There are many causes of infertility, among which female factors account for 45%, male factors account for 25%, both factors account for 22%, and unknown causes 8%. Among the factors affecting the female side, tubal infertility accounts for 25% to 50%.
The functions of the fallopian tubes are mainly four.
1, transporting sperm.
2.Capture of eggs.
3, the place where the egg and sperm are united.
4. transporting the fertilized egg to the uterine cavity.
Any factor that affects the patency and peristaltic or retroperistaltic movement of the official lumen of the fallopian tubes can affect conception or lead to ectopic pregnancy.
Etiology and pathology of tubal infertility
Etiological aspects.
Infections.
1. specific infections such as tuberculosis, and some non-specific infections, various bacteria including mycoplasma and chlamydia, etc. (As well as secondary infections can be caused by surgical operations such as abortion, induction of labor, IUD retrieval, tubal lavage and hysterosalpingography.)
2. Endometriosis: Extensive adhesions in the pelvis can restrict the peristalsis of the fallopian tubes.
3, congenital malformation: congenital developmental malformation of the fallopian tubes causes tubal incompetence, etc.
Pathological aspects.
Various causes cause tubal official narrowing, tubal official obstruction, tubal umbilical segment adhesion atresia, tubal pot belly effusion, pelvic adhesions.
Diagnosis of tubal infertility.
Tubal infertility can be diagnosed by the following common methods.
1. tubal lavage: the advantages are convenience, low cost and safety. The disadvantage is that it cannot reflect the morphology of the uterine tubes, the site of obstruction, and whether there is fluid accumulation, which is too subjective. Whether the fallopian tubes are patent or not is mainly judged by the operator’s feeling when pushing and the patient’s feeling, which has a misdiagnosis rate of more than 50%. Especially in the case of atresia of the umbilical segment of the fallopian tube or hydrocele in the jugular abdomen, it is possible that lavage of 20-30 ml will be smooth and the patient will not feel any obvious pain, resulting in misdiagnosis, which is actually not the case. In addition, repeated lavage can cause endometrial damage, secondary infection, and even trigger hydrosalpinx.
2. Hysterosalpingography (HSG) via X-ray: It is one of the most commonly used methods to examine the causes of infertility. Features: It shows the morphology and shape of the uterine cavity and fallopian tubes; it shows the obstruction site of the fallopian tubes; and it is useful for the treatment of mild tubal inflammation and adhesions. This method is more accurate, less risky and less expensive, and should be preferred. The disadvantages are: false negatives and false positives. If the patient has false tubal incompetence due to stress, tubal spasm and other factors. It cannot detect pelvic pathological changes and peri-fallopian tube adhesions. However, through the tubal alignment and the diffusion of contrast agent in the pelvic cavity, it can also roughly determine whether there are adhesions in the pelvic cavity.
3.Acoustic imaging: Ultrasound hysterosalpingography is an interventional ultrasound diagnostic technique developed in recent years. It uses the echo characteristics of ultrasound contrast agent to observe the flow and distribution of contrast agent in the uterine cavity and fallopian tube cavity, to understand the morphology of the uterine cavity and fallopian tubes, and to determine whether the fallopian tubes are patent. Advantages: less damage, compared to hysterosalpingography without radiation exposure, it can automatically collect all the information of the whole fallopian tube and completely show the alignment and structure of the fallopian tube. It also provides important information about the cervix, the endocervix and the uterine cavity. Limitations: It cannot show the external pelvis of the fallopian tubes, but only the lumen. In addition, due to the stimulation of the contrast agent, it can cause spasm of the fallopian tubes causing the illusion of obstruction.
4.Tuboscopy: It can visually observe the mucosa of the fallopian tubes and directly determine whether the tubes are blocked. Disadvantages: It is impossible to determine whether the fallopian tubes have peristaltic and transport functions, and requires high technical and equipment requirements.
