Fertility and age
Age definitely plays a major and often primary role in infertility. With age, egg quality decreases, as does egg number. Chromosomal abnormalities of eggs increase significantly after the age of 35, and continue to increase to very high levels. After the age of 40, chromosomal abnormalities of the egg may be 90 percent or higher. This means that successful fertilization does not occur, or that the embryo that does form may not implant into the lining of the uterus to grow, or may miscarry during early pregnancy. Often fertility doctors will obtain an AMH (anti-Müllerian hormone) level that is helpful in estimating egg number, but does not determine the quality of the eggs.
Infertility and Cost
CIGC physicians play a major role in fertility planning, providing patients with realistic information on pregnancy options and costs. Infertility can become very expensive, and all too often patients will undergo unnecessary IUI (intrauterine insemination), IVF, or other expensive fertility procedures that may not be beneficial or even indicated. Since in many cases IVF treatments are not covered or only partially covered by insurance and require out-of-pocket payments, make sure that the fertility services you are receiving are indicated and priced appropriately. Patients can always consult a CIGC physician for more information and planning strategies to help lower costs and increase success.
The causes of infertility include a variety of complex GYN conditions, including the following:
Endometriosis is associated with infertility in 50 percent of women in a variety of ways1. Endometriosis is an inflammatory process, and it is though that inflammation causes infertility by preventing the sperm and egg from joining into an embryo, as well as affecting tubal function and implantation of the embryo into the uterine lining. Endometriosis is the presence of endometrial tissue (the lining of the inside of the uterus) in a location outside of the uterus. This disease in the ovaries can cause the formation of endometriomas, disrupting ovarian function. Severe endometriosis can cause pelvic adhesions, preventing conception.
Endometriosis. A black implant noted on the left ovary, an endometrioma on the right ovary, and a blocked fallopian tube, or hydrosalpinx, which can decrease implantation of the embryo.
This is the same patient with Stage 4 endometriosis involving the left and right ovaries, and severe adhesions to the colon. The red structure is a laparoscopic tourniquet used for removal of fibroids.
Fibroids that push into the uterine cavity (submucosal fibroids) or those that impinge on or are close to the lining where the embryo implants are especially associated with lower implantation rates, lower pregnancy rates, and increased rates of miscarriage2. Fibroids, or leiomyomas, are benign tumors of the uterine wall. They are very common, affecting over 80 percent of all women. Fibroids can vary greatly in size and quantity. They can distort the size of the uterus as well as distort the inner lining.
Submucosal Fibroid in the Anterior (top) wall of the uterus.
Fibroids and focal adenomyosis in the uterus
Adenomyosis occurs when the lining of the uterus grows into the muscle of the uterine wall, and can grow over time to cause infertility. Infertility is the result of inflammation due to the growth of the endometrial cells into the muscle, which may affect implantation of the embryo. This is a very common condition in older fertility patients, and is often seen in patients who have previously had a cesarean section or myomectomy (fibroid removal). The reason for this is that surgery on the uterus often displaces the cells lining the uterine wall into the muscle, causing inflammation, thickening of the uterine muscle, decreased blood supply for the placenta to grow, and infertility.
Adenomyosis and MRI Scans
An MRI (magnetic resonance imaging) scan is the best option for diagnosing adenomyosis but misses the disease in up to 20 percent of patients and is expensive. For patients experiencing infertility and considering IVF treatments, an MRI is absolutely essential to ensure that “diffuse” adenomyosis is not present. Diffuse disease means that the adenomyosis involves the majority of the uterine muscle, and in these cases expensive IVF procedures may not be of benefit. There are cases in which patients with undiagnosed adenomyosis by their fertility specialist have undergone unsuccessful, multiple IVF cycles at very high costs. In fact, women with adenomyosis have a 28 percent reduction in pregnancy with IVF compared to those without3. Focal adenomyosis involves only a small area of the uterine muscle. Although focal disease can also cause infertility, diffuse disease has much lower pregnancy rates and more severe symptoms.
