UNDERSTANDING INFERTILITY
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the most concerning. Those fibroids which are completely (type 0) or partially within the
cavity (types 1-2) can often be removed vaginally via hysteroscopic resection. Regardless
of their location in the uterus, very large fibroids may also need to be addressed prior to
pregnancy, but may instead require laparoscopic (including robot-assisted) myomectomy.
In fewer cases, an abdominal procedure may be the only feasible method of removal.
There is insufficient evidence regarding the impact on fertility or early pregnancy loss
of fibroids that are not effecting the endometrial cavity (4). Endometrial polyps can also
disrupt carrying a normal pregnancy. Because of their location inside the uterus, polyps
can usually be removed by hysteroscopy.
ENDOMETRIOSIS
The exact causes for reduced fertility in women with endometriosis are not fully under-
stood. It seems that in lower stages (I-II) of the condition, the presence of endometriosis
releases enzymes that interfere with egg release and transport as well as the function of
the sperm cells and the implantation process. Higher stage disease (III-IV) causes ad-
ditional problems due to severe adhesions and distortion of the pelvic anatomy (Figure
2). In the most severe cases, this may lead to tubal blockage (5).
Laparoscopy is the preferred surgical approach. In milder cases, cutting adhesions
and restoring the proper relationship of the ovary may be beneficial (5). The biggest
impact on fertility lies in the excision of collections of endometriosis in the ovary called
endometriomata (Figure 3). Ideally the endometrioma wall can be removed with as little
damage to the remaining ovary as possible. Aggressive removal or cautery of ovarian
tissues may reduce the ovary’s ability to make eggs and may shorten its lifespan (6).
Removal of every vestige of endometriosis has not been shown to improve pregnancy
rates. Once a patient has undergone a fertility-focused surgery for endometriosis, and
she has not conceived promptly (six months or so) and there is no other known cause
of the couples infertility, infertility treatments including IVF should be considered (7).
The excision of endometriomata does not improve the success of IVF (8).
Women with high stage disease or women older than 35 should consider assisted re-
productive treatments earlier in the process and not be subjected to multiple surgeries.
While additional surgeries have been shown to be helpful in certain cases of treating
endometriosis pain, they have not demonstrated much success in treating fertility.
MULLERIAN ANOMALIES
Surgery may also be beneficial in cases where the uterine cavity is misshapen. Uterine
fibroids can cause distortion, but there are congenital malformations as well, called Mul-
lerian Anomalies (Figure 4). The uterine anatomy migrate to the midline and fuse to form
the teardrop shape of the normal uterus. Complete and incomplete fusion failures can
occur. Interestingly, pregnancy outcome is generally better in the more complete fusion
failures (didelphys, unicornuate and bicornuate) and therefore aggressive metroplasties
to unify the uterus are seldom needed.
Good improvements have been demonstrated at increasing pregnancy rates and reduc-
ing miscarriages in patients who have a dividing septum in the uterus (9). These septa are
usually fibrous in their lower portions and do not provide a good site for implantation.
Furthermore, they may interfere with fetal growth and position. Using a hysteroscopic
Mullerian anomalies: Cases courtesy of Dr. Sachintha Hapugoda and A.Prof Frank Gaillard, Radio-
paedia.org, rID: 11115.
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