Tubal-peritoneal infertility.

Tubal infertility in women is infertility caused by anatomical and functional disorders of the fallopian tubes due to diseases, injuries, scars, congenital malformations or other factors that prevent the movement of a fertilized or unfertilized egg into the uterus through the fallopian tubes.

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Epidemiology

Tubal-peritoneal infertility in women occupies a leading place in the structure of infertile marriage and is the most difficult pathology in restoring reproductive function. The frequency of tubal-peritoneal forms of infertility ranges from 35 to 60%. In this case, the tubal factor predominates (35-40%), and the peritoneal form of infertility occurs in 9.2-34% of cases.

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Symptoms tubal-peritoneal infertility

The main complaints of patients are the absence of pregnancy with regular unprotected sexual activity. In the case of a pronounced adhesion process in the small pelvis, endometriosis and chronic inflammatory process, there may be complaints of periodic pain in the lower abdomen, dysmenorrhea, bowel dysfunction, dyspareunia.

Forms

It is customary to distinguish 2 main forms of tubal-peritoneal infertility:

• dysfunction of the fallopian tubes - violation of the contractile activity of the fallopian tubes: hypertonicity, hypotonicity, discoordination;
• organic lesions of the fallopian tubes - obstruction, adhesions, sterilization, etc.

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Diagnostics tubal-peritoneal infertility

• Ultrasound of the pelvic organs allows detection of large hydrosalpinxes.
• Hysterosalpingography allows to detect pathology of the uterine cavity (endometrial polyps, endometrial hyperplasia, intrauterine adhesions, malformations, submucous myoma), characterize the state of the endosalpinx (folding, hydrosalpinx, adhesions, including in the ampullar region), suggest the presence of peritubal adhesions and the nature of their distribution. In the absence of large hydrosalpinxes, the reliability of the results is 60-80%.
• Laparoscopy provides an accurate assessment of the condition of the pelvic organs, the condition and patency of the fallopian tubes, the extent of the spread of the adhesion process in the pelvis, and allows for the detection of pathology of the pelvic organs (external genital endometriosis).

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Treatment tubal-peritoneal infertility

Treatment begins after excluding an inflammatory process of specific etiology - genital tuberculosis.

The first stage: correction of pathological changes in the pelvic organs during surgical laparoscopy and hysteroscopy.

The second stage: early rehabilitation treatment - from 1-2 days after endoscopic surgery. The duration of treatment is 3-10 days. Medication and non-medication methods of treatment are used.

Drug treatment

• Antibacterial therapy (begins with intraoperative administration of broad-spectrum antibiotics). Perioperative antibacterial prophylaxis consists of administering one therapeutic dose of broad-spectrum antibiotics intravenously during surgery and in the early postoperative period. Antibiotic prophylaxis reduces the risk of postoperative infectious complications by an average of 10–30%. The choice of antibiotics depends on the extent of the surgical intervention and the risk of developing postoperative infectious complications. The following have an adverse effect on the outcome of the surgical intervention:
  • the presence of chronic foci of infection (cervical erosion, chronic endometritis and salpingo-oophoritis; sexually transmitted infections);
  • long and traumatic intervention, large blood loss.

The need to continue antibacterial therapy depends on the factors listed above, as well as on the clinical picture and laboratory test results.

• Infusion therapy (using colloid and crystalloid solutions).

Non-drug treatment

• Physiotherapy.
• Efferent treatment methods - plasmapheresis, endovascular laser blood irradiation, ozone blood therapy.

Stage three. Delayed restorative treatment: non-drug and hormonal therapy is administered as indicated.

Drug treatment

• Combined estrogen-progestogen oral contraceptives, gestagens, GnRH agonists.

Non-drug treatment

• Physiotherapy: the method and number of procedures are selected individually.
• Efferent methods of treatment.

Stage 4: In patients with grade III–IV pelvic adhesions according to the Hulka classification, control hysterosalpingography is performed. If the patency of the fallopian tubes is confirmed, patients are allowed to have unprotected sexual intercourse against the background of ultrasound monitoring of folliculogenesis.

Stage five: if there is no positive effect from the treatment and the obstruction of the fallopian tubes persists, and anovulation is detected, it is recommended to use ovulation inducers or assisted reproduction methods.

If, as a result of the staged treatment, pregnancy does not occur within 1 year of observation in patients with grades I–II of the adhesion process and within 6 months in patients with grades III–IV of the adhesion process, they should be recommended methods of assisted reproduction.