Why should hydrosalpinx be repaired before IVF?

When the fimbria of the fallopian tubes become damaged, it may result in a tube that is blocked at the very distal end; the part farthest away from the uterus. If the tube then becomes filled with fluid, it is called a hydrosalpinx (“hydro” refers to water; “salpinx” refers to the fallopian tube itself). Women who have a hydrosalpinx should have their fallopian tubes either removed or cut prior to undergoing IVF. The surgery usually involves a simple outpatient procedure called laparoscopy. The tubes are cut or removed so that the tubal fluid, which would be toxic to an embryo or adversely affect the receptivity of the endometrial lining, does not flow backward into the uterine cavity, preventing implantation of the embryo.

It is now well recognized that women with an untreated hydrosalpinx have a substantially reduced chance for pregnancy with IVF. In addition, an untreated hydrosalpinx may increase the chance that a woman will experience a spontaneous abortion or miscarriage. For all these reasons, treating a hydrosalpinx should both increase the IVF pregnancy rate and decrease the chances for an early pregnancy loss. A patient with a single normal fallopian tube and a hydrosalpinx will also have a higher chance of achieving a spontaneous pregnancy after removal or ligation of the damaged tube. A hydrosalpinx, if present, is usually identified during the infertility diagnostic evaluation with a Hysterosalpingogram (HSG). This simple x-ray study should be performed in all infertile women unless a diagnostic laparoscopy has already been performed. Preoperatively, we advise all patients that we recommend removal or ligation of her tube(s) if a hydrosalpinx is discovered at laparoscopy.

Hydrosalpinx, Infertility and IVF

A hydrosalpinx is a blockage of the far end of a woman’s fallopian tube which results in the accumulation of fluid within the tube. The condition can affect one or both fallopian tubes. Often the affected area can become substantially swollen and grow even as big as a few centimeters in diameter.

Usually, there are few symptoms noticed by patients although some women may suffer from abdominal or pelvic pain. The most common mean by which a woman becomes aware that she has this problem is the development of infertility. Women, who are not trying to get pregnant and have no pain, may go undiagnosed.

Hydrosalpinx Impact on Fertility

As mentioned previously, the main presentation of a hydrosalpinx is infertility. The fallopian tube plays a crucial role in establishing a pregnancy. As sperm enter the vagina, they travel through the opening of the uterus (cervix), through the uterus, and into the fallopian tubes. If intercourse happens at the time of ovulation, then an egg may be present in one of the fallopian tubes. A sperm can fertilize the egg forming an embryo. Afterwards, the embryo migrates down the fallopian tube into the uterus. If the embryo implants into the uterus, a pregnancy has been established.

However, if this tube is blocked, the egg cannot be captured by the fallopian tube and the egg and sperm are prevented from meeting. Thus fertilization cannot occur and pregnancy is prevented. In addition, when women have one tube which is open, their chances for pregnancy are reduced if they have a hydrosalpinx on the other tube.

Probable Reasons for a lesser Success

There are various theories that try and explain why the success rates in these patients are so much lower. One suggests that the flow of fluid into the uterus could interfere with and hinder implantation of an embryo. This fluid could contain lower levels of proteins, various amounts of debris, and other toxic substances found in the body that are harmful to the embryo itself or possibly the lining of the uterus. Another theory states that the fluid is a mechanical flush for the uterus, sweeping away the embryo. It is not known whether these effects would be worse if both fallopian tubes are affected, although that is thought to be the case.

Hydrosalpinx also impacts the Success of IVF

In vitro fertilization bypasses fallopian tube blockage by extracting the eggs directly from the ovary and fertilizing them in the laboratory. The embryos are then placed directly into the uterus. Thus, the fallopian tubes are completely bypassed. With the growing success of IVF and other fertility treatments in the past years, many women suffering from a hydrosalpinx are turning to these treatments to enhance their chances of pregnancy. However, there is substantial evidence to suggest that the success of in vitro fertilization is significantly lower for women with hydrosalpinx compared to other causes of infertility.

·         The overall pregnancy rate was shown to decrease in the women with the hydrosalpinx. The women with no blockage had a pregnancy rate of high compared to the women with the hydrosalpinx.

·         The implantation rate, which looks at how many transferred embryos were able to implant in the uterine wall, also decreased in the women with a hydrosalpinx.

·         The delivery rate decreased drastically as well. Almost twice as many women delivered without a hydrosalpinx higher than with a hydrosalpinx.

·         The delivery rate was lower in part because less women became pregnant but also because more of the women miscarried. Early loss in pregnancy was seen more often in the women affected than not.

Generally, for a woman with hydrosalpinx trying IVF, the chances for pregnancy are greatly reduced compared to the average infertile woman. While the possibility for pregnancy still exists in these patients, these women should be counseled that their chances for live birth are significantly lower if they have a hydrosalpinx.

Treatment Options for Hydrosalpinx to improve Fertility

Salpingectomy

The complete surgical removal of a fallopian tube is called a salpingectomy. The procedure can be done laparoscopically or with a standard surgery performed by making a horizontal incision in the abdomen just above the pubic hair line. Both procedures are performed under general anesthesia so that the patient is completely asleep.

Laparoscopy is a minimally invasive way of performing surgery. An small fiber optic telescope is inserted in a small incision just below the navel. This allows the reproductive surgeon to see into the abdomen and pelvis. Two additional incisions of about one centimeter each are made above the pubic hair line. Through these small incisions, instruments can be placed that allow the reproductive surgeon to detach the tube from the uterus and blood vessels and to remove it from the abdomen. Laparoscopy is the preferred method for performing a salpingectomy since no overnight hospitalization is required and the smaller incisions are associated with a shorter recovery time.

Tubal Ligation

Tubal ligation is when the fallopian tubes are either severed or pinched shut, but not removed. It is often referred to as getting one’s “tubes tied.” This can also be done laparoscopically, abdominally, or even vaginally. The most common way to seal the tubes is by using a cauterizing clamp which when applied to the outside of the tube, will seal it shut. Other methods include placing strong, tight rings or rubber bands around the tube that pinch them closed. Theoretically, by blocking the fluid from entering the uterine cavity, this may restore a normal chance for achieving pregnancy. The most common use of tubal ligation is as a permanent form of birth control. It is generally not considered to be reversible.

