Tubal Disease

Published on 11/04/2015 by admin

Filed under Surgery

Last modified 22/04/2025

Print this page

This article have been viewed 3896 times

Chapter 47 Tubal Disease

Raedah Al-Fadhli, Togas Tulandi

INTRODUCTION

Tubal disease is one of the most common causes of infertility and is almost always preventable. It is usually the result of sexually transmitted disease; therefore, prevention is the key intervention for this cause of infertility. In the past, the surgical management of tubal disease often differentiated the skilled infertility expert from his peers. The advent of in vitro fertilization (IVF) has greatly diminished the role of reconstructive tubal surgery for severe forms of tubal disease but remains a viable option for mild to moderate disease. The quest by couples to have a natural conception with reduced risks of multiple pregnancies has made this approach appealing to many couples.

This chapter describes the classification and evaluation of tubal disease, including commonly used radiographic and surgical techniques. Special attention is paid to the management of hydrosalpinges in women undergoing IVF. Various treatment options for these conditions are also discussed.

ETIOLOGY AND CLASSIFICATION

Tubal disease accounts for 25% to 35% of female infertility. The most common cause of tubal damage is pelvic inflammatory disease (PID) (Fig. 47-1A; Table 47-1). Furthermore, the incidence of subsequent tubal occlusion is proportional to the number of PID episodes.¹ Other causes of tubal damage are ectopic pregnancy and iatrogenic tubal sterilization. A detailed discussion of the infectious causes of infertility is given in Chapter 33. In a smaller scale, in utero exposure to diethylstilbestrol (DES) has been implicated to cause fallopian tube abnormalities, such as foreshortened, sacculated, or convoluted tube.²

Figure 47-1 A, Patient with chronic pelvic inflammatory disease and (B) perihepatic adhesions (Fitz-Hugh–Curtis syndrome), usually related to previous gonorrhea or chlamydia infection.

Table 47-1 Etiology of Tubal Disease

Causes	Frequency
Pelvic inflammatory disease	50%
Previous pelvic surgery	27%
Iatrogenic posttubal sterilization	1–3%
Endometriosis	7–14%
Congenital anomalies	Rare

The fallopian tube can be occluded at multiple sites. However, it is common to classify the blockage as proximal, midtubal, or distal tubal. The reproductive performance after reconstructive tubal surgery depends on the extent and the location of tubal damage. Women with extensive tubal damage will have a low chance of conceiving and IVF would provide a better chance.

EVALUATION OF TUBAL DISEASE

There are multiple tests to evaluate tubal condition, including hysterosalpingography (HSG), sonohysterosalpingography, laparoscopy, and salpingoscopy. Serology for Chlamydia has also been advocated. Each diagnostic test has its own limitations.

Hysterosalpingography

HSG is a contrast study of the fallopian tubes and the uterine cavity. It is widely used because it is simple, cost-effective, and associated with minimal side effects. Distal tubal blockage is usually associated with a hydrosalpinx. A potential limitation of HSG is tubal spasm, which can give a false impression of proximal or cornual occlusion. The incidence of false-positive results is estimated to be 50%.³ Hurd and colleagues reported that an apparent unilateral obstruction might be resolved in more than 50% of the patients by rotating the patient in a direction that places the obstructed tube in more inferior position.⁴

Pregnancy can occur after HSG. Perhaps, this is due to dislodging of a mucus plug or necrotic debris from the tubal lumen. In a randomized study, the pregnancy rate in women with patent tubes was 64% after HSG using oil-soluble contrast medium and 56% after the use of water-soluble contrast medium.⁵

Sonohysterosalpingography

Sonohysterosalpingography, also referred to as hystero-contrast-sonography or HyCoSy, is an alternative to HSG. The technique involves introduction of fluid into the uterine cavity. This is an outpatient procedure that usually lasts about 20 minutes. Saline solution is an echo-free contrast medium for assessment of the uterine cavity. The fallopian tubes can be evaluated by another contrast medium, such as air, albumin with micro-air bubbles, or galactose with micro-air bubbles. This contrast medium outlines the fallopian tube, giving a hyperechoic appearance.⁶

In a meta-analysis that included more than 1000 women, a similar rate of detecting tubal pathology was reported between sonohysterosalpingography and HSG or laparoscopy.⁷ Sonohysterosalpingography showed a false tubal occlusion in 10% of cases when compared to laparoscopy and chromopertubation. When sonohysterosalpingography was compared to HSG, a false-positive rate of 13% was found.

