40-60% of women with infertility have problems with their fallopian tubes, such as tubal obstruction, adhesions or fluid retention. Many patients think that if the fallopian tubes are not working, they can just pass them. There are also patients who are eager to get pregnant and ask if they can undergo IVF directly. Is it better to have surgery or IVF? Today we have the honor to invite Li Yuan, the director of Beijing Chaoyang Hospital Reproductive Center, to talk about “When do I need IVF for blocked fallopian tubes”.
Part1.Why is tubal obstruction infertile?
Cowherd (sperm) and weaver (egg) magpie bridge (fallopian tube) meeting
Some patients ask why obstructed fallopian tubes cause infertility. We know that women want to get pregnant must have four elements: sperm, eggs, fallopian tubes, uterus. It goes without saying that sperm and eggs play a role, but you may not know that the place where sperm and eggs meet is the fallopian tube. If the fallopian tubes are blocked, it means that the cowherd boy (sperm) and the weaver girl (egg) cannot meet and an embryo can never be formed, thus leading to infertility. (Figure 1)
(Figure 1)
The percentage of those who choose to do IVF due to infertility caused by blocked fallopian tubes accounts for 60 to 80% of all IVF cases;. It can be said that IVF is actually a technique designed for patients with blocked fallopian tubes.
The accuracy rate of diagnosing tubal obstruction by X-ray imaging is 80%; ~90%;. So how to diagnose tubal obstruction? First of all is the technique of tubal imaging under X-ray. The tubal X-ray technique involves injecting a contrast agent into the patient’s uterine cavity, which can be visualized under X-ray.
(Figure 2)
The accuracy rate of tubal x-ray in diagnosing tubal obstruction is around 80% to 90%, which can basically determine whether the tubes are suitable for pregnancy or not. However, the limitation of tubal radiography is that it cannot accurately determine whether there are adhesions in the fallopian tubes and the function of the fallopian tubes. If you want to determine the condition of the fallopian tubes very accurately, you can do it by laparoscopic surgery. However, since surgery involves certain risks, we do not recommend it as a last resort. Therefore, if the tubal blockage is not clear after the imaging test, then the patient can be allowed to try to conceive naturally first, and the doctor can further determine the function of the tubes in conjunction with the medical history.
Knowing the medical history and actively trying to conceive before doing the test
When the doctor determines if the tubes are blocked, a tubal imaging test is not recommended right away, but only after a detailed medical history is taken and if further verification is needed. So what medical history is likely to affect the fallopian tubes? ①History of abortion: whether abortion, medical abortion or spontaneous abortion is a hidden risk of tubal obstruction because aborted embryos are a good bacterial culture agent, causing inflammation, fluid retention, obstruction of the fallopian tubes and eventually infertility, so it is recommended that you do not needlessly do these abortions. ②History of inflammatory pelvic disease and pelvic surgery: chronic appendicitis, chronic pelvic inflammatory disease, endometriosis or inflammatory state caused by pelvic surgery may cause adhesions and lead to tubal occlusion and obstruction. (iii) History of tuberculosis: Tuberculosis has become extinct in more developed areas, but has been on the rise in some less developed areas in the last two years. One should not think that tuberculosis only occurs in the lungs, but it is actually a disease that spreads through the blood and lymph and is particularly likely to affect the entire pelvis, causing tuberculosis and obstruction of the fallopian tubes, so certain areas should also be actively screened for the disease. In short, during the doctor’s consultation, if the presence of these factors is known, the patient will be actively advised to have her tubes checked.
Secondly, the doctor does not recommend rushing the test, but rather giving the patient time to try to conceive on her own. Younger patients usually try to conceive for a year or more, and older patients try to conceive for about six months. If you fail to conceive naturally within this time frame, you can check your fallopian tubes first, so as not to delay pregnancy in older patients.
Tubal imaging does not cause damage and does not affect pregnancy
Many patients are concerned about whether tubal imaging will damage the uterus, but this concern is unnecessary. When the contrast medium is injected into the uterine cavity, the scouring effect may damage the endometrium a little bit, but we also know that the endometrium will shed on its own every month to form menstruation, so this little bit of damage will not have any effect on the human body. In addition, there are patients who are worried that x-rays may affect the next step of pregnancy. Indeed, after a tubal imaging under x-ray, patients should preferably take 3 months to recuperate before trying to conceive. Now there are some new techniques of tubal imaging, which is a new technique using 4-dimensional ultrasound stereoscopic imaging, and this is the technique used in our hospital. As you know the amount of radiation from ultrasound is very small, and pregnant women are required to have this test during their maternity checkups during pregnancy, so you can imagine its safety. So patients should not try to conceive only in the month when the test is done, and they can try in the second month. And now the contrast agent under ultrasound used is itself some particulate protein, protein is part of the human body, so there are no toxic side effects.
