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Thoughts on Blocked Tubes

Initially, the primary indication for IVF was tubal disease. IVF clearly compensated for the tubes not being able to pick up an egg and transmit the fertilized egg into the uterus. One of the kinds of patient problems that fit into this category was that of patients with closed tubes that were distended with fluid, also called hydrosalpinx or hydrosalpinges. This was a typical finding after a severe pelvic infection. However, after IVF had been in existence for several years, many programs were able to determine from their data on patients with successful pregnancies, that patients who underwent IVF with a hydrosalpinx did less well than patients who underwent IVF with some other severe tubal problem, such as the tubes having been removed. Most publications identified a 50% miscarriage rate and a two to three fold difference in the pregnancy rate.

Current thinking is that the fluid in a hydrosalpinx runs back into the uterus and makes the endometrial cavity inhospitable to the implanting embryo. It even appears to change the cavity biochemically (integrin production). Excising or removing the hydrosalpinx from the uterus effectively reverses this problem. This surgical procedure both increases the pregnancy rate and decreases spontaneous miscarriage rate.

The data is strong enough to support the uniform recommendation of removing a hydrosalpinx prior to undertaking IVF. In the case of a one-sided or unilateral hydrosalpinx, the pregnancy rate using therapies other than IVF is also likely to be enhanced by removing the effected tube.

Tubes that are blocked where they leave the uterus (proximal blockage) present an entirely different situation. If the diagnosis is made by hysterosalpingogram (HSG), it is in error about 30% of the time. This can either be because of technical difficulties in performing the HSG or due to tubal spasm. The later is more likely if the procedure was painful for the patient. Confirmation that the tube is closed requires a laparoscopy. If the tube is closed and the surgeon has the hysteroscopic skills, often a guide wire can be passed through a hysteroscope and into the tube, opening it. Sometimes dried secretions block the tube or soft tissue like endometriosis and this procedure can correct the situation. If the tube has been closed due to fibrosis or salpingitis isthmic nodosum (an inflammatory condition), it cannot be opened. There is an old procedure (tubal re-implantations), which had very poor results and has long been abandoned. In this setting the procedure of choice if both tubes are proximally blocked is IVF, which bypasses the tubes.

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