Ultrasound-guided aspiration of hydrosalpinges is associated with improved pregnancy and implantation rates after in-vitro fertilization cycles

Which patients with hydrosalpinx will benefit more from reproductive surgery to improve natural pregnancy outcomes?: A systematic review and meta-analysis

BACKGROUND

The most common tubal disease leading to infertility occurs in the distal region, manifesting as hydrosalpinx. Tubal surgery is an effective alternative treatment. However, subpopulations that benefit the most from tubal repair surgery remain unclear. The objective of this study was to investigate the natural pregnancy outcomes of patients with hydrosalpinx after reproductive surgery and those with different grades of hydrosalpinx.

METHODS

We searched the major online databases (PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials) to collect observational studies on patients with hydrosalpinx who underwent surgeries to preserve natural fertility from January 2000 to August 2022. The outcome indicators were natural intrauterine pregnancy (IUP) and ectopic pregnancy (EP) rates. Studies on patients with hydrosalpinx who underwent laparoscopic surgeries and those who intended to be conceived naturally were included. Studies on patients with non-hydrosalpinx diseases, those who underwent open surgery, and those who intended to undergo assisted conception were excluded. The Newcastle-Ottawa scale for observational studies was used for quality evaluation. Meta-analysis of a single rate was performed using RevMan5.3 software.

RESULTS

A total of 10 articles were included in this study, including 1317 patients with hydrosalpinx. Seven studies were retrospective and 3 were prospective. It was found that after surgery for preserving natural fertility function, the IUP and EP rates of patients with hydrosalpinx were 27% (95% confidence interval [CI]: 22-32%) and 4.8% (95% CI: 2.91-8.26%), respectively. In addition, the IUP and EP rates in patients with mild (n = 254), moderate (n = 252), and severe (n = 473) hydrosalpinx were 50.5% (95% CI: 38.65-61.97%), 32.9% (95% CI: 21.88-46.24%), 10.7% (95% CI: 4.76-21.88%), and 7.4% (95% CI: 2.91-19.35%), 9.09% (95% CI: 6.54-13.79%), 8.3%, 8.26% (95% CI: 3.85-18.03%), respectively.

CONCLUSION

Patients with mild to moderate hydrosalpinx will benefit more from reproductive surgery to improve natural pregnancy outcomes. However, the small sample size in our study needs to be further expanded, and the grouping needs to be more refined, such as grouping based on age. This may provide more guidance in clinical practice.

Role of tubal surgery in the era of assisted reproductive technology: a committee opinion

This document reviews surgical options for reparative tubal surgery and the factors that must be considered when deciding between surgical repair and in vitro fertilization. This document replaces the document of the same name, last published in 2012 (Fertil Steril 2015;103:e37-43). This document reviews surgical options for reparative tubal surgery and the factors that must be considered when deciding between surgical repair and in vitro fertilization.

Effects of Hydrosalpinx on Endometrial Implantation Failures: Evaluating Salpingectomy in Women Undergoing in vitro fertilization

Hydrosalpinx is a disease characterized by the obstruction of the salpinx, with progressive accumulation in the shape of a fluid-filled sac at the distal part of the tuba uterina, and closed to the ovary. Women with hydrosalpinges have lower implantation and pregnancy rates due to a combination of mechanical and chemical factors thought to disrupt the endometrial environment. Evidence suggests that the presence of hydrosalpinx reduces the rate of pregnancy with assisted reproductive technology. The main aim of the present is review to make an overview of the possible effects of hydrosalpinx on in vitro fertilization (IVF). We conducted a literature search on the PubMed, Ovid MEDLINE, and Google Scholar data bases regarding hydrosalpinx and IVF outcomes. Hydrosalpinx probably has a direct toxic effect on sperm motility and on the embryos. In addition, the increasing liquid inside the salpinges could alter the mechanisms of endometrial receptivity. The window of endometrial receptivity is essential in the implantation of blastocysts, and it triggers multiple reactions arising from the endometrium as well as the blastocysts. Hydrosalpinx could influence the expression of homeobox A10 (HOXA10) gene, which plays an essential role in directing embryonic development and implantation. Salpingectomy restores the endometrial expression of HOXA10; therefore, it may be one mechanism by which tubal removal could result in improved implantation rates in IVF. In addition, salpingectomy does not affect the ovarian response, nor reduces the antral follicle count. Further studies are needed to establish the therapeutic value of fluid aspiration under ultrasonographic guidance, during or after oocyte retrieval, in terms of pregnancy rate and ongoing pregnancy.

