Wednesday, January 20, 2010

Three Miscarriages and HSG Shows Blocked Tubes


Question:

Dear Dr. Ramirez,

I have had three miscarriages in the last couple years and have been to two fertility clinics. I have had $8,500 dollars worth of tests done and all the male testing. I was told that my tubes are blocked by one doctor and the other one says that there is no way that they can just one day unblock. I was but on meformin and told that I have pcos. I read on pcos and it said that with Clomid a pregnancy is possible. What is your opinion on this?

Answer:

Thank you for your questions. You've thrown quite a lot of different things at me.

There are several issues that you have brought up. Let me see if I can answer them one at a time and give you the information that you are requesting:

1. Three miscarriages-There is an almost 40% chance of miscarriage with every pregnancy. Most are caused by a spontaneous chromosomal abnormality that occurs when the egg is dividing into an embryo. These usually lead to miscarriage within the first 8 weeks of the pregnancy. These patients will eventually be successful. A small percentage of recurrent miscarriages occur because of uterine abnormalities, hormonal abnormalities, immunological abnormalities, infectious diseases and health events like diabetes.

2. Blocked tube - Blocked tubes are evaluated by a test called an HSG (hysterosalopingogram). It is an x-ray test whereby a dye is injected into the tubes and xrays are taken as the dye flows through. If it doesn't flow through one or both tubes then that shows that the tubes are blocked. Once blocked, it is always blocked but there is an exception. Sometimes, the tube will be blocked by a mucus plug at the opening of the tube. In general, it is one side only. With increased pressure at the time of the HSG, this mucus plug can be pushed out and the tube opened. If this is the case, the HSG "helps" in clearing the tube and allowing for a natural pregnancy to occur. If pregnancy does not occur then this could not be done and that tube is probably blocked by scar tissue. The problem with one tube blocked is that the incident that caused the blockage was probably an inflammation or infection in the past, usually caused by a bacteria. These usually pass through both tubes but it affected one tube more than the other, so that one tube is blocked. That does not preclude damage in the other tube, however. As you know, it takes a very small hole to allow fluid, like the dye, to flow through. I usually counsel my patients to assume that the other tube is damaged. The inner structure can be damaged and render the tube non-functional even without it being blocked. Therefore, with any blockage, I counseled that IVF (In Vitro Fertilization) is probably the best option.

3. PCOS - I have explained this pretty extensively in past questions. Please refer to some of my previous blog posts. But to summarize for you, PCO is a disorder of the ovaries whereby ovulation does not occur. For this reason, fertility medications are required to stimulate the ovary to ovulate. Clomid is one of those medications that is used but does not work on all PCO patients. Metformin only is useful in PCO patients that have an elevated insulin level. So it does not work in over 50% of PCO patients.

I hope this answers your questions.

Follow-up Question:

If you don't mind, I was also told that when I had the HSG done that because I was in a lot of pain that my tubes could have contracted and acted like they were blocked. Is the possible? I have been pregnant 3 times and 2 of them were on Clomid alone. Is it possible that Clomid together with metformin would work?

Follow-up Answer:
Hello Again,

HSG's are generally painful, especially if the tubes are blocked. That is because they are increasing the pressure to see if the dye will flow through. Increased pain does not indicate tubal spasm, however, tubal spasm can prevent the dye from flowing through. We see this most often when injecting dye at the time of a laparoscopy. It is uncommon to see tubal spasm in both tubes, however. If you are concerned that you may have had tubal spams, then you should have the test repeated to confirm.

If the tubes are blocked, legitimately and not due to tubal spasm, then Clomid and/or metformin will not help. If the sperm and egg cannot get together, then fertilization cannot occur, and hence, pregnancy will not ensue. If the HSG result was due to tubal spasm, then it is possible they could help, so the tubes are the key element in this. Try to clear these issues with your specialist and proceed according to his/her recommendations. Good luck!

Sincerely,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.


29 comments:

  1. I have been trying to conceive for 2 years now and have been unsuccessful. I have had the HSG done and my result are showing a possible blockage in my right fallopian tube. My Dr. suggest that we do surgery to see if the tube is really blocked. I have had heavy periods for the last year that also include half-dollar size blood colts. I am 25 and really do not know what is wrong with me.

    After the surgery, she is planning on placing me on clomid and trying IUI. Will the surgery decrease my odd of pregnancy? How is this going to help diagnosis the heavy bleeding? What are the risks?

