Diagnosis and classification of tubal factor infertility


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  • 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

    1. 1. Dr.Sanjay Makwana Vasundhara Hospital & Fertility Research Centre Jodhpur www.vasundharafertility.com
    2. 2.  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 tubal function
    3. 3.  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
    4. 4.  Functional competence of the fallopian tubes implies both tubal patency as well as integrity of the mucosal lining or the endosalphinx.  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 hydrosalphinx formation.  Severe impairment of the tubal function can occur in presence of patent tube due to damage to the inner micro architecture.
    5. 5. 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)
    6. 6. 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)
    7. 7. Laparoscopy & Dye Test  The reference standard for tubal factor assessment  Patency, periadenxal adhesions & Endometriosis can be assessed  Additional information on uterine malformation  Advantage of correcting underlying pathology      Invasive Expensive General anaesthesia needed Surgical complications (1.3-1.5%) (human reprod.1998) Availablity of Operating facilities
    8. 8. Hysterosalpingography (HSG) 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)
    9. 9. HSG  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.
    10. 10.  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.
    11. 11. 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 Tubal Factor. ( 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.
    12. 12.  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 al., 2007).  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 reappraisal.  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.
    13. 13. SSG 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
    14. 14. Salpingography 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
    15. 15.  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.
    16. 16. Treatment of tubal factor infertility Conservative 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
    17. 17. Fecundity was reduced in tubal infertility and up to 10% of the pregnancies in women with TFI were ectopic. 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 )
    18. 18. Medical 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.
    19. 19. SURGERY Surgery has a complementary role to IVF in the management of patients with TFI. 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 observational studies.
    20. 20. 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 transient occlusion. (Fertil Steril 1999, Radiology 1994) Tubal cannulation , anastomosis & IVF
    21. 21. 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 management 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
    22. 22. 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.
    23. 23. 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 ) Surgery Mild disease stage I Moderate disease stage II Stage III 67% 41% 12% Stage IV 0% No Surgery 24% 10% 3% Surgery not offered
    24. 24. 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 .
    25. 25. 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 pregnancy rates.
    26. 26. Cochrane database review 2000  Postoperative hydrotubation-no improvement in     pregnancy rates Hydrotubation with steroid / antibiotics-not appears to improve the pregnancy rates. Second look laparoscopy with adhesiolysis-falls in the same category. Data suggest that most pregnancy resulting from tubal surgery occur between 12-14 months. fertil steril 1982,1991,1995
    27. 27. 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.
    28. 28. 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.
    29. 29. IVF for TFI  20% of the IVF cycles in UK in 2008 were undertaken for TFI.  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.)
    30. 30.  When deciding on treatment for TFI important factors are –patient selection and number of IVF cycles available  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 constrants.  Prognosis should be individualized taking into account local experience and age of the patient.
    31. 31. Challenges of evidence based approach to TFI  Lack of evidences  The diagnosis of TFI is influenced by the nature of the test used.  Difficulty in comparing the outcome with IVF  Maternal age  Cost effectiveness
    32. 32. conclusion  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.
    33. 33. conclusion  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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