CERVICAL RELATED PROBLEMS
The cervix is the neck of the womb, and plays an important part in reproduction. The cervix produces mucus which prevent bacteria from ascending up the genital tract and infecting the uterus and fallopian tubes. However, the mucus clearly needs to allow sperm to pass so that it can fertilise an egg. To allow this, changes in the mucus occur just before ovulation. In response to oestrogen produced by the developing follicle in the ovary, the mucus becomes thinner and more watery. If intercourse occurs at this time the sperm can pass through the cervix easily and fertilise the egg when it is released.
Should pregnancy occur, the cervix helps to hold the baby in place until it is fully developed and ready to be born. Abnormalities of the cervical mucus can make it difficult for the sperm to pass through the cervix, and therefore fertilisation does not occur. Infections of the cervix can also ascend to involve the rest of the reproductive tract, leading to pelvic inflammatory disease (PID). Cervical factors probably account for approximately 5% of all subfertile couples.
Infections of the cervix such as chlamydia or gonorrhoea are well known to cause subfertility by ascending through the cervix and affecting the uterus and fallopian tubes in pelvic inflammatory disease (PID). This can cause adhesions to form and thus affect fertility, and also increases the risk of ectopic pregnancy due to damage to the fallopian tubes. However, there is also some evidence that some infections can change the composition of the cervical mucus and thus prevent the passage of sperm.
The presence of antisperm antibodies, either from the male partner or in the mucus itself, or the use of some lubricants, can also change the mucus and make it more difficult for sperm to pass through the cervix.
The immune system provides us with a multi-layer defense against invading microbes and foreign intruders. It can recognize the difference between normal (self) and alien (non-self) cells, trigger a local or widespread inflammatory response, and retain the memory of the offending organism to repel it again if it should ever return. Like any finely-tuned machine, however, the system can break down and leave us open to the threat of infection, or, conversely, turn against our own healthy tissues, as occurs in such diseases as rheumatoid arthritis or lupus.
The immune system also plays an important role in human reproduction. Inflammatory cells and their secretory products are involved in the processes of ovulation and preparation of the endometrium for implantation of a fertilized egg. Dysfunction of the immune system can interfere with the normal reproductive processes and result in infertility. It has been estimated that an immune factor may be involved in up to 20% of couples with otherwise unexplained infertility. Although many of these associations with infertility remain unproven, there is solid scientific evidence to implicate the formation of antibodies against sperm as an important infertility factor.
Normally, sperm and embryos are the only two foreign entities the female immune system will not attack. The immune system produces an allo-immune response to the embryo, effectively quarantining it in the uterus and protecting it from attack. However, an unproven theory suggests that some women’s immune systems behave quite differently, attacking the sperm or embryo as if it were an invading cell.
For women with recurrent miscarriage, there are a group of antibodies that appear to attack an early developing pregnancy, resulting in either a miscarriage or severe preeclampsia with risk of intrauterine growth retardation or even fetal death. Collectively these belong to a class of antibodies known as antiphospholipid antibodies, which include the lupus anticoagulant and the anticardiolipin antibody. Testing for these antibodies are an integral part of the workup for recurrent pregnancy loss. However, it is unclear whether these antibodies play any role in the ability to conceive. Some physicians believe that the presence of antiphospholipid antibodies may decrease the chance for pregnancy through in vitro fertilization. Although this is a controversial subject, one of the largest studies that looked for these antibodies in women undergoing in vitro fertilization found that these antibodies were no more likely to be detected in those who did not become pregnant as in women who did conceive.
- Hysterosalpingogram (hsg)
- Endometrial Biopsy
The laparoscopy is an important diagnostic test which allows the physician to visualize the reproductive organs within the pelvic cavity. It is performed as a hospital inpatient procedure under general anesthesia. Two small incisions are made in the abdomen, one at the belly button and one above the pubic bone (at the pubic hair line).
