Hysteroscopy- Fibroid

Hysteroscopy- Fallopian Tube

Laperoscopy- Uterus
Laperoscopy- Ovaries
Laperoscopy- Right Ovary
Endometriosis
Peritoneal Endometriosis
Laparoscopy- Fallopian Tube
Hysteroscopy- Septum
Fibroids / Myomas
Myoma 1
Myoma 2
Myoma 3
Laparoscopic Myomectomy

 

 

Fertility Treatment Options

 

Lifestyle changes - Age

We cannot change our age, but if we reflect on the impact which age has on female fertility the message to patients having difficulty conceiving is to not shy away from the problem. The best time to conceive is now and therefore patients must not waste time. Below are some graphs to illustrate the effect of age on fertility.

 

See graphs on right showing cumulative success rates according to age.

 

Weight

Obesity is associated with a range of adverse health consequences. Widely recognised are the increased risks of cardiovascular disease, diabetes and some cancers. Obesity and low body weight can impact on reproductive function by causing hormone imbalances and ovulatory dysfunction. Abnormal weight is usually defined as a high BMI (kg/m2) of ≥25 and a low BMI of <20 and the effects of abnormal weight have been reported in several papers. Obesity is a common problem and needs to be addressed before embarking on fertility treatment.

 

The help of a dietician and joining an established weight management programme is imperative.

 

 

Smoking

Cigarette smoking has been associated with adverse effects on fertility, although this is not widely recognised. There is strong evidence of the adverse effects of smoking on fertility operating through a range of pathways in both the general and infertile population. In males, smoking negatively affects sperm production, motility and morphology and is associated with an increased risk of DNA damage.

 

In the female, the constituents of cigarette smoke may affect the follicular microenvironment and alter hormone levels in the luteal phase. Cotinine and cadmium have been detected in the follicular fluid of female smokers and those whose partner smokes, thus having access to the developing follicle. Menopause has been reported to occur one–four years earlier for women who smoke compared to non-smokers. A recent study demonstrated an increased thickness of the zona pellucida in smokers, which may make it more difficult for sperm penetration.


Alcohol, Caffeine and Stress

Although there is not the same level of evidence confirming the negative effects of alcohol, caffeine and stress it is strongly advised that alcohol and caffeine must be avoided and that stress be addressed.

 

The effect of increasing numbers of negative lifestyle variables on the cumulative conception rates within 1 year for a pregnant population.

 

 

Preconceptual Advice

1. All women planning a pregnancy should be advised to start folic acid supplementation (0.4mg daily) from the time contraception is discontinued to reduce the risks of neural tube defects in the foetus. A large Medical Research Council study found that such supplementation with folic acid reduced the incidence of neural tube defects by 72%.

 

2. An Omega 3 sup tplement should be taken. It has extensive advantages for general health and it has been shown to improve the cognitive function of babies born to mothers with high levels of Omega 3.

 

3. Women who are overweight or obese should be advised to lose weight prior to pregnancy. Obesity [body mass index] (BMI)>30 kgm2 is associated with an increased risk of infertility, miscarriage, hypertension and preeclampsia, gestational diabetes, thrombo-embolism, post-partum haemorrhage, shoulder dystocia and operative delivery. Encouraging weight loss is important for the woman's general health, but may also improve the chances of conception, thus providing a timely incentive.

 

4. All women who smoke should be advised to stop. Smoking reduces male and female fertility. The particular risks associated with smoking during pregnancy include an increased risk of ante partum haemorrhage from placenta praevia and placental abruption, small-for-gestational-age babies, and prematurity due to pre-term rupture of membranes and pre-term labour. Carbon monoxide freely crosses the placenta and decreases the oxygen-carrying capacity of haemoglobin. Nicotine stimulates adrenergic release causing generalised vasoconstriction and decreased uterine perfusion. The effects on birth weight are also relevant to passive smoking, and women find it harder to stop smoking if their partner smokes, providing a rationale for women planning a pregnancy to encourage their partners and family to stop smoking as well. Smoking also increases the risk of ear and respiratory infections in the infant within the first year of life, and increases the risk of the child developing asthma. In addition, there is a greater than two-fold increase in the risk of sudden infant death syndrome. Carcinogens and poisonous compounds present in cigarette smoke also pass to the foetus. Research has shown that early pregnancy is a time when women are more likely to give up smoking, and every effort should be made to encourage and support women to stop smoking.

