The Tubal Connection
from the book How to Have a Baby:
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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The fallopian tubes project out from each side of the body of the uterus and
form the passages through which the egg is conducted from the ovary into the
uterus. The fallopian tubes are about 10 cms long and the outer end of each tube
is funnel shaped, ending in long fringes called fimbriae. The fimbriae catch the
mature egg and channel it down into the fallopian tube when released by the
ovary . The tube itself is a muscular highly movable structure capable of highly
coordinated movement. The egg and sperm meet in the outer half of the fallopian
tube, called the ampulla. Fertilization occurs here, after which the embryo
continues down the tube toward the uterus. The uterine end of the tube, called
the isthmus, acts like a sphincter, and prevents the embryo from being released
into the uterus until just the right time for implantation, which is about 4 to
7 days after ovulation. The tube is much more complex than a simple pipe, and
the lining of the tube is folded and lined with microscopic hair like
projections called cilia which push the egg and embryo along the tube. The tubal
lining also produces a fluid that nourishes the egg and embryo during their
journey in the tube.
Fig 1. Normal tube and ovary, as seen during laparoscopy
Tubal abnormalities account for between 25% and 50% of female infertility .Tubal
damage usually occurs through pelvic infection , and this is called pelvic
inflammatory disease ( PID). Often, we cannot find out the cause for the
inflammation. However, some of the causes of pelvic infection that can be
pinpointed are :
- Sexually transmitted diseases (e.g. Gonorrhea, Chlamydia)
- Infection after childbirth, miscarriage, termination of pregnancy ( MTP)
or IUD (intrauterine device) insertion
- Post-operative pelvic infection (e.g. perforated appendix, ovarian cysts)
- Severe endometriosis
Besides causing blocked tubes, any pelvic inflammatory disease can also
produce bands of scar tissue called adhesions, which can alter the functioning
of the fallopian tubes. PID can be a silent disease, and most women with tubal
damage because of PID are completely unaware that they have this disease.
Pelvic tuberculosis is a fairly common cause of tubal damage in India. The
tuberculosis bacteria reach the tubes from the lungs through the bloodstream and
can cause irreparable tubal damage.
Making a Diagnosis of Tubal disease
A number of tests are available to judge whether or not the tubes are open.
The simplest and oldest test for tubal patency is the RT or Rubin's test
named after its inventor. In this test, gas is passed under pressure into the
tubes through the cervix and uterus - either with a special machine (Rubin's
apparatus) or with an ordinary syringe. The doctor then listens with a
stethoscope placed on the abdomen to determine if he can hear the sound of gas
passing through the fallopian tube. Even though this test is now obsolete,
because it is so unreliable, a number of doctors still do it.
Blood tests for chlamydial antibodies: Since an infection with chlamydia is
the commonest reason for tubal disease in the West, some doctors test the blood
for antibodies against chlamydia . Women who have antibodies against chlamydia
have been exposed to this infection in the past, and are considered to be at
higher risk for tubal damage.
Hysterosalpingogram (Uterotubogram) or HSG is a specialized X-ray of the
uterus and tubes. An HSG is done after the menstrual flow has just stopped -
usually on Day 6 or 7 of the period, at which time the lining of the uterus is
thin. It is done in an X-ray Clinic. The patient is advised to take an
antibiotic and a pain-killer before the procedure by many doctors. After being
positioned on the X-ray table, the doctor places a special instrument into the
cervix, called a cervical cannula, which is made of metal. Many doctors now
prefer to use a balloon catheter , as this makes the procedure less painful. A
radio-opaque dye (a liquid which is opaque to X-rays) is then injected into the
uterine cavity. This is done slowly under pressure, and pictures are taken -
preferably under an image intensifier. The passage of the dye into the uterine
cavity and then into the tubes and from there into the abdomen can be seen; and
X-ray pictures taken. These provide a permanent record.
At least 3 films need to be taken to provide a reliable record - including an
early film for the uterine cavity; and a delayed film to make sure the spill in
the abdomen is free.
