Journal of Gynecological Endoscopy and Surgery
Journal of Gynecological Endoscopy and Surgery Home | About us | Editorial Board | Ahead of print | Current issue | Back issues | Search | Instructions | Subscribe | Login 
Users online: 130 Wide layout Narrow layout Full screen layout Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size


 
REVIEW ARTICLE
Year : 2009  |  Volume : 1  |  Issue : 1  |  Page : 12-16 Table of Contents     

Hydrosalpinx functional surgery or salpingectomy? The importance of hydrosalpinx fluid in assisted reproductive technologies


Mandakini IVF Center, Chembur, Mumbai, India

Date of Web Publication5-Jun-2009

Correspondence Address:
Mandakini Parihar
Mandakini Fertility Clinic and IVF Center, 48, Swastik Park, Chembur, Mumbai - 400 071
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-1216.51903

Rights and Permissions
   Abstract 

The first IVF baby, Louise Brown, was born in a natural cycle IVF of a woman who had bilateral tubal block making IVF the only option for having a child. The last 3 decades has seen astounding progress in the field of ART. Today thanks to ART, tubal disease and tubal factor infertility is easily overcome.
The accepted theory today is that the hydrosalpinx fluid plays a causative role in the reduced pregnancy rate with ART. It is well known that the success of ART for patients with tubal disease with hydrosalpinx is reduced by half compared with patients without hydrosalpinx. Ideal would be removal of a hydrosalpinx by laparoscopic salpingectomy to improve pregnancy rates. However in some cases this is not feasible due to dense pelvic adhesions making access difficult. In such cases it is recommended that even de-linking the tube from the uterus would help in improving the ART outcome. There is suggestion that sonographically visible hydrosalpinges and those affected bilaterally have a poorer prognosis than those seen incidentally at laparoscopy. While there is clinical evidence supporting the causative role of the fluid itself, there is a lack of knowledge as to how the fluid exerts its negative effects. It is generally believed that the fluid holds a key position in impairing implantation potential. The aim of this review is to highlight the importance of identifying hydrosalpinges and its association with reduced fertility outcome using assisted reproductive technologies. Here we have discussed the different options available for the same, and highlighted the current modes of treatment.

Keywords: Hydrosalpinx, hydrosalpinx fluid, ART, pregnancy outcome


How to cite this article:
Parihar M, Mirge A, Hasabe R. Hydrosalpinx functional surgery or salpingectomy? The importance of hydrosalpinx fluid in assisted reproductive technologies. J Gynec Endosc Surg 2009;1:12-6

How to cite this URL:
Parihar M, Mirge A, Hasabe R. Hydrosalpinx functional surgery or salpingectomy? The importance of hydrosalpinx fluid in assisted reproductive technologies. J Gynec Endosc Surg [serial online] 2009 [cited 2017 Mar 23];1:12-6. Available from: http://www.gynecendoscopy.org/text.asp?2009/1/1/12/51903


   Introduction Top


When the first IVF baby, Louise Brown, was born in 1978, in-vitro Fertilization (IVF) was still an experimental technique. She was born in a natural cycle IVF of a woman who had bilateral tubal block, making IVF the only option for having a child. Prior to this, there was no hope for women with tubal factor infertility to ever conceive their own child. The results with tubal reconstructive surgery were unsatisfactory and had a high incidence of ectopic pregnancies. The last three decades has seen astounding progress in the field of Assisted Reproductive Technologies (ART). Today, thanks to advances in modern medicine, infertility treatment has become almost a routine procedure. With the advent of better quality ovulation induction drugs and increasing availability and accessibility of ART, there have been more than one-and-a-half million babies born with the help of ART. The happiness this has brought to families all over the world is incalculable. Today, thanks to ART, tubal disease and tubal factor infertility is easily overcome. The aim of this review is to highlight the importance of identifying hydrosalpinges and its association with reduced fertility outcome using ART. The ultimate aim of ART is to improve the take-home baby rate, and dealing with hydrosalpinx prior to ART is important. The literature review is done with the help of MEDLINE (1966 to November 2008), the Cochrane Library databases, and journal search, for the different options available for the same, and highlights of the current modes of treatment.


