Tubal Disease

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Chapter 47 Tubal Disease

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

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.

Laparoscopic Procedures

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 technique13 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.

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.

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.

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%

Microsurgical Resection and Anastomosis

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