{"paper_id":"737407b2-c3f3-4b8d-9642-1f450a2ece93","body_text":"RESEARCH Open Access\n© The Author(s) 2025. Open Access  This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 \nInternational License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you \ngive appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the \nlicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the \nmaterial. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or \nexceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit  h t t p  : / /  c r e a  t i  \nv e c  o m m  o n s .  o r  g / l  i c e  n s e s  / b  y - n c - n d / 4 . 0 /.\nYazicioglu et al. BMC Pregnancy and Childbirth          (2025) 25:403 \nhttps://doi.org/10.1186/s12884-025-07492-5\nIntroduction\nEndometriosis is an inflammatory process that occurs \nwhen endometrial tissue settles in an area other than \nthe intrauterine cavity [ 1]. Endometriosis affects 10% of \nwomen of reproductive age and approximately 17–44% \nof women with endometriosis have endometriomas [ 2]. \nIndividual immunological factors, and peritoneal clear -\nance mechanisms has been thought to be responsible \nfor the wide range of endometriomas in endometrio -\nsis patients [ 3]. Imaging techniques of endometriosis is \nevolving constantly. Detection of endometrioma is usu -\nally performed with transvaginal ultrasound (TVUSG) \nBMC Pregnancy and Childbirth\n*Correspondence:\nYigit Cakiroglu\ndryigit1@yahoo.com\n1Acibadem International Hospital, Istanbul, Türkiye\n2Acibadem Maslak Hospital Assisted Reproductive Technologies Unit, \n34668 Sarıyer, Istanbul, Türkiye\n3Department of Obstetrics and Gynecology, Acibadem Mehmet Ali \nAydinlar University, Istanbul, Türkiye\nAbstract\nBackground The endometrioma accompanying hydrosalpinx can affect the success rate of in vitro fertilization (IVF). \nWe aimed to determine the incidence of hydrosalpinx in infertile patients with endometrioma and its effects on in \nvitro fertilization success.\nMethods In our retrospective study, we performed hysterosalpingography (HSG) on patients diagnosed with \nendometrioma through ultrasound evaluation. Then, we performed diagnostic laparoscopy on patients with \nsuspected tubal pathology and/or hydrosalpinx after HSG assessment. Laparoscopic tubal occlusion was performed \nfor patients with hydrosalpinx.\nResults HSG was performed on 760 patients diagnosed with ovarian endometriosis. After the assessment of HSG \nimages, hydrosalpinx was detected in 184 of 760 patients (24.2%) and diagnostic laparoscopy was performed. \nUnilateral or bilateral hydrosalpinx were detected at 65 of 184 (35.3%) patients. Laparoscopy and proximal tubal \nocclusion were performed in these patients. Incidence of hydrosalpinx was found to be 8.5% in IVF patients with \novarian endometrioma.\nConclusion Tubal patency screening may be considered for the patients with endometrioma before embryo transfer \nto prevent IVF failure due to hydrosalpinx.\nKeywords IVF, Endometriosis, HSG, Endometrioma, Hydrosalpinx\nWhy should we check the tubes in IVF patients \nwith ovarian endometriosis before embryo \ntransfer? a retrospective study\nCaglar Yazicioglu1 , Aysen Yuceturk2 , Ozge Karaosmanoglu2 , Ilke Ozer Aslan2 , Nuri Peker2 , \nYigit Cakiroglu2,3*  and Bulent Tiras2,3\n\nPage 2 of 6\nYazicioglu et al. BMC Pregnancy and Childbirth           (2025) 25:403 \nand magnetic resonance imaging (MRI) almost close to \ndetection rates to the accepted gold standard– surgical \nvisualization of the lesion with histopathological confir -\nmation [ 4]. Diagnosis of ovarian endometriosis is made \nby its ground-glass appearance and the absence of blood-\nflow-containing papillary structures on transvaginal \nultrasonography (USG) [5, 6]. Kanti et al. have compared \nthe two techniques- TVUSG and MRI in a meta-analysis \nincluding 16 studies and have reported high accuracy for \nthe diagnosis of endometriosis with the two techniques \n[4].