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What About Tubes that are Blocked at the Other End, Near the Ovary?

This we call “distal occlusion” and it can take a few forms. The most obvious and severe is what’s called a hydrosaplinx (or hydro for short), or bilateral hydrosalpinges when both are affected. This type of tube is completely closed near the ovary (the distal end). Such a tube could be closed due to scar from a pelvic infection. The infection could be due to Chlamydia (most common), Gonorrhea or a post surgical infection. Sometimes scarring can occur after surgery without infection. Even when the surgery was on the uterus, myomectomy is a common culprit, the general healing of the pelvis could cause tubal scarring to occur. Occasionally these tubes are filled with fluid and are visible on ultrasound, but usually they are not. The diagnosis here is very straightforward. Either by HSG or at laparoscopy, the tubes are seen to be large, swollen and obvious. Hydros are quite a problem for patients because they can mean surgery, IVF or both. Surgery can work, but the odds of pregnancy after surgery have been reported to be about 20% lifetime (there are a few other studies with higher rates, but 20% seems to be the most commonly quoted number). The reason surgery does not succeed is that in many cases the scar tissue quickly returns and the tubes re-block. Even if the tubes remain open, the interior lining of the tubes, necessary to the transport of egg and sperm, has been permanently damaged.
IVF has a much higher pregnancy rate, so most patients head that way. There are some studies showing a hydro will lower the IVF rate by about 1/3, the predominant theory being fluid inside the tube backs up into the uterus and interferes with implantation, either by flooding the embryo away or poisoning the embryo with toxic substances. Therefore some patients elect to have their hyro tubes removed before IVF to maximize their odds. No one should be forced to have their tubes removed. The pregnancy rate may be lower, but there are tons of pregnancies in women who kept their tubes.
Distal blockage can be not as severe. In these cases there may be tubal enlargement, but they are open on HSG. There can be minor scar tissue around the ends of the tubes that is very treatable. Just cutting away the scar tissue can render the tubes open and very functional.

References:

  • Johnson NP, Mak W, Sowter MC. Surgical treatment for tubal disease in women due to undergo in vitro fertilisation. Cochrane Database Syst Rev 2004.
  • Kodaman PH, Arici A, Seli E. Evidenced-based diagnosis and management of tubal factor infertility. Curr Opin Obstet Gynecol 2004; 16(3):221-9.
  • ASRM Practice Committee. The role of tubal reconstructive surgery in the era of assisted reproductive technologies. Fertil Steril 2008; 90(5 Suppl):S250-3.
  • Johnson NP, Mak W, Sowter MC. Laparoscopic salpingectomy for women with hydrosalpinges enhances the success of IVF: a Cochrane review. Hum Reprod 2002; 17(3):543-7.
  • Kontoravdis A, Makrakis E, Pantos K, Botsis D, Deligeoroglou E, Creatsas G. Proximal tubal occlusion versus salpingectomy result in similar improvement in in-vitro fertilization outcome in patients with hydrosalpinx. Fertil Steril 2006; 86(6):1642-9.

I Called and an Embryo Picked Up the Phone

This is the truth.
Everyone’s job is at times difficult, including mine. We are overworked, don’t get enough sleep and basically tired. As interested as we are with the task at hand, we have to worry about the ongoing tasks and the upcoming tasks. It is rare that we can really think and reflect about the purpose of our labor, and the long-term permanent effects that may follow.
So my job is to help people get pregnant. Sounds great, and it is. With all of the demands of a busy medical practice it’s sometimes hard to appreciate that we in infertility are not just helping people get embryos, or heartbeats, or even deliveries and c sections. It’s obvious that it goes well beyond that, but for us, once we are happy about your heartbeat, we need to get happy about the next patient’s heartbeat etc.
Well, the other day I needed to call one of my past patients. Who picked up the phone, and said “hello, this is …..” ? Yes, it was the embryo. First it was a spec of an embryo, then a heartbeat. It then went on to be a 2 dimensional cute photo.
This is all wonderful and miraculous, but it took the phone call to really drive home the meaning. I was now interacting with the embryo. There was cause and effect. My task, the phone call to her mom, was dependent on the decision making of the embryo turned little girl. What a great day for me.
I hope that all of you reading this can someday have these types of experiences with your own families.

Blocked Tubes: 2 Cases of Proximal Tubal Occlusion

I commonly see patients whose tubes are blocked. It is very important for me to determine where the blockage is. There is a big difference between tubes blocked at their start and tubes blocked at the ends. The condition whereby the tube is blocked at the start is called “proximal tubal occlusion”. This is blockage at the point where the uterus ends and the tube begins. This is the most narrow part of the tube. Fixing this type of blockage is very successful, if necessary. Sometimes patients are told they have proximal tubal occlusion but they do not. How can this be? It’s either spasm or an inaccurate test.
Spasm. The tubes are narrow and consist of mostly muscle. If there is any spasm of the tube muscle, the tube will constrict and block dye from going through. Spasm is more likely to occur if the HSG is very painful. Uterine pain is mostly from the muscle cramping and this leads to tubal spasm.
Inaccurate test. Hysterogram tests are very mechanical. The doctor needs to use the right instrument in the right way or the test will not be adequate. Cervices come in all different shapes and sizes, and sometimes it’s just tough to get the dye in under the right pressure. If the dye can not be properly pushed up into the uterus, the tubes may look blocked. The same is true of tubes looking blocked during laparoscopy. Again, we are not talking about tubes that show blockage at the end, near the ovary, that’s a whole different story. For proximal tubal occlusion, even in the operating room under anesthesia, the doctor may not be able to get dye into the uterus well and this may lead to you being told your tubes are blocked.
This week I saw 2 patients who thought their tubes were blocked but they were not. The first had a hysterogram showing bilateral proximal tubal occlusion. I repeated her hysterogram and her tubes were open and perfect. The second had a laparoscopy and dye did not come out the tubes. She was referred to me for IVF. I did a hysterogram and her tubes were open and perfect. She will not need IVF anytime soon. Once again, please read disclaimer 5/17/06.

References:

  • Johnson NP, Mak W, Sowter MC. Surgical treatment for tubal disease in women due to undergo in vitro fertilisation. Cochrane Database Syst Rev 2004.
  • Kodaman PH, Arici A, Seli E. Evidenced-based diagnosis and management of tubal factor infertility. Curr Opin Obstet Gynecol 2004; 16(3):221-9.
  • ASRM Practice Committee. The role of tubal reconstructive surgery in the era of assisted reproductive technologies. Fertil Steril 2008; 90(5 Suppl):S250-3.
  • Johnson NP, Mak W, Sowter MC. Laparoscopic salpingectomy for women with hydrosalpinges enhances the success of IVF: a Cochrane review. Hum Reprod 2002; 17(3):543-7.
  • Kontoravdis A, Makrakis E, Pantos K, Botsis D, Deligeoroglou E, Creatsas G. Proximal tubal occlusion versus salpingectomy result in similar improvement in in-vitro fertilization outcome in patients with hydrosalpinx. Fertil Steril 2006; 86(6):1642-9.