Impact of Hydrosalpinx and Surgical Timing on Ovarian Reserve and Response in in vitro fertilization or intracytoplasmic sperm injection patients: A Retrospective Cohort Study with Propensity Score Analysis

Impact of Hydrosalpinx and Surgical Timing on Ovarian Reserve and Response in in vitro fertilization or intracytoplasmic sperm injection patients: A Retrospective Cohort Study with Propensity Score Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Hydrosalpinx and Surgical Timing on Ovarian Reserve and Response in in vitro fertilization or intracytoplasmic sperm injection patients: A Retrospective Cohort Study with Propensity Score Analysis QiuMin Wang, ShuLei Zhang, You Wu, KeKe Wei, Lei Yan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7817823/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 7 You are reading this latest preprint version Abstract Objective To investigate the impact of hydrosalpinx and the timing of surgical intervention on ovarian reserve and ovarian response in in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) patients. Design, setting, and participants: This study retrospectively collected the medical records of IVF/ICSI patients who underwent IVF/ICSI treatment in Reproductive Hospital Affiliated to Shandong University from January 2017 to December 2021. Patients were divided into hydrosalpinx group (n = 1366) and control group (n = 16038), and according to whether the hydrosalpinx was treated before controlled ovarian hyperstimulation (COH), the hydrosalpinx group was further divided into COH-first group (A) and surgery-first group (B). Finally, Group B was subdivided into three subgroups based on different surgical approaches. Results Compared to controls, the hydrosalpinx group had significantly lower AMH and AFC levels ( P < 0.0001). Additionally, this group required higher starting and total gonadotropin (Gn) doses, a longer duration of ovarian stimulation, and greater human chorionic gonadotropin (hCG) dosages during COH (all P < 0.05). Similarly, the A group showed markedly reduced AMH ( P < 0.0001) and AFC (vs. surgery-first and control groups, P < 0.0001). And AMH levels were higher in the salpingostomy group than in Group A (4.12 ± 2.93 vs 2.91 ± 2.00 ng/mL, P = 0.012). Gn starting doses were lower in the B and control groups than in the A group ( P < 0.0001), whereas stimulation duration and hCG dosage were elevated in the latter ( P < 0.05). On hCG trigger day, the B group had more follicles ≥ 14 mm ( P < 0.05), higher number of oocytes retrieved ( P < 0.05), and superior embryological outcomes (2PN, good-quality embryos, and blastocyst numbers; all P < 0.05) relative to both A and control groups. However, the salpingostomy group yielded more high-quality embryos than the salpingectomy group (4.85 ± 3.36 vs 3.33 ± 3.11, P = 0.034). Conclusion Hydrosalpinx is associated with diminished ovarian reserve and an impaired ovarian response during COH. Surgical treatment (especially salpingostomy) of hydrosalpinx prior to COH may improve these functional parameters. hydrosalpinx ovarian reserve ovarian response laparoscopic surgery assisted reproductive technology Figures Figure 1 INTRODUCTION Hydrosalpinx is one of the most important causes of female infertility, accounting for up to 30–40% of tubal factor infertility 1 . Its pathogenesis is typically linked to peritubal adhesions or distal tubal obstruction resulting from various factors, including infections (e.g., Neisseria gonorrhoeae, Chlamydia trachomatis ), chronic pelvic inflammatory disease, prior delivery or abortion, iatrogenic uterine injury, and endometriosis. With the development of Assisted Reproductive Technology (ART), it has become an important treatment for tubal infertility. However, hydrosalpinx significantly reduces the success rate of ART, and even unilateral hydrosalpinx can adversely affect pregnancy outcome 2 , through several mechanisms, such as mechanical flushing of the embryo by the hydrosalpinx, embryotoxicity of hydrosalpinx constituents, decreased endometrial tolerance, and suppression of ovarian function 3 . Ovarian reserve reflects the number and quality of remaining follicles in the ovary, while ovarian response refers to the degree of ovarian response to Gn, both of which are key factors affecting the outcome of ART. Therefore, it is important to explore the effects of hydrosalpinx on ovarian reserve and ovarian response to optimize the ART treatment plan and improve the success rate. However, most of the existing studies have focused on the effects of hydrosalpinx on embryos and the effects of different surgical procedures on pregnancy outcomes, while there have been relatively few studies on the effects of hydrosalpinx on ovarian reserve and ovarian response. In addition,surgical treatment for hydrosalpinx in clinical practice may be performed either prior to controlled ovarian hyperstimulation (COH) or prior to embryo transfer. The impact of different surgical timing on ovarian reserve remains controversial. Therefore, the aim of our study is to investigate the effects of hydrosalpinx and the timing of its surgical management on ovarian reserve and ovarian response. MATERIALS AND METHODS Research design and study population : This retrospective cohort study collected medical records of patients who underwent IVF or ICSI from January 2017 to December 2021 at the Affiliated Reproductive Hospital of Shandong University. The study was approved by the Ethics Review Committee of the Affiliated Reproductive Hospital of Shandong University (2017 Lun Zi [5]). Inclusion criteria: ① female age ≤ 40 years old; ② regular menstruation, menstrual cycle of 21–35 days; ③ IVF or ICSI treatment; ④ no history of treatment with sex hormone drugs in the last 3 months. Exclusion criteria: (1) egg donation or pre-implantation genetic testing, including PGT-A, PGT-M, PGT-SR; (2) diseases affecting ovarian reserve, such as ovarian endometrioma, adnexal tumors, premature ovarian insufficiency (POI), polycystic ovary syndrome(PCOS), etc.; (3) history of pelvic-abdominal surgery such as history of ovarian, tubal, or other surgery known to affect ovarian reserve or anatomy; (4) uterine malformation; (5) chromosomal abnormality ; (6) combining with other diseases affecting fertility, such as endometriosis/adenomyosis, genital tuberculosis, other endocrine-related diseases (e.g., pituitary tumors, etc.), immune-related diseases, malignant tumors, etc. Study participants were categorized into hydrosalpinx group and control group. The patients in the hydrosalpinx group were those who had been diagnosed with hydrosalpinx by hysterosalpingography (HSG) and/or laparoscopy, and the control group were those who were infertile without hydrosalpinx. According to whether the hydrosalpinx was treated before COH, the hydrosalpinx group was further divided into COH-first group (A) and surgery-first group (B). Finally, Group B was subdivided into three subgroups based on different surgical approaches (Fig. 1 ). Treatment procedures All infertile patients included in this study received IVF or ICSI treatment. The COH protocols used at our reproductive center include the long Gonadotropin-Releasing Hormone(GnRH) agonist protocol, ultralong GnRH agonist protocol, short GnRH agonist protocol, GnRH antagonist protocol, and minimal stimulation protocol. Oocyte maturation was triggered with 2000–12,000 IU hCG based on individual patient characteristics when transvaginal ultrasound revealed at least two follicles with a mean diameter of ≥ 18 mm or at least three follicles with a mean diameter of ≥ 17 mm. Transvaginal ultrasound-guided oocyte retrieval was performed under sedation 36–38 hours after hCG administration. IVF or ICSI was selected 4–6 hours after egg retrieval based on the patient's and her husband's medical history, semen examination, etc. Our reproductive Center uses the Puissant criteria to morphologically evaluate embryos at the cleavage stage (D3) and categorizes embryos at the D3 into five grades ranging from 0–4. Good quality embryos are defined as those with clear, regular blastomeres, minimal or no fragmentation, and rapid development to the 4-cell stage by 48 hours post-fertilization, scoring 5 or 6 on the Puissant scale 4 . The decision on the timing of surgical intervention was made based on the clinical judgment of the treating physicians in consultation with the patient, considering factors such as the severity of hydrosalpinx, patient's history, and ovarian reserve status. Intraoperative assessment guided the selection of surgical intervention, which included salpingectomy for non-salvageable tubes, salpingostomy for preserving fertility, or ligation for proximal obstruction. All procedures were conducted via laparoscopy unless contraindicated (e.g., severe adhesions). Outcome measures Demographic and clinical characteristics were documented for all participants, encompassing age, anthropometric measurements (height, weight, and body mass index (BMI)), and infertility classification. Transvaginal ultrasonography was conducted during the early follicular phase (menstrual cycle days 3–5) to assess the AFC. Concurrently, venous blood samples were obtained to evaluate baseline hormonal profiles, such as follicle-stimulating hormone (FSH), estradiol (E2), and AMH. Throughout the COH protocol, key parameters were monitored, including the starting dose of Gn, total Gn dose, as well as the duration of ovarian stimulation. On the day of hCG administration, a transvaginal ultrasound examination was performed to record the thickness of the endometrium and the number of follicles with a diameter ≥ 14 mm. Serum E2 levels were also determined at this timepoint. The primary endpoints focused on ovarian reserve indicators (AFC, AMH, basal FSH, and basal E2 levels) and ovarian response indicators (Gn starting dose, total Gn dose, duration of ovarian stimulation, hCG day E2, number of follicles ≥ 14 mm on hCG trigger day, number of retrieved oocytes). Additional outcome measures comprised the number of 2 pronuclei (2PN) zygotes, number of high-quality embryos, and number of blastocysts. Fertilization rate was calculated as the proportion of 2PN zygotes relative to the total oocytes retrieved. Statistical analysis : All statistical analyses and data visualization were conducted using IBM SPSS Statistics (Version 27.0, Chicago, USA). The normality of continuous variables was assessed using the Kolmogorov-Smirnov test. Normally distributed data were analyzed with Student’s t-test for two-group comparisons or one-way ANOVA for multiple groups, followed by post hoc LSD tests for pairwise comparisons. Results were reported as mean ± standard deviation (SD). Non-normally distributed variables were evaluated using the Mann-Whitney U test, with findings presented as median (interquartile range). Categorical variables were compared via the chi-square test and summarized as frequencies (percentages). To minimize selection bias and potential confounders, PSM was applied in a 1:1 ratio, with a caliper value of 0.01 on variables including age, BMI, duration of infertility, and infertility type. RESULTS 1 Effect of hydrosalpinx on ovarian reserve and ovarian response To mitigate potential selection bias and confounding effects, PSM was performed in a 1:1 ratio. Prior to matching, logistic regression analysis identified significant differences between the two groups in age ( P < 0.0001) and infertility type ( P < 0.0001). The matching variables included age, BMI, duration of infertility, and infertility type. After PSM, the SMD for all variables decreased to 0.1 or less, indicating the success of the matching procedure and each group (hydrosalpinx and control) consisted of 1363 well-matched cases. 1.1 Impaired ovarian reserve in hydrosalpinx patients Following PSM, the hydrosalpinx and control groups demonstrated comparable baseline characteristics, including age, BMI, duration of infertility, and infertility type ( P > 0.05). However, ovarian reserve markers exhibited significant differences between the groups. Compared to the control group, the hydrosalpinx group had significantly higher basal FSH levels (7.10 ± 2.43 vs. 6.67 ± 2.23; P < 0.0001) and lower AMH concentrations (3.30 ± 2.58 vs. 3.80 ± 2.84; P < 0.0001). Additionally, the AFC was significantly lower in the hydrosalpinx group (12.83 ± 5.82 vs. 14.08 ± 6.95; P < 0.0001). In contrast, no statistically significant difference was observed in basal E2 levels between the two cohorts (Table 1 ). Table 1 Comparison of Baseline Data and ovarian reserve Between hydrosalpinx and Control Groups Variables Control group (n = 1363) hydrosalpinx group (n = 1363) P -value Age (years) 31.56 ± 4.73 31.52 ± 4.25 0.811 BMI (kg/m2) 23.81 ± 3.58 23.69 ± 3.53 0.382 Duration of Infertility (years) 3.83 ± 3.09 3.72 ± 2.94 0.326 Infertility type, n (%) 0.817 Primary 619 (45.4) 612 (44.9) Secondary 744 (54.6) 751 (55.1) Basal FSH (IU/L) 6.67 ± 2.23 7.10 ± 2.43 < 0.0001 Basal E 2 (pg/mL) 39.30 ± 32.75 40.63 ± 27.30 0.252 AMH (ng/mL) 3.80 ± 2.84 3.30 ± 2.58 < 0.0001 AFC (n) 14.08 ± 6.95 12.83 ± 5.82 < 0.0001 Note: BMI: body mass index; FSH: follicle stimulating hormone; E 2 : estradiol; AMH: Anti-Mullerian Hormone; AFC: antral follicle count. 