Options for the management of tubal infertility
series on infertility,
Dr Valentine Akande
and Dr David Cahill explain what NICE
on tubal problems
Tubal damage accounts for 14-38 per cent of infertility in the Western world and up to 80 per cent in some developing countries. Very often we refer to tubal problems associated with infertility as blocked tubes. In fact, the majority of women with tubal problems are unlikely to have blocked tubes. The majority will have adhesions and scarring of the tubes, which restrict function and movement. In cases where tubal blockage (occlusion) does occur this could be partial or total and tends to most commonly affect the distal portion of the fallopian tubes. The resultant distal blockage often leads to the accumulation of fluid and therefore swelling of the tubes (hydrosalpinges).
The fallopian tube is a sophisticated organ that requires the cellular mucosal lining (endosalpinx) to be functionally normal in order to facilitate transport of the embryo down the tube to the uterus following fertilisation.
This endosalpinx is often destroyed following upper genital infections. So a functionally normal tube requires not only to be patent and free of adhesions but also to be free of internal damage. Because any damage caused to fallopian tubes is permanent and irreversible, management can be difficult.
Causes of tubal damage
Most commonly tubal damage is a consequence of acquired ascending genital tract infection, but this could also occur following surgery and extra-tubal infections arising in the abdomen and pelvis such as those due to appendicitis. Occasionally, damage and restriction of tubal function can occur in the presence of severe endometriosis. The role of IUCDs in the spread of tubal infection is controversial. By the mid-1980s at least 25 studies had reported an increased risk of PID among IUCD users as compared with non-users.
Although there is a higher risk of infection in the few weeks following insertion of an IUCD, more recent authors argue IUCD users selected for low risk of sexually transmitted infections (STI), or screened for them, are at no greater risk of pelvic inflammatory disease (PID) than that which occurs in the background population.
It is now widely recognised in the Western world that tubal damage is most likely to be caused by Chlamydia trachomatis leading to PID. As such, factors associated with acquiring chlamydial infections and PID are also associated with an increased risk of having tubal damage.
These factors include multiple sexual partners, young age at first intercourse, poor socio-economic status, heavy alcohol consumption, cigarette smoking and previous termination of pregnancies. Other sexually transmitted infections known to be frequently associated with tubal damage include gonorrhoea and Mycoplasma genitalium.
Tubal damage does not always occur following ascending genital infections or PID. After a single episode of acute PID, approximately 15 per cent of women will be infertile as a consequence of the resultant tubal damage. The risk of infertility doubles with each successive episode of PID and infertility is more likely to result from chlamydial infection than gonococcal or other infections. Therefore, prevention of STIs and aggressive treatment of suspected PID should result in fewer people becoming infertile due to tubal problems.
Infertile women who are found to have scarred or occluded tubes usually give no previous history of PID. This is often due to silent chlamydial infections (few infected women experience any symptoms of the acute episode). In these cases the sole manifestation is tubal damage discovered during the course of investigations for infertility. This 'silent' PID is not easily recognised on clinical grounds and accounts for a sizeable proportion if not the majority of tubal infertility.
Clinical experience has shown history and examination are very poor at detecting women with tubal damage. Screening for evidence of past chlamydial infection using serology has been shown to be a good way of detecting women likely to have tubal damage1. Such serological tests measure IgG antibodies in serum that remain detectable for many years following the primary infection.
Women with high serological antibody titres can then be referred for further diagnostic tests which include hysterosalpingography (HSG), hysterosalpingo-contrast sonography (HyCoSy) and laparoscopy with dye hydrotubation. Before any of these invasive tests it is important to screen for STIs as uterine instrumentation can lead to a flare of PID if the organisms are present in the cervix.
The HSG is an X-ray based contrast study of the fallopian tubes and uterine cavity which is very good at detecting tubal occlusion. This is because the contrast medium delineates the internal structure of the fallopian tube and the location of occlusion if present. But HSG cannot provide information on the presence of tubo-pelvic adhesions, which may be restricting tubal function.
HyCoSy is a recently introduced procedure in which an echodense contrast medium is passed through the cervix and passage through the fallopian tubes is visualised using ultrasonography, so it can be undertaken as an outpatient procedure.
The gold standard for the diagnosis of tubal damage and for assessment of tubal patency is a laparoscopy and dye hydrotubation.
In this test, dye is passed through the cervix and seen to come out of the fallopian tubes at laparoscopy if the tubes are patent. The main advantage of the laparoscopy is that adhesions can be visualised and often dealt with at the same time.
Sequelae of tubal damage
Because embryo transport is impaired in women with damaged fallopian tubes, ectopic pregnancies are common sequelae.
In any population, the ratio of ectopic pregnancy to intrauterine pregnancy is related to the prevalence of women exposed to pregnancy and the distribution of risk factors for ectopic pregnancy.
Women with a history of acute PID have been shown to have a seven-fold increased rate of ectopic pregnancies. Although most chlamydial infections are silent, ectopic pregnancies are also strongly associated with infection by this organism.
Evidence from an opportunistic cervical chlamydia screening programme in Sweden resulted in a significant decline in ectopic pregnancies2.
Management of tubal damage
Operative procedures to reconstruct occluded fallopian have been described for more than a century. Restoring patency and anatomy in anticipation of an improved ability of ovum pick-up and transfer is the main objective of tubal surgery. Infertility, however, is rarely absolute and many women with a diseased pelvis and fallopian tubes conceive without treatment.
The limiting factor is mainly irreversible tubal mucosal (endosalpinx) damage and the severity of disease3. As such, patient selection greatly influences success rates following tubal surgery. But because success rates continue to improve with IVF treatment some consider tubal surgery obsolete. Especially as there has been no significant recent advance in tubal surgery in the past decade
or so, in spite of the more
widespread use of laparoscopic surgery.
The majority of infertile women with tubal damage are unlikely to conceive without help and IVF offers the best option for most women with tubal damage. But at present in the UK, IVF is beyond the financial reach of many couples afflicted by tubal damage.
Tubal surgery offers them a viable alternative. Tubal surgery appears to only benefit women with minor or moderate damage. It is of no benefit to women with severe disease. In fact, there is growing evidence to support the practice of removing fallopian tubes afflicted by hydrosalpinges as they cannot be repaired by surgery and research has shown the presence of hydrosalpinges adversely affects the success of IVF treatment if not removed.
In women who have proximal tubal occlusion it may be possible to cannulate the fallopian tube under
X-ray guidance as an outpatient procedure and thus restore patency (selective salpingography).
Valentine Akande is a clinical lecturer
at St Michael's Hospital, University
David Cahill is a consultant senior lecturer at the Centre for Reproductive Medicine, University of Bristol
lHistory and examination are poor indicators of tubal damage
lFallopian tube damage is permanent and irreversible
lChlamydia is accepted as a major cause of tubal damage, the patient's history will often show their risk,
even if their infection was 'silent'
lIUCDs should be safe if patients are properly screened
lThe majority of infertile women with tubal damage will need IVF
lTubal surgery is a viable option in less severe cases
of tubal damage
1 Akande VA et al. Tubal damage in infertile women: prediction using chlamydia serology. Hum Reprod 2003;18:1841-47
2 Egger M et al. Screening for chlamydial infections and the risk of ectopic pregnancy in a county in Sweden: ecological analysis. BMJ 1998;316:1776-80
3 Akande V. Tubal pelvic damage: prediction and prognosis. Hum Fertil 2002;5 (Suppl 1):S15-20