Tubal Factor Tubal factor accounts for 25% to 35% of infertility. Noninfectious causes for tubal factor include tubal endometriosis, salpingitis isthmica nodosa, tubal polyps, tubal spasm, and intratubal mucous debris (10). The incidence of tubal infertility has been reported to be 8%, 19.5%, and 40% after one, two, and three episodes of PID, respectively (204). Live birth rates are negatively affected by the severity of a single episode of PID (205). C. trachomatis and Neisseria gonorrhoeae are common pathogens associated with PID and infertility. M. hominis and U. urealyticum have been implicated in PID, but their contribution to infertility is less clear (17). Many patients with documented tubal damage have no history of PID and are presumed to have had subclinical chlamydial infections (206,207).
Hysterosalpingography Hysterosalpingography (HSG) is performed after menses but prior to ovulation between cycle days 7 and 12 to avoid potential pregnancy and take advantage of the thinner proliferative phase endometrium. The patient is typically premedicated 30 to 60 minutes prior to the procedure with ibuprofen or related medication (208). Lidocaine injected intracervically may provide further pain relief (209). With the patient in the dorsal lithotomy position, either a metal cannula or a balloon catheter is inserted through the cervix and past the internal cervical os. Contrast dye is then injected under ﬂuoroscopy to visualize the uterine cavity, fallopian tube architecture, and tubal patency (208,210). Certain disease processes, such as salpingitis isthmica nodosa, have a characteristic appearance on HSG, with typical cornual or isthmic honeycombing resulting from contrast-filled diverticular projections (211). Compared to laparoscopy, HSG has a sensitivity and specificity of 86.5% and 79.8% for bilateral tubal patency and 90% and 97% for bilateral tubal occlusion, respectively. The specificity of HSG remains high but the sensitivity drops for unilateral tubal patency (212).
Hysterosalpingography Risks Although use of oil-based contrast has been associated with higher pregnancy rates following HSG when compared to water-based contrast (213,214), water-based contrast is generally preferred to avoid oil embolism or granuloma formation. Furthermore, patients should be screened for and pretreated with glucocorticoids if iodine allergy is found (210). The risk of PID after HSG is 0.3% to 3.1% overall but is greater than 10% in the setting of hydrosalpinges (215,216). Therefore, HSG should be avoided in the setting of known hydrosalpinges and/or current or suspected PID (208,216). The role of routine antibiotic prophylaxis for HSG is controversial, but in high-risk patients doxycycline could be considered (217). Recommended dosing is 100 mg twice daily, beginning the day before HSG and continuing for 3 to 5 days. If prophylaxis is not used and hydrosalpinges are noted on examination, postprocedure doxycycline treatment is recommended. Other rare complications of HSG include vascular intravasation, cervical laceration, uterine perforation, hemorrhage, vasovagal reactions, severe pain, and allergic response to the contrast dye (208).
Chlamydia Serology Chlamydia antibody testing appears to have comparable sensitivity and specificity to HSG but does not localize pathology and the utility of testing is controversial (211). It has been proposed that positive serologies in the setting of normal HSG should still prompt laparoscopy to rule out peritubal adhesions (207).