The mechanism responsible for the tubal factor infertility obviously involves anatomic abnormalites that prevent the union of sperm & ovum..The inflammatory damage to internal tubal mucosal architecture cannot be detected easily but may nonetheless impair sperm or embryo transfer.
No universally agreed classification ,distal tubal damage has been classified in mild ,moderate & severe ,based on peritubaladhesions,degree of fimbrial preservation .apppeararence of endosalphinx in HSG or size of hydrosalphinx (obstetGynecol 1978)
Gold standard in diagnosing tubal patency
Due to all these reason unsuiatble for routine planning,should be kept for high risk pt where pre operatively screening test can be done for assessment
Hsg & laparoscopy are the two classic method for evaluation of tubal patency in infertility & are complementary rather then mutually exclusive, each provide information that the other doesnot & each has advantages & disadvantages.
Most CAT are genus specific they cant diagnose infection specifily
45-82 % success,risk of ectopiv 2-8 %Natural conception & lower risk for multiple gestation ,disadvantage surgical insult, ectopic risk, Laparoscopy v/s laparotomy success rate are now equal yet ectopics are more with laparoscopic ,although patency rates are higher
Systemic review of five studies 2010
Diagnosis and classification of tubal factor infertility
Vasundhara Hospital & Fertility Research
The Fallopian tube plays an important
role in the mechanical transport and
physiological sustenance of the
gametes and early conceptus. Complex
and coordinated neuromuscular
activity, cilial action and endocrine
secretions are required for successful
Compromised tubal damage can occur after
external or internal injury, inhibiting the
normal transport of gametes. The overall
prognosis for fertility depends principally on
the insult and the severity of the tissue
damage; hence, assessment of tubal
damage plays a major role in predicting
occurrence of pregnancy and the likelihood
of developing ectopic pregnancy
Functional competence of the fallopian tubes implies both tubal
patency as well as integrity of the mucosal lining or the
Tubal factor infertility (TFI) includes an array of disorders
affecting one or more of the above components.
Transient or permanent and is manifested by peri-tubal
adhesions, proximal and/or distal tubal blockage or
Severe impairment of the tubal function can occur in presence
of patent tube due to damage to the inner micro architecture.
Classification for scoring Tubal damage
TFI in to the three groups (Grade I : filmy adhesions;
Grade II: unilateral severe damage ; and Grade III:
bilateral severe damage) using the “Hull and
Rutherford” classification system.( BJOG 2004)
Tubal patency testing
Tubal disease is probably best diagnosed by means of
laparoscopy and chromotubation (Lap and Dye) . It can
demonstrate tubal patency as well as assess the pelvis
for the presence of endometriosis and adhesions.
(Meta analysis –Fertil Steril 1995 )
Laparoscopy also helps in staging the tubal disease into
diagnostic and Prognostic categories.
(ASRM ,Fertil Steril 1989)
Laparoscopy & Dye Test
The reference standard for tubal factor assessment
Patency, periadenxal adhesions & Endometriosis can be
Additional information on uterine malformation
Advantage of correcting underlying pathology
General anaesthesia needed
Surgical complications (1.3-1.5%) (human reprod.1998)
Availablity of Operating facilities
First line most common test
(crosignani & rubin 2000.,lanzani et al 2004)
Hysterosalpingography (HSG) – Which involves a pelvic
X-ray following the injection of a radio opaque iodinebased dye through the cervix, is less invasive, and can be
helpful in cases where laparoscopy is contraindicated or
hazardous, or in women at low risk of pelvic pathology.
Its ability to identify the site of obstruction and to delineate
the mucosal pattern of the endosalphinx means that, HSG
has a role in assessing the extent of tubal
Disease.HSG also has a therapeutic effects
(Watson et al –Fertil Steril 1994., 2002.,
Sing. Med. J. 2007)
Relatively inexpensive OPD procedure.
As a test of tubal obstruction it has a sensitivity
0.65(95% CI 0.50 – 0.78) & a specificity of .83 (95% CI
0.77 – 0.88) compared to lap & dye.
( Meta analysis – Fertil Steril 1995)
HSG is a reliable indicator of tubal patency ,relatively
poor at identifying cases of tubal occlusion .( Fertil
Steril 2011 )
HSG has certain limitations in diagnosing spasm from
proximal tubal occlusion & pelvic pathology.
According to the fertility-guideline of the
National Institute for Clinical Excellence
(NICE, 2004), HSG should be offered to women
who are not known to have co-morbidities
(such as a history of pelvic inflammatory
disease, previous ectopic pregnancy or
endometriosis) to screen for tubal pathology. In
women who are assumed to have comorbidities, laparoscopy should be offered
instead of HSG.
