|
Ovary |
Pelvic Cavity
Ovary
Case: 29 year old G0 with a history of regular menstrual intervals every 28-29 x 4 days, a normal hormone evaluation (TSH and Prolactin concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT) and a husband with proven fertility (three pregnancies in a previous relationship) and a normal semen analysis. A pelvic evaluation is performed (in order to identify and treat possible pelvic factor infertility) at which time there were no abnormal findings.
Question: The patient asks whether she may be maturing, but not releasing, eggs at the time of ovulation?
Answer: A condition known as “LUFS” (luteinized unruptured follicle syndrome) has been proposed in which a corpus luteum cyst (“postovulatory” progesterone producing ovarian cyst) forms despite failure to release the egg from the follicular cyst (“preovulatory” estrogen producing cyst containing a maturing egg). It is unclear whether this syndrome really exists and if it does exist whether it has a significant impact on fertility.
The diagnosis of LUFS is generally made with serial (repeated) ultrasound examinations in which the growing ovarian follicle is not seen to collapse and subsequently there is development of a progesterone producing cyst. In reality, during a normal ovulatory cycle even daily ultrasounds can miss the collapse of a follicular cyst (the follicle may collapse and reaccumulate with liquid to form the corpus luteum cyst before another ultrasound is performed).
Treatment alternatives proposed for LUFS include controlled ovarian hyperstimulation with intrauterine insemination or In Vitro Fertilization. These are the same treatment alternatives generally suggested for “unexplained infertility.” Therefore, diagnosing LUFS (if you actually believe in the condition) is rarely important clinically since it does not usually alter the management plan.
Case: 31 year old G0 with a history of regular menstrual intervals every 27-28 x 5 days, a normal hormone evaluation (TSH and Prolactin concentration), an encouraging ovarian reserve (basal FSH and estradiol concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT) and a husband with proven fertility (one pregnancy in a previous relationship) and a normal semen analysis. An ultrasound is performed preoperatively which identifies a complex right ovarian cyst measuring 2.3 x 3.5 cm in diameter with a classic appearance of an endometrioma. A pelvic evaluation is suggested (in order to identify and treat otherwise undetected causes of pelvic factor infertility) at which time several superficial implants of endometriosis and a right ovarian cyst are identified.
Question: What surgery should be performed in this situation?
Answer: I generally try to remove all visible endometriosis and all nonfunctional (persistent) ovarian cysts. Therefore, in this case I would vaporize the implants of endometriosis (generally using ultrapulse char free power settings with a CO2 laser) and I would assess the right ovarian cyst.
If the right ovarian cyst was known to be persistent over the past several months then it should be removed as a persistent nonfunctional cyst. If the cyst has the classic appearance of an endometrioma on ultrasonography but is not known to be persistent then the ovarian cyst could be either (1) a nonfunctional cyst like an endometrioma or (2) a functional cyst like a corpus luteum cyst (that will resolve spontaneously). In this situation, I would most often aspirate some of the contents of the cyst and if “chocolate material” (old blood that has become thick and brown like “chocolate syrup”) returns then I would remove the cyst. If a sebaceous or mucinous material returns then then cyst should be removed as well. If the cyst appeared to be a corpus luteum cyst on direct inspection then I might consider leaving the cyst to resolve spontaneously (with postoperative followup ultrasonography to confirm its disappearance within 1-2 months).
Ovarian endometriosis and particularly endometriomas anecdotally appear to suppress ovarian response to menotropin controlled ovarian hyperstimulation (COH). Therefore, whenever COH is a possible (future) treatment option for a couple either in conjunction with intrauterine insemination or In Vitro Fertilization I suggest removal of all known or suspected endometriomas during pelvic evaluation.
