Tubal Factor Infertility and Hydrosalpinx
Patent or open fallopian tubes are required for an egg to be picked up by a tube, where it will later be fertilized, as well as for the resultant embryo to have a passageway to the uterus, where implantation occurs. Fallopian tubes can be blocked as a wanted consequence of prior surgery such as a tubal ligation or due to unwanted consequences of pelvic surgery such as adhesion or scar tissue formation. The tubal architecture can also be disrupted by prior pelvic infections such as those caused by chlamydia, gonorrhea, or tuberculosis.
A hydrosalpinx is defined as a fallopian tube that is filled with fluid. Injury to the end of the fallopian tube, the ampulla, and its delicate fingerlike endings, the fimbria, causes the end of the tube to close. Glands within the tube produce a watery fluid that collects within the tube, producing a sausage shaped swelling that is characteristic of hydrosalpinx.
Hydrosalpinx can be evaluated with several maneuvers: The hysterosalpingogram (HSG) is a procedure in which dye is placed through the cervix and into the uterus and fallopian tubes. This is x-ray test is done in the first 10 days of the month and is performed by Dr. Goldstein with the radiologist. The X-ray picture on the right reveals the outline of the uterus and tubes. A hydrosalpinx appears as a large-sausage-shaped dilation of the tubes. The folds that are present inside the tube disappear and a flat bulbous shape is seen. Dye does not spill out of the tube.
Ultrasound Diagnosis of Tubal Disease
Ultrasound uses sound waves to image the tubes, and is somewhat safer than HSG and more comfortable. The best view, most of the time, is obtained with a vaginal ultrasound probe. A normal fallopian tube is usually not visible; a hydrosalpinx appears as a characteristic sausage-shaped fluid collection between the ovary and fallopian tube. The wall of the hydrosalpinx is often thick and flat. Ultrasound provides a quick and painless screen of the pelvic organs and is an excellent first assessment of the tubes.
Another means of assessing the tubes and involves the use of a small television camera which is introduced through the belly button. The pelvic organs can be visualized on a television screen. It has been said that physicians with expertise at video games excel at the hand-eye coordination required to perform these procedures! Laparoscopy is the gold standard test for evaluation, since looking at the fallopian tubes will usually provide the best view of their anatomy.
Diagnostic tests such as ultrasound and HSG are not 100% accurate, and can be misleading, sometimes missing significant tubal disease, and sometimes showing abnormal results when the tubes are actually quite normal. Laparoscopy usually will confirm the diagnostic tests, but can show that tubes that were thought to be normal actually have significant disease, and vice versa. The risks of anesthesia and surgery dictate that laparoscopy is used for definitive therapy, rather than as a diagnostic test.
How do Hydrosalpinx form?
Hydrosalpinx is a result of injury to the tube, usually from an infection. The classic causes of hydrosalpinx are chlamydia and gonorrhea, which can run undetected for years, slowly injuring and destroying the delicate fimbria. IUDs, endometriosis, and abdominal surgery sometimes are associated with the problem. As a reaction to injury, the body rushes inflammatory cells into the area, and inflammation and later healing result in loss of the fimbria and closure of the tube. These infections usually affect both fallopian tubes, and although a hydrosalpinx can be one-sided, the other tube on the opposite side is often abnormal. By the time it is detected, the tubal fluid usually is sterile, and does not contain an active infection.
Not only does a hydrosalpinx cause infertility, it can also reduce the success rate of fertility treatment, even those treatments that bypass the fallopian tubes, namely In Vitro Fertilization (IVF). The blocked tube can communicate with the uterus, and the fluid in the tube can be expressed out of the tube into the uterus. This fluid is probably somewhat toxic to early embryo development, and certainly provides an unfavorable environment. The large volume of the fluid flow back into the uterus and can produce enough flow that embryos find it difficult to attach, since they have no ability to move against the tide. Fertility drugs may cause the fluid to build up in the tube, since the tubes are responsive to the ovarian hormones produced during fertility drug therapy.
Hydrosalpinx can be hazardous during fertility evaluation and treatment, since it is prone to re-infection. Hysterosalpingogram can be a particular problem, since the dye can inadvertently introduce bacteria into the tubes, and a serious infection can result. Fertility procedures like insemination and embryo transfer can cause similar problems. Infection in a hydrosalpinx, salpingitis, can be a serious surgical emergency and result in hospitalization.
Hydrosalpinx is a classic fertility problem that prevents embryos from reaching the uterus and limits pregnancy rates. It can interfere with fertility therapy and cause problems for in vitro fertilization. Fortunately, excellent methods are available to manage the hydrosalpinx. With the proper expertise, such as that provided by a board-certified reproductive endocrinologist, success rates are excellent.
In vitro fertilization is recommended fertility therapy in patients with bilateral hydrosalpinx. The ability to optimize fertilization rates, place embryos into their correct location, and provide excellent hormonal support to the early developing embryo have vastly improved success rates over the last few years. The ability to bypass the fallopian tubes and allow sperm to fertilize eggs from the ovary allows women with hydrosalpinx to achieve pregnancy.
Hydrosalpinx can be repaired in carefully selected cases, but pregnancy rates remain rather low. Hydrosalpinx can be treated laparoscopically, a procedure known as neosalpingostomy. In neosalpingostomy, an incision is made in the end of the hydrosalpinx and the edges of the incision are folded or flowered back, leaving an open tube. Unfortunately, the tube often closes back up, and the hydrosalpinx has a high recurrence rate.
A hydrosalpinx can have adverse effects on pregnancy rates with in vitro fertilization. As success rates with in vitro fertilization have improved dramatically over the past few years, surgical repair of the fallopian tubes holds less appeal. Removal of a damaged tube reduces the risk of complications of therapy and improves success rates with in vitro fertilization techniques.
Today, most patients with a hydrosalpinx do not try to repair it. Repair can be done in carefully selected young patients with minimal damage to their tubes, but should not be attempted with a large hydrosalpinx in an older woman. In these patients, the tube should be removed, via laparoscopic salpingectomy. Salpingectomy is an easy procedure that takes less than an hour. The risks with an experienced surgeon are low, and the benefits substantial. It is important to choose an experienced surgeon, since considerations of safety and preservation of the ovarian blood supply with improvement to later pregnancy rates require judgment and experience.