Methods in the Assessment of Infertility

Methods in the Assessment of Infertility DISCUSSION 6. DISCUSSION 6.1 Fertility depends on the presence of normal fallopian tubes. Tubal factors have been reported to account for 25% to 30% cases of infertility. [6]Partial or complete occlusion of fallopian tubes is one of the major etiological factors in infertility. 6.2 In the present study, 60 cases attending Gyneac OPD in Department of Obstetrics Gynaecology at Base Hospital were studied. Among all cases of primary infertility was found to be 73.3% in present study and cases of secondary infertility was found to be 26.6%. (Table -5.1). Allahabadia et al (1992) studied 50 patients, out of which 40 (80%) had primary infertility and 10 (20%) had secondary infertility. [61] 6.3 The average age in primary infertility group, in present study was found to be 25.27 years while that in secondary infertility group was 28.83 years (Table: 5.2 5.3).Average age of all cases of infertility was 27.05 years. Tufekci et al (1992) studied 44 cases. The mean age of patients was 24.17 + 2.83 years (age ranging from 20 years to 35 years).The maximum number of cases i.e. 29 (65.9%) of primary infertility were in 21-25 years age group. In secondary infertility group, the maximum number of cases i.e. 8 cases (50%) were found to be in 26 30 years age group. [79] S. Kore et al, in their study had similar observation. Maximum numbers of the patients in his study were between 25-30 years of age, 34 patients had primary infertility and 6 had secondary infertility. Mean duration of infertility in his study was 5.2 years. [8] S lal et al, studied 100 patient of infertility and majority of the patients i.e. 64% of the women were cases of primary infertility and maximum number belonged to the age group of 26-30 years .[57] 6.4 The average duration of infertility in primary infertility group was 7.78 years, while that in secondary infertility group was 9.58 years (Tables 5.5, 5.6). The maximum number of cases i.e. 17 cases (38.7%) of primary infertility were infertile for 1-5 years whereas for 6-10 years (Table 5.5, 5.6) in secondary infertility group i.e. 9 cases (56.3%). Among all cases of infertility, the maximum number of cases i.e. 24 cases (40%) were infertile for 6 -10 years (Table – 5.7). Similar finding were also reported by A.K. P. Ranaweera et al. (2013); in which study population comprised 42 infertile women in Srilanka.[80] Overall, the mean age was 31.95 years, with a range of 24–39 years. Mean duration of infertility was 2.98 years, range 1–10 years. Infertility was reported as primary and secondary by 38 (90.5%) and 4 (9.5%), respectively [84]. Another study which was done by Aziz N. (2010) on infertility cases, where cases were taken by ratio of primary and secondary infertility as 2:1.Out of 50 patients, 32 patients (64%) presented with primary infertility and 18 patients (36%) presented with secondary infertility. The mean duration of infertility was 3.7 years and 7.3 years in primary and secondary infertility respectively, while mean age of presentation was 28 years in primary infertility and 32 years in secondary infertility. [68] 6.5 On transvaginal sonosalpingography, out of 44 cases of primary infertility, tubes were found to be patent in 30 cases and blocked in 14 cases (Table 5.8). These 30 cases of patent tubes included 5 cases which showed delayed spill on one side and free spill on other side. Out of 14 cases of tubal block, 6 cases (13.7%) showed bilateral tubal block, 4 cases (9%) each showed right sided and left sided block respectively (Table – 5.8). Out of 16 cases of secondary infertility, 8 cases (50%) showed bilateral tubal patency and 4 cases (25%) showed bilateral tubal block. 1 case (6.2%) and 3 cases (18.8%) showed left sided and right sided block respectively (Table 5.9). Out of all 60 cases of infertility, 38 cases (63.3%) showed bilateral tubal patency and 22 cases (36.7%) showed tubal block (unilateral/bilateral) (Table – 5.10). Tubal block was found to be more common in secondary infertility cases i.e. 8 (50%) as compared to primary infertility cases 14 (31.7%) (Tables-5.8, 5.9). Bilateral tubal block was more common in secondary infertility cases i.e. 4 cases (25%) as compared to primary infertility cases i.e. 6 cases.(13.7%) (Tables- 5.8, 5.9). Tufekci et al (1992) performed transvaginal sonosalpingography and accurately showed patency in 26 patients and bilateral non-patency in 3 patients. [79] Allahabadia et al (1992) performed The Sion Test in 50 patients and found bilateral patency in 41 cases, (82%), bilateral block in 6 (12%) cases, left block in 2 (4%) cases and right block in 1 case (2%). [61] Transvaginal sonosalpingography could also pick up additional findings. Cystic ovary was observed in 5 cases (8.3%) and fibroid in 3 cases (5%) (Table 5.11). 6.6 In Primary infertility group, out of 44 cases chromolaparoscopy showed bilateral tubal patency in 31 cases (71.4%) and bilateral tubal block in 6 cases (13.6%). Left sided block and right sided block was seen in 3 cases (6.9%) and 4 cases (9.1%) respectively (Table 5.12). Out of 16 cases of secondary infertility, chromolaparoscopy showed bilateral tubal patency in 9 cases (56.2%), which included one case which showed delayed spill on one side. Bilateral tubal block was seen in 3 cases (18.8%). Left sided block and right sided block was seen in 1 case (6.2%) and 3 cases (18.8%) respectively (Table 5.13). 