Fertility success rates in patients with secondary infertility and symptomatic cesarean scar niche undergoing hysteroscopic niche resection

Abstract

Cesarean-induced niche can cause symptoms such as abnormal postmenstrual bleeding, pain, and associated infertility. Although hysteroscopic niche resection is generally considered an effective treatment to control abnormal uterine bleeding, the impact of surgical resection on fertility outcomes is still uncertain. In the present study, we aimed to evaluate the fertility outcomes of symptomatic patients following hysteroscopic niche resection. The design in this retrospective cohort study is Canadian Task Force classification II-2 and it is carried out in a tertiary medical center (Tel-Hashomer) and a private medical center (Herzliya), both in Israel. We included all patients who underwent a niche resection between 2011 and 2015 following at least one year of infertility. From 2011 to 2015, 39 patients with a symptomatic niche and secondary infertility were treated by hysteroscopic niche resection. The patients’ mean age was 37.2 (34–41) years, mean number of gestations was 7.04 (1–16), and mean parity 5.1 (1–14). The mean number of previous cesarean sections was 3.4 (1–6). Before the surgery, 32 patients attempted and failed to conceive spontaneously and seven patients underwent in vitro fertilization (IVF) treatment and failed. One year after the hysteroscopic resection, 18 patients conceived (14 spontaneously and four following IVF), leading to a cumulative pregnancy rate of 46.15%. Among the patients who failed to conceive after at least two IVF cycles prior to the hysteroscopic resection, 42.8% conceived following surgery (three patients out of seven). Hysteroscopic niche resection should be considered an effective treatment in patients suffering from secondary infertility.

Précis

Hysteroscopic niche resection is a safe option for patients with symptomatic secondary infertility, resulting in acceptable fertility rates.     

Hysteroscopic findings in women with primary and secondary infertility due to genital tuberculosis

Objective

To evaluate hysteroscopic findings of infertile women with genital tuberculosis.

Method

A retrospective study of the records of 94 women who underwent diagnostic hysteroscopy for infertility at All India Institute of Medical Sciences, New Delhi, India. Genital tuberculosis was diagnosed by laboratory studies of an endometrial biopsy and/or laparoscopic findings.

Results

For women with primary or secondary infertility, respectively, the hysteroscopic findings were normal in 15 (20.5%) vs 4 (9%) cases; and adhesions were grade 2 in 11 (15.1%) vs 3 (14) cases, grade 2a in 0 vs 1 (1.4%) cases, grade 3 in 11 (15.1%) vs 9 (42.9%) cases, grade 3b in 6 (8.2%) vs 0 cases, and grade 4 in 28 (38.4%) vs 2 (9.5%) cases.

Conclusion

Genital tuberculosis causes significant pelvic morbidity due to uterine adhesions and infertility.     

Combined diagnostic approach of laparoscopy and hysteroscopy in the evaluation of female infertility: results of 612 patients

AIM: To clarify the role of a combined diagnostic approach using laparoscopy and hysteroscopy in the evaluation of female infertility in developing countries. METHODS: In a prospective study, 612 consecutive infertile women underwent complete fertility evaluation at a tertiary university infertility clinic: 300 complained of primary infertility, 221 of secondary infertility, and 91 were requesting reversal of a previous tubal ligation. All the patients were examined by simultaneous combined laparoscopy and hysteroscopy as a part of their routine infertility evaluation. Focused hysteroscopic evaluation of the region of utero-tubal junction was attempted. RESULTS: Laparoscopy was successful in 608 and hysteroscopy in 597 patients. The most frequent pathologies detected hysteroscopically in the infertile group were adhesive in nature and believed to be post-traumatic and/or post-phlogistic. The number of intrauterine abnormalities found by hysteroscopy was significantly greater than by hysterosalpingography. The rate of diagnosis of significant lesions by laparoscopy of 64.3% rose to 76.6% when the hysteroscopic findings were included. A significant number of women with secondary infertility had abnormal hysteroscopic findings when compared to either women with primary infertility or those requesting sterilization reversal. Hysteroscopic evaluation of the region of utero-tubal junction revealed significant lesions believed to have caused infertility in comparison with those requesting sterilization reversal. CONCLUSION: The combined diagnostic approach of laparoscopy and hysteroscopy is recommended in the evaluation of female infertility in communities where the risk of pelvic infections is great.     

