TUBAL INTRAMURAL POLYPS AND THEIR RELATIONSHIP TO INFERTILITY

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1 FERTHJTY AND STERILITY Copyright c 98 The American Fertility Society Vol. 36, No.6. May 98 Printed. in U.SA. TUBAL INTRAMURAL POLYPS AND THEIR RELATIONSHIP TO INFERTILITY MENACHEM P; DAVID, M.D.* DAVIDBEN-ZWI, M.D. LEAH LANGER, M.D. Departments of Obstetrics and Gynecology "B" and Diagnostic Radiology, Municipal-Governmental MediCal Center, Serlin Maternity HoSpital and The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel In a search for polyps in the intramural portion of the fallopian tubes, 6 hysterosalpingograms were reviewed. In cases polyps of different size and form were detected. Correlation of the findings with fertility histories and follow-up revealed that about one-half (6%) of the women with polyps did not conceive. Among both women who conceived- and those who did not were women who had been treated for some other cause of infertility and also women of infertile couples who were classified as infertile normal. The results of this study suggest that women with tubal polyps should be regarded as having relative subfertility and should be treated for other causes of infertility if such exist. However, when treatment fails, and also in cases of unexplained infertility, the polyps should be regarded as a possible causal factor and surgical treatment should be considered. Fertil Steril 3:6; 98 The existence-of polyps in the intramural portion of the fallopian tubes was first described by Philipp and Huber l in four infertile women with diffuse endometriosis. Lisa et al. found a rather high incidence (33%) of these polyps in operated uteri. Only a few additional studies of this subject have been published and they are summarized in Table. 3-0 In all instances the diagnosis was established _ at hysterosalpingography, which in most cases was performed for investigation of infertility. In most groups who dealt with tubal polyps there -arose the question of a possible causal relationship between the infertility of the women and radiologic findings ofintramural tubal polyps. Some even tried sur.gical correction in a few women whose infertility was otherwise unexplained; however, all of these reported conventional tubal implantations were unsuccessful. 6, 7 Consequently; Gaudefroyet al. lo rejected Received July, 980; revised and accepted November 0, 980. *Reprint requests: Menachem P. David, Head, Department of Obstetrics and Gynecology "B," Serlin Maternity Hospital (Hakirya), P.O. Box 7079, Tel-Aviv, Israel. 6 the idea of surgical treatment but they still questioned the role of polyps in infertile women, Because of the doubts of other authors and our earlier interest, 7 we decided to review all hysterosalpingograms obtained in our hospital for 0 consecutive years in a search for tubal polyps in the intramural region of the tubes and to correlate the findings with the case histories of the patients. MATERIALS AND METHODS A review was made of 6 hysterosalpingograms obtained between 969 and 979. Fifty-four cases of intramural polyps were diagnosed and divided into four groups (Table ). Representative x-ray pictures of the different groups are depicted in Figures to 8. The frequency of polyps in our patient population was.%. Thirty-four additional cases of unilateral filling defects of small size were observed. In order to eliminate the possibility of false-positives and to ensure that only doubtless cases of polyps, according to our roentgenologic criteria, were included in the study these cases were eliminated from the series.

2 Vol. 3, No. TUBAL INTRAMURAL POLYPS AND INFERTILITY 7 TABLE. Summary of Literature Dealing. with Tubal Polyps Reference No. of cases (confinnation) Philipp and Huber! (939) (pathology) Lisa et a. (9) 33 (pathology) Zen~k3 (99) 0 (x-ray) Fernstrom and Lagerlof' 6 (x-ray, clinical) (96) Bret and GrepinetP (96) (x-ray, clinical) Btet and Grepinet } 6 (967) David and Soferman 7 (x-ray, clinical) (968) Gaudefroy and Empereur- Buisson 8 (968) Gaudefroy et al. 9 (969) 60 (x-ray, clinical) Gaudefroy et a. 0 (970) Frequency No. with histologic proof No. infertile 33.% 3 7 (7%).% 0 (%) (0%).3% 3 (3%) The case histories of the patients with polyps were then reviewed with special attention to the fertility histories of the patients as well as the follow-up oftheir fertility status after hysterosalpingography (HSG). All factors possibly responsible for infertility and all treatments given for such problems were noted. Eight case histories could not be recovered and thus only 6 cases are included in the final analysis. ceived after the polyps were documented at the HSG (Table 3). The conception rates before and after HSG were almost identical. Conception after HSG as Related to Indication for HSG. Conception rates f6r women who conceived after the detection of polyps were lowest among women with primary infertility and highest among women for whom HSG had not been RESULTS An initial analysis of the cases according to the different groups showed similar distributions of most parameters considered in the study. Also, the number of cases in each group was too small for an analysis of each group separately. Therefore the results presented were accumulated for the complete group. Conception before and after HSG. Some of the women in the study had conceived once or more before HSG, and there was no way of determining whether the polyps were present before these conceptions. Some of these women and others con- TABLE. Grouping of Patients with Tubal Polyps According to Size and Location of Polyps Size and location of polyps Frequency in 6 HSGs No. % Group : bilateral, large 0. (;;., mm) Group : bilateral, large 0. and small Group 3: unilateral, large Group : bilateral, small 3.06 «mm) Total. FIGS. (TOP) AND (BO'ITOM). Bilateral, large polyps.

