{"paper_id":"27c422f4-c588-43ce-9bc0-9f8534e9280f","body_text":"Hydrosalpinx is the accumulation of fluid within the ampullar lumen as a result of occlusion of the infundibulum. It is a common condition among women of reproductive age, and it is related to diminished pregnancy rates (PRs)\n 1 \n 2 \n 3 \nwith assisted reproductive technology (ART). The incidence of hydrosalpinx diagnosed by ultrasound among infertile women is between 10% and 13%, and it may increase to 30% with the use of hysterosalpingography or laparoscopy.\n 4\nThe diagnosis of hydrosalpinx is commonly made by ultrasonography (US) or hysterosalpingography, the latter representing the gold standard. However, under certain conditions, US is unable to detect small amounts of fluid inside the oviduct, which could consequently grow during ovarian stimulation, producing a deleterious effect on embryo implantation.\n 5 \n 6 \nThe exact mechanisms behind the adverse effects observed on pregnancy are not yet well understood. Hydrosalpinx fluid (HF) is known to be embryotoxic, and contains growth-factor inhibitors. Moreover, it seems that the liquid contained in the hydrosalpinx could reduce sperm motility and the velocity of motile spermatozoa following 24 hours of incubation.\n 7\nThe fallopian tube is distended during exogenous hormone administration, and this emphasizes that steroids affect the endoluminal ampullar secretion.\n 6 \nThe aim of the present review was to evaluate the effects of hydrosalpinx on reproductive outcomes: it has a negative effect either on the embryo or the endometrium. In addition, we assessed the different surgical managements of hydrosalpinx.\n\nThe present review included studies evaluating the effect of hydrosalpinx on IVF outcomes. The literature search was performed on the following databases: MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Health Technology Assessment Database, and Web of Science; we searched the entirety of those databses for studies published until July 2020. The literature search was conducted using the combination of the following Medical Subject Heading (MeSH) terms and any relevant keywords in different orders: “\n hydrosalpinx \n,” “\n hydrosalpinges \n,” “\n hydrosalpinx fluid \n,” “\n embryo toxicity \n,” “\n IVF \n,” “\n ART outcomes \n,” “\n implantation failure \n,” “embryotoxic,” “\n reproductive outcomes \n,” “\n live birth \n,” and “\n clinical pregnancy rate \n.” The search was performed in English. The reference lists of the included studies were also manually checked to look for studies that were not found in the electronic literature search.\n\nThe hydrosalpinges are associated with the presence of fluid in the uterine cavity, modifications in endometrial blood flow, the leukemia inhibitory factor, the inflammatory response, and\n HOXA10 \nexpression,\n 8 \n 9 \nin the joint, which could explain the mechanism leading to decreasing PRs and increasing miscarriage rates in women undergoing ART. Many retrospective studies have shown an impaired outcome of IVF in the presence of hydrosalpinx, and the meta-analyses have demonstrated that the probability of achieving pregnancy in the presence of hydrosalpinx halved.\n 10 \nThe miscarriage rate is increased in women with hydrosalpinx.\n 11 \n 12 \n 13 \nTheoretically, a good embryo could be implanted anywhere, as happens in the case if hysterectomized women,\n 14 \nhowever, perfect integrity of the endometrial cavity is required to maximize embryo implantation.\nIn recent years, the increased success rates of treatments using ART have as key factors embryo quality, endometrial receptivity, and embryo transfer as key factors.\n 15\nThe PR in most cases of IVF is below 40%; therefore, undiscovered pathologies in the uterus, endometrium and fallopian tubes could play a crucial role in implantation failure. Furthermore, some conditions, such as the presence of fluid within the uterine cavity,\n 16 \n 17 \ncould have a detrimental effect on endometrial receptivity. In particular, HF plays a role in reducing the PR in in-vitro fertilization programs.\n 11 \nKassabji et al.\n 18 \nDemostrated the deleterious effects of HF on IVF outcome, and, a few years later, a meta-analysis by Camus et al.