Join Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Abby Eblen from Nashville Fertility Center, and Dr. Susan Hudson from Texas Fertility Center as we tackle the ins and outs of dealing with damaged fallopian tubes and finding your way to pregnancy success. Listener questions about ectopic pregnancies and uterine malformations take center stage as we discuss when surgical intervention is necessary and how tests like HSGs and saline sonograms can help evaluate your tubes. If your tubes are damaged and need to be removed, rushing to remove them isn’t the best idea unless you’ve already created genetically normal embryos through IVF—timing is everything! We also explore why surgery can sometimes do more harm than good. Removing minor endometriosis could damage your ovaries, leading to fewer eggs or even requiring a second surgery if the tubes re-scar. Finally, we dive into the likelihood of successful IVF after ectopic pregnancies. There is plenty of hope, even if your tubes haven’t been cooperative in the past. Whether navigating tube troubles or looking for IVF insights, this episode is your go-to guide for staying on track.
Episode Transcript:
Susan Hudson (00:01)
You’re listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you’re struggling to conceive or just planning for your future family, we’re here to guide you every step of the way.
Abby Eblen MD (00:23)
Hi everybody, we’re back with another episode of Fertility Docs Uncensored. I’m Abby Eblen, your host from Nashville Fertility. And today I’m joined by my gorgeous and gregarious co-host, Dr. Susan Hudson from Texas Fertility Center, and Dr. Carrie Bedient from the Fertility Center of Las Vegas. How are you guys doing? Hey. Doing great. So what’s been going on guys? Had a good week?
Susan Hudson (00:36)
Hello.
Carrie Bedient MD (00:41)
How are you guys doing?
Susan Hudson (00:43)
Doing good!
Carrie Bedient MD (00:49)
Yeah, moving back into the swing of things post everything.
Abby Eblen MD (00:53)
Yeah, it’s kind of a letdown after the holidays are over and the wrapping has already been thrown away and you have to clean everything up. And so we were just talking about our favorite things that we eat and drink. And we were we got into discussion about what’s your favorite Pepsi, Dr. Pepper or Coke? Anybody like to start?
Susan Hudson (01:15)
I am definitely a Coca-Cola girl. Definitely, definitely. However, my family are big Dr. Pepper fans. Little factoid that Dr. Pepper actually originated in Texas and recently became the number two soda manufacturer in the United States. Very exciting.
Abby Eblen MD (01:33)
wow.
Carrie Bedient MD (01:34)
Dr. Pepper was bottled by either Coke or Pepsi depending on what part of the country it was in.
Susan Hudson (01:41)
Nope.
Carrie Bedient MD (01:42)
Huh, maybe I’m thinking of somebody else.
Susan Hudson (01:44)
Now, if they are sold, it’s kind of like depending on what part of the country, it will be either Dr. Pepper or Mr. Pibb. And I think there’s different relationships between Coca-Cola bottling company and PepsiCo. I think PepsiCo tends to go with Mr. Pibb, if I remember correctly, from my Minnesota days.
Abby Eblen MD (02:05)
I didn’t know they still made Mr. Pibb. I thought it was long gone. Yeah.
Carrie Bedient MD (02:07)
I haven’t seen it in forever.
Susan Hudson (02:09)
I don’t know. It’s not as good as a Dr. Pepper. What do y’all like?
Carrie Bedient MD (02:13)
So I tend to default to Coke products and have a varying relationship between regular Coke with real sugar versus Coke Zero or Diet Coke, depending on how I’m feeling. Depending on how I’m feeling at any moment. And the reason that I’m laughing is because Abby just took a very well-placed product placement if anyone was sponsoring us. And by the way, Coke, if you want to sponsor us, we are all for that. Susan’s got one too.
And so people from Coke come sponsor us. Please, please. Dr. Pepper would also be entirely acceptable. But yeah, I have a varying relationship with what type of sugar and more recently have been going with fully leaded Coca-Cola because I figure the regular sugar, at least my body knows what to deal with where all the other sugar products is a toss up, but that’ll change next week.
Abby Eblen MD (02:43)
Hahaha!
Carrie Bedient MD (03:05)
Nobody hang your hat on that. But I want to know what the, because I think Abby has declared her allegiance with her Coke can in front of her. If you are going to go with a flavored product, so vanilla, cherry, cream soda, whatever, like the variations, if you were going to hit the button on a Coke freestyle machine, what variation would you get?
