What is tubal infertility and how is it treated? Tubal-peritoneal factor of infertility.

Option female infertility caused by functional or organic obstruction fallopian tubes. There are no specific symptoms. Like other forms of infertility, it is manifested by the inability to become pregnant in the presence of regular sexual relations for 6-12 months. When making a diagnosis, hysterosalpingography, ultrasonic hysterosalpingoscopy, laparoscopy, laboratory tests to detect STIs. Treatment of tubal-peritoneal infertility includes medication and physiotherapy, hydrotubation, transcatheter recanalization, reconstructive plastic surgery, IVF.

Classification

Clinical classification of tubal infertility is carried out taking into account the localization of the pathological process, the presence or absence of anatomical changes. Specialists in the field of gynecology and reproductive medicine distinguish between:

• Actually tubal infertility . A woman cannot become pregnant due to functional or organic disorders in the fallopian tubes. In this case, the obstruction can be proximal with the presence of obstructions in the uterine part or isthmus of the tube and distal with impaired capture of the egg during ovulation.
• Peritoneal infertility. The egg cannot enter the funnel of the tube due to inflammatory or other processes in the pelvic organs. Often, peritoneal infertility is accompanied by morphological or functional changes in pipes.

Symptoms of tubal infertility

Specific symptoms characteristic of this variant of the disorder reproductive function, does not exist. As with other forms of infertility, the patient notes the absence of pregnancy for 6-12 months, although she maintains regular sexual life and is not protected. The pain syndrome is not pronounced or is characterized by low intensity - periodically disturbed by pain in the lower abdomen and (less often) in the lower back, which occur or intensify during menstruation and sexual intercourse. menstrual function usually kept. Some women remark copious discharge during menstruation.

Complications

The most formidable complication of tubal infertility that has arisen against the background of functional or partial organic obstruction of the fallopian tubes is ectopic pregnancy. A fertilized egg, if it is impossible to get into the uterus, is able to implant in the wall of the tube, ovarian tissue or organs abdominal cavity. Spontaneous termination of an ectopic pregnancy is accompanied by massive bleeding, expressed pain syndrome, critical fall blood pressure and other violations that pose a serious danger to a woman's life.

Diagnostics

When identifying tubal infertility, it is important to take into account anamnestic information about past cervicitis, endometritis, salpingitis, adnexitis, abdominal trauma, operations on the intestines and pelvic organs, abortions, complicated childbirth, invasive diagnostic and medical procedures. The survey plan includes methods such as:

• Gynecological examination. Bimanual examination may reveal slightly enlarged, indurated, and painful appendages. Sometimes the mobility of the uterus is limited, its position is changed, the vaults of the vagina are shortened.
• Hysterosalpingography. When contrasting, changes in the shape (local narrowing, expansion) and patency of the pipes are determined up to a complete violation, in which contrast agent does not enter the abdominal cavity.
• Ultrasonic hysterosalpingoscopy (EchoGSS, USGSS). Allows you to detect obstruction of the fallopian tubes and signs of adhesions in the pelvis.
• Fertiloscopy and laparoscopy with chromopertubation. Visually reveals adhesions, foci of endometriosis, provides an objective assessment of the patency of the fallopian tubes by controlling the flow of dye into the abdominal cavity, introduced into the cervical canal.
• Transcervical Falloscopy. Endoscopic examination epithelium and lumen of the tubes allows you to most accurately assess their condition.
• kymopertubation. Physical activity appendages upon admission to them carbon dioxide or air is broken.
• Laboratory diagnosis of STIs. Since in some cases the cause of tubal-peritoneal infertility is infectious processes, for the appointment of etiotropic treatment, it is important to identify the pathogen and evaluate its sensitivity to antibacterial drugs.

Tubal-peritoneal infertility must be differentiated from infertility caused by ovarian dysfunction, pathology of the uterine cavity, the action of the cervical factor and causes from the patient's husband. To conduct differential diagnosis attract a reproductive specialist and a gynecologist-endocrinologist.

Treatment of tubal infertility

To eliminate the causes that caused the violation of the patency of the pipes, conservative and operational methods treatment. Medical therapy includes:

• Antibacterial drugs. Etiopathogenetic treatment is aimed at eliminating the causative agent of STIs, which caused the inflammatory process.
• Immunotherapy. Allows to correct immunological disorders leading to prolonged and chronic course salpingitis and adnexitis.
• Absorption therapy. Local and general administration of enzyme preparations, biostimulants, glucocorticosteroids is indicated for the resorption of adhesions and synechia that have arisen after infectious and aseptic inflammation.
• hormone therapy. It is used for disorders that have developed against the background of an imbalance in the female hormonal sphere.
• Sedative drugs. Effective for the correction of functional disorders.

