Tubal factor infertility. Tubal-peritoneal infertility

The fallopian tubes perform the most important function in the process of conceiving a child. It is in the cavity of the tubes that the sperm must meet the egg, which leaves the ovary.

If there are any anatomical and functional disorders in the tubes, fertilization is difficult, since male and female cells do not have the opportunity to meet. As a result, the woman receives a diagnosis of infertility, or more precisely, tubal infertility. If conception is prevented by adhesions in the pelvic organs, this is peritoneal infertility. Very often these two types appear in combination. Tubal-peritoneal infertility accounts for about 30% of cases of all types of female infertility.

Causes and origins

Female infertility of tubal origin can manifest itself as various disorders fallopian tubes. Namely:

  • functional disorders: disturbance of the contractile activity of the tubes without visible anatomical changes;
  • organic lesions: visually noticeable signs in the form of torsions, ligations, adhesions of pipes, compression from pathological formations.

Infertility of tubal-peritoneal origin can occur for the following reasons:

  • production disturbances female hormones;
  • deviations in central regulation against the background of chronic psychological stress;
  • chronic inflammatory processes in the female genital organs due to infections, endometriosis, resulting in localized accumulation biologically active substances;
  • previous pelvic inflammatory diseases;
  • one or another surgical interventions on the genitals, intestines;
  • diagnostic or therapeutic procedures in the pelvic area;
  • various complications after childbirth and abortion.

Diagnostics

A couple is considered infertile if they do not become pregnant during sexual intercourse at least once a week for a year. Having checked a man for fertility and found no problems on this side, doctors take care of the woman’s health.

When diagnosing infertility, our specialists take into account all modern developments in this field. First of all, it is worth excluding endocrine causes of this problem. If, after using correctly selected hormonal therapy in our center, conception does not occur, it makes sense to suspect a tubo-peritoneal factor of infertility.

The most reliable research method in this case is diagnostic laparoscopy.

If its results confirm that the patient has tubal infertility, an adequate, most effective and safe treatment is selected.

Treatment

The choice of treatment required for tuboperitoneal infertility is usually between surgical laparoscopy and IVF. In the first case, the surgical method is supplemented in the postoperative period with restorative therapy and stimulation of ovulation.

Laparoscopic operations for tubal infertility are aimed at restoring the patency of the fallopian tubes. In this case, a woman should have no contraindications to this species treatment.

Contraindications to laparoscopic reconstructive plastic interventions are:

  • the patient's age is more than 35 years;
  • long-term infertility, more than 10 years;
  • extensive endometriosis;
  • acute inflammation in the pelvic area;
  • pronounced adhesive process;
  • tuberculosis of the genital organs;
  • previous similar operations.

When diagnosed with tubal infertility, treatment with laparoscopic intervention aims to free the tubes from the adhesions that compress them. The entrance to the fallopian tube is restored, and if this is not possible, a new opening is created in the closed section.

If tuboperitoneal infertility is diagnosed, surgical treatment is performed to separate adhesions and coagulate them. At the same time, our specialists will detect and eliminate other surgical pathologies during the operation. These include fibroids different types, endometrioid heterotopias, retention formations in the ovaries.

After laparoscopy surgery, to increase the effect of treatment, clinics must conduct restorative physiotherapy. This activates metabolic processes and prevents the formation of new adhesions. This treatment is carried out for a month; during this time and for another 1-2 months after, contraception is recommended. If pregnancy does not occur in the next six months, they switch to using ovulation inducers. The total period of surgical and subsequent treatment in this case is 2 years. If no effect is observed, doctors advise using in vitro fertilization.

If it is impossible to cure peritoneal-tubal infertility in one way or another, IVF becomes the only way to give birth to a child. The specialists of our center recommend assisted reproductive technologies when there is definitely no possibility of natural conception and there is no prospect of any reconstructive plastic surgery. Namely:

  • in the absence of fallopian tubes;
  • for deep anatomical pathologies;
  • after ineffective surgical intervention.

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Tubal infertility is considered the most difficult in terms of restoring a woman’s reproductive function. Let us recall that this form of infertility is most often a consequence of a chronic inflammatory process in the pelvis resulting from infection. Also, among the most common causes of tubal infertility, experts name various intrauterine manipulations, primarily abortions, organ surgeries abdominal cavity(in particular, appendicitis).

Anti-inflammatory treatment

If the adhesive process in the pipes has already begun, attempts to fight it, unfortunately, are rarely successful. However, women seeking treatment for infertility are first screened for infections. Usually a standard smear is sufficient, which shows the degree of the inflammatory process. If the smear indicates the presence of an exacerbation, thorough anti-inflammatory treatment must be carried out before starting infertility treatment. Of course, such therapy will not help cure infertility, but it is absolutely necessary in all cases when a woman is undergoing any intrauterine interventions: imaging of the uterus and tubes, laparoscopy, intrauterine insemination, IVF, etc. Preliminary anti-inflammatory treatment avoids exacerbation of the inflammatory process and increases the likelihood of pregnancy, reduce the risk of miscarriage if it occurs.

If a regular smear does not show any abnormalities, but the woman has all the signs of inflammation (pain, discomfort, itching, unusual leucorrhoea), doctors conduct a test for the presence of chlamydial and viral (herpes) infections. Fortunately, there are now many highly effective drugs that can cope with almost any of these infections.

Of course, in all cases, treatment should be carried out by both partners.

