Spyros Papaioannou

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).

Tubal evaluation in the investigation of subfertility: A structured comparison of tests

Fallopian tube obstruction is thought to play a role in 12% to 33% of subfertile couples. Assessing the patency of the fallopian tubes is, therefore, an important part of the work-up of a subfertile couple. There are several tests available for this purpose, including hysterosalpingography, laparoscopy and dye test, selective salpingography and hysterosalpingo-contrast sonography (Table 1). Each one of these tests differs in interand intra-observer reliability, diagnostic accuracy to predict blockage or other tubal disease, the prognostic information for treatmentindependent pregnancy, potential complications and costs. Moreover, some of these tests would allow assessment of the possible functioning of the tubes (e.g. measurement of tubal perfusion pressures during selective salpingography), evaluation of other pelvic pathology that may have an impact on fertility (e.g. laparoscopy to assess for endometriosis) or improve pregnancy rates in their own right (e.g. oil-based hysterosalpingography). Currently, there is a wide variation in the choice, combinations and ordering of tubal evaluation tests in different assisted conception units. While there could be several reasons for such variation in practice, one reason may be a lack of collated information that allows an easy comparison of the available tests. We, therefore, reviewed tubal evaluation tests for their interand intra-observer reliability, accuracy to predict tubal blockage and disease, prognostic value for treatment-independent pregnancies, effectiveness to improve pregnancy outcome and possible complications. We limited our review to visual tests only—non-visual tests such as chlamydial antibody testing were not considered in this review.

Anovulation with or without PCO, hyperandrogenaemia and hyperinsulinaemia as promoters of endometrial and breast cancer.

The relationship of infertility, endocrinology and cancer has become clearer in recent years. Polycystic ovaries (PCO) increase the risk of endometrial cancer. Prolonged amenorrhoea, therefore, should be prevented in such cases with the use of cyclical progestogens, in order for regular withdrawal bleeds to be induced and the endometrium protected from long-term unopposed oestrogen stimulation. There is no secure evidence base on which a relationship between PCO and breast cancer can be based. No specific breast screening for women with PCO is, therefore, recommended. Hyperandrogenaemia and hyperinsulinaemia are conditions whose significance in terms of increasing both endometrial and breast cancer risks is increasingly recognised. The exact mechanism with which they influence carcinogenesis is still far from clear. Whether they act in isolation or as expressions of the common background of the metabolic syndrome - in interaction with other components of this syndrome - is still the subject of research.

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.

Tubal assessment tests: still have not found what we are looking for

Interest in tubal assessment is as old as interest in fertility and infertility. The Fallopian tube is a particularly complex structure and, as such, an ideal method for its clinical assessment is very difficult to obtain. As a result, a number of different methods have been suggested. Some of these methods are more complementary to each other rather than potential substitutes for one another. Some have been used for many years with a clear evidence base for their performance as diagnostic tests. For other, relatively new tests, very little evidence about their performance is available. Research is moving from a purely anatomical approach (are the tubes open or blocked?) to encompassing functional enquiry (are the open tubes functional and, if not, are there interventions with which fertility performance can be improved?). The available evidence, or lack thereof, for the most commonly used tubal assessment tests is reviewed in this paper. Many questions remain, which, despite the increasing success of IVF, will continue to challenge and stimulate specialists and the public, who are interested in ways to maximize spontaneous as opposed to assisted fertility.

Obstetric and neonatal outcomes for women with reversed and non-reversed type III female genital mutilation

To record and compare obstetric and neonatal complication rates in women with reversed and non‐reversed type III female genital mutilation (FGM).

The role of selective salpingography and tubal catheterization in the management of the infertile couple.

Purpose of review This review is intended to update the reader about recent developments in the field of selective salpingography and tubal catheterization, to offer an interpretation of the information presented and to suggest further research links. Recent findings The measurement of tubal perfusion pressures at selective salpingography and tubal catheterization has offered a new dimension in the evaluation of the fallopian tube. A classification of infertile women based on tubal perfusion pressures is presented, and this is correlated with the possibility of spontaneous fertility, thus giving selective salpingography and tubal catheterization a prognostic profile in addition to diagnostic and therapeutic functions. Experience derived from the use of the technique in unselected infertile women (i.e. not with proximal tubal blockage) is presented. The use of selective tube catheterization for sterilization purposes joins the mainstream with the publication of the encouraging results of a multinational trial. The debate on the validity of the diagnosis of proximal tubal blockage is enriched by the suggestion that simply rotating the patient during hysterosalpingography will resolve most cases of the condition. The fertility gain by single-tube recanalization in women with unilateral proximal tubal blockage is given further support. The use of oil-based media for selective salpingography and tubal catheterization is discussed. A hypothesis on the pathophysiology of proximal tubal blockage is presented. Summary The evidence clearly supports the use of selective salpingography and tubal catheterization for infertile women with proximal tubal blockage. The potential of the technique to play a wider role in the management of infertility is demonstrated by recent research.

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.

Spontaneous disappearance of a normal adnexa associated with a contralateral polycystic-appearing ovary.

BACKGROUND Absence of the adnexa may be congenital or acquired. However, the etiology is often uncertain. CASE A 27-year-old woman presented with a 3-year history of subfertility. Her irregular menstruation was associated with acne vulgaris, alopecia, and elevated body mass index. Transvaginal ultrasonography of the pelvis showed a normal uterus, a normal right ovary, but a polycystic-appearing left ovary. A hysterosalpingogram demonstrated a normal uterine cavity, prompt filling and spilling of contrast material from the left fallopian tube, but no filling on the right. Subsequent laparoscopy showed an unexpected absence of right adnexa and presence of a solitary rounded free-floating mass enshrouded in the omentum. She did not have a history of abdominal pain or surgery. CONCLUSION The evidence suggests that the patient might have had an asymptomatic infarction of the right adnexa.

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),