Effect of the timing of surgical treatment of hydrosalpinx on in vitro fertilization/intracytoplasmic single-sperm injection pregnancy outcomes in patients with tubal factor infertility.

The general situation of groups A and B are presented in Table 1 . Adjusting for the age at oocyte retrieval, years of infertility, bLH, bFSH, AFC, BMI, number of transplanted embryos, and endometrial thickness on transplantation day, cleavage-stage embryo transfer rate, blastocyst transfer rate, Fresh embryo transfer rate, Frozen embryo transfer rate using multivariate logistic regression. No significant differences in clinical pregnancy, biochemical pregnancy, ectopic pregnancy, early abortion, late abortion, premature birth, and live birth rates were observed between the two groups ( p  > 0.05), as shown in Table 2 . Table 1 General situation of groups A and B and pregnancy outcomes after LAP Group A (n = 190) Group B (n = 187) t/Z/x 2 value P- value Age of oocyte retrieval(year) 31.00 (28.00,35.00) 31.00 (27.00,33.00) −2.416 0.016 years of infertility (year) 3.00 (2.00,5.00) 3.00 (2.00,6.00) −0.990 0.322 bLH(IU) 4.92 (3.69,6.11) 5.29 (4.14,6.59) −2.161 0.031 bFSH(IU) 6.77 (5.74,7.81) 6.62 (5.64,7.68) −0.884 0.377 AFC(n) 12.00 (8.00,18.00) 13.00 (10.00,18.00) −2.023 0.043 BMI (kg/m2) 21.50 (19.88,23.20) 21.20 (19.50,22.89) −1.610 0.107 Type of Infertility Primary 56.84%(108/190) 63.10% (118/187) 1.538 0.215 Secondary 43.16% (82/190) 36.90% (69/187) 1.538 0.215 Total dose of Gonadotropins(IU) 2100.00 (1500.00,2700.00) 1800.00 (1350.00,2700.00) −1.064 0.287 Gn days(d) 11.00 (9.75,12.00) 11.00(10.00,12.00) −1.339 0.181 the number of follicles diameter large then 14 mm on HCG day(N) 10.00(7.00,15.00) 10.00(7.00,14.00) −0.791 0.429 number of oocyte retrieved(N) 14.00(8.75,19.00) 14.00(9.00,20.00) −0.532 0.595 number of high-quality embryos (N) 6.00(4.00,9.00) 6.00(4.00,10.00) −0.551 0.582 2 PN fertilization rate % (n) 63.0% (1724/2737) 63.0% (1786/2833) 0.002 0.967 Number of embryos transferred (N) 1.00 (1.00,2.00) 1.00 (1.00,2.00) −0.365 0.715 Endometrial thickness on the day of embryo transfer (mm) 9.30(8.00,11.00) 10.00(9.00,12.00) −5.559 0.000 Type of embryo transfer cleavage-stage embryo transfer rate (%) 28.42% (54/190) 48.66% (91/187) 16.315  < 0.001 D5/D6 blastocyst transfer rate (%) 71.58%(136/190) 51.33%(96/187) 16.315  < 0.001 Type of transfer Fresh embryo transfer rate (%) 0%(0/190) 67.91%(127/187) 194.588  < 0.001 Frozen embryo transfer rate (%) 100%(190/190) 32.09%(60/187) 194.588  < 0.001 embryo implantation rate% (n) 46.8%(132/282) 51.4%(142/276) 1.202 0.273 clinical pregnancy rate% (n) 57.9%(110/190) 64.7%(121/187) 1.843 0.175 biochemical pregnancy rate % (n) 7.4%(14/190) 3.7%(7/187) 2.355 0.125 ectopic pregnancy rate % (n) 1.8%(2/110) 3.3%(4/121) 0.504 0.686 early abortion rate % (n) 4.5%(5/110) 11.6%(14/121) 3.767 0.052 late abortion rate % (n) 2.7%(3/110) 3.3%(4/121) 0.066 1.000 premature delivery rate% (n) 16.4%(18/110) 9.9%(12/121) 2.119 0.145 live birth rate % (n) 52.1%(99/190) 52.9%(99/187) 0.026 0.871 General situation of groups A and B and pregnancy outcomes after LAP the number of follicles diameter large then 14 mm on HCG day(N) Number of embryos transferred (N) Endometrial thickness on the day of embryo transfer (mm) Table 2 Pregnancy outcomes in groups A and B after adjusting for the age at oocyte retrieval, years of infertility, bLH, bFSH, AFC, BMI, number of transplanted embryos, and endometrial thickness on transplantation day, cleavage-stage embryo transfer rate, blastocyst transfer rate, Fresh embryo transfer rate,Frozen embryo transfer rate using multivariate logistic regression Unadjusted odds ratio Adjusted odds ratio OR 95%CI P -value OR 95%CI P -value clinical pregnancy rate% (n) 0.750 (0.495, 1.137) 0.715 0.841 (0.445, 1.591) 0.595 biochemical pregnancy rate % (n) 2.045 (0.806, 5.188) 0.132 2.309 (0.487, 10.958) 0.292 ectopic pregnancy rate % (n) 0.542 (0.097, 3.017) 0.484 0.342 (0.035, 3.368) 0.358 early abortion rate % (n) 0.364 (0.127, 1.046) 0.061 0.320 (0.074, 1.379) 0.126 late abortion rate % (n) 0.820 (0.179, 3.749) 0.798 1.839 (0.122, 27.641) 0.659 premature delivery rate% (n) 1.777 (0.814, 3.882) 0.149 2.284 (0.577, 9.037) 0.239 live birth rate % (n) 0.967 (0.645, 1.449) 0.871 1.023 (0.551, 1.900) 0.941 Pregnancy outcomes in groups A and B after adjusting for the age at oocyte retrieval, years of infertility, bLH, bFSH, AFC, BMI, number