PASADENA, CALIF. — The conundrum of whether tubal disease should be treated before moving on to assisted reproductive technologies has persisted for nearly 3 decades—since in vitro fertilization was first developed to compensate for tubal dysfunction.
During a recent talk at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California, Dr. Michael P. Diamond, director of reproductive endocrinology and infertility at Detroit Medical Center and Wayne State University in Michigan, offered his recommendations concerning the following three forms of tuboperitoneal disease:
Endometriosis
A number of relatively small studies and a metaanalysis suggest that significant diminishment of success rates for assisted reproductive technologies seems to occur mostly in women with stage III or IV endometriosis and particularly in those with large endometriomas, but not so much in women with less severe endometrial disease.
Early studies pointing to impaired pregnancy outcomes may be reflective of difficulties in laparoscopic oocyte retrieval, rather than success of the assisted reproductive technologies (ART) process itself. Dr. Diamond therefore recommends prior treatment of late-stage endometriosis with GnRH analog and possibly surgery when there is hope of reducing endometriomas, improving the environment for ART, and reducing toxicity associated with extensive endometriosis. The jury is still out with regard to treating stage I-II endometriosis before moving forward with ART, he said.
Hydrosalpinges
Hydrosalpinx has the potential of reducing fertility via a number of mechanisms, including deprivation of embryos of nutrients in the endometrial cavity and embryonic toxicity associated with exposure to hydrosalpinx fluid.
Hydrosalpinx can also impair endometrial receptivity through altered integrin expression, interleukins, progesterone receptors, and other factors.
It may interfere with normal endometrial peristalsis, and finally, in “a very mechanistic process,” it can cause embryos to literally wash out of the fallopian tube.
A Cochrane Database review shows that pregnancy and live birth rates were significantly improved if salpingectomy was performed prior to ART for patients with true hydrosalpinges (Cochrane Database Syst. Rev. 3:CD002125, 2001, update 2004).
However, “that's not the whole story. That's not how all of these patients present,” he said. There is no evidence in the literature that surgery improves ART outcomes for patients with mild tubal disease.
It is also unclear what the best course of treatment is for patients who have no evidence of hydrosalpinges on ultrasound, but who develop filling of the tube during a diagnostic hysterosalpingogram.
Pelvic Adhesions
If a patient is going to undergo ART for infertility, will adhesions around her ovaries and fallopian tubes have any deleterious effect on the procedure?
In fact, there have been papers that suggest that is the case, he said. Japanese researchers have demonstrated that periovarian adhesions interfere with diffusion of gonadotropins into the follicular fluid during IVF treatment, affecting both the follicular human chorionic gonadotropin (hCG) concentration and the ratio between follicular hCG and serum hCG concentration (Hum. Reprod. 1998;13:2072–6).
Very early studies by Dr. Diamond and associates were able to document the presence of adhesions over time when oocyte retrieval was achieved through laparoscopy (Fertil. Steril. 1988;49:100–3).
These studies found that although the number of follicles was not affected by periovarian adhesions, the number of oocytes retrieved was reduced by about a third, he said. The bottom line is that oocytes can still be obtained in patients with periovarian adhesions, and surgery offers no assurance of cure. Indeed, several studies suggest more extensive adhesion formation following surgery.
“While the data are mixed, I think there is good evidence you can get very reasonable ovarian response to gonadotropin stimulation even in the presence of pelvic adhesions and even if they're extensive around the ovary,” he said adding that surgery for adhesions “probably would not justify the expense and morbidity of a surgical procedure.”
'You can get a very reasonable ovarian response to gonadotropin stimulation even in the presence of pelvic adhesions.' DR. DIAMOND