In vitro fertilization with hydrosalpinx and embryo transfer after resection of hydrosalpinx. 1. The patient underwent open myomectomy in 1998 and had one spontaneous miscarriage before surgery. After the operation, she had contraception for 2 years due to scarred uterus and had not been pregnant for the last 4 years without contraception. She had 2-3 days/25-26 days of menstruation with moderate menstrual flow and no dysmenorrhea. Physical examination: T: 36.5°C, P: 76 beats/min, R: 18 beats/min, BP: 110/70 mmHg. General condition was acceptable, clear, mental, cardiopulmonary(-), abdominal softness, liver and spleen not reached; gynecological examination: normal vulvar development, vaginal patency, smooth cervical, hypertrophy, uterine body transitional size, posterior position, poor activity, thickened bilateral adnexal area without masses. Basal endocrine: FSH:8.3mIU/ml,LH:4.60mIU/ml,PRL:13.8ng/ml
T:0.2nmol/l, E2:195.51pmol/l. Hysterosalpingogram showed normal uterine cavity morphology, bilateral tubal obstruction and fluid accumulation at the left end. The husband’s semen routine suggested mild weak spermatozoa. The proposed IVF-ET was performed with a short regimen of ovulation promotion trimethoprim 0.1mg, subcutaneous injection, once daily, starting on the second day of menstruation to the day of HCG injection, high purity urotropin 225IU, starting on the third day of menstruation and injected intramuscularly once daily, vaginal ultrasound on the eighth day of menstruation showed: endometrial thickness: 0.6cm,
Type A; 1 follicle of 1.3cm, 1.2cm2 and 1.1cm on the right side; 3 follicles of 1.2cm on the left side. Ultrasound examination again: endometrial thickness: 0.8cm, uterine cavity line separation 0.1cm, right follicle 1.6cm1, 1.5cm21, 1.3cm1; left follicle: 1.5cm21, 1.2cm1. 3.2×2.6cm liquid dark area was seen on the outside of the left ovary, which was salivary, divided and thin walled. It was considered hydrosalpinx. On the 11th day of menstruation, the endometrial thickness was 0.8 cm, the uterine cavity line was separated by 0.2 cm, the right follicle was 1.8 cm, 1.7 cm2, 1.65 cm1; the left follicle was 1.75 cm2, 1.4 cm1. 10,000 IU of HCG was administered intramuscularly and the eggs were retrieved on May 7, 2004. On the second day after egg retrieval, the uterine cavity line was separated by 0.2 cm under ultrasound, and the fluid in the uterine cavity was drained by neonatal gastric tube. The remaining embryos were cryopreserved and luteal support was continued after the transfer. 14 days after the transfer, urine HCG was checked negative suggesting no pregnancy. After 3 menstrual periods the patient was transferred frozen embryos in natural cycle. Ultrasound on day 12 of menstruation showed: endometrium 0.85 cm without uterine line separation, 1 dominant follicle 1.75 cm on the right side and positive urinary LH. In March 2005, she asked for another IVT-ET, and because of the history of failure of the previous two transfers, she was instructed to surgically ligate or remove the hydrocele side of the fallopian tube, which she did not accept. On the 9th day of ovulation promotion, there were 4 dominant follicles in both ovaries and HCG 10,000 IU was injected. 3 eggs were obtained and 3 embryos were formed. The patient was told that the success rate was not high and she was advised to give up the fresh transfer, freeze and preserve the embryos and transfer the frozen embryos in a natural cycle after dealing with the hydrocele. She agreed to the above plan because she had learned from the previous two failures. After the next menstrual period, she underwent open proximal tubal ligation and distal ostomy on the left side and right tubal ligation, and transferred frozen embryos in the second month after the surgery. The fetus was born by cesarean section at 39 weeks of gestation, weighing 4000 grams, with normal appearance and development, Sun Xiqin, Reproductive Medicine Center, Jining First People’s Hospital. 2.
Infertility due to tubal factors is one of the indications for in vitro fertilization-embryo transfer (IVF-ET), in which the embryo implantation rate and clinical pregnancy rate decreased and the spontaneous abortion rate increased after IVF treatment in patients with untreated hydrocele in the fallopian tubes. Related studies have confirmed that hydrocele can affect IVF-ET outcomes in the following ways. (1) it may affect embryo quality, as hydrocele may alter the sperm acquisition/acrosome response, which may result in loss of sperm motility and inhibit the fertilization process; (2) it may alter endometrial tolerance, as hydrocele may alter endometrial morphology and hematology, including changes in endometrial histology, the number of cytosolic protrusions, which may affect endometrial tolerance, and endometrial glandular epithelial cell adhesion molecules, endometrial glandular cells, and endometrial glandular cells. adhesion molecules, expression of endometrial cytokines: integrin avβ3, matrix metalloproteinases (MMPs), endometrial gene homology frame (HOXA10), leukemia inhibitory factor (LIF). ; ③ Mechanical flushing action leads to altered pressure in the uterine cavity, and the pressure of continuous dilatation in the uterine cavity may also cause atrophy of the glandular lumen of the endometrium, with reduced or absent glandular secretions and glandular cells in a hypersecretory state; ④ Tubal effusion and adhesions may reduce the sensitivity of the ovaries to exogenous gonadotropins (Gn), resulting in a reduced ovarian response during controlled superovulation; ⑤ Tubal effusion may mechanically compress the ovarian vessels, affecting (5) Tubal effusion may mechanically compress the blood vessels of the ovaries, affecting the blood supply to the ovaries and affecting the function of the ovaries, reducing the responsiveness of the ovaries. (6) Hydrocele may change the peristaltic direction of the endometrium and the blood flow in the endometrium, which may inhibit the implantation of the embryo. Treatment of hydrosalpinx When the mucosa of the fallopian tube is intact without adhesions, i.e. mild hydrosalpinx, tuboplasty is feasible. The time to expect pregnancy after surgery should be based on the patient’s age and the male partner’s semen. If the patient is still not pregnant more than 12 months after the operation or if the patient is older, or if the patient is blocked again, tubectomy is feasible and IVF-ET is performed after the operation, while in case of moderate to severe tubal effusion, heavy tubal lesions and the diameter of the tubal effusion is more than 3 cm, tubectomy should be chosen. Laparoscopic salpingo-oophorectomy can reduce the incidence of ectopic pregnancy and recurrence of hydrosalpinx after IVF-ET compared to tubal ostomy. Classification of hydrosalpinx: Mild
The diameter of hydrosalpinx is <1.5cm, or there is no hydrosalpinx, the umbilical end is recognizable, there is no obvious adhesion around the fallopian tube or ovary, and the preoperative HSG pattern is normal. Moderate: 1.5-3.0 cm diameter of hydrocele, the structure of the umbilical end needs to be identified, there are adhesions around the fallopian tubes or ovaries, but they are not fixed yet, there are a few adhesions in the rectal fossa of the uterus, and the preoperative HSG morphology is lost. Severe: 3.0 cm diameter of hydrocele, atresia of the umbilical end, dense adhesions of the pelvic attachments, closure of the rectal fossa of the uterus, or freezing of the pelvis.