Chlamydial antibody testing (CAT) has become a popular
test because seroepidemiological studies have
demonstrated a link between serum antibodies ,
chlamydia trachomatis and TFI.
A meta analysis of 23 study reported the discriminative
capacity of CAT, comparable to HSG in diagnosing
( Meta analysis Fertil Steril 1997) (Mol et al .,1997)
Most importantly, a positive result gives no information
on the severity of TFI and therefore, fertility prognosis.
The advantage of HSG is that it has a high specificity
(Swart et al., 1995), accurate in confirming the absence
of tubal pathology, with oil-soluble contrast medium
has a positive effect on pregnancy rates (Luttjeboer et
So far, this positive effect on pregnancy rates has not
been found when water-soluble contrast medium was
used (Perquin et al., 2006).
The role of HSG in the fertility evaluation of low-risk
patients (i.e. CAT- negative women) deserves critical
In CAT-positive high-risk patients, HSG should be
omitted because of the 10% risk of post-HSG
complications in the absence of additional value in risk
assessment of tubal pathology.
Sonohysterosalpingography involves the use of ultrasound
along with injection of a sonoreflective contrast medium
through the cervix (HyCoSy)
In comparison to lap & dye test & HSG it has shown good
concordance. ( Eur J Radio 2000 )
Holz et al 97., performed a meta-analysis of the results of
three clinical studies comparing the ultrasound echo-contrast
with HSG .
Additional advantage of ultra sound assessment of pelvis & is
superior in detection of intrauterine lesions.
Campbell et al., 1994.,Heikkinen et al 1995
Salpingography, performed either laparoscopically of
hysteroscopically, offers an opportunity to visualize the
endosalphinx and diagnose intraluminal tubal damage.
The extent of tubal damage may not correspond with
that of peri-adnexal adhesions.
There are no experimental studies comparing this
approach with conventional methods of tubal evaluation.
Human Reprod 1999, J A G L 2001
Routine assessment of Tubal status is debatable in
situation where knowledge of tubal patency is unlikely
to change the proposed management plan – such as
severe male factor infertility.
Treatment of tubal factor infertility
Wu and Gocial explored cumulative conception rates in women
with untreated tubal disease, graded from 1 (mild) to 4
(extensive) based on the presence of adhesions , salpingitis , and tubal
occlusion and scored as mild, moderate , severe, or extensive.
Cumulative conception rates related to tubal disease grading, compared to normal
Fecundity was reduced in tubal infertility and up to
10% of the pregnancies in women with TFI were
Intrauterine pregnancies have been reported women
with tubal block diagnosed with HSG and lap and dye.
The cumulative pregnancy rate in women with tubal
disease on the waiting list for in vitro fertilization was
2.4%. ( Lancet 2002 )
Infection -as a causative factor in the genesis of TFI.
Tubal infection may persist despite repeated courses of antibiotics,
and the role of antibiotic therapy in cases of TFI secondary to
pelvic inflammatory disease is unproven.
Women with tuberculosis require chemotherapy, but this
will not reverse the damage present. After treatment, increased
ectopic and miscarriage rates are reported on a background of
decreased conception.(J.Indian med. Asso.1996,2002)
Tubal flushing with an oil-soluble contrast medium will
increase pregnancy rates compared with no intervention.
Surgery has a complementary role to IVF in the management of patients with
Counseling is complex and a number of factors should be taken into account
before a decision is made to embark on surgery.
Effect of surgery is not limited to one or more episodes of treatment.
Risk of ectopic pregnancy has to be kept in consideration.
The evidence underpinning the decision to perform surgery as opposed to other
interventions,as IVF & expectant management,is very limited.
There are few randomized trials and most of the data are from uncontrolled
Proximal tubal obstruction
Proximal tubal obstruction (PTO) may occur in
either the intramural segment or utero-tubal
junction. It accounts for 10-25% of tubal factor
infertility. In up to 40% of women is due to spasm or
(Fertil Steril 1999, Radiology 1994)
Tubal cannulation , anastomosis & IVF
Selective salpingography with tubal cannulation
Diagnostic selective salpingography differentiates true PTO from
blocks due to spasm or plugs and can delineate the exact site of
occlusion. Canalization can be done under sonography , fluroscopy
or under hysteroscopic guidance
Reocclusions, perforation, bleeding, infection
Pregnancy rates reported – 9-57%
No RCT’s or observational studies have compared with conservative
Hysteroscopic cannulation has much higher pregnancy rates then
salpingographic catherization. ( Fertil Steril 1999,2007 )
Tubo- Cornual anastomosis – 27-53% live birth rate (Fertil Steril 87)
( Post surgical ectopic rates are >8%)
- Int.J.Fertil 1998
Distal Tubal obstruction
Distal tubal obstruction accounts for 85% of all cases of
TFI and is caused by PID, adhesions from previous
surgery, and endometriosis.
