Will Removing Blocked Fallopian Tube Help This Patient Conceive?

Question:

Hi again Dr Ramirez, it's K. in NY.

I have written in the past about my multiple miscarriages/chemical pregnancies. I tested positive for the MTHFR mutation this past fall. I had a miscarriage at 9 weeks in August, which you believed was most likely due to a virus I contracted. I have followed up with a new specialist recently, and received some new information today.

First of all, my right tube is definitely blocked (although most of my miscarriages/chemical pregnancies resulted from ovulating on the right) We are led to believe that I most likely had a few early ectopic pregnancies. The specialist today suggested that I undergo surgery to remove the right tube completely. I am not sure how I feel about this, as surgery for any procedure is risky. Do you feel that having the tube removed would increase my odds of becoming pregnant? I am willing to do it if it makes sense, but hate to do it "just because". I am not sure if research supports this practice or if it doesn't really make a difference in the long run.

The second piece to this scenario is that my husband was diagnosed with a translocation between chromosomes 11 and 13 (46xy,t(11;13)(q21;14)). IVF (in vitro fertilization) was suggested to us, but we do not have the money for this and it is not an option unfortunately. Our Dr prefers to remove the tube and discuss fertility meds and other options after that point. While it explains many of our losses, I am curious if you have any other treatment suggestions. We have two healthy children that we had no difficulty conceiving. I have taken femara multiple times (pregnancy x1) and progesterone. We have not tried IUI, but were wondering if it would be of any benefit. I am just confused with all of this new information as to how to proceed conservatively. I am willing to take meds and try IUI, but I would rather not have surgery at this time unless there is a strong link between increased fertility and tube removal. Also, if we continue with meds and u/s, is there a point in being aggressive on months where I ovulate on the right?

We are just looking for the best path to take and I am hoping that you have some input to help us make an informed decision. Obviously this journey gets more difficult with every diagnosis. Thank you for your time.

Answer:
Hello K. from the U.S.(New York),

So sorry about your secondary infetility problems. To begin, there are no studies to either validate or invalidate the recommendation to remove a nonfunctioning tube unless it is blocked at the fimbriated end (called a hydrosalpinx). In that case, it has been shown to decrease pregnancies via IVF and is thought to impair implantation. It is recomnended to remove or separate the tube from the uterus. However, your doctor's recommendation is not unreasonable. Considering that it is not predictable as to which tube the egg will go into, each month you have a 50/50 chance that the egg will get picked up by the wrong/damage tube, and therefore will not get pregnant. In addition, you are risking ectopic pregnancy should the sperm get through on that side. I think that removing the tube might give you a better chance at getting pregnant because that only leaves one tube where the egg can go, and it does not matter which side the egg is ovulated from. They all go into the culdesac where the tubes lie.

In terms of your husband's translocation, that certainly can be a cause for miscarriages, just as your postive MTHFR can be a cause. There are no real good solutions for his problem other than doing PGS (preimplatation genetic screening) in conjuction with IVF. You'll just have to take your chances. I am not sure that IUI will offer you any more than trying as you have been, but statistically it does give a slightly increased chance of pregnancy if 2-3 eggs are ovulated at a time. That's the only advantage.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

Previous Ectopic, Left Salpingectomy, Painful HSG: Can I Still Get Pregnant?

Question:

Dear Dr. Ramirez,

Approximately 8 years ago, after the birth of my first child, I had an IUD (copper T) inserted. About 6 months later, I lost the thread,and went back to the medical practice for it to be removed and replaced, but was told that losing the thread wasn't a threat. Anyway, 2 more months later, I had an ectopic pregnancy which ruptured my left fallopian tube and resulted in an emergency salpingectomy...... the entire tube was removed (about 7 cm).

Fast forward 8 years, I am ready to have another child, however an HSG (hysterosalpingogram) revealed proximal blockage to my right tube. I was in an immense amount of pain during this procedure.....that I cried. I am not convinced that the results of the HSG are accurate because of the pain (similar to labor pains)that I felt. Also because the ectopic was due to a foreign object, I don't feel that there should be anything wrong with my right tube. Anyway, my questions are as follows and I really appreciate your time:

1. Since the IUD was the cause of my ectopic pregnancy, would I be considered a high risk for another ectopic (assuming my right tube is not blocked#?

2. Based on the pain that I was in, could the proximal blockage be a result of a tubal spasm? What are the stats on false hsg readings for proximal blockage?

3. Is it possible that a left salpingectomy could result in scar tissue blocking the remaining right tube?

4. And finally, my uterus and ovaries (I still have both) are healthy per the scan. There is evidence of scarring from my previous c-section. How feasible is it for my right tube to pick up an egg from my left ovary as I usually feel ovulation cramping on my left?

Thank you very much in anticipation. E. (age 35),USA

Answer:

Hello E. from the U.S.,

You cannot be sure that the IUD was the cause of the ectopic. That would be a false assumption. Certainly having an IUD in place can increase the risk of an ectopic but intrauterine pregnancies also occur with IUD's in place. The IUD does not block the tube, it creates a hostile bed for implantation of the embryo. Ectopic pregnancies mostly occur because of fine adhesions within the tube which prevent the embryo from migrating into the uterus. As a result, the embryo implants there. The most common reason for these adhesions are from some form of inflammatory event in the past, often a sub-clinical (no symptoms) infection by a bacteria. Chlamydia is the most common form but some studies also point to multiple different bacteria. In any case, this infection gets into the tube, causes the tubal lining to become inflamed thereby resulting in scar tissue formation. It is possible that this inflammation is was led to the blockage of the right tube, whereas the left tube was only partially blocked, hence the ectopic.

In terms of the pain with the HSG, yes, it could mean that you had tubal spasm but the more likely source was that because the tube is blocked, the increased pressure or pushing by the doc caused increased stretching of the uterus and hence increased pain. I would have to look up the statistics for false readings on HSG, but it is low and so HSG is the gold standard for the diagnosis of tubal blockage. I am sure there is some false positive or false negative readings, however.

If the surgery was performed without incident, a salpingectomy on the left should not cause blockage of the right tube at its entrance. Any pelvic surgery could lead to scar tissue formation within the pelvis and lead to blockage at the end of the tube, however (your previous c-section).

If the right tube is normal at the fimbriated end, and there are no adhesions within the pelvis, then there is a good chance of egg pickup even if ovulation is from the opposite side. The reason is that the egg from one side of the ovary does not necessarily go directly to the tube on that side. The opening to the tube is not that close to the ovary. In fact, the egg falls into a pool of fluid within the culdesac, a space behind the uterus, where the tube lies and through fluid motion, gets to the tube. So pregnancy can and have occurred in patients with a functioning ovary on one side and a normal tube, without an ovary, on the opposite side.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

Comment: Dear Dr. Ramirez, Thank you very much for your response. You are very knowledgeable and I feel very enlightened. Again, many thanks, E.