TUBAL FACTOR INFERTILITY Aetiology: (bilateral tubal block).
1. Congenital: aplasia or hypoplasia.
2. Traumatic: removal or ligation of the tubes during previous operations.
3. Inflammatory: (the commonest cause)
chronic salpingitis (the commonest cause):
• Infections reach tubes via its lumen: chlamydia & gonorrhea.
• Infections reach tubes via lymphatics & veins: puerperal sepsis & postabortive infection.
Previous pelvic peritonitis:
• Due to ruptured appendix.
• Results in pelvic adhesions.
4. Vascular: irradiation.
5. Neoplastic: bilateral cornual block e.g. fibroid.
6. Miscancellous: endometriosis.
TUBAL FACTOR INFERTILITY Diagnosis:
Symptoms:
• History of operative intervention that may affect tube.
• History chronic salpingitis (fever & bilateral lower abdominal pain mainly at tubal points).
• History of exposure to irradiation.
Signs: salpingitis & endometriosis may be suspected with enlarged tender cystic fixed masses.
TUBAL FACTOR INFERTILITY Investigations (tubal patency tests):
1) HSG.
2) Hysterosalpingography contrast sonography
. 3) Tuboscopy.
4) Laparoscopy.
5) Rubin test (obsolete).
6) Kymography (obsolete).
1. Hysterosalpingography (HSG):
Idea:
* Radio opaque dye injected into uterus then x-ray is taken.
* Patent tubes, the x-ray will detect the dye in the peritoneal cavity.
Contrast media(dye):
A. Lipiodol:
• Origin: 40% iodine in poppy seed oil (fat soluble).
• Advantages: better diagnosis & better therapeutic values.
• Disadvantages: peritubal adhesions & oil embolism.
B. Urographin:
• Origin: 40% iodine in water (water soluble).
• Advantages: * safe i.e. no risk of oil embolism.
* 2nd film is taken after 30 minutes.
• Disadvantages: *less accurate than lipiodol.
*No therapeutic values.
Timing: 2 days after the end of menstruation .why?
a) Endometrium is thin & less vascular ↓risk of oil embolism.
b) Avoid false –ve results due to block of tubal opening at the cornu by thick endometrium.
c) To exclude possibility of pregnancy.
Technique:
a) Give antispasmodic ½ hour before the test e.g. spasmofen i.m..
b) Vagina opened by Cusco speculum, cervix is grasped by vulsellum.
c) Antiseptic solution used to sterilize cervix.
d) Injection canula is introduced carefully through cervical canal.
e) Dye is injected (8ml) using injection canula
f) 1st film is taken immediately.
g) 2nd film is taken later:
* 24 hours if lipiodol is used.
* ½ hour if urographin is used.
Results:
The 1st film give an idea about uterine cavity, shape & direction of the tubes & dye stops at site of occlusion if present.
The 2nd shows peritoneal spill and give an idea about adhesions.
Complications:
Most common: collapse & neurogenic shock.
Most serious : infection.
Others: *Nausea & vomiting. * Endometriosis.
Contraindications
a) Pregnancy or general diseases contraindicating pregnancy.
b) PID.
c) Premenstrual, during menses or during any uterine bleeding.
d) Immediately postoperative.
Advantages: * Shows uterine, tubal & peritoneal abnormalities.
* Iodine has adhesolytic effect.
Disadvantages: false -ve results i.e. minor adhesions may be not detected.
2. Hysterosalpingography contrast sonography
Technique:
a) Normal saline is injected through the cervix into the uterus.
b) By U/S, we see the flow of fluid in the tubes.
c) If the fluid is detected in Douglas pouch, the tubes are patent.
Advantages:
a. No need for anesthesia.
b. No exposure to irradiation.
c. Ovaries can be assessed by U/S at the same time.
3. Tuboscopy:
Aim: direct inspection of the lumen & mucosa of fallopian tube using very small endoscope
Indication:
1) Abnormal HSG.
