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J Obstet Gynecol India Vol. 58 No.3: MayIJune 2008
Blocked Fallopian Tubes - Treatment Options
Gautam Allahbadia
Medical Director, Deccan Fertility Clinic
& Keyhole Surgery Center,
Shivaji Park, Mumbai and Rotunda
The Center for Human Reproduction Bandra (W),
,. Mumbai - 400 050. India.
91 98200 96000 Email: drallah @ gmailcom
The Journal of
OBSTETRICSAND
GYNECOLOGY
of India
J Obstet Gynecollndia Vol. 58, No.3.' May/June 2008
Editorial
Blocked Fallopian Tubes - Treatment Options
Tubal factors are said to account for about 20 to 30
percent of all infertility cases around the world 1. The
main contributing factor: blocked fallopian tubes. A
blocked fallopian tube, although not necessarily life
threatening, can be a very serious cause for concern
because although conventional surgery may provide
relief from the condition, damage to the tubes are
generally considered irreversible and hence,
subsequent pregnancy may prove almost impossible -
but not quite.
Blocked fallopian tubes following genital infection with
Chlamydia trachomatis is an escalating global public
health concern causing considerable morbidity and
socioeconomic burden worldwide. The major clinical
manifestations of genital chlamydial infection in women
include mucopurulent cervicitis, endometritis and pelvic
inflammatory disease 2. Genital infection with C.
trachomatis markedly enhances the risk for reproductive
tract sequelae in women, including tubal factor infertility,
chronic pain and ectopic pregnancy. Tubal infertility
following chlamydial infection is one of the leading
causes of infertility in the developed world.
A consequence of assisted reproduction technology
in infertility management has been a decline in tubal
surgery. Micro~urgery to correct localized damage has
the advantage of long-standing restoration of fertility.
A simple prognostic classification is lacking. The
severity of the tubal damage and the health of the
mucosa is key in determining outcome. Visualization of
the tube by hysterosalpingography (HSG) or by
sonosalpingography (The Sion Test) has limitations 3.
Laparoscopy has the advantage of inspecting the tube
and its relation to other pelvic organs. Differentiating
between anatomical obstruction or spasm at the uterine
end of the tube might be achieved by selective
salpingography and tubal catheterization (SSTC) and
should precede IVF 4. Laparoscopic ~icrosurgery
should be provided, if the skills are available, where
cannulation has failed 5. Laparoscopic microsurgical
tubal reanastomosis after tubal sterilization can be
performed using a remote-controlled robotic system.
Systematization of the operative steps allowed for
operative times that compare favorably with the time
needed for open microsurgical technique 5.
Transvaginal hydrolaparoscopy and fertiloscopy
appear to be an alternative to hysterosalpingography
as a first line procedure to investigate the tubal factor.
Assessment of mucosal health by fertiloscopy is claimed
to be less invasive. Fertiloscopy includes
hydrolaparoscopy, tubal patency testing by dye
hydrotubation, salpingoscopy and objective
demonstration if the mucosa is healthy 6. Where the
mucosa is unhealthy, surgery is not justified; early
referral for IVF is indicated. The prognostic value of
salpingoscopy during operative laparoscopy for tubal
factor infertility in terms of reproductive outcome has
been confirmed 7. The prognostic significance of
microsalpingoscopy needs further validation in large-
scale clinical trials 7.
A decrease in expertise in tubal microsurgery has
resulted largely from the use of IVF as the treatment
option for most causes of infertility and more specifically
for tubal factor infertility. Selective salpingography and
tubal cannulation have a unique role in the management
of tubal infertility and should be offered to selected
candidates prior to IVF 8. Tubal cannulation can be
used effectively to restore patency in a proportion of
cases of proximal tubal obstruction thus avoiding the
need for expensive assisted reproductive techniques 8.
Another option for women with blocked tubes and
hoping for a successful pregnancy is to resort to
Endoscopic Fallopian Tube Recanalisation; which
works best with proximal tubal occlusion & a method of
Tactile Cannulation using Laparoscopic guidance that
has been pioneered in India 9. (Figures I & 2).
203
Allahbadia Gautam
Figure 1. The Glide wire seen in the proximal portion of
the fallopian tube after tactile cannulation under
laparoscopic guidance.
Figure 1. The Glide wire seen in the proximal portion of
the fallopian tube after tactile cannulation under
laparoscopic guidance.
There are many different surgery techniques for
unblocking fallopian tubes and the differences generally
involve the length of the incision, the area affected, the
type of blockage present, and the method of unblocking
applied (e.g. complete removal or creation of another
opening).lo Tubal reanastomosis involves the complete
removal of the blocked portion of the tube and a
subsequent joining of the healthy ends. This procedure
is usually done today either with Laparotomy or
Laparoscopy.
