Reply: Ultrasound-guided hydrosalpinx aspiration during oocyte collection improves outcome in IVF

Sir, I read with interest the manuscript by Hammadeh et al. (2008). The authors prospectively analyzed 66 women between October 1999 and June 2003 who had hydrosalpinges (HSPX) noted on ultrasound on the ninth day of ovarian stimulation and were randomized into an aspiration group on the day of oocyte retrieval and a no intervention group. The study was terminated short of the 158 patients required in July 2003 at the recommendation of the Data Monitoring Committee. This represents the largest and only randomized study to date on the positive effects of HSPX aspiration on pregnancy rate, and the investigators need to be commended for such a trial. Few questions come to mind however. While the system in England entails referrals by other physicians for IVF and patients having to go on a waiting list for occasionally up to a year, how was the diagnosis of HSPX noted? Did these patients have an hysterosalpingogram or a prior laparoscopy, and if so, when? Would the management have been different if HSPX were noted at the time, rather than on Day 9 of ovarian stimulation when patients are close to oocyte retrieval? The authors note that 40 of 66 (61%) patients were diagnosed before treatment start, and if so, how were they diagnosed and were they offered any surgical correction of the HSPX then? Did any of the women with HSPX have any endometrial fluid collections at any point during the cycle, especially on the day of oocyte aspiration or embryo transfer (ET)? Prior publications show this subgroup of HSPX patients to have the worst prognosis (Sharara and McClamrock, 1997). In addition, of the 29 women who declined to participate in the study, what were their reasons? Also, were the HSPX measured? And what was the outcome of the three women who had fluid reaccumulation 2–3 days after oocyte aspiration? Prior publications point to the fact that some of the women who had endometrial fluid collections reaccumulated their HSPX within a matter of hours (Sharara and McClamrock, 1997; Hinckley and Milki, 2003). Those patients are unlikely to conceive with a fresh ET and are better served by cryopreserving their embryos for later transfer after surgical correction of the HSPX. What was the outcome of women who had bilateral HSPX in that study? Were there any pregnancies? Lastly, we were the first to report on HSPX aspiration at the time of oocyte aspiration (Sharara et al., 1996). We were exposed to some criticism at the time because of the potential fear of infection. None of our 11 patients developed any infections, and the studies that followed (Sowter et al., 1997; Van Voorhis et al., 1998), including Hammadeh’s, failed to show any negative sequelae. References