**7.3. A suggested flowchart for management of functionless hydrosalpnix prior to IVF/ICSI**

Endoscopy versus IVF: The Way to Go 43

(59) or direct embryo toxic effect. Furthermore, it is liable to be unintentionally punctured at the time of egg retrieval or it may disturb access to the ovary if it is too big. In a meta-analysis, it has been demonstrated that there is a reduction by half in the probability of achieving a pregnancy in the presence of hydrosalpinx, and an almost doubled rate of spontaneous abortion (60). In an animal study, hydrosalpinx fluid is shown to contain toxins that are potentially teratogenic (61). Proposed mechanisms of impaired implantation rate due to hydrosalpinges are well addressed in the literature (62). Selected patients with unilateral hydrosalpinges and a patent contralateral Fallopian tube may exhibit increased cycle fecundity after salpingectomy or proximal tubal occlusion of the affected tube, and may conceive without the need for IVF. In a retrospective case-control study, bilateral salpingectomy due to hydrosalpinges restored a normal delivery as well as implantation rate after IVF treatment compared to controls (63). Randomized controlled trials recommended performing laparoscopic salpingectomy prior to IVF, especially inpatients with ultrasound-visible hydrosalpinges (64). In a Cochrane review (65), it is concluded that further randomized trials are required to assess other surgical treatments for hydrosalpinx, such as salpingostomy, tubal occlusion or needle drainage of a hydrosalpinx at oocyte retrieval. Functionless hydrosalpinx can be defined as a large blocked tube with lost major and minor folds, as seen at

On sonography, the dilated fallopian tube presents as a thin- or thick-walled tubular fluidfilled structure that may be elongated or folded (figure). Longitudinal folds that are present in a normal fallopian tube may become thickened in the presence of a hydrosalpinx. The dilated fallopian tube may or may not show longitudinal folds. These longitudinal folds are pathognomonic of a hydrosalpinx . If the elongated nature of these folds is not noted, they may be mistaken for mural nodules of an ovarian cystic mass. Identification of a separate ovary helps distinguish a hydrosalpinx from a cystic ovarian mass, an important distinction because malignancy is rare with an extraovarian cystic adnexal mass. A significantly scarred hydrosalpinx may present as a multilocular cystic mass with multiple septa creating multiple compartments. These septa are generally incomplete, and the compartments can be connected. However, with more pronounced scarring, differentiation from an ovarian mass may not be possible (66). Potential pitfalls in the diagnosis of hydrosalpinx include

salpingoscopy after laparoscopic salpingoneostomy.

**Figure 4.** Sonographic appearance of a typical hydrosalpnix.

**Laparoscopic tubal surgery:** tubal factors include proximal tubal occlusion, distal tubal phimosis or occlusion or peritubal adhesions. Endoscopy (whether laparoscopy or hysteroscopy) play a central role in the management of tubal disease.


**Figure 3. HSG:** Hysterosalpingography. **TVS:** Transvaginal ultrasonography.
