Effect of salpingectomy on ovarian response to hyperstimulation during in vitro fertilization: does it really matter?

Abstract

View Crossmark data SALPINGECTOMY AND IVFEffect of salpingectomy on ovarian response to hyperstimulation during in vitro fertilization: does it really matter?Until the end of the twentieth century, the medical community has considered salpingectomy as a trivial appendix of more complex gynecological surgeries or as an "emergency" option to solve life-threatening conditions such as ruptured ectopic tubal pregnancies. In the last 20 years, however, something has changed. Salpingectomy "per se" achieved increasing consensus as a procedure which (1) can reduce the risk of serous ovarian carcinoma, (2) can improve IVF pregnancy rate in patients with hydrosalpinx, and (3) represents an effective method of permanent sterilization [1].The "Kurman theory" that considers the distal Fallopian tube as the site of origin for ovarian and peritoneal serous cancers [2] is achieving increasing consensus, leading many national societies to recommend consideration of prophylactic salpingectomy during surgery for benign conditions in women who accomplished their reproductive desire [3].On the other side, the Practice Committee of the American Society for Reproductive Medicine (ASRM) published in 2008 a Committee opinion supporting the practice of salpingectomy prior to in vitro fertilization (IVF) in patients with hydrosalpinx, with the aim of improving pregnancy rates [4]; the recommendation was reiterated in 2015 in a Committee opinion on the role of tubal surgery in the era of assisted reproductive technology [5].Hydrosalpinx adversely affect IVF outcomes, by reducing the implantation rate and increasing the risk of miscarriage [4,5]. Among the pathogenic mechanisms proposed, embryo-toxic effects, mechanical flushing and changes in endometrial receptivity are considered the most probable by reproductive gynecologists. According to these pathogenic theories, the rationale behind surgical treatment of hydrosalpinx prior to IVF is to eliminate the negative effect of the hydrosalpingeal fluid either by aspirating it (ultrasound-guided aspiration) or by removing the entire fallopian tubes (salpingectomy) or by isolating them from the uterine cavity (laparoscopic or hysteroscopic proximal occlusion).Therefore, in tubal factor infertility, when the cause is irreparable hydrosalpinx, IVF is now considered the best option rather than attempting to restore tubal function [4,5] and tubal surgery is recommended only to exclude the tubal content from the endometrial cavity before an embryo try to implant inside.Thanks to these procedures, the hydrosalpinx fluid can no longer reach the uterine cavity and exert its toxic effect on implantation, the most delicate phase of pregnancy. According to this view, everybody will agree that the correct method to verify the effectiveness of surgical treatments of hydrosalpinx (as salpingectomy or tubal occlusion) compared with no intervention prior to IVF is to evaluate the live birth rate or, at least, the clinical pregnancy rate as the main study outcomes. Nevertheless, in 2016, Fan and Ma [6] publish...