The Fallopian Tubes SN Tripathy
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1BASICS
  1. The Fallopian Tubes: An Overview
    (Mrs) SN Tripathy
  2. Surgical Anatomy of the Fallopian Tube
    Bhagyalaxmi Nayak
  3. Fimbria
    Bharathi Misra
  4. Molecular Biology of Endosalpinx
    Manoranjan Mahapatra, SN Tripathy
  5. Effect of Ovarian Steroids on Fallopian Tube
    Sushma Pandey, Gaurav Pandey, Seema Pandey Chaudhary, Supriya Sharma
  6. Reproductive Significance of Fallopian Tube Cilia
    Saswati Sanyal Choudhury
2

The Fallopian Tubes: An Overview1

(Mrs) SN Tripathy
The Fallopian tubes, also known as oviducts, uterine tubes, and salpinges (singular salpinx) is an enigmatic organ of the human body. Anatomists are intrigued throughout the ages about this most dynamic reproductive apparatus They are perhaps, the most intricately structured, yet, one of the most functionally significant and competent organs. Serving as a bridge between the ovary and the uterus, it is structurally and functionally equipped to carry out the sequential cascade of events from transportation of sperms from the cervix in one direction, then reversing its role in another direction to pick up the egg, its peristaltic transport to the site of fertilization, the ampulla, providing the right microenvironment for fertilization—the most promising feature of human reproduction and transport of the embryo to the uterus for implantation. Effective tubal transport of ova, sperm and embryos is a prerequisite for successful spontaneous pregnancy. Although there is much yet to be discovered about the mechanisms involved, it is evident that tubal transit is a far more complicated process than initially thought of. Propulsions of gametes and embryos is achieved by complex interaction between muscle contractions, ciliary activity and the flow of tubal secretions. The role of the fallopian tube in the process of natural conception is also very complex. Does fertilization occur in the fallopian tube only as a consequence of a chance collision, or is there a guidance mechanism and prencontact sperm-egg communication? Is our knowledge about tubes is sufficient to know all these mysteries? Whenever we unravel little mystery, the frontier again moves just like a mirage in a desert. Almost a century after Rubin , we are still only assessing the tubal patency. It is simplistic to presume that tubal patency alone is enough to assure tubal “potency”. Thus, currently we do not have satisfactory knowledge and technique to test all aspects of tubal functions.
Though the name ‘Fallopian tube’ is eponymous, some texts spell it with a lower case ‘f’ from the assumption that the adjective ‘fallopian’ has been absorbed into modern english as the de facto name for the structure. The Greek word salpinx (ςαλπιςζ) means “trumpet”.
Andreas Vesalius (1514–1564), considered the uterine tubes to be analogous to ‘semen-conveying ducts’ or ductus deferentes of the male. He described them as being attached to the ovaries, thus, reflecting the old interpretation of Galenus (AD 130–201). It was his main pupil, Gabrielis Fallopius, who was the first to describe the tubes more accurately. They are named after their discoverer, the 16th century Italian anatomist, Gabriele Falloppio (Fig. 1), who described these structures for the first time. But Reinier De Graaf (Fig. 2) was probably the first to comprehend and describe the true function of the Fallopian tubes.1,2 Moreover, he clearly recognized several pathological conditions. He described and illustrated the closed tube (hydrosalpinx) and understood the abnormality of that condition, linking its development to female infertility (Fig. 3). He also described the development of tubal pregnancy (Fig. 4), which was poorly understood or even unrecognized by his contemporaries.
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Fig. 1: Gabriele Falloppio
The original publications of van D Graaf was translated to 4english from the original Latin text by Jocelyn and Setchell (1972).3 The scientific methods used by De Graaf to achieve his goals are still an example for any modern scientist. De Graaf combined the findings from the dissecting table, animal experiments and clinical observations, and made a critical appraisal of the available literature. The insights thus achieved were a major contribution to the understanding of human procreation.4
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Fig. 2: Reinier De Graaf
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Fig. 3: Top: Figure I displays an abnormally arranged oviduct, where the end of the oviduct is abnormally stuck to the ‘testicle’. The small aperture in the end of the oviduct veiled all around with very leafy ornamentation.(Source: Plate XIX from De Mulierum Organis Generationi Inservenientibus)
Middle: Figure II displays an oviduct opened lengthwise.
Bottom: Figure III displays an oviduct, the end of which we found abnormally closed after being inflated.4
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Fig. 4: An ectopic pregnancy in right fallopian tube(Source: Plate XXI from De Mulierum Organis Generationi Inservenientibus, which De Graaf reprinted from Vassal's report to the Royal Society)4
5
Gabriele Falloppio (1523–1562), often known by his Latin name Fallopius, was one of the most important anatomists and physicians of the sixteenth century. He was perhaps the most outstanding and versatile of 16th century Italian anatomists. The initial anatomic description of the oviducts dates back to 1561, with the publication of Observationies Anatomicae by Gabriele Fallopius. He described the different portions of the fallopian tube, with the “trumpet” shape of its distal end, and remarked on the similarities of this organ among female mammals.5
He studied at Padua under Andreas Vesalius, becoming professor of anatomy at Pisa in 1548 and Padua in 1551. Fallopius extended Vesalius's work and corrected its details. He was the first to describe the clitoris and the tubes leading from the ovary to the uterus, which were subsequently named after him. He failed, however, to grasp the function of the Fallopian tubes. A friend and supporter of Vesalius, he joined him in a vigorous assault on the principles of the classic Greek anatomist Galen, which resulted in a shift of attitude essential to the development of Renaissance medicine. Though he died under forty, he had made his mark on anatomy for all time.
 
