Are the Tubes More Than a Tunnel? Their “Connection” to Ovarian Cancer

For decades, we thought of the fallopian tubes as no more than a plus one. Whether they were the sidekick to the ovaries or to the uterus, they were sort of like the accomplice that everyone overlooked. We did make some noise about damaged or blocked tubes in women who were trying to get pregnant because damaged tubes meant the sperm and egg would need to find another way to meet up. But for women who had let the fertility ship set sail, the tubes seemed like no more than an afterthought. However, times have changed: the tubes have taken center stage. Here’s why.

In order to understand the tube story, you must first hear the ovary story, specifically the part that addresses ovarian cancer and ovarian cancer screening. Unfortunately, when it comes to ovarian cancer screening tests, the ending is not a happy one. The tests either fail to detect ovarian cancers until they are advanced, or they over call benign processes (think simple cysts, dermoids, and endometriosis) as cancers. And while you certainly don’t want to miss an ovarian cancer, you also don’t want to put women through additional testing and surgery that they may not need. Hence, every GYN faces a conundrum when trying to screen for ovarian cancer. How do you avoid missing an ovarian cancer without miscalling something as ovarian cancer? Cue the tubes…

When the news broke that the tubes might play a big role in ovarian cancer (basically, that ovarian cancers might start in the tubes and the endometrium and then spread to the ovary) and that tubal removals (medically termed salpingectomies) could be the answer to early screening and detection, the OB/GYN community erupted in cheers. Could we have found a clue to cracking the ovarian cancer code? For decades, the theory had been that cancer spread from the ovary to the tube. Could it really be the opposite? Evidence suggested that for select types of ovarian cancer this could very well be the case. A breakthrough that could have big-time benefits: if you took out the tube, then you could take out or at least take down the chance of ovarian cancer later.

While the excitement in the OB/GYN community is palpable, neither the American Congress of Obstetricians and Gynecologists nor we are recommending salpingectomies for everyone. Rather, we are suggesting that you view the tubes as more than just an afterthought, that you treat them as more than a plus one. If you are planning to extract your uterus or you are planning a tubal sterilization procedure (a.k.a. tie your tubes), you should have a serious conversation about simply removing the tubes at the same time. Think of it this way: if you aren’t planning future fertility, those tubes will not be missed. And their departure might help you duck out of the way of ovarian cancer.

Ovarian cancer is like the enemy that lurks in the dark. You often can’t see it until it’s too late. And while many have attempted to find some good night-vision goggles (a.k.a. good screening tests), they have repeatedly come up short. Tubal awareness/removal may be the first light in the dark. And although there is still a lot of black and grey in the area of ovarian cancer prevention and early detection, the data on salpingectomies have certainly brightened the situation.

Maybe soon, we will be able to see it all.

The Tubes: More Than Just a Tunnel?

For any of us that drive, either to work or for pleasure, particularly in and around major cities with lots of congestion, getting stuck in traffic is not pleasant. It makes you late, it makes you frustrated, and it makes you anxious (it also eats your gas and costs money!). Where and why traffic arises is usually self-explanatory: an accident, construction, a street closure, or a blocked tunnel. The worse the situation, the more the traffic builds up.

Think of the fallopian tubes, the connection between the uterus and the ovaries, as a tunnel. The fallopian tubes serve as a conduit by which the sperm gets to the ovary/egg and the resultant embryo gets to the uterus. If they are blocked or severely damaged, flow to and from will be severely limited or shut down. In the worst of cases (think Midtown Tunnel during Hurricane Sandy), not only will the sperm be unable to pass, but also the normal tubular fluid will have no way out. The fluid will just sit there and become stagnant; stagnant fluid becomes filled with debris (a.k.a. junk). Even if a sperm or an embryo is able to swim this filthy sea, this cesspool of inflammatory mediators can harm an embryo’s ability to implant and grow. Tubal disease can be toxic to your fertility. It will shut the traffic of your reproductive system down, and without the help of a fertility specialist, everything will be at a standstill.

While tubal disease is not as common as traffic in New York City (all day, every day!), it does cause serious delays for a good percentage of women. Tubal disease is the culprit for about 10–15% of all couples with infertility. Unfortunately, there are not many flashing light “construction ahead” signs when it comes to tubal disease. Most of the time, it goes undiagnosed until a couple has struggled with infertility for some time. And when it comes to tubal disease, the sooner the police come to clear the accident, the sooner the road re-opens; a.k.a. the sooner you realize your tubes are shot, the sooner you can undergo treatment, and the sooner you will get pregnant.

