UNDERSTANDING INFERTILITY
SURGICAL INTERVENTIONS FOR FEMALE INFERTILITY
AUTHORS Daniel N. Ginn, DO, MPH, FACOG & Jonathan H. Reinstine, MD, FACOG, FACS
I
nfertility affects up
to 15% of couples
(1). The evaluation
of such cases can be
extensive and mul-
tifactorial, involving
either partner and
potentially respon-
sive to medical or surgical interventions. Starting with a purposeful
discussion with the patient about her goals, not just what can be
offered, is critically important. Some of the most challenging as-
pects of patient counseling are differences in known impacts of the
ability to conceive versus live birth rates. Additionally, any surgical
intervention for infertility may be subject to coverage restrictions
by a patient’s insurance carrier. Many of these causes, however, are
also accompanied by heavy menstrual bleeding or pain, which is
more likely to be included. The most common diagnoses in female
patients that are amenable to surgical intervention are uterine fi-
broids and polyps, endometriosis, Mullerian anomalies, and tubal
factor infertility. Neither this list nor the following discussion are
meant to be exhaustive, but it may serve as a starting point for the
non-gynecologist in identifying appropriate referrals.
UTERINE FIBROIDS AND POLYPS
Uterine leiomyomata, or “fibroids,” are very common. In fact, these
typically benign tumors of the uterus are found in 15-25% of re-
productive-age women, with a cumulative incidence of 70% in
all women. They are found in women of all ethnicities, with the
highest rates seen in African Americans (2,3,4). Fibroids can have
a significant impact on fertility, but the effect, as in real estate, is all
about “location, location, location” (Figure 1). Fibroids can cause
pelvic pain, heavy bleeding, difficulty conceiving, pregnancy loss,
or any combination of these symptoms, and are usually diagnosed
by pelvic ultrasound. Submucosal fibroids, which are either inside
of the endometrial cavity or are distorting its shape (types 0-2), are
(continued on page 24)
(left to right) Uterine fibroids: Case courtesy of Dr. Sachintha Hapugoda, Radiopaedia.org, rID: 62908; Endometriosis: Case courtesy of A.Prof Frank Gaillard,
Radiopaedia.org, rID: 9861; Endometrioma: Case courtesy of Dr. Maulik S Patel, Radiopaedia.org, rID: 12511.
SEPTEMBER 2019
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