Recurrent Pregnancy Loss
Reversal of Tubal Ligation
Preimplantation Genetic Diagnosis (PGD)
Pelvic pain is a common complaint. Its nature and intensity may fluctuate, and its cause is often obscure and in some cases no disease can be shown. Pelvic pain may originate from common sites such as the uterus, tubes, and ovaries, or in less common sites. At times, the pain may psychogenic, or at least related to emotional states. To diagnosis the causes of and prescribe treatment for pelvic pain, physicians conduct a thorough personal and medical history, with special attention to: type of discomfort, distribution and radiation of pain, duration of pain, associated symptoms, and relation to urination, bowel movements, and sexual intercourse. Particularly important is the relationship to the menstrual cycle. Pelvic pain may have multiple causes, including inflammation or direct irritation of nerves caused by adhesions or scar tissue. Appropriate management of pelvic pain ranges from conservative or medical management (including hormonal treatments and pain killers) to surgical management (often including laparoscopy). A thorough evaluation and directed treatment by a trained physician will relief pain in over 80% of women.
Menopause is the medical term for the end of a woman's menstrual periods. It is a natural part of aging, and occurs when the ovaries stop making hormones called estrogens. This causes estrogen levels to drop, and leads to the end of monthly menstrual periods. The average age of menopause is 51, but it can also occur when the ovaries are surgically removed or stop functioning earlier.
Declining estrogen levels are linked to some uncomfortable symptoms in many women. The most common and easy to recognize symptom is hot flashes - sudden intense waves of heat and sweating. Some women find that these hot flashes disrupt their sleep, and others report mood changes. Other symptoms may include irregular periods, vaginal or urinary tract infections, urinary incontinence (leakage of urine or inability to control urine flow), and inflammation of the vagina.
Because of the changes in the urinary tract and vagina, some women may have discomfort or pain during sexual intercourse. Many women also notice changes in their skin, digestive tract, and hair during menopause. About 75% of women report some troublesome symptoms during menopause. In the long term, some women experience problems related to the low levels of estrogen found after menopause.
These problems include osteoporosis and increased risk for heart disease. The period of time leading up to menopause is often characterized by irregular periods. In fact, changes such as shorter or longer periods, heavier or lighter menstrual bleeding, and varying lengths of time between periods may be a sign that menopause is near. Estrogen is also now known to be important in memory and the healthy functioning of nerve cells in the brain.
Some studies have shown that estrogen replacement therapy can preserve brain activity and even improve memory. Treatment of menopausal women with replacement hormones such as can slow the rate of bone thinning and may prevent bones from breaking. In addition, it is important that women take in enough calcium in their diet to strengthen the bones.
Calcium is naturally found in many foods, including dairy products, and may also be added to a food (for instance, some orange juices now have calcium added). Calcium tablets are another good way to add to calcium to your diet. The goal should be to reach a total daily intake of 1000 milligrams per day before menopause or 1500 milligrams per day after menopause.
Regular weight-bearing exercise, like walking, may also help prevent osteoporosis. Finally, the rate of heart disease rises considerably in women after menopause, an increase that can be prevented by estrogen replacement. Some experts believe that estrogen replacement therapy may be the single most important factor in preventing heart disease in women.
Premenstrual syndrome (PMS) occurs in approximately 5-10% of reproductive age women. They experience a variety of emotional symptoms each month during the second half of their menstrual cycle. While the exact cause of PMS is not known, clearly it is related to hormonal fluctuations. The objective of treatment is to make the patient more comfortable and enable her to function more normally.
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Treatment for PMS is quite varied. In some patients, simple life-style changes such as a diet and exercise program and stress management strategies may be extremely helpful. Decreasing caffeine and salt intake may decrease some physical symptoms. In other patients, hormonal treatments and even anti-depressant medications may be required to help the woman throught the most difficult days. Overall, the majority of women experience considerable improvement with appropriate treatment.
