Hydrosalpinx

A hydrosalpinx is a distally blocked fallopian tube filled with serous or clear fluid. The blocked tube may become substantially distended giving the tube a characteristic sausage-like or retort-like shape. The condition is often bilateral and the affected tubes may reach several centimeters in diameter. The blocked tubes cause infertility.

A fallopian tube filled with blood is a hematosalpinx, and with pus a pyosalpinx.

Hydrosalpinx is a composite of the Greek words ὕδωρ (hydor - "water") and σαλπιγξ (salpinx - ' "trumpet"); its plural is hydrosalpinges.

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Etiology

While the ciliae of the inner lining (endosalpinx) of the fallopian tube beat towards the uterus, tubal fluid is normally discharged via the fimbriated end into the peritoneal cavity from where it is cleared. If the fimbriated end of the tube becomes agglutinated, the resulting obstruction does not allow the tubal fluid to pass; it accumulates and reverts its flow downstream, into the uterus, or production is curtailed by damage to the endosalpinx. This tube then is unable to participate in the reproductive process: sperm cannot pass, the egg is not picked up, and fertilization does not take place.

The major cause for distal tubal occlusion is pelvic inflammatory disease (PID), usually as a consequence of an ascending infection by chlamydia or gonorrhea. However, not all pelvic infections will casue distal tubal occlusion. Tubal tuberculosis is an uncommon cause of hydrosalpinx formation.

Other causes of distal tubal occlusion include adhesion formation from surgery, endometriosis, and cancer of the tube, ovary or other surrounding organs.

A hematosalpinx is most commonly associated with an ectopic pregnancy. A pyosalpinx is typically seen in a more acute stage of PID and may be part of a tuboovarian abscess (TOA).

Tubal phimosis refers to a situation where the tubal end is partially occluded, in this case fertility is impeded, and the risk of an ectopic pregnancy is increased.

Symptoms

Symptoms can vary. Some patients have lower often recurring abdominal pain or pelvic pain, while others may be asymptomatic. As tubal function is impeded, infertility is a common symptom. Patients who are not trying to get pregnant and have no pain, may go undetected.

Diagnosis

Hydrosalpinx may be diagnosed using ultrasound as the fluid filled elongated and distended tubes display their typical echolucent pattern. However, a small hydrosalpinx may be missed by sonography. During an infertility work-up a hysterosalpingogram (HSG), an X-ray procedure that uses a contrast agent to image the fallopian tubes, shows the retort-like shape of the distended tubes and the absence of spillage of the dye into the peritoneum. If, however, there is a tubal occlusion at the utero-tubal junction, a hydrosalpinx may go undetected. When a hydrosalpinx is detected by an HSG it is prudent to administer antibiotics to reduce the risk of reactivation of an inflammatory process.

When a laparoscopy is performed, the surgeon will note the distended tubes, identify the occlusion, and may also find associated adhesions affecting the pelvic organs. A laparoscopy not only allows for the diagnosis of hydrosalpinx, but also presents a platform for intervention (see management).

Prevention

As PID is the major cause of hydrosalpinx formation, steps to reduce sexually transmitted disease will reduce hydrosalpinx. Also, as hydrosalpinx is a sequel to a pelvic infection, adequate and early antibiotic treatment of a pelvic infection is called for.

Management

For most of the past century patients with tubal infertility due to hydrosalpinx underwent tubal corrective surgery to open up the distally occluded end of the tubes (salpingostomy) and remove adhesions (adhesiolysis). Unfortunately, pregnancy rates tended to be low as the infection process often had permanently damaged the tubes, and in many cases hydrosalpinges and adhesions formed again. Further, ectopic pregnancy is a typical complication.^[1] Surgical interventions can be done by laparotomy or laparoscopy.

Non-infertile patients who suffer from severe chronic pain due to hydrosalpinx formation that is not relieved by pain management may consider surgical removal of the affected tube(s) (salpingectomy) or even a hysterectomy with removal of the tubes, possibly ovaries.

IVF and hydrosalpinx

With the advent of IVF which bypasses the need for tubal function a more successful treatment approach has become available for women who want to conceive. IVF has now become the major treatment for women with hydrosalpinx to achieve a pregnancy.

Several studies have shown that IVF patients with untreated hydrosalpinx have lower conception rates than controls and it has been speculated that the tubal fluid that enters the endometrial caviy alters the local environment or affects the embryo in a detrimental way.^[2] Thus, many specialists advocate that prior to an IVF attempt, the hydrosalpinx should be removed.^[2]

History

Regnier de Graaf may have been the first to understand basic tubal function, described hydrosalpinx, and linked the development of hydrosalpinx with female infertility.^[3] The usually infectious cause of the process was well known to physicians by the end of the nineteenth century.^[4] With the introduction of hysterosalpingography (1914) and tubal insufflation (1920) its non-surgical diagnosis became possible. Surgery was gradually displaced by IVF as the main treatment for tubal infertility after the birth of Louise Brown in 1978.

References

1. ^ Taylor RC, Berkowitz J, McComb PF.. "Role of laparoscopic salpingostomy in the treatment of hydrosalpinx". Fertil Steril. 2001 Mar;75(3):594-600.
2. ^ ^{a b} A. Strandell, A. Lindhard, U. Waldenström, J. Thorburn, P.O. Janson, and L. Hamberger. Hydrosalpinx and IVF outcome: a prospective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF.
3. ^ Ankum WM, Houtzager HL, Bleker OP. "Reinier De Graaf (1641-1673) and the Fallopian tube". Human Reproduction Update 1996, Vol.2, No.4, pp.365-369.
4. ^ Alexander Skene. Treatise on the Diseases of Women. D. Appleton & Co, New York, 1889. 

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