Physical examinations – Dr. Jessica Farren

While blood tests can provide a lot of insight into your fertility, they cannot identify anatomical problems such as blocked fallopian tubes.  If you’re having problems conceiving, it’s important to know what physical examinations might be needed.

Initial examination

If you’re struggling to conceive your doctor may examine your pelvic area to check for discharge, redness, lumps or tenderness, which could be a sign of conditions such as infection, fibroids, ovarian cysts or endometriosis. They may do this by performing a speculum examination (like when you have a smear test – with swabs taken to look for infection) and also an examination in which they put two fingers gently inside the vagina, and lay a hand gently on the lower abdomen (this is known as a bimanual examination – feeling the pelvic organs between two hands). This examination should not be painful. If it is uncomfortable, it is important to communicate this – as this is an important part of the assessment – but the doctor will stop what they are doing so as not to cause you pain.

They may also schedule you for an ultrasound scan – usually performed with a small probe inserted into the vagina. An ultrasound scan can be used to check your womb and ovaries. Healthy fallopian tubes are difficult to see on a basic ultrasound, but they may be seen if they are bigger than normal (usually called a hydrosalpinx – when they appear to be filled with fluid).

Why are the fallopian tubes important in fertility?

Your fallopian tubes play an incredibly important role. We all know that the egg has to travel down the tubes from the ovary to the womb, but did you know that it is actually where the sperm and egg first meet to create that all important embryo? And it is also where the developing embryo spends its first 3 or 4 days! Highly specialised hairs in the lining of the tubes ‘beat’ in order to move the embryo in the right direction towards the womb.  

As a result, scarring, damage or blockage of the tube or tubes can lead to infertility. The most common causes are:

  •       Sexually transmitted diseases such as chlamydia –  which can cause pelvic inflammatory disease
  •       Endometriosis
  •       Previous appendicitis (especially if severe or not treated promptly)
  •       Previous ectopic pregnancy

Again, if you know that any of these apply to you, or are worried that they might, please see your doctor sooner rather than later if you are trying to get pregnant.

Investigations to check the fallopian tubes

In order to check that your fallopian tubes are healthy, usually the first step is to perform a basic ultrasound scan to look for scar tissue or any evidence of endometriosis, which might make tubal blockage more likely, or a hydrosalpinx.

The next step is to do a test involving pushing fluid through the tubes to check that they are open. This can either be performed using x-ray (an HSG or hysterosalpingogram) or a special ultrasound (HyCoSy – Hysterosalpingo (womb and tubes) Contrast Sonography). In both of these procedures, a small amount of fluid is inserted into the womb using a tiny tube placed through the cervix during speculum examination, and the progress of this fluid along the fallopian tubes is checked on either x-ray (HSG) or ultrasound (HyCoSy) .

If these tests are inconclusive, you will sometimes be recommended to have a ‘laparoscopy and dye test’. This is an operation, performed under general anaesthetic, when, using a tiny telescope inserted through your bellybutton, all the pelvic organs are thoroughly examined. A blue dye is inserted into the womb and the surgeon checks that both fallopian tubes fill with this blue dye, and that it spills out of the end – confirming that the tube is open.

For all these investigations it is very important that you abstain from having sex, or use a very reliable contraceptive, from the time between your last period before the procedure, and the procedure. Without this, your procedure may be cancelled due to the risks that they could be harmful to a very early pregnancy (which may be too early to pick up on a pregnancy test).

What will happen if the tubes are found to be blocked?

 

If your fallopian tubes have become blocked or scarred, you may need surgery to repair the tubes.  Surgery can be used to break up the scar tissue in your fallopian tubes, making it easier for eggs to pass along them.  Because the tubes, and the special cells within them are such delicate structures, the results of surgery can be disappointing.

Depending on the type and extent of blockage, you may also be recommended to have IVF. Sometimes if you have hydrosalpinx (fluid in the fallopian tubes) in preparation for IVF you might be recommended to have your fallopian tubes ‘clipped’ or purposefully blocked off completely: this is because this is recognised to increase success rates from IVF and reduce the risk of an ectopic pregnancy (where the embryo implants into the fallopian tube)

If you know you have tubal blockage or a hydrosalpinx (fluid within the fallopian tube) then, if you miss a period and have a positive pregnancy test, it is important that you have an ultrasound scan early in pregnancy (usually at about six weeks – though earlier if you have any pain). This is because you are at a higher risk of an ectopic pregnancy (a pregnancy outside the womb, usually within the fallopian tube). Your risk of this is higher even after surgery to correct a blockage. If you’re worried, do get in touch with your GP who can advise on next steps.