Variation in the HLA-F gene locus with functional impact is associated with pregnancy success and time-to-pregnancy after fertility treatment

STUDY QUESTION

The aim of this study was to investigate a possible influence of three single nucleotide polymorphisms (SNPs) in the HLA-F gene locus on time-to-pregnancy and pregnancy success after fertility treatment.

SUMMARY ANSWER

HLA-F SNP genotypes and HLA-F diplotypes are associated with the number of fertility treatment cycles needed to achieve pregnancy and live birth.

WHAT IS KNOWN ALREADY

HLA class Ib molecules, including HLA-F, which are known to be expressed by extra-villous trophoblast cells have immunomodulatory properties and play a role at the feto-maternal interface. However, a few recent studies suggest that HLA-F expressed in the mid-luteal endometrium may play a part in the establishment of pregnancy as well. Three genetic polymorphisms in the HLA-F gene locus influence the expression of HLA-F in the mid-luteal endometrium and are associated with time-to-pregnancy in healthy women.

STUDY DESIGN, SIZE, DURATION

The current study included 102 female patients and 91 male patients attending for ART treatment and recruited between 2009 and 2014 at fertility clinics in a University Hospital setting, and 78 fertile female controls recruited in 2017 and 2018 at a department of Obstetrics and Gynaecology in a University Hospital. All women in the control group conceived naturally, and no other clinical data for the controls were retrieved.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Genotyping of genomic DNA from blood samples was performed with Sanger sequencing for the three SNPs of interest in the HLA-F gene locus: rs1362126 (G/A), rs2523405 (T/G) and rs2523393 (A/G). Furthermore, clinical data were collected for the couples in fertility treatment.

MAIN RESULTS AND THE ROLE OF CHANCE

There were no significant differences in the distributions of the three HLA-F SNP genotypes and alleles between the female fertile control group and the female infertility group. We considered if the number of treatment cycles was related to the HLA-F SNP genotypes and HLA-F diplotypes in a discrete time to event analyses. A significant association with longer time-to-pregnancy, measured as number of fertility treatment cycles, was observed for women in the ART group who carried the HLA-F genotypes that are associated with a lower amount of HLA-F mRNA expressed in mid-luteal endometrium. For the rs1362126 AA genotype relative to the GG genotype, the odds ratio (OR) was 0.30 (95% CI = 0.10-0.87, P = 0.02); for the rs2523405 GG genotype relative to the TT genotype, the OR was 0.40 (95% CI = 0.15-1.04, P = 0.06); and for the rs2523393 GG genotype relative to the AA genotype, the OR was 0.27 (95% CI = 0.09-0.78, P = 0.01). In addition to comparing the HLA-F genotypes by a standard likelihood-ratio test, a trend test based on the number of G or A alleles were also performed. The HLA-F genotypes associated with longer time-to-pregnancy in these tests were as follows: number of A alleles at rs1362126 (P = 0.01), the OR was 0.56 per A allele (95% CI = 0.35-0.89); number of G alleles at rs2523405 (P = 0.05), OR was 0.65 per G allele (95% CI = 0.42-1.00); and number of G alleles at rs2523393 (P = 0.01), OR was 0.56 per G allele (95% CI = 0.36-0.86). On average, for the rs1362126 SNP, 2.1 more treatment cycles for a woman who carried the AA genotype were needed to achieve pregnancy within the first eight treatment cycles compared with a woman who carried the GG genotype. Likewise, for the rs2523405 SNP, 1.8 more cycles for the GG genotype compared with the TT genotype were needed, and for the rs2523393 SNP, 2.2 more treatment cycles for a woman who carried the GG genotype compared with a woman who carried the AA genotype were needed. Adjustments for the covariates BMI, female age, IVF (yes/no for each cycle), ICSI (yes/no for each cycle), female factor (yes/no) and male factor (yes/no), were also performed modeling the cycle-specific probabilities and the genotypes remained significant and almost unchanged.

LIMITATIONS, REASONS FOR CAUTION

Specific types of ART will be chosen from the start of treatment, which means that the chances of achieving pregnancy could differ between the women solely due to their first line of treatment. However, multivariate analyses are performed to adjust for type of ART treatment.

WIDER IMPLICATIONS OF THE FINDINGS

To our knowledge, this is the first study that shows associations between, and implications of, HLA-F gene locus variation and time-to-pregnancy and pregnancy success in a clinical setting for fertility treatment/ART.

STUDY FUNDING/COMPETING INTEREST(S)

Supported by the Region Zealand Health Sciences Research foundation and by Zealand University Hospital through the ReproHealth Research Consortium ZUH. The authors declare no conflict of interest.

Soluble urokinase plasminogen activator receptor (suPAR) as a biomarker of early pregnancy location and viability compared with hCG, progesterone and estradiol

A circulating biomarker of early pregnancy outcome independent of ultrasonography and gestational age is a coveted goal. This study evaluated soluble urokinase plasminogen activator receptor (suPAR), a well-described marker of inflammation and immunological activation, for this purpose, and compared it with established early pregnancy biomarkers of the luteoplacental phase: progesterone, estradiol and hCG. We merged data from two prospective first trimester cohorts to conduct a case-control study comparing these analytes in women who had either a live birth, a miscarriage or an ectopic pregnancy. The ability to predict pregnancy location and viability was assessed by areas under the receiver operating characteristic curves (AUC). Comparing women irrespective of gestational age with a live birth, miscarriage or ectopic pregnancy showed significantly lower suPAR values in the latter group (2.4 vs. 2.4 vs. 2.0 μg/L, p = 0.032, respectively), as were all other analytes. Before 6 weeks' gestation, suPAR was significantly inferior to progesterone, estradiol and hCG in pregnancy location and viability prediction (in 124 pregnancies, suPAR AUC_location = 0.69 [CI: 0.54-0.83] and AUC_viability = 0.58 [CI: 0.48-0.69], while progesterone AUC_location = 0.95 [CI: 0.87-1.00] and AUC_viability = 0.84 [CI: 0.75-0.92]). After 6 weeks' gestation, suPAR prediction improved but was inferior to hCG, progesterone and estradiol (in 188 pregnanices, suPAR AUC_location = 0.71 [CI: 0.63-0.78] and AUC_viability = 0.70 [CI: 0.63-0.78] compared with hCG AUC_location = 0.96 [CI: 0.93-0.99] and AUC_viability = 0.96 [CI: 0.93-0.98]). Collectively, suPAR is less useful as a predictor of early pregnancy outcome than hCG, progesterone and estradol.

