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

The Effect of Salpingectomy on Ovarian Reserve Using Two Different Electrosurgical Instruments: Ultrasonic Shears Versus Bipolar Electrocautery

Background Salpingectomy is a common surgical procedure in gynecology performed for various indications. Given its proximity to the ovaries and shared vascular supply, concerns have arisen regarding compromised ovarian reserve post-salpingectomy. Objective We aim to study the effect of two different energy sources (group 1: salpingectomy using bipolar electrocautery followed by division with scissors versus group 2: salpingectomy with ultrasonic shears) on residual ovarian reserve. The effect on ovarian reserve was assessed using serum levels of follicle-stimulating hormone (FSH), anti-Müllerian hormone (AMH), antral follicle count (AFC), and ovarian size pre- and postoperatively. Materials and methods According to the inclusion criteria, 68 women were included in the study and randomized into the bipolar electrocautery group and the ultrasonic shear group. The final analysis included 34 women in the bipolar electrocautery group and 32 in the ultrasonic shear group. Preoperatively, the ovarian reserve of all women was assessed using FSH, AMH, AFC, and ovarian size. These parameters were then reassessed at three months postoperatively, and the percentage change was analyzed. Results The mean baseline serum AMH and serum FSH values in the bipolar electrocautery group were 3.9 ± 2.9 ng/ml and 6.6 ± 2.1 IU/L, respectively, comparable with the values in the ultrasonic shear group, where serum AMH was 3.2 ± 2.9 ng/ml and serum FSH was 7.3 ± 3.9 IU/L. AFC and ovarian size were comparable between the two groups preoperatively (bipolar electrocautery group AFC was 8 ± 2.2, ovarian size on the right side was 3.3 ± 0.7 cm and on the left was 3.2 ± 0.6 cm; ultrasonic shear group AFC was 5.7 ± 2.3, ovarian size on the right side was 3.4 ± 0.8 cm and on the left was 3.2 ± 0.8 cm). After three months of postoperative analysis, AFC showed a significant fall from the preoperative value in the bipolar electrocautery group compared to the ultrasonic shear group (AFC reduced from 8 ± 2.2 to 5.5 ± 2.3 vs. 8.6 ± 0.5 to 7.9 ± 2.3; p=0.002). The other parameters showed no statistically significant change. Conclusion Our study suggests that ultrasonic shear is safer than bipolar electrocautery for preserving ovarian reserve after salpingectomy. However, further research is needed to confirm these findings.

The influence of timing of oocytes retrieval and embryo transfer on the IVF-ET outcomes in patients having bilateral salpingectomy due to bilateral hydrosalpinx

Objective

The objective of the study was to investigate whether the sequence of oocyte retrieval and salpingectomy for hydrosalpinx affects pregnancy outcomes of in vitro fertilization and embryo transfer (IVF-ET) patients.

Study Design

There were 1,610 bilateral hydrosalpinx patients who underwent laparoscopy salpingectomy and IVF-ET/intracytoplasmic sperm injection (ICSI) from January 2009 to December 2018. They were divided into two groups: oocyte retrieval first group: 235 accepted oocyte retrieval before salpingectomy; operation first group: 1,375 accepted oocyte retrieval after salpingectomy. The basic information and pregnancy outcomes of the two groups were compared. The pregnancy outcomes and influencing factors were analyzed among patients at different starting times of frozen-thawed embryo transfer (FET) or oocyte retrieval after the salpingectomy.

Results

Patients in the oocyte retrieval first group had higher levels of basal follicle stimulating hormone and lower anti-Mullerian hormone levels (P < 0.05). There were no cases of pelvic infection or oocyte and embryo contamination after oocyte retrieval in the oocyte retrieval first group. In the frozen cycle, the clinical pregnancy and miscarriage rates of the oocyte retrieval first group were lower than those in the operation first group (P < 0.05), while the live birth rate was not significantly different (P > 0.05). The live birth rates of patients ≥35 years old in the operation first group and the oocyte retrieval first group were not significantly different (29.3% vs. 23.3%, P = 0.240). After adjusting for age and antral follicle count (AFC), oocyte retrieval 4-6 and 7-12 months after the operation had higher accumulated pregnancy rates [OR 1.439 (1.045-1.982), P = 0.026; OR 1.509 (1.055-2.158), P = 0.024] and higher accumulated live birth rates [OR 1.419 (1.018-1.977), P = 0.039; OR 1.544 (1.068-2.230), P = 0.021]. No significant difference was observed in the pregnancy outcomes of frozen embryo transfer at different times after salpingectomy (P > 0.05).

