Female Infertility

Polycystic ovarian syndrome is a condition in which there is a hormonal imbalance within the ovaries. It is a complex condition. In PCOS, the ovaries are bigger than average, and the outer surface of the ovary has an abnormally large number of smaller follicles (these are the sacs of fluid which grow around the egg in response to the stimulating hormones from the brain). In PCOS these follicles remain immature, which means that ovulation rarely happens and so the woman is often less fertile.

Women with PCOS may have the following problems:

– infertility due to lack of ovulation
– excessive body hair growth (hirsutism) due to an imbalance between hormones
– irregular menstrual cycles and heavy bleeding (cycles which are either less than 21 days or more than 35 days apart) due to lack of ovulation
– acne
– obesity

Some women with PCOS may have a higher than normal miscarriage rate if they become pregnant.

While it is not known if women are born with this condition, PCOS seems to run in families. Interestingly, when PCOS is passed down the man’s side of the family, the men are not infertile, but they do have a tendency to go bald before the age of 30.

Ongoing research is trying to clarify whether there is a clearly identifiable gene for PCOS. Women are also at a risk if they are overweight. Maintaining weight or body mass index (BMI) below a critical threshold is probably very important as weight loss improves hormonal abnormalities and improves the likelihood of ovulation and thus pregnancy.

The diagnosis of PCOS is made primarily on the woman’s medical history and examination. The diagnosis can be confirmed on ultrasound or by measuring the woman’s hormonal levels. A normal ultrasound or blood test result does not mean that the woman does not have the PCOS. Research suggests that women who do not have problems with their periods or have excessive hair growth can have ovaries, which on ultrasound, have the appearance of being polycystic.

The treatment of a woman with PCOS will depend on the presenting problems:

If infertility is the problem then clomiphene citrate (Clomid) given orally for 5 days early in the menstrual cycle may induce ovulation. Ovulation can be induced in 80% of women using Clomid and pregnancy rates approach those seen in the normal population (20-25% per month) provided that there are no other factors affecting fertility. If Clomid fails to induce ovulation or if the woman has tried Clomid for up to 6 cycles but has not become pregnant, follicle-stimulating hormone (FSH) at low doses may be given. Prior to using these drugs the treating doctor will want to make sure that the woman’s Fallopian tubes are open and that her pelvis is normal.

These drugs are given by injection and when the woman uses these drugs she needs to be monitored using blood tests and ultrasounds to make sure that the drugs are not causing her to develop too many eggs. The aim when these drugs are used is to cause only one egg to develop (similar to in a natural cycle).

Nevertheless, the multiple pregnancy rate may be 20-30% with 80% of these multiple pregnancies being twin pregnancies.

Weight loss is also of paramount importance. The disease process may be reversed with loss of weight and there is also evidence that the higher miscarriage rate may decrease to that in the general population. A dietician may be required.

PCOS can lead to a resistance to insulin, leading to the body producing excessively high levels in an attempt to compensate. This higher level of insulin is known to cause abnormal cholesterol and lipid levels, obesity and an increased likelihood of diabetes. Metformin is a type of drug known as an “insulin-sensitizing agent” which lowers the blood sugar level, in turn reducing the excessively high insulin.

There have been studies which show the use of insulin-sensitizing drugs as a treatment for PCOS. These suggest that it may well be useful in several areas: helping weight reduction, normalizing blood cholesterol and improving irregular periods (70%) leading to ovulation. One study looking at ovulation in particular found that compared to no treatment, 34% of women ovulated taking Metformin (compared to 4% who did not receive it) and when this was combined with clomiphene it was as high as 90% (compared to 8% who only received clomiphene). The most common side effects during treatment on Metformin are diarrhea, nausea, vomiting and abdominal bloating.

Alternatively, an operation called ovarian drilling can also be used to treat women with PCOS. This operation is usually reserved for women who want to be pregnant, and who have not ovulated on Clomid. In these women it may be used as an alternative to FSH. During this procedure the ovary is cauterized by drilling into it in a number of spots. We do not know exactly why this procedure works. If the operation is successful the effect may be long lasting.

In a small number of women, PCOS can be a very severe disease in that it can lead to the development of diabetes with all its complications. If the doctor suspects that the woman has this type of illness, she may need to undergo testing to make sure that she is not currently a diabetic. If diabetes is diagnosed then weight loss, diet and the possible use of tablets may be necessary.

Endometriosis is a relatively common condition that can cause significant pain and suffering. Overall, between 3-10% of women aged between 15-45 years have endometriosis. In women who have difficulties conceiving, this rises to about 25-35%.

Endometriosis is small deposits of the womb lining that are located outside of the womb cavity. The most common place to find it is on the ovary, the back of the uterus and the uterosacral ligaments. It can also be found on the peritoneum, on the tubes or between the vagina and rectum (rectovaginal septum).

