Differential Diagnosis for Infertility
The patient's presentation suggests a complex interplay of factors contributing to her infertility. The following differential diagnosis is organized into categories to facilitate a structured approach:
Single most likely diagnosis
- Asherman's syndrome: This condition, characterized by intrauterine adhesions, is a likely cause of the patient's infertility given her history of hysteroscopic resection of a submucosal fibroid. The procedure can lead to the formation of adhesions, which may cause menstrual abnormalities, such as amenorrhea or hypomenorrhea, and infertility. The patient's symptoms of monthly pelvic pain without bleeding and the failure of the progesterone withdrawal test to induce vaginal bleeding support this diagnosis.
Other Likely diagnoses
- Intrauterine scar tissue or synechiae not extensive enough to be classified as Asherman's syndrome: Even if not severe enough to meet the full criteria for Asherman's syndrome, any degree of intrauterine scarring could potentially interfere with implantation of an embryo, thus contributing to infertility.
- Endometrial damage or atrophy: The patient's history of surgery and subsequent lack of menstrual bleeding could indicate damage to the endometrial lining, which is essential for implantation of a fertilized egg.
- Anatomical issues related to the fibroid resection: Although the surgery was uncomplicated, there could be unforeseen anatomical changes or residual effects from the fibroid or its removal that affect fertility.
Do Not Miss diagnoses
- Uterine perforation with potential bowel or bladder injury: Although the patient did not exhibit immediate post-surgical complications like fever or abnormal discharge, a delayed presentation of a perforation injury could lead to significant morbidity if not identified and treated promptly.
- Infection or abscess formation: Despite the lack of symptoms suggestive of infection, it is crucial to consider and rule out any infectious process that could have developed post-surgery, as it could severely impact fertility and overall health.
Rare diagnoses
- Rokitansky syndrome or other Müllerian anomalies: These congenital anomalies of the female reproductive tract are rare but could be considered if other diagnoses are ruled out, especially given the patient's nulligravid status and lack of conception despite regular unprotected intercourse.
- Autoimmune disorders affecting fertility: Certain autoimmune conditions can impact fertility, although they would be less likely given the patient's normal screening tests and lack of other symptoms suggestive of an autoimmune process.