1.2 Impaired ovarian response in hydrosalpinx patients during COH Comparative analysis revealed significant differences in COH parameters between the hydrosalpinx and control groups. Patients with hydrosalpinx required higher Gn starting dose (181.90 ± 60.92 vs. 167.87 ± 53.62; P < 0.0001), greater total Gn dose (2072.66 ± 994.78 vs. 1878.76 ± 915.01; P < 0.0001), and longer duration of ovarian stimulation (9.77 ± 2.25 vs. 9.49 ± 2.24; P < 0.0001). At the time of trigger administration, patients with hydrosalpinx required significantly higher doses of hCG (7527.51 ± 1511.03 vs. 7321.72 ± 1379.84; P = 0.001) and exhibited greater serum E2 concentrations (3166.77 ± 1972.39 vs. 2910.80 ± 1740.48; P < 0.0001) compared to controls. Endometrial thickness on hCG trigger day and number of follicles ≥ 14 mm on hCG trigger day showed no statistically significant variation between the study groups. Notably, conventional ovarian response indicators - including number of retrieved oocytes, number of 2PN zygotes, fertilization rate, number of high-quality embryos, and number of blastocysts showed comparable outcomes between groups (Table 2 ). Table 2 Comparison of ovarian response between the hydrosalpinx group and the control group during COH Variables Control group (n = 1363) hydrosalpinx group (n = 1363) P -value Gn starting dose (IU) 167.87 ± 53.62 181.90 ± 60.92 < 0.0001 Total Gn dose (IU) 1878.76 ± 915.01 2072.66 ± 994.78 < 0.0001 Duration of ovarian stimulation (days) 9.49 ± 2.24 9.77 ± 2.25 < 0.0001 hCG dosage (IU) 7321.72 ± 1379.84 7527.51 ± 1511.03 0.001 Endometrial thickness on hCG trigger day (cm) 1.08 ± 0.22 1.07 ± 0.21 0.575 No. of follicles ≥ 14 mm on hCG trigger day (n) 9.77 ± 5.04 9.61 ± 5.03 0.398 hCG day E 2 (pg/mL) 2910.80 ± 1740.48 3166.77 ± 1972.39 < 0.0001 No. of retrieved oocytes(n) 9.76 ± 5.61 9.99 ± 5.89 0.302 2PN (n) 6.08 ± 3.89 6.36 ± 3.92 0.055 Fertilization rate (%) 62.56 ± 24.99 64.12 ± 24.36 0.100 No. of high-quality embryos(n) 3.61 ± 2.84 3.72 ± 2.91 0.338 No. of blastocysts (n) 4.19 ± 3.43 4.35 ± 3.37 0.218 Note: Gn: gonadotropin; HCG: human chorionic gonadotropin; 2PN: 2 pronuclei. 2 Effect of treatment of hydrosalpinx before COH on ovarian reserve and ovarian response The hydrosalpinx group was further categorized into the COH-first group (A, n = 1224) and surgery-first group (B, n = 139) according to whether the hydrosalpinx was pretreated before COH. 2.1 Treatment of hydrosalpinx prior to COH helps to improve ovarian reserve One-way ANOVA and chi-square tests showed that the base FSH levels in the B group and the control group (6.54 ± 1.68 & 6.67 ± 2.23 vs 7.16 ± 2.50; P < 0.0001) were significantly lower than those in the A group; Compared with the control group, the serum AMH levels in the A group (3.26 ± 2.58 vs. 3.80 ± 2.84; P < 0.0001) were significantly lower, and there was a trend of higher AMH levels in the B group compared with the A group, but there was no statistical difference; AFC (14.47 ± 5.94 & 14.08 ± 6.95 vs. 12.65 ± 5.77; P < 0.0001) was significantly higher in the B group and the control group than in the A group. There were no statistically significant differences in age, BMI, duration of infertility, infertility type and basal E2 levels among the three groups (Table 3 ). Table 3 Effect of pre-COH treatment of hydrosalpinx on baseline data and ovarian reserve Variables Control group (n = 1363) hydrosalpinx group (n = 1363) P -value A (n = 1224) B (n = 139) Age (years) 31.56 ± 4.73 31.57 ± 4.22 31.09 ± 4.45 0.478 BMI (kg/m2) 23.81 ± 3.58 23.67 ± 3.54 23.86 ± 3.44 0.573 Duration of Infertility (years) 3.83 ± 3.09 3.70 ± 2.89 3.85 ± 3.37 0.536 Infertility type, n (%) 0.600 Primary 619 (45.4) 555(45.3) 220 (41.0) Secondary 744 (54.6) 669 (54.7) 217 (59.0) Basal FSH (IU/L) 6.67 ± 2.23 b 7.16 ± 2.50 a 6.54 ± 1.68 b < 0.0001 Basal E 2 (pg/mL) 39.30 ± 32.75 41.11 ± 28.07 36.41 ± 18.75 0.114 AMH (ng/mL) 3.80 ± 2.84 b 3.26 ± 2.58 a 3.72 ± 2.62 a,b < 0.0001 AFC (n) 14.08 ± 6.95 b 12.65 ± 5.77 a 14.47 ± 5.94 b < 0.0001 Note: BMI: body mass index; FSH: follicle stimulating hormone; E2: estradiol; AMH: Anti-Mullerian Hormone; AFC: antral follicle count. Values with different superscript letters in the same row are significantly different (P < 0.05) based on post-hoc tests 2.2 Impact of Hydrosalpinx Treatment on Ovarian Response to COH Preovulatory management of hydrosalpinx improved ovarian response during COH. The Gn starting dose was significantly lower in the B and control groups compared to the A group (172.21 ± 47.37 & 167.87 ± 53.62 vs. 183.00 ± 62.19; P < 0.0001). However, the total Gn dose was higher in both the B and A groups than in controls (1946.58 ± 856.15 & 2086.98 ± 1008.63 vs 1878.76 ± 915.01; P < 0.0001). The A group required a longer duration of ovarian stimulation (9.76 ± 2.27 vs. 9.49 ± 2.24; P = 0.006) and higher hCG dosage (7542.48 ± 1502.19 vs. 7321.72 ± 1379.84; P = 0.001) than the control group, whereas no such differences were observed between the B and control groups(Table 4 ) . On the hCG trigger day, the B group had more follicles ≥ 14 mm than the A and control groups(10.70 ± 5.34 vs 9.49 ± 4.98 & 9.77 ± 5.04; P = 0.019). Additionally, serum E2 level on hCG trigger day were significantly elevated in the B and A groups compared to controls༈3366.67 ± 2086.62 & 3144.03 ± 1958.58 vs 2910.80 ± 1740.48; P = 0.001༉.No significant differences were found in endometrial thickness on hCG trigger day or retrieved oocytes among the three groups. Although the overall ANOVA test for the number of retrieved oocytes among the three groups did not reach statistical significance ( P = 0.053), post-hoc pairwise comparisons revealed that the B group yielded significantly more oocytes than both the A group (11.00 ± 5.63 vs. 9.87 ± 5.90; P = 0.028) and the control group (11.00 ± 5.63 vs. 9.76 ± 5.61; P = 0.015). And The B group demonstrated superior embryological outcomes—including the number of 2PN zygotes (7.39 ± 4.15 vs. 6.25 ± 3.89 and 6.08 ± 3.89; P = 0.001), high-quality embryos (4.43 ± 3.15 vs. 3.64 ± 2.88 and 3.61 ± 2.84; P = 0.005), and blastocysts (5.27 ± 3.99 vs. 4.25 ± 3.28 and 4.19 ± 3.43; P = 0.002) —compared to both the A and control groups. Fertilization rates, however, did not differ significantly among the groups (Table 4 ). Table 4 Effect of pre-COH treatment of hydrosalpinx on ovarian response during COH Variables Control group (n = 1363) hydrosalpinx group (n = 1363) P -value A (n = 1224) B (n = 139) Gn starting dose (IU) 167.87 ± 53.62 b 183.00 ± 62.19 a 172.21 ± 47.37 b < 0.0001 Total Gn dose (IU) 1878.76 ± 915.01 b 2086.98 ± 1008.63 a 1946.58 ± 856.15 a < 0.0001 Duration of ovarian stimulation (days) 9.49 ± 2.24 b 9.76 ± 2.27 a 9.79 ± 2.09 a,b 0.006 hCG dosage (IU) 7321.72 ± 1379.84 b 7542.48 ± 1502.19 a 7395.68 ± 1586.26 a,b 0.001 Endometrial thickness on hCG trigger day (cm) 1.08 ± 0.22 1.07 ± 0.20 1.08 ± 0.21 0.802 No. of follicles ≥ 14 mm on hCG trigger day (n) 9.77 ± 5.04 b 9.49 ± 4.98 b 10.70 ± 5.34 a 0.019 hCG day E 2 (pg/mL) 2910.80 ± 1740.48 b 3144.03 ± 1958.58 a 3366.67 ± 2086.62 a 0.001 No. of retrieved oocytes(n) 9.76 ± 5.61 b 9.87 ± 5.90 b 11.00 ± 5.63 a 0.053 2PN (n) 6.08 ± 3.89 b 6.25 ± 3.89 b 7.39 ± 4.15 a 0.001 Fertilization rate (%) 62.56 ± 24.99 63.87 ± 24.64 66.31 ± 21.70 0.140 No. of high-quality embryos(n) 3.61 ± 2.84 b 3.64 ± 2.88 b 4.43 ± 3.15 a 0.005 No. of blastocysts (n) 4.19 ± 3.43 b 4.25 ± 3.28 b 5.27 ± 3.99 a 0.002 Note: Gn: gonadotropin; hCG: human chorionic gonadotropin; 2 PN: two pronuclei; Values with different superscript letters in the same row are significantly different (P < 0.05) based on post-hoc tests 3. Effects of Different Surgical Approaches for Hydrosalpinx on Ovarian Reserve and Ovarian Response We further grouped the patients according to surgical approach and found that, baseline characteristics (age, BMI, infertility duration, basal FSH, E2, and infertility type) showed no significant differences between Group A and surgical subgroups ( P > 0.05). It is pleasurable that AMH levels were higher in the salpingostomy group than in Group A (4.12 ± 2.93 vs. 2.91 ± 2.00 ng/mL, P = 0.012), and AFC was increased in all surgical subgroups ( P = 0.002). However, Ovarian stimulation outcomes (Gn dose, duration, hCG dosage, endometrial thickness, follicle count, and E2 levels) and laboratory parameters (oocyte retrieval, fertilization rate, blastocyst formation) were comparable between the groups.( P > 0.05). Notably, the salpingostomy group yielded more high-quality embryos than the salpingectomy group (4.85 ± 3.36 vs 3.33 ± 3.11, P = 0.034) ( Supplementary Tables 1–2 ). DISCUSSION The findings of this study demonstrate that hydrosalpinx is associated with adverse effects on ovarian function, manifesting as diminished ovarian reserve and reduced responsiveness to COH. Importantly, our data indicate that surgical intervention (particularly salpingostomy,) for hydrosalpinx prior to initiating COH protocols can enhance both ovarian reserve parameters and ovarian response to Gn stimulation. As a prevalent contributor to female infertility 5 , hydrosalpinx typically develops following pelvic infections (such as those caused by Neisseria gonorrhoeae or Chlamydia trachomatis ), inflammatory pelvic conditions, obstetric procedures, iatrogenic uterine interventions, or endometriosis, with chronic pelvic inflammation representing a primary etiological factor 6 . This condition adversely impacts both spontaneous conception rates and ART outcomes. Previous studies have found that hydrosalpinx may reduce ART success through a variety of mechanisms including mechanical flushing of the embryo, embryotoxicity, reduced endometrial tolerance, and suppression of ovarian function, resulting in lower rates of implantation, lower clinical pregnancy rates, and an increased risk of early miscarriage and ectopic pregnancies 1 , 7 . While limited research exists regarding the direct influence of hydrosalpinx on ovarian reserve, our study showed that patients with hydrosalpinx had significantly lower AFC and AMH levels and significantly higher basal FSH levels. The decrease in ovarian reserve may be multifactorial. One proposed mechanism is mechanical compression of the ipsilateral ovarian-tubal mesenteric vessels by the thickened and twisted hydrosalpinx side of the tube. The vascularization index (VI) and vascularization flow index (VFI) of patients with hydrosalpinx were found to be lower than those of the normal population 8 , suggesting that hydrosalpinx may impair the blood supply to the ovary, resulting in delayed follicular development and decreased oocyte quality 9 . Additionally, the inflammatory fluid within the hydrosalpinx contains various mediators and cytokines, which have an adverse impact on the function of ovary through the blood circulation and the lymphatic circulation 10 . COH, a critical element of ART, aims to achieve synchronous follicular development through the administration of GnRH analogs (agonists or antagonists) in combination with exogenous Gn, thereby optimizing oocyte yield 11 , 12 . The ovarian response is a key determinant of treatment success, as it influences both the number of retrieved oocytes and subsequent embryo availability, ultimately impacting pregnancy outcomes 13 . Previous research has indicated that hydrosalpinx may impair ovarian responsiveness during COH 14 , manifesting as elevated baseline FSH levels and reduced oocyte retrieval. Potential mechanisms include compromised ovarian perfusion due to vascular compression by the hydrosalpinx, which may hinder follicular development, as well as the presence of inflammatory or toxic factors within the hydrosalpinx fluid that could diminish ovarian sensitivity to exogenous Gn, necessitating higher Gn dose 15 . In our study, patients with hydrosalpinx required increased initial and total Gn doses, prolonged stimulation duration, and higher hCG administration, accompanied by elevated E2 levels on the day of trigger. However, despite these adjustments, no significant difference in the number of retrieved oocytes was observed between the hydrosalpinx and control groups. This suggests that augmented Gn dosing may partially compensate for diminished ovarian responsiveness in these patients. Nevertheless, fertilization rates, number of high-quality embryos, and number of blastocysts remained comparable between groups, and the impact on clinical pregnancy outcomes warrants further investigation. With advancements in ART, the utilization of tubal-sparing procedures and structural reconstructive surgeries has declined. Nevertheless, hydrosalpinx remains a significant factor impairing pregnancy rates in ART cycles, necessitating surgical intervention as a critical pretreatment. A retrospective study involving 160 hydrosalpinx patients demonstrated that the clinical pregnancy rate following IVF-ET without prior surgical treatment was merely 16.1%, whereas patients who underwent salpingectomy after failed IVF-ET cycles achieved a markedly higher pregnancy rate of 51.7% 16 . These findings underscore the potential benefits of surgical management in enhancing embryo implantation and ART success. Our study highlights that preoperative hydrosalpinx management may enhance ovarian reserve and response