ANATOMY AND PHYSIOLOGY
The average length of fallopian tube is 10 cm ranging from 6 to 13 cm. The fallopian tube consists of three layers—serosa, muscle layer and mucosa. The external layer or serosa is peritoneal. It surrounds the fallopian tube by a double fold of peritoneum and fuses inferiorly to form the mesosalpinx. The blood supply of medial two-thirds is derived from uterine artery whereas lateral one-third is supplied by ovarian artery. It has got 5 segments, Fimbrial, Infundibular, Ampullary, Isthmic and Interstitial, which portion passes through the uterine muscle into the uterine cavity. The mucosal layer lies directly on muscularis. It consists of a luminal epithelial lining and a scanty lamina propria containing vessels and spindly or angular cells. The mucous membrane is thrown into a series of folds or plicae especially at the infundibular end. The isthmic and intramural portions each contain about 5 to 6 blunt plicae. In the ampulla, the plicae are frond like and delicate and both secondary and tertiary branches may be appreciated. The infundibular plical pattern is similar. By light microscopy the fallopian tube is seen to have single layer of cuboidal or columnar epithelium which often appears pseudostratified, because of crowding of cells, the epithelium is composed of nonciliated and ciliated cells. There are few intercilliary cells. The nonciliated cells are characterized by major secretory activity during the follicular phase of the cycle, culminating in the release of cytoplasmic components during the passage of the egg by providing important metabolic factors for transport and implantation.
Cyclical variation in tubal morphology was first described by Novak and Everett in 1928.6 The lining epithelium of Fallopian tube undergoes cyclical changes under the influence of estrogen and progesterone.710 Receptors for estradiol (E2) and progesterone have been identified within Fallopian tube epithelium and expression of these receptors varies according to the stage of ovarian cycle.10,11 The concentration of nuclear estradiol receptor markedly varied in isthmus and ampulla, being significantly higher at the late proliferative phase than at the secretory phases. The highest estradiol and progesterone binding could be detected in the ampullary region, significantly lower levels of estradiol and progesterone receptor were seen in the infundibulum and the isthmus.12
The fallopian tube is the essential link between the ovary and the uterus. It's transport mechanisms include orderly ovum transfer by the fimbria, and ovum and pre-embryo retention, with transport to the uterus on the third postovulatory day. Sperm/and ovum interaction ensures a reservoir and storage and activation system at the tubal isthmus. Ovum/tube interaction is driven by the HCO 3 ion in the tubal secretions, which also supply pyruvate and other essential substances to the pre-embryo.13
 
EMBRYOLOGY AND CONGENITAL ANOMALIES
The fallopian tube originate from the vertical portion of paramesonephric ducts (Mullerian Ducts) which arises as longitudinal invagination of the celomic epithelium on the anterolateral surface of urogenital ridge in the sixth week of development. Cranially the duct opens into the coelomic cavity. The caudal part fuses to form the uterus in 8th intrauterine life.14
The true incidence of congenital fallopian tube anomalies is unknown because abnormalities may be subtle and are often overlooked or thought to be due to acquired or iatrogenic causes.15 It is estimated that up to 70% of tubal malformations occur in the context of associated renal and/or uterine anomalies.16 As with many congenital anomalies, the pathogenesis is often traced back to embryologic development. Most Mullerian anomalies can therefore be explained by a failure or dysregulation of events that occur during embryologic development of the currently accepted sequence of normal development. Mullerian anomalies encompass a spectrum of heterogeneous malformations demonstrating 6the complexity of timing and regulation of embryologic events that can go awry. Pure Mullerian agenesis, or Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, consists of a complex malformation in which the vagina is absent and the uterus and fallopian tubes are either absent or rudimentary. The findings of fallopian tube anomalies in this group of patients has not been well described, though some investigators have suggested that normal, partial, or absent fallopian tubes may exist.
Anomalies of the fallopian tube, including complete absence, partial absence, duplication, and ectopic location, have all been described.17 Partial tubal atresia has been described both with and without uterine anomalies. When associated with a uterine malformation, it is typically seen with bicornuate uteri, where by the tube ipsilateral to the rudimentary, nonfunctioning horn contains an atretic ampullary segment.18 In these cases, the fimbriated end is connected to a shortened, patent ampullary segment. The origin of fimbria is not from the Mullerian system is thought of, because the presence of fimbria in women with cervical, vaginal, and uterine agenesis supports this concept.
Recently, there has been a lot of attention involving the fallopian tube as pertains to carcinogenesis. The fimbriated portion of the fallopian tube has been identified as a preferential site for the formation of early serous carcinomas, supporting the fimbria as a likely site of origin for ovarian epithelial neoplasm.19,20 Some of the differences in the oncologic potential of the distal tubal segment may be explained by its separate embryologic origin.
 