of transplanted embryos, and endometrial thickness on transplantation day, cleavage-stage embryo transfer rate, blastocyst transfer rate, Fresh embryo transfer rate,Frozen embryo transfer rate using multivariate logistic regression Multivariate logistic regression was used to adjust for the bLH, bFSH, AFC, the number of follicles diameter large then 14 mm on HCG day, endometrial thickness on the transplantation day, cleavage-stage embryo transfer rate (%), D5/D6 blastocyst transfer rate (%), fresh embryo transfer rate(%) frozen embryo transfer rate(%), no significant differences in clinical pregnancy, biochemical pregnancy, ectopic pregnancy, early abortion, late abortion, premature birth, and live birth rates were observed between the two groups ( p  > 0.05), as shown in Table 3 and Table S1 , S2 , S3 , S4 . Table 3 Pregnancy outcome between different ages and times of surgery after LAP 项目 Group A1(n=136) Group B1 (n=153) t/Z/x 2 值 P 值 Group A2 (n = 54) Group B2 (n = 34) t/Z/x 2 值 P 值 clinical pregnancy rate% (n) 64.00% (87/136) 66.00% (101/153) 0.132 0.716 42.60% (23/54) 58.80% (20/34) 2.200 0.138 biochemical pregnancy rate % (n) 6.60% (9/136) 3.90% (6/153) 1.064 0.302 9.30% (5/54) 2.90% (1/34) 1.311 0.252 ectopic pregnancy rate % (n) 2.30% (2/87) 4.00% (9/101) 0.418 0.688 0.00% (0/23) 0.00% (0/20) / / early abortion rate % (n) 4.60% (4/87) 10.90% (11/101) 2.521 0.112 4.30% (1/23) 15.00% (3/20) 1.439 0.323 late abortion rate % (n) 3.40% (3/87) 3.00% (3/101) 0.035 1.000 0.00% (0/23) 5.00% (1/20) 1.177 0.465 premature delivery rate% (n) 17.20% (15/87) 9.90% (10/101) 2.184 0.139 13.00% (3/23) 10.00% (2/20) 0.096 1.000 live birth rate % (n) 56.60% (77/136) 54.20% (83/153) 0.164 0.686 40.70% (22/54) 47.10% (16/34) 0.339 0.56 Pregnancy outcome between different ages and times of surgery after LAP Two patients in group A had abdominal pain and acute pelvic inflammatory disease after oocyte retrieval. After anti-infection treatment, LAP was performed during the elective period. The condition was diagnosed as pyosalpinx, and the affected side of the fallopian tube was removed. No postoperative complications were observed in group B, and oocyte contamination was not observed in both groups. Group A had significantly higher time and economic costs than Group B ( p  < 0.05), as shown in Table 4 . Table 4 Comparison of complications after oocyte retrieval, oocyte contamination, and time cost and economy costs between groups A and B Group A(n = 190) Group B(n = 187) t/Z value P- value Complications after oocyte retrieval %(n) 1.05%(2/190) 0%(0/187) / / oocyte contamination %(n) 0%(0/190) 0%(0/187) / / time cost(day) 200.94 (130.16,347.93) 155.98 (116.00,213.19) −4.321 0.000 economic cost(yuan) 65697.31 (56970.98,77803.99) 56306.73 (50923.35,64611.71) −6.001 0.000 Comparison of complications after oocyte retrieval, oocyte contamination, and time cost and economy costs between groups A and B 200.94 (130.16,347.93) 155.98 (116.00,213.19) 65697.31 (56970.98,77803.99) 56306.73 (50923.35,64611.71) After adjusting for the age at oocyte retrieval, years of infertility, bLH, bFSH, AFC, BMI, number of oocyte retrieved, number of transplanted embryos, and endometrial thickness on transplantation day, cleavage-stage embryo transfer rate, D5/D6 blastocyst transfer rate, fresh embryo transfer rate, frozen embryo transfer rate, using multivariate logistic regression, the early abortion rate was lower than in the group that underwent ET ≤ 3 months after LAP than in the group that underwent ET > 3 months after LAP，though the difference was not statistically significant ( p  = 0.066). No significant differences in clinical pregnancy, biochemical pregnancy, late abortion, premature birth, and live birth rates were observed ( p  > 0.05), as shown in Tables 5 , 6 , and Tables S5 , S6 . Table 5 The pregnancy outcomes of patients with different embryo transfer times after LAP embryo transfer after LAP ≤3 months group (n = 193) embryo transfer after LAP > 3 months group (n = 184) t/Z/x 2 value P -value clinical pregnancy rate% (n) 60.1%(116/193) 62.5%(115/184) 0.228 0.633 biochemical pregnancy rate % (n) 6.7%(13/193) 4.3%(8/184) 1.021 0.312 ectopic pregnancy rate % (n) 3.4%(4/116) 1.7%(2/115) 0.667 0.414 early abortion rate %(n) 4.3%(5/116) 12.2%(14/115) 4.731 0.030 late abortion rate %(n) 3.4%(4/116) 2.6%(3/115) 0.138 0.710 premature delivery rate%(n) 15.5%(18/116) 10.4%(12/115) 1.320 0.251 live