Dr H Rahmanpour Infertility specialists. Definition Infertility is defined as 1year of...
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Tubal evaluation in infertility Dr H Rahmanpour Infertility specialists
Dr H Rahmanpour Infertility specialists. Definition Infertility is defined as 1year of unnon-conception with unprotected intercourse in the fertile phase
Definition Infertility is dened as 1year of unnon-conception
with unprotected intercourse in the fertile phase of the menstrual
cycles (Evers,2002).
Slide 3
In normal couples the fecundity, or the chance to pregnancy
with in one cycle is 20%(Evers,2002). On this Basis it is assumed
that 85% of women should be pregnant in 1 year.
Slide 4
Common causes of infertility include male factor (25-45 %),
ovulation disorders (30-40 %) and tubal damage (30-40 %). A
combination of several factors is found in approximately 10-20 % of
all couples.
Slide 5
Un explained infertility 10-15%of in whom standard
investigations Including semen analysis,tests of ovulation and
tubal patency have failed to detect any gross abnormality
Slide 6
Initial Consultation Infertile couples are usually advised to
start their investigations after 12 months of trying to conceive or
after 6 months.
Slide 7
Earlier evaluation Earlier evaluation is warranted for couples
wherein the male partner has known or suspected poor semen quality
or the female partner has irregular or infrequent menses, a history
of pelvic infection or endometriosis, or is over 35 years of
age.
Slide 8
basic infertility evaluation should include tests aimed at the
4 most important causes of infertility (1) ovulatory dysfunction,
(2) abnormalities of semen, (3) abnormalities of the uterus and
fallopian tubes, (4) reproductive aging.
Slide 9
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Slide 11
tubal obstructions Proximal tubal obstructions prevent sperm
from reaching the distal fallopian tube where fertilization
normally occurs. Distal tubal occlusions prevent ovum capture from
the adjacent ovary.
Slide 12
Whereas proximal tubal obstruction is essentially an all or
none phenomenon, distal tubal occlusive disease exhibits a spectrum
ranging from mild (mbrial agglutination) moderate (varying degrees
of mbrial phimosis) severe (complete obstruction).
Slide 13
The etiology of tubal damage can be intrinsic : ascending
salpingitis, salpingitis isthmica nodosa),mucus pluck, polyp.
extrinsic :peritonitis, endometriosis and pelvic surgery).
Slide 14
Tubal factor evaluation The methods available for evaluating
the fallopian tubes include traditional HSG, laparoscopic
chromotubation, Sonohysterosalpingography and the chlamydia
antibody test (CAT).
Slide 15
hysterosalpingogram Assessment of tubal patency is one of the
first steps in fertility investigations. Hysterosalpingography
(HSG) is the most common first-line diagnostic test used for this
purpose. In addition to assessing tubal patency, HSG also provides
an image of the outline of the uterine cavity. It has also been
suggested that HSG has a therapeutic role in enhancing
subfertility
Slide 16
water-soluble or oil-soluble contrast media Over the years,
controversy has raged over the relative advantages and
disadvantages of water-soluble and oil-soluble contrast media. both
water-soluble and oil-soluble contrasts are appropriate, depending
on preference.
Slide 17
test of tubal patency, HSG is approximately 60% sensitive and
95% specific, meaning that when it suggests obstruction, the tubes
are often truly patent, but when it demonstrates patency, the tubes
are almost always truly open. 16 16
Slide 18
Normal HSG
Slide 19
The relatively poor sensitivity of HSG as a test of tubal
patency results from the difference in test accuracy for diagnosis
of proximal and distal tubal occlusion. The diagnosis of distal
tubal obstruction generally is accurate, but apparent proximal
tubal occlusions are often not real, representing artifacts of
transient uterine contractions, so-called tubal spasm, or catheter
placement (with the tip lying near one tubal orifice).
