**4. Salpingectomy**

Studies have shown that patients with hydrosalpinx visible by ultrasound, are generally the ones that benefit from salpingectomy. As a result, this group of patients are the ones who are recommended to perform prophylactic salpingectomy prior to IVF treatment.

The psychological impact of this surgery and the removal of the tubes in an infertile patient are significantly important and should be emphasized. Even if a patient has a clear candidate for salpingectomy, it is essential that she is psychologically prepared for the procedure. At times, it has been necessary for the patient to undergo a few failed cycles before one can bring up the discussion of surgery and salpingectomy. Obviously, the final decision to perform salpingectomy should be based on appropriate evaluation of the tubal mucosa at laparoscopy and therefore avoid unnecessary surgery for the patient. It is crucial that surgeons identify carefully that whether a hydrosalpinx should be excised or is acceptable enough for a surgical repair [71].

#### **4.1. Tubal ligation vs. salpingectomy**

There are no results from randomized trials to answer this question. The data from two retrospective studies by Surrey/Schoolcraft [77], did not show any significant differences in pregnancy outcome, but the number of patients has been too low to allow for any conclusion. Today, there is no evidence that transvaginal aspiration is as effective as salpingectomy, but it is an option for patients who will not undergo salpingectomy, and for those who develop tubal fluid during stimulation.

Hydrosalpinges with destroyed mucosa are not suitable for reconstructive surgery. However, patients with these also have an impaired success rate after IVF, possibly due to the leakage of fluid into the uterus. Salpingectomy is the only method that has been properly evaluated as a surgical approach to overcome the negative influence of the hydrosalpingeal fluid.

From the Scandinavian study, a clear conclusion was drawn: patients with hydrosalpinges large enough to be visible on ultrasound examination can be recommended laparoscopic salpingectomy prior to IVF in order to enhance their chance of a full-term pregnancy. Patients with large hydrosalpinges and without prospect of spontaneous conception should be recommended a salpingectomy, which truly increases their chances of a successful IVF treatment [71].

#### **4.2. Surgical vs. medical management**

group; however, this difference was not statistically significant. In summary, patients treated with doxycycline for extended periods whom had hydrosalpinx did not have lower IVF success rates. On the contrary, the highest implantation rate was present in the group with hydrosal‐

An unfavorable effect of a hydrosalpinx could be caused by a chronic or acute tubal bacterial infection that could potentially affect the endometrium. This detrimental effect could be suppressed and become ineffective by using extended antibiotic therapy. In addition, health‐ care cost can be prevented and minimized if initiating treatment with a 2-week course of an inexpensive antibiotic provides the same outcome comparable to surgical treatment of a

Studies have shown that patients with hydrosalpinx visible by ultrasound, are generally the ones that benefit from salpingectomy. As a result, this group of patients are the ones who are

The psychological impact of this surgery and the removal of the tubes in an infertile patient are significantly important and should be emphasized. Even if a patient has a clear candidate for salpingectomy, it is essential that she is psychologically prepared for the procedure. At times, it has been necessary for the patient to undergo a few failed cycles before one can bring up the discussion of surgery and salpingectomy. Obviously, the final decision to perform salpingectomy should be based on appropriate evaluation of the tubal mucosa at laparoscopy and therefore avoid unnecessary surgery for the patient. It is crucial that surgeons identify carefully that whether a hydrosalpinx should be excised or is acceptable enough for a surgical

There are no results from randomized trials to answer this question. The data from two retrospective studies by Surrey/Schoolcraft [77], did not show any significant differences in pregnancy outcome, but the number of patients has been too low to allow for any conclusion. Today, there is no evidence that transvaginal aspiration is as effective as salpingectomy, but it is an option for patients who will not undergo salpingectomy, and for those who develop

Hydrosalpinges with destroyed mucosa are not suitable for reconstructive surgery. However, patients with these also have an impaired success rate after IVF, possibly due to the leakage of fluid into the uterus. Salpingectomy is the only method that has been properly evaluated as

From the Scandinavian study, a clear conclusion was drawn: patients with hydrosalpinges large enough to be visible on ultrasound examination can be recommended laparoscopic salpingectomy prior to IVF in order to enhance their chance of a full-term pregnancy. Patients

a surgical approach to overcome the negative influence of the hydrosalpingeal fluid.

recommended to perform prophylactic salpingectomy prior to IVF treatment.

pinx [66].

