History
A 31-year-old woman and her 34-year-old partner are referred by the general practitioner because of primary infertility. They have been trying to conceive for over 2 years. The woman has regular menstrual periods bleeding for 4 days every 28–30 days. Her periods are not heavy and have never been painful. There is no intermenstrual bleeding or dis-charge and no postcoital bleeding. She has never been diagnosed with any sexually trans-n mitted infections.
The last smear was normal 1 year ago. She is a non-smoker and drinks alcohol very occasionally.
The partner’s only previous medical history was an appendectomy and a course of anti-helicobacter therapy after he developed epigastric pain and was diagnosed with the infec-tion. He previously smoked 20 cigarettes per day and drank up to 28 units of alcohol per week but has now stopped smoking and significantly reduced his alcohol intake. He works as buyer for a retail company.
The couple have intercourse 1–4 times per week and there is no reported sexual dysfunc-tion or pain on intercourse. They both deny recreational drug use.
Examination
On examination the woman has a body mass index of 23 kg/m2. There is no hirsutism or acne. There are no signs of thyroid disease. The abdomen is soft and non-tender. Speculum and bimanual palpation are unremarkable. Genital examination of the partner nis also normal.
Questions
• How do you interpret the investigation results?
• Are any further investigations necessary?
• How would you manage this couple?
Medicine
Day 21 progesterone above 30 nmol/L confirms ovulation, and this is supported by nor-mal follicle-stimulating hormone (FSH), luteinizing hormone (LH) and prolactin. Normal testosterone suggests that polycystic ovaries is an unlikely diagnosis. The semen analysis is normal, and therefore any male factor aetiology is unlikely. Rubella immunity should always be confirmed.
The hysterosalpingogram shows fill of contrast medium into both uterine tubes but no spill, suggesting tubal obstruction as the cause of the fertility problem. Further investigations Tubal blockage on hysterosalpinogram can sometimes be due to tubal spasm, and there-fore a laparoscopy and dye is needed to confirm the pathology and also to determine a cause such as adhesions from previous infection or possibly endometriosis (although the history does not support this diagnosis).
Management
If the tubes are found at dye test to be patent, then this would suggest that it is feasible to attempt pregnancy with in utero insemination. However if blocked tubes are confirmed then in vitro fertilization (IVF) is indicated. Abnormal tubes are usually removed prior to IVF, as success rates for pregnancy are better and ectopic pregnancy rate reduced after bilateral salpingectomy.
General advice should be given to take folic acid 400 μg daily to reduce the risk of neural tube defects, and to the partner to minimize his alcohol intake. In this case the laparoscopy showed bilateral hydrosalpinges and adhesions as well as peri- hepatic ‘violin-string’ adhesions. These findings are consistent with previous infection with chlamydia (or more rarely gonorrhoea). It is not unusual to find such severe pelvic adhesions even when there has never been a clear clinical history of pelvic infection or sexually transmitted infection. Although the infection may be long ago, it is sensible to treat both the woman and her partner with a course of antibiotics for pelvic inflammatory disease.
KEY POINTS
• Infertility may be due to anovulation, tubal or endometrial/uterine pathology as well as male factors.
• Up to 30 per cent of infertile couples have more than one factor causing infertility.
• Tubal obstruction on hysterosalpingogram is not always confirmed at laparoscopy.
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