I. Determination of tubal infertility.
It accounts for 20%-30% of female infertility, including anatomical abnormalities of the fallopian tubes, injury and/or obstruction of the fallopian tubes, weakened peristalsis of the fallopian tubes, and changes in the anatomical relationship between the fallopian tubes and ovaries affecting egg collection.
Second, risk factors for tubal infertility.
1. PID (pelvicinflammatorydisease) (pelvic inflammatory disease): the risk of tubal infertility is 12%, 23% and 54% after 1, 2 and 3 episodes; subclinical chlamydial infection, gonorrhea.
2. appendicitis: 4.8-fold increased risk of tubal infertility after perforation of the appendix.
3. History of tuberculosis.
4. History of miscarriage.
5. History of ectopic pregnancy.
6. History of previous surgery: adhesions are seen in 75% of patients after pelvic surgery.
7. Application of IUD (intrauterine device).
III. Diagnosis of tubal infertility by general lavage.
Initial screening method: false positive (tubal effusion) cannot determine the side of obstruction and the exact site; HSG understands the morphology of uterine cavity; shows the site of tubal obstruction; the sensitivity of diagnosing tubal obstruction or adhesion is 72% and the specificity is 88%.
Hysteroscopic lavage: to understand the uterine cavity and endometrium; mainly shows the proximal end of the fallopian tube, but not the distal end and pelvis; selective intubation/imaging can be performed at the same time, which can treat the proximal blockage of the fallopian tube. Laparoscopy: diagnoses endometriosis and periovarian adhesions; identifies the site of obstruction, currently recognized as the “gold standard” for evaluating tubal patency; performs corrective surgery at the same time; high technical requirements and high cost. Tuboscopy: direct visualization of the entire fallopian tube lining, with direct visualization for intubation, fluid removal and separation of adhesions; two routes: transvaginal/transumbilical; requires high technical and equipment requirements, not widely performed, pending experience.
Fertiloscopy fertiloscopy (water-filled laparoscopy + tuboscopy + microtuboscopy): proposed by Watrelot, France, in 1997; transvaginal water-filled laparoscopy for underwater examination of the pelvis, easier than pneumoperitoneum to identify slender, thin-layered adhesions, allows observation of the peritoneal environment of the fallopian tubes, but the scope of observation is more limited than laparoscopy; tuboscopy and microtuboscopy can be used to determine tubal mucosal lesions, and much information can be obtained about mucosal adhesions in the fallopian tube umbilicus and jugular abdomen; the biggest advantage is safety and minimally invasive, no injury to large blood vessels compared with laparoscopy, no CO2 pneumoperitoneum complications; if mucosal damage, surgery is not necessary, early IVF.
Pelvic imaging: shows whether the fallopian tubes are patent; shows whether the morphology of the umbilical end of the fallopian tubes is normal; shows whether there are adhesions formed in the ovaries, umbilical end of the fallopian tubes and pelvis. Advantages: no need for contraception, pregnancy can be carried out in the same month; for mild adhesions of the fallopian tubes can be unblocked; low cost, no need for hospitalization; assessment of the function and morphology of the fallopian tubes, preliminary determination of the need for tuboplasty; facilitates the removal of mild pelvic adhesions.
Indications for phlebotomy: the general time of phlebotomy is 2-5 days after menstruation, or if the cycle is disturbed, when the proliferating endometrium does not exceed 8 mm; in cases of infertility where tubal patency tests have not been performed; in cases where tubal patency tests have been performed but the findings are unclear or unreliable; in cases where pelvic adhesions are needed. Contraindications to phlebotomy: serious diseases of vital organs that cannot tolerate the procedure; bleeding and coagulation disorders or bleeding tendency; acute infection with body temperature over 37.5℃; vaginitis that has not been cured; uncontrolled psychosis; pelvic and abdominal malignant tumors or suspected cases.
The basic steps of visualization: the patient should fast from food and water 2 hours before the procedure; inject 50mg of intramuscular dulcolax half an hour before the procedure; routinely disinfect the vulva, vagina and cervix, and spread the towel; apply a double-lumen tube for lavage: inject about 50-100ml of metronidazole + dexamethasone mixed injection; puncture the liquid dark area under the guidance of vaginal ultrasound and pump saline into the pelvis via a peristaltic pump; observe the fallopian tubes under vaginal ultrasound. Postoperative attention: vaginal ultrasound was repeated two hours after surgery to observe again the morphology of the uterus, fallopian tubes and ovaries and the presence of intra-abdominal bleeding; antibiotics for three days. Ultrasound tubal imaging can: clearly show the situation of the fallopian tubes and pelvis, evaluate the function and morphology of the fallopian tubes, make preliminary judgment whether tubal plastic surgery is needed; make preliminary judgment of the uterine cavity; no need for contraception, pregnancy can be carried out in the same month; for mild adhesions of the fallopian tubes can be unblocked; low cost, no hospitalization is required.
