Abnormalities with the uterine cavity can result in infertility, as well as recurrent miscarriages. These include most commonly, uterine polyps, adhesions or submucous fibroids (protruding into uterine cavity). There can also be congenital anatomical conditions, such as a uterine septum or a bicornuate (double) uterus or a unicornuate uterus.
The Fallopian tubes may be damaged by infections or other pelvic conditions. A prior history of pelvic inflammatory disease (PID), tubal surgery, ectopic pregnancy, ruptured appendix, ovarian surgery or septic abortion strongly suggests the possibility of tubal disease. Pelvic inflammatory disease is a major cause of tubal factor infertility and ectopic pregnancies. The number and severity of pelvic infections increase the risk of tubal damage. The risk of ectopic pregnancy is also greatly increased after pelvic infections. However, some women who are found to have pelvic adhesions and/or tubal disease have no known prior history of pelvic infection. Chlamydia is often the cause of these “silent" asymptomatic infections.
Tubal factor infertility is due to any anatomic abnormality that prevents the union of sperm and egg. Proximal tubal occlusion prevents sperm from reaching the distal portion of the fallopian tube where fertilization normally occurs. Distal tubal adhesions or occlusion prevent egg pickup from the adjacent ovary. Distal tubal disease can range from mild (fimbrial adhesions) to severe (complete occlusion). If blockage occurs only at the distal end, then the secretions of the fallopian tube will not be able to drain out of the end of the tube. The resulting accumulation of fluid in the tube (hydrosalpinx) has a very negative effect on fertility, even when couples utilize in vitro fertilization (IVF) for treatment.
The diagnostic evaluation of tubal patency in infertile women can be accomplished by performing a hysterosalpingogram (HSG), or a saline infusion sonohystogram (SIS) or a laparoscopy. Evaluation of the uterine cavity can be performed with SIS or HSG or hysteroscopy (HSC). Each procedure has advantages and disadvantages.
Hysterosalpingography utilizes iodinated contrast media and x-ray fluoroscopy in order to image the uterine cavity and assess the internal architecture of the fallopian tubes. An HSG can be performed in just a few minutes, is much less costly than laparoscopy, but may be quite uncomfortable for many women. Premedication for pain often helps considerably. Cervical cultures for GC and Chlamydia should be performed prior to an HSG. Infectious complications resulting from an HSG are uncommon, but prophylactic antibiotic treatment utilizing doxycycline 100 mg twice daily for 3 to 5 days is a good idea especially when tubal disease is suspected. Injection of the contrast media may cause tubal spasm in the cornual region that may be misinterpreted as proximal tubal occlusion. In fact when an HSG reveals proximal obstruction, there is a good chance (greater than 50%) that the tube is in fact open based on laparoscopic follow-up.
Abnormal HSG (hydrosapinx R & L tubes)
SIS is similar to an HSG, but uses ultrasound (US) instead of an x-ray and sterile saline, instead of a radio opaque dye. It is simple to perform in the office and is associated with only mild cramping. Mixing a small amount of air with the saline greatly improves the visualization of the fallopian tubes. As with an HSG, prophylactic antibiotics are recommended by Dr Jacobs.
When evaluating the uterine cavity, a saline sonogram is even more sensitive than an HSG for detection of intrauterine pathology, such as polyps, adhesions or submucous fibroids. A 3-D US may be helpful for better visualization of the uterine cavity.
SIS: (Uterine Adhesions)
Diagnostic hysteroscopy is an out-patient surgical procedure usually done in an office, outpatient surgical center or hospital. Using a small telescopic instrument (hysteroscope) inserted vaginally through the cervix, the inside of the uterine cavity can be directly visualized after expanding the cavity with fluid or CO2.
As previously noted, a saline sonogram is more sensitive than a hysterosalpingogram for detection of intrauterine pathology, such as polyps, submucous fibroids or adhesions. Diagnostic hysteroscopy can occasionally detect pathology not identified by either a saline sonogram or a hysterosalpingogram.
If any uterine abnormalities are identified by any of the above procedures, they can be surgically corrected with operative hysteroscopy which involves placing certain instruments through ports in the hysteroscope that allow Dr Jacobs to cut, cauterize, or remove pathology such as polyps, submucous fibroids, adhesions or a septum.
HYSTEROSCOPY: NORMAL CAVITY
HYSTEROSCOPY: POLYP REMOVAL
HYSTEROSCOPY: SUBMUCOUS FIBROID
Laparoscopy is occasionally a tool in the diagnostic evaluation and treatment of female infertility. Laparoscopy is a surgical procedure under anesthesia that involves insertion of a narrow telescope-like instrument through a small incision in the navel. It is a method of visualizing the outside of the uterus, fallopian tubes (patency) and the ovaries to see if they are normal. Prior to 1995, laparoscopy was part of the standard infertility evaluation for all women. Today, it is rarely utilized as a diagnostic tool for infertility since it is an invasive surgical procedure and it has not been found to be cost-effective.
Why or when is it still done? Laparoscopy may help occasionally when an HSG shows possible tubal blockage which may be from tubal spasm.
Even so, today laparoscopy is rarely used as a diagnostic tool. Most women clearly do not need laparoscopy as part of their diagnostic evaluation. Laparoscopic treatment may still be performed when the doctor suspects that pelvic pathology may be present.