36 ORIGINAL ARTICLE Hysteroscopic tubal electrocoagulation in cases with communicating hydrosalpinx and planning for IVF - A pilot study Mona M. Aboulghar 1, Osama Azmy 2, Adel Nada 1, Ossama Shawky 1, Heba Mostafa 2 1. Cairo University, Department of obstetrics & Gynecology 2. Reproductive Health Research Department National research center, Dokki, Egypt ABSTRACT Objective: To evaluate the hysteroscopic tubal electrocoagulation for the purpose of tubal occlusion of communicating hydrosalpinx in patients scheduled for IVF. Subjects and intervention: Hysteroscopic rollerball and needle electrode coagulation of the cornual end of the tubes was performed in 10 patients with unilateral or bilateral communicating hydrosalpinx, prior to IVF. The rollerball electro coagulation technique was performed in 4 patients. The needle electrode technique was used on 10 tubes (in 6 patients). Results: Ten patients underwent the procedure successfully. The mean duration for both techniques used was 5 minutes. Postoperative complications included pain and vaginal spotting that lasted up to 3 days. In the group of the rollerball electro coagulation technique, the occlusion of 6 tubes was tried, one was successfully closed, 3 tubes were partially opened owing to the fact that a decrease of the hydrosalpinx mass was succeeded, and 2 tubes were totally opened. The needle electrode technique had a 90% success rate of occlusion (only one tube found opened). In total 6 patients have undergone an IVF trial following the procedure, 2 of whom underwent the rollerball electrocoagulation and had negative BHCG, and 4 of the patients of the needle electrode technique group ( two had positive BHCG, one chemical pregnancy and a clinical ongoing pregnancy). Conclusions: The hysteroscopic needle electrode occlusion of communicating hydrosalpinx seems to be a simple, effective and economic method, and it could be an alternative in patients with extensive pelvic adhesions, scheduled for tubal occlusion. Key words: Hydrosalpinx, hysteroscopy,electrocoagulation,in vitro fertilization INTRODUCTION The prevalence of hydrosalpinx in IVF ( in vitro fertilization) patients ranges from 10-13% when diagnosed by ultrasound 1,2 and could reach up to 30 % Correspondencing Author: Mona Aboulghar, 10, Geziret el arab Mohandeseen, Cairo 11431, Egypt Tel: +202 37491299, Fax: +202 33383049 E-mail: monaaboulghar71@gmail.com if diagnosed by HSG (hysterosalpingogram), laparoscopy or open surgery. 3,4,5 Hydrosalpinx is a bad prognostic factor according to published results of IVF. 2,6,7 It is believed that the fluid acts as a mechanical barrier to implantation of embryos.also, cytokines,prostaglandins and toxins are present in the fluid and contribute to the impact of hydrosalpinx to IVF success rates. 7 It has been proved that salpingectomy increases periimplantation endometrial Hoxa-10 expression in women with hydrosalpinx, a gene that is necessary for a successful implantation. 8 Studies have advocated salpingectomy prior to IVF 9,10 or proximal tubal occlusion 11 and this is currently performed laparoscopically in most cases. However, a large proportion of infertile tubal factor patients have severe pelvic adhesions that require open surgery and in some situations make the procedure impossible. 12 Hysteroscopic tubal occlusion by electro coagulation has been used as a method of sterilization. 13,14 This is a Pilot study that aims to the evaluation of the hysteroscopic electro coagulation as a new approach for proximal tubal occlusion in patients with communicating hydrosalpinx scheduled for IVF. MATERIALS AND METHODS The study tracked 10 patients from the outpatient clinic at the National Research Center and at the Kasr El Eini Teaching Hospital affiliated to Cairo University. A written approval was obtained from the Bioethical Committee of the National Research Center and an informed consent statement was signed by the patients prior to inclusion in the study. INCLUSION CRITERIA Age 20-40 years Primary or secondary infertility Diagnosis of communicating hydrosalpinx; diagnosed by HSG, TV U/S showing distended tubes and intrauterine fluid, or patient complaining of prolonged brownish vaginal discharge Necessity of an IVF procedure. Patients with non communicating hydrosalpinx, uterine anomalies or with a serious medical condition, contraindicating for pregnancy, were excluded. TIJM Volume I; Issue 2 April - June 2008
