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Management of hydrosalpinx before or during in vitro fertilization–embryo transfer: a national postal survey in France

2006; Elsevier BV; Volume: 86; Issue: 4 Linguagem: Inglês

10.1016/j.fertnstert.2006.02.120

1556-5653

Guillaume Ducarme, Michèle Uzan, Jean‐Noël Hugues, Isabelle Cédrin‐Durnerin, C. Poncelet,

Ovarian function and disorders

Using an anonymous and sealed questionnaire sent to all French IVF centers, the current management of hydrosalpinx before or during IVF was evaluated. Laparoscopic salpingectomy was recommended and undertaken in less than half of the centers, even though several other treatments were reported and despite medical evidence for this surgical option. Using an anonymous and sealed questionnaire sent to all French IVF centers, the current management of hydrosalpinx before or during IVF was evaluated. Laparoscopic salpingectomy was recommended and undertaken in less than half of the centers, even though several other treatments were reported and despite medical evidence for this surgical option. Tubal infertility remains one of the major indications for IVF. The cause of tubal infertility is also an important factor that could influence IVF results (1Camus E. Poncelet C. Goffinet F. Wainer B. Merlet F. Nisand I. Philippe H.J. Pregnancy rates after in-vitro fertilization in cases of tubal infertility with and without hydrosalpinx: a meta-analysis of published comparative studies.Hum Reprod. 1999; 14: 1243-1249Crossref PubMed Scopus (235) Google Scholar). Several reports have confirmed that the presence of distal tubal occlusion with unilateral or bilateral hydrosalpinx significantly impaired IVF outcomes (2Strandell A. Waldenstrom U. Nilsson L. Hamberger L. Hydrosalpinx reduces in-vitro fertilization/embryo transfer pregnancy rates.Hum Reprod. 1994; 9: 861-863PubMed Google Scholar, 3Strandell A. Lindhard A. Waldenstrom U. Thorburn J. Janson P.O. Hamberger L. Hydrosalpinx and IVF outcome: a prospective randomized multicenter trial in Scandinavia on salpingectomy prior to IVF.Hum Reprod. 1999; 14: 2762-2769Crossref PubMed Scopus (271) Google Scholar, 4Vandromme J. Chasse E. Lejeune B. Van Rysselberge M. Delvigne A. Leroy F. Hydrosalpinges in in-vitro fertilization: an unfavourable prognostic feature.Hum Reprod. 1995; 10: 576-579PubMed Google Scholar, 5Wainer R. Camus E. Camier B. Martin C. Vasseur C. Merlet F. Does hydrosalpinx reduce the pregnancy rate after in vitro fertilization?.Fertil Steril. 1997; 68: 1022-1026Abstract Full Text PDF PubMed Scopus (51) Google Scholar, 6Dechaud H. Daures J.P. Amal F. Humeau C. Hedon B. Does previous salpingectomy improve implantation and pregnancy rates in patients with severe tubal factor infertility who are undergoing in vitro fertilization? A pilot prospective randomised study.Fertil Steril. 1998; 69: 1020-1025Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar). Only one proper evaluation concerning the management of ultrasound-visible hydrosalpinges before IVF has been reported, in 1999, and showed an increased pregnancy rate after salpingectomy before IVF (3Strandell A. Lindhard A. Waldenstrom U. Thorburn J. Janson P.O. Hamberger L. Hydrosalpinx and IVF outcome: a prospective randomized multicenter trial in Scandinavia on salpingectomy prior to IVF.Hum Reprod. 1999; 14: 2762-2769Crossref PubMed Scopus (271) Google Scholar). Furthermore, in 2004, a meta-analysis reported in the Cochrane Database Systematic Review, concluded that laparoscopic unilateral or bilateral salpingectomy should be recommended for all women with unilateral or bilateral hydrosalpinx before an IVF attempt (7Johnson N.P. Mak W. Sowter M.C. Surgical treatment for tubal disease in women due to undergoing in-vitro fertilisation.Cochrane Database Syst Rev. 2004; 3: CD002125PubMed Google Scholar). However, in France, until now no current therapeutic consensus has been found concerning this setting. Many other simple methods to treat hydrosalpinges, such as salpingostomy, proximal tubal occlusion, and ultrasound-guided transvaginal aspiration of hydrosalpinx fluid, have been described. Their respective interest has been demonstrated mainly from retrospective studies without control groups (8Aboullghar M.A. Mansour R.T. Serour G. Sattar M. Awad M. Amin Y. Transvaginal ultrasonic needle guided aspiration of pelvic inflammatory cystic masses before ovulation induction for in vitro fertilization.Fertil Steril. 