8/19/2019 How to Deal With Fluid in the Endometrial Cavity During Assisted Reproductive Techniques

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How to deal with fuid in the endometrial cavityduring assisted reproductive techniquesRong-Huan Hea and Xiao-Ming Zhu

Purpose o review

Patients with endometrial cavity fuid (!"# in assisted reproductive techniques ($R%s# arepoor in prognosis& %his review presents the research development o !" during $R%s'particularly in treatment&Recent ndings!" patients with or without tu)al inertility may represent a di*erent clinical entity& !"impairs the $R% outcome in tu)al actor' )ut not polycystic ovarian syndrome' patients&$ctually' it was tu)al inertility' not only hydrosalpin+' that was related to the development o !"& ,oth appearance time and accumulation amount o !" are critical in the impact o !"on the $R% outcome& ince e+cessive !" (equal to or higher than.&/mm in the anterior0posterior diameter# usually had a negative impact on the $R%outcome' postponing em)ryo transer should )e considered& $ none+cessive !"usually disappeared )y the time o em)ryo transer& %he routine em)ryo transer in these!" patients could yield the same $R% outcome as in patients without !"& 1 anone+cessive !" persisted until the day o em)ryo transer' particularly in patients with

nontu)e inertility' transvaginal sonographic aspiration could )e an alternative o treatment&ummary

 %he treatment o !" during $R%s should )e individual according to the causes'appearance time and accumulation amount o !"&2eywordsassisted reproductive techniques' endometrial cavity fuid' polycystic ovariansyndrome' treatment' tu)e inertility

1ntroductionndometrial cavity fuid (!"# is a fuid accumulationwithin the endometrial cavity& 1t is not a common complicationduring assisted reproductive techniques($R%s#' )ut it' especially the e+cessive one' is detrimentalto em)ryo implantation and thus negatively impactsthe $R% outcome 34 55 '60478& %he relevant actors o !" during $R%s remain unclear' much less therelevant treatments 34 55 '60478& 1n this short review'the recent developments o !" during $R%s are highlightedand discussed' with particular emphasis on thedevelopment o !" treatment&

 %he relevant actors o !" developmentduring assisted reproductive techniques %he relevant actors o !" during $R%s have )eendocumented a lot& %u)al inertility (including hydrosalpin+#34 55 '.0/'9':8' polycystic ovarian syndrome (P!;# 3.'98' poor ovarian response 3<8'

physiological generation)y the genital tract 368' and so on were all included inthis respect&$s to tu)al inertility' a recent retrospective investigation)ased on the clinical data o 4//9 inertility patientsenrolled or the 1=" program showed again that it wastu)al inertility' not only hydrosalpin+' that was related tothe development o !" during $R%s 34 55 8& 1n thatclinic investigation' over hal (6>?@< cases' <7&>9A# o !" patients had tu)al inertility and only 46 cases(46?@< cases' 6<&7:A# had visi)le hydrosalpin+ on ultrasonography)eore ovarian stimulation& 1n those patientswith tu)al inertility' su)clinical uterine inections or the

su)sequent drainage imperection o uterine or allopiantu)e fuid might )e associated with the development o 

8/19/2019 How to Deal With Fluid in the Endometrial Cavity During Assisted Reproductive Techniques

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!" 3/'>8&$s to P!; as a relevant actor o !" during $R%s'over-reactive fuid generation and secretion o the genital tract or the peritonealmem)rane during $R%s in P!;patients might contri)ute to the development o !"36'.'448& Here' higher levels o serum estrogens or gonadotrophins

and the relevant changes o aquaporins ine+pression and fuid transport might )e a mechanism or!" development 36'.'44'468&2ey points 5 ,oth tu)al inertility and polycystic ovarian syndromeare the two main actors related to thedevelopment o endometrial cavity fuid (!"#& 5 1t was e+cessive !" (equal to or higher than.&/mm in the anterior0posterior diameter# thatwould have a negative impact on the assisted reproductivetechnique outcome' especially in thosepatients with tu)al inertility and with the !"persisted until the implantation period&