A hydrosalpinx is a fluid-filled fallopian tube that can cause infertility and occurs when the tube is blocked at the end. Inflammatory fluid accumulates within the tube, causing it to be dilated. It is thought that the inflammatory fluid can flow into the uterus, causing a hostile environment for an embryo and decreased implantation rates4. The presence of a hydrosalpinx is associated with a 50 percent lower success rate among women undergoing IVF5. A normal tube will push an embryo toward the uterus but a hydrosalpinx has abnormal flow — which increases the chance for the embryo to implant there, resulting in an ectopic pregnancy.
Hydrosalpinx right tube. A right hydrosalpinx - a dilated right tube that is fluid filled, and can decrease fertility.
Hydrosalpinx left tube. Left hydrosalpinx secondary to endometriosis
Pelvic adhesions surrounding the ovary may impair the ability of an egg to reach the tube after ovulation causing infertility. Adhesions of the tube can prevent the sperm from reaching the egg, or an embryo from reaching the uterus. Adhesions are the adhesion of structures within the pelvis and can vary widely in severity. They can simply be two structures adherent to one another, or they can be bands of adhesions between two structures. They can result from prior surgery, pelvic infection (such as pelvic inflammatory disease), or endometriosis.
Intrauterine adhesions can cause infertility by obstructing the tubal opening, which can prevent conception, or by disrupting the uterine lining, which may prevent implantation. Sixty-three percent of women with intrauterine adhesions have some degree of infertility. Intrauterine adhesions are usually the result of uterine trauma or infection. Risk factors include having had any uterine procedure, such as a dilation and curettage (D&C), myomectomy, or cesarean delivery, or pelvic infection.
It is thought that polyps cause infertility by disrupting the lining of the uterus, thus interfering with implantation of a fertilized embryo. Polyps are excess growths of the lining of the uterus, or endometrium. One study showed that pregnancy rates among women who had their polyps removed were 63 percent, as compared to 28 percent among women who did not6. Miscarriage rates are also higher among women with uterine polyps7.
Women with a uterine septum are at a significantly higher risk for miscarriage and infertility. It is thought that the septum is a poor environment for an embryo to implant in because of the poor vascular supply. A uterine septum is a type of congenital malformation where the uterine cavity has a wedge-like wall at the top of the uterus, which protrudes into the uterine cavity. If an embryo is able to successfully implant, the septum is unable to support the growing embryo with adequate blood supply and nutrients, resulting in early pregnancy loss. Presence of a uterine septum is associated with a 41 percent early miscarriage rate8.
A septum in the uterus dividing the uterus into two separate sections.
Symptoms of infertility can vary widely depending upon the condition. Some women will have no symptoms at all, and the condition might only be discovered during an evaluation for infertility. Polyps and fibroids can cause irregular or heavy menstrual bleeding. Endometriosis and adenomyosis can cause very painful periods, pelvic pain, pain with intercourse, pain with bowel movements, and low back pain. Intrauterine adhesions may sometimes cause abnormally light periods or even complete absence of periods, a condition known as Asherman’s Syndrome. Additional symptoms include cramping.
GYN conditions can be complex and often difficult to diagnose. Diagnostic tests and techniques range from imaging to in-office or operating room procedures including hysteroscopy (looking inside the uterine cavity) and laparoscopy (minimally invasive evaluation of the pelvis to look at the outside of the uterus, tubes, and ovaries). Imaging tests can show indications of polyps, fibroids, uterine septum, or abnormal tubes.
Imaging tests include ultrasound, MRI, sonohysterogram (ultrasound look at the inside of the uterus), or hysterosalpingogram (HSG), which evaluates whether the tubes are open and assesses their overall shape.
Pelvic adhesions and endometriosis cannot be seen on imaging tests. For a definitive diagnosis, the abnormalities must be seen directly with laparoscopy for evaluation and removal.
Hysteroscopy is the insertion of a small, thin, telescope-like camera into the uterus to identify and treat uterine polyps, fibroids, and septum. A hysteroscopy cannot see the ovaries or tubes, and can only see and treat abnormalities inside the uterine cavity.
Laparoscopy is the insertion of a small, thin, telescope-like camera into the abdomen, usually through the navel. This allows for a full evaluation of the pelvis, including the uterus, tubes, and ovaries. Endometriosis, pelvic adhesions, and hydrosalpinx would all be seen through the laparoscope. To evaluate whether the tubes are open, dye can be injected through the cervix and into the uterus in a procedure called chromopertubation. The tubes are confirmed to be open if the dye is seen to spill out of the tubes.