Soluble HLA-G and TGF-β in couples attending assisted reproduction - A possible role of TGF-β isoforms in semen?

Soluble isoforms of the non-classical Human Leukocyte Antigen (HLA)-G as well as Transforming Growth Factor (TGF)-β is expressed in seminal plasma possibly influencing the pregnancy potential. We wanted to examine the association of seminal plasma sHLA-G, TGF-β1, TGF-β2 and TGFβ3 with pregnancy success in a cohort of 127 couples and 4 single women attending fertility treatment with the use of assisted reproduction technologies (ART). Soluble HLA-G, TGF-β1, TGF-β2 and TGF-β3 in seminal plasma did not fluctuate significantly over time. We did not find any impact of seminal plasma sHLA-G, TGF-β1, TGF-β2 and TGF-β3 on time-to-pregnancy measured as number of treatment cycles. There was a significant association between concentrations of seminal plasma sHLA-G and HLA-G variations in the 3'untranslated region (3'UTR) of the HLA-G gene, supporting and extending previous findings. Furthermore, by comparing seminal plasma concentrations of sHLA-G, TGF-β1, TGF-β2 and TGF-β3 in male subjects with reduced semen quality, male subjects with normal semen quality, and sperm donors, we found that TGF-β2 was significantly lower, and TGF-β3 was significantly higher, in seminal plasma from sperm donors. These findings suggest that TGF-β isoforms may influence semen quality and fertility.

Serum anti-Müllerian hormone concentration before and after salpingectomy for ectopic pregnancy

RESEARCH QUESTION

Does salpingectomy for ectopic pregnancy affect the ovarian reserve measured by changes in pre- and post-operative levels of anti-Müllerian hormone (AMH)?

DESIGN

This is a prospective observational multicentre study of 64 women treated with salpingectomy for an ectopic pregnancy. AMH was measured in serum samples collected at admission before salpingectomy and at follow-up (median time to follow-up [interquartile range] was 3 [3-4] months). Changes in serum AMH levels were investigated using Wilcoxon signed-rank test and the relationship between changes in AMH and age, time to follow-up, and pre-operative serum AMH level was investigated using linear regression analysis. The biological variation of AMH was also calculated.

RESULTS

Serum AMH levels did not differ significantly before and after salpingectomy (median ∆AMH [follow-up value minus admission value] 0.40 pmol/l, interquartile range -2.0 to 4.0 pmol/l). ΔAMH was independent of age, time to follow-up and pre-operative serum AMH level. The intra-individual biological variation for AMH ranged from 12.1% to 26.3%, depending on time between the two samples.

CONCLUSIONS

This is the first paired study to investigate serum AMH values before and after salpingectomy in an unselected population of women presenting with an ectopic pregnancy, including both patients who conceived naturally and following fertility treatment. It was found that salpingectomy for ectopic pregnancy had no short-term effect on serum AMH levels, and changes in AMH levels were independent of age, time to follow-up, and pre-operative serum AMH level. Furthermore, the study demonstrated a 6-month biological variation of AMH of less than 30%.

Implications of uterine NK cells and regulatory T cells in the endometrium of infertile women

A range of studies have shown that the complex process of implantation and an establishment of a pregnancy also involves immune factors. Disturbances in these underlying immune mechanisms might lead to implantation and pregnancy failure and may be involved in the pathogenesis of unexplained infertility. Several studies have reported that imbalances in uterine NK (uNK) cell abundance are associated with infertility; however, controversies exist. An increased amount of CD56⁺ uNK cells along with a decrease in CD16⁺ uNK cells have been associated with normal fertility in some studies. Very few studies of FoxP3⁺ regulatory T cells (Tregs) in the pre-implantation endometrium have been performed. Results are sparse and controversial, studies reporting both increased and decreased numbers of Tregs, respectively, in women suffering from infertility. In conclusion, studies imply that uNK cells, Tregs and HLA-G carry pivotal roles regarding the establishment of a healthy pregnancy, and that abnormal immune mechanisms involving these parameters may be associated with infertility. However, more research in early phases of the reproductive cycle, such as investigating the conditions in the endometrium before implantation, is needed to further clarify the underlying mechanisms.

Glycodelin in endometrial flushing fluid and endometrial biopsies from infertile and fertile women

OBJECTIVE

To investigate in the natural cycle just before IVF, whether glycodelin levels in endometrial flushing fluid obtained days LH+1 and LH+7 can be used in predicting pregnancy in the following IVF cycle, and whether there are differences in women with tubal factor infertility compared to women with unexplained infertility and fertile controls.

