infertility iii

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DR/ ADEL FAROUK M.D DR/ ADEL FAROUK M.D . . ASSISTANT PROFFESOR ASSISTANT PROFFESOR of of Obstetrics & Gynecology Obstetrics & Gynecology Cairo university Cairo university Infertility III Infertility III

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Page 1: Infertility III

DR/ ADEL FAROUK M.DDR/ ADEL FAROUK M.D.. ASSISTANT PROFFESORASSISTANT PROFFESOR of of Obstetrics & GynecologyObstetrics & Gynecology

Cairo universityCairo university Infertility IIIInfertility III

DR/ ADEL FAROUK M.DDR/ ADEL FAROUK M.D.. ASSISTANT PROFFESORASSISTANT PROFFESOR of of Obstetrics & GynecologyObstetrics & Gynecology

Cairo universityCairo university Infertility IIIInfertility III

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Tubal factorTubal factor

•Physiology.•Etiology.•Diagnosis: 1-History

2-Examination

3-Investigations: Tubal patency tests

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Tubal factorTubal factor• Physiology: The physiological role of the tube for

pregnancy is: • 1-The fimbriae of the tube should move at the

time of ovulation to embrace the ovary and to pick up the ovum.

• 2- The tubal fluid should be non-hostile to sperms or ovum.

• 3- The tube should be patent. • 4-The tubal cilia and peristalsis should be normal

to help transport of the ovum and then the zygote.• Etiology of the tubal factor of infertility: see before.

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Tubal factorTubal factor• Diagnosis:

• (1) History:• History suggestive of salpingitis (acute abdominal pain,

fever and discharge).• History of puerperal sepsis.• History of previous operation on the tubes or other pelvic

operations.• History suggestive of endometriosis (dysmenorrhea,

dyspareunia and irregular bleeding).

• (2) Examination:• Inflammatory tubal swellings felt on bimanual

examination or nodules in Douglas pouch (in endometriosis).

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Tubal patency testsTubal patency tests IdeaIdea: Tubal patency tests depend upon : Tubal patency tests depend upon

injection of air, carbon dioxide, radio injection of air, carbon dioxide, radio opaque contrast or colored material opaque contrast or colored material through the cervix. If the tubes are patent, through the cervix. If the tubes are patent, the injected gas or material will pass the injected gas or material will pass through them into the peritoneal cavity through them into the peritoneal cavity and its presence can be detected or and its presence can be detected or demonstrated there. On the other hand, if demonstrated there. On the other hand, if the tubes are blocked no leakage will the tubes are blocked no leakage will occur.occur.

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Tubal patency testsTubal patency testsPrecautions:Precautions: The tests should be done under complete The tests should be done under complete aseptic conditions. aseptic conditions. Carbon dioxide is better than air because it is Carbon dioxide is better than air because it is soluble in the blood (less risk of embolism). soluble in the blood (less risk of embolism). The tests should be carried 3-5 days The tests should be carried 3-5 days postmenstrual to avoid the risk of embolism, postmenstrual to avoid the risk of embolism, false +ve results (from blockage of tubal cornu false +ve results (from blockage of tubal cornu by thick endometrium), theoretical risk of by thick endometrium), theoretical risk of endometriosis due endometrial implantation in endometriosis due endometrial implantation in the peritoneal cavity or risk of disturbing an the peritoneal cavity or risk of disturbing an already present pregnancy. already present pregnancy. The pressure should not exceed 200 mm.Hg. The pressure should not exceed 200 mm.Hg. High pressure increases the risk of embolism or High pressure increases the risk of embolism or might rupture closed tubes.might rupture closed tubes.

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Tubal patency testsTubal patency testsContraindications: Contraindications:

History or signs suggesting a chronic infection History or signs suggesting a chronic infection in the tubes, cervix or vagina. in the tubes, cervix or vagina.

Premenstrual periods (it should be Premenstrual periods (it should be postmenstrual) to avoid the risk of disturbing postmenstrual) to avoid the risk of disturbing already present pregnancy, to decrease the risk already present pregnancy, to decrease the risk of endometriosis and false resultsof endometriosis and false results

During menstruation or uterine bleeding (can During menstruation or uterine bleeding (can cause embolism or endometriosis). cause embolism or endometriosis).

