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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 16  |  Issue : 1  |  Page : 1-4

Study of intrauterine insemination with hydrotubation in women with infertility


Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences University, Wardha, Maharashtra, India

Date of Submission18-May-2020
Date of Decision16-Nov-2020
Date of Acceptance10-Jun-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Deepti Srivastava
Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-4534.322607

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  Abstract 


Background: Hydrotubation is the instillation of a solution of medicine through the cervix into the uterus and fallopian tubes under pressure into the peritoneal cavity. It has little value to test whether or not the tubes are blocked in the investigation of infertility and therapeutically to flush or clean the fallopian tubes. Materials and Methods: Sixty women with unexplained infertility were scheduled randomly for hydrotubation either with saline or low-dose lidocaine in saline. Hydrotubation was carried out 1 day before intrauterine insemination (IUI) in clomiphene citrate stimulated cycle. Outcome measures were rates of pregnancy, first trimester abortion, ectopic pregnancy, multiple pregnancy, and procedure-related pain. Results: There were higher clinical pregnancy rates in lidocaine group which had when compared with saline group but statistically no significant difference found. Conclusion: Hydrotubation with low-dose lidocaine in saline 1 day before IUI allowed a significant higher pregnancy rate when compared to saline alone in couples with unexplained infertility.

Keywords: HSG, hydrotubation, infertility, lidocaine, saline


How to cite this article:
Srivastava D, Shekhawat H, Shelke U. Study of intrauterine insemination with hydrotubation in women with infertility. J Datta Meghe Inst Med Sci Univ 2021;16:1-4

How to cite this URL:
Srivastava D, Shekhawat H, Shelke U. Study of intrauterine insemination with hydrotubation in women with infertility. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Sep 16];16:1-4. Available from: http://www.journaldmims.com/text.asp?2021/16/1/1/322607




  Introduction Top


Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.”[1] The World Health Organization estimates that 60–80 million couples worldwide currently suffer from infertility.[2]

Infertility may be classified as primary or secondary. The prevalence of infertility ranges from 7% to 26% of couples in the reproductive age in the developed countries.[3] A number of options of assisted reproductive technology have since emerged. For patients with unexplained infertility, controlled ovarian stimulation (COS) with homologous intrauterine insemination (IUI) or in vitro fertilization (IVF) have been found as some of the treatment options available.[4] The point of IUI is based on the principle of “increasing the number of gametes (sperms and oocytes) at the right place at the right time.” It helps to bypass the possible cervical factor in couples with abnormal mucus secretions. IUI is a relatively noninvasive and cost-effective first-line therapy for selected infertile patients such as having cervical factor, moderate male factor, unexplained infertility, endometriosis, immunological infertility, and infertility due to ejaculatory disorders. IUI in stimulated cycles can be offered in couples with unexplained infertility while waiting for IVF or when IVF is not affordable. Success rate of COS with IUI varies between 8% and 22%.[5]

The effect of IUI alone per cycle is small and only of marginal significance. As a result, several advances in the type of stimulation protocols, gonadotropins, tubal flushing, sperm preparation techniques, and ultrasound monitoring have led to promising success rates with IUI.

Tubal flushing or hydrotubation has previously proved to be one way of increasing the chance of achieving conception for couples with unexplained infertility and at early stages of endometriosis. The effect of hydrotubation on fertility can be mechanical and immunological, for example, inhibition of phagocytosis of spermatozoa and affecting levels of peritoneal factors such as cytokines, also by mechanically flushing out small mucus plugs or releasing flimsy adhesions due to pressure created inside tubes during hydrotubation.[6] This cross-sectional study was planned to investigate the therapeutic outcome of hydrotubation using antibiotics, steroids, xylocaine, and IUI in stimulated cycles in women with infertility.


  Materials and Methods Top


This study was carried out in patients who came to Wardha Test tube baby center, Acharya Vinoba Bhave Rural Hospital, Wardha. It was a prospective randomized, blinded control trial undertaken between January 2010 and March 2011. Patients who fulfilled the inclusion criteria–infertility due to all causes except tubal factor with at least one tube patent were included, both ovaries intact, age <40 years were included in this study. The exclusion criteria decided was endocrine disorders such as hypothyroidism, PCOS, ovarian surgeries, and adhesions, women with abnormal uterine bleeding, tubal factor infertility. The study protocol was made after taking approval from the institutional ethical committee and written informed consent was obtained. All patients were investigated for bacterial vaginosis,  Chlamydia trachomatis Scientific Name Search  and  Neisseria More Details gonorrhoeae and infected cases were treated medically before hydrotubation.

