Tubal infertility. Tubal-peritoneal infertility - consultation health potential

Tubal infertility is caused by anatomical and functional disorders of the fallopian tubes, peritoneal - adhesive process in the pelvic area. Due to their frequent combination in the same patients, this form of female infertility is often referred to by one term - tubal-peritoneal infertility (TPB). TPB accounts for 20–30% of all cases female infertility.

* Forms of tubal and tubal-peritoneal infertility

tubal infertility- occurs in the absence or obstruction of the fallopian tubes or in their functional pathology - a violation of the contractile activity of the fallopian tubes (discoordination, hypo- and hypertonicity).
Etiology: inflammatory processes of the genitals; surgical interventions on the organs of the abdominal cavity and small pelvis (myomectomy, resection of the ovaries, ligation of the fallopian tubes); postpartum complications (inflammatory and traumatic); external endometriosis; genital infections (chlamydia, gonorrhea, mycoplasma, trichomonas (herpetic, cytomegalovirus, etc.).

Most often, organic obstruction of the fallopian tubes is caused by sexually transmitted infections. Urogenital chlamydia causes inflammatory process in the pipes and leads to their occlusion, which is accompanied by the destruction of the fimbriae and the development of hydrosalpinx, and inflammatory response around the tubes leads to a decrease in their mobility, preventing the normal capture and advancement of the egg. Neisseria gonorrhoeae causes the development of an adhesive process and the appearance of adhesions in the pelvis. Mycoplasmas have a temporary ability to adsorb on cells, attach to the head or middle part of the spermatozoon, changing its mobility. Ureaplasma can penetrate into upper divisions reproductive system with the help of carriers - spermatozoa, cause narrowing or obliteration of the tubes; these pathogens are attached to the cells of the ciliated epithelium, have on it toxic effect, disrupting the advancement of the egg into the uterine cavity; ureaplasmas also reduce sperm motility, inhibit their penetration into the egg. Viruses cause a weakening of local immunity with the activation of intercurrent infection.

Peritoneal infertility- this is infertility due to adhesions in the area of ​​​​the uterine appendages. The frequency of peritoneal infertility is 40% of all cases of female infertility. The peritoneal form of infertility occurs as a result of inflammatory diseases of the internal genital organs, surgical interventions, and external endometriosis.

At the same time, there are morphological changes tubes: foci of sclerosis of their walls, alternating with foci of diffuse lymphocytic infiltration; chronic vasculitis, discompletion of muscle fibers, reduction of capillaries, arteriosclerosis, varicose veins venule; are celebrated dystrophic changes nerve fibers, deformation of the lumen of the tube with the formation of microcysts, diverticula, deposition of lime salts in the mucous membrane of the fallopian tubes.

In patients with endometriosis, along with the pathology of oogenesis in the ovaries and the detection of degenerative oocytes, unfavorable intraperitoneal conditions are created for gametes and the embryo. Peritoneal fluid in endometriosis contains an increased number of interferon-γ-producing T-cells and activated macrophages, which interferes with reproductive processes. With endometriosis, the capture of the egg by the fallopian tube immediately after ovulation and the transport of gametes and the embryo through the fallopian tube are disrupted; this is due to changes functional activity tubes due to overproduction of prostaglandin F2a by endometrioid foci. Infertility with endometriosis can be primary and secondary, as with anovulation and insufficiency. corpus luteum, and in a normal two-phase cycle.

In patients with peritoneal endometriosis and infertility, numerous villi and cilia were found on endometrial epitheliocytes in the late secretory phase. The preservation of the microvillous cover reflects the insufficiency of the secretory transformation of the endometrium due to the insufficiency of the luteal phase in this disease. Violation of secretory transformation and the associated deformation of the micro-relief of endometrial epithelial cells in endometriosis can lead to miscarriage or infertility. Microvilli and cilia are an obstacle to the full nidation of a fertilized egg in the uterine cavity, which leads to termination of pregnancy in early dates.

Functional pathology of the fallopian tubes occurs when:

♦ psycho-emotional instability;
♦ chronic stress;
♦ changes in the synthesis of sex hormones (especially their ratio), impaired functions of the adrenal cortex and sympathetic-adrenal system, hyperandrogenism;
♦ decrease in the synthesis of prostaglandins;
♦ increase in the metabolism of prostacyclin and thromboxane;
♦ inflammatory processes and operations on the pelvic organs.

ETIOLOGY AND PATHOGENESIS OF TUBE AND PERITONEAL INFERTILITY

The cause of obstruction of the fallopian tubes can be both their functional disorders and organic lesions. Functional disorders of the fallopian tubes include violations of their contractile activity (hypertonicity, hypotension, discoordination) without obvious anatomical and morphological changes.

Organic lesions of the fallopian tubes have visually detectable signs and are characterized by obstruction against the background of adhesions, torsion, ligation (with DHS), compression by pathological formations, etc.

It leads to dysfunction of the fallopian tubes:

• hormonal imbalance(especially against the background of a violation of the synthesis of female sex steroids and hyperandrogenism of various origins);
• persistent deviations in the sympathoadrenal system, provoked by chronic psychological stress due to infertility;
• local accumulation biologically active substances(prostaglandins, thromboxane A2, IL, etc.), intensively formed during chronic inflammatory processes in the uterus and appendages, provoked by persistent infection or endometriosis.

Causes of organic lesions of the fallopian tubes and peritoneal infertility are, as a rule, transferred PID, surgical interventions on the uterus, appendages, intestines (including appendectomy), invasive diagnostic and healing procedures(HSG, kymopertubation, hydrotubation, diagnostic curettage), inflammatory and traumatic complications after abortion and childbirth, severe forms external genital endometriosis.

