Fluoroscopic-guided hysteroscopic tubal cannulation results in high technical success and pregnancy rates comparable with the more traditional laparoscopically guided hysteroscopic tubal cannulation.

Objective: To compare women with proximal tubal obstruction (PTO) undergoing hysteroscopic tubal cannulation with fluoroscopic guidance vs. laparoscopic guidance. Design: Retrospective cohort study. Setting: All fluoroscopically-guided hysteroscopic tubal cannulations were performed in an ambulatory suite. All laparoscopically-guided hysteroscopic tubal cannulations were performed in a hospital operating room. Patients: Infertile women with unilateral or bilateral PTO on hysterosalpingography who failed selective salpingography in the radiology suite and had a planned laparoscopy or hysteroscopy in the operating room for defects seen on sonohysterography were studied. Intervention: All women had a Novy catheter system positioned hysteroscopically to cannulate the occluded fallopian tube(s). Women undergoing fluoroscopically guided hysteroscopic tubal cannulation (FHTC), which used contrast and C-arm pelvic imaging at an ambulatory center, were compared with those undergoing hospital-based laparoscopically guided hysteroscopic tubal cannulation (LHTC) with laparoscopic visualization. Main Outcome Measurements: Tubal cannulation success; bilateral cannulation success; tubal perforations; post-FHTC non-in vitro fertilization (non-IVF) intrauterine pregnancies; days from procedure to pregnancy for non-IVF intrauterine pregnancies; and time to non-IVF pregnancy hazards ratio. Results: A total of 76 infertile women undergoing either FHTC (34 women) or LHTC (42 women) between 2015 and 2019 were included. Demographic variables were similar among the 2 groups. A total of 31 (92%) of 34 of patients undergoing FHTC and 36 (86%) of 42 of patients undergoing LHTC had at least one tube successfully cannulated. In total, 30 (78%) of 34 of patients undergoing FHTC and 32 (79%) of 42 patients undergoing LHTC had all occluded tubes successfully cannulated. Tubal perforation occurred in 1 (3%) of 34 FHTC cases and 3 (7%) of 42 LHTC cases. A similar percentage of non-IVF treatment-induced intrauterine pregnancies were achieved in the FHTC and LHTC groups (10/34 [29%] vs. 12/42 [29%]). Among patients who conceived without IVF, time from procedure to pregnancy was lower in the FHTC group (101 ± 124.6 days) compared with the LHTC group (228 ± 216 days). There was a significant difference in time to pregnancy when only those who conceived were considered (hazard ratio, 9.39; 95% confidence interval, 2.42-36.51); however, there was no significant difference when all subjects regardless of pregnancy outcome were analyzed (hazard ratio, 1.48; 95% confidence interval, 0.64-3.446). Conclusion: Fluoroscopically guided hysteroscopic tubal cannulation is a safe, effective, incision free procedure that results in comparable rates of tubal patency and intrauterine pregnancies as LHTC. This technique should be considered in women undergoing treatment of PTO when operative laparoscopy is not otherwise indicated.

Systematic review and network meta-analysis of hydrosalpinx treatment before in vitro fertilization.

