UNDERSTANDING INFERTILITY
approach, the septum can be divided with minimal bleeding. The
use of cautery is avoided in these cases to reduce the formation of
intrauterine adhesions. There is no need to divide the thicker, more
muscular portions of the septum, as these sites have adequate blood
supply to support implantation. Laparoscopic guidance is often
needed if the external contours of the uterus are indeterminate (10).
Excision of vaginal septa do not improve fertility per se but are often
performed to reduce discomfort with intercourse.
FALLOPIAN TUBE DAMAGE
Tubal factor infertility can result from any damage to the fallopian
tubes. Patients most at risk for tubal damage are those with a his-
tory of pelvic infections (sexually transmitted infections, STIs) like
gonorrhea, chlamydia or trichomonas), multiple prior abdominal
or pelvic surgeries, or even endometriosis. These can all result in
blockages at any point along the course of the tube, resulting in either
complete blockage which prevents fertilization or partial blockage
which increases the risk of ectopic pregnancy. The most useful
test to identify tubal blockage is a hysterosalpingogram or during
laparoscopy with chromopertubation (Figure 5). Distal occlusions
that can be corrected with laparoscopic neosalpingostomy and
fimbrioplasty have a good prognosis (11). Proximal occlusions can
potentially be overcome by segmental resection and reanastomosis.
In cases where a tube is too damaged to be repaired, the best course
for pregnancy success may be removing it, as certain kinds of tubal
damage can even impair attempts at in vitro fertilization (IVF) (11).
For some patients, damage to the fallopian tubes was intentional
with a sterilization procedure. Obviously, bilateral salpingectomy
leaves a patient with only IVF or gestational carrier as options
for future pregnancy. Reversal, however, may be possible after
traditional bilateral tubal ligation via tubal reanastomosis, though
success rates are variable (12). Details about the exact method of
the prior tubal ligation is essential to appropriately counsel patients
regarding feasibility of this option. Hysteroscopic proximal tubal
occlusion (Essure) has largely fallen out of favor due to unforeseen
development of long term pelvic pain due to the occlusive implants
used. While the implants can be removed, this procedure is typically
accompanied by bilateral salpingectomy rather than reanastomosis.
Data about pregnancy after reversal of this procedure is scarce and
largely anecdotal. Rates of ectopic pregnancy are increased after
tubal surgery compared to IVF, 2 to10% and 2%, respectively (11).
CONCLUSION
While the causes of infertility discussed in this article are some of
the most common, there are also many others and, frequently, more
than one at a time are identified. Patients struggling with infertility
or pregnancy loss should seek consultation with a qualified obste-
trician-gynecologist.
Dr. Ginn and Dr. Reinstine practice obstetrics-gynecology and are associated with
Norton Health Care.
Hysterosalpingogram: Case courtesy of Dr. Matt A. Morgan, Radiopaedia.org,
rID: 41788
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