Tubal Problems

The fallopian tubes are the pathway to fertility. Sperm travel upward through the fallopian tubes to find an egg. After fertilization, the embryo travels back through the tube to the uterus. The fallopian tubes are a two-way path that allows the sperm and egg to meet and combine and the embryo to arrive in its resting place, the uterus.

The tube has three sections, the cornu, the isthmus, and the ampulla and fimbria. The cornu, which is the connection to the uterus, is a narrow valve that opens and closes in response to uterine contractions. It measures about half an inch in length, and is lined by glands that make fluids.

The isthmus, the narrowest connecting part of the tube is an intricate and tiny tube lined with cilia, the tiny hair-like projections off of cells that move in waves to pull sperm and embryos along the tube. The walls of the isthmus are thrown up into multiple complex folds. The isthmus is hardly a simple conduit, but rather a complex and active moving pathway.

The ampulla, the funnel-shaped end of the tube, is connected to the fimbria, feathery fingers that reach out to the ovary and pick up the newly released egg. These three portions of the tube work together to carry sperm out to the end of the tube, pick up the egg, and provide a site for fertilization. They then carry the fertilized embryo to its resting spot in the uterus.

The pathway to the egg is an arduous one; only a small proportion of the ejaculated sperm find the egg. At ejaculation, sperm are deposited in the vagina and then swim through the cervix and uterus and into the fallopian tubes. Some reports indicate that sperm can be found in the fallopian tubes within five minutes of ejaculation 51; they are quite speedy. The sperm travel with the motion of their own tails and with assistance from muscular contractions in the uterus and tubes, and with the motion of cilia, tiny hair-like cells that line the inside of the tube. The sperm travel to the end of the tube, where they meet and fertilize the egg. The fertilized egg, or embryo, then moves back down through the tube to the uterus, taking several days to make the journey.

With such a delicate and sophisticated pathway, it is common for problems to develop in the tubal system. Here are a few of these:

Cornual Occlusion: The connection between the uterus and fallopian tube is a fragile area that can become blocked. This is referred to as cornual occlusion or proximal tubal occlusion. Most blockages are actually contractions of the uterine muscle and are not true blockages. The diagnostic test to detect this can irritate the uterus and cause the uterine musculature to contract. This is a temporary condition that has no effect on fertility. Other blockages reflect true problems in this portion of the tube, which can result from infection or inflammation, fibroids or polyps, or use of an IUD. A common example is a condition known as Salpingitis Isthmica Nodosum (SIN), in which the tube becomes inflamed and nodules develop in the glands that line this portion of the tube.

Isthmic Occlusion: This condition occurs only rarely naturally. The isthmus is the smallest and narrowest portion of the tube, but has a thick muscular wall that is not easily damaged. Tuberculosis and other infections and tubal polyps are possible, but rare causes of isthmic occlusion. Most cases are intentional 51; this is the location where a tubal ligation is performed for sterilization.
Hydrosalpinx and Fimbrial Phimosis: The hydrosalpinx refers to a tube that is filled with water ("hydro" = water, "salpinx" = tube). With infection by bacteria, such as gonorrhea or chlamydia, the end of the tube can become inflamed. If the end of the tube becomes blocked, fluids can no longer drain from the tube, and build up under considerable pressure. These fluid filled tubes can become quite large, requiring surgical removal. A hydrosalpinx is unable to pick up eggs, resulting in infertility, and is subject to infection. Milder degrees of injury to the tube can result in loss of or damage to the feathery appendages of the tube, the fimbria. This is known as fimbrial phimosis. This can vary from quite subtle degrees of blockage to nearly complete obstruction of the tubes.

The tubes are quite delicate in their structure and function, and any of this delicate structure can be injured. The ciliary cells that help sperm and embryos move through the tubes can be lost. Studies often show patches of missing cells, probably victims of injury from bacterial infections. This can happen throughout the tubes. The folds that occur in several segments of the tubes can also be injured, resulting in blind cul-de-sacs through which sperm and embryos cannot pass.
Diagnosing these problems usually requires a medical study. The exact tests are determined in association with a fertility specialist, a physician who is board certified in reproductive endocrinology and infertility.