\n 3 \ndemonstrated that the probability of achieving pregnancy in the presence of hydrosalpinx is halved, whereas the incidence of miscarriage is doubled. It is not well-known how the HF affects the implantation. It may be due to embryotoxicity, or to a direct effect on the endometrium, resulting in HF formation, or, finally, poor endometrial receptivity caused by alterations in the expression of markers or key molecules in the endometrium.\nBeyler et al.\n 19 \nsuggested a potential deleterious effect of the HF on in-utero embryo development. They evaluated in-vitro mouse embryo development in the presence of HF collected from 10 infertile women. The HF had a detrimental effect on the development of mouse embryos. Therefore, the poor PR in women with hydrosalpinx could be explained, in part, by the reflux of a lipophilic embryotoxic factor into the uterine cavity.\n 19 \nThe HF may contain toxins that are potentially teratogenic. Morphological scores and the diameter of the yolk sac were significantly lower in embryos exposed to HF.\n 20\nRoberts et al.\n 21 \nevaluated the effects of different concentrations of HF, with and without lactate supplementation, on the preimplantation development and implantation of murine models. The rates of development of balstocysts were respectively of 45%, 55%, 12.5% and 17.5% depending on the concentration of HF, and, with lactate supplementation, the rates were of 35.0%, 52.5%, 12.5%; without lactate supplementation, the rate was of 5.0%, while in the control group, it was of 63.8%.\nThe implantation rates for the 0.1% and 1.0% groups with lactate supplementation were of 43.0% and 25.0% respectively, and the rates for the groups with lactate supplementation were of 50.6% and 61.8%, while in the control group the implantation rate was of 65.5%. Hence, these results made it possible to hypothesize that the HF has a concentration-dependent decline in in-vitro murine embryo development, with a minimal effect on the implantation rates. Furthermore, lactate supplementation did not significantly influence the implantation rate at any HF concentration.\nHowever, the embryotoxic effect of the HF has not been demonstrated in human embryos.\n 22 \n 23 \nThe analysis of the HF demonstrated the absence of bacteria, normal electrolyte concentrations with lower amounts of total protein and albumin, with a composition that does not differ from that of the normal tubal fluid.\n 22 \nAll fertilized eggs showed physiological segmentation, and the embryonal development rate was not impaired by the HF. Even the granulosa cells incubated in HF showed the same steroidogenic capacity as those incubated in its absence.\nIn the same way, Strandell et al.\n 23 \nshowed no negative effect on human embryonic growth: donated frozen embryos were incubated at concentrations of 50% and 100% of HF, but the HF had effects on blastocyst development.\nIn all likelihood, the low implantation rate in IVF patients with hydrosalpinx may not be due to an embryotoxic effect, and the differences regarding mouse embryos may be related to inter-species differences. Furthermore, the HF has a negative effect on sperm motility and survival after 24 hours of incubation, and the motility reduction depends on the concentration of HF.\n 7 \nHydrosalpinx epithelial cells may be producing a fluid milieu which is hostile to sperm and early embryo development.\n 24\nHydrosalpinx is associated with the presence of fluid within the endometrial cavity that may have a direct effect on the endometrium. The origin of the fluid is a point of controversy, but a leakage from the ampulla to the uterine cavity is the most accepted theory. Some authors have suggested that the reflux could have a “flushing” effect on the embryos, attributing to a mechanical interference with the implantation failure.\n 25 \n 26 \n 27 \nBefore the invasion of the trophoblast, there is a progressive reabsorption of intraluminal uterine allowing the interactions between the embryo and the epithelial.