Women in whom pregnancy or anesthesia is Women in whom pregnancy or anesthesia is contraindicated.contraindicated.

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Tubal patency testsTubal patency testsComplications:Complications:

Ascending pelvic infection. Ascending pelvic infection. Air or oil embolism. Air or oil embolism. Endometriosis. Endometriosis. Abortion of undiagnosed pregnancy.Abortion of undiagnosed pregnancy.Rupture of closed tubes. Rupture of closed tubes. Allergic reaction to iodine.Allergic reaction to iodine.

Advantages:Advantages:Although these tests are primarily diagnostic, they have Although these tests are primarily diagnostic, they have also a therapeutic value. The therapeutic values of tubal also a therapeutic value. The therapeutic values of tubal patency tests are attributed to: patency tests are attributed to: May dislodge mucus plug blocking the tubes. May dislodge mucus plug blocking the tubes. It may dissolve thin tubal adhesions. It may dissolve thin tubal adhesions. It may overcome fimbrial stenosis. It may overcome fimbrial stenosis. It may eliminate utero-tubal spasmIt may eliminate utero-tubal spasm

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Tubal patency testsTubal patency testsRubin’s insufflation:: T shaped tube, the vertical limb is T shaped tube, the vertical limb is connected with a manometer. One end of the horizontal limb is connected with a manometer. One end of the horizontal limb is connected with a CO2 source or a bulb and the other horizontal connected with a CO2 source or a bulb and the other horizontal limb is connected to a cannula passed through the cervix.limb is connected to a cannula passed through the cervix.

Criteria of tubal patencyCriteria of tubal patency: : 1- Drop of pressure in the manometer. 1- Drop of pressure in the manometer. 2- Auscultation of hissing sound over the lower abdomen. 2- Auscultation of hissing sound over the lower abdomen. 3- Shoulder pain. 3- Shoulder pain. 4- Sub-diaphragmatic pneumoperitoneum by X Ray.4- Sub-diaphragmatic pneumoperitoneum by X Ray.Disadvantages:Disadvantages: does not determine the site of the does not determine the site of the block, type of the block, uni or bilaterality of the block, type of the block, uni or bilaterality of the blockblock

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Rubin’s insufflationRubin’s insufflation

T shaped tube T shaped tube connected to a connected to a manometer, CO2 manometer, CO2 source and cannulasource and cannula

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Sharman’s KymographySharman’s Kymography The manometer in Rubin’s insufflation test is replaced The manometer in Rubin’s insufflation test is replaced by a lever recording the pressure on a rotating drum.by a lever recording the pressure on a rotating drum.

Can differentiate tubal block from spasm, stenosis          Can differentiate tubal block from spasm, stenosis           Precautions, contraindications and Precautions, contraindications and complicationscomplications: : As tubal patency testsAs tubal patency testsDisadvantagesDisadvantages::It cannot localize site of lesion (corneal, isthmical, It cannot localize site of lesion (corneal, isthmical, ampullary or fimbrial obstruction), the prognosis of ampullary or fimbrial obstruction), the prognosis of tubal block is better in cases of fimbrial compared by tubal block is better in cases of fimbrial compared by cornual obstruction.cornual obstruction.It does not differentiate uni from bilateral lesionsIt does not differentiate uni from bilateral lesions..

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Sharman’s KymographySharman’s Kymography

Tubal patencyTubal patency: : The gas pressure The gas pressure oscillates between oscillates between 40-60 mm Hg. where 40-60 mm Hg. where 5-10 oscillations per 5-10 oscillations per minute are observed minute are observed (caused by (caused by intestinal intestinal peristalsis).peristalsis).

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Sharman’s KymographySharman’s Kymography

• Tubal block: There is steep rise of pressure to 200 mm Hg. where it is maintained followed by fall when the gas is shut off.

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Sharman’s KymographySharman’s Kymography

• Tubal spasm: there is steep rise to 200 mm Hg. Followed by normal curve.

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Sharman’s KymographySharman’s Kymography

• Tubal stenosis: there is a rise of pressure to 150 mm Hg. Followed by a slow fall.

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HysterosalpingographyHysterosalpingography Idea:Idea:

Injection of a radio-opaque material in the uterine Injection of a radio-opaque material in the uterine cavity using a canula fixed to the cervix. cavity using a canula fixed to the cervix.

