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Tubal Dysfunction and Pelvic Lesions

by Robert W. Rebar, MD

Tubal dysfunction is fallopian tube obstruction or epithelial dysfunction that impairs zygote motility; pelvic lesions are structural abnormalities that can impede fertilization or implantation.

Etiology

Tubal dysfunction can result from

  • Pelvic inflammatory disease

  • Use of an intrauterine device (a rare cause of pelvic infection)

  • Ruptured appendix

  • Lower abdominal surgery leading to pelvic adhesions

  • Inflammatory disorders (eg, TB)

  • Ectopic pregnancy

Pelvic lesions that can impede fertility include

  • Intrauterine adhesions (Asherman syndrome)

  • Fibroids obstructing the fallopian tubes or distorting the uterine cavity

  • Certain malformations

  • Pelvic adhesions

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

Diagnosis

  • Hysterosalpingography

  • Sometimes laparoscopy or sonohysterography

All infertility evaluations include assessment of the fallopian tubes. Most often, hysterosalpingography (fluoroscopic imaging of the uterus and fallopian tubes after injection of a radiopaque agent into the uterus) is done 2 to 5 days after cessation of menstrual flow. Hysterosalpingography rarely indicates tubal patency falsely but indicates tubal obstruction falsely in about 15% of cases. This test can also detect some pelvic and intrauterine lesions. For unexplained reasons, fertility in women appears to be enhanced after hysterosalpingography if the test result is normal. Thus, if hysterosalpingography results are normal, additional diagnostic tests of tubal function can be delayed for several cycles in young women.

Tubal lesions can be further evaluated with laparoscopy. Intrauterine and tubal lesions can be detected or further evaluated by sonohysterography (injection of isotonic fluid through the cervix into the uterus during ultrasonography) or hysteroscopy. Diagnosis and treatment are often done simultaneously during laparoscopy or hysteroscopy.

Treatment

  • Laparoscopy or hysteroscopy to restore patency

During laparoscopy, pelvic adhesions can be lysed, or pelvic endometriosis can be fulgurated or ablated by laser. During hysteroscopy, adhesions can be lysed, and submucous fibroids and intrauterine polyps can be removed. Pregnancy rates after such treatments are low, so assisted reproductive techniques are often necessary.

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