Treatments and investigations

Tubal Surgery


Tubal problems are found in at least 15% of infertile couples whether or not there is a history suggesting such a cause for their infertility.

The past medical history can suggest the possibility of damaged fallopian tubes:

  • previous pregnancies or terminations of pregnancy with the same fertile partner;
  • past pelvic inflammatory disease;
  • appendicitis with peritonitis;
  • major pelvic surgery.

Infection can occur after a completely normal pregnancy or can complicate a miscarriage. It can also complicate the insertion of an IUCD (intra-uterine contraceptive device); but it is difficult to be sure whether the infection is related to the insertion of the device or whether it pre-existed the insertion and was stirred up by the IUCD.

Adhesions can follow surgery. The outer covering layer (serosa) of the abdominal and pelvic organs is very delicate. Inflammation of this delicate tissue during surgery can be caused by the presence of blood, which is often impossible to avoid, the use of surgical gauze packs to hold back the large bowel to get better exposure at the site of the operation, and even just the handling of the tissues being operated upon.

Occasionally there are surprises. Half of the women who are subsequently found to have blocked tubes have no significant past medical history that might indicate that there is a problem. Conversely, there can be a history highly suggestive of tubal disease and the tubes are found to be healthy.

Confirmation of a tubal damage is found at tubal patency testing. A hysterosalpingogram X-ray (HSG) may reveal obstructed tubes or tubes that appear to be open but tethered by adhesions (see Hysterosalpingography information). Laparoscopy and dye insufflation is generally accepted as being the "gold standard" for assessing the health of the tubes as it gives the specialist a direct view of the pelvic organs (see Laparoscopy & dye information).

If my tubes are blocked, what are my options?

If your tubes are blocked, you have become sterilised. The options that available to you are:

  • do nothing;
  • tubal surgery;
  • IVF;
  • adoption.

Your chances of becoming pregnant by doing nothing are nil. Yet this will be the right decision for you if you do not wish to have any further investigation or treatment.

From the information obtained at your laparoscopy, your specialist will be aware of the prospects of a successful outcome if you should decide upon surgery.

The degree of success from surgery will depend upon the degree of tubal damage. If there are only a few “cellophane-like” adhesions distorting the tubes or separating the tubes from the ovaries, surgery can be highly successful. This is because the tubes and ovaries beneath the adhesions are often completely healthy and normal. The division of adhesions around the tubes (an operation called salpingolysis) and from the ovaries (oophorolysis) can have a dramatic effect upon fertility. If the ovaries are enclosed in a fine bag of adhesions, freeing the ovaries and giving the eggs access to the tubes may be all that is required to restore fertility to normal. This type of surgery can usually be carried out at laparoscopy as a day case.

Sometimes the adhesion tissue is very dense and almost like plastic. In this situation the prospects of pregnancy resulting from surgery are remote.

If your tubes are blocked at their outer ends (known as a hydrosalpinx), when dye is instilled at HSG or laparoscopy the tubes become distended. Occasionally the pressure of instilling the dye forces some dye through the sealed off end of the tube, but this invariably seals off again. If there is no gross distension or distortion of the tubes, an operation (salpingostomy) can be performed to open the blocked ends, rather like the opening of a flower. To try and discourage the tubes from closing up again, very fine stitches can be placed so that the edges of the open tubes are slightly turned outwards rather like the lip of a vase. Some specialists will carry out salpingostomy operations by laparoscopy, while others may prefer to perform the tubal surgery as an open abdominal operation through a low “bikini” incision. Overall success rates of 30% are possible.

If the hydrosalpinx is grossly distended, you would be unlikely to benefit from salpingostomy. In all probability the original inflammation process that caused the obstruction will have destroyed the delicate and complex lining of the tubes. If you are going to have IVF as an alternative, a good case can be made for either removing a grossly distended hydrosaloinx (salpingectomy) or placing a clip on the tube at its junction with the uterus. The reason for this is that there is evidence that the fluid within the tubes can interfere with the successful implantation of a pregnancy by IVF. These procedures are usually performed at a laparoscopy. Your specialist will be able to discuss this fully with you.