STUDY DESIGN

A prospective observational multicentre study of 21 fertile and 75 infertile women (25 showed abnormal tubes with no signs of hydrosalpinges, 18 had uni- or bi-lateral hydrosalpinges, 17 were salpingectomised because of hydrosalpinges, and 15 women had unexplained infertility). Endometrial flushing at days LH+1 and LH+7, endometrial biopsy, and blood sampling at day LH+7 were performed before down-regulation for IVF. Glycodelin levels in endometrial flushing fluids (EFF), biopsies, and plasma samples were related to tubal pathology, endometrial dating and IVF outcome. Furthermore, total protein concentration was measured in EFF to investigate the influence of normal endometrial maturation on protein concentrations from days LH+1 and LH+7.

RESULTS

At day LH+1, EFF glycodelin levels were higher in infertile women with abnormal tubes compared to fertile women, particularly in women conceiving after the following IVF. For women with unexplained infertility, a higher level at day LH+1 was present only in women not conceiving after the following IVF. ROC curve analysis showed that at day LH+1 EFF glycodelin levels had no predictive value for IVF outcome. At day LH+7, glycodelin levels in endometrial flushing fluids and biopsies depended on endometrial dating.

CONCLUSIONS

At day LH+1, glycodelin concentration is increased in endometrial flushing fluid from infertile women with abnormal tubes compared to fertile controls without being a valuable predictor of subsequent pregnancy. At day LH+7 the glycodelin level depends on endometrial dating.

Ultrasound characteristics and histological dating of the endometrium in a natural cycle in infertile women compared with fertile controls

OBJECTIVE

To compare endometrial dating and ultrasound texture in a natural cycle before IVF and relate these to outcome and to fertile references.

DESIGN

Prospective study with a fertile reference group.

SETTING

Four university IVF clinics.

PATIENT(S)

Seventy-five IVF patients and 21 fertile women.

INTERVENTION(S)

Ultrasound, biopsy, blood sampling. In vitro fertilization-ET in the following cycle.

MAIN OUTCOME MEASURE(S)

Endometrial evaluation, P, IVF outcome.

RESULT(S)

At day LH+7, 42% infertile vs. 67% fertile women demonstrated endometria that were in phase (statistically nonsignificant difference). Nine percent had an accelerated endometrium, and 47% (infertile) vs. 24% (fertile) had a delayed endometrium (statistically nonsignificant difference). Statistically significantly fewer women with tubal factor and no hydrosalpinges had an endometrium in phase (20%) than was the case in fertile women (67%). Dating could not predict outcome. Statistically significantly more women in the hydrosalpinx group had a visible midline at day LH+7 compared with the case in other infertile groups. Forty-three percent conceived after IVF-ET. Plasma P was statistically significantly lower in nonpregnant women compared with in women with ongoing pregnancies and with fertile controls. A periovulatory hyperechogenic endometrium resulted in no ongoing pregnancies.

CONCLUSION(S)

In a natural cycle preceding IVF, a low midluteal P level predicts a low implantation rate. A periovulatory hyperechogenic endometrium or hydrosalpinges visible at ultrasound may have some predictive value. Endometrial dating was of no help.

Cost—effectiveness analysis of salpingectomy prior to IVF, based on a randomized controlled trial

BACKGROUND

In patients with ultrasound-visible hydrosalpinges, salpingectomy prior to IVF increases the chance of a live birth. This study compared the cost-effectiveness of this strategy (intervention) with that of optional salpingectomy after a failed cycle (control).

METHODS

Data from a Scandinavian randomized controlled trial were used to calculate the individual number of treatments and their outcomes. Only patients with ultrasound-visible hydrosalpinges were considered in the main analysis, and a maximum of three fresh cycles were included. The costs for surgical procedures, IVF treatment, medication, complications, management of pregnancy and delivery as well as of early pregnancy losses were calculated from standardized hospital charges.

RESULTS

Among the 51 patients in the intervention group, the live birth rate was 60.8% compared with 40.9% in 44 controls. The average cost per patient was 13,943 euro and 12,091 euro, respectively. Thus, the average cost per live birth was 22,823 euro in the intervention group and 29,517 euro in the control group. The incremental cost-effectiveness ratio for adopting the intervention strategy was estimated at 9306 euro.

CONCLUSIONS

The incremental cost to achieve the higher birth rate of the intervention strategy seems reasonable.

Association between human leukocyte antigen-G genotype and success of in vitro fertilization and pregnancy outcome

To determine if a 14-bp deletion/insertion polymorphism in the 3'-untranslated region of exon 8 of the gene encoding human leukocyte antigen (HLA)-G in a homozygous form is associated with repeated, unsuccessful in vitro fertilization (IVF) treatments, and with increased risk of recurrent spontaneous abortions (RSA), 29 white women undergoing IVF treatments, 61 RSA women and 93 fertile controls were HLA-G genotype. The HLA-G genotype, homozygous for the presence of the 14 bp sequence in exon 8, was significantly associated with reduced fertility with respect to unsuccessful IVF treatments and increased risk of recurrent miscarriage (combined P < 0.01). The 14-bp insertion/deletion polymorphism is associated with differences in HLA-G mRNA alternative splicing and levels of HLA-G. This might affect a possible immunomodulatory role of HLA-G expression in both the mother and foetus during implantation and pregnancy.

