Infertility Q&A

What is the definition of infertility?

Infertility is the inability to conceive following 12 months of unprotected intercourse. There are female factors and male factors that contribute to infertility. The most common female factor is a blockage of one or both fallopian tubes. This blockage is usually a mucus plug obstructing the opening of the fallopian tube.

How do you determine if the fallopian tubes are blocked?

The imaging test to determine whether the tubes are opened or blocked is called a Hysterosalpingogram or HSG.

Can a woman have the HSG procedure any day of her cycle? No, the HSG study is performed during days 5-12 of the menstrual cycle (day 1 being the first day of bleeding).

How is the HSG study performed?

A speculum is placed in the vagina and the cervical area is cleaned with an iodine based solution. A thin catheter is inserted in to the cervical opening and advanced in to the uterine cavity. The catheter has a small balloon near the tip. It is inflated to help secure the catheter from slipping out and preventing contrast material that is injected in to the tube from leaking out. The contrast (while clear to the naked eye) shows up black under xray allowing the Interventional Radiologist that’s performing the procedure to see the uterine cavity and to evaluate whether or not the fallopian tubes are open.

What should the tubes look like on a HSG?

The tubes have a proximal end connected to the uterus and a distal ovarian end which is open to the pelvic cavity. The tubes are very thin and linear. They should fill completely and not change significantly in caliber. Their distal ends are open to the pelvic cavity and should spill the contrast freely in to the pelvis. (See Figure 1). This contrast will get resorbed by the body and excreted in the patient’s urine.

What is the definition of infertility?
Figure 1 Normal HSG

How often are the fallopian tubes blocked on a HSG exam?

In 20-25% of cases there will be a blockage of one or both fallopian tubes typically at the proximal (uterine) end. (See Figure 2). If the fallopian tubes are blocked, patients are often referred to a Reproductive Endocrinologist for consideration for In Vitro Fertilization (IVF).

What is the definition of infertility?
Figure 2 Both tubes blocked (incidental air bubble in uterine cavity)

IVF is a very expensive process which is typically not covered by insurance and often costing tens of thousands of dollars. Besides the financial cost to the patient, there are numerous doctor visits for ultrasounds, checkups, and hormonal medications.

There is however another treatment option that most patients (and physicians) are unaware of. This procedure is called Transcervical Fallopian Tubal Recanalization (TFTR). Compared to IVF, TFTR is dramatically less expensive, less invasive, and allows women to have children naturally. TFTR starts with a HSG procedure which is typically covered by insurance. If the HSG demonstrates a proximal tubal blockage a small catheter is advanced over a tiny guidewire in an attempt to cross the blockage at the tubal opening. If successful, the catheter and guidewire combination are used to mechanically clear out the obstruction (See Figure 3). The technical success for TFTR is very high and it is very unusual not to open at least one of the two obstructed tubes. Once the tubes are unclogged, the patient can resume intercourse immediately and we recommend trying to conceive for the next six months. In 40-50% of cases, patients became pregnant and had children.

What is the definition of infertility?
Figure 3

Can the TFTR be repeated if the woman does not get pregnant within 6 months?

Yes, we recommend that if the patient does not get pregnant within 6 months, she should return to our Center for a HSG study. Roughly half of these women will have patent fallopian tubes identical to that from 6 months earlier when she underwent TFTR. The other half of the women had reformed the mucus plug and were blocked again. These women underwent TFTR for a second time and a number of these women became pregnant in the subsequent six months.

To learn more about Transcervical Fallopian Tubal Recanalization (TFTR), call the Atlanta Fibroid Center at 770-953-2600 or make an appointment online.