Tubal and peritoneal infertility. Infertility due to obstruction of the fallopian tubes and its treatment

A variant of female infertility caused by functional or organic obstruction of the 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:

Actually tubal infertility. A woman cannot become pregnant due to functional or organic disorders in fallopian tubes Oh. 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 has a 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 interruption ectopic pregnancy accompanied by massive bleeding, severe pain, a 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 tubes are determined up to a complete violation, in which the 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 surgical methods of treatment are used. 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 correction 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 is indicated for patients under the age of 35 with infertility less 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 inefficiency 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 the timely detection and treatment of 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.

Not always the desire to get pregnant is carried out without any problems. The diagnosis of "tubal infertility" is about 30% of women who cannot conceive a child. This complication, as a rule, appears as a result of obstruction of the fallopian tubes. However, many cases are known when, after treatment of tubal infertility, women have a chance to become a mother.

What lies behind the diagnosis of "Infertility"?

Female infertility is the inability of a woman of childbearing age to produce offspring. There are two degrees of infertility:

1 degree - pregnancy has never occurred;
2nd degree of infertility - there were a history of pregnancies.

There are also absolute and relative infertility: the first is caused by irreversible anomalies in the development of the female reproductive system, the second can be corrected during treatment. tubal infertility considered relative.

Infertility of tubal genesis occurs due to the appearance of adhesions or fluid in the fallopian tubes, which do not allow the mature egg to pass into the uterus and interfere with the meeting with the sperm, and, accordingly, the conception itself.

There are partial and complete obstruction of the pipes. If only one of the two fallopian tubes is impassable or the lumen is not completely blocked, then pregnancy is possible.

With the diagnosis of "incomplete obstruction", the possibility of becoming pregnant still exists, however, gynecologists, as a rule, prescribe special drugs to stimulate ovulation for women with such diagnoses.

What are the causes of the disease?

There are cases when obstruction of the fallopian tubes is caused by congenital pathologies development of the uterus, tubes and appendages. In addition, there are many reasons that can provoke tubal infertility in initially healthy woman. In the first place among the causes are inflammatory diseases of the female reproductive system. A history of sexual infections, the presence of fibroids, surgical interventions, abortions, the formation of adhesions in the pelvic organs. Endometriosis is another of the most common causes of tubal infertility.

There are cases when this disease is not associated with the above factors, but is caused by disorders hormonal background or metabolic process in the body.

In cases where the fallopian tubes are completely passable, but in some of their sections there are narrowings with impaired functionality, or if the tubes are partially impassable, this should not be ignored, such violations can be no less dangerous and can become. More about ectopic pregnancy

Often a woman may not be aware that she suffers from obstruction of the fallopian tubes, in principle there are no signs of the disease, it can only be detected through diagnostics. It is worth worrying if you are periodically disturbed drawing pains in the lower abdomen - this can be a symptom of tubal obstruction and, therefore, a symptom of tubal infertility.

How is obstruction diagnosed?

Currently, there are several methods for diagnosing tubal infertility that help determine how obstructed the fallopian tubes are. It should be noted that diagnostics should be carried out only when total absence inflammatory process and infections in the genital area.

The most accessible and accurate method is considered diagnostics of KGT (kymographic hydrotubation). The fallopian tubes are purged using a special apparatus that has an air reservoir, which makes it possible to determine the volume of air introduced.

The kymograph allows you to note the change in pressure in the tubes and uterus, based on the curve obtained, the doctor makes a conclusion about the degree of patency of the tubes. This research method allows not only to determine the condition of the fallopian tubes, but is also a therapeutic method that provides healing effect Thus, it turns out that the woman receives a double benefit.

The next research method that we will consider is − hysterosalpingography . Diagnostics using this method allows you to find out which of the pipes is impassable and where the adhesions are concentrated.

During this procedure, a special substance is injected into the uterus, and then pictures are taken. The first image is taken immediately, the next after 10 minutes, and the final after 24 hours from the moment the substance was injected. Based on the results of the images, the doctor makes a conclusion about the condition of the fallopian tubes and uterus.

Note that hysterosalpingography can cause an exacerbation of the inflammatory process in the uterine cavity and tubes, which in turn can lead to rupture of the fallopian tube. That is why, before deciding on a research method, it is worth consulting with a gynecologist and learning about alternative ways diagnostics.

It is also worth considering that women with diagnosed infertility are not recommended to be exposed to x-rays more often than 2 times a year.

Female infertility of tubal origin can be diagnosed using bicontrast gynecography , which allows you to identify adhesions that are around the ovaries and fallopian tubes. The study is recommended to be carried out in the second half of the cycle, however, it is strictly contraindicated for women suffering from heart disease, hypertension, and tuberculosis.