While it may take some time to identify the tubes as a problem, there are certain risk factors for tubal disease that might set the siren off a bit sooner. For example, if you have a history of a sexually transmitted infection, pelvic inflammatory disease, previous tubal surgery, previous abdominal surgery, an ectopic pregnancy, endometriosis, smoking, a previous case of appendicitis, or inflammatory bowel disease, go for a tubal evaluation early. Finding out that your tubes are damaged sooner rather than later will save you a lot of time and frustration. Think of it this way: if you know you have a bad driving record, you should consider taking out extra insurance. You may not need it, but if you do, you will save yourself a lot of money.

A diagnosis of tubal disease is generally made by a test called a hysterosalpingogram (HSG). Now, if you have any friends who have struggled with infertility or have read any blogs, these three letters probably made you gasp. An HSG has become synonymous with “that awful dye test that hurts so badly.” We are here to reassure you that, for most women, the test is quick and fairly painless.

If the tubes are open, the pain should be minimal. It’s when the tube or tubes are blocked that the test can be uncomfortable. Talk to your doctor before you go. Get a recommendation for a radiologist who specializes in these tests (when it comes to HSG, radiologists are not all created equal!), and consider taking some Ibuprofen about 30 minutes prior to the procedure. While an HSG is a pretty good way to pick up tubal problems, it is not uncommon for women to have a false positive result. Basically, the test says you have tubal disease, but you actually don’t. This tends to happen when there appears to be a problem in the proximal portion of the tube (the part that attaches to the uterus) rather than the distal part (the part that is near the ovary).

Nearly 60% of proximal tubal disease picked up on an HSG are false alarms—the tube will appear blocked when it is actually in spasm (clamping down) or is temporarily kinked. There could also be a piece of mucus that is stuck and giving the appearance of a blockage. That is why, if your test report comes back with an “F,” you may not really have flunked. Unfortunately, you need to take the test again (at least it doesn’t require studying!). If your repeat performance is the same, the diagnosis is clear.

There are more ways than just an HSG to interrogate the integrity of your tubal system. In certain cases, tubal disease will be identified in a laparoscopy. Additionally, vaginal ultrasound and MRI can strongly suggest tubal disease. However, unlike an HSG or a laparoscopy, they cannot tell whether your “tunnels” are open or closed. To truly get an accurate traffic report, you have to test drive the system (put fluid or dye in and see if it can come out both sides)!

In addition to the anger and the frustration traffic can cause, it can also be confusing. The obvious is obvious: an accident, construction, or some guy whose truck didn’t fit through the underpass but tried. (We never get that. If it says trucks higher than six feet can’t clear an underpass and your truck is seven, why go for it?). But what about when there is no reason—no accident, no construction, no guy who is vertically challenged? Why then have things slowed down or stopped? It makes no sense!

The same can go for a woman who winds up with tubal disease without any identifiable risk factors. This can be particularly true in cases of proximal tubal obstruction. The causes of this are things you have likely never heard of. (Neither did we before medical school!) They include diseases such as salpingitis isthmica nodsa (say that five times fast), endometriosis, or pelvic inflammatory disease. But unlike that guy who drove his truck under the underpass, let us reiterate that none of these processes are your fault…it’s just bad luck.

Luckily, fixing your tubes is not like fixing potholes on I-95. It won’t take years and years and cost endless amounts of money. After making the diagnosis, treatment plans can usually be implemented immediately with minimal hassle. While some cases will be amenable to surgical correction, the majority will require in-vitro fertilization (IVF). IVF allows you to bypass the tubes (it’s like Google Maps or Waze when trying to get to your favorite weekend spot in the summer!) and therefore is very successful in achieving a pregnancy. Women whose tubes are causing their infertility do quite well with IVF; their eggs are good, their partner’s sperm is good, and their uterus is ready and waiting.

The only catch here is that tubes damaged near the ovary (distal damage) that have filled with fluid (remember the stagnant pond) should be removed before undergoing IVF.  Reason being is that this fluid becomes a soup of inflammatory products that can be toxic to a developing embryo; simply stated, patients who do IVF with a dilated damaged tube (medically termed hydrosalpinx and commonly called “hydro”) in place can have about a 50% reduction in their pregnancy rate. Its presence can negatively affect an embryo’s ability to implant into the uterus. Your doctor will know if and when the tube(s) need to be removed. Trust their advice. They have the road map for your success.

Thinking about your tubes and what they look like (both inside and out) is probably a totally foreign concept. But how to weave in and out of traffic and deal with blockages is definitely not. You can pretty much always get to the other side, no matter how many roads, tunnels, or bridges are closed. It will take more time and will not be the route you planned, but with a little help from your friends (gotta love that navigation system), you will get there. Let your fertility doctor be your navigator; together, we can get you to your destination.