HLA-G and IL-10 in serum in relation to HLA-G genotype and polymorphisms

The expression and importance of the non-classical human leukocyte antigen (HLA) class Ib gene, HLA-G, at the feto-maternal interface have been recognized. The HLA-G molecule is almost monomorphic and expressed in both membrane-bound and soluble isoforms. It has been shown to inhibit NK-mediated cell lysis and influence cytokine expression. Recently, a possible boarder immunoregulatory function of HLA-G also in adult life has been recognized. HLA-G gene polymorphism has been linked to differences in gene expression profile of alternatively spliced HLA-G transcripts and levels of specific HLA-G mRNA isoforms. On this background it is of general interest to further elucidate any associations between HLA-G polymorphism and protein expression. We have HLA-G genotyped 85 individuals attending IVF treatment, and further studied sHLA-G1/HLA-G5 and interleukin-10 (IL-10) in serum samples. In 21% of the serum samples sHLA-G1/HLA-G5 could be detected. There was no correlation between sHLA-G1/HLA-G5 and IL-10 concentrations in serum. Soluble HLA-G1/HLA-G5 was not detected in any samples homozygous for a 14-bp insertion polymorphism in exon 8 of the 3'-untranslated region (3'UTR) of the HLA-G gene ( P=0.03; Fisher's exact test). Polymorphisms in the 5'-upstream regulatory region (5'URR) of the HLA-G gene were also studied. In conclusion, this study indicates that polymorphisms in the 3'UTR and the 5'URR of the HLA-G gene may influence the expression of sHLA-G of possible importance in pathological pregnancies and also in organ transplantation.

Embryo quality in natural versus stimulated IVF cycles

BACKGROUND

The impact of controlled ovarian stimulation (COS) on oocyte and subsequent embryo quality remains controversial. In the present study we have compared embryo quality in natural and stimulated cycles in the same group of patients.

METHODS

This retrospective study was comprised of patients with a regular menstrual cycle who had IVF after COS using rFSH in a long GnRH agonist protocol. In all stimulated cycles the patients had fresh embryos transferred and surplus good quality embryos cryopreserved. Subsequently the same patients were treated with a modified FER cycle (mFER) where thawing of the frozen embryos was combined with aspiration of the dominant follicle in the natural cycle. The embryo cleavage stage and quality score were compared between the stimulated and the natural cycle for the patients having an embryo in the natural cycle.

RESULTS

In 177 cases patients returned for mFER in a natural cycle. Spontaneous ovulation had occurred in 35 cycles. In 17 cycles no oocyte was retrieved at aspiration and in 125 cycles 128 oocytes were aspirated. In the stimulated cycles from these patients we had obtained 950 embryos (cleavage rate 70.4%) versus 85 embryos (cleavage rate 66.4%) (P = 0.34) in the natural cycles. Comparing the embryos in the natural and stimulated cycles in all patients having an embryo in the natural cycle, we found no difference in the distribution between the different cleavage stages. Of the cleaved embryos, 53% in the stimulated cycles had >or=4 cells versus 59% in the natural cycles after 2 days culture (P = 0.31). In the stimulated cycles 61% of the embryos had <10% fragmentation at the time of transfer on day 2, compared to 69% in the natural cycles (P = 0.15).

CONCLUSION

The administration of exogenous gonadotrophins was not reflected in cleavage capacity or quality assessment of the resulting embryos.

A prospective study of predictive factors of ovarian response in 'standard' IVF/ICSI patients treated with recombinant FSH. A suggestion for a recombinant FSH dosage normogram

BACKGROUND

The aim was to identify independent predictors of ovarian response to recombinant (r)FSH through a multiple regression analysis.

METHODS

Prospective study including 145 'standard' patients treated with 150 IU/day of rFSH during their first IVF/ICSI cycle. Down-regulation was achieved with long agonist protocol. The following were examined as possible predictive factors: age, body mass index, cycle length, smoking status and on day 2-5: total ovarian volume, total number of antral follicles (<10 mm), total Doppler score of the ovarian stromal blood flow, serum FSH, LH, estradiol, inhibin B, and testosterone.

RESULTS

Total number of antral follicles, total Doppler score, serum FSH, LH, estradiol, inhibin B, smoking status and cycle length were independent predictors of the number of aspirated follicles. The number of oocytes was predicted by the total number of antral follicles, total Doppler score, serum testosterone and smoking status. In bivariate linear regression analyses ovarian volume was a highly significant predictor of both the number of follicles (P < 0.001) and the number of oocytes (P < 0.001).

CONCLUSIONS

Among 12 investigated possible predictive factors in 'standard' patients, the total number of antral follicles and ovarian stromal blood flow assessed by total Power Doppler score are the two most significant predictors of ovarian response. Suggestion for an rFSH dosage normogram is presented.

Biochemical evaluation of endometrial function at the time of implantation

OBJECTIVE

To review the literature on various endometrial factors assumed to be of importance to implantation and to evaluate their potential clinical value in the assessment of endometrial function at the time of implantation in infertile women in natural and stimulated cycles.

DESIGN

Literature review.

RESULT(S)

Cytokines such as leukemia inhibitory factor, colony-stimulating factor-1, and interleukin-1 have all been shown to play important roles in the cascade of events that leads to implantation. They participate in a synchronized cooperation between the endometrium and the preimplanting embryo under the influence of steroid hormones. The same applies to the integrin alpha(v)beta(3), glycodelin, and the polymorphic mucin 1. The usefulness of these factors to assess endometrial receptivity and to estimate the prognosis for pregnancy in natural and artificial cycles remains to be proven.

CONCLUSION(S)

The studies performed to date have mostly included only small groups of patients with a lack of fertile controls, and only a few prospective, controlled trials have been carried out. Therefore, definite conclusions about the clinical value of these factors in the assessment of endometrial function and prognosis for pregnancy after artificial reproductive therapy cannot be drawn at present. Further evaluation of their importance for and function during implantation is needed.

Why does hydrosalpinx reduce fertility? The importance of hydrosalpinx fluid

The debate on hydrosalpinx and impaired IVF outcome has mainly focused on the best treatment before IVF and on functional surgery as an alternative treatment. We would like to initiate a debate on the possible reasons why the outcome is impaired. We know that salpingectomy is effective in terms of improved birth rates after IVF, but we do not know exactly why. The main focus is on embryotoxic properties of the hydrosalpinx fluid, which include micro-organisms, endotoxins, cytokines, oxidative stress and lack of nutrients. The endometrial receptivity may be reduced as an effect of disturbed expression of the cytokine cascade, which is essential for implantation. The presence of excessive fluid in the uterine cavity may also be a mechanical hindrance to implantation. We believe that the hydrosalpinx fluid is of crucial importance, but the actual mechanism of action needs to be clarified.