Physiotherapy

Anti-inflammatory treatment only helps get rid of the infection, that is, the cause of the inflammation. The consequences of the inflammatory process persist, very often becoming a serious obstacle to conception. Therefore, the next stage of treatment is physiotherapy, which allows you to restore normal nervous reactions, soften or completely remove adhesions, sometimes even open an already sealed pipe.

Hydrotubation

The complex treatment of tubal infertility quite often includes the procedure of hydrotubation, or blowing out the tubes. The meaning of this manipulation is that it is introduced into the pipes under pressure. medicinal solution, the purpose of which is to break through a sealed pipe. The idea itself is wonderful, but its implementation too often leads to even greater complications and a decrease in the chances of pregnancy. After all, it is very difficult, almost impossible, to predict where a pipe will burst - at a joint or in a healthy area.

Overstretching of pipes can also have serious consequences, as a result of which their functionality is significantly reduced and sometimes even lost. In addition, increased pressure in the tube can deform and even destroy microvilli, leaving bare areas through which the egg cannot pass into the uterus.

Until recently, the treatment of tubal infertility was limited to endless repetition of labor-intensive and tiring physiotherapeutic procedures and hydrotubation courses in combination with anti-inflammatory therapy for patients. It has long been established that the effectiveness of such treatment is extremely low. Moreover, very often it makes attempts at subsequent surgical treatment completely futile.

Surgery

Traditional surgical treatment also rarely meets the expectations of specialists.

It has been established that the pregnancy rate after reconstructive plastic surgery increases significantly only when “external” factors of obstruction are affected (for example, adhesions).

If the obstruction is associated with an internal (adhesive) process, the pregnancy rate even after microsurgical operations is only 0–5%. At the same time, these operations, performed through transection, are quite traumatic and involve a certain risk for the patient. Therefore in last years big abdominal operations are increasingly being replaced by small, laparoscopic ones, that is, performed during surgical laparoscopy.

Operative laparoscopy

With the help of operative laparoscopy, the following gynecological operations are performed in our time: dissection of adhesions in order to restore the patency of the fallopian tubes, removal of small ovarian cysts and myomatous nodes, cauterization of foci of endometriosis, coagulation of polycystic ovaries, it is even possible to remove the fallopian tube with ectopic pregnancy.

Laparoscopy has a number of specific advantages over major abdominal operations.

The most important among them are a significantly lower risk both in relation to the patient’s health and in relation to relapse of the adhesive process, as well as the speed of the patient’s return to active life. The very next day after the operation, the woman can be discharged from the hospital, after which she will be prescribed rehabilitation treatment in the form of a uterine massage, physical therapy, hydrotubation course, etc.

In the case of a combination of tubal obstruction with endocrine disorders a woman should undergo preliminary hormonal correction. Otherwise, the effect of plastic surgery on the tubes and subsequent restorative treatment will be unstable, associated with the risk of re-inflammation and recurrence of tubal obstruction. In this situation, it is not advisable to waste time on normalizing hormonal disorders after surgery.

A particular problem is the treatment of infertility in women after removal of both fallopian tubes (for example, due to ectopic pregnancy, purulent process, etc.). In world practice, only isolated cases of pregnancy are known after attempted tubal reconstruction during surgery. In the vast majority of cases, such women are doomed to childlessness.

It should be remembered that modern surgical laparoscopy does not help in all cases. So, for example, it becomes meaningless in the case of obstruction of the tube in its initial section, which passes through the thickness of the uterine wall. The doctor simply cannot reach this place. Insurmountable difficulties also arise when the final section of the tube, closer to the ovary, is sealed. In such cases, surgical intervention consists of cutting the adhesions and restoring a special fringe around the opening of the pipe. Unfortunately, most often this restored area “refuses” to function.

As a result, it happens that after a long and grueling rehabilitation treatment, x-rays or ultrasound show that the tubes are passable, but the woman still does not become pregnant. Most often, this indicates that the tube lacks peristalsis or microvilli. This is a dead, although passable, pipe.

Therefore, in the case of tubal infertility, a woman should not rely solely on restorative treatment, which is not always successful. Maybe, instead of wasting time, nerves and money on fruitless attempts to get pregnant, it makes sense to contact specialists in time about using the latest reproductive technologies(for example, IVF). This becomes especially relevant if there is no pregnancy during two years of treatment for tubal infertility.

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 curable in most cases. Timely therapy helps restore the ability to have children, but it is important to start treatment early. Since this pathology tends to progress, and late stages may be difficult to treat with medications.

Definition

Infertility is the inability to become pregnant in the presence of constant intimate life without contraception. Tubal infertility refers to a condition where pregnancy does not occur because the egg is not able to pass through the fallopian tube into the uterus, where it should unite 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 actively forms fibrous tissue. This tissue creates a barrier for the egg, which needs to get into the fallopian tube, since it is precisely before entering its canal that the maximum of this tissue is observed. That is, this type is not directly related to the tubes themselves, but to the impossibility of the egg getting into them.

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

Occurrence

This type of infertility 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 the 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 has greatest influence on the development of infertility. Tubal obstruction much more common than overgrowth connective tissue. In this case, functional tubal infertility and organic infertility are distinguished.

  • Functional is diagnosed when there are no physical changes or pathologies in the structure of the pipe itself. That is, it is completely passable and can normally conduct the egg. But this doesn't happen in mind functional disorders, such as hypertonicity, when as a result of contraction the canal closes and the egg does not pass through. Discoordination also occurs; with this pathology, different parts of the tube contract with different intensities and at different rates, which interferes with normal passage into the uterine cavity. Less common is hypotonicity - a condition in which contractions are so sluggish that the egg is not “drawn” into the canal, as it normally does;
  • Organic type. This type of infertility is much more difficult to cure; it is associated with the fact that there are physical changes in the structure, which impede passage, significantly reducing the lumen of the canal. This occurs when the mucous membranes swell during the inflammatory process, as well as in the presence of adhesions formed during surgery or also as a result of the inflammatory process.