Conclusion

No contamination of the embryo or infection was observed in patients who underwent oocyte retrieval before the operation. The interval between the operation and frozen embryo transfer did not affect the pregnancy outcomes. After adjusting for age and AFC, patients who underwent oocyte retrieval 4-6 and 7-12 months after the operation had higher accumulated pregnancy rates and live birth rates.

A retrospective analysis of ovarian response to gonadotropins after laparoscopic unilateral or bilateral salpingectomy for hydrosalpinges

BACKGROUND AND AIMS

We compared the effects of unilateral and bilateral salpingectomy for hydrosalpinx on ovarian function, oocyte retrieval, and embryogenesis.

METHODS

We retrospectively examined the hospital records of 109 women with unilateral hydrosalpinx and 57 women with bilateral hydrosalpinges who had undergone in vitro fertilization (IVF) treatment (280 oocyte retrieval cycles) between January 2011 and December 2018. We compared age at oocyte retrieval, level of anti-Müllerian hormone (AMH) measured within 1 year of oocyte retrieval, duration of infertility, number of previous IVF treatments, level of follicle stimulating hormone, total gonadotropin dose, number of oocytes retrieved, fertilization rate, blastocyst formation rate, and peak serum estrogen concentration. This study was approved by the institutional review board.

RESULTS

Of the women with unilateral hydrosalpinx, no significant differences were observed in ovarian response, rate of fertilization or rate of blastocyst production between the 21 women (24 cycles) who had undergone unilateral salpingectomy and the 88 women (146 cycles) who had not. Of the women with bilateral hydrosalpinges, the 13 (24 cycles) who had undergone bilateral salpingectomy had slightly lower AMH levels and significantly fewer oocytes retrieved (5.5 ± 3.9 vs 8.3 ± 5.5; P = .0068) than the 44 women (86 cycles) who had not had a salpingectomy. Women who had undergone bilateral salpingectomy also had significantly lower peak serum estrogen concentrations than those who had not undergone salpingectomy (1876.1 ± 765.9 vs 2489.5 ± 1551.4; P = .009).

CONCLUSION

In women with hydrosalpinx, bilateral salpingectomy may reduce ovarian function and response to gonadotropins, especially the number of oocytes retrieved. Unilateral salpingectomy does not have these effects.

Management of Hydrosalpinx in the Era of Assisted Reproductive Technology: A Systematic Review and Meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis evaluating the effect of hydrosalpinx on pregnancy outcomes, to compare different types of management of hydrosalpinx and their impact on pregnancy rates as well as on the ovarian reserve.

DATA SOURCES

Electronic search using Pubmed, EMBASE, Ovid MEDLINE, Google Scholar, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials and including all published studies that examined tubal infertility and its management (assisted reproductive technology or surgery) as well as the effects on ovarian reserve. The following medical subject headings (Mesh) terms combinations were used: "fallopian tube disease," hydrosalpinx," "tubal or salpinx occlusion or obstruction," "in vitro fertilization," "fallopian tube surgery," "salpingectomy," "salpingostomy," "infertility," "subfertility," "sterility" and "ovarian reserve."

METHODS OF STUDY SELECTION

All randomized trials, cohort, and case controls studies were included. We excluded review articles, meeting abstracts, case series and case reports, and abstracts without access to full texts. The search was limited to trials in humans and published in English.

TABULATION, INTEGRATION, AND RESULTS

Our electronic search initially retrieved 6354 articles. Finally, 19 studies were included in the quantitative evaluation of the effects of hydrosalpinx: 23 in the qualitative evaluation and 5 in the quantitative evaluation of different types of hydrosalpinx treatments; and 17 in the quantitative evaluation of ovarian reserve. The presence of a hydrosalpinx was associated with decreased rates of implantation and clinical pregnancy, and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx with salpingectomy, tubal occlusion, or hydrosalpinx aspiration led to better in vitro fertilization pregnancy rates. We found no difference in ovarian response to stimulation after salpingectomy except a decrease in antimüllerian hormone compared to no surgery.

