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Our objective was to define and propose a standardized magnetic resonance (MR) imaging structured report in patients with infertility to have clinical completeness on possible diagnosis and severity. Patients should be studied preferable on 3T equipment with a surface coil. Standard MR protocol should include high-resolution fast spin-echo T2-weighted, diffusion-weighted images and gradient-echo T1-weighted fat suppression images. The report should include ovaries (polycystic, endometrioma, tumor), oviduct (hydrosalpinx, hematosalpinx, pyosalpinx, peritubal anomalies), uterus (agenesia, hypoplasia, unicornuate, uterus didelphys, bicornuate, septate uterus), myometrium (leiomyomas, adenomyosis), endometrium (polyps, synechia, atrophy, neoplasia), cervix and vagina (isthmoceles, mucosal-parietal irregularity, stenosis, neoplasia), peritoneum (deep endometriosis), and urinary system-associated abnormalities. To be clinically useful, radiology reports must be structured, use standardized terminology, and convey actionable information. The structured report must comprise complete, comprehensive, and accurate information, allowing radiologists to continuously interact with patients and referring physicians to confirm that the information is used properly to affect the decision making process.

Objective To investigate the impact of salpingectomy in patients with IVF treatment on ovarian response. Design Meta-analysis. Setting Not applicable. Patient(s) Patients under treatment for infertility, during the cycles before and after treatment by salpingectomy for hydrosalpinx or ectopic pregnancy. Intervention(s) PubMed, MEDLINE, EMBASE databases, and CENTRAL in Cochrane Library up to July 2015. Either a fixed- or a random-effects model was used to calculate the overall combined risk estimates. The subgroup analysis was planned a priori before data were collected and analyzed. Main Outcome Measure(s) The amount of gonadotropin administered, the peak E 2 level, the number of oocytes retrieved, and the number of pregnancies. Result(s) After the final screening, 12 of the studies were retrospective and six were prospective. In this meta-analysis, 1,482 patients were enrolled, including a total of 657 patients with salpingectomy and 825 without salpingectomy. The comparisons before and after salpingectomy of the peak E 2 level (standardized mean difference [SMD] = −0.182; 95% confidence interval [CI], −0.166, 0.101; I 2 , 85.45%), the total gonadotropin dose used for stimulation (SMD = 0.127; 95% CI, −0.054 0.308; I 2 , 84.49%), and number of oocytes retrieved (SMD = −0.060; 95% CI, −0.189, 0.070; I 2 , 63.93%) did not reveal any significant differences. The number of pregnancies before and after salpingectomy did not differ significantly (odds ratio [OR] = 1.180; 95% CI, 0.854, 1.630; I 2 , 34.01%). Conclusion(s) Salpingectomy in infertile patients does not have any negative effect on their subsequent fertility treatment, but further studies should be performed before this result can be considered definitive.

Objective To investigate the success rate of proximal tubal occlusion with Essure devices in subfertile women with hydrosalpinges, and to observe the results of subsequent treatment with IVF. Design Prospective, single-arm, clinical study. Setting University hospital and teaching hospital. Patient(s) Ten women with uni- or bilateral hydrosalpinges prior to IVF. In all patients laparoscopy was felt to be contraindicated. Intervention(s) Hysteroscopic placement of Essure devices in an office setting. Main Outcome Measure(s) Placement rate, successful proximal tubal occlusion, and pregnancy rate after IVF. Result(s) All patients had successful placement of the Essure devices without any complications. Proximal tubal occlusion was confirmed by hysterosalpingography in 9 out of 10 patients. A 40% ongoing pregnancy rate was achieved with 20% life births after one IVF cycle and/or frozen embryo transfer. Conclusion(s) Proximal occlusion of hydrosalpinges with Essure devices before IVF is a successful treatment for patients with a contraindication for salpingectomy.

Objective Evaluation of uteroglobin (UG) expression in the fallopian tube in different tubal diseases. Design The UG was screened and quantified in samples of fallopian tubes from patients with salpingitis, hydrosalpinx, and ectopic pregnancy by exposing the UG with immunohistochemical techniques. Setting University hospital and electron microscopy center. Patient(s) Women with pelvic inflammatory disease (PID) and complicated tubal ectopic pregnancy consulting for medical care. Intervention(s) Salpingectomy. Main Outcome Measure(s) Tubal tissues were collected and examined using regular pathologic techniques. The UG immunoreactivity in the tubal epithelium was also assessed. Result(s) Fallopian tube epithelium displayed an increased UG expression in patients with PID and complicated tubal pregnancy compared with control patients. Conclusion(s) Uteroglobin is present in the human fallopian tube as a secretory protein and appears to be involved in immunosuppressive responses in the fallopian tube.

Objective To describe the use of Essure microinsert placement in patients with hydrosalpinges before IVF. Design Retrospective case-series. Setting An advanced endoscopic practice within a university-affiliated teaching hospital. Patient(s) Five women with unilateral or bilateral hydrosalpinges on transvaginal ultrasound, laparoscopy, or hysterosalpingogram who were planning further fertility therapy. In all patients, laparoscopy was felt to be relatively contraindicated because of previous extensive abdominopelvic surgery. Intervention(s) Hysteroscopic placement of the Essure microinsert in four patients under general anesthesia. One patient underwent fluoroscopically guided placement. Main Outcome Measure(s) Placement rates and postoperative recovery, technical challenges in Essure placement, and results of subsequent treatment with IVF when available. Result(s) Successful bilateral Essure placement was confirmed in two of five patients. Unilateral placement was achieved in two of five. There were no postoperative complications. No pregnancies have occurred thus far. Conclusion(s) Hysteroscopic placement of the Essure microinsert is a minimally invasive option for proximal tubal occlusion. In patients requiring occlusion of hydrosalpinges before IVF and with contraindications to abdominal surgery, this technique may offer a safer alternative. Preoperative documentation of proximal tubal patency helps predict placement success. Further research into this unique clinical scenario is required.

