Low implantation rate after in-vitro fertilization in patients with hydrosalpinges diagnosed by ultrasonography

The management of hydrosalpinges: tubal surgery or salpingectomy?

PURPOSE OF REVIEW

The clinical management of hydrosalpinges in infertile patients remains a contentious issue. This review aims to provide a critical analysis on the available treatments for hydrosalpinges, which have recently created a fierce debate between the promoters of salpingectomy and in-vitro fertilization and those who endorse tubal surgery.

RECENT FINDINGS

Hydrosalpinges have a detrimental effect on the outcome of in-vitro fertilization yet their mechanism is still unclear. Salpingectomy prior to in-vitro fertilization restores the likelihood of a successful outcome in a well defined group of patients with ultrasound-visible hydrosalpinges. However, not every woman with large hydrosalpinges should undergo salpingectomy as some fallopian tubes may be amenable to surgical repair. Preserved tubal mucosa indicates a good prognosis for tubal surgery, therefore an appropriate mucosal assessment should be routine prior to deciding upon further management.

SUMMARY

As salpingectomy is a definitive procedure it should be performed when the hydrosalpinges are beyond repair or in cases of in-vitro fertilization failure. Tubal surgery should be preferred to salpingectomy in mild to moderate tubal disease. A comparative study of restorative tubal surgery versus salpingectomy and in-vitro fertilization in selected women with hydrosalpinges is needed and will significantly help this debate. Prophylactic salpingectomy prior to in-vitro fertilization and tubal surgery is not competing but complementary in the treatment of hydrosalpinges-related infertility.

Ovarian response to gonadotropins after laparoscopic salpingectomy or the division of fallopian tubes for hydrosalpinges

OBJECTIVE

To compare the effect of prophylactic laparoscopic salpingectomy versus division of the fallopian tubes on ovarian response to gonadotropins in women undergoing IVF.

DESIGN

Retrospective study.

SETTING

National Health Service-based tertiary referral center for reproductive medicine.

PATIENT(S)

One hundred sixty-eight women with tubal factor infertility. Sixty-five women with hydrosalpinges had either salpingectomy (n = 40, group A) or proximal tubal division (n = 25, group B), while the remaining women with tubal disease but without hydrosalpinges acted as the control group (n = 103, group C).

INTERVENTION(S)

Prophylactic laparoscopic salpingectomy or proximal division of the fallopian tubes and ovarian stimulation with gonadotropins for IVF.

MAIN OUTCOME MEASURE(S)

Day 2 serum FSH levels before surgery and 3 months after surgery but before ovarian stimulation, ovarian response assessed as total dose of hMG administered, serum E2 concentrations on day 3 and day 8 of stimulation and on the day of hCG injection, number of follicles, and number of oocytes retrieved and fertilized.

RESULT(S)

In group A, baseline FSH levels were significantly raised after surgery compared with before surgery. Postsurgery FSH concentrations were significantly higher in group A compared with group B. The number of follicles (15-20 mm) was significantly lower in group A compared with group B and group C. The serum E2 levels on day 8 of stimulation were lower in group A compared with group B, and on the day of hCG injection it was significantly reduced in group A compared with groups B and C. The number of oocytes retrieved per cycle was significantly lower in group A compared with group B. There were no significant differences in pregnancy rates and miscarriage rates among the three groups.

CONCLUSION(S)

These findings suggest that prophylactic salpingectomy in women with hydrosalpinx may compromise ovarian response to stimulation without affecting pregnancy rates. A randomized control trial is recommended to determine the most appropriate laparoscopic procedure in the management of hydrosalpinx before IVF.

Comparison of endometrial and subendometrial blood flows among patients with and without hydrosalpinx shown on scanning during in vitro fertilization treatment

OBJECTIVE

To compare endometrial and subendometrial blood flows among patients with and without hydrosalpinx (HSP) during in vitro fertilization treatment as measured by a three-dimensional power Doppler ultrasound.

DESIGN

A prospective observational study.

SETTING

A tertiary assisted-reproduction unit.

PATIENT(S)

Twenty-one patients with HSP were compared with 42 matched controls without HSP.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Endometrial thickness, endometrial pattern, endometrial volume, pulsatility index (PI) and resistance index (RI) of uterine vessels, and the vascularization index (VI), flow index (FI), and vascularization flow index (VFI) of endometrial and subendometrial regions were measured on the day of oocyte retrieval.

RESULT(S)

The proportion of the non-multilayered endometrial pattern was significantly higher in the HSP group than in the non-HSP group. Patients in the HSP group had significantly lower endometrial and subendometrial VI and VFI. Endometrial thickness, endometrial volume, uterine PI, uterine RI, and endometrial and subendometrial FI were similar between the two groups. No significant differences were observed in endometrial and subendometrial VI, FI, and VFI among patients with unilateral and bilateral HSP.

CONCLUSION(S)

A change in endometrial pattern and a decrease in endometrial and subendometrial blood flows may be the reasons for impaired implantation in patients with HSP.

Expression of alpha 1 and beta 3 integrins subunits in the endometrium of patients with tubal phimosis or hydrosalpinx

OBJECTIVE

To determine the expression of alpha1 and beta3 integrin subunit on the endometrium of infertile patients with hydrosalpinx and infertile patients with tubal phimosis.

DESIGN

Case-control study.

SETTING

Tertiary medical center.

PATIENT(S)

Infertile patients with radiologic or laparoscopic diagnosis of hydrosalpinx (n = 11) or tubal phimosis (n = 12) as the only cause of infertility, and fertile controls (n = 17).

INTERVENTION(S)

Immunohistochemical analysis of alpha1 and beta3 integrin subunits was performed on endometrial biopsies obtained during the implantation window.

MAIN OUTCOME MEASURE(S)

Histologic score (HSCORE) on luminal and glandular endometrium of the patients with hydrosalpinx or tubal phimosis and the normal fertile controls.

RESULT(S)

The median (+/-SEM) HSCORE for beta3 subunit expression in endometrial glands was 0.39 +/- 0.23 and 0.42 +/- 0.18 for tubal phimosis and hydrosalpinx, respectively, and 1.74 +/- 0.26 for fertile controls. The median HSCORE for beta3 subunit expression in luminal epithelium for tubal phimosis, hydrosalpinx, and fertile controls was 0.07 +/- 0.06, 0.21 +/- 0.18, and 1.03 +/- 0.31, respectively. No statistical difference was observed on the expression of alpha1 integrin subunit expression between the three groups.

CONCLUSION(S)

The endometrial expression of beta3 integrin subunit is reduced in the presence of tubal phimosis or hydrosalpinx, during the window of implantation.

Benefits and challenges brought by improved results fromin vitrofertilization

Abstract In vitro fertilization (IVF), in which preimplantation-stage embryos are produced after ovarian stimulation and retrieval of preovulatory oocytes, now accounts for almost 2% of all births in Australia. For clinics performing in the top quartile of national results, the chance of a live birth for a woman under 35 years from one round of egg retrieval and IVF treatment is greater than 50%, albeit still with a greater than 20% risk of twins or higher order multiple pregnancy. Similar or better live birth rates are now obtainable with the elective transfer of a single embryo at the stage of blastocyst (5-6 days in culture), a policy that if adopted for younger women can reduce the risk of twins in a clinic to less than 15%. Current developments centre around improvements to embryo culture and the testing of embryos for chromosomal normality and other genetic and epigenetic variables before transfer, made possible by licences for embryo research protocols now being issued under the Commonwealth's Research Involving Human Embryos Act 2002.

