Woman With Secondary Infertility & Possible Blocked Tube: Misdiagnosed? Surgery? What To Do?

Question:

I had an HSG (hysterosalpingogram) in November. The dye flowed freely through my left tube, which appeared normal and healthy.  However, the dye would not enter my right tube until after the radiologist had me get on my right and then left side. The dye then went into the tube and appeared to flow freely, but then it stopped abruptly mid way in the tube.The visible part of the tube appeared normal and healthy.  My RE told me that it is extremely rare for a woman to have a blocked tube in the middle of the tube unless she's had her tubes tied and that it was possible I was just born with half a tube.

I recently had a laparoscopy in June to get more info about the cause of my infertility and to attempt to repair the right tube. The dye again flowed freely in the left tube. My doctor inspected the right tube, and found that it appeared to be completely normal and healthy in every respect. However, again, the dye entered the right tube and stopped mid way. 

After the surgery, my doctor told me that I had no endometriosis or adhesions of any kind. She also told me that I had no evidence of any tubal disease or previous infection in my pelvic cavity.  The only abnormalities that were found were a large paratubal cyst that had wrapped around my good left tube (the cyst was successfully removed), and a small polyp during the hysteroscopy (also removed).  I also have never had any other surgeries or ectopic pregnancies. 

My RE told me she had no idea what was blocking the tube, but not to worry about it because research shows that having one healthy tube does not really decrease your chances that much for Clomid/IUI or timed intercourse.  Still, it's very frustrating to me because I thought that laparoscopy was 100% method for diagnosing the cause of a blocked tube, but I have no more info about the cause of blocked tube than when I started.

I am 38 and my FSH and AMH values are excellent, and my hubby passed his sperm analysis. I have a 2 year old that was conceived after 8 months and we have been trying for #2 for 1.5 years.  Although I understand that having just one tube should not affect my chances that much, I am still concerned because at this point, it is our only known issue.    

My questions are:  1. What could have caused the blockage in my tube?  2. Is it possible that the tube is not actually blocked but is not flowing for some other reason (I've heard about false diagnoses of blocked tubes due to preferential flow or not enough dye being used)?  3.  Is there any other way to find out what is blocking my tube?  4.  Is it worth it to pursue surgery to repair the tube like I've seen for women who undergo tubal reversal surgery?  

Thank you! C. from Atlanta

Answer:

Hello C. from the U.S. (Atlanta),

To answer your questions in order:

1.  The most common cause of a mid-tubal blockage, that is not from prior surgery, is an internal tubal infection.  Many of the bacteria that cause this type of scarring can do so without any type of symptom.  A laparoscopy would not be able to find this type of injury and, other than the HSG, there is no way to examine the inside of the tubes.

2.  It is possible that there was tubal "spasm" causing the tube to appear blocked, but I doubt it because the Radiologist was able to get the dye to flow down part of the tube.  However, if you think that it my not be an accurate test, then I would recommend that you have another one, but have your doctor specifically request that they pay most attention to the right tube i.e. do the test so that the dye preferably goes down the right side.  Remember, fluid will always go down the side of least resistance.

3.  There is no other testing that can be done to examine the tube.  Scope technology is still not small enough.

4.  NO.  Such surgery can cause pelvic scar tissue and impair your fertility more.

First, I think you need to consider ALL the factors involved in your fertility potential.  Yes, it is possible to get pregnant naturally (intercourse or IUI) with one normal tube, but there is no way to prevent the egg from going into the tube that is blocked, so your chances are actually decreased. 

Second, you are 38 years old which means that your natural chances of pregnancy are already reduced significantly down to 3-5% per month (15% per year), which is further reduced if you add the tubal problem. Even with IUI your max chance of pregnancy based on your age is only about 7-10% per month not considering the tubal issue. The fact that you have been pregnant before is a positive factor and increases your success with assisted reproduction. If you want that second child right away and if you were my patient, I would strongly urge you to consider IVF. 

Third, you have to decide which of two assumptions are correct: the tube was blocked from a prior bacteria, which probably went to the opposite tube as well but did not cause blockage, but did cause damage vs the blocked tube was the only injury and the opposite tube is therefore normal.  If the open tube is injured, which cannot be proven but is possible, it may not be functioning normally despite being open.  Keep in mind that fluid can pass through even the smallest opening.  In that case, you will not be able to get pregnant naturally and so IVF would be the treatment of choice.  Because of your age, I would make the assumption that the tube is damaged (mainly because you have not been able to get pregnant naturally when you were able to previously) and therefore recommend IVF.  It is the most successful and expedient treatment option for you. 

If your doctor wants to waste time and try something less like ovulation induction or IUI, that is fine as you understand that the risk you are taking is losing the opportunity to get pregnant with your own eggs and more time passes. I hope this second opinion is useful to you.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

 

42 Yr. Old U.K. Patient With Poor Egg Quality, Tubal Damage, Given Troubling News: How To Proceed?

Question:

I am asking this question from the UK.

