A woman is born with a certain number of eggs and as far as we know she will not make any more eggs over the course of her life. Each month the number of eggs decreases: pregnant or not pregnant, with or without menstrual periods, on or off birth control pills. Once the number of eggs drops critically low, no more menstrual periods will occur and the woman is said to have menopause. Although the average age of menopause is 51, the fact is that 1/250 will go through menopause before age 35 and 1/100 before age 40. The early onset of menopause before age 40 is called Premature Ovarian Insufficiency (POI).
Although most women ovulate a single egg per month, some estimates suggest that she may lose between 100 and 1000 eggs during that same month. The loss of eggs is therefore a normal, natural process that every woman faces. There are no medical techniques known to help a woman keep up her egg count number. In this battle, nature always wins. The number of eggs that a woman has can be estimated with 3 medical tests.
The first test, a pelvic ultrasound, can provide an "antral follicle count", basically a traffic report of how many little egg sacs have started to develop that menstrual cycle. These egg sacs will compete with the largest one shutting down the brain hormones and eliminating the competition, thus resulting in usually a single ovulation.
The second test is a blood test called anti-mullerian hormone (AMH). This test measures the amount of hormone produced by the very small follicles (egg sacs) in the ovary. The higher the AMH the more eggs are deemed to remain in the ovary and the further away menopause is felt to be.
The third test measures a follicle-stimulating hormone level (FSH) on the second or third day of the menstrual cycle. Coupled with an estradiol level, this gives some estimate of the woman's brain's impression of how many eggs remain.
Evaluation of egg reserve at an earlier age, especially for women who have a family history of early menopause, may help in planning a reproductive future.
By
Dr. Wayne Maxson at 10 Nov 2014
A laparotomy is an incision in the abdominal wall, either at the bikini line as usually performed for cesarean sections or a midline incision from the belly button down. The utilization and placement of the incision is based on the surgeon's preoperative assessment of the best and safest route for successful completion of the operation.
Traditionally, most fibroid tumors in the uterus are removed through one of these laparotomy incisions.
Advantages:
1 - The ability to fully expose the uterus to maximize removal of fibroids.
2 - The ability for the surgeon to physically appreciate the uterus and feel fibroids that are deep under the surface, removing them as well.
3 - The ability to suture the uterus in multiple layers, creating the strongest closure possible and providing for a stronger uterus later, thus, potentially lowering the chance of the uterus splitting open during a pregnancy.
Disadvantages:
1 - This approach does involve an abdominal scar which can be several inches or more in length and while these incisions usually heal very well, the scars are sometimes a cosmetic concern.
2 - Usually the laparotomy approach requires at least an overnight stay in the hospital.
3- Pain following a laparotomy is often more significant or requires more medication than the robotic approach.
4 - Some reports have shown greater blood loss with the laparotomy than with the robotic approach, but it is not clear whether these cases are more of an exception or a standard.
5 - The laparotomy approach uses sutures that dissolve rapidly and patients are able to try conceiving as early as 2 months after the procedure, whereas, with the robotic approach, the patient often needs to wait 4 to 6 months for the sutures to dissolve before attempting pregnancy.
The bottom line is that the traditional approach to removing fibroids is tried and true. However, for a woman with very discreet fibroids, that could be approached robotically, a laparotomy may not be necessary as long as the additional delay of pregnancy is acceptable. The laparotomy approach is often superior to the robotic approach in the ability to dig out deeper fibroids which often cannot be visualized with the robot, as well as the fact that it can be accomplished more quickly in the operating room than the robotic surgery.
Newer concerns have also arisen about the potential spread of fibroid tissue around the abdomen because these masses are typically ground up at the time of the robotic surgery. This spread is much less likely with a laparotomy, as the fibroids are removed intact.
It is important for you to talk to your doctor in detail about the pros and cons of each of these surgical options with special consideration for the number and depth of your fibroids and the long-term goals for your planned procedure.
By
Dr. Wayne Maxson at 3 Oct 2014
Common confusion results from the simple fact that IUI and IVF begin with the same letter "I." The processes are similar in that something is inserted in the uterine cavity. However, they differ markedly thereafter.