114 Genital Infections and Infertility

hydrosalpinx prior to IVF treatment.

**4.1. Tubal ligation vs. salpingectomy**

tubal fluid during stimulation.

**4. Salpingectomy**

repair [71].

Different hypothesis on medical management for hydrosalpinx have been considered. This is not just prophylactic antibiotics to patients after the puncture of hydrosalpinx. Sharara et al. in 1996 suggested giving prophylactic antibiotics to selected groups of patients with elevated serum Chlamydia trachomatis IgG antibody titers or considered as a routine before oocyte retrieval for all patients.

Nevertheless, this hypothesis of antibiotic treatment specifically in hydrosalpinx patients has not been studied or evaluated prospectively.

Hurst et al. in 2001 in a retrospective study worked on hydrosalpinx and antibiotic treatment. In this study, patients with hydrosalpinx who received prolonged doxycycline treatment during an IVF cycle were compared to those who did not receive antibiotics and had other conditions, such as (endometriosis/unexplained infertility or tubal occlusion without hydro‐ salpinx/adhesions). Implantation and pregnancy rates were similar in all groups. This concludes that antibiotic treatment could also minimize the detrimental effect of hydrosalpinx. Even though this method is simple and safe, its benefits should be evaluated in a prospective trial before it becomes a standard of care [71].

#### **4.3. Salpingectomy vs. proximal tubal occlusion**

One of the secondary benefits salpingectomy provides, is the removal of a mass that may possibly be infected and could also be a source of torsion. Hydrosalpinx left in situ, can potentially have a negative impact because it can cause an increase in the risk of infection and decrease in access to the ovary during oocyte aspiration.

On the contrary, there are potential disadvantages to the performance of salpingectomy. Salpingectomy is a procedure that would need expertise because it would be difficult to perform in patients with extensive pelvic adhesions, also considered an invasive procedure and could potentially increase the possibility of injury to the surrounding tissues and struc‐ tures. In addition, transection of the tube too close to the cornua may also increase the risk of an interstitial pregnancy after ET, a devastating complication [72].

Salpingectomy could also hypothetically result in a decrease in ovarian perfusion, as part of the blood supply to the ovaries is provided by branches of the uterine artery and the meso‐ salpingeal vascular arcade [73]. Acute reduction in ovarian blood flow may have a direct impact on ovulatory function in the rat model [74]. In a study by Lass et al. [75], it was shown that fewer follicles were developed and fewer oocytes were retrieved from the ipsilateral ovary in women who had undergone unilateral salpingectomy.

On the contrary, Dar et al. [76] reported that ovarian response in assisted reproductive technology cycles that was performed before and after laparoscopic salpingectomy for ectopic pregnancy was not affected by surgery [76].

Of note, proximal tubal occlusion constitutes a significantly less invasive approach that includes minimal surgical intervention and less time allocated for the surgery, while at the same time eliminating retrograde flow of hydrosalpingeal fluid into the endometrial cavity. The current study demonstrated that laparoscopic proximal occlusion of the affected fallopian tube with bipolar cautery had similar ovarian response and IVF-ET cycle outcome as that of controls or as of those who have undergone laparoscopic salpingectomy [77].

In conclusion, prophylactic surgical management of hydrosalpinges by either proximal tubal occlusion or laparoscopic salpingectomy demonstrated statistically similar responses to controlled ovarian hyperstimulation and IVF-ET cycle outcomes. There is no evidence of any compromise in ovarian response induced by either surgical procedure [77].

#### **4.4. Spontaneous or surgical drainage of the hydrosalpinx**

Studies have shown that draining hydrosalpinges surgically or with the help of ultrasound guidance have improved pregnancy and implantation rates [78].

Even though this technique would potentially decrease the overall volume of hydrosalpingeal fluid, drainage cannot eliminate its source or its ability to flow into the endometrial cavity even in decreased amounts. Sowter et al. [79] have shown that surgical drainage of distended hydrosalpinges offered no benefits in enhancing implantation or pregnancy rates over untreated controls. In addition, Bloechle et al. [59] have demonstrated re-accumulation of hydrosalpingeal fluid within 3 days of aspiration performed at oocyte retrieval, which would precede the time of embryo implantation. As a result, this would hypothetically eliminate the benefit of drainage alone.