DIAGNOSIS OF TUBE AND PERITONEAL INFERTILITY

For the diagnosis of TPB, first of all, the anamnesis matters: an indication of past STIs and chronic inflammatory diseases reproductive organs, performed surgical interventions on the pelvic organs, features of the course of post-abortion, postpartum, postoperative periods, the presence of pelvic pain syndrome, algomenorrhea, inflammatory urogenital diseases in a partner.

TPB can also be suspected in patients with endocrine infertility who do not restore natural fertility within 1 year after the start of adequately selected hormonal therapy. At gynecological examination TPB is evidenced by signs of an adhesive process: limited mobility and a change in the position of the uterus, shortening of the vaginal vaults.

To diagnose the presence of tubal-peritoneal infertility and its causes, a clinical and anamnestic method, identification of the causative agent of STIs, hysterosalpingography, laparoscopy, and salpingoscopy are used.

The final stage of research, finally clarifying the presence/absence of TPB, is diagnostic laparoscopy. It is carried out without fail if TPB and endometriosis are suspected, and regardless of the results of the HSG (if such a study was carried out). Diagnostic laparoscopy is also prescribed for patients with endocrine (anovulatory) infertility after 6–12 months of hormone therapy, which ensures the restoration of ovulation, but does not lead to overcoming infertility. In addition, diagnostic laparoscopy is also used in patients with a preliminary diagnosis of unexplained infertility, the cause of which cannot be suspected during the initial polyclinic examination.

TREATMENT OF TUBE AND PERITONEAL INFERTILITY

Treatment of tubal-peritoneal infertility is carried out conservatively and surgically.

*Conservative treatment of tubal-peritoneal infertility

1. When an STI is detected, a complex etiopathogenetic therapy is carried out, aimed at eliminating the pathogen that caused the inflammatory process of the pelvic organs.

2. Immunotherapy (application), because in chronic inflammatory processes of the uterine appendages great importance have immunological disorders.

3. Resolving therapy, including general and local (tampons, hydrotubation) use of biostimulants, enzymes (wobenzym, serta, lidase, trypsin, ronidase, etc.), glucocorticoids.
As a type of local therapy, hydrotubation with enzymes is used, antibacterial agents, hydrocortisone. Unfortunately, clinical experience demonstrated both the insufficient effectiveness of this method of treating tubal infertility and the frequent occurrence of complications (exacerbation of inflammatory processes, hydrosalpinxes, disruption of the structure and function of endosalpinx cells, a decrease in the ability of the tube to peristaltic movement of the egg).

4. Physiotherapy for tubal-peritoneal infertility.

1. Medicinal electrophoresis using I, Mg, Ca salts, enzyme preparations and biogenic stimulants, daily, no. 10-15.

2. Ultraphonophoresis of the pelvic organs. Lidase, hyaluronidase, terrilitin, 2-10% preparations are used as contact media. oil solution vitamin E, ichthyol, indomethacin, naftalan, heparoid, heparin, troxevasin ointment, 1% potassium iodide on glycerin. Affect the lower abdomen, daily, No. 15.

In the presence of a vaginal electrode, they act through the posterior or lateral vaults, depending on the predominant localization of the adhesive process.

3. Electrical stimulation of the uterus and appendages - the vaginal electrode (cathode) is inserted in the mirrors into posterior fornix vagina, the other (anode) - with an area of ​​150 cm2 is placed on the sacrum. Rectangular monopolar pulses are used, frequency 12.5 Hz for 5-6 minutes, daily No. 10-12, starting from 5-7 days of MC.

4. EHF-therapy of tubal-peritoneal infertility is started after 1 month. after surgical treatment, from 5-7 days of MC. 3 times every day with 2-hour breaks, 30 procedures per course. This improves hemodynamics in vascular pool small pelvis.

5. Gynecological irrigation - use hydrogen sulfide, arsenic, radon or nitrogen, siliceous, low-mineralized mineral waters; Ґ = 37-38 °С, 10-15 min, every other day, No. 12.

6. Gynecological massage use daily, No. 20-40 (Appendix 5).

7. Mud applications on the "trigger" zone, t° = 38-40 °С; vaginal mud tampons (39-42 °C), 30-40 min, every other day or 2 days in a row with a break on the 3rd day, No. 10-15.

8. Abdominal-vaginal vibration massage - enhances tissue metabolism, increases the permeability of cell membranes and improves diffusion processes, which helps to improve blood flow and lymphatic drainage, tissue trophism, prevents the occurrence of adhesive processes, and leads to rupture of previously formed adhesions. Procedures are carried out daily, for a course of 10-12 procedures.

Surgical treatment of tubal-peritoneal infertility

Methods surgical treatment tubal-peritoneal infertility are more effective than conservative therapy and include: laparoscopy, micro surgical operations and selective salpingography with transcatheter recanalization of the fallopian tubes.

Laparoscopy has an advantage over other methods of surgical treatment of infertility, since it allows not only to diagnose the fact and cause of obstruction of the fallopian tubes (by examining and performing chromosalpingoscopy), but also to immediately carry out prompt recovery their patency (salpingolysis, salpingostomy, etc.).

Used in the treatment of TPB as operative laparoscopy(supplemented in the postoperative period with restorative therapy and ovulation stimulators), and IVF.

