Objective: To compare postoperative reproductive outcomes between salpingectomy and neosalpingostomy for bilateral severe hydrosalpinges. Design: Single center, prospective cohort study. Setting: A hospital affiliated to a medical college in China. Population: Women aged 20 to 45 years old, diagnosed with bilateral hydrosalpinges and scheduled for surgery were initial eligibility criteria. Women with previous tubal surgery or tubal pregnancy, no fertility intention, or no confirmation of severe bilateral hydrosalpinges during surgery were excluded. Methods: Bilateral salpingectomy or neosalpingostomy was performed based on a shared decision approach. Main outcome measures: The primary outcome was the cumulative livebirth rate. Secondary outcomes included time to first live birth, biochemical pregnancy, clinical miscarriage, ectopic pregnancy, mode of conception, and gestational age at delivery. Results: A total of 113 women were involved in the analysis. When the result of In Vitro Fertilization (IVF) in the neosalpingostomy group was incorporated, salpingectomy resulted in a higher cumulative livebirth rate (85.3% vs 76.0%, hazard ratio of the whole survival curve = 2.18, 95% CI 1.37 - 3.45), a lower risk of ectopic pregnancy (1.8% vs 20.7%, risk ratio = 0.07, 95% CI 0.01 - 0.57), and a shorter time to live birth than neosalpingostomy. 16/58 (27.6%) women in the neosalpingostomy group had a live birth via natural conception, compared to 0/55 (0.0%) in the salpingectomy group. Conclusions：Salpingectomy for bilateral severe hydrosalpinges resulted in a higher cumulative livebirth rate and a lower risk of ectopic pregnancy. However, neosalpingostomy can offer certain option for women to conceive naturally without IVF treatment.