 5 1n !" patients with nontu)e inertility' em)ryotranser can )e perormed saely i the !" hasdisappeared and not returned )y the day o em)ryotranser& 5 Removing !" with an em)ryo transer catheterimmediately )eore em)ryo transer may )e a successulmethod o treatment to those none+cessive!" patients with nontu)e inertility& 5 1n patients with e+cessive !"' particularly thosewith tu)al inertility' postponing em)ryo transerwith medical or surgical intervention should' however')e considered&

 %he relevant impact o !" on the assistedreproductive technique outcome %he $R% cycles with !" were considered )y mostresearchers to have low implantation and pregnancy ratesas well as a high incidence o cycle cancellation 34 55 '.0:8&$ recent retrospective controlled investigation in thisaspect demonstrated that no signicant di*erence wasound in clinical pregnancy rate )etween the patientswith their !" )elow .&/mm in the anterior0posteriordiameter o !" and the control group (./&@> vs& .7&@9A'PB7&7/#& Co clinical pregnancy was ound among thosepatients with their !" equal to or higher than .&/mm inthe anterior0posterior diameter 34 55 8& %his investigation

indicates that it was e+cessive !" (equal to or higherthan .&/mm in the anterior0posterior diameter#' not thenone+cessive !" (D.&/mm in the anterior0posteriordiameter#' that would have a negative impact on the $R%outcome& %he presence o a relatively small amount o !" at the day o oocyte retrieval did not appear tonegatively impact the $R% outcome& %his was similar tothose in this respect descri)ed previously in somerelevant studies 36'.8& %he researchers o those studiesheld that !" o)served in patients with P!; or withouttu)al inertility may represent a di*erent clinicalentity rom that in patients with tu)al diseases& 1 the!" was generated physiologically or reactively )y the

genital tract during $R%s' the clinical pregnancy rate o the involved !" patient was not worse than that o 

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those patients without !" and no impact o this Eind o !" on em)ryo implantation was ound&$s mentioned a)ove' the amount o !" is critical in theimpact o !" on the $R% outcome& +cessive !"would have a negative impact on the $R% outcome&$mong the previous relevant studies' only two were

conducted on the e*ects o !" amount on the $R%outcome 34 55 '@8& %he earlier one reported that the !"greater than .mm in the largest diameter o the endometrialcavity was a large amount o !" and that thelarge amount o !" was usually detrimental to em)ryoimplantation 3@8& 1n the later study' the large amount o !" was dened as the !" equal to or higher than.&/mm in the anterior0posterior diameter 34 55 8& %hesmall amount o !" (D.&/mm in the anterior0posteriordiameter# usually disappeared )y the time o em)ryotranserF whereas the large amount o !" usually persistedand even enlarged until during implantationperiod& %he presence o a small amount o !" did not appear to negatively impact

the $R% outcome' whencompared with that o the control patients without !"'whereas the large amount o !" would do 34 55 8& %he time o !" development is also important in theimpact o !" on the $R% outcome& Many studiesdemonstrated that the !" detected during ovarianstimulation usually had a negative impact on the $R%outcome 3.'<'9':8& 1 !" transiently developed aterreceiving a human chorionic gonadotropin (H!G# inectionand disappeared )y the day o em)ryo transer' the!" did not impact the clinical pregnancy rate 34 55 '.'<8&

 %he relevant treatment o !" during assisted

reproductive techniques %here is a mostly accepted opinion )y clinicians that!" during $R%s could )e o)served in patients with)oth tu)al and nontu)al actors 34 55 '.'@8& !" o)servedin patients with or without tu)al inertility may representa di*erent clinical entity 36'.8& ,oth appearance time andaccumulation amount o !" are critical in the impact o !" on the $R% outcome 3.'<'9':8& %hereore' thetreatment o !" during $R%s should )e individualaccording to the causes' the appearance time and theaccumulation amount o !"& $ny methods )enecial toeliminate causes' to prevent fuid rom over generation orrom entering the uterine cavity' to promote the drainage

