The fallopian tube serves as the major conduit between the ovary and the uterus. It provides mechanical transport and physiological support of gametes and cleavage stage embryos. Tubal damage can either exist due to external or internal injury which leads to dysfunctional transport of gametes. Assessment of tubal disease plays a major role in determining a woman’s fertility potential.
This blog post aims to briefly review the different diagnostic tools available to assess tubal patency. The technical aspects of the procedures as well as the risks, advantages, and utility of each are discussed.
The WHO simply defines infertility as “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.” The American Society of Reproductive medicine recommends evaluation after 6 months in women 35 and older. Tubal disease accounts for 25-30% of overall infertility cases. This includes proximal obstruction and distal obstruction as well as narrowing and dilation of the fallopian tube. This ranges from conditions that change tubal function due to changes to the internal structure of the tube as well as external pathology that results in compromise of normal tubal architecture.
Causes of tubal factor infertility include infection, prior abdominal/pelvic surgery, and endometriosis. Tubal disease as a result of infection is typically due to salpingitis from pelvic inflammatory disease. Other infectious/inflammatory processes that may cause tubal damage include tuberculosis and gastrointestinal disease (i.e., appendicitis, Crohn’s disease).
Proximal tubal blockage that is present in 10-25% of women with tubal factor infertility can be caused by obstruction as a result of tubal spasm, tubal debris, or blockage by intrauterine pathology (endometrial polyps, submucosal myomas, and intrauterine adhesions) or by occlusion as a result of fibrosis due to infection or endometriosis.
A diagnostic test should be cost-effective and minimally invasive while maintaining a relatively high sensitivity and specificity. The current “gold standard” in tubal assessment is laparoscopy with chromopertubation with or without concomitant hysteroscopy. However, the hysterosalpingogram (HSG) has become the first-line diagnostic tool for the assessment of tubal patency.
Assessment of tubal patency plays a vital role in determining a woman’s fertility potential. As stated above, tubal disease accounts for 25-30% of all cases of infertility. A diagnostic test should be accurate, cost-effective, and reliable as well as minimally invasive with a low-risk profile. The different imaging and laboratory modalities are currently utilized to assess for tubal factor infertility. While hysterosalpingosonography appears to provide the most comprehensive study with the ability to assess the endometrial cavity, fallopian tubes, as well as the adnexa, it is not currently widely used.
The first-line test should be either sono-HSG or HSG unless otherwise indicated. When these office procedures indicate tubal factor infertility, a laparoscopy should be performed for a definitive diagnosis and possible treatment.