Abby Eblen MD (03:12)
Yeah, Diet Coke.
Absolutely, cherry coke.
Susan Hudson (03:31)
Vanilla.
Carrie Bedient MD (03:31)
I usually go vanilla, but now that you’re mentioning it, I feel like the next time I see one of those, because there’s one in the hospital doctor’s lounge, which is the highlight of me going to do surgery at the hospital, I feel like I should go 50-50 cherry vanilla.
Abby Eblen MD (03:42)
Ooh, that’d a good combo. Good combo.
Carrie Bedient MD (03:47)
Yeah, I also default to a of cream soda when I’m when I get those machines because I like cream soda.
Abby Eblen MD (03:52)
Yeah, one little known fact, unless you’re one of the billions of visitors who visit the Coke Museum in Atlanta, is that Suntrust now Truist, I think when the original Coke recipe was written, it was kept in their vault, and I think they still have the secret recipe in their vault in Atlanta.
Carrie Bedient MD (04:09)
Mm-hmm, they do. At least from the last time I was there when I was at fellowship.
Abby Eblen MD (04:13)
Yeah, very cool. All right, well enough about Coke and Dr. Pepper and all that stuff. And today we’re going to talk about tubal issues. We have listener questions that we’re going to talk about. So you got a question for us, Susan?
Susan Hudson (04:15)
Very cool.
I do. My age is 43, preparing for at least two or three egg retrievals. I had two egg retrievals at 42. I got one normal PGT-A embryo from each retrieval. My first transfer failed. My second lead ruptured ectopic. Prior to IVF, I got pregnant naturally at 41, but was terminated for pregnancy of unknown location. During that pregnancy, I believe I expelled a decidual cast.
I’ve since had two HSG’s both showing no blockage. One, what causes decidual cast? Why are they associated with ectopic pregnancy? And two, what is your guess as to why I had an ectopic from an IVF transfer and can this risk be reduced? Do you recommend proactively removing my other tube?
Carrie Bedient MD (05:11)
All right, Abby, tackle whichever part of that question you want.
Abby Eblen MD (05:15)
Okay, I missed part of it. So just tackle why can I get an ectopic pregnancy from an IVF cycle? And the question is, I don’t know. But we know that when we put the embryo inside the uterine cavity, we know that it can go more than one place. And in fact, there was a video presentation at our national fertility meeting a few years ago that won a prize paper where somebody actually put the embryo in. And of course we can’t see the embryo when we inject it, but we can see that air bubble at the tip of the catheter, which is our signal that the egg got released, the embryo got released, and it’s about to implant in the cavity. And so every five minutes for like three hours, they would show a snippet and they put it together like, and it was a video over five minutes, and it looked like a bumblebee flying around in the cavity. The bubble went everywhere in the cavity over about five minutes. And so, we know that the embryo can move because you move and anytime you move, probably, things move on in the inside. We don’t really know, but we do know that that sometimes the embryo can be flushed or somehow get back into the tubal segment in between where the tube connects. And sometimes it can even get further back in the tube and there’s really not a good explanation for it. But one thing I would say is the chances are very low of that happening more than once. I that’s a rare occurrence. And if you’re somebody that has ectopic pregnancies and your doctor said you need to do IVF, it is a safer bet than just trying it on your own because presumably if you’ve had ectopic pregnancies, there’s some damage in the tubes and sometimes it’s damage that’s really mild and we can’t see with an HSG. So when we push dye through, we can see dye go through the tubes and there may not be enough scar tissue there that we can really see it, but there may be enough scar tissue there that an embryo could get attached and grow there. So ultimately IVF doesn’t completely decrease your chances, but the chances of you having a second ectopic pregnancy are pretty low, because it’s a rare event when you do IVF.
Carrie Bedient MD (06:59)
So looking at the decidual cast part of this discussion. A decidual cast is when instead of having a period where you get drips and drops coming out over the course of several days usually, it’s when everything just comes out all at once. And so as a result, it’s a little bit more formed and it looks more like a cast of the inside of your uterus where you’ve got the upside down triangle shape that is associated with what most, internal structure of most uterine cavities look like. It just all comes out at once. Now that happens to be pretty painful because if you’ve ever passed a really large clot, you know that while that clot is coming out is rather upsetting. But once it is out, you feel so much better because all of a sudden the cramping just lightens up pretty quickly. And so when you have an ectopic pregnancy, your hormones are all screwy.