6.7 Out of all 60 cases of infertility, chromo-laparoscopy revealed tubal block in 20 cases (33.3%) and bilateral tubal patency in 40 cases (66.7%) (Table 5.14). Tubal block was found in 7 cases (11.7%) in secondary infertility group as compared to 13 cases (21.7%) in primary infertility group (Table 5.14). Darwish AM et al study, where SHG agreed with laparoscopy for the patency of right and left tubes in 72.4% and 60.5% cases. [75] Allahabadia et al (1992) observed bilateral tubal patency in 41 cases (82%); bilateral tubal block in 6 cases (12%) left block in 2 cases (4%) and right block in 1 case (2%). [61] 6.9 Out of additional findings picked up by chromolaparoscopy in all cases of infertility, adhesions (peritubal / periovarian) were most commonly observed i.e. in 21 cases (35%). Cystic ovary and fimbrial cyst were observed in 4 cases each (6.6%) respectively. Fibroid was seen in 3 cases (5%). Tubo-ovarian mass, acute kinking of tube and endometriosis were seen in one case each respectively (1.6%) (Table 5.15). Aziz N (2010) observed tubal blockage in 21.9% and 33.3% cases of primary and secondary infertility respectively. Out of all 15.6% cases of primary infertility were detected as polycystic ovaries (PCO) which was not found in cases of secondary infertility. Endometriosis was found in 12.5% cases with primary infertility and 11.1% cases with secondary infertility. Pelvic inflammatory disease (PID) was found in 3.1% and 16.7% cases of primary and secondary infertility respectively. Peritubal and periovarian adhesions were detected in 6.3% cases with primary infertility and 22.2% cases with secondary infertility. Fibriod was found in 6.3% and 5.6% cases of primary and secondary infertility respectively. Ovarian cyst detected in 6.3% cases with primary infertility while none was found in cases of secondary infertility. [68] 6.10 A significant advantage of chromolaparoscopy over other methods of detecting tubal patency is that, it permits the visualisation of additional pelvic pathology, particularly pelvic adhesions. This is particularly relevant in assessing the feasibility of their surgical intervention. If dense pelvic adhesions are seen to be associated with totally disorganised tubes, laparotomy may not be indicated. This is of further value with reference to genital tuberculosis, as it presents a real diagnostic problem.Reliable diagnosis of genital tuberculosis is of significance not only to enable proper specific treatment, but also to avoid futile and possibly hazardous surgery.Inability to diagnose accurately the peri-tubal adhesions is an important shortcoming of transvaginal sonosalpingography. 6.11 The presence of peritubal and periovarian adhesions and that too, with high incidence is a significant finding in this study. It implies that adhesions can affect the tubal function with-out affecting the tubal patency. Adhesions affect the fallopian tube by restricting its mobility, interfering with ovum pick up and changing its peristalsis. Laparoscopy provides additional information concerning The site of adhesions whether peritubal or periovarian. b)The extent of adhesions. c)The effect on the course of the tube. d)Anatomical relation between fimbia and ovary Exact site of tubal block could not be diagnosed by transvaginal sonosalpingography.Out of 7 cases of tubal block in secondary infertility group, 2 cases (12.5%) each showed corneal block and midtubal block was seen in 1case (6.2%) and 4 cases (25%) showed fimbrial block (Table 5.17). 6.12 When results of transvaginal sonosalpingography and chromolaparoscopy were compared in all cases of infertility, 38 cases (63.4%), showed bilateral tubal patency by transvaginal sonosalpingography, whereas by chromolaparoscopy 40 cases (66.6%) showed bilateral tubal patency.Agreement regarding tubal patency was seen in 63.4% of cases. Regarding tubal block, agreement was seen in 33.4% cases. On the whole, agreement was seen in 96.6% cases (Table 5.18). Tufekci et al (1992) found completely consistent results in 76.32% of cases by transvaginal sonosalpingography and chromolaparoscopy and partially consistent results in 21.05% cases, and inconsistent results in 2.63% case. [79] Allahbadia et al (1992) performedSiontest and chromolaparoscopy in 50 patients. They found 100% agreement between the two methods for tubal patency. [61] 6.13 Comparison between transvaginal sonoslpingography and chromolaparoscopy in tubal block group (Table 5.19) showed that regarding bilateral tubal block, agreement was seen in 40.9% cases. Regarding unilateral tubal block, agreement was seen in 50% cases, and on the whole agreement was seen in 90.9% cases. Out of 60 cases 22 cases (36.6%) showed tubal block by transvaginal sonosalpingography whereas by chromolaparoscopy only 20 cases (33.4%) showed tubal block. Two cases were falsely picked up by transvaginal sonosalpingography