Tubal subfertility and ectopic pregnancy. Evaluating the effectiveness of diagnostic tests Mol, B.W.J.

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1 UvA-DARE (Digital Academic Repository) Tubal subfertility and ectopic pregnancy. Evaluating the effectiveness of diagnostic tests Mol, B.W.J. Link to publication Citation for published version (APA): Mol, B. W. J. (1999). Tubal subfertility and ectopic pregnancy. Evaluating the effectiveness of diagnostic tests General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam ( Download date: 04 Dec 2017

2 Introduction 1. Introduction Subfertility is defined as failure of conception after at least one year of unprotected intercourse. In the United States, about 8% of all women between 15 and 44 years are suffering from subfertility. 1 In the Netherlands, the percentage couples suffering from subfertility is estimated to be between 12% and 17%, depending on the age of the female partner of the couple. 2 With sperm defects and ovulation disorders, tubal pathology ranks among the most frequent causes of subfertility. Tubal pathology can be defined as any abnormality of die fallopian tube, a structure of 8 to 20 centimeters length that connects the abdominal cavity with the uterine cavity. The function of the fallopian tube is to facilitate transport of sperm to the abdominal cavity and of the zygote back to the uterus, after fertilization of the oocyte has taken place in die ampulla. The inside of the tube is covered with cilia that beat in the direction of the uterus, thereby probably facilitating egg transport. Apart from the cilia, die muscular wall of the fallopian tube is facilitating transport by causing peristaltic movements. The most important cause of tubal pathology is infection. Pelvic inflammatory disease is caused by sexually transmitted infectious agents, of which Neisseria gonorrhea and Chlamydia trachomatis are the most common. In the Netherlands, experts estimate the incidence of C. trachomatis to be between 2 and 300 per 10,000 women. 2 Although C. trachomatis can cause fulminant pelvic inflammatory disease, the course of the infection is asymptomatic in die majority of the cases. Tubal function can be compromised after either symptomatic or asymptomatic infection, thereby increasing the risk of tubal subfertility and ectopic pregnancy. The prevalence of subfertility after pelvic inflammatory disease varies between 6% and 60%, depending on the seventy of the infection, the number of infections and the age of the woman. 3 Several tests exist for the evaluation of tubal pathology. At hysterosalpingography (HSG), (first performed with lipiodol in ), oü or water based dye is injected slowly through the cervical canal into die uterine cavity. Subsequent X-ray imaging visualizes the uterine cavity, the fallopian tubes and, in case of tubal patency, the abdominal cavity. Apart from its diagnostic value, HSG is also thought to improve 'spontaneous' fertility chances. 6 Hysterosalpingography is performed as an outpatient procedure, but is sometimes painful. The main complication of HSG is the occurrence of pelvic infection, which is reported in 1-3% of all cases. 7 8 The risk of infection can be decreased by an adequate medical history for previous infections, Chlamydia culture of die cervix and prophylactic antibiotics. 8 Laparoscopy with dye, first performed in the 1960s, allows direct visualization of the tubes, but also of peritubal adhesions and endometriosis Laparoscopy with dye is generally regarded as die best test in die evaluation of tubal pathology. 11 There is no knowledge on the effect of laparoscopy on 'spontaneous' fertility chances, but if HSG improves fertility chances by pertubation of die fallopian tubes, laparoscopy might also have beneficial effect on spontaneous conception chances. Furthermore, laparoscopy enables treatment of endometriosis grade I/II, which is also beneficial for fertility prospects