DISEASES OF THE TUBES
Infection leading to pelvic inflammatory disease (PID), ectopic pregnancy, tuberculous salpingitis and malignancy are major diseases of the tubes. PID in its turn results in infertility and ectopic pregnancy.
 
Infertility and Tubes
The incidence of tubal factor infertility is increasing. There are multiple and diverse etiologic factors responsible for it. The incidence of infertility due to tubal pathology varies in different parts of the world which is around 20% tubal factors account for 40% female infertility and 15 to 25% of these have proximal tubal block. Majority of the proximal tubal block are due to amorphous debris and tubal spasm. In presence of tubal obstruction, proper evaluation of fallopian tubes is necessary to determine whether tubal surgery or IVF to be undertaken.
 
Tubal Functions
Interest in tubal assessment is as old as interest in fertility and infertility. The fallopian tube is a particularly complex structure and, as such, an ideal method for its clinical assessment is very difficult to obtain. As a result, a number of different methods have been suggested. Some of these methods are more complementary to each other rather than potential substitutes for one another. Some have been used for many years with a clear evidence-base for their performance as diagnostic tests. For others, relatively new tests, very little evidence about their performance is available. Research is moving from a purely anatomical approach (are the tubes open or blocked?) to encompassing functional enquiry (are the open tubes functional and, if not, are there interventions with which fertility performance can be improved?). Many questions remain, which, despite the increasing success of IVF, will continue to challenge Commonly used tools for assessing tubal function are HSG, USG, Laparoscopy and hysteroscopy. Many other methods are employed of recent development or of by gone days , but still they are not comparable to HSG and Laparoscopy.
 
HYSTEROSALPINGOGRAPHY
Hysterosalpingography (HSG) is a corner stone and time honored method for tubal function tests to see tubal patency, anatomical changes and the whole length of FT and any associated changes in the uterine cavity and cervix. The HSG is noninvasive, simple and less expensive. The first hysterosalpingographic study may have been performed only 15 years after Roentgen discovered X-rays.21 It is a standard test that figures prominently in the modern decision-making for infertile couples. The drawback of HSG is that when HSG diagnoses obstruction, it may actually be patent in many cases. On the other hand, when patency is seen in HSG it is very unlikely that tube is blocked. The interpretation of proximal and distal tubes patency in HSG also differ. The diagnosis of distal tube obstruction by HSG is almost accurate, but when proximal part of tube is seen occluded it is not confirmatory, and may be due to artefact or spasm and to be confirmed by hysteroscope and or laparoscope. HSG itself has also therapeutic effect. Sixty percent of patients of proximal tubal block determined by HSG showed patency one month after repeat HSG. Fifty to sixty percent of patients shown by HSG to have proximal tubal block occlusion were found to have patent tubes on subsequent laparoscopy. The diagnostic performance of HSG was compared to 7laparoscopy and dye test for tubal occlusion and peritubal adhesions in a meta-analysis.22 This meta-analysis showed a sensitivity of 65% (95% CI 50–78%) and specificity of 83% (95% CI 77–88%) for the diagnosis of tubal occlusion. An abnormal result should be confirmed by laparoscopy, but with a normal result laparoscopy is likely to show tubal patency in 95% of cases.23
 
Laparoscopy and Hysteroscopy
Laparoscopy and dye test allows the clinician to assess the pelvic cavity for presence of adhesions and endometriosis directly. Usually, this procedure is performed at the end of the fertility work-up, when a HSG or CAT has been assessed as being abnormal or sooner if the patient has co-morbidity such as a medical history of PID, ectopic pregnancy or previous pelvic surgery. Laparoscopy cannot be considered the gold standard for assessing tubal patency as presumed tubal obstruction may be due to differences in resistance between the tubes, spasm, or technical failure. This was illustrated in a cohort study comparing results of HSG and laparoscopy which implicated that 35% of the tubes that were found to be occluded at laparoscopy showed patency at HSG.24 Compared to HSG, laparoscopy has the advantage to assess if microsurgery is feasible in the presence of tubal pathology. and to decide about the treatment of endometriosis. Both are complimentary and supplementary to each other.
 
