Tubal factor infertility

1. Benha University Hospital, Egypt
Aboubakr Elnashar

2. 30% of infertile couples.
Aboubakr Elnashar

3. 1. Infection
PID
Appendicitis,
2. Endometriosis
3. Previous tubal surgery
4. Pelvic adhesions
5. Congenital anomalies of the tubes
Aboubakr Elnashar

4. PID
one, two, or three episodes:
12%, 23%, and 54%, respectively tubal disease
Chlamydial infections:
major cause of tubal factor infertility
Ruptured appendix:
5X tubal disease
No identifiable risk factors
50% of patients with documented tubal factor
infertility
Aboubakr Elnashar

5. Aboubakr Elnashar

6. Aboubakr Elnashar

7. European Society of Human Reproduction &
Embryology (ESHRE) (2000)
Infertility testing should be classified into 3
groups depending on correlation with pregnancy
rates
I. Tests that have an established association with
pregnancy:
1. Conventional semen analysis
2. Tubal patency tests,
3. Tests of ovulation
Aboubakr Elnashar

8. II. Tests that are not consistently associated with
pregnancy:
Post-coital test,
Antisperm antibody tests
Zona-free hamster egg penetration test
III. Tests that have no association with pregnancy:
Endometrial biopsy
Varicocele assessment
Chlamydia testing
Aboubakr Elnashar

9. 1. Hysterosalpingography
The most commonly performed screening test for
tubal patency.
Advantages:
1.Position of tubal occlusion
2. unilateral patency can be dd from bilateral
patency.
3. Degree of damage to tubal endothelium
4. Peritubal adhesion.
5. uterine cavity
Aboubakr Elnashar

10. 4. Relatively cheap & simple.
5. HSG is in agreement with the laparoscopic
findings approximately two thirds of the time.
Sensitivity: 73
Specificity: 83%
High specificity makes it useful in ruling in
tubal obstruction
Aboubakr Elnashar

11. HSG findings:
1. Mucosal rugae
Present:
favorable prognostic factor for subsequent
pregnancy: 60% PR
Absence:
severely damaged tubal epithelium: 7.3% PR
Aboubakr Elnashar

12. Aboubakr Elnashar

13. 2. Periadnexal adhesions
 An irregular distribution of loculated contrast
medium around the fimbriated end of the tube
Not reliable in evaluation of peritubal
adhesions
Aboubakr Elnashar

14. Aboubakr Elnashar

15. Disadvantages
1. The pelvis including the ovaries is exposed
to radiation: significant problem if the patient
had an early pregnancy.
2. Abdominal pain which peaks 5 min after
starting & usually settles within 30 min.
Aboubakr Elnashar

16. 3. Intravasation
Network of streaklike opacities adjacent to
the uterine cavity that extend toward the
pelvic side walls and subsequently migrate in
a cephalad direction.
Early detection of intravasation: minimizes
complications.
Whenever there is evidence of
intravasation, injection should be
discontinued immediately, regardless of the
contrast medium used.
Aboubakr Elnashar

17. 4. False occlusion: 12.5%
false patency: 11%
{high incidence of false cornual obstruction}
two separate tubal studies should be performed
before the diagnosis of proximal tubal obstruction
is confirmed.
(Holz et ao, 1997)
Aboubakr Elnashar

18. Proximal Tubal Obstruction
Fibrosis obliteration & SIN 40%
Endometriosis & Cornual polyp 10%
Cornual spasm 20%
Amorphous material 50%
Viscous secretions 30%
 Mucosal agglutination
 Stromal edema
Tubal catheterization can be used both as
diagnostic & therapeutic method
Valle 1996Aboubakr Elnashar

19. The optimal contrast medium
Oil-soluble Water-soluble
Uterine image Sharp Less sharp
Ampullary rugae Difficult to define Easier to define
Viscosity Viscous Less viscous
Absorption Months hours
Pain Minimal Significant
Granuloma formation Rare Very rare
Embolism Rare anaphylaxis No major sequalae
Pregnancy after HSG Doubled No effect
Aboubakr Elnashar

20. Mechanisms by which HSG may enhance fertility
1. Mechanical lavage of a partially obstructed tube,
2. Stimulation of the tubal cilia
3. Inhibition of hostile peritoneal fluid immune cells
Although oily media are now rarely used, there may
be a place for it in the treatment of unexplained
infertility
(Steiner et al,2003)
Aboubakr Elnashar

