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J Obstet Gynecol India Vol. 58 No.3: MayIJune 2008

Blocked Fallopian Tubes - Treatment Options

Gautam Allahbadia

Medical Director, Deccan Fertility Clinic& Keyhole Surgery Center,Shivaji Park, Mumbai and RotundaThe Center for Human Reproduction Bandra (W),

,. Mumbai - 400 050. India.

91 98200 96000 Email: drallah @ gmailcom

The Journal of

OBSTETRICSAND

GYNECOLOGYof India

J Obstet Gynecollndia Vol. 58, No.3.' May/June 2008

Editorial

Blocked Fallopian Tubes - Treatment Options

Tubal factors are said to account for about 20 to 30

percent of all infertility cases around the world 1. Themain contributing factor: blocked fallopian tubes. Ablocked fallopian tube, although not necessarily lifethreatening, can be a very serious cause for concernbecause although conventional surgery may providerelief from the condition, damage to the tubes aregenerally considered irreversible and hence,subsequent pregnancy may prove almost impossible ­but not quite.

Blocked fallopian tubes following genital infection withChlamydia trachomatis is an escalating global publichealth concern causing considerable morbidity andsocioeconomic burden worldwide. The major clinicalmanifestations of genital chlamydial infection in womeninclude mucopurulent cervicitis, endometritis and pelvicinflammatory disease 2. Genital infection with C.trachomatis markedly enhances the risk for reproductivetract sequelae in women, including tubal factor infertility,chronic pain and ectopic pregnancy. Tubal infertilityfollowing chlamydial infection is one of the leadingcauses of infertility in the developed world.

A consequence of assisted reproduction technologyin infertility management has been a decline in tubalsurgery. Micro~urgery to correct localized damage hasthe advantage of long-standing restoration of fertility.A simple prognostic classification is lacking. Theseverity of the tubal damage and the health of themucosa is key in determining outcome. Visualization ofthe tube by hysterosalpingography (HSG) or bysonosalpingography (The Sion Test) has limitations 3.

Laparoscopy has the advantage of inspecting the tubeand its relation to other pelvic organs. Differentiatingbetween anatomical obstruction or spasm at the uterineend of the tube might be achieved by selectivesalpingography and tubal catheterization (SSTC) andshould precede IVF 4. Laparoscopic ~icrosurgery

should be provided, if the skills are available, wherecannulation has failed 5. Laparoscopic microsurgicaltubal reanastomosis after tubal sterilization can be

performed using a remote-controlled robotic system.Systematization of the operative steps allowed foroperative times that compare favorably with the timeneeded for open microsurgical technique 5.

Transvaginal hydrolaparoscopy and fertiloscopyappear to be an alternative to hysterosalpingographyas a first line procedure to investigate the tubal factor.Assessment of mucosal health by fertiloscopy is claimedto be less invasive. Fertiloscopy includeshydrolaparoscopy, tubal patency testing by dyehydrotubation, salpingoscopy and objectivedemonstration if the mucosa is healthy 6. Where themucosa is unhealthy, surgery is not justified; earlyreferral for IVF is indicated. The prognostic value ofsalpingoscopy during operative laparoscopy for tubalfactor infertility in terms of reproductive outcome hasbeen confirmed 7. The prognostic significance ofmicrosalpingoscopy needs further validation in large­scale clinical trials 7.

A decrease in expertise in tubal microsurgery hasresulted largely from the use of IVF as the treatmentoption for most causes of infertility and more specificallyfor tubal factor infertility. Selective salpingography andtubal cannulation have a unique role in the managementof tubal infertility and should be offered to selectedcandidates prior to IVF 8. Tubal cannulation can beused effectively to restore patency in a proportion ofcases of proximal tubal obstruction thus avoiding theneed for expensive assisted reproductive techniques 8.

Another option for women with blocked tubes andhoping for a successful pregnancy is to resort toEndoscopic Fallopian Tube Recanalisation; whichworks best with proximal tubal occlusion & a method ofTactile Cannulation using Laparoscopic guidance thathas been pioneered in India 9. (Figures I & 2).

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Allahbadia Gautam

Figure 1. The Glide wire seen in the proximal portion ofthe fallopian tube after tactile cannulation underlaparoscopic guidance.

Figure 1. The Glide wire seen in the proximal portion ofthe fallopian tube after tactile cannulation underlaparoscopic guidance.

There are many different surgery techniques forunblocking fallopian tubes and the differences generallyinvolve the length of the incision, the area affected, thetype of blockage present, and the method of unblockingapplied (e.g. complete removal or creation of anotheropening).lo Tubal reanastomosis involves the completeremoval of the blocked portion of the tube and asubsequent joining of the healthy ends. This procedureis usually done today either with Laparotomy orLaparoscopy.

