Recurrent miscarriage is diagnosed when a woman miscarries consecutively 3 times, before 20 weeks gestation. It is true that some women miscarry more often than chance alone would expect. When considering how common recurrent miscarriage actually is, we need to consider some numbers.
How common is recurrent miscarriage?
It is well known that overall 15% of all clinically recognised pregnancies end in miscarriage. The main cause is a problem with the gene cross-over at time of conception. This is due to chance alone, and nothing can be done to prevent it. The miscarriage is nature's way of ensuring health throughout the whole of your offspring's life. When pregnancy is diagnosed much earlier, with very sensitive hormone tests, it is found in fact that up to 60% of pregnancies end in miscarriage - most would just present as a heavier late period if undiagnosed. So 2 early miscarriages is really likely to be no more than just bad luck.
Considering this figure of 15%, we would expect only 0.4% of women to miscarry 3 times consecutively, and it be due to nothing more than chance. In fact, 0.8-1.0% of women do so, suggesting other factors may be involved.
What is important to remember through all of this, is that 60-75% of women who have recurrent miscarriage (RM) will go on to have a successful pregnancy the next time - without any kind of tests or treatment. When a woman is investigated for RM, the majority of the time, no cause is found.
What are the things which can make one prone to recurrent miscarriage?
Remembering that most often no cause is found, below are some of the things which are thought to be associated with RM:
General disease - eg. Systemic Lupus Erythematosus (SLE) which is a disease affecting many systems of the body. People affected often have a butterfly-rash over the cheeks and bridge of the nose.
Antiphospholipid antibody syndrome - this is an immune disease where the main problems are RM, clots in the veins or arteries and often a low count of one of the blood components, the platelets. If pregnancy is successful, it can be complicated by poor growth of the baby and a disease of pregnancy called preeclampsia.
Chromosome problems - ie Mum & Dad are fine, but when put together an unusual gene mismatch occurs (only 3% of RM).
Uterine (womb) abnormality - eg. double-womb or a septum down the middle. This is only associated in about 4% of RM and is found in 1.8-3.6% of the normal population. Whether this type of problem actual is to blame hasn't been proven, and the risks of surgery to correct the problem must be weighed against any potential benefit. In most women with these findings they don't cause miscarriage, hence the uncertainty.
Fibroids - whorls of normal uterus tissue growing in the muscle, sometimes causing misshaping of the womb cavity.
Cervical incompetence (weakness) - may cause miscarriage in 2nd trimester. Only likely to be a cause if there is clear history of severe or recurrent trauma to the cervix (not, for example, just a one D&C or cone biopsy) with RM. Some women are just born with a weak cervix. This is not as common as some people report, and the diagnosis is very difficult to make.
Polycystic ovary syndrome - often this disease causes infertility or trouble even getting pregnant. It has also been found when this is present with a raised hormone level (LH) there is an increased risk of miscarriage. Hormonal treatment for this is being looked into presently, but there is minimal evidence available at the moment on who might benefit. It does appear that women with very irregular periods and a raised LH may do so.
Immune problems - couples with RM may have some similar components of the immune system. This can make it difficult for Mum to make the appropriate response to pregnancy. This is a controversial finding, and no immune therapy has been found to improve chances above and over the 60-75% seen without intervention.
Hormone 'deficiency' - in pregnancies which end in miscarriage, sometimes the levels of a hormone called progesterone are found to be low. This is thought to reflect an early pregnancy failure, and is probably the RESULT rather than the cause of the miscarriage. Certainly progesterone supplements do not increase the likelihood of an ongoing pregnancy.
Things unlikely to cause recurrent miscarriage
Retroversion - or backward tilting of the uterus.
Infection - such as toxoplasmosis, listeria, brucella, chlamydia, herpes simplex and cytomegalovirus.
Endocrine or metabolic disease - hypothyroidism (underactive thyroid), diabetes mellitus, Crohn's disease, sickle cell or endometriosis.
Occupational exposures - very little reliable evidence exists for things such as herbicide spraying, electromagnetic fields, chemical inhalation, anaesthetic gases or VDU usage.
Not resting enough - bedrest doesn't alter whether you miscarry or not. Nor does working when you're pregnant, exercise, making love or flying.
Is there any treatment?
Progesterone supplements have been evaluated in clinical trials and have not been shown to be of any benefit. A few people still use them, but it must be realised that they are not any better than placebo (no treatment). There will be women who had miscarriage 3 times then went on to deliver the following 2 times with progesterone supplements - most doctors certainly wouldn't deny the treatment again, but the fact remains that properly conducted studies (as opposed to anecdotal reports) have not found them to be of benefit. Surrogacy is becoming a likely choice for people suffering from recurrent miscarriages.
Hysterectomy is a surgery to remove the uterus and fibroids, usually through an abdominal incision. The procedure requires the same hospitalization and recovery time as myomectomy. After the uterus is removed, a woman may not have any more children. If the ovaries are removed at the time of hysterectomy, a woman will enter into early menopause.
Hysterectomy may lead to bladder problems, even if none existed before surgery. Many women report a period of depression after this surgery. The uterus is intimately associated with feelings of sexuality and the possibility of bearing children. Patients should talk with friends who have had a hysterectomy before electing this final solution. Some women report a decreased sense of sexual arousal
DIFFERENT TYPES OF HYSTERECTOMIES
All hysterectomies are major operations involving removal of at least the uterus. Some types of hysterectomies involve removing other organs as well. It is important to talk with your doctor about the kind of hysterectomy recommended for you.
This operation involves removing both the body of the uterus and the cervix, which is the lower part of the uterus. The cervix is usually removed to prevent subsequent cervical cancer. It can sometimes be done through the vagina (vaginal hysterectomy); at other times, a surgical incision in the lower belly (abdominal hysterectomy) is preferable. For example, if you have large fibroid tumors, it is difficult to safely remove the uterus through the vagina.
Vaginal hysterectomy, when it can safely be performed, generally involves fewer complications, a shorter recovery period and no visible scar.
In a total hysterectomy and bilateral (both sides) salpingo-oophorectomy, the ovaries and fallopian tubes are removed, along with the uterus and cervix. "Complete hysterectomy," which is sometimes used to refer to this procedure, is not a medical term.
In this operation, only the upper part of the uterus is removed, but the cervix is not. Tubes and ovaries may or may not be removed. This procedure is always done through the abdomen.
This procedure is reserved for serious disease such as cancer. The entire uterus and usually both tubes and ovaries as well as the pelvic lymph nodes are removed through the abdomen. Since cancer is unpredictable, other organs or parts of other systems are sometimes removed as well.
Q. What is endometriosis?
A. Endometriosis is a disease characterized by the presence of tissue which is histologically identical to endometrium (the inner lining of the uterine wall) outside the uterine cavity. Usually, endometriosis is confined to the pelvic and lower abdominal cavity; however, it has occasionally been reported to be in other areas, as well.
Endometriosis is one of the most common problems that gynecologists currently face. It is one of the most complex and least understood diseases in our field and, despite many theories, we still do not have a clear understanding of the cause or of its relationship to infertility. Since this disorder is primarily a human disease and rare in other animal species, accumulation of the facts has been slow.
Although endometriosis has been considered a pathological or separate disease entity, it may not be a disease at all. It may actually be the clinical manifestation of a more basic underlying disorder, such as a basic chemical or physiological abnormality that affects the tubal motility or immune system which could be responsible for the initiation or progression of endometriosis in patients with retrograde menstrual flow. By the same token, endometriosis may not be the cause of infertility, but the result of it. Historically, it has been shown that sometimes our understanding of a disease has awaited the technology to explain it. This may very well be the case with endometriosis, especially in regard to its immunological aspects. Further technological developments may be necessary in order for us to fully understand this problem.
Q. How common is endometriosis?
A. In literature, the prevalence of this disease in the general population has been reported to be about five percent of the female population of reproductive age. However, in women with severe menstrual cramps, the incidence of endometriosis has been reported to be between 25 and 35 percent.
Q. Is there any age group which is more prone to endometriosis?
A. Endometriosis has been reported only in the reproductive ages, which means right after the start of the menstrual cycle until menopause or immediate post-menopausal years.
We believe that ovarian function is necessary for the development and maintenance of these endometrial implants. The disease is normally not seen before age 15 or after menopause. In recent years, we have seen more patients with endometriosis below the age of 20. This is due to the use of laparoscopy in evaluating women with symptoms suggestive of endometriosis.
In a recent study of 140 patients aged 10.5 years to 19 years who were complaining of severe pelvic pain, 47 percent had documented endometriosis at laparoscopy as the sole reason for their pelvic pain.
Q. Is endometriosis based on a genetic or familial factor?
A. Several studies have shown that the incidence of endometriosis is much higher in women having a sister or mother who has already had endometriosis. There was a study conducted involving more than 150 women with endometriosis; of these, 18 (12 percent) were found to have a mother or sister with endometriosis. However, in the same group of women, only two (1.5 percent) showed that they had a mother-in-law or sister-in-law who had endometriosis. This clearly shows that there is a familial tendency with endometriosis. As one can see from these figures, there is almost an eight-fold increase in the risk of endometriosis in women whose mother or sister has been diagnosed as having the disease.
Equally important was the finding that endometriosis on a familial basis tended to be at a more advanced stage when diagnosed and also that it acts more aggressively. It has been suggested that endometriosis might result from an inheritable immunodeficiency state.