Salpingectomy involves the surgical removal of the
infected or blocked fallopian tube. It is usually done on
204
patients who have a hydrosalpinx and want to improve
their chances of pregnancy through in vitro fertilization
(IVF).11This procedure is preferred over salpingostomy
which is another surgical procedure available for
dealing with hydrosalpinges (fluid-filled blocked
fallopian tubes).12 Salpingostomy is a procedure that
requires an incision through the affected fallopian tube.
In neosalpingostomy, the idea is to create a new opening
in the part of the tube closest to the ovary while in
linear salpingostomy the incision serves as the pathway
to release the blockage. Neosalpingostomy is generally
used in dealing with hydrosalpinges. This technique
however more often than not merely provides temporary
unblocking as it is a common occurrence for scar tissue
growth to reseal the new opening created by
neosalpingostomy thereby effectively blocking of the
tube once more. When the problem is a partial blockage
or a scarring in the fimbriae (fingerlike projections at
the end of the fallopian tube near the ovary),
Fimbrioplasty is an option where the blockage or the
scar adhesions are removed and the fringed ends are
rebuilt such that wafting motion of the fimbriae are
restored. All these surgical interventions are being
replaced gradually by Assisted Reproductive
Technologies.
Conclusion
Treatment should be individualized, based upon the
findings of the tubal investigation, the couple's wishes
and the costs involved. The age of the female is the
most important factor that affects the outcome with both
treatment options. The live birth rate per cycle with IVF
is 28% at best, whereas surgical intervention on the
tubes if done with microsurgical principles yields a birth
rate that exceeds 45%, without increased risk of multiple
pregnancy. It offers the couple multiple cycles in which
to achieve conception naturally, and the opportunity
to have more than one pregnancy from a single
intervention. The real dilemma lies with the "hyper-
marketing' of IVF, and its frequent use as primary
treatment for infertility. The dilemma is heightened by
the fact that reconstructive tubal microsurgery is being
taught and practised less and less, thereby eliminating
this credible surgical option in most centres.
References
1. Das S, Nardo LG, Seif MW. Proximal tubal disease: the
place for tubal cannulation. Reprod Biomed Online.
2007; 15:383-8.
2. den Hartog 'lE, MO[fl~ SA, Land lA. Chlamydia
trachomatis-associated tubal factor subfertility:
Immunogenetic aspects and serological screening. Hum
Reprod Update. 2006;12:719-30.
3. Allahbadia GN, Nalawade YV, Patkar VD" Niyogi GM,
Shah PK. The Sion Test. Aust NZ J Obstet Gynaecol
1992;32:67-70.
4. Rawal N, Haddad N, Abbott GT. Selective
salpingography and fallopian tube recanalisation:
experience from a district general hospital. J Obstet
Gynaecol. 2005;25:586-8.
5. Vlahos NF, Bankowski BJ, King JA, Shiller DA.
Laparoscopic tubal reanastomosis using robotics:
experience from a teaching institution. J Laparoendosc
Adv Surg Tech A. 2007;17:180-5.
6. Watrelot A. Place of transvaginal fertiloscopy in the
management of tubal factor disease. Reprod Biomed
Online. 2007;15:389-95.
7. Marana R, Catalano GF, Muzii L. Salpingoscopy. Curr
Opin Obstet Gynecol. 2003;15:333-6.
8. Papaioannou S, Afnan M, SharifK. The role of selective
salpingography and tubal catheterization in the
Editorial
management of the infertile couple. Curr Opin Obstet
Gynecol. 2004;16:325-9.
9. Allahbadia GN, Mangeshikar P, Pai Dhungat PB, Desai
SK, Gudi AA, Arya A. Hysteroscopic fallopian tube
recanalization using a flexible guide cannula and
hydrophilic guide wire. Gynaecological Endoscopy
2000;9:31-35
10. Rodgers AK, Goldberg JM, Hammel JP, Falcone T. Tubal
anastomosis by robotic compared with outpatient
minilaparotomy. Obstet Gynecol. 2007;109:1375-80.
11. Ozmen B, Diedrich K, Al-Hasani S. Hydrosalpinx and
IVF: assessment of treatments implemented prior to
IVE Reprod Biomed Online. 2007;14:235-41.
12. Strandell A. Treatment of hydrosalpinx in the patient
undergoing assisted reproduction. CUIT Opin Obstet
Gynecol. 2007;19:360-5.
