{"paper_id":"8838c7cc-a871-47a2-883b-9a90d90a678b","body_text":"Couples that fail to concieve despite regular\nintercourse for at least one year are evaluated\nfor infertility. The workup of such patients include basic infertility tests. These tests involve\nthe spermiogram, a marker of sperm production, a hysterosalpingogram (HSG) which\ndetermines tubal patency, and the evaluation\nof ovulation. The pregnancy rate in normally\nfertile couples is 20-25%, while this rate averages between 2-4% in infertile couples ( 1 ).\nSince controlled ovarian hyperstimulation\nplus intrauterine insemination (COH+IUI) is\nless expensive and less laborious than intracytoplasmic sperm injection or  in vitro  fertilization (ICSI/IVF), the former is considered as a first treatment choice. Studies to increase the suc-\ncess of this treatment modality are ongoing.\nHysterosalpingography, which is one of the basic tests of infertility, has a mechanical washing\neffect on the uterine cavity and tubes. Particularly\nafter performing this test with an oil-based contrast\nmedium, the chance of spontaneous pregnancy increases. Given that the HSG is normal, expectant\nmanagement reveals a pregancy rate of up to 40%\nin such patients. If the same patients were to undergo\nappropriate treatment, the pregnancy rate generally\nreaches 30%. Therefore, following an HSG with an\noil-based contrast, management with an average duration of six months is preferred in most centers ( 2 )\nThe positive effect of this phenomenon may be utilized by introducing uterine cavity pertubation prior\nto infertility treatment. Considering cases of early\nstage endometriosis, the mechanical effect of pertubation may decrease minor tubal adhesions. The proposed immunologic effect is based on the prevention\nof sperm phagocytosis and the removal of peritoneal\ncytokins and immunological factors ( 3 )\nWe considered the mechanical and immunological effect of uterine cavity pertubation on treatment\nprotocols for patients with unexplained infertility.\nTo demonstrate a possible beneficial impact of this\nprocedure we designed a randomized prospective\nstudy, in which uterine washing was administered\nprior to insemination in patients diagnosed with\nunexplained infertility.\n\nThis study was carried out in patients who presented to Gazi University Hospital, Division of\nInfertility Services with diagnoses of unexplained\ninfertility. This was a single-center, prospective,\nrandomized, blinded control trial undertaken at\na tertiary care university fertility center between\nJanuary 2010-March 2011\nPatients who fulfilled the inclusion criteria\n(180 cases) were randomized by systemic randomization in which they were sequentially allocated to two treatment groups. This systemic\nrandomization was performed by the nurse coordinator on the hCG injection day in the absence of the clinicians.\nWe included 180 patients in the study. It was initially planned to form to equal groups, namely the\ncontrol and study groups, however only 79 eligible\nparticipants gave writen consent and accepted the\npertubation procedure. The other 101 participants received the planned treatment protocol only (control\ngroup). We excluded one patient from the study group\ndue to cycle cancellation. The study group eligibility\ncriteria included: age of 18-44 years; presence of regular menstrual cycles and ovulation; absence of tubal\nocclusion on HSG; sperm concentration >15 million\nspermatoza/ml and total sperm number >39 million/\nml according to WHO criteria ( 4 ). Exclusion criteria\nwere the presence of endocrinologic disease; use of\nnonsteroidal anti-inflammatory drugs (NSAIDs) or\ncorticosteroids; clinical findings suggestive of pelvic\ninflamatory disease; and the presence of undiagnosed\nuterine bleeding.\nFollitropin alpha (Gonal F, rec-FSH, Serona,\nTurkey), follitropin beta (Puregon, rec-FSH Organon, Turkey), urinary hMG (Merional, Aris,\nTurkey veya Menogon, Erkim, Turkey) and urofolitropin (Fostimon, Aris, Turkey) were used\nfor ovarian stimulation. Ovulation induction\nwas started between 2-5 days of menstruation\non patients who had no residual cysts larger\nthan 15 mm as visualized with basal transvaginal USG (ultrasound). All patients had 75-150\nIu/day drug as an initial dose. On cycle day 5-6,\nstimulated follicles were measured ultrasonographically. Induction doses were increased or\ndecreased between 37.5-75 IU/day according to\nfollicle size. Blood estriol and LH levels were\nmonitored and recorded during follow up. When\n1-2 follicles reached a mean diameter of 17 mm,\nwe administered 250 µg of recombinant hCG\nto trigger ovulation. Treatment was discontinued when two or more follicles showed equal\nmaturation in order to avoid the risk of multiple\npregnancies. In case of maturation of two follicles because of the risk of a twin pregnancy,\ntreatment was discontinued. At 35-36 hours after the hCG injection, IUI was performed. Two\ndays following insemination micronized vaginal progesterone (400-600 mg/day, Progestan,\nKocak, Turkey) was administered to support the\nluteal phase until the pregnancy was confirmed.