Management Options For Hydrosalpinx: Salpingostomy or IVF
Date
2020
Authors
Petrucco, Oswald Marino
Editors
Advisors
Seamark, Robert
Robertson, Sarah
Dekker, Gustaaf
Robertson, Sarah
Dekker, Gustaaf
Journal Title
Journal ISSN
Volume Title
Type:
Thesis
Citation
Statement of Responsibility
Conference Name
Abstract
Hydrosalpinx refers to a dilated Fallopian tube containing clear fluid, commonly
bilateral and generally accepted to be the end result of bacterial infection and
resolved pyosalpinx.
Infertility can result from distal tubal obstruction and agglutination of tubal fimbriae
preventing ovum entry and fertilisation in the distal Fallopian tube.
As a consequence of fluid accumulation, intraluminal pressure rises despite patency of
the proximal (cornual) Fallopian tube with intermittent release of fluid to the uterine
cavity. The original inflammatory process also commonly causes structural damage
and loss of physiological function of the Fallopian tube.
Since the introduction and progressive improvement in outcome with IVF, use of
restorative surgery as a treatment option has remained static. Because of the
recognised deleterious effect of hydrosalpinx fluid on embryo implantation, to prevent
fluid entering the uterine cavity, hydrosalpinges are commonly excised or proximately
obstructed prior to commencing IVF.
These procedures exclude natural conception, with IVF remaining the only treatment to
achieve a pregnancy.
A minority of hydrosalpinx affected women achieve intrauterine pregnancies following
“salpingostomy” or” neo-salpingostomy” (surgical reopening of the distal hydrosalpinx),
however the majority fail to conceive or develop tubal ectopic pregnancies.
This thesis explores how tubal function is affected by hydrosalpinx formation with the
aim of determining the extent of the role, if any, of salpingostomy in the current
management of hydrosalpinx.
Morphological, physical and biochemical studies were performed comparing rabbit
hydrosalpinx to control oviducts and hydrosalpinx and normal Fallopian tubes in
women Rabbit studies
Systematic evaluation of changes in morphological, physical and biochemical tissue
levels were made utilising a surgically induced model of hydrosalpinx in the rabbit. The
oviduct distension occurring during hydrosalpinx formation resulted in significant
changes in all parameters studied. Major alterations were observed in morphology
(light and surface electron microscopy), most notably epithelial deciliation, and tissue
biochemistry including tissue DNA/RNA content and turnover, collagen, electrolyte,
water and lipid levels.
Progessive reduction in tubal blood flow was noted with increasing intraluminal
pressure.
Tubal muscular contractility, epithelial ciliary and secretory activity are critically
influenced by ovarian steroids, therefore detailed examination of changes in tissue
oestrogen and progesterone cytosolic and nuclear receptor levels were measured in
healthy and hydrosalpinx affected oviducts.
With progressive increase in tubal distension, reduction in steroid hormone receptor
levels occurred.
Reversal of all these abnormalities was achieved following microsurgical tubal
reconstruction, including restoration of fertility.
Human studies
The study confirmed that in women hydrosalpinx results in similar adverse
morphological and biochemical changes with variable segmental epithelial deciliation.
Steroid hormone receptor levels were significantly reduced in hydrosalpinx compared
to normal controls. Receptor levels measured during the proliferative, secretory
phases of the menstrual cycle, menopause, early pregnancy and postpartum, reflected
changes in circulating steroid hormone levels.
Fallopian tubes obtained from women with ectopic pregnancies and post-sterilisation also showed a reduction in hormone receptor levels, in parallel with a decline in mean
ciliation index (MCI).
The study confirmed that following salpingostomy, intrauterine pregnancies could be
achieved when an adequate MCI was found to be present in epithelial microbiopsies
taken at the time of salpingostomy procedure. Women with reduced or low MCI
subsequently experienced ectopic pregnancies or failed to conceive.
Assessment of tubal morphology is laboratory dependant and requires subjecting
women to a diagnostic procedure prior to carrying out salpingostomy when MCI is
found to be favourable.
In an attempt to predict which Fallopian tubes are worthy of conservative surgery at a
single operation, a review of the literature was undertaken to evaluate what role
inspection of the tubal lumen by salpingoscopy (transabdominal) or fertiloscopy
(transvaginal) plays in assessment of mucosal pathology.
The aim was to assess whether inspection of the tubal mucosa gave comparable
information to MCI.
Review of salpingoscopy prediction results, suggests that women with hydrosalpinges
associated with severe intraluminal adhesions, denuded or flattened mucosal folds
(high abnormality grade according to set scale), had negligible chance of intrauterine
pregnancy following salpingostomy. As a corollary, these pathological changes are a
contraindication to restorative surgery. To perform salpingostomy an abdominal
approach is preferred when correction of hydrosalpinx is considered, as opening of the
distal part of the Fallopian tube, intraluminal inspection and salpingostomy procedure
can best be achieved by this route.
The data also suggests that with a single endoscopic intervention, salpingoscopy
followed by salpingostomy has up to a 30% chance of successful intrauterine
pregnancy outcome. Women with hydrosalpinges that have mucosal folds with limited
intraluminal and peritubal adhesions therefore warrant consideration of conservative rather than destructive surgery.
Having confirmed also that mucosal assessment can be further improved by utilising
microsalpingoscopy, this procedure should also be considered for assessment of the
tubal mucosa. This latter procedure which involves contact epithelial inspection will
determine whether post- inflammatory changes remain present at the cellular level,
thus facilitating a decision of Fallopian tube conservation. Salpingostomy is particularly
relevant for ovulatory women over 40 years of age who have a low chance of success
with IVF treatment. The higher success rate (intrauterine pregnancy and live births)
achieved by women aged 40-47 who had tubal surgery (reversal of sterilisation), in
comparison to IVF treatment is consistent with this interpretation (Petrucco et al
2007).
The observation of progressive deterioration in tubal function with increasing
intraluminal pressure in the rabbit model, suggests that women diagnosed with
bilateral hydrosalpinx wanting future fertility could be offered salpingostomy at initial
diagnosis of hydrosalpinx before fertility is considered. This endoscopic day surgery
procedure may prevent deterioration in tubal function as progressive dilatation occurs
with time and allow the possibility of subsequent spontaneous conception, rather than
having to rely completely on artificial reproductive technology (ART) and IVF.
It is proposed that conservative surgery to achieve conception in women with
hydrosalpinges should be considered when salpingoscopic assessment predicts a
favourable outcome. As well as providing a chance of spontaneous conception of more
than one pregnancy, this approach would reduce the enormous cost burden on society
of providing repeated cycles of IVF currently funded by our national health system.
Further studies and evaluation beyond this current study are required to support this
proposal.
School/Discipline
School of Medicine
Dissertation Note
Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2020
Provenance
This electronic version is made publicly available by the University of Adelaide in accordance with its open access policy for student theses. Copyright in this thesis remains with the author. This thesis may incorporate third party material which has been used by the author pursuant to Fair Dealing exceptions. If you are the owner of any included third party copyright material you wish to be removed from this electronic version, please complete the take down form located at: http://www.adelaide.edu.au/legals