Delivery rates after in-vitro fertilization following bilateral salpingectomy due to hydrosalpinges: a case control study.

This retrospective case-control study assessed the impact of bilateral salpingectomy due to uni- or bilateral hydrosalpinges on the outcome of in-vitro fertilization (IVF) in a large consecutive series of patients. The effect of bilateral salpingectomy due to hydrosalpinges on pregnancy outcome was compared in 139 patients (263 cycles) and 139 age-matched controls with tubal infertility without hydrosalpinges (296 cycles). The delivery rates per initiated cycle as well as the implantation rates were equal in the two groups (21.7 versus 21.6% and 19 versus 21%). The number of embryos, the cleavage stage, and the embryo morphology score were equal in the two groups. Among 92 patients treated with 182 IVF cycles who underwent salpingectomy between 1.5 and 5 years prior to their first IVF cycle, the delivery and the implantation rates were 22.5 and 20.5% respectively. Of the patients with salpingectomy after an average of 1.7 failed IVF cycles and who re-entered the IVF programme 3 and 6 months subsequent to surgery, 47 were treated with 83 IVF cycles. The live birth and the implantation rates after surgery in this group were 20.5 and 20% respectively. It is concluded that bilateral salpingectomy due to hydrosalpinges restores a normal delivery as well as implantation rate after IVF treatment compared to controls. A favourable outcome is also found in patients operated on after repeated IVF failures. Furthermore, a normal live birth rate as well as a high implantation rate is maintained for at least three IVF cycles subsequent to surgical treatment.     

The dilemma of the optimal surgical procedure in ectopic pregnancies occurring in in-vitro fertilization.

Ectopic pregnancy remains one of the undesired sequelae of in-vitro fertilization (IVF) treatment. It seems that mechanical infertility increases the risk of this complication in IVF. Thus, the surgeon treating such a case faces the dilemma of the optimal surgical procedure because of the increased risk for repeated ectopic pregnancy in subsequent IVF cycles. Two cases are presented with repeated ectopic pregnancy occurring in IVF. One case underwent salpingectomy on the first occasion and eventually developed a contralateral repeat ectopic gestation ending with salpingectomy. The second case underwent a conservative salpingotomy in the first event and developed a repeated ectopic gestation on the same side, undergoing bilateral salpingectomy. In order to prevent repeated ectopic pregnancies in an IVF programme, a definitive surgical procedure, such as bilateral salpingectomy, should be considered in the first episode in patients referred for IVF because of tubal pathology.     

Spontaneous intrauterine pregnancy following salpingectomy for a unilateral hydrosalpinx

The effect of salpingectomy for unilateral hydrosalpinx with a contralateral normal tube was evaluated in two infertile patients in which unilateral hydrosalpinx, visualized by vaginal ultrasound, was treated by unilateral salpingectomy as a preparatory step before IVF. Spontaneous pregnancy occurred in both patients while waiting to be enrolled in an IVF trial. In conclusion, unilateral salpingectomy for hydrosalpinx in the presence of a contralateral healthy tube could result in spontaneous pregnancy.     

Salpingectomy or proximal tubal occlusion of unilateral hydrosalpinx increases the potential for spontaneous pregnancy

BACKGROUND: Studies carried out over the past 10 years have suggested that hydrosalpinges reduce the pregnancy rate in IVF. Here we report our observations of spontaneous pregnancies in patients who underwent salpingectomy (n = 18) or proximal tubal occlusion (n = 7) following diagnoses of unilateral hydrosalpinges and patent contralateral tubes. METHODS: This multi-centre, retrospective study included 25 infertility patients with known unilateral hydrosalpinges with a patent contralateral Fallopian tube. Laparoscopic treatment of unilateral hydrosalpinges by either salpingectomy or tubal occlusion was performed in each patient. Rates of subsequently observed spontaneous pregnancy, and time to pregnancy, are reported. RESULTS: The average duration of infertility in these patients was 3 years with a range of 1-10 years. Following laparoscopic surgical treatment, a total of 22 patients (88%) achieved intrauterine pregnancies, all without IVF treatment. Pregnancies occurred in an average of 5.6 months with a range of 1-21 months. There were no ectopic pregnancies in the study population. CONCLUSIONS: Selected patients with unilateral hydrosalpinges and a patent contralateral Fallopian tube may exhibit increased cycle fecundity after salpingectomy or proximal tubal occlusion of the affected tube and conceive without the need for IVF.     

