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Frequently
Asked Questions
- Infertility is not uncommon. Infertility is defined as the
inability of a couple in the reproductive age group to conceive
despite regular attempts.
- The incidence of infertility is equal in both men and women.
- Approximately 6 million couples will experience infertility
in the U.S. This translates to about one couple out of every
10 in the reproductive-age
- It is important to appreciate that complex treatments such
as , in vitro fertilization (test tube babies)and similar treatments
account for less than 3% of infertility services.
- The good news is that in around 90% of couples in the reproductive
age group can be treated with conventional medical therapies
such as medication or surgery.
Questions about Infertility- General
A: Pregnancy is a complicated process that
depends upon many factors, all of which need to be optimal.
Some of the factors that are important for the process depend
on the production of healthy sperm, healthy eggs ; patent
(open) fallopian tubes that allow the sperm to reach the
egg; the sperm's ability to fertilize the egg when they
meet; the ability of the fertilized egg (embryo) to become
implanted in the woman's uterus; and sufficient embryo quality.
Finally, for the pregnancy to continue to full term the
embryo must be healthy and the woman's hormonal and uterine
environment should be adequate for its development. When
just one of these factors is impaired, infertility can result.
A:
Infertility is defined as the inability to conceive after
one year of unprotected intercourse. This definition is
reduced to six months for:
- Women over 35
- Women with a history of painful
periods, irregular cycles, pelvic inflammatory disease
and miscarriages
- Couples who know that the male
partner has a low sperm count
A:
Infertility is often a couple's problem, and is commonly
due to some contribution from both the male and female partners.
On an average, about one-third of infertility cases are
caused by problems with the woman's reproductive system.
Another third can be traced to factors in the man. Of the
remaining cases, combinations of male and female factors
are at play. Interestingly, about 20 percent of infertility
cases don't have a known cause despite all investigations.
This is termed unexplained infertility.
A:A man is
most likely infertile due to low sperm count, poor sperm
motility, abnormally shaped sperm or some combination of
all three. Most cases of low sperm counts are "idiopathic"
or unexplained. Some cases are associated with a swollen
varicose vein in the scrotum, called a varicocele. Varicocele
is the most common reversible cause of male infertility
and can be corrected by minor outpatient surgery. Lifestyle
can influence the number and quality of a man's sperm. Tobacco,
alcohol and drugs can temporarily reduce sperm quality.
Environmental toxins, including pesticides and lead, may
cause some cases of infertility in men. In rare cases, infertility
in men may be caused by genetic diseases. Short term illnesses,
significant stressful periods, and some medications may
temporarily affect sperm counts.
A:Female
infertility may be divided into several categories: Ovulatory
problems; Cervical factors; Pelvic and tubal factors; and
Uterine factors.
The most common cause is an ovulation disorder. Failed ovulation
/ anovulation occur most commonly in Polycystic ovary syndrome
(PCOS). It can also occur secondary to malfunction of the
hypothalamus and pituitary gland which are organs in the
brain that are responsible for sending signals and secreting
hormones that are responsible for initiating egg maturation
in the ovaries, scarred ovaries and premature menopause.
Ovulation can be seriously affected by abnormalities of
the thyroid gland, overproduction of prolactin (a hormone
leading to breast milk production), excessive male hormone
(androgens) and physical stress, psychological stress and
extreme lifestyle changes. Often, combinations of these
problems exist.
Cervical infertility involves inability of the sperm to
pass into the uterine cavity due to damage to the cervix.
This can occur because of inadequate or hostile cervical
mucus, infections of the cervix with common sexually transmitted
diseases such as chlamydia, gonorrhea, or trichomonas and
immune attack of sperm or "sperm allergy"
Pelvic causes of infertility include any disruption of the
normal pelvic anatomy by scar tissue or "adhesions" as in
pelvic inflammatory disease, endometriosis, blocked, scarred,
or distorted fallopian tubes and benign tumors (fibroids)
of the uterus.
Uterine causes of infertility include a thin or abnormal
uterine lining and anatomic uterine problems such as polyps,
uterine fibroids and abnormal shape of the uterus, septum
or "dividing wall" within the uterus.
A: Approximately
10 - 30% of all couples undergoing infertility treatment
are diagnosed with "unexplained infertility." This simply
means that the commonly performed tests available to fertility
specialists to diagnose the cause of infertility are all
normal and do not define the reason for infertility. These
difficult to diagnose causes are subtle and include difficulty
in picking up the egg by fallopian tube, failure of implantation
of the embryo into the uterus and failure of the sperm to
fertilize the egg even when in contact. The prognosis for
conceiving for couples that are diagnosed with unexplained
infertility is usually good. Couples who are diagnosed with
unexplained infertility are encouraged to seek treatment.
These couples usually respond well to an appropriate treatment
regimen. Success rates for couples with unexplained infertility
working with fertility medication and intrauterine inseminations
(IUI) are between 15 - 20%. Success rates are even higher
with assisted reproductive technology such as in vitro fertilization
(IVF). The success of all treatments is age dependent with
reduced success rates in older patients.
A: As a woman
ages, the many biological changes taking place in her body
are responsible for the decrease in her ability to become
pregnant and carry a pregnancy to term. There is a direct
association between advancing female age and infertility.
From age 30 to 35, the chances of becoming pregnant gradually
decline and after age 40 there is a sharp decline. The probability
of having a baby decreases 3-5% per year after age 30 and
even faster after age 40. There are numerous reasons for
this decline in fertility including diminished egg quality,
decline in the number of eggs produced, and irregularity
of ovulation, decreased production of estrogen and progesterone
by the ovaries and resistance of the eggs to fertilization.
