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A case of Infertility caused by Bilateral Hydrosalpinges December 2004 Initial Presentation Cathy is a 27 year old woman with 12 months of primary infertility. She is fit and well. She has a 28 day menstrual cycle with dysmenorrhoea starting with the onset of menstruation. She uses Nurofen to control this. Her only relevant past medical history is an episode of laparoscopically proven PID 5 years ago. Cervical swabs diagnosed Chlamydia. She was treated with broad spectrum antibiotics and 4 weeks of Doxycycline. A recent smear was normal. Abdominal and pelvic examination was unremarkable. Her partner Paul is fit and well with no significant past illnesses.
The history is strongly suggestive of tubal factors contributing to her infertility, however the routine investigations should be done first to confirm ovulation and normal spermatogenesis Cathy had blood taken on day 21 of her cycle for serum progesterone, rubella and varicella titres. Paul was asked to provide a semen analysis. They were reviewed with the results which confirmed ovulation and normal spermatogenesis. The need to establish the condition of the fallopian tubes was discussed.
Hysterosalpingogram would confirm tubal occlusion but not help to show the extent of the damage and the possible need for further surgery (either reconstructive or salpingectomy). Hysteroscopy, laparoscopy and dye studies whilst more invasive, provide more information that is useful in planning further management. Cathy opted to have a laparoscopy with dye studies and hysteroscopy because she decided that she wanted to have as much information about what had happened to her fallopian tubes as possible. The hysteroscopy was normal but the laparoscopy demonstrated bilateral thin walled hydrosalpinges with extensive peri-tubular and peri-ovarian adhesions, with complete obliteration of the Pouch of Douglas by adhesions. Bilaterally there were pinhole ostea allowing passage of dye. At the post-operative visit these findings were discussed at length. The irreversible nature of the damage was explained and the option for IVF was introduced. The possibility of the need for a second procedure to remove both hydrosalpinges was briefly discussed. They were given IVF information booklets and went away to think about these options.
Based on clinical evidence, where hydrosalpinges are visible on pelvic ultrasound, their removal by surgical means may be considered. A laparoscopic approach is usually possible. It is thought that the fluid produced by the hydrosalpinx may be embryotoxic. A hydrosalpinx is usually patent proximally and the leakage of fluid in the uterine cavity may interfere with implantation. As a possible future management option in women where large hydrosalpinges are present and the risks of surgery are high, (eg marked obesity or dense pelvic adhesions), the placement of the Essure hysteroscopic sterilization device has been used to block the tubes proximally in 3 cases without incident. It is early days as yet but this may become a less invasive alternative to surgical removal of the hydrosalpinges. (J Kerin, personal communication)  PRINT THIS PAGE
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