Female infertility: a systematic approach to radiologic imaging and diagnosis

In vitro effect of hyoscine-N-butyl bromide and diclofenac sodium in human tuba uterina

INTRODUCTION

To investigate the in vitro effect of diclofenac on tubal smooth muscle as an alternative to hyoscine-N-butyl bromide, which is used for premedication before hysterosalpingography (HSG).

MATERIAL AND METHODS

Fallopian tubes were retrieved from seven healthy women after bilateral tubal ligation and in vitro contractility and histological studies were conducted using tissue bath and immunohistochemistry.

RESULTS

Diclofenac sodium and hyoscine-N-butyl bromide did not significantly change the basal mean tension; however, they decreased the contractions induced by potassium chloride (KCl). The relaxant effect of diclofenac sodium and hyoscine-N-butyl bromide was not statistically significantly different. The presence of cyclooxygenase (COX)-2 enzyme in the fallopian tube was demonstrated by immunohistochemical studies.

CONCLUSIONS

The in vitro relaxant effect of diclofenac sodium on the fallopian tube is similar to hyoscine-N-butyl bromide. Diclofenac may have the potential to be used as an alternative to hyoscine-N-butyl bromide in premedication in HSG.

State-of-the-art and future perspectives in infertility diagnosis: Conventional versus nanotechnology-based assays

According to the latest World Health Organization statistics, around 50 to 80 million people worldwide suffer from infertility, amongst which male factors are responsible for around 20 to 30 % of all infertility cases while 50 % were attributed to the female ones. As it is becoming a recurrent health problem worldwide, clinicians require more accurate methods for the improvement of both diagnosis and treatment schemes. By emphasizing the potential use of innovative methods for the rapid identification of the infertility causes, this review presents the news from this dynamic domain and highlights the benefits brought by emerging research fields. A systematic description of the standard techniques used in clinical protocols for diagnosing infertility in both genders is firstly provided, followed by the presentation of more accurate and comprehensive nanotechnology-related analysis methods such as nanoscopic-resolution imaging, biosensing approaches and assays that employ nanomaterials in their design. Consequently, the implementation of nanotechnology related tools in clinical practice, as recently demonstrated in the selection of spermatozoa, the detection of key proteins in the fertilization process or the testing of DNA integrity or the evaluation of oocyte quality, might confer excellent advantages both for improving the assessment of infertility, and for the success of the fertilization process.

Lipiodol flushing under ultrasound guidance at time of hystero-salpingo contrast sonography (HyCoSy): A retrospective observational study

BACKGROUND

Up to 30% of female infertility can be attributed to tubal abnormalities. Assessment of fallopian tube patency forms a component of the basic assessment of infertility. Tubal patency can be checked through hysterosalpingogram (HSG) under radiologic guidance with oil- or water-based contrast medium (OBCM or WBCM), or hystero-salpingo contrast sonography (HyCoSy) under ultrasound guidance with WBCM. Tubal flushing with OBCM has been shown to improve fertility rates.

OBJECTIVES

To study the feasibility and tolerability of performing Lipiodol (ethiodised oil) flush concurrently with HyCoSy. To examine the in vivo sonographic visibility of Lipiodol vs normal saline.

MATERIALS AND METHODS

Retrospective observational study of patients with subfertility referred for Lipiodol flushing under ultrasound guidance between August 2017-September 2020 at six private ultrasound practices in Sydney, Australia.

RESULTS

There were 412 patients who were referred for Lipiodol flushing. Of these, 86 patients did not have concurrent Lipiodol flush at HyCoSy performed due to strict exclusion criteria. Of the 326 patients who proceeded with Lipiodol flushing at HyCoSy, all cases were successful, with no cases of extravasation. There were no major complications. In vivo sonographic visualisation of Lipiodol was similar to that of the commonly used agitated 0.9% saline (n = 20; mean visibility score 4.3 ± 0.9 vs 4.0 ± 1.2).

CONCLUSION

Our study has shown that Lipiodol flushing at time of HyCoSy as a single procedure is feasible and tolerable to patients. Flushing with Lipioidol during HyCoSy is likely as sonographically visible as 0.9% saline.

Establishing a predictive model for the evaluation of fecundity

AIM

We aim to establish a predictive model for the evaluation of fecundity based on infertility-related factors.

METHODS

A total of 410 expectant couples who visited the First Affiliated Hospital of Xinjiang Medical University on January 1, 2017 and June 10, 2019 were included in this study. The 1-year follow-up was carried out to investigate the pregnancy of the female. They were divided into model group and test group, respectively. The basic information, life behavior and clinical indices were screened using the Logistics regression analysis and LASSO regression analysis. In addition, the multivariate logistic regression was used to establish the model for the prediction of fecundity risk.

RESULTS

The risk factors for the predictive model included female age and occupational pressure, gynecological disease, anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), fasting plasma glucose (FPG), depression, as well as male smoking. The area under the curve (AUC) for the model A and model B was 0.954 (0.931 ~ 0.978) and 0.955 (0.931 ~ 0.979), respectively. The AUC in the test group was 0.917 (0.869 ~ 0.965) and 0.921 (0.873 ~ 0.968). There were no statistical differences in the fitting value and measured values in the model group.

CONCLUSIONS

We established a predictive model for the evaluation of fecundity, which showed a satisfactory accuracy and discriminatory power.

Comparation of magnetic resonance hysterosalpingography and hysterosalpingosonography for the assessment of fallopian tubal occlusion of female infertility: A protocol for systematic review and meta-analysis

OBJECTIVE

To evaluate the diagnostic performance of magnetic resonance hysterosalpingography (MR-HSG) for fallopian tubal occlusion in the context of female infertility when compared to the diagnostic performance of hysterosalpingosonography in evaluation of fallopian tubal occlusion of female infertility.

METHODS

We will search PubMed, Web of Science, Cochrane Library, and Chinese biomedical databases from their inceptions to the October 31, 2021, without language restrictions. Two authors will independently carry out searching literature records, scanning titles and abstracts, full texts, collecting data, and assessing risk of bias. Review Manager 5.2 and Stata14.0 software will be used for data analysis.

RESULTS

This systematic review will investigate whether MR-HSG has more diagnostic value than hysterosalpingosonography in evaluation of fallopian tubal occlusion of female infertility.

CONCLUSION

Our meta-analysis indicated MR-HSG may serve as an alternative for further evaluation of fallopian tubal occlusion of female infertility.

SYSTEMATIC REVIEW REGISTRATION

INPLASY2021110050.