Progesterone supplementation during early gestations after IVF or ICSI has no effect on the delivery rates: a randomized controlled trial

BACKGROUND

The aim was to study whether prolongation of luteal support during early pregnancy influences the delivery rate after IVF.

METHODS

Dual centre study including 303 women who achieved pregnancy after IVF or ICSI was used. All were treated with the long protocol using GnRH agonists and given luteal support with 200 mg vaginal progesterone three times daily during 14 days from the day of transfer until the day of a positive HCG test. The study group (n = 150) withdrew vaginal progesterone from the day of positive HCG. The control group (n = 153) continued administration of vaginal progesterone during the next 3 weeks of pregnancy.

RESULTS

The number of miscarriages prior to and after week 7 of gestation was seven (4.6%) and 15 (10.0%) in the study group and five (3.3%) and 13 (8.5%) in the control group respectively. The number of deliveries was 118 (78.7 %) in the study group and 126 (82.4 %) in the control group. The differences were not significant.

CONCLUSIONS

Prolongation of progesterone supplementation in early pregnancy has no influence on the miscarriage rate, and thus no effect on the delivery rate. Progesterone supplementation can safely be withdrawn at the time of a positive HCG test.

A Wallace malleable stylet for difficult embryo transfer in an in vitro fertilization program: a case-control study

BACKGROUND

The aim of the study was to evaluate the impact of using a Wallace malleable stylet in combination with an Edwards-Wallace embryo replacement catheter in case of difficult embryo transfer (ET).

METHODS

A retrospective case-control study was used. The standard ET procedure at the clinic was to use a single tooth tenaculum, and a speculum to straighten the cervical canal prior to inserting the Edwards-Wallace embryo replacement catheter. In 205 of 2041 (10%) fresh ET difficulties were experienced during ET and a Wallace malleable stylet was used to place the outer catheter sheath correctly. This stylet transfer group was compared with a control transfer group of 410 ET performed just before and after each stylet transfer.

RESULTS

No differences in number of transferred embryos, cleavage stage, or embryo morphology score were found between the two groups. We found no differences in implantation rates (20.7 and 19.2% [95% confidence interval (CI) 0.8-1.5]) or delivery rates (29.3 and 25.4% [CI 0.8-1.8]) between the study and control group.

CONCLUSION

Using a Wallace malleable stylet in combination with an Edwards-Wallace embryo replacement catheter in case of difficult ET has no negative impact on implantation and delivery rates.

Hydrosalpinx and IVF outcome: cumulative results after salpingectomy in a randomized controlled trial

BACKGROUND

A randomized controlled trial of salpingectomy prior to IVF in patients with hydrosalpinges has been conducted in Scandinavia. The results from the first transfer cycle have been published and clearly demonstrated an improved pregnancy outcome after salpingectomy had been performed in patients with hydrosalpinges large enough to be visible on ultrasound. The present article is aimed at analysing the effect of salpingectomy on cumulative birth rate, including all individual transfer cycles.

METHODS AND RESULTS

A total of 186 women underwent 452 cycles. Among the 77 women randomized to no surgical intervention, 24 underwent salpingectomy after one or two failed cycles. Cumulative results were analysed by Cox regression, taking into account the number of cycles per patient and the presence of a salpingectomy after a previous transfer. Salpingectomy implied a significant increase in birth rate (hazard ratio 2.1, 95% CI 1.6-3.6, P = 0.014). Within the subgroup of patients with ultrasound-visible hydrosalpinges, the birth rate was even higher (hazard ratio 3.8, 95% CI 1.5-9.2, P = 0.004). Implantation rate was significantly higher in patients who had undergone salpingectomy (27.2% versus 20.2, P = 0.03) and, in the subgroup of patients with ultrasound-visible hydrosalpinges, the difference was even larger (30.3% versus 17.1%, P = 0.003).

CONCLUSIONS

The results of the cumulative cycles strengthen the recommendation for a laparoscopic salpingectomy prior to IVF in patients with ultrasound-visible hydrosalpinges.

Prophylactic salpingectomy does not impair the ovarian response in IVF treatment

To examine the effect of prophylactic salpingectomy in patients with hydrosalpinges on the ovarian response to stimulation prior to IVF, 26 patients were included in a study in which they acted as their own controls. They were all part of a randomized controlled study, in which they had been randomized to no surgical intervention prior to IVF. After one or two failed cycles, they underwent laparoscopic uni- or bilateral salpingectomy of their diseased tubes. The cycles before and after surgery were compared and the ovarian response was assessed as the dose and duration of gonadotrophins and the number of retrieved and fertilized oocytes. There were no significant differences in any of the measured outcomes. The increasing age between cycles did not influence the ovarian response, assessed by a comparison with two matched control groups from the same original study; 46 patients salpingectomized before IVF and 25 patients without surgery. It is concluded that removal of hydrosalpinx as a prophylactic laparoscopic procedure does not compromise ovarian function.

Progesterone supplementation during early gestation after in vitro fertilization has no effect on the delivery rate

OBJECTIVE

To compare the delivery rate with IVF or ICSI in women who did and did not receive progesterone supplementation in the first 3 weeks after a positive hCG test result.

DESIGN

Retrospective study.

SETTING

Fertility Clinic, Rigshospitalet University Hospital, Copenhagen, Denmark.

