Objective
To determine whether previous salpingectomy is associated with serum antiMüllerian hormone (AMH) level and ovarian reserve in women under 40 years presenting for in vitro fertilization and embryo transfer.
Study Design
We retrospectively compared serum AMH levels measured on the ovulation induction initiation day in patients with unilateral salpingectomy, bilateral salpingectomy, and no tubal surgery, and examined the relationship with length of time after surgery and in vitro fertilization and embryo transfer parameters.
Results
A total of 198 women were included; 83 received unilateral salpingectomy, 41 bilateral salpingectomy, and 74 no tubal surgery. The baseline characteristics of the groups were similar. The mean AMH level was significantly higher in women without tubal surgery as compared with those with bilateral salpingectomy (183.48 vs 127.11 fmol/mL; P ≤ .037). The mean follicle stimulation hormone level was significantly lower in women without surgery as compared with those with bilateral salpingectomy (7.85 vs 9.13 mIU/mL; P = .048). No significant differences in duration of gonadotropin therapy, amount of gonadotropin used, estradiol level on the human chorionic gonadotropin injection day, thickness of the endometrium, number of oocytes retrieved, number of 2-pronuclei, viable embryos, and good quality embryos were found between the 3 groups. AMH level was not correlated with the number of oocytes or age in women that had undergone unilateral or bilateral salpingectomy.
Conclusion
Salpingectomy is associated with decreased AMH level and increased follicle stimulation hormone in women seeking in vitro fertilization, though AMH level is not correlated with the number of oocytes retrieved in patients that have undergone unilateral or bilateral salpingectomy. These results suggest that salpingectomy is associated with decreased ovarian reserve.
It is generally recognized that removal of a hydrosalpinx can increase the implantation rate of in vitro fertilization and embryo transfer (IVF-ET). However, whether salpingectomy affects ovarian reserve is uncertain, with some studies suggesting that salpingectomy deceases ovarian reserve, and other studies indicating that it has no effect on ovarian reserve. Various studies, however, have used different measures of ovarian reserve including the duration of gonadotropin stimulation, amount of gonadotropin used, number of follicles, number of oocytes retrieved, fertilization rate, implantation rate, clinical pregnancy rate, live birth rate, and antiMüllerian hormone (AMH) level.
AMH is a glycoprotein dimer secreted primarily by granulocytes of preantral follicles and small antral follicles. AMH levels are relatively constant throughout the menstrual cycle, correlate with the number of follicles and ovarian reserve, and are predictive of both over and poor response to controlled ovarian stimulation. For these reasons, AMH levels can be used to evaluate changes in ovarian reserve after salpingectomy.
The purpose of this study was to determine whether previous salpingectomy is associated with serum AMH level and ovarian reserve in women under 40 years of age presenting for IVF-ET.
Patients and Methods
Patients
IVF-ET patients who visited Shanghai Ji Ai Genetics and IVF Institute and the Obstetrics and Gynecology Hospital of Fudan University between October 2012 and May 2013 were eligible for inclusion in this study. Inclusion criteria were age <40 years, regular menstrual cycles, and no history of ovarian surgery. Women with polycystic ovarian syndrome, ovulatory dysfunction, and endometriosis were excluded from the analysis. Subjects were assigned into 1 of 3 groups according to their history of preIVF tubal surgery: unilateral salpingectomy, bilateral salpingectomy, or no tubal surgery. The institutional review board approved this retrospective study.
Measurement of hormone levels
A 10-mL blood sample was drawn on the third day of menstruation (IVF-ET initiation day). The sample was centrifuged for 5 minutes, and the supernatant serum was collected and stored at −20° C. Before testing, the sample was thawed and vortexed. Estradiol (E2), progesterone, luteinizing hormone, and follicle stimulating hormone (FSH) levels were measured with a Beckman Acoulter Access automated chemiluminescence immunoassay analyzer with reagent kits from Beckman (Beckman–Coulter Inc., Brea, CA). Testing was performed according to the manufacturer’s instructions. AMH levels were measured by an enzyme linked immunosorbent assay using a Bio-Rad iMark microplate absorbance reader with reagent kits from Bio-Rad (Bio-Rad Laboratories Inc, Hercules, CA). Per the manufacturer, the interassay coefficient of variability is ≤10%, and the intraassay coefficient of variability is ≤15%.
Determination of antral follicle count
On the third day of menstruation (IVF-ET initiation day), transvaginal sonography was performed to evaluate the status of the uterus and ovaries, measure the ovarian size, and determine the antral follicle count (AFC). A Philips HDII ultrasonography machine (Philips, Amsterdam, the Netherlands) was used at a probe frequency of 3∼7 MHz.
