In vitro fertilization (IVF) was originally developed in the late 1970s as a treatment of last resort for severe tubal disease. IVF was used after microsurgery failed. While IVF success rates increased rapidly during the 1980s, surgical results did not improve. By the early 1990s it was clear that IVF was more successful than surgery in women with severely damaged tubes and IVF became the primary treatment.
Hydrosalpinx, a dilated tube occluded at the ovarian end, is the most common form of severe tubal damage. Although surgery can open such tubes, it is a short-lived solution because the tubes frequently close back up. The diagnosis of a hydrosalpinx is typically made on an HSG x-ray exam (see image below) and confirmed by laparoscopy.
HSG showing large hydrosalpinx
In 1994, Dr. Annika Strandell and colleagues observed that women with a hydrosalpinx had about 60% lower success rates with IVF than women with damaged but open tubes. It is the backflow of fluid from the hydrosalpinx into the uterine cavity that interferes with attachment of embryos to the uterine wall.
Fortunately, severing the connection between the hydrosalpinx and the uterine cavity either by removal of the tube or by tubal ligation restores success rates with IVF to expected levels. Since hydrosalpinges are usually present on both sides, severing their connection to the uterus leaves IVF as the only route to conception.
Some women with tubal infertility have a hydrosalpinx on one side only while the other tube remains open. In 2003 I and colleagues published an article repoprting a series of 25 women with a unilateral hydrosalpinx, 22 of whom (88%) conceived shortly after surgery without IVF. Since most conceptions occurred within 5 months, a one-sided hydrosalpinx appears to act as a contraceptive preventing implantation of embryos from the open tube.
A very recent article by Dr. Hong Jiang and colleagues from Hefei, China reports that drainage and chemical occlusion of a large hydrosalpinx visible on ultrasound with 98% alcohol also restores IVF pregnancy rates to normal levels.
For additional information about the diagnosis and treatment of tubal factor visit www.abivf.com/challenges/inftubaldisease.html.
As these ironic twists and turns in the hydrosalpinx story demonstrate, best practice in infertility does not rely upon a simplistic choice between either surgery or IVF but upon utilizing both techniques as most appropriate in an individual case.
