Tubal factor infertility

Prof Aboubakr Elnashar

Benha University Hospital, Egypt

ABOUBAKR ELNASHAR

CONTENTS
1. CAUSES
2. EVALUATION
3. TREATMENT

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 INCIDENCE
30% of infertile couples.

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CAUSES
1. Infection
PID
Appendicitis
2. Endometriosis
3. Previous tubal surgery
4. Pelvic adhesions
5. Congenital anomalies of the tubes

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 EVALUATION

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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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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6. Relatively cheap & simple.
7. HSG
▪ in agreement with the laparoscopic findings: 2/3
▪ Sensitivity: 73
▪ Specificity: 83%
High specificity makes it useful in ruling in tubal
obstruction
8. Tubal flushing using oil based contrast medium
increases CPR within 6 months after randomization&
may increase LBR (Wang et al, 2SR, 2019)
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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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❑ 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
▪extend toward the pelvic side walls and
subsequently migrate in a cephalad direction.
▪Early detection:
▪minimizes complications
▪injection should be discontinued immediately,
regardless of the contrast medium used.

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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
ABOUBAKR ELNASHAR Valle 1996
❑ Contraindications
▪ Absolute
▪ Possible pregnancy
▪ History of acute PID.
▪ Relative
▪ History suggestive of PID
▪ Recent uterine instrumentation,
▪ Iodine allergy.

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2. Sono hystero salpingography

▪ An US contrast dye or saline (10-40 ml) is injected into the
uterus through the cervix by a Foley catheter

▪ Passage of the dye is followed by TVS.

▪ 75% concordance rate with laparoscopy dye
▪ The addition of pulsed wave or color Doppler imaging
±improve the predictive value
▪ Experience
▪ effective alternative to HSG(NICE, 2013)

▪ The ideal test:

▪ HyCoSy which combines cavity check with tubal
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 3. Laparoscopy
Indication
1. Abnormal HSG or US
2.History or symptoms suggestive of pelvic disease.
▪ PID
▪ Ectopic
▪ Pelvic surgery.
▪ Chronic pelvic pain

Why?

▪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). ABOUBAKR ELNASHAR

❑Advantage
1. Direct visualization of the pelvic anatomy.
2. Determine:
▪ appearance of the fimbria
▪ presence of periadnexal adhesions

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. ABOUBAKR ELNASHAR
❑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 in
▪ symptom free patients with
▪ no suspicion of pelvic pathologies
(Nawroth et al,2001).

❑THL in association with minihysteroscopy:

▪ more information
▪ 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.

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TREATMENT
1. IVF
▪Main player for tt of tubal factor.
▪Indication
1. Moderate to severe tubal disease
▪ Distal tubal occlusion with hydrosalpiges >1.5 cm in diameter

▪ 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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❑ 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 disconection

for women undergoing IVF who have
1. Hydrosalpinges

adversely affect implantation rates during IVF,

because of antegrade flow of noxious fluid.

2. Tubal damage and history of ectopic pregnancy

{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
▪ does not impair the ovarian response during
subsequent IVF treatment (Pere et al SR, 2019)

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2. Laparoscopic Surgery:
▪Fimbrioplasty
Lysis of fimbrial adhesions or
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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3. Transcervical cannulation of 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
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▪5% to 13%

Selective salpingography plus tubal catheterisation, or

hysteroscopic tubal cannulation

▪Proximal tubal disease

▪If no pregnancy within 12 mo of surgery: IVF

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4. Microsurgical reanastomosis of the fallopian
tubes:
▪ for tubal ligation reversal.
▪ performed by
▪ Laparotomy
▪ Laparoscopy
comparable rates of success

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5. OS-IUI for unilateral tubal block (UTB) diagnosed

by HSG (Tan et al, SR, 2019)
▪ Similar PR, compared with those with bilateral
tubal patency &unexplained infertility
▪ Distal UTB have lower odds of pregnancy.
▪ These differences may reflect inherent diagnostic
limitations of HSG or differences in underlying
pathologies.

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