Laparoscopic Procedures

Laparoscopic Chromopertubation

This has been the gold standard for investigating tubal patency. Furthermore, laparoscopy permits direct visualization of the whole peritoneal cavity, including other pathology such as perihepatic adhesions (see Fig. 47-1B). Details of this procedure are reviewed in Chapter 44.

Transhydrolaparoscopy

This technique involves the use of a culdoscopic approach and the use of a small endoscope to explore the pelvic cavity. It is performed with the patient in the dorsal lithotomy position. Using saline solution as a distension medium, the posterior aspect of the uterus and tubo-ovarian structures are inspected. The saline instillation continues throughout the procedure to float the tubes and the ovaries. The advantage of this procedure is that it can potentially be used in an office setting. The disadvantage of this procedure is that it does not allow evaluation of the whole abdominal or pelvic cavity. The main concern of transhydrolaparoscopy is bowel injury (about 0.65%).⁸

Salpingoscopy

This is an endoscopic approach to visualize the intraluminal part of the fallopian tube. The procedure is usually done with a rigid salpingoscope.⁹ The salpingoscope is introduced into the abdominal cavity through the operating channel of the laparoscope. An atraumatic forceps in the secondary port is used to grasp and align the ampullary segment of the tube. The salpingoscope is then slowly advanced into the tube from the fimbrial end. The inner portion of the tube is visualized until the tubal ostium. Saline solution is used as the distension medium.

Salpingoscopic findings can be classified into five grades. Grade I refers to normal mucosal folds; in grade II, major folds are separated and flattened; grade III refers to the presence of a focal lesion (adhesions, polyps, or strictures); in grade IV, there are extensive lesions with either preservation or loss of the mucosal folds; and grade V is complete loss of the mucosal folds. The cumulative pregnancy rate is inversely related to the degree of tubal damage.^10,¹¹ Salpingoscopy can also be performed through transvaginal hydrolaparoscopy.¹²

Falloposcopy

This transvaginal endoscopic technique ¹³ involves the use of an extremely narrow microendoscope (0.45 to 0.5 mm in diameter) for transcervical tubal cannulation using local anesthesia. The entire fallopian tube can be visualized. There are two techniques. The first (coaxial technique) is a hysteroscopic approach where a flexible guidewire enclosed in a soft catheter is introduced into the uterotubal ostium. The catheter and the guidewire are slowly advanced for a distance of approximately 12 cm or until resistance is encountered. The guidewire is removed and the falloposcope is introduced through the catheter. In a multicenter trial, it was found that 40% of normal tubes diagnosed on HSG had abnormalities observed on falloposcopy.¹⁴ This coaxial approach lacks a uniform scoring system and the image quality is poor. The second technique involves the use of a linear everting catheter by a transvaginal approach that does not require hysteroscopy.¹⁵ This procedure is also limited by image quality. Neither procedure is commonly used.

MANAGEMENT OF TUBAL INFERTILITY

Depending on the type and degree of tubal dysfunction, various methods of treatment are available. The results depend on patient age, ovarian function, and the presence or absence of male fertility factor. Patients with bilateral multisite tubal obstruction or with severe pelvic adhesions will benefit from IVF rather than surgery.

Basic Principles of Tubal Surgery

Most reproductive surgery is performed by laparoscopy. Compared to open surgery, laparoscopic surgery is a low-risk procedure, usually does not require hospitalization, and is associated with less postoperative pain than laparotomy. Nevertheless, it requires gentle handling of the tissue, good hemostasis, and careful dissection of the tissue.

At operative laparoscopy, dissection is better performed using sharp dissection with minimal use of electrical or laser energy. Thermal damage is associated with higher risk of adhesion formation. The use of sutures should be limited as well. However, if needed the suture material should be fine and nonreactive (e.g., 6-0 polyglactin or polyglycolic acid). The sutures should be placed without strangulating the tissue. Hemostasis is achieved using microbipolar forceps.

