Infertility - Uterine Factor

Abnormalities of the uterus are a relatively uncommon cause of infertility but should always be considered. The anatomic uterine abnormalities that may adversely affect fertility include congenital malformations, leiomyomas ( fibroids ), intrauterine adhesions ( scarring ) , and endometrial polyps. These same abnormalities can also adversely affect pregnancy outcome ( recurrent pregnancy loss ).

Congenital Uterine Malformations

Developmental uterine anomalies have long been associated with pregnancy loss and obstetric complications, but the ability to conceive is generally not affected.

When discovered during evaluation for infertility, anomalies cannot, therefore, be regarded as the likely cause or even as an important contributing cause of infertility but only as another obstacle that must be considered when choosing from the range of treatment options once evaluation is completed. For example, treatments that are associated with substantial risk for multifetal gestations ( superovulation with IUI, IVF ) present even greater risks to women with uterine malformations. The septate uterus may be one specific exception to this general rule.

Among all congenital uterine abnormalities, the septate uterus is both the most common and the most highly associated with reproductive failure and obstetrical complications, including first and second trimester miscarriage, preterm delivery, fetal malpresentation, intrauterine growth retardation, and infertility.

Uterine Leiomyomas ( Fibroids )

Available evidence indicates that pregnancy and implantation rates are significantly lower in women with submucous myomas but not in those with subserosal or intramural myomas that do not encroach on or clearly distort the endometrial cavity, at least when they are relatively modest in size ( less than 5 - 7 cm ).

Judgments concerning the indications for surgical intervention in infertile women with myomas in many ways parallel those in women with congenital uterine malformations. Like septate uteri, submucous myomas are associated with a decreased probability for successful pregnancy and are most often amenable to that has relatively low morbidity and avoids the risks and consequences of abdominal uterine surgery. The management of uterine myomas in infertile women must be highly individualized.

Consideration is given to the relative risks, benefits, and consequences of different surgical treatments, as well as age, ovarian reserve, reproductive history, duration of infertility, other infertility factors and the treatment they require, plus the size, number, and location of myomas.

Intrauterine Adhesions ( Asherman's Syndrome )

Menstrual disorders and infertility are the most common presenting symptoms in women with intrauterine adhesions ( also known as synechiae ); others include recurrent pregnancy loss and placenta accreta. Any insult severe enough to remove or destroy endometrium can cause adhesions, and the gravid uterus seems particularly susceptible to injury ( D & Cs for miscarriages, elective abortions, or postpartum curettage or caesarian sections). Less commonly, adhesions may develop as a postoperative complication of abdominal or hysteroscopic myomectomy, metroplasty or septoplasty procedures, or other uterine surgery.

Chronic inflammatory or infectious insults, notably genital tuberculosis, also can result in intrauterine adhesions ( rare in the United States ). Hysteroscopy is the method of choice for treatment of intrauterine adhesions and is safer and more effective than blind curettage.

Endometrial Polyps

The overall prevalence of polyps in infertile women is approximately 3% - 5%. The prevalence is higher in women with other symptoms ( abnormal bleeding ) and may also be higher in those with endometriosis. Polyps can be identified by HSG or transvaginal ultrasound.

Myomectomy

Myomectomy, the surgical removal of fibroids from the uterus, allows the uterus to remain in place to preserve or restore fertility and to lessen the probability of miscarriage caused by fibroids. The procedure is the preferred fibroid treatment for women who want to become pregnant. Sometimes, before vitro fertilization, myomectomy is performed to improve the chances of fertilization.

Uterine fibroids ( also known as myomas ) affect 30% of women. They occur in various sizes, numbers, and location in the uterus requiring different types of myomectomy. A pelvic exam, ultrasound, MRI, or hysteroscopy accurately diagnose fibroids. If your physician determines that removal of the fibroids will increase your chance of pregnancy, either a hysteroscopy, laparoscopy, or laparotomy is advised.

Hysteroscopy involves inserting a lighted viewing instrument through the vagina and cervix into the uterus; there is no incision so this is an outpatient procedure. Recovery time takes from two days to about two weeks.

Laparoscopy uses a lighted viewing instrument and one or more small incisions ( cuts ) in the abdomen. This option is an outpatient procedure that may require a day's stay in the hospital and two to four weeks to recover.

Laparotomy requires a larger abdominal incision; therefore, an average hospital stay of one to four days is required and a recovery period of two to four weeks.

Of women who have a myomectomy for infertility and who have no other known cause of infertility, 60% then become pregnant. Following myomectomy, a cesarean section may be needed for delivery. This depends in part on where and how big the myomectomy incisions are on the tubes.

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All information on our Web site is provided for educational purposes. Your health care professional should always be consulted for specific treatment recommendations.