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Infertility
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Reproduction
Removal of fluid filled tubes before IVF
Hydrosalpinx & IVF
Blocked tubes - what next?
Pregnancy Loss, Tubal Disease, Hysterosalpingogram
Question: I had IVF 4 years ago
and have a 3-year-old child. My tubes are twisted and full
of fluid. The doctor recommends that we remove the tubes before
we do IVF again. He said that there is a study that says the
fluid in the tubes is toxic to the embryos. Would you recommend
this to one of your patients?
Comment: I used to not believe that
this could make a difference and was cautious over the first
reports of improved IVF success after removal of fluid filled
tubes (hydrosalpinges). Now, at least four major studies have
come to the same conclusion-- remove, or at least occlude
the tubes that are fluid-filled. The tube is a living organ
that produces fluid to support the developing conceptus and
prevent it from adhering as it moves toward the uterus. Even
blocked tubes still may function somewhat and change in size
through the normal or stimulated cycle. There are two possible
reasons that a hydrosalpinx may decrease success. First, it
may be a mechanical wash out of embryos from the fluid back
flowing into the uterus around the time of implantation. Since
the distal end of the tube is blocked, this fluid may leak
into the uterus and disrupt implantation. It is well known
that a very small amount of media must be used when embryos
are transferred after IVF. Increased fluid decreases success.
A second reason is that the fluid itself has been shown to
be embryo toxic. Since most hydrosalpinges, arise form a previous
infection, there may still be agents in this fluid that cause
a inflammatory response and either alter the uterine environment,
or the health of the conceptus (embryo). We still don't know
whether the tube must be removed, or just closed-off near
the uterus (tubal sterilization). We also not know whether
larger hydrosalpinges are worse than smaller ones. I understand
your reluctance for surgery. You may also want to read "What’s
up doc?"-Assisted reproduction section in the CARS archive
that reviews a recent article on this subject. sst
Question: I was reading an article in
your “What’s Up Doc from Fertility and Sterility
regarding the success of IVF when the patient has a hydrosalpinx.
I have had a salpingostomy via laparoscopy but was not quite
ready to have a salpingectomy. (Left tube is the culprit -
right side is questionable but no hydrosalpinx). I have had
one unsuccessful IVF and one unsuccessful FET. How successful
has your center been in treating patients with hydrosalpinx,
and did I make a mistake by not having the left tube removed?
Comment: This relatively new data about
the effect of hydrosalpinx has made my life much more difficult
as a laparoscopist. Before, we did our best to open the tubes
and if unsuccessful, we proceeded to IVF. Now, as a portion
of informed consent, I must explain to each patient with suspected
tubal disease that closure or removal of the tube may be in
their best interest. It is still a hard decision for everyone
to end natural fertility. . It seems clear that hydrosalpinx
decreases IVF success. This is supported in many studies.
The mechanism is probably related to a back flow of fluid
into the uterus around the time of implantation. Presently,
my recommendation depends on the status of the tubes. While
I am not a big advocate of hysterosalpingograms, an HSG may
be in your best interest before another IVF attempt. If there
is clearly a hydrosalpinx on ultrasound, or a fluid collection
outside the ovary during your IVF cycle, an HSG might not
be necessary. If a hydrosalpinx is found, all evidence now
suggests the tube, or tubes be closed or removed. A potential
down side of removal of the tubes is the alteration of the
blood supply and possibly diminished ovarian function. Obviously
care should be taken during this procedure. sst
Question: What does your center recommend
as treatment for blocked tubes. I may have blocked tubes.
My doctor wants to do another HSG to be sure. If they are
in fact blocked, then he's recommending a transcervical wire
tuboplasty to be done by an invasive radiologist. What are
your comments on this?
Comments: In some ways this is a more
complex question than you might think. The overall plan of
action should take into account your age, length of infertility,
ovulatory status, and male factors and results of the first
hysterosalpingogram (HSG). About 10-20% of HSG's gives false
positive results and there may be no blockage, only tubal
spasm. So, things might not be as bleak as they appear. Personally,
I do few HSG's. This is somewhat unconventional and many still
believe that they are a standard part of an early fertility
investigation. I don't do HSG's because they hurt, are costly,
and often give inclusive results. If the HSG is positive,
(meaning that something is found), a laparoscopy and hysteroscopy
is indicated. If negative, (normal), I don't trust the results.
