Controversies in the modern management of hydrosalpinx.

The management of hydrosalpinx is a difficult clinical problem. Surgical treatment includes fimbrioplasty for patients with fimbrial obstruction and salpingostomy to fashion a stoma in the distal Fallopian tube in patients with a damaged fimbrial end. Surgery is only suitable for a small thin-walled hydrosalpinx with healthy mucosa. These operations can be performed via laparoscopy or open microsurgery. The proper selection of patients for surgical treatment and of the type of surgical technique are essential to achieve good results. The results of open microsurgery and laparoscopic surgery are summarized. In general, the prognosis of surgery is poor; however, in well selected cases, good results can be achieved by an experienced surgeon. In-vitro fertilization (IVF) is the main line of treatment for infertility caused by hydrosalpinx. In 1991, our group was the first to report on fluid accumulation in the uterine cavity before embryo transfer as a possible hindrance for implantation. Later, several publications reported an association between patients with hydrosalpinx and a reduced pregnancy rate when treated by IVF. The cause of a low pregnancy rate could be due to mechanical, chemical or toxic effects of the tubal fluid on the endometrium preventing implantation. All these mechanisms are reviewed in detail. The literature is controversial concerning the effect of transvaginal aspiration of hydrosalpinx on the outcome of IVF. Several reports suggest that surgical correction of the hydrosalpinx may improve the outcome of IVF. Further studies are required to verify this assumption and to find out the most suitable surgical procedure and if there is a subgroup of patients who could benefit most from salpingectomy.