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26/May/2015

Uterine septum is a deviation from normal shape of the uterus which is present congenitally (from birth). The uterine cavity is normal or slightly enlarged with a central septum. It is like a curtain dividing the uterine cavity into two spaces. This curtain can be partial i.e. dividing only the upper part of the cavity into two or complete, in which case the curtain divides the entire uterine cavity into two.

Arcuate-uterus

(Laparoscopic view of Arcuate uterus / uterus with septum)

Uterine-Septum-2

3D Ultrasound image of T shaped uterus

 

Uterine-Septum-3
USG image of T shaped uterus

septum-4

T shaped uterus due to uterine septum

What is the cause of septum?
The uterus is formed in a female fetus by fusion of two tubes. Incomplete central absorption of the tubes can lead to a septate uterus.
Why the absorption should be incomplete is not known. Septate uterus can be hereditary but not always. It may be associated with congenital anomalies of kidney and ureters.

subseptate-uterus-5

Around 3 % of women in reproductive age group will have septate uterus in some or another form. Around 15 % of women with history of recurrent abortion might have an underlying septate uterus.

What are the symptoms of septate uterus?
In many a women septate uterus may never be diagnosed. They may even have history of normal pregnancy. Some of the women may have history of excessive bleeding during menses.

However it may lead to infertility and pregnancy loss. In a septate uterus, the septum or the curtain has less blood supply compared to the walls of uterus. If the embryo implants onto the septum, it may not grow due to poor blood supply and thus leading to failure of implantation. Infertility may be thus result of failure of implantation. In some cases the embryo may implant onto the septum, will grow to some extent, but then due to poor blood supply may lead to spontaneous (women may start bleeding soon after missed period) or missed (fetal heart activity may not be seen) abortion.

Abortion may also occur as the uterine cavity may not be big, enough due to the septum, for the embryo to grow. Even pregnancy losses between 3 to 6 months are common as congenital malformation of uterus is often associated with weak cervix (mouth of the uterus). This is however avoidable if USG is done to check the cervix. If any doubt of weak cervix is present on USG or the woman has past history of pregnancy loss after 3 months, a cervical stitch can be place to avoid any complications.

How is septate uterus diagnosed?
It is most commonly diagnosed on Hysterosalpingography (HSG) or ultrasonography (USG).

In HSG either two cavities are seen or indentation onto the uterine fundus is visualized. A septum may be commonly diagnosed on USG as it is a routine investigation done for women with infertility or recurrent pregnancy loss.

Hysteroscopy is not a routine investigation to diagnose uterine septum but is used to treat the septum. Sometimes a small septum may be diagnosed during hysteroscopy, which can be treated in the same sitting.

MRI can also accurately diagnose a uterine septum. However other modalities are as sensitive in diagnosis and therefore it is not a cost-effective method for routine diagnosis of septate uterus.

Transvaginal USG showing evidence of septate uterus

Transvaginal USG showing evidence of septate uterus-6

MRI showing septate uterus

MRI showing septate uterus-6

How is septate uterus treated?
As such if the woman has no symptoms there is no need to treat septate uterus. Infertility and recurrent pregnancy loss are indications for treatment of septate uterus.
Surgery is the only method for treatment for septate uterus. Medications cannot treat it.

Hysteroscopic visualization and resection is the gold standard of treatment.

Hysteroscopic septal resection or fundal metroplasty is the surgery which needs to be performed. In this a special knife mounted on resectoscope is used through which electric current is passed. This knife is used to cut the narrow walls of the uterine cavity and make the cavity broad. As the entire procedure is done under hysteroscopic guidance, it is very safe and equally effective.

 

A balloon may be kept in the uterine cavity to keep the cavity distended and to prevent scar formation for one week. Also some medications may be given for the lining to grow over the cut portion. Follow up may be scheduled after 7 days, when the balloon is removed. The growth of lining and response to surgery is monitored for the next month or more.

What are the complications of the surgery?
The complications are same as in other operative hysteroscopy surgeries. However complication rates are negligible in hands of expert


26/May/2015

Intrauterine Adhesions & Asherman’s Syndrome

Asherman’s syndrome or intrauterine adhesions, is an acquired uterine condition, characterized by formation of adhesions or scar tissue within the uterus. In simple language these are thick bands of scar tissue which make the front and back wall of uterus stick to each other. (To naked eye they look like dried glue bands). The scar tissue may lead to obliteration of the cavity. They may occupy only a part of uterus or the entire cavity. Depending on the extent of adhesions we can classify the syndrome as mild, moderate or severe. These adhesions are generally avascular.

 

Video of calcification

(Video lateral wall synechiae)

There is a variant of Asherman’s syndrome that is more difficult to manage called as “unstuck Asherman’s” or “endometrial sclerosis”. In this condition the uterine walls are not stuck together, instead the endometrium is peeled off and destroyed.

adhesions-1

How do I know that I may have Asherman’s syndrome?

Symptoms depend upon the severity of adhesions , with some women having no symptoms at all. Many a times in such women, Asherman’s syndrome is diagnosed during investigation for infertility or recurrent pregnancy loss. Most women, however present with either decreased blood flow during their menstrual periods or complete amenorrhoea (absence of menstrual flow). Some women experience excessive pain during menstrual periods as uterine muscle have to contract harder to get rid of menstrual fluid past the scar tissue. Sometimes the scar tissue may completely obstruct the menstrual fluid and cause severe pelvic pain.

 

What causes intrauterine scarring or synechiae?

Normally uterus is lined by endometrium which is shed cyclically in every menstrual cycle. Trauma to this endometrial lining triggers the process of wound healing which leads to formation of scar tissue or adhesions. For example if you get a cut in your skin the two edges will stick to each other and form a scar. Similar process can occur if there is deep cut or trauma to both front and back wall of uterus. When this trauma heals it forms a scar which will finally make both the walls stick to each other.

Pregnancy related dilatation and curettages (D & C’s) account for 90 % of Asherman’s cases. These include D & C performed because of missed or incomplete abortions, elective abortions or after delivery for heavy bleeding in cases of retained products. Asherman’s risk increases with the number of D&Cs performed; after a single procedure the risk is 16% however after 3 or more D&Cs the risk jumps to 32%. Adhesions may also occur following pelvic surgeries such as caesarean section, fibroid removal and septal surgeries. In developing countries like India, infection particularly Tuberculosis and other RTI/ STIs are also an important cause of intra uterine scarring.

normal-hsg-2 narrow-constricted-3

What is the incidence of Asherman’s syndrome?

Asherman’s is thought to be under-diagnosed because it is usually undetectable by routine diagnostic procedures such as ultrasound scan. The condition is estimated to affect 1.5% of women undergoing HSG, between 5 and 39% of women with recurrent miscarriage, and up to 40% of patients who have undergone D&C for retained products of conception following childbirth or incomplete abortion.

What investigations will help in the diagnosis?

Direct visualization of the uterus via Hysteroscopy is the most reliable method for diagnosis. Other methods are sonohysterography (SHG) and hysterosalpingogram (HSG).

Fig showing Hysterosalpingogram with filling defects suggestive of intrauterine adhesions.

 intrauterine-adhesions-4 intrauterine-adhesions-5

What is the treatment of Asherman’s syndrome?

Asherman’s must be treated by an experienced surgeon via hysteroscopy (sometimes assisted by Laparoscopy). Under direct visualization of hysteroscope the scar tissue is cut with scissors. However one should remember that adhesions have a tendency to reform especially in more severe cases. In order to prevent re-scarring after surgery, estrogen supplementation may be given to stimulate uterine healing and growth of endometrium. A balloon can be placed in the cavity to prevent apposition of the walls during the immediate post-operative healing phase for 1 week. The pre-operative instructions are same as in other hysteroscopic surgeries.

 


26/May/2015

Tubal cannulation is a procedure to open up tubal corneal blocks (origin of fallopian tubes near the uterus). It is done under hysteroscopic guidance (a procedure that allows the Gynaecologist to see inside the womb by means of a fine telescope called Hysteroscope, introduced through the neck of the womb). It involves passage of a fine wire through the hysteroscope into the opening of fallopian tubes.

This part of the fallopian tube at the junction of uterus and tubes, it is as thin as a hair and such a procedure often removes blockage due to mucous plugs or debris, thus restoring tubal patency. Simultaneous Laparoscopy is needed to visualize the distal end of the fallopian tubes and confirmation of their normal status. Laparoscopy is also needed for the passage of guide wire through the tube followed by pushing a blue dye to check whether tube has opened (chromopertubation).

Tubal-Cannulation-1

Tubal-Cannulation-2

Video of Cannulation

 

Video of cannulation 2

When is this procedure usually done?

This procedure is done in women who have cornual block (That portion of the tube where it arises from the uterus).

This is usually diagnosed prior on hysterosalpingography. Many a time cornual block may be diagnosed at the time of diagnostic laparoscopy. This procedure is not to be performed if there is a distal tubal pathology.