Hydrosalpinx and IVF outcome: a prospective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF.

Many retrospective studies have shown that hydrosalpinx is associated with poor in-vitro fertilization (IVF) outcome. The mechanism of the actual cause is not yet fully understood. A clinical practice of performing salpingectomy before IVF has developed, without any evidence from prospective trials. The aim of the present prospective randomized trial was to test if a salpingectomy prior to IVF was effective in terms of increased pregnancy rates. Patients with hydrosalpinx were randomized to either a laparoscopic salpingectomy or no intervention before IVF. A total of 204 patients was available for an intention-to-treat analysis and 192 actually started IVF. Clinical pregnancy rates per included patient were 36.6% in the salpingectomy group and 23.9% in the non-intervention group (not significant, P = 0.067) and the ensuing delivery rates were 28.6% and 16.3% (P = 0.045). The corresponding delivery rates per transfer cycle were 29.5% versus 17. 5% (not significant, P = 0.083). A subgroup analysis revealed significant differences in favour of salpingectomy, in implantation rates in patients with bilateral hydrosalpinges (25.6% versus 12.3%, P = 0.038) and in clinical pregnancy rates (45.7% versus 22.5%, P = 0.029) and delivery rates (40.0% versus 17.5%, P = 0.038) in patients with ultrasound visible hydrosalpinges. The delivery rate was increased 3.5-fold in patients with bilateral hydrosalpinges visible on ultrasound (P = 0.019).     

Ultrasound-guided aspiration of hydrosalpinges is associated with improved pregnancy and implantation rates after in-vitro fertilization cycles

Previous reports have shown that the presence of hydrosalpinges may have a detrimental effect on in-vitro fertilization (IVF) outcomes and salpingectomy has been recommended by some authors as a means of improving IVF pregnancy rates. Our first objective was to determine the effect of hydrosalpinges diagnosed by ultrasound on IVF outcomes in our clinic. Our second objective was to examine the effects of aspiration of hydrosalpinges at the time of oocyte retrieval on IVF outcomes. Women with hydrosalpinges (n=34) were compared with women who had tubal disease but no hydrosalpinges (n=124) and were found to have a reduced clinical pregnancy rate (18 % versus 37%, P=0.053), a reduced ongoing pregnancy rate (15 versus 34%, P=0.051), and a reduced implantation rate (7 versus 18%, P=0.003) after IVF procedures. Among women with hydrosalpinges present, 16 had their hydrosalpinges aspirated at the time of oocyte retrieval and 18 did not. Aspiration of hydrosalpinges was associated with a higher clinical pregnancy rate (31 versus 5%, P=0.07), a higher ongoing pregnancy rate (31 versus 0%, P=0.015), and a higher implantation rate (14 versus 1%, P=0.015). This study confirms the association between the presence of hydrosalpinges and poor IVF outcomes. We find that aspiration of hydrosalpinges at the time of oocyte retrieval leads to improved pregnancy rates and may be an acceptable alternative to salpingectomy for treatment of these patients.      

Spontaneous bilateral cornual uterine dehiscence early in the second trimester after bilateral laparoscopic salpingectomy and in-vitro fertilization: case report.

A bilateral cornual uterine dehiscence is reported, which occurred 14 weeks after in-vitro fertilization (IVF) in a patient having a medical history of previous bilateral salpingectomy via laparoscopy. Uterine rupture is a rare obstetric complication usually occurring during the third trimester of pregnancy within a uterus which has previously undergone an operation. Ectopic pregnancy is a well known complication of IVF. Post-salpingectomy cornual localization with rupture has also been published. Possible causes are discussed and the attention of the counselling physician is directed to the necessary awareness of such a complication in this high risk population. The reported case is an extreme rarity: a similar case has not been previously published in the literature.     

