I. Executive Summary: The Necessity of Pre-IVF Hydrosalpinx Management

The successful outcome of In Vitro Fertilization (IVF) cycles is significantly impaired by the presence of hydrosalpinx (HS), a common pathology among women with tubal-factor infertility.1 Clinical data consistently demonstrate that HS reduces pregnancy, implantation, and ultimately, live birth rates.1 Consequently, current international practice guidelines, including those from the American Society for Reproductive Medicine (ASRM), advocate for proactive intervention—specifically surgical isolation or complete removal of the affected tube—to eliminate the negative influence of the pathological fluid prior to embryo transfer.3

Laparoscopic salpingectomy (Sx), the complete excision of the fallopian tube, remains the established gold standard procedure, as it definitively removes the source of the detriment.3 However, proximal tubal occlusion (PTO) serves as a critically important, highly effective alternative, particularly when clinical considerations necessitate mitigation of risk to the patient’s ovarian reserve (OR).4 Accurate pre-surgical characterization of the hydrosalpinx is crucial, and advanced three-dimensional (3D) imaging techniques, such as 3D-HyCoSy, offer high-fidelity, non-invasive diagnostic precision that is nearly comparable to Magnetic Resonance Imaging (MRI), thereby facilitating precise and individualized treatment planning.5

II. Pathophysiology and Rationale for Tubal Intervention: Decoding the Detrimental Effects

The compelling rationale for intervening against hydrosalpinx before IVF treatment stems from complex pathophysiological mechanisms that disrupt the reproductive environment, encompassing both fluid toxicity and chronic inflammatory dysregulation of the uterine cavity.7

2.1 The Molecular Basis of Impaired Endometrial Receptivity

The primary destructive process involves the retrograde leakage of hydrosalpinx fluid (HSF) into the uterine cavity, which creates an environment hostile to blastocyst implantation.7 This fluid is not passively detrimental; it actively signals pathological changes that fundamentally undermine endometrial receptivity.1 The hydrosalpinx acts functionally as an active, chronically inflamed structure that signals pathological changes across the uterotubal junction, directly impacting gene expression critical for implantation.

HSF causes abnormal expression patterns of key molecules required for successful endometrial receptivity. Specifically, the presence of hydrosalpinx negatively influences the expression of the essential Homeobox A10 ($HOXA10$) gene, which is vital for directing embryonic development and implantation.8 Following salpingectomy, the normal endometrial expression of $HOXA10$ is restored, indicating a direct reversal of the pathological state by eliminating the HS influence.8

Similarly, the expression of the critical cell adhesion molecule, integrin $\alpha v\beta 3$, is often found to be significantly out of phase from the expected timing in the presence of hydrosalpinx. Clinical biopsies demonstrated that surgical removal of the tubal pathology restored $\alpha v\beta 3$ expression in 70% of the cases studied, confirming that successful intervention directly improves the likelihood of a receptive endometrium.8

2.2 The Immune System Reset and Inflammation

Beyond molecular markers, intervention drives a beneficial immunological shift within the endometrium. RNA sequencing analysis revealed that before occlusion, the endometrium exhibits pathological activation of immune-related pathways associated with chronic inflammation and cytotoxicity, including natural killer cell–mediated cytotoxicity, cellular senescence, antigen processing and presentation, and complement and coagulation cascades.9

Successful intervention, such as tubal occlusion, leads to the beneficial inactivation of these pathological immune-related pathways. This process is marked by the upregulation of $CXCL14$ expression and a concurrent increase in anti-inflammatory M2 macrophage infiltration.9 This shift, observed as a higher proportion of T follicular helper cells before occlusion (P=0.02) transitioning to increased M2 macrophage infiltration after occlusion (P=0.029), promotes a low-inflammatory, receptive state.9 The reversal of these inflammatory markers following occlusion suggests that the primary benefit of surgery is permanently silencing this inflammatory signal, which actively prevents implantation, and confirms that this immunological mechanism is effectively addressed by both salpingectomy and proximal occlusion.9

