1 Département d'Obstétrique et de Gynécologie, Hôpital Pellegrin, Bordeaux, 2 Institut National pour la Santé et la Recherche Médicale, U 330 (Epidémiologie, Santé Publique et Développement), Bordeaux and 3 Laboratoire de Biologie de la Reproduction Génétique Biologique, Hôpital Pellegrin, Bordeaux, France
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Abstract |
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Key words: IVF/sterilization reversal
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Introduction |
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In these situations, two medical options are possible: (i) microsurgical tubal anastomosis; and (ii) IVFembryo transfer. A number of investigators have reported various pregnancy success rates after tubal reversal, ranging from 54.8% (Kim et al., 1997) to 83% (Dubuisson et al., 1995
), and 6087% with bilateral or unilateral anastomosis (Yoon et al., 1999
) using a microsurgical technique for the tubal re-anastomosis. In some cases, however, tubal anastomosis is impossible because of the type of sterilization that has been performed, and because of peritoneal factors and the patient's general condition. In recent years, IVF has represented a new treatment alternative for women who have undergone surgical sterilization.
In this retrospective study, the request for IVFembryo transfer was analysed in the light of two factors: (i) the clinical conditions of any prior sterilization; and (ii) the efficacy of IVF compared with that of tubal pathologies over the same period, and in the same hands.
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Materials and methods |
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Ovarian stimulation
All patients were stimulated using a combination of gonadotrophin-releasing hormone (GnRH) agonist (Buserelin®; Hoechst, Paris, France or Triporelin®; Ipsen-Biotech, Paris, Boulogne, France). All patients treated at given times received the same GnRH protocol, independently of their indication. Three protocols for ovulation induction were utilized: (i) a short protocol with flare-up (injection of GnRH agonist on day 1); (ii) a luteal protocol with down-regulation for 7 days (GnRH agonist in luteal phase); and (iii) a long protocol with down-regulation for 15 days (GnRH agonist on day 1 of the cycle by either s.c. or delayed i.m. injection). HCG was administered when the largest follicles reached a diameter of 18 mm; 10 000 IU were administered and ovocyte retrieval was performed 36 h later, using vaginal ultrasonography. The luteal phase was supported by using three 1500 UI doses of human chorionic gonadotrophin (HCG) and progesterone supplementation (intravaginal retroprogesterone) from the day of retrieval and thereafter until pregnancy status was known.
IVF
Each cumulusoocyte complex recovered was inseminated in B2 Ménézo medium (CDD-France, Paris, France) with 5x104 spermatozoa selected by either a swim-up or the Percoll gradient centrifugation technique. At 1620 h after insemination, fertilization was assessed by confirming the presence of two pronuclei. Before replacement, embryo quality was assessed under an inverted light microscope equipped with Nomarski optics (Nikon Diaphot, Tokyo, Japan) at x200 magnification. Embryos were classified according to two characteristics of their morphology, the form of the blastomeres (C criterion) and the percentage of fragments (D criterion): C1 for equally sized blastomeres, C0 for unequal-sized blastomeres, D1 for <10% fragments, D2 for >10 to 50% fragmentation, and D3 >50% fragmentation. Embryos with the best morphology and the most advanced stage of development were selected for transfer.
Embryo transfer
Uterine transfer of embryos was performed 2 or 3 days after oocyte retrieval, with a maximum of three embryos. Previous findings have established that there is no significant difference whether transfer is performed on either on day 2 or day 3 (Van Os et al., 1989). Any excess embryos were cryopreserved.
Statistical analysis
Data were expressed as mean (± SD) and as percentages. Student's t-test and the 2 were used to discriminate between groups. Significance was asessed by using the Stata program (University Drive East, College Station USA; version 5.0). Variables considered were age, anterior parity, stimulation protocol, total number of human menopausal gonadotrophin (HMG) ampoules, number of oocytes obtained, number of embryos and their quality (C and D criteria), and ongoing pregnancy (defined as a pregnancy which continued >12 weeks after transfer).
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Results |
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In 11 cases IVF was requested because of failure of tubal microsurgical anastomosis. In 18 cases the sterilization procedure report or laparoscopy performed before repermeabilization ruled out this possibility because of the type of sterilization procedure or peritoneal factors. In eight cases IVF was the first procedure proposed, albeit for different reasons.