Laparoscopic reconstructive plastic surgery aims to restore the anatomical patency of the fallopian tubes, they can be prescribed to patients with TPB who have no contraindications to surgical treatment. IVF is used either with the initially established futility of performing any reconstructive plastic surgery (in patients with no fallopian tubes or with their deep anatomical changes), or after ascertaining the inefficiency of overcoming TBI with the use of endosurgery.

Depending on the nature of the revealed pathological changes during laparoscopic reconstructive plastic surgery, the fallopian tubes are released from adhesive adhesions compressing them (salpingolysis), the entrance to the funnel of the fallopian tube (fimbrioplasty) is restored, or a new hole is created in the overgrown ampullary section of the tube (salpingostomy). In peritoneal infertility, adhesions are separated and coagulated. In parallel with laparoscopy, detectable concomitant surgical pathology (endometrioid heterotopias, subserous and intramural fibroids, ovarian retention formations) is eliminated.

Microsurgical operations:

1. Fimbryolysis - release of the fimbriae of the tube from adhesions.
2. Salpingolysis - separation of adhesions around the pipes, elimination of kinks, curvature.
3. Salpingostomatoplasty - creation of a new hole in the tube with a sealed ampullary end.
4. Salpingosalpingoanastomosis - resection of a part of the tube, followed by end-to-end connection.
5. Transplantation of the tube into the uterus with obstruction in the interstitial section.

Contraindications for surgical treatment of TPB in order to restore natural fertility:

• age over 35 years, duration of infertility over 10 years;
• acute and subacute inflammatory diseases;
• endometriosis III-IV degree according to AFS classification;
• adhesive process in the small pelvis III-IV degree according to the Hulka classification;
• previously transferred reconstructive plastic surgery on the fallopian tubes;
• tuberculosis of the internal genital organs.

*Contraindications for microsurgical operations:

1. Absolute:
bleeding from the genital tract;
active inflammatory process;
recent operations on the genitals;
genital tuberculosis.

2. Relative:
the age of the patient is older than 35 years;
duration of tubal infertility for more than 5 years;
frequent exacerbations of inflammatory processes of the uterine appendages and an acute inflammatory process transferred during the previous year;
the presence of large hydrosalpinxes;
a pronounced adhesive process in the small pelvis;
malformations of the uterus;
intrauterine neoplasms.

Regarding the advisability of using the operation of salpingostomy in the presence of hydrosalpinx, there is no single point of view. There is an opinion that the reconstruction of the tube with hydrosalpinx makes sense only when it small sizes(less than 25 mm), the absence of pronounced adhesions in the area of ​​​​the appendages and in the presence of fimbriae.

With damage to the fallopian tubes in the isthmic and interstitial sections, as well as with absolute tubal infertility (in the absence of fallopian tubes, tuberculous lesions of the internal genital organs), IVF is recommended. In the postoperative period, to increase the effectiveness of endoscopic operations, restorative physiotherapeutic procedures can be used to activate local and general metabolic processes, normalization of microcirculation, prevention of postoperative adhesion formation (zinc and copper electrophoresis, pulsed ultrasound, supratonal frequency currents). The duration of physiotherapy treatment is 1 month. During the period of physiotherapy and within 1-2 months after its completion, contraception is mandatory. Subsequently, in the absence of pregnancy within the next 6 months, it is advisable to switch to treatment with the use of ovulation inducers, prescribed in 4-6 cycles. The total duration of TPB treatment with surgical and conservative methods should not exceed 2 years, after which, with continued infertility, patients are recommended to be referred for IVF.

*Insufficient efficiency of microsurgical operations on the fallopian tubes is associated with the frequent development of adhesions in the postoperative period, which leads to the resumption of tubal obstruction.

Selective salpingography with transcatheter recanalization for obstructive lesions of the proximal fallopian tubes is rarely used due to high frequency complications (perforation of the tube during the manipulation of the conductor, infectious complications, ectopic pregnancy in the ampullar sections of the tubes).

Prevention of TPB

Prevention of TB is the prevention and effective treatment inflammatory diseases of the genital organs, rational management of childbirth and the postpartum period, rehabilitation measures in the early stages after gynecological operations.

Tubal-peritoneal factor of infertility in our practice is the most frequent. What causes obstruction of the fallopian tubes? This question is asked by every woman who receives a doctor's opinion after a hysterosalpingography procedure. And of course, the most common cause is all kinds of organic disorders, such as adhesions in the pelvis after undergoing reconstructive plastic surgery in the pelvis and abdominal cavity, after undergoing urogenital infections, chronic inflammatory diseases on the uterine appendages, endometriosis, and also due to medical abortions.

At the reception, when clarifying the data of the anamnesis, we are faced, for example, with the transferred in childhood acute appendicitis and operated without any complications. And such a seemingly insignificant surgical intervention can play a fatal role in the formation of tubal infertility. Various diagnostic and therapeutic procedures, such as diagnostic laparoscopy, curettage of the uterine cavity, hydrotubation, also leave an indelible mark and form dense fibrous adhesions that violate the anatomical location of the fallopian tubes and their function.

By the way, the function of the fallopian tube is even more important, and dysfunction is difficult to determine by any research methods. This happens due to hormonal imbalance, disorders in the endocrine system of organs, chronic stress, as well as with widespread endometriosis and chronic persistent urogenital infection.

Highly important point is the problem of dilated fallopian tubes, the so-called hydrosalpinx. Unfortunately, when a patient comes to us with identified hydrosalpinx, it can be quite difficult to convince her that such an enlarged fallopian tube is a source of chronic infection and prevents pregnancy in the most direct way. We recommend surgical removal of such fallopian tubes, and after the operation, it becomes possible to carry out auxiliary methods. reproductive technologies.