Case: 25 year old G0 with a history of regular menstrual intervals every 28 x 4 days, a normal hormone evaluation (TSH and Prolactin concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT) and a husband with proven fertility (two pregnancies in a previous relationship) and a normal semen analysis. A preoperative ultrasound is performed in preparation for pelvic evaluation that reveals a 5.3 x 5.7 cm left ovarian cyst that has some internal echoes and other complex features. Surgery is delayed to further assess the persistence of this cyst and the cyst is found to remain present during the follicular phase of the cycle (ultrasounds performed between cycle days 2-5) for 3 months. A pelvic evaluation is then performed at which time minimal pelvic endometriosis or pelvic adhesions are identified. The left ovarian cyst is removed and found to be a benign serous cystadenoma.
Question: Can a persistent nonfunctional ovarian cyst impair fertility?
Answer: The available medical literature does not (to my knowledge) have any high quality studies (prospective randomized clinical trials) directly associating the presence of a nonfunctional ovarian cyst such as this one to fertility. On the other hand, it is known that chronic irritation (inflammation) within the pelvis can reduce fertility and any nonfunctional tissue or mass may be able to cause significant local irritation. Additionally, the cyst is relatively large compared to the remainder of the ovary so that the cyst can displace the ovary from its usual location within the pelvis.
I would suggest removing any persistent nonfunctional ovarian cysts in order to confirm the benign nature of the cyst and to reduce the possibility that the cyst is causing a reduction in fertility. Anecdotally, there does seem to be enhanced fertility when these types of cysts are removed.
Case: 31 year old G0 with a history of regular menstrual intervals every 26-27 x 2-3 days, a normal hormone evaluation (TSH and Prolactin concentration), an encouraging ovarian reserve (basal FSH and estradiol concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT) and a husband with unproven fertility yet a normal semen analysis. A pelvic evaluation is performed (in order to identify and treat possible pelvic factor infertility) at which time clear vesicles (blisters) are seen along the surface of the ovary and there are minimal filmy adhesions between the ovaries and the adjacent fallopian tubes.
Question: What surgery should be done in this situation?
Answer: This couple had unexplained infertility prior to the pelvic evaluation and only minimal endometriosis and adhesions are seen at laparoscopy.
In this situation, I would normally use char free (ultrapulse) power settings with a CO2 laser to lyse the filmy adhesions between the ovaries and the tubes since the (anatomic) relationship between these structures is critical to fertility. Therefore, any abnormality (even scanty filmy adhesions) may reduce fertility. I would also vaporize the blisters along the surface of the ovary using char free power settings on a CO2 laser since these blisters (blebs, vesicles) most likely represent early active stage endometriosis.
When removing even minimal findings within the pelvis it remains very important to use microsurgical techniques to reduce the formation of postoperative adhesions. I do not generally use cautery or the harmonic scalpel in these regions since I have found that postoperative adhesions can be extensive (more than theoretically expected and more than are usually found with the CO2 lasers).
Pelvic Cavity
Case: 35 year old G0 with a history of regular menstrual intervals every 27-29 x 4-5 days, a normal hormone evaluation (TSH and Prolactin concentration), an encouraging ovarian reserve (basal FSH and estradiol concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT) and a husband with proven fertility (one pregnancy in a previous relationship) and a normal semen analysis. A pelvic evaluation is suggested in order to identify and treat possible pelvic factor infertility.
Question: What is the chance that endometriosis will be found at the time of pelvic evaluation given an almost complete absence of pelvic pain with menstruation?
Answer: This couple has “unexplained infertility” following a basic noninvasive infertility evaluation designed to detect an ovulation dysfunction, a male factor, and some of the possible pelvic factors (using the HSG and PCT). In this situation, I have generally been able to identify pelvic pathology during pelvic evaluation (laparoscopy and hysteroscopy) that could account for subfertility (or infertility) about 75% of the time (3 out of 4 times). Therefore, at this point I usually suggest the pelvic evaluation.
All stages of endometriosis are associated with subfertility. The mechanism by which endometriosis causes subfertility is currently poorly understood and is under active investigation. I generally suggest surgical treatment of any identified endometriosis (with charfree power settings of a CO2 laser) when laparoscopy is being performed for infertility.
