Fallopian tubes are an important part of the reproductive system in women. It is a muscular and extremely motile tube, capable of very intricate and coordinated movements. The lining of the fallopian tube is filled with tiny hairs called cilia that push the egg along the inside of the tube. At the juncture of the tube and the uterus, the tube acts as a sphincter, contracting and closing, holding the egg back until exactly the right time to release it into the uterus. For fertilization to take place successfully the fallopian tubes must remain open, undamaged and in a proper functioning state. The resulting embryo is then transported to the uterus for pregnancy. Tubal factor infertility is the result of scarring, blockage or dilation (hydrosalpinx) of the fallopian tube. A blockage may occur due to pelvic surgery, endometriosis or pelvic infections, in particular, pelvic inflammatory disease (PID). Hysterosalpingogram (HSG) is one of the most preferred medical tests to evaluate the fallopian tubes. It can also be evaluated by a specialized ultrasound (Fem-Vue procedure) or occasionally at the time of laparoscopy. In Vitro Fertilization (IVF) is the best fertility treatment for women with tubal factor infertility that cannot be surgically corrected. In this article, you will find useful content regarding fallopian tubes and some of the standard test to check fallopian tube blockage or damages.
In this article we will look at the following aspects:
- What is a Fallopian tube?
- What is the function of the Fallopian tube?
- What is Tubal Factor Infertility?
- What is fallopian Tube Tests?
- What are the causes of Blocked Fallopian Tubes?
- What are the different tests available for Fallopian Tubes?
The female reproductive tract is represented by one ovary and one fallopian tube on each side of the uterus in a woman. They are muscular tubes that are lined with delicate hair-like structures. These hairs work in both directions, helping an egg to travel from the ovaries down to the womb (uterus) and helping sperm travel up from the womb. Each tube measure about the size of a pencil and consists of a lumen surrounded by smooth muscle. The lumen is trumpet-shaped, the end attached to the uterus is narrow and the end adjacent to the ovaries is wide.
Each of the fallopian tubes ends at the fimbriae, a small, fingerlike projection through which eggs move from the ovaries to the uterus. The fimbriae are connected to the ovary. The fimbriae catch and guide an egg once the ovary releases it. The fallopian tubes play an important role in conception because most eggs are fertilized in the fallopian tubes when natural intercourse is taken into consideration. If any part of the fallopian tube is damaged, for example by surgery or an infection, there is a possibility of blockage due to the scar tissue.
Functions of the Fallopian Tube:
The fallopian tubes have three main important functions:
- Picking up the eggs (oocytes) from the ovary
- Fertilizing the oocytes
- Transporting the fertilized ovum into the uterus.
The fallopian tubes can be evaluated with the help of a laparoscopic procedure or a hysterosalpingogram. It can also be combined with chromotubation (passing dye through the tubes). The uterine tube allows passage of the egg from the ovary to the uterus. When an oocyte is developing in an ovary, it is compressed in a spherical collection of cells known as an ovarian follicle. Just prior to ovulation, the primary oocyte completes meiosis I. It forms the first polar body and a secondary oocyte which is arrested in metaphase of meiosis II. This secondary oocyte is then successfully ovulated. The ovaries and the follicle wall rupture, allowing the secondary oocyte to escape. The secondary oocyte is caught by the fimbriated end and travels to the ampulla of the uterine tube where typically they meet the sperm and fertilization occurs. Here, meiosis II is promptly completed. The fertilized ovum, now a zygote, travels towards the uterus boosted by the activity of tubal cilia and activity of the tubal muscle. The early embryo requires significant development in the fallopian tube. Successful embryo implantation occurs on the fifth or sixth day at the desired location. The endometrium of the uterus reestablishes after the implantation so that the embryo comes to be deeply embedded in the endometrium itself. The release of an oocyte seems to be random and does not alternate between the two ovaries. Occasionally, the embryo implants into the fallopian tube instead of the uterus, creating an ectopic pregnancy, also known as a ‘tubal pregnancy’.
