50% of All Infertility
50% of all infertility is the result of some abnormality of the woman’s reproductive organs. Damage to the female reproductive tract most commonly occurs from either endometriosis, damage from a previous pelvic infection or damage from previous pelvic surgery. In fact, the most common reason for pelvic adhesions is previous pelvic surgery.
Other major but less common causes include congenital abnormalities of the uterus or tubes and DES exposure which is fortunately becoming a problem of historical interest only - at least in terms of infertility. Fibroid tumors of the uterus are quite common, though less so in women trying to conceive.
Damage to or congenital abnormalities of the reproductive organs may either keep a woman from conceiving or may predispose her to recurrent miscarriage. Sometimes, the same problem will do both, depending on its severity. Fibroids are an example of this. Smaller fibroids may cause a woman to lose pregnancies whereas very large fibroids will keep her from conceiving. The location of the fibroids is often more important than their size.
A woman who is DES exposed also has the same problem - some will lose pregnancies and others will not become pregnant.
Prior to 20 years ago, the only way to diagnosis abnormalities of the reproductive tract was to perform an X-ray called a hysterosalpingogram. We now recognize, however, that the hysterosalpingogram can be inaccurate in a substantial percentage of cases. Women thought to have a problem by hysterosalpingogram often turn out to have nothing wrong at all. If the hysterosalpingogram is performed incorrectly, it will show an abnormality when none exists. However, women can have very significant degrees of pelvic damage, particularly from endometriosis, with a totally normal X-ray.
The only way to accurately assess the status of the woman’s reproductive organs is to look at them and this requires laparoscopy. Not only is laparoscopy diagnostic, but because of the advances in technology over the last 10 years or so, it has become therapeutic as well. In fact, for many types of problems, laparoscopy and laparoscopic therapy are the only treatments necessary. Problems that would have required open surgery can now be treated completely, effectively and even better by laparoscopic techniques. There are problems such as very severe endometriosis, severe tubal disease, and severe post-operative adhesions that still require open surgery.
The same is true for abnormalities of the uterus where hysteroscopy is used to both diagnose and treat problems such as fibroids inside the uterus and some congenital abnormalities as well. Many problems diagnosable by hysteroscopy may be missed by a hysterosalpingogram.
In many instances, it is necessary to use the information from both the laparoscopy and X-ray to accurately assess the problems that a woman might have. This is vitally important because the treatment that is offered depends upon knowing exactly how bad the damage is. Now that IVF is becoming routine and fairly successful as it is (30% in a good program but only 20% overall), many couples are opting to go directly into an IVF program rather than go through the surgery necessary to correct severely damaged tubes. This is true because the success rate from correcting severely damaged tubes is the same as the success rate for IVF. However, before this advice can be given to a couple, it is critically important to determine exactly how bad the damage is. I have seen many women who were prematurely pushed toward IVF when they had problems that were easily and highly treatable by traditional means.
Unfortunately, another factor that must be considered is whether or not that couple’s insurance company will pay for IVF or whether they have the financial resources necessary to pay for it on their own. Many couples who are actually better candidates for IVF may be forced into undergoing corrective surgery or other therapies because that is the only treatment their insurance company will pay for.
Pelvic damage from either a pelvic infection or pelvic surgery is usually easy to diagnose and the treatment is straight forward.
Endometriosis is its own special case and has been dealt with in another pamphlet.
DES exposure is also a special case. Many women were exposed to DES but do not know it. However, the appearance of the uterus on X-ray is very typical and makes the diagnosis even when no history is available.
Most women who are DES exposed have impaired fertility. Unfortunately, there is nothing that can be done to substantially alter that situation. Nonetheless, women who are DES exposed frequently have other complicating factors such as endometriosis. Even though the DES created damage cannot be fixed, treating the other problems will allow the couple to achieve a successful pregnancy. Fortunately, DES is no longer used. At one time, it was very common to see DES exposed women with infertility problems. Now, the vast majority of DES exposed women are of the age where fertility is no longer a consideration.
Another common pelvic problem is the presence of fibroid tumors - the most common benign tumor in the female pelvis. If appropriate studies are done, probably 50% of women by the time they reach the age of 40 have one or more small fibroids. These are of no consequence and do not require treatment.
The real dilemma occurs in women with a fertility problem or in women who will, at some time in the future, wish to have a baby.
For women with significant fibroids who wish to preserve their future fertility, removal of the fibroids is the treatment of choice. This operation, called a “myomectomy”, is usually quite successful in forestalling any more radical surgery. However, women undergoing myomectomy must understand that they have a 25-40% chance of needing additional pelvic surgery in the future. It is not a magic cure-all despite an attempt by some recent books and TV programs to make women believe that it is a simpler and easier alternative to hysterectomy. A myomectomy is major surgery that is at least as complicated as a hysterectomy and often more so.
A larger dilemma arises when a woman who is trying to have a baby is discovered to have fibroids. If that woman has a history of recurrent miscarriage and it seems fairly certain that the fibroids are responsible for this, then again, removal of the fibroids is the treatment of choice. This is easy when the fibroid actually projects into the uterine cavity.
Unfortunately such women are a relatively small percentage of women with fibroids. More often, women who are trying to get pregnant are discovered to have fibroids but in these women, they have never achieved a pregnancy. It can then be quite difficult to determine whether or not the fibroids themselves are playing a significant role and whether surgical removal is necessary. The location of the fibroid is important but so is the size. Large fibroids (larger than 3-4 cm in diameter) probably play a role in infertility even if they are not near the lining of the uterus.
Another significant problem that is becoming more common are those women who have small fibroids that are initially of no consequence. However, with many of the therapies currently used in infertility, most notably Pergonal or similar drugs, the very high estrogen levels achieved during the menstrual cycle stimulate these fibroids to grow. What was then a minimal problem becomes a significant problem and many of these women ultimately undergo myomectomy because the fibroids have enlarged to a significant degree.
Hysteroscopy is another important diagnostic and therapeutic tool. The hysteroscope is a smaller version of a laparoscope and permits direct visualization of the interior of the uterus. Many problems are best diagnosed and treated by hysteroscopy. The treatment of a uterine septum, a problem which formerly required open surgery, can be carried out much better and much more simply by resection through a hysteroscope. Scar tissue within the uterus can be best diagnosed and treated through a hysteroscope. Fibroids that impinge on the uterine cavity can also be resected through a hysteroscope if they are not too large, thereby sparing the woman an open surgery.
Minor degrees of pelvic damage or early endometriosis can also be treated by this technique.
A newer technique you may read about is called “Transvaginal Hydrolaparoscopy”. A small laparoscope is inserted through the upper vagina and the pelvis is filled with saline to float the pelvic organs. It can be done in the office under local anesthesia. Visibility is limited but it may become a good screening technique. However, it is too new to be sure.
Pelvic damage from a previous pelvic infection is another common reason for infertility. The bacteria that causes the damage is Chlamydia. The real problem is that 90% of the infections caused by Chlamydia are clinically silent. The woman has either no symptoms or such mild ones that she does not seek out medical attention.
Fortunately, there is a blood test to detect the presence of antibodies to Chlamydia. This blood test should be a part of every infertility evaluation and if the test is positive, it indicates a high degree of probability that pelvic damage from the infection is playing a role in that couple’s problem.
If a woman has a positive Chlamydia antibody, she should undergo a Hysterosalpingogram prior to any other investigations. It is important to know whether a woman has any evidence of tubal disease prior to a laparoscopy.
If the antibody is negative, the likelihood of the Hysterosalpingogram showing an abnormality is in the range of 2-3%. Therefore, the x-ray need not be done.