Medical Treatment for Infertility
Certain medical conditions – especially those that can interfere with the normal menstrual cycle – can contribute to infertility and, in some cases, may be the only factor standing between you and pregnancy. More complicated fertility treatments certainly can work in these situations but, many times, correction of the underlying condition restores normal ovulation and may allow you to conceive without any further treatment. Management of your medical issues is extremely important not only to achieve pregnancy, but to optimize your chances of having a healthy and uneventful pregnancy course. Here are several examples of the most common medical conditions we see contributing to irregular menses and infertility:
THYROID DISEASE
Although we most commonly see irregular menses associated with hypothyroidism, an overactive or underactive thyroid gland can interfere with normal menstruation. If your history suggests you may have hypothyroidism, your doctor can order a few simple blood tests to check your thyroid hormone levels. If levels are low, the thyroid hormone can be replaced in pill form to correct the underlying deficiency.
DIABETES/INSULIN RESISTANCE
Patients with elevated levels of the hormone insulin can have irregular menses and infertility due to a lack of ovulation. This can be seen not only in patients with actual diabetes but in those with prediabetes as well. Simple blood tests can be ordered to screen for insulin resistance, if your history suggests you may be at risk. In many cases, weight loss through diet and exercise may be all that is needed to restore normal menses and is in fact the best ‘treatment’ for reducing the risk of diabetes. In other cases, treatment with an oral medication can improve the underlying condition and may restore ovulation.
ELEVATED PROLACTIN (HYPERPROLACTINEMIA)
The hormone prolactin is produced by the pituitary gland in the brain and has many functions including control of lactation during breastfeeding. Elevated levels of the hormone, typically caused by a benign growth in the pituitary, can suppress ovulation and menstruation, and cause infertility. A simple blood test can be done to screen for this condition if you have irregular menses and, typically, an oral medication is all that is necessary to shrink the growth and lower the prolactin levels, allowing for ovulation to occur. If your prolactin levels are elevated, your doctor may order an MRI of the head to be sure the growth is not too large, especially if you are having associated headaches or vision changes.
Surgical Treatment for Infertility
Some cases of infertility may be caused by an underlying structural abnormality within the reproductive tract, and surgical correction may be all that is needed to allow you to conceive naturally. Conditions that can alter the uterine cavity, where the baby implants and grows, can contribute not only to infertility but to recurrent pregnancy loss. During your consultation, your history may suggest a possible underlying surgical issue, and your doctor can perform or order an imaging procedure for confirmation – typically a special ultrasound, x-ray dye test or MRI. Any significant abnormality of the uterine cavity should be corrected prior to any additional infertility treatment to optimize your chance for success. Here are a few of the more common issues we encounter:
UTERINE FIBROIDS
Fibroids, or myomas, are growths in the uterus made of up smooth muscle cells. Although you may hear them referred to as tumors, the vast majority of fibroids are benign. Fibroids are also very common, possibly affecting at least 50% of all women over the course of their lifetime. In most cases, they do not cause symptoms and do not have to be removed. However, if a fibroid is pushing into and distorting the uterine cavity, it can be a problem at any size. Occasionally, fibroids can grow so large as to cause pain and pressure and thus should be removed for patient comfort even if they do not cause problems with infertility. Surgery for removing a fibroid is called a myomectomy, and the surgical approach varies depending on the size, number and location of the fibroid.
If the fibroid is small and is mostly within the uterine cavity, it can typically be removed by hysteroscopy. In this procedure, the cervix is dilated and a long thin camera is passed into the uterus. Instruments are then passed through the camera and used to remove the fibroid. This is a same-day surgical procedure, and since all instruments are passed through the vagina, there are no incisions or scars. For more information, see our handout on hysteroscopy.
If the fibroid is larger, or if the majority of it is not within the uterine cavity, you may need to undergo an abdominal myomectomy. In this procedure, an incision is made in the skin similar to a C-section scar (“bikini cut”) and the fibroid is removed through this incision. The uterus is then sewn back together to restore normal anatomy. This surgery must be performed at the hospital and typically involves a 1- or 2-night hospital stay.
