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Overview - Evaluation - Treatment Options - Diagnosis

Methods of Evaluating Tubal Problems

Chlamydia Antibody Titer
The tuboperitoneal algorithm is depicted in the chart. Virtually every patient experiencing difficulty conceiving should have what is known as a chlamydia antibody titer. This is a blood test that can detect whether or not a woman has ever been exposed to chlamydia. Since this infection can occur without any symptoms whatsoever, this blood test may provide the only evidence, short of surgical evaluation, that there has been an infection. The blood test provides no information about when the infection occurred; it simply tells us that there has been an infection at some point. Chlamydia may also infect areas other than the fallopian tubes, so a positive result does not necessarily mean that there has been a tubal infection. It is, however, suggestive enough that evaluation by laparoscopy is warranted.

If the chlamydia titer is negative (i.e., there is no evidence of prior infection), if there is no history of prior surgery, and if no abnormalities are noted on the initial exam and ultrasound, the next step should be a hysterosalpingogram, not a laparoscopy.

Hysterosalpingogram
A hysterosalpingogram (HSG) is an X-ray procedure in which an iodine-based dye is injected through the cervix, into the uterus, and out through the fallopian tubes. This procedure is performed soon after a period ends but before ovulation occurs, usually between days seven and ten of the menstrual cycle. It is appropriate to give a two- or three-day course of antibiotics for this procedure since dye is being injected through the cervix and into the fallopian tubes. This reduces the risk of infection as a consequence of doing this procedure to less than one percent.

In the X-ray department, a speculum is placed in the vagina and a small instrument is attached to the cervix. Under fluoroscopy, which allows the physician to observe the procedure as it is being performed, dye is slowly injected and is observed as it first fills the uterine cavity, then proceeds into the fallopian tubes, and finally out the ends of the fallopian tubes into the abdominal cavity. X-rays are taken at key points during the procedure, and the entire procedure usually takes less than ten minutes. There may be some mild cramping after this procedure, but patients can usually return to work that same day without difficulty.

Usefulness of HSGs
HSGs are an excellent means of evaluating the uterine cavity to be sure that there is no scarring in the cavity, no polyps or other masses such as fibroids, which can distort the uterine cavity, and no uterine anomaly or abnormal shape. HSGs are also excellent for evaluating the internal appearance of the fallopian tube including the proximal segment, or isthmus, and for demonstrating that the tubes are open. In addition, there are a couple of important points to know about HSGs:

This does not have to be a terribly painful experience. Much of the pain often reported with HSGs occurs as a result of using instruments, such as balloons, that are placed into the uterine cavity. This can cause extreme cramping and discomfort. This procedure can be done every bit as well, if not better, by using instruments that are inserted only a short way into the cervix. This eliminates and avoids most of the discomfort. Mild to moderate menstrual cramping is the most that is usually experienced. Taking ibuprofen or some other mild pain reliever prior to the procedure will reduce the discomfort even further.
There is very good evidence that HSGs can be therapeutic as well as diagnostic. Conception rates improve for several months after an HSG (partly due, perhaps, to a simple flushing effect on the tubes, but also due to other effects of the X-ray contrast material). However, this improvement of pregnancy rates after an HSG has been demonstrated only if the procedure is performed using oil-soluble contrast material. I prefer to do the diagnostic part of the procedure using water-soluble contrast material, and then, having been assured that everything looks normal, inject the oil-soluble contrast material to obtain the therapeutic benefit.

(Note: HSGs are not the best procedure for evaluating the presence of scarring around the fallopian tubes or ovaries. While the physician may get some idea by observing the pattern of the spill of the dye from the tubes into the abdominal cavity [and this is one reason that the physician should observe the procedure under fluoroscopy while it is being done], the reliability of the HSG for evaluating for adhesions around the tube is not great. However, in the absence of prior infection or prior surgery and with no evidence of endometriosis, the chances of adhesions around the tubes should be very small indeed and the HSG is a very reliable and worthwhile procedure.)

If the HSG is normal, evaluation and treatment should continue with the assumption that the tuboperitoneal factor is normal.