3 8 DAVIDETAL. May 98 FIos. 3 (TOP) AND (BOTl'OM). Bilateral polyps, large and small. FIos. (TOP) AND 6 (BOTl'OM). Unilateral large polyps. perfonned. for infertility but for other reasons such as repeated abortions and cervical incompetence (Fig. 9). Possible Causes of Infertility. In 8 cases the infertility could be explained by a reasonable and detectable disturbance. Since there was no awareness of the possible role of polyps in the infertility problem at the time of perfonnance of HSG, the couples were treated according to the detected disturbance and as a result women (0%) conceived. In 7 instances no reasonable explanation for infertility could be found; therefore no treatment was instituted. Eleven women of this group conceived and six remained infertile and were thus regarded as infertile nonnal (Fig. 0). Insufficient infonnation could be gathered. from the file of one woman, only the fact that she had not conceived. The most common diagnosis in the group with detectable disturbances was anovulation (including two patients with Stein-Leventhal syndrome). The conception rate after treatment was high (8 of women conceived). When other infertility fac- tors and combinations offactors were involved, the conception rate was much lower (Fig. ). Analysis of Patients Who Did Not Conceive. Of the group of 6 women, did not conceive after the presence of polyps was documented by HSG. Fourteen had reasonable explanations for their primary or secondary infertility and were treated without success, and six were classified. as having unexplained infertility. There were no significant differences among the various groups with polyps, except for the lower incidence of infertility in group 3, with large polyps unilaterally (Table ). DISCUSSION The aim of this study was to examine and evaluate the role of polyps in infertility. In assessing our case histories we came to understand the doubts expressed. in previous publications regarding the causal relationship between tubal polyps and infertility. There are two major reasons for these uncertainties: () A considerably high number of women conceive after the detection of polyps, that

4 Vol. 3, No. TUBAL INTRAMURAL POLYPS AND INFERTILITY 9 II) I Z III ;: 0 ct Q. o CONCEIVED o DID NOT CONCEIVE.:; Z o PRIMARY STERILITY SECONDARY STERILITY OTHER INDICATIONS FIG. 9. Conception rate related to indication for HSG. FIGS. 7 (TOP) AND 8 (BOTTOM). Bilateral small polyps. is, with their presence. () Many women who do not conceive have reasonable functional or organic disturbances which alone can explain their infertility. In previous publications the incidence of infertility was stated to be between 7% and 3%. In our series, women did not conceive (6%). There were women who conceived and women who did not conceive both among those with reasonable explanations for their infertility and those without any detectable cause (Table ). These findings may be explained by two primary conclusions.. Since half of the women with clearly defined fertility disturbances conceived after treatment, treatment seems indicated even in the presence of the polyps. This statement is especially valid in cases of anovulation, where the success rate is TABLE 3. Summary of Conceptions Related to HSG Patients who conceived Patients who did not conceive Before HSG (8%) (%) After HSG (%) (6%) highest. Whether induction of ovulation also acts directly on the size of the polyps or on some of their other characteristics can only be speculated upon. Such speculations are based on knowledge that the histologic structure of polyps is endometrial., -6 The qualification in the statement suggesting treatment is whether treatment in presence of polyps should be time-limited. Prolonged treatment is expensive in terms of cost of medication, patient's time, and additional laboratory studies. It is also a stress-creating situation. Procrastination of other possible forms of treatment can diminish the patient's chances for conception because of her advancing age. VI I- 0 z... / j: ct Q. - 0 /0.,; z o ~ CONCEIVED o DID NOT CONCEIVE (jj) TOTAL WITH WITHOUT UNKNOWN CAUSE CAUSE for for STERILITY STERILITY FIG. 0. Conception rate related to presence or absence of infertility factors.

