Hydrosalpinx is a pathology of the fallopian tubes caused by one– or two-sided accumulation of transudate in their lumen. It may be asymptomatic and be detected for the first time in connection with infertility. Clinically pronounced forms of hydrosalpinx are accompanied by pain in the lower abdomen (pulling, bursting, pulsating), abundant watery whites, febrility and general weakness. In order to diagnose hydrosalpinx, gynecological examination, ultrasound of the pelvic organs, hysterosalpingography, sampling and evaluation of smears, diagnostic laparoscopy are performed. Hydrosalpinx treatment is most often operative – salpingostomy, tubectomy.
Hydrosalpinx is a violation of the patency of the fallopian tubes caused by the deposition of serous effusion in them. It is the most common cause of tubal-peritoneal female infertility. The frequency of detection of hydrosalpinx in patients resorting to assisted reproductive technologies in connection with tubal infertility is 10-30%. In women with hydrosalpinx, the possibility of independent pregnancy is halved, embryo implantation in IVF procedures is 3-5 times less frequent, cases of miscarriage and the frequency of ectopic pregnancy are doubly increased. The available statistics demonstrate the extreme urgency of this problem and the search for its solution for obstetrics and gynecology.
Sactosalpinx is a common name for the pathology of the fallopian tubes, in which its cavity is sealed and filled with liquid contents. With hydrosalpinx, the contents of the sac cavity are represented by a transparent serous fluid, with pyosalpinx – pus. Pathology can have unilateral or bilateral localization.
According to morphological features, there are simple and follicular (multicameral) hydrosalpinx. A simple form is diagnosed when one closed cavity is formed in the fallopian tube, a follicular form is diagnosed when several cavities are formed, separated by adhesions. In cases where the saccular cavity is periodically emptied, and its contents are poured into the uterine cavity and then out, a valve (or draining) hydrosalpinx is diagnosed. The course of the hydrosalpinx can be acute (active phase of inflammation) or chronic (sluggish inflammation). The size of the hydrosalpinx varies from one to several centimeters.
Transformation of the fallopian tubes by the type of sactosalpinx (saktos – bag) promotes the adhesive process that develops as a result of diseases of the pelvic organs. At the same time, connective tissue grows in the lumen of the pipe, partitions form, forming pseudocysts. The lumen of the pipe narrows down to complete obstruction in a certain area. Due to a violation of blood and lymph circulation in the walls of the tube, a transudate begins to accumulate in the formed cavity, consisting of secretions produced by the mucosa, blood plasma and extracellular fluid. When filling the cavity with transudate, the walls of the pipe are significantly stretched, deformed and thinned. The liquid can periodically pour out or be partially absorbed by the walls, however, the presence of adhesions and an inflammatory reaction causes the re-formation of the hydrosalpinx and the recurrent nature of the disease.
In most cases, hydrosalpinx is preceded by a local infectious and inflammatory process (salpingitis, salpingoophoritis, endometritis) caused by both nonspecific microbial flora (including mixed infection) and STI pathogens (chlamydia, gonorrhea, mycoplasmosis, trichomoniasis, etc.). Patients with endometriosis, those who have undergone reconstructive operations on the fallopian tubes and other surgical interventions on the pelvic organs.
A small hydrosalpinx with an inactive inflammatory process, as a rule, does not manifest itself in any way and is detected accidentally during a planned ultrasound of the pelvic organs. With a significant accumulation of fluid and overgrowth of the tube, there is a feeling of heaviness in the lower lateral parts of the abdomen, chronic pelvic pain. Body temperature can periodically rise to subfebrile figures. With a draining hydrosalpinx, patients notice periodic discharge of abundant, watery whites from the genital tract.
In the case of acute inflammation, there is a rise in temperature to 38 ° — 39 ° C, intense bursting or pulsating pain with irradiation in the groin. Sometimes the hydrosalpinx clinic resembles an acute surgical pathology (appendicitis), intestinal or renal colic. Severe malaise, hectic fever, chills, myalgia, as a rule, indicate the development of pyosalpinx.
Violation of the patency of the fallopian tubes due to hydrosalpinx directly affects the reproductive function. If the lumen of the tube closes completely, this makes it impossible for an egg to enter it and fertilization – the so-called tubal infertility develops. Therefore, it is often the unsuccessful attempts of a woman to get pregnant that become the reason for the gynecologist’s examination. However, even if the lumen is not completely closed, damage to the ciliated epithelium, smoothness of mucosal folding and atrophy of muscle fibers cause a violation of the peristalsis of the tube and, as a consequence, the development of ectopic pregnancy. Hydrosalpinx not only prevents pregnancy from occurring naturally, but also reduces the effectiveness of in vitro fertilization several times. The presence of hydrosalpinx supports the course of chronic endometritis, which also affects the success of ART methods.
