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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Once the doctor has assessed the damage and pinpointed the location of the
blockages he will decide on treatment alternatives and how to proceed. The first
choice in the past used to be an attempt at surgery to repair the tubal damage.
However, because results with tubal surgery were not very encouraging, many
patients with tubal damage are now advised to undergo IVF (in vitro
fertilization) as their first treatment option.
In order to select between IVF and tubal surgery, we need to differentiate
between intrinsic tubal damage and peritubal damage. If the tubes have been
damaged because of a problem outside the fallopian tubes, such as peritubal
adhesions or endometriosis, which have caused the tubes to get kinked, then
surgery may be useful. However, surgery is not advisable for patients if the
tubes have been blocked because of TB; the tubes are very badly damaged; if the
tubes are blocked at multiple places; or if the tubes have been blocked because
of intrinsic tubal disease.
The likelihood of surgical success (in terms of pregnancy), depends on the
severity of the tubal damage. If a previous infectious process has caused
scarring of the fallopian tube, the inner delicate lining may have become
irreversibly damaged. All operations can result in re-establishing patency in
some cases - but the main aim of the surgery is not to just open the tubes, but
to achieve pregnancy - and the tubes have to become capable of capturing the egg
and transporting it to the uterus for this to happen. Unfortunately, surgery
cannot reverse tubal damage once this has occurred.
What if only one tube is blocked? One normal tube is sufficient to allow a
pregnancy - and most surgeons would not advise tubal surgery for these patients.
Obviously, the chances of pregnancy for such patients is half that of normal
women and therefore establishing a pregnancy may take twice as long. The danger
of trying to surgically repair a single blocked tube is that adhesions because
of the surgery may cause both the tubes to become blocked !
Microsurgery entails the use of the following surgical techniques:
- Using a microscope (for adequate magnification)
- Avoiding unnecessary trauma to the tissues
- Employing delicate surgical instruments
- Employing fine suture (stitching) material and ensuring precise suturing
- Handling tissues with great care and respect, to minimize tissue damage
- Ensuring that no bleeding is left unattended and no clots are left behind
(because this can lead to the formation of adhesions or scar tissue after
The microsurgery operation may take from 1 to 4 hours. Depending on the
extent of pelvic damage and is usually done under spinal or general anesthesia.
The incision used is usually a "bikini cut" (Pfannensteil incision)
The length of stay in hospital is usually 3 to 7 days. Tubal microsurgery can be
expensive and may cost up to Rs.40,000. Sometimes a "check or second-look
laparoscopy " is performed about one week after surgery to ensure that
tubal patency is maintained and to remove any small adhesions that may have
started to re-form.
Proximal Tubal Damage
The tubal obstruction could be at the uterotubal junction and this is called
a cornual block. The conventional surgical repair of cornual blocks involved
reimplanting the tube into the uterus - and had dismal success rates. However,
with microsurgery, it is possible to see the very fine ends of the tubes under
high magnification and to join them together. This has a pregnancy rate of about
50%, since the function of the rest of the tube is basically intact.
Recently, doctors have realized that a number of patients have cornual blocks
because of the presence of mucus plugs and debris in the very fine cornual
segment of the tubes. Newer nonsurgical methods have now been devised to treat
this. These involve the passage of a fine guide wire or a fine balloon into the
cornual end of the tube through the uterus. This is called a "balloon
tuboplasty" or "cornual recanalisation," and can be done under
ultrasound guidance; hysteroscopic guidance; or fluoroscopic (X-ray) guidance.
This is a significant advance, since it saves patients the need for major
surgery; and also has excellent pregnancy rates.
This procedure entails division of adhesions surrounding the tubes. When no
other damage is apparent, success rates may be as high as 65%.
These include a variety of procedures which involve removing the damaged
portion of the tubes and rejoining the healthy ends of the tube together .
Success rates vary according to the area of damage but are usually within the
range of 20 - 50%.The chances of success are higher when the defect occurs in
the middle section of the tube.
