Distal tubal disease

Abstract

Tubal occlusion can affect any segment of the fallopian tubes, but most commonly affects the distal tube and accounts for ˜80 % of tubal diseases. Tubal impairment often occurs following pelvic inflammatory disease, pelvic and abdominal surgery and endometriosis. Pathology in the distal portion of the tube may vary from peritubal adhesions, damaged fimbriae, distorted tubal anatomy to tubal blockage leading to the formation of hydrosalpinx. Various tubal and uterine screening modalities such as hysterosalpingography (HSG), Ultrasonography and Sonohysterography (USS), laparoscopy and Hysterosalpingo-Contrast Sonography (HyCoSy) are used in different centres. Laparoscopy is still considered as the “golden standard”. For couple with infertility associated with distal tubal disease, there are two therapeutic options: reconstructive tubal surgery and in vitro fertilization. The decision-making process requires detailed discussion on the effectiveness, adverse effects and cost of the procedures. Tubal surgery is not obsolete. It may be more cost-effective than IVF in selected cases and improves the results of IVF treatment. Endoscopic evaluation of the tubal mucosa (salpingoscopy) is essential to help decide if reconstructive tubal surgery is appropriate. In the case of unsuccessful reconstructive surgery or if a tube is irreparably damaged, a salpingectomy prior to in vitro fertilization ought to be considered. For patients with dense adhesions between the fallopian tube and the bowel or pelvic side wall, other options to improve the outcome of IVF should be considered, including proximal tubal occlusion or hysteroscopic tubal occlusion. Tubal surgery should be performed in women with hydrosalpinx, prior to IVF treatment.