Proximal Tubal Occlusion

Proximal tubal occlusion is found in 10% to 25% of women with tubal disease. It is mainly due to salpingitis isthmica nodosa. Other causes of failed filling of the tubes are chronic pelvic infection, congenital malformation, and tubal spasm. Tuberculosis may cause varying degrees of tubal damage from minimal to extensive proximal tubal block.¹⁶ The thick muscular wall of the proximal tube, with its physiologic sphincter and its narrow lumen, makes it susceptible for “obstruction” by mucous debris.¹⁷

The therapeutic approach for proximal tubal occlusion includes selective salpingography and tubal catheterization under fluoroscopy, hysteroscopic transcervical tubal cannulation, and resection and reanastomosis.

Selective Salpingography and Tubal Catheterization under Fluoroscopy

This is an established procedure for diagnosis and treatment of proximal tubal occlusion (Fig. 47-2). The procedure is performed by passing a catheter through the cervix into the proximal tubes. Radiocontrast medium is then injected under fluoroscopic guidance. Similar to HSG, the pressure induced by the injection may help in overcoming the obstruction. Otherwise, a guidewire is introduced into the fallopian tube to overcome the obstruction.

Figure 47-2 Bilateral cornual blockage seen at the time of selective tubal catheterization.

Several catheter systems with different lumen sizes are available. A three-catheter system developed by BEI Medical Systems (Hackensack, N.J.) consists of a cervical catheter, an ostial catheter for selective salpingography, and a cornual catheter for tubal catheterization.

The procedure is usually performed under paracervical block with or without intravenous sedation. The first catheter is introduced through the cervix into the uterine cavity. A balloon is inflated to occlude the cervix. The second (ostial) catheter is then passed through the central lumen of the cervical catheter and advanced to the uterine cornua. Radiopaque contrast medium is injected into the tube directly (Fig. 47-3). Repeated radiographs are done to demonstrate the filling of the tube proximally and distally and whether peritoneal spillage occurs.

Figure 47-3 The ostial catheter is advanced into the uterine cornua and radiopaque contrast medium is injected into the tube.

If selective salpingography is not successful, the third (uterine cornual) catheter with a guidewire is used. Threading of an atraumatic guidewire through the catheter into the ostium and the isthmus (tubal cannulation) unblocks the obstruction. In most cases (85%), the tubal occlusion can be overcome. Yet, reocclusion rate is high (30%). Tubal perforation can occur in 3% to 11% of cases; however, it heals spontaneously without any further treatment. The pregnancy rate after selective salpingography and tubal catheterization is about 50% (Table 47-2). The procedure can be repeated if the tubes reocclude. If the procedure fails, patients can be offered IVF or reconstructive tubal surgery.

Table 47-2 Pregnancy Rates after Selective Tubal Catheterization

Technique	Pregnancy Rate (%)	Ectopic Rate (%)
Fluoroscopic technique	50%	2–9%
Hysteroscopic technique	50%	5%

Hysteroscopic Transcervical Tubal Cannulation

This hysteroscopic procedure is similar to selective salpingography and tubal catheterization. This procedure typically uses a Novy cornual cannulation set (Cook Ob/Gyn, Spencer, Ind.). A catheter is introduced into the working channel of an operative hysteroscope. The catheter is then advanced toward the tubal orifice and wedged against the ostium (Fig. 47-4). Dilute indigo carmine is then injected while observing laparoscopically for spillage from the fimbriated end of the tube. If there is no spill an inner catheter with a guidewire is then introduced. The guidewire is introduced through the uterotubal junction and then into the tube. Only then is the inner catheter introduced. No resistance should be met. The guidewire is then removed and dilute indigo carmine is injected.

Figure 47-4 Hysteroscopic view of a primary rigid catheter that is curved toward the tubal ostia.

Microsurgical Resection and Anastomosis

The indications for microsurgical technique are failed tubal cannulation or proximal tubal occlusion due to salpingitis isthmica nodosa. The procedure is done by either laparotomy or laparoscopy. Both techniques are similar. First, dilute solution of vasopressin (0.2 units/mL of saline solution) is injected into the uterine cornual junction. Vasoconstriction will occur, and the occluded part of the tube is circumferentially incised from the myometrium. Hemostasis is secured using microbipolar forceps. The tube is transected with microscissors at 2-mm intervals until patency is reached, as indicated by the passage of methylene blue dye that is injected into the uterine cavity.