CONCLUSIONS

The presence of hydrosalpinx is associated with decreased pregnancy rate and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx, regardless of the type of treatment, leads to an increased chance of pregnancy.

Salpingectomy may decrease antral follicle count but not live birth rate for IVF-ET patients aged 35-39 years: a retrospective study

Purpose

Problems with fallopian tubes are one of the main reasons for women to undergo in vitro fertilization-embryo transfer (IVF-ET). A large proportion of women with ectopic pregnancy, fallopian tube obstruction and hydrosalpinx have had one or both fallopian tubes removed by salpingectomy. With increasing age, ovarian reserve deteriorates, the numbers of retrieved oocytes, available embryos and high-quality embryos are reduced, and the live birth rate for women treated with IVF treatment is affected. Thus, it is important to understand how salpingectomy affects live birth rates for IVF patients of different ages. This study analyzed how patients’ age and salpingectomy influenced ovarian reserve, ovarian response and pregnancy outcomes for infertile women undergoing IVF-ET.

Methods

A total of 1922 patients that underwent IVF-ET treatment from January 1, 2012, to December 31, 2018, were included in this retrospective study. The patients were divided into two groups according to whether or not they had a previous history of salpingectomy. The salpingectomy (group A, 534 patients) and control groups (group B, 1388 patients) were then further divided into two subgroups according to patient age (age<35 years, and age 35–39 years). Ovarian reserve, ovarian response, and IVF outcomes were investigated for each subgroup. Logistic regression model was used to estimate the relationship between clinical pregnancy and live births and patients’ baseline characteristics.

Results

In the salpingectomy group, antral follicle counts (AFC) were significantly lower for the subgroup aged 35 to 39 years compared with the control group. But this difference did not appear in women younger than 35 years. In addition, there were no significant differences in levels of basal follicle stimulation hormone (FSH), basal luteinizing hormone (LH), basal estradiol (E₂), total gonadotropins (Gn) dose, duration of Gn, numbers of retrieved oocytes, fertilization rates, numbers of available embryos, live birth rates, clinical pregnancy rates, miscarriage rates, ectopic pregnancy rates, or multiple pregnancy rates between the salpingectomy group and the control group (P > 0.05). Age is a risk factor for the clinical pregnancy and live birth.

Conclusion

Salpingectomy may decrease antral follicle count but not live birth rate for IVF-ET patients aged 35–39 years. The increased female age was negative related with clinical pregnancy and live birth.

Proximal Fallopian Tubal Embolization by Interventional Radiology prior to Embryo Transfer in Infertile Patients with Hydrosalpinx: A Prospective Study of an Off-label Treatment

STUDY OBJECTIVE

To evaluate in vitro fertilization (IVF) outcomes of proximal fallopian tube embolization by interventional radiology compared with laparoscopic salpingectomy before embryo transfer (ET) in patients with hydrosalpinx.

DESIGN

A single-center, off-label, nonrandomized prospective study.

SETTING

Academic university hospital.

PATIENTS

One hundred fifty-five patients with hydrosalpinx were identified on ultrasound or hysterosalpingography desiring IVF between April 2016 and December 2017.

INTERVENTIONS

Radiologically guided tubal occlusion with embolization microcoils (RTO-EM) and laparoscopic salpingectomy.

MEASUREMENTS AND MAIN RESULTS

Of the 155 analyzed patients, 42 were treated with RTO-EM and 113 with laparoscopic salpingectomy. The subsequent IVF outcomes, including implantation, clinical pregnancy, miscarriage, ectopic pregnancy, and ongoing pregnancy (i.e., a fetal heartbeat on ultrasound beyond 10 weeks) were compared between the 2 groups. Implantation and clinical pregnancy per ET cycle in the RTO-EM group were similar to that of the salpingectomy group (26.7% vs 30.2% [p = .51] and 39.0% vs 45.3% [p = .40], respectively), with a similar miscarriage rate. There was no statistically significant difference in ectopic pregnancies between the 2 groups. Moreover, no difference was detected in ongoing pregnancy per cycle between the 2 groups (33.9% vs 41.2%; p = .32). The ongoing-pregnancy rate per patient following RTO-EM was 47.6% (20 of 42) compared with 61.9% (70 of 113) following salpingectomy (odds ratio, 0.56; 95% confidence interval, 0.27-1.14; p = .11).