The following general data is reflective of the effects
of age on pregnancy rates: 86% of women in the 20-24 year
age group, 78% in the 25-29 year age group, 63% in the 30-34
year age group and 52% in the 35-39 year age group, conceive
within 12 months.
Pregnancy occurring at a later age is associated with increased
chances of miscarriage and chromosomal abnormalities, resulting
in birth defects such as Down's syndrome. A woman in her
20's has only a 12-15% chance of having a miscarriage each
time she becomes pregnant, while there is a 40% risk of
miscarriage for a woman in her 40's. Also, assisted reproductive
technologies, including in vitro fertilization and intracytoplasmic
sperm injection become less successful as age increases.
Most, men retain the ability to produce viable sperm until
late in life although there can be a decline in the volume
and "quality" of the ejaculate. However, the semen analysis
is a mandatory infertility test and must be performed early
in the evaluation of the couple. Latest statistics indicate
that male factor infertility is a component in approximately
47% of couples.
A: A medical
evaluation may determine the reasons for a couple's infertility.
Usually this process begins with physical examination and
medical and sexual histories of both partners. If there
is no obvious problem, like improperly timed intercourse
or absence of ovulation, specific tests may be recommended.
For a man, testing usually begins with tests of his semen
(semen analysis) to look at the number, shape, and movement
of his sperm. Sometimes other kinds of tests, such as hormone
tests, are done.
For a woman, the first step in testing is to find out if
she is ovulating each month. There are several ways to do
this. For example, she can keep track of changes in her
morning body temperature and in the texture of her cervical
mucus. Another tool is a home ovulation test kit, which
can be bought at drug or grocery stores. Checks of ovulation
can also be done in the doctor's office, using blood tests
for hormone levels or ultrasound tests of the ovaries. If
tests indicate that there is no problem with ovulation,
more tests will need to be done. Depending on a couple's
individual circumstances, these include an x-ray of the
fallopian tubes and uterus to see if the lumen of the tubes
and uterine cavity are open (patent). Sometimes, a laparoscopy
which is performed as an outpatient procedure may be necessary
to look for endometriosis or scar tissue. All of these tests
can usually be accomplished within 1-2 months.
A: The good
news is that 85-90% of couples in the reproductive age group
can be treated with conventional medical therapies such
as medication or surgery. The treatment of infertility depends
on its cause. Based on the test results, different treatments
can be suggested. Fertility drugs may be used for women
with ovulation problems. If needed, surgery can be done
to repair damage to a woman's ovaries, fallopian tubes,
or uterus. Sometimes a man has an infertility problem that
can be corrected by surgery. When these initial therapies
fail, advanced reproductive techniques (ART) come into play.
It is important to appreciate those complex treatments such
as, in vitro fertilization (test tube babies) and similar
treatments account for less than 3% of infertility services.
A: It is
recommended that you seek evaluation after twelve months
of unsuccessful attempts to get pregnant. If you are older
than 35 years, you should see a reproductive endocrinologist
(fertility expert) after six months. Women greater than
40 years should begin evaluation immediately.
A: Yes, patients
have the option of surgically reuniting the fallopian tubes
through a process called microscopic tubal reanastomosis.
This can commonly be done as an outpatient procedure with
good results. Depending on other infertility factors, couples
are able to conceive in a short interval of time. An alternative
to this procedure would be in vitro fertilization (IVF),
where the eggs are fertilized outside the body. The resulting
embryo is then placed into the uterine cavity for implantation,
thereby by-passing the blocked fallopian tubes. The best
way to move forward would require a consultation with the
physician and to consider all other fertility factors.
A: Laparoscopy
is a minimally invasive surgical procedure that allows for
a complete examination and evaluation of a woman's pelvic
and abdominal structures. It is performed as an outpatient
surgical procedure and is particularly helpful in diagnosing
and effectively treating endometriosis or pelvic adhesions
(scar tissue). Both of these conditions can cause pelvic
pain and/or infertility. In individuals with either of these
conditions, a laparoscopy can dramatically improve the chances
of conception.
A: It all
depends on your insurance plan. Most insurance plans cover
office visits and diagnostic tests. Treatment, on the other
hand, may not be covered unless you have specific fertility
coverage. You are encouraged to call our office to discuss
any insurance questions or concerns.
Questions about In Vitro Fertilization
(IVF) /
Advanced Reproductive Techniques (ART)
A: IVF
is an advanced reproductive technique, usually undertaken
when other simpler fertility therapies have been unsuccessful
or are not possible. It has become the treatment of choice
for patients with irreparably damaged fallopian tubes,
profoundly low sperm counts, advanced endometriosis or
failure to conceive after adequate attempts of intrauterine
insemination. IVF is a complex, multi step process, which
involves incubating eggs with sperm, resulting in the
creation of embryos in the laboratory. The embryos are
then transferred into the uterine cavity for potential
implantation. IVF treatment enables many patients to achieve
their dream of parenthood. Anticipated pregnancy rates
for many patients depending on each individual situation,
may exceed 50 percent.
A: IVF
and other assisted reproductive technologies provide many
couples with the opportunity to get pregnant that otherwise
wouldn't be able to have children on their own. During
your consultation with Dr. Pinto, the discussion will
focus on each patient's unique circumstances and he will
give you a realistic expectation as to your individual
chance for success.
A: Once
the decision is made to proceed with IVF, several test
results on both partners are usually required to be reviewed
prior to the initiation of the IVF cycle. These include
tests such as hormonal profile, ovarian reserve screening,
semen analysis, tests for infectious screening (HIV, Hepatitis
B, Syphilis etc…), genetic testing when indicated
and uterine cavity assessment. If you have been referred
by your obstetrician, and some of these tests have already
been performed in the recent past, you may not need to
repeat them. Dr. Pinto will ask for your prior test results
to be reviewed.
