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Tubal Factor Infertility

INTRODUCTION

Damaged fallopian tubes are the cause of infertility in up to 25 percent of infertile women. The incidence of tubal damage is increasing, partially due to the frequency of sexually transmitted diseases in our society. The good news is that many women with tubal damage can achieve pregnancy through the use of modern techniques.

Advances in reproductive medicine such as surgical treatment and invitro fertilization (IVF) now make pregnancy an achievable goal for many women with tuba! damage.

Normal Tubal Function

The fallopian tubes are two hollow structures connected to each side of the uterus and extending to the surface of each ovary (Figure 1). The end of each fallopian tube adjacent to the ovary is flared open and consists of many fine, delicate “fingers” of tissue known as fimbriae. When the ovary releases an egg (oocyte), the fimbriae pick up the egg and direct it into the tube. The fallopian tube lining provides the egg with nutrition and creates a hospitable environment for the sperm on its voyage to fertilize the egg. The lining of the fallopian tube is also important for fertilization, which usually occurs in the distal portion of the tube (the portion farthest from the uterus).

The Tube is vital for the survival of the fertilized egg. which moves through the fallopian tube for up to five days before it passes into the uterus and implants on the wall of the uterine cavity.
Damage to the fimbriae may reduce or eliminate their ability to pick up the egg and direct it into the tube. Damage to the cells lining the tube may prevent or greatly reduce the chance of fertilization. Blockage in the tube can prevent the fertilized egg from moving to the uterus, increasing the incidence of ectopic pregnancy. Thus. The fallopian tubes play an important role in the process of fertilization and pregnancy.

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Causes of Tubal Damage

Tubal damage can result from tubal ligation (tubal sterilization) for contraceptive purposes, tubal infection, or scarring.

There are two types of tubal blockage” proximal tubal blockage is located close to uterus and distal tubal blockage is located away from the uterus (Figure 2). Proximal tubal blockage can be caused by previous pelvic infection, a thickening and inflammation of the tubal wall called salpingitis isthmica nodosa (SIN) , mucus plugs, or endometriosis. Distal tubal blockage is generally caused by pelvic inflammation, which may be secondary to infection or endometriosis. Endometriosis occurs when tissue that normally lines the uterus grows outside the uterine cavity. This misplaced tissue can cause pelvic irritation, pain. and scarring. Scar tissue may also be present in women who have undergone previous abdominal or pelvic surgery.
Endometriosis can cause tubal obstruction if there is scar tissue on or near the tubes. Scar tissue as a result of moderate or severe endometriosis can result in a decreased chance of pregnancy compared to women with milder forms of the disease. Unfortunately, some women do not experience any symptoms of endometriosis. such as heavy menstrual cycles and painful menstrual cramps, so the disease can go undetected. A laparoscopy is often the only valid way to diagnose endometriosis.

Pelvic infection is commonly caused by sexually transmitted diseases such as gonorrhea or chalmydia but may also be the result of appendicitis or a bowel infection. Douching can increase the incidence of pelvic infection. Many women are unaware that they have experienced a pelvic infection serious enough to damage the tubes and only discover the damage when they attempt pregnancy and fail to conceive.

Gonorrhea was once the most common sexually transmitted disease, but now chlamydia is primarily responsible for pelvic infection. Although multiple episodes of chlamydia are more likely to cause infertility, even a single infection can produce severe damage. If identified early, both gonorrhea and chlamydia are easily treated with antibiotics. For this reason, physicians may try to identify the presence of these organisms early in the infertility workup.

Scar tissue or adhesions around the tube and ovary can occur in women who have never had a pelvic infection. Previous tubal surgery or surgery performed in other areas of the abdominal cavity can result in tubal problems and pelvic scarring especially if the surgery was extensive or involved a severe infection such as a ruptured appendix. Any distortion or constriction of the tube can prevent an egg and sperm from meeting or increase the likelihood of a tubal pregnany . Tubal damage and scarring are rarely the result of a ruptured ovarian cyst.

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Figure 2. Distal tubal blockade (left): Proximal tubal blockage (right).

Diagnosis of Tubal Damage

Because tubal factor, infertility is a common problem, tests to determine if the tubes are open and undamaged are an important part of the infertility workup. Most physicians rely on two tests :a hysterosalpingogram(HSG) and a diagnostic laparoscopy.

