Infertility Causes > Woman > Fallopian Tubes and Surrounding Structures

Overview - Evaluation - Treatment Options - Diagnosis

Tuboperitoneal evaluation means making sure all of the pelvic structures, including the fallopian tubes, are in the right place, in proper relationship to one another, and capable of functioning. A couple of points about normal function must be kept in mind. When an egg is ovulated by the ovary, it doesn't just pop into the fallopian tube. The fimbria, or finger-like projections on the end of the tube near the ovary, must actively go and get the egg and feed it into the fallopian tube. The fimbria must, therefore, be in close proximity to the ovary. Secondly, the fallopian tube is not just some hollow tube that lets the egg fall into the uterus. It is a marvelously complex structure that nourishes the egg and early embryo, allows fertilization to occur, and actively transports the egg to meet the sperm and then transports the embryo into the uterus.

Hysterosalpingogram

A hysterosalpingogram (HSG) is an X-ray procedure that does not require any anesthesia and can be performed in just a few minutes. It is performed at the time in the cycle after the period stops but before ovulation occurs. A regular speculum exam is performed in the X-ray department, and a small instrument is attached to the cervix. A special X-ray dye is then injected through the cervix, up into the uterus, and out into the fallopian tubes. Under fluoroscopy, which allows the physician to observe the procedure as it is being performed, dye is slowly injected and is observed as it first fills the uterine cavity, then proceeds into the fallopian tubes, and finally out the ends of the fallopian tubes into the abdominal cavity. X-rays are taken at key points during the procedure, and the entire procedure usually takes less than ten minutes.  This procedure allows visualization of the uterine cavity and of the fallopian tubes. If the tubes are open, the dye can be seen spilling into the abdominal cavity.

The advantages of the HSG include the fact that it is a nonsurgical procedure, does not require anesthesia, and is relatively inexpensive. A further advantage is the fact that if oil-soluble dye is used, pregnancy rates after a HSG are actually increased, thus rendering it therapeutic as well as diagnostic. (HSG can be performed using water-soluble contrast material or oil-soluble contrast material; postprocedure enhancement of conception rates has been demonstrated only following the use of oil-soluble contrast material.) The biggest disadvantage of the HSG is the inability to visualize other pelvic structures. Only the interior of the tubes and uterus can be seen, and thus adhesions, endometriosis, or other problems lying outside the tubes and uterine cavity may go undetected.

. There may be some mild cramping after this procedure, but patients can usually return to work that same day without difficulty.

Usefulness of HSGs

HSGs are an excellent means of evaluating the uterine cavity to be sure that there is no scarring in the cavity, no polyps or other masses such as fibroids, which can distort the uterine cavity, and no uterine anomaly or abnormal shape. HSGs are also excellent for evaluating the internal appearance of the fallopian tube including the proximal segment, or isthmus, and for demonstrating that the tubes are open. In addition, there are a couple of important points to know about HSGs:

1. This does not have to be a terribly painful experience. Much of the pain often reported with HSGs occurs as a result of using instruments, such as balloons, that are placed into the uterine cavity. This can cause extreme cramping and discomfort. This procedure can be done every bit as well, if not better, by using instruments that are inserted only a short way into the cervix. This eliminates and avoids most of the discomfort. Mild to moderate menstrual cramping is the most that is usually experienced. Taking ibuprofen or some other mild pain reliever prior to the procedure will reduce the discomfort even further.

2. There is very good evidence that HSGs can be therapeutic as well as diagnostic. Conception rates improve for several months after an HSG (partly due, perhaps, to a simple flushing effect on the tubes, but also due to other effects of the X-ray contrast material). However, this improvement of pregnancy rates after an HSG has been demonstrated only if the procedure is performed using oil-soluble contrast material. I prefer to do the diagnostic part of the procedure using water-soluble contrast material, and then, having been assured that everything looks normal, inject the oil-soluble contrast material to obtain the therapeutic benefit.

( Note: HSGs are not the best procedure for evaluating the presence of scarring around the fallopian tubes or ovaries. While the physician may get some idea by observing the pattern of the spill of the dye from the tubes into the abdominal cavity [and this is one reason that the physician should observe the procedure under fluoroscopy while it is being done], the reliability of the HSG for evaluating for adhesions around the tube is not great. However, in the absence of prior infection or prior surgery and with no evidence of endometriosis, the chances of adhesions around the tubes should be very small indeed and the HSG is a very reliable and worthwhile procedure.)

Proximal Tubal Disease

If the HSG is abnormal, further evaluation is warranted. If the uterine cavity is abnormal, a hysteroscopy should be performed to further evaluate the abnormality and treat it. If the tubes are abnormal, unless the abnormality is proximal tubal disease, a laparoscopy should be considered to further evaluate and treat the abnormality. However, if severe tubal disease is present on the HSG, laparoscopy may not be warranted to surgically correct the tubes. IVF (in vitro fertilization) will offer much better pregnancy rates than will surgical correction. There is actually evidence to suggest that severely damaged tubes should be removed rather than corrected, in that IVF success rates appear to be higher if the tubes are removed (see laparoscopy below).

There are several possible causes of proximal tubal disease or abnormalities of the portion of the tube immediately adjacent to the uterus:

Salpingitis isthmica nodosa (SIN)

This is a destructive change related to an inflammatory process. This is best treated by proceeding to IVF. The other alternative is a major operative procedure in which the diseased portion of tube is removed and the remaining healthy tube is reconnected. This procedure carries a fifty percent chance of success at best, and IVF is probably a better alternative.