Often the tubes are open, but endometriosis and/or scar tissue
prevents normal functioning and egg pick-up. Usually, I will
ensure all other parameters are normal, even give a couple
of cycles of clomiphene, then proceed to laparoscopy. But
in your case we must have a high suspicion that tubal disease
might be present. In the hands of an experienced radiologist
the opening of the proximal, or cornual, obstruction is relatively
effective. I am not sure why another HSG is needed before
the radiologist evaluates the tubes Can’t this be done
at the same time? I can see nothing wrong with the approach
your doctor has taken. However, it is not the approach I usually
use. In your case, I would perform a laparoscopy and hysteroscopy
to evaluate the entire pelvis. If there were only a proximal
blockage, I would use hysteroscopy to visualize the opening
of the tubes into the uterus and try to open them with a wire
or catheter, such as above. I feel it is important to know
the status of the other, distal, ends of the tubes as well.
If these are blocked, the prognosis for natural fertility
is relatively slim. It even may be preferable to purposely
block, or remove the tubes, or a tube, if severely damaged.
Still, with tubal disease our chances for pregnancy may be
excellent, although in vitro fertilization may be required.
sst
Question: I am 33 years old and had
two miscarriages two years ago. Since then my husband and
I have been trying to get pregnant with no luck. I am going
to have a tubal patency test soon and wonder what it is, what
it can detect, and what's next?
Comment: A hysterosalpingogram (HSG)
is a screening test usually performed in a hospital x-ray
department in order to evaluate the contour of the uterine
cavity and to determine if the tubes are patent (open.) During
an HSG, liquid dye is passed through an instrument placed
in the cervix. Passage of the dye and outline of the uterus
and tubes can easily be visualized by a special x-ray technique
called fluoroscopy. Some women conceive after an HSG without
additional therapy. This is thought to be due to a "flushing
out" effect on the tubes and the removal of small bits
of scar tissue. HSG is an excellent method to evaluate the
possibility of some congenital abnormalities of the uterus,
but its overall usefulness is questioned. We know with the
establishment of pregnancy that at least one tube must be
open. About one in three cases will give a false HSG reading.
Either there will not appear to be a problem when there actually
is, or the test will be read as abnormal when no abnormality
exists. If the HSG is abnormal, a laparoscopy and/or hysteroscopy
is needed for confirmation and treatment. If the test is negative
and nothing has been found, the results can’t be completely
trusted and a laparoscopy or hysteroscopy may be necessary
to exclude a problem. It is relatively common for the tube
to have a muscle spasm during the procedure and appear blocked
when in reality, it is open. The ability of the tubes to be
freely mobile is very important. The tubes may be open, but
scarring (adhesions) may prevent the tubes from capturing
the egg at ovulation. Open tubes do not equal normal tubes
and often this cannot be detected by HSG. The HSG is associated
with mild to moderate pain that is usually limited to the
time during which the dye is being injected thought the cervix.
It is advisable that some type of non-steroidal anti-inflammatory
drug (ibuprofen naprosyn, aspirin, etc.) be taken 30 minutes
before the procedure. It is also useful to have the male partner
present for support. Often both of you are allowed to see
the procedure and discuss the results. One reason for recurrent
pregnancy loss is a congenital anomaly (birth defect) of the
uterus. This problem is more often found in individuals who
have lost pregnancy at 9-15 weeks and after there has been
fetal heart activity identified by ultrasound. When a pregnancy
loss occurs can tell us much about why the loss has happened.
Losses before 8 weeks are most often due to hormonal and genetic
problems rather than anatomic problems. HSG is one of the
standard tests for recurrent pregnancy loss and may be performed
before, or after, more intensive endocrine evaluation and
perhaps even a trial of clomiphene and or progesterone. sst
Also see Fact Sheets - General
Infertility
Forum - Assisted
Reproduction
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