I am 42 years old, and have recently had a failed IVF cycle. It was my first IVF cycle and I had a low response. I had a total of 3 eggs harvested.

There were 2 from mature follicles and 1 from a small follicle. I know this is a poor response because I was on the maximum amount of drugs. I was on Buserelin 1mg/ml - 0.5ml per day, puregon 300 units and menopur 300 units per day. Not only did I have a poor response but the egg quality was also very poor. The egg from the small follicle burst before the embryologist could perform ICSI on it. The other 2 eggs did not change or develop in anyway when ICSI was performed on them. And ICSI was done because my husband's sperm is low in number and has problems with motility and morphology.

I recently had a follow up session with the fertility specialist and he advised me to not do any more IVFs and to consider egg donation if I want to proceed. And he even went on to say that even if by some miracle I did get pregnant my egg quality is so poor that the child would most probably have serious birth defects. I was so devastated.

My questions are I only had one IVF and the FSH on day 3 was 9.3, so can my doctor tell from one IVF that I have a low egg reserve and all my eggs are of poor quality. I forgot to say that both my tubes are blocked so an IUI wouldn't be useful.

Could it be that on another cycle an IVF might give better results? I have always had regular periods. Could my ovaries just have responded badly the first time and might they respond better to a second IVF? And most importantly, even if by some miracle I get pregnant, does my poor egg quality in this IVF cycle mean that a child would most probably have serious birth defects?

I want to do another IVF cycle. I want to see if a different drug protocol might cause a better result. Please tell me if you think that I should have any hope for a better result or if I must face the brutal truth that there is no hope and I must only consider egg donation.Thank you so much for taking the time to answer my questions.

ANSWER:

Hello P. from the U.K.,

In answer to your questions:

1. Low ovarian reserve (the stimulation response) and low egg quality are two different factors. You had both in this cycle. The elevated FSH of 9.3 is an indication that the ovaries probably will not stimulate very well with maximum stimulation as you did. It does not indicate poor egg quality,however. Your age is more of a factor indicating poor egg quality. As you know, pregnancy rates decrease significantly with increasing age, especially after 35. This is mainly due to poor egg quality. There is no way to correct poor egg quality other than trying to recruit and extract multiple eggs in the hope that a good egg will be present in that group. I don't think that all your eggs are poor quality but certainly the majority (90% or more) are.

2. There have been several studies on poor responders showing that each cycle is unique and yields a different result. So, there is still a chance, that even with one embryo, you could be successful in a subsequent cycle. However, to keep from giving you false hope, the chances would be low so you would need to be prepared for failure and to have to try several attempts. There was recently an article in the New York Times here in the U.S. about a 49 year old woman who conceived and delivered by IVF using her own eggs. I believe she is the oldest in the world to have done so (get pregnant with her own eggs by IVF). However, they were clear to point out that it took her two years of doing IVF to attain that success.

3. I disagree with your doctor's statement that if you got pregnant you would almost certainly have an defective child. Because of your age there is a strong risk for miscarriage or a genetic abnormality such as Down's syndrome. However, abnormal embryos rarely implant or lead to a successful pregnancy. The only reason Down's syndrome gets by is because it is a mild genetic defect (only one chromosome is abnormal). If you get pregnant, and it successfully progresses beyond 8 weeks gestational age, your chances are good of having a normal child. We do recommend genetic testing, however, for those few that are abnormal. Poor egg quality usually leads to an embryo with multiple abnormalities, poor embryonic development and either no pregnancy or an early miscarriage.

4. I don't see any reason why you can't keep trying with your own eggs as I mentioned above. I see miracles happen all the time. However, you have to be prepared for a bad result, and if you can handle that, go ahead and keep trying as long as your ovaries still respond. You can switch to donor eggs at any time and at almost any age (although we tend to limit it to below 50) so that option will always be there. That being said however, I would probably have counseled the same as your doctor because we want you to be successful in the shortest time, least amount of attempts, least amount of emotional cost, and least amount of financial cost.

Follow-Up Question:

Dr. Ramirez,

Hello, it's P. again.

My next question concerns trying to fix my blocked tubes.

I wonder if I should consider a procedure to have one or both of my tubes unblocked. I have read that sometimes a tube can be so scarred that even having a procedure to unblock it doesn't work.

If one of my tubes was unblocked and remained so, then I could become pregnant naturally, couldn't I? I know I would still be battling with a poor egg reserve and a lot of eggs that are poor quality because of my age. Do blocked tubes mostly remained blocked even after a tubal opening operation? I am also very overweight, will this make a difference to how easily a surgeon could perform such an operation?