Q. Is it true that women who have their tubes tied are protected against endometriosis?
A. Theoretically, blockage of the tubes by tubal ligation or by any other cause (for instance, pelvic inflammatory disease) should protect against the further production of endometriosis. However, a recent investigation of women requesting tubal ligation reversal has not supported this concept. The prevalence rates for endometriosis were found to range from 2 percent through 12 percent in two studies. When an infertile population is studied, these rates range from 5 percent through 35 percent.
Q. Is it true that intercourse during the menstrual cycle increases the risk of endometriosis?
A. This has not been proved. It has been suggested that intercourse during menses might increase tubal activity and increase the backflow of the menstrual cycle through the tubes and thus increase the risk of endometriosis. However, there are no statistics to bear this out.
Q. At the time of my laparoscopy, my doctor was not able to get a biopsy. Is the physical appearance of endometriosis adequate for diagnosis?
A. A biopsy of the lesion does document the presence of endometrial tissue. I believe that the gross appearance of endometriosis and visual inspection of the pelvis is adequate and accurate for diagnosis of endometriosis. However, before any treatment starts, the diagnosis should be confirmed by visual inspection. In a recent study in 86 patients with a visual diagnosis via laparoscopy, diagnosis was confirmed in 93 percent by biopsy. However, in those cases that were believed not to have endometriosis by visual inspection, only 6 percent had a tissue diagnosis of endometriosis confirmed.
It is also important that the surgeon you select is well educated in the appearance of endometrial lesions. Today, many surgeons will videotape the laparoscopy and this can be reviewed at a later date if there are any questions.
Q. Why does endometriosis seem to be discussed more in recent years?
A. Endometriosis is one of the most common gynecological diseases and is responsible for a significant portion of gynecological surgeries each year. Almost as important as the numbers is the fact that young women with endometriosis are often faced with difficult decisions regarding their future reproduction. One of the main symptoms or consequences of endometriosis is infertility, and since there has been a renewed interest in the United States in fertility, there has also been a renewed interest in this disease. The introduction of the laparoscope for more accurate diagnosis of endometriosis has also helped us to diagnose more cases in earlier stages in younger women.
The result of this increased attention is that more and more women are now forewarned about the symptoms of the disease.
Q. Is it true that endometriosis is more common in some races?
A. There seems to be some evidence among researchers that Caucasian women are at greater risk than blacks. Two studies have found the prevalence of endometriosis in blacks to be half that of whites. However, the notion that black women rarely suffer from endometriosis is incorrect. Some data shows that the risk of disease among Asian women is even higher than in Caucasians. There are also several studies which suggest that this disease is more common among higher socio-economic groups of women.
Q. Is there a characteristic menstrual cycle of the woman who has endometriosis?
A. Yes. Many studies have shown that women with endometriosis begin their menstrual cycle at a significantly younger age than women without the condition. Endometriosis is more prevalent in women who have a regular cycle than in women who have an irregular cycle. Another interesting characteristic is that patients with endometriosis have a shorter interval between their periods (less than 27 days). Severe menstrual cramps are also seen much more frequently in endometriosis.
It has been shown that the chance of having endometriosis is four times greater in patients with severe menstrual cramps as compared to women with mild menstrual cramps. Another point is that patients with a prolonged menstrual flow are apt to have endometriosis. It has also been found that if the menstrual flow is longer than a week, the risk of developing endometriosis is 2.5 times greater than in women who have a menstrual flow lasting less than a week.
It has been suggested that the total bulk of endometrial cells cast into the peritoneal cavity may be a factor. Women with a greater number of menstrual days (a factor of days of flow and cycle interval) had twice the risk of developing endometriosis.
Q. Is there a relationship between endometriosis and the use of tampons?
A. This is unlikely. Scientifically, there has not been any basis to conclude that the use of tampons increases the risk of developing endometriosis. Also, with regard to other hygienic practices (such as douching after the menstrual period), it has not been shown that this increases the risk of endometriosis.
Q. Do women with more menstrual cramps have a greater tendency to acquire endometriosis?
A. Although one of the most common characteristics of women with endometriosis is severe menstrual cramps, this appears to be the result of the disease rather than a precursor to it.
Q. If I put off having children until my 30s or later, do I have a greater chance of getting endometriosis? Also, is there any truth to the belief that delayed childbirth can lead to endometriosis?
A. This theory first surfaced in the early 1950s along with the idea that early childbearing offered protection against endometriosis. Although the incidence of endometriosis is higher in women who delay having their first child, this may be because of the fact that endometriosis causes infertility. It is therefore difficult to distinguish whether the infertility preceded or followed the endometriosis. We do believe, however, that pregnancy does have a protective effect on women with endometriosis.
Q. I have heard that career women have a higher chance or risk of developing endometriosis. Is there any truth to this?
A. At the present time there is no scientific justification that supports this theory, and it is more of a myth than a fact that endometriosis is primarily a disease of thin, Caucasian, career women with compulsive personalities.
Although there are studies that show women who exercise regularly had a lower risk of developing endometriosis than women who did not, the protective effect appeared to be confined to women who had begun their activity at an early age and who exercise more than two hours weekly. The types of activity most likely associated with decreased risk were conditioning exercises such as jogging. It is presumed that exercise may influence the risk of this disease through its effect on the level of hormones, such as estrogen, in the women's bodies.
Q. My mother used DES while she was pregnant with me. Does this use of DES in utero increase the risk of endometriosis?
A. At the present time, there is no clear study which can relate an increase in endometriosis incidence with DES exposure.
Q. Are you seeing more endometriosis in younger women today?
A. We are diagnosing this disease right now in a younger age group of women. Twenty-five years ago, our diagnosis was mainly based on severe symptoms and palpable masses in the pelvic area, and was confirmed by laparotomy. Patients were typically in their mid or late 30s. However, with the use of laparoscopy, the typical age at which the diagnosis is being made has dropped significantly. Currently, it is somewhere in the mid to late 20s. We are expecting a further decline in the average age of diagnosis because of the added knowledge of the disease in younger women and also the availability and increased use of laparoscopy in confirming diagnosis.
Q. Do you see endometriosis after menopause?
A. Normally, no. This is because the growth of endometrial implants are dependent upon the female hormone. After menopause, the ovaries cease to produce the hormones that promote the growth of endometriosis and we usually do not see many cases. However, after menopause, there are two factors which may promote or maintain endometriosis. One is the use of estrogen replacement therapy and the other is the presence of high endogenous estrogen in obese patients.
Q. Is endometriosis a disease of modern times?
A. The presence of endometrial tissue outside the uterus was first reported about 300 years ago in 1696 by Sabiard. However, since the turn of the century, and especially in the 1920s, it has been known that endometrial tissue outside of the uterus is responsible for painful menstruation, pelvic pain, pain with intercourse and infertility. The fact that we have been hearing more about endometriosis in the past two or three decades is, I think, due to more awareness by the public and physicians about the condition.
Today, physicians are looking more for this condition in patients who have pelvic pain, pain with menstruation and infertility. Also, there are better tools for diagnosing endometriosis, especially in the early stages. The primary tool was once only the pelvic examination, or at the time of surgery. However, with the use of laparoscopy, we are diagnosing this disease in women in earlier stages who have the above-mentioned symptoms.
Q. What does endometriosis look like?
A. The presence of endometriosis is characterized by blue-gray lesions on the peritoneal surface, over the pelvic peritoneum or pelvic structures. This distinct appearance can be attributed to the encapsulated menstrual blood and menstrual debris. However, the appearance is critically dependent upon the longevity of the tissue implanted. The initial appearance may be just an irregularity or discoloration of the peritoneal surface. Initially, these lesions may appear tan or hemorrhagic in color. After establishment of viable endometrial transplant and menstrual shedding, the presence of entrapped menstrual debris gives the tissue the typical blue-gray and powder burn appearance.
Many times the lesion of endometriosis may not have any color at all. These lesions are called nonpigmented endometriosis. Many experts believe that a young patient or a patient in the reproductive ages (15 to 50) who has an area on the peritoneal surface that does not look normal, and who is having symptoms of endometriosis (i.e., pelvic pain, pain with periods or intercourse, and infertility), should be considered as having endometriosis until it is proven otherwise.
Clinically, these early lesions, although less impressive than pigmented ones when viewed laparoscopically, are just as important in producing pain and infertility.
Q. What are the most common symptoms of endometriosis?
A. The symptoms of endometriosis may be highly variable from one patient to another. The magnitude of the symptoms may not correlate with the extent of the disease, either. For example, a patient with severe disease may have very little pain. However, the likelihood of infertility does increase as the severity of the disease increases. The clinical presentation and symptoms of the disease are also frequently related to the anatomical site of the disease.
The most common sites of the disease are the ovaries, the pelvic peritoneum, the cul-de-sac behind the uterus, the uterosacral ligament, and also the posterior surface of the uterus. The most common symptom is pelvic pain, which can be spontaneous, pain with menstruation or pain with intercourse. Other common symptoms are abnormal uterine bleeding, spotting prior to periods, and infertility.
Q. Do these endometrial implants or endometriosis act like normal endometrium inside the uterus?
A. Not always. Endometrial implants can undergo cyclic histological changes similar to those found in normal endometrium. This shows that in most cases, ectopic endometrium is responding to hormonal changes that occur in the female every month. The endometrial tissue in endometriosis also undergoes atrophy after menopause, or after prescription of the medication that stops ovarian function.