Fourth, the principles of choosing tubal examination.
1. from simple to complex: lavage/imaging/pelvic imaging-laparoscopy.
2, age >35 years – laparoscopy.
3. suspected tubal incompetence or hydrocele – laparoscopy
4. suspected tuberculosis – angiography
5.Suspected endometriosis-laparoscopy.
V. Treatment of tubal infertility.
1. tubal reconstruction surgery: mild tubal lesions are most suitable.
2. Interventional treatment: mainly used for proximal obstruction.
3. Assisted conception techniques: IVF is the most important indication.
VI. Classification of tubal adhesions and distal obstruction.
1. Mild: tubal effusion <1.5cm in diameter or no effusion; tubal umbrella visible; no obvious adhesions around the fallopian tubes or ovaries; normal preoperative HSG morphology.
2.Moderate: tubal effusion diameter 1.5-3.0 cm; structure of the umbrella needs to be identified; adhesions around the fallopian tubes or ovaries, but not yet fixed; a few adhesions in the rectal trap of the uterus; loss of normal preoperative HSG morphology.
3. Severe: tubal effusion >3.0 cm in diameter; umbilical atresia, not visible; dense pelvic or adnexal area to the broad ligament/pelvic sidewall/reticulum/intestinal wall; closed uterine rectal sink; frozen pelvis (dense pelvic adhesions, making it difficult to identify pelvic organs).
VII. Surgical procedures related to tubal infertility.
Postoperative pregnancy rate 6% (severe tubal lesions) – 69% (minor tubal lesions); main factors affecting: severity of tubal lesions, fertilization capacity, male partner’s age, duration of infertility, previous pregnancy history, surgical technique; effectiveness of surgical treatment compared with expectant therapy and conception aid treatment is not known and a large sample of randomized controlled trials is needed.
Purpose of laparoscopic surgery: to restore the anatomy of the fallopian tubes; to restore the reproductive function of the tubes and to improve and enhance the patient’s ability to conceive. Key points of laparoscopic tubal adhesion separation surgery: minimize disturbance and damage to tissues; separate intrapelvic adhesions as much as possible; reduce damage to the fallopian tubes and peritoneum; stop bleeding carefully; keep tissues moist; reduce the impact on ovarian blood supply.
Surgical steps: first separate the intrapelvic adhesions; separate the adhesions between the fallopian tubes and ovaries? ; separation of ovarian surface adhesions; separation of tubal adhesions; tubal shaping; flushing of the pelvic cavity and hemostasis; injection of anti-adhesive medication (sodium hyaluronate) into the surface of the tubal ovaries and pelvic organs.
Postoperative management: tubal lavage after the first postoperative menstruation; herbal or Chinese medicine; pelvic physiotherapy. Is tubal reconstruction replaced by IVF? Recent articles report: live birth rate >35% in IVF cycle, much higher than surgery; IVF time is fast, pregnancy can be achieved within 1 month from the start of treatment, surgery may wait 2 years; surgery has many risks such as anesthesia, IVF is relatively safe; live birth rate after tubal reconstruction 32%, ectopic pregnancy rate 12%; combined proximal + distal surgery live birth rate 11%, ectopic pregnancy rate 14%; simple The rate of live births is 32% after tubal reconstruction; the rate of live births is 11% after combined proximal + distal surgery and 14% after ectopic pregnancy; 65% intrauterine and 35% ectopic pregnancies after simple adhesion release; 33% intrauterine and 67% ectopic pregnancies after tubal anastomosis; resection of the tube with hydrocele is recommended instead of tubal reconstruction.
VIII. Choice between tubal reconstruction and IVF in ART.
The following are the main considerations: patient age; combination of other infertility factors; risk of ectopic pregnancy; rate of multiple births; economic factors; severity and extent of tubal lesions, degree of pelvic lesions; combined distal and proximal tubal lesions.
IX. Indications for IVF (tubal infertility).
Severe tubal lesions; tubal mucosal damage; dense pelvic adhesions, ovarian adhesions; old age of the patient, diminished ovarian function; prolonged infertility, primary infertility.
X. Removal of hydrosalpinxed fallopian tubes before IVF.
Evidence that hydrosalpinx reduces IVF 50% live birth rate; pathogenic mechanisms: toxicity to embryos, reduced endometrial tolerance, washout of embryos; meta-analysis of 11 studies 6700 cycles, combined hydrosalpinx pregnancy rate 16.4%, lower than 31.2% for tubal factors alone without combined hydrosalpinx, 2-3 times higher miscarriage rate, no increased risk of ectopic pregnancy; 3 randomized controlled trials confirmed that both proximal ligation and resection of the fallopian tubes significantly increased the pregnancy rate compared to the nonsurgical control group, with no significant difference between the 2 surgical methods; the significance of other methods such as transvaginal ultrasound-guided aspiration of hydrocele, blockage of the fallopian tubes under X-ray, and antibiotic therapy is unclear.