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IVF & Hydrosalpinx (Dr. Ahmed Walid Anwar Morad)

Management of patient with Hydrosalpinx undergoes IVF (Dr. Ahmed Walid Anwar Morad)

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IVF & Hydrosalpinx (Dr. Ahmed Walid Anwar Morad)

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  1. IVF & Hydrosalpinx DR/ Ahmed Walid Anwar Morad Professor of OB/GYN Faculty of Medicine Benha University 2023

  2. Definition • Pathophysiology • Etiology • Diagnosis • Strategies of tubal factor infertile • IVF & Hydrosalpinx • Take Home Message • References

  3. Definition • Fluid-filled distension of the fallopian tube may be:

  4. Pathogenesis • Obstruction of tubal drainage  accumulation of secretions within the tube  Fluid-filled dilatation of FT. • Tubal Occlusion may :

  5. Etiology • PID:Commonest • Hydrosalpinx is the end result of a tubal infection with the closure of the fimbriae, resulting in a watery collection inside the tube. • Chlamydia trachomatis is a common cause/ Gonorrhea/ TB • Other causes:

  6. Clinical Presentation: • History suggestive of; ( PID, Endometriosis, pelvic surgery) • Asymptomatic: Accidently discovered during infertility work up • Symptomatic: • Infertility • Pelvic pain: worse during or right after your menstruation. • Abnormal Vaginal Discharge: Sticky or stained • Menstrual irregularities ? • Urinary symptoms?

  7. Diagnosis: • HSG: Sensitivity 65% and specificity 85% • Retort-like shape of the distended tubes • Absence of free spillage

  8. Diagnosis: • TVS:Hydrosalpinx: Sensitivity 84% and specificity 99% • Tubular anechoic fusiform structure (C or S shaped) separated from ovary and uterus • Wall : (hyper-echogenic) Well-defined, thin ; may be thick. • Longitudinal Section: • Incomplete septation “Beads on a string sign" • “Waist” sign: refers to diametrically opposed indentations in the wall of the cystic lesion. • Cross section: Longitudinal folds become thick and give a “Cogwheel” appearance

  9. Diagnosis: • Hystero-Contrast-Salpingogram (HyCoSy) • CT:A fluid-attenuation tubular adnexal structure, separate from the ovary. • MRI:if adnexal mass is inadequately evaluated with ultrasound. • A dilated fallopian tube between the uterus and ovary with fluid signal intensity. • Incomplete septa + eroded mucosal plicae+ the tube wall is uniformly smooth and thin. • Laparoscopy: • a) Distended tubes b) Associated adhesions affecting the pelvic organs

  10. Hydrosalpinx and Infertility • Incidence: • How can hydrosalpinx cause infertility? • Tubal obstruction: Physical blockage of sperm meeting ovum. • Hydrosalpinx fluid: • Mechanical effects: • Wash-out of embryos through leakage of fluid through uterine cavity • Embryo toxic effects : embryotoxic components , growth inhibiting factors. • Endometrial alterations: hostile to embryo implantation and development.

  11. Treatment of hydrosalpinx associated infertility

  12. IVF & Hydrosalpinx • IVF is still the treatment of choice for infertile women with hydrosalpinx. • IVF in patients with hydrosalpinx has poor outcome compared to other types of tubal infertility as it is associated with: •  Implantation, Pregnancy , Live birth rates : to half • Miscarriage rate: doubled • IVF and endoscopic surgery must be thought as complementary rather than competing techniques in tubal diseases to improve fertility outcome

  13. IVF with hydrosalpinx: Management Options Aim: eliminate the detrimental effect of the hydro-salpingeal fluid before IVF-ET Before starting IVF During ovarian stimulation: • If hydrosalpinx • Accessible Laparoscopic Salpingectomy • InaccessibleTubal occlusion • Alternative:TVUS aspiration ± Sclerotherapy • Transvaginal aspiration of hydrosalpingeal fluid at the time of oocyte retrieval. • Freeze all embryos, + surgery for hydrosalpinx and then freeze ET.

  14. 1- Laparoscopic salpingectomy • When to be considered: • Ultrasound‐visible hydrosalpinges • Hydrosalpinx is accessible • PROS: • Natural fertility: positive effect on natural pregnancy after unilateral salpingectomy when the contralateral tube is healthy • IVF: Doubled clinical, ongoing pregnancy and live birth rate compared with those who did not have any surgery before IVF • Ovarian response to COS after salpingectomy: not significantly impaired • CONS: • Carries a potential risk of damaging vascular and nervous supply to the ovary • Ovarian reserve: the impact was dependent on the indication for salpingectomy (Less in case of ectopic pregnancy)

  15. 1- Laparoscopic salpingectomy • Advantages: • Removes the chronically infected hydrosalpinx, • Decreasing the risk of infection after oocyte retrieval • Increasing the accessibility to the ovary NB: A salpingotomycan be considered if the mucosa is healthy and the patient is young enough to await natural pregnancy.

