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Infertile patients expect that their doctors will provide them with treatment to improve their chances of having a baby. Tragically, some medical procedures can actually end up reducing your fertility !

Here's a list of the top ten procedures which can actually harm you, rather than help you ! If your doctor advises any of these, please get a second opinion before agreeing !

1. D&C ( dilatation and curettage) . This is a "minor" surgical procedure in which the doctor dilates the mouth of the uterus ( the cervix) and scrapes the uterine lining using a curette
( curettage). This endometrial tissue is then sent for pathological examination. In the past, when doctors had very little to offer to their patients, this used to be the mainstay of the treatment of an infertile couple. In fact, even today, some women will ask the doctor to do a D&C for them because their mother conceived after doing this procedure ! They feel that it helps to "clean the uterus", thus improving their fertility ! While it is true that some women will get pregnant after a D&C ( sometimes this is just a placebo effect; while sometimes the endometrial inflammation induced by the procedure can improve uterine blood flow and fertility), this is an obsolete procedure which should be used in this day and age only for confirming the diagnosis of endometrial tuberculosis.

2. Metroplasty. This has become quite a fashionable procedure in some parts of India, where the doctor "improves" the shape of the uterine cavity to improve fertility. It can actually create uterine scarring and induce fertility. It's only in India that doctors use this technique for "treating" infertility. In all other countries, it is reserved for correcting uterine anomalies or removing intrauterine adhesions.

3. Hydrotubation. This is a procedure in which the doctor flushed the uterus and the tubes with fluid ( which often contains a concoction of chemicals such as steroids and antibiotics) to treat infertility. While it can help some women with cornual blocks, for the vast majority this painful treatment ( which is often repeated many times in one month) is a waste of time and money.

4. Empiric treatment for abnormal sperm . This continues to remain a major time-waster for infertile couples. Tragically, most doctors are still unaware of the recently revised criteria of what a normal sperm count is - and will often reflexively treat men with what they think is an "abnormal sperm report". There are various levels of sophistication to this futile effort. To cloak this with an aura of scientific respectability, high tech labs will now test sperm for DNA fragmentation levels - and doctors are quite happy to "fix" the problems these tests will often pick up. What many patients do not realise that there is very little correlation between these test results and their fertility potential - and that even fertile men have high DNA fragmentation levels ( but are fortunately unaware of this, as they have enough sense not to get their sperm tested in a lab !)

5. Treatment for genital tuberculosis. We are now seeing an "epidemic" of uterine TB in India - especially in north India, where it appears that practically even woman who goes to a gynecologist has TB ! Doctor use dodgy tests called PCR to test the endometrium for the presence of DNA fragments which are supposed to be be specific markers for the tubercle bacilli - without even bothering to determine what the prevalence of this TB PCR positivity is in the fertile population ! Not only do these poor patients end up taking 6 months of toxic and expensive drugs; their husbands will often stop having sex with them ( because they are worried that they will transmit the TB to them); while others are scared that they will give the TB in their uterus to their baby !

6. Treatment for TORCH infections. Women who have been unfortunate enough to have a miscarriage will get routinely ( and mindlessly) tested for the presence of antibodies against the TORCH group of infections. If any of these tests is positive, the doctor then promptly treats this infection with antibiotics ( which are completely useless and uncalled for !). The truth is that pregnancy. You can read about this at www.drmalpani.com/torch.htm

7. IUI ( Intrauterine insemination ) for treating couples men with a low sperm count. Since everyone knows that " you need just one sperm to fertilise an egg", it seems to make a lot of sense to treat infertile couples who have a low sperm count with IUI . After all, IUI is a simple and inexpensive treatment, which every gynecologist can offer - and patients understand the logic as to why it should help. The truth is that the problem with men with low sperm counts is not just that their sperm count is low - its often that the sperm are functionally incompetent - and no amount of concentrating the good sperm or washing them is going to help !

8. Diagnostic laparoscopy. Once upon a time, a laparoscopy was a major advance in evaluating the infertile woman, because it actually allowed the doctor to visualise the ovaries and fallopian tubes without having to cut open the patient ! Minimally invasive surgery was a major advance then , but now it's being overused. Many doctors still routinely perform a laparoscopy for all infertile women, which is completely unnecessary surgery, as is does not change the therapeutic options for these patients. The status of the fallopian tubes can as easily be checked with a simple HSG, which is much less expensive ! It's true that a laparoscopy allows the doctor to also "find" adhesions and endometriosis, but making the diagnosis of this ( or "treating" them ) does not really improve the patient's fertility at all !

