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ABNORMALITIES OF THE UTERUS
Abnormalities of the uterus are a relatively uncommon cause of infertility but should always be considered. The anatomic uterine abnormalities that may adversely affect fertility include congenital malformations, leiomyomas (fibroids), intrauterine adhesions (scarring) , and endometrial polyps. These same abnormalities can also adversely affect pregnancy outcome (recurrent pregnancy loss).
CONGENITAL UTERINE MALFORMATIONS
Developmental uterine anomalies have long been associated with pregnancy loss and obstetric complications, but the ability to conceive is generally not affected.
When discovered during evaluation for infertility, anomalies cannot, therefore, be regarded as the likely cause or even as an important contributing cause of infertility but only as another obstacle that must be considered when choosing from the range of treatment options once evaluation is completed. For example, treatments that are associated with substantial risk for multifetal gestations (superovulation with IUI, IVF) present even greater risks to women with uterine malformations. The septate uterus may be one specific exception to this general rule.
Among all congenital uterine abnormalities, the septate uterus is both the most common and the most highly associated with reproductive failure and obstetrical complications, including first and second trimester miscarriage, preterm delivery, fetal malpresentation, intrauterine growth retardation, and infertility.
MoonDragon's ObGyn Information: Female Infertility
MYOMAS / LEIOMYOMAS OF THE UTERUS (FIBROIDS)
Uterine fibroids (also known as myomas) affect 30 percent of women. They occur in various sizes, numbers, and location in the uterus requiring different types of myomectomy.
Available evidence indicates that pregnancy and implantation rates are significantly lower in women with submucous myomas but not in those with subserosal or intramural myomas that do not encroach on or clearly distort the endometrial cavity, at least when they are relatively modest in size (less than 5 to 7 centimeters).
A pelvic exam, ultrasound, MRI, or hysteroscopy accurately diagnose fibroids. If your health care provider determines that removal of the fibroids will increase your chance of pregnancy, either a hysteroscopy, laparoscopy, or laparotomy is advised.
Myomas are very common, benign uterine tumors. They may be single or multiple and vary greatly in size, occasionally reaching massive proportions. The present as firm irregular nodules in continuity with the uterine surface. Occasionally a myoma projecting laterally can be confused with an ovarian mass; a nodule projecting posteriorly can be mistaken for a retroflexed fundus. Submucous myomas project toward endometrial cavity and are not themselves palpable although they may be suspected because of an enlarged uterus.
Judgments concerning the indications for surgical intervention in infertile women with myomas in many ways parallel those in women with congenital uterine malformations. Like septate uteri, submucous myomas are associated with a decreased probability for successful pregnancy and are most often amenable to that has relatively low morbidity and avoids the risks and consequences of abdominal uterine surgery. The management of uterine myomas in infertile women must be highly individualized.
MYOMECTOMY
Myomectomy, the surgical removal of fibroids from the uterus, allows the uterus to remain in place to preserve or restore fertility and to lessen the probability of miscarriage caused by fibroids. The procedure is the preferred fibroid treatment for women who want to become pregnant. Sometimes, before vitro fertilization, myomectomy is performed to improve the chances of fertilization.
HYSTEROSCOPY
Hysteroscopy involves inserting a lighted viewing instrument through the vagina and cervix into the uterus; there is no incision so this is an outpatient procedure. Recovery time takes from two days to about two weeks.
LAPAROSCOPY
Laparoscopy uses a lighted viewing instrument and one or more small incisions (cuts) in the abdomen. This option is an outpatient procedure that may require a day's stay in the hospital and two to four weeks to recover.
LAPAROTOMY
Laparotomy requires a larger abdominal incision; therefore, an average hospital stay of one to four days is required and a recovery period of two to four weeks.
FOLLOWING A MYOMECTOMY
Of women who have a myomectomy for infertility and who have no other known cause of infertility, 60 percent then become pregnant. Following myomectomy, a cesarean section may be needed for delivery. This depends in part on where and how big the myomectomy incisions are on the tubes.
Consideration is given to the relative risks, benefits, and consequences of different surgical treatments, as well as age, ovarian reserve, reproductive history, duration of infertility, other infertility factors and the treatment they require, plus the size, number, and location of myomas.
UTERINE (ENDOMETRIAL) POLYPS
The overall prevalence of polyps in infertile women is approximately 3 to 5 percent. The prevalence is higher in women with other symptoms ( abnormal bleeding ) and may also be higher in those with endometriosis. Polyps can be identified by HSG or transvaginal ultrasound.
Polyps or fibroids, lesions of glandular or muscle tissue, are found on the wall of the uterus. They disrupt the uterine cavity and may result in repeated pregnancy losses or heavy/irregular menstrual bleeding. The uterine cavity shape can initially be evaluated by hysterosalpingogram (HSG) or sonohysterogram. These radiologic and ultrasound procedures can image the uterine cavity. They would be seen as a filling defect. Polyps and fibroids can be removed by hysteroscopic resection.
INTRAUTERINE ADHESIONS (ASHERMAN'S SYNDROME)
Menstrual disorders and infertility are the most common presenting symptoms in women with intrauterine adhesions (also known as synechiae); others include recurrent pregnancy loss and placenta accreta.
Any insult severe enough to remove or destroy endometrium can cause adhesions, and the gravid uterus seems particularly susceptible to injury such as D&Cs (curettage) for retained tissue for miscarriages (spontaneous abortion), elective (therapeutic) abortions, or postpartum curettage (after delivery) or cesarean sections. Less commonly, adhesions may develop as a postoperative complication of abdominal or hysteroscopic myomectomy (removal of a fibroid from the uterus), metroplasty or septoplasty procedures, or other extensive uterine surgery.
