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Proximal Fallopian Tube
Case: 24 year old G0 with a history of regular menstrual intervals every 26-27 x 3-4 days, a normal hormone evaluation (TSH and Prolactin concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral proximal tubal occlusion (there was a great deal of crampy pain during the HSG examination), a normal postcoital test (PCT) and a husband with proven fertility (one pregnancy in a previous relationship) and a normal semen analysis.
Question: What further testing or treatments should be considered in this situation?
Answer: The causes of proximal tubal occlusion often remain unknown.
During the HSG examination the uterine wall may undergo spasm (tetanic uterine contraction), which may result in severe midline crampy pelvic pain and occlusion of the tubal ostia (openings of the fallopian tubes into the uterine cavity). If the proximal tubal occlusion seen on HSG is subsequently not seen at the time of pelvic evaluation or a repeat HSG (prior to proximal tubal catheterization) then the diagnosis of spasm is suggested.
Many infertility experts believe that (persistent) proximal tubal occlusion usually results from the damage that is caused by a (previous) local infection. Others believe that mucus or other proteinaceous (protein rich) substances find the way into the small tubal ostia (openings into the uterine cavity) and plug the tubes. Endometrial polyps or submucosal fibroids may also grow in front of the tubal ostia (openings) and eventually occlude the tubes.
In this (presented) case, the couple has undergone a basic infertility evaluation and the only abnormal finding is proximal tubal occlusion. The options could reasonably include an attempt at proximal tubal catheterization (a radiologic procedure similar to the HSG during which a catheter is fed through the uterine cavity to the occluded tubal ostium and dye is pushed selectively into the tube in an attempt to dislodge a plug or open the tube) or pelvic evaluation (at which time the fallopian tube can be further assessed under direct visualization).
Case: 38 year old G0 with a history of regular menstrual intervals every 30 x 5 days, a normal hormone evaluation (TSH and Prolactin concentration), an encouraging assessment of ovarian reserve (basal FSH and estradiol concentrations), a hysterosalpingogram (HSG) revealing a normal uterine cavity and unilateral proximal tubal occlusion (there was a fair amount of crampy pain during the HSG examination), an abnormal postcoital test (PCT) with only 0-1 motile sperm per high power field 6 hours after intercourse a day prior to ovulation, and a husband with unproven fertility yet a normal semen analysis.
Question: What further testing or treatments should be considered in this situation?
Answer: The causes of unilateral proximal tubal occlusion on HSG exam include (1) a difference in the luminal diameters of the fallopian tubes (if the opening to one of the tubes is even slightly larger than the opening that is present on the other side the liquid dye will preferentially travel the “path of least resistance” = the larger diameter tubal opening), (2) uterine muscle spasm (tetanic contraction of the uterine muscular wall may preferentially occlude one of the fallopian tubes such that the dye travels through only the other tube), and (3) local anatomic abnormalities (endometrial polyps or fibroids may be present in the vicinity of, and occlude only one of, the fallopian tubal ostia).
In this situation, the couple would generally consider a few cycles of timed (natural or spontaneous cycle) intrauterine insemination (IUI) as a (nonaggressive and often effective) treatment for a sperm mucus abnormality (abnormal postcoital test). The reproductive importance of the unilaterial proximal tubal occlusion on HSG in this context is controversial. There are some reports of relatively favorable pregnancy rates in the presence of “untreated” unilateral proximal tubal occlusion, although these rates are usually somewhat lower than if both tubes are known to be patent. Therefore, I generally would suggest proximal tubal catheterization to selectively assess and open the occluded fallopian tube.
If the proximal tubal catheterization is unsuccessful at opening the occluded fallopian tube then I would usually suggest a few cycles of spontaneous cycle IUI. If the couple is not pregnant with this treatment alternative then I would usually suggest a pelvic evaluation to further assess (and optimize) the pelvic condition.
Case: 27 year old G0 with a history of regular menstrual intervals every 28-29 x 4-5 days, a normal hormone evaluation (TSH and Prolactin concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral salpingitis isthmica nodosa (however both tubes were patent), a normal postcoital test (PCT) and a husband with unproven fertility yet a normal semen analysis.
Question: What further testing or treatments should be considered in this situation?
Answer: Salpingitis isthmica nodosa (SIN) can be defined as the invasion of tubal epithelium (the endosalpinx) into or through the muscular wall of the tube to a variable distance between the tubal lumen (on the inside) and the tubal serosa (covering the outside) of the fallopian tube. The causes of SIN are unclear but may involve chronic local inflammation (possibly due to endometriosis, infection, or persistent nonfunctional ovarian cysts).
There are no accepted (effective) treatments for SIN. It is known that ectopic pregnancy rates appear to be increased in the presence of SIN with one research study reporting microscopic evidence of SIN in roughly 50% (1 in 2) of fallopian tubes removed for an ectopic pregnancy compared to roughly 5% (1 in 20) of control fallopian tubes (without a history of ectopic pregnancy). Therefore, I routinely advise women in whom SIN is identified at HSG that they have an increased potential for ectopic pregnancy and that they should always seek early pregnancy care (when pregnant) to rule out an ectopic gestation.
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