However, the response is not similar in all cases. One reason for this discrepancy is the finding that estrogen receptors have been identified in a minority of endometriotic tissues. Another possible answer to the discordancy between normal endometrium and endometriosis and the apparent failure of drug therapy in some women is the lack of enzymes in endometriotic tissue for hormonal actions.
Q. Why are ovaries the most common site of endometriosis?
A. If we accept the theory that retrograde menstruation is in large part responsible for the initiation of endometriosis in those women susceptible to the implantation of the endometrial cells, then the number one reason is the position of the ovary. The ovaries are adjacent to the opening of the tube in the pelvic area and that location alone will make the ovaries more prone to be contaminated with the regurgitated menstrual flow.
The other reason is that the ovaries have the highest level of steroid hormone compared to any other organ and hence they represent an ideal environment for implantation and growth of the endometrial tissue. In different studies, the involvement of the ovaries (either unilaterally or bilaterally) has been reported up to 75 percent of the time.
Q. What is a chocolate cyst?
A. Ovarian endometriosis probably starts as a surface lesion. The process becomes invasive and the endometriotic lesion internalizes into the ovarian tissue. Once the menstrual flow and debris collect at the site of endometriosis in the ovaries, endometrial cysts form that are filled with chocolate-colored liquid. These are commonly called chocolate cysts, or endometriomA. These are nothing more than cysts which represent debris from prolonged cyclic menstruation in an enclosed areA. These cysts may sometimes attain impressive size, with some documented as large as a baseball or grapefruit that completely obliterate the normal ovary. However, usually there is a well-demarcated separation between the cyst wall and the normal adjacent ovarian tissue.
Q. I was told that the changes in the peritoneal fluid due to endometriosis is one of the causes of my infertility. What does this mean?
A. Peritoneal fluid is the fluid which every person has in their abdominal cavity and which functions as a lubricant for the abdominal and pelvic organs. It has become apparent in the past decade or so that the presence of endometriosis is associated with changes in this peritoneal fluid, its volume, its cellular population and its biochemistry. Generally, it has been shown that the volume of the fluid is increased in women with endometriosis. The leukocytes have also been shown to be increased in number in the fluid of patients with endometriosis.
Also, the prostaglandin hormone concentration has been reported to be elevated in peritoneal fluid as well as the level of proteolytic enzymes which are all consistent with the localized inflammatory reaction around the endometriotic implants. Since these hormones could each alter the environment of the peritoneal fluid, which is in very close proximity to the ovaries and tubes, it can potentially alter their function. In recent studies, it has been shown that the peritoneal fluid in patients with endometriosis can act as a toxin to an embryo and may even stop the growth of the embryo in its early stages.
Q. What are the most common sites of endometriosis in the pelvic area?
A. If we accept the theory of retrograde menstruation as the main cause for the initiation of endometriosis, the ovaries are the most frequently involved organ (in 75 percent of cases) because of the unique characteristics of their site. The next most common areas are the posterior cul-de-sac (70 percent of cases), the area between the uterus and the bowel, and the anterior fold of the uterus between the uterus and the bladder (35 percent of cases). Presumably, this is due to the effects of gravity. The next most common area is the posterior aspect of the pelvic wall and the uterosacral ligaments (35 percent) which are attached behind the uterus. The ureters are the most commonly affected pelvic organs also due to their site, which is again sitting close to the ovarian bed or opening of the tube to the pelvis. The next most common sites are the uterus (10 percent), the tubes, the sigmoid colon and the appendix. Due to high motility and active peristalsis, the small bowel is the least frequent organ involved in endometriosis (less than one percent).
Q. What are the other common areas outside of the pelvis where we find endometriosis?
A. Endometriosis has been found in the appendix (2 - 5 percent of cases), large bowel (3 to 4 percent of cases) and the small bowel (less than one percent of cases). Much less frequently, we find endometriosis in the gall bladder, stomach, spleen and liver.
Q. I was told that I have endometriosis on my incision where I had a Cesarean section. How is this possible?
A. At the time of a C-section, pieces of the uterine lining could be transplanted in the incision and start growing. In a recent study of 56 cases of endometriosis in surgical sites, almost half of the cases followed a C-section. These lesions cause local cyclical pain and, on occasion, even cyclical bleeding. Treatment is obviously surgical removal of the involved area.
Q. What are pelvic adhesions? Why do people with endometriosis have adhesions?
A. Scarring of the peritoneum around endometriosis is a typical and very common finding. The explanation for this is that the bleeding that occurs around each menstrual cycle gets collected, and since there is no escape for this blood, it will start irritating the adjacent peritoneal surface, then start producing irritation and inflammation and eventually, scarring. These adhesions are most common in the immobile pelvic structures, and are most commonly found in the pelvic sidewalls, behind the uterus, between the sigmoid bowel or colon, and on the posterior aspect of the uterus and cervix.
Q. If the retrograde flow of menstrual bleeding through the fallopian tube is a major mechanism for endometriosis, why don't all women have endometriosis?
A. Although some degree of menstrual backflow occurs almost universally, only those women who are predisposed to having endometriosis will allow the cells to implant in the pelvic areA. Patients who have some deficiency in their immunological system, women who have more frequent periods (shorter than 27 days), or women who have longer days of bleeding with their period (more than 7 days) are more prone to develop endometriosis.
Q. Is there any evidence that viable cells are in the menstrual flow?
A. Yes. The presence of viable endometrial cells in the menstrual flow has been demonstrated by culturing the menstrual flow and obtaining tissue cultures. Other evidence has been the presence of viable endometrial cells in the fallopian tube. Endometrial cells which have been obtained from the menstrual flow have been demonstrated to be plantable to other areas of the abdomen (i.e., the abdominal wall).
Other evidence supporting this theory is that endometriosis is extremely common at the site of the menstrual blood flow through the tube into the peritoneal cavity; for example, the pelvic sidewall next to or adjacent to the tube and the ovarian surface. Another interesting point is that the mobile pelvic structures, such as the bowel or fallopian tubes themselves, are less likely to allow attachment of transplanted endometrial cells, whereas fixed structures are anticipated and also have been shown to have a higher frequency of having these implants on them.
After reviewing all of these reasons, it becomes obvious that the preponderance of evidence suggests that endometriosis is a consequence of implantation of viable endometrial cells through the fallopian tubes at the time of menses.
Q. Are there any other theories as to how endometriosis is developed besides this backflow theory?
A. Other theories for how endometriosis comes about include the following:
1. Spread of endometrial cells to other areas of the pelvis or other organs through the lymphatic channels.
2. Spread of endometrial cells through the blood vessels. The presence of many cases of endometriosis which have been reported in the lung, skin, thigh and extremities can be explained by this mode of transport.
3. Spread of endometrial cells through surgery. For example, at the time of cesarean section, some of the endometrial tissue can be spread or trapped in the abdominal wall and produce endometriosis in the future.
Q. Are there any women who are more prone to have endometriosis?
A. Yes. Women in the reproductive age group are more prone to have endometriosis.
Endometriosis is also common in women who have had uninterrupted cyclic menstruation for periods of more than five years. By this, I mean a woman who has had a period every month for five years which has not been interrupted by pregnancy. Endometriosis is less commonly seen in women with irregular cycles who are not ovulatory (not producing an egg), and in women who have stopped their regular cyclic period by any means such as pregnancy and lack of ovulation. Giving medication to produce pseudo-pregnancy or pseudo-menopause can stop the growth of endometriosis and give clinical improvement to the patient. Frequent pregnancies, especially those initiated early in the menstrual life (during the teen years), seem to insulate women against endometriosis, at least temporarily. Also, we have seen that endometriosis occurs more frequently in some families than in others.
Q. How old is the disease?
A. Theoretically, endometriosis should have existed since the beginning of time. However, the first description was about 300 years ago and the first detailed description was in 1860 by a physician named Von Rokitansky.
Our modern-day understanding of endometriosis began with the pioneering efforts of a private physician named Sampson in Albany, New York, in the 1920s. Dr. Sampson proposed that the menstrual backflow through the tubes contained viable endometrial cells which could be transplanted to ectopic sites.
Between 20 percent and 40 percent of women past age 35 have fibroids. These are noncancerous tumors of the uterus that appear during your childbearing years. Also called myomas, fibromyomas or leiomyomas, fibroids can appear on the inside or outside lining of your uterus, or within its muscular wall. They usually develop from a single smooth muscle cell that continues to grow.
You may have a single fibroid or several. Fibroids can range from pea sized to the size of a grapefruit. Although most fibroids remain small, their growth can be unpredictable. Some grow slowly, while others may grow very quickly. Most of the time, however, fibroids aren't dangerous. They are not associated with an increased risk of uterine cancer and almost never develop into cancer.
If you have uterine fibroids, you may not know it. At least half of all women with fibroids have no symptoms. In fact, most fibroids are discovered during a routine pelvic exam or during prenatal care. The most common symptoms of fibroids include:
MRKH stands for Mayer-Rokitansky-Kuster-Hauser Syndrome, named after four men who studied this birth defect. It is a defect wherein a woman is born without a uterus, cervix, and, in many cases, a vagina, and therefore cannot reproduce. The woman is also likely to be missing one kidney.
How do you "get" MRKH?
How do you know you have it?
MRKH is usually diagnosed when the girl reaches sixteen or thereabouts and never gets her period.
How many women have MRKH?
