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Apr 12

Diagnosis & Suitable Treatment

The two main female hormones are estrogen and progesterone. The amount of these hormones in the blood stream varies at different times during the menstrual cycle. Estrogen is produced throughout the cycle, however progesterone is produced only after ovulation.

No progesterone will be produced in women who do not ovulate. Therefore, if a woman is suspected not to ovulating, a progesterone level measured around day 22 of the menstrual cycle will show if she ovulated or not. In women on clomid [used to induce ovulation] a day 22 progesterone is commonly checked to make sure the dose of clomid does not need to be increased.

In some women, there is inadequate amount of progesterone produced after ovulation. In these women an endometrial biopsy will show abnormal changes before the onset of the menstrual cycle. These women may benefit from being placed on some supplemental ovulation, and some doctors treat this inadequate progesterone production by using clomid.- Estrogen levels are not very useful to measure in most infertility patients. In patients that are on high power drugs to make them ovulate [Pergonal ] then estrogen levels are commonly checked.

Polycystic Ovary Syndrome (PCO)

Polycystic ovarian syndrome is a hormonal disorder that affects approximately six to ten percent of pre-menstrual women and is the major cause of infertility in American women. Polycystic ovarian syndrome is the result of the overproduction of hormones in a women body. During ovulation, the ovaries receive hormones from the pituitary gland.

These hormones, follicule-stimulating hormone [FSH] and luteinizing hormone [LH] help the egg reach maturity in preparation to be fertilized. In women with PCOS There is an abnormal level of FSH and LH being secreted. The overproduction of LH Causes the ovaries to overproduce androgen. Increased production produces hight LH levels and low FSH levels, so the follicules are prevented from producing a mature egg.

Thus the ovulatory process is not allowed to complete itself. The partially-developed egg [inside its follicule shell] dies. Without egg production, the follicules swell with fluid and form into cyst, and it is these cyst that create polycystic ovaries.

Every time an egg is trapped withing the follicule, another cyst forms, so the ovary Swells, sometimes reaching the size of a grapefruit. Without ovulation progesterone is no longer produced whereas estrogen levels remain normal. Although polycystic ovarian syndrome presents itself during adolescence or the early adult years, women often do not know they have the disorder until after they attempt to conceive. No two women affected by PCOS have the same symptoms.

Common characteristics associated with PCOS are:

  • Irregular menstrual cycles [oligomenorrhea] or no menstrual cycles [amenorrhea]
  • Excessive facial and body hair growth [hirsutism]
  • Male patterm hair loss [androgenic alopecia]
  • Acne
  • Polycystic ovaries
  • Obesity/weight gain
  • Infertility

Swabs & cervical smear

Pap Smear:

Very few experiences can be as frightening as receiving a call that your pap smear came back abnormal. Although cervical cancer is the first thing that may comes to mind, most of the time an abnormal pap smear indicates a minor problem with the cervix that may or may not need treatment.

During a pap smear some cells are scraped or brushed off the cervix and prepared on a slide that can be examined under a microscope. The purpose of the pap smear test is to detect changes that may lead to cervical cancer long before cancer develops. Pre-cancer of the cervix is easily treated and almost always prevents cancer from developing.

Endometriosis

The tissue that normally lines the inside of the uterus is called the endometrium. In some women endometrium grows outside the uterus. When this happens a woman has a condition called endometriosis. The most common areas for this abnormal growth of endometrium are the reproductive organs [ovaries, fallopian tubes, uterus]. Endometrium may also grow on the intestines, bladder, or even in the rectum. It usually looks like dark brown, black spots on the ovaries, tubes or tissue around the uterus.

This misplaced tissue responds to the hormones of the menstrual cycle and bleeds each month in the same way the lining of the uterus responds to hormones. However if the tissue is not in the uterus, the blood shed from the tissue has no way to leave the body. When the tissue bleeds, cysts, adhesions, and scar tissue form and the area around the endometriosis thickens.

How does it occur ?

Why some women develop endometriosis is not known. There are many theories but none of them explains all cases. One theory suggests that in some women some of the endometrial tissue flows backward during menstrual flow into the fallopian tubes and abdomen. Where it attaches and grows.

Anther theory suggests that some endometrial tissue in the uterus backs up in all women. The immune system may then destroy the misplaced tissue. Women who develop endometriosis, however may have an immune system that is not able to destroy the misplaced tissue.

Endometriosis is believed to be quite common. It is estimated that between 25% And 50% of women with infertility have endometriosis.

These endometrial, or misplaced tissues implants will still respond to a woman’s monthly hormonal cycle, causing pain and disconfort, slowly increasing in number and size with each menstrual cycle and eventually causing scarring and inflammation. Endometrial implants in the ovaries or fallopian tubes are particularly likely to cause infertility, even if the endometriosis is mild.