birth rate %(n) 52.8%(102/193) 52.2%(96/184) 0.017 0.895 The pregnancy outcomes of patients with different embryo transfer times after LAP Table 6 Pregnancy outcomes in groups with different embryo transfer times after LAP after adjusting for the age at oocyte retrieval, years of infertility, bLH, bFSH, AFC, BMI, number of oocyte retrieved, number of transplanted embryos, endometrial thickness on transplantation day, cleavage-stage embryo transfer rate, D5/D6 blastocyst transfer rate, fresh embryo transfer rate, frozen embryo transfer rate, using multivariate logistic regression Unadjusted odds ratio Adjusted odds ratio OR 95%CI P-value OR 95%CI P-value clinical pregnancy rate%(n) 0.904 (0.597, 1.369) 0.633 0.941 (0.598, 1.479) 0.792 early abortion rate %(n) 0.325 (0.113, 0.934) 0.037 0.342 (0.109, 1.072) 0.066 live birth rate %(n) 1.027 (0.686, 1.540) 0.895 1.850 (0.962, 3.557) 0.815 Pregnancy outcomes in groups with different embryo transfer times after LAP after adjusting for the age at oocyte retrieval, years of infertility, bLH, bFSH, AFC, BMI, number of oocyte retrieved, number of transplanted embryos, endometrial thickness on transplantation day, cleavage-stage embryo transfer rate, D5/D6 blastocyst transfer rate, fresh embryo transfer rate, frozen embryo transfer rate, using multivariate logistic regression Pregnancy outcomes of patients with different oocyte retrieval times after LAP After adjusting for the age at oocyte retrieval, years of infertility, bLH, AFC, BMI, cleavage-stage embryo transfer rate, D5/D6 blastocyst transfer rate, fresh embryo transfer rate, frozen embryo transfer rate, using multivariate logistic regression, No significant differences in clinical pregnancy, biochemical pregnancy,ectopic pregnancy, early abortion, late abortion, premature birth, and live birth rates were observed (P > 0.05), as shown in Table 7 . Table 7 The oocyte retrieval situation and pregnancy outcome of patients with different oocyte retrieval times after lap oocyte retrieval after LAP≤3 months group ( n  = 83) oocyte retrieval after LAP > 3 months group ( n  = 104) t/Z/x 2 value P -value Total dose of Gonadotropins (IU) 1800.00 (1450.00,2400.00) 1912.50 (1350.00,2906.25) −0.735 0.462 Gn days (d) 11.00(10.00,12.00) 11.00(10.00,12.00) −1.117 0.264 the number of follicles diameter large then 14 mm on HCG day (N) 8.00(6.00,13.00) 10.50(7.00,14.00) −1.534 0.125 number of oocyte retrieved (N) 13.00(8.00,19.00) 15.00(9.25,20.00) −1.447 0.148 number of high-quality embryos (N) 6.00(3.00,10.00) 7.00(4.00,10.75) −0.782 0.434 2 PN fertilization rate % (n) 63.0%(745/1183) 63.1%(1041/1650) 0.004 0.950 embryo implantation rate% (n) 53.8%(63/117) 49.7%(79/159) 0.467 0.494 clinical pregnancy rate% (n) 65.1%(54/83) 64.4%(67/104) 0.008 0.928 biochemical pregnancy rate % (n) 3.6%(3/83) 3.8%(4/104) 0.007 1.000 ectopic pregnancy rate % (n) 3.7%(2/54) 3.0%(2/67) 0.048 0.826 early abortion rate % (n) 11.1%(6/54) 11.9%(8/67) 0.020 0.887 late abortion rate % (n) 3.7%(2/54) 3.0%(2/67) 0.048 1.000 premature delivery rate% (n) 14.8%(8/54) 6.0%(4/67) 2.618 0.106 live birth rate % (n) 53.0%(44/83) 52.9%(55/104) 0.000 0.986 The oocyte retrieval situation and pregnancy outcome of patients with different oocyte retrieval times after lap 1800.00 (1450.00,2400.00) 1912.50 (1350.00,2906.25)

This retrospective study included 377 patients with tubal factor infertility who underwent LAP unilateral or bilateral salpingectomy due to moderate and severe hydrosalpinx, IVF/ICSI-ET, or frozen ET (FET) at the Department of Reproductive Medical Center, Guangdong Women and Children Hospital, between June 2013 and April 2023. Inclusion criteria were the age of 20–40 years and the presence of unilateral/bilateral hydrosalpinx on hysterosalipingography or ultrasound uterosalpingography. An LAP examination was performed. During the surgery, according to the “American Society for Reproductive Medicine’s Classification of Distal Obstruction of the Fallopian tube [ 9 ], “fallopian tube lesions were evaluated as moderate to severe distal obstruction of the fallopian tube. Unilateral or bilateral salpingectomy was performed under LAP, pelvic adhesions were released, the pelvic organs were restored to the normal anatomical position, and the pelvic cavity was fully rinsed with normal saline. Surgery was performed by the same chief physician, and all patients provided informed consent before surgery. Exclusion criteria