OVARY

Objectives
✢ Discuss the following:
○ Location
○ Relations
○ Ligaments
○ Blood Supply
○ Venous Drainage
○ Lymphatic Drainage
○ Innervation
Ovary
✢ almond shaped and –sized female
gonads in which the oocytes develop
✢ 4 x 2 x 3 cm in size in reproductively
mature women
✢ Dull white in color and consist of
dense fibrous tissue in which ova are
embedded
✢ Progressively becomes scarred as
corpora lutea involute and degenerate
Ovary
✢ Tunica albuginea: connective tissue
capsule
✢ Ovarian mesothelium: single layer of
cuboidal cells continuous with
peritoneal mesovarium
✢ Function
○ Production of female germ cells
○ Production of female sex hormones (estrogen
and progesterone)
Ovary: Location
✢ Lie on each side of the uterus
close to the lateral pelvic wall,
in a depression called ovarian
fossa
✢ Suspended in the pelvic cavity
and attached to the upper limit
of the posterior aspect of
broad ligament by the
mesovarium
Ovary: Location
✢ Embryonic and fetal life:
situated in the lumbar region
near the kidneys  descend
along the gubernaculum 
stops at the lesser pelvis
✢ Variable in position but
commonly found hanging
down in the rectouterine
pouch
Ovary: Location
✢ Pregnancy: ovaries are lifter high in the
pelvis
✢ 14 weeks of gestation: become partly
abdominal structures
✢ 3rd trimester: totally abdominal structures
and lie vertically behind and lateral to the
parous uterus
 Ovary: Relations
Lateral Contacts parietal
peritoneum in ovarian
fossa
(R) Ileocaecal junction,
caecum and appendix
Medial Uterus and uterine
vessels in broad
ligament
Rectum
 Ovary: Relations
Posterior Internal iliac vessels
Ureter
Obturator vessels and
nerve
Origin of uterine artery
Anterior Posterior leaf of broad
ligament
 Ovary: Relations
Superior Fimbria
Distal section of uterine
tube
External iliac vessels
(R) Ileocaecal junction,
caecum and appendix
(L) Sigmoid colon passes
over and joins rectum
Inferior Points towards the pelvic
floor
 Ovary: Ligaments
✢ Infundibulopelvic/
Suspensory Ligament
○ Peritoneal fold attached to the upper
part of the lateral surface of the ovary
○ Part of the broad ligament extending
between the attachment of the
mesovarium and the lateral wall of
the pelvis
○ Contains ovarian vessels and nerves
Ovary: Ligaments
✢ Round Ligament of the
Ovary/ Ovarian Ligament
○ Represents the remains of the
upper part of the gubernaculum
○ Connects lateral margin of the
uterus to the inferomedial
extremity of ovary
Ovary: Ligaments
✢ Mesovarium
○ Short double fold of
peritoneum which attaches the
ovary to the back of the broad
ligament
○ Subdivision of the broad
ligament
○ Carries blood vessels and
nerves to the ovarian hilum
 Ovary
Arterial Ovarian artery
Supply -From abdominal aorta at the level of L1
Venous Ovarian Vein
drainage -(R) Drains into inferior vena cava
-(L) Drains into renal vein
Lymph Follow the ovarian artery and drain into Para-
Drainage aortic nodes at the level of L1
Nerve Derived from Aortic Plexus and accompanies
Supply the ovarian artery
 Ovary
✢ Blood supply, lymphatic drainage, and nerve
supply of the ovary pass over the pelvic inlet
✢  cross the external iliac vessels
✢  pass through lateral end of broad
ligament (suspensory ligament)
✢  mesovarium
✢  ovary hilum
Fallopian Tube
Objectives
✢ Discuss the following
○ Communications
○ Parts
○ Ligaments
○ Blood Supply
○ Venous Drainage
○ Lymphatic Drainage
○ Innervation:
✢ Define Tubal Ligation
✢ State the purpose of tubal ligation
 Fallopian Tube
✢ Also called uterine tube,
salphinges or oviducts
✢ About 4 in. (10 cm)
✢ Lie in the upper border of the
broad ligament
✢ Connects peritoneal cavity in
the region of the ovary with the
cavity of the uterus
 Fallopian Tube
✢ Medial opening is located at the
superior angle of the uterine cavity
✢ Ideal: extend symmetrically
posterolaterally to the lateral pelvic
walls, where they arch anterior and
superior to the ovaries
✢ Ultrasound: commonly
asymmetrical with one often lying
superior and even posterior to uterus
Fallopian Tube
✢ Functions:
○ Receives ovum from ovary
○ Site of fertilization (usually in ampulla)
○ Provides nourishment for the fertilized ovum
and transports it to the cavity of the cavity of
the uterus
○ Conduit along which spermatozoa travel to
reach the ovum
Fallopian Tube
Parts:
1. Infundibulum