Can't be held this diagnosis and inflammation of the genital organs or uterine bleeding. This method quite accurately allows you to determine the functions that pipes are capable of performing, and is also indispensable for determining the breadth of the adhesive process.

Another method for detecting pathologies is laparoscopy . During this study, tissues that are involved in the inflammatory process are studied. This diagnostic method is widely used in preparing women for an operation to restore tubal patency.

So, as can be seen from the foregoing, currently in medicine is used enough methods to detect obstruction of the fallopian tubes and diagnose tubal infertility. But it is worth remembering that it is better to consult with your gynecologist about the diagnostic method in advance, who will help you choose the most suitable option for your particular case.

Can tubal factor infertility be treated?

Despite the fact that tubal infertility is considered one of the most difficult forms, there are ways to combat this disease.

First of all, women who present with suspected infertility are examined for infections, and if detected, anti-inflammatory treatment is prescribed. Of course, such therapy is not able to cope with the problem of infertility, but it is necessary before intrauterine interventions: diagnosis and treatment of tubal obstruction.

Anti-inflammatory treatment helps in the fight against infection, but it is recommended to eliminate the effects of inflammation with the help of physiotherapy, which can restore nervous reactions in tissues, softens and even removes adhesions.

Blowing out the fallopian tubes (hydrotubation) is another step in the treatment of tubal infertility. But it is worth remembering that this procedure, carried out repeatedly, can cause a rupture of the fallopian tube, so it is carried out strictly according to indications and under the supervision of the attending physician.

Most effective method treatment of tubal infertility is considered operative laparoscopy , this method is used to cut the adhesions that caused the obstruction of the tube. The method has many more advantages than abdominal operations: after the intervention, the woman quickly recovers and returns to her usual life, the risk to health is minimal, and there are practically no recurrences of adhesive disease.

Note that operative laparoscopy may be useless in some cases.

Quite often there are situations when, after the treatment and restoration of the patency of the tubes, a woman still cannot become pregnant. This happens when there is no peristalsis or microvilli in the pipes - such pipes are called dead.

What to do if after the treatment of tubal infertility the desired pregnancy did not occur?

Alternative methods of getting pregnant

If two years or more have passed after treatment, and pregnancy has not occurred, then it is worth contacting specialists and choosing another way to solve the problem. Tubal infertility is an indication for IVF.

This procedure begins with tracking the menstrual cycle, then ovulation is stimulated. Careful monitoring of the maturation of the egg is carried out in order to extract it in time.

The most important stage is the stage of fertilization of the egg and the development of embryos. If everything went well at this stage, the embryo is placed in the uterus, where the baby continues to grow and develop. A woman is prescribed certain drugs that help support the body.

Summing up all of the above, I would like to emphasize that one of the most important factors during the treatment of tubal infertility is psychological factor. Only positive attitude and your confidence will help to cope with the problem. Follow the doctor's instructions and be sure to believe in the success of the treatment!

Answers

Infertility is not as rare a problem as it might seem. More than 5% of the world's population faces difficulties in conceiving a child. There can be many reasons: uterine pathology, poor sperm characteristics, antibodies. Tubal infertility is the absence of conception due to the pathology of the fallopian tubes. It accounts for 25-30% of all cases of infertility. The tubal factor is diagnosed both at and at.

There is also tubal-peritoneal infertility, when the blockage is located not in the fallopian tube, but on the border with the ovary. At untimely treatment obstruction diagnose infertility, ectopic pregnancy and a symptom of chronic pelvic pain.

Female infertility is a condition in which a woman of childbearing age is unable to reproduce. There are two degrees of infertility: degree 1 (primary), when there has never been a conception, and degree 2 (secondary), when the patient already has children.

There is absolute and relative infertility. Absolute infertility is often associated with irreversible malformations that have disrupted the function of the genital organs. Relative infertility has a cause that can be eliminated and the restoration of reproductive function ensured. Tubal infertility is classified as the second type.

The importance of the fallopian tubes

The fallopian or fallopian tubes are a paired organ that is responsible for moving the egg after fertilization to the uterus. Blockage of the lumen of the tube with adhesions or fluid prevents the free movement of the egg. Displacement of the fallopian tubes by adhesions also leads to infertility.

The fallopian tubes adjoin the ovaries with a cylindrical funnel-shaped canal. The egg moves along it. In a healthy female body, the fallopian tubes are lined with microvilli, fimbriae. Their role is to move the mature egg to the spermatozoa.

Natural fertilization occurs in another section of the fallopian tube. The egg moves back to the uterus due to contractions of the tube. It takes 3-5 days for the cell to travel through the tubes and into the uterus, where it attaches itself to its inner surface.

Fallopian tube obstruction

Natural conception takes place in the fallopian tubes. Any pathology of this area of the genital organs can cause infertility. The most common cause is a violation of the patency of the fallopian tubes. This phenomenon diagnosed with the formation of adhesions or accumulation of fluid. Obstruction stops the egg and it simply cannot merge with the sperm.

