Tubal Factor Infertility – By Dr Ankita Kaushal

Tubal Factor Infertility

Why are fallopian tubes important?

Tubal factor infertility occurs when the fallopian tubes are blocked, preventing the egg from reaching the uterus for fertilization. Fallopian tubes are hollow muscular tubes, inside they are lined by hair-like bristles. They originate from the uterine cavity and end on top of the ovaries. There are 2 fallopian tubes one on each side. The ovarian end has finger-like structures that help to suck in the egg in the tube after ovulation. The sperms swim from the vaginal cavity into the uterine cavity to the tubes. The egg is fertilized by the sperm in the tubes. This is where the embryo forms and starts to develop further. After a few days of development in the tubes. The embryo is shifted to the uterine cavity where it implants after which you are pregnant.

In case of any kind of damage to the fallopian tubes. The sperm will not reach the egg for fertilization, the embryo might not form, and the embryo might not survive in damaged tubes.

For all of the above to happen and pregnancy to occur. Patient & functional fallopian tubes are more important.

What damage can happen to the tubes?

• One or both tubes can be blocked. Tubes can be blocked at the point of origin from the uterus (proximal block or corneal block). In this case, sperm will not be able to reach the egg and fertilization will not happen. Tubes can be blocked at the fimbrial end (near the ovaries). In this case, fluid can accumulate in the tubes. Which might drain into the uterine cavity and hamper implantation of the embryo (in the case of IVF/ICSI).
• Tubal scarring due to previous surgeries (ruptured appendix, ruptured ectopic pregnancy, ovarian torsion, ruptured ovarian cyst, endometriosis.)
• Disturbed tubal anatomy ( adhesions due to pelvic infections, endometriosis, previous surgeries, pelvic tuberculosis).
• Kinking of the tubes due to adhesions.

What are the causes of Tubal damage? 

• Infections: pelvic infections; sexually transmitted diseases such as chlamydia, gonorrhea, pelvic tuberculosis.
• Endometriosis.
• Ruptured Ectopic pregnancy. (The affected tube is removed)
• Previous surgeries for a ruptured appendix, ovarian cyst, endometriosis, and ectopic pregnancy.
• History of Tubal ligation

How to diagnose tubal problems?

Tubes are usually checked only when a couple is evaluated for infertility. It is commonly found in younger age groups.

• HYSTEROSALPINGOGRAM: a dye is passed through your uterus, if tubes are open, pit asses through the tubes and leaks into the pelvis. X-RAY films are taken at 0, 5, and 10 minutes to record the presence/ absence of dye in the tubes and leaking into the pelvis. Done on an OPD basis, no anesthesia required.
• SONOSALPINGOGRAPHY: sterile normal saline is passed through the uterine cavity with the help of a flexible catheter. On sonography, the presence of saline (water) is seen below the uterus, suggesting that either one or both tubes are open and that is how saline leaked into the pelvic cavity. It is an OPD procedure, and no anesthesia is required.
• HIGH CONTRAST SONOSALPINGOGRAPHY: same as sonosalpingography, but in place of normal saline, contrast is passed which is visible on sonography. It is an OPD procedure, and no anesthesia is required.
• LAPAROSCOPY AND CHROMOPERTUBATION: a laparoscope is inserted in the lower part of the tummy. Methylene blue dye Is passed into the uterus and is documented under direct vision if tubes are open ( dye flows out) or blocked ( dye does not flow out). This is the gold standard for the diagnosis of blocked tubes. It requires anesthesia and hospital admission.

What is another diagnosis, If tubes are not blocked?

• Tubal muscle spasm ( corneal fimbrial): Sometimes due to mild pelvic infections or any other reasons, the two open points of the tubes ( uterine end and ovarian end) can go into spasm. This can give a blocked tube like of picture on HSG/SSG/HYCOSY. Only on laparoscopic evaluation, if the dye is pushed forcefully, it might relieve the muscle spasm and tubes will be patent and functional.
• Thin adhesions: Due to some other pathology or previous surgery, thin flimsy adhesions form that might cause kinking of tubes, giving an impression of blocked tubes. On laparoscopic evaluation, once the adhesions are removed, the tubes become patent and functional.

How to treat blocked tubes?

1. If tubes are normal in structure and are blocked due to other problems ( tubal muscle spasm, thin adhesions) once the correction is done, tubal function is restored.
2. If tubes are blocked but there are no signs of any other pathology, tubal cannulation can be done to relieve muscle spasms This will restore the functional capacity of the tubes. Tubes can get blocked after this also. This also might increase the chances of Ectopic pregnancy.
3. If the tubal pathology is severe ( bilateral block, tuberculosis, hydrosalpinx, endometriosis), ASSISTED REPRODUCTIVE TECHNIQUES (IVF/ICSI) give better chances of achieving pregnancy.
4. In the case of hydrosalpinx (fluid-filled in tubes) or pyosalpinx (plus-filled in tubes), it might drain into the uterine cavity decreasing the chances of implantation of the embryo. In such situations, removal of affected tube/tubes or clipping of tube/tubes should be done, to increase chances of pregnancy following embryo transfer.