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

Progesterone and Inflammatory Response in the Oviduct during Physiological and Pathological Conditions

Progesterone has been shown to be a potent suppressor of several inflammatory pathways. During pregnancy, progesterone levels increase, allowing for normal pregnancy establishment and maintenance. The dysregulation of progesterone, as well as inflammation, leads to poor pregnancy outcomes. However, it is unclear how progesterone imbalance could impact inflammatory responses in the oviduct and subsequently result in early pregnancy loss. Therefore, in this review, we describe the role of progesterone signaling in regulating the inflammatory response, with a focus on the oviduct and pathological conditions in the Fallopian tubes.

Endometrial cavity fluid is associated with deleterious pregnancy outcomes in patients undergoing in vitro fertilization/intracytoplasmic sperm injection: a retrospective cohort study

Background

The effects of endometrial cavity fluid (ECF) on in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) pregnancy outcomes following embryo transfer (ET) are still controversial. We conducted the present study to investigate whether the presence of ECF in infertile patients scheduled to undergo IVF or ICSI was associated with pregnancy outcomes.

Methods

A retrospective cohort study design was used. Among infertile patients undergoing IVF/ICSI, those with and without ECF were matched 1:1 using propensity score matching (PSM). After ensuring that the baseline levels of the two matched groups were consistent, the pregnancy and obstetrical outcomes of the two groups were compared.

Results

Patients with ECF had significantly lower clinical rates of pregnancy (1,061/1,862, 57% vs. 1,182/1,862, 63.5%; P<0.001), live birth (902/1,862, 48.4% vs. 1,033/1,862, 55.5%; P<0.001), biochemical pregnancy (1,182/1,862, 63.5% vs. 1,288/1,862, 69.2%; P<0.001), and embryo implantation (1,500/3,740, 40.1% vs. 1,661/3,740, 44.4%, P<0.001) than patients without ECF. Also, patients with ECF had a higher incidence of gestational diabetes (17/78, 22% vs. 8/94, 9%, P=0.014). However, there were no differences in gestational weeks at delivery or birth weight between the two groups.

Conclusions

ECF was significantly associated with adverse pregnancy outcomes but showed no significant association with adverse obstetric outcomes (except for gestational diabetes).

Hydrosalpinx functional surgery or salpingectomy? The importance of hydrosalpinx fluid in assisted reproductive technologies

The first IVF baby, Louise Brown, was born in a natural cycle IVF of a woman who had bilateral tubal block making IVF the only option for having a child. The last 3 decades has seen astounding progress in the field of ART. Today thanks to ART, tubal disease and tubal factor infertility is easily overcome. The accepted theory today is that the hydrosalpinx fluid plays a causative role in the reduced pregnancy rate with ART. It is well known that the success of ART for patients with tubal disease with hydrosalpinx is reduced by half compared with patients without hydrosalpinx. Ideal would be removal of a hydrosalpinx by laparoscopic salpingectomy to improve pregnancy rates. However in some cases this is not feasible due to dense pelvic adhesions making access difficult. In such cases it is recommended that even de-linking the tube from the uterus would help in improving the ART outcome. There is suggestion that sonographically visible hydrosalpinges and those affected bilaterally have a poorer prognosis than those seen incidentally at laparoscopy. While there is clinical evidence supporting the causative role of the fluid itself, there is a lack of knowledge as to how the fluid exerts its negative effects. It is generally believed that the fluid holds a key position in impairing implantation potential. The aim of this review is to highlight the importance of identifying hydrosalpinges and its association with reduced fertility outcome using assisted reproductive technologies. Here we have discussed the different options available for the same, and highlighted the current modes of treatment.