OBJECTIVES: To compare different methods to treat hydrosalpinx, based on both ablative and non-ablative approaches, in infertile patients before undergoing IVF-ET. METHODS: Systematic review and network meta-analysis (NMA) of comparisons between different treatments of hydrosalpinx in infertile patients undergoing IVF. DATA SOURCES: structured searches in common citation databases. Study inclusion criteria: peer-reviewed randomized trials (RCT) or cohort studies comparing effects of salpingectomy, laparoscopic proximal tubal occlusion (LTO), insertion of intratubal device (ITD), sclerotherapy, ultrasound-guided aspiration and no treatment, on live birth, ongoing pregnancy, clinical pregnancy as main outcomes, considering also miscarriage, ectopic pregnancy and complications as secondary outcomes. Principal NMA included RCT, and aggregated NMA of RCT and observational studies was carried out. Pooled effects have been estimated by Odds Ratio (OR) and its 95% confidence interval (CI) for direct and indirect-mixed comparisons, derived from random-effects models. Imprecision and heterogeneity of NMA estimations was assessed by comparison of its 95% CI with predefined intervals for clinically relevant size of effect (OR <0.9 or >1.1). Surface under the cumulative ranking curve (SUCRA) were used to predict treatment rankings for each outcome. RESULTS: Nine RCT were included in main analysis, plus 17 additional observational studies in additional analysis. NMA of RCT did not identify significant differences in the effect of compared treatments on live birth rate, and LTO was the option with the highest value of SUCRA (0.92, mean rank: 1.2). Salpingectomy and US-aspiration associated to a significant increase of ongoing pregnancy rate compared to no treatment, according to NMA results (NMA OR: 4.35; 95% CI: 1.7, 11.14 and 2.8; 95% CI: 1.03, 7.58 respectively). Salpingectomy had the highest SUCRA value (0.88, mean rank: 1.4). NMA estimated significant increase of clinical pregnancy rate for salpingectomy compared with no treatment (NMA OR: 2.24; 95% CI: 1.3, 3.86) as well as for LTO versus no treatment (NMA OR: 2.55; 95% CI: 1.2, 5.41). Both comparisons were affected by a high grade of heterogeneity. For clinical pregnancy, LTO was the intervention with highest SUCRA (0.85; mean rank: 1.6). Regarding secondary outcomes, feasible NMA estimates did not support significant differences between treatments effects. According to aggregated NMA including randomized and observational studies, sclerotherapy showed significant beneficial effects on live birth rate compared to no treatment (NMA (OR: 4.6; 95% CI: 1.21, 17.46). Compared with untreated patients, the aggregated NMA estimates a higher ongoing pregnancy rate in patients treated with salpingectomy (NMA OR: 3.35; 95% CI: 2.12, 5.12), US-aspiration (NMA OR: 2.16; 95% CI: 1.28, 3.65) and LTO (NMA OR: 2.46; 95% CI: 1.11, 5.43). Salpingectomy and LTO produced a higher beneficial effect compared to ITD, based on both direct and indirect comparisons. Salpingectomy obtained the highest SUCRA value in rank of effects on ongoing pregnancy (0.94; mean rank: 1.2). NMA found significant effects on clinical pregnancy for comparisons between the different active management procedures compared with no treatments, with the exception of ITD insertion. LTO had more increasing effect on clinical pregnancy rate compared with US-aspiration (NMA OR: 2.04; 95% CI: 1.05, 3.97), while for the rest of the comparisons between procedures no significant differences were identified. NMA ranked LTO as the treatment with a highest SUCRA value (0.91; mean rank: 1.5). NMA prediction models identified LTO as best intervention to reduce miscarriage (SUCRA value: 0.84; mean rank: 1.8), as sclerotherapy as safer option in terms of ovarian response to IVF stimulation. CONCLUSIONS: The present NMA fails to support the effectiveness of any option to treat hydrosalpinx before IVF in order to improve live birth rates, although the beneficial effect of salpingectomy and US aspirations on ongoing pregnancy rates and of both salpingectomy and LTO on clinical pregnancy rates emerges from our analysis, which reinforces current recommendations. Based on the aggregated analyses, sclerotherapy could be a promising alternative to conventional laparoscopic techniques, combined with a favorable safety profile. This article is protected by copyright. All rights reserved.

Comparison of microbial abundance and diversity in uterine and peritoneal fluid in infertile patients with or without endometriosis.

INTRODUCTION: Endometriosis (EM) is a multifactorial disease that affects 10 - 15% of women of reproductive age. Additionally, 30-50% of women with EM suffer from infertility. The mechanism of infertility caused by EM has not yet been consistently explained. In recent years, studies have shown a link between infertility associated with EM and changes in the reproductive tract microbiota. METHODS: In this study, we involved 26 EM patients (8 cases of stage I-II and 18 cases of stage III-IV) and 31 control subjects who were tubal obstruction-related infertility (TORI). The samples from peritoneal fluid (PF) and uterine fluid (UF) were collected and sequenced by 16 S rRNA amplicon. RESULTS: In the comparison of microbial diversity, we found no significant differences in the microbial diversity of PF and UF between patients with stage I-II EM and those with TORI. However, there was a significant difference in microbial diversity among patients with stage III-IV EM compared to the previous two groups. Lactobacillus decreased in PF of EM compared to the control group, while it increased in UF. In PF, the abundance of Pseudomonas, Enterococcus, Dubosiella and Klebsiella was significantly higher in patients with stage III-IV compared to TORI patients. And in UF, the main differences existed between stage I-II EM compared to the other two groups. The abundance of pontibacter, aquabacterium, Rikenellaceae and so on at the genus level was significantly enriched in the EM patients with stage I-II. In the analysis based on KEGG database, EM may affect the receptivity related pathways of the endometrium by influencing changes in the uterine microbiota. CONCLUSION: Our results indicated that as EM progresses, the microorganisms in UF and PF keep changing. These changes in the microbiota, as well as the resulting alternations in gene functional classification, may play an important role in the infertility associated with EM.

Revolutionizing Fallopian Tube Evaluation in Infertility: Transvaginal Sonography Case Study.