were the presence of premature ovarian failure, polycystic ovary syndrome, hyperprolactinemia, uterine adhesion, uterine malformation, uterine fibroids, ovarian tumor, ovarian endometriosis, recurrent abortion, diabetes, hyperthyroidism, hypothyroidism, autoimmune diseases, and chromosomal abnormalities in either of the couple. Based on the timing of surgery for hydrosalpinx, patients were divided into two groups: those who underwent COH and oocyte retrieval first, followed by embryo freezing, LAP salpingectomy, and FET (Group A, n  = 190) and those who underwent LAP salpingectomy first, followed by controlled super-promoting ovulation, oocyte retrieval, and ET/FET (Group B, n  = 187). The selection between two surgical timing options involves a thorough evaluation of the patient’s age, duration of infertility, ovarian reserve function, treatment timeline, and economic considerations. After the doctor carefully weighs the pros and cons of each approach and conducts personalized informed communication, the patient ultimately selects their preferred path based on personal preference. According to age, patients were divided into groups A1 ( < 35 years, n  = 136), A2 (≥35 years, n  = 54), B1 ( < 35 years, n  = 153), and B2 (≥35 years, n  = 34). We compared IVF/ICSI-ET/FET pregnancy outcomes, complications after oocyte retrieval, oocyte contamination, and time and economic costs between group A and group B. The entire transplant cycle was the first cycle after LAP, the study flowchart showed in Fig. 1 . According to the different ET times after LAP, 377 patients were further divided into two groups: those who underwent ET ≤ 3 months after LAP ( n  = 193), > 3 months after LAP ( n  = 184). the study flowchart showed in Fig. 2 . We compared the pregnancy outcomes between two groups. According to the different oocyte retrieval times after LAP, the patients in group B ( n  = 187) were further divided into two groups: those who underwent oocyte retrieval ≤3 months after LAP ( n  = 83), > 6 months after LAP ( n  = 104). We compared the oocyte retrieval situation and pregnancy outcomes between the two groups, the study flowchart showed in Fig. 3 . This study was approved by the Ethics Committee of our hospital and complied with its administrative regulations. Fig. 1 Grouping flowchart of different surgical management timing Fig. 2 Grouping flow charts for different embryo transfer times after LAP Fig. 3 Grouping flowchart of different oocyte retrieval times after LAP Grouping flowchart of different surgical management timing Grouping flow charts for different embryo transfer times after LAP Grouping flowchart of different oocyte retrieval times after LAP Age at oocyte retrieval, years of infertility, basic luteinizing hormone (bLH), basic follicle stimulant hormone (bFSH), body mass index (BMI), and antral follicle count (AFC) were evaluated. Medium-length luteal and antagonist regimens were administered. Diafrin (1.0 mg; Ipson Biotechnology Company) was administered through subcutaneous injection in the metaphase of the luteal period before ovulation induction, and gonadotropin (Gn) was administered for ovulation induction after the downregulation standard was reached 14 days later, and the dosage was adjusted according to the test results. When two or more mature follicles ≥18 mm in diameter or three or more follicles ≥17 mm in diameter were observed, human chorionic gonadotropin (HCG) was administered at night. HCG (8,000– 10,000 IU) was injected intramuscularly, and the oocytes were aspirated using transvaginal ultrasound with negative pressure 35–36 h later. Regarding the antagonist regimen, Gn was used to promote excretion from approximately day 3 of the cycle, and antagonists were administered on the day of HCG administration using a fixed or flexible regimen. Regarding the fresh ET cycle, according to the scoring criteria for embryos or blastocysts, the selection of high-quality embryos on day 3 and top-quality blastocysts on day 5 or day 6 require ET. Progesterone was administered at a dose of 10 mg orally twice daily or 40 mg intramuscularly once daily, or senolone was administered at a dose of 90 mg transvaginally once daily to support the functional branch of the corpus luteum. The medication was maintained for 8–10 weeks. After post-implantation for 14 days, the patient’s blood HCG levels were measured. If the test result was positive, a transvaginal ultrasound