Tubal Disease, Hydrosalpinges and Infertility

Approximately 25% of female infertility is due to blockage of the fallopian tubes. The fallopian tubes are very delicate structures that are responsible for picking up the egg and providing the site for fertilization and early embryo development. The tube is narrowest at the inner portion that joins the uterus and then widens in the outer portion that has ¬ne projections called ¬mbria. The ¬mbria are responsible for picking up the egg. The cells lining the tube produce secretions that nourish the egg and embryo. The tubes can frequently be damaged by infections (e.g., chlamydia, gonnorrhea) or other pelvic conditions such as endometriosis or even severe appendicitis. Scar tissue and blockage can occur at either the inner or outer portion or in both of those regions. If blockage occurs at the outer portion, tubal secretions will not be able to drain out of the end of the tube and can be retained in the tube (hydrosalpinx). If the tube is open at the uterine end, those embryotoxic secretions can drain back into the uterus, impairing implantation or result in the miscarriage of an implanted pregnancy.

There are two di erent approaches to treating infertility that results from tubal damage. If there is mild damage, surgical repair can be attempted. If there is severe damage, the results of surgery are frequently poor and IVF (in vitro fertilization) is recommended to bypass the damaged fallopian tubes. The success rate of surgical treatment of a tube that has become a hydrosalpinx is usually very low.

The IVF process includes 4 steps designed to bypass the fallopian tubes:

1. Stimulation of the ovaries with fertility drugs to produce multiple eggs (ovulation induction.)
2. Retrieval of eggs from the ovary. This is performed by placing a needle through the upper vagina into the ovary under ultrasound guidance using deep sedation or spinal analgesia.
3. The eggs are then fertilized with the partner’s sperm.
4. The resulting embryos are allowed to develop in the laboratory for 3-5 days and are then transferred into the uterus.

It would seem that the ability to bypass the tube with IVF makes this the ideal treatment for tubal damage. Careful analysis of the results of this treatment have shown a low rate of success if a hydrosalpinx is present. One of the ¬rst studies showing this e ect was published as early as 1994 by a group from Sweden that found only a 6.6% IVF success rate in the presence of hydrosalpinx compared to 18.2% with tubal disease and no hydrosalpinx.

A paper in January of 1998 showed only four deliveries in women with a hydrosalpinx who had undergone 47 IFV cycles (8.5%.) As a controlled group, there were 97 patients who had tubal disease, but did not have a hydrosalpinx. In this group, there were 44 deliveries in 145 embryo transfers (30.3%.) This striking difference in the success rate seems to confi¬rm the negative effect of the hydrosalpinx. The suspected mechanism of this effect is that the fluid that builds up within the fallopian tube flows backward into the uterus. This fluid can be toxic to the embryos and can have a negative effect on the uterine lining. It stands to reason that the negative effect would be eliminated by preventing the fluid from flowing back into the uterus. Thus, we recommend that laparoscopic surgery or hysteroscopic with Essure plugs be performed on all patients with a hydrosalpinx which communicate with the uterus prior to IVF. Depending on the extent of the tubal damage, we recommend either blocking the tube with cautery or Essure, or removing the damaged tubes.

Twelve women with a hydrosalpinx who had not conceived with previous IVF attempts in that 1998 study had surgery performed. Of 16 subsequent IVF attempts 6 (37.5%) deliveries resulted. Subsequently surgery was performed by the same group on an additional 25 women who had a hydrosalpinx, but had never been through IVF before. Their 29 IVF cycles following the surgery resulted in 15 deliveries (51.7%.) This is very convincing data that surgically treating hydrosalpinx prior to IVF overcomes the negative effect.

The negative effect of hydrosalpinx has been confirmed by the vast majority of the many studies evaluating this issue. This is a very important ¬finding as it may explain why some women with a hydrosalpinx have failed to conceive despite good IVF cycles. Careful consideration should therefore be given to surgically correcting hydrosalpinges prior to attempting any IVF cycle.


Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center

Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.