tubal factor infertility
DESCRIPTION
Tubal factor infertilityTRANSCRIPT
Benha University Hospital, Egypt
Aboubakr Elnashar
30% of infertile couples.
Aboubakr Elnashar
1. Infection
PID
Appendicitis,
2. Endometriosis
3. Previous tubal surgery
4. Pelvic adhesions
5. Congenital anomalies of the tubes
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PID
one, two, or three episodes:
12%, 23%, and 54%, respectively tubal disease
Chlamydial infections:
major cause of tubal factor infertility
Ruptured appendix:
5X tubal disease
No identifiable risk factors
50% of patients with documented tubal factor
infertility
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Aboubakr Elnashar
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European Society of Human Reproduction &
Embryology (ESHRE) (2000)
Infertility testing should be classified into 3
groups depending on correlation with pregnancy
rates
I. Tests that have an established association with
pregnancy:
1. Conventional semen analysis
2. Tubal patency tests,
3. Tests of ovulation
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II. Tests that are not consistently associated with
pregnancy:
Post-coital test,
Antisperm antibody tests
Zona-free hamster egg penetration test
III. Tests that have no association with pregnancy:
Endometrial biopsy
Varicocele assessment
Chlamydia testing
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1. Hysterosalpingography The most commonly performed screening test for
tubal patency.
Advantages:
1.Position of tubal occlusion
2. unilateral patency can be dd from bilateral
patency.
3. Degree of damage to tubal endothelium
4. Peritubal adhesion.
5. uterine cavity
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4. Relatively cheap & simple.
5. HSG is in agreement with the laparoscopic
findings approximately two thirds of the time.
Sensitivity: 73
Specificity: 83%
High specificity makes it useful in ruling in
tubal obstruction
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HSG findings:
1. Mucosal rugae
Present:
favorable prognostic factor for subsequent
pregnancy: 60% PR
Absence:
severely damaged tubal epithelium: 7.3% PR
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2. Periadnexal adhesions
An irregular distribution of loculated contrast
medium around the fimbriated end of the tube
Not reliable in evaluation of peritubal
adhesions
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Aboubakr Elnashar
Disadvantages
1. The pelvis including the ovaries is exposed
to radiation: significant problem if the patient
had an early pregnancy.
2. Abdominal pain which peaks 5 min after
starting & usually settles within 30 min.
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3. Intravasation
Network of streaklike opacities adjacent to
the uterine cavity that extend toward the
pelvic side walls and subsequently migrate in
a cephalad direction.
Early detection of intravasation: minimizes
complications.
Whenever there is evidence of
intravasation, injection should be
discontinued immediately, regardless of the
contrast medium used.
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4. False occlusion: 12.5%
false patency: 11%
{high incidence of false cornual obstruction}
two separate tubal studies should be performed
before the diagnosis of proximal tubal obstruction
is confirmed. (Holz et ao, 1997)
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Proximal Tubal Obstruction
Fibrosis obliteration & SIN 40%
Endometriosis & Cornual polyp 10%
Cornual spasm 20%
Amorphous material 50%
Viscous secretions 30%
Mucosal agglutination
Stromal edema
Tubal catheterization can be used both as
diagnostic & therapeutic method
Valle 1996 Aboubakr Elnashar
The optimal contrast medium
Oil-soluble Water-soluble
Uterine image Sharp Less sharp
Ampullary rugae Difficult to define Easier to define
Viscosity Viscous Less viscous
Absorption Months hours
Pain Minimal Significant
Granuloma formation Rare Very rare
Embolism Rare anaphylaxis No major sequalae
Pregnancy after HSG Doubled No effect
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Mechanisms by which HSG may enhance fertility
1. Mechanical lavage of a partially obstructed tube,
2. Stimulation of the tubal cilia
3. Inhibition of hostile peritoneal fluid immune cells
Although oily media are now rarely used, there may
be a place for it in the treatment of unexplained
infertility (Steiner et al,2003)
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Contraindications
Absolute
Possible pregnancy
History of acute PID.
