Tubal Disease and InfertilityDr Chinmayie R
Tubal disease is among the most common causes of infertility and is the primary diagnosis in approximately 25% of female infertility cases. The fallopian tubes are very delicate structures that are responsible for picking up the egg and providing the site for fertilization of the egg as well as early embryo development and transport to the uterine cavity. The cells lining the tube produce secretions that nourish the egg and embryo.
In a normal pregnancy, an ovary releases an egg into the fallopian tube where it meets with a sperm that fertilizes the egg. The fertilized egg then travels to the uterus and attaches to the uterine lining for nine months.
In the event that the fallopian tube is damaged, misshapen or blocked in some way, a sperm and an egg cannot meet, resulting in infertility. A blockage can also be small enough to allow the sperm in, but not to allow the embryo to get to the uterus.
A tubal blockage is usually identified by its location:
A tubal blockage located close to the uterus is called a “proximal” tubal blockage. According to ASRM, proximal tubal blockage accounts for 10 to 25 percent of tubal disease and is generally a relatively easy condition to treat.
Mid-segment tubal blockage occurs when the middle of the fallopian tube is damaged or scarred, typically as a result of permanent sterilization (tubal ligation) or the reversal of that sterilization (tubal ligation reversal).
A blockage that is located further from the uterus is called a distal tubal blockage. In addition, the fallopian tube can be completely blocked. The tubes can also be partially blocked or narrowed due to scarring, which can also cause problems getting pregnant.
Fimbria are the finger-like fringes of tissue that help to sweep an unfertilized egg into the fallopian tube. Damage to the fimbriae can prevent the egg from travelling from the ovary into the fallopian tubes.
The most common cause of tubal factor infertility is infection. Additional causes of blocking and scarring include:
> Endometriosis, a disease in which the tissue that normally lines the uterus grows outside the uterus.
> Pelvic inflammatory disease (PID), an infection of the female reproductive organs.
> Sexually transmitted disease (STD), most commonly chlamydia and gonorrhea.
> Ectopic pregnancy.
> Previous surgery.
Patients have a high risk of tubal factor infertility if they’ve had a ruptured appendix or previous abdominal surgeries, including surgeries for ectopic pregnancies, a condition in which the embryo grows outside of the uterus. Due to the location of these conditions, tubal issues are more likely to occur.
Symptoms and diagnosis of tubal factor infertility
The main symptom of tubal factor infertility is the inability to become pregnant. Many women do not realize that they have fallopian tube damage until they have consulted a doctor for infertility.
In addition, when infertility is accompanied by signs of a pelvic inflammatory disease, such as chronic lower abdominal pain, tubal infertility may be present. The two tests used to diagnose tubal factor infertility are a hysterosalpingogram and a laparoscopy.
Hysterosalpingogram (HSG) is an X-ray in which a dye is passed through the cervix into the uterus. The dye can be followed through the fallopian tubes to see if they are open. It is important to note that if the tubes are open, it does not mean that they are functioning normally. There may be extreme scarring or blockage inside the lining of the tube that cannot be detected with this test.
Laparoscopy is a minimally invasive surgical procedure involving a small incision just below the belly button with insertion of a small surgical instrument, called a laparoscope, to view the fallopian tubes. Chromopertubation, the injection of a dilute blue dye through an intrauterine cannula permits the clear evaluation of tubal patency. The major advantage to laparoscopy is the ability to treat some of the mild diseases, such as early endometriosis and/or peritubal adhesions, at the time of the diagnosis.
Saline Sonohystogram (SIS): SIS is similar to an HSG, but uses ultrasound and sterile saline. It is simple to perform in the office and is associated with only mild cramping. Mixing a small amount of air with the saline improves the visualization of the fallopian tubes. SIS is more sensitive than HSG for detection of intrauterine pathology, such as polyps or submucous fibroids.
Treatment of tubal factor infertility
The two main treatments for tubal factor infertility are surgical and nonsurgical procedures to repair the damaged tube(s). If these attempts fail, IVF can be done to achieve pregnancy.
There are several ways to repair a tube, including:
Tubal cannulation involves inserting a catheter guided by a wire and attached to a balloon into the fallopian tubes in order to unblock them. This option is an outpatient procedure. Tubal cannulation should only be done if an imaging test shows a proximal blockage in one or both fallopian tubes.
Fimbrioplasty is a laparoscopic procedure that rebuilds the fimbriae, or finger-like ends of the fallopian tube, by sewing the fimbriae back together. This option is only a good choice for patients with minimal distal tubal blockage.
Salpingectomy refers to the surgical removal of the damaged or diseased fallopian tube.
Salpingostomy refers to the the surgical creation of an opening into the fallopian tube, often to remove an ectopic pregnancy. However, the tube itself is not removed in the procedure.
Tubal ligation reversal: The most common reasons for requesting tubal reversal include new partners, changes in family planning desires, or loss of a child. For women who want to conceive again, microsurgical tubal reanastomosis remains a legitimate option under certain circumstances. The prognosis for a successful pregnancy after microsurgical tubal reversal relates to her age, type and location of the tubal ligation and the final length of the repaired fallopian tube. It is crucial to evaluate for any male factor infertility in the partner. Younger women (< 35 y/o) who have had tubal ligation performed with rings and clips and have no other fertility factors, including male factor, have the best prognosis. Laparoscopic tubal reanastomosis is also an option in order to avoid laparotomy , but there are only a few highly skilled reproductive surgeons experienced in this technique.
Hydrosalpinx removal before IVF: Numerous studies strongly suggest that hydrosalpinges can adversely impact IVF pregnancy outcomes by as much as 30-50%. Comprehensive meta-analyses have concluded that IVF success rates in women with hydrosalpinges are significantly reduced, compared to IVF outcomes in women after salpingectomy or women without hydrosalpinges. Therefore, salpingectomy or tubal ligation should be considered for all women with hydrosalpinges before undergoing IVF. Several theories have been proposed to explain the adverse effects of the hydrosalpinges on IVF pregnancy outcomes, including mechanical interference of the tubal fluid with implantation as well as possible toxic effects on the embryos or endometrium.
Steady advances in assisted reproductive technologies (ART) have improved IVF outcomes to where they now approach or exceed those achieved with tubal reconstructive surgery. Tubal surgery remains a legitimate treatment option for young women (< 35 y/o) seeking pregnancy after a previous tubal sterilization, or for those with mild distal tubal disease and for women with apparent proximal tubal occlusion. Under virtually all other circumstances IVF is the best choice.
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