Abstract
What is the chance of natural conception when salpingostomy is used to treat hydrosalpinx?. The natural clinical pregnancy rate following salpingostomy is 27%, in the hands of experienced surgeons who publish their results. Tubal surgery is not commonly offered for women with hydrosalpinges since the advent of assisted conception treatment. This is the first systematic review to investigate natural conception rates following salpingostomy in the treatment of hydrosalpinx. A systematic review and meta-analysis of 22 observational studies encompasses 2810 patients undergoing salpingostomy and attempting natural conception. Literature searches were conducted to retrieve observational studies which reported salpingostomy for hydrosalpinx. Databases searched included MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINAHL, with no language restriction. Only studies that focused on salpingostomy (rather than other tubal conserving surgeries) for the treatment of hydrosalpinx were included. A total of 22 studies matched the inclusion criteria. The pooled natural clinical pregnancy rate from the 22 observational studies (including 2810 patients) was 27% (95% confidence interval (CI): 25-29%) after salpingostomy was performed for hydrosalpinx. The cumulative clinical pregnancy rates were 8.7% (95% CI: 6.6-11.5%) at 6 months, 13.3% (95% CI: 10.6-16.7%) at 9 months, 20.0% (95% CI: 17.5-22.8%) at 12 months, 21.2% (95% CI: 18.6-24.1%) at 18 months and 25.5% (95% CI: 22.2-29.4%) at 24 months after salpingostomy. The pooled live birth rate (10 studies, 1469 patients) was 25% (95% CI: 22-28%) after salpingostomy was performed for hydrosalpinx. The pooled ectopic pregnancy rate (19 studies, 2662 patients) was 10% (95% CI: 9-11%). The pooled miscarriage rate (seven studies, 924 patients) was 7% (95% CI: 6-9%). The included studies scored well on the Newcastle Ottawa quality assessment scale. Strict inclusion criteria were used in the conduct of the systematic review. However, the studies included are clinically heterogeneous in many aspects including patient characteristics, surgical technique and duration of follow-up after salpingostomy. The findings of this systematic review suggest that salpingostomy is an alternative treatment strategy to tubal clipping or salpingectomy in patients presenting to fertility services with hydrosalpinx. Further prospective, large and high quality studies are needed to identify the subpopulation that would most benefit from tube conserving surgery. No external funding was either sought or obtained for this study. The authors have no competing interests to declare. N/A.
Highlights
25% of all female fertility is caused by tubal factors (Sharif and Coomarasamy 2012)
A total of 143 of these publications were excluded because 63 were review articles, opinion letters, case reports or questionnaires; two were duplicate articles; 17 articles did not specify the nature of the tubal disease and 46 performed tubal surgeries other than salpingostomy, e.g. salpingectomy, essure or transvaginal drainage of hydrosalpinx; six reported outcomes that were not of interest, e.g. ovarian response after tubal surgery or endometrial receptivity; two articles reported salpingostomy in the in vitro fertilization (IVF) population and seven articles reported data that could not be extracted
Our systematic review adds further weight to this recommendation from the Cochrane review, as our results demonstrate that reasonable clinical pregnancy rates can be achieved with salpingostomy in carefully selected patients
Summary
25% of all female fertility is caused by tubal factors (Sharif and Coomarasamy 2012). Before IVF/ICSI treatment became commonplace it was the remit of reproductive surgeons to correct tubal pathology (including hydrosalpinx) to enable women to increase their chances of natural conception (Winston and Margara, 1991; Winston, 1992; Vandromme et al, 1995; Chanelles et al, 2011). These techniques included peritubal adhesiolysis, fimbrioplasty and in the most severe tubal disease, salpingostomy. There is evidence that using these sterilizing techniques doubles the chances of IVF/ICSI success (Strandell et al, 1994; Akman et al, 1996; Johnson et al, 2010) in women with hydrosalpinges and this has become common clinical practice
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