Tubal
Blockage
"Tubal disease has various clinical forms. Its clinical
prognosis depends on the site of damage. Most diagnostic
methods give similar findings. Diagnoses correlate with
laparoscopy in almost 90% of cases, and disagreements are
often due to pelvic abnormalities. Hysterosalpingography
involves radiation and is unacceptable for patients with
intolerance to contrast agents. Chromolaparoscopy requires
surgery and anesthesia and it allows fimbrial motility and
ovum pick-up to be evaluated. Contrast-enhanced visualization
of the uterus and oviducts localizes defects with minimal
invasive risk, including structures within the uterine cavity
and tubal lumen, and usually correlates well with other
methods. Ultrasound alone cannot visualize the morphology
of normal tubes.
"Patients with peritoneal disease, involving pelvic
adhesions, are asymptomatic, particularly after a prior
chlamydial salpingitis. Repeated episodes of PID are a prime
cause of pelvic adhesions, and a risk of secondary infertility
arises in 23% of patients after one episode, 35% after two,
and >75% after three. Pelvic adhesions are included in
the severity score for pelvic endometriosis by the American
Fertility Society. They impair fertility anatomically and
functionally by mechanically obstructing ovum pick-up by
tubal fimbriae or by preventing ovum escape from an ovary
involved in adhesions. They can impair tubal motility and
function even if the ovaries are free. The value of laser
treatment and microdiathermy is still debated. There is
no convincing evidence of the superiority of laparoscopic
surgery. Salpingolysis is effective for grade I (loose web-like
structures), to grade III (blockage of both tubes and ovaries).
Tissue must be handled gently, adhesions exposed with atraumatic
glass rods under irrigation with heparinized serum, and
no "raw" areas left where further adhesions might
form. A second-look laparoscopy within 6 weeks after surgery
is valuable because new adhesions are still poorly vascularized
and can be removed with lower recurrence rates."
(Excerpts from: Principles and Practice of Assisted Human
Reproduction. Edwards and Brody. W.B Saunders Company, 1995)