examination was performed after 2 weeks to assess the presence of an internal gestational sac, even in cases in which embryo development had ceased, and identify ectopic pregnancies. Clinical pregnancy was confirmed using these findings, and the number of gestational sacs was recorded while monitoring the pregnancy’s progress. The frozen ET cycle involved the natural cycle/ovarian stimulation cycle/hormone replacement cycle and D3/D5/D6 frozen embryo transplant. Progesterone was administered at a dose of 10 mg orally twice daily, or 40 mg intramuscularly once daily, or senolone at a dose of 90 mg transvaginally once daily to support the functional branch of the corpus luteum and maintain medication for 8–10 weeks. After post-implantation for 14 days, the patient’s blood HCG levels were measured. If the test result is positive, a transvaginal ultrasound examination will be performed after 2 weeks to assess the presence of an internal gestational sac (including cases in which embryo development has ceased) and identify ectopic pregnancies. Clinical pregnancy was confirmed by these findings, and the number of gestational sacs was recorded while monitoring the pregnancy progress. The total Gn dose, number of Gn administration days, number of follicles > 14 mm in diameter on HCG administration day, number of oocyte retrieved, number of high-quality embryos, two pronuclear (2 PN) fertilization rate (number of 2 PN fertilized embryos/total number of oocyte retrieved), number of transplanted embryos, endometrial thickness on transfer day, embryo implantation rate (total number of transplanted embryos observed under vaginal ultrasound 4 weeks after transplantation/total number of transplanted embryos), clinical pregnancy rate (transfer cycles observed under vaginal ultrasound 4 weeks after transplantation/number of cycles), biochemical pregnancy rate (serum HCG > 5 mIU/mL after transplantation for 14 days; 4 weeks after transplantation vagina ultrasound does not see the number of gestational sac cycles/transplant cycles), ectopic pregnancy rate (number of ectopic pregnancy cycles/number of clinical pregnancy cycles), early abortion rate (number of weeks of abortion ≤ 12 weeks of cycles/number of clinical pregnancy cycles), late abortion rate (number of weeks of abortion > 12 weeks of cycles/number of clinical pregnancy cycles), premature delivery rate (number of deliveries at < 37 weeks but ≥28 weeks of pregnancy/number of clinical pregnancy cycles), and live birth rate (number of live birth [number of gestational weeks ≥ 28 weeks] cycles/number of transplant cycles) were evaluated. Complications of oocyte retrieval, including postoperative pelvic infection, puncture injury, and pelvic bleeding, were also evaluated. Oocyte contamination was defined as the contamination of oocytes or embryo culture observed after oocyte retrieval. Time Cost: Encompasses the entire duration, (measured in days, commencing with the preoperative evaluation for ovulation induction or laparoscopic examination and extending through to the post-transplantation serological testing and ultrasound confirmation of clinical pregnancy. Economic Cost: Comprises all expenses, (quantified in yuan, incurred for diagnostic procedures, medications, surgical interventions, and hospitalization services rendered at our outpatient and inpatient departments throughout the period spanning from preoperative evaluations to the post-transplantation confirmation of clinical pregnancy. Statistical analyses were performed using IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, N.Y., USA). Normally distributed continuous variables were presented as mean and standard deviation (±s) and compared using an independent sample t-test or analysis of variance. Non-normally distributed continuous variables were presented as the median and interquartile range (M[Q1, Q3]). The Mann–Whitney U test was used to compare two groups, whereas the Kruskal–Wallis test was used to compare multiple groups. Categorical data were presented as percentages (%) and were compared using the chi-square or Fisher’s exact test. In addition, multivariate logistic regression analysis was performed on variables that significantly influenced clinical pregnancy outcomes. Statistical significance was set at p  < 0.05 (two-tailed). The robustness of the findings was rigorously validated employing the Bootstrap resampling method, utilizing 1000 iterations.

