Why should hydrosalpinx be repaired before IVF?

When the fimbria of the fallopian tubes become damaged, it may result in a tube that is blocked at the very distal end; the part farthest away from the uterus. If the tube then becomes filled with fluid, it is called a hydrosalpinx (“hydro” refers to water; “salpinx” refers to the fallopian tube itself). Women who have a hydrosalpinx should have their fallopian tubes either removed or cut prior to undergoing IVF. The surgery usually involves a simple outpatient procedure called laparoscopy. The tubes are cut or removed so that the tubal fluid, which would be toxic to an embryo or adversely affect the receptivity of the endometrial lining, does not flow backward into the uterine cavity, preventing implantation of the embryo.

It is now well recognized that women with an untreated hydrosalpinx have a substantially reduced chance for pregnancy with IVF. In addition, an untreated hydrosalpinx may increase the chance that a woman will experience a spontaneous abortion or miscarriage. For all these reasons, treating a hydrosalpinx should both increase the IVF pregnancy rate and decrease the chances for an early pregnancy loss. A patient with a single normal fallopian tube and a hydrosalpinx will also have a higher chance of achieving a spontaneous pregnancy after removal or ligation of the damaged tube. A hydrosalpinx, if present, is usually identified during the infertility diagnostic evaluation with a Hysterosalpingogram (HSG). This simple x-ray study should be performed in all infertile women unless a diagnostic laparoscopy has already been performed. Preoperatively, we advise all patients that we recommend removal or ligation of her tube(s) if a hydrosalpinx is discovered at laparoscopy.

Hydrosalpinx, Infertility and IVF

A hydrosalpinx is a blockage of the far end of a woman’s fallopian tube which results in the accumulation of fluid within the tube. The condition can affect one or both fallopian tubes. Often the affected area can become substantially swollen and grow even as big as a few centimeters in diameter.

Usually, there are few symptoms noticed by patients although some women may suffer from abdominal or pelvic pain. The most common mean by which a woman becomes aware that she has this problem is the development of infertility. Women, who are not trying to get pregnant and have no pain, may go undiagnosed.

Hydrosalpinx Impact on Fertility

As mentioned previously, the main presentation of a hydrosalpinx is infertility. The fallopian tube plays a crucial role in establishing a pregnancy. As sperm enter the vagina, they travel through the opening of the uterus (cervix), through the uterus, and into the fallopian tubes. If intercourse happens at the time of ovulation, then an egg may be present in one of the fallopian tubes. A sperm can fertilize the egg forming an embryo. Afterwards, the embryo migrates down the fallopian tube into the uterus. If the embryo implants into the uterus, a pregnancy has been established.

However, if this tube is blocked, the egg cannot be captured by the fallopian tube and the egg and sperm are prevented from meeting. Thus fertilization cannot occur and pregnancy is prevented. In addition, when women have one tube which is open, their chances for pregnancy are reduced if they have a hydrosalpinx on the other tube.

Probable Reasons for a lesser Success

There are various theories that try and explain why the success rates in these patients are so much lower. One suggests that the flow of fluid into the uterus could interfere with and hinder implantation of an embryo. This fluid could contain lower levels of proteins, various amounts of debris, and other toxic substances found in the body that are harmful to the embryo itself or possibly the lining of the uterus. Another theory states that the fluid is a mechanical flush for the uterus, sweeping away the embryo. It is not known whether these effects would be worse if both fallopian tubes are affected, although that is thought to be the case.

Hydrosalpinx also impacts the Success of IVF

In vitro fertilization bypasses fallopian tube blockage by extracting the eggs directly from the ovary and fertilizing them in the laboratory. The embryos are then placed directly into the uterus. Thus, the fallopian tubes are completely bypassed. With the growing success of IVF and other fertility treatments in the past years, many women suffering from a hydrosalpinx are turning to these treatments to enhance their chances of pregnancy. However, there is substantial evidence to suggest that the success of in vitro fertilization is significantly lower for women with hydrosalpinx compared to other causes of infertility.

·         The overall pregnancy rate was shown to decrease in the women with the hydrosalpinx. The women with no blockage had a pregnancy rate of high compared to the women with the hydrosalpinx.