 

Is there any alternative to tubal cannulation?

Tubal defect or disease accounts for 25 – 30 % of infertility in women, of which proximal tubal obstruction accounts for 10 –15 % . The traditional treatment for cornual / proximal tubal block is an open surgery and IVF (Test tube baby). Open surgery causes significant patient discomfort, is tedious, time consuming and causes delay in recovery. There incidence of ectopic pregnancies also increases after an open surgery.

Other management option is the use of in vitro fertilization (IVF), but this is, costly, time consuming, with 40-45% success per attempt. On the other hysteroscopic tubal cannulation is a simple and short day care procedure. Also, since it is generally done with laparoscopy the presence of distal tubal disease or other pathologies can also be diagnosed and treated simultaneously. It is cost effective, the results are also comparable with minimal complication and ectopic pregnancy rates. Post procedure pregnancy rates reported in various studies range from 20-40 %. If pregnancy is not achieved in six months after the procedure then tubal patency needs to be confirmed by hysterosalpingogram.

 

What are the potential complications?

  • Failure to navigate the tube and open the obstruction can occur in 10-30 % women.
  • Pinhole tubal perforation or tubal dissection is known to occur in 3.7 % cases.
  • Other complications which can occur with any hysteroscopic procedure.
  • There is no increased ectopic pregnancy rate with this procedure as opposed to open or microscopic surgeries.

 


26/May/2015

A uterine polyp, also known as endometrial polyp is an overgrowth of lining of the uterus. The concept is similar to that of a skin tag – basically normal tissue, but growing in an abnormal fashion. They are soft, fleshy growths that form on the inside of the uterus. Polyps remain attached to the uterus by a large base (sessile) or thin stalks (pedunculated).

Why does a polyp occur?

Uterine polyps arise from cells which form the endometrium, the inside lining of the uterus. During monthly cycle, the endometrial lining begins to grow, in preparation for implantation or attachment of an embryo. If no embryo is implanted i.e. if there is no pregnancy, this lining sheds in the form of periods. Sometimes however, due to hormonal imbalance or many a times unknown reasons, this endometrial lining grows too much, causing tiny clumps to form. These clumps are known as uterine polyps.

How common are they?

Between 10-25% of women develop polyps at some point of their lives. The risk for developing polyps increases as you grow older until menopause, with most women developing in their 30s and 40s. Polyps are rare in women under the age of 20 and above the age of 50.

How do I know whether I have a polyp?

Uterine polyps rarely cause symptoms. Some common symptoms are as follows:

  • Irregular menstrual bleeding
  • Spotting between periods
  • Bleeding after intercourse
  • Cramping in lower abdomen
  • Infertility or miscarriage

uterine-polyp-2

Different Locations of Uterine Polyps

How does a polyp affect fertility?

Many polyps are very small, a few millimeters in diameter, and do not cause any compromise in reproductive capabilities. However, larger polyps or multiple polyps can interfere with reproduction.

Uterine polyps as already mentioned affect the lining of the uterus.This lining is very important when it comes to embryo implantation. If the lining becomes unstable or unhealthy due to uterine polyps, it can interfere with implantation and also increase the risk of miscarriage. Few polyps can block the cervical canal or the area where fallopian tube connects to the uterine cavity which would prevent the sperm from entering the uterus or fallopian tube respectively.

Is there any risk of polyp being cancerous?

A polyp is considered a benign growth. However there is a small chance of them turning cancerous. Less than 1 % of polyps are associated with cancer. Examination of tissue under microscope is the only way to reliably determine whether the polyp is benign (non cancerous) or malignant (cancerous).

If they rarely cause symptoms, how are they diagnosed?

Most common non invasive way of diagnosis is ultrasound. It is easy to diagnose polyp between the 9th day and 15th day of the cycle. During rest of the menstrual cycle it is difficult to visualize and diagnose a polyp.

A polyp can also be diagnosed on a Hysterosalpingogram (HSG). HSG is an examination of uterus and fallopian tube using X-ray. A contrast dye is injected into uterus and fallopian tubes, to make it easier to visualize polyps.

A sonohysterogram is a special type of ultrasound in which the uterine cavity is filled with saline using a narrow catheter. The saline distends the cavity and creates a space between the walls. This aids in visualizing the polyps that may be missed with traditional ultrasound.

Hysteroscopy is a procedure using a small telescope inserted through the vagina and cervix into the uterus to view polyp and determine their size and extent. Removal of the polyp can be carried out in the same sitting.

Video of Hysteroscopic polyp

In olden days polyps were also diagnosed at the time of dilatation and curettage when an irregularity was felt in the uterine cavity while curetting. This is a blind technique and is no longer followed.

Is the removal of polyp necessary?

If a women has a uterine polyps and she’s experiencing infertility than removal of polyp/ polyps could boost her fertility. Also women who have to undergo in-vitro fertilization (IVF) treatment are generally advised to have uterine polyps removed before conducting embryo transfer procedure. About 80 % women get successfully pregnant in 12 months following removal of polyp. In women with polyps not related to fertility, large polyps causing symptoms or with suspicion of carcinoma have to be removed.

How are polyps removed?

Traditional methods to remove polyp include dilatation and curettage. However this is a blind procedure and does not guarantee removal of polyp.
Hysteroscopy can directly visualize the polyp; determine its location and size. Also removal can be carried out hysteroscopically under direct vision.

Video of hysteroscopic polyp resection

A pedunculated polyp can be removed by cutting the stalk directly; however larger and sessile polyps need removal in layers. The tissue is removed from the uterine cavity and sent for histopathology.

How many days do I need to rest after the procedure?

This procedure is a day care procedure, which means that you can go home in 6-8 hrs after surgery. No more than a day rest is needed and a couple of days leave from work is all that is required.

What type of anaesthesia is used?

Hysteroscopy is usually performed under a general anaesthesia, although sometimes local anaesthesia is used instead. Anaesthesia fitness will be done by an anaesthetist before the procedure.

What are the complications?

Hysteroscopy is considered safe however it carries some risks that a patient should be aware of.

  • Pelvic infection is not common but may manifest with lower abdominal pain, fever and offensive vaginal discharge and can be treated with antibiotics.
  • Hemorrhage and need for blood transfusion is very rarely necessary.
  • Although rare, the gas or fluid used to distend the uterine cavity could spill into your bloodstream and cause serious problems.
  • Occasionally there might be failure to visualize the uterine cavity if the neck of the womb is too tight.
  • Uterine perforation wherein scope or an instrument may pass through and through the uterine wall occurs in less than 1 % of cases.

Most of the time the injury may heal by itself and there are no furthur future complications. However there may be a need of prolongedhospital stay or sometimes further intervention. A laparoscopy (insertion of telescope through your umbilicus) may be performed to investigate any possible internal injury. Very rarely, a laparotomy (An operation through a larger incision) is necessary to repair an injury.

Anaesthesia may carry a small risk. Problems may arise with the medications given.

Complications are very rare under experienced hands. Hysteroscopic polypectomy is associated with major complication rate of less than 1 in 10000.

Are there any side effects?

It is usual to have some bleeding after hysteroscopy, which is bright red at first and should gradually reduces to a brownish discharge. This can last up to 2 weeks. Some degree of pain is to be expected but this is not severe and relieved by painkillers.

When do I follow up with the doctor?

The histopathology report takes approximately 5-7 days. You can follow up after a week to collect the report and to discuss further line of management.

Do polyps tend to recur?

In 10-15% of women there may be a tendency for polyps to recur. There are no medications which can prevent this. And the only treatment available is surgical removal. So if at all the polyp tends to recur in a women desirous of fertility, she may have to undergo a repeat surgery. It is therefore advisable to start treatment for fertility with a fertility specialist as soon as you get operated for a polyp.


26/May/2015

The normal uterine or womb cavity is triangular in shape and spacious. Such a normal triangular cavity is a prerequisite for attachment of embryo and carrying the pregnancy for 9 months. In a T shaped uterus this normal triangular cavity is replaced with a cavity resembling English alphabet ‘T’, i.e. the cavity is broader at the top and narrow tube like below. Such a cavity is not spacious enough and may lead to infertility, abortions and preterm delivery.

Normal triangular uterine cavity T- shaped uterine cavity

t-shaped-uterine-1

However some women may have normal pregnancy with T- shaped uterus. It can be considered as a variant of normal shape.

What are the symptoms of T-shaped uterus?
As such women with T-shaped uterus do not have any symptoms. They may have less bleeding during menstrual cycle. They are usually diagnosed and treated as they may have associated infertility, previous abortions or preterm delivery.

What are the causes of T-shaped uterus?
Many a time a definite cause cannot be found. T-shaped uterus could be congenital (from birth) or may be related to pelvic infections. For example, Tuberculosis of the pelvis may cause scarring and narrowing of the cavity making the uterus T-shaped.

