In-vitro fertilization outcome in women with hydrosalpinx

Management of Hydrosalpinx in the Era of Assisted Reproductive Technology: A Systematic Review and Meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis evaluating the effect of hydrosalpinx on pregnancy outcomes, to compare different types of management of hydrosalpinx and their impact on pregnancy rates as well as on the ovarian reserve.

DATA SOURCES

Electronic search using Pubmed, EMBASE, Ovid MEDLINE, Google Scholar, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials and including all published studies that examined tubal infertility and its management (assisted reproductive technology or surgery) as well as the effects on ovarian reserve. The following medical subject headings (Mesh) terms combinations were used: "fallopian tube disease," hydrosalpinx," "tubal or salpinx occlusion or obstruction," "in vitro fertilization," "fallopian tube surgery," "salpingectomy," "salpingostomy," "infertility," "subfertility," "sterility" and "ovarian reserve."

METHODS OF STUDY SELECTION

All randomized trials, cohort, and case controls studies were included. We excluded review articles, meeting abstracts, case series and case reports, and abstracts without access to full texts. The search was limited to trials in humans and published in English.

TABULATION, INTEGRATION, AND RESULTS

Our electronic search initially retrieved 6354 articles. Finally, 19 studies were included in the quantitative evaluation of the effects of hydrosalpinx: 23 in the qualitative evaluation and 5 in the quantitative evaluation of different types of hydrosalpinx treatments; and 17 in the quantitative evaluation of ovarian reserve. The presence of a hydrosalpinx was associated with decreased rates of implantation and clinical pregnancy, and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx with salpingectomy, tubal occlusion, or hydrosalpinx aspiration led to better in vitro fertilization pregnancy rates. We found no difference in ovarian response to stimulation after salpingectomy except a decrease in antimüllerian hormone compared to no surgery.

CONCLUSIONS

The presence of hydrosalpinx is associated with decreased pregnancy rate and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx, regardless of the type of treatment, leads to an increased chance of pregnancy.

Impact of endometrial cavity fluid on assisted reproductive technology outcomes

BACKGROUND

The impact of endometrial cavity fluid (ECF) on assisted reproductive technology (ART) outcomes has not been evaluated in a meta-analysis.

OBJECTIVES

To evaluate the impact of ECF on the outcome of ART cycles.

SEARCH STRATEGY

PubMed, China Academic Journals Full-text Database, and China Doctoral/Masters Dissertations Full-text Databases were searched for reports published in any language before January 1, 2015, using relevant keywords.

SELECTION CRITERIA

Studies were included if they compared the outcome of ART in women with and without ECF.

DATA COLLECTION AND ANALYSIS

Background information, participants' characteristics, and study outcomes were recorded. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel method.

MAIN RESULTS

Six studies evaluating 5928 ART cycles were included. The pregnancy rate was significantly lower in the group with ECF than in the group without ECF (OR 0.74, 95% CI 0.55-0.98; P=0.03). The same association was observed if the analysis included only patients with hydrosalpinx (OR 0.36, 95% CI 0.15-0.86; P=0.02).

CONCLUSIONS

The clinical pregnancy rate after ART is significantly lower among patients with ECF than among those without ECF. In addition, if ECF is found in patients with hydrosalpinx, ART cycles should be cancelled after oocyte retrieval.

State-mandated insurance coverage is associated with the approach to hydrosalpinges before IVF

The aim of this study was to determine whether practice in states with infertility insurance mandates is associated with physician-reported practice patterns regarding hydrosalpinx management in assisted reproduction clinics. A cross-sectional, internet-based survey of 442 members of Society for Reproductive Endocrinology and Infertility or Society of Reproductive Surgeons was performed. Physicians practising in states without infertility insurance mandates were more likely to report performing diagnostic surgery after an inconclusive hysterosalpingogram than physicians practising in states with mandates (RR 1.2, 95% CI 1.1-1.3, P < 0.01). Additionally, respondents in states without mandates were more likely to report that, due to lack of infertility insurance coverage, they did not perform salpingectomy (SPX) or proximal tubal occlusion (PTO) before assisted reproduction treatment (RR 1.4, 95% CI 1.1-1.8, P = 0.01). Finally, respondents in states without mandates were less likely to report that the presence of assisted reproduction treatment coverage determined the urgency with which they pursued SPX or PTO before treatment (RR 0.7, 95% CI 0.5-1.0, NS). These results persisted after controlling for physician years in practice, age and clinic volume. In conclusion, self-reported physician practice interventions for hydrosalpinges before assisted reproduction treatment may be associated with state-mandated infertility insurance. Fallopian tube dysfunction is a known cause of infertility and severe dysfunction is manifested by dilation and occlusion, known as hydrosalpinx. Outcomes with assisted reproductive techniques (ART) are lower when hydrosalpinges are present and while there are several theories for this, reproductive specialist recommend "neutralizing" the tube either by occlusion or removal in order to enhance pregnancy rates. In the United States, coverage for infertility services is not uniform with only 15 states having some legislation requiring infertility benefits. Some states where ART is covered liberally, physicians might have different practice patterns related to the neutralization of hydrosalpinges compared to those who are in non -mandated states. We utilized a survey of over 400 providers in the United States to examine their practice patterns as it relates to hydrosalpinges based on which state they practice in and whether or not that state has mandated coverage of not.

How members of the Society for Reproductive Endocrinology and Infertility and Society of Reproductive Surgeons evaluate, define, and manage hydrosalpinges

OBJECTIVE

To describe the management of hydrosalpinges among Society for Reproduction Endocrinology and Infertility (SREI)/Society of Reproductive Surgeons (SRS) members.

DESIGN

Cross-sectional survey of SREI/SRS members.

SETTING

Academic and private practice-based reproductive medicine physicians.

PARTICIPANT(S)

A total of 442 SREI and/or SRS members.

INTERVENTION(S)

Internet-based survey.

MAIN OUTCOME MEASURE(S)

To understand how respondents evaluate, define, and manage hydrosalpinges.

RESULT(S)

Of 1,070 SREI and SRS members surveyed, 442 responded to all items, for a 41% response rate. Respondents represented both academic and private practice settings, and differences existed in the evaluation and management of hydrosalpinges. More than one-half (57%) perform their own hysterosalpingograms (HSGs), and 54.5% involve radiologists in their interpretation of tubal disease. Most respondents thought that a clinically significant hydrosalpinx on HSG is one that is distally occluded (80.4%) or visible on ultrasound (60%). Approximately one in four respondents remove a unilateral hydrosalpinx before controlled ovarian hyperstimulation (COH)/intrauterine insemination (IUI) and clomiphene citrate (CC)/IUI (29.3% and 22.8%, respectively), and physicians in private practice were more likely to intervene (COH: risk ratio [RR] 1.81, 95% confidence interval [CI] 1.31-2.51; CC: RR 1.98, 95% CI 1.33-2.95). Although laparoscopic salpingectomy was the preferred method of surgical management, nearly one-half responded that hysteroscopic tubal occlusion should have a role as a primary method of intervention.

CONCLUSION(S)

SREI/SRS members define a "clinically significant hydrosalpinx" consistently, and actual practice among members reflects American Society for Reproductive Medicine/SRS recommendations, with variation attributed to individual patient needs. Additionally, one in four members intervene before other infertility treatments when there is a unilateral hydrosalpinx present.