Tubal Factor Infertility:
Fallopian tubes are highly fragile if they are blocked. Certain diseases like Endometriosis, Pelvic Inflammatory Disease (PID), infections, and Sexually Transmitted Diseases (STD’s) can cause damage to the fallopian tubes. The fallopian tube allows the sperm to swim from the uterus toward the egg, while the distal end of the fallopian tube (the fimbria) picks up the ovulated egg.
When fertilization takes place in the fallopian tube at least one of the tubes should function properly allow the sperm to fertilize an egg, so that the resulting embryo can be successfully transported to the uterus. If the fallopian tube is blocked, distorted or scarred, the egg and sperm cannot combine. Additionally, a partially blocked or damaged fallopian tube may allow the sperm to reach the egg for fertilization but not be able to lead to the implantation of the embryo in the uterus of the concerned woman. This ultimately leads to ectopic or tubal pregnancy, which can lead to serious complications in the respective pregnancy.
What are the Fallopian Tube Tests?
The fallopian tube test is an important part of the overall testing for infertility treatment. Several women who have experienced recurrent miscarriages or who have not successfully conceived despite trying for many years are usually sent in for fallopian tube test to check for the presence of any problems. Tubal disease and abnormalities are responsible for nearly half of the cases of female infertility. Damage to the fallopian tubes can occur as a result of infection or inflammation in the pelvis. Pelvic infection and inflammation is called Pelvic Inflammatory Disease (PID) and is caused by the following:
- Sexually transmitted diseases such as Chlamydia and gonorrhea
- Infections following a miscarriage, termination of a pregnancy, childbirth, or the insertion of an IUD
- Infections following surgery for ovarian cysts or a perforated appendix
Blockages and adhesions (scar tissue) can alter the function of the fallopian tubes which can cause infertility. Some women with tubal damage from PID are not aware it has happened until they try to become pregnant.
Fallopian Tube Testing: The Basics:
There are several ways for a doctor to provide treatment if the fallopian tubes are blocked or damaged. Diagnostic testing is important in determining the issue and how best to deal with it. The simplest and oldest diagnostic test for blocked fallopian tubes is the Rubin Test (RT) where gas is released into the uterus through the cervix either with a syringe or a special machine called a “Rubin apparatus”. The doctor listens to the abdomen with a stethoscope to check if the gas is passing through the fallopian tubes. It is not a reliable test and most doctors do not prefer it today. Blood tests to check for chlamydial antibodies are another way to determine the possible cause of any damage to the fallopian tubes. Chlamydia is one of the most common tubal conditions that affects most of the women in the West. If blood antibodies for Chlamydia are found it indicates exposure to the Sexually Transmitted Diseases (STD’s) at some point, putting the woman at high risk for tubal damage.
Causes of Blocked Fallopian Tube:
Scar tissue or pelvic adhesions is usually one of the reasons for a blocked Fallopian tube. However a number of factors can be responsible for it, these are as follows:
- Pelvic inflammatory disease(PID): PID can cause scarring or hydrosalpinx in the fallopian tubes.
- Endometriosis: A painful disorder in which tissue that normally lines the inside of the uterus (endometrium) grows outside the uterus. Endometriosis most commonly involves fallopian tubes, ovaries and the tissue lining your pelvis. The endometrial tissue hardly spread beyond the pelvic organs.
- Sexually Transmitted Diseases (STDs): Gonorrhea and Chlamydia are important preventable causes of Pelvic Inflammatory Disease (PID) and infertility. Without proper care and treatment, Chlamydia can develop into fallopian tube infection in women. It is very dangerous because this disease develops without showing any notable signs and symptoms. Further progression of PID and such silent infection in the upper genital tract are known to cause permanent damage to the fallopian tubes, uterus, and surrounding tissues, ultimately leading to infertility.
- Ectopic Pregnancy: Past ectopic pregnancy can also scar the fallopian tubes to a certain extent.