CONCLUSION

Pregnancy in the RTO-EM group was comparable to the salpingectomy group in patients with hydrosalpinx before ET treatment. RTO-EMs may be an alternative to salpingectomy for patients with hydrosalpinx planning for IVF-ET.

Treatment of hydrosalpinx in relation to IVF outcome: a systematic review and meta-analysis

Salpingectomy is the most widely used treatment for hydrosalpinx. The effect of salpingectomy on the stimulation response during subsequent IVF treatment, however, remains unclear. The aim of this systematic review was to evaluate the ovarian response and pregnancy outcome of IVF treatment carried out after salpingectomy compared with other pre-IVF treatment options for hydrosalpinx. We conducted a literature search using PubMed, Ovid MEDLINE, Google Scholar, ClinicalTrials.gov and the Cochrane Central Register of Controlled Trials. Five randomized studies and nine observational studies were included in the systematic review and evaluated using Cochrane Collaboration's tool for randomized, Newcastle-Ottawa scale for observational studies and GRADE guidelines for certainty of evidence assessment. The mean number of retrieved oocytes was similar between the groups in randomized (mean difference [MD] = -0.03, 95% CI -0.75 to 0.70) and observational studies (MD = -0.15, 95% CI -2.32 to 2.02). Live birth (RR 1.59, 95% CI 1.17 to 2.16), clinical pregnancy (RR 1.27, 95% CI 1.02 to 1.57) and implantation rates (RR 1.55, 95% CI 1.16 to 2.08) were higher in the salpingectomy group in randomized studies. The present systematic review and meta-analysis showed that salpingectomy does not impair the ovarian response during subsequent IVF treatment.

Clinical application of serum anti-Müllerian hormone as an ovarian reserve marker: A review of recent studies

It has been more than 15 years since the measurement of serum anti-Müllerian hormone (AMH) first allowed the quantitative assessment of ovarian reserve. Meanwhile, the clinical implication of serum AMH has been expanding. The measurement of serum AMH has been applied in various clinical fields, including assisted reproduction, menopause, reproductive disorders and assessment of ovarian damage/toxicity. Well-known findings about the usefulness of serum AMH revealed by numerous studies executed in the early era include decline with aging, a good correlation with oocyte yield in assisted reproduction, upregulation in polycystic ovarian syndrome and a decrease on ovarian surgery and toxic treatment. More intensive research, including a meta-analysis, cutting-edge clinical trial and advances in AMH assays, has yielded newer findings and firmer clinical interpretations in serum AMH in the past few years. Variations in the AMH decline trajectory in the general population do not support the accurate prediction of menopause. The ability to predict pregnancy in infertility treatment and natural conception is poor, while a nomogram integrating serum AMH as a stimulation protocol is useful for avoiding poor and/or hyper-responses. On the other hand, improvements in measuring very low concentrations of serum AMH may be capable of distinguishing women with poor ovarian function. Age-independent standardization of AMH values may be helpful for comparing ovarian reserves among women at different ages.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Unilateral Salpingectomy and Methotrexate Are Associated With a Similar Recurrence Rate of Ectopic Pregnancy in Patients Undergoing In Vitro Fertilization

STUDY OBJECTIVE

To determine whether different treatment approaches of ectopic pregnancy (EP), particularly unilateral salpingectomy and methotrexate, affect its recurrence rate in patients undergoing in vitro fertilization (IVF).

DESIGN

A retrospective cohort study (Canadian Task Force classification II-2).

SETTING

An academic medical center.

PATIENTS

Patients with a history of a previous EP who achieved pregnancy after IVF cycles between January 2004 and August 2015 were included. The recurrence rate of EP was compared between patients who underwent different treatment approaches for a previous EP.

INTERVENTIONS

IVF.

