Management Options For Hydrosalpinx: Salpingostomy or IVF

Hydrosalpinx refers to a dilated Fallopian tube containing clear fluid, commonly bilateral and generally accepted to be the end result of bacterial infection and resolved pyosalpinx. Infertility can result from distal tubal obstruction and agglutination of tubal fimbriae preventing ovum entry and fertilisation in the distal Fallopian tube. As a consequence of fluid accumulation, intraluminal pressure rises despite patency of the proximal (cornual) Fallopian tube with intermittent release of fluid to the uterine cavity. The original inflammatory process also commonly causes structural damage and loss of physiological function of the Fallopian tube. Since the introduction and progressive improvement in outcome with IVF, use of restorative surgery as a treatment option has remained static. Because of the recognised deleterious effect of hydrosalpinx fluid on embryo implantation, to prevent fluid entering the uterine cavity, hydrosalpinges are commonly excised or proximately obstructed prior to commencing IVF. These procedures exclude natural conception, with IVF remaining the only treatment to achieve a pregnancy. A minority of hydrosalpinx affected women achieve intrauterine pregnancies following “salpingostomy” or” neo-salpingostomy” (surgical reopening of the distal hydrosalpinx), however the majority fail to conceive or develop tubal ectopic pregnancies. This thesis explores how tubal function is affected by hydrosalpinx formation with the aim of determining the extent of the role, if any, of salpingostomy in the current management of hydrosalpinx. Morphological, physical and biochemical studies were performed comparing rabbit hydrosalpinx to control oviducts and hydrosalpinx and normal Fallopian tubes in women Rabbit studies Systematic evaluation of changes in morphological, physical and biochemical tissue levels were made utilising a surgically induced model of hydrosalpinx in the rabbit. The oviduct distension occurring during hydrosalpinx formation resulted in significant changes in all parameters studied. Major alterations were observed in morphology (light and surface electron microscopy), most notably epithelial deciliation, and tissue biochemistry including tissue DNA/RNA content and turnover, collagen, electrolyte, water and lipid levels. Progessive reduction in tubal blood flow was noted with increasing intraluminal pressure. Tubal muscular contractility, epithelial ciliary and secretory activity are critically influenced by ovarian steroids, therefore detailed examination of changes in tissue oestrogen and progesterone cytosolic and nuclear receptor levels were measured in healthy and hydrosalpinx affected oviducts. With progressive increase in tubal distension, reduction in steroid hormone receptor levels occurred. Reversal of all these abnormalities was achieved following microsurgical tubal reconstruction, including restoration of fertility. Human studies The study confirmed that in women hydrosalpinx results in similar adverse morphological and biochemical changes with variable segmental epithelial deciliation. Steroid hormone receptor levels were significantly reduced in hydrosalpinx compared to normal controls. Receptor levels measured during the proliferative, secretory phases of the menstrual cycle, menopause, early pregnancy and postpartum, reflected changes in circulating steroid hormone levels. Fallopian tubes obtained from women with ectopic pregnancies and post-sterilisation also showed a reduction in hormone receptor levels, in parallel with a decline in mean ciliation index (MCI). The study confirmed that following salpingostomy, intrauterine pregnancies could be achieved when an adequate MCI was found to be present in epithelial microbiopsies taken at the time of salpingostomy procedure. Women with reduced or low MCI subsequently experienced ectopic pregnancies or failed to conceive. Assessment of tubal morphology is laboratory dependant and requires subjecting women to a diagnostic procedure prior to carrying out salpingostomy when MCI is found to be favourable. In an attempt to predict which Fallopian tubes are worthy of conservative surgery at a single operation, a review of the literature was undertaken to evaluate what role inspection of the tubal lumen by salpingoscopy (transabdominal) or fertiloscopy (transvaginal) plays in assessment of mucosal pathology. The aim was to assess whether inspection of the tubal mucosa gave comparable information to MCI. Review of salpingoscopy prediction results, suggests that women with hydrosalpinges associated with severe intraluminal adhesions, denuded or flattened mucosal folds (high abnormality grade according to set scale), had negligible chance of intrauterine pregnancy following salpingostomy. As a corollary, these pathological changes are a contraindication to restorative surgery. To perform salpingostomy an abdominal approach is preferred when correction of hydrosalpinx is considered, as opening of the distal part of the Fallopian tube, intraluminal inspection and salpingostomy procedure can best be achieved by this route. The data also suggests that with a single endoscopic intervention, salpingoscopy followed by salpingostomy has up to a 30% chance of successful intrauterine pregnancy outcome. Women with hydrosalpinges that have mucosal folds with limited intraluminal and peritubal adhesions therefore warrant consideration of conservative rather than destructive surgery. Having confirmed also that mucosal assessment can be further improved by utilising microsalpingoscopy, this procedure should also be considered for assessment of the tubal mucosa. This latter procedure which involves contact epithelial inspection will determine whether post- inflammatory changes remain present at the cellular level, thus facilitating a decision of Fallopian tube conservation. Salpingostomy is particularly relevant for ovulatory women over 40 years of age who have a low chance of success with IVF treatment. The higher success rate (intrauterine pregnancy and live births) achieved by women aged 40-47 who had tubal surgery (reversal of sterilisation), in comparison to IVF treatment is consistent with this interpretation (Petrucco et al 2007). The observation of progressive deterioration in tubal function with increasing intraluminal pressure in the rabbit model, suggests that women diagnosed with bilateral hydrosalpinx wanting future fertility could be offered salpingostomy at initial diagnosis of hydrosalpinx before fertility is considered. This endoscopic day surgery procedure may prevent deterioration in tubal function as progressive dilatation occurs with time and allow the possibility of subsequent spontaneous conception, rather than having to rely completely on artificial reproductive technology (ART) and IVF. It is proposed that conservative surgery to achieve conception in women with hydrosalpinges should be considered when salpingoscopic assessment predicts a favourable outcome. As well as providing a chance of spontaneous conception of more than one pregnancy, this approach would reduce the enormous cost burden on society of providing repeated cycles of IVF currently funded by our national health system. Further studies and evaluation beyond this current study are required to support this proposal.Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 202