- Fibroids: When the fibroid is closely attached or bulged into the uterine cavity, it can have a significant impact on the fallopian tube. Fibroids can obstruct the fallopian tubes, resulting in difficulty while trying to conceive. Fibroid blockage of the tube does not allow the embryo to pass into the uterine cavity, where it could successfully implant on the endometrial lining. Fibroids can also cause problems during pregnancy as well.
- Pelvic Adhesions: Pelvic adhesion can significantly pose to be a hindrance to female infertility. Pelvic adhesions may be associated with such an infection in the tubes. The presence of pelvic adhesions may not necessarily block a fallopian tube, but render it dysfunctional by distorting or separating it from the ovary. It has been reported that women with distal tubal occlusion have a greater risk of HIV infection.
One cannot prevent each of the causes of blocked fallopian tubes. However, one can decrease the risk of sexually transmitted infections by using a condom during sex.
Fallopian Tube Assessment Tests:
Various medical tests and procedures have been described but only a few of them are currently in vogue in clinical practice. These are given below:
Laparoscopy is a surgical procedure in which numerous small (about half an inch to an inch) incisions are made in the abdomen. A camera is placed through one of the incisions and long, thin instruments are placed through the other incisions. The camera is used to visualize the pelvic organs while the instruments are used to retract and operate as needed. A laparoscopy procedure is usually performed on an outpatient basis or as part of the patients stay in a hospital. The procedure of the test conducted differs significantly depending on the patient’s condition and also the doctor’s practices. A laparoscopy is generally done while the patient is asleep under general anesthesia. Laparoscopy can be done for various reasons. It can be done for purely diagnostic reasons to determine if there are pelvic adhesions, fallopian tube issues, endometriosis or a whole host of other issues present that can affect the pelvis and fertility. It can also be done for corrective reasons. Surgery can be used to treat endometriosis, pelvic pain or adhesions and remove or fix the Fallopian tubes. Chromopertubation is a method for the study of patency of fallopian tube in women suspected of suffering from infertility. The catheter is infused with blue dye and finally placed in the uterus. The camera that was placed in the abdomen, as part of laparoscopy, is utilized directly for viewing and assessing the fallopian tubes and dye. If the dye fills up and spills out the tubes (fill and spill) then doctors can analyze if the tubes are open. Chromopertubation is considered the gold standard or one of the best tests to evaluate the fallopian tubes. However, Chromopertubation is usually not the first test performed because it requires surgery while a hysterosalpingogram does not.
- Hysterosalpingogram (HSG):
A Hysterosalpingogram (HSG) is the process of checking the fallopian tube and the uterine cavity with the help of an x-ray. Hysterosalpingogram is an outpatient procedure that usually takes less than 5 minutes to perform. This test is usually conducted after the menstrual period ends but before ovulation. The test can be done under x-ray guidance or under ultrasound guidance at one of the local hospitals. HSG does not require surgery, therefore, it is much less invasive than a laparoscopy. A traditional HSG is done under fluoroscopic (X-ray) guidance where a catheter is placed in the uterus and contrast (a dye that can be seen on x-rays) is infused into the uterus. Several x-rays are taken and the doctor observes if the dye fills up and spills out of the tubes (fill and spill). The latest version of HSG is popularly known as “Sono HSG”. This test is most often performed in some of the best infertility centers. It is done under ultrasound guidance so it avoids exposing patients to x-ray radiation. Similar to a traditional HSG, a catheter is infused with saline and water and placed inside the patient’s uterus. An ultrasound is performed and the doctor sees if the air bubbles fill up and spill out of the tubes (fill and spill). If fill and spill occur, the doctor can easily conclude if the tubes are open. If this does not occur the tubes may not be truly blocked. There are several reasons such as tubal spasms which can cause blockage even though the tubes are open. Sometimes if an HSG is abnormal, a laparoscopy and Chromopertubation are performed to check and confirm if a true blockage is present.
