Pelvic Adhesions and Infertility: Causes, Diagnosis, and Treatment Options

In short: Pelvic adhesions are bands of scar tissue between the uterus, ovaries, fallopian tubes, bowel and bladder. They cause 15–20% of cases of infertility by blocking the tubes or stopping them working. The main causes are pelvic infection, abdominal surgery and endometriosis. They are treated by removing the adhesions by laparoscopy, after which the pregnancy rate is between 25% and 75%.

Pelvic adhesions are bands of fibrous scar tissue that can form in the pelvic cavity, connecting the uterus, ovaries, tubes, bowel, and bladder. Adhesions can also develop inside the fallopian tubes and uterus, where they may block or distort the tubes and affect fertility.

The formation—and sometimes re-formation—of these adhesions is a common issue that can cause a range of symptoms in women, including difficulty conceiving.

Pelvic adhesions are thought to be responsible for around 15% to 20% of infertility cases.

Tubal-related infertility accounts for about 30% to 40% of the causes of female infertility.

How Common Are Adhesions After Surgery?

Studies show that pelvic adhesions can develop in 55% to 100% of women after open abdominal surgery (laparotomy). Interestingly, before anesthesia and antiseptic surgical techniques became standard in the late 19th century, adhesions were rarely discussed by doctors — simply because safe, routine abdominal surgery was still new.

As awareness of this problem grew, surgeons began adopting gentler techniques such as microsurgery and laparoscopy, specifically designed to reduce trauma to the delicate pelvic tissues.

Before laparoscopy became widespread, microsurgical methods introduced a new level of care for reproductive organs — a big shift from older, more invasive surgical approaches.

The goal of these refined techniques is simple: reduce the risk of adhesions around the tubes and ovaries through gentle tissue handling, keeping tissue moist, and careful control of bleeding.

Modern laparoscopic (keyhole) surgery follows these same microsurgical principles. The gas used to gently expand the abdomen during the procedure creates space and allows magnified, close-up viewing of delicate structures — similar to using a microscope during laparoscopy.

How Do Adhesions Form? (Simplified)

The lining of the pelvic and abdominal cavity, called the peritoneum, is made of several thin layers. When this lining is injured — which can happen during any surgery — the body triggers a natural healing response. Inflammatory substances are released, blood vessels expand, and white blood cells rush to the area. This creates a sticky fibrin-rich fluid at the injury site.

Normally, the body breaks this fibrin down through a natural clot-dissolving process. But if that process is incomplete, the fibrin can turn into permanent scar tissue, gradually developing its own blood supply and becoming a true adhesion.

This process usually begins and completes within about one to seven days after injury. Over the following months, these early adhesions can become thicker and more vascular.

Types of Adhesions

• Filmy adhesions: very thin and can be easily broken apart with gentle pressure
• Thick adhesions: often vascular and need energy to be removed like electrical or laser energy
• Band adhesions: string like bands between two or more structures
• Flat adhesions: result when two structures are stuck together
• Filmy adhesions: very thin and can be easily broken apart with gentle pressure

Tubal blockage versus adhesions:

It’s important to understand the difference between a tube that is completely blocked and one that is open but restricted by surrounding adhesions. A blocked tube means there is an actual obstruction inside it, which can usually be diagnosed with a hysterosalpingogram (HSG) — a specialized X-ray test. Adhesions, on the other hand, can typically only be confirmed through surgery, since they sit outside the tube itself.

Risk Factors for Developing Pelvic Adhesions

• Intra abdominal infection
• Tissue hypoxia or ischemia.
• May result from excessive tissue handling, suturing, crushing, ligating, cauterizing or peritoneum stripping
• Tissue drying.
• Presence of reactive foreign body. The common foreign bodies that may be introduced into the field during surgery include:
• sutures
• talc powder from surgical gloves,
• Lint from drapes, gowns, masks or laparotomy pads.
• Presence of intraperitoneal blood.
• Dissection of prior adhesions.

Main Causes of Pelvic Adhesions and Tubal Damage

There are 3 main causes of pelvic adhesions and tubal lesions:

Pelvic infections

Surgical traumas

Endometriosis

1. Pelvic infections (PID)

These infections often cause mild or no symptoms, especially when caused by Chlamydia, and many women with tubal damage do not remember ever having an infection. They can spread upward within the reproductive tract or arise from nearby conditions such as appendicitis. Chlamydia is behind roughly half of these cases. It can cause adhesions and lead to blockages (such as hydrosalpinx), affecting the delicate lining of the tubes. Genital tuberculosis, though less common, should also be considered.

2. Surgical traumas

Certain surgeries carry a higher risk of adhesion formation, including ovarian cyst removal, fibroid (myomectomy) surgery, ectopic pregnancy treatment, bowel surgery, and appendectomy — which appears to carry a similar risk to gynecological surgery.

Reconstructive Tubal Surgery: Repairing blocked fallopian tubes is a delicate procedure that often involves removing existing adhesions. Unfortunately, the healing process from surgery itself can sometimes lead to new adhesions forming.