AT complex treatment for tubal-peritoneal infertility, physiotherapeutic methods are widely used: electrophoresis, transvaginal ultraphonophoresis, electrical stimulation of the fallopian tubes and uterus, gynecological irrigation, mud applications , EHF-therapy , vibration and gynecological massage . To restore impaired tubal patency, minimally invasive interventions are also used - transcatheter recanalization, hydrotubation, pertubation.

More effective way The solution to the problem of tubal infertility is the use of surgical approaches. Surgical treatment indicated for patients under the age of 35 years with infertility not more than 10 years in the absence of acute and subacute inflammation, tuberculous lesions of the genital organs, severe endometriosis and adhesions. To restore tubal patency, such reconstructive-plastic laparoscopic interventions are used as:

• Salpingolysis. During the operation, the tube is released from the adhesions surrounding it.
• Salpingostomy. With massive adhesions and adhesions in the funnel area, the formation of a new hole is effective.
• fimbriolysis and fimbrioplasty. The operation is aimed at freeing the fimbriae of the fallopian tube from adhesive adhesions or plastics of its infundibulum.
• Salpingo-salpingoanastomosis. After excision of the affected area, the remaining parts of the pipe are interconnected.
• Pipe transplant. If the interstitial part of the tube is obstructed, it is recommended to move it to another part of the uterus.

Often such interventions are supplemented with a course of postoperative hydrotubation. In addition to tubal plasty during laparoscopy, it is possible to coagulate and separate adhesions, remove concomitant neoplasms that can prevent conception and pregnancy, such as retention ovarian cysts, intramural and subserous uterine fibroids, and foci of endometriosis. In the presence of contraindications and ineffectiveness of surgical treatment, IVF is recommended for patients with tubal infertility.

Forecast and prevention

The prognosis of TPB depends on the type of disorders and their severity. After reconstructive plastic surgery, pregnancy occurs in 20-50% of cases, while largest number conception is noted in the first year after the operation, subsequently the probability of gestation is significantly reduced. When using IVF, the efficiency is from 35 to 40%. The main methods of preventing tubal infertility are early detection and treatment inflammatory processes, endocrine disorders, comprehensive rehabilitation after operations on the pelvic organs, adequate obstetric care, refusal of abortions and unjustified invasive medical and diagnostic procedures.

Tubal and tubal-peritoneal factor of infertility belong to the same ICD-10 code and are synonymous concepts that subsequently lead to female infertility. Distinctive features is the pathogenesis of impaired conception.

• Pipe factor infertility is a partial or complete obstruction of the fallopian tubes resulting from inflammatory processes or diseases associated with the genital organs. In this case, obstruction is most often caused by the accumulation of fluid.

  The movement of the egg through the tube slows down, as a result of which fertilization either does not occur, or the fertilized egg does not reach the uterine cavity and is attached in the tube or, much less often, in the abdominal cavity to the intestinal walls, omentum and other anatomical structures.

• Peritoneal factor occurs as a result of the formation of adhesions in the pelvis, as a result of which the egg cannot penetrate the fallopian tube and meet with the sperm for fertilization. The causes of this pathology may be inflammation or surgery.

Both types of disorders lead to the development of infertility.

Types of violation of the patency of the fallopian tubes

The fallopian tubes are an integral part in the conception of a child. If any tube pathologies occur, a woman can be diagnosed with infertility. It can be caused by the following diseases:

Reference! Fallopian tube obstruction usually does not have obvious symptoms, so the possibility of such a disease should be considered after surgical intervention in the abdominal cavity or a sexually transmitted infection.

What can cause pathology?

Infertility of this genesis cannot appear on its own, it is caused by various pathological processes in a woman's body. Experts identify the following factors that can cause tubal infertility:

Before making a diagnosis of tubal infertility, a specialist must find out the presence of these factors in order to make sure that the directed diagnosis and further treatment are correct.

Symptoms

Usually this pathology does not cause symptoms, a woman learns about the presence of the disease when she cannot become pregnant or when an ectopic pregnancy occurs. There is unilateral and bilateral obstruction, as well as complete and partial. In each case, pathology can make itself felt in different ways:

1. Unilateral obstruction less likely, but still gives a woman the opportunity to become pregnant, provided that the second pipe is completely passable.
2. Bilateral obstruction, is manifested by the main symptom of the inability to become pregnant for a long amount of time. Pathology is detected through diagnosis.
3. Complete or partial obstruction, also does not provide an opportunity for the egg to meet with the sperm, which does not allow fertilization. In the case of partial obstruction, there may be ectopic pregnancy, which may lead to the removal of pipes.

