Infertility and Hydrosalpinx

Mr. Moses Batwala

ST6

Jessop Women’s Hospital, Sheffield.

Definition • Hydro- water, salpinx- trumpet.

• A Distally blocked Fallopian Tube filled with serous or clear fluid which may become substantially distended giving the tube a sausage/retort-like shape.

• Can distend several centimeters in diameter and associated with infertility.

Definitions cont.

• Hematosalpinx- filled with blood

• Pyosalpinx- filled with pus.

• Tubal phimosis- partially occluded tube.

• Commonly bilateral, but can be unilateral.

• Plural- hydrosalpinges

For Conception to Occur:

• 1: A fertile viable sperm

• 2: Must meet

• 3: A fertile viable ovum (egg)

• 4: And resulting embryo should be transported

• 5: And implanted in a suitable endometrium to develop.

Conception

Causes of Infertility

Fallopian Tube • Two fine tubes, approximately 10cm long,

leading from the ovaries to the uterus.

• Infundibulum, Ampulla, Isthmus and Intramural

Transverse Fallopian Tube • 2-3 layers of tight circular and loose spiral

muscle layers.

• Hormone Responsive lumen (Endosalpinx).

• Columnar epithelial cells line the lumen. 80% ciliated.

• 20%:- Peg (secretory) and reserve basal (lymphoid).

Pathophysiology of Hydrosalpinx:

• Inflammatory process affects the fimbriae.

• Body launches inflammatory response.

• Fibrosis and agglutination causes clubbing and blockage of infundibulum.

• Fluid normally produced by peg cells cannot be expelled into peritoneal cavity.

• Accumulates forming Hydrosalpinx.

Hydrosalpinx

Causes:

• Approx 90% caused by PID. Mainly chlamydia and gonorrhea. Rarely tuberculosis.

• Endometriosis

• Pelvic Surgery

• Appendicitis

• Pelvic Malignancies.

• NB: Not all PID will lead to Hydrosalpinx, damage may only be at cellular-level.

Symptoms and Incidence: • Pelvic Pain (acute and chronic)

• PV discharge

• Menstrual disorders

• Asymptomatic

• Miscarriage

• Infertility!

Incidence:

• 10-13% of IVF patients with tubal factor infertility (1996).

• Extrapolated- 0.16% of population.

Diagnosis:

• 1: Hystero-Salpingo-Gram (HSG) Sensitivity 65% and specificity 85%.

• 2: Pelvic Ultrasound Scan

• 3: Hystero-Contrast-Salpingogram (HyCoSy)

• 4: MRI

• 5: Laparoscopy- Gold Standard

Imaging • HSG USS

Prevention:

• Antibiotics in acute PID refer to GUM.

• Screening and prophylaxis before instrumentation of uterus.

Treatment:

• USS or laparoscopic aspiration:- re-accumulation.

• Salpingostomy- tubal reconstructive surgery. Increased risk of ectopic pregnancy.

• Salpingectomy- tubal excision, mainly laparoscopic.

Fertility and IVF:

• Hydrosalpinx caused a physical blockage of sperm meeting ovum.

• IVF circumvented this physical blockage.

• But IVF live-birth rates in women with hydrosalpinx were 14% vs 30% without.

IVF and Hydrosalpinx:

• Fallopian tube not inert-conduit.

• Clinicians speculated that fluid in hydrosalpinx was embryotoxic and leaked into endometrial cavity.

• Suggested salpingectomy may increase IVF success rate.

Cochrane Review:

• 2002 meta-analysis (RCT’s involving 800 pts) showed salpingectomy, mainly laparoscopic, improved IVF live birth rates to 30%. Johnson et al (Current standard Management)

• Suggested further research on needle aspiration, tubal occlusion and salpingostomy.

New Developments: • Speculation Salpingectomy may affect ovarian

blood supply and ovarian reserve.

• AMH (Anti Mullerian Hormone) levels affected?

• Women with severe co-morbidity e.g. COPD, raised BMI, previous extensive pelvic surgery, not be suitable for laparoscopy.

Laparoscopic Proximal Tubal Occlusion

• Gaining popularity.

• Filshie clip and Diathermy.

• Easier, quicker and cheaper.

• Meta-analysis 2009 (RCT’s involving 650 pts, laparoscopic occlusion techniques just as good as salpingectomy.

Are we satisfied???

Hyseteroscopic Tubal Occlusion:

• Developed for Contraception.

• 2 main types in UK.

• ESSURE and ADIANA.

• Can be inserted under GA, regional, local anaesthetic or mild sedation

Hyseteroscopic Tubal Occlusion:

• ESSURE: Nickel titanium coil inserted in ostia

• ADIANA: Radiofrequency treatment followed by silicon plug.

• Can be fitted in out-patient setting freeing up theatre time and reducing costs.

Essure v Adiana

• Essure Adiana

Case Reports:

• Several case reports on successful IVF following ESSURE, RCT underway in Holland.

• ADIANA newer technique. Jessop wing has 1st case resulting in successful IVF in UK-Dec 2011.

Still early days:

• Foreign body in uterus with ADIANA.

• Need HSG to confirm.

• 6 month patency with Essure is 0% but Adiana is 6%.

• Doesn’t address chronic pain.

• Not diagnostic.

• Unilateral Tubal disease?

• Need well designed RCT.

Aim and Result:

Thank you

• Any Questions?