There is complete or partial obstruction. With partial one pipe may be free or all will not be completely blocked. With this diagnosis, the chance of conceiving a child naturally yes, but very small. As long as there is at least one healthy section of the tube, the chance of getting pregnant remains, but the probability will depend on the size of the hole. Complete obstruction is often due to the accumulation of fluid in the pipes ().

It happens that only one scar is formed, but it covers exactly the edge of the fallopian tube, which also complicates the process of conception. The phenomenon is also called partial obstruction. Such pathologies increase the risk of ectopic pregnancy.

Most often, obstruction is eliminated surgically. To improve the effect, the patient is prescribed drugs to stimulate ovulation.

Causes of tubal infertility

Obstruction of the fallopian tubes can be congenital or acquired. It happens that girls are born with an abnormal structure of the uterus and fallopian tubes. Acquired obstruction can occur against the background of endocrine failure, severe inflammation or illness.

Obstruction is most often the result of inflammation or infection. The inflammatory process can be associated with specific and non-specific flora. In particular, chlamydia, gonococci and mycoplasmas cause inflammation in the fallopian tubes. Without timely treatment adhesions will form around the tubes, ovaries, and in the pelvis.

Often, infectious complications are diagnosed after childbirth, abortion, curettage, or surgery on the pelvic organs or intestines. Often, adhesions appear against the background of complications after the removal of the appendix.

The cause of inflammation can be endometriosis (overgrowth of endometrial cells). Many sexually transmitted infections cause acute inflammatory processes in the genitals and small pelvis (herpes, gonorrhea).

It is not necessary that the inflammation "adjacent" to the fallopian tubes. Diseases of the upper respiratory tract can cause chronic In the risk group of women with inflammatory processes in the intestines.

Large uterine fibroids benign tumor) against the background of endometriosis can provoke blockage of the fallopian tubes.

There is an opinion that hormonal disruptions and metabolic problems also affect the patency of the tubes and the possibility of conception. In particular, an increase in the level of male sex hormones and an incorrect ratio of progesterone and estrogen.

Tubal peritoneal infertility occurs due to adhesions in the peritoneal cavity. Adhesions are dangerous because they can displace organs: the uterus, fallopian tubes and ovaries in wrong position work with violations. It is also noteworthy that even small adhesions can cut off the fallopian tubes from the ovary.

Often such infertility is diagnosed after operations on the genitals and in the peritoneum. chronic inflammation- the right way to dysfunction of the reproductive system.

It happens that the pipes are passable, but some sections are narrowed or do not function properly. The phenomenon will not be accompanied by pronounced symptoms, so many leave it unattended. However, these minor problems can send the embryo out of the uterus.

It is often too late, and the obstruction is found along with the ectopic pregnancy. A woman may not be aware of the deviation for a long time and will try to conceive a child. And since the pipes are passable, it is quite real, but, unfortunately, risky.

It can also cause tubal infertility. Constant stress and an unstable psycho-emotional state negatively affect the body as a whole. An excess of stress hormones exacerbates any abnormal processes.

Symptoms and diagnosis of tubal infertility

Tubal infertility usually develops without symptoms. Sometimes a woman may feel short-term pain in the lower abdomen. The only sure sign will be the absence of pregnancy. Infertility is diagnosed only after a year of unsuccessful attempts. If the partners are over 35 years old, doctors give a year and a half. The absence of pregnancy is serious reason to go to the clinic. The inability to conceive a child is not dangerous in itself, much more dangerous is the disease that caused infertility.

The problem of infertility is dealt with by a reproductive specialist. To find out the reason, it is necessary to take tests for both the woman and the man. This is because male infertility meets hardly less often female. Diagnosing tubal infertility is quite difficult, so you should only contact an experienced doctor with such a problem.

Diagnostics

If there is a suspicion of obstruction of the fallopian tubes, a series of studies is prescribed to confirm the diagnosis. It is worth remembering that you can not undergo an examination in the presence of an inflammatory process or an acute infection.

First of all, the doctor studies the anamnesis, complaints. When diagnosing infertility, an important role is played by a gynecological history (STIs, pregnancies, abortions, operations, etc.) and a menstrual cycle calendar. Gynecological examination required.

Additional tests:

study of a gynecological smear;
bacteriological research;
polymerase chain reaction method.

Hysterosalpingography

The most effective are (), (surgical examination of the fallopian tubes and nearby organs), echohysterosalpingoscopy (ultrasound with saline). Sometimes they also examine the blood for anti-chlamydial antibodies, but they do not always indicate the presence of an obstruction.