The edges of the transected tube are examined under the microscope or close-contact laparoscope. Depending on the laparoscope and the distance between the end of the scope and the tissue, magnification up to 10-fold can be obtained. The two cut ends of the tube are approximated with several interrupted sutures of 6-0 polyglactin in the mesosalpinx. Three to four interrupted 7-0 sutures are then placed in the mucosa and muscularis layers circumferentially. The pregnancy rate following cornual anastomosis is approximately 50% (Table 47-3). A meta-analysis of different techniques found that the pregnancy rate after microsurgical repair of cornual obstruction is 58.9%, with an ectopic pregnancy rate of 7.4 %.²⁵ Most patients choose IVF after failed cannulation techniques rather than a surgical approach.

Table 47-3 Reproductive Outcome after Surgical Reconstruction of Cornual Occlusion

Midtubal Occlusion

Tubal sterilization is the most common permanent method of contraception in females. However, more than 1% of sterilized women subsequently seek restoration of their fertility. Data from 2253 women who had tubal sterilization showed a strong correlation between regret and age or change in marital status.²⁶

Reversal of tubal sterilization is the most common indication for surgery of midtubal occlusion (Fig. 47-5). The technique is demonstrated in Figures 47-6 to 47-10. At the beginning of the procedure, the type of occlusion should be reported according to the American Society for Reproductive Medicine (ASRM, formerly the American Fertility Society) classification of tubal occlusion secondary to tubal ligation (Fig. 47-11).²⁷

Figure 47-5 The middle part of the tube is missing as a result of tubal ligation.

Figure 47-6 Dilute solution of vasopressin 0.2 units/mL of saline solution is injected into the mesosalpinx adjacent to the occluded part of the tube.

Figure 47-7 The proximal end of the tube has been circumferentially incised. Chromopertubation with solution of methylene blue dye indicates the patency of the proximal tubal portion.

Figure 47-8 Sutures have been placed in the mucosa and muscular layers of the proximal tube.

Figure 47-9 Approximation of the tubal portions.

Figure 47-10 Tubal anastomosis with the da Vinci robotic device. A, The suture (8-0 Vicryl) is grasped with the right microneedle holder while the left robotic arm grasps the tissue around the proximal anastomosis site. B, The needle is driven into the lumen of the proximal isthmic portion of the tube at the 6 o’clock position.

(Pictures courtesy of Dr. T. Falcone.)

Figure 47-11 The American Fertility Society (now the American Society for Reproductive Medicine) classification of tubal occlusion secondary to tubal ligation.

Isthmic–isthmic tubal anastomosis yields the best pregnancy rate (81%). A similarly high pregnancy rate can be obtained by a laparoscopic approach (Table 47-4). Yoon and coworkers reported a pregnancy rate of 82.8%.²⁸ There has been no randomized trial comparing tubal anastomosis by laparoscopy and laparotomy. Using a life table analysis, Hawkins and colleagues reported that there is no difference in cumulative pregnancy rates between tubal anastomosis by laparoscopy and laparotomy.²⁹ The ectopic pregnancy rates at 18-month follow-up were 11.8% and 12% in the laparoscopy and laparotomy groups, respectively.

Table 47-4 Reproductive Outcome after Reversal of Sterilization

The technical difficulty of accomplishing this task by laparoscopy has led to modified versions of the classical two-layer closure. Using a one-stitch technique after laparoscopic tubal anastomosis, Dubuisson and Chapron reported an 87.5% patency rate, 53.1% intrauterine pregnancy rate, and an ectopic pregnancy rate of 6.25%.³⁵ Falcone and colleagues reported on laparoscopic reversal of sterilization with the assistance of a robotic device.³⁶ The daVinci robotic arms can turn 360 degrees and theoretically facilitate laparoscopic suturing (see Fig. 47-10). Although initial reports showed increased operative time, this may decrease as the technology improves.

Distal Tubal Occlusion

Distal tubal damage represents 85% of all cases of tubal infertility. The causes of distal tubal occlusion are PID, pelvic peritonitis, and previous surgery. A standardized method of operative report should be used. There are different scoring systems for distal tubal disease, but the most widely used is the ASRM classification for distal tubal occlusion (Fig. 47-12).²⁷

Figure 47-12 The American Society for Reproductive Medicine classification of distal tubal occlusion.

