Nahed Hammadieh

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).

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),