Effect of ultrasound-guided aspiration of hydrosalpingeal fluid during oocyte retrieval on the outcomes of in vitro fertilisation-embryo transfer: a randomised controlled trial (NCT01040351)

OBJECTIVE

To determine whether the ultrasound-guided aspiration of hydrosalpingeal fluid at the time of oocyte retrieval can improve the outcomes of in vitro fertilisation-embryo transfer (IVF-ET).

PATIENTS

One hundred and ten women with ultrasound-visible hydrosalpinges were randomised to two groups based on computer generated randomisation list. Fifty-four women underwent ultrasound-guided aspiration of hydrosalpingeal fluid prior to IVF-ET and 53 women underwent IVF-ET without any prior intervention.

RESULTS

Patients who underwent aspiration of hydrosalpinges demonstrated a significantly increased implantation, clinical pregnancy rates. Among the patients in the aspiration group, the implantation rate and pregnancy rates were higher in the subgroup of patients with no reaccumulation of hydrosalpingeal fluid within the first 2 weeks after aspiration compared to patients with reaccumulation of hydrosalpingeal fluid within the first 2 weeks after aspiration, but this difference failed to reach statistical significance. Furthermore, no pregnancies occurred in the four patients with uterine fluid collection detected during IVF-ET cycles.

CONCLUSION

The aspiration of hydrosalpingeal fluid at the time of oocyte retrieval is simple, safe and effective procedure for treatment of patients with ultrasound-visible hydrosalpinges particularly those without rapid reaccumulation of hydrosalpingeal fluid after aspiration or uterine fluid collection during the IVF-ET cycles.

Surgical treatment for tubal disease in women due to undergo in vitro fertilisation

BACKGROUND

Tubal disease, and particularly hydrosalpinx, has a detrimental effect on the outcome of in-vitro fertilisation (IVF). Performing a surgical intervention such as salpingectomy, tubal occlusion, aspiration of the hydrosalpinx fluid, or salpingostomy, prior to the IVF procedure in women with hydrosalpinges is thought improve the likelihood of successful outcome.

OBJECTIVES

To assess and compare the value of surgical treatments for tubal disease prior to IVF.

SEARCH STRATEGY

Trials were sought in the Cochrane Menstrual Disorders and Subfertility Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PSYCHMED and in Conference proceedings and reference lists up until Ocober 28 2009. Researchers in the field were contacted to reveal unpublished studies.

SELECTION CRITERIA

All trials comparing a surgical treatment for tubal disease with a control group generated by randomisation were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. The studied outcomes were live birth, ongoing pregnancy, viable-, clinical- and biochemical pregnancy, ectopic pregnancy, miscarriage, multiple pregnancy, ovarian function and complications.

MAIN RESULTS

Five randomised controlled trials involving 646 women were included in this review. Four studies assessed salpingectomy versus no treatment, two of which also included a tubal occlusion arm, and one trial assessed aspiration versus no treatment. No trials reported on the primary outcome: live birth. The odds of ongoing pregnancy (Peto OR 2.14, 95%CI 1.23 to 3.73) and of clinical pregnancy (Peto OR 2.31, 95%CI 1.48 to 3.62) however were increased with laparoscopic salpingectomy for hydrosalpinges prior to IVF. Laparoscopic occlusion of the fallopian tube versus no intervention did not increase the odds of ongoing pregnancy significantly (Peto OR 7.24, 95%CI 0.87 to 59.57) but the odds of clinical pregnancy (Peto OR 4.66, 95%CI 2.47 to 10.01) had sufficient power to show a significant increase. Comparison of tubal occlusion to salpingectomy did not show a significant advantage of either surgical procedure in terms of ongoing pregnancy (Peto OR: 1.65, 95%CI 0.74, 3.71) or clinical pregnancy (Peto OR 1.28, 95%CI 0,76 to 2.14). One RCT reported efficacy of ultrasound guided aspiration, however the odds of pregnancy did not show a significant increase in the odds of clinical pregnancy (Peto OR 1.97, 95%CI 0.62 to 6.29), and confidence intervals were wide. Throughout the different comparisons no significant differences were seen in adverse effects of surgical treatments.

AUTHORS' CONCLUSIONS

Surgical treatment should be considered for all women with hydrosalpinges prior to IVF treatment. Previous evidence supported only unilateral salpingectomy for a unilateral hydrosalpinx (bilateral salpingectomy for bilateral hydrosalpinges). This review now provides evidence that laparoscopic tubal occlusion is an alternative to laparoscopic salpingectomy in improving IVF pregnancy rates in women with hydrosalpinges. Further research is required to assess the value of aspiration of hydrosalpinges prior to or during IVF procedures and also the value of tubal restorative surgery as an alternative (or as a preliminary) to IVF.

Involvement of cystic fibrosis transmembrane conductance regulator (CFTR) in the pathogenesis of hydrosalpinx induced by Chlamydia trachomatis infection

BACKGROUND

Genital Chlamydia (C) trachomatis infection has been recognized as the single most common cause of pelvic inflammatory disease leading to severe tubal damage, ectopic pregnancy, infertility and hydrosalpinx. However, the mechanism underlying the formation of hydrosalpinx induced by C. trachomatis infection remains largely unknown. We performed this study to determine the involvement of cystic fibrosis transmembrane conductance regulator (CFTR), a cAMP-activated chloride channel that regulates epithelial electrolyte and fluid secretion, in hydrosalpinx fluid formation.

METHODS

Western blot analysis was used to determine CFTR expression in the hydrosalpinges that were seen on the ultrasound scans of infertile assisted reproduction treatment patients. Correlation with C. trachomatis infection was done by testing patients' sera for C. trachomatis immunoglobulin G antibody titer using a Capita enzyme-linked immunosorbent assay based kit. CFTR involvement was further verified in a rat C. trachomatis infection model and confirmed using CFTR mutant (CFTR(tm1Unc)) mice.

RESULTS

Here we report on the up-regulated expression of CFTR in the hydrosalpinx tissues of infertile patients with detectable serum levels of C. trachomatis antibody (immunoglobulin G). In a rat model, increased CFTR expression and fluid accumulation could be observed in the uterine horns infected with C. trachomatis elementary bodies, which was reversed by antibiotics treatment. In C. trachomatis-infected CFTR(tm1Unc) mice, however, no detectable fluid accumulation was observed.

CONCLUSION

These findings suggest the involvement of CFTR in the pathogenesis of hydrosalpinx fluid formation and may provide grounds for a better treatment strategy to improve assisted reproduction treatment outcome in infertile patients with hydrosalpinx.

Hydrosalpinx and IVF: assessment of treatments implemented prior to IVF

It is well known that the success of artificial reproductive techniques, especially IVF, for patients with tubal pathologies such as hydrosalpinx is reduced by half compared with patients without hydrosalpinx. Notably, there are also substantial increases in both early pregnancy loss and ectopic pregnancies. Alterations in the outcome of these patients generally reflect a detrimental effect of hydrosalpinx. However, although many theories have been published, a single explanation has not yet been found over a period of decades. Therefore, the negative effects of hydrosalpinx have generally been attributed largely to: (i) mechanical effects; (ii) embryo and gametotoxicity; (iii) alterations in endometrial receptivity markers; or dwindled cross talk between embryo-endometrium resulting in hindered implantation, and (iv) direct effect on endometrium, leading to intrauterine fluid formation. On the other hand, the most important question is selection of the preferred treatment option with either surgical or medical therapies. How should hydrosalpinx be managed? Does selection of the surgical method, either proximal obstruction or salpingectomy, depending on patients' clinical findings, differ in outcome, or is routine prophylactic salpingectomy needed? Additionally, the requirement for IVF or intracytoplasmic sperm injection is still controversial in patients with unilateral hydrosalpinx who have been treated with unilateral salpingectomy.