o !"' could )e utiliIed to deal with !"& %he relevanttreatment options include e+pectant treatment' postponingem)ryo transer' transvaginal sonographic !"aspiration' and other su)sidiary modications and optimiIationsin $R%s& +pectant treatment and postponing em)ryo transer are two main Einds otreatment optionsthat have proved e*ective in improving $R% outcome inpatients with !"& %ransvaginal sonographic aspirationmay also )e considered as a suita)le alternative o treatmenti !" persisted and was not e+cessive' )ut thisoption has only )een evaluated in a small sample and isthus o less validity& Cew treatments and modicationsin $R%s may improve the $R% outcome o patients

with !"&+pectant treatment

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+pectant treatment is mainly used in patients with atransient !" during $R%s& Jots o !"s during $R%swere transient' particularly those generated physiologicallyor reactively )y the genital tract during $R%s inpatients without tu)e inertility 36'.'98& $ retrospectiveinvestigation showed that the ratio o transient !" in

patients with P!; was >>&:A (6@?69# 3.8& %hose transient!"s usually appeared ater H!G administrationduring $R%s or earlier during undergoing the ovarianstimulation& Most o them were none+cessive in volumeand disappeared )eore the day o em)ryo transer34 55 '6'.'478& %he same em)ryo implantation rate andclinical pregnancy rate were also o)served ater thescheduled em)ryo transer )etween those nontu)e-inertilitypatients with and without !" 36'.8& 1t was concludedthat' or those possi)ly transient !"s' e+pectanttreatment could )e used and the scheduled em)ryo transercould )e conducted on time34 55 '6'.8&Kuring e+pectanttreatment' continuous monitoring o the sequelae o !"

is mandatory 3>8& 1 the !" persisted and even enlargeduntil the scheduled day or em)ryo transer' the su)sequentstrengthened treatments' such as postponingem)ryo transer' transvaginal sonographic !" aspiration'and so on' should )e considered 34 55 '.0478&

Postponing em)ryo transerPostponing em)ryo transer is a mainstream treatment o !" during $R%s& 1t consists o em)ryo cryopreservationand the su)sequent optional roIen em)ryo transer'accordingly and medical and surgical interventions34 55 '.0478& %he treatment was originally designed orthe treatment o tu)e-inertility patients with !"'particularly those with e+cessive !" during $R%s34 55 '@'98& Here' the dening value o e+cessive !"was the anterior0posterior diameter o !" equal toor higher than .&70.&/mm 34 55 '@8& %he e+cessive !"state during $R%s usually persisted and even enlargeduntil during implantation period& 1n this situation' the$R% outcome o em)ryo transer usually was poor 34 55 '@8& %hat is why many researchers recommend postponingem)ryo transer as the main treatment o this Eind o !" 34 55 '@'98& %hrough postponing em)ryo transer andmedical and surgical interventions' a physiological state o uterine cavity andendometrium or em)ryo implantationand development' and thereore a )etter $R%

outcome' could )e e+pected&$s to the patients with nontu)e inertility and withe+cessive !"' such as the patients with P!;' postponingem)ryo transer and some medical interventionsduring the su)sequent roIen em)ryo transer programare recommended 347'4.'4@8& Here' the supplementedmedical intervention' including a mild ovarian stimulationor a modied natural cycle 34/ 5 '4< 5 8' is intendedto avoid ovarian hyperstimulation and thus to o)tain a)etter milieu o uterine cavity and endometrium or thesu)sequent roIen em)ryo implantation and development& %he use o the natural cycle in this respect has)een descri)ed in one retrospective study 34.8& Patients

with hydrosalpinges undergoing 1=" in a natural cycle(nL96# demonstrated signicantly higher pregnancyrates compared with patients who received controlled