Rather than with a normal period where you’ve got just a gradual decline in your hormone levels, an ectopic can have a much sharper drop in those levels. And your uterus gets mixed signals of we’re fine, we’re fine, we’re fine, we’re not fine, shed, and then it happens rather quickly. So it is a bit more common after an ectopic pregnancy, although I’ve certainly seen it after just normal periods as well.
Part of the reason it’s anxiety provoking is because people think, my gosh, I’m passing a pregnancy and this is a miscarriage and I’m looking at baby tissue. And in actuality, it’s not, you’re looking at the lining that just happens to be pretty well formed, but it can be very surprising when someone finds it. And so that’s as part of the reason why it causes a little bit more drama. Now, if you happen to pass one, and you know you’re pregnant or even if you don’t know you’re pregnant, it’s worth checking to make sure that this really and truly isn’t an ectopic, that you don’t have anything growing in the adnexa, that your HCG levels are dropping because you don’t want to attribute it to, this is a miscarriage I’m done, when in reality it’s an ectopic that’s going to come back to bite you.
Susan Hudson (08:58)
I think y’all covered that one. That’s great. Next one. Hi, I’m 29 with unexplained infertility, stage one endometriosis and a 4.06 AMH. My first and only pregnancy was an IUI that resulted in an ectopic with removal of my right tube earlier this year. My fertility doctor has basically told me IVF is my only real option as my left ovary is lazy but is the only side with a tube now. Should I attempt to IUI or just move on to IVF as per recommendation? Is there any other testing I should ask for in regard to my unexplained infertility? I’m so thrilled I found your podcast. I have learned so much from you all. So thank you for listening. I’m gonna take the first part of this, which is nothing to do with tubes, but you do not have unexplained infertility.
Abby Eblen MD (09:42)
That’s right. Tubal factor infertility.
Susan Hudson (09:51)
Correct, correct. Unexplained means there’s nothing else that’s identifiable that’s going on. You have tubal factor. And so after that, I’ll punch from you guys. But understand for our listeners, unexplained infertility is someone who’s had a complete fertility evaluation and there’s no tubal factor, there’s no egg factor, there’s no sperm factor, there’s nothing else going on that’s affecting fertility that is diagnostically available to us.
Abby Eblen MD (10:21)
So if you had your right fallopian tube removed, then that suggests that your doctor was able to visualize and look at your left fallopian tube. A lot of times that the left fallopian tube looks normal. Sometimes, it’s reasonable to try and see if you can conceive on that side. I wouldn’t say that you can’t get pregnant that way. Little bit higher chance of having an ectopic over there if you’ve already had an ectopic on the other side. But certainly I think it’s reasonable if you’re not ready to jump to IVF right now to just try. He can also put you on ovulation induction medication, which can make it more likely for you to, I mean, you have two ovaries, right? One tube? Yeah, so ovulation induction medicine that can potentially make you ovulate a little bit more frequently, maybe on that side that you have the tube on, on your left side. It can be monitored with ultrasound to see which side you’re actually ovulating on each month. If you look like you’re ovulating on the left side, that might be, you might wanna hit the ground running and think about doing intrauterine insemination to give you a little bit better chance to get sperm and egg there. So, it depends a little bit on age. You’re young and so since you’re young, I would just make sure somebody you’re in a doctor’s care so that if you do get pregnant, somebody really needs to check on you really early on and make sure it’s in the right place. I think it’d be reasonable to try that first before you jump to IVF.