2. Ampulla
3. Isthmus
4. Intramural part
Fallopian Tube
✢ Infundibulum
○ Funnel-shaped lateral end that
projects beyond the broad
ligament and overlies the
ovary
○ Opens into the peritoneal
cavity through the abdominal
ostium
Fallopian Tube
✢ Infundibulum
○ Fimbriae
○ fingerlike processes draped
over the ovary and found at
the free edge
○ One large ovarian fimbria is
attached to the superior pole
of the ovary
 Fallopian Tube
✢ Ampulla
○ Widest and longest part of the
tube (1 cm max. diameter, 5 cm
long)
○ Begins at the medial end of the
infundibulum
○ Has thin wall and tortuously
folded luminal surface
○ Where fertilization of oocyte
usually occurs
 Fallopian Tube
✢ Isthmus
○ Narrowest and thick walled part of
the tube
○ 1-5 mm wide and 3 cm long
○ Rounded, muscular and firm
○ Lies just lateral to the uterus
○ Enters the uterine horn
 Fallopian Tube
✢ Intramural part
○ Segment that pierces the uterine
wall
○ 0.7 mm wide, 1 cm long
○ Lies within the myometrium
○ Passes through the wall of the
uterus and opens via the uterine
ostium into the uterin cavity at
the uterine horn
Fallopian Tube
✢ Mesosalpinx
○ Narrow mesentery where
the uterine tubes lie in
○ Part of the broad ligament
between the uterine tube
and the mesovarium
 Fallopian Tube
Arterial Lateral 1/3: Ovarian artery  abdominal aorta
Supply Medial 2/3: Uterine Artery  internal iliac artery
Venous Lateral 2/3: via pampiniform plexus to the ovarian
drainage veins  inferior vena cava (R) or renal vein (L)
Medial 2/3: via uterine plexus  internal iliac vein
 Fallopian Tube
Lymph Internal Iliac and Para-aortic nodes
Drainage Gray: it is possible for lymph to reach the inguinal
nodes via round ligament
Nerve Sympathetic and Parasympathetic nerves from the
Supply inferior hypogastric plexuses
 Tubal Ligation
✢ Method of obtaining
permanent birth
control
✢ The fallopian tubes are
tied or ligated to
prevent the sperm
from reaching the
ovum
 Tubal Ligation
✢Open Abdominal Tubal
Ligation
○ Performed through a short
suprapubic incision made at the
pubic hairline
○ Involves interruption, often
removal of a segment of the tube
○ Tubal closure: suture ligation
 Tubal Ligation
✢Laparoscopic Tubal
Ligation
○ Done with a fiber optic
laparoscope inserted through a
small incision, usually near the
umbilicus
○ Tubal continuity is interrupted
by applying cautery, rings or
clips
 Tubal Ligation
✢ Usually restricted to women who already have
children
✢ Ova that are discharged from the ovarian follicles
degenerate in the tube proximal to the obstruction
 Complications
✢ Infertility 2° tubal scarring
○ 10% risk after a single episode of PID
○ 30% risk after 2 episodes
○ 50% risk after 3 or more episodes
 Complications
✢ Chronic pelvic pain
○ Found in up to 18% of women after resolution of PID.
✢ Adhesions
✢ Dyspareunia
 Complications
✢ Ectopic Pregnancy
○ Also 2° to tubal scarring
○ 7-10 fold increased risk after a single episode
 Complications
✢ Ectopic Pregnancy
 Complications
Pyosalpinx is defined as pus in the fallopian tube
Hydrosalpinx is a collection of watery sterile fluid
inside the fallopian tube.
Tubo-ovarian abscess
Serious sequelae of PID causing 350,000 hospitalizations
and 150,000 surgeries/yr.
Occurs in 15-30% of women requiring hospitalization for
PID treament.
Ruptured TOA has a mortality rate as high as 9%.
 Complications
✢ Tubo-ovarian abscess
○ Can be diagnosed by
ultrasound with 94%
sensitivity.
○ Can attempt conservative
management with
antibiotics but often require
drainage or excision via
laparoscopy.
○ 86-93% infertility rate
 Complications
 Fitz-Hugh-Curtis Syndrome
 Extrapelvic manifestation of PID associated with RUQ pain
abdominal pain aggravated by breathing, coughing or
laughing, which may be referred to the right shoulder due to
inflammation of the liver capsule and diaphragm.
 As with PID, it is mainly caused by N. gonorrhea and C.
trachomatis.
 Probably spreads via direct seeding into the peritoneal
cavity, although hematogenous and lymphatic spread can’t
be ruled out.
 Occurs in 15-30% of women with PID worldwide though
this is probably less in developed countries.
 Benign Tubal Neoplasms
 Adenomatoid tumors  Lipoma
 Leiomyoma  Hemangioma
 Teratomas  Lymphangioma
 Fibroma  Mesothelioma
 Fibroadenoma  Mesonephroma
 Papilloma
 Pre-invasive Disease