In this study, the outcomes of egg retrieval versus surgical procedures for hydrosalpinx patients undergoing IVF/ICSI were comparable. When clinical pregnancy rates were similar between groups, the surgical approach demonstrated lower costs, shorter gestation periods, and reduced complication rates compared to egg retrieval. Regarding transplantation timing after laparoscopic adnexectomy (LAP), a trend toward higher early miscarriage rates emerged after three months. However, the study did not identify optimal intervals for ovarian stimulation and egg retrieval. Limitations include a small sample size and some statistically insignificant trend changes. The lack of differentiation between IVF/ICSI and embryo transfer/fetal embryo transfer (ET/FET) methods, along with potential confounding factors, requires further investigation. Future research should consider large-scale prospective randomized controlled trials to provide more objective treatment strategy evaluations for patients.

Hydrosalpinx negatively impacts the outcomes of assisted reproductive pregnancy. The surgical pretreatment of hydrosalpinx has become an industry consensus [ 10 ]. Therefore, certain questions need to be answered, such as whether oocyte retrieval or surgery should be performed first. How long is the best postoperative transplantation time? How long is the best time for oocyte retrieval in patients who first undergo surgery? However, clinical evidence is insufficient to answer these questions. In clinical practice, surgical intervention timing is determined through a thorough assessment of factors including patient age, duration of infertility, ovarian reserve function, duration of treatment, and economic costs. Physicians clearly outline the advantages and disadvantages of both surgical options to patients. Following informed consultation, patients then make decisions based on their personal preferences. This study provides valuable insights for clinical decision-making by comparing clinical pregnancy outcomes, postoperative complications, timeframes, and financial implications across multiple dimensions of the two surgical timing approaches. Various studies have focused on whether salpingectomy damages the blood supply to the ovaries. In these studies, salpingectomy was performed along the mesosalpinx. Vascular communication was observed between the fallopian tube and the ovary, and surgical injury was associated with the severity of pelvic adhesions and operative proficiency. Different studies have investigated whether salpingectomy affects ovarian function by damaging the blood supply. It has been suggested in animal experiments that the separation of blood vessels between the fallopian tube and ovary reduces the number of ovulations in the ovary [ 11 ]. It has been suggested mostly in early clinical studies that fallopian tube resection may affect ovarian function [ 12 , 13 ], and fallopian tube ligation is considered to cause less damage to the blood supply of the ovary and can also achieve the aim of blocking hydrosalpinx; therefore, it is considered a safer method. Furthermore, it has been suggested in some studies that hydrosalpinx may recur after ligation, with the inflammation not eliminated and the pelvic environment not improved, and recurrent hydrosalpinx will affect the outcome of IVF pregnancy [ 14 ], including tubal embolization [ 15 ] and sclerosing agent injection, which all have the same challenges. Notably, it has been suggested in recent studies that tubal resection does not affect ovarian function and can more thoroughly eliminate pelvic inflammation and improve the pelvic environment [ 16 – 18 ]. The influence of tubal surgery on ovarian function may not be evident in the short term, and ovarian reactivity is an indicator of clinical concern. Clinicians are primarily concerned about the effects of tubal surgery on ovarian blood supply and reactivity [ 19 , 20 ]. The two groups showed no significant differences in Gn dosage, Gn days, oocytes obtained, high-quality embryos, or 2 PN fertilization rate. The results did not indicate that fallopian tube removal prior to oocyte retrieval reduced ovarian responsiveness. Whether hydrosalpinx caused damage to the developmental process of oocytes remains unknown. Obstetricians and gynecologists with surgical experience may know that when the pelvic cavity is seriously attached, the hydrosalpinx or even an abscess is enlarged, the ovary is wrapped in it, and the hydrosalpinx fully contains inflammatory substances [ 21 – 23 ]. Certain questions need to be answered, such as whether the inflammatory substances will reach the ovaries via vascular transport, whether oocyte development is affected by the inflammatory environment, and whether long-term ovarian function is likely to be affected as the disease progresses. During oocyte retrieval, these inflammatory substances may also enter the culture medium during oocyte recovery, contaminating oocytes and embryos and affecting subsequent embryonic development. Eliminating pelvic inflammation may also improve the environment of the ovaries in which the oocyte develops. In cases of severe pelvic adhesions, the bladder and intestinal canal can densely adhere to the uterine attachment, with even the uterine rectal fossa closed, which increases the risk of pelvic organ damage during oocyte retrieval. LAP is performed before oocyte retrieval to loosen the adhesion and restore the normal anatomical position of the pelvic organs, which helps reduce the risk of infection and bleeding after oocyte retrieval. Notably, some patients may also simultaneously