Common Conditions
Tubal Factor Infertility
Tubal disease is a common cause of female infertility. There are many causes of tubal-factor infertility. Some women previously had tubal sterilization procedures and now wish to be fertile. Others have blocked tubes from endometriosis, prior pelvic surgery or infection, or unexplained reasons.
An HSG is most commonly used to screen for abnormalities. If abnormalities are detected on HSG or if the findings are not inconclusive, laparoscopy (surgery) is the technique used to definitively diagnose and sometimes treat tubal disease. The treatment of tubal factor depends on the cause, whether or not the condition is correctable, and the goals of the patient.
If the tubes are blocked or damaged beyond repair, IVF is generally the method required to achieve pregnancy. In fact, if blocked tubes are the only abnormality discovered during an infertility investigation, then the couple has a very good prognosis for pregnancy with IVF.
If the tubes are blocked due to a prior sterilization procedure, the patient has two choices: tubal ligation reversal or IVF. Tubal reversal surgery is usually not paid for by insurance. The best candidates for tubal reversal surgery are women under 35 years old with normal ovarian reserve testing and a partner with a normal sperm count. Furthermore, sterilization by one of the following procedures improves the probability of successful surgical repair: Filshie clip, Hulka clip, Fallope Ring, or Pomeroy occlusion. Women with the ends of the tubes removed (fimbriectomy), less than 6 cm of tube remaining, or whose tubes were burned (coagulated) are less likely to succeed with tubal reversal surgery. We recommend getting a copy of your operative report and bringing it to your initial appointment.
Hydrosalpinx: this is a condition in which the tubes are blocked at the end where they meet the ovary. If both tubes are blocked this way, it is nearly impossible to get pregnant without assistance. Usually an HSG, and sometimes ultrasound, will diagnose this problem.
The treatment of hydrosalpinges depends on the goal of the patient. One can attempt to repair the tube by laparoscopy and create a new opening at the end of the tube (neosalpingoscopy). The success of this type of procedure depends on the severity of the dilation, surrounding scar tissue and whether the tube is otherwise normal. Despite our best efforts, many of these patients will require IVF ultimately if they wish to conceive, as dilated and scarred tubes will often become reoccluded even after they are surgically opened.
Unfortunately, most women with hydrosalpinges cannot proceed directly to IVF. Since the fluid in the tubes can not drain out the far end, it flows back into the uterus. This fluid is toxic to embryos and alters the uterine lining to make it less inviting to an embryo. Some studies demonstrate that hydrosalpinges reduce IVF success rates by nearly 50%. Therefore before IVF, surgery is generally recommended to open or remove the tubes. This is thought to restore normal IVF success rates.
Proximal tubal occlusion is blockage of the tubes where they connect to the uterus. This type of tubal disease can be caused by mucus plugs, fibroids, endometriosis, scarring or inflammation. Proximal occlusion is usually diagnosed by HSG. However, many women diagnosed with proximal tubal occlusion on HSG actually have normal tubes after further investigation via laparoscopy. While the patient is under anesthesia, blue dye is injected into the uterus under higher pressure than can be obtained during an HSG. If the tube still demonstrates proximal occlusion, hysteroscopy can then be performed to attempt repair. This procedure is called hysteroscopic canulation and is often successful.
There is one type of proximal tubal disease that is not easily correctible and deserves special mention. It is called Salpingitis Isthmica Nodosa, or SIN. The cause of SIN has not been well established, but is associated with endometriosis and may be related to prior inflammation in the tube. The HSG images typically show “cauliflower” lesions which are diverticula (out-pouching) of the tubes. Tubes affected by SIN are typically thick and tough when evaluated by laparoscopy. Women with SIN are at increased risk for infertility and ectopic pregnancy (pregnancy in the fallopian tube). IVF is often recommended for individuals with SIN.