Hydrosalpinx, Infertility and IVF
A hydrosalpinx is a blockage of the far end of a woman’s fallopian tube which results in the accumulation of fluid within the tube. The condition can affect one or both fallopian tubes. Often the affected area can become substantially swollen and grow even as big as a few centimeters in diameter.
Usually, there are few symptoms noticed by patients although some women may suffer from abdominal or pelvic pain. The most common mean by which a woman becomes aware that she has this problem is the development of infertility. Women, who are not trying to get pregnant and have no pain, may go undiagnosed.
Hydrosalpinx Impact on Fertility in General
As mentioned previously, the main presentation of a hydrosalpinx is infertility. The fallopian tube plays a crucial role in establishing a pregnancy. As sperm enter the vagina, they travel through the opening of the uterus (cervix), through the uterus, and into the fallopian tubes. If intercourse happens at the time of ovulation, then an egg may be present in one of the fallopian tubes. A sperm can fertilize the egg forming an embryo. Afterwards, the embryo migrates down the fallopian tube into the uterus. If the embryo implants into the uterus, a pregnancy has been established.
However, if this tube is blocked, the egg cannot be captured by the fallopian tube and the egg and sperm are prevented from meeting. Thus fertilization cannot occur and pregnancy is prevented.
In addition, studies have shown that even when women have one tube which is open, their chances for pregnancy are reduced if they have a hydrosalpinx on the other tube.
Possible Reasons for Less Success
There are various theories that try and explain why the success rates in these patients are so much lower. One suggests that the flow of fluid into the uterus could interfere with and hinder implantation of an embryo. This fluid could contain lower levels of proteins, various amounts of debris, and other toxic substances found in the body that are harmful to the embryo itself or possibly the lining of the uterus. Another theory states that the fluid is a mechanical flush for the uterus, sweeping away the embryo. It is not known whether these effects would be worse if both fallopian tubes are affected, although that is thought to be the case.
Hydrosalpinx also impacts the Success of IVF
In vitro fertilization bypasses fallopian tube blockage by extracting the eggs directly from the ovary and fertilizing them in the laboratory. The embryos are then placed directly into the uterus. Thus, the fallopian tubes are completely bypassed. With the growing success of IVF and other fertility treatments in the past years, many women suffering from a hydrosalpinx are turning to these treatments to enhance their chances of pregnancy. However, there is substantial evidence to suggest that the success of in vitro fertilization is significantly lower for women with hydrosalpinx compared to other causes of infertility.
Study on Hydrosalpinx and IVF
Investigators recently compiled the results from 14 different studies to try and see what the IVF success rates are in women with this condition. The analysis compared two groups of women. Of a total of 5592 patients, 1004 of them had one or both tubes blocked by a hydrosalpinx and 4588 of them had tubal blockage but with out a hydrosalpinx. A total of 8703 IVF embryo transfers were performed with either fresh or frozen embryos.
There were four outcomes measured:
1. The overall pregnancy rate was shown to decrease in the women with the hydrosalpinx. The women with no blockage had a pregnancy rate of 31.2% compared to the women with the hydrosalpinx at 19.67%.
2. The implantation rate, which looks at how many transferred embryos were able to implant in the uterine wall, also decreased in the women with a hydrosalpinx. It went from 13.68% in women with out a hydrosalpinx to 8.53% in women with one.
3. The delivery rate decreased drastically as well. Almost twice as many women delivered without a hydrosalpinx (23.4%) than with a hydrosalpinx (13.4%).
4. The delivery rate was lower in part because less women became pregnant but also because more of the women miscarried. Early loss in pregnancy was seen more often in the women affected than not. The rate for affected women was 43.65% loss compared to 31.11% loss.
Other studies have come out with results similar to these. Generally, for a woman with hydrosalpinx trying IVF, the chances for pregnancy are greatly reduced compared to the average infertile woman. While the possibility for pregnancy still exists in these patients, these women should be counseled that their chances for live birth are significantly lower if they have a hydrosalpinx.
TREATMENT OPTIONS FOR HYDROSALPINX TO IMPROVE FERTILITY
The complete surgical removal of a fallopian tube is called a salpingectomy. The procedure can be done laparoscopically or with a standard surgery performed by making a horizontal incision in the abdomen just above the pubic hair line. Both procedures are performed under general anesthesia so that the patient is completely asleep.
Laparoscopy is a minimally invasive way of performing surgery. An small fiber optic telescope is inserted in a small incision just below the navel. This allows the reproductive surgeon to see into the abdomen and pelvis. Two additional incisions of about one centimeter each are made above the pubic hair line. Through these small incisions, instruments can be placed that allow the reproductive surgeon to detach the tube from the uterus and blood vessels and to remove it from the abdomen.
Laparoscopy is the preferred method for performing a salpingectomy since no overnight hospitalization is required and the smaller incisions are associated with a shorter recovery time.
Tubal ligation is when the fallopian tubes are either severed or pinched shut, but not removed. It is often referred to as getting one’s “tubes tied.” This can also be done laparoscopically, abdominally, or even vaginally. The most common way to seal the tubes is by using a cauterizing clamp which when applied to the outside of the tube, will seal it shut. Other methods include placing strong, tight rings or rubber bands around the tube that pinch them closed.
Theoretically, by blocking the fluid from entering the uterine cavity, this may restore a normal chance for achieving pregnancy.
The most common use of tubal ligation is as a permanent form of birth control. It is generally not considered to be reversible.
Salpingectomy vs. Tubal Ligation: Which method is best for improving fertility?
If a woman has one fallopian tube blocked with a hydrosalpinx and the other tube is normal, the chances for pregnancy are reduced.
In a recent study, researchers looked at 25 women with one hydrosalpinx and one open fallopian tube. They attempted to determine whether treatment of the hydrosalpinx with either a salpingectomy or tubal ligation was more effective for improving pregnancy rates naturally without IVF. 18 underwent a salpingectomy and 7 had a tubal ligation of the abnormal tube. In the end, 22 (88%) women achieved pregnancy after the surgeries without the use of IVF. There were no ectopic pregnancies and no multiple births.
Both procedures seemed to improve the chances for becoming pregnant. Interestingly, the women who had a salpingectomy became pregnant more quickly compared to the women who had a tubal ligation.
This research seems to indicate although a one sided hydrosalpinx can cause infertility, it may be possible to reverse the effects of this condition. These women did not need further fertility treatment and their mean time to pregnancy was only 5.6 months after the procedures. For that reason, if a woman with one hydrosalpinx has been unable to achieve a pregnancy, treatment of the hydrosalpinx is a reasonable treatment option.
Obviously, if both fallopian tubes are blocked, than natural conception is impossible. Several studies have looked at whether treatment of hydrosalpinges is effective for improving the chances for pregnancy with IVF. Studies have looked at various alternatives such as salpingectomy and tubal ligation. Some studies even sought to determine whether draining the fluid from the hydrosalpinx (transvaginal aspiration) might be helpful.
Published guidelines from the American Society for Reproductive Medicine listed the following conclusions:
1. Patients with hydrosalpinges undergoing IVF experience approximately one-half the pregnancy rate of patients who do not have hydrosalpinges.
2. Salpingectomy performed for hydrosalpinx prior to IVF improves subsequent pregnancy, implantation, and live birth rates.
3. Current data are insufficient to permit recommendation of other treatment alternatives such as transvaginal aspiration of hydrosalpinx fluid or proximal tubal ligation.