9. Medications for treating endometriosis. Endometriosis is an enigmatic and frustrating disease; and mot doctors will still reflexively "treat " this with medications, such as GnRH analogs. While these medications are great at suppressing the endometriosis (and will provide dramatic pain relief), this suppression is only temporary - and does not improve the patient's fertility at all (since they also suppress ovulation at the same time !) Once the meds are stopped, the endo recurs ! Even worse, "treating" the endo with meds just wastes the patient's time - something which most infertile patients cannot really afford to fritter away !

10. Operative laparoscopy for myomectomy and cystectomy. One problem with today's high tech diagnostic tools ( such as vaginal ultrasound scans) is that it allows the doctor to "diagnose" small 1 cm size ovarian cysts and fibroids. Now while cysts and fibroids are very common in fertile women as well; and small cysts and fibroids do not affect fertility, once the sonographer has "reported" his "diagnosis", the patient often panics ! The doctor is happy to point out these abnormalities - and convinces the patients that it is these abnormalities which are the cause of her infertility - and that once these are "treated", she'll get a baby quickly ! What's worse is that it's easy to do the surgery with a laparoscopy ( which is just "minor surgery"), that patients are quite happy to sign on the dotted line without realising that these are incidental findings of no clinical importance; and that the surgery will not help them. What's worse, is that this unnecessary surgery can reduce your fertility as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.

I sometimes think we are seeing an epidemic of overtesting and overtreatment. Doctors seem to like doing tests - and patients like being tested ! Unfortunately, patients are still not sophisticated enough to differentiate between useful tests and useless tests - and the truth is that some tests can actually be harmful !

The hidden danger with a lot of these unnecessary testing is that patients get fed up; lose confidence in doctors; and refuse to pursue more effective treatment options, because they do not trust doctors any more !

The message is simple - if you have a medical problem, remember that Information Therapy is invaluable ! Please get a second opinion if you are unsure and confused. Send me your medical details by filling in the free second opinion form at www.drmalpani.com/malpaniform.htm and I'll be happy to help !

A chocolate cyst of the ovary ( also known as an endometrioma, endometrioid cyst, or endometrial cyst) is found in some infertile women who have endometriosis. In this disease, the inner lining of the uterus ( called the endometrium ) grows in various abnormal locations within the pelvis . One of the commonest sites this aberrant endometrial tissue can be found in is the ovary. With every menstrual period, this tissue grows, enlarges , bleeds, and sloughs off . Here it forms a cyst; and because the contents of this cyst are black, tarry and thick, they resemble dark chocolate , hence the name ! ( I feel that sometimes doctors can have a perverse sense of humor . For most women, the word chocolate produces happy feelings, because chocolates are a woman’s favourite treat. To label a disease condition after a dessert is something which only an unfeeling man would do ! )

How is the diagnosis made ? While an alert doctor will often suspect the diagnosis in infertile women with progressively painful periods, often women with chocolate cysts may have no symptoms at all. This means this diagnosis is made during a regular infertility workup ; or even during a routine pelvic examination. While some cysts are large enough to be felt on pelvic examination, many are small and cannot be detected on clinical examination.

Ultrasound scanning is an excellent way of diagnosing chocolate cysts and can pick up cysts which are very small. On scanning, chocolate cysts are complex masses ( which have both solid and cystic components); and are often tender. They have a typical ground glass appearance because they contain old blood. They can vary in size from a few mm to over 10 cm; and can be bilateral. However, it’s not possible to make a definitive diagnosis of endometriosis on ultrasound scanning, as many other conditions can also produce cysts in the ovary. The diagnosis can be confirmed either by aspirating the cyst under ultrasound guidance ( and finding the typical dark old blood which is diagnostic of endometriosis); or by doing a laparoscopy.

In the past, a laparoscopy was the gold standard for making the diagnosis of endometriosis, as this allowed the doctor to actually inspect the pelvic contents. However, because it involves surgery, many infertility specialists no longer do a laparoscopy for their patients.

There are 3 key factors which doctors need to evaluate when making a decision as to how to treat chocolate cysts in infertile women.