1990; 53: 311-314PubMed Google Scholar, 9Stadtmauer L.A. Riehl R.M. Toma S.K. Talbert L.M. Cauterization of hydrosalpinges before in vitro fertilization is an effective surgical treatment associated with improved pregnancy rates.Am J Obstet Gynecol. 2000; 183: 367-371Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 10Murray D.L. Sagoskin A.W. Widra E.A. Levy M.J. The adverse effect of hydrosalpinges on in vitro fertilization pregnancy rate and the benefit of surgical correction.Fertil Steril. 1998; 69: 41-45Abstract Full Text PDF PubMed Scopus (105) Google Scholar, 11Surrey E.S. Schoolcraft W.B. Laparoscopic management of hydrosalpinges before in vitro fertilization–embryo transfer: salpingectomy versus proximal tubal occlusion.Fertil Steril. 2001; 75: 612-617Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar). Easily realized, these options lacked clear clinical evaluation. Recently, Hammadieh et al. (12Hammadieh N. Afnan M. Evans J. Sharif K. Amso N. Olufowobi O. A postal survey of hydrosalpinx management prior to IVF in the United Kingdom.Hum Reprod. 2004; 19: 1009-1012Crossref PubMed Scopus (22) Google Scholar) reported a survey of hydrosalpinx management before IVF treatment in the United Kingdom. Their interesting results highlighted a wide variation in hydrosalpinx management before IVF, with many treatment options that could be questionable. The aim of the present survey was to determine the current hydrosalpinx management choices before or during an IVF attempt, and the frequency of their use in France. All registered IVF centers in France (100 centers) were surveyed by first-class mail with anonymous sealed questionnaires asking for their management of hydrosalpinges in infertile women before IVF treatment. Postage-paid return envelopes were provided. The clinicians and biologists were asked to assess their center's attitudes to hydrosalpinx management and how frequently each treatment was used. Hydrosalpinx diagnosis was made by hysterosalpingography, pelvic ultrasound, and/or laparoscopy. The treatment options for unilateral and bilateral hydrosalpinx were medical treatment, transvaginal sonographic aspiration, transvaginal sonographic aspiration with or without medical treatment, and surgical treatment. Medical treatment consisted in antibiotics with or without corticoids. Transvaginal sonographic aspiration was done before or during oocyte collection. For surgical management, the different treatment options were laparoscopic salpingostomy, salpingectomy, proximal tubal occlusion, or laparotomic salpingectomy. Each center could offer more than one treatment modality, so the numbers and percentages exceeded the total number of centers. Only one questionnaire was sent to the official gynecologists and biologists at each of the 100 registered assisted reproductive technology (ART) centers in France. Eighty-two centers replied to the letters up to 4 months after the questionnaires had been mailed. No responding center was excluded from the survey. Most of them (55 of 82; 67%) had 10–20 years of experience in infertility. Fifty-one percent of the responding ART centers were in public hospitals. Eighty-three percent (68 of 82) of the IVF units had an infertility-specialized surgeon and discussed the management of hydrosalpinx before IVF treatment in multidisciplinary staff. Eighty (98%) of the 82 responders indicated that they discussed prospectively the effect of hydrosalpinx on the IVF outcome. Six centers (7.5%) suggested no specific hydrosalpinx treatment, whereas 12 (15%), 53 (66.2%), and 9 (11.3%) suggested any treatment casually, strongly, and very strongly, respectively. Treatment options (N = 171) proposed by physicians, summarized in Table 1, were medical treatment (n = 38; 22.2%), transvaginal sonographic aspiration with or without medical treatment (n = 22; 12.9%), and surgical treatment (n = 111; 64.9%). No difference was observed concerning unilateral or bilateral hydrosalpinx management. No pre– or post–hydrosalpinx treatment data were available concerning IVF results. Eleven percent of the centers had guidelines for