The tubes are prone to injury. The fimbria are the delicate fingers that extend from the funnel-shaped end of the fallopian tube to the ovary. The fimbria actively search out the egg after it is released, or ovulated, and carry the egg to the waiting sperm within the fallopian tube. The fimbria are lined with delicate cells that contain the actively moving hair-like cilia, which move the eggs and sperm together. With injury, not only are the fimbria themselves injured and fused together, but also the delicate lining cells are lost. Fluid collects within the closed tube. A normally rich and supportive tubal environment becomes the dead sea of the hydrosalpinx.
Hydrosalpinx is a result of injury to the tube, usually from an infection. The classic causes of hydrosalpinx are chlamydia and gonorrhea, which can run undetected for years, slowly injuring and destroying the delicate fimbria. IUDs, endometriosis, and abdominal surgery sometimes are associated with the problem. As a reaction to injury, the body rushes inflammatory cells into the area, and inflammation and later healing result in loss of the fimbria and closure of the tube. These infections usually affect both fallopian tubes, and although a hydrosalpinx can be one-sided, the other tube on the opposite side is often abnormal. By the time it is detected, the tubal fluid usually is sterile, and does not contain an active infection.
Not only does a hydrosalpinx cause infertility, it can also reduce the success rate of fertility treatment, even those treatments that bypass the fallopian tubes. The blocked tube can communicate with the uterus, and the fluid in the tube can be expressed out of the tube into the uterus. This fluid is probably somewhat toxic to early embryo development, and certainly provides an unfavorable environment. The large volume of the fluid flow back into the uterus and can produce enough flow that embryos find it difficult to attach, since they have no ability to move against the tide. Fertility drugs may cause the fluid to build up in the tube, since the tubes are responsive to the ovarian hormones produced during fertility drug therapy.
Hydrosalpinx can be hazardous during fertility evaluation and treatment, since it is prone to re-infection. Hysterosalpingogram is a particular problem, since the dye can inadvertently introduce bacteria into the tubes, and a serious infection can result. Fertility procedures like insemination and embryo transfer can cause similar problems. Infection in a hydrosalpinx, salpingitis, can be a serious surgical emergency and result in hospitalization.
Hydrosalpinx can be evaluated with several maneuvers:
The hysterosalpingogram (HSG) is a procedure in which dye is placed through the cervix and into the uterus and fallopian tubes. An X-ray picture then reveals the outline of the uterus and tubes. A hydrosalpinx appears as a large-sausage-shaped dilation of the tubes. The folds that are present inside the tube disappear and a flat bulbous shape is seen. Dye does not spill out of the tube.
Ultrasound uses sound waves to image the tubes, and is somewhat safer than HSG and more comfortable. The best view, most of the time, is obtained with a vaginal ultrasound probe. A normal fallopian tube is usually not visible; a hydrosalpinx appears as a characteristic sausage-shaped fluid collection between the ovary and fallopian tube. The wall of the hydrosalpinx is often thick and flat. Ultrasound provides a quick and painless screen of the pelvic organs and is an excellent first assessment of the tubes.
Laparoscopy is another means of assessing the tubes, but is generally used only for treatment and not for assessment. In laparoscopy, a small television camera is introduced through the belly button. The pelvic organs can be visualized on a television screen. It has been said that physicians with expertise at video games excel at the hand-eye coordination required to perform these procedures! Laparoscopy is the gold standard test for evaluation, since looking at the fallopian tubes will usually provide the best view of their anatomy.
Diagnostic tests such as ultrasound and HSG are not 100% accurate, and can be misleading, sometimes missing significant tubal disease, and sometimes showing abnormal results when the tubes are actually quite normal. Laparoscopy usually will confirm the diagnostic tests, but can show that tubes that were thought to be normal actually have significant disease, and vice versa. The risks of anesthesia and surgery dictate that laparoscopy is used for definitive therapy, rather than as a diagnostic test.
In vitro fertilization is the ultimate fertility therapy. The ability to optimize fertilization rates, place embryos into their correct location, and provide excellent hormonal support to the early developing embryo have vastly improved success rates over the last few years. In patients with hydrosalpinx, the fallopian tubes can be bypassed, since eggs are taken out of the ovary, fertilized in the lab, and transferred back into the uterus. A hydrosalpinx can be repaired, but with improving success rates from in vitro fertilization, should it be?
Hydrosalpinx can be repaired in carefully selected cases, but pregnancy rates remain rather low. Hydrosalpinx can be treated laparoscopically, a procedure known as neosalpingostomy. In neosalpingostomy, an incision is made in the end of the hydrosalpinx and the edges of the incision are folded or flowered back, leaving an open tube. Unfortunately, the tube often closes back up, and the hydrosalpinx has a high recurrence rate.
A small hydrosalpinx is the most successfully repaired. Since pregnancy requires six months to a year after surgery, younger women with relatively healthy ovaries and eggs, and lots of time, tend to have the best success rates. Women with a large hydrosalpinx and those in older age groups do not benefit from surgical repair.
A hydrosalpinx can have adverse effects on pregnancy rates with in vitro fertilization. As success rates with in vitro fertilization have improved dramatically over the past few years, surgical repair of the fallopian tubes holds less appeal. Indeed, the concerns over re-infection of a hydrosalpinx and problems with fluid build-up with fertility drug therapy have raised the stakes for a hydrosalpinx. Removal of a damaged tube reduces the risk of complications of therapy and improves success rates with in vitro fertilization techniques.
Today, most patients with a hydrosalpinx do not try to repair it. Repair can be done in carefully selected young patients with minimal damage to their tubes, but should not be attempted with a large hydrosalpinx in an older woman. In these patients, the tube should be removed, via laparoscopic salpingectomy. Salpingectomy is an easy procedure that takes less than an hour. The risks with an experienced surgeon are low, and the benefits substantial. It is important to choose an experienced surgeon, since considerations of safety and preservation of the ovarian blood supply with improvement to later pregnancy rates require judgment and experience.
Hydrosalpinx is a classic fertility problem that prevents embryos from reaching the uterus and limits pregnancy rates. It can interfere with fertility therapy and cause problems for in vitro fertilization. Fortunately, excellent methods are available to manage the hydrosalpinx. With the proper expertise, such as that provided by a board-certified reproductive endocrinologist, success rates are excellent.