Salpingoscopy and Falloposcopy
The first description of selective tubal catheterization appeared in The Lancet in 1849, decades before the first X-ray image. William Tyler Smith25, a lecturer in the Hunterian School in London, proposed a “new method of treating sterility by removal of obstructions of the fallopian tubes.” He used a transvaginal route and tactile impression to pass a whalebone bougie through a J-shaped silver cannula positioned in the uterine cornua, thereby clearing proximal occlusions. He was inspired by the technique of Gairal, a French surgeon, who used whalebone bougies to catheterize the auditory tubes. In his 1849 article, Smith suggested the possibility that the fallopian tube was blocked by a “glutinous deposit,” an opinion confirmed 148 years later by Sulak et al.26 Low-grade inflammation of the uterus and retrograde menstruation may explain proximal tubal obstruction by amorphous debris in some women. However, despite its long recognition as a cause of infertility, the underlying cause for tubal obstruction has never been proved. Interestingly, also in 1849, Friorep in Berlin used the transcervical approach to the fallopian tube for the opposite purpose. He applied silver nitrate through a cervical cannula to the proximal portion of the tubes and to the uterine cornua to provoke a noninvasive tubal sterilization.27 In the following years, these techniques of transcervical catheterization were used mainly for sterilization purposes, with various chemical agents or physical devices applied to occlude the proximal tube If proximal tubal occlusion is suspected at HSG or laparoscopy, selective salpingography and tubal catheterisation can be performed under fluoroscopic guidance to assess whether proximal tubal blockage is caused by cornual spasm. In this procedure the tubes are cannulated and are flushed with contrast media.28
In varieties of ways, the proximal tubal pathology is diagnosed and treated. They are linear Everting catheter, coaxial falloposcopy. Guidewire seen entering the tubal ostia, Tactile fallopian tube recanalization with Labotect cannula, Hysteroscopic tubal catheterization, selective salpingography and transcervical FTR, Fluoroscopically guided transcervical balloon tuboplasty, Sonographic FTR, etc.
There are many many other tests to asses tubal function, i.e. the tubal patency but they have not stood the test of time like HSG , they are, USG, CT, MRI, transvaginal hydrolaparoscopy, hysterosalpingoscintigraphy, Hystero-salpingo-contrast-sonography (HoCoSy).
 
Transvaginal Hydrolaparoscopy
Transvaginal hydrolaparoscopy (THL) is a technique that makes use of microendoscopic instruments. A scope is entered through the posterior fornix of the vagina into the pelvic cavity. By means of aquaflotation, using instillation of warm saline, the tubo-ovarian structures are assessed. The procedure is usually combined with hysteroscopy and chromopertubation and can be combined with falloposcopy. The procedure can be performed using local anesthesia or sedation and could be done in an outpatient setting. Findings at THL appear to be in agreement with laparoscopic findings.29
 
Hystero-contrast-sonography
Transvaginal hysterosalpingo contrast sonography (HyCoSy) combines the instillation of contrast agents into the uterine cavity with a transvaginal ultrasound and through this allows assessment of the uterine cavity, tubal patency as well as ovarian morphology. The procedure can be performed in an outpatient clinic and requires similar time to perform as the HSG. The performance of HyCoSy as a screening test for tubal infertility compares well with 8HSG with a high concordance rate. A diagnosis of occlusion requires additional laparoscopy for confirmation.30,31
 
Ultrasonography
The normal fallopian tube is difficult to identify by transabdominal or transvaginal sonography. Ultrasound in case of tubal abnormalities which include infection, pregnancy and neoplasm requires both transvaginal and transabdominal approach. Addition of 3D and color Doppler facilities helps in having more accurate diagnosis, good assessment of therapy as well as differentiating benigns from malignant masses.
 
Hysterosalpingoscintigraphy
The hysterosalpingoscintigraphy (HSSG) is a technique of using radionucleotide labeled macroagregates to evaluate the utero tubal transport mechanism. The 99mTc–labeled human serum albumin macroaggregates migrate spontaneously through the female reproductive tracts following application into the posterior vaginal fornix. Serial images captured with a gamma camera reveal the pattern of radio nucleotide uptake and transport. In normal individuals a selective uptake and transport to the side of the dominant follicle is seen (ipsilateral side). It gives less radiation exposure to the ovary and less painful than HSG. It is a helpful investigation and a negative HSSG patient should opt for IVF and ET even if her tubes are patent by other tubal function tests.
Royal college of obstetricians and gynecologists (RCOG) recommendation for tubal assessment is clear and precise. In absence of any comorbidity like pelvic inflammatory disease (PID), previous ectopic pregnancy, endometriosis, etc. HSG should be offered to screen tubal occlusion. HoCoSy is an effective alternative to HSG where expertise is available. In patients with co-morbidities, laparoscopic chromopertubation should be used so that tubal as well as other pelvic pathology can be assessed at the same time.
 