In the laparoscopy, a small “telescope” is inserted through one of the incisions and the surgical tools are passed, and operated, through the other. The abdomen is filled with gas which allows the physician to clearly view the surfaces of the internal organs such as the ovaries, tubes, and uterus.
Many times our patients have already had one or more laparoscopies by the time they seek specialist care. Laparoscopy, for the diagnosis and treatment of infertility, should always be performed by a reproductive specialist who has extensive training and experience in microsurgery.
The incidence of complications from laparoscopy, such as scarring or adhesions, may be less when a specialist performs the laparoscopy. It is oftentimes possible to treat conditions, such as endometriosis, during the diagnostic laparoscopy. The operating surgeon must have the skills necessary to perform the complex surgery that is often required.
A hysterosalpingogram is an X-ray of the uterus and fallopian tubes which allows visualization of the inside of the uterus and tubes. The picture will reveal any abnormalities of the uterus as well as tubal problems such as blockage and dilation (hydrosalpinx). If sterilization reversal is planned, the point at which the tubes are blocked can be seen. This helps to plan the reconstructive procedure.
If the tubes are not blocked by scar tissue or adhesions, the dye will flow into the abdominal cavity. This is a good sign but it does not guarantee that the tubes will function normally. It does give a rough estimate of the quality of the tubal structure and the status of the tubal lining. Some cases where the tubes appear to be blocked where they join the uterus, may in fact be normal. Often blockage at this location may be due to spasm of the opening from the uterus into the tube or from accumulated debris and mucus blocking the opening. This can be managed by passing a very thin catheter into the fallopian tube either at the time of hysterosalpingogram or during a hysteroscopic procedure.
A hysterosalpingogram may also indicate endometrial polyps, submucus fibroids, intrauterine adhesions (synechia), uterine and vaginal septa uterine cavity abnormalities, or the after-effect of genital tuberculosis. The hysterosalpingogram may or may not be able to detect pelvic adhesions, mild hydrosalpinx, small polyps, endometriosis, tubal phimosis (clubbing of the fimbria at the end of the tube), or immotility of the tube. Other tests, such as hysteroscopy or laparoscopy may be necessary to accurately evaluate your uterus.
Although the purpose of the hysterosalpingogram is not therapeutic, sometimes forcing dye through the tube will dislodge any material which blocks it. A number of women have become pregnant following a hysterosalpingogram without further treatment.
Hysteroscopy is a procedure used to examine the uterine cavity. The telescope (and any other instruments that are needed during the operation) is entered into the womb by passing it first through the vagina and then through the cervix, which is the entrance of the womb lying in the deep part of the vagina.
This diagnostic test can also treat blockages, endometriosis or adhesions. Hysteroscopy is useful in the treatment of uterine fibroids that impact the cavity, scarring, polyps and congenital malformations such as a uterine septum.
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.
Uterine fibroids ( also known as myomas ) affect 30% of women. They occur in various sizes, numbers, and location in the uterus requiring different types of myomectomy. A pelvic exam, ultrasound, MRI, or hysteroscopy accurately diagnose fibroids. If your physician determines that removal of the fibroids will increase your chance of pregnancy, either a hysteroscopy, laparoscopy, or laparotomy is advised.
A woman may be ovulating, but in some cases the uterine lining does not develop adequately for implantation of the embryo. In an endometrial biopsy, a small sample of the woman’s uterine lining (endometrium) is removed. This biopsy is the most reliable measure of a woman’s luteal phase (the portion of a menstrual cycle before menstruation, but after ovulation).
By performing a biopsy, healthcare providers can evaluate whether or not the uterine lining responds normally to progesterone. The effect of progesterone is measured by the adequate preparation of the uterine lining.
An endometrial biopsy can also evaluate abnormal uterine bleeding, which is also generally reflective of hormone imbalances.
The procedure is usually done three to seven days before a woman’s menstrual period is expected to begin and is performed in our rooms. Before an endometrial biopsy, it is important to make certain that the woman is not pregnant.