Download hydrosalpingx - to treat or not?

Hydrosalpinx – To Treat or Not
A. Strandell
Reproductive Medicine Unit, Department of Obstetrics and Gynecology, Sahlgrenska
University Hospital, G‫צ‬teborg, Sweden
Summary
Several retrospective studies have shown an impaired outcome of in vitro
fertilization (IVF) in the presence of hydrosalpinx. It is believed that the
fluid exerts a detrimental effect on the endometrium by altering the
receptivity or simply by causing a mechanical hindrance for implantation.
Different treatment options would then be salpingectomy, tubal ligation,
salpingostomy or aspiration of hydrosalpingeal fluid. Laparoscopic
salpingectomy is the only procedure that has been evaluated in a
randomized controlled trial and it was found to be beneficial in patients
with large hydrosalpinges that were visible on ultrasound. Pregnancy and
birth rates were twice as high among patients who underwent
salpingectomy as compared with those without any surgery before IVF.
Introduction
Tubal factor infertility has been the major reason for treatment with IVF
since the method’s introduction, but patients with hydrosalpinges have
been identified as a subgroup with significantly impaired pregnancy
outcome compared with patients suffering from other types of tubal
damage. Data from retrospective studies have been compiled,
demonstrating a reduction by half in clinical pregnancy and delivery rates
and a doubled rate of spontaneous abortion in women with hydrosalpinx.
The poor result of IVF in hydrosalpinx patients certainly suggests there is
a need for further treatment.
One of the main explanations has implied that the leakage of fluid into the
uterine cavity creates an unfavorable endometrial environment to
implantation and could also affect embryo development. Retrospective
studies have indicated that the larger the hydrosalpinx, the worse the
outcome after IVF, which raised the question of embryotoxic properties
of the fluid. However, the results of embryo cultures in hydrosalpingeal
fluid have been contradictory among murine models, and human embryo
development did not express any toxic influence of hydrosalpingeal fluid.
Obviously, the lack of substrate in pure hydrosalpingeal fluid is harmful
to the embryo development, but the potential embryotoxic property of
hydrosalpingeal fluid is still a controversy. It has also been suggested that
the leakage of fluid to the uterine cavity causing a watery interface is
enough to prevent implantation.
13 Strandell
Whatever the exact mechanism, an interruption of the communicating
hydrosalpinx seems suitable to improve the endometrial environment to
implantation. The present article will explore the different treatment
options and present the available evidence for each method.
Treatment Options
According to the theory that the hydrosalpingeal fluid plays a causative
role, any surgical intervention interrupting the communication to the
uterus would remove the leakage of the hydrosalpingeal fluid and restore
pregnancy rates. Which are the theoretical options? Through the
laparoscopic route, salpingectomy, distal salpingostomy and tubal ligation
are available methods, but only salpingectomy has been evaluated in a
randomized controlled trial. Transvaginal ultrasound-guided aspiration of
the hydrosalpingeal fluid in combination with antibiotics has been
suggested as a less invasive method.
Salpingectomy
Hitherto, salpingectomy is the only method of prophylactic surgery in
patients with hydrosalpinx that has been evaluated in randomized
controlled trials. Two studies were of small sizes and did not show any
statistically significant differences in pregnancy rates (D‫י‬chaud et al.
1998, Goldstein et al. 1998). A multicenter study conducted in
Scandinavia, showed a significant improvement in pregnancy and birth
rates after salpingectomy in patients with hydrosalpinges that were large
enough to be visible on ultrasound before ovarian stimulation was
initiated, when first cycle was considered (Strandell et al. 1999). Clinical
pregnancy rates were 46% vs. 27% (p=0.049) and birth rates were 40%
vs. 17% (p=0.040) in salpingectomized patients vs. patients without any
surgical intervention. When all subsequent cycles were considered,
including all patients regardless of the size of the hydrosalpinx,
salpingectomy implied a doubled birth rate as compared to patients with
persistent hydrosalpinges. Data revealed that the benefit of salpingectomy
mainly affected patients with hydrosalpinges visible on ultrasound, and
consequently, those are the only to be recommended prophylactic
salpingectomy prior to IVF.
The psychological aspect of removing the tubes in an infertile patient is
very important and has to be considered. Even if it is obvious that the
patient would benefit from salpingectomy, it is crucial that she is
psychologically prepared to undergo the procedure. In some cases it takes
one or several failed cycles before the patient is ready to give her consent.
