Reproductive · Year 2 · from Reproductive
Case 1: Tubal Factor Infertility
Clinical Image
Source: Wikipedia - Hysterosalpingography - CC BY-SA 3.0
Case Presentation
A 33-year-old G0 woman and her husband present for infertility evaluation after 18 months of unprotected intercourse without conception. Her menstrual cycles are regular at 28-30 days, suggesting normal ovulation. She has no history of sexually transmitted infections that she is aware of, but she was treated for pelvic inflammatory disease at age 21 while in college. She has no chronic medical conditions. Her husband's semen analysis is normal. Mid-luteal progesterone is 12 ng/mL, confirming ovulation. Day 3 FSH is 7 mIU/mL and AMH is 2.8 ng/mL, indicating adequate ovarian reserve. Hysterosalpingography (HSG) is performed, demonstrating a normal uterine cavity but bilateral tubal occlusion with proximal blockage on the right and a dilated, club-shaped left tube consistent with hydrosalpinx. No contrast spills into the peritoneal cavity bilaterally. The diagnosis is tubal factor infertility secondary to prior PID with bilateral tubal damage. Given the bilateral tubal disease and hydrosalpinx, IVF is recommended. She is counseled that the hydrosalpinx fluid is toxic to embryos and associated with reduced IVF success rates. Laparoscopic left salpingectomy is performed before IVF. She undergoes IVF with a good response to stimulation, and a single euploid blastocyst is transferred. She conceives on the first IVF cycle and delivers a healthy infant at term.
Key Learning Points
- Tubal factor infertility accounts for 25-30% of female infertility; pelvic inflammatory disease (often from Chlamydia trachomatis) is the most common cause, with risk increasing with each episode of PID
- Hysterosalpingography (HSG) is the first-line test for tubal patency; it can identify tubal occlusion, hydrosalpinx, and uterine abnormalities
- Hydrosalpinx (dilated, fluid-filled fallopian tube) reduces IVF success by approximately 50%; salpingectomy or proximal tubal occlusion before IVF improves pregnancy rates
- IVF bypasses the fallopian tubes entirely and is the treatment of choice for bilateral tubal disease