How is the diagnosis made?
Diagnosis is usually made on ultrasonography of the pelvis. Also these women do not have well developed endometrium (lining) as evident on ultrasound. The lining usually remains thin inspite of medicinal support. Endometrial volume measured with help of ultrasound is less than 2 cubic mm done on 10-14 day of periods is also confirmative. A 3 D ultrasound can also be helpful in case of any doubts.

t-shaped-uterine-diagnosis-2

Other useful means of diagnosis is with Hysterosalpingogram, where an X-ray of pelvis is taken after injecting a dye. Many a times diagnosis is made while doing a routine diagnostic hysteroscopy.

 

Normal Uterine cavity on HSG

T-shaped-Uterine-cavity-on-HSG-3

T-shaped Uterine cavity on HSG

t-shaped-uterine-4

What is the treatment?
The treatment is surgical.

Hysterocopic adhesiolysis is the surgery which needs to be performed. In this a special knife mounted on resectoscope is used through which electric current is passed. This knife is used to cut the narrow walls of the uterine cavity and make the cavity broad. As the entire procedure is done under hysteroscopic guidance, it is very safe and equally effective.

hysteroscopic-lateral-metroplasty-5 hysteroscopic-lateral-metroplasty-6 hysteroscopic-lateral-metroplasty-7

Video of lat metroplasty:

 

 

 

 

A balloon may be kept in the uterine cavity for one week to keep the cavity distended and to prevent scar formation. Also some medications may be given for the lining to grow over the cut portion. Follow up may be scheduled after 7 days, when the balloon is removed. The growth of lining and response to surgery is monitored for the next one month or more. A Hysterosalpingogram done 4 weeks after surgery may show improvement in the cavity size.

Can I be sure of a pregnancy after this surgery?
Hysteroscopic adhesiolysis of grade 1 adhesions have shown to improve pregnancy rates and reduce abortion rates. Studies have shown that this decreases the abortion rates from 88% to 12.5% and term delivery rates improved from 3% to 87%. A cervical stitch may be required in some women who have undergone this to prevent preterm delivery.


25/May/2015

Video of diagnostic Hysteroscopy

 

Hysteri = uterus; scopy = to see

Hysteroscopy is a procedure that allows Gynaecologist to see inside the womb by means of a fine telescope (Hysteroscope) that can be introduced through the (cervix) neck of the womb. Hysteroscopy can be painless and can be done in an outpatient basis. More often it is done in an operation theatre under anaesthesia. Hysteroscopy usually follows investigations such as Hysterosalpingography or transvaginal ultrasound.

A small telescope, the hysteroscope, is passed through the cervix and the inside of the uterine cavity can be seen. A small camera is attached to the telescope and the view is projected on a video monitor. This magnifies the picture and also allows the physician to perform the surgery while sitting in a comfortable position.

hysteroscopic-view-of-normal-uterine-cavityhysteroscopic-view-of-left-ostia hysteroscopic-view-of-right-ostia uterine-cavity-on-hysteroscopy

 

If I have difficulty in conceiving do I need to undergo hysteroscopy as a routine investigation?

No. We at Ankoor clinic do not advise hysteroscopy for all infertility patients as hysteroscopy is not recommended as a routine investigation for infertility.

 

What are the indications for a Hysteroscopy?

You may need to undergo hysteroscopy if you have any of the following:

  • Abnormal hysterosalpingography (HSG) (Screening test for tubal patency wherein a dye is) injected in the uterus and visualized under X-ray control).

hsg3Abnormal bleeding pattern

  • Uterine abnormalities or pathology suspected on ultrasonography
  • Unexplained infertility.(Inability to conceive despite all routine investigation being normal)

Hysteroscopy enables the gynaecologist to inspect the lining of the womb and to detect possible causes for the above problems like polyps or fibroids. Many experts in radiology and imaging feel that high resolution ultrasound can pick up intrauterine pathology accurately, in which case hysteroscopy is more often considered as a see and treat procedure.

How will a Hysteroscopy help in unexplained infertility?

Review of literature shows that positive hysteroscopic findings were found in as many as 15 % cases despite having normal HSG and no history suggestive of intra uterine lesions.

If I am undergoing laparoscopy for infertility should hysteroscopy be done at the same time?

There are certain indications when both hysteroscopy and laparoscopy are done at the same time. However it is not done in all cases. It depends on the individual patient.

For eg. In a woman coming with large intrauterine polyp, if the patency of fallopian tubes is not known then it is better to do a laparoscopy along with polyp removal by hysteroscopy. This will help us to check for the fallopian tubes as well as the uterus and ovaries.

There is no harm in doing hysteroscopy at the same time as laparoscopy. It does not take extra time or exhorbitant cost, is safe and has low complication rate.

How many days do I have to take off from work?

Hysteroscopy can be done as a day care procedure i.e. you will be able to go home in few hours after the operation. However to be on safer side or if there are any potential difficulties, the gynaecologist may advice an overnight stay. You will not need more than a couple of days off at work. Recovery period is very short as there are no scars.

How do I prepare for a hysteroscopy?

You may have to do a few blood investigations before your operation. Do not eat or drink (even water) after midnight on the night before your operation. You can bathe in the morning before surgery.

Your doctor may also have additional instructions for you. Some surgeons recommend use of vaginal misoprostol (a vaginally introduced tablet) 2-4 hrs prior to hysteroscopy to reduce cervical resistance and thereby cervical trauma due to dilatation.

Can I know how is the operation performed?

The operation is done from the vagina (Birth passage) and leaves no scar.

After giving anaesthesia the cervix (neck of the womb) is dilated to pass the hysteroscope into the womb. The cavity of your womb is then distended with fluid. All four walls as well as the fundus and the lining of the womb (endometrium) are examined systematically.

If any abnormality is found, it can be tackled at the same time (Operative hysteroscopy) or at a later date as per the woman’s wish. Many a times curetting (scraping of lining of uterus i.e. endometrium) of the uterine wall is carried out after hysteroscopy. This endometrial material can be sent for histopathology and other investigations to diagnose hormonal problems or infections like tuberculosis etc.

Which other procedures may be usually performed during Hysteroscopy?

Curettage and polypectomy are commonly performed procedures during hysteroscopy.

Curettage includes gentle scraping of lining of the womb by a slender instrument. The sample is sent for histopathology. Polyps are harmless fleshy growths that are attached to lining of the womb by stalks. Polyps are removed by using a forceps or by using cautery to cut them. They are also sent to laboratory for histopathology. The reports are generally available in a week’s time.

What type of anaesthesia is used?

Hysteroscopy is usually performed under a general anaesthesia, although sometimes a local anaesthesia is used instead. You will be always seen by an anaesthetist before you come in for your operation.

What are the complications?

Hysteroscopy is considered safe however it carries some risks that a patient should be aware of.

  • Occasionally there might be failure to visualize the uterine cavity if the neck of the womb is too tight.
  • Uterine perforation wherein scope or an instrument may pass through and through the uterine wall occurs in less than 1 % of cases.
  • Pelvic infection is not common as we now-a-days give peri-operative antibiotics, but may manifest with lower abdominal pain, fever and offensive vaginal discharge and can be easily treated.
  • Hemorrhage and need for blood transfusion is very rarely necessary.
  • Although rare the gas or fluid used to distend the uterine cavity could spill into your bloodstream and cause serious problems.
  • Anaesthesia may carry a small risk. Side-effects may arise with the medications given

 

Level of complication is almost negligible in expert surgeon hands. Most of the time the injury may heal by itself and there are no further future implications. However there may be a need of prolong hospital stay or sometimes further intervention. A laparoscopy (insertion of telescope through your umbilicus) may be performed to investigate any possible internal injury. Very rarely, a laparotomy (An operation through a larger incision) is necessary to repair an injury.

Are there any side effects?

It is usual to have some bleeding after hysteroscopy, which is bright red at first and should gradually reduce to a brownish discharge. This can last for up to 2 weeks. Some degree of pain is to be expected but this is not severe and relieved by painkillers like paracetamol or ibuprofen.
Submucous Or Intramural Fibroid

Which fibroids can be treated hysteroscopically?
As already explained in link of fibroids, they can either be subserosal (on the outer surface of uterus), submucous fibroids (inside the uterine cavity) or intramural (within the wall of uterus). It is the submucous fibroids which can mainly be treated with hysteroscopic resection. Also intramural fibroids may require hysteroscopic management if they protrude within the uterine cavity. Other intramural and subserosal fibroids need laparoscopic removal.

fibroids-1

Hysteroscopic classification of fibroids:
European Society for Gynaecological Endoscopy (ESGE) Classification of submucous myomas (Adapted from Wamsteker’s classification):

Type 0 – Entirely within endometrial cavity

No myometrial extension (pedunculated)

Type I – < 50% myometrial extension (sessile)

< 90 degree angle of myoma surface to uterine wall

Type II – > or = 50% myometrial extension (sessile)

>or = 90 degree angle of myoma surface to uterine wall

Type 0 and type I can be removed hysteroscopically, while type II is to be removed laparoscopically.
What does hysteroscopic resection of fibroid mean?