When all of the tests are reviewed, the IVF treatment
cycle begins. Each patient's treatment plan is unique.
Dr. Pinto will discuss your specific treatment plan in
detail, so that you will know what to expect every step
of the way. He will always be available to answer all
of your questions. This is a general outline of steps
followed in an IVF treatment cycle plan. The patient is
placed on oral contraceptives (birth control pills) for
approximately 14-35 days followed by Lupron for approximately
12-14 days. These drugs prepare the body for the ovarian
stimulation that will follow. A baseline ultrasound is
performed at this time. Ovarian stimulation with fertility
medications is begun and continues for approximately 10-12
days. Close monitoring with blood tests and ultrasound
examination occurs during this time. Based on the test
results, a trigger shot of hCG is given at the appropriate
time, and is followed 34-36 hours later by egg retrieval.
Progesterone supplementation is also usually started around
this time. Fertilization of retrieved eggs with the sperm
sample then occurs in the laboratory under the supervision
and monitoring of an embryologist. Embryo transfer occurs
3-5 days after the egg retrieval. A pregnancy test is
performed approximately 14 days later, followed by subsequent
ultrasounds to detect a fetal heart beat.
A: The
duration of a treatment cycle from the start of the birth
control pills to the time of embryo transfer is approximately
6 weeks.
A: On
the day of egg retrieval, the male partner is asked to
provide a sperm sample. The quality of this sample is
dependent upon what happened in the male's body 3 months
ago. This is because sperm development takes 3 months.
Patients are encouraged to follow the guidelines listed
below to help ensure that the semen sample is of the best
possible quality.
- A fever of 101 degrees Fahrenheit
or higher within 3 months prior to IVF treatment may
adversely affect sperm quality. Sperm count and motility
may appear normal, but fertilization may not occur.
If you become sick during the IVF cycle, please notify
Dr. Pinto, and take Tylenol to keep your temperature
below 101 degrees Fahrenheit.
- Keep the use of alcohol and
cigarettes to a minimum before and during IVF treatment.
Do not use any "recreational" drugs.
- If any prescription medication
has been taken during the last 3 months, notify Dr.
Pinto.
- Do not sit in hot tubs, spas,
Jacuzzis, or saunas during or 3 months prior to the
IVF cycle.
- Do not begin any new form
of endurance exercise during or 3 months prior to the
IVF cycle. Physical activity at a moderate level is
acceptable and encouraged.
- Avoid all testosterone, DHEA,
and Androstenedione / Androstanediol hormone containing
supplements.
- Inform Dr. Pinto, if you have
ever had genital herpes, or suspect you may have been
exposed to genital herpes in the past and if you have
pre lesion symptoms, develop a lesion, or have healing
lesions before or during the IVF cycle.
- Refrain from ejaculation for
2-3 days, but not more than 5 prior to collecting the
semen sample for the IVF cycle.
We usually have a previously collected frozen semen sample
as a backup for use on the day of egg retrieval. This will
be used in the event that the fresh sample is of poor quality.
A: This
will be discussed with you at the time of consent signing.
We usually follow the recommendations of The Society for
Reproductive Medicine guidelines:
- Under 30 years old = 1-2 embryos
- 30-35 years of age = 2-3 embryos
- 35-40 years of age = 3 embryos
These numbers may vary depending on individual diagnosis
and clinical circumstance.
A: Alcohol
should be avoided during infertility treatment and pregnancy.
Some medications may interfere with the fertility medications
prescribed, some are not safe to use before an operation
or medical procedure, and others might interfere with
ovulation or pregnancy implantation. A prenatal or multivitamin
will be prescribed. Please inform Dr. Pinto, if you are
taking any prescribed or over the counter medication.
Stop smoking before ovulation induction begins. It is
best to discontinue tobacco at least 2 months prior to
an IVF cycle. Tobacco has been demonstrated to be toxic
to the oocyte (egg). Numerous studies have also demonstrated
that smoking during pregnancy results in reduced birth
weight and fetal compromise.
Heavy exercise such as aerobics, jogging, weight lifting
etc. is prohibited during ovarian stimulation and until
the pregnancy test results are known.
A: A pregnancy
test is performed 14 days after the Embryo Transfer. If
pregnant, the patient is asked to return to the office
for repeat blood work and ultrasounds to ensure an ongoing
successful pregnancy. After a fetal heartbeat has been
confirmed, patients are referred to their referring obstetrician
for the remainder of the pregnancy. If patients do not
have an obstetrician, Dr. Pinto will be happy to refer
you to one. It is not necessary to follow-up with a high
risk obstetrician, unless your obstetrician deems it necessary.
A high risk obstetrician is only needed when there are
complications that put the mother or baby at increased
risk, or in the case of multiple births. Other than a
higher incidence of multiple births, IVF does not increase
the risk to the fetus.
The miscarriage rate is about the same for pregnancy after
IVF as the general population. Many times, older women
undergo IVF and their miscarriage rates are naturally
higher. Since pregnancy testing is done two weeks after
embryo transfer, we often know about spontaneous miscarriages
in the very early stages of pregnancy. These miscarriages
would probably go unnoticed in the general population.
A: The
egg donation process is usually considered for women with
advanced maternal age over 42 years, in patients with
poor ovarian reserve, premature ovarian failure, prior
surgical removal of the ovaries and Turner syndrome. Usually
this is an anonymous process where the eggs are removed
from the donor, fertilization is allowed to occur in the
laboratory using the husband's sperm and the resulting
embryos are then transferred into the recipient's uterine
cavity for implantation to occur. Success rates are extremely
high with this process.