PATIENT(S)

200 pregnant women who did not receive progesterone (intervention group) and 200 pregnant women who received progesterone for 3 weeks after a positive hCG result.

INTERVENTION(S)

In the study group, vaginal progesterone therapy was withdrawn on the day of positive hCG result. In the control group, treatment with progesterone, 600 mg/d, was continued for 3 weeks after a positive hCG result. Both groups received 600 mg of progesterone starting on the day of embryo replacement until testing positive for pregnancy 14 days after embryo transfer.

MAIN OUTCOME MEASURES

Delivery rate.

RESULT(S)

The number of deliveries was 126 in the study group and 128 in the control group.

CONCLUSION(S)

The delivery rate was the same in pregnant women who received and those who did not receive progesterone for 3 weeks after a positive hCG result. Progesterone supplementation for more than 2 weeks after embryo transfer may therefore yield no benefit in terms of pregnancy.

Hydrosalpinx and ART. Salpingectomy prior to IVF can be recommended to a well-defined subgroup of patients

The result of the Scandinavian multicentre study on salpingectomy prior to IVF has promoted a discussion on whether there is a risk of unnecessary salpingectomies being performed. We agree that physicians have to discriminate carefully between a hydrosalpinx that should be removed and one that is suitable for surgical repair. Tubal endoscopy is the most advanced tool for that purpose, while transvaginal ultrasound is not appropriate in selecting patients to undergo either salpingectomy or salpingostomy. The Scandinavian study showed that patients with hydrosalpinges which are large enough to be visible on ultrasound before ovarian stimulation, benefit from salpingectomy in terms of improved fertility outcome after IVF. The result of the study does not interfere with the management of distal tubal infertility in general, since it was concluded that not every woman with a large hydrosalpinx should undergo salpingectomy. Hydrosalpinges with preserved mucosa may be better treated with reconstructive surgery as primary treatment instead of salpingectomy and IVF. The latter option may, however, be the secondary treatment after failed conception and re-occlusion of the tubes. Unnecessary salpingectomies should, of course, not be performed and they may easily be avoided by appropriate evaluation of the tubal mucosa at laparoscopy before any final decision of salpingectomy is made. We do not see a major conflict: functional surgery to the tubes with healthy mucosa and salpingectomy to the dilated tubes that are visible on ultrasound and have a severely damaged mucosa.

[Infertility in ethnic groups. Etiology and treatment]

In this retrospective case control study we analysed the causes and treatments of infertility in 100 ethnic couples consecutively discharged from the Fertility Clinic in the period October 1995 to March 1999. The mean age at referral was 28 years (19-37) for ethnic women and 31 years (24-39) for Danish women. Male infertility was the most frequent cause in ethnic couples compared to Danish couples (24% vs. 16%; NS). Tubal infertility was less frequent in ethnic than in Danish couples (19% vs. 45%; p < 0.01), ovulatory defects were more frequent in ethnic couples than in Danish (13% vs. 4%; p < 0.04). Among ethnic couples 57 (118 cycles) underwent IVF and ICSI treatment vs. 85 (198 cycles) Danish couples (p < 0.01). The ongoing pregnancy rate per initiated cycle was 29.6% in ethnic couples vs. 24.2% in Danish couples (NS). Forty four percent of the ethnic couples did not complete the whole treatment program vs. 29% of Danish couples (p < 0.04). This may be due to cultural differences and difficult communication.

Hydrosalpinx and IVF outcome: a prospective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF

Many retrospective studies have shown that hydrosalpinx is associated with poor in-vitro fertilization (IVF) outcome. The mechanism of the actual cause is not yet fully understood. A clinical practice of performing salpingectomy before IVF has developed, without any evidence from prospective trials. The aim of the present prospective randomized trial was to test if a salpingectomy prior to IVF was effective in terms of increased pregnancy rates. Patients with hydrosalpinx were randomized to either a laparoscopic salpingectomy or no intervention before IVF. A total of 204 patients was available for an intention-to-treat analysis and 192 actually started IVF. Clinical pregnancy rates per included patient were 36.6% in the salpingectomy group and 23.9% in the non-intervention group (not significant, P = 0.067) and the ensuing delivery rates were 28.6% and 16.3% (P = 0.045). The corresponding delivery rates per transfer cycle were 29.5% versus 17. 5% (not significant, P = 0.083). A subgroup analysis revealed significant differences in favour of salpingectomy, in implantation rates in patients with bilateral hydrosalpinges (25.6% versus 12.3%, P = 0.038) and in clinical pregnancy rates (45.7% versus 22.5%, P = 0.029) and delivery rates (40.0% versus 17.5%, P = 0.038) in patients with ultrasound visible hydrosalpinges. The delivery rate was increased 3.5-fold in patients with bilateral hydrosalpinges visible on ultrasound (P = 0.019).

A Danish national cohort of 730 infants born after intracytoplasmic sperm injection (ICSI) 1994-1997

This national cohort study included all clinical pregnancies obtained after intracytoplasmic sperm injection (ICSI) registered in Denmark between January 1994 and July 1997 at five public and eight private fertility clinics. Laboratory and clinical data were obtained from the fertility clinics. The couples answered a questionnaire regarding the pregnancy and the health of the child (response rate 94%). Data validation was carried out through discharge charts. The mean age of the women was 32.1 years. In 84.2% of couples, male factor was the main reason for performing ICSI, and in 4.8% epididymal spermatozoa were used. The mean number of embryos replaced was 2.3 (range 1-3) and in 95% of cases fresh embryos were transferred. Only 183 women (28.5%) underwent prenatal diagnosis, resulting in 209 karyotypes with seven (3.3%) chromosome aberrations. Six major chromosomal abnormalities (2.9%) and one inherited structural chromosome aberration (0.5%) were found, but no sex chromosome aberrations. The frequency of multiple birth, Caesarean section rate, gestational age, preterm birth, and birth weight were comparable with previous studies. The perinatal mortality rate was 13.7 per 1000 children born with a gestational age of 24 weeks or more. In 2.2% (n = 16) of the liveborn infants, and in 2.7% (n = 20) of all infants, major birth defects were reported by the parents. Minor birth defects were found in nine liveborn infants (1.2%). In conclusion, the results of this study on outcome of ICSI pregnancies are in line with earlier reports, except that no sex chromosome abnormalities were found.