Effect of endometrial cavity fluid on clinical pregnancy rate in tubal embryo transfer (TET)

PURPOSE

In this study, we assess whether the endometrial cavity fluid (ECF) generated physiologically by the genital tract have negative effect on the pregnancy rate during tubal embryo transfer (TET) in patients who do not have hydrosalpinx or bilateral tubal obstruction.

METHODS

We retrospectively collected samples from 176 women with 195 cycles receiving TET due to male factor, unexplained infertility or endometriosis from June 1999 to Dec. 2003, and divided them into two groups (group I: patient with fluid accumulation >1 mm in the anterior-posterior diameter in the uterine cavity; group II: patient without fluid accumulation in the uterine cavity). Endometrium thickness was measured as a maximal distance between anterior and posterior myometrium-endometrium interface under the long-axis view. The A-P diameter of ECF was measured via vaginal sonar on the day of ovum pick-up (OPU).

RESULTS

From a total of 195 ART cycles involving 176 patients, the accumulation of ECF was detected in 10 cycles (5.1%). Seven of ten cycles (70%) with the accumulation of ECF were proved to be pregnant clinically. However, in the rest 185 cycles (group II), 98 of them (53%) were proved to be pregnant. At the mean time, the implantation rate was 29.03% and 25.71% in the groups I and II, respectively. No significant difference of the clinical pregnancy rate and the implantation rate was found between the two groups.

CONCLUSIONS

According to our study, if the ECF was generated physiologically by the genital tract during controlled ovarian hyperstimulation (COH), the clinical pregnancy rate is not worse and no influence of embryo implantation was found.

Proximal tubal occlusion and salpingectomy result in similar improvement in in vitro fertilization outcome in patients with hydrosalpinx

OBJECTIVE

To evaluate and compare the clinical impact of proximal tubal occlusion and salpingectomy when performed before IVF in patients with hydrosalpinges.

DESIGN

Prospective randomized study.

SETTING

Assisted reproduction unit in an obstetrics and gynecology department in a university hospital in Greece as well as assisted reproduction unit in an urban clinic in a major city in Greece.

PATIENT(S)

One hundred fifteen patients with unilateral or bilateral hydrosalpinges who were candidates for IVF treatment.

INTERVENTION(S)

Laparoscopic proximal tubal occlusion, laparoscopic salpingectomy, controlled ovarian hyperstimulation, IVF, and embryo transfer.

MAIN OUTCOME MEASURE(S)

Implantation rate, clinical-pregnancy rate, ongoing-pregnancy rate, abortion rate, and ectopic-pregnancy rate.

RESULT(S)

Patients who underwent proximal tubal occlusion before IVF demonstrated significantly increased implantation, clinical-pregnancy, and ongoing-pregnancy rates compared with those with no surgical intervention and demonstrated implantation, clinical-pregnancy, and ongoing-pregnancy rates comparable to those who underwent salpingectomy.

CONCLUSION(S)

Proximal tubal occlusion, when performed in women with unilateral or bilateral hydrosalpinges before their IVF treatment, represents a potentially beneficial surgical procedure, increasing significantly the chances for successful implantation and for clinical and ongoing pregnancy. Proximal tubal occlusion may be viewed as a valid alternative when salpingectomy is technically difficult or not feasible.

Estimating causal effects from multiple cycle data in studies of in vitro fertilization

Prospective studies of reproductive outcomes frequently record data at multiple cycles. For example, studies of in vitro fertilization and embryo transfer (IVF-ET) follow women or couples for possibly several IVF cycles and record outcomes such as pregnancy status and embryo implantation. Several time-varying covariates, such as age and diagnostic markers, typically are available as well. When attention is focused on measurement of exposure effects, the use of multiple cycle data poses several complications. If the study is observational, the exposure probability may depend on subject characteristics. Moreover, attrition rates in IVF-ET can be substantial, and the attrition process can be expected to depend heavily on prior outcome. In fact, both success (pregnancy) and failure (lack of embryo implantations) can be prognostic of dropout. In this paper, we illustrate the use of causal modeling for multiple cycle data. Key assumptions are reviewed, and inference based on weighted estimating equations is described in detail. The methods are applied to a study of the effects of hydrosalpinx among women with tubal disease undergoing IVF-ET.

Comparison of endometrial and subendometrial blood flows among patients with and without hydrosalpinx shown on scanning during in vitro fertilization treatment

OBJECTIVE

To compare endometrial and subendometrial blood flows among patients with and without hydrosalpinx (HSP) during in vitro fertilization treatment as measured by a three-dimensional power Doppler ultrasound.

DESIGN

A prospective observational study.

SETTING

A tertiary assisted-reproduction unit.

PATIENT(S)

Twenty-one patients with HSP were compared with 42 matched controls without HSP.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Endometrial thickness, endometrial pattern, endometrial volume, pulsatility index (PI) and resistance index (RI) of uterine vessels, and the vascularization index (VI), flow index (FI), and vascularization flow index (VFI) of endometrial and subendometrial regions were measured on the day of oocyte retrieval.

RESULT(S)

The proportion of the non-multilayered endometrial pattern was significantly higher in the HSP group than in the non-HSP group. Patients in the HSP group had significantly lower endometrial and subendometrial VI and VFI. Endometrial thickness, endometrial volume, uterine PI, uterine RI, and endometrial and subendometrial FI were similar between the two groups. No significant differences were observed in endometrial and subendometrial VI, FI, and VFI among patients with unilateral and bilateral HSP.

CONCLUSION(S)

A change in endometrial pattern and a decrease in endometrial and subendometrial blood flows may be the reasons for impaired implantation in patients with HSP.

Increased cystic fibrosis transmembrane conductance regulator (CFTR) expression in the human hydrosalpinx

BACKGROUND

Hydrosalpinx (HSP), characterized by abnormal fluid accumulation in the Fallopian tube, is one of the main causes of infertility in women; however, the mechanism underlying the formation of hydrosalpinx fluid (HF) remains elusive. The present study investigated the possible involvement of cystic fibrosis transmembrane conductance regulator (CFTR), a cAMP-dependent chloride channel, in the pathogenesis of hydrosalpinx.

METHODS

Masson's trichrome staining was used to characterize epithelial transformation in human HSP; RT-PCR, immunohistochemistry and immunofluorescence staining were used for CFTR expression and localization.

RESULTS

Masson's trichrome staining showed areas of epithelial transformation, focally attenuated and pseudostratified. Immunostaining showed enhanced CFTR immunoreactivity in the focally attenuated and pseudostratified areas of HSP epithelium. RT-PCR revealed that CFTR expression in HSP was significantly greater than that in normal Fallopian tubes.

CONCLUSIONS

These results indicate that HSP epithelium undergoes epithelial transformation with elevated CFTR expression, which may lead to increased transepithelial electrolyte and fluid secretion resulting in HF formation. The present findings may lead to the development of new treatment strategies for infertile patients with HSP.

