Tubal damage is one of the commonest causes of infertility. The Fallopian tubes are not merely “pipes”; they are highly complex structures that pick up the ovulated egg and help move it towards the uterus. Normal fertilization occurs in the tube. Damage to the Fallopian tubes is most often caused by pelvic inflammatory disease (PID). The most common culprits are the microorganism, chlamydia trachomatis and neisseria gonorrhea, which are both sexually transmitted. Infections with either organism can occur without symptoms. This helps explain why the diagnosis is often only detected only after infertility is diagnosed.

PID almost always affects both tubes (even when one tube appears to be open, it is still highly likely to be damaged and functionally compromised). In some cases, when infection occurs following pregnancy (miscarriage or delivery), the uterine lining might become infected, leading to scarring and sometimes permanent damage with resultant inability to thicken sufficiently to support an implanting pregnancy. Other causes of tubal damage include, adhesions resulting from a ruptured or twisted ovarian cyst, pelvic surgery, peritonitis (due to conditions such as appendicitis, diverticulitis, Crohn’s disease, Ulcerative colitis ,trauma, etc.) or from endometriosis . A history of an ectopic pregnancy (pregnancy growing in the Fallopian tube) is another indicator of underlying tubal damage.

Tubal blockage can readily be diagnosed by laparoscopy when dye injected via the cervix into the uterus fails to pass via the tubes into the pelvic cavity. A hysterosalpingogram (HSG) is a less invasive method of assessing the status of the Fallopian tubes. With HSG, a radio-opaque dye is injected through the cervix into the uterus. Successive x-rays are then taken in rapid succession to track passage of the dye into the uterus and then to determine whether it passes into the Fallopian tubes and then spills into the pelvic cavity. It is important to recognize that determination of the tubes being patent does not rule out tubal damage. All it tells you is that the petal-like fimbriated ends of the tubes have not fused and blocking their ends. It is especially important to take bear this fact in mind whenever the tubes are found to be open, in spite of there being a history of prior PID.

Tubal blockage can occur anywhere in the fallopian tubes. It sometimes occurs in the part of the Fallopian tube that passes through the wall of the uterus. It can also occur in the mid-section of the tube. Most commonly however, it occludes the far end of the tubes.

In some cases Fallopian tubes damaged by PID will become distended with trapped tubal secretions that often contain toxins that are capable of killing eggs, sperm and embryos. Such distended Fallopian tubes (hydrosalpinges) can leak fluid back into the uterine cavity where the can destroy transferred embryos upon contact. This is why patients who have hydrosalpinges and are considering undergoing IVF, should first have hydrosalpinges surgically removed or at the very least have the affected tube(s) surgically clipped or tied as they emerge through the uterine wall. This will avoid subsequent back flow when IVF is performed. Understandably, it is often hard for patients to come to terms with the fact that following such surgery they no longer have any possibility of having functional Fallopian Tubes. Such women should be counseled that hydrosalpinges are functionless tubes anyway and that any attempt to open such tubes surgically in an attempt to restore fertility would be an exercise in futility, anyway.

In a nutshell: Infertility associated with tubal blockage, especially if due to PID, is an absolute indication for IVF. I would go even further in stating that any tubal damage due to PID, whether or not it is associated with blockage is an indication for IVF.

Tubal surgery is a very poor alternative to IVF. Besides, with more than 10% of pregnancies that occur following surgery to correct on PID-related damage ending up as ectopic pregnancies (a potentially life-threatening situation). Why take such a risk anyway?