Chronic inflammatory or infectious insults (uterine infection), notably genital tuberculosis, also can result in intrauterine adhesions (rare in the United States).
This condition may present as infertility or recurrent spontaneous pregnancy losses. The appearance of filling defects on hysterosalpingography (HSG) may be the first evidence this condition exists. Hysteroscopy (hysteroscopic guided lysis) is the method of choice for treatment of intrauterine adhesions and is safer and more effective than blind curettage.
ADHESIONS OF THE PELVIS
Adhesions in the pelvis my result from previous surgery, infection, or any inflammatory process in the abdomen. The body "walls off" injured areas with scar tissue or adhesions. The major impact is on the function of the fallopian tubes. The end of the tubes have finger-like projections called fimbria. They help sweep the egg into the tube after ovulation. The egg and the sperm meet in the tube where fertilization takes place. The embryo is transported down the tube to the uterus where implantation takes place. When scar tissue involves the tube or fimbria then normal transport of egg, sperm, and embryo are interrupted and the possibility of pregnancy is markedly reduced. Removing the scar tissue will improve normal tubal function.
A laser is often used to treat these conditions. It is an intense beam of light which can cut and remove (ablate or vaporize) abnormal tissues. Removal of scar tissue (adhesiolysis), ablation of endometriosis, and repair of fallopian tubes can therefore be performed. Removal of severely diseased fallopian tubes or ovarian cysts can also be performed. The advantage of using a laser is that it minimizes injury to surrounding areas and facilitates precise cutting and removal of abnormal tissues.
UTERINE PROLAPSE
Prolapse of the uterus results from weakness of the supporting structures of the pelvic floor and is often associated with a cystocele and rectocele. In progressive stages the uterus becomes retroverted and descends down the vaginal canal to the outside.
In first degree prolapse, the cervix is still well within the vagina.
In second degree prolapse, it is at the introitus.
In third degree prolapse, also called procidentia uteri, the cervix and vagina are outside the introitus.
RETROVERSION & RETROFLEXION OF THE UTERUS
MODERATE RETROVERSION OF THE UTERUS
Retroversion of the uterus refers to a tilting backward of the entire uterus including both body and cervix. It is a common variant, occurring in about 1 out of 5 women. In moderate degrees of retroversion the fundus may not be accessible to either examining hand.
MARKED RETROVERSION OF THE UTERUS
In marked retroversion, the fundus may often be felt through the rectum. The cervix faces forward rather than back.
RETROFLEXION OF THE UTERUS
Retroflexion of the uterus refers to a backward angulation of the body of the uterus in relationship to the body of the uterus in relationship to the cervix. The cervix maintains its usual position. The fundus may be palpable through the anterior rectal wall. This position is a variant of normal.
ENDOMETRIOSIS
Endometriosis disease is caused by the abnormal presence of endometrial tissue (lining of the uterus) on the surface of pelvic organs.
Endometriosis is a serious disorder involving chronic abdominal pain and infertility, which may be present in 6 million women in the U.S. alone. It involves the unnatural growth outside of the uterus of the endometrial tissue which normally lines only the inside of the uterus.
Endometriosis forms adhesions and tissue growths between organs in the abdominal cavity, which interfere with reproduction, become painful during a woman's monthly cycle, and cause pain during bowel movements and during intercourse. Severe cases require multiple surgeries, strong medication, and sometimes hysterectomies to remove the uterus and/or ovaries.
The incidence of endometriosis has risen dramatically in the last few decades, but scientists are not sure of the cause.
A normal woman's endometrium undergoes a predictable monthly menstrual cycle based on well organized cell-cell interactions regulated locally by cytokines and growth factors under the direction of steroid sex hormones. Scientists believe that the onset and progression of endometriosis may result from disruptions of this well balanced cellular equilibrium, and may involve a faulty immune system. Endometriosis is probably caused by an interaction between multiple inherited genetic traits (vulnerabilities) and environmental influences. Endometrial tissue growth is promoted by estrogen; therefore, traditional medical therapy uses hormones to limit the action of estrogen in patients' bodies.
Women with endometriosis are twice as likely to be infertile as women without this condition. Endometriosis can only be confirmed and classified by laparoscopy. A uniform system of classification that takes into account the amount and location of endometriosis and adhesions is used. This staging system, formulated by the American Society for Reproductive Medicine classifies the disease as minimal, mild, moderate, and severe (stages I - IV).
Treatment of endometriosis may be surgical or hormonal and is based on a confirmed laparoscopic diagnosis, the patient's age, and the extent, location, and severity of the disease. Endometriosis has many different appearances. A high level of expertise and experience is necessary to identify this abnormal tissue in its many forms. Initial treatment should be accomplished at the time of laparoscopy. The use of conventional electrocoagulation is often utilized. Nevertheless, an ultrasonic knife and lasers can be more effective in removing the disease and decreasing future scarring.
UTERINE CANCER
Cancer of the endometrium, which is the lining of the uterus usually affects postmenopausal women ages 50 to 60 years and is the most common female pelvic malignancy in the United States. A second type of uterine cancer, sarcoma, is less common. There is a difference between the two types of cancer.
Uterine sarcoma is a disease in which malignant (cancer) cells form in the muscles of the uterus or other tissues that support the uterus. Uterine sarcoma is a very rare kind of cancer that forms in the uterine muscles or in tissues that support the uterus. Uterine sarcoma is different from cancer of the endometrium, a disease in which cancer cells start growing inside the lining of the uterus.
FEMALE REPRODUCTIVE CANCER LINKS FROM MOONDRAGON
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