Once the eggs are released (ovulated) from the ovarian follicles they must be picked up by the fimbriated end of the fallopian tubes. The fimbria are fingerlike projections that assist in collection of the egg. As the egg starts to travel down the fallopian tube, fertilization occurs. The embryo remains in the tube for several days prior to reaching the uterus. Any condition that inhibits this passage, such as a blockage or other tubal disease, can lead to infertility.
To determine if tubal disease infertility is present, the tubes are evaluated using a hysterosalpingogram (HSG). This test is discussed in the “Fertility Tests” section. Essentially, tubal damage which can lead to infertility, is observed by x-ray examination after introduction of dye into the uterus. The dye flows back through the uterine cavity and into the fallopian tubes.
Tubal blockage, or damage, can be caused by endometriosis, which can attach to, and even penetrate, the fallopian tubes. Severe pelvic infections (pelvic inflammatory disease or PID) can cause serious tubal damage as can scar tissue from previous surgeries. Rarely, a woman will be born without one, or both, of her tubes. Salpingitis Isthmica Nodosa (SIN) can also be a cause of proximal blockage of the fallopian tubes. Tubal reversal surgery is now sought by many women.
In vitro fertilization (IVF) is often the ‘treatment of first choice” for tubal disease. IVF is also employed in women with tubal sterilization instead of tubal reversal surgery. Using IVF, the eggs are retrieved directly from the ovaries and combined with sperm in the lab, thus eliminating the need for fallopian tube transport. IVF success rates exceed natural intercourse after tubal reversal surgery.
Tubal reversal surgery is often effective. Even so, women must be strongly cautioned that tubal ligation is considered a permanent means of birth control. Whether or not the tubes can be reconnected via tubal reversal surgery depends upon several factors, including where they were tied, how much tube remains, how they were tied (electrocautery, etc.) and other factors. The risk of ectopic pregnancy is 10%, or greater, if pregnancy occurs after tubal reversal. The risk of ectopic pregnancy after IVF is usually less than 2%.
In general, numerous studies demonstrate that pregnancy success per cycle is higher using IVF than tubal reversal surgery. In some women, especially younger women, there may be a reasonable argument for surgery. The number of times a younger couple can have intercourse to attempt pregnancy is virtually unlimited. For example, if they are having regular intercourse, they are attempting a “natural cycle pregnancy” each month. IVF cycles are relatively expensive and the total number is often limited by cost. Some couples may only be able to attempt one of two IVF cycles with the pregnancy rate varying according to many patient specific variables. Their overall cumulative chance for pregnancy may be similar after surgery and 2-3 years of intercourse compared to one IVF cycle. This is highly dependent upon several “couple specific” variables.
Women in their mid to late thirties should seek care from a reproductive endocrinologist/ fertility specialist early in their care as fertility can decline very rapidly in this age group. The pregnancy success rates for these couples are usually significantly higher when IVF is employed.