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.     

Salpingotomy or salpingectomy in tubal ectopic pregnancy: What do women prefer?

There is an ongoing debate whether tubal ectopic pregnancy should be treated by salpingotomy or salpingectomy. It is unknown which treatment women prefer in view of the potentially better fertility outcome but disadvantages of salpingotomy. This study investigated women surgically treated for tubal ectopic pregnancy and subfertile women desiring pregnancy and their preferences for salpingotomy relative to salpingectomy by means of a web-based discrete choice experiment consisting of 16 choice sets. Scenarios representing salpingotomy differed in three attributes: intrauterine pregnancy (IUP) chance, risk of persistent trophoblast and risk of repeat ectopic pregnancy. An ‘opt out’ alternative, representing salpingectomy, was similar for every choice set. A multinomial logistic regression model was used to analyse relative importance of the attributes. This study showed that the negative effect of repeat ectopic pregnancy was 1.6 times stronger on the preference of women compared with the positive effect of the spontaneous IUP rate. For all women, the risk of persistent trophoblast was acceptable if compensated by a small rise in the spontaneous IUP rate. The conclusion was that women preferred avoiding a repeat ectopic pregnancy to a higher probability of a spontaneous IUP in the surgical treatment of tubal ectopic pregnancy.An ectopic pregnancy occurs when a fertilized egg gets stuck inside the Fallopian tube where it starts growing instead of passing on to the uterus. This may lead to serious problems, such as internal bleeding and pain. Therefore, in the majority of women, it is necessary to remove the ectopic pregnancy by means of an operation. Two types of surgery are being used in removing the ectopic pregnancy. A conservative approach, salpingotomy, preserves the tube but bears the risk of incomplete removal of the pregnancy tissue (persistent trophoblast), which then needs additional treatment, and of a repeat ectopic pregnancy in the same tube in the future. A radical approach, salpingectomy, bears no risk of persistent trophoblast and limits the risk of repeat tubal pregnancy, but leaves only one tube for reproductive capacity. It is unknown which type of operation is better, especially for future fertility. We investigated women’s preferences between these two treatments for ectopic pregnancy, i.e. does a better fertility prognosis outweigh the potential disadvantages of persistent trophoblast and an increased risk for ectopic pregnancy in the future? The study results show in the surgical treatment of tubal ectopic pregnancy that women preferred avoiding a repeat ectopic pregnancy to gaining a higher chance of a spontaneous intrauterine pregnancy. The risk of additional treatment in the case of persistent trophoblast after salpingotomy was acceptable if compensated by a small rise in intrauterine pregnancy rate.     

Essure® hydrosalpinx occlusion prior to IVF-ET as an alternative to laparoscopic salpingectomy

Objective

To investigate the success rate of proximal tubal occlusion with Essure^® devices in subfertile women with unilateral or bilateral hydrosalpinx and to observe the results of subsequent treatment with IVF-ET and/or frozen embryo transfer.

Study design

Prospective, single-arm, clinical study in 20 women with unilateral or bilateral hydrosalpinges (all visible on transvaginal ultrasound) due to undergo IVF-ET and/or frozen embryo transfer. In all patients, laparoscopy was considered to be contraindicated due to extensive pelvic adhesions.

Result(s)

In all patients the Essure^® devices were placed in an ambulant setting without any complications. Proximal tubal occlusion was confirmed by hysterosalpingography in 19 out of 20 patients (95%) and in 26 of 27 treated tubes (96%). After 45 embryo transfer procedures in 19 patients, 18 pregnancies with 12 live births, 6 miscarriages and 1 immature delivery (probably related to cervical insufficiency leading to chorioamnionitis and subsequent rupture of the membranes) were observed.

Conclusion(s)

Essure^® devices are effective in inducing proximal tubal occlusion in subfertile patients with hydrosalpinges. After artificial reproductive treatments a cumulative live birth rate per patient of 63% and a cumulative live birth rate per transfer of 27% were achieved. The latter was related to the large proportion of patients with severe endometriosis.     