Delivery rates after in-vitro fertilization following bilateral salpingectomy due to hydrosalpinges: a case control study

This retrospective case-control study assessed the impact of bilateral salpingectomy due to uni- or bilateral hydrosalpinges on the outcome of in-vitro fertilization (IVF) in a large consecutive series of patients. The effect of bilateral salpingectomy due to hydrosalpinges on pregnancy outcome was compared in 139 patients (263 cycles) and 139 age-matched controls with tubal infertility without hydrosalpinges (296 cycles). The delivery rates per initiated cycle as well as the implantation rates were equal in the two groups (21.7 versus 21.6% and 19 versus 21%). The number of embryos, the cleavage stage, and the embryo morphology score were equal in the two groups. Among 92 patients treated with 182 IVF cycles who underwent salpingectomy between 1.5 and 5 years prior to their first IVF cycle, the delivery and the implantation rates were 22.5 and 20.5% respectively. Of the patients with salpingectomy after an average of 1.7 failed IVF cycles and who re-entered the IVF programme 3 and 6 months subsequent to surgery, 47 were treated with 83 IVF cycles. The live birth and the implantation rates after surgery in this group were 20.5 and 20% respectively. It is concluded that bilateral salpingectomy due to hydrosalpinges restores a normal delivery as well as implantation rate after IVF treatment compared to controls. A favourable outcome is also found in patients operated on after repeated IVF failures. Furthermore, a normal live birth rate as well as a high implantation rate is maintained for at least three IVF cycles subsequent to surgical treatment.

Pregnancy after assisted ejaculation procedures in men with spinal cord injury

OBJECTIVE

To present the results of fertility treatment in 28 men with spinal cord injury (SCI) and their partners.

DESIGN

Retrospective analysis.

SETTING

University hospital outpatient clinic and home.

PATIENTS

Twenty-eight anejaculatory men with SCI and their partners seeking treatment for infertility.

INTERVENTION

Penile vibratory stimulation and electroejaculation as semen retrieval methods. Assisted reproductive techniques used: vaginal self-insemination at home, intrauterine insemination, in vitro fertilization with or without intracytoplasmic sperm injection.

MAIN OUTCOME MEASURES

Ejaculation rate; sperm count and motility; pregnancy rates.

RESULTS

All of the men were able to ejaculate either by penile vibratory stimulation (79%) or electroejaculation (21%). Median total sperm count was 65 million (range, 0.1 to 480) with a median motility of 13% (range, 1% to 60%). Overall, 9 of 28 couples (32%) achieved 10 pregnancies (4 self-insemination, 3 intrauterine insemination, 1 in vitro fertilization, and 2 intracytoplasmic sperm injection).

CONCLUSIONS

An ejaculation rate of 100% was achieved using penile vibratory stimulation as a first treatment option with electroejaculation as a second option. Motivated couples with adequate semen quality may be offered penile vibratory stimulation combined with self-insemination at home. Together with intrauterine insemination or fertilization techniques used in vitro, the pregnancy rate per treatment cycle for SCI couples may approach that of natural procreation in healthy and fertile couples.

Surgical management of tubal infertility. A regional study

OBJECTIVE

To investigate an unselected group of patients in a regional area undergoing tubal surgery for infertility and to identify those women who would benefit from surgery and those who should be referred directly to in vitro fertilization (IVF).

DESIGN

A retrospective study based on medical records and questionnaires.

SETTING

The Departments of Obstetrics and Gynecology, Gentofte. Glostrup and Herlev Hospitals, University of Copenhagen, Denmark.

SUBJECTS

Two hundred and thirty-six women with primary or secondary infertility undergoing tubal surgery or adhesiolysis during a five year period from 1985 to 1989 with a follow-up period of minimum of 24 months.

RESULTS

Ninety-four women (40%) became pregnant at least once and accounted for the total number of 144 pregnancies. One hundred and forty-two patients (60%) did not become pregnant. The delivery rate was 25%, and 37 women (16%) had at least one ectopic pregnancy. There were no significant differences in the delivery rates of the operations in between, but the risk of ectopic pregnancy was significantly lower after adhesiolysis only than after tubal surgery (p < 0.05). The initial laparoscopic findings could not be used to predict the probability of intrauterine pregnancy.

CONCLUSION

There is still a place for surgical treatment of tubal infertility, but the risk of ectopic pregnancy should be taken into account before a decision concening line of treatment is made.

[The postmenopausal ovary--should it be preserved?]

Oophorectomia per occasionem is often performed in connection with hysterectomy in peri- and postmenopausal women as prophylaxis against ovarian cancer. Reviewing published articles has shed little light on whether the postmenopausal ovaries have an endocrine function, and whether such a function may have physiological importance. Population studies of healthy women, comparisons of oophorectomized and non-oophorectomized postmenopausal women and measurements of ovarian venous gradients have shown that the postmenopausal ovaries contribute substantially to the production of androgens, and produce about half the body's circulating testosterone. In a number of women there is a continued significant oestrogen production in the ovaries during the first five to ten years following menopause. After this period the ovarian contribution to the total oestrogen production is very small. To what extent the continued androgen production could have physiological importance cannot be decided by reviewing the literature. Androgens seem to have importance for sexual function, but could possibly also have negative effects in the form of an increased risk of cardiovascular disease. We lack both epidemiological investigations and in-vitro perfusion studies of human ovaries in order to illuminate the physiological function of the postmenopausal ovary. In deciding on oophorectomia per occasionem in the postmenopausal woman the possible advantages of continued ovarian hormonal production must be weighed against the risk of later development of ovarian cancer, which is 2%, identical to that of the risk in the background population.