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Fig:Hysterosalpingogram (HSG)

A hysterosalpingogram is an x-ray study in which a liquid, dye-like solution is injected through the cervix so that the inside shape of the uterus and fallopian tubes can he viewed (Figure 3). This procedure is performed before ovulation to avoid x-ray exposure to a fertilized egg. An HSG is performed while the patient is awake and causes moderate cramping. Taking a small dose of pain reliever (such as ibuprofen) prior to the procedure reduces discomfort. Some physicians may treat women with oral antibiotics (such as doxycycline) near the time of the procedure to help minimize the risk of pelvic infection. From an HSG study, the physician can tell whether the tubes are open or damaged, and whether the uterine cavity is normal. Some physicians believe that an HSG increases fertility potential in the first cycles following the test. possibly due to the solution’s flushing effect. An HSG is generally considered an important early step in the infertility workup.

Diagnostic laparoscopy. usually performed on an outpatient basis, can determine the outer condition of the tubes (Figure 4). This procedure complements the information obtained by an HSG. While the patient is under general anesthesia, the physician inserts a laparoscope. a long. thin. lighted telescope-like instrument. through an incision in the navel into the abdominal cavity. Other small incisions in the abdomen may he made to insert various instruments to aid visualization of the fallopian tubes, uterus, ovaries, and other pelvic contents. A liquid solution may be flushed into the uterus up through the tubes to determine if they are open. Often during laparoscopy. minor tubal blockage or scar tissue surrounding the tubes or ovaries can be cut and removed, thereby improving fertility. Physicians may perform laparoscopy as a final diagnostic step in the infertility workup.

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Fig 4: Laparoscopic view of the internal female reproductive organs.

Fig 4: Laparoscopic view of the internal female reproductive organs.
TREATMENT OF TUBAL FACTOR INFERTILITY

Infertility caused by blocked or damaged tubes can usually be treated with surgery or assisted reproductive technologies such as in vitro fertilization (1VF).

Surgical Repair of the Tubes

Proximal tubal blockage may be opened during an HSG by placing a very narrow, flexible tube through the vagina into the uterine cornu. Sometimes pressure is used to force a mucus plug out of the tube. or a small wire can he used to relieve the blockage. This type of procedure is called a transcervical cannulation,. also known as selective salpingography or retrograde hysterosalpingography. Proximal tubal damage can also be treated in the same way using hysteroscopy. During this procedure, a hysteroscope, a thin lighted, telescope-like instrument, is placed through the cervix into the uterine cavity to visualise the tubal opening into the uterus. Tiny flexible tubes or other devices can then be inserted through the hysteroscope to remove the blockage.

Distal tubal blockage may be cleared by operative laparoscopy or by laparotomy, a major surgery requiring an abdominal incision. Following operative laparoscopy the woman leaves the hospital the same day and is often able to return to work within the next few days. If a laparotomy is performed, the woman usually remains in the hospital for three to five days and is instructed to limit activity for two to six weeks.

During laparoscopy or laparotomy. the surgeon can often open some types of distal blockage or remove adhesions with the help of microsurgical techniques. Microsurgery refers to very delicate surgery performed with the aid of magnification and is generally used to repair small organs such as fallopian tubes or blood vessels. Because pregnancy rates for repeat surgical repairs are quite low. it is important that the first surgery is performed meticulously by a well-trained and experienced surgeon. A second attempt at tubal surgery is rarely indicated.

Surgical success depends primarily on the extent of the tubal damage. Success may be limited because scar tissue frequently returns despite the surgeon’s best efforts. If the damage is slight and the surgeon only needs to remove scar tissue around the tubes, pregnancy rates can run as high as 50 to 60 percent. If the fimbrae have been significantly damaged, pregnancy rates are much lower. Opening a blocked tube which is closed at the distal end (hydrosalpinx) produces a pregnancy rate between 15 to 30 percent for moderate to severe disease. Opening a tube which is blocked at the proximal end generally produces lower rates. Because of the poor success achieved with surgical treatment of moderate to severe tubal disease. 1VF may be the primary choice for therapy in many patients.

Women who have damaged tubes, whether they have been repaired or not. are at risk of having a tubal pregnancy. A tubal pregnancy can rupture the fallopian tube and cause profuse bleeding into the pelvic cavity, resulting in a life-threatening situation if left untreated. Therefore, it is very important that a woman who has undergone tubal surgery see her physician as soon as she suspects that she is pregnant, so that the location of the pregnancy can be determined.

