Oocyte quality and IVF outcome after coasting to prevent ovarian hyperstimulation syndrome

OBJECTIVE:To evaluate, in a large cohort of patients, oocyte quality and IVF outcome after coasting used to prevent ovarian hyperstimulation. SETTING: Retrospective study. PATIENTS: IVF cycles which had reached estradiol serum levels of at least 4,000 pg/mL without being coasted (control group, n = 208), or where coasting was applied (coasted group, n = 157). METHOD: IVF data of coasted cycles were compared with the control group. Within the group of coasted cycles, we also analyzed whether indirect parameters related to coasting had an effect on IVF results. RESULTS: Coasted patients showed higher maximum estradiol levels and greater numbers of large follicles than the control group, but lower oocyte recovery rates. There were no other significant differences between the two groups of patients. Within the group of coasted patients, no significant relation was found between the number of days of coasting, the estradiol level on the day of hCG, or the fall in estradiol and the outcome, whether measured in terms of oocyte quality, pregnancy rate, or incidence of ovarian hyperstimulation. CONCLUSION: Coasting seems to be associated with a reduced oocyte collection rate, especially when the coasting period is prolonged. However, this does not result in reduced oocyte quality. The length of the coasting period and degree of estradiol decrease do not seem to alter the results in terms of pregnancy rates.     

Early laparoscopy after pelvic operations to prevent adhesions: safety and efficacy

Laparoscopy 12 days after 256 consecutive operations for infertility allowed early diagnosis and treatment of postoperative adhesions that might otherwise have jeopardized the result. Despite scrupulous microsurgical techniques, complete absence of adnexal adherences was present in only 31 of 73 (42.5%) patients without initial adhesions and in 15 of 183 (8.2%) patients who had adhesions lysed. New or reformed adhesions usually were easily separable, often without bleeding, and often with much apparent improvement in fimbrio-ovarian anatomy. There were no significant complications and the safety of early postoperative (second-look) laparoscopy seems established. A modification of the 1979 American Fertility Society endometriosis scoring system was used to quantitate adhesions in 38 patients who subsequently underwent an additional (third-look) pelvic procedure. Adhesions were worse as a result of the laparoscopy in no patients, unchanged in 5 patients, and improved in 33 patients; overall, there was a significant reduction in median adhesion scores from 8 at laparoscopy (95% confidence limits of median, 6 to 10) to 2 at final observation (95% limits, 0 to 4; P less than 0.001, rank sum test). Laparoscopy between the time of serosal healing (8 days) and established adhesion fibrosis (21 days) is a safe and effective way of reducing peritoneal adhesions after pelvic operations in young women.     

How to prevent complications of open laparoscopy

Infraumbilical minilaparotomy as a substitute for needle and trocar puncture continues to attract gynecologists for safety reasons. Although the open entry technique should eliminate aortic and iliac vessel injuries, other complications are occurring. In September 1984 a survey of 18 board-certified gynecologists who had performed a total of 10,840 open laparoscopies revealed 18 instances of wound infection and 6 cases of bowel laceration. Some features of surgical technique can minimize the risks of open laparoscopy.     

Hysteroscopic hydrosalpinx occlusion with Essure device in IVF patients when salpingectomy or laparoscopy is contraindicated

Objective

To evaluate, in patients with hydrosalpinges, the effect on in vitro fertilization (IVF) outcome of the insertion by hysteroscopy of an intratubal blocking device, in cases where laparoscopic salpingectomy or laparoscopy was contraindicated.

Study design

A prospective interventional case series study was conducted in fifteen women with unilateral (N = 6) or bilateral hydrosalpinges (N = 9) submitted for IVF. In all of them, laparoscopic salpingectomy was contraindicated. Hysteroscopic insertion of the Essure intratubal device in a consultation room setting was performed. IVF results were compared with those of women where hydrosalpinx was treated by laparoscopic salpingectomy (48 women, 76 cycles).

Results

There were no complications during or immediately after the procedure in any of the patients. There were four pregnancies from 16 embryo-transfers with own oocytes, one spontaneous pregnancy after unilateral Essure insertion, and one pregnancy after oocyte donation. In one case the hydrosalpinx grew and pelvic inflammatory disease developed 6 months after the insertion, requiring bilateral adnexectomy. Although not of statistical significance, IVF pregnancy rates were somewhat lower than in the laparoscopic salpingectomy group, which was attributed to the lower ovarian reserve before Essure insertion.

Conclusion

The hysteroscopic insertion of the Essure intratubal device prior to IVF is a reasonable option in cases where laparoscopic salpingectomy is contraindicated. Larger series are required to assess pregnancy outcome.     