    ReplyDelete
  2. Hello,

    I don't know how the laparoscopy is going to help see if the tube is blocked or not. With laparoscopy you can only look at the outside of the tube, so if the tubal blockage were at the very end of the tube then it might help to see if you have a hydrosalpinx or scar tissue. However, if the blockage is within the tube, the laparoscopy cannot see in the tube so it is not of much use. Certainly any surgery can cause scar tissue formation and thereby decrease the chances of pregnancy.

    A laparoscopy is where a scope and camera are inserted through the belly button to look into the pelvis. This will not help with the evaluation or diagnosis of the bleeding problem. A different procedure, call hysteroscopy, is where a scope is passed through the vagina and cervix to look into the uterine cavity. This is used in the evaluation of uterine bleeding disorders. Some doctors will combine the laparoscopy with a hysteroscopy at the same time. You'll have to check with your doctor.

    A laparoscopy is a surgery that requires general anesthesia so it has all the risks of any surgery.

    If it is known that one tube is blocked, then you have to make an assumption regarding the other tube: is it damaged or not? If it is damaged but not blocked, then you have an increased risk for failure to get pregnant by Clomid or for a tubal pregnancy (ectopic). If it is not damaged then you should be able to get pregnant by natural means. There is no test to see if it is damaged or not. That will have to be a guess. In that case, why haven't you gotten pregnant up to now? Why is your doctor considering using Clomid? Do you have an ovulatory disorder (irregular cycles)? Is your doctor a fertility subspecialist or a general Ob/Gyn? Most general Ob/Gyn's have a limited scope of what they can do, so they will usually default to within that scope such as laparoscopy or Clomid. If one tube is blocked, before you go to surgery, I would recommend a consult with a fertility subspecialist so that you can learn all your treatment options.

    Good Luck

    ReplyDelete
  3. Hi Dr. Ramirez,
    I am 39, am married, and have a beautiful 3 year old daughter. I had an HSG in January this year due to a chemical pregnancy and two missed miscarriages last year. The RE doctor tried to place the catheter three times, and the third time, the catheter was placed so high it was bending at the top of my uterus, and looked like it was pushed right into the top of my tube (think of a backwards 7). Therefore, he got the dye to go through that tube, and there was no valid information gained from the procedure. It is was what you call a failed HSG. It was very painful. Then, the next day, long, mucous like material came out into the toilet when I used the restroom(it's so heavy it sinks to the bottom). This happened again the second day after, and then I got a yeast infection and UTI right after that, within 2-3 days after the HSG. Could this have caused me to be infertile? I have read that the HSG has a one percent chance of causing infertility if bacteria enters the reproductive tract. I am scared because my doctor is not taking me seriously, and said that only an STD could cause problems, and I don't have one, so the procedure couldn't cause any damage. I keep having this thick, heavy, mucous material come out of me at all times of the month (before HSG I only had excess cervical fluid come out during fertile time of the month). Before the HSG I was fertile myrtle and got pregnant easily (just ended up with miscarriages). Now, we've been trying since January, right after I had the HSG, and cannot get pregnant at all. I also have pains in my lower abdomen and had an unusually painful period when it was due after the HSG (had to take 800mg ibuprofen for 2 days). What should I do? Should I go back to my OB? I'm scared to go the the RE again. And, what kind of testing should I request to see if there is something that went wrong? Should I request an ultrasound? I'm thinking about it. Or, how long should I wait before seeing the doctor?
    Thank you for your precious time.
    Sincerely, Stephanie

    ReplyDelete
  4. Hello Stephanie,

    I think that you are over worrying about the HSG. The likelihood of developing tubal blockage due to infection from an HSG is very small, as you cited. If you had an infection, it would be terrible and you probably would have ended up in the emergency room. It is called PID or pelvic inflammatory disease. I am not sure what the discharge is, but I would have that checked out if it does not seem normal to you. Your Ob/Gyn can do that and take cultures.

    Since you are not comfortable with your RE, then that is the wrong type of relationship. I would recommend that you find a new one and pursue your evaluation further.

    Good Luck

    ReplyDelete
    Replies
    1. Dear Dr. Ramirez,

      Thank you so much for answering my questions! My Ob/Gyn and RE did cultures for chlamydia, gonorrhea, etc., and I do not have any STD's. They also do not know why I'm having this mucous coming out of me since the HSG (I have a feeling the mucous is why I'm not getting pregnant). At first my Ob/Gyn said it was normal for mucous to be coming out after an HSG. And, now that more time has passed, she's saying the mucous could be due to my hormones. My bloodwork that was done by the RE is all normal, normal TSH, FSH, etc.