   Hydrosalpinx and Art Outcome Top


The accepted theory today is that the hydrosalpinx fluid plays a causative role in the reduced pregnancy rate with ART. It is well known that the success of ART for women with tubal disease with hydrosalpinx is reduced by half when compared with women without hydrosalpinx. During the past decade, the influence of the presence of hydrosalpinx on IVF success rates has been an issue of debate and research. Many retrospective studies have shown an impaired outcome of IVF in the presence of hydrosalpinx, and the meta-analyses has demonstrated that the probability of achieving a pregnancy in the presence of hydrosalpinx is reduced by half and even if pregnancy is achieved the incidence of spontaneous abortion is doubled. [1],[2],[3] Hence, any surgical intervention blocking the communication between the tube and the uterus would remove the leakage of the hydrosalpinx fluid and restore pregnancy rates. The ideal solution would be the removal of the hydrosalpinx by laparoscopic salpingectomy, to improve pregnancy rates. [4],[5],[6] However, in some cases this is not feasible due to dense pelvic adhesions making access difficult. In such cases it is recommended that even de-linking the tube from the uterus would help in improving the ART outcome. [7]

The results of prospective randomized studies on salpingectomy in women with hydrosalpinges are now forthcoming and greatly assist the debate on whether or not IVF will benefit from salpingectomy. In a study by Strandell et al, [5] the diagnosis of hydrosalpinx was made by a previous hysterosalpingography (HSG) or diagnostic laparoscopy, at which time reconstructive surgery had been rejected. The patients were divided into groups, IVF after salpingectomy and IVF cycle without removing the hydrosalpinges. The authors reported the outcome of the first IVF cycle and concluded that salpingectomy can be recommended for women with hydrosalpinges, especially those enlarged enough to be visible on ultrasound and in particular for those affected bilaterally. [5] These studies have resulted in the Cochrane library recommendation of salpingectomy for hydrosalpinges. [8],[9] Although there is clinical evidence supporting the causative role of the fluid itself, there is a lack of knowledge as to how the fluid exerts its negative effects. It is generally believed that the fluid holds a key position in impairing the implantation potential.


   Sonographically Visible Hydrosalpinx - Is it a New Clinical Entity ? Top


The hydrosalpinx that is visible on transvaginal sonography has been proposed as a new clinical entity by de Wit et al. in 1998, [10] although the diagnostic and pathophysiological features of this subgroup are poorly defined. However, transvaginal ultrasound prior to HSG / laparoscopy identifies 34% of the patients with a hydrosalpinx. This means that many hydrosalpinges that are present may be missed if one relies on ultrasound alone. [11] It is also believed that those patients with ultrasonographically visible hydrosalpinx have a poorer outcome if it is not removed. These also tend to enlarge more during ovarian stimulation. The mechanism of the enlargement of hydrosalpinges during ovarian stimulation is unknown. [12] In experimental conditions, distal occlusion results in a very slow distension of the mechanically induced hydrosalpinx, taking more than 12 weeks, whereas, the combination of a distal and proximal block results in a significant distension within two weeks. It can be speculated that uterine junctional zone contractions play a fundamental role in the movements of both uterine and tubal fluids. [13],[14] The altered fluid movements caused by the junctional zone contractions during ovarian stimulation, in the presence of a thin-walled hydrosalpinx, could be responsible for the adverse effect, for example, by acting as a mechanical barrier to embryo implantation. [12],[14],[15],[16]


   Is There a Role for Salpingoscopy in Selecting Cases for Tubal Surgery ? Top


The question to address is, how the patients that are most suitable for functional surgery can be selected?

The studies of Dechaud et al, [17] Strandell et al., [18] indicated the removal of thick-walled hydrosalpinges as well as the ones that are sonographically visible. Also, it is to be remembered that the sonographically visible hydrosalpinx is always likely to be a thin-walled hydrosalpinx. Thick-walled hydrosalpinges with a mean diameter of one to two centimeters, a wall thickness of 2 - 10 mm, and a frequently obliterated lumen are not likely to distend during ovarian stimulation and are, or become, visible on an ultrasound. [19],[20]

Vasquez et al, [21],[22] in a prospective study, concluded that mucosal adhesions were the most important factors in determining the fertility outcome. Their study with thin-walled hydrosalpinges showed that in the presence of normal or flattened mucosa, with no mucosal adhesions, there was a 58% pregnancy rate and a low risk of tubal pregnancy. However, thin-walled hydrosalpinges with mucosal adhesions had a high rate of tubal pregnancy, and thick-walled hydrosalpinges with fibrosis of the wall were incompatible for a normal pregnancy. [20],[21],[22]

However, tubal endoscopy has not yet gained widespread clinical acceptance. [23] Several studies on hydrosalpinges have shown that when salpingoscopy can exclude the presence of mucosal adhesions it can thereby identify the subgroup with a more than 50% intra-uterine and a less than 5% tubal pregnancy rate following reconstructive surgery. [24],[25],[26],[27],[28],[29] Functional surgery is, therefore, indicated in patients with thin-walled hydrosalpinges with minimal or no mucosal adhesions. It is, however, unclear whether these patients represent the same subgroup as the patients with sonographically visible hydrosalpinx.


