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

Comparison of salpingectomy and tubal occlusion for hydrosalpinx in in-vitro fertilization outcome

The occurrence of hydrosalpinx can reduce the success rate of assisted reproductive technology. The laparoscopic salpingectomy and tubal occlusion have been shown to improve in-vitro fertilization (IVF) outcomes in this disease. The primary goal of this review was to assess and compare the IVF outcome following salpingectomy or tubal occlusion in the published literature. The authors included studies with at least one of the following outcomes: days of controlled ovarian hyperstimulation, retrieved oocyte number, fertilization rates, clinical pregnancy rate, miscarriage rate, or ectopic pregnancy rate. In conclusion, proximal tubal occlusion outperforms salpingectomy in terms of fertilization rate while offering no evident advantages in terms of days of controlled ovarian hyperstimulation, retrieved oocytes number, IVF results, or problems in treating hydrosalpinx patients prior to IVF. These data may help clinicians choose the best therapy for patients with hydrosalpinx prior to IVF.

Role of inflammatory factors in the etiology and treatment of recurrent implantation failure

Recurrent implantation failure (RIF) is characterized by the absence of implantation after high-grade embryos are transferred to the endometrium by at least three in vitro fertilization cycles. It is one of the most important factors contributing to reproductive failure. After numerous barriers have been overcome to obtain good-quality embryos, RIF causes extreme distress and frustration in women and couples. In recent years, significant progress has been made in understanding how inflammatory factors, which include pro-inflammatory factors, anti-inflammatory factors, chemokines, and other molecules, contribute to RIF. Immunological abnormalities, hypercoagulability, and reproductive diseases are considered potential causes of RIF. In alloimmune disorders, inflammatory factors can affect the success rate of embryo implantation by altering T helper (Th)1/Th2 and Th17/regulatory T cell ratios and causing imbalances of uterine natural killer cells and macrophages. Autoimmune disorders can also lead to RIF. Inflammatory factors also play key roles in RIF-related disorders such as hypercoagulability, chronic endometritis, adenomyosis, hydrosalpinx, and endometriosis. This review focuses on the roles of inflammatory factors in RIF, including immune factors, blood hypercoagulable states, and reproductive diseases such as chronic endometritis, adenomyosis, hydrosalpinx, and endometriosis. It also summarizes the different treatments according to the causes of RIF and discusses the efficacy of sirolimus, peripheral blood mononuclear cells, low-dose aspirin combined with low-molecular-weight heparin, blocking interleukin-22, and gonadotropin-releasing hormone agonists in the treatment of RIF.

Ovarian Response, Pregnancy Outcomes, and Complications Between Salpingectomy and Proximal Tubal Occlusion in Hydrosalpinx Patients Before in vitro Fertilization: A Meta-Analysis

Objectives

Contradictory findings exist in studies comparing salpingectomy and proximal tubal occlusion (PTO) in treating hydrosalpinx patients before in vitro fertilization (IVF). Therefore, this meta-analysis aimed to comprehensively compare ovarian response, pregnancy outcomes, and complications between salpingectomy and PTO in treating these patients.

Methods

Embase, PubMed, and Web of Science were searched to identify relevant articles published from 1980 to August 31, 2020. Eight studies that involve 716 hydrosalpinx patients before IVF were included, among whom 408 patients received salpingectomy and 308 patients received PTO. The data were pooled; the standardized mean difference (SMD) or odds ratio (OR) was calculated.

Results

Proximal tubal occlusion-treated patients had higher fertilization rate (SMD = 0.35, 95% CI: 0.11–0.59), while similar days of controlled ovarian hyperstimulation (COH) (SMD: 0.15, 95% CI: −0.36–0.67) and number of retrieved oocytes (SMD = −0.22, 95% CI: −0.54–0.10) compared with salpingectomy-treated patients. Furthermore, no difference of implantation rate (OR = 1.17, 95% CI: 0.62–2.20), clinical pregnancy rate (OR = 0.82, 95% CI: 0.59–1.15), ongoing pregnancy rate (OR = 0.64, 95% CI: 0.36–1.13), or live birth rate (OR = 0.67, 95% CI: 0.16–2.72) was shown between salpingectomy-treated patients and PTO-treated patients. Additionally, ectopic pregnancy rate (OR = 1.13, 95% CI: 0.21–5.92) and miscarriage rate (OR = 0.88, 95% CI: 0.31–2.48) were similar between salpingectomy-treated patients and PTO-treated patients.

Conclusion

Proximal tubal occlusion exhibits a higher fertilization rate but no obvious benefits on days of COH, number of retrieved oocytes, pregnancy outcomes, and complications over salpingectomy in hydrosalpinx patients before IVF.

ART Outcomes After Hysteroscopic Proximal Tubal Occlusion Versus Laparoscopic Salpingectomy for Hydrosalpinx Management in Endometriosis Patients

The objective of this paper is to compare assisted reproductive technology (ART) cumulative live birth rates after hysteroscopic proximal tubal occlusion and laparoscopic salpingectomy in endometriosis patients, for management of hydrosalpinx. This is an observational cohort study at a university hospital, including all endometriosis patients with hydrosalpinges undergoing ART, between January 2013 and December 2018. The patients underwent either laparoscopic salpingectomy or hysteroscopic proximal tubal occlusion with Essure® when laparoscopy was not an option (extensive pelvic adhesions at exploratory laparoscopy or a history of multiple abdominal surgeries with frozen pelvis). The diagnosis of endometriosis was based on published imaging criteria using transvaginal sonography (TVUS) and magnetic resonance imaging (MRI). Endometriosis patients with hydrosalpinges diagnosed by hysterosalpingography and/or TVUS and/or MRI were included. The primary outcome was the cumulative live birth rate. A total of 104 patients were included in the study; 74 underwent laparoscopic salpingectomy and 30 underwent proximal tubal occlusion with Essure®. The Essure® group had longer infertility durations (58.9 ± 30.0 months vs. 39.5 ± 19.1 months, p = 0.002) and a higher incidence of associated adenomyosis (76.7% vs. 39.1%, p < 0.001) than the salpingectomy group. The cumulative live birth rate was 56.6% after 44 ART cycles in the Essure® group and 40.5% after 99 ART cycles in the salpingectomy group (p = 0.13). In a population of endometriosis patients undergoing ART, women treated by Essure® for management of hydrosalpinx have similar cumulative live birth rates as women treated by laparoscopic salpingectomy.

Scar Pregnancy and Extrauterine Implants

Cesarean scar pregnancy (CSP) is a rare occurrence consisting in the implantation of the embryo within the myometrium of a prior cesarean delivery scar. The CSP could be a dangerous condition for women because of the related complications such as placenta previa or accreta, uterine rupture, and hemorrhage. Therefore, early diagnosis and rapid treatment are crucial. Extrauterine implants or ectopic pregnancy (EP) consists in the implantation of an embryo in a site other than the endometrium of the uterine cavity. It occurs in 1%-2% of all reported pregnancies. The most common extrauterine location is the fallopian tube, which represents 96% of cases. The diagnosis of CSP and EP is based on history, clinical examination, levels of serum β-human chorionic gonadotropin (β-hCG), and ultrasonography findings. In last 20 years, new treatments were developed, varying from medical management, minimally invasive surgical approach and local treatment including systemic or local infusion of metotrexate (MTX), and uterine artery embolization (UAE). UAE has been used widely to control hemorrhage and preserve the uterus and it is considered an affective adjuvant treatment of CSP and EP, especially associated with other therapies.