The current study revealed that the aspiration of hydrosalpinx fluid under ultrasound guidance is more effective than antibiotic treatment in preventing the negative impact of hydrosalpinx on the results of IVF-ET .
Several researchers suggested that the flow of hydrosalpinx fluid into the endometrial cavity is the reason of the negative impact of hydrosalpinx on the results of IVF-ET (10). Two studies revealed that the presence of hydrosalpinx decreases the expression of uterine receptivity markers (Homeobox A10, β-integrin and leukemia inhibitory factor) and that salpingectomy increases the expression of these markers (14, 15).
Several authors suggested that the inflammatory process in the hydrosalpinx caused by bacteria ( mainly Chlamydia trachomatis ) could extend to the endometrium thought the flow of hydrosalpinx fluid into endometrial cavity or through lymphatics or blood vessels (9). It was postulated that the inflammatory mediators released by chronic inflammatory cells present in hydrosalpinx may cause embryonic damage or alter endometrial receptivity (16.17).
The results of the current study suggested that antibiotic therapy is not effective in the prevention of the adverse effect of hydrosalpinx on IVF-ET outcome. In contrast to our results, a small retrospective study comparing the outcome of IVF-ET cycles of patients with hydrosalpinx who were treated with extended doxycycline regimen with the outcome of IVF-ET cycles of patients with adhesions /proximal tubal block and patients with endometriosis /unexplained infertility, revealed that the success of IVF-ET cycles was comparable between the three groups (9).
The results of the current study are in accordance with several studies which reported that the aspiration of hydrosalpinx fluid at the time of ovum pick up is a simple, safe and inexpensive procedure that can prevent the negative impact of hydrosalpinx on the results of IVF-ET (2, 7, 18). Moreover, the data presented in the current study suggest that the aspiration of hydrosalpinx fluid under ultrasound guidance is less effective in the management of patients with rapid recollection of hydrosalpinx fluid and ineffective in the management of patients with endometrial fluid collection on the day of embryo transfer.
Two randomized controlled trials compared aspiration of hydrosalpinx fluid under ultrasound guidance at the time of ovum pick up with no intervention in patients with ultrasound visible hydrosalpinges who undergo IVF-ET. Fouda et al reported that the implantation, clinical pregnancy, and ongoing pregnancy rates were higher in the aspiration group (18.70% Vs. 8.33%, 31.48% Vs. 13.21% and 27.78% Vs 9.43% respectively) (2). Hammadieh et al reported that the chemical pregnancy rate was 43.8% in the aspiration group and 20.6% in the control group (P value = 0.04). The clinical pregnancy rate was higher in the aspiration group but the difference failed to reach statistical significance (31.3% vs. 17.6%, P = 0.20)(18) .
In a randomized controlled trial including 160 patients with ultrasound visible hydrosalpinx, Fouda et al compared the effectiveness of aspiration of hydrosalpinx fluid under ultrasound guidance with salpingectomy in the management of patients with hydrosalpinges who undergo IVF-ET. Rapid recollection of hydrosalpinx fluid ( i.e. within 2 weeks after embryo transfer) was noticed in 34.21% of the patients in the aspiration group. The clinical pregnancy and the implantation rates were higher in salpingectomy group compared with the subgroup of patients with rapid recollection of hydrosalpinx fluid (42.67% vs. 19.23% and 18.95% vs. 7.58%, respectively). On the other hand, the clinical pregnancy and the implantation rates were comparable between the salpingectomy group and the subgroup of patients with no recollection of hydrosalpinx fluid (42.67% vs. 34% and 18.95% vs. 15.5% respectively)(7).
In the current study, four patients in the aspiration group and eight patients in the antibiotic group had endometrial fluid collection on the day of embryo transfer. None of those patients conceived. The results of the current study are in accordance with numerous studies which reported that the subgroup of patients with endometrial fluid collection on the day of embryo transfer has the lowest pregnancy rates (2, 7, 19, 20). Several authors suggested that the ideal treatment option for this subgroup of patients is to cryopreserve the embryos and to transfer the embryos in subsequent cycles after performing salpingectomy or proximal tubal occlusion (21)(7).
The major weakness of the current study is the retrospective design. However, our study has several strengths. Our study is largest study which reported the use of antibiotic therapy in patients with ultrasound visible hydrosalpinges who undergo IVF-ET. Moreover, the current study is the first study which compared the efficacy of antibiotic therapy with aspiration of hydrosalpinx fluid under ultrasound guidance in the management of patients with ultrasound visible hydrosalpinges who undergo IVF-ET.