Ovulatory Problems | Ovulation Induction | PCOS | IUI | Pelvic Factors | Endometriosis | Tubal Disease | Evaluation Procedures | Fertility Preservation | HSG | SIS | Surgery | da Vinci Robotic Surgical System | Laparoscopy | Hysteroscopy | Myomectomy | Repair of Uterine Abnormalities | Tubal Reanastomosis
OVERVIEW: FEMALE INFERTILITY CAUSES AND TREATMENTS
Ovulatory problems are the most common cause of infertility in women. This may include anovulation (lack of ovulation) or irregular cycles (oligoovulation). There may be a problem with the number of eggs in the ovary, the signals for ovulation to occur or other hormonal irregularities (thyroid, prolactin). A common problem with ovulation is polycystic ovarian syndrome, associated with irregular periods, weight gain, diabetes related symptoms and increase in androgenic symptoms (acne, thinning hair, etc). Specific evaluation and therapy is required to treat ovulatory problems effectively; these include ovulation induction with or without intrauterine insemination.
Ovulation induction involves stimulating the ovary to mature one or more eggs. It may be accomplished with several different medications.
Medications may include:
- Clomiphene Citrate (Clomid) — oral medication to help produce eggs
- Follicle Stimulating Hormone (FSH) – injection medication to produce eggs
- Human Chorionic Gonadotropin (HCG) – injection medication to trigger the egg release
- Combination gonadotropins (i.e., Follistim, Gonal-F, Bravelle, Menopur) – subcutaneous injections
Most of the approaches to treatment focus on raising FSH (follicle stimulating hormone) levels to enhance follicular growth and development, ultimately resulting in the release of one or more healthy mature egg(s) (ovulation).
Ovulation induction is an effective means of restoring fertility in many women who do not ovulate or who ovulate irregularly. Pregnancy rates with Clomiphene range from 8-10% per cycle and multiple pregnancy rates are low if < 3 follicles are produced. Gonadotropins may be used to induce ovulation in women that do not respond to Clomiphene and/or have irregular signals for ovulation from the pituitary gland in the brain. Additionally, gonadotropins may be used to induce superovulation for the development and release of multiple eggs in ovulatory women undergoing various other infertility treatments. Careful selection of treatment regimens combined with appropriate levels of monitoring result in excellent outcomes. The chance of pregnancy ranges from 15-20% per cycle with superovulation. Increased age of the woman and medical factors such as endometriosis, male factor, etc. may further decrease success rates. With superovulation, multiple gestations can occur at an overall rate of 20% twins, 3-5% triplets, 2% quads or greater (if more than four follicles). IUI may be performed with ovulation induction.
Polycystic ovary syndrome (PCOS) is a condition in which the ovary produces too much of androgenic (male type) hormone. The condition consists of chronic lack of ovulation and menses over a long period of time or irregular periods and hirsutism (excessive hair growth). Numerous studies have also revealed that patients with PCOS have a high chance of insulin resistance with too much insulin production (hyperinsulinemia). The only way to diagnose hyperinsulinemia is by blood testing, which includes insulin and glucose levels. This will also identify diabetes and problems with glucose tolerance. It is important to note if you are diagnosed with any of these conditions, you may be at a higher risk for coronary artery disease and should see an internist at regular intervals.
Treatment includes weight loss, exercise and/or medication therapy. A weight loss of just 10% can be very significant to improve ovulation. There are a number of programs available for weight loss. Your physician will help you decide one suitable for you.
Therapy may include medications which may help to lower insulin levels. These drugs are not necessarily recommended for treatment of PCOS or hyperinsulinemia. However, use of these drugs may improve ovulation. They are officially considered “experimental” for this use. The most commonly used drug is Glucophage.
How does Glucophage work?
Glucophage decreases liver production of glucose and decreases intestinal absorption of glucose. Glucophage also improves the ability of major body organs to move glucose into the cells. Glucophage also increases the ability of ovarian cells to use insulin and glucose. Other medications include ovulation induction medications such as Clomiphene or FSH.
Intrauterine insemination is a procedure to increase pregnancy potential for couples with:
- Male factor infertility
- Poor cervical mucus
- Unexplained infertility
- Donor insemination
The husband’s sperm is prepared by a special gradient procedure that separates the most fertile sperm for placement into the wife’s uterus. Other preparations of sperm may be required for very low counts or sperm antibodies. The insemination is performed with a gentle catheter placed through the cervix into the uterus, increasing the number of healthy sperm reaching the tube for spontaneous fertilization of the egg.
Intrauterine insemination aided with ovulation induction with gonadotropins (Bravelle, Repronex, Menopur, Follistim, and Gonal-F) may benefit couples who have not conceived after an appropriate time with routine therapy and all infertility factors corrected. This applies to couples in which the wife has one or more open tubes with an ovulatory problem, unexplained infertility, or minimal or mild endometriosis.
Intrauterine insemination(s), along with ovulation induction with gonadotropins, appear to improve pregnancy chance due to increasing the number of available eggs and sperm to maximize the chance of pregnancy to approximately 15 to 20% per attempt. Multiple gestations occur at a rate of 20% twins, 3-5% triples, 2% quads or greater if combined with superovulation. If combined with routine ovulation, lower pregnancy rates occur, as do very low multiple gestations.
