1 Shady Grove Fertility Reproductive Science Center, Rockville, MD, 2 Center for Womens Medicine, Division of Reproductive Endocrinology and Infertility, Greenville, SC and 3 Alta Bates IVF Program, Alta Bates Medical Center, Berkeley, CA, USA
4 To whom correspondence should be addressed at: Shady Grove Fertility Reproductive Science Center, 15001 Shady Grove Road, Suite 400, Rockville, MD 20850, USA. e-mail: ARTSAGOS{at}aol.com
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Abstract |
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Key words: hydrosalpinx/IVF/salpingectomy/tubal occlusion
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Introduction |
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Materials and methods |
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Results |
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Discussion |
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The treatment of unilateral and bilateral hydrosalpinx remains controversial. Even though intrauterine pregnancy rates remain low after neosalpingostomy (Rock et al., 1978), some investigators still feel that neosalpingostomy is indicated in a select subgroup of patients (Taylor et al., 2001
). Many studies have shown that patients with hydrosalpinges undergoing IVF without proximal ligation or salpingectomy of the affected tubes have a lower pregnancy rate compared with those without hydrosalpinges (Kassabji et al., 1994
; Strandell et al., 1994
, 1999
; Vandromme et al., 1995
; Akman et al., 1996
; Fleming and Hull, 1996
; Katz et al., 1996
; Blazar et al., 1997
; Murray et al., 1998
; Nackley and Muasher, 1998
; Zeyneloglu et al., 1998
; Camus et al., 1999
; Cohen et al., 1999
). Decreased implantation rates have also been reported in patients with hydrosalpinges demonstrated by sonography (Andersen et al., 1994
).
There are various ideas formulated to explain this negative effect of the hydrosalpinges. One theory suggests a mechanical effect of hydrosalpinx fluid mediated by reflux currents that may thrust embryos away from the implantation site, thus affecting pregnancy rates (Eytan et al., 2001). Most theories support the concept of a negative effect of the hydrosalpinx fluid on endometrial receptivity, supported by the observation of an impairment of endometrial
v
3 integrin expression in women with this disorder (Meyer et al., 1997
; Bildirici et al., 2001
). Still others have suggested a toxic effect of hydrosalpinx fluid on embryo quality, although not all studies agree (Sachdev et al., 1997
; Granot et al., 1998
; Koong et al., 1998
; Strandell et al., 1998
).
The present data clearly support surgical treatment of a unilateral hydrosalpinx, in selected infertile patients with a normal patent contralateral tube. Salpingectomy or proximal tubal occlusion may reverse the negative impact on implantation rates, presumably through the prevention of hydrosalpinx fluid efflux into the uterine cavity, thus avoiding adverse effects on endometrial receptivity. The overall increase in cycle fecundity in these patients treated with salpingectomy or tubal interruption suggests an alternative treatment to IVF, especially considering the short time to conception in natural cycles following the surgical treatment. Two studies (Murray et al., 1998; Surrey and Schoolcraft, 2001
) demonstrated similar increased pregnancy rates in patients undergoing salpingectomy or proximal tubal occlusion of hydrosalpinges prior to IVF, thus recommending either as treatment prior to IVF.
However, in this study there was a statistically significant shorter time to achieve pregnancy in the salpingectomy group compared with the proximal tubal ligation group. This observation among patients attempting spontaneous pregnancy raises the question as to whether the residual non-communicating hydrosalpinx in those patients who underwent proximal tubal occlusion continues to allow a hostile environment, increasing the time to pregnancy. The sequelae of occluding a tube (as opposed to resection) were not examined. However, removal of a large hydrosalpinx, when possible, may avoid the need for further surgery for such reasons as pelvic pain. It should be noted that normal tubal anatomy and fimbria on the remaining contralateral tube is probably an important prognostic factor in the overall success that we observed and should be considered at the time of laparoscopy.
The findings in the present study demonstrated that 88% of patients achieved a spontaneous pregnancy in an average of 5.6 months after surgery. It has been reported that non-IVF pregnancy rates in patients with a unilateral hydrosalpinx treated with neosalpingostomy were higher than in patients with bilateral hydrosalpinges treated with neosalpingostomy (Dlugi et al., 1994; McComb and Taylor, 2001
). The McComb study also suggests that the difference in pregnancy rates is probably secondary to the removal of the detrimental effect of the hydrosalpinx fluid. An ectopic pregnancy rate of 5.3% was reported in the Dlugi study and 4% in the McComb study, whereas no ectopic pregnancies were noted in our series. In fact, ectopic pregnancy rates have been reported to be higher in patients undergoing IVF who have had previous distal tubal surgery (Zouves et al., 1991
).
In conclusion, selected patients with a unilateral hydrosalpinx and a normal patent contralateral Fallopian tube may increase their fecundity after salpingectomy or proximal tubal occlusion of the affected tube, without the need for IVF. It appears, though, that salpingectomy is more effective in achieving a spontaneous pregnancy sooner. Unilateral salpingectomy or proximal tubal occlusion may be a better option than attempted neosalpingostomy since the latter choice has an associated increased risk for ectopic pregnancy or re-occlusion of the treated tube. The apparent increase in spontaneous conception following unilateral surgery is a compelling reason to consider this as the first option prior to attempting IVF. Given the relatively limited size of this select patient population and the strength of the observed trends, randomization of patients to a prospective trial, while always ideal, may present practical and perhaps even ethical concerns.
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References |
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Submitted on July 9, 2003; accepted on September 15, 2003.