Each time that you have a normal period, so does this endometriosis, and this leads to cyclical swelling, stretching of tissues, inflammation and scarring. Eventually all the scarring and inflammation can lead to symptoms even when you’re not having a period.

The most common problems are:

– Pelvic pain
– Painful periods
– Pain during intercourse
– Infertility

The link between endometriosis and infertility is sometimes difficult to explain. When the disease is so bad that there is much scarring around the tubes, or there are ovarian cysts, it is not surprising that this interferes with normal fertility. But it is less clear how a few small spots of endometriosis might have a detrimental effect on attempts at pregnancy. Nevertheless, studies have found that endometriosis is more common in women who have difficulty conceiving.

Treatments for endometriosis

There are several options for treating endometriosis, and each has its place for different women’s disease. The options are as follows:

– No treatment at all
– Management of symptoms, e.g. using painkillers.
– Medical management, e.g. suppressing endometriosis, usually with GnRH agonists or the birth control pill.
– Conservative surgery, e.g. Laparoscopic surgery.
– Radical surgery, e.g. Hysterectomy.

Once the extent of your endometriosis has been evaluated your options would be reviewed and a specific course of treatment recommended.

Fibroids are benign (non-cancerous) growths of the muscle of the uterus (womb). They are sometimes called myomas, fibromyomas or leiomyomas, but most people call them fibroids. Fibroids are common – around 20% of women get them.

Fibroids are most common in women in their 40s and 50s, towards the end of the reproductive years. They are more common in women of Afro-Caribbean origin, who also tend to be affected at a younger age. Fibroids are more likely to be found in women who have had no children or who only have one child. Obesity (being very overweight) is also associated with an increased risk of developing fibroids. They do not appear to run in families.

Fibroids grow very slowly and tend not to cause any problems or symptoms in younger women. They can cause symptoms as they grow bigger, but even so, at least half of all fibroids cause no problems at all.

Fibroids can be tiny or very large and a woman may have one or many. Their growth is stimulated by the hormone oestrogen, which is released from the ovaries during the reproductive years. Fibroids tend to become smaller after the menopause when oestrogen levels fall.

There are different types of fibroids, named according to where they are found:-

– Intramural fibroids are found within the muscular wall of the uterus.
– Subserosal fibroids grow outwards from the outside wall of the uterus. They can become very large.
– Submucosal fibroids grow from the inner wall of the uterus and can take up space inside the uterus. These account for only 5% of all fibroids.

The problems that fibroids may cause depend on their location. Fibroids are not the same as polyps. Polyps grow from the lining of the uterus (the endometrium) rather than from the underlying muscle (myometrium) as is the case with fibroids.

What are the symptoms?

Heavy periods

Up to half of all women with fibroids have heavy periods. In some cases this can lead to anemia. Fibroids do not usually cause other problems with the menstrual cycle, such as bleeding between periods.

Pressure symptoms

Fibroids tend to enlarge the uterus. This may lead to lower abdominal discomfort or backache, or may press on the bladder causing symptoms such as needing to pass urine more often than normal. The uterus may also press on the rectum causing constipation. Some women experience pain or discomfort during sexual intercourse (dyspareunia) because of fibroids.

Problems with fertility

It is estimated that fertility problems are one of the presenting features in about a 1/4 of women with fibroids. There is a well-established relationship between the presence of fibroids and lower fertility or childlessness. When compared to other causes of infertility, however, they are a relatively uncommon cause, being implicated in only 3% of couples. It may be that a delay in having children (whether voluntary or involuntary) predisposes to the development of fibroids and this is more often an association rather than a causative feature.

Fibroids can affect the shape and internal environment of the uterus. They can make it more difficult to conceive but they only account for about 3% of the total cases of infertility.

Pain

Fibroids can cause discomfort because of pressure symptoms. Heavier periods can lead to worse period pains. Severe pain is quite rare but can occur if a fibroid grows on a stalk, which they twists (torsion) or if a fibroid outgrows its blood supply causing it to break down (red degeneration).

Diagnosis of fibroids

A doctor may suspect fibroids if he or she feels an enlarged uterus during a pelvic examination (an “internal”). An ultrasound scan is a useful way of confirming the present of fibroids. Here, a probe is placed on the woman’s lower abdomen and sound save signals are translated into pictures on a screen.

Fibroids can be detected by chance when women have ultrasound scans during pregnancy. Fibroids can also be detected by hysteroscopy, where a small telescope is passed through the cervix to view the inside of the uterus, or by laparoscopy, where a camera is passed into the abdomen through a keyhole incision and the outer wall of the uterus can be seen.

Treatment of fibroids

Fibroids don’t need to be treated if they cause no symptoms, or only mild symptoms, and if the diagnosis is certain. A repeat ultrasound scan may be carried out to ensure that the fibroids are not growing too rapidly.