1. Whether the patient has any symptoms
2. The size of the cyst
3. The AMH level

Thus, when a small chocolate cyst is picked up when doing a routine vaginal ultrasound scan in a young asymptomatic infertile woman , the best course of action maybe masterly inactivity. This is because this is an incidental finding which is best documented and left alone. Remember that doctors do not treat ultrasound images - we treat patients ! Many fertile young women also have endometriotic cysts which they live with happily for all their lives ( and because they have enough sense not to go to a doctor, they often do not even know that they have a chocolate cyst !) Unfortunately, many doctors tend to be trigger-happy, and when they find a cyst on a pelvic ultrasound scan, they reflexly perform laparoscopic surgery – both to confirm the diagnosis; and to treat the cyst ! The danger is that this unnecessary surgery can actually reduce your fertility , as normal ovarian tissue is also removed along with the cyst wall, thus reducing your ovarian reserve.


Small cysts ( less than 3 cm in size) can be happily left alone . If they are larger, they can be monitored by serial scans, before making a decision as to what the definitive treatment should be.

As regards treatment choices, the options include medical therapy or surgery. Medical therapy consists of medicines such as danazol or GnRH analogs to suppress the endometriosis; and while this is very effective in providing temporary symptom relief , it is not very effective in treating the cyst, which tends to remain inspite of the treatment.

The definitive solution is surgical; and this usually consists of operative laparoscopy . Very few doctors will now do open surgery ( laparotomy) to treat a cyst, no matter how large it is.
There are many controversies regarding the optimal surgical management of chocolate cyst s in an infertile woman, which is why it is important that you go to an expert. In the past , doctors would try to excise ( completely remove) the entire cyst , to reduce the risk of its recurring . However, because this meant that they needed to also sacrifice normal ovarian tissue during this process, they often ended up pushing infertile patients from the frying pan into the fire by reducing their ovarian reserve and worsening their infertility ! This is why most doctors today prefer to be far more conservative in infertile women with chocolate cysts ; and will usually just create an opening in the cyst wall ( marsupialisation) to drain the contents. This often provides dramatic temporary relief. During the operative laparoscopy, the doctor also has an opportunity to remove the adhesions (scar tissue) and the other endometrial implants which are often found in women with chocolate cysts and treating these can also help to enhance their fertility for a few months. The chances of achieving a pregnancy are maximal within a few months after the surgery. However, if a patient has failed to conceive within one year of the surgery, then the chances of success with repeat surgery are quite poor; and it’s better to consider assisted reproduction.

The major bugbear with chocolate cysts is that they tend to recur. This is why doctors will often combine medical suppression with surgical treatment. However, all these are temporizing measures, which help to buy the patient time – we really do not have any way of curing this enigmatic disease !

If the chocolate cyst recurs, patients are understandably upset, and feel that the doctor was incompetent and did not do a good job with the surgery. This is not always true, because endometriosis can be quite an aggressive disease in some women, and can recur even if the surgeon was very skilled. It’s important to ask for DVD documentation of all surgical intervention, so that the video can be reviewed later on, if needed.

If the cyst recurs, patients will often go to another surgeon ( who they feel is more expert) to try to correct the problem. The pelvis in some of these patients starts resembling a battle field, because they often end up having many laparoscopies done by many different surgeons, each of whom claims to be the best ! The surgery can be extremely challenging in these patients . The scarring , adhesions and previous surgery tend to distort the anatomy and the pelvis sometimes is completely frozen. Operative complications in these cases ( for example, inadvertently opening the bladder or rectum) are not uncommon.

The AMH level is a very important factor which many doctors tend to overlook in treating infertile women with endometriosis. The major danger with endometriosis is that the chocolate cyst replaces normal ovarian tissue, as a result of which many of these patients have little normal ovarian tissue and poor ovarian reserve as a result of their disease. This is why it’s important to assess your ovarian reserve by checking your AMH level and your antral follicle count before doing anything further ! If your AMH level is low, then it’s best to avoid surgery and to move on to IVF to maximize your chances of having a baby quickly ( before the disease becomes worse and eats away more of your precious reserve).

