What is the recommended treatment for hydrosalpinx (fluid-filled fallopian tube)?

Treatment of Hydrosalpinx

For women with hydrosalpinx planning to undergo IVF, laparoscopic salpingectomy is the recommended first-line treatment to improve pregnancy outcomes. 1, 2

Diagnosis of Hydrosalpinx

• Transvaginal ultrasound (TVUS) is the initial imaging modality of choice with 86% sensitivity in detecting hydrosalpinx 3
• MRI is useful for detection of hydrosalpinges with 75.6% accuracy in surgically confirmed cases, and is superior to TVUS in assessment of pelvic inflammatory disease (PID) 3
• Hysterosalpingography (HSG) allows detection of tubal patency, size, irregularity, and peritubal disease with 65% sensitivity and 85% specificity compared to laparoscopy 3, 4
• Hysterosalpingo-contrast sonography (HyCoSy) has similar accuracy to HSG when compared with laparoscopy and can be performed as part of a comprehensive infertility examination 3, 4

Treatment Options

1. Surgical Management

Laparoscopic Salpingectomy

• First-line treatment for women planning IVF, especially with ultrasonically visible hydrosalpinges 5, 2
• Improves IVF outcomes by removing the source of hydrosalpingeal fluid that can adversely affect embryo implantation 1, 6
• Should be performed laparoscopically when possible 1

Proximal Tubal Occlusion

• Alternative when salpingectomy is technically difficult 6, 2
• Can be performed laparoscopically or hysteroscopically 6
• Network meta-analysis suggests this may be the most effective intervention in terms of relative ranking for ongoing and clinical pregnancy rates 2

Salpingostomy

• Option for women desiring natural conception 1
• Only suitable for small thin-walled hydrosalpinx with healthy mucosa 7
• Associated with ectopic pregnancy rates as high as 10% 1
• Generally poor prognosis but can achieve good results in well-selected cases with experienced surgeons 7

2. Non-surgical Management

Ultrasound-guided Aspiration

• May be considered when surgical approaches are contraindicated 6, 2
• Literature is controversial regarding its effect on IVF outcomes 7
• Less effective than surgical interventions but better than no intervention 2

Treatment Algorithm

1. For women planning IVF:

   • First choice: Laparoscopic salpingectomy 1, 2
   • If laparoscopy is contraindicated due to dense pelvic adhesions: Consider proximal tubal occlusion via hysteroscopy 6
   • If both approaches are contraindicated: Consider ultrasound-guided aspiration of hydrosalpingeal fluid 6, 2

2. For women desiring natural conception:

   • Consider salpingostomy only if hydrosalpinx is small with thin walls and healthy mucosa 7
   • Counsel regarding high risk of ectopic pregnancy (up to 10%) 1
   • If poor prognostic factors exist (large or thick-walled hydrosalpinx): Recommend IVF with prior surgical management 7, 5

Considerations and Caveats

• Hydrosalpinx is most commonly caused by prior pelvic inflammatory disease (PID) 3
• The presence of hydrosalpinx significantly reduces implantation and pregnancy rates in IVF due to mechanical and chemical factors disrupting the endometrial environment 1, 5
• Antibiotic prophylaxis should be considered at the discretion of the physician if there is a prior history of PID or if hydrosalpinx is noted at the time of any diagnostic procedure 3
• When performing surgical procedures for hydrosalpinx, coordination with other indicated surgeries (such as colorectal procedures) should be considered when appropriate 3