A: CDC's
ninth annual ART report summarizes national trends and
provides information on success rates for 399 fertility
clinics around the country. Overall, 28 percent of ART
procedures resulted in the birth of a baby for women who
used their own fresh eggs.
The 2003 report offers more evidence that a woman's age
is one of the most important factors in determining whether
she will have a live birth by using her own eggs. Women
in their 20s and early 30s had relatively high rates of
success for pregnancies, live births, and single live
births. But success rates declined steadily once a woman
reached her mid-30s."
Overall, 37 percent of the fresh non-donor procedures
started in 2003 among women younger than 35 resulted in
live births. This percentage of live births decreased
to 30 percent among women aged 35-37, 20 percent among
women aged 38-40, 11 percent among women aged 41-42 and
4 percent among women older than 42.
Women 42 or older are more likely to have a successful
ART procedure if they use donor eggs. Egg donors are typically
in their 20s or 30s. The average live birth rate for women
who used ART with donor eggs is 50 percent, and is independent
of age.
A: When
low sperm counts or poor sperm motility (movement) is
the cause of infertility, a procedure called ICSI (Intracytoplasmic
Sperm Injection - pronounced ICK-SEE) can help. In these
situations, the sperm require extra help to fertilize
the oocyte (egg). After egg retrieval, the embryologist
performs this micromanipulation procedure in the laboratory
by capturing an individual sperm and injecting it into
the mature egg by means of a small pipette. This process
is repeated for each individual egg. For some couples,
ICSI has overcome severe male infertility when only a
few sperm were available for fertilization.
Questions about our practice
A: A Reproductive
Endocrinologist / Infertility Specialist is a physician
who has received two to three years subspecialty fellowship
training after the completion of an obstetric and gynecology
residency program. A fellowship in Reproductive Endocrinology
provides focused training in all aspects of infertility
as well as laparoscopy and microsurgery, endocrinology,
menopausal problems, and endometriosis problems. Dr. Pinto,
the Medical director of ReproMed Fertility Center has
received three years of subspecialty training in Reproductive
Endocrinology and Infertility at Washington University
School of Medicine, St. Louis, MO.
A: We
are dedicated to helping couples with fertility problems
achieve their dream of parenthood. Our practice also specializes
in the evaluation and treatment of endometriosis, polycystic
ovarian syndrome (PCOS), recurrent pregnancy loss, and
laser laparoscopic gynecologic surgery. We offer a variety
of diagnostic tests and treatment procedures including
the following:
- Semen Analysis
- Sperm antibody studies
- Post Coital Test
- Reproductive hormone assays
- Ovarian reserve screening
- Ultrasound Examination
- Hysterosalpingogram (dye test)
- Diagnostic and operative Laparoscopy
- Diagnostic and operative Hysteroscopy
- Ovulation induction
- Intrauterine insemination
- Male infertility services
including donor sperm insemination
- In vitro fertilization
- Intracytoplasmic sperm injection
(ICSI)
- Embryo cryopreservation
- Assisted Hatching (AH)
- Donor Egg
- Gestational carrier/ surrogacy
- Preimplantation Genetic Diagnosis
(PGD)
- Laser laparoscopic gynecologic
surgery
- Laparoscopic myomectomy
A: As
a center dedicated to helping patients with infertility,
we work closely with your primary care physician and obstetrician.
With your permission, we will send a complete report to
your physician detailing the types of tests and procedures
performed here. When patients become pregnant, we refer
them back to their obstetrician or family practice physician
for ongoing prenatal care. Our practice does not provide
general obstetrical care. If you do not have an obstetrician,
Dr. Pinto will be happy to refer you to one.
A: We
have three offices in Dallas, Grapevine and Carrollton.
Patients can choose to see Dr. Pinto at any of these three
convenient locations. Contact
Us
A: To
make an appointment, please call the main office at 214-
827-8777. If you prefer, you may also call the Grapevine
office at 817-310-6686 and the Carrollton office at 214-483-3131.
We are available to see patients Monday through Friday
from 9 am - 5 pm by appointment only. Weekend appointments
are scheduled for specific treatments and time sensitive
tests. We also remain flexible to accommodate patients
who require appointments outside of the regular office
hours.
A: We
understand the anxiety associated with meeting a new physician
in a new practice. We are here to alleviate your fears
and support you during this process. If you are unable
to follow any of the instructions detailed below, we will
assist you with this process at the time of your visit.
Your comfort is our priority and we encourage you to call
us if you have any questions prior to your appointment.
Plan at least one hour for your first visit. Your first
visit is usually a consultation with Dr. Pinto. You are
encouraged to have your partner participate in the discussion.
Dr. Pinto will discuss your medical history, any prior
tests and treatments and your diagnosis. If appropriate,
future treatment options will be discussed. He will answer
any questions you may have. If indicated, a physical exam
and / or an ultrasound may be performed at this visit.
In order to maximize the benefit of your first meeting,
you are encouraged to address few important issues prior
to your appointment. Please bring copies of all medical
records relating to infertility, on yourself and your
partner. If you fill out the "Request for Medical records"
form (downloaded from this website) and send it to your
physician before your appointment, we will have your past
records in our office for review at the time of your appointment.
It is also advisable to download the required forms and
complete all paperwork prior to your appointment. Alternatively,
you have the option of doing this at the office. We do
ask that you arrive 15 minutes early for your first appointment
to give you time to complete the necessary forms. We make
every effort to remain on schedule and to not keep you
waiting. In order to do so, we kindly ask the same consideration
from you.