Tubal dysfunction is relatively easy to treat. The condition of organic tubal infertility often requires surgical intervention.

Peritoneal

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

Causes

Why does such a pathological process take place? It develops as a result of the following reasons:

  • Inflammatory processes that cause swelling of the mucous membrane, reducing the patency of the tubal canal, lead to the formation of adhesions, both in the tubes and near the entrance to them. Such processes are caused by microbes, less commonly viruses and fungi. Typically, such an infection enters the body sexually, so the predisposing factor is frequent change sexual partners in the absence of barrier contraception;
  • Consequences of surgery, such as scars and, again, adhesions. They appear when the patient is prone 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 curettages, certain diagnostic methods (for example, laparoscopy), etc.;
  • Sometimes this phenomenon develops as a complication after childbirth or surgery (without connection with adhesions);
  • Functional problems develop in the presence of hormonal imbalance, when the level of those hormones that are responsible for the contraction of the canal is disturbed. The reasons for the development of pathology are an increased level male hormones, stress, problems with the adrenal glands, etc.;
  • Peritoneal factor appears during inflammatory processes in the pelvic area.

Therapy for pathology must necessarily take into account the reasons that caused it.

Symptoms

Strictly speaking, the main symptom of infertility is the inability to become pregnant. At the same time, inability as such is spoken of 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 contraception. Although this type of infertility can also manifest itself with other symptoms, such as:

  1. Nagging pain in the lower abdomen, indicating adhesions;
  2. Violation menstrual cycle, indicating hormonal imbalance;
  3. Heavy periods;
  4. 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 the actual inability to have children. While initially such infertility may be of a relative nature, that is, only reduce the likelihood of pregnancy, and not eliminate it completely, over time it can become absolute, that is, it will be impossible to get pregnant.

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

Diagnostics

IN diagnostic purposes the following methods are used:

  1. Hysterospalpingography - x-ray examination of an organ with a contrast agent;
  2. Hydrosalpingoscopy - ultrasound with filling the appendages with water;
  3. Kymographic pertubation - introduction of gases to determine the contractile activity of the tubes;
  4. Falloscopy – visualization of the appendages.

As additional method Laparoscopy and blood tests for hormone levels are used.

Treatment

It depends on the type of infertility and can be surgical or medicinal.

Medication

Effective for functional infertility. Hormonal drugs are used to restore hormone levels, as well as anti-inflammatory and antispasmodic drugs. Sometimes sessions with a psychotherapist and physical therapy using various techniques (massage, hydrotherapy, ultrasound, balneotherapy, etc.) are indicated. Sometimes it is necessary to treat the current inflammatory process with antibiotics; in case of a chronic condition, drugs are prescribed to enhance immunity.

Surgical

It is carried out mainly in case of peritoneal factor and organic tubal obstruction. The following types of interventions are used:

  1. Salpingolysis – cutting of adhesions;
  2. Salpingostomy - making a hole in the site of overgrowth;
  3. Removal of an impassable area with further connection of the ends of passable parts;
  4. Restoration of the entrance to the tube with removal of excess fibrous tissue.

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

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My mission as a doctor

Infertility- this is the inability of the body to conceive, the absence of pregnancy in a woman childbearing age with its typical localization. A marriage is considered infertile if there is no pregnancy within a year of married life without contraception.

Female infertility is one of the most pressing topics in medicine today. The incidence of infertility in different countries ranges from 4 to 29% and tends to increase in some regions. In our country, this problem is of particular importance due to the difficult demographic situation, characterized by a significant decrease in the birth rate. Studies conducted several years ago in the USA revealed that 10-15% of couples aged 15 to 44 years are infertile. According to WHO, when the incidence of infertility is 15% or more, its impact on demographic indicators significantly exceeds the total impact of miscarriage and perinatal losses. With such a frequency of infertility, a socio-demographic problem of national scale arises.

According to leading gynecologists, in diagnosing infertility, the most rational is a three-stage scheme of examination and treatment of patients, providing for close cooperation and continuity of primary care, the Center for Endoscopic Surgery and Gynecology and the Center for Reproduction and Family Planning.

To determine the type of infertility and indications for surgery, as well as to choose the correct tactics for surgical treatment, you must send it to my personal email address [email protected] [email protected] copy Full description Ultrasound of the pelvic organs, if possible, data on the patency of the fallopian tubes, blood results for hormones, indicate age and main complaints. Then I will be able to give a more accurate answer to your situation.


At stage I (in the conditions of antenatal clinics) To make a diagnosis, a wide range of measures is used, including the study of complaints and anamnesis (the nature of the development of menstrual function, changes in body weight over a short period of time, the presence of discharge from the mammary glands, previous surgical interventions, previous STDs, previous examinations for infertility, assessment of reproductive function, methods of regulating fertility, sex life), general and special gynecological examination, general clinical examinations, testing for STDs, examination of smears from the vagina, urethra, cervical canal for purity and flora, measurement basal temperature at least 2 menstrual cycles, determination of body mass index and hirsute number, ultrasound of the pelvic organs using transvaginal sensors on days 5-7 of the menstrual cycle, hysterosalpingography, hormonal screening (LH, FSH, PRL, E2, P, T, K, T4 , TSH, DEAS, 17-KS). It should be noted that a single determination of the basal level of hormones in the blood may not always be informative.