Hysteroscopic metroplasty in patients with a uterine septum and otherwise unexplained infertility

Objective

To evaluate the reproductive outcomes of patients with a uterine septum and otherwise unexplained infertility who underwent hysteroscopic metroplasty, and to compare them with those of patients with the same diagnosis who did not have hysteroscopic metroplasty.

Methods

The present retrospective study included 127 patients with diagnosis of a uterine septum and otherwise unexplained infertility. The reproductive outcomes of 102 patients who underwent hysteroscopic metroplasty (group 1) and 25 patients who rejected the operation (group 2) were compared.

Results

Of the 102 patients who underwent hysteroscopic metroplasty, 44 (43.1%) were able to achieve pregnancy, as compared with 5 (20%) of the 25 patients who did not undergo the operation (P = 0.03). The abortion rate was 11.4% (5/44) in group 1, compared with 60% (3/5) in group 2 (P = 0.02). The live birth rate was 35.3% (36/102) in group 1, as compared with 8% (2/25) in group 2 (P = 0.008).

Conclusions

The results indicate that hysteroscopic metroplasty improves reproductive outcome for patients with a uterine septum and otherwise unexplained infertility.     

A prospective comparative study between hysterosalpingography and hysteroscopy in the detection of intrauterine pathology in patients with infertility

AIM: To investigate the accuracy of hysterosalpingography (HSG) in comparison to hysteroscopy in the detection of intrauterine pathology in patients with infertility, where hysteroscopy is the gold standard. METHODS: A prospective, comparative study included 336 patients undergoing both HSG and diagnostic hysteroscopy. Main outcome measures were sensitivity, specificity, positive and negative predictive value, and accuracy rate of HSG. RESULTS: Intrauterine abnormalities were shown on HSG in 286 patients and confirmed in 200 at hysteroscopy. Contrarily intrauterine lesions were detected by hysteroscopy in 4 out of 50 patients in whom HSG were normal. The most common intrauterine finding of 336 patients on hysteroscopy were intrauterine adhesions (IUA) (74), followed by endometrial polyps (56), and submucous myoma, 26 patients. Statistical analysis revealed that HSG in the detection of intrauterine pathology had a sensitivity of 98.0%, specificity of 34.9%, positive predictive value of 69.9%, negative predictive value of 92.0%, and accuracy rate of 73.2% with false-positive and false-negative rates of 30.1% and 8.0%, respectively. The common incorrect diagnoses of HSG were misdiagnosing a condition of cervical stenosis as severe IUA in 24 patients, endometrial polyps as submucous myoma in 22 out of 50 patients, and submucous myoma as endometrial polyps in 12 out of 72 patients. CONCLUSIONS: Hysterosalpingography is still a useful screening test for the evaluation of the uterine cavity. If a hysterogram demonstrates intrauterine abnormalities, hysteroscopy should be considered to make a definite diagnosis and treatment. Both procedures should be complementary to each other.     

Decidual polyps are associated with preterm delivery in cases of attempted uterine cervical polypectomy during the first and second trimester

Objective: To clarify which types of cervical polyp removed during the first and second trimester are associated with the risk of spontaneous abortion and preterm delivery.

Methods: Pregnant females who underwent attempted polypectomy of cervical polyps during pregnancy and delivered singleton infants between 2005 and 2011 were evaluated. The clinical courses and outcomes of preterm delivery after polypectomy stratified according to the pathologic diagnosis of the polyps were retrospectively reviewed. The removed polyps were classified into decidual polyps and endocervical polyps.

Results: The pathological diagnoses included 41 decidual polyps and 42 endocervical polyps. No malignant polyps were found. The removal of decidual polyps during pregnancy carried a higher risk of spontaneous abortion (12.2% versus 0%, p?=?0.026) and preterm delivery (34.2% versus 4.8%, p?=?0.001) than that of endocervical polyps. According to the multivariate logistic regression analysis, risk factors for preterm delivery before 37 weeks’ gestation were the presence of decidual polyps and a history of preterm delivery.

Conclusions: The risk of abortion and preterm delivery associated with polypectomy during pregnancy is greater in patients with decidual polyps. It might be safer not to remove cervical polyps during pregnancy, except in cases in which the polyps are suspected to be malignant.     