No exact figures are known, as the defect often goes unnoticed by anyone outside of the immediate family of the woman. Figures range from one in ten thousand to one in a million. . Other problems may include kidney problems, skeletal problems and/or hearing loss. Not all women have all of these symptoms. There are many treatments available to these women who want to create a vagina. Some have surgery to create a vagina. Some use dilators to stretch the short vagina to the proper length. The dilators are devices that are inserted into the vagina to apply pressure to the lengthen the vagina. Dilation usually has great results, but does take time. Most women are able to have normal sexual relationships after treatment to create a vagina. The Women can also choose no treatment at all. These women do not "need" to have treatment, only if they choose to do so. Most women with the help of medical technology are able to have their own familys. While many adopt, many now are able to have genetic children through Surrogacy.
What is lupus?
Lupus is a chronic (long-lasting) autoimmune disease where the immune system, for unknown reasons, becomes hyperactive & attacks normal tissue. This attack results in inflammation & brings about symptoms.
What are the different kinds of lupus?
Discoid lupus (also known as Cutaneous lupus) affects the skin.
Systemic lupus attacks multiple systems in the body which may include- the skin, joints, blood, lungs, kidneys, heart, brain & nervous system.
Drug-induced lupus may develop after taking certain prescription medications. Symptoms generally disappear after the drug is discontinued.
What are the symptoms of systemic lupus?
The symptoms can include- Arthritis (swelling and pain of the joints), muscle pain and weakness, fatigue, sun-sensitivity, hair loss, "Butterfly" or malar rash (a rash across the nose and cheeks), fever, anaemia, headaches, recurrent miscarriages. For more symptoms & descriptions of symptoms see the symptoms page. Some people will have only a few symptoms, others may have them all.
What causes lupus?
The exact cause is unknown, but it is likely to be a combination of factors. A person's genetic make-up & exposure to certain trigger factors may provide the right environment in which lupus can develop.
How common is lupus?
It is not known why, but lupus occurs more often in certain ethnic groups. The incidence in Caucasians is approx. 1:1000. In African-Americans, the incidence is approx. 1:250. In Latinos the incidence is approx. 1:500.
What are antiphospholipid antibodies?
There are several kinds of antiphospholipid antibodies. The most widely measured are the lupus anticoagulant and anticardiolipin antibody. These antibodies react with phospholipid, a type of fat molecule that is part of the normal cell membrane. Lupus anticoagulant and anticardiolipin antibody are closely related, but are not the same antibody. This means that someone can have one and not the other. There are other antiphospholipid antibodies, but they are not commonly measured.
How successful is treatment in people with lupus who have had a miscarriage in association with these antibodies?
The treatment of pregnant women with antiphospholipid antibodies to prevent a possible miscarriage is not well understood at the current time. Some women are helped by combinations of aspirin, Prednisone, and/or subcutaneous heparin, whereas other women continue to have miscarriages even when they are taking these medications. Subcutaneous heparin is less likely than Prednisone to cause diabetes and an increase in blood pressure during pregnancy. Other treatments, including plasmapheresis or intravenous gammaglobulin, may be considered in individual cases.
What is the major cause of female infertility?
An investigational drug that helps insulin function more efficiently also appears to assist in treating infertility in women with polycystic ovary syndrome (PCOS). PCOS is the most common cause of female infertility. The drug, D-chiro-inositol occurs naturally in fruits and vegetables and appears to have no side effects in the small number of women with PCOS who took part in the trial.
PCOS affects 5-10% of American women of reproductive age. The ovaries of women with PCOS appear to be filled with numerous small cysts. The cyst-like appearance results from accumulation of immature ovarian follicles, the bubble-like structures that, upon maturation, rupture and give rise to the egg cell.
PCOS may cause those women who fail to ovulate or menstruate to have abnormally high insulin levels, obesity, high blood pressure, hardening of the arteries, or high triglyceride levels. PCOS patients have high levels of testosterone, which may cause them to grow excess facial hair or body hair.
Current findings of the study suggest that PCOS results from failure to use insulin properly. Dr. John E. Nestler, Chairman of Endocrinology at University of Virginia Medical College in Virginia, believes this failure causes insulin to rise. The high testosterone levels will halt egg maturation and interfere with menstrual cycles.
Researchers followed 44 obese women with PCOS; half received D-chiro-inositiol and half received a placebo. Of the 22 women who received the drug, 86% ovulated, compared with only 27% in the placebo group. Women receiving the drug also saw improvements in their insulin levels, blood sugar, blood pressure, testosterone, and triglyceride levels.
For pregnancy to occur, several things must happen: an egg must develop and ovulate properly each month, and a sperm must fertilize the ovulated egg. The resulting embryo must be transported to the uterus and implanted.
If any of these events does not occur or is disrupted, infertility will result. Some women are unable to produce eggs. Others produce eggs, but do not ovulate. In others, conception cannot occur due to blockage of the fallopian tubes, scarring of the uterus, or the inability to produce cervical mucous of sufficient quantity or quality. These problems account for just over half of all infertility.
How is female infertility treated?
Many treatments are available, depending on the cause of the infertility, and it is always important to investigate both partners. Fertility drugs such as clomiphene citrate or recombinant human FSH (follicle stimulating hormone) may bring about ovulation in women. Insemination directly into the uterus can manage infertility related to problems in the cervical mucous. Blocked fallopian tubes can sometimes be surgically repaired. In-vitro fertilization, with a surrogate mother and related assisted reproductive technologies are the most dramatic treatments for female infertility. Although these techniques may be time-consuming and costly, they offer hope to many women who previously were unable to conceive.
For most people, infertility conjures up the image of a couple without a child. But what about the couple who has borne a child, and now wants to extend their family but find they are unable to do so?
Secondary infertility, is the inability to conceive after one or more successful pregnancies. The medical causes are similar to those of primary infertility, and include sperm problems, tubal factors, endometriosis, and ovulation difficulties. However, there are differences. For one thing, the couple is older, which is why time is at a premium!
Moreover, there are emotional aspects that are unique. The couple experiencing secondary infertility often finds it difficult to gain understanding or sympathy from family, friends and relatives. Since they have one child, most people assume that the couple will have no problem having another. Even other infertile couples offer little sympathy! Patients with primary infertility often resent couples who have a baby, and believe their own pain would disappear if only they too could bear one child. A common remark is, "You have one child, you should be grateful for that." These couples are caught between two worlds, fertile and infertile - and are excluded from both!
Guilt and frustration are common emotional responses. The frustration is borne out of surprise because the couple didn't think it would be difficult to conceive a second time (unless they had difficulty in getting pregnant the first time as well). However, just because they have got pregnant once doesn't make them immune to all the illnesses which can cause infertility - and tubes can get blocked and sperm counts drop as time goes by!
Secondarily infertile couples who had an elective abortion done for the first pregnancy and cannot conceive a second time around have a very hard time coping with their feelings of guilt. They often feel they are being punished for their sin of rejecting the child when they had it.
Couples with a child at home may also feel guilty. This arises because they catch themselves feeling that their one child isn't good enough for them; and also for their inability to provide their child with a sibling.
The child of a secondarily infertile couple may also bring unwitting pressure on his parents by asking when he 'll have a baby brother or sister. This is especially difficult when the child is being asked by his friends why he doesn't have a baby brother or sister and then begs his parents for a baby.
Parents may become very overprotective, fearing that something may happen to the one child they do have. They may also push pin all their hopes on their one child, and may push him to be a high achiever.
Many couples with secondary subfertility choose never to take medical treatment; often, this is because they are unsure about whether they do have a problem - and they keep on trying, hoping to hit the jackpot once again (after all, if they could do it once, why can't they do it again?)
What are the chances of a couple with secondary subfertility conceiving with medical treatment? While this would depend on the individual's problem, their chances are really about the same as a couple with primary subfertility. While they have the benefit of having "proven" their fertility once, they usually have the handicap of an increased age against them.
If the couple chooses to seek medical intervention, they also must decide what to tell their child about medical procedures. The presence of a child at home can make coping with the demands of infertility treatment much more difficult!
The financial burden of taking treatment can also add to the emotional burden of the couple and they may wonder if they shouldn't be spending the money on the child they already have rather than pursuing the hope of expanding their family.
Adoption can be a choice for some of these couples - but it's often more complicated because they worry about the possibility of "favoritism" ; and may also feel that it is unfair to their biological child to bring an adopted child into the family. Surrogacy, however, gives couples a chance to have another biological child from at least one of the parents.
Coming to terms with secondary infertility is no easier than coming to terms with primary infertility - and it's important that the family of the secondarily infertile couple share their feelings together and maintain a positive attitude.
An abortion after which some tissue remains inside the uterus. A D&C must be performed to remove the tissue and prevent complications.
An abortion where the fetus dies in the uterus but there is no bleeding or cramping. A D&C will be needed to remove the fetal remains and prevent complications.
A pregnancy loss during the first twenty weeks of gestation.
A procedure used to terminate a pregnancy before the fetus can survive on its own.
Spotting or bleeding that occurs early in the pregnancy. May progress to spontaneous abortion.
A hormone produced by the pituitary gland to stimulate the adrenal glands. Excessive levels may lead to fertility problems.
Scar tissue occurring in the abdominal cavity, fallopian tubes, or inside the uterus. Adhesions can interfere with transport of the egg and implantation of the embryo in the uterus.
Male hormones produced by the adrenal gland which, when found in excess, may lead to fertility problems in both men and women. Excess androgens in the woman may lead to the formation of male secondary sex characteristics and the suppression of LH and FSH production by the pituitary gland. Elevated levels of androgens may be found in women with polycystic ovaries, or with a tumor in the pituitary gland, adrenal gland, or ovary. May also be associated with excess prolactin levels.
