Bolarinde Ola

Ultrasound-guided hydrosalpinx aspiration during oocyte collection improves pregnancy outcome in IVF: a randomized controlled trial

BACKGROUND Hydrosalpinges have adverse effects on IVF outcomes. Salpingectomy is effective in improving outcomes, but it is not always practical or safe. Ultrasound-guided aspiration of hydrosalpinges at oocyte collection is an option for those who develop hydrosalpinges during controlled ovarian stimulation; however, there is no randomized evidence to show whether this practice is effective. METHODS Between October 1999 and June 2003, consenting women of age <or=39 years with an ultrasound diagnosis of hydrosalpinx were randomized before oocyte collection to transvaginal aspiration of hydrosalpinx under antibiotics cover or no aspiration. Third-party randomization was performed using a computer algorithm, and allocation concealment was achieved with opaque sealed envelopes. Outcomes were biochemical and clinical pregnancies, implantation, spontaneous abortion, ectopic pregnancy and pelvic infection rates. Analysis was by intention to treat. RESULTS Sixty-six women were recruited to the trial, 32 to the aspiration group and 34 to the no-aspiration group. Aspiration resulted in a greater biochemical pregnancy rate [14/32 (43.8%) versus 7/34 (20.6%), relative risk (RR) = 2.1 (1.02, 4.6), P = 0.04]. Clinical pregnancy rates for aspiration versus control groups were 31.3% (10/32) and 17.6% (6/34), respectively [RR = 1.8 (0.8, 4.3), P = 0.20]. There were no changes in implantation rate or spontaneous abortion risk with aspiration and no differences between the groups in infection or ectopic pregnancy rates. CONCLUSIONS In women who are identified to have hydrosalpinges during controlled ovarian stimulation during IVF, aspiration of hydrosalpinges during oocyte collection may be effective in improving pregnancy rates (Trial Registration Number: NCT00566956).

The expression of inducible nitric oxide synthase in the human fallopian tube during the menstrual cycle and in ectopic pregnancy

OBJECTIVE To investigate the production of inducible nitric oxide synthase (iNOS) in the fallopian tube (FT) during the menstrual cycle and whether epithelia from FTs bearing an ectopic pregnancy differ from healthy tubes in iNOS expression. DESIGN Prospective study. SETTING Academic unit of reproductive and developmental medicine. PATIENT(S) Fallopian tubes from the different stages of the menstrual cycle (n=12), FTs bearing an ectopic pregnancy (n=15), and FTs from pseudopregnant women (n=6) were collected. INTERVENTION(S) In the pseudopregnant group, patients were injected with hCG in the days leading up to hysterectomy. Samples were processed for immunohistochemistry staining and quantitative reverse transcriptase polymerase chain reaction. MAIN OUTCOME MEASURE(S) To compare iNOS protein and messenger RNA expression between the different groups. RESULT(S) This is the first report on cyclicity in iNOS production by human fallopian tube during the menstrual cycle. The intensity of expression of iNOS was higher in the ectopic pregnancy group compared with the pseudopregnant group (P<0.05). CONCLUSION(S) The cyclicity in iNOS expression by the tube suggests its involvement in fertilization and early embryonic development. Pathologic generation of nitric oxide through increase iNOS production may decrease tubal ciliary beats and smooth muscle contractions and thus affect embryo transport, which may consequently result in ectopic pregnancy.

Diagnostic and therapeutic value of selective salpingography and tubal catheterization in an unselected infertile population

OBJECTIVE To present diagnostic findings and fertility outcome after selective salpingography and tubal catheterization in an unselected infertile population. DESIGN Cohort study. SETTING Tertiary reproductive medicine unit. PATIENT(S) One hundred ten consecutive infertile women. No exclusion criteria were applied. Follow-up ranged from 16 to 54 months. INTERVENTION(S) Selective salpingography and tubal catheterization under fluoroscopic guidance as the primary test for the assessment of the fallopian tubes. MAIN OUTCOME MEASURE(S) Incidence of tubal disease at selective salpingography, therapeutic effectiveness of tubal catheterization, and fertility outcome after the procedure. RESULT(S) Tubal disease was present in 31.4% of the tubes examined. Of tubes proximally blocked at selective salpingography, 52.1% were found to be normal after tubal catheterization. Proximal tubal blockage (bilateral or unilateral) was detected in 34.8% of women. This was reduced to 5.5% after tubal catheterization. Spontaneous conceptions occurred in 21.9% of the women. In total, 36.2% conceived without IVF or ICSI. CONCLUSION(S) Selective salpingography and tubal catheterization can be useful as a primary tubal assessment tool in the investigation of infertility. In cases of proximal tubal blockage, an effective see-and-treat approach can be adopted. More research into the possible therapeutic benefits of the procedure is justified.

The learning curve of selective salpingography and tubal catheterization

OBJECTIVE To determine the effect of increasing experience in fluoroscopically guided selective salpingography and tubal catheterization on radiation doses and screening times, thus establishing a learning curve for the procedure. DESIGN Retrospective case note analysis. SETTING IVF center of an academic teaching hospital. PATIENTS Three hundred sixty-six patients with infertility seen over 3.5 years. INTERVENTION(S) Fluoroscopically guided selective salpingography and tubal catheterization. MAIN OUTCOME MEASURE(S) Reductions in radiation doses and screening times for different categories of selective salpingography and tubal catheterization, expressed as percentage reductions during the study period and reductions per 10 procedures. RESULT(S) During the study period, The median dose of radiation decreased by 62.6%-71.9%, and the median screening time declined by 61.5%-78.5%. Reductions per 10 procedures were 2.5%-4.2% and 2.7%-5%, respectively. CONCLUSION(S) Significant reductions in radiation doses and screening times start early in a clinical teams practice of selective salpingography and tubal catheterization and continue even as trainees are added to the pool of operators.