A: Dr.
Pinto will be personally involved in your treatment every
step of the way from the initial consultation, through
the monitoring to the final ultrasound confirming a pregnancy.
You can be confident that you will receive the best possible,
personalized and individualized care with a commitment
to detail.
After evaluating your medical history and reviewing test
results, Dr. Pinto will perform a physical examination
including a pelvic exam. Initial tests to determine hormone
levels and ovulatory function will be done before making
a diagnosis. After the diagnosis, Dr. Pinto will discuss
options for increasing your chances of a pregnancy including
ovulation-inducing medications, assisted reproductive
technologies (IVF and ICSI) or if appropriate, the use
of an egg donor when other therapies fail.
Since each patient's needs are unique, he will formulate
a fertility plan that is right for you with an emphasis
on patient education and a focus on patient safety.
A: Payment
is expected at the time of service. ReproMed Fertility
Center participates in a variety of health insurance plans
Click here
to read about Financial Matters. If you have questions
regarding our insurance participation, please contact
our office.
We encourage you to contact your insurance carrier to
determine your insurance coverage prior to visiting our
office. We will help you navigate the insurance maze.
We will provide you with specific codes so that you can
request a written explanation of specific benefits. If
necessary, we will also attempt to contact your insurance
carrier to confirm your benefits prior to your visit,
although this does not guarantee payment by the insurance
carrier for services provided.
Questions about Endometriosis
A: Endometriosis
is a benign (non-cancerous) condition in which the lining
of the uterus (called the endometrium) migrates / grows
outside the uterus and is present in places where it is
not normally found.
Endometriosis is usually confined to the pelvis. Common
sites of involvement are the ovaries, space behind the
uterus (cul-de-sac, rectum, uterosacral ligaments) and
urinary bladder. Although most common in the pelvis, endometriosis
has been documented in nearly every location of the body,
including such remote and unusual sites as the brain,
sciatic nerve, lungs and even skin.
The endometriotic implants outside the uterus continue
to break down and bleed periodically; the result is internal
bleeding, degeneration of blood and tissue shed from the
growths, inflammation of the surrounding areas, and formation
of painful adhesions and scar tissue. These endometrial
lesions can block the fallopian tubes or impair ovulatory
function.
A: According
to the American College of Obstetricians and Gynecologists
(ACOG), endometriosis is a common condition affecting
10 to 15 percent of reproductive-age women. Endometriosis
occurs in about 30 percent of all infertility cases.
A: There
are several theories, none of which have been proven.
However, research has shown that many women with endometriosis
appear to have a defect in their immune system. Other
causative factors may be: Retrograde menstruation or the
spillage of menstrual blood into the pelvis through open
fallopian tubes; Transplantation theory or the movement
of endometrial cells throughout the pelvis (and even outside
of the pelvis) through blood and lymphatic systems; and
Coelomic metaplasia or the ability of certain cells to
change into endometrial cells. Heredity is also said to
be a factor in endometriosis. Some believe that endometriosis
may actually be caused by "a combination of several factors."
A: The
symptoms of endometriosis may be highly variable from
one patient to another. The clinical presentation and
symptoms of the disease are frequently related to the
anatomical site of the disease. The most common symptom
is pelvic pain, which can be spontaneous non-cyclic pain,
painful menstrual periods, pain with intercourse or chronic
pelvic pain. Other symptoms include abnormal uterine bleeding,
spotting prior to periods, severe cramping, infertility,
diarrhea and painful bowel movements especially during
menstruation, abdominal tenderness, painful or burning
urination, urinary frequency, retention, or urgency.
The magnitude of the symptoms may not correlate with the
extent of the disease. Symptoms may be completely disabling
or mild. Sometimes the condition is present and causes
few to no symptoms or a patient with severe disease may
have very little pain. However, the likelihood of infertility
does increase as the severity of the disease increases.
Endometriosis rarely causes symptoms following natural
or surgical menopause.
A: Scarring
of the peritoneum around endometriosis is a typical and
very common finding. This occurs because of periodic bleeding
from the endometriotic spots and collection of the blood
in these areas. Since there is no escape for this blood,
it will start irritating the adjacent peritoneal surface,
causing inflammation and eventually, scarring. The 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.
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.
A: Endometriosis
has been identified as a major cause of infertility. Endometriosis
with scarring that distorts the anatomy of the pelvic
organs may impair fertility. Endometriosis is the cause
of infertility in approximately 35% of women with the
disease. When there is no distortion of the pelvic organs
or blockage of the fallopian tubes, endometriosis is less
likely to impair fertility. Some women with endometriosis
conceive without trouble.
With appropriate treatment pregnancy can certainly be
achieved by a woman with endometriosis. Sometimes, surgery
may improve the chance of pregnancy in women with endometriosis.
A: The
gold standard to diagnose endometriosis is by laparoscopy,
a surgical procedure in which a thin scope is placed through
the belly button into the abdomen to view the uterus,
ovaries, and fallopian tubes directly. While a biopsy
of the lesion does document the presence of endometrial
tissue, the gross appearance of endometriosis and visual
inspection of the pelvis is also considered adequate and
accurate for diagnosis of endometriosis. Surgeons can
videotape the laparoscopy for documentation and this can
be reviewed at a later date if there are any questions.
Ultrasounds, MRIs, CT Scans and other diagnostic tests
are not conclusive for the diagnosis of endometriosis.
