When couples get married, they often
view parenthood as the next stage in their family life. They want to have a
child, they want to be “mom” and “dad”, they cannot imagine that this may be
hard to achieve or may not be a natural process. When several trials to
conceive fail, they are shocked. Their basic expectation about family life gets
shattered. Most of the couples are desperately looking for medical therapy that
will end into a misery. Clearly this is not a struggle to survive; it is a
struggle to fulfill a dream, to achieve what they view as a “full life”.
is needed for pregnancy?
the male partner, sperms are normally produced in the testes after puberty
(after attainment of characters like growth of beard, moustache etc). From the
testes, they are carried through the sperm conducting ducts (epididymis, vas,
seminal vesicle and prostate gland). Then during sexual stimulation, after
proper erection and ejaculation, they come out through penis. During sexual
intercourse, these sperms, present in semen, are deposited inside the vagina.
In female partner, the deposited sperms must
travel from vagina through the cervix (the mouth of the uterus). The cervix
acts as gate-keeper, a it prevents entry of dead and abnormal sperms as well as
bacteria present in semen, in the uterus. From uterus, sperms reach the
Fallopian tubes (the tubes that are attached to the both sides of the uterus)
where the sperms must meet the egg (ovum). The eggs are produced only before
birth and so, there are fixed number of eggs inside the ovary. The ovum
released from the ovary, into the abdomen at the time of ovulation (rupture of
the surface of ovary to release the ovum). That ovum must be taken by the tube
and thus inside the tube an embryo (earliest form of the baby) is formed, by
meeting of the egg and the sperm.
should be mentioned that out of nearly 200-300 million sperms, in average,
deposited in vagina, hardly 500- 800 sperms can reach near the eggs and only
one will succeed to form the embryo. The embryo then travels through the tube
into the uterus and the uterus attaches the embryo firmly with it and thus the
pregnancy starts. So, if there is defect in any one of them there will be
difficulty in achieving pregnancy.
to summarise, pregnancy requires
of healthy (“Normal Morphology”) and movable (“Normal Motility”) sperms in
adequate number (“Normal Count”) in the testes
of these sperms through the sperm conducting ducts from testes to penis
Erection and Ejaculation during Intercourse to deposit adequate number of these
sperms in the vagina
of these sperms from vagina through cervix to the uterus and the tubes
of sufficient number of eggs inside the ovary and ability to release the eggs
from the ovaries
up of the eggs by the tubes
of eggs and the sperms to form the embryo
of embryo from the tubes into the uterus
of the embryo by the uterus and its growth
the word “Infertility” means inability to conceive. But in reality, there are
very few couples, who have no chance of natural conception and are called
“Absolutely Infertile”. In fact, in many couples who present to infertility
clinics, pregnancy may be the matter of time, thus the chance factor.
should be kept in mind that, if there is factors to question fertility of
either male or female or the female is of age less than 35 years; after one
cycle (one month) of regular frequent intercourse, the chance of conception in
human being is only 15%. That means, out of 100 couples trying for
conception, only 15 will be able to succeed after one month of trying. The
word “Regular” and “Frequent” are important; because to achieve pregnancy,
couples are advised to keep intimate relationships for at least 2-3 times a
week and this should be increased particularly around the time of ovulation
(Middle of the menstrual cycle). Thus chance of pregnancy after 6 months, 12
months and 24 months of regular trying are respectively 60%, 80% and 100%.
word, “Subfertility” seems better and more scientific than “Infertility”, to
describe the couples who have reduced chance of conception, due to any cause.
However, the word “Infertility”, seems more popular, although it puts pressure
on the couples. In most cases, usually we advise to investigate after one
year of regular and frequent intercourse, when the couples fail to conceive.