For young women with normal ovarian reserve, open fallopian tubes ( as proven on HSG) and small chocolate cysts who have no symptoms, it’s worth trying IUI before doing anything more aggressive. However , if the patient is symptomatic and the endometriosis is causing pain, then this become a trickier issue ! You need to set your priorities – is pain control more important ? Or is having a baby more important ? This is often a difficult decision to make, but you need to decide. It’s best to make a list of all your options so you can think through these logically.
If having a baby is key, then it’s best to manage your pain symptomatically and concentrate your energies on getting pregnant quickly. IVF is very effective , as it maximizes your chances of getting pregnant quickly . The beauty with IVF is that it allows you to kill 2 birds with one stone – not only do you get your deeply desired baby, you also have dramatic pain relief for at least 1 year ( because your periods will stop during your pregnancy and your postpartum period ). As an added bonus, the endometriosis will also get better as a result of the pregnancy in some women ! This is why many doctors advise that the best treatment for a young woman with endometriosis is a pregnancy. Of course, this is easier said than done, because endometriosis does affect your fertility !

Do you have a chocolate cyst and are unsure what to do ? Send me your medical details by filling in the free second opinion form and I'll be happy to help !

Missing a period can be very difficult for infertile women ! Every time you miss a period, you hope ( against hope) that maybe you are finally pregnant ! However , you are worried about getting your hopes up too high, because you are scared that they will come dashing down again – and you remember all the false alarms you have had in the past !

There are many reasons for missing a period, including stress ; side effects of medications you are taking; and a systemic illness. The first step, of course, is to rule out a pregnancy. You can do this by checking with a urine pregnancy test kit. The new ones are very reliable, and a negative test result usually means that you are not pregnant. If you are unsure, you can repeat the test in 2 days. A better option is to do a blood test to check your HCG level. This is much more reliable ( but it’s also much more expensive !) . A blood level of less than 10 mIU/ml confirms you are not pregnant.

If you miss three menstrual periods in a row, your doctor will make the diagnosis of “secondary amenorrhea “. This is just medical jargon for – “ has missed more than three menstrual periods”. It’s not really a diagnosis – just a description of your problem.

So what are the reasons for a missed period ? And what can you do about this ?

Let’s review some basic biology first. The reason women who ovulate get a natural menstrual period is because of a drop in the circulating blood levels of the reproductive hormones, estrogen and progesterone hormones. When these levels drop, the uterine lining loses its hormonal support, as a result of which it is shed as a menstrual period. This is called a estrogen primed progesterone withdrawal bleed.

A missed period means there is a problem with the normal balance between estrogen and progesterone in your body. This usually happens when you do not ovulate. This is called anovulation.

Most women ( for example, those with PCOD) have high estrogen levels, but because you have not ovulated, your progesterone levels remain low, as a result of which you do not get a withdrawal bleed.

In other cases, the corpus luteum forms a functional cyst. Because this continues to produce estrogen and progesterone, there is no progesterone withdrawal, and the lining remains thick and does not shed.

Others have low estrogen levels ( as a result of which your uterine lining remains thin and does not develop at all). This is commonly seen in lean athletic women who exercise a lot. The missed period in these women is called hypothalamic amenorrhea.

In order to come to the right diagnosis, the doctor may need to do a vaginal ultrasound scan .
This should check for the following.
a. Is there a cyst in the ovaries ? Are the ovaries small ? What’s their volume ? The antral follicle count ?
b. The endometrial thickness and texture.

Patients with PCOD will have a thick uterine lining, which suggests they have high estrogen levels. Women with hypothalamic amenorrhea have small ovaries with a thin lining; as do perimenopausal women who have reached the oopause and whose ovaries are failing. A functional cyst will be easily apparent on the scan.

It’s also possible to confirm this diagnosis by checking the blood levels of estrogen and progesterone.

After making a diagnosis, it’s easy to induce a period, based on the problem.

If the uterine lining ( endometrium) is thick, this means that the level of estrogen in the body is already high ; and it's easy to induce a period by taking 5 days of progestins, such as medroxyprogesterone acetate. There are many options available. These include:Tab Provera ( medroxyprogesterone acetate), 10 mg, twice a day. The period will usually start 3-7 days after taking the last tablet. This is called inducing a withdrawal bleed with progestins.

On the other hand, in women with low estrogen levels who have a thin uterine lining, we first need to build up the lining with estrogens and then induce a period with progesterone . We give the estrogen and progesterone hormones sequentially, thus mimicking a natural cycle. This is what a typical prescription would look like.

Estrogen tablets from Day 1 - Day 25. There are many options available. The least expensive is Tab Ethinyl estradiol ( Lynoral), 0.05 mg daily. Other choices include:
Tab Premarin, 1.25 mg daily; or
Tab Progynova ( estradiol valerate, 2 mg), 2 tab daily. You may feel some nausea and have some temporary fluid retention while taking the estrogen.

