A positive fertility experience starts with the people around you.
If surgery is required as part of your fertility journey at Oasis our team will refer you on to our trusted network of Gynaecologists.
Please use the links below to direct you to the services required.
Caesarean Scar Defect (CSD) is defined as the presence of a “niche” at the site of a Caesarean delivery scar site.
With the rising rate of caesarean section, prevalence of CSD is between 24% and 70% in a random population of women with at least one Caesarean delivery.
The issue arises when the defect becomes a pouch, or isthmocele in the lower uterine segment and accumulates fluid or blood. When old menstrual blood becomes trapped in the isthmocele and uterine cavity, it sets up an inflammatory response in the uterus impairing embryo implantation.
It is postulated that accumulated blood in the niche can ultimately degrade cervical mucus and sperm function, as well as inhibit sperm transport, a proposed mechanism of infertility.
A British study has reported that 30 percent of women who had a C-section were not able to conceive another child. The National Institutes of Health (NIH) says Caesarean scars are clinically relevant or cause symptoms in 19-88% of C-section patients.
A retrospective case–control study including 310 IVF patients showed that a caesarean section scar can could decrease the chances of embryo implantation (24.01 vs. 34.67%) and reduce the pregnancy rate (40.28 vs. 54.22%)
The presence of a Caesarean scare “niche” is associated with future potential fertility problems including an increased likelihood of needing a C-section in a subsequent pregnancy, ectopic pregnancy in the scar, miscarriage, potential uterine rupture in a future pregnancy, and secondary infertility.
CDS may be asymptomatic or present with range of symptoms: pelvic pain, abnormal bleeding, vaginal discharge, painful periods and infertility.
Women having a difficulty falling pregnant following a previous C-section should seek medical consultation to evaluate the possibility of CSD being the cause.
Diagnosis of CSD can be made with the following:
• Ultrasound
• Saline infusion sonohysterography
• Magnetic resonance imaging (MRI)
• 3-D ultrasonography
To promote fertility and decrease symptoms, the defect must be repaired. Laparoscopic repair of the defect is recommended for women who desire future fertility. A major benefit of laparoscopic repair is about 75% of patients become pregnant following niche repair. It is recommended to wait at least 3 months before attempting conception.
There are two successful techniques described for laparoscopic repair of CSD: one without processing scar resection and other with processing scare resection. Pregnancy outcome is similar irrespective of the approach.
The role of fallopian tube is to pick up the egg released form the ovary, allow the sperm to travel through it, provide site for fertilisation. Once the egg is fertilised, the resulting embryo must travel from the fallopian tubes to the uterus in order for pregnancy to occur. Damaged or blocked fallopian tubes can prevent a woman from getting pregnant by interfering with the movement of the sperm to the egg or the fertilised egg to the uterus. About 20-30% women with infertility have tubal problems.
Tubal blockages or damage may be caused by pelvic inflammatory disease, endometriosis, previous surgeries, ectopic pregnancy or tubal ligation. Most women with damaged or blocked fallopian tubes do not experience any symptoms.
1. hysterosalpingogram (HSG) test
2. saline sonogram (HyCoSy)
3. laparoscopy and dye test
There are several types of treatment for damaged or blocked fallopian tubes are available. Though these procedures are aimed to open the tubes, one must remember open tube is not equivalent to a functional tube. The pathology causing the blocked tube significantly affects physiological function of the tube affecting reduced success rate following surgery and increasing risk of ectopic pregnancy.
Tubal reanastomosis is often used to reverse a tubal ligation or to repair a part of the fallopian tube damaged by disease. The blocked or diseased part of the tube is removed. Then the two healthy ends of the tube are joined. The outcome of such surgical procedure depends on condition of the residual tube. Also there is a significant risk of ectopic pregnancy post surgery.
Salpingectomy is the removal of part of a fallopian tube. It’s done to improve IVF success when a tube has a build-up of fluid inside the tube known as hydrosalpinx. Hydrosalpinx reduces the success of IVF procedure. Salpingectomy is preferred over salpingostomy for treating a hydrosalpinx before IVF.
Salpingostomy is also done when the end of the fallopian tube is blocked by a build up of fluid. This procedure creates a new opening in the part of the tube closest to the ovary. But it’s common for scar tissue to regrow after a salpingostomy. This can reblock the tube.
Fimbrioplasty may be done when the part of the tube closest to the ovary is partially blocked or has scar tissue. These problems can prevent normal egg pickup. This procedure rebuilds the fringed ends of the fallopian tube.