HYSTEROSCOPIC ELECTROCOAGULATION PRIOR TO IVF 37 Picture 1. Bilateral hydrosalpinx diagnosed by HSG Before any intervention is deceided, a gynecological history with special attention to the cause of infertility, symptoms of vaginal discharge, congestive dysmenorrhea, and abdominal surgeries,was acquired. A pelvic examination was performed to examine the cervix, the vaginal wall, to detect pelvic organ abnormalities and evaluate the pelvic pain and vaginal discharge. All patients had a HSG within the last 6 months showing unilateral or bilateral hydrosalpinx. A Transvaginal Ultrasound examination was conducted and an hydrosalpinx was confirmed by various appearances; cogwheel, interrupted septae. SUBJECTS OF THE STUDY The mean age of the patients was 32.1 years (range 28-36). Seven cases (70%) had primary infertility and 3 cases (30%) secondary infertility. Six of the patients had no previous IVF procedures, one case had one failed IVF,one had 2 previous failed IVFs and 2 patients had three failed IVFs. Six patients were diagnosed with bilateral hydrosalpinx (picture 1), the remaining four had a unilateral hydrosalpinx. All patients underwent diagnostic laparoscopies confirming the condition. Eight of the patients reported a history of pelvic surgery; ovarian cystectomy (5 cases), adhesolysis (2 cases) and a Caesarean section (1 case). HYSTEROSCOPY AND TUBAL ELECTROCOAGULATION Eight interventions were performed at El Ebtessama Hospital and 2 cases at Kasr El eini (Cairo university) teaching hospital. All hysteroscopies were performed in the early follicular phase up to day 9 of the menstrual cycle. All procedures were performed under general anesthesia. We used a standard, rigid 4-mm hysteroscope with a 30 forward-oblique lens and a 5.5-mm diagnostic sheath (Karl Storz, Germany). Uterine distension allowed a panoramic view of the uterine cavity and identification of the tubal ostia. Two techniques were used, the roller ball (Ball Electrode, unipolar, 5 Fr) for the coagulation of the interstitial part of the tube and the uterine cornu area. Coagulation was done using Martin electrosurgical unit; the average time of current flow was 40-55 seconds of intermittent pulses (3-4 seconds per pulse). The second technique used a needle electrode (Betocchi needle electrode, unipolar 5 Fr) inserted into the interstitial part of the tube for about 5mm ( Picture 2). Coagulation was done using the Martin electrosurgical unit, and using 40-50 watt power for 4-6 seconds. FOLLOW UP The patients were under follow up for 6-10 weeks following the procedure, HSG was done in the postmenstrual phase, after the second cycle postoperatively. RESULTS The electro coagulation roller ball was used in 4 cases and the electrocoagulation needle in 6 cases (picture2). The mean duration of the procedure was 5 minutes (from the start of hysteroscope introduction). Postoperative pain was perceived by the patients for a maximum of two days; 3 out of the 4 patients of the roller ball group had pain lasting two days, all patients of the needle electrode group had pain lasting only one day. Postoperative spotting occurred in all cases and lasted for 2 days in one case of the roller ball electro coagulation