Video of hysteroscopc resection of fibroid

A resectoscope (thin long telescope like instrument) is a special operative instrument that is attached to a normal hysteroscope. To this resectoscope a special loop is loaded which can conduct electricity. It is this electricity that is used to cut the fibroid into pieces and then remove it through the cervix / vagina.

6

Hysteroscope

This procedure is performed as outpatient surgery without any incisions and virtually no postoperative discomfort. Anesthesia is needed because the surgery may take one to two hours. A small telescope, the hysteroscope, is passed through the cervix and the inside of the uterine cavity can be seen. A small camera is attached to the telescope and the view is projected on a video monitor. This magnifies the picture and also allows the physician to perform the surgery while sitting in a comfortable position.

Electricity passes through the thin wire (resectoscope) attachment at the end of the hysteroscope, allowing the instrument to cut through the fibroid like a hot knife cutting through butter. As the fibroid is shaved out, the heat from the instrument blocks blood vessels and the blood loss is usually minimal. Women go home the same day, and recovery is remarkably fast, with most patients able to go back to normal activity, work and exercise in one or two days.

Is it necessary to remove submucous fibroids?
Many studies have found that submucous fibroids that change the shape of the uterine cavity decreased pregnancy rates by as much as 70%. Not only is the pregnancy rate reduced but also there is an increased chance of abortion. When these fibroids were removed there was an increase in the pregnancy rates.

The reason submucous fibroids leads to infertility is not clear, but current theories are that the fibroids change blood supply to a the developing embryo, or block passage of the embryo through the fallopian tube, or cause inflammation in the uterine lining, or interfere with attachment of embryo to the uterine lining or hamper embryo development. Only a few years ago, treatment for fibroids in the cavity of the uterus involved major surgery-an abdominal incision and either cutting open the entire uterus to remove the fibroid or performing a hysterectomy. Such a major surgery did not significantly improve pregnancy outcomes. Also an incision on uterus increased rate of complications in pregnancy. Hysteroscopic myomectomy has been a major advance in the treatment of women who have submucous fibroids.

Hysteroscopic removal definitely improves pregnancy rates. Also there is no increased incidence of complications in pregnancy.

Can these fibroids be managed with medicines?
No, there is no definitive medical management for fibroids. Surgical removal is the only way to get rid of the fibroid and obtain optimal result. It is just like a mole on the skin, it needs to be removed no medicines can treat it.

How long does the surgery take?
Since the fibroid has to be cut and removed chip by chip, it may take 30 min to 2 hours to remove a submucous myoma depending upon the size and extent. One can remove as large as 6-7 cm fibroid at a time. Sometimes if the fibroid is very large the entire procedure may need to be done in two sittings with a gap of 3-4 weeks. This ensures complete removal and lesser complication rates.

Once removed do fibroid come back again?
If completely removed the fibroid does not come back again, however new fibroids can appear. The location and size of fibroids may vary and you may or may not require further surgery.

What anaesthesia is used?
General anaesthesia is used for this surgery. It means you will be put to complete sleep and won’t feel any pain or discomfort during surgery.

How do I prepare prior to surgery?
Preparation for the surgery is similar to any other hysteroscopic surgery. Some medicines may be prescribed to you prior to surgery and a fasting of 6 hours is sufficient. A vaginal tablet (Misoprostol) may be inserted 2 hours prior to surgery to reduce cervical resistance and thereby cervical trauma.

How many day will I be hospitalized? How many days do I need to take rest after surgery?
You may be discharged on the same day evening. In cases of larger fibroids where surgery went on for a longer time you may be kept overnight for observation. You will be mobilized after 4 hours of surgery and can go home walking. You may go back to work after 2 days of rest.

What are the complications?
Minor discomfort in the pelvic region and few cramps are normal. There might be slight bleeding which will subside in 3-4 days. Major complications like uterine perforation, trauma to bladder or rectum, severe hemorrhage and fluid overload are rare.


25/May/2015

Pelvic inflammatory disease is a general term used to describe infection of uterus (womb), fallopian tubes (tubes that carry egg, sperm, embryo between ovaries and uterus), ovaries and other reproductive organs.

The pelvic organs get infected commonly due to bacterial organisms. These organisms reach the uterus, tubes and ovaries through sexual route i.e. vagina. Gonorrhoea and chlamydia are two common bacterial organisms that cause PID. Tuberculosis can also cause PID. Tuberculosis can be transmitted via the sexual route or through blood when some other organ in body is infected.

While infection of the uterus is called endomyometritis. Salpingitis and salpingoophoritis indicates infection of tube and ovary. Infection may spread to surrounding organs such as intestines (bowel) and bladder. These organs may get stuck to each other to prevent further spread of infection leading to what is called as Pelvic adhesions (similar to fevicol smeared in between fingers) or Tubo-ovarian mass (collection of mass due to sticking together of the surrounding structures).

 

Adhesions between the bowel and anterior abdominal wall

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Adhesion

How does PID cause Infertility?

Untreated, undiagnosed and repeated infections may lead to permanent damage to reproductive organs leading to infertility. This may present with intrauterine adhesions, hydrosalpinx, pelvic adhesions or deforming tubo-ovarian relation. All these leads to altered anatomy of the uterus, fallopian tubes and ovaries leading to difficulty in the egg being picked up by the fallopian tube or the meeting of the egg with the sperm or sometimes the attachment of the embryo in the womb (inner cavity of uterus.)

 

Video of mid tubal block

 

In INTRAUTERINE ADHESIONS the two walls of uterus or womb get stuck to each other after infection causing closure of cavity and preventing the lining of womb to grow and therefore the embryo or egg cannot implant (enter the lining). It is like when two pieces of wood get stuck to each other with glue there is no space between them.

intrauterine-adhesions

HYDROSALPINX (Fluid within the tube) occurs after infection of the tubal lining. The inner lining of the fallopian tube is ciliated i.e it has some finger like projections for movement of the sperm, egg and embryo. This lining is extremely delicate. When there is infection of the fallopian tubes this lining gets affected and inflamed leading to permanent loss of function of the cilias in most cases.

The tube lining gets infected with bacterial organisms and produces a fluid to fight the infection. The infection may get cured but the fluid remains. Also the tube lining may get destroyed due to infection. Fallopian tubes are very important structures through which the ovum or female eggs go from ovary to uterus, the sperms or male eggs go from uterus to tube, also the early embryo develops within the tube and then goes to uterus.

hydrosalpingb-i-hydrosalpingx
Video of Hydrosalpingx

 

hydrosalpinx

When the tubes get destroyed with formation of hydrosalpinx these functions are lost and thereby causing infertility. Also the fluid in hydrosalpinx is toxic to embryo so it can also lead to failure of IVF. In such cases separation of tubes (delinking) from the uterus will be required for successful IVF. This procedure delinks (detaches) the fallopian tubes from the uterus and hence prevents the spread of the toxic fluid to the uterus and embryos. This leads to increase chances of pregnancy in cases of IVF /ICSI.

 

Delinking of the tube from the uterus in case of Hydrosalpinx

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(Bowel stuck to the uterus and left tube and ovary)

Video of delinking

Another important complication of PID especially in cases of tubal involvement is ECTOPIC PREGNANCY. It has been seen that the fallopian tubes are involved in almost 90% of cases of PID. If pregnancy results in these cases there is a very high risk of the embryo attaching and implanting in the tubes itself. This is known as ectopic pregnancy. Such pregnancy cannot grow as the tubes are very small and may rupture any time leading to blood in the abdomen and life threatening condition.

Ectopic-pregnancy_3

Ectopic-pregnancy_2

Above pictures show right tubal ectopic pregnancy and its laparoscopic excision.

Therefore it is very important to do serial serum beta HCG once you are pregnant. This should be followed by USG to localise the pregnancy. In case of early ectopic pregnancies medical management can be done in the form of methotrexate injections. If the ectopic pregnancy is detected late than surgical removal is the only option. Once methotrexate is used, after the beta HGC values in the blood come to normal , the next pregnancy can be planned in 3 – 6 months.

When infection reaches outside the tube into abdominal cavity, women’s body tries to prevent the spread of infection to other parts of body. When this occurs, the intestine, the fallopian tubes and the ovaries may get stuck to each other, leading to what is called PELVIC ADHESIONS. In the process the normal relationship between tube and ovaries get destroyed. Normally tubes and ovaries are arranged in such a way that when an egg ruptures it is directly transferred to the tube.

Due to the adhesions the tube and ovary may be pulled away from each other and therefore even if there is normal ovulation or rupture of egg, it does not enter the tube.

b-i-cornual-block

 

loculates-spill-adhesions

How do women get PID?

Sexually active women in their childbearing years are at most risk, and those under age 25 are more likely to develop PID than those older than 25. This is because the cervix of teenage girls and young women is not fully matured, increasing their susceptibility to the bacteria that cause PID.