during COH. Current clinical approaches for hydrosalpinx include salpingectomy, salpingostomy, and proximal tubal occlusion. However, the influence of surgical pretreatment on ovarian function remains debated. Given that ovarian perfusion plays a pivotal role in folliculogenesis and steroidogenesis, any compromise in vascular supply may adversely affect ovarian reserve 17 . Our findings indicate that surgical management of hydrosalpinx prior to COH, especially salpingostomy, demonstrated beneficial effects on ovarian reserve parameters (AMH and AFC). Salpingectomy has been associated with elevated resistance indices (RI) in ovarian blood flow 18 , potentially due to disruption of the vascular anastomosis between the ovarian and uterine arteries 19 . In contrast, salpingostomy and proximal tubal occlusion exert minimal effects on ovarian perfusion 20 , 21 , leading to superior fertilization rates and higher-quality embryos 22 . Moreover, recurrent hydrosalpinx after laparoscopic salpingostomy does not significantly alter IVF/ICSI outcomes, yielding comparable results to non-hydrosalpinx patients 23 . Proximal tubal occlusion is a viable alternative to salpingostomy, particularly in cases of mild to moderate hydrosalpinx. While salpingostomy preserves ovarian vascularity, its clinical utility is limited by high recurrence rates and a 10% risk of ectopic pregnancy 1 . Conversely, salpingectomy is the preferred approach for severe hydrosalpinx, as it definitively resolves the pathology and optimizes ART success 24 . In our study, there was no significant difference in postoperative AMH levels between the salpingectomy group and other groups, indicating that ovarian reserve was not markedly affected. Although some literature reports that salpingectomy has a negative impact on ovarian function, our study indicates that through meticulous surgical techniques and individualised selection of surgical approaches, ovarian reserve and oocyte retrieval numbers can still be maintained at favourable levels. This aligns with the perspective of the ASRM 25 . However, various surgical treatment of hydrosalpinx did not revealed significant differences in COH outcomes. The lack of differences in stimulation parameters and embryological results may suggests comparable efficacy among treatment approaches, which is consistent with existing research findings 26 , 27 . In accordance with the 2021 ASRM practice recommendations 25 , laparoscopic salpingostomy represents the optimal approach for patients aged < 35 years with good ovarian reserve and mild hydrosalpinx. Conversely, salpingectomy is recommended for patients with moderate to severe hydrosalpinx. Younger patients with adequate ovarian reserve typically undergo salpingostomy to maintain tubal integrity. This conservative surgical approach, along with proximal tubal occlusion, appears to have negligible impact on ovarian blood supply 20 , 21 , potentially explaining the observed improvements in embryo quality 22 , which corroborates our study results. This study has several limitations that should be acknowledged. First, while the investigation primarily examined the impact of hydrosalpinx on ovarian reserve and ovarian response-related parameters, it did not conduct a stratified analysis of different ovarian stimulation protocols. Second, the effects of hydrosalpinx on ART outcomes were not explored, future research should incorporate ART outcome data to enhance the validity and comprehensiveness of the findings. Finally, as with all retrospective studies, despite employing PSM techniques, we cannot entirely rule out the influence of confounding variables on the findings. Future large-scale prospective studies are required to further validate these results. CONCLUSION The present study demonstrates that hydrosalpinx is associated with diminished ovarian reserve (DOR), and patients with hydrosalpinx exhibit impaired ovarian responsiveness during COH, requiring higher Gn doses and prolonged stimulation. Notably, surgical intervention prior to COH significantly improves ovarian reserve and enhances ovarian response. This supports the clinical rationale for pre-COH surgical management of hydrosalpinx to optimize ART outcomes. Declarations Ethical approval The study was approved by the Ethics Review Committee of the Affiliated Reproductive Hospital of Shandong University (2017 Lun Zi [5]). All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Consent to Participate declaration Not applicable. Clinical trial number Not applicable. Consent for publication Not applicable. Data availability The raw data of this study are available on request to the corresponding author. Competing interests The authors declare no competing interests. Funding This work was supported by the National Key R&D Program of China (Program Nos. 2024YFC2707500). Author contributions Conception: QMW, SLZ, and LY, Design: QMW and LY, Acquisition of data: SLZ and YW. Analysis of data: QMW , YW, and SLZ. Interpretation of data: LY and KKW, Drafted the manuscript: QMW and SLZ. Critically revised the manuscript: LY and KKW. “The authors read and approved the final manuscript. Acknowledgements We extend our gratitude to all the staff at the fertility centers who contributed to its execution. References Ng KYB, Cheong Y. Hydrosalpinx - Salpingostomy, salpingectomy or tubal occlusion. Best Pract Res Clin Obstet Gynaecol Aug. 2019;59:41–7. 10.1016/j.bpobgyn.2019.01.011 . Yang X, Zhu L, Le F, et al. Proximal Fallopian Tubal Embolization by Interventional Radiology prior to Embryo Transfer in Infertile Patients with Hydrosalpinx: A Prospective Study of an Off-label Treatment. J Minim Invasive Gynecol Jan. 2020;27(1):107–15. 10.1016/j.jmig.2019.02.026 . Cohen A, Almog B, Tulandi T. Hydrosalpinx Sclerotherapy Before In Vitro Fertilization: Systematic Review and Meta-analysis. J Minim Invasive Gynecol May-Jun. 2018;25(4):600–7. 10.1016/j.jmig.2017.12.004 . Puissant F, Van Rysselberge M, Barlow P, Deweze J, Leroy F. Embryo scoring as a prognostic tool in IVF treatment. Hum Reprod Nov. 1987;2(8):705–8. 10.1093/oxfordjournals.humrep.a136618 . Chen H, Jiang W, Lin G, Lu G, Gong F. Hysteroscopic Placement of Platinum Microinsert in Patients With Hydrosalpinx Before In Vitro Fertilization and Embryo Transfer. J Minim Invasive Gynecol Sep-Oct. 2019;26(6):1157–63. 10.1016/j.jmig.2018.08.033 . Perez-Milan F, Caballero-Campo M, Carrera-Roig M, et al. Hydrosalpinx treatment before in-vitro fertilization: systematic review and network meta-analysis. Ultrasound Obstet Gynecol Apr. 2025;65(4):414–26. 10.1002/uog.27697 . D'Arpe S, Franceschetti S, Caccetta J, Pietrangeli D, Muzii L, Panici PB. Management of hydrosalpinx before IVF: a literature review. J Obstet Gynaecol. 2015;35(6):547–50. 10.3109/01443615.2014.985768 . El-Mazny A, Ramadan W, Kamel A, Gad-Allah S. Effect of hydrosalpinx on uterine and ovarian hemodynamics in women with tubal factor infertility. Eur J Obstet Gynecol Reprod Biol Apr. 2016;199:55–9. 10.1016/j.ejogrb.2016.01.046 . Gelbaya TA, Nardo LG, Fitzgerald CT, Horne G, Brison DR, Lieberman BA. Ovarian response to gonadotropins after laparoscopic salpingectomy or the division of fallopian tubes for hydrosalpinges. Fertil Steril May. 2006;85(5):1464–8. 10.1016/j.fertnstert.2005.10.036 . Orvieto R, Saar-Ryss B, Morgante G, Gemer O, Anteby EY, Meltcer S. Apr. Does salpingectomy affect the ipsilateral ovarian response to gonadotropin during in vitro fertilization-embryo transfer cycles? Fertil Steril . 2011;95(5):1842–4. 10.1016/j.fertnstert.2010.11.061 Pacchiarotti A, Selman H, Valeri C, et al. Ovarian Stimulation Protocol in IVF: An Up-to-Date Review of the Literature. Curr Pharm Biotechnol. 2016;17(4):303–15. 10.2174/1389201017666160118103147 . Venetis CA, Storr A, Chua SJ, et al. What is the optimal GnRH antagonist protocol for ovarian stimulation during ART treatment? A systematic review and network meta-analysis. Hum Reprod Update May. 2023;2(3):307–26. 10.1093/humupd/dmac040 . Alviggi C, Conforti A, Esteves SC, et al. Understanding Ovarian Hypo-Response to Exogenous Gonadotropin in Ovarian Stimulation and Its New Proposed Marker-The Follicle-To-Oocyte (FOI) Index. Front Endocrinol (Lausanne). 2018;9:589. 10.3389/fendo.2018.00589 . Fleming C, Hull MG. Impaired implantation after in vitro fertilisation treatment associated with hydrosalpinx. Br J Obstet Gynaecol Mar. 1996;103(3):268–72. 10.1111/j.1471-0528.1996.tb09717.x . Copperman AB, Wells V, Luna M, Kalir T, Sandler B, Mukherjee T. Presence of hydrosalpinx correlated to endometrial inflammatory response in vivo. Fertil Steril Oct. 2006;86(4):972–6. 10.1016/j.fertnstert.2006.02.113 . Murray DL, Sagoskin AW, Widra EA, Levy MJ. The adverse effect of hydrosalpinges on in vitro fertilization pregnancy rates and the benefit of surgical correction. Fertil Steril Jan. 1998;69(1):41–5. 10.1016/s0015-0282(97)00447-0 . Raba G. Effect of internal iliac artery ligation on ovarian blood supply and ovarian reserve. Climacteric Feb. 2011;14(1):54–7. 10.3109/13697130903548916 . Venturella R, Morelli M, Lico D, et al. Wide excision of soft tissues adjacent to the ovary and fallopian tube does not impair the ovarian reserve in women undergoing prophylactic bilateral salpingectomy: results from a randomized, controlled trial. Fertil Steril Nov. 2015;104(5):1332–9. 10.1016/j.fertnstert.2015.08.004 . Ye XP, Yang YZ, Sun XX. Jan. A retrospective analysis of the effect of salpingectomy on serum antiMullerian hormone level and ovarian reserve. Am J Obstet Gynecol . 2015;212(1):53 e1-10. 10.1016/j.ajog.2014.07.027 Bulent Tiras M, Noyan V, Ozdemir H, Guner H, Yildiz A, Yildirim M. The changes in ovarian hormone levels and ovarian artery blood flow rate after laparoscopic tubal sterilization. Eur J Obstet Gynecol Reprod Biol Dec. 2001;1(2):219–21. 10.1016/s0301-2115(01)00410-9 . Kelekci S, Yilmaz B, Yasar L, Savan K, Sonmez S, Kart C. Ovarian reserve and ovarian stromal blood supply after tubal ligation by the Pomeroy technique: comparison with controls. Gynecol Endocrinol May. 2005;20(5):279–83. 10.1080/09513590500097192 . Vignarajan CP, Malhotra N, Singh N. Ovarian Reserve and Assisted Reproductive Technique Outcomes After Laparoscopic Proximal Tubal Occlusion or Salpingectomy in Women with Hydrosalpinx Undergoing in Vitro Fertilization: A Randomized Controlled Trial. J Minim Invasive Gynecol Sep-Oct. 2019;26(6):1070–5. 10.1016/j.jmig.2018.10.013 . Liu H, Yao Z, Zhang R, Wu S, Lv S, Yan L. Effect of Recurrence of Hydrosalpinx after Tubal Ligation on the Outcome of In vitro Fertilization Treatment: A Retrospective Cohort Study. Gynecol Minim Invasive Ther . Jul-Sep. 2020;9(3):118–22. 10.4103/GMIT.GMIT_27_19 . Chen J, Huang D, Shi L, et al. Cornual Suture at the Time of Laparoscopic Salpingectomy Reduces the Incidence of Interstitial Pregnancy after In Vitro Fertilization. J Minim Invasive Gynecol . Sep-Oct. 2018;25(6):1080–7. 10.1016/j.jmig.2018.02.009 . Practice Committee of the American Society for Reproductive Medicine. Electronic address Aao. Role of tubal surgery in the era of assisted reproductive technology: a committee opinion. Fertil Steril May. 2021;115(5):1143–50. 10.1016/j.fertnstert.2021.01.051 . Tsiami A, Chaimani A, Mavridis D, Siskou M, Assimakopoulos E, Sotiriadis A. Surgical treatment for hydrosalpinx prior to in-vitro fertilization embryo transfer: a network meta-analysis. Ultrasound Obstet Gynecol Oct. 2016;48(4):434–45. 10.1002/uog.15900 . Chan CC, Ng EH, Li CF, Ho PC. Impaired ovarian blood flow and reduced antral follicle count following laparoscopic salpingectomy for ectopic pregnancy. Hum Reprod Oct. 2003;18(10):2175–80. 10.1093/humrep/deg411 . Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 07 Apr, 2026 Reviews received at journal 20 Jan, 2026 Reviewers agreed at journal 11 Jan, 2026 Reviewers invited by journal 27 Oct, 2025 Editor assigned by journal 16 Oct, 2025 Submission checks completed at journal 16 Oct, 2025 First submitted to journal 09 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7817823","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":535364662,"identity":"19923cbf-da4a-44d8-957e-a03d8517b8c2","order_by":0,"name":"QiuMin Wang","email":"","orcid":"","institution":"Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"QiuMin","middleName":"","lastName":"Wang","suffix":""},{"id":535364663,"identity":"aaa6f64a-f0c1-4d70-a22a-2cd8642ecee5","order_by":1,"name":"ShuLei Zhang","email":"","orcid":"","institution":"Shandong University","correspondingAuthor":false,"prefix":"","firstName":"ShuLei","middleName":"","lastName":"Zhang","suffix":""},{"id":535364664,"identity":"3a54ba72-eab7-41a8-843c-23521d51408f","order_by":2,"name":"You Wu","email":"","orcid":"","institution":"Shandong University","correspondingAuthor":false,"prefix":"","firstName":"You","middleName":"","lastName":"Wu","suffix":""},{"id":535364667,"identity":"327d70c1-1535-4981-bf9c-462ebc6a5a31","order_by":3,"name":"KeKe Wei","email":"","orcid":"","institution":"Shandong University","correspondingAuthor":false,"prefix":"","firstName":"KeKe","middleName":"","lastName":"Wei","suffix":""},{"id":535364670,"identity":"7c96f972-4cb2-49b1-a647-cffbe58df548","order_by":4,"name":"Lei Yan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYHACxgMMBjYMDAeATB5i9QC1pJGsheEwCVoMjp89cOBDwXl7vhsJjA/etjHImxPUciYv4eAMg9uJM28kMBvObWMw3NlASMuBHIPDPAa3EwxuJLBJ87YxJBgcIKTl/BuDw38MztkDtbD/Jk7LDaAtQLsYNwBtYSZKi+SNNwYHewySE2eeedgsOeechOEGQlr4zucYPvjxx86e73jywQ9vymzkCdqigFDA2AAkJAioBwL5BsJqRsEoGAWjYKQDAMqsR7ycRZcRAAAAAElFTkSuQmCC","orcid":"","institution":"Shandong University","correspondingAuthor":true,"prefix":"","firstName":"Lei","middleName":"","lastName":"Yan","suffix":""}],"badges":[],"createdAt":"2025-10-09 13:08:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7817823/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7817823/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95189964,"identity":"9afa4d00-a652-4715-b51c-f49dd2f044b1","added_by":"auto","created_at":"2025-11-05 10:07:07","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5020816,"visible":true,"origin":"","legend":"","description":"","filename":"RBE1014.docx","url":"https://assets-eu.researchsquare.com/files/rs-7817823/v1/0287096d83907df8d6465ec2.docx"},{"id":95229194,"identity":"d40272f2-e138-4d18-8f9f-fb5e0661d625","added_by":"auto","created_at":"2025-11-05 16:34:35","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7392,"visible":true,"origin":"","legend":"","description":"","filename":"a8f9993292ce4e9281273238f97a6966.json","url":"https://assets-eu.researchsquare.com/files/rs-7817823/v1/199d8903b1daa1164c0606e4.json"},{"id":95189959,"identity":"12d176f8-fe72-409a-8096-b8ece0b07a38","added_by":"auto","created_at":"2025-11-05 10:07:06","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":23893,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable.docx","url":"https://assets-eu.researchsquare.com/files/rs-7817823/v1/842fde92105a14c875cb31aa.docx"},{"id":95189963,"identity":"3cd8033c-68e3-49b5-8681-7eb7200a27f3","added_by":"auto","created_at":"2025-11-05 10:07:06","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":117572,"visible":true,"origin":"","legend":"","description":"","filename":"a8f9993292ce4e9281273238f97a69661enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7817823/v1/aff87a6c0a13ba7a317341cb.xml"},{"id":95189960,"identity":"49d287b4-d655-47d8-b1d2-01f824750613","added_by":"auto","created_at":"2025-11-05 10:07:06","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":182730,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7817823/v1/a73076672eaa2c50ce529bb4.png"},{"id":95189967,"identity":"2ece7ae4-aafb-495a-a47c-e744b863acb0","added_by":"auto","created_at":"2025-11-05 10:07:07","extension":"xml","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":119763,"visible":true,"origin":"","legend":"","description":"","filename":"a8f9993292ce4e9281273238f97a69661structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7817823/v1/8a38b579391d4b6786d09f5d.xml"},{"id":95189966,"identity":"6dbacd90-c5e3-43cb-bce5-03fd02df6b0d","added_by":"auto","created_at":"2025-11-05 10:07:07","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":130279,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7817823/v1/ddd4fadeb00a4a4a3fe69e9c.html"},{"id":95189961,"identity":"1fd28fa5-9b2b-491f-867e-c49aba2e00d9","added_by":"auto","created_at":"2025-11-05 10:07:06","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":361284,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of patient inclusion\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7817823/v1/ff9ef9db692b2d11e83e8ddf.jpeg"},{"id":95230870,"identity":"f5f290c1-1d76-4a39-8f4d-f0a2f64b7db8","added_by":"auto","created_at":"2025-11-05 16:38:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1422749,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7817823/v1/8deb0606-2601-455f-90b8-5f1d76df7262.pdf"},{"id":95227477,"identity":"04edfcf3-55f0-4839-a6af-a40779019ee3","added_by":"auto","created_at":"2025-11-05 16:32:32","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":23893,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable.docx","url":"https://assets-eu.researchsquare.com/files/rs-7817823/v1/6948e20c08fb6e62098cd411.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Hydrosalpinx and Surgical Timing on Ovarian Reserve and Response in in vitro fertilization or intracytoplasmic sperm injection patients: A Retrospective Cohort Study with Propensity Score Analysis","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eHydrosalpinx is one of the most important causes of female infertility, accounting for up to 30\u0026ndash;40% of tubal factor infertility\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Its pathogenesis is typically linked to peritubal adhesions or distal tubal obstruction resulting from various factors, including infections (e.g., \u003cem\u003eNeisseria gonorrhoeae, Chlamydia trachomatis\u003c/em\u003e), chronic pelvic inflammatory disease, prior delivery or abortion, iatrogenic uterine injury, and endometriosis. With the development of Assisted Reproductive Technology (ART), it has become an important treatment for tubal infertility. However, hydrosalpinx significantly reduces the success rate of ART, and even unilateral hydrosalpinx can adversely affect pregnancy outcome\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, through several mechanisms, such as mechanical flushing of the embryo by the hydrosalpinx, embryotoxicity of hydrosalpinx constituents, decreased endometrial tolerance, and suppression of ovarian function\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Ovarian reserve reflects the number and quality of remaining follicles in the ovary, while ovarian response refers to the degree of ovarian response to Gn, both of which are key factors affecting the outcome of ART. Therefore, it is important to explore the effects of hydrosalpinx on ovarian reserve and ovarian response to optimize the ART treatment plan and improve the success rate. However, most of the existing studies have focused on the effects of hydrosalpinx on embryos and the effects of different surgical procedures on pregnancy outcomes, while there have been relatively few studies on the effects of hydrosalpinx on ovarian reserve and ovarian response. In addition,surgical treatment for hydrosalpinx in clinical practice may be performed either prior to controlled ovarian hyperstimulation (COH) or prior to embryo transfer. The impact of different surgical timing on ovarian reserve remains controversial. Therefore, the aim of our study is to investigate the effects of hydrosalpinx and the timing of its surgical management on ovarian reserve and ovarian response.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cb\u003eResearch design and study population\u003c/b\u003e: This retrospective cohort study collected medical records of patients who underwent IVF or ICSI from January 2017 to December 2021 at the Affiliated Reproductive Hospital of Shandong University. The study was approved by the Ethics Review Committee of the Affiliated Reproductive Hospital of Shandong University (2017 Lun Zi [5]). Inclusion criteria: ① female age\u0026thinsp;\u0026le;\u0026thinsp;40 years old; ② regular menstruation, menstrual cycle of 21\u0026ndash;35 days; ③ IVF or ICSI treatment; ④ no history of treatment with sex hormone drugs in the last 3 months. Exclusion criteria: (1) egg donation or pre-implantation genetic testing, including PGT-A, PGT-M, PGT-SR; (2) diseases affecting ovarian reserve, such as ovarian endometrioma, adnexal tumors, premature ovarian insufficiency (POI), polycystic ovary syndrome(PCOS), etc.; (3) history of pelvic-abdominal surgery such as history of ovarian, tubal, or other surgery known to affect ovarian reserve or anatomy; (4) uterine malformation; (5) chromosomal abnormality ; (6) combining with other diseases affecting fertility, such as endometriosis/adenomyosis, genital tuberculosis, other endocrine-related diseases (e.g., pituitary tumors, etc.), immune-related diseases, malignant tumors, etc. Study participants were categorized into hydrosalpinx group and control group. The patients in the hydrosalpinx group were those who had been diagnosed with hydrosalpinx by hysterosalpingography (HSG) and/or laparoscopy, and the control group were those who were infertile without hydrosalpinx. According to whether the hydrosalpinx was treated before COH, the hydrosalpinx group was further divided into COH-first group (A) and surgery-first group (B). Finally, Group B was subdivided into three subgroups based on different surgical approaches (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTreatment procedures\u003c/strong\u003e\u003cp\u003eAll infertile patients included in this study received IVF or ICSI treatment. The COH protocols used at our reproductive center include the long Gonadotropin-Releasing Hormone(GnRH) agonist protocol, ultralong GnRH agonist protocol, short GnRH agonist protocol, GnRH antagonist protocol, and minimal stimulation protocol. Oocyte maturation was triggered with 2000\u0026ndash;12,000 IU hCG based on individual patient characteristics when transvaginal ultrasound revealed at least two follicles with a mean diameter of \u0026ge;\u0026thinsp;18 mm or at least three follicles with a mean diameter of \u0026ge;\u0026thinsp;17 mm. Transvaginal ultrasound-guided oocyte retrieval was performed under sedation 36\u0026ndash;38 hours after hCG administration. IVF or ICSI was selected 4\u0026ndash;6 hours after egg retrieval based on the patient's and her husband's medical history, semen examination, etc. Our reproductive Center uses the Puissant criteria to morphologically evaluate embryos at the cleavage stage (D3) and categorizes embryos at the D3 into five grades ranging from 0\u0026ndash;4. Good quality embryos are defined as those with clear, regular blastomeres, minimal or no fragmentation, and rapid development to the 4-cell stage by 48 hours post-fertilization, scoring 5 or 6 on the Puissant scale\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. The decision on the timing of surgical intervention was made based on the clinical judgment of the treating physicians in consultation with the patient, considering factors such as the severity of hydrosalpinx, patient's history, and ovarian reserve status. Intraoperative assessment guided the selection of surgical intervention, which included salpingectomy for non-salvageable tubes, salpingostomy for preserving fertility, or ligation for proximal obstruction. All procedures were conducted via laparoscopy unless contraindicated (e.g., severe adhesions).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eOutcome measures\u003c/strong\u003e\u003cp\u003eDemographic and clinical characteristics were documented for all participants, encompassing age, anthropometric measurements (height, weight, and body mass index (BMI)), and infertility classification. Transvaginal ultrasonography was conducted during the early follicular phase (menstrual cycle days 3\u0026ndash;5) to assess the AFC. Concurrently, venous blood samples were obtained to evaluate baseline hormonal profiles, such as follicle-stimulating hormone (FSH), estradiol (E2), and AMH. Throughout the COH protocol, key parameters were monitored, including the starting dose of Gn, total Gn dose, as well as the duration of ovarian stimulation. On the day of hCG administration, a transvaginal ultrasound examination was performed to record the thickness of the endometrium and the number of follicles with a diameter\u0026thinsp;\u0026ge;\u0026thinsp;14 mm. Serum E2 levels were also determined at this timepoint. The primary endpoints focused on ovarian reserve indicators (AFC, AMH, basal FSH, and basal E2 levels) and ovarian response indicators (Gn starting dose, total Gn dose, duration of ovarian stimulation, hCG day E2, number of follicles\u0026thinsp;\u0026ge;\u0026thinsp;14 mm on hCG trigger day, number of retrieved oocytes). Additional outcome measures comprised the number of 2 pronuclei (2PN) zygotes, number of high-quality embryos, and number of blastocysts. Fertilization rate was calculated as the proportion of 2PN zygotes relative to the total oocytes retrieved.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eStatistical analysis\u003c/b\u003e: All statistical analyses and data visualization were conducted using IBM SPSS Statistics (Version 27.0, Chicago, USA). The normality of continuous variables was assessed using the Kolmogorov-Smirnov test. Normally distributed data were analyzed with Student\u0026rsquo;s t-test for two-group comparisons or one-way ANOVA for multiple groups, followed by post hoc LSD tests for pairwise comparisons. Results were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). Non-normally distributed variables were evaluated using the Mann-Whitney U test, with findings presented as median (interquartile range). Categorical variables were compared via the chi-square test and summarized as frequencies (percentages). To minimize selection bias and potential confounders, PSM was applied in a 1:1 ratio, with a caliper value of 0.01 on variables including age, BMI, duration of infertility, and infertility type.