Evaluating Fallopian Tube Patency: What the Radiologist Needs to Know

Impaired tubal patency accounts for up to 35% of cases of subfertility and infertility. Hysterosalpingography (HSG) or hysterosalpingo-contrast sonography (HyCoSy) represents a first-line test in evaluating fallopian tube patency. Despite the association of HSG with ionizing radiation, HSG is a reference standard in assessing fallopian tube patency and tubal conditions such as tubal occlusion, salpingitis isthmica nodosa, and hydrosalpinx. HSG is widely available and utilizes either a water-soluble contrast medium (WSCM) or an oil-soluble contrast medium (OSCM). Compared with WSCM, HSG with OSCM results in a higher incidence of non-in vitro fertilization pregnancies and, therefore, may be preferred in women younger than 38 years with unexplained subfertility. HSG may also be helpful in assessment after sterilization or before fallopian tube recanalization. US-based tubal tests are free of ionizing radiation and include HyCoSy, with either air-saline or microbubble US contrast material, and hysterosalpingo-foam sonography (HyFoSy), a tubal patency test that utilizes a gel foam. A comprehensive US infertility evaluation of the pelvis and fallopian tubes can be achieved in one setting by adding coronal three-dimensional imaging of the uterus, saline infusion sonohysterography, and HyCoSy or HyFoSy to routine pelvic US. MR HSG and virtual CT HSG also depict tubal patency and uterine and adnexal pathologic conditions and may be considered in select patients. While laparoscopic chromopertubation remains the standard for tubal patency evaluation, its disadvantages are its invasiveness and cost. Knowledge of the different fallopian tube tests and radiologic appearance of normal and abnormal fallopian tubes results in fewer pitfalls, accurate interpretation, and optimal patient care. Online supplemental material is available for this article. ^©RSNA, 2021.

Magnetic Resonance Imaging of Uterine Cervix: A Pictorial Essay

Uterine cervix is the lower constricted part of uterus which is best evaluated by magnetic resonance imaging (MRI) due to its higher soft tissue and contrast resolution. The cervical cancer is a common gynecological cancer causing much morbidity and mortality especially in developing countries. Cervical carcinomas mainly occurs in reproductive age group with prognosis mainly depending on the extent of disease at the time of diagnosis, hence it is important to identify these cancerous lesions early and stage them accurately for optimal treatment. In this article, we will review the following: (1) the normal MRI anatomy of uterine cervix; (2) MRI protocol and techniques in evaluation of cervical lesions; (3) imaging of spectrum of various congenital abnormalities and pathologies affecting uterine cervix which ranges from congenital abnormalities to various benign lesions of cervix like nabothian cysts, tunnel cysts, cervicitis, cervical fibroid, and, lastly, endometriosis which usually coexists with adenomyosis; the malignant lesions include carcinoma cervix, adenoma malignum or direct extension from carcinoma endometrium or from carcinoma of vagina; (4) Accurately stage carcinoma of cervix using FIGO classification (2018); and (5) posttreatment evaluation of cervical cancers. MRI is the most reliable imaging modality in evaluation of various cervical lesions, identification of cervical tumors, staging of the cervical malignancy, and stratifying patients for surgery and radiation therapy. It also plays an important role in detection of local disease recurrence.

Conventional and magnetic resonance hysterosalpingography in assessing tubal patency-A comparative study

Context:

Tubal factors, one of the leading causes of female infertility, have been conventionally evaluated by hysterosalpingography (HSG). The role of magnetic resonance imaging (MRI) in assessing female infertility is gaining importance because of its inherent efficiency in detecting structural abnormalities. Magnetic resonance hysterosalpingography (MR HSG) is less invasive and avoids exposure of ovaries to ionizing radiation. Its utility is extrapolated to visualize fallopian tubes.

Aims:

To assess the diagnostic accuracies of dynamic MR HSG and conventional HSG (cHSG) in identifying tubal patency in women with infertility using diagnostic laparoscopy (DL) as gold standard.

Materials and Methods:

A prospective study of 40 patients was conducted over a period of 6 months. The patients were subjected to MR HSG followed by cHSG during the preovulatory period. If tubes were blocked, the patients were subjected to DL in the next menstrual cycle. If the tubes were patent and there was failure of conception, they were subjected to DL in the interval of 3 months.

Results:

Twenty-four patients had bilateral tubal spill which was confirmed using cHSG and DL. One patient had discordant MR HSG and cHSG results and six patients had discordant MR HSG and DL results. No statistical difference was observed between MR HSG and cHSG.

Conclusion:

Pelvic MRI is an inevitable tool in infertility evaluation. MR HSG can be used in addition as it avoids exposure of the reproductive organs to radiation and has the same efficacy as cHSG.

Hysterosalpingography using Magnetic Resonance Imaging for infertility patients

OBJECTIVE

Some studies have shown that it is possible to evaluate tubal permeability through MRI. Our aim is to perform a prospective study and to perform a comprehensive review in the literature regarding HSG-MRI.

METHODS

We carried out a PUBMED search using the following keywords: hysterosalpingogram, hysterosalpingography, magnetic resonance imaging and MRI. As inclusion criteria, we included only papers published in English, and exams ran on humans. We also conducted a prospective inclusion of patients who had visited a human reproduction clinic between May/2017 and April/2019 for laboratory image diagnoses using HSG-MRI.

RESULTS

Following the inclusion and exclusion criteria, we included seven original papers. Review papers and those written in a language other than English, were excluded. Between the period of May/2017 and April/2019, we selected ten patients for our study. The average exam duration was 30 minutes. Cervical catheterization was possible in all cases. There were no major complications. We highlight that in 8/9 of patients, we could directly visualize uterine tubes with contrast (excluding one patient with bilateral tubal ligation).

CONCLUSIONS

Our initial experience with HSG-MRI shows promise. We demonstrated an optimized protocol for conducting an HSG-MRI (with excellent image quality). HSG-MRI had some advantages, such as not using ionized radiation, less pain and being able to analyze pelvic anatomy. Patients referred for a pelvic MRI as part of a more detailed investigation into infertility can also benefit from undergoing a simultaneous HSG using MRI.

A randomized pilot study of electro-acupuncture treatment for hysterosalpingography pain relief and related anxiety

Objective:

To investigate the effect of acupuncture on reducing pain and anxiety related to hysterosalpingography (HSG).