Carrie Bedient MD (11:31)
There’s a new product out, which is an IUI catheter called FemaSeed. The difference between this and a regular IUI catheter is that it directs the sperm towards one tube or the other. And so it is more expensive device. It is a little bit more uncomfortable to put in because it’s a little bit bigger. Because what it does is it angles the sperm into the tube, puts a balloon behind it so it blocks it. We were part of the original study that looked at it. Now that it’s approved we’re starting to introduce it into practice, which it is more expensive. It is not for everybody, but it’s something that may be helpful in a case like this. Now, I don’t think that it’s a be all end all. I think that it is concerning that you had an ectopic before. It is concerning that you were diagnosed with endometriosis because tubes are very close together and something that ticks off the one can tick off the other because they’re only a couple centimeters apart. I tend to be very distrustful of tubes. I have a bias against them. When one has misbehaved, like you are who your friends are. And so if you’re hanging out with a misbehaving tube, there’s a much higher chance that you are also a misbehaving tube. Not 100%, not every bad apple turns everybody else around at a bad apple. But I do have a much higher level of concern when someone’s got an ectopic before. So I think you can make the argument either way. Some of this is going to depend on your insurance coverage, because if you have coverage for IUIs but not IVF, there’s absolutely more reason to try another cycle or two of IUI. It’s just you’ve been through a neck topic and you know what that’s like. And they’re very anxiety provoking for everybody.
They do pose a real risk. And so, we don’t want you to go through that with that risk, if we can avoid it.
Susan Hudson (13:19)
I’d like to just add, I completely agree that once you’ve had a misbehaving fallopian tube, I’m never going to trust that other one. So you’re going to be monitored early, but also realize everybody imagines your uterus as being your body and your fallopian tubes as being your arms sticking out to the side. And they’re more like drooping down into the pelvis. And so when you ovulate your ovary squeezes out the fluid and that fluid that contains the egg ends up in the base of your pelvis and so if you have one fallopian tube, yes it is a little bit less likely to get picked up by the opposite fallopian tube but it’s still there as long as there aren’t adhesions keeping it away or anything like that.
If for some reason IVF is not feasible or you understand the risks and benefits of using that one fallopian tube that we’re questioning, it can be a reasonable thing to do. But understanding you are at a higher risk of ectopic pregnancy and IVF would by definition avoid those fallopian tubes for the most part and also give you much, much higher chances of conception, more around 60 to 70 % than 15 to 25.
Carrie Bedient MD (14:38)
Yay. Okay, what’s the next question?
Susan Hudson (14:41)
Okay, we’ve got an ectopic pregnancy run here. I recently had an ectopic pregnancy and lost my right tube. I’m 33 years old, have zero risk factors in two previous healthy pregnancies with no issues. No one can give me answers as to why this happened. Just received my pathology report and it says, “focal double lumen consistent with tubal duplication.” I am finding very little research on this topic, but looks like this can lead to ectopics. Would love to learn here more information. Thank you.
Carrie Bedient MD (15:16)
Ooh, embryology. Yay. Okay, so the way that the uterus, tubes, ovaries, vagina, all of those things form, they come from two separate areas. So ovaries are one separate thing, and then tubes, uterus, upper third of the vagina comes from a separate area when you’re forming. And so as those things come together, sometimes the signals get crossed.
Susan Hudson (15:19)
Go Carrie
Carrie Bedient MD (15:44)
The most common and what I think is the easiest way to visualize is when they don’t fully come together. And so they’re touching at the bottom and that’s really it. And that’s when you have a didelphys which is a complete duplication of the whole system. You’ve got two uteri, two cervices, two everything. Well, there’s other ways that that can get distorted. So sometimes you can have a bicornuate which is the bottom half is fused, but the top half isn’t. Sometimes you can get a septate where you’ve got a septum all the way down the middle. So you’ve got essentially one uterus, but it’s divided into two rooms. And so one of the lesser known ways that that can go awry is if you have tubal duplication. And when we think of this type of duplication, we see it more often coming out of the kidneys where you’ve got two ureter, that’s the tube that connects the kidney to the bladder.
But you can really have it with any kind of tube. And so the issue is if you’ve got two tubes running next to each other where there should only be one is one of them functioning less effectively. Yeah, less effectively than the other one. And so that’s what puts you at a higher risk for ectopic. And so it’s something where, yeah, you can have two prior deliveries that were completely boring with no drama whatsoever.
And then, and this one, an egg or a sperm, or both happened to take a detour and they should have turned left at Albuquerque and they didn’t. And props to anybody who gets that reference from Bugs Bunny way the hell a long time ago. It should have turned in one direction. It didn’t. And it happened to turn in the direction that took it through a worse neighborhood and you’ve got an ectopic and here we are. So it’s nothing you did. It’s nothing you can control.
Short of IVF, it’s really not something that anybody else can control either because that is, that’s totally dependent. If you’re doing an IUI, for example, we’re just putting the sperm and helping the egg come out at the right time. We are not controlling where they are going. And so to 100%, well, to 98 and a half percent control this, you would need IVF with placement into the uterus, but even then it can still float into the wrong direction because bodies do whatever the hell they want to do.