Hydrosalpinges, is surgery to remove it better than just ligating it?

·         Removing the hydros by cutting them off and taking them out of the body

·         Ligating or clipping them prior to IVF

·         Opening the end of the tube and leaving them in place (not usually recommended)

We know that on the average success is higher after surgically "fixing the hydros" However, it is not clear whether surgery to remove the tube vs. clipping or burning it close to the uterus and leaving the hydro in place is any different.

·         There is some concern that removal of the tube could have a negative impact on the blood supply to the ovary. This might result in reduced ovarian response to the IVF medications.

·         A reduced response to stimulation means fewer eggs to work with and a lower chance for pregnancy. The number of eggs retrieved correlates with the chance for IVF success.

How much higher is IVF success after hydro surgery?

The improvement in IVF success rates in studies is substantial but not huge. Some studies suggest that a woman under 35 might have a 35% success rate without surgery and a 50% success rate after having hydros removed. IVF success rates are very clinic-dependent. Therefore, decision making about treating hydros is not a clear-cut "black and white" situation. It is a grey area - and fertility doctors don't all agree about how to treat women with hydros.

·         Some doctors say you need to have surgery because it improves the chance for success

·         Some prefer not do surgery, and go to IVF - and if the first cycle fails, then think about whether to do surgery before the next IVF attempt.

·         Some doctors’ say it should be whatever the woman wants - have the surgery to fix the hydros, or don't have the surgery and accept a lower chance for success.

·         At our clinic we discuss surgery as an option and educate patients so that they can decide whether they want surgery first - or to go straight to IVF.

What causes hydrosalpinx?

Hydrosalpinx is often caused by tubal infection such as pelvic inflammatory disease (PID). The infection causes the tubes to become inflamed. After healing is finished the tubes are often blocked with residual fluid inside. Continued fluid buildup over time dilates the tube more resulting in hydrosalpinges of various sizes.

Thin uterine lining is another frustrating cause of IVF Failure

The fertility problem arises when the patient has a poor Endometrium or a thin uterine lining. This could lead to low estrogen levels, poor blood flow or damaged Endometrium; the frustrating complex and unusual problem of a thin uterine lining often seen in infertile patients. One of the most challenging problems to deal with is that of the patient with a poor endometrium or a thin uterine lining. Embryos need to implant in the endometrium, and an optimal endometrium is thick and Trilaminar, One of the most frustrating problems in IVF today is the patient with a persistently poor (thin) uterine lining.

Normally, the endometrium should grow and become thick more than 8 mm and Trilaminar as the follicles grow, so that it is receptive and ready to accept the embryos when they are transferred into the uterine cavity. However, sometimes this does not happen. We do know that the growth of the endometrium depends upon:

·         The estrogen level in the blood

·         Blood flow to the uterus

·         The health of the endometrial tissue itself

Endometrial lining is routinely measured using the vaginal ultrasound in IVF cycles and is expected to be of adequate thickness for embryo implantation. An endometrial thickness of 8 mm or greater is generally considered adequate thickness and less than 7 mm has been associated with lower pregnancy rates, with almost no pregnancies observed with a lining less than 5 mm.

Poor endometrial lining most commonly occurs in women with a history of unexplained recurrent IVF failures or early recurrent miscarriages and is usually attributable to the following factors:

·         Endometritis: Chronic infection of the endometrial cells.

·         Fibroids of the uterine wall (non-cancerous muscle tumors of the uterus).

·         In-Utero exposure to the synthetic hormone called diethylstilbestrol. (DES)

·         Women using Clomiphene citrate.

·         Scar tissue of the endometrium. (Intra-uterine adhesions or formerly known as Asherman’s syndrome).

·         Distal tubal blockage (hydrosalpinx) and leakage of toxic fluid back into the uterus.

When thin endometrial lining is observed during an IVF cycle, additional estrogen in the form of vaginal suppositories may improve the overall endometrial thickness and outcome. Some investigators have used baby aspirin to improve the outcome, but results have been quite variable and most likely there is no benefit. Acupuncture and other relaxation techniques may be helpful in some cases, but large scale studies are needed to demonstrate a significant improvement with these treatment modalities. In some cases, the endometrial lining never reaches the acceptable thickness.

Sildenafil (Viagra) is a commonly used drug for erection problems in the male and has been shown to increase the penile blood flow. Investigators have used Viagra to increase the blood flow to the uterus with the hope of delivering more estrogen hormone to the uterine lining. Viagra vaginal suppositories can be used to achieve this goal in IVF cycles, in which the endometrial lining is thin despite additional vaginal estrogen treatment. In most cases of thin lining, the underlining cause can be identified and treated without the need for additional intervention.

A problem with any of these will cause the uterine lining to remain poor. Thus, poor estrogen levels will cause the lining to remain thin. This is commonly seen in patients who have a poor ovarian response. It's easy to check this by testing the estradiol level in the blood. If this is low, this is easy to treat by giving estradiol vale rate.

As with any other tissue, the uterine lining needs an adequate blood supply to develop optimally. Uterine blood flow can be measured by doing a colour Doppler. While it was originally hoped that this would provide useful information, sadly we still do not know what to do with this data. Doctors have tried improving uterine perfusion by treating these patients with vasodilators but the results have been mixed.

Sometimes, it's the endometrial tissue itself which has been damaged. This is often seen in patients who have had endometrial tuberculosis in the past. Similarly, uterine surgery can also disrupt the uterine lining. We find this in women who have had a dilatation and curettage done after having had a missed abortion. Over-enthusiastic curettage can result in the removal of the basal layer of the uterine lining, called the basalis. Once this has been denuded, new endometrial tissue cannot grow and the lining remains persistently thin, resulting in a variant of Asherman syndrome which is very difficult to treat.  A normal endometrium requires adequate blood flow; and high estrogen levels. Thus, if the lining is thin there are 3 possibilities: the estrogen levels may be low; the blood flow is poor; or the endometrium is damaged. We need to systematically examine all these 3 possibilities, so that we can pinpoint what the problem is in the individual patient, and then try to correct it.

If the doctor finds the endometrium is poor during the IVF cycle , often the best option is not to transfer the embryos but to freeze all of them. The patient can then be treated with high doses of exogenous estrogens, to see if this causes the endometrium to become thick. If the endometrium grows well , it's then possible to transfer the frozen embryos after thawing them into an estrogen primed endometrium.

