Salpingectomy for hydrosalpinx prior to in vitro fertilization

Salpingectomy for hydrosalpinx prior to in vitrofertilization Practice Committee of the American Society for Reproductive Medicine in collaboration with TheSociety of Reproductive Surgeons The American Society for Reproductive Medicine, Birmingham, Alabama Salpingectomy for hydrosalpinges before in vitro fertilization increases the success rate. (Fertil SterilÒ2008;90:S66–8. Ó2008 by American Society for Reproductive Medicine.) In vitro fertilization (IVF) generally is accepted as the treat- dence interval [CI], 41.4–62.2) The effect was observed ment of choice for women with distal tubal occlusive disease in both fresh and frozen embryo transfer cycles. The likeli- who wish to conceive; the role of tubal reconstructive surgery hood of miscarriage also was 2.3-fold (95% CI, 1.6–3.5) is quite limited. Whereas surgery still may be considered for higher among women with hydrosalpinges. The likelihood selected young women (<age 35 years) with mild tubal dis- of ectopic pregnancy could not be evaluated precisely even ease and no other coexisting infertility factors and for those in this data set, suggesting a small, if any, effect on ectopic who reject or have no practical access to IVF, the outcomes rates. A second meta-analysis included nine published studies achieved with surgery otherwise are almost uniformly poor and five abstracts involving 5592 women, including many of Evidence indicates that the presence of hydrosalpinges the same studies used in the first meta-analysis Delivery adversely affects results achieved with IVF, decreasing live rates per cycle start were 13.4% in 1418 cycles with hydrosal- birth rates by approximately 50% Whether these ad- pinx and 23.4% in 6735 cycles without hydrosalpinx (OR verse effects are common to all hydrosalpinges or may be limited to those that are larger and thus visible with transva-ginal ultrasonography remains uncertain Treatment ofhydrosalpinges by salpingectomy or by proximal tubal occlu- sion improves results achieved with subsequent IVF. The pur- The effect of interrupting proximal tubal patency or salpin- pose of this document is to review these data and the gectomy on the outcomes achieved with subsequent IVF pathophysiologic mechanisms that may explain the observa- has been assessed in three randomized controlled trials (RCTs). One was a pilot study that included 60 patientswith hydrosalpinges or proximal tubal disease related to sal-pingitis isthmica nodosa who underwent laparoscopy; 30 women were treated by salpingectomy, and, in the remaining A number of mechanisms have been proposed to explain the 30, the tubes were left intact. Unfortunately, the results for adverse effects of hydrosalpinges on the live birth rate patients with proximal occlusion do not address the primary achieved with IVF. These include a direct embryotoxic effect question and reduce the power of the already small study. The a decrease in endometrial receptivity, and the possibility pregnancy rates per cycle were 23.7% (14 of 59) after salpin- that tubal fluid may mechanically flush the embryo from the gectomy and 16.3% (8 of 49) without salpingectomy; the on- going pregnancy rates per embryo transfer were 34.2% (13 of38) after salpingectomy and 18.7% (6 of 32) without salpin- Several early reports indicated that the presence of unilateral In a trial involving 204 patients with hydrosalpinges, the or bilateral hydrosalpinges adversely affects implantation and delivery rates were 28.6% in the 116 patients randomized pregnancy rates achieved with IVF. Outcomes have been sum- to salpingectomy before IVF and 16.3% in the 88 who did marized in two meta-analyses. The first included over 6700 not receive preliminary surgical treatment (P¼.045) . In treatment cycles from 11 studies, four of which were pub- a subgroup analysis limited to patients having hydrosalpinges lished only as abstracts. The pregnancy rate observed among that were visible with ultrasonography, the corresponding women with hydrosalpinges (165 pregnancies/1004 cycles; delivery rates with and without preliminary salpingectomy 16.4%) was 49% lower than that observed in women with were 40.0% and 17.5%, respectively (P¼.038).
tubal factor infertility without hydrosalpinges (1478 pregnan- A third RCT involving 115 patients compared the results cies/4736 cycles; 31.2%) (odds ratio [OR] 50.7; 95% confi- observed after laparoscopic salpingectomy or proximal tubalocclusion with those in control women who received no sur- gical treatment The ongoing pregnancy rates after the Revised August 2008.