Examples of tests used for diagnosing tubal problems are:
Ultrasound: Most patients will start with an ultrasound, in which uterine and ovarian relationships can be studied. A normal fallopian tube is almost always invisible on ultrasound. A hydrosalpinx may appear as a large fluid filled cyst between the ovary and uterus.

Hysterosalpingogram (HSG): The HSG is a dye study of the uterus. At pelvic exam, a catheter is placed in the cervix and dye flushed into the uterus and tubes with gentle pressure. An X-Ray picture is taken of the uterus and tubes. It may reveal cornual occlusion, or a hydrosalpinx, the most common abnormalities, or more subtle problems like tubal polyps and fimbrial phimosis. Commonly one of the tubes fills and spills dye more easily than the other, a phenomenon known as preferential spill. The HSG can cause cramping, which is usually mild, but can be quite strong in women with a sensitive uterus. Ibuprofen taken 2 hours before the procedure can help reduce the cramps. The procedure carries a small risk of infection, but this is usually only seen when tubal injury is present.
Treating these problems is highly individualized and depends on the patient's age, medical problems, and patient wishes. The available procedures are:

Laparoscopy: Laparoscopy is the classic procedure to evaluate and treat tubal disease. Under anesthesia, an incision is placed in the belly button, and a small television camera is placed through the incision. The doctor can look at the pelvic organs, and introduce some treatment equipment through small ¼ inch incisions. Problems can be treated with scissors, cautery, or a laser.

Tubal cannulation: Devised for the treatment of cornual occlusion, a tiny wire is placed through the cervix and uterus and into the tube. The wire gently opens the tube and may relieve an obstruction in this area. Tubal cannulation can be performed in the X-Ray department under fluoroscopy or via a hysteroscope. A physician who is experienced in the techniques is essential.
Evaluation of these problems can be complex, and devising a treatment plan requires a close relationship with a physician with experience in these areas. A few common scenarios follow:

Hydrosalpinx: A hydrosalpinx carries risk of infection and very low pregnancy rates even after treatment. Hydrosalpinx can be treated laparoscopically, a procedure known as neosalpingostomy. In neosalpingostomy, an incision is made in the end of the hydrosalpinx and the edges of the incision are folded or flowered back, leaving an open tube. The best outcomes occur in young women with a small hydrosalpinx. Unfortunately, the tube often closes back up, and pregnancy rates are relatively low. Even when the fallopian tubes are bypassed, via techniques such as in vitro fertilization, a hydrosalpinx can have adverse effects on pregnancy rates. Basically a small hydrosalpinx in a young woman might be repaired, with the understanding that further surgery might be necessary if the repair is unsuccessful; a larger hydrosalpinx should be removed.

Bipolar Disease: Bipolar disease refers to the situation in which there exists injury to both the cornual and the ampullary or fimbrial portion of the tube. It is very difficult to get a satisfactory repair when problems are present at both ends of the fallopian tubes. Most patients with bipolar disease should proceed to in vitro fertilization.

Tubal adhesions: Some patients with an otherwise normal evaluation, including a normal Hysterosalpingogram, can have subtle adhesions over the fallopian tube and ovaries. These adhesions appear like cobwebs over the surface of these organs, and can prevent eggs successful ovulation, prevent the tubes from picking up eggs, and limit the mobility of the tubes. Patients at special risk for these problems include those who have used IUDs, had abdominal problems, such as appendicitis or an ovarian cyst removal. Limited adhesions benefit from laparoscopy. The adhesions can be removed with scissors, cautery, or a laser. Age is a significant factor in who will respond to these procedures 51; younger women benefit more than older women.

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Treatment: Donor Insemination (DI)

Donor insemination (DI) is the process of inseminating a woman with sperm obtained from a sperm donor. The sperm is usually obtained as a frozen specimen from a sperm bank or may come from a known sperm donor.

Most women seeking donor insemination are doing so because they are single, are lesbian, or their husband has no sperm production at all.

Donor insemination is usually performed in natural cycles without the use of any fertility medications. If a woman has already attempted donor insemination in natural cycles and has been unsuccessful, a fertility evaluation may be warranted and fertility medications may be recommended.