Given the absence of obvious symptoms, it is necessary to carefully consider all factors that can cause this species infertility. And if you suspect this pathology, consult a gynecologist.

Diagnostics

When contacting a specialist with complaints about the impossibility of getting pregnant, a woman is examined as follows:

One more important detail in the correct diagnosis is to obtain detailed information about the menstrual cycle, which includes their frequency and duration. Special attention the doctor will draw on past diseases of the genital organs, infections and surgical interventions, which could provoke the process of blockage.

Important! The appointment of diagnostics with subsequent treatment should be handled exclusively by a gynecologist.

Treatment

Today, experts use wide range methods that allow you to get rid of the problem with tubal infertility, and also makes it possible to become pregnant. Therapies currently being used this disease:

1. Surgical: This method is especially effective in the presence of adhesions. Treatment is performed by dissecting adhesive processes by laparoscopy. This procedure is the introduction of a tube into the abdominal cavity, through which tools are passed to remove adhesions. Now, such an operation makes it possible to resume the entrance to the fallopian tubes or create holes in them.
2. ECO: this procedure is an alternative way the onset of pregnancy. It is usually prescribed to women who have been trying to get pregnant for more than two years and none of the other methods gives positive results. The procedure itself is tracking the menstrual cycle, ovulation stimulation and egg retrieval. After that, they are fertilized with sperm and placed in the uterus, where the embryo continues to grow.

Particular attention in the treatment of this type of infertility should be given to psychological state women, eliminating all sorts of stressful situations.

Forecast

When making a diagnosis of female infertility of tubal-peritoneal origin, the prognosis can be very different. An important factor is what caused such changes in the body of a woman. Therefore, first of all, doctors eliminate the causes, which include inflammation and infection. The prognosis of pregnancy after treatment of tubal infertility is as follows.

Fallopian tube pathology is one of the most frequent (35-74%) causes of infertility. The main causes that cause impaired patency of one or both fallopian tubes, especially in combination with adhesions, include sexually transmitted diseases (STDs), complicated abortions, spontaneous miscarriages, childbirth, numerous therapeutic and diagnostic hydroturbations, surgical interventions on the pelvic organs.

Despite advances in the treatment of inflammatory diseases of the female genital organs, their specific gravity among the causes of infertility in women is significant. There was no trend towards a decrease in the frequency of obstruction of the fallopian tubes.

Most often, operations for tubal-peritoneal infertility are performed to separate adhesions and restore patency of the fallopian tubes (salpingostomy, salpingoneostomy).

For each operation, the limits of technical operability should be determined, but there are several conditions under which surgery contraindicated.
1. Tuberculosis of the fallopian tubes.
2. Pronounced sclerotic process in the tubes.
3. Short tubes with no ampulla or fimbria as a result of previous surgery.
4. The length of the tube is less than 4 cm after a previous operation.
5. Widespread adhesive process as a result of recurrent inflammatory disease pelvic organs.
6. Additional incurable factors of infertility. Additional examination includes the entire research algorithm for infertile marriages. Attention is focused on the exclusion of STDs and the analysis of the results of bacteriological analysis.

HSG is recognized as the leading method for diagnosing tubal infertility. As a rule, the operation is performed in the first phase of the menstrual cycle (7-12th day).

Operational technique

Access

The operation is performed using three trocars: paraumbilical (10 mm) and additional, inserted into both iliac regions(5 mm). At the time of trocar insertion, the patient is in horizontal position, then it is changed to the Trendelenburg position.

Salpingolysis- release of the tube from adhesions, which involves the dissection of adhesions between the tube and the ovary, between the appendages and the side wall of the small pelvis, between the appendages and the intestines, the omentum.
1. Spikes are tightened by creating traction and counter-traction. To do this, change the position of the uterus using an intrauterine probe, capturing the adhesions themselves with a manipulator or changing the position of the tubes and ovaries. Adhesions are excised with scissors with or without EC.
2. Chromosalpingoscopy is performed: 10-15 ml of methylene blue or indigo carmine solution is injected through the cannula of the uterine probe.

Fimbrioplasty or fimbriolysis is performed with partial or complete occlusion of the fimbriae of the tube, preserved fimbriae and the possibility of their identification. The operation is also performed with phimosis of the fimbriae and their eversion.

