Hysteroscopic hydrosalpinx occlusion with Essure device in IVF patients when salpingectomy or laparoscopy is contraindicated

Abstract

Objective

To evaluate, in patients with hydrosalpinges, the effect on in vitro fertilization (IVF) outcome of the insertion by hysteroscopy of an intratubal blocking device, in cases where laparoscopic salpingectomy or laparoscopy was contraindicated.

Study design

A prospective interventional case series study was conducted in fifteen women with unilateral (N = 6) or bilateral hydrosalpinges (N = 9) submitted for IVF. In all of them, laparoscopic salpingectomy was contraindicated. Hysteroscopic insertion of the Essure intratubal device in a consultation room setting was performed. IVF results were compared with those of women where hydrosalpinx was treated by laparoscopic salpingectomy (48 women, 76 cycles).

Results

There were no complications during or immediately after the procedure in any of the patients. There were four pregnancies from 16 embryo-transfers with own oocytes, one spontaneous pregnancy after unilateral Essure insertion, and one pregnancy after oocyte donation. In one case the hydrosalpinx grew and pelvic inflammatory disease developed 6 months after the insertion, requiring bilateral adnexectomy. Although not of statistical significance, IVF pregnancy rates were somewhat lower than in the laparoscopic salpingectomy group, which was attributed to the lower ovarian reserve before Essure insertion.

Conclusion

The hysteroscopic insertion of the Essure intratubal device prior to IVF is a reasonable option in cases where laparoscopic salpingectomy is contraindicated. Larger series are required to assess pregnancy outcome.

Introduction

In tubal factor infertility due to bilateral hydrosalpinx, in vitro fertilization (IVF) is the first option rather than attempting to restore tubal function [1]. The hydrosalpinges, however, adversely affect IVF outcomes, reducing the implantation rate and increasing the risk of miscarriage [2], [3]. A number of underlying pathogenic mechanisms have been proposed: embryotoxic effects, mechanical flushing and changes in endometrial receptivity [1], [4]. Since the hydrosalpinx fluid is in free communication with the uterine cavity, any surgical intervention interrupting this communication could improve the pregnancy rates [1], [5], [6]. Laparoscopic salpingectomy has been demonstrated to be an effective option and has the advantages of removing the risk of pelvic inflammatory disease and ectopic pregnancies and of improving the accessibility of ovarian tissue. It has drawbacks, however, including the invasiveness, potential risks of surgical injury and anesthesia, and technical difficulty in the case of adhesions [1]. Given this, a number of alternative options have been proposed such as laparoscopic proximal tubal occlusion [6], ultrasound-guided hydrosalpinx aspiration [7], and Essure insertion [8], [9], [10], [11].

The Essure device induces a benign local fibrous tissue response that results in occlusion of the tubal lumen and encapsulation of the device [12], and it is now widely used for tubal sterilization. Recently Essure insertion has been proposed as a safe, effective and minimally invasive alternative to salpingectomy in IVF patients with hydrosalpinges, especially when laparoscopic treatment is contraindicated, for example in cases with severe obesity, massive adhesions or anesthesic risk [8], [11], [13], [14], [15]. IVF outcome after Essure occlusion of the hydrosalpinx has been reported to be similar to the general population [9] or lower [15], although in none of the studies was a control group presented, nor were IVF data presented in detail.

The aim of this work is to report our experience with the Essure device in IVF patients with hydrosalpinx where laparoscopic salpingectomy was contraindicated, and to compare IVF results with those obtained in patients where hydrosalpinx was treated by laparoscopic salpingectomy.