Dr Suman Bijlani, Gynaecologist, Sonologist, Infertility Specialist, Obstetrician and Laparoscopic Surgeon, Mumbai.

Infertility due to damaged tubes

What are fallopian tubes? How do they help achieve pregnancy?

fertilisation

The fallopian tubes are pipe-like structures which transport the sperms towards the ovum (unfertilised egg) and also transport the fertilised egg from the fallopian tube to the uterus so that it can get embedded into the uterus and pregnancy can result.

The fallopian tubes have the following special features which allow the tubes to function normally:

  • The inner lining of the tubes have fine hair called ‘cilia’ which help to move the sperm/egg in one direction or the other.
  • The inner lining of the tube is lubricated with fluid which allows smooth passage of the sperm/egg and also nourishes the egg during transportation.
  • The muscle layer of the tube contracts and relaxes (just as our intestines contract to move our food forward) to help the passage of the sperm/egg.

The good news is that even if one tube is open and is functioning normally, you have the ability to conceive.

What tests do I need to undergo to find out if my tubes are normal? What information do these tests give?

There are several tests to find out if the tubes are ‘normal’ or ‘blocked’ or ‘diseased’.

There is no one perfect test. Every gynaecologist has preferences based on his/her experiences and he/she may individualise the tests for you depending on your particular needs.

These are the tests available for tubal evaluation:

Hysterosalpingography (HSG) is a simple, cheap and commonly-performed test in which dye is injected into the uterus and xays are taken. Thus the outline of the uterus and fallopian tubes can be seen clearly. It is performed on out-patient basis and does not need anaesthesia. It can tell us whether the tubes are blocked and if so, at what level. It may not tell us the cause, however. Also, in early tubal disease, the HSG report may be completely normal.

HSG

Damaged tubes may present in the following ways:

  • Distorted tubes – tubes which are pulled to one side or the other and may be kinked
  • Beaded tubes (appearing as beads of a necklace) as seen on xray (hysterosalpingogram)
  • Blocked tubes – may be blocked near the uterus, in the mid-portion or at the far end
  • Dilated tubes - collection of fluid or pus/blood (rare)

Sometimes the tubes may appear normal, but their function may be damaged (one cannot prove that).

Occasionally, the HSG may show that both the tubes are blocked at the very beginning (cornual block). This may happen due to spasm (temporary contraction of the tubal muscles due to pain or anxiety) and the tubes may be completely normal. Laparoscopy can tell differentiate between cornual block (block due to disease) and spasm.

Laparoscopy is a procedure performed to evaluate the pelvic organs under general anaesthesia. A telescope is inserted into the abdominal cavity through the umbilicus and the organs are examined under magnification. We can examine the uterus, tubes, ovaries and their relationship to each other. We can diagnose tubal disease – whether the tubes are blocked, and if so, at what level and the cause may be determined in most cases.

At laparoscopy, the fertility specialist can also decide what kind of treatment is going to work (whether to go for surgery or IVF). At the same time, he/she can correct the problem by operations like adhesiolysis (removing adhesions around the tube/uterus/ovaries), cauterisation of endometriotic spots or tubal surgery to open up the tubes.

Hysteroscopy:

A telescope is inserted into the uterus to assess the inside of the uterine cavity. In cases of cornual block (tubes blocked at the junction of the uterus and tubes), a procedure known as cornual cannulation may be performed. A thin tube is introduced into the tubal opening and the opening is widened. It is a very simple procedure with minimum risk and has a success rate of 60-70% in opening up at least one tube.

Salpingoscopy:

In this technique, a telescope is introduced into the fallopian tube to evaluate its inner lining (insides). It is not widely used, but can give valuable information about the health of ciliary hair and inner lining. Salpingoscopy can be done at the time of laparoscopy or hysteroscopy.

My doctor has told me that my tubes are open. Does that not mean that my tubes are normal? Is it possible that my tubes are open, but there is still a problem?

It is a common notion that if the tubes are ‘open’, there is no problem. But that need not always be true. Often the tubes are open (not blocked physically), but if the transport mechanism is not working properly, they will not be able to help the sperm and ovum meet to cause fertilisation. This may prevent pregnancy or cause ectopic pregnancy (pregnancy within the tube).

What are the causes of tubal disease? What are the consequences?

In many conditions such as PID (pelvic inflammatory disease which is caused by pelvic infection), genital tuberculosis, endometriosis or post-operative damage, the inner lining of the tube or the muscle layer may be damaged and the tube may not be functioning to its best. This may result in infertility or ectopic pregnancy.

What are my options if my tubes are diseased / damaged?

The first obvious rule is to treat the cause.

  • If the cause is tuberculosis, you have to be treated to a full course of anti-tuberculous medicines.
  • If the cause is infection, you need to take a full course of antibiotic therapy.
  • If the cause is endometriosis, surgery for endometriosis can help restore the position and shape of the tubes.

The unfortunate part, sometimes, is that the damage already caused may be irreversible. In that case, treatment may prevent further damage, but the prior damage may not be cured.

How do I know whether surgery or test tube baby is best for me?

There are two ways to overcome tubal disease:

Surgery – to open the tubes

Test tube baby (IVF/ICSI) – to bypass the tubes

Tubal Surgery:

hydrosalpinx

During tubal surgery, the diseased part of the fallopian tube is cut away and the remaining parts are stitched together and adhesions around the tube, if any, are removed or cut. If a long segment of the tube is damaged, surgery does not work well as the remaining length of the tube is very small and may not support conception.

Surgery works best for patients who have early disease (with minimum damage to the inner lining) and for mid-tubal block. If the tube is dilated (hydrosalpinx) or the block is at the cornu (the uterine end of the tube) or at the fimbria (the far end of the tube), the results of surgery are not as good.

Also, one should rule out other factors which may affect fertility. For example, your husband’s semen should be within normal limits and your uterus should be normal and ovaries should be capable of producing eggs.

Surgery has very good success rates in good surgical hands and in properly selected cases, but may not be useful for many women (as mentioned above), especially in cases of genital tuberculosis.

IVF/ICSI:

Assisted reproductive techniques are very useful in patients with severely damaged or blocked tubes. Since the union of the sperm and egg is carried out outside the body (in a petri dish inside a lab), the tubes are not needed for fertilisation. The fertilised egg is put back into the uterus, so pregnancy can result.

Today, most fertility specialists prefer test tube baby procedures to surgery.

My doctor has told me to do surgery for excision of hydrosalpinx (dilated part of tube). How will that help? How will I conceive if the doctor removes a part of my tube?

A hydrosalpinx is a fluid-filled part of the fallopian tube which is formed due to infection. The fluid contains inflammatory substances and toxic material which may harm the egg/sperm/embryo. It has been found that women with hydrosalpinx have lower success rates with IVF/ICSI. Hence, you may be advised to remove the hydrosalpinx before attempting IVF/ICSI.

In summary, tubal disease can present in many forms, but advanced fertility treatments give hope to many women.

I hope this article has helped you understand your body and your fertility challenge better. You may leave a comment or query so that I may be able to help you better.

 

 

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