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Friday, 28 February 2014

Male infertility

Many people still believe that infertility is primarily a problem in the woman. This is not true and 50% of the time a problem can be identified in the male partner either in isolation or along with a female contributory cause. Therefore the couple should always be investigated simultaneously. I have had couples who insist on having the woman investigated first, to the extent of having even painful surgeries to ensure that everything is "normal" before the husband relents to having a semen analysis. This is most unfortunate and apart from ignorance there is a morbid psychological fear (that there may indeed be a problem with their semen) in some men that may be responsible for this behaviour.

A fact that is not well known is that we do not have an adequate test that REALLY tests fertility of the man. Yes, we do have semen analysis and we can check how many sperms are present, how many of these are motile and what percent of the sperms have a normal shape. There is a wide overlap in the findings of semen analysis between fertile and infertile men. And the fact remains that just by looking at a semen analysis report no one can say with certainty whether that man is fertile or nor. Of course the exception to this is when there are no sperms at all!

Sperm parameters (i.e., count, motility and morphology) also fluctuate widely and therefore if there are any concerns, the doctor will ask you to repeat the test. It is extremely important that the entire ejaculate is collected. It is the first part which is sperm-rich and in the event where the first few drops are lost, the analysis may be abnormal.

Monday, 24 February 2014

Prolactin and Thyroid Hormones

In my last several posts, I have been relating the various causes of subfertility in the female and with this I am coming to the end of the common causes. In this post, I am going to talk about abnormal Prolactin and Thyroid hormone levels causing subfertility. 

Prolactin is a hormone with a number of functions, the most important is the growth of milk glands in the breast and milk production after giving birth. Prolactin excess can lead to menstrual irregularities, secretion of milk (not associated with childbirth) or just infertility even in the absence of any symptoms. Pregnancy, breastfeeding and even the stress of blood test can increase Prolactin levels. Women with Polycystic ovary disease often have raised levels. Other causes are medications, tumours in pituitary, some brain diseases, chest wall injuries and decreased thyroid gland function. The good news is that most of the time the levels are only raised mildly and these can be easily reversed using medicines. In case of high levels of course, further tests and treatment may be required.

An overactive and underactive thyroid gland can also interfere with fertility and as such levels of TSH are usually checked in women trying to conceive. Underactive thyroid is quite common and often undiagnosed. It is extremely essential to achieve and manage  normal levels of thyroid hormones not just when trying to conceive but also during pregnancy with the help of an endocrine doctor in conjunction with your fertility doctor/gynaecologist. This is because thyroid hormone requirements increase during pregnancy and the unborn baby can be affected in case these requirements are not met.

Suggestions/Comments/Questions are welcome. 

Unexplained infertility in the next post.....

Saturday, 22 February 2014

Uterine malformations: Does it matter?

Like all our body parts the way our reproductive organs form while still in the mother's womb can sometimes go a little awry. The reason why this happens is usually impossible to decipher though. But the big question is what can go wrong and does it matter?

What all can go wrong is too complicated for this forum but the range is complete lack of development of vagina and/or uterus to very mild changes in the shape.  For obvious reasons severe malformations preclude fertility and will require the assistance of fertility specialists. For example, if there is a block or curtain (called septum by doctors) in vagina but the upper structures are normal, then the surgical removal of the septum would suffice but if the uterus is absent or too underdeveloped then surrogacy is the only option.

It is important to keep in mind that a girl who has entered puberty and is having abdominal pain some days of the month but not having periods may have a problem like hymen without perforation or a vaginal septum. This required immediate treatment through a gynaecologist.  

The presence of uterine malformations has been linked with infertility, miscarriage, preterm labour and pregnancy complications such as placental abruption, growth problems in the baby, prematurity and death of the baby. The correlation between uterine malformations and these complications is hard to prove and surgical correction of all malformations may not be beneficial. The decision has to be individualized by the treating doctor. In patients with infertility or with recurrent miscarriages, removal of uterine septum is generally recommended. Other more complicated surgeries to unite two uterine cavities into one are generally not recommended nowadays.

