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Endometriosis
 Endometriosis is a condition in which there is a growth of tissues outside
of the uterus that can either cause pelvic pain or infertility. It is
without question one of the most baffling conditions that affect women. An
estimated 10 million women in the US are affected by this disease, and it is
one of the leading causes of infertility in women. Though there are many
effective treatments, there is no known cure. The diagnosis is confirmed
when uterine or endometrial cells are identified outside their usual
location inside the uterus.
Endometriosis may be found on the outside of the uterus, inside and outside
the ovaries, or implanted upon the fallopian tubes, bowel, urinary tract,
and anywhere in the abdomen. When a woman gets her period the endometriosis
often responds to the menstrual cycle's hormonal signals. When the
endometriosis bleeds, the woman may have sensations of deep pain or
cramping. The body responds to the bleeding by surrounding it with
inflammation often causing adhesions and leaving scar tissue. Endometriosis
is estimated to be present in 15% of all reproductive age women, but as many
as 30-40% of all infertile women. The exact ways that endometriosis affects
infertility are not fully understood. Scar tissue and adhesions are known to
interfere with the path the egg and sperm must travel to unite and become
fertilized and implanted. In some women, endometriomas (a special type of
ovarian cyst that contain endometrial cells that grow and bleed during
menstruation) may form inside the ovaries causing enlargement of the
ovaries, therefore interfering with normal ovarian functions such as
ovulation. There also may be links between endometriosis and hormonal
imbalances or immune system abnormalities that can also interfere with
fertility. Some women with endometriosis experience severe pain during their
menstrual cycle or during intercourse, excessive or irregular bleeding
during menstruation, or urinary or bowel problems in conjunction with
menstruation.
Other symptoms may include fatigue; painful bowel movements with periods;
lower back pain with periods; diarrhea and/or constipation and other
intestinal upset with periods. The amount of pain is not necessarily related
to the extent or size of growths. Other women experience no symptoms, and
their endometriosis goes undiagnosed until they seek medical help to explain
their inability to conceive. Because endometriosis is progressive, the key
to preserving fertility in women who have endometriosis is early diagnosis
and treatment of the symptoms that interfere with conception and pregnancy.
Ultrasound scans may detect the presence of endometriomas in the ovaries,
while laparoscopy is typically the definitive way endometriosis is
diagnosed. Laparoscopy is typically performed as an outpatient surgical
procedure in which a fiberoptic telescope is inserted into a female's
abdomen below the navel to look for endometriosis, scarring, and adhesions.
While there is no known cure for this disease, effective treatment of the
symptoms is available. In general, surgery and hormonal treatments may be
helpful for the treatment of pain related to endometriosis. For infertility,
there may be a need for other types of treatment following surgery to
increase the number of eggs ovulated in a given month. In extreme cases, in
which the endometriosis has caused extreme tubal damage, in vitro
fertilization may be needed to bypass the scarred Fallopian tubes.
Fibroids
 Uterine fibroids are benign tumors of the uterus that can cause infertility,
heavy periods, severe menstrual cramps, and pelvic pressure. These abnormal
growths are among of the most common causes of infertility in women. There
are no known causes for uterine fibroids, though the explanation appears to
be an absence of a signal to turn off division of the muscle cells that make
up the walls of the uterus. While traditionally hysterectomy has been
recommended for women with fibroids, women with fibroid tumors are now being
offered more conservative treatments such as myomectomies. A myomectomy is a
surgical procedure in which the fibroid tumor is removed, yet the uterus is
left in place. Reconstruction of the uterus is a vital part of this
procedure. Specialists who perform myomectomies are often able to save a
woman from needing a hysterectomy, enabling her to retain her child-bearing
ability. For some fibroids, the myomectomy can be done on an out-patient
basis (laparoscopically or hysteroscopically). Medications are another
option for treating fibroid tumors in some women. Prescription medications
are available that can shrink the size of the fibroid and lessen heavy
bleeding and pain. These medications can only be used for a limited period
of time, however, and require careful monitoring by a physician.
Reversal of Tubal Ligation
Patients who have undergone previous tubal sterilization are candidates for
either tubal reconstructive surgery or IVF. The most ideal candidates for
tubal reconnection are women in whom investigations reveal that the
subsequent total tubal length following reconnection will be greater 4 cm.,
and cases where the tubes have been divided relatively close to the uterus.
The statistical chance of ideal candidates for microsurgical tubal
reconnection subsequently becoming pregnant within two years is in the range
of 60-75 percent with a subsequent ectopic pregnancy incidence of about 10
percent.
Ectopic Pregnancy
 2-3%
of all pregnancies occur outside of the uterus, and are called ectopic
pregnancies. The majority of these occur in the Fallopian tubes, and can be
life threatening if not treated. Traditional treatment included removal of
the entire fallopian tube. More recently, these tubal pregnancies have been
managed conservatively, either by laparoscopic surgery or by medical
treatment (Methotrexate). Any infertility patient with abnormal bleeding and
pelvic pain should consider ectopic pregnancy as a real possibility, and
should have a pregnancy test performed.
Multiple Gestation
A frequent complication of fertility treatments, multiple pregnancies may
cause pre-term labor, pregnancy-induced hypertension, and diabetes. Early
diagnosis is vital in order to provide preventative care, and explore all
medical options, including multifetal reduction in cases of higher order
multiple gestations (triplets, quadruplets, etc.). The key to the treatment
of multiple pregnancies is to avoid their occurrence by carefully monitoring
patients receiving fertility drugs, and minimizing the embryos transferred
in patients undergoing in vitro fertilization.
Endometrial Polyps
Overgrowths of the uterine lining are called endometrial polyps. Some polyps
are found incidentally, and do not require treatment. Others may cause
irregular bleeding, and, at times, infertility, and should be surgically
removed. When performed by an experienced surgeon, the treatment of
endometrial polyps can be performed hysteroscopically as an out-patient
procedure, and should be safe and effective.
Preimplantation Genetic Diagnosis (PGD)
 Traditional methods used to identify genetic disease require prenatal
diagnosis through amniocentesis or CVS, followed by potential termination of
the pregnancy if the fetus is found to be affected. Recent scientific
advances now allow the diagnosis of some genetic disorders before pregnancy
is established using a technique known as PGD. PGD combines the technology
of in-vitro fertilization (IVF) with new molecular biology techniques.
Following fertilization of an egg, a single cell is removed from an embryo
in a procedure called an "embryo biopsy." If the embryo is found not to
contain the genetic disorder being tested for, the embryo is transferred
into the uterus, and allowed to develop. Couples with a known genetic
disorders can now have unaffected children without the emotional and ethical
challenges associated with traditional prenatal diagnosis.
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