Fig. 1.1
HSG features of distal tubal disease. (a) Bilateral distal tubal obstruction with hydrosalpinx, the left being more obvious than the right side; (b) Proximal tubal blockage affecting the right tube and distal tubal obstruction in the left tube resulting in the formation of a hydrosalpinx
Ultrasonography and Sonohysterography
Transvaginal sonography may, from time to time, detect hydrosalpinges (Fig. 1.2). A European multicenter study involving nine medical centers and 1,066 women with known adnexal masses before surgical evaluation reported a sensitivity of 86 % for detecting hydrosalpinx [5]. In differentiating hydrosalpinx from other pathologic conditions, the sensitivity and specificity of ultrasonography was 93.3 and 99.6 % respectively [6].
Fig. 1.2
(a, b) Ultraonographic appearance of hydrosalpinges. Hydrosalpinges typically appear as a tubular cystic lesion in the adnexa, often with incomplete septa corresponding to the bends (arrows) and kinks of the dilated tube. The fluid inside the hydrosalpinges may have variable echogenecity, depending on the presence or absence of blood or pus inside the dilated tube
Laparoscopy
Whilst laparoscopy is considered as the gold standard for the diagnosis of tubal disease, it is not recommended as a first line, routine investigation for women with infertility because it is a surgical procedure and so incurs risks and costs. Laparoscopy should be considered only in a selected population of women with infertility when the likelihood of tubal or pelvic pathology is increased, for example, when HSG shows evidence of tubal disease, or when there is relevant history such as repeated pelvic inflammatory disease or pelvic surgery, or in the presence of significant symptoms such as dysmenorrhoea or dysparaunia. The advantage of laparoscopy on the other hand is that it enables accurate diagnosis and treatment to be carried out at the same time. Figure 1.3 shows a selection of various pathology affecting the fallopian tube in women with infertility.
Fig. 1.3
A selection of laparoscopic findings in women with tubal infertility. (a) Unilateral distal tubal obstruction with the formation of a relatively small hydrosalpinx (arrow) without peri-tubal adhesion; (b) Peritubal adhesions involving the fimbrial end and the ovary (arrow); (c) Bilateral tubal occlusion with large distal haematosalpinges (arrow); (d) Distal fimbrial atresia without the formation of hydrosalpinx (arrow); (e) Congenital absence of mid-segment of the tube; (f) Left tube adherent to the abdominal wall; (g) the distal portion of both fallopian tubes are stuck together in the Pouch of Douglas; (h) An old ectopic pregnancy tissue (arrow) over the fimbrial end of the tube causing obstruction; (i) Congenital absence of left fallopian tube and left ovary
Other Methods
A number of other methods are also available but each has its limitations. Ultrasound and HyCoSy enables provides simultaneously evaluation of ovarian reserve and structure, uterine cavity contour, myometrial structure and tubal architecture and patency. However, its sensitivity in the diagnosis of distal tubal disease is not as good as HSG. Transvaginal hydro-laparoscopy is more sensitive than HyCoSy in the diagnosis of distal tubal disease but unlike laparoscopy, it does not permit tubal surgery to be carried out at the same time. Fertiloscopy is now almost obsolete.
Treatment of Hydrosalpinges: Surgery or IVF?
In women with infertility associated with hydrosalpinges, the treatment options are either tubal surgery or IVF. The latter option appears more popular because IVF treatment has a number of apparent advantages. First, the success rate of IVF treatment is steadily increasing, with many centers achieving a clinical pregnancy rate of >30 % per cycle initiated, which is as good as, if not better than the mean pregnancy rate achieved following salpingostomy reported in the literature. Second, IVF treatment produces a result faster than surgery, as it takes time for the patient to recover from the surgery and then to conceive. Third, IVF treatment along with the associated technological advances seems more fashionable than traditional tubal surgery and is therefore more appealing to most patients. Lastly, surgery is often considered as a more invasive option and is chosen only after simple, medical treatment has not been successful. Not surprisingly, many patients and specialists opt for IVF treatment in preference to tubal surgery.