However, if there are factors to question fertility; for example female with
age more than 35 years, or with previous surgery in tubes/ ovaries/ uterus or
known diseases like PCOS or endometriosis; or male partner having surgery in
scrotum or groin or any hormonal problems or sexual dysfunctions- the wait
period is usually reduced and couples can be investigated, even soon after
look at the point “Thus, to summarise, pregnancy requires” where 9 points have
the common causes may be
in male- total absence of production of sperms, less than adequate number of
sperms, problems in morphology and motility of sperms (most sperms not healthy
or movable), blockage in transport of sperms and inability to deposit sperms in
the vagina (sexual dysfunction- Erectile Dysfunction or less commonly,
Ejaculatory Dysfunction). Examples include hormonal problems (Testosterone,
thyroid, prolactin), diabetes, liver problems, causes present since birth,
chromosomal abnormalities, surgery, infection, sexually transmitted diseases,
smoking, exposure of scrotum to high temperature, some medicines or
in female- total absence of less than adequate number of eggs in the ovaries,
problems in ovulation, problems in picking of eggs by the tubes, blockage of
tubes, problems in conduction of sperms or embryo by the uterus, problems in
accepting the embryos by the uterus. Examples include causes present since
birth, chromosomal abnormalities, polycystic ovarian syndrome (PCOS), old age,
increased weight, fibroid, endometriosis, pelvic inflammatory diseases (PID),
tuberculosis (TB), infections, smoking, surgery, some medicines, hormonal
problems (thyroid, prolactin) or excessive stress.
causes- Despite thorough investigations, 25-30% causes of infertility remain
unknown. This is called “Unexplained Infertility”. The reason may be mere
chance factors or there may be some causes which, still medical science has yet
to discover. But this should be kept in mind while treating infertility. That
means, even with correction of the possible factors (like improving sperm
counts or thyroid problems etc) or with proper treatment (IUI, IVF or
ICSI), unfortunately the treatment can fail and the exact reason, why the
treatment failed, is sometimes difficult to find out.
general, what are the treatment options for infertility?
start with, please remember there is no hard and fast rules for infertility
treatment. Often medical science fails to understand why couples with very
severe form of infertility conceive sooner than those who are having all tests
normal. That means, whatever treatment is offered, it’s very important to
continue regular sexual intercourse, as the chance of natural pregnancy is
usually there in almost all couples. Your doctor will present the facts to
you, without pressurizing you on a particular option. After coming to know all
pros and cons of different treatment options, you can take decision. Do not
hurry. It’s quite natural that you might be in stress.
general, after the initial tests, a few periods of natural trying is allowed. After
that, ovulation induction (giving medicines to release eggs from the ovaries)
is offered, failing which IUI and finally IVF is offered. What will be the
preferred treatment for you, will depend on your age, duration of marriage,
male and female factors and of course, your age. For example, a woman with both
tubes blocked or a male with very low sperm count, IVF would be the first line
What is Fallopian Tube(s)?
tubes (commonly called “the tubes”) are the structures that are connected to
the both sides of the uterus, as mentioned above. Each tube is of 10 cm length.
The part attached to the uterus is called
the “cornu” and the part remaining free is called the “fimbria”. It’s the
fimbria, that is present near the ovary and picks up the ovum and transports it
inside the tube. The cornu received the sperms from the uterus and passes it
inside. Inside the tube, the sperms and the egg meet to form the embryo, which
then travels down the tubes into the uterus and then the pregnancy starts.
What happens if tubes are blocked?
both the tubes are blocked completely, anywhere along the length (cornu,
fimbria or the middle), pregnancy is not
possible. This is quite obvious, because either the sperm cannot enter or
the egg is not picked up or they cannot meet.
if any of the tubes are partially blocked, then the sperms and egg can pass and
meet but the embryo cannot come down into the uterus. As a result, the
pregnancy continues inside the tube, which is called “Ectopic pregnancy” that is life-threatening for the mother. It’s
important to remember that ectopic pregnancy can happen even if both the tubes
What are the reasons for tubal
the exact cause is not known. Infection
is the commonest cause. The infections may be due to sexually transmitted
infection (STI), particularly Chlamydia
infection or infection from bowel or appendix. Tuberculosis is very common in
our country and can affect the tubes, silently, without affecting any other
parts (not even the lungs) of the body. Endometriosis
is also a common reason for tubal blockage. Any pelvic surgery (surgery in ovaries, tubes, uterus, even appendix)
can block the tubes by “adhesion”.