*Gautam AUahbadia
*Medical Director, Deccan Fertility Clinic & Keyhole Surgery Center,
Shivaji Park, Mumbai
and
Rotunda - The Center For Human Reproduction
Bandra (W) 400 050, India
91 9820096000 Email: drallah@~mail.com

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Blocked fallopian tubes treatment options

  • 1. r- J Obstet Gynecol India Vol. 58 No.3: MayIJune 2008 Blocked Fallopian Tubes - Treatment Options Gautam Allahbadia Medical Director, Deccan Fertility Clinic & Keyhole Surgery Center, Shivaji Park, Mumbai and Rotunda The Center for Human Reproduction Bandra (W), ,. Mumbai - 400 050. India. 91 98200 96000 Email: drallah @ gmailcom
  • 2. The Journal of OBSTETRICSAND GYNECOLOGY of India J Obstet Gynecollndia Vol. 58, No.3.' May/June 2008 Editorial Blocked Fallopian Tubes - Treatment Options Tubal factors are said to account for about 20 to 30 percent of all infertility cases around the world 1. The main contributing factor: blocked fallopian tubes. A blocked fallopian tube, although not necessarily life threatening, can be a very serious cause for concern because although conventional surgery may provide relief from the condition, damage to the tubes are generally considered irreversible and hence, subsequent pregnancy may prove almost impossible - but not quite. Blocked fallopian tubes following genital infection with Chlamydia trachomatis is an escalating global public health concern causing considerable morbidity and socioeconomic burden worldwide. The major clinical manifestations of genital chlamydial infection in women include mucopurulent cervicitis, endometritis and pelvic inflammatory disease 2. Genital infection with C. trachomatis markedly enhances the risk for reproductive tract sequelae in women, including tubal factor infertility, chronic pain and ectopic pregnancy. Tubal infertility following chlamydial infection is one of the leading causes of infertility in the developed world. A consequence of assisted reproduction technology in infertility management has been a decline in tubal surgery. Micro~urgery to correct localized damage has the advantage of long-standing restoration of fertility. A simple prognostic classification is lacking. The severity of the tubal damage and the health of the mucosa is key in determining outcome. Visualization of the tube by hysterosalpingography (HSG) or by sonosalpingography (The Sion Test) has limitations 3. Laparoscopy has the advantage of inspecting the tube and its relation to other pelvic organs. Differentiating between anatomical obstruction or spasm at the uterine end of the tube might be achieved by selective salpingography and tubal catheterization (SSTC) and should precede IVF 4. Laparoscopic ~icrosurgery should be provided, if the skills are available, where cannulation has failed 5. Laparoscopic microsurgical tubal reanastomosis after tubal sterilization can be performed using a remote-controlled robotic system. Systematization of the operative steps allowed for operative times that compare favorably with the time needed for open microsurgical technique 5. Transvaginal hydrolaparoscopy and fertiloscopy appear to be an alternative to hysterosalpingography as a first line procedure to investigate the tubal factor. Assessment of mucosal health by fertiloscopy is claimed to be less invasive. Fertiloscopy includes hydrolaparoscopy, tubal patency testing by dye hydrotubation, salpingoscopy and objective demonstration if the mucosa is healthy 6. Where the mucosa is unhealthy, surgery is not justified; early referral for IVF is indicated. The prognostic value of salpingoscopy during operative laparoscopy for tubal factor infertility in terms of reproductive outcome has been confirmed 7. The prognostic significance of microsalpingoscopy needs further validation in large- scale clinical trials 7. A decrease in expertise in tubal microsurgery has resulted largely from the use of IVF as the treatment option for most causes of infertility and more specifically for tubal factor infertility. Selective salpingography and tubal cannulation have a unique role in the management of tubal infertility and should be offered to selected candidates prior to IVF 8. Tubal cannulation can be used effectively to restore patency in a proportion of cases of proximal tubal obstruction thus avoiding the need for expensive assisted reproductive techniques 8. Another option for women with blocked tubes and hoping for a successful pregnancy is to resort to Endoscopic Fallopian Tube Recanalisation; which works best with proximal tubal occlusion & a method of Tactile Cannulation using Laparoscopic guidance that has been pioneered in India 9. (Figures I & 2). 203