Objective To determine whether women with hydrosalpinx would have diminished endometrial HOXA10 expression and whether salpingectomy would reverse HOXA10 suppression. The homeobox gene HOXA10 is a transcription factor that is necessary for embryo implantation; its expression in human endometrium correlates with receptivity and implantation. Increased endometrial HOXA10 expression may be one mechanism by which salpingectomy results in increased implantation rates in IVF. Design Prospective clinical trial. Setting Academic medical center. Patient(s) Women with unilateral or bilateral hydrosalpinx. Intervention(s) Expression of HOXA10 was examined prospectively during the midluteal phase in endometrium obtained from infertile women (n = 9) with hydrosalpinges before and after salpingectomy, as well as from fertile controls (n = 6). Quantitative HOXA10 mRNA expression was determined by real-time reverse-transcription polymerase chain reaction, and HOXA10 protein expression was determined by immunohistochemistry. Main Outcome Measure(s) Expression of HOXA10 mRNA and protein. Result(s) Expression of HOXA10 mRNA was significantly lower in infertile women with hydrosalpinges, compared with the case of fertile controls. Salpingectomy resulted in a statistically significant, 15-fold increase in endometrial HOXA10 expression. Immunohistochemical analysis confirmed the quantitative real-time reverse-transcription polymerase chain reaction findings. Increased HOXA10 expression was evident in both glandular epithelial cells and endometrial stroma. Conclusion(s) HOXA10 is necessary for implantation. Here, we demonstrate decreased HOXA10 expression in response to hydrosalpinx fluid as a potential molecular mechanism for diminished implantation rates. Salpingectomy restores endometrial HOXA10 expression. This may be one mechanism by which salpingectomy results in augmented implantation rates in IVF.

Objective To compare endometrial dating and ultrasound texture in a natural cycle before IVF and relate these to outcome and to fertile references. Design Prospective study with a fertile reference group. Setting Four university IVF clinics. Patient(s) Seventy-five IVF patients and 21 fertile women. Intervention(s) Ultrasound, biopsy, blood sampling. In vitro fertilization–ET in the following cycle. Main Outcome Measure(s) Endometrial evaluation, P, IVF outcome. Result(s) At day LH+7, 42% infertile vs. 67% fertile women demonstrated endometria that were in phase (statistically nonsignificant difference). Nine percent had an accelerated endometrium, and 47% (infertile) vs. 24% (fertile) had a delayed endometrium (statistically nonsignificant difference). Statistically significantly fewer women with tubal factor and no hydrosalpinges had an endometrium in phase (20%) than was the case in fertile women (67%). Dating could not predict outcome. Statistically significantly more women in the hydrosalpinx group had a visible midline at day LH+7 compared with the case in other infertile groups. Forty-three percent conceived after IVF-ET. Plasma P was statistically significantly lower in nonpregnant women compared with in women with ongoing pregnancies and with fertile controls. A periovulatory hyperechogenic endometrium resulted in no ongoing pregnancies. Conclusion(s) In a natural cycle preceding IVF, a low midluteal P level predicts a low implantation rate. A periovulatory hyperechogenic endometrium or hydrosalpinges visible at ultrasound may have some predictive value. Endometrial dating was of no help.

Using an anonymous and sealed questionnaire sent to all French IVF centers, the current management of hydrosalpinx before or during IVF was evaluated. Laparoscopic salpingectomy was recommended and undertaken in less than half of the centers, even though several other treatments were reported and despite medical evidence for this surgical option.

Objective To compare the effect of prophylactic laparoscopic salpingectomy versus division of the fallopian tubes on ovarian response to gonadotropins in women undergoing IVF. Design Retrospective study. Setting National Health Service-based tertiary referral center for reproductive medicine. Patient(s) One hundred sixty-eight women with tubal factor infertility. Sixty-five women with hydrosalpinges had either salpingectomy (n = 40, group A) or proximal tubal division (n = 25, group B), while the remaining women with tubal disease but without hydrosalpinges acted as the control group (n = 103, group C). Intervention(s) Prophylactic laparoscopic salpingectomy or proximal division of the fallopian tubes and ovarian stimulation with gonadotropins for IVF. Main Outcome Measure(s) Day 2 serum FSH levels before surgery and 3 months after surgery but before ovarian stimulation, ovarian response assessed as total dose of hMG administered, serum E 2 concentrations on day 3 and day 8 of stimulation and on the day of hCG injection, number of follicles, and number of oocytes retrieved and fertilized. Result(s) In group A, baseline FSH levels were significantly raised after surgery compared with before surgery. Postsurgery FSH concentrations were significantly higher in group A compared with group B. The number of follicles (15–20 mm) was significantly lower in group A compared with group B and group C. The serum E 2 levels on day 8 of stimulation were lower in group A compared with group B, and on the day of hCG injection it was significantly reduced in group A compared with groups B and C. The number of oocytes retrieved per cycle was significantly lower in group A compared with group B. There were no significant differences in pregnancy rates and miscarriage rates among the three groups. Conclusion(s) These findings suggest that prophylactic salpingectomy in women with hydrosalpinx may compromise ovarian response to stimulation without affecting pregnancy rates. A randomized control trial is recommended to determine the most appropriate laparoscopic procedure in the management of hydrosalpinx before IVF.