Relative
History suggestive of PID
Recent uterine instrumentation,
Iodine allergy.
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The risk for PID after HSG
1% to 3%
Routine antibiotic prophylaxis
Patients at risk for acute PID
Doxycycline: 100 mg twice a day for 3 days for all
patients.
Prophylactic antibiotics before uterine instrumentation if screening for CT
has not been carried out. (NICE, 2013)
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2. Sonohysterosalpingography
An ultrasound contrast dye or saline (10-40 ml) is
injected into the uterus through the cervix by a Foley
catheter & the passage of the dye is followed by TVS.
76% concordance rate with laparoscopy dye
The addition of pulsed wave or color Doppler
imaging may improve the predictive value of
transvaginal sonosalpingography
experience
effective alternative to HSG (NICE, 2013)
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HS-contrast-US
Free fluid collection in the cul-de-sac following
successful demonstration of oviductal patency.
Oviductal fimbria are clearly observed in the collected
fluid. Aboubakr Elnashar
Hydrosalpinx
well-constrained fluid
accumulation in the adnexae.
In some cases, adhesions
between the oviduct and ovary
may be visualized.
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3. Laparoscopy
Indication
1. Abnormal HSG or
2.History or symptoms suggestive of pelvic disease.
Normal HSG or no history suggestive of tubal
disease:
probability of clinically relevant tubal disease or
endometriosis is very low: laparoscopy is not justified
or cost effective
(Fatum et al, 2002).
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Laparoscopy may reveal
minimal or mild endometriosis or
peritubal adhesions.
Surgery or medical treatment has not been proven to
improve fecunditity.
With the current success rates of ART& the relatively
low contribution of diagnostic laparoscopy to the
decision making of treating patients with normal HSG,
laparoscopy should be omitted in couples with
unexplained infertility.
These patients should be treated as UI (by 3 cycles
of combined gonadotropins & IUI & if unsuccessful
ART) Aboubakr Elnashar
Advantage
1. Direct visualization of the pelvic anatomy.
2. Determine:
appearance of the fimbria
presence of periadnexal adhesions
endometriosis.
3. Correct timing will enable evidence of
ovulation to be obtained.
4. No exposure to radiation
5. Can be combined with salpingoscopy &/or
hysteroscopy.
6. Adhesiolysis or tubal constructive surgery
can be performed.
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Laparoscopic findings:
1. Postinfection tubal disease .
The most common
Pelvic adhesions, phimotic fimbria, hydrosalpinges,
or tubal obstruction.
2. Endometriosis
2nd most common
An extremely variable (5% to 60%)
Laparoscopic visualization, biopsy, or both are
required for the diagnosis of endometriosis because
there are no specific screening tests.
3. Isolated proximal occlusion
10% to 20% of tubal factor infertility.
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ASRM classifications of
adnexal adhesions,
distal tubal occlusion, and
endometriosis is based on laparoscopic findings and
provides a rational foundation for therapy
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Disadvantages
1. An invasive test requiring a GA with its
associated risk
2. Small risk of visceral damage on insertion
3. Not always possible to determine the actual
site of occlusion.
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Hysteroscopy Not an initial investigation unless clinically indicated
{effectiveness of surgical treatment of uterine
abnormalities on improving pregnancy rates has not
been established}. (NICE, 2013)
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4. Transvaginal hydrolaparoscopy (THL)
±Method of choice for the clarification of
mechanical infertility factors in symptom free patients
with no suspicion of pelvic pathologies
(Nawroth et al,2001).
THL in association with minihysteroscopy provide
more information & is better tolerated than HSG in
outpatient infertility investigation
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5. Chlamydia antibody testing (CAT)
HSG is more accurate than CAT in predicting tubal
disease (Elnashar et al,2000).
If both tests were negative the tubal disease was
identified on laparoscopy in only 4 % of case.