Clinical characteristics and pregnancy outcomes of infertile patients with endometriosis and endometrial polyps: A retrospective cohort study

ObjectiveThe aim of this study was to discuss the clinical characteristics and the prognosis of surgically diagnosed endometriosis complicated by endometrial polyps and investigate the association between pregnancy outcomes during subsequent pregnancies.Materials and methodsFrom January 2013 to December 2016, 1263 infertile patients were enrolled in the study. We identified 451 patients with endometriosis, and divided them into a polyp group (n = 204) and a non-polyp group (n = 247) based on whether or not they were associated with endometrial polyps. Postoperative clinical pregnant women (n = 82) among the polyp group were then classified into a study group and a control group composed of those undergoing a singleton pregnancy (n = 164) who delivered during the same time period. Clinical statuses and complications during pregnancy and delivery were collected from hospitals and by telephone interviews and surveys through the mail.ResultsThe prevalence rate of endometriosis infertile group was obviously higher than the non-endometriosis infertile group ([45.23%; 204/451] versus [17.12%; 139/812]). Women suffering from stage 1 to 4 endometriosis had a 42.44% (73/172), 40.69% (59/145), 55.89% (38/68) and 51.52% (34/66) occurrence rate of endometrial polyps, respectively. The frequency of endometrial polyps for stage 3 and 4 patients was obviously higher than that of stage 1 and 2 patients ([53.73%; 72/134] versus [41.64%; 132/317]). Moreover, the occurrence rate of deep infiltrating endometriosis (DIE) was 57.81% (37/64), which was obviously higher than that of ovarian endometriosis (42.42%; 98/231) and peritoneal endometriosis (44.23%; 69/156). Of the 204 women diagnosed with posterior endometrial polyps, 89 became pregnant, 7 pregnancies ended in a spontaneous abortion, and 82 successfully delivered a baby. The clinical pregnancy rate of patients in stages 1 and 2 was wholly higher than that of patients in stages 3 and 4 ([48.70%; 56/115] versus [37.71%; 26/82]). The postsurgical pregnancy status of patients suffering from peritoneal endometriosis was slightly better than those with ovarian or DIE, but differences were not statistically significant (P = 0.626). We also found that the pregnancy rate was statistically elevated in patients whose EFI scores range from 7 to 10. When compared to the control group, women with endometriosis and endometrial polyps had a higher risk of their pregnancy being complicated by placenta previa (13.41%) and cesarean delivery (59.76%).ConclusionPatients with endometriosis have a higher frequency of endometrial polyps. We found that a combined hysteroscopy and laparoscopy surgical procedure is an effective way to increase pregnancy rates. Different endometriosis stages and types in patients were associated with clinical pregnancy and spontaneous abortion rates. Women affected by both endometriosis and endometrial polyps have an independently elevated risk of placenta previa and cesarean delivery during pregnancy.     

Ubiquitin-specific protease (USP26) gene alterations associated with male infertility and recurrent pregnancy loss (RPL) in Iranian infertile patients

Background and purpose

The human X chromosome is enriched with testis-specific genes that may be crucial for male fertility. Mutations in USP26 gene have been proposed to be associated with male infertility. Moreover, the importance of the ubiquitin pathway during different stages of mammalian fertilization and even embryo development has been addressed. Some mutations and haplotypes on this gene have been proposed to be associated with male infertility. In this study, five different mutations on USP26 were investigated: 1737 G > A, 1090 C > T, 370-371ins ACA, 494 T > C and 1423 C > T.

Methods

The study included 166 infertile men with non-obstructive azoospermia, 72 male partners of couples who had previously experienced ≥3 clinical first trimester spontaneous abortions and 60 fertile men. Besides family history of reproduction, hormonal evaluation and semen analysis were performed. DNA was extracted from blood samples. PCR-SSCP, PCR-RFLP and PCR Product Cloning methods were used and resumed by sequencing to insure about the mutations. Moreover, USP26 gene expression was studied by Real-Time PCR after RNA extraction followed by cDNA synthesis from 24 testis biopsies in obstructive and non-obstructive azoospermia patients.

Results

The results indicate that there is a haplotype between three observed mutations in Iranian population include: 370-371insACA, 1423C > T and 494 T > C. This haplotype was seen in control group as well. Surprisingly, total frequency of mutations in men with history of idiopathic RPL and azoospermic cases were significantly higher than that of in control groups (p < 0.05). Serum testosterone concentrations and testicular volume did not differ in the mutation positive group compared with the non-mutation group. About the USP26 gene expression, there is a significant difference between the expression levels of obstructive azoospermia, complete maturation arrest samples and SCO samples (P < 0.05).

Conclusions

According to our results, the USP26 gene may play an important role in male reproduction. The alterations of this gene may be involved in male infertility and RPL in Iranian population and may negatively affect testicular function.     

