INFERTILITY FAQ

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1. What is infertility?
2. What causes infertility and how do you treat it?
3. How do I know if my tubes are blocked?
4. How do I test my sperm?
5. How do I know if I ovulate?
6. How do I know when I ovulate?
7. How do I know if I have enough eggs left to become pregnant?
8. What is polycystic ovary syndrome (PCOS)?
9. What is a Luteal Phase Defect?
10. What is the role of cervical mucus?
11. What is a post coital test?
12. How is male factor infertility treated?
13. What is Intrauterine Insemination (IUI)?
14. What is clomiphene citrate (Clomid)?
15. What is in vitro fertilization (IVF)?
16. Who needs IVF?
17. What is Intracytoplasmic Sperm Injection (ICSI)?
18. What is endometriosis?
19. What are the symptoms of endometriosis?
20. How do I know if I have endometriosis?
21. How does endometriosis affect fertility?
22. What is the treatment for endometriosis?
23. Does endometriosis need to be treated?
24. What is laparoscopy?
25. What is hysteroscopy?
26. What is hydrosonogram or fluid ultrasound?
27. Do blocked tubes need to be removed in preparation for IVF?
28. Should I have surgery to reconnect my tubes (tubal reversal)?

1. What is infertility?

Infertility is a common problem that affects 15-20% of couples. Every menstrual cycle there is 20% chance of conceiving in women less than age 35 and therefore 50% of couples trying to conceive will become pregnant in 3 months and 85% within 12 months. In women over the age 35, these percentages are lower. Infertility is defined as inability to conceive despite one year of unprotected intercourse in women less than age 35 and 6 months of unprotected intercourse in women over the age of 35.

2. What causes infertility and how do you treat it?

The main causes of infertility are male factor (35%), tubal or pelvic pathology (35%), ovulation problems (15%), unexplained infertility (10%) and other causes (5%). Many patients classified as having unexplained infertility are likely to have undiagnosed issues relating to egg quality, (such as maternal age >35 and/or increased FSH, Estrogen, AMH levels), or immunologic issues affecting the ability of the embryo(s) to attach to the uterine lining (implantation). A small portion of women will have structural abnormalities of their uterus or conditions in which the brain does not signal the ovaries to produce mature eggs.  Treatment is targeted towards the cause where some patients will only need basic treatments such as (i.e. medication to induce ovulation and/or intrauterine inseminations); others will need more advanced treatments, such as in vitro fertilization (IVF) or advanced reproductive surgery.

3. How do I know if my tubes are blocked?

The most commonly utilized test is a hysterosalpingogram (HSG) or the dye test in which a small amount of dye is injected through the cervix into the uterine cavity and simultaneous x-ray films show the dye spilling into the pelvis. In some cases the tubes are patent, but there may be damage within the tube that destroys its normal function especially with a history of previous pelvic infection.  A diagnosis of tubal disease is best treated by IVF. Damage to the tubes is often caused by a silent previous pelvic infection. The most common culprit is a microorganism known as Chlamydia, which is the most common sexually transmitted disease in the US, causing pelvic inflammatory disease (PID), which often causes no symptoms in women until they find out that they are infertile. Other causes of PID include an organism known as gonorrhea and other diverse organisms that gain entry and grow in the female reproductive tract following miscarriage, abortion and delivery. Other causes of tubal damage are due to endometriosis or previous abdominal surgery, especially due to a ruptured appendix or a ruptured ovarian cyst. A history of ectopic pregnancy (pregnancy in the tube) is another indicator of tubal damage. Tubal occlusion can also be diagnosed by laparoscopy if dye cannot be observed passing through the tubes. Laparoscopy is the best method to both diagnose and treat tubal disease.

4. How do I test my sperm?

A normal sperm cell has three parts: a head, which contains the genetic material; a tail, which moves the sperm cell forward; and a mid-piece, which provides the energy. Sperm parameters can be assessed by a semen analysis. A sperm sample is produced after 2-3 days of abstinence and analyzed in the laboratory for volume, count, motility (active movement) and morphology (appearance). A normal sample should have a volume of ≥ 1.5 – 2 cc (milliliters), a count of ≥ 20 million sperm/cc, ≥50% motility and ≥ 14% normal morphology (Kruger’s strict criteria).