The 60 participants were divided randomly into two groups. Randomization will be done according to a computer generated random numerical table.

Ovarian stimulation was done with tablet clomiphene citrate 50 mg 1BD for 5 days starting from day 2 of the cycle. Starting from day 9 of the cycle, serial folliculometry was done. Endometrial thickness was measured on the day of human chorionic gonadotropin (hCG ) administration at the greatest diameter perpendicular to the midsagittal plane in the fundal region using transvaginal ultrasound scan using Logiq C5 machine.

hCG (10,000 IU) was administered intramuscularly as a trigger for ovulation when there will be at least one follicle measuring ≥18 mm in mean diameter. Cycle was cancelled if there were 3 follicles ≥16 mm in mean diameter or inadequate ovarian response. Hydrotubation was done 1 day before IUI. The patient will be placed in the lithotomy position with an empty bladder, cervix exposed by a Cusco's speculum and parts cleaned.

A Leech Wilkinson's Cannula was inserted into the cervical canal after checking it is patency with normal saline solution, the catheter balloon was inflated with 0.5–1 cc saline and the catheter pulled against cervix. Hydrotubation was done by mixing 20 ml normal saline, injection metrogyl 20 cc injection dexamethasone 12 mg with xylocaine 1% 2 ml in one group and plain normal saline of equal volume in another group. Hydrotubation was performed slowly and steadily. The patients were asked to take rest for 10 min and instructed to come back on the next day for IUI.

IUI was performed 24–36 h after the administration of hCG, using an intrauterine catheter attached to a 2 ml syringe. Semen was collected by masturbation into a sterile bottle after 2–4 days of sexual abstinence. The standard swim-up technique was used for semen preparation. The cervix exposed and cleaned by using the same technique described during hydrotubation. The cannula was inserted gently into the uterine cavity without touching the fundus and the sperm suspension (0.5–1 ml) gradually released. The patient was advised to take rest in the same position for 15–20 min before discharge. Two weeks after IUI, serum β subunit hCG was measured for identification of pregnancy, confirmed clinically at 6 weeks using ultrasound scan. Only one completed treatment cycle was offered to each couple.

Statistical analysis

Data obtained were statistically analyzed using the Statistical Package for Social Sciences (SPSS, Chicago, USA) software version 15.0 for Windows. Results were expressed as mean ± standard deviation, numbers and percentages. Means were compared using the unpaired Student's t-test while proportions were compared using the Chi-square test. Differences were considered of statistical significance if P < 0.05.

Ethical clearance

The Institutional Ethics Committee of DMIMSDU has approved the Research work proposed to be carried out at Jawaharlal Nehru Medical College, Sawangi(M), Wardha. Date: 17th Nov 2009 with Reference no DMIMS(DU)/IEC/2009-10/1810.


  Results Top


Amongst 60 patients, the mean age group taken was 26 years ± 2 years in saline group and 27 years ± 1.8 years in lidocaine group. Mean body mass index (BMI) in saline group found was 24.09 ± 1.8, and in lidocaine group, it was 25.12 ± 2.1. Out of 60 patients, 30 were taken for saline instillation while 30 were given lidocaine. In saline group, 23 patients were found primary infertile cases and 18 primary infertile patients seen in lidocaine group. The mean duration of infertile years seen in both groups were 4 ± 1.2 and 5 ± 1.8 years, respectively, as shown in [Table 1].
Table 1: Patients' demographic characteristics

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[Table 1] describes demographic characteristics in between saline group and lidocaine group in terms of age in saline group varying 26–28 years and in lidocaine group varying about 27–28 years BMI ranging from 24 to 25 in both the groups, respectively. Primary infertility in saline group were 23 cases while in lidocaine group were 18 cases, however cases of secondary infertility were 7 and 12 in each group.

