DETERMINING A DIAGNOSIS: OVERVIEW
After completing the fertility workup, the doctor looks at all of the evidence and begins to narrow down potential diagnoses. As mentioned, these can include problems with the uterus, tubes, ovaries or the areas around the pelvic organs. Blood tests and a variety of imaging studies are usually needed to narrow down a diagnosis.
Many women experiencing fertility issues have undiagnosed endometriosis. This is surprising to patients because many do not have the classic symptoms of endometriosis, such as pain during menstruation. Even if you have no pelvic pain and don’t experience any of the classic symptoms, you still may have fertility-compromising endometriosis! Even mild endometriosis can interfere with fertility. Therefore, all fertility evaluations in women should always include a thorough analysis to rule out endometriosis.
DIAGNOSIS: FAILED IVF OF UNKNOWN ORIGIN
Many of Dr. Nezhat’s fertility success stories come from patients who experienced years of failed IVFs before investigating surgical alternatives. As it turns out, clinics that specialize in IVF sometimes are biased toward – well, IVF! As a result, conditions that may be better addressed through surgical therapies are sometimes downplayed or ignored altogether. The case of endometriosis is particularly striking. Patients with untreated endometriosis have higher rates of IVF failures. After undergoing surgical treatment of their endometriosis, IVF success rates increase dramatically.
If you’ve experienced failed IVFs, it’s worth it to seek out a second opinion.
You can click here to read Dr. Nezhat’s article on this subject.
DIAGNOSIS: BLOCKED FALLOPIAN TUBES
Healthy fallopian tubes are essential for natural pregnancies to occur. When tubes are abnormal, it can make getting pregnant naturally impossible. There are many causes for abnormal tubes. Some women are born with abnormal tubes. Other causes include endometriosis, previous pelvic infections, adhesions, and cysts. Other women have had their tubes tied; that is, they’ve had tubal sterilization to prevent pregnancies. Whatever the cause, the good news is that the majority of damaged fallopian tubes can be restored to proper function by minimally invasive surgery.
DIAGNOSIS: UTERINE ABNORMALITIES
Uterine abnormalities are a significant cause of infertility and recurrent pregnancy miscarriages. Usually these abnormalities are congenital, meaning that they have been present since birth.
Two uteri: Many don’t realize it, but the female fetus actually starts out with two uteri, which at first are located on the side of each kidney. Eventually each uterus migrates to just above the vagina. In normal development, the two uteri will fuse together to form one uterus. If anything goes wrong during these fetal developmental stages, reproductive tract anomalies can result. The most common anomalies include:
– septate uterus
– bicornuate uterus
– unicornuate uterus
– uterine didelphys
Septate Uterus – A septum occurs when the two uteri fuse incompletely, leaving a portion of tissue in the middle of the uterus. This extra tissue can interfere with proper implantation of a pregnancy. Even if implantation does occur, miscarriage often happens.
Bicornuate Uterus: This occurs when the two uteri only fuse at the bottom and remain separate at the top. In this condition, the patient has two small uterine cavities and a single cervix. These cavities each have an attached fallopian tube. Therefore, while pregnancy is possible, the chances are significantly reduced. In addition, when pregnancy does result, the risk of premature labor and miscarriage is very high as the uterus cannot grow as large as it normally would with a normal pregnancy.
Unicornuate Uterus: Sometimes only one of the two uteri forms during embryologic development. This uterus has only one fallopian tube and it is called a unicornuate (1 horn) uterus. Both ovaries will still be present, as they derive from different embryologic tissue. The chance for pregnancy in these patients is also reduced because pregnancy can only occur during months in which the woman ovulates from the ovary on the same side as the fallopian tube.
Uterine Didelphys: On very rare occasions, both uteri are present but they fail to fuse at all. This condition results in two separate uteri each with its own fallopian tubes and cervix. This condition can be diagnosed on a routine pelvic exam because there are two cervices
DIAGNOSIS: OTHER ABNORMALITIES
In addition to the congenital uterine abnormalities described above, there are a variety of other uterine abnormalities that can develop after birth. Examples include endometrial polyps, intrauterine adhesions, and uterine fibroids.
Infections can also interfere with fertility. Therefore, many tests and exams are performed to detect whether infections are present.
DIAGNOSIS: INTRAUTERINE ADHESIONS
Intrauterine adhesions usually result from damage to the uterine cavity. Damage can happen from previous surgeries to the uterine cavity, pelvic infections and even from previous pregnancies. The most common cause is from a previous D&C procedure. Intrauterine adhesions can be minor or they can affect the entire uterine cavity. These adhesions can prevent proper implantation of a pregnancy or can cause miscarriages.
DIAGNOSIS: UTERINE POLYPS
Uterine polyps usually grow inside the uterine cavity. These growths originate from one cell of the endometrial lining, which then begins duplicating abnormally. Polyps often cause no symptoms, but can cause abnormal bleeding between your periods. Polyps can also interfere with pregnancy by preventing implantation of an embryo to the uterine wall.
Polyps may also cause a chronic inflammatory response within the uterus, as the body launches an immune response in order to try to destroy the abnormal growth. It is hypothesized that this chronic state of inflammation is another way that polyps interfere with the implantation process.
Polyps can occasionally become malignant (cancerous), so it is important to remove them even if you do not wish to become pregnant.
DIAGNOSIS: POLYCYSTIC OVARIAN SYNDROME
Polycystic Ovarian Syndrome (PCOS) is a syndrome where there is a defect in the ovary that causes many cysts and irregular periods. There is a problem in the signaling from the brain to the ovaries to cause ovulation and hormone production. There are three criteria needed to diagnose PCOS:
- irregular menses
- symptoms or blood work showing an excess of androgens (male hormones). Symptoms include male pattern hair growth, acne and central obesity.
- Polycystic- appearing ovaries on ultrasound
Because there are irregularities in ovulation, patients with PCOS have difficulty getting pregnant.
DIAGNOSIS: DEPLETED OVARIAN RESERVE
Contrary to long-standing beliefs about supposed finite egg supplies, recent studies suggest that women may actually have the capacity to replenish at least some of their egg supply through egg-generating stem cells.
However, it appears that such regenerative capacities may occur only rarely or in small measures. Therefore, in practice we unfortunately still have to consider ovarian reserve something that is subject to depletion as a woman ages.
Beginning at puberty, eggs are released from the ovary every month and if not fertilized will pass with the menstrual blood. As women age, the amount of eggs and the quality of eggs decrease. As time goes by, this makes it more difficult for women to become pregnant, either because there are not enough eggs left or the quality of the eggs left are not suitable for pregnancy. This usually happens a few years prior to menopause, but can happen sooner in some patients. There are blood tests that can help diagnose this, such as the FSH (follicle stimulating hormone) test, which must be taken on day 3 of your menstrual cycle, and tests to measure the AMH (antimullerian hormone) and estradiol levels.