子宫内膜异位症生育力指数对腹腔镜术后自然妊娠预测价值的研究

【摘要】 目的 探讨子宫内膜异位症生育力指数（endometriosis fertility index, EFI）评分系统对子宫内膜异位症合并不孕患者的腹腔镜术后自然妊娠概率的预测价值。方法 回顾性分析2008年1月至2011年12月北京大学第三医院生殖医学中心256例进行腹腔镜联合宫腔镜检查,诊断为子宫内膜异位症合并不孕症并进行EFI评分患者的临床资料,随访其术后2年的自然妊娠情况。并对患者的不同EFI得分、临床特征、术后妊娠时间及妊娠率等进行统计学分析。结果 256例患者中,230例（89.8%）完成2年的随访,其中自然妊娠128例（55.7%）。其余未孕。各EFI得分组妊娠率分别为： EFI 10分组81.0%（17/21）,EFI 9分组70.0%（35/50）,EFI 8分组49.0%（24/49）,EFI 7分组52.6%（30/57）,EFI 6分组52.0%（13/25）,EFI 5分组35.0%（7/20）,EFI≤4分组25.0（2/8）,可见随着EFI得分的升高妊娠率呈升高趋势。ROC曲线分析得出的EFI临界点为8.5分,EFI得分＞8.5分者妊娠率为73.2%（52/71）,得分<8.5分者妊娠率为47.8%（76/159）,两组比较,差异有统计学意义（P=0.000）。术后一年内妊娠率（43.5%,100/230）与一年后妊娠率（21.5%,28/130）比较,差异有统计学意义（P=0.000）。结论 子宫内膜异位症生育力指数对子宫内膜异位症合并不孕患者腹腔镜术后自然妊娠概率有一定预测价值。     

After the FLUSH trial: a prospective observational study of lipiodol flushing as an innovative treatment for unexplained and endometriosis-related infertility

OBJECTIVES: To assess the demographics, efficacy and safety of lipiodol flushing fertility treatment. DESIGN: Prospective observational study. SETTING: Secondary level care infertility clinic and radiology centre based in Auckland, New Zealand. POPULATION: The first cohort of 100 New Zealand women with infertility to undergo lipiodol flushing as an innovative fertility treatment. METHODS: Women received lipiodol flushing performed by a hysterosalpingogram technique and were followed up at 6 months. MAIN OUTCOME MEASURES: Clinical pregnancy at 6 months post-treatment; and live birth or ongoing pregnancy. RESULTS: The overall pregnancy rate was 30% and the live birth or ongoing pregnancy rate 27%. For women under 40 years old, a 32% pregnancy rate and a 25% live birth or ongoing pregnancy rate were seen in women with unexplained infertility, and a 50% pregnancy rate and a 47% live birth or ongoing pregnancy rate were seen in women with endometriosis. Of women aged 40 years and older, the pregnancy rate was 13% and the live birth or ongoing pregnancy rate was 13%. The pregnancy rates included those occurring after additional interventions, such as intrauterine insemination and in vitro fertilisation, accounting for 12 of the 30 pregnancies. There were no treatment complications. CONCLUSION: This study provides further evidence of the efficacy and safety of lipiodol flushing fertility treatment.     

A prospective comparative study between hysterosalpingography and hysteroscopy in the detection of intrauterine pathology in patients with infertility

AIM: To investigate the accuracy of hysterosalpingography (HSG) in comparison to hysteroscopy in the detection of intrauterine pathology in patients with infertility, where hysteroscopy is the gold standard. METHODS: A prospective, comparative study included 336 patients undergoing both HSG and diagnostic hysteroscopy. Main outcome measures were sensitivity, specificity, positive and negative predictive value, and accuracy rate of HSG. RESULTS: Intrauterine abnormalities were shown on HSG in 286 patients and confirmed in 200 at hysteroscopy. Contrarily intrauterine lesions were detected by hysteroscopy in 4 out of 50 patients in whom HSG were normal. The most common intrauterine finding of 336 patients on hysteroscopy were intrauterine adhesions (IUA) (74), followed by endometrial polyps (56), and submucous myoma, 26 patients. Statistical analysis revealed that HSG in the detection of intrauterine pathology had a sensitivity of 98.0%, specificity of 34.9%, positive predictive value of 69.9%, negative predictive value of 92.0%, and accuracy rate of 73.2% with false-positive and false-negative rates of 30.1% and 8.0%, respectively. The common incorrect diagnoses of HSG were misdiagnosing a condition of cervical stenosis as severe IUA in 24 patients, endometrial polyps as submucous myoma in 22 out of 50 patients, and submucous myoma as endometrial polyps in 12 out of 72 patients. CONCLUSIONS: Hysterosalpingography is still a useful screening test for the evaluation of the uterine cavity. If a hysterogram demonstrates intrauterine abnormalities, hysteroscopy should be considered to make a definite diagnosis and treatment. Both procedures should be complementary to each other.     

