Tubal damage is one of the commonest causes of infertility. It is most often due to pelvic inflammatory disease (PID) caused by sexually transmitted bacterial infection with chlamydia trachomatis and Neisseria gonorrhea. Acute PID caused by such usually are associated with severe clinical manifestations such as rapid onset of fever, peritonitis and severe abdominal pain and as such cases are usually readily identified and treated. The problem is that the diagnosis is often missed because early symptoms mimic lesser clinical problems such as urinary, cervical and vaginal inflammation. As a result, (especially in 1st world countries) doctors often tend to “jump the gun” and initiate treatment with (often the wrong) antibacterial agents, without first conducting the appropriate urinary, cervical and vaginal cultures that are required to make a definitive diagnosis. This serves to explain why in countries such as the U.S.A, more than 70% of infertility caused tubal damage is unassociated with a history of a prior acute PID attack and goes undetected until irreparable damage has already been done and comes as a surprise. It is essential to recognize that PID almost always affects both tubes and even when one tube appears to be open, both are likely to be damaged and functionally compromised. The reason that this is important to know is that patients are often erroneously led to believe that because one tube appears to be patent, they have a good chance of conceiving via that tube, even if the other tube is blocked. In some cases, when inflammation results from retention of products of conception (following miscarriage or child birth), the uterine lining (endometrium) might become infected (endometritis), leading to scarring and sometimes permanent damage with resultant inability to thicken sufficiently (in response to estrogen), to support an implanting pregnancy. Other less frequent causes of tubal damage include, adhesions resulting from a ruptured or twisted ovarian cyst, pelvic surgery, peritonitis (due to conditions such as appendicitis, diverticulitis, Crohn’s disease, Ulcerative colitis ,trauma, etc.) or from endometriosis. Tubal damage through infection with tuberculosis is uncommon is a serious condition and irreparable. It is common in Asia (especially in India) but fortunately rarely encountered in the U.S.A. and other 1st world countries. It is noteworthy, that a history of an ectopic pregnancy (pregnancy growing in the Fallopian tube) is highly suggestive of preceding tubal damage, usually due to PID. This is why once a woman has had an ectopic pregnancy, she has a reduced chance of conceiving again, and if she does, the chance of a second ectopic is about 20 times greater. Tubal blockage can readily be diagnosed by a hysterosalpingogram (HSG) where a radio-opaque dye is injected through the cervix into the uterus. Successive x-rays are then taken in rapid succession to track passage of the dye into the uterus and then to determine whether it passes into the Fallopian tubes and then spills into the pelvic cavity. It is important to recognize that determination of the tubes being patent does not rule out tubal damage. All it tells you is that the petal-like fimbriated ends of the tubes have not fused and blocking their ends. It is especially important to take bear this fact in mind whenever the tubes are found to be open, in spite of there being a history of prior PID. The diagnosis can also be made by performing an out-patient surgical procedure known as laparoscopy where a thin telescope-like instrument introduced into the pelvic cavity allows visualization of pelvic organs and thus the failure of dye injected via the cervix into the uterus fails to pass via the tubes into the pelvic cavity. Tubal blockage can occur anywhere along the course of the fallopian tube(s). It sometimes occurs in the part of the Fallopian tube that passes through the wall of the uterus (this is often due to post-pregnancy endometritis) It can also occur in the mid-section of the tube. Most commonly however, it occludes the far end of the tubes. In some cases Fallopian tubes damaged by PID will become distended with trapped tubal secretions that often contain toxins that are capable of killing eggs, sperm and embryos. Such distended Fallopian tubes (hydrosalpinges) can leak fluid back into the uterine cavity where the can destroy transferred embryos upon contact. This is why patients who have hydrosalpinges and are considering undergoing IVF, should first have hydrosalpinges surgically removed or (at the very least) have the affected tube(s) surgically clipped or tied as they emerge through the uterine wall. This will avoid subsequent back flow when IVF is performed. Understandably, it is often hard for patients to come to terms with the fact that following such surgery they no longer have any possibility of having functional Fallopian Tubes. Such women should be counseled that hydrosalpinges are functionless tubes anyway and that any attempt to open such tubes surgically in an attempt to restore fertility would be an exercise in futility, anyway. In a nutshell: Infertility associated with tubal blockage, especially if due to PID, is an absolute indication for IVF. I would go even further in stating that any tubal damage due to PID, whether or not it is associated with blockage is an indication for IVF, especially when detected in older women and those who because of age or diminished ovarian reserve (DOR) have no time to waste on other less successful treatments. Finally, tubal surgery is a very poor alternative to IVF. Besides, with more than 10% of pregnancies that occur following surgery to correct on PID-related damage ending up as ectopic pregnancies (a potentially life-threatening situation). Why take such a risk?
Fertility Topics Explained from the Experts at SFS