This chapter addresses the controversies surrounding the impact and surgical management of hydrosalpinges and uterine leiomyoma on in vitro fertilization (IVF) cycle outcome. Evidence accumulated over the last 15 years suggests that either unilateral or bilateral hydrosalpinges may exert deleterious effects on IVF cycle outcome. Hydrosalpinx fluid may have a direct embryotoxic effect and may also inhibit fertilization. This deleterious effect may be mediated by the presence of inflammatory cytokines present within hydrosalpinx fluid. Several groups have reported that only large hydrosalpinges, visible on ultrasound, resulted in reduced implantation and pregnancy rates. The impact of uterine leiomyomata specifically on the outcome of assisted reproductive technologies has been evaluated with conflicting results. Evaluation of the uterine cavity by hysteroscopy or sonohysterography should be a routine part of the pre-cycle evaluation. The accuracy of routine ultrasound evaluation and hysterosalpingography is more limited.

Usually investigation for infertility is carried out by gynecologists, because if a couple failed to conceive it has been traditionally expected that the woman has a problem and should visit a doctor. The general examination starts when the patient comes into the consulting room from observations of body habitus, skin, hair excess, gait and posture. Ultrasonography is a more accurate method compared with bimanual examination so more precise data about ovaries and uterus may be obtained with a transvaginal ultrasound probe than with palpation. The assessment of ovulation involves history, examination and investigation. At hysterosalpingography (HSG) radio-opaque dye is injected through the small canula via the cervix into the uterine cavity under X-ray screening. In patients with infertility, diagnostic hysteroscopy is usually combined with laparoscopy. X-chromosome abnormalities may affect fertility in women with Turner syndrome, especially in mosaic form.

This chapter discusses the usefulness of ultrasound in diagnosing normal and abnormal fallopian tubes using two-dimensional (2D) and three-dimensional (3D) transvaginal ultrasonography (TVS) and hysterosalpingo-contrast sonography (HyCoSy). HyCoSy involves the introduction of fluid into the uterine cavity and the fallopian tubes. The role of HyCoSy as a first-line procedure for the assessment of tubal patency has been examined in several studies. In most of the studies, the diagnostic capabilities of HyCoSy have been compared with the established reference methods of hysterosalpingography (HSG) or laparoscopy with dye insufflation, or both, and in the majority of the studies Echovist was used as the ultrasonographic contrast medium. A multicenter study in Scandinavia compared laparoscopic salpingectomy with no intervention prior to the first in vitro fertilization (IVF) cycle. The study demonstrated significant improvement in pregnancy and birth rates after salpingectomy in patients with hydrosalpinges that were large enough to be visible on ultrasound.

The classification of uterine anomalies divides the uterine septum into complete (septate) or partial (subseptate) groups according, respectively, to whether the septum approaches the internal os or does not. The complete septum that divides both the uterine cavity and the endocervical canal may be associated with a longitudinal vaginal septum. Although surgery (hysteroscopy, alone or with laparoscopy), constitutes the gold standard for the diagnosis of uterine septum, various imaging tools including hysterosalpingography (HSG), ultrasonography, and magnetic resonance imaging (MRI) have great value in the diagnosis, with high levels of accuracy. In infertility patients it is believed that incidentally discovered uterine septum and even arcuate uterus should be corrected hysteroscopically prior to any infertility treatment to enhance reproductive outcome. While the hysteroscopic approach for surgical resection of uterine septum is safe and effective, the choice of surgical technique (using sharp scissors or electrocautery) is an operator preference.

Hysterosalpingography (HSG) is the first diagnostic test used for patients with suspected mllerian anomalies. HSG can detect a two-chambered uterus and allow assessment of the size and extent of a septum. Two-dimensional (2D) ultrasonography was previously done by the transabdominal route, but transvaginal ultrasonography (TVS) is superior to the transabdominal route and is now the standard imaging technique for the uterus. The main advantage of three-dimensional (3D) ultrasonography over 2D is the ability to image the three orthogonal planes of the uterus, of which the coronal view is the most important. Sonohysterography is an ultrasound-aided technique that entails injection of normal saline into the uterine cavity. Many magnetic resonance imaging (MRI) studies have shown a very high sensitivity of 100%, and more recently values of 95% have been reported in cases of mllerian anomalies. Uterine mllerian anomalies have a high frequency of adverse obstetric implications.

Hysterosalpingography allowed gynecologists and infertility specialists to study the uterine cavity, shape, and any abnormalities that could result from either congenital problems or acquired disease processes. Irregular uterine bleeding is not an uncommon phenomenon during reproductive period. Many of these cases are dysfunctional uterine bleeding that require endocrine evaluation as well as hematologic studies. Salpingography identifies a normal fallopian tube lumen or abnormalities related to iatrogenic factors such as tubal sterilization or pathology as a result of infection and various kinds of obstructive disease. Various pathological conditions have been identified in the isthmic portion of the fallopian tube with the use of hysterosalpingography. One of these conditions is salpingitis isthmica nodosa. Fallopian tube disease is the single most common cause of infertility and women routinely undergo hysterosalpingography in the course of the infertility work-up to evaluate this factor.

Female fertility begins to decline many years before menopause, despite continued regular ovulatory cycles. Decreased fecundity with increasing female age has long been recognized in demographic and epidemiological studies. Traditionally, the evaluation of the infertile female consists of: (i) ovulation assessment (ovulatory factors), (ii) evaluation of the uterine morphology (ovulation assessment) and tubal patency (tubal factors), (iii) assessment of the presence of pelvic pathology (by laparoscopy) (peritoneal factors), and (iv) postcoital test (cervical factors). Hysterosalpingography (HSG), laparoscopy are widely used in assessing infertility. Chlamydia antibody testing is a screening method for assessing tubal infertility. HSG, sonohysterography, hystero-salpingo contrast sonography (HyCoSy), magnetic resonance imaging (MRI) and hysteroscopy are used in assessment of uterine factors related to infertility. Currently, the best method to monitor ovulation is transvaginal ultrasound, which can be used to demonstrate the growth of a dominant follicle and provide presumptive evidence of ovulation and leutinization.

This chapter presents a comprehensive review of the reproductive problems that could be associated with uterine septum. The classification of uterine anomalies divides the uterine septum into complete (septate) or partial (subseptate) groups, according to whether the septum approaches the internal os or not, respectively. Although surgery (hysteroscopy, alone or with laparoscopy) constitutes the gold standard for the diagnosis of uterine septum, various imaging tools including hysterosalpingography (HSG), ultrasonography, and magnetic resonance imaging (MRI) have great value in the diagnosis with high level of accuracy. The hysteroscopic approach for surgical resection of uterine septum is a safe and effective approach. While generally it is an operator preference whether to utilize ablative energy, for example, electrical diathermy or laser, or to utilize sharp scissors without energy, the outcome of treatment is comparable as regards complication and reproductive performance after surgery.