Human Reproduction Vol.17, No.4 pp.

1099–1100, 2002

CASE REPORT

Spontaneous intrauterine pregnancy following

salpingectomy for a unilateral hydrosalpinx

M.A.Aboulghar1, R.T.Mansour and G.I.Serour

The Egyptian IVF–Embryo Transfer Center, Maadi, Cairo, Egypt
1To whom correspondence should be addressed at: 3, 161 St. Hadaek Al Maadi, Maadi, Cairo, Egypt. E-mail: ivf@link.net

The effect of salpingectomy for unilateral hydrosalpinx with a contralateral normal tube was evaluated in two
infertile patients in which unilateral hydrosalpinx, visualized by vaginal ultrasound, was treated by unilateral
salpingectomy as a preparatory step before IVF. Spontaneous pregnancy occurred in both patients while waiting
to be enrolled in an IVF trial. In conclusion, unilateral salpingectomy for hydrosalpinx in the presence of a
contralateral healthy tube could result in spontaneous pregnancy.

Key words: salpingectomy/spontaneous pregnancy/unilateral hydrosalpinx/vaginal ultrasound

Introduction salpingectomy was performed. It was decided to start IVF 3

Very early in our IVF programme, we noticed that hydro-
salpinges associated with fluid accumulation in the uterine
cavity resulted in IVF failure (Mansour et al., 1991). In other
larger studies, several investigators reported that the presence
of hydrosalpinges negatively affects the outcome of IVF
(Strandell et al., 1994). Kassabji et al. found that both unilateral
and bilateral hydrosalpinges were associated with diminished
fecundity following IVF (Kassabji et al., 1994). It has also
been reported that the implantation rate in IVF is significantly
improved after salpingectomy for hydrosalpinges (Vandromme
et al., 1995).
The objective of this paper is to present two case reports of
patients who became pregnant spontaneously after salping-
ectomy for a unilateral hydrosalpinx, which was detected by
vaginal ultrasound.
Case Reports
Case 1
The patient was a 29-year-old woman, who presented with
4 years primary infertility. The semen count of the husband
was normal. Hysterosalpingography showed a unilateral hydro-
salpinx on the right side and the left tube was patent with free
peritoneal spill. Vaginal ultrasound showed a right hydrosalpinx
measuring 2⫻4 cm in diameter. The patient gave a history
of appendectomy following acute abdomen and localized
peritonitis, which could possibly explain the right-sided
hydrosalpinx. She previously underwent three trials of ovarian
stimulation and intrauterine insemination, but did not become
pregnant. She was scheduled for an IVF trial, but as our policy
during the past 2 years has been to council for salpingectomy
of ultrasonically visible hydrosalpinges, right laparoscopic
© European Society of Human Reproduction and Embryology
months later. The patient had a spontaneous pregnancy during
the second cycle after salpingectomy and the pregnancy was
uneventful and she delivered a healthy baby at 38 weeks.
Case 2
The patient was a 31-year-old woman, who presented with
primary infertility for 4 years. Previous hysterosalpingography
showed a unilateral hydrosalpinx. A laparoscopy report done
in another centre described a unilateral large hydrosalpinx
and mild peritoneal adhesions with an apparently normal
contralateral tube.
The patient had one failed IVF trial in the same centre after
transferring three good quality embryos. After evaluating
her previous history, vaginal ultrasound revealed a large
hydrosalpinx. The patient was counselled for a unilateral
salpingectomy and a possible bilateral salpingectomy after
evaluation of the contralateral tube during laparoscopy.
Excision of the hydrosalpinx was done and the other tube
looked healthy and patent; consequently, it was not removed.
The patient was scheduled for IVF in our unit 4 months later.
In her third cycle after salpingectomy the patient had a
spontaneous pregnancy, which is ongoing.
Discussion
The presence of a unilateral hydrosalpinx together with a