A sporadic case of delayed implantation after in-vitro fertilization in the human?

A possible case of delayed implantation after in-vitro fertilization(IVF) is described. The patient was sterilized in 1981, andmade fertile again by tubal anastomosis in 1988. In 1990 and1992 the patient had two right-sided tubal pregnancies, thefirst was treated with prostaglandin instillation, the secondwith salpingectomy. In connection with the salpingectomy in1992, the left tube was observed to be constricted in the middlepart and with phimosis of the ostium. In 1994 three IVF embryoswere transferred, but 15 days after the transfer, serum humanchorionic gonadotrophin (HCG) was negative (<10 IU/ml). Sevenweeks after the embryo transfer, menstruation was still missing,and the serum HCG was now positive (329 IU/ ml). Subsequentultrasound scans were compatible with an intrauterine pregnancy,progressing normally, but 5 weeks delayed compared with theoocyte aspiration. The pregnancy was successfully carried toterm. Such a long delay in detection of HCG, in associationwith a normal pregnancy, has not been described in the literaturebefore.     

Hydrosalpinx and IVF outcome: cumulative results after salpingectomy in a randomized controlled trial.

BACKGROUND: A randomized controlled trial of salpingectomy prior to IVF in patients with hydrosalpinges has been conducted in Scandinavia. The results from the first transfer cycle have been published and clearly demonstrated an improved pregnancy outcome after salpingectomy had been performed in patients with hydrosalpinges large enough to be visible on ultrasound. The present article is aimed at analysing the effect of salpingectomy on cumulative birth rate, including all individual transfer cycles. METHODS AND RESULTS: A total of 186 women underwent 452 cycles. Among the 77 women randomized to no surgical intervention, 24 underwent salpingectomy after one or two failed cycles. Cumulative results were analysed by Cox regression, taking into account the number of cycles per patient and the presence of a salpingectomy after a previous transfer. Salpingectomy implied a significant increase in birth rate (hazard ratio 2.1, 95% CI 1.6-3.6, P = 0.014). Within the subgroup of patients with ultrasound-visible hydrosalpinges, the birth rate was even higher (hazard ratio 3.8, 95% CI 1.5-9.2, P = 0.004). Implantation rate was significantly higher in patients who had undergone salpingectomy (27.2% versus 20.2, P = 0.03) and, in the subgroup of patients with ultrasound-visible hydrosalpinges, the difference was even larger (30.3% versus 17.1%, P = 0.003). CONCLUSIONS: The results of the cumulative cycles strengthen the recommendation for a laparoscopic salpingectomy prior to IVF in patients with ultrasound-visible hydrosalpinges.     

Bilateral salpingectomy does not compromise ovarian stimulation in an in-vitro fertilization/embryo transfer programme

The question whether salpingectomy has a negative influenceon ovarian function and the outcome of pregnancy in an in-vitrofertilization (IVF) and embryo transfer treatment programmeis not yet answered. We performed a retrospective case-controlstudy to investigate the possible negative effect of salpingectomyon ovarian response to human menopausal gonadotrophins (HMG)during IVF and embryo transfer. The study group was composedof 26 patients with bilateral salpingectomy. In 67 cycles weanalysed different parameters of ovulation such as the numberof days of ovarian stimulation, numbers of ampoules of HMG,pre-ovulatory oestradiol concentrations and the numbers of oocytesretrieved. These parameters were compared to a control groupof 134 cycles in 134 women with healthy Fallopian tubes. Nodifferences were found. Implantation ratio, pregnancy rate andoutcome were the same in both groups. We conclude that bilateralsalpingectomy had no detrimental effect on ovarian performanceduring IVF and embryo transfer treatment nor on the outcome.     