2.3 Direct Effects of Hydrosalpinx Fluid

While the primary hindrance is related to endometrial disruption, the HSF itself poses a direct risk. HSF has been shown to contain suboptimal levels of critical metabolic components, such as glucose and lactate, potentially having negative effects on early embryo development

in vitro.11 Furthermore, HSF demonstrates concentration-dependent negative effects on sperm motility and survival after 24 hours of incubation, suggesting that the fluid milieu produced by the hydrosalpinx epithelial cells is directly hostile to gametes and early embryo survival within the uterine cavity.12

III. Diagnostic Precision and Pre-Surgical Tubal Evaluation

Accurate diagnosis and characterization of the hydrosalpinx are prerequisites for determining the optimal treatment strategy (salpingectomy vs. occlusion) and for distinguishing between communicating and non-communicating hydrosalpinges.

3.1 The Advanced Role of 3D Transvaginal Ultrasound and HyCoSy

Three-dimensional transvaginal ultrasonography (3D-TVUS) has revolutionized the evaluation of tubal pathology. It offers significant advantages over older techniques like Hysterosalpingography (HSG) because it is non-invasive, fast, and does not expose the patient to radiation.13 Crucially, 3D-TVUS allows for superior visualization of the uterine cavity and adnexa in previously unavailable planes, such as the coronal view, facilitating accurate diagnosis of uterine anomalies.13

When combined with contrast media (3D-HyCoSy), the technique provides high accuracy in assessing tubal patency and obstruction. 3D-HyCoSy demonstrated a strong diagnostic accuracy of 92.50% for obstruction detection, showing good agreement with the gold standard of surgical confirmation (laparoscopy or FTRH, Kappa = 0.894).5 This high fidelity enables clinicians to visualize the specific morphological characteristics of the diseased tube, such as typical retort-shaped, S-shaped, or multiloculated cystic lesions, which is crucial for determining the surgical complexity pre-operatively.6 A non-invasive test like 3D-HyCoSy, with such high accuracy for obstruction, efficiently guides the patient pathway by often negating the need for diagnostic laparoscopy and allowing the clinician to proceed directly to therapeutic surgery.

3.2 Comparative Diagnostic Performance: 3D-US versus MRI

While 3D-US excels in efficiency and accessibility, its diagnostic performance is often compared against Magnetic Resonance Imaging (MRI). MRI generally maintains a slight advantage in overall diagnostic accuracy (95.3% sensitivity, 89.7% specificity, 93.5% NPV/PPV average) compared to 3D-US (88.7% sensitivity, 85.2% specificity, 87.9%/86.4% NPV/PPV average), particularly in assessing complex pelvic pathology or coexisting Müllerian anomalies.14

However, for the specific diagnosis and detailed characterization of hydrosalpinx morphology, the superior visualization offered by 3D TV-USG provides findings that are considered “almost comparable” to an MRI scan.6 Therefore, 3D-US/HyCoSy functions as the optimal, cost-effective tool for initial HS diagnosis and characterization, reserving the more expensive and less accessible MRI for cases flagged as complex or involving concurrent structural or deep pelvic lesions.14 Integrating both MRI and 3D-US enhances diagnostic precision and facilitates highly tailored management strategies.14

A summary of diagnostic efficacy is provided below:

Diagnostic Performance of 3D Imaging Modalities (Reference: FTRH/Laparoscopy)

IV. Surgical Management Techniques and Comparative Efficacy

The objective of surgical management is to definitively interrupt the flow of HSF into the uterine cavity, thereby restoring implantation rates to levels similar to those found in women without hydrosalpinx.3