Hysterosalpingography allows you to calculate the obstructed tube and the area of accumulation of adhesions. Before the procedure, a special liquid is injected into the uterus, which makes it possible to take pictures. The first is done immediately, then another one in ten minutes and the last one in a day. Experienced doctor will be able to make or refute the diagnosis on the basis of such images.

However, the method is not secure. If inflammation develops in the genitals at the time of the test, the study may aggravate it, up to the rupture of the fallopian tubes. Hysterosalpingography is recommended only as a last resort. This is also due to the fact that infertile women can only have x-rays twice a year.

Kymographic hydrotubation

Doctors willingly use KGT as a diagnostic method. Kymographic hydrotubation allows you to determine the amount free space in the fallopian tubes: they are purged, the volume of air introduced is determined and the patency of the tubes is calculated. The device allows you to record pressure fluctuations in the tubes and uterus in the form of a curve, according to which the doctor can determine the degree of patency. The CTG method is not only diagnostic, but also therapeutic.

Bicontrast gynecography allows diagnosing adhesions around the ovaries and fallopian tubes. The study is useful in that it makes it possible to assess the intensity. The results will be more accurate if you test in the second half of the cycle.

Contraindications to BG:

inflammation of the genital organs;
uterine bleeding;
heart disease;
tuberculosis;
hypertension.

Laparoscopy allows you to examine inflamed tissue. The study gives a complete picture in preparation for the surgical restoration of patency.

All methods for diagnosing obstruction of the fallopian tubes can be dangerous, so each patient should first consult with a gynecologist. All tests give results, but not everyone is suitable in a certain situation.

Treatment of tubal infertility

This infertility is considered one of the most difficult. It may be amenable to conservative treatment or require surgical intervention.

The conservative method consists in prescribing anti-inflammatory drugs, physical procedures, hydroturbation and perturbation. Hydroturation is the introduction of liquid medicines directly into the uterus. Perturbation - treatment of the fallopian tubes with air currents. The procedure is risky, therefore, requires the supervision of a doctor. Blowing out the fallopian tubes can cause them to rupture.

If infertility has developed against the background endocrine disorders, hormonal correction is added to the course of treatment. This is a prerequisite for surgical intervention. Hormonal disruptions can make any treatment ineffective, and will only exacerbate the spread of adhesions.

The conservative method of treating tubal infertility is used less and less. Often it is aimed at eliminating infections and inflammations before diagnosis and surgery. Physiotherapy is recommended as a “cleansing” from the effects of inflammation: restore reactions in tissues, soften and even remove adhesions.

Surgery

Surgery is required for patients with complete or partial obstruction, torsion, or induration. Most often resort to laparoscopy. The operation is carried out through a small hole, when all adhesions are disconnected and tubal plasty is performed to further restore patency. The pipes are returned to the correct position in relation to the pelvic organs. Laparoscopy is considered best method treatment of tubal infertility. Its advantage lies in rapid recovery, minimal risk, and a small chance of recurrence. To prevent the recurrence of adhesions, surgeons apply anti-adhesion barriers.

Contraindications for surgery:

depressed or anxious state of the patient;
intensive formation of adhesions;
age from 30 years (sometimes).

With pronounced stressful condition the patient is prescribed sedatives and other drugs that can improve the mood and mental state of the woman.

Surgical intervention may not give results, especially when the anatomy of the tubes has changed too much. And there are indeed many such cases. It happens that after the removal of adhesions, the pipes cannot recover: there is no peristalsis, the microvilli do not function. In this case, the fallopian tubes are considered dead.

In case of failure, doctors advise IVF, because this method allows you to fertilize the egg artificially and completely bypass the fallopian tubes when the embryo is placed in the uterus.

Prevention of tubal infertility

In order to avoid problems with reproductive function due to pathologies of the fallopian tubes, all inflammations should be treated on time, regardless of their location. This is especially true of the genital organs and appendicitis. It is important to fully recover after surgery.

Prevention of infections is carried out by using contraceptives. Otherwise, any potentially dangerous sexual intercourse should be excluded. Every day a woman must observe the rules of personal hygiene. Any symptom and discomfort should be investigated. Consultation with a gynecologist is obligatory 2 times a year.

It is necessary to monitor not only physical condition but also respond to psychological disruptions. Strong feelings, stress, chronic fatigue and anxiety can harm the body no worse than tangible infections. A woman needs to control emotions and fight fears.

IVF for tubal infertility

The optimal waiting period for conception after the restoration of the tubes is 2 years. Such patients are recommended alternative methods which provide modern reproductive technologies. Tubal infertility automatically becomes an indication for IVF.

In vitro fertilization requires careful monitoring of all phases of the menstrual cycle. The patient is prescribed drugs that stimulate ovulation. The maturation of the egg is controlled and the finished one is retrieved.