Proximal tubal occlusion

HSGs will at times reveal proximal tubal occlusion because of mucus plugs, related to endometriosis, or for reasons that are unclear. Selective tubal cannulization (placing a small plastic catheter directly into the affected tube) can be performed at the time of the HSG. This will often result in clearing of this type of obstruction.

Tubal spasm

Saline Infusion Sonohysterography

Saline infusion sonohysterography is a procedure performed in the office. It allows one to assess the uterine cavity, and to a certain extent, the fallopian tubes in the office using ultrasound. At the time of a pelvic exam, a small catheter is placed through the cervix and into the uterus. The speculum is removed and the vaginal ultrasound probe is introduced. Saline is slowly injected through the catheter and the outlines of the uterine cavity are evaluated. This is an excellent means of evaluating the uterine cavity for abnormalities such as polyps, fibroids and congenital anomalies. Its utility, however, is somewhat limited by the compromised evaluation and visualization of the fallopian tubes, which it provides. It does not allow nearly the accuracy or detail that an HSG does in terms of the status of the tubes. As we have discussed above, we rely fairly heavily on the results of the HSG. The HSG may very well be the only form of tubal evaluation we perform. The reliability and accuracy of saline infusion sonohysterograpy are not good enough to use it instead of the HSG for tubal evaluation. Furthermore, there is no evidence that doing saline infusion sonohysterography improves conception rates following the procedure. Therefore, HSG is preferred for tubal evaluation. If we are simply interested in evaluating the uterine cavity for abnormalities; saline infusion sonohysterography is a perfectly appropriate means of doing so.

Laparoscopy

If the history is suggestive ( i.e ., prior surgical procedures), if the chlamydia titer is positive (suggestive of prior infection), if the initial exam and ultrasound suggest significant endometriosis, or if the HSG is abnormal, laparoscopy should be the next step.

Laparoscopy is a minor surgical procedure that is performed under general anesthesia on an outpatient basis. A small instrument resembling a telescope and measuring less than half an inch in diameter is inserted just under the belly button. A small amount of gas is then introduced into the abdominal cavity, allowing complete visualization of the pelvic and abdominal organs. Often this procedure is videotaped to allow the patient to view the findings and procedure at a later date. Recovery in the hospital usually takes an hour or two. After a few days (at most) at home, recovery is usually complete and normal activity may be resumed.

Uses of Laparoscopy

Laparoscopy is a time-honored means of evaluating the ovaries, tubes and surrounding structures to see if they are normal, and laparoscopy certainly still has its place. It is one of the most valuable tools available to the physician evaluating and treating the subfertile female. But there are extremely rare circumstances under which it should be done simply for diagnostic purposes in evaluating infertility. If a laparoscopy is done, it can be done as a potentially therapeutic procedure by which the physician can treat and correct virtually any pathology or abnormality found.

One to three, or even four, additional small (5mm) incisions can be made in inconspicuous areas to allow the physician to introduce additional instruments for the purpose of operating and correcting abnormalities. The following surgical procedures can be done by laparoscopy: removal of adhesions, repair of the fallopian tubes, removal of ovarian cysts, treatment of endometriosis (laser, cautery, etc.), removal of ectopic pregnancies, removal of ovaries and/or tubes, appendectomy and hysterectomy.

The key point about laparoscopy is this - in the hands of an experienced laparoscopic surgeon, virtually any procedure that can be performed by a major surgical procedure (one performed through a major abdominal incision, and requiring a hospital stay and six to eight weeks of recovery) can be accomplished via laparoscopy. And there are significant advantages to a laparoscopic approach: Recovery is quicker and easier, and the results are as good if not better than those obtained by major surgery.

There's also this consideration. Let  us suppose we do a laparoscopy and see that there are adhesions and distal tubal occlusion (the end of the tube by the ovary is blocked), perhaps as a result of a chlamydia infection. There are two options. We can go ahead and remove the adhesions and open the tubes at the time of the laparoscopy or we can see the problem, quit, and come back and do a major surgical procedure to remove the adhesions and open the tubes. In terms of chances of success, the two approaches are essentially equal in the hands of a skilled laparoscopic surgeon. In terms of patient suffering, inconvenience and disability, there is no comparison. In terms of financial liability, there is no question which approach makes better sense. Be sure that you find out what the surgeon performing your laparoscopy intends to accomplish at the time of your laparoscopy.

Evaluating Degrees of Tubal Damage and Assessing Treatments

There are certainly different degrees of tubal damage. It can range from a few thin and easily removed adhesions around the tube and ovary, to virtually complete destruction of the fallopian tube and very extensive adhesions. The chances of a successful pregnancy following surgical correction are directly related to the extent of the damage. Minimal disease can be corrected with up to a sixty percent or higher chance of successful pregnancy. Tubes that are severely damaged, on the other hand, may have only a three to five percent chance of working properly following surgery, whether it is major surgery or surgery performed laparoscopically. Again, there is good evidence that severely damaged tubes should be removed rather than corrected - correction results in very poor chances of successful pregnancy while removal seems to improve the success rate of IVF, which will be the more successful alternative anyway.   

There are very few reasons to have major surgery for purposes of improving fertility. Removal of large fibroids and tubal reanastamosis following a tubal ligation are probably still best done via a major surgical approach. Virtually every other problem is best treated through the laparoscope. The chances of successful pregnancy following major surgery for treatment of severe tubal disease do not justify the pain and cost of the procedure. IVF is a better alternative: It costs less, is more successful, and is less invasive.

© 2005 Jarrett Fertility Group