A. Strandell and L. Hamberger
Department of Obstetrics and Gynecology
Sahlgrenska University Hospital, Göteborg, Sweden
Several retrospective studies have shown an impaired outcome of IVF in the presence of hydrosalpinx. The main theories trying to explain the underlying mechanisms have focused on potential embryo toxic properties of the fluid or impaired endometrial receptivity to implantation. Salpingectomy has been suggested as the most radical treatment and other options like salpingostomy and transvaginal aspiration of the fluid from the hydrosalpinx have also been discussed. In a recently performed randomized controlled trial in Scandinavia, salpingectomy was tested and found to be of benefit in patients with hydrosalpinges large enough to be visible on ultrasound.
Since 1994 there has been a large number of retrospective studies dedicated to the effect of hydrosalpinges on pregnancy results in IVF, most of them showing an impaired outcome. The retrospective data have been compiled and presented in meta-analyses, demonstrating a reduction by half in the probability of achieving a pregnancy in the presence of hydrosalpinx and an almost doubled rate of spontaneous abortion (1). Several mouse studies have suggested an embryo toxic effect of the hydrosalpingeal fluid (2), which is not supported in studies on human embryos (3). 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. Treatment with salpingectomy has been suggested and has entered into clinical practice without proper evidence for its benefit. Concerns have also been raised about the potential hazard to ovarian circulation and function, the surgical intervention could implement. A randomized controlled trial on salpingectomy prior to IVF has now been conducted as a multi-center study in Scandinavia. The results of first cycle are completed (4) while results from cumulative cycles are still preliminary.
Material and Methods
Nine IVF centers in Sweden, Denmark, Norway and Iceland recruited 204 patients with uni- or bilateral hydrosalpinges prior to their first IVF cycle. They were randomized to laparoscopic salpingectomy or no intervention before IVF in a ratio 3:2. Twelve patients did not start any IVF treatment. Ovarian stimulation was conducted according to similar long protocols. ICSI was performed in 13% in each group. Eight patients did not reach transfer, yielding a total withdrawal rate of 9.8%. Two embryos were routinely transferred. A total of 185 transfer cycles from first treatment and 432 transfer cycles on a cumulative basis were available for analysis.
If all transfer cycles performed so far are included, calculated on a cumulative basis per patient, salpingectomy implied a 1.7-fold increase in delivery rate (95% CI 0.97-3.0). Within the subgroup of patients with bilateral hydrosalpinges, the delivery rate was more than doubled (OR 2.2, 95% CI 0.95-5.0) and in patients with ultrasound visible hydrosalpinges more than three times higher (OR 3.5, 95% CI 1.4-8.8). The combined subgroup of patients with bilateral hydrosalpinges visible on ultrasound expressed an 8-fold increase in delivery rate (OR 8.1, 95% CI 2.0-33.3).
The correlation between the presence of hydrosalpinx and poor IVF outcome is supported by the overwhelming consistency in the retrospective studies and confirmed by the prospective study in which patients subjected to salpingectomy expressed higher pregnancy rates. A clearly defined subgroup of patients with large enough hydrosalpinges to be visible on ultrasound showed significantly higher pregnancy and delivery rates after salpingectomy compared with patients without any surgical intervention. The result support the theory of hydrosalpingeal fluid causing alterations in the endometrial environment resulting in impaired implantation. Prophylactic salpingectomy prior to IVF can be recommended to women with ultrasound visible hydrosalpinges, but a general recommendation to all women with hydrosalpinx is not justified. References
1. Zeyneloglu, H.B., Arici, A. Olive, D.L. Adverse effects of hydrosalpinx on pregnancy rates after in vitro fertilization-embryo transfer. Fertil.Steril., 70, 492-499, 1998.
2. Mukherjee, T., Copperman, A.B., McCaffrey, C., et al. Hydrosalpinx fluid has embryotoxic effects on murine embryogenesis: a case for prophylactic salpingectomy. Fertil. Steril., 66, 851-853, 1996.
3. Strandell, A., Sjögren, A., Bentin-Ley, U., et al. Hydrosalpinx fluid does not adversely affect the normal development of human embryos and implantation in vitro. Hum.Reprod., 13, 2921-2925, 1998.
4. Strandell, A., Lindhard, A., Waldenström, U., et al. Hydrosalpinx and IVF outcome: A prospective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF. Hum.Reprod. In press, 1999.