Management of Tubal Factor Infertility
Prevention and adequate treatment of sexually transmitted diseases will reduce the incidence of tubal factor infertility. Education of public regarding sexually transmitted disease (STD), use of condom, care at the insertion of intrauterine contraceptive device (IUCD), adequate treatment of PID as soon as diagnosed, will go a long way to prevent the damage to the fallopian tubes.
Until the mid sixty's, the only treatment available for tubal factor infertility was surgery. The techniques at that time were crude and the results disappointing, frequently due to severe postoperative adhesions. The late sixty's and early seventy's witnessed the introduction of microsurgical techniques which significantly improved outcomes. However, tubal patency did not always translate into a pregnancy, largely due to the severity of prior tubal damage.
The definitive treatment of tubes is surgical. The surgery is known as tuboplasty. The operation can be done by conventional method, i.e. laparotomy or by microsurgery which in its turn can be done by laparotomy or laparoscopy, at present the method of surgery to be opted is microsurgery by laparoscopy, the overall results being good.
Therapeutic approaches for PTO include. Transcervical tubal cannulation and selective salpingography, tubocornual anastomosis, tubouterine implantation and IVF–ET.
The various surgical interventions available for DTO are salpingostomy or salpingoneostomy, fimbrioplasty, and IVF-ET.
Successful Robotic Laparoscopic microsurgical tubal anastomosis has got very good results by a well trained microscopical surgeon, the tubal patency rate being 89% post surgical 6 weeks and ongoing pregnancy rate 50%.
Tubotubal anastomosis is performed to reverse a previous tubal sterilization. It can be intramural-isthmic, intramural-ampullary, isthmic-isthmic, isthmic-ampullary, ampullary-ampullary or ampullary-infundibular. The treatment for hydrsalpinx is drainage, salpingostomy, proximal tubal ligation and salpingectomy.
Due to the increasing use of assisted reproductive technology (ART), the role of reconstructive tubal surgery was minimized. Nevertheless, the operative reconstruction and restoration of tubal function can offer a relevant alternative to ART especially in younger women or in case of minor tubal damage. In addition, the treatment of distal tubal occlusion can increase the success rate after IVF treatment. Furthermore, tubal reconstructive surgery might offer an alternative after multiple unsuccessful IVF attempts. In this respect modern diagnostic procedures and therapy of tubal infertility are still relevant and allow an individually adapted optimal selection of suitable treatment options.32
 
Ectopic Pregnancy
The modern management of ectopic pregnancy is one of medicine's greatest success stories. It was first described in 11th century and as a fatal event. No treatment were available.33 First documentation of unruptured ectopic was in 1693, may be infertility is the cause in 1752. In the mid 19th century PID was implicated as a cause. As the fetus was the cause so many devices were employed 9to kill the fetus like starvation, purging, bleeding, surgically puncturing the sac, resulting in maternal death. Though surgery started as early as 1600, there was no mention for it 100 years after. The first surgery was reported in France in 1714, then two cases in America in 1759 and 1791. The survival rates were very poor. Harbert first suggested early surgery to stop fatal bleeding.34
Robert Lawson Tait first ligated the tubes and broad ligament to stop bleeding.35
In spite of asepsis, anesthesia and antibiotics the results were poor as regards maternal mortality in the first half of 20th century. But there is a great stride in the 2nd half of 20th century in the management of ectopic pregnancy shifting from surgical management to medical to even expectant management simultaneously reducing the maternal mortality rate as well as preserving the fertility. It is now accepted that minimal access surgery provides the best and most efficient method of treating ectopic pregnancies where surgey is necessary. (RCOG Grade A recommendation but today management intervention occurs prior to tubal rupture in more than 80% cases. This can be due to HCG estimation, USG and laparoscopy.36
As regards future fertility outcome previous extrauterine pregnancies are associated with higher rates of preterm birth and infants of low birth weight in subsequent pregnancies.37
 
Risk Factors
Conditions which serve to increase risk of implantation in the tubes rather than the normal site implantation in the uterus include previous ectopic pregnancy, history of tubal surgery, including a previous tubal sterilization, history of sexually transmitted infection, tubal infection, or pelvic adhesions, current use of an intrauterine device; conception resulting from assisted reproduction, cigarette smoking, etc.38
The classic symptom triad of ectopic pregnancy (pain, amenorrhea, and vaginal bleeding) is present in only about 50% of patients, and is most typical in patients in whom an ectopic pregnancy has ruptured. Abdominal pain is the most common presenting symptom.
The findings before rupture and hemorrhage are nonspecific, and vital signs are normal. Tachycardia, hypotension, decreased bowel sounds, distended abdomen with marked tenderness and rebound tenderness, and cervical motion tenderness are features of ruptured tubal pregnancy.
Laparoscopy is rarely required for diagnostic purposes only; TVS and HCG measurements are usually sufficient for diagnosis To date, therapeutic options for women with tubal EP are surgery, medical treatment or expectant management.
Advances in technology have facilitated early diagnosis of ectopic pregnancy, which in turn has increased the scope for non-surgical treatment. The American Congress of Obstetricians and Gynecologists (ACOG) (2008) guideline states that comparisons of medical treatment with tube preserving surgery (salpingotomy) showed no differences in overall rates of tubal preservation, tubal patency, repeat ectopic pregnancy, or future pregnancies.
A 3-month waiting period should elapse for women who are planning pregnancy39 after the MTX treatment Many cases of ectopic pregnancy will spontaneously resolve, so that “watchful waiting” and β-hCG follow-up will separate true viable ectopic pregnancies from spontaneously resolving ectopic pregnancies.40
 