\nHysterosalpingography (HSG) is a potential tool to \nevaluate the endometrial cavity and the tubes per -\nformed by the intracavitary injection of the contrast \nmedia under fluoroscopic guidance [ 7]. The fallopian \ntubes are accepted as patent on HSG when the perito -\nneal spillage is free from the distal tubal parts. Tubal \nfactors are the cause of almost 25% of infertility, and \nthe most severe form is hydrosalpinx [ 8]. Obstruction \nof the distal part of the tubes is defined as hydrosalpinx \n(swelling and enlargement of the tubes) and constitutes \n10–30% of tubal diseases [ 9]. In IVF patients, hydro -\nsalpinx reduces implantation and pregnancy rates by \naffecting the embryo and endometrium through both \na mechanical washing and toxic effect [ 8, 9]. Capmas et \nal. have analyzed the effects of hydrosalpinx in the era \nof Assisted Reproductive Technology (ART) in a meta-\nanalysis investigating 19 studies [ 10]. Their results have \nrevealed decreased implantation rate per embryo trans -\nfer (OR of 0.41 [0.32–0.53]) as well as increased rates of \nectopic pregnancy (OR = 3.48; [1.60 − 7.60]) and miscar -\nriage (OR = 1.68; [1.17 − 2.40]). Therefore, in patients with \nhydrosalpinx, in order to increase the success of IVF, it \nis recommended to remove fallopian tube/tubes, perform \ntubal ligation, or hydrosalpinx aspiration. All the tech -\nniques have pros and cons in regards of surgical tech -\nnique and ovarian reserve. In the same meta-analysis, no \ndifference in ovarian response to stimulation after salpin-\ngectomy has been reported except a decrease in antimul -\nlerian hormone compared to no surgery.\nWhen evaluated in terms of IVF success, the IVF out -\ncomes in patients with endometriosis-associated infer -\ntility are similar to those treated for other reasons [ 11]. \nIn two different meta-analyses previously published, the \nlive birth rates (LBR) and the clinical pregnancy rates \n(CPR) in patients with endometrioma were reported \nto be similar to those of IVF patients without endome -\ntrioma, although the mean number of retrieved oocytes \nand the cycle cancellation rates were reported to be nega-\ntively affected in the study subjects [ 11, 12]. Although \nthe mean number of retrieved oocytes were lower and \nthe cycle cancellation rates were higher in patients with \nendometrioma undergoing IVF treatment, these nega -\ntive effects have not resulted in lower pregnancy success \nrates probably due to relatively less affected endometrial \nreceptivity [ 11, 12]. Also, patients’ previous history of \nsurgery leading to diminished ovarian reserve might also \nbe a contributing underlying factor for the explanation of \npoor response.\nRecently, Demirel et al. published an article demon -\nstrating the relationship between severity of endometrio -\nsis and hydrosalpinx development and concluded that \ntubal endometriosis was significantly higher in patients \nwith stage 4 endometriosis (92.9%) [ 13]. Both the dis -\nruption of the tubal flow due to adhesions with possible \nintratubal endometriosis might play role for the tendency \nof hydrosalpinx in endometriosis patients.\nIn this study, we aimed to investigate the incidence of \nhydrosalpinx in IVF patients with ovarian endometrioma \nand whether HSG before embryo transfer in this group \nof patients could be helpful to increase the success rate \nof IVF in such patients. If the presence of hydrosalpinx \nwould be higher especially in this specific population of \nendometrioma patients, then the role of monitorization \nof the tubes would gain much importance during the ini -\ntial evaluation before embryo transfer.\nMethods\nThis retrospective study was performed at Acibadem \nMaslak Hospital IVF Center, in Istanbul, Türkiye, in \nbetween January 2015 and December 2021. The study \nprotocol was approved by the Institutional Review Board \nand Ethics Committee of Acibadem Mehmet Ali Aydinlar \nUniversity (ATADEK-2021/21 − 19).