Correlation between salpingoscopic score and subsequent pregnancy outcome in patients with tubal infertility

Loss of nerve fibers in the oviduct isthmus in women with hydrosalpinx

Apart from the abnormalities of tubal anatomy, the main concern linked to infertility is impaired tubal motility associated with hydrosalpinx, which is thought to be controlled by hormones and nerves. The objective of this study was to determine the distribution of nerve fibers in the oviduct isthmus in women with and without hydrosalpinx. Histological sections of the oviduct isthmus tissue were obtained from 18 women undergoing salpingectomy for hydrosalpinx, and from 15 women undergoing hysterectomy and salpingectomy for benign gynecologic diseases. The tissues were immunohistochemically stained for protein gene product (PGP) 9.5, protein S100, neuropeptide tyrosine (NPY), and vasoactive intestinal peptide (VIP) to reveal all nerve fibers, as well as sympathetic and parasympathetic nerve fibers, in the oviduct isthmus. We detected the presence of PGP9.5, S100, VIP, and NPY-immunoreactive nerve fibers in the oviduct isthmus in all study subjects. However, the densities of PGP9.5, S100, VIP, and NPY-immunoreactive nerve fibers in the oviduct isthmus were all significantly decreased in women with hydrosalpinx compared with those in women without hydrosalpinx (P<0.01). Our results suggest that reduced nerve fibers in the oviduct isthmus in women with hydrosalpinx compared with women without hydrosalpinx may have an important function in the mechanism of hydrosalpinx-associated infertility.

Tubal disease: towards a classification

Tubal disease is a major cause of infertility. The amount of damage can vary greatly in extent, anatomical location and nature. For women with infertility due to tubal disease, prognostication for pregnancy often remains unclear and there is no universally accepted classification. A classification system that reliably distinguishes infertile patients with tubal disease into favourable and unfavourable groups would be useful if subsequent management could depend on this assessment, especially if the classification is able to define which group of patients would benefit most from interventions such as surgery. The progress of IVF questions the contribution of the Fallopian tube to the successful achievement of pregnancy in infertile women. Nonetheless, several studies reveal that severity is the key factor in the determining outcome, and the classifications reviewed in this paper imply that women with tubal disease could be categorized into prognostic groups using a simple classification system based on severity. However, prospective trials are needed to validate and assert the usefulness of any particular classification.

The management of hydrosalpinges: tubal surgery or salpingectomy?

PURPOSE OF REVIEW

The clinical management of hydrosalpinges in infertile patients remains a contentious issue. This review aims to provide a critical analysis on the available treatments for hydrosalpinges, which have recently created a fierce debate between the promoters of salpingectomy and in-vitro fertilization and those who endorse tubal surgery.

RECENT FINDINGS

Hydrosalpinges have a detrimental effect on the outcome of in-vitro fertilization yet their mechanism is still unclear. Salpingectomy prior to in-vitro fertilization restores the likelihood of a successful outcome in a well defined group of patients with ultrasound-visible hydrosalpinges. However, not every woman with large hydrosalpinges should undergo salpingectomy as some fallopian tubes may be amenable to surgical repair. Preserved tubal mucosa indicates a good prognosis for tubal surgery, therefore an appropriate mucosal assessment should be routine prior to deciding upon further management.

SUMMARY

As salpingectomy is a definitive procedure it should be performed when the hydrosalpinges are beyond repair or in cases of in-vitro fertilization failure. Tubal surgery should be preferred to salpingectomy in mild to moderate tubal disease. A comparative study of restorative tubal surgery versus salpingectomy and in-vitro fertilization in selected women with hydrosalpinges is needed and will significantly help this debate. Prophylactic salpingectomy prior to in-vitro fertilization and tubal surgery is not competing but complementary in the treatment of hydrosalpinges-related infertility.

Controversies in the surgical management of hydrosalpinx

The surgical management of hydrosalpinges is a controversial subject. Chronic pathology of the fallopian tube with distal obstruction leads to the formation of a hydrosalpinx, and is associated with very poor pregnancy rates after surgery. In these cases, in-vitro fertilization has proved to be a much better alternative. However, several studies have shown that patients with hydrosalpinges have significantly lower pregnancy and implantation rates after in-vitro fertilization compared with patients with other forms of tubal damage. The exact mechanism by which the hydrosalpinx adversely affects in-vitro fertilization results is not yet fully understood. The value of performing a salpingectomy before in-vitro fertilization has been studied extensively. Currently, a clear benefit in salpingectomies has been proved for patients with ultrasonically visible hydrosalpinges.

Microendoscopy of the human fallopian tube

Advances in fiberoptic technology make it possible to evaluate the tubal lumen endoscopically. Two basic procedures are salpingoscopy and falloposcopy. The former is a transfimbrial approach allowing visualization from the ampullary-isthmic junction to the fimbriae. The latter is a transcervical approach allowing assessment of the tubal lumen from the uterotubal ostium to the fimbriae. Both may be performed without general anesthesia. The procedures provide more sensitive information than laparoscopy with chromotubation or hysterosalpingography alone. Findings provide a strong correlation with conception. Technical shortcomings make falloposcopy more difficult than the more straightforward transfimbrial technique. With more widespread acceptance, endoscopic evaluation of the fallopian tube may become a standard component of the infertility evaluation.