Undescended fallopian tubes and ovaries: a rare incidental finding during an infertility investigation work up

Abstract

Congenital anomalies of tubes and ovaries are quite uncommon. Failure of descent of the ovary has been reported in the literature. Evans and Cade presented the first case while Walker made references to another three cases (1–3). Transabdominal migration of the testis compared with the ovary occurs at the 10–15 weeks of gestation in the human and inguinoscrotal migration occurs at 26–35 weeks of gestation (4). Hutson et al. previously proposed that the first phase of migration is controlled by mullerian inhibiting substance, although this remains controversial. The second phase is androgen dependent and is possibly mediated indirectly through the release from the genitofemoral nerve of the neuropeptide calcitonin gene-related peptide. This paper is the first reported case of such malpositioned organs as an incidental finding during the routine infertility investigation work-up A 19-year-old female, gravida 0, presented with a desire to bear children with a history of unprotected intercourse for 1.5 years in duration. Her menstrual periods were regular, 25 days interval with 7 days of normal amount of bleeding. On the speculum examination the cervix was normal in appearance. On bimanual examination, the uterus was retroverted and normal in size. Transvaginal ultrasonographic examination failed to demonstrate both ovaries. Cycle day 3 plasma FSH, LH, PRL and TSH levels were all in normal laboratory ranges. Her husband's semen parameters revealed normal values. Hysterosalpingography revealed a bicornuate uterine appearance with bilateral tubal extending all the way up to the level of the third lumbar vertebra. Tubal patency was confirmed by the visualization of the radioopaque fluid in paracolic area. There was no dye found in the pelvic localization. 1-3 Hysterosalpingographic appearance of the case. Note the uterine biocornuate shape. Left tube extending to the hypocondriac area and distribution of the radioopaque dye. Right Tube extending to the right hypocondriacarea and tubal passage of the dye. A diagnostic laparoscopy was performed. Left and right tubes were extending cranially to the hipocondriac areas crossing the iliac vessels and ureters anteriorly on both sides.Figures 4–6. Methylene blue passed from the fimbrial ends of both tubes. Panoramic view of the internal genitalia. Fig. 5. Right adnexial structure. Fig. 6. Right proper ligament of the ovary and the right tube crossing the iliac vessels. There are reports in the literature about undescended ovary and its relation with the adverse reproductive outcome. Seoud et al. reported a case of a ruptured ectopic pregnancy in an undescended fallopian tube. The tube and its ipsilateral ovary were located near the splenic flexura of the colon (5). Knudsen and Clausen reported an ectopic pregnancy in a non-communicating undescended fallopian tube. A rare embryological failure in development consisted of a right hemiuterus, remotely located non-communicated left fallopian tube and undescended left ovary; associated with the agenesis of the left kidney (6). They suggested that a non-communicating fallopian tube should be removed to prevent ectopic pregnancy; immediately when recognized. Granat et al. reported the first case of pregnancy in the proximal end of a fallopian tube situated in the left upper quadrant, attached to the peritoneum (7). However, in their patient, the ipsilateral ovary was found in the mid-abdomen and both structures were unattached to the pelvic organs by any structure. All three cases in the literature have occured in the undescended fallopian tubes. Authors have thought that ectopic pregnancies found in the undescended tubes could have occured via transperitoneal migration of the sperm through the normal contralateral tube. There are reports in the literature unrelated to adverse reproductive outcome. Machiels et al. presented a case of ectopic ovary in a 5-month-old-baby in the left labia majora (8). Kriplani et al. and Peedicayil et al. reported ectopic ovaries in the omentum (9, 10). The ectopic ovary in a stillborn female is the first report described by Lachman and Berman (11). Carosso and Rickenbacher presented an ectopic avary and fallopian tube without fimbriated end in a 17-year-old-female with a retroperitoneal cystic tumor (12). Peer et al. published a case of bilateral adnexal agenesis with an ectopic ovary (13). We present a rare case that is well documented and illustrated, but we are not able to explain why this patient is infertile. Apparently the major risk is ectopic pregnancy and the review of the literature on this complication could be more elaborated and the results tabulated. From this point of view our case is unique in the literature for being both tubes and ovaries undescended may be a causative factor for infertility. We would like to emphisize that under the light of this limited literature, in the case of undescended ovaries and tubes, there is a need of investigation whether this rare event may cause infertility.