Treatment of infertility can be achieved through minimally invasive GYN surgery, either hysteroscopically, laparoscopically, or through a combination of both.
The diagnosis of endometriosis can only be made by laparoscopy, in which the extent of the disease is diagnosed, and then removed at the same surgical procedure. Too many patients with this disease are not diagnosed early, or at all, by their OBGYN. The result is persistent pain, bleeding, and progressive infertility over time. Any diagnosis of endometriosis requires pathological confirmation — meaning that excised implants of the disease are sent for analysis to confirm that endometriosis is present. There is no role for the clinical diagnosis (nonsurgical diagnosis) and medical management of this disease using birth control or other hormonal therapy for fertility patients. The reason for this is clear — medical management does not diagnose the extent of the disease, does not confirm that the disease is present, and does not remove or adequately treat the condition. Time is never on the side of any fertility patient, since egg quality decreases over time. The use of medical management over a longer time period will allow for progression of the disease, increased pain and bleeding, and decreased egg quality.
Laparoscopic removal of endometriosis has significant benefits in managing pain and bleeding, and will decrease inflammation, thereby potentially allowing for an increased pregnancy rate following surgery. Laparoscopy will help guide the CIGC surgeon toward referral to a fertility specialist sooner rather than later, especially for those patients with extensive disease. Laparoscopic removal of moderate to severe disease has shown to increase IVF rates as well by decreasing inflammation, which may help with implantation of the embryo into the uterine lining at the time of transfer9,10.
Surgical removal of fibroids involving the uterine cavity or those fibroids near or impinging on the cavity (intramural fibroids) need to be removed.
Although patients with fibroids can become pregnant, when fertility is an issue or when IVF is required, it is important to remove any fibroids involving the uterus that may impair fertility. This will allow for higher pregnancy rates for patients trying to conceive naturally by enhancing tubal function (fibroids obstructing the tubes), optimizing implantation (removing fibroids near or in the uterine cavity), and allowing for growth of a normal pregnancy when larger fibroids involve the muscle. For those patients with IVF, fibroid removal is more important to optimize the uterine cavity for implantation and normal growth of the baby. IVF is an expensive process. Sometimes fibroid removal is necessary to minimize the number of cycles being used to achieve pregnancy.
Fibroid locations in the uterus
Large numbers and size of fibroids in the uterus, affecting fertility.
This patient had many fibroids in the uterus, some of which were the same size or larger than the uterus itself.
At CIGC, laparoscopic removal of fibroids is through the LAAM® technique — laparoscopically-assisted myomectomy. This procedure allows for removal of fibroids involving the cavity or muscle, and has significant benefits over standard laparoscopic or robotic removal in that tactile sense — the ability to feel the fibroids — is preserved, ensuring removal of even the deepest fibroids to the cavity. LAAM allows for removal of many fibroids at all locations, and provides for a strong muscle closure and a fast recovery back to work in two weeks. This is a very reasonable option for fertility patients requiring an effective treatment method with the fastest recovery possible.
Adenomyosis is not amenable to laparoscopic or surgical removal, since removing adenomyosis will also remove large areas of the uterine muscle, leading to uterine scarring to the muscle and cavity. At times, a “focus” of adenomyosis can be removed, but often extensive scarring results. For those patients with diffuse disease that are not able to become pregnant, surrogacy should be offered. The use of a surrogate uterus allows someone else’s uterus to become pregnant with the patient’s egg and partner’s sperm. Surrogacy is expensive, but is often the best option for patients with extensive adenomyosis, or for those patients undergoing extensive fibroid removal with a severely damaged uterus.
Dilated or abnormal tubes, also known as hydrosalpinx, which stands for water in tubes, can be evaluated at the time of laparoscopy and can require removal. For any fertility patient, it is important to understand that flow of toxic fluid from a dilated tube can impair fertility up to 60 percent of the time. Tubes that are swollen are damaged, and removal of the entire tube is the best option. Attempts at preservation of the tube lead to a high rate of scarring, recurrence of the hydrosalpinx, and possible ectopic pregnancy — the implantation of an embryo into the tube, which can be a medical emergency if not treated. Ectopic pregnancies can rupture and bleed extensively, and can also cause permanent damage to the tube.