38 Picture 2. Needle electrode diathermy applied in the tubal ostia and 3 days in the remaining 3 patients of this group. As for the needle electrode technique, 2 cases complained about spotting for 1 day and 4 for a maximum of 2 days. In total 5 cases complained of heavy first menstrual cycle (following procedure) and all patients had a normal second menstrual cycle. An incidental finding was relief of pelvic congestion symptoms. (All patients had congestive dysmenorrhea in addition to the vaginal discharge and occasionally dyspareunia). FOLLOW UP This was scheduled to take place after the second menstrual cycle. For the roller ball electro coagulation technique, 6 tubes underwent intervention (in 4 patients), with only one tube successfully closed, 3 tubes partially opened with reduction of the hydrosalpinx morphology, and 2 tubes opened totally. As for the needle electrode technique, 10 tubes were tested, in 6 patients, and only one tube was found opened and 9 closed,with no visible hydrosalpinx at the follow up via HSG (Picture 3). Six of the patients in the study have undergone an IVF following the procedure. Two of them, were in the rollerball electrocoagulation group, and had a negative BHCG (Beta Human Chorionic Gonadotropin), and four in the needle electrode technique group: two of them had a positive BHCG, one turned out to be a chemical pregnancy and the second a clinical ongoing pregnancy. DISCUSSION The latest meta-analysis Cochrane review 10, recommended the laparoscopic unilateral or bilateral salpingectomy to all women with hydrosalpinx prior to IVF.The most studied technique has been laparoscopic salpingectomy as well as proximal tubal occlusion with good results for both techniques. 15,11 Patients with hydrosalpinges, have in many instances severe pelvic adhesions. In addition, many of these patients have already undergone several pelvic surgeries and therefore are considered high surgical risk for laparoscopic salpingectomy or even proximal tubal occlusion. The laparoscopic route necessitates general anesthesia, involves recognized complications including; vascular damage, visceral organ injury or unintended laparotomy 16,17 hospital stay and recovery period is much longer than hysteroscopy performed under local anesthesia. 16 A theoretical risk of decreased ovarian vascular perfusion has been suggested by some authors 18,19 however Murray et al 20 and Ejdrup et al 21 in their study showed no negative effect of salpingectomy prior to IVF. Hysteroscopy whether diagnostic or operative does have its reported complications; uterine perforation, bleeding and fluid overload, these have been found to be significantly higher with operative procedures (p<0.01) 22 due to longer operating time and the need for greater cervical dilatation. The current complication rate for operative hystereroscopic procedures lies around 3%. 22,23,24 with the half of uterine perforations be related to dilation. 22 In our patients no cervical dilation was needed as office hysteroscopy with 4mm diameter was used. The duration of the procedure did not exceed 5 minutes, which entails minimal distension. The hysteroscopic route has been used successfully for tubal sterilization 16, 25 only one case of successful hysteroscopic tubal occlusion and IVF pregnancy has been reported, following Essure procedure, a microinsert use
HYSTEROSCOPIC ELECTROCOAGULATION PRIOR TO IVF 39 in the proximal tubal orifice. 26 Although this technique is more expensive than hysteroscopic electrocoagulation, it is cheaper than laparoscopy. 27 In the old series of cornual end tubal elecrocoagulation (for sterilization) the complication rate was similar to recent literature (3.2%), however there were all major complications28,out of 773 cases studied;7 uterine perforations, 3 bowel damage with peritonitis,4 cases of acute peritonitis, 8 ectopic pregnancies and 1 death from bowel perforation and peritonitis. In addition, 5% of minor complications were reported including bleeding, cramps, pain and endometritis. Animal studies have tested occlusion of the cornual end of fallopian tube in rabbits, using radiofrequency electrocoagulation, the technique was successful with no complications reported. 