A woman with three ectopic pregnancies after in-vitro fertilization and embryo transfer

Although a higher incidence of ectopic pregnancy has been reported after in-vitro fertilization (IVF) and embryo transfer, three ectopic pregnancies in the same woman is very rare. A patient of 32 years underwent IVF-embryo transfer six times within 3 years. Three of four conceptions resulted in ectopic pregnancies. The first involved simultaneous intrauterine and left tubal pregnancy, the second was a right tubal pregnancy, and the third was a right interstitial pregnancy. In IVF-embryo transfer, bilateral salpingectomy does not remove the risk of interstitial or cornual pregnancy.      

Cost--effectiveness analysis of salpingectomy prior to IVF, based on a randomized controlled trial

BACKGROUND: In patients with ultrasound-visible hydrosalpinges, salpingectomy prior to IVF increases the chance of a live birth. This study compared the cost-effectiveness of this strategy (intervention) with that of optional salpingectomy after a failed cycle (control). METHODS: Data from a Scandinavian randomized controlled trial were used to calculate the individual number of treatments and their outcomes. Only patients with ultrasound-visible hydrosalpinges were considered in the main analysis, and a maximum of three fresh cycles were included. The costs for surgical procedures, IVF treatment, medication, complications, management of pregnancy and delivery as well as of early pregnancy losses were calculated from standardized hospital charges. RESULTS: Among the 51 patients in the intervention group, the live birth rate was 60.8% compared with 40.9% in 44 controls. The average cost per patient was 13,943 euro and 12,091 euro, respectively. Thus, the average cost per live birth was 22,823 euro in the intervention group and 29,517 euro in the control group. The incremental cost-effectiveness ratio for adopting the intervention strategy was estimated at 9306 euro. CONCLUSIONS: The incremental cost to achieve the higher birth rate of the intervention strategy seems reasonable.     

Laparoscopic salpingectomy for women with hydrosalpinges enhances the success of IVF: a Cochrane review

BACKGROUND: The aim of this study was to determine whether surgical intervention is effective for women with tubal disease who are due to undergo treatment with IVF. METHODS: A systematic review employing the principles of the Cochrane Menstrual Disorders and Subfertility Group was undertaken. Three randomized controlled trials were included, the population of women in all three studies having hydrosalpinges. RESULTS: The odds of pregnancy [odds ratio (OR) = 1.75, 95% confidence interval (CI) 1.07-2.86] and of ongoing pregnancy and live birth (OR = 2.13, 95% CI 1.24-3.65) were increased with laparoscopic salpingectomy for hydrosalpinges prior to IVF. There were no significant differences in the odds of embryo implantation (OR = 1.34, 95% CI 0.87-2.05), ectopic pregnancy (OR = 0.42, 95% CI 0.08-2.14), miscarriage (OR = 0.49, 95% CI 0.16-1.52) or treatment complications (OR = 5.80, 95% CI 0.35-96.79). No data were available concerning the odds of multiple pregnancy or the proportion of IVF cycles resulting in embryo transfer. CONCLUSION: Laparoscopic salpingectomy should be considered for all women with hydrosalpinges due to undergo IVF; further research is required to assess other pre-IVF surgical interventions (such as needle aspiration of hydrosalpinx fluid, laparoscopic proximal tubal occlusion and laparoscopic salpingostomy) for women with hydrosalpinges.     

Hydrosalpinx and ART. Salpingectomy prior to IVF can be recommended to a well-defined subgroup of patients

