This document discusses IVF and hydrosalpinx. It defines hydrosalpinx as a fluid-filled distension of the fallopian tube that is most commonly caused by pelvic inflammatory disease. The presence of hydrosalpinx is associated with lower IVF success rates compared to other causes of tubal infertility due to mechanical and toxic effects on embryos. Surgical treatment of hydrosalpinx prior to IVF through laparoscopic salpingectomy, tubal occlusion, or transvaginal aspiration of fluid can help improve IVF outcomes by eliminating the detrimental effects of hydrosalpingeal fluid. Among the options, laparoscopic salpingectomy provides the strongest evidence for improving pregnancy

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
fertilization‐embryo transfer. Fertil Steril. 1998;70:492–9.
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:
a prospective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF. Hum Reprod.
1999;14:2762–9.
4 Melo P, Georgiou EX, Johnson N, van Voorst S, Sowter MC, Strandell A, Mol BWJ, Becker C, Granne IE.
Surgical treatment for tubal disease in women due to undergo in vitro fertilisation. Cochrane Database of
Systematic Reviews 2019, Issue 12. Art. No.: CD002125. DOI: 10.1002/14651858.CD002125.pub4.
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laparoscopic management of hydrosalpinx: a systematic review and meta‐analysis. Fertil Steril. 2017;108:84–95.
6 Kotlyar A, Gingold J, Shue S, Falcone T. The effect of salpingectomy on ovarian function. J Minim Invas
Gynecol. 2017;24:563–78.
7 Yu X, Cai H, Zheng X, Feng J, Guan J. Tubal restorative surgery for hydrosalpinges in women due to in vitro
fertilization. Arch Gynecol Obstet. 2018;297:1169–73.
8 Mijatovic V, Veersema S, Emanuel MH, Schats R, Hompes PGA. Essure hysteroscopic tubal occlusion device
for the treatment of hydrosalpinx prior to in vitro fertilization‐embryo transfer in patients with a contraindication for
laparoscopy. Fertil Steril. 2010;93:1338–42.
9 Dreyer K, Lier MC, Emanuel MH, Twisk LW, Mol BW, Schats R, Hompes PG, Mijatovic V. Hysteroscopic
proximal tubal occlusion versus laparoscopic salpingectomy as a treatment for hydrosalpinges prior to IVF or ICSI:
an RCT. Hum Reprod. 2016;31:2005–16.
10 Fouda UM, Sayed AM, Abdelmoty HI, Elsetohy KA. Ultrasound guided aspiration of hydrosalpinx fluid versus