5. Hysteroscopy (HSC): more clinically used. To understand the uterine cavity and endometrium; to show the opening of the fallopian tubes, selective intubation and lavage of both fallopian tubes can be performed at the same time, and mild adhesion obstruction at the proximal end of the fallopian tubes can be treated. Advantages: both diagnostic and therapeutic functions. Disadvantages: unable to show the patency of the distal fallopian tubes and the pelvic cavity. Clinically, a hysteroscopic intubation and lysis is usually followed by a negative ultrasound to see if there is free fluid in the pelvis. If there is free fluid, it indicates patency of the fallopian tubes. Or, if the patient has blue staining in urine 2 hours after the hysteroscopic intubation, it can be presumed that the fluid enters the pelvic cavity and is discharged through urine by absorption, thus to determine whether the fallopian tubes are open or not.
6.Laparoscopy (LSC): the gold standard for diagnosis of tubal infertility; laparoscopy combined with tubal lavage is the most accurate examination method recognized at present. Advantages: it can be observed under direct vision whether the fallopian tubes function abnormally after lysis and has a high diagnostic value for intrapelvic and extra-tubal lesions. Limitations: High technical operation requirements, high cost and invasive.
Having these definitive examinations does not mean that the patient needs to have them all performed one by one. It is particularly important to note the following sequence of examinations of the fallopian tubes.
A hysterosalpingogram (HSG) is done first for an initial determination, and further treatment is judged based on the results of the angiogram. If the test results show that the fallopian tubes are basically open, or slightly adherent, or open but not open, conservative treatment with medication can be given; if the interstitial part of the fallopian tubes is incompetent and the patient requests further treatment, hysteroscopy and hysteroscopic intubation can be done; if the umbilical segment of the fallopian tubes is adherent, laparoscopy can be chosen to separate and stoma the umbilical segment of adhesions under laparoscopy; if the proximal end of one fallopian tube is incompetent, the distal end of the other fallopian tube is incompetent. If the proximal end of one tube is incompetent and the distal end of the other tube is incompetent, combined hysteroscopic and laparoscopic treatment can be done. If the patient is older, unwilling to undergo treatment, or has been treated for a long time but with poor results, IVF can also be chosen directly.
Treatment of tubal infertility
After being diagnosed with tubal infertility through a series of examinations in the early stage, the following three modalities can be referred to for treatment.
I. Conservative treatment: including comprehensive treatment (Chinese medicine [blood circulation and blood stasis] + Western medicine [anti-inflammatory] + physical therapy [microwave and ultra-short wave]), which is important to persist in order to achieve obvious treatment results.
Second, surgical treatment: according to the patient’s condition, different methods can be adopted.
1. Hysteroscopic tubal intubation and lavage.
(1) Insert the tube to a depth of 0,5 – 1,0 cm.
(2) Mechanical separation of membranous adhesions at the opening of the fallopian tube and the interstitial part; the main pressure of intubation can be several times or even more than ten times higher than that of conventional lavage.
(3) It is used to diagnose and treat proximal tubal obstruction and can unblock some mild adhesions. However, the rate of clearing obstruction in the middle part of the fallopian tube is low, and it is impossible to understand and deal with obstruction in the distal part of the fallopian tube, external adhesions and abdominal lesions.
2. Interventional tubal treatment.
(1) With the help of the guidewire thrust and the guidewire itself, it has a separating effect on the proximal adhesions of the adhesively blocked fallopian tubes.
(2) It is suitable for proximal tubal obstruction with high recanalization rate and low pregnancy rate. The high rate of tubal obstruction again, the possible tubal injury and inflammation may easily lead to re-adhesion in the tubal lumen and aggravate tubal infertility. Therefore, it should not be operated repeatedly and it is better to cooperate with keeping treatment after the operation.
3.Laparoscopy.
(1) The scope and extent of pelvic adhesions, pelvic tuberculosis and endometriosis can be observed under direct vision.
(2) Because of the higher cost, laparoscopy is usually chosen for treatment purposes, and the corresponding surgery can be performed in time to remove lesions, separate adhesions, and make umbilical stoma of the fallopian tubes.