21. Contraindications
Absolute
Possible pregnancy
History of acute PID.
Relative
History suggestive of PID
Recent uterine instrumentation,
Iodine allergy.
Aboubakr Elnashar

22. The risk for PID after HSG
1% to 3%
Routine antibiotic prophylaxis
Patients at risk for acute PID
Doxycycline: 100 mg twice a day for 3 days for all
patients.
Prophylactic antibiotics
before uterine instrumentation if screening for CT
has not been carried out.
(NICE, 2013)
Aboubakr Elnashar

23. 2. Sonohysterosalpingography
An ultrasound contrast dye or saline (10-40 ml) is
injected into the uterus through the cervix by a Foley
catheter & the passage of the dye is followed by TVS.
76% concordance rate with laparoscopy dye
The addition of pulsed wave or color Doppler
imaging may improve the predictive value of
transvaginal sonosalpingography
experience
effective alternative to HSG
(NICE, 2013)
Aboubakr Elnashar

24. HS-contrast-US
Free fluid collection in the cul-de-sac following
successful demonstration of oviductal patency.
Oviductal fimbria are clearly observed in the collected
fluid.
Aboubakr Elnashar

25. Hydrosalpinx
well-constrained fluid
accumulation in the adnexae.
In some cases, adhesions
between the oviduct and ovary
may be visualized.
Aboubakr Elnashar

26. 3. Laparoscopy
Indication
1. Abnormal HSG or
2.History or symptoms suggestive of pelvic disease.
Normal HSG or no history suggestive of tubal
disease:
probability of clinically relevant tubal disease or
endometriosis is very low: laparoscopy is not justified
or cost effective
(Fatum et al, 2002).
Aboubakr Elnashar

27. Laparoscopy may reveal
minimal or mild endometriosis or
peritubal adhesions.
Surgery or medical treatment has not been proven to
improve fecunditity.
With the current success rates of ART& the relatively
low contribution of diagnostic laparoscopy to the
decision making of treating patients with normal HSG,
laparoscopy should be omitted in couples with
unexplained infertility.
These patients should be treated as UI (by 3 cycles
of combined gonadotropins & IUI & if unsuccessful
ART)
Aboubakr Elnashar

28. Advantage
1. Direct visualization of the pelvic anatomy.
2. Determine:
appearance of the fimbria
presence of periadnexal adhesions
endometriosis.
3. Correct timing will enable evidence of
ovulation to be obtained.
4. No exposure to radiation
5. Can be combined with salpingoscopy &/or
hysteroscopy.
6. Adhesiolysis or tubal constructive surgery
can be performed. Aboubakr Elnashar

29. Laparoscopic findings:
1. Postinfection tubal disease .
The most common
Pelvic adhesions, phimotic fimbria, hydrosalpinges,
or tubal obstruction.
2. Endometriosis
2nd most common
An extremely variable (5% to 60%)
Laparoscopic visualization, biopsy, or both are
required for the diagnosis of endometriosis because
there are no specific screening tests.
3. Isolated proximal occlusion
10% to 20% of tubal factor infertility.
Aboubakr Elnashar

30. Aboubakr Elnashar

31.  ASRM classifications of
adnexal adhesions,
distal tubal occlusion, and
endometriosis is based on laparoscopic findings and
provides a rational foundation for therapy
Aboubakr Elnashar

32. Disadvantages
1. An invasive test requiring a GA with its
associated risk
2. Small risk of visceral damage on insertion
3. Not always possible to determine the actual
site of occlusion.
Aboubakr Elnashar

33. Hysteroscopy
Not an initial investigation unless clinically indicated
{effectiveness of surgical treatment of uterine
abnormalities on improving pregnancy rates has not
been established}.
(NICE, 2013)
Aboubakr Elnashar

34. 4. Transvaginal hydrolaparoscopy (THL)
±Method of choice for the clarification of
mechanical infertility factors in symptom free patients
with no suspicion of pelvic pathologies
(Nawroth et al,2001).
THL in association with minihysteroscopy provide
more information & is better tolerated than HSG in
outpatient infertility investigation
Aboubakr Elnashar

35. 5. Chlamydia antibody testing (CAT)
HSG is more accurate than CAT in predicting tubal
disease
(Elnashar et al,2000).
If both tests were negative the tubal disease was
identified on laparoscopy in only 4 % of case.
Aboubakr Elnashar

