Chapter 12 – Tubal Factor Infertility and Tubal Surgery




Abstract




Tubal factor infertility is a common cause for infertility worldwide. Prior to the introduction of in vitro fertilisation (IVF), tubal surgery was the mainstay of fertility treatment in women with tubal disorders. However, in the era of assisted reproductive technology the use of tubal surgery has gradually declined. This chapter investigates tubal factor infertility and the current role of tubal surgery in the age of assisted reproductive technology. In conclusion, tubal surgery remains an important option that can supplement and in some cases substitute IVF treatment.





Chapter 12 Tubal Factor Infertility and Tubal Surgery


Mostafa Metwally and Tulay Karasu



1 Introduction


Tubal factor infertility is a common cause for infertility worldwide. Prior to the introduction of in vitro fertilisation (IVF), tubal surgery was the mainstay of fertility treatment in women with tubal disorders. However, in the era of assisted reproductive technology the use of tubal surgery has gradually declined. This chapter investigates tubal factor infertility and the current role of tubal surgery in the age of assisted reproductive technology. In conclusion, tubal surgery remains an important option that can supplement and in some cases substitute IVF treatment.


Diseased fallopian tubes are an important cause for infertility worldwide and are responsible for 30% to 35% of female infertility [1]. Tubal disease can involve the proximal, midtubal, distal or entire fallopian tube and vary in severity. Pelvic inflammatory disease is the most common cause of tubal disease, representing more than 50% of cases, and may affect the fallopian tube at multiple sites [2]. Other causes for tubal damage are ectopic pregnancy and sterilisation.


Prior to the introduction of IVF, tubal surgery was the mainstay of fertility treatment in women with tubal disorders. The introduction of IVF in 1978 witnessed a gradual decline in the use of tubal surgery leading many to believe that tubal surgery is now an obsolete art, a common misconception held by many. Indeed an editorial in Fertility and Sterility some years ago was titled ‘Infertility surgery is dead, only the obituary remains’ [3]. However, in this chapter it is argued that tubal surgery remains an integral part of fertility treatment. In many cases tubal surgery is an essential adjuvant treatment to IVF aimed at increasing the success rates of assisted reproductive procedures. In many other cases tubal surgery, in well-trained hands can, in fact, be a substitute for IVF treatment, yielding similar results. This chapter investigates tubal factor infertility and the current role of tubal surgery in the age of assisted reproductive technologies.



2 Proximal Tubal Blockage


Proximal tubal blockage demonstrated at hysterosalpingogram by failure of the dye to enter the fallopian tubes is not an uncommon finding and is diagnosed in about 10–25% of cases of tubal infertility [4]. Bilateral proximal tubal occlusion is found in about 3% of cases of proximal tubal disease and the condition is unilateral in about 2% of cases [5].


When this clinical situation is presented, a decision needs to be made as to whether to proceed directly with IVF treatment or to investigate further. The decision depends on many variables, taking into consideration the patient’s wishes and values. For example in the presence of an additional fertility problem such as severe male factor or in the case of advanced maternal age, the decision may be made to proceed directly with IVF. However, in many cases the decision is made to investigate further and therefore proceed with laparoscopic assessment of the fallopian tubes.



2.1 Causes of Proximal Tubal Blockage


The causes of proximal tubal blockage include the following:




  1. 1. Tubal spasm


    This is one of the commonest causes of proximal tubal blockage diagnosed particularly at the time of hysterosalpingogram, where considerable pain can lead to tubal spasm and a false diagnosis of tubal occlusion. These women should proceed to have laparoscopic inspection under a general anaesthetic and with the pain no longer a confounding factor, often these tubes are found to easily fill with dye.



  2. 2. Mucous plug


    This is a common cause of proximal tubal blockage. The presence of a small amount of mucous or endometrial debris can lead to a temporary occlusion of the proximal fallopian tube. Injection of dye under laparoscopic guidance often relieves the problem. In these cases, if necessary, tubal cannulation is quite successful at dislodging the obstructing mucous plug.