The presence of cytokines and growth factors in hydrosalpingeal fluid

PURPOSE

To examine the presence of cytokines and growth factors in hydrosalpingeal fluid.

METHODS

Eighteen hydrosalpingeal fluids were compared with 15 follicular fluids and serum samples regarding the presence of interleukin-8 (IL-8), IL-12, IL-1alpha, epidermal growth factor (EGF), granulocyte macrophage colony stimulating factor (GM-CSF), leukemia inhibitory factor (LIF), tumor necrosis factor-alpha (TNFalpha), interferon-gamma (IFNgamma), and transforming growth factor-beta2 (TGFbeta2).

RESULTS

IL-8 and EGF were detected in all the hydrosalpinx samples. IL-8, IL-12, IL-1alpha, TNFalpha, TGFbeta2, GM-CSF, and LIF were detected to a significantly larger extent in hydrosalpingeal than follicular fluids (p < 0.01). The same cytokines, with the exception of IL-8, TGFbeta2, and LIF, were also more frequently present in comparison with serum.

CONCLUSION

The abundant presence of cytokines in hydrosalpingeal fluid suggests an increased expression from the tubal epithelium. Whether high concentrations have a negative influence on embryo development and implantation needs further investigation.

Surgical treatment for tubal disease in women due to undergo in vitro fertilisation

BACKGROUND

Tubal disease, and particularly hydrosalpinx, has a detrimental effect on the outcome of in-vitro fertilisation (IVF). It has been less clear whether surgical intervention for tubal disease prior to IVF is effective in improving the likelihood of successful outcome. Most data are retrospective or poorly controlled. To date no single prospective randomised trial has shown a significant benefit from such surgical treatment prior to IVF.

OBJECTIVES

To assess the value of surgical treatment for tubal disease prior to IVF.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (10 March 2004), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004), MEDLINE (January 1966 to February 2004), EMBASE (January 1985 to February 2004), reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

All trials comparing a surgical treatment for tubal disease with a control group generated by randomisation were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. The studied outcomes were live birth (and ongoing pregnancy), pregnancy, ectopic pregnancy, miscarriage, multiple pregnancy and complications.

MAIN RESULTS

Three randomised controlled trials involving 295 (or couples) were included in this review. The odds of ongoing pregnancy and live birth (Peto odds ratio (OR) 2.13, 95% confidence interval (CI) 1.24 to 3.65) were increased with laparoscopic salpingectomy for hydrosalpinges prior to IVF. The odds of pregnancy were also increased (Peto odds ratio (OR )1.75, 95%CI 1.07 to 2.86). There was no significant difference in the odds of ectopic pregnancy (Peto OR 0.42, 95%CI 0.08 to 2.14), miscarriage (Peto OR 0.49, 95%CI 0.16 to 1.52) or treatment complications (Peto OR 5.80, 95%CI 0.35 to 96.79). No data were available concerning the odds of multiple pregnancy.

REVIEWERS' CONCLUSIONS

Laparoscopic salpingectomy should be considered for all women with hydrosalpinges prior to IVF treatment. Currently unilateral salpingectomy for a unilateral hydrosalpinx (bilateral salpingectomy for bilateral hydrosalpinges) should be recommended, although this requires further evaluation. Further randomised trials are required to assess other surgical treatments for hydrosalpinx, such as salpingostomy, tubal occlusion or needle drainage of a hydrosalpinx at oocyte retrieval. The role of surgery for tubal disease in the absence of a hydrosalpinx is unclear and merits further evaluation.

Rapid reaccumulation of hydrometra after drainage at embryo transfer in patients with hydrosalpinx

OBJECTIVE

To report the occurrence and management of hydrometra at the time of scheduled embryo transfer in two patients who underwent drainage of hydrosalpinges at oocyte retrieval.

DESIGN

Case report. University IVF clinic.

PATIENT(S)

Two patients with hydrosalpinges visible on ultrasonography who deferred tubal surgery. Although no fluid was seen at the time of oocyte retrieval, hydrometra was noticed and drained before planned embryo transfer (ET).

MAIN OUTCOME MEASURE(S)

Reoccurrence of hydrometra after drainage.

RESULT(S)

Rapid reaccumulation of hydrometra despite drainage was seen in both patients, one of whom had reoccurrence in 1 hour. Embryo transfer was deferred until after tubal surgery, and all embryos were cryopreserved.

CONCLUSION(S)

In patients with hydrosalpinges, ultrasonography before ET is useful to detect newly developed hydrometra. Aspiration of the uterine fluid is unlikely to help because of rapid reaccumulation of hydrometra. Cryopreservation of the embryos for future transfer after the hydrosalpinx is removed or ligated is recommended.

Peritonitis after a ruptured left pyosalpinx in a patient undergoing in vitro fertilization

OBJECTIVE

To report acute abdomen in a young woman with infertility due to small asymptomatic bilateral hydrosalpinges who was on the 12th day of an IVF cycle.

DESIGN

Case report.

SETTING

Private IVF clinic.

PATIENT(S)

A 35-year-old woman with asymptomatic bilateral hydrosalpinges.

INTERVENTION(S)

Abdominal laparoscopy.

MAIN OUTCOME MEASURE(S)

Pus and a ruptured left pyosalpinx.

RESULTS

The patient suddenly developed acute abdomen while lifting a disabled person at a nursing home where she worked as a nurse. About 200 mL of pus was aspirated, and the patient had a ruptured left pyosalpinx. Bilateral salpingectomy was done by laparoscopy; the patient's postoperative recovery was uneventful.

CONCLUSION

We report a rare case of acute abdomen due to peritonitis after a ruptured pyosalpinx in an IVF patient who lifted a disabled person.

An Australasian survey of the management of hydrosalpinges in women due to undergo in vitro fertilisation

OBJECTIVE

To ascertain current practice of surgical interventions for women with hydrosalpinges prior to in vitro fertilisation and to compare this with a subsequent systematic review of the literature.

DESIGN

Survey.

SETTING

Specialists in Australasian IVF clinics.

METHODS

Questionnaire sent to all specialists in Australasian IVF clinics via the clinical directors of these units.

RESULTS

There were 79 respondents from 33 fertility clinics. Although only 66% expressed a belief that there was convincing evidence of an improvement in pregnancy outcomes from surgical treatment for hydrosalpinges prior to in vitro fertilisation, 94% currently offer surgical treatment for hydrosalpinges prior to in vitro fertilisation, 32% always and 62% only in selected cases. Of the 74 respondents offering surgery, all but three expressed a preference for the laparoscopic approach. Of those offering surgery, 89% performed unilateral or bilateral salpingectomy depending whether unilateral or bilateral hydrosalpinges were present, 5% routine bilateral salpingectomy 14% proximal tubal occlusion with clips, 24% salpingostomy, 7% ultrasound-guided needle aspiration of hydrosalpinges at the time of egg collection.