The result of the Scandinavian multicentre study on salpingectomy prior to IVF has promoted a discussion on whether there is a risk of unnecessary salpingectomies being performed. We agree that physicians have to discriminate carefully between a hydrosalpinx that should be removed and one that is suitable for surgical repair. Tubal endoscopy is the most advanced tool for that purpose, while transvaginal ultrasound is not appropriate in selecting patients to undergo either salpingectomy or salpingostomy. The Scandinavian study showed that patients with hydrosalpinges which are large enough to be visible on ultrasound before ovarian stimulation, benefit from salpingectomy in terms of improved fertility outcome after IVF. The result of the study does not interfere with the management of distal tubal infertility in general, since it was concluded that not every woman with a large hydrosalpinx should undergo salpingectomy. Hydrosalpinges with preserved mucosa may be better treated with reconstructive surgery as primary treatment instead of salpingectomy and IVF. The latter option may, however, be the secondary treatment after failed conception and re-occlusion of the tubes. Unnecessary salpingectomies should, of course, not be performed and they may easily be avoided by appropriate evaluation of the tubal mucosa at laparoscopy before any final decision of salpingectomy is made. We do not see a major conflict: functional surgery to the tubes with healthy mucosa and salpingectomy to the dilated tubes that are visible on ultrasound and have a severely damaged mucosa.     

Salpingectomy improves the pregnancy rate in in-vitro fertilization patients with hydrosalpinx

The objective of this study was to assess the impact on pregnancyoutcome of excising hydrosalpinx(ges) in patients with repeatedin-vitro fertilization (IVF) failures. A group of 15 patientswho had previously undergone failed IVF attempts and had unilateralor bilateral hydrosalpinx was subjected to an operative laparoscopywith excision of the affected tube(s). Of these, 10 patientsunderwent a unilateral salpingectomy and five had a bilateralsalpingectomy. Stimulated cycles of IVF and/or cryo-thaw cycleswere then carried out post-salpingectomy and the results werecompared to those of pre-salpingec-tomy cycles. There was nostatistically significant difference between the number of matureeggs retrieved, peak oestra-diol concentrations, number of daysto human chorionic gonadotrophin administration, or number ofpre-zygotes frozen in the stimulated cycles pre- versus post-salpingectomy.Pre-salpingectomy, 15 patients underwent 38 stimulated cyclesand eight patients underwent 14 cycles with cryopreserved-thawedembryos, achieving one pregnancy from a fresh transfer thatresulted in a miscarriage. Post-salpingectomy, eight patientsunderwent 12 stimulated cycles, achieving five clinical pregnancies(two miscarriages and three ongoing pregnancies, i.e. eitherdelivered or a pregnancy >20 weeks), and nine patients underwent10 cycles with cryopreserved-thawed embryos, achieving fourclinical pregnancies (one miscarriage and three ongoing). Weconclude that excision of hydrosalpinx(ges) improves the pregnancypotential after IVF, and that new and repeat IVF patients shouldbe counselled accordingly.     

Pregnancy rates after in-vitro fertilization in cases of tubal infertility with and without hydrosalpinx: a meta-analysis of published comparative studies.

This meta-analysis was intended to evaluate differences in pregnancy rates after in-vitro fertilization (IVF) in tubal fertility with and without hydrosalpinx. It examined nine published retrospective comparative series and five series published as abstracts for which additional information was obtained. In all, these studies involved 5592 patients (1004 with hydrosalpinx and 4588 with tubal infertility without hydrosalpinx). The main outcome measures were rates of pregnancy, implantation, live delivery, and early pregnancy loss. Pregnancy rates were significantly lower in the presence of hydrosalpinx: 31.2% for the tubal sterility group without hydrosalpinx and 19.7% for the group with hydrosalpinx (odds ratio: 0.64; 95% confidence interval: 0.56, 0.74). Similarly, the implantation rate and the delivery rate per transfer in the hydrosalpinx group were only slightly more than half those of the non-hydrosalpinx group (implantation: 8.5 and 13.7%, respectively; delivery: 13.4 and 23.4%). The incidence of early pregnancy loss was also higher in the hydrosalpinx group (43.7%) than in the control group (31.1%). This meta-analysis makes it clear that hydrosalpinx present during IVF-embryo transfer has negative consequences on the rates of pregnancy, implantation, live delivery, and early pregnancy loss. It would be premature, nonetheless, to conclude that routine salpingectomy should be performed on all patients with hydrosalpinx.     