\nThe study included all IVF patients between 20 and 40 \nyears of age, with either unilateral or bilateral endome -\ntrioma ≥ 1 cm on transvaginal USG, and who had under -\ngone HSG before an IVF procedure in the study period. \nWomen > 40 years of age were not recruited in order to \nrule out a possible embryonic aneuploidy. Also, 1  cm \ncut-off was selected as the lowest threshold to detect the \nendometrioma under ultrasound. Women with previous \npelvic surgery, pelvic inflammatory disease, and pelvic \ntuberculosis were excluded from the study. Addition -\nally, patients who met the following criteria which may \ndirectly affect IVF success were excluded from the study. \nRegarding to male infertility, men with azoospermia \nand criptozoospermia were excluded. When evaluated \nin terms of female infertility; 1-women with polycys -\ntic ovarian syndrome (PCOS), 2- diminished ovarian \nreserve, 3- uterine abnormalities (septate, unicornuate, \nbicornuate, didelphus uterus), 4- Asherman’s syndrome, \n5- thin endometrium and 6- recurrent IVF failure were \nexcluded from the study.\nDiagnosis of endometrioma on transvaginal USG was \nbased on the following criteria: ovarian benign tumor \nwith circular view, thickened enclosure, smooth external \nrim, and homogenous and little liquid with internal echo \n\nPage 3 of 6\nYazicioglu et al. BMC Pregnancy and Childbirth           (2025) 25:403 \n[9]. Endometriomas were measured by three-dimen -\nsional configuration on USG. Even though ultrasound \ndiagnosis of endometrioma has some limitations, no \nstatistically significant difference in diagnostic accuracy \nhas been shown in between USG and MRI [ 4]. Similarly, \nultrasonographic diagnosis of endometrioma has been \nshown to have similar diagnostic rates compared to the \ngold-standard technique- the surgical technique espe -\ncially for ovarian, bladder, and bowel endometriosis [ 14]. \nWhen these factors have been considered, USG has been \nselected as the diagnostic tool in this study.\nHSG was performed in all patients with unilateral or \nbilateral endometrioma as a part of routine institutional \nprotocol applied to all patients. Before HSG, a short \nanamnesis from each patient about the last menstrual \nperiod, existence of any intrauterine device, sign of pelvic \ninfection, allergy, and suspected pregnancy was taken. A \nspeculum was applied to the vagina, and disinfection was \nconducted with povidone-iodine at the lithotomy posi -\ntion. A 5-F flexible balloon catheter inflated with saline \nwas inserted into the cervical canal. No routine anesthe -\nsia was applied. Non-ionic, water-soluble contrast was \nused because of the low risk of allergic reaction. HSG was \ncarried out by real-time fluoroscopy, and spot x-ray views \nwere taken during the procedure. Hydrosalpinx was iden-\ntified as the fluid-filled expansion of the tube. The aver -\nage dose of radiation applied to the ovaries is estimated \nat 2.7 mGy, with an effective dose of 1.2 mSv. At the end \nof the procedure, doxycycline 100 mg tablets twice a day \nfor five days were ordered as prophylaxis. A nonsteroid \nanti-inflammatory pill was suggested, if necessary, for \npain relief. HSG images were evaluated by the same IVF \nspecialist. One IVF specialist (BT) evaluated all images in \norder to ensure consistency and to reduce bias. Findings \nsuggestive of tubal pathology in HSG are listed below [9]:\n1-Dilated fallopian tube with complete or partial con -\ntrast filling but lack of spill from the tube to pelvic or \nabdominal cavity.\n2-Loculated contrast spill or pooling collections of \nspilled contrast.\nLaparoscopy is the gold standard procedure to evalu -\nate the tubal pathologies therefore, it was performed on \npatients with suspected hydrosalpinx in HSG [ 8, 9]. Dur-\ning the procedure, transcervical-intrauterine methylene \nblue was applied, and a unilateral or bilateral proximal \ntubal occlusion was performed to the proximal tuba on \nthe sides where hydrosalpinx was confirmed.\nStatistical analysis\nA statistical analysis was conducted using SPSS software \n[Version 22.0; SPSS Inc., Chicago, IL, USA]. Continuous \nvariables were expressed as mean ± standard deviation \nor median [minimum–maximum]. Categorical variables \nwere expressed as numbers and percentages [%]. The \nKolmogorov–Smirnov test was used to check the distri -\nbution of the data. Comparisons between the two groups \nwere made using student’s t-test. Adjustments for poten-\ntial confounding factors were made. Categorical values \nwere analyzed by chi-square test. P < 0.05 was considered \nstatistically significant.