Sometimes, people who came for IVF, are asking whether the Fallopian tubes need to be removed before IVF.

Normally, what happens inside our body?
The sperms, deposited in the vagina during sexual intercourse, are travelling through the uterus into the Fallopian tubes (attached on the either side of the uterus), where the eggs released from the ovaries ("Ovulation") are also entering. Thus, inside the tube, the egg and the sperm meets ("fertilization") to produce the embryo, which then comes down inside the uterus. The embryo then attaches to the uterus and gives rise to pregnancy.

We need to understand how IVF is done.
By giving some medicines (injections) in the body, the eggs in the ovaries are grown and then they are collected with a fine needle from the ovaries. The sperms are collected from the male partner. In the laboratory, the eggs and sperms are fertilized to produce the embryo. The embryo is then transferred back inside the uterus, where it can give rise to pregnancy. Thus, basically what happens inside the fallopian tubes are done in the laboratory. Therefore, we are bypassing the function of the fallopian tubes during IVF.

So, IVF can be done whether the fallopian tubes remain open (Sperm problems, low egg counts, endometriosis, unexplained infertility, ejaculation problems, azoospermia) or blocked (in HSG, SSG and/or Laparoscopy). So, there is NO NEED OF REMOVAL OF THE TUBES BEFORE IVF.

However, there is one exception.
That is hydrosalpinx, where there is swelling of the fallopian tubes (one or both the tubes) because of accumulation of fluid. That fluid can come down from the tubes into the iterus and can damage the embryo transferred after IVF. In that case, the diseased fallopian tube is doing more harm than good. Therefore, the diseased tube MUST be removed before IVF. So, in most cases, IVF can be done keeping the Fallopian tubes inside the body.

What are the causes of Ejaculation problems?
The problem may be due to some previous surgery (in the prostate gland, hernia, in the abdomen for cancer), diabetes neurological problems, spinal cord injury, diseases of prostate, some obstruction in the sperm conducting ducts etc

What is the next step?
Please do not hesitate to inform your doctor. He/ she will ask some questions and examine you to find out the cause. Some blood tests (like sugar) may be advised. Urine test is commonly advised. In few men, the problem may be retrograde ejaculation (Semen going into bladder instead of moving forward). In that case, sperms can be found in the urine immediately after masturbation. Scrotal ultrasound examines the details of your scrotum (testes and the organs surrounding them). TRUS (Transrectal ultrasound) is advised to see the problems in the prostate gland and around, here the ultrasound probe is inserted inside the anus.

What are the treatment options?
In very few cases, some medicines can help to improve ejaculation. These can help, particularly in retrograde ejaculation. However, in most cases, medicines are not helpful. Nevertheless, pregnancy is possible and you can become the biological father of your kids.

Vibro-ejaculator can sometimes be helpful. It is a small device applied on the front part of the penis ("Glans Penis") to discharge the semen. You can collect the semen in this way and use it at home.

How sperms can be collected?
Non-toxic condom- If you have nocturnal emission (“Night fall”) you can use this condom over penis while sleeping and collect the semen and carry it to the laboratory. The sperms can be frozen for furture use by IUI/ ICSI.
Vibro-ejaculator- can help to collect the sperms, which can be frozen for future IUI/ ICSI.
Testing urine- The sperms can be retrieved from urine and can be used for IUI/ ICSI. However, you need special preparation to reduce the normal acidity of the urine.
Prostatic message- If urine test shows no sperms, inserting lubricated gloved fingers inside your anus to message your prostate gland can sometimes help.
Electroejaculation- If prostatic message fails, your prostate gland can be stimulated using a small probe inserted through the anus under general anaesthesia. However, it is not widely available.
Testicular biopsy- If all of the above method fails, sperms can be collected from the epididymis (small gland above the testis) by small needle (PESA- Percutaneous Epididymal Sperm Aspiration) or and or sometimes, by a small cut (MESE Microsurgical Epididymal Sperm Extraction). All these are done under anaesthesia. If these fail, TESA (Testicular Sperm Aspiration- a small needle is inserted inside the testes) or TESE (Testicular Sperm Extraction- a small cut is made) can be done. Sperms collected by this way, can only be used for ICSI.
In all cases, sperms can be frozen for future use.
What should be the option- IUI or ICSI?
If your wife's results are satisfactory (At least one Fallopian Tube is open, adequate number of eggs in the ovaries), IUI (Intrauterine Insemination) can be a suitable option. In IUI, your sperms can be used, if your sperm count is satisfactory.

In IUI, the sperms are inserted through a small tube, inside the uterus. IUI is cheaper, but the success rate is 10-15% per cycle (out of 100 couples doing IUI, 10-15 can conceive in one month).

However, ICSI is to be done if your sperm count is very low and sperms are collected by TESA/ TESE/ MESA/ PESA. ICSI (Intracytoplasmic Sperm Injection) should also be considered if your wife's reports are not satisfactory (both the Fallopian Tubes blocked, ovaries have less number of eggs) and you have done 4-6 cycles of IUI.

ICSI is a special type of IVF (In Vitro Fertilization). In standard IVF, your wife will be given some injections to mature her eggs, which will be collected through the vagina. These eggs are then mixed with the sperms in the laboratory to produce the embryos.

In ICSI, the sperms collected from your body are directly injected, under the microscope, inside the eggs. The success rate of ICSI is 40% per cycle but it's expensive.

When Donor sperms should be used?
If a couple cannot afford ICSI but IUI using husband's sperm is not possible, Donor-Sperm-IUI is the option, if the wife's reports are satisfactory. Again if TESE sample fails to retrieve adequate amount of good quality sperms, IUI/ICSI should be done with donor sperms.

