Tubal disease is a common cause of female infertility. A woman’s fallopian tubes may become blocked from endometriosis, prior pelvic surgery or infection, or unexplained reasons.
Treatment of tubal factor infertility depends on the cause, whether or not the condition is correctable, and the goals of the patient.
A hysterosalpingogram, or HSG, is commonly used to screen for tubal abnormalities. If abnormalities are detected on the HSG or if the findings are inconclusive, laparoscopy (surgery) may be used to definitively diagnose and sometimes treat tubal disease.
If the tubes are blocked or damaged beyond repair, IVF is generally the method required to achieve pregnancy. In fact, if blocked tubes are the only abnormality discovered during an infertility investigation, then the couple has a very good prognosis for pregnancy with IVF.
Types of tubal disease
Hydrosalpinx is a condition in which the fallopian tubes are blocked at the end where they meet the ovary. If both tubes are blocked this way, it is nearly impossible to get pregnant without assistance. In addition to an HSG, an ultrasound may be used to diagnose this problem. View a surgical photograph of hydrosalpinx here.
Treatment of hydrosalpinx depends on the goals of the patient. Laparoscopic surgery can be used to create a new opening at the end of the tube, in a procedure called neosalpingoscopy.
The success of this procedure depends on the severity of the dilation, surrounding scar tissue and whether the tube is otherwise normal.
Despite our best efforts, many of these patients will ultimately require IVF if they wish to conceive, as dilated and scarred tubes will often become re-occluded even after they are surgically opened.
Unfortunately, most women with hydrosalpinx cannot proceed directly to IVF. Since the fluid in the tubes cannot drain out the far end, it flows back into the uterus. This fluid is toxic to embryos and alters the uterine lining to make it less hospitable to an embryo.
Some studies demonstrate that hydrosalpinx reduces IVF success rates by nearly 50%. Therefore, surgery is generally recommended to open or remove the tubes before starting IVF. This is thought to restore normal IVF success rates.
Proximal tubal occlusion
Proximal tubal occlusion is blockage of the fallopian tubes where they connect to the uterus. Mucus plugs, fibroids, endometriosis, scarring or inflammation can cause this type of tubal disease.
Proximal occlusion is usually diagnosed by HSG. However, many women diagnosed with proximal tubal occlusion on HSG actually have normal tubes after further investigation via laparoscopy.
While the patient is under anesthesia, blue dye is injected into the uterus under higher pressure than can be obtained during an HSG. If the tube still demonstrates proximal occlusion, a surgical procedure called hysteroscopic canulation can then be performed to attempt repair.
Salpingitis isthmica nodosa (SIN)
Salpingitis isthmica nodosa, or SIN, is one type of proximal tubal disease that is not easily correctible and deserves special mention. The cause of SIN has not been well established, but is associated with endometriosis and may be related to prior inflammation in the tube.
HSG images of SIN typically show “cauliflower” lesions, which are diverticula (out-pouching) of the tubes. Tubes affected by SIN are typically thick and tough when evaluated by laparoscopy.
Women with SIN are at increased risk for infertility and ectopic pregnancy (pregnancy in the fallopian tube). IVF is often recommended for individuals with SIN.
Tubal ligation or sterilization
If the tubes are blocked due to a prior sterilization procedure, the patient has two choices: tubal ligation reversal or IVF. Tubal reversal surgery is usually not paid for by insurance.
The best candidates for tubal reversal surgery are women under 35 years old with normal ovarian reserve testing and a partner with a normal sperm count. Sterilization by one of the following procedures improves the probability of successful surgical repair:
- Filshie clip
- Hulka clip
- Fallope Ring
- Pomeroy occlusion
Women with the ends of the tubes removed (fimbriectomy), less than 6 cm of tube remaining, or whose tubes were burned (coagulated) are less likely to succeed with tubal reversal surgery. We recommend getting a copy of your operative report and bringing it to your initial appointment.