However if the lining remains thin in spite of high doses of estrogen, this means the problem is either one of poor blood supply ; or a damaged endometrium. Some doctors have used color Doppler ultrasound to measure uterine blood flow, but the results with this have been mixed. Others have tried using Vaginal Viagra to try to improve endometrial blood flow. Since there is no reliable method to assess uterine blood flow, the next step is to determine whether the endometrium has been damaged or not. There are two possible causes of end-organ damage when the endometrium is nonresponsive. One is that the endometrium has been anatomically distorted because of intrauterine adhesions ( a common cause for this in India is uterine tuberculosis. This condition is called Asherman syndrome; and this can be diagnosed either with a Hysterosalpingogram, which shows filling defects within the uterine cavity; or with hysteroscopy, during which procedure the scars can be surgically removed.

If a patient has an unexpectedly poor lining during an IVF cycle, it's often best to freeze all the embryos rather than transfer them in the fresh cycle. We can then work on improving the uterine lining before transferring the frozen embryos back into the uterus.

If patients have a history of a poor lining, we use the following protocol to see if their lining responds to an increased dose of estrogen. However, if the uterine lining remains persistently thin, we try doubling the dose of Lynoral and repeating the scan. If it still does not improve, this confirms this is an end-organ defect in the endometrial tissue. This can be very difficult to treat. For these patients, we do a hysteroscopy, to confirm there is no correctable anatomic problem (for example, adhesions) which we can remove. We can also do an endometrial biopsy on Day 2 or 3 of the IVF cycle. This deliberate endometrial injury is supposed to provoke increased uterine blood flow, and sometimes causes the lining to improve.

Treatment options for specific causes:

 In cases of endometritis (infection of the uterine lining), an endometrial biopsy with documentation of chronic inflammation or with bacterial cultures confirms the diagnosis, which necessitates antibiotic treatment. Multidrug treatment for at least 7-10 days is recommended to eradicate chronic inflammation of the uterine lining. A repeat endometrial biopsy is not necessary to document resolution of inflammation and patients can resume fertility treatment within one menstrual cycle.

DES exposure is relatively uncommon in reproductive age women because its use in pregnancy was banned in 1971 in the United States. Although uterine malformations due to DES or most other causes cannot be corrected surgically, surrogacy in such cases results in excellent reproductive outcome. If fibroids are present, they can be surgically removed and the uterus can be reconstructed to establish a healthy pregnancy.

Clomid treatment can result in thin endometrial lining because the drug acts as an anti-estrogen at the level of the uterus. In such cases, either additional estrogen is administered along with Clomid or a different type of fertility medication is used. Alternatives are Femara, Tamoxifen or injectible FSH medications. Femara and Tamoxifen are oral medications, but they are not commonly used to induce ovulation or for the purpose of superovulation currently. Although their safety has been established by medical studies, a drug company warning on the use of Femara and risks on the developing fetus has limited its use in women trying to conceive. Among the three options, injectible FSH preparations result in the highest pregnancy rates and successful ovulation can be accomplished 100% of the time.

Intra-uterine adhesions or scar tissue can result from prior uterine infections, pelvic inflammatory disease, multiple uterine procedures, and prior termination of pregnancy or postpartum curettage of the uterine cavity. Hysteroscopic diagnosis and treatment of adhesions results in high pregnancy rates in most cases. Mild adhesions are relatively easy to treat, but severe adhesions generally need multiple hysteroscopic procedures to restore a normal uterine cavity. If adhesions are so severe that correction is not possible, surrogacy becomes a viable alternative treatment option.

Distal blockage of fallopian tubes (hydrosalpinx) results in accumulation of toxic fluid inside the tube that can drain back into the uterine cavity. Such drainage of toxic fluid can result in the diminishment of embryo binding sites called integrins in the uterine lining and result in no implantation, thin endometrial lining or miscarriages. It is almost standard practice currently to remove such diseased tissue (removal of blocked tube(s) – salpingectomy) by laparoscopy. Once the drainage of toxic fluid is eliminated, it has been shown that integrins (embryo binding sites) are replenished and pregnancy rates significantly increased.

Pregnancy rates with surrogacy treatment are much higher than patients who are trying to become pregnant and suffer from uterine problems including a thin endometrial lining. Even though surrogacy is the last option and not desirable initially, in some cases it may be the only option. A detailed discussion and evaluation with an infertility specialist is highly recommended in cases of uterine problems, especially thin endometrial lining.

For patients whose lining remains refractory to all therapeutic intervention, surrogacy is the final treatment option which has a very high success rate.

Do the uterus fibroids causes Infertility?

What about the relationship of fibroids and infertility? It's easy to understand how a sub mucous 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.

The uterus is a muscular organ that accepts an embryo and supports or protects the development of a fetus to term. Following fertilization of the egg in the fallopian tube, the resulting embryo migrates to the uterine cavity, where it implants. Uterine fibroids can cause infertility depending on their location and size. Fibroid(s) are distorting the uterine cavity or endometrium may result in infertility. In order for the embryo to properly implant, the uterine cavity should be free of large obstructions caused by polyps or fibroids, and must be normally shaped. About 60 – 75% of women have uterine fibroids and often are completely unaware that they even are present. They most often appear between the ages of 20 to 35.

Most women with fibroids have completely normal pregnancies and deliver healthy babies with no complications. Women with large fibroids may have an increased risk of some problems during pregnancy, however, such as breech presentation of the fetus, premature rupture of the "bag of waters", and a condition in which the placenta separates from the uterine wall during the pregnancy. The relationship between fibroids and infertility is still a controversial topic. In fact, most fibroids in infertile women do not need any treatment at all, since they do not affect fertility or pregnancy. Unnecessary surgery can actually reduce your fertility, because it causes adhesions and scarring which can damage the tubes. They are diagnosed through ultrasound examination as well as a few additional tests.

