(See also Overview of Infertility Overview of Infertility Infertility is a disease defined by the inability to achieve a pregnancy and/or the need for medical intervention to achieve a successful pregnancy. In patients who have not achieved a pregnancy... read more .)
Etiology of Tubal Dysfunction and Pelvic Abnormalities
Tubal dysfunction can result from
Ruptured appendix
Lower abdominal surgery leading to pelvic adhesions
Inflammatory disorders (eg, inflammatory bowel disease Overview of Inflammatory Bowel Disease Inflammatory bowel disease (IBD), which includes Crohn disease and ulcerative colitis, is a relapsing and remitting condition characterized by chronic inflammation at various sites in the gastrointestinal... read more , tuberculosis Tuberculosis (TB) Tuberculosis is a chronic, progressive mycobacterial infection, often with an asymptomatic latent period following initial infection. Tuberculosis most commonly affects the lungs. Symptoms include... read more )
Pelvic structural abnormalities that can impede fertility include
Intrauterine adhesions (Asherman syndrome)
Fibroids Uterine Fibroids Uterine fibroids (leiomyomas) are benign smooth muscle tumors of the uterus. Fibroids frequently cause abnormal uterine bleeding and pelvic pressure and sometimes urinary or intestinal symptoms... read more obstructing the fallopian tubes or distorting the uterine cavity
Certain malformations (eg, bicornuate uterus)
Endometriosis Endometriosis In endometriosis, functioning endometrial cells are implanted in the pelvis outside the uterine cavity. Symptoms depend on location of the implants. The classic triad of symptoms is dysmenorrhea... read more 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 Abnormal Cervical Mucus Rarely, abnormal cervical mucus impairs fertility by inhibiting penetration or increasing destruction of sperm. (See also Overview of Infertility.) Normally, cervical mucus is stimulated to... read more .
Diagnosis of Tubal Dysfunction and Pelvic Abnormalities
Tests for cervical gonorrhea or chlamydia, if cervicitis Cervicitis Cervicitis is infectious or noninfectious inflammation of the cervix. Findings may include cervical or vaginal discharge and cervical erythema and friability. Diagnosis is with tests for cervical... read more or pelvic inflammatory disease Pelvic Inflammatory Disease (PID) Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be caused by sexually... read more 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 Diagnosis Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent... read more or chlamydia Diagnosis Sexually transmitted urethritis, cervicitis, proctitis, and pharyngitis (that are not due to gonorrhea) are caused predominantly by chlamydiae and less frequently by mycoplasmas. Chlamydiae... read more . Also, screening for sexually transmitted infections Overview of Sexually Transmitted Infections Sexually transmitted infection (STI) refers to infection with a pathogen that is transmitted through blood, semen, vaginal fluids, or other body fluids during oral, anal, or genital sex with... read more 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.
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.
Treatment of Tubal Dysfunction and Pelvic Abnormalities
Antibiotics if cervicitis or pelvic inflammatory disease (PID) is present
Laparoscopy and/or hysteroscopy
Assisted reproductive technologies
Sometimes tubal surgery, in younger women
Cervicitis Cervicitis Cervicitis is infectious or noninfectious inflammation of the cervix. Findings may include cervical or vaginal discharge and cervical erythema and friability. Diagnosis is with tests for cervical... read more or PID Pelvic Inflammatory Disease (PID) Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be caused by sexually... read more , 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 In vitro fertilization (IVF) Assisted reproductive technologies (ARTs) involve manipulation of sperm and ova or embryos in vitro with the goal of producing a pregnancy. For assisted reproductive technologies, oocytes and... read more is often recommended instead.
Assisted reproductive technologies Assisted Reproductive Technologies Assisted reproductive technologies (ARTs) involve manipulation of sperm and ova or embryos in vitro with the goal of producing a pregnancy. For assisted reproductive technologies, oocytes and... read more are often either a necessity or an alternative particularly in women < 30 years.