Case Report: Treating Hydrosalpinx by Surgical Removal (Salpingectomy) as a Prelude to IVF

Case Report:

**For the purposes of anonymity, I will be referring to the patient as RL throughout this blog.**

RL, a 31-year-old woman, presented with a 7 year history of inability to conceive, in spite of 2 prior fresh and 1 frozen IVF attempts, where a total of six good quality blastocysts had been transferred to her uterus. Her husband PL, had normal sperm and had initiated 2 pregnancies in a prior relationship.

RL had normal ovarian reserve (based on prior blood FSH and AMH levels, good follicle development, and good egg/embryo quality during her 2 fresh IVF cycles). A prior hysterosalpingogram (dye X-ray/HSG) had revealed the cause of this couple’s infertility to be blockage of the ends of both Fallopian tubes, which was traceable back to an episode of Chlamydia-induced pelvic inflammatory disease (PID) in her teen years.

A routine pelvic ultrasound that I performed revealed a cystic lesion to the right of her uterus. It suggested a hydrosalpinx (a fluid-distended Fallopian tube). I recommended a laparoscopy to confirm the diagnosis and then the removal of the affected tube(s). She underwent a laparoscopy, where it was found that while her right tube was most affected, both tubes in fact were hysdrosalpinges. Because both tubes were diseased and functionless, I surgically removed them (salpingectomy).

RL subsequently underwent a third fresh cycle of IVF (her first at SIRM), where I transferred 2 good quality blastocysts (and cryopreserved 3 remaining embryos for future use). She went on to conceive, and recently gave birth via cesarean section to a healthy full term baby girl.

Discussion:

Damage to the Fallopian tubes as a result of prior pelvic inflammation is one of the most common female causes of infertility. Commonly (as was the case with RL), this results in blockage of the tubes at their ends, while leaving them open and connected to the uterine cavity. In such cases, the Fallopian tubes often progressively fill with fluid (hydrosalpinx) that contains dead cells and other noxious products, which are potentially toxic to embryos.

Leakage of such fluid backwards into the uterus can severely compromise implantation of transferred embryos. This is why women with hydrosalpinges are strongly advised to have the diseased tubes removed or ligated (at the point that they emerge from the uterine wall), prior to undergoing embryo transfer.  Admittedly, it is often hard for patients to accept that their tubes will be gone, as it means that future conception will require IVF. This is where it is necessary to explain that such tubes are non-functioning, and that even if they could be opened through surgery, the likelihood of pregnancy would be remote.

In RL’s case, there was a high likelihood that her failure to conceive was due solely to the above mentioned effect.  And so with all else working in her favor (young age, normal male fertility, good ovarian response and a receptive uterus), removal of the hydrosalpinges led to her conceiving in a subsequent IVF attempt. Hopefully, should she desire to have another baby in the future, she will be able to readily do so using her remaining cryostored embryos.

Women with tubal occlusion who want to have a baby will invariably require IVF.  In many such cases, one or both of their tubes will, over time, have progressively filled with toxic fluid that can drain back into the uterine cavity and thwart post-ET implantation. It follows that all cases of tubal blockage should be carefully evaluated for hydrosalpinges before ET, and that when detected, they first be surgically addressed through tubal ligation or removal (salpingectomy).

6 Comments

danielle

For hydrosalpingix, can you do stimulation for egg retrieval/embryo freezing first, then remove the tube before implantation? Does this affect IVF outcomes?

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Dr. Geoffrey Sher

Yes you can. You would freeze the blastocysts, do the surgery and the come back after recovery and do an FET using the cryostored blastocysts…in a subsequent cycle.

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Emily

I just read your case study blog on removal of hydrosalpinx. I recently was diagnosed with one in July. I’m in the process of undergoing IVF and am going to have egg banking cycles in hopes of getting a good number of embryos during the last banking cycle when they are fertilized. (I would have preferred embryo banking but cost is almost double).

Anyways, my RE said we can evaluate whether my tube needs to be removed during these banking cycles as she can see whether any fluids are seen when monitoring during these times. I guess she is fairly conservative and thinks if it isn’t completely necessary we wont’ remove them.

My other tube might be blocked but the diagnosis during HSG was slightly inconclusive. The blockage would be at the beginning and not the end as it is in the other tube which as the hydrosalpinx. The diagnosis was a big surprise to me. I have had two miscarriages from natural pregnancies and also one chemical pregnancy – also natural. She tested me for the various chlamydia strains and all were negative. To my knowledge I’ve never had any of the obvious causes for blocked tubes. The last mc was already 2 years ago and I haven’t been able to get pregnant since then though. The only guess I have is the hysteroscopy I had two years ago because there was a small tissue left that had to be removed.

I guess I have two questions. Do you think it will be conclusive to see whether or not to remove the tube based on u/s monitoring for fluids? And what could be other causes for my blocked tubes? I’m completely stumped as to how it happened. From the miscarriages?

Thank you Dr. Sher.

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Dr. Geoffrey Sher

The detection by US (if done expertly) would likely be conclusive but the inability to detect it, might not be as reliable. If it is not seen, I would probably still do a hysterosalpingogram.

Geoff Sher

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Emily

Thanks for the reply. So you are saying we should be able to know that it must be removed if we see fluids – but not necessarily conclusive if we don’t see anything so can’t be sure whether it is safe to leave them? So you would suggest a repeat of the HSG after egg retrievals but before embryo transfer?

How about the cause? Is the miscarriage that left some kind of tissue in the uterus the most likely cause in my case?

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Dr. Geoffrey Sher

Clearly you did develop tubal infection, either secondary to inflammation of retained products of conception (endometritis) or independent sexually transmitted tubal inflammation. I believe the former is more likely.

And, yes, you need an HSG prior to FET.

Geoff sher

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