\u003c/p\u003e"},{"header":"RESULTS","content":"\n\u003ch3\u003e1 Effect of hydrosalpinx on ovarian reserve and ovarian response\u003c/h3\u003e\n\u003cp\u003eTo mitigate potential selection bias and confounding effects, PSM was performed in a 1:1 ratio. Prior to matching, logistic regression analysis identified significant differences between the two groups in age (\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and infertility type (\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). The matching variables included age, BMI, duration of infertility, and infertility type. After PSM, the SMD for all variables decreased to 0.1 or less, indicating the success of the matching procedure and each group (hydrosalpinx and control) consisted of 1363 well-matched cases.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e1.1 Impaired ovarian reserve in hydrosalpinx patients\u003c/h2\u003e\u003cp\u003eFollowing PSM, the hydrosalpinx and control groups demonstrated comparable baseline characteristics, including age, BMI, duration of infertility, and infertility type (\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, ovarian reserve markers exhibited significant differences between the groups. Compared to the control group, the hydrosalpinx group had significantly higher basal FSH levels (7.10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.43 vs. 6.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2.23; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and lower AMH concentrations (3.30\u0026thinsp;\u0026plusmn;\u0026thinsp;2.58 vs. 3.80\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Additionally, the AFC was significantly lower in the hydrosalpinx group (12.83\u0026thinsp;\u0026plusmn;\u0026thinsp;5.82 vs. 14.08\u0026thinsp;\u0026plusmn;\u0026thinsp;6.95; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). In contrast, no statistically significant difference was observed in basal E2 levels between the two cohorts (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Baseline Data and ovarian reserve Between hydrosalpinx and Control Groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;1363)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ehydrosalpinx group (n\u0026thinsp;=\u0026thinsp;1363)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31.56\u0026thinsp;\u0026plusmn;\u0026thinsp;4.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.52\u0026thinsp;\u0026plusmn;\u0026thinsp;4.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.811\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.81\u0026thinsp;\u0026plusmn;\u0026thinsp;3.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.69\u0026thinsp;\u0026plusmn;\u0026thinsp;3.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.382\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of Infertility (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.83\u0026thinsp;\u0026plusmn;\u0026thinsp;3.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.72\u0026thinsp;\u0026plusmn;\u0026thinsp;2.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.326\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfertility type, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.817\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e619 (45.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e612 (44.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e744 (54.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e751 (55.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBasal FSH (IU/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBasal E\u003csub\u003e2\u003c/sub\u003e(pg/mL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39.30\u0026thinsp;\u0026plusmn;\u0026thinsp;32.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.63\u0026thinsp;\u0026plusmn;\u0026thinsp;27.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.252\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAMH (ng/mL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.80\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.30\u0026thinsp;\u0026plusmn;\u0026thinsp;2.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAFC (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.08\u0026thinsp;\u0026plusmn;\u0026thinsp;6.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.83\u0026thinsp;\u0026plusmn;\u0026thinsp;5.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eNote: BMI: body mass index; FSH: follicle stimulating hormone; E\u003csub\u003e2\u003c/sub\u003e: estradiol; AMH: Anti-Mullerian Hormone; AFC: antral follicle count.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e1.2 Impaired ovarian response in hydrosalpinx patients during COH\u003c/h2\u003e\u003cp\u003eComparative analysis revealed significant differences in COH parameters between the hydrosalpinx and control groups. Patients with hydrosalpinx required higher Gn starting dose (181.90\u0026thinsp;\u0026plusmn;\u0026thinsp;60.92 vs. 167.87\u0026thinsp;\u0026plusmn;\u0026thinsp;53.62; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), greater total Gn dose (2072.66\u0026thinsp;\u0026plusmn;\u0026thinsp;994.78 vs. 1878.76\u0026thinsp;\u0026plusmn;\u0026thinsp;915.01; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and longer duration of ovarian stimulation (9.77\u0026thinsp;\u0026plusmn;\u0026thinsp;2.25 vs. 9.49\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). At the time of trigger administration, patients with hydrosalpinx required significantly higher doses of hCG (7527.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1511.03 vs. 7321.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1379.84; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.001) and exhibited greater serum E2 concentrations (3166.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1972.39 vs. 2910.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1740.48; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) compared to controls. Endometrial thickness on hCG trigger day and number of follicles\u0026thinsp;\u0026ge;\u0026thinsp;14 mm on hCG trigger day showed no statistically significant variation between the study groups. Notably, conventional ovarian response indicators - including number of retrieved oocytes, number of 2PN zygotes, fertilization rate, number of high-quality embryos, and number of blastocysts showed comparable outcomes between groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of ovarian response between the hydrosalpinx group and the control group during COH\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;1363)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ehydrosalpinx group (n\u0026thinsp;=\u0026thinsp;1363)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGn starting dose (IU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e167.87\u0026thinsp;\u0026plusmn;\u0026thinsp;53.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e181.90\u0026thinsp;\u0026plusmn;\u0026thinsp;60.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Gn dose (IU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1878.76\u0026thinsp;\u0026plusmn;\u0026thinsp;915.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2072.66\u0026thinsp;\u0026plusmn;\u0026thinsp;994.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of ovarian stimulation (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.49\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.77\u0026thinsp;\u0026plusmn;\u0026thinsp;2.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ehCG dosage (IU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7321.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1379.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7527.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1511.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEndometrial thickness on hCG trigger day (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.575\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of follicles\u0026thinsp;\u0026ge;\u0026thinsp;14 mm on hCG trigger day (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.77\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.61\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.398\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ehCG day E\u003csub\u003e2\u003c/sub\u003e (pg/mL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2910.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1740.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3166.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1972.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of retrieved oocytes(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.76\u0026thinsp;\u0026plusmn;\u0026thinsp;5.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.99\u0026thinsp;\u0026plusmn;\u0026thinsp;5.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.302\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2PN (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.36\u0026thinsp;\u0026plusmn;\u0026thinsp;3.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.055\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFertilization rate (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62.56\u0026thinsp;\u0026plusmn;\u0026thinsp;24.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64.12\u0026thinsp;\u0026plusmn;\u0026thinsp;24.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of high-quality embryos(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.61\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.72\u0026thinsp;\u0026plusmn;\u0026thinsp;2.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.338\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of blastocysts (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.19\u0026thinsp;\u0026plusmn;\u0026thinsp;3.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.35\u0026thinsp;\u0026plusmn;\u0026thinsp;3.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.218\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eNote: Gn: gonadotropin; HCG: human chorionic gonadotropin; 2PN: 2 pronuclei.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e2 Effect of treatment of hydrosalpinx before COH on ovarian reserve and ovarian response\u003c/h3\u003e\n\u003cp\u003eThe hydrosalpinx group was further categorized into the COH-first group (A, n\u0026thinsp;=\u0026thinsp;1224) and surgery-first group (B, n\u0026thinsp;=\u0026thinsp;139) according to whether the hydrosalpinx was pretreated before COH.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Treatment of hydrosalpinx prior to COH helps to improve ovarian reserve\u003c/h2\u003e\u003cp\u003eOne-way ANOVA and chi-square tests showed that the base FSH levels in the B group and the control group (6.54\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68 \u0026amp; 6.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2.23 vs 7.16\u0026thinsp;\u0026plusmn;\u0026thinsp;2.50; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) were significantly lower than those in the A group; Compared with the control group, the serum AMH levels in the A group (3.26\u0026thinsp;\u0026plusmn;\u0026thinsp;2.58 vs. 3.80\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) were significantly lower, and there was a trend of higher AMH levels in the B group compared with the A group, but there was no statistical difference; AFC (14.47\u0026thinsp;\u0026plusmn;\u0026thinsp;5.94 \u0026amp; 14.08\u0026thinsp;\u0026plusmn;\u0026thinsp;6.95 vs. 12.65\u0026thinsp;\u0026plusmn;\u0026thinsp;5.77; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) was significantly higher in the B group and the control group than in the A group. There were no statistically significant differences in age, BMI, duration of infertility, infertility type and basal E2 levels among the three groups (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEffect of pre-COH treatment of hydrosalpinx on baseline data and ovarian reserve\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;1363)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003ehydrosalpinx group (n\u0026thinsp;=\u0026thinsp;1363)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA (n\u0026thinsp;=\u0026thinsp;1224)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB (n\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31.56\u0026thinsp;\u0026plusmn;\u0026thinsp;4.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.57\u0026thinsp;\u0026plusmn;\u0026thinsp;4.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31.09\u0026thinsp;\u0026plusmn;\u0026thinsp;4.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.478\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.81\u0026thinsp;\u0026plusmn;\u0026thinsp;3.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23.86\u0026thinsp;\u0026plusmn;\u0026thinsp;3.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.573\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of Infertility (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.83\u0026thinsp;\u0026plusmn;\u0026thinsp;3.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.70\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.536\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfertility type, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.600\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e619 (45.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e555(45.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e220 (41.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e744 (54.