Check the status of various links reproductive system or hormonal tests (progesterone, clomiphene, tests with metoclopramide, dexamethasone, human chorionic gonadotropin) can help determine their reserve abilities. In addition, it is shown histological examination endometrial biopsy in the 2nd phase of the menstrual cycle (1-2 days before the expected next menstruation) and colposcopy, which allows to identify signs of colpitis, cervicitis, endocervicitis, cervical erosion - manifestations of chronic genital infection.

Important has an immunological examination, including a postcoital test. The latter makes it possible to indirectly judge the presence of antisperm antibodies, which may be present in a woman’s blood serum, cervical mucus and peritoneal fluid with a frequency of 5 to 65%. The main immunological screening method is the MAP test, which detects antisperm antibodies in the ejaculate.

TO additional methods examinations used according to indications in women with irregular menstrual rhythms include x-rays of the skull and sella turcica, CT scan and nuclear magnetic resonance, ultrasound thyroid gland.

A comprehensive clinical and laboratory examination of women in infertile marriages reveals the following: causes of infertility:

  • sexual dysfunction;
  • hyperprolactinemia;
  • organic disorders of the hypothalamic-pituitary region;
  • amenorrhea with increased FSH levels;
  • amenorrhea with normal level estradiol;
  • amenorrhea with reduced estradiol levels;
  • oligomenorrhea;
  • irregular menstrual cycle and/or anovulation;
  • anovulation with regular menstruation;
  • congenital anomalies of the genital organs;
  • tubo-peritoneal;
  • adhesions in the pelvis;
  • genital endometriosis;
  • acquired pathology (tumors of the uterus and ovaries);
  • genital tuberculosis;
  • iatrogenic causes;
  • systemic reasons;
  • negative postcoital test;
  • unidentified reasons (when laparoscopy was not performed);
  • infertility of unknown origin (using all examination methods, including endoscopic).

According to the international algorithm for diagnosing female infertility, developed by WHO, accurate diagnosis can be placed only if endoscopic methods are included in the examination complex.

Clarification of indications and surgical intervention (stage II) carried out at the Center for Endoscopic Surgery and Gynecology of the Swiss University Hospital. Laparoscopy and hysteroscopy are considered not only as the final stage of diagnosis, but also as the first pathogenetically substantiated stage of therapy. Minimally invasive technologies make it possible to make an accurate diagnosis and carry out low-traumatic microsurgical correction of identified changes (separation of adhesions, restoration of fallopian tube patency, excision of endometriotic lesions, removal of ovarian cysts, conservative myomectomy) without subsequent development of the adhesive process. Hysteroscopy can be performed independently or in combination with laparoscopy to clarify the condition of the endometrium and its biopsy under vision control.

Fig.1. Hysteroscopic diagnosis and treatment of intrauterine pathology (scheme)

Intrauterine surgery allows for the correction of almost any pathological changes in the uterine cavity. Hysteroresectoscopic dissection of the intrauterine septum has become the gold standard for the treatment of this disease. The reason for this is easy to understand: during endoscopic surgery, the uterine wall is not dissected, so there is no need for further caesarean section. The same applies to hysteroscopic removal of endometrial polyps, submucous fibroids uterus and dissection of intrauterine synechiae. In addition, it is important to significantly reduce women’s hospital stay after such surgical interventions, more fast rehabilitation and restoration of patients’ performance, cosmetic effect.

Early restorative treatment, started 1-2 days after surgery, as well as delayed restorative treatment, lasting 1-6 months, should be carried out at the Center for Reproduction and Family Planning (stage III). It provides for the use drug therapy and other therapeutic methods. A parallel assessment of the results of endoscopic surgery and rehabilitation treatment (control HSG, repeat and control hysteroscopy, control of hormonal screening, etc.) allows us to outline further tactics for managing patients. If, as a result of the treatment, pregnancy does not occur, the patient should be referred for IVF and ET.

Surgical treatment of female infertility

Endoscopy is a method that allows one to accurately determine the pathology of the pelvic organs, significantly reduce the examination time and carry out low-traumatic correction of identified changes without the subsequent development of adhesions. More than twenty years of experience in its use in female infertility indicates that with a regular menstrual rhythm, laparoscopy is indicated for all patients without exception, since 70-85% of them have various gynecological diseases. In women with various forms violations reproductive function laparoscopy is advisable already at the initial stages of the examination, as it allows timely diagnosis of peritoneal forms of infertility, “small” forms of endometriosis, tumor-like formations of the uterus and ovaries of small size, which cannot be detected with the same degree of reliability by other methods.

As for patients with endocrine disorders, in this group laparoscopy should be performed after 6-12 months of unsuccessful hormonal therapy, since the absence of pregnancy during this period with adequate treatment indicates the presence of combined factors of infertility.

Laparoscopy for female infertility is indicated in all cases when further examination and treatment of infertility is impossible without direct inspection pelvic organs:

  • suspicion of adhesions in the pelvic cavity, obstruction of the fallopian tubes and sactosalpinx (HSG data);
  • scleropolycystic ovarian disease;
  • tumor-like formations of the ovaries;
  • external genital endometriosis;
  • myomatous nodes;
  • malformations of the internal genital organs;
  • infertility of unknown origin;
  • absence of pregnancy against the background of hormonal stimulation for at least 3-6 cycles (with stimulation of ovulation it was possible to achieve an ovulatory menstrual cycle);
  • with ovulatory and anovulatory oligomenorrhea;
  • with amenorrhea against the background of hyperprolactinemia;
  • with amenorrhea against the background of hyperandrogenism.