Progestin tablets, from Day 16 - Day 25. There are many options available. These include:Tab Provera ( medroxyprogesterone acetate), 10 mg, twice a day.

This regimen is called Hormone Replacement Therapy , and is available commercially in some countries in the form of a pack, called CycloProgynova.
The withdrawal period ( menstrual period) will start approximately 3-6 days after you take the last tablet, as the levels of the administered hormones decline in your body because they get excreted in the urine.

It’s also possible to achieve the same results with a 21 day course of birth control pills, since these contain both estrogen and progesterone. It's best to take the old-fashioned monophasic birth control pills, which contain a sufficient amount of estrogen and progestins ( combined together in one "active" tablet). A typical choice would be Ovral, which contains 50 ug of ethinyl estradiol and 500 ug of norgestrel ( a type of progestin). The withdrawal bleeding induced when you take birth control pills may be scanty as compared to a regular period. This is normal.

If the reason for the missed period is a functional cyst, you may have to wait till it resolves. It will usually do so on its own. If needed, the doctor can induce a period with mifegest ( RU-486), a very powerful antiprogestin.

Premature Ovarian Failure (POF), also known as premature ovarian insufficiency, primary ovarian insufficiency , premature menopause and primary ovarian failure, hypergonadotropic hypogonadism, is the loss of ovarian function before the age or 40. hypoestrogenism. POF affects 1% of the population.

On an average, in a normal woman the ovaries will produce eggs until the age 51, which is the average age of natural menopause. In some women, the ovaries stop functioning much earlier. This is called premature ovarian failure. Most women with POF will have irregular menstrual cycles. Initially, these are light or infrequent; and soon stop completely. The age of onset can be as early as the teenage years but varies widely. If a girl never begins menstruation, this is called primary ovarian failure. The age of 40 was chosen as the cut-off point for a diagnosis of POF. This age was chosen somewhat arbitrarily, as all women's ovaries decline in function over time.

POF is diagnosed by finding abnormally low levels of estrogen and high levels of FSH, which demonstrate that the ovaries are no longer responding to circulating FSH by producing estrogen and developing fertile eggs. On ultrasound scanning, the ovaries are small ( atrophic) with a very low antral follicle count. Women suffering from POF usually experience menopausal symptoms, which are generally more severe than the symptoms found in older menopausal women. The symptoms vary from patient to patient and the disorder may occur abruptly or spontaneously or it may develop gradually over several years. Women may experience hot flashes, night sweats, irritability, moodiness, sleep disturbance, decreased libido, hair coarseness and vaginal dryness.

In most patients with POF , the cause cannot be determined. Some cases of POF are attributed to autoimmune disorders, others to genetic disorders such as Turner syndrome and Fragile X syndrome. Radiation treatments for cancer can sometimes cause ovarian failure. Family history and ovarian or other pelvic surgery earlier in life are also implicated as risk factors for POF.

Serum follicle-stimulating hormone (FSH) measurement can be used to diagnose the disease. Two FSH measurements with one-month interval have been a common practice. Because the eastradiol levels in patients with POF are low, the FSH levels are very high. The typical FSH level in POF patients is over 40 mlU/ml (post-menopausal range). Many women get confused with their FSH levels. They feel that the high FSH is the cause of the POF; and if this can be treated, then their problem with get solved. The fact is that while it’s very easy to suppress the high FSH level back to the normal range by using estrogen tablets, this will not help the patient with POF to grow eggs or to have a baby.

A new and more reliable marker for ovarian function today is the blood test for checking the AMH level. The diagnosis can be confirmed by checking the AMH level, which is very low in patients with POF.

Often the diagnosis comes as a rude shock – both to the patient and the doctor. Most young women have irregular periods because of another disorder called PCOD, which is much commoner. Many doctors assume that a young woman with irregular periods have PCOD, as a result of which the correct diagnosis of POF is often missed for many years. The cessation of menstrual periods is often incorrectly attributed to a variety of conditions, such as stress, without appropriate testing or consideration, delaying the diagnosis even further. In addition, many women who are affected by POF may have been incorrectly treated for irregular bleeding with oral contraceptives, which may have masked symptoms. All too often, POF is not diagnosed until the woman becomes interested in fertility and the oral contraceptives are stopped when the patient wants to conceive.