Medicines

There are no long-term drug treatments that can “cure” fibroids. However, drugs are available that can help relieve the symptoms.

One group of drugs aimed at reducing the size of fibroids are called gonadotrophin releasing hormone analogues (GnRH analogues). These drugs stop the ovaries from producing hormones. Their effect is sometimes described as a “medical menopause” and they can cause menopausal symptoms such as hot flushes. However, there are increased risks of harmful side-effects such as osteoporosis (thinning of the bones) if they are given for more than six months. They may be used to control symptoms in women who are close to the menopause for whom symptoms may soon be about to improve anyway.

GnRH analogues are sometimes given before surgery on the uterus because shrinking the fibroids makes the operation easier.

Surgery

– Hysterectomy – this is a major operation to remove the uterus, usually via a “bikini-line” cut in the abdomen or, if the fibroids are not too large, via the vagina.
– Myomectomy – this is the removal of individual fibroids, leaving the uterus intact. It is usually only considered for women who still wish to have a baby. This may be done with through small cuts in the belly, using a laparoscope (keyhole surgery), but may require an open operation.
– Hysteroscopic resection – fibroids within the uterus can sometimes be removed during hysteroscopy using a hot wire loop (diathermy).
– Uterine artery embolisation – this is a new technique in which the blood supply to a fibroid is blocked, causing the fibroid to shrink. It is still undergoing research and is not yet widely available.

Fibroids are often detected at a routine scan during pregnancy. They do not necessarily cause any problems. However, there is an increased risk of miscarriage, premature labor and bleeding in women who have fibroids so it’s important to consider seeking specialist care from an obstetrician.

Most fibroids (around 80%) do not increase in size during pregnancy despite the extra hormones. Fibroids sometimes cause a severe abdominal pain during pregnancy if they break down (this is called red degeneration). The treatment for this is rest and painkillers.

Cancer arising in a fibroid is very rare. However, surgery to remove fibroids may still be recommended if there are symptoms of pain, bleeding and/or rapid growth of fibroids, especially in a post-menopausal woman.

The number of couples in their late 30s and 40s attempting pregnancy is increasing. Currently 25% of patients at Barbados Fertility Centre are aged 40 or over. It is common to delay starting a family for a number of reasons: second relationships, career and educational demands, desire for financial stability, waiting for a stable relationship, however it is important to understand that fertility in women declines with age, particularly in the late 30s and 40s. This is a normal part of the ageing process.

As women become older, the chance of becoming pregnant is lower, the chance of having a miscarriage is higher and there is an increased risk of chromosomal abnormalities in the baby. In the general population, the chance of becoming pregnant after the age of 40 is estimated to be only 5% per cycle compared to about 25% per cycle in the under 40 age groups. One-third of couples where the woman is over 35 may have fertility problems. Treatments such as IVF cannot reverse the effects of age on fertility.

As men become older, the chances of achieving a pregnancy are lowered to a lesser degree than in women, as sperm generation continues throughout life. Women, on the other hand, are born with a finite number of eggs and do not produce any more during a lifetime. Geneticists believe genetic mistakes do increase with age in males. This is thought to be in the order of 0.5% in males over 40 years of age and increases to 1% at 45, 2% at 50 and 5% at 55.

Reasons for Decline in Fertility

There is an increased incidence of gynecological problems as women age. Endometriosis, fibroids, and pelvic infections all may reduce fertility, however the ageing of the eggs is thought to be the major cause of reduced fertility. Girls are born with about 400,000 eggs in their ovaries. The eggs are matured and ovulated during each menstrual cycle. For every egg that is released many more degenerate and are re-absorbed into the body. Eventually the ovary does not respond to the hormones that mature and release eggs and the woman experiences menopause. Because the eggs are present in the ovaries from birth, they age as the woman grows older, reducing their quality.

This is in contrast to male reproduction where sperm are constantly manufactured and replaced. The ageing of the eggs reduces their ability to be fertilized and to divide properly, leading to chromosomal abnormalities and a higher risk of miscarriage. Older women who receive eggs from a younger donor have a much higher chance of conceiving, confirming that the age of the eggs is crucial in achieving a pregnancy.

In IVF, age has a number of effects on the success of the treatment. The number of eggs collected is lower in older women and the quality of the embryos also generally decreases.

Higher doses of hormones are usually required in older women and there is also a higher risk of not having an egg collection due to poor or no response to the stimulating drugs. Unfortunately there is no way to reverse these effects of age on fertility.

Although age is not an absolute barrier to pregnancy, such factors as regular menstrual cycles or having had children before, do not necessarily indicate that pregnancy is possible in the late 30s and 40s.

For some women donor egg treatment may be the best chance to achieve a pregnancy. Information about the Donor Egg Program at Barbados Fertility Centre is available from your nurse coordinator, counselor or clinician.