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.

Treatment of hydrosalpinx in relation to IVF outcome: a systematic review and meta-analysis

Salpingectomy is the most widely used treatment for hydrosalpinx. The effect of salpingectomy on the stimulation response during subsequent IVF treatment, however, remains unclear. The aim of this systematic review was to evaluate the ovarian response and pregnancy outcome of IVF treatment carried out after salpingectomy compared with other pre-IVF treatment options for hydrosalpinx. We conducted a literature search using PubMed, Ovid MEDLINE, Google Scholar, ClinicalTrials.gov and the Cochrane Central Register of Controlled Trials. Five randomized studies and nine observational studies were included in the systematic review and evaluated using Cochrane Collaboration's tool for randomized, Newcastle-Ottawa scale for observational studies and GRADE guidelines for certainty of evidence assessment. The mean number of retrieved oocytes was similar between the groups in randomized (mean difference [MD] = -0.03, 95% CI -0.75 to 0.70) and observational studies (MD = -0.15, 95% CI -2.32 to 2.02). Live birth (RR 1.59, 95% CI 1.17 to 2.16), clinical pregnancy (RR 1.27, 95% CI 1.02 to 1.57) and implantation rates (RR 1.55, 95% CI 1.16 to 2.08) were higher in the salpingectomy group in randomized studies. The present systematic review and meta-analysis showed that salpingectomy does not impair the ovarian response during subsequent IVF treatment.

Essure a novel option for the treatment of hydrosalpinx: a case series and literature review

OBJECTIVE

The aim of this study is to evaluate the use of hysteroscopic Essure device placement for the treatment of hydrosalpinx (HS)-related infertility in patients with laparoscopic contraindications and compared their pregnancy outcomes following IVF-ICSI treatment with those patients having had laparoscopic tubal occlusion (LTO).

PATIENTS

From 2008 to 2014 a total of 50 patients were diagnosed with unilateral or bilateral hydrosalpinges: 29 patients had laparoscopic contraindications and were treated hysteroscopically and 21 patients were treated with laparoscopical salpingectomy.

RESULTS

Of the 29 patients who underwent treatment with Essure(®), 21 began a cycle of in vitro fertilization (IVF), and 13 finished in embryo transfer that resulted in seven clinical pregnancies. Furthermore, in the group of women treated with salpingectomy, 17 started an IVF cycle that resulted in 12 clinical pregnancies. The clinical pregnancy rate per patient with an IVF cycle started was 33.3% and 70.6%, the live-birth rate per patient was 14.3% and 52.9%, the miscarriage rate was 57.1% and 18.2%, and the implantation rate was 16.3% and 34.1% for hysteroscopy and laparoscopy, respectively.

CONCLUSION

Essure(®) placement is an alternative method for occlusion of hydrosalpinges before IVF. Monitoring the live-birth rate confirms that this option may be considered when laparoscopy is impossible or contraindicated.

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.

Salpingostomy in the treatment of hydrosalpinx: a systematic review and meta-analysis

STUDY QUESTION

What is the chance of natural conception when salpingostomy is used to treat hydrosalpinx?.

SUMMARY ANSWER

The natural clinical pregnancy rate following salpingostomy is 27%, in the hands of experienced surgeons who publish their results.

WHAT IS KNOWN ALREADY

Tubal surgery is not commonly offered for women with hydrosalpinges since the advent of assisted conception treatment. This is the first systematic review to investigate natural conception rates following salpingostomy in the treatment of hydrosalpinx.

STUDY DESIGN, SIZE, DURATION

A systematic review and meta-analysis of 22 observational studies encompasses 2810 patients undergoing salpingostomy and attempting natural conception.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Literature searches were conducted to retrieve observational studies which reported salpingostomy for hydrosalpinx. Databases searched included MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINAHL, with no language restriction. Only studies that focused on salpingostomy (rather than other tubal conserving surgeries) for the treatment of hydrosalpinx were included. A total of 22 studies matched the inclusion criteria.