  3. 3. Preferential tubal flow


    This is often the case during hysterosalpingogram or even during laparoscopy when the dye will pass preferentially through one fallopian tube rather than the other. This can be excluded by gently blocking the proximal end of the patent tube using an atraumatic instrument followed by injection of the dye. The dye can then be seen to flow freely through the contralateral fallopian tube previously thought to be obstructed.



  4. 4. True proximal tubal occlusion


    This may be as a result of a number of tubal and pelvic pathologies, such as endometriosis and pelvic inflammatory disease. Chronic inflammation and nodular thickening of the proximal tube is sometimes seen at laparoscopy and is known as salpingitis isthmica nodosa. This is a particular pathology that surgeons should look for, as its presence is a poor prognostic factor for attempted tubal surgery.



  5. 5. Intrauterine pathology


    Proximal tubal obstruction may occasionally be caused by the presence of endometrial pathology such as intrauterine adhesions or an endometrial polyp, which overlies the tubal ostium. Hysterosalpingogram may give rise to suspicion by showing an irregular endometrial cavity as is often the case in Asherman’s syndrome, or the presence of a filling defect as in the presence of a polyp. Performing combined hysteroscopic and laparoscopic examination will diagnose and often allow treatment of the cause.



2.2 Diagnosis of Proximal Tubal Disease




  1. 1- Hysterosalpingogram


    This is the usual initial screening test performed in the absence of high risk factors for tubal disease as recommended by the NICE guidelines [6]. Hysterosalpingogram correlates with laparoscopic findings in about 75% of cases, with a false positive rate of 6–25% and a false negative of 8–24% [7]. Although a good test for excluding proximal tubal disease, failure of the dye to pass into the fallopian tubes is often a result of a false positive test due to, as indicated above, a mucous plug, tubal spasm or preferential flow. The presence of proximal tubal blockage on hysterosalpingogram is an indication for further assessment of the tube using laparoscopy.



  2. 2- Laparoscopy and chromotubation


    Diagnostic laparoscopy will allow a detailed examination of the fallopian tube. False positive diagnoses, as a result of preferential flow, mucous plug or tubal spasm are easily excluded during laparoscopic assessment. Combined laparoscopic and hysteroscopic assessment will also allow exclusion of intrauterine factors which may be obstructing the tubal ostium. If true proximal tubal obstruction is diagnosed then laparoscopic assessment of the remainder of the tube as well as assessment of other relevant pelvic pathologies is essential to determine the feasibility of surgical correction. The presence of bipolar tubal disease (proximal and distal blockage), the presence of salpingitis isthmica nodosa or significant pelvic pathology such as grade IV endometriosis would be a contraindication for proximal tubal cannulation and may be an indication to proceed with IVF treatment.



  3. 3- Hysterosalpingocontrastsonography


    Although a recent meta-analysis showed that hysterosalpingocontrastsonography (HyCoSy) was comparable to hysterosalpingogram for diagnosis of proximal tubal disease, the study noted that there was no differentiation between proximal versus distal tubal disease in individual reports [7]. It remains, however, that in well-trained hands, hysterosalpingosonography can be a useful diagnostic tool for diagnosing proximal tubal disease with a potential advantage of avoiding exposure to radiation.



  4. 4- Fluoroscopic guided salpingography


    Proximal tubal cannulation can also be performed under fluoroscopic control and several studies have reported encouraging results [7,4]. In addition, fluoroscopic balloon tuboplasty can be performed [8]. However, hysteroscopic tubal cannulation does offer several advantages over performing the procedure under only fluoroscopic control as a full evaluation of the endometrial cavity can be performed. This allows the option to deal with any adhesions or endometrial polyps. Furthermore, performing the procedure only under fluoroscopic control does lead to the potential of missing significant pathologies such as bipolar tubal disease, which would be achieved using a combined hysteroscopic and laparoscopic approach.