MEASUREMENTS AND MAIN RESULTS

A total of 594 patients were included. Seventeen patients had a recurrence of EP (2.9%). Patients with a history of ≥2 EPs were associated with a significantly higher recurrence rate of EP than those with 1 previous EP (8.5% vs. 1.8%; p = .01; odds ratio [OR] = 2.2; 95% confidence interval [CI], 1.2-4.4). Patients who underwent unilateral salpingectomy (n = 245) had a comparable recurrence rate of EP after IVF with those who received methotrexate (n = 283) (3.6% vs. 2.8%; p = .5; OR = 1.3; 95% CI, 0.4-3.4). This OR remained unchanged after adjusting for patient's age, number of previous EPs, number of transferred embryos, and peak estradiol level during stimulation (adjusted OR = 1.4; 95% CI, 0.5-3.8). None of the patients who underwent bilateral salpingectomy (n = 45) or salpingostomy (n = 21) had a recurrence of EP after IVF.

CONCLUSION

The recurrence rate of EP significantly correlates with the number of previous EPs. Treatment of EP with methotrexate has a comparable recurrence rate of EP after IVF with unilateral salpingectomy. Therefore, the risk of recurrence should not be a reason to favor salpingectomy over methotrexate in this population.

The Effect of Salpingectomy on Ovarian Reserve and Ovarian Function

BACKGROUND

The effect of salpingectomy on ovarian reserve and ovarian function is still a controversial issue, and more investigations are needed.

OBJECTIVE

The aim of this study was to determine the effect of salpingectomy on ovarian reserve and ovarian function.

STUDY STRATEGY

PubMed, Embase, Medline, Web of Knowledge, and the Cochrane trial register were searched.

SELECTION CRITERIA

Studies must have similar study method and be published in English; clear data can be extracted from full test.

DATA COLLECTION AND ANALYSIS

Data were collected and analyzed by Review Manager 5.3.

MAIN RESULTS

A total of 13 studies were eligible. The level of anti-müllerian hormone is lower, and early follicular phase follicle-stimulating hormone is higher in salpingectomy groups. The level of early follicular phase estradiol and the ovarian volume of salpingectomy groups are the same as control. The total dose of follicle-stimulating hormone needed during in vitro fertilization and embryo transfer (IVF-ET) treatment cycles, the number of collected oocytes, and the clinical pregnancy rate are similar in salpingectomy and control groups.

CONCLUSIONS

Salpingectomy does not appear to affect ovarian function, ovarian response to gonadotropin stimulation, or outcome of IVF-ET in the short run. It may, however, impair ovarian reserve in the long run.

Preventive Salpingectomy and Ovarian Reserve: Experimental Study

The levels of anti-Müllerian hormone, follicle-stimulating hormone, and testosterone were studied in rats after removal of the uterine horns, oviducts, or combined surgery. The effects of preventive salpingectomy on ovarian reserve were studied. After preventive salpingectomy, the level of anti-Müllerian hormone was low throughout the experiment, follicle-stimulating hormone increased only by the end of observation (on day 40), and testosterone level decreased only on day 10. Hysterectomy alone caused no changes in the concentrations of the studied hormones on day 10 after surgery. Salpingectomy alone reduced the concentrations of anti-Müllerian hormone and testosterone and did not change the level of follicle-stimulating hormone during this period.

Salpingectomy before assisted reproductive technologies: a systematic literature review

Salpingectomy is largely used in case of hydrosalpinx in infertile women scheduled for assisted reproductive technologies (ART), whereas there is no consensus on its role in absence of hydrosalpinx. The current is a systematic literature review to collate all available evidence regarding salpingectomy as fertility enhancement procedure before ART in infertile patients. Our primary endpoint was to assess the impact of the surgical procedure on ovarian reserve, and secondary outcomes were to evaluate its benefits and harms on ART outcomes. We identified 29 papers of which 16 reporting data on the impact of tubal surgery on ovarian reserve and 24 (11 previously included) on ART outcomes. Available data suggested an absence of variation in ovarian reserve markers after unilateral salpingectomy while contradictory results were reported for bilateral surgery. Considering ART outcomes, data reported a significant improvement in ongoing pregnancy/live-birth rate in treated subjects without significant reduction in ovarian response to gonadotropin stimulation. In case of tubal disease, a surgical approach based on unilateral salpingectomy may be considered safe, without negative effects on ovarian reserve and ovarian response to controlled ovarian stimulation whilst having a positive effect on pregnancy rate. Data regarding bilateral salpingectomy and ovarian reserve are conflicting. Further trials are needed to confirm both the benefits of salpingectomy before ART and the safety of bilateral salpingectomy on ovarian reserve, and to clarify the role of uni- or bilateral surgery in case of tubal blockage without hydrosalpinx.

