Surgery for tubal infertility.

BACKGROUND: Surgery remains an acceptable treatment modality for tubal infertility despite the rise in usage of in vitro fertilisation (IVF). Estimated livebirth rates after surgery range from 9% for women with severe tubal disease to 69% for those with mild disease; however, the effectiveness of surgery has not been rigorously evaluated in comparison with other treatments such as IVF and expectant management (no treatment). Livebirth rates have not been adequately assessed in relation to the severity of tubal damage. It is important to determine the effectiveness of surgery against other treatment options in women with tubal infertility because of concerns about adverse outcomes, intraoperative complications and costs associated with tubal surgery, as well as alternative treatments, mainly IVF. OBJECTIVES: The aim of this review was to determine the effectiveness and safety of surgery compared with expectant management or IVF in improving the probability of livebirth in the context of tubal infertility (regardless of grade of severity). SEARCH METHODS: We searched the following databases in October 2016: the Cochrane Gynaecology and Fertility (CGF) Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO; as well as clinical trials registries, sources of unpublished literature and reference lists of included trials and related systematic reviews. SELECTION CRITERIA: We considered only randomised controlled trials to be eligible for inclusion, with livebirth rate per participant as the primary outcome of interest. DATA COLLECTION AND ANALYSIS: We planned that two review authors would independently assess trial eligibility and risk of bias and would extract study data. The primary review outcome was cumulative livebirth rate. Pregnancy rate and adverse outcomes, including miscarriage rate, rate of ectopic pregnancy and rate of procedure-related complications, were secondary outcomes. We planned to combine data to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). We planned to assess statistical heterogeneity using the I2 statistic and to assess the overall quality of evidence for the main comparisons using GRADE methods. MAIN RESULTS: We identified no suitable randomised controlled trials. AUTHORS' CONCLUSIONS: The effectiveness of tubal surgery relative to expectant management and IVF in terms of livebirth rates for women with tubal infertility remains unknown. Large trials with adequate power are warranted to establish the effectiveness of surgery in these women. Future trials should not only report livebirth rates per patient but should compare adverse effects and costs of treatment over a longer time. Factors that have a major effect on these outcomes, such as fertility treatment, female partner's age, duration of infertility and previous pregnancy history, should be considered. Researchers should report livebirth rates in relation to severity of tubal damage and different techniques used for tubal repair, including microsurgery and laparoscopic methods.

Retention of factual knowledge after practical training for intrapartum emergencies.

OBJECTIVE: To determine knowledge retention 1 year after training for intrapartum emergencies. METHODS: Training was undertaken in 6 hospitals and the Bristol Medical Simulation Centre, UK, between November 2004 and March 2005. Participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were randomly recruited from participating hospitals and underwent practical training at their local hospital or simulation center with or without additional teamwork training. The primary outcome was change in factual knowledge over time, as assessed by a 185-question multiple-choice questionnaire before and after training. RESULTS: Mean scores at 6 (97.6 ± 23.0; n = 107) and 12 (98.2 ± 21.6; n = 98) months remained higher than those before training (79.6 ± 21.9, n = 140; both P < 0.001), but were slightly lower than those immediately after training (101.0 ± 21.3, n = 133; P < 0.001 and P = 0.007, respectively). The type of training had no effect on retention of knowledge. CONCLUSION: Training was associated with sustained retention of factual knowledge of obstetric emergencies care for at least 1 year. The decay in knowledge was small compared with the original gain in knowledge. Neither training location nor inclusion of teamwork training affected knowledge retention. Annual training seemed to be satisfactory for all staff groups.

Deflation of gastric band balloon in pregnancy for improving outcomes.

BACKGROUND: In line with the rise in the prevalence of obesity, an increasing number of women of childbearing age are undergoing laparoscopic adjustable gastric banding (LAGB), resulting in an increasing number of pregnancies with a band in place. Currently, there is no consensus on optimal band management in pregnancy. Some clinicians advocate leaving the band balloon inflated to reduce gestational weight gain and associated adverse perinatal outcomes. However, there are concerns that maintaining balloon inflation during pregnancy might increase the risk of band complications and adversely affect fetal development and/or growth as a result of reduced nutritional intake. OBJECTIVES: To compare maternal and perinatal outcomes for elective gastric band balloon deflation versus intention to maintain balloon inflation during pregnancy. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2012) and the Web of Science database (1940 to September 2012). SELECTION CRITERIA: Randomised-controlled trials comparing elective deflation of the gastric band balloon with intention to maintain balloon inflation in pregnant women who have undergone LAGB. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion. MAIN RESULTS: No studies met the criteria for inclusion in the review. AUTHORS' CONCLUSIONS: To date no randomised controlled trials exist that compare elective deflation of the gastric band balloon in pregnancy versus intention to maintain balloon inflation. Further research is needed to define the optimum management of the gastric band balloon in pregnancy.

The relationship between serum Chlamydia antibody levels and severity of disease in infertile women with tubal damage.