hydrosalpinx management.TABLE 1Treatment options offered by clinicians or biologists (total = 171).Category/treatment optionn (% of total)n (% of category)Surgical treatment111/171 (64.9) Laparoscopy/salpingectomy75 (67.6) Laparotomy/salpingectomy2 (1.8) Salpingostomy24 (21.6) Proximal tubal occlusion10 (9)Medical treatment38/171 (22.2) Antibiotics31 (81.6) Corticoids0 (0) Antibiotics + corticoids7 (18.4)Ultrasound-guided aspiration with or without medical treatment22/171 (12.9) Without treatment During oocyte collection7 (31.8) Before oocyte collection6 (27.3) With treatment9 (40.9)Note: The numbers and percentages exceed the total number of ART centers (82 respondents of 100 surveyed) because each center offered more than one treatment modality.Ducarme. Hydrosalpinx management and IVF in France. Fertil Steril 2006. Open table in a new tab Note: The numbers and percentages exceed the total number of ART centers (82 respondents of 100 surveyed) because each center offered more than one treatment modality. Ducarme. Hydrosalpinx management and IVF in France. Fertil Steril 2006. The negative correlation between the presence of hydrosalpinx and IVF outcome is supported by the overwhelming consistency in many studies (2Strandell A. Waldenstrom U. Nilsson L. Hamberger L. Hydrosalpinx reduces in-vitro fertilization/embryo transfer pregnancy rates.Hum Reprod. 1994; 9: 861-863PubMed Google Scholar, 3Strandell A. Lindhard A. Waldenstrom U. Thorburn J. Janson P.O. Hamberger L. Hydrosalpinx and IVF outcome: a prospective randomized multicenter trial in Scandinavia on salpingectomy prior to IVF.Hum Reprod. 1999; 14: 2762-2769Crossref PubMed Scopus (271) Google Scholar, 4Vandromme J. Chasse E. Lejeune B. Van Rysselberge M. Delvigne A. Leroy F. Hydrosalpinges in in-vitro fertilization: an unfavourable prognostic feature.Hum Reprod. 1995; 10: 576-579PubMed Google Scholar, 6Dechaud H. Daures J.P. Amal F. Humeau C. Hedon B. Does previous salpingectomy improve implantation and pregnancy rates in patients with severe tubal factor infertility who are undergoing in vitro fertilization? A pilot prospective randomised study.Fertil Steril. 1998; 69: 1020-1025Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 9Stadtmauer L.A. Riehl R.M. Toma S.K. Talbert L.M. Cauterization of hydrosalpinges before in vitro fertilization is an effective surgical treatment associated with improved pregnancy rates.Am J Obstet Gynecol. 2000; 183: 367-371Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 10Murray D.L. Sagoskin A.W. Widra E.A. Levy M.J. The adverse effect of hydrosalpinges on in vitro fertilization pregnancy rate and the benefit of surgical correction.Fertil Steril. 1998; 69: 41-45Abstract Full Text PDF PubMed Scopus (105) Google Scholar, 11Surrey E.S. Schoolcraft W.B. Laparoscopic management of hydrosalpinges before in vitro fertilization–embryo transfer: salpingectomy versus proximal tubal occlusion.Fertil Steril. 2001; 75: 612-617Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar). One meta-analysis has clearly demonstrated a pregnancy probability reduction and an increased spontaneous abortion risk in the presence of hydrosalpinx (1Camus E. Poncelet C. Goffinet F. Wainer B. Merlet F. Nisand I. Philippe H.J. Pregnancy rates after in-vitro fertilization in cases of tubal infertility with and without hydrosalpinx: a meta-analysis of published comparative studies.Hum Reprod. 1999; 14: 1243-1249Crossref PubMed Scopus (235) Google Scholar). Experimental results were in line with this clinical observations (13David A. Garcia C.R. Czernobilsky B. Human hydrosalpinx Histologic study and chemical composition of fluid.Am J Obstet Gynecol. 1969; 105: 400-411Abstract Full Text PDF PubMed Scopus (47) Google Scholar, 14Sachdev R. Kemman E. Bohrer M.K. el-Danasouri I. Detrimental effect of hydrosalpinx fluid on the development and blastulation of mouse embryos in vitro.Fertil Steril. 1997; 68: 531-533Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 15Rawe V.J. Liu J. Shaffer S. Compton M.G. Garcia J.E. Katz E. Effect of human hydrosalpinx fluid on murine embryo development and implantation.Fertil Steril. 1997; 68: 668-670Abstract Full Text PDF PubMed Scopus (47) Google Scholar, 16Lessey B.A. Yeh I. Castelbaum A.J. Fritz M.A. Ilesanmi A.O. Korzeniowski P. et al.Endometrial progesterone receptors and markers of uterine receptivity in the window of implantation.Fertil Steril. 