This means the tube may be open but attached to the bowel or rotated on itself,
so that the tube cannot pick up the eggs from the ovaries. Sometimes fibroid of uterus can compress the tube
and cause blockage. Women, with previous history of ectopic pregnancy, are at risk. Uncommonly, some abnormalities,
present since birth can block the tubes.
What are the types of tubal
block may be one sided or both sided. It may involve only a particular part of
a tube or multiple parts of a tube. The site of the block may be the cornu, the
fimbria or the middle portion.
is a thing that you must know. In this condition, the tube is blocked but the
mid-portion is dilated and contains some fluid (often infected). This tube is
not functional. And the problem is even if there is pregnancy by IVF inside the
uterus, this fluid from the tube may trickle down, coming in contact with the
embryo and can potentially kill the
How can I understand that the tubes
very few women have signs or symptoms indicating tubal block. However, if you
had previous infections in pelvis, tuberculosis in any part of the body,
appendicectomy or other gynaecological surgery, there is chance of tubal block.
Patients with fibroid and endometriosis are also at risk of tubal block. If you
feel severe pain during periods or during intercourse, there is a chance that
the tubes may be blocked.
When the tubes should be tested?
mentioned earlier, the routine investigation of infertility includes testing
for the ‘open-ness’ of the tubes- “Tubal
patency tests”. That means if pregnancy does not come within 12 months of regular intercourse, then
we usually advise the tests. Sometimes, tests are needed, after 6 months of trying (see above). However,
in some women, with low risk of tubal block (no risk factors as mentioned above),
it may be appropriate to start treatment
and continue it for few cycles and if no response, then tubes should be
How the tubes are tested?
method of tubal patency test depends on your risk of having blocked tubes and
also your wishes, availability of resources, other fertility factors and of
course the affordability.
Routine ultrasound (like TVS)
cannot detect tubal patency. However, it can detect the
hydrosalpinx in most of the cases.
you do not have any risk factors (like pain during periods, endometriosis,
previous infections or surgery), you can choose either HSG or SIS. These are
done in out-door basis, without any need
is a method by which, your tubes will be seen under Xray. After visualizing
your cervix (mouth of the uterus) by a speculum (instrument inserted in the
vagina) a small screw will be inserted inside the cervix and a contrast
material (which can be seen by the X ray) will be given through it. If tubes
are open, the Xray will show that the contrast material will be going through
the tubes into the abdomen.
advantage of HSG is that, a test showing open tube has good correlation with
tubal patency (if HSG shows the tubes are open, it’s likely that tubes are
open). It is widely available and also cheaper.
the problem is that most of the women feel it painful, although they are given
pain-killers for it. In addition, there is small risk of infection, for which
antibiotics are prescribed. The contrast material can rarely give rise to
allergy in some sensitive women and it may be life-threatening in very rare
cases. Another problem is the false
positive result. That means if tubes are found to be blocked in HSG, in 50%
cases, they will be found to be open subsequently in laparoscopy. This is
mainly because of some spasm of the muscles of the tube during the test.
SIS (Saline infusion sonography)
or HyCoSy (Hystero-Contrast-Sonography) is
the method by which tubal patency is checked by ultrasound (TVS) along with
water like material inserted inside the uterus through a small tube. If tubes
are open, the passage of water can be seen going into the abdomen through the
tubes, in the ultrasound.
advantage of HyCoSy is that it’s much less painful than HSG, although mild
discomfort may be there. Pain-killers and antibiotics are prescribed usually.
Additionally, problems inside the uterus can be better visualized, even better
than normal TVS. In addition, the false positive result is much lower, only 7%.
That means if HyCoSy suggests that the tubes are blocked, in most cases, the
tubes will be found to be blocked at laparoscopy.
problem with HyCoSy is mainly the cost and it’s not available everywhere.
important merit of doing the tubal test is that, sometimes the water or the
contrast material used in these tests can open the “mild” block. That’s why we often find patients who
conceive spontaneously with pregnancy inside the uterus, after apparently “blocked”
tubes in HSG or HyCoSy.
laparoscopy is reserved for those,
who are at high risk of tubal block. This includes women with risk factors
(pain, surgery, infection etc) o women having “blocked” tube in HSG or HyCoSy.