Laparoscopic reconstructive plastic surgery on the fallopian tubes, restoring the normal anatomical arrangement of organs, the patency of the fallopian tubes, removing dense fibrous adhesions, of course, is effective, however, we are wary of such operations. Quite often we have to observe adverse outcomes of such operations. Hydrosalpinxes reappear in the same fallopian tube that was once operated on. It's amazing that women manage to deliberately go for surgery several times and operate on the same tube several times. As a result, in such a pipe there is a high probability of occurrence ectopic pregnancy. And also such a modified pipe is not removed, but only peeled off fertilized egg. We know of cases of multiple repeated ectopic pregnancies in the same tube.

After any surgical intervention, of course, it is necessary rehabilitation treatment, including drugs that reduce postoperative adhesion formation, improve microcirculation in the vessels of the small pelvis, aimed at improving metabolic processes, restorative physiotherapy procedures (electrophoresis, ultrasound, etc.)

There is no doubt that for any type of tubal-peritoneal infertility, the most highly effective and fastest method to achieve pregnancy is the IVF program.

Will I have children?

This is the same question. He is mercilessly exploited in books and movies. We saw a hundred times how, against the backdrop of white tiled walls, a necessarily fat doctor (iha) says sternly: “You will never have children,” and then disturbing music sounds. The fortune-telling industry thrives on predictions about childbearing, removing damage to childlessness costs a lot of pennies. Sometimes I am asked this question cheerfully and jokingly, for no reason or reason, as part of friendly chatter: “Well, tell me, tell me, you’re a doctor, now I’m 35, what’s all, I’m not giving birth?” Yes, where are you going, give birth. And again Friday evening, laughter and wine. This does not count, this is the exploitation of my specialty, nothing more.

And sometimes they ask anxiously, worrying about the “terrible” ureaplasma found or no less terrible erosion. But how difficult it is to answer this question when it sounds in the office from the lips of a woman quite seriously and to the point. Such women have a special look - between despair and hope. Always with tons of papers-analyzes-ultrasounds and so on, it's all laid out in files and folders, they know exactly their ovulation days, progesterone levels, they are savvy with information from various "mother's" forums, and how many doctors go-go-go... Yes, the world is often unfair, and it happens that Nature, rewarding a woman with a thirst for motherhood, deprives her of such an opportunity. And she comes to us for help. And we try, we try very, very hard...

Fallopian tube obstruction-briefly about the main

* tubal-peritoneal factor - leading cause of female infertility; every third case of female infertility is associated with a tubal factor (20-72% according to different authors).

* the patency and proper functioning of the fallopian tubes is an indispensable condition for the onset of pregnancy. The tubes must have a clearance for unhindered movement of spermatozoa up and the fertilized egg down. But just a clearance is not enough, it is necessary that the pipes are able to function correctly - this is their main task! The mucous membrane of the fallopian tubes (oviduct) is like rails along which a thick, clumsy egg must roll into the lumen of the uterus. They wriggle, pushing the egg forward, wrapping it in mucus for better glide, and multiple cilia lining the path ensure fast movement so she doesn't get stuck along the way. And then the egg, preoccupied with the speedy attachment to the mucous membrane (there is a hungry embryo inside it!), Doesn’t really think where it is - in the uterus or even on the way. If its speed of movement decreases, then it may well stick to the blood vessels right on the spot. And if this happens, then an ectopic (tubal) pregnancy is obtained! This is bad.

* Diagnosis is difficult. Yes, we can easily check the pipes for clearance, but will this guarantee their good functioning?

* treatment is not always effective.

* Cases of "missed time" are not uncommon. For example, a couple is examined for a long time, a man undergoes a many-month course of treatment, a woman is prescribed treatment - either “for infections”, or “for hormones”, then - cycles of stimulation, then rest from her, etc. As a result, they remember about checking the pipes after a long time, when fatigue has already accumulated, there is a feeling of persistent infertility, etc. Or after laparoscopy (for any reason: diagnostic, ectopic, cysts, hydrosalpings, etc.) it is recommended to wait a year or two ...

* Is the process reversible? Yes and no. If a we are talking about self-treatment, without medical conservative (pills) or surgical (scalpel) interventions, then in this case we are talking about functional reasons obstruction. This is what numerous stories about spontaneous pregnancy after “let go of the situation”, “turn off your head”, go on vacation, stop counting days, stop taking vitamins, etc. tell about this. The second name of the miracle is the restoration of the sympathoadrenal balance and the hypothalamic-gapophyseal-adrenal system. What's happening? Relaxes muscle layer pipes, their lumen expands, the rheology and composition of the pipe fluid improves and - cheers, positive test! Organic lesions do not heal on their own.

* prioritization. It is not uncommon for a couple to quickly identify the cause of infertility: male factor, anovulation, etc. All forces are rushed to eliminate it, and this psychologically eliminates the possibility of the presence of other factors (of course, I'm talking about obstruction of the tubes, today is their J day). Both patients and doctors must remember that the obviousness of the cause is not at all a guarantee of its uniqueness! You can achieve an excellent spermogram or finally ovulation, but the long-awaited meeting of the cells will not happen.

Functional obstruction of the fallopian tubes- violation of the correct muscle contractile activity without obvious anatomical and morphological changes. Adequately functioning tubes are similar to worms - flexible, wriggling, they are sensitive to hormonal signals and are most active during ovulation. If the muscle layer is spasmodic (hypertonicity), excessively relaxed (hypotonicity) or functions in a discoordinated way, then this sharply reduces the final performance.

