Blocked Tubes

image description

BLOCKED TUBES

Damage to the fallopian tubes as a result of prior infection, endometriosis or previous pelvic surgery is one of the most common causes of infertility. Tubal blockage can occur in several locations. Often the ends of the tubes are obstructed, while the openings into the uterus are still patent/open. In many cases the tube is filled with fluid which is called a hydrosalpinx. Whereas surgery is not indicated to improve fertility outcome in the era of IVF for patients with significant tubal disease, the exception is the presence of hydrosalpinges.

Recent literature has shown that fluid in the tubes (hydrosalpinx) contains dead cells and other toxic products that are highly detrimental to embryo development and implantation. Hydrosalpingeal fluid can leak back into the uterus, cause a mechanical barrier to implantation and also decrease the binding proteins (i.e. integrins) that are essential to embryo attachment to the uterine wall. In a prospective randomized trial, pregnancy rates were significantly higher following IVF in patients who had removal of hydrosalpinges (compared to leaving them intact). Additionally, the expression of these binding proteins on the uterine wall significantly improved after removal of hydrosalpinges.

Treatment of hydrosalpinx includes re-opening of the tubes to allow natural conception (neosalpingostomy), proximal ligation of the tubes to prevent fluid leakage back into the uterine cavity or removal of the diseased tissue (salpingectomy).

Whereas neosalpingostomy may allow natural conception, the chances of a spontaneous pregnancy are very low and the risk of having an ectopic pregnancy (tubal pregnancy) is high. Therefore, this treatment method is no longer favored, except in a few cases in which the prognosis is high (such as very young patients with mild tubal disease, one sided blockage with no other identifiable pathology and those who cannot afford IVF treatment).

Proximal tubal ligation involves interruption of the communication between the uterine cavity and the fallopian tube. It is generally preferred over salpingectomy in patients with severe pelvic adhesions (scarring) that would require extensive tissue dissection during surgery. This tissue may increase the risk of pelvic organ injury. The main drawback to this type of procedure is the presence of diseased tissue in the pelvis after surgery which may cause pain or in some cases twist on its pedicle and result in adnexal torsion.

Currently, salpingectomy is the preferred method for treating hydrosalpinges as it allows removal of the diseased tissue that may significantly decrease pregnancy success rates, and additionally eliminates the risk of adnexal torsion or pelvic pain from remaining hydrosalpinx in the future.

Proximal ligation and salpingectomy can be done via laparoscopy, a minimally invasive surgery that allows patients to be discharged home the same day. It is often difficult for patients to accept that their tubes will be removed, as it means that conception is impossible without assistance. However the presence of hydrosalpinges means that the tubes are non-functional and even if these tubes could be rendered patent (open), the likelihood of pregnancy occurring would be remote. Treatment options for hydrosalpinx should be discussed with patients and the appropriate method selected for each individual case.