All About Tubes

Improving Your Chances of Falling Pregnant by Opening Your Tubes

 

Morning, everyone let’s have a chat today about tubes, blocked tubes, swollen tubes, previous sterilizations. One of the most frequent questions we get. Let’s have a run through of what they are, what can go wrong with them, and what are your treatment options if you’ve got a problem with the tubes.

So, let’s start with what the tubes are and where they are. So, if you have a look where the ovary is, this is where you will ovulate. Your egg every month, it gets picked up by this tube, travels to the tube where it meets the sperm and the little embryo then travels all the way down into the uterus. So, you can think about this as the highway that connects the sperm and the eggs.

So now we can understand why tubes are so important, without functional tubes, your egg and your sperm won’t be able to meet. When we are talking about tubes, most people are fixated on is the tube open or not. And that’s only one aspect to think about. You can’t just think about a tube as a little pipe that needs to just be open or blocked. When are we talking about a tube, it’s got these little finger-like processes called fimbria at the very end, which are very important. It’s got this entire length of tube and this needs to be free and not be stuck down.

You need to remember that the tube has got some muscle in it and you need to think of it as a structure that can go on top of the ovary, cover with ovulation is happening and be free to actually move around. If it’s stuck down and I’ll show you a picture of what a stuck down tube looks like now, and I can’t quite get the, it obviously makes it more difficult for the tube to pick up that egg.

So, here’s an illustration of what adhesions can look like. Adhesions is a fancy word for scar tissue and if you’ve got a lot of scar tissue holding down those tubes, then obviously they can’t do their job. So, we now know the tubes need to be open, they need to be free to be able to move around. We also know that the inside of the tube needs to have a normal structure. It’s not just a bland pipe; it has these little hairs on the inside called cilia. But actually, beat the little egg, and then embryo along. Those cilia can become damaged and you can get scar tissue.

So, what are the most common causes for blocked tubes, swollen tubes, or damaged tubes? Blocked tubes might be from sterilization. So, if you think you have completed your family and you have a sterilization, that’s when we medically block the tube to stop you being able to fall pregnant in the future. Another thing is you can sometime get some debris inside of the tube, so there can just be some slough or some tissue that’s blocking the tube. And that will be a best-case scenario for block tube. The most realistic thing is usually if there’s scar tissue inside of the tube, that’s actually blocking off the access or one side to the other side of the tube.

Tubes can also be swollen and sick and damages the fancy word for this is a hydrosalpinx. So, what can happen is when the tube has been damaged, usually by infection, it swells up at the end. You can get an idea over here with this tube, it’s very swollen at the very end. If it blocks off on this side, this can accumulate a lot of fluid. It can sometimes give you a bit of pain in the cycle, but this is very important. A blocked hydrosalpinx, something we will talk about later. So not only can a tube be blocked, but it can also be swollen and damaged. If an infection does cause this, I’m often asked can’t I just take an antibiotic. And the best way to think about this is like a house that’s been on fire. You can put out the flames, the same as with an infection, you can treat it with an antibiotic and all infections should be treated. But you can’t undo the damage that is there.

The third thing to think about, if you have a free tube that is open, that might also be functionally damaged, just in terms of the inside of the tube. So those little hairs they’re on the inside of the tube that help to move the egg along. I mean, the little embryo along. If those hairs are damaged, you can’t generally regrow them or there might be scar tissue inside of that tube. And that might then stop the egg and the sperm meeting, or the little embryo transferring along the tube as it should to the uterus. So just to summarize, it’s not only blocked tubes, we have to think about, but it’s swollen tubes and damage to the actual structure, to the tube. As well as the tube that is stuck down and is not free and able to move around.

So, what are the common causes of damage to the tubes? So most commonly we’ll always talk about STDs. So sexually transmitted infections, such as chlamydia and gonorrhea. A lot of the time, you won’t actually know you’ve had some infection, 50% of the time you’re asymptomatic. You may not know that there’s been this damage, but the infection does spread to the tube and causes damage there silently until it has been treated by an antibiotic.

One of the other things is a sterilization, like we discussed previously. Endometriosis, which is when the inner most lining inside of the uterus starts to grow inside of the tummy, it can cause a lot of period pain usually. But the kind of inflammation and irritation and scar tissue they can cause in the tummy can damage tubes. If you’ve had a bad infection inside of the tummy, such as a boost appendix, or if you’ve had a peritonitis or something else, bowel problems you might have problems with tubes.

A lot of the time people talk about having had a swollen appendix and taken out, that’s probably not an issue. In terms of surgery in the tummy, you might have some damage to the tubes, whether it’s taking out fibroids. If it’s the appendix surgery, or if you’ve had cysts removed, you might have some adhesions. So, scar tissue that sticks down the tube, and then it can’t do its job properly. You might’ve previously had a pregnancy in the tube, which is when that little embryo that’s formed, gets stuck in the tube, and doesn’t make its way down to the uterus. Sometimes we can remove the ectopic from the tube itself. Other times we have to remove the whole tube, so that can cause damage to the tubes.