X Ray is taken showing the outline of the uterine X Ray is taken showing the outline of the uterine cavity and tubes.cavity and tubes.

A second film is taken later to show peritoneal A second film is taken later to show peritoneal spill due to scattering of the dye by intestinal spill due to scattering of the dye by intestinal movements.movements.

The shadow of radio-opaque material may be The shadow of radio-opaque material may be visualized during injection using image visualized during injection using image intensifier.intensifier.

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HysterosalpingographyHysterosalpingography

Technique:Technique:

Timing 2-3 days after the end of menstruation.Timing 2-3 days after the end of menstruation.

Dorsal position. Cervix is exposed by a Dorsal position. Cervix is exposed by a speculum and grasped by a volsellum.speculum and grasped by a volsellum.

No anesthesia (except if dilation is needed in No anesthesia (except if dilation is needed in cases of cervical stenosis).cases of cervical stenosis).

Complete aseptic precautions. Complete aseptic precautions. Antispasmodics: to overcome tubal spasm.Antispasmodics: to overcome tubal spasm.

The cannula is introduced into the cervical The cannula is introduced into the cervical canal.canal.

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HysterosalpingographyHysterosalpingographyContrast media:Contrast media:

LipiodolLipiodol:: oily medium (40% organic iodine in poppy- seed oily medium (40% organic iodine in poppy- seed oil).oil).- Valuable for detection of peritubal adhesions in control - Valuable for detection of peritubal adhesions in control film.film.- The second film is taken 24 hours later with risk of oil - The second film is taken 24 hours later with risk of oil embolism or oil granuloma.embolism or oil granuloma.

Urografin:Urografin: water soluble, second film is taken 10- 30 water soluble, second film is taken 10- 30 minutes later.minutes later.- No risk of oil embolism or oil granuloma.- No risk of oil embolism or oil granuloma.- Sharp outline of the uterus and tubes, not valuable for - Sharp outline of the uterus and tubes, not valuable for detection of peritubal adhesions. detection of peritubal adhesions. Amount of contrast mediumAmount of contrast medium: : The capacity of the normal The capacity of the normal uterine cavity is 6-8cc. larger amounts may be needed uterine cavity is 6-8cc. larger amounts may be needed when the cavity is enlarged e.g. uterine fibroids.when the cavity is enlarged e.g. uterine fibroids.

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Hysterosalpingography (contrast Hysterosalpingography (contrast medium)medium)

 Item Lipidol Urografin

Nature Iodine in oil Iodine in water

Injection Difficult injection Easy injection

Value Slowly absorbed, shows peri-tubal adhesions

Rapidly absorbed shows integrity of tubal mucosa

2nd film   2nd film after 24 hours

2nd film after 15 minutes

Complications May cause oil granuloma

 

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Hysterosalpingography (advantages)Hysterosalpingography (advantages)

1- Diagnosis of uterine anomalies as bicornuate 1- Diagnosis of uterine anomalies as bicornuate uterus or submucous fibroid.uterus or submucous fibroid.

2- Diagnosis of unilateral or bilateral tubal lesions.2- Diagnosis of unilateral or bilateral tubal lesions.

3- Diagnosis of the type of tubal lesion (stenosis, 3- Diagnosis of the type of tubal lesion (stenosis, occlusion or spasm).occlusion or spasm).

4- Diagnosis of peritubal adhesions (second film) 4- Diagnosis of peritubal adhesions (second film) normally show the presence of free peritoneal spill normally show the presence of free peritoneal spill due to scattering of lipiodol by intestinal due to scattering of lipiodol by intestinal movements if the tubes are patent, loculated spill movements if the tubes are patent, loculated spill may indicate peritubal adhesions and dilated may indicate peritubal adhesions and dilated appearance of the tubes may suggest appearance of the tubes may suggest hydrosalpinges.hydrosalpinges.