Chances of pregnancy after dropping out from infertility treatments: Evidence from a social survey in Japan

PurposeWe examined a patient''s chances of pregnancy after dropping out from infertility treatments, an issue that has been largely understudied.MethodDrawing from a nationwide Internet survey in Japan with 1930 respondents, we used data from 199 individuals (109 women and 90 men) who had undergone an infertility treatment. We estimated linear probability models to investigate the extent to which the probability of pregnancy was affected by dropping out after controlling for a couple''s attributes.ResultsAmong the 199 respondents who had experienced an infertility treatment, 91 (45.7% of the entire sample) became pregnant during the treatment, and 108 (54.3%) dropped out. Among these 108 dropouts, 66 (33.2%) eventually became pregnant. After controlling for a couple''s attributes, treatment discontinuation reduced the probability of pregnancy by 31.6% (standard error: 5.0%). A relatively limited reduction in the chances of pregnancy was also observed after a patient dropped out of any of the three treatment stages (timed intercourse, intrauterine insemination, and in vitro fertilization).ConclusionsThe results suggest that dropping out from infertility treatments does not preclude any chance of a future pregnancy. More follow‐up attention should be provided to dropout patients.     

The effect of ICSI in infertility couples with non-male factor: a systematic review and meta-analysis

PurposeWe performed a systematic review and meta-analysis of available literature to investigate the efficacy of the intracytoplasmic sperm injection (ICSI) in couples with non-male factor with respect to the clinical outcomes.MethodsThe literature search was based on EMBASE, PubMed, and the Cochrane Library. All studies published after 1992 until February 2020 and written in English addressing patients in the presence of normal semen parameters subjected to ICSI and in vitro fertilization (IVF) were eligible. Reference lists of retrieved articles were hand-searched for additional studies. The primary outcomes were fertilization rate, clinical pregnancy rate, and implantation rate; the secondary outcomes were good-quality embryo rate, miscarriage rate, and live birth rate.ResultsFour RCTs and twenty-two cohort studies fulfilling the inclusion criteria were included. Collectively, a meta-analysis of the outcomes in RCTs showed that compared to IVF, ICSI has no obvious advantage in fertilization rate (RR = 1.16, 95% CI: 0.83–1.62), clinical pregnancy rate (RR = 1.04, 95% CI: 0.66–1.64), implantation rate (RR = 1.12, 95% CI: 0.67–1.86), and live birth rate (RR = 1.17, 95% CI: 0.43–3.15). Pooled results of cohort studies demonstrated a statistically significant higher fertilization rate (RR = 1.16, 95% CI: 1.03–1.31) and miscarriage rate (RR = 1.04, 95% CI: 1.01–1.06) in the ICSI group; furthermore, higher clinical pregnancy rate (RR = 0.85, 95% CI: 0.77–0.94), implantation rate (RR = 0.78, 95% CI: 0.65–0.95), and live birth rate (RR = 0.86, 95% CI: 0.79–0.94) was founded in the IVF group; no statistically significant difference was observed in good-quality embryo rate (RR = 0.98, 95% CI: 0.93–1.04).ConclusionICSI has no obvious advantage in patients with normal semen parameters. Enough information is still not available to prove the efficacy of ICSI in couples with non-male factor infertility comparing to IVF.Electronic supplementary materialThe online version of this article (10.1007/s10815-020-01970-9) contains supplementary material, which is available to authorized users.     

A relationship between increased peritoneal leptin levels and infertility in endometriosis

Endometriosis is a common, complex and chronic disease related to ectopic implantation and growth of endometrial tissue that may manifest by pelvic pain, and accounts for over 20% of all cases of infertility in women. Endometriosis may be associated with increased levels of leptin in peritoneal fluid. However, the association of leptin with infertility has not been definitely documented. Therefore, the aim of the present study was to search for a relationship between concentrations of peritoneal-fluid leptin and patients' clinical status. The study included 56 patients being diagnosed for infertility and/or pelvic pain. Peritoneal fluid was aspirated during routine laparoscopic examination. Concentrations of leptin in peritoneal fluid were evaluated by a specific enzyme-linked immunosorbent assay. The results revealed that the levels of peritoneal-fluid leptin did not correlate with different stage of endometriosis. However, they correlated with body mass index. Leptin levels were significantly higher in infertile patients than in patients with pelvic pain (p = 0.0023 by Mann–Whitney U test or p = 0.0045 by analysis of variance). It may suggest that increased leptin levels in the peritoneal fluid may play a role in pathogenesis of infertility.     