Laparoscopy or laparotomy for distal tubal surgery? A meta-analysis

Of couples with subfertility, 25% have complete or partial blockage of the fallopian tube. Since the advent of in vitro fertilization (IVF), the role of tubal surgery has diminished. However, this type of surgery continues to be undertaken on selected patients with mild tubal disease, and in those with severe tubal disease, in centres where IVF is not available. This systematic review was undertaken to compare pregnancy outcomes after laparoscopic surgery with that of open microsurgical technique. Studies comparing laparoscopic techniques with conventional microsurgery requiring laparotomy for treatment of distal tubal disease were included. The relevant trials were identified from Cochrane Menstrual Disorders and Subfertility Groups of Specialised Register of Controlled Trials (searched up to July 2005). The following strategies were adapted using the OVID platform, MEDLINE (1966 to July 2005), Cochrane Central Register of Control Trials, CENTRAL, and EMBASE (1980 to July 2005). Outcomes analysed were: 'take home baby' rate, intrauterine pregnancy rate and ectopic pregnancy rate per pregnancy. Subgroup analysis was carried out to compare intrauterine pregnancy rate in the laparoscopy and conventional microsurgery groups according to the extent of tubal damage. Six relevant studies were identified. Overall, no significant difference was observed in the intrauterine pregnancy rate between the two groups, combined OR 1.32 (95% confidence interval [CI], 0.58 - 3.02). For patients with mild tubal disease, there was no significant difference in the intrauterine pregnancy rate between treatment and control group, OR 1.06 (95% CI, 0.42 - 2.70). For patients with severe tubal disease, there was a significantly increased intrauterine pregnancy rate in the laparotomy group, OR 0.34 (95% CI, 0.14 - 0.86). Appropriate patient selection is the main factor affecting outcome in terms of fertility. These data do not indicate a significant difference in pregnancy rates between open and laparoscopic techniques for lesser degrees of tubal damage. Other factors, such as costs and hospital stay, will come into the decision making, and are likely to favour laparoscopic techniques. If a decision is made to open the badly damaged tubes of a patient, then an open microsurgical technique should be employed.     

Does tubal sterilization influence the subsequent risk of menorrhagia or dysmenorrhea?

OBJECTIVE: To evaluate the relation between tubal ligation, change in menstrual cycle characteristics, and early follicular phase hormones. DESIGN: Cross-sectional analysis of women 36-44 years of age. SETTING: The greater Boston area. PATIENT(S): Nine hundred seventy-six premenopausal women with intact uteri. INTERVENTION(S): A comparison of women with and without a history of tubal ligation. MAIN OUTCOME MEASURE(S): Menstrual and reproductive histories were self-reported. Early follicular phase blood samples were obtained to assess FSH, LH, and E(2). We compared menstrual cycle changes from the first 5 years after menarche with completion of the baseline questionnaire in women with and without a prior history of tubal ligation. RESULT(S): Cycle length, cycle regularity, menses length, flow volume, dysmenorrhea, and hormone levels were similar in women with and without a history of tubal ligation. However, among parous women with a history of cesarean section, those with a tubal ligation >5 years ago experienced a marginal increase in volume of menstrual flow compared with women with no tubal ligation history. CONCLUSION(S): We found no significant change in menstrual cycle characteristics or hormone levels in women with or without a history of tubal ligation. However, tubal ligation may have a modest effect on the change in menstrual flow volume over time among parous women with a history of cesarean section.     

Additional salpingectomy after previous prophylactic oophorectomy in high-risk women: sense or nonsense?

OBJECTIVES: Since BRCA1/2 germ line mutation carriers are also at a higher risk of developing fallopian tube carcinoma, resection of the fallopian tubes is currently included at the time of risk reducing surgery. In this study, we comment on the need of additional bilateral prophylactic salpingectomy (BPS) following previous bilateral prophylactic oophorectomy (BPO) in women at high risk of ovarian cancer. METHODS: Retrospectively, the medical files of 42 high-risk women, who had undergone BPO only, were reviewed. RESULTS: In our center, risk-reducing surgery consisted of BPO only for 42 women. Twenty-seven women received an informative letter in which counseling for additional BPS was offered. In total, 15 women opted for additional BPS. Surgery was performed with a mean interval of 65 months (range 6-101) in 10 BRCA1 carriers, one BRCA2 carrier, one BRCA1 and 2 carrier, and three women with non-informative test results. The procedure was readily done by laparoscopy in 13 women and two needed a laparotomy. No post-operative complications had occurred. Histopathological examination revealed no malignancy. CONCLUSIONS: We believe that additional risk reduction of cancer necessitates BPS in BRCA1/2 carriers after previous BPO. BPS after previous BPO was easily performed. Today, physicians should include resection of the fallopian tube at prophylactic surgery in high-risk women and should consider additional BPS in women who have undergone BPO only.     

Pyosalpinx caused by the tubal migration of an intrauterine device – a case report

Migration of an intrauterine device (IUD) is a complication occurring at or following insertion. After having perforated the uterine wall, the IUD usually will settle into the peritoneal cavity. Tubal migration of an IUD is extremely rare and little is known about its mechanism. We describe a case of pyosalpinx caused by the tubal migration of a copper IUD. The tail of the device was embedded in the mesocolon.     

Can open tubal microsurgery still be helpful in tubal infertility treatment?

