MANAGING INFERTILITY

Often infertility can be the result of treatable conditions or lifestyle issues. Listed below are some health issues that if managed effectively would result in conception.

Fibroids and Pregnancy

Because fibroids can grow back, those women who are planning to become pregnant in the future must try to conceive as early as possible after the myomectomy procedure. However, following surgery, Dr Alexander will advise you to wait for 4 to 6 months until the uterus heals.

Before undergoing any treatment for infertility, Dr Alexander may recommend a hysterosalpingogram, an X-ray test to check the uterus and fallopian tubes.

The incisions made in the wall of the uterus to remove fibroids may cause placental problems and improper functioning of the uterus during labour may need a caesarean delivery.

In rare cases, a hysterectomy may be needed if the uterus has grown too large with fibroids.

Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) is a common endocrine disorder and one of the common causes of infertility among women.  

It is characterized by an ovulation dysfunction or impedance to the normal growth and release of eggs from the ovaries.  It is commonly seen in women of childbearing age and is rare after menopause.

The hormonal imbalance results in enlarged ovaries containing several small cysts (fluid-filled sacs).

Causes of Polycystic Ovarian Syndrome (PCOS)

The exact cause of polycystic ovarian syndrome is unknown. However, several factors including genetics have been implicated to play a role in the development of PCOS.

Women with a family history of polycystic ovarian syndrome are at a higher risk of developing this condition.

Researchers have also found an association between excessive insulin production and development of PCOS. Insulin hormone regulates blood sugar levels and any disorder affecting the insulin mechanism may result in excessive insulin secretion, which triggers androgen secretion from the ovaries.

Low grade inflammation, in response to ingestion of certain foods, may lead to the release of substances that can cause insulin resistance and cholesterol accumulation in the blood vessels or atherosclerosis.

Clinical studies have demonstrated the presence of low-grade inflammation in women with PCOS. Excessive exposure to the male hormone during the fetal period may disrupt the function of normal genes and increase the risk of insulin resistance and low-grade inflammation.

Symptoms of Polycystic ovarian syndrome (PCOS)

The symptoms of polycystic ovarian syndrome vary from person to person and depend upon the nature and severity of the condition.

Some of the symptoms of PCOS include

infertility,

absent or irregular menstrual cycle, and

obesity or accumulation of fat usually around the waist.

Abnormal facial and body hair,

adult acne

male pattern baldness or hair thinning may develop due to excessive androgen secretion.

In some patients black or dark brown patches are seen around the skin of the neck, arm, breasts or thighs. Patients often experience anxiety or depression and breathlessness during sleep.

Diagnosis of Polycystic ovarian syndrome (PCOS)

The diagnosis of polycystic ovarian syndrome is based on the medical history along with a physical and pelvic examination to evaluate the condition of the patient and help identify the underlying cause.

Test conducted could include:

Blood tests are conducted to determine the level of various hormones.

Glucose tolerance test and

Evaluation of blood cholesterol may also be conducted.

Pelvic ultrasound is performed to evaluate the appearance of the ovaries and the uterine lining.

Treatments for Polycystic ovarian syndrome (PCOS)

The treatment of polycystic ovarian syndrome is based on the symptoms and individual concerns such as infertility, irregular menstrual cycle, acne or obesity.

Both medications and surgical treatment can be used for the management of PCOS. Infertility may be treated by fertility therapy with ovulation-inducing drugs.

  • Drug Therapy: Clomiphene citrate,  may be prescribed to patients, the drug 25mg-100mg dose can be given day2 to day 6 of your cycle, it can also be given day 5 to day 9 of the cycle. In some patients, the doctor may add metformin to clomiphene to inhance the function of the drug and help induce ovulation. Another oral drug that is superior to Clomid is Letrozol, the usual dose 2.5-5 mg and given day 3 to day 9 of the cycle. Dr Alexander will be doing ultrasound to check the growth of follicles and determines the time of ovulation.

In patients not responding to clomiphene and metformin, gonadotropins, namely, follicle-stimulating hormone (FSH) can be administered by injection.

  • Lifestyle Modifications and anti-diabetic medications may be prescribed for the management or prevention of obesity and diabetes mellitus.

  • Surgery may be recommended in patients who do not respond to medications. Laparoscopic ovarian drilling, an outpatient surgical procedure, may be used to treat the condition and induce ovulation.

If PCOS is Not Treated

Patients with polycystic ovarian syndrome frequently develop other serious medical conditions such as

  • diabetes mellitus,

  • cardiovascular diseases,

  • pregnancy induced high blood pressure,

  • miscarriage or premature delivery.

These patients are also at risk of uterine cancer, anxiety or depression.

Cancer Related issues for Women

The treatment of cancer may pose temporary or permanent fertility problems in both men and women. The effects may be immediate or show up much later in life.

Various factors, such as the type of cancer, treatment and age, determine your chances of infertility following treatment.

