1 Pediatric and Reproductive Endocrinology Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 2 Reproductive Medicine Associates of New Jersey, Morristown, NJ and 3 Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Walter Reed Army Medical Center, Washington, DC, USA
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Abstract |
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Key words: cancellation rates/endometrium/fluid/hydrosalpinx/IVF
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Introduction |
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Appropriate endometrial growth and differentiation during IVF cycles are important variables that contribute to IVF success (Noyes et al., 1995; Rinaldi et al., 1996
; Oliveira et al., 1997
; Sharara et al., 1999
; Weissman et al., 1999
; De Geyter et al., 2000
). While the importance of endometrial thickness during ART cycles has been investigated, the significance of ECF remains unclear. A few studies involving low numbers of patients have reported the development of ECF in patients undergoing ART. Mansour et al. first described endometrial fluid collections in three patients with hydrosalpinges and suggested that the fluid might hinder embryo implantation (Mansour et al., 1991
). In 1996, Anderson et al. studied 38 patients with hydrosalpinges who were treated with IVF (Anderson et al., 1996
). In their report, three patients developed uterine fluid before human chorionic gonadtrophin (HCG) administration, and six patients were noted to have fluid in the endometrial cavity 5 days after embryo transfer. None of the patients who developed ECF either during gonadotrophin stimulation or after embryo transfer in that study achieved a clinical pregnancy (Anderson et al., 1996
). Sharara and McClamrock reported two patients with hydrosalpinges who developed intrauterine fluid only after HCG administration during ART cycles, both of whom failed to become pregnant (Sharara and McClamrock, 1997
). Bloechle et al. observed that endometrial fluid collections recurred in one patient with hydrosalpinges, even after tubal aspiration during an IVF cycle (Bloechle et al., 1997
). Sharara and Prough reported endometrial fluid collections in four patients with polycystic ovaries who did not have hydrosalpinges (Sharara and Prough, 1999
). The authors suggested that the fluid collections resulted from an abnormal endometrial environment in these patients.
What is not known is whether ECF is associated with hydrosalpinges and whether the development of fluid in the uterine cavity negatively impacts ART outcome. The prevalence of ECF during ART cycles also remains undefined. To address these questions, we studied the prevalence of ECF in a large cohort of patients undergoing controlled ovarian hyperstimulation for assisted reproduction. In particular, we investigated the relationship between hydrosalpinges and the development of ECF, as well as the relationship of ECF to clinical pregnancy rates (CPRs) and to infertility diagnoses.
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Materials and methods |
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The principle outcome variable was the establishment of a clinical pregnancy as determined by transvaginal ultrasound at 56 weeks gestation. Clinical pregnancy was defined as the presence of a gestational sac with a fetal pole present. CPR was expressed per started cycle. Implantation rate was defined as the total number of embryos transferred divided by the number of gestational sacs documented by transvaginal ultrasound at 56 weeks gestation. Cancellation rate was defined as the number of cycles in which patients stopped treatment prior to oocyte retrieval (most commonly due to poor ovarian response; there were no cancellations after oocyte retrieval due to failed fertilization or fragmentation) divided by the total number of cycles studied. Statistical analysis was performed using Fisher's exact test and the unpaired t-test, where appropriate. An alpha error of 0.05 was considered significant. Sample size was determined by the duration of the study (2 years), and was not based on a prospective calculation since the prevalence of ECF was unknown at the start of the study.
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Results |
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The number of embryos transferred on day 3 (3.33 versus 3.22) or on day 5 (2.05 versus 2.14) did not differ between the two groups (ECF versus no ECF). The percentage of patients transferred on day 3 (63.5 versus 65.0%) or on day 5 (36.5 versus 35.0%) also did not differ significantly between the two groups. Similarly, the implantation rate did not differ significantly between patients who developed ECF compared with those who did not (31.5 versus 25.9%). The CPR per started cycle was significantly lower (P < 0.05) for patients who developed ECF during stimulation (15/57; 26.3%) compared with patients who did not (333/786; 42.4%) (Table I). While there was a lower CPR per retrieval in cycles where patients developed ECF during stimulation (37.5 versus 51.0% respectively), the difference did not reach statistical significance.
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For cycles where ECF was noted only after the administration of HCG (i.e. not during stimulation but at oocyte retrieval), six (6/12; 50.0%) patients achieved a clinical pregnancy (Table III). The CPR in these 12 cycles did not differ significantly from cycles where ECF was not observed at oocyte retrieval.
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Discussion |
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We observed that ECF often developed in patients with diagnoses other than tubal factor infertility; nearly half of the cycles in which ECF developed involved patients with infertility diagnoses other than tubal factor. While it is possible that some of these patients had occult hydrosalpinges not detected at ultrasound during monitoring, it is unlikely since the majority of our patients had either a hysterosalpingogram, laparoscopy or both at some point during their infertility evaluation. In a prior report (Sharara and Prough, 1999), four patients with polycystic ovarian syndrome (PCOS) undergoing ART cycles developed endometrial fluid collections early during stimulation. Not only did ECF develop in patients with PCOS in our study, but it also developed in patients with endometriosis, male factor infertility and unexplained infertility. In the present study, the frequency of USV hydrosalpinges in ART cycles involving patients with tubal factor infertility was 21.7% (71/327), which was somewhat higher than that noted in previous reports of 1013% (Anderson et al., 1994
; Katz et al., 1996
). Contrary to our expectations, ECF was detected during stimulation in only five of the 71 cycles where USV hydrosalpinges were present, and two of the five patients with both USV hydrosalpinges and ECF during stimulation achieved a clinical pregnancy.