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Hysterosalpingography (advantages)Hysterosalpingography (advantages)

5- It cannot localize site of lesion (corneal, 5- It cannot localize site of lesion (corneal, isthmical, ampullary or fimbrial obstruction), the isthmical, ampullary or fimbrial obstruction), the prognosis of tubal block is better in cases of prognosis of tubal block is better in cases of fimbrial compared by cornual obstruction.fimbrial compared by cornual obstruction.6- May suggest a specific pathology. (T.B) (dwarf 6- May suggest a specific pathology. (T.B) (dwarf uterus, lymphatic intravasation and extensive uterus, lymphatic intravasation and extensive intra-uterine adhesions, pipe stem tubal rigidity, intra-uterine adhesions, pipe stem tubal rigidity, beaded tube with extensive peritubal adhesions).beaded tube with extensive peritubal adhesions).7- More beneficial therapeutic value: as the 7- More beneficial therapeutic value: as the hydrostatic pressure is more effective in hydrostatic pressure is more effective in overcoming tubal spasm or dislodgement of overcoming tubal spasm or dislodgement of mucous plug and iodine may cause Lysis of thin mucous plug and iodine may cause Lysis of thin adhesions.adhesions.

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Hysterosalpingography Hysterosalpingography (complications)(complications)

• Shock or collapse.

• Oil granuloma.

• Oil embolism.

• Intravasation lymphatic or venous.

• Allergic reaction to iodine.

• Infection (cervicitis and salpingitis).

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HysterosalpingographyHysterosalpingography

Cannula for hysterosalpingographyCannula for hysterosalpingography

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HysterosalpingographyHysterosalpingography

• The technique of hysterosalpingography

dye injection through canula in the cervix

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Hysterosalpingography

Bicornuate uterus

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Hysterosalpingography

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Hysterosalpingography

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HysterosalpingographyHysterosalpingography

Multiple filling Multiple filling defect are seen defect are seen within the within the uterine cavity uterine cavity (polypi)(polypi)

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Right tube lead pipe + Right tube lead pipe + Intravasation left sideIntravasation left side

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Hysterocontrast sonography Hysterocontrast sonography (HyCoSy)(HyCoSy)

This a modern, ultrasound bases This a modern, ultrasound bases investigation using a negative (normal investigation using a negative (normal saline) or positive (Echovist[galactose saline) or positive (Echovist[galactose microparticles]) contrast media injected microparticles]) contrast media injected through the cervix (by a special cannula or through the cervix (by a special cannula or pediatric Foley’s catheter) under vaginal pediatric Foley’s catheter) under vaginal ultrasound guidance to outline the uterine ultrasound guidance to outline the uterine cavity and the fallopian tubes (simple test cavity and the fallopian tubes (simple test with no exposure to X- rays or anesthesia) with no exposure to X- rays or anesthesia)

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Laparoscopy Indications:Indications:

1-When hysterosalpingography shows a tubal 1-When hysterosalpingography shows a tubal block or peritubal adhesions.block or peritubal adhesions.

2- When all the investigations show no 2- When all the investigations show no abnormalities and pregnancy does not abnormalities and pregnancy does not occur within 6 months. it can detect some occur within 6 months. it can detect some factors as (endometriosis).factors as (endometriosis).

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LaparoscopyLaparoscopyIdea:Idea:Injection of colored material (Methylene blue) into the Injection of colored material (Methylene blue) into the uterus to appear at the abdominal ostium of the tube. uterus to appear at the abdominal ostium of the tube. Laparoscopy can also reveal the presence of pelvic Laparoscopy can also reveal the presence of pelvic endometriosis, cystic ovaries, tuberculous salpingits, and endometriosis, cystic ovaries, tuberculous salpingits, and recent corpous luteum denoting ovulation or the rare recent corpous luteum denoting ovulation or the rare possibility of luteinized unruptured follicle syndrome.possibility of luteinized unruptured follicle syndrome.

Technique:Technique:Under anesthesia, bladder evacuated, the cervix is exposed by Under anesthesia, bladder evacuated, the cervix is exposed by a speculum and grasped by a volsellum. A cannula is inserted a speculum and grasped by a volsellum. A cannula is inserted into the cervix. The patient shifted to Trendelenberg position into the cervix. The patient shifted to Trendelenberg position Pneumoperitoneum: 2-3 liters of CO2 are introduced in the Pneumoperitoneum: 2-3 liters of CO2 are introduced in the peritoneal cavity by a special needle inserted at the lower peritoneal cavity by a special needle inserted at the lower margin of the umbilicus.margin of the umbilicus.Trocar and cannula are introduced, the trocar is removed and Trocar and cannula are introduced, the trocar is removed and the laparscope is introduced through the cannula into the the laparscope is introduced through the cannula into the peritoneal cavity.peritoneal cavity.Light source in connected to the laparoscopy through a Light source in connected to the laparoscopy through a fiberoptic cable (cold light).fiberoptic cable (cold light).

