Ep 335: Untangling Blocked Tubes: Listener Questions on Tubal Testing, Anatomy, and Choosing IVF vs. Surgery

0:00Dr. Carrie Bedient: 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.

0:21Dr. Susan Hudson: This episode is brought to you by Receptiva DX. What if unexplained infertility isn't actually unexplained? For many women, hidden inflammation associated with endometriosis and other uterine conditions can go undetected for years, even when everything else appears normal. For more than a decade, fertility specialists have trusted Receptiva DX to provide deeper insight into the uterine environment, helping women and their physicians uncover answers and make more informed treatment decisions. Hello, everyone. This is Dr. Susan Hedson from Texas Fertility Center with another episode of Fertility Docs Uncensored.

0:59Dr. Susan Hudson: I am here with my audacious, amazing co-host, Dr. Keri Vedient from the Fertility Center of Las Vegas. How are you doing, Keri? Hello. How are you, my dear? I am good. I am good. I understand we are envisioning some remodeling going on in your household?

1:16Dr. Carrie Bedient: So remodeling is a really strong word because to me, remodeling implies a lot more work and money than what I have planned. Really, I have a paint job planned with possibly the replacement of a mirror and maybe a new light and some pictures on the wall. But I have a downstairs powder room that is builder grade boring AF and I am tired of it. I want to paint it like a really deep blue and then get a metallic paint to go over it that's got like a shimmer and put it into a stencil pattern. And I see that look in your eyes, Susan Hudson. You are looking at me like I'm a crazy person, which is not wrong.

1:53Dr. Carrie Bedient: But I think I've picked the stencil and the metallic color, and now I'm just trying to find the base color in the mirror and then figure out how to get my husband on board with it, who he always listens to this. Dear, I'm working very hard to not present you with a zillion and a half options and just give you a couple so that your brain does not explode.

2:11Dr. Susan Hudson: Most importantly, is it going to be in a PowerPoint?

2:14Dr. Carrie Bedient: Not yet, but I have done a PowerPoint in the past for it. I just haven't figured out how to do the PowerPoint in the colors that I want. So if any listeners have great input on how to do that, I would appreciate that because I can't find the paint swatch of the metallic color online.

2:30Dr. Susan Hudson: Well, have you used AI? I mean, seriously, we use AI for everything nowadays. You could take a picture, you have part of it, and then you go and say, hey, I want to add blah, blah, blah, blah, blah, and get a pretend picture and like imaginatively create like that.

2:47Dr. Carrie Bedient: How much work on the podcast do you want me to do in the next two weeks versus playing with this with AI? A little bit of both. All right, I'll work on it. We'll see. I've been working on this project for months, so nothing is going to happen anytime soon, nor does it have to. So we're probably good there.

3:04Dr. Susan Hudson: All good. All good. All right. Well, today we're going to do a question episode and our question episode is going to be all about fallopian tubes which they tend to cause us a lot of pain in the patootie personally. What do you think Keri?

3:21Dr. Carrie Bedient: I really hate the fact that testing for fallopian tubes is so non-specific because there's nothing more than I like besides data and I generally resist telling my patients that I'm a data whore, but that is 100 % what I am. And I want more data. And we just don't get it from the tests that are available. We get the basics, but I think that's what makes tubes such a pain in the butt.

3:47Dr. Susan Hudson: I think it's not even that we get the basics. I mean, the testing we have says whether tubes look relatively normal, but it's pretty nonspecific. We have no functional assay at this point in time with tubes because tubes are more than just pipelines. They are dynamic organs with very delicate structures on the inside that we have no way to evaluate. And it's just really hard that something that can actually cause one of the few major emergencies in our specialty, really, that our testing mechanisms are so far behind.

4:22Dr. Carrie Bedient: Agreed. Okay.

4:24Dr. Susan Hudson: Well, let's go for our first question. So our first question is, thank you all so much for your incredible work. Hoping for your thoughts. I am currently doing IVF after two ectopics that required emergency surgery. The first tubal rupture occurred approximately five weeks, one day required self injectomy, which means removing of the tube and a second at five weeks and five days with a corneal ectopic, which is essentially in the top angle of the uterus by the fallopian tube.

4:55Dr. Carrie Bedient: Much nasty surgeries. Yep.

4:58Dr. Susan Hudson: She had significant internal bleeding. My clinic assured me, IVF was the safest option due to close monitoring. I just had my first HCG 201 and the plan was to do an early ultrasound at five weeks and two days. But since that falls on a weekend, they are having me come in at five weeks and one day, which is a Friday, and told me that if we don't see anything on ultrasound, they won't see me on the weekend. They are open and I need to wait until Monday. I was hoping they would take my history a little more seriously. Am I being irrational? I just want to clarify. Am I wrong to feel that they aren't taking my history and risk more seriously?

5:39Dr. Susan Hudson: In ectopic situations in my experience, there is very little time that separates the use of methotrexate and an emergency situation in surgery. So I feel like 24 hours matters. I am not one to complain to medical providers, but they don't seem to have any protocol in place to manage these situations. Thank you so much.

5:58Dr. Carrie Bedient: Poor girl. Ectopics keep me awake at night worrying about them. What do you do when you've got a patient out there who's swirling in the ether where you know that an ectopic is a possibility?

6:11Dr. Susan Hudson: Well, I think there's a couple of things. So, number one, I'm watching their HCG levels very closely. So most, not all, most tech topics, the HCG level is not going to be rising appropriately. So what is a normal rise? A normal rise is a rise of at least 60 % over 48 hours. A lot of people have that doubling thing. We do that to keep it easy in our mind, but it does need to be ideally greater than 60%. And when we're watching that, if it's rising appropriately and you're not having any pain and we get you in for those early ultrasounds at around early five weeks, then in most situations, we're going to catch things appropriately.

6:56Dr. Susan Hudson: I think one thing is making sure you have good access to good real health care. And when we're talking about ectopics, this is not the time to go to your freestanding emergency room. If you need help, you need to go to an emergency room that is attached to a hospital that if you have something bad, they can treat you from beginning to end. Safety is our number one importance. But like I said, if you're not having appropriate rises, then that's one thing. But I think appropriate rises with early ultrasound is another factor.

7:34Dr. Carrie Bedient: One thing that comes up in this particular case is the gestational age at which she had an event, whether that's rupture of a tube, bleeding within the cornea. She said it was five weeks and one, five weeks and two days. And I'm guessing. The second one was five weeks and five days. Five and five and five and one. So I'm guessing that both of those are spontaneous pregnancies. And spontaneous pregnancies are a bit different in that we don't usually know exactly when ovulation and implantation occurred. With many patients who are going through fertility treatment, we've got a much closer idea because you're much more actively watching.

8:16Dr. Carrie Bedient: When are you ovulating? You know when your periods are supposed to come. So we can narrow it down. But even then, there's still leeway in both directions as to when implantation actually occurred. And most people come in later than they think they are or earlier than they think they are. And that plays an important role here because typically I wouldn't expect to see anything on an ultrasound before about five weeks and five days, maybe five and four. But in an IVF pregnancy, your dating is very exact. I think they are taking your history into consideration by having you come in at five and one because normally we would never do that because we can't see anything.

8:55Dr. Carrie Bedient: So whether it's ectopic or not, it doesn't matter because you can't see it because the HCG is too low. You haven't reached the zone of discrimination, which is the point at which your HCG is high enough that we would reasonably expect to see something on a vaginal ultrasound. This part of the reason why we didn't do ultrasounds earlier is that the expectation is that you're not going to be able to see anything. So I think they actually probably are listening to you and they're having you come in earlier rather than later because most of the time we would push for a few extra days there. to have a higher likelihood of seeing something in the uterus, especially for someone who's got a history of ectopics, where if you go in at five and one and they don't see anything, which is most likely what's going to happen, your anxiety is going to ratchet up six levels.

9:38Dr. Carrie Bedient: But they're going to be seeing you and you're going to be talking with them and everybody's going to be on top of it. It's worth paying attention to your body, but I think they probably are actually listening to you because that's an early first ultrasound.

9:50Dr. Susan Hudson: Yeah, five and a half weeks is really where we see what's called the gestational sac. So it's a black circle with a white rim all around it. And we should be able to see a yolk sac, which is a tiny little circle that'll be in the black. And those are the signs that say, yes, the pregnancy is where it needs to be. Definitely.

10:10Dr. Carrie Bedient: But hopefully for this patient, they are watching her HCGs compulsively. So not just the day 10 HCG, but they're getting a day 12 or 14 and maybe at least another one in there so that they've got a good fighting idea as to is this going up normally or not in the interim. Absolutely.

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11:36Dr. Carrie Bedient: Okay, for our next question. I have been listening for quite a while to prep for my first round of IVF. I've been trying to conceive for two and a half years with no luck. I have a 7 and a 9-year-old that were both conceived naturally at 28 and 31 years of age. I'm now 38. My AMH is 4, and I have a right proximal block, that means kind of on the close side, of the right fallopian tube. I can't imagine my tube is the only reason after this long that I haven't conceived. Is this a futile situation due to my age? I'm not open to donor egg at this point and can truly only afford one round of IVF. Thank you for your input.

12:12Dr. Carrie Bedient: What do you think?

12:14Dr. Susan Hudson: Well, my first thought is your tube may or may not truly be blocked. So when we do HSGs, the dye test of the fallopian tubes, very often people have cramping, which is the reason why you see all over everybody's blogs and social medias about how terrible an HSG can be. Well, the thing is, is when you have cramping, the muscle of the uterus contracts, and potentially the very, very, very tiny opening to the fallopian tube can get blocked just from that contraction. Anytime I see a proximal blockage and it's from an HSG, I take it with a grain of salt. Now, HSGs are screening tests. A screening test means there can be false positives, there can be false negatives.

13:04Dr. Susan Hudson: But when we see that proximal blockage, it does err on the side of it may or may not truly be blocked. Now, if somebody has a distal blockage, so out towards the length of the fallopian tube, those I usually believe because those are much less likely due to spasm because it's a different type of muscle that's around that part of the tube. I would say that most likely you still have very good odds of conceiving. Your AMH is fantastic for somebody who's 38. In fact, it's high enough that you might not be ovulating all the time on your own, and you may just need something a little bit gentler. And I would honestly probably try a couple of cycles of ovulation induction with insemination to see if you can get pregnant, especially if you're only planning on one more child.

14:00Dr. Susan Hudson: If you're wanting more than one child, then IVF directly, I think, is a great route. But I don't think that proximal blockage of one tube and somebody who's had two children in the past with a fantastic AMH is necessarily where you have to start.

14:14Dr. Carrie Bedient: I think that's fair. I think that that AMH of four is not only good for a 38-year-old, I think it's good for a 28-year-old. And so it's a nice place to be. Like Susan said, you may not be ovulating and that is worth following up on. Some of this is going to be based on what your insurance does and does not cover. Let's say your insurance covers some form of IUI. Well, take it and run. If it doesn't, that's where you have to be a little bit more selective on, do I want to spend the money on IUIs? Do I want to try an ITI, the intratubal insemination? Or am I so emotionally burnt out and frustrated and tired of time passing that I want to just go straight to IVF regardless because I don't want to deal with a 10-ish percent success rate.

14:59Dr. Carrie Bedient: So as with every fertility decision, there's way more that's going to go into this beyond just the straight pathology and what's going on. I think your ovarian reserve, specifically ovarian quality, is going to play a part of this. Now, that may not have been playing much of a part when you were 32, 33, but at 38, it definitely is. Even if you've got a ton of eggs and you aren't ovulating, those eggs have been sitting there longer. And so the quality is lower. So there may be an egg component of this as well, not just with ovulation, but with the quality of the egg once it has ovulated. I think your next step is to decide how much uncertainty can you tolerate?

15:42Dr. Carrie Bedient: How much potential bad news can you tolerate? What is your financial wiggle room? Are you at a point where you can only do one round of IVF, but could maybe do a couple of IUIs and see if you can gamble and get lucky? Or is it really just one round of treatment? You want to go straight to the big guns because that's what's most effective and take a run for it? All of these are very legitimate answers. It's just we need to know what your priority is, because my guess is if you walk in there and you tell your REI, this is my priority. It's timing. It's getting there fastest. It's spending the least amount of money.

16:16Dr. Carrie Bedient: It's doing the least invasive. If you tell them that, they'll be able to pick out a plan pretty quickly.

16:22Dr. Susan Hudson: Absolutely. Another thing I thought of is, and this may be me reading between the lines because we see this quite often, and this may or may not be the same partner you had seven and nine years ago. If this is a different partner and they may have a normal semen analysis, maybe looking at doing something like a sperm QT test that looks at the genes that determine how well sperm can bind to, penetrate, and actually fertilize the egg. because we may have an underlying nail factor that IVF is the best way forward because we need that to help address that. Like I said, it may be the same partner. It may not be an issue.

16:59Dr. Susan Hudson: Even if it is the same partner, it might not be a bad idea to make sure we don't have something that age has intervened. Yeah.

17:06Dr. Carrie Bedient: How often do you get someone who is coming in with a partner who says, no, I've got kids before, whether it's this relationship or another one, And their view is, no, no, I've had children before. It's not me. I don't need to be a part of any of the testing at all. I refuse to go somewhere else to ejaculate into a cup.

17:26Dr. Susan Hudson: Almost every single day. I mean, it's a very, very common story. And though it is very reassuring that you've been able to reproduce in the past, it doesn't always show us what is the potential at this moment in time. But it at least knows, hey, we do have sperm or eggs and they've worked in the past. And that's always a bonus and a good thing forward. But it's not actually a marker of what's happening at this moment in time. Starting a family is one of life's greatest adventures. But sometimes the path to parenthood isn't as straightforward as expected. Shady Grove Fertility is there to guide hopeful parents every step of the way, offering compassionate care and advanced fertility treatments to help make parenthood possible.

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18:55Dr. Susan Hudson: My question is about whether I should remove my tubes before transfer. My HSG revealed a small distal hydrosalpinx on my right tube. Still has some spill and left tube has full distal blockage. Ari said she wouldn't recommend tube removal because of how small the hydro is and recommends seeing how transfer goes. I've had a full workup, AMH 3.15, FSH 7.2, estradiol 63, TSH 1.7. No male factor. Husband has great numbers and motility. Thank you. Carrie, what are your thoughts?

19:30Dr. Carrie Bedient: And live from Las Vegas, the question is, what kind of a gambler are you? All right, here's what I mean by that. You know that there's tubal issues. You know that those tubes are not doing you any favors. The one is fully blocked. The other one, frankly, it's the right one that's partially open that scares me way the hell more than the left one that's blocked. And the reason is because tubes are super persnickety. And just because something can get through on one side doesn't mean they can't go through on or doesn't mean that they can go through on the flip side, meaning egg and sperm can come together, potentially fertilize.

20:08Dr. Carrie Bedient: But if the movement is abnormal, they won't make it back down to the uterus. If you know that you are in the IVF realm and that's the way that you're going, I would probably lean towards taking out those tubes. If you have any reservations, of course, don't do it. If you are worried about surgery, if you've got other health problems that make surgery a bigger deal, then of course, this is going to be personalized to you. But I think it really does come down to what kind of a gambler are you? It also comes down to what kind of chips are you playing with. For example, if you do an IVF cycle and you've got five gorgeous embryos to play with, that is a very different story than someone who goes through and they've got one day six, almost day seven embryo.

20:52Dr. Carrie Bedient: And it's the only one that was euploid out of the bunch. Because if you're only playing with one, you're going to be a little bit more cautious and maybe more likely to do this bilateral salpingectomy. So taking out both sides of the tubes and going in that direction. So what kind of a gambler are you? Do you want to know that you've done absolutely everything? Are you willing to go through the hassle of a surgery? Or are you thinking more, you know what? I've got wiggle room here, either because you can do another cycle of IVF, you've got a bunch of embryos, and you can maybe skip the big and dramatic of the surgery and go for a transfer and see what happens.

21:25Dr. Carrie Bedient: What do you think?

21:27Dr. Susan Hudson: So as much as I consider myself a surgery minimalist when it comes to hydrosalpinx, hydrosalpinx and using nicotine, those are the two things that essentially double the amount of times you have to do IVF to be successful. So in my opinion, don't use nicotine of any way, shape or form and take care of tubes that need to be taken care of. Now, I have had patients and these are very, very rare and far in between that either were bad surgical candidates for it or I know I had one patient whose pelvis was so frozen we actually couldn't ever find her fallopian tube surgically. It was it was really bad.

22:10Dr. Susan Hudson: And in those situations, we used doxycycline, an antibiotic through transfer, and I extended it longer than I normally did. And we were successful multiple times. Now, this is a very, very, very rare situation. My first thought is have your hydrosal pinks removed or at least ligated. Now, with that being said, that's not the only way to do something. Number two, I actually usually recommend having this done after you know you have embryos to transfer. Because I always feel terrible when we're like, okay, let's take out the tubes. And then we ended up taking out tubes and maybe you didn't get any chromosomally normal embryos.

22:54Dr. Susan Hudson: And you're like, we were one and done and we don't have the resources for whatever those resources are for another IVF cycle. and you just had a big surgery that you didn't need to have. I mean, a laparoscopy is a, quote, minimally invasive surgery, but it is still invasive, though it is minimally invasive. You're still going to have to take off work. There's still healing time. And with every surgery you have on your belly, that makes the next surgery you have on your belly more dangerous and more apt to something bad happening. The best belly to ever do surgery on is the one that's never been touched.

23:30Dr. Susan Hudson: I think that there's not a cut and dry yes or no, but my tendency is to address hydrosalpinks, but make sure we have embryos available for transfer first.

23:42Dr. Carrie Bedient: Yeah, I think that's fair. I think that's totally fair. All right. For our next question. Hi again, docs. I had a lap last week to remove my damaged fallopian tubes, and it was confirmed that I had a dermoid cyst in my left fallopian tube. Right was a hydrosalpinks. The surgery took nearly three hours because I had so many adhesions. There was potentially a small amount of endometriosis found, but not excised due to the intensity of my surgery already. Questions. How can this happen? Can a dermoid cause that much damage? How unusual is it to have a dermoid in the fallopian tubes? As I prepare for FET, would you do a Lupron suppression?

24:16Dr. Carrie Bedient: I'm 34, have four euploid embryos frozen, three failed to implant FETs. Many biopsies reveal chronic endometritis. Should this resolve my endometritis?

24:24Dr. Susan Hudson: That's a lot. Okay, so I would say very, very, very unusual to have a dermoid in your fallopian tube. However, dermoids are funny little creatures in all ways, shapes, and forms. And so I think it's good that it was removed. I think it was good that your other fallopian tube was removed as well. As to could the dermoid cause damage? Yeah, anything growing abnormally in the fallopian tube. There are very few things in the human body that are as delicate as the fallopian tube. So anything that mucks with it, I mean, seriously, when we do surgery, we don't even like to touch the actual fallopian tube if we can avoid it.

25:06Dr. Susan Hudson: When we're in medical school, it was eat when you can, sleep when you can, and avoid the pancreas. For gynecologists, it's avoid touching the fallopian tubes.

25:14Dr. Carrie Bedient: One little fact, there is a special surgical tool that we use specifically for fallopian tubes. So most of the time we're using clamps. So imagine tongs where one side fully touches the other side. With fallopian tubes, it's tongs where one side touches the other side in just a tiny little bit, but there's a big opening. It allows you to pick it up. imagine your thumb and your forefinger together, but you've got a circle with the rest of it. It allows you to put the fallopian tube in what would amount to be that circle so that you never compress it because fallopian tubes, when they get pissed off, they will pick up their toys and they will go home and they will not come back.

25:53Dr. Carrie Bedient: There's special instruments specifically for those little buggers.

25:57Dr. Susan Hudson: Exactly. As to the Lupron suppression, I would absolutely recommend either Lupron suppression or suppression with oralisa for two months. When we were reading through this and it was like, I have four euploid embryos frozen at first, I'm like, not necessarily. And then three failed to implant. So yes, if you've had three failed to implant, we know you have some endometriosis. You've had all kinds of stuff going on in your pelvis. Go ahead and do two months of suppression leading into your embryo transfer. It will make everyone sleep easier. As to chronic endometritis. I don't think that there's anything to say that this is specifically related, but endometritis is a strange bird as well.

26:39Dr. Susan Hudson: We often don't understand why some people have more trouble with things like this. What do you think about that, Carrie?

26:47Dr. Carrie Bedient: I think that having the hydrosalpynx removed is helpful because that certainly wasn't doing any favors. I think having the dermoid removed was helpful because that wasn't doing any favors. One thing that we do know about dermoids is when they spill, they are incredibly irritating to everything that's around them. While I doubt that there was an open communication between the dermoid and your uterine cavity in any way, mostly because if there was, you would have been a very unhappy camper, I think that it's certainly not going to hurt you. Now, I would, in this setting, go back and cross-check and make sure that the endometritis has resolved.

27:28Dr. Carrie Bedient: So would take the antibiotics, would heal from the surgery, and then go back in, do a quick hysteroscopy, and take a look around. I think that with everything you have going on with the endometriosis, the hydrosalpinks, the ton of adhesions, the dermoid that's now removed, I think it is well worth giving some legit healing time to make sure that as much inflammation is out of the way as possible so that when they go in and do, even if it's just a hysteroscopy without anesthesia, quick camera in, out, done, that everybody can feel a little bit more reassured that, yes, your uterus is behaving and that that's not a factor that's impacting your ability to use those beautiful embryos that you've got left.

28:10Dr. Susan Hudson: Our next question is, I had a tubal reversal in 2024, leaving my left tube at 6 centimeters and my right at 4 centimeters, conceived November of 24, ended in ectopic, and the loss of my right tube in 25. Long story short, Obie gave me letrozole for seven cycles to help us conceive, which failed. She did a saline bubble test and said she could see fluid and bubbles in my uterus, but not in my tube. Days later, she said there was no spillage in an email. I am scheduled for a weighted HSG in hopes that it can open the tube. There has been talk of a laparoscopy to possibly look and open the tube, but wouldn't this put me at higher risk of another ectopic?

28:50Dr. Susan Hudson: Are there other options besides IVF or is IVF my only option at this point?

28:55Dr. Carrie Bedient: Well, going to your last question first, are there any other options at this point? I've applied many times to be the grand poobah of the universe. Nobody's ever gotten back to me on that application. So, and as far as I know, most other REIs are in the same bucket, although I'm sure there are a couple who would say that they are in charge of the universe if you ask them. That said, no REI is ever going to say never because all of us have gotten our hands smacked by the universe before where we thought tubes were so beyond function and then somebody came in and had a totally normal pregnancy. That said, the odds are not particularly in your favor in this one.

29:34Dr. Carrie Bedient: For a safety perspective, for an efficiency perspective, for a let's just get this done in the way that we want, I would go towards IVF. And the reason for that is that you had intentional damage to the tubes with your tubal. You then had a secondary set of damage to your tubes with the reversal. And even though it was damage done in favor of restoring normal anatomy, it is still inherently a form of damage because you are still running, albeit itty-bitty, teeny, teeny, tiny sutures through it. There's still damage. There's still inflammation that occurs there. And a two of six centimeters at repair is not bad, but I think you have had plenty of opportunities to do this on your own in terms of the letrozole.

30:25Dr. Carrie Bedient: I think getting the other ectopic that took that right tube out for good is a warning shot. And I would hate to have you go through another one because sure, They can technically go in and do more surgery. I know many REs would not lean that way. Just because you can doesn't mean you should. And you already know that they didn't see spill when they went through again. Running dilator through that, trying to excise the obstructed part and put the other two remaining pieces of tube together, that's all going to be a lot of trauma. At this point, I would definitely lean towards you have dodged several bullets already.

31:05Dr. Carrie Bedient: I would not keep running into gunfire in the hopes that your luck will hold out. I would just cut my losses, know that I did everything I could and head towards IVF. What would you do, Susan?

31:16Dr. Susan Hudson: Completely agree. I have really nothing significant to add. Your safety is always our number one. You've already dodged a bullet because, quite frankly, we've talked about lots of ectopic pregnancies today. but people can die from ectopic pregnancies. They are one of the few life-threatening emergencies that we have in our specialty and that's why we look at them so so intently because they scare us and and they should scare you and the fact that you are healthy and you have made it through one ectopic pregnancy I think that IVF is a very good option. Is it the only option? No because we've all seen never happen and we never say never.

31:56Dr. Susan Hudson: If you want to know what's the best way for you to be successful and the safest way for you to be successful, I think IVF is where you need to go.

32:04Dr. Carrie Bedient: And an only vaguely related question, how do you say never say never without saying never? Ever, ever. Ever, ever. I feel like there's a song back from my youth so many years ago that goes through this. Anyway, all right, next question. I'm 35, have two embryos banked, want two kids, no more money for retrievals. In my initial consultation, I was told I had one fully blocked tube and the other may have small holes, but to be determined. I was hospitalized with PID 10 years ago after being cheated on. Rude, how dare he? And was unknowingly carrying an STD for months. My current doc isn't sure if we should remove the tube before FET because he says it's an older school of thought.

32:41Dr. Carrie Bedient: I prefer not to lose both my tubes and the chance I could maybe conceive naturally by a miracle. What's the consensus on taking out the tubes for FET success? Your work means so much to many of us. Thank you. Oh, you are so welcome. All right, Susan, 10 bucks says I know what you're going to say, but say it anyway.

32:56Dr. Susan Hudson: It sounds like you have cell phangitis ishmachonodosum, which is a condition.

33:02Dr. Carrie Bedient: Which is noted as sin. And just because I come from Sin City does not mean that we have it everywhere here. I just want to say that. Sorry. Continue.

33:11Dr. Susan Hudson: I would say it's probably higher in Sin City. Maybe higher STD rates, possibly. Maybe. Maybe. I actually haven't seen that borne out. I will inquire. You'll inquire. So that's essentially where you have little projections into the fallopian tube due to prior damage in the past. And it was possibly related to this PID you had 10 years ago. It does not sound like you have hydrosalpinx or swollen fallopian tubes. In that situation, I think it's optional. I don't think you have to have your tubes removed or ligated. And I don't think that there's any strong evidence that says that SIN has to be addressed before doing embryo transfer.

33:57Dr. Susan Hudson: It's something that makes us more nervous about you potentially developing hydrosalpinx in the future, but it's not here in the present.

34:05Dr. Carrie Bedient: This might be a case where I would consider doing a diagnostic laparoscopy to take a look at that tube and doing chromoperturbation and getting an idea when you challenge it with a little bit of extra fluid, what happens. because if we know that we've got two embryos and a desire for two kids, I think it's worth testing these tubes because if they're truly, truly blocked and no fluid goes through them, then you don't necessarily have to remove them because the tubal blockage is doing what the removal would do in that it's blocking the fluid you don't want to get into the uterus from getting into the uterus.

34:40Dr. Carrie Bedient: And that's one way to keep your tube and avoid losing it. And so that may feel better to you. And like I said, never say never. I think this might be worth a diagnostic laparoscopy where you go in, but know that there is a possibility that that may mean taking out your tubes, which is going to take out your chance of natural conception at all. This is not an easy one. This is not an easy one at all.

35:03Dr. Susan Hudson: Also new in a diagnostic laparoscopy, we don't get to see the inside of your fallopian tube at all. So all we're able to do is judge everything by the outside structure, not the inside structure. So if you're making your decision based on the inside structure, you already know what that looks like.

35:20Dr. Carrie Bedient: One way to cut your losses on this one is to do what Susan was talking about earlier, which is the prolonged antibiotic protocol going into the transfer. And it's usually about two weeks or so of doxy. And that might be a way to mitigate some damage from the tubes while also not actually taking them out. So that may be a happy medium where you can land and preserve your chances as much as possible.

35:43Dr. Susan Hudson: Hello, love your podcast. Thank you. Thank you so much for listening. After two years of trying to conceive and my irregular periods being dismissed for stress and quote normal for me, I found out that I have PC or now PMOS, but normal function of my androgen gland with no insulin resistance. I tried two cycles of Clomage, which were unsuccessful, and then found out via HSG that I had blocked tubes and a big hydro. They said I needed surgery, but did an ultrasound before proceeding. Ultrasound came back normal. I advocated for an MRI which showed no suspicious findings. Minimal prominence of the left fallopian tube.

36:21Dr. Susan Hudson: And also focal adenomyosis. My doc said I can proceed with IVF and don't need surgery. Is that still not technically a hydro? Should I be concerned? Age 29, AMH 8.4, 8 blasts and opted for PGTA.

36:35Dr. Carrie Bedient: Susan, I don't know if you see this at all. When we're doing HSGs or tool testing of any variety, when we're pushing the dye through, sometimes the tubes can act like, think about Saturday morning cartoons back when that was a thing. And the character would put their foot on a garden hose that was running and the garden hose would have this giant balloon of water that filled up. And then as soon as they took their foot off, the balloon would move down. And of course, it would come out and get the other guy in the face and so forth. But sometimes that's kind of what happens with an HSG, where you go in and you've got a narrowing of some sort.

37:18Dr. Carrie Bedient: Maybe it is a true blockage. Maybe it's just a narrowing. Whatever it is, it doesn't allow all that fluid to pass. What happens is that the fluid is going to take the path of least resistance. In many cases, that is swelling out to look like a hydro because the walls of the fallopian tube are not made out of concrete. They are stretchy. And so they can expand. It's part of the reason why ectopics are so dangerous is because they expand right up until the point where they don't. So it may not be a hydro in the true sense of the word of consistent fluid that is sitting there all the time. And it's true that imaging of hydros is not terribly reliable.

38:00Dr. Carrie Bedient: Using an ultrasound is the most reliable. MRIs, unless it is a huge hydro, same with CTs, it's really hard to see the tubes because they are just tiny little suckers. I don't know that I would live and die by the MRIs assessment. But I think your decision forward, like everything we talk about on this podcast, is what do you want? You've got eight blasts and PGTA. So I'm hoping that that means you've got eight euploid blasts. So hopefully that means you've got a decent number of opportunities to try. You may decide, all right, let's go ahead and try. In this situation, I think if you opted to go for the transfer with no hydrosine, and I don't think I would pitch a fit about that at all.

38:43Dr. Carrie Bedient: With focal adenomyosis, at that point, you may want to do Lupron or something like that to shut it down. But those are the things that I'm thinking about when I hear this question. What are you thinking about, Susan?

38:52Dr. Susan Hudson: I would probably take out that tube. If it's big enough that they called it a large hydrosalpinx, yes, we see that happen when we do laparoscopies. And I'm sure that same thing happens when we do HSGs. But the thing is, is how are you ever going to distinguish between that and in an HSG as a hydro and a not a hydro? You have to have a gigantic hydrosalpinx for you to see it on ultrasound. I've never seen anything listing an MRI as a reliable, I don't even trust MRIs when it comes to septums. So in pelvic anatomy, unless I'm looking at fibroids, I'm very skeptical about MRIs. So I would err more on the side of take out that tube, just take it out, move on, at least do a ligation on that side so the bad fluid isn't potentially moving back in and go from there.

39:41Dr. Carrie Bedient: Yeah, I think that's a reasonable approach as well. So a lot of the questions that we answer and talk about on the podcast in particular, they're fantastic for us to think about because they're interesting and they're nuanced and how that patient sees their life and their fertility and their future influences everything we do. With all of these, we love thinking about these questions because it's, okay, how would I do it? How would you do it? But for our patients and listeners, know that oftentimes there is no one way to do things because if there was, you probably wouldn't be writing in the question about it.

40:17Dr. Susan Hudson: Yeah, and it's definitely, the art to medicine. And there are many ways for us to get to our end result. We're just trying to give some perspective on how we think about it. You got it. All right. Well, thank you so much for spending your day with us.

40:33Dr. Carrie Bedient: If you enjoyed this episode, subscribe, leave a review, and send us your questions at fertilitydocsuncensored.com.

40:40Dr. Susan Hudson: And if you want even more fertility information, pick up a copy of the IVF Blueprint, our practical guide to understanding fertility treatment, IVF, and the decisions you'll face along the way.

40:50Dr. Carrie Bedient: Before we go, remember, this podcast is for education and entertainment only.

40:55Dr. Susan Hudson: While we are fertility doctors, we are not your doctors.

40:58Dr. Carrie Bedient: Nothing we discuss should replace medical advice from your own doc who knows your individual history and your circumstances.

41:05Dr. Susan Hudson: Thank you so much for listening. Bye.

41:10Dr. Susan Hudson: This podcast is sponsored by Receptiva DX. When fertility questions remain unanswered, Receptiva DX helps reveal why. Trusted by fertility specialists for over a decade, Receptiva DX identifies inflammatory changes in the uterine lining associated with endometriosis and other conditions that may interfere with implantation and pregnancy. From unexplained infertility, recurrent pregnancy loss, or simply undiagnosed pain, Receptiva DX helps women and their physicians make more informed treatment decisions and move forward with confidence.