Tubal factor infertility is a common indication for treatment using in vitro fertilization (IVF). While individuals with proximal (isthmic) tubal occlusion have excellent success rates using IVF, it has been shown in numerous studies that distal disease leading to a dilated hydrosalpinx has a deleterious effect on IVF outcome.
Exactly how the presence of a hydrosalpinx impacts IVF success rates is not well understood, but it has been proposed that the draining tubal fluid is toxic to the developing embryo, or to the endometrium by inhibiting the expression of substances that are important to implantation, or perhaps, the fluid results in mechanical flushing of the embryo from the uterus.
Although the mechanism is not well-established, current data clearly demonstrates a significant adverse impact of a dilated hydrosalpinx on pregnancy outcome in individuals undergoing IVF. Two separate meta-analyses each concluded that the presence of a hydrosalpinx reduces implantation, pregnancy and live birth rates by nearly 50% and increases the rate of early pregnancy losses.
Various treatment alternatives have been proposed, but there is insufficient data to reach a definitive conclusion about the optimal approach. One study demonstrated that antibiotic use in women with hydrosalpinges before and after embryo transfer resulted in outcomes that were equivalent to other groups of patients undergoing IVF.
This finding has not been confirmed by follow-up studies. Others have advocated aspiration of the hydrosalpinx fluid at the time of oocyte retrieval. There is conflicting data regarding the effectiveness of this technique as the fluid often reaccumulates within 2 days of the procedure. Several small case reports have documented successful pregnancies following hysteroscopic placement of a microinsert (EssureTM) to occlude the proximal Fallopian tube. Further studies with more patients are needed before this procedure can be advocated.
The mainstay of successful treatment of dilated hydrosalpinges, to improve IVF outcome, is through laparoscopic surgery. Possible surgical alternatives include distal neosalpingostomy, proximal tubal occlusion with cautery (tubal ligation) and salpingectomy. While neosalpingostomy will allow decompression and drainage of the hydrosalpinx, one study with approximately 30 patients reported a 70% recurrence of the hydrosalpinx postoperatively and a very poor ongoing pregnancy rate.
This method should probably be reserved for those patients who are opposed to more definitive surgical procedures that will eliminate the possibility of conception through means other than IVF. Although there is more data to support the efficacy of salpingectomy over tubal ligation, several studies have shown similar outcomes for these two techniques.
Proximal tubal occlusion has the advantage of being easier to perform than salpingectomy, especially in the presence of extensive pelvic adhesions. In addition, it is less likely to interfere with blood flow to the ovary, which could compromise the response to medication. Concerns with this approach relate primarily to the potential for pain or infection that might result from leaving a dilated tube in place that is blocked both proximally and distally. This has not been reported to be a significant complication of this procedure in published studies thus far.
In summary, individuals with hydrosalpinges represent a unique subgroup of patients undergoing assisted reproduction who might benefit from surgical intervention, prior to IVF. Counseling is critical to identify those couples that might wish to accept an approximately 50% lower pregnancy rate and two-fold higher rate of miscarriage in hopes of avoiding an invasive surgical procedure.