Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Columbia Presbyterian Medical Center, College of Physicians and Surgeons, Columbia University, PH 1628, 622 West 168th Street, New York, NY 10032, USA
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Abstract |
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Key words: : hydrosalpinx/implantation/in-vitro fertilization/oocyte donation
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Introduction |
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Prior studies examining the effect of hydrosalpinges on IVF cycles have employed autologous oocytes. Using a donor oocyte model we sought to control for confounding variables, such as ovarian and uterine senescence, male factor, embryo quality and number, and the ovarian stimulation protocol with its effect on the endometrium. In this manner we effectively isolated the intrauterine environment so as to analyse early implantation events more accurately.
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Materials and methods |
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Oocyte donors underwent ovarian stimulation with follicle stimulating hormone (FSH) and were monitored by transvaginal ultrasound and serum oestradiol concentrations (Sauer, 1995). When the follicles reached 1820 mm, human chorionic gonadotrophin (HCG) was given to trigger ovulation. Thirty-six hours later follicles were aspirated transvaginally under ultrasound guidance. The oocytes were then incubated with spermatozoa. Fertilization was documented, and resulting embryos were transcervically transferred after 2 or 3 days to the recipient's uterus. Recipients were carefully synchronized with the donors to ensure the endometrium was appropriately primed for implantation. Synchronization was achieved with exogenous oestrogen and progesterone supplementation. Nine and 12 days after embryo transfer the patient was tested for pregnancy with serum HCG.
The two study groups were analysed for donor and recipient age, number and grade of embryos transferred. Measured outcomes included gross pregnancy rates (a positive ß-HCG) and ongoing pregnancy rates (a documented fetal heart rate), as well as implantation, miscarriage, and ectopic pregnancy rates. The embryo implantation rate included only known intrauterine pregnancies. The ongoing pregnancy rate included only intrauterine pregnancies progressing beyond 12 weeks gestational age.
Statistics were performed with the SPSS statistical package. 2 and Fisher's t-test were used. Significance was defined as a P value < 0.05.
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Results |
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Discussion |
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This study is unique in using a donor oocyte model to focus on the intrauterine environment. This model allows the dissociation of the donor's gametogenesis and steroidogenesis from the recipient's inherent endometrial receptivity and has been employed before to study isolated parameters that affect IVF outcome such as male factor (Gallardo et al., 1996) and ovarian and uterine senescence (Sauer, 1997
). Because extrauterine factors were controlled for in this study, the adverse events appear to be mediated through alterations of the recipient's intrauterine environment.
The early survival of embryos and their ability to express HCG does not appear to be impaired in our study. In fact the presence of two ectopic gestations in the hydrosalpinx group underscores the notion that the tubal fluid itself is not embryotoxic. Deleterious effects are most apparent after weeks of observation, not days, which may reflect chronic endometrial changes rather than acute embryotoxic causes.
In the past we encountered few recipients with hydrosalpinges. More recently the indications for donor IVF have been expanded to include poor responders (Remohi et al., 1993) and failed IVF (Burton et al., 1993
). Thus, we are noting a larger percentage of hydrosalpinges in this population.
This study confirms the deleterious effects of hydrosalpinges on IVF pregnancy rates. This effect is noted after weeks and suggests a chronic rather than acute process, which may reflect a chronic alteration of the endometrium rather than an embryotoxic effect of the tubal fluid. In our practice, patients are offered salpingectomy to remove the source of the noxious fluid. Although Shelton et al. (Shelton et al., 1996) have reported improved IVF outcome after salpingectomy, this approach still awaits controlled randomized trials to prove efficacy. Simply removing diseased Fallopian tubes may not reverse the chronic endometrial changes that lead to this phenomenon. Freeman et al. (Freeman et al., 1998
) also noted an improvement in pregnancy outcome after salpingectomy, although a significant impairment of implantation remained. In addition, embryos that were not transferred were at greater risk of growth arrest and degeneration, suggesting a deleterious effect of the hydrosalpinx on the ovary as well. One possible alternative to salpingectomy is aspiration of the hydrosalpinx prior to IVF, which has shown benefit in some small series of patients (Russell et al., 1991
; Van Voorhis et al., 1998
).
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Notes |
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1 To whom correspondence should be addressed
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References |
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Submitted on July 3, 1998; accepted on December 2, 1998.