Background: Transvaginal four-dimensional hysterosalpingo-contrast sonography (TVS 4D-HyCoSy) is a pivotal diagnostic tool in the assessment and management of infertility. Conventionally, a 20mL syringe is employed for contrast agent injection, either at a constant or pulsatile pressure. However, in cases of bilateral fallopian tube obstruction, continued injection can lead to discomfort and excessive pressure within the uterine cavity, necessitating discontinuation of the examination. Case Presentation: In this illuminating case study, a patient underwent TVS 4D-HyCoSy due to infertility concerns. Initial contrast agent injection failed to visualize both fallopian tubes, accompanied by acute pain. Bilateral tubal obstruction was diagnosed, prompting an innovative approach. A 2.5mL syringe was chosen for pulsed injection, leading to successful visualization of patency in one fallopian tube. Remarkably, the patient achieved natural pregnancy within three months of the examination. Conclusion: Pulsed injection using a small-volume syringe emerges as a promising technique in cases of fallopian tube obstruction during TVS 4D-HyCoSy. This method not only enhances patient comfort but also improves the likelihood of visualizing fallopian tube patency, contributing to accurate infertility assessments. As a supplementary technique, it addresses limitations associated with constant pressure injection and offers a novel approach to enhance diagnostic success.

[Impact of Endometriosis on the Therapeutic Effect of Hysteroscopic Fallopian Tube Catheterization Combined With Laparoscopy in Infertile Patients With Proximal Tubal Obstruction].

Objective: To investigate the impact of endometriosis on the therapeutic effect of hysteroscopic fallopian tube catheterization combined with laparoscopy in infertile patients with proximal tubal obstruction. Methods: We conducted a retrospective analysis of patients who underwent hysteroscopic fallopian tube catheterization combined with laparoscopy for infertility caused by proximal fallopian tube obstruction between January 19, 2016 and March 20, 2020 at the Department of Reproductive Endocrinology, West China Second Hospital, Sichuan University. During the operation, hydrotubation was performed to verify whether there was proximal tubal obstruction. Then, the patients were categorized into an endometriosis group and a non-endometriosis group according to whether their proximal tubal obstruction was combined with endometriosis. The baseline data were balanced by propensity score matching and the rate of successful surgical unblocking of proximal tubal obstruction in infertile patients by hysteroscopic fallopian tube catheterization combined with laparoscopy was calculated. Treating cases lost to follow-up in both groups as non-pregnant cases according to the principle of intention-to-treat analysis, we followed up the pregnancy outcomes after surgery. The primary indicators included overall successful surgical unblocking rate, clinical pregnancy rate, and spontaneous pregnancy rate, while the secondary indicators included live birth rate, miscarriage rate, ectopic pregnancy rate, and the mean time to spontaneous pregnancy after surgery. The primary indicators included overall successful surgical unblocking rate, clinical pregnancy rate, and spontaneous conception rate, while the secondary indicators included live birth rate, miscarriage rate, ectopic pregnancy rate, and the mean time to spontaneous pregnancy after surgery. Results: After propensity score matching, 113 cases were included in each of the two groups, with the overall successful surgical unblocking rate being 72.6%. The successful surgical unblocking rate of patients in the endometriosis group was higher than that of the non-endometriosis group, with the difference being statistically significant (78.8% vs. 66.4%, P<0.05). A total of 38 patients were lost after follow-up matching. Postoperative follow-up was performed to date and, through intention-to-treat analysis, the spontaneous conception rate was found to be higher in the endometriosis group than that in the non-endometriosis group (44.2% vs. 30.1%, P<0.05), while the mean time to spontaneous pregnancy after surgery was shorter in the endometriosis group than that in the non-endometriosis group (46 months vs. 53 months, P<0.05). There was no significant difference in clinical pregnancy rate, live birth rate, miscarriage rate, and ectopic pregnancy rate between the endometriosis group and the non-endometriosis group ( P>0.05). Conclusion: When infertility caused by proximal tubal obstruction is combined with endometriosis, performing hysteroscopic fallopian tube catheterization combined with laparoscopy contributes to the improvement of reproduction outcomes.

Fluoroscopically-Guided Hysteroscopic Tubal Cannulation: A Procedure for Proximal Tubal Obstruction.

