Citation Nr: 1329169 Decision Date: 09/11/13 Archive Date: 09/17/13 DOCKET NO. 09-10 738 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for a gynecological disorder, to include residuals of a tubal occlusion, status post cannulation (claimed as infertility). REPRESENTATION Appellant represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION The Veteran served on active duty from September 1983 to May 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision of the Huntington, West Virginia Regional Office (RO) of the Department of Veterans Affairs (VA), which denied the benefits sought on appeal. This case was subsequently transferred to the RO in Atlanta, Georgia. This case was previously before the Board in August 2012 at which time it was remanded for more development. The Board notes that the issue in this case has previously been phrased as entitlement to service connection for residuals of a tubal occlusion, status post cannulation (claimed as infertility). However, the Board observes that the medical evidence of record reveals additional gynecological disorders which existed prior to the Veteran's in-service tubal occlusion, status post cannulation. In June 2013 correspondence the Veteran suggested that her many gynecological disorders are related to her endometriosis, which, she claims, was diagnosed in service. Notably, the only gynecological-type disorder for which the Veteran is already service connected is anemia. The September 2012 VA gynecological examination report below notes several gynecological disorders which were not considered to be residuals of a tubal occlusion, status post cannulation for which service connection has been granted below. Significantly, the September 2012 VA examiner noted that the Veteran was diagnosed with endometriosis and dysmenorrhea during her military service. Thus, the Board has recharacterized the issue as "entitlement to service connection for a gynecological disorder, to include residuals of a tubal occlusion, status post cannulation (claimed as infertility)" to reflect a broad definition of the claim. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (a claimant without medical expertise cannot be expected to precisely delineate the diagnosis of his mental illness; he filed a claim for the affliction his mental condition, whatever it is, causes him). In the August 2012 Board remand, the Board noted that the issues of: entitlement to special monthly compensation for the loss of use of a creative organ and entitlement to a temporary total evaluation for the March 15, 2008, urethral repair surgery had been raised by the record (see Veteran's Statement, April 23, 2008), but had not yet been adjudicated by the Agency of Original Jurisdiction (AOJ). It appears that the RO has not yet adjudicated these issues. Therefore, as the Board does not have jurisdiction over these issues they are, once again, referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The medical evidence suggests that the Veteran experiences residuals of her in-service tubal occlusion, status post cannulation (claimed as infertility) to include the Veteran's February 2008 total abdominal hysterectomy and resulting laceration of the right ureter along with chronic pelvic pain, adhesions, and uterine fibroids. 2. The medical evidence shows that the Veteran was diagnosed with endometriosis and dysmenorrhea during military service and has current diagnoses of each disorder. CONCLUSION OF LAW Service connection for a gynecological disorder, to include residuals of an in-service tubal occlusion, status post cannulation, specifically, the Veteran's February 2008 total abdominal hysterectomy and resulting laceration of the right ureter along with chronic pelvic pain, adhesions, and uterine fibroids, is warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION In light of the fully favorable determination in this case, no further discussion of compliance with VA's duty to notify and assist is necessary. The Veteran asserts that she suffers from residuals of an October 2004 in-service tubal occlusion, status post cannulation (claimed as infertility). Legal Criteria Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Disorders diagnosed after discharge may still be service connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 38 U.S.C.A. § 5107(b). Analysis During active duty in June 2004, the Veteran presented to P.L.B., M.D., for evaluation and potential therapy regarding a seven-year history of difficulty in achieving conception. Her gynecological procedures included a cesarean section in 1988, and no evidence of an abnormal Pap smear requiring treatment. Dr. P.L.B.'s impression was to (1) rule out the male factor, (2) rule out the tuboperitoneal factor, and (3) an age-related decline in fertility. The Veteran was referred for additional testing. See Private Treatment Record, P.L.B., M.D., June 30, 2004. Shortly thereafter, in July 2004, the Veteran underwent a fluoroscopic hysterosalpingogram. The study demonstrated complete opacification of a normal appearing cavity with opacification of the