      I also had an ultrasound done and my Ob/Gyn "thinks" she "might" see a bicornate uterus. I asked her if it's certain that she saw a bicornate uterus, and she said, "No," but another HSG could show if it is or isn't for sure. But, there is no way I'm going through that again! If I was going to get something like that done again, it would be an MRI, as I have read that an MRI is more accurate in detecting any problems. We'll just keep trying.

      Thanks again for your thoughtful response and your help to women facing problems with fertility.

      Delete
  5. Hi Dr. Ramirez,

    I had a n HSG done about 2 years ago that confirmed that my tubes weren't blocked. I had a laparoscopy done on May 24th. During the surgery, my doctor discovered endometriosis. He told me that he got rid of as much of it as he could.

    During the surgery he checked once again to see if my tubes were open. He told me that he couldn't see the dye move out the other side of the tube, so he came to the conclusion that one of my tubes were blocked by scarring.

    He also mentioned that he didn't quite understand that seeing as when I had my HSG done, my tubes were completely open. By the way, the HSG was performed by a different doctor. My doctor told me that he would recommend a fertility specialist who could possibly remove the scarring from the opening of my tubes.

    My doctor didn't remove the scarring because he said that he didn't want to get too close and damage something. So, he said either a fertility specialist could possible remove the scarring or my only other option would be IVF.

    I'm just wondering what your opinion is. Should I get another HSG done in order to confirm whther or not my tubes are open? How can an HSG show that my tubes were open and then when my doctor checks during the laparoscopy, he can't see the dye going through?

    Would our last and final option be IVF? I just have no idea what to think or do anymore. I really need help doctor. Thank you.

    ReplyDelete
  6. Hello Scarlet,

    The HSG is the better method to check for tubal blockage, not the laparoscopy. Often with the manipulation that goes on with the laparoscopy, the tube could spasm and close so that the dye does not run through. Also, fluid will go through the path of least resistance, so if the tube spasms, the fluid will preferentially go through the tube that is wide open. When I inject dye at the time of a laparoscopy and get an abnormal result, I always do an HSG to verify.

    Now you know that you have endometriosis. What you don't describe is how much endometriosis you have. We usually give it a grade, stage 1-4. With stage 1-2, you can try treatments other than IVF. With stage 3-4 you should go directly to IVF. If you have the lower stages, then I will usually recommend Lupron depot therapy for 3 months followed by trying to get pregnant aggressively after. By aggressive I mean a structured treatment plan such as ovulation induction with timed intercourse or IUI. It sounds like it would be best for you to see an infertility specialist.

    ReplyDelete
  7. Dear dr Ramirez
    I had a HSG test 2 days ago, the doctor had to abandon the test because the catheter kept falling out almost immediately when the die was injected. I can't find any information as to why this happened. I don't have any children and have been TTC for 18 months. Any info you can provide on why this happened would be appreciated. I now have to have a laparoscopy instead.

    ReplyDelete
    Replies
    1. Hello June 28th,

      It is highly likely that the catheter was not place within the endometrial cavity but rather, was in the cervical canal. This could be from an abnormal cavity, cervical canal scar tissue and blockage, technical difficulties, a sharply deviated canal or inabilities or a faulty catheter. You should probably have an ultrasound done before laparoscopy to look at the uterus and have your doctor look at the endometrial canal pathway (and take a picture of it). The HSG can be attempted again, or it could also be done under ultrasound guidance for placement of the catheter. Laparoscopy won't necessarily help this issue unless chromopertubation (injecting a blue dye) can be done and visualized through the laparoscope. Again that will require that the catheter be placed correctly.

      Good Luck

      Delete
  8. I had HSG in 2008, I was told one tube was blocked and one scared. But i became pregnant n 2007,2012 both were miscarriages. So does this mean i'll never carry a pregnancy full term?

    ReplyDelete
    Replies
    1. Hello July 19,

      The quick answer to your question is "NO". But the problem you have is that your ovaries are probably no functional. I don't know how far you got with the miscarriages, so I can't give you more specific information. If the miscarriages occurred very early, before they could be confirmed by ultrasound, then it is possible that you may have had ectopic or tubal pregnancies that didn't get very far.

      Bottom line is that there are lots of ways to get pregnant so I would not worry or infer from your previous experiences that you can't be successful. It just may not be easy.

      Delete
  9. Dr. Ramirez,

    I just had an HSG to see if I have any abnormalities that could be causing my miscarriages. I am 35 and have had 3 miscarriages (all via D&C) over the past 18 months. The doctor performing the HSG said my tubes were normal, but that one side of my uterus looks larger than the other side. He's not sure if this is something I was born with, and didn't say much else other than that he'll review the pictures further and give a report to my OBGYN. I've been googling 'one side of uterus is larger than the other' and can't seem to pinpoint what this means exactly (heart shaped, bicornute, etc.) I came across this blog and am hoping I can get some answers. Please help!