\nResults\nA total of 760 IVF patients with unilateral or bilateral \novarian endometrioma ≥ 1 cm and who underwent HSG \nbefore starting IVF treatment were included. After the \nassessment of the HSG images, 184/760 patients (24.2%) \nhad underwent laparoscopy due to suspicion of hydrosal-\npinx on HSG. All 760 patients were analyzed under three \ngroups: Group I consisted of 119/184 (64.7%) patients \nin whom hydrosalpinx was suspected but had not been \nconfirmed laparoscopically; Group II consisted of 65/184 \n(35.3%) patients who had been diagnosed with unilateral \nor bilateral hydrosalpinx during diagnostic laparoscopy \nand underwent proximal tubal occlusion; Group III con -\nsisted of 576/760 patients in which hydrosalpinx was not \ndetected in HSG. There was no statistically significant \ndifference between the three groups in terms of age, body \nmass index, duration of infertility, number of ovarian \nendometriosis and follicle stimulating hormone (FSH) \nlevels. There was also no statistically significant differ -\nence in the frequency of unilateral or bilateral endome -\ntriomas between the groups (Table 1).\nThe mean number of previous IVF attempts was signifi-\ncantly higher in Group I, however there was no difference \nbetween Group II and Group III. When endometrioma \nsizes were compared, patients in Group I and II have sta -\ntistically significantly larger endometriomas than patients \nin Group III ( p < 0.01, p < 0.01). The mean anti-mulle -\nrian hormone (AMH) levels were significantly higher \nin Group I and Group III when compared to Group II, \nthe highest value in Group I, and the lowest in Group II. \nTotal amount of gonadotropin dose and the duration of \nuse in Group II were higher than those in Group III, but \nit was not statistically significant.\nThe mean endometrial thickness on the day of human \nchorionic gonadotropin (hCG) administration were \n10.5 ± 0.3, 10.6 ± 0.4 and 9.4 ± 0.4 respectively and signifi-\ncantly greater in Group I and Group III, and the less in \nGroup II. The number of retrieved oocytes, number of \nMII oocytes and estradiol level on the day of trigger were \ncomparable among the three groups (Table 2).\nIn terms of hCG positivity, there was no statistically \nsignificant difference among three groups, however when \ncompared regarding the chemical pregnancy rate, it was \nstatistically significantly highest in Group I and lowest \nin Group II. Miscarriage rates were significantly higher \nin Group II. Ectopic pregnancies occurred exclusively in \n\nPage 4 of 6\nYazicioglu et al. BMC Pregnancy and Childbirth           (2025) 25:403 \nGroup I, with a total of three cases. The live birth rate was \nstatistically significantly higher in Group III (Table 3).\nDiscussion\nTubal factors account for approximately 25% of female \ninfertility [ 8]. Endometriosis, acute or chronic pelvic \ninfections, tuberculosis, previous pelvic surgery may \ncause infertility by causing obstruction in the distal or \nproximal segment of the fallopian tubes. Hydrosalpinx is \na condition when the distal part of the fallopian tube is \nblocked for various reasons and filled up with fluid and, \noccurs %10–30 of tubal infertility cases [ 8].\nThe preliminary screening test in tubal infertility is \nHSG. It is a non-invasive and cheap procedure. Sensi -\ntivity and specificity are 84% and 75% respectively [ 10, \n15]. On the other hand, laparoscopy is the gold standard \nin diagnosis and treatment [ 16]. In a study conducted \nby Tan et al., the results of HSG were checked by lapa -\nroscopy and the positive predictive value of HSG in the \ndiagnosis of tubal occlusion was found 87.2% [ 16]. The \nnegative predictive value for the right and the left tubal \nocclusions were 92.08% and 95.44%. In our study, we \nfound that the incidence of hydrosalpinx is 8.5% among \npatients with ovarian endometriosis and HSG performed \nbefore IVF treatment could detect about one third of \nTable 1 Patient characteristics and cycle parameters of the patients with the diagnosis of endometriosis\nGroup I\n(n = 119)\nGroup II\n(n = 65)\nGroup III\n(n = 576)\np\nAge (years) 35.3 ± 5.2 36.3 ± 5.5 34.7 ± 6.0 ns\nPartner’s age (years) 36.9 ± 5.6 38.2 ± 6.9 37.6 ± 5.9 ns\nBMI (kg/m2) 25.2 ± 4.9 25.9 ± 5.6 24.9 ± 4.6 ns\nInfertility duration (months) 66.5 ± 56.6 53.7 ± 36.4 52.8 ± 54.3 ns\nNumber of previous IVF attempts (n) 2.11 ± 2.4 1.9 ± 0.7 1.2 ± 1.7 b\nGravida 0.7 ± 1.0 0.7 ± 1.1 0.7 ± 1.2 ns\nEndometrioma size (mm) 25.3 ± 12.8 23.6 ± 14.1 19.4 ± 9.5 b.c\nNumber of endometriomas 1.3 ± 0.5 1.3 ± 0.5 1.3 ± 0.7 ns\nEndometrioma\nUnilateral\nBilateral\n51/119 (42.9%)\n68/119 (57.1%)\n41/65 (63.1%)\n24/65 (36.9%)\n214/576 (37.2%)\n362/576 (62.8%)\nns\nFSH (mIU/mL) 11.8 ± 13.2 14.1 ± 14.9 14.0 ± 16.3 ns\nAMH (ng/mL) 2.5 ± 2.8 0.5 ± 1.0 1.5 ± 2.1 a, b,c\np < 0.05: Statistically significant. a: Statistically different in between groups 1 and 2. b: Statistically different in between groups 1 and 3. c: Statistically different in \nbetween groups 2 and 3\nTable 2 IVF outcomes\nGroup 1\n(n = 119)\nGroup 2\n(n = 65)\nGrup 3\n(n = 576)\np\nTotal gonadotropin \ndose (IU)\n4023 ± 1761 3812 ± 1796 3512 ± 1618 b\nGonadotropin \nduration(days)\n8.8 ± 2.3 8.6 ± 2.4 8.3 ± 2.1 b\nE2 level (pg/ml) on \nhCG day\n1803 ± 1604 1421 ± 1643 1955 ± 1857 ns\nEndometrial thickness \non hCG day\n10.5 ± 2.8 9.4 ± 2.6 10.6 ± 2.9 a, \nc\nNumber of retrieved \noocytes\n9 ± 7 9 ± 10 10.9 ± 9.8 ns\nNumber of mature \noocytes (M2)\n6.4 ± 5.5 6.4 ± 7.5 7.6 ± 6.3 ns\nNumber of 2 pronuclei \nembryos\n5.5 ± 5.0 6.7 ± 6.6 6.7 ± 5.6 ns\nNumber of cleavage \nstage embryos\n5.9 ± 4.8 6.7 ± 6.3 6.7 ± 5.5 ns\nNumber of blastocyst \nstage embryos\n6.3 ± 4.5 5.6 ± 6.2 5.9 ± 4.1 ns\np < 0.05: Statistically significant. a: Statistically different in between groups 1 and \n2. b: Statistically different in between groups 1 and 3. c: Statistically different in \nbetween groups 2 and 3. hCG: human chorionic gonadotropin. E2: Estradiol\nTable 3 Pregnancy outcomes\nGroup 1\n(n = 119)\nGroup 2\n(n = 65)\nGrup 3\n(n = 576)\np\nPositive hCG test 56/119 (47.1) 32/65 (49.2) 298/576 (51.7) ns\nBiochemical pregnancy 8/56 (14.3) 3/32 (9.4) 15/298 (5.0) b, c\nMiscarriage 4/56 (7.1) 5/32 (15.6) 34/298 (11.4) a, b\nEctopic pregnancy 3/56 (5.4) 0 0 a, b\nLivebirth rate 41/119 (34.5) 24/65 (36.9) 249/576 (43.2) b, c\np < 0.05: Statistically significant. a: Statistically different in between groups 1 and 2. b: Statistically different in between groups 1 and 3. c: Statistically different in \nbetween groups 2 and 3\n\nPage 5 of 6\nYazicioglu et al. BMC Pregnancy and Childbirth           (2025) 25:403 \nlaparoscopically confirmed hydrosalpinx. To our knowl -\nedge, this is the first study to examine the incidence of \nhydrosalpinx and the efficacy of preprocedural HSG in \ndetecting hydrosalpinx in this patient population.\nThe relationship between the size of endometrioma \nand the incidence of hydrosalpinx has not been clearly \nrevealed yet. We found only one study reporting that \nthe risk of hydrosalpinx increases in relation to endome -\ntrioma size [ 17], however there should be a direct rela -\ntionship between the severity of endometriosis and the \nlikelihood of developing hydrosalpinx. In our study, we \ndid not classify the patients in terms of the stages of the \nendometriosis. Also, we did not find any statistically sig -\nnificant relationship between the size and the presence \n(unilateral/bilateral) of endometrioma and the incidence \nof hydrosalpinx.\nStudies have revealed a correlation between low AMH \nlevels and endometriosis however, there is insufficient \ndata regarding the relationship between endometrioma \nsize and AMH value [ 18, 19]. In a study with Akgul et \nal., an inverse relationship was found between the AMH \nlevel and the presence of the endometrioma, but no rela -\ntionship was observed between the size of the endome -\ntrioma and AMH level [18]. In another study, Zareii et al., \nobserved a moderate decrease in AMH levels as endome -\ntrioma size increases, but reported that it was not statisti-\ncally significant [19]. In our study, we found a statistically \nsignificant difference between three groups of patients \nnamely, the mean AMH level is the lowest in Group II, \nsuggesting that the presence of hydrosalpinx may be one \nof the factors causing low ovarian reserve and low AMH. \nMuzii et al. have evaluated the AMH levels in the pres -\nence of endometrioma in a systematic review and meta-\nanalysis [ 20]. Their results have revealed reduced AMH \nlevels in patients with ovarian endometriomas compared \nto patients with healthy ovaries and with patients with \nother benign ovarian cysts.\nIn literature, many articles support that the presence of \nhydrosalpinx decreases the rate of pregnancy in patients \nreceiving IVF treatment [ 21]. It has been suggested that \nthe fluid leakage into the endometrial cavity affects \nimplantation by modifying the expression of Home -\nbox A10 (HOXA10) gene. This gene regulates embry -\nonic development and implantation [ 22]. Additionally, \nhydrosalpinx may have toxic effect directly on sperm and \nembryo as well on the endometrium altering the endo -\nmetrial receptivity [ 22]. In our study, endometrial thick -\nness in Group II was statistically significantly lower than \nthe other groups. We hypothesize that this could be asso-\nciated with the presence of hydrosalpinx. We further \nspeculate that this might be related to the washing effect \nof hydrosalpinx on the endometrium. Infective or inflam-\nmatory fluid collection in the tubes might pass through \nthe isthmic part of the tubes towards the endometrial \ncavity and might result in a change in the receptive endo-\nmetrium. Another factor might be the low E2 levels in \nGroup II, although the difference was not statistically \nsignificant.\nLaparoscopic proximal tubal occlusion before embryo \ntransfer significantly increases the pregnancy rates [ 23, \n24]. Strandell et al. conducted a clinical trial and reported \nthat clinical pregnancy rate was 36.6% in salpingectomy \ngroup and 23.9% in non-salpingectomy group [ 23]. In \nour study, there is no statistical difference among three \ngroups in terms of hCG positivity, because embryo trans-\nfer was performed after laparoscopic tubal occlusion in \npatients with hydrosalpinx. The biochemical pregnancy \nrate is the lowest in Group III, compromising patients \nwithout the diagnosis of hydrosalpinx. One of the most \nimportant factors that may play role in the physiopathol -\nogy of biochemical pregnancy is hydrosalpinx [ 25] so it \nis not surprising to observe the lowest biochemical preg -\nnancy rate in Group III. Also, the frequency of miscar -\nriage was statistically significantly higher in Group II. In \na recent meta-analysis by Yang et al., it was suggested \nthat ovarian endometrioma had a negative effect on the \nnumber of M2 oocytes and embryos but not on embryo \nquality and IVF results [ 11]. Hamdan et al., reported \nthat miscarriages rate, ongoing pregnancy rate and live \nbirth rate were similar between patients with and with -\nout endometrioma [ 12]. The higher miscarriage rates \nobserved in Group II cannot be explained by hydrosal -\npinx alone. Miscarriages may have resulted as a conse -\nquence of other factors, such as embryo euploidy.\nThere are certain limitations on this study. First, the \nsample size was limited. Additionally, we were not able \nto exclude other possible causes of hydrosalpinx, such as \nprevious infection, together with endometrioma. Diag -\nnosis of endometrioma with USG may also be a limiting \nfactor, as it may cause difficulty in differential diagnosis \nwith ovarian hemorrhagic cysts. Lack of endometriosis \nstaging is another limitation of the study, since the differ-\nence in AMH levels might also raise the suspicion that it \nmight be due to the different stages of endometriosis.\nConclusion\nAlthough laparoscopy is the gold standard for diagnosing \nhydrosalpinx, it is not feasible to perform this procedure \non all patients; instead, HSG screening may be consid -\nered before embryo transfer for each patient with endo -\nmetrioma to prevent IVF failures caused by hydrosalpinx, \nwhich might be a frequent condition in endometrioma \npatients.\nAcknowledgements\nNone.\n\nPage 6 of 6\nYazicioglu et al. BMC Pregnancy and Childbirth           (2025) 25:403 \nAuthor contributions\nC.Y., A.Y., O.K., I.O.A., N.P ., Y.C., B.T. designed the study; C.Y., A.Y., O.K., I.O.A., N.P ., \nanalysed the data, C.Y., A.Y., O.K., Y.C. wrote the manuscript; Y.C., B.T. edited and \nrevised the manuscript.\nFunding\nNone.\nData availability\nThe datasets used and/or analysed during the current study are available from \nthe corresponding author on reasonable request.\nDeclarations\nEthics approval\nThe study protocol was approved by the Institutional Review Board \nand Ethics Committee of Acibadem Mehmet Ali Aydinlar University \n(ATADEK-2021/21 − 19) and adhered the latest legislations of Helsinki \nDeclaration.\nConsent to participate\nConsent to participate was deemed unnecessary by the Institutional Review \nBoard and Ethics Committee of Acibadem Mehmet Ali Aydinlar University.\nConsent for publication\nNot applicable.\nCompeting interests\nThe authors declare no competing interests.\nClinical trial number\nNot applicable.\nReceived: 11 February 2025 / Accepted: 18 March 2025\nReferences\n1. Johnson NP , Hummelshoj L, Adamson GD, Keckstein J, Taylor HS, Abrao MS, et \nal. World endometriosis society consensus on the classification of endome-\ntriosis. Hum Reprod. 2017;32(2):315–24.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 0 9 3  / h  u m r e p / d e w \n2 9 3.\n2. Hoyle AT, Puckett Y. Endometrioma. In: StatPearls. Treasure Island (FL); 2025.\n3. Bulun SE, Yilmaz BD, Sison C, Miyazaki K, Bernardi L, Liu S, et al. Endometr \nEndocr Rev. 2019;40(4):1048–79.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 2 1 0  / e  r . 2 0 1 8 - 0 0 2 4 2.\n4. Kanti FS, Gorak Savard R, Bergeron F, Zomahoun HTV, Netter A, Maheux-\nLacroix S. Transvaginal ultrasound and magnetic resonance imaging in \nthe diagnosis of endometrioma: a systematic review and meta-analysis of \ndiagnostic test accuracy studies. J Obstet Gynaecol. 2024;44(1):2311664.  h t t p  \ns : /  / d o i  . o  r g /  1 0 .  1 0 8 0  / 0  1 4 4  3 6 1  5 . 2 0  2 4  . 2 3 1 1 6 6 4.\n5. Nickkho-Amiry M, Savant R, Majumder K, Edi-O’sagie E, Akhtar M. The effect \nof surgical management of endometrioma on the IVF/ICSI outcomes when \ncompared with no treatment? A systematic review and meta-analysis. Arch \nGynecol Obstet. 2018;297(4):1043–57.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 0 0 7  / s  0 0 4 0 4 - 0 1 7 - 4 6 \n4 0 - 1.\n6. Van Holsbeke C, Van Calster B, Guerriero S, Savelli L, Paladini D, Lissoni AA, \net al. Endometriomas: their ultrasound characteristics. Ultrasound Obstet \nGynecol. 2010;35(6):730–40.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 0 0 2  / u  o g . 7 6 6 8.\n7. Ghonge NP , Ghonge SD. Hystero-Salphingography in current clinical \npractice-old flames, die hard! Abdom radiol (NY). 2025;50(1):213–23.  h t t p  s : /  / \nd o i  . o  r g /  1 0 .  1 0 0 7  / s  0 0 2 6 1 - 0 2 4 - 0 4 4 5 6 - 9\n8. Ng KYB, Cheong Y. Hydrosalpinx - Salpingostomy, salpingectomy or tubal \nocclusion. Best Pract Res Clin Obstet Gynaecol. 2019;59.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 0 \n1 6  / j  . b p  o b g  y n . 2  0 1  9 . 0 1 . 0 1 1.:41– 7.\n9. Ambildhuke K, Pajai S, Chimegave A, Mundhada R, Kabra P . A review of tubal \nfactors affecting fertility and its management. Cureus. 2022;14(11):e30990.  h t t \np  s : /  / d o i  . o  r g /  1 0 .  7 7 5 9  / c  u r e u s . 3 0 9 9 0.\n10. Capmas P , Suarthana E, Tulandi T. Management of hydrosalpinx in the era of \nassisted reproductive technology: A systematic review and Meta-analysis. J \nMinim Invasive Gynecol. 2021;28(3):418–41.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 0 1 6  / j  . j m i g . 2 0 \n2 0 . 0 8 . 0 1 7.\n11. Yang C, Geng Y, Li Y, Chen C, Gao Y. Impact of ovarian endometrioma on ovar-\nian responsiveness and IVF: a systematic review and meta-analysis. Reprod \nBiomed Online. 2015;31(1):9–19.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 0 1 6  / j  . r b m o . 2 0 1 5 . 0 3 . 0 0 5.\n12. Hamdan M, Dunselman G, Li TC, Cheong Y. The impact of endometrioma \non IVF/ICSI outcomes: a systematic review and meta-analysis. Hum Reprod \nUpdate. 2015;21(6):809–25.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 0 9 3  / h  u m u p d / d m v 0 3 5.