Depending on the size, location and number of fibroids, you may be a candidate for a robotic-assisted laparoscopic myomectomy. This procedure also involves abdominal incisions but, instead of one large incision, several small incisions are made and the fibroid(s) are removed using a camera and long, thin instruments passed into the abdomen. Larger fibroids can be cut into smaller pieces and removed through these small incisions. As in an abdominal myomectomy, the uterus is sewn together to restore normal anatomy. Robotic-assisted laparoscopic myomectomy can be a same-day procedure and typically involves a shorter recovery time because the incisions are smaller. Please note that for patients with many fibroids, or those in whom the fibroids are either very large or in a difficult location in the uterus, we may recommend abdominal myomectomy instead. For more information on robotic-assisted laparoscopic myomectomy, please see the following links:
ENDOMETRIAL POLYPS
Endometrial polyps are growths within the lining of the uterus. The vast majority of polyps are benign, and they can be various shapes and sizes, solitary or numerous. Depending on their location within the uterine cavity, they can interfere with your ability to achieve pregnancy, so surgical removal is recommended. Endometrial polyps are typically removed hysteroscopically. In this procedure, the cervix is dilated and a long, thin camera is passed into the uterus. Instruments are then passed through the camera and used to remove the polyp(s). This is a same-day surgical procedure, and since all instruments are passed through the vagina, there are no incisions or scars. A gentle curettage, or scraping of the uterine lining, may also be performed at the same time to ensure all polyps have been removed. For more information, see our handout on hysteroscopy.
UTERINE SEPTUM
A uterine septum is a condition in which the uterus is divided at the top by a wedge of extra tissue. This septum can be minor or can extend all the way from the top of the uterus to the cervix. This extra tissue has a poor blood supply, so embryos either fail to implant or may implant but fail to develop. Uterine septum can therefore be a cause of infertility or recurrent pregnancy loss. This condition is congenital, meaning you are born with it. A septum is otherwise asymptomatic, so patients typically do not find out about it until they are trying to conceive.
Surgical correction of a uterine septum is typically performed hysteroscopically. In this procedure, the cervix is dilated and a long, thin camera is passed into the uterus. Instruments are then passed through the camera and used to resect the septum. The septum does not need to be cut out; it only needs to be divided to allow the uterus to attain a normal shape. This is a same-day surgical procedure, and since all instruments are passed through the vagina, there are no incisions or scars. Depending on the extent of the septum, you may require more than one procedure to ensure it has been completely resected.
ENDOMETRIOSIS
Endometriosis is a condition in which cells that line the uterus (endometrial cells) are found in other parts of the body – typically elsewhere in the abdominal cavity (e.g., the lining of the abdominal cavity or peritoneum, the ovary, the fallopian tubes, etc). These cells respond to hormones like normal endometrium, so every month in response to your cycle, they grow then bleed a small amount. This causes inflammation that can lead to scarring in the abdomen and pelvis.
Endometriosis can be asymptomatic or can cause severe pain. This pain typically starts only with menses, but in more extensive cases, the pelvic pain can last throughout the cycle. Endometriosis can also contribute to infertility in several ways. Scarring in the pelvis can lead to blocked fallopian tubes or other distortions of the normal anatomy, while the disease itself seems to impair egg quality.
If diagnostic testing suggests scarring around the fallopian tubes, a laparoscopy can be performed to determine whether the scar tissue can be cut and normal anatomy restored. This can be done with traditional methods or using the surgical robot for improved visualization and dexterity, if significant adhesions are anticipated. Even in patients not trying to get pregnant, surgery can be performed to resect the endometriosis, cut scar tissue and hopefully provide pain relief. Unfortunately, it is usually difficult to remove all of the endometriosis since much of it is microscopic, so pain relief may only be temporary. If you are not trying to achieve pregnancy, birth control pills or other medications can be offered to suppress your hormonal fluctuations and potentially provide relief of symptoms.
