Endometriosis / endometrioma
Possible scaring after surgery
IVF success after removal of tubes for ectopic pregnancy
Reduced fertility after reproductive surgery
Tubal obstruction
Removal of hydrosalpinx before IVF
Cervical dysplasia
Laparoscopy for endometriosis
Diagnosing endometriosis
Congenital uterine anomaly
Question: I just recently had a laparoscopy after trying to
conceive for 18 cycles. I had an endometrioma on each ovary
and adhesions pulling my ovaries down and they were stuck
to the back of my uterus. Luckily my tubes were fine. They
were able to free everything up and get all the endometriosis
out. I feel very blessed. I did not conceive the same cycle
as my lap nor was I expecting to since I had so much healing
to do. My question is what are my chances of conceiving now?
Are there any statistics on success after having a laparoscopy?
Also, my RE thinks I may have another endometrioma developing
on my right ovary. He saw this only three weeks after my surgery.
Could it be possible that it could already be growing back?
Also, could it be scarring from my surgery where he removed
the endometrioma? This scares me. Please help. Do I have any
chance of conceiving?
Comment: First the bad news. Endometriosis is usually not
"cured". With what sounds like at least moderate
(stage 3 and possibly severe stage 4) endometriosis, "all"
the endometriosis is never removed. Repeat scarring after
surgery is common. Our hope with surgery is that the resulting
adhesions are much less severe than those removed. Now, the
good news is that endometriosis can be effectively treated.
Our therapeutic goals are to move individuals from intolerable
to tolerable pain patterns and from infertility to fertility.
A realistic expectation from surgery alone is about 25-33%.
Chances of fertility are dependant on the amount/location
of endometriosis, how much and how well the endometriosis
was removed. Our major treatment options for endometriosis
are laparoscopic surgery and GnRH analogs such as Lupron.
Use of Lupron can be effective in reducing the amount of endometriosis
and should be considered depending on the amount of endometriosis
remaining and pain. Lupron use is hardly mandatory. Sometimes,
a pregnancy is achieved in the first several cycles after
surgery. It is also very good news that both tubes are open.
If there is an additional problem of ovarian dysfunction/lack
of ovulation, the situation becomes more complicated. If there
is advanced endometriosis, ovulation problems and especially
if there is and additional male factor, I am usually relatively
quick to move to IVF.
Question: I am 25 years old. I had a salpingo-oophorectomy
at age 15 due to torsion of an ovarian cyst. Now I have been
trying to conceive for a year. Meanwhile, I was diagnosed
with borderline hypothyroidism and treated with 50 micrograms
Levoxyl. My TSH is normal now, but I am still not pregnant.
My periods are very regular, five days in length every 28
days, and I ovulate regularly on day 14. I am due on next
cycle for a hysterosalpingogram. What could be the cause of
infertility in my case? Is it my one ovary? Or hypothyroidism?
Or what else? My husband's test results were normal.
Comment: If the TSH is normal, periods regular and temperature
charts /ovulation detection kits suggest ovulation, then there
should be concern about anatomic factors. There could be tubal
blockage, which often is seen during a hysterosalpingogram
(HSG), or it may be due to scar tissue from the previous surgery
that may only be revealed by a laparoscopy. sst
Question: When I had my tubes removed (after a tubal pregnancy)--I
was told that without my tubes I had a better chance for pregnancy
if I chose IVF. Is this true? I am 30 and everything else
is working well (ovulation regular--ovaries in great shape,
and hubby is fine). I have talked with some other women that
have similar problems, and some say that people with a history
of blocked tubes may have a problem with the tubes being “toxic”
for IVF. What are your thoughts?
Comment: Please check the "What's up doc?” portion
of our site. It contains a review of an article concerning
this very issue. Your doctor was right. Unfortunately for
some, the first part of preparation for IVF is removal of
fluid filled tube(s) (hydrosalpinges). It is good that this
has already been done for you. You sound like a very good
candidate for IVF. sst
Question: I am 34 years old, my husband is 39. We just experienced
a failed IVF attempt. One previous attempt was not fully completed
because of the different maturation rates of the follicles.
