Tubal infertility is a variant of female infertility caused by functional or organic obstruction of the fallopian tubes. There are no specific symptoms. Like other forms of infertility, it is manifested by the inability to get pregnant in the presence of regular sexual relations for 6-12 months. When making a diagnosis, hysterosalpingography, ultrasound hysterosalpingoscopy, laparoscopy, laboratory tests are used to detect STIs. Treatment of tubal-peritoneal infertility includes medication and physiotherapy, hydrotubation, transcatheter recanalization, reconstructive plastic surgery, IVF.
Tubal (tubal-peritoneal) infertility or TI is detected in 35-60% of patients with complaints about the absence of pregnancy. At the same time, anatomical damage or dysfunction of the tubes is observed in 35-40%, the adhesive process – in 9-34% of cases. Since these variants of pathology are often combined with each other, have similar etiological factors and pathogenetic mechanisms, specialists in the field of gynecology have combined these two factors of infertility with one general term. In more than half of cases, tubal infertility is relative and can be corrected during treatment. TI can be both primary and secondary — occurring in women who have already had a pregnancy.
Functional disorders and organic changes in the pelvic organs lead to a violation of the patency of the fallopian tubes. Functional disorders are manifested by a decrease or increase in the tone of smooth muscle fibers of the tube wall, a violation of the coordination of their contractions, a deterioration in the mobility of the cilia of the epithelial layer, insufficient mucus production without visible anatomical and morphological changes. Their main reasons are:
- Hormonal balance disorders. Usually, functional tubal obstruction occurs against the background of reduced synthesis of female and increased levels of male sex hormones.
- High activity of inflammatory mediators. Functional disorders are one of the local effects of prostaglandins, interleukins, eicosanoids and other physiologically active compounds that are intensively synthesized during chronic inflammatory processes in the pelvis.
- Changes in the sympathoadrenal system. Such deviations are characteristic of chronic stress, including constant experiences due to infertility.
Organic tubal obstruction occurs when there are physical obstacles in the way of egg movement – occlusion, adhesions, compression by volumetric neoplasms, etc. The reasons for such anatomical changes are:
- Inflammatory diseases. Adhesions, synechiae, adhesions, fluid in the tubes are detected both with nonspecific inflammation and (especially) against the background of sexually transmitted infections.
- Surgical interventions. Adhesions in the pelvis develop after abdominal operations on the intestines, uterus and its appendages.
- Invasive procedures. The provoking factors of tubal-peritoneal infertility can be abortions, diagnostic curettage, hydrotubation, hydrosalpingography, kimopertubation, etc.
- Traumatic injuries. Anatomical tubal obstruction is caused by penetrating injuries of the abdominal cavity, severe childbirth.
- Tubal ligation. Voluntary surgical sterilization of a woman is actually one of the forms of tubal infertility.
- Volumetric processes in the pelvis. The tubes can be squeezed by large ovarian tumors, subserous fibroids, and other neoplasms.
- External genital endometriosis. Severe forms of the disease are complicated by a violation of tubal patency.
The key link in the pathogenesis of infertility under the action of tubal-peritoneal factors is a violation of the promotion of an unfertilized mature egg or embryo into the uterine cavity. A completely impassable tube becomes a barrier that excludes fertilization of a mature egg by a sperm cell. With a functional violation of the contractile activity of the wall and partial organic obstruction, the movement of the egg through the fallopian tube slows down. As a result, she either does not fertilize at all, or the embryo is implanted in the tube and an ectopic tubal pregnancy occurs.
The clinical classification of tubal infertility is carried out taking into account the localization of the pathological process, the presence or absence of anatomical changes. Specialists in the field of gynecology and reproductive medicine distinguish:
- Actually tubal infertility. A woman cannot get pregnant because of functional or organic disorders in the fallopian tubes. In this case, the obstruction may be proximal with the presence of obstacles in the uterine part or isthmus of the tube and distal with impaired egg capture during ovulation.
- Peritoneal infertility. The egg cannot enter the funnel of the tube due to inflammatory or other processes in the pelvic organs. Often, peritoneal infertility is accompanied by morphological or functional changes in the tubes.
Symptoms of tubal infertility
There are no specific symptoms characteristic of this variant of reproductive dysfunction. As with other forms of infertility, the patient notes the absence of pregnancy for 6-12 months, although she leads a regular sex life and is not protected. The pain syndrome is not pronounced or is characterized by low intensity – periodically bothered by pain in the lower abdomen and (less often) in the lower back, which occur or increase during menstruation and sexual intercourse. Menstrual function is usually preserved. Some women note abundant discharge during menstruation.
The most formidable complication of tubal infertility that has arisen against the background of functional or partial organic obstruction of the fallopian tubes is ectopic pregnancy. A fertilized egg, if it is impossible to get into the uterus, can be implanted into the tube wall, ovarian tissue or abdominal organs. Miscarriage of ectopic pregnancy is accompanied by massive bleeding, severe pain syndrome, a critical drop in blood pressure and other disorders that pose a serious danger to a woman’s life.