Poor personal hygiene in either or both the couple may increase the incidence of PID.

The sperm (tail of the sperm) and the vaginal flora may also carry the infection into the female reproductive tract i.e. uterus and fallopian tubes.

Women who douche (clean their vagina with jet of water or soap water) may have a higher risk of developing PID compared with women who do not douche. Research has shown that douching changes the vaginal flora (organisms that live in the vagina) in harmful ways, and can force bacteria into the upper reproductive organs from the vagina.

Women who have an intrauterine device (IUD e.g. Copper T) inserted may have a slightly increased risk of PID near the time of insertion. However, this risk is greatly reduced if a woman is examined and, if necessary, treated with antibiotics before an IUD is inserted.

Intrauterine invasive surgeries if not performed using proper antiseptic precautions and under the cover of antibiotics can also lead to PID. Therefore dilatation and curettage, MTP and abortions can also predispose to PID.

What are the symptoms of PID?

Symptoms of PID may vary from none to severe. Those women who have symptoms may have one or more of the following:

  • Pelvic pain or tenderness
  • Pelvic pain during intercourse (dysparaeunia)
  • Smelly yellow or green vaginal discharge
  • Irregular periods
  • Fever or chills
  • Mild to severe nausea

Many a times a woman may experience mild symptoms or no symptoms at all, while serious damage is being done to her reproductive organs. Because of unclear symptoms, PID goes unrecognized by women and their doctors about two thirds of the time.

How is PID diagnosed in women with fertility problems?

Women may present with symptoms of vaginal discharge or pain in lower abdomen. However frequently they have no symptoms and chronic PID may be diagnosed on USG (sonography), HSG (hysterosalpingography) or at the time of diagnostic laparoscopy.

Hydrosalpinx and intrauterine adhesions are visualized on USG. Many a time lack of growth of lining of the uterus may be suggestive of old infection. T-shaped uterus seen on USG may also indicate past infection. Non-motile or adherent ovary with probe tenderness may also reflect adhesions in the pelvis.

HSG findings like extravasation of the dye, T-shaped uterus, dilated thick beaded tubes, absent spill in one or both tubes, or loculated spill are suggestive of damage done due to PID.

Many a times a diagnostic laparoscopy and hysteroscopy may be planned for other reasons and hydrosalpinx, blocked tubes or adhesions may be picked at that time. In these cases, we at Ankoor clinic also do adhesiolysis as well, so that the patient does not have to undergo a repeat procedure (only after the couple’s consent).

How can all this be treated?

Acute infection causing severe pain and vaginal discharge is treated with antibiotics. It is always better to treat both the women and her male partner as the infection is usually sexually transmitted.

However most women who come to infertility clinic, have an old infection i.e. chronic PID. These women will have no symptoms. The diagnosis is based on evidence seen on USG, like presence of hydrosalpinx or intrauterine adhesions. This can be treated surgically only.

Laparoscopy and hysteroscopy are gold standard for treatment for chronic PID. On laparoscopy serial examination of the pelvis and upper abdomen is done to see presence of adhesions, hydrosalpinx etc. Under laparoscopic guidance these adhesions can be released, infected fluid drained and normal anatomy can be established. Tubal patency can be checked by pushing a dye through the tubes.

In case of a hydrosalpinx, the tube needs to be either removed or cut off from the uterus. This is done because as explained before these tubes are non functional and would not allow normal conception (pregnancy). In which case the women will finally require IVF or test tube baby. The fluid from the tube is toxic to the embryos which are put in the uterus during IVF and therefore it is better to cut the tubes from the uterus. This will improve the success rates of IVF.

Intrauterine adhesions and T-shaped uterus a sequel of old infection need to be treated hysteroscopically. Adhesiolysis and metroplasty are the surgeries used to treat these. These women may sometimes need more than one surgery to finally restore normal uterine cavity.

What are the complications of PID if left untreated?

Besides causing problem in conceiving, untreated infection can lead to problems like ectopic pregnancy or abortions.

Scar tissue formed in the fallopian tubes, prevents movement of a fertilized egg towards the uterus. This causes the embryo to implant within the fallopian tube itself, which can be life-threatening.

Thin lining of the uterus decreases the blood supply to the implanted embryo and may lead to missed abortion. Also in presence of hydrosalpinx the infective material from the tube can be toxic to embryo and may lead to early pregnancy loss.

Besides this complication, chronic infection can lead to constant dull aching pain in the lower abdomen and may hamper day to day life of a woman.
If a woman conceives and the pregnancy continues there are chances of preterm labour and low birth weight of the baby.

 


25/May/2015

PCOS or polycystic ovarian syndrome or polycystic ovarian disease is a name given to a hormonal imbalance which may present as following:

  • Menstrual irregularities: No menses, irregular menses, less bleeding during menses.
  • Abnormal (androgenic pattern) hair growth over chin, upper lip, cheeks etc or excessive hair growth on arms and legs.
  • Increase in weight.

There is enlargement of one or both the ovaries which leads the ovaries and a gland (pituitary) in the brain to secrete hormones in an irregular manner. This hormonal irregularity further leads to failure of ovulation (egg) from the ovaries and thereby difficulty in conceiving, increased and abnormal hair growth and weight gain.

What is the cause of PCOS?

Various causes have been cited in literature to explain the cause of PCOS, but to pinpoint a single cause is impossible.

It may run in family and the woman may inherit it from either of her parents. Even males can carry the PCOS gene though the manifestations are different. The underlying problem with PCOS is a hormonal imbalance. In women with PCOS, the ovaries make more androgens than normal. Androgens are primarily male hormones that are produced by females too. High levels of these hormones affect the development and release of eggs during ovulation.

Some researchers also believe that insulin may be linked to PCOS. Insulin is a hormone that controls the change of sugar, starches, and other food into energy for the body use or for stores. Many women with PCOS have too much insulin which is believed to increase production of androgens. This high androgen levels can lead to acne, excessive androgenic hair growth, weight gain and problems with ovulation.

Literature also suggests that PCOS treatment can be precipitated by stress, irregular lifestyle (not having timely meals or sleep) and faulty diet (eating more junk and / fried food and eating less fruits and vegetables). Obesity or overweight per say can also precipitate development of hormonal imbalance.

How does PCOS cause Infertility?

As already discussed the hormonal imbalance in PCOS women leads to anovulation. This means that the egg does not mature properly and is also not released from the ovaries, hence not able to fertilise with the sperm and form an embryo. In some cases the quality of the egg is also poor. This diminished release of egg leads to infertility and decreases chances of having a baby. In addition increased body fat can also have harmful effect on the lining of the uterus and thereby failure of implantation. Weight gain, which goes hand in hand with PCOS can also affect fertility, though indirectly.

What is the treatment for PCOS and infertility?

Simultaneous weight loss significantly helps in achieving results earlier with lesser dosage of drugs and injections. These women are also benefitted by antidiabetic drug called metformin. It affects the way insulin controls blood glucose (sugar) and lowers testosterone production. It also slows the growth of abnormal hair and, after a few months of use, may help return of ovulation. Use of metformin along with ovulation inducing drugs have shown better results and higher pregnancy rates.

If the above treatment modality fails to achieve ovulation than laparoscopic surgery called ovarian drilling can be done. This involves puncturing the ovary with a small needle carrying electric current to destroy small portion of the bulky polycystic ovary. This procedure carries a small risk of adhesion formation, which can however be avoided by washing the ovary with saline after the drilling. This surgery helps lower male hormone levels and ovulation. But, these effects may only last a few months.

VIDEO OF PCOS DRILLING

PCOS


23/May/2015

What are Fibroids?

Uterine fibroids are benign (not cancer) growths in the womb (uterus). They are made of muscle and other tissue. Fibroids almost never develop into cancer. They are also called leiomyomas or myomas.

Uterine fibroids are very common in women of childbearing age (20-45 years).
The size, shape, and location of fibroids can vary greatly. They may appear inside the uterus (submucous fibroids), on its outer surface (subserosal), within its wall (intramural), or attached to it by a stem like structure (pedunculated).

Fibroids can range in size from small, pea-sized growths to large, round ones that may be more than 5–6 inches wide. As they grow, they can change the normal structure of the uterus and disturb the lining (endometrium).

A woman may have only one fibroid or many of varying sizes and location. They may remain very small for a long time, suddenly grow rapidly, or grow slowly over a number of years

 

What are the types of Fibroids?

Fibroids are categorised by where they grow in the uterus

Intramural

These grow in the wall of the womb and are the most common type of fibroid.

Subserous

These fibroids grow from the outer layer of the womb wall and sometimes grow on stalks (called pedunculated fibroids). Subserous fibroids can grow to be very large.

Submucous

Submucous fibroids develop in the muscle underneath the inner lining of the womb. They grow into the womb and can also grow on stalks which, if long enough, can hang through the cervix (Mouth of uterus).