    ReplyDelete
    Replies
    1. Hello,

      It may mean nothing in terms of your fertility or ability to get pregnant. The possibilities would include a slight angle of the uterus as the HSG was being done. For instance if you or your uterus were slightly rotated to one side such that the one side is more forward that the other, the lower part of the uterus might look smaller. Or this could be a congenital abnormality since the uterus is formed from two parts that fuse together. In which case one side did not develop as fully as the other.

      I don't think this finding explains the reason for your miscarriages.

      Good Luck

      Delete
  10. hi i really need your advice.

    2 years ago i had a misscarriage at 7 weeks which i therefore had to have an operation to remove it. since then i have had abdominal pains for a year and suddenly irregular period which has never happend. sometimes after sex it feels as if a tube hurts? which sometimes happends. i have not been able to get pregnant since. doctors thought i had PID but then said it couldnt be that as i have never had an STD. i really want them to test for blocked tubes as that is what i feel is the problem. what do you reacon? PLEASE HELP.

    ReplyDelete
    Replies
    1. A miscarriage or D&C to remove it should not cause pelvic or abdominal pain, nor irregular cycles. Something else is going on and needs evaluation. I would recommend a laparoscopy to evaluate for the pelvic pain, hormone blood tests to evaluate for the irregular periods and, certainly if you want it, you can have an HSG to check for tubal patency.

      Delete
  11. Hello Dr,

    Writing here with lots of hopes..
    I ttc from 2 years now....I never had regular cycle.So after 6 months of trying We asked Dr..my Thyroid level elevated...it came to normal after 3 months..then tried Clomid 50..no ovulation..then on (Clomid 150+Dexamathsone+Bravelle)was able to conceive...but in 8weeks miscarried.After that we thought I wil get pregnant easily..but then we tried same medication+sonogram 4 cycle with Ovulation but negative result.So my Dr is suggesting IVF or Laproscopy..Its huge money..and question comes in mind...what is happening wrong? (husband sperm count is excellent)I am on break from last 2 months..Dr prescribed me Metformin1500...so also getting regular cycle 30days.Also taking Chasteberry Vitex supplements.So what do you think on this all?What could be problem...my tubes blocked now?or eggs r not good quality?Please reply...Thanks a lot.

    ReplyDelete
  12. Dr. Ramirez, I have had one successful pregnancy about 10 years ago with no problems, 8 years later, i am trying to get pregnant again and have had 3 miscarriages. I have had all the test done including the HSG test-Dye Test and one of my tubes was blocked but with the pressure during the procedure it unblocked my one tube that was apparentley clogged. If everything else is fine, and they have unclogged this tube of mine fine, is it possible for me to carry a pregnancy fine the next time I get pregnant? Do you think this was the problem? How is it that the egg can travel down and I can get pregnant but it dosent hold is this due to the blocked tube, and why is it possible that it causes miscarriages...

    ReplyDelete
  13. Hello Dr,
    If the HSG was perfomed when the egg had already been released and it was in the tube, could that couse the results to be that the tube is blocked?

    ReplyDelete
  14. Dr. Ramirez,
    I had an HSG this morning. (The most painful thing I've ever felt in my life) passing kidney stones was mild compared to this! The Dr. Mentioned my right tubal was not seen?? My left was open.. I had severe cramps, and at the time just wanted to go into the bathroom and cry! So I didn't ask him what that meant.. do I only have 1? Can it be hidden? I'm so confused! I'm still bleeding, cramps, passing small clots and mucus this evening. Is this normal? My period ended on Saturday, perhaps this is leftover from my cycle? Thanks for your help! -Michelle

    ReplyDelete
    Replies
    1. The fact that the dye did not fill the right tube means either the tube is blocked, there is no tube, or there was tubal spasm that closed off the tube so the dye could not get in. My assumption would be that the tube is blocked because that is the most common reason. There are no other tests to check the tubes other than doing a laparoscopy and injecting the tubes with dye to see if they will fill and spill.

      The symptoms you are having are normal.

      Delete
  15. Hi doctor... I'm 32 and ttc since that last 1.5 years. I had two miscarriages one in may 14 and one in feb 15.
    All my tests came normal except tsh(11.2) which came down to 2.25 last month and I'm still on 5mcg thyronorm. After march when i dis not ovulate my ob gyn started ovulation induction starting with 50 mg cc then 100 with hcg shot and i ovulated on day 18 but no pregnancy. Also my endometrial thickness is not very good on all occassions. After threen months of this ovulation induction and not bein able to conceive i stopped and took a break of three months from all medicines. Last month i again went for follicular study and my fol size only grew till 17mm on day 21 after which doc stopped the study. Should i go for hsg? What are my other options as i feel really hopeless. Please help me.

