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Infertility, investigations and management
Infertility is when a couple cannot conceive despite having regular unprotected sex. Around one in six or seven couples may have difficulty conceiving. However, the number of couples who are actually infertile is low, around 5%. About 85% of couples will conceive naturally within one year and 95% within two years if they have regular unprotected sex. A couple will only be diagnosed as being infertile if they have not managed to have a baby after two years of trying. Women over the age of 35, and anyone who is already aware that they may have fertility problems, should seek medical advice sooner.
Infertility can be caused by many different factors. About one third of infertility is due to problems in the female, another third is due to male factors, and in 30%, a cause cannot be identified.
Ovulation disorders
Infertility, in women, is most commonly caused by disorders of ovulation, either irregular or absent ovulation. This includes premature ovarian failure, where the ovaries cease to ovulate before age of 40 and polycystic ovary syndrome (PCOS), a condition of the ovary that makes ovulation difficult. Women with thyroid disorders (both underactive and overactive thyroid gland) also have irregular ovulation.
Tubal factors
Fallopian tubes are thin elongated structures extending from the ovary to the uterus (womb) on each side. The ovum (egg) is fertilised by the sperm as it travels down the fallopian tubes, and when it reaches the uterus (womb) it implants on to the lining where it continues to grow. If the fallopian tubes are damaged or blocked, it may become difficult to conceive naturally. This can occur after pelvic surgery which may cause damage and adhesions to the fallopian tubes. Endometriosis can also cause infertility as the adhesions or cysts may obstruct or distort the tubes and ovaries making it difficult for an egg to be released and transported to the uterus for implantation. Pelvic inflammatory disease (PID) is an infection of the upper female genital tract including the endometrial lining and fallopian tubes with resulting damage to the fallopian tubes and failure of transport of the ovum (egg).
A full medical, sexual and social history is taken which helps to identify any possible factors that may be causing fertility problems.
A number of investigations are usually undertaken:
Semen analysis in the male partner for volume, count, motility and morphology.
Almost all of the other investigations are done in the female partner.
Progesterone test
A sample of blood is tested for progesterone levels which indicates ovulation. This is done seven days before the next period is due or on Day 21 from the first day of the last menstrual period.
Other hormone tests
Day 2 LH/FSH ratio
Luteinising Hormone (LH) and Follicle Stimulating Hormone (FSH) are 2 other hormones in the female that are tested on the 2nd or 3rd day of the menstrual cycle, i.e. day 2 or day 3 after start of periods.
Thyroid function tests
It is estimated that between 1.5 to 5.1 percent of infertile women have an abnormal thyroid function, and testing for it is an important part of the infertility workup.
Prolactin is yet another hormone that is tested for; elevated levels indicate lack of ovulation and also an underlying disorder.
Test for Chlamydia
Chlamydia is a sexually transmitted infection (STI) that can affect fertility. A swab is used to collect cells from the cervix to test for infection. If tested positive for chlamydia, antibiotics are prescribed for treatment.
Transvaginal ultrasound is done to assess for normality of the uterus and ovaries. Polycystic ovaries may be detected on ultrasound which when associated with abnormal LH/FSH ratio and other symptoms would then be called Polycystic Ovarian Syndrome.
Hysterosalpingogram
A hysterosalpingogram is an x-ray of the uterus and tubes after introducing a dye through the cervix. The dye is seen to fill the uterus and tubes and then spill into the pelvis indicating normal structures. This examination helps to identify a polyp or small fibroid in the uterine cavity or to identify a block in the fallopian tubes.
Hysteroscopy and Laparoscopy
It may become necessary to obtain maximum information and also to surgically treat certain conditions by surgical procedures like hysteroscopy and laparoscopy.
Treatment-Medical
Commonly used medications to assist fertility are as below.
Clomifene helps to encourage ovulation (the monthly release of an egg) in women who do not ovulate regularly or who cannot ovulate at all.
Metformin is prescribed where clomifene has not worked, and is thought to be particularly beneficial for women with polycystic ovary syndrome (PCOS) and a body mass index (BMI) of over 25.
Gonadotrophins are hormones that act on the pituitary gland in the brain which drives the ovaries to ovulate, and are used to induce ovulation.