Infertility is the failure of a couple to conceive after one year of having regular, unprotected sexual intercourse. In women over the age of 35, it is often prudent to begin an evaluation of the couple after only 6 months. Nearly one in five couples experience infertility and seek treatment. There is a natural decline in fertility that comes with aging. This decline occurs more quickly after age 30. Primary infertility describes a couple who has never conceived, while secondary infertility refers to a couple who has achieved a pregnancy in the past but is unable to do so again. There are some differences in their evaluation and treatment, since theoretically, a couple who previously achieved a pregnancy had all the basic components of their reproductive systems intact. This implies a much greater likelihood that one or both partners have recently developed a problem that is responsible for their current infertility.
Recurrent Pregnancy Loss
Miscarriage occurs in 15 to 25% of pregnancies. The rate of miscarriage risk increases markedly when a woman passes the age of 40, in some studies, approaching 50%. Most miscarriages are due to chromosomal abnormalities, but other causes may be related to anatomic, hormonal, infectious, or immunological abnormalities. Spontaneous abortion is the technical name for miscarriage. Recurrent miscarriage is usually defined as at least three miscarriages with no more than one pregnancy extending into the third trimester. When a couple presents with this history, the physician attempts to identify any abnormalities that may be causing the frequent losses. A direct cause is found less than half the time these evaluations are performed.
Fortunately, couples with such unexplained recurrent miscarriage usually have a high chance of a successful subsequent pregnancy. If the woman does get treated for recurrent miscarriage and subsequently gets pregnant, it is difficult to know whether the treatment was responsible for the pregnancy's success. Unfortunately, few studies have been well done on this subject, and many of the suggested treatments are expensive and experimental. Common tests performed on a couple who have experienced recurrent miscarriages include checking their chromosomes (karyotypes), checking a woman's uterine anatomy (hysterosalpingogram), evaluating common hormonal problems (thyroid, prolactin, glucose), checking for infections (chlamydia and mycoplasma), and checking for common immunologic problems (antibody testing). Treatment can often be simple, ranging from taking a baby aspirin each day or undergoing an out-patient surgical procedure to remove a fibroid (hysteroscopic myomectomy), to more complicated immunotherapy.
Prolactin is a hormone occassionally overproduced by the brain, interfering with normal reproductive function
Prolactin is a hormone secreted by the pituitary gland (located at the base of the brain). Normally, prolactin is present in the blood stream in low levels inf nonpregnant women. During pregnancy, prolactin levels increase approximately ten-fold and stimulate milk formation. Hyperprolactinemia is a condition in the brain secretes too much prolactin in a woman who is not pregnant. Hyperprolactinemia can produce a variety of reproductive dysfunctions including inadequate progesterone production during the luteal phase after ovulation, irregular ovulation and menstruation, absence of menstruation, and galactorrhea (breast milk production by a woman who is not nursing). Prolactin levels should be measured in women who experience these conditions. Prolactin secretion may increase mildly with sleep, stress, intercourse, exercise, nipple stimulation, ingestion of certain foods and drugs, and pregnancy. If a woman's prolactin level is elevated the first time it is tested, a second sample should be checked when she is fasting and non-stressed. If the prolactin level continues to be markedly elevated, it is important to look for a cause. Confirmed elevations of prolactin need to be evaluated. In some cases, magnetic resonance imaging (MRI) or computerized tomography (CT) of the brain will be performed to look for small tumors. Low thyroid hormone production is a common medical condition that can cause hyperprolactinemia. In approximately 30 percent of cases, the hyperprolactinemia is unexplained. Parlodel and Dostinex are the two drugs commonly used to treat prolactin excess. They both work by suppressing prolactin production. Ovulation and menstruation generally return within six weeks of normalizing prolactin levels. Galactorrhea takes more time and is less certain to resolve. The side effects of these medications (including lightheadedness, nausea, and headache) usually resolve within the first month of use. Hyperprolactinemia is a common problem found in up to one-third of patients with absence of menstruation and in up to 90 percent of women with galactorrhea. Observation and expectant management is appropriate for some of these women, and medical management is highly successful in others.
