Fallopian Tube Reconstruction: Background, History of the Procedure, Problem

Background

The fallopian tubes are symmetrical paired tubular organs that connect the peritoneal cavity to the endometrium in the uterine cavity. The fallopian tubes are more than simple conduits or "open pipes." The fallopian tubes capture the ovum after ovulation and serve as a conduit for its travel toward the uterus. Fertilization of the egg by the sperm occurs in the fallopian tube. Following fertilization, the zygote develops into an embryo and continues to travel through the fallopian tube into the uterine cavity, where it implants in the endometrium. The fallopian tubes provide the environment and conditions for conception and for the early development of the conceptus.

Furthermore, the ovum, zygote, and embryo have no intrinsic motility. The fallopian tube is both the conduit and the transporter of the ovum and the early conceptus. Tubal function also aids transport of sperm to the site of fertilization. The fallopian tubes are thus essential and necessary in normal, natural, unassisted reproduction in women.

The multiple and complex functions of the fallopian tubes can be affected by disease, resulting in infertility and, in extreme cases, sterility. Fallopian tube reconstruction has been the traditional method of restoring reproductive function to women with tubal infertility. Today, in vitro fertilization (IVF) and embryo transfer (ET) bypass the fallopian tubes in the reproductive process and are additional options in the treatment of these patients.

For more information, see Medscape's Pregnancy Resource Center.

History of the Procedure

Fallopian tube reconstruction for tubal disease was first documented in 1896. The procedure reimplanted the fallopian tubes into the uterus. The results were dismal.

Early tubal reconstructive surgeries were performed using what is today described as macrosurgical technique. The purpose of these surgeries was to provide an open conduit from the peritoneal cavity into the uterus. Knowledge of the other multiple functions of the fallopian tubes was scanty, thus little attention was given to protecting or restoring these functions, and the results were relatively poor.

Over time, a better understanding of fallopian tube physiology, advances in perioperative care, and improvements in surgical techniques have resulted in better outcomes. Advances in macrosurgical techniques in fallopian tube reconstruction were made throughout the early 20th century. Microsurgical approaches to tubal reconstruction began to be developed during the 1960s-1970s.

Microsurgical technique is a delicate surgical style that emphasizes the use of magnification, fine atraumatic instrumentation, microsuturing, continuous irrigation to prevent desiccation, and pinpoint hemostasis. The goals are to remove pathology, restore normal anatomy, and regain function with minimal damage to adjacent normal tissue. This is achieved by minimizing inflammation and preventing adhesion formation. The microsurgical approach is more likely to preserve the function of the uterotubal junction, maintain the blood supply, and preserve the integrity of the tubal musculature.

The use of microsurgical technique in tubal reconstructive procedures has been shown to dramatically improve clinical results and has become the standard in these procedures. It requires specialized training and practice prior to its clinical application in order to achieve optimal results.

Problem

The fallopian tubes have critical functions in the reproductive process, including providing a conduit from the peritoneal cavity to the uterine cavity. The uterine cavity is the site of implantation and pregnancy. Fertilization and early embryonic growth occur in the fallopian tubes. The secretory cells of the tubal mucosa must provide the nutrients and growth factors necessary at the time of conception and for successful early embryonic development.

The fallopian tubes are involved in the transport of the ovum and sperm to the site of fertilization and in the movement of the early embryo to the uterine cavity. The ciliary motion of cells lining the tubal mucosa and the coordinated muscular activity of the uterus/fallopian tubes result in the successful transport of the gametes and early embryo through the fallopian tubes. These functions are partly regulated by the cyclical hormones of the reproductive cycle. Tubal secretory and muscular functions require normal circulation and neuronal input. Tubal blockage, damage to the tubal mucosa and muscularis, and disruption of circulatory and neuronal inputs to the fallopian tube can result in infertility and increase the risk of tubal ectopic pregnancy.

The image below depicts the sites and frequencies of ectopic pregnancy.

Sites and frequencies of ectopic pregnancy. By Donna M. Peretin, RN. (A) Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian, 0.2%; (G) Cervical, 0.2%.

Surgical techniques to reconstruct the fallopian tubes must achieve patency while minimally disrupting the tubal and pelvic anatomy in order to preserve subsequent function. Microsurgical technique in tubal reconstructive surgery best accomplishes these goals.

Epidemiology

Frequency

Infertility is defined as the inability to achieve pregnancy after 1 year of unprotected intercourse. An estimated 15% of couples of reproductive age meet this criterion and are considered infertile. A female factor is responsible in up to 50-60% of all cases. Tubal dysfunction is the cause in approximately 40% of infertile women.

Etiology

The major contributor to fallopian tube infertility is pelvic inflammatory disease (PID). The most common causes of PID are sexually transmitted diseases such as those caused by Chlamydia trachomatis and Neisseria gonorrhea. Symptoms of PID can include adnexal tenderness, strawberry cervix, and cervical motion tenderness; however, women can contract sexually transmitted diseases that can lead to tubal blockage without their knowledge because of lack of symptoms.

