SART Fertility Experts - Tubal Surgery in the IVF Era

In this episode of SART Fertility Experts, Dr. Brad Hurst joins host, Dr. Mark Trolice, to review the indications for tubal surgery, including current reasons for and likelihood of success with tubal surgery, as well as when patients might be better suited for the treatment option of in vitro fertilization (IVF).

Bradley S. Hurst, M.D. is Director of Assisted Reproduction and Director of the Reproductive Endocrinology Division at Carolinas Medical Center in Charlotte, NC.

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and SART. These podcasts are provided as a source of general information and are not a substitute for consultation with a physician. Welcome to SART Fertility Experts, a podcast that brings you discussions on important topics for people trying to build a family.

Our experts are members of SART, the Society for Assisted Reproductive Technology, an organization dedicated to ensuring you receive quality fertility care. Hi, everyone, and welcome to another edition of the SART guest. I'm your host, Dr. Mark Trolice, and with me today is a good friend.

His name is Dr. Brad Hurst. Brad is the president of the Society of Reproductive Endocrinology and Infertility. He's also the division director at H.E.M. Health Carolina's Medical Center.

Brad did his training at Duke University, where he did his residency, and then he did a fellowship at Johns Hopkins. Brad, welcome to our podcast. Well, thank you.

So, Brad, let's go back to before IVF, and when we didn't have the accessibility to that, or when surgeons didn't do that, what were we seeing with pregnancy rates? You know, when we were really going out to having to take care of hydrosalpinges or extensive lysis of adhesions, what kind of counseling were we giving patients as to success rates? I think we had quite a bit of data about the expected outcomes, and I think the information we gave patients was pretty good. Obviously, the prognosis depended on a number of factors, including primarily the severity of the tubal disease, but also patient age and whether or not the semen parameters were normal or not. And some conditions, like patients who'd had tubal ligation with minimal tubal damage, had an extremely good prognosis with tubal surgery.

But patients who had a large hydrosalpinges had an extremely poor prognosis with tubal surgery. The sad thing is that, at the time, that was the best that we could offer patients. And over the years, the prognosis for tubal surgery really hasn't improved, but IVF success rates have markedly improved.

So, at this point, diagnoses tends to be a better prognosis than a lot of the tubal surgeries that we have done in the past. So, since this is on tubal surgery, it's a good idea for our listeners to know the different types of tubal surgeries and when we would apply. So, there's blockage in the fallopian tubes, and that could be in the very, very beginning, where it enters the uterine cavity.

That's called proximal occlusion. And then there's distal, which is at the end of the tube, closer to the ovary. And typically, a distal occlusion that are blocked and swollen, we call those hydrosalpinges.

And then, of course, there's the condition where patients that had tubal ligation, and they have the option of an anastomosis, which is connecting the fallopian tubes for patency to open them again. So, in keeping with the talk about hydrosalpinges, Brad, we know there's four stages, essentially, and the minimal ones that they could still be open but swollen, and then, of course, the severe. And the minimal ones, they could still be open but swollen, and then, of course, the severe, stage four, blocked, large, dilated, swollen, and a lot of scarring.

What patient, now that there is IVF, what patient would you say is a candidate to try to open that fallopian tube versus removing the fallopian tube and go to IVF? And I just want to preface this for our listeners to say that what we now know is that if a tube is blocked and swollen, that fluid is actually toxic to the embryos and it can seep back into the uterine cavity, and it will reduce IVF success rate by about 50%. What's also known is that removing a damaged fallopian tube can actually improve the fertility in natural cycles with the other fallopian tube. So, given that, who's a candidate in your eyes for, in the era of IVF, to do surgery on a hydrosalpinx? It always pains me to, any structure, including a hydrosalpinx.

So, when I counsel my patients, I tell them that the plan will be to do a salpingectomy when there's a large hydrosalpinx. And by large, usually we're referring to something that we can see on ultrasound without any type of special dye studies. So, something that's pretty big.

There's really not a whole lot of evidence that a small hydrosalpinx, especially the ones that still will drain fluid in the direction of the ovary, there's still not solid evidence that that compromises overall success with IVF. But when I do surgery, a lot of times a hydrosalpinx is caused by infection, inflammation, and in those cases, usually there's damage on the outside of the fallopian tube and on the inside of the fallopian tube, and the overall success with that is usually extremely poor. Sometimes a hydrosalpinx, though, is caused by endometriosis, and the inflammatory process with endometriosis tends to be different than with infections.

