Management of patient with Hydrosalpinx undergoes IVF

1. IVF & Hydrosalpinx
DR/ Ahmed Walid Anwar Morad
Professor of OB/GYN
Faculty of Medicine
Benha University
2023

2.  Definition
 Pathophysiology
 Etiology
 Diagnosis
 Strategies of tubal factor infertile
 IVF & Hydrosalpinx
 Take Home Message
 References

4. Definition
 Fluid-filled distension of the fallopian tube
may be:
Fluid content
Pathology
Watery fluid
1. Hydrosalpinx
Pus
2. Pyosalpinx
Blood
3. Haematosalpinx

5. Pathogenesis
 Obstruction of tubal drainage  accumulation of secretions
within the tube  Fluid-filled dilatation of FT.
 Tubal Occlusion may :
Degree
Laterality
Involve
Complete
Bilateral
Distal end
Common
Partial (Tubal
phimosis)
Unilateral
Both ends
Less
common

6. Etiology
1) PID: Commonest
• Hydrosalpinx is the end result of a tubal infection with the closure
of the fimbriae, resulting in a watery collection inside the tube.
• Chlamydia trachomatis is a common cause/ Gonorrhea/ TB
2) Other causes:
 Tubal ligation
 Endometriosis
 Tubal malignancy
 Ovulation induction
 Post-hysterectomy (without salpingo-oophorectomy)

8. Clinical Presentation:
 History suggestive of; ( PID, Endometriosis, pelvic surgery)
 Asymptomatic: Accidently discovered during infertility work up
 Symptomatic:
 Infertility
 Pelvic pain: worse during or right after your menstruation.
 Abnormal Vaginal Discharge: Sticky or stained
 Menstrual irregularities ?
 Urinary symptoms?

9.  Diagnosis:
HSG: Sensitivity 65% and specificity 85%
• Retort-like shape of the distended tubes
• Absence of free spillage

10.  Diagnosis:
TVS: Hydrosalpinx: Sensitivity 84% and specificity 99%
 Tubular anechoic fusiform structure (C or S shaped) separated
from ovary and uterus
 Wall : (hyper-echogenic) Well-defined, thin ; may be thick.
 Longitudinal Section:
• Incomplete septation  “Beads on a string sign"
• “Waist” sign: refers to diametrically opposed indentations in the
wall of the cystic lesion.
 Cross section: Longitudinal folds become thick and give a
“Cogwheel” appearance

12.  Diagnosis:
 Hystero-Contrast-Salpingogram (HyCoSy)
 CT: A fluid-attenuation tubular adnexal structure, separate from the ovary.
 MRI: if adnexal mass is inadequately evaluated with ultrasound.
 A dilated fallopian tube between the uterus and ovary with fluid signal
intensity.
 Incomplete septa + eroded mucosal plicae + the tube wall is uniformly
smooth and thin.
 Laparoscopy:
a) Distended tubes b) Associated adhesions affecting the pelvic
organs

15. Hydrosalpinx and Infertility
 Incidence:
How can hydrosalpinx cause infertility?
 Tubal obstruction: Physical blockage of sperm meeting ovum.
 Hydrosalpinx fluid:
1) Mechanical effects:
• Wash-out of embryos through leakage of fluid through uterine cavity
2) Embryo toxic effects : embryotoxic components , growth inhibiting
factors.
Hydrosalpinx
Tubal factors
10-30% of tubal factor of infertility
25-35% of female infertility

16. Treatment of hydrosalpinx associated
infertility

18. IVF & Hydrosalpinx
IVF is still the treatment of choice for infertile women with
hydrosalpinx.
IVF in patients with hydrosalpinx has poor outcome compared to
other types of tubal infertility as it is associated with:
•  Implantation, Pregnancy , Live birth rates : to half
• Miscarriage rate: doubled
 IVF and endoscopic surgery must be thought as
complementary rather than competing techniques in tubal
diseases to improve fertility outcome

20. IVF with hydrosalpinx: Management
Options
 If hydrosalpinx
1. Accessible Laparoscopic
Salpingectomy
2. Inaccessible Tubal
occlusion
 Alternative: TVUS
aspiration ±
Sclerotherapy
1. Transvaginal aspiration of
hydrosalpingeal fluid at the
time of oocyte retrieval.
2. Freeze all embryos, +
surgery for hydrosalpinx and
then freeze ET.
Before starting IVF
During ovarian
stimulation:
Aim: eliminate the detrimental effect of the hydro-salpingeal fluid
before IVF-ET