Objective To compare endometrial and subendometrial blood flows among patients with and without hydrosalpinx (HSP) during in vitro fertilization treatment as measured by a three-dimensional power Doppler ultrasound. Design A prospective observational study. Setting A tertiary assisted-reproduction unit. Patient(s) Twenty-one patients with HSP were compared with 42 matched controls without HSP. Intervention(s) None. Main Outcome Measure(s) Endometrial thickness, endometrial pattern, endometrial volume, pulsatility index (PI) and resistance index (RI) of uterine vessels, and the vascularization index (VI), flow index (FI), and vascularization flow index (VFI) of endometrial and subendometrial regions were measured on the day of oocyte retrieval. Result(s) The proportion of the non-multilayered endometrial pattern was significantly higher in the HSP group than in the non-HSP group. Patients in the HSP group had significantly lower endometrial and subendometrial VI and VFI. Endometrial thickness, endometrial volume, uterine PI, uterine RI, and endometrial and subendometrial FI were similar between the two groups. No significant differences were observed in endometrial and subendometrial VI, FI, and VFI among patients with unilateral and bilateral HSP. Conclusion(s) A change in endometrial pattern and a decrease in endometrial and subendometrial blood flows may be the reasons for impaired implantation in patients with HSP.

Objective To report the occurrence and management of hydrometra at the time of scheduled embryo transfer in two patients who underwent drainage of hydrosalpinges at oocyte retrieval. Design Case report. Setting University IVF clinic. Patient(s) Two patients with hydrosalpinges visible on ultrasonography who deferred tubal surgery. Intervention(s) Although no fluid was seen at the time of oocyte retrieval, hydrometra was noticed and drained before planned embryo transfer (ET). Main outcome measure(s) Reoccurrence of hydrometra after drainage. Result(s) Rapid reaccumulation of hydrometra despite drainage was seen in both patients, one of whom had reoccurrence in 1 hour. Embryo transfer was deferred until after tubal surgery, and all embryos were cryopreserved. Conclusion(s) In patients with hydrosalpinges, ultrasonography before ET is useful to detect newly developed hydrometra. Aspiration of the uterine fluid is unlikely to help because of rapid reaccumulation of hydrometra. Cryopreservation of the embryos for future transfer after the hydrosalpinx is removed or ligated is recommended.

Objective: To determine the effect of hydrosalpinx fluid on the expression of HOXA10, an essential regulator of endometrial receptivity. Design: In vitro study. Setting: Academic medical center. Patient(s): Patients with unilateral or bilateral hydrosalpinx. Intervention(s): Hydrosalpinx fluid was aspirated from 10 patients at laparoscopy. The fluid was serially diluted in minimum essential medium. Ishikawa cells (an endometrial adenocarcinoma cell line, representative of endometrial epithelium) were incubated with this fluid at concentrations of 10% and 50% for 48 hours. Cells were also incubated in undiluted minimum essential medium (MEM) and in 10% serum as controls. After incubation, the cells were lysed in Trizol, and total RNA was extracted and analyzed by Northern blot using a 32 P-labeled HOXA10 riboprobe. A 32 P-labeled G3PDH probe was used as a control for loading. Main Outcome Measure(s): HOXA10 mRNA expression. Result(s): HOXA10 mRNA expression in endometrial cells decreased with increasing concentrations of hydrosalpinx fluid. Densitometric analysis of the northern blot revealed that HOXA10 mRNA expression was different from control at both concentrations ( P Conclusion(s): HOXA10 is necessary for implantation in the murine model. HOXA10 expression is diminished by hydrosalpinx fluid. This effect on HOXA10 is a potential molecular mechanism by which implantation rates are diminished in women with hydrosalpinges.

Objective To assess and compare pregnancy outcomes in hydrosalpinx (HX) patients treated by Essure, laparoscopic salpingectomy, and proximal tubal occlusion (LPTO) before IVF. Design Systematic review and meta-analysis. Setting University-affiliated teaching hospital. Patient(s) Women undergoing Essure, laparoscopic salpingectomy, and LPTO for HX before IVF. Intervention(s) The overall combined risk estimates were calculated by means of fixed- or random-effects models. Main Outcome Measure(s) Clinical pregnancy rate (CPR) and live birth rate (LBR). Result(s) In total, 3,065 patients were included in 33 studies. Thirteen of them were comparative studies among 3 surgical methods and no intervention. In the analysis of comparative studies, there were no significant differences in implantation rate (IR), CPR, and ongoing pregnancy rate/LBR between salpingectomy and LPTO groups. The CPR, IR, and LBR of Essure were significantly lower than those of the laparoscopic surgery (salpingectomy and LPTO) group, with a CPR of 34.1% vs. 44.0% (relative risk [RR] 0.71; 95% confidence interval [CI] [0.51, 0.98]), an IR of 17.3% vs. 38.0% (RR 0.45; 95% CI [0.27, 0.74]), and an LBR of 22.2% vs. 37.4% (RR 0.57; 95% CI [0.35, 0.91]). Conclusion(s) Management of HX by laparoscopic salpingectomy and LPTO yielded the same effect on the improvement of the pregnancy outcome after IVF. The hysteroscopic placement of Essure devices to treat HX before IVF produces inferior pregnancy outcomes compared with those following the laparoscopic approach. More multicenter randomized, controlled trials are warranted in future research to further examine the conclusion from this meta-analysis.

The endometrium of women with hydrosalpinx has an increased number of neutrophils and lower expression of elafin, an elastase inhibitor and natural antimicrobial molecule. These findings suggest that women with hydrosalpinx have a reduced antimicrobial and antielastase activity.

Objective: To establish the predictive value of the observation of a "cobblestone" pattern of the distal tube mucosa shown on the selective salpingogram as an indicator of significant and probably irreparable damage to the ciliated epithelium. Design: Clinical study. Setting: Fertility and Laser Center and Academic Radiology Department. Patient(s): Patients with primary or secondary infertility and obstruction of the fallopian tubes documented on hysterosalpingogram. Intervention(s): Transcervical recanalization of obstructed tubes followed by reassessment by selective salpingogram. Main Outcome Measure(s): Progression of mucosal disease with resultant low likelihood of intrauterine pregnancies and high probability of ectopic pregnancy. Result(s): In 32 asymptomatic patients, there was progression to coalescence and agglutination of mucosal folds in 13, to a thick wall pyosalpinx in 4. Five thin wall and 8 thick wall hydrosalpinges in asymptomatic patients showed no significant progression of mucosal disease but increasing peritubular fibrosis. In 12 symptomatic patients, progressive fusion of mucosal folds with polypoid hyperplasia was observed in 11, a thin wall hydrosalpinx in 2. Conclusion(s): Cobblestone appearance of the distal tubes heralds significant mucosal damage, prone to progressive disease and hence, a poor chance for conception.