Using the strict criteria, if less than 14% of sperm cells are normal looking, the chance of fertilization is decreased.  If less than 4% of sperm cells are normal, the chance of spontaneous fertilization is very low and treatment with IVF and intra-cytoplasmic sperm injection (ICSI) is recommended. Mild abnormalities of the semen analysis can be successfully treated with intrauterine inseminations (IUI), however, moderate to severe abnormalities should be treated with IVF/ICSI to offer the best chance of success. Semen analysis is a good initial test in evaluating the sperm quantity, but does not provide information about its quality.

In order to test the sperm quality, the most practical method today is sperm DNA fragmentation test commonly known as DFI or SCSA. These tests evaluate the sperm for DNA breaks and immaturity. In cases of high percentage of DNA breaks or immaturity, fertility potential is significantly reduced even in the presence of normal semen parameters.

5. How do I know if I ovulate?

Abnormalities of ovulation account for 10-15% of all infertility and approximately 35% of infertility problems among women. The menstrual cycle has two parts, which are separated by ovulation. In the first half, the proliferative phase, the ovary produces eggs and the estrogen hormone. In the second half, the secretor (or luteal) phase, the ovary produces both estrogen and progesterone following ovulation. The length of the cycle is determined by the first half, which can vary in duration, while the second half is usually constant in most women and typically 13-14 days. The most reliable predictor of ovulation is the occurrence of regular menstrual bleeding accompanied by cramping and breast tenderness. These symptoms are caused by the female hormone progesterone, which is only produced after ovulation. It is also possible to document ovulation by measuring the progesterone level in the second half of the menstrual cycle. Other indicators of probable ovulation include sustained elevation of the basal body temperature (not reliable) or the detection of an LH surge using an ovulation detector kit. Irregular menstrual cycles are often a sign of an abnormality of ovulation and can be caused by a disturbance of thyroid function, increased levels of prolactin hormone or an imbalance of male to female hormone ratios, commonly seen in a condition called polycystic ovary syndrome (PCOS).

6. How do I know when I ovulate?

Knowing the timing of ovulation is important because a woman only ovulates once per month and the ovulated egg can only survive for 24 hours. In most women, ovulation occurs 13-14 days prior to the onset of bleeding, which would be day 14 in a cycle of 28 days.  However, since the length of the cycle varies depending of the length of the first half of the cycle, ovulation does not always occur on the same day. An inexpensive method of determining the day of ovulation is to chart the basal body temperature (BBT) each morning prior to arising from bed.  In the first half of the cycle the normal basal temperature is around 970 F.  Twelve (12) to 24 hours after ovulation the temperature increases to 980 F. The BBT is helpful for documenting ovulation, but is less desirable for timing intercourse, as the temperature rise begins only after ovulation has occurred and is not a reliable method. Ovulation predictor kits can be purchased at most pharmacies over the counter and are useful for timing intercourse, as they can predict ovulation before it happens. They function by measuring the spontaneous LH surge in the urine (similar to a home pregnancy test), which is the trigger hormone for ovulation. A positive test indicates that ovulation will be occurring within the next 12-36 hours and can be used to time intercourse and inseminations, as well as provide information regarding the length of the second part of the cycle.

7. How do I know if I have enough eggs left to become pregnant?

Fertility potential decreases with age and the decline is steeper after the age of 35. This decline continues until menopause, which occurs around age 51 (range: 40-55yrs) in the U.S. Unlike men who continue to produce sperm throughout their lives, women are born a finite number of eggs. At the time of puberty a woman has approximately 500,000 eggs, 25,000 at age 37 and less than 500 at the time of menopause. The development of eggs is controlled by the pituitary gland, which releases a hormone called follicle-stimulating hormone (FSH).  FSH signals the ovary to stimulate a group of antral follicles to grow. The follicle produces estrogen and Anti-Mullerian hormone (AMH), which signals the brain to limit FSH release.

At the beginning of a woman’s reproductive lifespan, the ovary responds readily to stimulation from the brain to produce a mature egg.  As the number of eggs decrease in the ovaries, the pituitary gland releases more FSH in an attempt to stimulate the ovary to produce an egg.

We often measure the FSH along with the estradiol level on the third day of the menstrual cycle to measure ovarian reserve. If the FSH level is greater than 9 U/L or Estradiol >50 pg/mL, it is often referred to a state of decreased ovarian reserve. In some cases, FSH level may be normal but the estradiol level is elevated. In such cases, true FSH level is not normal and elevated, but somehow suppressed to normal levels by the already elevated estradiol hormone. In rare cases, both FSH and estradiol are elevated which suggests significant elevation of FSH and diminishes the chances of conception significantly.