Objectives: To evaluate the cannulation success rate, cumulative pregnancy, and time to intrauterine pregnancy rate following fluoroscopically-guided hysteroscopic tubal cannulation (FHTC) for infertile subjects with proximal tubal obstruction. Methods: This retrospective study evaluated subjects with unilateral or bilateral proximal tubal obstruction on hysterosalpingography, who failed concomitant selective salpingography and subsequently underwent FHTC at the time of a hysteroscopy performed for findings seen on sonohysterography. FHTC employed a Novy Catheter (CooperSurgical, Inc, Trumbull, CT.) with or without the 3 French inner catheter and guidewire, to cannulate the occluded fallopian tube(s), followed by the injection of HypaqueTM (Amersham Health, Inc, Princeton, NJ.) contrast under C-arm imaging. Technical success rates, complications, post-procedure pregnancies, and average time from surgery to pregnancy were evaluated. Results: Thirty-two women between January 1, 2017 and December 31, 2019 met the entry criteria and underwent FHTC. Of those women with bilateral obstruction, 6/6 (100%) of subjects achieved at least unilateral patency, while patency was achieved in 23/26 (88.5%) subjects with unilateral obstruction. Twenty-nine of 32 (90.6%) subjects had at least one tube successfully cannulated with 34/38 (89.5%) of proximally obstructed tubes opened. Asymptomatic tubal perforation occurred in 1/38 tubes (2.6%). Ten subjects (34.5%) achieved intrauterine pregnancies without in vitro fertilization in an average of 64.9 days from the procedure. There were no multiple pregnancies and one ectopic pregnancy. Conclusions: FHTC is a safe, effective, incision free procedure that results in 90% of tubes successfully cannulated, and an observed short time to intrauterine pregnancy.

Evaluation of the safety and effectiveness of tubal inflammatory drugs in patients with incomplete tubal obstruction after four-dimensional hysterosalpingo-contrast-sonography examination.

BACKGROUND: To investigate the safety and effectiveness of tubal inflammatory drugs in patients with incomplete tubal obstruction of at least one side after four-dimensional hysterosalpingo-contrast-sonography (4D-HyCoSy) examination. METHODS: Two hundred fifteen cases of tubal incomplete obstruction were diagnosed by ultrasonography from February 2019 to November 2020.According to retrospective analysis,the patients in this study were divided into experimental and control groups; the experimental group combined with salpingitis drugs, and the control group received blank control. Basic information, degree of pain, postoperative complications, and pregnancy rate were then compared between the two groups. RESULTS: Compared with the control group, there was no significant difference in the basic information; in preoperative, intraoperative, or postoperative pain; or in postoperative complications (P > 0.05). The cumulative pregnancy rate of the experimental group (26.8%) was statistically different from that of the control group (14.4%) (P < 0.05). CONCLUSIONS: We observed that for infertile patients with incomplete obstruction of at least one fallopian tube as diagnosed by contrast-enhanced ultrasonography, salpingitis-treatment drugs effectively improved the pregnancy rate postoperatively, with high effectiveness and safety. This regimen is thus worthy of further investigation and promotion in the future.

Transvaginal Sonography Post-Office Hysteroscopy as a Screening Tool for Tubal Patency: A Reliable and Feasible Technique in an Outpatient Setting.

OBJECTIVE: To determine feasibility and accuracy of post-hysteroscopic transvaginal ultrasonography (TVUS) measurement of pelvic fluid accumulation as a screening method for tubal patency (TP). METHODS: We conducted a retrospective cohort study of 85 patients who underwent uterine cavity assessment by office hysteroscopy at our university-affiliated fertility centre from November 2019 to October 2020. During the study period, two-dimensional (2D) TVUS was performed pre- and post-hysteroscopy to evaluate TP. Patient records were reviewed for demographics, diagnosis, and prior/subsequent TP testing. Predictive values for TP were calculated. RESULTS: Pelvic fluid accumulation post-hysteroscopy was found in 65.9% of patients (56). Accumulation of fluid was seen with the use of as little as 10-50 mL of saline. Using more fluid did not increase the likelihood of demonstrating TP (P = 0.17). A trend towards more false-negative results for TP was observed when less fluid was used (7.7% with 10-50 mL vs. 3.8% with 60-190 mL and 1.3% with 200-760 mL; P = 0.10). The positive predictive value (PPV) of TVUS post-hysteroscopy in comparison to known patency/occlusion was 100%; negative predictive value (NPV) was 33%; sensitivity was 82.8%; and specificity was 100%. Similar values were seen in a second analysis that included patients with highly suspected patent or occluded tubes (n = 60); presumed predictive values were: PPV 100%, NPV 42%, sensitivity 78.8%, and specificity 100%. The use of more fluid did not increase pain (P = 0.75). This finding remains after accounting for confounders (e.g., pre-medication, endometrial biopsy). CONCLUSION: TVUS pre- and post-hysteroscopy is feasible in an outpatient setting, and can serve as a reliable screening tool for TP. When hysteroscopy is performed and TP is not known, TVUS can be added for screening, potentially omitting the need for more invasive examinations. With limited non-urgent ambulatory services, it is of upmost importance to maximize information from a single procedure.