Be aware of the uterus fibroids

Most uterine fibroids are harmless, do not cause symptoms, and shrink with menopause. But some fibroids are painful; press on other internal organs, bleed and cause anemia, or cause pregnancy problems. If you have a fibroid problem, there are several treatments to consider. Fibroids can be surgically removed, the blood supply to fibroids can be cut off, the entire uterus can be removed, or medicine can temporarily shrink fibroids. Your choice will depend on whether you have severe symptoms and whether you want to preserve your fertility. If you have fibroids, there is no way of knowing for certain whether they are affecting your fertility. Fibroids are the cause of infertility in only a small number of women. Many women with fibroids have no trouble getting pregnant.

If a fibroid distorts the wall of the uterus, it can prevent a fertilized egg from implanting in the uterus. This may make an in vitro fertilization less likely to be successful, if the fertilized egg doesn't implant after it is transferred to the uterus.

If a study is made on women's life it will show that a majority of women go through the fearful thought of the life threatening word cancer when they find some abnormality with their normal periodical cycle. But, in most of the cases the fear is baseless because the abnormal bleeding is often found as a result of uterine fibroid. Uterine fibroid is one type of tumor that grows on the muscle of uterus. No one can surely confirm why a fibroid takes place. But it is normally find that it grows as long a woman's menstruation cycle goes on. So it must have some relations with the hormones that controls a woman's cycle. A uterine fibroid tumor never causes womb cancer as they are completely benign in nature. So, it is quite baseless to get panicky if one hears that she is having a uterine tumor.

Many women do not understand that she is having fibroid because it is too tiny and does not show any alarming symptoms. In those cases it does not need any treatment because this is one type of womb tumors which does not keep any harmful affect on the body. But in some cases the size of the fibroid increases with time and shows the disturbing symptoms. There are various symptoms of uterus fibroids. One of the most common symptoms is heavy bleeding with clotting at the time of period. Often there are incidents of bleeding between two cycles. The heavy bleeding can make a patient anemic and in few cases patient may go through a stage of trauma. Constant lower abdominal pain is another syndrome of having uterus tumor. Some complain of having pelvic pain.

When one suffers from these symptoms she must take medical help and consult with her doctor. Doctors normally suggest an USG to be sure that there is one or more than one fibroid in the uterus. Sometimes if the patient suffers from the problem of overweight it becomes quite difficult to find out the fibroid. The doctor decides about the uterus fibroids Treatment evaluating the age of the patient and the stage of the fibroid. His first concern is to decrease the bleeding so that it does not make the patient anemic. Normally contraceptive pills and iron supplementary are given to reduce heavy bleeding and to stop the patient from being anemic. Sometime doctors prefer for hormonal therapy for a short period.

But when these processes fail to stop the growth of the fibroid then doctor prefers to go for surgical way for treatment of fibroids. If the patient is planning for pregnancy doctors do not take any chance and surgically remove the fibroid from the uterine wall which is known as myomectomy. Sometimes doctors use surgical methods to stop blood flow to the fibroid which automatically shrinks the fibroid. But, when nothing works and fibroids come back on uterine wall again and again and affect the general health with heavy bleeding doctors have no option but to go for hysterectomy.

Treating uterine fibroid is not a severe issue and it is not a life threatening problem. So, whenever find some abnormality in your regular cycle visit a doctor and make life hassle less.

Understanding Uterine Fibroids and Symptoms

Uterine Fibroids refers to non-cancerous tumour that is founds in the uterus. Approximately 622,000 hysterectomies are performed annually for treating these fibroids. These fibroids are widely found among the women aged above 30 years of age. It is only under rare circumstances that women below 20 years suffer from it. Thanks to the medical advances that Uterine Fibroids Treatment is now possible. Hysterectomy is the most preferred treatments when all other avenues have been explored. Like no two female bodies are similar, so is the case with fibroids. Hence, make sure that you explore various options before zeroing-in on one treatment.

As slated above, these fibroids are non-cancerous growth that develops in female uterus. This growth is more to be found during the reproductive years. When it comes to Uterine Fibroids Medical Treatment, they are also referred as leiomyomas, fibromyomas and myomas. They develop on different parts of female uterus. However, cervix and lower part are the most affected ones. It is the location of fibroid on the basis of which doctors determine its nature. There are three types of fibroids.

Most of these fibroids are undisruptive. As far as Uterine Fibroid Symptoms are considered they vary from one to another. In many cases, these fibroids shrink with menopause. However, contrary to it are fibroids that are extremely painful, bleed leading to anaemia, press other internal organs. In fact, they can also cause complication in pregnancy. If you are suffering from problem of fibroids then you can choose from various medical treatments available.

Uterine Fibroids Surgery is the option that health care professionals advice in extreme cases. During the surgery, fibroids are removed. This will discontinue the blood supply to these fibroids and the entire can be removed. The decision is entirely yours. Females who want to preserve fertility opt for medicinal treatment in which these fibroids are made to shrink however in cases where symptoms are severe, the only option left is surgery.

These fibroids are widely found in women who are still into their fertility years. Although medical science has achieved new heights, there is no concrete cause that can ascertain the formation of fibroids. Researchers suggest that overweight and obese women are more prone to Uterine Fibroid Tumour. Family history is yet another cause that increases the chances of developing fibroids. Birth control pills taken by girls aged between 13 and 16; high intake of alcohol and girls who start menstruating prior to the age of 10 are more susceptible to develop fibroids.

Uterine fibroids surgery can also lead to serious consequences and irreversible infertility. However, doctors usually consider performing fibroids surgery when there is a clear danger from uterine fibroids such as having cancerous fibroids. The only way you can ever eliminate uterine fibroids and prevent their recurrence is by diagnosing your condition from within by listening to what your body tries to tell you, work with it and free yourself.

Intramural tumor grows inside the uterine wall resulting in the uterus feeling and looking larger. This can make the woman look pregnant, or have a pot belly which will not go away despite dieting or exercise.

The common symptoms of this type of tumor include:

·         Excessive bleeding

·         Pain in the Pelvic region and back

·         Frequent urination

·         May be responsible for infertility and miscarriages

·         Pressure in the bladder and uterus

·         Based on whether the intramural fibroids are close to the outside of the uterus or the endometrium, the symptoms will be similar to sub-mucosal or sub-serous fibroids.

In extreme cases if the size of these fibroids is large, it may block the blood supply, oxygen and nutrients to other body organs like kidneys. In some patients very large intramural fibroids may also cause permanent damage to the kidneys.