A serious complication of hydrosalpinx can be a rupture of the fallopian tube, the occurrence of which is indicated by sudden sharp pain in the corresponding half of the abdomen, tachycardia, arterial hypotension, pallor of the skin, cold sweat. In case of rupture of the pyosalpinx, there is a high probability of developing peritonitis, pelvioperitonitis, an abscess of the Douglas space. In some cases, the breakthrough of pus does not occur in the abdominal cavity, but in the bladder, vagina or rectum.
Hydrosalpinx and ECO
Research in the field of reproduction convincingly proves the negative impact of hydrosalpinx on the prognosis of IVF. At the same time, not only the chances of a successful embryo transplant decrease significantly, but also the risks of ectopic pregnancy, spontaneous termination of pregnancy in the early stages increase. This causal relationship is explained by a number of pathological effects that the contents of the hydrosalpinx can cause:
- Mechanical action. It is assumed that the draining hydrosalpinx, emptying into the uterine cavity, can “wash out” early embryos.
- Embryotoxic effect. In addition to the direct mechanical removal of embryos from the uterine cavity, the contents of the hydrosalpinx have a destructive effect on them. The liquid from the hydrosalpinx in large quantities contains microorganisms and their toxins, lymphocytes, prostaglandins, proinflammatory cytokines, etc., which have a pronounced cytotoxic and embryotoxic effect. This effect persists even with 50% dilution of the contents of the hydrosalpinx.
- Endometrial damage. With the help of morphological and immunohistochemical methods, pathomorphological changes of the endometrium were revealed in the conditions of the existence of the hydroalpinx. A decrease in local immunity, expression of progesterone and estradiol receptors, a decrease in subendometrial blood flow, structural disorders of the glandular and stromal components of the endometrium – any of these factors may cause a violation of embryo implantation.
Clinical, laboratory and instrumental diagnostics aimed at detecting hydrosalpinx includes examination on a chair with sampling of swabs from the genital tract, examination of the patency of the fallopian tubes, sonography, laparoscopy. During vaginal examination, the formation of a rounded or ovoid form of a tight-elastic consistency, usually moderately painful, can be palpated between the uterus and the ovary.
Transvaginal or combined gynecological ultrasound complements and clarifies the data of gynecological examination. Expanded elongated fallopian tubes with homogeneous (with hydrosalpinx) or heterogeneous (with pyosalpinx) contents are echographically visualized. An intact ovary is determined next to the thickened tube. Free fluid may be detected in the rectal-uterine recess. Hysterosalpingography and HSG help to clarify the patency of the fallopian tubes and identify pathology.
The most reliable data for the presence of hydrosalpinx can be obtained during diagnostic laparoscopy. At the same time, the monitor shows thickened fallopian tubes with edematous fimbriae, thinned tube walls through which the watery contents shine through. Laparoscopy is also the main component of conservative surgical management tactics for patients with hydrosalpinx.
It is not possible to cure hydrosalpinx only in a conservative way. The preservation of pathomorphological prerequisites for the accumulation of transudate causes a recurrent course of pathology. In addition, the presence of hydrosalpinx casts doubt on the successful implementation of reproductive plans. Currently, all patients with this problem are undergoing two-stage treatment. Initially, adequate anti-inflammatory therapy is prescribed, aimed at stopping the activity of the infectious process in the fallopian tubes. Antibacterial drugs, vitamin therapy, physiotherapy (electrophoresis, magnetophoresis, laserophoresis) are prescribed.
Laparoscopic techniques are preferred at the surgical stage. Depending on the localization and severity of pathological changes, various reconstructive interventions can be performed on the fallopian tubes (salpingo-oovariolysis, fimbriolysis, salpingostomy or salpingoneostomy). In the postoperative period, mud treatment, balneotherapy, electrostimulation of the fallopian tubes are performed.
However, even the elimination of adhesions and reocclusion of the tubes is not a guarantee of an independent pregnancy, since it is not always possible to restore the full peristaltic activity of the fallopian tubes. Therefore, women planning pregnancy with the help of artificial insemination, reproductologists recommend performing laparoscopic tubectomy (salpingectomy). Removal of the fallopian tube increases the effectiveness of the IVF program three or more times.
Prognosis and prevention
Hydrosalpinx is associated with low chances of pregnancy, both when trying to conceive independently and as part of IVF protocols. Functional reconstructive surgery does not always allow achieving the desired pregnancy naturally, therefore, tubectomy with subsequent IVF cycle becomes the method of choice for a significant part of patients.
Prevention of hydrosalpinx is the prevention and adequate treatment of PID (salpingo-oophoritis, endometritis) and STDs, exclusion of casual sexual contacts, refusal of abortions, regular supervision of a gynecologist.