BACKGROUND: The study explores the relationship between serum Chlamydia antibody titres (CAT) using the whole-cell inclusion immunofluorescence (WIF) test and severity of tubal damage in infertile women undergoing laparoscopy. METHODS: Comparisons between the extent of specific lesions, including their severity found at laparoscopy, and CAT levels were analysed in 408 infertile women with tubal damage. CAT levels were assayed using the WIF test. RESULTS: There were significant differences in the severity of individual lesions (tubal occlusion, tubal pathology, fimbrial state, extent and type of tubal and ovarian adhesions, type of tubal and ovarian adhesions) for both left and right adnexa in relation to CAT (P < 0.0001). The presence and severity of lesions found in one adnexum significantly correlated with the findings on the contra-lateral side (r > 0.5; P < 0.01). The American Fertility Society grades for tubal occlusion and adhesions in the right adnexum did not correlate with CAT. CONCLUSIONS: CAT levels are quantitatively related to the severity of tubal damage in infertile women. Wide variations in the severity of lesions observed in relation to CAT were suggestive of broad individual differences in response to chlamydial infection.

Significance of positive Chlamydia serology in women with normal-looking Fallopian tubes.

Chlamydia trachomatis poses a potential threat to the fertility of women by causing tubal damage. Many women with serological evidence of past Chlamydia infection have normal tubal appearances on laparoscopic assessment. The aim of this study was to assess if serological evidence of past chlamydial infection affects the likelihood of conception in women with normal tubes. Infertile couples in which the female partner was under the age of 40 years, with normal ovulatory function and a male partner with normal sperm function were studied. All women had normal tubes as assessed by laparoscopy. Serum Chlamydia antibody titres were assayed using the immunofluorescence test. Pregnancy rates were related to grouped Chlamydia antibody titres (<64, 64-256 and > or =512). A total of 174 women were studied. The cumulative pregnancy rates (SE) according to these titres were 45.1% (6.2), 42.6% (9.3), 59.1% (11.8) and the risk ratios (95% confidence interval) were 1, 1.59 (0.82-3.07) and 1.04 (0.52-2.08) respectively. The differences were not statistically significant. Therefore, in women with normal-looking tubes, serological evidence of past chlamydial infection does not appear to have an adverse effect on pregnancy rates. These findings suggest that laparoscopic findings and not Chlamydia serological titres are the key to prognosis.

Surgery for tubal infertility.

BACKGROUND: Tubal surgery is a widely accepted treatment for tubal infertility. Estimated livebirth rates after surgery range from 9% for women with severe tubal disease to 69% for those with mild disease, however, its effectiveness has not been rigorously evaluated in comparison with other treatments such as in vitro fertilisation (IVF) and expectant management (no treatment). Livebirth rates have not been adequately assessed in relation to the severity of tubal damage. It is important to determine the effectiveness of surgery against other treatment options in women with tubal infertility because of concerns about adverse outcomes, intra-operative complications and the costs associated with tubal surgery. OBJECTIVES: The aim of this review was to determine whether surgery improves the probability of livebirth compared with expectant management or IVF in the context of tubal infertility (regardless of grade of severity). SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group's trials register (searched August 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue, 2007), MEDLINE (1970 to August 2007), EMBASE (1985 to August 2007) and reference lists of articles. We also handsearched relevant conference proceedings and contacted researchers in the field. SELECTION CRITERIA: Only randomised controlled trials were considered eligible, with livebirth rate per woman as the primary outcome of interest. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed eligibility and quality of trials. MAIN RESULTS: No suitable randomised controlled trials were identified. AUTHORS' CONCLUSIONS: Any effect of tubal surgery relative to expectant management and IVF in terms of livebirth rates for women with tubal infertility remains unknown. Large trials with adequate power are warranted to establish the effectiveness of surgery in these women. Future trials should not only report livebirth rates per woman, but also compare adverse effects and costs of the treatments as outcomes. Factors that have a major effect on these outcomes, such as fertility treatment, female partner's age, duration of infertility, and previous pregnancy history should be considered. Livebirth rates in relation to the severity of tubal damage, and different techniques used for tubal repair including microsurgery and laparoscopic methods should also be reported.

Tubal disease: towards a classification.

Tubal disease is a major cause of infertility. The amount of damage can vary greatly in extent, anatomical location and nature. For women with infertility due to tubal disease, prognostication for pregnancy often remains unclear and there is no universally accepted classification. A classification system that reliably distinguishes infertile patients with tubal disease into favourable and unfavourable groups would be useful if subsequent management could depend on this assessment, especially if the classification is able to define which group of patients would benefit most from interventions such as surgery. The progress of IVF questions the contribution of the Fallopian tube to the successful achievement of pregnancy in infertile women. Nonetheless, several studies reveal that severity is the key factor in the determining outcome, and the classifications reviewed in this paper imply that women with tubal disease could be categorized into prognostic groups using a simple classification system based on severity. However, prospective trials are needed to validate and assert the usefulness of any particular classification.

The predictive value of the "Hull & Rutherford" classification for tubal damage.