Salpingectomy involves the surgical removal of theinfected or blocked fallopian tube. It is usually done on

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patients who have a hydrosalpinx and want to improvetheir chances of pregnancy through in vitro fertilization(IVF).11This procedure is preferred over salpingostomywhich is another surgical procedure available fordealing with hydrosalpinges (fluid-filled blockedfallopian tubes).12 Salpingostomy is a procedure thatrequires an incision through the affected fallopian tube.In neosalpingostomy, the idea is to create a new openingin the part of the tube closest to the ovary while inlinear salpingostomy the incision serves as the pathwayto release the blockage. Neosalpingostomy is generallyused in dealing with hydrosalpinges. This techniquehowever more often than not merely provides temporaryunblocking as it is a common occurrence for scar tissuegrowth to reseal the new opening created byneosalpingostomy thereby effectively blocking of thetube once more. When the problem is a partial blockageor a scarring in the fimbriae (fingerlike projections atthe end of the fallopian tube near the ovary),Fimbrioplasty is an option where the blockage or thescar adhesions are removed and the fringed ends arerebuilt such that wafting motion of the fimbriae arerestored. All these surgical interventions are beingreplaced gradually by Assisted ReproductiveTechnologies.

Conclusion

Treatment should be individualized, based upon thefindings of the tubal investigation, the couple's wishesand the costs involved. The age of the female is themost important factor that affects the outcome with bothtreatment options. The live birth rate per cycle with IVFis 28% at best, whereas surgical intervention on thetubes if done with microsurgical principles yields a birthrate that exceeds 45%, without increased risk of multiplepregnancy. It offers the couple multiple cycles in whichto achieve conception naturally, and the opportunityto have more than one pregnancy from a singleintervention. The real dilemma lies with the "hyper­marketing' of IVF, and its frequent use as primarytreatment for infertility. The dilemma is heightened bythe fact that reconstructive tubal microsurgery is beingtaught and practised less and less, thereby eliminatingthis credible surgical option in most centres.

References

1. Das S, Nardo LG, Seif MW. Proximal tubal disease: theplace for tubal cannulation. Reprod Biomed Online.2007; 15:383-8.

2. den Hartog 'lE, MO[fl~ SA, Land lA. Chlamydia

trachomatis-associated tubal factor subfertility:Immunogenetic aspects and serological screening. HumReprod Update. 2006;12:719-30.

3. Allahbadia GN, Nalawade YV, Patkar VD" Niyogi GM,Shah PK. The Sion Test. Aust NZ J Obstet Gynaecol1992;32:67-70.

4. Rawal N, Haddad N, Abbott GT. Selective

salpingography and fallopian tube recanalisation:experience from a district general hospital. J ObstetGynaecol. 2005;25:586-8.

5. Vlahos NF, Bankowski BJ, King JA, Shiller DA.Laparoscopic tubal reanastomosis using robotics:experience from a teaching institution. J LaparoendoscAdv Surg Tech A. 2007;17:180-5.

6. Watrelot A. Place of transvaginal fertiloscopy in themanagement of tubal factor disease. Reprod BiomedOnline. 2007;15:389-95.

7. Marana R, Catalano GF, Muzii L. Salpingoscopy. CurrOpin Obstet Gynecol. 2003;15:333-6.

8. Papaioannou S, Afnan M, SharifK. The role of selectivesalpingography and tubal catheterization in the

Editorial

management of the infertile couple. Curr Opin ObstetGynecol. 2004;16:325-9.

9. Allahbadia GN, Mangeshikar P, Pai Dhungat PB, DesaiSK, Gudi AA, Arya A. Hysteroscopic fallopian tuberecanalization using a flexible guide cannula andhydrophilic guide wire. Gynaecological Endoscopy2000;9:31-35

10. Rodgers AK, Goldberg JM, Hammel JP, Falcone T. Tubalanastomosis by robotic compared with outpatientminilaparotomy. Obstet Gynecol. 2007;109:1375-80.

11. Ozmen B, Diedrich K, Al-Hasani S. Hydrosalpinx andIVF: assessment of treatments implemented prior toIVE Reprod Biomed Online. 2007;14:235-41.

12. Strandell A. Treatment of hydrosalpinx in the patientundergoing assisted reproduction. CUIT Opin ObstetGynecol. 2007;19:360-5.

*Gautam AUahbadia

*Medical Director, Deccan Fertility Clinic & Keyhole Surgery Center,

Shivaji Park, Mumbaiand

Rotunda - The Center For Human Reproduction

Bandra (W) 400 050, India

91 9820096000 Email: drallah@~mail.com