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Tubal Disease

The fallopian tube is the actual site where fertilization and early embryo development occur. It is a complex structure that has differing functions along its entire length. From the distal end where the ovulated oocyte is picked up to the midsection where the different nutrients secreted by the cells lining the tube enhance pre-embryonic development the tube is crucial for conception. The tube can be damaged by infections which ascend from the uterine cervix, like Chlamydia or Gonorrhea. Such infections could cause the tube to be occluded and dilated distally (hydrosalpinx) or damaged microscopically yet still be patent. Occasionally the fine fimbriated ends of the tube, which act like delicate fingers to pick up the egg, become agglutinated and no longer function properly yet the tube is still open. Scar tissue could displace the tube so that it is anatomically unable to function. Endometriosis, a condition that predisposes to scar tissue may affect tubal integrity.

Tubal disease is often diagnosed by hysterosalpingogram (HSG), ultrasound exam, or laparoscopy. Tubal disease may account for about 20% of infertility. In the past, surgery was often performed to treat tubal disease. An important factor is the health of the tubal lumen. The following table summarizes the outcomes following tubal surgery as reported by Silverberg and Hill in 1991.

Outcomes Following Tubal Surgery

Treatment

Pregnancy Rate (%)

Salpingiolysis/ovariolysis
 (remove adhesions around tube and ovary)
25-62
Fimbrioplasty  (remove adhesions about end of tube) 60-70
Fimbrioplasty (post infection) 27
Salpingostomy (tubal reconstruction) 21-39
Tubal reversal (prior tubal ligation) 52-82
Tubal anastomosis (for block at uterus/tube junction) 50-69
Tubal cannulation 25-35
Salpingostomy for ectopic pregnancy 38-80
Methotrexate for ectopic pregnancy 50-55
Fulgaration of endometriosis 40-75

From the above, surgery is a valid fertility treatment for many patients and laparoscopy often is the only way to diagnose these pelvic problems. Luckily, laparoscopic treatment is easily accomplished for most patients. Many physicians turned to in vitro fertilization which totally bypasses the fallopian tubes as a fertility treatment instead of surgery. While it seemed to work, several studies were published that indicated that the pregnancy rates were actually lower when a hydrosalpinx was present. The fluid in the tube was unable to go out the end due to the blockade so it backed up into the uterus where the embryos were placed. It was postulated that this fluid may be embryo toxic, negatively affect the endometrium with respect to adhesion molecules or position, or literally flush the embryos out through the cervix.

A number of publications have suggested that removal of the diseased tube improves pregnancy rates with IVF. Hydrosalpinges noted on ultrasound exam may have a worse prognosis. The exact procedure to treat the tube, complete removal or proximal clip placement, is debatable.

All patients that undergo IVF need some evaluation of the fallopian tubes before the procedure.
 

 

 

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