In cases of unilateral hydrosalpinx and a contralateral healthy tube, the
chance of spontaneous conception after a unilateral salpingectomy may be
13 Strandell
increased, as demonstrated by the Scandinavian study in which two
patients conceived and gave birth after a unilateral procedure.
Is there a risk of impaired ovarian function subsequent to a
salpingectomy? Hitherto, only one recent study has shown an adverse
effect on the ovary ipsilateral to a salpingectomy, due to ectopic
pregnancy (Lass et al. 1998). However, there was no difference in the
overall performance when the sides were not separated, which may
suggest a compensatory mechanism in the contra lateral adnex. In a study
including almost exclusively patients who were unilaterally
salpingectomized due to ectopic pregnancy after IVF, no negative effect
of surgery on response parameters was seen, nor was the operated side
more affected (Dar et al. 2000). In a prospective study of 26 women, the
cycles before and after prophylactic salpingectomy were compared and
the ovarian response was assessed as the dose and duration of
gonadotrophins and the number of retrieved and fertilized oocytes without
any significant differences detectable in any of the measured outcomes.
(Strandell et al. 2001). Obviously, there is no impairment of the overall
ovarian function subsequent to salpingectomy. However, theoretically it
seems important to be very cautious not to damage the vascular and
nervous supply when performing a salpingectomy.
Proximal tubal occlusion
Is tubal ligation as effective as salpingectomy? There are no randomized
trial to answer this question. Two retrospective studies have not been able
to show any significant differences in pregnancy outcome, but the number
of patients has been too low to allow for any conclusion. Surrey et al.
investigated retrospectively 94 patients with tubal disease, of which 32
with hydrosalpinges were treated by salpingectomy prior to IVF and 15
were treated by tubal ligation regardless of adhesion status (Surrey et al.
2001). Implantation rates were 29 % and 19 % respectively (not
statistically significant). In another retrospective study, 45 of 60 patients
with hydrosalpinges accepted laparoscopic surgery, and salpingectomy
was performed if possible, while tubal ligation and distal drainage was
performed in cases of extensive adhesions (Stadtmauer et al. 2000). Only
the surgically untreated group expressed significantly lower clinical
pregnancy rates as compared with both salpingectomy and tubal ligation.
Distal tubal repair
Is there a risk of unnecessary salpingectomies being performed when a
clear recommendation of salpingectomy has been formulated to a defined
patient group? Hydrosalpinges with preserved mucosa may be better
treated with reconstructive surgery as primary treatment instead of
13 Strandell
salpingectomy and IVF. The latter option may, however, be the secondary
treatment after failed conception and re-occlusion of the tubes.
Unnecessary salpingectomies should, of course, not be performed and
they may easily be avoided by appropriate evaluation of the tubal mucosa
at laparoscopy before any final decision of salpingectomy is made. It is
important that physicians discriminate carefully whether a hydrosalpinx
should be removed or is suitable for surgical repair. A prerequisite is that
the patient is well informed about the different treatment options, their
success rates in terms of pregnancy outcome and also the risk of ectopic
pregnancy.
Tubal repair with distal salpingostomy or fimbrioplasty gives the patient
the chance of a spontaneous conception. If conception does not occur, the
surgical procedure might be of benefit when IVF is undertaken, unless the
distal opening has re-occluded. However, there are no studies to prove
this theory, only occasional cases as part of a control group in
retrospective studies have been reported.
Transvaginal aspiration
The least invasive surgical method, transvaginal ultrasound-guided
aspiration of fluid, has been described in several case reports and in two
retrospective studies. Different conclusions regarding the benefit of
drainage at the time of oocyte retrieval in terms of improved pregnancy
and implantation rates were drawn (Sowter et al. 1997, VanVoorhis et al.
1998). The first and largest study showed no effect on pregnancy rates
while the latter study showed a significant improvement. There is a rapid
reoccurrence of fluid already noticeable at the time of transfer in many
cases, which is likely to compromise any beneficial effect of drainage.
Transvaginal aspiration before start of ovarian stimulation has been
described without any improvement in pregnancy rates (Aboulghar et al.
1990).
There is a need to properly evaluate transvaginal aspiration at the time of
oocyte retrieval including the potential risk of infection associated with
the puncture of a hydrosalpinx. The occurrence of infections in
association with puncture of hydrosalpinx seems to be rare when
antibiotics have been given according to the published reports. The
method has the obvious advantage of being less invasive than the other
available surgical methods. Today, there is no evidence that transvaginal
aspiration is as effective as salpingectomy, but for patient who will not
undergo salpingectomy and for those who develop tubal fluid during
stimulation it is an option.
