Rehan Salim MD MRCOG
Consultant Gynaecologist & Subspecialist in Reproductive Medicine
Wolfson Fertility Centre - Hammersmith Hospital
Damage and blockage of Fallopian tubes is one of the common causes of fertility problems.
What are the causes of blockages?
Tubal disease resulting in infertility can be the result of an inflammatory process in or around the fallopian tube. Infection of the fallopian tubes is one reason for the alteration in the tubal epithelial lining. In some cases, the infection may be caused by sexually transmitted organisms such as chlamydia or gonorrhoea. The damage may be mild and may not block the tubes completely, however, it may damage the fine structures that are found inside the Fallopian tube meaning that whilst still open, they are non functional.
Hydrosalpinx as result of a genital tract infection
Sometimes the blocked tubes swell and fill with fluid and these blocked and dilated fluid filled Fallopian tubes are called hydrosalpinges. A hydrosalpinx is a particular type of tubal blockage in which the tube is obstructed near the fimbria end (the outside end of the fallopian tube that is in contact with the surface of the ovary), and the tube becomes filled with clear watery fluid. The reason for the obstruction of the tube in the region of the fimbria is in most cases a genital tract infection, e.g. with Chlamydia.
Furthermore, pelvic tuberculosis could still be a cause of infertility in some ethnic groups. Congenital tubal abnormalities do occur but are rare.
Abdominal surgery like tubal ligation removal and complication from lower abdominal surgery such as cesarean section might also cause damage. Moreover, diseases like endometriosis and uterine fibroids possibly may cause scarring between the end of the fallopian tube and ovary.
Depending on the severity of the damage, fallopian tubes may remain patent but will function ineffectively, or may be completely blocked. When the cause of the tubal damage is infectious, the damage is usually bilateral. If the cause is endometriosis or obstruction due to a fibroid, it is possible that only one tube could be affected with the unaffected one is working properly.
Symptoms of blocked or damaged fallopian tubes
Most women with tubal infertility do not experience any symptoms. Often they do not realise that their fallopian tubes are blocked until they consult a doctor for infertility. However, in some cases, women with extensive tubal damage may experience severe pelvic pain.
Diagnosing Blocked or Damaged Fallopian Tubes
A medical history and pelvic exam are necessary to make the assumption that there might be a tubal obstruction but to confirm the tubal block other medical examinations are needed to confirm the diagnosis or any abnormalities.
Hysterosalpingogram (HSG) is an x- ray using a contrast dye to view any obstruction in the fallopian tubes and the abnormalities like polyps or fibroids inside the uterus. The dye is injected through a thin tube that is placed up through the vagina into the womb. X-rays are taken to determine if there is an injury or abnormal shape of the uterus and fallopian tubes, including obstruction of the tubes.
Hystero-Contrast -Sonography (HyCoSy) is a procedure where a special ultrasound visible dye is used to see how space inside of the uterus (cavity) is shaped and also the Fallopian tubes. This test may help to determine issues such as uterine fibroids inside the uterine cavity. With the ultrasound, the doctor will also visualise the ovaries and the tubes to exclude hydrosalpinx or ovarian cysts.
Laparoscopy is a minimally invasive surgery using a laparoscope, a telescope that is put through the umbilicus (belly button) to allow viewing the womb, the ovaries, and the tubes. To see whether the tubes are patent, a dye will be injected from the vagina via the womb (like in the HSG), and the surgeon will evaluate whether the dye will be visible at the fimbria of the tubes. In some cases, it is possible to improve the situation during surgery (e.g. to remove scar tissue or endometrial tissue that obstructing the fallopian tubes).
What is the medical procedure to open blocked Fallopian Tubes?
The treatment options for tubes found to be blocked, scarred or damaged depends of course on the findings, but in general they are surgery and in vitro fertilisation (IVF).
Procedures involving the repair or reconstruction of fallopian tubes is known as tuboplasty. A tuboplasty maybe performed via laparoscopy (in exceptional cases via laparotomy), to successfully reopen a fallopian tube.
If the obstruction is present at the proximal (where the fallopian tube inserts into the uterus) portion of the fallopian tube, success in opening the tube may be accomplished by performing a hysteroscopy. However, if the distal (farthest) portion of the fallopian tube is blocked, it may also be opened either through microsurgery or by laparoscopic laser surgery.
However, there is a possibility of scar tissue and adhesion re-growth. The tubes may become blocked again or adhered to the abdominal wall, other parts of the reproductive organs or other organs surrounding the location, for example, bladder. Also, there is a great risk for ectopic pregnancy, particularly tubal pregnancy. A tubal pregnancy is a serious health problem that is more likely to occur after tubal surgery or tubal disease. So in case a woman will get pregnant after tubal surgery, a close follow-up is necessary to exclude any chance of an ectopic pregnancy.
In Vitro Fertilisation
Although some tubal problems are correctable with surgery, women with severely damaged tubes have such poor chances of achieving pregnancy naturally that In Vitro Fertilisation (IVF) offers them the best option for a successful pregnancy.
However, if the tubes show presence of hydrosalpinx and are severely damaged, the success rates of IVF are reduced, and the doctor may recommend removal or closure of damaged tubes prior to IVF or puncture the hydrosalpinx during the IVF. Hence, a removal of the tube will also cause a long-term reduction of the ovarian reserve since the vascularisation of the ovary will decrease after removal of the tube.