Fertility Topics Explained from the Experts at SFS
Case Report: **For the purposes of anonymity, I will be referring to the patient as RL throughout this blog.** RL, a 31-year-old woman, presented with a 7 year history of inability to conceive, in spite of 2 prior fresh and 1 frozen IVF attempts, where a total of six good quality blastocysts had been transferred to her uterus. Her husband PL, had normal sperm and had initiated 2 pregnancies in a prior relationship. RL had normal ovarian reserve (based on prior blood FSH and AMH levels, good follicle development, and good egg/embryo quality during her 2 fresh IVF cycles). A prior hysterosalpingogram (dye X-ray/HSG) had revealed the cause of this couple’s infertility to be blockage of the ends of both Fallopian tubes, which was traceable back to an episode of Chlamydia-induced pelvic inflammatory disease (PID) in her teen years. A routine pelvic ultrasound that I performed revealed a cystic lesion to the right of her uterus. It suggested a hydrosalpinx (a fluid-distended Fallopian tube). I recommended a laparoscopy to confirm the diagnosis and then the removal of the affected tube(s). She underwent a laparoscopy, where it was found that while her right tube was most affected, both tubes in fact were hysdrosalpinges. Because both tubes were diseased and functionless, I surgically removed them (salpingectomy). RL subsequently underwent a third fresh cycle of IVF (her first at SFS), where I transferred 2 good quality blastocysts (and cryopreserved 3 remaining embryos for future use). She went on to conceive, and recently gave birth via cesarean section to a healthy full term baby girl. Discussion: Damage to the Fallopian tubes as a result of prior pelvic inflammation is one of the most common female causes of infertility. Commonly (as was the case with RL), this results in blockage of the tubes at their ends, while leaving them open and connected to the uterine cavity. In such cases, the Fallopian tubes often progressively fill with fluid (hydrosalpinx) that contains dead cells and other noxious products, which are potentially toxic to embryos. Leakage of such fluid backwards into the uterus can severely compromise implantation of transferred embryos. This is why women with hydrosalpinges are strongly advised to have the diseased tubes removed or ligated (at the point that they emerge from the uterine wall), prior to undergoing embryo transfer. Admittedly, it is often hard for patients to accept that their tubes will be gone, as it means that future conception will require IVF. This is where it is necessary to explain that such tubes are non-functioning, and that even if they could be opened through surgery, the likelihood of pregnancy would be remote. In RL’s case, there was a high likelihood that her failure to conceive was due solely to the above mentioned effect. And so with all else working in her favor (young age, normal male fertility, good ovarian response and a receptive uterus), removal of the hydrosalpinges led to her conceiving in a subsequent IVF attempt. Hopefully, should she desire to have another baby in the future, she will be able to readily do so using her remaining cryostored embryos. Women with tubal occlusion who want to have a baby will invariably require IVF. In many such cases, one or both of their tubes will, over time, have progressively filled with toxic fluid that can drain back into the uterine cavity and thwart post-ET implantation. It follows that all cases of tubal blockage should be carefully evaluated for hydrosalpinges before ET, and that when detected, they first be surgically addressed through tubal ligation or removal (salpingectomy).
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