Saline Salpingosonography (SSG) test can be performed in an infertility clinic. This procedure takes 15 minutes and is done under ultrasound (sonography). The patient does not need anesthesia as it is well tolerated. Women usually prefer SSG over other diagnostic procedures for blocked or damaged tubes. In this, sterilized saline is passed through the uterus. The expert surgeons check as the fluid flow through the tube. The tubes appear grey and the fluid tends to appear black. It is originally performed during laparotomy for reconstructive tubal surgery to assess the mucosa of the infundibulum and ampulla. Prediction of fertility outcome by laparoscopy can be improved when combined with salpingoscopy. The two medical tests significantly complement rather than substitute each other. Special expertise and equipment are required, making salpingoscopy an expensive proposition. As it is implemented during laparoscopy, its risk profile is differentiated. It was the first tubal assessment test that disclosed a new world of detailed in-vivo images of the actual site of human fertilization. It can clearly determine the presence or absence of anatomical distortions, especially adhesions between and destruction of mucosal folds on a micro-endoscopic. Lesions of the infundibulum and ampullary segment have been detected in patients with apparently normal tubes on HSG and laparoscopy.
Falloposcopy is an advanced medical diagnostic and operative procedure that involves introducing a tiny camera into the fallopian tubes. The tubes are inserted through the vagina to look into the cell layer that lines in the inside of the tube known as the epithelium. It also helps to keep a check and see if there are any obstructions in the fallopian tubes that may block the passage of eggs. Falloposcopy is helpful for the evaluation of abnormalities in the fallopian tube that can cause infertility in women, and in some cases to correct any abnormality present in the same.
Abnormal conditions of the fallopian tubes that require Falloposcopy are:
- Damage to the interior cell lining
- Damage or abnormal conditions of blood vessels
- Shrinking, narrowing or blockage of the tubes
- Impacted debris
Falloposcopy is considered a delicate procedure that can be associated with various complications. Falloposcope by itself can damage or rarely even perforate the fallopian tube, if not performed correctly. For this reason, it may be considered if a woman is suspected to have a potentially treatable tubal factor infertility. Correction is easily available in case of abnormalities such as narrowing and blockage during the procedure. Medically assisted methods of fertilization can be considered such as In Vitro Fertilization (IVF) if the conditions of the fallopian tube are considered optimal. Although not commonly practiced, the falloposcopy can also be inserted during open or laparoscopy surgery through the fimbria.
- Transvaginalhydrolaparoscopy (THL)
Transvaginalhydrolaparoscopy (THL) is an alternative procedure to Hysterosalpingography (HSG) and laparoscopy that allows direct visualization of the female peritoneal cavity. THL is more commonly performed in Europe and China than in the United States. In this procedure, a trocar is passed through the vagina into the Pouch of Douglas, and an optic scope is placed through the trocar sleeve, allowing close examination of the uterus, ovaries, fallopian tubes, and peritoneum. No abdominal incision is required in Salpingoscopy. This procedure can be successfully accomplished in a basic clinical setup. THL can also be performed in conjunction with Chromopertubation, salpingoscopy, microlaryngoscopy, and hysteroscopy. Dr. Antoine Watrelot a famous gynecologist from France coined the term “fertiloscopy” for the combination of these procedures. In contrast to traditional HSG for evaluation of tubal patency, THL additionally permits direct inspection of the tubal mucosa. Because the vaginal trocar is passed parallel to the axis of the fallopian tubes, the optic scope can more easily enter the tubal lumen. This permits inspection of the inner tubal microarchitecture. A vaginal and rectovaginal examination is performed to evaluate the axis, size, and mobility of the uterus and to evaluate for pelvic masses or pathology in the Pouch of Douglas. A speculum is then efficiently placed in the vagina. If in a clinical setup, local anesthesia may be given by rubbing a lidocaine swab on the vaginal mucosa for 10 min followed by a paracervical block of lidocaine. THL has the advantage of not requiring an abdominal incision, thus perhaps being more cosmetically appealing to patients. Also, in contrast to traditional HSG for evaluation of tubal patency, THL is favorable in that it allows direct examination of the tubal mucosa because the axis of optic scope insertion through the vagina permits easy access for salpingoscopy. Lysis of adhesions, ablation of endometriosis, and ovarian drilling also can be performed using the transvaginal approach. Patients with extensive adhesions and endometriosis are probably better served by a laparoscopic approach that permits insertion of more than one operative instrument at a time. THL also may be combined with hysteroscopy.