Materials and Methods:

A total of 107 patients planned to undergo HSG were randomly separated into 3 groups; the acupuncture group (n=36), intramuscular diclofenac sodium group (n=35), and control group (n=37). In the acupuncture group, electro-acupuncture was applied to specified points for 20 mins before the procedure. In the intramuscular diclofenac sodium group, an intramuscular injection of 75 mg diclofenac sodium was applied 30 mins before the procedure. No analgesics were administered to the patients in the control group before intervention. Pain was evaluated with a Visual Analog scale (VAS) and anxiety with the State-trait Anxiety inventory -state (STAI-S), preoperatively and at specified times postoperatively.

Results:

The VAS scores at 1 and 5 minutes after HSG were similar in acupuncture group and intramuscular diclofenac sodium group, and significantly lower than in the control group. At 30 mins postoperatively, there was no significant difference between the 3 groups in respect of the VAS scores. The STAI-S scores at 1 hour preoperatively were similar in all the groups (p=0.563). In the comparisons of the STAI-S values at preoperative 5 mins, following acupuncture in acupuncture group and the diclofenac injection in intramuscular diclofenac sodium group, and at postoperative 30 mins, the acupuncture group values were determined to be statistically significantly lower than those of the other groups (p<0.001, p<0.001).

Conclusion:

Acupuncture has similar effects on the reduction of pain as other analgesics and reduces anxiety. It can therefore be used in HSG in suitable clinics.

The effect of hyoscine-N-butylbromide on pain perception during and after hysterosalpingography in infertile women: a systematic review and meta-analysis of randomised controlled trials

This paper reports a systematic review and meta-analysis of the effectiveness of hyoscine-N-butylbromide (HBB) administration in hysterosalpingography (HSG). Four electronic databases were searched for randomised controlled trials (RCTs) that compared HBB versus placebo or no intervention in infertile women undergoing HSG. Pain during and after HSG and different adverse events including nausea, vomiting, and dizziness were evaluated. Three RCTs with 335 patients were included. The analysis showed HBB was significantly effective in reducing pain during and after HSG (MD = -0.76 mm, 95% CI [-1.35, -0.17], p = 0.01) and (MD = -0.81 mm, 95% CI [-1.07, -0.56], p < 0.001), respectively. There were no significant differences in adverse events between HBB and control groups. The methodological evidence quality was high as evaluated by GRADEpro. In conclusion, this review provides good evidence that prior administration of HBB is effective in reducing induced pain during and after HSG with tolerable side effects.

Effects of three abnormal conditions of fallopian tube on outcomes of the in vitro fertilization and embryo transfer technique

AIM

The aim of this study was to demonstrate whether salpingitis affects the outcomes of in vitro fertilization and embryo transfer (IVF-ET).

METHODS

The retrospective study includes patients from 2013 to 2018 who received their first IVF-ET treatment during this period. On the basis of their tubal conditions, the patients were subgrouped as: hydrosalpinx (group A), salpingitis (group B), tubal occlusion (group C). It had a total of 726 cycles, of which 208 cycles were in group A, 201 cycles in group B and 317 cycles in group C. The outcomes of the IVF-ET treatment were compared amongst the three groups.

RESULTS

Group C had the highest number of retrieved oocytes as compared to the groups A and B, and the rate of the high-quality embryos at day 3 (66-68 h after insemination) was higher in the groups C and A compared to the group B. The blastocyst formation rate was significantly higher in group C compared to that of the group B. Group C had higher rates of implantation, clinical pregnancy and live birth compared to both groups A and B, while the birth weight of newborns did not differ amongst the three groups.

CONCLUSION

Salpingitis has adverse effects on the success rate of the IVF-ET treatment, exemplified by lower implantation, clinical pregnancy and live birth rates compared to tubal occlusion, it may be necessary to carry out appropriate management of salpingitis before IVF-ET treatment.

Comparison of Hysterosalpingography and Laparoscopy as Diagnostic Tool for Tubal Infertility in Bangladesh

Background: Tubal evaluation is an integral part of the evaluation of female infertility. Hysterosalpingography (HSG) is the radiographic evaluation of the uterus and fallopian tubes, which has been used as a first-line test for tubal assessment since 1920s. Laparoscopy is considered to be the gold standard for the diagnosis and management of tubo-peritoneal pathology. The objective of this study is to evaluate and compare the diagnostic value of both HSG and laparoscopy for assessment of tubal occlusion.

Methods: This is a prospective cross-sectional study. Laparoscopic chromopertubation was conducted on 125 consecutive infertile women who attended the “Infertility Management Center” from October 2018 to September 2019. All patients had HSG performed in the radiology department of different hospitals. Laparoscopic findings were used as a reference standard to analyze the findings of HSG for tubal occlusion. Data were analyzed by SPSS software (version 16).

Results: Normal HSG findings were seen in 53 patients (42.4%). Unilateral tubal occlusion was present in 38 (30.7%), and bilateral occlusion in 34 (27.2%) patients. Laparoscopy showed normal findings in 85 (68.0%) patients. Unilateral tubal occlusion was demonstrated in laparoscopy in 27 (21.6%) and bilateral tubal occlusion in 13 (10.4%) patients. HSG findings for diagnosis of tubal occlusion was true positive in 30 (24%) cases, false positive in 42 (33.6%) cases, false negative in 10 (8%) cases, and true negative in 43 (34.4%) cases in comparison to laparoscopy findings. Sensitivity of HSG was found to be 75.0%, specificity 50.6%, and accuracy 58.4%. Positive predictive value and negative predictive value were 41.7% and 81.1%, respectively.

Conclusion: HSG is widely used for tubal assessment in Bangladesh as it is a relatively inexpensive, low-risk office procedure. But it has a low specificity and positive predictive value with a relatively high negative predictive value. Laparoscopy, on the other hand, is preferable when there is high suspicion of tubal pathology.

Multicentric, prospective observational data show sperm capacitation predicts male fertility, and cohort comparison reveals a high prevalence of impaired capacitation in men questioning their fertility

RESEARCH QUESTIONS

Can a previously defined relationship between sperm capacitation and the probability of a man generating pregnancy within three cycles, prospectively predict male fertility in diverse clinical settings? A second study asked, what is the prevalence of impaired sperm fertilizing ability in men questioning their fertility (MQF), and does this relate to traditional semen analysis metrics?