Salpingostomy

The procedure to open a distally occluded tube is called a terminal salpingostomy or salpingoneostomy. A systematic approach is required. First, any adhesions around the tubes should be liberated. The tube is then distended with dilute solution of contrast medium solution, which is injected through the intrauterine cannula (Figs. 47-13 and 47-14). The distended hydrosalpinx is then inspected. An opening on the hydrosalpinx along the avascular white line of the hydrosalpinx is created using laparoscopic scissors (Fig. 47-15). The tube is immobilized by uterine manipulation and with the help of laparoscopic forceps. Eversion of the mucosal flap can be achieved by suturing them in place with interrupted sutures of 6-0 polyglactin (Fig. 47-16). It can also be achieved by light coagulation of the serosal flap approximately 5 mm from the tubal margin. This leads to retraction of the mucosal flap, creating an eversion (Fig. 47-17).

Figure 47-13 Dense adhesions surrounding the tubes and ovaries. Chromopertubation revealed bilateral distal tubal occlusion.

Figure 47-14 The tube is grasped with a traumatic forceps.

Figure 47-15 An opening is made with laparoscopic scissors at the avascular line.

Figure 47-16 Salpingostomy is completed by everting the mucosal flap with sutures.

Figure 47-17 Salpingostomy has been completed.

Depending on the degree of tubal damage, the overall pregnancy rate after salpingostomy is between 10% and 35% (Table 47-5). A meta-analysis found that increased term pregnancy rates and decreased ectopic rates were associated with microscopic salpingostomy compared to the macroscopic method.³⁷ They also found that intrauterine pregnancy rates were significantly lower with the laparoscopic approach. However, this conclusion was based on the findings of four nonrandomized studies.

Table 47-5 Reproductive Outcome after Laparoscopic Salpingostomy

Fimbrioplasty

Fimbrioplasty is release of adhesions covering the fimbriae or the peritoneal bands surrounding the fimbria. The procedure is performed for fimbrial phimosis, which is an incomplete obstruction of the fallopian tube. Some of these adhesions can appear as minimal agglutination between fimbriae. Gentle division with scissors should be performed.

In more severe forms of fimbrial disease, the distal tube may be dilated but patent. The peritoneal adhesive bands are divided by laparoscopic scissors. The procedure can also be done by inserting two graspers into the tubal lumen and then spreading them apart. The procedure is repeated until the fimbria is opened. In severe cases, several interrupted sutures of 6-0 polyglactin to maintain the tubal opening are needed. The results of laparoscopic fimbrioplasty are depicted in Table 47-6.⁴⁷^–⁵⁰

Table 47-6 Reproductive Outcome after Laparoscopic Fimbrioplasty

Salpingectomy

Several studies have shown the deleterious effect of hydrosalpinx on the outcome of IVF–embryo transfer (ET).⁵¹^–⁵⁵ Perhaps this is due to toxic agents in hydrosalpinx fluid that enter the uterine cavity and impair implantation. Meta-analysis of large retrospective series revealed that the IVF pregnancy rate in women with hydrosalpinx is half of those with tubal infertility of other causes, and the miscarriage rate is double.^56,⁵⁷ In attempt to improve the live birth rate of IVF treatment, it is recommended that the tubes be removed before IVF.^58,⁵⁹ In particular, hydrosalpinges that are visible on ultrasound should be removed. However, it is less certain if removal is necessary for mild cases seen only on HSG. Interestingly, salpingectomy or proximal tubal occlusion of a unilateral hydrosalpinx has been shown to increase spontaneous pregnancy rates.⁶⁰ Treatment options for hydrosalpinx-related IVF include drainage, salpingostomy, proximal tubal ligation, and salpingectomy.

Drainage of hydrosalpinx fluid can be performed by transvaginal needle aspiration under ultrasound guidance, either before the IVF cycle or at the time of oocyte retrieval. The efficacy of this technique is unclear. Furthermore, the fluid tends to reaccumulate after drainage.

Salpingostomy is particularly appealing to young women with hydrosalpinx who do not wish their tubes removed because they wish to retain the potential for spontaneous conception. It carries the risk of reocclusion of the hydrosalpinx. Whether the rates of IVF pregnancy after salpingostomy are similar to those after salpingectomy is unknown.