Importance of Fallopian Tube Testing:
Tubal disease and abnormalities are responsible for nearly half of the cases of female infertility. Any kind of inflammation or infection in the pelvis can damage the fallopian tubes. Pelvic infection and inflammation is called Pelvic Inflammatory Disease (PID) and is caused by:
- STDs such as Chlamydia and Gonorrhea
- Presence of Endometriosis
- Infections following a miscarriage, termination of a pregnancy. Infections which occur after childbirth, or the insertion of an IUD
- Infections which occur following surgery for ovarian cysts
The function of the fallopian tubes can also be altered by blockages and adhesions ultimately causing infertility. Some women with tubal damage from PID are not aware it has happened until they try to become pregnant.
- Rubin’s test: Tubal perfusion pressures
- Dye injections with culdocentesis
- Injection of radiolabeled xenon solution with gamma-camera screening
- Selective salpingography and tubal catheterization
- Hystero Contrast sonography
Women who are suffering from endometriosis, previous ectopic pregnancy or PID are recommended HSG to screen for tubal occlusion. For ruling out tubal occlusion this can be a more reliable test, less invasive and makes more efficient use of resources than laparoscopy procedure. Further, more research needs to be done to ascertain the value of Fertiloscopy and Falloposcopy while examining couples who experience fertility problems. The couples who are not able to conceive after having one year of regular unprotected sexual intercourse can opt for further clinical treatments, including semen analysis and assessment of ovulation. These treatments can help the infertile couple to live their parenthood dream successfully. There are three categories of medical tests that have an established correlation with pregnancy, namely semen analysis, tubal patency tests by hysterography or laparoscopy and tests to detect ovulation. Women suspected to have similar conditions should opt for laparoscopy so that any tubal and other pelvic pathology can be detected early and treatments can be provided at the right time.
A patient can undergo three cycles of ovulation induction before checking tubal patency in case there are no complications associated with pelvic or tubal blockages. For infertile couples evaluation of tubal patency is a key component of the diagnostic workup. However, there are technical limitations for available methods for evaluation of tubal factors. This must be considered when technique yields abnormal results. The difficulties involved in tubal function should not be overlooked by a single test while assessing the tube through various medical tests available. Looking for tubal patency by flushing liquids through the tubes should not be taken into account. For women with tubes that might be open as simple pipes that conduct fluid, just simple patency of the tube might give false reassurance. It is not always functional as far as eggs and sperm are concerned. Various tests are available when it comes to the treatment of tubal damages in terms of safety, accuracy, effectiveness, and prognostic ability. However, the evidence base is good for the older tests, i.e. HSG and laparoscopy with a dye test. We hope this article provided you with detailed and useful information regarding the fallopian tube and the different types of medical test for checking fallopian tube blockage or damage.
SOURCES AND REFERENCES:
- Keywords: Signs and Symptoms of Blocked Fallopian Tubes | Medical News Today Medicalnewstoday.com, 25 June 2019
- Fallopian Tube Testing | Duke Fertility Center Dukefertilitycenter.org, 25 June 2019
- Fallopian Tube | Wikipedia En.wikipedia.org, 25 June 2019
- Blocked Fallopian Tubes and Tubal Factor Infertility | Advanced Reproductive Medicine Arm.coloradowomenshealth.com, 25 June 2019
- Fallopian Tube Test Hysterosalpingogram before Infertility Treatments Drmalpani.com, 25 June 2019