the deleterious impact of hydrosalpinx on fertility is best exemplified by studies showing a 50% reduction in ivf pregnancy rates in their presence ( 1 ) . chlamydia infection and pelvic inflammatory disease are associated with an increased risk of both tubal infertility and ectopic pregnancy , with the association proportionate to the number of infections(2 ) . various theories have been proposed to explain the observation of lower ivf pregnancy rates in the setting of hydrosalpinx , to include mechanical effects , embryo and gametotoxicity , decreased expression of key implantation molecules , and/or a direct effect on the endometrium leading to intrauterine fluid formation(3 ) . drainage of hydrosalpingeal fluid into the endometrial cavity may exert a mechanical effect by washing the transferred embryo from the cavity . cultured epithelial cells isolated from hydrosalpinx affected tubes produce a fluid which is hostile to both spermatozoa and early mouse embryo development(4 ) . multiple studies have demonstrated deficiency in endometrial markers of embryo receptivity in the presence of hydrosalpinx . il-2 , t lymphocytes , cd3 + , cd8 + , cd4 + , alpha v beta 3 integrin , lif , mmps and hoxa10 have all been shown to be decreased in the endometrium from women with versus without hydrosalpinx(5 - 8 ) though molecular inflammatory changes in the setting of hydrosalpinx are documented , a hysteroscopic endometrial phenotype in the presence of hydrosalpinx has not been well characterized . eighteen months prior to presentation , she was diagnosed with a chlamydial infection by cervical culture and treated with a single dose azithromycin . a negative chlamydia culture was confirmed four months prior to presentation . as part of her initial infertility evaluation at our center , a hysterosalpingogram ( hsg ) was performed in a window of doxycycline prophylaxis which demonstrated bilateral hydrosalpinges , with the right tubal diameter measuring greater than the left and bilateral tubal occlusion ( figure 1 ) . hysterosalpingogram demonstrating bilateral distal tubal occlusion with hydrosalpinges staged combined endoscopy was performed in the operating room . hysteroscopy revealed endometrial inflammation as evidenced by diffuse hyperemia and mucosal oedema ( figure 2a ) . laparoscopic findings were significant for a right sided hydrosalpinx measuring over 2 centimeters in diameter and dense adhesions of the bowel to the left hydrosalpinx and ovary . she underwent right salpingectomy and left tubal occlusion at the visible isthmic region via clip placement . she experienced an unremarkable postoperative course and was scheduled for in vitro fertilization ( ivf ) treatment . hysteroscopic appearance of endometrial cavity immediately pre - salpingectomy ( a ) and six months after interruption of communication with hydrosalpinges ( b ) . for each series , images from left to right depict right cornual , fundal and left cornual regions , respectively . six months later , the patient underwent hysteroscopic endometrial cavity evaluation in preparation for ivf . at hysteroscopy , the patient subsequently underwent ivf with transfer of a single blastocyst culminating in the delivery of a healthy infant at term . given the importance of tubal patency in non - ivf treatment and the detrimental impact of tubal pathology such as hydrosalpinx , oviductal evaluation represents an important part of the initial female infertility work up . given the trend among women to present for infertility care later in the reproductive lifespan , patients undergoing ivf may not have had prior tubal evaluation via either of the standard modalities . transvaginal ultrasound in the detection of hydrosalpinx has been reported , albeit with user - dependent sensitivity . the present case suggests that an inflamed endometrial appearance may be a hysteroscopic sign of a communicating hydrosalpinx requiring dedicated tubal study prior to initiating fertility treatment as depicted in figure 2 , the endometrial surface appears erythematous with friable and tortuous vascularity in the setting of a hydrosalpinx , and normal appearing after surgical interruption of hydrosalpingeal drainage . subsequent ivf treatment and transfer of a single blastocyst resulted in an intrauterine pregnancy , with subsequent term delivery , indicative of functional embryo receptivity on a molecular level , although no molecular evidence is available for confirmation . in view of these findings , we propose an inflamed appearance at hysteroscopy for endometrial cavity screening should prompt a dedicated study to rule out hydrosalpinx prior to proceeding with ivf treatment . to date , such a hysteroscopic endometrial phenotype in the presence of hydrosalpinx has not been described .
we report the hysteroscopic findings in a 22 year old nulligravid patient with bilateral communicating hydrosalpinges . 
 the inflamed hyperemic endometrial cavity encountered preoperatively normalized at second look hysteroscopy six months after bilateral tubal interruption . 
 the patient underwent successful ivf with culmination in a singleton , live birth . 
 we propose that an inflamed appearance at hysteroscopy , done for endometrial cavity screening , should prompt a dedicated study to rule out hydrosalpinx prior to proceeding with ivf treatment . to date , such a hysteroscopic endometrial phenotype in the presence of hydrosalpinx has not been well characterized .