CONCLUSIONS

The diverse practice among Australasian fertility specialists reflects the apparent conflict in the literature prior to this survey. A Cochrane Review has now demonstrated the efficacy of laparoscopic salpingectomy in improving the odds of live birth for women with hydrosalpinges due to undergo in vitro fertilisation. It will be interesting to review whether this leads to greater uniformity of practice in the coming years.

Effect of hydrosalpinx fluid on secretion of trophoblastic matrix metalloproteinases

OBJECTIVE

To determine if hydrosalpinx fluid affects trophoblastic metalloproteinases (MMPs) secretion.

DESIGN

Measurement of the effect of hydrosalpinx and peritoneal fluids (as controls) added to the medium on the MMPs secreted by cytotrophoblastic cells.

SETTING

Academic research center.

PATIENT(S)

Five samples of hydrosalpinx fluid were obtained at the time of ovocyte retrieval. Three samples of peritoneal fluids were collected at laparoscopic sterilization.

MAIN OUTCOME MEASURE(S)

The concentration and activity of MMP-2 and MMP-9, the concentration of the tissue inhibitor of metalloproteinases (TIMP-1), and the total gelatinolytic activity of the cytotrophoblastic cells were measured in the culture medium.

RESULT(S)

Hydrosalpinx significantly stimulated MMP-2, MMP-9, and TIMP-1. The net result was a significant stimulation of the total gelatinolytic activity. Peritoneal fluids increased MMP-2, MMP-9, and TIMP-1 concentrations, but the total gelatinolytic activity was not modified.

CONCLUSION(S)

In contrast to peritoneal fluids, hydrosalpinx stimulates the total gelatinolytic activity of cytotrophoblastic cells. This might indicate that the effect of hydrosalpinx on implantation rates may not be due to an inhibition of the capacity of an embryo to invade the endometrium. However, the stimulatory effect of hydrosalpinx on the net gelatinolytic activity could partly explain the increased incidence of ectopic pregnancies that have been described in the presence of hydrosalpinx.

The mechanism of hydrosalpinx in embryo implantation

BACKGROUND

Hydrosalpinx adversely affects embryo implantation and contributes to poor implantation rates post embryo transfer. Embryo transport depends on concomitant intrauterine fluid motion induced by uterine wall motility, the result of spontaneous myometrial contractions towards the fundus.

METHODS AND RESULTS

The uterine dynamics of five patients with hydrosalpinx were recorded and analysed by image-processing techniques: the frequency was higher while the amplitudes and passive widths were lower compared with healthy volunteers. The existing peristaltic activity should have induced intrauterine fluid flow; however, the recordings failed to show the expected transport of fluid bolus. This observation was supported by mathematical simulations based on the hypothesis that fluid accumulation in the Fallopian tube of a patient with hydrosalpinx increases tubal pressure and thereby induces a pressure gradient between the fundus and the cervix. This pressure gradient acts adversely to the cervix-to-fundus intrauterine peristalsis and generates reflux currents that may thrust embryos away from the implantation site.

CONCLUSIONS

The reflux phenomenon could explain the reduced implantation rate associated with hydrosalpinx. Resolution of the issue of whether the removal of a Fallopian tube with hydrosalpinx should be undertaken for improving IVF pregnancy rates should be accompanied by prospective randomized clinical trials.

Endometrial cavity fluid is associated with poor ovarian response and increased cancellation rates in ART cycles

BACKGROUND

Endometrial cavity fluid (ECF) is occasionally observed during assisted reproductive technology (ART) cycles. However, few reports have described its prevalence or significance.

METHODS AND RESULTS

We examined the relationships between ECF, clinical pregnancy rate (CPR), tubal factor infertility and ultrasound-visible (USV) hydrosalpinges. In 843 ART cycles involving 721 patients, ECF was observed during stimulation in 57 cycles and after human chorionic gonadotrophin (HCG) administration in 12 cycles, with an overall incidence of 8.2% (69/843). When ECF was observed during stimulation, the cancellation rate due to poor ovarian response was significantly higher (29.8 versus 16.9%, P <0.05) and the CPR per started cycle was significantly lower (26.3 versus 42.4%, P <0.05) than cycles without ECF. When ECF developed after HCG administration, the CPR was similar compared with that of the group for which ECF was not observed. In the 327 cycles involving tubal factor infertility patients, USV hydrosalpinges were noted in 71 cycles (71/327; 21.7%), and ECF developed in five of those cycles (5/71; 7.0%). A total of 27 cycles during which ECF developed (27/57, 47.4%) involved non-tubal factor patients.

CONCLUSIONS

ECF during stimulation was associated with increased cancellation rates and lower CPRs per started cycle, and was not associated with USV hydrosalpinges. Furthermore, ECF observed after HCG administration did not impact CPR and may represent a different clinical entity.

Hydrosalpinx fluid affects murine embryonic development in a coculture system with epithelial endometrial cells

OBJECTIVE

The aim of the present investigation was to assess whether a coculture system protects from the effect of hydrosalpinx fluid (HF) on murine embryo development, evaluated through blastocyst cell number.

DESIGN

Controlled prospective study.

SETTING

Academic research center.

PATIENT(S)

Endometrium and HF from six patients and endometrium from six normal patients.

INTERVENTION(S)

Murine embryos were exposed to the absence or presence of different concentrations of human HF: 0% HF (control), 50% HF, 70% HF in human tubal fluid, and 100% HF, in a simple culture system (SCS), epithelial coculture system (ECS), and hydrosalpinx epithelial coculture system (HECS).

MAIN OUTCOME MEASURE(S)

Embryonic development at 72 hours and blastocyst cell number determined by the Tarcowsky method.

RESULT(S)

In SCS, 91.9% of the embryos reached the blastocyst stage, and no significant differences were shown in the presence of HF. However, significant differences were observed in the blastocyst cell number. Of the embryos cultured in ECS, 97.1% reached the blastocyst stage, and high concentrations of HF caused a decrease in embryonic development. A significant difference was observed between ECS and HECS in embryo development without HF. When HF was added, a significant decrease in blastocyst cell number was seen in embryos exposed to HECS compared with ECS.

CONCLUSION(S)

Our data suggest that normal and hydrosalpinx endometria do not protect from the deleterious effect of HF on embryo development at the concentrations evaluated. This effect is dose dependent and was determined through the blastocyst cell number.

Effects of human hydrosalpinx fluid on in-vitro murine fertilization

Patients with hydrosalpinges show a decrease of both fertility and clinical outcome of IVF and embryo transfer treatment. Several reports have demonstrated the negative effects of hydrosalpinx fluid (HSF) on embryo development and implantation. The aim of this study was to determine whether human HSF, collected from infertile patients, might exhibit a deleterious effect on gametes and fertilization using a murine IVF system. Murine gametes were co-incubated during IVF until first cleavage with human HSF diluted to 50% from four patients (HSF1-4). It was demonstrated that HSF affected fertilization, as determined by the count of the 2-cell embryos. Pre-incubation of spermatozoa with HSF during capacitation significantly lowered the percentage of 2-cell embryos (P < 0.05). While HSF1-3 had no significant effect on motility and viability of spermatozoa, HSF4 almost completely affected their survival. In contrast, pre-incubation of ovulated oocytes surrounded by their cumulus cells with HSF before IVF did not impede first cleavage. Taken together, these results suggest that HSF has a cytotoxic effect on spermatozoa and/or impairs the fertilization process, probably by altering capacitation/acrosome reaction and/or ligand(s)-receptor(s) interactions. Hydrosalpinges may be partly associated with sterility through HSF inhibitory effects on fertilization.