Cost-effectiveness of recombinant versus urinary follicle stimulating hormone; whose point of view?

Mrs. LR was a 29-year-old housewife referred to our infertility clinic for IVF treatment. She had suffered one miscarriage and three ectopic pregnancies in the past, leading to the loss of both fallopian tubes and the left ovary. The couple had had one unsuccessful fresh cycle of IVF and one of frozen embryo transfer in 1997. On this occasion, they could not afford the cost of another cycle of IVF and had sought the financial support of their local health authority. The health authority advised the use of cheaper drugs as they ‘would not support increased prescribing costs’. At the following visit, the patients wanted clarification on the types and costs of super-ovulation drugs, the relative effectiveness and whether or not the use of a cheaper option would compromise outcome of their treatment. To provide answers on clinical effectiveness, a three-part clinical question was formed: In patients undergoing assisted conception, will recombinant FSH lead to a better pregnancy rate than urinary FSH? The Cochrane Library, Medline and Embase were searched, in addition to a hand search of recent journals for publications that were not yet indexed. The best and most recent evidence, the meta-analysis by Daya and Gunby (1), was critically appraised (2). Cost effectiveness was subsequently derived from their data. The limitation of our approach is that cost effectiveness was based on clinical pregnancy rate alone, and not on adverse outcomes as these were not measured in Daya and Gunby’s paper. Complication rates are, however, generally similar (3). The couple were told of the two main types of FSH in use in our clinic. Recombinant FSH (e.g. Gonal F. Serono Hertz UK), which is pure, lacks LH activity and is highly efficacious; and the highly purified urinary derivative (e.g. Metrodin HP. Serono Hertz, UK), also lacking LH activity and protein contaminants, but considerably cheaper. The paper by Daya and Gunby (1) was a rigorously conducted meta-analysis of a homogenous pool of randomized controlled trials, comparing effectiveness of recombinant (rFSH) with urinary FSH (uFSH). The overall clinical pregnancy rates using fixed effect model were 29.8% and 26.1%, respectively. The risk difference was 3.7% (95% CI 0.5 to 6.9),

Recombinant or urinary follicle-stimulating hormone? A cost-effectiveness analysis derived by particularizing the number needed to treat from a published meta-analysis.

OBJECTIVE To demonstrate that particularizing pooled results of a meta-analysis can derive incremental cost effectiveness of superovulation with recombinant follicle-stimulating hormones (rFSH) vs. the highly purified urinary form (uFSH) for assisted conception. DESIGN A retrospective study. SETTING An assisted conception unit in the United Kingdom. PATIENT(S) One hundred forty-five fresh in vitro fertilization (IVF) and 58 fresh intracytoplasmic sperm injection (ICSI) cycles. INTERVENTION(S) rFSH vs. uFSH. MAIN OUTCOME MEASURE(S) Incremental cost-effectiveness (i.e., cost needed to treat, or CNT) and budget-impact analyses of rFSH vs. uFSH. RESULT(S) In women less than 30 years old, the clinical pregnancy rate was 37.7% (95% CI 24.8%-52.1%), the particularized number needed to treat (pNNT) was -19, and the cost needed to treat was 5070.51 pounds sterling (3660.53 pounds sterling to 7619.32 pounds sterling). For the 30- to 35-year-old age group, the clinical pregnancy rate was 29.9% (95% CI 20.0%--41.4%), the particularized number needed to treat was -24, and CNT was 7335.59 pounds stering (5284.11 pounds sterling to 10,941.22 pounds sterling). For the 36- to 40-year-old age group, the clinical pregnancy rate was 30.6.0% (95% CI 19.6%--43.7%), the particularized number needed to treat was -23.0, and the CNT was 8569.67 pounds sterling (5998.70 pounds sterling to 13,413.24 pounds sterling). CONCLUSION(S) The CNT and thus the budget impact analyses (the extra number of cycles that can be funded by the CNT) both increase directly with age of the patient, and inversely with the clinical pregnancy rate.

Modification of the coaxial technique for selective salpingography with measurement of tubal perfusion pressures

This article describes the use of the fallopotorque catheter system for transcervical selective salpingography and tubal catheterization under fluoroscopic guidance for the diagnosis and treatment of obstruction of the proximal Fallopian tube. The technique of tubal perfusion pressure assessment during the procedure, using the same catheter system, is also described. The relative advantages of this method of selective salpingography and tubal catheterization are then discussed in the background of previously described techniques.

Long-term fertility prognosis following selective salpingography and tubal catheterization in women with proximal tubal blockage

BACKGROUND The possibility of conception following selective salpingography and tubal catheterization is believed to decline sharply a few months after the procedure. This observation may be due to the relatively small number of patients and short follow-up of previous studies. Furthermore, couples with other causes of infertility apart from proximal tubal blockage have usually been excluded. METHODS Survival analysis of conceptions of 218 consecutive infertile women with proximal tubal blockage who underwent selective salpingography and tubal catheterization was performed. There were no exclusion criteria. Follow-up ranged from 16 to 56 months. RESULTS A total of 47.2% of spontaneous conceptions and 43.2% of all conceptions, apart from those achieved by IVF or ICSI treatments, occurred after the first 12 months following selective salpingography and tubal catheterization. The decline in the possibility of pregnancy during the study period (conception hazard rate) was only minimal. CONCLUSIONS In a population of infertile women with proximal tubal blockage, a significant proportion of conceptions occur after the first 12 months following selective salpingography and tubal catheterization. The presence of any additional causes of infertility in the couple should not be regarded as an absolute contraindication to the procedure.