Valentine Akande

Impact of Chlamydia trachomatis in the reproductive setting: British Fertility Society Guidelines for practice.

Chlamydia trachomatis infection of the genital tract is the most common sexually transmitted infection and has a world-wide distribution. The consequences of infection have an adverse effect on the reproductive health of women and are a common cause of infertility. Recent evidence also suggests an adverse effect on male reproduction. There is a need to standardise the approach in managing the impact of C. trachomatis infection on reproductive health. We have surveyed current UK practice towards screening and management of Chlamydia infections in the fertility setting. We found that at least 90% of clinicians surveyed offered screening. The literature on this topic was examined and revealed a paucity of solid evidence for estimating the risks of long-term reproductive sequelae following lower genital tract infection with C. trachomatis. The mechanism for the damage that occurs after Chlamydial infections is uncertain. However, instrumentation of the uterus in women with C. trachomatis infection is associated with a high risk of pelvic inflammatory disease, which can be prevented by appropriate antibiotic treatment and may prevent infected women from being at increased risk of the adverse sequelae, such as ectopic pregnancy and tubal factor infertility. Recommendations for practice have been proposed and the need for further studies is identified.

Surgery for tubal infertility

BACKGROUNDnSurgery remains an acceptable treatment modality for tubal infertility despite the rise in usage of in vitro fertilisation (IVF). Estimated livebirth rates after surgery range from 9% for women with severe tubal disease to 69% for those with mild disease; however, the effectiveness of surgery has not been rigorously evaluated in comparison with other treatments such as IVF and expectant management (no treatment). Livebirth rates have not been adequately assessed in relation to the severity of tubal damage. It is important to determine the effectiveness of surgery against other treatment options in women with tubal infertility because of concerns about adverse outcomes, intraoperative complications and costs associated with tubal surgery, as well as alternative treatments, mainly IVF.nnnOBJECTIVESnThe aim of this review was to determine the effectiveness and safety of surgery compared with expectant management or IVF in improving the probability of livebirth in the context of tubal infertility (regardless of grade of severity).nnnSEARCH METHODSnWe searched the following databases in October 2016: the Cochrane Gynaecology and Fertility (CGF) Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO; as well as clinical trials registries, sources of unpublished literature and reference lists of included trials and related systematic reviews.nnnSELECTION CRITERIAnWe considered only randomised controlled trials to be eligible for inclusion, with livebirth rate per participant as the primary outcome of interest.nnnDATA COLLECTION AND ANALYSISnWe planned that two review authors would independently assess trial eligibility and risk of bias and would extract study data. The primary review outcome was cumulative livebirth rate. Pregnancy rate and adverse outcomes, including miscarriage rate, rate of ectopic pregnancy and rate of procedure-related complications, were secondary outcomes. We planned to combine data to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). We planned to assess statistical heterogeneity using the I2 statistic and to assess the overall quality of evidence for the main comparisons using GRADE methods.nnnMAIN RESULTSnWe identified no suitable randomised controlled trials.nnnAUTHORS CONCLUSIONSnThe effectiveness of tubal surgery relative to expectant management and IVF in terms of livebirth rates for women with tubal infertility remains unknown. Large trials with adequate power are warranted to establish the effectiveness of surgery in these women. Future trials should not only report livebirth rates per patient but should compare adverse effects and costs of treatment over a longer time. Factors that have a major effect on these outcomes, such as fertility treatment, female partners age, duration of infertility and previous pregnancy history, should be considered. Researchers should report livebirth rates in relation to severity of tubal damage and different techniques used for tubal repair, including microsurgery and laparoscopic methods.

The relationship between serum Chlamydia antibody levels and severity of disease in infertile women with tubal damage.

BackgroundThe study explores the relationship between serum Chlamydia antibody titres (CAT) using the whole-cell inclusion immunoflourescence (WIF) test and severity of tubal damage in infertile women undergoing laparoscopy.MethodsComparisons between the extent of specific lesions, including their severity found at laparoscopy, and CAT levels were analysed in 408 infertile women with tubal damage. CAT levels were assayed using the WIF test.ResultsThere were significant differences in the severity of individual lesions (tubal occlusion, tubal pathology, fimbrial state, extent and type of tubal and ovarian adhesions, type of tubal and ovarian adhesions) for both left and right adnexa in relation to CAT (Pxa0<xa00.0001). The presence and severity of lesions found in one adnexum significantly correlated with the findings on the contra-lateral side (rxa0>xa00.5; Pxa0<xa00.01). The American Fertility Society grades for tubal occlusion and adhesions in the right adnexum did not correlate with CAT.ConclusionsCAT levels are quantitatively related to the severity of tubal damage in infertile women. Wide variations in the severity of lesions observed in relation to CAT were suggestive of broad individual differences in response to chlamydial infection.

The predictive value of the ‘Hull & Rutherford’ classification for tubal damage

Objectiveu2003 This study explores the predictive value for live birth following tubal reconstructive surgery of the ‘Hull and Rutherford’ (H&R) classification system.

Deflation of gastric band balloon in pregnancy for improving outcomes

BACKGROUNDnIn line with the rise in the prevalence of obesity, an increasing number of women of childbearing age are undergoing laparoscopic adjustable gastric banding (LAGB), resulting in an increasing number of pregnancies with a band in place. Currently, there is no consensus on optimal band management in pregnancy. Some clinicians advocate leaving the band balloon inflated to reduce gestational weight gain and associated adverse perinatal outcomes. However, there are concerns that maintaining balloon inflation during pregnancy might increase the risk of band complications and adversely affect fetal development and/or growth as a result of reduced nutritional intake.nnnOBJECTIVESnTo compare maternal and perinatal outcomes for elective gastric band balloon deflation versus intention to maintain balloon inflation during pregnancy.nnnSEARCH METHODSnWe searched the Cochrane Pregnancy and Childbirth Groups Trials Register (30 September 2012) and the Web of Science database (1940 to September 2012).nnnSELECTION CRITERIAnRandomised-controlled trials comparing elective deflation of the gastric band balloon with intention to maintain balloon inflation in pregnant women who have undergone LAGB.nnnDATA COLLECTION AND ANALYSISnTwo review authors independently assessed studies for inclusion.nnnMAIN RESULTSnNo studies met the criteria for inclusion in the review.nnnAUTHORS CONCLUSIONSnTo date no randomised controlled trials exist that compare elective deflation of the gastric band balloon in pregnancy versus intention to maintain balloon inflation. Further research is needed to define the optimum management of the gastric band balloon in pregnancy.

Tubal disease: towards a classification

Tubal disease is a major cause of infertility. The amount of damage can vary greatly in extent, anatomical location and nature. For women with infertility due to tubal disease, prognostication for pregnancy often remains unclear and there is no universally accepted classification. A classification system that reliably distinguishes infertile patients with tubal disease into favourable and unfavourable groups would be useful if subsequent management could depend on this assessment, especially if the classification is able to define which group of patients would benefit most from interventions such as surgery. The progress of IVF questions the contribution of the Fallopian tube to the successful achievement of pregnancy in infertile women. Nonetheless, several studies reveal that severity is the key factor in the determining outcome, and the classifications reviewed in this paper imply that women with tubal disease could be categorized into prognostic groups using a simple classification system based on severity. However, prospective trials are needed to validate and assert the usefulness of any particular classification.