Tubal Factor Infertility
Tubal factor infertility at a glance
- Tubal factor infertility occurs when diseases, damage, scarring or obstructions in the fallopian tubes prevent sperm from reaching the ovary to fertilize an egg, or prevents a fertilized embryo from reaching the uterus for pregnancy.
- Tubal factor infertility is most commonly caused by pelvic inflammatory diseases, sexually transmitted diseases or other diseases such as endometriosis.
- The American Society for Reproductive Medicine (ASRM) says that 25 to 35 percent of female infertility is due to tubal factors.
- Tubal factor infertility can be treated surgically to repair the tubes.
- Women with tubal problems that can not be surgically corrected, or who do not want the surgery, can undergo in vitro fertilization (IVF).
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What is tubal factor infertility?
Tubal factor infertility occurs when the fallopian tube(s) prevent sperm from reaching the ovary to fertilize an egg or prevents a fertilized embryo from reaching the uterus for pregnancy. The fallopian tubes on either side of the uterus connect the ovaries to the uterus.
In a normal pregnancy, an ovary releases an egg into the fallopian tube where it meets with a sperm that fertilizes the egg. The fertilized egg then travels to the uterus and attaches to the uterine lining for nine months.
In the event that the fallopian tube is damaged, misshapen or blocked in some way, a sperm and an egg cannot meet, resulting in infertility. A blockage can also be small enough to allow the sperm in, but not to allow the embryo to get to the uterus.
A tubal blockage is usually identified by its location:
- A tubal blockage located close to the uterus is called a “proximal” tubal blockage. According to ASRM, proximal tubal blockage accounts for 10 to 25 percent of tubal disease and is generally a relatively easy condition to treat.
- Mid-segment tubal blockage occurs when the middle of the fallopian tube is damaged or scarred, typically as a result of permanent sterilization (tubal ligation) or the reversal of that sterilization (tubal ligation reversal).
- A blockage that is located further from the uterus is called a distal tubal blockage. In addition, the fallopian tube can be completely blocked. The tubes can also be partially blocked or narrowed due to scarring, which can also cause problems getting pregnant.
- Fimbria are the finger-like fringes of tissue that help to sweep an unfertilized egg into the fallopian tube. Damage to the fimbriae can prevent the egg from travelling from the ovary into the fallopian tubes.
The most common cause of tubal factor infertility is infection. Additional causes of blocking and scarring include:
- Endometriosis, a disease in which the tissue that normally lines the uterus grows outside the uterus.
- Pelvic inflammatory disease (PID), an infection of the female reproductive organs.
- Sexually transmitted disease (STD), most commonly chlamydia and gonorrhea.
- Ectopic pregnancy.
- Previous surgery.
Patients have a high risk of tubal factor infertility if they’ve had a ruptured appendix or previous abdominal surgeries, including surgeries for ectopic pregnancies, a condition in which the embryo grows outside of the uterus. Due to the location of these conditions, tubal issues are more likely to occur.
Symptoms and diagnosis of tubal factor infertility
The main symptom of tubal factor infertility is the inability to become pregnant. Many women do not realize that they have fallopian tube damage until they have consulted a doctor for infertility.
In addition, when infertility is accompanied by signs of a pelvic inflammatory disease, such as chronic lower abdominal pain, tubal infertility may be present. The two tests used to diagnose tubal factor infertility are a hysterosalpingogram and a laparoscopy.
- Hysterosalpingogram (HSG) is an X-ray in which a dye is passed through the cervix into the uterus. The dye can be followed through the fallopian tubes to see if they are open. It is important to note that if the tubes are open, it does not mean that they are functioning normally. There may be extreme scarring or blockage inside the lining of the tube that cannot be detected with this test.
- Laparoscopy is a minimally invasive surgical procedure involving a small incision just below the belly button with insertion of a small surgical instrument, called a laparoscope, to view the fallopian tubes. The laparoscope can determine whether or not the tubes are blocked or if there are other issues such as scar tissue adhesions.
Treatment of tubal factor infertility
The two main treatments for tubal factor infertility are surgical and nonsurgical procedures to repair the damaged tube(s). If these attempts fail, IVF can be done to achieve pregnancy.
There are several ways to repair a tube, including:
- Tubal cannulation involves inserting a catheter guided by a wire and attached to a balloon into the fallopian tubes in order to unblock them. This option is an outpatient procedure. Tubal cannulation should only be done if an imaging test shows a proximal blockage in one or both fallopian tubes.
- Fimbrioplasty is a laparoscopic procedure that rebuilds the fimbriae, or finger-like ends of the fallopian tube, by sewing the fimbriae back together. This option is only a good choice for patients with minimal distal tubal blockage.
- Salpingectomy refers to the surgical removal of the damaged or diseased fallopian tube.
- Salpingostomy refers to the the surgical creation of an opening into the fallopian tube, often to remove an ectopic pregnancy. However, the tube itself is not removed in the procedure.
As success rates have improved over the past few years, IVF has become a mainstay treatment for tubal factor infertility. Instead of attempting to repair, the physician will avoid surgery and the problem of tubal damage altogether. The success rates of IVF for tubal factor infertility are usually good in women younger than age 39 because these women are unlikely to have other infertility problems.
Tubal factor infertility treatment considerations
The advantages and disadvantages of IVF and tubal surgery should be reviewed with the patient to provide assistance in decision making. The main advantages of IVF are good per-cycle success rates and the fact that it is less surgically invasive. Its disadvantages include cost (especially if more than one cycle is required) and the need for frequent hormone injections and monitoring for several weeks.
If the woman has a hydrosalpinx, a form of tubal damage where the distal fallopian tube is blocked and fluid accumulates in the tube, the fluid may leak back into the uterine cavity from the fallopian tube. Even if a good embryo from IVF is placed into the fallopian tube in a woman with hydrosalpinx, the patient has a lower pregnancy rate because the fluid may wash the embryo away. It is for this reason that providers may wish to remove or block the fallopian tubes so that the fluid does not leak back into the uterine cavity.
The most significant risks include the occurrence of multiple pregnancy (twins or more, which carries risks for mother and babies) and ovarian hyperstimulation syndrome (a condition that occurs when patients are exposed to too much of a fertility hormone, which can lead to swelling of the ovaries and other severe symptoms including abdominal pain, vomiting and shortness of breath). IVF has also been associated with a higher incidence of adverse perinatal outcomes in infants, such as low birth weight, intrauterine growth restriction and congenital malformations.
In addition, several patient factors should also be considered when choosing between the two treatment options, including:
- Ovarian reserve (the number of eggs the patient has).
- Prior fertility outcomes.
- Number of children desired.
- Site and extent of tubal damage.
- Presence of other infertility factors.
- Experience of the surgeon.
Patient preference, religious beliefs, cost and insurance reimbursement also figure into the equation. A semen analysis can also be performed early in the infertility investigation, as these results may influence the decision between tubal surgery and IVF.
Patients opting for tubal surgery should know that these procedures increase the risk of scar tissue and adhesions. There is also a chance of recurrent blocked tubes after surgery, pelvic infection or an ectopic pregnancy. The chance of conceiving naturally after surgery is greater if the patient is young and has a minimal amount of scar tissue blocking the fallopian tubes.