An elevated FSH level does not necessarily mean that the woman is entering menopause early, but that her reproductive potential may be reduced. Most women with increased FSH levels continue to have regular periods and a healthy productive life. Women with very high FSH levels do not respond well to stimulation with fertility medications and are best treated using donor eggs.

8. What is polycystic ovary syndrome (PCOS)?

Polycystic ovary syndrome (PCOS) is a complex endocrine disorder that presents with oligo (irregular) or anovulation (no ovulation) along with polycystic appearing ovaries on ultrasound and varying degrees of hormonal imbalance. The main culprit is anovulation and irregular menstrual cycles that generally result in infertility and in some cases endometrial hyperplasia (rapidly dividing endometrial cells due to lack of progesterone production every month), which is a pre-cancerous condition, if it is left untreated. Most PCOS patients have a condition called insulin resistance (a pre-diabetic state) that increases the risk of developing diabetes in the future. Some patients can have overt diabetes already at the time of PCOS diagnosis and need immediate treatment.

Treatment is directed towards the patient’s desire for fertility and involves the use of fertility medications to induce ovulation. The first step is usually treatment with the pill called clomiphene citrate (Clomid) although some patients may not respond to this medication. Injectable gonadotropins (FSH with or without LH – Gonal-F, Follistim, Menopur, Bravelle) can be used and almost always induce ovulation successfully. However, these patients are at risk for multiple gestations (twins and high order multiples) and a condition called ovarian hyperstimulation syndrome (OHSS).

If a patient with PCOS who is not considering pregnancy right away, birth control pills can be used to regulate menstrual cycles. When fertility is desired, ovulation-inducing agents should be used to achieve pregnancy.

9. What is a Luteal Phase Defect?

Following ovulation, the remainder of the dominant follicle transforms itself into a structure called the corpus luteum (CL) which produces estrogen and progesterone. The purpose of progesterone is to prepare the uterus for implantation and maintain the quiescence of the uterine muscle. The life span of the CL is predetermined to be 12-14 days, unless rescued by a signal from the early pregnancy called the HCG hormone. If pregnancy does not occur, CL stops producing progesterone and menses ensue 1-2 days later. For most women the length of the second half of the menstrual cycle (the luteal phase) is constant at 14 days. A small percentage of infertile women (3-4%) have a shortened luteal phase. This may result in the loss of pregnancy support before the implanting embryo has a chance to signal the ovary that it is attaching to the uterine wall. The lining of the uterus (the endometrium) has a specific appearance that changes throughout the menstrual cycle, such that a biopsy of the lining a few days prior to expected menstruation, can date endometrial development.

By definition, 2 or more days of discrepancy between endometrial dating by biopsy and cycle day as determined by the start of the next menstrual period is indicative of a luteal phase defect (LPD). Sequential mid luteal progesterone levels < 10 ng/dl may also suggest LPD. Luteal phase defect can be treated with clomiphene citrate, progesterone supplementation or HCG injections. Currently, an endometrial biopsy is not a part of infertility evaluation as it was in the past, because it does not add additional information or change the management ultimately, but causes pain, adds cost and may possibly delay treatment.

10. What is the role of cervical mucus?

Cervical mucus is normally thick and prevents bacteria from entering the uterus, upper genital organs and the abdomen. Around the time of ovulation and under the influence of estrogen, the mucus becomes watery, thin and stretchy to facilitate the entry of sperm into the reproductive tract. In some women the mucus never becomes receptive to the sperm, preventing the sperm from reaching the egg. Additionally, some women make antibodies against their partner’s sperm, immobilizing them in the mucus and destroying them. Abnormalities of the cervical mucus can be diagnosed using the post coital (PCT). Hostile mucus can be by-passed through the use of intrauterine insemination. The presence of significant anti-sperm antibodies should be treated with IVF.

11. What is a post coital test?

The post-coital test (PCT) evaluates the interaction of the sperm with the cervical mucus. A small sample of mucus is removed from the cervix 6-18 hours after sexual intercourse and examined under the microscope for the presence of motile sperm. The presence of 6-10 progressively motile sperm/high power field is indicative of a good sperm/mucus interaction.  However, the test must be performed just prior to ovulation so that the mucus will be receptive (thin and stretchy). The most common explanation for a poor test is improper timing. If sperm are “stuck to one another” rather than moving forward purposefully, this often suggests the presence of anti-sperm antibodies. Intrauterine insemination (IUI) is recommended for the treatment of repeatedly poor PCT in the face of a normal semen analyses. Post coital test is no longer a part of infertility evaluation because of its poor reproducibility and lack of sensitivity.