Abby Eblen MD (17:57)
So you were talking about duplications and along with ectopics made me think of, I’ve seen probably three people in my career that have had this where basically you have two separate tubes like Carrie said, they don’t fuse correctly, they don’t fuse at all. So you have a didelphic uterus on one side, it fuses all the way down. The other uterus doesn’t fuse at all, it just has a tube connected to it.
And so sometimes when that happens, the problem that you get into, particularly if there’s the structure of the lining is good. So if you have endometrium in there, sometimes when people get pregnant, they can actually have a pregnancy that, or they can ovulate on that side, somehow sperm can get over there and they can actually have a pregnancy inside that uterus. And so the concern with that is that can act much like an ectopic pregnancy, except it can be more dangerous because the pregnancy can grow there.
Endometrium can continue to grow, the uterus can continue to grow, and sometimes in some women that can actually unfortunately result in a ruptured uterus and that’s really dramatic. Sometimes it’s hard to pick up on once you get further along in pregnancy too because it’s really hard to tell that it doesn’t connect with the other pelvic structures. One of those three patients, so I will say, went on to have a healthy baby. It was a very tenuous, scary pregnancy and she was managed by High Risk OB every visit, but she went on to deliver baby I think at 34 weeks and did really, really well actually. Most of time it doesn’t end that well, unfortunately.
Susan Hudson (19:16)
Our next one. Hello, I have suspected endo for a while now, but I just had my HSG and both of my tubes are completely blocked. I was told IVF is the best option now, but surgery couldn’t be an option. I was told success rates are low because the damage to the tubes is already causing them to both be blocked and there is a risk for more damage to the surgery. They said surgery is needed either way.
I would recommend trying IVF first in case any further damage happens with surgery. They also said even if they could get a tube unblocked because there was damage, they would still suggest IVF. Is IVF what you would usually recommend in this instance, or is surgery worth trying? So I would imply by the questions that there are probably something called hydrosalpinx or swollen fallopian tubes if you’re being told that you absolutely have to have surgery, even if you’re doing IVF. Now the reason why that’s important to know, and that’s a question for you to ask your doctor is, do I have hydrosalpinx present? Is we know that in this situation where we have swollen fallopian tubes, that the fluid within those fallopian tubes can actually go back into the uterus, and it’s what we consider it to be embryotoxic or it can actually stop a developing pregnancy from continuing. Those studies are mainly done in IVF pregnancies, but we know that the presence of a hydrosalpinx that is not surgically removed or transected, essentially preventing that fluid from going backwards, can decrease your chances of success.
I’ll pass on the other things from here, but I think that’s an important clarification. If you only had blocked fallopian tubes and it didn’t look like they were swollen or hydrosalpinx, I don’t think that most of us would necessarily say you have to have surgery in coordination with IVF.
Carrie Bedient MD (21:19)
I think that looking at when you are planning IVF and you’ve got hydros and whether or not you need to have surgery and when you need to have surgery is it’s a very nuanced question.
If you have a big hydro, but you can still access the ovaries, then you can go ahead and do the egg retrieval component of it. Get your embryos. Once you know you have embryos, you then move on to preparing the uterus with or without taking out those hydros. If you have a big endometrioma on the ovary that really may impair getting to the eggs, that poses a different question.
And in this case, size matters because it usually does in life. And whether you have a really large endometrioma or a much smaller one, whether it is blocking your access to the eggs or the ovaries or not, all of those things play a factor. The skill of the surgeon, how much endometriosis surgery they do. This is something where it takes so much time. Personally, endometriosis surgery is kind of driving me nuts because I am a bit of a perfectionist and I want to get absolutely everything. And that is not always realistic and for the amount of time that it takes for me, I will spin myself in circles doing it. However, there’s a couple of fantastic endosurgeons in town. So whenever I have a case that I know is going to be challenging, I send it to them because that gives the patient the best outcome. And it also gives the surgeon something they really love working on. And like most other things, if you’re passionate about what you do, you tend to be pretty good at it. And the endosurgeons are exemplary in describing this. So whether or not you do surgery before or after depends on the full picture. What is the accessibility of the ovaries? How accessible is your abdomen? Some people have had a zillion and a half surgeries and there’s a ton of scar tissue in there. As a result, maybe doing surgery isn’t a good idea. Maybe you need to go with the doxycycline protocol for a couple of weeks leading into your transfer because going in surgically really does pose a much higher risk for you than the next person.
