Tubal infertility. Treatment implications of IVF and surgery regarding hydrosalpinx and ectopic pregnancy

Abstract

Tubal disease is a major cause of female infertility. Genital infection as the dominating aetiology, often results in hydrosalpinx formation and an increased risk of ectopic pregnancy.Objective: The aim of this study was to examine risk factors of ectopic pregnancy in patients treated by surgery or IVF and analyse pregnancy results after IVF in the subgroup of patients with hydrosalpinx. Further aims were to examine hydrosalpinx fluid for potential embryotoxic properties and determine whether intervention with salpingectomy was beneficial in terms of improved pregnancy rates in patients with hydrosalpinx undergoing IVF.Methods: Risk factors of ectopic pregnancy were retrospectively analysed by comparison of background data and variables related to the treatment, by means of logistic regression, in patients with a subsequent intrauterine or ectopic pregnancy. Pregnancy outcome in patients suffering from tubal infertility undergoing IVF was analysed with respect to presence of hydrosalpinx. The influence of hydrosalpinx fluid on human embryos was studied by analysing the effect of addition of hydrosalpinx fluid to culture medium with respect to blastocyst development. In a randomised controlled trial, patients with hydrosalpinx were randomised to laparoscopic salpingectomy or no intervention prior to IVF and subsequent pregnancy outcome was analysed. Results: Previous ectopic pregnancy was the most important risk factor of ectopic pregnancy after microsurgery and endometriosis was an additional risk factor. Patients with a previous ectopic pregnancy should therefore not be subjected to microsurgery but instead referred for IVF. However, the most important risk factor of ectopic pregnancy after IVF was tubal infertility. Myomectomy was identified as an additional risk factor. An association between the presence of hydrosalpinx and poor pregnancy outcome after IVF was demonstrated. The hydrosalpinx fluid was suggested to be involved in the mechanism explaining the impaired implantation. The embryo culture experiment did not support the presence of a potent embryotoxic factor and the negative action was more likely to be mediated by impaired implantation. Laparoscopic salpingectomy prior to IVF was shown to be beneficial in patients with large hydrosalpinges that were visible on ultrasound, which supports the theory of the fluid being involved in the impaired implantation process.