Update on the impact of Chlamydia trachomatis infection on male fertility

With approximately 90 million cases annually, infection with Chlamydia trachomatis is the most prevalent sexually transmitted bacterial disease in the world. Considering that these infections are often asymptomatic and cause major complications like acute pelvic inflammatory disease, ectopic pregnancy, infertility or infant pneumonia, the estimated costs for diagnosis and treatment in the USA amounts to 2.2 million US dollars for each 500 cases. Therefore, there is a high need for correct, quick and cost-effective diagnosis and treatment of this urogenital tract infection. New innovative therapies provide good results with regard to efficacy and patients' compliance. The success rates of treatments are at least 95%. However, the occurrence of antibiotic resistance should not be ignored and new treatment schemes must be developed. The state-of-the-art of diagnosis and treatment of chlamydial infections as well as the pathophysiology is discussed in this review. In conclusion, infections with C. trachomatis is an important public health problem, especially in third world and developing countries, and more socio-economic studies linking secondary prevention of chlamydial infections, infertility and adverse pregnancy outcome are needed to understand more of its aetiology. In addition, diagnosis and treatment should be improved. Data in men revealed that past infections but not present infections are more related to male infertility. There is still controversial results. In future studies, function of the seminal vesicles and evaluation of the antioxidant capacity should be taken into account when role of C. trachomatis infection on male fertility is assessed.

Surgical treatment for tubal disease in women due to undergo in vitro fertilisation

BACKGROUND

Tubal disease, and particularly hydrosalpinx, has a detrimental effect on the outcome of in-vitro fertilisation (IVF). It has been less clear whether surgical intervention for tubal disease prior to IVF is effective in improving the likelihood of successful outcome. Most data are retrospective or poorly controlled. To date no single prospective randomised trial has shown a significant benefit from such surgical treatment prior to IVF.

OBJECTIVES

To assess the value of surgical treatment for tubal disease prior to IVF.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (10 March 2004), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2004), MEDLINE (January 1966 to February 2004), EMBASE (January 1985 to February 2004), reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA

All trials comparing a surgical treatment for tubal disease with a control group generated by randomisation were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. The studied outcomes were live birth (and ongoing pregnancy), pregnancy, ectopic pregnancy, miscarriage, multiple pregnancy and complications.

MAIN RESULTS

Three randomised controlled trials involving 295 (or couples) were included in this review. The odds of ongoing pregnancy and live birth (Peto odds ratio (OR) 2.13, 95% confidence interval (CI) 1.24 to 3.65) were increased with laparoscopic salpingectomy for hydrosalpinges prior to IVF. The odds of pregnancy were also increased (Peto odds ratio (OR )1.75, 95%CI 1.07 to 2.86). There was no significant difference in the odds of ectopic pregnancy (Peto OR 0.42, 95%CI 0.08 to 2.14), miscarriage (Peto OR 0.49, 95%CI 0.16 to 1.52) or treatment complications (Peto OR 5.80, 95%CI 0.35 to 96.79). No data were available concerning the odds of multiple pregnancy.

REVIEWERS' CONCLUSIONS

Laparoscopic salpingectomy should be considered for all women with hydrosalpinges prior to IVF treatment. Currently unilateral salpingectomy for a unilateral hydrosalpinx (bilateral salpingectomy for bilateral hydrosalpinges) should be recommended, although this requires further evaluation. Further randomised trials are required to assess other surgical treatments for hydrosalpinx, such as salpingostomy, tubal occlusion or needle drainage of a hydrosalpinx at oocyte retrieval. The role of surgery for tubal disease in the absence of a hydrosalpinx is unclear and merits further evaluation.

Peritonitis after a ruptured left pyosalpinx in a patient undergoing in vitro fertilization

OBJECTIVE

To report acute abdomen in a young woman with infertility due to small asymptomatic bilateral hydrosalpinges who was on the 12th day of an IVF cycle.

DESIGN

Case report.

SETTING

Private IVF clinic.

PATIENT(S)

A 35-year-old woman with asymptomatic bilateral hydrosalpinges.

INTERVENTION(S)

Abdominal laparoscopy.

MAIN OUTCOME MEASURE(S)

Pus and a ruptured left pyosalpinx.

RESULTS

The patient suddenly developed acute abdomen while lifting a disabled person at a nursing home where she worked as a nurse. About 200 mL of pus was aspirated, and the patient had a ruptured left pyosalpinx. Bilateral salpingectomy was done by laparoscopy; the patient's postoperative recovery was uneventful.

CONCLUSION

We report a rare case of acute abdomen due to peritonitis after a ruptured pyosalpinx in an IVF patient who lifted a disabled person.

How to treat hydrosalpinges: IVF as the treatment of choice

Two treatment options are available for patients suffering from tubal infertility due to hydrosalpinges. Surgical distal tubal repair is appropriate only for patients with preserved tubal mucosa, otherwise the subsequent intrauterine pregnancy rate is unacceptably low and the ectopic pregnancy rate too high. The alternative treatment, IVF, has also demonstrated low success rate in patients with untreated hydrosalpinges, possibly due to leakage of fluid into the uterus. Salpingectomy has been suggested as a method to overcome the negative influence of the hydrosalpingeal fluid on implantation and embryo development. A randomized controlled trial in Scandinavia has demonstrated a benefit of salpingectomy in patients with hydrosalpinges that were large enough to be visible on ultrasound. If only the first cycle was considered, patients having undergone salpingectomy expressed significantly higher clinical pregnancy (46% versus 22%) and birth (40% versus 17%) rates. It is concluded that patients with large hydrosalpinges and without prospect of spontaneous conception should be recommended salpingectomy, which truly increases their chances of a successful IVF treatment.

The mechanism of hydrosalpinx in embryo implantation

BACKGROUND

Hydrosalpinx adversely affects embryo implantation and contributes to poor implantation rates post embryo transfer. Embryo transport depends on concomitant intrauterine fluid motion induced by uterine wall motility, the result of spontaneous myometrial contractions towards the fundus.

METHODS AND RESULTS

The uterine dynamics of five patients with hydrosalpinx were recorded and analysed by image-processing techniques: the frequency was higher while the amplitudes and passive widths were lower compared with healthy volunteers. The existing peristaltic activity should have induced intrauterine fluid flow; however, the recordings failed to show the expected transport of fluid bolus. This observation was supported by mathematical simulations based on the hypothesis that fluid accumulation in the Fallopian tube of a patient with hydrosalpinx increases tubal pressure and thereby induces a pressure gradient between the fundus and the cervix. This pressure gradient acts adversely to the cervix-to-fundus intrauterine peristalsis and generates reflux currents that may thrust embryos away from the implantation site.

CONCLUSIONS

The reflux phenomenon could explain the reduced implantation rate associated with hydrosalpinx. Resolution of the issue of whether the removal of a Fallopian tube with hydrosalpinx should be undertaken for improving IVF pregnancy rates should be accompanied by prospective randomized clinical trials.

Endometrial cavity fluid is associated with poor ovarian response and increased cancellation rates in ART cycles

BACKGROUND

Endometrial cavity fluid (ECF) is occasionally observed during assisted reproductive technology (ART) cycles. However, few reports have described its prevalence or significance.