Sunday, 16 February 2014


Adenomyosis is a variant of endometriosis in which the endometriotic lesions occur within the muscle wall of the uterus. The lesions caused by adenomyosis may be limited to a small area or may involve a substantial part of the uterine wall leading to a moderate increase in the size of the uterus. It may be asymptomatic in as many as one-third of patients. It frequently co-exists with fibroids and endometriosis in the pelvis. Frequently associated symptoms include painful periods, deep pain during intercourse, painful evacuation of bowels and heavy, prolonged periods. There is some evidence that  by impairing implantation, adenomyosis may lead to infertility and lower chances of pregnancy after infertility treatment. 

Adenomyosis  can be more easily diagnosed through MRI and 3D ultrasound scan. It can often be misdiagnosed on ultrasound. Hence a possibility of adenomyosis must be kept in mind so as to diagnose correctly and plan the management as appropriate.

Hysterectomy is the most effective surgical treatment for adenomyosis but is obviously not suitable for patients who have not completed their family. The conservative options in this case would include removal of the adenomyotic area through either keyhole surgery or an open surgery. Alternatively Mirena intrauterine system or three to six month course of GnRH agonist injections can be tried immediately prior to an IVF/ICSI cycle. There is little evidence to show that corrective surgery improves fertility. As surgery involves cutting into the uterine muscles, patients who conceive after surgical removal are at an increased risk of uterine rupture in pregnancy or during labour. The patients should therefore be monitored closely and advised a planned caesarean section for delivery. 

Friday, 14 February 2014

Fibroids and Infertility

Bulk of the uterus is made of muscle fibres that run crisscross. These have the ability to relax and expand in the event of a growing pregnancy and the contractions of these muscles causes delivery of the baby. During menstruation the muscles contract (which is perceived as period cramps). Imperceptible contractions also occur at other times (especially around the time of ovulation) that aim at helping the sperms to move up towards the Fallopian tubes. This aids the sperms to reach the  tubes, where the fertilisation of egg can occur and later lead to a pregnancy.

Fibroids are harmless (non-cancerous) growths in the muscle wall of the uterus. These can be single or multiple, vary in size and may not be symptomatic. Depending on the location, fibroids are of three types: those that grow in the muscle wall (intramural), those that are growing towards and into the cavity of the uterus (submucous), and those that are growing outwards or on the surface of the uterus (subserosal). 

Various studies have quoted the overall incidence of fibroids between 5 and 21%. More than 80% of African American women and about 70% of caucasian women may develop fibroids by the time they are 50 yrs old. Indian women seem to be at a lower risk. Fibroids that impinge the cavity may interfere in implantation and thus cause infertility. Also those growing near the openings of the fallopian tubes may cause blockage. They may also cause interference with the contraction patterns in the uterine muscles. 

There is insufficient evidence pertaining to the role of operative intervention in improving fertility. As subserosal fibroids are the most innocuous, they may be left alone. Appropriate investigations such as 3-D ultrasound by an experienced radiologist may assist in deciding the best management. It is crucial to thoroughly counsel patient regarding the lack of sufficient evidence supporting surgery as well as potential complications such as emergency hysterectomy and blood transfusion. The patient should also understand that there is the possibility of scar tissue in the wall and in the cavity of the uterus which in turn may have an adverse effect on fertility. In short the evidence to decide the right management is lacking and the discretion of the doctor and patient wishes after thorough counselling should dictate the action to be taken. 


Thursday, 13 February 2014

Endometriosis and Infertility

The cells that line the inside of the uterus (endometrium) are special in that there is a cycle of growth and shedding with bleeding in response to the hormones that are released from the ovaries (oestrogen and progesterone). When an abnormal growth of cells that resemble the endometrial cells occurs outside uterus, this condition is called endometriosis. The sites where the cells may grow vary, commonest being the ovaries, the Fallopian tubes, the outer surface of uterus, and the surface lining of the pelvic cavity. Rare sites of endometriosis that have been reported are plenty including vagina, cervix (the neck of the uterus), old surgery scars, nose, bladder, bowels and even brain!