The stage of direct fertilization occurs "in vitro". Are being created favorable conditions only the best spermatozoa are selected. In a successful scenario, the embryo is placed in the uterus without affecting the fallopian tubes. If the embryo takes root, the fetus will develop normally. For the purpose of prevention, strengthening drugs are additionally prescribed.

Conclusion

With any diagnosis and outcome, you need to morally insist on victory. In matters of infertility, the psychological factor plays essential role, because the body of a woman, especially during the period of maturation of the egg, when hormones are raging, reacts sharply to emotions and experiences.

Fallopian tube pathologies are one of the most common causes of infertility. However, modern diagnostic methods make it possible to thoroughly study the problem, and treatment regimens have been successfully applied in practice for many years.

Infertility is much easier to prevent than to cure. Prevention is the guarantor of health, because tubal infertility is only a complication of another disease. And often this disease is treated very quickly. The main thing is to seek help in a timely manner.

Tubal-peritoneal infertility in women, undoubtedly occupying a leading place in the structure of infertile marriages, is also the most difficult pathology in terms of restoring reproductive function. The frequency of tubal-peritoneal forms of infertility ranges from 35 to 60% and is found on average in half of all patients seeking infertility treatment. It is assumed that the prevailing pipe factor(35-40%), and the peritoneal form of infertility occurs in 9.2-34% of cases.

Reasons for the formation of tubal-peritoneal infertility:

previous inflammatory diseases of the pelvic organs;
intrauterine manipulations, including artificial abortions;
previously transferred surgical interventions on the organs of the small pelvis and abdominal cavity;
endometriosis.

The formation of connective tissue adhesions between the visceral and parietal peritoneum of the small pelvis contributes to a change not only in the anatomical, but also functional state internal genital organs and all organs of the small pelvis, which leads to a violation of the mechanisms of ovulation, the perception of the egg, its transport, the formation of chronic pain syndrome, dyspareunia, dysmenorrhea, dysfunction of the intestines, urinary system, etc.

Thus, the adhesive process in the small pelvis can cause multiple organ disorders of the female body and trigger the formation of many additional factors of female infertility - partial or complete obstruction of the patency of the fallopian tubes, acquired pathology of the uterus, cervix and ovaries, endometriosis, neuro-endocrine imbalance in the form chronic anovulation, etc.

1. Pelvic inflammatory disease (PID) occupy a leading place among the factors in the formation of tubal-peritoneal infertility.

According to the results of multicenter studies, only 25% couples with tubal-peritoneal infertility do not have a history of sexually transmitted diseases (STDs) in any of the partners. In the case of a history of infection in one or both partners, occlusion of the fallopian tubes is detected 2 times more often (in 52.4% of patients).

Currently, the most common microbial factor causing the formation of adhesions in the pelvis is chlamydial infection. The increase in the prevalence of chlamydia, according to researchers, is due, on the one hand, to a true increase in the infection of the population, and on the other hand, to the improvement of methods for diagnosing this disease, which presents certain difficulties, since almost 2/3 of patients with chlamydia have an asymptomatic course.

At morphological study biopsy specimens of the fallopian tubes reveal their swelling, violation of the integrity of the epithelium, adhesion of the edges of the tube folds, which leads to obliteration of the tubes, mainly in the interstitial sections, in almost 70% of patients who have had chlamydia. Whereas in women with a "banal" bacterial inflammatory process, 50% are diagnosed with one- or two-sided obstruction of the fallopian tubes in the ampullary sections.

When analyzing the nature of the adhesive process in the pelvic area, it was revealed that more widespread adhesion formation (III-IV stage) is more common in patients after polybacterial PID, while in patients suffering from chlamydia, I-II stage prevails. the severity of the adhesive process. The degree of damage to the ampullar sections of the fallopian tubes in both of the above groups of patients does not have significant differences.

Usage modern methods diagnostics allows to detect chlamydia in half of patients with PID, in 57% of women suffering from infertility, in 87% of patients with hypertrophic erosions of the cervix.

The combination of chlamydia with other pathogens of sexual infection is characteristic - gonococci, ureaplasma, mycoplasma, gardnerella, candida and viral infection etc.

Most objective methods diagnostics of chlamydia are cultural, DNA hybridization method, polymerase chain reaction, enzyme immunoassay, methods of direct and indirect immunofluorescence using immunochromatography test systems, the methods of which are described in detail in special manuals.

It should also be pointed out the role of genital tuberculosis as one of the factors in the development of adhesions in the small pelvis. The development of tuberculous endometritis and salpingitis is possible in 1-2% of patients with infertility. In this regard, an examination for tuberculous lesions of the genitals should be carried out in the direction of a gynecologist in specialized clinics in all patients with primary adhesive lesions of the pelvic organs and an indication of frequent bronchopulmonary diseases, positive tuberculin tests in history.

