Fertility Problems

Ovarian cysts are very common and can happen to a woman at any age. Most cysts are follicle cysts which are functional cysts that are harmless, fluid-filled sacs of tissue which are formed in the ovaries as part of the menstrual cycle. Occasionally, one of the sacs doesn’t break open to release an egg and, instead, fails to dissolve and keeps on growing. These cysts are usually painless and benign (non-cancerous) and will often dissolve naturally and disappear without treatment within a few months.

Ovarian cysts, such as corpus luteum cysts, fail to dissolve and grow very large, changing into a hormone producing yellow body filled with fluid or blood. If ruptured they can cause bleeding. Birth control pills may help make the cyst smaller and lessen the chance of new ones forming.

Endometriomas or Chocolate Cysts are tiny cells that line the uterine cavity which can become transplanted to form small cysts on the outside of the ovary. These cysts respond to hormone stimulation during the menstrual cycle and can enlarge to produce endometriosis of the ovary and can even replace normal ovarian tissue.  These cysts are called chocolate cysts because they are filled with a thick, chocolate-type material which can rupture and spill into the pelvic area, around the uterus, bladder and bowel, causing adhesions to develop which can cause pelvic pain.  Endometriomas can also interfere with egg follicle development and therefore a possible cause of infertility.

Some ovarian cysts can grow to almost four inches in size and can bleed or twist the ovary and cause pain.  These “Dermoid cysts” can contain can contain a range of tissues, such as hair, skin or teeth, because they form from cells that make eggs in the ovaries.  Dermoid cysts are rarely malignant and can be removed with laparoscopic surgery by a skilled surgeon, irrespective of their size.

Most ovarian cysts don’t cause any symptoms. If they do, ultrasound can be used to monitor the size of the cyst to see if treatment is needed. A pelvic exam can be used to monitor more larger cysts.

Polycystic Ovarian Syndrome (PCOS) is a condition in which small follicles (cysts) in the ovaries fail to develop into larger, mature follicles. Typically a woman with PCOS will have a number of small cysts around the edge of her ovaries. It’s also characterised by hormone imbalances typically caused by high levels of the male hormone testosterone, which is produced by the ovaries, and unpredictable ovulation patterns. Irregular periods, excessive hair growth, acne and obesity can also indicate PCOS.

Polycystic Ovary Syndrome cannot be cured, but the symptoms can be effectively treated.  Diet and exercise and hormone treatment and IVF may be possible solutions.  Elevated blood insulin levels are common in women with PCOS.  In excess this can cause over stimulation of the ovaries and induce them to produce greater amounts of the male hormone, testosterone, which then prevents ovulation.  Losing weight can therefore reduce the amount of insulin and therefore testosterone levels to improve the chances of ovulation. Metformin, a drug used for treating diabetes, is a new treatment for PCOS which, together with other fertility drugs and treatment, can also help increase ovulation and may also reduce the effect of abnormal levels of male hormones.

Hydrosalpinx ocurs when a blockage in a fallopian tube causes the tube to dilate (increases in diameter) and fill with fluid.  The fluid blocks the egg and sperm preventing fertilisation and pregnancy.  If only one fallopian tube is blocked it may still be possible to achieve pregnancy but this depends on how well the ovaries are functioning and what caused the blocked tube in the first place.

An HSG with a contrast dye can detect whether fallopian tubes are normal (patent) or blocked.

Click “Hydrosalpingogram (HSG)”  showing normal fallopian tubes where the contrast dye can be seen flowing freely from the end of each tube.

Click “HSG Hydrosalpinx” showing an HSG of a blocked fallopian tube where the contrast dye is pooling on the left-hand side.

It’s also possible for a fallopian tube to become partially blocked which can increase the risk of a tubal pregnancy, also known as an ectopic pregnancy where the fertilised egg has implanted outside the womb or in one of the fallopian tubes instead. An ectopic pregnancy can also occur in other places, eg. the ovary, the abdomen, the cervix and at the join between the tube and the womb, the cornua.

An ectopic pregnancy can never be viable and ultimately ends in death of the foetus.  If left untreated, it can also be fatal for the mother. An ectopic pregnancy can also cause the fallopian tube to split (rupture) causing internal abdominal bleeding and life threatening blood loss.

Without timely diagnosis and treatment an ectopic pregnancy can become a life-threatening situation. In most cases both the fallopian tube and the foetus would have to be surgically removed.