Clearly, it’s done after hospitalization under general anaesthesia inside the
OT. Two or three small opening (key-hole surgery) will be put inside the
abdomen and through vagina a coloured material (“dye”) will be given inside the
uterus. If the tubes are open, the laparoscopic camera will show that dyes
coming out of the tubes inside the abdomen.
advantage is that it’s a definitive test, can help you to make final decision.
It also provides the options of treatment. If there is corneal block in HSG, we
can make attempt to open the tubes using laparoscopy (see below). In addition,
if there is hydrosalpinx, where the tube serves no function, the tubes can be
removed (salpingectomy) or clipped (we put clips to block the tubes) to improve
the chance of pregnancy if IVF is the only option left for you. In addition,
laparoscopy helps us to see whether there is any other diseases that have been
missed by routine tests and that may account for infertility. We can treat the
cysts of PCOS (by applying current to destroy some cysts), remove any large
cysts, remove any adhesion, treat endometriosis etc.
disadvantage of laparoscopy is of course, the need of anaesthesia and
associated surgical and anaesthetic risks, although in modern era, the serious
complications are uncommon.
What are my options if tubes are
found to be blocked in HSG?
are simply two options. It depends on your age, fertility factors and
affordability. Number one is directly, you can go for IVF. In that case, you
can save time and cost. It may be a preferred option, if you are aged or have
some other fertility factors (low sperm count, endometriosis etc). The chance
of pregnancy per cycle of IVF is usually 40%.
option is that you can confirm the block by other tests, keeping in mind that
you may need IVF if the tubes are found blocked ultimately. We usually advise
to have laparoscopy. However, some women want to give a trial with HyCoSy,
because if HyCoSy shows the tubes are open, then you can avoid laparoscopy and
you can try different fertility treatment options.
laparoscopy, first we see if tubes are open or not. If open, there is no need
of further treatment in laparoscopy. However, if tubes are found blocked,
especially if the block is in cornu, we can try “hysteroscopic tubal cannulation”, where we put a small catheter
through hysteroscope (a telescope, like endoscope, put inside the uterus
through vagina so that we can see inside the uterus using a camera) to open the
tubes. If tubes can be opened, you have all options for fertility treatment
open. However, if we fail to open the
tubes, the only option left is IVF. In addition, if there is fimbrial block, it
can be released and new opening in the fimbria can be made. The treatment of
hydrosalpinx by laparoscopy has already been discussed (see above).
said that, there are some group of women, who conceive while waiting for IVF or
laparoscopy after a blocked tube found in HSG.
What can I do if tubes are blocked
this case also, there is choice between the two- laparoscopy first and IVF
What can I do if laparoscopy
suggests tubal block?
in that case, the only option left is IVF. As mentioned before, if hydrosalpinx
is found it must be treated before IVF. However, sometimes we find hydrosalpinx
in laparoscopy but cannot cut the tube of clip it, simply because you did not
give consent to us for doing so. In that case, we can suck out (“aspirate”) the fluid from the hydrosalpinx
under ultrasound guidance (no need of further laparoscopy) using the
How tubal block is dealt in
your particular centre by Dr Sujoy Dasgupta?
We believe in patient’s
autonomy. So we want to give time on discussion and presentation of facts
and figures to the couples. We encourage questions from the couples and
take utmost care so that no question remains unanswered.
We do not take decisions
and impose it on the couples. We advise the couples to take time before
taking decision on a particular treatment. If the couple decides, we
respect and support their decision.
We prefer to have SIS or HyCoSy,
rather than HSG, to reduce the pain to the women. We discuss all the options if
tubes are found blocked.
factor can account for 20-25% cases of female infertility. It’s more common in
secondary infertility (women who conceived earlier-
whatever be the fate of the pregnancy). Tubal test is a part of infertility
investigation. The choice between HSG and HyCoCy is open to you. If tubes are
found blocked, the options are IVF directly or confirming the block by