DESIGN

In the multicentric, prospective observational study, data (n = 128; six clinics) were analysed to test a published relationship between the percentage of fertilization-competent, capacitated spermatozoa (Cap-Score) and probability of generating pregnancy (PGP) within three cycles of intrauterine insemination. Logistic regression of total pregnancy outcomes (n = 252) assessed fit. In the cohort comparison, Cap-Scores of MQF (n = 2155; 22 clinics) were compared with those of 76 fertile men.

RESULTS

New outcomes (n = 128) were rank-ordered by Cap-Score and divided into quintiles (25-26 per group); chi-squared testing revealed no difference between predicted and observed pregnancies (P = 0.809). Total outcomes (n = 252; 128 new + 124 previous) were pooled and the model recalculated, yielding an improved fit (P < 0.001). Applying the Akaike information criterion found that the optimal model used Cap-Score alone. Cap-Scores were performed on 2155 men (with semen analysis data available for 1948). To compare fertilizing ability, men were binned by PGP (≤19%, 20-29%, 30-39%, 40-49%, 50-59%, ≥60%). Distributions of PGP and the corresponding Cap-Scores were significantly lower in MQF versus fertile men (P < 0.001). Notably, 64% of MQF with normal volume, concentration and motility (757/1183) had PGP of 39% or less (Cap-Scores ≤31), versus 25% of fertile men.

CONCLUSIONS

Sperm capacitation prospectively predicted male fertility. Impaired capacitation affects many MQF with normal semen analysis results, informing diagnosis versus idiopathic infertility.

Lipiodol visibility under ultrasound

BACKGROUND

Lipiodol is an oil-based solution commonly used in hysterosalpingogram (HSG), but not hysterosalpingo contrast sonography (HyCoSy). In women with unexplained infertility, evidence suggests that tubal flushing with Lipiodol results in improved fertility post-procedure. We propose that Lipiodol can be visualised under ultrasound similar to commonly used saline, and hence utilised for HyCoSy, allowing the benefit of an oil-based tubal flushing to occur with HyCoSy.

AIMS

To examine whether Lipiodol is visible sonographically, assess optimal agitated Lipiodol mix and ultrasound settings for visibility, and compare visibility to agitated saline, routinely used for HyCoSy.

MATERIALS AND METHODS

Two separate sonographers with identical ultrasound machines and model pelvises recorded images with varying degrees of agitated Lipiodol and ultrasound settings, in addition to capturing images with no fluid and agitated saline. Each test was performed in quadruplicate and in random order. Images were read by 47 blinded reporters and visibility reported on a scale of one (not visible) to five (clearly visible).

RESULTS

The mean visibility score for images captured where the Lipiodol sample was agitated five times prior to injection to allow the formation of air microbubbles, regardless of ultrasound setting, were higher than or not different from that for agitated saline (all P > 0.7 when not different, <0.001 when higher).

CONCLUSIONS

Sonographic visualisation of agitated Lipiodol is similar or better than that of agitated saline. Lipiodol may therefore present a possibility for use with HyCoSy, with the added benefit of oil-based tubal flushing, avoiding the radiation exposure of HSG and concurrently providing pelvic soft-tissue evaluation.

Role of Interventional Procedures in Obstetrics and Gynecology

Radiological guided intervention techniques are discussed in obstetric and gynecologic patients. Fallopian tube recanalization, postpartum hemorrhage control, techniques of treating uterine leiomyomas, pelvic congestion treatment, and the use of percutaneous and transvaginal ultrasonography-guided aspirations and biopsy are covered. These techniques use basic radiological interventional skills and show how they are adapted for use in the female pelvis.

Imaging of Infertility, Part 1: Hysterosalpingograms to Magnetic Resonance Imaging

Infertility, or subfertility, is the inability to achieve a clinical pregnancy after a 1-year period of regular unprotected sexual intercourse in women younger than 35 and after 6 months in women older than 35. Although initial assessment involves a multitude of factors, including a detailed medical history, physical examination, semen analysis, and hormonal evaluation, diagnostic imaging of the female partner often plays an important role in establishing the etiology for infertility. This article provides an overview of the multimodality imaging assessment of female infertility and details the developmental and acquired pelvic abnormalities in which diagnostic imaging aids in evaluation.

Immersive virtual reality as analgesia for women during hysterosalpingography: study protocol for a randomized controlled trial

BACKGROUND

Hysterosalpingography (HSG) is an accepted radiologic diagnostic modality for initial infertility workup, and is generally considered uncomfortable and painful. However, the management of pain related to HSG remains inefficient. As an emerging nonpharmacologic and noninvasive pain control strategy, virtual reality (VR) distraction has been successfully used in areas such as burns, blunt force trauma, hospital-based needle procedures, dental/periodontal procedures, and urological endoscopy patients. This study aims to evaluate the analgesic effect of VR during HSG.

METHODS/DESIGN

A single-center, parallel-group, randomized controlled trial will be carried out in the Radiology Department of Yinchuan Women and Children Healthcare Hospital, Yinchuan. A total of 200 participants who are scheduled for HSG will be enrolled in this study. The participants will be randomized (1:1) into two groups: a VR group and a blank control group. The VR group will receive routine care plus immersive VR intervention and the blank control group will receive routine care. Outcomes will be monitored at baseline, immediately after HSG and 15 min after HSG for each group. The primary outcome is the worst pain score during HSG by a visual analog scale (VAS). The secondary outcomes include: affective pain, cognitive pain, and anxiety during the HSG procedure; worst pain within 15 min after HSG; patient satisfaction and acceptance with pain management; physiological parameters; adverse effects; HSG results; and immersion perception score of the VR system (for the VR condition only).

DISCUSSION

This study will focus on exploring a simply operated, noninvasive and low-cost analgesia during the HSG procedure. The results of this trial will provide data on the feasibility and safety of VR distraction therapy during HSG.

TRIAL REGISTRATION

Chinese Clinical Trial Register, ChiCTR1900021342. Registered on 16 February 2019.

