It’s one of those interesting phenomena that most gynecologists have seen in their practice at least once. You do an HSG, and the woman with longstanding infertility becomes pregnant the very next cycle!
HSG – that’s short for hysterosalpingogram, a study in which dye is injected through the uterus into the fallopian tubes to see if they are blocked or open.
Post-HSG pregnancies happened often enough that we all thought thought it must be a real effect of the HSG. We theorized that the flushing of the tubes must be opening up a previously undiagnosed blockage of the tubes. But we secretly wondered whether what we were really doing was flushing out the bad humors.
As it turns out, our experiences were indicative of a real phenomenon, and our secret theory was not so crazy. In the past decade, several randomized studies have confirmed that doing nothing but performing an HSG increases pregnancy odds by as much as two to three times. (Cochrane review here). Studies have also confirmed that tubal flushing decreases the concentration of cytokines and other inflammatory proteins in the fallopian tube, and reduces sperm phagocytosis (ie, bad humors).
Now, some docs are wondering if flushing of the tubes could become more than just an observed phenomenon but a planned part of infertility treatment.
Researchers at the Karolinska Insitute in Stockholm have published a nice little study in which they randomized couples with unexplained infertility to one of two treatment arms – (a) Clomid (a drug that stimulates ovulation) plus intrauterine insemination or (b) the same plus pertubation (flushing) of the fallopian tubes with an anesthetic solution just prior to insemination.
Among the 67 patients whose tubes were flushed, there were 10 clinical pregnancies (15%) vs only 2 (3%) in the 63 women whose tubes were not flushed, a statistically significant difference.
But before you get yourself too worked up about these results, it’s worth noting that a fertility-expert friend of mine says that the pregnancy rate in the control group was unusually low, and suspects that this may make the intervention look better than it really is.
In addition, the authors point out that the overall pregnancy rates using this technique are significantly lower than the 30% pregnancy rate expected with IVF in the same population of patients. But their lower tech method is cheaper and faster, and they propose that it may be appropriate for couples who either don’t want IVF or want to do something while they are waiting for IVF.
It’s an interesting idea that needs a bit more study before implementing it outside a research setting. Stay tuned…
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Disclaimer – I am NOT a fertility expert, just a plain-old gynecologist reading the latest literature and doing a little wondering. My little musings should not be mistaken for medical advice. The best person to decide your teatment is your doctor, not me.
I have an honest question – I’m not trying to disparage you or ob/gyn’s in any way – I’m wondering about an observation that many in the infertility community have made.
Why do OB/GYNs take so long to recommend an RE? There are so many stories of women who were put off by their regular ob/gyn even after asking for years. Is there a disconnect with the fact that the older someone is the less successful intervention is? Or is there a bias against younger women who “should” be healthy?
Thanks.
I assume you mean general Ob-Gyn’s playing infertility doc as opposed to referring everyone off.
That’s not always inappropriate. The work up of infertility can be fairly straightforward – HSG or sonohysterogram, Semen analysis, temp charts or ovulation predicting kits. Many women will respond to Clomid, especially if the issue is PCOS or anovulation. Some docs are quite good at doing inseminations in the office – it’s not really rocket science. And if you have a sonogram machine and a good lab to work with, you can monitor the follicles and the cycle quite nicely.
IVF is not the first stop for everyone, even those who see the fertility docs. And wait lists to get to these docs can be long. If the patient is young and the issue straightforward, and the doc likes treating infertility and is good at it, I don’t see a problem with it. Treating for years, though, makes no sense. If you havenlt had success in 6 months or so, send them off, I say.
I happen to practice in the shadow of some of the best infertility docs in the world, so I tend to hand most folks off very early in the process given that many are approaching 35 rapidly or are already there.
80% of normal couples will get pregnant within 6 months, so I do ask my patients to at least give it that on their own unless there is an obvious problem up front.
Thanks for reading!
