Tubal factor infertility is a common indication for treatment using in vitro fertilization (IVF). While individuals with proximal (isthmic) tubal occlusion have excellent success rates using IVF, it has been shown in numerous studies that distal disease leading to a dilated hydrosalpinx has a deleterious effect on IVF outcome (1-4). Exactly how the presence of a hydrosalpinx impacts IVF success rates is not well understood, but it has been proposed that the draining tubal fluid is toxic to the developing embryo, or to the endometrium by inhibiting the expression of substances that are important to implantation, or perhaps, the fluid results in mechanical flushing of the embryo from the uterus (5-10).
Although the mechanism is not well-established, current data clearly demonstrates a significant adverse impact of a dilated hydrosalpinx on pregnancy outcome in individuals undergoing IVF. Two separate meta-analyses each concluded that the presence of a hydrosalpinx reduces implantation, pregnancy and live birth rates by nearly 50% and increases the rate of early pregnancy losses (11, 12).
Various treatment alternatives have been proposed, but there is insufficient data to reach a definitive conclusion about the optimal approach. One study demonstrated that antibiotic use in women with hydrosalpinges before and after embryo transfer resulted in outcomes that were equivalent to other groups of patients undergoing IVF (13). This finding has not been confirmed by follow-up studies. Others have advocated aspiration of the hydrosalpinx fluid at the time of oocyte retrieval (14, 15). There is conflicting data regarding the effectiveness of this technique as the fluid often reaccumulates within 2 days of the procedure. Several small case reports have documented successful pregnancies following hysteroscopic placement of a microinsert (EssureTM) to occlude the proximal Fallopian tube (16-19). Further studies with more patients are needed before this procedure can be advocated.
The mainstay of successful treatment of dilated hydrosalpinges, to improve IVF outcome, is through laparoscopic surgery. Possible surgical alternatives include distal neosalpingostomy, proximal tubal occlusion with cautery (tubal ligation) and salpingectomy. While neosalpingostomy will allow decompression and drainage of the hydrosalpinx, one study with approximately 30 patients reported a 70% recurrence of the hydrosalpinx postoperatively and a very poor ongoing pregnancy rate (20). This method should probably be reserved for those patients who are opposed to more definitive surgical procedures that will eliminate the possibility of conception through means other than IVF. Although there is more data to support the efficacy of salpingectomy over tubal ligation, several studies have shown similar outcomes for these two techniques (21-23). Proximal tubal occlusion has the advantage of being easier to perform than salpingectomy, especially in the presence of extensive pelvic adhesions. In addition, it is less likely to interfere with blood flow to the ovary, which could compromise the response to medication. Concerns with this approach relate primarily to the potential for pain or infection that might result from leaving a dilated tube in place that is blocked both proximally and distally. This has not been reported to be a significant complication of this procedure in published studies thus far (21-23).
In summary, individuals with hydrosalpinges represent a unique subgroup of patients undergoing assisted reproduction who might benefit from surgical intervention, prior to IVF. Counseling is critical to identify those couples that might wish to accept an approximately 50% lower pregnancy rate and two-fold higher rate of miscarriage in hopes of avoiding an invasive surgical procedure.
1. Practice Committee of the American Society of Reproductive Medicine. Salpingectomy for hydrosalpinx prior to in-vitro fertilization. Fertil Steril 2008; 90(Suppl):S66-8.
2. Shelton KE, Butlere L, Toner JP, Oehnineger S, Muasher J. Salpingectomy improves pregnancy rate in in-vitro fertilization patient with hydrosalpinx. Human Reproduction 1996; 11: 523-525.
3. Strandell A, Waldenstrom U, Nilsson L, Hamberger L. Hydrosalpinx reduces in-Vitro fertilization/embryo transfer pregnancy rates. Human Reproduction 1994;9: 861-863.
4. Vandrome J, Chaase E, Lejeune B, Van Rysselberg M, Delvigne A, Leroy F. Hydrosalpinges in in-vitro fertilization: An unfavorable prognostic feature. Human Reproduction 1995; 10: 576-579.
5. Daftary G, Kayisli U, Seli E, Bukulmez O, Arici A, Taylor H. Salpingectomy increases peri-implantation endometrial HOXZ10 expression in women with hydrosalpinx, Fertil Steril 2007; 87: 367-371.