Pelvic Inflammatory Disease
Pelvic inflammatory disease (PID) is an infection caused by inflammatory continuum from the cervix to the peritoneal cavity. (ACOG, 2010). The PID is one of the most serious infections facing young women today. It results in severe morbidity like infertility, chronic pelvic pain, and increased risk of ectopic pregnancy, etc. The PID also has a significant economical and psychological impact.
Recent developments in this area include the identification of new pathogens and a greater understanding of the interaction between previously recognized pathogens and the host immune response. Accurate diagnosis of PID remains a challenge, but a number of large randomized trials provide clear guidance on appropriate empirical therapy when PID is suspected.
A wide variety of aerobic and anaerobic bacteria can be isolated from the fallopian tubes of women presenting with acute PID. Some of these appear to be normal commensals of the vagina (e.g. Gardnerella vaginalis, Mobiluncus or Bacteroides) that have ascended into the upper genital tract, while others are sexually transmitted pathogens such as Chlamydia trachomatis and Neisseria gonorrhoeae,41 the newer organisms implicated are M genitalium and Atopobium Vaginae.42
The risk factors are young age, multiple partners, recent new partner, past history of sexually transmitted disease (in the patient or their partner), termination of pregnancy; insertion of intrauterine device within the past six weeks and previous episode of acute PID.
The diagnosis of acute pelvic inflammatory disease (PID) is primarily based on historical and clinical findings. The diagnostic process is imprecise, with no single piece of 10historical, physical, or laboratory information found to be highly specific or sensitive for the disease. The symptoms suggestive of a diagnosis of PID are lower abdominal pain-usually bilateral; dyspareunia-particularly of recent onset; abnormal bleeding-intermenstrual and postcoital bleeding can occur secondary to associated cervicitis and endometritis; abnormal vaginal or cervical discharge-as a result of associated cervicitis, endometritis or bacterial vaginosis. Physical science are lower abdominal tenderness; adnexal tenderness on bimanual vaginal examination; cervical motion tenderness on bimanual vaginal examination fever (>381 C). The PID should be considered in a patient with the clinical signs and/or symptoms outlined above or in an asymptomatic individual from a high-risk group. Clinical symptoms and signs lack sensitivity and specificity. Hence, CDC has established certain criteria for the diagnosis of PID. and for institution of empiric treatment, For outpatient treatment, there are two currently accepted treatment regimens for PID as provided by the CDC 2010, Regimen A and Regimen B.4345
Pelvic inflammatory disease is a preventable disease, sex education, prevention of sexually transmitted diseases will go a long way to prevent PID, as soon as diagnosed, empirical treatment must start immediately. For details see the Chapter 13 on PID.
 
Fallopian Tube Malignacy
Primary carcinoma of the fallopian tube carcinoma (FTC) is a rare and extremely aggressive malignant tumor. The prevalence of FTC is 0.3 to 1.8% among the neoplasms of the female genital tract.4648 The 5-year survival rate is only about 35%.47,49 The clinical signs and symptoms are almost same as epithelial ovarian cancer and rarely diagnosed preoperatively. Danielle Vicus et al50 in their study opined that the risk factors for fallopian tube cancer are similar to the known risk factors for ovarian cancer. Two of the traditional risk factors for ovarian cancer (oral contraceptive use and parity) were also found to be protective for fallopian tube cancer. A possible increased risk was found with HRT, in keeping with the epidemiology of ovarian cancer. They concluded, their results support the hypothesis that there is similar pathogenesis for serous ovarian cancer and fallopian tube cancer.
The site of origin of pelvic high-grade serous carcinoma has been the subject of debate for 60 years. There is a belief at present that pelvic serous carcinoma originates from the fallopian tube mucosa. In a review by Salvador et al searching the english language literature in the MEDLINE database between the years 1995 and 2007 using the following keywords: fallopian tube neoplasia, ovarian serous adenocarcinoma, pregnancy, oral contraceptive, infertility, pelvic inflammatory disease, cytokines, menstruation, and tubal ligation, followed by an extensive review of bibliographies from articles found through the search. Put forward a theory that inflammation in the tube, caused by menstrual cytokines or infection, is critical to the genesis of these tumors. They discussed the clinical implications of this theory, and a change in surgical practice is recommended, with salpingectomy at the time of simple hysterectomy. This theory also has implications for the development of new methods of screening for pelvic serous carcinomas, as there are no screening methods that are currently available to find this form of cancer in an early stage.51
Surgical management too has turned more radical in the last 10 years. Early lymphogenous metastases, which the relevant literature describes as soon as in clinical Stage I, are the reason why complete pelvic and para-aortic lymphadenectomy is part of today's surgical standards.52 The bad prognosis of FTC is particularly ascribed to early lymphogenous metastasis.5355 Metastases of the lymph nodes are reported to occur with a frequency of up to 50%. The specific lymphatic situation of the fallopian tube makes metastases spread simultaneously into pelvic and para-aortic regions.53,5658
At present, the primary treatment for FTC is TAH with BSO, omentectomy, and radical pelvic, and para-aortic lymphadenectomy followed by49,50 systemic chemotherapy. In cases in which cytostatic chemotherapy is contraindicated, or in patients with single metastases, the sensitivity of FTC for irradiation should be considered for treatment.59
 