Abby Eblen MD (23:23)
Yeah, and one thing to consider too would be your age. Sometimes if I have patients that are, and I didn’t hear the age of our person who asked the question, but if you’re on the older side of things and we’re afraid that we’re not gonna have any normal embryos, you don’t wanna go and fix something that’s not broken. If your tubes are blocked and you don’t have pain related to that, there’s no reason to go out and have surgery on your tubes, no reason to do it if it turns out we don’t get any eggs. Same thing with endometriosis.
25 years ago, if we saw any endometrioma that we even thought was an endometrioma, we would go in surgically and get rid of that. We’d get rid of any other endometriosis that was there because we thought that that really made a big difference. Turns out it doesn’t make a tremendous amount of difference if there’s a small amount of endometriosis there. And same thing with an endometrioma. It’s a collection of endometriosis in the ovary. If we cut into the ovary to take that out, as Carrie alluded to, sometimes you do more harm than good because you’re damaging the little egg cells that are there. So same thing with endometriosis.
If you know you’ve had it in the past and maybe they see something on ultrasound, if you’re not really having problems with it, there’s not a good reason to go in and do surgery on you if you have no other issues other than that. So it’s best to leave it alone if we don’t really need to do anything about it. No symptoms.
Susan Hudson (24:33)
Alright, here’s our next one. Hi there, just finished my first egg retrieval and got zero blasts. Only have one ovary due to a dermoid cyst 14 years ago. She’s 29, AMH of 2.3, husband semen analysis came back great.
Cause of infertility is bilateral hydrosalpinx and have surgery scheduled to remove both tubes and address any endofound. Heard in your podcast that tubal removal can lead to lower vascular supply to the ovaries. Do I proceed with surgery and then do another retrieval or should I be concerned with the impact of surgery on my ovarian reserve? Great question.
Carrie Bedient MD (25:12)
Go for it, Abby.
Abby Eblen MD (25:13)
Just taking the tubes out, I’ve really not seen that big of an impact with basically blood supply to the ovaries. It sounds like that you got eggs, but they just didn’t develop well. I don’t really think that probably taking your tube out is gonna make that big of a difference. I would lean more toward kind like your surgeon did, stimulating you first, see if we can get an embryo and then take your tube out. Because again, If you don’t need to have the surgery, why do it if you don’t have any embryos to transfer?
Carrie Bedient MD (25:40)
I think evaluating whether or not those hydros are blocking access to that remaining ovary is important. If they are, that makes a much stronger case for getting them out. Sometimes going with a stronger stimulation may be something you guys should consider. You didn’t give us any details about your IVF cycle, which is totally fine. That’s not part of the question, but sometimes you can be a lot more aggressive about the stimulation and that can give you more eggs to work with because I don’t think that the tubes are impacting your ability to get blasts in this point.
Susan Hudson (26:11)
I agree with that. I would hold off on doing surgery until you know you have blasts because who wants to go through a laparoscopy and recovery from that? And I would say that even though your risk is not high, I would do nothing at this point to compromise your vasculature to your remaining ovary until we know we have blasts in hand.
Carrie Bedient MD (26:36)
The heat source that’s used to take out anything near the ovaries are really what we’re most worried about. A lot of the devices that we use provide a very specific directed heat source to block off the vasculature so it doesn’t bleed so that we can safely cut through it. When you get that heat source too close to the ovaries, that’s when we worry about impact to the ovaries’ ability to produce eggs. If you cut too close to the ovaries, the concern is you’re going to compromise vascular supply. Anybody who’s doing this who knows you’re in the midst of fertility is going to be more meticulous about that. But those are the things to kind of consider there.
Abby Eblen MD (27:17)
Yeah, and the only time I’ve really seen a situation where surgery caused decreased blood supply to the ovary and decreased ability to retrieve eggs was when people have like hysterectomies because that really, really cuts off a lot of different sources of blood supply to the ovary. And I do think in those situations, it’s not uncommon for patients to have a poor stimulation just because they don’t have as much blood supply to the remaining ovaries since the uterus is gone.