Surgery & ART
Non-randomized data suggest higher pregnancy rates in
women who were treated surgically compared with
those who were not. Surgery was more effective in
women with mild disease and the outcome was
closely linked to the severity of tubal damage.
There are no randomized trails comparing IVF with tubal surgery. In
women with mild adhesions or distal Blockage, observational data
suggest that pregnancy rates after tubal surgery are comparable to
those following IVF.
Pregnancy rates after micro surgery ranged from 5% to 40% in 36
months to 50 months & ectopic rates 23%
(Cochrane database of systemic review 2000.,CD000221.2007 CD
0006415 Fertil Steril 1986,98., human reprod. 2004 )
Mild disease stage I
Moderate disease stage II
In a retrospective cohort study, BJOG 2004 , explored
the live birth following tubal reconstructive surgery in
women under 40 years. Women were grouped
according to the severity of disease.
Grade I tubal damage involved Filmy adhesions,
grade II and Grade III referred to Unilateral severe
damage and bilateral severe damage, respectively.
Ectopics rates increased with severity .
Cochrane database review 2000
No difference in pregnancy rates - laser adhesiolysis or
diathermy (53% vs.52%)
Use of operating microscope vs loupe for micro tubal
surgery ( 72% vs. 78% )
Laparoscopy vs. laparotomy for distal tubal surgery –
overall pregnancy rates were comparable ,in severe
tubal disease laparotomy was found to have higher
Cochrane database review 2000
Postoperative hydrotubation-no improvement in
Hydrotubation with steroid / antibiotics-not appears
to improve the pregnancy rates.
Second look laparoscopy with adhesiolysis-falls in the
Data suggest that most pregnancy resulting from tubal
surgery occur between 12-14 months.
fertil steril 1982,1991,1995
In younger women with mild distal tubal occlusive disease,
laparoscopic surgery may be viewed as an alternative to IVF, but
when disease is severe or pregnancy does not occur during the
first postoperative year, IVF is the logical choice.
For older women with any significant degree of distal tubal
disease, IVF is generally the first and best option because cycle
fecundability after distal tubal surgery is low (1-2 %), time is
limited, and IVF is both more efficient and more effective.
Reversal of sterilization
Systemic review failed to identify any trials comparing
IVF verses reversal of sterilization.
Age ,type & site of anastomosis, final length of the
repaired tube and risk of ectopic must be considered.
IVF for TFI
20% of the IVF cycles in UK in 2008 were undertaken
Success with expectectant management is so poor for
moderate and severe tubal disease that there is a little
equipoise to support - a randomized trial comparing it
with IVF –Human reproduction 1994 , 1999.
Hydrosalpinges affect the outcome of the IVF by lower
pregnancy rates, poor implantation and early
pregnancy loss . salpingectomy prior to IVF results in
increase live birth rates (cochrane database 2010.)
When deciding on treatment for TFI important factors
are –patient selection and number of IVF cycles
Reserving surgery for PTO, low grade disease and
reversal of clip sterilization- number of operations can
be reduced , repeated attempts at conception allowed
and good live birth rates achieved .
This must be balanced against the risk of OHSS ,
multiple pregnancies , and the fact that, at present
many women have fewer cycles of IVF due to cost
Prognosis should be individualized taking into
account local experience and age of the patient.
Challenges of evidence based
approach to TFI
Lack of evidences
The diagnosis of TFI is influenced by the nature of the
Difficulty in comparing the outcome with IVF
The evidence based underpinning interventions for
the diagnosis & treatment of tubal factor infertility is
limited & mainly reliant on observational data. despite
the absence of data from RCTs current pregnancy &
live birth rates associated with IVF suggest that this is
the treatment of choice for older women with
moderate to severe tubal factor infertility.
Selective salpingography or hysteroscopic cannulation
of the tube is useful in confirming true PTO and may
have role in treating this condition.
Risk of ectopic pregnancy are relatively high following
both IVF as well as tubal surgery.
There is need for more trials of surgery verses IVF and
of alternative surgical techniques in mild tubal disease
& post tubal sterilization.
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