The long-term consequences of PID include tubal occlusion, adnexal and pelvic adhesions, recurrent PID, chronic pelvic/abdominal pain, tubo-ovarian abscess, dyspareunia, and menstrual pain. The risk of subsequent infertility is approximately 12% after 1 episode of PID, 35% after 2 episodes, and 75% after 3 or more episodes.

PID is not the only cause of tubal dysfunction amenable to reconstructive surgery. Other offenders include endometriosis, tubal sterilization, salpingitis isthmica nodosa, tuberculosis, abdominal or pelvic adhesions (resulting from surgery or other inflammatory processes), ectopic pregnancy, and, less commonly, congenital tubal anomalies, polyps, and neoplasms. Most often, the dysfunction of the fallopian tubes is a consequence of a disease process that involves inflammation, infection, adhesions, fibrosis, scarring, and obstruction. The resulting tubal dysfunction frequently has no overt clinical symptoms and remains undiagnosed until the woman discovers she is unable to conceive and seeks reproductive medical advice.

Pathophysiology

The many processes that result in tubal dysfunction involve different pathophysiologies. PID commonly causes tubal blockage, either proximally at the site of insertion into the uterus or distally at the fimbrial end. Less commonly, a midtubal segment may become occluded. Blockage at the fimbrial end results in a hydrosalpinx because the continued secretions of the tubal mucosa have no drainage into the peritoneal cavity (see the image below). As the hydrosalpinx enlarges, the tubal muscularis thins. The secretory and ciliary properties of the endosalpinx are eventually disrupted. The probability of pregnancy after repair of hydrosalpinges with a diameter of more than 3 cm is very poor. Evacuation of the fluid within a large hydrosalpinx does not restore function to the tube. Other possible sequelae of PID include pyosalpinx, tubal or tubo-ovarian abscess, and peritubal adhesions.

Hydrosalpinx. Image courtesy of Jairo E. Garcia, MD.

The pathophysiology after tubal sterilization depends on the method used. Electrocautery of a segment or segments of the fallopian tube occludes the lumen and causes more damage to the surrounding tissues than placement of a ring or a clip over the mid portion of the tube or surgical interruption of the tube (eg, Pomeroy technique, Irving technique). Increasing the amount of damage to the fallopian tube may increase the success of the sterilization procedure, but it decreases the chance of achieving subsequent successful reconstruction. The length of a tube after a reconstructive procedure correlates with success in terms of achieving pregnancy. Patients with tubes longer than 5 cm after reconstruction have better outcomes than patients whose tubes measure 3 cm or less.

Any inflammatory condition in the pelvis, such as endometriosis or the sequelae of pelvic or abdominal surgery, may cause adhesions, tubal blockage, or injury to the tubal mucosa and/or muscularis, resulting in tubal damage and dysfunction.

Presentation

Women with tubal infertility usually present to their obstetrician/gynecologist for evaluation and treatment after trying to achieve pregnancy with unprotected intercourse over an extended period. Eighty-five percent of couples of reproductive age achieve conception within 1 year of having unprotected sex (unless an obvious problem such as a previous tubal sterilization exists); therefore, couples should allow plenty of time to conceive prior to submitting themselves to costly, somewhat risky, and possibly unnecessary fertility evaluations and treatments.

A basic fertility evaluation must assess (1) the ability of the woman to ovulate, (2) whether the woman has a healthy reproductive tract, and (3) the availability of viable sperm. These components are the essentials necessary to have a possibility of pregnancy; therefore, if a tubal factor is identified early during the evaluation of a couple, a woman should not undergo tubal reconstruction unless it has been established that she can ovulate, that her uterus is otherwise normal, and that her male partner has adequate sperm. Proceeding otherwise risks subjecting a patient to tubal reconstructive surgery without a realistic possibility of success, defined as subsequent pregnancy and delivery of a live infant.

The initial history, physical examination, and laboratory evaluation should focus on uncovering risk factors for infertility.

Age is very important in the evaluation of female fertility. Fertility in women decreases with increasing age, reflecting decreased ovarian function. The decrease in female fertility starts at approximately age 35 years. Fertility decreases with advancing age and there is increased risk of miscarriage, congenital malformations, and complications during pregnancy. In one study, only 14.3% of women older than 40 years who had a tubal sterilization reversal procedure delivered live children.

The menstrual history is essential to evaluate a possible ovulatory factor. The obstetrical history establishes whether the woman has ever been able to conceive and whether she has had any pregnancy complications, such as an ectopic pregnancy or postpartum endometritis, that may have compromised her reproductive tract.