 

5. Alcohol reduces both male and female fertility. It is a teratogen associated with a specific syndrome in babies exposed to very high doses from mothers with chronic and continued alcohol abuse and dependence throughout pregnancy.

 

Infertility is without a doubt a life altering experience. From your self-esteem, to your plans and dreams for the future, relationships with your friends, family and even your spouse can all be affected. Attention is primarily focused on the physical aspects of infertility, while the emotional aspects often go ignored and untreated. People aren't aware of how emotionally challenging and overwhelming infertility can be.

 

As time goes by and your baby plans don't unfold as expected, even the most harmless questions can seem overwhelming. Suddenly you feel overcome and the only thing everyone wants to know is, "Are you pregnant yet?" Give some thought as to how much of your personal life you are comfortable sharing, and with whom.

 

Anger or disappointment at your own body or your partner's is also a prevalent feeling among women. The stress, sadness and other feelings you might be experiencing are common.

 

At Dawie Slabbert Fertility Practice, a clinical psychologist with extensive experience in fertility issues will guide and advise you. These support groups, in addition to other wellness programmes including nutrition and personalised counselling, can also help you learn how to cope with the physical and emotional impacts of infertility. We have found that many of our patients not only benefit from regular exercise including aerobic, yoga, and pilates, but sharing the experience with others who understand is equally, if not, more important.

 

Don't be afraid to call upon all your support systems whether they're family members, friends, social group friends, or professional support groups.

 

Endometriosis

 

What is endometriosis?

Endometriosis is a very common condition where cells of the lining of the womb (the endometrium) are found elsewhere, usually in the pelvis and around the womb, ovaries and fallopian tubes. It mainly affects women during their reproductive years. It can affect women from every social group and ethnicity. Endometriosis is not an infection and it is not contagious. Endometriosis is not cancer.

See Graphic image link of an endometrioma on left under search panel.

 

What if I am having difficulty getting pregnant?

Getting pregnant can be a problem for some women with endometriosis. Your doctor should provide you with full information about your options, such as assisted conception.

 

What treatment can I get?

The options for treatment may be: Pain relief: Pain-relieving drugs reduce inflammation and help to ease the pain.

 

Hormone treatments: There is a range of hormone treatments to stop or reduce ovulation (the release of an egg) to allow the endometriosis to shrink or disappear. The hormonal methods below are contraceptives and will prevent you from becoming pregnant:

 

• The Combined Oral Contraceptive (COC) pill or patch : These contain the hormones oestrogen and progestogen and work by preventing ovulation and can make your periods lighter, shorter and less painful.

 

• The Intrauterine System (IUS) : This is a small T-shaped device which releases the hormone levonorgestrel. This helps to reduce the pain and makes periods lighter. Some women get no periods at all. The hormonal methods below are non-contraceptive, so contraception will be needed if you do not want to become pregnant:

 

• Use of hormonal progestogens or testosterone derivatives

 

• GnRH agonists – these drugs prevent oestrogen being produced by the ovaries and cause a temporary and reversible menopause.

 

Surgery

Surgery can be used to remove areas of endometriosis. Surgery including hysterectomy does not always successfully remove the endometriosis. There are
different types of surgery, depending on where the endometriosis is and how extensive it is. The success of the surgery can vary and you may need further surgery. Your gynaecologist will discuss this with you before any surgery.

 

• Laparoscopic surgery

The gynaecologist removes patches of endometriosis by destroying them or cutting them out.

 

• Laparotomy

If the endometriosis is severe and extensive, you may be offered a laparotomy. This is major surgery which involves a cut in the abdomen, usually in the bikini line.