The stage of endometriosis is often independent of the amount of pain that it causes during menses. This may be due to the fact that (1) some women have very few sensory nerve fibers (pain sensors) in the pelvic tissue (peritoneum) affected by endometriosis so that they feel no discomfort despite extensive (severe) endometriosis; while (2) other women have abundant sensory nerve fibers (pain sensors) along the pelvic peritoneum (that is affected by endometriosis) so that they feel incapacitating pain despite minimal endometriosis. Therefore, the personal history of no pain with menses should not mislead one into thinking that endometriosis is not present. This is especially true in the context of otherwise unexplained infertility.
Case: 29 year old G0 with a history of regular menstrual intervals every 28 x 5 days, a normal hormone evaluation (TSH and Prolactin concentration), no pain with menses (dysmenorrhea), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT) and a husband with unproven fertility yet a normal semen analysis. A pelvic evaluation is performed and reveals minimal endometriosis.
Question: What treatment should be considered in this situation?
Answer: All stages of endometriosis are strongly associated with reduced fertility. However, the treatment of the different stages of endometriosis remains controversial.
Severe (stage 4) and moderate (stage 3) endometriosis often causes so much local inflammation that the delicate tissues of the reproductive tract are replaced (over time) with scar tissue (adhesions). In these cases, a mechanical barrier may reduce fertility. This type of disorder is generally treated surgically (ideally with a char free ultrapulse CO2 laser).
Mild (stage 2) and minimal (stage 1) endometriosis also reduces fertility but the mechanism by which they do this often remains unexplained. It may be that the endometriosis lesions produce a substance that is “embryotoxic” (harmful to fertilized eggs). The available medical literature does not strongly suggest improved reproductive potential with surgical management of stage 1 or stage 2 endometriosis. However, there is a recent study that does report improvement in pregnancy rates with CO2 laser treatment of early stage endometriosis.
I generally do vaporize endometriosis whenever I identify it at the time of laparoscopy using the ultrapulse (char free) power settings of the CO2 laser. I feel that removal of these abnormal lesions may improve fertility immediately, reduce progression of disease (which may then cause subfertility in other ways), and help with any dysmenorrhea (painful menses) experienced.
Case: 24 year old G0 with a history of regular menstrual intervals every 26-27 x 2-4 days, a normal hormone evaluation (TSH and Prolactin concentration), “normal” midline pelvic crampy discomfort with menses, a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT), and a husband with proven fertility (two pregnancies in a previous relationship) and a normal semen analysis. A pelvic evaluation is performed (to identify and treat possible pelvic factor infertility) and massive pelvic adhesions and severe endometriosis is identified including a right ovarian “chocolate cyst.”
Question: What surgical treatment should be considered in this situation?
Answer: The extensive amount of pelvic pathology in this case is NOT suggested by the woman’s prior medical (gynecologic) history (eg., unremarkable pain with menses) or her prior radiologic studies (such as the HSG).
However, the finding of extensive pelvic disease is usually not very surprising to an experienced infertility surgeon since finding “more than what is expected” based on history alone at the time of laparoscopy is fairly common. The medical (gynecologic) history and the noninvasive (radiologic) testing that is currently available during an assessment of pelvic factor infertility is often insensitive (unable to detect even significant involvement or abnormalities) and nonspecific (unable to distinguish pelvic factor infertility from other possible abnormalities).
The pelvic evaluation (laparoscopy and hysteroscopy) is a very important diagnostic tool for infertility work since it can allow the infertility surgeon to identify and treat problems that otherwise would remain undiagnosed (and untreated). I generally suggest a pelvic evaluation if the initial testing (detection of ovulation, semen analysis, HSG, and PCT) is entirely normal or if the abnormalities found during the initial testing are adequately treated without success (pregnancy).
When I am faced with extensive pelvic pathology during pelvic evaluation (such as in this case) I generally try to repair as many of the abnormalities as possible while (1) maintaining a low (surgical) risk profile (if the repair involves a greater surgical risk to the patient then I take pictures or tissue samples intraoperatively to document or identify the pathology and discuss further surgical options with the woman after the “low risk” laparoscopic case is concluded) and (2) limiting the abdominal incisions to “minimally invasive” surgery (laparoscopy) unless the woman specifically stated to me preoperatively that she would want me to proceed with an “elective” laparotomy (larger incision) if I found pathology that could not safely be handled laparoscopically.