Distal Tubal Damage
If the tubes have been severely damaged and have formed a hydrosalpinx (in
which the fimbriae stick to one another and the tube is closed off) the surgery
required is called neosalpingostomy, in which the surgeon opens the hydrosalpinx
and creates a new opening for the repaired tube. While this is technically easy,
success rates are very poor (about 20%) because the physiologic functioning of
the fimbriae rarely returns to normal.
If the damage is less severe (fimbrial agglutination, in which the fimbriae
are stuck to one another; or phimosis, in which the tube is narrowed, but open),
then surgical repair is more successful, with pregnancy rates being about 50%.
The risk of having an ectopic (tubal) pregnancy is increased following tubal
surgery. Fallopian tubes which have been operated on may have a damaged inner
lining, and this can impair the movement of the embryo down the tube. This is
why, in patients who have had tubal surgery, the diagnosis of a pregnancy should
be made as soon as possible (preferably within a few days of missing a menstrual
period), to rule out the possibility of an ectopic pregnancy.
The best chance of success is with the first surgical operation; therefore,
you need to go to a specialized centre. The chances of success will depend upon
the extent of tubal damage and also on the skill of the surgeon. The best chance
of achieving a pregnancy is in the surgeon. The best chance of achieving a
pregnancy is in the first few months after surgery, and most women who are going
to get pregnant after tubal surgery will conceive within this time. Some doctors
believe that using ovulation induction and / or intrauterine insemination after
tubal surgery helps to maximize the chances of a pregnancy.
If the patient has not conceived within one year after the surgery, then
follow-up testing in the form of an HSG and / or laparoscopy is advisable, to
determine whether the fallopian tubes are still open.
If the first surgery has been unsuccessful, the chance of success as a result
of reoperation is very low, and IVF is the only treatment choice for such
In the future, it is possible that tubal transplants may become a reality and
that scientists may also develop artificial synthetic tubes to replace damaged
With operative laparoscopy, it is now possible to open damaged tubes through
the laparoscope, thus saving the patient major surgery. A hydrosalpinx can be
repaired by opening it with a laser or cautery and then keeping it open with
sutures: and even the complicated operation of tubal reanastomosis has been
performed by experienced surgeons through the laparoscope (using sutures or
special adhesive glue).
Fig 4. Schematic showing damaged fallopian tubes because of
pelvic inflammatory disease ( PID). The left tube has formed a hydrosalpinx; and
the right is engulfed in peritubal adhesions.
Fig 5. Operative laparoscopy, during which an adhesion is
being divided (adhesiolysis)
Reversal of Sterilization
In women, sterilization for family planning is usually done through an
operation called tubal ligation, which is usually carried out through the
laparoscope. The aim of the operation is to block the tubes and prevent the
sperm and egg from meeting each other.
Why Do Women Ask for Reversal?
The vast majority of people are very happy with sterilization. Nevertheless,
there are a few women who are very distressed afterwards and would do almost
anything to get things undone. The commonest reason why such women regret
sterilization is because their child dies or because they have remarried and
wish to bear their new husbandís child.
What Can Be Done?
If there is a reasonable amount of tube remaining, even if only on one side,
then it may be possible to perform tubal microsurgery to rejoin the tubes. On
the whole, the more tube which has been left undamaged, the better the chances
of success. Thus, patients who have had a tubal ligation done through the
laparoscope, using Falope rings (silastic bands) or clips, have an excellent
chance of achieving a pregnancy after microsurgical reversal of the ligation,
because these methods cause minimal tubal damage.
After reviewing the operative notes, a laparoscopy may be advised, so that
the exact state of the fallopian tubes can be assessed. If the patient has
enough normal tube, tubal microsurgery may be attempted and pregnancy rates can
be as high as 75% in favorable cases. If, unfortunately, the patient has had
both tubes completely removed or if the tubes are very badly damaged, then the
only chance of success will be with IVF.
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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