Objective: To compare ovarian response and IVF-ET cycle outcome in patients with hydrosalpinges managed by either laparoscopic salpingectomy or proximal tubal occlusion. Design: Retrospective analysis. Setting: Tertiary-care assisted reproductive technology program. Patient(s): One hundred four consecutive fresh IVF-ET cycles in 94 patients with tubal-factor infertility. Intervention(s): Laparoscopic salpingectomy (group 1: 35 cycles) or bipolar proximal tubal occlusion (group 2: 17 cycles), controlled ovarian hyperstimulation, and IVF-ET. Control groups consisted of both tubal-factor patients without hydrosalpinges (group 3: 37 cycles) and those with prior bilateral tubal ligation for sterilization (group 4: 15 cycles). Main Outcome Measure(s): Uterine artery Doppler flow, controlled ovarian hyperstimulation response, and implantation and clinical pregnancy rates. Result(s): There were no differences in mean uterine artery pulsatility indices or ovarian response among any of the groups. A trend toward a higher cycle cancellation rate in group 1 did not approach statistical significance. Clinical pregnancy and implantation rates were not significantly different between group 1 (57.1%, 29.2 ± 5.9%, respectively) and group 2 (46.7%, 19.4 ± 6.1%, respectively) or compared with those of controls. Conclusion(s): [1] Management of hydrosalpinges by laparoscopic salpingectomy or bipolar proximal tubal occlusion yielded statistically similar responses to controlled ovarian hyperstimulation and IVF-ET cycle outcome. [2] The latter approach may be preferable in patients who present with dense pelvic adhesions and easy access only to the proximal fallopian tube.

Objective: To identify risk factors for ectopic pregnancy (EP) after IVF-ET. Design: Retrospective cohort study. Setting: In vitro fertilization clinic at a university hospital. Patient(s): A total of 725 women who conceived after IVF were studied with regard to background factors, indications for IVF, and factors related to the IVF procedure through review of their medical charts. The rate of EP was 4%, corresponding with 29 EPs, of which 2 were heterotopic. Intervention(s): None. Main Outcome Measure(s): Pregnancy outcome, defined as intrauterine pregnancy or EP. Background factors, indications for IVF, and factors related to the IVF procedure were analyzed for possible correlation with the outcome of EP. Risk factors for EP were identified by logistic regression analysis. Result(s): Tubal factor infertility, various previous abdominal surgeries, previous EP or pelvic infection, presence of a hydrosalpinx or fibroid, and type of transfer catheter used showed a positive correlation with EP as outcome. Logistic regression analysis identified two factors with predictive power: tubal factor infertility and previous myomectomy. Conclusion(s): Tubal factor infertility was the most prominent risk factor for EP after IVF. Previous myomectomy appeared to be another important risk factor, but this is a new finding that needs to be confirmed by further study.

Objective: To test the hypothesis that IVF-ET pregnancy rates (PRs) for patients with tubal factor infertility are decreased in patients with hydrosalpinges and that surgical correction reverses this effect. Design: Retrospective chart review. Setting: Private practice IVF-ET program. Patient(s): Patients ( n = 160) undergoing 238 cycles of IVF-ET were stratified into groups based on the presence of hydrosalpinges and whether surgical correction had been performed. Patients > 39 years old and patients with male factor infertility were excluded from the study. Intervention(s): Patients with hydrosalpinges were offered surgical correction. Main Outcome Measure(s): Clinical pregnancy defined by an intrauterine gestational sac. Result(s): Patients with hydrosalpinges had significantly decreased implantation rates and PRs per transfer (2.8% and 8.5%, respectively) than patients with tubal factor infertility but without hydrosalpinges (15.7% and 38.6%). Surgical correction improved implantation rates and PRs in patients with prior failed cycles (16.1% and 37.5%) and in patients undergoing surgery before IVF-ET (21.8% and 51.7%). The type of surgery performed did not affect success rates in the small number of patients evaluated. Conclusion(s): The presence of a hydrosalpinx during an IVF-ET cycle results in significant decreases in implantation rates and PRs. Surgical treatment of hydrosalpinges before IVF-ET cycles improves implantation rates and PRs.

Objective: To determine the effect of hydrosalpinges on the pregnancy rate in an IVF program. Design: Multicentric retrospective analysis of clinical and laboratory data. Setting: Two assisted reproductive technology centers in university hospitals. Patient(s): Four hundred forty-three women, under 38 years of age, with pure tubal infertility. The patients were classified into the following five groups: bilateral hydrosalpinges ( n = 37), unilateral hydrosalpinx ( n = 54), bilateral tubal occlusion ( n = 207), unilateral tubal occlusion ( n = 55), and severe tubal disease without complete occlusion ( n = 90). Main Outcome Measure(s): Pregnancy and implantation rates. Result(s): The pregnancy and the implantation rates per transfer (12.3% and 5.4%) obtained by women with bilateral hydrosalpinges are significantly lower than the rates (means = 23.1% and 12%) for all other tubal infertility groups. Conclusion(s): Bilateral hydrosalpinges have a deleterious effect on the outcome of IVF program.