3. Endometriosis

Different studies report varying rates of endometriosis-related adhesions (up to 40% in some cases). Endometriotic nodules commonly appear on the left tube, the ovary, the surrounding peritoneum, and the pelvic side wall.

How Adhesions Can Affect Fertility

• The fallopian tube is a muscular organ that retrieves the egg from the ovary and transfers it toward the sperm. If the mobility of the tube is restricted by adhesions or if infection has stripped the cilia from the tubal lining, the tube cannot perform its function.
• Adhesions can block the passage of the ovum (egg) from the ovaries into the fallopian tubes.
• Adhesions around the fallopian tubes can interfere with sperm transport to the ovum through functional alterations, a reduction of the mobility of the tube.
• The disappearance of ciliation can also interfere with sperm transport to the ovum.
• Dysfunction of ovulation and immune-related factors, as seen in endometriosis

Falloposcopy (Tuboscopy)

Falloposcopy is a specialized micro-endoscopic technique performed through the vagina, allowing doctors to examine the inside of the fallopian tube from end to end. It can also be used to remove debris or gently release thin adhesions inside the tube.

Salpingoscopy

Salpingoscopy allows doctors to visually examine the inner lining of the tube during laparoscopy or open surgery. This detailed evaluation can help guide treatment decisions for tubal infertility by identifying which patients have healthy tubal tissue:

Research suggests that 76% to 80% of cases with adhesions around the tubes and ovaries, and 35% to 42% of cases with hydrosalpinx, may benefit most from reconstructive tubal surgery. In these patients, some studies report intrauterine pregnancy rates of 70% or higher following surgical adhesion removal, and around 60% following tubal opening procedures (Brosens, 1996; Marana et al., 1997).

Ideally, salpingoscopy should be considered during diagnostic laparoscopy, especially for patients with suspected tubal factors, to help decide between surgery and assisted reproduction.

However, limited availability of the specialized equipment (a 2.8 mm rigid salpingoscope) means this technique isn’t used in every clinical setting.

Choosing the Right Candidates for Surgery

Once the diagnosis is clear and a treatment plan has been outlined, it’s important for patients to be fully informed about expected outcomes, possible risks, and realistic timeframes for pregnancy. All treatment options should be discussed so the couple can make an informed decision together:

Surgery versus Assisted Reproductive Techniques

For many decades, surgical removal of adhesions was the only real option for patients with pelvic adhesions and infertility. After the birth of the first IVF baby, assisted reproductive technology (ART) transformed the field.

These techniques include:

-(IVF-ET) In vitro fertilization, embryo transfer

• Gamete intrafallopian transfer (GIFT) and Zygote intrafallopian transfer (ZIFT), which were used in the past but have now been replaced by IVF with transfer of the embryo into the uterus.

-Intracytoplasmic sperm injection (ICSI).

-PESA, MESA, TESA, TESE, etc.

As IVF and related technologies became more widely available, fewer patients with tubal or mechanical infertility undergo reconstructive tubal surgery, with many couples now proceeding directly to IVF and embryo transfer.

The growing success of IVF over the years has reshaped how doctors evaluate and treat infertile couples.

In the early 1980s, when IVF pregnancy rates per cycle were under 10%, surgery played a central role in treating female infertility.

IVF success rates have since improved considerably — by 1990, roughly one in six cycles resulted in pregnancy, and by 1999, close to one in three. As IVF outcomes improved, the role of surgery in treating tubal infertility gradually declined.

Published pregnancy rates after surgical treatment of pelvic adhesions vary widely, from about 25% to 75%. The average pregnancy rate of around 37% reported after surgery for moderate adhesions is broadly comparable to typical IVF clinical pregnancy rates, which range from about 30% to 55% per cycle in published literature.

My own comparative results

Laparoscopic adhesiolysis PR% (two years follow-up):

• Mild : 65%
• Moderate: 35%
• Severe : 22%

ART Pregnancy rate (clinical pregnancy rate per fresh Embryo Transfer):

• Patients aged 35 years and less 65.2%
• Overall PR 50.6%

That said, when comparing cumulative pregnancy rates over six IVF cycles versus six months following surgical adhesiolysis, IVF tends to show a clear advantage overall. Still, it would be a mistake to think surgery no longer has a role — it remains valuable and necessary in several clinical situations.

One good example is laparoscopic removal of thin, avascular adhesions around the ovary or the outer end of an otherwise healthy fallopian tube. Recent studies on this type of surgery (salpingolysis or salpingo-ovariolysis) report success rates as high as 70%. Even in more complex cases involving dense adhesions around the fimbrial end of the tube, cumulative pregnancy rates after laparoscopic fimbrioplasty (around 51.4%) can be higher than what’s typically seen with a single IVF cycle — often at a lower overall cost.

The decision whether to pursue tubal surgery or IVF depends on several factors:

Before choosing between surgery and ART, one must consider the following:

Tubal mucous layer (intra-tubal adhesions and folds): The degree of tubal mucosa damage is the most important prognostic factor in tubal surgery.