Diagnostic laparoscopy in infertile women with normal hysterosalpingograms

OBJECTIVE: To assess the value of laparoscopy in infertile women with normal hysterosalpingograms, with and without risk factors suggesting pelvic disease. STUDY DESIGN: We retrospectively reviewed 1,022 consecutive charts from a tertiary infertility practice. In 265 women, laparoscopies were performed after normal hysterosalpingograms. RESULTS: Laparoscopies were normal in 136 (51%) women, whereas 129 (49%) had one or more abnormal laparoscopic findings, including minimal or mild endometriosis (n = 85), moderate or severe endometriosis (n = 11), adnexal adhesions (n = 27), subserosal myomas (n = 17), ovarian neoplasms (n = 5), distal phimosis (n = 1) and salpingitis isthmica nodosa (n = 1). Only 7% of cases had findings that might require standard operative laparoscopy or laparotomy, although not all were causally related to infertility. A history of dysmenorrhea or dyspareunia increased the likelihood of detecting endometriosis from 41% to 64% and 69%, respectively. The presence of both symptoms increased the likelihood to 83%. CONCLUSION: In the presence of a normal hysterosalpingogram, laparoscopy identified other pelvic disease in about half of patients. Because most abnormalities were mild, this knowledge can be used to plan a micro-laparoscopic approach for many women, reserving traditional or operative laparoscopy for women with an abnormal hysterosalpingogram or extensive disease following micro-laparoscopy. Alternately, knowledge of the nature and severity of the expected laparoscopic findings might lead to bypassing laparoscopy in favor of assisted reproduction when the perceived benefit of surgical intervention is small.     

IVM is an alternative for patients with PCO after failed conventional IVF attempt

Purpose  

To determine if IVM of oocytes from unstimulated cycle is a treatment option for patients who did not deliver after standard IVF-ET.     

Pregnancy rates after hysterosalpingography with oil- and water-soluble contrast media

Hysterosalpingography can be accomplished with either oil or water-soluble contrast medium. This randomized prospective study compared pregnancy rates in women who had hysterosalpingography with either water- or oil-soluble contrast material and were followed for six months. Fifteen of 60 (25%) patients who received water-soluble dye conceived compared with 14 of 46 (30%) patients in the oil-soluble group, a statistically insignificant difference. Furthermore, no difference in pregnancy rates within each subgroup of fertility diagnosis was detected. Intravasation was more common in patients administered oil-based contrast materials (six of 46 versus one of 60 patients, P = .02), although no serious consequences occurred. No difference in the amount of pain as assessed by pain scoring was experienced by patients in each group. The authors conclude that pregnancy rates are similar after hysterosalpingography with oil- and water-soluble contrast material, during at least the first six months after the procedure.     

子宫输卵管碘油造影和腹腔镜检查对盆腔粘连不孕诊治价值的探讨

目的 比较子宫输卵管碘油造影(HSG)和腹腔镜检查对不同程度盆腔粘连不孕患者的临床诊治价值.方法 选择2004年1月至2006年6月在北京协和医院接受HSG和腹腔镜通液检查的不孕症198例,其中162例腹腔镜下诊断合并不同程度的盆腔粘连,36例无盆腔粘连.根据盆腔粘连评分将盆腔粘连患者分为3组轻度粘连组51例,输卵管99条;中度粘连组47例,输卵管90条;重度粘连组64例,输卵管123条.无粘连组36例,输卵管72条.共检查输卵管384条.结果 HSG与腹腔镜均诊断输卵管通畅的阳性符合率(敏感度)79.0%,两者诊断不通的阴性符合率(特异度)61.6%.随着盆腔粘连严重程度的加剧,HSG的敏感度递减(95.5%,86.3%,73.5%,51.5%),特异度递增(18.2%,34.3%,68.1%,81.5%).各组HSG的敏感度比较差异均无统计学意义(P＞0.05),特异度比较差异均有统计学意义(P＜0.05).HSG对于输卵管形态异常,伞端粘连、积水等病变与腹腔镜下的检查结果 均有70%以上的符合率.结论 HSG对于不同程度盆腔粘连的不孕患者检查的敏感度与特异度有所不同,盆腔粘连越重,敏感度越低,特异度越高;腹腔镜在确诊输卵管疾病的同时,能够发现与改善或去除盆腔粘连等可能导致不孕的因素;如果合并有明确的盆腔粘连病史者,不管HSG结果 如何,应积极进行腹腔镜检查.     

Cerebral embolization and coma after hysterosalpingography with oil-soluble contrast medium

A case of coma due to embolization after HSG, using oil-soluble contrast medium is presented. The patient was in a comatose state 11 days and then spontaneously regained full consciousness. The safety of oil-contrast medium for HSG is questionable.     

