What is new in the management of
hydrosalpinx in IVF?
B. Hédon, A. Torre
Department of Obstetrics and Gynaecology Reproduc?ve Medicine Unit
Montpellier University Medical School (France)
[email protected]
What we know
• Impaired implanta?on rate in tubal infer?lity pa?ents compared to other types of infer?lity
• Impaired pregnancy rate and delivery rate
• Increased ectopic pregnancy rate
• Special issue with hydrosalpinges
Influence of hydrosalpinges on implantation rates of embryos
Author Methodology Pa0ents included Diagnosis of hydrosalpinx Pa0ents with hydrosalpinx Significant finding
Larry I et al, 1999 Retrospec?ve 1000 with tubal infer?lity Baseline ultrasound tubal collec?on at all IVF cycle
60 Implanta?on rate: 16% vs
21%
Preclinical pregnancy los : 37%
vs 14%
Ectopic pregnancy: 8% vs 3%
Cohen MA et al, 1999 Retrospec?ve 110 involved in oocytes dona?on program
Ultrasond or Salpingography 10 oocytes recipiants
Implanta?on rate: 7.1% vs 19.3%
Miscarriage: 75% vs 14.9%
Ectopic pregnancy: 33.3% vs 0%
Murray DL et al. 1998 Retrospec?ve 160 aged under 39 Salpingography or surgery 26 Implanta?on rate: 2.8% vs
15.7%
Pregnancy rate: 8.5% vs 38.6%
De Wit W et al. 1998 Cohort 550 with tubal pathologies Ultrasound 124 Implanta?on rate : OR 0.43
(0.26–0.73)
Clinical pregnancy rate: OR 0.42 (0.23–0.76)
Ongoing implanta?on rates:
0.42 (0.20–0.85)
Hydrosalpinx/no hydrosalpinx
Camus E. et al.
“Big” hydrosalpinges
De Wit W et al. 1998
Mechanisms by which hydrosalpinges
can impair implantation rates of embryos
• Flushing effect of the endometrial cavity
• Inflammatory cells
First studies: Dechaud et al. (1998)
• 60 pa?ents with severe tubal factor (salpingography and laparoscopy), randomized before IVF:
• Laparoscopic tubal abla?on
• No interven?on
• Implanta?on rate 10.4% vs 4.6%
• Ongoing pregnancy rate per transfer: 34.2% vs 18.7%
• Probability of becoming
pregnant: 75% vs 63%
Strandell et al.
• 204 pa?ents with hydrosalpinx (all kind), randomized before IVF:
• Laparoscopic abla?on
• No interven?on
• Global results
• Clinical pregnancy rates: 36.6% vs 23.9%, p=0.067
• Ensuing delivery rates: 28.6% vs 16.3%, p=0.045
• Delivery rates per transfer: 29.5% vs 17.5%, p=0.083
• In bilateral ultrasound hydrosalpinx
• implanta?on rate 25.6% vs 12.3%, p=0.038
• Clinical pregnancy rates: 45.7% vs 22.5%, p=0.029
• Delivery rate: 40.0% vs 17.5%, p=0.038
• 5 randomised controlled trials, on 646 women
• All kind on hydrosalpinx
• Salpingectomy vs nothing
• Ongoing pregnancy: OR 2.14, 95%CI 1.23-‐3.73
• Clinical pregnancy: OR 2.31, 95%CI 1.48-‐3.62
• Tubal occlusion vs nothing
• Clinical pregnancy: OR 4.66, 95%CI 2.47-‐10.01
• Tubal occlusion vs
salpingectomy : NS
Salpingectomy
+ -‐
o Clinically demonstrated as being efficient
o Suppresses poten?el contaminated structures o Decreases risk of ectopic pregnancy
o Unilateral hydrosalpinx++++++
o Needs thorough explana?ons o IVF becomes the only possibility
Alternatives to salpingectomy (1)
• An?bio?c administra?on
Hurst B. et al.+ -‐
o Easy o Cheap
o No randomized trial
Alternatives to salpingectomy (2)
• Aspira?on of hydrosalpinx
Fouda U.+ -‐
o Done during follicular aspira?on o Treats the bigger hydrosalpinges
o Fluid re-‐accumulates in few hours o Ignores the small hydrosalpinges
o Poten?al follicular fluid contamina?on o No randomized trial
Alternatives to salpingectomy (3)
• Drainage of hydrosalpinx (salpingostomy)
+ -‐
o Psychologically beher accepted
o If tube sufficiently healthy, can allow spontaneous pregnancy
o Increases the overall cumula?ve pregnancy rate
o Favors subsequent pregnancies
o Re-‐occlusion of the tubes o Ectopic pregnancy
o No randomized trial
Criteria for tubal repair : -‐ Thin adhesions
-‐ No mucosal synechiae -‐ Thin wall
Alternatives to salpingectomy (4)
• Proximal occlusion (clip)
+ -‐
o Interrupts the flow of fluid o Easy procedure
o Leaves the inflammatory structure o No randomized trial
Alternatives to salpingectomy (5)
• Proximal occlusion (Essure)
+ -‐
o Interrupts the flow of fluid o Easy ambulatory procedure o No general anesthesia
o Device
o Inflammatory tubes
Tubal infer?lity
Laparoscopy
Favorable tubal prognosis Unfavorable tubal prognosis
Salpingostomy
No pregnancy Spontaneous pregnancy
Re-‐occlusion No re-‐occlusion
IVF
Salpingectomy feasible Salpingectomy Not feasible
Salpingectomy
An?bioprohylaxis Aspira?on
Clip Essure Uncertain prognosis