3 Chapter 1 Chlamydia antibody testing (CAT) was introduced in the work-up for subfertility in the 1980s. Acute infection is diagnosed with detection of immunoglobulin (Ig) M in serum. High serum titers of IgG antibodies against Chlamydia indicate a previous Chlamydia infection, and are therefore especially of use in the assessment of the fallopian tubes In contrast to HSG and laparoscopy, CAT does not allow visualization of tubal abnormalities. At this moment, there is no consensus on which tests to use for the diagnostic work-up of tubal pathology. Whereas many authors have advocated the use of HSG, a recent guideline of the Dutch College of Obstetrics and Gynecology advised to start the work-up with CAT, and perform HSG only at indication. 15 Laparoscopy should be performed for an evaluation of possible tubal pathology in case the CAT is increased. The aim of this part of the thesis is to assess the test performance of HSG, CAT and laparoscopy, and to provide guidelines for the work-up of tubal padiology. Chapter 2 focuses on the reproducibility of the interpretation of HSG with respect to proximal and distal tubal occlusion, hydrosalpinx and peritubal adhesions. A low reproducibility of the interpretation of one these items would seriously limit the use of HSG in the diagnostic work-up for tubal pathology. Chapter 3 provides a systematic review of the published literature in which HSG is compared with laparoscopy with respect to the diagnosis of tubal pathology and peritubal adhesions. The performance of HSG is expressed in terms of sensitivity and specificity. Chapter 4 provides a systematic review of the published literature in which CAT is compared with laparoscopy. The performance of CAT is expressed in terms of sensitivity and specificity. Chapters 5 and 6 deal with the capacity of HSG and laparoscopy to predict fertility outcome. Chapter 5 focuses on the question which HSG findings have a significant impact on fertility outcome, using a cohort of over 350 women undergoing HSG in the Academic Medical Center in Amsterdam, The Netherlands. The prognostic impact of one- and twosided tubal pathology as observed at HSG is expressed using fecundity rate ratios. The impact of potential bias caused by informative censoring is assessed. In chapter 6, a direct comparison is made between the prognostic capacity of HSG and laparoscopy in a cohort of over 800 patients, using data collected in the Canadian Infertility Treatment Evaluation Study (CITES). 16 In chapter 7, die results of the studies from chapter 2 to 6 axe used in a cost-effectiveness analysis of the diagnostic work-up of tubal subfertility. The central question of this chapter is which strategy is expected to reveal the highest live birth rates (effectiveness) at the lowest possible cost per live birth (cost-effectiveness). The results of this chapter are used to formulate guidelines for the diagnostic work-up for tubal subfertility. 1.1 References 1. Fecundity and infertility in the Unites States: incidence and trends. Fertil Steril 1991;56: Bonsel GJ, Van der Maas PJ. Aan de wieg van de toekomst. Scenario's voor de zorg rond de menselijke voortplanting Bohn Stafleu van Loghum bv. Houten Weström L. Incidence, prevalence, and trends of acute pelvic inflammatory disease and its consequences in industrialized countries. Am J Obstet Gynecol 1980;138:

4 Introduction 4 Heuser C. La radiographie de l'utérus, des trompes et des ovaires avec ou sans injection de hpiodol, pour le diagnostic précoce de la grossesse, de la stérilité, de la perméabilité des trompes. Bul Soc Rad Méd Frances. T. XIII no. 199; Hanlo EAJM. Utero-salpingographie. Proefschrift. SW Melchior. Amersfoort Watson A, Vandekerckhove P, Lilford R, Vail A, Brosens I, Hughes E. A meta-analysis of the therapeutic role of oil-soluble contrast media at hysterosalpingography: a surpnsing result? Fertil Steal i;j4;61:4/u-/. 7. Stumpf PG, March CM. Febrile morbidity following hysterosalpingography: identification ot risk factors and recommendations for prophylaxis. Fertil Steril 1980^3: Pittaway DE, Winf.eld AC, Maxson W, Darnell j, Herbert C, WenG AC. Prevention of acute pelvic inflammatory disease after hysterosalpingography: efficacy of doxycychne prophylaxis. Am J Obstet Gynecol 1983;147: Siegler AM, Berenyi KJ. Laparoscopy in gynecology. Obstet Gynecol : Van Hall EV, Buytaert P. Laparoscopic in de gynaecologie. Ned Tijdschr Geneesk 1969;113: Tnmbos-Kemper GCM. Tubachirurgie. Thesis. Leiden Marcoux S, Mafieux R, Bérubé S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. N Engl J Med 1997;337: Wang SP Grayston JT. Immunologic relationship between genital TRIC, lymphogranuloma venereum, and related organisms in a new microfiter indirect immunofluoresence test. Am J Opfhalmo'l 1970;70: Threharne JD, Darougar S, Jones BR. Modification of the microimmunofluresence test to provide a routine sérodiagnostic test for chlamydial infection. J Clin Path : NVOG Richtlijn Oriënterend Fertiliteits-Onderzoek (OFO) Werkgroep Voortplantings- Endocnnologie en Fertilität (VEF). Nederlandse Vereniging voor Obstetrie en Gynaecologie (NVOG) Collins JA, Burrows EA, Willan AR. The prognosis for live birth among untreated infertile couples. Fertil Steril 1995;64:

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