METHODS AND RESULTS

We examined the relationships between ECF, clinical pregnancy rate (CPR), tubal factor infertility and ultrasound-visible (USV) hydrosalpinges. In 843 ART cycles involving 721 patients, ECF was observed during stimulation in 57 cycles and after human chorionic gonadotrophin (HCG) administration in 12 cycles, with an overall incidence of 8.2% (69/843). When ECF was observed during stimulation, the cancellation rate due to poor ovarian response was significantly higher (29.8 versus 16.9%, P <0.05) and the CPR per started cycle was significantly lower (26.3 versus 42.4%, P <0.05) than cycles without ECF. When ECF developed after HCG administration, the CPR was similar compared with that of the group for which ECF was not observed. In the 327 cycles involving tubal factor infertility patients, USV hydrosalpinges were noted in 71 cycles (71/327; 21.7%), and ECF developed in five of those cycles (5/71; 7.0%). A total of 27 cycles during which ECF developed (27/57, 47.4%) involved non-tubal factor patients.

CONCLUSIONS

ECF during stimulation was associated with increased cancellation rates and lower CPRs per started cycle, and was not associated with USV hydrosalpinges. Furthermore, ECF observed after HCG administration did not impact CPR and may represent a different clinical entity.

Hydrosalpinx treated with extended doxycycline does not compromise the success of in vitro fertilization

OBJECTIVE

To determine if extended treatment with doxycycline before and after an in vitro fertilization (IVF) procedure can minimize the detrimental effect of a hydrosalpinx.

DESIGN

Retrospective analysis.

SETTING

University IVF program.

PATIENT(S)

Patients undergoing IVF, including 17 with a hydrosalpinx, 25 with adhesions or proximal tubal occlusion, and 22 with endometriosis or unexplained infertility.

INTERVENTION(S)

Women with a documented hydrosalpinx were prescribed doxycycline 100 mg twice daily starting 1 week before expected retrieval and continued until 6 days after retrieval. No antibiotics were prescribed in the other groups.

MAIN OUTCOME MEASURE(S)

Implantation rates and IVF outcomes.

RESULT(S)

Implantation rates were 30% for the doxycycline-treated group of patients with a hydrosalpinx, 27% for the group with tubal occlusion/adhesion, and 24% for the group with endometriosis or unexplained infertility. Eight (47%) of 17 patients with a hydrosalpinx had a live birth, compared with 11 (44%) of 25 for the group with tubal occlusion/adhesion and 12 (55%) of 22 for the group with endometriosis/unexplained infertility. There were no differences between the groups in patient age, number of oocytes retrieved, fertilization rate, or number of blastomeres of the transferred embryos.

CONCLUSION(S)

No detrimental effect of a hydrosalpinx was evident for patients treated with extended doxycycline. Tremendous cost savings can be realized if treatment with 2 weeks of an inexpensive antibiotic provides outcomes comparable to surgical correction of a hydrosalpinx before IVF.

Effects of human hydrosalpinx fluid on in-vitro murine fertilization

Patients with hydrosalpinges show a decrease of both fertility and clinical outcome of IVF and embryo transfer treatment. Several reports have demonstrated the negative effects of hydrosalpinx fluid (HSF) on embryo development and implantation. The aim of this study was to determine whether human HSF, collected from infertile patients, might exhibit a deleterious effect on gametes and fertilization using a murine IVF system. Murine gametes were co-incubated during IVF until first cleavage with human HSF diluted to 50% from four patients (HSF1-4). It was demonstrated that HSF affected fertilization, as determined by the count of the 2-cell embryos. Pre-incubation of spermatozoa with HSF during capacitation significantly lowered the percentage of 2-cell embryos (P < 0.05). While HSF1-3 had no significant effect on motility and viability of spermatozoa, HSF4 almost completely affected their survival. In contrast, pre-incubation of ovulated oocytes surrounded by their cumulus cells with HSF before IVF did not impede first cleavage. Taken together, these results suggest that HSF has a cytotoxic effect on spermatozoa and/or impairs the fertilization process, probably by altering capacitation/acrosome reaction and/or ligand(s)-receptor(s) interactions. Hydrosalpinges may be partly associated with sterility through HSF inhibitory effects on fertilization.

Laparoscopic management of hydrosalpinges before in vitro fertilization-embryo transfer: salpingectomy versus proximal tubal occlusion

OBJECTIVE

To compare ovarian response and IVF-ET cycle outcome in patients with hydrosalpinges managed by either laparoscopic salpingectomy or proximal tubal occlusion.

DESIGN

Retrospective analysis.

SETTING

Tertiary-care assisted reproductive technology program.

PATIENT(S)

One hundred four consecutive fresh IVF-ET cycles in 94 patients with tubal-factor infertility.

INTERVENTION(S)

Laparoscopic salpingectomy (group 1: 35 cycles) or bipolar proximal tubal occlusion (group 2: 17 cycles), controlled ovarian hyperstimulation, and IVF-ET. Control groups consisted of both tubal-factor patients without hydrosalpinges (group 3: 37 cycles) and those with prior bilateral tubal ligation for sterilization (group 4: 15 cycles).

MAIN OUTCOME MEASURE(S)

Uterine artery Doppler flow, controlled ovarian hyperstimulation response, and implantation and clinical pregnancy rates.

RESULT(S)

There were no differences in mean uterine artery pulsatility indices or ovarian response among any of the groups. A trend toward a higher cycle cancellation rate in group 1 did not approach statistical significance. Clinical pregnancy and implantation rates were not significantly different between group 1 (57.1%, 29.2 +/- 5.9%, respectively) and group 2 (46.7%, 19.4 +/- 6.1%, respectively) or compared with those of controls.

CONCLUSION(S)

[1] Management of hydrosalpinges by laparoscopic salpingectomy or bipolar proximal tubal occlusion yielded statistically similar responses to controlled ovarian hyperstimulation and IVF-ET cycle outcome. [2] The latter approach may be preferable in patients who present with dense pelvic adhesions and easy access only to the proximal fallopian tube.

Role of laparoscopic salpingostomy in the treatment of hydrosalpinx

OBJECTIVE

To determine pregnancy rates after laparoscopic salpingostomy in occlusive distal tubal disease. To evaluate the relative impact of various historical, physical, and operative factors on pregnancy outcome using a multivariate statistical analysis.

DESIGN

Prospective cohort.

SETTING

University-affiliated tertiary care infertility clinic.

PATIENT(S)

One hundred thirty-nine infertile women with occlusive distal tube disease.

INTERVENTION(S)

Laparoscopic salpingostomy.

MAIN OUTCOME MEASURE(S)

The occurrence of intrauterine (IUP) and ectopic pregnancy (EP).

RESULT(S)

The overall IUP and EP rates were 24.5% and 16.5%, respectively. Analysis of historical variables, assessed independently, demonstrated a significantly higher IUP rate with a positive history of gonorrhea and a significantly higher EP rate with a positive history of pelvic inflammatory disease, lack of history of intrauterine device (IUD) usage, or the performance of a bilateral procedure. The logistic regression model to predict intrauterine pregnancy had an overall predictive value of 77.5% and included the following significant variables: secondary infertility, positive history of gonorrhea, and the operative finding of moderate periadnexal adhesions. The logistic regression model to predict ectopic pregnancy had an overall predictive value of 89.0% and included the following significant variables: previous ectopic pregnancy, negative history of IUD use, positive history of PID, a bilateral procedure, and perihepatic adhesions.

