Pednekar R*, Parulekar SV**.
(* Assistant Professor, ** Professor and Head, Department of Obstetrics and Gynecology, Seth GS Medical College & KEM Hospital, Mumbai, India.)
This paper presents an incidental finding of segmental absence of mid portion of left fallopian tube in a 32 years old multigravida during a lower segment cesarean section with tubal ligation. Around 1 cm stump of left fallopian tube seen at the cornu and a well-defined fimbrial end was seen in the fold of broad ligament laterally. The middle portion of the fallopian tube between these two ends could not be traced and found to be absent. There was no other abnormal finding in the anatomy of uterus, right fallopian tube and ligaments around the uterus. There are very few cases reported in a literature. The possible etiology of the condition is discussed here.
Fallopian tube is a 8 to 14 cm long tubular structure extending from uterine cornu on each side, into the broad ligament, which is then called mesosalpinx. The fallopian tube is divided into an interstitial portion, isthmus, ampulla, and infundibulum or fimbrial extremity. The embryological development of the fallopian tube is from paramesonephric duct or mullerian duct. Unilateral partial or complete absence of fallopian tube is a rare condition. It may be congenital or acquired. One such case is presented here and its pathogenesis is discussed.
A 32 years old woman, married for 13 years, gravida 4, para 3, living 3, previous all full term normal vaginal deliveries, rpesented at 39 weeks of gestation in labor. Her past medical and surgical history was not contributory. Her past menstrual cycles were regular. There was no history suggestive of pelvic inflammatory disease or endometriosis. There had been no episode of acute pelvic pain in the past, which had settled on its own. She had not undergone any pelvic surgery in the past. Her general and systemic examination was normal. Abdominal examination showed a full term uterus with single longitudinal lie in vertex presentation, with uterine activity, and normal fetal heart sounds. On per vaginal examination the cervix was 2 cm dilated and 40% effaced. The station was - 4. She subsequently required an emergency lower segment cesarean section for fetal distress. She also wanted a sterilization operation. It was found that the uterus and the right fallopian tube were normal, while the middle portion of the left fallopian tube was absent. There was a 1 cm long stump of the tube at the cornu and well defined infundibulum and fimbrial end (figure 1). The two parts were connected by a free fold of the mesosalpinx. Pomeroy’s sterilization operation was done on the right fallopian tube, while the lateral end of the left tubal stump was cut and ligated along with fimbriectomy after the cesarean section. The patient made an uneventful recovery.
Figure 1. Intraoperative view of left fallopian tube, showing absent medial portion (yellow line), cornual 1 cm of stump (white arrows), infundibulum and fimbrial end (black arrows).
Structural abnormalities of the fallopian tube like partial or complete absence are very rare.[1,2,3] Other congenital anomalies of the fallopian tube include complete absence, duplication, multiple lumina, accessory ostia , or segmental deletion.[4,5,6,7] Nawroth et al reported only 18 patients with partial atresia of the fallopian tubesinn a comprehensive survey of the literatue in 2006. Segmental atresia could occur unilaterally or bilaterally, but most cases (14/18) reported displayed unilateral; partial tubal atresia. Several cases of partial tubal atresia (4/18) were associated with the uterine anomalies of bicornuate or unicornuate uterus.
This rare condition may be due to congenital malformation or torsion. Congenital absence is frequently associated with developmental alteration of mesonephric and paramesonephric ducts. The mesonephric ducts appear in the embryo at approximately 5 weeks, while the paramesonephric ducts, located do so at 7 weeks, lateral to mesonephric ducts. The paramesonephric duct grows caudally, crosses the mesonephric duct and fuses with the paramesonephric duct of the other side. The upper and the middle segments of paramesonephric duct form the fallopian tube. An absence of a uterine horn, fallopian tube, kidney and ureter on the affected side is seen with combined congenital absence of mesonephric or paramesonephric ducts. Partial defects of a fallopian tube are due to a failure of development of a paramesonephric duct, possibly due to inadequate blood supply.[7,8]
Torsion of the uterine adnexa is not uncommon condition that causes acute pelvic pain. Symptoms may, however be mild or even absent, especially when occurring during pregnancy. Torsion of the fallopian tube with /or without that of the ovary may occur in utero or in childhood. Asymptomatic torsion consequently leads to avascular necrosis and resorption of the tissue (fallopian tube and/or ovary).[7,10] Isolated torsion of the fallopian tube is reported to occur in one in 1.5 million women. It may be due to excessive length or spiral course of fallopian tube, hematosalpinx, neoplasm, or long mesosalpinx, and extrinsic causes like a paraovarian cyst, uterine enlargement by pregnancy or neoplasm, adhesion, pelvic congestion leading to spiraling of the veins of the mesosalpinx, and hypermobility of the fallopian tube. For most of the cases reported to date, the true etiologies of partial absence of the fallopian tube remain unclear. If there are other anomalies of the genital tract or the urinary system, the etiology is likely to be congenital. Absence of other anomalies suggests torsion as the cause. If the uterus and the other fallopian tube are normal, the fertility of the woman is unlikely to be affected. In our patient, there was neither a history of acute pelvic pain or past surgery. But there were no other anomalies too. Thus the cause of partial absence of her fallopian tube cannot be stated with certainty, though it may have been due to asymptomatic torsion of the adnexa.
- Semmens JP. Congenital anomalies of the female genital tract. Functional classification based on review of 56 personal cases and 500 reported cases. Obstet Gynecol, 19 : 328-350, 1962.
- Woolf RB, Allen WM. Concomitant malformations : the frequent simultaneous occurrence of congenital malformations of the reproductive and urinary tracts. Obstet Gynecol, 2 :236-265, 1953.
- Yazawa H, Yabe M, Endo S, Hayashi S. A case of congenital unilateral partial absence of fallopian tube. Fukushima J Med Sci. 2010 Jun;56(1):44-9.
- Nawroth F, Nugent W, Ludwig M. Congenital partial atresia of fallopian tube. Reprod Biomed Online, 12 : 205-208, 2006.
- Beyth Y, Kopolovic J. Accessory tubes, a possible contributing factor in fertility. Fertile Sterile, 38 : 382-383, 1982.
- Daw E. Duplication of uterine tube. Obstet Gynecol, 42 :137-138, 1973.
- Eustace DL. Congenital absence of fallopian tube and ovary. Eur J Obstet Gynecol Reprod Biol, 46 : 157-159, 1992.
- Paternoster DM, Costantini W, Uglietti A, Vasile C, Bocconi L. Congenital or torsion-induced absence of fallopian tubes. Two case reports. Minerva Ginecol. 1998 May;50(5):191-4.
- Dresler S. Antenatal torsion of a normal ovary and fallopian tube. Am J Dis Child, 131 : 236, 1977
- Uckuyu A, Ozcimen EE, Ciftci FCS. Unilateral congenital ovarian absence with twisted tube. J Minim Invasive Gynecol, 16 : 126-127, 2009.
- Hansen OH. Isolated torsion of fallopian tube. Acta Obstet Gynecol Scand, 49 : 3-6, 1970.
- Sankaran S, Shahid A, Odejinmi F. Autoamputation of the fallopian tube after chronic adnexal torsion. J Minim Invasive Gynecol, 16 : 219-221, 2009.
- Antoniou N, Varras M, Akilivis C, Kitsiou E, Stefanki S, Salanalekis E. Isolated torsion of the fallopian tube : a case report and review of the literature. Clin Exp Obstet Gynecol, 31 : 235-238, 2004.