Uterine rupture in first or second trimester of pregnancy after in-vitro fertilization and embryo transfer

We report five cases of early rupture of cornual pregnancy withhistory of previous salpingectomy and cornual resection followingin-vitro fertilization (IVF) and embryo transfer. We discussthe predisposing factors, diagnostic and therapeutic modalitiesin these patients. A high index of suspicion is required foran early diagnosis. It is imperative that the physicians whocare for the patients be fully aware of the possibility of sucha complication in a high risk population; therefore, appropriatecounselling and close follow-up might help to avoid such obstetricalcatastrophes, by termination of pregnancy, either surgicallyor medically.     

Prophylactic salpingectomy does not impair the ovarian response in IVF treatment

To examine the effect of prophylactic salpingectomy in patients with hydrosalpinges on the ovarian response to stimulation prior to IVF, 26 patients were included in a study in which they acted as their own controls. They were all part of a randomized controlled study, in which they had been randomized to no surgical intervention prior to IVF. After one or two failed cycles, they underwent laparoscopic uni- or bilateral salpingectomy of their diseased tubes. The cycles before and after surgery were compared and the ovarian response was assessed as the dose and duration of gonadotrophins and the number of retrieved and fertilized oocytes. There were no significant differences in any of the measured outcomes. The increasing age between cycles did not influence the ovarian response, assessed by a comparison with two matched control groups from the same original study; 46 patients salpingectomized before IVF and 25 patients without surgery. It is concluded that removal of hydrosalpinx as a prophylactic laparoscopic procedure does not compromise ovarian function.     

The influence of hydrosalpinx on IVF and embryo transfer: a review

Several retrospective studies have shown an impaired outcomeof IVF in the presence of hydrosalpinx. The retrospective datahave been compiled and presented in meta-analyses, demonstratinga reduction by half in the probability of achieving a pregnancyin the presence of hydrosalpinx and a doubled rate of spontaneousabortion. The main theories trying to explain the underlyingmechanisms have focused on potential embryotoxic propertiesof the fluid or impaired endometrial receptivity to implantation.Several mouse studies have suggested an embryotoxic effect ofthe hydrosalpingeal fluid, a finding which is not supportedin studies on human embryos. It is believed that the fluid exertsa detrimental effect on the endometrium by altering the receptivityor simply by causing a mechanical hindrance for implantation.Different treatment options would then be tubal ligation, salpingostomy,aspiration of hydrosalpinx fluid or salpingectomy. The effectof aspiration has been studied in a few retrospective trialswith contradictory results. Treatment with salpingectomy hasentered into clinical practice without proper evidence for itsbenefit. Concerns have also been raised about the potentialhazard of surgical intervention to ovarian circulation and function.A randomized controlled trial on salpingectomy prior to IVFhas now been conducted as a multicentre study in Scandinavia.Laparoscopic salpingectomy prior to IVF was shown to be beneficialin patients with large hydrosalpinges that were visible on ultrasound,a result which supports the theory of the fluid being involvedin the impaired implantation process.     

Comparison of outcome of pregnancy after intra-uterine insemination (IUI) and IVF

INTRODUCTION: Pregnancy outcome after IVF has been shown to be worse than after spontaneous conception. There is discussion as to whether this results from the technique itself or the patient characteristics. This study compares pregnancy outcome after IVF and intra-uterine inemination (IUI) in a matched patient group. METHODS: Data were obtained from our IVF and IUI databases (1997-2001). Matching was performed for maternal age, parity and plurality, and 126 IUI pregnancies were compared with 126 IVF pregnancies. Outcome variables were pregnancy duration, birth weight, Caesarean section rates, preterm contraction rates, neonatal intensive care unit admission, Apgar score, blood loss rates and maternal hypertension. RESULTS: None of the analysed parameters was statistically different between the groups. CONCLUSION: This matched case-control study does not show different pregnancy outcomes after IVF and IUI. Since there is no reason to believe that the IUI technique in itself leads to an increased obstetric or neonatal risk, this study suggests that the worse pregnancy outcome after IVF as compared with spontaneous conceptions is due to the specific patient characteristics, rather than to the use of IVF itself.