A normal HSG defines the inside of the reproductive tract. This appears as a
triangle (usually white on a black background) which represents the uterine
cavity; and from here the dye enters the tubes which appear as two long thin
lines, one on either side of the cavity. When the dye spills into the abdomen
from a patent ( open) tube, this appears as a smudge in the X-rays.
Fig 2. Normal HSG findings ( the dye appears black and
outlines a normal cavity and fallopian tubes)
An abnormal HSG may show a problem in the uterine cavity - and this appears
as a gap or filling defect. However, the commonest problems on HSG appear in the
tubes. If the tubes are blocked at the cornual end (at the uterotubal junction),
then no dye enters the tubes and they cannot be seen at all. If the block is at
the fimbrial end then the tubes fill up; but the dye does not spill out into the
abdominal cavity and the end of the tubes are often swollen up.
Sometimes, like any other medical test, the HSG may provide erroneous
results. For example, the cornu of the uterus may go into spasm, as a result of
which the dye may not enter the tubes at all. This may be interpreted as a tubal
block, whereas in reality the tubes are open. Also, if a hydrosalpinx is very
thin and if the dye is injected under pressure, the dye may appear to spill into
the abdomen through a tear in the wall of the hydrosalpinx - suggesting tubal
patency when really the tubes are closed.
While the HSG is usually very reliable for determining whether or not the
tubes are open, it provides little information on structures outside the tube
which could nevertheless impair tubal function - such as peritubal adhesions. If
the spill is "loculated",(i.e. it collects in small puddles), the
presence of adhesions can be suspected, but not confirmed.
An HSG can be painful - and when the dye is injected into the uterine cavity,
most women will experience a considerable amount of pain. You should be prepared
for this - and taking a pain-killer prior to the procedure will help to reduce
An HSG can be technically difficult for some women (especially if the cervix
is too small or too tight) - and it is better if a gynecologist is present at
the time of the HSG to assist the radiologist if needed. Many gynecologists will
do the HSG themselves.
The major risk of an HSG is that of spreading an unrecognized infection from
the cervix up into the tubes. This is uncommon, but in order to reduce the risk,
many doctors advise antibiotic coverage during the procedure.
If the HSG shows that the tubes are closed, then it may be advisable to
repeat the HSG; and also to do a laparoscopy to confirm this diagnosis.
Laparoscopy. This has already been described, and is the gold standard for
making a diagnosis of tubal disease.
Limitations of HSG and laparoscopy
The trouble with both HSG and laparoscopy is that they only provide
information as to whether or not the tube is open or closed. While a closed tube
will never work, they do not provide any information on how well an apparently
open tube works. Remember, that just because a tube is patent does not
necessarily mean that it works!
Fig 3. Laparoscopy shows a large hydrosalpinx on the right
Another limitation is that they will rarely provide any information as to why
the tubes are blocked. Occasionally, however, this can be suspected by other
signs (for example, by seeing the tubercles diagnostic of TB in the abdomen
Recent innovations in this field include:
Fluoroscopic guided procedures: Using an image intensifier, and
techniques borrowed from coronary angioplasty, the radiologists can now insert
special catheters under fluoroscopic guidance into each of the tubes. This is
called selective salpingography; and allows much better visualization of each
tube. It also allows the radiologist to treat cornual blocks which are due to
mucus plugs by tubal cannulation.
Sonosalpingography: Under ultrasound guidance, with Doppler facilities
if available, the gynecologist can inject fluid into the tubes through the
cervix and see the flow of the fluid into the tubes and abdomen on the
ultrasound screen. This is a simple bedside test which a gynecologist can do to
judge if the tubes are normal - and can be reassuring if positive.
Tuboscopy: At the time of laparoscopy, the doctor can insert a fine
telescope into the fallopian tube through its fimbrial end, to inspect the inner
lining of the tube, to judge whether or not it is healthy.
Falloposcopy is a very recent exciting advance, pioneered by Dr Kerin
of USA. In this method, a very fine flexible fiberoptic tube is guided through
the cervix and uterus into each fallopian tube, thus allowing the doctor to
actually visualize the inner lining of the entire length of the fallopian tube -
something which was never possible so far. This can provide useful information
about the extent of tubal damage - and the possibility for successful repair.
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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