Tubal factor infertility

Tubal disease accounts for 15-20% of cases of primary infertility and approximately 40% of secondary infertility. It represents the aftermath of pelvic infection or surgery resulting in tissue damage, scarring and adhesion formation. This can affect tubal function and result in either partial or total tubal occlusion. As the distal portion of the tube is commonly affected, fluid can accumulate within the tubes causing a hydrosalpinx. Functional competence of the fallopian tubes implies not just patency but also the integrity of the mucosal lining or the endosalpinx. As any damage to the fallopian tubes tends to be irreversible correction can be difficult. Due to current limitations in investigating tubal function it is only possible to assess the macroscopic appearance and patency of the fallopian tubes.

INFECTION

The principal cause of tubal disease is pelvic inflammatory disease (PID) which may occur spontaneously or as a complication of miscarriage, puerperium, intrauterine instrumentation and pelvic surgery. A single episode of PID carries up to 10% risk of future tubal factor infertility. The risk is aggravated by further infections due to Chlamydia trachomatis or Neisseria gonorrhoeae. Chlamydia is now the most common sexually transmitted disease (STD) in Europe and responsible for at least 50% of identifiable cases of PID. Due to its silent nature, most affected women give no prior history of chlamydia infection, although three quarters of them have anti-chlamydial antibodies in their serum. Factors associated with chlamydia infection contribute to an increased risk of tubal disease. These include multiple sexual partners, young age at first intercourse, poor socio-economic status, heavy alcohol consumption and cigarette smoking. Opinion on previous termination of pregnancy is divided; some recent publications claim that there is no added increase in risk once other factors had been adjusted for.

SURGERY

Lower abdominal surgery is a risk factor for tubal infertility. Most abdominal and pelvic surgery causes adhesions. Gynaecological surgery, appendicectomy, bowel resection and urological operations are all thought to increase the risk of subsequent tubal disease.

OTHER CAUSES

The role of intrauterine contraceptive devices (IUCDs) in the aetiology of tubal disease is controversial. In the 1980s a number of studies reported an increased risk of PID in women who used IUCDs as compared to non-users. More recent data suggest that IUCD users, who are at low risk of sexually transmitted infections, face no added risks of PID. Congenital abnormalities are uncommon causes of tubal pathology and are associated with developmental anomalies of the urinary system. Endometriosis, cornual fibroids or polyps can cause cornual block or tubal distortion. Another relatively rare cause, salpingitis isthmica nodosa, described as nodular thickening of the proximal part of the fallopian tube is of unknown aetiology.

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