Laparoscopic management of hydrosalpinges before in vitro fertilization-embryo transfer: salpingectomy versus proximal tubal occlusion

OBJECTIVE

To compare ovarian response and IVF-ET cycle outcome in patients with hydrosalpinges managed by either laparoscopic salpingectomy or proximal tubal occlusion.

DESIGN

Retrospective analysis.

SETTING

Tertiary-care assisted reproductive technology program.

PATIENT(S)

One hundred four consecutive fresh IVF-ET cycles in 94 patients with tubal-factor infertility.

INTERVENTION(S)

Laparoscopic salpingectomy (group 1: 35 cycles) or bipolar proximal tubal occlusion (group 2: 17 cycles), controlled ovarian hyperstimulation, and IVF-ET. Control groups consisted of both tubal-factor patients without hydrosalpinges (group 3: 37 cycles) and those with prior bilateral tubal ligation for sterilization (group 4: 15 cycles).

MAIN OUTCOME MEASURE(S)

Uterine artery Doppler flow, controlled ovarian hyperstimulation response, and implantation and clinical pregnancy rates.

RESULT(S)

There were no differences in mean uterine artery pulsatility indices or ovarian response among any of the groups. A trend toward a higher cycle cancellation rate in group 1 did not approach statistical significance. Clinical pregnancy and implantation rates were not significantly different between group 1 (57.1%, 29.2 +/- 5.9%, respectively) and group 2 (46.7%, 19.4 +/- 6.1%, respectively) or compared with those of controls.

CONCLUSION(S)

[1] Management of hydrosalpinges by laparoscopic salpingectomy or bipolar proximal tubal occlusion yielded statistically similar responses to controlled ovarian hyperstimulation and IVF-ET cycle outcome. [2] The latter approach may be preferable in patients who present with dense pelvic adhesions and easy access only to the proximal fallopian tube.

Surgical treatment for tubal disease in women due to undergo in vitro fertilisation

BACKGROUND

Tubal disease, and particularly hydrosalpinx, has a detrimental effect on the outcome of in-vitro fertilisation (IVF). It has been less clear whether surgical intervention for tubal disease prior to IVF is effective in improving the likelihood of successful outcome. Most data are retrospective or poorly controlled. To date no single prospective randomised trial has shown a significant benefit from such surgical treatment prior to IVF.

OBJECTIVES

To assess the value of surgical treatment for tubal disease prior to IVF.

SEARCH STRATEGY

The search strategy of the Menstrual Disorders and Subfertility Group was used for the identification of relevant randomised controlled trials.

SELECTION CRITERIA

All trials where a surgical treatment for tubal disease was compared with a control group generated by randomisation were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Three randomised controlled trials were identified and included in this review, after an attempt to obtain further information from the authors of all three trials. All trials were assessed for quality criteria. The studied outcomes were live birth (and ongoing pregnancy), pregnancy, ectopic pregnancy, miscarriage, multiple pregnancy, complications, implantation rate and the proportion of IVF cycles resulting in embryo transfer.

MAIN RESULTS

The odds of pregnancy (OR 1.75, 95%CI 1.07, 2.86) and of ongoing pregnancy and live birth (OR 2.13, 95%CI 1.24, 3.65) were increased with laparoscopic salpingectomy for hydrosalpinges prior to IVF. There was no significant difference in the odds of ectopic pregnancy (OR 0.42, 95%CI 0.08, 2.14), miscarriage (OR 0.49, 95%CI 0.16, 1.52), treatment complications (OR 5.80, 95%CI 0.35, 96.79) or implantation rate (OR 1.34, 95%CI 0.87, 2.05). No data were available concerning the odds of multiple pregnancy or the proportion of IVF cycles resulting in embryo transfer.

REVIEWER'S CONCLUSIONS

Laparoscopic salpingectomy should be considered for all women with hydrosalpinges prior to IVF treatment. Currently unilateral salpingectomy for a unilateral hydrosalpinx (bilateral salpingectomy for bilateral hydrosalpinges) should be recommended, although this requires further evaluation. Further randomised trials are required to assess other surgical treatments for hydrosalpinx, such as salpingostomy, tubal occlusion or needle drainage of a hydrosalpinx at oocyte retrieval. The role of surgery for tubal disease in the absence of a hydrosalpinx is unclear and merits further evaluation.

Cauterization of hydrosalpinges before in vitro fertilization is an effective surgical treatment associated with improved pregnancy rates

OBJECTIVE

Our purpose was to determine whether proximal tubal cauterization is an effective method of reversing the decreased pregnancy rates seen in patients undergoing in vitro fertilization-embryo transfer with hydrosalpinges present.

STUDY DESIGN

We studied a group of 94 patients with tubal factor infertility. Sixty patients had hydrosalpinges documented by either hysterosalpingography or laparoscopy, or both. Forty-five had surgical treatment of hydrosalpinges by salpingectomy or by proximal tubal cauterization. In vitro fertilization-embryo transfer was performed within 3 months after surgery. Pregnancy and implantation rates were compared.

RESULTS

Patients with hydrosalpinx had significantly decreased clinical pregnancy and implantation rates per cycle (14% and 8%, respectively) compared with those of patients undergoing proximal tubal cauterization before the in vitro fertilization cycle (73% and 36%, respectively). These pregnancy and implantation rates are comparable with those found in patients with tubal factor infertility without hydrosalpinges (53% and 22%, respectively), as well as in salpingectomy-treated patients (46% and 24%, respectively).

CONCLUSIONS

Proximal tubal cauterization is effective in reversing the adverse effects of hydrosalpinges.

Controversies in the surgical management of hydrosalpinx

The surgical management of hydrosalpinges is a controversial subject. Chronic pathology of the fallopian tube with distal obstruction leads to the formation of a hydrosalpinx, and is associated with very poor pregnancy rates after surgery. In these cases, in-vitro fertilization has proved to be a much better alternative. However, several studies have shown that patients with hydrosalpinges have significantly lower pregnancy and implantation rates after in-vitro fertilization compared with patients with other forms of tubal damage. The exact mechanism by which the hydrosalpinx adversely affects in-vitro fertilization results is not yet fully understood. The value of performing a salpingectomy before in-vitro fertilization has been studied extensively. Currently, a clear benefit in salpingectomies has been proved for patients with ultrasonically visible hydrosalpinges.

Management of hydrosalpinx: reconstructive surgery or IVF?

