Question 27. Can fallopian tubes be repaired and why would a blocked tube be an issue if I am doing IVF anyway?

Not sure that anyone really missed me over these past 2 weeks but I was out of town for several days and am trying to catch up. This past weekend was my 25th Reunion for Princeton (see DrG in the photo with 2 of his college roomies). Note the traditional Reunion Blazer that is provided to all members of the class to wear at all Princeton events. As always, Princeton Reunions is an event that has to be seen to be believed. Needless to say, orange and black are not the most flattering colors (except at Halloween). So after overdosing on Princeton I am back and ready to catch up with my blog.

Several patients have posted regarding repairing fallopian tubes. In general, most of us have moved away from surgery and towards IVF. However, it is important to know where the blockage is in such cases. Tubes that simply fail to fill on an HSG can be further assessed by fluoroscopic tubal canalization...essentially a Roto-Rooter job performed by an interventional radiologist that is often 80-90% successful at getting a blocked tube open. Repairing the delicate end of the tube (the fimbria) is more problematic and there is a significant risk of ectopic pregnancy in such cases.

So here is today's Question of the Day from the upcoming 2nd Edition of 100 Questions and Answers about Infertility:

27. Can fallopian tubes be repaired and why would a blocked tube be an issue if I am doing IVF anyway?

Prior to the advent of IVF, surgical repair of damaged fallopian tubes was considered standard medical care. Unfortunately, most patients did not become pregnant following this procedure, and 10% to 20% experienced tubal (ectopic) pregnancies. Today, IVF has replaced reparative tubal surgery for most patients with damaged fallopian tubes for two reasons: (1) IVF is a nonsurgical treatment and (2) it results in excellent pregnancy rates, especially for patients with tubal disease.

Some patients ask, “Why is it so difficult to repair damaged tubes?” Unfortunately, the problems that cause tubal disease, such as pelvic infections, usually damage the tubal fimbria—that is, the delicate finger-like projections at the end of the tube that are responsible for capturing the egg when it is released from the ovary. Pelvic infections may also damage the entire thickness of the tube from the tubal muscle to the inner mucosal layer, leaving behind a scarred, nonfunctional organ that is not amenable to surgical repair.

In general, most patients with tubal disease are best treated using IVF. Tubal reparative surgery is usually not effective and, in fact, it may increase the woman’s risk for having an ectopic or tubal pregnancy. If a couple is not interested in IVF or if they are not deemed to be good candidates for IVF, then tubal surgery may be the only option available to them in terms of fertility treatment.

Damage to the fimbria of the fallopian tubes may result in a tube that is blocked at the very distal end—the part farthest away from the uterus. A tube that becomes filled with fluid is called a hydrosalpinx (“hydro” refers to water; “salpinx” refers to the fallopian tube itself). A hydrosalpinx is usually discovered during a hysterosalpingogram (HSG) performed as part of the infertility diagnostic evaluation. This simple x-ray study should be performed in all infertile women unless a diagnostic laparoscopy has already been performed as some assessment of the status of the fallopian tubes is a key part of the fertility evaluation. We advise all patients undergoing a laparoscopy that we recommend removal or ligation of her tube(s) if a hydrosalpinx is discovered.

Over the past decde many studies have demonstrated reduced IVF pregnancy rates in patients who have a hydrosalpinx. It has been theorized that the fluid in the tube may flow backward into the uterine cavity. This fluid may contain toxic substances that may adversely affect the receptivity of the endometrium preventing implantation. Alternatively, the fluid may actually flush the embryo out of the cavity or even prove toxic to the embryo itself. Some studies suggest that the presence of an untreated hydrosalpinx will reduce IVF pregnancy rates by 50%.

In addition, an untreated hydrosalpinx may increase the chance that a woman will experience a spontaneous abortion or miscarriage. For all these reasons, treating a hydrosalpinx should both increase the IVF pregnancy rate and decrease the chances for an early pregnancy loss. A patient with a single normal fallopian tube and a hydrosalpinx will also have a higher chance of achieving a spontaneous pregnancy after removal or ligation of the damaged tube.