MAIN RESULTS AND THE ROLE OF CHANCE

The pooled natural clinical pregnancy rate from the 22 observational studies (including 2810 patients) was 27% (95% confidence interval (CI): 25-29%) after salpingostomy was performed for hydrosalpinx. The cumulative clinical pregnancy rates were 8.7% (95% CI: 6.6-11.5%) at 6 months, 13.3% (95% CI: 10.6-16.7%) at 9 months, 20.0% (95% CI: 17.5-22.8%) at 12 months, 21.2% (95% CI: 18.6-24.1%) at 18 months and 25.5% (95% CI: 22.2-29.4%) at 24 months after salpingostomy. The pooled live birth rate (10 studies, 1469 patients) was 25% (95% CI: 22-28%) after salpingostomy was performed for hydrosalpinx. The pooled ectopic pregnancy rate (19 studies, 2662 patients) was 10% (95% CI: 9-11%). The pooled miscarriage rate (seven studies, 924 patients) was 7% (95% CI: 6-9%). The included studies scored well on the Newcastle Ottawa quality assessment scale.

LIMITATIONS, REASONS FOR CAUTION

Strict inclusion criteria were used in the conduct of the systematic review. However, the studies included are clinically heterogeneous in many aspects including patient characteristics, surgical technique and duration of follow-up after salpingostomy.

WIDER IMPLICATIONS OF THE FINDINGS

The findings of this systematic review suggest that salpingostomy is an alternative treatment strategy to tubal clipping or salpingectomy in patients presenting to fertility services with hydrosalpinx. Further prospective, large and high quality studies are needed to identify the subpopulation that would most benefit from tube conserving surgery.

STUDY FUNDING/COMPETING INTERESTS

No external funding was either sought or obtained for this study. The authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Ultrasound guided aspiration of hydrosalpinx fluid versus salpingectomy in the management of patients with ultrasound visible hydrosalpinx undergoing IVF-ET: a randomized controlled trial

BACKGROUND

The aim of this study was to compare the efficacy of ultrasound guided aspiration of hydrosalpinx fluid at the time of oocyte retrieval with salpingectomy in the management of patients with ultrasound visible hydrosalpinx undergoing IVF-ET.

METHODS

One hundred and sixty patients with ultrasound visible hydrosalpinx were randomized into salpingectomy group and aspiration group using computer generated randomization list and sequentially numbered sealed envelopes containing allocation information written on a card.

RESULTS

The clinical pregnancy rate per started cycle and the implantation rate were non- significantly higher in the salpingectomy group compared with the aspiration group [40% vs. 27.5% (p value = 0.132) and 18.95% vs. 12.82% (p value =0.124), respectively]. In the aspiration group, 34.21% of patients had rapid re-accumulation of the hydrosalpinx fluid (i.e. within first two weeks after embryo transfer). Whereas, the clinical pregnancy rate per transfer cycle and the implantation rate were significantly higher in salpingectomy group compared with the subgroup of patients with rapid re-accumulation of hydrosalpinx fluid [42.67% vs. 19.23% (p value = 0.036) and 18.95% vs. 7.58% (p value = 0.032), respectively], no significant differences were detected between the salpingectomy group and the subgroup of patients with no re-accumulation of hydrosalpinx fluid (42.67% vs. 34% (p value = 0.356) and 18.95% vs. 15.5% (p value = 0.457), respectively).

CONCLUSION

The small sample size could be the cause of failure of detecting significant increase in implantation and pregnancy rates in salpingectomy group compared with aspiration group. Further larger randomized controlled trials are needed to determine whether salpingectomy is more effective than aspiration of hydrosalpinx fluid or not. Moreover, the data presented in this study suggested that rapid re-accumulation of hydrosalpinx fluid is an obstacle against successful implantation and the cause of lower success rate with ultrasound guided aspiration of hydrosalpinx fluid compared with salpingectomy.

TRIAL REGISTRATION

Clinical trials.gov ( NCT02008240 ), registered 8 December 2013.

