Tubal Dysfunction and Pelvic Abnormalities

Tubal dysfunction can result from

• Pelvic inflammatory disease (PID)

• Ectopic pregnancy

• Ruptured appendix

• Lower abdominal surgery leading to pelvic adhesions

• Inflammatory disorders (eg, inflammatory bowel disease, tuberculosis)

Pelvic structural abnormalities that can impede fertility include

• Intrauterine adhesions (Asherman syndrome)

• Fibroids obstructing the fallopian tubes or distorting the uterine cavity

• Intrauterine polyps

• Certain malformations (eg, bicornuate uterus)

Endometriosis can cause tubal, uterine, or other lesions that impair fertility.

Also, cervical factors, including cervicitis or injury (eg, conization procedures for cervical intraepithelial neoplasia, obstetric cervical laceration), may contribute to infertility by impairing the production of cervical mucus.

• Tests for cervical gonorrhea or chlamydia, if cervicitis or pelvic inflammatory disease are suspected

• Saline infusion sonohysterography (SIS) or hysterosalpingography (HSG), if SIS is not available

• Hysteroscopy to further evaluate abnormalities

• Rarely laparoscopy

If pelvic infection is suspected, tests should be done for gonorrhea or chlamydia. Also, screening for sexually transmitted infections is typically done as part of routine preconception care.

All infertility evaluations include assessment of the fallopian tubes.

For initial evaluation of tubal dysfunction and assessment of the uterine cavity, SIS (injection of isotonic fluid through the cervix into the uterus during ultrasonography), where available, has now replaced HSG (fluoroscopic imaging of the uterus and fallopian tubes after injection of a radiopaque agent into the uterus). Advantages of SIS compared with HSG include: can be performed in the clinician's office; does not involve exposure to radiation; and is less costly. The false-positive rate with SIS may be slightly lower than the 15% observed with HSG, and both rarely indicate tubal patency falsely. Both tests can also detect some pelvic and intrauterine abnormalities (magnetic resonance imaging may be required or a definitive diagnosis).

Both SIS and HSG are done 2 to 5 days after cessation of menstrual flow. For unexplained reasons, fertility in women appears to be enhanced after HSG or SIS, if the test result is normal. Thus, if results are normal, additional diagnostic tests of tubal function can be delayed for several cycles in young women.

Fallopian Tube Obstruction

Image

ZEPHYR/SCIENCE PHOTO LIBRARY

Hysteroscopy may be done to further evaluate intrauterine lesions.

Rarely, laparoscopy is done to further evaluate tubal lesions.

Diagnosis and treatment are often done simultaneously during laparoscopy or hysteroscopy.

• Antibiotics if cervicitis or pelvic inflammatory disease (PID) is present

• Laparoscopy and/or hysteroscopy

• Assisted reproductive technologies

• Sometimes tubal surgery, in younger women

Cervicitis or PID, if present, is treated with antibiotics. Treatment of existing infection is important in general and may improve cervical mucus. Antimicrobial therapy does not treat pelvic adhesions caused by current or past pelvic infection.

During laparoscopy, pelvic adhesions can be lysed, and pelvic endometriosis can be fulgurated or ablated by laser. During hysteroscopy, intrauterine adhesions can be lysed, and submucous fibroids and intrauterine polyps can be removed. Pregnancy rates after laparoscopic treatment of pelvic abnormalities are low (typically no more than 25%), but hysteroscopic treatment of intrauterine abnormalities is often successful, with a pregnancy rate of approximately 60 to 70%.

Surgery can be done to repair a fallopian tube with distal tubal damage (eg, due to ectopic pregnancy or infection) or to reverse a prior tubal sterilization procedure (tubal reanastomosis surgery), especially in younger women and if the damage is not severe. However, these surgeries have low success rates. The chances of an ectopic pregnancy are higher than usual both before and after such surgery. Consequently, in vitro fertilization is often recommended instead.

Assisted reproductive technologies are often either a necessity or an alternative particularly in women < 30 years.