Tubal disease remains the most important factor in female infertility. Many investigators reported that patients with hydrosalpinx had a decreased clinical pregnancy rate and an increased miscarriage rate, resulting in a decreased ongoing pregnancy rate when compared to that of patients with other types of tubal disease. Different studies showed a deleterious effect of the presence of hydrosalpinx on the outcome of in vitro fertilization-embryo transfer, because toxic agents flowing from the hydrosalpinx to the uterus impair the implantation rate. Operative laparoscopy is effective in the treatment of hydrosalpinges (Stage I or II). Fertility outcome is related to tubal damage. Patients with Stage III and IV disease should be managed from the beginning with in vitro fertilization. Excision of hydrosalpinx(-ges) improves the pregnancy potential after in vitro fertilization. We believe that assisted reproductive technology and reproductive surgery can be complementary. The development of laparoscopic surgery and in vitro fertilization improved the pregnancy rate in patients with tubal factor infertility.

Salpingectomy for repeated embryo nonimplantation after in vitro fertilization in patients with severe tubal factor infertility

PURPOSE

To evaluate the impact of salpingectomy on the rates of embryo implantation and pregnancy in patients with severe, irreversible tubal factor sterility.

METHODS

A retrospective study of patients with repeated failure of in vitro fertilization due to nonimplantation of the embryo. Seventy-two patients with severe and irreversible tubal factor sterility were selected following repeated failure of in vitro fertilization (IVF) due to assumed nonimplantation of the embryo: 35 underwent a salpingectomy before continuing IVF cycles and 37 continued IVF cycles without salpingectomy.

RESULTS

After the first IVF cycle consecutive to diagnosis of embryo nonimplantation, the implantation rate was 10.2% in the salpingectomy group and 6.1% in the group without the procedure (P = 0.5). After all IVF cycles, the rate was, respectively, 6.9% and 4.5% (P = 0.2). Salpingectomy improved the pregnancy rate (PR) per transfer (23.5% vs. 9.9%; P = 0.01). The curves of the cumulative probability of becoming pregnant show that salpingectomy resulted in pregnancy more rapidly.

CONCLUSIONS

Salpingectomy improves the PR per transfer in patients with severe and irreversible tubal factor sterility who have experienced repeated failure of IVF due to embryo nonimplantation. This procedure also reduces the number of IVF attempts needed to obtain pregnancy.

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).

Effects of hydrosalpingeal fluid on murine embryo development and implantation

PURPOSE

Our purpose was to evaluate the effects of various concentrations of hydrosalpingeal fluid (HSF) on the preimplantation development and implantation of murine embryos.

METHODS

One-cell mouse embryos were cultured in KSOM culture medium with 0.1, 1.0, 10, or 50% HSF, without and with lactate supplementation. Late-stage embryos were transferred into the uteri of pseudopregnant CD-1 females to determine implantation rates. The embryo transfer technique used was developed by our group and its effectiveness was evaluated during this experiment.

RESULTS

Blastocyst development in the 0.1, 1.0, 10, and 50% group was 45, 55.0, 12.5, and 17.5%, respectively, with lactate supplementation, and 35.0, 52.5, 12.5, and 5.0%, respectively, without lactate supplementation, while in the KSOM (control) group it was 63.8%. Blastocyst development was reduced compared to controls in the 10% HSF and 50% HSF groups. Implantation rates for the 0.1 and 1.0% groups with lactate supplementation were 43.0 and 25.0%, respectively, and those with lactate supplementation were 50.6 and 61.8%, respectively, while in the KSOM group the implantation rate was 65.5%. None of the implantation rates were significantly different.

CONCLUSIONS

Hydrosalpingeal fluid has a concentration-dependent inhibitory effect on in vitro murine embryo development, but it has minimal effects on implantation rates.

Controlled ovarian hyperstimulation adversely affects implantation following in vitro fertilization-embryo transfer

PURPOSE

Our purpose was to determine if controlled ovarian hyperstimulation adversely affects implantation.

METHODS

A retrospective comparison of pregnancy rates (PRs) and implantation rates was made between oocyte recipients versus their donors, who shared half of the retrieved oocytes, and regular patients undergoing in vitro fertilization-embryo transfer (IVF-ET) who were not sharing eggs.

RESULTS

Higher implantation rates (39.0 vs 22.5%; P < 0.05) were found in recipients compared to donors in the stimulated cycle. However, no differences were seen in PRs or implantation rates in frozen ET cycles. The data for standard IVF patients were almost-identical to those for donors.

CONCLUSIONS

Superior implantation rates and PRs in oocyte recipients versus donors were not related to better oocyte quality for recipients because of egg sharing or to a better uterine environment because of similar results with frozen ET in all three groups. An adverse effect of the hyperstimulation regimen best explains the difference.

The effect of hydrosalpinges on IVF-ET outcome

PURPOSE

Our purpose was to determine if the presence of a hydrosalpinx effects the outcome of in vitro fertilization (IVF)-embryo transfer.

METHODS

We performed a retrospective analysis of IVF cycle stimulation sheets.

RESULTS

A total of 1000 patients with tubal factor infertility was analyzed. There were 60 hydrosalpinx patients who underwent 116 initiated cycles with 106 embryo transfers, compared to 940 control patients undergoing 1428 initiated cycles with 1150 embryo transfers. Both groups had a similar response to ovarian stimulation, number of oocytes retrieved, and number of embryos transferred. The hydrosalpinx group had a significantly higher preclinical loss rate (22/59 = 37% vs 80/566 = 14%; P = 0.001), a significantly lower implantation rate (55/352 = 16% vs 795/3795 = 21%; P = 0.013), a trend toward a reduced delivery rate per transfer (28/106 = 26% vs 387/1150 = 34%; P = 0.066), a significantly higher ectopic pregnancy rate (5/59 = 8% vs 16/566 = 3%; P = 0.04), and a similar spontaneous abortion rate (9/37 = 24% vs 99/486 = 20%; P = 0.28) compared to the control tubal factor group.

CONCLUSIONS

This study demonstrates a decrease in implantation rates and an increase in preclinical miscarriages and ectopic pregnancies in patients with hydrosalpinges compared to tubal-factor patients without sonographic evidence of dilated fallopian tubes.

The embryo toxicity of hydrosalpinx fluid is only apparent at high concentrations: an in vitro model that stimulates in vivo events

OBJECTIVE

To simulate the in vivo model in studying the effect of hydrosalpinx fluid on embryonic development.

DESIGN

Controlled prospective study.

SETTING

Academic research center.

PATIENT(S)

Five hundred eighty-seven two-cell murine embryos.

INTERVENTION(S)

Embryos were grown under two sets of conditions. Half were cultured using 10% fetal calf serum in RPM1 medium in varying concentrations of hydrosalpinx fluid (0, 1%, 10%, 50%, 75%, and 100%). To more closely mimic the in vivo environment, the other half were grown in an endometrial coculture system with the same media and hydrosalpinx fluid concentrations.

MAIN OUTCOME MEASURE(S)

Embryonic development.

RESULT(S)

For each stage of embryogenesis, diminished development was noted with increasing concentrations of hydrosalpinx fluid. In the group of embryos grown without endometrial coculture, only at a minimum concentration of 50% hydrosalpinx fluid was diminished development noted for the blastocyst, hatching, and outgrowth stages. When an endometrial coculture system was used, development was not inhibited until exposure to a minimum of 75% hydrosalpinx fluid. Embryogenesis was enhanced when an endometrial coculture system was used for each concentration of hydrosalpinx fluid.