A procedure where a thin, lighted tube (hysteroscope) is inserted into the uterus through the cervix to examine the inside of the uterus.
Diagnose Uterine Problems: Identifies issues like fibroids, polyps, scar tissue, and abnormalities in the shape of the uterus that could affect fertility.Treat Uterine Issues: Allows for the removal of fibroids, polyps, and scar tissue, or the correction of uterine abnormalities, which can improve the chances of pregnancy.
Minimally Invasive: Less invasive than traditional surgery, with a faster recovery time.Detailed View: Provides a clear view of the inside of the uterus, allowing for accurate diagnosis and treatment such as septoplasty and polypectomy.
Risks: As with any procedure, there are some risks, including infection, bleeding, or injury to the uterus.Recovery: Most patients experience minimal discomfort and recover quickly.
When to Consider Hysteroscopy
• Unexplained Infertility: When other fertility tests have not identified a cause.
• Recurrent Miscarriages: To check for and treat uterine abnormalities that could be contributing to miscarriages.
• Abnormal Uterine Findings: To diagnose and treat abnormalities found during other fertility tests, like an ultrasound.
A uterine septum is a congenital (present from birth) abnormality. It is the presence of a large fibrous band in the uterine cavity. This type of malformation is also called a müllerian anomaly or defect. A uterine septum (or septate uterus) is the most common uterine abnormality associated with reproductive failure, although some women with this condition conceive without any problems.
A uterine septum affects women during pregnancy much more often than it affects their ability to conceive. Women with a uterine septum may experience repeated miscarriages because the uterus is shaped abnormally. There may also be instances in which the uterine septum may cause problems with conception because the defect limits the blood supply available to the uterine wall, sometimes making it difficult for an embryo to implant.
A uterine septum may also cause additional problems once a woman becomes pregnant, including preterm labour or malpresentation during the birthing process.
There are four modalities of investigations are used to diagnose uterine septum.
• Ultrasound
• MRI of the uterus
• HSG
• Hysteroscopy
The uterine septum is removed using a minimally invasive procedure called operative hysteroscopy (septoplasty). There are very few complications, and this procedure has proven to be very successful in treating fertility problems which are due to a septate uterus (or uterine septum).
Uterine fibroids are benign (noncancerous) tumours of muscle tissue in the uterus. Fibroids occur when a single muscle cell in the wall of the uterus multiplies and grows to form a noncancerous tumour. Fibroids can change the shape or size of the uterus and sometimes the cervix (lower part of the uterus).
Whether fibroids cause symptoms or require treatment depends on their location, size, and number.
Fibroids are usually found in or around the body of the uterus, but sometimes are in the cervix. There are three main types of fibroids based on where they are found:
• Subserosal are in the outer wall of the uterus (55%)
• Intramural are found in the muscular layers of the uterine wall (40%)
• Submucosal protrude into the uterine cavity (5%)
Fibroids are found in 20% of women of reproductive age, but are more common in African-American women (50%-80%). The exact cause of uterine fibroids is unclear, but there is evidence that it may be a combination of genetic, hormonal, and environmental factors.
There are several ways uterine fibroids can reduce fertility:
• Enlarged size or specific location fibroids can hinder the transport of the sperm and egg, as well as their implantation.
• Fibroids seem to alter uterine contractions leading to an inflammatory reaction in the uterus. The latter may hinder implantation.
• Blood flow to the uterine cavity can be affected. This can decrease the ability of an embryo to stick (implant) to the uterine wall or to develop.
• Reduced endometrial receptivity: Two important markers – HOXA 10 and glycodelin, of endometrial receptivity are reduced in presence of fibroid.
• A physical disruption of the junctional zone, caused by intramural fibroids, may also lead to implantation failure or early pregnancy loss.
• uNK cells are the most abundant and important immune cells in the uterus at the time of implantation. An alteration of uNK cell numbers has been associated with implantation failure. The presence of fibroids appears to influence the number of uNK cells and macrophage cells.
Myomectomy as a potential surgical treatment for fibroids has been explored in many case studies. In general, approximately 50% of women with infertility and fibroids become pregnant after myomectomy, although the numbers differ depending on the study. Whether performed hysteroscopically or by laparotomy or laparoscopically (depending on the location and the size), myomectomy has led to a rise in pregnancy rates; however, only the rise regarding submucosal fibroids was statistically significant. Then again, the literature review has shown that myomectomy before IVF has significantly increased the success rate in fibroids without submucosal component.
The benefit of myomectomy highly depends on the location and size of the fibroids.