\nTwo weeks after insemination, blood beta-hCG\nlevels were analyzed. If the result was negative,\nprogesterone support was discontinued. Patients\nwith positive hCG titers received progesterone\nsupport until nine weeks of gestation.\nThe swim up prcedure was used for sperm washing. A Rocket Embryo IUI catheter was used during insemination.\nSince our study aimed to evaluate the use of\npertubation prior to ovulation, the procedure\nwas performed on the same day as the hCG\ninjection, prior to its administration. The pertubation procedure was performed in the dorsal lithotomy position after the application of\na vaginal speculum. The vaginal portion of the\ncervix was cleansed with a povidone-iodine\n(PVP-I) solution to prevent potential uterine infections. Povidone-iodine is a stable chemical\ncomplex of polyvinylpyrrolidone (povidone,\nPVP) and elemental iodine (I). It is used for\nthe prevention and treatment of skin infections,\nand the treatment of wounds. This solution has\ncytotoxic effects on sperm and embryo. However PVP-I is used on the hCG injection day,\n36 hours before IUI. Similarly, many clinics\nuse betadine for cervical preparation prior to\nthe oocyte pick-up procedure. Vaginal preparation by betadine does not seem to affect the IVF\nresults ( 5 ).\nUterine washing was accomplished by introducing a silicone catheter through the internal cervical\nos, after which 20 cc saline and 1 cc jetocain were\nslowly injected. Special attention was given to infuse the solution over a few seconds, since rapid\ninjections could give rise to pelvic pain. Jetocain\nwas used for its local anesthetic effects. The speculum was removed and the procedure completed\nafter the injection.\nTwo weeks after insemination, a blood beta\nhCG level was obtained. Two days later, patients whose results were positive had a repeat\ntest to ascertain a healthy increase in beta hCG\nlevels. Patients whose control beta hCG level\ndecreased or those who experienced vaginal\nbleeding were classified as biochemical pregnancies. Patients with a healthy beta hCG increase were evaluated two weeks later for\nclinical pregnancy status. A regular intrauterine\ngestational sac and presence of fetal cardiac\nactivity confirmed the clinical pregnancy. Patients who experienced pregnancy loss after the\nsac was visualized were considered as clinical\nmiscarriages. Pregnancies over 20 gestational\nweeks that resulted in births were defined as\nlive births.\nThis study was approved by the Ethics Committee clinical studies in Ankara and received approval on 25.11.2009.\nPertubation was considered the independent variable. Pregnancy rate (chemical and clinical) was\nthe primary dependent outcome variable.\nData were analyzed with the SPSS software\nversion 15.0 for Windows (SPSS Inc., Chicago,\nIllinois, USA). Continuous variables (age, duration of infertility, total motile sperm count,\n3 rd  day FSH, initial and total dose of ovulation\ninduction agent, follicle count and size, and endometrial thickness) were presented as mean ±\nSD. Categorical variables (alcohol or cigarette\nuse, agent of ovulation induction, fertilization\nrate or pregnancy outcomes) as frequency and\npercentage. Student’s t test was used to compare normally distributed continuous variables\nand the Mann-Whitney U test for variables\nwithout normal distribution. Categorical variables were compared using the chi-square test.\nA two-tailed p value of <0.05 was considered\nstatistically significant.\n\nAmong the 180 patients included, 135 were primarily infertile. There were 51 (64%) primary infertile patients in the study group and 84 (83%)\nprimary infertile patients included in the control\ngroup. In a comparison between groups, we noted\nthat secondary infertility was more common in the\ncontrol group (p<0.05).