Fig.2. Pronounced adhesions of the pelvic organs (diagram)

Fig.3. Carrying out intraoperative chromosalpingoscopy to check the patency of the fallopian tubes

Fig.4. The results of chromosalpingoscopy during laparoscopic surgery - the right tube is passable, in the left the contrast stopped in terminal department

Salpingo-ovariolysis - surgical treatment of infertility

Fig.5. Cross-shaped dissection of the ampullary part of the fallopian tube during salpingostomy.

Fig.6. Point endocoagulation of the peritoneum of the fimbrial part of the fallopian tube, accompanied by eversion of the mucous membrane

Fig.7. Fixation of neostoma edges with microsurgical sutures (diagram)

Fig.8. Excision of foci of external endometriosis in the area of ​​the uterosacral ligaments - stage of laparoscopic surgery (diagram)

Fig. 10. Type of polycystic ovaries (PCOS) during diagnostic laparoscopy (scheme)

Fig. 11. Performing diathermocauterization of the ovaries - stage of laparoscopic surgery (scheme)

Preoperative preparation for the treatment of female infertility

Preoperative preparation does not differ from that of other gynecological operations and includes:

1. Standard preoperative examination: general analysis blood, urine test, basic examination biochemical parameters blood (glucose, total protein, bilirubin, ALT, AST, urea, creatinine, residual nitrogen), coagulogram, blood test for HIV infection, Wasserman reaction, blood group and Rh factor, ECG, fluoroscopy (graphy) chest, examination by a therapist and anesthesiologist, ultrasound of the pelvic organs, vaginal examination.

2. Bowel preparation (cleansing enema the day before and on the day of surgery).

3. Prescription of sedatives on the eve of surgery.

Surgical treatment of tubo-peritoneal infertility

In 30-85% of cases, the main cause of infertility is pathology of the fallopian tubes, most often of inflammatory origin. The concept of “peritoneal form of infertility” first appeared in Russian literature in the works of M.N. Pobedinsky (1949). This form of infertility is a consequence of surgical interventions on the pelvic organs (18-35%), complicated childbirth (15-18%), intrauterine interventions (53-63%), and previous inflammatory diseases of the uterine appendages (23-85%). In 20-25% of women, inflammatory changes in the genitals are detected after infected abortions, childbirth and spontaneous miscarriages. Direct changes in the fallopian tubes are reduced to complete or partial obstruction due to damage to the epithelial and muscle layers its walls, adhesive peritubar processes, impaired contractile function. This makes it difficult or impossible to perceive the egg, its transport to the uterus, as well as some stages of its development during the period of passage through the fallopian tube. With peritoneal infertility (9.2-34%), the patency of the fallopian tubes is not changed, however, the presence of adhesions or adhesions that disrupt the topography of the pelvic organs can also prevent physiological processes conception. Violation of the functional activity of the fallopian tubes during their anatomical patency occurs in 76% of women. To assess the severity of the adhesive process in the pelvis, the Hullka classification is used.

In recent years, the number of sexually transmitted diseases (STDs) has risen sharply. Upon detailed examination married couples with this factor of infertility, a high degree of infection of the genital tract of partners is revealed with chlamydia (38-56%), ureaplasma (25.8%), mycoplasma (8.6-25.4%), herpes simplex virus (4.9%), gardnerella (3.7%), gonococci (44-64%). In 17.2%, a mixed chlamydial-ureaplasma infection is observed.

Significant role External genital endometriosis plays a role in the occurrence of tubo-peritoneal infertility in women, accounting for 20-50%. The trend towards an increase in the frequency of this disease can be explained by improved diagnosis, as well as a decrease in the immune background caused by stress and other unfavorable factors. Most probable cause Reduced ability to conceive with endometriosis are anatomical defects of the pelvic organs, including tubo-ovarian, peritoneal adhesions, deformation of the fallopian tubes, disrupting the capture of the egg and the transport of gametes and embryos to the uterus. A decrease in the number of associated estrogen receptors in this pathology, a change in the number of total progesterone receptors and a change in their ratio in these women can lead to the formation pathological processes in hormonally dependent organs. Significant shifts in the dynamics of the secretion of sex steroids and gonadotropic hormones of the pituitary gland are manifested by ovulatory and endocrine dysfunction. There is an increase in basal secretion during phases 1 and 2 of the menstrual cycle with additional releases of luteinizing hormone and follicle-stimulating hormone into the bloodstream, the magnitude of which in some cases exceeds the ovulatory peak. Other endocrine factors of infertility in endometriosis are considered to be anovulation, luteinization syndrome of a non-ovulated follicle, shortening of the luteal phase of the cycle, a combination of endometriosis with galactorrhea, etc. against the background of relative or absolute hyperestrogenemia.

Changes in peritoneal fluid may be an additional factor in impaired generative function. An increase in the level of prostaglandins (F2α) and the activity of peritoneal immune factors leads to the development of infertility and the so-called minor forms of endometriosis. Peritoneal fluid in endometriosis contains increased amount T cells producing interferon gamma and activating macrophages, which prevents reproductive processes. The peritoneal fluid of patients with endometriosis has a damaging effect on sperm in vitro, reducing the number of motile sperm to 15.4%, reducing the speed of their movement to 8 μm/sec. Lymphokines and monokines of the peritoneal fluid have an inhibitory effect on reproductive processes (sperm motility, egg fertilization, embryo implantation and development, trophoblast proliferation).