Involvement of mesosalpinx in endometrioma is a possible risk factor for decrease of ovarian reserve after cystectomy: a retrospective cohort study

BACKGROUND

Serum anti-Müllerian hormone (AMH) concentration has been used to assess ovarian reserve in patients with endometriosis, especially when endometrioma surgery is involved. Previously, we reported that decreased serum AMH levels after cystectomy for endometriomas can recover to preoperative levels in some cases. In this present study, we assessed the sequential changes in serum AMH levels before and after cystectomy in terms of the state of the mesosalpinx prior to surgery.

METHODS

The retrospective cohort study recruited 53 patients from a series of prospective studies conducted from 2009 to 2015. All patients underwent laparoscopic cystectomy for endometriomas. If either mesosalpinx was involved in the endometrioma or adnexal adhesion before cystectomy, the case was defined as 'involved mesosalpinx' (n = 14). If both mesosalpinx remained anatomically correct, the case was classified as 'intact mesosalpinx' (n = 39). Blood samples were obtained from the patients 2 weeks before surgery, and at 1 month and 1 year after surgery to assess serum AMH levels.

RESULTS

The serum AMH levels (the involved group vs. the intact group) were 1.92 vs. 0.98 (P = 0.552) preoperatively, 0.59 vs. 1.99 (P = 0.049) at 1 month postoperatively, and 0.48 vs. 2.37 ng/mL (P = 0.007) at 1 year postoperatively. The involved mesosalpinx group showed a further decrease in serum AMH levels at 1 year postoperatively, while serum AMH levels in the intact mesosalpinx group tended to recover.

CONCLUSION

These results suggest that pre-existing mesosalpinx disturbance, in combination with adhesiolysis, may be involved in the medium- and long-term decrease in ovarian reserve after endometrioma surgery. A disturbance in ovarian blood supply via the mesosalpinx may underlie this.

TRIAL REGISTRATION

UMIN-CTR UMIN000019369 . Retrospectively registered October 15, 2015.

Change in the ovarian environment after hysterectomy with bilateral salpingectomy: is it the technique or surgery itself?

OBJECTIVE

To compare the effects of total laparoscopic hysterectomy with bilateral salpingectomy (TLH-BS) and total abdominal hysterectomy with bilateral salpingectomy (TAH-BS) on ovarian function among women of reproductive age.

STUDY DESIGN

One hundred and three patients with a diagnosis of benign uterine disorder were divided into two groups in this prospective longitudinal study. Patients who had never had sexual intercourse and patients with uterovaginal disproportion underwent TAH-BS (n=57), and the remaining patients (n=46) underwent TLH-BS. Ovarian function was assessed before and 6 months after surgery; ovarian volume was assessed by gray-scale ultrasonography, and levels of serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), oestradiol (E2), anti-Mullerian hormone (AMH) and inhibin B were measured.

RESULTS

Postoperative serum FSH, LH and inhibin B decreased significantly in both groups. Postoperative serum E2 did not change significantly. Postoperative serum AMH and ovarian volume decreased significantly in the TAH-BS group (p=0.016 and p<0.001, respectively), but not in the TLH-BS group. Significant differences were observed between the TLH-BS and TAH-BS groups with respect to change in FSH (p=0.012) and ovarian volume (p=0.001); between-group differences were not significant for changes in AMH and inhibin B.

CONCLUSIONS

Although serum AMH did not change significantly in patients who underwent TLH-BS, ovarian aging commenced following both surgical procedures.

Anti-Müllerian hormone as a marker of ovarian reserve: What have we learned, and what should we know?