A: Endometriosis
is a progressive disease. While there is no known cure
for endometriosis, medications and surgery can help delay
the progression of the disease. In general, endometriosis
is managed most effectively with a combination of properly
performed surgery and the use of appropriate medical therapies.
Medications that are helpful in alleviating symptoms and
controlling pain include gonadotropin-releasing hormone
(GnRH) agonists including Lupron, Aromatase inhibitors
such as Letrozole and birth control pills.
Surgical Management includes laparoscopic surgery to remove
the lesions--laser laparoscopy can remove endometrial
tissue and blockages from the body by excision, fulguration,
cauterization, and ablation. Hysterectomy is also an option
but will not eradicate the disease. Patients with infertility
may benefit from in vitro fertilization.
After surgery, approximately 50% of patients experience
major pain relief, a further 30% have adequate improvement
and the final 20% are not improved. In 50% of patients,
symptoms can recur with 6 months to a year.
Alternative medicine, acupuncture, herbal therapy, massage
techniques, good nutrition, and adopting a generally healthy
lifestyle may also contribute towards improving symptoms.
A: There
is no current manner of preventing Endometriosis, and
it is not a disease which is "contracted" or "caused"
by anything the patient did - nor is it contagious. It
is, however, suspected to be genetic.
Questions about PCOS
A: Polycystic
Ovarian Syndrome (PCOS) is a common endocrine (hormonal)
disorder in women of reproductive age. This disorder is
a "syndrome" which is defined as having a set of symptoms.
PCOS is a collection of symptoms related to infrequent
ovulation, characterized by irregular menstrual periods
and evidence of excess androgens (male hormones), which
can cause excessive facial hair growth, acne, and/or male-pattern
baldness. Women with PCOS may or may not have many small
cysts in their ovaries. PCOS is a health problem that
affects a woman's menstrual cycle, fertility, hormones,
insulin production, heart, blood vessels, and appearance.
This syndrome was originally named Stein-Leventhal Syndrome
in recognition of the two physicians who, in 1935, first
described the condition. Other names for PCOS include
hyperandrogenic chronic anovulation and functional ovarian
hyperandrogenism.
A: An
estimated five to 10 percent of women of childbearing
age have PCOS. As many as 30% of women have at least some
characteristics of the syndrome. It is a leading cause
of infertility. In fact, PCOS causes 75 percent of all
cases of anovulatory infertility.
A: The
exact cause of PCOS is unknown. Women with PCOS frequently
have a mother or sister with PCOS. Some studies are looking
at the possibility of a genetic link to this disorder.
Researchers are also looking at the relationship between
PCOS and the body's ability to make insulin. Since some
women with PCOS make too much insulin, it's possible that
the ovaries react by making too many male hormones, called
androgens. This can lead to acne, excessive hair growth,
weight gain, and ovulation problems.
A: Signs
and symptoms of PCOS often begin around the time of puberty,
but for others, symptoms do not develop until adulthood.
Symptoms vary among women, but can include:
- Appearance of small, multiple
cysts on the ovary, enlarged ovaries visible by ultrasound
- Irregular periods, infrequent
menses or lack of menstruation (amenorrhea) due to infrequent
or absent ovulation
- Infertility and miscarriage
- Elevated blood levels of male
hormones (androgens), especially testosterone
- Adult acne /oily skin/seborrhea
- Excess facial and body hair
(hirsutism)
- Male-pattern baldness, hair
loss or thinning hair (alopecia)
- Weight problems especially
around the midsection (central obesity)
- High blood pressure (hypertension)
- Abnormal lipid levels including
elevated tricylercides and high cholesterol
- Impaired glucose tolerance,
insulin resistance, hyperinsulinemia, & type II
diabetes
- Skin tags (acrochordons) and
dark velvety patches of thickened and dark brown or
black skin on the neck, arms, breasts, or thighs (acanthosis
nigricans)
- Chronic pelvic pain
- sleep apnea (excessive snoring
and breathing stops at times while asleep)
Any or all of these symptoms may be present, but some women
have none of these symptoms and still can carry the diagnosis.
These tend to be very lean, athletic women who may be even
underweight and this may mask the PCO syndrome.
A: A normal
menstrual cycle is dependent upon regular cyclic changes
in the blood hormone levels of estrogen and progesterone.
These hormones are produced in the ovaries. A woman's
ovaries have follicles, which are tiny sacs filled with
liquid that hold the eggs. Each month about 20 eggs start
to mature, but usually only one becomes dominant. The
growing follicle produces the hormone estrogen. As the
one egg grows, the follicle accumulates fluid in it. When
that egg matures, the follicle breaks open to release
the egg so it can travel through the fallopian tube for
fertilization. When the single egg leaves the follicle,
ovulation takes place. After ovulation occurs, the remainder
of the ruptured follicle in the ovary produces progesterone.
This is the process that occurs normally on a monthly
basis in women with regular menstrual cycles.
In women with PCOS, the ovary doesn't make all of the
hormones it needs for any of the eggs to fully mature.
They may start to grow and accumulate fluid. But no one
egg becomes large enough. Instead, some may remain as
cysts and continue to produce estrogen. Since no egg matures
or is released, ovulation does not occur and the hormone
progesterone is not made. Also, the cysts produce male
hormones, which continue to prevent ovulation.
It is the abnormal hormone levels that lead to irregular
periods in women with PCOS. As a result, the inside lining
of the uterus - called the endometrium - is exposed to
the hormone estrogen for great lengths of time without
being exposed to the hormone progesterone. It is the cyclic
rise and fall in both estrogen and progesterone that cause
menstrual bleeding. In the case of PCOS, there can be
prolonged lengths of time without the production of progesterone.