What causes endometriosis is not known. The most popular theory is that the retrograde flow of menstrual blood causes some of the cells to get implanted in the pelvis. The inflammation that is caused at the time of menstruation causes pain, scarring and also makes organs stick to each other. In ovaries, the periodic bleeding causes accumulation of this blood that over time becomes thick and degeneration leads to a colour change to brown. The contents resemble liquid chocolate, these cysts that form in the ovaries are therefore also called chocolate cysts.

The symptoms of endometriosis are variable. The commonest symptom is cyclical pain that builds up premenstrually and is at its peak during periods. What is baffling is that the symptoms may not mirror the extent of the disease. While some women with a few spots of endometriosis may have severe pelvic pain, some others with severe endometriosis may have little or no pain. Other symptoms are painful intercourse, heavy periods, infertility, pain while passing urine or opening bowels, etc. 

The only way to diagnose endometriosis is through laparoscopy or keyhole surgery. The prevalence is difficult to quote as not all women who may be suffering undergo laparoscopy but has been reported to be higher in infertile women than in women undergoing laparoscopy for sterilisation (33 vs 4)!

As many as 30 to 50% of women with endometriosis may have difficulty in conceiving. The most plausible explanation of endometriosis causing infertility is the distortion that occurs with organs sticking together and scarring. As a result there be an impaired egg release, or pick up and transport by the fallopian tubes. This does not however explain infertility in all affected women as many have a normal ovulation, patent tubes with no distortion of anatomy. The other explanations are an altered immune system, changes in the hormonal environment of eggs and decrease in the number and quality of eggs in the ovaries.

The treatment of endometriosis has to be individualised by the treating doctor. Medical management is of little or no use in women trying to conceive. It may be prudent not to delay conception in women who have endometriosis. Please consult an infertility specialist for guidance regarding further surgery (especially if you have already undergone operations such as cystectomies) and plan fertility treatment for best results.

Monday, 10 February 2014

What can go wrong with the tubes?

Normal Fallopian tube

What can go wrong with the tubes? Well they can be blocked, or even if they are not blocked, the inside of the tube can be damaged to an extent that it is no longer able to do its function. Sometimes when the ends of the tubes get blocked, the fluid that is secreted by the cells lining the inside of the tube cannot drain and the fluid gets accumulated, this condition is called hydrosalpinx. Intermittently this stale fluid can get discharged into the uterus. So while swollen tubes can be seen on ultrasound scan, these same tubes may not be seen if they have emptied the retained fluid!

Hydrosalpinx (Swollen fallopian tube)

The tubes get damaged because of infections such as those caused by Chlamydia, Gonorrhoea, Tuberculosis and other pelvic infections.The tubes can also get damaged as a result of endometriosis. The degree of damage varies and sometimes the damage is so subtle that the tubes can look apparently normal on the evaluation tests that are available. If you have had an ectopic pregnancy wherein the pregnancy settles in the tube, it is likely that there may have been a damage to the tube. It is also probable that what has caused damage to one tube may have affected the other as well!

To fully evaluate tubes is not possible. Normal tubes cannot be seen at ultrasound scan. All that can be done is to check whether they are open or not. This can be done either by x-ray or ultrasound. In both procedures solutions that can be 'seen' on the x-ray or ultrasound are injected through the neck of the womb (cervix) and simultaneously x-ray or ultrasound is done to check whether this fluid is passing through the uterus and through each of the tubes into the cavity of the tummy. The x-ray test is called hysterosalpingogram (HSG) and the ultrasound test is called Sonosalpingography (SSG). These tests are not always foolproof. Sometimes the tubes can go into a spasm and the dye therefore doesn't go through giving the impression of blockage in the tubes. If the HSG or SSG findings are anything but normal, it is recommended that laparoscopy is done to examine the tubes before any further fertility treatment.

If there are any indications that the tube/s may have a problem, in my opinion it would be prudent to move on to IVF or test tube baby after a short trial (if at all) of natural conception or intrauterine inseminations (IUI). In case of hydrosalpinx, the swollen tube should either be removed or at least delinked from the uterus to enable best outcome with IVF.