Ovarian reserve reflects the quality and quantity of available oocytes. This reserve has become indispensable for the better understanding of reproductive potential. Measurement of the serum anti-Müllerian hormone (AMH) level allows quantitative evaluation of ovarian reserve. It has been applied to a wide range of clinical conditions, and it is well established that the measurement of serum AMH levels is more useful than qualitative evaluation based on the menstrual cycle. AMH levels are monitored during infertility treatments; in patients undergoing medically assisted reproductive technology; and in the diagnosis of ovarian failure, polycystic ovarian syndrome, and granulosa cell tumor. It is also useful in the evaluation of iatrogenic ovarian damage. Population-based studies have indicated a potential role for serum AMH in the planning of reproductive health management. While AMH is currently the best measure of ovarian reserve, its predictive value for future live births remains controversial. Furthermore, there is a serious practical issue in the interpretation of test results, as currently available assay kits use different assay ranges and coefficients of variation due to the absence of an international reference standard. The pros and cons of the serum AMH level as a definitive measure of ovarian reserve merits further review in order to guide future research.

Ectopic pregnancy secondary to in vitro fertilisation-embryo transfer: pathogenic mechanisms and management strategies

BACKGROUND

Ectopic pregnancy (EP) is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with in vitro fertilisation and embryo transfer (IVF-ET). The co-existence of an EP with a viable intrauterine pregnancy (IUP) is known as heterotopic pregnancy (HP) affecting about 1% of patients during assisted conception. EP/HP can cause significant morbidity and occasional mortality and represent diagnostic and therapeutic challenges, particularly during fertility treatment. Many risk factors related to IVF-ET techniques and the cause of infertility have been documented. The combination of transvaginal ultrasound (TVS) and serum human chorionic gonadotrophin (hCG) is the most reliable diagnostic tool, with early diagnosis of EP/HP permitting conservative management. This review describes the risk factors, diagnostic modalities and treatment approaches of EP/HP during IVF-ET and also their impact on subsequent fertility treatment.

METHODS

The scientific literature was searched for studies investigating EP/HP during IVF-ET. Publications in English and within the past 6 years were mostly selected.

RESULTS

A history of tubal infertility, pelvic inflammatory disease and specific aspects of embryo transfer technique are the most significant risk factors for later EP. Early measurement of serum hCG and performance of TVS by an expert operator as early as gestational week 5 can identify cases of possible EP. These women should be closely monitored with repeated ultrasound and hCG measurement until a diagnosis is reached. Treatment must be customised to the clinical condition and future fertility requirements of the patient. In cases of HP, the viable IUP can be preserved in the majority of cases but requires early detection of HP. No apparent negative impact of the different treatment approaches for EP/HP on subsequent IVF-ET, except for risk of recurrence.

CONCLUSIONS

EP/HP are tragic events in a couple's reproductive life, and the earlier the diagnosis the better the prognosis. Due to the increase incidence following IVF-ET, there is a compelling need to develop a diagnostic biomarker/algorithm that can predict pregnancy outcome with high sensitivity and specificity before IVF-ET to prevent and/or properly manage those who are at higher risk of EP/HP.

Effect of Xianziyizhen Recipe Capsule on PGI2-PPARδ Signaling Pathway in Embryo Implantation Dysfunction Mice

PROBLEM

We investigated the effect of Xianziyizhen recipe capsule (XRC), a kidney-tonifying herb, on the PGI2-PPARδ signaling pathway at the maternal-fetal interface in embryo implantation dysfunction (EID) mice.

METHOD OF STUDY

Intragastric administration of Progynova (estradiol) or XRC was performed in EID mouse model, following experimental induction of kidney deficiency by co-treatment with chemotherapy drug hydroxyurea and antiprogesterone mifepristone. The PPARδ and IL-11 mRNA expression in endometrium were detected by real-time relative reverse transcription-polymerase chain reaction (RT-PCR). Further, the protein expression of COX-2, PGI2, MMP-9, and TIMP-3 was detected in endometrial glandular epithelium and in stromal cells by immunohistochemical (IHC) assay.

RESULTS

The results showed that hydroxyurea and mifepristone-induced EID were associated with significantly lower PPARδ and IL-11 mRNA levels in endometrium and reduced COX-2, PGI2, MMP-9, and TIMP-3 levels in endometrial glandular epithelium, compared with normal controls. However, XRC and Progynova treatment reversed these effects, leading to significant increases in PPARδ and IL-11 mRNA expression, and COX-2, PGI2, MMP-9 and TIMP-3 protein levels, when compared with the levels observed in EID mice.

