Monday, 19 August 2013

Is endometrial polyp the cause of infertility and implantation failure?

Endometrial Uterine polyps are excess tissues that grow on the inner walls of your uterus. Uterine polyps can develop in women of any age, but generally they develop in women during their 40’s and 50’s. Uterine polyps sometimes cause problem with fertility or can increase your risk of miscarriage. A normal and healthy uterine cavity and endometrial lining is necessary for a woman to conceive and maintain a healthy pregnancy. Most of the polyps are very small and do not represent a compromise to reproductive capabilities. But, larger and multiple polyps can interfere with the reproduction and thus causing infertility or increases the risk of miscarriage. Endometrial or uterine polyps are soft, finger like growths which develop in the lining of the uterus (the endometrium). These are very common benign growths; and are often found in infertile women. Endometrial or uterine polyps are soft, finger like growths which develop in the lining of the uterus (the endometrium). They develop because of excessive multiplication of the endometrial cells, and are hormonally dependent, so that they increase in size depending upon the estrogen level. They can usually be detected on an ultrasound scan if this is done mid-cycle, when estrogen levels are maximal, but are easily missed if the scan is not done at the right time of the menstrual cycle.

In addition, uterine polyps are an important cause of dysfunctional menstruation, providing the basis for these symptoms in certain women who have abnormal uterine bleeding. These polyps can also be a risk factor for uterine cancer, as well.  (Such cancer is much less likely in Pre-menopausal women).  Uterine polyps can become symptomatic in women of any age but are more likely to become evident in per menopausal or postmenopausal women (in whom they can cause light bleeding).  Risk factors for uterine polyps include age, menopause, and presence of cervical polyps. Most uterine polyps are noncancerous but, when removed, they are sent to the lab for biopsy.  If polyps are too expensive for hysteroscopic removal or show signs of being precancerous or cancerous, the team may recommend a hysterectomy.

How are Endometrial Polyps Diagnosed?
HSGs or Hysterosalpingogram are commonly performed to determine if the fallopian tubes are open.  A dye is injected into the uterus and passes into the fallopian tubes.  Therefore, an image of the uterus is obtained in addition to determining whether the tubes are open or obstructed.  The image of the uterus could reveal abnormalities within the uterus.  Typically, these abnormalities are polyps, fibroids, adhesions, and/or a uterine septum.

Another diagnostic test is a screening vaginal sonogram.  When this is performed in the mid portion of a cycle (around the time of ovulation), abnormalities of the endometrium may be discovered.

It may be necessary to remove the abnormality and restore the uterus to normal.  The removal of these abnormalities is best performed by hysteroscopy, which involves using a small scope that is passed through the cervix into the intrauterine cavity so that the inside of the uterus can be visualized directly.  An anesthetic is utilized to eliminate any discomfort from the procedure.  With direct visualization, a polyp can be removed without disturbing the rest of the endometrium.  Prior to hysteroscopy, the polyps were removed by “blind” D&C.  A D&C involves scraping the entire lining of the uterus, expecting that the polyp was being removed with the procedure.  A blind D&C should be avoided if possible, because there is always a risk of creating scar tissue in the uterus from the procedure. The hysteroscopic removal of an endometrial polyp is an outpatient procedure.  It usually takes less than one hour to complete.  Patients are asked to take off work the day of the surgery because of the anesthetic sedation.  However, patients are able to return to work on the following day.

Need to know about Endometriosis first
Chief among symptomatic endometrial conditions is endometriosis, an often-painful condition that can also affect fertility. The condition brings discomfort that in some women can significantly detract from quality of life. Endometriosis affects millions of women.

The clumps of uterine tissue that grow outside of the uterus (“implants”) and around reproductive and other pelvic organs in this disease get thicker during the menstrual cycle and then break down and bleed.  But because this tissue is outside the uterus, the blood cannot be released normally.  These areas can get irritated and sore. They can also form scar tissue or fluid-filled sacs that may be painful and that can affect fertility.

What will polyps do in our body?
Usually, uterine polyps nourish on estrogen hormone. If you have more estrogen with uterine polyps, your polyps will grow more and more. Once these polyps attain a certain size, then they swill tart to protrude into your uterine cavity. The size of polyps ranges from a few millimeters to several centimeters. Usually, polyps are attached to the uterine walls by a large base or a thin stalk. During in some cases, these polyps are slips down into the cervix.

