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Hydrosalpinges and IVF

Hydrosalpinges are dilated and occluded fallopian tubes generally the result of a prior pelvic infection. These are a cause of female infertility in a number of patients. Essentially the eggs and sperm cannot meet because of the blockade. The diagnosis is often made during the initial evaluation when the HSG is performed. A diagnostic laparoscopy may also confirm the diagnosis, and the fallopian tubes may be opened (i.e. neosalpingostomy) or removed (i.e. salpingectomy). The photo below shows a hyrosalpinx on the right side.

IVF has been used to ‘bypass’ the fallopian tubes. However, some studies showed that the presence of hydrosalpinges lowered the pregnancy rates. Barmat et al (1) showed a higher pregnancy loss rate (37% vs. 14%), decreased implantation rate (16% vs. 21%) and an increased ectopic pregnancy rate (8% vs. 3%) in IVF patients that had hydrosalpinges compared to other tubal pathology. Several other studies (2-5) found similar trends with and overall decrease in pregnancy rates in fresh IVF cycles. Hydrosalpinges were also reported to reduce the pregnancy rates and implantation rates when cryopreserved embryos were implanted (6) and when donor oocytes were used (7). While these studies were not prospective and randomized in nature, they do indicate a potential area of concern.

Several potential mechanisms have been proposed including the production of some toxic factor (present in rodent model but not human), mechanical disruption of implantation, altered expression of factors critical to implantation (8), and possibly lack of nutrients in the hydrosalpinx fluid. A number of studies were published examining the effect of salpingectomy (surgical removal of the affected tube) on IVF pregnancy rates. The Cochrane Database Systematic Review (9) summarized the best studies and found that the evidence supports removal of the affected fallopian tube. One study (10) evaluated the cost-effectiveness of salpingectomy prior to IVF and found that the average cost per live birth was lower in patients that had the salpingectomy. There have been concerns of the effects of salpingectomy of the response to the ovaries with subsequent IVF stimulation. It has been postulated that some of the blood supply for the ovaries comes off the mesosalpinx (supporting structure for the tube) and that removal of the tube may compromise this. Gelbaya et al (11) found an increase in the day#3 FSH levels, lower number of follicles, and lower peak estradiol levels in patients that had laparoscopic salpingectomy for hydrosalpinges. However, the pregnancy rates overall were not compromised. Strandell et al (12) no impairment in response to IVF treatment in women that had salpingectomy. Some investigators have suggested division of the proximal fallopian tube in order to decrease the potential risk of affecting ovarian responses.

References:

1. Barmat L, Rauch E, Spandorfer S, Kowalik A, Sills E, Schattman G, Liu H, Rosenwaks Z. 1999. The effect of hydrosalpinges on IVF-ET outcome. Journal of Assisted Reproduction and Genetics. 16(7):350-354.

2. Vandromme J, Chasse E, Lejeune B, Van Rysselberge M, Delvigne A, Leroy F. 1995. Hydrosalpinges in in-vitro fertilization: an unfavourable feature. Hum. Repro. 10(3):576-9.

3. Katz E, Akman MA, Damewood MD, Garcia JE. 1996. Deleterious effect of the presence of hydrosalpinx on implantation and pregnancy rates with in vitro fertilization. Fertil. Steril. 66(1):122-5.

4. Andersen AN, Yeu Z, Meng Z, Petersen K. 1994. Low implantation rate after in-vitro fertilization in patients with hydrosalpinges diagnoses by ultrasonography. Hum. Repro. 9(10): 1935-8.

5. Strandell A, Waldenstrom U, Nilsson L, Hamberger L. 1994. Hydrosalpinx reduces in-vitro fertilization/embryo transfer pregnancy rates. Hum. Repro. 9(5): 861-3.
6. Akman MA, Garcia JE, Damewood MD, Watts LD, Katz E. 1996. Hydrosalpinx affects the implantation of previously cryopreserved embryos. Hum. Repro. 11(5): 1013-4.

7. Cohen MA, Lindheim SR, Sauer MV. 1999. Hydrosalpinges adversely affect implantation in donor oocyte cycles. Hum. Repro. 14(4): 1087-9.

8. Seli E, Kayisli U, Cakmak H, Bukulmez O, Bildirici I, Guzeloglu-Kayisli O, Arici A. 2005. Removal of hydrosalpinges increases endometrial leukemia inhibitory factor (LIF) expression at the tie of the implantation window. Hum. Repro. 20(11):3012-17.

9. Johnson N, MaK W, Sowter M. 2004 Surgical treatment for tubal disease in women due to undergo in vitro fertilization. Cochrane Database Syst. Rev. 2004;(3). 2125.

10. Strandell A, Lindhard A, Eckerund I. 2005. Cost-effectiveness analysis of salpingectomy prior to IVF, based on a randomized controlled trial. Hum. Repro. 20(12):3284-92.

11. Gelbaya T, Nardo L, Fitzgerald C, Horne G, Brison D, Lieberman. 2006. Ovarian response to gonadotropins after laparoscopic salpingectomy or division of fallopian tubes for hydrosalpinges. Fertil Steril. 85(5): 146468.

12. Strandell A, Lindhard A, Waldenstrom U, Thorburn J. 2001. Prophylactic salpingectomy does not impair the ovarian response in IVF treatment. Hum. Repro. 16(6):1135-39.
 

 

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