Today, I have asked Dr. Brian Barnett to discuss tubal factor infertility. Dr. Barnett was also featured in an American Fertility Association video discussing the most common causes and treatments for tubal disease leading to infertility.
What is tubal factor infertility?
Tubal factor infertility is disease or damage of the fallopian tubes that prevents the sperm and the egg from meeting, preventing fertilization/pregnancy or leading to tubal pregnancy. The fallopian tubes are attached to the uterus and are responsible for picking up an egg each month as it is ovulated from the ovary. Sperm travel from the vagina and fertilize the egg in the tubes. Tubal factor infertility commonly accounts for 25-35% of reported cases of infertility.
What causes tubal factor infertility?
Tubal factor infertility can be caused by a wide range of factors. Any disease state that causes damage to any portion of the fallopian tube can lead to obstruction of the tube or tubes or impaired egg/ovum transport through the tubes with resulting infertility or an ectopic pregnancy.
The distal ends of the tubes, known as fimbria, are very susceptible to pelvic infections. When the fimbria are damaged or scarred closed, egg pick up is impaired or prevented. Additionally, there are millions of little hair-like structures known as cilia that line the inner portions of the tubes. These cilia function to transport eggs and embryos. When these cilia are damaged, tubal function is impaired.
The most common reasons for tubal factor infertility are:
Sexually transmitted diseases, most notably pelvic inflammatory disease (PID) caused by Gonorrhea or Chlamydia
Endometriosis
Previous pelvic or abdominal surgery
Most notably surgery performed for a ruptured appendicitis or other bowel surgeries can lead to scar tissue formation
A prior cesarean section is also a risk factor for developing tubal factor infertility
Previous tubal surgery such as for reversal of tied tubes or ectopic pregnancy
Tubal ligation and other types of elective sterilization
Lastly, some women may have tubal factor infertility without having any risk factors or any identifiable causes.
Is there any way to avoid tubal related infertility?
Some forms of tubal related infertility are avoidable and some are not. As sexually transmitted diseases (STDs) are common causes of tubal damage, preventing the contraction of STDs is one way to avoid developing tubal factor infertility. The use of condoms in sexually active women who are not trying to conceive is essential to reduce the risk of contracting an STD that can compromise future fertility. Although oral contraceptive pills and other forms of contraception reduce the risk of pregnancy from occurring, only condoms, as a barrier method, reduce the risk of transmission of STDs.
If you do develop an STD such as Gonorrhea or Chlamydia, prompt diagnosis and treatment can limit the risk of tubal damage. If left untreated, Gonorrhea and/or Chlamydia can lead to more advanced forms of pelvic infections, known as PID, or pelvic inflammatory disease. Developing PID can greatly increase tubal damage, and thus, tubal factor infertility.
Anytime a woman undergoes a pelvic surgery there is a risk of developing scar tissue. Scar tissue can lead to tubal damage or obstruction. Improved surgical techniques over the last few decades have greatly reduced the risk of scar tissue forming following the surgical treatment of pelvic and abdominal disorders. The advent and increased use of minimally invasive surgery, most notably laparoscopy, replacing larger incisions, known as laparotomy, reduces the risk of scar tissue formation. Unlike laparotomy which requires a large abdominal incision often several inches in length, laparoscopy can be performed through one or a few small incisions. Fewer incisions means less tissue trauma, which means less scarring.
What are the common tests for tubal infertility?
The common initial screening test for tubal infertility is a hysterosalpingogram, commonly known as an HSG. HSGs have been employed for several decades as one of the basic diagnostic studies for infertility couples. With an HSG, a special dye is injected into the uterus and x-rays are taken to see if the tubes are open or obstructed. If the tubes are open, the liquid flows out of the tubes and is seen on the x-ray image. If the tubes are blocked, the liquid may either not enter into the tubes at all or not be able to exit the tubes. If the dye cannot exit the tubes due to scarred fimbria, swelling of the tubes (also termed a hydrosalinx) can be seen on the x-ray.
A hydrosalpinx forms when the distal end of the tube is blocked. The tubes can accumulate fluid which can then leak back into the uterus and lower the chance of IVF from working by 50%.
Hysterosalpingograms are not always accurate. Tubes can spasm shut during the procedure and may appear blocked when they are really open. Alternatively, tubes may seem to be patent on HSG, when in fact they are diseased or surrounded by a pocket of scars. The Hysterosalpingogram can reveal that a tube is patent, but it cannot demonstrate whether the cilia, or hairs that line the lumen or inside of the tube are functional.
What is the best treatment for tubal factor infertility?
There are basically two treatment options for women with tubal disease, Tubal surgery to repair, reconstruct, or remove a woman’s fallopian tube(s) or in-vitro fertilization (IVF).
Let’s first discuss surgical treatment of tubal damage. For chronically damaged tubes, tubal reconstructive surgery has a high failure rate. Scar tissue often reforms following surgery. IVF should always be considered the preferred treatment of choice for women with extensive tubal or pelvic pathology. In contrast, for minimal pelvic disease, outpatient laparoscopy has demonstrated a long history of success. As a hydrosalpinx can lower the chance of IVF from working by 50%, surgical removal of the hydrosalpinx is recommended before a woman undergoes IVF.
However, when considering the best treatment for infertility, the physician must take all factors into account including maternal age, treatment costs, number of children desired, and other coexisting infertility factors. When there are multiple factors present leading to infertility (such as a tubal factor and severe male factor), it may be in the best interest of the patient to proceed with IVF, unless there is a hydrosalpinx.
IVF should always be considered the preferred treatment of choice for woman who are older, or who have a narrow reproductive window. Delaying IVF with tubal surgery in these women can dramatically compromise their ability to conceive. Although IVF pregnancy rates have improved dramatically over recent years, they still decline with increasing age of the woman, especially for women in their late 30’s and early 40’s.
Women who have undergone previous tubal sterilization should weigh the risks and benefits of IVF vs. tubal reversal. In our practice, IVF is recommended over tubal reversal.
With IVF, the fallopian tubes are bypassed. Oocytes, or eggs, are retrieved from a woman and are fertilized with her husband’s sperm. The resulting embryos are then placed back in the woman, bypassing the tubes completely. Tubal reconstructive surgery has fewer indications in the current era of IVF and other assisted reproductive technologies, than it did in the past.
Source: Clinical Gynecologic Endocrinology and Infertility 7th edition, Leon Speroff (Author), Robert H. Glass (Author)
* Dr. Barnett is one of the infertility specialists at Dallas IVF.
Dr. Lowell T. Ku, M.D. is an award winning and leading Reproductive Endocrinology and Infertility specialist at Dallas IVF, one the nation’s premiere infertility centers. Dr. Ku clarifies the many confusing terms used in the world of Infertility using straightforward explanations.