The polycystic ovary syndrome (PCOS) is a condition in which the ovaries accumulate tiny îcysts' (actually little follicles, two to five millimetres in diameter, each of which contains an egg) instead of the follicles growing and going on to ovulate they stall and secrete male hormone into the blood. Ovulation can be rare without the help of medications. In some women, there will be a long history of irregular periods and, perhaps, an increase in facial and body hair caused by more than the normal amount of male hormone in the blood. There are estimates that about 20 percent of all women have mild polycystic ovaries (PCO). It's probably genetic - often coming down the male side of the family. When a woman is not trying to get pregnant, oral contraceptive pills are good treatments: they stop follicles and male-hormone-producing tissue from accumulating, stops complications such as abnormal hair growth from taking place, gives regular periods, provides contraception, and protects future fertility.
If you are attempting pregnancy then the drug clomiphene (Clomid) is the first choice to induce ovulation. If clomiphene doesn't work then physicians often use injectable medications such as Pergonal, Humegon, Gonal-F , Follistim, and Repronex. Using hMG to induce ovulation in preparation for getting pregnant naturally is often complicated, however it is most challenging in women with PCO, since often up to 10 or 20 follicles will respond and try to ovulate. It is important that if this happens, the cycle be cancelled, and the next month be started with lower doses of medications.
Laparoscopy, hysteroscopy, laparotomy, and other surgeries used to evaluate and treat diseases of the female reproductive tract.
Certain diseases require surgery for correction. Often times, the treatment of abnormalities of the uterus, ovaries, and fallopian tubes can be performed safely as an out-patient or "same-day" surgical procedure. It is important that your physician have advanced training and extensive experience in performing laparoscopic and hysteroscopic surgery to make your surgery safe, convenient, and minimally invasive. Other pelvic surgeries such as myomectomies, laparoscopically-assisted vaginal hysterectomies, and endometrial ablations also require significant surgical expertise.
Endometriosis is a condition in which there is a growth of tissues outside of the uterus that can either cause pelvic pain or infertility. It is without question one of the most baffling conditions that affect women. An estimated 10 million women in the US are affected by this disease, and it is one of the leading causes of infertility in women. Though there are many effective treatments, there is no known cure. The diagnosis is confirmed when uterine or endometrial cells are identified outside their usual location inside the uterus.
Endometriosis may be found on the outside of the uterus, inside and outside the ovaries, or implanted upon the fallopian tubes, bowel, urinary tract, and anywhere in the abdomen. When a woman gets her period the endometriosis often responds to the menstrual cycle's hormonal signals. When the endometriosis bleeds, the woman may have sensations of deep pain or cramping. The body responds to the bleeding by surrounding it with inflammation often causing adhesions and leaving scar tissue. Endometriosis is estimated to be present in 15% of all reproductive age women, but as many as 30-40% of all infertile women. The exact ways that endometriosis affects infertility are not fully understood. Scar tissue and adhesions are known to interfere with the path the egg and sperm must travel to unite and become fertilized and implanted. In some women, endometriomas (a special type of ovarian cyst that contain endometrial cells that grow and bleed during menstruation) may form inside the ovaries causing enlargement of the ovaries, therefore interfering with normal ovarian functions such as ovulation. There also may be links between endometriosis and hormonal imbalances or immune system abnormalities that can also interfere with fertility. Some women with endometriosis experience severe pain during their menstrual cycle or during intercourse, excessive or irregular bleeding during menstruation, or urinary or bowel problems in conjunction with menstruation.
Other symptoms may include fatigue; painful bowel movements with periods; lower back pain with periods; diarrhea and/or constipation and other intestinal upset with periods. The amount of pain is not necessarily related to the extent or size of growths. Other women experience no symptoms, and their endometriosis goes undiagnosed until they seek medical help to explain their inability to conceive. Because endometriosis is progressive, the key to preserving fertility in women who have endometriosis is early diagnosis and treatment of the symptoms that interfere with conception and pregnancy.