Occluding the proximal tube appears to be a reasonable alternative for women with hydrosalpinx undergoing IVF. Pregnancy rates after proximal tubal occlusion are similar to those after salpingectomy.⁶¹ In one retrospective study of patients undergoing IVF treatment, it was observed that management of hydrosalpinx by laparoscopic salpingectomy or by occluding the proximal tubes yielded statistically similar responses to an IVF–ET cycle.⁶¹ Occluding the proximal portion of the tubes is simpler and is a method of choice for women with severe pelvic adhesions. Recently some case reports have suggested a possible role for hysteroscopic tubal occlusion in patients with hydrosalpinx and severe pelvic disease at high risk for complications.

Salpingectomy has been shown to be effective. A randomized trial comparing laparoscopic salpingectomy to no treatment for hydrosalpinx before IVF found the pregnancy and delivery rates (37% and 29%, respectively) in the salpingectomy group were significantly higher than in the nontreated group (24% and 16%, respectively).⁵⁹ It seems clear that salpingectomy is a worthwhile procedure before IVF.⁶² The technique of salpingectomy could affect the blood supply to the ovary; caution should be exercised when excising the tube.

Prophylactic antibiotics may be all that is necessary to improve implantation rates in the presence of hydrosalpinx, at least in theory. It has been reported in a retrospective study that doxycycline treatment improved the IVF pregnancy rate.⁶³ However, in general, a tubal occlusion procedure is recommended.

Periadnexal Adhesions

Reproductive surgery can cause adhesion formation. Most surgery on reproductive organs is not performed for infertility but in women who have a disorder such as a myoma or ovarian cyst and want to conceive in the future. Measures such as meticulous handling of the tissue, frequent irrigation with isotonic solution, gentle and minimal tissue handling, and good hemostasis decrease but do not eliminate adhesion formation. Adjunctive therapies, such as prophylactic antibiotics, intraperitoneal corticosteroids, and adhesion-preventing substances also fail to improve the reproductive performance of these women (see Chapter 52).

Peritubal and periovarian adhesions impair fertility by interfering with gamete transfer and the ovum pickup mechanism. Removal of these adhesions is associated with improved fecundity. The ASRM (American Fertility Society) classification of adnexal adhesions is shown in Figure 47-18.²⁷ Tulandi and colleagues evaluated pregnancy occurrence in infertile women with periadnexal adhesions.⁶⁴ The pregnancy rate in women whose adhesions were lysed by laparotomy was higher than in those untreated. The cumulative probability of conception at 12 and 24 months follow-up were 8% and 13%, respectively, in the nontreated group and 40% and 42%, respectively, in the treated group. The ectopic pregnancy rate between the treated and nontreated group was similar. Intrinsic damage to the fallopian tube is more important in the development of ectopic pregnancy than the adhesions.

Figure 47-18 American Fertility Society (ASRM) classification of adnexal adhesions.

Lysis of adhesions can be performed using laparoscopic scissors, electrocautery, or laser. The results are similar.⁶⁵^–⁶⁸ The vascular type of adhesions should be coagulated first or vaporized with the laser. The procedure is performed by keeping the adhesions under tension with grasping forceps and divided. Filmy adhesions are divided, but dense adhesions should be excised. The overall pregnancy rate after laparoscopic salpingo-ovariolysis is 60% and the ectopic pregnancy rate is 5%.⁶⁵ However, the pregnancy rate after salpingo-ovariolysis in women with severe and dense adhesions is poor (10% to 15%). These patients are better treated with IVF.

In a retrospective study, there was no statistical difference between the cumulative conception rates of microsurgical and laparoscopic adhesiolysis after being stratified according to the duration of infertility.⁶⁶ In addition, there was no difference in adhesion score after microsurgical and laparoscopic adhesiolysis. However, the laparoscopic approach has additional benefits, such as reduced postoperative pain, fast recovery, short hospital stay, and reduced risk of infection and thromboembolic accidents.

The benefit of second-look laparoscopy was studied by Tulandi and coworkers in a randomized, prospective study.⁶⁸ There was no increase in the pregnancy rate or decrease in the incidence of ectopic pregnancy after a second-look laparoscopy done 1 year after reproductive surgery.