Part2.When to choose IVF for tubal obstruction
There are several types of blocked fallopian tubes
There are several types of tubal obstruction: ① Proximal obstruction. We know that the fallopian tube is connected to the uterus and ovaries, and when the place connected to the uterus is blocked, we call it proximal obstruction. ②Distal obstruction. A blockage at the end of the fallopian tube connected to the ovary is called distal obstruction. (3) Tubal obstruction means that there may be some adhesions around the fallopian tube, but it is not completely blocked and still has some function. When we encounter a patient with patent fallopian tube, we usually recommend to try to conceive for 3-6 months first. If the fallopian tubes are indeed unable to perform their duties, we will then consider the next step of treatment.
Tubal blockage cannot be treated medically
First of all, it should be clear that medication is not effective in treating tubal obstruction. This is because the fallopian tubes, whether adhesions or obstructions, are formed by fibrous tissue (similar to the scars we get after a skin injury) left over from a previous disease or surgery. We know that if you have a scar on your face that is unsightly, you can’t get rid of it by applying medicine or taking medication, and the same is true for tubal obstruction.
There are only two ways to treat blocked fallopian tubes: surgery or IVF
There are two main types of treatment for blocked fallopian tubes – surgery and IVF. The surgical approach is divided into conventional surgery and laparoscopic surgery, both of which are based on the same principle of removing the scar of adhesions to restore the flow of the fallopian tubes. The limitation of the surgery is that new scars may grow in the area of the surgery and cause adhesions again. The outcome of the surgery depends on the patient’s recovery. As long as the new scar does not affect the function of the fallopian tubes too much and allows the sperm and egg to meet, then the surgery is successful. After surgery we cannot repeat the surgical examination to see how well the fallopian tubes have recovered. Instead, we advise patients to try to conceive for six months or a year after surgery, and if they are still not pregnant, then the surgery is considered a failure and IVF pregnancy assistance needs to be considered. Of course, if the tubal patency is assessed by the doctor to be poor, or if the adhesions around the fallopian tubes are themselves caused by the surgery, or if the patient is unwilling to undergo surgery due to the possible risks of the surgery itself, the patient can also be treated directly with IVF technology.
Young, normal ovulation and normal semen can be attempted
In order to increase the success rate of the procedure, which groups of people are suitable for surgical treatment? In general, we believe that the following 3 conditions can be met by both partners: ① The female partner is <35 years old, because she needs to try to conceive for six months to one year after the operation, and the fertility of women over 35 years old is declining linearly, and the ovarian function is deteriorating. For these patients, time is life and we do not have time to try again and again; ② the female partner needs to have normal ovulation. If the patient herself is not ovulating normally, the patient has to embark on the path of ovulation promotion, which is also a torment to the patient; ③ the male partner needs to have normal semen. If the male partner is suffering from weak sperm, oligospermia or deformed sperm, then it is wise to choose IVF directly.
Some patients say, “Since the surgery may not be successful and there are damages and risks, can I do IVF directly?” Yes, of course, it is possible.
The normal chance of natural conception is 30% to 40%; IVF can reach 50% to 60%. Many patients are concerned about the success rate of IVF. With the advancement of clinical technology and the improvement of laboratory conditions, the success rate of IVF has reached 50%; ~60%;. Some patients are still not satisfied with this figure, why is it not 100%; or 99%;? We should know that normal young couples can’t conceive whenever they want to, and the chance of getting pregnant every month is only 30% to 40%, which shows that the technology of IVF has surpassed. Usually after two embryo transfers, most patients are able to conceive successfully. If after two transfers there is still no success, we have to continue to look for factors that affect conception and after correcting these factors, the vast majority of patients will be able to conceive as they wish.
Factors affecting IVF success rate
What are the factors that may affect the success rate of IVF? ①The skill level of the doctor and the medical facility. Experienced doctors are able to keep track of every aspect of a patient’s treatment and make timely adjustments to the treatment plan based on the patient’s condition. ②The patient’s ovarian function. The older the patient is, the worse the ovarian function is, the lower the quality of the eggs, and the success rate of IVF will be affected. ③The quality of sperm. Nowadays, men have a lot of work pressure, plus some unhealthy lifestyles, which can cause unhealthy sperm. ④The environment of the endometrium. We compare the embryo to a seed, the uterine lining is the land where the seed grows, even if the seed is good enough to grow on concrete, it won’t grow a crop. Therefore, it is necessary to adjust the uterine environment in advance to remove the undesirable causes and prepare for embryo implantation.