12. How is male factor infertility treated?

The treatment of male factor infertility is one of the true success stories in the field of assisted reproduction. Disorders of sperm parameters range from a low count or motility to a complete absence of sperm production. Deformities of the sperm shape (morphology) are also important in its ability to fertilize the egg. Mild abnormalities of semen parameters can be effectively treated using techniques that “wash” out the seminal plasma and improve the concentration of normally shaped motile sperm, which are then transferred to the uterus via an intrauterine insemination. However, for more severe conditions this type of treatment is inadequate. With a total motile sperm concentration of less than 10 million/ml or a normal morphology of less than 7% by strict criteria, the chance of fertilization is very low, even with conventional IVF.  With the advent of Intra-Cytoplasmic Sperm Injection (ICSI) high rates of fertilization can be achieved in patients who previously would have had little hope of conceiving.

Treatments advocated in the past for male infertility such as clomiphene, gonadotropin injections, HCG injections, and/or ligation of a varicocele have less of a role in the era of ICSI. Patients with previous vasectomy, especially greater than 10 years, are at great risk of forming anti-sperm antibodies and should also be treated with ICSI. Even certain patients with complete absence of sperm in the ejaculate may be able to father their own children through advanced procedure, in which sperm is extracted directly from the testicle, called Testicular Sperm Extraction (TESE).

13. What is Intrauterine Insemination (IUI)?

Intrauterine insemination (IUI) is a simple procedure in which a small sample of highly concentrated motile sperm is injected in the uterus through a thin catheter at the time of ovulation. The sample is produced after 2-3 days of abstinence and processed in the laboratory to remove the seminal plasma and non-motile sperm. It is important that the IUI be timed as close as possible to the time of ovulation, so that the sperm are waiting for the egg when it arrives in the fallopian tube. Proper timing can be achieved using an ovulation predictor kit, which will predict the time of ovulation within 12 hours, or by using an injection of HCG, which causes ovulation to occur 36-40 hours after administration. Ultrasonographic monitoring of follicular development is often used to determine the timing of the HCG injection.

IUI is indicated to treat cervical factors caused by poor mucus quality, cases of unexplained infertility and mild male factor infertility. IUI is not helpful in cases of moderate to severe male factor, decreased ovarian reserve or in the presence of significant tubal disease, which should all be treated with IVF.

14. What is clomiphene citrate (Clomid)?

Clomiphene citrate (Clomid, Serophene) is a fertility medicine taken orally. It acts as an anti-estrogen in some tissues and stimulates the production of more FSH, leading to improved follicular development. Clomiphene works best for patients who do not ovulate, helping them to produce a dominant follicle. In other women (ovulating women) it can help develop two or more follicles, improving the chances of conception in any given cycle. However pregnancy rates are not drastically improved. A success rate of 5-8% per cycle is generally expected, which is usually better than the couple could expect to achieve on their own, but still less than the 15-20% in the general population (in women less than age 35).

The benefits of clomiphene include its low cost and ease of administration (oral). Disadvantages include anti-estrogenic effects on the cervical mucus, which usually require the addition of intrauterine inseminations, and on the endometrial lining, which may decrease the chance of implantation. The risk of having twins is slightly increased with clomiphene at 5% compared to 1% in the general population. Clomiphene is a good starting point in the treatment of many infertility cases.  However, the majority of the effect is seen within the first three cycles of treatment. If a pregnancy has not occurred after 4-6 cycles, it is time to move on to more aggressive therapies.

15. What is in vitro fertilization (IVF)?

IVF is a procedure first developed in 1978 in which ovaries are stimulated with fertility medications to produce multiple mature eggs, which are then aspirated from the ovaries and fertilized in the laboratory with the partner’s (or donor) sperm. The resulting embryos are cultured for 3 or 5 days and the embryos are then transferred back into her uterus.

16. Who needs IVF?

Indications for IVF include decreased ovarian reserve, blocked fallopian tubes, moderate or severe male factor infertility, unexplained infertility and endometriosis. Maternal age >40 is a relative indication because of the rapid decline in the egg reserve.

Women who do not ovulate due to a condition called polycystic ovary syndrome (PCOS) are at risk for high order multiple gestations (triplets or higher) and IVF can be a good choice because the number of embryos implanted can be controlled with IVF compared to IUI treatments. Endometriosis is another common cause of infertility and a common indication for IVF especially in advanced cases. Patient with mild endometriosis have higher success rates with IVF compared to patients with advanced endometriosis.