So how can you doctor test for a tube problem? We shouldn’t routinely be testing in every patient. Your doctor should do an individualized assessment, whether we think there is risk. And whether we think you need to have the test done. There are a lot of different ways we decide this based on your medical history, surgeries, previous infections, as well as how long you’ve been trying to fall pregnant and other issues that we might pick up. They might suggest that maybe we should be looking at the tubes. Sometimes we decide after a few cycles of treatment that we should revisit having a look at the tubes. One of the most common options for looking at the tubes is called an HSG. This is a test done in radiology because you need an x-ray. So here at CAPE Fertility. We send our patients to Kingsbury Hospital across the road to the Radiology department where our experienced radiologist will do this test for you.

So, what you can expect, we place a speculum inside of the vagina, just like a pap smear and a little catheter, just through the cervix of the mouth of the womb, into the very entrance of the uterus. We then fill up the uterus with a special contrast. The idea is if this tube is open, that contrast is going to spill all the way out to the end. And I’ll show you a picture of what a normal HSG looks like now. So here you can see an example of a normal HSG. So, the big triangle that’s very bright and white in the middle is the uterus, which you can see here is a little tube, and this is where the dyes are spilling out. Same is on this side, little tube dye spilling out. That would be considered a normal HSG.

Other things we can sometimes see is a blockage. So, on this side, you can see this block, the dyes, and coming through. And on this side, we can see a big sick swirling tube called a hydrosalpinx. We can also tell quite a lot about the uterus itself. If we look at this example here, you can see, this is not a normal looking uterine cavity with a lot of sort of spiky edges on the side there. And we know we then need to go and have a look inside of that uterus.

So, what can you expect from the HSG? Well, it is invasive; you do need to have a speculum, so it might be a bit uncomfortable. When they put it in the catheter that can also cause cramping, and when they insert the dye, you can also expect some cramping as well.

Different women experience it differently, some don’t feel very much. Some feel mild cramping, much like period pain and some describe a lot of period pain. Quite significant pain they need to take painkillers afterwards. That’s something you can have a chat to about your doctor, if you’re nervous and you want to take some painkillers before. Another option is to look surgically. Obviously, we don’t want to go and do surgery unless we absolutely need to, but sometimes you might need to go and have a look inside the tummy to see if there’s a problem stopping you falling pregnant. The way we like to do this is with keyhole surgery or minimally invasive surgery. It’s a tiny little cuts is made through the belly button. We put a camera inside of the tummy, we make a few more tiny little centimeter cuts, the lower part of the tummy that we can operate through. And that’s why it’s called keyhole surgery.

We have a look inside of the tummy, we can put some dye inside of the uterus, much like the HSG except you are asleep. You’re under an anesthetic and we can watch to see that the dye spills out the end of the tube. So again, we put some dye in here and we watch to see that the dye spills out into the tube because we’re looking with the camera into the tummy. So, when we’re looking inside of the tummy you can also see scar tissue that might be trapping this tube, we can release that. If we have blocked ends of the tube where it’s sick and swollen, we might be able to release that as well. Also gives us an opportunity to look around the rest of the pelvis and look for other problems like endometriosis and any of the issues that we can fix.

One of the most common questions we get asked on our Facebook site is about patients who’ve had a previous sterilization who would now like to fall pregnant. It does happen quite often; you might decide that your family is complete. Then you move on to a new relationship later on in your life. You decide you want to have more children, your partner might not have children, and we’re here to help in that situation. A few things need to be taken into consideration when we are talking about reversing a sterilization. First of all, how was it done? When we do a sterilization, we obviously want to damage the tube. So, the sperm cant meets. So, what is often done is we put a little clip on this part of the tube, it might be a little silicone ring or a little clip that compresses it and causes that piece of tube to die.

When we want to repair that, that’s a best-case scenario because all we then do is cut out that little section of tube that’s been damaged and reconnect the two sides. We can’t always do this because sometimes if you have a sterilization at the same time as the Caesar, they might’ve cut a significant piece of the tube off. And if that’s the case, there’s just not enough tube to actually join up together. Sometimes the damage is too severe, and we won’t be able to fix it, but ideally, we’ll be able to fix at least one side out of the two sides.

How do we decide whether it’s with a string laparoscopy to see if we can actually reverse the sterilization or we need to take the whole picture into account. There might be other reasons why you need IVF and not the surgery. For example, if you were older and were worried about air quality, if your partner has a problem with sperm. There might be a reason why you need IVF. There’s some other reason for you to undergo IVF treatment, then obviously we wouldn’t recommend the surgery. We always have to think about how much damage we think there has been to the tube and we need to take your age into account. If you are 25, obviously you’ve got a lot longer with a lot better eggs because you are younger ahead of you. So, the surgery might be more beneficial because you can get more pregnancies out of one surgery going forward.