CONCLUSION(S)

Operative laparoscopy may be effective for the correction of hydrosalpinges in selected patients. The probability of achieving an intrauterine or an ectopic pregnancy can be predicted based on combinations of significant variables.

Surgical treatment for tubal disease in women due to undergo in vitro fertilisation

BACKGROUND

Tubal disease, and particularly hydrosalpinx, has a detrimental effect on the outcome of in-vitro fertilisation (IVF). It has been less clear whether surgical intervention for tubal disease prior to IVF is effective in improving the likelihood of successful outcome. Most data are retrospective or poorly controlled. To date no single prospective randomised trial has shown a significant benefit from such surgical treatment prior to IVF.

OBJECTIVES

To assess the value of surgical treatment for tubal disease prior to IVF.

SEARCH STRATEGY

The search strategy of the Menstrual Disorders and Subfertility Group was used for the identification of relevant randomised controlled trials.

SELECTION CRITERIA

All trials where a surgical treatment for tubal disease was compared with a control group generated by randomisation were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Three randomised controlled trials were identified and included in this review, after an attempt to obtain further information from the authors of all three trials. All trials were assessed for quality criteria. The studied outcomes were live birth (and ongoing pregnancy), pregnancy, ectopic pregnancy, miscarriage, multiple pregnancy, complications, implantation rate and the proportion of IVF cycles resulting in embryo transfer.

MAIN RESULTS

The odds of pregnancy (OR 1.75, 95%CI 1.07, 2.86) and of ongoing pregnancy and live birth (OR 2.13, 95%CI 1.24, 3.65) were increased with laparoscopic salpingectomy for hydrosalpinges prior to IVF. There was no significant difference in the odds of ectopic pregnancy (OR 0.42, 95%CI 0.08, 2.14), miscarriage (OR 0.49, 95%CI 0.16, 1.52), treatment complications (OR 5.80, 95%CI 0.35, 96.79) or implantation rate (OR 1.34, 95%CI 0.87, 2.05). No data were available concerning the odds of multiple pregnancy or the proportion of IVF cycles resulting in embryo transfer.

REVIEWER'S CONCLUSIONS

Laparoscopic salpingectomy should be considered for all women with hydrosalpinges prior to IVF treatment. Currently unilateral salpingectomy for a unilateral hydrosalpinx (bilateral salpingectomy for bilateral hydrosalpinges) should be recommended, although this requires further evaluation. Further randomised trials are required to assess other surgical treatments for hydrosalpinx, such as salpingostomy, tubal occlusion or needle drainage of a hydrosalpinx at oocyte retrieval. The role of surgery for tubal disease in the absence of a hydrosalpinx is unclear and merits further evaluation.

Effect of human hydrosalpinx fluid on in vitro mouse embryogenesis

OBJECTIVE

Women with hydrosalpinx have an unfavorable pregnancy rate. As one approach to elucidate the effect of hydrosalpinx on uterine tubal functioning, we examined the effect of hydrosalpinx fluid on early embryo development in mice.

METHODS

Hyperovulation was induced in ICR mice, and late 2-cell-stage embryos were harvested 42 hours after administration of human chorionic gonadotropin (hCG). Hydrosalpinx fluid was obtained from patients during surgery after informed consent was obtained. The embryos were cultured in 3 culture fluids: (1) mBWW medium containing 0.3% bovine serum albumin (positive-control medium) (BSA), (2) Ca2+, Mg2+-free phosphate buffered saline (negative-control medium) (PBS), and (3) 100% human hydrosalpinx fluid. The developmental status of the embryos 120 hours after hCG administration was examined.

RESULTS

Embryogenesis from a 2-cell-stage embryo to a blastocyst was observed in 98.3% (118/120) of the embryos cultured in the mBWW medium, in 0% (0/120) of the embryos cultured in PBS, and in 98.3% (118/120) of the embryos cultured in 100% human hydrosalpinx fluid.

CONCLUSION

In the micro-environment of human hydrosalpinx fluid, late 2-cell embryos of ICR mice developed normally to blastocysts. The present results also suggest that non-species-specific embryogenetic factors might be present in human hydrosalpinx fluid.

Controversies in the surgical management of hydrosalpinx

The surgical management of hydrosalpinges is a controversial subject. Chronic pathology of the fallopian tube with distal obstruction leads to the formation of a hydrosalpinx, and is associated with very poor pregnancy rates after surgery. In these cases, in-vitro fertilization has proved to be a much better alternative. However, several studies have shown that patients with hydrosalpinges have significantly lower pregnancy and implantation rates after in-vitro fertilization compared with patients with other forms of tubal damage. The exact mechanism by which the hydrosalpinx adversely affects in-vitro fertilization results is not yet fully understood. The value of performing a salpingectomy before in-vitro fertilization has been studied extensively. Currently, a clear benefit in salpingectomies has been proved for patients with ultrasonically visible hydrosalpinges.

Management of hydrosalpinx: reconstructive surgery or IVF?

Tubal disease remains the most important factor in female infertility. Many investigators reported that patients with hydrosalpinx had a decreased clinical pregnancy rate and an increased miscarriage rate, resulting in a decreased ongoing pregnancy rate when compared to that of patients with other types of tubal disease. Different studies showed a deleterious effect of the presence of hydrosalpinx on the outcome of in vitro fertilization-embryo transfer, because toxic agents flowing from the hydrosalpinx to the uterus impair the implantation rate. Operative laparoscopy is effective in the treatment of hydrosalpinges (Stage I or II). Fertility outcome is related to tubal damage. Patients with Stage III and IV disease should be managed from the beginning with in vitro fertilization. Excision of hydrosalpinx(-ges) improves the pregnancy potential after in vitro fertilization. We believe that assisted reproductive technology and reproductive surgery can be complementary. The development of laparoscopic surgery and in vitro fertilization improved the pregnancy rate in patients with tubal factor infertility.

Salpingectomy for repeated embryo nonimplantation after in vitro fertilization in patients with severe tubal factor infertility

PURPOSE

To evaluate the impact of salpingectomy on the rates of embryo implantation and pregnancy in patients with severe, irreversible tubal factor sterility.

METHODS

A retrospective study of patients with repeated failure of in vitro fertilization due to nonimplantation of the embryo. Seventy-two patients with severe and irreversible tubal factor sterility were selected following repeated failure of in vitro fertilization (IVF) due to assumed nonimplantation of the embryo: 35 underwent a salpingectomy before continuing IVF cycles and 37 continued IVF cycles without salpingectomy.

RESULTS

After the first IVF cycle consecutive to diagnosis of embryo nonimplantation, the implantation rate was 10.2% in the salpingectomy group and 6.1% in the group without the procedure (P = 0.5). After all IVF cycles, the rate was, respectively, 6.9% and 4.5% (P = 0.2). Salpingectomy improved the pregnancy rate (PR) per transfer (23.5% vs. 9.9%; P = 0.01). The curves of the cumulative probability of becoming pregnant show that salpingectomy resulted in pregnancy more rapidly.

CONCLUSIONS

Salpingectomy improves the PR per transfer in patients with severe and irreversible tubal factor sterility who have experienced repeated failure of IVF due to embryo nonimplantation. This procedure also reduces the number of IVF attempts needed to obtain pregnancy.