Tuberculous Salpingitis
Tuberculous salpingitis is a major cause of tubal infertility. In our study, the incidence of infertility among women with genital TB is 58% and who had a tubal factor for infertility, pelvic TB is the cause in 41%.60 In another study, 300 Indian women who had a tubal factor for infertility, pelvic TB was determined to be the underlying cause in 117 (39%)61 The fallopian tube is the primary site of infection in the female genital tract and the usual route is hematogenous. Occasionally, lymphatic spread from peritoneal seedling or direct extension from an intestinal lesion can occur. The fallopian tubes are affected in 94 to 100% of women with genital tuberculosis, and in most patients, there is bilateral but asymmetrical tubal involvement. As the tube heals, it becomes encased in connective scar tissue, and the lumen develops a 11beaded appearance due to multiple strictures or a rigid pipestem contour. Obstruction of the fallopian tube may result in hydrosalpinx, and in the late stages of disease, there may be calcification of the tubes in the form of linear streaks or tiny nodules. Tubal tuberculosis spreads to the endometrium in about 50% of cases.
Diagnosis of genital tuberculosis has always been a problem. It has a wide spectrum of clinical presentation and presents a diagnostic dilemma even for physicians with a great deal of experience in the disease. Rarely a provisional diagnosis of GT is made. Out of the 290 cases (till 2004 August) of histologically proved genital tuberculosis, in only 17% cases we made a provisional diagnosis of GT.58 A positive histopathological report or isolation of the Mycobacterium tuberculosis or definite positive findings in hysterosalpingography should be used before treating a case as one of genital tuberculosis. Treatment can be started if combination of factors are positive like positive PCR. and positive laparoscopic finding, or positive hysteroscopic finding of FGTB. Treatment can be started if there are specific findings on laparoscopic or hysteroscopic evidence of tubercles, caseous nodules and other stigmata of FGTB with clinical signs and symptoms. Treatment should not be started only on positive PCR or positive serological tests.
Early detection and treatment is crucial to ensure the future fertility of the patients. The World Health Organization's recommendations for genital TB treatment are identical to the treatment for pulmonary TB. But the disease is so elusive that it is difficult to diagnose, even if diagnosed and treated the pregnancy outcome is very poor. Our take home baby rate is only 8.7%.62 The IVF and ET results are equally depressing, being less than 30% from different centers of the world.6367
 
Endometriosis and Tubes
Endometriosis was described as early as 1800. But John Simpson of Abany, New York in 1921 described the disease in detail and gave the name ‘Endometriosis.’68 Fallopian tube involvement in endometriosis is rare. Endometriosis cause tubal factor infertility by massive dense pelvic adhesions resulting from the chronic irritation and inflammation of endometriosis obliterating the cul de sac behind the uterus, distorting the normal relationship between the ovaries and the fallopian tubes, destroying the delicate fimbrial ends of the fallopian tubes, completely occluding the fallopian tube so that the tube becomes fluid filled (hydrosalpinx), and covering the surface of the ovaries which may result in fibrotic deterioration. Randomized controlled studies have demonstrated a significant improvement in fertility when treating these types of changes surgically (without treatment the pregnancy rate is less than 10% and following surgery the pregnancy rates can rise to greater than 50%). But Forrest et al do not agree with these results.69 Till today, the effects of endometriosis on tubal factor infertility is controversial.
 