Susan Hudson (27:41)
Yeah, I think there’s some data to support that that can be a complication, I mean, AMH is pretty good. I mean, but if you were sitting there at 40 and it was like, eugh, but I would rather be safe than sorry. Absolutely. All right, next one. Long story short, my doctors confirmed that both of my tubes are blocked. Are there procedures to unblock your tubes? having an ectopic pregnancy. I’m trying to stay positive.
Abby Eblen MD (27:48)
Yeah, it is. is.
Susan Hudson (28:07)
and think that there might be a blessing, but I’m not able to get pregnant through intercourse. Can I get pregnant naturally if I were to unblock my tube? My husband also has low motility and morphology. The percentage of motility is 14%. Is IVF my only option?
Carrie Bedient MD (28:23)
So going through blocked tubes, it’s always, I think all of us have gotten burned by this in one way or the other. I’m phrase this answer very carefully because I have very clear memories of being in the operating room with one of my OBGYN colleagues who had called me in to take a look at these tubes. The woman had bad endometriosis. Her tubes were completely blocked. We tried to run dye through them a couple of times. Nothing happened. We ended up doing an IVF cycle later.
Got her one, maybe two embryos. She had really horrible ovarian reserve because of her endo. And then before we had the opportunity to transfer them, she had the audacity to get pregnant by herself. And if I had not had been there watching, we tried several different ways to get those tubes to open and sure enough, there was nothing and then…sperm and egg or itty bitty teeny tiny and there was a baby and it was in the right place and everything was fine, even though I think I had a heart attack for the couple of weeks while we were waiting to confirm that was truly in the uterus. So anything can happen. That said, we don’t bet on the miracle. You hope for the miracle, but you don’t make a life plan surrounding the miracle. And so I think that the the plan you have of going through IVF to get your kiddos makes a lot of sense. Surgery to repair tubes is not known for being particularly effective and is known for increasing your risk of ectopic. So most of us are not real big fans of that. There are two types of tubal damage. One, what’s considered to be distal damage, which is closer to the ovaries. There’s proximal damage, which is more likely to be a tubal spasm and not true blockage.
Where the tubes and the muscles surrounding them just get ticked off, they spasm, it looks like the dye can’t go through, but in reality it can. And the types of surgery you do in response to those are different and your approach is different.
Abby Eblen MD (30:27)
So Carrie, I have something to add that when you said we’ve all been burned by this, what you said was not one of the two things I was thinking of. The two things I was thinking of when we’ve all been burned by this is one is you go in to try and unblock tubes that you think are gonna look nasty. You get in there, the tubes look beautiful, you push die and the die goes right through. And that’s the situation you just described where there’s damage right where the tubes connect with the uterus. The other way that I thought about being burned was when I first started out in the first half of my career, we were much more adamant to jump right in and fix tubes because 20 years ago, pregnancy rates were 30 % with IVF. Now they’re almost 70%. And so we were lot more likely to go in and go, yeah, let’s see, there’s a few filmy adhesions, let’s see what we can do. Or in some cases, patients would be, really don’t want my tubes taken out, I want you to try and fix them. And if you have to create a whole new hole in the tube and create little prongs of fimbria coming out, it just doesn’t work that well. And so…Really the worst way I think you can get burned is A, you can try and fix the tubes and they can get an ectopic in them. You can make them just good enough that the egg and the sperm get together, but they can’t get all the way through the tube. The other way is, have a discussion about, maybe we should just take your tube out because it’ll give you a better chance with IVF. And the patient’s like, no, I really want you to try and fix it. Well then you go in and fix it. Two months later you go back in, three months later you go back in, you put dye through, and the tubes are back to the way they were. They’ve closed and now they’re blocked at the end. Now you’re left with, Okay, now we have to go back in again and take the tubes out. So tubal surgery is just not very reliable. The caliber of the tube is really small. And sometimes we can even go in from the inside of the uterus, almost like you’re trying to unclog your drain and put a little wire through. And then on top of that, put a little tube through that and then a bigger tube to try and see if we can get dye to go through. And again, sometimes you can make that work, but when you get finished, two or three months later, that tube caliber is so small that it just closes back up again. So the big concern I have other than that topic is if you go in and try and do tubal surgery, it rarely is very effective if you have a really damaged tube. So I wouldn’t recommend it. I would recommend IVF would be a better route to go for sure.