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e669 (54.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e217 (59.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBasal FSH (IU/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2.23\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.16\u0026thinsp;\u0026plusmn;\u0026thinsp;2.50\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.54\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBasal E\u003csub\u003e2\u003c/sub\u003e(pg/mL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39.30\u0026thinsp;\u0026plusmn;\u0026thinsp;32.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.11\u0026thinsp;\u0026plusmn;\u0026thinsp;28.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36.41\u0026thinsp;\u0026plusmn;\u0026thinsp;18.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.114\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAMH (ng/mL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.80\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.26\u0026thinsp;\u0026plusmn;\u0026thinsp;2.58\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.72\u0026thinsp;\u0026plusmn;\u0026thinsp;2.62\u003csup\u003ea,b\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAFC (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.08\u0026thinsp;\u0026plusmn;\u0026thinsp;6.95\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.65\u0026thinsp;\u0026plusmn;\u0026thinsp;5.77\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.47\u0026thinsp;\u0026plusmn;\u0026thinsp;5.94\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eNote: BMI: body mass index; FSH: follicle stimulating hormone; E2: estradiol; AMH: Anti-Mullerian Hormone; AFC: antral follicle count.\u003c/p\u003e\u003cp\u003eValues with different superscript letters in the same row are significantly different (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) based on post-hoc tests\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Impact of Hydrosalpinx Treatment on Ovarian Response to COH\u003c/h2\u003e\u003cp\u003ePreovulatory management of hydrosalpinx improved ovarian response during COH. The Gn starting dose was significantly lower in the B and control groups compared to the A group (172.21\u0026thinsp;\u0026plusmn;\u0026thinsp;47.37 \u0026amp; 167.87\u0026thinsp;\u0026plusmn;\u0026thinsp;53.62 vs. 183.00\u0026thinsp;\u0026plusmn;\u0026thinsp;62.19; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). However, the total Gn dose was higher in both the B and A groups than in controls (1946.58\u0026thinsp;\u0026plusmn;\u0026thinsp;856.15 \u0026amp; 2086.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1008.63 vs 1878.76\u0026thinsp;\u0026plusmn;\u0026thinsp;915.01; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). The A group required a longer duration of ovarian stimulation (9.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.27 vs. 9.49\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.006) and higher hCG dosage (7542.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1502.19 vs. 7321.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1379.84; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.001) than the control group, whereas no such differences were observed between the B and control groups(Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. On the hCG trigger day, the B group had more follicles\u0026thinsp;\u0026ge;\u0026thinsp;14 mm than the A and control groups(10.70\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34 vs 9.49\u0026thinsp;\u0026plusmn;\u0026thinsp;4.98 \u0026amp; 9.77\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.019). Additionally, serum E2 level on hCG trigger day were significantly elevated in the B and A groups compared to controls༈3366.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2086.62 \u0026amp; 3144.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1958.58 vs 2910.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1740.48; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.001༉.No significant differences were found in endometrial thickness on hCG trigger day or retrieved oocytes among the three groups. Although the overall ANOVA test for the number of retrieved oocytes among the three groups did not reach statistical significance (\u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.053), post-hoc pairwise comparisons revealed that the B group yielded significantly more oocytes than both the A group (11.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.63 vs. 9.87\u0026thinsp;\u0026plusmn;\u0026thinsp;5.90; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.028) and the control group (11.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.63 vs. 9.76\u0026thinsp;\u0026plusmn;\u0026thinsp;5.61; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.015). And The B group demonstrated superior embryological outcomes\u0026mdash;including the number of 2PN zygotes (7.39\u0026thinsp;\u0026plusmn;\u0026thinsp;4.15 vs. 6.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.89 and 6.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.89; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.001), high-quality embryos (4.43\u0026thinsp;\u0026plusmn;\u0026thinsp;3.15 vs. 3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;2.88 and 3.61\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.005), and blastocysts (5.27\u0026thinsp;\u0026plusmn;\u0026thinsp;3.99 vs. 4.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.28 and 4.19\u0026thinsp;\u0026plusmn;\u0026thinsp;3.43; \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.002) \u0026mdash;compared to both the A and control groups. Fertilization rates, however, did not differ significantly among the groups (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEffect of pre-COH treatment of hydrosalpinx on ovarian response during COH\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;1363)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003ehydrosalpinx group (n\u0026thinsp;=\u0026thinsp;1363)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA (n\u0026thinsp;=\u0026thinsp;1224)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB (n\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGn starting dose (IU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e167.87\u0026thinsp;\u0026plusmn;\u0026thinsp;53.62\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e183.00\u0026thinsp;\u0026plusmn;\u0026thinsp;62.19\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e172.21\u0026thinsp;\u0026plusmn;\u0026thinsp;47.37\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Gn dose (IU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1878.76\u0026thinsp;\u0026plusmn;\u0026thinsp;915.01\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2086.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1008.63\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1946.58\u0026thinsp;\u0026plusmn;\u0026thinsp;856.15\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of ovarian stimulation (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.49\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.27\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.79\u0026thinsp;\u0026plusmn;\u0026thinsp;2.09\u003csup\u003ea,b\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ehCG dosage (IU)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7321.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1379.84\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7542.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1502.19\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7395.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1586.26\u003csup\u003ea,b\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEndometrial thickness on hCG trigger day (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.802\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of follicles\u0026thinsp;\u0026ge;\u0026thinsp;14 mm on hCG trigger day (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.77\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.49\u0026thinsp;\u0026plusmn;\u0026thinsp;4.98\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.70\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.019\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ehCG day E\u003csub\u003e2\u003c/sub\u003e (pg/mL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2910.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1740.48\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3144.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1958.58\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3366.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2086.62\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of retrieved oocytes(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.76\u0026thinsp;\u0026plusmn;\u0026thinsp;5.61\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.87\u0026thinsp;\u0026plusmn;\u0026thinsp;5.90\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.63\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.053\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2PN (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.89\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.89\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.39\u0026thinsp;\u0026plusmn;\u0026thinsp;4.15\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFertilization rate (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62.56\u0026thinsp;\u0026plusmn;\u0026thinsp;24.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.87\u0026thinsp;\u0026plusmn;\u0026thinsp;24.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e66.31\u0026thinsp;\u0026plusmn;\u0026thinsp;21.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.140\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of high-quality embryos(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.61\u0026thinsp;\u0026plusmn;\u0026thinsp;2.84\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;2.88\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.43\u0026thinsp;\u0026plusmn;\u0026thinsp;3.15\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of blastocysts (n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.19\u0026thinsp;\u0026plusmn;\u0026thinsp;3.43\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.28\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.27\u0026thinsp;\u0026plusmn;\u0026thinsp;3.99\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eNote: Gn: gonadotropin; hCG: human chorionic gonadotropin; 2 PN: two pronuclei;\u003c/p\u003e\u003cp\u003eValues with different superscript letters in the same row are significantly different (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) based on post-hoc tests\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e3. Effects of Different Surgical Approaches for Hydrosalpinx on Ovarian Reserve and Ovarian Response\u003c/h3\u003e\n\u003cp\u003eWe further grouped the patients according to surgical approach and found that, baseline characteristics (age, BMI, infertility duration, basal FSH, E2, and infertility type) showed no significant differences between Group A and surgical subgroups (\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). It is pleasurable that AMH levels were higher in the salpingostomy group than in Group A (4.12\u0026thinsp;\u0026plusmn;\u0026thinsp;2.93 vs. 2.91\u0026thinsp;\u0026plusmn;\u0026thinsp;2.00 ng/mL, \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.012), and AFC was increased in all surgical subgroups (\u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.002). However, Ovarian stimulation outcomes (Gn dose, duration, hCG dosage, endometrial thickness, follicle count, and E2 levels) and laboratory parameters (oocyte retrieval, fertilization rate, blastocyst formation) were comparable between the groups.(\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Notably, the salpingostomy group yielded more high-quality embryos than the salpingectomy group (4.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.36 vs 3.33\u0026thinsp;\u0026plusmn;\u0026thinsp;3.11, \u003cb\u003eP\u0026thinsp;=\u003c/b\u003e\u0026thinsp;0.034) (\u003cb\u003eSupplementary Tables\u0026nbsp;1\u0026ndash;2\u003c/b\u003e).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe findings of this study demonstrate that hydrosalpinx is associated with adverse effects on ovarian function, manifesting as diminished ovarian reserve and reduced responsiveness to COH. Importantly, our data indicate that surgical intervention (particularly salpingostomy,) for hydrosalpinx prior to initiating COH protocols can enhance both ovarian reserve parameters and ovarian response to Gn stimulation.