Tubal Disease & Fertility

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TUBAL DISEASE & FERTILITY

Tubal disease is a common cause of infertility and constitutes 15-20% of all infertility cases. Fallopian tubes pick up the egg and have peristaltic movements allowing the transport of the embryo into the uterus after the egg is fertilized. If tubes are blocked, sperm and the egg cannot meet and infertility follows. The best treatment option for tubal disease is in vitro fertilization (IVF).

Most common causes of tubal disease include prior pelvic infections (chlamydia or gonorrhea), pelvic inflammatory disease (PID), pelvic adhesions (scar tissue), prior pelvic surgery and endometriosis. Other uncommon causes are pelvic tuberculosis, prior cesarean delivery and intestinal surgery.

A common method of diagnosing tubal disease is by hysterosalpingogram (HSG) commonly known as the dye test. This test can be done while on birth control pills anytime or right after the period ends and before ovulation. Dye is injected vaginally through the cervix and x-rays are taken to evaluate the inside of the uterus (endometrial cavity) as well as the fallopian tubes.

Tubes can be blocked at the level of their connection to the uterus (isthmus) which is called proximal block. This is typically due to endometriosis, pelvic adhesions or prior pelvic inflammatory disease. The treatment is hysteroscopic tubal cannulation, which has been shown to be 40-50% successful in women younger than 35. The success rates are lower in women over 35 or if other factors are present.

Mid-tubal blockage is uncommon and can be due to tubal ligation, prior severe pelvic infection, pelvic tuberculosis or endometriosis. If tubes are blocked, swollen and dilated, tubal repair is not recommended and diseased/blocked tube(s) should be removed (salpingectomy).

When tubes are blocked at the end (distal block), the pathology is called hydrosalpinx. This is typically due to a prior pelvic infection or pelvic adhesion. Pelvic adhesions can be treated with laparoscopy and tubes can be opened. If the problem is extrinsic such as pelvic adhesions, success rates are high. If the tubes are damaged from the inside (intrinsic) due to a prior pelvic infection, repair of such tubes does not yield high success rates. Tuboplasty can be done to open tubes, but in most cases tubes can get blocked again, requiring additional surgery to remove them. Additionally, if pregnancy is accomplished, the risk of having a tubal pregnancy (ectopic pregnancy) is very high.

The current recommended treatment for hydrosalpinx is removal of diseased tissue followed by IVF. Removal is recommended prior to IVF because blocked tubes can contain toxic fluid that can drain back into the uterine cavity at the time of implantation. Patients undergoing IVF with blocked tubes have significantly lower pregnancy rates and higher miscarriage risk (based on numerous medical studies).