Susan Hudson (32:21)
I think it’s a good thing for us to remind our listeners that fallopian tubes are dynamic organs. They have little projections within them that help egg, sperm, embryos all end up in the right direction. There are chemical signals that are sent between the tube and the egg, embryo, sperm, et cetera, back and forth to each other to make sure things are going in the right direction. And there is no way for us to test that functionality.
All we can tell is does it look swollen, not swollen, does it open, does it look closed. Those are the pieces of information we have and no one’s going to be able to tell you the actual functionality of your fallopian tube. And so we have to know from our experience and what studies have shown us and knowledge that we’ve gained through the years in whether or not this sounds like it may be the right thing for you within your own personal constraints. There are some people who utilizing things like IVF are not going to be in the cards. And for some of those people, maybe doing tubal surgery is a good idea, but you also have to understand that, One, going through pregnancy is probably the most risky thing most women in the United States ever do in their lives. Part of that risk is the risk of an ectopic pregnancy or pregnancy in the wrong place. We talk about, obviously our listeners have written in about stories about methotrexate, having to take medicine to solve an ectopic or having to have surgery for an ectopic, but there’s a very small percentage, but there is a percentage of people within the United States that die each year from an ectopic pregnancy. And so it is a life-threatening emergency. And that’s the reason why we take this so, so heavily is because we want you to be safe and we want you to be successful. And sometimes tubes make that a lot more challenging.
Abby Eblen MD (34:38)
Well said.
Carrie Bedient MD (34:39)
Agree.
Abby Eblen MD (34:40)
So do we want to do one more?
Susan Hudson (34:42)
We can do one more. Okay, here it is. Hi, I just had my second ectopic pregnancy. Had had an ectopic pregnancy, then a successful pregnancy with the birth of a healthy baby, and then a following ectopic, which has now resulted in bilateral salpingectomy. What does the IVF process look like in this situation and how does it differ from another reason for IVF? For reference, she’s 34 years old, no health concerns, incidentally diagnosed with BV, being treated with metronidazole, following up with OB-GYN shortly, who will refer her to a fertility clinic. Thank you. I’m very happy I found your podcast.
Abby Eblen MD (35:21)
I mean, I would say the chances, like I said at the very beginning, are not zero if you have another ectopic, unfortunately. And I have had somebody that had two ectopics and then had an ectopic after IVF, so it can happen. I tend to, whether it’s kind of folklore, it just makes me feel better, I tend to transfer the embryo a little bit lower in those patients and try and keep them as far away from the tube as I can. But still, your chances are much lower if you get pregnant through IVF than they’ve ever been when you tried to conceive. Even that second pregnancy, you have a much lower chance of having an ectopic pregnancy. So I think it’s the safest route to go. I think you’ll probably do fine. I think you can carry a pregnancy well. You’ve had a baby, and so I think there’s a good chance that you’ll do really well. So your doctor’s going to be watching you really closely. We always check hormone levels very early, usually every other day for about three different times to make sure that the HCG level, the pregnancy hormone level is going up well. And then you would be somebody that would need an early ultrasound. So about five weeks, we should be able to see if there’s a sac in the uterus.
And certainly your doctor’s gonna be watching you like a hawk and I’m certain they’re gonna wanna bring you in really early, really to confirm that there’s a pregnancy in the uterus. And I think those chances are really, really good for you.
Carrie Bedient MD (36:37)
You’re a really good candidate. Your young, tubes seem to be the primary issue. Bring it on. Let’s do it.
Susan Hudson (36:44)
I mean as much as we sit here and talk about we worry about tubes and ectopic pregnancies also know some of our most successful people are tubal issues because we’re not dealing with an abnormality of egg or sperm function and so good chances of warm and fuzzy.
Carrie Bedient MD (37:03)
Yay!
Abby Eblen MD (37:04)
All right, very good episode. Any last thoughts that you guys have? All right, well to our audience, thanks for listening and subscribe to Apple Podcast to have next Tuesday’s episode pop up automatically for you. Be sure to subscribe to YouTube. We really love to hear from you and we’d love to see you.
Carrie Bedient MD (37:21)
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Susan Hudson (37:32)
As always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we’ll talk to you soon. Bye!
Carrie Bedient MD (37:41)
Bye!