I lost a lot of time trying to get fertility help in the obstetric community. I have PCOS. Clomid did not work, and in fact it caused me to grow even more cysts. When I researched the manufacturer’s information on it, it said that it is not a frontline therapy for PCOS. I did what I consider to be tons of research and found that PCOS is caused by insulin resistance. I went to a REGULAR endocrinologist and was treated with insulin-sensitizing medications. At no time did I have diabetes. It required a combination of two medications, Glucophage and Avandia, but once I was on the combo I got pregnant within 2 months. I went from not having ovulated since I was 16, to becoming a mother at 40, just by this intervention.
I’m just bringing this up because I feel that the insulin resistance root is not addressed in the OB community. I can understand if it’s not an area that you feel comfortable with prescribing for, but I do think that a referral to a regular endocrinologist even for parallel treatment is not out of line. I also understand very well that the typical infertility patient wants to be pregnant yesterday and many DO want some kind of higher level treatment of symptoms. However this is one case in which it really can be much more effective (and totally covered by insurance) to treat it at the root.
My girl will be 6 in just a few weeks; I’m so glad I got to be a mom!!!!!!!
Celeste – Congratulations! Glad to hear Glucophage and avandia worked for you.
Actually, there has been quite a lot of interest in insulin lowering medications for ovulation induction in the gyn community. But the success rate at getting women to ovulate using that approach is actually lower than with clomid, as found in a recent review. So for now, Clomid really is the first line. If that fails, then insulin lowering drugs can be added or used instead.
Every woman is an idividual, and finding the right treatment for each is not as straightforward as you might think. In your case, I’m glad you found the right approach.
It is cool to see the HSG phenomenon sort of validated. 🙂
I Have a question. I got pregnant in 2001 with no problem, got thrown from a car in 2002 and have not been able to get pregnant again. We tried Clomid and even did an IUI. My Endocrinologist says he doesn’t think my tubes are clogged or collapsed. I’m not so sure all he says he can see from testing me and my husband is my muscus is thick and my husbands swimmers are slow and my OB keeps saying lose weight. I was bigger when I got pregnant the first time. I don’t know if I should spend the money on the HSG test and or IUI again. Any advice would be great. Thanks Jen
Jenni – Hope you understand that I cannot give medical advice on the blog. I suggest you discuss this issue with your doctor. So sorry.
Best,
how many times do i need to flush my tubes before i can conceieve.
I was twenty when I had my first child but since then I have not any. I went to see the Doc and I was dignosed blocked tubes. They were flused four times and given Clomid but still have concieved.What do I do?
Helen
I was twenty when I had my first child but since then I have not had any again. I went to see the Doc and I was dignosed blocked tubes. They were flused four times and given Clomid but still have not concieved.What do I do?
Helen
Helen –
I hope you understand that I cannot give out medical advice on this blog. Do talk to your doctor about your concerns or seek another opinion if you are not satisfied with your results so far. Some women with tubal infertility will do well with IVF.
Peggy
Could you please e-mail me the Cochrane review…your link leads to a page that says it’s no longer available. I am trying to build a case on evidence/research that shows HSG increases chance of pregnancy…for a woman with severe endometriosis and blocked fallopian tubes do you know if periodic flushing could be a recommendation? Thank you
sheristeer –
I’ve updated the broken link. Hope it helps.
Thanks for reading.
Peggy
Just wanna know what u think about iui and been told tubes are clogged
I’m sorry, but personal medical questions will not be posted or answered on this blog. Please see Disclaimer.
Thanks
Just wanna know i have been trying to concieve its now five years but not getting any help. My doctor has been giving me clomid but didnt help , now planning to do the tubes flushing. Is it gonna help
Yes its gonna happen just hav faith, l flashed my tubes yesterday bt mi am sure l will conceive just hav faith
I need to kown if I can get hsg test done to flush out my system after an ultrasound result that showed I had submucosal and then intermural fabroid.
Please discuss matters related to your personal health with your physician. This blog is not meant to provide medical advice.
Best –
I’m only 27 years old we have been trying for 3 years now we had 4 Failed IUI ❌ and I just had my tubes flushed and endometriosis removed for the 3rd time it’s been 4 months and still not pregnant and my periods and pain have been worse then ever they say if you don’t get pregnant within 5 months from the procedure then back to fertility I fear we will never get pregnant and it’s stressful I also have pcos