Lysis of Adhesions
Sometimes, adhesions can be removed to help open the tubes and mobilize the ovaries. Treatment of pelvic adhesions has been shown to improve pregnancy rates by restoring normal anatomic locations of the pelvic organs and removing barriers to conception.
Uterine polyps, submucosal fibroids, intrauterine adhesions, and uterine septum can be removed hysteroscopically. Hysteroscopic procedures do not require any incisions, and most women are able to return to work the following day.
Polyps and fibroids can be resected using a resectoscope, and filmy or mild intrauterine adhesions can be cut with hysteroscopic scissors. Extremely dense adhesions are removed using a resectoscope, often with the assistance of a laparoscope to avoid perforation of the uterus.
Intrauterine adhesions can be prevented by using good surgical techniques, minimizing trauma to the uterus and uterine lining, and preventing infection. Following an extensive uterine surgery or resection of intrauterine adhesions, an intrauterine balloon can be placed inside the uterus for approximately seven days to help further prevent adhesion formation. At CIGC, a special “form fitting” balloon is placed inside the uterine cavity that covers the lining better than other types of balloons. This keeps the walls within the uterus from touching each other as they heal, thus preventing them from adhering to each other. High-dose estrogen can be given at the same time to help the uterine lining to proliferate, which also prevents adhesion formation. This is usually taken for one to two months, after which time seven to 10 days’ worth of progesterone is taken to induce a period.
Cook form fitting intrauterine balloon
A second look inside the uterus with the hysteroscope is usually conducted one to two months afterwards. Severe adhesions may require several rounds of this protocol.
The CIGC Difference
Conditions that can cause infertility include fibroids, endometriosis, pelvic or intrauterine adhesions (scarring), uterine polyps, uterine septum, and hydrosalpinx (inflammation of the fallopian tubes). For women struggling with infertility, time is of the essence and choosing the best minimally invasive infertility surgeon to treat your condition can help with a faster recovery. CIGC minimally invasive GYN procedures are designed to diagnose your situation and treat your condition with as short a recovery period as possible.
CIGC physicians will also provide advice and assistance on navigating through the various options for fertility care, especially when those options involve IVF. Optimal surgical outcomes will enhance fertility rates, and CIGC surgeons provide specialized techniques and procedures that help to increase success. Certain types of IVF procedures may not be necessary for many patients, and sometimes it is the responsibility of the patient’s CIGC surgeon to ensure that money is not spent unwisely and that time frames are kept to a minimum. For more information on ways to optimize fertility care and decrease costs, consult with a CIGC surgeon for more information.
Specialists Not OBGYNs
It might be your first instinct to get treated by your OBGYN when you first find out that you are infertile. Many patients have strong relationships with their OBGYNs and do not realize that there may be a better option when it comes to diagnosing the cause of — and treating — their infertility. However, diagnosing the cause of infertility often requires a surgical procedure when imaging tests don’t provide all the answers. Since OBGYNs are generalists, not specialists, they are not trained or experienced with advanced minimally invasive technology. Many OBGYNs are only trained in performing open or robotic procedures, which are more painful, more expensive, and higher-risk. CIGC, however, is a leader in the field of minimally invasive infertility surgery. Our powerful and unique technologies allow our surgeons to identify all of the anatomy during the surgery with only tiny incisions. Some of our procedures are so minimally invasive that many patients are able to return to work the next day.
We Partner with OBGYNs
Your OBGYN focuses on obstetrics care. Our focus is GYN surgery only. It is always better to have an infertility treatment from a specialist, and CIGC physicians have experience with the most common causes of infertility, including endometriosis, fibroids, and adenomyosis. CIGC surgeons have specialty training in laparoscopic surgery and hysteroscopic procedures, leading to better outcomes and higher fertility rates. For more information, book a consult with a CIGC surgeon to review your fertility options.
Ready for a Consultation
If you’re struggling with infertility, our specialists are ready to provide an evaluation of your symptoms and conditions and recommend an appropriate solution.
Related Blog Posts
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