·         The implantation rate, which looks at how many transferred embryos were able to implant in the uterine wall, also decreased in the women with a hydrosalpinx.

·         The delivery rate decreased drastically as well. Almost twice as many women delivered without a hydrosalpinx higher than with a hydrosalpinx.

·         The delivery rate was lower in part because less women became pregnant but also because more of the women miscarried. Early loss in pregnancy was seen more often in the women affected than not.

Generally, for a woman with hydrosalpinx trying IVF, the chances for pregnancy are greatly reduced compared to the average infertile woman. While the possibility for pregnancy still exists in these patients, these women should be counseled that their chances for live birth are significantly lower if they have a hydrosalpinx.

Treatment Options for Hydrosalpinx to improve Fertility

Salpingectomy

The complete surgical removal of a fallopian tube is called a salpingectomy. The procedure can be done laparoscopically or with a standard surgery performed by making a horizontal incision in the abdomen just above the pubic hair line. Both procedures are performed under general anesthesia so that the patient is completely asleep.

Laparoscopy is a minimally invasive way of performing surgery. An small fiber optic telescope is inserted in a small incision just below the navel. This allows the reproductive surgeon to see into the abdomen and pelvis. Two additional incisions of about one centimeter each are made above the pubic hair line. Through these small incisions, instruments can be placed that allow the reproductive surgeon to detach the tube from the uterus and blood vessels and to remove it from the abdomen. Laparoscopy is the preferred method for performing a salpingectomy since no overnight hospitalization is required and the smaller incisions are associated with a shorter recovery time.

Tubal Ligation

Tubal ligation is when the fallopian tubes are either severed or pinched shut, but not removed. It is often referred to as getting one’s “tubes tied.” This can also be done laparoscopically, abdominally, or even vaginally. The most common way to seal the tubes is by using a cauterizing clamp which when applied to the outside of the tube, will seal it shut. Other methods include placing strong, tight rings or rubber bands around the tube that pinch them closed. Theoretically, by blocking the fluid from entering the uterine cavity, this may restore a normal chance for achieving pregnancy. The most common use of tubal ligation is as a permanent form of birth control. It is generally not considered to be reversible.

Hydrosalpinges, is surgery to remove it better than just ligating it?

·         Removing the hydros by cutting them off and taking them out of the body

·         Ligating or clipping them prior to IVF

·         Opening the end of the tube and leaving them in place (not usually recommended)

We know that on the average success is higher after surgically "fixing the hydros" However, it is not clear whether surgery to remove the tube vs. clipping or burning it close to the uterus and leaving the hydro in place is any different.

·         There is some concern that removal of the tube could have a negative impact on the blood supply to the ovary. This might result in reduced ovarian response to the IVF medications.

·         A reduced response to stimulation means fewer eggs to work with and a lower chance for pregnancy. The number of eggs retrieved correlates with the chance for IVF success.

How much higher is IVF success after hydro surgery?

The improvement in IVF success rates in studies is substantial but not huge. Some studies suggest that a woman under 35 might have a 35% success rate without surgery and a 50% success rate after having hydros removed. IVF success rates are very clinic-dependent. Therefore, decision making about treating hydros is not a clear-cut "black and white" situation. It is a grey area - and fertility doctors don't all agree about how to treat women with hydros.

·         Some doctors say you need to have surgery because it improves the chance for success

·         Some prefer not do surgery, and go to IVF - and if the first cycle fails, then think about whether to do surgery before the next IVF attempt.

·         Some doctors’ say it should be whatever the woman wants - have the surgery to fix the hydros, or don't have the surgery and accept a lower chance for success.

·         At our clinic we discuss surgery as an option and educate patients so that they can decide whether they want surgery first - or to go straight to IVF.

What causes hydrosalpinx?

Hydrosalpinx is often caused by tubal infection such as pelvic inflammatory disease (PID). The infection causes the tubes to become inflamed. After healing is finished the tubes are often blocked with residual fluid inside. Continued fluid buildup over time dilates the tube more resulting in hydrosalpinges of various sizes.