THE NEW FRONTIERS
 
Tubal Transplantation
Tubal transplantation was attempted as early as 1946; this was a nonvascular transplantation and obviously failed. The introduction of microsurgery rekindled the thought of tubal and tubo-ovarian transplantation for individuals who had no tubes or had inoperable severe tubal damage. In 1975, Patric Steptoe suggested research on both fronts, i.e. tubal transplantation and IVF ET.70 But time has shown that tubal transplants is not feasible because, IVF works better, and is safer, and less expensive.
Any transplant requires taking antirejection medication for the rest of the life. This is rather dangerous medication. That too in reproductive medicine other than the technique itself, transplantation poses several problems like subjecting to an intervention the donor who supplies the organ for a nonlife saving purpose, subsequent rejection of the grafted organ, and clinical and ethical considerations of the procedure and the use of immunosuppressive drugs. As it stands today tubal transplantation has got no future at present to treat tubal pathology for infertility.
 
Robotic Surgery
The robotic system involves two components: a patient side-cart (also referred to as the robot) and a surgeon's console. The robot is placed adjacent to the patient and has several attached arms. Each arm has a unique surgical instrument and performs a specialized surgical function. The surgeon sits near the patient at the surgeon's console and visualizes the surgery through a monitor. The surgeon performs the entire reversal surgery using controllers located inside the surgeon's console.
Robotic surgery offers numerous potential benefits over a conventional surgery. They are significantly less painful, there is less blood loss and fewer transfusions, less risk of infection, less scarring, shorter hospital stay and shorter recovery time. The surgeries at present undertaken are tubal ligation reversal and salpingo-oophorectomy. But for the surgery a good laparoscopic and microscopic surgeon is necessary.
12
 
Tubes as a Source of Mesenchymal Stem Cells
A research team in Brazil71 has shown that cells from postoperatively discarded fallopian tubes can be used for stem cell research. The team, based at the University of Sao Paolo, showed that fallopian tubes discarded after hysterectomies contain ‘mesenchymal’ stem cells that are pluripotent; they are capable of developing into multiple tissue types like muscle, bone, cartilage, etc.
Kadam et al72 from India had detected stem cells in the discarded tubes after hysterectomy. A pure population of mesenchymal like cells was obtained from the Fallopian tube samples. The immunocytochemistry of these cells revealed the presence of classical mesenchymal stem cell markers like smooth muscle actin, vimetin, nestin, desmin, CD44, CD90 and CD117. These fallopian tube derived mesenchymal stem cells could be induced to differentiate into adipocytes, chondrocytes, osteocytes, neuronal and pancreatic lineage under the influence of lineage specific differentiation cocktails. They opined such documentation of multipotent stem cells in a fallopian tube may be of significance for instant repair of the tract as and when necessary so as to assist uninterrupted transport of eggs for possible fertilization thus facilitating reproduction.
 
Stem Cell Therapy to Restore Tubal Functions
Though no body has tried till date to restore tubal function by instituting stem cell therapy, but I see a bright future for the restoration of the same by stem cell therapy, be it from self damaged tubes or other sources of stem cells, like cord blood, bone marrow, etc. As of today more than 75 grievous diseases are treated with stem cells or are on trial, then why not in damaged tubes.
 
CONCLUSION
The incidence of tubal factor infertility is increasing. There are multiple and diverse etiologic factors responsible for it. Prevention and adequate treatment of sexually transmitted diseases will reduce the incidence of tubal factor infertility. Education of public regarding STD, use of condom, care at the insertion of IUCD, adequate treatment of PID as soon as diagnosed, will go a long way to prevent the damage to the fallopian tubes.
Appropriate preliminary investigation to find out the cause, nature and extension of tubal damage is essential for the success of treatment. The evidence suggests that surgery should retain its place in the treatment of tubal infertility. The ART has its limitations. Surgery and ART are complementary approaches that can be used singly or in combination to improve the outcome for couples with tubal infertility.
Mild to moderate adnexal adhesions can be treated with laparoscopic lysis of adhesions as a first line treatment, whereas extensive, thick and vascular adhesions should undergo IVF-ET. Patients who fail to conceive after one year of adhesiolysis should proceed with IVF-ET.
Tuberculous salpingitis is a major cause of tubal infertility. It is an elusive disease, difficult to diagnose, treatment is with short course chemotherapy, even if treated the pregnancy outcome is very poor, natural as well as with IVF and ET.
Advances in technology have facilitated early diagnosis of ectopic pregnancy, which in turn has increased the scope for nonsurgical treatment. A high degree of suspicion, and judicious use of beta HCG estimation, USG and laparoscopy will definitely improve the prognosis of ectopic pregnancy.
Primary carcinoma of the fallopian tube corcinoma (FTC) is a rare and extremely aggressive malignant tumor. At present the primary treatment for FTC is TAH with BSO, omentectomy, and radical pelvic, and para-aortic lymphadenectomy followed by systemic chemotherapy. All these gives a better 5-year survival rate.
Like all other branches of medicine , so many mysteries are unraveling about tubes. We are very near to know how fertilization is taking place in the molecular millue inside the tubes and how exactly the transportation system works. On the treatment frontier, robotic surgery, stem cell therapy, etc. are in the door step and on the horizon.
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