A 36-year-old nulligravida comes to the office for an infertility evaluation. Eight months ago, she was found to have a submucosal fibroid and underwent an uncomplicated hysteroscopic resection. The patient had light spotting for several days after surgery but no fever or abnormal vaginal discharge. Her last menstrual period was immediately prior to the procedure, but now she has monthly pelvic pain without bleeding. The patient has had regular, unprotected intercourse for the last 6 months without conception. She has no chronic medical conditions and has had no other surgeries. Vital signs are normal. The uterus is small, mobile, and nontender. Pregnancy test is negative. FSH, TSH, and prolactin levels are normal. Sexually transmitted infection screening is negative. A progesterone withdrawal test does not induce vaginal bleeding. Which of the following is the most likely cause of this patient's infertility?

Question

A 36-year-old nulligravida comes to the office for an infertility evaluation.  Eight months ago, she was found to have a submucosal fibroid and underwent an uncomplicated hysteroscopic resection.  The patient had light spotting for several days after surgery but no fever or abnormal vaginal discharge.  Her last menstrual period was immediately prior to the procedure, but now she has monthly pelvic pain without bleeding.  The patient has had regular, unprotected intercourse for the last 6 months without conception.  She has no chronic medical conditions and has had no other surgeries.  Vital signs are normal.  The uterus is small, mobile, and nontender.  Pregnancy test is negative.  FSH, TSH, and prolactin levels are normal.  Sexually transmitted infection screening is negative.  A progesterone withdrawal test does not induce vaginal bleeding.  Which of the following is the most likely cause of this patient's infertility?

Quizplus · Accepted Answer

11ec25c8_da0e_ea1e_bc81_b91a515a23dc_MD0003_00 Infertility is the inability to conceive after 6 months of unprotected intercourse in women age ≥35 (or after 12 months in women age <35). This patient's infertility and secondary amenorrhea after her hysteroscopic myomectomy is likely due to Asherman syndrome-the development of symptomatic intrauterine synechiae. Patients such as this one, who undergo intrauterine surgery (eg, hysteroscopic myomectomy, curettage), are at risk of damage to the endometrial basalis layer, which creates an inflamed, denuded endometrium that causes the uterus to adhere to itself, resulting in obliteration of the uterine cavity. The lack of endometrium results in the development of light menses, secondary amenorrhea, infertility (due to lack of implantation), and a negative progesterone withdrawal test (despite normal estrogen and progesterone levels). Some patients may have cyclic pelvic pain if the endometrial cavity is not totally obliterated due to small pockets of obstructed, proliferative endometrium. A hysteroscopy is performed for diagnosis and treatment via lysis of adhesions. (Choice A) Endometriosis causes cyclic pelvic pain (ie, dysmenorrhea) due to ectopic endometrial implants, which trigger intraabdominal inflammation, scarring, and distortion of pelvic architecture, resulting in a fixed, tender uterus. Although endometriosis causes infertility, it is not associated with amenorrhea. (Choice C) Uterine fibroids may recur and cause pelvic pain secondary to uterine enlargement and a mass effect on the bowel and bladder. In addition, intracavitary and submucosal fibroids are associated with infertility and recurrent spontaneous abortion. Although this patient has had fibroids, a recurrent fibroid would cause regular, heavy menses rather than amenorrhea, making this diagnosis unlikely. submucosal fibroids (Choice D) Tubal occlusion may occur due to adhesions from pelvic inflammatory disease, endometriosis, or prior pelvic surgery. Although tubal blockage is a common cause of infertility, this patient has none of these risk factors. pelvic inflammatory disease (Choice E) A uterine septum is a uterine lateral fusion defect resulting in 2 uterine cavities. Due to the small and poorly vascularized uterine cavities, patients with a septate uterus are at increased risk of recurrent spontaneous abortion, fetal growth restriction, and preterm delivery. A uterine septum does not cause amenorrhea or infertility. uterine septum Educational objective: Intrauterine synechiae (ie, Asherman syndrome) is a complication of intrauterine surgeries such as hysteroscopic myomectomy or curettage. Due to the scarring of the endometrial cavity, patients often have amenorrhea, infertility, and a negative progesterone withdrawal test. References: A comprehensive review of Asherman's syndrome: causes, symptoms and treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/28582327) Asherman's syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21437822)

A 36-Year-Old Nulligravida Comes to the Office for an Infertility