    ReplyDelete
  16. I have a 6 yr old son by normal pregnancy.after that i conveives 3 times easily but had 3 miscarriages.i did many test so discovered i hv pco n my harmones are abnormal.though i had regular menses every month.nw for pco hv been given metphor and harmones level normal by medication n i am on letroz since 4 mth.my menses come on fix dates and trying but no luck.my gyno says shpuld do hsg test to c if any blockage. Shld i go for it.plz help m tired of testing. Or should wait n try again

    ReplyDelete
    Replies
    1. I think that if you have not had a full infertility evaluation, then you should do that before moving forward with treatment, otherwise the treatment may not be treating the proper problem. Also, 3 miscarriages makes the diagnosis of recurrent pregnancy loss and there is a specific evaluation for that too. You need to see a specialist for these problems to be evaluated properly and treated appropriately.

      Delete
  17. Hello doctor... I have had 3 iui (natural) and a failed ivf I am 38. My first iui was a chemical my hcg levels were going up but not enough and it ended at 5 and a half weeks. My second also a chemical this time my period was only 5 days late and the last time I felt like something was happening but my period came on time. So I had ivf and had 4 embryos until day 5 when 3 of them died and I was left with only one. Could this be that my eggs are just rubbish? Or could there be something else my amh level was 13.7 which as far as I'm aware is ok for my age? I've had a lot of blood tests for auto ammune but never a hormone profile and I've never had an hsg. What would your advice be? Thank you Helen

    ReplyDelete
  18. Hello doctor.. I'm not sure if my last comment was sent so I'm sorry if you receive this twice... I'm 38 and just had a failed ivf, I had 4 embryos until day 5 when 3 of them died and I was left with 1 blacosyst. Before this I had 3 iui's 1st one was a chemical and I got my period at 5 and a half weeks..2nd was chemical but got my period at 4 and half weeks the 3rd I felt like something was happening but then I got my period on time. I have had blood tests for auto ammune, bit d etc (which was low and had a course of tablets) everything else was ok. However I haven't had a hormone profile or an hsg. Are all my eggs just rubbish? My amh level was 13.7 which I'm told is ok for my age. Or could I have mild endometriosis? I would appreciate any advice you could give me. Thanks Helen

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  19. Hello Doctor I had an HSG test done which showed that both tubes are blocked 1 year ago, but after missing my period for two months and feeling heavy cramps I did two pregnancy test which show positive, the day after I did the tests I started feeling more cramps and spotting or pink color discharge then this reddish brown liquid or what I think is blood along with severe cramps occurred for just 1 day could this mean that I have had a miscarriage? If yes are my tubes still blocked?

    ReplyDelete
  20. Hi Dr I have had an hsg about a year ago, that showed my left tube blocked. I have had 5 missed miscarriages back to back. I have an almost 5 yr old son and it seems like I have been pregnant at least once a yr since him and they have all ended in missed miscarriages or blighted ovum. So I am able to get pregnant but it doesn't seem to go past the 6 wk development however my body never realizes this and I always end up needing a d&c. This is very frustrating and upsetting as I was very much hoping to give my son a sibling. I had my amh tested as well to learn that it was at a low of .50 then retested again after a parathyroidectomy and it had come up to .70 so I'm not sure what it is now but is there any hope of my conceiving another child? I am 33 yrs old. All the other hormones were in normal range for including fsh my progesterone is a little low however but that doesn't seem like a reasonable answer as I have been put on progestin each time I'm pregnant. Could the blocked tube be causing a hostile environment for the egg during the fertilization process? Any insight would be greatly appreciated. Thank you.

    ReplyDelete
  21. Hello doctor! I am 39.I got married in June 2012. Though all my husband's and my tests were normal but because of extreme stress as my relationship with my spouse was not harmonious I could not conceive. Then I underwent HSG to check if my tubes were fine or not. Both my tubes were fine. In March 2015 I fell pregnant naturally but after 7 weeks it ended in miscarriage. Again in January 2016 I fell pregnant naturally but it too ended in miscarriage. After second miscarriage we stopped trying for a while due to weakness in my body. Now its been six months we have been trying without success. Lately I voluntarily underwent HSG which shows both my tubes blocked also my AMH has dropped to 1.20. I want to ask is IVF is the only solution for me?

    ReplyDelete

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