2.3 Treatment of Proximal Tubal Obstruction by Hysteroscopic Tubal Cannulation


A 5 mm saline hysteroscopy is performed allowing inspection of the uterine cavity. This also allows exclusion of any intrauterine adhesions or endometrial polyps. A dedicated tubal catheter is then passed through the hysteroscope into the tubal ostium. In our Unit the Cook Novy® catheter is used. This has an outer sheath that curves towards the cornu and hence facilitates placement of the inner catheter and guide wire that are used to cannulate the tube. The procedure should be performed under laparoscopic guidance to avoid undue trauma and perforation of the fallopian tube (occurring in rare cases). The catheter should only be introduced a few millimetres through the tubal ostium. This usually results in the treatment of the blockage. Dye can then be injected (selective salpingography) and free flow of the dye can be observed laparoscopically. The process of hysteroscopic tubal cannulation is a simple procedure with a short learning curve, requires only basic diagnostic hysteroscopic skills and when successful can be highly rewarding to both the patient and the surgeon.



2.3.1 Success Rate of Laparoscopic Guided Hysteroscopic Tubal Catheterisation

In a recent study it was found that tubal cannulation could lead to a significant improvement in pregnancy rates, resulting in a cumulative pregnancy rate of approximately 43% over a two-year period [9]. The procedure was successful in tubal cannulation in up to 62% of patients. This study also found a clinically significant higher pregnancy rate in those who required only unilateral cannulation. Other studies have also shown similar encouraging results with one study reporting a recanalisation success rate of about 26% and a pregnancy rate approaching 28% [10] and a second study reporting a recanalisation success rate of 67% and pregnancy rate of 55% [11].These success rates are extremely encouraging and approach or sometimes even exceed the results expected after IVF treatment. This emphasises the importance that the reproductive surgeon considers the option of hysteroscopic tubal cannulation in women with proximal tubal obstruction.



2.3.2 Complications of Tubal Hysteroscopic/Fluoroscopic Tubal Cannulation

The main complication is the potential risk for perforation of the fallopian tube. Again, this is where laparoscopic guidance offers a clear advantage where the assistant can help during the process of hysteroscopic cannulation by gently straightening the fallopian tube therefore minimising the risk of the guide wire perforating the tube. Furthermore, the guide wire should never be advanced beyond the few millimetres required to unblock the proximal part of the fallopian tube. In the presence of a longer segment of obstruction, hysteroscopic cannulation is not a suitable technique. Other options would include either proceeding with IVF or microsurgical tubocornual anastomosis.



2.4 Microsurgical Tubal Anastomosis/Cornual Reimplantation


In the presence of significant proximal tubal blockage where tubal cannulation has either been unsuccessful or is deemed to have a low success rate such as in women with salpingitis isthmica nodosa or fibrosis and obstruction affecting a long segment, then microsurgical reanastomosis is a valid option. The surgeon first excises the occluded portion of fallopian tube, taking extreme care not to extend the dissection into the broad ligament where troublesome bleeding may occur. After identification of the patent proximal and distal portions of the fallopian tube, 7/0 or 8/0 of a monofilament delayed absorbable sutures can be used to reinsert the tube into the uterine cornua or reanstomose the two ends of the tube. This is best achieved using the operative microscope for correct placement of the sutures. The fallopian tube is approximated in two layers, seromuscular and serosal while avoiding the tubal lumen. A tubal stent of Prolene 0 or 1 suture can be used at the time to facilitate correct approximation of the tubal lumen. The procedure should, of course, be carried out using microsurgical principles to minimise trauma and ensure a moist, relatively blood-free operating field with minimal tissue handling and the use of anti-adhesion agents at the end of the procedure. With adequate training and careful patient selection, intrauterine pregnancy rate following tubal anastomosis can be extremely encouraging reaching between 38 and 68% [12].



2.5 Distal Tubal Disease


Distal tubal disease is one of the most significant tubal disorders faced by the reproductive medicine specialist as it can have a serious impact on the results of the fertility treatment, in particular, assisted conception treatment. Distal tubal disease can vary from partial to complete occlusion of the distal end of the fallopian tube. This may be associated with a wide spectrum of damage to the remainder of the fallopian tube and can be combined with proximal tubal disease (bipolar disease).