The Donor Insemination Process
Once a woman has decided that she would like to undergo donor insemination, she must select a sperm donor from one of several sperm banks. A woman may choose to work with most any certified sperm bank of her choice. Sperm banks vary widely in the number of donors available, ethnic diversity of donors, information available on the donor including family medical history and availability of donor identification. Certified sperm banks must meet specific requirements for infectious disease testing of their donors. In order to virtually eliminate the risk of transmission of infectious disease through donation, sperm is "quarantined." The sperm donor is tested for infectious diseases, donates the sperm and the sperm is frozen and held at the sperm bank for six months. The donor is then re-tested for HIV before sperm is released to clinics and patients.

Some women prefer to perform inseminations at home in which case they will usually be performing an intra-vaginal insemination. If a woman seeks insemination with a physician, the sperm is shipped directly to our office from the bank and it is stored here until the appropriate time in the cycle for insemination.

Intrauterine insemination is usually recommended because studies have shown that the chances of successful conception are higher if timing of exposure to sperm is controlled, and if sperm is placed in higher numbers closer to the egg or eggs. As we usually perform intrauterine inseminations (at Pacific Fertility Center, San Francisco), we request that the selected sperm be prepared at the sperm bank for intrauterine insemination. It is possible to process sperm that has not been prepared at the bank for intrauterine insemination but there is an additional fee at the clinic for this processing.

The patient is responsible for contacting the sperm bank, selecting the donor from the bank's profiles, and paying the sperm bank directly for the sperm and shipping. The sperm is shipped to the Center as a vial of frozen sperm and we immediately transfer the frozen sperm to our liquid nitrogen storage tanks. The sperm is held in this frozen state until the day of the insemination when the laboratory thaws the vial or vials of sperm for insemination. We will always perform a sperm count and evaluate the percent of motile sperm in the specimen prior to insemination.

Using Sperm from a Known Sperm Donor
In some cases, a woman may know a friend who is willing to donate sperm to her for purposes of conception. Obviously, this raises some social issues concerning the role that the donor may play in the parenting of any child that may be conceived from known donor sperm insemination. Also, if the sperm to be used is to be freshly donated on the day of insemination (no freezing or quarantine), there are issues of potential for infectious disease transmission which must be addressed.
Because of the potential issues involved with parental rights and responsibilities, we at Pacific Fertility Center strongly recommend that the woman being inseminated and the sperm donor have a legal contract established outlining these rights and responsibilities (or lack thereof) prior to the insemination. We can refer patients to appropriate sources for preparation of these contracts. In addition, Pacific Fertility Center requires at least one session of counseling with a family counselor or psychologist familiar with issues which may arise from this arrangement. We have a family counselor on site or we can refer you to other counselors in the Bay Area. The counselor must meet or speak by phone with both the donor and the recipient of the donor sperm.

Infectious disease testing is required for sperm donation, as at any sperm bank. If the woman is using fresh sperm from a known donor, he must also undergo a blood test known as polymerase chain reaction (PCR) for the HIV virus just prior to the insemination cycle (within two weeks of the insemination). Although this testing significantly reduces the risk that the sperm donor is carrying the virus that causes AIDS, it does not completely eliminate this possibility and the recipient of the donated sperm must sign a consent form acknowledging this risk.
Sperm donors are also tested for Hepatitis B and C, syphilis, and another HIV-like virus, HTLV-1. Known sperm donors must also have either a urine sample or urethral swab culture for gonorrhea and chlamydia to reduce the risk that the recipient of the donor sperm may become infected with these sexually transmitted diseases from the insemination.

If the sperm is to be donated fresh on the day of the insemination, the sperm can be collected at home and brought within one hour to the office or can be produced in a clinic's sperm collection rooms. The laboratory will then perform a sperm count and motility evaluation and prepare the sperm. The usual preparation procedure takes about two hours. After preparation, the sperm concentrate is placed into the uterus, through the cervix, using a small catheter. Some of the sperm will also be placed directly into the cervix. The actual insemination process takes approximately 5 to 10 minutes. It is optimal for men to abstain from ejaculation for 1 to 3 days prior to the anticipated insemination. Abstaining for more than 5 days can result in decreased motility.

