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Pelvic Factor

Normal Events

Pelvic Factor Detection

Pelvic Abnormalities
  • Abnormal Male Outflow
  • Vaginal Problems
  • Cervical Problems
  • Uterine Problems
  • Proximal Tubal Disease
  • Bilateral Tubal Ligation
  • Distal Tubal Disease
  • Pelvic Adhesions
  • Endometriosis

Clinical Evaluation

Treatment Options

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Distal Fallopian Tube

Case: 33 year old G0 with a history of regular menstrual intervals every 28 x 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 distal tubal occlusion with hydrosalpinges (about 2 cm in diameter on each side with presence of rugae), 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 treat probable pelvic factor infertility.

Question: What treatment alternatives should be reviewed in dealing with these damaged fallopian tubes?

Answer: In this case, the fallopian tubes are found to be occluded and dilated (hydrosalpinges) on the HSG examination. As is often the case, the cause of these problems is not clear from the available medical or gynecologic history.

I generally will review the couple’s findings with each diagnostic test that is completed. The HSG findings of bilateral hydrosalpinges measuring 2 cm (diameter) with the presence of rugae along the lumen suggests a severe pelvic factor infertility issue that may be able to be successfully repaired. The prognosis (in terms of future fertility) after treatment (repair) of damaged fallopian tubes relies heavily on the extent of damage that has accumulated prior to surgical repair and the microsurgical techniques used to repair the tubes.

Reproductive alternatives to surgical repair of the damaged fallopian tubes include In Vitro Fertilization (IVF) with the tubes in place, IVF after removal of the fallopian tubes (salpingectomy), and adoption.

I review (with the couple) the medical literature and my own surgical experience when discussing the reproductive prognosis after the repair of damaged fallopian tubes. The prognosis of repair is much less favorable when the dilatation of the fallopian tubes is greater than 3 cm diameter and there is a loss of the rugae (folds, wrinkles, creases) that are normally seen along the inner lumen of the tube. The prognosis is more favorable when the dilatation of the fallopian tubes is less than 1-1.5 cm in diameter.

If the couple wants to have the fallopian tubes repaired I routinely inform them that there is a chance that the tubes will re-close following fimbrioplasty (opening of the distal end of the fallopian tubes) regardless of the initial prognosis of repair. The reason for tubal reclosure is often unclear and probably involves the reason that the tubes closed in the first place. Therefore, if a repair is performed and the tubes reclose then further surgery may be suggested prior to IVF. Further surgery prior to IVF may be advised since the success rates of IVF are significantly reduced in the presence of hydrosalpinges, such that repair or removal of the fallopian tubes (at least tubal ligation) is generally advised before the IVF procedures.

Many women desire an initial attempt at repair of the fallopian tubes and then subsequent reevaluation (HSG) if she does not become pregnant within a reasonable amount of time. If the HSG demonstrates patent (open) fallopian tubes then proceeding to either controlled ovarian hyperstimulation (using FSH containing medication) with intrauterine insemination (COH/IUI) or IVF may be appropriate.




Case: 33 27 year old G0 with a history of regular menstrual intervals every 28 x 5 days, a normal hormone evaluation (TSH and Prolactin concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral fallopian tube fill without clear evidence of spill (no hydrosalpinx is identified), 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 further identify and treat possible tubal factor infertility.

Question: What surgery should be considered in this situation?

Answer: When there is no dilatation of the distal fallopian tubes with (apparent) complete distal tubal occlusion (on HSG) I often suggest a pelvic evaluation to further assess the status of the tubes.

At the time of laparoscopy I normally perform a chromopertubation (liquid colored with an inert dye is injected into the uterine cavity through the cervix and normally flows through the fallopian tubes into the pelvis where it can be seen with a laparoscope) to identify possible tubal occlusion.

If the dye flows freely through the tubes into the pelvic cavity then patency is easily demonstrated. If the tubes are occluded distally and there is no dilatation of the distal tube then I would generally suggest opening the distal tube (fimbrioplasty) since the prognosis (in terms of future fertility) is favorable. If the tubes are found to be occluded and dilated then a decision should be made (ideally preoperatively involving both the surgeon and the fertility seeking couple) concerning repair or removal (depending on the extend of the damage that is found and the future prognosis for fertility after a repair).




Case: 33 36 year old G0 with a history of regular menstrual intervals every 30-31 x 7 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 the delicate fimbriae of the fallopian tubes are found to be stuck together (fimbrial agglutination).

Question: What surgery should be performed in this situation?

Answer: It is possible to have a completely normal HSG result and extensive fimbrial agglutinations since the mere presence of these agglutinations does not necessarily prevent the radioopaque dye from flowing out through the distal end of the tube.

Fimbrial agglutinations can obstruct the ability of the fallopian tube to capture and transport an egg. Therefore, the distal ends of the fallopian tubes should be carefully examined and fimbrial agglutinations should be removed or lysed when identified. I generally use char free (ultrapulse) power settings with a CO2 laser to accomplish this.




Case: 33 29 year old G0 with a history of regular menstrual intervals every 27 x 3 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 performed (in order to identify and treat possible pelvic factor infertility) at which time clear and yellow vesicular lesions (blisters) are seen along the surface of the fallopian tubes.

Question: What surgical procedure should be considered in this situation?

Answer: The pelvic evaluation is being performed for otherwise unexplained infertility.

The blebs (vesicles that are filled with clear or yellow fluid) along the fallopian tubes are not normally present and most likely represent atypical early stage endometriosis. In this situation, I would generally vaporize all of the blisters that are identified since local inflammation (resulting in blistering of the peritoneal surface) along the fallopian tube can certainly reduce reproductive potential. Care must be taken to use microsurgical techniques. I almost exclusively use an ultrapulse (char free) CO2 laser for this sort of work.




Case: 33 32 year old G0 with a history of regular menstrual intervals every 29-30 x 3-5 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 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 round cystic structures (about .5 to 1 cm diameter) are seen hanging down from the distal end of the fallopian tubes (by thick avascular stalks).

Question: What surgical procedure should be performed in this situation?

Answer: All human pregnancies normally have two sets of embryonic structures that can eventually differentiate (mature) into either male or female internal genitalia. If the growing embryo is to become a female then the female set of internal structures (known as the Mullerian ducts) form into the uterus and fallopian tubes while the male set of internal structures (known as the Wollfian ducts) degenerate. If the growing embryo is to become a male then the male set of internal structures (Wollfian ducts) develop while the female set of internal structures (Mullerian ducts) degenerate.

It is not uncommon for remnants of the Wollfian duct system (the male structures) to be found in the pelvis of women during laparoscopy. These remnants are often found as small cystic structures that hang from the distal end of the fallopian tube. These benign cysts are called “cysts of Morgagni” or “hydatid cysts.”

The cysts of Morgagni have no known function in women. They can hang from the distal end of the fallopian tube and disrupt the normal (anatomic) relationship between the ovary and the tube so as to reduce the ability of the tube to capture an egg that is ovulated. Therefore, I tend to remove these cysts whenever seen so as to restore the normal relationship between the tubes and ovaries.



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