Organic tube pathology- this is a situation in which a "blockage" of the tube develops from the inside or squeezing them from the outside, that is, the path through which the spermatozoa could reach the egg is mechanically blocked. Organic lesions of the fallopian tubes have visually detectable signs and are characterized by obstruction against the background of adhesions, torsion, compression by pathological formations, etc.

tubal infertility occurs in the absence of the fallopian tubes, their obstruction or functional pathology - a violation of the contractile activity of the fallopian tubes and / or a change in the properties of the relief of the mucous membrane of the tubes.

peritoneal(peritoneal ) infertility due to adhesions in the area of ​​the uterine appendages. That is, adhesions are formed between the outlet of the tubes (fimbriae) and the ovary, preventing the egg from entering the lumen of the tube.

Organic lesions:
- inflammatory processes specific and non-specific nature (chlamydia, gonorrhea, mycoplasma, trichomonas, herpetic, etc.).
This is the most common cause. If pathogens enter the fallopian tubes and trigger an acute inflammatory process, then this causes the tubes to defend themselves. Mucous swells, saturated with cellular weapons to resist the enemy. It would seem that everything is fine - the mechanism of struggle has been launched, but only here, as after any war, losses are inevitable. In the inflammatory period, the mucous membrane of the fallopian tubes is no longer the same - it loses its morphological properties, good ability to contraction, the cilia lining the pipes from the inside die. Swollen walls stick to each other and, sometimes, forever.

- surgical interventions on the organs of the abdominal cavity and small pelvis. The body does not know that when it is cut, something is cut off, instruments are introduced, suture material- it's good. In any case, the organs inside are scared and, defending themselves, they hide with a fibrin coating. And these are future spikes.

Prevention of the development of adhesions in the abdominal cavity-the desire to minimize surgical intervention!

Preference should be given to the laparoscopic method (especially when carrying out planned surgical interventions on the pelvic organs in women of reproductive age).
-intrauterine manipulations(artificial abortion, separate diagnostic curettage of the cervical and uterine mucosa, hysteroscopy with removal of endometrial polyps or submucosal myoma nodes, etc.)

- endometriosis. Insidious endometriosis hits literally all positions: along with problems in the development of eggs in the ovaries (pathological oogenesis), it also contributes to the creation of unfavorable conditions for the movement of the embryo. Violates the capture of the egg by fimbriae immediately after ovulation. Changes the composition of peritoneal and tubal fluids, increasing the level of prostaglandins, T-cells and other active substances, which makes the chemical composition of fluids aggressive.
Endometriosis can spread its foci from the inside, in the thickness of the tube, closing its lumen. To be fair, it should be noted that such an isolated form internal endometriosis tubal localization is rare.
External genital endometriosis is the main enemy. Retrocervical (behind the cervix) ovarian endometriosis generalizes the process: involves the intestines, bladder, ligaments, peritoneum, etc. And it's all about the adhesions, the formation of which endometriosis is engaged in regularly and diligently. Foci of endometriosis periodically pour out blood (menstrual-like reaction), which coagulates, turns into a clot (fibrin) and gets stuck between organs - tubes, ovaries, ligaments, etc. And so once a month ... Here is a simplified mechanism: external genital endometriosis → progressive adhesive process → change normal anatomy and physiology of the fallopian tubes → tubal-peritoneal infertility.
The greater the prevalence of endometriosis, the more severe the course, harder treatment and worse forecasts.

- postpartum traumatic and inflammatory complications.

Functional lesions
- psycho-emotional instability. chronic stress like psychological consequence infertility becomes an independent background of a persistent deviation from the norm of the neuroendocrine system. Created vicious circle"infertility-stress-infertility".
- hormonal imbalance. An increase in the level of some hormones, a decrease in others; their incorrect interaction, too intense or insufficient reaction of cells and tissues to hormonal orders and other disorders, in fact, hormonal dysfunction. This applies not only to sex hormones, but also to others - thyroid gland(hypo- and hyperthyroidism), pancreas (diabetes mellitus), etc.
- accumulation of active biological substances in the mucous membrane of the tubes. In chronic inflammation and / or endometriosis, the tissues constantly maintain a “mode heightened danger", thanks to high level prostaglandins, thromboxane A2, interleukins, etc. how defense mechanism, invented by nature, this is expedient, since it prevents the spread of the process, localizing the problematic focus. However reverse side is an muscle tone, that is, a functional spasm of the fallopian tubes.

1. Anamnesis. Often patients are surprised why the interrogation of an anamnesis takes so long and in detail. Not at all out of idle curiosity, because this is the first stage on the way to diagnosing, and therefore solving the problem. It is important to know about everything, especially about past sexually transmitted infections, chronic inflammatory diseases of the genital organs, surgical interventions on the pelvic organs, the nature of menstruation, various complications (after childbirth, curettage, etc.), the presence endocrine pathology.
2. Inspection. During a gynecological examination, signs of an adhesive process can be suspected: restriction of mobility and a change in the position of the uterus, shortening of the vaginal arches, but a diagnosis cannot be made! “The doctor looked at the chair and said that the pipes are closed” - this does not happen.
3. Swabs, PCR and others methods laboratory diagnostics allow you to reduce or increase alertness in relation to the pipes (as part of the analysis of signs of the inflammatory process).
4. SGG- (aka: echohysterosalpingography, hydrosonography, ultrasound hysterosalpingography). In case of CHS, it is introduced into the uterine cavity saline(water) and with the help of ultrasound, the patency of the fallopian tubes is assessed. This is a highly informative, fast, convenient, almost painless and affordable method. .