Alpha-fetoprotein Test (AFP):
A blood test performed to evaluate the development of the fetus and to look for fetal abnormalities.
AID (Artificial Insemination Donor):
See Artificial Insemination Donor.
AIH (Artificial Insemination Homologous):
See Artificial Insemination Homologous.
Refers to a woman who has never had a period.
A term describing a woman who has menstruated at one time, but who has not had a period for six months or more.
Male sex hormones.
A physician-scientist who performs laboratory evaluations of male fertility. May hold a Ph.D. degree instead of an M.D. Usually affiliated with a fertility treatment center working on in vitro fertilization.
A life-threatening eating disorder; self-imposed starvation. Severe weight loss and malnutrition from this disorder cause anovulation.
The failure to ovulate; ovulatory failure.
Chemicals made by the body to fight or attack foreign substances entering the body. Normally they prevent infection; however, when they attack the sperm or fetus, they cause infertility. Sperm antibodies may be made by either the man or the woman.
Antibodies are produced by the immune system to fight off foreign substances,like bacteria. Antisperm antibodies attach themselves to sperm and inhibit movement and their ability to fertilize.
Artificial Insemination (AI):
The depositing of sperm in the vagina near the cervix or directly into the uterus, with the use of a syringe instead of by coitus. This technique is used to overcome sexual performance problems, to circumvent sperm-mucus interaction problems, to maximize the potential for poor semen, and for using donor sperm. See also Artificial Insemination Donor; Artificial Insemination Homologous.
Artificial Insemination Donor (AID):
Artificial insemination with donor sperm. A fresh donor semen specimen or a thawed frozen specimen is injected next to the woman's cervix.
Artificial Insemination Homologous (AIH):
Artificial insemination with the husband's sperm. The sperm may be washed and injected directly into the wife's uterus (IAIH). Often used with poor semen or to overcome sperm-mucus problems.
An artificial, surgically created pouch used to collect sperm from men with irreversible tubal blockage.
A condition where the uterine walls adhere to one another. Usually caused by uterine inflammation.
Assisted Reproductive Technology (ART):
Several procedures employed to bring about conception without sexual intercourse, including IUI, GIFT and ZIFT.
Low sperm motility.
Semen containing no sperm, either because the testicles cannot make sperm or because of blockage in the reproductive tract.
Bacterial Vaginosis Infection:
A vaginal infection that causes a burning sensation and a gray, malodorous discharge. May interfere with fertility.
Basal Body Temperature (BBT):
Your body temperature when taken at its lowest point, usually in the morning before getting out of bed. Charting BBT is used to predict ovulation.
Basal Body Temperature, Biphasic:
A basal body temperature pattern consistent with ovulation and the formation of the corpus luteum, which secretes progesterone. This hormone will elevate the basal body temperature about one-half degree during the latter half of the menstrual cycle.
Basal Body Temperature, Monophasic:
An anovulatory basal body temperature pattern where the temperature remains relatively constant throughout the cycle.
Beta hCG Test:
A blood test used to detect very early pregnancies and to evaluate embryonic development.
A congenital malformation of the uterus where the upper portion (horn) is duplicated.
An oral medication used to reduce prolactin levels and reduce the size of a pituitary tumor when present. This medication often causes dizziness and upset stomach and must be started with a small dose which is gradually increased as needed. This medication is equally effective when the tablet is placed into the vagina.
An eating disorder characterized by voracious eating followed by forced vomiting. The resulting weight loss and malnutrition may cause anovulation.
A long-acting GnRH available in Europe as a nasal spray and used to create the pseudomenopause desirable for reducing the size and number of endometriotic lesions. It can also be used to treat fibroid tumors, PMS, hirsutism, ovulation induction and for in vitro fertilization.
An infection that may be uncomfortable and itchy and may impair fertility.
A process that sperm undergo as they travel through the woman's reproductive tract. Capacitation enables the sperm to penetrate the egg.
To burn tissue with electrical current (electrocautery) or with a laser. Used in surgical procedures to remove unwanted tissue such as adhesions and endometrial implants. Also used to control bleeding.
A viscous fluid plugging the opening of the cervix. Most of the time this thick mucus plug prevents sperm and bacteria from entering the womb. However, at midcycle, under the influence of estrogen, the mucus becomes thin, watery, and stringy to allow sperm to pass into the womb. See also Cervix
A sample of the cervical mucus examined microscopically to assess the presence of estrogen (ferning) and white blood cells, indicating possible infection.
A blockage of the cervical canal from a congenital defect or from complications of surgical procedures. See also Cervix.
The opening between the uterus and the vagina. The cervical mucus plugs the cervical canal and normally prevents foreign materials from entering the reproductive tract. The cervix remains closed during pregnancy and dilates during labor and delivery to allow the baby to be born.
A weakened cervix, which opens up prematurely during pregnancy and can cause the loss of the fetus. A CERVICAL CERCLAGE is a procedure in which a stitch or two is put around the cervix to prevent its opening until removed when the pregnancy is to term.
A cyst in the ovary that is filled with old blood; endometrioma. Occurring when endometriosis invades an ovary, it causes the ovary to swell. Frequently, patients with large endometriomas do not have any symptoms. If the cyst ruptures or the ovary containing the cyst twists, emergency surgery may be necessary. Usually treatment can be carried out through the laparoscope.
The structures in the cell that carry the genetic material (genes); the genetic messengers of inheritance. The human has forty-six chromosomes, twenty-three coming from the egg and twenty-three coming from the sperm.
Tiny hairlike projections lining the inside surface of the fallopian tubes. The waving action of these "hairs" sweeps the egg toward the uterus.
The small erectile sex organ of the female which contains large numbers of sensory nerves; the female counterpart of the penis.
Clomiphene Citrate (Clomid, Serophene):
A fertility drug that stimulates ovulation through the release of gonadotropins from the pituitary gland."
Intercourse; the sexual union between a man and a woman.
The early products of conception; the embryo and placenta.
Therapy prescribed to reduce the number of sperm antibodies in the woman by using a condom during intercourse for six months or more and by the woman refraining from all skin contact with the husband's sperm. The woman's antibody level may fall to levels that will not adversely affect the sperm.
A surgical procedure used to remove precancerous cells from the cervix. The procedure may damage the cervix and thus disrupt normal mucus production or cause an incompetent cervix, which may open prematurely during pregnancy.
Congenital Adrenal Hyperplasia:
A congenital condition characterized by elevated androgens which suppress the pituitary gland and interfere with spermatogenesis or ovulation. Women may have ambiguous genitalia from the excess production of male hormone.
A congenital condition characterized by elevated androgens which suppress the pituitary gland and interfere with spermatogenesis or ovulation. Women may have ambiguous genitalia from the excess production of male hormone.
A medication that prevents ovulation and pregnancy. Up to 3 percent of women taking the Pill will become anovulatory when they stop taking it. The regulatory effects of the Pill can also disguise symptoms of fertility problems-- for example, an irregular cycle or endometriosis. May be used to control the symptoms and development of endometriosis.
The yellow-pigmented glandular structure that forms from the ovarian follicle following ovulation. The gland produces progesterone, which is responsible for preparing and supporting the uterine lining for implantation. Progesterone also causes the half-degree basal temperature elevation noted at midcycle during an ovulatory cycle. If the corpus luteum functions poorly, the uterine lining may not support a pregnancy. If the egg is fertilized, a corpus luteum of pregnancy forms to maintain the endometrial bed and support the implanted embryo. Picture of a corpus luteum. A deficiency in the amount of progesterone produced (or the length of time it is produced) by the corpus luteum can mean the endometrium is unable to sustain a pregnancy. This is called Luteal Phase Defect (LPD).
The protective layer of cells surrounding the egg.
A condition characterized by an overproduction of adrenal gland secretions. The person will suffer from high blood pressure and water retention as well as a number of other symptoms. A concurrent elevation of adrenal androgens will suppress pituitary output of LH and FSH and result in low sperm production or ovulatory failure. A woman may also develop male secondary sex characteristics, including abnormal hair growth. Cushing's Disease is another condition in which these same symptoms occur, but as the result of a pituitary tumor.
D&C (Dilation and Curettage):
A procedure used to dilate the cervical canal and scrape out the lining and contents of the uterus. The procedure can be used to diagnose or treat the cause of abnormal bleeding and to terminate an unwanted pregnancy.
A medication used to treat endometriosis. Suppresses LH and FSH production by the pituitary and causes a state of amenorrhea during which the endometrial implants waste away. Many women experience oily skin, acne, weight gain, abnormal hair growth, deepening of the voice and muscle cramps with this medication.
A condition in which the man fakes orgasm and does not actually ejaculate when having sex.
A condition in which the youngster fails to complete puberty and develop secondary sex characteristics by sixteen years of age. Puberty may be stimulated with hormonal replacement therapy. Some will outgrow the condition without treatment.
A medication prescribed in the 1950s and 1960s to women to prevent miscarriage. Male and female fetuses exposed in utero to this drug developed numerous deformities including blockage of the vas deferens, uterine abnormalities, cervical deformities, miscarriages, and unexplained infertility. DES is no longer prescribed for this indication.
See Adrenal Androgens.
A tetracycline derivative; an antibiotic that inhibits many of the microorganisms infecting the reproductive tract. Often used for treating ureaplasma infections. Many physicians find routine treatment with this antibiotic more cost-effective than performing multiple cultures on both the husband and wife looking for infection.