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Laparoscopy

• Verrus needle (for peritoneal insuffulation) and Troacar and Cannula used for laparoscopy

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Laparoscopy

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Laparoscopy

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Laparoscopy

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laparoscopy

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LaparoscopyLaparoscopy Complications::1- Arrhythmias or cardiac arrest (due to pneumoperitoneum and 1- Arrhythmias or cardiac arrest (due to pneumoperitoneum and trendlenberg position).trendlenberg position).2- Gas embolism (CO2 under high pressure).2- Gas embolism (CO2 under high pressure).3- Surgical emphysema: injection of CO2 in the tissues of 3- Surgical emphysema: injection of CO2 in the tissues of abdominal wall abdominal wall 4- Bowel injury (direct or electrocautery).4- Bowel injury (direct or electrocautery).5- Bleeding from injury of blood vessels in the abdominal wall or 5- Bleeding from injury of blood vessels in the abdominal wall or abdominal cavity.abdominal cavity.6- Infection.6- Infection.Laparoscopy has a therapeutic rule (salpingolysis or treatment Laparoscopy has a therapeutic rule (salpingolysis or treatment of endometriosis), should be performed at the same timeof endometriosis), should be performed at the same timeN.B: N.B: Some workers prefer to use H.S.G. to delineate tubal Some workers prefer to use H.S.G. to delineate tubal mucosa and to do laparoscopy to assess pelvic adhesions as mucosa and to do laparoscopy to assess pelvic adhesions as H.S.G. gives very high incidence of false +ve and false -ve H.S.G. gives very high incidence of false +ve and false -ve results in diagnosing peritubal adhesions.results in diagnosing peritubal adhesions.

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Tubal patency testsTubal patency tests

VI) FalloposcopyVI) Falloposcopy: : Introduced from the Introduced from the fimbrial end of the tube through fimbrial end of the tube through laparoscopy to visualize the interior of the laparoscopy to visualize the interior of the tube, its main role in cases of unexplained tube, its main role in cases of unexplained infertility or abnormal salpingography. It infertility or abnormal salpingography. It may have a therapeutic role.may have a therapeutic role.

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LaparoscopyLaparoscopy

Salpingitis (retort Salpingitis (retort shaped appearance shaped appearance of the fallopian tube) of the fallopian tube) detected by detected by laparoscopy.laparoscopy.

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LaparoscopyLaparoscopy

• PCO detected by laparoscopy.

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Laparoscopy

Adhesions around the fallopian tube seen on laparoscopy

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LaparoscopyLaparoscopy

• Endometriosis seen at laparoscopy.

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LaparoscopyLaparoscopy

Positive hydrotubation Positive hydrotubation test test

(a spill of methylen (a spill of methylen blue dye is seen blue dye is seen coming out from the coming out from the fimbrial end of the fimbrial end of the tube)tube)

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Laparoscopic treatment of pelvic Laparoscopic treatment of pelvic adhesionsadhesions

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Treatment of tubal factor

• A- Conservative treatment:• 1- Hydrotubation • 2- Short wave therapy • 3- Repeated insufflations • B- Surgical treatment: Operations to restore tubal patency (tuboplasty).C-In vitro fertilization and embryo transfer (I.V.F. &

E.T).

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Treatment of tubal factorTreatment of tubal factorA- A- Conservative treatmentConservative treatment: : It has a limited value in the It has a limited value in the management of tubal occlusion (rarely used). It includes management of tubal occlusion (rarely used). It includes

1- Hydrotubation1- Hydrotubation::Repeated intrauterine injection of hydrocortisone, Repeated intrauterine injection of hydrocortisone,

streptomycin and streptomycin and chemotrypsin is believed to have effect chemotrypsin is believed to have effect especially in cases with peritubal adhesions. The procedure is especially in cases with peritubal adhesions. The procedure is done in the pre-ovulatory period for several cycles.done in the pre-ovulatory period for several cycles.

2- Short wave therapy:2- Short wave therapy:About 24 sittings should be given, it leads to temporary About 24 sittings should be given, it leads to temporary hyperemia of the pelvic organs, which may help to resolve hyperemia of the pelvic organs, which may help to resolve some adhesions, (doubted effect).some adhesions, (doubted effect).

