Last month I went for an HSG and discovered that both tubes are blocked. My OB/GYN is suggesting I go for IVF. He said he would not advise me to have tubal surgery because of the high rate of ectopic pregnancy. My husband and I do not want IVF. Does this mean these tubes cannot be blown open? Is IVF the only chance I have to get pregnant?

E.E.

The hysterosalpingogram (HSG) is a test to see if the fallopian tubes are open. They can be blocked at the uterus, at the midportion or at the fine, flowerlike fimbriated ends.

In some cases, the HSG test itself may enhance fertility by opening tubes that may be clogged by debris or mucus. Still, whenever I hear people suggesting "blowing the tubes open," I picture physicians standing in a bunker and pushing a TNT plunger hoping an explosion will correct the problem. The fallopian tubes cannot really be "blown open." They are delicate structures that must function normally in all regards. They are more than a conduit to allow the sperm and egg to meet; they provide the chemicals and nutrients necessary to nourish the fertilized egg during its first few days of life.

If the blockage occurs where the fallopian tube joins the uterus, a procedure called fallopian tube recanalization can often clear that blockage. However, when the blockage is at the end of the fallopian tubes, surgery can often create a new opening, but this does little to restore normal function. The result is quite often an ectopic pregnancy or a recurrence of the tubal blockage. Success rates following tubal surgery to correct a blocked and dilated fallopian tube are often less than 10 percent, with a 15-25 percent risk of an ectopic pregnancy. In this situation, IVF is certainly the safest option (because ectopic risk is much lower) and the most cost-effective (because success rates are higher).

Unfortunately, many insurance companies do not yet understand the benefits of IVF. Nor do they recognize that success rates have improved, making IVF a cost savings when compared with repeated surgical attempts to restore fertility. The shortsightedness of the insurance industry has lead many women to undergo repeated surgical procedures that offer little hope of success. While I cannot address your last question regarding what choices you have without a more thorough evaluation, if your only fertility factor is blocked fallopian tubes, IVF would certainly appear to offer the greatest chance for success.