Any cancer therapy would involve one or more of the three general techniques –

  • chemotherapy or the use of high-end medication,

  • radiotherapy, which is the use of high-energy radiation and

  • surgery to destroy and remove cancer cells.

The higher the dose of chemo and radiation therapy, and the older you are, the greater its effect on fertility.

Cancer therapy can damage the endocrine glands (glands that release hormones essential for puberty and fertility.

Fertility Preserving Options for Women

The options for women may include:

  • Embryo freezing: involves the collection of mature eggs and fertilization with sperm in the laboratory. The resulting fertilized embryos are frozen and preserved until the woman is ready to become pregnant.

  • Oocyte freezing: involves the collection of mature eggs and freezing them (without fertilization with sperm).

    • In case of early-stage cervical cancer and ovarian cancer, fertility preserving surgery is performed to remove the cervix and affected ovary, respectively, keeping the uterus intact.

    • This will help the woman to get pregnant and deliver the baby by caesarean section.

  • Oophoropexy: Involves surgically moving the ovaries away from the path of radiation and bringing them back to their original position after treatment, with an intention of protecting the ovaries from radiation therapy.

  • In girls who have not yet entered puberty, ovarian tissue preservation is performed, which involves the surgical removal of ovarian tissue and preserving it by freezing. The tissue may be transplanted back into the girl after the cancer treatment.

Fertility-preserving procedures may vary for each individual and each condition. You can discuss with Dr Alexander in detail before you decide.

Recurrent Pregnancy Loss

Infertility and recurrent pregnancy loss

Infertility is defined as not being able to get pregnant despite having frequent, unprotected sex for at least a year for most people and six months in certain circumstances.

It is a myth that infertility is always a “woman’s problem.” About one third of infertility cases are due to problems with the man (male factors) and one third are due to problems with the woman (female factors).

Other cases are due to a combination of male and female factors or to unknown causes.

Recurrent First trimester pregnancy loss

(under 12 weeks)

Pregnancy loss or miscarriage unfortunately is common in the first trimester.

The majority is due to genetic abnormalities in the embryo formation. This can happen without necessarily a family history, and can happen to any couple. Obviously increased maternal age will increase the risk.

Recurrent miscarriages in the first trimester however can be associated with various other problems, including

  • blood disorders,

  • immunological disorders,

  • metabolic disorders,

  • pelvic pathology like endometriosis and

  • uterine cavity abnormalities like adhesions, uterine septum and intra uterine fibroids

We test for the above and address as appropriate.

Recurrent Second Trimester

(between 16-22 weeks)

Pregnancy Loss due to Cervical Incompetence

Cervical sutures can be either trans-vaginal inserted prophylactically at around 11-13 weeks gestation or Transabdominal cervical suture performed before your pregnancy for a better success .

Fertility Treatments for Women with Cervical Incompetence

Transabdominal placement of a cerclage at the cervicoisthmic junction appears to be a safe and effective procedure for reducing the incidence of spontaneous pregnancy loss in selected patients with cervical insufficiency.

Potential advantages of transabdominal over transvaginal cerclage are more proximal placement of the stitch (at the level of the internal os), decreased risk of suture migration, absence of a foreign body in the vagina that could promote infection, and the ability to leave the suture in place for future pregnancies.

A disadvantage of this approach is the potential need for laparotomy to place the suture and then C/S for delivery of your baby.

Transabdominal placement of a Cerclage

Transabdominal placement of a cerclage at the cervicoisthmic junction appears to be a safe and effective procedure for reducing the incidence of spontaneous pregnancy loss in selected patients with cervical insufficiency.

Potential advantages of transabdominal over transvaginal cerclage are more proximal placement of the stitch (at the level of the internal os), decreased risk of suture migration, absence of a foreign body in the vagina that could promote infection, and the ability to leave the suture in place for future pregnancies.

A disadvantage of this approach is the potential need for laparotomy to place the suture and then C/S for delivery of your baby.

Timing of Transabdominal cerclage

Transabdominal cerclage placement is usually performed either prior to conception or during early pregnancy (at 11 to 14 weeks). Placement of the cerclage later in pregnancy is undesirable since the large size of the uterus makes the procedure difficult and thus may be associated with a higher risk of complications.

Indications and Contraindications

Transabdominal cerclage is a more morbid procedure than transvaginal cerclage. It usually requires a laparotomy for placement and delivery by cesarean. For these reasons, most experts recommend reserving the transabdominal approach for women with cervical insufficiency who have either failed two or more previous transvaginal cerclages or in whom a transvaginal cerclage is technically impossible to perform due to extreme shortening, scarring, or laceration of the cervix.

No studies have compared the outcome of patients who underwent surgery prior to conception versus those whose placement was in early pregnancy. The pre-conception approach is associated with less blood loss and avoids the risk of pregnancy-associated complications (eg, rupture of the fetal membranes).

Contraindications to transabdominal cerclage are similar to those for transvaginal cervical cerclage