1996; 65: 477-483PubMed Google Scholar). Moreover, salpingectomy has shown its positive impact on endometrial receptivity (17Meyer W.R. Castelbaum A.J. Somkuti S. Sagoskin A.W. Doyle M. Harris J.E. et al.Hydrosalpinges adversely affect markers of endometrial receptivity.Hum Reprod. 1997; 12: 1393-1398Crossref PubMed Scopus (246) Google Scholar) and IVF results. Clear recommendations have been formulated (3Strandell A. Lindhard A. Waldenstrom U. Thorburn J. Janson P.O. Hamberger L. Hydrosalpinx and IVF outcome: a prospective randomized multicenter trial in Scandinavia on salpingectomy prior to IVF.Hum Reprod. 1999; 14: 2762-2769Crossref PubMed Scopus (271) Google Scholar, 7Johnson N.P. Mak W. Sowter M.C. Surgical treatment for tubal disease in women due to undergoing in-vitro fertilisation.Cochrane Database Syst Rev. 2004; 3: CD002125PubMed Google Scholar). The negative effect of untreated hydrosalpinx on IVF-ET outcome seemed of immense interest to fertility specialists, and this may explain the high return rate (82%). However, no treatment difference was observed between unilateral or bilateral hydrosalpinx. Only 2% of the responding ART centers in France did not discuss the deleterious effects of hydrosalpinx on IVF outcome with patients, and only 7.5% recommended no treatment, whereas 77.5% recommended strongly or very strongly any treatment. In order to improve the chances of a full-term pregnancy in patients with hydrosalpinx undergoing IVF, different approaches have been purposed in the literature. Table 1 shows a wide variation in treatment modalities offered to patients, with 67.6% surgical treatment, 44% of which is radical treatment. In contrast to Hammadieh et al. (12Hammadieh N. Afnan M. Evans J. Sharif K. Amso N. Olufowobi O. A postal survey of hydrosalpinx management prior to IVF in the United Kingdom.Hum Reprod. 2004; 19: 1009-1012Crossref PubMed Scopus (22) Google Scholar), in our experience only 2% of centers still performed open salpingectomy (compared with 45% in the United Kingdom). Explanations for this discrepancy between the United Kingdom and France remained unclear. Unilateral or bilateral salpingostomy can be performed by laparoscopy with conservative ovarian functions (4Vandromme J. Chasse E. Lejeune B. Van Rysselberge M. Delvigne A. Leroy F. Hydrosalpinges in in-vitro fertilization: an unfavourable prognostic feature.Hum Reprod. 1995; 10: 576-579PubMed Google Scholar, 10Murray D.L. Sagoskin A.W. Widra E.A. Levy M.J. The adverse effect of hydrosalpinges on in vitro fertilization pregnancy rate and the benefit of surgical correction.Fertil Steril. 1998; 69: 41-45Abstract Full Text PDF PubMed Scopus (105) Google Scholar, 18Kassabji M. Sims J.A. Butler L. Muasher M.J. Reduced pregnancy outcome in patients with unilateral or bilateral hydrosalpinx after in-vitro fertilization.Eur J Obstet Gynecol Reprod Biol. 1994; 56: 129-132Abstract Full Text PDF PubMed Scopus (98) Google Scholar, 19Shelton K.E. Butler L. Toner J.P. Oehninger S. Muasher S.J. Salpingectomy improves the pregnancy rate in in-vitro fertilization patients with hydrosalpinx.Hum Reprod. 1996; 11: 523-525Crossref PubMed Scopus (102) Google Scholar, 20Bredkjaer H.E. Ziebe S. Hamid B. Zhou Y. Loft A. Lindhard A. et al.Delivery rates after in-vitro fertilization following bilateral salpingectomy due to hydrosalpinges: a case control study.Hum reprod. 1999; 14: 101-105Crossref PubMed Scopus (41) Google Scholar, 21Verhulst G. Vandersteen N. Van Steirteghem A.C. Devroey P. Bilateral salpingectomy does not compromise ovarian stimulation in an in-vitro fertilization/embryo transfer programme.Hum Reprod. 1994; 9: 624-628Crossref PubMed Scopus (49) Google Scholar, 22Lass A. Ellenbogen A. Croucher C. Trew G. Margara R. Beccatini C. et al.Effect of salpingectomy on ovarian response to superovulation in an in-vitro fertilization–embryo transfer program.Fertile Steril. 