36. Aboubakr Elnashar

37. Management strategy
The role of surgery (open laparotomy or extensive
laparoscopic surgery) for the treatment of tubal factor
is shrinking
(Aboulghar, 2003).
Laparoscopic surgery has a role in peritubal
adhesions
Open laparotomy is only indicated in reversal of
sterilization
(ESHRE,2001).
Aboubakr Elnashar

38. IVF
Main player for treatment of tubal factor.
Indication
1. Moderate to severe tubal disease
A. Distal tubal occlusion with hydrosalpiges >1.5 cm
in diameter.
B. Distortion of the intraluminal architecture or
endotubal adhesions detected by HSG, salpingoscopy or falloscopy
2. Other factors
A. Sperm dysfunction
B. Age >36 yr Aboubakr Elnashar

39. •Post-ligation:
open microsurgery
•Distal Tubal disease:
Mild: Laparoscopic surgery
Moderate to severe: IVF
•Proximal tubal disease:
Tubal catheterization
•Distal & proximal tubal disease:
IVF
•If pregnancy has not occurred within 12 mo of
surgery: IVF
Aboubakr Elnashar

40. British Fertility Society Classification of
Tubal disease
Minor
Proximal
occlusion without
tubal fibrosis
Distal occlusion
without tubal
distension
Healthy mucosal
appearance at HSG,
salpingoscopy
flimsy
peritubal/ovarian
adhesions.
Intermediat
e
Unilateral
severe tubal
damage
Limited
dense
adhesions of
tubes &
ovaries
Severe
Bilateral severe
tubal damage
Extensive tubal
fibrosis
Tubal distension >1.5
cm
Abnormal mucosal
appearance
Bipolar occlusion
Extensive dense
adhesion
Aboubakr Elnashar

41. Aboubakr Elnashar

42. Peritubal adhesions
with healthy
endosalpinx
•Laparoscopic
surgery
•IVF
Chronic salpingitis
• IVF
• Salpingectomy
before IVF in
hydrosalpinx
Post ligation
Open
microsurgery
Management of tubal factor
Aboubakr Elnashar

43. 1. Laparoscopic Surgery:
Fimbrioplasty
Lysis of fimbrial adhesions or the dilation of fimbrial
strictures.
Neosalpingostomy
Creation of a new opening in a fallopian tube with a
distal occlusion.
Adhesiolysis
more likely to work in the presence of patent tubes &
filmy adhesions
Aboubakr Elnashar

44. Aboubakr Elnashar

45. Aboubakr Elnashar

46. 2. Transcervical cannulation of the proximal
fallopian tube
Methods
hysteroscopy
fluoroscopy, or
sonography
Results
successful catheterization
80% to 90%
cumulative pregnancy
23% and 39% within the first 6 to 12 months.
Ectopic pregnancy
5% to 13%
Aboubakr Elnashar

47. Selective salpingography plus tubal
catheterisation, or hysteroscopic tubal
cannulation
Proximal tubal disease
If pregnancy has not occurred within 12 mo
of surgery: IVF
Aboubakr Elnashar

48. 3. Microsurgical reanastomosis of the fallopian
tubes:
 Patients who want to become pregnant after
having undergone tubal sterilization may be
candidates for tubal ligation reversal.
Although tubal ligation reversal has traditionally
been performed by laparotomy, recent studies
suggest that laparoscopic surgical reanastomosis
may be associated with comparable rates of success
Aboubakr Elnashar

49. 4. In Vitro Fertilization
Indications
1. Tubal factor infertility,
2. male factor infertility,
3. endometriosis
4. unexplained infertility.
5. IVF is recommended for all conditions that have
not been successfully treated with other
treatment strategies.
Aboubakr Elnashar

50. IVF or ICSI:
IVF should be the initial treatment of choice
(Aboulghar et al,1996; Bukulmez et al,2000).
{No significant difference in PR. or take-home
baby}.
Aboubakr Elnashar

51. Bilateral salpingectomy or tubal sterilization
for women undergoing IVF who have
1. Hydrosalpinges, which adversely affect
implantation rates during IVF, because of antegrade
flow of noxious fluid.
2. Tubal damage and history of ectopic pregnancy
because of the increased risk of a further ectopic
pregnancy.
Aboubakr Elnashar

52. Hydrosalpinges
salpingectomy, preferably by laparoscopy, before
IVF treatment
{improves the chance of a live birth}.
Aboubakr Elnashar

53. Benha University Hospital, Egypt
Email:elnashar53@hotmail.com
Aboubakr Elnashar