This type of fibroid can have a negative impact on the woman's fertility and result in miscarriages. Woman with this problem are also at a greater risk of undergoing premature delivery or a caesarean.

Treatment of fibroids

If you don't have any symptoms, or if your symptoms are mild, you won't need treatment. If you have more severe symptoms, there's a range of treatments available. Discuss with your doctor which treatment is most suitable for you. Intramural uterine fibroid treatment options are:

1. Abdominal myomectomy is the most common intramural fibroid treatment option. This treatment is particularly recommended if

A.       The size of the fibroids are more 5 or 7 centimeters, or

B.      There are multiple fibroids which need to be removed.

In rarest of cases where the fibroids can be life threatening or the symptoms severe, it would be worthwhile to pursue surgery or hormonal uterine fibroid treatment option. The occurrence of uterine fibroids is triggered by many internal factors, that's why it can only be treated by tackling all the internal factors which responsible for fibroids formation. Action of calming the pain, taking birth control pills, hormones or removing the fibroids or the uterus with surgical procedures is not 100% guaranteed and have their risks and complications.

Do you realize that common drugs used to treat uterine fibroids can have serious side effects? They may damage your digestive systems and block your opportunity to get pregnant. Common drugs prescribed by doctors to treat fibroids cannot destroy the root cause of fibroids and more over cause the following side effects:

•           Leg swellings

•           Cardiovascular problems and heart attacks

•           Digestive system disorders

•           Acne, facial fair, deep voice and depression

•           Excessive weight gain

•           Damage to your reproductive system which can seriously hinder the chances of carrying baby.

Going by what medical reports have to suggest, 3 of 4 women develop fibroids. However, lack of awareness minus symptoms is the reasons that you fail to notice its growth. That is why it becomes vital to get an annual checkup done by gynaecologist and stay fit and healthy.

Medicines :

There is no medicine that cures fibroids. Hormone-based treatments such as the oral contraceptive pill can help regulate your periods and relieve your symptoms. While there have been previous reports of fibroids growing in response to use of the pill, this is more likely with older, high-dose formulations.

There are medicines that lower your oestrogen level to try and shrink fibroids. However, they have side effects similar to that of menopause, such as hot flushes and vaginal dryness. And if these medicines are used for more than six months, they increase your risk of osteoporosis (thinning of the bones). These medicines are most likely to be used for the three to four months prior to surgery, to try and reduce the size of the fibroids to make it easier for the surgeon to remove them. Non-steroidal anti-inflammatory drugs (NSAIDs) may be effective in relieving pain related to fibroids. Talk to your doctor regarding whether a medicine will be able to help you.

Surgery :

There are a number of surgical options for treating fibroids, including those outlined below.

Myomectomy

A myomectomy is an operation to remove fibroids, leaving your womb in place. It may be done through a cut in your tummy, or sometimes it may be possible for your surgeon to use keyhole surgery. Myomectomy is usually only offered to women who would like the option to become pregnant in the future. Because your womb isn't removed there is a chance that more fibroids will grow in the future, so you may need to have further treatment.

Uterine Artery Embolisation (UAE)

This procedure blocks the blood supply to a fibroid, causing it to shrink. It's performed under local anaesthesia, meaning that feeling in the area will be completely blocked but you will stay awake during the operation. UAE gives relief from symptoms such as bleeding and pain for at least six in every 10 women treated. It's only recommended to be used for treating women with infertility related to fibroids as part of a clinical trial.

Endometrial ablation or resection

Endometrial ablation is a procedure to remove most of the lining of your womb or to destroy or remove an individual fibroid using energy such as microwaves or heat. During an endometrial resection, the lining of your womb or the fibroid is cut away. Endometrial ablation helps stop heavy and prolonged bleeding, but doesn't affect fibroids sitting outside the inside lining of the womb.

Hysterectomy

A hysterectomy is a major operation to remove your entire womb, usually via a 'bikini-line' cut in your abdomen or, if the fibroids aren't too large, via your vagina. You and your doctor may also choose to remove your fallopian tubes and ovaries. You no longer have periods after a hysterectomy and you can't become pregnant. Discuss with your doctor which of these options is right for you.

Understanding the Conception, Ovulation and Fertilization

THE CONCEPTION PROCESS

Let's be honest while most of us enjoy or are at least quite intrigued by the act of conception, few of us understand what transpires between the extremely fun part of the process and the part where you start saving up for another human's college education.

Women are born with millions of immature eggs, which are contained in multicellular structures called follicles. Roughly once a month, the hypothalamus sends a signal to the pituitary gland to release follicle-stimulating hormone. This hormone prompts several follicles small, fluid-filled cysts to develop into mature eggs.

One of these will grow dominant over the others and, within two to three days following its maturity, the egg will react to the release of a luteinizing hormone it stimulates the sex hormones needed for pregnancy and push through the wall of the ovary. The follicle that initially released the egg sends out a call for increased estrogen production. This estrogen is the body's cue that an egg is now mature.

This egg only has 24 hours to find its partner: a sperm cell that can penetrate its outer layer. It's normal for 3 out of 10 sperm cells to be abnormally formed, and for 4 out of 10 to be bad swimmers. The odds are poor for any single sperm cell which may be a male or a female sperm cell for one thing, it has about a quarter-billion competitors that will be joining it in the vagina.

Within minutes of ejaculation, most of the sperm cells will die due to the acidic nature of the vagina. They're viewed initially at least by the woman's immune system as foreign bodies that should be destroyed. From there, they must enter the cervix, swim through cervical mucus, enter the uterus and find the opening to the fallopian tube; and once they're there, if no egg is present or on the way, it's been a fruitless journey for the hard-charging survivors.

But how does the egg make its own arrival in the fallopian tube? How is it fertilized? And why is a college education so expensive for the product of a fertilized egg? In order to understand the conception process, first we must understand ovulation, and it just so happens to be what we'll discuss in the next section.

THE OVULATION PROCESS

Females are born with millions of immature eggs, hundreds of which will mature in their lifetimes. Each egg is about the size of a pinhead.

Women get their periods in cycles that occur about every 28 days, though it's normal for cycles to last 21 to 35 days, or even 45 days for young women. Between periods, women ovulate, releasing a mature egg from one of the ovaries. Ovulation usually occurs about a week before or after a woman's period, although ovulation can be quite irregular and can occur even during the period. Generally, however, counting from the last menstrual period, most women will ovulate sometime between day 11 and day 21.

