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Disruption of the patency of the fallopian tubes is one of the common causes of female infertility. Its frequency is from 25 to 35% of all causes of pregnancy failure.
When the fallopian tubes are blocked, the egg and sperm cannot meet each other. Such women cannot become pregnant naturally, so the cause of infertility is classified as a “tubal factor”.
What are the causes of fallopian tube obstruction?
Most of the reasons that lead to impaired patency of the fallopian tubes are related to inflammatory processes of the pelvic organs, followed by endometriosis of the fallopian tubes.
- Pelvic inflammatory diseases
- Non-inflammatory causes: endometriosis – proliferation of endometrial cells from the uterine cavity into the lumen of the fallopian tubes
- Iatrogenic factors (surgical interventions in the uterine cavity after a frozen pregnancy, termination of pregnancy, removal of uterine nodes, postpartum complications – placental abruption, postpartum endometritis, surgical interventions in the abdominal cavity, etc.).
Hydrosalpinx is one of the most severe clinical forms of damage to the fallopian tubes – it is an obstruction of the tube with the expansion of its lumen and the accumulation of fluid in it, which has an extremely negative effect on female fertility.
The fluid in the fallopian tube in endometriosis contains cells that come out during menstruation. When such contents enter the lumen of the fallopian tube, the female immune system first of all tries to limit the process of its spread, and forms an increased number of immunological cells in the organs of the small pelvis, which causes a constant chronic inflammatory process and the formation of adhesions.
When salpingitis (inflammation of the fallopian tubes) occurs and the epithelium (the inner lining of the tubes) is affected, damage of ciliated cells starts. They line the inner surface and are responsible for the advancement of spermatozoa to the ovum before ovulation and the movement of the embryo towards the uterine cavity immediately after fertilization of the ovum.
What happens to an affected fallopian tube?
The inflammatory process in the fallopian tubes primarily affects the ability of the cilia to ensure the passage of spermatozoa to the ovum and advance the embryo to the uterine cavity. That is, not only the patency of the fallopian tubes, but also the functionality is very important. In order for the fallopian tubes to perform their function, the peristalsis of the fallopian tubes is also important, that is, the muscle layer must contract correctly under the influence of sex hormones. As a rule, after inflammation in the fallopian tubes, the villous layer and the ability to contract the muscles of the fallopian tubes are lost (destroyed).
Unfortunately, after medical treatment of salpingitis, cilia do not recover. Their loss or damage leads to fibrosis in the fallopian tube, causing occlusion (impassability) and a fibrous process in the pelvic cavity. The inflammatory reaction around the fallopian tubes leads to a decrease in their mobility, which prevents the normal capture of the egg.
After medical treatment of salpingitis, areas of the fallopian tube without cilia are promising places for embryo implantation, due to the slowed down transport of the fertilized egg into the uterine cavity. The risk of ectopic (ectopic) pregnancy in this case increases by 5-8 times.
The relationship between low response during stimulation in the IVF program and the presence of an inflammatory process in the fallopian tubes is also well known. Because this source of inflammation has a toxic effect on the maturation of oocytes and their readiness for fertilization.
Many retrospective studies, reviews and meta-analyses confirm that the presence of an inflammatory process in the fallopian tubes in women, who are at the stage of pregnancy planning or IVF programs are associated with a decrease in the frequency of pregnancy, a decrease in the probability of embryo implantation, and also in turn increase frequency of early abortions and ectopic pregnancies. The decrease in the obtained result is directly proportional to the degree of damage to the tubes.
How does inflammation of the fallopian tubes affect pregnancy?
- Direct embryotoxic effect:
If there is an inflammatory liquid in the tube, the development of the embryo is disturbed – an embryotoxic effect occurs.
- Toxic effect on the receptivity of the endometrium:
The accumulated inflammatory fluid leads to a change in the sensitivity of endometrial cell receptors to sex hormones and their readiness to perceive the embryo during implantation.
- Mechanical factors, such as fluid accumulation between the embryo and the surface:
There is a continuous flow of fluid from the fallopian tube into the uterine cavity, which has a mechanical effect on the embryo, preventing its contact with the endometrium and excluding the possibility of implantation.
- Also known is the “reflux phenomenon”, which is generated by the pressure gradient caused by the accumulation of fluid in the fallopian tube. Thus, the increased contractile activity of the uterus can explain low implantation rates.
Based on the data of randomized controlled trials, it was concluded that in patients with hydrosalpinx visualization on ultrasound, the frequency of pregnancy and development of a healthy child is significantly lower than in patients without hydrosalpinx visualization, who underwent IVF due to tubal factor infertility. Accordingly, surgical treatment of hydrosalpinx (removal of the fallopian tube with inflammation) is recommended for patients in whom damage to the fallopian tubes is visualized during ultrasound, before IVF (namely, the stage of transfer of the embryo into the uterine cavity).
What is the treatment for tubal obstruction?
Currently, the generally recognized international method of treatment is the removal of the affected fallopian tube, which means the removal of the focus of the chronic inflammatory process and the focus of toxic influence.
Unfortunately, no drug therapy is able to restore the normal anatomy and functionality of the fallopian tube. Even if the plastic surgery of the tube is performed, with the preservation of its “conditionally healthy” areas, the fate of the cilia, which are responsible for the transport of the embryo from the ampullary part to the uterine cavity, remains unknown. Due to this, after such treatment, the probability of an ectopic (tubal) pregnancy increases sharply.
Restoring natural fertility through laparoscopic tubal surgery is extremely difficult, requires a long time to evaluate effectiveness, and unfortunately, the chances of success are very limited with a high percentage of inflammatory fluid accumulation in the lumen of the fallopian tubes. Therefore, achieving pregnancy through IVF is the first choice for most patients and allows fertilization to take place in the embryology laboratory, replacing the function of the tubes.
Puncture and drainage of the hydrosalpinx do NOT have a positive effect on a woman’s reproductive prognosis, they only contribute to the risk of local complications. In addition, it is necessary to take into account the high risk of filling the tube with liquid again, which occurs quite quickly after its evacuation.
In vitro fertilization, as a method of treating tubal factor infertility, has an excellent prognosis, so currently, tubal obstruction or even its absence after surgical removal of fallopian tubes (salpingectomy) is not a serious obstacle to achieving pregnancy.