Niche role of MRI in the evaluation of female infertility

Infertility is a major social and clinical problem affecting 13-15% of couples worldwide. The pelvic causes of female infertility are categorized as ovarian disorders, tubal, peritubal disorders, and uterine disorders. Appropriate selection of an imaging modality is essential to accurately diagnose the aetiology of infertlity, since the imaging diagnosis directs the appropriate treatment to be instituted. Imaging evaluation begins with hystero- salpingography (HSG), to evaluate fallopian tube patency. Uterine filling defects and contour abnormalities may be discovered at HSG but usually require further characterization with pelvic ultrasound (US), sono-hysterography (syn: hystero-sonography/saline infusion sonography) or pelvic magnetic resonance imaging (MRI), when US remains inconclusive. The major limitation of hysterographic US, is its inability to visualize extraluminal pathologies, which are better evaluated by pelvic US and MRI. Although pelvic US is a valuable modality in diagnosing entities comprising the garden variety, however, extensive pelvic inflammatory disease, complex tubo-ovarian pathologies, deep-seated endometriosis deposits with its related complications, Mulllerian duct anomalies, uterine synechiae and adenomyosis, often remain unresolved by both transabdominal and transvaginal US. Thus, MRI comes to the rescue and has a niche role in resolving complex adnexal masses, endometriosis, and Mullerian duct anomalies with greater ease. This is a review, based on the authors' experience at tertiary care teaching hospitals and aims to provide an imaging approach towards the abnormalities which are not definitively diagnosed by ultrasound alone.

Effect of intramuscular hyoscine-n-butyl bromide on fallopian tube spasm and pain perception during and after hysterosalpingography in infertile women: A randomized single-blind controlled clinical trial

Background: Hysterosalpingography plays an important role in diagnostic work-up and treatment planning for infertile women. This procedure is usually uncomfortable and painful. The present study plans to investigate the effect of intramuscular Hyoscine-N-Butyl Bromide (HBB) on fallopian tube spasm and pain perception during and after hysterosalpingography (HSG) in infertile women.

Methods: This randomized single-blind controlled clinical trial (IRCT2017021132455N2) was conducted on infertile women scheduled for HSG in one radiology clinic affiliated to Arak University of Medical Sciences between July and August 2017. Patients were selected by convenience sampling and were randomly assigned to HBB (n=50) and a control group (n=50). Women received 20 mg/1cc HBB intramuscularly in the intervention group, 30 minutes before the procedure. Women in the control group did not receive any medication. The patients were requested to complete the Numeric Pain Rating Scale after injection of the dye, and also 30 minutes following the end of the HSG. Presence or absence of tubal spasm was determined after checking the radiographic images. For the data analysis using SPSS version 18, descriptive statistics, and analytical tests such as independent sample t-test, Mann- Whitney test, chi-square or Fisher’s exact tests and logistic regression and ANCOVA were used.

Results: Statistically significant differences were not observed in pain scores between the HBB and the control groups at the point of dye injection and 30 minutes after ending the HSG (p>0.05). Also, tubal spasm in the HBB group was lower than in the control group, but the differences were not statistically significant between the two groups (p=0.37).

Conclusion: The use of intramuscular HBB before HSG has no advantage in reducing tubal spasm and the induced pain during dye injection and 30 minutes after the HSG procedure. Thus, we don’t recommend HBB use before the HSG in order to relief from pain and spasm.

Clinical Aspects of HyFoSy as Tubal Patency Test in Subfertility Workup

BACKGROUND

Tubal patency testing is an essential part of female subfertility evaluation. Traditionally, hysterosalpingography (HSG) was the first step to evaluate tubal patency. However, during the past decade Hysterosalpingo-Contrast Sonography (HyCoSy) was introduced in order to avoid radiation exposure and Hysterosalpingo-Foam Sonography (HyFoSy) has been developed as a safe and less painful alternative.

OBJECTIVES AND RATIONALE

The aim of this narrative review is to provide an overview of the currently available HyFoSy literature and related clinical aspects.

SEARCH METHODS

A literature search was conducted using PubMed and Embase from the introduction of HyFoSy to March 2019. Unfortunately, a meta-analysis was not possible due to a too small number of studies, being mutually incomparable for the various subjects of clinical aspects, even for the reliability as a test for tubal patency.

OUTCOMES

Nine small studies concluded that the accuracy and effectiveness as a test for tubal patency of 2D- and 3D-HyFoSy are comparable or even better than HSG or HyCoSy. With or without using Doppler techniques, 3D-HyFoSy does not seem to offer benefits above real-time 2D-HyFoSy. Five studies reported on pain and discomfort during HyFoSy, concluding that HyFoSy is a well-tolerated, less painful procedure compared to HSG, without a need for the use of analgesics. There are suggestions about an increased pregnancy rate in the first three cycles after the procedure but in no studies pregnancy outcome after HyFoSy was compared with other or no intervention.

WIDER IMPLICATIONS

HyFoSy is a promising and safe alternative for HSG with regard to accuracy and effectiveness. HyFoSy lacks radiation and iodine exposure and is a well-tolerated and less painful procedure than HSG, without the need for analgesics. However more research is needed to make clear statements regarding a therapeutic effect of HyFoSy.

Intrauterine Linear Echogenicities in the Gravid Uterus: What Radiologists Should Know

Intrauterine linear echogenicity (ILE) is a common ultrasonographic finding in the gravid uterus and has variable causes and variable maternal and fetal outcomes. Correctly categorizing ILE during pregnancy is crucial for guiding surveillance and advanced imaging strategies. Common causes of ILE include membranes in multiple gestations, uterine synechiae with amniotic sheets, and uterine duplication anomalies. Less common causes include circumvallate placenta, chorioamniotic separation, and hemorrhage between membranes. Amniotic band syndrome is a rare but important diagnosis to consider, as it causes severe fetal defects. Imaging findings enable body stalk anomaly, a lethal defect, to be distinguished from amniotic bands, which although destructive are not necessarily lethal. This review describes the key imaging findings used to differentiate the various types of ILE in pregnancy, thus enabling accurate diagnosis and appropriate patient counseling. Online supplemental material is available for this article. ^©RSNA, 2018.

Hysterosalpingogram findings among subfertile women undergoing assisted reproductive technology

PURPOSE

The objectives of our study included comparing reproductive histories and causes of infertility between patients with and without a hysterosalpingogram (HSG) investigation, and summarizing the prevalence and extent of tubal abnormalities among patients who underwent HSG. Outcomes following assisted reproductive technology (ART) were compared between HSG and non-HSG groups.

MATERIALS AND METHODS

A cross-sectional study was conducted to review the medical records of 200 Saudi women with subfertility. In addition to information on HSG, patient data extracted included age, body mass index (BMI), infertility duration, miscarriage experience, parity, cause of infertility, and history of previous surgery, ectopic pregnancy, endometriosis, tubal surgery, pelvic inflammatory disease (PID), in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), pregnancy, and live birth.

RESULTS

One hundred and ninety six (98.0%) patients had either IVF (n=18; 9.0%) or ICSI (n=178; 89.0%) performed; ICSI was performed in 157 (90%) and 21 (81%) patients. Of the 12 women with tubal factor who did not undergo HSG, 3 (25.0%) became pregnant after ART, 8 (66.7%) did not, and the status of 1 (8.3%) is yet unknown.

