(See also Overview of Infertility Overview of Infertility Infertility is usually defined as inability of a couple to conceive after 1 year of unprotected intercourse. Infertility is defined as a disease by the World Health Organization (WHO). Frequent... read more .)
Etiology of Tubal Dysfunction and Pelvic Lesions
Tubal dysfunction can result from
Use of an intrauterine device Intrauterine Device (IUDs; IUD) In the US, 12% of women who use contraception use intrauterine devices (IUDs); IUDs are popular because of their advantages as a contraceptive method: IUDs are highly effective. IUDs have minimal... read more (a rare cause of pelvic infection)
Lower abdominal surgery leading to pelvic adhesions
Inflammatory disorders (eg, inflammatory bowel disease, tuberculosis)
Pelvic lesions that can impede fertility include
Intrauterine adhesions (Asherman syndrome)
Fibroids Uterine Fibroids Uterine fibroids are benign uterine tumors of smooth muscle origin. Fibroids frequently cause abnormal uterine bleeding, pelvic pain and pressure, urinary and intestinal symptoms, and pregnancy... read more obstructing the fallopian tubes or distorting the uterine cavity
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.
Diagnosis of Tubal Dysfunction and Pelvic Lesions
Hysterosalpingography 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.
Sonohysterography (injection of isotonic fluid through the cervix into the uterus during ultrasonography) is done to detect or further evaluate intrauterine and tubal lesions.
Rarely, laparoscopy is done to further evaluate tubal lesions.
Hysteroscopy may be done to further evaluate intrauterine lesions
Diagnosis and treatment are often done simultaneously during laparoscopy or hysteroscopy.
Treatment of Tubal Dysfunction and Pelvic Lesions
Laparoscopy and/or hysteroscopy
Assisted reproductive techniques
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 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. ARTs may result in multifetal pregnancy, but risk is... read more are often necessary for women with pelvic abnormalities and are generally preferable.