Diagnosis: Infertility Caused by PID Scar Tissue
By: Carolyn

What PID Scarring Means and Its Impact on Fertility

Many women who have suffered an attack of pelvic inflammatory disease (PID) also suffer from infertility caused by the infection. PID can be caused either by a sexually transmitted disease or bacterial vaginosis. An infection can cause scarring in the fallopian tubes or in the abdomen. Blocked fallopian tubes hinder an egg’s ability to travel into the uterus to be fertilized, and scarring in the abdomen can effectively cement the fallopian tubes in place (making it nearly impossible for them to “catch” an egg) and completely separate them from the ovaries.

PID is frequently misdiagnosed, especially if the patient does not test positive for a sexually transmitted disease. A bad attack causes severe stomach/abdominal pain and an infection that must be treated with antibiotics. If you suspect you have had PID, inform your OB/GYN or RE so they can complete further testing.

It’s important to note that any kind of abdominal infection or abdominal surgery can cause scarring that may lead to infertility. You should inform your physician if you have any cause to suspect that you may have scar tissue.

Diagnostic Process

Unfortunately, the only way to definitively diagnose infertility caused by PID scarring is through a laparoscopy. Your doctor may decide a lap is indicated if an HSG shows that your tubes are blocked, if you have a known history of PID or abdominal infection/surgery, or if an HSG shows that your uterus and/or tubes seem to be pulled into an awkward position. If scarring is found during a lap, your doctor will remove all that (s)he can.

Treatment Options

Since many women who suffer from infertility caused by PID scarring (or scar tissue in general) have blocked tubes, unblocking them is frequently the first step. This is typically done during a laparoscopy. The best treatment for scar tissue is to remove it, however, because the nature of scar tissue is to grow back, removal may only result in a short window (usually 6 months to 1 year) of fertility. Aggressive scar tissue can grow back even more quickly.

IUI may not be recommended for a woman who suffers from PID scarring if she has blocked fallopian tubes or tubes that cannot retrieve an egg once ovulation has occurred. In those cases, or in the case of a woman whose scar tissue has grown back aggressively after removal, IVF is the only option.

Personal Experience

I suffered from a bad attack of PID three years before my diagnosis. The initial infection was misdiagnosed by no fewer than three doctors, all of whom assumed that I had a burst ovarian cyst. My HSG was perfectly normal, though a later review of the films showed that one of my tubes was pulled in a suspicious direction. After 15 months of infertility, a new OB/GYN recommended an exploratory laparoscopy just to rule out any problems that could have been caused by the infection. Lo and behold, I had scar tissue everywhere. My fallopian tubes were thankfully clear, but my tubes and ovaries were completely cut off from one another, and my tubes were tied down by scar tissue.

Not every doctor thinks to perform a lap before labeling an infertile patient “unexplained.” I will forever be grateful that mine decided to take that step before we wasted time and money on IUIs that would not have worked. As grateful as I am to my doctor, however, I never would have found him if I hadn’t been determined to find a diagnosis for my infertility. In my case, getting aggressive was likely the only way for me to find a cause and to determine which treatment options were best for us.

Postcoital Exam
by Melissa

Why would you be doing a postcoital exam?

It seems like doctors don’t use them very much anymore, but we had a postcoital exam to determine whether IUI was a good option or whether we should jump to IVF. A postcoital exam evaluates the cervical mucous and determines whether it is a good conductor for the sperm.

Thalia wrote in the comments (and I’ve added it here): There’s a reason why doctors don’t do these any more. The doctor I saw recently said, imagine a picture of a station after the train has just left. The postcoital test is like using that picture to estimate how many people got on the train. Enough said, in my opinion. If your doctor suggests one, ask why. If they insist, look for another doctor who has better kept up to speed with developments in fertility treatments [unless the test is being used to test the quality of the cervical mucous close to ovulation].

What to expect

Postcoital exams are conducted close to ovulation, when optimal cervical mucous is being produced. Simply put, the couple has sex (at home!) and comes to the clinic within a set period of time. A swab is inserted near the cervix to collect a sample of mucous. The mucous is analyzed and the couple is given a report on the quality of the cervical mucous. For the most part, the RE is looking to see how many sperm are still alive and moving in the mucous. And also the quality of the mucous (as well as quantity).

Problems that may arise and ways to troubleshoot

Except that you may not get to the RE’s office in time? There really aren’t many things that could go wrong with a postcoital exam. It’s a simple, painless test.

Personal tips

The worst part of the postcoital is that it’s embarrassing. In reality, all fertility tests and treatments are embarrassing, but this one is particularly blush-enducing since you just had sex prior to arriving at the RE’s office. Some women drink green tea daily from CD 1 until ovulation in order to produce larger quantities of cervical mucous. I’m not sure if this is even a proven result of drinking green tea, but it can’t hurt to down a cup or two a day in the days leading up to the test.

Varicocelectomy
by Serentity

Why would you be having a Varicocele Repair (Varicocelectomy)?

A varicocele is a tangle of enlarged blood vessels (a varicose vein) in the testicles. It is fairly common, affecting 15 % of men overall and about 40% of men with diagnosed infertility. A varicocele is caused by faulty valves in the blood vessels, allowing blood to pool in the vein, increasing the temperature in the testicles and therefore depressing sperm production.

A varicocele repair – also known as a varicocelectomy or varicocele ligation – is a surgical procedure in which a urologist will tie off the enlarged and weakened veins. It is generally done on an outpatient basis, under general anesthesia, though some urologists prefer to use a local anesthesia.

What you can expect

The night before the procedure, you will be instructed not to eat after midnight. Someone must take you to and from the procedure – like with all procedures under general anesthesia, you will not be allowed to drive yourself home.

