(See also Overview of Infertility Overview of Infertility Infertility is usually defined as the inability to conceive after 1 year of regular, unprotected sexual intercourse. Infertility is defined as a disease by the World Health Organization (WHO)... read more .)
Etiology of Tubal Dysfunction and Pelvic Abnormalities
Tubal dysfunction can result from
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 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 or PID are suspected
Hysterosalpingography or sonohysterography
Hysteroscopy to further evaluate abnormalities
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.
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 abnormalities. 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.
Sonohysterography (injection of isotonic fluid through the cervix into the uterus during ultrasonography) is done to detect or further evaluate intrauterine and tubal abnormalities; it has replaced hysterosalpingography in many specialized infertility centers.
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 PID is present
Laparoscopy and/or hysteroscopy
Assisted reproductive techniques
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, or 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 about 60 to 70%.
Assisted reproductive techniques Assisted Reproductive Techniques Assisted reproductive techniques (ARTs) involve manipulation of sperm and ova or embryos in vitro with the goal of producing a pregnancy. For assisted reproductive techniques, oocytes and sperm... read more are often either a necessity or an alternative particularly in women < 30 years.