The effect of unilateral tubal block diagnosed by hysterosalpingogram on clinical pregnancy rate in intrauterine insemination cycles: systematic review and meta-analysis.

BACKGROUND: Fallopian tube occlusion is a common cause of infertility, but the effect of unilateral tubal block (UTB) on pregnancy rates (PR) after controlled ovarian hyperstimulation and intrauterine insemination (COH-IUI) remains controversial. OBJECTIVE: To evaluate PR after COH-IUI among infertile women with proximal and distal UTB diagnosed by hysterosalpingogram (HSG), compared against women with bilateral patent tubes experiencing unexplained infertility. SEARCH STRATEGY: We searched EMBASE, MEDLINE, Google Scholar, Cochrane Library, and PUBMED from inception to 14 January 2018. SELECTION CRITERIA: Studies that report PR/cycle or cumulative PR among women with UTB and controls were included. DATA COLLECTION AND ANALYSIS: Two authors independently selected and extracted study characteristics and data. Methodological quality was assessed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. MAIN RESULTS: Among 2965 patients and 5749 IUI cycles across ten studies, no significant difference in PR/cycle (odds ratio, OR = 0.88; 95% confidence interval, 95% CI = 0.69-1.12) and cumulative PR (OR = 0.80, 95% CI = 0.62-1.04) was observed. Patients with proximal UTB demonstrated similar PR/cycle (OR = 1.06, 95% CI = 0.68-1.66) and cumulative PR (OR = 1.10, 95% CI = 0.75-1.62), compared with controls, whereas patients with distal UTB had significantly lower cumulative PR (OR = 0.49, 95% CI = 0.25-0.97, P = 0.04). Patients with proximal block also demonstrated significantly improved cumulative PR, compared with patients with distal block (OR=2.41, 95% CI = 1.37-4.25, P = 0.002). CONCLUSION: Infertile patients with proximal UTB diagnosed by HSG can expect similar pregnancy rates after COH-IUI, compared with those with bilateral tubal patency and unexplained infertility, whereas patients with distal UTB have lower odds of pregnancy. These differences may reflect inherent diagnostic limitations of HSG or differences in underlying pathologies. TWEETABLE ABSTRACT: Meta-analysis evaluates pregnancy outcomes after COH-IUI in women with unilateral tubal block diagnosed by HSG.

Endometriosis: a critical appraisal of the advances and the controversies of a challenging health problem.

Endometriosis is an enigmatic disorder with obscure pathogenesis. The objective of this review was to critically appraise the recent advances in the etiopathogenesis, diagnosis and clinical management of endometriosis. Several studies support the familial role in the initiation of the disease with key roles of endometriosis-associated polymorphisms in the genes that control fibrinolysis, angiogenesis, steroidogesis, aromatization of androgens, proliferation and cytokine production. Many active substances (cytokines, growth factors, hormones and oxidative stress parameters) have been identified in endometriosis patients at different stages of the disease. In addition to the traditional diagnostic role of ultrasonography and CA 125, evidence is accumulating regarding a potential role sonorectovaginography. Currently the routine use of antiflammatory drugs and birth control pills is not supported by evidence. New protocols of medications incorporation new gonadotrophin releasing hormone agonists with add back therapy, androgenic agents and aromatase inhibitors have been proposed. Prospective randomiazed controlled trials proved that surgical treatment of endometriosis is better than placebo for endometriosis related pain and infertility for patients with stage I and II disease.

Peritoneal fluid environment in endometriosis. Clinicopathological implications.

Endometriosis is a puzzling disorder with obscure pathogenesis. The objective of this review was to evaluate the complex role of peritoneal fluid in the etiopathogenesis of endometriosis. Several studies suggest that peritoneal fluid is a key inflammatory environment associated with endometriosis. Many active substances (cytokines, growth factors, hormones and oxidative stress parameters) have been identified in endometriosis patients at different stages of the disease. Inflammatory mediators may be involved in the endometriosis associated-infertility and possibly pain. Furthermore, these mediators may represent a non surgical method for diagnosing endometriosis. Better understanding of the mechanism of cytokines, growth factor and reactive oxygen species production and detoxification and further investigation of their effects on the peritoneal fluid environment are essential to obtain new insight into this disease and eventually develop novel diagnostic and therapeutic remedies.

Prediction of endometriosis with serum and peritoneal fluid markers: a prospective controlled trial.

BACKGROUND: The objective of this prospective controlled trial was to investigate the ability of a group of serum and peritoneal fluid (PF) markers to predict, non-surgically, endometriosis. METHODS AND RESULTS: Serum and PF samples were obtained from 130 women while undergoing laparoscopy for pain, infertility, tubal ligation or sterilization reversal. Concentrations of six cytokines [interleukin (IL)-1beta, IL-6, IL-8, IL-12, IL-13 and tumour necrosis factor (TNF)-alpha] were measured in serum and PF, and reactive oxygen species (ROS) in PF, and levels were compared among women who were allocated to groups according to their post-surgical diagnosis. Fifty-six patients were diagnosed with endometriosis, eight with idiopathic infertility, 27 underwent tubal ligation or reanastomosis (control group) and 39 were excluded due to bloody PF. Only serum IL-6 and PF TNF-alpha could be used to discriminate between patients with and without endometriosis with a high degree of sensitivity and specificity (P < 0.001). A threshold of 15 pg/ml PF TNF-alpha provided 100% sensitivity and 89% specificity (positive likelihood ratio of 9.1 and negative likelihood ratio of 0). A threshold of 2 pg/ml for serum IL-6 provided a sensitivity of 90% and specificity of 67% (positive likelihood ratio of 2.7 and negative likelihood ratio of 0.14). CONCLUSIONS: By measuring serum IL-6 and PF TNF-alpha, it was possible to discriminate between patients with endometriosis and those without. Before these markers can be used as a non-surgical diagnostic tool, these data should be verified in a larger study.

Recurrent osseous metaplasia of the cervix after loop electrosurgical excision.

BACKGROUND: Osseous metaplasia of the uterus is a rare pathologic entity usually affecting the endometrial cavity without cervical extension. It has been reported after abortion, in cases of chronic endometritis, and as a result of metabolic disorders as hypervitaminosis D, hyperparathyroidism, hypercalcemia, and hyperphosphatemia. CASE: A woman developed osseous metaplasia of the cervix shortly after loop electrosurgical excision procedure (LEEP) for severe cervical dysplasia. Normal transvaginal ultrasonograms before the LEEP, and failure to detect osseous metaplasia after histologic review of the tissue obtained from that procedure indicate that the osseous metaplasia had been induced by the LEEP. The heterotopic bone formation rapidly recurred after initial removal. Her serum calcium, phosphorus, and vitamin D levels were normal. CONCLUSION: LEEP may result in healing with metaplastic bone formation.

Varicocelectomy improves intrauterine insemination success rates in men with varicocele.

PURPOSE: We determined whether varicocele treatment before intrauterine insemination significantly affects intrauterine insemination success rates. MATERIALS AND METHODS: A total of 58 infertile couples, of whom the women had normal evaluations and men had abnormal semen analyses and a history of varicocele, were included in this study. They were identified after reviewing the charts of all women undergoing intrauterine insemination for male factor infertility at our center. Of the men 24 participated in 63 intrauterine insemination cycles without varicocele treatment, while in the remaining 34 varicocele was treated before a total of 101 intrauterine insemination cycles. Variables associated with pregnancy or live birth were analyzed using repeat measures logistic regression with generalized estimating equation techniques. An initial stepwise generalized estimating equation was performed without including varicocele treatment status. Subsequently varicocele treatment status and the significant associated factors were included in analysis. The semen characteristics of untreated and treated varicocele groups were compared with repeat measures analysis of variance. RESULTS: On pre-wash semen analysis patients with untreated varicocele had significantly higher mean motility plus or minus standard error than patients whose varicoceles were treated (48.6% +/- 2.3% versus 38.1% +/- 1.8%, p = 0.02). However, no statistically significant difference was noted in the mean post-wash total motile sperm count in the treated and untreated groups (7.2 +/- 1.0 versus 14.8 +/- 2.6, p = 0.1). Despite these findings the pregnancy and live birth rates per cycle were significantly higher in patients in whom varicocele was treated than in those without varicocele treatment (11.8% versus 6.3%, p = 0.04 and 11.8% versus 1.6%, p = 0.007, respectively). CONCLUSIONS: Varicocele treatment may not improve semen characteristics in all men but it appears to improve pregnancy and live birth rates among couples undergoing intrauterine insemination for male factor infertility. A functional factor not measured on routine semen analysis may affect pregnancy rates in this setting. Men should be screened for varicocele before intrauterine insemination is initiated for male factor infertility.