 

• Hysterectomy

Some women have surgery to remove their ovaries or womb (a hysterectomy). Having this surgery means that you will no longer be able to have children after the operation. Depending upon your own situation, your doctor should discuss hormone replacement therapy (HRT) with you if you have your ovaries removed. can affect fertility. Endometriosis should preferably be treated laparoscopically by an expert surgeon. Laparoscopy allows for better visualization and reduces the trauma during surgery and therefore the postoperative adhesions.


Fibroids

Fibroids are benign tumours of the smooth muscle of the wall of the womb. Fibroids are very common and can be found in up to 50% of patients at the age of their menopause. They are usually asymptomatic and the patient will not require any treatment except counselling and reassurance.

 

The most common symptoms are excessive uterine bleeding and pelvic pain. Other symptoms include repeated miscarriages and premature labour. Large uterine fibroids, especially those that are located close to the lower uterine segment, may cause hydronephrosis.

 

Fibroids are known to occur more frequently in women with a history of infertility. Whilst these benign tumours are associated with subfertility in 5–10% of cases, when all other causes of reproductive dysfunction are excluded, fibroids may be responsible for only 2–3% of cases. Despite the existence of many studies assessing the correlation between uterine myomas and infertility, the mechanisms by which fibroids have a detrimental effect on reproductive function remain largely unknown.

 

Removing fibroids surgically is called a myomectomy. A myomectomy can be performed hysteroscopically or through laparoscopy or a laparotomy. In women wanting to preserve their fertility the laparoscopic route is preferred.


Recurrent Miscarriages

 

What is recurrent miscarriage?

A miscarriage is when you lose a foetus at some point in the first 23 weeks. When this happens three or more times doctors call this recurrent miscarriage. For women and their partners it is a very distressing problem.

 

Around one woman in every 100 has recurrent miscarriages. This is about three times more than you would expect to happen just by chance, so it seems that for some women there must be a specific reason for their losses. For others, though, no underlying problem can be identified: their repeated miscarriages may be due to chance alone.

 

Why does it happen?

Often, in spite of careful investigations, the reasons for recurrent miscarriages cannot be found. However, if you and your partner feel able to keep trying, you still
have a good chance of a successful birth in future. There are a number of things which may play a part in recurrent miscarriage. It is a complicated problem and more research is still needed.

 

• Your age and past pregnancies
The older you are, the greater your risk of having a miscarriage. The more miscarriages you have had already, the more likely you will be to have another
one.

 

• Genetic factors
For around three to five in every 100 women who have recurrent miscarriages, they or their partner have an abnormality on one of their chromosomes (the genetic structures within our cells that contain our DNA and the features we inherit from our parents). Although such abnormalities may cause no problem for you or your partner, they may sometimes cause problems if passed on to your baby.

 

• Abnormalities in the embryo
An embryo is a fertilised egg. An abnormality in the embryo is the most common reason for single miscarriages. However, the more miscarriages you have, the less likely this is to be the cause of them.

 

• Autoimmune factors
Antibodies are substances produced in our blood in order to fight off infections. Around 15 in every 100 women who have had recurrent miscarriages have particular antibodies, called antiphospholipid (aPL) antibodies, in their blood; fewer than two in every 100 women with normal pregnancies have aPL antibodies. Some people produce antibodies that react against the body's own tissues; this is known as an autoimmune response and it is what happens to women who have aPL antibodies. If you have aPL antibodies and a history of recurrent miscarriage, your chances of a successful pregnancy may be only one in ten.

 

• Womb structure
It is not clear how far major irregularities in the structure of your womb can affect the risk of recurrent miscarriages. Estimates of the number of women with recurrent miscarriage who also have these irregularities range from two out of 100 to as many as 37 out of 100. Women who have serious anatomical abnormalities and do not have treatment for them seem to be more likely to miscarry or give birth early. Minor variations in the structure of your womb do not cause miscarriages.