2. Intrauterine manipulations - artificial abortions, diagnostic curettage of the endometrium, the use intrauterine contraceptives is a fairly common cause of tubal-peritoneal infertility in Russia.

Long-term complications of these manipulations are often encountered in cases where they were performed without taking into account the contraindications existing in patients, traumatically, with non-compliance with the necessary rules of asepsis and antisepsis. Great importance has timely measures to prevent possible development early complications these intrauterine interventions.

The wound surface formed during intrauterine manipulations on the mucous membrane of the uterine body, a decrease in local immunity, menstrual irregularities, the presence of foreign body in the uterine cavity (IUD), etc., ascending infection of the uterine cavity during manipulations are factors predisposing to the development of a local inflammatory process in the form of endometritis. In most cases, this process is local, asymptomatic and ends in self-healing as a result of rejection of the altered endometrium during the next menstruation. However, in some cases, the inflammatory process can spread to deeper layers with the formation of endomyometritis, chronic PID with ascending infection of the fallopian tubes, the formation of hydrosalpinxes, sactosalpinxes up to the development of pelvioperitonitis and the formation of subsequent extensive adhesive adhesions in the small pelvis. Factors predisposing to the development of these complications of intrauterine manipulations are the presence of any inflammatory diseases pelvic organs or general infectious conditions and traumatic manipulation with damage to the basal layer of the endometrium.

Separately, it should be noted the possibility of developing tubal-peritoneal forms of infertility after repeated therapeutic hydrotubation of the fallopian tubes with various medicinal solutions. In cases of undiagnosed salpingitis, the mechanical flow of the solution into the fallopian tubes contributes to the outflow of inflammatory exudate into the abdominal cavity with the development of an asymptomatic flow against the background of the administered antibacterial drugs pelvioperitonitis and the formation of extensive adhesions of the pelvic organs. In addition, enzyme components medicinal solutions(lidase, chymotrypsin, etc.) lead to chemical damage to the epithelium of the fallopian tubes, adhesion of the folds of the endosalpinx and fimbrial sections of the tubes with the formation of hydrosalpinxes. In this regard, at present, therapeutic hydrotubation of the fallopian tubes is not performed in the clinic of female infertility.

3. Surgical interventions on the pelvic and abdominal organs , produced by laparotomy, constitute the next high-risk group for the formation of tubal-peritoneal infertility.

According to WHO, one- or two-sided occlusion of the fallopian tubes can form in 15% of patients after appendectomy, in 60-80% of patients after ovarian surgery, conservative myomectomy, for tubal pregnancy, especially those performed for emergency indications.

The mechanism of development of the postoperative adhesive process is multifactorial. Such factors of adhesion formation as mechanical intraoperative trauma, tissue ischemia, damaging the peritoneum of the applied non-absorbable suture material, activation of postoperative infection against the background of a decrease in local and general immunity as a result of trauma, the presence of blood in the abdominal cavity, the duration of the operation, etc.

Damage to the peritoneum and subsequent inflammatory changes lead to the deposition of fibrin and fibrinolysis. In the process of restoring the integrity of the peritoneum, a decisive role is assigned to macrophages, immune system peritoneum, angiogenesis processes, increased production of fibroblasts and collagen.

Local activation of fibrinolysis and proteolysis promotes the resorption of primary fibrinous deposits without the formation of adhesions. In cases of prolongation of the inflammatory-dystrophic process of the peritoneum with blocking of the processes of fibrinolysis and proteolysis, fibrinous formations at the site of the surgical injury, due to increased local production of collagen, turn into connective tissue adhesions.

According to the retrospective analysis data, the severity of the adhesive process in the pelvis correlates with the degree of adhesive disease in the abdominal cavity and depends on the volume of the intervention. An extensive adhesive process in the pelvis is detected after operations of conservative myomectomy, resection of the ovaries, for ectopic pregnancy, performed by traditional access. Adhesion formation leads to displacement and fixation of the pelvic organs in a non-physiological position with a local disturbance of hemodynamics and their function.

In this regard, in optimal conditions the method of choice for planned surgical interventions on the pelvic organs in women reproductive age endoscopic approach should be considered.

4. Genital endometriosis.

In the presence of "small" forms of endometriosis, the patency of the fallopian tubes, as a rule, is not impaired and the adhesive process in the small pelvis is not detected. With deep infiltrative endometriosis and endometrioid ovarian cysts, causing the appearance clinical symptoms and currently united by the term "endometrioid disease", develops of varying degrees, often very pronounced, adhesive process with secondary involvement in the endometrioid conglomerate of the body of the uterus, fallopian tubes and ovaries, and thus, tubal-peritoneal infertility is formed.