Dr. Ramirez, do you think this could be an option for me? Thank you for answering my questions. It is truly wonderful that you give up your time to help women like myself. God Bless you for your kindness.

Follow-Up Answer:

Hello Again,

Despite what anyone may tell you, tubal damage is NOT repairable or reversible except for two exceptions:

1. The fimbriated end of the tube is blocked by scar tissue that was causes externally, such as by previous surgery or a ruptured appendix.

2. The opening to the tube at the uterus is blocked by mucous, in which case, an HSG can sometimes unblock them and they would function normally.

Anything else that caused tubal damage cannot be fixed, and surgery does not exist for this. In addition, because of your age and ovarian reserve, even if that technology did exist (such as tubal transplantation), your "natural" chances of pregnancy would only be 1% per year of trying. It definitely would not be worth the surgical cost or risks. IVF has a better chance of 25-27% per attempt.

Good luck, P. and don't lose heart!

Sincerely,

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:
Dr. Ramirez answered my questions clearly, completely and kindly. He obviously has a genuine desire to help women that find themselves in the terrible position of needing fertility help.

I Had An Ectopic, Can I Get Pregnant With Only One Fallopian Tube?

Question:

Hello, I am from India and I hope you would be able to help me.

I had an ectopic pregnancy 3 months back wherein I had to undergo laparoscopic surgery to remove my right fallopian tube where the fertilized egg had embedded.

Both my ovaries are intact.I didn't have any fertility issues before conceiving. My question is whether it is possible for left fallopian tube to collect the eggs released by right ovary? Also, I wanted to check with you whether the ovaries release eggs in alternate months. In your opinion, approximately how long it might take for me to conceive the next time?

Please help me with these questions!

Answer:

In answer to your questions, yes, it is possible for an egg that is ovulated from the right side to enter through the left tube.

That is because no matter what side the egg ovulates from, it falls into a space in the middle, called the culdesac, where the end of the tubes are usually hanging. Eggs are released randomly from the ovaries. They do not alternate. The problem that you have is that you had an ectopic pregnancy. This is usually caused by scar tissue within the fallopian tube. The egg/embryo gets stuck on this scar tissue and cannot advance, therefore, it implants there. If you have scar tissue on one side, you are at risk for having scar tissue on the opposite side because usually the inflammation that affects one tube, also affects the other tube (that is where the scar tissue came from). For that reason, you are at increased risk of another ectopic on the opposite side.

Your chances of getting pregnant are still the same, despite only having one tube, but you have a 30-50% chance of an ectopic. The treatment that I would recommend at this point would be to consider IVF so that the tubes can be bypassed.

I hope you succeed in your efforts to become pregnant and that you keep in mind the risk involved with trying to get pregnant naturally with your past medical history.

Sincerely,

Edward Ramirez, MD, FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF
Monterey, CA

Patient Had Laparoscopic Ovarian Drilling & Damaged Tubes, What To Do Next?

Question:

I am from the United Arab Emirates. I had problems with my periods earlier since beginning of my teenage, like the absence of periods for years. Then I started taking contraceptive pills for regularizing my periods but it didn't help me. After that I thought it would be ok after I got married but then I didn't get pregnant for 1 year. After that, I had Laparoscopic ovarian drilling done.

I take no medicine till now after the surgery I got my period twice on my own 28 days difference but on the 3rd month I didn't get my periods at all. I thought I got pregnant then but I had blood tests done twice but it showed me negative. Before the surgery I had taken injectables, Clomid and what not, but it didn't help me ovulate actually. Both of my tubes were blocked but now after the surgery one of them is working. The doctor said I have less hormone & right now I am on primolute to get periods. So after consuming primolute for 10 days when should I expect my periods???? and what has to be done for my hormones???

By the way my age is 21 and my height is 162 cm and have been married for 1 and half years . My husband's semen was tested and they said that it's normal. Thank you very much!

Answer:

It sounds like you have PCOD (polycystic ovarian disease). Ovarian drilling is a very, very old fashioned treatment for PCOD. It is a procedure whereby a laparoscope is inserted into the abdomen and a needle, electrode or laser is used to make holes (yes, holes) in the capsule of the ovary. In the past, it was used as the mainstay treatment for PCOS, and in some cases was successful in getting the ovaries to function normally, at least for a short while. But, it does not work in all cases, and the problem is that damage to the ovary can induce scar tissue around the ovary, tubes and pelvis, thereby rendering the patient infertile by obstructing movement of the egg to the tube. Contemporary fertility surgery preaches minimal tissue damage to prevent or reduce scar tissue formation. This procedure contradicts this philosophy, did not work in most cases and, in some cases, made the fertility problem worse. We don't use it very much in the U.S. any more, and I cannot recommend it.

You have two problems in regards to your fertility: (

Number One: because of the PCOD you don't ovulate and Number 2: you have a tubal problem.