\u003c/p\u003e\u003cp\u003eAs a prevalent contributor to female infertility\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, hydrosalpinx typically develops following pelvic infections (such as those caused by \u003cem\u003eNeisseria gonorrhoeae\u003c/em\u003e or \u003cem\u003eChlamydia trachomatis\u003c/em\u003e), inflammatory pelvic conditions, obstetric procedures, iatrogenic uterine interventions, or endometriosis, with chronic pelvic inflammation representing a primary etiological factor\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. This condition adversely impacts both spontaneous conception rates and ART outcomes. Previous studies have found that hydrosalpinx may reduce ART success through a variety of mechanisms including mechanical flushing of the embryo, embryotoxicity, reduced endometrial tolerance, and suppression of ovarian function, resulting in lower rates of implantation, lower clinical pregnancy rates, and an increased risk of early miscarriage and ectopic pregnancies\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. While limited research exists regarding the direct influence of hydrosalpinx on ovarian reserve, our study showed that patients with hydrosalpinx had significantly lower AFC and AMH levels and significantly higher basal FSH levels. The decrease in ovarian reserve may be multifactorial. One proposed mechanism is mechanical compression of the ipsilateral ovarian-tubal mesenteric vessels by the thickened and twisted hydrosalpinx side of the tube. The vascularization index (VI) and vascularization flow index (VFI) of patients with hydrosalpinx were found to be lower than those of the normal population\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, suggesting that hydrosalpinx may impair the blood supply to the ovary, resulting in delayed follicular development and decreased oocyte quality\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Additionally, the inflammatory fluid within the hydrosalpinx contains various mediators and cytokines, which have an adverse impact on the function of ovary through the blood circulation and the lymphatic circulation\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eCOH, a critical element of ART, aims to achieve synchronous follicular development through the administration of GnRH analogs (agonists or antagonists) in combination with exogenous Gn, thereby optimizing oocyte yield\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. The ovarian response is a key determinant of treatment success, as it influences both the number of retrieved oocytes and subsequent embryo availability, ultimately impacting pregnancy outcomes\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Previous research has indicated that hydrosalpinx may impair ovarian responsiveness during COH\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, manifesting as elevated baseline FSH levels and reduced oocyte retrieval. Potential mechanisms include compromised ovarian perfusion due to vascular compression by the hydrosalpinx, which may hinder follicular development, as well as the presence of inflammatory or toxic factors within the hydrosalpinx fluid that could diminish ovarian sensitivity to exogenous Gn, necessitating higher Gn dose\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. In our study, patients with hydrosalpinx required increased initial and total Gn doses, prolonged stimulation duration, and higher hCG administration, accompanied by elevated E2 levels on the day of trigger. However, despite these adjustments, no significant difference in the number of retrieved oocytes was observed between the hydrosalpinx and control groups. This suggests that augmented Gn dosing may partially compensate for diminished ovarian responsiveness in these patients. Nevertheless, fertilization rates, number of high-quality embryos, and number of blastocysts remained comparable between groups, and the impact on clinical pregnancy outcomes warrants further investigation.\u003c/p\u003e\u003cp\u003eWith advancements in ART, the utilization of tubal-sparing procedures and structural reconstructive surgeries has declined. Nevertheless, hydrosalpinx remains a significant factor impairing pregnancy rates in ART cycles, necessitating surgical intervention as a critical pretreatment. A retrospective study involving 160 hydrosalpinx patients demonstrated that the clinical pregnancy rate following IVF-ET without prior surgical treatment was merely 16.1%, whereas patients who underwent salpingectomy after failed IVF-ET cycles achieved a markedly higher pregnancy rate of 51.7%\u003csup\u003e16\u003c/sup\u003e. These findings underscore the potential benefits of surgical management in enhancing embryo implantation and ART success. Our study highlights that preoperative hydrosalpinx management may enhance ovarian reserve and response during COH. Current clinical approaches for hydrosalpinx include salpingectomy, salpingostomy, and proximal tubal occlusion. However, the influence of surgical pretreatment on ovarian function remains debated. Given that ovarian perfusion plays a pivotal role in folliculogenesis and steroidogenesis, any compromise in vascular supply may adversely affect ovarian reserve\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Our findings indicate that surgical management of hydrosalpinx prior to COH, especially salpingostomy, demonstrated beneficial effects on ovarian reserve parameters (AMH and AFC). Salpingectomy has been associated with elevated resistance indices (RI) in ovarian blood flow\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, potentially due to disruption of the vascular anastomosis between the ovarian and uterine arteries\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. In contrast, salpingostomy and proximal tubal occlusion exert minimal effects on ovarian perfusion\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, leading to superior fertilization rates and higher-quality embryos\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Moreover, recurrent hydrosalpinx after laparoscopic salpingostomy does not significantly alter IVF/ICSI outcomes, yielding comparable results to non-hydrosalpinx patients\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Proximal tubal occlusion is a viable alternative to salpingostomy, particularly in cases of mild to moderate hydrosalpinx. While salpingostomy preserves ovarian vascularity, its clinical utility is limited by high recurrence rates and a 10% risk of ectopic pregnancy\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Conversely, salpingectomy is the preferred approach for severe hydrosalpinx, as it definitively resolves the pathology and optimizes ART success\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. In our study, there was no significant difference in postoperative AMH levels between the salpingectomy group and other groups, indicating that ovarian reserve was not markedly affected. Although some literature reports that salpingectomy has a negative impact on ovarian function, our study indicates that through meticulous surgical techniques and individualised selection of surgical approaches, ovarian reserve and oocyte retrieval numbers can still be maintained at favourable levels. This aligns with the perspective of the ASRM\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHowever, various surgical treatment of hydrosalpinx did not revealed significant differences in COH outcomes. The lack of differences in stimulation parameters and embryological results may suggests comparable efficacy among treatment approaches, which is consistent with existing research findings\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. In accordance with the 2021 ASRM practice recommendations\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e, laparoscopic salpingostomy represents the optimal approach for patients aged\u0026thinsp;\u0026lt;\u0026thinsp;35 years with good ovarian reserve and mild hydrosalpinx. Conversely, salpingectomy is recommended for patients with moderate to severe hydrosalpinx. Younger patients with adequate ovarian reserve typically undergo salpingostomy to maintain tubal integrity. This conservative surgical approach, along with proximal tubal occlusion, appears to have negligible impact on ovarian blood supply\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, potentially explaining the observed improvements in embryo quality\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, which corroborates our study results.\u003c/p\u003e\u003cp\u003eThis study has several limitations that should be acknowledged. First, while the investigation primarily examined the impact of hydrosalpinx on ovarian reserve and ovarian response-related parameters, it did not conduct a stratified analysis of different ovarian stimulation protocols. Second, the effects of hydrosalpinx on ART outcomes were not explored, future research should incorporate ART outcome data to enhance the validity and comprehensiveness of the findings. Finally, as with all retrospective studies, despite employing PSM techniques, we cannot entirely rule out the influence of confounding variables on the findings. Future large-scale prospective studies are required to further validate these results.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe present study demonstrates that hydrosalpinx is associated with diminished ovarian reserve (DOR), and patients with hydrosalpinx exhibit impaired ovarian responsiveness during COH, requiring higher Gn doses and prolonged stimulation. Notably, surgical intervention prior to COH significantly improves ovarian reserve and enhances ovarian response. This supports the clinical rationale for pre-COH surgical management of hydrosalpinx to optimize ART outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Review Committee of the Affiliated Reproductive Hospital of Shandong University (2017 Lun Zi [5]). All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe raw data of this study are available on request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis\u0026nbsp;work\u0026nbsp;was\u0026nbsp;supported\u0026nbsp;by\u0026nbsp;the National Key R\u0026amp;D Program of China\u0026nbsp;(Program\u0026nbsp;Nos.\u0026nbsp;2024YFC2707500).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception: QMW, SLZ, and LY, Design: QMW and LY, Acquisition of data: SLZ and YW. Analysis of data: QMW , YW, and SLZ. Interpretation of data: LY and KKW, Drafted the manuscript: QMW and SLZ. Critically revised the manuscript: LY and KKW. \u0026ldquo;The authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our gratitude to all the staff at the fertility centers who contributed to its execution.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNg KYB, Cheong Y. Hydrosalpinx - Salpingostomy, salpingectomy or tubal occlusion. Best Pract Res Clin Obstet Gynaecol Aug. 2019;59:41\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bpobgyn.2019.01.011\u003c/span\u003e\u003cspan address=\"10.1016/j.bpobgyn.2019.01.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang X, Zhu L, Le F, et al. Proximal Fallopian Tubal Embolization by Interventional Radiology prior to Embryo Transfer in Infertile Patients with Hydrosalpinx: A Prospective Study of an Off-label Treatment. J Minim Invasive Gynecol Jan. 2020;27(1):107\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jmig.2019.02.026\u003c/span\u003e\u003cspan address=\"10.1016/j.jmig.2019.02.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCohen A, Almog B, Tulandi T. Hydrosalpinx Sclerotherapy Before In Vitro Fertilization: Systematic Review and Meta-analysis. J Minim Invasive Gynecol May-Jun. 2018;25(4):600\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jmig.2017.12.004\u003c/span\u003e\u003cspan address=\"10.1016/j.jmig.2017.12.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePuissant F, Van Rysselberge M, Barlow P, Deweze J, Leroy F. Embryo scoring as a prognostic tool in IVF treatment. Hum Reprod Nov. 1987;2(8):705\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/oxfordjournals.humrep.a136618\u003c/span\u003e\u003cspan address=\"10.1093/oxfordjournals.humrep.a136618\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen H, Jiang W, Lin G, Lu G, Gong F. Hysteroscopic Placement of Platinum Microinsert in Patients With Hydrosalpinx Before In Vitro Fertilization and Embryo Transfer. J Minim Invasive Gynecol Sep-Oct. 2019;26(6):1157\u0026ndash;63. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jmig.2018.08.033\u003c/span\u003e\u003cspan address=\"10.1016/j.jmig.2018.08.033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePerez-Milan F, Caballero-Campo M, Carrera-Roig M, et al. Hydrosalpinx treatment before in-vitro fertilization: systematic review and network meta-analysis. Ultrasound Obstet Gynecol Apr. 2025;65(4):414\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/uog.27697\u003c/span\u003e\u003cspan address=\"10.1002/uog.27697\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eD'Arpe S, Franceschetti S, Caccetta J, Pietrangeli D, Muzii L, Panici PB. Management of hydrosalpinx before IVF: a literature review. J Obstet Gynaecol. 