An audit of investigation of tubal disease in couples seen in fertility clinic at Shrewsbury and Telford Hospitals, 2009 Dr. Vanishree L Rao, ST3 LAT Shrewsbury and Telford Hospitals NHS Trust Welsh Obstetrics and Gynaecology Society Meeting 25/03/2011
Background Tubal disease is present in 25 35% of female infertility 1
NICE guidelines for investigation of subfertile couples 2 - Assessing tubal damage Hysterosalpingography or hysterosalpingo-contrast ultrasonography or chlamydia antibody titre are methods to screen for tubal disease Women with history suggestive of comorbidities should be offered laparoscopy
Chlamydia antibody titre and tubal disease The incidence of tubal disease in women with positive chlamydia antibodies depends on the titre of antibodies 3 Chlamydia antibody titre 1 in 256 55 Incidence of tubal disease(%) 1 in 512 70 1 in 1024 80 1 in 2048 90 1 in 4096 100
Tubal damage in infertile women: prediction using chlamydia serology 3
Hull and Rutherford staging of tubal disease 4
Pregnancy rate in tubal disease in women <40 years post surgery 5 Grade of tubal disease Pregnancy rate postsurgery Grade 1 70% Grade 2 60% Grade 3 20%
Methodology All women presenting to Shropshire and Midwales Fertility Centre in the year 2009 Download of all chlamydia antibody results Download of all HSG results Review of clinic letters for all couples presenting in 2009 with positive chlamydia antibodies Review of all operative notes for those women surveyed who underwent laparoscopy
Results Number of couples seen in 2009 = 522 Number of women who had serum screening for chlamydia antibody = 477 (91%) 9% not screened because either they were previously screened or were lost to follow up Number of screened women with negative chlamydia antibody (titre 64) = 337 (70%) Number of screened women with positive chlamydia antibodies ( 128) = 140(30%)
Distribution of chlamydia antibodies 60 55 (12%) 50 48 (10%) 40 30 28 (6%) 128 256 512-768 1024 20 10 9 (2%) 0 128 256 512-768 1024
Laparoscopy in infertile women with positive CAT ( 128) total 35 140 1024 12 28 number who had laparoscopy total number of women 512-768 18 55 128-256 5 57
Exclusions to perform laparoscopy Sperm swim up consistently 1 million/ml Severe ovarian decline or ovarian failure Chlamydial antibody titre <512
52 5 7 6 2 8 3 14 2 6 Reason for not doing laparoscopy CAT <512 other laparoscopy not discussed or no reason given lost to follow up conceived while awaiting further investigation given clomiphene with laparoscopy delayed poor ovarian reserve and poor sperm function sperm swim up 1 million/ml and poor sperm function obesity ovarian decline or advanced maternal age
Tubal disease in all laparoscoped women (n=35) 1, 3% 12, 34% 12, 34% normal grade1 grade 2 grade 3?grade 3, 9% 7, 20%
Titre 512-768 (n=18) 1, 6% 5, 28% 6, 32% normal grade 1 grade 2 grade 3?grade 1, 6% 5, 28%
Titre 1024 (n=12) 4, 33% 4, 33% normal grade 1 grade 2 grade 3 2, 17% 2, 17%
Titre 128 and 256 (n=5) 2, 40% normal grade 3 3, 60%
HSG Number of women screened with HSG=313 (59%) 41% not screened because Previously screened Investigated elsewhere Lost to follow up Needed laparoscopy Suitable for IVF only
HSG (n=313) 10, 3% 49, 16% normal abnormal failed 253, 81%
10, 3% 8, 2.5% 2, 0.5% 6, 2% 14, 4% 19, 6% Abnormal HSG (n=49) failed HSG uterine abnormality combination hydrosalpinx distal block proximal block 0 2 4 6 8 10 12 14 16 18 20
1 5 7 3 1 10 2 2 Reasons for not doing laparoscopy when HSG abnormal or failed on waiting list others lost to follow up conceived while awaiting investigations poor ovarian reserve and poor sperm function poor sperm function obesity ovarian decline or advanced age 0 2 4 6 8 10 12
Proximal block Number with suspected proximal block = 19 Laparoscopy done in 9 Proximal block confirmed in 3 (33%) 6 5 4 3 2 3 2 bilateral unilateral 1 0 2 1 1 normal grade 2 grade 3
Distal block Number of women with suspected distal block = 14 Laparoscopy done in 4 Distal block confirmed in 2 (50%) 2.5 2 1.5 1 2 bilateral unilateral 0.5 1 1 0 normal grade 2 grade 3
Hydrosalpinx on HSG Number of women = 6 Laparoscopy done in 2 Hydrosalpinx confirmed in 1 1.2 1 0.8 0.6 0.4 0.2 0 1 1 normal grade 3 bilateral unilateral
Combination Number of women = 2 Proximal block + hydrosalpinx = 1 Proximal + distal block = 1 1 0.5 0 1 1 normal garde 3 proximal block+hydrosalpinx proximal+distal block
Uterine abnormality on HSG 4.5 4 4 3.5 3 3 2.5 2 unicornuate bicornuate subseptate 1.5 1 1 0.5 0 unicornuate bicornuate subseptate
Uterine abnormality contd., Number of women = 8 (16%) 4 had hysteroscopy 1 had laparoscopy contrary tube patent, grade 1 disease
Failed HSG Number of women = 10 Laparoscopy done in 3 2 2 1.5 1 0.5 1 number of women 0 normal grade 1
Conclusions 1 - Chlamydial Antibodies 30% of screened infertile women had positive chlamydia antibody titres 18% of screened women had high titres ( 512) 25% with positive CAT s had laparoscopy 34% of these had no visible tubal disease 66% had tubal disease 34% had severe tubal disease
Conclusions 2 - Chlamydial antibodies At high titres( 1500), 100% had tubal disease and 50% had severe tubal disease Even at low positive titres, 40% had tubal disease at laparoscopy
Conclusions 3 - HSG 16% (49/313) of women screened with HSG had abnormal result 37% (18/49) of these were further investigated with laparoscopy 50% (9/18) had normal laparoscopy HSG has poor sensitivity to diagnose tubal damage, but is good to confirm tubal patency
Area of good practice Good documentation of chlamydia serology results
Recommendations 1 To offer laparoscopy for all women with positive chlamydial antibodies, regardless of titre, except where IVF/ICSI is appropriate To review HSG as a screen for tubal damage and consider Hycosy To document tubal disease found on laparoscopy for infertile women according to Hull and Rutherford classification
Recommendations 2 To document in the notes the reason for not offering laparoscopy in women with positive chlamydial antibody titres To re audit annually
References 1. Serafini P, Batzofin J. Diagnosis of female infertility. A comprehensive approach. J Reprod Med 1989;34:29 40 2. National Institute for Clinical Excellence. Assessment and Treatment for People with Fertility Problems. London: RCOG Press; 2004 3. Akande VA, Hunt LP, Cahill DJ, Caul EO, Ford WC, Jenkins JM. Tubal damage in infertile women: prediction using chlamydia serology. Hum Reprod 2003;18:1841 7 doi:10.1093/humrep/deg347
4. Rutherford AJ, Jenkins JM. Hull and Rutherford classification of infertility. Hum Fertil (Camb) 2002;5(1 Suppl):S41 5. 5. Akande VA, Cahill DJ, Wardle PG, Rutherford AJ, Jenkins JM. The predictive value of the Hull & Rutherford classification for tubal damage. BJOG 2004;111:1236 41. doi:10.1111/j.1471-0528.2004.00408
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