CONCLUSION(S)

When a model is used that more accurately mimics the in vivo conditions of IVF-ET in a patient with hydrosalpinges, it appears that high concentrations of hydrosalpinx fluid are required to signiticantly impede embryogenesis. The endometrium appears to help detoxify hydrosalpinx fluid.

A decade of salpingoscopy

With the introduction of the salpingoscopy of the tubal ampullary mucosa in the 1980s, this diagnostic endoscopic examination not only disclosed an exciting world of sharp and detailed in vivo images of the actual site of human fertilization. Its systematic use in the assessment of the tubal factor in subfertile couples also provides specific, clinically relevant and prognostically valuable information, since it clearly demonstrates the presence or absence of anatomical distortions, especially adhesions between and destruction of mucosal folds, on a micro-endoscopic, i.e., mucosal level. The routine salpingoscopy of a free, patent tube is easy to perform and the procedure then takes about 10 min for both sides. In contrast with hysterosalpingography, a proximal (e.g., tubocornual or isthmic) block does not prevent us from examining the ampullary mucosa with the salpingoscope, whereas a small incision at the site of the occlusion with one of the techniques of operative laparoscopy, enables the inspection of the mucosa of a hydrosalpinx. With salpingoscopy, and using a simple classification system, a trained endoscopist can evaluate the sequelae of tubal inflammatory disease and their impact on fertility nearly as efficiently as with mucosal microbiopsies and they can direct their patients accordingly, either towards reconstructive (micro)surgery or towards medically assisted reproduction. In case of a tubal pregnancy, the effort to salpingoscopically evaluate both the affected and unaffected side may help to understand the underlying ethiology of the ectopic. Since patency and a normal appearance of the fimbriated end surely do not imply the absence of endoluminal pathology, it is advisable to select only salpingoscopically normal tubes to perform tubal transfers of gametes, zygotes or embryos. In the still ongoing discussion regarding preventive salpingectomy prior to IVF-ET in case of a uni- or bilateral hydrosalpinx, blind victimization of the Fallopian tube can in our opinion be avoided by a proper endoscopic selection of cases.

Effect of salpingectomy on ovarian response to superovulation in an in vitro fertilization-embryo transfer program

OBJECTIVE

To investigate the effect of salpingectomy on the response of each ovary in patients undergoing an IVF-ET treatment cycle and to compare the results with those of patients who had not had surgery and were undergoing IVF-ET during the same period.

DESIGN

A prospective study.

SETTING

Tertiary referral academic IVF unit.

PATIENT(S)

Twenty-nine ET cycles were evaluated in 29 patients who previously had undergone unilateral salpingectomy because of ectopic pregnancy (study group). Seventy-three patients with unexplained or male factor infertility served as controls.

INTERVENTION(S)

Ovulation induction and IVF-ET.

MAIN OUTCOME MEASURE(S)

In the study group, mean ovarian volume, number of follicles, and number of oocytes recovered from each ovary were assessed and compared. The overall results, cycle characteristics, and pregnancy rates of the two groups were compared.

RESULT(S)

Among the patients who had undergone salpingectomy, significantly fewer follicles developed and consequently fewer oocytes were retrieved from the ovary on the operated side (4.4 versus 8.2 follicles and 3.8 versus 6.0 oocytes). There were no differences in the total numbers of follicles and oocytes recovered from both ovaries, the cycle characteristics, or the pregnancy rates between study and control groups.

CONCLUSION(S)

Salpingectomy has no detrimental effect on the total ovarian performance during IVF-ET treatment or on the outcome of IVF-ET. However, the ipsilateral ovary could be adversely affected. This could be detrimental in selected patients undergoing IVF-ET, in whom the second ovary already is compromised or missing.

Adverse effects of hydrosalpinx on pregnancy rates after in vitro fertilization-embryo transfer

OBJECTIVE

To determine the effect of hydrosalpinx on the establishment of pregnancy after IVF-ET.

DESIGN

Metaanalysis.

SETTING

University medical center.

PATIENT(S) AND INTERVENTION(S)

All published reports (n=13) and abstracts (n=10) in English that examined the relation between hydrosalpinx and IVF-ET were included in the analysis. The metaanalysis was performed by first calculating the odds ratios for each trial and then combining them to obtain a pooled estimate of the odds ratio and a 95% confidence interval.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy.

RESULT(S)

A total of 5,569 cycles was reviewed in the group without hydrosalpinx, and a total of 1,144 was reviewed in the group with hydrosalpinx. The clinical pregnancy rate was approximately 50% lower in patients who had hydrosalpinx. Similarly, the implantation rate was decreased by 50%. These effects were observed also in thawed ET cycles. The abortion rate was more than twofold higher in patients who had hydrosalpinx.

CONCLUSION(S)

This metaanalysis suggests that hydrosalpinx is associated with a reduced chance of implantation and an increased risk of pregnancy loss.

The relation between immunoglobulin G antibodies to Chlamydia trachomatis and poor ovarian response to gonadotropin stimulation before in vitro fertilization

OBJECTIVE

To determine whether a relation exists between previous exposure to Chlamydia trachomatis and impaired ovarian response to gonadotropin stimulation.

DESIGN

Controlled clinical study.

SETTING

Two university IVF centers.

PATIENT(S)

Two hundred forty-two patients receiving IVF treatment and 81 control patients. Ninety-four patients with a poor response to IVF, defined by cycle cancellation in response to a daily stimulation dose of 300 IU of FSH, and 148 patients with a good response were matched for age. Twenty-eight pregnant controls and 53 controls of proven fertility also were included.

INTERVENTION(S)

Serum samples were obtained from patients and controls. Serum levels of immunoglobulin (Ig) G antibodies to C. trachomatis were determined by ELISA.

MAIN OUTCOME MEASURE(S)

The prevalence of serum IgG antibodies to C. trachomatis in critically defined poor responders was compared with that of age-matched good responders.

RESULT(S)

A significantly higher proportion of poor responders had serum IgG antibodies to C. trachomatis compared with good responders (44.7% and 30.4%, respectively). Patients undergoing IVF had a significantly higher prevalence of IgG antibodies to C. trachomatis (36%) than did either pregnant or nonpregnant controls (12%).

CONCLUSION(S)

A significantly higher prevalence of serum IgG antibodies to C. trachomatis was observed in critically defined poor responders, suggesting a possible detrimental effect of C. trachomatis on subsequent ovarian function.

Does previous salpingectomy improve implantation and pregnancy rates in patients with severe tubal factor infertility who are undergoing in vitro fertilization? A pilot prospective randomized study

OBJECTIVE

To evaluate the implantation rate and pregnancy rate (PR) in patients with severe tubal factor infertility who were undergoing IVF. Patients who had undergone salpingectomy were compared with those who had not.

DESIGN

A prospective randomized study.

SETTING

A department of obstetrics and gynecology at a university hospital.

PATIENT(S)

Thirty patients who previously had undergone salpingectomy and 30 patients who had not undergone salpingectomy before IVF treatment.