Fimbriolisis with phimosis of the distal fallopian tube

2. Adhesions are dissected using an L-shaped electrode, trying to lift them above the pili. With a pronounced adhesive process or gluing of the fimbria through a small hole into the lumen of the tube, the branches of the dissector are introduced, then they are smoothly moved apart, separating the adhesions. Bleeding areas are carefully coagulated.

Salpingostomy, or salpingoneostomy, is indicated when the tube is completely occluded and the fimbria cannot be identified (for example, with hydrosalpinx).

Salpingostomy. Cross-shaped opening of the ampullar part of the fallopian tube

Salpingoneostomy. Creation of a new hole in the ampulla of the fallopian tube

Postoperative management

Complications

In the structure of infertility, the frequency of endometriosis is about 50%.

Most often, endometrioid lesions are located on the wide sacro-uterine ligaments, in the retrouterine space and on the ovaries. The most rare localization is the anterior uterine space, tubes and round ligaments uterus.

A comparative study of infertility treatment methods for endometriosis showed that the use of only endoscopic coagulation of foci or removal of ovarian cysts leads to pregnancy in 30-35% of cases.

Slightly better results (35-40%) can be obtained with the use of drug therapy.

It is possible to increase the efficiency of restoration of menstrual-reproductive function to 45-52% and prevent recurrence of the disease when using two stages of treatment - laparoscopic and medical. We perform hormonal correction in case of common forms of endometriosis or after non-radical surgery.

In case of radical operations for endometriosis, we recommend the resolution of pregnancy without prescribing hormonal treatment.

G.M. Savelyeva

Tubal peritoneal infertility This is a type of obstruction of the fallopian tubes. Peritoneal infertility is said to be when an adhesion is located between the ovary and the uterine tube, creating a barrier to the release of the egg from the ovary. Obstruction can be partial or complete. About a third of all women diagnosed with infertility suffer from tubal peritoneal infertility.

At normal operation ovary and fallopian tubes, the egg produced by the ovaries travels down the tube where it meets the sperm. Movement may not occur or be difficult due to adhesions located in the fallopian tubes. In this case, even the sperm will not be able to get to the right place in the tube, where it will fertilize the egg. This article explains the causes of infertility. this kind, as well as the most effective methods overcoming peritoneal infertility.

Causes of tubal peritoneal infertility

Tubal obstruction most often occurs after an infection that has led to inflammatory reactions in the female pelvic organs. The infection can be commonplace - non-compliance with the rules of personal hygiene, brought from instruments during an abortion, as well as specific (sexually transmitted infections) - herpes, gonorrhea, etc. At the same time, infections may well proceed haphazardly for the time being, until a woman asks a gynecologist about the reason for the impossibility of conception. After transferred surgical interventions on the pelvic organs, the formation of adhesions and scarring in the tubes is also possible. Endometriosis (overgrowth of the endometrium) is the most common cause tubal obstruction. So, the reasons why tubal peritoneal infertility develops are summarized in a separate list:

1. Transferred inflammatory processes.
2. Growth of the endometrium.
3. Consequences of surgical interventions.
4. After an abortion.
5. Complications that appeared during childbirth.

adrenal dysfunction, hormonal imbalance, failures in the synthesis of prostaglandins and steroids, stressful situations - all this can cause peritoneal infertility due to impaired motility of the elements of the fallopian tubes.

Treatment of tubal peritoneal infertility

((banner2-left)) There are two methods to deal with this infertility:

• laparoscopy;
• ECO.

Laparoscopy - instrumental surgical removal scars and adhesions. Effective for small partial obstruction of the pipes. The laparoscope will remove the scars around the tubes, and the pregnancy should come very soon. But if the patency is significant, laparoscopy will not only not help, but also hurt. At the same time, one session of laparoscopy is enough to either gain the opportunity to conceive, or forever abandon the idea of ​​​​natural conception. But in the second case, help will come ECO.

In vitro fertilization is carried out in this way. A healthy egg is taken from a woman, and viable sperm from a man. Under laboratory conditions, the embryo is cultivated, which after 3-5 days is implanted in the uterine cavity. The probability of getting pregnant with 1-2 IVF attempts is very high.

If you pay attention to the statistics, it can be noted that tubal-peritoneal infertility is a pathology that is diagnosed in 40% of cases in women who seek medical help.

The main reason for the development of such a pathology is the presence of inflammatory processes localized in the pelvic organs. In case of failure to provide timely medical care inflammation goes into chronic form. This also happens if an infection gets inside or as a result of an unsuccessful termination of pregnancy.