   Hydrosalpinx Fluid Top


Many retrospective studies have shown that the hydrosalpinx is associated with poor IVF outcome. [3],[4],[15],[30],[31],[32] Recent data suggest that women with hydrosalpinx constitute a heterogeneous population with potentially different outcomes. [20],[32],[33] It would be valuable to identify a subset of patients who would benefit most from elective salpingectomy. The area of major concern is whether or not there is an impact on ovarian function. Many studies have reported that there is no effect on ovarian response, [3],[4],[20],[34] some mention equivocal response, [32],[33],[35],[36] and some show that there is a definite decrease in ovarian response the blood supply is affected during salpingectomy. [37] The role of hydrosalpinx aspiration at oocyte retrieval still awaits evaluation in a well-designed prospective trial. [38],[39],[40]


   Constituents of Hydrosalpinx Fluid Top
[15]

Epidermal growth factor (EGF)

Tumor necrosis factor-α (TNF-α)

Cytokines

Integrin β

Growth factors


   Why is There Reduced Fertility with Hydrosalpinx ? Top


The answer to this will be evident only when we understand the possible mechanisms causing embryotoxicity. To date, there are no reasons that are clearly defined. However, there have been a variety of cause-effect postulations by different authors. The hydrosalpinx fluid is suggested to act on two different target systems: directly on the transferred embryos or on the endometrium and its receptivity for implantation, or both. There are many theories postulated, but none actually proven. We mention them all in brief here as it is not possible to discuss all of them at length. [3],[4],[6],[7],[9],[13],[14],[15],[31],[32],[33]

In spite of so much research and so many theories, there is no single explanation over a period of decades. The evidence clearly points to adverse effects in the presence of a hydrosalpinx and these are due to:

  1. Mechanical effects
  2. Embryo and gametotoxicity
  3. Alterations in endometrial receptivity markers, resulting in poor implantation
  4. Direct effect on the endometrium, leading to intrauterine fluid formation

   Questions Regarding the Mechanism of Toxicity of the Hydrosalpinx Fluid that are Still Unanswered Top


  1. Are there any embryotoxic properties of the hydrosalpinx fluid - the doubt raised is - is there a common toxin or are there individual variations?
  2. Is the hydrosalpinx fluid toxic - there are no pathogenic microorganisms, but there are elevated concentrations of endotoxins in the fluids.
  3. Oxidative stress? Oxidative stress has been defined as an elevation in the steady-state concentration of various reactive oxygen species on a cellular level, and has been suggested to be of importance in hydrosalpinx cases. [41] This hypothesis needs further evaluation.
  4. Do transferred embryos starve in the presence of hydrosalpinx fluid? Glucose rather than pyruvate is the energy substrate needed during the development of blastocysts. Studies on embryo development in the hydrosalpinx fluid suggest a lack of nutrients, which explains the impaired development of blastocysts. Is this the possible explanation for the reduced implantation rates? [31],[32],[42],[43],[44]
  5. Does it affect endometrial receptivity? There is evidence to suggest that the link to implantation is the cross-talk between the embryo and endometrium. The dialogue between the embryo and endometrium is mediated by the secretion and expression of certain cytokines and other substances during the implantation window. This balance may be disturbed in the presence of hydrosalpinx fluid. [1],[31],[45],[46],[47]
  6. Are embryos simply washed out? The leakage of hydrosalpingeal fluid through the uterine cavity, resulting in the disposal of embryos, has been suggested as a mechanism by several authors. [13],[14],[15],[30],[31],[48]
  7. Does hydrosalpinx fluid cause increased endometrial peristalsis? Ijland et al. , investigated the relationship between endometrial wave-like activity and fecundability, in spontaneous cycles Conception cycles showed the slowest wave production. There may also be a role of reflux of the fluid from the tube due to a pressure gradient. [16],[20],[30],[32]