One group of women with blocked tubes are those who have undergone sterilisation as a means of permanent contraception. For a variety of reasons a woman will sometimes request to have her sterilisation operation reversed. If the request for reversal is because she has a new partner, it is essential to first make sure that his semen analysis is normal. It would be ridiculous to undertake major surgery and only later find out that he was sterile! There is also a place for carrying out a preliminary laparoscopy to see if a reversal is even feasible. The actual sterilisation site on the tube will affect the success rate because the further away from the uterus that the tube has been sterilised, the lower the chance of success. The bore or lumen of the tube does not change close to the uterus but widens rapidly towards the middle and outer portions of the tube. If the sterilisation has been performed in the middle of the tubes, a reversal would have a poorer chance of success because of the technical difficulties in trying to join a narrow bore portion of tube to a wider bore section. Sometimes sterilisations are performed by removing a portion of each tube (a method most commonly performed either at Caesarean section or shortly after delivery). If an excessively large portion of tube has been removed, reversal may be impossible. If the sterilisation has been performed by diathermy (a form of cautery using intense heat), the entire tube is likely to be destroyed leaving nothing to reverse. The ideal prospect for reversal is when the sterilised portion of tube is relatively close to the uterus and only a minimal amount of each tube has been destroyed as with clip or ring sterilisations.

With the use of skilled microsurgery techniques, fine operating instruments, fine non-absorbable and non-reactive suture materials, minimal tissue handling and the avoidance of using gauze packs, a successful outcome with live birth rates of above 75% can be expected.

Reversals can be performed at laparoscopy, but as in salpingostomy operations, some specialists will prefer to carry out this surgery at an open abdominal operation.

What are the complications of tubal surgery?

There are no specific immediate problems linked to having tubal surgery apart from the surgical and anaesthetic risks. Tubal surgery is rather like having internal plastic surgery and is a delicate and highly skilled procedure. The main complications are long term.

To operate on adhesions can cause adhesions. Tissue handling and particularly the use of gauze packs can traumatize the serosa layer that covers the bowel and the tubes. As a result these areas of "bruised" serosa can stick together forming adhesions. The adhesions in themselves are not dangerous but may result in the surgery failing.

The major long-term risk of having tubal surgery is the danger of an ectopic pregnancy. The fallopian tubes are not simply open pipes leading from the uterus to the ovaries. They have to be free of external adhesions and be able to move and transport a fertilised egg to he uterus. If there are internal tubal adhesions these can distort the complex lining of the tubes and sometimes cause scarring and narrowing of the lumen. These may not block the tube enough to prevent sperm from reaching and fertilising the egg, but may trap the much larger embryo on its 5-day journey to the uterus. If the embryo implants in the wall of the uterus as an ectopic pregnancy, a life-threatening haemorrhage may result when the ectopic eventually ruptures through the thin wall of the tube.

If you have undergone tubal surgery and are now "at risk" of becoming pregnant, you must keep an accurate record of your period dates. Even if a period is only a few days overdue, have a pregnancy test. A positive pregnancy test is exciting news but an ectopic pregnancy must be excluded with some urgency. Your GP or specialist will be able to arrange for you to have an urgent ultrasound scan by the 6th week.

Surgery versus IVF

It is important not to ignore the option of tubal surgery if your specialist feels that this offers a reasonable chance of success. Tubal surgery to remove adhesions or to open tubes that have become blocked through infection should be available through the NHS. An experienced fertility specialist should carry out this type of surgery.

Reversal of sterilisation is not generally available through the NHS, except in the rare circumstance of you having no living children. Some Primary Care Trusts are generous in their interpretation of this and will fund the operation if you have no children living with you.

The cost of reversal in the private sector is one of the factors that you will need to take into account. The cost is very similar to the cost of a full IVF cycle. The big advantage of reversal over IVF is that if the tubes remain open and healthy after surgery, you will have an opportunity of becoming pregnant every cycle – 13 chances a year. This contrasts well with IVF where you will only have a chance of a pregnancy during an embryo transfer cycle.

If a pregnancy does not occur within 6-12 months of reversal, it is worthwhile to consider having an HSG to check that at least one tube is still open.

March 2009