Currently no fertility treatment has been found to effectively increase fertility in women with POF. While some women with POF can and do become pregnant on their own, this is unpredictable and uncontrolled. Medically, the best treatment option is the use of donor eggs. While it can be very difficult for young women to come to terms with the fact that they may have to use donor eggs to have a baby, the good news is that this option has a very high success rate in patients with POF. Other options include: embryo adoption; childfree living; and adoption.
Patients with POF have low estrogen levels and this can result in painful sex ( because of lack of vaginal lubrication); as well as osteoporosis. Hormone replacement therapy ( HRT) with estrogens and progesterone can help to deal with these problems very effectively. However, while HRT can help women with POF to have regular cycles, it will not help them to have a
baby !


Many women find this very confusing, because they feel that if the medications can help them to have regular periods, they should be able to help them to have a baby as well. Sadly, the woman with POF has no eggs left in her ovaries, which means we cannot help her to grow these.

Also known as "Endometriosis of the uterus," adenomyosis ( adeno= glands; myo = muscle) is a benign condition which occurs when the glandular cells of the uterine lining ( the endometrium) penetrate deep into the uterine muscle (myometrium) and invade into it. Adenomyosis used to be called "endometriosis interna," since it can look somewhat like endometriosis under the microscope . However, this occurs within the muscle wall of the uterus, not on pelvic surfaces as does endometriosis.

Most commonly, the disease affects the back wall (posterior side) of the uterus. When this occurs, the uterus is enlarged usually more than twice the normal size and very hard. The disease may be localized with well-defined borders ; or diffuse, meaning it has no limits or borders. When the disease is localized , it is called an adenomyoma. These adenomyomas can be located at different depths of the uterine muscle .

The disease is often under-diagnosed because many doctors do not consider this possibility . Patients who have localized adenomyosis are often misdiagnosed as having fibroids. Others are just labeled as having a “bulky uterus” or DUB ( dysfunctional uterine bleeding). This disease can only be diagnosed with 100% certainty by doing a biopsy of the uterine muscle, a procedure which is done very rarely ! About 10% of women with adenomyosis have also had endometriosis in other sites such as the pelvic wall, ovaries, fallopian tubes etc. The highest incidence is seen in women in their forties, and though this disease may cause infertility, it usually occurs in women who have already had children.

Symptoms

As with Endometriosis, patients with Adenomyosis may not show any symptoms (asymptomatic). However, women most commonly experience excessive, heavy or prolonged menstrual bleeding and painful periods (dysmenorrhea). The amount of bleeding and cramps is usually associated with the degree of disease involvement and depth of penetration into the uterine walls. Extensive involvement of the uterine muscle can also interfere with the normal contractility of the muscle which then leads to excessive bleeding.

Diagnosis

An exact diagnosis is often difficult to establish pre-operatively because abnormal patterns of bleeding (dysfunctional bleeding) and fibroid tumors can result in similar symptom patterns. Sometimes during a D&C procedure to remove intra-uterine polyps or small fibroid tumors, uterine tissue is removed , enabling a pathologist to make the tissue diagnosis. However, this is often an incidental finding. Pelvic exam findings can reveal a slightly enlarged uterus . In some women, the uterus is enlarged (upto twice the normal size) and can also be tender and “boggy”. Vaginal ultrasound shows the uterus is enlarged and bulky, but it's difficult to make an accurate diagnosis of adenomyosis with ultrasound, since the density of the invading endometrial tissue may not differ sufficiently from the surrounding uterine muscle wall. Occasionally the uterus may be described as slightly enlarged in a symmetrical fashion, with a fuzzy shadowy pattern seen in the muscle wall. MRI can also be used to distinguish adenomyomas from fibroid tumors.
Since no medicine eradicates adenomyosis, medical treatments are frustrating for patients as well as physicians . Since the uterus is a hormonally responsive organ, hormones are the mainstay of medical treatment of symptoms. Your doctor may prescribe birth control pills or progesterone pills or shots. Although gonadotropin-releasing hormone agonists such as Lupron have been found to reduce uterine symptoms of adenomyosis during treatment, the symptoms return quickly after the medicine wears off. Pain pills, whether over the counter or prescription, can be used to tide the patient over rough spots.