  • 3. Allahbadia Gautam Figure 1. The Glide wire seen in the proximal portion of the fallopian tube after tactile cannulation under laparoscopic guidance. Figure 1. The Glide wire seen in the proximal portion of the fallopian tube after tactile cannulation under laparoscopic guidance. There are many different surgery techniques for unblocking fallopian tubes and the differences generally involve the length of the incision, the area affected, the type of blockage present, and the method of unblocking applied (e.g. complete removal or creation of another opening).lo Tubal reanastomosis involves the complete removal of the blocked portion of the tube and a subsequent joining of the healthy ends. This procedure is usually done today either with Laparotomy or Laparoscopy. Salpingectomy involves the surgical removal of the infected or blocked fallopian tube. It is usually done on 204 patients who have a hydrosalpinx and want to improve their chances of pregnancy through in vitro fertilization (IVF).11This procedure is preferred over salpingostomy which is another surgical procedure available for dealing with hydrosalpinges (fluid-filled blocked fallopian tubes).12 Salpingostomy is a procedure that requires an incision through the affected fallopian tube. In neosalpingostomy, the idea is to create a new opening in the part of the tube closest to the ovary while in linear salpingostomy the incision serves as the pathway to release the blockage. Neosalpingostomy is generally used in dealing with hydrosalpinges. This technique however more often than not merely provides temporary unblocking as it is a common occurrence for scar tissue growth to reseal the new opening created by neosalpingostomy thereby effectively blocking of the tube once more. When the problem is a partial blockage or a scarring in the fimbriae (fingerlike projections at the end of the fallopian tube near the ovary), Fimbrioplasty is an option where the blockage or the scar adhesions are removed and the fringed ends are rebuilt such that wafting motion of the fimbriae are restored. All these surgical interventions are being replaced gradually by Assisted Reproductive Technologies. Conclusion Treatment should be individualized, based upon the findings of the tubal investigation, the couple's wishes and the costs involved. The age of the female is the most important factor that affects the outcome with both treatment options. The live birth rate per cycle with IVF is 28% at best, whereas surgical intervention on the tubes if done with microsurgical principles yields a birth rate that exceeds 45%, without increased risk of multiple pregnancy. It offers the couple multiple cycles in which to achieve conception naturally, and the opportunity to have more than one pregnancy from a single intervention. The real dilemma lies with the "hyper- marketing' of IVF, and its frequent use as primary treatment for infertility. The dilemma is heightened by the fact that reconstructive tubal microsurgery is being taught and practised less and less, thereby eliminating this credible surgical option in most centres. References 1. Das S, Nardo LG, Seif MW. Proximal tubal disease: the place for tubal cannulation. Reprod Biomed Online. 2007; 15:383-8. 2. den Hartog 'lE, MO[fl~ SA, Land lA. Chlamydia
  • 4. trachomatis-associated tubal factor subfertility: Immunogenetic aspects and serological screening. Hum Reprod Update. 2006;12:719-30. 3. Allahbadia GN, Nalawade YV, Patkar VD" Niyogi GM, Shah PK. The Sion Test. Aust NZ J Obstet Gynaecol 1992;32:67-70. 4. Rawal N, Haddad N, Abbott GT. Selective salpingography and fallopian tube recanalisation: experience from a district general hospital. J Obstet Gynaecol. 2005;25:586-8. 5. Vlahos NF, Bankowski BJ, King JA, Shiller DA. Laparoscopic tubal reanastomosis using robotics: experience from a teaching institution. J Laparoendosc Adv Surg Tech A. 2007;17:180-5. 6. Watrelot A. Place of transvaginal fertiloscopy in the management of tubal factor disease. Reprod Biomed Online. 2007;15:389-95. 7. Marana R, Catalano GF, Muzii L. Salpingoscopy. Curr Opin Obstet Gynecol. 2003;15:333-6. 8. Papaioannou S, Afnan M, SharifK. The role of selective salpingography and tubal catheterization in the Editorial management of the infertile couple. Curr Opin Obstet Gynecol. 2004;16:325-9. 9. Allahbadia GN, Mangeshikar P, Pai Dhungat PB, Desai SK, Gudi AA, Arya A. Hysteroscopic fallopian tube recanalization using a flexible guide cannula and hydrophilic guide wire. Gynaecological Endoscopy 2000;9:31-35 10. Rodgers AK, Goldberg JM, Hammel JP, Falcone T. Tubal anastomosis by robotic compared with outpatient minilaparotomy. Obstet Gynecol. 2007;109:1375-80. 11. Ozmen B, Diedrich K, Al-Hasani S. Hydrosalpinx and IVF: assessment of treatments implemented prior to IVE Reprod Biomed Online. 2007;14:235-41. 12. Strandell A. Treatment of hydrosalpinx in the patient undergoing assisted reproduction. CUIT Opin Obstet Gynecol. 2007;19:360-5. *Gautam AUahbadia *Medical Director, Deccan Fertility Clinic & Keyhole Surgery Center, Shivaji Park, Mumbai and Rotunda - The Center For Human Reproduction Bandra (W) 400 050, India 91 9820096000 Email: drallah@~mail.com