We did not make it to the retrieval stage. On this attempt,
four eggs were retrieved; three fertilized and were placed
in my uterus. My pregnancy tests last week were negative.
The doctor appears frustrated with my low response in terms
of follicle development at my age. I have, over the years,
had six abdominal surgeries, including a ruptured appendix
many years ago, which resulted in adhesions on my ovaries
and fallopian tubes. All of one tube and the majority of the
other were removed nearly two years ago. Our hopes have nearly
been shattered. What could be some of the possible reasons
for the low follicle development and for the embryos not attaching
to the uterine wall? Is there such a surgery as tubal "replacement"
(donor fallopian tubes)? Could an abundance of candida in
the system (male/female) have had any effect on the success?
We may make one more attempt... Is there anything we can do
to increase success or to increase our hopes?
Comments: The ovary has a finite number of oocytes that are
present at birth and are gradually depleted over the next
50 years. In cases of multiple abdominal or pelvic surgeries
it is possible that a portion of the ovary was removed and
therefore would advance the "biologic” age of the
ovary. A second possibility is that ovarian function may be
diminished by altering the blood supply to the ovary. This
is easy to do with tubal surgery. Thirdly, the pelvic adhesion
may encapsulate the ovary and prevent the growth of multiple
follicles. Each of these, or a combination of the three, may
be a possibility in your case. I don't know a way of restoring
normal ovarian activity and if it has been severely compromised,
oocyte donation may be the best solution. You might improve
your chances by changes in the ovarian stimulation protocol.
It's hard to say whether more, or less, would be better. This
is better left to a discussion with your infertility specialist
who knows the details of your response thus far. There is
no possibility of donor tubes because of the high chance of
rejection of the organ graft. Candida is everywhere, especially
through out the digestive tract. It has been linked to immunologic
compromise and general poor health but I know of no relationship
between yeasts and IVF failure. If in doubt, treat-- treatment
is usually easy. sst
Question: What does your center recommend as treatment for
blocked tubes. I may have blocked tubes. My doctor wants to
do another HSG to be sure. If they are in fact blocked, then
he's recommending a transcervical wire tuboplasty to be done
by an invasive radiologist. What are your comments on this?
Comments: In some ways this is a more complex question than
you might think. The overall plan of action should take into
account your age, length of infertility, ovulatory status,
male factors and results of the first hysterosalpingogram
(HSG). About 10-15% of HSG's gives false positive results
and there may be no blockage, only tubal spasm. So, things
might not be as bleak as they appear. I do few HSG's. This
is somewhat unconventional and many still believe that they
are a standard part of an early fertility investigation. I
don't do HSG's because they hurt, are costly, and often give
inclusive results. If the HSG is positive, (meaning that something
is found), a laparoscopy and hysteroscopy is indicated. If
negative, (normal), I don't trust the results. Often the tubes
are open, but endometriosis and/or scar tissue prevents normal
functioning and egg pick-up. Usually, I will ensure all other
parameters are normal, even give a couple of cycles of clomiphene,
then proceed to laparoscopy. But in your case we must have
a high suspicion that tubal disease might be present. In the
hands of an experienced radiologist the opening of the proximal,
or cornual, obstruction is relatively effective. I am not
sure why another HSG is needed before the radiologist evaluates
the tubes Can’t this be done at the same time? I can
see nothing wrong with the approach your doctor has taken.