Objective: To assess the effects of hydrosalpinx fluid on human cytotrophoblast viability and function in vitro. Design: Human cytotrophoblasts obtained from third-trimester placentas were cultured in vitro with hydrosalpinx fluid, and cell viability and protein production were assayed. Setting: A university hospital. Patient(s): Ten hydrosalpinx fluid samples obtained from seven women with clearly diagnosed hydrosalpinges. Intervention(s): Recovery of hydrosalpinx fluid by transvaginal aspiration or at the time of surgery. Main Outcome Measure(s): Cell viability was assessed by the XTT assay. Secretion of trophoblast oncofetal fibronectin (tropho-uteronectin) and β -hCG by cultured trophoblasts was determined by Western blot and ELISA of the culture media. Result(s): With increasing concentrations of hydrosalpinx fluid from 0% to 20%, there was a significant increase in trophoblast cell viability (1.63-fold increase in 20% hydrosalpinx fluid). Likewise, both Western blot and ELISA assays demonstrated a significant increase in trophouteronectin production by trophoblasts with increasing hydrosalpinx fluid concentrations (3.76-fold increase in 20% hydrosalpinx fluid). β -Human chorionic gonadotropin production also increased significantly in the presence of hydrosalpinx fluid (3.31-fold increase in 20% hydrosalpinx fluid). Conclusion(s): These findings suggest that hydrosalpinx fluid improves human trophoblast viability in vitro and enhances the production of tropho-uteronectin and β -hCG by these cells.

Objective: To determine the impact of hydrosalpinx on pregnancy rates in patients undergoing IVF for infertility caused by tubal disease. Design: Review of the records of all patients who had undergone IVF for tubal factor infertility at our institution between May 1988 and October 1994. Setting: A university-sponsored, hospital-based IVF facility. Patient(s): Two hundred fifty patients were identified with infertility due to tubal disease; 67 of these had at least one documented hydrosalpinx whereas the remaining 183 did not. Main Outcome Measure(s): Numbers of oocytes retrieved and fertilized, the number of embryos transferred and implanting, and resulting pregnancy rates. Result(s): The groups were similar in age and cycle cancellation rates. The patients with hydrosalpinx had greater numbers of oocytes retrieved per cycle (15.0 versus 11.6) and embryos transferred per cycle then those without hydrosalpinges (4.21 versus 3.98). The hydrosalpinx group also undertook more cycles per patient (2.31 versus 1.96). Fertilization rates between the two groups were similar, but implantation rates were decreased in those with hydrosalpinx (8.5% versus 11.2%). Conclusion(s): Hydrosalpinx did not result in impaired ovarian stimulation or decreased oocyte fertilization. It did, however, interfere with implantation and reduce to some degree the success of IVF in achieving an ongoing pregnancy. The validity of routine salpingectomy for hydrosalpinx is debatable, but its use in selected individuals may well be appropriate.

Objective To report a case of ovarian pregnancy following in vitro fertilization-embryo transfer (IVF-ET) treatment for which the cornual fistulae was the most probable explanation of the cause. Design Case report. Setting University department and assisted reproduction unit. Patient(s) A 29-year-old woman with primary infertility. Intervention(s) Hydrosalpinx of the bilateral fallopian tubes has been noted in patients who have decreased pregnancy rates in the IVF-ET treatment cycles. Salpingectomy before IVF cycles has been suggested to increase the pregnancy rate. We report a patient who presented with bilateral hydrosalpinx for whom bilateral salpingectomy was performed before IVF treatment. Main outcome measure(s) Clinical pregnancy. Result(s) The treatment cycle resulted in a primary ovarian pregnancy and required laparoscopic operation. A cornual fistulae was found that have might led to ectopic implantation of the embryos. Conclusion(s) Ovarian pregnancy may be an unexpected complication of those receiving bilateral salpingectomy before IVF treatment. The presence of cornual fistulae after salpingectomy was probably the cause of the ectopic pregnancy.

Objective To determine the effect of the presence of a unilateral or bilateral hydrosalpinx on the outcome with IVF-ET. Design Retrospective analysis of clinical and laboratory data. Setting Hospital-based private IVF center. Patients Eight hundred forty-six patients with tubal disease younger than age 40 years undergoing 1,766 stimulation cycles. In 118 cycles, a hydrosalpinx was noted sonographically (group I) whereas, in 1,648 cycles, no such image was documented. Main Outcome Measures Pregnancy and implantation rates. Results Group I displayed a significantly lower pregnancy rate per transfer than group II (16.84% versus 36.83%) and a lower implantation rate (3.92% versus 11.53%). Conclusion The presence of hydrosalpinx adversely affects the outcome of IVF.

Objective To correlate the severity and extent of intraluminal tubal abnormalities assessed by transfimbrial salpingoscopy with traditional criteria for evaluating distal tubal disease at laparoscopy. Design Prospective 2-year clinical trial with long-term follow-up. Setting University-affiliated tertiary care reproductive medicine and surgery practice. Patients Fifty-five infertile women with suspected distal tubal disease or unexplained infertility. Interventions Transfimbrial salpingoscopy was performed at the time of laparoscopy and terminal neosalpingostomy when appropriate. Salpingoscopic and laparoscopic findings of 91 fallopian tubes were scored independently. Results No correlation between laparoscopic and salpingoscopic findings was noted in group I tubes (n = 51) categorized as having minimal disease or no pathology by traditional staging. In contrast, a strong correlation was noted between findings obtained from these two techniques in group II tubes (n = 40) diagnosed as having moderate-to-severe tubal disease at laparoscopy. Intrauterine pregnancy was achieved in 38.9% (7/18) of patients with mean salpingoscopy scores ≤ 12 versus 3.8% (1/26) of patients with mean scores > 12. Life-table analyses of cumulative estimated pregnancy rates were significantly different between the groups. Conclusions Fallopian tubes with minimal pathology appreciated at laparoscopy may have more significant intraluminal disease appreciated at salpingoscopy. In contrast, laparoscopic and salpingoscopic findings do correlate well in cases of more severe distal disease. Elevated mean salpingoscopy scores are associated with an extremely poor prognosis for conception.