INTERVENTION(S)

Laparoscopy with or without salpingectomy followed by IVF with the use of combined GnRH agonist and hMG therapy in a long stimulation protocol.

MAIN OUTCOME MEASURE(S)

Embryo implantation rate and ongoing PR per transfer. The cumulative PRs were compared for the two groups of patients.

RESULT(S)

After the first IVF attempt, the implantation rate was 10.4% in the group with salpingectomy and 4.6% in the group without salpingectomy. For all IVF attempts, the respective embryo implantation rates in the two groups were 13.4% and 8.6%. The ongoing PR per transfer was 34.2% in the group with salpingectomy compared with 18.7% in the group without salpingectomy. After four IVF attempts, the probability of becoming pregnant was greater in the group of patients with salpingectomy (75%) than in the group without salpingectomy (63%).

CONCLUSION(S)

Previous salpingectomy in patients with severe tubal factor infertility who are undergoing IVF seems to increase the embryo implantation rate and the PR per cycle of IVF. This monocentric study must be followed by other similar studies to allow for a metaanalysis and confirm this clear trend with definitive evidence.

The management of hydrosalpinges before in-vitro fertilization and embryo transfer

Several recent studies have shown that the presence of hydrosalpinges adversely affects clinical pregnancy rates achieved with in-vitro fertilization and embryo transfer. Hydrosalpinx fluid may be toxic to the endometrium or embryo, or may mechanically interfere with implantation. Some authors recommend surgical correction of hydrosalpinges before in-vitro fertilization and have shown promising results with this approach. Proper patient selection for this therapy still needs to be defined.

The significance of hydrosalpinx in in vitro fertilization

OBJECTIVE

To review the effects of hydrosalpinx on IVF/ET and the role of salpingectomy.

DESIGN

The literature on hydrosalpinx, IVF/ET, embryotoxicity, and salpingectomy for hydrosalpinx was identified through MEDLINE searches and reviewed.

RESULT(S)

Hydrosalpinx has been associated with poor fertility prognosis. IVF/ET is a better alternative to tubal surgery for those patients with severe distal tubal disease, and it is also more cost effective. However, the presence of hydrosalpinx has a negative effect on IVF/ET by decreasing the pregnancy rates and implantation rates compared with patients undergoing IVF/ET for tubal disease but without hydrosalpinx. The hydrosalpingeal fluid has been demonstrated to be embryotoxic to developing embryos, thus leading to increased early pregnancy losses. Poor endometrial receptivity has also been demonstrated in the presence of hydrosalpinges. Removal of the hydrosalpinges leads to improved IVF/ET rates comparable to those patients without hydrosalpinx. Therefore, salpingectomy has been recommended for patients with hydrosalpinx who will be undergoing IVF/ET.

CONCLUSION(S)

The presence of hydrosalpinx has a negative effect on IVF/ET because of the suspected embryotoxicity of the hydrosalpingeal fluid. Surgical removal of the hydrosalpinx has been shown to improve IVF/ET rates.

An increased number of replaced embryos counteracts the adverse effect of hydrosalpinges on IVF/ET outcome

PURPOSE

The relationship between the number of replaced embryos and the outcome of IVF-ET in patients with hydrosalpinges was investigated in a retrospective, nonrandomized study performed at a governmental IVF center.

METHODS

One hundred patients undergoing 161 IVF cycles ending in embryo transfer were studied. Previously diagnosed hydrosalpinges were evident on transvaginal sonography in 48 cycles in 26 patients (group I) and not evident in 15 cycles in 10 patients (group II). The control group included 98 cycles in 64 patients with tubal lesions other than hydrosalpinx. Pregnancy and implantation rates were the main outcome measures.

RESULTS

Replacement of three or fewer embryos was associated with significantly lower implantation rates in group I compared to controls. Despite the difference in the rank of IVF trial within the same group, significantly lower implantation rates were found when four or fewer embryos were replaced in the control group and not in group I.

CONCLUSION

An increased number of replaced embryos counteracts the adverse effect of hydrosalpinges on IVF/ ET outcome.

The adverse effect of hydrosalpinges on in vitro fertilization pregnancy rates and the benefit of surgical correction

OBJECTIVE

To test the hypothesis that IVF-ET pregnancy rates (PRs) for patients with tubal factor infertility are decreased in patients with hydrosalpinges and that surgical correction reverses this effect.

DESIGN

Retrospective chart review.

SETTING

Private practice IVF-ET program.

PATIENT(S)

Patients (n = 160) undergoing 238 cycles of IVF-ET were stratified into groups based on the presence of hydrosalpinges and whether surgical correction had been performed. Patients >39 years old and patients with male factor infertility were excluded from the study.

INTERVENTION(S)

Patients with hydrosalpinges were offered surgical correction.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy defined by an intrauterine gestational sac.

RESULT(S)

Patients with hydrosalpinges had significantly decreased implantation rates and PRs per transfer (2.8% and 8.5%, respectively) than patients with tubal factor infertility but without hydrosalpinges (15.7% and 38.6%). Surgical correction improved implantation rates and PRs in patients with prior failed cycles (16.1% and 37.5%) and in patients undergoing surgery before IVF-ET (21.8% and 51.7%). The type of surgery performed did not affect success rates in the small number of patients evaluated.

CONCLUSION(S)

The presence of a hydrosalpinx during an IVF-ET cycle results in significant decreases in implantation rates and PRs. Surgical treatment of hydrosalpinges before IVF-ET cycles improves implantation rates and PRs.

Is there any need for diagnostic laparoscopy in couples undergoing intracytoplasmic sperm injection for severe male-factor infertility

PURPOSE

Our purpose was to determine whether there is a need for a preliminary diagnostic laparoscopy in couples undergoing intracytoplasmic sperm injection (ICSI) because of severe male-factor infertility.

METHODS

In this retrospective study, the results of diagnostic laparoscopy in 342 women with a normal fertility workup undergoing ICSI were evaluated and sperm parameters were correlated with the findings at laparoscopy. Subgroups of patients were defined according to sperm quality, which was expressed as total normal motile count [TNMC = volume (ml) x concentration (10(6)/ml) x percentage progressive motility/100 x percentage normal morphology/100].

RESULTS

When sperm morphology was evaluated according to Kruger's strict criteria, the probability of finding pathology on laparoscopy in the normal male group (16.7%) was statistically higher than that in the group with severely abnormal sperm (1.8%; P < 0.01).

CONCLUSIONS

There is no need to perform a preliminary diagnostic laparoscopy in the female partner if a full workup is normal in couples with severe male-factor infertility willing to undergo ICSI.

Does hydrosalpinx reduce the pregnancy rate after in vitro fertilization?

OBJECTIVE

To determine the effect of hydrosalpinges on the pregnancy rate in an IVF program.

DESIGN

Multicentric retrospective analysis of clinical and laboratory data.

SETTING

Two assisted reproductive technology centers in university hospitals.

PATIENT(S)

Four hundred forty-three women, under 38 years of age, with pure tubal infertility. The patients were classified into the following five groups: bilateral hydrosalpinges (n = 37), unilateral hydrosalpinx (n = 54), bilateral tubal occlusion (n = 207), unilateral tubal occlusion (n = 55), and severe tubal disease without complete occlusion (n = 90).