Pelvic adhesions can be thick or thin (filmy) and they can most often be effectively treated surgically (lysed = cut and also possibly removed from the abdomen). The exact location and the thickness of the adhesions largely determine whether these adhesions can be treated safely. Often surgical adhesiolysis by a (good) fertility surgeon takes several hours since meticulous attention to detail is required to limit postoperative adhesion (re-) formation (which if formed would reduce future fertility).
Pelvic endometriosis may assume many different possible appearances. I generally attempt to vaporize all visible endometriotic lesions with char free power settings (using a CO2 laser) to optimize postoperative recovery and fertility. If nonfunctional ovarian cysts such as an endometrioma are encountered, I generally remove the entire cyst wall while conserving as much normal ovarian tissue as possible.
Case: 27 year old G0 with a history of regular menstrual intervals every 31 x 5 days, a normal hormone evaluation (TSH and Prolactin concentration), progressive dysmenorrhea (pain with menses) over the past 1-2 years, a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT) and a husband with proven fertility (one pregnancy in a previous relationship) and a normal semen analysis. A pelvic evaluation is suggested in order to identify and treat possible endometriosis or pelvic factor infertility. At the time of laparoscopy, many different (abnormal) lesions within the pelvis are identified that are consistent with varying (different) stages of endometriosis.
Question: Can different stages of development of endometriosis coexist within a pelvis?
Answer: Absolutely.
Endometriosis forms when the normal tissue that lines the uterine cavity (endometrium) finds its way outside the body of the uterus and starts to grow in abnormal locations. The most common locations for endometriosis appear to be near the end of the fallopian tubes (within the pelvis) suggesting that at least one potential mechanism of transmission is transmigration through the fallopian tubes during the menstrual flow.
Endometriosis is a progressive disorder that develops (worsens) over time. As more and more transmigration through the tubes (or other enabling process) occurs to allow more and more endometriosis to build up within the pelvis, the extent of the lesions (abnormal growths) and the subsequent symptoms also may increase.
Early endometiotic lesions along the pelvic peritoneum may initially be microscopic (so small that they are invisible to the naked eye and indeed require a microscope to visualize). These “invisible” lesions can cause pelvic pain if they are growing near a sensory nerve ending, which is (most likely) why some women have severe or incapacitating pelvic pain and no visible lesions on laparoscopy. In these circumstances, the peritoneal surface in the region of the woman’s pelvic pain can be “stripped” or vaporized with the intention that when the peritoneum reforms (within a few weeks) it will no longer have the microscopic foci of endometriosis (and the pelvic pain will be relieved).
Early active endometriosis may appear as red “flame” lesions, clear blisters (vesicles or blebs), or a “gel like” growth along the peritoneum (like strawberry jam applied to the region). These early lesions reportedly are composed of endometrial like tissue that responds to circulating estrogen and progesterone. These early active endometriosis lesions may produce more (or different) molecules (substances) than the more advanced lesions.
Older foci of endometriosis may appear as “powder burn” marks or white “burned out” lesions. The powder burn marks are usually small (less than 2 cm diameter) rounded lesions that look like charred tissue that might otherwise have been produced via a burning process. The white lesions vary in size, are often stellate in shape, and look like scar tissue (chronic inflammation of the delicate peritoneum often causes the normal tissue to be replaced by dense fibroconnective tissue, the type of tissue that might otherwise be found in scar tissue).
As endometriosis develops over a several year timeframe, the lesions that are identifiable can vary tremendously even within the same pelvic cavity.
Case: 26 year old G0 with a history of regular menstrual intervals every 26-27 x 2-4 days, a normal hormone evaluation (TSH and Prolactin concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency (yet there is a suggestion of peritubal adhesions), a normal postcoital test (PCT) and a husband with proven fertility (one pregnancy in a previous relationship) and a normal semen analysis. A pelvic evaluation is performed in order to identify and treat possible pelvic factor infertility.