Part3: Preparations to be made before IVF for blocked fallopian tubes
Patients with hydrosalpinx must be treated surgically before IVF
For patients with tubal obstruction, even if you have decided to do IVF, you cannot leave all tubal problems unattended. Especially for patients with hydrosalpinx, surgery is necessary before IVF. Why? First of all, because the fluid is caused by inflammation and the fallopian tubes are connected to the uterine cavity. Once the fluid enters the uterine cavity, it will bring a lot of inflammatory substances into it, and these inflammatory substances will affect the embryo’s implantation. In addition, the fluid may enter the uterine cavity and wash away the embryo.
Therefore, for patients who have fluid in the fallopian tubes, the doctor will recommend ligation or removal of the tubes before IVF. This is because the blood supply to the fallopian tubes and ovaries comes from the same artery and the return flow is from the same vein. During the procedure, the doctor will carefully separate the blood vessels so as not to disrupt the blood supply to the ovaries and not to affect their function as much as possible. However, we know that the distribution of blood vessels varies from person to person and the surgeon cannot guarantee that every operation will not affect the function of the ovaries. Therefore, it is important to take advantage of the timing after the tubal surgery and enter the IVF cycle as soon as possible.
Eliminate all the influencing factors and strive for success in one go
The following question then is how to eliminate all the previously mentioned factors that affect the success rate of IVF. We will assess the physical condition and reproductive function of both men and women, solve any problems, and then enter the IVF cycle for a single success. Below we briefly explain how to perform the assessment.
1. Ovarian function tests: Ovarian function tests generally include these: ① Hormone 6 test: blood test on an empty stomach in the morning of the 2nd to 4th day after the onset of menstruation. The purpose is to detect folliculopoietin (FSH), luteinizing hormone (LH), estradiol (E2), progesterone (P), testosterone (T) and prolactin (PRL) to understand female endocrine function; ②Sinus follicle count: the number of basic sinus follicles (sinus follicles are the form of follicles before the appearance of mature follicles. (3) Anti-Müllerian hormone (AMH) test: AMH is a hormone secreted by the granular layer cells of the ovarian follicles, which are produced by the baby girl from 9 months of age. Combining the results of these tests, the doctor will have a good idea of how the patient’s ovaries are functioning.
2. Sperm examination: We cannot ignore the male factor in fertility, and we should not wait until we find that the quality of the embryos produced is not good before we turn around and check the male partner. The sperm check generally needs to be done at least twice, and if it is not normal, or if there is a big difference between the two, only then will it be checked a third time. The examination includes: chromosome examination, biochemical examination of seminal plasma, sperm fertilization ability, etc. Attention should also be paid to whether the male partner has any other conditions that may affect the quality of the embryo, such as bilateral varicocele, very unhealthy lifestyle, excessive obesity, history of diabetes and hypertension, which may affect the quality of the embryo. Therefore, we recommend these men to undergo adjustment treatment before proceeding to IVF. Patients with severe oligozoospermia are more difficult to treat, but because one egg with one sperm is enough, patients can enter the IVF cycle after some treatment, as long as healthy sperm are present.
3. Evaluation of endometrium: ①B ultrasound examination: ultrasound examination is done near the time of ovulation, and it is more accurate to determine the thickness and shape of endometrium. ②Hysteroscopy: Hysteroscopy is more accurate. You can visually see the inside of the uterine cavity under the endoscope, such as polyps, adhesions, inflammation, bleeding spots, etc. Uterine cavity lesions are sometimes relatively difficult to treat, such as adhesions, especially the more severe ones, which may recur after separation. Adhesions are often the result of previous surgical operations, especially abortion and curettage. Hysteroscopy can also detect inflammation, and it is difficult for oral antibiotics to reach the uterine cavity, and it is difficult for drugs to have a therapeutic effect if they do not reach the site of action. Therefore, we are reminded to love the uterus and to pay more attention to avoid inflammatory infections.
Women under 45 years old for IVF
We have mentioned several times the relationship between ovarian function and age. It is important to know that the number of follicles in a woman’s ovaries is determined from the moment she is born. Starting with the first menstrual period at puberty, each menstrual period mobilizes a portion of the follicles, of which only one matures and the others that are mobilized will then wither away. So instead of only one follicle being used each month, there are dozens or even tens of follicles being depleted. As we age, the number of follicles gets smaller and the quality gets worse, and the decline in ovarian function is irreversible. There are still many women nearing menopause who want to conceive through IVF, but the consensus in China is to keep the age of women below 45 years old before trying; the chance of getting a healthy baby for women over 45 years old is only 1%; therefore, we do not recommend women over 45 years old to try IVF to conceive, considering the patient’s financial, physical and success rate.