First, let me deal with the tubal problem. In reality, there are NO surgeries that can correct a tubal problem. Surgery can be used to open the ends of the tubes, but the major damage is usually within the tube and this cannot be repaired. The fallopian tubes are not just pipes. Opening them is not enough. They are working organs with muscle layers and small hairlike cilia that help to move the egg and sperm together. Because this damage cannot be repaired, the only realistic treatment option is to proceed with IVF "in vitro fertilization". This allows us to bypass the tubes.

The second problem is PCOD. In this case the ovaries are difficult to ovulate safely (only allowing 2-3 eggs to ovulate). For that reason, the majority of PCOD women have to proceed with IVF. This is because we can extract all the eggs and control the number that are put back in. This is necessary because PCOD patients tend to over-respond to injectable medication, which is the only medication that will work to stimulate most PCOD ovaries. Clomid usually doesn't work.

So my recommendation is to see a fertility specialist and undergo IVF. The primolute is a progesterone, I believe, and is only being used to induce a period. It is not doing anything else.

Follow-Up Question:

So what do you say doctor, just Laparoscopic ovarian drilling and Clomid will not work after getting my periods thru primolute? I am waiting for my periods to come and so I can start with clomid and injections. This is the first clomid cycle after my surgery? Well, what I think is let me wait and see and then next we will go for IVF.

Follow-Up Answer:

Hello Again,

There is a good chance that the Clomid might stimulate your ovaries to ovulate. The ovarian drilling can sometimes make the ovaries more receptive to this medication. However, the chances are not good. The biggest problem that you have is a tubal problem. Because Clomid with either timed intercourse or IUI rely completely on the fact that there has to be normal tubes, if they are not, that is what will prevent you from getting pregnant.

In any case, miracles do happen and you may be the exception to the rule! So as long as you don't mind trying the Clomid, then it is okay to try.

Good Luck.

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Hydrosalpinges and Miscarriages

Question:
I am 34 years old, writing from Australia. I have had one child (3 years old) and two miscarriages. The first miscarriage (embryo stopped growing 6.5 weeks) on Jan. 09, the second Nov. 09 (9.5 weeks). Just before I became pregnant with the most recent one, I found out I had bilateral hydrosalpinges that showed up on the transvaginal ultrasound.

We were considering having surgery to remove the fallopian tubes ( on the advice of an IVF specialist) then start IVF, when suddenly we found out we were pregnant. Unfortunately, at 9.5 weeks I had a miscarriage.

We are awaiting results of tissue testing to determine if chromosomal abnormality exists. We are also booked in for a repeat ultrasound.

1. Does having bilateral hydrosalpinges cause you to miscarry at 10 weeks pregnant? If so, by how much (i.e. what %)? Gyn says they do not make you miscarry but more likely to not allow implantation.

2. Would the preferred option be to clip them, or just remove them and commence IVF even though I have gotten pregnant naturally? Or would the best option be to give it one more go naturally?

Any other advice would be appreciated.

Answer:

Hello,

You present a very interesting scenario because women with hydrosalpinges usually cannot get pregnant. The reason is because the cause of the hydrosalpinges is a tubal infection that caused the damage to the tubes. Not only did it cause the tube to be obstructed, but it even usually leads to damage of the inner lining of the tube that is important for egg and sperm transport. Therefore the recommendation is to proceed with IVF. Your case negates that thinking.

Hydrosalpinges can lead to non-implantation, and by the same mechanism, miscarriage. It is thought that the hydrosalpinx has inflammatory fluid within that migrates back into the uterus. Several studies have found decreased pregnancy rates in IVF when hydrosalpinges are present. That is why it is recommended to clip the tubes or remove them prior to IVF. This inflammatory fluid causes a mild inflammation of the uterine lining causing the lack of implantation. If implantation were to occur, I would expect that the same inflammation could lead to the death of the embryo from a mild amnionitis. That, however, is theoretical.

Because you have shown that you are the exception to the rule, you have two options. You can have a laparoscopy and have the tubes opened (salpingoplasty) or you can have the tubes clipped/removed. If the tubes are opened, you have the opportunity to become pregnant naturally, like you showed that you could. It would allow the fluid to escape into the abdomen, thereby reducing the chances of backflow into the uterus. However, if there is tubal damage within, you are at increased risk of a tubal pregnancy called an ectopic pregnancy. That can be life threatening if it ruptures and you hemorrhage. The second option, which then requires IVF is certainly the safer option, but the more expensive option. You need to discuss these two options with your docs.

If I were counseling you, I would almost be inclined to recommend the former (tubal repair) as long as you were completely aware of the risk of ectopic and willing to take that chance. I would then watch you very closely if you were to become pregnant to rule out the ectopic at the beginning of your pregnancy.

I hope that this answers your questions.

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