Tubal Infertility

Tubal infertility is failure to conceive because of blocked, damaged or absent fallopian tubes.

• Common causes are pelvic inflammatory disease (chlamydia and gonorrhoea), genital tuberculosis, endometriosis, previous tubal surgery or ectopic pregnancy, and adhesions.
• Proximal blockage, distal blockage and hydrosalpinx need different treatment.
• In vitro fertilisation bypasses the tubes.

Failure to conceive after 12 months of regular unprotected intercourse (6 months if aged 35 or over); a history of pelvic infection, ectopic pregnancy, appendicitis or pelvic surgery; some women have no history.

• Normal menses, normal pelvic examination or tender adnexal masses.
• Differential diagnosis: anovulation, male factor infertility, uterine factors, endometriosis, unexplained infertility.
• Complications: ectopic pregnancy, hydrosalpinx, repeated treatment failure and psychological distress.

Diagnosis rests on tubal assessment.

• Hysterosalpingography or sonosalpingography to test tubal patency.
• Laparoscopy with dye test for adhesions and distal damage when the test is abnormal or the history is suggestive.
• Chlamydia antibodies, endocervical NAAT; HIV and syphilis tests; semen analysis for the partner.
• Mid-luteal progesterone and anti-Müllerian hormone to assess ovulation and reserve.
• Xpert MTB/RIF on menstrual blood or endometrial tissue where tuberculosis is suspected.

Management depends on the cause and the woman's age.

• Supportive: couple counselling; folic acid 400 micrograms oral daily; stop smoking and limit alcohol; treat partners for infection.
• Pharmacological: antibiotic cover at hysterosalpingography or tubal surgery: doxycycline 100 mg oral 12-hourly for 5 days. Active infection: ceftriaxone 500 mg IM single dose plus doxycycline 100 mg oral 12-hourly plus metronidazole 400 mg oral 12-hourly for 14 days. Genital tuberculosis: isoniazid 5 mg/kg (maximum 300 mg), rifampicin 10 mg/kg (maximum 600 mg), pyrazinamide 25 mg/kg and ethambutol 15 mg/kg, all oral once daily for 2 months, then isoniazid and rifampicin once daily for 4 months, with pyridoxine 25 mg oral daily.
• Procedures: in vitro fertilisation for most blocked tubes, for women aged 35 or over, and for severe damage; salpingectomy or proximal occlusion for hydrosalpinx before in vitro fertilisation; laparoscopic adhesiolysis or fimbrioplasty and tubal cannulation for selected young women with mild disease and a good tubal lining.
• Special groups: in HIV infection optimise antiretroviral treatment and use timed intercourse or assisted reproduction with sperm washing in serodiscordant couples. After tubal surgery or in vitro fertilisation, confirm intrauterine pregnancy by ultrasound at 6 weeks to exclude ectopic pregnancy.
• Red flags: abdominal pain with a positive pregnancy test, fever after procedures, vaginal bleeding.
• Follow-up: review after 3 months of treatment; refer for in vitro fertilisation if no pregnancy within 12 months after tubal surgery.