Factors affecting the success of fallopian tube recanalization in treatment of tubal obstructive infertility.

OBJECTIVE: To examine potential risk factors associated with the success rate following fallopian tube recanalization (FTR) in infertile women with obstruction of the proximal fallopian tube. METHODS: We retrospectively studied patients who underwent FTR for tubal obstructive infertility between January 2016 and December 2018 at the Third Affiliated Hospital of Guangzhou Medical University. FTR was performed using a catheter and guidewire system to clear tubal obstruction. Predictive factors potentially associated with the success rate were assessed by logistic regression. RESULTS: A total of 762 patients were included. Multivariable analysis showed that age (odds ratio [OR] = 2.38, 95% confidence interval [CI]: 1.24-4.58), infertility type (OR = 2.82, 95% CI: 1.36-6.21), history of ectopic pregnancy (OR = 7.87, 95% CI: 4.05-15.81), history of abdominal surgery (OR = 4.30, 95% CI: 2.22-8.60), history of artificial abortion curettage (OR = 4.08, 95% CI: 2.12-8.03), and duration of infertility (OR = 2.03, 95% CI: 1.06-3.85) were independently associated with postoperative tubal patency. CONCLUSIONS: Our findings suggest that risk factors, such as age ≥35 years, secondary infertility, duration of infertility ≥5 years, and histories of ectopic pregnancy, abdominal surgery, and artificial abortion curettage, affect the success rate of FTR. These factors may also predict surgical success in treating tubal obstructive infertility.

A two-third majority of infertile women exhibit endometriosis in pre-ART diagnostic hysteroscopy and laparoscopic chromopertubation: only one-third have a tubal obstruction.

PURPOSE: This study was undertaken to evaluate the prevalence of endometriosis in infertile women of couples with non-male factor infertility. METHODS: A retrospective validation analysis was carried out of consecutive women of infertile couples with non-male factor infertility who received combined diagnostic hysteroscopy and laparoscopy, in the period from January 2017 to August 2019 in the Department for Gynecology and Reproductive Medicine (n = 300). Type, stage and site of endometriosis were assessed and matched with the occurrence of tubal stenosis. Binary regression analysis was used to estimate the prevalence of endometriosis. RESULTS: Endometriosis was diagnosed in 67% (n = 201). Primary infertility (OR 1.76; p = 0.036), dysmenorrhea (OR 2.47; p = 0.002), and a shorter cycle length (OR 0.972; p = 0.036) were independent risk factors for detection of endometriosis in diagnostic hystero-laparoscopy. The most frequent endometriosis sites were pelvic side wall (53.2%) and uterosacral ligaments (41.8%). Patients with endometriosis showed less often a tubal occlusion (34.32% vs. 41.4%; p = 0.205) and presented a lower rate of bilateral obstruction (9.5% vs. 18.8.%, p = 0.024). Women with endometriosis of a Fallopian tube showed a higher rate of tubal occlusion on the same side (right side p = 0.002; left side p = 0.001). Patients with rASRM score III showed the highest rate of tubal obstruction. CONCLUSIONS: The prevalence of endometriosis in infertile women was higher than expected. The indication for operative infertility diagnostics by minimal invasive techniques should be made much more generous as well as the complete clarification of the causes of female infertility.

Bilateral but not unilateral tubal obstruction is associated with positive chlamydia serology.

OBJECTIVE: To assess the association between positive Chlamydia trachomatis (C. trachomatis) serology and unilateral or bilateral tubal obstruction. METHODS: This was a cross sectional study that evaluated the association of positive C. trachomatis serology (Immunofluorescence Indirect Serology, IIF or Enzyme Immune Essay, EIE), in two infertile groups: A. 243 patients (27 with unilateral obstruction and 216 without it). B. 247 patients (31 with bilateral obstruction and 216 without it). The exclusion criteria were tubal ligation (tubectomy) and tubal surgery. The statistical test (SPSS 17.0) was the Chi-Square with a p=5%. Tubal obstruction was diagnosed through hysterosalpingography (HSG). RESULTS: The mean age of the patients without obstruction was 33.6 years, SD 4.9. The mean age of the patients with unilateral obstruction was 33.7 years SD 4.9. The mean age of the patients with bilateral obstruction was 33.6 years, SD 4.9. There was no statistically significant difference between the age groups. In group A (unilateral obstruction versus serology) the Chi-Square was 0.02 (p=n.s.) and the Attributable Risk (AR) = 0.7%. In Group B (bilateral obstruction versus serology) the Chi-Square test was 9.87 (p<0.005) and the AR = 14.8%. CONCLUSION: This study found a strong and statistically significant association between bilateral tubal obstruction and C. trachomatis positive serology. The power of the test was 86%. There was no association between unilateral obstruction and positive serology.