Pelvic factors such as endometriosis, scar tissue, tubal disease or uterine myomas may cause infertility. Each factor requires evaluation and may include hysterosalpingogram (HSG), sonar insufflation study (SIS) or laparoscopy/hysteroscopy. If a patient’s tubes have been tied or ligated, a reversal or reanastomosis may be performed to reunite them. Myomas may need to be removed with a myomectomy. Appropriate therapy choices are individually based on the severity of the factors and potential best outcomes.
When some of the tissue that lines the uterus (endometrium) goes out the tubes during a period, endometriosis can occur. This can cause infertility, painful menstrual periods, pain with bowel movements, urination or intercourse. The damage from this can result in blocked tubes, scar tissue or ovarian cysts full of endometrial fluid (endometriomas). Endometriosis can involve the large intestine or bladder as well. Medication such as Lupron can be used to decrease the pain of endometriosis but it delays attempting pregnancy. Surgical removal of the disease at laparoscopy by an experienced Reproductive Endocrinologist can improve both pain and fertility potential. Some patients require IVF to obtain a pregnancy. Autoimmune factors may be evaluated as well.
Unfortunately tubes can be damaged by infection or endometriosis, resulting in a tube that is no longer open or able to pick up an egg. Depending on the severity of the damage, tubes may be repaired through a laparoscopy or removed if severely damaged. A repaired tube has a small chance of pregnancy (up to 35% over a two-year period) and a chance of tubal pregnancy higher than a normal tube. Some patients will not be able to obtain a pregnancy with their tubes and IVF will be required. Unhealthy blocked tubes may be removed or “tied off” to decrease fluids from entering the uterus and preventing pregnancy with IVF. If tubes have been previously tied or “ligated” to prevent pregnancy in the past, a tubal reanastomosis may be performed.
Hysterosalpingogram (HSG) – The hysterosalpingogram (HSG) is an X-ray study of the uterus and fallopian tubes. The procedure involves placing radiopaque dye into the uterus through a soft catheter. X-ray pictures are then taken as the dye passes from the uterus and out of the ends of the tubes. This test helps to determine that the tubes are open and that the uterus is normally shaped.
We have developed a technique to perform the HSG that results in less discomfort than the traditional method. During the procedure, you may experience some mild cramping. You may also have cramping along with spotting for a day or so after the procedure. These symptoms are to be expected and should not be cause for alarm. You may return to work the same day if you desire. You will be instructed to take Ibuprofen 30 minutes prior to the test. Doxycycline will be prescribed to reduce the chance of infection. You may take additional ibuprofen in the afternoon following the procedure if you are uncomfortable. This procedure is scheduled between the fourth and the twelfth day of your cycle. You should call the office when your period starts to schedule sonar insufflation study (SIS). If you have questions regarding this procedure, please do not hesitate to call.
Sonar Insufflation Study (SIS) – Your physician may recommend that you undergo an office procedure called sonar insufflation study (SIS). You may have heard this procedure referred to as hysterosonography. The procedure involves placing a soft catheter through the cervix into the uterine cavity. Fluid is placed in the cavity and using ultrasound we will evaluate the shape and contour of your uterine cavity. You may be able to watch the sonar screen while the procedure is being done. If it is detected that there is an irregularity in the uterine cavity such as fibroids or polyps, further treatment may be indicated.
The SIS procedure is usually well tolerated. Ibuprofen 600 mg one half hour prior to the test is given to prevent cramping. An antibiotic, Doxycycline, is given to help prevent the possibility of infection. It is important that you take both of these medications as directed and these medications must be taken with food. You will continue the antibiotic for three more doses. You may take additional ibuprofen in the afternoon following the procedure if you are uncomfortable. This procedure is scheduled between the fourth and the twelfth day of your cycle. You should call the office when your period starts to schedule sonar insufflation study (SIS). If you have questions regarding this procedure, please do not hesitate to call.
da Vinci Robotic Surgery – Drs. Honea, Houserman, Long and Allemand have all been specially trained to perform robotic tubal reversals and robotic myomectomies using the da Vinci Robotic Surgical System. The robotic procedure requires tiny, 1-2 cm. incisions so patients can recover quicker and return to normal activities; usually within days rather than weeks that are required with traditional surgery. With the da Vinci Robotic Surgical System, our physicians can operate with greater precision and control, minimizing pain and risk associated with large incisions.
To learn more about the da Vinci Robotic Surgical System and how this minimally invasive surgery could benefit you, please speak with your physician or contact our office for additional information.
Laparoscopy – This procedure is performed to find the cause of infertility, pelvic pain or other problems in the reproductive organs. In these cases, a physician cannot tell from a physical exam or from a patient’s symptoms exactly what is wrong. Looking inside the pelvis with a laparoscope is the only accurate way to find endometriosis or scar tissue. Laparoscopy often leads to more appropriate and specific treatment. Treatment for certain problems such as scar tissue and endometriosis, blocked tube (hydrosalpinx) can be performed at the operative laparoscopy by the Reproductive Endocrinologist using laser or guided laparoscopic instruments.