If you’re 40, you might not have as much time, you might not have that many eggs. We might need to expedite things, we don’t want you to try and fall pregnant for a year on your own and lose a year full of valuable eggs at that point, which isn’t a concern when you are much younger. We do need to think how many children you want to have, if you just want to have one more child. Then IVF might be a very good option because we have excellent success rates with a single cycle. If you want to have many children as the example, when you were younger, we might prefer to do the surgery for you.

We need to consider what the costs are. Not all medical aides will pay for the surgery. So, the surgery then needs to be paid for upfront in cash to the hospital, which is the largest part of the actual bill. When you talk about paying for a surgery privately, you need to pay the surgeon, they anesthetist, the hospital, hospital is unfortunately the bigger chunk. We can help with getting quotes for this, but essentially it ends up costing the same as an IVF cycle. So, if you’re looking for a more efficient treatment, if you’re looking for equally cost-effective treatment versus the surgery, then IVF is a good option for you.

Something else to take into account is there might be risks involved in the surgery. So not only the anesthetic, when we do any surgery, the risks of damage to other organs, such as the bowel, the pipe between the kidney and the bladder, blood vessels, risks of infection. Obviously, this time of year, we’re not doing elective surgery, so that needs to be on hold due to COVID-19. We also have to remember that when I’m taking a tube that’s been structurally damaged and putting it back together, there’s the trends that you might get some scar tissue. So, it might actually not work, the surgery. If you do have that scar tissue, there’s a chance you might have an ectopic pregnancy; so, a pregnancy that forms in that part of the tube. That can be an emergency, and if it ruptures might result in us having to remove that tube. It’s not a viable pregnancy unfortunately.

The alternative to surgery is doing IVF. IVF I will explain in a later video. We do also have a video on our website, and I have loaded it on the Facebook page as to what IVF involves. If you’re going to be paying privately for the surgery, like I’ve said, IVF is very cost effective with a very good success rate. It’s the only reason you’re not falling pregnant is a sterilization. We always do individualized your chance of success, so coming in and have a chat to us and we can discuss but more clearly the risks and benefits of surgery.

Some patients have asked about how they can flush out their tubes. If we do an HSG test to check the tubes, and there’s a little bit of debris just blocking the tube, the force of the fluid might flush that open, might. This is not an established treatment and if there’s scar tissue damage inside of the tube, we can’t flush that out. There’s no medication or natural way to unblock tubes; if we’re talking blocked tubes confirm that on an HSG test or laparoscopy, then we’re going to need to do IVF.

Another thing to consider is the swollen tube. So, if you have a damaged, swollen tube, yes, we can open the end of it. So, for example, here’s your big swollen tube and this end is blocked. What we can do is open this end to allow the tube to be open. So, you might be unblocking tube but remember there’s a lot that goes into the tube. Is it free to move around? And it’s the inside structurally normal? Is it able to carry that little egg along and transfer that embryo? So just because we open a tube, it doesn’t mean it will stay open and it doesn’t mean that you will definitely fall pregnant. It’s obviously a better chance that if the tube is closed, but it’s not a guarantee.

And again, I’m not talking about a block right here or a block in the middle, I’m talking about the swollen to where we can open up this end and show that the tube does drain. There is always the chance that you might block again and that’s something we can’t necessarily prevent. Some of you might have heard of us needing to take our tubes prior to IVF. The reason being, if you have a big sick swollen tube full of fluid, and we do IVF and put those precious little embryos inside of the uterus, we now know, and this has been proven time and time again, that you halve your transfer success with those big sick swollen tubes.

What we think might happen is that that fluid that collects inside the tubes might wash inside of the uterus. It might provide a toxic environment, there might be a lot of inflammatory cytokines there that affect implantation. But we know that your chances of success re conceiving drop by 50%. That is why we always recommend with big sick swollen tubes that when you take them out prior to IVF.

Thanks for listening today. Please let me know if you’ve got any questions and if we can explain anything more clearly. We’ve run through what the tubes are, the kind of problems you can expect with tubes, the risk factors for those problems and what your treatment options are. Quite often, we get an inquiry about how much it’s going to cost to have a sterilization reversed. That’s something we do need to individualize, as I explained, we can send a letter through to the medical aid and ask for motivation for them to pay. But if they don’t then unfortunately under those circumstances, we’ll have to get a quote from the hospital itself.

So, we don’t unfortunately have just a standard quote for the sterilization reversible cost. We can tell you our fee, that reception can help with. Doctors don’t unfortunately keep a book full of different prices. So, check with reception and we can always try and arrange a quote for you for what it would cost for a reversal. Any questions I’m going to drop a link right down here. You can drop emails to info@capefertility.co.za. If you already have a doctor at CAPE Fertility, you can email them directly or your IVF coordinator directly. We’re always happy to answer your questions. See you tomorrow.