Endometriosis III and IV as a risk factor for tubal obstruction in infertile women.

OBJECTIVE: A previous study carried out among infertile women with tubal obstruction identified a relative risk of 2.5 for Chlamydia trachomatis seropositivity. However, endometriosis may also be associated with increased risk. This study aimed to evaluate the risk of tubal obstruction associated with endometriosis III/IV among women submitted to assisted reproductive procedures. METHODS: A case-control study was performed among 144 women with and without tubal obstruction. We calculated the odds ratio with 95% CI regarding the association of endometriosis III/IV and tubal obstruction. Calculations were performed using the SPSS v.17.0 package. RESULTS: The mean age was 33.7 years (4.76 SD), and the mean infertility duration time was 66.7 months (120.6 SD). The total prevalence of endometriosis was 20/144 (13%). Among 144 women, the risk group with tubal obstruction and endometriosis III/IV comprised 7out of 20 (35%), compared with the group without such risk, that comprised 22 out of 124 (17%). The X2 test was 3.19 with a p-value of 0.07. The odds ratio (OR) was 2.5 (95% CI: 0.647-9.639). CONCLUSION: Although the OR was 2.5, there was no significant difference between the groups with and without endometriosis III/IV. Further studies are needed to increase the sample size.

Hysteroscopic evaluation of tubal peristaltic dysfunction in unexplained infertility.

It has been realised that rhythmic peristalsis of the ostia and tubes can be observed during hysteroscopy. The aim of this study was to examine the presence of tubal peristaltic dysfunction in unexplained infertility (UI). Hysteroscopy was performed in 35 women with UI and in 37 healthy fertile women. Bilateral tubal peristalses were assessed hysteroscopically by the observation of methylene blue injection and its transport to the Fallopian tubes. Tubal patency was evaluated with laparoscopic chromopertubation. Two women in control group (6.67%) and eight women in UI group (30.77%) had no tubal peristalsis, at least one tube with normal tubal patency. The difference was statistically significant (p = .019). Tubal peristaltic dysfunction may be a hidden cause of subfertility in women with bilateral patent Fallopian tubes. There is a definite need for larger trials to identify tubal peristaltic dysfunction as a cause of UI. Impact statement What is already known on this subject? Unexplained infertility has no identified pathophysiologic basis. It has been realised that rhythmic peristalsis of the ostia and tubes can be observed during hysteroscopy. What do the results of this study add? Tubal peristaltic dysfunction was detected in two tubes (3.70%) in a control group and nine tubes (19.57%) in women with unexplained infertility, when the tubes were patent. The difference was statistically significant (p = .012). What are the implications of these findings for clinical practice and/or further research? In cases of bilateral patent Fallopian tubes such as in unexplained infertility, tubal peristaltic dysfunction may be a hidden additional cause of subfertility.

A previous caesarean section is not a risk factor for tubal abnormalities in the infertile population.

In this retrospective cohort study of 1716 cases of women undergoing infertility treatment between the years 1999-2012, we aimed to identify whether parturients with a previous surgical history are at a higher risk for tubal abnormalities as determined by hysterosalpingography (HSG) in this infertile population. Amongst the study population, tubal obstruction was identified on HSG in 15.8% of patients with no past history of an abdominal surgery and 16.3% of patients with a previous caesarean section (CS) delivery. These rates were significantly lower than those for women with a previous gynaecological surgery (34.7%) or abdominal surgery (27%) (p < .001 for all comparisons). Our results suggest that past history of CS poses no additional risk for tubal abnormality within the infertile population, whereas a history of other abdominal or gynaecological surgical procedures doubles this risk. Impact Statement What is already known on this subject? While numerous risk factors for tubal factor infertility have been established, to date, the relation between previous abdominal surgeries and the risk for tubal factor infertility remains inconclusive. What the results of this study add? In this study, we aimed to evaluate the correlation between previous CS history and the risk for having tubal factor infertility. Our results demonstrated that previous caesarean section delivery does not increase the risk for tubal factor infertility in the infertile population, whereas history of other abdominal or gynaecological surgical procedures doubles this risk. What the implications are of these findings for clinical practice and/or further research? Further research is needed for further evaluation of this association and its clinical implications.