as cases of tubal block. Jeanty P (2000) observed that Air-sonohysterography and laparoscopy with chromopertubation showed agreement in 79.4%. In 17.2% of patients, the tubes were considered nonvisualized by air-sonohysterography when they were patent. The sensitivity was 85.7% and specificity was 77.2%. [70] 6.14 One of the cases which showed right sided block by transvaginal sonosalpingography and bi-lateral tubal patency by chromolaparoscopy showed flimsy peritubal and periovarian adhesions and delayed spill on instillition of methylene blue dye from right side, when chromolaparoscopy was performed. The other case which showed bilateral tubal block by transvaginal sonosalpingography, showed apparently healthy tubes and free spill from both sides by chromolaparoscopy. This might be due to spasm which was relieved under general anaesthesia. Study has done by Tanawattanacharoen S et al. (2000) Shows corresponding results between HyCoSy and chromolaparoscopy in 80.0%. The agreement between both procedures in assessing the uterine pathology was 80.4% (68%). [77] Dietrich, M et al. (1996) find corresponding results with regard to the tube patency between HyCoSy and conventional chromolaparoscopy in 82.5% of cases .Right sided block was observed in 31.8% by both methods. Left sided block was seen in 22.7% by transvaginal sonosalpingography however chromolaparoscopy confirmed block in 18.1%. Percentage of false positive results as shown by transvaginal sonosalpingography was 4.6 %, whereas no false negative results were seen. [63] Allahabadia et al (1992) observed bilateral tubal block in 12%, left sided block in 2% by both Sion test and chromolaparoscopy. [61] 6.15 Divergent observations emphasize the difficulty encountered in accurate localisation. Cornual occlusion for example either functional or structural precludes any evaluation of the remainder of the tube. Furthermore, the patients with apparent cornual block may show a block at the ampulla on repeated film. Chromolaparoscopy revealed more of additional findings as compared to sonosalpingography (Table 5.15). 6.16 Comparison between these two methods in patients of tubal block showed that chromolaparoscopy was the most reliable method for diagnosing tubal block. Out of 22 cases of tubal block by transvaginal sonosalpingography, 2 cases showed patent tubes by chromolaparoscopy and only in 20 cases, the tubal block was confirmed. Level of agreement between these two methods regarding bilateral block was found to be 40.9%. Regarding unilateral block, agreement was seen in 50% cases. On the whole, agreement regarding tubal block was 90.9%.Sensitivity of transvaginal sonosalpingography was found to be 95 %, whereas specificity was found to be 100 %. There were no false negative results by transvaginal sonosalpingography whereas 5% results were false positive. Allahabadia et al (1992) found that transvaginal sonosalpingography showed bilateral occlusion with sensitivity of 100% and tubal patency with 96% specificity. [61] Sensitivity and specificity of transvaginal sonosalpingography as diagnostic test for tubal patency by various studies: The results of this study confirm that both transvaginal sonosalpingography and chromolaparoscopy constitute valuable methods in the assessment of infertility. Though, superiority of chromolaparoscopy over transvaginal sonosalpingography has been clearly demonstrated but the 2 techniques should be considered complimentary and not as a substitute for each other. Transvaginal sonosalpingography can safely replace HSG for determining tubal patency as a routine diagnostic procedure. Trans-vaginal sonosalpingography when compared with HSG: Is more accurate in demonstrating the presence of tubal patency Is potentially safer. Is potentially more convenient and less expensive. Idiosyncracy to contrast agent cannot be expected. Can be performed on ambulatory basis. Trasvaginal sonosalpingography can be criticized on the grounds that- Exact site of tubal block cannot be determined Peritubal adhesions and mobility of tube cannot be properly assessed. It does not provide an accurate assessment of intrauterine and tubal anatomy. It is advocated that young women, as a first examination for fallopian tube patency, should undergo transvaginal sonosalpingography of the pelvis. If tubal patency is demonstrated, the patient should be recommended a six month trial period to become pregnant before invasive procedures are initiated. Chromolaparoscopy should be a vital part of the investigation in all cases of unexplained infertility as it may document hitherto unsuspected pelvic pathology. It is also an essential step former to any tubal surgery at it may not only preclude the requirement of operation but may also provide essential information regarding the nature and extent of future surgery. It is observed again that transvaginal sonosalpingography is not a substitute for chromolaparoscopy; it is offered as a screening test which is very cheap, noninvasive, simple, and cost effective with no infectious morbidity. It is a promising screening and diagnostic technique in evaluation of tubal patency on an ambulatory basis. 1