREST(S)

The FOAM study was an investigator-initiated study funded by ZonMw, The Netherlands organization for Health Research and Development (project number 837001504). ZonMw funded the whole project. IQ Medical Ventures provided the ExEm-foam^® kits free of charge. The funders had no role in study design, collection, analysis and interpretation of the data. K.D. reports travel and speaker fees from Guerbet. F.J.M.B. reports personal fees as a member of the external advisory board for Merck Serono, The Netherlands, and a research support grant from Merck Serono, outside the submitted work. C.B.L. reports speakers’ fee from Ferring in the past, and his department receives research grants from Ferring, Merck and Guerbet. J.S. reports a research agreement with Takeda on MR of motility outside the submitted work. M.V.W. reports leading The Netherlands Satellite of the Cochrane Gynaecology and Fertility Group. B.W.J.M. is supported by an NHMRC Investigator grant (GNT1176437). B.W.J.M. reports consultancy for Guerbet and research funding from Merck and Guerbet. V.M. reports non-financial support from IQ medicals ventures, during the conduct of the study; grants and personal fees from Guerbet, outside the submitted work. The other authors do not report conflicts of interest.

TRIAL REGISTRATION NUMBER

NTR4746/NL4587 (https://www.trialregister.nl)

TRIAL REGISTRATION DATE

19 August 2014

DATE OF FIRST PATIENT’S ENROLMENT

7 May 2015

High dose letrozole in infertile women with unilateral tubal block: a preliminary report

Background

Till now, there is no universal agreement on the best management of women with unilateral blocked tube. The aim of this study was to evaluate the use of high dose letrozole in infertile women with one blocked tube. This prospective non-randomized study was conducted at a university-affiliated infertility unit. It included 15 women with one blocked tube (proximal or mid segmental block) with a period of 1–6 years of infertility. Letrozole (10 mg/day for 5 days) was prescribed for all of them for a maximum of three cycles. The primary outcome was Live birth rate.

Results

Nine out of the 15 women conceived (60%). Live birth rate was 53% (8/15). All women had a good response to this regimen. None complained of side effects of this dose. No multiple pregnancies and/or congenital anomalies were reported.

Conclusions

This preliminary report showed that treatment of infertile women, with unilateral tubal block, with high dose letrozole is effective. To our knowledge, this is the first report in the English literature on the use of high dose of letrozole in such cases.

Treatment of Infertile Women with Unilateral Tubal Occlusion Diagnosed by Hysterosalpingography: The Role of Intrauterine Insemination

The optimal assisted reproductive treatment strategy for infertile women with unilateral tubal obstruction remains uncertain. To investigate the role of intrauterine insemination (IUI) in the treatment of infertile women with unilateral tubal occlusion, the data of 148 couples were retrospectively collected and analyzed. Seventy-eight infertile women with unilateral occlusion diagnosed by hysterosalpingography (HSG) were categorized as the study group and 70 others with unexplained infertility as the control group. The study group was divided into a proximal occlusion subgroup and a mid-distal occlusion subgroup for further analysis. The main outcomes, namely the clinical pregnancy rate (CPR), ongoing pregnancy rate (OPR), and live birth rate (LBR) per cycle, were analyzed. Our results showed a tendency of lower CPR, OPR, and LBR in the study group than in the control group, without statistical significance. Further investigations revealed that the unilateral proximal occlusion subgroup had similar CPR, OPR, and LBR as the control group, while the unilateral mid-distal occlusion subgroup had significantly lower CPR (5.1% vs. 20.0%, P=0.035), OPR (5.1% vs. 20.0%, P=0.035), and LBR (5.1% vs. 20.0%, P=0.035) than the control group. In conclusion, the clinical outcomes of IUI were worse in patients with unilateral tubal occlusion than in those with unexplained infertility. This might be primarily caused by the worse outcome of patients with unilateral mid-distal tubal occlusion instead of proximal occlusion.

Hysteroscopic Assessment of Tubal Patency: A Randomized Comparison between the Flow and Parryscope Techniques

STUDY OBJECTIVE

To evaluate the accuracy of the "Parryscope" and "flow" techniques for hysteroscopic assessment of tubal patency.

DESIGN

Prospective randomized clinical trial.

SETTING

From May to October 2019, women with subfertility undergoing laparoscopic and hysteroscopic surgery at the Medical University of Vienna were invited to participate in the study. The primary outcome was accuracy of Fallopian tube patency relative to the gold standard of laparoscopic chromopertubation.

PATIENTS

Sixty women with subfertility.

INTERVENTIONS

Hysteroscopy with either the "Parryscope" or the "flow" techniques for tubal assessment, directly followed by laparoscopy with chromopertubation.

MEASUREMENTS AND MAIN RESULTS

Hysteroscopic prediction of fallopian tube patency was possible in a statistically significant manner in both study groups (p <0.05). The Parryscope technique achieved higher sensitivity (90.6%, 95% CI: 61.7-98.4) and specificity (100%, 95% CI: 90.0-100.0) than the flow technique (sensitivity: 73.7%, 95% CI: 48.8-90.9 and specificity: 70.7%, 95% CI: 54.5-83.9).

CONCLUSION

Using the Parryscope technique to determine if air bubbles traverse the ostia can provide valuable additional information during hysteroscopy and is more accurate in predicting fallopian tubal occlusion than the flow method.

Intrauterine insemination: simultaneous with or 36 h after HCG? A randomized clinical trial

RESEARCH QUESTION

Does intrauterine insemination (IUI) carried out simultaneously with HCG triggering ('simultaneous IUI') increase the ongoing pregnancy rate compared with IUI 32-36 h after HCG triggering ('regular IUI')?

STUDY DESIGN

An open-label randomized clinical trial was conducted in seven Dutch fertility clinics. One hundred and sixty-six couples were randomized to receive simultaneous IUI and 208 couples to receive regular IUI. Treatment was allocated using a computer-based randomization algorithm using sealed opaque envelopes. Data were analysed according to the intention-to-treat principle. Couples with unexplained or mild-to-moderate male factor subfertility were eligible. Exclusion criteria were female age 42 years or older, female body mass index 35 kg/m² or over, double-sided tubal pathology or severe male factor subfertility. Mild ovarian stimulation was carried out by subcutaneous FSH self-administration. 'Simultaneous IUI' was carried out at the point of HCG triggering for ovulation. 'Regular IUI' was carried out 32-36 h after HCG triggering.

RESULTS

The cumulative ongoing pregnancy rate after a maximum of four cycles was 26.2% for simultaneous IUI (43 ongoing pregnancies) and 33.7% for regular IUI (70 ongoing pregnancies) (RR 0.78 95% CI 0.57 to 1.07). Ongoing pregnancy rates per cycle in the simultaneous IUI group were 6.8%, 10.5%, 9.5% and 7.4% for the first, second, third and fourth IUI cycle. In the regular IUI group, ongoing pregnancy rates were 8.3%, 16.4%, 13.5% and 9.0% for the first, second, third and fourth IUI cycle.

CONCLUSIONS

This multicentre randomized controlled trial did not demonstrate that IUI carried out at the point of HCG triggering increases pregnancy rates compared with IUI carried out around the time of ovulation.