Distal tubal disease is commonly caused by pelvic inflammatory disease as a result of chlamydial infection. Women with at least one previous attack of chlamydia have a 30% increased risk of pelvic inflammatory disease, ectopic pregnancy and tubal factor infertility over their lifetime [13]. Other causes of distal tubal disease include pelvic adhesions as a result of previous pelvic surgery, endometriosis and inflamed pelvic organs such as appendicitis. Distal tubal disease can result in complete occlusion and distension of the fallopian tube with fluid leading to a hydrosalpinx.



2.6 Effect of Hydrosalpinges on the Results of Assisted Conception


The negative effect of hydrosalpinges and the significant improvement in pregnancy rates after treatment has been clearly demonstrated in many studies including a Cochrane meta-analysis which has shown that treatment of a hydrosalpinx by salpingectomy, salpingostomy or occlusion can result in almost doubling the chance of conceiving [14].


Hydrosalpinges can impair pregnancy chances by several mechanisms including embryo toxicity, decreasing endometrial receptivity or mechanical flushing of the embryos from the uterine cavity [[15,16,17]. Hydrosalpingeal fluid has an effect on cytokines and integrins essential for successful implantation. Studies have shown that leukaemia inhibitory factor (LIF) expression is reduced in the mid-luteal endometrium of women with a hydrosalpinx and improved following salpingectomy or salpingostomy [18,19]. Furthermore, alteration of HOXA10 and HOXA11 expression has been associated with decreased implantation in women with a hydrosalpinx. HOX genes are essential for endometrial development and receptivity [20].


Another study demonstrated impaired endometrial and ovarian blood flow in women with hydrosalpinges, which may have an effect on endometrial receptivity and oocyte quality [21].


The effect is so significant that the suspicion of a hydrosalpinx during fertility investigations should almost always be investigated further to either confirm or refute the diagnosis. In this context it is important to remember that ultrasound is not an accurate method for diagnosing hydrosalpinges and furthermore hydrosalpinges can be intermittent and therefore may not always be seen on ultrasound scan. Therefore, if a hydrosalpinx is suspected then a laparoscopy should always be considered.



2.7 The Diagnosis of Distal Tubal Disease


Similar to proximal tubal disease, laparoscopy is the gold standard for diagnosis of distal tubal disease and is usually the first line of investigation in women with significant risk factors such as previous chlamydial infection [6]. This offers the opportunity to both diagnose and treat at the same time. It is imperative at laparoscopy that a full assessment of the degree of tubal damage is performed. The presence of a hydrosalpinx is significant regardless of whether it is partial or complete, unilateral or bilateral. The thickness of the wall, the presence of peri-tubal adhesions and intraluminal adhesions should be assessed and the presence of bipolar disease should be excluded. A proper assessment of the extent of tubal damage by an experienced surgeon is fundamental to planning future management and deciding whether to undertake surgical correction or proceed directly with IVF after removal of the hydrosalpinx.


A hydrosalpinx may also be seen when a hysterosalpingogram has been performed. This should usually be followed by a laparoscopy to evaluate further and decide the best approach for treatment (salpingectomy, salpingostomy or occlusion).


Some studies have advocated the use of chlamydial antibody testing as a screening method for tubal disease. However, evidence for the efficacy of this approach remains controversial; while some studies have shown a strong correlation between tubal factor and fertility and anti-chlamydial antibody testing [22], others have shown doubtful value [23]. Similarly centres that perform HyCoSy may identify possible hydrosalpinges but again the opportunity to fully assess the fallopian tube and its suitability for restorative surgery versus excisional treatment is lost except by performing a laparoscopy.

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Oct 26, 2020 | Posted by in GYNECOLOGY | Comments Off on Chapter 12 – Tubal Factor Infertility and Tubal Surgery
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