  16. 2- Tubal occlusion • Definition: Permanent blocking of the proximal part of the tube + Dilated part remains in place ± Sclerotherapy of dilated part (not tested in RCTs) • Indications: • Severe adhesions make salpingectomy technically difficult • If there is a risk of damaging the ovary. • Routes: • Laparoscopy:A Cochrane review included two small RCTs of showed a benefit in clinical pregnancy rate compared with no intervention • Hysteroscopy (if laparoscopy is risky or contraindicated): • Essure device: RCThas demonstrated inferior pregnancy outcomes compared with salpingectomy • Micro inserts and diathermy: not evaluated in RCTs

  17. 3- Transvaginal US aspiration of the hydrosalpingeal fluid • a- At the time of oocyte retrieval: • A meta‐analysis of three randomized trial shows: increased clinical pregnancy rates compared with no intervention . • However, one trial comparing aspiration with salpingectomy suggested that aspiration may be inferior • b- An option during ovarian stimulation: • If fluid develops and hydrosalpinx becomes visible on the ultrasound scan. • NB: • Drawbacks:Recurrence  Sclerotherapy is suggested but no difference in the rate of recurrence • The alternative option is to freeze the embryos and perform salpingectomy

  18. N.B:Sclerotherapy before IVF • Method: TVUS guided aspiration of hydrosalpingeal fluid then injection of Sclerosing agent • Aim: decrease recurrence rate • Effect: effective and less invasive prophylactic intervention alternative to salpingectomy with hydrosalpinx. (Clin Exp Reprod Med. 2012 Dec; 39(4): 182–186)

  19. Take Home Message

  20. Take Home Message • Hydrosalpinx represents 10-30% of tubal factor of infertility. • IVF is still the treatment of choice for infertile women with hydrosalpinx. • IVF in patients with hydrosalpinx has poor outcome compared to other types of tubal infertility • IVF and endoscopic surgery must be thought as complementary rather than competing techniques in tubal diseases to improve fertility outcome

  21. Take Home Message • Among the three suggested surgical procedures ; Laparoscopic salpingectomy is still the best evidence‐based intervention to improve pregnancy rates, but tubal occlusion and aspiration of hydrosalpingeal fluid also have their places among therapeutic options.

  22. References 1Zeyneloglu HB, Arici A, Olive DL. Adverse effects of hydrosalpinx on pregnancy rates after in vitro fertilization‐embryo transfer. FertilSteril. 1998;70:492–9. 2 Savaris RF, Giudice LC. 2007; The influence of hydrosalpinx on markers of endometrial receptivity. SeminReprod Med. 3 Strandell A, Lindhard A, Waldenström U, Thorburn J, Janson PO, Hamberger L. Hydrosalpinx and IVF outcome: a prospective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF. Hum Reprod. 1999;14:2762–9. 4 Melo P, Georgiou EX, Johnson N, van Voorst S, Sowter MC, Strandell A, Mol BWJ, Becker C, Granne IE. Surgical treatment for tubal disease in women due to undergo in vitro fertilisation. Cochrane Database of Systematic Reviews 2019, Issue 12. Art. No.: CD002125. DOI: 10.1002/14651858.CD002125.pub4. 5 Xu B, Zhang q, Zhao J, Wáng, Xu D, Li Y. Pregnancy outcome of in vitro; fertilization after Essure and laparoscopic management of hydrosalpinx: a systematic review and meta‐analysis. FertilSteril. 2017;108:84–95. 6 Kotlyar A, Gingold J, Shue S, Falcone T. The effect of salpingectomy on ovarian function. J Minim Invas Gynecol. 2017;24:563–78. 7 Yu X, Cai H, Zheng X, Feng J, Guan J. Tubal restorative surgery for hydrosalpinges in women due to in vitro fertilization. Arch Gynecol Obstet. 2018;297:1169–73. 8 Mijatovic V, Veersema S, Emanuel MH, Schats R, Hompes PGA. Essure hysteroscopic tubal occlusion device for the treatment of hydrosalpinx prior to in vitro fertilization‐embryo transfer in patients with a contraindication for laparoscopy. FertilSteril. 2010;93:1338–42. 9 Dreyer K, Lier MC, Emanuel MH, Twisk LW, Mol BW, Schats R, Hompes PG, Mijatovic V. Hysteroscopic proximal tubal occlusion versus laparoscopic salpingectomy as a treatment for hydrosalpinges prior to IVF or ICSI: an RCT. Hum Reprod. 2016;31:2005–16. 10 Fouda UM, Sayed AM, Abdelmoty HI, Elsetohy KA. Ultrasound guided aspiration of hydrosalpinx fluid versus salpingectomy in the management of patients with ultrasound visible hydrosalpinx undergoing IVF‐ET: a randomized controlled trial. BMC

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