However, it is not the approach I usually use. In your case,
I would perform a laparoscopy and hysteroscopy to evaluate
the entire pelvis. If there were only a proximal blockage,
I would use hysteroscopy to visualize the opening of the tubes
into the uterus and try to open them with a wire or catheter,
such as above. I feel it is important to know the status of
the other, distal, ends of the tubes as well. If these are
blocked, the prognosis for natural fertility is relatively
slim. It even may be preferable to purposely block, or remove
the tubes, or a tube, if severely damaged. Still, with tubal
disease our chances for pregnancy may be excellent, although
in vitro fertilization may be required. sst
Question: I was reading an article in your archives from Fertility
and Sterility regarding the success of IVF when the patient
has a hydrosalpinx. I have had a salpingostomy via laparoscopy
but was not quite ready to have a salpingectomy. (Left tube
is the culprit - right side is questionable but no hydrosalpinx).
I have had one unsuccessful IVF and one unsuccessful FET.
How successful has your center been in treating patients with
hydrosalpinx, and did I make a mistake by not having the left
tube removed?
Comment: This relatively new data about the effect of hydrosalpinx
has made my life much more difficult as a laparoscopist. Before,
we did our best to open the tubes and if unsuccessful, we
proceeded to IVF. Now, as a portion of informed consent, I
must explain to each patient with suspected tubal disease
that closure or removal of the tube may be in their best interest.
It is still a hard decision for everyone to end natural fertility.
. It seems clear that hydrosalpinx decreases IVF success.
This is supported in many studies. The mechanism is probably
related to a back flow of fluid into the uterus around the
time of implantation. Presently, my recommendation depends
on the status of the tubes. While I am not a big advocate
of hysterosalpingograms, an HSG may be in your best interest
before another IVF attempt. If there is clearly a hydrosalpinx
on ultrasound, or a fluid collection outside the ovary during
your IVF cycle, an HSG might not be necessary. If a hydrosalpinx
is found, all evidence now suggests the tube, or tubes be
closed or removed. A potential down side of removal of the
tubes is the alteration of the blood supply and possibly diminished
ovarian function. Obviously care should be taken during this
procedure.
Question: Can dysplasia affect your fertility, especially
after being treated with cryosurgery?
Comment: Generally cryosurgery will have no effect on fertility.
Deeper biopsy or destruction of the glands of the cervical
canal can affect fertility by destroying the cervix's capacity
to serve as a reservoir for sperm or by altering mucus production.
sst
Question: I am 30 years old and my husband and I have been
trying to conceive for four years! I had a laparoscopy 3 years
ago and laser surgery for moderate to severe endometriosis.
My doctor told us to wait 6 months after the surgery to see
if we would get pregnant naturally. Then I went on drug therapy
and finally a year after surgery tried induced ovulation that
failed. Now we just tried IVF once and that failed as well.
I feel the endometriosis has come back and need another surgery
to remove adhesions and scar tissue before trying IVF again.
I have severe pain at times and believe I have adhesions between
my uterus and bowels. Would this prevent the embryos from
implanting? Do you think a second surgery could possibly improve
the chances of IVF working? Please help! We only have 2 more
tries with IVF before throwing in the towel.
Comment:
The scoring system used by the American Society for Reproductive
Medicine (ASRM) ranks the degree of endometriosis as minimal,
mild, moderate, or severe (Stages I-IV). This scoring system
is considerably more accurate in predicting fertility than
pain. Some have argued that fertility is not decreased with
minimal and mild endometriosis, but is often significantly
decreased with moderate and severe endometriosis. Success
with IVF is significantly lessened in those with severe endometriosis.
A part of this reduction may be attributed to an adverse effect
on tubal function, but most important is the issue of reduced
the egg stores, whether by the effect of endometriosis in/on
the ovary itself, or surgery on the ovary to remove endometriosis.
At 30 and with moderate endometriosis, your chances of IVF
success should be quite good. There is no conclusive proof
that endometriosis alters implantation. The decision about
surgery should be based on the pain pattern, or presence of
endometriotic cysts, perhaps even more than infertility. It
seems logical that the more normal the pelvic anatomy is,
the greater the likelihood of success. sst
Question: I am 39, have an eight-year-old son. I have always
had painful menstrual cycles since the onset at age 12. I
have been trying to conceive over the past year and have not
been successful. I have used the ovulation prediction kits
and still no success. My cycles have varied from 26-30 days.