4.1 Laparoscopic Salpingectomy (Sx)

Salpingectomy involves the complete removal or excision of the fallopian tube.15 As the gold standard, this technique definitively eliminates the pathological structure and the source of toxic fluid. Randomized clinical trials and meta-analyses confirm that salpingectomy restores the rates of pregnancy and live birth to normal baseline levels in women undergoing IVF.3 Specific results from prospective studies demonstrate that salpingectomy significantly increases delivery rates, leading to a 72% improvement compared to no intervention among patients starting IVF.2 Furthermore, for the specific subgroup of patients presenting with bilateral hydrosalpinges visible on ultrasound, the delivery rate was increased 3.5-fold.2

Surgical nuance is critical during this laparoscopic procedure, which is favored over open surgery due to shorter recovery times and fewer complications.3 The surgeon must carefully manage the dissection, maximizing exposure to the tube and optimizing tissue presentation while providing gentle yet constant traction to ensure efficient excision.16 A major consideration is the proximity of the tubal and ovarian arteries, which necessitates precise technique to avoid compromising the adjacent ovarian blood supply.17

4.2 Proximal Tubal Occlusion (PTO)

Proximal tubal occlusion represents a viable alternative that achieves the goal of isolating the hydrosalpinx fluid from the uterine cavity. PTO involves interrupting the tubal lumen at the isthmic segment, typically performed laparoscopically using bipolar diathermy applied at two separate sites near the uterine cornua (approximately 1 to 1.5 cm from the corneal section).19 When performed, the hydrosalpinges are generally left in situ.19

PTO is viewed as a beneficial surgical procedure that significantly increases the chances for successful implantation and clinical and ongoing pregnancy outcomes.4 It is specifically valuable as a valid alternative when salpingectomy is judged to be technically difficult or not feasible, often due to extensive pelvic adhesions.4

4.3 Comparative Outcomes Analysis (Salpingectomy versus PTO)

Both interventions are highly effective. Pooled analyses and network meta-analyses (NMA) comparing active interventions often report no significant differences in the Live Birth Rate (LBR) between salpingectomy and laparoscopic tubal occlusion (LTO).20 In fact, LTO sometimes achieves the highest success ranking for LBR in NMA models.20

This high ranking of PTO is instructive; although salpingectomy offers total curative removal, the fact that PTO performs comparably suggests that the successful physical interruption of retrograde flow is the dominant factor in restoring IVF success, rather than the extent of tissue removal. This finding supports the crucial clinical principle that effectiveness and minimizing surgical risk must be balanced. If proximal occlusion successfully blocks the inflammatory signal and prevents fluid backflow, its benefit is equivalent to salpingectomy, especially when considering PTO’s potential advantage in preserving ovarian reserve.10

V. Analysis of Potential Risks: Ovarian Reserve and Surgical Complications

The primary point of differentiation between salpingectomy and proximal tubal occlusion lies in their comparative impact on ovarian reserve (OR), evaluated predominantly by markers such as Anti-Müllerian Hormone (AMH) and Antral Follicle Count (AFC).18

5.1 The Anatomical Risk to Ovarian Blood Supply

The heightened concern regarding salpingectomy stems from the anatomical arrangement of the ovarian and tubal arteries, which course together within the mesosalpinx, forming a critical collateral circulation pathway to the ovary.17 The total removal of the fallopian tube, which requires coagulation and division of the mesosalpinx, introduces a risk of direct vascular interruption or thermal injury from electrosurgery used for hemostasis.17 Studies have reported impaired ovarian blood flow and reduced AFC following laparoscopic salpingectomy, supporting the basis for this clinical concern.18

5.2 Comparison of Ovarian Reserve Markers

While some individual studies suggest salpingectomy has no detrimental effect on OR in the short term, even after bilateral procedures 10, meta-analyses comparing the two surgical techniques indicate that PTO offers a measure of protection to ovarian function. Evidence shows that the PTO group may exhibit significantly higher AFC and AMH levels post-operatively compared to the salpingectomy group.10

A detailed pooled analysis of AFC results comparing the two groups found a statistically significant difference at two months post-surgery, favoring PTO.21 This suggests a measurable, albeit potentially temporary, acute vascular insult following salpingectomy that minimally affects follicular recruitment in the short-term. Conversely, PTO, being localized proximally far from the ovarian vascular arcades, minimizes this acute post-operative disruption.