healthy contralateral tube is an uncommon condition. Tubal
pathology resulting from ascending infection is usually bilat-
eral. In one of our two patients, the hydrosalpinx followed
acute appendicitis. Other possible causes of this condition
include endometriosis and previous surgery in the adnexa.
The exact mechanisms by which the hydrosalpinx fluid has
an adverse effect on implantation are not yet clearly understood.
1099
M.A.Aboulghar, R.T.Mansour and G.I.Serour
The fluid passing to the uterine cavity can exert a mechanical
effect (Mansour et al., 1991). Various substances such as
cytokines, prostaglandins, leukotrines and other compounds
could be deleterious to intrauterine embryos and prevent
implantation (Strandell et al., 1994).
Shelton et al. observed the effects of salpingectomy in
patients with hydrosalpinx who had failed IVF and demon-
strated a significant improvement in pregnancy rate after
unilateral or bilateral salpingectomy for hydrosalpinx (Shelton
et al., 1996).
In a retrospective study, Wainer et al. reported that only
bilateral and not unilateral hydrosalpinges appear to have a
significant effect on the pregnancy rate after IVF (Wainer
et al., 1997). They did not recommend salpingectomy for
unilateral hydrosalpinges. However, the diagnosis of hydrosalp-
inx was based only on hysterosalpingography and/or laparos-
copy. Ultrasound was used only during ovarian stimulation to
visualize, but not to measure, tubal dilation. The authors did
not mention in the results or the discussion section any
information about the effect of ultrasonically detected unilateral
or bilateral hydrosalpinges on the outcome of IVF. In a
well-designed large prospective multicentre randomized study,
Strandell et al. showed that salpingectomy significantly
improved the delivery rates after IVF for hydrosalpinges,
which are detected by vaginal ultrasound, and in particular
bilateral cases (Strandell et al., 1999). The authors also reported
two spontaneous pregnancies after unilateral salpingectomy.
However, one woman with a unilateral hydrosalpinx also
conceived in the non-intervention group.
Choe and Check were the first to report on two patients
who became pregnant spontaneously after unilateral salpingec-
tomy for hydrosalpinx (Choe and Check, 1999). Both patients
had failed IVF trials and repeated ovarian stimulation/intrauter-
ine insemination before the unilateral salpingectomy was
performed.
In a case report, Kiefer and Check reported that a patient
failed to conceive in 12 cycles of IVF, including seven with
donor oocytes or embryos (Kiefer and Check, 2001). Following
unilateral salpingectomy for hydrosalpinx, their patient con-
ceived in three of four trials. She had two deliveries and one
chemical pregnancy. The authors concluded that the data
strongly suggest that the unilateral salpingectomy played a
great role in this conception, and that transfer of embryos from
donor oocytes can be adversely influenced by the presence of
unilateral hydrosalpinx.
In our report, salpingectomy was performed for the two
patients as a preparatory step before IVF. It has become our
policy to counsel all patients with hydrosalpinges visualized
by vaginal US for salpingectomy prior to IVF.
Other options, such as transvaginal aspiration of hydrosalp-
inges at the time of oocyte retrieval, may improve the pregnancy
rate (Van Voorhis et al., 1998). Distal neosalpingostomy
(Murray et al., 1998), which has shown some improvement in
the pregnancy rate in IVF, may also be used. However, it may
increase the risk of ectopic pregnancy, and the hydrosalpinx
may re-accumulate. This procedure is an option for the patient
who is reluctant to lose her tubes.
It is possible that salpingectomy prevented the harmful
effect of the hydrosalpinx, allowing normal implantation of
embryos reaching the uterine cavity from the contralateral side.
1100
The diagnosis of unilateral hydrosalpinx and a patent
contralateral tube is usually done by hysterosalpingography.