Hydrosalpinges Impair the Success Rate of IVF
Nevertheless, the presence of hydrosalpinges is associated with a poorer IVF-ET outcome, significantly lower implantation and intrauterine pregnancy rates compared with other types of tubal disease. Accumulated hydrosalpingeal fluid is thought to be embryo toxic [7] and may also disrupt endometrial receptivity [8]. The live birth rate (LBR) of patients with hydrosalpinges undergoing IVF is only half that of women who do not have hydrosalpinges. A prospective randomized multicentre trial on salpingectomy prior to IVF showed that LBR of women with hydrosalpinges after salpingectomy was 28.6 %, which was significantly higher than women who did not have prior salpingectomy (16.3 %). In a Cochrane review, salpingectomy before IVF was found to produce 1.75- to 2.13-fold higher odds of pregnancy and live birth, respectively. For patients who had unilateral hydrosalpinx with a contra-lateral patent tube, removal of the unilateral hydrosalpinx before treatment also has a positive effect on pregnancy rates after IVF.
It has been shown that leukaemia inhibitory factor (LIF) expression in the mid-luteal phase endometrium of infertility women with hydrosalpinges was significantly lower than control fertile subjects. On the other hand, salpingectomy resulted in increase of LIF expression in 80 % (8/10) subjects with hydrosalpinges [9]. A further study confirmed that the expression of LIF and L-selectin ligand in the endometrium of women with hydrosalpinx improved after salpingectomy or salpingostomy [10].
Is Tubal Surgery Prior to IVF Cost Effective?
Although there is convincing evidence that in women with hydrosalpinges, salpingectomy prior to IVF treatment improves outcome, it is debatable whether it is cost effective to routinely perform surgery prior to IVF treatment in this group of women, as surgery itself incurs an extra procedure and the associated cost. One may reasonably ask, is it more appropriate to proceed with IVF treatment first and to consider surgery only if the IVF treatment has not been successful. The cost effectiveness of routine salpingectomy prior to IVF treatment has been examined in a randomized control trial. In the group of women who proceeded to IVF treatment (up to three cycles) without salpingectomy, the average cost per live birth was 29,517 Euro, compared with a significantly reduced cost per live birth of 22,823 Euro in women who underwent salpingectomy before undergoing IVF treatment. There is therefore a strong argument to recommend routine salpingectomy prior to IVF treatment.
Salpingostomy or Salpingectomy?
Whilst the case for surgery to remove hydrosalpinx prior to IVF treatment has been established, a further question remains: should all hydrosalpinges be removed or should tubes be removed (salpingectomy) only if they are grossly damaged with little prospect of spontaneous conception but tubes which are minimally damaged with a good prospect of spontaneous conception be reconstructed (salpingostomy)? The answer to the question depends on the likely outcome of salpingostomy. A published report claimed that term delivery rate after salpingostomy in two non-special hospitals was only 5 % (2/40) [11]. However, in another center with a special interest in tubal surgery, the mean success rate was much higher, with live birth rate (LBR) of 29 % (28/97) and intrauterine pregnancy rate of 34 % (33/97) [12]. More importantly, it has been demonstrated that careful case selection is a most important factor in determining the success rate, based on the severity of the tubal damage [13]. The term pregnancy rate after salpingostomy in women with mildly damaged tube was as high as 39 %, but in women with severely damaged tube it was as low as 8 %. In general, features indicative of good prognosis for reconstructive tubal surgery (salpingostomy) include a small size hydrosalpinx, the wall of which is not thickened, with no or minimal peri-tubal adhesions and most importantly, the mucosa of the tube is normal or only minimally damaged.
Assessing Tubal Mucosa
At laparoscopy direct inspection of the distal one-third of the lumen and mucosa of the fallopian tube may be carried out, a procedure called salpingoscopy. Historically, salpingoscopy was performed with a specially designed and adapted laparoscope called salpingoscope but salpingoscopy can nowadays be easily performed with the use a diagnostic hysteroscope, as shown in Fig. 1.4. The hysteroscope, connected to a separate camera system to the laparoscope, can be introduced through an accessory trocar on the side of the pelvis opposite to the tube to be examined [14]. Under guidance of the laparoscope, the hysteroscope (salpingoscope) is introduced via the fimbrial end to the ampullary region of the tube. As in the case of hysteroscopy, fluid (water or normal saline) may be introduced into the tubal lumen which then distends the lumen and permits examination of the mucosa. Normal tubal mucosa is characterized by the presence of three major folds, pink mucosa with normal vasculature, and absence of intra-luminal adhesions and fibrosis (Fig. 1.5). The prognosis in such cases is good [15]. On the other hand, the presence of intra-luminal mucosal adhesions and fibrosis indicates a poor prognosis for reconstructive surgery and so the tube should be removed (Fig. 1.5).