13 Strandell
Medical treatment
The use of antibiotics has also been discussed, not only as prophylactics
when a hydrosalpinx has been punctured but also when given to selected
groups of patients with elevated serum Chlamydia trachomatis IgG
antibody titres or as a routine before oocyte retrieval to all patients
(Sharara et al. 1996). However, antibiotic treatment specifically in
hydrosalpinx patients has never been prospectively evaluated. One
retrospective study has compared patients with hydrosalpinx who
received extended doxycyclin treatment during an IVF cycle to patients
with other indications (tubal occlusion without hydrosalpinx/ adhesions or
endometriosis / unexplained infertility) who did not receive any
antibiotics (Hurst et al. 2001). Implantation and pregnancy rates were
similar in all groups, suggesting that antibiotic treatment would minimize
the detrimental effect of hydrosalpinx. The method is advantageously
cheap and simple, but its benefit still needs to be evaluated in a
prospective trial.
Conclusion
In order to improve the chances of a full-term pregnancy in patients with
hydrosalpinges undergoing IVF, different surgical approaches have been
discussed. Salpingectomy is the only method that has been properly
evaluated and from the Scandinavian study a clear recommendation has
been formulated: Patients with hydrosalpinges large enough to be visible
on ultrasound examination can be recommended laparoscopic
salpingectomy prior to IVF in order to enhance their chance of a full term
pregnancy. Less invasive methods like tubal ligation and transvaginal
aspiration still awaits to be evaluated in a prospective well-designed trial.
References
Aboulghar,M.A., Mansour,R.T., Serour,G.I. et al. (1990) Transvaginal
ultrasonic needle guided aspiration of pelvic inflammatory cystic masses
before ovulation induction for in vitro fertilization. Fertil.Steril. 53, 311314.
Dar,P., Sachs,G.S., Strassburger,D., et al. (2000) Ovarian function before
and after salpingectomy in artificial reproductive technology patients.
Hum.Reprod., 15, 142-144.
Hurst,B.S., Tucker,K.E., Awoniyi,C.A., Schlaff,W.D. (2001)
Hydrosalpinx treated with extended doxycyclin does not compromise the
success of in vitro fertilization. Fertil.Steril., 75, 1017-1019.
Lass,A., Ellenbogen,A., Croucher,C., et al. (1998) Effect of
salpingectomy on ovarian response to superovulation in an in vitro
fertilization-embryo transfer program. Fertil.Steril., 70, 1035-1038.
13 Strandell
Sharara,F.I., Scott Jr,R.T., Marut,E.L. et al. (1996) In-vitro fertilization
outcome in women with hydrosalpinx. Hum.Reprod., 11, 526-530.
Sowter,M.C., Akande,V.A., Williams,J.A. et al. (1997) Is the outcome of
in-vitro fertilization and embryo transfer treatment improved by
spontaneous or surgical drainage of a hydrosalpinx? Hum.Reprod., 12,
2147-2150.
Stadtmauer,L.A., Riehl,R.M., Toma,S.K. et al. (2000) Cauterization of
hydrosalpinges before in vitro fertilization is an effective surgical
treatment associated with improved pregnancy rates.
Am.J.Obstet.Gynecol. 183, 367-371.
Strandell,A., Lindhard,A., Waldenstr‫צ‬m,U. et al. (1999) Hydrosalpinx
and IVF outcome: A prospective, randomized multicentre trial in
Scandinavia on salpingectomy prior to IVF. Hum.Reprod., 14, 27622769.
Strandell,A., Lindhard,A., Waldenstr‫צ‬m,U. et al. (2001) Salpingectomy
prior to IVF does not impair the ovarian response. Hum.Reprod., 16,
1135-1139.
Surrey,E.S., Schoolcraft,W.B. (2001) Laparoscopic management of
hydrosalpinges before in vitro fertilization-embryo transfer:
salpingectomy versus proximal tubal occlusion. Fertil.Steril., 75, 612617.
Van Voorhis,B.J., Sparks,A.E., Syrop,C.H. et al. (1998) Ultrasoundguided aspiration of hydrosalpinges is associated with improved
pregnancy and implantation rates after in-vitro fertilization cycles.
Hum.Reprod., 13, 736-739.
13 Strandell