In this situation, it is not possible to assess the morphology
of the patent tube and the presence or absence of peritubal
adhesions, the condition of endotubal mucosa, or signs of
chronic pelvic peritonitis on the side of the patent tube.
The condition of the contralateral tube is best assessed by
laparoscopy, which will confirm or exclude that the
pathological lesion is localized to one side of the pelvis
and affecting only one tube. Salpingoscopy could also be
performed to assess the integrity of tubal mucosa (Puttemans
and Brosens, 1996).
During diagnostic laparoscopy, performed to evaluate the
condition of the contralateral tube, laparoscopic salpingectomy
for hydrosalpinx could be performed in the same sitting.
Patients who may benefit from unilateral salpingectomy, with
or without IVF should be properly counselled for possible
salpingectomy before performing diagnostic laparoscopy and
detailed consent should be signed.
The data from this report suggest that unilateral salpingec-
tomy for hydrosalpinx in the presence of a contralateral healthy
tube could result in spontaneous pregnancy. In this clinical
situation, it would be a reasonable step to wait for some cycles
after unilateral salpingectomy and possibly to try a few cycles
of controlled ovarian stimulation and intrauterine insemination
before resorting to IVF.
Note added at proof
A healthy baby has been delivered.
References
Choe, J. and Check, J.H. (1999) Salpingectomy for unilateral hydrosalpinx
may improve in vitro fecundity. Gynecol. Obstet. Invest., 48, 285–287.
Kassabji, M., Sims, J.A., Butler, L. and Muasher, S.J. (1994) Reduced
pregnancy outcome in patients with unilateral or bilateral hydrosalpinx after
in vitro fertilization. Eur. J. Obstet. Gynecol. Reprod. Biol., 56, 129–132.
Kiefer, D.G. and Check, J.H. (2001) Salpingectomy improves outcome in the
presence of a unilateral hydrosalpinx in a donor oocyte recipient: a case
report. Clin. Exp. Obstet. Gynecol., 28, 71–72.
Mansour, R.T., Aboulghar, M.A., Serour, G.I. and Riad, R. (1991) Fluid
accumulation of the uterine cavity before embryo transfer: a possible hinder
for implantation. J. in vitro Fertil. Embryo Transfer, 8, 175.
Murray, D.L., Sagoskin, A.W., Widra, E.A. and Levy, M.J. (1998) The adverse
effect of hydrosalpinges on in vitro fertilization pregnancy rates and the
benefit of surgical correction. Fertil. Steril., 69, 41–45.
Puttemans, P.J. and Brosens, I.A. (1996) Salpingectomy improves in-vitro
fertilization outcome in patients with a hydrosalpinx: blind victimization of
the Fallopian tube? Hum. Reprod., 11, 2079–2081.
Shelton, K.E., Butler, L., Toner, J.P., Oehninger, S. and Muasher, S.J. (1996)
Salpingectomy improves the pregnancy rate in in-vitro fertilization patients
with hydrosalpinx. Hum. Reprod., 11, 523–525.
Strandell, A., Waldenstrom, U., Nilsson, L. and Hamberger, L. (1994)
Hydrosalpinx reduces in-vitro fertilization/embryo transfer pregnancy rates.
Hum. Reprod., 9, 861–863.
Strandell, A., Lindhard, A., Waldenstrom, U., Thorburn, J., Janson, P.O. and
Hamberger, L. (1999) Hydrosalpinx and IVF outcome: a prospective
randomized multicenter trial in Scandinavia on salpingectomy prior to IVF.
Hum. Reprod., 14, 2762–2769.
Vandromme, J., Chasse, E., Lejeune, B., Van Rysselberge, M., Delvigne, A.
and Leroy, F. (1995) Hydrosalpinges in in-vitro fertilization: an unfavourable
prognostic feature. Hum. Reprod., 10, 576–579.
Van Voorhis, B.J., Sparks, A.E., Syrop C.H. and Stovall, D.W. (1998)
Ultrasound-guided aspiration of hydrosalpinges is associated with improved
pregnancy and implantation rates after in-vitro fertilization cycles. Hum.
Reprod., 13, 736–739.
Wainer, R., Camus, E., Camier, B., Martin, C., Vasseur, C. and Merlet, F.
(1997) Does hydrosalpinx reduce the pregnancy rate after in vitro
fertilization? Fertil. Steril., 68, 1022–1026.
Submitted on July 24, 2001; resubmitted on October 9, 2001; accepted on
November 12, 2001