Study of the patency of the fallopian tubes-a necessary and important part of the initial examination in the treatment of infertility.

This procedure is prescribed for suspected tubal failure of pregnancy: history of inflammatory diseases (especially chlamydia), operations (especially abdominal and / or with complications), endometriosis (especially active and / or confirmed), etc. In situations of “high suspicion”, you can not wait a year, but carry out the CHS procedure earlier. But each case is different! Someone can immediately watch the patency, and someone can postpone the procedure, given other reasons. The essence of the method is the introduction of a sterile saline solution into the uterus, which should fill the uterine cavity, pass through the fallopian tubes and pour out of them into the abdominal cavity. This whole process is visible on the monitor of the ultrasound machine. With normal patency of the fallopian tubes, the doctor sees saline in the abdominal cavity, and if the tubes are impassable, then the water will remain in the tube at the level of the obstacle. Contraindications to hysterosalpingography: inflammatory diseases - endometritis, salpingitis, cervicitis, colpitis various etiologies.

Treatment of tubal and peritoneal infertility

Efficiency conservative therapy, of course, is significantly lower compared to the operational one. It is used as a necessary step in the treatment of inflammation and / or as preparation for a subsequent surgical step. Often, conservative therapy is a "consolation" in situations where it is impossible to perform surgery and / or IVF for various reasons(personal, financial, religious, etc.).

*Anti-inflammatory and antibiotic therapy. Complex treatment selected upon detection of sexually transmitted infections and / or other pathogens and proven necessity (morphological verification, pathological titer, sensitivity to drugs).
* Immunomodulatory. It can be used as one of the components of the treatment of tubal-peritoneal infertility.
*Antifibrosing therapy (proteolytic enzymes).
*Physiotherapy (drug electrophoresis, ultraphonophoresis, electrical stimulation, EHF-therapy, different kinds massages, etc.).

Surgical treatment indicated in the detection of obstruction of the fallopian tubes by HSG or SHG methods, inefficiency conservative treatment during the year, regardless of the results of the GHA or SGG.

Laparoscopy has an advantage over other methods of surgical treatment of infertility, since it allows not only to diagnose the fact and cause of obstruction of the fallopian tubes, but also to immediately carry out surgical restoration of their anatomical patency.

Depending on the nature of the revealed pathological changes during laparoscopic reconstructive plastic surgery, the fallopian tubes are freed from adhesive adhesions compressing them (salpinolysis), the entrance to the funnel of the fallopian tube (fimbrioplasty) is restored, or a new hole is created in the closed ampullary section of the tube (salpingostomy). In peritoneal infertility, adhesions are separated and coagulated. In parallel, during laparoscopy, detectable concomitant surgical pathology (endometrioid heterotopias, subserous and intramural fibroids, ovarian retention formations, etc.) is eliminated.

Alternative Treatment- in vitro fertilization. Recommended in the absence of pipes (this can be either congenital pathology, or the pipes were previously promptly removed); with their deep anatomical changes that cannot be corrected by reconstructive methods; after 1-2 years (depending on other reasons) the absence of pregnancy after laparoscopy and restoration of tubal patency.

About 60% of women diagnosed with infertility have problems with obstruction or the very structure of the fallopian tubes, as well as the appearance of adhesions in the ovaries. Each of these pathologies can independently affect the reproductive system. In some cases, the factors are interrelated and occur simultaneously. Therefore, almost 30% of women are diagnosed with tubal-peritoneal infertility (TPB).

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Proper functioning of the reproductive system

The surface of the fallopian tubes of a woman is covered with thin villi. Their main function is the promotion of a mature egg to spermatozoa. The end of the tube, adjacent to the ovary, has a cylindrical shape. It is in this "funnel" that the egg must fall. After fertilization, it moves through the tubes to the uterus, receiving the right amount of nutrients.

During normal operation reproductive organs conception occurs in a remote section of the tube. Its movement to the uterus is facilitated by villi and contractile movements. The process of moving a fertilized cell takes up to 5 days, after which it is implanted in the uterus.

TPB: concept, complications, consequences

TPB is a combination of tubal and peritoneal infertility. Conception does not occur due to a violation of the patency of the fallopian tubes or their structure with an adhesive process occurring in parallel in the region of the ovaries.

If the pathology touched only one of the tubes, then the chances of successful conception are reduced by half. If both pathways are damaged, infertility occurs. A fertilized egg will not be able to move through the tubes and will not enter the uterus.

Such infertility in women is common, but poorly amenable to restorative therapy. Adhesions may reappear, especially after surgical treatment. In many cases, assisted reproductive techniques are offered: intrauterine insemination, ICSI, IVF.

Tubal peritoneal infertility can cause complications such as chronic pain in the pelvis or ectopic pregnancy. In the latter case, the fertilized egg attaches itself outside the uterus. The result can be bleeding and death.

The main forms and causes of infertility

Tubal-peritoneal infertility has several forms:

• pipe;
• peritoneal;
• functional disorders of the fallopian tubes.

The reasons for the development of each of the forms are different. They can occur individually or in combination.

What causes the development of pathologies of the fallopian tubes?

Tubal infertility is detected in the complete absence or obstruction of the pathways. It can also be caused by malfunctions. The fallopian tubes lose their ability to contract (hypo-, discoordination).