(3) Less trauma, less pain, faster recovery and shorter hospital stay.
(4) At present, combined hysterolaparoscopic surgery is recommended to understand the pelvic cavity under direct vision, solve the problems of interstitial, proximal and distal obstruction of the fallopian tubes, and repair the adhesions and distortions around the fallopian tubes, thus restoring the patency of the fallopian tubes and the function of egg collection.
4. Open surgery.
III. Fertility treatment: IVF technology, for those who still have difficulty getting pregnant after conservative treatment or surgical treatment, or if the patient is older, or if the male partner has abnormal sperm quality, IVF can be chosen directly.
Tuboplasty
Among the surgical treatment options, tuboplasty is the most important. Tuboplasty can be divided into
Tubal anastomosis: recanalization of the fallopian tubes after ligation.
Tubal stoma drainage: adhesions at the umbilical segment.
Dense adhesions release.
Tubal horn anastomosis.
Reconstruction of the umbilical segment of the fallopian tube.
Factors affecting the success of tuboplasty include: depending on the degree of tubal lesion and the surgical approach.
1. the degree and nature of adhesions.
2. the diameter of the tubal effusion.
3. the destruction of tubal adhesions
4. the thickness and softness of the tubal wall.
Tubal effusion infertility
The common clinical condition of hydrosalpinx can affect the success rate of natural conception and IVF because the tubal lumen and uterine cavity are connected and the hydrosalpinx can back up into the uterine cavity, thus affecting the tolerance of the endometrium. The process of hydrosalpinx discharge may also flush out the embryos transferred into the uterine cavity, thus reducing the success rate of IVF.
What are the treatments for tubal effusion causing infertility?
1. Tubal umbilical stoma: Patients who do not want to choose IVF can choose this procedure, and after the operation, they may cooperate with conservative treatment.
2.Tubectomy: (before IVF)
3.Proximal tubal ligation and distal ostomy: (before IVF)
4.Proximal tubal occlusion or mucosal blockage: (before IVF)
5. Tubal aspiration under negative ultrasound: (at the same time of IVF egg retrieval)
The following are some conclusions drawn from some literature and clinical statistics.
1. Results of laparoscopic separation of adhesions in infertility due to tubal lesions and parallel tubal ostomy: high pregnancy rate after surgery for grade I and II lesions, decreased pregnancy rate after surgery for grade III-IV lesions and increased risk of ectopic pregnancy.
2. The effect of years of infertility and different time periods after laparoscopy on pregnancy: the longer the time of infertility, the lower the chance of pregnancy after surgery; 65% of the total number of pregnancies occurred within 6 months after laparoscopy, and 97% of the total number of pregnancies occurred within 12 months after laparoscopy.
3. Comparison of pregnancy rates in different time periods after hysteroscopy: the pregnancy rate within six months after surgery is 73% of the total pregnancy rate, so within six months after surgery is the best time for pregnancy conception.
4. Comparison of postoperative pregnancy rate between those with tubal effusion ≥3cm in diameter and those with diameter <3cm: it is not very meaningful to do tubal plastic surgery for those with more tubal effusion, and the chance of pregnancy after surgery is very low.
Application of assisted reproductive technology
Nowadays, more patients with tubal infertility prefer to undergo assisted reproductive technology, and the following is a detailed introduction to this technology.
Assisted reproductive technology (IVF): In vitro fertilization-embryo transfer (IVF-ET) treatment can be considered for patients with severe tubal disease or those who still cannot get pregnant with conservative treatment.
The procedure involves inserting a probe into the vaginal vault under ultrasound monitoring, inserting a needle from the vault into the follicle, and aspirating the follicular fluid through negative pressure. As the follicular fluid flows out, the mound complex is dislodged and the eggs are picked out under a microscope. At the same time, sperm is taken and the sperm and eggs are put together for fertilization, cultured for 2 or 3 days or cultured for 5 days into blastocysts and the embryos are transferred to the hysteroscope, which is a simple procedure of IVF.