Hydrosalpinx and IVF outcome: a prospective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF

Many retrospective studies have shown that hydrosalpinx is associated with poor in-vitro fertilization (IVF) outcome. The mechanism of the actual cause is not yet fully understood. A clinical practice of performing salpingectomy before IVF has developed, without any evidence from prospective trials. The aim of the present prospective randomized trial was to test if a salpingectomy prior to IVF was effective in terms of increased pregnancy rates. Patients with hydrosalpinx were randomized to either a laparoscopic salpingectomy or no intervention before IVF. A total of 204 patients was available for an intention-to-treat analysis and 192 actually started IVF. Clinical pregnancy rates per included patient were 36.6% in the salpingectomy group and 23.9% in the non-intervention group (not significant, P = 0.067) and the ensuing delivery rates were 28.6% and 16.3% (P = 0.045). The corresponding delivery rates per transfer cycle were 29.5% versus 17. 5% (not significant, P = 0.083). A subgroup analysis revealed significant differences in favour of salpingectomy, in implantation rates in patients with bilateral hydrosalpinges (25.6% versus 12.3%, P = 0.038) and in clinical pregnancy rates (45.7% versus 22.5%, P = 0.029) and delivery rates (40.0% versus 17.5%, P = 0.038) in patients with ultrasound visible hydrosalpinges. The delivery rate was increased 3.5-fold in patients with bilateral hydrosalpinges visible on ultrasound (P = 0.019).

Effects of hydrosalpingeal fluid on murine embryo development and implantation

PURPOSE

Our purpose was to evaluate the effects of various concentrations of hydrosalpingeal fluid (HSF) on the preimplantation development and implantation of murine embryos.

METHODS

One-cell mouse embryos were cultured in KSOM culture medium with 0.1, 1.0, 10, or 50% HSF, without and with lactate supplementation. Late-stage embryos were transferred into the uteri of pseudopregnant CD-1 females to determine implantation rates. The embryo transfer technique used was developed by our group and its effectiveness was evaluated during this experiment.

RESULTS

Blastocyst development in the 0.1, 1.0, 10, and 50% group was 45, 55.0, 12.5, and 17.5%, respectively, with lactate supplementation, and 35.0, 52.5, 12.5, and 5.0%, respectively, without lactate supplementation, while in the KSOM (control) group it was 63.8%. Blastocyst development was reduced compared to controls in the 10% HSF and 50% HSF groups. Implantation rates for the 0.1 and 1.0% groups with lactate supplementation were 43.0 and 25.0%, respectively, and those with lactate supplementation were 50.6 and 61.8%, respectively, while in the KSOM group the implantation rate was 65.5%. None of the implantation rates were significantly different.

CONCLUSIONS

Hydrosalpingeal fluid has a concentration-dependent inhibitory effect on in vitro murine embryo development, but it has minimal effects on implantation rates.

The embryo toxicity of hydrosalpinx fluid is only apparent at high concentrations: an in vitro model that stimulates in vivo events

OBJECTIVE

To simulate the in vivo model in studying the effect of hydrosalpinx fluid on embryonic development.

DESIGN

Controlled prospective study.

SETTING

Academic research center.

PATIENT(S)

Five hundred eighty-seven two-cell murine embryos.

INTERVENTION(S)

Embryos were grown under two sets of conditions. Half were cultured using 10% fetal calf serum in RPM1 medium in varying concentrations of hydrosalpinx fluid (0, 1%, 10%, 50%, 75%, and 100%). To more closely mimic the in vivo environment, the other half were grown in an endometrial coculture system with the same media and hydrosalpinx fluid concentrations.

MAIN OUTCOME MEASURE(S)

Embryonic development.

RESULT(S)

For each stage of embryogenesis, diminished development was noted with increasing concentrations of hydrosalpinx fluid. In the group of embryos grown without endometrial coculture, only at a minimum concentration of 50% hydrosalpinx fluid was diminished development noted for the blastocyst, hatching, and outgrowth stages. When an endometrial coculture system was used, development was not inhibited until exposure to a minimum of 75% hydrosalpinx fluid. Embryogenesis was enhanced when an endometrial coculture system was used for each concentration of hydrosalpinx fluid.

CONCLUSION(S)

When a model is used that more accurately mimics the in vivo conditions of IVF-ET in a patient with hydrosalpinges, it appears that high concentrations of hydrosalpinx fluid are required to signiticantly impede embryogenesis. The endometrium appears to help detoxify hydrosalpinx fluid.

A decade of salpingoscopy

With the introduction of the salpingoscopy of the tubal ampullary mucosa in the 1980s, this diagnostic endoscopic examination not only disclosed an exciting world of sharp and detailed in vivo images of the actual site of human fertilization. Its systematic use in the assessment of the tubal factor in subfertile couples also provides specific, clinically relevant and prognostically valuable information, since it clearly demonstrates the presence or absence of anatomical distortions, especially adhesions between and destruction of mucosal folds, on a micro-endoscopic, i.e., mucosal level. The routine salpingoscopy of a free, patent tube is easy to perform and the procedure then takes about 10 min for both sides. In contrast with hysterosalpingography, a proximal (e.g., tubocornual or isthmic) block does not prevent us from examining the ampullary mucosa with the salpingoscope, whereas a small incision at the site of the occlusion with one of the techniques of operative laparoscopy, enables the inspection of the mucosa of a hydrosalpinx. With salpingoscopy, and using a simple classification system, a trained endoscopist can evaluate the sequelae of tubal inflammatory disease and their impact on fertility nearly as efficiently as with mucosal microbiopsies and they can direct their patients accordingly, either towards reconstructive (micro)surgery or towards medically assisted reproduction. In case of a tubal pregnancy, the effort to salpingoscopically evaluate both the affected and unaffected side may help to understand the underlying ethiology of the ectopic. Since patency and a normal appearance of the fimbriated end surely do not imply the absence of endoluminal pathology, it is advisable to select only salpingoscopically normal tubes to perform tubal transfers of gametes, zygotes or embryos. In the still ongoing discussion regarding preventive salpingectomy prior to IVF-ET in case of a uni- or bilateral hydrosalpinx, blind victimization of the Fallopian tube can in our opinion be avoided by a proper endoscopic selection of cases.

Adverse effects of hydrosalpinx on pregnancy rates after in vitro fertilization-embryo transfer

OBJECTIVE

To determine the effect of hydrosalpinx on the establishment of pregnancy after IVF-ET.

DESIGN

Metaanalysis.

SETTING

University medical center.

PATIENT(S) AND INTERVENTION(S)

All published reports (n=13) and abstracts (n=10) in English that examined the relation between hydrosalpinx and IVF-ET were included in the analysis. The metaanalysis was performed by first calculating the odds ratios for each trial and then combining them to obtain a pooled estimate of the odds ratio and a 95% confidence interval.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy.

RESULT(S)

A total of 5,569 cycles was reviewed in the group without hydrosalpinx, and a total of 1,144 was reviewed in the group with hydrosalpinx. The clinical pregnancy rate was approximately 50% lower in patients who had hydrosalpinx. Similarly, the implantation rate was decreased by 50%. These effects were observed also in thawed ET cycles. The abortion rate was more than twofold higher in patients who had hydrosalpinx.