MAIN OUTCOME MEASURE(S)

Pregnancy and implantation rates.

RESULT(S)

The pregnancy and the implantation rates per transfer (12.3% and 5.4%) obtained by women with bilateral hydrosalpinges are significantly lower than the rates (means = 23.1% and 12%) for all other tubal infertility groups.

CONCLUSION(S)

Bilateral hydrosalpinges have a deleterious effect on the outcome of IVF program.

The presence of hydrosalpinx may not adversely affect the implantation and pregnancy rates in in vitro fertilization treatment

PURPOSE

To evaluate the effects of hydrosalpinx on the outcome of in vitro fertilization (IVF) treatment, a retrospective study was undertaken at a tertiary referral center for infertility.

METHODS

Results of the first IVF treatment cycles in 144 patients from 1 January 1993 to 31 December 1995, who had tubal infertility only and were less than 38 years old, were reviewed. The duration/dosage of hMG used, serum estradiol level on the day of hCG, number of oocytes aspirated and fertilized, number of embryos replaced, implantation rate, clinical pregnancy rate, and pregnancy outcome were compared in patients with and without hydrosalpinx.

RESULTS

The mean implantation rate and clinical pregnancy rate were similar in patients with or without hydrosalpinx. Both groups had similar ovarian responses and fertilization rates. There was no increase in clinical abortion in the hydrosalpinx group but ectopic pregnancies were more common in patients with hydrosalpinx.

CONCLUSIONS

The presence of hydrosalpinx did not adversely affect the implantation and pregnancy rates in in vitro fertilization treatment when the results of the first cycle were compared. However, it can lead to a higher incidence of ectopic pregnancies.

Detrimental effect of hydrosalpinx fluid on the development and blastulation of mouse embryos in vitro

OBJECTIVE

To study the effects of human hydrosalpinx fluid on mouse embryo blastulation rate.

DESIGN

Comparison of mouse embryo blastulation rate in media containing increasing concentrations of hydrosalpinx fluid.

SETTING

Tertiary care center.

PATIENT(S)

Women undergoing laparoscopic evaluation or treatment for infertility noted to have hydrosalpinx or paratubal cyst.

INTERVENTION(S)

Exposure of mouse embryos to hydrosalpinx or paratubal cyst fluid collected during laparoscopy.

MAIN OUTCOME MEASURE(S)

Blastulation rate of mouse embryos.

RESULT(S)

Culture of mouse embryos at 0% (controls), 0.3%, 0.6%, and 0.9% hydrosalpinx fluid concentrations demonstrated significantly lower blastulation rate at each level compared with the controls.

CONCLUSION(S)

Hydrosalpinx fluid is highly embryotoxic.

Hydrosalpinx fluid enhances human trophoblast viability and function in vitro: implications for embryonic implantation in assisted reproduction

OBJECTIVE

To assess the effects of hydrosalpinx fluid on human cytotrophoblast viability and function in vitro.

DESIGN

Human cytotrophoblasts obtained from third-trimester placentas were cultured in vitro with hydrosalpinx fluid, and cell viability and protein production were assayed.

SETTING

A university hospital.

PATIENT(S)

Ten hydrosalpinx fluid samples obtained from seven women with clearly diagnosed hydrosalpinges.

INTERVENTION(S)

Recovery of hydrosalpinx fluid by transvaginal aspiration or at the time of surgery.

MAIN OUTCOME MEASURE(S)

Cell viability was assessed by the XTT assay. Secretion of trophoblast oncofetal fibronectin (tropho-uteronectin) and beta-hCG by cultured trophoblasts was determined by Western blot and ELISA of the culture media.

RESULT(S)

With increasing concentrations of hydrosalpinx fluid from 0% to 20%, there was a significant increase in trophoblast cell viability (1.63-fold increase in 20% hydrosalpinx fluid). Likewise, both Western blot and ELISA assays demonstrated a significant increase in tropho-uteronectin production by trophoblasts with increasing hydrosalpinx fluid concentrations (3.76-fold increase in 20% hydrosalpinx fluid). beta-Human chorionic gonadotropin production also increased significantly in the presence of hydrosalpinx fluid (3.31-fold increase in 20% hydrosalpinx fluid).

CONCLUSION(S)

These findings suggest that hydrosalpinx fluid improves human trophoblast viability in vitro and enhances the production of tropho-uteronectin and beta-hCG by these cells.

The impact of hydrosalpinx on successful pregnancy in tubal factor infertility treated by in vitro fertilization

OBJECTIVE

To determine the impact of hydrosalpinx on pregnancy rates in patients undergoing IVF for infertility caused by tubal disease.

DESIGN

Review of the records of all patients who had undergone IVF for tubal factor infertility at our institution between May 1988 and October 1994.

SETTING

A university-sponsored, hospital-based IVF facility.

PATIENT(S)

Two hundred fifty patients were identified with infertility due to tubal disease; 67 of these had at least one documented hydrosalpinx whereas the remaining 183 did not.

MAIN OUTCOME MEASURE(S)

Numbers of oocytes retrieved and fertilized, the number of embryos transferred and implanting, and resulting pregnancy rates.

RESULT(S)

The groups were similar in age and cycle cancellation rates. The patients with hydrosalpinx had greater numbers of oocytes retrieved per cycle (15.0 versus 11.6) and embryos transferred per cycle then those without hydrosalpinges (4.21 versus 3.98). The hydrosalpinx group also undertook more cycles per patient (2.31 versus 1.96). Fertilization rates between the two groups were similar, but implantation rates were decreased in those with hydrosalpinx (8.5% versus 11.2%).

CONCLUSION(S)

Hydrosalpinx did not result in impaired ovarian stimulation or decreased oocyte fertilization. It did, however, interfere with implantation and reduce to some degree the success of IVF in achieving an ongoing pregnancy. The validity of routine salpingectomy for hydrosalpinx is debatable, but its use in selected individuals may well be appropriate.

Age-dependent decrease in embryo implantation rate after in vitro fertilization

OBJECTIVE

To investigate the relation between the implantation rate per embryo after replacement in IVF-ET in relation to female age.

DESIGN

Retrospective study using linear and biphasic models in a multivariate analysis.

SETTING

Academic tertiary care institution.

INTERVENTION(S)

In vitro fertilization-ET and determination of gestational sacs at 6 to 7 weeks of pregnancy buy ultrasound.

MAIN OUTCOME MEASURE(S)

Implantation rate as defined by the number of gestational sacs per embryo replaced.

RESULT(S)

Woman's age and embryo morphology were strongly related to the implantation rate, indication for IVF-ET and cycle rank number also were related significantly but less strongly. A linear model was built describing the decrease in implantation rate with age, resulting in a decrease of approximately 7%. A biphasic model was tested also and performed significantly better, resulting in a yearly decrease of > 20% after 37 years of age.

CONCLUSION(S)

The most important independent factors related to the ability of embryos to implant are female age and embryo morphology. The best way to describe the relation with female age is biphasic model with a discontinuity at approximately 37 years of age.