Safety and Assisted Reproductive Technology Outcomes of Hysteroscopic Tubal Microinserts Versus Laparoscopic Proximal Tubal Occlusion or Salpingectomy for Hydrosalpinges Treatment.

OBJECTIVE: This study sought to answer the following question: What are the complications and assisted reproductive technology outcomes among women with hydrosalpinges managed by hysteroscopic microinsert tubal occlusion compared with women with hydrosalpinges managed by laparoscopic proximal tubal occlusion or salpingectomy? METHODS: This was a retrospective cohort study conducted from January 2009 to December 2014 at two academic, tertiary care, in vitro fertilization centres in Toronto, Ontario. All patients (n = 52) who underwent hysteroscopic tubal occlusion for hydrosalpinges were identified. Patients who proceeded with embryo transfer cycles after hysteroscopic microinsert (n = 33) were further age matched to a cohort of patients who underwent embryo transfer after laparoscopic proximal tubal occlusion or salpingectomy (n = 33). Main outcome measures were clinical pregnancy rate per patient and per embryo transfer cycle. RESULTS: Among 33 patients, there were 39 fresh and 37 frozen embryo transfer cycles in the hysteroscopic group (group A); among 33 patients in the laparoscopic group (group B), there were 42 fresh and 29 frozen embryo transfer cycles. The cumulative clinical pregnancy rate in group A and group B was similar (66.7% vs. 69.7%, respectively; P = 0.8). The clinical pregnancy rate per embryo transfer cycle was also similar in both groups (28.9% in group A vs. 32.4% in group B; P = 0.6). There were two incidents of ectopic pregnancy in the laparoscopic group and no ectopic pregnancy in the hysteroscopic group. There were three major complications: tubo-ovarian abscess, distal migration of the coil after microinsert placement, and an acute abdomen following the hysteroscopic procedure. CONCLUSION: Pregnancy outcomes after hysteroscopic placement of a microinsert for hydrosalpinx management before embryo transfer were comparable to those following laparoscopic proximal tubal occlusion or salpingectomy. However, caution is advised regarding microinsert placement for hydrosalpinges before proceeding with assisted reproductive technology.

Conservative Management of Cervical Ectopic Pregnancy.

OBJECTIVE: To evaluate the safety and effectiveness of conservative management for cervical ectopic pregnancies. METHODS: We conducted a retrospective review of all cases of cervical ectopic pregnancy diagnosed at our tertiary care academic centre between January 2002 and July 2014. The diagnosis of cervical ectopic pregnancy was made using transvaginal ultrasound according to published criteria. Management decisions were made by individual clinicians. RESULTS: Cervical ectopic pregnancy was diagnosed in 27 women with a median age of 34 years. Two thirds of them were nulliparous, and 44% (12/27) reported infertility. The mean gestational age at diagnosis was seven weeks. The median serum human chorionic gonadotropin level was 11 300 IU/L (range 610 to 163 700). Fetal cardiac activity was present in 19 pregnancies (70%). Vaginal bleeding was the most common presentation, occurring in 23 cases (85%). Three women presented with acute life-threatening hemorrhage. All cases were successfully managed conservatively, allowing uterine preservation. Systemic methotrexate (single or multi-dose protocol) was the mainstay of therapy. Other minimally invasive interventions included ultrasound-guided injection of potassium chloride into the pregnancy, uterine artery embolization, vaginal ligation of cervical branches of the uterine arteries, and dilatation and curettage, with or without dilute vasopressin cervical infiltration and Foley catheter tamponade. CONCLUSION: Systemic methotrexate alone or in combination with other minimally invasive techniques can be effective conservative treatment for cervical pregnancies. A fertility-sparing approach is the optimal treatment for this patient population, which has high rates of infertility and nulliparity. We present a management algorithm based on our results to aid in standardizing the management of cervical ectopic pregnancies.

Objectif : Évaluer l'innocuité et l'efficacité de la prise en charge conservatrice des grossesses ectopiques cervicales. Méthodes : Nous avons mené une analyse rétrospective de tous les cas de grossesse ectopique cervicale diagnostiqués au sein de notre centre universitaire tertiaire entre janvier 2002 et juillet 2014. Le diagnostic de grossesse ectopique cervicale a été établi par échographie transvaginale, conformément aux critères publiés. Les décisions quant à la prise en charge ont été prises par les cliniciens concernés. Résultats : Une grossesse ectopique cervicale a été diagnostiquée chez 27 femmes (âge médian : 34 ans). Les deux tiers d'entre elles étaient nullipares et 44 % (12/27) ont signalé une infertilité. L'âge gestationnel moyen au moment du diagnostic était de sept semaines. Le taux sérique médian de gonadotrophine chorionique humaine était de 11 300 UI/l (plage : de 610 à 163 700). Une activité cardiaque fœtale était présente dans 19 grossesses (70 %). Les saignements vaginaux constituaient la présentation la plus courante; de tels saignements étaient présents dans 23 cas (85 %). Trois femmes ont connu une hémorragie aiguë constituant un danger de mort. Tous les cas ont fait l'objet d'une prise en charge conservatrice réussie qui a permis la préservation de l'utérus. Le méthotrexate administré par voie générale (protocole à dose unique ou à doses multiples) constituait l'élément principal du traitement. Parmi les autres interventions à effraction minimale, on trouvait l'injection (orientée par échographie) de chlorure de potassium dans la grossesse, l'embolisation des artères utérines, la ligature vaginale des rameaux cervicaux des artères utérines et la dilatation-curetage (avec ou sans infiltration cervicale de vasopressine diluée et tamponnement par sonde de Foley). Conclusion : Le recours à du méthotrexate administré par voie générale, seul ou en combinaison avec d'autres techniques à effraction minimale, peut constituer un traitement conservateur efficace en présence d'une grossesse cervicale. Une approche permettant de préserver la fécondité constitue le traitement optimal pour cette population de patientes, laquelle compte des taux élevés d'infertilité et de nulliparité. Nous présentons un algorithme de prise en charge fondé sur nos résultats dans le but de contribuer à la standardisation de la prise en charge des grossesses ectopiques cervicales.

The presence of pinopodes in the human endometrium does not delineate the implantation window.

OBJECTIVE: To assess pinopode formation in human endometrium during the luteal phase of the menstrual cycle and in the first trimester of pregnancy. DESIGN: Prospective clinical study. SETTING: Outpatient infertility clinics and outpatient family planning clinic. PATIENT(S): Thirty-two regularly cycling infertile women, 15 regularly cycling fertile women, 9 women receiving elective termination of pregnancy, and 1 woman receiving GnRH agonist and hormone therapy addback. INTERVENTION(S): Endometrial tissue was collected by suction pipelle and examined by scanning electron microscopy for pinopode formation. MAIN OUTCOME MEASURE(S): Endometrial tissue was scored (0, 1, 2, 3, or 4) depending on the percentage of the surface covered in pinopodes (from 0% to >20% of 100 fields). RESULT(S): Pinopodes were present throughout the luteal phase of the menstrual cycle, up to the 11th week of pregnancy, and in the endometrium of the woman on GnRH agonist and hormone therapy. CONCLUSION(S): Pinopodes can be detected in the progesterone-exposed endometrium for an extended period of time, in contradistinction to the perception that they are markers for the implantation window in the human endometrium.