Ultrasound scans may detect the presence of endometriomas in the ovaries, while laparoscopy is typically the definitive way endometriosis is diagnosed. Laparoscopy is typically performed as an outpatient surgical procedure in which a fiberoptic telescope is inserted into a female's abdomen below the navel to look for endometriosis, scarring, and adhesions. While there is no known cure for this disease, effective treatment of the symptoms is available. In general, surgery and hormonal treatments may be helpful for the treatment of pain related to endometriosis. For infertility, there may be a need for other types of treatment following surgery to increase the number of eggs ovulated in a given month. In extreme cases, in which the endometriosis has caused extreme tubal damage, in vitro fertilization may be needed to bypass the scarred Fallopian tubes.
Uterine fibroids are benign tumors of the uterus that can cause infertility, heavy periods, severe menstrual cramps, and pelvic pressure. These abnormal growths are among of the most common causes of infertility in women. There are no known causes for uterine fibroids, though the explanation appears to be an absence of a signal to turn off division of the muscle cells that make up the walls of the uterus. While traditionally hysterectomy has been recommended for women with fibroids, women with fibroid tumors are now being offered more conservative treatments such as myomectomies. A myomectomy is a surgical procedure in which the fibroid tumor is removed, yet the uterus is left in place. Reconstruction of the uterus is a vital part of this procedure. Specialists who perform myomectomies are often able to save a woman from needing a hysterectomy, enabling her to retain her child-bearing ability. For some fibroids, the myomectomy can be done on an out-patient basis (laparoscopically or hysteroscopically). Medications are another option for treating fibroid tumors in some women. Prescription medications are available that can shrink the size of the fibroid and lessen heavy bleeding and pain. These medications can only be used for a limited period of time, however, and require careful monitoring by a physician.
Reversal of Tubal Ligation
Patients who have undergone previous tubal sterilization are candidates for either tubal reconstructive surgery or IVF. The most ideal candidates for tubal reconnection are women in whom investigations reveal that the subsequent total tubal length following reconnection will be greater 4 cm., and cases where the tubes have been divided relatively close to the uterus. The statistical chance of ideal candidates for microsurgical tubal reconnection subsequently becoming pregnant within two years is in the range of 60-75 percent with a subsequent ectopic pregnancy incidence of about 10 percent.
2-3% of all pregnancies occur outside of the uterus, and are called ectopic pregnancies. The majority of these occur in the Fallopian tubes, and can be life threatening if not treated. Traditional treatment included removal of the entire fallopian tube. More recently, these tubal pregnancies have been managed conservatively, either by laparoscopic surgery or by medical treatment (Methotrexate). Any infertility patient with abnormal bleeding and pelvic pain should consider ectopic pregnancy as a real possibility, and should have a pregnancy test performed.
A frequent complication of fertility treatments, multiple pregnancies may cause pre-term labor, pregnancy-induced hypertension, and diabetes. Early diagnosis is vital in order to provide preventative care, and explore all medical options, including multifetal reduction in cases of higher order multiple gestations (triplets, quadruplets, etc.). The key to the treatment of multiple pregnancies is to avoid their occurrence by carefully monitoring patients receiving fertility drugs, and minimizing the embryos transferred in patients undergoing in vitro fertilization.
Overgrowths of the uterine lining are called endometrial polyps. Some polyps are found incidentally, and do not require treatment. Others may cause irregular bleeding, and, at times, infertility, and should be surgically removed. When performed by an experienced surgeon, the treatment of endometrial polyps can be performed hysteroscopically as an out-patient procedure, and should be safe and effective.
Preimplantation Genetic Diagnosis (PGD)
Traditional methods used to identify genetic disease require prenatal diagnosis through amniocentesis or CVS, followed by potential termination of the pregnancy if the fetus is found to be affected. Recent scientific advances now allow the diagnosis of some genetic disorders before pregnancy is established using a technique known as PGD. PGD combines the technology of in-vitro fertilization (IVF) with new molecular biology techniques. Following fertilization of an egg, a single cell is removed from an embryo in a procedure called an "embryo biopsy." If the embryo is found not to contain the genetic disorder being tested for, the embryo is transferred into the uterus, and allowed to develop. Couples with a known genetic disorders can now have unaffected children without the emotional and ethical challenges associated with traditional prenatal diagnosis.