\nParticipants included in the study were be-\ntween the ages of 18-44 years. The mean age of\nthe study group was 28.8 ± 5.3 years and 28.2\n± 4.7 for the control group (p=0.401). The average infertility period was 3.6 ± 2.3 years in\nthe study group and 3.8 ± 2.8 years in the con-\ntrol group. This difference was not statistically\nsignificant (p=0.684). As seen in table 1, day-3\nbasal FSH levels were not significantly different between groups (p>0.05).\nThere were 21 smokers in the study, of which 7\n(8.9%) were from study group and 14 (13.9%) were in\nthe control group. There was no statistical difference\nbetween both groups when compared for distribution of smokers (p=0.300). Both groups did not include\npatients that had a background of regular alcohol use.\nThere was no significant difference between\nthe types and initial or total doses of gonadotrophins (p>0.05, Tables 2,  3 ). There was also\nno significant difference between the study\nand control groups in terms of dominat follicle\ncount, mean follicle diameter and endometrial\nthickness.\nThe mean total motile sperm number in the study\ngroup was 99.706 ± 85.214 and for the control\ngroup, it was 86.304 ± 61.057. A comparison of\nboth groups showed no significant differnce in total motile sperm count (p=0.405).\nFrom the 180 participants, 39 concieved. A total of 15 pregnancies were from the study group\nand 24 from the control group. In the study\ngroup 3 patients had biochemical pregnancies,\n1 miscarried and 10 patients had live births. In\nthe control group, 1 patient had a biochemical\npregnancy, 3 patients miscarried and 20 patients\nhad live births. Between the two groups, there\nwas no significant difference in pregnancy rates\n(p=0.296, Tables 4,  Fig 1 ). Pregnancy loss rates\nwere statistically similar.\nPatients’ demographic characteristics\nDistribution of gonadotropins within groups\nİnitial and total dose of ovulation induction agents\nPregnancy results\nDistribution of pregnancy outcomes.\n\nInfertility affects 10-15% of the reproductive\nage group ( 6 ). Around 10% of the infertile population is classed as unexplained. Ovulation induction and intrauterine insemination is the accepted first line treatment plan for unexplained\ninfertility.\nIn order to obtain a homogenous patient population we only included patients diagnosed with\nunexplained infertility in this study.\nAt least three cytokines are synthesized by the\nendometrium, colony stimulating factor-1 (CSF- 1 ), leukemia-inhibitory factor (LIF) and interleukin-1 (IL- 1 ), which are associated with implantation ( 7 ). CSF-1 expression from endometrium and\npreimplantation embryo. Cadherin is an important\nagent for intercellular junctional providing on epithelial cells. In the peri-implantation phase, E-cadherin and E-cadherin mRNA expression from endometrium ( 8 ). E-cadherin and E-cadherin mRNA\nlevels are lower in the proliferative endometrium\nthan during the secretion phase. The adhesive\nfunction of the endometrium is to be activated after ovulation.\nT helper (Th) 1 and 2 expression increases in\nperipheral lymphocytes of patients with recurrent\nartificial reproductive tecnology (ART) failure ( 9 ).\nIn pregnancy, Th 2 concentration is higher than Th\n1 concentration. The Th1/Th2 rate is higher in patients who have recurrent abortions and recurrent\nimplantation failure when compared with a fertile\ncontrol group ( 10 ). In some studies, findings have\nshown increases in the numbers of peripheral natural killer cells. However this finding has not been\nfully verified ( 11 ).\nWe can analyze the effect of immunological\nfactors on implantation success in patients with\nhydrosalpinx. The liquid of the hydrosalpinx\nblocks implantation either by a direct embrotoxic effect, a negative impact on the endometrium, and mechanical impact. Implantation\nand pregnancy rate is lower in patients with hydrosalpinx than in a normal control group ( 12 ).\nProspective rondomized studies have shown that\nthe success of an ART procedure increases with\nsalpingectomy in patients who have hydrosal-\npinx. This effect is the same on both of the first\nART cycles and with recurrent ART cycles ( 13 ,\n 14 ). The endometrial environment becomes more ideal for implantation with cleaning of embry-\notoxic cytokines. In a similar way, during the\npertubation, thin adhesions in the endometrial\ncavity was opened with rapid fluid pressure.\nThe downfall of the current study was the use\nof an open randomized technique during patient\nrecruitment. As a result when we compared both\ngroups, it was evident that in the study group secondary infertile patients outnumbered primary\ninfertile couples, whereas in the control group\nprimarily infertile patients were more common.