Endometrial Biopsy

The lining of the uterus undergoes very specific changes on a day by day basis during a woman’s cycle. Especially after ovulation the changes that occur are related to the effects of the female hormones-estrogen and progesterone. Inadequate amounts of either of these hormones may make the lining of the uterus unable to support a fertilized egg even if conception occurs.

Therefore, an endometrial biopsy may be helpful in determining if the lining of the uterus is properly prepared. The procedure is relatively painless-and done similar to a pap-smear. The procedure is usually performed a few days before the anticipated start of the menstrual period.

A small catheter is placed up into the uterus and a sample of the lining is removed. This usually just takes a few seconds. Some mild cramping can occur during this time, and spotting for a few days afterward is typical. The tissue obtained is then sent to a pathologist who can tell from the tissue about how many days before ovulation should have occurred. The patient is asked to call back and let the doctor know when the period actually starts.

If there is a difference between the expected day of the start of the period based on the biopsy and the actual start of the period, this can indicate a hormonal problem that may need to be fixed. There is minimal risk with this procedure however since it is performed after ovulation there is a slight chance that if conception occurred on its own that the biopsy might disrupt an early pregnancy.

Therefore for patients that would find this offensive, contraception or abstinence should be considered during this test cycle.

Hysteroslpingography (HSG)

HSG is used to detect a blockage in the Fallopian tubes. This may result from damage caused by infection, endometriosis [in which tissue similar to that lining the uterus is found elsewhere in the abdomen] and sterilization. It can also reveal an abnormality within the uterus.

The procedure is performed in the X-ray department and takes about 20 minutes. No anesthetic is necessary, but some mild discomfort may be experienced which will be relieved by painkillers given before and during the procedure. You will be asked to go to the toilet to empty your bladder.

An instrument called a speculum is inserted into the vagina to hold the walls apart so that the cervix can be seen. A fine tube is then inserted through the cervix and a balloon inflated at its tip to hold it in position. The speculum is removed and a special dye that can be seen on X-rays is then injected through the tube.

X-rays ere taken which should demonstrate the dye filling the uterine cavity, passing along the Fallopian tubes and spilling out at the ends.

As this procedure involves using X-rays it can be carried out only in the first half of the menstrual cycle, after the bleeding has stopped but before ovulation. This is to prevent cells from the lining of the uterus being pushed through the tube into the abdomen, and to prevent damage to the fetus if pregnancy has occurred.

Antibiotics are routinely given after the procedure to prevent the possibility of infection.

Ultrasound with HyCoSe

Ultrasound with HyCoSe is a procedure used to detect a blockage in the Fallopian tubes. This may result from damage caused by infection, endometriosis [in which tissue similar to that lining the uterus is found els-where in the abdomen] and sterilization. It can also reveal an abnormality within the uterus. The procedure take 20 minutes. No anesthetic is necessary, but some mild discomfort may be experienced, particularly if a tube is blocked, which will be relieved by painkillers given before and during the procedure.

You will be asked to go to the toilet to empty your bladder. An instrument called a speculum is inserted into the vagina to hold the walls apart so that the cervix can be seen. A fine tube is then inserted through the cervix and a balloon inflated at its tip to hold it in position. The speculum is removed and a special sugar-based dye is injected through the tube into the uterus .

An ultrasound probe is then inserted into the vagina. The dye should then be observed filling the uterine cavity, passing along the Fallopian tubes and spilling out at the ends.

This procedure has the advantages that it can be performed at the same time as an ultrasound examination and it avoids the use of X-rays.

Antibiotics are routinely given after the procedure to prevent the possibility of infection.

Hysteroscopy

Hysteroscopy is used to examine the uterus. Hysteroscopy will confirm the presence of any abnormality within the uterus and if it has been agreed beforehand this can be surgically treated at the same time.

  • Hysteroscopy is usually performed under a general and sometime under a local anesthetic as a day-case procedure. The examination takes approximately 20 minutes.

  • The procedure involves passing a small fibre-optic [telescope] through the vagina and the cervix into the uterus. The cavity of the uterus can then be clearly seen.

  • When the hysteroscope has been removed, a small sample of tissue from the lining of the uterus is taken to confirm that it agrees with the time in the menstrual cycle reported by the patient.

  • Conditions that may be treated during hysteroscopy include polyps, a septum [a piece of tissue dividing the uterus] and fibroids [tissue in the wall of the uterus].

  • After the procedure, the patients usually experience mild discomfort, with period-like cramps, but this will be relieves with painkillers. You will usually be able to resume normal activities the following day. However, if surgery is carried out at the same time, you need to stay at home for a few days.

