Tubal Diseases

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. (Source: Principles and Practice of Assisted Human Reproduction. Edwards and Brody. W.B Saunders Company, 1995)