Painful menstruation. This may be a sign of endometriosis.
Painful coitus for either the man or the woman.
A pregnancy outside of the uterus, usually in the fallopian tube. Such a pregnancy can rarely be sustained, and often leads to decreased or complete loss of function in the affected tube. Methotrexate is now used to dissolve the pregnancy without causing major damage to the tube.
A procedure used to obtain eggs from ovarian follicles for use in in vitro fertilization. The procedure may be performed during laparoscopy or by using a long needle and ultrasound to locate the follicle in the ovary.
The semen and sperm expelled during ejaculation.
The physiological process by which the semen is propelled from the testicles, through the reproductive tract, and out the opening of the penis.
The early products of conception; the undifferentiated beginnings of a baby; the conceptus.
Placing an egg fertilized outside the womb into a woman's uterus or fallopian tube.
Empty Sella Syndrome:
A condition that occurs when spinal fluid leaks into the bony chamber (fossa) housing the pituitary gland. The fluid pressure compresses the pituitary gland and may adversely affect its ability to secrete LH and FSH and may elevate prolactin levels.
A test to check for Luteal Phase Defect. A procedure during which a sample of the uterine lining is collected for microscopic analysis. The biopsy results will confirm ovulation and the proper preparation of the endometrium by estrogen and progesterone stimulation
A condition where endometrial tissue is located outside the womb. The tissue may attach itself to the reproductive organs or to other organs in the abdominal cavity. Each month the endometrial tissue inbreeds with the onset of menses. The resultant irritation causes adhesions in the abdominal cavity and in the fallopian tubes. Endometriosis may also interfere with ovulation and with the implantation of the embryo.
The lining of the uterus which grows and sheds in response to estrogen and progesterone stimulation; the bed of tissue designed to nourish the implanted embryo.
Natural narcotics manufactured in the brain to reduce sensitivity to pain and stress. May contribute to stress-related fertility problems.
A coiled, tubular organ attached to and lying on the testicle. Within this organ the developing sperm complete their maturation and develop their powerful swimming capabilities. The matured sperm leave the epididymis through the vas deferens.
The process during which the erectile tissue of the penis becomes engorged with blood, causing the penis to swell and become rigid.
The female hormone produced in the ovary. Responsible for formation of the female secondary sex characteristics such as large breasts; supports the growth of the follicle and the development of the uterine lining. At midcycle the peak estrogen level triggers the release of the LH spike from the pituitary gland. The LH spike is necessary for the release of the ovum from the follicle. Fat cells in both obese men and women can also manufacture estrogen from androgens and interfere with fertility.
Female sex hormone.
Expectant Therapy (Endometriosis):
A wait-and-see approach used after laparoscopic surgery for mild endometriosis.
Ducts through which eggs travel to the uterus once released from the follicle. Sperm normally meet the egg in the fallopian tube, the site at which fertilization usually occurs.
Female Kallman's Syndrome:
A condition characterized by infantile sexual development and an inability to smell. Since the pituitary cannot produce LH and FSH, the woman must take hormone supplements to achieve puberty, to maintain secondary sex characteristics, and to achieve fertility.
A pattern characteristic of dried cervical mucus viewed on a slide. When the fern pattern appears, the mucus has been thinned and prepared by estrogen for the passage of sperm. If it does not fern, the mucus will be hostile to the passage of the sperm.
A rare disorder characterized by an LH deficiency leading to low testosterone levels and poor sperm production. Male secondary sex characteristics will be incomplete and sex drive will be low.
A physician specializing in the practice of fertility. The American Board of Obstetrics and Gynecology certifies a subspecialty for OB-GYNs who receive extra training in endocrinology (the study of hormones) and infertility.
Any method or procedure used to enhance fertility or increase the likelihood of pregnancy, such as ovulation induction treatment, varicocoele repair, and microsurgery to repair damaged fallopian tubes. The goal of fertility treatment is to help couples have a child.
The initial medical examinations and tests performed to diagnose or narrow down the cause of fertility problems.
The combining of the genetic material carried by sperm and egg to create an embryo. Normally occurs inside the fallopian tube (in vivo) but may also occur in a petri dish (in vitro). See also In Vitro Fertilization.
A term used to refer to a baby during the period of gestation between eight weeks and term.
Fibroid (Myoma or Leiomyoma):
A benign tumor of the uterine muscle and connective tissue.
The opening of the fallopian tube near the ovary. When stimulated by the follicular fluid released during ovulation, the fingerlike ends grasp the ovary and coax the egg into the tube.
A normal tube and ovary as seen at laparoscopy.
Fluid-filled sacs in the ovary which contain the eggs released at ovulation.
Each month an egg develops inside the ovary in a fluid filled pocket called a follicle. This follicle is one inch in size and is about ready to ovulate.
The fluid inside the follicle that cushions and nourishes the ovum. When released during ovulation, the fluid stimulates the fimbria to grasp the ovary and coax the egg into the fallopian tube.
Follicle Stimulating Hormone (FSH):
A pituitary hormone that stimulates spermatogenesis and follicular development. In the man FSH stimulates the Sertoli cells in the testicles and supports sperm production. In the woman FSH stimulates the growth of the ovarian follicle. Elevated FSH levels are indicative of gonadal failure in both men and woman.
The pre-ovulatory portion of a woman's cycle during which a follicle grows and high levels of estrogen cause the lining of the uterus to proliferate. Normally takes between 12 and 14 days.
A clear or milky discharge from the breasts associated with elevated prolactin.
A reproductive cell:Sperm in men, the egg in women.
Gamete Intrafallopian Transfer (GIFT):
A technique that may be used in lieu of in vitro fertilization for women with patent tubes. After egg retrieval the eggs are mixed with the husband's sperm and then injected through the fimbria into the woman's fallopian tubes for in vivo fertilization.
The external sex organs, as the labia and clitoris in the woman and the penis and testicles in the man. Also called genitalia.
In the male the testicular cell that divides to produce the immature sperm cells; in the woman the ovarian cell that divides to form the egg (ovum). The male germ cell remains intact throughout the man's reproductive life; the woman uses up her germ cells at the rate of about one thousand per menstrual cycle, although usually only one egg matures each cycle.
Germ Cell Aplasia (Sertoli Cell Only):
An inherited condition in which the testicles have no germ cells. Since men with this condition have normal Leydig cells, they will develop secondary sex characteristics. May also be caused by large and/or prolonged exposure to toxins or radiation.
Hormones which control reproductive function: Follicle Stimulating Hormone and Lutenizing Hormone.
Gonadotropin Releasing Hormone (GnRH):
A substance secreted by the hypothalamus every ninety minutes or so. This hormone enables the pituitary to secrete LH and FSH, which stimulate the gonads. See also FSH; LH.
The gland that makes reproductive cells and "sex" hormones, as the testicles, which make sperm and testosterone, and the ovaries, which make eggs (ova) and estrogen.
An infection that is usually asymptomatic, but that may cause a bad-smelling yellowish vaginal discharge and red and swollen vaginal walls. If it reaches the fallopian tubes, the woman will suffer pain, develop a high fever, and possibly develop tubal blockage. The responsible organism may also impair sperm and prevent pregnancy. In the man gonorrhea seldom leads to damage, but it may cause a painful infection.
A test of the ability of sperm to penetrate a hamster egg which has been stripped of the Zona Pellucida (outer membrane). Also called SPERM PENETRATION ASSAY (SPA).
The overabundance of body hair, such as a mustache or pubic hair growing upward toward the navel, found in women with excess androgens.
Also called a "surrogate gestational mother." A couple's embryo is transferred to another woman who carries the pregnancy to term and returns the baby to the genetic parents immediately after birth.
Cervical mucus that impedes the natural progress of sperm through the cervical canal.
Human Chorionic Gonadotropin (HCG):
The hormone produced in early pregnancy which keeps the corpus luteum producing progesterone. Also used via injection to trigger ovulation after some fertility treatments, and used in men to stimulate testosterone production.
Human Menopausal Gonadotropin (HMG - PERGONAL, HUMEGON):
A combination of hormones FSH and LH, which is extracted from the urine of post-menopausal women. Used to induce ovulation in several fertility treatments.
The lutenizing and follicle-stimulating hormones recovered from the urine of post-menopausal women. Used to stimulate multiple ovulation in some fertility treatments.
A condition in which the pituitary gland secretes too much prolactin. Prolactin can suppress LH and FSH production, reduce sex drive in the man, and directly suppress ovarian function in the woman.
Hyperstimulation (Ovarian Hyperstimulation Syndrome, OHSS):
A potentially life-threatening side effect of Pergonal ovulation induction treatment. Arises when too many follicles develop and hCG is given to release the eggs. May be prevented by withholding the hCG injection when ultrasound monitoring indicates that too many follicles have matured.
Overproduction of thyroid hormone by the thyroid gland. The resulting increased metabolism "burns up" estrogen too rapidly and interferes with ovulation..
Having lower than normal levels of estrogen.
A spectrum of diseases resulting in low pituitary gland output of LH and FSH. Men with this disorder have low sperm counts and may lose their virility; women do not ovulate and may lose their secondary sex characteristics.
Low sperm production.
A part of the brain, the hormonal regulation center, located adjacent to and above the pituitary gland. In both the man and the woman this tissue secretes GnRH every ninety minutes or so. The pulsatile GnRH enables the pituitary gland to secrete LH and FSH, which stimulate the gonads. See also FSH; LH; Ovary; Pituitary Gland; Testicle.