Ovulation induction and IVF protocols
Short controlled ovarian hyperstimulation protocol
Daily subcutaneous triptorelin 0.1 mg was given from the third day of menstruation to the day of human chorionic gonadotropin (hCG) injection. Gonadotropin 75-300 IU/day by injection was started on the fourth day, and adjusted according to ultrasonography results and serum E 2 level.
Minimal ovarian stimulation protocol
Oral clomiphene 50-100 mg was given from the third day of menstruation to the day of hCG injection. Daily human menopausal gonadotropin 75-150 IU by injection was given starting on the fifth day of clomiphene. When 1 dominant follicle reached 18 mm in diameter, or 2 follicles reached 16 mm in diameter, intramuscular injection of hCG 3000-10000 IU was given. Oocytes were retrieved under transvaginal ultrasonography guidance within 34-36 hours of hCG injection.
IVF
Quality sperm was selected for IVF/intracytoplasmic sperm injection. Eighteen hours after fertilization, the oocyte was observed to confirm the formation of a pronucleus. After 3 days of culture, the embryo was observed and scored under a microscope.
Evaluation of embryo quality
Embryos of class I-III were considered viable. Good quality embryos were defined as having a normal cleavage rate, even-sized blastomeres, and fragments <10%.
Statistical analysis
Continuous variables were presented as means and standard deviations (SDs). Categorical variables were presented as counts and percentages. One-way analysis of variance with Bonferroni post hoc testing was performed to compare the differences between women with unilateral salpingectomy, with bilateral salpingectomy, and without surgery with respect to baseline characteristics and treatment-related factors. Because the variables were normally distributed, Pearson coefficient correlation ( r ) was performed to investigate the linear correlation between AMH vs time after surgery, number of oocytes, and age in women with unilateral salpingectomy and bilateral salpingectomy. A 2-sided P value < .05 was considered to indicate statistical significance. All statistical analyses were performed with SPSS 17.0 statistics software (SPSS Inc., Chicago, IL).
Results
Patient characteristics
A total of 198 women were included in the study, with 83 in the unilateral salpingectomy group, 41 in the bilateral salpingectomy group, and 74 in the group that had not received tubal surgery. Patient characteristics by group are shown in Table 1 . There were no differences in age, E2, progesterone, luteinizing hormone, AFC, ovarian stimulation protocol used, the length of secondary infertility, and the reason of infertility between the 3 groups (all, P > .05). The mean AMH level was significantly higher in women without tubal surgery as compared with those with bilateral salpingectomy (183.48 vs 127.11 fmol/mL, P ≤ .037). The mean FSH level was significantly lower in women without surgery as compared with those with bilateral salpingectomy (7.85 vs 9.13 mIU/mL, P = .048). The mean duration of primary infertility was significantly higher in women without surgery as compared with those with unilateral and bilateral salpingectomy (3.6 vs 0.31 and 0.82 years, P < .001). The reasons for having surgery were significantly different between the unilateral and bilateral salpingectomy groups. The percentage of patients with an ectopic pregnancy was greater in the unilateral salpingectomy group, and the percentage of patients with a hydrosalpinx was greater in the bilateral salpingectomy group ( Table 1 ).
| Characteristic | Unilateral salpingectomy (n = 83) | Bilateral salpingectomy (n = 41) | Without surgery (n = 74) | P value |
|---|---|---|---|---|
| Age, y | 33.02 ± 4.66 | 33.58 ± 3.95 | 33.8 ± 4.67 | .553 |
| AMH, (fmol/mL) | 167.56 ± 127.03 | 127.11 ± 93.23 | 183.48 ± 104.37 a | .037 |
| E2, pg/mL | 38.3 ± 14.91 | 41.41 ± 16.59 | 36.49 ± 16.77 | .291 |
| Progesterone, nmol/L | 0.52 ± 0.29 | 0.55 ± 0.33 | 0.54 ± 0.32 | .848 |
| LH, mIU/mL | 4.06 ± 1.56 | 3.94 ± 1.75 | 4.26 ± 2.09 | .63 |
| FSH, | 8.42 ± 2.3 | 9.13 ± 3.2 | 7.85 ± 2.69† | .048 |
| AFC, | 10.7 ± 3.62 | 9.58 ± 3.73 | 11.22 ± 4.16 | .097 |
| BMI, kg/m 2 | 21.63 ± 2.46 | 21.1 ± 2.85 | 21.43 ± 2.83 | .582 |
| Testosterone | 38.59 ± 13.42 | 32.55 ± 9.86 | 37.42 ± 18.02 | .152 |
| Protocol | .071 | |||
| Short COH | 52 (62.65) | 17 (41.46) | 38 (51.35) | |
| Minimal ovarian stimulation | 31 (37.35) | 24 (58.54) | 36 (48.65) | |
| Reason for surgery | < .001 | |||
| Tuboovarian abscess | 1 (1.2) | 1 (2.44) | − | |
| Ectopic pregnancy | 79 (95.18) | 24 (58.54) | − | |
| Hydrosalpinx | 3 (3.61) | 16 (39.02) | − | |
| Primary infertility, y | 0.31 ± 1.13 | 0.82 ± 1.96 | 3.6 ± 4.15 a,b | < .001 |
| Secondary infertility, y | 2.85 ± 2.81 | 3.23 ± 3.24 | 2.36 ± 3.32 | .369 |
| Reason of infertility | ||||
| Unknown | 0 (0) | 0 (0) | 2 (2.7) | .184 |
| Oligoasthenoteratospermia | 41 (49.4) | 15 (36.59) | 28 (37.84) | .239 |
| Severe oligoasthenoteratospermia | 2 (2.41) | 1 (2.44) | 6 (8.11) | .178 |
| Obstructive azoospermia | 2 (2.41) | 0 (0) | 4 (5.41) | .245 |
| Both male and female factors | 28 (52.83) | 15 (55.56) | 26 (55.32) | .959 |
a P < .05, significantly different with unilateral salpingectomy group
b P < .05, significantly different with bilateral salpingectomy group.
