Ultrasound-guided hydrosalpinx aspiration during oocyte collection improves pregnancy outcome in IVF: a randomized controlled trial

Surgical treatment for tubal disease in women due to undergo in vitro fertilisation

BACKGROUND

Tubal disease, and particularly hydrosalpinx, has a detrimental effect on the outcome of in-vitro fertilisation (IVF). Performing a surgical intervention such as salpingectomy, tubal occlusion, aspiration of the hydrosalpinx fluid, or salpingostomy, prior to the IVF procedure in women with hydrosalpinges is thought improve the likelihood of successful outcome.

OBJECTIVES

To assess and compare the value of surgical treatments for tubal disease prior to IVF.

SEARCH STRATEGY

Trials were sought in the Cochrane Menstrual Disorders and Subfertility Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PSYCHMED and in Conference proceedings and reference lists up until Ocober 28 2009. Researchers in the field were contacted to reveal unpublished studies.

SELECTION CRITERIA

All trials comparing a surgical treatment for tubal disease with a control group generated by randomisation were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. The studied outcomes were live birth, ongoing pregnancy, viable-, clinical- and biochemical pregnancy, ectopic pregnancy, miscarriage, multiple pregnancy, ovarian function and complications.

MAIN RESULTS

Five randomised controlled trials involving 646 women were included in this review. Four studies assessed salpingectomy versus no treatment, two of which also included a tubal occlusion arm, and one trial assessed aspiration versus no treatment. No trials reported on the primary outcome: live birth. The odds of ongoing pregnancy (Peto OR 2.14, 95%CI 1.23 to 3.73) and of clinical pregnancy (Peto OR 2.31, 95%CI 1.48 to 3.62) however were increased with laparoscopic salpingectomy for hydrosalpinges prior to IVF. Laparoscopic occlusion of the fallopian tube versus no intervention did not increase the odds of ongoing pregnancy significantly (Peto OR 7.24, 95%CI 0.87 to 59.57) but the odds of clinical pregnancy (Peto OR 4.66, 95%CI 2.47 to 10.01) had sufficient power to show a significant increase. Comparison of tubal occlusion to salpingectomy did not show a significant advantage of either surgical procedure in terms of ongoing pregnancy (Peto OR: 1.65, 95%CI 0.74, 3.71) or clinical pregnancy (Peto OR 1.28, 95%CI 0,76 to 2.14). One RCT reported efficacy of ultrasound guided aspiration, however the odds of pregnancy did not show a significant increase in the odds of clinical pregnancy (Peto OR 1.97, 95%CI 0.62 to 6.29), and confidence intervals were wide. Throughout the different comparisons no significant differences were seen in adverse effects of surgical treatments.

AUTHORS' CONCLUSIONS

Surgical treatment should be considered for all women with hydrosalpinges prior to IVF treatment. Previous evidence supported only unilateral salpingectomy for a unilateral hydrosalpinx (bilateral salpingectomy for bilateral hydrosalpinges). This review now provides evidence that laparoscopic tubal occlusion is an alternative to laparoscopic salpingectomy in improving IVF pregnancy rates in women with hydrosalpinges. Further research is required to assess the value of aspiration of hydrosalpinges prior to or during IVF procedures and also the value of tubal restorative surgery as an alternative (or as a preliminary) to IVF.

Hydrosalpinx functional surgery or salpingectomy? The importance of hydrosalpinx fluid in assisted reproductive technologies

The first IVF baby, Louise Brown, was born in a natural cycle IVF of a woman who had bilateral tubal block making IVF the only option for having a child. The last 3 decades has seen astounding progress in the field of ART. Today thanks to ART, tubal disease and tubal factor infertility is easily overcome. The accepted theory today is that the hydrosalpinx fluid plays a causative role in the reduced pregnancy rate with ART. It is well known that the success of ART for patients with tubal disease with hydrosalpinx is reduced by half compared with patients without hydrosalpinx. Ideal would be removal of a hydrosalpinx by laparoscopic salpingectomy to improve pregnancy rates. However in some cases this is not feasible due to dense pelvic adhesions making access difficult. In such cases it is recommended that even de-linking the tube from the uterus would help in improving the ART outcome. There is suggestion that sonographically visible hydrosalpinges and those affected bilaterally have a poorer prognosis than those seen incidentally at laparoscopy. While there is clinical evidence supporting the causative role of the fluid itself, there is a lack of knowledge as to how the fluid exerts its negative effects. It is generally believed that the fluid holds a key position in impairing implantation potential. The aim of this review is to highlight the importance of identifying hydrosalpinges and its association with reduced fertility outcome using assisted reproductive technologies. Here we have discussed the different options available for the same, and highlighted the current modes of treatment.

Salpingectomy for hydrosalpinx prior to in vitro fertilization

Salpingectomy for hydrosalpinges before in vitro fertilization increases the success rate.