So, after removing scar tissue surrounding the fallopian tubes, sometimes you look at the fallopian tube and it looks gorgeous, and I never want to remove a fallopian tube that I think looks gorgeous. So, in that case, patients do have a possibility of conceiving. There is always a possibility that the hydrosalpinx can reform, and if you repair the fallopian tube, you might have to go back and remove it at some point in the future.

Because it re-blocks. Yeah, it closes back again in about 30% of the surgical cases. So, what do you do? I've had conditions where a patient's tube on the histosalpingram, and for everyone, this is the outpatient radiologist center or your physician's office, and we determine if the fallopian tubes are open.

So, what do you do, Brad, when the tubes are blocked? You think that they're closed. You do the surgery, then, and then you inject dye, and you could see it actually being, showing dye coming out. So, it's open, but very swollen.

What do you do with an open tube that you know is a really damaged tube? She has committed to doing IVF if you're going to remove the tube. Do you remove that tube? Do you keep it? If I'm doing surgery, and I've already made the incisions, I'm already doing the procedure, and it's clear that the tube is damaged, I want to do everything that I can to try to ensure success for that patient's IVF cycle. Because I know the overall success with tubal surgery with severe disease is in the order of about 10 to 20 percent at the patient's reproductive years.

That's not very good. If there's moderate disease, the overall success is closer to about 20 to 40 percent, but again, that's for patients the remainder of her reproductive years, and I don't think that's very good either. I can do an IVF procedure, do a single embryo transfer, and based on national statistics, we can expect to have a birth rate that's in the range of about 50 percent for a woman under 35.

Yeah, based on age of the patient. So, you would remove the tube if she's prepared to do IVF, and if it's very, very damaged, but even though it's maybe open. Correct.

Because I don't want to go back. I don't want to have to subject a patient to subsequent surgery. And the other thing for our listeners is that a damaged fallopian tube puts them at risk for a life-threatening ectopic pregnancy, and this is a pregnancy implanted usually in the fallopian tube, and if not detected early, could require emergency surgery, and rarely, of course, mortality.

But that's the worry on our eyes all the time, is that, you know, what kind of a condition is this fallopian tube? What kind of risk are we taking by leaving the fallopian tube? Correct, and again, when there's damage on the outside of the fallopian tube, there's almost always damage on the inside of the fallopian tube as well. We hope you're finding this episode of SART Fertility Experts helpful. Remember, for more information on this and related topics, visit www.sart.org and click on the tab labeled Patients.

And now, back to SART Fertility Experts. Okay, so let's switch now to the other side of the tube, and that's the beginning portion where the uterus enters the fallopian tube, and that's a proximal tubal occlusion. So you have a patient, 28 years old, been trying to conceive for about a year.

Sperm counts good. She's ovulating. We do an HSG.

Both tubes are blocked in the beginning. So walk us through how you take care of this patient. Well, I have to be skeptical and suspicious about any type of blockage at the uterus, because if you just simply repeat the test at a different time, you'll find that the fallopian tube is open 60 to 70 percent of the time.

So there's a lot of reasons why the fallopian tube can look blocked at the uterus when it's really not. First, the uterus is a big muscle, and if that muscle is contracting, it can cause the fallopian tube to close. And if the uterus has the opportunity to relax, sometimes you can see contrast that flows into the fallopian tube.

So that's one thing. Second thing is that sometimes there's a blockage with mucus or a plug of cellular debris, and it's not really a true blockage, but it's something that looks that way with the HSG test, the dye test. And in that circumstance, sometimes the fallopian tube will eventually open during the procedure, and sometimes it doesn't.

And if it doesn't, there's relatively simple things that can be done short of surgery and short of IVF that can be successful. So quickly for the audience, injecting dye too fast into the uterus is really a setup for that kind of a scenario where both tubes are blocked, because it can cause a cramp with the uterus being what's called a smooth muscle. It just expands and contracts real hard, and that's why patients have moans and contracts real hard, and that's why patients have most of the discomfort from an HSG by injecting dye a little bit too fast.

So you have a condition where either now you're pretty certain that one or both tubes are blocked. With one blocked, overall success rate probably the same as two being open versus one being open. Yeah, eventually.