Objective To correlate Chlamydia trachomatis immunoglobulin gamma (IgG) titers with psammoma bodies, dystrophic peritoneal calcification, degree of calcification, adhesions, and hydrosalpinges. Design This is a prospective single-blinded histologic analysis of tissue and retrospective analysis of historical laboratory and clinical variables. Setting Tertiary hospital and private practice patient charts. Patients Sixty consecutive patients with C. trachomatis IgG titers reported on the coding sheets of a previous study for endometriosis. Main Outcome Measures The histologic slides were reviewed in a blinded fashion for calcification. Previously used data sheets were reviewed for C. trachomatis IgG titers. Historical data, adhesion scores, hystrosalpingogram findings, and laparoscopic findings were obtained from charts. Results Dystrophic calcification, psammoma bodies, moderate-to-severe dystrophic calcification and hydrosalpinges were associated with positive C. trachomatis IgG titers. Conclusion This study suggests relationship of C. trachomatis with dystrophic calcification, psammoma bodies, adhesions, and hydrosalpinges. This relationship suggests that C. trachomatis IgG titers can be used as a marker to help determine those infertility patients who might best benefit from hysterosalpingogram or laparoscopy and in clinical studies of endometriosis, infertility, pain, or ovarian cancer. However, there is no current data to suggest a need for therapy on the basis of a positive C. trachomatis IgG titer or of dystrophic peritoneal calcification.

The endometrium is one of the most fascinating tissues in the human body. Its sole purpose is to enable implantation of an embryo during a relatively short window of opportunity in the menstrual cycle. It is becoming clear that overcoming the current bottleneck in improvements to assisted reproductive techniques will require a closer look at the interface between uterus and embryo. Indeed, embryo implantation requires a cross talk with a receptive endometrium. Using sonography, hysteroscopy and endometrial biopsy we can learn about anatomical and functional markers of endometrial receptivity. This article reviews the factors which might cause defective endometrial receptivity. These include uterine polyps, septa, leiomyomata and adhesions. The effect of thin endometrium, endometriosis and hydrosalpinx is also described. Finally contemporary investigation of molecular markers of endometrial receptivity is described. Improving embryo implantation by a closer look inside the uterus is the key to increasing pregnancy rates in IVF.

Objective: To determine if extended treatment with doxycycline before and after an in vitro fertilization (IVF) procedure can minimize the detrimental effect of a hydrosalpinx. Design: Retrospective analysis. Setting: University IVF program. Patient(s): Patients undergoing IVF, including 17 with a hydrosalpinx, 25 with adhesions or proximal tubal occlusion, and 22 with endometriosis or unexplained infertility. Intervention(s): Women with a documented hydrosalpinx were prescribed doxycycline 100 mg twice daily starting 1 week before expected retrieval and continued until 6 days after retrieval. No antibiotics were prescribed in the other groups. Main Outcome Measure(s): Implantation rates and IVF outcomes. Result(s): Implantation rates were 30% for the doxycycline-treated group of patients with a hydrosalpinx, 27% for the group with tubal occlusion/adhesion, and 24% for the group with endometriosis or unexplained infertility. Eight (47%) of 17 patients with a hydrosalpinx had a live birth, compared with 11 (44%) of 25 for the group with tubal occlusion/adhesion and 12 (55%) of 22 for the group with endometriosis/unexplained infertility. There were no differences between the groups in patient age, number of oocytes retrieved, fertilization rate, or number of blastomeres of the transferred embryos. Conclusion(s): No detrimental effect of a hydrosalpinx was evident for patients treated with extended doxycycline. Tremendous cost savings can be realized if treatment with 2 weeks of an inexpensive antibiotic provides outcomes comparable to surgical correction of a hydrosalpinx before IVF.

Objective To present a unique case of pelvic pain. Design Case report. Setting Academic institution. Patient(s) Thirty-nine year-old with history of endometriosis presented with pelvic pain and possible adnexal mass. Intervention(s) Imaging results were not consistent and suggested possible adnexal mass and hydrosalpinx in different studies. Physical exam was concerning for a vaginal mass that was felt not to be contiguous with the adnexa. At laparoscopy, a 3cm pararectal mass was identified immediately lateral to the uterosacral ligament and medial to the ureter. This mass was completely resected laparoscopically. Main Outcome Measure(s) Resolution of pelvic pain. Result(s) Pathologic diagnosis was ganglioneuroma. Postoperatively, the patient had resolution of her pelvic pain. Conclusion(s) Pelvic ganglioneuromas are a very rare entity but emphasize the importance of a broad differential for pelvic pain.

Objective To report a case of mature cystic teratoma of the fallopian tube. Design Case report. Setting Medical college–affiliated hospital. Patient(s) A 31-year-old woman, gravida 0, visited our outpatient clinic with infertility. Hysterosalpingography (HSG) showed a swollen right fallopian tube whose patency was not confirmed. Intervention(s) Laparoscopic right salpingectomy was perfomed for a solid-appearing mass ∼2 × 1.5 cm in diameter in the ampullary region. Histopathologic examination showed components from each germ cell layer; therefore, the diagnosis of a mature cystic teratoma of the right fallopian tube was confirmed. The patient became pregnant with IVF-ET and gave birth to a baby boy. Conclusion(s) In cases where hydrosalpinx is suspected, a careful assessment by either HSG or laparoscopy is necessary at the time of infertility examination.