How polyps affect your fertility?
Endometrial polyps have been found to be associated with infertility.  There is at least one good study that revealed that removal of the polyp increases the chances of conceiving.  The study found that when a polyp was removed, the pregnancy rate was 63%.  However, if the polyp was not removed at hysteroscopy, the pregnancy rate was only 28%.

Another study found that the most common area in the uterus for an endometrial polyp to be found was on the posterior uterine wall.  Interestingly, polyps that were found in the cornual portion of the uterus (the area of the opening of the fallopian tubes into the uterus) were associated with a higher chance of pregnancy when these polyps were removed compared to removing polyps from other locations within the uterus.  This suggests that polyps in this location are more likely to be associated with difficulty in conceiving.  However, the exact mechanism is unknown.

It has been speculated that a endometrial polyp may cause irritation of the lining of the uterus interfering with implantation of an embryo. These polyps can interfere with implantation, effectively preventing an embryo from attaching to the uterine wall. It is common for polyps to induce a chronic inflammatory response within the uterus, as the body mounts a reaction to try to destroy the polyp. This may be the mechanism by which polyps interfere with the establishment of a pregnancy. It is appropriate that the uterus be evaluated during the fertility investigation.  If an abnormality in the uterus is discovered, it is recommended that the woman should undergo a hysteroscopy to remove the abnormal.

What are the symptoms that you experience with uterine polyps?
For some women polyps won’t cause any symptoms. But some may experience symptoms such as:
·         Painful or heavy periods
·         Unpredictable or irregular menstrual bleeding
·         Vaginal bleeding even after the menopause
·         Infertility

What is Adenomyosis?
Sometimes abnormal growth of endometrial tissue can result in the endometrium invading the muscle wall of the uterus is called adenomyosis, this condition can cause discomfort due to swelling and pressure.  The symptoms are usually more evident during the premenstrual portion of the menstrual cycle and the condition occurs most often in women over 30 (especially in their 40s) who have had a full-term pregnancy.  Adenomyosis can also cause additional bleeding during periods. The condition is a common cause of cyclical menstrual pain and is sometimes referred to as internal endometriosis.  When endometrial tissue is in the muscle wall it can trap blood that would normally be released with the menses, resulting in cramping and prolonged bleeding.  Adenomyosis can occur in the presence of fibroids (for which it is often mistaken), cysts, or other gynecologic conditions. Patients with the condition may also have endometriosis.  Women who have previously had surgery to their uterus (fibroid removal, C-section, etc.) are more likely to develop adenomyosis than women who have not.

Adenomyosis can cause the uterus to become enlarged.  However, so can fibroids, which produce similar bleeding symptoms, so the team must differentiate the two, usually using pelvic ultrasound. Treatments are similar to those for endometriosis; however, because of the depth of the tissue growths, laparoscopic endometrial ablation may be of limited use.  Hysterectomy is considered the only treatment that is dependably successful in relieving adenomyosis pain in most women.  Some women, though, may chose conservative care, knowing that symptoms of the condition usually disappear after menopause.

What are the treatments used to remove polyps?
Most of the polyps do not require any treatment. But treatment is suggested for people who experience severe discomfort. They include:

Hormone medication - drugs such as progestin and GnRH agonists can be used to block estrogen production and thereby shrink uterine polyps. These drugs induce an artificial state of menopause so the patient is unlikely (and not advised) to get pregnant until after the treatment is finished. Hormones may not be the answer for infertility patients because the uterine polyps tend to grow back when the treatment ends.

Surgical removal - a surgical procedure called a hysteroscopic polypectomy is used to take out uterine polyps. This is the treatment most likely to be offered to infertility patients. The doctor inserts his surgical instruments into the uterus via a Hysteroscope (a device which helps him see into the uterus) and removes the polyps.

Hysterectomy - this surgical procedure involves the removal of the uterus. This is the most radical treatment used to remove uterine polyps and is usually performed only if the uterine polyps are cancerous. Obviously, once the uterus has been removed, it is not possible for the patient to become pregnant.


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