Slide 20
The HSG diagnosis of proximal tubal obstruction must,
therefore, be confirmed, either by repeating the study, or by
performing either fluoroscopic or hysteroscopic selective tubal
catheterization.
Slide 21
Both false-negative (obstructions that are not real) and
false-positive results (patency that is not real) occur, the former
being much more common than the latter.
Slide 22
HSG is best scheduled during the 25 day interval immediately
following the end of men-ses, to minimize risk for infection, avoid
interference from intrauterine blood and clot, and to prevent any
possibility that the procedure might be performed after
conception.
Slide 23
Bilateral tubal abstraction
Slide 24
Hydrosalpinx
Slide 25
Uterine cavity abnormalities can be a contributing cause of
subfertility in 10 % of women. Abnormal uterine findings are
reported in as many as 50 % of women with recurrent implantation
failure. These findings include endometrial polyps or fibroids,
intrauterine adhesions and congenital abnormalities.
Slide 26
Bicorn uterus
Slide 27
Uterus with Septume
Slide 28
Unicorn uterus
Slide 29
Uterine myoma
Slide 30
Severe Asherman
Slide 31
TB
Slide 32
Sonohysterography:
Slide 33
The Thickened endometrium may be a Submucosal leiomyomas
Laparoscopic Chromotubation Although generally more accurate
than HSG, the diagnosis of proximal tubal occlusion has the same
pitfalls as HSG and, ideally, should be confirmed by selective
tubal catheterization.
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Slide 42
Chlamydia antibody test The most common causes of pelvic
inflammatory disease (PID) are Chlamydia trachomatis, Neisseria
gonorrhoeae. Studies have demonstrated that the severity of tubal
damage found in infertile women is directly related to their serum
chlamydia antibody IgG titer (CAT)
Slide 43
Chlamydia antibody test Most asymptomatic tubal pathology is
mainly attributed to the history of pelvic inflammatory disease
(PID). past Chlamydia infection using serology is readily available
and the test is simple and quick to perform.
Slide 44
Chlamydia antibody test Several European studies have suggested
that the sensitivity of CAT for detection of tubal pathology
approaches that of HSG and laparoscopic chromotubation. At least in
theory, the CAT should help to identify women with tubal pathology
who might benefit most from more specific tests, such as HSG or
laparoscopic chromotubation. However, at present, the diagnostic
accuracy of the CAT has not been established and the test is not
used widely in the United States.
Slide 45
Chlamydia antibody test So while a negative CAT can be
reassuring, a positive test would warrant more invasive diagnostic
procedures, such as laparoscopy, to assess the severity of the
disease even if there is no history of chlamydial PID.
Slide 46
Chlamydia antibody test The Dutch Society for Obstetrics and
Gynaecology (NVOG) recommends the use of CAT as a first-line test
in the basic work-up of subfertile couples, with a fixed cut-off
level (immunoglobulin G MIF 1:32 or ELISA 1.1) above which
post-infectious pelvic disease should be ruled out with laparoscopy
and chromotubation.
Slide 47
Human Reproduction, Vol.26, No.5 pp. 967971, 2011 Should a
hysterosalpingogram be a first-line investigation to diagnose
female tubal subfertility in the modern subfertility workup?
Slide 48
Conclusion CAT is comparatively inexpensive, less invasive and
can be performed at any time during the menstrual cycle and can
identify patients who need further evaluation. Laparoscopy remains
the gold standard in diagnosing tubal pathology. We also suggest a
flow chart of investigations for determining tubal pathology in
women with subfertility as a compromise between invasiveness and
diagnostic accuracy (Fig. 1), rather than a blanket policy of using
HSG.
Slide 49
For CAT-positive patients, laparoscopy may be warranted,
whereas CAT-negative patients should have a HyCoSy that carries a
similar cost and has at least the same accuracy as HSG while
avoiding radiation. We feel that HSG is out of date and has no
place in modern evidence-based fertility investigations.