Tubal infertility is caused anatomical and functional disorders of the fallopian tubes. The cause of peritoneal infertility is an adhesive process in the pelvis with the patency of one or both fallopian tubes. The fallopian tubes have a complex neurohormonal regulation aimed at ensuring the transport function in the reproductive system. Physiological processes, occurring in the fallopian tubes, ensure the reception of sperm and eggs, nutrition and transport of gametes and the embryo. Too fast or slow movement of the embryo can also affect its further development. important mechanisms in the reception of the egg and the movement of gametes are the contraction of fimbriae and muscles, the movement of cilia and the flow of fluid.

There are two main forms of tubal infertility: violation of the function of the fallopian tubes and organic damage to the fallopian tubes.

Functional disorders include a violation of the contractile activity of the fallopian tubes: hypertonicity, hypotonicity, discoordination.

Organic lesions of the fallopian tubes include obstruction, adhesions, torsion, sterilization, etc.

Numerous reasons lead to dysfunction of the fallopian tubes: chronic psychological stress due to infertility, impaired synthesis of sex hormones, prostaglandins, impaired glucocorticoid function of the adrenal cortex, inflammatory processes in the fallopian tubes and in the pelvic area.

Organic lesions of the fallopian tubes are accompanied by their obstruction. The reasons may be: inflammatory diseases of the genital organs, pelvic or general peritonitis, appendicitis followed by appendectomy, surgical interventions on the internal genital organs (myomectomy, ovarian resection, tubal ligation, etc.), postpartum complications- inflammatory and traumatic, polyps, endometriosis of the fallopian tubes and other forms of external endometriosis.

The peritoneal form of infertility develops as a result of inflammatory diseases in the genital organs, after surgical interventions on the genitals, pelvic organs and abdominal cavity.

If tubal-peritoneal factor of infertility is suspected, our clinic conducts a study of the patency of the fallopian tubes using the hysterosalpingography method.

Via this method not only establish the presence or absence of occlusion of the fallopian tubes, but also reveal intrauterine pathology - intrauterine synechia, malformations of the uterus, submucosal node, endometrial polyps. In addition, the method of hysterosalpingography can reveal signs of adhesions in the pelvic cavity. The presence of intrauterine pathology serves as an indication for hysteroscopy, and the pathology of the fallopian tubes and peritoneal adhesions - for laparoscopy.

The main cause of dysfunction of the fallopian tubes and the formation of adhesions are inflammatory processes caused by infection. Currently, the most common sexually transmitted infections are chlamydia, mycoplasma, ureaplasma infections, as well as genital herpes, cytomegalovirus infection, gonorrhea, trichomoniasis. Some of the listed infections can be asymptomatic, so they are determined in the infertility clinic, and both spouses must be treated simultaneously with mandatory control of the cure.

If tubal-peritoneal infertility factors are suspected, the diagnostic capabilities of ultrasound examination of the pelvic organs are limited mainly to the identification of hydrosalpinxes, while adhesions can be directly visible only with laparoscopy. Therefore, when it is impossible to establish the causes of infertility by the indicated methods (hysterosalpingography, ultrasound), in the presence of an ovulatory cycle and fertile sperm of the spouse, it is necessary to promptly refer the woman for laparoscopy.

Collapse

Female infertility has many causes and a variety of classifications depending on them. Tubal peritoneal infertility is common. Although this type of pathology is common, it is quite treatable in most cases. Timely therapy helps to restore the ability to have children, but it is important to start treatment in a timely manner. Since such a pathology tends to progress, and on late stages may be difficult to treat with medication.

Definition

Infertility is the inability to conceive due to persistent intimate life without means of protection. Tubal infertility refers to a condition where pregnancy does not occur because the egg is not able to pass through the fallopian tube to the uterus, where it should connect with the sperm. That is, the cause of tubal infertility lies in the physical obstruction of the fallopian tubes.

Peritoneal infertility is a different condition. With it, the peritoneum is actively formed fibrous tissue. This tissue creates a barrier for the egg, which needs to get into the fallopian tube, since it is in front of the entrance to its channel that the maximum of this tissue is observed. That is, this type is not associated directly with the tubes themselves, but with the impossibility of getting an egg into them.

Tubal peritoneal infertility is a term used to refer to a condition where fertilization does not occur because the egg cannot enter the uterine cavity through the fallopian tube, regardless of why this situation has developed.

Occurrence

It is this type of infertility that is one of the most common. It accounts for more than half of all cases of impossibility of pregnancy due to pathology on the part of a woman. Some researchers claim that this figure is even higher - 60% of all infertile women suffer from this particular pathology.

Classification

The condition has a fairly diverse classification, depending on the reasons for which it developed and how it proceeds. At the same time, several types of tubal infertility are distinguished separately.

Pipe factor

It is this factor that greatest influence for the development of infertility. Tubal obstruction is much more common than tubal overgrowth connective tissue. At the same time, functional tubal infertility and organic type infertility are distinguished.