[Table 2] shows higher pregnancy rate in lidocaine group as compared to saline group. No cases of ectopic pregnancy were seen in either of the group.
Table 2: Distribution of pregnancy outcomes

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  Discussion Top


Unexplained infertility is a diagnosis of exclusion. Ovarian stimulation combined with intra uterine insemination (IUI) is a recommended form of treatment for women with unexplained infertility. Pregnancy rates vary between 10% and 20%, depending on various factors.[7] Tubal flushing/hydrotubation/pertubation may increase chances of conception in infertile couples by mechanically breaking the flimsy adhesions or decreasing the sperm phagocytosis.[8]

In this study, two groups of infertile patients were taken. One group underwent hydrotubation by saline and others were given lidocaine randomly. Retrospectively, these patients were studied for their underlying cause of infertility. The success of hydrotubation in different studies carried out in different geographical locations greatly varies.

Aboulghar et al., in their prospective randomized trial of hydrotubation versus no hydrotubation before IUI, found results that are not statistically significant yet the conception rate is more in hydrotubation group.[9] This difference in results could likely to be due to difference in demographic features of the study population, the media used for flushing and skills of the surgeon. The better prognosis of this study could be due to carefully selected population with majority of women in younger age group.

Today, thanks to ART, tubal disease and tubal factor infertility may easily be overcome. However, many retrospective studies have shown that the hydrosalpinx is associated with poor IVF outcome. The hydrosalpinx fluid possibly acts on two different targets; directly on the transferred embryos or on the endometrium and its receptivity for implantation, or both. There are many theories postulated, but none actually proven.[10],[11] The results of prospective randomized studies on salpingectomy in women with hydrosalpinges are now forthcoming and have resulted in the Cochrane library recommendation of salpingectomy for hydrosalpinges.[12] The endometrial environment becomes more ideal for implantation with cleaning of embryotoxic cytokines. In a similar way, during the pertubation, thin adhesions in the endometrial cavity were opened with rapid fluid pressure.

Although the pregnancy rate was higher in the control group, this was not statistically significant when compared with the study group (P = 0.296). When we evaluated both biochemical and clinical pregnancies, the pregnancy rate was 17.8% in the study group and 23.8% in the control group. The rate of live births, which was the main purpose of this treatment was 12.7% in the study group and 19.8% in the control group.

Around 10%–15% of natural pregnancies end up in spontaneous abortions. Many infertility centers have reportedly shown a much higher incidence in the range of 18%–30%, of spontaneous abortion among assisted reproductive technology pregnancies.[13] If serial HCG is measured to detect early subclinical pregnancy loss, this rate would increase. In our study, 21% of total pregnancies aborted. This rate was not higher than the expected pregnancy loss rates in normal cycles. When we compared pregnancy loss rates in both groups, there was no significant difference observed (P > 0.05).

Aboulghar et al. studied 213 patients in a study where, they performed hydrotubation on 103 patients. They used clomiphene citrate and urinary HMG for ovulation induction followed by IUI. In our study, we only used gonadotropins for ovulation induction. Both studies have performed IUI after ovulation induction. Aboulghar et al. reported an ongoing pregnancy rate of 12.6% in their hydrotubation group. Similarly, our research resulted an ongoing pregnancy rate of 12.7% in the study group. Therefore, our results were compatible with the aforementioned study.[9]

In our study, the control group's fecundability rate was 23.8% and the continued pregnancy rate was 19.8%. There was no significant difference between the study and control groups. However, the relatively higher rate in the control group suggested the negative effects of pertubation.

In a prospective randomized study by Edelstam et al., to evaluate the effect of pertubation on pregnancy rates in couples with unexplained infertility. Pertubation was performed prior to ovulation. A total of 130 cycles were investigated. There was a significant difference between the pregnancy rates (14.9 vs. 3.2%) of both the groups. The authors concluded that pertubation could be used in conjunction with ovulation induction and IUI as a first line management protocol in couples with unexplained infertility.[6]

In a prospective nonrandomized observational study by Adesiyun et al. the authors concluded that with good case selection, therapeutic hydrotubation may be beneficial in resource poor countries, especially in patients with incomplete tubal block (bilateral perifimbrial adhesions) and as part of treatment for unexplained infertility.[14]

Lei et al. have reported the effects hydrotubation in 50 formerly proven tubal occlusive patients. The hysteroscopic procedure involved the passage of a thin plastic cannula through the  Fallopian tube More Details simultaneously using irrigation media that contained hydrocortisone, gentamycin, and procaine. The use of additional therapeutic agents in hydrotubation might explain their increased rate of fecundability.