\n 28 \n 29 \nThe HF has a direct, cytotoxic effect on developing mouse embryos, but not on human embryos,\n 19 \n 21 \n 22 \n 23 \nin whom it reduces the implantation and pregnancy rates. The peaks of reabsorption of intraluminal uterine fluid occur at the expected time of implantation in rodents,\n 30 \n 31 \nand are controlled the by ovarian hormone secretions, local ion and water channels. The mechanisms underlying the fluid formation in the hydrosalpinx are poorly-known or not consistent.\n 32\nThe involvement of epithelial transporters and ion channels of the fallopian tube is a possibility, particularly the cystic fibrosis transmembrane conductance regulator (CFTR). In pelvic inflammatory disease (PID), which is mainly caused by infection by\n Chlamydia trachomatis \n, CFTR-mediated events may culminate in hydrosalpinx formation,\n 33 \n 34 \nand there is evidence\n 35 \navailable that shows that ∼ 20% of woman affected by chlamydial lower-genital-tract infection develop PID. A shift between the chlamydial and endometrial infections was reported in a study by Jones et al.,\n 36 \nin which\n C. trachomatis \nwas recovered from uterine and fallopian tubes in women affected by acute salpingitis.\n 37 \nIn both cases, there was a higher incidence of miscarriage rates\n 38 \nand higher levels of chlamydial heat shock proteins (HSPs), which seem to be responsible for the local immune response followed by an inflammatory reaction and poor embryo implantation.\n 39 \nSpandorfer et al.\n 40 \ndemonstrated that HSP antibodies were more prevalent in women with hydrosalpinx and tubal occlusion than in patients with male factor infertility.\nFurthermore, Witkin et al.\n 39 \nreported that the immunoglobulin A (IgA) antibodies against Chlamydia detected in the uterine cervix dramatically correlated to lower PRs in women undergoing IVF and embryo transfer (IVF-ET).\nAlthough the connection between PID, Chlamydia infection and hydrosalpinx is largely recognized, the sequence of events that leads to the formation of fluid is still debated and not clearly demonstrated (\n Fig. 1 \n).\nMechanisms responsible for the formation of the hydrosalpinx fluid.\nIt is known that the movement of water in the oviducts, which does not depend on active transport, may represent the response to osmotic gradients due to the transportation of ions.\n 41 \nIn particular, chloride ions move actively in the direction of the oviduct lumen, from the tubal serosa to the tubal mucosa,\n 42 \n 43 \nand generate a transepithelial potential difference across cultured cells.\n 44 \n 45\nThe inner mucosa of the fallopian tubes is lined with ciliated columnar epithelial cells and peg cells (non-ciliated secretory cells). The loss of membrane polarity could generate HF after PID. Sodium/hydrogen exchangers (NHEs) and anion Cl\n − \n/HCO3\n − \n(AE), well-known plasma membrane transporters in human epithelial cells, are involved in this process. The CFTR has a well-recognized function as a cyclic adenosine 3′,5′-monophosphate (cAMP)-activated chloride channel. The increases in the levels of cAMP are followed by an increase in the transepithelial potential difference in current, leading to enhancements in fluid secretion.\n 46 \nThe CFTR is a transporter of chloride ions; furthermore, it acts as a receptor for some bacteria in the epithelial cells.\n Pseudomonas aeruginosa \nbinds to the CFTR in pulmonary epithelial cells, whereas\n Salmonella typhi \nand\n Cholera vibro \nbind to the CFTR in gastrointestinal cells, increasing the serosa-to-mucosa fluxes of sodium and chloride, with subsequent diarrhea.\n 47 \n 48\nIt is possible that Chlamydia elementary bodies (EBs) can use the CFTR as a receptor for cellular internalization in female infections of the reproductive , modifying the profile of the fluid transport in the oviducts, leading to hydrosalpinx (\n Fig. 2 \n). Downing et al.\n 49 \nstudied the effects of inflammatory mediators, which may increase microvascular permeability, leading to fluid formation by the tubal epithelium. Histamine, serotonin, prostaglandins and the platelet-activating factor (PAF) are involved in this process. In particular, histamine, in cultured epithelial cells, influences ion movements and tubal secretions of fluid. In the presence of fimbrial adhesions, which are the consequence of infection and inflammatory disease, the epithelial secretion is blocked within the oviduct, leading to the formation of hydrosalpinx.