In some cases, tubal-peritoneal infertility develops if:

• The motility of the fallopian tubes is impaired;
• Previously, operations were performed on the abdominal organs;
• Has endometriosis.

Among the most dangerous infectious diseases include gonorrhea, genital herpes, chlamydia, mycoplasmosis, ureaplasmosis, trichomoniasis, and cytomegalovirus. A woman should understand that many of these diseases can occur in latent form. It will be possible to detect them only after passing the tests and passing the appropriate examination. Positive result ensured if both spouses are treated.

If the inflammatory process is accompanied by infection activity, then the risks of adhesion formation will be very high. As a result of this phenomenon, the egg will not be able to move normally through the fallopian tubes, which is the reason for the diagnosis of infertility of tubal peritoneal origin.

What explains the decline in a woman's fertility?

A woman's propensity to conceive may decrease for the following reasons:

• Poor patency of the fallopian tubes or tubal infertility;
• The presence of adhesions in the pelvic area or tubal peritoneal infertility factor;
• A combination of the two previous reasons.

Obstruction of the fallopian tubes may be the result of organic lesions or functional disorders.

Organic lesions

Some of these reasons include:

• The consequences of operations on the internal genital organs, in particular, this applies to myomectomy and resection of the ovaries;
• The penetration of pathogens and infections that cause the development of inflammatory processes. It can be venereal diseases, appendicitis or peritonitis;
• Postpartum complications;
• Consequences of artificial termination of pregnancy.

Functional disorders

• Prostaglandins are not metabolized;
• The work of the adrenal glands is disturbed;
• Systematic experience stressful situations;
• Violation of the association of steroid hormones;
• Violation of the association of prostaglandins.

Tubal-peritoneal infertility - diagnosis

If the doctor suspects that the patient has tubal-peritoneal infertility, he will prescribe a procedure for her to check the patency of the fallopian tubes. This one is different diagnostic method called hysterosalpingography. Through such a study, it is possible to discover why this pathology develops. Perhaps there are polyps of the inner layer of the uterus, a defect in its development, synechia, or other problems.

To understand tubal peritoneal infertility - what it is, hysterosalpingography will help. Through this method the presence of adhesions in the pelvis is determined. If, after receiving the results, the presence of intrauterine pathology was revealed, then the woman is offered to do a hysteroscopy. To confirm the diagnosis primary infertility tubal genesis, a woman is sent for laparoscopy.

For more information and exact definition uterine disease necessarily prescribe gynecological ultrasound diagnostics.

Tubal peritoneal infertility - classification of problems detected during diagnosis

This examination reveals:

• Chronic endometriosis;
• Intrauterine synechia;
• Fibroids;
• Defect in the structure of the uterus;
• Adenomyosis nodular or diffuse form.

If you need to exclude or confirm the presence tumor formations in the ovaries or on them, then the woman is prescribed echography.

If tracking status functional cysts in certain periods monthly cycle, then treatment can be dispensed with without surgery. This is due to the fact that such cysts often develop in the opposite form. That is, under the influence hormonal drugs they can disappear in two or three menstrual cycle. As for the true formations, for example, dermoid, endometrioid and other cysts, they do not change in this way.

If there is a need to confirm or exclude the presence of tumors, the doctor prescribes a laparoscopy for the patient. In this case, it is impossible to give a full assessment of such a pathology through one ultrasound.

Tubal peritoneal infertility factor is determined after the detection of adhesions by laparoscopy. All other diagnostic methods are effective for detecting other diseases, which, by the way, can also cause female infertility.

Summing up, it is worth saying that laparoscopy is prescribed to a woman if it is not possible to identify tubal peritoneal infertility by other methods. Treatment of this pathology will be prescribed based on the results of the laparoscopic examination.

According to doctors and based on practical indicators, pregnancy can occur as early as six months after the operation, provided there are no complications and consequences.

Infertility 2 tubal peritoneal genesis - treatment of pathology

Treatment of this disease, which caused infertility, can be carried out by one of two methods.

Surgery

Today, surgical treatment is carried out through laparoscopy. This method of treatment reduces the risk of complications after surgery. In addition, the body recovers much faster than after a standard surgical operation.

A successful outcome of the operation is guaranteed if:

• The doctor has a high professional qualification;
• The area of ​​damage to the fallopian tube is small;
• Functional Ability fimbria are normal. These are a kind of villi that move a mature egg into the fallopian tube for its further fertilization.

in vitro fertilization

This method of treatment is used if other medical and surgical methods of dealing with the disease have not given positive results.