But now they're both blocked, and IVF is not an option for them. So what do we offer this patient? Well, there are several different ways that tubal cannulation can be performed, where a catheter is placed into the uterus and then advanced into the opening of the fallopian tube. That's successful at opening the fallopian tube in the large majority of patients who have that procedure done.

And a number of studies have shown big variation in subsequent pregnancy rates, but some studies have shown pregnancy rates as high as 50 percent, some even higher. I'm a little bit skeptical of the ones that are much opportunity to conceive naturally, and if that doesn't work, then she'll have to consider other options. But there is also, excellent points, and there is also the risk that they can re-block or re-occlude.

Oh yeah, of course. I think it's about a third or so of these patients when you do another look, but don't know how long that's going to take. But it is a way to avoid inexpensive IVF cycles, certainly, to do an outpatient.

Especially if it works. So it looks like the beginning portion or proximal endometriosis may have a role, possible prior infection, certainly with the end of the fallopian tube, often a chronic infection or inflammation from a prior pelvic infection, sometimes endometriosis though as well. It brings us to a more sticking point to me, a difficulty, is what do you do with the patient who's had a bilateral tubal ligation, where tubes have been tied, and they come to you and say, what should I do? Should I get them reversed? Should I do in vitro fertilization? How do you counsel a patient? That can be a difficult question to answer because the success with a patient who's had a tubal ligation depends on how much of the fallopian tube was damaged, how old she is, what her ovarian reserve testing might be, and whether or not her husband has a normal semen analysis.

So all of those things go to factor into her prognosis. So before I commit either to surgery or IVF, there's a few basic things that I want to get. I want to test ovarian reserve to determine what her prognosis might be for IVF.

If it's really low, meaning that we wouldn't expect to get many eggs when we do an ovarian stimulation for IVF, in that case, I would probably recommend tubal surgery because every month that woman ovulates, she'll have an opportunity to conceive. On the other hand, if we do a semen analysis and the sperm counts are terrible, we can do surgery. And it might be the results might be good from a surgical standpoint, but she may never be able to conceive because her husband's sperm counts or partner's sperm counts are just not high enough.

Is there an age, now to put you on the spot, is there an age that you would say, I really don't think we should reverse your tubes? Or is there an age that you would say, I really don't think we should do IVF? Well, your job is to put me on the spot. So I totally expect that. As a woman, almost paradoxically, the overall success with tubal re-anastomosis for a woman between age 40 and 45 is usually, usually better than the overall success of a single IVF cycle, especially unless a woman has a tremendous response to fertility drugs with IVF.

Up to 50% you're seeing overall. Cumulative pregnancy rates between 30 to 50%, which for a woman who's 40, 41, 42, 43, much higher than what we expect in most patients who undergo IVF at that age. And the difference is that every month when a woman ovulates, she has a chance to conceive.

She may have a perfect egg, and as long as that combines with a healthy sperm and she has a normal uterus, there's a possibility of pregnancy. Whereas IVF is a one-shot thing. So over the course of a year, a woman will have 12 or 13 ovulation cycles.

Over the course of five years, 60. And there's no way we can get 60 eggs when we do an IVF procedure, even in, except in unusual circumstances. So just to try to summarize, and for all the listeners, if you have a tubal problem, this is really valuable information to know which direction to go.

So you can have the potential blockage in the beginning, which is proximal. Option for that would be trying to open the fallopian tube with the tubal cannulation. The end of the fallopian tube that's closer to the ovary, that's a distal, and often a hydrosalpinx.

There's surgery option there. And then, of course, the tubal ligation, which is usually in the middle of the fallopian tube, and you can try to reconnect the fallopian tube. IVF is increasing in usage and is available to patients.

But I think it's important in our specialty, and for all of you to know, that reproductive surgery is still alive and well, even in the era of IVF. Wouldn't you say, Brad? Yes, definitely with that. Well, I want to thank you all for listening.

This was very, very exciting and valuable information to me. I hope you all, I know you all gained from this. We want to thank Dr. Brad Hurst, who is the president of the Society of Reproductive Endocrinology and Infertility, and also the division director at Atrium Health at Carolinas Medical Center in Charlotte, North Carolina.

Brad, thank you for joining us. Thank you for listening to SART Fertility Experts, your resource for information on IVF. If you found this podcast useful, please like us on your favorite social media platform and tell your friends about us.

For more family building resources, visit www.sart.org slash patient dash information or www.reproductivefacts.org.