\n13. Demirel E, Ali A, Seraji S, Khullar P , Nezhat FR, INCIDENCE OF FALLOPIAN, TUBE \nENDOMETRIOSIS AND ITS ASSOCIATION WITH ENDOMETRIOMAS, HYDRO-\nSALPINX, AND PERITUBAL ADHESIONS.: A PROSPECTIVE COHORT STUDY. In: \nFertility and Sterility: 2024; 2024: e158-e9.\n14. Abrao MS, Andres MP , Gingold JA, Rius M, Neto JS, Goncalves MO, et al. \nPreoperative ultrasound scoring of endometriosis by AAGL 2021 endo-\nmetriosis classification is concordant with laparoscopic surgical findings \nand distinguishes early from advanced stages. J Minim Invasive Gynecol. \n2023;30(5):363–73.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 0 1 6  / j  . j m i g . 2 0 2 2 . 1 1 . 0 0 3.\n15. Panchal S, Nagori C. Imaging techniques for assessment of tubal status. J \nHum Reprod Sci. 2014;7(1):2–12.  h t t p  s : /  / d o i  . o  r g /  1 0 .  4 1 0 3  / 0  9 7 4 - 1 2 0 8 . 1 3 0 7 9 7.\n16. Tan J, Deng M, Xia M, Lai M, Pan W, Li Y. Comparison of hysterosalpingog-\nraphy with laparoscopy in the diagnosis of tubal factor of female infertility. \nFront Med (Lausanne). 2021;8:720401.  h t t p  s : /  / d o i  . o  r g /  1 0 .  3 3 8 9  / f  m e d . 2 0 2 1 . 7 2 0 \n4 0 1.\n17. Yavuzcan A, Caglar M, Dilbaz S, Ustun Y, Ozdemir I, Yildiz E, et al. Clinical \nsymptoms and diagnostic tools that are related to infertility and hydrosalpinx \nformation in women with advanced stage endometriosis complicated by \nendometrioma. Ginekol Pol. 2013;84(9):765–9.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 7 7 7  2 /  g p / 1 \n6 3 7.\n18. Akgul OK, Guraslan H, Kovalak EE, Karacan T, Aydin TO, Cay T. Association of \nendometrioma size with serum Anti-mullerian hormone. J Coll Physicians \nSurg Pak. 2022;32(9):1132–6.  h t t p  s : /  / d o i  . o  r g /  1 0 .  2 9 2 7  1 /  j c p  s p .  2 0 2 2  . 0  9 . 1 1 3 2.\n19. Zareii A, Askary E, Ghahramani A, Chamanara K, Abadi AKH, Afzalzadeh A. \nEvaluation of endometrioma size effect on ovarian reserve, embryo quality \nand pregnancy outcome after in vitro fertilization cycle; a cross-sectional \nstudy. BMC Womens Health. 2023;23(1):327.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 1 8 6  / s  1 2 9 0 5 - 0 \n2 3 - 0 2 4 8 2 - 1.\n20. Muzii L, Di Tucci C, Di Feliciantonio M, Galati G, Di Donato V, Musella A, et al. \nAntimullerian hormone is reduced in the presence of ovarian endometrio-\nmas: a systematic review and meta-analysis. Fertil Steril. 2018;110(5):932–\ne401.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 0 1 6  / j  . f e  r t n  s t e r  t .  2 0 1 8 . 0 6 . 0 2 5.\n21. Melo P , Georgiou EX, Johnson N, van Voorst SF, Strandell A, Mol BWJ, et al. \nSurgical treatment for tubal disease in women due to undergo in vitro fertili-\nsation. Cochrane Database Syst Rev. 2020;10(10):CD002125.  h t t p  s : /  / d o i  . o  r g /  1 \n0 .  1 0 0 2  / 1  4 6 5  1 8 5  8 . C D  0 0  2 1 2 5 . p u b 4.\n22. Li T, Lu F, Wu C, Cai YL, Yang L, Cai H. Study of hydrosalpinx on endometrial \ngrowth and expression of HOXA10mRNA and related factors. Heliyon. \n2023;9(6):e17063.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 0 1 6  / j  . h e  l i y  o n . 2  0 2  3 . e 1 7 0 6 3.\n23. Strandell A, Lindhard A, Waldenstrom U, Thorburn J, Janson PO, Hamberger L. \nHydrosalpinx and IVF outcome: a prospective, randomized multicentre trial in \nScandinavia on salpingectomy prior to IVF. Hum Reprod. 1999;14(11):2762–9.  \nh t t p  s : /  / d o i  . o  r g /  1 0 .  1 0 9 3  / h  u m r e p / 1 4 . 1 1 . 2 7 6 2.\n24. Tjahyadi D, Udayana IS, Nisa AS, Rachmawati A, Djuwantono T. Comparison \nof salpingectomy and tubal occlusion for hydrosalpinx in in-vitro fertilization \noutcome. Ann Med Surg (Lond). 2024;86(2):886–90.  h t t p  s : /  / d o i  . o  r g /  1 0 .  1 0 9 7  / \nM  S 9 .  0 0 0  0 0 0 0  0 0  0 0 0 1 5 4 8.\n25. Merviel P , Lourdel E, Cabry R, Boulard V, Brzakowski M, Demailly P , et al. \nPhysiopathology of human embryonic implantation: clinical incidences. Folia \nHistochem Cytobiol. 2009;47(5):S25–34.  h t t p s :   /  / d o  i .  o r  g  /  1 0  . 2 4   7 8  / v 1 0  0 4 2 -  0 0 9 \n-  0 0 5 8 - 3.\nPublisher’s note\nSpringer Nature remains neutral with regard to jurisdictional claims in \npublished maps and institutional affiliations.","source_license":"CC0","license_restricted":false}