The bilateral fallopian tubes were not visualized

Women usually undergo certain examinations before preparing to have a child. This can not only ensure the health of the woman, but also prevent future children from having any medical problems. Sometimes women will find that after an examination, both sides of their fallopian tubes are not visible in the film. This is most likely caused by fallopian tube blockage. Will this have any adverse effects? Is there any way to solve this problem?

Fallopian tube blockage is the main cause of female infertility, accounting for 25% to 35% of female infertility, and the main cause of fallopian tube damage is pelvic inflammatory disease (PID). The incidence of secondary fallopian tube obstruction is directly related to the incidence of PID. Reproductive capacity after fallopian tube reconstruction depends on the site and extent of fallopian tube damage. Women with extensive fallopian tube damage have a lower chance of becoming pregnant, and IVF can improve their pregnancy rates.

Causes

1. Infection

Most cases of fallopian tube disease are secondary to infection, particularly pelvic inflammatory disease (PID). Other possible causes of infection include a perforated appendix, infection after abortion, or postoperative complications, such as endometriosis and inflammatory states caused by surgery, which can lead to occlusion of the fallopian tubes due to adhesions. Rarely, embryologically absent fallopian tubes are a factor in infertility, and the final cause may also be iatrogenic, such as tubal ligation.

Although pelvic inflammatory disease can be caused by a variety of microorganisms, chlamydia is the main cause of infertility. Damage to the fallopian tubes may already exist before the application of antimicrobial therapy. Sometimes the infection may be subclinical and exist in the fallopian tubes for months before diagnosis and treatment. This is in stark contrast to the acute onset of PID caused by Neisseria gonorrhoeae. It is now highly suspected that chlamydia infection damages the mucosa of the fallopian tube through immunopathological mechanisms, while Neisseria gonorrhoeae damages the fallopian tube through related cytotoxicity. Other latent infectious pathogens include Mycoplasma hominis and endogenous aerobic or anaerobic bacteria. Pelvic tuberculosis accounts for 40% of tubal infertility in developing countries.

Infectious abortion is another major risk factor for tubal infertility. Preoperative examinations include bacterial vaginosis and cervicitis. Culture and serological tests should be performed when necessary, and the test results should be understood before surgery. We routinely use preventive antibiotics after abortion.

2. Inflammation/adhesion

Tissue trauma caused by surgical operations can also lead to a pre-inflammatory state or even adhesions. The incidence of postoperative adhesions is approximately 75%, and laparoscopy cannot prevent the occurrence of adhesion sequelae. The application of adhesion barriers (such as anti-adhesion membranes) can reduce the occurrence of adhesions by an average of 50%. The removal of adhesions will increase the rate of infertility. If serious diseases exist, in vitro fertilization-embryo transfer (IVF-ET) may be the only option.

Clinical manifestations

Generally speaking, there are no typical symptoms. The most common manifestation is infertility. The fallopian tube plays an important role in transporting sperm, absorbing eggs and transporting fertilized eggs to the uterine cavity. Blockage of the fallopian tube hinders the passage of sperm and fertilized eggs, leading to infertility or ectopic pregnancy. If the fallopian tube obstruction is caused by pelvic inflammation, it may be accompanied by lower abdominal pain, back pain, increased secretions, pain during sexual intercourse, etc.

examine

1. Physical examination

Signs of infection should be checked, and cervicitis should be checked. Signs of PID should be carefully checked, including cervical lifting pain and adnexal tenderness. Increased vaginal discharge should not be ignored, and cervical secretion culture is a good choice. Patients with signs of endometriosis such as uterine sacral tenderness or nodules should be examined rectally and vaginally. If the patient has had this disease, chlamydial antibody (CAT) testing should be performed. Many studies support the relationship between CAT and fallopian tube disease. Retrospective analysis shows that its sensitivity and specificity are 92% and 70%, respectively.

2. Auxiliary examination

If the patient is at low risk for tubal disease or has no other causes of infertility, HSG is the first choice. If the patient is at higher risk or has the potential for disease, laparoscopic evaluation may be considered. The gold standard for fallopian tube assessment is by laparoscopy and methylene blue dye injection.

(1) Tubal peristalsis is a procedure in which methylene blue or saline solution is injected into the uterine cavity from the cervix and then flows into the fallopian tube from the uterine cavity. The resistance during injection and the backflow of the fluid are used to determine whether the fallopian tube is unobstructed. Due to the advantages of simple equipment, easy operation and low price, this method of fallopian tube permeability examination was widely used before the 1980s. However, since the entire process relies on the doctor's subjective feeling and judgment, and the location of the fallopian tube blockage cannot be determined, the tension during the examination can cause fallopian tube spasm and cause false positives. In recent years, surgery can be performed under ultrasound monitoring, which has improved the accuracy rate, but in actual clinical work, it was found that this method has a high misdiagnosis rate, so it is not an ideal examination.

(2) Hysterosalpingography (HSG) was first used in the 1920s. It involves injecting high-density substances composed of high atomic numbers (such as iodine, diatrizoate, etc.) into the uterine cavity through the cervical canal. Under X-ray, they form a clear artificial contrast with the surrounding tissues, making the tubal cavity visible. It can detect tubal occlusion, tubal motility, mucosal damage caused by previous infection or tubal endometriosis, hydrosalpinx, isthmus nodules, adhesions and tubal abnormalities (such as accessory valves and diverticula). It is a fast, economical and low-risk examination. HSG has a sensitivity of 65% for tubal occlusion and adhesions, but painful tubal spasm can cause false positives, while pain, infection, and contrast agent invasion into the vascular system are rare complications.

(3) Fallopian tube endoscopy is a method of imaging the intraluminal structure of the fallopian tube. A rigid fallopian tube endoscope is required for examination. It can evaluate the entire length of the fallopian tube and the mucosa and patency of the entire fallopian tube. During the examination, fallopian tube recanalization can be performed. Therefore, it has a potential therapeutic effect on proximal fallopian tube obstruction. However, fallopian tube endoscopy has high requirements for technology and equipment, so it is not widely used at present. In addition, fallopian tube endoscopy can also be performed through the transvaginal water injection laparoscopic route into the abdominal cavity.

(4) Laparoscopic examination: methylene blue is injected into the uterine cavity through the uterine catheter. Laparoscopic observation shows that the fallopian tube is unobstructed if methylene blue overflows from the fimbria of the fallopian tube into the pelvic cavity. If the fallopian tube is blocked at the proximal end (interstitial and isthmus of the fallopian tube), methylene blue fluid will not overflow from the fimbria of the fallopian tube into the abdominal cavity. If the fallopian tube is blocked at the distal end (ampulla and fimbria of the fallopian tube), the fimbria and ampulla of the fallopian tube will be seen to be dilated, thickened and stained blue, but no methylene blue fluid will flow from the fimbria of the fallopian tube into the abdominal cavity. Laparoscopy can directly visualize the site of fallopian tube obstruction and the adhesions around it and can simultaneously separate and treat the adhesions. It is the gold standard for diagnosing fallopian tube obstruction, but it requires general anesthesia and surgical treatment. It is not widely used at present and is only used for patients whose fallopian tubes are abnormal as indicated by tubal perfusion or angiography.

(5) Water injection laparoscopy is a new technology developed in recent years. It uses a small endoscope to explore the entire pelvic cavity from the posterior fornix. During the operation, the patient is required to adopt the lithotomy position. The water-soluble expander used during the examination allows the uterus and fallopian tube-ovarian structures to be fully exposed when viewed from the back. During the entire operation, the ovaries and fallopian tubes are always in a suspended state due to the continuous dripping of saline solution. The advantage of this technology is that it can be used in an outpatient setting and is less invasive; the disadvantage is that the entire abdominal and pelvic cavity cannot be evaluated, and there is also the possibility of intestinal damage, with an incidence of approximately 0.65%.