It is advisable to carry out surgical correction of tubal-peritoneal infertility in the 1st phase of the menstrual cycle in order to ensure optimal conditions for tissue regeneration and the possibility of rehabilitation measures. The tubes are inspected before the contrast is introduced (indogocarmine, methylene blue solution), and then the movement of the contrast through the tube and its appearance from the fimbrial region are traced.

Before attempting any surgical manipulation related to the fallopian tubes, it is advisable (if technical capabilities are available) to perform a tuboscopy to assess the condition of the endosalpinx and identify the degree of disruption of its folding, which has a very great prognostic value. Attempts to restore patency of the fallopian tube with poor condition its mucous membrane does not give a positive effect, the method of choice for treating these patients is in vitro fertilization.

The purpose of the operation is to restore normal topographic relationships by cutting the adhesions around the fallopian tube and ovary, isolating them from each other. Salpingo-ovariolysis is performed either as an independent operation or as a preparatory step for surgery on the fallopian tube. The fallopian tube (ovary) is picked up with atraumatic forceps and moved upward if possible. The adhesions are cut with endoscissors after their preliminary coagulation. After dissection, rough adhesions are excised and removed from the abdominal cavity. After complete release of the fallopian tube from the adhesions along its entire length, ovariolysis is performed. When performing ovariolysis, it is imperative to lift the ovary and inspect its surface facing the broad uterine ligament, since adhesions can often be localized there.

Fimbryolysis - surgical treatment of infertility

Performed for phimosis of the fimbrial part of the fallopian tube. Maintaining tight filling of the fallopian tube, endoscissors make gradual dissection along the radial scars and the center of the stellate scar. After that, atraumatic forceps are inserted into the lumen of the tube in a closed state, the jaws are opened to a width of 2.5-3 cm and removed in this position. The procedure is performed 2-3 times.

Salpingostomy - surgical treatment of infertility

It is performed in case of obstruction of the tube in the ampullary section. The ampullary section is fixed between two clamps (against the background of tight filling with a solution of methylene blue). Endo-scissors are used to crosswise dissect the sealed ampullary section of the fallopian tube. The edges of the fimbrial section are everted to a distance of 1-1.5 cm and by point endocoagulation of the peritoneum of the fimbrial section at a distance of 0.5-0.7 cm from the edge of the mouth of the tube along its perimeter according to the Brua method, it is fixed in the required position. As a result of endocoagulation, the outer layers of the tube wall contract, and the edges of the stoma turn outward, which prevents them from gluing in the postoperative period.

Salpingoneostomy

This operation involves creating a new artificial opening in the ampulla of the fallopian tube. The operation is performed when it is impossible to open the tubal lumen in the fimbrial region. After filling the tube with methylene blue at the site of the intended dissection of the wall on the side opposite the mesosalpinx, linear endocoagulation is performed with a point coagulator at a distance of 2-3 cm along the ampullary section, followed by opening the lumen. The edges of the neostomy are turned out 0.5-1.0 cm on each side along the incision, 2 sutures are applied using the intracorporeal knot tying technique.

After surgery performed in phase 1 of the cycle, it is advisable to resolve pregnancy in the next cycle.

Salpingectomy

Removal of the fallopian tube, which has changed due to inflammatory processes and has no prospects for restoring its function, is indicated for chronic salpingitis that is not amenable to conservative treatment (especially in the presence of hydrosalpinxes), and can also be a preparatory step for subsequent in vitro fertilization. This operation is usually recommended by fertility specialists.

Endometriosis and infertility

For external endometriosis and infertility inThe following types of surgical interventions are possible: excision of foci, enucleation of endometrioid ovarian cysts, operations associated with the presence of concomitant pathology. Since it is not always possible to determine the depth of invasion of endometriosis by its visual manifestations, leading gynecologists give preference to excision of endometrioid heterotopias, which makes it possible to ensure their radical removal.

This is especially true for retrocervical endometriosis. The scope of the operation in this case depends on the degree of spread, infiltrative growth, involvement of the straight wall in the process, sigmoid colon, rectovaginal septum. In stages I and II of spread, when endometrioid lesions are located within the rectovaginal tissue, as a rule, it is possible to excise endometriosis within healthy tissue. If the uterosacral ligaments and serous cover of the rectum are involved in the process, they are partially excised ligamentous apparatus and the serous membrane of the rectum.

In case of retrocervical endometriosis involving the rectal mucosa with tissue infiltration reaching the pelvic walls, resection of a section of the intestine is performed. For endometrioid ovarian cysts, the cyst is resected within healthy tissue with enucleation of the capsule of the endometrioid cyst and additional treatment of the cyst bed with a bipolar coagulator.

It should be noted that the treatment of this group of patients should be combined (endoscopic surgery and hormonal therapy), since the results of restoration of reproductive function increase almost three times.

Surgical interventions for scleropolycystic ovarian disease

Polycystic ovary syndrome (PCOS) – pathological condition, resulting from a disturbance in the physiological rhythm of GnRH production. An increase in the frequency and amplitude of luliberin emissions leads to increased secretion of LH and a decrease in the frequency and amplitude of FSH impulses, which regulates steroidogenesis in the ovaries. A change in their concentration leads to an increase in the amount of androgens.