Considering Operative Laparoscopy Versus Laparotomy for Tubal Surgery

Many gynecologic, reproductive, or tubal operations have been performed using “major” surgery (laparotomy). Laparotomies are generally performed through a “bikini” or “up and down” skin incision. Patients generally remain in the hospital between two and five days following surgery and may return to work in two to six weeks, depending on the level of physical activity required. More recently many of these operations can be performed using the laparoscope (operative laparoscopy). Although the same types of procedures are performed by laparotomy. Operative laparoscopy uses much smaller skin incisions, generally three to four. Approximately one quarter to one-half inch wide. Following operative laparoscopy patients are generally able to go home the day of surgery and recover more quickly returning to full activities in three to seven days.

Notwithstanding the advantages of operative laparoscopy. not all procedures can be performed with this technique. Some types of operations may be too risky to perform laparoscopically. while in others it is not clear that laparoscopy yields results as good as those by laparotomy. Finally, the surgeon’s training, skill, and experience also play a significant role in deciding whether operative laparoscopy or laparotomy should be used. When considering a pelvic or reproductive operation the patient and doctor should discuss the pros and cons of performing a laparotomy versus an operative laparoscopy. including surgical results, the physician’s training and skill, and the overall risks.

In Vitro Fertilization for Tubal Damage

Another way to treat tubal factor infertility is to bypass the tubes altogether with a technique called in vitro fertilization (IVF). This technique is often preferable to surgery when the tubal damage is more advanced or when a previous surgical approach has been unsuccessful. The woman is given ovulation-inducing drugs to produce multiple eggs. which are collected by a fine needle placed through the top of the vagina using ultrasound guidance. This collection procedure is known as egg aspiration or oocyte retrieval. After retrieval, the mature eggs are mixed with the sperm in a petridish. Depending on the age of the partners and the quality of the eggs and sperm, fertilization occurs about 60 to 90 percent of the time in the laboratory. The resulting embryos are carefully incubated in the lab for one to three days and then placed into the woman’s uterus via a procedure known as embryo transfer.

Because women with tubal disease are frequently young and have undamaged ovaries. IVF is usually a valid option. After embryo transfer, a healthy baby will result approximately 30 percent of the time. Many factors can affect the success of IVF. Consideration of IVF as a solution to fertility problems requires extensive discussion between a woman, her partner, and her physician.

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Figure 5: One type of tubal ligation results in extensive tubal destruction (left) Another type uses rings (right) and causes less damage.

Reversal of Tubal Ligation

Surgical reversal of a previous tubal ligation (also known as “untying the tubes”) is one of the most effective tubal reconstructive surgeries available, especially if the tubal ligation was performed with clips or rings (Figure 5). In these cases, the tubes remain open after surgery 70 to 80 percent of the time. but pregnancy rates are slightly lower, in the range of 55 to 65 percent. As with any type of tubal surgery, the reversal of a tubal ligation increases the woman’s risk of a tubal pregnancy. The surgery is less successful if the tubes were cut (burned) using an electrocautery instrument or if other pelvic disease such as scarring or endometriosis is present. Reversal of tubal ligation is performed by laparotomy (major surgery) using magnification and microsurgical techniques and should only be performed by surgeons with expertise in this procedure. The actual tubal ligation reversal is a lengthy and exacting procedure, requiring a microscope and very fine suture material. Afterwards, the woman can expect to stay in the hospital for a few days. It may be up to six weeks before she can return to work.

If a woman is considering this surgery, her physician may review the operative and pathology notes from the initial tubal ligation. Further information may also be gained from an HSG. Finally, if any doubt exists that the procedure can be successfully performed, the physician may perform a diagnostic laparoscopy before reversing the tubal ligation.

CONCLUSION

Infertility due to damaged fallopian tubes is common. Fortunately, when the tubal damage is mild to moderate, modern surgical techniques can often help to achieve pregnancy. Some tubal surgeries are now being performed as outpatient procedures through the laparoscope. thus minimizing recovery time and expense. For women with severe or surgically uncorrectable tubal disease, in vitro fertilization offers a chance of achieving pregnancy. For women who have had tubal ligations microscopic tubal reversal frequently results in acceptable pregnancy rates. Although women with infertility due to tubal factors once had a poor prognosis, today they have a good chance of experiencing the joys of parenthood.