5 T 30 DAVID ET AL. 8 TABLE. Summary of Conceptions Related to Existence of Cause of Infertility May 98 0 Ea CONCEIVED.,.. D OlD NOT CONCEIVE z ~.. : 'l; 0 z " TOTAL ANOVUlATION MALE MECHANICAL ANOVULATION MECHAN ANOVUL FACTOR FACTOR a MALE a MALE a FACTOR FACTOR MECHAN. FACTOR FIG.. Conception rate in patients treated for detected fertility disturbances. In view of these arguments it seems reasonable that, when all detectable causes of infertility have been corrected but conception has not occurred, the case should be reevaluated. On this occasion the possible role of polyps should be assessed. The duration of treatment after detection of polyps should be determined individually for each case with regard to all of the above-mentioned reservations.. Some women without any obvious reason for their infertility conceived after the detection of the polyps. Thus polyps cannot be regarded as an absolute cause of infertility. However, the fact that some of these women had initial difficulty in becoming pregnant and there remained some who could not conceive is suggestive of some role of polyps in fertility problems. We suggest defining this role as relative subfertility. Previous publications and our study indicate that there are patients who will not conceive for TABLE. Causes of Infertility Among Women Who Did Not Conceive Cause Anovulation Male factor Mechanical (tubal or peritoneal) factor Mechanical and male Anovulation and male Total with cause No detectable cause Unknown Total Group : BL : B.8 3: UL : BS 8 6 Total BL, bilateral large polyps; BLS, bilateral large and small polyps; UL, unilateral large polyps; BS, bilateral small polyps. Women who conceived Women who did not conceive With reasonable cause of infertility Without reasonable cause of infertility Unknown 6 long periods of time and some who will not conceive at all. These comprise both women who have been treated unsuccessfully and women whose infertility remains unexplained. Forty-six per cent of patients in our study did not conceive during follow-up periods of to 0 years. These patients pose the question of further management of a problem for which no solution has yet been found. Hormone treatment aimed at diminishing the size of the polyps has thus far been unsuccessful. 6, 0 Some authors, 6, 7 have tried a surgical approach, resecting the intramural portion of the tube and the polyp and reimplanting the tube into the cornual region by one of the conventional methods. So far no successful results have been reported. Microsurgery has recently been applied by Boeckx et al. in a few cases of tubal cornual polyps in unexplained infertility; however, results with this procedure have not yet been published. The results of the present study do not clarify the role of intramural tubal polyps beyond the definition of relative subfertility. However, occasionally a patient with long-standing infertility is encountered whose only abnormality is unilateral or bilateral tubal polyps as demonstrated by HSG. The decision of whether or when to suggest surgical therapy will have to be made on an individual basis until additional data are collected. Surgical techniques different from the previously unsuccessful ones, such as microsurgery or the implantation method of Peterson et al., might eventually prove to be beneficial. REFERENCES. Philipp E, Huber H: Cause of endometriosis with contribution on the pathology of the interstitial portion of the tube. Zentralbl Gynaekol 67:7,939. Lisa GR, Gioia JD, Rubin IC: Observation on the interstitial portion of the fallopian tube. Surg Gynecol Obstet 99:9, 9 3. ZeniAek L: Die Salpingogramme bei der Endometriumhyperplasie. Fortschr Roentgenstr 90:, 99

6 Vol. 3, No. TUBAL INTRAMURAL POLYPS AND INFERTILITY 3. Fernstrom L, LagerlofB: Polyps in the intramural part of the fallopian tubes. J Obstet Gynaecol Br Commonw 7:68, 96. Bret HJ, Grepinet J: Polypes endometriaux de l'extremite uterine de la trompe. Bull Fed Soc Gynecol Obstet Fr 7:677,96 6. Bret HJ, Grepinet J: Polypes endometriaux de la trompe. Leur rapport avec la sterilite et l'endometriose. Sem Hop Paris 3:83, David MP, Soferman N: Tubal polyps: report of four cases. Int Surg 9:38, Gaudefroy M, Empereur-Buisson R: Polypes endometriaux de la portion intramurale de la trompe. J Sci Med Lille 86:63, Gaudefroy M, Empereur-Buisson R, Sailly E: Les polypes endometriaux de la portion intramurale de la trompe. C R Soc Fr Gynecol 39:99, Gaudefroy M, Empereur-Buisson R, Sailly E: Les polypes endometriaux de la portion intramurale de la trompe. Rev Fr Gynecol 6:7, 970. Boeckx W, Brosens I, Gordts S, Vasquez G: Tubal cornual polyps: microsurgical polypectomy and cornual anastomosis. (Abstr.) Presented at the Fifth European Congress on Sterility, Venice, October 978, p 7. Peterson EP, Musich JR, Behrman SJ: Uterotubal implantation and obstetric outcome after previous sterilization. Am J Obstet Gynecol 8:66, 977