Tubal Factor Infertility

Tubal infertility is due to damage or obstruction of the fallopian tubes. The changes or obstruction are associated with previous pelvic inflammatory disease (PID), previous pelvic or tubal surgery, and peritoneal factors. Tubal and peritoneal factor infertility often occur concurrently, and their treatments are often similar. Tubal and peritoneal factors account for 30% to 40% of female infertility cases. Salpingitis is the most important etiologic factor in tubal infertility. The risk of infertility is high after a single bout of PID. In addition. PID increases the incidence of ectopic pregnancy, which also can contribute to infertility. The incidence of infertility doubles with successive bouts of salpingitis, reported to be 12%, 23%, and 54% after one. two, and three episodes of PID, respectively.

A common test used to assess tubal factor is the HSG, which has 76% sensitivity and 83% specificity. In general, an abnormal HSG should be confirmed by laparoscopy, which complements the HSG because it allows for direct visualization of the fallopian tubes, ovaries, and peritoneal surface. Operative laparoscopy is a therapeutic option for both tubal and peritoneal factors, thus avoiding the need for a laparotomy. Falloposcopy, which is a technique that allows for direct visualization of the tubal lumen, can provide information in addition to laparoscopy and may offer prognostic information about the damaged fallopian tube.

The outcome of surgical management of tubal factor infertility is dependent on the following factors: I) severity of the disease process that affected the pelvis, 2) extent of the tubal damage caused by previous disease or surgery, 3) length of the reconstructed tube. 4) other fertility factors, and 5) surgical technique.

Proximal tubal obstruction can be treated with tubocornual anastomosis.

The procedure is associated with a success rate of 44%; however, it requires a laparotomy. In recent years, proximal tubal obstruction has been approached transcervically with the aid of ultrasound, fluoroscopy, or hysteroscopy, and either catheters or balloons. Distal tubal obstruction can be treated with fimbrioplasty or neosalpingoplasty. Both procedures can be performed via laparotomy or laparoscopy. A large hydrosalpinx (fluid-filled tube), abnormal fimbriae, and extensive pelvic or adnexal adhesions are associated with a poor prognosis. Patients who present with a combined proximal and distal obstruction or segmental tubal obstruction (as seen in salpingitis isthmica nodosa)

usually have a poor prognosis. These women should be given the option of in vitro fertilization (IVF). Tubal surgery is associated with an increased incidence of ectopic pregnancy.

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