In conclusion, POI involves the trio of amenorrhea, elevated gonadotropins, and estrogen defciency which are often associated with other long-term health consequences including vasomotor symptoms, vulvovaginal atrophy, psychological stress, increased risks of cardiovascular disease, decreased bone mineral density, and markedly reduced fertility. Our patient is one of the rare women with POI who was fortunate enough to have succeeded in the delivery of a healthy child through IVF. Like all women with POI, she must be followed up to ensure adequate treatment with hormonal replacement therapy aiming at supporting her gynecological, cardiovascular, bone, and sexual health.

References

1.\ Nelson LM. Clinical practice. Primary ovarian insuffciency. N Engl J Med. 2009;360:606–14. 2.\ Coulam CB, Adamson SC, Annegers LF. Incidence of premature ovarian failure. Obstet

Gynecol. 1986;67:604–6.

3.\ Hoek A, Schoemaker J, Drexhage HA. Premature ovarian failure and ovarian autoimmunity. Endocr Rev. 1997;18:107–34.

4.\ Nelson LM, Covington SN, Rebar RW. An update: spontaneous premature ovarian failure is not an early menopause. Fertil Steril. 2005;83:1327–32.

5.\ Bakalov VK, Vanderhoof VH, Bondy CA, Nelson LM. Adrenal antibodies detect asymptomatic autoimmune adrenal insuffciency in young women with spontaneous premature ovarian failure. Hum Reprod. 2002;17:2096–100.

6.\ Alzubaidi NH, Chapin HL, Vanderhoof VH, Calis KA, Nelson LM. Meeting the needs of young women with secondary amenorrhea and spontaneous premature ovarian failure. Obstet Gynecol. 2002;99:720–5.

7.\ Sullivan SD, Sarrel PM, Nelson LM. Hormone replacement therapy in young women with primary ovarian insuffciency and early menopause. Fertil Steril. 2016;106:1588–99.

peritubal adhesions could be the cause for the obstruction and hence her infertility. The other option was to procced with in vitro fertilization (IVF) which would bypass the fallopian tubes. The patient declined surgery and decided to proceed with IVF. Ovarian stimulation with gonadotropins yielded 15 oocytes of which 12 fertilized. Endometrial thickness was 10 mm. A single high-grade blastocyst was transferred. The remaining six blastocysts underwent preimplantation genetic testing for aneuploidy (PGT-A) and were frozen.

She did not become pregnant with the fresh embryo transfer. Of the six PGT-A tested blastocysts, three were euploid. She was subsequently scheduled for a natural cycle frozen embryo transfer (FET). On the day of her LH surge, however, ultrasound examination revealed a thin layer of free fuid in the endometrial cavity, anding which persisted and was also visualized on the day of the scheduled transfer. Therefore FET was canceled.

Given all the ndings up to this point of her treatment, a laparoscopy was subsequently performed which con rmed moderate peritubal and pelvic adhesions, and bilateral hydrosalpinges. Lysis of adhesions and bilateral salpingectomies were performed uneventfully. Follow-up evaluation of the cavity demonstrated a normal endometrial stripe with no fuid. The patient subsequently underwent a natural cycle FET, promptly conceived and delivered a healthy baby at term.

Discussion

Tubal disease is identi ed in approximately 25–35% of female factor infertility [1]. Tubal factor may range from subtle damage within the lumen of the fallopian tube, to outright blockage associated with hydrosalpinges and/or peritubal adhesions. The gold standard for evaluating tubal factor is the HSG. A hydrosalpinx, caused by a fuid buildup within a blocked fallopian tube, leads to the characteristic sausage-like appearance, easily discerned on HSG and even on ultrasound. More than half of the hydrosalpinges are due to salpingitis from PID (chlamydia, gonorrhea, rarely tuberculosis), but they may also result from prior history of ectopic pregnancy, generalized peritonitis, and pelvic infammation of various etiologies (ruptured appendix is a notable example). However, one needs to recognize that tubal obstruction shown on HSG can sometimes be caused by tubal spasm of the interstitial region secondary to the irritation of the contrast on the tube [2]. Typically, if spasm is the etiology, patients may experience a higher degree of discomfort during the procedure. This may be relieved by sedatives allowinglling and spillage of dye through the fallopian tube.

