Discussion.
1) Subfertility.
Subfertility is defined as conception has not occurred after 12 months of regular unprotected intercourse. It can be classified as primary and secondary infertility. Primary subfertility is a couple without prior or pregnancy while secondary subfertility is a couple with a prior to pregnancy. There are many causes which bring to subfertility. Table below shows percentages and causes by NICE guidelines 2013.
Causes
Percentages
Male Factor
30%
Ovulatory factor
25%
Tubal
20%
Uterine or peritoneal
10%
Unexplained
25%
Coital or cervical
The discussion will more focus on tubal subfertility because more related to the case.
Tubal subfertility need to be investigated to assess if the tube is severely occluded or not. The investigations are: o Hysteroscopy, lap and dye. o Hysterosalpingogram. o Hystero-contrast sonosalpingography (HyCoSy) o Chromopertubation – invasive procedure.
However, an ideal investigation is not yet to be found but HyCoSy is considered as the gold standard for assessment of tubal patency and pathology [1].
Tubal reconstruction is a procedure that can improved tubal patency that can led to fertility. The surgical treatment can be divided based on the site of the occlusion. o Proximal occlusion.
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It is a leading cause of maternal death in the 1st trimester about 16.7/100,000 patient. The common site of ectopic pregnancy is at the distal part of the fallopian tube which is the ampulla about 97% and isthmus, proximal part of the fallopian tube is the 2nd commonest site about 4%. Other than that are cornual 2.5%, ovary 0.4%, cervix 0.1% and abdominal 0.03%. In her case, the ectopic pregnancy can happen in the tube and it is likely will be either one of the sites. There are many risk factors that can contribute to ectopic pregnancy and it can be divided to high, moderate and low risk as it shows in the table below