Fibroids are abnormal growths of the smooth muscle that formsthe wall of the uterus. They can also contain fibrous tissue and vary in shape and size. Fibroids can differ in type depending on where they are located.

Intramural uterine fibroids form in the inner wall of the uterus and the most common type of fibroid found in women. Subserosal fibroids grow on the outside the wall of the uterus and into the pelvis and can become very large. Submucosal fibroids can develop in the muscle beneath the inner lining of the uterus wall and can grow into the middle of the uterus.

Pendunculated fibroids grow from the outside wall of the uterus and are attached by a narrow stalk. Cervical fibroids develop in the wall of the cervix (the neck of the uterus).

The cause of fibroids is unknown.  There is often a history of women in the same family developing fibroids. For reasons unknown fibroids are three times more common in non-Caucasian women. Women who are overweight are also more likely to develop fibroids. There is some link between fibroid growth and the hormone oestrogen which is produced by the ovaries. They tend to increase in size when oestrogen levels are high, such as during pregnancy. They are also known to shrink when oestrogen levels are low, such as after the menopause and therefore why they are most likely to occur in women between the ages of thirty and fifty.

Many women are unaware they have fibroids because they don’t have any symptoms and, over time, fibroids will often shrink and disappear without any treatment being necessary. While fibroids do not always cause symptoms, their size and location can lead to problems, including pressure symptoms and painful or heavy periods which can have a significant impact on everyday life.  Large fibroids, may cause discomfort or bloating (swelling) in your stomach.  They may also cause pain in the back and legs, frequent urination (if they press on the bladder) and Constipation. If fibroids grow near the vagina or the cervix sexual intercourse may become painful.

High levels of oestrogen during pregnancy can cause fibroids to develop or increase in the size and may lead to complications with the development of a baby or cause problems during labour.  In rare cases fibroids can cause miscarriage.  When fibroids are very large infertility may occur as they can sometimes prevent a fertilised egg attaching itself to the lining of the womb.  If you have a submucosal fibroid it may block a fallopian tube preventing eggs from passing from the ovaries to the womb making it harder to conceive.  An ultrasound scan of the womb or hysteroscopy, a small telescope that can see inside the womb, is often used to confirm a diagnosis of fibroids. A transvaginal scan can also aid diagnosis and involves inserting a small scanner into the vagina to take a closeup image of the womb.  A laparoscopy can also be used to take a biopsy (a tissue sample) of the inside lining or outer layer of the womb which will be sent to a laboratory for further examination. Medication, frequently hormonal treatment and other non-surgical techniques, may be prescribed. If these prove ineffective it may be necessary to use surgical techniques if symptoms are particularly severe.

A uterine polyp is an overgrowth of tissue that arises from the endometrium – the lining of the uterus. This tissue is expelled during the menstrual cycle. After a period, the endometrium regenerates rapidly under the influence of hormones. Polyps occur in areas where the lining grows in excess. Uterine polyps are oval or round, they remain attached to the uterine wall by a large base (sessile) or a thin stalk (peduncular).

Polyps usually occur in perimenopausal or postmenopausal women. Although polyps are usually contained within the uterus, they may occasionally arise on the surface of the cervical canal. The main difference between uterine polyps and uterine fibroids is that fibroids are composed of muscle tissue and polyps are made of endometrial tissue. Unlike fibroids small polyps may shrink at any stage but can also cause infertility. Polyps are usually benign and rarely cancerous. Endometrial adenocarcinomas, which are malignant tumours of the glandular component of the endometrium, have only been reported in 0.6% of cases of endometrial polyps.

Endometrial polyps are usually diagnosed by taking a biopsy of the endometrium after D&C (dilation and curettage) where the cervix is gradually dilated to allow removal of the uterine lining at which time any endometrial polyps that are found can be removed. However, removal of polyps or other structural abnormalities may be missed by D&C alone therefore techniques such as curettage using ultrasound for guidance or hysteroscopy is useful. Using hysteroscopy, the inside of the uterus is examined by introducing a small camera with a light source on the end of a tube (hysteroscope) directly into the uterus by passing it through the vagina and cervix.

Sperm morphology refers to the size and shape of sperm which can be investigated by semen analysis. When sperm are viewed under a microscope. abnormal sperm morphology may be seen which is one cause of male infertility.

When looking for normal sperm, doctors look for sperm that have oval heads and a long tail. This is considered normal. Abnormal sperm can have many defects such as head and tail defects including crooked or double tails or even double heads. These abnormal sperm have a very difficult time reaching the egg and fertilising it.

