Friday, June 4, 2010

Young PCOD Patient With Tubal Blockage Unable To Conceive: Surgery or IVF?


I'm really searching for some advice. I was diagnosed with PCOS (not insulin resistant) this month (after four years of "maybe yes") as well as finding out I have a blocked fallopian tube.

I'm seeing an IVF specialist who recommended having hysteroscopy and laparoscopy surgery to clear the blockage and determine if there is scar tissue or endometriosis that can be fixed. I've suffered from very heavy irregular periods for the last 4 years.

I was told that if I chose not to go with the surgery the next step will probably be IVF. I thought IVF was a little extreme, completely skipping over Clomid and other fertility drugs. I know it's possible to get pregnant with one working tube, and I really don't want to do surgery unless it's absolutely necessary. I've been told by family I should get a second opinion, that sometimes surgeries are recommended when it's not really needed, because of money, etc. My Dr office did tell me I have excellent health insurance coverage. I don't think that's the case but it just seems like 2 extreme methods. I'm at one of the best fertility clinics in South Florida and feel like they should know better than me.

I'm 26 and not overweight (I lost 40 pounds 3.5 years ago), I've been off birth control for 5 years, and we've actively been Trying to conceive for over 8 months. My husband's sperm count is great. I used ovulation kits for 3 months but was never able to get a positive result. Is surgery the only way to tell if I have endometriosis?Would it be more beneficial to have the surgery then to start IVF without it?Is it usual to skip all other fertility medications in situations like mine and just use IVF? Is this a situation that you would recommend getting a second opinion?

Any advice you can shed is greatly appreciated.

Thank you, S. from Palm Beach County, FL


Hello S. from Florida,

I guess I can be your second opinion. As you have described, you have two problems thus far: PCOD and tubal blockage. Certainly if PCOD were the only problem, ovulation induction with Clomid, Femara or injectables would be an option and could be combined with intercourse or IUI. However, keep in mind that most PCOD patients do not respond well to these medications and many (up to 85%) end up having to go to IVF because of this. However, if this were the only problem, then you would have more options.

Tubal blockage is another problem. The more problems you have, the worst the prognosis for achieving a natural pregnancy and the more you need to consider IVF. Tubal blockage by itself is enough to consider IVF, however. You don't describe where the tube is blocked but the only situation where surgery might help with tubal blockage is if it is blocked at the very end AND there has been no internal tubal damage, such as is caused by endometriosis. If the tube is blocked anywhere along the tube, it cannot be repaired and surgery would therefore not be indicated. The most common cause of tubal blockage is some form of inflammatory disease that ascended into the tube via the vagina and uterus. Because both tubes open to the uterus, this inflammation/infection problem got into both tubes but affected them unevenly such that only one tube is completely blocked. That does not mean that the other tube is normal, however. It could mean that the other tube was affected and damaged but did not scar enough to block completely. Usually when I see one side blocked, I make the assumption that the other tube is also not functional based on the fact that if it were, the patient would probably have achieved pregnancy on their own. Considering how long you have been trying, that makes me suspicious that the open tube is not functional. In that case, the ONLY treatment option is IVF because that is the only way to bypass the tubes. Remember that the internal part of the tube cannot be repaired and repair of the tube at the very end of the tube does not work well (1% pregnancy rate).

So, now, if you combine these two problems, then you can see that IVF is the treatment of choice for you. In that case, why have the surgery? Any other problems found, like endometriosis, will just be additional reason to do IVF. It does not affect your IVF chances. The only reason to have a laparoscopy if you are considering IVF is if the tube is swollen with fluid, called a hydrosalpinx, in which case that tube either needs to be removed or severed from the uterus to prevent the fluid within from leaking into the uterus. Studies have found that IVF pregnancy rates decrease by 50% when a hydrosalpinx is present. The only other reason is if you had any kind of ovarian mass or cyst. That would need to be removed prior to IVF as well. Remember, the treatment has to treat and overcome the problems.

Just choosing a treatment arbitrarily, like fertility medications, does not necessarily overcome all the problems present.

I hope that answers your questions.

Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
Twitter with me at @montereybayivf, and follow me on Facebook at

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