Dealing with a DiagnosisSandy Kendall
Tilted Uterus or Cervix
Many women are told, often casually, upon an annual OB-GYN exam, that their uterus is tipped. Or that their cervix is tilted (the cervix is just the bottom opening of the uterus, so this amounts to the same thing.) This means that instead of the top of the uterus sitting up straight or leaning forward toward the belly, it tilts the other way toward the back. This is also called “retroverted uterus” or “retroflexed uterus,” and according to the Mayo Clinic, about 20 percent of women are built this way.
It’s quite common for women with this “diagnosis” to worry that it will cause them problems in trying to conceive. If they already feel they have been trying a long time, it may seem like a logical explanation. But in itself it is unlikely to be a show stopper.
“Your tilted uterus will not cause a problem; typically this isn’t a major impediment [to conception],” says Dr. Gerald M. DiLeo, an OB-GYN in private practice since 1981. “The vagina is called a ‘potential space;’ that is, it’s not a space unless something occupies it (e.g., baby, tampon). When not occupied, the vaginal walls, roof, and floor all meet together—collapse, squishing any fluid-like substance (semen) toward the back, where your cervix—tilted or not—is.” If your partner’s sperm are motile, this whole arrangement is a set-up for the sperm’s successful migration toward conception.
During pregnancy, the uterus tends to straighten up as it fills out and grows, so rarely does a tilted uterus or tilted cervix present a problem in fetal growth or delivery.
In some instances, the uterus is pushed out of place, or retroflexed, by endometriosis. In such a case, it’s the endometriosis compromising fertility, not the position of the uterus.
Other abnormalities in uterine structure can be more problematic. Dr. John C. Jarrett, author of The Fertility Guide: A Couples Handbook for When You Want to Have a Baby (More Than Anything Else), says, “When the uterus is abnormal, the chances of miscarriage are significantly increased. Much of this is probably due to the fact that there is not a good blood supply to the abnormal uterine tissue. If the placenta begins to grow on this tissue, it cannot get the blood supply it needs to survive.” Abnormalities might include the organ’s shape or its being partially or completely divided; surgical correction dramatically improves the chances of a successful pregnancy, in some cases.
Another scary-sounding diagnosis is dysplasia of the cervix. This is also likely to be turned up at an annual gynecological exam, a preconception exam, or if you are being evaluated for infertility. Cervical dysplasia is the presence of abnormal cells on the cervix, most commonly caused by exposure to the human papillovirus (HPV). HPV exposure comes from sexual contact, but development of dysplasia may come years or even decades after exposure. HPV is also the cause of the more commonly known “genital warts,” but you can have dysplasia without any evident warts.
Cervical dysplasia is serious business, as evidenced by its often being called “pre-cancerous.” That will get your attention. Beth M. Iovinelli, RN, BSN, IBCLC, says, “Cancer can develop in the cervix when abnormal cells grow at a rapid rate—when normal cells come into contact with cancer-causing agents. In the case of cervical cancer, HPV is often the agent.” There is now a “cervical cancer vaccine,” actually a vaccine against HPV, recommended for girls starting at age 11.
If you have cervical dysplasia, your doctor may do a loop electrical excision procedure, or LEEP, which will remove the lesion completely as well as provide a specimen to allow for thorough diagnosis. This makes it a superior procedure to freezing or applying a laser to the spot on the cervix. Unfortunately, all such destructive procedures carry a small risk of incompetent cervix with a subsequent pregnancy, says Dr. DiLeo. “Tell your doctor you’re planning a pregnancy soon, so he or she will take special care to do the LEEP as shallow as possible,” he advises those planning to conceive.
The cervix should heal from the LEEP in about four weeks, and in another month will be back to normal. But, “partner with your doctor on when to attempt pregnancy,” says Dr. DiLeo, “since he or she will provide the continuity of care from your dysplasia and its elimination to your pregnancy.”
