Because of the intricate and complex nature of the female reproductive tract, there can be many reasons why a woman is having trouble achieving successful pregnancy. Some of these factors may include:
- Ovarian cysts
- Polycystic Ovarian Syndrome
- Pelvic Adhesions
- Decreased Ovarian Reserve
- Premature Ovarian Failure
Uterine fibroids are benign (noncancerous) growths of the muscular wall of the uterus. The growths, which may appear singly or in groups, range from the size of a pea to the size of a grapefruit. They may either be confined to the uterine wall or grow outward on thin stalks. Fibroids often cause no symptoms, unless they grow large enough to press painfully on other organs or even distort the shape of the abdomen. Fibroids are quite common and typically affect women between ages 30 and 45. Large fibroids may narrow the uterine cavity and lead to miscarriage or infertility.
Fibroids can impact fertility if they grow inside of the uterus. They change the environment of the uterus in a way that can interfere with embryo implantation or predispose a woman to have early miscarriages. Fibroids have a tendency to grow during pregnancy and may cause deformity of the arms and legs of the baby if they press on the fetus.
If fibroids are found, your doctor will recommend removing them prior to any IVF procedure.
Endometriosis is a common disorder that affects the tissue that lines the uterus, causing it to grow outside the uterine cavity. The tissue becomes attached to reproductive or abdominal organs, and swells with blood during menstruation as if it were still in the uterus.
Because this blood is trapped within the tissue and cannot be shed through the vagina, blood blisters form and may develop into cysts, scar tissue, or adhesions (fibrous bands that link together other tissues that are normally separated). This can be very painful. Endometriosis is a leading cause of infertility and typically impacts women between 25 and 40 years of age.
Endometriosis affects the ability for a woman to achieve pregnancy by inducing scar tissue formation that compromises the normal function of the fallopian tubes. Endometriosis cells can also secrete substances that might interfere with the sperm/egg interaction, preventing fertilization. Women with endometriosis have a high chance of having other hormonal dysfunction conditions, like progesterone deficiency, that can make implantation weak and cause early miscarriages.
Women can be treated medically or surgically:
- Medically. Ovulation can be blocked, or the menstrual cycle can be stopped for four to six months
- Surgically. Laparoscopy or laparotomy can be performed to cauterize the endometrial implants to destroy the endometriosis
An ovarian cyst is a fluid-filled sac that forms in the ovary. Ovarian cysts are common and, in the vast majority of cases, they are benign (non-cancerous) in patients younger than 35.
Ovarian cysts affect fertility if they interfere with normal ovulation or represent a mechanical obstacle for the fertilization process.
Ovarian cysts can be aspirated (collapsing the cyst) under ultrasound guidance through the vagina or by laparoscopy. In either event, the fluid must be sent for cytology (take cell samples for analysis) to rule out any malignancy. Some cysts have a tendency to recur. Therefore, patients can benefit from three to four months of birth control pills after removing the cysts before attempting IVF treatment.
Polycystic Ovarian Syndrome
Polycystic ovarian syndrome (“PCOS”) is a medical condition characterized by:
- infrequent menstrual cycles
- hirsutisum (extra hair on extremities, face, chest, abdomen and back), associated with acne and increase in male hormone levels in the blood
- dysfunction in the production of the LH and FSH hormones that control ovulation
In certain cases, PCOS is associated with other endocrine gland problems like the adrenal gland and thyroid gland. In certain patients, the condition may occur along with hyper insulinism or peripheral resistance to insulin and adult onset diabetes.
Diagnosis is made by obtaining a history of the menstrual cycle and observation of the conditions listed above, results of blood tests and a pelvic ultrasound where the ovaries show a typical characteristic of enlarged ovaries with multiple small sized cysts at the periphery of the ovaries.
PCOS impacts fertility by decreasing the number of times a woman will ovulate throughout her lifetime. Furthermore, patients have a tendency to have heavy menstrual periods that could develop endometrial polyps and other changes at the endometrial lining level. This makes it difficult for embryo implantation.
The patient should be evaluated by a reproductive endocrinologist in order to establish the cause of the problem. Treatments will be recommended, possibly including hormone medications (fertility drugs) to induce ovulation.
Pelvic adhesions are scars or fibrotic tissue that develops around the tubes, ovaries, bowel and the uterus. Usually this is a result of previous pelvic inflammatory disease, venereal diseases like chlamydia, gonorrhea, but also could be the result of previous surgeries within the area. They could be the result of a ruptured appendix with abscess formation or endometriosis.
Pelvic adhesions impact fertility by interfering with the ability of the fallopian tube to pick up the oocyte at the time of ovulation.
Adhesions can be removed by laparoscopy or by laparotomy. In some cases the amount, characteristics and location of the adhesions may be such that the only alternative left is IVF.
Decreased Ovarian Reserve
Decreased ovarian reserve (DOR) is a normal physiological condition that commonly happens during the pre-menopausal years. It can affect patients after the age of 36 although it is more common after the age of 40. Occasionally we have seen patients in the late 20s and early 30s with this condition. It is also seen in patients who have had surgery on the ovaries for ovarian cyst treatment or removal of endometriosis. The number of eggs available each month is decreased, therefore the FSH hormone is elevated on the second or third menstrual cycle day. These patients have a tendency to overlap menstrual cycles, shortening the cycle to 21 days. Therefore the ovulation occurs around day seven to eight of the menstrual cycle by the time the menstrual flow has finished so the endometrial lining doesn’t have time to prepare for the arrival of the embryo. This causes infertility – due to lack of implantation.
Decreased ovarian reserve is diagnosed by blood tests for estradiol and FSH on the second menstrual cycle day along with pelvic ultrasound that documents the presence of an early follicle in the ovary.
In the early stages of DOR, there are some menstrual cycles that are still normal and the patient could conceive on her own. But if the patient is a candidate for IVF, we need to look for those “normal” menstrual cycles in order to have a good response to the administration of fertility drugs.
Premature Ovarian Failure
Premature ovarian failure (POF) is the onset of menopause before the age of 40. Most of the time, the cause is unknown, but it may be associated with chromosome problems, immune disorders (patient develops antibodies against the ovary), lupus or thyroid disorders.
Premature ovarian failure is diagnosed by blood tests, which demonstrate that FSH and LH levels are within the menopause range in a patient who has had no menstrual period for more than six months.
POF impacts fertility. If no eggs are being released, conception cannot occur. In vitro fertilization using a donor egg is the only option for these patients.