In some cases, we find one Fallopian tube is Open in HSG and another tube is blocked in HSG. What to do in that case?
Please remember, one Fallopian tube can be sufficient for pregnancy. So, you DO NOT need any Laparoscopy or IVF if all other factors are normal.

If one tube is blocked and other is open, do I need Laparoscopy?
In this case, laparoscopy is needed ONLY in the following circumstances-

1) If any tube is swollen (Hydrosalpinx), because the fluid inside the Hydrosalpinx can damage the embryo. In that case, even if you need IVF, the hydrosalpinx MUST be removed by laparoscopy.

2) If you need laparoscopy for other reasons like Severe pain during periods, Ovarian Cyst, Endometriosis, Fibroid. In these cases, laparoscopy is needed to remove these diseases and improve your chance of pregnancy.

If only oneFallopian tube is open and other is closed, can I try naturally?
Of course, you can try. Even you can have Ovulation Induction (OI), by which medicine is given to improve your chance of pregnancy. However, for how long you will continue this type of treatment, depends on your age, duration of trying for pregnancy, condition of your husband's sperms and your ovaries. If any of these are not satisfactory, you should not rely on trying "naturally" for long periods.

If one tube is blocked and another tube is open, can I try IUI?
In most of cases, if your ovaries and your husband's sperms are good and your age is relatively young, you can try IUI. In most cases, the results of IUI is good. However, in some specific tube block, IUI result is not satisfactory.

Do I need IVF if one Fallopian tube is open?
You need IVF only if your husband's sperm condition is not good, your ovaries are not functioning well, you have been trying for pregnancy for long time or your age is on the higher side. If IUI fails, in that case, also you need to think about IVF.

Conclusion
In majority of the cases of one Fallopian tube block (and other tube remaining open), you don't need to worry. There is no need for laparoscopy or IVF if all other factors remain satisfactory.

How can one know that the Fallopian tubes are blocked?
Unfortunately, most women do not have signs or symptoms suggesting tubal block. However, if you had previous infections in pelvis, tuberculosis in any part of the body, previous ectopic pregnancy, appendicectomy or gynaecological surgery, or feel severe pain during periods or during intercourse, there is a chance of tubal blockage.

How the tubes are tested?
Whether tubes are open (“patent”) or not, is usually checked by a special X-ray, called Hystero-salpingogram (HSG), in which a contrast material will be given through the neck of the uterus (cervix). It is cheaper and easily available. However, some women can feel discomfort during HSG. Usually some pain-relief medications are given during the procedure.

Another method is Saline Infusion Sonography (SIS) or SSG, in which water is inserted inside the uterus with the ultrasound probe put inside the vagina (TVS). It is more accurate than HSG and causes less discomfort. Both HSG and SIS are done in out-door basis, without any need of anaesthesia.

When Laparoscopy is advised?
If HSG or SIS show both the tubes are blocked, then the only way to confirm the blockage is by laparoscopy. This is, because, sometimes, the spasm of the muscles of the tube during HSG or SIS can lead to “false positive” result; that means if tubes are found to be blocked by those tests, the tubes may actually be found open actually during laparoscopy.

Laparoscopy is also advised to check the tubal patency, if there are other reasons (like removal of cyst or severe pain) or when HSG or SIS could not be done for technical difficulties.

Laparoscopy is done under general anaesthesia with two or three small opening (key-hole surgery) in the abdomen and a coloured material (“dye”) is introduced through the uterus.

Why Sperm analysis is done?

Sperm analysis is an essential part of evaluation of an infertile couple. In most cases, this is the only test, a male partner requires. However, a single abnormal semen analysis does not always mean that there is any abnormality in the man.

In a man, sperm production requires 3 months and it needs cool temperature than rest of the body. This is why, men have their testes hanging outside the body in the scrotum. Thus, today's semen analysis reflects a man's health 3 months before. If, for any reason (for example, high fever, tight underwear, hot tub bath etc), the man's health was abnormal 3 months ago, the semen analysis may become abnormal. Again, the results can vary from one laboratory to another.

Is there any difference between semen and the sperms?

Semen consists of 2 parts- the sperms and the fluid ("seminal plasma"). The sperms cannot be seen by the naked eye. The fluid that you can see, is the semen. So, semen and the sperms are not the semen.

How semen is tested?
In the laboratory semen is tested for certain parameters like- volume (amount of semen), liquefaction (time needed for semen to become liquid), colour, appearance etc. The sperms are checked for total count, motility (ability of the sperms to move), morphology (the appearance of the sperms), vitality (whether sperms are living or not) etc. It is important for the laboratory to follow WHO 2010 criteria for semen analysis (not the older criteria like 1992). Sometimes, some special tests may be done on the semen depending on your scenario.

How semen collection and analysis is done?
The easiest and the most commonly used method is masturbation. You should collect it in the laboratory in a room with adequate privacy and comfort. Of course, for most of the men, it seems awkward to collect semen in unfamiliar environment, away from home. Usually most laboratories provide a separate room where you can bring your partner with you.

Is any preparation required?
Please maintain abstinence for 3 to 5 days (not more than 5, not less than 3). That means you should avoid intercourse and masturbation for 3-5 days prior to the test. This is because, both long term (more than a week) and short (less than 2 days) period of abstinence can lead to false results regarding quality and quantity of the sperms. Get relaxed. Wash your hands properly before the collection. It's important to collect all the semen in the collection pot and not to spill a portion outside.Do not hesitate to tell your doctor if you feel any problem.

In the next video, we will discuss what to do if you feel problem during semen collection in the laboratory.