A condition in which the thyroid gland produces an insufficient amount of thyroid hormone. The resulting lowered metabolism interferes with the normal breakdown of "old" hormones and causes lethargy. Men will suffer from a lower sex drive and elevated prolactin (see Hyperprolactinemia), and women will suffer from elevated prolactin and estrogen, both of which will interfere with fertility.
The surgical removal of the uterus. May also include the removal of other reproductive structures, such as the fallopian tubes and ovaries.
An x-ray of the pelvic organs in which a radio-opaque dye is injected through the cervix into the uterus and fallopian tubes. This test checks for malformations of the uterus and blockage of the fallopian tubes.
A procedure in which the doctor checks for uterine abnormalities by inserting a fiber-optic device. Minor surgical repairs can be executed during the procedure.
IAIH (Intrauterine Artificial Insemination Homologous):
Artificial insemination where the husband's sperm is injected directly into the uterus to avoid cervical mucus problems or to maximize the potential for poor semen. See also Artificial Insemination.
See also Intracytoplasmic Sperm Injection
Immature Sperm (Germinal Cell):
A sperm that has not matured and gained the ability to swim. In the presence of illness or infection such sperm may appear in the semen in large numbers. Imperforate Hymen: A condition where the membrane (hymen) covering the vagina fails to open and allow menstrual flow.
The embedding of the embryo into tissue so it can establish contact with the mother's blood supply for nourishment. Implantation usually occurs in the lining of the uterus; however, in an ectopic pregnancy it may occur elsewhere in the body.
The inability of the man to have an erection and to ejaculate.
See Cervix, Incompetent
Intracytoplasmic Sperm Injection (ICSI):
A micromanipulation procedure where a single sperm is injected into the egg to enable fertilization with very low sperm counts or with non-motile sperm.
In Vitro Fertilization (IVF):
Literally means "in glass." Fertilization takes place outside the body in a small glass dish.
The inability to conceive after a year of unprotected intercourse or the inability to carry a pregnancy to term.
A male feedback hormone made in the testicles to regulate FSH production by the pituitary gland.
A female feedback hormone made in the ovary to regulate FSH production by the pituitary gland.
IUD (Intrauterine Device):
A device placed into the uterus to prevent pregnancy. IUD insertion has been associated with an increased incidence of infection, which may damage the fallopian tubes, and is therefore not recommended for women with multiple sexual partners.
A congenital hypothalamus dysfunction which has multiple symptoms including the failure to complete puberty.
A test performed to analyze chromosomes for the presence of genetic defects.
A genetic abnormality characterized by having one Y (male) and two X (female) chromosomes. May cause a fertility problem.
A small telescope that can be inserted into a hole in the abdominal wall for viewing the internal organs; the instrument used to perform a laparoscopy. Used to diagnose and treat a number of fertility problems including endometriosis, abdominal adhesions, and polycystic ovaries. Also used in egg retrieval for in vitro fertilization.
Examination of the pelvic region by using a small telescope called a laparoscope.
Major abdominal surgery where reproductive organ abnormalities can be corrected and fertility restored, such as tubal repairs and the removal of adhesions.
The testicular cell that produces the male hormone testosterone. The Leydig cell is stimulated by LH from the pituitary gland.
Post-ovulatory phase of a woman's cycle. The corpus luteum produces progesterone, which cause the uterine lining to thicken to support the implantation and growth of the embryo.
Luteal Phase Defect (or deficiency) (LPD):
A condition that occurs when the uterine lining does not develop adequately because of inadequate progesterone stimulation; or because of the inability of the uterine lining to respond to progesterone stimulation. LPD may prevent embryonic implantation or cause an early abortion.
Luteinized Unruptured Follicle (LUF) Syndrome:
A condition in which the follicle develops and changes into the corpus luteum without releasing the egg.
Luteinizing Hormone (LH):
A pituitary hormone that stimulates the gonads. In the man LH is necessary for spermatogenesis (Sertoli cell function) and for the production of testosterone (Leydig cell function). In the woman LH is necessary for the production of estrogen. When estrogen reaches a critical peak, the pituitary releases a surge of LH (the LH spike), which releases the egg from the follicle.
Luteinizing Hormone Surge (LH SURGE):
The release of luteinizing hormone (LH) that causes release of a mature egg from the follicle. Ovulation test kits detect the sudden increase of LH, signaling that ovulation is about to occur (usually within 24-36 hours).
A technique used to collect semen for analysis and for artificial insemination; manual stimulation of the penis leading to ejaculation.
A testicular condition in which at one stage of sperm production all sperm development halts throughout all testicular tubules. May result in oligospermia or azozoospermia.
The cell division, peculiar to reproductive cells, which allows genetic material to divide in half. Each new cell will contain twenty-three chromosomes. The spermatids (immature sperm) and ova (eggs) each contain twenty-three chromosomes, so when they combine (fertilize), the baby will have a normal complement of forty-six.
Heavy or prolonged menstrual flow.
The cyclical shedding of the uterine lining in response to stimulation from estrogen and progesterone.
Metrodin (Pure FSH):
An injectable form of Follicle Stimulating Hormone used to stimulate ovulation.
Menstrual spotting during the middle of the cycle.
Spontaneous loss of an embryo or fetus from the womb.
The division of a cell into two identical cells in which all forty-six human chromosomes are duplicated; the first division of the germ cell.
The discomfort felt on one side of the lower abdomen at the time of ovulation.
Surgery performed to remove fibroid tumors.
Infrequent menstrual periods.
A sperm count below 20 million; a low sperm count; a sperm count low enough to cause a fertility problem.
The psychological and physical thrill that accompanies sexual climax. For the man orgasm causes ejaculation.
A fluid-filled sac inside the ovary. An ovarian cyst may be found in conjunction with ovulation disorders, tumors of the ovary, and endometriosis. See also Chocolate Cyst.
The failure of the ovary to respond to FSH stimulation from the pituitary because of damage to or malformation of the ovary. Diagnosed by elevated FSH in the blood.
The release of the egg (ovum) from the ovarian follicle.
Medical treatment performed to initiate ovulation. See also Clomiphene Citrate; Pergonal.
Ovulatory Failure (Anovulation):
The failure to ovulate.
The egg; the reproductive cell from the ovary; the female gamete; the sex cell that contains the woman's genetic information.
Complete pituitary gland failure.
The condition of being open, as with tubes that form part of the reproductive organs.
Pelvic Inflammatory Disease (PID):
An infection of the pelvic organs that causes severe illness, high fever, and extreme pain. PID may lead to tubal blockage and pelvic adhesions.
A device surgically inserted into the penis to provide rigidity for intercourse. Used to treat impotence.
The male organ that becomes enlarged and erect for the purpose of depositing semen in the woman's vagina.
A medication used to replace the pituitary hormones, LH and FSH. May be used to induce ovulation in women who do not respond to clomiphene citrate. Most frequently used with women who do not normally produce estrogen because of a pituitary gland or hypothalamic malfunction. May also be used with men to stimulate sperm production.
See Pelvic Inflammatory Disease
The master gland; the gland that is stimulated by the hypothalamus and controls all hormonal functions. Located at the base of the brain just below the hypothalamus, this gland controls many major hormonal factories throughout the body including the gonads, the adrenal glands, and the thyroid gland.
The embryonic tissue that invades the uterine wall and provides a mechanism for exchanging the baby's waste products for the mother's nutrients and oxygen. The baby is connected to the placenta by the umbilical cord.
The discarded genetic material resulting from female germ cell division. See also Meiosis.
Polycystic Ovaries (PCOS or "Stein-Leventhal Syndrome"):
A condition found in women who don't ovulate, characterized by excessive production of androgens (male sex hormones) and the presence of cysts in the ovaries. Though PCOS can be without symptoms, some include excessive weight gain, acne and excessive hair growth.
Post Coital Test (PCT):
A microscopic examination of the cervical mucus best performed twelve or more hours after intercourse to determine compatibility between the woman's mucus and the man's semen; a test used to detect sperm-mucus interaction problems, the presence of sperm antibodies, and the quality of the cervical mucus.
The ducts that store and deliver the sperm to the opening of the penis; also includes the glands that produce seminal fluids.
A condition in which the man becomes so sexually excited that most of the time he ejaculates prior to penetrating the woman's vagina.
Premature Ovarian Failure:
A condition where the ovary runs out of follicles before the normal age associated with menopause.
The male hormonal system responsible for stimulating sperm production and the development of male secondary sex characteristics.
The hormone produced by the corpus luteum during the second half of a woman's cycle. It thickens the lining of the uterus to prepare it to accept implantation of a fertilized egg.
A diagnostic procedure used to analyze menstrual irregularity and amenorrhea; uterine "bleeding" that occurs within two weeks after taking progesterone; a procedure used to demonstrate the presence or absence of estrogen and to demonstrate the ability of the uterus and reproductive tract to "bleed." Prior to ovulation induction therapy, progesterone withdrawal may be used to induce a menstrual period.
The hormone that stimulates the production of milk in breastfeeding women. Excessive prolactin levels when not breastfeeding may result in infertility.
A hormone secreted by the uterine lining. It is hypothesized that prostaglandins secreted by active, young endometrial implants may interfere with the reproductive organs by causing muscular contractions or spasms.
A gland in the male reproductive system that produces a portion of the semen including a chemical that liquefies the coagulated semen twenty minutes to go one hour after entering the vagina.