Ideally, ovulation induction should be monitored by tracking the development of follicles by ultrasound.
Some surgical procedures like hysteroscopy and laparoscopy may be used to investigate fertility problems and assist with fertility.
Laparoscopic surgery is often used for women who have endometriosis. In women with polycystic ovaraian syndrome (PCOS), laparoscopic ovarian drilling may be done if ovulation induction has not worked. This involves using diathermy to make about 4 to 5 puncture holes in each ovary to correct the local hormonal imbalance.
Hysteroscopic surgery is used for resection of polyps or small submucosal fibroids which may interfere with implantation of the fertilised ovum.
Some women do not respond to the above measures and need referral to an IVF unit. For more information, please contact Dr Dasmahapatra for guidance
Laparoscopy represents a surgical procedure for creating minute incisions in the abdomen area with the help of sophisticated instruments. The abdomen is inflated with carbon dioxide gas and the pencil-like tool or the laparoscope is inserted in the abdomen to obtain image of the inside under powerful light and a video camera, which is seen on a TV monitor in the operation theatre. Additional small incisions are made in the adjoining area for other sophisticated instruments to perform the surgery.
It is the process to see the inside of uterus, which is performed in abnormal conditions and the diagnostic hysteroscopy is done to detect ailments. It may be followed by operative hysterectomy to rectify defects simultaneously without calling for another session of surgery.
Common indication of Hysteroscopy:
Evaluation of infertility patients.
Evaluation post menopausal bleeding
Removal of endometrial polyp
Removal of submucous myoma.
Trans cervical resection of endometrium(DUB)
Resection of uterine septum.
Lateral meroplasty in ivf patients
Tubal cannulation for blocked fallopian tube.
Advantages of Laparoscopy
Laparoscopy is preferred because it needs very few tiny incisions on abdomen compared to the traditional open surgery. There is less harm to body tissue, organs and muscles and the patient is able to recover earlier with a shorter hospital stay. There is the opportunity to join the normal work without much restriction and limitation. The patient does not face major post operative complications as well. In short, the patient gets;
Perfect cosmetic value
Lesser chances of post operative infection, hernia and minimum discomfort
Negligible blood loss in the surgical procedure
Short stay in the hospital and quicker recovery compared to the open surgery cases
Diagnostic Laparoscopy and Operative Laparoscopy
With diagnostic laparoscopy, the doctor looks inside the abdomen to detect abnormalities just like the physical examination in symptoms of pelvic pain, infertility and so on. The operative laparoscopy permits the surgeon to complete the treatment by removal of the diseased tissue or by repairing damaged structures inside the abdomen.
Types of Minimal Invasive Surgeries
Several kinds of minimal invasive surgeries are performed using the technique including gynecological conditions such as:
1. Abnormal uterine bleeding
2. Ectopic pregnancy
3. Endometriosis
4. Fibroids
5. Hysterectomy
6. Hysteroscopic surgeries
7. Infertility
8. Ovarian cysts
9. Pelvic adhesions
10. Pelvic pain of unspecific origin
11. Prolapse of uterus
12. Tubal ligation
13. Urinary incontinence
14. Uterine anomalies
Even large fibroids and large uterus is possible to be removed with laparoscopic procedure, which can be performed by the specialist gynecological surgeon with the help of sophisticated instruments.
Laparoscopy is normally safer that open surgery as it involves minimum harm to body tissues. However, unforeseen problems may occur during the surgical process or afterwards owing to internal bleeding or injury, which are properly managed by the attending surgeon in most cases. Complications may arise for patients with other medical problems. The modern day general anesthesia is a safe process, but carries some risks due to reactions, which are rare. In exceptional cases, the procedure is not possible to complete by laparoscopy and the doctor may have to convert to open surgery or lapractomy.
Choosing the Best Doctor for Laparoscopy
Choosing the right gynecologist requires certain important aspects. The patient should prefer the surgeon who has taken a special training in obstetrics and gynecology and also has specific qualifications for gynecological endoscopic surgery. The experience of the doctor in this topic is also a great milestone for the choice of the gynecologist.