When detecting tubal infertility, it is important to take into account anamnestic information about past cervicitis, endometritis, salpingitis, adnexitis, abdominal injuries, operations on the intestines and pelvic organs, abortions, complicated childbirth, invasive diagnostic and therapeutic procedures. The survey plan includes methods such as:
- Gynecologist’s examination. During a bimanual examination, slightly enlarged, compacted and painful appendages may be detected. Sometimes the mobility of the uterus is limited, its position is changed, the arches of the vagina are shortened.
- Hysterosalpingography. When contrasting, changes in shape (local constrictions, extensions) and the patency of the tubes are determined up to a complete violation, in which the contrast agent does not enter the abdominal cavity.
- Ultrasound hysterosalpingoscopy. Allows you to detect obstruction of the fallopian tubes and signs of adhesions in the pelvis.
- Fertility and laparoscopy with chromopertubation. Visually identifies adhesions, foci of endometriosis, provides an objective assessment of the patency of the fallopian tubes by controlling the entry into the abdominal cavity of the dye injected into the cervical canal.
- Transcervical falloposcopy. Endoscopic examination of the epithelium and the lumen of the tubes allows you to most accurately assess their condition.
- Kimopertubation. The motor activity of the appendages when carbon dioxide or air enters them is disrupted.
- Laboratory diagnostics of STIs. Since in some cases the cause of tubal-peritoneal infertility is infectious processes, it is important to identify the pathogen and assess its sensitivity to antibacterial drugs for the appointment of etiotropic treatment.
Tubal-peritoneal infertility must be differentiated from infertility caused by ovarian dysfunction, pathology of the uterine cavity, the action of the cervical factor and causes on the part of the patient’s husband. A reproductologist and gynecologist-endocrinologist are involved in the differential diagnosis.
Tubal infertility treatment
To eliminate the causes that caused the violation of the patency of the pipes, conservative and operative methods of treatment are used. Drug therapy includes:
- Antibacterial drugs. Etiopathogenetic treatment is aimed at eliminating the pathogen of STIs that caused the inflammatory process.
- Immunotherapy. It allows correcting immunological disorders that lead to a prolonged and chronic course of salpingitis and adnexitis.
- Resorption therapy. Local and general use of enzyme preparations, biostimulants, glucocorticosteroids is indicated for the resorption of adhesions and synechiae that have arisen after infectious and aseptic inflammation.
- Hormone therapy. It is used for disorders that have developed against the background of an imbalance in the female hormonal sphere.
- Sedatives. Effective for the correction of functional disorders.
Physiotherapy techniques are widely used in the complex treatment of tubal-peritoneal infertility: electrophoresis, transvaginal ultraphonophoresis, electrostimulation of the fallopian tubes and uterus, gynecological irrigation, mud applications, EHF therapy, vibration and gynecological massage. Minimally invasive interventions – transcatheter recanalization, hydrotubation, pertubation – are also used to restore the impaired patency of pipes.
A more effective way to solve the problem of tubal infertility is the use of surgical approaches. Surgical treatment is indicated for patients under the age of 35 with a period of infertility of no more than 10 years in the absence of acute and subacute inflammation, tuberculous lesions of the genitals, pronounced endometriosis and adhesions. To restore the tubal patency, such reconstructive-plastic laparoscopic interventions are used as:
- Salpingolysis. During the operation, the pipe is released from the surrounding adhesions.
- Salpingostomy. With massive splices and adhesions in the funnel area, the formation of a new hole is effective.
- Fimbriolysis and fimbrioplasty. The operation is aimed at releasing the fimbriae of the fallopian tube from the adhesions or plasticizing its funnel.
- Salpingo-salpingo-anastomosis. After excision of the affected area, the remaining parts of the pipe are connected to each other.
- Pipe transplantation. In case of obstruction of the interstitial part of the tube, it is recommended to move it to another part of the uterus.
Often such interventions are supplemented with a course of postoperative hydrotubation. In addition to tube plasty during laparoscopy, it is possible to coagulate and separate adhesions, remove concomitant neoplasms that may interfere with conception and gestation – retention ovarian cysts, intramural and subserous uterine fibroids, foci of endometriosis. In the presence of contraindications and ineffectiveness of surgical treatment, IVF is recommended for patients with tubal infertility.
Prognosis and prevention
The prognosis of TI depends on the type of disorders and the degree of their severity. After reconstructive plastic surgery, pregnancy occurs in 20-50% of cases, while the largest number of conceptions is noted in the first year after surgery, in the subsequent the probability of gestation decreases significantly. When using ECO, the efficiency ranges from 35 to 40%. The main methods of prevention of tubal infertility are timely detection and treatment of inflammatory processes, endocrine disorders, comprehensive rehabilitation after pelvic organ surgery, adequate obstetric care, refusal of abortions and unjustified invasive medical and diagnostic procedures.