The indications for IVF-ET are as follows.
1. Gamete transport disorders caused by various factors on the female side: such as tubal transport disorders caused by tubal lumen inaccessibility, umbilical segment inaccessibility, tubal effusion, etc.
2, ovulation disorders: the most common clinically is polycystic ovary syndrome with non-ruptured follicles luteinized.
3, endometriosis.
4.Low and weak spermatozoa in the male partner.
5, unexplained infertility
6.Immune infertility.
In the latter three cases, if the fallopian tubes are patent, you can choose IUI first, and then IVF if you still cannot get pregnant after 3 cycles.
The success rate of IVF treatment is 40-60%. The main factors that can affect the success rate are the following.
Age: >35 years old success rate decreases significantly. The age of the patient must be taken into account in the treatment of infertility. If older patients are not to be treated conservatively without restriction, IVF should be chosen as early as possible. Otherwise, at older age, the ovarian reserve function is very low and failure to retrieve follicles will miss the timing of IVF pregnancy assistance.
Male factor: mainly refers to the quality of sperm.
Causes of infertility: Tubal factors have the highest success rate.
Response to superovulation: ovarian responsiveness to drugs.
Influence of laboratory environment and operations.
Psychological factors, ideological stress.
A clinical comparison of the natural pregnancy rate after 7 months after hysteroscopy with the IVF-ET pregnancy rate concludes that the IVF-ET pregnancy rate is significantly higher than the natural pregnancy rate. Therefore, if pregnancy does not occur within six months after surgery and the patient is older, IVF-ET should be considered as early as possible.
Summary: Treatment strategies for tubal infertility
The choice of treatment plan for tubal infertility must be based on a comprehensive assessment and weighing of the woman’s age, ovarian function, male partner’s sperm status, specific causes of infertility and the extent of tubal lesions. Each patient’s condition varies clinically, but the following treatment strategies are summarized for reference based on the different conditions commonly seen.
Strategy 1: For primary infertility patients with no pelvic history and infertility duration <2 years, if the imaging suggests that the fallopian tubes are generally patent, they should be given 6-9 months of observation as long as the ovarian function allows. If the male partner's semen is normal, follicle monitoring can be performed and conception can take place under the guidance of the doctor, generally the chance of conception within 1 year can be about 40%.
If there is no conception for more than 1 year, artificial insemination (IUI), or weak ovarian stimulation with IUI for 3 cycles can be attempted, and if no conception is achieved, IVF treatment can be performed directly.
Strategy 2: For young patients with pelvic adhesions or suspected endometriosis, surgical treatment (laparoscopic surgery is recommended) is the first course of action. For those with normal male semen after tuboplasty, doctor-directed conception under ovulation check; if the male partner has weak sperm, artificial insemination (IUI) treatment can be chosen. For those who are still infertile 1 year after surgery, IVF treatment can be performed directly.
Note: The prime time for conception after laparoscopic surgery for tubal lesions is one year after surgery.
Strategy 3: For patients >35 years old or with a tendency to ovarian hypoplasia (FSH >10 U/L or AFC <6), long years of infertility, complicated infertility factors or recurrent ectopic pregnancies, direct IVF treatment is recommended to avoid repeated treatment of the fallopian tubes so as not to miss the best time to help conception. although IVF-ET is not the only option, interventions to help conception can be actively taken to shorten the waiting time to conceive and rationalize the use of the limited follicular reserve.
Strategy 4: In young patients with severe hydrocele, preemptive proximal tubal ligation or dissection or tubectomy can help improve the pregnancy rate of IVF-ET. Pay attention to the patient’s informed consent before surgery.
Strategy 5: In older patients with severe tubal effusion and who have shown obvious signs of diminished ovarian function, but considering the effect of surgery on ovarian reserve function, trial IVF treatment may be preferred and frozen embryos may be preserved as much as possible. In case of implantation failure due to hydrocele and fluid in the fallopian tube, frozen embryo transfer can be performed after surgical treatment of the fallopian tube.