Tubal factor infertility: diagnosis and management in the era of assisted reproductive technology

Tubal factor infertility accounts for a large portion of female factor infertility. The most prevalent cause of tubal factor infertility is pelvic inflammatory disease and acute salpingitis. The diagnosis of tubal occlusion can be established by a combination of clinical suspicion based on patient history and diagnostic tests, such as hysterosalpingogram, sonohysterosalpingography, and laparoscopy with chromopertubation. Depending on several patient factors, tubal microsurgery or more commonly in vitro fertilization with its improving success rates are the recommended treatment options.

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.

Laparoscopic proximal tubal division can preserve ovarian reserve for infertility patients with hydrosalpinges

AIM

To investigate whether laparoscopic proximal tubal division for the treatment of hydrosalpinges could preserve ovarian function.

METHODS

From June 2002 to October 2006, before assisted reproductive treatment (ART), a total of 17 infertile patients with bilateral hydrosalpinges were studied--11 patients underwent laparoscopic proximal tubal division (PTD group), and six underwent laparoscopic salpingectomy (salpingectomy group). In both groups, the basal follicle-stimulating hormone (FSH) values before and after surgery, the operation time and outcome of ART treatment were retrospectively evaluated.

RESULTS

The mean FSH value before laparoscopic PTD was similar to that after surgery. The FSH value before laparoscopic salpingectomy significantly increased after surgery (6.8 +/- 1.1 vs 14.1 +/- 9.3). The operation time in the PTD group was significantly shorter than in the salpingectomy group. The outcomes of ART were similar in both groups. The pregnancy rate per patient in the PTD and salpingectomy groups were 45.5% and 50%, respectively.

CONCLUSIONS

Laparoscopic proximal tubal division preserved ovarian function and was an optimal operation method for infertility patients with hydrosalpinges. The basal FSH values after laparoscopic proximal tubal division were comparable to those before surgery.

Hydrosalpinx functional surgery or salpingectomy? The importance of hydrosalpinx fluid in assisted reproductive technologies

The first IVF baby, Louise Brown, was born in a natural cycle IVF of a woman who had bilateral tubal block making IVF the only option for having a child. The last 3 decades has seen astounding progress in the field of ART. Today thanks to ART, tubal disease and tubal factor infertility is easily overcome. The accepted theory today is that the hydrosalpinx fluid plays a causative role in the reduced pregnancy rate with ART. It is well known that the success of ART for patients with tubal disease with hydrosalpinx is reduced by half compared with patients without hydrosalpinx. Ideal would be removal of a hydrosalpinx by laparoscopic salpingectomy to improve pregnancy rates. However in some cases this is not feasible due to dense pelvic adhesions making access difficult. In such cases it is recommended that even de-linking the tube from the uterus would help in improving the ART outcome. There is suggestion that sonographically visible hydrosalpinges and those affected bilaterally have a poorer prognosis than those seen incidentally at laparoscopy. While there is clinical evidence supporting the causative role of the fluid itself, there is a lack of knowledge as to how the fluid exerts its negative effects. It is generally believed that the fluid holds a key position in impairing implantation potential. The aim of this review is to highlight the importance of identifying hydrosalpinges and its association with reduced fertility outcome using assisted reproductive technologies. Here we have discussed the different options available for the same, and highlighted the current modes of treatment.

Salpingectomy for hydrosalpinx prior to in vitro fertilization

Salpingectomy for hydrosalpinges before in vitro fertilization increases the success rate.

Ultrasound-guided hydrosalpinx aspiration during oocyte collection improves pregnancy outcome in IVF: a randomized controlled trial

BACKGROUND

Hydrosalpinges have adverse effects on IVF outcomes. Salpingectomy is effective in improving outcomes, but it is not always practical or safe. Ultrasound-guided aspiration of hydrosalpinges at oocyte collection is an option for those who develop hydrosalpinges during controlled ovarian stimulation; however, there is no randomized evidence to show whether this practice is effective.

METHODS

Between October 1999 and June 2003, consenting women of age <or=39 years with an ultrasound diagnosis of hydrosalpinx were randomized before oocyte collection to transvaginal aspiration of hydrosalpinx under antibiotics cover or no aspiration. Third-party randomization was performed using a computer algorithm, and allocation concealment was achieved with opaque sealed envelopes. Outcomes were biochemical and clinical pregnancies, implantation, spontaneous abortion, ectopic pregnancy and pelvic infection rates. Analysis was by intention to treat.