   Conclusions and Take - Home Messages Top


Hydrosalpinx is a common cause of female infertility. Lower implantation and pregnancy rates have been reported in women with hydrosalpinges. How hydrosalpinx exerts its negative effect on the implantation process is not clearly understood. It is intriguing that there is an effective treatment (salpingectomy) for its management, but we do not know how and why it works. It is not only of academic interest to know this, it is also of clinical value. In women who are identified to have hydrosalpinges during controlled ovarian stimulation, during IVF, aspiration of hydrosalpinges during oocyte collection may be effective in improving pregnancy rates. Laparoscopic surgery has a place in the diagnosis and management of the hydrosalpinx. Further randomized trials are required to assess other surgical treatment options for the hydrosalpinx, such as, laparoscopic salpingostomy, laparoscopic or hysteroscopic tubal occlusion, and drainage of the hydrosalpinx before or during oocyte retrieval. [40],[50]

 
   References Top

1.Strandell A. The influence of hydrosalpinx on in-vitro fertilisation and embryo transfer: A review. Hum Reprod Update 2000;6:387-95.  Back to cited text no. 1      
2.Puttemans P, Campo R, Gordts R, Brosens I. Hydrosalpinx and ART. Hum Reprod 2000;15:1427-30.  Back to cited text no. 2      
3.Camus E, Poncelet C, Goffinet F, Wainer B, Merlet F, Nisand I, et al . Pregnancy rates after in-vitro fertilization in cases of tubal infertility with and without hydrosalpinx: A meta-analysis of published comparative studies. Hum Reprod 1999;14:1243-9.  Back to cited text no. 3      
4.Dar P, Sachs GS, Strassburger D, Bukovsky I, Arieli S. Ovarian function before and after salpingectomy in artificial reproductive technology patients. Hum Reprod 2000;15:142-4.  Back to cited text no. 4      
5.Strandell A, Lindhard A, Waldenstrφm U, Thorburn J, Janson PO, Hamberger L. Hydrosalpinx and IVF outcome: A prospective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF. Hum Reprod 1999;14:2762-9.  Back to cited text no. 5      
6.Strandell A, Sjogren A, Bentin-Ley U, Thorburn J, Hamberger L, Brδnnstrφm M. Hydrosalpinx fluid does not adversely affect the normal development of human embryos and implantation in vitro . Hum Reprod 1998;13:2921-5.  Back to cited text no. 6      
7.Chen CD, Yang JH, Lin KC, Chao KH, Ho HN, Yang YS. The significance of cytokines, chemical composition, and murine embryo development in hydrosalpinx fluid for predicting the IVF outcome in women with hydrosalpinx. Hum Reprod 2002;17:128-33.   Back to cited text no. 7      
8.Johnson NP, Mak W, Sowter MC. Laparoscopic salpingectomy for women with hydrosalpinges enhances the success of IVF: A Cochrane review. Hum Reprod 2002;17:543-8.  Back to cited text no. 8      
9.Johnson NP, Mak W, Sowter MC. Surgical treatment for tubal disease in women due to undergo in vitro fertilization. Cochrane Database Syst Rev 2004;4:CD002125.  Back to cited text no. 9      
10.de Wit W, Gowrising CJ, Kuik DJ, Lens JW, Schats R. Only hydrosalpinges visible on ultrasound are associated with reduced implantation and pregnancy rates after in-vitro fertilization. Hum Reprod 1998;13:1696-701.  Back to cited text no. 10      
11.Lass A. What effect does a hydrosalpinx have on assisted reproduction? What is the preferred treatment for hydrosalpinges? The ovary's perspective. Hum Reprod 1999;14:1674-7.  Back to cited text no. 11      
12.Strandell A, Lindhard A, Waldenstrom U, Thorburn J. Hydrosalpinx and IVF outcome: Cumulative results in a randomized controlled trial. Hum Reprod 2001;16:2403-10.  Back to cited text no. 12      
13.Levi AJ, Segars JH, Miller BT, Leondires MP. Endometrial cavity fluid is associated with poor ovarian response and increased cancellation rates in ART cycles. Hum Reprod 2001;16:2610-5.  Back to cited text no. 13      