Question: What is the chance that pelvic adhesions will be found at the time of pelvic evaluation given an unremarkable medical and gynecologic history?
Answer: Adhesions are inflammatory bands that connect the surfaces of different tissues. They are not normally present within the pelvis although they are also not uncommon. Any chronic inflammatory process can lead to adhesion formation between adjacent tissues; including infection, endometriosis, exposure to (chemical) irritants that might leak from a nonfunctional ovarian cyst (such as sebaceous material from a dermoid cyst), foreign bodies (such as suture material that may have been placed in the body during a prior surgery), and free blood (possibly from a ruptured hemorrhagic ovarian cyst).
The inflammatory process that leads to adhesion formation often also results in pelvic discomfort. However, pelvic discomfort does not always occur with pelvic inflammation. Therefore, a large amount of pelvic or abdominal adhesions can form in some women despite an absence of any symptoms. In these cases, a laparoscopy may identify otherwise unexpected pelvic adhesions.
Since a significant amount of pelvic adhesions may form over time without any recognized illness or symptoms I generally suggest a pelvic evaluation after the basic noninvasive infertility testing when the cause of the infertility remains unknown.
Case: 43 year old G0 with a history of regular menstrual intervals every 27-30 x 5-6 days, a normal hormone evaluation (TSH and Prolactin concentration), an encouraging ovarian reserve (basal FSH and estradiol concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT) and a husband with proven fertility (one pregnancy in a previous relationship) and a normal semen analysis. A pelvic evaluation is suggested in order to identify and treat possible pelvic factor infertility.
Question: Should a pelvic evaluation be discouraged for women over 40 years of age who are seeking fertility?
Answer: This couple has “unexplained infertility” following a basic infertility evaluation. Of course, there is a well recognized decline in fertility that is related to the woman’s age. When the female partner is 43 years of age I carefully discuss the couple’s reproductive potential in general during the initial office consultation. If the couple has a desire to identify and treat pathology after knowing their ballpark chances of reproductive success (becoming pregnant and carrying to term) then I do not think that it is my place to discourage the couple. In fact, I have helped several couples to successfully become pregnant in which the female partner is between 42-46 years of age.
An obvious treatment alternative that is discussed early on with women over 40 years of age is the use of donor eggs (oocytes retrieved from a younger woman with presumably eggs of greater reproductive potential). The major disadvantages with the use of donor eggs include (1) the genetic makeup of the donated eggs is not the same as the genetic makeup of the woman seeking fertility and (2) the cost of donor egg In Vitro Fertilization tends to be very high (in the USA the cost may be 25,000 to 30,000 dollars per attempt due to payment of the egg donor and all of her medical expenses).
In Vitro Fertilization (IVF) pregnancy rates are generally reduced for women with increasing maternal age, especially over the age of 40. Therefore, I often suggest less aggressive treatment alternatives for women in this age group and specifically ones that allow the woman to use her own fallopian tubes for fertilization of the eggs. When the initial infertility evaluation does not suggest the cause of the fertility problem I generally review the risks, benefits and alternatives of a pelvic evaluation and if desired I proceed with this procedure.
I recently (surgically) treated severe pelvic factor infertility for a 45 year old woman (seeking fertility) and she became pregnant within 4 months of the surgery. This pregnancy has done quite well to date and I anticipate delivery of a normal fetus in the near future. It is cases like this one that allow me to remain cautiously optimistic when dealing with couples in this difficult situation.
Case: 38 year old G0 with a history of regular menstrual intervals every 25-26 x 2-3 days, a normal hormone evaluation (TSH and Prolactin concentration), an encouraging ovarian reserve (basal FSH and estradiol concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency (with a suggestion of peritubal adhesions), a normal postcoital test (PCT) and a husband with unproven fertility yet a normal semen analysis. At pelvic evaluation the cul de sac (normally behind the uterus) is obliterated with massive bowel adhesions to the back wall of the uterus and adhesions from the adnexae (ovaries and fallopian tubes) to the posterior wall of the uterus.