\nAccording to one study performed at our center,\nindependent factors which increased clinic pregnancy rates were secondary infertiliy and unexplained infertility. However these factors did not\naffect live birth rates ( 15 ).\nAlthough the pregnancy rate was higher in the\ncontrol group, this was not statistically significant\nwhen compared with the study group (p=0.296).\nWhen we evaluated both biochemical and clinical\npregnancies, the pregnancy rate was 17.8% in the\nstudy group and 23.8% in the control group. The\nrate of live births, which was the main purpose of\nthis treatment was 12.7% in the study group and\n19.8% in the control group.\nSpontaneous miscarriage occurs in 15-20% of\nknown pregnancies. If serial hCG is measured to\ndetect early subclinical pregnancy loss, this rate\nwould increase to 30% ( 16 ,  17 ). In our study, 21%\nof total pregnancies were abort. This rate was not\nhigher than the expected pregnancy loss rates in\nnormal cycles. When we compared pregnancy loss\nrates in both groups, there was no significant difference observed (p>0.05).\nAboulghar et al. included 213 patients in a study\nwhere they performed hydropertubation on 103\npatients. They used clomiphen citrate and urinary\nHMG for ovulation induction followed by IUI. In\nour study, we only used gonadotropins for ovulation induction. Both studies have performed intrauterine insemination after ovulation induction.\nGenerally the expected fecundability rate associated with this type of treatment protocol is approximately 17% ( 18 ). Aboulghar et al. reported\nan ongoing pregnancy rate of 12.6% in their study\ngroup. Similarly, our research resulted in a rate of\nfecundability of 17.8% and an ongoing pregnancy\nrate of 12.7% in the study group. Therefore our\nresults were compatible with the aforemenioned study ( 19 ).\nIn our study the control group’s fecundability\nrate was 23.8% and the continued pregnancy rate\nwas 19.8%. There was no significant difference\nbetween the study and control groups. However\nthe relatively higher rate in the control group suggested the negative effects of pertubation.\nYapça et al. investigated the effectivity of\nhydrotubation in unexplained infertility therapy by evaluating 80 patients and 144 cycles\n( 20 ). They reported 11(15.7%) pregnancies and\n9(12.86%) clinical pregnancies in a total of 70\ncycles in the study group. A total of 74 cycles\nin the control group yielded 4(5.4%) pregnan-\ncies and 2(5%) clinical pregnancies. There was\na significant overall difference between the two\ngroups (p=0.0219). When evaluated on the basis of individual patients, 11(27.5%?) pregnancies and 9(22.5%) clinical pregnancies occurred\nfollowing two cycles of therapy in 40 patients\nof the study group. In the control group of 40\npatients, there were 4(10%) pregnancies and 2\n(5%) clinical pregnancies following two cycles\nof therapy. When compared on the basis of individual patients, a significant difference was\nnoted (p=0.0231). As a result, the uterine lavage had a positive effect on treatment success\nin unexplained infertile subjects. Although this\nstudy was similar to ours, we were unable to\nestablish a positive effect of pertubation on fecundability. In contrast to a study by Yapça, the\ncurrent study included a larger population (180\nvs. 80), where each patient underwent a single\ncycle of treatment.\nLei et al. have reported the effects hydrotubation in 50 formerly proven tubal occlusive patients\n( 21 ). The hysteroscopic procedure involved the\npassage of a thin plastic canula through the fallopian tube simulatenously using irrigation media\nthat contained hydrocortisone, gentamycine and\nprocain. The use of additional therapeutic agents\nin hydrotubation might explain their increased rate\nof fecundability.\nEdelstam et al. performed out a prospective\nrandomized study to evaluate the effect of pertubation on pregnancy rates in patients with\nunexplained infertility ( 3 ). Pertubation was performed prior to ovulation. A total of 130 cycles\nwere investigated. There was a significant difference between the pregnancy rates (14.9 vs.\n3.2%) of both groups. The authors concluded\nthat pertubation could be used in conjuction\nwith ovulation induction and intrauterine insemination as a first line management protocol\nin couples with unexplained infertility.\n\nIn sum, results of this study revealed that pertubation prior to insemination did not effect pregnancy rates.","source_license":"CC-BY-4.0","license_restricted":false}