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The obstacles that impede fertilisation

letto 6277 volte | autore: Claudio Manna, ginecologo specialista in fecondazione assistita (vai al curriculum)

         

The ovule and the spermatozoa cannot reach each other and fertilisation is made impossible by an “obstacle” at the level of the uterus or the tubes. Causes and remedies to resolve the problem:

Abnormalities of the female genital tract can be found among the causes of  infertility. About a quarter of fertility disturbances can be blamed on problems of permeability of the tubes. Normally when the ovule is expelled from the ovaries, during ovulation, it is collected in the tubes where it is then reached by the spermatozoa that have crossed the uterus and travelled down the tube.  An obstacle, however, can impede the normal development of these events.  Let us distinguish between an obstruction of the uterine cavity, on the side of the ovaries : the ovule cannot be released into this space. The obstacle, however, can also be found at the entrance of the tubes, on the side near the uterus, and in this instance it’s the spermatozoa that cannot advance and reach the ovule.

Other causes
In most cases, the obstructions are caused by genital infections, of the tubes (salpingitis), almost always caused by sexually transmitted diseases (STD), for example chlamydia, which can go unobserved but are sufficient to cause an obstruction.  This is why it is important for all women to prevent the risks of STD’s, adequately protecting themselves during intercourse with occasional partners and regularly visiting the gynaecologist.  Other than infections, among the causes of obstructions, there are also adhesions that cause the sticking together of the walls of the tubes, and also problems associated with endometriosis.   

Discover the problem
In order to identify a tubal patency problem, the following exams are recommended:

  • A fertiloscope, which is a new, mini-invasive, method of exploring the posterior pelvis which allows for a complete valuation of the mechanical factors of female infertility.
  • A hysterosalpingogram, which is an x-ray of the pelvis which is conducted after the injection of a radio-opaque product into the uterus, through the vagina.  The exam is generally conducted by a radiologist and a gynaecologist, it entails the insertion of a catheter attached to a syringe containing the contrast liquid.  The product is gradually injected and the x-rays are made. Normally the tubes become opaque gradually and carries on till the radio-opaque product passes into the peritoneal cavity.

Presently the actual use of this method is relegated almost exclusively to the evaluation of  tubal patency and for the identification of possible congenital abnormalities of the uterus (e.g. uterus with a septum, uterus bicornis etc).  Sometimes, the hysterosalpingogram , which is a diagnostic operation, becomes therapeutic. It is not uncommon that the pressure used for injecting the contrast agent resolves the tubal narrowing.  The exam can be relatively painful but does not require anaesthesia. Sometimes anti-allergic pre-medication or prophylactic antibiotic-therapy is suggested.  This method has risks but they are rare : allergic reactions, infections (salpingitis, endometritis, reactivation of chronic salpingitis).

  • Hysteroscopy : the objective is to examine the uterine cavity using an endoscope passed through natural passages.  It can be divided into diagnostic hysteroscopy and operative hysteroscopy.  The first is effected in a completely pain free way without the use of anaesthesia using a fine hysteroscope with a hydraulic mechanism.  With this approach it is sometimes possible to perform small surgical operations (e.g. the removal of polyps on a stalk).  The second is effected under general anaesthetic and allows for serious surgery for example the removal of fibroids and uterine sects, etc. It is important to remember that in some facilities, a diagnostic hysteroscopy  is undertaken with old generation hysteroscopes and requires either local anaesthetic or total anaesthetic.
  • Hysterosonosalpingograph: consists of injecting  physiological solution into the uterus and evaluating the tubal patency with an ultrasound and colour doppler.  The reliability is almost overshadows that of a hysterosalpingograph (used very frequently in the USA) and is less fastidious. On the down side it is less reproducible in  respect to the hysterosalpingograph.
  • A celioscopy , is an exam that requires anaesthetic.  The surgeon makes a small incision at the level of the navel and inserts a fibre optic scope in order to examine the tubes from the inside with or without the use of a special dye.
  • An ultrasound indispensable for an accurate evaluation of the pelvis (uterus, ovaries, etc).  It can be used , especially the 3D – 4D methods, to find and correctly measure the size of uterine sects that can often cause problems if they are ample.  It can identify potential pelvic adhesions suspected in a high number of cases of endometriosis (the diagnosis of which sometimes requires a celioscopy).  Obviously an ultrasound is indispensable for the diagnosis of endometrial polyps, submucal fibroids, ovarian masses and some tubal pathologies.  Unfortunately the one real handicap of  an ultrasound is that it is often used superficially and often as a brief epilogue to a consultation. As is often highlighted, even at the beginning of congresses and courses: with ultrasound you only see what you have looked for carefully.  Most of the failures attributed to this method are in reality failures of the ultrasound operator.

Getting around the obstacle
The tubes can be re-canalised to render them functional again, this however, requires a direct action.  Generally, this means a surgical operation : the obstructed part of the tube is eliminated and the pieces are “glued” back together, the obstructed cavity is reopened.  The percentage of success in this sort of surgery is extremely variable and also increases the risk of extra-uterine pregnancies.  For some years now an interesting alternative exists, selective hysterography. A probe is placed at the entrance of the obstructed tube and a product is injected using progressive pressure. This allows for the “unblocking” of the tube without surgery.

Disclaimer: the information provided on this site is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her existing physician.

venerdì 21 marzo 2008


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