The diagnostic criteria for PCOS are: bilateral ovarian enlargement, a smooth, thickened, whitish-gray capsule with a vascular pattern of varying severity, the presence of subcapsular cysts with yellow content, and the absence of free peritoneal fluid. Histology of ovarian biopsies reveals thickening of the tunica albuginea with the presence of many cystic follicles at different stages of atresia; in some cases, single follicles are found against the background of multiple proliferation of connective tissue.

Diathermocautery of the ovaries

Radial dissection of the ovarian tissue to the hilum to a depth of 1 cm in the amount of 6-8 using an endo-hook in places where the follicles are transilluminated.

Follicular fluid flows out from the treatment site, and by the end of the operation the ovary is reduced to normal sizes.

Studies have shown that the effectiveness of various endoscopic techniques in the treatment of PCOS does not differ significantly. The choice of method depends on the equipment and instruments available in the operating room and on the surgeon’s commitment to a particular type of operation.

Efficiency PCOS treatment is assessed according to two criteria: restoration of menstrual function and pregnancy. It is advisable to observe patients after surgery for 3-4 months. If there is no effect from surgical intervention, ovulation induction is performed in order to restore a regular menstrual cycle and pregnancy. The percentage of fertility restoration clearly correlates with the duration of the disease: the earlier surgical treatment is performed, the higher the pregnancy rate.

The experience of leading clinics reliably proves that the method of choice surgical correction tuboperitoneal infertility and polycystic ovaries is laparoscopy. The modern development of minimally invasive surgery allows all operations on the pelvic organs to be performed using laparoscopic access at an early optimal time for restoring fertile function. The undeniable advantages of this access allow us to talk about a completely new quality of life for women in the pre- and postoperative periods.

Every day I spend several hours answering your letters.

By sending me a letter with a question, you can be sure that I will carefully study your situation and, if necessary, request additional medical documents.

Vast clinical experience and tens of thousands of successful operations will help me understand your problem even from a distance. Many patients require no surgical care, but correctly selected conservative treatment, while others need urgent surgery. In both cases, I outline tactics of action and, if necessary, recommend a passage additional examinations or emergency hospitalization. It is important to remember that some patients require preliminary treatment of concomitant diseases and proper preoperative preparation for successful surgery.

In the letter, be sure (!) to indicate age, main complaints, place of residence, contact phone number and email address for direct communication.

So that I can answer all your questions in detail, please send along with your request scanned reports of ultrasound, CT, MRI and consultations of other specialists. After reviewing your case, I will send you either a detailed response or a letter with additional questions. In any case, I will try to help you and justify your trust, which is the highest value for me.

Yours sincerely,

surgeon Konstantin Puchkov"

Tubal infertility is caused by anatomical and functional disorders of the fallopian tubes, peritoneal infertility is caused by adhesions 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 - tubo-peritoneal infertility (TPI). TPB accounts for 20–30% of all cases of female infertility.

*Forms of tubal and tubo-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 abdominal and pelvic organs (myomectomy, ovarian resection, tubal ligation); postpartum complications(inflammatory and traumatic); external endometriosis; genital infections (chlamydial, gonorrheal, mycoplasma, trichomonas (herpetic, cytomegalovirus, etc.).

Most often, organic obstruction of the fallopian tubes is caused by sexually transmitted infections. Urogenital chlamydia causes an inflammatory process in the tubes and leads to their occlusion, which is accompanied by the destruction of fimbriae and the development of hydrosalpinx, and the inflammatory reaction 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 sperm, changing its motility. Ureaplasma can penetrate into the upper parts of the reproductive system with the help of carriers - sperm, causing narrowing or obliteration of the tubes; these pathogens attach to the cells of the ciliated epithelium and have a toxic effect on it, disrupting the advancement of the egg into the uterine cavity; ureaplasma also reduces sperm motility and inhibits their penetration into the egg. Viruses cause weakening of local immunity with activation of intercurrent infection.

Peritoneal infertility- infertility caused by adhesions in the area of ​​the uterine appendages. The frequency of peritonial 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.

In this case, morphological changes in the tubes are observed: foci of sclerosis of their walls, alternating with foci of diffuse lymphocytic infiltration; chronic vasculitis, muscle fiber deficiency, capillary reduction, arteriosclerosis are detected, varicose veins venulus; dystrophic changes are noted nerve fibers, deformation of the tube lumen 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 identification of degenerative oocytes, unfavorable intraperitoneal conditions are created for gametes and the embryo. Peritoneal fluid in endometriosis contains an increased number of T cells producing interferon γ 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 embryos through the fallopian tube are disrupted; this is due to changes in the functional activity of the tubes due to overproduction of prostaglandin F2a by endometrioid foci. Infertility with endometriosis can be primary and secondary, both with anovulation and insufficiency of the corpus luteum, and with a normal two-phase cycle.

In patients with peritoneal endometriosis and infertility, numerous villi and cilia were found on endometrial epithelial cells in the late secretory phase. The preservation of the microvillous cover reflects the insufficiency of secretory transformation of the endometrium due to 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 complete nidation of a fertilized egg in the uterine cavity, which leads to early termination of pregnancy.

Functional pathology of the fallopian tubes occurs when:

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

ETIOLOGY AND PATHOGENESIS OF TUBAL 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 disorders of their contractile activity (hypertonicity, hypotonicity, incoordination) without obvious anatomical and morphological changes.

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

Leads to dysfunction of the fallopian tubes:

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

Causes of organic lesions of the fallopian tubes and peritoneal form of infertility usually include previous PID, surgical interventions on the uterus, appendages, intestines (including appendectomy), invasive diagnostic and therapeutic procedures (HSG, cypertubation, hydrotubation, diagnostic curettage), inflammatory and traumatic complications after abortion and childbirth, severe forms external genital endometriosis.