It is the job of the cervix to stay shut and keep a pregnancy safely in the uterus until it is time to deliver. According to Dr. Jarrett, “In some individuals, the cervix just does not form quite properly, and in others it malfunctions as a result of prior surgery or manipulation.” An incompetent cervix usually starts dilating fairly painlessly in the second trimester of pregnancy, and can lead to miscarriage or premature delivery. When it is discovered in time, mothers are put on bed rest.
Since the cervix rarely shows sign of “incompetence” before pregnancy, it is very hard to diagnose preconceptually. According to a University of Illinois Medical Center fact sheet, if a woman has no history of an incompetent cervix, it usually cannot be prevented. After the diagnosis is made, treatment is available for future pregnancies.
It can be treated with procedure called cerclage, in which the cervix is stitched shut. This is usually done about 14 weeks into the pregnancy. The procedure is done through the vagina and the cerclage can be removed before delivery (or left in place if delivery is by Cesarean section).
An transabdominal cerclage is a surgical procedure called for if a vaginal cerclage fails. This is also placed around the cervix, but behind the vaginal wall. The consistency of the cervix there is much better for holding when constricted by the wrap-around nature of the cerclage. It is preferable to put it place before a next pregnancy, because there’s less bleeding, no risk to a baby, and it doesn’t interfere with conception. It means you need C-sections thereafter, but if that’s the only way to have babies, it’s worth it, remarks Dr. DiLeo. “I’ve had mixed results with the comfort level with an internal cerclage,” he says. “Some of my patients were able to work to the day of delivery. Others had cramping throughout the pregnancy, which is a little nerve-racking, but harmless.”
Previous Therapeutic Abortion
Abortions performed under sterile surgical conditions don’t tend to cause complications in subsequent pregnancies. If there were an overzealous scraping of the uterus during one, says Dr. DiLeo, this could cause scarring and affect implantation. The greater the number of elective abortions, the greater the chance for scarring.
Illegal abortions, on the other hand, “have an unquestioned adverse effect on fertility and pregnancy outcome,” according to a National Institute of Health article.
Adhesions, Cysts, and Varicies
Adhesions are excess tissue and scarring caused usually by previous surgery, infection, or endometriosis. If you’ve had no previous surgeries but are diagnosed with adhesions, then you may have had endometriosis at some point; your doctor can tell if the adhesions look like old burned-out endometriomas. If you’ve had neither surgery nor endometriosis, then you may have had an infection such as chlamydia in the past. “ You might need a test to tell if your tubes are open,” says Dr. Dileo.
Adhesions can be removed through laparoscopic surgery, but mild ones are not definite roadblocks to conception, and, notes Dr. Jarrett, “surgical treatment of mild endometriosis [adhesions] is not associated with any improvement in the chances of getting pregnant.”
The most common type of ovarian cyst is a follicular cyst. They come the fluid-filled sac in the ovary that contains an egg. In some cycles, this “follicle” grows larger than normal and does not rupture to release the egg. This usually resolves over the course of days to months. Endometrial cysts are full of blood. Dermoid cysts are usually benign tumors containing a mix of cell types. Cysts can be removed from the ovaries without impairing ovarian function. After you’ve healed, unless you’re on the pill, if your cycles are regular then it indicates that you’re ovulating well.
Pelvic varices are essentially varicose veins in and around the uterus, that can occur during pregnancy as well as in nonpregnant women. According to an article in The Journal of Diagnostic Medical Sonography, they commonly involve the broad ligaments and neighboring connective tissue and are usually found adjacent to or surrounding the uterus, lower uterine segment, and cervix. Although pelvic varices can be prominent, they rarely cause obstetrical complications, the article says.
Many women who suffer a miscarriage or ectopic pregnancy want to jump back into action and try to conceive again fast. They are often frustrated by being advised to wait for three months.
One of the ways to document the complete resolution of an ectopic pregnancy, as with a spontaneous abortion or miscarriage, is by the levels of HcG (pregnancy hormone) going down to zero. Furthermore, your body will probably not ovulate well until the HcG is gone.