Aboubakr Elnashar
Aboubakr Elnashar
Management strategy
The role of surgery (open laparotomy or extensive
laparoscopic surgery) for the treatment of tubal factor
is shrinking
(Aboulghar, 2003).
Laparoscopic surgery has a role in peritubal
adhesions
Open laparotomy is only indicated in reversal of
sterilization
(ESHRE,2001).
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IVF
Main player for treatment of tubal factor.
Indication
1. Moderate to severe tubal disease
A. Distal tubal occlusion with hydrosalpiges >1.5 cm
in diameter.
B. Distortion of the intraluminal architecture or
endotubal adhesions detected by HSG, salpingoscopy or falloscopy
2. Other factors
A. Sperm dysfunction
B. Age >36 yr
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•Post-ligation:
open microsurgery
•Distal Tubal disease:
Mild: Laparoscopic surgery
Moderate to severe: IVF
•Proximal tubal disease:
Tubal catheterization
•Distal & proximal tubal disease:
IVF
•If pregnancy has not occurred within 12 mo of
surgery: IVF Aboubakr Elnashar
British Fertility Society Classification of
Tubal disease
Minor
Proximal
occlusion without
tubal fibrosis
Distal occlusion
without tubal
distension
Healthy mucosal
appearance at HSG,
salpingoscopy
flimsy
peritubal/ovarian
adhesions.
Intermediat
e
Unilateral severe tubal
damage
Limited
dense
adhesions of
tubes &
ovaries
Severe
Bilateral severe
tubal damage
Extensive tubal
fibrosis
Tubal distension >1.5
cm
Abnormal mucosal
appearance
Bipolar occlusion
Extensive dense
adhesion Aboubakr Elnashar
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Peritubal adhesions
with healthy
endosalpinx
•Laparoscopic
surgery
•IVF
Chronic salpingitis
• IVF
• Salpingectomy
before IVF in
hydrosalpinx
Post ligation
Open
microsurgery
Management of tubal factor
Aboubakr Elnashar
1. Laparoscopic Surgery:
Fimbrioplasty
Lysis of fimbrial adhesions or the dilation of fimbrial
strictures.
Neosalpingostomy
Creation of a new opening in a fallopian tube with a
distal occlusion.
Adhesiolysis
more likely to work in the presence of patent tubes &
filmy adhesions
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2. Transcervical cannulation of the proximal
fallopian tube
Methods
hysteroscopy
fluoroscopy, or
sonography
Results
successful catheterization
80% to 90%
cumulative pregnancy
23% and 39% within the first 6 to 12 months.
Ectopic pregnancy
5% to 13%
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Selective salpingography plus tubal
catheterisation, or hysteroscopic tubal
cannulation
Proximal tubal disease
If pregnancy has not occurred within 12 mo
of surgery: IVF
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3. Microsurgical reanastomosis of the fallopian
tubes:
Patients who want to become pregnant after
having undergone tubal sterilization may be
candidates for tubal ligation reversal.
Although tubal ligation reversal has traditionally
been performed by laparotomy, recent studies
suggest that laparoscopic surgical reanastomosis
may be associated with comparable rates of success
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4. In Vitro Fertilization
Indications
1. Tubal factor infertility,
2. male factor infertility,
3. endometriosis
4. unexplained infertility.
5. IVF is recommended for all conditions that have
not been successfully treated with other
treatment strategies.
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IVF or ICSI:
IVF should be the initial treatment of choice (Aboulghar et al,1996; Bukulmez et al,2000).
{No significant difference in PR. or take-home
baby}.
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Bilateral salpingectomy or tubal sterilization
for women undergoing IVF who have
1. Hydrosalpinges, which adversely affect
implantation rates during IVF, because of antegrade
flow of noxious fluid.
2. Tubal damage and history of ectopic pregnancy
because of the increased risk of a further ectopic
pregnancy.
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Hydrosalpinges
salpingectomy, preferably by laparoscopy, before
IVF treatment
{improves the chance of a live birth}.
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