Question: What surgical treatment should be considered given the desire for fertility?
Answer: When I recommend a pelvic evaluation during the course of an infertility evaluation I usually review possible findings at the time of the surgery. Of note, the HSG does not usually identify pelvic adhesions (even extensive adhesions) reliably. If a tremendous amount of pelvic adhesions are identified, then the couple can elect to have me repair the damage to the best of my ability or they can have me leave the damaged tissues virtually untouched and elect to proceed to In Vitro Fertilization.
In this situation, most of my patients have desired that I perform a surgical repair of the pelvis, understanding that the ability to successfully re-establish reproductive function depends largely on the extent of damage that has occurred prior to the surgery. I also suggest maintaining a low risk profile during the initial case such that if a component of the surgical repair would expose the woman to significantly increased surgical risk (which might involve an emergency laparotomy (larger incision), need to repair inadvertent injury to surrounding tissues (such as bowel, bladder or ureter), or excessive bleeding) then I simply collect as much information about the damage as possible (including photographs of the damage) and schedule a surgical repair at a future date if desired by the couple (after understanding that there may be increased exposure to surgical risk). This allows me to attempt a repair while maintaining a very low surgical risk for the patient.
In situations in which there is a “frozen pelvis” (cul de sac behind the uterus), I have often been able to successfully free up the reproductive tissues from their adhesions to surrounding structures. In a rare case, these pelvic adhesions may be so extensive and thick that it is impossible to reliably determine where an adhesion ends and normal tissue begins (the tissues are essentially fused together into a thick walled complex) which is then more dangerous (and sometimes even impossible) to repair. A full surgical repair and reconstruction of extensive adhesions in the pelvis may take several hours to complete.
Case: 25 year old G0 with a history of regular menstrual intervals every 30 x 5 days, a normal hormone evaluation (TSH and Prolactin concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT) and a husband with proven fertility (one pregnancy in a previous relationship) and a normal semen analysis. A pelvic evaluation is suggested (in order to identify and treat possible pelvic factor infertility) and at surgery the right fallopian tube is seen to be pulled slightly out of its usual place by a few filmy adhesions. The bowel in the area of the appendix is adherent to the lateral abdominal side wall and the appendix cannot be seen through these adhesions.
Question: What surgical procedure should be considered in this situation (including a possible appendectomy)?
Answer: The normal anatomical relationship between the fallopian tube and the ovary should be carefully re-established by lysing and removing the adhesions around the fallopian tube. Care needs to be exercised in this region since the distal end of the fallopian tube contains very delicate tissue that can be traumatized easily.
The bowel adhesions in the vicinity of the appendix suggest a prior (unrecognized) appendicitis or some other inflammation in the general vicinity of the appendix. If the health of the appendix cannot be assured through direct visualization, I would generally call for an intraoperative surgical consultation to locate and assess the appendix. In this case, the woman had no gastrointestinal or other abdominal complaints so I would suspect that she might have had appendicitis years before that remained undiagnosed. The desirability of removing the appendix at this time in the absence of symptoms would best be assessed after seeing the appendix directly.
Case: 23 year old G0 with a history of regular menstrual intervals every 27-28 x 4 days, a normal hormone evaluation (TSH and Prolactin concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT) and a husband with unproven fertility yet a normal semen analysis. A pelvic evaluation is suggested but at the preoperative visit (to review the upcoming surgery and sign consent) the woman complains of the recent onset of abdominal pain, fever to 102o F, difficulty walking comfortably, and a malodorous (foul smelling) vaginal discharge. On examination, there is marked tenderness on moving the cervix (severe cervical motion tenderness), tenderness diffusely throughout the pelvis, and a purulent discharge from the cervix. Initial labwork revealed a negative pregnancy test and an elevated white blood cell count (18,000 cells per mL).
Question: Should the pelvic evaluation be performed in this situation?