The time of life when the body begins making adult levels of sex hormones - (estrogen or testosterone) and the youngster takes on adult body characteristics: developing breasts, growing a beard, pubic hair, and auxiliary hair; attaining sexual maturity.
A period of time after orgasm during which a man or woman cannot have another; a recovery period.
An ovary that cannot respond to the follicle-stimulating message sent by FSH. Primitive germ cells will be present in the ovary; however, they will not respond to FSH stimulation.
A male fertility problem that allows the sperm to travel into the bladder instead of out the opening of the penis due to a failure in the sphincter muscle at the base of the bladder.
Surgical removal of the fallopian tube.
Surgery performed to remove adhesions that restrict the movement and function of reproductive organs.
Surgical repair made to the fallopian tubes; a procedure used to open the fimbria.
The bag of skin and thin muscle surrounding the man's testicles.
The inability of a couple which has successfully achieved pregnancy to achieve another. This strict medical definition includes couples for whom the pregnancy did not go to term. The common vernacular, however, refers to a couple which has one biological child but is unable to conceive another.
Secondary Sex Characteristics:
The physical qualities that distinguish man and woman, such as beard, large breasts, and deep voice. Formed under the stimulation of the sex hormones (testosterone or estrogen), these characteristics also identify those people who have gone through puberty (sexual maturity).
The fluid portion of the ejaculate consisting of secretions from the seminal vesicles, prostate gland, and several other glands in the male reproductive tract. The semen provides nourishment and protection for the sperm and a medium in which the sperm can travel to the woman's vagina. Semen may also refer to the entire ejaculate, including the sperm.
A laboratory test used to assess semen quality: sperm quantity, concentration, morphology (form), and motility. In addition, it measures semen (fluid) volume and whether or not white blood cells are present, indicating an infection.
The liquid flow or consistency of the semen.
Glands in the male reproductive system which produce much of the semen volume, including fructose (sugar) for nourishing the sperm and a chemical that causes the semen to coagulate on entering the vagina.
The testicular tubules in which the sperm mature and move toward the epididymis.
A uterus divided into right and left halves by a wall of tissue (septum). Women with a septate uterus have an increased chance of early pregnancy loss.
Brand name for clomiphene citrate. (See CLOMID.)
Sertoli (Nurse) Cell:
A testicular cell responsible for nurturing the spermatids (immature sperm). Secretes inhibin, a feedback hormone, which regulates FSH production by the pituitary gland. When stimulated by FSH, the Sertoli cell initiates spermatogenesis.
A condition caused by profuse hemorrhage at the time of delivery. The severe blood loss shocks the pituitary gland, which dies and becomes nonfunctional.
Short Luted Phase:
A condition in which the corpus luteum deteriorates prematurely, causing the menstrual period to begin approximately ten days (instead of fourteen) after ovulation. Frequently found with women undergoing ovulation induction treatment.
Use of high-frequency sound waves for creating an image of internal body parts. Used to detect and count follicle growth (and disappearance) in many fertility treatments. Also used to detect and monitor pregnancy.
The microscopic cell that carries the male's genetic information to the female's egg; the male reproductive cell; the male gamete.
Sperm clumping caused by antibody reactions or by infection.
Antibodies that attack and maim sperm. May be formed by either the man against his own sperm or by the woman against her husband's sperm.
A place where sperm are kept frozen in liquid nitrogen for later use in artificial insemination.
The number of sperm in ejaculate. Also called sperm concentration and given as the number of sperm per milliliter.
A process during which the sperm grow and gain their ability to swim. Sperm take about ninety days to reach maturity.
A semen analysis factor that indicates the number or percentage of sperm in the sample that appear to have been formed normally. Abnormal morphology includes sperm with kinked, doubled, or coiled tails.
The ability of sperm to swim. Poor motility means the sperm have a difficult time swimming toward their goal---the egg.
The ability of the sperm to penetrate the egg so it can deposit the genetic material during fertilization.
Sperm production in the testicles.
The stretchability of cervical mucus; the stringy quality that occurs at midcycle under the influence of estrogen. See also Postcoital Test.
A method used to concentrate the sperm for insemination; separating the semen into two portions: the first portion of the ejaculate, which is rich in sperm, and the second portion, which contains mostly seminal fluid.
See Abortion, Spontaneous.
Another name for polycystic ovaries.
An irreversible condition that prevents conception.
The death of a fetus between the twentieth week of gestation and birth.
Stimulation of multiple ovulation with fertility drugs; also known as controlled ovarian hyperstimulation (COH).
A woman who is artificially inseminated and carries to term a baby which will be raised by its genetic father and his partner.
A minor surgical procedure used to take a small sample of testicular tissue for microscopic examination; a test used to diagnose male fertility problems when no other means is available (this is because the biopsy procedure itself may cause testicular damage).
A minor surgical procedure used to take a small sample of testicular tissue for microscopic examination; a test used to diagnose male fertility problems when no other means is available (this is because the biopsy procedure itself may cause testicular damage).
Testicular Enzyme Defect:
A congenital enzyme defect that prevents the testes from responding to hormonal stimulation. Will result in oligospermia or azozoospermia.
Testicular Failure, Primary:
A congenital, developmental, or genetic error resulting in a testicular malformation that prevents sperm production.
Testicular Failure, Secondary:
Acquired testicular damage - for example, from drugs, prolonged exposure to toxic substances, or a varicocoele.
An enzymatic defect that prevents a man from responding to the male hormone testosterone. The man will look like a woman, but karyotyping will reveal a normal XY male chromosome pattern, and testosterone levels will be in the normal male range.
The ability of the testicles to produce sperm and testosterone.
Testicular Stress Pattern:
A semen analysis result showing depressed sperm production, poor sperm motility, and poor sperm morphology. The pattern is consistent with secondary testicular failure or illness.
The male hormone responsible for the formation of secondary sex characteristics and for supporting the sex drive. Testosterone is also necessary for spermatogenesis.
The endocrine gland in the front of the neck that produces thyroid hormones to regulate the body's metabolism.
The twisting of the testis inside the scrotum. Besides causing extreme pain and swelling, the rotation twists off the blood supply and causes severe damage to the testicle. Torsion of the ovary may also occur in a woman suffering from hyperstimulation, a complication of ovulation induction treatment.
An infection that may produce a greenish, bad-smelling vaginal discharge.
Surgery performed to remove a blocked portion of the fallopian tube and to reconnect the tube to the uterus. Tubouterine implantation may also be performed to remove fallopian tube blockage near the uterus and reimplant the tube in the uterus.
Surgery performed to remove a diseased portion of the fallopian tube and reconnect the two ends; sterilization reversal.
The most common genetic defect contributing to female fertility problems. The ovaries fail to form and appear as slender threads of atrophic ovarian tissue, referred to as streak ovaries. Karyotyping will reveal that this woman has only one female (X) chromosome instead of two.
A test used instead of X rays to visualize the reproductive organs; for example, to monitor follicular development and to examine the tubes and uterus. The instrument works by bouncing sound waves off the organs. A picture displayed on a TV screen shows the internal organs.
Two arteries and one vein encased in a gelatinous tube leading from the baby to the placenta. Used to exchange nutrients and oxygen from the mother for waste products from the baby.
Undescended Testicles (Cryptorchidism):
The failure of the testicles to descend from the abdominal cavity into the scrotum by one year of age. If not repaired by age six, may result in permanent fertility loss.
An abnormality in which the uterus is "one sided" and smaller than usual.
An infection that may cause the formation of sperm antibodies and an inflammation of the uterine lining, either of which may interfere with implantation of the embryo.
The tube that allows urine to pass between the bladder and the outside of the body. In the man this tube also carries semen from the area of the prostate to the outside.
A physician specializing in the genitourinary tract.
The hollow, muscular organ that houses and nourishes the fetus during pregnancy.
The canal leading from the cervix to the outside of the woman's body; the birth passage.
Yeast, bacterial vaginosis, or trichomonas infections of the vagina. Frequent vaginitis may indicate the presence of pelvic adhesions and tubal blockage from other infections, such as chlamydia. Vaginitis may interfere with sperm penetration of the cervical mucus, and the symptoms may even interfere with the ability and desire to have intercourse.
A dilation of the veins that carry blood out of the scrotum. The resulting swollen vessels surrounding the testicles create a pool of stagnant blood, which elevates the scrotal temperature. A major cause of male infertility.
One of the tubes through which the sperm move from the testicles (epididymis) toward the seminal vesicles and prostate gland. These tubes are severed during a vasectomy performed for birth control.
The accidental or elective surgical separation of the vasa deferential a procedure used for birth control.
Any infection that can be sexually transmitted, such as chlamydia, gonorrhea, ureaplasma, and syphilis. Many of these diseases will interfere with fertility and some will cause severe illness. See also PID.
Masculinization; having male secondary sex characteristics; being able to perform sexually.
The congenital, developmental, or genetic information in the cell that transmits the information necessary to make a female. All eggs contain one X chromosome, and half of all sperm carry an X chromosome. When two X chromosomes combine, the baby will be a girl. See also Y. Chromosome.
The genetic material that transmits the information necessary to make a male. The Y chromosome can be found in one-half of the man's sperm cells. When an X and a Y chromosome combine, the baby will be a boy. See also X Chromosome.
A fertilized egg which has not yet divided.
Zygote Intrafallopian Transfer (ZIFT):
An ART in which eggs are removed from a woman's ovaries, fertilized with the man's sperm in a lab dish, and the resulting embryos are transferred into the woman's fallopian tubes during a minor surgical procedure