Human Reproduction, Vol. 14, No. 3, 577-578,
March 1999
© 1999 European Society of Human Reproduction and Embryology
Debate |
The role of hydrosalpinx in IVF: simply mechanical?
Department of Obstetrics and Gynecology and Reproductive Sciences, Division of Reproductive Endocrinology and Infertility, University of Maryland Medical Center, 3rd Floor, 405 West Redwood Street, Baltimore, MD 21201–1703, USA
I read with interest the manuscript by De Wit et al. (1998) which sheds a new light on the hotly debated subject of the adverse role that hydrosalpinx plays in in-vitro fertilization (IVF). The authors need to be congratulated for successfully showing that women with hydrosalpinges are indeed a heterogeneous group: when hydrosalpinges are clearly visualized by ultrasound, the implantation rate (IR) and pregnancy rate (PR) are markedly reduced compared with other women with hydrosalpinges that were identified by hysterosalpingography or laparoscopy, but not seen on ultrasound. It is unfortunate that in this retrospective study no measurements of the size of the hydrosalpinx were taken, a point also missed in the first study using ultrasound as the diagnostic method for hydrosalpinx (Andersen et al., 1994
). Prior investigations, unfortunately again not using size measurements, suggest that women with `marked' distension of one or both Fallopian tubes have a poorer outcome compared to women with `slight' distension (Strandell et al., 1994). However, Andersen et al. (1996), without reporting on measurements, could not find a difference `in the largest diameter of the hydrosalpinx between those patients who conceived as compared to those who failed to conceive'. Clearly the impact of the size of the hydrosalpinx needs to be assessed in the ongoing prospective trials to clarify this controversy.
While some of the definitions used in De Wit's manuscript are not shared by most investigators (such as `giving a score of one implantation for cases of miscarriages before ultrasonography was performed, in cases of ectopic pregnancy, and when no gestational sac was observed'), the conclusions are critical nonetheless. With more recent publications showing no embryonic toxicity of the hydrosalpinx fluid in humans (Granot et al., 1998; Strandell et al., 1998), unlike earlier studies in mice (Mukherjee et al., 1996; based on which the authors' recommended `prophylactic salpingectomy'), it is clear that the most likely effect of hydrosalpinx is simply mechanical. It is logical to assume that embryonal apposition to the endometrial surface will be compromised when a fluid interface exists. De Wit's data also indicate that surgical therapy (salpingectomy or proximal tubal interruption) should only be offered to women whose hydrosalpinx is clearly visible on ultrasound because these women are at increased risk of having reflux of hydrosalpinx fluid into the uterine cavity (Mansour et al., 1991; Russell et al., 1991; Strandell et al., 1994; Andersen et al., 1996; Bloechle et al., 1997; Sharara and McClamrock, 1997). Which size is critical remains to be defined, but it is this author's experience that a diameter >3 cm prior to initiation of ovarian stimulation is associated with a high chance of enlargement during ovarian stimulation and reflux of fluid into the endometrial cavity. It has been our practice to offer surgical correction prior to IVF only to those women regardless of the findings of hysterosalpingography or laparoscopy. If reflux is identified at the time of oocyte aspiration, we recommend that all embryos be cryopreserved and replaced after surgical correction of the hydrosalpinx (Sharara and McClamrock, 1997). Indiscriminate salpingectomies on women with hydrosalpinx is clearly not the answer (Puttemans and Brosens, 1996).
Despite their important contribution, I wish that De Wit et al. (1998) addressed whether they had any patients with hydrosalpinx fluid reflux into the endometrium. This may be inherent to the deficiencies of a retrospective study, however a review of the surgical notes or ultrasound still pictures of the endometrial lining at the time of oocyte aspiration may shed light into this very important issue. We previously published that reflux can occur only after human chorionic gonadotrophin (HCG) administration in some patients, which could be totally missed if the endometrium is not evaluated at the time of oocyte retrieval (Sharara and McClamrock, 1997). We believe that these women have the worst prognosis at conception, and benefit markedly from surgical correction of the hydrosalpinx prior to IVF. This investigator believes that the endometrium should be assessed first, and all future and currently ongoing prospective trials dealing with the impact of hydrosalpinx on IVF outcome have to record the maximal diameter of the hydrosalpinx, whether it is present on baseline ultrasound prior to initiation of ovarian stimulation, whether it enlarges in response to gonadotrophins, and whether fluid reflux to the uterus is clearly visible by ultrasound on the day of gonadotrophin start, on the day of oocyte aspiration, and the day of embryo transfer. Only then would we have the correct answers to counsel our patients appropriately, and help them avoid unnecessary surgery.
Notes
This debate was previously published on Webtrack 48, January 15, 1999
References
Andersen, A.N., Yue, Z., Meng, F.J. and Petersen, K. (1994) Low implantation rate after in-vitro fertilization in patients with hydrosalpinges diagnosed by ultrasonography. Hum. Reprod., 9, 1935–1938.
Andersen, A.N., Linhard, A., Loft, A. et al. (1996) The infertile patient with hydrosalpinges – IVF with or without salpingectomy. Hum. Reprod., 11, 2081–2084.
Bloechle, M., Schreiner, T. and Lisse, K. (1997) Recurrence of hydrosalpinges after transvaginal aspiration of tubal fluid in an IVF cycle with development of a serometra. Hum. Reprod., 12, 703–705.
De Wit, W., Gowrising, C.J., Kuik, D.J. et al. (1998) Only hydrosalpinges visible on ultrasound are associated with reduced implantation and pregnancy rates after in-vitro fertilization. Hum. Reprod., 13, 1696–1701.
Granot, I., Dekel, N., Segal, I. et al. (1998) Is hydrosalpinx fluid cytotoxic? Hum. Reprod., 13, 1620–1624.
Mansour, R.T., Aboulghar, M.A., Serour, G.I. and Riad, R. (1991) Fluid accumulation of the uterine cavity before embryo transfer: a possible hindrance for implantation. J. In Vitro Fertil. Embryo Transfer, 8, 157–159.[Web of Science][Medline]
Mukherjee, T., Copperman, A.B., McCaffrey, C. et al. (1996) Hydrosalpinx fluid has embryotoxic effects on murine embryogenesis: a case for prophylactic salpingectomy. Fertil. Steril., 66, 851–853.[Web of Science][Medline]
Puttemans, P.J. and Brosens, I.A. (1996) Salpingectomy improves in-vitro fertilization outcome in patients with hydrosalpinx: blind victimization of the Fallopian tube? Hum. Reprod., 11, 2079–2081.
Russell, J.B., Rodriguez, Z. and Komins, J.I. (1991) The use of transvaginal ultrasound to aspirate bilateral hydrosalpinges prior to in vitro fertilization: a case report. J. In Vitro Fertil. Embryo Transfer, 8, 213–214.[Web of Science][Medline]
Sharara, F.I. and McClamrock, H.D. (1997) Endometrial fluid collection in women with hydrosalpinx after human chorionic gonadotrophin administration: a report of two cases and implications for management. Hum. Reprod., 12, 2816–2819.
Strandell, A., Sjögren, A., Bentin-Ley, U. et al. (1998) Hydrosalpinx fluid does not have any major adverse effects on normal human embryo development and implantation in vitro. Hum. Reprod., 13, 2921–2925.
Strandell, A., Waldenstrom, U., Nilsson, L. and Hamberger, L. (1994) Hydrosalpinx reduces in-vitro fertilization/embryo transfer pregnancy rates. Hum. Reprod., 9, 861–863.
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