\n 49\nMechanisms through which the chlamydia cycle occurs within infected cells.\nThe tumor necrosis factor (TNF) may be involved in the pathogenesis of acute tubal injury associated with Chlamydia infection. In fact, in women who are culture-positive for\n C. trachomatis \n, the TNF was identified only in those fallopian tubes with visual evidence of the disease, while the fluids obtained from morphologically normal tubes were negative. Therefore, localized cell-mediated activation of the immune system, which is identified by TNF production, appears to be a typical component of salpingitis.\n 38\nEndometrial integrins may also modify endometrial receptivity. Meyer et al.\n 50 \nstudied 103 patients affected by hydrosalpinx who underwent endometrial biopsies during the window of implantation, searching for three integrins as markers of endometrial receptivity: α\n 1 \nβ\n 1 \n, α\n 4 \nβ\n 1 \n, and α\n v \nβ\n 3 \n. Women with hydrosalpinx expressed significantly lower levels of α\n v \nβ\n 3 \ncompared with the control group, while there was no difference in the expression of the other two integrins. From a histological point of view, the endometrium with an absence of expression of α\n v \nβ\n 3 \nwas significantly out of phase compared with the control group. Furthermore, women biopsied after hydrosalpinx removal demonstrated an increase in α\n v \nβ\n 3 \nexpression in 70% of the cases. The present study confirms that a lower implantation rate in hydrosalpinx may be caused by poor endometrial receptivity, and that the tubal surgical removal in these patients can improve the IVF-ET outcome.\nThe window of endometrial receptivity is essential in the implantation of blastocysts, and it triggers multiple reactions from the endometrium as well as the blastocysts.\n 51 \nThe receptive endometrium and stimulated blastocysts function simultaneously to achieve blastocyst implantation, leading to pregnancy.\n 52 \nPoor endometrial receptivity may be due to an abnormal expression of key molecules in the endometrium, cytokines, steroid hormones, peptides, growth factors and enzymes, which are essential for implantation.\n 53 \nThe dialogue between the endometrium and the embryo is mediated by the expression of certain cytokines and other substances during the implantation window. The\n HOXA10 \nis a protein-coding gene that plays an essential role in directing embryonic development and implantation.\n 54 \n 55 \nIts expression is necessary for endometrial receptivity.\n 55 \n 56 \n 57\nA targeted disruption or a target mutation of the\n HOXA10 \ngene in mice causes implantation failure, but the same mice produce good embryos that normally implant in a wild-type surrogate. In contrast, wild-type embryos fail to implant in\n HOXA10 \ndeficient mice.\n 58 \nThe\n HOXA10 \nis expressed in the uterus during the menstrual cycle, and its expression increases during the mid-secretory phase of the menstrual cycle, corresponding to the time of implantation. In this “window,” the levels of expression of the\n HOXA10 \nincrease dramatically in the glands, and even in the stromal cells.\n 59 \n 60 \n 61 \n 62 \nIn cultured endometrial cells, the expression of HOXA10 was stimulated by estrogen or progesterone with a concentration-dependent dose, for progesterone.\n 56 \nReduction of maternal HOXA10 results in proportionally diminished windows of implantation. Furthermore, altered levels of HOXA10 expression regulate the degree of endometrial receptivity.\n 63\nThe\n HOXA10 \ngene influences embryo implantation through several mechanisms, such as pinopod development,\n 64 \nleukocyte infiltration, and stromal decidualization.\n 62 \n 65\nA defect in the endometrial expression of the\n HOXA10 \ngene is present in several aberrations and pathologies involving the uterus, ovaries and salpinges, such as endometriosis, submucosal uterine leiomyomas, polycystic ovary syndrome (PCOS) and hydrosalpinges. In fact, optimal anatomy and physiology are necessary for normal implantation and placentation.\n 8\nThe expression of the\n HOXA10 \nwas significantly lower in infertile patients with hydrosalpinges compared with controls with fertile women. Salpingectomy resulted in a statistically significant 15-fold increase in endometrial\n HOXA10 \nexpression.