During this time the endometrium is continuously exposed
to estrogen. The result of this prolonged estrogen exposure
is the buildup /growth of the endometrium. When the endometrium
becomes too thick, heavy and irregular bleeding can occur.
Also when the endometrium is exposed to estrogen for prolonged
periods of time, cell changes can occur in which the cells
of the endometrium become abnormal and, if not treated
appropriately, can develop into cancer of the uterus.
Progesterone prevents this build-up of the endometrium.
A: Although
PCOS is primarily a problem of the ovaries, the condition
alters hormone levels and affects tissues throughout the
body.
Weight gain and obesity - PCOS is associated with gradual
weight gain and obesity in about one-half of the women
with this condition. Diet and exercise can help maintain
a normal body weight. For some women with PCOS, the obesity
develops at the time of puberty.
Insulin abnormalities and diabetes - PCOS is also associated
with abnormal blood insulin levels, the hormone that regulates
blood sugar levels. These abnormalities may include:
- Hyperinsulinemia (excess production
of insulin)
- Insulin resistance (poor response
of body tissues to insulin)
- Impaired glucose tolerance
(a condition of borderline diabetes mellitus)
- Type 2 diabetes mellitus (non-insulin-dependent
diabetes mellitus, a condition characterized by elevated
blood sugar levels)
Insulin resistance and hyperinsulinemia can occur in both
normal-weight and overweight women with PCOS. By age 40,
up to 35 percent of obese women with PCOS develop impaired
glucose tolerance, and up to 10 percent of obese women with
PCOS develop type 2 diabetes. These rates are much higher
than expected for normal women at this young age.
Impaired glucose tolerance and diabetes are usually detected
by blood tests. Often a fasting blood test is sufficient,
but sometimes a glucose tolerance test is needed. Weight
loss, exercise, and drugs can help normalize blood sugar
levels.
Heart disease and hypertension-The presence
of both obesity and insulin resistance might increase a
woman's risk for coronary artery disease, which is the narrowing
of the arteries that supply blood to the heart. Both weight
loss and treatment of insulin abnormalities can decrease
this risk.
Uterine cancer - Irregular menstrual periods
and the absence of ovulation cause women to produce the
hormone estrogen, but not the hormone progesterone. Without
progesterone, which causes the endometrium to shed each
month as a menstrual period, there is a hormonal imbalance.
This promotes persistent growth of the endometrium (the
lining of the uterus). Eventually, this can lead to endometrial
hyperplasia or cancer. Treatment with oral contraceptives
or intermittent progesterone-like drugs can promote normal
menstrual bleeding and lessen overgrowth of the endometrium.
Sleep apnea - Sleep apnea has been reported
to occur in up to 30 percent of women with PCOS. This is
a disorder characterized by excessive snoring at night with
brief spells where breathing stops (apnea). Patients with
this problem experience fatigue and daytime sleepiness
Hirsutism - Hirsutism is the excess growth
of coarse dark hair in a predominantly male pattern. Women
affected by PCOS commonly experience hirsutism due to increased
levels of the male hormones called androgens. The longer
a woman with PCOS goes untreated the more severe her hirsutism
will become.
Infertility- Lack of ovulation or infrequent
ovulation results in difficulty in getting pregnant.
Most of these above mentioned effects can be anticipated
and thus prevented or promptly treated before they pose
significant health problems.
A:
Women with PCOS generally have irregular, infrequent,
or even absent ovulation. Without ovulation there is no
egg or ovum that is available for fertilization. Also,
due to the abnormal hormone levels, the endometrium, or
inside lining of the uterus, does not develop normally
in women with PCOS. Therefore, even if a rare ovulation
was to occur and the egg was fertilized, the endometrium
may not be properly developed to allow for the attachment
and growth of the embryo.
The good news is that this problem with ovulation be fixed
with medications. These include ovulation induction agents,
insulin sensitizing drugs and Gonadotropins. . It is important
to know that these options work best for women who are
not obese. Even a modest amount of weight loss may improve
the effectiveness of the medications.
Medications called ovulation induction agents, such as
clomiphene citrate stimulate the ovaries to release one
or more eggs. Clomiphene citrate triggers ovulation in
about 80 percent of women with PCOS, and about 50 percent
of these women will actually become pregnant. In women
taking clomiphene, ovulation can be confirmed by blood
and urine tests or by measurement of body temperature.
If the original dose of clomiphene does not trigger ovulation,
a higher dose may help.
Several studies have shown that the insulin-sensitizing
drug, metformin, increases the effectiveness of clomiphene
in producing ovulation. However, it is unknown if this
drug is safe during pregnancy, and is stopped once the
woman is pregnant.
Gonadotropin therapy is a second, more aggressive medical
treatment for PCOS-related infertility. Gonadotropins
include Leutinizing hormone (LH) and Follicle Stimulating
Hormone (FSH). FSH is used without LH for women with PCOS,
and is given as a daily injection under the skin for 7
to 10 days. These drugs trigger ovulation in almost all
women with PCOS and can lead to pregnancy in approximately
60 percent.
Surgery is an option in rare situations. In very rare
cases, ovulation is not achieved with medications and
ovarian surgery may be necessary to stimulate ovulation.
This surgery is usually performed via the laparoscope.
If the above mentioned treatments are not successful in
producing a normal pregnancy, then the use of the assisted
reproductive technologies (ART), such as in vitro fertilization,
can be attempted.
In conclusion, a diagnosis of PCOS suggests that you are
likely to have some difficulty becoming pregnant. However,
with help from your physician, pregnancy should be an
option for almost everyone with PCOS.