14.Eytan O, Azem F, Gull I, Wolman I, Elad D, Jaffa AJ. The mechanism of hydrosalpinx in embryo implantation. Hum Reprod 2001;16:2662-7.  Back to cited text no. 14      
15.Chen CD, Yang JH, Lin KC, Chao KH, Ho HN, Yang YS. The significance of cytokines, chemical composition, and murine embryo development in hydrosalpinx fluid for predicting the in-vitro fertilization outcome in women with hydrosalpinx. Hum Reprod 2002;17:128-33.  Back to cited text no. 15      
16.IJland MM, Hoogland HJ, Dunselman GA, Lo CR, Evers JL. Endometrial wave direction switch and the outcome of in vitro fertilization. Fertil Steril 1999;71:476-81.  Back to cited text no. 16      
17.Dechaud H, Daurθs JP, Arnal F, Humeau C, Hιdon B. Does previous salpingectomy improve implantation and pregnancy rates in patients with severe tubal factor infertility who are undergoing in vitro fertilization? A prospective randomized pilot study. Fertil Steril 1998a;69:1020-5.  Back to cited text no. 17      
18.Puttemans PJ, Brosens IA. Salpingectomy improves in-vitro fertilization outcome in patients with a hydrosalpinx: Blind victimization of the Fallopian tube? Hum Reprod 1996;11:2079-81.  Back to cited text no. 18      
19.Strandell A, Waldenstrφm U, Nilsson L, Hamberger L. Hydrosalpinx reduces in-vitro fertilization/embryo transfer pregnancy rates. Hum Reprod 1994;9:861-3.  Back to cited text no. 19      
20.Sharara FI. What effect does hydrosalpinx have on assisted reproduction? The role of hydrosalpinx in IVF: Simply mechanical? Hum Reprod 1999;14;577-8.  Back to cited text no. 20      
21.Vasquez G, Boeckx W, Brosens I. Prospective study of tubal mucosal lesions and fertility in hydrosalpinges. Hum Reprod 1995a;10:1075-8.   Back to cited text no. 21      
22.Vasquez G, Boeckx W, Brosens I. No correlation between peritubal and mucosal adhesions in hydrosalpinges. Fertil Steril 1995b;64:1032-3.   Back to cited text no. 22      
23.Puttemans PJ, De Bruyne F, Heylen SM. A decade of salpingoscopy. Eur J Obstet Gynecol Reprod Biol 1998;81:197-206.   Back to cited text no. 23      
24.Dechaud H, Daurθs JP, Hedon B. Prospective evaluation of falloposcopy. Hum Reprod 1998b;13:1815-8.  Back to cited text no. 24      
25.Marana R, Muzii L, Rizzi M, dell'Acqua S, Mancuso S. Prognostic role of laparoscopic salpingoscopy of the only remaining tube after contralateral ectopic pregnancy. Fertil Steril 1995;63:303-6.  Back to cited text no. 25      
26.Marana R, Catalano GF, Muzii L, Caruana P, Margutti F, Mancuso S. The prognostic role of salpingoscopy in laparoscopic tubal surgery. Hum Reprod 1999;14:2991-5.  Back to cited text no. 26      
27.Watrelot A, Dreyfus JM, Andine JP. Evaluation of the performance of fertiloscopy in 160 consecutive infertile patients with no obvious pathology. Hum Reprod 1999;14:707-11.  Back to cited text no. 27      
28.Surrey ES. Microendoscopy of the human fallopian tube. J Am Assoc Gynecol Laparosc 1999;6:383-9.  Back to cited text no. 28      
29.De Bruyne F, Puttemans P, Boeckx W, Brosens I. The clinical value of salpingoscopy in tubal infertility. Fertil Steril 1989;51:339-40  Back to cited text no. 29      
30.Andersen AN, Lindhard A, Loft A, Ziebe S, Andersen CY. The infertile patient with hydrosalpinges - IVF with or without salpingectomy? Hum Reprod 1996;11:2081-4.  Back to cited text no. 30      
31.Zeyneloglu HB, Arici A, Olive DL. Adverse effects of hydrosalpinx on pregnancy rates after in vitro fertilization-embryo transfer. Fertil Steril 1998;70:492-9.  Back to cited text no. 31      
32.Strandell A, Lindhard A. Why does hydrosalpinx reduce fertility? The importance of hydrosalpinx fluid. Hum Reprod 2002;17:1141-5.   Back to cited text no. 32      
33.Puttemans P, Campo R, Gordts S, Brosens I. Hydrosalpinx and ART - surgery or ART? Hum Reprod 2000;15:1427-30.   Back to cited text no. 33      
34.Bontis JN. Laparoscopic management of hydrosalpinx. Ann N Y Acad Sci 2006;1092:199-210.   Back to cited text no. 34      