Of the 12 patients who developed ECF only after HCG administration, eight had a diagnosis of tubal factor, four of whom had USV hydrosalpinges. Previously, investigators reported two patients with hydrosalpinges who developed fluid collections only after HCG administration (Sharara and McClamrock, 1997); both failed to get pregnant. In our study, of the four patients with hydrosalpinges who developed ECF after HCG administration, two patients achieved clinical pregnancies and subsequent live births (one set of twins and one singleton), while one patient had a chemical pregnancy (Table III
).
Perhaps most importantly, our data suggest that there may be two clinical scenarios in which ECF may be observed during ART cycles. The first, `early' ECF, was visualized during ovarian stimulation and was associated with significantly increased cancellation rates. The second, `late' ECF, occurred only after the administration of HCG and did not appear to impact CPR in these few patients. Further studies may help to delineate better the significance of these two presentations of ECF.
The mechanisms responsible for the negative effects of hydrosalpinges on IVF outcome are not completely understood. While evidence exists that the cytotoxic effects of hydrosalpinx fluid can impair embryo development and implantation, some studies refute this mechanism (Granot et al., 1998; Strandell et al., 1998
). In fact, other factors may play a more important role. Reduced endometrial receptivity, secondary to adverse effects of hydrosalpinx fluid on
vß3 expression, appears to decrease implantation and pregnancy rates (Anderson et al., 1994
; Meyer et al., 1997
). The mechanical `flushing' effect of hydrosalpinx fluid at the time of embryo transfer and during the window of implantation may also contribute to lower clinicals pregnancy rates (Mansour et al., 1991
; Bloechle et al., 1997
; Sharara and Prough, 1999
). While surgical correction of hydrosalpinges appears to increase implantation and CPR, the effects of hydrosalpinx fluid upon the endometrium, ovarian function, follicular development and oocyte quality may be permanent (Meyer et al., 1997
; Freeman et al., 1998
).
Elevated serum Chlamydia trachomatis IgG antibody titres and antibodies to C. trachomatis heat shock proteins are prevalent among patients with tubal factor infertility (Sharara et al., 1997; Ault et al., 1998
). Furthermore, it has been postulated that these antibodies may induce immune-mediated pregnancy failure in select patients (Neuer et al., 2000
). Studies have demonstrated an association between the production of these antibodies and poor ART outcome (Witkin et al., 1994
, 1995
; Neuer et al., 1997
; Sharara and Queenan, 1999
). Others, however, could not detect a relationship between serum antibodies and IVF outcome (Spandorfer et al., 1999b
) or an association between antibodies and poor IVF outcome in patients treated with antibiotics prior to stimulation (Sharara et al., 1996
, 1997
). In our study, 327 cycles (327/843; 38.8%) involved patients with tubal factor infertility, and USV hydrosalpinges were detected in 71 of those cycles (71/327; 21.7%). Moreover, 52.6% (30/57) of patients with ECF during stimulation had a diagnosis of tubal factor infertility. Because markers of infectious disease, specifically C. trachomatis IgG antibodies and antibodies to Chlamydial heat shock proteins, are not routinely measured at our centre, we were unable to make any inferences about these antibodies and the development of ECF in these patients. To draw any further conclusions, a prospective study evaluating these markers of infectious disease, their relationship to the development of ECF, and consequent ART outcome is needed.
The composition of hydrosalpinx fluid has been described (David et al., 1969; Granot et al., 1998
). However, the specific content of ECF encountered during ovarian stimulation and after HCG administration has not been fully investigated. These collections may consist of blood, mucus, endometrial secretions, and/or tubal fluid. While cytokines and interleukins originating from hydrosalpinx fluid may exert toxic effects on human embryos (Ben-Rafael and Orvieto, 1992
; Jakobs et al., 1992
; Tekatani et al., 1992), their release into the endometrial cavity remains to be investigated.
In conclusion, ECF was seen during 8.2% of 843 ART cycles during a 2 year interval. Results of this study suggest that ECF observed during stimulation was associated with lower CPRs per started cycle, higher cancellation rates secondary to poor ovarian response, and was observed in only a small fraction of patients with hydrosalpinges. ECF observed after HCG administration did not appear to impact CPRs. Thus, there may be two clinical scenarios in which ECF may be observed in ART cycles: during stimulation, which is associated with poor ovarian response and increased cancellation rates, and after HCG administration, which does not appear to affect ART outcome. An explanation for the association between the appearance of ECF during stimulation and poor ovarian response remains to be elucidated.
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Acknowledgements |
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Notes |
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* The views expressed in this article are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, nor the US Government.
** Presented at the 56th Annual Meeting of the American Society of Reproductive Medicine, San Diego, California, USA, October, 2000.
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References |
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Submitted on June 21, 2001; accepted on September 4, 2001.