experience pelvic, tubal, and endometrial tuberculosis. These patients must be diagnosed both surgically and pathologically. After standardized anti-turticure treatment, oocyte retrieval and ET should be performed to shorten the time of embryo freezing. Research has shown that the levels of inflammatory markers are elevated in the peripheral blood of patients with pelvic inflammatory disease, and severe tubal effusion may be accompanied by chronic endometritis and repeated uterine effusion. After eliminating inflammatory factors, it takes time for the inflammatory state in the body to subside, which helps improve endometrial receptivity [ 24 ]. In cases of simultaneous salpingectomy and hysterectomy due to uterine disease, preventive salpingectomy may be considered to reduce the risk of malignant ovarian tumors. [ 25 – 27 ]. However, owing to the lack of available embryos, patients in group A may tend to be conservative in their surgical decision-making. If salpingectomy is not accepted during intraoperative communication, there is a higher likelihood of the recurrence of postoperative hydrosalpinx and even the likelihood of a reoperation. The most significant advantage of undergoing oocyte retrieval first is that it can determine whether the available embryos can be obtained earlier and help understand ovarian reactivity and embryo quality. With the development of embryo cryopreservation technology and improvements in endometrial preparation programs, the advantages of thawed ET, such as the reduction of the occurrence of ovarian hyperstimulation syndrome and increased time for intrauterine adhesion treatment, are becoming increasingly apparent. Furthermore, because available embryos have been obtained, the choice of fallopian tube surgery is more flexible, and psychological acceptance is higher. The disadvantage of undergoing oocyte retrieval first is that in the process of COH, due to increased hormonal levels, the secretion of glands in the tubal cavity tissue increases, making the swelling of the existing hydrosalpinx more apparent, and some hydrosalpinx masses can reach > 10 cm. Furthermore, the third-space fluid increases, resulting in abdominal fluid accumulation. Moderate-to-severe hydrosalpinx is often accompanied by severe pelvic adhesions. The adnexa of the uterus can form a dense envelope and adhere to the intestinal tube and pelvic walls, thereby forming a number of grids. Fluid accumulates in these grids, and with a significant increase in the volume of the ovary, the original anatomical position of the pelvic organs changes. For instance, the ovary moves higher, which increases the difficulty of oocyte retrieval. Notably, some inflammatory masses also block the path of the oocyte collection needle puncture; therefore, the puncture needle must pass through these inflammatory masses, increasing the risk of pelvic organ injury, bleeding, and infection. In the present study, two cases of pelvic infection after oocyte retrieval were observed in group A, and subsequent LAP proved the condition to be pyosalpinx in both cases. In contrast, pelvic infection after oocyte retrieval was not observed in group B, suggesting that undergoing salpingectomy first may help reduce the risk of infection during oocyte retrieval. In addition, because whole-embryo freezing was required in group A, the opportunity for fresh ET was lost. Furthermore, after COH, it takes approximately two menstrual cycles to wait for hormone decline and ovarian volume reduction, after which LAP is performed, which incurs large time costs and increases the waiting time for ET. No significant differences in the clinical pregnancy rate were observed between groups A1 and B1 (64.00% vs. 66.00%), and group A2 had a lower clinical pregnancy rate than group B2 (42.60% vs. 58.80%), although the difference was not statistically significant. These two surgical regimens are considered to have no significant impact on pregnancy outcomes. We also evaluated the time and economic costs of the two surgical regimens; that is, the time cost required to promote ovulation or preoperative LAP examination to obtain clinical pregnancy (days) and the economic cost required to promote ovulation or preoperative LAP examination to obtain clinical pregnancy (yuan). Notably, group A had significantly higher time and economic costs than group B (200.94 [130.16, 347.93] vs. 155.98 [116.00, 213.19] [days], p  < 0.05; 65,697.31 [56970.98, 77,803.99] vs. 56,306.73 [50923.35, 64,611.71] [Yuan], p  < 0.05). Because group A had the opportunity to undergo fresh ET, the waiting time for ET was shorter, and the cost of embryo freezing was lower. In cases in which the clinical pregnancy outcomes in the two groups were similar, group B spent less costs and obtained clinical pregnancy within a shorter time than group A. As confirmed in recent studies, removing the hydrosalpinx can improve pregnancy outcomes. The primary reason for this is to eliminate pelvic inflammation and reduce the impact of inflammation on endometrial receptivity. Inflammation-induced Changes in the body are long-term and chronic processes. After the hydrosalpinx is removed, it is essential to know how long it takes for the inflammatory state of the pelvic cavity and endometrium to return to normal. However, there is no clear clinical evidence to answer this question. It is also important to know the optimal time for ET after salpingectomy. In this investigation, all patients were stratified into two groups based on the interval between laparoscopic salpingectomy and embryo transfer: those undergoing transfer within ≤3 months