1998; 70: 1035-1038Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar). This treatment was offered by 21.6% of the responders, but only 16% of them used it very frequently. In the units with first-intention surgical treatment, responders recommended a conservative attitude in 56% (46 of 82), exclusively represented by salpingostomy. Efficacy and costs of selected conservative surgery versus radical management with IVF should be specifically analyzed, especially in countries where the number of IVF attempts has been limited. Furthermore, in women with hydrosalpinx, the spontaneous intrauterine pregnancy rate with repaired tubes should be the first endpoint of tubal infertility management. Good surgical indications and techniques allowing pregnancy chances at each menstrual cycle should not be forgotten, in contrast to few very costly IVF attempts. A laparoscopy with a proper tubal evaluation, including mucosal status can be done primarily (23Boer-Meisel M.E. te Velde E.R. Habbema J.D. Kardaun J.W. Predicting the pregnancy outcome in patients treated for hydrosalpinx: a prospective study.Fertil Steril. 1986; 45: 23-29Abstract Full Text PDF PubMed Scopus (138) Google Scholar). Conservative surgery (neosalpingostomy) should not be denigrated in selected cases. Therefore, systematic laparoscopic (LSC) salpingectomy could be questionable, because of no chance of natural pregnancy, although only this treatment has been actually evaluated. Our results recalled previous considerations (24Puttemans P.J. Brosens I.A. Salpingectomy improves in-vitro fertilization outcome in patients with a hydrosalpinx: blind victimization of the fallopian tube?.Hum Reprod. 1996; 11: 2079-2081Crossref PubMed Scopus (58) Google Scholar). The discrepancy between proposed and actually undertaken treatments recalled the radical solution of LSC salpingectomy, especially in infertile patients. Bilateral salpingectomy seemed to be not easily accepted. Furthermore, physicians should be convinced that LSC salpingectomy could be the best option for patients with deeply damaged tubes. Individual beliefs or personal experiences are obstacles. In patients with hydrosalpinx, this treatment should be discussed before any fertility surgery or IVF attempt. In cases of significant pelvic adhesions or long history of pelvic surgeries, medical treatment alone (antibiotics and/or corticoids), aspiration of hydrosalpinx fluid with or without antibiotics, or proximal tubal occlusion could be interesting options for hydrosalpinx management (25VanVoorhis B.J. Sparks A.E. Syrop C.H. Stoval C.H. Ultrasound-guided aspiration of hydrosalpinges is associated with improved pregnancy and implantation rates after in-vitro fertilization cycles.Hum Reprod. 1998; 13: 736-738Crossref PubMed Scopus (70) Google Scholar, 26Strandell A. The influence of hydrosalpinx on IVF and embryo transfer: a review.Hum Reprod. 2000; 6: 523-525Crossref Scopus (43) Google Scholar, 27Rosenfield R.B. Stones R.E. Coates A. Matteri R.K. Hesla J.S. Proximal occlusion of hydrosalpinx by hysteroscopic placement of microinsert before in vitro fertilization–embryo transfer.Fertil Steril. 2005; 83: 1547-1550Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar). However these minimally invasive solutions should be strictly evaluated. Effectively, potential infectious hormonal dependant sites are left in place. Furthermore, no current data were available concerning accidental puncture of an excluded hydrosalpinx. The detrimental effect of pelvic infectious disease on pregnancy evolution should certainly not be underestimated. We could only wonder why so few centers had edited guidelines concerning hydrosalpinx management. Salpingectomy has shown itself to be of most interest. Other treatment modalities should be properly evaluated, e.g., conservative tubal treatment seemed to be of some interest, in the light of all alternative management observed in our survey. Furthermore, efficacy and cost-effectiveness of these different options should be evaluated. In summary, a wide variation in practice and use of hydrosalpinx management options was observed in France. Surgery before IVF treatment was the most frequent treatment modality, in line with the results of the latest meta-analysis on this topic. However LSC salpingectomy was proposed to slightly less than half of patients. Too few centers had specific guidelines concerning hydrosalpinx management before or during IVF attempts. Protocols and/or national guidelines for hydrosalpinx management are needed to optimize successful IVF outcome.