Acupuncture to Treat Primary Dysmenorrhea in Women: A Randomized Controlled Trial

We examined the effectiveness of acupuncture to reduce the severity and intensity of primary dysmenorrhea. A randomized controlled trial compared acupuncture with control acupuncture using a placebo needle. Eligible women were aged 14–25 years with a diagnosis of primary dysmenorrhea. Women received nine sessions of the study treatment over 3 months. The primary outcomes were menstrual pain intensity and duration, overall improvement in dysmenorrhea symptoms and reduced need for additional analgesia, measured at 3, 6 and 12 months from trial entry. A total of 92 women were randomly assigned to the intervention (acupuncture n = 46 and control n = 46). At 3 months although pain outcomes were lower for women in the acupuncture group compared with the control group, there was no significant difference between groups. Women receiving acupuncture reported a small reduction in mood changes compared with the control group, relative risk (RR) 0.72, 95% confidence interval (CI) 0.53–1.00, P = .05. Follow-up at 6 months found a significant reduction in the duration of menstrual pain in the acupuncture group compared with the control group, mean difference –9.6, 95% CI –18.9 to –0.3, P = .04, and the need for additional analgesia was significantly lower in the acupuncture group compared with the control group, RR 0.69, 95% CI 0.49–0.96, P = .03, but the follow-up at 12 months found lack of treatment effect. To conclude, although acupuncture improved menstrual mood symptoms in women with primary dysmenorrhea during the treatment phase, the trend in the improvement of symptoms during the active phase of treatment, and at 6 and 12 months was non-significant, indicating that a small treatment effect from acupuncture on dysmenorrhea may exist. In the study, acupuncture was acceptable and safe, but further appropriately powered trials are needed before recommendations for clinical practice can be made

A Theory Of Axiom Systems.

Doctor of Education (EdD)MathematicsUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/187236/2/6902272.pd