proximal to mid fallopian tubes, bilaterally. The impression was a normal ovarian cavity contour with obstruction of both fallopian tubes. See Private Treatment Record, M.H.U.M.C., July 7, 2004. As a result of the fluoroscopic hysterosalpingogram findings, the Veteran determined to undergo a diagnostic laparoscopy, diagnostic hysteroscopy, and operative hysteroscopy with bilateral tubal cannulation in an attempt to increase her chances of conception. This procedure was performed in October 2004, from which the Veteran recovered with no complications. See Private Treatment Record, M.H.U.M.C., October 21, 2004. Following this procedure, the Veteran continued to report significant abdominal pain and inability to conceive. In September 2007, a VA pelvic sonogram revealed the presence of follicular cysts. See VA Treatment Record, September 19, 2007. In February 2008, the Veteran underwent a transabdominal hysterectomy and bilateral salpingo-oophorectomy. See Private Treatment Record, L.R.M.C., February 26, 2008 - March 1, 2008. One week later, she developed lower abdominal pain and transvaginal exploration by her surgeon, Z.S., M.D., demonstrated an urinoma at the vaginal cuff. Unfortunately, the Veteran then developed persistent incontinence from a right ureterovaginal fistula and was re-admitted to the hospital in March 2008, where she underwent an endoscopic procedure with right ureteroscopy. There was a rent in the medial ureter, but no evidence of suture, staple or other foreign body. A ureteral stent was placed and she was discharged. After six weeks, the stent was removed and the Veteran's fistula was noted to have closed spontaneously. In July 2008, on imaging, the Veteran was found to have a stricture at this site. On July 8, 2008, she underwent a second endoscopic procedure, which successfully dilated the ureteral stricture and again a stent was placed. On September 24, 2008, the stent was removed and a follow-up x-ray six weeks later demonstrated some persistent obstruction, but the right kidney drained satisfactorily. Ultrasound imaging in March 2009, revealed mild to moderate hydronephrosis, from which the Veteran was asymptomatic and did not develop recurrent infections. The Veteran was noted to be at risk for recurrent scarring. As above, in August 2012 the Board remanded this issue for additional development. Specifically, the Board requested that the RO schedule the Veteran for a VA gynecological examination, with an appropriate expert, to determine whether she currently suffers from any residuals of her in-service laparoscopy with tubal cannulation. The VA examiner was specifically asked to address the following: (a) State whether the Veteran suffers from any current gynecological disorders. If so, indicate each disorder with specificity. (b) For each gynecological disorder identified, the VA examiner should state whether the identified disorder is the result of the Veteran's 2004 in-service laparoscopy with tubal cannulation. (c) State whether the Veteran's diagnosed follicular cysts are the result of her 2004 in-service laparoscopy with tubal cannulation. (d) State whether the Veteran's 2008 total abdominal hysterectomy and the resulting disabilities thereafter were the result of her 2004 in-service laparoscopy with tubal cannulation. Pursuant to the August 2012 Board remand, the Veteran was afforded a VA gynecological examination in September 2012. Upon examination of the Veteran, and with regard to question (a), the examiner determined that the Veteran suffers from the following gynecological disorders: pelvic pain, urinary incontinence, menopause, and more likely than not pelvic adhesions and endometriosis. With regard to question (b) in the August 2012 Board remand, the examiner wrote that it was less likely than note that the Veteran's menopause resulted from her 2004 in-service laparoscopy with tubal cannulation. The examiner noted that surgical menopause results from the bilateral oophorectomy. It was noted that Dr. Z.S. documented in his report of operation dated February 2012 that the Veteran's ovaries were normal. The examiner also wrote that it was less likely than not that the Veteran's urinary incontinence resulted from the 2004 laparoscopy with tubal cannulation because these symptoms, reportedly, did not begin shortly after the 2004 the 2004 laparoscopy and instead began after the hysterectomy in 2008. Thus, the examiner concluded that the Veteran's urinary incontinence was the result of the post-service hysterectomy. With regard to pelvic pain and adhesions, the examiner opined that this was at least as likely as not the result of the 2004 in-service laparoscopy with tubal cannulation because Dr. S.Z. documented that the post-operative findings for the hysterectomy included adhesions and that pelvic adhesions can cause pelvic pain. With regard to the endometriosis, the examiner opined that it was less likely than not that the Veteran's endometriosis was caused by the 2004 laparoscopy with tubal cannulation because the Veteran's service treatment records show that she had endometriosis at