Functional is diagnosed when the pipe itself does not have physical changes and pathologies in the structure. That is, it is completely passable and can normally conduct the egg. But this does not happen in view of functional disorders, such as hypertonicity, when, as a result of contraction, the channel closes and the egg does not pass. Discoordination also occurs, with this pathology, different parts of the tube contract with different intensity and at different rates, which interferes with normal passage into the uterine cavity. Less common is hypotonicity - a condition in which the contractions are so sluggish that the egg is not "pulled" into the channel, as it normally is;
Organic type. This type of infertility is much more difficult to cure, it is due to the fact that there are physical changes in the structure in the tube, which prevent passage, significantly reducing the lumen of the canal. This occurs with swelling of the mucous membranes during the inflammatory process, as well as in the presence of adhesions formed during surgery or also as a result of the inflammatory process.

Relatively easy to treat tubal dysfunction. The condition of organic tubal infertility often requires surgical intervention.

peritoneal

The peritoneal factor of infertility occurs when an adhesive process has occurred in the small pelvis, which caused the formation of a large number of fibrous tissues, that is, adhesions. Such a process develops as a result of inflammation that occurred during microbial infection in a sterile environment of internal organs. Sometimes they can also form during surgery, with a certain tendency for the patient to form scars. This type of infertility has no internal classification.

Causes

Why is this pathological process takes place? It develops as a result of the following reasons:

Inflammatory processes that cause swelling of the mucosa, reducing the patency of the tubal canal, lead to the formation of adhesions, both in the pipes and near the entrance to them. Such processes are caused by microbes, less often by viruses and fungi. Usually, such an infection enters the body sexually, therefore the predisposing factor is frequent change sexual partners in the absence of barrier contraception;
The consequences of surgery, such as scars and, again, adhesions. They appear when the patient is inclined to this, and also when the sanitation of the operating pit (the cavity in which the manipulations were carried out) was poorly carried out. It is also possible with frequent abortions, childbirth, miscarriages, diagnostic curettage, some diagnostic methods (for example, laparoscopy), etc.;
Sometimes such a phenomenon develops as a complication after childbirth or surgery (without connection with adhesions);
Functional problems develop in the presence of hormonal imbalance, in violation of the level of those hormones that are responsible for the reduction of the channel. The reasons for the development of pathology are elevated level male hormones, stress, problems with the adrenal glands, etc.;
The peritoneal factor appears in inflammatory processes in the pelvic area.

Therapy for pathology without fail should take into account the reasons that caused it.

Symptoms

Strictly speaking, the main symptom of infertility is the inability to conceive. At the same time, inability as such is said in cases where pregnancy does not occur within two years or more of regular sexual activity, including during the period of ovulation, without the use of contraceptives. Although given type Infertility may also present with other symptoms, such as:

Pulling pains in the lower abdomen, indicating adhesions;
Violation of the menstrual cycle, talking about hormonal imbalance;
Abundant menstruation;
Pain during sexual intercourse.

Tubal infertility may not manifest itself in any way. Therefore, even in the absence of symptoms, but when pregnancy does not occur, it is necessary to consult a doctor.

Complications

The complication in this case is actually the inability to have children. While initially such infertility can be relative, that is, it only reduces the likelihood of pregnancy, and not completely eliminate it, then over time it can become absolute, that is, it will be impossible to get pregnant.

In addition, in the early stages, such a pathology is often quite successfully curable. Whereas, as it develops, the probability favorable prognosis and complete cure is reduced. In addition, unpleasant symptoms can become very pronounced, which will cause significant discomfort.

Diagnostics

For diagnostic purposes, the following methods are used:

Hysterospalpingography - X-ray examination organ with a contrast agent;
Hydrosalpingoscopy - ultrasound with filling of the appendages with water;
Kymographic pertubation - the introduction of gases to determine the contractile activity of the tubes;
Falloscopy - visualization of the appendages.

As additional method laparoscopy and a blood test for hormone levels are used.

Treatment

Depends on the type of infertility and can be surgical or medical.

Medical

Effective in functional infertility. Are used hormonal preparations to restore hormone levels, as well as anti-inflammatory and antispasmodics. Sometimes sessions with a psychotherapist and physiotherapy with various methods (massage, hydrotherapy, ultrasound, balneotherapy, etc.) are shown. Sometimes it is necessary to treat the current inflammatory process with antibiotics; in a chronic condition, drugs are prescribed to increase immunity.

Surgical

It is carried out mainly with the peritoneal factor and with organic obstruction of the tubes. The following types of interventions are used:

Salpingolysis - cutting adhesions;
Salpingostomy - making a hole in the place of overgrowth;
Removal of the impassable section with further connection of the ends of the passable parts;
Restoration of the entrance to the tube with the removal of excess fibrous tissue.

The method is quite effective, but the probability of pregnancy will still be reduced by 25-50%.

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