Hydrosalpinx and IVF: assessment of treatments implemented prior to IVF

It is well known that the success of artificial reproductive techniques, especially IVF, for patients with tubal pathologies such as hydrosalpinx is reduced by half compared with patients without hydrosalpinx. Notably, there are also substantial increases in both early pregnancy loss and ectopic pregnancies. Alterations in the outcome of these patients generally reflect a detrimental effect of hydrosalpinx. However, although many theories have been published, a single explanation has not yet been found over a period of decades. Therefore, the negative effects of hydrosalpinx have generally been attributed largely to: (i) mechanical effects; (ii) embryo and gametotoxicity; (iii) alterations in endometrial receptivity markers; or dwindled cross talk between embryo-endometrium resulting in hindered implantation, and (iv) direct effect on endometrium, leading to intrauterine fluid formation. On the other hand, the most important question is selection of the preferred treatment option with either surgical or medical therapies. How should hydrosalpinx be managed? Does selection of the surgical method, either proximal obstruction or salpingectomy, depending on patients' clinical findings, differ in outcome, or is routine prophylactic salpingectomy needed? Additionally, the requirement for IVF or intracytoplasmic sperm injection is still controversial in patients with unilateral hydrosalpinx who have been treated with unilateral salpingectomy.

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.

Modulation of trophoblast function by tumor necrosis factor-alpha: a role in pregnancy establishment and maintenance?

OBJECTIVE

Trophoblast differentiation is a critical process for successful implantation and establishment of the human placenta. The aim of this study was to characterize the effect of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) on the expression of markers of trophoblast function and differentiation.

STUDY DESIGN

Human cytotrophoblasts were stimulated with 1 and 10 ng/mL recombinant TNF-alpha or IL-6. Cell viability was determined and conditioned culture media was analyzed by gelatin zymography to assess protease secretion and by enzyme-linked immunosorbent assays to measure production of beta-human chorionic gonadotropin and oncofetal fibronectin.

RESULTS

TNF-alpha increased secretion of urokinase-type plasminogen activator up to 3-fold of basal unstimulated production. Stimulation of cytotrophoblasts with this cytokine also inhibited beta-human chorionic gonadotropin secretion up to 75%. TNF-alpha did not modify the secretion of matrix metalloproteinase-9 and oncofetal fibronectin. IL-6 had no effect on these trophoblast differentiation markers.

CONCLUSION

These results show that TNF-alpha stimulated cytotrophoblasts modulate the expression of differentiation markers, down-regulating the autocrine signals that promote syncytialization, and increasing their invasive capacity through up-regulation of proteases. We suggest that this regulatory mechanism of trophoblast function could play an important role during trophoblast implantation, in pregnancy failure and in the normal and pathologic rupture of fetal membranes.

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.

Effect of human hydrosalpinx fluid on in vitro mouse embryogenesis

OBJECTIVE

Women with hydrosalpinx have an unfavorable pregnancy rate. As one approach to elucidate the effect of hydrosalpinx on uterine tubal functioning, we examined the effect of hydrosalpinx fluid on early embryo development in mice.

METHODS

Hyperovulation was induced in ICR mice, and late 2-cell-stage embryos were harvested 42 hours after administration of human chorionic gonadotropin (hCG). Hydrosalpinx fluid was obtained from patients during surgery after informed consent was obtained. The embryos were cultured in 3 culture fluids: (1) mBWW medium containing 0.3% bovine serum albumin (positive-control medium) (BSA), (2) Ca2+, Mg2+-free phosphate buffered saline (negative-control medium) (PBS), and (3) 100% human hydrosalpinx fluid. The developmental status of the embryos 120 hours after hCG administration was examined.

RESULTS

Embryogenesis from a 2-cell-stage embryo to a blastocyst was observed in 98.3% (118/120) of the embryos cultured in the mBWW medium, in 0% (0/120) of the embryos cultured in PBS, and in 98.3% (118/120) of the embryos cultured in 100% human hydrosalpinx fluid.

CONCLUSION

In the micro-environment of human hydrosalpinx fluid, late 2-cell embryos of ICR mice developed normally to blastocysts. The present results also suggest that non-species-specific embryogenetic factors might be present in human hydrosalpinx fluid.

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.

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.

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.