Factors of importance for the outcome of IVF-treatment in women with tubal infertility

Abstract

In vitro fertilization embryo transfer (IVF-ET) is a well-established infertility treatment caused by damage of the fallopian tube, which is one of the largest diagnostic categories in most IVF programs. This study evaluates factors of importance for the outcome of IVF-treatment: age, tubal damage grade, extent of reconstructive surgery, endocrine ovarian function and endometrial development. In order to assess whether the women's age influences IVF treatment outcome, when Using a long GnRHa-hMG or a CC-hMG ovarian stimulation protocol, 200 women were investigated. One hundred under the age of 35 and 100 women 35 years of age and older (mean 31.8 years and 36.7 years respectively). Our findings were in accordance with others, showing woman's age as an important factor for treatment outcome. Using the long GnRHa-hMG protocol for ovarian stimulation in "older" women, seems to counteract the negative impact of advanced age. Increasing age is often correlated with high cancellation rate due to a poor response to ovarian stimulation, independently of the drug used.

The post inflammatory tubal damage grade appears to be another important factor for the outcome of IVF treatment. The grade of tubal damage and extent of surgery for the outcome of IVF treatment was evaluated in 53 women with tubal infertility. Ovarian function was assessed before IVF-treatment during two complete screening cycles. The first was a randomly selected natural cycle, and during the second cycle CC challenge test was performed. FSH on cycle day 3 and 10 and E2 and P4 AUC in the luteal phase of a CC stimulated cycle were used as hormonal predictors. When the Predictive value was calculated for these hormonal indicators, the highest was for E2 AUC during the luteal phase. The relation between grade of tubal damage and pregnancy rate following IVF treatment was evaluated in women who had not undergone tubal surgery. Indicators of low ovarian response were the number of ampoules needed, pre ovum retrieval E2 levels, and the number of oocytes recovered. A gradual decline in number of pregnancies following IVF-treatment in relation to tubal damage grade was observed.

When the success rate of IVF-treatment was compared between women who underwent surgery before IVF-treatment and those who did not, the pregnancy rate was higher in the latest group. Indications about the negative impact of tubal surgery on the outcome of IVF-treatment were found, at least in women with advanced tubal damage. None of the women who underwent extensive surgery with ovarian intervention became pregnant. Endometrial quality was evaluated in relation to ovarian function and the outcome of IVF treatment. Biopsies were obtained on cycle days LH+2 to LH+6 in women on the waiting list for IVF- treatment and in controls with proven fertility. An increased occurrence of retarded endometrial development was found in the women who did not become pregnant compared with the controls, suggesting that the endometrial quality could have some importance for successful implantation.

Our study clearly indicates, that ovarian function is the most important factor for the outcome of IVF treatment. Factors influencing ovarian function such as age could be improved by using a GnRHa-hMG protocol in women 35 years of age and older. In tubal infertility, a close relation was observed between higher grade of tubal damage and impaired ovarian hormonal function, both in women who underwent reconstructive surgery and those who were not operated before IVF- treatment. The morphological endometrial retardation observed in women who did not become pregnant following rVF-treatment suggests, that the endometrium could have a significant role for unsuccessful implantation. Other facts, such as the possible implantation in tubal mucosa or peritoneum, indicate that endometrial quality may be of less importance as compared to embryo quality. Basal FSH and CC challenge test followed by repeated measurements of E2 and P4 in the luteal phase, appear to be a promising prognostic test battery for the outcome of IVF treatment, which could be used for pre-treatment patient counselling.