State-mandated insurance coverage is associated with the approach to hydrosalpinges before IVF

The aim of this study was to determine whether practice in states with infertility insurance mandates is associated with physician-reported practice patterns regarding hydrosalpinx management in assisted reproduction clinics. A cross-sectional, internet-based survey of 442 members of Society for Reproductive Endocrinology and Infertility or Society of Reproductive Surgeons was performed. Physicians practising in states without infertility insurance mandates were more likely to report performing diagnostic surgery after an inconclusive hysterosalpingogram than physicians practising in states with mandates (RR 1.2, 95% CI 1.1–1.3, P < 0.01). Additionally, respondents in states without mandates were more likely to report that, due to lack of infertility insurance coverage, they did not perform salpingectomy (SPX) or proximal tubal occlusion (PTO) before assisted reproduction treatment (RR 1.4, 95% CI 1.1–1.8, P = 0.01). Finally, respondents in states without mandates were less likely to report that the presence of assisted reproduction treatment coverage determined the urgency with which they pursued SPX or PTO before treatment (RR 0.7, 95% CI 0.5–1.0, NS). These results persisted after controlling for physician years in practice, age and clinic volume. In conclusion, self-reported physician practice interventions for hydrosalpinges before assisted reproduction treatment may be associated with state-mandated infertility insurance.Fallopian tube dysfunction is a known cause of infertility and severe dysfunction is manifested by dilation and occlusion, known as hydrosalpinx. Outcomes with assisted reproductive techniques (ART) are lower when hydrosalpinges are present and while there are several theories for this, reproductive specialist recommend “neutralizing” the tube either by occlusion or removal in order to enhance pregnancy rates. In the United States, coverage for infertility services is not uniform with only 15 states having some legislation requiring infertility benefits. Some states where ART is covered liberally, physicians might have different practice patterns related to the neutralization of hydrosalpinges compared to those who are in non –mandated states. We utilized a survey of over 400 providers in the United States to examine their practice patterns as it relates to hydrosalpinges based on which state they practice in and whether or not that state has mandated coverage of not.     

The significance of preoperative hysterosalpingography and laparoscopy for predicting the pregnancy outcome in patients with a bilateral hydrosalpinx

We analyzed the importance of 3 factors derived from the HSG (nature of the mucosal pattern, diameter of the hydrosalpinx, expandability of the ampulla) and of four factors from the findings at laparoscopy (extent of adhesions, nature of adhesions, thickness of tubal wall and diameter of the hydrosalpinx) for predicting the pregnancy outcome in 98 patients with bilateral hydrosalpinx. Each factor was categorized into 3 scores and each patient was scored for both the right and the left tube, resulting in 6 score-combinations. An association between the pregnancy prospects based on the score-combinations and the actual pregnancy outcome seemed to be present for all factors evaluated, except for the extent of adhesions and the diameter of the hydrosalpinx (laparoscopy). The results further indicate that a favourable score on the nature of mucosal pattern in one or both tubes concurs with good pregnancy prospects. In contrast, the presence of an unfavourable score for most of the other factors in at least one tube is associated with a poor fertility prognosis, regardless of the condition of the other tube.     

Diagnostic and remedial capability of transcervical falloposcopy in conjunction with laparoscopy

Abstract

Study objective: Tubal factor accounts for 25–30% of cases of female infertility. Laparoscopy “Gold Standard” for tubal evaluation. However, it is known that during the initial infection of the fallopian tube mucosal damage occurs, a condition which plays a decisive role in reproduction.

Materials and methods: In this prospective randomized study, 468 infertile women with evidence of fallopian tube disease were included. In this, for 256 patients (group 1) after laparoscopic salpingolysis, salpingostomy we performed an additional step operation transcervical falloposcopy tubal dilatation (TFTD). 212 patients (group 2) produced only laparoscopic salpingolysis, salpingostomy.

Results: As a result, TFTD patency of the fallopian tubes for coaxial catheter was restored in 50 (78%) of 64 tubes with bilateral total occlusion, in 238 (93%) of 254 with partial occlusion of the bilateral, in 14 (58%) of 24 total unilateral occlusion and 26 (92%) of 28 with partial unilateral occlusion. Total number of pregnancies for one year in the first group of patients was 152 (59.3%), in the second 57 (27.1%), of which in the first group 147 –intrauterine pregnancies (57.4%) and in the second – 46 (21.7%).

Conclusion: Falloposcopy surgeon provides good opportunities for the diagnosis and treatment of intralumen lesions. Significant increase in the frequency of uterine pregnancy in the case of an additional step – TFTD during salpingolysis, salpingostomy in patients with tubal factor infertility.     

Diagnostic hysteroscopy to evaluate the cause of abnormal uterine bleeding

Diagnostic hysteroscopy has become an important and valuable tool for the gynecologist in the evaluation of many conditions previously evaluated with blind and inaccurate techniques. The safety, ease of proficiency, and ability to see and diagnose in an office setting have taken much of the guesswork out of office diagnosis. This modality brings the evaluation of many pathologic conditions, including the cause for abnormal uterine bleeding, infertility, and recurrent pregnancy loss, back into a relaxed office environment.