Objective To prove the safety and feasibility of evaluating pelvic anatomy with a new imaging technique called saline intraperitoneal sonogram (SIPS). Design Prospective clinical case series. Setting Outpatient fertility clinic. Patient(s) Ten women with unexplained infertility and normal hysterosalpingograms (HSG). Five women with no known risk factors and five women with known risk factors for adhesive disease were enrolled. Intervention(s) Step 1 required performing a sonohysterogram. Step 2 involved directing a 17-g oocyte retrieval needle into a pocket of peritoneal fluid under ultrasound guidance and infusing normal saline. The pelvic anatomy was evaluated with the three-dimensional and four-dimensional mode on pelvic ultrasound. Main Outcome Measure(s) Technical feasibility, safety, time, fluid infusion, and deficit volumes. Result(s) All 10 patients successfully completed the protocol. One of the five women with no risk factors for adhesive disease and a normal HSG was discovered to have a unilateral hydrosalpinx and filmy adhesive disease on SIPS. Both findings were confirmed on laparoscopy. Three out of the five women with known risk factors had abnormal SIPS imaging and were confirmed on laparoscopy to have significant adhesive disease. The average procedure time was 45 minutes (±15 minutes). Conclusion(s) This study demonstrates that SIPS is a safe, quick, and potentially cost-effective method for evaluating pelvic adhesive disease in an outpatient facility in women with unexplained infertility and a normal HSG.

In this prospective comparative study, compared with fertile control subjects (n = 12), infertile patients with hydrosalpinx (n = 18) had lower E-cadherin and a trend toward decreased N-cadherin H-scores in the endometrium (3.6 ± 0.6 vs. 2.4 ± 0.8 and 0.57 ± 1.0 vs. 0.52 ± 0.5, respectively). In hydrosalpinx, epithelial N-cadherin expression was discontinuous and disappeared in atrophic patches.

In this prospective clinical study, ultrasound-guided transvaginal aspiration and sclerotherapy with 98% ethanol was performed before the IVF cycle in 33 patients with hydrosalpinx. The results showed that ultrasound aspiration and sclerotherapy could improve the endometrial receptivity and outcomes of IVF, with no recurring sign of the hydrosalpinx and no adverse effect on ovarian reserve or responsiveness during the IVF procedure.

Objective To present a case in which the use of a titanium/nickel microinsert in the management of unilateral hydrosalpinx contributed to a spontaneous intrauterine pregnancy. Design Case report. Setting University hospital. Patient(s) A 37-year-old nulligravid female with dense pelvic adhesive disease and unilateral hydrosalpinx. Intervention(s) Unilateral proximal occlusion of left fallopian tube with titanium/nickel microinsert. Main Outcome Measure(s) Pregnancy. Result(s) Spontaneous intrauterine pregnancy after confirmation via hysterosalpingogram of left tubal occlusion and right tubal patency. Conclusion(s) Transcervical proximal tubal occlusion using titanium/nickel microinserts provides an alternative in the management of hydrosalpinx in the setting of tubal factor infertility. Additionally, in the setting of a unilateral hydrosalpinx, unilateral occlusion can contribute to spontaneous intrauterine pregnancy.

Objective: To characterize the secretion of cytokines and growth factors in hydrosalpingeal fluid. Design: Retrospective analysis. Setting: Hospital-based infertility practice. Patient(s): Ten infertile women who underwent laparoscopic aspiration of their hydrosalpingeal fluid before salpingectomy or neosalpingostomy. Intervention(s): Samples were cryopreserved, then thawed and centrifuged to remove cellular debris. Main Outcome Measure(s): The supernatants were analyzed for the presence of human interferon-γ, epidermal growth factor, transforming growth factor-β2, and tumor necrosis factor-α by quantitative enzyme immunoassay kits. Result(s): Interferon-γ and transforming growth factor-β2 were not detected in any of the hydrosalpingeal fluid samples. Epidermal growth factor was present in 5 of 10 hydrosalpingeal fluid samples, with a mean (±SE) concentration of 26.7 ± 11.4 pg/mL. Tumor necrosis factor-α was detected in 7 of 10 samples, with a mean (±SE) concentration of 6.2 ± 3.6 pg/mL. Three of the 10 samples contained both tumor necrosis factor-α and epidermal growth factor. Conclusion(s): For the first time, we described the absence of interferon-γ and transforming growth factor-β2, and the presence of epidermal growth factor and tumor necrosis factor-α in human hydrosalpingeal fluid. Because the fundamental role of the human fallopian tube is secretory in nature, the alteration in substances secreted from the tubal epithelium that reflux into the uterine cavity may explain the deleterious effects that hydrosalpingeal fluid has on pregnancy rates after IVF-ET.

Objective To provide a summary of the actual knowledge about the clinical factors affecting the oocyte recipient (other than those associated with uterine cavity abnormalities) on the outcome of oocyte donation cycles. Design Review of the literature. Setting Information regarding the association between age, body mass index (BMI), endometrial priming, tobacco consumption, hydrosalpinx, and endometriosis/adenomyosis in oocyte recipients and the results of oocyte donation cycles. Result(s) Recipient age and the presence of hydrosalpinx are clearly associated with a poorer outcome in oocyte donation cycles. The negative impact of tobacco consumption has recently been confirmed. The exact relevance of an elevated BMI is under debate but it is likely that it determines a lower ongoing pregnancy rate (PR). Endometriosis may be significant for endometrial receptiveness in the context of a natural cycle, but no negative impact is detected when standard endometrial priming protocols are used in oocyte donation. The same may be true for adenomyosis, although its relevance to endometrial receptiveness is less clear. Conclusion(s) Accumulated knowledge in the field of oocyte donation has led to the recognition of clinical variables that affect cycle outcome by impairing endometrial receptiveness. Many studies are being carried out on endometrial molecular and gene expression changes taking place in these circumstances. In the near future a comprehensive understanding of these processes should be achieved, from a genetic, molecular, and clinical perspective. These advances in the collective knowledge will lead to an improvement in the diagnosis and treatment of infertile patients.