Cervical

Cervical fibroids grow in the wall of the cervix (neck of the womb) and are difficult to remove without damaging the surrounding area.

If you have fibroids, you may have one or many. You may also have one type of fibroid or a number of different fibroids. fibroids-1

What is the incidence of Fibroids?

Fibroids affect more than 1 in every 5 women under age 50. Many women who have fibroids are not aware of them because the growths can remain small and not cause symptoms or problems. However, in some women, fibroids can cause problems because of their size, number, and location.

 

What is the cause of uterine fibroids?

Although fibroids are quite common, little is known about what causes them. There are various theories as to the cause of fibroid.

Fibroids tend to run in family. If a woman has fibroids chances are that her mother, sister, aunt and her daughters may also have them at some time of their lives.

Some studies prove that fibroids are hormone dependent. Estrogen, which is a hormone present in women of childbearing age, tends to increase the size of fibroids. This is proven by the fact that the size of fibroids decreases during menopause, when this hormone secretion reduces. However there is no definite relation.

 fibroids-uterus-2

What are the symptoms?

Many women don’t feel any symptoms. Without symptoms, you probably won’t even know that you have fibroids. Fibroids can cause some of these symptoms

  • Changes in menstruation – More bleeding, longer or more frequent menstrual periods, menstrual pain (cramps), vaginal bleeding at times other than menstruation i.e bleeding between periods.
  • Anemia (from blood loss)
  • Feeling “full” in the lower part of your stomach (pelvic pressure)
  • Continuous lower back pain or lower abdomen pain.
  • Increased frequency of urination or sensation of incomplete urination.
  • Constipation or straining at stools
  • Infertility, miscarriages/abortion or premature labour and delivery (before 8 months)

 

How do fibroids cause infertility?

Fibroids may cause infertility in a number of different ways:

  • A fibroid may cause compression on the uterine tubes resulting in a blockage of the passage of sperm or eggs.
  • A large fibroid may disturb the relation between the uterine tube and ovary making it difficult for the uterine tube to capture an egg at the time of its release.
  • If a fibroid pushes the lining of the uterus, there may not be enough space in the womb for the embryo to attach itself to the lining (Implantation).
  • Some studies have suggested that fibroids in the muscle portion of the uterus may cause an alteration or reduction of blood flow to the uterine lining making it more difficult for an implanted (attached) embryo to grow and develop causing miscarriage or abortion.

 

How do fibroids cause abortion?

Fibroids that bulge into the uterine cavity (submucous) or are within the cavity (intracavitary) may sometimes cause miscarriages. The fertilized egg comes down the fallopian tube and takes hold in the lining of the uterus. If a submucosal fibroid happens to be nearby, it can thin out the lining and decreases the blood supply to the developing embryo. The fetus cannot develop properly, and miscarriage may result.

However, with the next pregnancy, it is possible that the egg will settle in another location, and pregnancy may proceed without problems. However, if you do have a miscarriage and a fibroid is found bulging into the uterine cavity, it is advisable to have it removed

 

How are fibroids diagnosed?

The first signs of fibroids may be detected during a routine pelvic exam. There are a number of tests that may show more information about fibroids:

Ultrasonography (USG)

Ultrasonography (USG) or pelvic scan is the commonest way of detecting fibroids. It helps in detecting the exact location and size too. Transvaginal scan done with a probe introduced through the vagina is more informative than transabdominal. This is a non-invasive and easily acceptable investigation for detecting fibroids.

 

USG picture of fibroid uterus

 usg-picture-of-fibroid-uterus-3usg-picture-of-fibroid-uterus-4

 

Hysterosalpingography (HSG)

Hysterosalpingography (HSG) is a special X-ray test done by pushing dye into uterus through vagina. It may detect abnormal changes in the size and shape of the uterus and fallopian tubes. It is not very confirmative and may require a USG to definitely diagnose fibroid.

 

Laparoscopy

Sometimes small or asymptomatic fibroids are diagnosed on routine diagnostic laparoscopy.

 fibroids-uterus-5 fibroids-uterus-6

Hysteroscopy

Hysteroscopy uses a slender device (the hysteroscope) to help the doctor see the inside of the uterus. It is inserted through the vagina and cervix (opening of the uterus). This permits the doctor to see some fibroids inside the uterine cavity.

Detailed discussion is done in the section of hysteroscopy

 

Cervical

Cervical fibroids grow in the wall of the cervix (neck of the womb) and are difficult to remove without damaging the surrounding area.

 

Is it necessary to treat fibroids?

Fibroids that do not cause symptoms, are small, or occur in a woman nearing menopause often do not require treatment. Certain signs and symptoms, though, may signal the need for treatment:

  • Infertility
  • Recurrent abortions
  • Heavy or painful menstrual periods
  • Bleeding between periods
  • Uncertainty whether the growth is a fibroid or another type of tumor, such as an ovarian tumor
  • Rapid increase in growth of the fibroid
  • Pelvic pain

 

In which cases of infertility do fibroids need to be operated?

Fibroids that change the shape of the uterine cavity (submucous) or are within the cavity (intracavitary) decrease fertility by about 70% and removal of these fibroids increases fertility. Other types of fibroids, those that are within the wall (intramural) but do not change the shape of the cavity, or those that bulge outside the wall (subserosal) do not decrease fertility, and removal of these types of fibroids does not necessarily increase fertility.

It’s easy to understand how a submucous fibroid which protrudes into the uterine cavity or causes distortion of the uterine cavity may act as a foreign body, and present a mechanical barrier to implantation. However, most other fibroids do not affect fertility. This is still controversial, because some doctors believe that intramural fibroids may cause an alteration or reduction of blood flow to the uterine lining, making it more difficult for an implanted embryo to grow and develop. Subserosal fibroid near cervix or tubes or more than 5 cm in size need to be removed.

Most fibroids in infertile women do not need any treatment at all, because they do not affect fertility or pregnancy. They are best left alone! In fact, unnecessary surgery can actually reduce your fertility, because it causes adhesions and scarring which can damage the tubes.

However, submucous and few intramural fibroids in infertile women (those within the uterine cavity or causing significant distortion of the cavity) do need to be removed; and these are best removed by doing an operative hysteroscopy and laparoscopy.

In general irrespective of its position, a fibroid which is more than 4cm is removed as it may cause problems in conception as well as delivery of the baby. If there are multiple (7-8 or more) small fibroids (2-3 cm each), then it is better that these are also removed as it has been seen that removal of these increases chances of pregnancy.


What are the treatment options for management of fibroids in an infertile woman?

Treatment options would include medical and surgical management. The medical management includes use of oral contraceptive pills or injections called as GnRh agonist. These drugs may help in shrinkage of fibroids and will also provide relief from symptoms. Medical management is not of much use in women having difficulty conceiving as the treatment itself is a contraceptive treatment. Also as soon as the medicines are stopped fibroids tend to grow again.

The ideal and quickest method of dealing with fibroids in an infertile woman would be surgical removal. Removal of fibroids surgically is termed as myomectomy. With the advance in surgical techniques and under the hands of experienced surgeon this can easily be done by laparoscopy or hysteroscopy. Medical treatment prior to surgery is beneficial in cases where the fibroid is to be removed hysteroscopically, as it reduces the size of fibroid. However it also makes the fibroid soft and hence not advised before laparoscopic surgery as it makes the removal of fibroid difficult. Other radical options may include uterine artery embolization and hysterectomy. Both of these are to be avoided.

 

  1. Myomectomy

VIDEO of Myomectomy

 


Myomectomy is the surgical removal of fibroids while leaving the uterus in place. Because a woman keeps her uterus, she may still be able to have children in future. Myomectomy may be done in a number of ways:

  • Laparotomy
  • Laparoscopy
  • Hysteroscopy

The method used depends on the location and size of the fibroids. For a laparotomy, an incision (cut) is made in the abdomen. The fibroids then are removed through the incision.

Fibroids also can be removed through the laparoscope that is used to view the inside of the abdomen.

Hysteroscopy can be used to remove fibroids that protrude into the cavity of the uterus. It is done in cases where around 1/4th or more of the fibroid bulges within the uterine cavity. The fibroids may be removed with a resectoscope, a tiny wire loop that uses electric power, or with a laser. Either of these instruments can be inserted through the hysteroscope.

  1. Uterine Artery Embolization

Another way to treat fibroids is called uterine artery embolization (UAE). With this procedure, the blood vessels supplying blood to the fibroid are blocked.
This cuts off the blood flow to the fibroid and causes it to shrink. The procedure works even if you have more than one fibroid. However this is not the treatment of choice in women with fertility related problems as this procedure may also reduce the blood flow to ovaries and uterus thus further compromising fertility.

  1. Hysterectomy

Hysterectomy is the removal of the uterus. The ovaries may or may not be removed. It depends on other factors. This is not an option for infertile women. However in women with multiple symptomatic fibroids with severely distorted cavity the uterus may have to be removed to cure symptoms.
In such a case surrogacy with IVF may be the only option.