CONCLUSION(S)

This metaanalysis suggests that hydrosalpinx is associated with a reduced chance of implantation and an increased risk of pregnancy loss.

The management of hydrosalpinges before in-vitro fertilization and embryo transfer

Several recent studies have shown that the presence of hydrosalpinges adversely affects clinical pregnancy rates achieved with in-vitro fertilization and embryo transfer. Hydrosalpinx fluid may be toxic to the endometrium or embryo, or may mechanically interfere with implantation. Some authors recommend surgical correction of hydrosalpinges before in-vitro fertilization and have shown promising results with this approach. Proper patient selection for this therapy still needs to be defined.

The significance of hydrosalpinx in in vitro fertilization

OBJECTIVE

To review the effects of hydrosalpinx on IVF/ET and the role of salpingectomy.

DESIGN

The literature on hydrosalpinx, IVF/ET, embryotoxicity, and salpingectomy for hydrosalpinx was identified through MEDLINE searches and reviewed.

RESULT(S)

Hydrosalpinx has been associated with poor fertility prognosis. IVF/ET is a better alternative to tubal surgery for those patients with severe distal tubal disease, and it is also more cost effective. However, the presence of hydrosalpinx has a negative effect on IVF/ET by decreasing the pregnancy rates and implantation rates compared with patients undergoing IVF/ET for tubal disease but without hydrosalpinx. The hydrosalpingeal fluid has been demonstrated to be embryotoxic to developing embryos, thus leading to increased early pregnancy losses. Poor endometrial receptivity has also been demonstrated in the presence of hydrosalpinges. Removal of the hydrosalpinges leads to improved IVF/ET rates comparable to those patients without hydrosalpinx. Therefore, salpingectomy has been recommended for patients with hydrosalpinx who will be undergoing IVF/ET.

CONCLUSION(S)

The presence of hydrosalpinx has a negative effect on IVF/ET because of the suspected embryotoxicity of the hydrosalpingeal fluid. Surgical removal of the hydrosalpinx has been shown to improve IVF/ET rates.

The adverse effect of hydrosalpinges on in vitro fertilization pregnancy rates and the benefit of surgical correction

OBJECTIVE

To test the hypothesis that IVF-ET pregnancy rates (PRs) for patients with tubal factor infertility are decreased in patients with hydrosalpinges and that surgical correction reverses this effect.

DESIGN

Retrospective chart review.

SETTING

Private practice IVF-ET program.

PATIENT(S)

Patients (n = 160) undergoing 238 cycles of IVF-ET were stratified into groups based on the presence of hydrosalpinges and whether surgical correction had been performed. Patients >39 years old and patients with male factor infertility were excluded from the study.

INTERVENTION(S)

Patients with hydrosalpinges were offered surgical correction.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy defined by an intrauterine gestational sac.

RESULT(S)

Patients with hydrosalpinges had significantly decreased implantation rates and PRs per transfer (2.8% and 8.5%, respectively) than patients with tubal factor infertility but without hydrosalpinges (15.7% and 38.6%). Surgical correction improved implantation rates and PRs in patients with prior failed cycles (16.1% and 37.5%) and in patients undergoing surgery before IVF-ET (21.8% and 51.7%). The type of surgery performed did not affect success rates in the small number of patients evaluated.

CONCLUSION(S)

The presence of a hydrosalpinx during an IVF-ET cycle results in significant decreases in implantation rates and PRs. Surgical treatment of hydrosalpinges before IVF-ET cycles improves implantation rates and PRs.

Does hydrosalpinx reduce the pregnancy rate after in vitro fertilization?

OBJECTIVE

To determine the effect of hydrosalpinges on the pregnancy rate in an IVF program.

DESIGN

Multicentric retrospective analysis of clinical and laboratory data.

SETTING

Two assisted reproductive technology centers in university hospitals.

PATIENT(S)

Four hundred forty-three women, under 38 years of age, with pure tubal infertility. The patients were classified into the following five groups: bilateral hydrosalpinges (n = 37), unilateral hydrosalpinx (n = 54), bilateral tubal occlusion (n = 207), unilateral tubal occlusion (n = 55), and severe tubal disease without complete occlusion (n = 90).

MAIN OUTCOME MEASURE(S)

Pregnancy and implantation rates.

RESULT(S)

The pregnancy and the implantation rates per transfer (12.3% and 5.4%) obtained by women with bilateral hydrosalpinges are significantly lower than the rates (means = 23.1% and 12%) for all other tubal infertility groups.

CONCLUSION(S)

Bilateral hydrosalpinges have a deleterious effect on the outcome of IVF program.

The presence of hydrosalpinx may not adversely affect the implantation and pregnancy rates in in vitro fertilization treatment

PURPOSE

To evaluate the effects of hydrosalpinx on the outcome of in vitro fertilization (IVF) treatment, a retrospective study was undertaken at a tertiary referral center for infertility.

METHODS

Results of the first IVF treatment cycles in 144 patients from 1 January 1993 to 31 December 1995, who had tubal infertility only and were less than 38 years old, were reviewed. The duration/dosage of hMG used, serum estradiol level on the day of hCG, number of oocytes aspirated and fertilized, number of embryos replaced, implantation rate, clinical pregnancy rate, and pregnancy outcome were compared in patients with and without hydrosalpinx.

RESULTS

The mean implantation rate and clinical pregnancy rate were similar in patients with or without hydrosalpinx. Both groups had similar ovarian responses and fertilization rates. There was no increase in clinical abortion in the hydrosalpinx group but ectopic pregnancies were more common in patients with hydrosalpinx.

CONCLUSIONS

The presence of hydrosalpinx did not adversely affect the implantation and pregnancy rates in in vitro fertilization treatment when the results of the first cycle were compared. However, it can lead to a higher incidence of ectopic pregnancies.

The impact of hydrosalpinx on successful pregnancy in tubal factor infertility treated by in vitro fertilization

OBJECTIVE

To determine the impact of hydrosalpinx on pregnancy rates in patients undergoing IVF for infertility caused by tubal disease.

DESIGN

Review of the records of all patients who had undergone IVF for tubal factor infertility at our institution between May 1988 and October 1994.

SETTING

A university-sponsored, hospital-based IVF facility.

PATIENT(S)

Two hundred fifty patients were identified with infertility due to tubal disease; 67 of these had at least one documented hydrosalpinx whereas the remaining 183 did not.

MAIN OUTCOME MEASURE(S)

Numbers of oocytes retrieved and fertilized, the number of embryos transferred and implanting, and resulting pregnancy rates.

RESULT(S)

The groups were similar in age and cycle cancellation rates. The patients with hydrosalpinx had greater numbers of oocytes retrieved per cycle (15.0 versus 11.6) and embryos transferred per cycle then those without hydrosalpinges (4.21 versus 3.98). The hydrosalpinx group also undertook more cycles per patient (2.31 versus 1.96). Fertilization rates between the two groups were similar, but implantation rates were decreased in those with hydrosalpinx (8.5% versus 11.2%).

CONCLUSION(S)

Hydrosalpinx did not result in impaired ovarian stimulation or decreased oocyte fertilization. It did, however, interfere with implantation and reduce to some degree the success of IVF in achieving an ongoing pregnancy. The validity of routine salpingectomy for hydrosalpinx is debatable, but its use in selected individuals may well be appropriate.