CONCLUSIONS

Our study aimed to contribute to resolving the debate regarding the continuing role of HSG in an environment where ART has become established as a successful approach to treat infertility. Most of the HSGs were done as per the attending physician's discretion, and not according to any specific policy.

Transient uterine contractions as a potential pathology mimic on premenopausal pelvic MRI and the role of routine repeat T2 sagittal images to improve observer confidence

INTRODUCTION

Pelvic MRI has an increasingly important role in the evaluation of non-malignant uterine pathology including uterine leiomyomas, adenomyosis and endometriosis. Normal physiological myometrial junctional zone transient contractions can also be identified on MRI and have the potential to act as pathology mimics. This study aims to evaluate both the incidence of visible physiological contractions in premenopausal female pelvic MRI and also to support the routine acquisition of a repeat T2 sagittal sequence to differentiate transient physiological contractions from true underlying pathology and therefore improve observer confidence.

METHODS

A total of 279 female patients of child-bearing age who had undergone a pelvic MRI over a 16 month period met the inclusion criteria. All patients underwent a standard examination protocol on the same hardware. This included performing two separate T2-weighted sagittal sequences as part of the protocol firstly as the initial and then as the final series for the examination. The sagittal series were reviewed separately by four readers and conclusions made for each case with regards to the presence of identifiable contractions on one or both series and their potential to act as pathology mimics.

RESULTS

Of the 279 cases, there were 34 cases (12.2%) that were found to have transient junctional zone contractions acting as pathology mimics, resembling either leiomyomata or adenomyosis.

CONCLUSIONS

Standard MRI sequences need to be able to distinguish normal transient physiological uterine contractions from true pathology to avoid diagnostic error. The routine utility of a repeat T2-weighted sagittal sequence performed at the conclusion of a patient's examination was shown to improve reader confidence in distinguishing transient contractions from true uterine pathology while adding minimal time penalty to the overall examination. It is therefore advocated that all premenopausal female pelvic MRI cases have a T2 sagittal series as the initial and then the final series as part of a routine protocol.

Effect of Premedication Hyoscine-N-Butylbromide before Hysterosalpingography for Diagnosis of Proximal Tubal Obstruction in Infertile Women: A Randomized Double-Blind Controlled Trial

STUDY OBJECTIVE

To assess the effect of hyoscine-N-butylbromide (HBB) as premedication on the rate of proximal tubal obstruction during hysterosalpingography (HSG).

DESIGN

A randomized, double-blind controlled trial (Canadian Task Force classification I).

SETTING

The Infertility Clinic of Songklanagarind Hospital.

PATIENTS

One hundred and forty-six infertile women indicated for HSG investigation.

INTERVENTIONS

Between May 1, 2016, and March 31, 2017, patients were assigned at random to receive either oral HBB 20 mg or placebo 30 minutes before the HSG procedure. If proximal tubal obstruction was found, participants were be assigned to undergo a second confirming HSG or laparoscopy with chromopertubation within 6 months.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the rate of proximal tubal obstruction. The secondary outcome was the false-positive result of proximal tubal occlusion from HSG. Proximal tubal obstruction was found in 6 of 70 patients in the HBB group and in 16 of 71 in the placebo group. The rate of proximal tubal obstruction was significantly lower in the HBB group than in the placebo group (8.6% vs 22.5%; p = .04; absolute difference, 13.9%; 95% confidence interval [CI], 0.02-0.26; relative risk, 0.38; 95% CI, 0.16-0.92). After the second HSG or laparoscopy was performed (n = 22), the rate of false occlusion was 20% (1 of 6 patients) in the HBB group, compared with 69.2% (9 of 16 patients) in the placebo group.

CONCLUSION

Premedication with HBB before HSG can reduce the rate of diagnosis of proximal tubal obstruction and false occlusion.

Environmentally relevant levels of bisphenol A affect uterine decidualization and embryo implantation through the estrogen receptor/serum and glucocorticoid-regulated kinase 1/epithelial sodium ion channel α-subunit pathway in a mouse model

OBJECTIVE

To investigate whether bisphenol A (BPA) exposure is associated with uterine decidualization and embryo implantation failure in mice.

DESIGN

Experimental animal study and in vitro study.

SETTING

University-based infertility center.

ANIMAL(S)

ICR mice.

INTERVENTION(S)

Mice treated with different doses of BPA; Ishikawa cells cultured in medium of different concentrations of BPA.

MAIN OUTCOME MEASURE(S)

Embryo implantation sites, uterine weight, quantitative real-time reverse transcriptase-polymerase chain reaction, Western blot analysis, hematoxylin and eosin staining, and immunohistochemical, cell proliferation, and statistical analyses.

RESULT(S)

In the experiment of mouse model, administration of 1-100 μg/kg/day of BPA by gavage led to reduction of the number of embryo implantation sites in a dose-dependent manner; 100 μg/kg/day of BPA statistically significantly reduced the number of implantation sites compared with the control group. The uterine weight change (the wet weight of the decidualized uterine horn divided by the wet weight of the undecidualized uterine horn of the mouse) in groups exposed to BPA (100-10,000 μg/kg/day) were statistically significantly lower compared with the control group. Immunohistochemical analysis demonstrated that administration of 100, 1,000, or 10,000 μg/kg/day of BPA by gavage statistically significantly down-regulated the expression of epithelial Na⁺ channel α-subunit (ENaCα) in the luminal epithelial cells and desmin in decidual cells of the oil-induced decidualized uterine horns. Administration of 100 μg/kg/day BPA on embryo days 0.5-3.5 by gavage statistically significantly decreased the level of uterine serum and glucocorticoid-regulated kinase 1 (SGK1) protein expression on embryo days 4 and 6. After treatment with 0.001, 0.01, 0.1, or 1.0 μg/mL of BPA for 48 hours, the SGK1, ENaCα, and phospho-SGK1 protein expression of Ishikawa cells was down-regulated, and the effect of BPA on SGK1 could be abrogated by fulvestrant.

CONCLUSION(S)

Our study provides the first indication that BPA exposure at levels as low as 100 μg/kg/day can impair embryo implantation in mice and BPA can affect decidualization of the uterus in mouse model. Our results suggest that BPA can down-regulate SGK1 and ENaCα protein expression through estrogen receptors in Ishikawa cells.