Laparoscopic Surgery

Laparoscopic-Surgery-7

The laparoscope is a slender telescope that is inserted through the navel to view the pelvic and abdominal organs. Two or three small, half-inch incisions are made below the pubic hairline and instruments are passed through these small incisions to perform the surgery.

Laparoscopic Myomectomy

Video of lap myomectomy

 

(Steps of surgery : Injection of vasopressin, Incision over the fibroid, Enucleation / morcellation of fibroid, Achieving hemostasis at the bed of fibroid, Closure of the incision)

injection-of-vasopressin-in-the-fibroid-to-reduce-bleeding-during-dissection-8

(Picture showing injection of vasopressin in the fibroid to reduce bleeding during dissection)

 

For laparoscopic myomectomy, a small scissors is used to open the thin covering of the uterus. The fibroid found underneath this covering is grasped, and freed from its attachments to the normal uterine muscle. After the fibroid is removed from the uterus, it must be brought out of abdominal cavity. The fibroid is cut into small pieces with a special instrument called a morcellator, and the pieces are removed through one of the small incisions. The openings in the uterus are then sutured closed. The entire procedure can take one to three hours, depending on the number, size, and position of the fibroids.

 

How Can We Remove a Big Fibroid Through a Small Laparoscopic Incision?

Less than a decade ago, removing fibroids after laparoscopic myomectomy was a difficult and time-consuming task. However, a few years ago an electrically powered device, called a morcellator, was invented and now allows us to quickly cut up the fibroid and easily remove it from the abdomen. The device is a hollow tube with a sharp circular blade at the end that rotates quickly and takes small slices off the fibroid in a few seconds. A large fibroid can now be removed by cutting it into small sausage shaped pieces and also removed by a small abdominal incision. All this takes a few minutes only. Therefore, we are now able to perform laparoscopic myomectomy on women with even large fibroids. This device has allowed a major advance in our laparoscopic technique.

 

Will I definitely become pregnant after Myomectomy?

Surgical removal of submucous or intramural fibroids has shown to improve implantation rates (attachment of embryo to uterine lining) and also reduce abortion rates. However one has to remember that there are several factors which can contribute to infertility which includes proper and timely release of egg, patency of uterine tubes, good quality motile sperms, timely fertilization and implantation. Age of the female partner also has a contributing factor in conceiving.

The chances of pregnancy will definitely improve after surgery if fibroid is the only contributing factor. Therefore it is advisable to get yourself completely investigated for other factors causing infertility before making a decision for surgery. Complete discussion and clarification of doubts from your doctor will help you in making a decision.

 

What are the complications of surgery?

Complications incidence is same as in any laparoscopic surgery. Commonest includes intraoperative bleeding and wound infection. But with modern advances in surgery, skilled surgeon and potent antibiotics the incidence of complications are almost negligible. One of the important long term complications is rupture of scar of myomectomy. Such cases are fortunately very few. In these cases there may be rupture of the scar tissue from where the fibroid was removed either during pregnancy or delivery. This occurs mostly in cases of neglected labour and delivery.

 

How many days after surgery should I wait to get pregnant?

It varies depending upon the extent of surgery but is ideal to give 6 weeks or 2-3 months for the sutures to heal completely before trying to get pregnant. Your fertility specialist will be able to guide you depending on your condition.

 

What if I have fibroids and become pregnant? Will they affect my pregnancy?

If you are pregnant and have fibroids, they mostly won’t cause problems for you or your baby.

During pregnancy, fibroids may increase in size. Most of this growth occurs from blood flowing to the uterus. Coupled with the extra demands placed on the body by pregnancy, growth of fibroids may cause discomfort, feelings of pressure, or pain. Sometimes the fibroid also becomes very soft and large due to increased vascularity (red degeneration). However, fibroids decrease in size after pregnancy in most cases.

However, fibroids may increase the risk of:

  • Miscarriage (in which the pregnancy ends before 20 weeks)
  • Preterm birth (early labour and delivery)
  • Breech and transverse position (in which the baby is in a position other than head down)
  • More blood loss after delivery

Rarely, a large fibroid can block the opening of the uterus or keep the baby from passing into the birth canal. In this case, a cesarean delivery is done. In most cases, even a large fibroid will move out of the fetus’s way as the uterus expands during pregnancy. Women with large fibroids may have more blood loss after delivery. Often, fibroids do not need to be treated during pregnancy. If you are having symptoms such as pain or discomfort, your doctor may advice rest. Sometimes a pregnant woman with fibroids will need to stay in the hospital for a while because of pain, bleeding, or threatened preterm labor.

 

Can Fibroids Hurt the Developing Baby?

Fibroids almost never cause injury to a baby. Review of the entire world’s medical literature for the past 25 years discovered only four babies affected by a fibroid.

Do Fibroids Mean You Need a Caesarean Section?

Rarely, a fibroid may grow near the cervix (mouth of the uterus) during pregnancy. If it is large enough, it may prevent the baby from coming through the birth canal. This is not dangerous and can often be diagnosed by a sonogram before labor begins.

Sometimes this problem is discovered during labor because the baby does not come down the birth canal. A caesarean section is then performed. However, most women with fibroids deliver their babies normally without any problems.

Sometimes during a cesarean section if fibroids are encountered , especially serosal fibroids , then these can be removed in the same sitting . This is known as cesarean myomectomy.

 


22/May/2015

Endometriosis is a common condition that affects women during the reproductive years. Endometriosis is a condition where tissue, similar to the one that normally grows inside the uterus (lining of uterus), also grows outside of the uterus. The tissue inside the uterus is called “endometrium” and the tissue outside of the uterus is called “endometriosis”. The most common places where endometriosis occurs are the ovaries, the fallopian tubes, the bowel, and the areas in front, in back, and to the sides of the uterus.

If you have severe pain during menses and also having some trouble in conceiving then you may be having endometriosis. While some women with endometriosis have severe symptoms some may have few or no symptoms.

There is no cure for endometriosis, but there are several treatment options. The best treatment depends on your individual situation which can be judged by your fertility specialist.

At Ankoor clinic the treatment is custom made for each individual depending upon the symptoms and severity of the condition. Such individualization gives the best results to our patients.

 

What are the causes of endometriosis?

The cause of endometriosis is not known. A common theory is that some menstrual blood and endometrium flows backwards through the fallopian tubes and into the pelvis during a menstrual period. This tissue then grows where ever it lands in the pelvis. This is called the retrograde menstruation theory. It explains external endometriosis.

In some cases internal endometriosis is seen. The Germ line theory explains it. In these cases the endometrium grows internally due to the germ cells that grow in this abnormal location causing endometriosis.

There are several other theories. However it is best to focus on treatment rather than cause in cases of endometriosis.

How does endometriosis cause infertility?

There are many ways in which endometriosis affects fertility.

  1. Anatomical distortion – Moderate to severe endometriosis causes damage to the ovaries or fallopian tubes which leads to fibrosis and scarring. This may lead to anatomical distortion of the fallopian tubes leading to blockage of the fallopian tubes or any obstruction between the fallopian tube and ovaries.
  2. Immunological aspects – It has been seen that even in mild cases of endometriosis the women produce antibodies against the sperm or even the egg and embryo leading to infertility.
  3. Quality of egg / oocyte – In case of even mild degree of endometriosis the quality of egg is also compromised leading to infertility or even abortions.
  4. Interlukin (IL) induced damage of gametes – Endometriosis causes release of toxic Interlukins(ILs) and Cytokines(CKs) in the woman. These adversely affect both the sperm as well as the egg or ova leading to their damage and hence difficulty in conception.

What are the symptoms associated with endometriosis?

The symptoms of endometriosis vary a lot. While some women with endometriosis have no symptoms a few may have very severe symptoms like severe pain in the pelvic area, especially with periods. The common symptoms are:

    1. Pain during menses (Dysmenorrhoea) 
    • Pelvic pain caused by endometriosis can occur:
      • Just before or during the menstrual period. In some women, painful periods get worse over time (Dysmenorrhoea)
      • Between menstrual periods, with worsened pain during the period
      • With bowel movements or while urinating, especially during the period

    Pelvic pain can also be caused by many other conditions, such as pelvic infections and irritable bowel syndrome. A gynaecologist can help to figure out if endometriosis may be the cause of your pain.

    1. During or after sex (Dyspareunia) –

    Some women experience severe pain during or just after intercourse/ sex due to endometriosis induced adhesions and scarring between the pelvic structures.

    1. Difficulty getting pregnant (Infertility)

    Endometriosis can make it more difficult to become pregnant. This might occur because endometriosis causes scar tissue to develop, which can damage the ovaries or fallopian tubes. Even women with endometriosis who do not have scar tissue can have difficulty becoming pregnant due to reasons explained above.