In 30 years, 1,669 patients underwent open microsurgery for tubal diseases. Several techniques like adhesiolysis, reanastomosis, fimbrioplasty, salpingoneostomy, proximal reconstruction, isthmo-ostial anastomosis and reimplantation are described. Results were excellent for patients with a favourable prognosis (1,517 patients) and with very high pregnancy rate: 80% pregnancies with delivery for tubal reversal, 68% for proximal diseases, 75.1% for fimbrioplasty and 55% for salpingoneostomy. Risks of ectopic pregnancy were very low: 1.5% for tubal reversal (because the tubes were healthy), 4% for proximal diseases, 4% for fimbrioplasty and 6.7% for salpingoneostomy. Results were very low for patients with a poor prognosis (152 patients): 10% pregnancies with delivery for distal diseases, less than 20% for proximal diseases and 22% ectopic pregnancies. Open microsurgery can still be helpful in treating tubal infertility: results are better than those obtained with laparoscopic reconstructive surgery and better than those obtained with in vitro fertilization for patients with a favourable prognosis. Patients are only operated one time and can have several pregnancies. Open tubal microsurgery is a minimal invasive surgery and saves costs (it requires a small number of instruments and minimises sutures; patients can return home 4 days after surgery, at the latest). Results on fertility are very favourable.     

Pomeroy technique or Filshie clips for postpartum sterilisation? Retrospective study on comparison between Pomeroy procedure and Filshie clips for a tubal occlusion at the time of Caesarean section

Objective  

To compare the failure rate (pregnancies) of a Pomeroy procedure and Filshie clips tubal occlusion at the time of Caesarean section.     

An artificial sperm – next year or never?

The idea that a sperm or egg might be formed outside of a gonad is perhaps as bizarre today as human assisted conception and test-tube babies were 30–40 years ago and has received a similar amount of media copy. Here, we review briefly the derivation of mammalian germ cells and sperm cells from embryonic stem cells in?vitro, ask whether these methods are viable and could provide therapies in the future, and discuss what constitutes an ‘artificial’ sperm.     

Vaginal delivery or cesarean section at term breech delivery – chance or risk?

Aim: The aim of the study was to examine maternal age, parity, and estimated neonatal birth weight (BW) depending on the mode of a full-term breech presentation (BP) birth delivery and neonatal outcomes.

Material and methods: One hundred and forty-six singleton term breech presentation pregnancies were included in a retrospective study conducted at the Department of Gynecology/Obstetrics, Clinical Center of Serbia in Belgrade in 2013. Statistical analysis: Student's-t test, χ² likelihood ratio, and the Fisher's exact test. The level of statistical significance was set at p?<0.05.

Results: An ECS was the most common mode of delivery in (81.2%) nulliparous older than 35 years and most of the neonates (66.67%) with an estimated birth weight (BW) above 3500 grams were delivered by elective cesarean section (ECS). Perinatal asphyxia remained increased in the successful vaginal delivery (SVD) group (23.8%) compared with the urgent CS (UCS) group (13.3%) (p?=?0.035). Birth asphyxia was the most common in neonates were delivered by SVD (23.8%). There were no cases of perinatal deaths.

Conclusion: ECS remained the recommended mode of breech term delivery in nulliparous women older than 35 years, as well as in neonates with an estimated BW above 3500 grams.     

Controversy on the method of sterilization during cesarean section: tubal ligation or hysterectomy? Review of the literature

During 1982-1992, 111 cesarean sections followed by 109 tubal ligations (Pomeroy method) and two hysterectomies were performed at two hospitals in Yaounde, Cameroon. All the patients were informed of the necessity of limiting births because of risks posed by future pregnancies. All women gave informed consent. The leading indications for cesarean section were limited pelvis associated with previous cesarean section(s)-related scarred uterus (59 cases) and fetal distress (33 cases). The two principal indications for tubal ligation were previous cesarean sections (64 cases) and grand multiparity (i.e., 5 births) (45 cases). 37.1% of tubal ligation cases had more than five children. The number of tubal ligation cases after cesarean section was highest in 1983 (16 cases), 1984 (13 cases), 1990 (16 cases), 1991 (13 cases), and 1992 (12 cases). No woman younger than 24 years old underwent tubal ligation. 77.1% of tubal ligations occurred to women aged 30-40. Immediate hysterectomy was required in two cases to control severe hemorrhaging. Three tubal ligation cases lost more than 1000 cc of blood and had to be transfused. All 111 cesarean section cases received prophylactic antibiotics. The surgeon perforated the bladder of a patient who had had three previous cesarean sections when he/she dissected the lower segment of the peritoneal cavity. This case suffered no postoperative complications. Surgeons had to reintervene two hours after the tubal ligation because the ligature thread loosened at the level of the two fallopian tubes, causing a hemorrhage. No one developed fever. There were no fetal or maternal deaths. The peri- and post-operative complication rate was lower than that of other like studies. The researchers recommend tubal ligation as the preferable sterilization method after cesarean section. Hysterectomy should only be used in cases of severe hemorrhaging which can lead to maternal death.