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ovarian hyperstimulation (nL@:F 4> vs& 9A' PD7&7/#34.'4@8&1n the patients with tu)e inertility and' particularly'with a detecta)le hydrosalpin+ 34@'498' surgical interventionshould )e supplemented as a part o the treatmento postponing em)ryo transer& ,eore the optional

roIen em)ryo transer' the underlying pathology inpatients with tu)e inertility' particularly in thosewith a detecta)le hydrosalpin+' should )e corrected3.'/'>'4@'49'4> 55 8& Perorming the supplemented surgicalintervention is thought to improve the liEelihood o successul$R%outcome in patients with hydrosalpinges3.'/'>'4> 55 8&urgical interventions or hydrosalpin+ include salpingectomy'pro+imal tu)al occlusion' aspiration o thehydrosalpin+ fuid' or salpingostomy 34@'4> 55 8& $ recent!ochrane data)ase systematic review showed that )othsalpingectomy and pro+imal tu)al occlusion are alternativeso treatments in improving $R% outcome in

patients with hydrosalpinges 34> 55 8& "urther research isrequired in this respect to assess the value o aspiration o hydrosalpinges prior to or during $R%s and the value o tu)al restorative surgery 34> 55 8& %hroughout the di*erentcomparisons' no signicant di*erences were seen inadverse e*ects o these Einds o surgical treatments orhydrosalpin+ 34> 55 8&1 the !" persisted until the em)ryo transer period'transvaginal sonographic !" aspiration could )e used asan alternative treatment o !" 3@8&

 %ransvaginal sonographic !" aspiration %ransvaginal sonographic !" aspiration was originallydesigned or the treatment o patients with !" who did not wish to postpone theem)ryo transer during their$R%s 3/'>'4:8& $ successul pregnancy could )e conceivedin a patient with tu)e inertility ater up to 9mlvolume o !" was aspirated at the time o em)ryotranser 3/8& Cow' this Eind o treatment has )een developedto a suita)le alternative o treatment only orpatients with their !" persisted until at the day o em)ryo transer and not e+cessive in volume' especiallythose with nontu)e inertility' or e+ample' the !"in patients with P!; 3.'4:'678& %he none+cessive!" developed in P!; patients is usually reactive'sel-limited and' thus' seldom recurrent' unliEe the high

risE o !" recurrence ater the transvaginal fuid aspirationin patients with hydrosalpinges 3>'4:'678& %heo)servation o the same $R% outcome in nontu)einertilitypatients with transient !" as that without!" also provided a support to the treatment o transvaginal !" aspiration without a delay o em)ryotranser 36'.8&Removing !" with a transvaginal em)ryo-transercatheter was usually conducted immediately )eoreem)ryo transer 3/8& %he on-time em)ryo transer could)e conducted in either transvaginal intrauterineem)ryo transer or laparoscopic tu)al em)ryo transer36'/8& %he administration o prophylactic anti)iotics

was recommended as a su)sidiary medical treatmentto the transvaginal aspiration 3/'>'4@8& ,ecause o nodelay in em)ryo transer' this Eind o treatment o 

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!" could avoid some disadvantages in )iology andpsychology when compared with the treatment o postponingem)ryo transer' such as avoiding a possi)lydecreased implantation rate rom roIen em)ryo transer'and avoiding rustration and disappointment orthe inertile couple 3/8&

$s to the impact o the removal operation o !" onem)ryo implantation' a prospective matched controlledstudy was perormed 3648& 1n that study' no reduction o em)ryo implantation was ound ater the !" aspirationprior to em)ryo transer& ,oth )iochemical and ongoingpregnancy rates per em)ryo transer were compared withthose in matched control patients (respectively' .< vs&..A' PL7&>@F .. vs& .7A' PL7&>/#& o it is concludedthat !" aspiration prior to em)ryo transer is a welltolerated operation and' possi)ly' to improve the $R%outcome )y acilitating the process o implantation'namely adhesion o the em)ryo to the endometrial surace3648&

!onclusion,oth tu)al inertility and P!; are related to the developmento !"& !" patients with or without tu)alinertility may represent a di*erent clinical entity& $partrom causes' the appearance time and accumulation amount o !" are critical inthe impact o !" onthe $R% outcome& %he treatment o !" should )eindividual according to the causes' the appearance timeand the accumulation amount o !"& Cew treatmentsand modications in $R%s may improve the $R% outcomeo patients with !" 34/ 5 '4< 5 8&