1 Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin 70300, Israel, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel and 2 Department of Obstetrics and Gynecology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY 10461, USA
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Abstract |
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Key words: artificial reproduction technology/ovarian function/salpingectomy
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Introduction |
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It is well established that ectopic pregnancy is far more frequent in patients undergoing artificial reproduction technology for mechanical infertility than in the normal population (Herman et al., 1990; Dubuisson et al., 1991
; Zouves et al., 1991
). Using multivariate analysis of the risk factors for recurrent ectopic pregnancy, a scoring system has been proposed that allows a selection of information-based treatments to decrease recurrence (Pouly et al., 1991
). Even though ectopic pregnancy may still occur following salpingectomy (Chang et al., 1998
), for high-risk patients the authors suggested a laparoscopic ipsilateral salpingectomy with contralateral sterilization. In the presence of hydrosalpinx, in which significantly decreased pregnancy rates were reported (Singhal et al., 1991
; Camus et al., 1999
), some investigators recommended consideration of salpingectomy before the artificial reproduction technology cycle (Mukherjee et al., 1996
; Shelton et al., 1996
). Furthermore, it was suggested recently that the performance of salpingectomy before in-vitro fertilization (IVF) in all cases of severe infertility, may improve implantation and pregnancy rates (Dechaud et al., 1998
; Bredkjaer et al., 1999
). However, before embarking on such a radical and irreversible treatment in high-risk patients without hydrosalpinx, the short- and long-term implications of the procedure must be considered. In view of the close anatomical association of the blood supply and nervous system of these organs, potential adverse effects of the physical and functional presence or absence of the tube on ovarian function were postulated (McComb and Delbeke, 1984
; Rumeu et al., 1987
; Lass et al., 1998
). However, current data are still inconclusive and contradictory. This study was undertaken to determine and compare ovarian response in artificial reproduction technology patients before and after salpingectomy for ectopic pregnancy.
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Materials and methods |
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Ovulation induction in all cases was accomplished with menstrual long-acting gonadotrophin-releasing hormone (GnRH) analogue/human menopausal gonadotrophin (HMG)/human chorionic gonadotrophin (HCG) protocol described previously (Herman et al., 1990). IVF was carried out in all but two cycles in which intracytoplasmic sperm injection (ICSI) was utilized.
Ovarian response was measured by the duration and quantity of HMG used in the cycle, the pre-ovulatory concentrations of oestradiol, number of oocytes retrieved and quality of embryos (Puissant et al., 1987). Ovarian response was compared between cycles before and after salpingectomy as well as between affected and unaffected sides before and after salpingectomy.
Statistical analysis
Paired t-test was used to compare ovarian response parameters; 2 test was used to assess the differences in proportions. Values are mean ± SD; P < 0.05 was considered statistically significant.
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Results |
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Salpingectomies were performed in all cases by laparoscopy. Additional surgery was performed in three women. Contralateral salpingectomy was performed in one case. A contralateral tubal cauterization was done for two other women who had had repeated ectopic pregnancies and on laparoscopic examination had been found to have severe adhesions and/or hydrosalpinx. Informed consent involved a complete explanation of the procedure, the surgical options, and the uncertainty of subsequent ovarian response to the radical and irreversible options.
Implantation rate and clinical pregnancy rates following the post-salpingectomy cycle were 23.07 and 19.23 respectively. One woman had a repeated ectopic pregnancy (3.84%) and a laparoscopic salpingectomy was performed. In all parameters examined to evaluate ovarian performance (Table I) no significant differences were found before and after the salpingectomy. Moreover, to determine whether the lack of difference was due to a decrease in ovarian response on the affected side with a compensatory increase in response on the unaffected side, we compared the number of oocytes retrieved from the same ovary before and after surgery. Notwithstanding that the women were significantly older during the post-salpingectomy cycle, no significant difference was found (Table I
).
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Discussion |
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Some recent studies of ovarian performance following salpingectomy resulted in different findings and conclusions. Lass et al. compared ovarian response in artificial reproduction technology cycles between 29 patients who had undergone unilateral salpingectomy because of ectopic pregnancy and 73 patients with no preceding tubal surgery (Lass et al., 1998). They found fewer follicles and retrieved oocytes on the operated side, but no difference in overall number of follicles and oocytes as compared to the control group. These findings introduce the possibility of a compensatory mechanism in the unaffected tube. Our study does not support such a possibility. In a study of 26 women who underwent bilateral salpingectomy (Verhulst et al., 1994
) it was found that ovarian performance subsequent to surgery was equivalent to the control group. Moreover, no difference in ovarian function was reported in five women before and after bilateral salpingectomy. This series as well as our own supports the hypothesis that tubal removal does not compromise ovarian function. A third study compared implantation and pregnancy rates in IVF patients with severe mechanical factor who underwent laparoscopic salpingectomy and those with no prior surgery (Dechaud et al., 1998
). The authors found that the antecedent surgery tended to increase implantation and pregnancy rates. These findings were also confirmed by others (Bredkjaer et al., 1999
).
The most important blood supply for the tube is the medial tubal artery, which originates at the same level as the median ovarian artery. Laparoscopic surgery, the predominant method for treatment of ectopic pregnancy today, in combination with early detection of ectopic pregnancy, permits resection of the unruptured tube as close as possible to its surface in the isthmical region. This minimizes the damage to the ovarian blood supply and thus may decrease the occurrence of adverse effects as reflected in our results.
Although not addressed in our study, the long-term impact of salpingectomy on ovarian function, such as timing of menopause, is an important concern. It has been shown (Siddle et al., 1987) that the mean age of ovarian failure was lower in women who had undergone hysterectomy. However, salpingectomy and hysterectomy are scarcely comparable since the latter is far more devastating to the ovarian nerve and blood supply than the laparoscopic procedure. Furthermore, the local hypertension that results from the occlusion of the ovarian ligament may have a role in deterioration of ovarian function. Clearly, more studies are needed to elucidate the long-term effects of salpingectomy on the ovary.
In conclusion, our data suggest that laparoscopic salpingectomy is a safe procedure in regard to conservation of ovarian response in subsequent artificial reproduction technology cycles. In view of the high risk of ectopic pregnancy in patients with pathological tubes who will need assisted reproduction, salpingectomy, when indicated, should not be avoided because of concern for deterioration of ovarian function.
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Notes |
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References |
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Submitted on June 14, 1999; accepted on October 8, 1999.