I have always been 28-30 days each month. I never know from
month to month if the pain is going to be unbearable to the
point of vomiting from the pain. I do not know if I should
have an exam to find out if I have endometriosis. If the doctor
finds endometriosis, is this treatable and are there chances
that I could have another child?
Comment: It is commonly stated that approximately 30% of infertile
women will have endometriosis to some degree. The triad of
painful menstruation (dysmenorrhea) painful intercourse (dyspareunia)
and painful bowel movements (dyskezia) are the most common
reported pain abnormalities. The more pain, the more likely
the diagnosis of endometriosis. Abnormal pain associated with
menstruation or ovulation is endometriosis until proven otherwise.
While ultrasound scan cannot detect the scarring or implants
of endometriosis, it may yield a high suspicion if a persistent
cyst is found. An endometrioma, often called a chocolate cyst
because of the enclosed endometrial fluid, is often associated
with some degree of ovarian compromise and its removal usually
is needed. While history and pelvic exam may suspect the diagnosis
of endometriosis, it is only by direct viewing at surgery
that the definitive diagnosis is made. It is quite possible
that you have endometriosis and have had for a long time.
At age 39, your age may take precedence over this diagnosis.
It is important that a blood test on cycle day 2-3 be obtained
to measure egg stores. While a laparoscopy may be in order,
there may not be the time for medical therapy if a primary
objective is fertility. This is an excellent example of the
need for a good working relationship with your fertility specialist
and a discussion of how your objectives can be best put into
a plan. sst
Question: After trying to get pregnant for nine months, I
went to a specialist who performed vaginal ultrasounds, estradiol
checks, and finally an HSG. The HSG was extremely uncomfortable,
and the results showed a very small uterus and cervix. In
addition, the left side of the uterus was not visible, apparently
due to scar tissue, and my uterus appears to be subseptate.
The physician is recommending a laparoscopy and hysteroscopy
to fix the dip in my uterus. What are the risks of these two
procedures? What are the risks of pregnancy without these
procedures assuming I eventually got pregnant? What are the
risks of not having the surgery if I decide not to have children?
Comment: What your physician seems to be describing is a sub-septate
uterus. If this turns out to be the case, the problem is congenital,
a birth defect. The uterus begins its development as 2 tubes
that merge into one. The center is then hollowed out. All
of this occurs before birth. Failure of the tubes to either
completely fuse, or to incompletely undergo the "hollowing
out” process is a relatively common problem. A septum
is a band of tissue that remains in the center of the uterus.
Sometimes surgery is helpful, sometimes not. It is usually
a relatively easy procedure to remove a simple septum through
the hysteroscope, although sometimes it may be more difficult.
It depends on the individual case. There are many varieties
of these defects. The diagnosis is made by hysterosalpingogram
(HSG), or hysteroscopy. Many believe that uterine abnormalities
do not cause infertility unless they are quite severe. There
is definitely an increased risk of miscarriage, but it is
probably less than 25%. There is also an increased risk of
preterm labor; probably less if corrected, but a correction
does not make the risk disappear. Sometimes a C-section will
be recommended if there has been intensive surgery on the
wall of the uterus. There is a 10-25% risk of an abnormality
of the urinary tract, sometimes even an absent kidney. Some
recommend that a dye test called an intravenous pyelogram
(IVP) where a small amount of dye, injected intravenously,
outlining the path of urine from the kidneys into the bladder,
be performed to evaluate the kidneys and ureters. The IVP,
unlike the HSG, is painless. There is a vast array of these
abnormalities and your physician has the most direct evidence
of your particular situation. All the questions that you have
posed should be asked of him/ her and should be satisfactorily
addressed, although the precise answer may not be known. They
are an integral part of informed consent about the procedure.
Your physician should also have experience in surgical treatment
of such problems. Many, if not most, fertility specialists
do. sst
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