Some women are able to feel an ache in the ovary area during ovulation. It's also possible to detect ovulation through a change in cervical secretion, which will be wetter and more slippery directly before and during ovulation. Ovulation usually causes a small dip in body temperature, followed by a spike, and women often measure their temperatures when trying to detect ovulation. Ovulation may also coincide with an increased sex drive, light spotting, a feeling of being bloated and even heightened senses, such as taste or smell.

Normally, one egg passes from either of the ovaries through the fallopian tubes. This only happens once per cycle. Sometimes two eggs (or, rarely, more) are released within a single 24-hour span. If both eggs are fertilized, it can result in fraternal twins.

The fallopian tube is where fertilization occurs. Each ovary is attached to a fallopian tube, and the opening from ovary to fallopian tube is about half an inch (13 millimeters) in diameter, but narrows down to a much smaller opening at the other end. Inside the fallopian tubes are tiny hairs called cilia. They help pass the egg through the tube from the ovary toward the uterus. The entire journey takes several days, during which the egg exists in a perfect environment that provides it with nutrients.

Meanwhile, the uterus prompted by signals released by the follicle that formed the egg has formed an internal lining (endometrium) rich in blood and nutrients that's prepared to house and nurture the egg should it become fertilized. If no fertilization occurs, the egg disintegrates into the uterine lining that will soon pass from the body during a woman's period.

THE FERTILIZATION PROCESS

As long as a sperm cell is alive in the fallopian tube, it's capable of fertilizing an egg. If there's no egg in the fallopian tube, there's no chance of fertilization. The fallopian tubes are about four inches (10 centimeters) long and transport the egg from the ovary to the uterus. They also provide sperm that make it that far with nutrients and a safe environment, the same kind the egg enjoys as it passes through. Of the millions of sperm cells that initially enter the cervix, there may be anywhere from one to a couple hundred that arrive at the fallopian tube.

Eggs will survive about a day after they're released from the ovaries. If not fertilized, they'll break down. It's only during this day that a woman can become pregnant, though it may be a result of a sexual encounter days earlier, since sperm can survive in the fallopian tubes for a few days.

When an egg does pass through, the sperm have receptors that allow them to smell the eggs, which are surrounded by cells releasing the sweet scent: progesterone. Sperm cells most definitely become very active when an egg is present. In fact, progesterone makes sperm become so active that they slough off layers of proteins. Both the surge in activity and the loss of proteins enables sperm to pierce the egg. This process is called capacitation. Once this occurs, the sperm only have a few hours to live. Only a few perhaps half a dozen or less sperm cells will ever share proximity with the egg.

How does the sperm cell actually penetrate the egg? The head of the sperm, once making contact with the exterior of the egg, will more or less pop, releasing enzymes that allow it to cross through the barrier. Once a sperm cell penetrates the exterior of the egg, fertilization occurs; its DNA payload is delivered as the sperm is absorbed by the egg. The genetic blueprint of the child is now set in stone. Once a single sperm enters the egg, the egg's protective protein covering changes and doesn't allow other sperm to enter. From one egg that has been fertilized by one sperm cell, encoded genetic information coupled with cell growth will eventually create an entire human being.

Is it possible that irregular menstrual cycle makes you less fertile?

Every woman's menstrual cycle can get thrown off by a number of factors at some point in her menstrual history. Our article answers some pointed questions about abnormal menstrual cycles and how they might affect a woman's fertility.

Why is my period irregular?

Your best friend can set her watch by the arrival of her period; the fourth Monday of every month, between 4 and 5 PM. You, on the other hand, bounce between four-, five-, and six-week cycles. You may even skip a menstrual cycle every once in a while. What's going on here? It may reassure you to know that somewhat irregular menstrual cycles are actually more common than regular ones. Your cycle may fluctuate for a variety of reasons, including illness, travel, stress, exercise level, and significant weight loss or gain. Adolescents, women who are breast feeding, and those who have recently stopped taking birth control pills also commonly experience fluctuations in their menstrual cycles.

Should I worry if my menstrual cycle is irregular?

Are you less likely to get pregnant than your punctual friend? Not necessarily. Fertility depends on ovulation; the release of a healthy egg from the ovary rather than on menstruation. As long as you're ovulating normally and can determine when ovulation occurs, your chances of getting pregnant won't be affected by irregular periods.

The exception to this rule is if your cycles are very long. It's mathematically obvious that women who ovulate every six weeks  or about nine times a year  have fewer opportunities to get pregnant than those who ovulate monthly. For this reason, women with long cycles are sometimes given fertility drugs like Clomid to regulate ovulation. Women over 35 and those who don't ovulate regularly are more likely to be candidates for drug therapy than are those who simply have irregular cycles.

Tips for Maximizing Fertility

If your cycle is irregular, it's impossible to guesstimate when ovulation will occur. You must use ovulation predictor kits, examine your cervical mucus, or take daily basal body temperature readings preferably some combination of the three.

If you exercise a great deal say, if you work out every day for several hours, or you're in training for a marathon peak to your doctor to determine whether you need to cut back. Women need a certain level of body fat in order to ovulate normally. If you're seriously overweight, speak to your doctor about starting a gradual weight-loss program. Obesity may affect hormonal signals to the ovaries and interfere with ovulation. In addition, increased weight can cause insulin levels to climb, causing the ovaries to overproduce male hormones and stop releasing eggs.

WHEN ARE YOU MOST FERTILE?

Believe it or not, you can look at fertility in much the same way as businesspeople look at economics large scale (macro) and small scale (micro). On other levels, of course, we wouldn't wish to compare the deeply personal and intimate act of creating a child with the cold world of industry and commerce, but when it comes to the issue of conception timing, you really have to look at what's happening with the big picture of your life as well as the month-to-month details.

Following this line of thinking, the large-scale, or macro, viewpoint of fertility looks at the period when you're most fertile during your childbearing years. The small-scale, or micro, perspective focuses on when during any given month you're most likely to conceive. If you're a woman, you're at your most fertile from the ages of 20 to 24. Of course, in our current society, many couples are choosing to start families later. And while you can't deny biology, not having a child in your early 20s doesn't mean you're not capable of having one later on. By the time you're 40 years old, your odds of getting pregnant have dropped from 90 percent to 67 percent. This means that you still have a chance although not as great of a chance of conceiving.