It appears that the drainage of a hydrosalpinx might not have much benefit to implantation. Generally, re-accumulation of fluid in the tubes can cause subsequent drainage into the uterus, resulting in the distention of the uterine cavity, which has been reported by Mansour et al. in 1991 [110] and many others.

Failure to benefit from drainage of hydrosalpinges might not necessarily be a result of incomplete drainage leaving some fluid to spill into the uterine cavity or from fluid reaccumulation. There could potentially be a functional destruction to the tube which would enhance retrograde passage of transferred embryos, both increasing the risk of ectopic pregnancy, and also contributing by wastage of embryos to the observed decrease of intrau‐ terine implantation. If, indeed, this was a notable mechanism causing decreased intrauterine implantation, there would also be no advantage from undertaking distal salpingostomy simply to maintain tubal drainage.

The study results highly recommend that transvaginal drainage of hydrosalpinges provides no benefit at the time of oocyte retrieval for IVF treatment [80].

#### **4.5. Summary**

On the contrary, Dar et al. [76] reported that ovarian response in assisted reproductive technology cycles that was performed before and after laparoscopic salpingectomy for ectopic

Of note, proximal tubal occlusion constitutes a significantly less invasive approach that includes minimal surgical intervention and less time allocated for the surgery, while at the same time eliminating retrograde flow of hydrosalpingeal fluid into the endometrial cavity. The current study demonstrated that laparoscopic proximal occlusion of the affected fallopian tube with bipolar cautery had similar ovarian response and IVF-ET cycle outcome as that of

In conclusion, prophylactic surgical management of hydrosalpinges by either proximal tubal occlusion or laparoscopic salpingectomy demonstrated statistically similar responses to controlled ovarian hyperstimulation and IVF-ET cycle outcomes. There is no evidence of any

Studies have shown that draining hydrosalpinges surgically or with the help of ultrasound

Even though this technique would potentially decrease the overall volume of hydrosalpingeal fluid, drainage cannot eliminate its source or its ability to flow into the endometrial cavity even in decreased amounts. Sowter et al. [79] have shown that surgical drainage of distended hydrosalpinges offered no benefits in enhancing implantation or pregnancy rates over untreated controls. In addition, Bloechle et al. [59] have demonstrated re-accumulation of hydrosalpingeal fluid within 3 days of aspiration performed at oocyte retrieval, which would precede the time of embryo implantation. As a result, this would hypothetically eliminate the

It appears that the drainage of a hydrosalpinx might not have much benefit to implantation. Generally, re-accumulation of fluid in the tubes can cause subsequent drainage into the uterus, resulting in the distention of the uterine cavity, which has been reported by Mansour et al. in

Failure to benefit from drainage of hydrosalpinges might not necessarily be a result of incomplete drainage leaving some fluid to spill into the uterine cavity or from fluid reaccumulation. There could potentially be a functional destruction to the tube which would enhance retrograde passage of transferred embryos, both increasing the risk of ectopic pregnancy, and also contributing by wastage of embryos to the observed decrease of intrau‐ terine implantation. If, indeed, this was a notable mechanism causing decreased intrauterine implantation, there would also be no advantage from undertaking distal salpingostomy

The study results highly recommend that transvaginal drainage of hydrosalpinges provides

no benefit at the time of oocyte retrieval for IVF treatment [80].

controls or as of those who have undergone laparoscopic salpingectomy [77].

compromise in ovarian response induced by either surgical procedure [77].

**4.4. Spontaneous or surgical drainage of the hydrosalpinx**

benefit of drainage alone.

1991 [110] and many others.

simply to maintain tubal drainage.

guidance have improved pregnancy and implantation rates [78].

pregnancy was not affected by surgery [76].

116 Genital Infections and Infertility

Hydrosalpinges is a chronic inflammatory condition that could unfavorably affect the chance of endometrial receptivity.

Several studies have shown changes in the inflammatory and immunological markers in the endometrium of patients exposed to hydrosalpingeal fluid. Markers identified were IL-2, NKκB, and LIF.

Today, prior to IVF treatment, the routine approach is a surgical intervention performing laparoscopic salpingectomy or proximal tubal occlusion.

Some studies have demonstrated the most surgical benefit in the subset of patients with bilateral hydrosalpinges or ultrasound visible hydrosalpinges.