6. Meyer WR, Castelbaum AJ, Somkuti S, Sagoskin AW, Doyle M, Harris JE, Lessey BA. Hydrosalpinges adversely affect markers of endometrial receptivity. Human Reproduction 1997; 12: 1393-1398.
7. Chanelles O, Siefer C, Hugues JN, Uzan M, Poncelet C. Hydrosalpinx and Infertility What about conservative surgical management? Fertil Steril 2009;88(Suppl): S125
8. Mukherjee, T, Copperman, AB, McCaffrey C, et al. Hydrosalpinx fluid has embryotoxic effects on murine embryogenesis: a case for prophylactic salpingectomy. Fertil Steril 1996; 66: 851-853.
9. Mansour, RT, Aboulghar, MA, Serour, GI and Riad, R. Fluid accumulation of the uterine cavity before embryo transfer: a possible hindrance for implantation. In Vitro Fert Embryo Transfer 1991; 8: 157-159.
10. Shahara, FI. The role of hydrosalpinx in IVF: simply mechanical? Hum Reprod 1999; 14: 577-578.
11. Zeyneloglu, HB, Arici, A, Olive, DL. Adverse effects of hydrosalpinx on pregnancy rates after in vitro fertilization-embryo transfer. Fertil Steril 1998; 70: 492-499.
12. Camus, E, Poncelet, C, Goffinet, F, Wainer, B, et al. Pregnancy rates after in vitro fertilization in cases of tubal infertility with and without hydrosalpinx: a meta analysis of published comparative Studies. Hum Reprod 1999; 14: 1243-1249.
13. Hurst, BS, Tucker KE, Awoniyi, CA, Schlaff, WD. Hydrosalpinx treated with extended doxycycline does not compromise the success of in vitro fertilization. Fertil Steril 2001; 75:1017-1019.
14. Van Voorhis, BJ, Sparks, AE, Syrod, CH, Stoval, DW. Ultrasound-guided aspiration of hydrosalpinges is associated with improved pregnancy and implantation rates after in-vitro fertilization cycles. Hum Reprod 1998; 13:736-739.
15. Hammadieh N, Coomarasamy A, Ola B, Papaioannou S, et al. Ultrasound-guided hydrosalpinx aspiration during oocyte collection improves pregnancy outcome in IVF: a randomized controlled trial. Hum Reprod 2008; 23: 1113-1117.
16. Hitkari J, Singh S, Shapiro H, Leyland N. Essure treatment of hydosalpinges. Fertil Steril 2007; 90: 1663-1666.
17. Mijatovic V, Veersema S, Emanuel MH, Schats R, Hompes P. Essure hysteroscopic tubal occlusion device for the treatment of hydrosalpinx prior to in vitro fertilization- embryo transfer in patient with a contraindication for laparoscopy. Fertil Steril 2010; 93: 1338-1342.
18. Galen DI. Utilization of the Essure® mocro-insert for the treatment of hydrosalpinx prior to in vitro fertilization. Fertil Steril 2009;88(Suppl): S126.
19. Nichols JE, West JR. Success of Essure® with micro inserts in the treatment of hydrosalpinx prior to in vitro fertilization (IVF)/frozen embryo transfer (FET) and pregnancy outcomes. Fertil Steril 2010; (Suppl):S245.
20. Bayrak A, Harp D, Saadat P, Mor E, Paulson R. Recurrence of hydrosalpinges after cuff neosalpingostomy in a poor prognosis population. Fertil Steril 2003; (Suppl): S82.
21. Kontravdis A, Makrakis E, Pantos K, Botsis D, Deligeoroglou E, Creatsas G.
Proximal tubal occlusion and salpingectomy result in similar improvement in in vitro fertilization outcome in patients with hydrosalpinx. Fertil Steril 2006;86: 1642-1649. 22. Surrey ES, Schoolcraft WB. Laparoscopic management of hydrosalpinges before in vitro fertilization-embryo transfer: salpingectomy versus proximal tubal occlusion. Fertil Steril 2001; 75: 612-617.
23. Stadtmauer LA, Riehl RM, Toma SK, Talbert LM. Cauterization of hydrosalpinges before in vitro fertilization is an effective surgical treatment associated with improved pregnancy rates. Am J Obstet Gynecol 2000; 183: 367-371.