2015;35(6):547\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/01443615.2014.985768\u003c/span\u003e\u003cspan address=\"10.3109/01443615.2014.985768\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEl-Mazny A, Ramadan W, Kamel A, Gad-Allah S. Effect of hydrosalpinx on uterine and ovarian hemodynamics in women with tubal factor infertility. Eur J Obstet Gynecol Reprod Biol Apr. 2016;199:55\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ejogrb.2016.01.046\u003c/span\u003e\u003cspan address=\"10.1016/j.ejogrb.2016.01.046\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGelbaya TA, Nardo LG, Fitzgerald CT, Horne G, Brison DR, Lieberman BA. Ovarian response to gonadotropins after laparoscopic salpingectomy or the division of fallopian tubes for hydrosalpinges. Fertil Steril May. 2006;85(5):1464\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.fertnstert.2005.10.036\u003c/span\u003e\u003cspan address=\"10.1016/j.fertnstert.2005.10.036\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOrvieto R, Saar-Ryss B, Morgante G, Gemer O, Anteby EY, Meltcer S. Apr. Does salpingectomy affect the ipsilateral ovarian response to gonadotropin during in vitro fertilization-embryo transfer cycles? \u003cem\u003eFertil Steril\u003c/em\u003e. 2011;95(5):1842\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.fertnstert.2010.11.061\u003c/span\u003e\u003cspan address=\"10.1016/j.fertnstert.2010.11.061\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePacchiarotti A, Selman H, Valeri C, et al. Ovarian Stimulation Protocol in IVF: An Up-to-Date Review of the Literature. Curr Pharm Biotechnol. 2016;17(4):303\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2174/1389201017666160118103147\u003c/span\u003e\u003cspan address=\"10.2174/1389201017666160118103147\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVenetis CA, Storr A, Chua SJ, et al. What is the optimal GnRH antagonist protocol for ovarian stimulation during ART treatment? A systematic review and network meta-analysis. Hum Reprod Update May. 2023;2(3):307\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/humupd/dmac040\u003c/span\u003e\u003cspan address=\"10.1093/humupd/dmac040\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlviggi C, Conforti A, Esteves SC, et al. Understanding Ovarian Hypo-Response to Exogenous Gonadotropin in Ovarian Stimulation and Its New Proposed Marker-The Follicle-To-Oocyte (FOI) Index. Front Endocrinol (Lausanne). 2018;9:589. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fendo.2018.00589\u003c/span\u003e\u003cspan address=\"10.3389/fendo.2018.00589\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFleming C, Hull MG. Impaired implantation after in vitro fertilisation treatment associated with hydrosalpinx. Br J Obstet Gynaecol Mar. 1996;103(3):268\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1471-0528.1996.tb09717.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1471-0528.1996.tb09717.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCopperman AB, Wells V, Luna M, Kalir T, Sandler B, Mukherjee T. Presence of hydrosalpinx correlated to endometrial inflammatory response in vivo. Fertil Steril Oct. 2006;86(4):972\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.fertnstert.2006.02.113\u003c/span\u003e\u003cspan address=\"10.1016/j.fertnstert.2006.02.113\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMurray DL, Sagoskin AW, Widra EA, Levy MJ. The adverse effect of hydrosalpinges on in vitro fertilization pregnancy rates and the benefit of surgical correction. Fertil Steril Jan. 1998;69(1):41\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0015-0282(97)00447-0\u003c/span\u003e\u003cspan address=\"10.1016/s0015-0282(97)00447-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRaba G. Effect of internal iliac artery ligation on ovarian blood supply and ovarian reserve. Climacteric Feb. 2011;14(1):54\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/13697130903548916\u003c/span\u003e\u003cspan address=\"10.3109/13697130903548916\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVenturella R, Morelli M, Lico D, et al. Wide excision of soft tissues adjacent to the ovary and fallopian tube does not impair the ovarian reserve in women undergoing prophylactic bilateral salpingectomy: results from a randomized, controlled trial. Fertil Steril Nov. 2015;104(5):1332\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.fertnstert.2015.08.004\u003c/span\u003e\u003cspan address=\"10.1016/j.fertnstert.2015.08.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYe XP, Yang YZ, Sun XX. Jan. A retrospective analysis of the effect of salpingectomy on serum antiMullerian hormone level and ovarian reserve. \u003cem\u003eAm J Obstet Gynecol\u003c/em\u003e. 2015;212(1):53 e1-10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajog.2014.07.027\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2014.07.027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBulent Tiras M, Noyan V, Ozdemir H, Guner H, Yildiz A, Yildirim M. The changes in ovarian hormone levels and ovarian artery blood flow rate after laparoscopic tubal sterilization. Eur J Obstet Gynecol Reprod Biol Dec. 2001;1(2):219\u0026ndash;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0301-2115(01)00410-9\u003c/span\u003e\u003cspan address=\"10.1016/s0301-2115(01)00410-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKelekci S, Yilmaz B, Yasar L, Savan K, Sonmez S, Kart C. Ovarian reserve and ovarian stromal blood supply after tubal ligation by the Pomeroy technique: comparison with controls. Gynecol Endocrinol May. 2005;20(5):279\u0026ndash;83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/09513590500097192\u003c/span\u003e\u003cspan address=\"10.1080/09513590500097192\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVignarajan CP, Malhotra N, Singh N. Ovarian Reserve and Assisted Reproductive Technique Outcomes After Laparoscopic Proximal Tubal Occlusion or Salpingectomy in Women with Hydrosalpinx Undergoing in Vitro Fertilization: A Randomized Controlled Trial. J Minim Invasive Gynecol Sep-Oct. 2019;26(6):1070\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jmig.2018.10.013\u003c/span\u003e\u003cspan address=\"10.1016/j.jmig.2018.10.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu H, Yao Z, Zhang R, Wu S, Lv S, Yan L. Effect of Recurrence of Hydrosalpinx after Tubal Ligation on the Outcome of In vitro Fertilization Treatment: A Retrospective Cohort Study. \u003cem\u003eGynecol Minim Invasive Ther\u003c/em\u003e. Jul-Sep. 2020;9(3):118\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/GMIT.GMIT_27_19\u003c/span\u003e\u003cspan address=\"10.4103/GMIT.GMIT_27_19\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen J, Huang D, Shi L, et al. Cornual Suture at the Time of Laparoscopic Salpingectomy Reduces the Incidence of Interstitial Pregnancy after In Vitro Fertilization. \u003cem\u003eJ Minim Invasive Gynecol\u003c/em\u003e. Sep-Oct. 2018;25(6):1080\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jmig.2018.02.009\u003c/span\u003e\u003cspan address=\"10.1016/j.jmig.2018.02.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePractice Committee of the American Society for Reproductive Medicine. Electronic address Aao. Role of tubal surgery in the era of assisted reproductive technology: a committee opinion. Fertil Steril May. 2021;115(5):1143\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.fertnstert.2021.01.051\u003c/span\u003e\u003cspan address=\"10.1016/j.fertnstert.2021.01.051\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsiami A, Chaimani A, Mavridis D, Siskou M, Assimakopoulos E, Sotiriadis A. Surgical treatment for hydrosalpinx prior to in-vitro fertilization embryo transfer: a network meta-analysis. Ultrasound Obstet Gynecol Oct. 2016;48(4):434\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/uog.15900\u003c/span\u003e\u003cspan address=\"10.1002/uog.15900\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChan CC, Ng EH, Li CF, Ho PC. Impaired ovarian blood flow and reduced antral follicle count following laparoscopic salpingectomy for ectopic pregnancy. Hum Reprod Oct. 2003;18(10):2175\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/humrep/deg411\u003c/span\u003e\u003cspan address=\"10.1093/humrep/deg411\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"reproductive-biology-and-endocrinology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"rbej","sideBox":"Learn more about [Reproductive Biology and Endocrinology](http://rbej.biomedcentral.com)","snPcode":"12958","submissionUrl":"https://submission.nature.com/new-submission/12958/3","title":"Reproductive Biology and Endocrinology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"hydrosalpinx, ovarian reserve, ovarian response, laparoscopic surgery, assisted reproductive technology","lastPublishedDoi":"10.21203/rs.3.rs-7817823/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7817823/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo investigate the impact of hydrosalpinx and the timing of surgical intervention on ovarian reserve and ovarian response in in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) patients.\u003c/p\u003e\u003ch2\u003eDesign, setting, and participants:\u003c/h2\u003e\u003cp\u003eThis study retrospectively collected the medical records of IVF/ICSI patients who underwent IVF/ICSI treatment in Reproductive Hospital Affiliated to Shandong University from January 2017 to December 2021. Patients were divided into hydrosalpinx group (n\u0026thinsp;=\u0026thinsp;1366) and control group (n\u0026thinsp;=\u0026thinsp;16038), and according to whether the hydrosalpinx was treated before controlled ovarian hyperstimulation (COH), the hydrosalpinx group was further divided into COH-first group (A) and surgery-first group (B). Finally, Group B was subdivided into three subgroups based on different surgical approaches.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eCompared to controls, the hydrosalpinx group had significantly lower AMH and AFC levels (\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Additionally, this group required higher starting and total gonadotropin (Gn) doses, a longer duration of ovarian stimulation, and greater human chorionic gonadotropin (hCG) dosages during COH (all \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Similarly, the A group showed markedly reduced AMH (\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and AFC (vs. surgery-first and control groups, \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). And AMH levels were higher in the salpingostomy group than in Group A (4.12\u0026thinsp;\u0026plusmn;\u0026thinsp;2.93 vs 2.91\u0026thinsp;\u0026plusmn;\u0026thinsp;2.00 ng/mL, \u003cb\u003eP\u003c/b\u003e\u0026thinsp;=\u0026thinsp;0.012). Gn starting doses were lower in the B and control groups than in the A group (\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), whereas stimulation duration and hCG dosage were elevated in the latter (\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). On hCG trigger day, the B group had more follicles\u0026thinsp;\u0026ge;\u0026thinsp;14 mm (\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), higher number of oocytes retrieved (\u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and superior embryological outcomes (2PN, good-quality embryos, and blastocyst numbers; all \u003cb\u003eP\u003c/b\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) relative to both A and control groups. However, the salpingostomy group yielded more high-quality embryos than the salpingectomy group (4.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.36 vs 3.33\u0026thinsp;\u0026plusmn;\u0026thinsp;3.11, \u003cb\u003eP\u0026thinsp;=\u003c/b\u003e\u0026thinsp;0.034).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eHydrosalpinx is associated with diminished ovarian reserve and an impaired ovarian response during COH. Surgical treatment (especially salpingostomy) of hydrosalpinx prior to COH may improve these functional parameters.\u003c/p\u003e","manuscriptTitle":"Impact of Hydrosalpinx and Surgical Timing on Ovarian Reserve and Response in in vitro fertilization or intracytoplasmic sperm injection patients: A Retrospective Cohort Study with Propensity Score Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-05 10:07:02","doi":"10.21203/rs.3.rs-7817823/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-07T07:44:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-20T11:18:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320552536954184274367715082381717847740","date":"2026-01-11T23:14:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-27T07:33:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-16T09:07:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-16T09:01:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"Reproductive Biology and Endocrinology","date":"2025-10-09T12:52:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"reproductive-biology-and-endocrinology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"rbej","sideBox":"Learn more about [Reproductive Biology and Endocrinology](http://rbej.biomedcentral.com)","snPcode":"12958","submissionUrl":"https://submission.nature.com/new-submission/12958/3","title":"Reproductive Biology and Endocrinology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"03cbea61-554d-4beb-b977-e74c9f23894c","owner":[],"postedDate":"November 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-07T07:56:09+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-05 10:07:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7817823","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7817823","identity":"rs-7817823","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}