RESULTS

Sixty-six women were recruited to the trial, 32 to the aspiration group and 34 to the no-aspiration group. Aspiration resulted in a greater biochemical pregnancy rate [14/32 (43.8%) versus 7/34 (20.6%), relative risk (RR) = 2.1 (1.02, 4.6), P = 0.04]. Clinical pregnancy rates for aspiration versus control groups were 31.3% (10/32) and 17.6% (6/34), respectively [RR = 1.8 (0.8, 4.3), P = 0.20]. There were no changes in implantation rate or spontaneous abortion risk with aspiration and no differences between the groups in infection or ectopic pregnancy rates.

CONCLUSIONS

In women who are identified to have hydrosalpinges during controlled ovarian stimulation during IVF, aspiration of hydrosalpinges during oocyte collection may be effective in improving pregnancy rates (Trial Registration Number: NCT00566956).

Infertility treatment: the viability of the laparoscopic view

Assisted reproductive technology (ART) and laparoscopy are not mutually exclusive, but coexisting and potentially complimentary treatments. For disease conditions contributing to infertility in addition to other concomitant or potential morbidity, laparoscopy represents a more comprehensive approach.

Treatment of hydrosalpinx in the patient undergoing assisted reproduction

PURPOSE OF REVIEW

Patients with hydrosalpinx are a recognized group with poor prognosis in in-vitro fertilization. This review presents evidence for the effectiveness of different treatment options.

RECENT FINDINGS

Theories explaining the mechanisms behind the impaired outcome of in-vitro fertilization still focus on the hydrosalpingeal fluid. Gamete and embryotoxic effects have been demonstrated, but it is not a consistent finding. Endometrial receptivity may be altered by the reduced expression of cytokines and integrins important to implantation, and reduced endometrial and subendometrial blood flows may play a role. The rationale for treatments to improve the results of in-vitro fertilization is based on interruption of the leakage of hydrosalpinx fluid into the uterine cavity. Laparoscopic salpingectomy has been evaluated in a large randomized trial and proved effective in restoring birth rates. Proximal tubal ligation may also be effective according to one smaller randomized trial. Other suggested methods such as transvaginal drainage have been poorly investigated.

SUMMARY

Pre-in-vitro fertilization salpingectomy is the only method that has proved effective in restoring birth rates in patients with hydrosalpinx. The underlying mechanism explaining reduced implantation and embryo development awaits further research.

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.

Laparoscopic Management of Hydrosalpinx

Hydrosalpinx is a common cause of female infertility. Lower implantation and pregnancy rates have been reported in women with hydrosalpinges. How hydrosalpinx exerts its negative effect on the implantation process is not clearly understood. Mechanical factors, toxicity of the hydrosalpingeal fluid, and receptivity dysfunction may explain the impaired IVF outcome in the presence of hydrosalpinx. Laparoscopic surgery has a place in the diagnosis and management of hydrosalpinx. Analysis of the results of laparoscopic management of hydrosalpinx underscores the positive role of laparoscopy in fertility outcomes in women with this pathological tubal disease. Laparoscopic salpingectomy should be offered in those women who have bilateral disease or in cases where hydrosalpinges are large enough to be visible on ultrasound. Further randomized trials are required to assess other surgical treatment options for hydrosalpinx, such as laparoscopic salpingostomy, laparoscopic or hysteroscopic tubal occlusion, and drainage of hydrosalpinx before or during oocyte retrieval.

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.

Management of hydrosalpinx before or during in vitro fertilization-embryo transfer: a national postal survey in France

Using an anonymous and sealed questionnaire sent to all French IVF centers, the current management of hydrosalpinx before or during IVF was evaluated. Laparoscopic salpingectomy was recommended and undertaken in less than half of the centers, even though several other treatments were reported and despite medical evidence for this surgical option.

The management of hydrosalpinges: tubal surgery or salpingectomy?

PURPOSE OF REVIEW

The clinical management of hydrosalpinges in infertile patients remains a contentious issue. This review aims to provide a critical analysis on the available treatments for hydrosalpinges, which have recently created a fierce debate between the promoters of salpingectomy and in-vitro fertilization and those who endorse tubal surgery.

