In Infertility, Consider Pelvic Factors
By Charles Miller, MD, Reproductive Endocrinologist and Director, Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital
Infertility -- its causes, treatments, heartbreaks and triumphs -- has become part of our national dialogue. With infertility affecting approximately 7.3 million people in the United States (according to a 2002 National Survey of Family Growth), chances are you know someone who has struggled with the inability to conceive or carry a baby to term. Perhaps it’s a struggle you yourself face.
One area of infertility that the general public seems to be underinformed about is the role pelvic factors play in the process of becoming pregnant. A more thorough understanding of these factors, among both the general population and within the medical community, I believe, could go a long way toward improving positive outcomes for women undergoing fertility treatments.
Understanding Pelvic Factors and their Role in Infertility
First, let me give you a clear definition of infertility. According to the National Infertility Association: “Infertility is defined as the inability to conceive after one year of unprotected intercourse (6 months if the woman is over age 35) or the inability to carry a pregnancy to live birth.” Both men and women can have fertility issues. Male infertility is noted approximately 40% of the time. In the case of the female, 40% are secondary to problems in the pelvis, 20% are caused by disruption in ovulation, and roughly 1 in 10 infertile cases are due to problems at the cervix, i.e. – hostile mucus. Moreover, in 5% - 10% of cases, the cause is unknown.
It is interesting to note, though, that approximately 40% of the fertility issues can be attributed to pelvic factors. In short, pelvic factors are physical obstacles that adversely affect a woman’s ability to conceive or carry a pregnancy to term. Pelvic factors include:
- Uterine fibroids that disrupt implantation
- Endometriosis, which can cause inability of eggs to be picked up by fallopian tubes, impact hormones, egg quality, egg production and implantation
- Decreased ovarian function because of cysts in ovaries
- Tubal disease that negatively impacts ability of sperm and egg to meet
- Abnormally-shaped uterus
- Scar tissue in uterus, perhaps from a previous surgery
Treatments like in-vitro fertilization (IVF) can help overcome many of these problems, especially those which involve the egg and sperm coming together. But, in many cases, the success of IVF, and other infertility treatments, can be improved dramatically when these pelvic factors are addressed surgically beforehand. In some cases, surgery to correct the pelvic factor responsible for the infertility can even result in a spontaeous pregnancy -- meaning no additional fertility treatment is required.
Think of the surgery as removing physical obstacles on the path to pregnancy.
Robotics Front and Center at Advocate Lutheran General Hospital
Having been involved in this kind of surgery since I arrived at Advocate Lutheran General Hospital (ALGH) in 1983, I have seen its amazing progression. In the early years, we performed open surgery using magnification to minimize the risk of post-operative scar tissue. From there, we advanced to laparoscopic surgery using a monitor. Today, we are one of the leaders in robotic surgery.
There are many benefits of robotic surgery for treating pelvic factors. In treating uterine fibroids, for instance, robotic techniques involve removing the fibroid and repairing the uterus in several layers, with the goal of creating a healthy uterus. Robotics also allow the precise removal of tissue when treating ovarian endometriosis, a common pelvic factor. Robotic surgery can be used to open up blocked fallopian tubes, clearing the pathway for fertilization to take place in the tubes. The precision afforded by robotic surgery minimizes the destruction of surrounding tissues. Additionally, because of the 3-D visualization that robotics facilitates, surgeons are better able to determine normal versus abnormal tissue. The more normal tissue we can identify, the better our results will be. Minimal disturbance of normal tissue ensures the best chance of proper function and minimizes the risk of adhesion.
The positive outcomes of minimally invasive surgery for pelvic factors are very good. For instance, women with an abnormal, heart-shaped uterus generally have a 1-in-6 chance of becoming pregnant. After a minimally invasive surgery to remove the septum of the uterus, thus restoring it to a healthier state, that number increases dramatically to 5-in-6 women having a successful pregnancy.
Patients that should consider looking at pelvic factors early on in the process of becoming pregnant are those with a past history of previous uterine surgery (including D&C), endometriosis, appendicitis, uterine fibroids or ovarian cysts; in fact, any surgery that could cause scar tissue in the pelvis. Additionally, women who are not achieving pregnancy when all other factors seem to be “normalized,” may want to seek advice on whether pelvic factors are playing a role in their inability to conceive.
It is important to find a specialist who has the ability to do an accurate work-up that considers pelvic factors as a potential problem. The specialist should also be specifically trained in minimally invasive surgery for pelvic factors. This training is focused on minimizing the risk of scarring and restoring the pelvis to a more normal situation, both of which are crucial for ensuring good outcomes.
Advocate Lutheran General Hospital is an excellent place to begin your search. No facility in Chicagoland is doing more minimally invasive surgical treatment for pelvic factors than ALGH. I’ve had the privilege of being part of the team that has shaped surgical aspects of fertility treatments at the hospital over the last 30 years. We are thought leaders on laparoscopic and hysteroscopic surgery. Our advanced robotics program has earned us the honor of being designated a “Genesis Site” -- meaning other hospitals learn, from us, how to set up a robotics program in their hospital. We are the second hospital in the country to have earned this distinction.
By Charles Miller, MD, Reproductive Endocrinologist, Director, Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge, Ill.