21. 1- Laparoscopic salpingectomy
 When to be considered:
1. Ultrasound‐visible hydrosalpinges
2. Hydrosalpinx is accessible
 PROS:
 Natural fertility: positive effect on natural pregnancy after unilateral
salpingectomy when the contralateral tube is healthy
 IVF: Doubled clinical, ongoing pregnancy and live birth rate compared with
those who did not have any surgery before IVF
 Ovarian response to COS after salpingectomy: not significantly impaired
 CONS:
1. Carries a potential risk of damaging vascular and nervous supply to the ovary
2. Ovarian reserve: the impact was dependent on the indication for salpingectomy
(Less in case of ectopic pregnancy)

22. 1- Laparoscopic salpingectomy
 Advantages:
1. Removes the chronically infected hydrosalpinx,
2. Decreasing the risk of infection after oocyte retrieval
3. Increasing the accessibility to the ovary
NB:
A salpingotomy can be considered if the mucosa is healthy and the
patient is young enough to await natural pregnancy.

23. 2- Tubal occlusion
 Definition: Permanent blocking of the proximal part of the tube + Dilated part
remains in place ± Sclerotherapy of dilated part (not tested in RCTs)
 Indications:
1. Severe adhesions make salpingectomy technically difficult
2. If there is a risk of damaging the ovary.
 Routes:
1. Laparoscopy: A Cochrane review included two small RCTs of showed a
benefit in clinical pregnancy rate compared with no intervention
2. Hysteroscopy (if laparoscopy is risky or contraindicated):
 Essure device: RCT has demonstrated inferior pregnancy outcomes
compared with salpingectomy
 Micro inserts and diathermy: not evaluated in RCTs

24. 3- Transvaginal US aspiration of the hydrosalpingeal
fluid
a- At the time of oocyte retrieval:
• A meta‐analysis of three randomized trial shows: increased clinical
pregnancy rates compared with no intervention .
• However, one trial comparing aspiration with salpingectomy suggested that
aspiration may be inferior
b- An option during ovarian stimulation:
• If fluid develops and hydrosalpinx becomes visible on the ultrasound scan.
NB:
 Drawbacks: Recurrence  Sclerotherapy is suggested but no
difference in the rate of recurrence

25. N.B: Sclerotherapy before IVF
 Method: TVUS guided aspiration of hydrosalpingeal fluid then injection of
Sclerosing agent
 Aim: decrease recurrence rate
 Effect: effective and less invasive prophylactic intervention alternative to
salpingectomy with hydrosalpinx. (Clin Exp Reprod Med. 2012 Dec; 39(4): 182–186)

26. Take Home Message

27. Take Home Message
 Hydrosalpinx represents 10-30% of tubal factor of infertility.
 IVF is still the treatment of choice for infertile women with
hydrosalpinx.
 IVF in patients with hydrosalpinx has poor outcome compared
to other types of tubal infertility
 IVF and endoscopic surgery must be thought as
complementary rather than competing techniques in tubal
diseases to improve fertility outcome

28. Take Home Message
 Among the three suggested surgical procedures ;
Laparoscopic salpingectomy is still the best
evidence‐based intervention to improve pregnancy rates,
but tubal occlusion and aspiration of hydrosalpingeal fluid also
have their places among therapeutic options.


29. References
1 Zeyneloglu HB, Arici A, Olive DL. Adverse effects of hydrosalpinx on pregnancy rates after in vitro
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2 Savaris RF, Giudice LC. 2007; The influence of hydrosalpinx on markers of endometrial receptivity. Semin
Reprod Med.
3 Strandell A, Lindhard A, Waldenström U, Thorburn J, Janson PO, Hamberger L. Hydrosalpinx and IVF outcome:
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9 Dreyer K, Lier MC, Emanuel MH, Twisk LW, Mol BW, Schats R, Hompes PG, Mijatovic V. Hysteroscopic
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10 Fouda UM, Sayed AM, Abdelmoty HI, Elsetohy KA. Ultrasound guided aspiration of hydrosalpinx fluid versus