Psychological and emotional concomitants of infertility diagnosis in women with diminished ovarian reserve or anatomical cause of infertility.

OBJECTIVE: To examine the magnitude and predictors of emotional reactions to an infertility diagnosis in two groups of women: those with diminished ovarian reserve (DOR), and those clinically diagnosed with an anatomical cause of infertility (ACI). DESIGN: Cross-sectional study. SETTING: Academic and private fertility clinics. PATIENT(S): Women diagnosed with DOR (n = 51) and women diagnosed with ACI (n = 51). INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Fertility Problem Inventory (infertility distress), Rosenberg Self-Esteem Scale, Health Orientation Scale (emotional reactions to receiving a diagnosis). RESULT(S): Women with DOR had statistically significantly higher infertility distress scores than women with ACI and higher scores on subscales assessing distress from social concerns, sexual concerns, and a need for parenthood. In both groups, higher self-esteem was associated with lower infertility distress. Hierarchical multiple regression analyses revealed that for women with DOR and those with ACI lower infertility distress but not self-esteem predicted a more positive emotional reaction toward receiving a fertility diagnosis. CONCLUSION(S): Women diagnosed with DOR have greater infertility distress but similar self-esteem and emotional reactions to their diagnosis compared with women who have an anatomical cause of infertility. These results suggest that for both groups distress surrounding infertility itself may influence the way women respond to learning the cause of their infertility.

Intraoperative Factors that Predict the Successful Placement of Essure Microinserts.

STUDY OBJECTIVE: To determine whether the number of coils visualized in the uterotubal junction at the end of hysteroscopic microinsert placement predicts successful tubal occlusion. DESIGN: Cohort retrospective study (Canadian Task Force classification II-2). SETTING: Department of obstetrics and gynecology in a teaching hospital. PATIENTS: One hundred fifty-three women underwent tubal microinsert placement for permanent birth control from 2010 through 2014. The local institutional review board approved this study. INTERVENTION: Three-dimensional transvaginal ultrasound (3D TVU) was routinely performed 3 months after hysteroscopic microinsert placement to check position in the fallopian tube. MEASUREMENTS AND MAIN RESULTS: The correlation between the number of coils visible at the uterotubal junction at the end of the hysteroscopic microinsert placement procedure and the device position on the 3-month follow-up 3D TVU in 141 patients was evaluated. The analysis included 276 microinserts placed during hysteroscopy. The median number of coils visible after the hysteroscopic procedure was 4 (interquartile range, 3-5). Devices for 30 patients (21.3%) were incorrectly positioned according to the 3-month follow-up 3D TVU, and hysterosalpingography was recommended. In those patients the median number of coils was in both the right (interquartile range, 2-4) and left (interquartile range, 1-3) uterotubal junctions. The number of coils visible at the uterotubal junction at the end of the placement procedure was the only factor that predicted whether the microinsert was well positioned at the 3-month 3D TVU confirmation (odds ratio, .44; 95% confidence interval, .28-.63). When 5 or more coils were visible, no incorrectly placed microinsert could be seen on the follow-up 3D TVU; the negative predictive value was 100%. No pregnancies were reported. CONCLUSION: The number of coils observed at the uterotubal junction at the time of microinsert placement should be considered a significant predictive factor of accurate and successful microinsert placement.

Rendimiento diagnóstico de la histerosalpingografía por resonancia magnética: resultados iniciales / Diagnostic performance of magnetic resonance hysterosalpingography: initial results Abstract

Objetivo: Determinar el rendimiento diagnóstico de la histerosalpingografía por resonancia magnética (HSG-RM), utilizando la laparoscopia como método de referencia. Materiales y métodos: Se incluyeron 22 pacientes. A todas se les realizó una HSG-RM con un resonador 1.5 Tesla y luego una laparoscopia con cromotubación. Dos radiólogos examinaron las RM, determinando la permeabilidad tubaria por consenso. Se realizaron análisis descriptivos y de rendimiento diagnóstico. Resultados: La HSG-RM tuvo una tasa de éxito del 91%. La duración del estudio fue 49ą15 minutos, el volumen inyectado 26 ą 16 cm³ y la escala de dolor 30ą 19 de 100. La sensibilidad y especificidad de la HSG-RM fueron del 100% para la prueba de Cotte global y a la izquierda, y del 25% y 93,3% para la prueba de Cotte a la derecha, respectivamente. Hubo 2 complicaciones menores y ninguna importante. Discusión: Nuestros resultados iniciales demostraron una alta sensibilidad y especificidad. Si bien otros estudios analizaron la capacidad de la HSG-RM para evaluar la permeabilidad tubaria con buenos resultados, el uso de un patrón de referencia defectuoso dejaba margen para una duda razonable, impidiendo una recomendación basada en pruebas sólidas. Sin embargo, al cotejar nuestros resultados con los publicados, observamos un alto grado de concordancia en tanto el derrame positivo se diagnostica correctamente con una especificidad de 100% o con un porcentaje cercano a esta cifra. Conclusión: La HSG-MR es una alternativa factible y segura de la HSG convencional o virtual, la histerosonografía y la cromotubación.