The motility of the sperm is evaluated. The World Health Organization defines normal motility as 50% of observed sperm, measured within 60 minutes of collection, or at least 8 million per millilitre showing good forward movement.

However, a man can have a total number of sperm far over 20 million sperm cells per millilitre but have bad quality sperm because too few of them are motile. Conversely, a man can have a sperm count far less than 20 million sperm cells per millilitre and his sperms still have good motility and show good forward movement. The motility of sperm are divided into four different grades:

Approximately 2 to 13% of all sperm are genetically abnormal (aneuploid) in normally fertile men. There is evidence that this percentage may be increased in men who are sub-fertile.

It has been recently found that there is no direct correlation between sperm morphology and aneuploidy as sperm aneuploidy can also be found in sperm with normal morphology.  However, particular types of morphological defects may be linked to sperm aneuploidy including globozoospemia (also called round-headed spermatozoa) where a lacking a chrosome containing enzymes for penetrating the oocyte is often found.  Amorphous heads, multiple heads and severe tail defects may also be linked with aneuploid sperms.

Recent studies are now revealing that men with very poor sperm quality results using routine semen analysis can have sperm with very little DNA damage. Conversely men with relatively normal results can have sperm with a high degree of DNA damage which can be revealed by Sperm DNA Fragmentation Assay (SDFA). The degree of DNA fragmentation correlates very highly with the inability of the sperm to initiate a birth, regardless of the technology used to fertilise the egg such as insemination, IVF or ICSI (intra cytoplasmic sperm injection).

Abnormal sperm DNA fragmentation is found in around 20-30% of men with sub-fertility, nearly ten times higher than that found in fertile men.  Sperm with high DNA fragmentation may fertilise an egg yet embryo development stops before implantation or may even initiate a pregnancy but there is a significantly higher likelihood that it will result in miscarriage. By testing for sperm DNA fragmentation (SFDA test) many cases of formally “unexplained” infertility can now be explained.

The SDFA test evaluates sperm DNA damage, The test uses a high precision light microscope and an orange stain to determine DNA damage, intact DNA showing fluorescent green and broken DNA staining yellow to red. Yellow indicates ICSI as a possible method of IVF treatment, red indicating that the sperm are more likely to be beyond the DNA repair capacity of the egg.

Total azoospermia is the total absence of sperm present in a man’s semen after ejaculation. This can be due to a blockage, absence of the vas deferens (a coiled tube that carries the sperm out of the testes) or failure of the testes to produce spermatozoa.

It is quite easy to recover sperm directly from a testis or from the epididymis, which are spermatic ducts that store, mature and transport spermatozoa between the testis and the vas deferens. Sperm collected in this way are not able to fertilise an egg naturally therefore assisted conception using ICSI will be necessary with a success rate for fertilisation of around 65%.

It is also possible to collect a few sperm by  performing testicular biopsies. If some motile sperm are recovered the chances of these sperm fertilising an egg are good.

Percutaneous Epididymal Sperm Aspiration (PESA) uses a needle to penetrate the scrotal skin and draw a small amount of sperm from the epididymis. Percutaneous Testicular Biopsy (PTBX) removes small cores of testes tissue.

The PESA and PTBX procedures are either performed through the skin (percutaneous) or through a small opening in the skin about half an inch in size. With microsurgical techniques in a process known as Microscopic Epididymal Sperm Aspiration (MESA), sperm can be gathered from the epididymis. Epididymal Sperm Aspiration (MESA), sperm can be gathered from the epididymis.

Testicular Sperm Extraction (TESE) involves removing small samples of testis tissue for processing and eventual extraction of sperm. Microscopic TESE (MicroTESE) is a very exacting search for sperm under high magnification in cases of extremely low sperm production.

The vas deferens is a major part of the male reproductive system which connects to the epidydimis, a muscular, partially coiled tube that sits behind the testes to collect sperm.  It is the vas deferens that then transports sperm from the epididymis into the pelvic cavity in preparation for ejaculation.

Congenital absence of the vas deferens (CAVD) is a rare condition.  Although testicular function is normal, the vas deferens is mssing and therefore unable to contribute sperm to the ejaculate.  In such cases, however, sperm cells can be collected directly from the epididymis and used for in-vitro fertilisation (IVF) using intra-cytoplaspic sperm injection  (ICSI).

Many men with this problem are carriers of the cystic fibrosis gene and should also go through genetic screening.