    However, in women who become pregnant, endometriosis does not harm the pregnancy. Symptoms of endometriosis often improve after pregnancy.

     

    1. Premenstrual spotting-

    Some women do not have any major symptoms or complaints other than just a few days of premenstrual spotting.

    1. Asymptomatic-

    Some women do not have any symptom of endometriosis and are diagnosed to have a blood filled cyst incidentally on USG. This cyst is called as an endometrioma. Endometriomas are usually filled with old blood that resembles chocolate syrup; thus, they are sometimes called chocolate cysts. Endometriomas are sometimes seen during a pelvic ultrasound or felt during a pelvic exam.

    1. Rare symptoms-

    Sometimes if there are endometriotic deposits in the bladder or bowel region then the women may have bleeding while passing urine or even blood in stools.

     

How is endometriosis diagnosed?

Endometriosis may be suspected if the woman has any of the above symptoms.

Clinical examination by your fertility specialist can help further confirm endometriosis.

In other cases a pelvic ultrasound may reveal endometriosis in the form of persistent fluid collection in the pouch of douglas (suggestive of endometriosis), endometrioma which are type of ovarian cyst or rarely if there are dense adhesions.


CHOCHOLATE CYST ON USG

 

However, the only way to know for sure if you have endometriosis is to have surgery. Symptoms of the patient do not routinely point towards the severity of the disease as women with mild disease can have severe symptoms, and women with severe disease can have mild symptoms. Endometriosis is considered mild, moderate, or severe depending on what is found during surgery. During surgery the endometriosis can be divided into 4 stages depending upon the severity, with stage 1 being the mildest form of endometriosis and stage 4 the severest form. Treatment is based on the staging of endometriosis.

CHOCOLATE CYST ON USG 2

In some cases for differentiation a CTscan or MRI may be required.

MRI - CHOCOLATE CYST

 

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What are the different stages of endometriosis?

The American Society for Reproductive Medicine (ASRM) classification system for endometriosis is the most accepted.

Endometriosis is classified into one of four stages:

I-minimal, II-mild, III-moderate, and IV-severe.

This classification depends on location, extent, and depth of endometriosis implants; presence and severity of adhesions; and presence and size of ovarian endometrioma.

A majority of women have minimal or mild endometriosis, which is characterized by mild adhesions and superficial implants.

Moderate and severe endometriosis is characterized by chocolate cysts and more severe adhesions.

The stage of endometriosis does not correlate with the presence of or severity of symptoms; with stage IV endometriosis, infertility is very likely.

STAGING OF ENDOMETRIOSIS 1

STAGING OF ENDOMETRIOSIS

 

However , unfortunately no staging system correlates well with the chance of conception following therapy. This poor predictive ability is related to the arbitrary assignment of point scores for pathology and arbitrary cut off.

 

What are the treatment options available?

There are many treatment options for endometriosis. But the treatment depends on many factors such as age of the women, desire for fertility, need of contraception, severity of symptoms, extent of endometriosis (excessive involvement of bowel or bladder) and last of all patient’s desirability. So the treatment has to be tailor made for a particular woman.

However here we will be discussing management of endometriosis related to fertility. Medical management with pain killers or oral contraceptive pills or only progesterone pills is not suitable for these patients. In some cases GnRh injections are given to relieve from symptoms but again these are not advisable in women who desire fertility.

The best protocol of management in infertile patient is usually surgical clearance followed by ovulation induction and IUI or IVF-ICSI in very severe disease. Many a time surgical clearance is followed by spontaneous pregnancies also. However sometimes ovulation induction with planned relations or IUI can precede surgical intervention with good pregnancy rates. In some cases of severe disease wherein there is spread to bladder or rectum an IVF cycle may be planned without clearing the disease completely. The decision of treatment has to be taken by the doctor and couple after understanding the pros and cons.

Research has not firmly proved that removing mild endometriosis improves fertility. For moderate to severe endometriosis, surgery will improve your chances of pregnancy. In some severe cases, a fertility specialist will recommend skipping surgical removal and using IVF.

Generally in Stage 1 and 2 of endometriosis management includes gonadotrophin stimulated 3 to 6 cycles of intra uterine insemination (IUI) depending upon the age of the woman and her AMH levels. In severe cases of endometriosis like Stage 3 and 4, surgery is followed by gonadotrophins. In these cases the success rate in terms of pregnancy following an IUI is generally poor around 5%. Hence, in such women better results are achieved by using GnRh therapy for 4-6 months followed by IVF or ICSI.

Stage 1 3 to 6 cycles of Gonadotrophin stimulated intra uterine insemination (IUI)
Stage 2 3 to 6 cycles of Gonadotrophin stimulated intra uterine insemination (IUI)
Stage 3 Surgery is followed by gonadotrophins may be tried but pregnancy rates are very low

Surgical clearance followed by ovulation induction and IUI or IVF-ICSI gives better results

Stage 4 Surgical clearance followed by ovulation induction and IUI or IVF-ICSI

 

How is endometriosis managed laparoscopically?

Laparoscopy is the most common procedure used to diagnose and remove mild to moderate endometriosis. Instead of using a large abdominal incision, the surgeon inserts a lighted viewing instrument called a laparoscope through a small incision. If the surgeon needs better access, he or she makes one or two more small incisions for inserting other surgical instruments.

The internal organs are examined to look for signs of endometriosis (dark blackish or brownish powdery spots, also called as gun powder appearance) and other possible problems like adhesions or blood filled cysts. Any visible endometriosis implants and scar tissue that may be causing pain or infertility are removed. Removal of endometriosis or scar tissue involves using one of the various techniques, including cutting and removing tissue (excision) or destroying it with a laser beam or electric current (electrocautery).

4-endometriosis

 

 

 

 

If an endometriosis cyst is found growing on an ovary (endometrioma), it is likely to be removed. There are various ways of surgically treating an endometrioma, including draining it, cutting out part of it, or removing it completely (cystectomy). Any of these treatments brings pain relief for most women but not all. Cystectomy is most likely to relieve pain for a longer time, prevent an endometrioma from growing back, and prevent the need for another surgery.

 

Video of Endometrioma

What are the risks and complications involved?

The complications are more or less similar to any laparoscopic surgery. However in case of extensive endometriosis there is a slightly more chance of organ injury.

In some instances minimal to mild endometriosis spots may not be seen during a laparoscopy surgery and these may flare up later during treatment and may need additional surgery.

 

Why and How to prevent recurrence of endometriosis ?

Management of infertility along with endometriosis can be long and tiring for some patients. It is seen that some women do not continue the treatment of endometriosis, but this has severe repercussions and can lead to extensive endometriosis and scarring. Few women after undergoing the surgery and 3 to 4 few IUI cycles, if they do not conceive then become frustrated and stop the treatment . This leads to recurrence of endometriotic lesions and further damage to the tubes and ovaries.

If the couple/ woman is exhausted physically or mentally and wants to a break then it is a good idea to take some simple medications like hormonal pills eg.

1) Oral contraceptive pills continuously for months together so that she does not get her menses and future endometriosis can be avoided.

2) Progesterone supplementation can also be used for shorter duration of period in woman planning for conception as this will prevent further endometriosis and if in case the women becomes pregnant it will benefit the pregnancy too.

However, waiting for too long is not advisable in cases of endometriosis as it further lowers the chances of getting pregnant.

 

Another important aspect is that women with endometriosis have shown to have an adverse pregnancy outcome as compared to women who do not have endometriosis. Hence vigilant monitoring and care during pregnancy is also very important.

 

I am 21 years and have been diagnosed with endometriosis. Will it affect my chances of getting pregnant in future? How long can I postpone my pregnancy

Yes, endometriosis affects the changes of getting pregnant adversely. Studies have shown that the endometriotic lesions and cysts go on increasing in size if not treated and will damage the normal architecture and functioning of the reproductive organs.

Endometriotic/ chocolate cysts damage the normal ovarian tissue and hence reduce the ovarian reserve. Studies have shown that in untreated cases , over a period of time the AMH (Anti mullerian hormone ) values go on decreasing. (AMH is a marker of ovarian reserve).

To summarise , waiting for too long is not advisable in cases of endometriosis as it further diminishes the chances of pregnancy due to ovarian damage and tubal adhesions formation.

 

I am 28 years old, married and have undergone surgical excision of chocolate cyst 2 months back. I am tired of the prolonged treatment for infertility and endometriosis. What should I do?

If the couple/ woman is exhausted physically or mentally and wants to a break then it is a good idea to take some simple medications like hormonal pills eg.

1) Oral contraceptive pills continuosly for months together so that she does not get her menses and future endometriosis can be avoided.

2) Progesterone supplementation can also be used for shorter duration of period in woman planning for conception as this will prevent further endometriosis and if in case the women becomes pregnant it will benefit the pregnancy too.

However , waiting for too long is not advisable in cases of endometriosis as it further diminishes the chances of pregnancy due to ovarian damage and tubal adhesions formation.

 




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