3- Repeated insufflations3- Repeated insufflations.. It is important to determine whether antibodies to Chlamydia It is important to determine whether antibodies to Chlamydia trachomatis are present in the serum by measuring IgG trachomatis are present in the serum by measuring IgG antibodies to this organism as there is a good correlation antibodies to this organism as there is a good correlation between presence of these antibodies and tubal adhesions.between presence of these antibodies and tubal adhesions.

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Treatment of tubal factorTreatment of tubal factor B- Surgical treatment:B- Surgical treatment: Operations to restore Operations to restore

tubal patency (tuboplasty). The aim of the tubal tubal patency (tuboplasty). The aim of the tubal surgery is to restore the normal anatomy. Tubal surgery is to restore the normal anatomy. Tubal damage has been graded depending upon the severity damage has been graded depending upon the severity of the disease with grade 1 being the least damaged of the disease with grade 1 being the least damaged and grade 3 and 4 being severely damaged and and grade 3 and 4 being severely damaged and surgery is only indicated in grades 1 and 2. surgery surgery is only indicated in grades 1 and 2. surgery can be done by laparoscopy or by open laparotomy can be done by laparoscopy or by open laparotomy but following the microsurgical techniques is but following the microsurgical techniques is essential with complete hemostasis and minimal essential with complete hemostasis and minimal handling of tissueshandling of tissues

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Tuboplasty Tuboplasty

• Indications:

• Young patients with

• Bilateral tubal occlusion,

• With no other cause of infertility and the male is normal.

• Laparoscopy is performed for proper assessment. Exclude active infection or T.B of the genital tract. One of the following operations may be done.

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TuboplastyTuboplasty• Salpingolysis: Freeing the tube from

surrounding adhesions.

• Fimbriolysis: Freeing the fimbrial end in cases of partial fimbrial occlusion.

• Salpingostomy: Artificial ostium in cases of fimbrial obstruction e.g. hydrosalpinx.

• Excision of stricture and end-to-end anastmosis.

• Tubal re-implantation in the uterus: In cornual occlusion.

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TuboplastyTuboplasty• Prevention of adhesions: -Complete hemostasis.

Microsurgical techniques (minimal tissue trauma).Antibiotics. - Corticosteroids.Anti-inflammatory agents.

• Prognosis: Success rate does not exceed 30-35%.- Best results in salpingolysis (mucosa is not

affected).reversal of tubal sterilization achieve good results as the tubal damage is unlikely and the woman has proven fertility.

- Laparoscopy should be performed later on to assess the results of the operation.

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Tubal fimbria closed by salpingitisTubal fimbria closed by salpingitis

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Opening the closed fimbriaOpening the closed fimbria

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Neo- salpingostomyNeo- salpingostomy

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Completing neosalpingostomyCompleting neosalpingostomy

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Transcervical cannulation of the tubeTranscervical cannulation of the tube: : in in cornual occlusion, done by either cornual occlusion, done by either falloposcopy or salpingograghy. In 50% of falloposcopy or salpingograghy. In 50% of these cases the obstruction is not organic but these cases the obstruction is not organic but due to thickened endometrium, tubal spasm due to thickened endometrium, tubal spasm or tubal plugs.or tubal plugs.A wire of soft platinum tip is passed through the A wire of soft platinum tip is passed through the uterine opening of the tube, it is done through uterine opening of the tube, it is done through hysteroscope, transvaginal sonography or hysteroscope, transvaginal sonography or fluoroscopy, a catheter is then passed over the fluoroscopy, a catheter is then passed over the giuide wire to perform selective salpigography to giuide wire to perform selective salpigography to confirm the diagnosis of organic cornual block prior confirm the diagnosis of organic cornual block prior to treatmentto treatment

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Tubal cannulation for treatment of Tubal cannulation for treatment of proximal tubal blockproximal tubal block

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Treatment of tubal factorTreatment of tubal factorC- In vitro fertilization and embryo C- In vitro fertilization and embryo transfer (I.V.F. & E.T). : transfer (I.V.F. & E.T). : In irreparable tubal In irreparable tubal damage in grade 3 and 4 tubal damage.damage in grade 3 and 4 tubal damage.

Steps: Steps: see assisted conception techniques see assisted conception techniques laterlater

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