DIAGNOSTICS OF TUBAL AND PERITONEAL INFERTILITY

For the diagnosis of TPB, anamnesis is primarily important: an indication of previous STIs and chronic inflammatory diseases of the genital organs, surgical interventions performed on the pelvic organs, features of the course of the post-abortion, postpartum, postoperative periods, the presence of pelvic pain syndrome, algodismenorrhea, inflammatory urogenital diseases in the 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. During a gynecological examination, TPB is indicated by signs of an adhesive process: limited mobility and changes in the position of the uterus, shortening of the vaginal vault.

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

The final stage of research that finally clarifies the presence/absence of TPB is diagnostic laparoscopy. It is carried out without fail if there is a suspicion of TPB and endometriosis, and regardless of the results of HSG (if such a study has been carried out). Diagnostic laparoscopy is also prescribed for patients with endocrine (anovulatory) infertility after 6–12 months of hormonal therapy, which restores 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 outpatient examination.

TREATMENT OF TUBAL AND PERITONEAL INFERTILITY

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

*Conservative treatment of tubo-peritoneal infertility

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

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

3. Absorbable therapy, including general and local (tampons, hydrotubation) use of biostimulants, enzymes (Wobenzyme, Serta, Lidase, trypsin, Ronidase, etc.), glucocorticoids.
Hydrotubation with enzymes, antibacterial agents, and hydrocortisone is used as a type of local therapy. Unfortunately, clinical experience has 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, decreased ability of the tube to peristaltically move 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. Preparations of lidase, hyaluronidase, terrilitin, 2-10% oil solution of vitamin E, ichthyol, indomethacin, naphthalan, heparoid, heparin, troxevasin ointment, 1% potassium iodide on glycerin are used as contact media. Affect lower sections abdomen, daily, No. 15.

If there is a vaginal electrode, the effect is applied through the posterior or lateral fornix, depending on the predominant localization of the adhesive process.

3. Electrical stimulation of the uterus and appendages - a vaginal electrode (cathode) is inserted into the speculum posterior arch vagina, the other (anode) - with an area of ​​150 cm2, is located 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 the MC.

4. EHF therapy for tubal-peritoneal infertility begins after 1 month. after surgical treatment, from 5-7 days of MC. 3 times every day with 2-hour breaks, for a course of 30 procedures. At the same time, hemodynamics in the vascular basin of the pelvis improves.

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

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

7. Mud applications to the “trigger” zone, t° = 38-40 °C; vaginal mud tampons (39-42 °C), 30-40 minutes, 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 improves blood flow and lymph drainage, tissue trophism, prevents the occurrence of adhesive processes, and leads to the rupture of previously formed adhesions. The procedures are carried out daily, for a course of 10-12 procedures.

Surgical treatment of tubo-peritoneal infertility

Methods of surgical treatment of tubo-peritoneal infertility are more effective than conservative therapy and include: laparoscopy, microsurgical 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 (through examination and chromosalpingoscopy), but also to immediately carry out surgical restoration of their patency (salpingolysis, salpingostomy, etc.).

In the treatment of TPB, both surgical laparoscopy (supplemented in the postoperative period with restorative therapy and ovulation stimulants) and IVF are used.

Laparoscopic reconstructive plastic surgeries aim 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 when it is initially established that there is no prospect of performing any reconstructive plastic surgery (in patients with the absence of fallopian tubes or in cases of deep anatomical changes in them), or after it has been established that it is ineffective to overcome TPB using endosurgery.

Depending on the nature of the identified pathological changes, during laparoscopic reconstructive plastic surgery, the fallopian tubes are freed from adhesions compressing them (salpingolysis), the entrance to the funnel of the fallopian tube is restored (fimbryoplasty), or a new opening is created in the closed ampullary section of the tube (salpingostomy). In case of peritoneal infertility, separation and coagulation of adhesions are performed. In parallel, during laparoscopy, detected concomitant surgical pathology is eliminated (endometrioid heterotopias, subserous and intramural fibroids, ovarian retention formations).

Microsurgical operations:

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

Contraindications to surgical treatment of TPB for the purpose of restoring natural fertility:

  • age over 35 years, duration of infertility over 10 years;
  • acute and subacute inflammatory diseases;
  • endometriosis grade III–IV according to AFS classification;
  • adhesions in the pelvis of grade III–IV according to the Hulka classification;
  • previous 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 genital surgery;
tuberculosis of the genitals.

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

There is no single point of view regarding the advisability of using salpingostomy in the presence of hydrosalpinx. There is an opinion that performing tube reconstruction for hydrosalpinx makes sense only if it is small sizes(less than 25 mm), the absence of pronounced adhesions in the area of ​​the appendages and 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 aimed at activating local and general metabolic processes, normalization of microcirculation, prevention of postoperative adhesions (electrophoresis of zinc and copper, pulsed ultrasound, supratonal frequency currents). The duration of physiotherapeutic treatment is 1 month. During the period of physiotherapy and for 1–2 months after its completion, contraception is required. Subsequently, in the absence of pregnancy over the next 6 months, it is advisable to switch to treatment using ovulation inducers prescribed in 4–6 cycles. The total duration of treatment for TPH using surgical and conservative methods should not exceed 2 years, after which, if infertility persists, patients are recommended to be referred for IVF.

*The insufficient effectiveness 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 manipulation of the guidewire, infectious complications, ectopic pregnancy in the ampullary sections of the tubes).

Prevention of PTB

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