 Carcinoma in situ (CIS)

 Papillary endosalpingeal lining with cytologically malignant, mitotically
actice nuclei
 Intact basement membrane
 Often incidental finding at segmental salpingectomy
 BSO recommended
– Fertility is not an issue if recent sterilization
 Primary Tubal Malignancies

 Adenocarcinoma
 Sarcoma
 Choriocarcinoma
 Other
– Metastases to tubes are common
 Fallopian Tube Cancer
 One of the rarest malignancies of the female genital tract
– 0.3% of all gyn malignancies
– 3.6 per million women
 Mean age at diagnosis in the 50’s
– ⅔ are menopausal
 Risk factors
– Nulliparity
– Chronic salpingitis
– Infertility
 70% of cases
Fallopian Tube Cancer
 Presentation
 Delay of diagnosis common
– Only 6% were actually asymptomatic
– 23% with (+) cervical cytology, including psammoma bodies
 Triad
1. Vaginal bleeding
 Present in more than 50%
 Postmenopausal bleeding, (-) D&C
2. Hydrops tubae profluens
 Colicky pain
 Profuse serosanguinous vaginal discharge
3. Adnexal mass
 Diagnosis
 Preoperative diagnosis is rare
– 80% have known pelvic or abdominal mass noted before surgery
– 10-25% have cancer on cervical cytology
 Sonography
 Serum CA-125
– London Trial, 20% of cancers detected were fallopian tube cancers
 Pathology
 Almost exclusively adenocarcinoma
– Endometrioid
– Papillary serous
– Clear cell
 10-25% bilaterality
 Peritoneal disease common before ovarian spread
 87% stain for CA-125
 Propensity for lymphatic spread
 Pathology

1. Main tumor should be visualized in tube

2. Tubal mucosa should be involved with a papillary pattern with
histologic characteristics of the endosalpinx.
3. If the tubal wall is involved, transition from benign to malignant
tubal epithelium should be demonstrated
 Stage I
Confined to Fallopian Tubes

 Stage IA: Confined to one tube

 Stage IB: Both tubes
 Stage IC: One or both tubes and:
– Involvement of tubal serosa
– Malignant ascites
– (+) washings from the abdomen/pelvis
 Stage II
Confined to Pelvis

 Stage IIA: Involvement of uterus or ovaries, or both.

 Stage IIB: Other pelvic tissue
– bladder, sigmoid colon, or the rectum.
 Stage IIC: IIA or IIB with (+) washings, malignant ascites
 Stage III
Extrapelvic Disease
 Stage IIIA: Microscopic disease of upper abdomen
 Stage IIIB: Upper abdominal involvement, but less than 2 cm in
size
 Stage IIIC:
– Lymph node involvement, inguinal included.
– Upper abdominal disease ≥ 2 cm
 Stage IV
Distant Spread

 Stage IV: Distant metastasis

– Liver parenchyma
– Lung parenchyma
– Malignant pleural fluid
– Other distant organs located outside of the peritoneal cavity