Many variables need to be considered when counseling patients with tubal factor infertility. Chronological age of the female, ovarian reserve, presence of male factor, site and extent of the tubal disease, experience of the surgeon, and access to IVF are all factors to be discussed with the patient. Management of tubal factor infertility depends on the location of the pathology, i.e. proximal or distal, whether it is unilateral or bilateral, and the extent of the disease.

Presuming that all other factors are optimal, unilateral obstruction can be managed by expectant management, controlled ovarian hyperstimulation with or

decreased endometrial receptivity, altered endometrial blood fow, and the direct embryotoxic effect of the hydrosalpinx fuid on the embryo or sperm itself [6].

A meta-analysis on the impact of hydrosalpinx on IVF success demonstrated that hydrosalpinges caused a 50% decrease in pregnancy, implantation, and delivery rates, and a twofold increase in the spontaneous abortion rate [7]. Speci cally, it is thought that those with hydrosalpinges large enough to be visible on ultrasound might be more signi cantly affected. Several randomized controlled trials have shown that laparoscopic salpingectomy in women with hydrosalpinges achieved similar live birth rates as compared to women without hydrosalpinx [8]. Even in patients with unilateral hydrosalpinx, higher IVF pregnancy rates have been reported after unilateral salpingectomy. Therefore we generally recommend salpingectomy for patients with unilateral or bilateral hydrosalpinges before undergoing IVF.

Salpingectomy can be readily performed laparoscopically by sequentially coagulating and dividing the mesosalpinx, generally from the distal to proximal end of the fallopian tube. Upon reaching the proximal end, the tube is cauterized and divided as close to the cornua as possible. It should be noted that there had been reports suggesting that salpingectomy and tubal ligation are associated with subsequent diminished ovarian reserve; however the clinical signi cance of this observation has been debated. While it has been demonstrated that antral follicle count and blood fow to the ovary are reduced after laparoscopic salpingectomy performed for ectopic pregnancy [9], in one such study where IVF was performed before and after salpingectomy, no signi cant difference was found in the total dose or duration of gonadotropins administered, peak estradiol levels, number of oocytes retrieved or embryo quality between cycles or between the ovaries [10]. Regardless, during salpingectomy, great care should be exercised to resect as close to the tube as possible along the mesosalpinx in order to avoid compromising blood supply to the ovaries.

Proximal occlusion of the fallopian tube during laparoscopy can be an alternative to salpingectomy when severe pelvic adhesions preclude access to the entire tube for removal. Previously published randomized controlled trials demonstrated that proximal tubal occlusion was effective in restoring IVF pregnancy rates in women with hydrosalpinges [11]. In addition, it has not been shown that this technique had any negative impact on ovarian reserve [12]. The preferred method for occlusion, cautery or mechanical clips, is debated. A randomized controlled trial found that bipolar cautery had an adverse effect on ovarian volume and antral follicle counts while mechanical clips did not [13]. However, neither technique was associated with appreciable changes in day-3 FSH, estradiol, inhibin-B, or anti-Mullerian hormone levels. Another theoretical concern of proximally occluding the tube is that it may lead to increased swelling of the hydrosalpinx, as the fuid is precluded from draining into the uterus, which in turn may lead to increased incidence of pelvic pain and risk of torsion.

Ultrasound-guided aspiration of hydrosalpinges at the time of oocyte retrieval is a less invasive option. The literature supporting such an approach is sparse, with conficting results in two small retrospective studies [14, 15]. A randomized controlled study comparing ultrasound-guided aspiration to a nontreated control group reported signi cantly higher clinical pregnancy rates of 31.3% with aspiration