Most women will begin menstruating again sooner than 12 weeks, but the first period may be weird—early or late, light or heavy. It won’t be until you get your second period that you’ll know you’re back to normal cycling again. Still, becoming pregnant before the HcG goes down to zero from the previous pregnancy leads to much confusion: Is the new rising HCG because of a new pregnancy? Or is it that the ectopic pregnancy still has some viable tissue, indicating a continuing dangerous process? Doctors try to keep things clear by separating the two pregnancies from each other: The previous ectopic pregnancy and the hopefully ensuing intrauterine one. In that way he or she can use HcG levels to monitor the resolution of the first with the fetal well-being of the second.
Only One Fallopian Tube
Sometimes women with ectopic pregnancies have to have one fallopian tube removed. And some women are born with or develop only one functioning tube.
Having one fallopian tube removed will make it less likely for you get pregnant in the short term, but as time goes on and there are more ovulations on the side where your remaining tube is, your chances of conception increase—ultimately to the same pregnancy rates as those with both tubes. Your biggest risk in conceiving after an ectopic pregnancy, says Dr. DiLeo, is that whatever made you prone to the first ectopic pregnancy (old infection, scarring, etc.) may also be present in your remaining tube. Check with your doctor about what shape your remaining tube is in.
If you have only ever had one tube, again the longer you try to conceive, the better your chances. It is just a matter of raising the odds of having had more ovulations take place on the side with the tube over a longer period of time. Unfortunately, ovulation kits cannot determine which side you ovulate from; if you retain both ovaries, they “race” to ovulate first, the other falling in function when one has “won.”
Only One Testicle
Some men have lost one testicle to cancer, testicular torsion, accident, or an undescended testicle.
Removing one testicle does not impair fertility or sexual function. The remaining testicle can produce sperm and hormones adequate for reproduction. But that doesn’t exclude a man from having other unrelated fertility concerns. Or, if the loss of the testicle was from cancer, there are related fertility complications. Sometimes the disease will have curtailed sperm production, but if not, doctors frequently advise banking some sperm before undergoing invasive procedures, including surgery, radiation, or chemotherapy.
What are your chances of getting pregnant if you have a tubal ligation, and later decide that you want it reversed?
Reversing a tubal ligation is not as simple an operation as “untying tubes” sounds. It requires exquisite surgical technique and is also very expensive; insurance rarely pays for it. “Even if you do get the tubes reconnected,” points out Dr. DiLeo, who is not a fan of tubal ligation, “there’s scarring at the junction where they were repaired, enough of a rough spot where a fertilized egg can get hung up on its way to your uterus.” This means an increased risk of an ectopic pregnancy, which may end up being a surgical emergency leading to loss of the tube, blood, and even life.
He also cites “post tubal syndrome,” in which some but not all doctors believe, where the blood supply to the ovaries is damaged, leading to faulty hormonal regulation and therefore faulty ovulation. Fixing the continuity of the tubes later won’t help the ovaries work better; the best tubes in the world don’t benefit from bad cycles.
With the advent of assisted reproductive technologies, such as intrauterine insemination (IUI), GIFT, and ZIFT, you can bypass the uncertainty of the tubes for the more controlled uncertainty of the laboratory. Before reversing the tubal ligation, check with your doctor for a referral to an infertility specialist. If your tubes have been ligated and you really want a baby badly, then it’s a bargain at any price. And the results are getting better and better, says Dr. DiLeo.
Reversing male sterilization (vasectomy) is a bit less problematic. A vasectomy reversal rejoins the vas deferens, which has been snipped and cauterized. It is performed under light sedation with the aid of a microscope. Pregnancy rates following a vasectomy reversal are generally over 50 percent, says Dr. Michael M. Alper, of Boston IVF. A major factor that impacts fertility following the reversal is the time elapsed since the vasectomy was performed (the less time the better).
At the time of the surgery a sperm sample can be aspirated near the testes and then frozen. If the surgery turns out to be unsuccessful, the sperm sample can be used as part of IVF treatment later on.