Tubal wall: thickness

• The patient’s age.
• Previous reproductive surgery??.
• Condition of the tubes
• Severity of adhesions (type and size) extensive and dense adhesions have a poor prognosis of surgery
• Coexistent infertility factors, for example: poor semen, suspected cervical or immunological causes.
• Experience of the surgeon.
• The success rate of IVF and factors in IVF and ICSI failure.
• The financial constraints.
• And last, but not least, the couple’s wishes.

The Role of Laparoscopic Surgery Alongside IVF

Even when IVF is the recommended path, laparoscopic surgery can still play an important supporting role.

Part of the surgeon’s job is making sure the ovaries are accessible for egg retrieval through the vaginal route, which may require releasing adhesions if the ovaries are hard to reach. Older techniques like tubal or laparoscopic embryo transfer (GIFT, TET, ZIFT) are now largely outdated, replaced by the less invasive transvaginal embryo transfer, which offers comparable outcomes.

Surgeons will typically also recommend removing a tube affected by hydrosalpinx before IVF, since fluid buildup in the tube can lower IVF success rates. Removing the affected tube (salpingectomy) prior to IVF has been shown to improve pregnancy, implantation, and live birth outcomes in these cases.

Adjuvants for adhesion reduction.

Methods that decrease adhesions:

• Inhibiting the coagulation cascade and promoting fibrinolysis.
• decrease inflammatory response
• Using barriers for separation of surfaces at high risk for adhesion formation.

Many of the agents listed below were tried in the past and are no longer used, either because they did not work or because of side effects. Today, only a few barriers — such as oxidized regenerated cellulose, hyaluronic acid gels and icodextrin — are used in selected cases; they may reduce adhesions, but there is no clear evidence yet that they increase pregnancy rates.

1. Fibrinolytic agents (fibrinolysis , plasminogen activators stimulation)

Fibrinolysin, Streptokinase, Urokinase, Hyaluronidase, Chymotrypsin, Trypsin, Pepsin

Plasminogen activators

2. Anticoagulants (prevention of clot and fibrin formation)

Heparin, Citrates, Oxalates

3. Anti-inflammatory Agents (reduce vascular permeability, decrease histamine release and, lysozomes stabilisation)

Corticosteroids, Nonsteroidal anti-inflammatory agents, Anti-histamines, Progesterone Calcium channel blockers, Colchicine

4. Antibiotics (prevent infection)

Tetracycline, Cephalosporin

5. Mechanical Separation (surface separation and hydro flotation)

Intra-abdominal Instillates:

Dextran, Mineral oil, Silicone, Vaseline, Crystalloid solutions, Carboxymethylcellulose

Hyaluronic acid, Chelated hyaluronic acid, Poloxamer, Icodextrin 4%

Barriers:

Endogenous tissues:

Omental grafts, peritoneal grafts, Bladder strips, fetal membranes

Exogenous materials:

Fibrin glue ,Polytetrafluoroethylene ,Oxidized cellulose ,Oxidized regenerated cellulose Gelatin ,Rubber sheets ,Metal foils ,Plastic hoods

A traditional strategy to reduce adhesions is irrigating the pelvis with a crystalloid solution (hydroflotation) during surgery, then leaving some fluid (around 300–500 ml) in the abdomen afterward to help keep organs separated as they heal; however, studies have not shown that this alone reduces adhesions. Common solutions include saline, Ringer’s lactate, and Hartmann’s solution — valued for being simple, widely available, and low-cost.

However, these fluids are absorbed by the body fairly quickly — at a rate of about 30 to 60 ml per hour — meaning that within 10 to 12 hours after surgery, little of the fluid remains in the pelvis.

Since peritoneal healing can take 5 to 7 days, there’s a window of time where fibrin from healing tissue can still stick to nearby structures, forming adhesions. This is why longer-lasting fluid barriers may, in theory, offer better adhesion prevention.

Intergel (a hyaluronic acid solution) was developed for this purpose but was withdrawn from the market in 2003 because of side effects; other hyaluronic acid gels are still used in some centres.

Another option, Icodextrin 4% (Adept), is a clear, non-thick solution that remains in the pelvic cavity for at least about 4 days.

Why Good Surgical Technique Matters

Adhesions are most likely to form when tissue is deprived of oxygen — often due to tight surgical knots or damaged tissue surfaces touching one another.

Interestingly, research shows that stitching the peritoneum closed isn’t always necessary for proper healing after surgery. In fact, leaving it unsutured often leads to fewer adhesions, since sutures themselves can trigger inflammation and a foreign-body reaction.

Gentle handling of the ovaries and generous irrigation to prevent tissue drying are also essential during surgery.

Careful attention to bleeding control matters too, since blood left in the pelvic cavity increases the risk of adhesions forming afterward.

Overuse of electrosurgical tools can also cause significant tissue damage.

Ultimately, no liquid barrier or gel can fully make up for poor surgical technique — skilled, gentle surgery remains the best form of prevention.

If you’re concerned about pelvic adhesions, tubal health, or ongoing fertility challenges, the team at Dr. Najeeb Layyous’s clinic can help guide you through diagnosis and the treatment options best suited to your situation.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist