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Frequently Asked Questions

About Hysterosalpingogram (HSG)
What exactly is a hysterosalpingogram? What steps are involved? Does it involve any pain? Karen

Hysterosalpingogram (HSG) is an X-ray study of the uterus that uses a special dye visible on X-rays. A series of X-ray images taken as the dye flows into the uterus and through the fallopian tubes helps doctors evaluate the size and shape of the uterine cavity and determine whether the fallopian tubes are open, and sometimes even if there are adhesions near the tubes.

HSG is best scheduled two to three days after the last day of menstrual flow. It is important to ensure that you are not pregnant at the time this study is performed, so if there is any doubt about whether you are pregnant, or if the flow is light, a pregnancy test should be performed beforehand. Many physicians will recommend a dose of antibiotics to reduce the risk of infection and a non-steroidal anti-inflammatory agent such as ibuprofen (Advil) or naproxen (Aleve) to minimize cramping.

The doctor begins by inserting a speculum into the vagina. The cervix is wiped with an antiseptic, and a catheter (narrow tube) is inserted into the uterine cavity. There may be a mild cramp with this portion of the procedure. The speculum will be removed, and you will be repositioned on the X-ray table. Your physician or the radiologist will place tension on the uterus to straighten the bend and give a better picture of the uterine cavity. Next, the dye is injected into the uterus through the catheter. This is often associated with cramping. If you are relaxed and in the hands of a gentle physician, the cramping is usually mild. However, if the dye does not flow through the fallopian tubes, additional pressure may be necessary to see if the tubes are really blocked. This can cause more intense discomfort.

After the X-ray, you will be asked to remain lying down for another 5 - 10 minutes to allow the cramping to subside. Arrangements should be made with your physicians so that you know when you will be asked to return to discuss the results and determine the next step in your treatment plan. If you experience increasing pain, fever or heavy bleeding after the procedure, you should contact your physician.

Age & Fertility Loss
Can you explain why it is harder for a woman to get pregnant as she gets older? Is an older egg simply harder to fertilize, but would develop normally if fertilized? Or are the eggs not harder to fertilize, but more likely to develop abnormally and so fail to implant? In other words, is the mechanism that explains higher birth defects with age the same as that which explains lower fertility? Mary

This is an interesting question and addresses an area where much research is being carried out. The adverse effect of age does not appear to be mediated by a decrease in "fertilizability," but rather seems related to abnormal chromosomes in the egg.

Let's go back to review how the egg forms. All human cells other than sperm and egg normally have 46 chromosomes. The egg and sperm each contribute 23 chromosomes to the developing fetus. This means that as the egg and sperm are formed, the number of chromosomes needs to reduced to 23. This process of chromosome reduction is called meiosis.

In men, the process is ongoing, and new sperm are continually being produced. In the woman, the situation is a bit different. Before her birth, while she is still an embryo, the number of her eggs increases up to about 4-7 million. After about 20 weeks of gestation, her fetal body stops producing new eggs. These eggs must also undergo the process of meiosis to reduce from 46 to 23 chromosomes. But at 20 weeks, the eggs are surrounded by an envelope of cumulus cells; this arrests the meiotic process and keeps the eggs healthy until they're needed for ovulation. An egg resumes its growth about three months before ovulation. In fact, meiosis is not actually completed until after ovulation and fertilization has occurred.

We know that older women ovulate eggs that are more likely to contain chromosomal abnormalities, such as extra or missing chromosomes. What we don't know is when this anomaly occurs. Does it occur while the eggs are dormant, in a state of suspended animation awaiting their chance to grow and ovulate? Or does it occur after hormonal signals involved in ovulation stimulate the egg to resume meiosis?

Researchers have hypothesized that perhaps the cumulus cells surrounding the egg lose their ability over time to maintain healthy eggs. Some believe that chemical abnormalities within the cell are responsible for errors in chromosomal reduction (meiosis), and that transfer of cellular material from a younger woman may resuscitate the egg. While initial studies have shown that this cytoplasmic transfer can be carried out and the egg can be fertilized and develop normally, the question of whether this corrects age-related defects has not been answered. Hopefully we will have answers in the next two or three years.

Age & IVF Success
I'm a 39-year-old woman with 4 children. My husband and I are thinking about having another baby and -- because I had my tubes tied -- we're considering in vitro fertilization (IVF). Since our insurance won't cover the procedure, we can probably only afford one round of treatment. What are the odds that one IVF will prove successful for a woman of my age? Amy

When it comes to the likelihood of successful tubal reversal and in vitro fertilization, the odds are against women your age and older. Fertility drops after age 35 (especially after 38), and delivery rates per IVF cycle started are only about 15% as the 40th birthday nears. This rate is similar to the live birth rate following tubal reversal for a woman of your age.

Before undergoing any treatment for infertility, you should consider a couple of tests to measure your fertility potential. One is called a clomiphene challenge test; the other is a day 3 FSH blood level test. If these test results come back abnormal, the likelihood of successful fertility treatment with your own eggs is even less than noted above. At our center, more than just age determines "success" with IVF, and each couple should undergo a thorough assessment to offer a complete understanding of prognosis and likely outcome.

Age & Risk of Birth Defects
I will be 35 in June. I am overweight but active, and I have regular cycles. My husband is 36, and we have two healthy sons, age four and seven. We would love to have another child soon. What are the odds of our having a child with birth defects because of my age? Does it make any difference that I did not start my periods until I was 16.5 years old? Do two previous healthy uneventful pregnancies lower the chances of birth defects or chromosomal problems? I have searched the web endlessly and have not found answers to these specific questions. Justine

One chief concern of pregnancy after age 35 is increased risk of chromosomal abnormalities. Age-related chromosomal abnormalities such as Downs Syndrome occur in only about 1 in 200 pregnancies (about one-half of a percent) for women aged 35, so this is not a great concern for you at this time. However, for women age 40 at the time of pregnancy, the risk rises to about 1-2 percent.

Age-related chromosomal problems typically originate at the time of meiosis, when the egg cell eliminates half of its 46 chromosomes to accommodate the male's genetic contribution. The chromosomes are separated by tiny filaments called spindles, which appear to become brittle and break or to become detached from the chromosomes as women age. This breakage or detachment can result in an abnormal number of chromosomes in the egg, a condition called aneuploidy. This occurs in about 33 percent of eggs at age 35 and 50 percent of eggs at age 40. Luckily, few of these irregular eggs will fertilize or develop into detectable pregnancies. As such, the risk of a genetically abnormal pregnancy is much lower than the risk of an abnormal egg.

As you age, your risk also rises for nonchromosomal birth defects and pregnancy complications such as gestational diabetes, pre-eclampsia and intrauterine growth retardation. At age 35, however, your age plays little role in any of these complications. The age at which you began menstruating (menarche) does not seem to influence this risk, nor does your prior history of a normal pregnancy.

I'm sure you are well aware that there is a significant decrease in fertility as a woman ages, and that now we have testing available to evaluate your fertility potential.

Abnormal Sperm Morphology
My husband went for a semen analysis and the result showed that the morphology was 90 percent abnormal. Is this something you are born with, or does it have to do with a healthy diet or cigarette smoking? Ashley

Morphology refers to the shape and structure of the sperm. A normal-looking sperm has an oval head and a tail seven to 15 times longer than the head. On a semen analysis, in which we look at sperm under the microscope, we can identify defective sperm by their large heads or strange tails -- kinked, doubled, or coiled.

The World Health Organization (W.H.O.) says good quality semen should contain 60 percent normal sperm morphology. A closer evaluation called a strict morphology, or Kruger morphology, is more time-consuming and usually predicts normal sperm function when more than 15 percent are normal. That means that a semen sample can include up to 40 percent abnormal sperm and still be considered fine.

All men produce many abnormal sperm. The reason is not known, but considering the rate at which a man's production line operates -- 10 million to 50 million new sperm per day -- some "factory seconds" should be expected. We do know that toxins such as lead have been linked to reduced motility (swimming ability), cigarette smoke to abnormal morphology, organic solvents to coiled tails, and excessive scrotal heat to coiled tails in animal sperm. When you lower your exposure to these agents, abnormal morphology levels usually decrease. I remember one man with a high level of abnormal sperm who transferred to a different job at his company so he could avoid exposure to heat from a blast furnace. He also began taking 1,000mg of vitamin C each day. Within a few months his sperm motility and morphology showed definite improvement.

Allen-Masters Windows, Pouches, Endometriosis & Fertility
I recently had endometriosis surgery. They gave me a video to watch of the pertinent parts of the procedure. The doctor stated I have a Masters Window. What does that mean? How it will affect my trying to get pregnant? Harriet

During your menstrual period, endometrial cells may travel from your uterus into your abdomen. Endometrial cells are present in the abdominal fluid in most women at the time of their period. In women with endometriosis, for some as-yet-unknown reason, the body is just not as effective at clearing these cells from the abdominal cavity, and these cells are more likely to attach and grow.

Allen-Masters windows are pockets or infoldings in the peritoneum, a thin membrane that lines the inside of your abdominal cavity. These pockets tend to trap endometrial cells expelled into the peritoneal cavity during your period. At laparoscopy, a biopsy of the tissue at the base of the Allen-Masters windows frequently shows endometriosis. Many physicians recommend that the peritoneal lining be completely stripped from the Allen-Masters pocket at the time of surgery.

The presence of these pockets should in no way effect your fertility. The more important question you did not ask is whether mild or minimal endometriosis lesions on the peritoneal surface are a cause for infertility. The data are confusing at best. While there is certainly a greater risk of finding endometriosis at the time of a laparoscopy for infertility evaluation, this does not necessarily mean that the endometriosis causes infertility. Endometriosis can be the result of a failure to achieve a pregnancy, or it may be due to a genetic or immune factor that is also causing the fertility problems.

The evidence to date, in all but one study, strongly indicates that treating endometriosis does not improve fertility. Unless significant structural abnormalities such as tubal damage, adhesions or ovarian endometriomas are present, most studies suggest that the best approach to fertility is to ignore the endometriosis and to choose the same treatments as would be used for unexplained infertility. Remember that the only way to diagnose endometriosis for sure is by a biopsy (requiring surgery).

Allergic to Dye for HSG
My doctor wanted me to have a hysterosalpingogram, but when I arrived at the radiologist, I found I could not have the test done because I am allergic to iodine. Is there any other test that can be done to serve this purpose? He is starting me on Clomid. Iris

Iodine allergies are a confusing issue. The first consideration must be the type of allergic reaction experienced in the past. With more severe reactions, I would definitely avoid using an iodine-based dye. The next consideration is based on the type of dye. There are ionic and non-ionic iodine dyes. Allergic reactions are almost unheard of with use of a non-ionic dye. For my patients with mild reactions in the past, I will premedicate with a steroid and Benadryl (an antihistamine) and use a non-ionic dye. I have not yet seen any patients have problems using this approach. Still, this does not remove all risk, and you should discuss the alternatives with your own physician.

Another test to consider might be saline sonography using a special material called Albuminex, which will allow the tubes to be visualized easier. The standard saline sonogram does not generally allow the tubes to be seen at all. Yet an another alternative test is laparoscopy. This outpatient surgical procedure involves placing a miniature viewing device and surgical instruments through tiny incisions in the abdominal wall while you are under anesthesia. A colored dye that does not contain iodine is injected through the cervix; the doctor then watches to see it spill out the ends of the fallopian tubes.

A recently developed office-based procedure, vaginal hydrolaparoscopy (VHL), is undergoing clinical studies. VHL enables your physician to evaluate your fallopian tubes by placing a needle-thin telescope through the top of the vagina into the abdomen after injecting local anesthesia. The space behind the uterus is filled with fluid, and the fallopian tubes and ovary float into view. The state of the tubes can be determined by injecting a colored dye (that doesn't contain iodine) through a tube placed into the cervix. The dye is seen exiting the end of the fallopian tube. The doctor can also look for adhesions or endometriosis.

In any case, your physician should first consider whether it is likely that tubal damage or blockage is present. Review of your medical history for pelvic infections, previous pelvic surgery, painful intercourse or painful periods may indicate an increased risk of fallopian tube problems. A blood test for chlamydial antibody may show that you have had a previous chlamydia infection that may have damaged the tubes. If nothing in the laboratory results and review of your medical history suggests the presence of tubal blockage, the likelihood of damage is less than 5 percent, and further testing can be deferred.

Alternatives to Vasectomy Reversal
After my wife and I had the children we wanted, I got a vasectomy. Some years later we divorced. Now my new partner wants us to have children of our own, and I am currently configured otherwise! I've read up on vasectomy reversal, and I am not squeamish about the surgery, but the success rate after 10 years isn't that hot. Plus there are such factors as cost and discomfort. So I'm wondering: Is the amount of sperm retrieved by extraction sufficient for artificial insemination? Or is something more invasive recommended, like IVF? The lady has no fertility problems. Tom

Sperm extraction -- regardless of whether the sperm are obtained from testicular biopsy or aspiration or aspiration from the epididymis -- does not provide sufficient numbers of motile sperm to use for insemination. Other than vasectomy reversal, your choices after vasectomy are insemination with donor sperm; retrieval of sperm and eggs for IVF; sperm-egg injection at the time of IVF (a procedure called ICSI); or adoption.

Are Blocked & Damaged Tubes Fixable?
I am 40 years old and have been trying to have a baby for six years. I had a laparoscopy about a year ago that showed I have a few things wrong: a blocked tube, endometriosis and a cyst. Plus the fingerlike things that are supposed to help guide the eggs in the right direction are bent the opposite way. My doctor said she didn't want to try and fix them, because it was too delicate an operation and might make things worse. Do I still stand a chance? Can they be fixed? Betty

Before we could offer any guidance in a case like this, we would need more information. There are many other factors that we would need to consider before proceeding with tubal repair.

To begin with, at age 40, monthly odds of conception are significantly lower than 10 percent for most women -- and that's with all things being optimal; as you described them, they are not. In some women, age has already adversely affected their eggs to the point where egg donation would be required. To determine age-related infertility, we would need to conduct a clomiphene challenge test or a test of day 3 FSH, estradiol and inhibin B. It would also be important to consider the fertility of the woman's partner. You did not mention whether your partner had a semen analysis. He should have this test before you have surgery. Unfortunately, too many physicians will take their patients to surgery before checking the male. If this happened in your case, that should send up a red flag that you are getting infertility care by a less-experienced physician.

You also mention endometriosis. Some research has suggested that the presence of minimal endometriosis will lower your monthly odds of conception by about 30 percent.

Overall surgical success to repair tubes with damaged ends is about 10-50 percent. However, without a video or photo of the ends of your tubes, we would have no idea how best to advise you. Your physician, who did see your tubes, obviously wanted any surgical repair to be performed by a more experienced surgeon. It is unfortunate that too many women enter the operating room expecting to get competent infertility care only to find that they need a second surgery because the first surgeon did not have the skills to deal with the abnormalities he or she found.

Autoimmune Disorders & Fertility
I have an autoimmune disorder that, over the last 10 years, has caused problems with my thyroid, liver, heart, blood platelets, etc. I have recently started worrying about how this would affect my ability to get pregnant and carry a child full-term. Do you have any thoughts on this? K.

Autoimmune diseases result from inappropriate production of antibodies that attack normal organs and tissue such as the thyroid, parathyroid, pancreas, ovary, joints, platelets and the placenta. They can also attack blood vessels and cause inflammation of veins and arteries, which can lead to inappropriate blood clotting (thrombosis). Lupus, idiopathic thrombocytopenia, and Graves' disease (a form of thyroid disorder) are just a few of the more common autoimmune conditions. No one is certain why these conditions develop, nor is there an obvious cure. Newer antiinflammatory agents can help suppress the immune system's attack and the resulting symptoms. If a hormone-producing organ is damaged, replacement hormones may be necessary; this is the case with diabetes (treated with supplements of insulin) or hypothyroidism (treated with thyroid hormone).

Antiphospholipid syndrome is often diagnosed in women with abnormal antibodies to blood-vessel wall components such as cardiolipin, serine and ethanolamine who experience an episode of abnormal clotting. This can involve thrombophlebitis (clotted vein) in an extremity, mid-trimester placental infarction (loss of circulation to the placenta and fetal death), or pulmonary embolus (a blood clot in one of the pulmonary vessels).

The role these antibodies play in early recurrent pregnancy loss or infertility is unclear and the data are often conflicting. Still, many physicians will check the immune system for the antiphospholipid antibodies listed in the previous paragraph. They may also test for lupus anticoagulant (if this is present, you are actually at increased risk of abnormal clotting). If any of these are present, physicians may choose to treat with a combination of low-dose baby aspirin and twice-daily heparin injections to prevent abnormal clotting. This therapy is not without risks, and you need to have a detailed discussion with your physician of your own situation, the likely benefit and associated risks.

ANA is often measured to rule out lupus, but the data do not support the use of this test or its many subtests (ssDNA, dsDNA, histones) as having any value in the diagnosis or treatment of infertility. The presence of thyroid antibodies does not directly result in infertility or pregnancy loss. However, if these antibodies have damaged the thyroid and a low thyroid hormone level is present, your fertility may be hampered. In addition, women with a propensity to make one inappropriate antibody, may in fact make others.

While the presence of inappropriate antibodies may not directly affect your chances of pregnancy or result in miscarriage, it is best to make sure "all systems are go" and that you are in the best health possible before attempting pregnancy.

Both Tubes are Blocked
Last month I went for an HSG and discovered that both tubes are blocked. My OB/GYN is suggesting I go for IVF. He said he would not advise me to have tubal surgery because of the high rate of ectopic pregnancy. My husband and I do not want IVF. Does this mean these tubes cannot be blown open? Is IVF the only chance I have to get pregnant? Eses

The hysterosalpingogram (HSG) is a test to see if the fallopian tubes are open. They can be blocked at the uterus, at the midportion or at the fine, flowerlike fimbriated ends.

In some cases, the HSG test itself may enhance fertility by opening tubes that may be clogged by debris or mucus. Still, whenever patients suggest "blowing the tubes open," we picture physicians standing in a bunker and pushing a TNT plunger hoping an explosion will correct the problem. The fallopian tubes cannot really be "blown open." They are delicate structures that must function normally in all regards. They are more than a conduit to allow the sperm and egg to meet; they provide the chemicals and nutrients necessary to nourish the fertilized egg during its first few days of life. If the blockage occurs where the fallopian tube joins the uterus, a procedure called fallopian tube recanalization can often clear that blockage. However, when the blockage is at the end of the fallopian tubes, surgery can often create a new opening, but this does little to restore normal function. The result is quite often an ectopic pregnancy or a recurrence of the tubal blockage. Success rates following tubal surgery to correct a blocked and dilated fallopian tube are often less than 10 percent, with a 15-25 percent risk of an ectopic pregnancy. In this situation, IVF is certainly the safest option (because ectopic risk is much lower) and the most cost-effective (because success rates are higher).

Unfortunately, many insurance companies do not yet understand the benefits of IVF. Nor do they recognize that success rates have improved, making IVF a cost savings when compared with repeated surgical attempts to restore fertility. The shortsightedness of the insurance industry has lead many women to undergo repeated surgical procedures that offer little hope of success. While we cannot address your last question regarding what choices you have without a more thorough evaluation, if your only fertility factor is blocked fallopian tubes, IVF would certainly appear to offer the greatest chance for success.

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