The downfall of the current study was the use of an open randomized technique during the patient recruitment. As a result when we compared both groups, it was evident that in the study group secondary infertile patients outnumbered primary infertile couples, whereas in the control group primarily infertile patients were more common.[15],[16],[17],[18]


  Conclusion Top


Results of this study revealed that pertubation prior to insemination does affect pregnancy rates with no statistical difference seen in the saline group as well as lidocaine group. However, total clinical pregnancy rate was found to be a little more in the lidocaine group than the saline group.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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2.
Rutstein: Infecundity, Infertility, and Childlessness. Google Scholar. Available from: https://scholar.google.com/scholar_lookup?title=Infecundity,+infertility,+and+childlessness+in+developing+countries.+DHS+Comparative+Reports+No+9&publication_year=2004&. [Last accessed on 2020 Apr 21].  Back to cited text no. 2
    
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Boivin J, Bunting L, Collins JA, Nygren KG. International estimates of infertility prevalence and treatment-seeking: Potential need and demand for infertility medical care. Hum Reprod 2007;22:1506-12.  Back to cited text no. 3
    
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Ganguly I, Singh A, Bhandari S, Agrawal P, Gupta N. Pregnancy predictors after intrauterine insemination in cases of unexplained infertility: A prospective study. Int J Reprod Med 2016;2016:1-5.  Back to cited text no. 4
    
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Prasad. Preovulatory Normal Saline Pertubation Prior to Intrauterine Insemination Increases Conception Rate in Unexplained Infertility. Available from: http://www.fertilityscienceresearch.org/article.asp?issn=2394-4285;year=2015;volume=2;issue=2;spage=143;epage=149;aulast=Prasad#ref3. [Last accessed on 2020 Apr 23].  Back to cited text no. 7
    
8.
Mohiyiddeen L, Hardiman A, Fitzgerald C, Hughes E, Mol BW, Johnson N, et al. Tubal flushing for subfertility. Cochrane Database Syst Rev 2015;2015:1-5.  Back to cited text no. 8
    
9.
Aboulghar MA, Mourad LM, Al-Inany HG, Aboulghar MM, Mansour RT, Serour GA. Prospective randomized study for hydrotubation versus no hydrotubation before intrauterine insemination in unexplained infertility. Reprod Biomed Online 2010;20:543-6.  Back to cited text no. 9
    
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Dar P, Sachs GS, Strassburger D, Bukovsky I, Arieli S. Ovarian function before and after salpingectomy in artificial reproductive technology patients. Hum Reprod 2000;15:142-4.  Back to cited text no. 11
    
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Wang JX, Norman RJ, Wilcox AJ. Incidence of spontaneous abortion among pregnancies produced by assisted reproductive technology. Hum Reprod 2004;19:272-7.  Back to cited text no. 13
    
14.
Adesiyun AG, Cole B, Ogwuche P. Hydrotubation in the management of female infertility: Outcome in low resource settings. East Afr Med J 2009;86:31-6.  Back to cited text no. 14
    
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Singh BR, More A, Ambad RS, Bankar N, Gajbe U, Ghogare AS. Comparative Study of Transferring Frozen Embryo with Short Culture Versus Overnight Culture and Also Assess Prevalence Rate of Psychological Distress Amongs Infertility Patient. Int J Res Pharm Sci 2020;11:2489-92. Available from: https://doi.org/10.26452/ijrps.v11i2.2243. [Last accessed on 2020 May 18].  Back to cited text no. 15
    
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Tayawade AV, More A, Salve M, Shrivastava D. Effect of Occupational Environment on Male Infertility. Int J Cur Res Rev 2020;12: S117-21. Available from: https://doi.org/10.31782/IJCRR.2020.SP99. [Last accessed on 2020 May 18].  Back to cited text no. 16
    
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