postoperatively and those exceeding > 3 months. Analysis revealed no statistically significant disparity in clinical pregnancy rates or live birth rates between the groups ( p  > 0.05). Strikingly, however, the cohort with a postoperative transfer window > exceeding 3 months demonstrated a significantly higher early pregnancy loss rate (12.2% vs. 4.3%) compared to the ≤3 months group. Following adjustment via multi-factor logistic regression, this difference retained no statistical significance (OR 0.325 [0.113,0.934], p  = 0.037; OR 0.342 [0.109,1.072], p  = 0.066). Prior research indicates that elevated inflammatory cytokines in the peripheral blood and endometrial tissue of hydrosalpinx patients necessitate time for resolution after surgical intervention. While we anticipated a gradual decline in inflammation, our findings counterintuitively revealed increased early pregnancy loss rates beyond the 3-month postoperative mark. This compelling discrepancy not only challenges conventional clinical wisdom but also conflicts with established research. The limited sample size in this study may underlie the inconsistency, making further analysis with larger cohorts imperative. In most studies, it has been reported that salpingectomy does not affect ovarian function. In group B in the present study, clinicians paid more attention to ovarian reactivity. However, it is important to know how long it takes to initiate COH after salpingectomy. In this investigation, patients initially assigned to the surgical group were stratified into two distinct cohorts based on the interval between laparoscopic salpingectomy and subsequent ovarian stimulation: those initiating stimulation within 3 months post-surgery and those delaying beyond 3 months. Crucially, no statistically significant differences emerged between these groups regarding oocyte yield, clinical pregnancy rate, or live birth rate ( p  > 0.05). The ovaries, nestled within the pelvic cavity, remain highly vulnerable to pelvic inflammatory disease. Robust evidence consistently demonstrates that chronic inflammation significantly compromises ovarian reserve function and diminishes oocyte quality. However, the precise impact of surgically removing pelvic inflammatory foci on subsequent oocyte quality, alongside the duration of residual ovarian inflammatory response, remain elusive. This compelling gap strongly suggests a critical research frontier worthy of dedicated exploration.

Tubal factor infertility is the most common cause of female infertility, accounting for approximately 20%–25% of cases. Moderate and severe hydrosalpinx has adverse effects on in vitro fertilization-embryo transfer (IVF-ET) pregnancy outcomes [ 1 ], including the toxic effect of hydrosalpinx on embryos [ 2 ], the mechanical washing of the endometrium, and reduction of the endometrial receptivity. Furthermore, the inflammatory mass compresses the ovarian blood vessels and affects the ovarian blood supply [ 3 ], and persistent chronic inflammation results in a pelvic inflammatory environment. Pretreatment of hydrosalpinx before IVF-ET has become a consensus [ 4 ]. Surgical methods include laparoscopic (LAP) proximal tubal ligation, salpingectomy, salpingostomy, proximal tubal embolism, and ultrasound hydro-tubal aspiration [ 5 ]. To improve pregnancy outcomes, LAP proximal tubal ligation and salpingectomy are relatively stable. Because tubal surgery may damage the ovarian blood supply, most previous studies have focused on the impact of tubal surgery on ovarian function, whereas a few have focused on surgical timing [ 6 – 8 ]. The timing of surgery can be divided into two schemes: 1.) controlled ovarian hyperstimulation (COH) first, followed by embryo freezing, LAP, and thawed ET; 2.) LAP first, followed by COH, and fresh or thawed ET. The two schemes have their advantages and disadvantages, and clinical decisions are made based on the patient’s ovarian function and willingness. However, there is no clear medical evidence to support which plan is better. In the 2020 Cochrane Database systematic review, moderate-quality evidence suggested that salpingectomy before ART may enhance clinical pregnancy rates for hydrosalpinx patients compared to no surgical intervention. However, the optimal timing for this procedure remained undefined, and a paucity of high-quality studies utilizing live birth rate as the primary endpoint existed, alongside an absence of detailed data on surgical non-complications. Since 2020, numerous investigations exploring optimal surgical timing have emerged, yet their findings are conflicting and inconclusive. Our study stands out as one of the few specifically designed with live birth rate as the endpoint while meticulously observing post-oocyte retrieval complications. Another distinct innovation of our research was the evaluation of the time and economic burdens associated with two different surgical timing protocols, which highlighted statistically significant differences between groups—a crucial factor overlooked in prior investigations. For surgical decision-making, these temporal and financial costs represent paramount considerations beyond purely medical technical aspects, significantly influencing the ultimate surgical plan. This study is a retrospective cohort study, which analyzed the clinical data and discussed the effects of two different timing of surgery on the pregnancy outcome of patients undergoing IVF/ISCI, and provided more references for clinical treatment decision.

Below is the link to the electronic supplementary material. Supplementary Material 1 Supplementary Material 1