Studies have been done demonstrating that one well-timed insemination per cycle is as effective as two inseminations per cycle so most clinics, including Pacific Fertility Center, perform a single insemination per cycle.

Preparing for an Donor Insemination Cycle
After consultation with your fertility physician, a treatment plan is usually made between you and your physician. Some women will need some testing to be performed in order to make sure that she is in good reproductive health and has no specific barriers to conception with donor insemination. All women who have regular menstrual cycles should have an early cycle FSH and estradiol blood level tested. She should also be tested for Rubella (German measles) and Varicella (Chicken pox) immunity. We require documentation of the blood type as well.

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Insurance Policies - Part 2 (Overview)

Be your own insurance advocate:
You may need pre-certification or predetermination or preauthorization. At Pacific Fertility Center, we have financial consultants who will assist you by providing insurance-specific codes for the services to be rendered.
We recommend that you request predetermination in writing.

• Pre-certification: Your benefits will not be paid if you commence treatment before obtaining the pre-certification from the insurance company.

• Preauthorization: Referral from your Primary Care Physician or OB/GYN to a Reproductive Endocrinologist must be preauthorized by HMO/IPA.

• Investigate infertility riders, which are now being added to basic coverage by some insurance companies. You may be required to register as an infertility patient and meet criteria set by the insurance company.
Submitting your claims:

• If possible your Physician will process the claims directly, but if you must submit on your own, request documentation from your Physician and attach to your claim.

• Keep your explanation of benefits (EOB), all receipts and all documents from the insurance company. These will be invaluable in the event you receive denials and you need to appeal.

• Financial consultants can provide a valuable service to you and together with your input we can avoid loss of benefits due and maximize your reimbursement.
I hope you find this information useful. The information enclosed pertains to the issues we see at our clinic but it should help provide you a framework in order to go about maximizing your fertility benefits. If you have any questions on this issue, I’d love to hear from you!

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Insurance Policies - Part 1 (Overview)

The insurance aspect of infertility treatment can be confusing. Below you will find information in an effort to help clarify the basic categories and coverage available to many patients. These categories of coverage pertain to IVF as well as other forms of fertility treatments and procedures. Where I practice, Pacific Fertility Center, San Francisco, we have financial consultants who are available to work with our patients so they may receive the benefits their insurance company provides.
Plans vary considerably in coverage for infertility. Some plans cover diagnostic procedures only and some cover diagnostic procedures and treatment, but only specific types of treatment may be covered.

There are 3 main categories of insurance policies:
1. Private Indemnity
Any Doctor of Your Choice May have a deductible:
• Usually 80%-100% reimbursement. 0%-20% of the Physicians' fee are your responsibility.

2. Preferred Provider Organization (PPO)
Services Rendered by a Network of Physicians Contracted with the Insurance Company
• Deductible Must be met before 80%-90% insurance reimbursement of their usual and customary fees.
• Patients responsibility: 0%-10% of the usual and customary fees.
• Services provided by physicians outside of network are not subject to usual customary fees.

3. Health Maintenance Organization (HMO)
a. Basic HMO
Services provided through Physicians controlled by the HMO
• Services must be requested by the Primary Care Physician and authorized by the HMO. Co-pay ranges from $5-$20 per service. Some plans allow 50% co-pay for infertility services.
b. Individual Practice Association (IPA)
Services provided through direct contracts with independent physicians.
• Services must be preauthorized by IPA. Co-pay ranges from $5-$20 per service.
• Some plans allow for additional deductible, additional co-pay amounts, and additional waiting periods before reimbursement.

Know your coverage:
• Get a copy of the contract and/or the summary plan description. Plans usually list services which are included and services which are excluded from the plan.
Determine exclusions:
• "Infertility services excluded" means neither diagnostic procedures nor treatment is covered.
• "Infertility covered, but no artificial insemination, assisted reproductive technology covered", usually means diagnostic procedures, surgery or monitoring of drug therapy may be covered.

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