IVF conditions
Patient data relating to the IVF in the two groups are listed in Table I. The anterior parity level was 89.2% in the TL group, and 23% in the TP group. There was no difference in embryo quality between the groups. In the TL group, the 56 IVFembryo transfer cycles resulted in seven ongoing pregnancies (12.5%), while in the TP group 404 IVFembryo transfer attempts resulted in 66 ongoing pregnancies (16.3%).
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Discussion |
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The request for surgical tubal re-anastomosis preceded IVFembryo transfer in 29 cases (78%), and 62% of those patients could not be operated on, usually because the techniques used for sterilization had been too mutilating. Even if the sterilization were to be considered as final, these techniques should not be used. Indeed, it has been found (Langer et al., 1993) that patients considered surgical reversal to be preferable to IVF because of the `restoration of the mutilation'. Sometimes, this satisfaction with reversal is independent of the pregnancy achieved.
IVFembryo transfer
IVFembryo transfer now represents a new treatment alternative for women after tubal ligation, but so far there are insufficient data available relating to this question. In the present study a high pregnancy rate was expected in sterilized women because of their potential fertility, as proved by their prior parity (in 89% of cases). Paradoxically, it was found that the ongoing pregnancy rate was lower in the TL than in the TP group (12.5% versus 16.3%) (Table I). This is probably due to the fact that sterilized women were significantly older at the time of IVF, than TP women (36 versus 32 years). Age is known to be an important factor affecting the outcome of fertility treatment. In cases of tubal sterilization, the pregnancy rates after tubal anastomosis were reported to decrease with increasing patient age (Yoon et al., 1999
), while others (Glock et al., 1996
) have reported a high frequency of spontaneous abortion in women aged
40 years; the pregnancy rate after IVF has been reported to reduce strongly after the age of 37 years (Templeton et al., 1996
). In our previous study (Commenges-Ducos et al., 1998
), it was found specifically that older women had a lower probability of having oocytes and a lower probability of embryo implantation.
Subsequently, in the present study the IVFembryo transfer result was compared in both groups, but only women aged <38 years were included (Table II). The 36 IVF cycles in the sterilized group of women aged <38 years resulted in six pregnancies (16.7%). In the control group, 60 pregnancies were obtained from 350 IVFembryo transfer attempts (17.1%). It is possible that the difference between the crude pregnancy rates was indeed due to the difference in age distribution between the two groups. However, the lower mean age of the control group in our study, even when only women aged <38 years were included (Table II
), must be recognized as a limitation which restricts the interpretation of the results. The fact that TP women needed significantly more HMG for ovarian stimulation (see Table I
) can be explained by difficulties of the diffusion of exogenous gonadotrophins into the follicular fluid in patients with peri-ovarian adhesions (Nagata et al., 1998
).
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Acknowledgements |
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Notes |
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References |
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Commenges-Ducos, M., Tricaud, S., Papaxanthos-Roche, A. et al. (1998) Modelling of probability of success of stages of in vitro fertilisation and embryo transfer: stimulation, fertilisation and implantation. Hum. Reprod., 13, 7883.[Abstract]
Dubuisson, J.-B., Chapron, Ch., Nos, C. et al. (1995) Sterilization reversal: fertility result. Hum. Reprod., 10, 11451151.[Abstract]
Glock, J.L., Kim, A.H., Hulka, J.F. et al. (1996) Reproductive outcome after tubal reversal in women 40 years of age or older. Fertil. Steril., 65, 863865.[ISI][Medline]
Kim, S.H., Shin, C.J., Kim, J.G. et al. (1997) Microsurgical reversal of tubal sterilization: a report on 1,118 cases. Fertil. Steril., 68, 865870.[ISI][Medline]
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Nagata, Y., Honjou, K., Sonoda, M. et al. (1998) Peri-ovarian adhesion interfere with diffusion of gonadotrophin into follicular fluid. Hum. Reprod., 13, 20722076.[Abstract]
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Yoon, T.K., Sung, H.R., Kang, H.G. et al. (1999) Laparoscopic tubal anastomosis: fertility outcome in 202 cases. Fertil. Steril., 72, 11211126.[ISI][Medline]
Submitted on July 28, 2000; accepted on January 4, 2001.