Tubal infertility can be caused by the following reasons:

• Genital infections that are sexually transmitted. So, chlamydia provokes an inflammatory process. The destruction of the villi develops, the mobility of the pathways decreases. As a result, the normal capture and movement of the egg becomes impossible. Gonorrhea causes adhesive processes, the appearance of adhesions. Mycoplasma can temporarily settle on the cells, then attach to the spermatozoon. This reduces his mobility.
• Surgical interventions regarding the pelvic organs, abdominal cavity (tubal ligation, myomectomy, ovarian resection).
• External causes the accumulation of a significant amount of biologically active substances near the fallopian tubes. The disease leads to the growth of the lining of the uterus beyond its limits. Under the influence of regular cyclic changes, foci filled with liquid are formed from it. Neoplasms appear in the form of cysts.
• Inflammatory or traumatic complications after childbirth.
• Hormonal imbalances may be associated with underproduction female and / or excessive secretion of male biologically active substances. Sometimes there are excessive releases of adrenaline during prolonged nervous tension, excitement.

Reasons for the formation of adhesions

Peritoneal infertility is a condition caused by adhesions in the ovaries. The appearance of adhesive processes can cause inflammatory diseases of the organs reproductive system, external endometriosis, surgical interventions.

Fallopian tubes undergo changes. Foci of adhesions alternate with lymphocytic accumulations, pathologies of capillaries, veins, arteriosclerosis appear, changes in nervous tissues are observed, tube lumens are deformed, cysts can form. External endometriosis creates unfavorable conditions for the embryo, preventing the normal course reproductive processes. The capture of the egg, its movement is disturbed.

Postoperative complications can also cause peritoneal infertility (appearance of decay processes in the abdominal cavity), chronic infections genital organs (especially chlamydia).

Causes of dysfunction of the fallopian tubes

Functional pathology is characterized by malfunctions in the muscle layer of the tubes: increased / decreased tone, imbalance with nervous system. Main reasons:

• chronic stress condition;
• psycho-emotional instability;
• imbalance in the secretion of male and female hormones;
• inflammation of the organs of the reproductive system;
• surgical interventions.

Conservative treatments for infertility

• In the presence of infections in the genital tract is prescribed complex therapy aimed at eliminating the causative agent of the inflammatory process.
• Additionally, drugs are used to increase the self-defense of the body. Chronic inflammation of the appendages leads to immunological disorders, so the restoration of the system is necessary for the full elimination of infections.
• Resolving therapy involves the use of enzymes, biostimulants, glucocorticoids. Sometimes hydrotubation with antibacterial drugs, hydrocortisone is used. This technique, unfortunately, is not effective enough and causes a number of complications: exacerbation of inflammation, impaired ability of the tubes to move the egg, etc.
• Physiotherapy can involve a whole range of measures for the treatment of TPB.

A woman is invited to attend electrophoresis daily with the use of enzymes, biostimulants, magnesium salts, iodine, calcium. An alternative may be ultraphonophoresis of the pelvic organs. A solution of vitamin E (2-10%), potassium iodide based on glycerol (1%), ichthyol, terralitin, lidase, hyaluronidase, naphthalene, heparoid and other ointments are used.

As physiotherapy, electrical stimulation of the uterus and appendages is used. It is used daily starting from the 7th day of the cycle. If conducted surgery, in a month appointed KVCh. This procedure must be done three times a day with breaks of 2 hours. Therapy is aimed at improving the condition vascular system small pelvis.

Gynecological irrigation and massage can be used for treatment. In the first case, mineral water filled with hydrogen sulfide, radon, nitrogen, etc. will be prescribed. Mud swabs in the vagina can also be used. To improve metabolic processes in tissues, vaginal hydromassage is prescribed. It enhances diffusion, blood flow, prevents the formation of adhesions and leads to rupture of existing ones. Such procedures can be obtained in specialized clinics and sanatoriums.

Surgical treatment and contraindications to its use

Surgical intervention in the treatment of TPB gives better results than conservative therapy. It includes: laparoscopy, selective salpingography (artificial creation of a hole in the pathways when they are completely overgrown), microsurgical operations.

Laparoscopy

The advantage of using such treatment is the possibility of diagnosing obstruction of the fallopian tubes, identifying the causes with its simultaneous elimination. The type of operation will depend on the nature of the identified pathologies:

• freeing paths from splices;
• restoration of the entrance to the "funnel" of the fallopian tube;
• creation of a new passage in the area of ​​complete infection;
• separation or removal of adhesions.

Laparoscopy may be accompanied by the removal of other pathologies detected. AT postoperative period rehabilitation therapy and stimulation of ovulation are prescribed.

Microsurgical operations

Microsurgical intervention allows:

• free the villi of the pipes from splicing;
• eliminate kinks, curvature, external adhesions;
• remove part of the damaged pipe and connect the remaining ends.

Insufficient efficiency of microsurgical operations is associated with a high probability of adhesions after their completion, which again makes the tubes impassable.

When the prescribed treatment fails, which makes tubal infertility absolute, IVF may be recommended. These are cells with subsequent implantation of the resulting embryo into the uterus. IVF is also applied in case of total absence ways. Women who have absolutely no possibility of natural conception get a chance to give birth to a baby.

Contraindications to surgical interventions

As with any intervention or when taking drugs, there are contraindications in this case:

• the age of the woman exceeds 35 years;
• the duration of the period of infertility is more than 10 years;
• active inflammatory processes;
• tuberculosis of the organs of the reproductive system;
• presence from the genital tract;
• malformations in the development of the uterus;
• recent operations on the organs of the reproductive system;
• neoplasms inside the uterus.

Despite all the limitations, you should not stop at contacting one specialist. It is better to undergo several examinations and get advice from different doctors. In addition, do not forget that there is and . If the partner is also not doing well with the reproductive system, then there is simply no point in stimulation. It is necessary to be treated simultaneously and in the case of detection of diseases of an infectious nature.