29 Quinones 14 in his study (1976) noted the effect of the coagulating current on the uterine serosal surface in hysterectomy specimens, starting at 25 seconds of coagulation. This, of course, is a much longer duration than used in our study where coagulation was applied for 4-6 seconds only. In our pilot study we used two techniques; the roller ball, which had a high failure rate (83.3%), this could be attributed to the fact that the technique relies on action of the coagulation on the endometrium of the cornua that possibly is shedded in the next cycle allowing recanalisation of the tube. The second technique; electro-coagulation using the needle electrode had much lower failure rate; 10%,this is because the needle is inserted into the tube for 5mm and allows complete damage of the endosalpinx and hence complete damage of the intramural portion of the tube. Our results using the needle electrode technique are considered reproducible when compared to previous clinical trials. Richart 13 had a success rate of 84%, similarly Quinones 14, had a success rate of 87.7% using hysteroscopic electro coagulation, for the purpose of sterilization, on 350 cases. These studies involved the use of an electro coagulation catheter which is very much similar to the needle electrode. In the above reported series only one complication of cornual pregnancy was reported. Two other studies 29,30 had a lower success rate of 75% and 73 % respectively. An additional advantage of needle electrode is that postoperative pain and spotting duration was less when compared to the roller ball. All patients had complete relief of symptoms of pelvic congestion (dysmenorrhea & dysparunia), even those in whom the tubes were found patent, and had a decrease in the mass of hydrosalpinx or no visible hydrosalpinx. Possibly this could be explained by atrophy of the epithelium or absorption of the hydrosalpinx fluid. The timing for the follow up examinations with HSG in the reported trials ranges from 6-16 weeks postoperatively. 13,14 In our study we performed the follow up HSG after an average of 8-10 weeks after the intervention. CONCLUSIONS This pilot study suggests that the technique of hysteroscopic tubal electro coagulation seems to be a simple, time-sparing and minor-interventional procedure, in addition economic to be performed, in cases with communicating hydrosalpinx, and alternatively in patients with extensive pelvic adhesions, scheduled for tubal occlusion. The feasibility, safety and success of the sug- Picture 3. Bilateral tubal occlusion in follow up with HSG
40 gested procedure as well as of the subsequent IVFs will depend on the results of larger series. REFERENCES 1. Anderson AN, Yue Z, Meng FJ,Petersen K. Low implantation rate after in-vitro fertilization in patients with hydrosalpinges diagnosed by ultrasonography. Hum. Reprod 1994; 9: 1935-38. 2. Katz E, Akman MA, Damewood MD, García JE. Deleterious effect of the presence of hydrosalpinx on implantation and pregnancy rates with in vitro fertilization. Fertil Steril.1996; 66: 122-125. 3. Strandell A, Waldenstrom U, Nilsson L, Hamberger L. Hydrosalpinx reduces in-vitro fertilization/embryo transfer pregnancy rates. Hum Reprod, 1994; 9: 861-863. 4. Blazar AS, Hogan JW, Seifer DB, Frishman GN, Wheeler CA, Haning RV. The impact of hydrosalpinx on successful pregnancy in tubal factor infertility treated by in vitro fertilization. Fertil Steril. 1997; 67; 517-520. 5. Murray CA, Clarke HJ, Tulandi T,Tan SL. Inhibitory effect of human hydrosalpingeal fluid on mouse preimplantation embryonic development is significantly reduced by the addition of lactate. Hum Rerod. 1997; 11: 2504-2507. 6. Barmat LI, Rauch E, Spandorfer S, Kowalik A, Sills ES, Schattman G, et al.the effect of hydrosalpinges on IVF-ET outcome. J Assist Reprod Genet. 1999 ; 16(7):350-4. 7. Ajonuma LC, Ng, YU EH and Chan HC. New insights into mechanisms underlying hydrosalpinx and its adverse effect on IVF outcome. Human Reproduction. 2002 ; 3:255-264. 8. Daftary GS, Kayisli U, Seli E, Bukulmez O, Arici A, Taylor HS. Salpingectomy increases peri-implantation endometrial HOXA10 expression in women with hydrosalpinx. Fertil Steril. 2007;87(2):367-72. 