Regardless of where you are in your reproductive years, there's another, smaller-scale guide to your fertility, and that is your monthly cycle. Women tend to be most fertile in the days leading up to and during ovulation (when a matured egg is released and ready for fertilization). Ovulation occurs toward the middle of your menstrual cycle. Once released, a typical egg lives 12 to 24 hours, and generally only one egg is released during each cycle. So, if pregnancy is your goal, take advantage of the days around ovulation when your body is at its most fertile.

TRACKING YOUR FERTILE DAYS

The methods for preventing pregnancy are fairly direct although not always foolproof. When it comes to conceiving, however, you may find that there's a lot more planning and even guessing involved. How can something so natural take so much work? Fortunately, it may be easier than you think to find those magical days of ovulation when you're most fertile. There are a number of options, and most can be done on your own:

Bodily observations: Ovulation isn't nearly as conspicuous as menstruation, but if you pay attention to your body, you can sometimes tell you're ovulating. Signs might include light spotting, slight abdominal pain on one side and increased sex drive.

Calculating your cycle: Ovulation generally occurs in the middle of your cycle, and can be anywhere from day 11 to day 21. To pinpoint this phase, count from the first day of your last menstrual period. There are many online ovulation calculators you can use to help with this.

Charting your basal body temperature; when your body releases an egg, it also releases progesterone, a hormone that thickens your uterine lining and also slightly increases your body temperature. You can find basal thermometers at most drugstores, and use them to see if you can detect a rise in temperature during certain times of the month.

Tracking the luteinizing hormone (LH); this hormone is responsible for releasing an egg during ovulation. Ovulation kits that check for LH levels in your urine provide a fairly accurate means for determining ovulation.

Now that you know how to find your most fertile days, your next step is to take advantage of them. And don't pressure yourself to find the exact day of ovulation; viable sperm can live in the reproductive tract for up to three days.

FACT: Age affects men's fertility also

A lot of emphasis is put on women's fertile years probably because it's a narrower window of time, but men are also less likely to reproduce as time goes by. Like women, men become more infertile as they age and more prone to producing children with illnesses and birth defects. 

Can an ovarian cyst stop my conceiving or pregnancy?

An ovarian cyst is a fluid-filled sac that forms on or inside a woman's ovary, the two organs responsible for producing eggs and certain hormones in women. Most ovarian cysts aren't dangerous to a woman's health, which is good considering they most often occur between puberty and menopause -- during a woman's child-bearing years. Most cysts are benign, meaning they are not cancerous. For women planning on having children, the issue of a cyst can raise plenty of questions. In this article, we'll look at how ovarian cysts affect a woman's body, in particular her fertility.

Will having an ovarian cyst affect my fertility?

Ovarian cysts do not usually affect your fertility. However, some types of surgery to remove cysts can affect your ability to have a child. Most women who get an ovarian cyst have a functional cyst, which is usually small and will go away by itself. This type of cyst will not affect your ability to have a child. Ovarian cysts will usually only affect your fertility because of a condition called polycystic ovary syndrome. This is when you have many cysts (usually at least 10) on your ovary. However, if you have an ovarian cyst that needs treatment, some types of surgery can affect your fertility. This will depend on the type of surgery you have.

If you're having surgery to remove an ovarian cyst, there is a small risk of fertility problems as a result of complications from the procedure, for example, if you start to bleed more than is expected. The risk is lower if your gynaecologist (a doctor specializing in women’s reproductive health) does a keyhole procedure called a gynecological laparoscopy (in which small instruments and a tube-like telescopic camera are inserted through small cuts in your abdomen to remove your ovarian cyst). Your gynaecologist will explain how these risks apply to you before you have the operation. If you're having surgery to remove an ovary or fallopian tube, you will normally still be able to have a child as long as you have one ovary left, or even part of an ovary. Your gynaecologist will usually only recommend removing your ovary or fallopian tube if there is a problem. It’s likely that your gynaecologist will try to preserve as much ovarian tissue as he or she can, which will help with your fertility and prevent you going through the menopause early. If your ovarian cyst is found to be malignant, you may be advised to have a full hysterectomy (operation to remove your womb) to help prevent the cancer from spreading. This operation will mean you will no longer be able to become pregnant. Your gynaecologist will discuss the different options available to you before you have any surgery. If you feel unhappy with what he or she is suggesting, then you may be able to ask for a second opinion.

Do ovarian cysts lower your chances of falling pregnant?

Yes, ovarian cysts affect your fertility. They are not just a pain that you feel; they contribute to 'insulin resistance', which results in your body converting more energy into fat so you gain weight and your chances of falling pregnant fast are lowered dramatically. They often occur due to imbalances with the female reproductive hormones and these imbalances can be a major contributor to weight gain and lowered fertility potential.

Does having an ovarian cyst mean I have cancer?

No. Most ovarian cysts are benign (not cancerous). A very small proportion of ovarian cysts do turn out to be cancerous. The chance that your ovarian cyst is malignant (cancerous) will depend on your individual circumstances, including the exact type of ovarian cyst you have. Functional cysts (the most common type of ovarian cyst found in women before the menopause) are mostly benign. Some other types of ovarian cysts do turn out to be cancerous. The chances of an ovarian cyst being cancerous are outlined below.

About one in 1,000 ovarian cysts are found to be cancerous in women who have not yet gone through the menopause.

About three in 1,000 ovarian cysts turn out to be cancerous in women over the age of 50.

However, this figure also depends on the exact type of cyst you have. It also depends on other factors in your medical history, such as being infertile, having had breast cancer or relatives who have breast cancer, and whether or not you smoke. You will have a number of tests to check whether your ovarian cyst is benign or malignant. Talk to your GP if you're worried about your chance of having ovarian cancer.

Is there a link between ovarian cysts and fertility?

Some ovarian cysts can be associated with decreased fertility. However, it depends on the type of ovarian cyst you have. Ovarian cysts that can affect your fertility include:

·         Endometriomas - Endometriomas are cysts caused by endometriosis, a condition in which the tissue normally lining your uterus (endometrium) grows outside the uterus. These ovarian cysts may be associated with fertility problems.