RECENT FINDINGS

Hydrosalpinges have a detrimental effect on the outcome of in-vitro fertilization yet their mechanism is still unclear. Salpingectomy prior to in-vitro fertilization restores the likelihood of a successful outcome in a well defined group of patients with ultrasound-visible hydrosalpinges. However, not every woman with large hydrosalpinges should undergo salpingectomy as some fallopian tubes may be amenable to surgical repair. Preserved tubal mucosa indicates a good prognosis for tubal surgery, therefore an appropriate mucosal assessment should be routine prior to deciding upon further management.

SUMMARY

As salpingectomy is a definitive procedure it should be performed when the hydrosalpinges are beyond repair or in cases of in-vitro fertilization failure. Tubal surgery should be preferred to salpingectomy in mild to moderate tubal disease. A comparative study of restorative tubal surgery versus salpingectomy and in-vitro fertilization in selected women with hydrosalpinges is needed and will significantly help this debate. Prophylactic salpingectomy prior to in-vitro fertilization and tubal surgery is not competing but complementary in the treatment of hydrosalpinges-related infertility.

Outcomes From Assisted Reproductive Technology

The use of assisted reproductive technology (ART) for treating the infertile couple is increasing in the United States. The purpose of this paper is to review the short-term outcomes after ART. Pregnancy rates after ART have shown nearly continuous improvement in the years since its inception. A number of factors affect the pregnancy rate, with the most important being a woman's age. Certain clinical diagnoses are associated with a poorer outcome from ART, including the presence of hydrosalpinges, uterine leiomyomata that distort the endometrial cavity, and decreased ovarian reserve. Multiple gestations are the major complication after ART. New laboratory techniques, including extended embryo culture, may allow the transfer of fewer embryos to maintain pregnancy rates while reducing the risk of multiple gestations. Although much of the morbidity in children born after ART is the result of multiples, recent analysis suggests that even singletons are at higher risk for perinatal morbidity, including preterm delivery and small for gestational age infants. In vitro fertilization may be associated with a slight increased risk for birth defects. The major short-term complication of ART in women is the development of ovarian hyperstimulation syndrome. This syndrome is difficult to predict, but new treatments are being developed that may limit its frequency. Because of its high pregnancy rate, couples are moving to ART more quickly in the management of their infertility. All outcomes of ART, including pregnancy rates and adverse complications, need to be compared with standard non-ART therapy when deciding the appropriate course of treatment for a given couple.

Cost—effectiveness analysis of salpingectomy prior to IVF, based on a randomized controlled trial

BACKGROUND

In patients with ultrasound-visible hydrosalpinges, salpingectomy prior to IVF increases the chance of a live birth. This study compared the cost-effectiveness of this strategy (intervention) with that of optional salpingectomy after a failed cycle (control).

METHODS

Data from a Scandinavian randomized controlled trial were used to calculate the individual number of treatments and their outcomes. Only patients with ultrasound-visible hydrosalpinges were considered in the main analysis, and a maximum of three fresh cycles were included. The costs for surgical procedures, IVF treatment, medication, complications, management of pregnancy and delivery as well as of early pregnancy losses were calculated from standardized hospital charges.

RESULTS

Among the 51 patients in the intervention group, the live birth rate was 60.8% compared with 40.9% in 44 controls. The average cost per patient was 13,943 euro and 12,091 euro, respectively. Thus, the average cost per live birth was 22,823 euro in the intervention group and 29,517 euro in the control group. The incremental cost-effectiveness ratio for adopting the intervention strategy was estimated at 9306 euro.

CONCLUSIONS

The incremental cost to achieve the higher birth rate of the intervention strategy seems reasonable.

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.

Rapid reaccumulation of hydrometra after drainage at embryo transfer in patients with hydrosalpinx

OBJECTIVE

To report the occurrence and management of hydrometra at the time of scheduled embryo transfer in two patients who underwent drainage of hydrosalpinges at oocyte retrieval.

DESIGN

Case report. University IVF clinic.

PATIENT(S)

Two patients with hydrosalpinges visible on ultrasonography who deferred tubal surgery. Although no fluid was seen at the time of oocyte retrieval, hydrometra was noticed and drained before planned embryo transfer (ET).

MAIN OUTCOME MEASURE(S)

Reoccurrence of hydrometra after drainage.