The gynecological history reveals possible problems with the reproductive organs that may affect fertility or the possibility of pregnancy. For example, a history of Asherman syndrome with extensive destruction of the endometrial surface may preclude the possibility of embryonic implantation. The presence of fibroids or other malformations of the reproductive tract (eg, unicornuate/bicornuate uterus, uterine septum, malformations secondary to intrauterine diethylstilbestrol exposure) may affect the uterine cavity in a way that prevents a fetus from developing to viability at birth.

The medical history uncovers possible causes of ovulatory dysfunction secondary to hypothalamic/pituitary disorders or intrinsic ovarian malfunction. A history of PID, endometritis, and other causes of pelvic inflammation, such as endometriosis or appendicitis, should be elicited. Correctible medical contraindications to pregnancy (and surgery), such as uncontrolled diabetes, hypertension, or cardiac or renal disease, should be excluded or corrected.

The surgical history should focus on the pelvis because any surgery on the reproductive organs, bowel, or bladder can cause pelvic inflammation, adhesions, and tubal damage.

The physical examination should confirm normal pubertal development with the presence of normal secondary sexual characteristics. Manifestations of hormonal disorders that can affect ovulation, such as hirsutism or galactorrhea, should be sought. Examination of the abdomen may reveal scars from previous surgeries that may have affected the reproductive organs. A pelvic examination may reveal gross abnormalities of the reproductive tract. Pregnancy after a tubal sterilization reversal procedure is mostly likely to occur within the first year. Most pregnancies occur within 6 months after surgery.

Indications

Tubal reconstructive surgery is indicated in women younger than 39 years who are trying to achieve pregnancy. These women must have proven tubal infertility amenable to tubal reconstruction with an otherwise normal uterine cavity, the capacity to ovulate, and a male partner who produces enough sperm for conception through intercourse or artificial insemination.

Relevant Anatomy

The fallopian tubes are seromuscular paired tubular organs that run medially from the ovaries to the cornua of the uterus. The fallopian tubes are situated toward the upper margins of the broad ligament. The tubes connect the endometrial cavity in the uterus with the peritoneal cavity toward the ovaries on each side. The tubes average 10 cm in length (range, 7-14 cm).

The tubes can be divided into 4 parts (proximally at the endometrial cavity to their distal portion near the ovary):

• The intramural or interstitial portion (from the endometrial cavity, through the uterine wall, and to the uterine cornua)
• The isthmus (the proximal third of the fallopian tubes outside the uterine wall)
• The ampulla (the distal two thirds of the fallopian tubes outside the uterine wall)
• The infundibulum, the funnel-shaped opening to the peritoneal cavity

The fimbriae are fingerlike extensions from the margins of the infundibulum toward the ovaries on each side. The intraluminal diameter varies and increases from 0.1 mm in the intramural portion to 1 cm in the ampullary portion of the tubes. The fallopian tubes receive their blood supply from the tubal branches of the uterine arteries and from small branches of the ovarian arteries. The fallopian tubes receive sensory, autonomic, and vasomotor nerve fibers from the ovarian and inferior hypogastric plexi.

Histologically, the uterine tubes are composed of 3 layers—the mucosa, muscularis, and serosa. The 3 different cell types within the mucosa of the uterine tubes include the columnar ciliated epithelial cells (25%), secretory cells (60%), and narrow peg cells (< 10%).

For more information about the relevant anatomy, see Uterine Tube (Fallopian Tube) Anatomy.

Contraindications

Absolute contraindications to fallopian tube reconstruction

• Aged 40 years or older
• Decreased ovarian reserve or ovarian failure
• Tubal infertility not amenable to tubal reconstruction
• Extensive tubal damage
• Hydrosalpinx with a diameter of more than 3 cm
• Inadequate proximal or distal tubal segment for anastomosis
• Projected tubal length of less than 3 cm after the reconstruction procedure
• Extensive pelvic/peritubal adhesions
• Abnormal uterine cavity
• Any contraindication to pregnancy or surgery
• Severe male factor infertility or male sterility

Relative contraindications to fallopian tube reconstruction

• Age 38-39 years
• Mild male factor infertility

Workup



Krystene B DiPaola, MD Medical Director, Assistant Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Cincinnati College of Medicine

Krystene B DiPaola, MD is a member of the following medical societies: American Medical Association, American Society for Reproductive Medicine, Sigma Xi, Society for Assisted Reproductive Technology

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School of Medicine

Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists

Chief Editor

Richard Scott Lucidi, MD, FACOG Associate Professor of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine

Richard Scott Lucidi, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine



Suzanne R Trupin, MD, FACOG Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, International Society for Clinical Densitometry, AAGL, North American Menopause Society, American Medical Association, Association of Reproductive Health Professionals

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Sites and frequencies of ectopic pregnancy. By Donna M. Peretin, RN. (A) Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian, 0.2%; (G) Cervical, 0.2%.

Salpingitis isthmica nodosa. Image courtesy of Jairo E. Garcia, MD.

Hydrosalpinx. Image courtesy of Jairo E. Garcia, MD.