How does salpingectomy (surgical removal of a fallopian tube) for peritubal adhesions or loculated spillage affect In Vitro Fertilization (IVF) outcomes?

Salpingectomy for Peritubal Adhesions or Loculated Spillage and IVF Outcomes

Salpingectomy should be performed before IVF in patients with hydrosalpinx visible on ultrasound, as it significantly improves clinical pregnancy rates (46% vs 22%) and live birth rates (40% vs 17%), but for isolated peritubal adhesions without hydrosalpinx, salpingectomy is not routinely indicated and may unnecessarily reduce ovarian reserve. 1

When Salpingectomy Improves IVF Outcomes

Hydrosalpinx (The Clear Indication)

• Salpingectomy is strongly recommended for hydrosalpinx visible on ultrasound before IVF treatment, as hydrosalpingeal fluid has toxic effects on embryo implantation and development 1, 2

• The Scandinavian randomized controlled trial demonstrated that patients with large hydrosalpinges who underwent salpingectomy had significantly higher clinical pregnancy rates (46% versus 22%) and birth rates (40% versus 17%) compared to those who did not have the procedure 1

• Women with untreated hydrosalpinges have consistently lower implantation and pregnancy rates in IVF due to mechanical and chemical factors that disrupt the endometrial environment 2

• Laparoscopic salpingectomy is the preferred surgical approach to minimize morbidity and hospitalization time 3, 2

Loculated Spillage Context

• "Loculated spillage" typically refers to hydrosalpinx with compartmentalized fluid collections, which falls under the same treatment paradigm as standard hydrosalpinx 2

• The severity of tubal distension and visibility on ultrasound should guide the decision—if the hydrosalpinx is large enough to be visualized ultrasonographically, salpingectomy is indicated 1

When Salpingectomy Does NOT Improve IVF Outcomes

Isolated Peritubal Adhesions Without Hydrosalpinx

• For peritubal adhesions alone (without hydrosalpinx or fluid accumulation), salpingectomy is not indicated and may be detrimental 4, 5

• A retrospective study found no significant difference in postoperative pregnancy rates between women who had laparoscopic salpingotomy versus salpingectomy for tubal pregnancy, with both groups showing 60-65% subsequent conception rates 4

• The revised American Fertility Society (re-AFS) adhesion score was a better predictor of subsequent pregnancy outcomes than the surgical approach itself—higher adhesion scores (mean 3.1) correlated with repeat ectopic pregnancy, while lower scores (mean 0.4) predicted intrauterine pregnancy 4

• Removing a tube with only peritubal adhesions (but patent lumen and no hydrosalpinx) eliminates a potentially functional tube and may reduce natural conception chances without improving IVF outcomes 5

Clinical Decision Algorithm

Step 1: Imaging Assessment

• Obtain transvaginal ultrasound to assess for hydrosalpinx visibility and size 1
• If hydrosalpinx is visible on ultrasound → proceed to salpingectomy before IVF 1, 2

Step 2: Evaluate Adhesion Severity

• If only peritubal adhesions are present without hydrosalpinx → do not perform salpingectomy 4, 5
• Consider adhesiolysis only if attempting natural conception, but understand this has limited benefit for IVF outcomes 5

Step 3: Consider Alternative Approaches

• For complex pelvic anatomy or severe adhesions making laparoscopic surgery difficult, proximal tubal occlusion (historically with Essure devices) can be considered, though this has shown lower pregnancy and live birth rates compared to salpingectomy 2
• Salpingostomy (distal tubal plastic surgery) is only appropriate for women desiring natural conception and has ectopic pregnancy rates as high as 10% 2

Important Caveats

Ectopic Pregnancy Risk

• The risk of ectopic pregnancy increases with the number of embryos transferred, up to 20-fold, and this risk is elevated regardless of whether salpingectomy was performed 3
• Single embryo transfer (SET) should be strongly considered to minimize ectopic pregnancy risk in patients with tubal factor infertility 3

Ovarian Reserve Concerns

• Salpingectomy may impact ovarian reserve by disrupting blood supply to the ovary, though this effect is debated in the literature 2
• The decision should weigh the proven benefit of removing hydrosalpinx against the theoretical risk of reduced ovarian function 2

Timing Considerations

• Salpingectomy should be performed before initiating IVF stimulation to maximize the benefit on implantation rates 1, 2
• Allow adequate healing time (typically 6-8 weeks) between surgery and IVF cycle initiation 2

What NOT to Do

• Do not perform salpingectomy for minor peritubal adhesions without hydrosalpinx—this removes a potentially functional tube without improving IVF outcomes 4, 5

• Do not rely on salpingostomy for hydrosalpinx in patients planning IVF—recurrence rates are high and ectopic pregnancy risk is substantial 2

• Do not proceed with IVF in the presence of ultrasound-visible hydrosalpinx without addressing it first—this significantly compromises success rates 1, 2