Infertility and Hydrosalpinx

Mr. Moses Batwala ST6 Jessop Womens 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:- reaccumulation.
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 (RCTs 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 (RCTs 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%. Doesnt address chronic pain. Not diagnostic. Unilateral Tubal disease? Need well designed RCT.

Aim and Result:

Thank you
Any Questions?