RESULT(S)

Rapid reaccumulation of hydrometra despite drainage was seen in both patients, one of whom had reoccurrence in 1 hour. Embryo transfer was deferred until after tubal surgery, and all embryos were cryopreserved.

CONCLUSION(S)

In patients with hydrosalpinges, ultrasonography before ET is useful to detect newly developed hydrometra. Aspiration of the uterine fluid is unlikely to help because of rapid reaccumulation of hydrometra. Cryopreservation of the embryos for future transfer after the hydrosalpinx is removed or ligated is recommended.

Surgical intervention in infertility management

Despite improvement in the success of IVF, reproductive surgery will remain an important option and complement to assisted reproductive technologies (ART) for many couples. Reproductive surgery should be considered as the first-line treatment when the correction of infertility pathologies is simple and a good result is expected once corrected, when the pathology is causing symptoms such as pain or abnormal bleeding, or if uncorrected will compromise the results or increase the risks of ART. The success of surgical infertility treatment depends on the careful selection of cases using appropriate investigative techniques, with procedures performed in centres with sufficient expertise. For both specialized reproductive and general gynaecological surgery it is crucial to follow microsurgical principles to avoid adhesion formation and conserve normal tissues, especially tubal and ovarian. These aspects of reproductive surgery, and different surgical techniques used for various tubal, peritoneal, uterine and ovarian conditions to achieve the optimal reproductive outcome are discussed in this article.

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.

An Australasian survey of the management of hydrosalpinges in women due to undergo in vitro fertilisation

OBJECTIVE

To ascertain current practice of surgical interventions for women with hydrosalpinges prior to in vitro fertilisation and to compare this with a subsequent systematic review of the literature.

DESIGN

Survey.

SETTING

Specialists in Australasian IVF clinics.

METHODS

Questionnaire sent to all specialists in Australasian IVF clinics via the clinical directors of these units.

RESULTS

There were 79 respondents from 33 fertility clinics. Although only 66% expressed a belief that there was convincing evidence of an improvement in pregnancy outcomes from surgical treatment for hydrosalpinges prior to in vitro fertilisation, 94% currently offer surgical treatment for hydrosalpinges prior to in vitro fertilisation, 32% always and 62% only in selected cases. Of the 74 respondents offering surgery, all but three expressed a preference for the laparoscopic approach. Of those offering surgery, 89% performed unilateral or bilateral salpingectomy depending whether unilateral or bilateral hydrosalpinges were present, 5% routine bilateral salpingectomy 14% proximal tubal occlusion with clips, 24% salpingostomy, 7% ultrasound-guided needle aspiration of hydrosalpinges at the time of egg collection.

CONCLUSIONS

The diverse practice among Australasian fertility specialists reflects the apparent conflict in the literature prior to this survey. A Cochrane Review has now demonstrated the efficacy of laparoscopic salpingectomy in improving the odds of live birth for women with hydrosalpinges due to undergo in vitro fertilisation. It will be interesting to review whether this leads to greater uniformity of practice in the coming years.

Conversion of high-response gonadotropin intrauterine insemination cycles to in vitro fertilization results in excellent ongoing pregnancy rates

OBJECTIVE

To determine whether conversion of gonadotropin/IUI cycles at high risk of high-order multiple pregnancies to IVF yields a pregnancy rate high enough to warrant the added intervention.

DESIGN

Case-control study.

SETTING

Brigham and Women's Hospital assisted reproductive technology program.

PATIENT(S)

Seventy-seven patients converted from gonadotropin/IUI to IVF, 77 consecutive age and attempt number-matched controls (sequential controls [SCs]), and 77 consecutive age-, attempt-, and E(2)-matched controls (E(2) controls [ECs]).

INTERVENTION(S)

Gonadotropin/IUI cycles with exuberant responses were converted to IVF (cases) to avoid cycle cancellation and high-order multiple pregnancies.

MAIN OUTCOME MEASURE(S)

Pregnancy rates, delivery rates, E(2) levels, follicle and oocyte number, and fertilization and implantation rates.