Effectiveness of interventions for pain relief in hysterosalpingographyAnetwork meta-analysis and systematic review

Objective:

We aimed to evaluate the effectiveness of placebo, oral opioid analgesic (OOA), intravenous opioid analgesic (IOA), non-opioid analgesic (NOA), topical anesthetic (TA) and locally injected anesthetic (LIA) for pain relief duringhysterosalpingography (HSG) using a Bayesian network meta-analysis of data from randomized controlled trials.

Methods:

PUBMED, EMBASE, and CENTRAL search engines were used to search and identify clinical trials that evaluated interventions for pain relief in HSG. Methodological studies quality was assessed by the Cochrane Collaboration tool for assessing risk of bias.

Result:

Sixteen trials involving 1263 participants were included in this study. IOA got excess but not statistically significant lower visual analogue score (VAS) pain score during HSG or more than 30 minutes after HSG compared with the other groups. OOA resulted in excess but not statistically significant higher VAS pain score during HSG compared with the other groups except placebo group. According to SUCRA regarding the lower VAS pain score during HSG, the treatments rank was the following: IOA, TA, NOA, LIA, OOA and placebo; as regard lower VAS pain score at 30 minutes or more after HSG, the treatments rank was the following: IOA, LIA, OOA, TA, NOA and placebo.

Conclusion:

This new Bayesian data network meta-analysis from randomized controlled trials demonstrated that IOA resulted in the highest probability to reduce the pain during HSG or at 30 minutes or more after HSG among the six interventions considered.

The imaging findings of typical and atypical genital and gynecologic infections

Genital and gynecologic infections are common medical problems, affecting millions of women worldwide. The spectrum of these infections extends from the labia, including processes such as necrotizing fasciitis and anogenital warts, to the upper reproductive tracts in conditions including endometritis and pelvic inflammatory disease. Although often a clinical diagnosis, the radiologist plays an important role in determining the etiology of acute abdominal and pelvic pain as well as facilitating the diagnosis for cases which are not clinically straightforward. Imaging also plays an important role in assessing the complications and sequelae of these conditions, including infertility, chronic abdominal and pelvic pain, and pelvic adhesions. Familiarity with the appearances of these infections, their complications, and their potential mimics on sonography, computed tomography, magnetic resonance imaging, and hysterosalpingography is important for timely diagnosis and optimal clinical outcomes.

Role of 3.0 Tesla magnetic resonance hysterosalpingography in the diagnostic work-up of female infertility

BACKGROUND

Imaging evaluation plays a crucial role in the diagnostic work-up of female infertility. In recent years, the possibility to evaluate tubal patency using 1.5 Tesla magnetic resonance (1.5T MR) has been studied.

PURPOSE

To assess the feasibility of 3.0 Tesla magnetic resonance (3.0T MR) hysterosalpingography and its role in the diagnostic work-up of female infertility and to evaluate if this fast "one-stop-shop" imaging approach should be proposed as a first-line examination.

MATERIAL AND METHODS

A total of 116 infertile women were enrolled in this prospective study; all underwent 3.0T MR hysterosalpingography. After standard imaging of the pelvis, tubal patency was assessed by acquiring 3D dynamic time-resolved T1-weighted (T1W) sequences during manual injection of 4-5 mL of contrast solution consisting of gadolinium and normal sterile saline. Images were evaluated by two radiologists with different experience in MR imaging (MRI).

RESULTS

The examination was successfully completed in 96.5% of cases, failure rate was 3.5%. Dynamic sequences showed bilateral tubal patency in 64.3%, unilateral tubal patency in 25.9%, and bilateral tubal occlusion in 9.8%. Extratubal abnormalities were found in 69.9% of patients. Comprehensive analysis of morphological and dynamic sequences showed extratubal abnormalities in 43.1% of patients with bilateral tubal patency.

CONCLUSION

3.0T MR hysterosalpingography is a feasible, simple, fast, safe, and well-tolerated examination, which allows evaluation of tubal patency and other pelvic causes of female infertility in a single session, and it may thus represent a "one-stop-shop" solution in female infertility diagnostic work-up.

[Pictures balance for optimal surgical management of pelvic endometriosis. Imaging and surgery of endometriosis]

Endometriosis is a frequent benign pathology that is found in 10-15% of women and in 20% of infertile women. It has an impact on fertility, but also in everyday life. If medical treatment fails, surgical treatment can be offered to the patient. To provide adequate treatment and give clearer information to patients, it seems essential to achieve an optimal preoperative imaging assessment. Thus, the aim of this work is to define the information expected by the surgeon and the indications of each imaging test for each compartment of the pelvis, allowing an ideal surgical management of pelvic endometriosis. We will not discuss imaging techniques' principles and we will not develop the indications and surgical techniques.

Comparison of four different pain relief methods during hysterosalpingography: a randomized controlled study

BACKGROUND

Hysterosalpingography (HSG) is the most commonly used method for evaluating the anatomy and patency of the uterine cavity and fallopian tubes, and is an important tool in the evaluation of infertility. The most frequent side effect is the pain associated with the procedure.

OBJECTIVES

To evaluate four analgesic methods to determine the most useful method for reducing discomfort associated with HSG.

METHODS

In the present prospective study, 75 patients undergoing HSG for evaluation of infertility were randomly assigned to four groups: 550 mg of a nonsteroidal anti-inflammatory drug (NSAID) (group 1); 550 mg NSAID + paracervical block (group 2); 550 mg NSAID + paracervical analgesic cream (group 3); or 550 mg NSAID + intrauterine analgesic instillation (group 4). A visual analogue scale was used to assess the pain perception at five predefined steps.

RESULTS

Instillation of the liquids used for HSG was found to be the most painful step of HSG, and this step was where the only significant difference among groups was observed. When comparing visual analogue scale scores, group 2 and group 3 reported significantly less pain than the other groups. Group 1 reported significantly higher mean (± SD) scores (7.2 ± 1.6) compared with groups 2 and 3 (4.7 ± 2.5 and 3.8 ± 2.4, respectively) (P<0.001). In addition, group 2 reported significantly less pain than group 4 (4. 7 ± 2.5 versus 6.7 ± 1.8, respectively) (P<0.02).

CONCLUSIONS

For effective pain relief during HSG, in addition to 550 mg NSAID, local application of lidocaine cream to the posterior fornix of the cervix uteri and paracervical lidocaine injection into the cervix uteri appear to be the most effective methods.

