A 33-year-old woman presents to our office with her husband for an infertility evaluation after trying to conceive for 18 months without success. Her husband has not fathered a pregnancy before. She has a history of regular menstrual cycles and she has used ovulation predictor kits, which turn positive around cycle days 14-16. They time intercourse appropriately. She passed tests for thyroid-stimulating hormone (TSH), prolactin, follicle-stimulating hormone (FSH), and semen analysis, which were normal.
Her past gynecologic history is notable for chlamydia infection three years ago and pelvic inflammatory disease (PID) with a gonorrhea infection ten years ago. She and her partner were treated. Her cervical cancer screening tests have been normal and her last one was six months ago. She and her husband are otherwise healthy and deny smoking, alcohol, or drug use. She is taking prenatal vitamins. The patient and her husband’s family histories were unremarkable for any significant medical or genetic disorders.
To complete her infertility evaluation, she had a hysterosalpingogram (HSG) ordered with doxycycline prophylaxis, given her history of PID.
Tubal Factor Infertility
Tubal factor infertility accounts for approximately 25-40 percent of female factor infertility. Over 50 percent of tubal factor infertility is due to salpingitis. Salpingitis typically results from sexually transmitted pelvic infections causing PID. Other causes of tubal factor infertility include peritonitis, inflammatory changes from endometriosis, appendicitis, Crohn’s disease, or ulcerative colitis, and adhesions or damage from other pelvic surgeries including ectopic pregnancy, ovarian cystectomies, abdominal myomectomy, or multiple laparotomies.
Tubal factor infertility may be due to occlusion of the tubes either proximally or distally. The tubes are traditionally evaluated during the initial tubal factor infertility workup with a HSG or saline infusion sonohysterogram with agitated saline or ultrasound contrast. The reliability of these tests is quite good for confirming patency. Proximal tubal obstruction may not be as reliably detected as distal. Repeating an HSG to reevaluate fallopian tubes with suspected proximal occlusion a month later demonstrates tubal patency in about 60 percent of cases. Uterine spasm can make the fallopian tubes appear occluded on HSG. The proximal fallopian tube has a very small diameter at the cornual portion where it traverses through the myometrium. The spasm may not be present on repeat testing. Alternatively, minor debris within the tube may have been partially cleared during the initial HSG. Proximal tubal occlusion can be treated with tubal cannulation with a coaxial system either during fluoroscopy in the radiology suite or intra-operatively with combined laparoscopy and hysteroscopic tubal cannulation. Tubal cannulation has 60-95 percent success in resolving the obstruction with about 50 percent of patients conceiving and one-third re-occluding. Tubal perforation is reported in 3-11 percent of cases but has no clinical consequences. Occasionally, correcting a proximal tubal occlusion will reveal an additional distal tube occlusion, which has a poor prognosis.
Mid- and distal tubal occlusions are not due to spasm since there is minimal muscle surrounding the tube and no myometrial tissue. The diameter of the mid- and distal tube is larger than the proximal tube. Laparoscopy with chromopertubation performed under general anesthesia is considered the gold standard to assess for tubal patency. Distal tubal obstruction occurs with hydrosalpinges. A hydrosalpinx is a dilated, sterile serous fluid-filled fallopian tube. On HSG, a hydrosalpinx appears as a collection of contrast material in an oblong or tubular structure with blunted, rounded ends. Hydrosalpinges may also be detected on 2D ultrasound, saline infusion sonohysterogram, or transvaginal hydrolaparoscopy with chromopertubation.
Hydrosalpinges appear to have negative impact on fertility beyond simply obstructing the tubes, and patients undergoing IVF with untreated hydrosalpinges have a 50 percent reduction in pregnancy rates. The reduced pregnancy rate may be caused by fluid from the hydrosalpinx passing into the uterine cavity, where it may be embryotoxic, may flush the embryo out of the uterine cavity, or may impair uterine receptivity.
Salpingectomy is recommended before IVF and gonadotropin therapy for women with bilateral hydrosalpinges. There appears to be no significant impact on ovarian reserve,
The data are more limited for women with unilateral hydrosalpinx, but salpingectomy is generally performed,
Alternative approaches such as hysteroscopic proximal tubal occlusion and ultrasound-guided hydrosalpinx aspiration appear to have better pregnancy rates than no treatment, but not as good as salpingectomy or ligation prior to assisted reproductive technologies (ART),
In good prognosis cases, tuboplasty can be considered, but it appears to have lower success rates and higher ectopic rates than IVF. Tuboplasty should not be performed in women with significant tubal disease.