No reprints will be available.
first embryo transfer were 37.8% with 45 transfers after Fertility and Sterilityâ Vol. 90, Suppl 3, November 2008 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc.
salpingectomy, 48.9% with 47 transfers after proximal tubal residing within the uterine cavity may exert a contraceptive occlusion, and 7.1% after 14 transfers in control patients.
effect similar to that of an intrauterine device. A small Both procedures produced statistically significantly better observational study found that eight of 17 patients (47%) results than no surgical intervention, and the outcomes with hydrosalpinges who were treated with doxycycline for achieved with the two surgical treatments were not materially 1 week before and after oocyte retrieval achieved a live birth, different (P¼.20) Whether proximal tubal occlusion may compared with 11 of 25 (44%) patients with proximal tubal induce expansion of hydrosalpinges that may require later occlusion or pelvic adhesions and 12 of /22 (55%) women and more extensive surgical treatment is unknown.
with endometriosis or unexplained infertility who receivedno such treatment . At least in theory, neosalpingostomy Based on results from the three trials, the ongoing may effectively negate the adverse effect of hydrosalpinges pregnancy rate after laparoscopic salpingectomy or tubal on IVF outcomes while also permitting the possibility of occlusion (34%) is twofold higher than in controls (17%) natural conception, but no clinical studies have examined ). The 17% rate difference implies that for every six (95% CI, 3–9) women with hydrosalpinges, one more ongo-ing pregnancy will be achieved if salpingectomy or tubalocclusion is performed before IVF.
1. The live birth rate achieved with IVF among women with hydrosalpinges is approximately one half thatobserved in women without hydrosalpinges.
Options other than salpingectomy or proximal tubal occlu- 2. In women with hydrosalpinges, preliminary laparo- sion have not been adequately evaluated in RCTs. Transvagi- scopic salpingectomy or proximal tubal occlusion nal aspiration of the hydrosalpinges during oocyte retrieval improves subsequent pregnancy and live birth rates was unsuccessful in one study and possibly helpful in an- achieved with IVF. For every six women with hydrosal- other . Another RCT observed that clinical pregnancy pinges, one more ongoing pregnancy will be achieved if rates were 31.3% (10 of 32) after aspiration and 17.6% (6 salpingectomy or tubal occlusion is performed before of 34) without (RR ¼ 1.8; 95% CI, 0.8–4.3; P¼.2) Two reports have described three women with hydrosal- 3. Data are insufficient to permit recommendations pinges who conceived via IVF after hysteroscopic placement regarding the effectiveness of alternative treatments of the Essureâ (Conceptus, Mountain View, CA) microinsert such as laparoscopic neosalpingostomy, transvaginal device A small case series found that bilateral place- aspiration of hydrosalpingeal fluid, hysteroscopic tubal ment of the Essureâ device could be accomplished only in two of five patients with hydrosalpinges; neither of the twowomen who subsequently underwent IVF conceived Acknowledgments: This report was developed under the direction of the Prac- There is also the possibility that the portion of the device tice Committee of the American Society for Reproductive Medicine and theSociety of Reproductive Surgeons as a service to its members and other prac-ticing clinicians. Although this document reflects appropriate management ofa problem encountered in the practice of reproductive medicine, it is not in- tended to be the only approved standard of practice or to dictate an exclusivecourse of treatment. Other plans of management may be appropriate, taking Effect of treating hydrosalpinges before in vitro into account the needs of the individual patient, available resources, and insti- tutional or clinical practice limitations. This report was approved by the Prac-tice Committee of the American Society for Reproductive Medicine and theBoard of Directors of the American Society for Reproductive Medicine.
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