the time of the 2004 laparoscopy with tubal cannulation. With regard to question (c) in the August 2012 Board remand, the examiner wrote that it was less likely than not that the Veteran's diagnosed follicular cysts were the result of her 2004 in-service laparoscopy with tubal cannulation. Specifically, the examiner wrote that the February 2008 operative report shows that the Veteran's ovaries were normal. With regard to question (d) in the August 2012 Board remand, the examiner wrote that it was at least as likely as not that the Veteran's 2008 abdominal hysterectomy and resulting disabilities were the result of her 2004 in-service laparoscopy with tubal cannulation. The examiner noted that anytime a patient has surgery, there is an increased risk that adhesions may develop. Dr. S.Z. documented in the Veteran's February 2008 operative report that the Veteran had pelvic adhesions. Pelvic adhesions make the surgical procedure more technically difficult and increase the risk of complications. According to the Consensus Article from the Obstetrician and Gynecologist, Vol 6 #2 24JAN 2011, adhesions are extremely common and occur after almost every abdominal procedure. A sizeable proportion of cases (of adhesions) can lead to serious short- and long-term complications including chronic pelvic pain. Adhesion-related complications place a significant burden on patients, surgeons, and the health system, in terms of increased complications, additional and often more complicated and time-consuming surgical procedures. Recent epidemiological data have demonstrated the true extent of adhesion formation, showing that over one-third of patients who undergo open surgery are readmitted with adhesion-related complications within ten years. The data also revealed that laparoscopic procedures can be associated with a high incidence of adhesion-related readmissions and confirmed that certain open surgical procedures (including tubal) have a higher risk of adhesion formation. Therefore, the examiner opined that it was at least as likely as not that the Veteran's chronic pelvic pain, adhesions and the laceration of the right ureter and the resulting urological treatment, were causally related to the Veteran's laparoscopy with tubal cannulation. In January 2013, an addendum opinion was obtained to determine whether the Veteran's post-service hysterectomy was medically related to any gynecological symptoms during service. At that time the examiner provided a positive nexus opinion with regard to uterine fibroids, anemia, and dysmenorrhea. It was noted that the Veteran had a hysterectomy performed in February 2008 due to anemia, dysmenorrhea, menometorrhagia, and uterine fibroids. The examiner noted that a pelvic ultrasound in 2007 showed fibroids and, since the Veteran was discharged from military service in May 2006, the examiner opined that it was at least as likely as not that the Veteran's uterine fibroids began during her military service. The examiner also noted that the Veteran was diagnosed with uterine fibroids, anemia, and dysmenorrhea while in the military. Specifically, the examiner noted that uterine fibroids were diagnosed as early as June 2004, anemia was diagnosed as early as July 2003, and dysmenorrhea was diagnosed as early as November 1994. The examiner further opined that it was at least as likely as not that the Veteran's anemia and dysmenorrhea documented while she was in service was the same anemia that was one of the reasons for her hysterectomy in 2008. In this case, resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for gynecological disorders, to include residuals of an in-service tubal occlusion, status post cannulation (claimed as infertility) is warranted. See 38 U.S.C.A. § 5107(b). As above, the September 2012 VA gynecological examiner opined that the Veteran currently suffers from several residuals of her in-service tubal occlusion, status post cannulation (claimed as infertility), specifically, the Veteran's February 2008 total abdominal hysterectomy and resulting laceration of the right ureter along with chronic pelvic pain, adhesions, and uterine fibroids. The September 2012 VA examiner also noted that the Veteran was diagnosed with endometriosis and dysmenorrhea during military service and, currently, suffers from these disorders. As such, service connection for a gynecological disorders to include endometriosis and dysmenorrhea as well as residuals of an in-service tubal occlusion, status post cannulation (claimed as infertility), to include the Veteran's February 2008 total abdominal hysterectomy and resulting laceration of the right ureter along with chronic pelvic pain, adhesions, and uterine fibroids is granted. ORDER Service connection for a gynecological disorder, to include residuals of a tubal occlusion, status post cannulation (claimed as infertility), specifically, the Veteran's February 2008 total abdominal hysterectomy and resulting laceration of the right ureter along with chronic pelvic pain, adhesions, and uterine fibroids is granted. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs