Tubal factor infertility

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| caption = The fallopian tubes are the site of tubal factor infertility

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| field = Obstetrics, gynecology

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Tubal factor infertility (TFI) is female infertility caused by diseases, obstructions, damage, scarring, congenital malformations or other factors which impede the descent of a fertilized or unfertilized ovum into the uterus through the fallopian tubes and prevents a normal pregnancy and full term birth. Tubal factors cause 25-30% of infertility cases.{{cite web| title = Fallopian Tube Disorders| last= Bardawil, MD |first= Tarek |editor1-last= Lucidi, MD |editor1-first =Richard Scott |publisher=Medscape| url = http://emedicine.medscape.com/article/275463-overview#aw2aab6b7 | access-date = 2015-03-31 }} Tubal factor is one complication of chlamydia trachomatis infection in women.{{cite journal|last1=Ljubin-Sternak|first1=Suncanica|last2=Mestrovic|first2=Tomislav|title=Review: Chlamydia trachonmatis and Genital Mycoplasmias: Pathogens with an Impact on Human Reproductive Health|journal=Journal of Pathogens|date=2014|volume=2014|issue=183167|pages=183167|doi=10.1155/2014/183167|pmid=25614838|pmc=4295611|doi-access=free}}

Sexually transmitted chlamydia and genital mycoplasma infections are preventable causes of infertility and negative pregnancy outcomes. When the infections progress and ascend, they can result in TFI. Infertility can have multiple possible causes and may not be recognized for years after a gonorrhea, chlamydia or Mycoplasma infection has caused tubal damage, as the affected woman may not have attempted to become pregnant until years later.

Signs and symptoms

Infertility is the major symptom of TFI and is generally defined as a woman under 35 who has not become pregnant after 12 months without the use of contraception. Twelve months is the lower reference limit for Time to Pregnancy (TTP) by the World Health Organization.{{cite journal |vauthors=Cooper TG, Noonan E, von Eckardstein S, Auger J, Baker HW, Behre HM, Haugen TB, Kruger T, Wang C, Mbizvo MT, Vogelsong KM | title = World Health Organization reference values for human semen characteristics | journal = Hum. Reprod. Update | volume = 16 | issue = 3 | pages = 231–45 | year = 2010 | pmid = 19934213 | doi = 10.1093/humupd/dmp048 | doi-access = free }} When the inability to conceive is accompanied by signs and symptoms of pelvic inflammatory disease such as lower abdominal pain, TFI may be present. A history of pelvic inflammatory disease, the laproscopic evidence of scarring and a diagnosis of salpingitis supports the diagnosis.

Cause

Tubal factor infertility can be due to chlamydia infection and testing for chlamydia antibodies is one diagnostic tool.{{cite journal|vauthors=Kodaman PH, Arici A, Seli E | title=Evidence-based diagnosis and management of tubal factor infertility. |journal=Current Opinion in Obstetrics and Gynecology |pmid=15129051|volume=16|issue=3|date=June 2004|pages=221–9|doi=10.1097/00001703-200406000-00004| s2cid=43312882 }} A Mycoplasma genitalium infection has also been linked to TFI.{{Cite book|title=Williams gynecology|others=Schorge, John O.,, Hoffman, Barbara L.,, Bradshaw, Karen D.,, Halvorson, Lisa M.,, Schaffer, Joseph I.,, Corton, Marlene M.|isbn=9780071849081|edition= Third|location=New York|pages=65|oclc=944920918|last1 = Schorge|first1 = John O.|last2=Halvorson|first2=Lisa M.|last3=Schaffer|first3=Joseph I.|last4=Corton|first4=Marlene M.|last5=Bradshaw|first5=Karen D.|last6=Hoffman|first6=Barbara L.|date=2016-04-22}} Women have difficulty getting pregnant or carrying a baby to term due to the buildup of scar tissue in the fallopian tubes causing damage to the cilia on the epithelial cells.{{cite journal |vauthors=Tay JI, Moore J, Walker JJ | title = Ectopic pregnancy | journal = West. J. Med. | volume = 173 | issue = 2 | pages = 131–4 | year = 2000 | pmid = 10924442 | pmc = 1071024 | doi = 10.1136/ewjm.173.2.131 }}{{cite book|vauthors=Speroff L, Glass RH, Kase NG |title=Clinical Gynecological Endocrinology and Infertility, 6th Ed. |publisher=Lippincott Williams & Wilkins (1999) |page=1149ff |isbn=978-0-683-30379-7|year=1999 }} TFI can also be due to endometriosis.{{cite web | title = Fact Sheet and Information Booklets: Endometriosis: Does It Cause Infertility? |publisher=ASRM | url = http://www.asrm.org/FACTSHEET_Endometriosis_Does_It_Cause_Infertility/ | access-date = 2015-04-01 }}

Diagnosis

The physician will obtain a medical history and evaluate for tubal obstructions and infections. Obstruction can occur anywhere along the length of the tube. It can be partially or completely blocked. The extent of obstruction is typically assessed using hysterosalpingogram (HSG). Some use laparoscopy to establish the extent of the disease. Pelvic adhesions can be visualized, if present.

Distal tubal obstruction is more often observed (70%) than proximal obstruction. It can be caused by hydrosalpinges, pelvic adhesions, or fusion of the fimbriae. Tubal obstruction is caused by infection, endometriosis, myomas, salpingitis isthmica nodosa (SIN), or dried mucus. Because the tube can spasm during the injection of the dye during a hysterosalpingogram, it can be misdiagnosed.

Treatment

If tubal factor infertility is suspected to be the cause of the infertility treatment begins with or without confirmation of infection because of complications that may result from delayed treatment. Appropriate treatment depends on the infectious agent and utilizes antibiotic therapy. Treating the sexual partner for possible STIs helps in treatment and prevents reinfection.{{cite web|title=Pelvic Inflammatory Disease (PID) Partner Management and Public Health Measures|url=http://www2a.cdc.gov/stdtraining/self-study/pid/pid_partner_management_self_study_from_cdc.html|website=cdc.gov|access-date=21 February 2015|date=October 2014|archive-date=22 February 2015|archive-url=https://web.archive.org/web/20150222021754/http://www2a.cdc.gov/stdtraining/self-study/pid/pid_partner_management_self_study_from_cdc.html|url-status=dead}}

Antibiotic administration affects the short or long-term major outcome of women with mild or moderate disease.{{cite journal |vauthors=Walker CK, Wiesenfeld HC |title=Antibiotic therapy for acute pelvic inflammatory disease: the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines |journal=Clin. Infect. Dis. |volume=44 |issue=Suppl 3 |pages=S111–22 |year=2007 |pmid=17342664 |doi=10.1086/511424|doi-access=free }}

For women with infections of mild to moderate severity, parenteral and oral therapies are prescribed.{{cite journal |vauthors=Ness RB, Soper DE, Holley RL | year = 2002 | title = Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial | journal = Am J Obstet Gynecol | volume = 186 | issue = 5| pages = 929–37 | doi=10.1067/mob.2002.121625| pmid = 12015517 |display-authors=etal}}Ness RB, Hillier SL, Kip KE et al. Bacterial vaginosis and risk of pelvic inflammatory disease" Obstet Gynecol 2004; 44 (Supp 3): S111–22.{{cite journal |vauthors=Smith KJ, Ness RB, Wiesenfeld HC | year = 2007 | title = Cost-effectiveness of alternative outpatient pelvic inflammatory disease treatment strategies | journal = Sex Transm Dis | volume = 34 | issue = 12| pages = 960–6 |display-authors=etal| pmid = 18077847 | doi = 10.1097/01.olq.0000225321.61049.13 | s2cid = 31500831 | doi-access = free }} Typical antibiotics used are cefoxitin or cefotetan plus doxycycline, and clindamycin plus gentamicin.{{cite web|url=https://www.cdc.gov/std/treatment/2010/pid.htm#a2|title=CDC - Pelvic Inflammatory Disease - 2010 STD Treatment Guidelines|work=cdc.gov}} An alternative parenteral regimen is ampicillin/sulbactam plus doxycycline. Once infection has been eliminated, surgery may be successful in opening the lumen of the fallopian tubes to allow a successful pregnancy and birth.{{cite web | title = Fallopian Tube Surgeries for Infertility: Laparoscopy & More |first=Richard |last=Sherbahn MD| url = http://www.webmd.com/infertility-and-reproduction/fallopian-tube-procedures-for-infertility |publisher=WedMD| access-date = 2015-03-31 }}