Life-table analysis of artificial insemination pregnancy rates for couples with male factor and idiopathic infertility

Background :  In the summer of 2002, standard guidelines for the application of assisted reproductive technology were reported by a research group of the Ministry of Health, Labor and Welfare. The present study aimed to examine the relationship between the number of cycles of artificial insemination and the cumulative pregnancy rates according to the cause of infertility.
Methods :  Patients who experienced their first cycle of artificial insemination during the period of January 1999–December 2002 were included in the study and were divided into a male factor infertility group and an idiopathic infertility group. Cumulative pregnancy rates resulting from artificial insemination with the husband's semen were calculated by the life-table approach.
Results :  During the study period, 139 couples entered the assisted reproduction program and underwent 581 cycles. Significant differences were observed in cumulative pregnancy rates between the two groups.
Conclusion :  It is recommended that couples with male factor infertility and who fail to conceive within six or seven cycles of intrauterine insemination, consider a modification of treatment strategy such as in vitro fertilization, because cumulative pregnancy rates of this group were reached at a plateau within six or seven cycles. In contrast, patients with idiopathic infertility, the cumulative pregnancy rates appeared to increase constantly with each subsequent cycle. It is important to consider modifications of treatment strategy in the light of the cause of infertility. (Reprod Med Biol 2004; 3 : 27–31)     

The vanishing endometrioma: the intriguing impact of pregnancy on small endometriotic ovarian cysts

Abstract

There is a general belief that pregnancy has a beneficial effect on endometriosis but evidence is scanty. Moreover, some recent warning reports documented progression-growth of ovarian endometriomas during pregnancy. To further elucidate this aspect, we set up a prospective cohort study. We recruited 24 women carrying endometriomas at the time of in vitro fertilization who got pregnant. Selected women were contacted about 12–18 months after oocyte retrieval and invited to refer for ultrasound. The primary aim was to evaluate the modifications of endometriotic cysts after pregnancy. Twenty-four women carrying 40 endometriomas accepted to participate. The number of cysts per patient was significantly reduced following pregnancy (p?=?0.003). It was unchanged in eight cases (33%), increased in two cases (8%) and reduced in three cases (13%). In the remaining 11 women (46%), no cyst could be detected. A comparison of the size of the endometrioma could be done in 21 cysts; the mean?±?SD diameter before and after pregnancy was 20?±?9 and 18?±?7?mm, respectively (p?=?0.27). In conclusion, pregnancy has a beneficial effect on endometriomas. A consistent proportion of cysts becomes undetectable after delivery. Further studies are warranted to clarify the mechanisms determining the disappearance of these cysts.     

Fibroids and reproductive outcomes: a systematic literature review from conception to delivery

We examined the published relationship between uterine fibroids and reproductive outcomes. Submucosal fibroids had the strongest association with lower ongoing pregnancy rates, odds ratio, 0.5; 95% confidence interval, 0.3-0.8, primarily through decreased implantation. Cumulative pregnancy rates appeared slightly lower in patients with intramural fibroids 36.9% vs 41.1%, which may reflect biases in the literature; however, patients with intramural fibroids also experienced more miscarriages, 20.4% vs 12.9%. Adverse obstetric outcomes are rare and may reflect age or other differences in fibroid populations. Increased risk of malpresentation (odds ratio, 2.9; 2.6-3.2), cesarean (odds ratio, 3.7; 3.5-3.9), and preterm delivery (odds ratio, 1.5; 1.3-1.7) are reported; however, the incidence of labor dystocia was low (7.5%). There was no conclusive evidence that intramural or subserosal fibroids adversely affect fecundity. More prospective, controlled trials are needed to assess the effects of myomectomy. Good maternal and neonatal outcomes are expected in pregnancies with uterine fibroids.     

Effects of life events on infertility diagnosis: comparison with presumably fertile men and women

Objective: To compare the occurrence and degree of stress attributed to life events during childhood/adolescence and adulthood between individuals diagnosed with infertility and presumably fertile individuals, and to examine the effect of life events occurrence and stress levels on an infertility diagnosis.

Background: Although stress has been explored as a consequence of the experience of infertility, its role as a predictor of this disease still lacks research, particularly regarding the use of adequate control groups composed of non-parents.

Methods: The final sample had 151 infertile subjects (74 males and 77 females) and 225 presumably fertile participants (95 males and 130 females), who completed a questionnaire indicating occurrence (y/n) and degree of stress of life events (1–5) during childhood/adolescence and adulthood.

Results: Significant differences regarding occurrence were found in seven stressful life events in men and in nine events in women, with infertile groups presenting higher occurrence than presumably fertile groups. Eleven stressful life events were rated differently by men and women regarding the degree of stress, with group significant differences observed in both directions. While most events were rated as more stressful by infertile men, infertile women reported less stress resulting from these events than presumably fertile women. After controlling for age, the degree of stress induced by life events in childhood/adolescence and adulthood were not significant predictors of infertility diagnosis, for both men and women.

Conclusion: The amount of stress associated with earlier or concurrent life events does not seem to be related with infertility. Further prospective research is needed to validate these findings.