IUI stands for “intrauterine insemination”. This is the placement of washed sperm through a small straw into the uterine cavity. This very small, soft tube is inserted through the vagina, past the cervix, and placed where the baby is supposed to grow. This procedure is excellent when there are no obvious problems in the woman and when the sperm count is moderately low.
While it is true that only one sperm fertilizes an egg, it actually takes a whole gang of sperm with good movement (motility) to clean layers from around cells off the egg, so that a single sperm can attach to the egg shell and fertilize the egg. Most sperm die in the vagina after intercourse, due to normal vaginal acidity.
IUI is not beneficial if the fallopian tubes are blocked, if the sperm count is extremely low, or if there are significant problems with the sperm motility or quality.
IUI has also been used in conjunction with medicines to augment ovulation. In couples with otherwise unexplained infertility, IUI is very helpful in some cases where some couples are so stressed that they are unable to have intercourse at the proper time of the menstrual cycle. IUI is also useful if the cervix is quite tight or if the cervix is lacking mucus (a slippery substance required to help the sperm swim safely from the vagina up into the uterine cavity).
IVF, In vitro fertilization, is an entirely different process. Unlike IUI which requires natural egg release, this requires retrieving eggs from the ovary by passing a needle through the vagina and into the ovary. These eggs are then paired with sperm in the laboratory, leading to fertilization and hopefully, embryo development. Embryos are then transferred back into the uterine cavity with a small straw, just like in the process of IUI. IVF is an excellent procedure when the patient has problems safely picking up an egg (blocked tubes, pelvic adhesions, or endometriosis), when the sperm counts are low, or when infertility is otherwise unexplained.
By
Dr. Wayne Maxson at 11 Sep 2014
Many couples will present with infertility (more than one year of unprotected intercourse without conception), initially, without any obvious reason. Truly unexplained infertility, when a full work-up has been completed, is actually quite rare and occurs in less than 5% of our patients.
Often, a couple will be told they have "unexplained” infertility after the following three determinations: a semen analysis has shown normal looking sperm, a hysterosalpingogram has shown a normal appearing cavity and open fallopian tubes, and the patient has menstrual cycles that are regular. In more than 70% of these women, a problem inside the pelvis can be detected, which neither ultrasound scan or hysterosalpingogram x-rays can discern. The most common intra-abdominal problems causing infertility are endometriosis and pelvic adhesions (scar tissue). As these are usually invisible to standard diagnostic techniques, they require a surgical procedure (laparoscopy) to find and treat them. Only if the laparoscopy and the other studies are completely normal will the patient be determined to have truly unexplained infertility.
Subtle reasons for infertility include absent or abnormal eggs, failure of egg release at the time of supposed ovulation, failure of the fallopian tube to pick up the eggs, failure of the sperm to fertilize the egg, or failure of a fertilized embryo to implant in the uterus. Unfortunately, these events are all microscopic and elude normal diagnostic techniques.
In cases of truly unexplained infertility,in vitro fertilization (IVF) can bypass egg pick-up and sperm transportation, as well as bypass endometriosis and pelvic adhesions. Even with a diagnosis of truly unexplained infertility there is still a solution that could result in a successful pregnancy.
By
Dr. Wayne Maxson at 5 Sep 2014
A woman is born with a certain number of eggs and that number decreases as her age advances.
While the average age of menopause is over 50, some women do go through menopause early. The frequency is estimated at 1 in 250 women under 35 and 1 in 100 women under 40.
Although in most instances the reason for early menopause is unknown, there are a number of known causes such as:
- Missing or abnormal X chromosome
- Reaction of the body to the ovaries or the ovarian follicles (egg sacs), termed as autoimmune cause
- Chemotherapy or radiotherapy
There also may be specific, minute genetic defects that can lead to early loss of eggs, but these are still being investigated.
It is important to diagnoses the condition of early menopause as soon as possible. Although there is usually no treatment, in some cases eggs can be retrieved and frozen in order to preserve future fertility. In addition, the loss of the ovarian hormone estrogen at an early age can cause poor health later in life, including a potential increase in heart disease and osteoporosis. Estrogen replacement may be very beneficial in younger women who have lost ovarian function.
By
Dr. Wayne Maxson at 29 Aug 2014