A: There
appears to be a higher rate of miscarriage, gestational
diabetes, pregnancy-induced high blood pressure, and premature
delivery in women with PCOS. Preliminary studies also
suggest that metformin might reduce the risk of early
pregnancy loss and the development of gestational diabetes
mellitus (diabetes during pregnancy) in women with PCOS,
while pregnant. Researchers are also looking at how the
drug lowers male hormone levels and limits weight gain
in women who are obese when they get pregnant. It is not
yet known if Metformin usage is safe during pregnancy,
since the drug crosses the placenta.
A: There
is no single test to diagnose PCOS. A physician can often
diagnose PCOS by obtaining a detailed medical and gynecological
history and performing a physical exam. At the physical
exam, evaluation of the areas of increased hair growth
will be important. During a pelvic exam, the ovaries may
be enlarged or swollen by the increased number of small
cysts. Blood hormone levels such as testosterone levels
are often measured to confirm the diagnosis. Additionally,
glucose or sugar levels, as well as insulin blood hormone
levels may be measured. A vaginal ultrasound may be performed
to help distinguish PCOS from other disorders that cause
multiple cysts in the ovaries. The ultrasound exam can
also identify a thickened uterine lining. If menstrual
periods have been irregular or absent, an endometrial
biopsy may be necessary to rule out a pre-cancerous endometrial
condition.
The current criteria for the diagnosis of PCOS include
the following three items:
- Irregular or absent periods
- Signs of excess androgens
(male hormones) in the form of excess hair growth or
blood tests that show elevated levels of androgen
- Lack of any other conditions
that would explain the above two conditions, such as
problems with the pituitary, thyroid or adrenal glands
The combination of a detailed history, physical exam and
blood testing is usually adequate to diagnose PCOS.
A: There
is no cure for PCOS, but it is manageable with medications,
diet, and exercise. Adequate treatment can help prevent
serious long-term risk factors. The treatment is relatively
simple and based upon the goals of the patient. Some patients
may be concerned primarily with fertility, while others
may be more concerned about menstrual cycle regulation,
hirsutism or acne. Regardless of the primary goal, patients
are advised to report all symptoms to their physician
as specifically as possible.
Below are general descriptions of treatments used for
PCOS:
- Birth control pills:
For women who don't want to become pregnant, birth control
pills can regulate menstrual cycles, reduce male hormone
levels, and help to clear acne. However, the birth control
pill does not cure PCOS. The menstrual cycle will become
abnormal again if the pill is stopped. A pill that only
has progesterone can also regulate the menstrual cycle
and prevent endometrial problems. But progesterone alone
does not help reduce acne and hair growth.
- Diabetes Medications:
The medicine, Metformin, also called Glucophage, which
is used to treat type 2 diabetes, also helps with PCOS
symptoms. Metformin affects the way insulin regulates
glucose and decreases the testosterone production. Abnormal
hair growth will slow down and ovulation may return
after a few months of use. These medications will not
cause a person to become diabetic.
- Fertility Medications:
The main fertility problem for women with PCOS is the
lack of ovulation. Even so, a sperm analysis should
be performed and the tubes checked to make sure they
are open before fertility medications are used. Clomiphene
(pills) and Gonadotropins (shots) can be used to stimulate
the ovary to ovulate. If medications do not succeed
in achieving a pregnancy, In vitro Fertilization (IVF)
is sometimes recommended. Metformin can be taken with
fertility medications and helps to make PCOS women ovulate
on lower doses of medication.
- Medication for increased
hair growth or extra male hormones: If a woman
is not trying to get pregnant there are some other medicines
that may reduce hair growth. Spironolactone is a blood
pressure medicine that has been shown to decrease the
male hormone's effect on hair. Propecia, a medicine
taken by men for hair loss, is another medication that
blocks this effect. Both of these medicines can affect
the development of a male fetus and should not be taken
if pregnancy is possible. Other non-medical treatments
such as electrolysis or laser hair removal are effective
at getting rid of hair. A woman with PCOS can also take
hormonal treatment to keep new hair from growing.
- Surgery: Although
it is not recommended as the first course of treatment,
surgery called ovarian drilling is available to induce
ovulation. It is an option in very rare cases. A very
small incision IS made above or below the navel, and
a small instrument that acts like a telescope is inserted
into the abdomen. This is called laparoscopy. The doctor
then punctures the ovary with a small needle carrying
an electric current to destroy a small portion of the
ovary. This procedure carries a risk of developing scar
tissue on the ovary. This surgery can lower male hormone
levels and help with ovulation. But these effects may
only last a few months. This treatment doesn't help
with increased hair growth and loss of scalp hair.
- Weight Loss: Maintaining
a healthy weight is another way women can help manage
PCOS. Since obesity is common with PCOS, a healthy diet
and physical activity help maintain a healthy weight,
which will help the body lower glucose levels, use insulin
more efficiently, and may help restore a normal period.
Even loss of 10% of her body weight can help make a
woman's cycle more regular.
A:
No. PCOS is a condition that can be managed, but currently
no cure exists. Treatment of the symptoms can help reduce
risks of future health problems. Today, several drugs and
lifestyle modifications can help control the signs and symptoms
of PCOS. Medical and surgical treatment can also help women
who want to become pregnant, but are having difficulty conceiving.
Treatment is individualized and depends on each woman's
symptoms, reproductive goals, and presence of other medical
conditions. In some women, symptoms of PCOS may be minor
and simply annoying, and treatment may seem unnecessary.
However, untreated PCOS may increase a woman's risk of other
health problems over time. Women with PCOS should take an
active role in their medical care by learning as much as
they can about the condition and by working with their physician
to develop the best treatment plan.
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