OBJECTIVE: This study explores the predictive value for live birth following tubal reconstructive surgery of the "Hull & Rutherford" (H&R) classification system. DESIGN: Retrospective cohort study. SETTING: Tertiary infertility referral service, University of Bristol. POPULATION: Infertile women younger than 40 years with tubal damage undergoing tubal surgery. METHODS: Women (n= 192) were grouped according to three severity grades of disease based on the H&R classification. Essentially, the main features of grade I tubal damage were filmy adhesions, whereas grades II and III referred to unilateral severe damage and bilateral severe damage, respectively. Standard surgical techniques were employed. Pregnancy and live birth rates were calculated and compared using time-specific univariate Kaplan-Maier curves and multivariate Cox's regression analysis. MAIN OUTCOME MEASURES: Pregnancy, ectopic and live birth within three years of surgery. RESULTS: A significant trend towards higher ectopic pregnancy rates (P < 0.001) with increasing severity of tubal damage was noted, but not miscarriage rates. Univariate analysis revealed significant differences in the live birth rates of 69%, 48% and 9% for grades I, II and III, respectively. Multivariate analysis (controlling for age, duration of and primary infertility) confirmed these differences to be significant with risk ratios of 13.7 (95% CI: 4.49-41.9) and 6.54 (95% CI: 2.48-17.24) for grades I and II disease, respectively, compared with grade III disease, used as the reference. CONCLUSIONS: The H&R classification is a simple classification system that is able to distinguish women into three distinct groups giving a favourable, fair and poor prognosis for live birth following tubal surgery.

The practical implications of a raised serum FSH and age on the risk of IVF treatment cancellation due to a poor ovarian response.

PURPOSE: Chronological age, or biological age as indicated by elevated FSH levels, are related to ovarian reserve. This study addresses the likelihood of cancellation of IVF treatment due to a poor ovarian response utilising both basal serum FSH and woman's age. METHODS: A prospective cohort of 536 infertile but ovulating women were studied in their first cycle of IVF treatment. Standardised methods of pituitary desensitisation and ovarian stimulation prior to IVF treatment were employed. Treatment cycles cancelled due to a poor ovarian response to gonadotrophins were studied. A series of logistic regression models were used to explore the probabilities of cancellation in relation to age and FSH. RESULTS: Both age and basal serum FSH levels were independently associated with the risk of treatment cancellation. A low risk of treatment cancellation was observed in women under the age of 35 irrespective of serum FSH, however in older women the risk of treatment cancellation was most likely in women with a high FSH. CONCLUSIONS: In combination both age and FSH may serve as a valuable indicator of poor ovarian response leading to treatment cancellation. However, among older women FSH has particular importance, while less so in younger women with regular menstrual cycles.

Differences in time to natural conception between women with unexplained infertility and infertile women with minor endometriosis.

BACKGROUND: Opinion remains divided as to whether finding endometriotic lesions in the absence of adhesions has an adverse effect on the likelihood of conception. METHODS: This was a retrospective study of 192 fully investigated infertile couples, followed up for up to 3 years following laparoscopy. Women studied were ovulating, <40 old years and their partners had normal sperm parameters. All 117 women with unexplained infertility and 75 with minimal/mild endometriosis without adhesive disease were managed conservatively. RESULTS: Women with endometriosis were found to have a lower probability of pregnancy compared with women with unexplained infertility (36% versus 55%; P<0.05). Other factors adversely associated with pregnancy were primary infertility, smoking and longer duration (>3 years) of infertility. However, the effects of duration of infertility and primary infertility were not observed to be statistically significant for women with endometriosis. CONCLUSIONS: The findings, although undertaken in a select population undergoing laparoscopy, suggest the likelihood of pregnancy is reduced in infertile women with minimal/mild endometriosis compared with those infertile women with a normal pelvis. Duration of infertility and a previous history of pregnancy are important in predicting the likelihood of pregnancy in women with no obvious cause for their infertility (unexplained), whilst the relationship may be more complex in women with minor endometriosis

Tubal damage in infertile women: prediction using chlamydia serology.

BACKGROUND: The study explores the relationship between serum chlamydia antibody titres (CATs) and detection of tubal damage in infertile women. METHODS: The tubal status and pelvic findings in 1006 women undergoing laparoscopy for infertility were related to CAT, which was measured using the whole-cell inclusion immunofluorescence test. RESULTS: A negative correlation between CAT and age was noted. A linear trend between serum CAT and the likelihood of tubal damage, including severe damage, was observed (P < 0.001). Titres in women with tubal damage (median 1:1024; range <1:64-1:4096) were significantly (P < 0.001) higher than in women with endometriosis alone (median <1:64; range <1:64-1:512) or those with a normal pelvis (median <1:64; range <1:64-1:1024). Women with positive titres were more likely to have pelvic adhesions than tubal occlusion unless titres were very high, when tubal damage was likely to be more severe. CONCLUSIONS: CATs are of predictive value in the detection of tubal damage and are quantitatively related to the severity of damage. For practical clinical purposes, Chlamydia serology is useful mainly as a screening test for the likelihood of tubal damage in infertile women and may facilitate decisions on which women should proceed with further investigations without delay.