·         Ovarian cysts resulting from polycystic ovary syndrome - Polycystic ovary syndrome (PCOS) is a condition marked by many small cysts in your ovaries, irregular periods and high levels of certain hormones. PCOS contributes to problems with fertility in some women. Unless they become very large, these types of ovarian cysts don't affect fertility:

·         Functional cysts - Such as follicular cysts or corpus luteum cysts — are the most common type of ovarian cyst. Functional cysts form during a normal menstrual cycle and don't cause or contribute to infertility. In fact, functional cysts actually indicate that the necessary functions leading to fertility are taking place.

·         Cystadenomas - Cystadenomas are growths in the ovary that arise from the surface of the ovaries. Although they need treatment, they don't affect fertility.

·         Dermoid cysts - These cysts contain tissue - such as skin, hair or even teeth instead of fluid. Dermoid cysts aren't associated with infertility.

What are ovarian cysts and how do they affect my fertility?

 Ovarian cysts often manifest as an irregularity of ovulation, dramatically decreasing your chances of falling pregnant naturally.  Normally the ovary develops a cyst that holds the egg every month during the normal menstrual cycle. When an egg is mature, the sac breaks open to release the egg, so it can travel through the fallopian tube for fertilization. Then the sac dissolves.

One irregularity is when the sac doesn't break open to release the egg and the cyst continues to grow. Another type of cyst can form after a successful ovulation when the sac doesn't dissolve afterwards. Instead, the sac seals off after the egg is released. Fluid then builds up inside of it and forms a cyst that can grow up to four inches or more and bleed, twist the ovary or cause pain.

Another reason you may form cysts is 'Estrogen dominance', an imbalance where excess estrogen contributes to weight gain and lowered fertility. Other female hormonal imbalances such as PCOS, Fibroids and Endometriosis may be causing your Cysts to form.

This can be caused by endocrine-disrupting chemicals (EDC's) that are common in our everyday life. These are environmental pollutants such as hormones in meat, plastics, and chemicals found in household products like cleaning products and make up. These chemicals mimic or block the action of our own hormones, setting the body up for the "right environment" for cysts to form. The problem is that once you have a cyst it can be like a "vicious cycle" as the cyst can continue to feed excess estrogen into your system.

What will happen if I'm diagnosed with an ovarian cyst while I’m pregnant?

If you're found to have an ovarian cyst while you’re pregnant, your doctor will usually just need to monitor it. Most ovarian cysts are benign and go away on their own. Occasionally, you may need to have the cyst removed before you have your baby. As women have a number of scans during their pregnancy, ovarian cysts are often diagnosed at this time. The majority of ovarian cysts found during pregnancy are small (under 5cm) and harmless – your doctor will probably just need to monitor it. This may mean having additional ultrasound scans carried out during your pregnancy.

Having an ovarian cyst won't harm your baby. However, if your ovarian cyst is large (over 7cm) or is suspected of being cancerous, you may need to have it removed. Laparoscopic (keyhole) surgery is a safe and effective procedure that can be carried out at any time during your pregnancy. However, you may be advised to wait to have the operation until after you have given birth to your baby.

Does the cyst have any bearing on my being unable to fall pregnant?

An ovarian cyst does not usually affect a woman's ability to conceive. The fact that you have been pregnant before is a good indicator that you will be able to conceive again. The length of time it takes for a woman to become pregnant varies greatly. No investigations are usually advised until a couple has been trying to conceive for a year with regular intercourse (at least twice a week). The only condition in which ovarian cysts are linked with difficulty in conceiving is polycystic ovary syndrome (PCOS). Women who have it tend to be overweight, have excessive hair growth and suffer from irregular or inon-existant periods. No single test can diagnose the syndrome, but blood tests for hormone levels and an ultrasound scan are helpful. It doesn't sound as though you have any symptoms suggestive of this condition. It is likely that you will conceive before long. In the meantime it would be a good idea to make sure that you are fit and well and that your body is ready to become pregnant. Try to ensure that you have a good varied diet and that you exercise regularly. If you smoke try to stop and cut down on your alcohol intake. Getting plenty of sleep and making time for relaxation are also important. Women trying to conceive should take daily folic acid supplements and continue with this for the first twelve weeks of pregnancy.

What are the symptoms of Ovarian Cysts?

Most cysts don't cause any symptoms and go away on their own. A large ovarian cyst can cause abdominal discomfort. If a large cyst presses on your bladder, you may feel the need to urinate more frequently because bladder capacity is reduced. The symptoms of ovarian cysts, if present, may include:

·         Menstrual irregularities

·         Pelvic pain - a constant or intermittent dull ache that may radiate to your lower back and thighs

·         Pelvic pain shortly before your period begins or just before it ends

·         Pelvic pain during intercourse  

·         Pain during bowel movements or pressure on your bowels

·         Nausea, vomiting or breast tenderness similar to that experienced during pregnancy

·         Fullness or heaviness in your abdomen

·         Pressure on your rectum or bladder that causes a need to urinate more frequently or difficulty emptying your bladder completely

Are ovarian cysts and pelvic inflammatory disease linked?

Although ovarian cysts and pelvic inflammatory disease have similar symptoms, the two conditions are very different. Ovarian cysts are not caused by an infection, but pelvic inflammatory disease is mostly caused by a sexually transmitted infection (STI). You may or may not have any symptoms if you have either ovarian cysts or pelvic inflammatory disease. Many women have these conditions without knowing it. If you do have symptoms, these may include pain in your abdomen (tummy) and pain during sexual intercourse.

If you have an ovarian cyst, you may have other symptoms, which include:

·         Difficulty with or changes in your bowel movements

·         Needing to urinate more often or having trouble urinating

·         Indigestion or heartburn, or feeling very full after eating

If you have pelvic inflammatory disease, you may have other symptoms, which include:

·         An abnormal vaginal discharge that may be smelly

·         Irregular periods, bleeding between periods or having heavier periods than usual

·         Pain when you pass urine

·         A high temperature (over 38ºC)

·         Feeling sick or vomiting

If you have any of these symptoms, see your GP. If you’re diagnosed with ovarian cysts, you may not need any treatment because certain types of cysts will often go away on their own in about two or three months. If you’re diagnosed with pelvic inflammatory disease, your GP will prescribe you antibiotics to treat the infection.