Falloscopy

Falloposcopy is a specialized technique that is used to examine the internal lining of the Fallopian tubes. Falloposcopy is usually performed under a general anesthetic as a day-case procedure and takes about 20 minutes. The procedure involves passing a small fibre-optic [telescope] through the vagina and cervix into the uterus. The entrance to each Fallopian tube is then identified and the telescope passed into each tube in turn. The whole length of the tube can be inspected and any abnormality identified.

After the procedure patients usually experience mild discomfort with period-like cramps, but this will be relieved with painkillers. You will usually be able to resume normal activities after 1-2 days.

Laparoscopy

Laparoscopy is used to examine the reproductive organs lying within the abdomen. If an abnormality is found at the time of laparoscopy, [keyhole surgery] may be performed. This has the advantages of avoiding a further anaesthetic, less postoperative discomfort and a faster recovery, with a shorter hospital stay.

Laparoscopy is usually performed under general anaesthetic as a day-care procedure and takes approximately 20 minutes. Carbon dioxide gas is pumped into the abdomen to separate the organ so that they be can seen more clearly. A small incision is made through which the small fibre-optic telescope the laparoscope is inserted. A second incision may also be made so that a probe can be inserted to manipulate the organs lying within the abdomen.

Once the reproductive organs have been inspected, a dye can be injected through the vagina and cervix into the uterus to detect any blockage in the Fallopian tubes. If the tubes are not blocked the dye should pass along the Fallopian tubes and spill out into the abdomen. This can be observed through the telescope in the abdomen. After the procedure you will feel some discomfort and bloating caused by some of the gas used to separate the tissues becoming trapped. If any gas gets trapped under the rib cage pain may be experienced at the shoulder tip but this will be relieved by painkillers. You will be able to resume normal activities within 2-3 days.

Adhesiolysis

Adhesiolysis is the removal of scar tissue called adhesions, which can form between the internal organs causing them to stick together, reducing their mobility. Adhesions are often the result of infection or previous surgery, but may also be caused by endometriosis [when tissue similar to that lining the uterus is found elsewhere in the abdomen].

The operation is performed under a general aneasthetic. Ideally it should be performed using “keyhole surgery”, but a conventional incision in the abdomen may be necessary in severe cases.

The adhesions are broken down using specially designed instruments. Synthetic coverings may be placed around the organs that are separated to reduce the likelihood of the scar tissue reforming.

You will feel some discomfort after the operation, but this will be relieved with painkillers.

Following “keyhole surgery” you will usually be able to return home the same day or the following day and will be able to resume normal activities after about 1 week. Following a conventional operation, however you will usually need to stay in hospital for up to 5 days and will not be able to resume normal activities for up to 6 weeks.

The adhesions may never recur in some patients, but may do so in others to a varying degree. For this reason, patients are advised to try to conceive within 1 year.

Salpingostomy

Salpingostomy is used to treat a blockage of the end of Fallopian tubes, which can result in the tube becoming swollen. The blockage is usually the result of previous infection.

During the operation, any scar tissue covering the end of the tube is removed. The tube is then opened and turned back on itself so that it will remain open. The procedure is carried out under a general anaesthetic and takes about 40 minutes. The operation may be performed either using “keyhole surgery” or through a conventional incision in the abdomen.

You will feel some discomfort after the operation, but this will be relieved with painkillers. You will also be given antibiotics to prevent any infection which may cause further damage to the tubes.

The length of time you will need to spend in hospital will depend on how the operation is performed. Following “keyhole surgery” you will usually need to stay in hospital for 1-2 days and will be able to resume normal activities after about 1 week.

Following a conventional operation however you will usually need to stay in hospital for 5-7 days and will not be able to resume normal activities for up to 6 weeks. The tubes can be opened successfully in 80% of cases, but only about 20% of these women achieve a pregnancy as a result.

Mammography

Mammography has made significant contributions to the diagnosis of breast disease in symptomatic women and to the early detection of breast cancer,in asymptomatic [healthy] women. Mammography can find breast cancer too small to be felt by the women or her physician. Early detection of breast cancer while they are small and localized greatly improves a women’ chances for successful treatment.

Ovarian Hyperstimulation Syndrome

Ovarian Hyperstimulation Syndrome is an iatrogenic complication induced by exogenous administration of substances which are used to stimulate follicular growth and ovulation. The crucial event in the development of the syndrome is the administration of Human Chorionic Gonadotropin [HCG] although, several studies have reported the onset of OHSS after gonadotropin stimulation despite withholding HCG. OHSS is represented by a broad spectrum of clinical and laboratory manifestations which in the severest from, can induce a life-threatening condition. It is always important to remember that OHS is a potentially lethal condition.

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