17. What is Intracytoplasmic Sperm Injection (ICSI)?

ICSI is a procedure that allows treatment of the most severe male factor infertility cases. Using ultra fine instruments, it is possible to select a single sperm and inject it into the egg to accomplish fertilization without damaging the egg. Before ICSI there was no effective treatment for poor sperm other than to use donor sperm. In the era of ICSI, male factor infertility cases have the high success rates with IVF.

18. What is endometriosis?

The lining of the uterus is called the endometrium. When endometrial cells are found in places other than their normal location, the disease is called endometriosis. There are several theories as to the etiology of endometriosis, but the exact cause is unknown.  The most accepted theory is retrograde menstruation. This theory asserts that some of the endometrial tissue, which would normally be shed through the vagina as menstrual blood, passes back through the fallopian tubes into the pelvic cavity where it can attach to the ovaries, uterus, bowel, peritoneum and other intra-abdominal structures, causing pain, scarring, pelvic adhesions and inflammation. Approximately 20-30% of infertile women have some evidence of endometriosis at laparoscopy, which is the only sure way to diagnose this disease. Endometriosis is a progressive disease that is stimulated by the female hormone estrogen.

19. What are the symptoms of endometriosis?

The symptoms of endometriosis are quite variable. Most commonly, women report pain associated with their periods, which begins prior to bleeding and lasts more than 48 hours. Pain can also occur mid-cycle at the time of ovulation. Additionally, endometriosis can present as pain during intercourse, with bowel movements or urination. However the amount of pain does not necessarily correlate with the severity of disease. Some women have no pain, but may have severe disease, while others suffer significant pain, but only have a small amount of endometriotic lesions. The stage of the disease correlates with pregnancy rates; women with moderate-severe endometriosis have lower egg reserve and related lower success rates.

20. How do I know if I have endometriosis?

Symptoms of cyclic pain are suggestive of endometriosis, but are nonspecific, because majority of women report some pain with their periods. An ultrasound can identify large ovarian cysts, called endometriomas, indicative of advanced disease, but cannot identify early stages of endometriosis. The only way to truly diagnose endometriosis is surgically by laparoscopy. It is recommended that patients be evaluated with laparoscopy when response to medical treatment is suboptimal.

21. How does endometriosis affect fertility?

Endometriosis can affect fertility in many ways. At early stages, endometriosis appears to impact the immune system; at advanced stages, there is an additional mechanical blockade and low egg reserve. In the presence of severe disease, there is often scarring and pelvic adhesions that block the fallopian tubes, preventing the egg from reaching the sperm and the uterus. Adhesions can cover the ovary and prevent the ovulated egg from escaping the ovary. Adhesions may also immobilize the fallopian tubes, preventing them from capturing the egg even if they are open.

Large endometriomas can compress normal ovarian tissue, reducing the number of good quality eggs or compromise the response to medications. IVF is indicated in the presence of severe disease or low egg reserve and surgical or medical treatment of endometriosis can improve the outcome with IVF. However, patients with all stages of endometriosis have decreased fertility compared with age-matched controls. Even at mild stages, endometriosis causes an inflammatory reaction resulting in the activation of the immune system, which may lead to an abnormal immune response in the endometrium that could prevent implantation.

22. What is the treatment for endometriosis?

Endometriosis can be treated surgically or medically. The first line treatment for pain is usually over the counter or prescription strength analgesics, which can be given based on symptoms without a definite diagnosis. Additionally, birth control pills can be given along with painkillers if pregnancy is not desired.

If these medications are insufficient in relieving the symptoms, the next step is laparoscopy for diagnosis and treatment. Surgery is considered the best treatment for pain associated with endometriosis. Small lesions can be treated with cautery and pelvic adhesions can be removed. Large endometriomas should be removed along with their cyst wall to prevent recurrence. However, endometriosis is a progressive disease and new lesions will develop after surgery as long as the patient continues to produce estrogen. Medications such as Lupron, danazol or progesterone can be used to control disease progression, although each of these medications has side effects, which limit their usefulness. Regarding fertility, patients with advanced disease exhibiting pelvic adhesions and endometriomas should strongly consider IVF, especially over the age of 35.

23. Does endometriosis need to be treated?

The treatment of endometriosis centers on two issues, pain and infertility. Pain warrants treatment regardless of stage. If infertility is the main concern, it should be treated surgically; pelvic adhesions should be removed and the integrity of the tubal anatomy should be restored. Minimal or mild endometriosis does not appear to mechanically affect the tubes, but can affect fertility negatively and easily treated surgically. 