Answer: This woman’s physical signs and subjective symptoms strongly suggest the diagnosis of pelvic inflammatory disease (PID). PID lacks a precise definition in that it includes inflammatory processes caused by a variety of infections in the upper genital tract. The diagnosis of PID is most often made on the basis of the patient’s history and physical examination. However, the “gold standard” and the most accurate way of diagnosing PID is via laparoscopy.
I generally diagnose PID solely on the basis of the history and physical exam. I have not used laparoscopy for diagnostic purposes when dealing with PID, rather, laparoscopy seems to be more of a research tool when the precision of the diagnosis justifies the additional exposure to risk and expense.
If this woman had gastrointestinal symptoms as well as her gynecologic symptoms, then a surgical consultation (to assess the possibility of appendicitis) would also be considered. If the surgical consultation did not think that immediate surgical abdominal exploration to identify and treat appendicitis was necessary then I would usually suggest broad spectrum aggressive antibiotic treatment for presumed PID.
Once the acute episode of PID was adequately treated and the clinical symptoms were fully resolved I would consider the pelvic evaluation in order to identify and treat pelvic factor infertility.
Case: 37 year old G0 with a history of regular menstrual intervals every 29-30 x 5-7 days, a normal hormone evaluation (TSH and Prolactin concentration), an encouraging ovarian reserve (basal FSH and estradiol concentration), status post (after) laparotomy (larger abdominal incision) with removal of a left ovarian ruptured hemorrhagic cyst by an obstetrician-gynecologist 14 years ago, a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT) and a husband with proven fertility (one pregnancy in a previous relationship) and a normal semen analysis. A pelvic evaluation is suggested (in order to identify and treat possible pelvic factor infertility) at which time extensive pelvic adhesions are identified in the vicinity of the prior ovarian surgery and several surgical metal clips are also seen in this area.
Question: What should be done in this situation?
Answer: When there are adhesions in the vicinity of (or directly involving) the reproductive organs (including the ovaries, tubes, or uterus) I try to lyse and remove all of the scar tissues and reestablish the normal local anatomic relationships.
If there is foreign material (including surgical clips, suture material, prostheses) in the vicinity of adhesions I generally try to remove this foreign material (after evaluating their potential benefits) since the unnatural material could be causing local irritation and excessive adhesion formation. I also try to minimize the use of foreign materials in the vicinity of the reproductive tissues when fertility is an issue.
During adhesiolysis, I also tend to give antibiotics prophylactically so as to reduce the chance of reactivating a dormant (or “sleeping”) infection in the area of surgery
Case: 33 year old G0 with a history of regular menstrual intervals every 26-28 x 3-4 days, a normal hormone evaluation (TSH and Prolactin concentration), an encouraging ovarian reserve (basal FSH and estradiol concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, a normal postcoital test (PCT) and a husband with unproven fertility yet a normal semen analysis. This woman had a history of a motor vehicle accident 12 years ago with severe intraabdominal injuries and bleeding (requiring an emergency splenectomy) with a serious intraabdominal infection (peritonitis) developing following her (trauma) surgery. A pelvic evaluation is suggested (in order to identify and treat possible pelvic factor infertility) at which time extensive pelvic and abdominal adhesions are identified.
Question: What should be done in this situation?
Answer: Any source of pelvic or abdominal irritation, including free blood or an infection in the pelvis and abdomen, can result in adhesion formation and subfertility. In addition, during the course (time period) of the (active or chronic) irritation the function of the reproductive system may be impaired. The exact mechanism of the reduced fertility in the context of chronic irritation is unclear but may involve either reduced fertilization of the egg within the fallopian tube or a reduction in the ability of the fallopian tube to capture (and transport) the egg to the site of fertilization.
At the time of pelvic evaluation all pelvic adhesions would generally be lysed and removed (while maintaining a low exposure to surgical risk), prophylactic antibiotics would be administered, and any bleeding would be meticulously controlled (and any blood cleansed from the pelvis with the irrigation solution).
|
|