Adenomyosis and infertility

The relationship between adenomyosis and infertility is still very controversial . Many doctors believe that adenomyosis does not reduce fertility, since it affects only the muscle wall of the uterus. This means that the uterine cavity and the uterine lining in these patients are normal, which means their fertility should be normal as well. However, real effect on fertility is virtually impossible to know since it is so difficult to diagnose the disease in women who have an uterus.
If an infertile woman is found to have adenomyosis, we usually do not offer any specific treatment for this diagnosis , as this diagnosis does not affect your treatment options !

Many infertile couples are very confused about how their treatment. Unfortunately, many gynecologists add to their confusion. Thus, if an infertile woman is found to have endometriosis, they will spend a lot of time, money and energy on "treating " the endometriosis with medicines. Similarly, the woman has irregular periods, they will concentrate on trying to "regularise the cycle" !

Why are these approaches flawed ?

The truth is that we really do not have any effective treatment for endometriosis. This is hardly surprising, when you consider that we do not even know what causes this enigmatic disease ! While we are very good at suppressing this medically ( with GnRH analogs), this suppression is only temporary. Even worse, while these medicines are very effective as suppressing the endometriosis , they also suppress normal fertility ( because they stop ovulation). This medical treatment just wastes time and money ; and patients get fed up and lose confidence in doctors and in themselves !

What about laparoscopic surgery for removing the endometriosis ? While this is effective in some selected cases ( those patients with open tubes, good ovarian reserve, and anatomic distortion because of adhesions), it's not helpful for the majority. In fact, in some women, unnecessary surgery actually reduces fertility as normal ovarian tissue is also removed along with the wall of the chocolate cyst, thus reducing their ovarian reserve.

Unfortunately, patients believe that once the doctor has made a diagnosis of endometriosis, this disease is the cause of their infertility; and that once this is "treated", their fertility will be restored, and they will be able to get pregnant in their own bedroom. However, this is also a flawed assumption ! Endometriosis is a very common finding, even in fertile women; the endometriosis found on the laparoscopy in an infertile woman may just be a red herring, and not the cause of the infertility. This is why "treating" it may not help at all !

Similarly, patients with irregular cycles are often very poorly managed. Many patients are unsure about the relationship between their irregular cycles and their fertility, and consider this as a chicken and egg problem. They naively believe that once the cycles are regularised, they will then get pregnant in their own bedroom ! After all, if the reason they are not getting pregnant is the fact that their periods are irregular, then surely fixing the irregularity problem will them to have a baby ! Many doctors also seem to subscribe to this belief, and will regularise the cycles by putting these infertile couples on birth control pills ! While this will regularise the cycle while they are taking the pills, this is hardly helping them to have a baby ! They obviously cannot get pregnant while taking the pill - and once they stop the pill, their cycles continue remaining irregular, because they are still not ovulating !

If you are infertile, how can you make sure your doctor is providing you with the most effective treatment ? The answer is surprisingly simple ! Remember, that the reason you are infertile ( no matter what your actual diagnosis is !) is the fact that your eggs and sperm are not being able to meet. The question you need to ask is - what is the doctor doing to increase the chances of the eggs and sperm meeting ?

Thus, if he is simply suppressing your endometriosis with drugs; or regularising your cycles with birth control pills, he is wasting your time and not doing a good job ! We need to look for solutions - not waste time in finding problems which maybe irrelevant . Fortunately, our technology for bypassing problems ( even without identifying them precisely ) is better than our technology for identifying problems !

Remember, the question should NOT be "Why am I not getting pregnant ? " Rather, it should be - What can I do in order to get pregnant ?" After all, no one cares about problems - we only care about results - about having a baby ! The quality of a doctor’s answers depend upon the quality of the patient’s questions !

Not sure if you are on the right track ? I'll be happy to provide a free second opinion ! Send me your medical details by filling in the second opinion form, and I'll be happy to help !

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I saw a patient who wanted a third opinion. She was completely confused. As part of her infertility workup, she had had a HSG ( hysterosalpingogram) done. The X-ray showed that her uterine cavity was normal; the dye filled the fallopian tubes , but the spill into the abdominal cavity was loculated.

When she saw her doctor with the report, he told her that this suggested that there were adhesions around the tubes, and she needed an operative laparoscopy to treat this. Another doctor, to whom she had gone for a second opinion advised her against the laparoscopy. He felt that since the tubes were open, her best option would be to do an IUI, to improves the chances of the eggs and sperm meeting. This patient then sought a third opinion, which is why she came to me !