RESULT(S)

Compared with SCs and ECs, cases had more follicles (16.3 +/- 0.6 vs. 13.3 +/- 0.9 and 14.4 +/- 0.9) and higher E(2) at hCG administration (1,951 +/- 93 vs. 1,568 +/- 96 and 1,939 +/- 89 pg/mL). Delivery rates among the three groups (45.5% vs. 32.5% and 39.0%) did not differ significantly. Despite the transfer of fewer embryos in cases than in controls (2.5 +/- 0.1 vs. 3.1 +/- 0.1 and 2.9 +/- 0.1), three triplet pregnancies occurred in cases and three in controls.

CONCLUSION(S)

Conversion of high responder gonadotropin/IUI patients to IVF is an effective alternative to cycle cancellation and offers a delivery rate as high or higher per cycle than that of planned IVF. Sample size limited the statistical power of the study.

Hydrosalpinx and IVF outcome: cumulative results after salpingectomy in a randomized controlled trial

BACKGROUND

A randomized controlled trial of salpingectomy prior to IVF in patients with hydrosalpinges has been conducted in Scandinavia. The results from the first transfer cycle have been published and clearly demonstrated an improved pregnancy outcome after salpingectomy had been performed in patients with hydrosalpinges large enough to be visible on ultrasound. The present article is aimed at analysing the effect of salpingectomy on cumulative birth rate, including all individual transfer cycles.

METHODS AND RESULTS

A total of 186 women underwent 452 cycles. Among the 77 women randomized to no surgical intervention, 24 underwent salpingectomy after one or two failed cycles. Cumulative results were analysed by Cox regression, taking into account the number of cycles per patient and the presence of a salpingectomy after a previous transfer. Salpingectomy implied a significant increase in birth rate (hazard ratio 2.1, 95% CI 1.6-3.6, P = 0.014). Within the subgroup of patients with ultrasound-visible hydrosalpinges, the birth rate was even higher (hazard ratio 3.8, 95% CI 1.5-9.2, P = 0.004). Implantation rate was significantly higher in patients who had undergone salpingectomy (27.2% versus 20.2, P = 0.03) and, in the subgroup of patients with ultrasound-visible hydrosalpinges, the difference was even larger (30.3% versus 17.1%, P = 0.003).

CONCLUSIONS

The results of the cumulative cycles strengthen the recommendation for a laparoscopic salpingectomy prior to IVF in patients with ultrasound-visible hydrosalpinges.

Hydrosalpinx and assisted reproduction: options and rationale for treatment

Salpingoscopy during laparoscopy yields the best prognosis in patients with hydrosalpinx. It has been demonstrated that in-vitro fertilization (IVF) patients with hydrosalpinx have decreased pregnancy rates as compared with control individuals. If a patient with hydrosalpinx is to be treated with IVF, then the communication between the uterine tube and the uterine cavity should be blocked via salpingectomy or proximal tubal ligation, with or without distal tubal fenestration. This is because there is evidence that hydrosalpinx, especially when it is bilateral and visible by ultrasonography, impacts negatively on pregnancy and implantation rates after IVF cycles.

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.

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.

Cauterization of hydrosalpinges before in vitro fertilization is an effective surgical treatment associated with improved pregnancy rates

OBJECTIVE

Our purpose was to determine whether proximal tubal cauterization is an effective method of reversing the decreased pregnancy rates seen in patients undergoing in vitro fertilization-embryo transfer with hydrosalpinges present.

STUDY DESIGN

We studied a group of 94 patients with tubal factor infertility. Sixty patients had hydrosalpinges documented by either hysterosalpingography or laparoscopy, or both. Forty-five had surgical treatment of hydrosalpinges by salpingectomy or by proximal tubal cauterization. In vitro fertilization-embryo transfer was performed within 3 months after surgery. Pregnancy and implantation rates were compared.

RESULTS

Patients with hydrosalpinx had significantly decreased clinical pregnancy and implantation rates per cycle (14% and 8%, respectively) compared with those of patients undergoing proximal tubal cauterization before the in vitro fertilization cycle (73% and 36%, respectively). These pregnancy and implantation rates are comparable with those found in patients with tubal factor infertility without hydrosalpinges (53% and 22%, respectively), as well as in salpingectomy-treated patients (46% and 24%, respectively).

CONCLUSIONS

Proximal tubal cauterization is effective in reversing the adverse effects of hydrosalpinges.

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.

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).