How Uterine Abnormalities Contribute to Infertility

What Is a Septate Uterus?

One in four women will suffer from repeated missed pregnancies due to a congenital factor known as a septate uterus. According to RESOLVE: The National Fertility Association, it is the most common congenital uterine anomaly to affect women. A septate uterus is described as a condition where a wall or septum partially or fully divides the uterus into two cavities.

Initially, the diagnosis is made by a combination of clinical facts and detection using a hysterosalpingogram (HSG), which is a uterine x-ray. This method of detection is used frequently to locate scar tissue, polyps, fibroid tumors and abnormalities of the uterus.

The surgery necessary to remove the septum and treat a septate uterus is called a metroplasty. It can be performed hysteroscopically (through a telescope-like device that is placed in the vagina and then into the uterus) or laparoscopically, through a small incision in the abdomen called a laparotomy. Recovery time is generally shorter when the surgery is a hysteroscopy. The success rate of this surgery is good with 80% of women who have had a metroplasty to remove the septum and reshape the uterus going on to have a healthy pregnancy and deliver a full-term baby.

How DES Exposure Affected Children

In a bid to lower miscarriage risk, doctors during the 1940s and 1950s gave some pregnant women a synthetic hormone called di-ethyl-stilbestrol, or DES. Over time it was discovered to have no effect on miscarriage prevention. However, it did have an unfortunate outcome in terms of causing embryological abnormalities in the children of the women who took it over those two decades.

Exposure to DES can lead to certain abnormalities in the upper vagina, especially the flattening of the neck of the cervix. While infertility with DES exposure is not common, it can happen. More often the issue is spontaneous miscarriage as a result of an abnormal “T” shape of the uterine cavity or lack of strength of the cervix due to its abnormal development. These difficult- to-treat abnormalities are consistent with DES exposure. A weak cervix can be helped with a cerclage, a special, sturdy stitch placed surgically around the cervical neck. However, the T-shaped uterine cavity, if severe, will not hold a pregnancy very long.

The Scars of Abortion

Intrauterine adhesions, known as Asherman’s Syndrome, is the presence of scar tissue in the uterine cavity. When this syndrome is severe it causes amenorrhea, the absence of menstruation. Women with less severe scarring may experience very light periods. Asherman’s Syndrome occurs most frequently following an endometrial curettage, which is a scraping procedure done to empty the uterine cavity of pregnancy tissue – most often from a spontaneous, incomplete, or elective abortion. The scraping of the lush uterine lining causes scar tissue that creates an unwelcome environment for pregnancy.

In order to detect Asherman’s Syndrome, which usually presents with amenorrhea after the curettage, an HSG is performed in order to check the uterine cavity. If a woman has a reduced flow during menses, or no menstruation at all, the HSG is done and if Asherman’s Syndrome is present it is treated by removing the scar tissue bands, and replenishing the endometrial tissue (uterine lining) with estrogen. In order to prevent the reforming of scar tissue an IUD may be inserted.

Why Can’t I Get Pregnant?

Adenomyosis is a condition that is similar to endometriosis in that it is uterine tissue that is growing where it shouldn’t be growing. In the case of adenomyosis, the endometrium (the inner lining of the uterus) grows in the middle, muscular layer of the uterus called the myometrium. Endometriosis spreads throughout the pelvic cavity, but adenomyosis is confined to the walls of the uterus only.

Adenomyosis presents with abnormal uterine bleeding and pelvic pain, especially during menses. This condition has been linked to several other uterine disorders including fibroids and endometrial polyps. Unfortunately the only sure treatment for this uterine abnormality is a total hysterectomy. Gonadotropin releasing hormone (GnRH) supplements have been used in some cases, however, it is a very short term fix and the adenomyosis returns in less than half a year.

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