Measures to prevent the development of TPB

Tubal-peritoneal factor of infertility is a very common phenomenon, but it is possible to prevent its development. It is important to eliminate all infectious and inflammatory diseases of the reproductive system in a timely manner. Therapy should be continued until complete recovery. Protect from different kind genital infections can barrier contraceptives (condoms).

It is imperative to adhere to the rules of personal hygiene, to prevent casual sexual intercourse. Pregnancy planning helps to exclude abortions. Every woman needs to visit a gynecologist at least once every six months. And most importantly - to believe that everything will work out! And the long-awaited stork will arrive soon, you just need to try a little more!

Approximately half of the women who seek professional help in the treatment of infertility are diagnosed with tubal-peritoneal factor of non-pregnancy. This term is understood as a violation of the patency of the fallopian tubes or the formation of mechanical obstacles on the way of the egg to the uterus.

If a woman is diagnosed with this form of infertility, the egg or can not be fertilized, as it does not reach the meeting point with the sperm. If we consider this type of female infertility in more detail, we can divide it into tubal and peritoneal factors. The former is considered to be more common.

The mechanism of development of tubal-peritoneal infertility

In the body of a healthy woman, an egg cell matures every month, which at a certain moment menstrual cycle exits the ovary and enters the fallopian tube. Further, due to the peristalsis of the tube and the presence of villi on its inner surface, the egg moves towards the uterus, where it must meet with the sperm for fertilization.

If, for any reason, the egg cannot reach the uterine cavity, they speak of tubal-peritoneal infertility. Moreover, each form has its own characteristics:

• In the case of the pipe factor talk about a violation of the patency or peristalsis of the fallopian tube itself.
• In case of peritoneal factor we are talking about a mechanical obstruction in the area between the ovary and the entrance to the fallopian tube (on the peritoneum).

It should be noted that the tubal infertility factor can be associated both with a violation of the peristalsis of the tube, and with the presence of a mechanical obstacle in the way of the germ cell.

Why does tubal peritoneal infertility develop?

Most often, connective tissue, which is formed in the appendages as a result of the inflammatory process, becomes an obstacle to the movement of the egg, mechanical injury tissues or the development of endometrial processes. Each of these reasons has its own characteristics:

• Inflammatory diseases of the pelvic organs . In 75% of cases, they talk about an infectious process, which entails inflammation of the pelvic organs. An infectious process is most often understood as sexually transmitted diseases, such as chlamydia, mycoplasmosis, ureaplasmosis, etc. The causative agents of these infections cause an inflammatory process, accompanied by swelling of the mucous membranes of the fallopian tubes and peritoneum, followed by a violation of their integrity. This causes the formation of adhesions, consisting of connective tissue, which form an obstacle in the path of the egg.
• Operations on the reproductive organs. Any surgical interventions intrauterine nature can lead to the formation of coarse scar tissue and the development of adhesions in the pelvis. Most often we are talking about such operations as artificial abortions, diagnostic curettage of the endometrium, the use of intrauterine contraceptives. Also, the cause of scarring and adhesions can be surgical operations in the pelvic area, in particular, a previous appendectomy, myoectomy, ovarian surgery, etc.
• Endometriosis. Endometriosis is the pathological growth of the inner layer lining the uterus, and its exit beyond the uterine cavity. In some cases, areas of the overgrown endometrium act as an obstacle to the normal passage of the egg through the fallopian tubes.
• Hormonal disorders . Changes in the normal ratio of female sex hormones can lead to a deterioration in peristalsis of the fallopian tubes, which causes functional tubal infertility.

Symptoms of tubal-peritoneal infertility

Quite often, a woman is not aware of the development of tubal or peritoneal infertility in her until such time as there are no difficulties with conceiving a child with regular sexual life. Symptoms of such pathological processes cannot be called characteristic and pronounced, however, many of the fair sex note the following signs:

• periodic pain in the lower abdomen;
• plentiful and painful menstruation;
• pain and discomfort during intercourse.

It is important to understand that the risk group is made up of women who have experienced abortions, diagnostic curettage, operations on the lower abdomen or genital organs in the past, and also have a history of adnexitis (salpingoophoritis).

Treatment of tubal-peritoneal infertility

The method of treatment of tubal-peritoneal infertility depends on the cause of its development. If we are talking about a violation of peristalsis, the specialist will prescribe medicines, the action of which is aimed at enhancing the functional activity of the pipes. If adhesions, areas of endometriosis and scar formations were identified during the diagnostic process, treatment is carried out surgically, most often using laparoscopic techniques. In cases where hormonal disorders are the cause of infertility, therapy is appropriate.

Considering the fact that the main th the cause of the development of tubal-peritoneal infertility in a woman is an inflammatory process, special attention is paid to the elimination of this etiological factor. If the cause lies in an acute infectious process, they are prescribed antibacterial drugs and anti-inflammatory drugs. Treatment of the consequences of inflammation in the pelvis requires the use of active complex drugs with an antioxidant effect. One of these drugs is, which demonstrates the following effects:

• Reducing the permeability of capillaries and strengthening them, which helps to relieve inflammation and swelling of tissues.
• Normalization of immunity due to the antioxidant effect of the components of the drug.

And most importantly - do not despair when you hear the diagnosis of "tubal-peritoneal infertility". Remember that medicine does not stand still, and those problems that could become an insurmountable obstacle to conception twenty years ago are successfully solved today and not necessarily in expensive ways. Feel free to contact your doctor if long-awaited pregnancy does not occur within one year.