Laparoscopy is performed with general anesthesia with a slender telescope-like instrument, called a laparoscope. This is inserted through a small incision at the navel. If needed, surgical instruments can be inserted through the laparoscope or through other small incision(s) lower in the abdomen near the pubic hair. With the aid of the laparoscope and other instruments, pelvic organs can be seen and evaluated, adhesions can be separated and removed, laser of endometriosis or resection of endometriosis may be performed, and tissue can be sampled. Your recovery is usually short depending on the procedures performed.
Laparoscopy is an operation with minimal risk; however, complications occur in about three of every 100 women who have this diagnostic procedure. These complications can include minor problems such as infection as well as injuries to nearby organs, bleeding or complications from anesthesia. Most problems can be treated and corrected at the time of surgery. Your doctor will have a good idea how to proceed with your care from the findings at your laparoscopy.
Hysteroscopy – Hysteroscopy is a procedure to look inside the uterus. A hysteroscope, a thin, telescope-like instrument that is inserted directly into the uterus through the vagina and cervix, is used. This procedure may be used to diagnose abnormal uterine bleeding, infertility, repeated miscarriages, adhesions and abnormal growths, such as polyps and fibroids. Additionally, hysteroscopy may be performed at the same time as laparoscopy (usually under general anesthesia).
When hysteroscopy is used to diagnose certain conditions, it may be used to correct them as well. Uterine adhesions, septums, polyps or small intracavity fibroids can often be removed through the hysteroscope.
Hysteroscopy is a relatively safe procedure. Problems such as injury to the cervix or the uterus, infection, heavy bleeding or side effects of the anesthesia occur in less than 1% of cases. Diagnostic hysteroscopy can often be performed without intubation with general anesthesia. The procedure and recovery time are usually brief, less than two days.
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Myomectomy – Myomectomy is the surgical removal of fibroids from the uterus. Uterine fibroids are non-cancerous, smooth muscle growths that occur quite often in women. Fibroids may cause no symptoms and may require no treatment. Some fibroids may cause bleeding, pain and can be related to infertility or pregnancy loss. Myomectomy allows the uterus to be left in place and preserves fertility. A myomectomy may be performed either by laparotomy or hysteroscopy. The method used usually depends on the size and location of the fibroids. If fertility is desired, most myomectomies are performed by mini-laparotomy unless the size requires a full exploratory laparotomy. Small fibroids may be removed through the hysteroscope if they invade the uterine cavity. Recovery is 2-6 weeks from laparotomy.
Repair of Uterine Abnormalities (septum, adhesions, etc.) – The normal uterine cavity is shaped like a triangle on the HSG, ultrasound or MRI. If the uterus has an abnormal shape from birth, such as a uterine septum, it appears heart shaped on HSG rather than like a triangle. The area of indentation may cause late miscarriage or be associated with a premature birth. The septum can be removed through an outpatient laparoscopy and hysteroscopy procedure. Most women can return to work in three to four days after surgery. The risk of pregnancy loss should be significantly decreased.
Other problems such as scar tissue (adhesions) or fibroids may be found and can be resolved through a similar procedure. The amount of scarring in the uterus will be a factor for future pregnancy results.
Tubal Reanastomosis – Tubal reanastomosis, also known as tubal reversal, can be performed to reverse a tubal ligation. There are many types of tubal ligations and not all can be reversed. A tube is normally 9 – 11 cm in length (approximately 3-4 inches) and success rates are highest if there is more than 4-5 cm (1 ½ – 2 inches) of continuous tube after reversal. The less damage done to the tube at ligation, the higher the success rate (i.e., using “clips” or “loops” produces the least amount of damage and has a better chance of success). If the end of the tube is removed, it is unlikely any surgical procedure will be successful. Providing a copy of the operative note helps us to determine the type of ligation that was performed, the extent of the damage and the potential for reversibility. If a pathology report is available, it can also be helpful in assessing how much tube was removed. A hysterosalpingogram (HSG) may help determine how much tube remains near the uterus for reversal and the location for the reversal. Tubal damage that is internal secondary to infection or endometriosis is usually not possible to correct with surgery; in vitro fertilization (IVF) is most often the best option under these circumstances.
A tubal reanastomosis is generally performed through a “mini-lap” (smaller incision). The size of the incision is based on the size of the patient and previous surgeries. The average patient can return to work in two to four weeks. Pregnancy rates may be as high as 70-80% (over a two-year period) for women who have regular cycles and have healthy tubes for repair.
Unless we are certain ahead of time that the tubes are reversible, we prefer to perform a laparoscopy prior to performing any major surgery. A laparoscope is an endoscope-like instrument similar to a telescope. By making a small incision in the belly button, we are able to view the pelvis to determine the status of the tubes, ovaries, and uterus. It is then much easier to decide whether a tubal reversal is feasible. If other pelvic pathology is found, such as scarring and/or endometriosis, the chances of the tubal reversal being successful may be markedly lower.
A laparoscopy the day of reversal is performed first if operative notes and/or pathology reports are not available or suggest a poor chance of reversal success.