[Evaluation of home pregnancy tests]

Three home pregnancy tests, Clearblue (Tjellesen), Clearblue one step (Tjellesen) and Predictor (Organon), were tested and compared with respect to sensitivity, specificity, prozone-phenomenon and convenience for use. In addition, they were compared with two well-known pregnancy tests, HCG-Novoclone (Novo) and HCG-Nostick (Organon), which are used in several hospitals and drugstores. All three home pregnancy tests were found to be in agreement with the instructions for use with regard to sensitivity and prozone phenomenon. One test, Clearblue one step, showed false positive results when LH was added. Clearblue was found to be laborious and unhygienic in performance. Predictor seems to be the test of choice.

Postmortem findings and prenatal diagnosis of Zellweger syndrome. Case report

The postmortem findings of siderosis, renal cortical cysts, pachygyria, cortical heterotopia of the brain and cerebellar hypoplasia in a seven-week-old infant with craniofacial dysmorphism and hypotonia prompted the diagnosis of Zellweger syndrome. This was confirmed by analysis of very-long-chain fatty acids in blood spots from filter paper, collected in the neonatal period, and allowed first trimester diagnosis in the subsequent pregnancies.

Frequency of curettage in middle-aged women treated with sequential preparations versus untreated women

Over a 2-month period a register was kept of all dilatation and curettage procedures performed in Frederiksborg County, Denmark, involving women aged 40-59 years. The total recorded was 284. In the same period, questionnaires were sent out to 1200 women in the county who fell within the same, randomly selected age group, to establish the number of women treated with sequential oestrogen/progestogen and those who had been hysterectomized. Based on the results and the total female population in the county, it was calculated that the frequency of the procedure in sequentially-treated women as compared with untreated women was 3.1 times higher in the 55-59 age group. In the 40-54 age group no difference in the incidence of curettage in the sequentially-treated women could be demonstrated.

The implications of introducing the symphyseal-fundal height-measurement. A prospective randomized controlled trial

A total of 1639 women attending the antenatal clinic of Gentofte University Hospital, Copenhagen, during 1986-1987 was randomized into a symphyseal fundal (SF)-group and a control group. The women in the SF-group had their fundal height measured from the 29th week until delivery. The measurements were used along with the other usual screening procedures. The SF-measurements were not found helpful in the prediction of small-for-gestational-age infants and no significant differences were found between the two groups regarding the number of interventions, additional diagnostic procedures, or the condition of the newborns.

The effect of incisional plastic drapes and redisinfection of operation site on wound infection following caesarean section

In a randomized prospective multicentre study of post-caesarean wound infection among 1,340 women in eight hospitals, the effect of redisinfection of the skin around the incision before skin closure and the effect of adhesive skin drapes were investigated. The overall rate of wound infection with pus was 5.0% (range 3.5-8.9%). The study showed a reduction in postoperative wound infection associated with redisinfection (P = 5.5%), while no benefit from adhesive plastic drapes could be demonstrated.

A controlled study on the effect of epidural analgesia with local anaesthetics and morphine on morbidity after abdominal surgery

A hundred patients scheduled for elective abdominal surgery were randomized to either general anaesthesia (low-dose fentanyl) and systemic morphine for postoperative pain or combined general anaesthesia and epidural analgesia with etidocaine 1.5% intraoperatively (T4-S5) and bupivacaine 0.5% 5 ml/4 h for 24 h and morphine 4 mg/12 h for 72 h. Postoperative pain was better controlled by the epidural regimen (P less than 0.0001). We found no significant reduction in postoperative mortality (6% to 2%), pneumonia (28% to 20%), cardiac dysrhythmia (10% to 5%) and wound complications (14% to 11%) by the epidural analgesic regimen. The incidence of deep venous thrombosis (125I-fibrinogen scan) was 32% after general anaesthesia and low-dose heparin and 34% after epidural analgesia with no prophylactic antithrombotic treatment (P greater than 0.9). Postoperative weight loss and decrease in serum-albumin and serum-transferrin, as well as the reduction in haemoglobin and the need for postoperative transfusions, were similar in the two groups. Convalescence, as assessed by postoperative fatigue, restoration of bowel function (flatus, bowel movement and food intake) and the time until the patients were self-aided at their preoperative level, was not reduced by epidural analgesia. Since 50% of the patients in each group suffered from one or more of the above-mentioned postoperative complications, this epidural regimen was not effective in reducing postoperative morbidity after major abdominal surgery despite the achievement of adequate pain relief.

Appendix mass: conservative management without interval appendectomy

Forty-nine patients had conservative treatment of an appendix mass without interval appendectomy. Five were lost to follow-up within 6 months, and 44 patients were followed for between 6 months and 22 years. In nine patients (20 percent) recurrent appendicitis developed, and six (14 percent) suffered chronic pain not thought to be due to appendicitis. Of the recurrences, 66 percent occurred within 2 years of the initial attack. Barium examination of the cecum was successful in diagnosing two of three additional patients in whom a right iliac fossa mass was not due to appendicitis. The morbidity and expense of routine interval appendectomy was thus eliminated in 80 percent of the patients.