Methods of Diagnosis Without Fertiloscopy
At the present time, the initial diagnostic testing that is carried out is limited. Diagnosis of ovulatory problems is routinely carried out at an early stage and is not mentioned further in this paper.
Physical abnormalities of the fallopian tubes, including blockage and mucosal damage, and in the pelvic cavity, including endometriosis and adhesions, are not generally subjected to a comprehensive diagnosis in most countries. The same applies to uterine abnormalities.
The normal diagnostic practice is as follows:
- Blockage of the fallopian tubes is mainly diagnosed today by hysterosalpingography (HSG) or Hystero Contrast Sonography (HyCoSy) in which either X-ray contrast media or aqueous fluid are forced up the fallopian tube to create an image on X-ray or ultrasound. This image demonstrates (or excludes) the possibility for sperm to swim up and for ova to migrate downwards.
- In earlier times, a technique known as a "Laparoscopy and Dye" (Lap and Dye) test was used in which dye was forced up the fallopian tube and its presence observed in the pelvic cavity during laparoscopic surgery.
- The literature indicates that HSG has very poor predictive value (15% false positives and 30-35% false negatives). The relative merits of these techniques are currently being debated, but for the purposes of this document the important point is that they only diagnose the presence of a passage through the tube, and give little information about the condition of the tubal mucosa.
- Again, the paper by Papaiannou, Afnan and Jafettas makes useful reading in this regard.
- There is no convenient method for assessing the condition of the tubal mucosa (Salpingoscopy), which in theory could be carried out during laparoscopy. This is because the point of entry to the abdomen for conventional laparoscopy is such that the distal end of the fallopian tube points away from the point of entry, and is thus inaccessible. Thus Salpingoscopy can only be carried out if a second laparoscope is inserted in a different place, requiring two complete sets of equipment. For this reason the technique is unsuitable for routine use
- Moreover, even if Salpingoscopy is carried out in individual cases, the macroscopic examination is not fully revealing. It has been found that, on microscopic examination, cellular damage can often be seen in cases where the macro structures are intact. Obviously, this technique is not routinely used, for the same reasons as apply to Salpingoscopy
- This means that, at the present time tubal patency is diagnosed rather inaccurately with HSG or HyCoSy, but very few patients are assessed for the condition of their mucosa in spite of the fact that damaged mucosa affect more patients than have blocked tubes.
- In relation to other pelvic organs, some abnormalities (such as myomas and some cases of endometriosis) can be identified by ultrasound, but other endometriosis and adhesions can only be identified by laparoscopy. The problem is that ultrasound does not find all of these (especially adhesions), and laparoscopy (as previously stated) is too costly and traumatic to be commonly employed as a primary diagnostic tool in the early stages of assessment
- A full hysteroscopy is not often carried out. As a result the possibility of uterine abnormalities is not normally assessed at the outset of treatment
The overall conclusion is that:
- The most important pelvic abnormalities are never diagnosed in the early stages of assessment
- The state of the fallopian tubes is only incompletely assessed, and therefore
- No rational choice can be made between: expectant management or IUI; tubal surgery; surgery for removal of endometriosis and/or adhesions; surgical treatment of uterine abnormalities, or IVF/ICSI
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