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Uterine Problems and IVF

The normal menstrual cycle is 28 days long. Oligomenorrhea is defined as cycle intervals greater than 35 days. Polymenorrhea is an interval less than 24 days. Menorrhagia is normal regular intervals with excessive flow and duration. Metrorrhagia is excessive flow and duration at irregular intervals (as patients would say ‘bleeding all the time’). For patients undergoing ART, it is absolutely necessary that the structural and hormonal causes of irregular menses be evaluated prior to treatment. Failure to do so could risk miscarriage or other failed implantation. Hormonal problems include hypo and hyperthyroidism, hyper prolactinemia, and PCOS.

In order to assess that uterus several modalities are available. Transvaginal ultrasound may show fibroid tumors in the uterus. There may be subserosal, intramural, or submucosal. Saline infusion sonography (SIS) combines ultrasound with the instillation of normal saline into the cavity in order to have better contrast. Uterine polyps may also be visualized. A hystersalpingogram (HSG) may demonstrate irregularities of the cavity caused by submucosal myomas, polyps, or scar tissue, but the myometrium is not visualized. A hysteroscopy gives the physician a direct view of the cavity and may be considered the gold standard evaluation of the cavity. To address the question concerning the effects of leiomyomas on ART outcomes, prospective randomized need to be performed with adequate numbers of patients. These definitive studies are lacking. Most studies are retrospective in nature and results seem to vary, especially on the issue of intramural myomas. Surrey (1) found that intramural myomas that distort the cavity lead to decreased pregnancy rates and need to be removed. If there was no distortion, no effect was seen. This is similar to what Jun et al (2) found in a retrospective study. Check et al (3) found that intramural myomas <5 cm in size had no effect on pregnancy rates if they did not disrupt the cavity, but that a trend, though not statistically significant was noted showing lower live delivery rates and increased miscarriage rates. Several studies showed a lower pregnancy rate. Hart et al (4) reported ½ the pregnancy rate with intramural myomas present. Eldar-Geva et al (5) showed a negative effect of intramural myomas, even without cavity distortion. Taken together, patients and clinicians need to make informed decisions here in the absence of the definitive studies. Thus, for IVF patients with irregular menstrual cycles due to leiomyomas appropriate evaluation of the cavity should be undertaken and the decision to remove them based on those findings.

References:

1. Surrey ES. Impact of intramural leiomyomata in in-vitro fertilization-embryo transfer cycle outcome. 2003. Current Opin. Obstet. Gynecol. 15(3)239-42.

2. Jun SH, Ginsburg ES, Racowski C, Wise LA, Hornstein MD. Uterine leiomyomas and their effect on in vitro fertilization outcome: a retrospective study. 2001. J Assist. Reprod. Genet. 18(3):139-43.

3. Check JH, Choe JK, Lee G, Dietterich C. The effect on IVF outcome of small intramural fibroids not compressing the uterine cavity as determines by a prospective matched control study. 2002. Hum. Reprod. 17(5):1244-8.

4. Hart R, Khalaf Y, Yeong CT, Seed P, Taylor A, Braude P. A prospective controlled study of the effects of intramural uterine fibroids on the outcome of assisted conception. 2001. Hum. Reprod. 16(11):2411-7.

5. Eldar-Geva T, Meagher S, Healy DL, MacLachlan V, Breheny S, Wood C. Effect of intramural, subserosal, and submucosal uterine fibroids on the outcome of assisted reproductive technology treatment. 1998. Fert. Steril. 70(4):687-91.
 

 

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