9. Bildirici I, Bukulmez O, Ensari A, Yarali H, Gurgan T. A prospective evaluation of the effect of salpingectomy on endometrial receptivity in cases of women with communicating hydrosalpinges. Hum Reprod 2001;16(11):2422-6. 10. Johnson NP, Mak W, Sowter MC. Surgical treatment for tubal disease in women due to undergo in vitro fertilization. Cochrane Database Syst Rev. 2004;(3):CD002125. 11. Kontoravdis A, Makrakis E, Pantos K, Botsis D, Deligeoroglou E, Creatsas G. Proximal tubal occlusion and salpingectomy result in similar improvement in in vitro fertilization outcome in patients with hydrosalpinx. Fertil Steril. 2006; 86(6):1642-9. 12. Hammadieh N, Afnan M Evans J, Sharif K, Amso N, Olufowobi O. A postal survey of hydrosalpinx management prior to IVF in the United Kingdom. Human Reproduction. 2004; 19: 1009-1012. 13. Richart RM, Neuwirth RS. Israngkun C, Phaosavasdi S. Female sterilization by electrocoagulation of tubal ostia using hysteroscopy. AM J Obstet Gynecol. 1973;15;117(6):801-4. 14. Quniones GR, Alvarado AD, Ley EC. Tubal electrocoagulation under hysteroscopic control (three hundred and fifty cases). Am J Obstet Gynecol. 1975;121(8):1111-3. 15. Surrey ES, Schoolcraft WB. Laparascopic management of hydrosalpinges before in vitro fertilization-embryo transfer: salpingectomy versus proximal tubal occlusion. Fertil Steril. 2001;75(3):612-7. 16. Cooper JM, Carignan CS, Cher D, Kerin JF; Selective Tubal Occlusion Procedure 2000 Investigators Group. Microinsert nonincisional hysteroscopic sterilization. Obstet Gynecol. 2003;102(1):59-67. 17. Garcia FA, Steinmetz I, Barker B, Huggins GR. Economic and clinical outcomes of microlaparoscopic and standard laparoscopic sterilization. A comparison. J Reprod Med. 2000;45:372 6. 18. Lass A, Ellenbogen A, Croucher C, Trew G, Margara R, Becattini C, et al. Effect of salpingectomy on ovarian response to superovulation in an in vitro fertilization-embryo transfer program. Fertil Steril. 1998;70(6):1035-8. 19. Freeman MR, Whitworth CM, Hill GA. Permenant impairment of embryo development by hydrosalpinges. Hum Reprod. 1998; 13(4):983-6. 20. Murray DL, Sagoskin AW, Widra EA,Lewy MJ. The adverse effect of hydrosalpinges on in vitro fertilization pregnancy rates and the benefit of surgical correction. Fertil Steril. 1998; 69(1):41-5. 21. Ejdrup Bredkjaer H, Zeib S, Hamid B, Zhou Y, Loft A, Lindhard A,et al. Delivery rates after in vitro fertilization following bilateral salpingectomy due to hydrosalpinges A case control study. Hum Reprod. 1999 ;14: 101-10. 22. Jansen FW, Vredevoogd CB, Van Ulzen K, Hermans J, Trimbos JB, Trimbos-Kemper TC.Complication of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. 200;96(2):266-70. 23. Popst AM, Liberman RF, Harlow BL, Ginsburg ES.Complications of hysteroscopic surgery: predicting patients at risk.obstset Gynecol 2000;96(4)517-20. 24. Shveiky D, Rojansky N Revel A, Benshushan A, Laufer N, Shushan A. Complications of hysteroscopic surgery: "Beyond the learning curve". Complications of hyseroscopic surgery. Beyond the learning curve,j minim Invasive Gynecol 2007;14(2):218-22. 25. Sinha D, Kalathy V, Gupta JK, Clark TJ. The feasibility, success and patient satisfaction associated with outpatient hysteroscopic sterilisation. BJOG. 2007 ;114(6):676-83. 26. Rosenfield RB, Stones RE, Coates A, Matteri RK, Hesla JS. Proximal occlusion of hydrosalpinx by hysteroscopic placement of microinsert before in vitro fertilization-embryo transfer. Fertil Steril. 2005;83(5):1547-50. 27. Hopkins MR, Creedon DJ, Wagie AE, Williams AR, Famuyide AO. Retrospective cost analysis comparing Essure hysteroscopic sterilization and laparoscopic bilateral tubal coagulation.j minim invasive Gynecol 2007;14(1):97-102. 28. Darabi KF, Richart RM. Collaborative study on hysteroscopic sterilization procedures. Preliminary report. Obstet Gynecol 1977:49(1):48-54. 29. Neuwirth RS, Levine RU and Richart RM. Hysteroscopic tubal sterilization.a preliminary report. AM J Obstet Gynecol;1116(1):82-5. 30. Cibils LA. Permanent sterilization by hysteroscopic cauterization. American Journal of Obstetrics and Gynecology 121(4)513-518.