**7. Role of endoscopy in cases of hydrosalpnix**


In recent years, considerable attention has been given to the possible impact of the presence of hydrosalpinx on implantation and ongoing pregnancy rates following IVF/ICSI (51,52). The mechanism of disruption remains uncertain. However, proposed mechanisms may be attributed to alteration in endometrial receptivity ordirect embryo toxic effect (53). Furthermore, hydrosalpnix is liable be unintentionally punctured at the time of egg retrieval or it may disturb the access to the ovary if it is too big. A systematic review of three RCTs (54) showed that tubal surgery such as laparoscopic salpingectomy significantly increased live birth rate (OR 2.13; 95% CI 1.24 to 3.65) and pregnancy rate (OR 1.75; 95% CI 1.07 to 2.86) in women with hydrosalpinges before IVF when compared with no treatment. There are no significant differences in the odds of ectopicpregnancy (OR 0.42; 95% CI 0.08 to 2.14), miscarriage (OR 0.49; 95% CI 0.16 to 1.52), treatment complication (OR 5.80; 95% CI 0.35 to 96.79) or implantation (OR 1.34; 95% CI 0.87to 2.05). Since hydrosalpinx reduces IVF pregnancy rates (14,55), it is therefore suggested that women with hydrosalpinges should be offered diagnostic/operative laparoscopy and a trial of salpingoneostomy. If failed or inaccessable, salpingectomy could be offered prior to IVF/ICSI to improve the chance of a live birth. Sometimes, laparoscopic access to the isthmic part of the tube is not feasible even in experienced hands particularly in patients with history of repeated laparotomies, intestinal reanastomosis, or kidney transplantation. This situation may pave the way to hysteroscopic occlusion of the fallopian tubes based on the reported success in hysteroscopic tubal cannulation and sterilization techniques. The effectiveness of draining of hydrosalpinges or performing salpingostomy on improving live birth rate prior to IVF/ICSI needs further evaluation.