The comparisons of treatment-related factors between the three groups are shown in Table 2 . No significant differences in duration of gonadotropin therapy, amount of gonadotropin used, E2 level on the hCG injection day, thickness of the endometrium, number of oocytes retrieved, number of 2-pronuclear zygote (2PN), viable embryos, and good quality embryos were found between the 3 groups (all, P > .05).
| Variable | Unilateral salpingectomy (n = 83) | Bilateral salpingectomy (n = 41) | Without surgery (n = 74) | P value |
|---|---|---|---|---|
| Duration of Gn therapy, d | 9.6 ± 1.76 | 9.39 ± 2.12 | 9.78 ± 1.62 | .523 |
| Gn amount (vials) | 23.75 ± 10.31 | 23.77 ± 10.79 | 24.95 ± 9.85 | .732 |
| E2 level on the hCG injection day, pg/mL | 3822.99 ± 1630.06 | 3286.05 ± 1629.64 | 3727.36 ± 1891.94 | .257 |
| Thickness of endometrium, mm | 9.84 ± 3.3 | 8.98 ± 2.58 | 9.84 ± 2.95 | .27 |
| Number of oocytes retrieved | 7.83 ± 4.16 | 6.98 ± 4.15 | 8.42 ± 4.04 | .199 |
| Number of 2-pronuclear zygote | 4.95 ± 3.43 | 4.76 ± 3.61 | 5.49 ± 3.06 | .453 |
| Number viable embryos | 3.39 ± 3.03 | 3.15 ± 2.51 | 3.5 ± 2.6 | .807 |
| Number of good quality embryos | 2.72 ± 2.69 | 2.44 ± 2.24 | 2.69 ± 2.39 | .826 |
Correlation between AMH level and time after surgery and number of oocytes
The correlations between AMH level and time after surgery, number of oocytes, and age for women with a unilateral salpingectomy are shown in Figure 1 , and the correlations for women with a bilateral salpingectomy are shown in Figure 2 . For women with a unilateral salpingectomy, a significant linear correlation was found between AMH level and time after surgery (r = 0.399, P < .001) ( Figure 1 , A). No significant linear correlations were found between AMH and number of oocytes (r = 0.145, P = .192) and age (r = 0.141, P = .202) ( Figure 1 , B and C, respectively). For women with a bilateral salpingectomy, no significant linear correlations were found between AMH level and time after surgery (r = −0.049, P = .760), number of oocytes (r = 0.180, P = .260), and age (r = −0.277, P = .079) ( Figure 2 , A, B, and C, respectively). Significant linear correlations were found between AFC and number of oocytes in women with a bilateral salpingectomy, but not with unilateral salpingectomy (bilateral: r = 0.348, P = .028; unilateral: r = −0.026, P = .815) ( Appendix ; Supplemental Figures 1 and 2 ). No significant linear correlations were found between AMH level and AFC in women with a unilateral salpingectomy (r = −0.013, P = .904) or with a bilateral salpingectomy (r = 0.274, P = .087) ( Supplemental Figures 3 and 4 ). No significant linear correlation was found between AMH level and age in all women (r = −0.067, P = .352) ( Supplemental Figure 5 ). A significant linear correlation was found between AMH level and age in women without surgery (r = −0.273, P = .019) ( Supplemental Figure 6 ).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