Proximal Tubal Disease
If the HSG is abnormal, further evaluation is warranted. If the uterine cavity is abnormal, a hysteroscopy should be performed to further evaluate the abnormality and treat it. (Hysteroscopy is fully discussed in Chapter 10.) If the tubes are abnormal, unless the abnormality is proximal tubal disease, a laparoscopy should be considered to further evaluate and treat the abnormality. However, if severe tubal disease is present on the HSG, laparoscopy may not be warranted to surgically correct the tubes. IVF (in vitro fertilization) will offer much better pregnancy rates than will surgical correction. There is actually evidence to suggest that severely damaged tubes should be removed rather than corrected, in that IVF success rates appear to be higher if the tubes are removed (see Laparoscopy below). There are several possible causes of proximal tubal disease or abnormalities of the portion of the tube immediately adjacent to the uterus: Salpingitis isthmica nodosa (SIN)

This is a destructive change related to an inflammatory process. This is best treated by proceeding to IVF. The other alternative is a major operative procedure in which the diseased portion of tube is removed and the remaining healthy tube is reconnected. This procedure carries a fifty percent chance of success at best, and IVF is probably a better alternative.

Proximal tubal occlusion
HSGs will at times reveal proximal tubal occlusion because of mucus plugs, related to endometriosis, or for reasons that are unclear. Selective tubal cannulization (placing a small plastic catheter directly into the affected tube) can be performed at the time of the HSG. This will often result in clearing of this type of obstruction.

Tubal spasm
On rare occasions, the tubes will go into spasm (like a muscle cramp) and will not allow the passage of dye. Using instruments that cause a minimum of uterine irritation will minimize the chances of this.

Laparoscopy
If the history is suggestive (i.e., prior surgical procedures), if the chlamydia titer is positive (suggestive of prior infection), if the initial exam and ultrasound suggest significant endometriosis, or if the HSG is abnormal, laparoscopy should be the next step.

Laparoscopy is a minor surgical procedure that is performed under general anesthesia on an outpatient basis. A small instrument resembling a telescope and measuring less than half an inch in diameter is inserted just under the belly button. A small amount of gas is then introduced into the abdominal cavity, allowing complete visualization of the pelvic and abdominal organs. Often this procedure is videotaped to allow the patient to view the findings and procedure at a later date. Recovery in the hospital usually takes an hour or two. After a few days (at most) at home, recovery is usually complete and normal activity may be resumed.

Uses of Laparoscopy
Laparoscopy is a time-honored means of evaluating the ovaries, tubes and surrounding structures to see if they are normal, and laparoscopy certainly still has its place. It is one of the most valuable tools available to the physician evaluating and treating the subfertile female. But there are extremely rare circumstances under which it should be done simply for diagnostic purposes in evaluating infertility. If a laparoscopy is done, it can be done as a potentially therapeutic procedure by which the physician can treat and correct virtually any pathology or abnormality found.

One to three, or even four, additional small (5mm) incisions can be made in inconspicuous areas to allow the physician to introduce additional instruments for the purpose of operating and correcting abnormalities. The following surgical procedures can be done by laparoscopy: removal of adhesions, repair of the fallopian tubes, removal of ovarian cysts, treatment of endometriosis (laser, cautery, etc.), removal of ectopic pregnancies, removal of ovaries and/or tubes, appendectomy and hysterectomy.

The key point about laparoscopy is thisCin the hands of an experienced laparoscopic surgeon, virtually any procedure that can be performed by a major surgical procedure (one performed through a major abdominal incision, and requiring a hospital stay and six to eight weeks of recovery) can be accomplished via laparoscopy. And there are significant advantages to a laparoscopic approach: Recovery is quicker and easier, and the results are as good if not better than those obtained by major surgery.

There's also this consideration. Let=s suppose we do a laparoscopy and see that there are adhesions and distal tubal occlusion (the end of the tube by the ovary is blocked), perhaps as a result of a chlamydia infection. There are two options. We can go ahead and remove the adhesions and open the tubes at the time of the laparoscopy or we can see the problem, quit, and come back and do a major surgical procedure to remove the adhesions and open the tubes. In terms of chances of success, the two approaches are essentially equal in the hands of a skilled laparoscopic surgeon. In terms of patient suffering, inconvenience and disability, there is no comparison. In terms of financial liability, there is no question which approach makes better sense. Be sure that you find out what the surgeon performing your laparoscopy intends to accomplish at the time of your laparoscopy.