35.Granot I, Dekel N, Segal I, Fieldust S, Shoham Z, Barash A. Is hydrosalpinx fluid cytotoxic? Hum Reprod 1998;13:1620-4.  Back to cited text no. 35      
36.Barmat LI, Nasti K, Yang X, Spandorfer S, Kowalik A, El-Roeiy A. Are cytokines and growth factors responsible for the detrimental effects of hydrosalpingeal fluid on pregnancy rates after in vitro fertilization-embryo transfer? Fertil Steril 1999;72:1110-2.  Back to cited text no. 36      
37.Dechaud H, Hedon B. What effect does hydrosalpinx have on assisted reproduction? The role of salpingectomy remains controversial. Hum Reprod 2000;15:234-5.   Back to cited text no. 37      
38.Hammadieh N, Coomarasamy A. Ultrasound-guided hydrosalpinx aspiration during oocyte collection improves pregnancy outcome in IVF: A randomized controlled trial. Hum Reprod. 2008;23:1113-7.   Back to cited text no. 38      
39.Sharara FI. Ultrasound-guided hydrosalpinx aspiration during oocyte collection improves outcome in IVF. Hum Reprod 2009;24:756.  Back to cited text no. 39      
40.Van Voorhis BJ, Sparks AE, Syrop CH, Stovall DW. Ultrasound-guided aspiration of hydrosalpinges is associated with improved pregnancy and implantation rates after in-vitro fertilization cycles. Hum Reprod 1998;13:736-9.  Back to cited text no. 40      
41.Bedaiwy MA, Goldberg JM, Singh M, Sharma R, Wang X, Nelson D, et al . Relationship between oxidative stress and embryotoxicity of hydrosalpingeal fluid. Hum Reprod 2002;17:601-4.  Back to cited text no. 41      
42.de Vantιry Arrighi C, Lucas H, El-Mowafi D, Campana A, Chardonnens D. Effects of human hydrosalpinx fluid on in-vitro murine fertilization. Hum Reprod 2001;16:676-82.  Back to cited text no. 42      
43.Tay JI, Rutherford AJ, Killick SR, Maguiness SD, Partridge RJ, Leese HJ. Human tubal fluid: Production, nutrient composition and response to adrenergic agents. Hum Reprod 1997;12:2451-6.  Back to cited text no. 43      
44.Dickens CJ, Maguiness SD, Comer MT, Palmer A, Rutherford AJ, Leese HJ. Human tubal fluid: Formation and composition during vascular perfusion of the Fallopian tube. Hum Reprod 1995;10:505-8.  Back to cited text no. 44      
45.Simón C, Gimeno MJ, Mercader A, O'Connor JE, Remohi J, Polan ML, et al . Embryonic regulation of integrins beta 3, alpha 4, and alpha 1 in human endometrial epithelial cells in vitro . J Clin Endocrinol Metab 1997;82:2607-16.  Back to cited text no. 45      
46.Sawin SW, Loret de Mola JR, Monzon-Bordonaba F, Wang CL, Feinberg RF. Hydrosalpinx fluid enhances human trophoblast viability and function in vitro : implications for embryonic implantation in assisted reproduction. Fertil Steril 1997;68:65-71.  Back to cited text no. 46      
47.Meyer WR, Castelbaum AJ, Somkuti S, Sagoskin AW, Doyle M, Harris JE, et al . Hydrosalpinges adversely affect markers of endometrial receptivity. Hum Reprod 1997;12:1393-8.  Back to cited text no. 47      
48.Mansour RT, Aboulghar MA, Serrour GI, Riad R. Fluid accumulation of the uterine cavity before embryo transfer: A possible hindrance for implantation. J In vitro Fert Embryo Transf 1991;8:157-9.  Back to cited text no. 48      
49.Kontoravdis A, Makrakis E, Pantos K, Botsis D, Deligeoroglou E, Creatsas G. Proximal tubal occlusion and salpingectomy result in similar improvement in IVF outcome in patients with hydrosalpinx. Fertil Steril 2006:1642-9.  Back to cited text no. 49      
50.Ozmen B, Diedrich K, Al-Hasani S. Hydrosalpinx and IVF: Assessment of treatments implemented prior to IVF. Reprod Biomed Online 2007;14:235-41.  Back to cited text no. 50      




 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
    Introduction
    Hydrosalpinx and...
    Is There a Role ...
    Hydrosalpinx Fluid
    Why is There Red...
    Questions Regard...
    Sonographically ...
    Constituents of ...
    Conclusions and ...
    References

 Article Access Statistics
    Viewed7862    
    Printed372    
    Emailed3    
    PDF Downloaded594    
    Comments [Add]    

Recommend this journal