CONCLUSION

These results strongly suggested that XRC is beneficial in EID treatment and that XRC may mediate its effects through regulation of the PGI2-PPARδ signaling pathway.

Recent progress in the utility of anti-Müllerian hormone in female infertility

PURPOSE OF REVIEW

To discuss the recent developments in the utility of anti-Müllerian hormone (AMH) in the context of female infertility.

RECENT FINDINGS

AMH measurements have entered the clinical practice in counseling of women before in-vitro fertilization (IVF) treatment. AMH measurements can predict both poor and hyperresponse, and can enable clinicians to individualize the treatment strategies. In natural conception, AMH is a good predictor of age at menopause, but it is unclear whether AMH correlates with the fecund ability in the normal population. AMH has also proven its utility in the assessment of ovarian damage due to gonadotoxic treatment or ovarian surgery. Lastly, AMH might assist in the initial diagnosis of oligomenorrhea or amenorrhea, as high levels of AMH are suggestive of polycystic ovarian syndrome and seem to correlate with the severity of the syndrome.

SUMMARY

AMH is a glycoprotein secreted by the granulosa cells of small growing follicles and indirectly reflects the primordial follicle pool. The ovaries contain a limited number of primordial follicles and their depletion marks the menopause. Thus, the remaining primordial follicle pool is referred to as the ovarian reserve. The clearest data for the clinical utility of AMH is in the context of IVF. The support for other indications is weaker, but rapidly increasing.

A retrospective analysis of the effect of salpingectomy on serum antiMüllerian hormone level and ovarian reserve

OBJECTIVE

To determine whether previous salpingectomy is associated with serum antiMüllerian hormone (AMH) level and ovarian reserve in women under 40 years presenting for in vitro fertilization and embryo transfer.

STUDY DESIGN

We retrospectively compared serum AMH levels measured on the ovulation induction initiation day in patients with unilateral salpingectomy, bilateral salpingectomy, and no tubal surgery, and examined the relationship with length of time after surgery and in vitro fertilization and embryo transfer parameters.

RESULTS

A total of 198 women were included; 83 received unilateral salpingectomy, 41 bilateral salpingectomy, and 74 no tubal surgery. The baseline characteristics of the groups were similar. The mean AMH level was significantly higher in women without tubal surgery as compared with those with bilateral salpingectomy (183.48 vs 127.11 fmol/mL; P ≤ .037). The mean follicle stimulation hormone level was significantly lower in women without surgery as compared with those with bilateral salpingectomy (7.85 vs 9.13 mIU/mL; P = .048). No significant differences in duration of gonadotropin therapy, amount of gonadotropin used, estradiol level on the human chorionic gonadotropin injection day, thickness of the endometrium, number of oocytes retrieved, number of 2-pronuclei, viable embryos, and good quality embryos were found between the 3 groups. AMH level was not correlated with the number of oocytes or age in women that had undergone unilateral or bilateral salpingectomy.

CONCLUSION

Salpingectomy is associated with decreased AMH level and increased follicle stimulation hormone in women seeking in vitro fertilization, though AMH level is not correlated with the number of oocytes retrieved in patients that have undergone unilateral or bilateral salpingectomy. These results suggest that salpingectomy is associated with decreased ovarian reserve.

Assessment of ovarian reserve using anti-Müllerian hormone levels in benign gynecologic conditions and surgical interventions: a systematic narrative review

The usefulness of anti-Müllerian hormone (AMH) for the quantitative evaluation of ovarian reserve has been established. Therefore, serum AMH has been recently applied to the assessment of ovarian reserve outside infertility treatment. We conducted a computer-based search, using keywords, through the PubMed database from inception until May 2014 and summarized available studies evaluating ovarian damage caused by gynecologic diseases, such as endometriosis and ovarian tumor, as well as surgical interventions, such as cystectomy and uterine artery embolization (UAE), to discuss the usefulness of serum AMH. Most of the studies demonstrated a decline of serum AMH levels after cystectomy for endometriomas. It is not conclusive whether electrocoagulation or suturing is preferable. The effects of other gynecologic diseases and interventions, such as hysterectomy and UAE, on ovarian reserve are controversial. Serum AMH levels should be considered in determining the indication and selection of operative methods for benign gynecologic conditions.