2) Unexplained infertility.
Advantage: shows anatomy & physiology of fallopian tube (mucosal cilia).
4. Laparoscopy:
Principle: injection of methylene blue into the uterus, the dye will be seen at the abdominal ostium of the tube by laparoscopy (chromotubation).
Timing: can be done premenstrual to obtain PEB at the same sitting.
Indications 1. Doubt about tubal block or peritubal adhesions by HSG. 2. Pregnancy delayed for more than 6 months after all investigations revealed no any abnormalities.
Contraindications
General:
1. Severe cardio-pulmonary disease.
2. Marked obesity.
Local:
1. Extensive abdominal scar or extensive abdominal hernia.
2. History of peritoneal affection e.g. peritonitis.
Technique:
a) General anesthesia is better used.
b) Trendlenberg position, with beneficial effect pushing intestine away.
c) Sterilization of the vulva & abdomen with antiseptic solution.
d) Catheterization dealing with the full bladder, giving better field.
e) Bimanual examination.
f) Volsellum is used to grasp the cervix after posterior vaginal wall retracted.
g) Pneumoperitoneum.
h) Insertion of laparoscope using trocar & canula.
5. Rubin test (obsolete): tubal insufflation test
Idea: * co2 is injected into the uterus under pressure. * If the tubes are patent, the gas passes into the peritoneal cavity.
Criteria of tubal patency:
-Bubbling sound can be heard over the lower abdomen.
– Manometer will record drop of pressure.
– Shoulder pain due to diaphragmatic irritation.
– X-ray: showing gas under diaphragm.
6. Kymography (obsolete):
♦ ♦♦ ♦ The same as Rubin’s, instead connected with a rotating drum recording results.
Treatment of tubal factor of infertility:
A. Prophylactic treatment:
Microsurgical techniques:
1) Good exposure during surgical operations.
2) Using very fine instruments & special types of suture materials.
3) Proper hemostasis & proper dissection of tissues.
4) Don’t allow chance for peritoneal irritation.
5) Peritonization: cover any raw area without peritoneal surface.
Prevention of infection:
1) Prevent infections by prophylactic antibiotics & proper sterilization.
2) Floating theory; heparin & corticosteroids in the peritoneal cavity.
B. Active treatment:
I. Conservative treatment (ineffective, so rarely used):
1) Hydrotubation: using mixture of α-chemotrypsin, corticosteroids & antibiotics injected through tube, may resolve adhesions.
2) Short wave therapy: May resolve thin adhesions by resulting hyperemia.
3) Repeated insufflations.
II. Tuboplasty = salpingoplasty:
Precautions: laparoscopy should be done before the operation to assess the extent and degree of the disease. Indications 1) Bilateral tubal block, repairing at least one tube.
2) Young age woman.
3) Other causes of female infertility are excluded.
4) Normal male investigations.
Contraindications:
A. Absolute:
1) TB. Infection especially during active phase.
2) Medical diseases contraindicating pregnancy.
B. Relative:
1) Infertility due to male factor.
2) Tuboplasty failed in previous attempts.
3) Unilateral tubal block.
Procedures:
A. Open surgery:
1) Adhesolysis: cutting adhesions around the tube.
2) Salpingostomy artificial ostium for fimbrial obstruction.
3) Fimbriolysis: cutting adhesions closing fimbrial end.
4) Resection anastomosis: excision of stricture & end to end anastomosis.
5) Tubo-cornual anastomosis: reimplantation of the tube in case of cornual obstruction.
B. Endoscopic surgery:
1) Laparoscopy: salpingolysis & salpingostomy.
2) Hysteroscopy: Proximal tubal obstruction, treated by tubal cannulation & balloon tuboplasty.
Prognosis:
Success of the treatment monitored by pregnancy. 30% is a satisfactory ratio for success rate. Best results in adhesolysis (no affection of tubal lumen). Higher incidence of ectopic pregnancy must be oriented with.
III. Assisted reproductive techniques (ART).