 

• Weak cervix
In some women, the entrance of the womb (the cervix) opens too early in the pregnancy and causes a miscarriage in the third to sixth month. This is known as having a weak (or 'incompetent') cervix. It is overestimated as a cause of miscarriage because there is no really reliable test for it outside of pregnancy.

 

What could it mean for me in future?

Your doctors will not be able to tell you for sure what will happen if you become pregnant again. However, even if they have not found a definite reason for your miscarriages, you still have a good chance (three out of four) of a healthy birth.

 

Is there anything else I should know?

What can be done?

 

Supportive antenatal care
Women who have supportive care from the beginning of a pregnancy have a better chance of a successful birth. There is some evidence that attending an early pregnancy clinic (if there is one in your area) can reduce the risk of further miscarriages. Screening for any abnormalities is a must, covering all aspects from the structure of your womb, genetic problems, and abnormalities in the embryo to infections.


Polycystic Ovarian Syndrome

Polycystic ovary syndrome (PCOS) is a common reproductive endocrine disorder, affecting about 5% of women. In PCOS, excessive amounts of androgens ("male" hormones such as testosterone) are produced by the ovaries. PCOS is a common cause of infertility, menstrual irregularity, and hirsutism (excessive hair growth). An international consensus meeting in 2003 defined PCOS to include women who demonstrate two of the following three characteristics: 1) chronic anovulation; 2) chronic hyperandrogenism; and 3) polycystic appearing ovaries (PCO) on ultrasound.

 

Women who have PCOS may have irregular, infrequent menstrual cycles, hirsutism, acne and/or infertility. Many, but not all women with PCOS have ovaries enlarged with many small cysts (fluid-filled sacs), that are visible on ultrasound. Polycystic appearing ovaries are also seen in approximately 20% of women with normal menstrual cycles. Because of the variable nature of PCOS, its diagnosis is based upon the combination of clinical, ultrasound and laboratory features.

 

Lack of ovulation in women with PCOS results in continuous exposure of their uterine lining (endometrium) to oestrogen. This may cause excessive thickening of the endometrium and heavy, irregular bleeding. Over many years, endometrial cancer may result due to the continuous stimulation of the endometrium by oestrogen unopposed by progesterone.

 

Women with PCOS may be at increased risk for developing the metabolic syndrome, which is characterised by abdominal obesity, cholesterol abnormalities, hypertension, and insulin resistance that impairs blood sugar regulation. Women with PCOS have an increased risk for developing Type 2 diabetes, and possibly heart disease too.

 

Obesity is common in women with PCOS. Diet and exercise that result in weight loss improves the frequency of ovulation, improves fertility, lowers the risk of diabetes, and lowers androgen levels in many women with PCOS, and is therefore an important component of therapy. Increasing physical activity is an important step in any weight reduction programme.

 

If you are diagnosed with PCOS, treatment will depend upon your goals. Some patients are primarily concerned with fertility, while others are more concerned about menstrual cycle regulation, hirsutism, or acne. Regardless of your primary goal, PCOS should be treated because of the long-term health risks it poses.


If fertility is your immediate goal, ovulation may often be induced with clomiphene citrate (Clomid®, Serophene®), an orally administered fertility medication. Treatment with medications that increase your body's sensitivity to insulin, such as metformin (Glucophage®), may lead to more regular ovulation. Gonadotropins (injectable fertility medications), may be used to induce ovulation if you do not respond to simpler treatments. Gonadotropin therapy, however, is expensive and associated with a greater chance of multiple pregnancy and side effects than oral therapies.

 

If fertility is not an immediate concern, hormonal therapies are usually successful in temporarily correcting the problems associated with PCOS. Oral contraceptive pills (OCs) are commonly prescribed to reduce hirsutism and acne, maintain regular menstrual periods, prevent endometrial cancer, and prevent pregnancy. OCs may be combined with medications that decrease androgen action, such as spironolactone, to improve hirsutism. Vaniqa® cream has been approved to reduce facial hair. Methods that remove hair, such as electrolysis and laser, are also helpful.