24. What is laparoscopy?

Laparoscopy is an outpatient (same day) surgery in which a thin telescope-like instrument is inserted into the abdominal cavity through the belly button. Using this instrument (laparoscope), the surgeon is able to visualize the abdominal/pelvic contents, including the uterus, fallopian tubes, ovaries, bowel, appendix, liver and gallbladder. Additional small (5mm) incisions in the lower abdomen are necessary to help with the manipulation of pelvic organs.

Laparoscopy can be used to treat most gynecologic and infertility problems for which surgery is required. Such problems include the removal of pelvic adhesions, ovarian cysts, some types of uterine fibroids, swollen tubes (hydrosalpinx), tubal pregnancy, treatment of endometriosis, and the documentation of tubal patency. The recovery time following laparoscopy is less than open abdominal surgery (days compared to weeks). The complications of laparoscopy are rare and the same with all types of surgery and include, infection, injury to adjacent organs such as the bowel or bladder and blood loss that may rarely require a blood transfusion. There is also a small risk of conversion to conventional open surgery to fix a problem that cannot be addressed through the laparoscope, but this is rare.

25. What is hysteroscopy?

Hysteroscopy is an outpatient (same day) surgery in which a small telescope-like instrument is inserted into the uterine cavity through the vagina. Various types of fluids can be used to distend the uterine cavity and abnormalities such as polyps, scar tissue and intrauterine fibroids can be visualized and treated. Hysteroscopy can be performed with limited anesthesia and the recovery time from the procedure is quick. Most patients are ready to resume normal activities the next day.  The risks of hysteroscopy are rare and the same as for any surgery and include infection, bleeding, and injury to adjacent organs such as the bowel or bladder. Hysteroscopy has the additional small risk of making a hole in the uterine wall called uterine perforation. This complication occurs rarely and usually has no bearing on future fertility. Hysteroscopy is the best method for evaluation of the uterine cavity.

26. What is hydrosonogram or fluid ultrasound?

Sonohysterography (fluid ultrasound, hydrosonography) is a simple method for imaging of the uterine cavity and it is performed in the office without anesthesia. A thin catheter is introduced into the cervix through the vagina and a transvaginal ultrasound is performed while 10-20 cc of saline (salt water) is injected into the uterus. The cavity is distended by the fluid, revealing the presence of intrauterine fibroids, adhesions or small polyps missed on hysterosalpingogram (HSG). The distention of the uterus causes some cramping which is well tolerated by most patients and later dissipates rapidly once the procedure is finished. Lesions detected on sonohysterography cannot be treated at the same time and a hysteroscopy is indicated as a separate procedure for treatment of lesions.

27. Do blocked tubes need to be removed in preparation for IVF?

Tubal damage as a result of prior infection, endometriosis or previous pelvic surgery is one of the most common causes of fertility. Tubal blockage can occur in several locations. Often the distal ends of the tubes are obstructed, while the openings into the uterus are still open and in such cases the blocked tubes fill with fluid and called hydrosalpinx. For most patients with significant tubal disease, surgery is not indicated to improve fertility outcome in the era of IVF. The exception is the presence of hydrosalpinx. Recent literature has shown that the fluid in swollen tubes, which contains dead cells and other toxic products, is highly toxic to embryos. Additionally, the fluid can leak back into the uterus and cause a mechanical barrier to implantation and also change the expression of important implantation proteins. Patients with hydrosalpinx should strongly consider having their tubes removed or ligated prior to undergoing treatment. It is often difficult for patients to accept that their tubes will be removed, as it means that conception is impossible without assistance. However the presence of hydrosalpinges means that the tubes are non-functional and the chance of conceiving normally is extremely low or zero.

28. Should I have surgery to reconnect my tubes (tubal reversal)?

Depending on the method used, a tubal ligation can usually be reversed. Following surgery the tubes will be open 70-80% of the time and a woman will have a 50-60% chance of conception in her reproductive lifetime. Once the tubes are reconnected, the couple will often not need any further treatment. This surgery is performed through a mini-laparotomy incision and requires a 2-week recovery period. Tubal reversal is a reasonable choice for young women (less than 35), who would like more than one child following tubal reversal. In patients with a history of tubal ligation, IVF can offer pregnancy rates up to 50-80% because these patients don’t have infertility but rather adequate contraception.