Transvaginal aspiration of pelvic cystic inflammatory masses guided by a real time ultrasound vaginal transducer is described. The technique was successfully used in 32 patients to aspirate these masses before ovulation induction for in vitro fertilization (IVF). It is a safe and simple procedure that resulted in significantly higher ovarian response to stimulation for IVF, easier ultrasonic follow-up of the follicles, significant increase in the average number of oocytes per pick-up, and significant increase in the number of embryos per transfer when compared with the control group.

Objective To propose a new theory describing the development of the fallopian tube fimbria. Design Case series report. Setting Metropolitan tertiary care children's hospital. Patient(s) Two girls, aged 12 and 20 years, who presented with pelvic pain. Intervention(s) Magnetic resonance imaging, laparoscopy with salpingectomy, and pathologic analysis. Main Outcome Measure(s) Description of a novel theory regarding the embryologic development of the fallopian tube and its fimbria. Result(s) In two non–sexually active girls the cause of their pelvic pain was found to be a hydrosalpinx associated with a discontinuous fallopian tube in which the fimbriated end did not directly communicate with the remainder of the fallopian tube. Conclusion(s) The two cases of pure congenital fallopian tube atresia, the presence of fimbriae in patients with mullerian (uterine, cervical, and vaginal) agenesis, and the role of the fimbria in ovarian-like and peritoneal cancers, support a novel hypothesis that the fimbria of the fallopian tube may arise separately from the rest of the tube.

A case of a genital tuberculosis found during laparoscopic evaluation for recurrent acute pelvic pain is presented. The symptoms of genital tuberculosis can vary greatly, and a laparoscopic approach is effective for making the diagnosis. Clinicians should consider tuberculosis as a differential diagnosis when encountering clinical presentations of pelvic pain and ascites.

To determine the impact of salpingectomy on the ovarian reserve. Comparisons are made with the contralateral side in patients with unilateral salpingectomy undergoing intracytoplasmic sperm injection (ICSI) cycles.Patients under 40 with unilateral salpingectomy and without history of ovarian surgery were selected for the multicentre retrospective study. Women with bilateral salpingectomy and history of endometriosis were excluded from the study. Antral follicle count, controlled ovarian hyperstimulation (COH) parameters and number of collected oocytes were the main outcome measures of the study.A total of 56 patients were eligible for this study. The mean age of the patients was 31.6 ± 4.7 years. The reasons for the salpingectomy were hydrosalpinx (39.3%, n = 22) and ruptured ectopic pregnancy (60.7%, n = 34). The ongoing pregnancy rate per embryo transfer was 30.6%. There was no statistically significant difference between the operated and non-operated sides in antral follicle count (AFC), follicles ≥ 17 mm and 10-17 mm on day of human chorionic gonadotrophin (hCG), or number of aspirated oocytes. In the subgroup analysis, AFC, number of growing follicles on day of hCG and number of collected oocytes were comparable between the ectopic pregnancy group and hydrosalpinx group.The study suggests that salpingectomy is not associated with detrimental effects on AFC and ovarian response.

Objective : To determine the effect of hydrosalpinx fluid-containing medium on murine embryo development and implantation. Design : The development of one-, two-, and four-cell mouse embryos in medium containing 5%, 10%, and 20% of human hydrosalpinx fluid was observed. Implantation rates of mouse embryos transferred into the uterine horn with hydrosalpinx fluid-containing media were determined. Setting : Private hospital-based fertility center and IVF program. Main Outcome Measure(s) : Percentage of embryos continuing cell division and implantation rates after ET. Result(s) : Hydrosalpinx fluid in culture medium affected embryo development in a dosedependent fashion. The injection of hydrosalpinx fluid-containing medium into the uterine horn did not affect embryo implantation. Conclusion(s) : Hydrosalpinx fluid negatively affects murine embryo development, but its presence in the uterine horn at ET did not affect implantation.

Objective To evaluate and compare the clinical impact of proximal tubal occlusion and salpingectomy when performed before IVF in patients with hydrosalpinges. Design Prospective randomized study. Setting Assisted reproduction unit in an obstetrics and gynecology department in a university hospital in Greece as well as assisted reproduction unit in an urban clinic in a major city in Greece. Patient(s) One hundred fifteen patients with unilateral or bilateral hydrosalpinges who were candidates for IVF treatment. Intervention(s) Laparoscopic proximal tubal occlusion, laparoscopic salpingectomy, controlled ovarian hyperstimulation, IVF, and embryo transfer. Main Outcome Measure(s) Implantation rate, clinical-pregnancy rate, ongoing-pregnancy rate, abortion rate, and ectopic-pregnancy rate. Result(s) Patients who underwent proximal tubal occlusion before IVF demonstrated significantly increased implantation, clinical-pregnancy, and ongoing-pregnancy rates compared with those with no surgical intervention and demonstrated implantation, clinical-pregnancy, and ongoing-pregnancy rates comparable to those who underwent salpingectomy. Conclusion(s) Proximal tubal occlusion, when performed in women with unilateral or bilateral hydrosalpinges before their IVF treatment, represents a potentially beneficial surgical procedure, increasing significantly the chances for successful implantation and for clinical and ongoing pregnancy. Proximal tubal occlusion may be viewed as a valid alternative when salpingectomy is technically difficult or not feasible.

Objective To discuss the possible role of abnormal embryo migration as a cause of ectopic pregnancy during IVF with hydrosalpinges. Design Case report. Setting University-based reproductive endocrinology and fertility clinic. Patient(s) A patient presenting with a tubal ectopic pregnancy after spontaneous conception in a preexisting hydrosalpinx. Intervention(s) Laparoscopic salpingectomy. Main Outcome Measure(s) Ultrasound and operative findings. Result(s) Case demonstration of abnormal embryo migration into a surgically documented preexisting hydrosalpinx during a spontaneous conception. Conclusion(s) The mechanism of increased tubal ectopic pregnancy rates during IVF with hydrosalpinges remains unexplained. This case supports abnormal embryo migration due to the hydrosalpinx as a contributing factor.