Objective: To determine the diagnostic performance of magnetic resonance hysterosalpingography (MRHSG) using laparoscopic chromotubation as a method of reference. Materials and methods: Twenty-two patients were included. The MRHSG was performed in a 1.5 Tesla MR scanner. Afterwards, patients underwent laparoscopic chromotubation. MR images were examined by two trained radiologists, and tubal patency was determined by consensus. A descriptive analysis was carried out, as well as an analysis of the diagnostic performance. Results: MRHSG had a 91% success rate. Exam duration of the examination was 49ą15min, with an injected volume 26ą 16cc, and pain scale 30ą 19 out of 100. Sensitivity and specificity of MRHSG was 100% for global and left Cotte, and 25% and 93.3% for right Cotte, respectively. Only 2 minor and no major complications were observed. Discussion: The initial results of MRHSG have shown high sensitivity and specificity. Even though other studies have analysed the potential of MRHSG with good results, the use of a flawed reference standard left a margin for a reasonable doubt as regards its true potential, thus preventing a solid evidence based recommendation. Nevertheless, if our results are compared to those published, a high level of agreement is observed in that positive spillage is correctly diagnosed with specificities near or at 100%. Conclusion: MRHSG is a feasible and safe alternative to conventional or virtual HSG, ultrasound-hysterography and chromotubation.

Spontaneous bilateral torsion of fallopian tubes presenting as primary infertility.

UNLABELLED: Case presented at "Stump the Professors" 44th American Association of Gynecologic Laparoscopists Global Congress on Minimally Invasive Gynecology, NV, USA, 15-19 November 2015 BACKGROUND: Spontaneous torsion of the fallopian tubes is a rare condition, usually seen in acute settings or as incidental findings during laparoscopy. PRESENTATION OF THE CASE: A 34-year-old nulligravid woman with inability to conceive for 7 months presented to our center. Her hysterosalpingography revealed a blind-ending right fallopian tube, and a blocked and dilated left fallopian tube. Laparoscopy showed a long, auto-amputated right fallopian tube, disconnected from the fimbriae and a long, dilated left fallopian tube, with several twists around its axis. Bilateral salpingectomy was performed. The patient subsequently underwent IVF, resulting in an ongoing pregnancy. CONCLUSION: Spontaneous torsion of the fallopian tubes can manifest as primary infertility without any antecedent symptoms, and should be considered in the differential diagnosis of bilateral tubal obstruction.

Cytokine profile in Nigerians with tubal infertility.

INTRODUCTION: Immune response to genital Chlamydia trachomatis infection is involved in both immunity and pathology. The cytokine profile during infection has been implicated in the disease outcome, either resolution or severe sequelae. Serum cytokines of Chlamydia positive Nigerian women with tubal infertility were assessed to determine their possible relationship with tubal occlusion. MATERIAL AND METHODS: One hundred and fifty age-matched consenting women (100 fertile and 50 with tubal infertility) were recruited based on C. trachomatis antibody positivity and grouped into infertile Chlamydia positive (CTpos) women (n = 50), fertile Chlamydia positive women (n = 50) and fertile Chlamydia negative (CTneg) women as controls (n = 50). High vaginal swabs and endo-cervical swabs were collected for microscopy, culture and gram staining. Cytokines [transforming growth factor ß1 (TGF-ß1), interferon γ (IFN-γ), tumor necrosis factor α (TNF-α), interleukin (IL)-4, IL-10 and IL-17A] were estimated by ELISA in sera. Data were analyzed using ANOVA, χ (2) and Spearman's correlation at p = 0.05. RESULTS: Lower IFN-γ levels were observed in infertile women compared to fertile women. Fertile CTneg women had significantly higher TNF-α, and TGF-ß1 compared to fertile and infertile CTpos women, respectively. Lower IL-10 levels were seen in fertile CTpos women compared to the infertile CTpos group. Vaginal discharge was negatively correlated with TNF-α and IFN-γ and positively with IL-4 in Chlamydia positive women. CONCLUSIONS: Chlamydia positive women with tubal infertility have higher IL-10 and lower IFN-γ levels than controls, which may contribute to their development of tubal pathology.