The pelvic factors infertility include abnormalities of the uterus ,fallopian tubes,ovaries and adjacent pelvic structure .Factors in the history that are suggestive of a pelvic factor include any history of pelvic infection, such as salpingitis or appendicitis,use of intrauterine devices,endometritis and septic abortion . Endometriosis is included as pelvic factor in infertility and may be suggested by worsening dysmenorrhea,dyspareunia,or previous surgical report. Any history of etopic pregnancy, adnexal surgery, leiomyomas, or exposure to diethylstilbestrol surgery (DES) in utero should be noted as possibly contributory to the diagnosis of a pelvic factor.
A transvaginal office ultrasound examination can be efficient means of supplementing information gained from the standard bimanual examination. Hydrosalpinges,leiomyoma,and ovarian cysts and tumor can be often be observed. and the appropriate focused evaluation initiated sooner.
After pelvic examination, the evaluation of the pelvic factor usually begins with the hysterosalpingogram.Abnormal finding that can be found during this procedures are congenital malformations of the uterus, submucous leiimyomas,intrauterine synnechiae(Asherman’s syndrome) intrauterine polyps,salpingitis isthmica nodosa,and proximal or distal tubal occlusion. The test is usually scheduled for interval after menstrual bleeding and prior to ovulation.The procedure involves instillation of radiographic liquid dye into the uterine cavity using either a pediatric Foley catheter or a suction catheter which is passed through the cervical canal.After 3-5mL of dye is instilled an image is obtained, and additional dye is added to fill the uterine tubes.The procedure is witnessed by practitioner under image intensification- or key films are obtained by a radiologist skilled in the procedure in order to determine the uterine contour, the patency of the tubes, and the ability of the dye to freely spill into the pelvic.
The information regarding the pelvic factor obtained with a hysterosalpingogram is completed by a laparoscopy with dye instillation. When hysteroscopy is also done, sypplementary information about the uterine contour can be obtained at the same time as the laparoscopy. Tubal abnormalities such as agglutinated fimbria or filmy adhesion (which restrict motion of the tubes) or peritubal cysts mat suggest tubal disease that would not necessarily be detected on hysterosalpingogram .The diagnosis of endometriosis is usually based on laparoscopic findings. Endometriosis may be suggested by history but can be diagnosed only by laparoscopy or laparotomy.The association between endometriosis and infertility is strong ,although understanding of the mechanism by which the disease contribute to infertility is poor.The timing of laparoscopy is one key factor. In young couples with negative history, is usually offered after all other tests are completed and discussed .In older couple or if the history suggests a pelvic factor ,it is often indicated as one of the primary evaluations.In some patients with long standing infertility,laparoscopy might be offered in conjunction with stimulation of the ovaries and ovum retrieval in order to combine the diagnostic potential with an attempt to achieve pregnancy. This may be done either by IVF,to confirm the ability of the eggs and sperm to interact, or by placing spern and egg in the normal uterine tube.
Documentation of the laparoscopic procedure by either video or still photography, can be a valuable aid for the couple and may assist in determining subsequent therapy particularly if referral to a consultant is indicated.With thoughtful preparation and discussion prior to prior to the procedure, it is frequently possible to accomplish treatment of pathologic findings at the time of laparoscopy. Particularly if significant endometriosis is encountered during hysteroscopy,they can be resected through the hysteroscope in some cases.
Laparoscopy is usually done in an outpatient surgery center with the patient under general anaesthesia,although in some settings it is offered under local anesthesia with good results.
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