Despite these differences in OR markers, the impact on immediate ART outcome is often mitigated: analyses comparing oocyte retrieval found no significant difference in the number of harvested oocytes between cases undergoing tubal occlusion and those undergoing salpingectomy.10 However, the persistence of measurable differences in AFC and AMH favoring PTO reinforces the clinical approach: for patients with pre-existing Diminished Ovarian Reserve (DOR), PTO is the preferred safer surgical avenue to maximize follicular yield in subsequent IVF cycles.10

Crucially, the long-term effect of salpingectomy on ovarian reserve remains uncertain, highlighting the need for future research with medium- to long-term follow-up to definitively address this concern.18

VI. Clinical Decision-Making and Integration of Management Strategies

The decision between salpingectomy and PTO is determined by a synthesis of diagnostic information, ovarian reserve assessment, and surgical complexity.

6.1 Patient Selection Algorithm

6.2 Non-Surgical Alternatives: Sclerotherapy

In specific instances where surgical access is complicated—for example, due to severe intra-abdominal adhesions—non-surgical management becomes necessary.23 Ultrasound-guided aspiration of HSF followed by the injection of a sclerosing agent in situ (sclerotherapy) is a valuable and simpler approach.23

Sclerotherapy demonstrates significantly improved fertility outcomes compared to simple aspiration alone.24 While salpingectomy remains the established primary recommendation, sclerotherapy improves implantation and clinical pregnancy rates in infertile women when compared to no intervention.24 In cases of anticipated surgical difficulty, sclerotherapy has been shown to result in a similar number of retrieved oocytes and pregnancy rates not significantly different from salpingectomy.23 This technique functions as a crucial chemical occlusion mechanism for high-surgical-risk patients.

6.3 Optimal Timing of Oocyte Retrieval Post-Intervention

Data suggest that timing the initiation of IVF following surgical or ablative intervention is important. A pooled analysis of patients undergoing tubal occlusion demonstrated that delaying oocyte retrieval significantly reduced both clinical pregnancy (multivariate-adjusted odds ratio = 0.904, P = 0.001) and live birth rates (OR = 0.926, P = 0.010).9

Curve estimation and piecewise regression analysis indicated that the period of improved pregnancy outcomes occurred within seven months after occlusion.9 This finding suggests that the molecular environment of the endometrium, which undergoes an immunological “reset” following the cessation of HSF exposure (inactivating immune-related pathways and fostering M2 macrophage polarization), requires this optimal window to maximize receptivity before the effects potentially diminish or chronic factors reassert themselves.9 The prompt initiation of IVF cycles within this seven-month timeframe is therefore advisable to capitalize on the maximal enhancement of endometrial receptivity.

VII. Conclusion and Future Research Directions

Surgical management of hydrosalpinx, primarily through laparoscopic salpingectomy or proximal tubal occlusion, is a mandatory step before initiating IVF to restore endometrial receptivity and significantly improve live birth rates. Salpingectomy provides curative removal and is the gold standard; however, proximal tubal occlusion offers statistically comparable pooled pregnancy outcomes while minimizing the demonstrated acute risk of ovarian vascular compromise, making it the preferred strategy for patients with diminished ovarian reserve.

Diagnostic precision, facilitated by highly accurate, non-invasive 3D imaging techniques like 3D-HyCoSy, allows clinicians to tailor treatment decisions based on anatomical complexity and vascular risk assessment. The recognition that hydrosalpinx actively perturbs the uterine immune and molecular environment—a pathology successfully reversed by physical blockage of the fluid—validates both excisional and occlusive strategies. Future clinical protocols should focus on extended, long-term randomized controlled trials (RCTs) to fully characterize the cumulative long-term impact of salpingectomy on ovarian longevity and to establish definitive guidelines for integrating non-excisional methods, such as hysteroscopic occlusion and sclerotherapy, into mainstream frontline care.

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