Chapter 47 Tubal Disease

INTRODUCTION

Tubal disease is one of the most common causes of infertility and is almost always preventable. It is usually the result of sexually transmitted disease; therefore, prevention is the key intervention for this cause of infertility. In the past, the surgical management of tubal disease often differentiated the skilled infertility expert from his peers. The advent of in vitro fertilization (IVF) has greatly diminished the role of reconstructive tubal surgery for severe forms of tubal disease but remains a viable option for mild to moderate disease. The quest by couples to have a natural conception with reduced risks of multiple pregnancies has made this approach appealing to many couples.

This chapter describes the classification and evaluation of tubal disease, including commonly used radiographic and surgical techniques. Special attention is paid to the management of hydrosalpinges in women undergoing IVF. Various treatment options for these conditions are also discussed.

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

Figure 47-1 A, Patient with chronic pelvic inflammatory disease and (B) perihepatic adhesions (Fitz-Hugh–Curtis syndrome), usually related to previous gonorrhea or chlamydia infection.

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.

Hysterosalpingography

HSG is a contrast study of the fallopian tubes and the uterine cavity. It is widely used because it is simple, cost-effective, and associated with minimal side effects. Distal tubal blockage is usually associated with a hydrosalpinx. A potential limitation of HSG is tubal spasm, which can give a false impression of proximal or cornual occlusion. The incidence of false-positive results is estimated to be 50%.³ Hurd and colleagues reported that an apparent unilateral obstruction might be resolved in more than 50% of the patients by rotating the patient in a direction that places the obstructed tube in more inferior position.⁴

Pregnancy can occur after HSG. Perhaps, this is due to dislodging of a mucus plug or necrotic debris from the tubal lumen. In a randomized study, the pregnancy rate in women with patent tubes was 64% after HSG using oil-soluble contrast medium and 56% after the use of water-soluble contrast medium.⁵

Sonohysterosalpingography

Sonohysterosalpingography, also referred to as hystero-contrast-sonography or HyCoSy, is an alternative to HSG. The technique involves introduction of fluid into the uterine cavity. This is an outpatient procedure that usually lasts about 20 minutes. Saline solution is an echo-free contrast medium for assessment of the uterine cavity. The fallopian tubes can be evaluated by another contrast medium, such as air, albumin with micro-air bubbles, or galactose with micro-air bubbles. This contrast medium outlines the fallopian tube, giving a hyperechoic appearance.⁶

In a meta-analysis that included more than 1000 women, a similar rate of detecting tubal pathology was reported between sonohysterosalpingography and HSG or laparoscopy.⁷ Sonohysterosalpingography showed a false tubal occlusion in 10% of cases when compared to laparoscopy and chromopertubation. When sonohysterosalpingography was compared to HSG, a false-positive rate of 13% was found.

Laparoscopic Procedures

Laparoscopic Chromopertubation

This has been the gold standard for investigating tubal patency. Furthermore, laparoscopy permits direct visualization of the whole peritoneal cavity, including other pathology such as perihepatic adhesions (see Fig. 47-1B). Details of this procedure are reviewed in Chapter 44.

Transhydrolaparoscopy

This technique involves the use of a culdoscopic approach and the use of a small endoscope to explore the pelvic cavity. It is performed with the patient in the dorsal lithotomy position. Using saline solution as a distension medium, the posterior aspect of the uterus and tubo-ovarian structures are inspected. The saline instillation continues throughout the procedure to float the tubes and the ovaries. The advantage of this procedure is that it can potentially be used in an office setting. The disadvantage of this procedure is that it does not allow evaluation of the whole abdominal or pelvic cavity. The main concern of transhydrolaparoscopy is bowel injury (about 0.65%).⁸

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 technique ¹³ 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.

Basic Principles of Tubal Surgery

Most reproductive surgery is performed by laparoscopy. Compared to open surgery, laparoscopic surgery is a low-risk procedure, usually does not require hospitalization, and is associated with less postoperative pain than laparotomy. Nevertheless, it requires gentle handling of the tissue, good hemostasis, and careful dissection of the tissue.

At operative laparoscopy, dissection is better performed using sharp dissection with minimal use of electrical or laser energy. Thermal damage is associated with higher risk of adhesion formation. The use of sutures should be limited as well. However, if needed the suture material should be fine and nonreactive (e.g., 6-0 polyglactin or polyglycolic acid). The sutures should be placed without strangulating the tissue. Hemostasis is achieved using microbipolar forceps.

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.