The first thing I did was to ignore the earlier opinions, and asked to see a copy of the original HSG X-ray films, so I could make up my own mind . Unfortunately, there was only one film, and this was of poor quality . The radiologist had done a sub-optimal study, because he had not taken any delayed films ( perhaps to save some money ?), as a result of which it was hard to draw a firm conclusion based on the HSG films. This meant were now back to square one.

The choices were; repeat the HSG; do a laparoscopy; or assume the tubes were fine and proceed with treatment. Each has advantages and disadvantages, and patients need to think their way carefully through their choices, so they can make the right decision. Unfortunately, most patients are not used to making choices regarding their medical treatment. Even worse, most doctors are not comfortable offering these choices to their patients. "The doctor knows best" is the model most patients ( and doctors) are happy to adopt - which means that often the wrong decision is made ( and usually for the wrong reasons).

We could repeat the HSG in a better clinic and make sure that it was done under fluoroscopic guidance and that delayed films were taken. While this option would give a much better X-ray image of the tubes, she was understandably reluctant to repeat the HSG. This is quite a painful procedure - and few women have the courage to do it again !

Laparoscopy is a surgical procedure, which means it costs more; however, the quality of the documentation is much better, because the surgeon can take videos of the pelvic anatomy. However, it cannot provide information on tubal function - which is really the only thing the patient wants to know - are my tubes working properly or not ?

Doing a laparoscopy was an option - but this is an expensive surgical procedure - and while it provides useful diagnostic information, it often does not change treatment options , which is why we are very reluctant to perform this in our clinic. What's the point of doing a test if it does not impact treatment alternatives ?

So what are patients supposed to do when their doctors disagree ? Some of them get very angry and upset when doctors do not see eye to eye ! I actually feel it's good for patients when doctors disagree. Each doctor will present his point of view and justify why this is better than the alternative proposed by the other doctor . The patient gets to see the pros and cons of both options, so she can make a better-informed decision !

Fibroids are very common in infertile women. Most are intramural fibroids , which are present in the wall of the uterus) , and these do not need to be removed prior to IVF, as they do not affect embryo implantation. You can read more about this at http://www.drmalpani.com/fibroids-and-infertility.htm. It is only submucous fibroids ( those which are in the uterine cavity) need to be removed. These can be best removed with an operative hysteroscopy.

Unfortunately, most doctors have itchy fingers and are happy to operate at the drop of a hat.

The following combination of facts adds up to a trigger-happy situation

1. Fibroids are very common in infertile women
2. Infertile women are desperately seeking a reason for their infertility, so the doctor can "fix" the problem and help them to have a baby
3. Modern ultrasound scan machines with their zoom functions are excellent at picking up small asymptomatic fibroids which are of no clinical importance
4. Sonographers are happy to report these findings as abnormalities. Usually, the fibroids are measured in mm rather than cm, so they seem to be even bigger than they really are
5. No one bothers to explain to patients that fibroids are very common in fertile women; that most of them do not affect fertility; and that surgery can actually reduce their fertility
6. Gynecologists are trained to operate - and are very happy to do so ! This is far more profitable than reassuring the patient or advising watchful waiting ! Many will justify their advise for surgery by saying - If I do not operate, then someone else will, so I might as well do the surgery myself !
7. The surgery involved is a " simple " laparoscopy. which does not need the doctor to ut open the belly. This is "minor surgery" , which is done on a day-care basis, so why not just fix the problem since the solution is so simple !

In fact, many gynecologists actually end up scaring patients into saying yes for surgery. They take advantage of the patient's ignorance, and trot out a large ( and very creative list !) of reasons for why surgery is the best solution for them.

This includes the following reasons, none of which are the unalloyed truth.

The fibroid needs to be removed now, because ( choose one or more of the following) :

It will grow during pregnancy and become even larger
It will compress the baby; prevent the baby from growing; and will cause growth retardation
It will cause a miscarriage
It will cause preterm labour

The advise seems to be - removing the fibroid may not help your fertility, but it's still a good idea to do so, because some fibroids can cause problems during pregnancy, so why take a chance ? Most infertile women are very emotionally vulnerable, and are happy to do everything they can to prevent problems during their much-awaited pregnancy. This is why many happily sign up for "preventive surgery" - without reaslising the risk they are running !