Tubal Factor (Fallopian Tubes) Infertility
Tubal factor infertility at a glance
- Two fallopian tubes connect each of the two ovaries to the uterus. The egg released from the ovary moves through these tubes toward the uterus, and any present sperm also travels though the tubes, which is where fertilization of the egg normally occurs.
- Tubal factor infertility occurs when the fallopian tubes are blocked due to diseases, damage, scarring or obstructions that prevent sperm from reaching an egg for fertilization or prevent an embryo from reaching the uterus for pregnancy.
- Tubal factor infertility is most commonly caused by pelvic inflammatory disease, sexually transmitted infections or other conditions such as endometriosis.
- The American Society for Reproductive Medicine (ASRM) says that 25% to 35% of female infertility is due to tubal factors.
- Tubal factor infertility can sometimes be treated surgically to repair the tubes, depending on the degree of damage.
- Women with tubal problems that cannot be surgically corrected or who do not want the surgery can undergo in vitro fertilization (IVF). This may include removing severely damaged tubes prior to IVF.
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What are fallopian tubes?
Fallopian tubes are the delicate hollow tissue that connects each ovary to the uterus. Once an ovary releases an egg, it travels through the fallopian tube toward the uterus. If sperm are present in the uterus, they will swim up the tube toward the egg.
Fertilization normally takes place in the fallopian tubes. Tiny hair-like tissue inside the tubes, called cilia, then sweep the embryo toward the uterus. Once there, it should implant into the uterine lining and grow for nine months.
What is tubal factor infertility?
Tubal factor infertility occurs when the fallopian tube(s) prevents sperm from reaching the egg for fertilization or prevents a fertilized egg (an embryo) from reaching the uterus for pregnancy.
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. Alternatively, the tube’s damage may still allow fertilization of the egg and sperm but the embryo is unable to travel to the uterus and remains in the tube (ectopic, or tubal pregnancy).
Female reproductive system
Blocked fallopian tubes
A tubal blockage is usually identified by its location as follows.
- A tubal blockage located close to the uterus is called a “proximal” tubal blockage. ASRM reports that proximal tubal blockage makes up 10% to 25% of cases of tubal disease, which may be able to be treated relatively easily.
- Mid-segment tubal blockage is in middle of the fallopian tube and can be caused by some form of damage or scarring, which can occur from tubal ligation (having one’s “tubes tied”), ectopic (tubal) pregnancy or the unsuccessful attempt of surgical reversal of sterilization (tubal ligation reversal).
- A blockage that is located further from the uterus is called a distal tubal blockage. Fallopian tubes may be partially or completely blocked at their end.
- Fimbriae are the finger-like fringes of tissue that help to sweep an unfertilized egg from the ovary into the fallopian tube. Damage to the fimbriae can prevent the egg from reaching the fallopian tubes.
Tubal factor infertility causes
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 infections (STIs), most commonly chlamydia and gonorrhea.
- Ectopic pregnancy, a condition in which the embryo grows outside of the uterus, most commonly in the tube.
- Previous surgery.
Patients have a higher risk of tubal factor infertility if they’ve had a ruptured appendix or previous abdominal surgeries, including surgeries for ectopic pregnancies. 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 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 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 scarring or damage inside the lining of the tube that cannot be detected with this test.
Laparoscopy is a minimally invasive surgical procedure involving small incisions and the 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), and allows the surgeon to attempt to repair the tubes.
Tubal factor infertility treatments
The two main treatments for tubal factor infertility are surgical and nonsurgical procedures to repair the damaged tube(s). If these attempts fail, in vitro fertilization (IVF) is typically performed to achieve pregnancy. IVF may also be the initial treatment if the doctor and the patient determine it offers the best chance of success and is the best option for them.
Our fertility specialists have several ways to repair a tube and choose the technique based on the location and extent of the tubal damage.
- 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 opens the fimbriae, located at the end of the fallopian tube near the ovary. This option is only a good choice for patients with minimal tubal damage. This can lead to an increased chance of ectopic pregnancy and has a low success rate.
- Salpingectomy surgically removes the fallopian tubes with disease or damage.
- Salpingostomy creates a surgical opening in the fallopian tube without removing the tube, and is primarily done to treat an ectopic pregnancy.
As success rates of IVF have improved over the past years, it has become the mainstay treatment for tubal factor infertility. Instead of attempting to repair the tube, the physician will avoid surgery and the problem of tubal damage altogether. The success rates of IVF for tubal factor infertility are very good in women younger than age 39 as long as there are no other infertility problems.
IVF vs. tubal surgery
The opportunity to get pregnant and carry a fetus to term depends on age, co-existing fertility issues such as ovarian aging and male factor infertility, how bad the tubal damage is, where in the tubes the blockage is located, and what type of surgery is used to correct the tubal condition.
The advantages and disadvantages of IVF and tubal surgery are something the patient and provider will discuss to assist decision making.
A fertility specialist may recommend tubal surgery if the fallopian tube problem is the only fertility obstacle and the tubal damage is minimal. The downside of surgery is that it takes many weeks to fully heal, so there’s a delay in the pregnancy process.
The main advantages of IVF are good per-cycle success rates and the fact that it is less surgically invasive. IVF may be a likely option for women aged 35 or older, for those who have severe tubal damage, or if time is of the essence. The disadvantages include cost (especially if more than one cycle is required) and the need for hormone injections.
Treating hydrosalpinx with IVF
If a 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 uterus in a woman with hydrosalpinx, she has a much lower pregnancy rate because the fluid may wash the embryo away. It is for this reason that providers recommend removing or blocking the fallopian tubes so that the fluid does not leak back into the uterine cavity. This requires a surgical procedure.
Patient factors & risks to consider in choosing infertility treatment
Several patient factors should also be considered when choosing between surgery or IVF, including:
- Ovarian reserve (the number of eggs the patient has).
- Prior fertility outcomes.
- Number of children desired.
- Site and extent of tubal damage including whether a hydrosalpinx is present.
- Presence of other infertility factors.
Patient preference, religious beliefs, cost and insurance reimbursement also figure into the equation. A semen analysis should 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.
The most significant risks of IVF as a tubal treatment include the occurrence of multiples in pregnancy (twins or more, which carries risks for mother and babies) and ovarian hyperstimulation syndrome. This condition occurs when patients over respond to the fertility injections, which can lead to swelling of the ovaries and other severe symptoms including abdominal pain, vomiting and shortness of breath. Overall, IVF is a very safe and effective fertility treatment for tubal infertility.