 

Dealing with PCOS can be emotionally difficult. Women with PCOS may feel self conscious about their excessive hair growth or weight, as well as worry about their ability to have children. Nevertheless, it is important to consult your physician as soon as possible to discuss the treatments available for PCOS.


Ovarian Hyperstimulation Syndrome

What is OHSS?

Ovarian hyperstimulation syndrome (OHSS) is a potentially serious complication of fertility treatment, particularly of in vitro fertilisation (IVF) treatment.

 

What are the symptoms of OHSS?

The symptoms are abdominal swelling or bloating because of enlarged ovaries, nausea and, as the condition gets worse, vomiting.

 

• Mild OHSS – mild abdominal swelling or bloating, abdominal discomfort and nausea.

 

• Moderate OHSS – symptoms of mild OHSS but the swelling and bloating is worse because fluid is building up in the abdomen. There is abdominal pain and vomiting.

 

• Severe OHSS – symptoms of moderate OHSS plus extreme thirst and dehydration because so much fluid is building up in the abdomen, passing very small amounts of urine which is very dark in colour (concentrated), difficulty breathing because of build-up of fluid in the chest and a red, hot, swollen and tender leg due to a clot in the leg or lungs (thrombosis). If you
develop any of the symptoms, seek medical help immediately.

 

What causes it?

Fertility drugs stimulate the ovaries to produce many egg sacs (follicles).
Sometimes there is an excessive response to fertility drugs and this causes OHSS.

 

What you need to know

Overstimulated ovaries enlarge and release chemicals into the bloodstream that make blood vessels leak fluid into the body. Fluid leaks into your abdomen and, in severe cases, into the space around the heart and lungs. OHSS can affect the kidneys, liver and lungs. A serious, but rare complication is a blood clot (thrombosis). A very small number of deaths have been reported.

 

Who gets it?

Mild symptoms are common in women having IVF treatment. As many as one in three (33%) women develop mild OHSS. About one in 20 (5%) women develops moderate or severe OHSS.

 

The risk of OHSS is increased in women who:
• have polycystic ovaries;
• are under 30 years of age;
• have had OHSS previously; and
• get pregnant, particularly if this is a multiple pregnancy (twins or more).

 

What should I do if I have mild OHSS?

• Make sure you drink clear fluids at regular intervals. Make sure you do not drink in excess. If you have pain, take ordinary paracetamol or codeine (no more than the maximum dose). You should avoid anti-inflammatory drugs (aspirin or aspirin-like drugs such as ibuprofen), which can affect how the kidneys are working.


• Even if you feel tired, make sure you continue to move your legs.

 

• Your fertility clinic should provide you with full written information about your fertility treatment, including the risk of OHSS and a 24-hour helpline number.

 

• If you develop OHSS, your fertility clinic will advise changing from hCG (human chorionic gonadotrophic) injections to progesterone injections or suppositories. The hCG injections can make OHSS worse.

 

Laparoscopy

Laparoscopy is minimal invasive surgery. It is a procedure where a telescope is put into the abdominal cavity in order to visualise the cavity. The telescope is usually inserted after the abdominal cavity has been filled and therefore distended with CO2 gas. A laparoscopy can be either diagnostic (only having a look) or operative where pathology is addressed and corrected where possible.

 

Many of the procedures which traditionally could only be done through a large incision can now be done through minimal invasive surgery. Examples are endometriosis surgery, myomectomies, hysterectomy, ectopic pregnancy and the treatment of adhesions.

 

The advantages of laparoscopy are:

• a shorter hospital stay;
• less postoperative pain;
• reduced trauma to the tissues; and
• an improved cosmetic result.

 

Hysteroscopy

Hysteroscopy is the placing of a small telescope through the vagina and cervix into the uterine cavity. Hysteroscopy can also be used for diagnostic purposes and operative purposes.

Procedures done hysteroscopically are myomectomies, polypectomies, resection of uterine septum and the resection of uterine adhesions. Hysteroscopy has become an essential tool in the assessment and treatment of infertility patients.


 
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