Single-nucleotide polymorphisms in the lysyl oxidase-like protein 4 and complement component 3 genes are associated with increased risk for endometriosis and endometriosis-associated infertility

This study was conducted to assess genetic associations with endometriosis in a Puerto Rican population. Statistically significant differences in the allelic frequencies and genotype distribution of genetic variants in lysyl oxidase-like protein 4 (LOXL4) and complement component 3 (C3) were documented in patients with endometriosis-associated infertility versus controls, and in patients with endometriosis versus controls, respectively. In women who have the risk genotype at both single-nucleotide polymorphisms, the estimated risk for endometriosis nearly doubled.     

Nitric oxide donors increase the pregnancy rate in patients with unexplained infertility undergoing clomiphene citrate stimulation and intrauterine insemination: a randomized controlled pilot study

This study evaluated the effects of nitric oxide donor’s treatment on the pregnancy rate and uterine blood flow in patients with unexplained infertility undergoing clomiphene citrate stimulation and intrauterine insemination. A total of 120 patients were randomly allocated to a control group who received 100?mg clomiphene citrate daily from day 5 to 9 of cycle plus placebo vaginal tablets, and a study group received clomiphene citrate plus isosorbide mononitrate 10?mg vaginal tablets. Vaginal ultrasound was done before treatment and every other day starting from day 12 of cycle to count mature follicles and ovulation was triggered by IM injection of 10 000?IU hCG when one follicle measured 18?≥?mm followed by intrauterine insemination after 36?h. The endometrial thickness, uterine arteries resistance and pulsation indices, and endometrial vascular flow and vascular flow indices were measured before treatment and at day of hCG injection. Results were analyzed after one cycle treatment using the Mean?±?SD, the Student t test and the Fisher Exact test. Significant result was considered at p values?<0.05. The study group had significant higher pregnancy rate/cycle, higher endometrial and lower uterine artery blood flow indices (p?相似文献   

Low follicular fluid IL-6 levels in IVF patients are associated with increased likelihood of clinical pregnancy

Purpose  

Relationships between follicular fluid levels of IL-6 with ovarian response and clinical pregnancy were evaluated in IVF-ET cycles.     

Placental site trophoblastic tumor in a patient with secondary infertility and radiological findings consistent with a leiomyoma: a case report

Placental site trophoblastic tumor (PSTT) is the rarest form of gestational trophoblastic diseases. We report a 40-year-old woman who presented initially after a year of secondary infertility with prolonged menstrual flow. Her last pregnancy ended in a suction dilation and curettage at 8 weeks' gestation for a missed abortion. A hysterosalpingogram revealed a solid 5 x 4.5 cm filling defect impinging on the endometrial cavity suggestive of a submucosal leiomyoma. A vaginal sonogram confirmed the findings. The patient underwent a laparotomy for excision of the 5-cm friable, necrotic mass that was performed by curetting. Pathologic examination of the specimen revealed sheets of intermediate trophoblastic cells characterized by large polyhedral cells and positive human placental lactogen staining consistent with PSTT. The patient eventually underwent total abdominal hysterectomy 4 weeks later with no evidence of residual tumor on histologic examination.     

Improved in vitro fertilization success and pregnancy outcome with autologous platelet-rich plasma treatment in unexplained infertility patients that had repeated implantation failure history

Repeated implantation failure (RIF) due to suboptimal endometrial lining is a major challenge in reproductive medicine. The study aims to evaluate effect of intrauterine platelet-rich plasma (PRP) treatment on frozen-thawed embryo transfer (FET) cycles in patients whose endometrium was unable to achieve optimal lining in unexplained infertility patients with history of RIF. We retrospectively analyzed the charts of a total of 302 cycles performed in 273 patients attending Diyar Life ART Centre between January 2014 and January 2017. After excluding 232 cycles, we compared pregnancy outcomes of 34 patients who had suboptimal endometrial lining and underwent PRP?+?FET and 36 patients who had optimal endometrial lining and underwent only FET. We observed that, endometrial thickness was higher after 48?hours from PRP when compared to endometrial thickness before PRP (10?mm vs. 6.25?mm, p?<?.001). Clinical pregnancy rate, and importantly live birth rate were also significantly higher in PRP group than the control group. Based on this information, we showed that intrauterine autologous PRP infusion is a safe, inexpensive adjuvant treatment for optimizing endometrium especially in patients with RIF history and intrauterine PRP infusion improved not only endometrial lining but also in vitro fertilization success and pregnancy outcome.