Endometriosis represents a particular condition where tissues resembling the lining of uterus are detected elsewhere in the abdomen. They are found on ovaries, in the pelvic cavity, on the fallopian tube and pelvic sidewall and so on. It is normally associated with pain, which is the major symptom. Sometimes the pain becomes severe and affects the normal lifestyle of the patient. These lesions are capable of distorting the internal anatomy and result in severe conditions such as 'frozen pelvis'. It is also a major cause of infertility. The main symptom is pain, which may be associated with diarrhea, constipation, abdominal bloating, heavy bleeding or irregular bleeding, fatigue and so on.
The treatment depends on the individual patient and on the severity of the condition, symptoms, age, marital status and her fertility desires. The patient should consult with the best gynecologist in Kolkata to determine the treatment procedure. Hence, the treatment may be a combination of hormonal therapy and surgery for better results. Laparoscopic surgery is a great help in this condition for diagnosing and treating the ailment successfully.
Uterine fibroids are benign tumors that are found in the uterus, which are also termedFibroids, Myoma, Fibromyomaand and Leiomyoma. It is very common in the childbearing age and may affect one out of every five women. Symptoms include abdominal fullness, constipation, bleeding between periods, heavy menstrual bleeding, increased urine frequency, extended menstrual periods with the complaint of pelvic cramp and pain. Women over the age of 30 are susceptible to this condition more.
The cause of uterine fibroids is still unknown, but evidence suggests that they use estrogen for growth of fibroids, which is evident as fibroids grow more during pregnancy because the system produces additional estrogen. When the estrogen level drops during menopause, Fibroid growth declines.
Fibroids are categorized into three groups, subserous, intramural and submucous. The first one is found on the outer wall of uterus, the second one is found on the muscular layers of the uterine wall and the third one is found on the inner wall and may reach up to the cavity. Half of the fibroids are subserous and the submucous are in negligible numbers. Infertility is occasionally related to fibroids and the couple should undergo a thorough investigation to determine the cause of infertility.
Uterine fibroids are determined after a pelvic examination. The presence of fibroids needs to be confirmed by other tests because there may be ovarian tumors, bowel masses or early pregnancy, which are sometimes mistaken as fibroids. Ultrasonogrpahy of the abdomen or vaginal area is a great way to determine the presence and size of the fibroid. Diagnostic laparoscopy is a process to reach a definitive diagnosis in this subject, which also helps in removal of the fibroid. Diagnostic hysteroscopy is also used to determine the presence and size of the fibroid. It is performed under local anesthesia in the outpatient department of a hospital. Cases are done under general anesthesia to remove fibroids in the operating room for indoor patients.
Surgical removal of fibroids is known as myomectomy for large fibroids with different symptoms or rapidly growing fibroids. The chances of future pregnancy are kept alive with the process of myomectomy where the patient retains the uterus. The size and the position of the fibroid determine the right procedure of removal.
Hysterectomy is the process of removal of uterus; it may also include the removal of ovaries and fallopian tubes, which is performed in total hysterectomy. When the surgical process is done with the help of laparoscope and allied instruments, it is called laparoscopic hysterectomy.
Small incisions compared to the open surgery of 10-15 centimeters
The surgeon is able to look into different organs of the abdomen clearly and performs the surgical operation accurately
Much quicker recovery period and less hospital stay
Lesser complications in post-operative conditions, lesser chances of infection, etc.
Improved cosmetic status
Lesser chances of hernia
Normally most patients can undergo laparoscopic hysterectomy. Even a patient with a past history of the procedure can undergo with correction and removal of adhesions of the previous operation. It is possible to treat ovarian, tubal and uterine diseases in the same laparoscopic hysterectomy. The patient undergoes routine tests as desired for the laparoscopic hysterectomy. Patients with diabetes and high blood pressure can also undergo the surgical procedure when the limit of the disease is controlled properly.
It is advisable to contact the best laparoscopic gynecological surgeon in Kolkata so that the patient gets the best quality treatment with sophisticated equipment with quality backup facilities. Generally the hospital stay is for only 1-2 days. The patient joins normal work very quickly; however strenuous exercising, lifting of weighty materials, swimming and intercourse are to be evaded for 6 weeks.
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About Dr. Mahapatra
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MILLENIUM CLINIC, TEGHORIA MAIN ROAD KANCHANJHUNJHA APARTMENT, KOLKATA 700059
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