\n 66\nThe present research demonstrates that the decrease in\n HOXA10 \nexpression in response to HF may constitute a potential molecular mechanism for diminished implantation rates. Salpingectomy restores endometrial\n HOXA10 \nexpression, resulting in improved implantation rates in IVF-ET.\nHydrosalpinx has a negative effect on the outcome of IVF; therefore, any surgical intervention performed on the damaged tube should increase the chances of a successful outcome.\n 67\nJohnson et al.\n 68 \npublished a complete review in 2010 that compared the surgical treatments on the fallopian tubes, prior to IVF, in women with hydrosalpinx. The authors included five randomized controlled studies involving 646 women, regarding salpingectomy, laparoscopic tubal occlusion, ultrasonographic aspiration of HF before or during the oocyte collection and, finally, salpingostomy. The results showed that the odds of ongoing pregnancy and clinical pregnancy increased after laparoscopic salpingectomy, prior to IVF, for patients with hydrosalpinx.\n 68 \nTubal occlusion compared with salpingectomy did not show a significant advantage in terms of ongoing pregnancy or clinical pregnancy.\nThe Practice Committee of the American Society for Reproductive Medicine (ASRM), in collaboration with the Society of Reproductive Surgeons (SRS), published a study about IVF outcomes in women with unilateral or bilateral hydrosalpinges.\n 69 \nThe PR in patients with hydrosalpinges was lower than that of the control group, with identical negative effects in both fresh and frozen embryo transfer cycles. Even the miscarriage rate was 2.3 times higher among women with hydrosalpinx than among those unaffected. Preliminary laparoscopic salpingectomy or proximal tubal occlusion, prior to IVF, improves pregnancy and live birth rates, whereas data was insufficient to evaluate the effectiveness of alternative treatments such as laparoscopic neosalpingostomy, transvaginal aspiration of HF, hysteroscopic tubal occlusion, or antibiotic treatment. Transvaginal aspiration of HF during egg collection is still controversial.\n 70 \n 71 \nThe data in the literature is insufficient to determine whether hysteroscopic tubal occlusion could be considered helpful in preventing the deleterious effect of HSF. A recent study reports that the placement of Essure (Bayer AG, Leverkusen, Germany) is an alternative method for fallopian tube occlusion in hydrosalpinx before IVF when laparoscopy is contraindicated.\n 72\nThe hysteroscopic proximal occlusion by intratubal devices improves the chance of achieving clinical pregnancy compared with no intervention. Nevertheless, the Essure implant is associated with a higher miscarriage rate compared with the other interventions.\n 73 \nUnfortunately, insertion of the Essure in the management of hydrosalpinx prior to IVF remains off-label, although the implant could increase fluid within the uterine cavity, with a consequent lower PR.\n 74 \nIn fact, the hysteroscopic placement of Essure devices before IVF produces inferior pregnancy rates compared with the laparoscopic approach.\n 75 \nTherefore, salpingectomy should be the first option for women with hydrosalpinx before undergoing an IVF cycle. Salpingostomy should be considered to conserve the fallopian tubes, enabling natural conception.\n 76 \n 77\n\nHydrosalpinx is associated with poor IVF outcomes, with reduced live birth rates and higher pregnancy loss. Therefore, accurate diagnosis of hydrosalpinx are critical, especially when a tiny amount of fluid inside the Fallopian tubes may be almost undetectable. The surgical removal of hydrosalpinx prior to IVF improves PRs and reproductive outcomes.\n 78 \nIn addition, salpingectomy does not affect the ovarian response, nor reduces the antral follicle count.\n 79 \nLaparoscopic salpingectomy is the optimal surgical approach; therefore, it should be recommended. Further studies are needed to establish the therapeutic value of HF aspiration under ultrasonographic guidance, during or after oocyte retrieval, in terms of PR and ongoing pregnancy.","source_license":"CC-BY-4.0","license_restricted":false}