Rectal indomethacin use in pain relief during hysterosalpingography: A randomized placebo controlled trial

AIM

To evaluate the effectiveness of a rectal nonsteroidal anti-inflammatory drug (indomethacin) for pain relief during a hysterosalpingography (HSG).

MATERIALS AND METHODS

This prospective, randomized study included 82 women divided randomly into two groups. The study group received self-administered rectal indomethacin, while the control group received a placebo before the procedure. Degrees of pain were evaluated using the visual analog scale (VAS) at four different steps during the procedure and 30 min afterwards. The anxiety-depression status of the patients was evaluated using a validated Turkish version of the Beck anxiety-depression form before the procedure.

RESULTS

There were no statistically significant differences in the demographic characteristics of patients. The mean pain scores during tenaculum application (step 2), cervical traction (step 3), contrast injection (step 4) and 30 min after the procedure, were significantly lower in the study than the control group (P < 0.05). Step 4 was the most painful in both groups (VAS scores 3.2 ± 0.6 study vs. 5.3 ± 1.1 control). The mean pain score in step 4 for patients with abnormal HSG results was significantly higher than in patients with normal HSG results (P < 0.05). The mean anxiety and depression scores immediately before the procedure were not statistically different between the groups (P = 0.610 and P = 0.129, respectively).

CONCLUSION

Our study demonstrated a significant reduction in pain in patients who received a single rectal dose of indomethacin; therefore, we recommend the use of rectal indomethacin for reducing pain during a HSG procedure.

Comparison of uterine and tubal pathology identified by transvaginal sonography, hysterosalpingography, and hysteroscopy in female patients with infertility

Background

The causes of female infertility are multifactorial and necessitate comprehensive evaluation including physical examination, hormonal testing, and imaging. Given the associated psychological and financial stress that imaging can cause, infertility patients benefit from a structured and streamlined evaluation. The goal of such a work up is to evaluate the uterus, endometrium, and fallopian tubes for anomalies or abnormalities potentially preventing normal conception. To date, the standard method for assessing these structures typically involves some combination of transvaginal sonography (TVS), hysterosalpingography (HSG), and hysteroscopy (HSC). The goal of this review is to compare the diagnostic accuracy of TVS, HSG, and HSC for diagnosing abnormalities in infertility patients to determine if all studies are necessary for pre-treatment evaluation.

Results

We identified infertility patients prior to initiation of assisted reproductive technology who had baseline TVS, HSG, and HSC within 180 days of each other. From medical record review, we compared frequencies of each finding between modalities. Of the 1274 patients who received a baseline TVS over 2 years, 327 had TVS and HSG within 180 days and 55 patients had TVS, HSG and HSC. Of the 327, TVS detected fibroids more often than HSG (74 vs. 5, p < .0001), and adenomyosis more often than HSG (7 vs. 2, p = .02). HSG detected tubal obstruction more often than TVS (56 vs. 8, p = .002). Four (1.2 %) patients had endometrial polyps on both HSG and TVS.

In the 55 patients with HSG, TVS, and HSC, HSC identified endometrial polyps more often than TVS (10 vs. 1, p = .0001) and HSG (10 vs. 2, p = .0007). TVS detected more fibroids than HSC (17 vs. 5, p < .0001). Tubal obstruction was identified more often by HSG than HSC (19 vs. 5, p < .0001).

Conclusions

TVS is superior for evaluation of myometrial pathology. HSG is superior for evaluation of tubal pathologies. Endometrial pathologies are best identified with HSC.

Evidence-Based Care for Couples With Infertility

When couples cannot achieve pregnancy, they often seek health care from medical and nursing specialists. The care the couple receives begins with a thorough assessment to determine the possible cause of infertility and to plan appropriate care to ensure the best chance for the couple to have a biological child. In this article, we provide an overview of the etiology and evaluation of infertility, the various treatment options available, and the appropriate clinical implications.

Human parasitic protozoan infection to infertility: a systematic review

Protozoan parasitic diseases are endemic in many countries worldwide, especially in developing countries, where infertility is a major burden. It has been reported that such infections may cause infertility through impairment in male and female reproductive systems. We searched Medline, PubMed, and Scopus databases and Google scholar to identify the potentially relevant studies on protozoan parasitic infections and their implications in human and animal model infertility. Literature described that some of the protozoan parasites such as Trichomonas vaginalis may cause deformities of the genital tract, cervical neoplasia, and tubal and atypical pelvic inflammations in women and also non-gonoccocal urethritis, asthenozoospermia, and teratozoospermia in men. Toxopalasma gondii could cause endometritis, impaired folliculogenesis, ovarian and uterine atrophy, adrenal hypertrophy, vasculitis, and cessation of estrus cycling in female and also decrease in semen quality, concentration, and motility in male. Trypanosoma cruzi inhibits cell division in embryos and impairs normal implantation and development of placenta. Decrease in gestation rate, infection of hormone-producing glands, parasite invasion of the placenta, and overproduction of inflammatory cytokines in the oviducts and uterine horns are other possible mechanisms induced by Trypanosoma cruzi to infertility. Plasmodium spp. and Trypanosoma brucei spp. cause damage in pituitary gland, hormonal disorders, and decreased semen quality. Entamoeba histolytica infection leads to pelvic pain, salpingitis, tubo-ovarian abscess, and genital ulcers. Cutaneous and visceral leishmaniasis can induce genital lesion, testicular amyloidosis, inflammation of epididymis, prostatitis, and sperm abnormality in human and animals. In addition, some epidemiological studies have reported that rates of protozoan infections in infertile patients are higher than healthy controls. The current review indicates that protozoan parasitic infections may be an important cause of infertility. Given the widespread prevalence of parasitic protozoa diseases worldwide, we suggest further studies to better understanding of relationship between such infections and infertility.

Preimplantation Exposure to Bisphenol A and Triclosan May Lead to Implantation Failure in Humans

Endocrine disrupting chemicals (EDCs) are chemicals that have the capacity to interfere with normal endocrine systems. Two EDCs, bisphenol A (BPA) and triclosan (TCS), are mass-produced and widespread. They both have estrogenic properties and similar chemical structures and pharmacokinetic features and have been detected in human fluids and tissues. Clinical evidence has suggested a positive association between BPA exposure and implantation failure in IVF patients. Studies in mouse models have suggested that preimplantation exposure to BPA and TCS can lead to implantation failure. This paper reviews the relationship between preimplantation exposure to BPA and TCS and implantation failure and discusses the remaining problems and possible solutions.