The procedure itself will take 1-2 hours, depending on the urologist. Once in the recovery area, you will be required to eat and drink something and walk before you can be discharged.

Most surgeons do the procedure as a laparoscopy, so you will have about a 2-3 inch incision on your groin. Expect some pain in the first few days from the incision; you will also have a lot of bruising in the area. That is normal. It will take about 2-4 weeks for the incision to heal completely, however, generally you can resume light work duties 1-2 days after the surgery and full strenuous activity within 1 week.

Generally you will be given a prescription for pain medication for the first few days, but in many cases Tylenol is sufficient to control the pain.

Your urologist will schedule a post operation follow-up with you within a couple weeks of the surgery. If the surgery is infertility related, you will have to undergo both a 3 and 6-month post operation semen analysis.

Problems that may arise

You may have some problems recovering from the surgery; some issues include infection in the incision site and/or potential fluid build-up in the scrotum.

Some people also report slight pain during sex for a couple of weeks after the procedure – mostly related to the bruising in the pubic area. This is normal. If you feel severe pain or recurring pain once the bruising is gone, call your doctor.

Personal tips

A bag of frozen peas (or corn or just ice) is VERY nice during the recovery period. My husband’s urologist used both a local in the incision area and general anesthesia, so he didn’t feel much pain at all until the next day. We found that if he iced the area every couple of hours, he didn’t need as much pain medication.

It takes longer than you’d expect for the incision to fully heal. Both my husband and I were concerned when his incision wasn’t fully closed three weeks after the procedure. However, his urologist told him at the 3 week post-op appointment that he was healing just fine.

IUI
by Melissa

Why would you be doing an IUI?

IUI or inuterine insemination is used for numerous reasons. If the woman doesn’t have a partner or her partner is also female, an IUI can be used to impregnant her. It can be used if there is borderline male factor infertility and the RE is worried about motility (this technique places the sperm close to the egg so that they don’t have to swim very far). It can be used if a person doesn’t have enough cervical mucous to transport the sperm up towards the fallopian tubes (you would know if there was a problem with cervical mucous after a post-coital exam). Often times, it is used before proceding to IVF with unexplained infertility. IUIs can either be natural or medicated. Medicated cycles range in invasiveness from Clomid to injectible medications.

What to expect

Protocols differ from clinic to clinic so ask your doctor what to specifically expect when you begin your IUI cycle. We jumped immediately to medicated IUIs with injectibles. Our experience was that drugs were used in the first half of the cycle to assist ovulation and create better eggs (Clomid and Follistim). Two nights before the IUI, we took a trigger shot of hcG at 10 p.m. (the timing is important because you will ovulate 36 hours later). We then showed up at the clinic at 8 a.m. two days later (for instance, trigger on Wednesday night and the IUI was on Friday morning) and deposited a sperm sample. Sperm can be collected at home, but there are guidelines with transporting it to the clinic to keep it viable.

We had a two hour wait while the sperm was washed. When they prepare the sperm, they concentrate the best quality sperm with the greatest motility. At 10 a.m. a catheter was inserted through a speculum and into my uterus. The sperm was then injected through the catheter and we rested on the table for 20 minutes to help the sperm stay close to the fallopian tube.

Problems that may arise and ways to troubleshoot

There aren’t many problems that crop up with an IUI that you can do anything about–it’s all in the hands of your doctor. One word of caution is that medicated cycles should be closely monitored. Blood draws and sonograms should help the RE determine the proper time to conduct the IUI. No one should take follicle stimulating drugs without monitoring (including Clomid).

Also, though it’s very rare, report any pain after an IUI because infections can occur any time a catheter is placed inside the body.

Unsurprisingly, IUIs have a lower success rate than IVF. The rate varies from clinic to clinic and also varies due to other factors such as age or the number of follicles. The decision to try IUI should be made in conjunction with your doctor. On one hand, the lower success rate may mean that it’s not worth the time and money to try it before IVF. On the other hand, IUI is much less expensive and much less invasive. Some religions that do not permit IVF do accept IUI.

Personal tips

I found the IUI uncomfortable only because they had trouble inserting the catheter due to the way my uterus tipped. Ask for pictures of your follicles to keep in case the IUI is a success.

Clomid
by Kelly

Otherwise known as Clomiphene Citrate

Why would you be taking clomid?

Clomid is generally the first fertility drug that women use and has been in use. It is (relatively) inexpensive as fertility drugs go, it is easily taken (orally rather than by injection) and it is the first line drug used for ovulation induction in patients with PCOS and other ovulatory disorders. It has been used for patients with luteal phase defect.

When used to induce ovulation, Clomid is taken for approximately five days early in the menstrual cycle. This may be either days 3-7 or days 5-9. Some women who do ovulate also use clomid to induce a ‘stronger’ ovulation.

Most women begin with 50 mg and this is increased if ovulation does not occur. Once ovulating, most pregnancies occur in the first 6 cycles of treatment. Clomid is said to be able to induce ovulation in as much as 85% of the women who use it, though only half of those will actually become pregnant. Most authorities agree that continuing for more than 6 ovulatory cycles in not likely to increase the chances of success.

What to expect

The most common side effects of clomid are hot flashes, multiple births (most commonly twins. There is a 7% chance vs. 2% in the general population), minor GI symptoms, visual symptoms, headache, ovarian hyperstimulation (OHSS), cysts, breast discomfort, weight gain, moodiness, stronger PMS symptoms–bloated, cramps, sore breasts, etc, allergies, rash, cervical mucus changes, and tubal pregnancy.

Problems that might arise and ways to troubleshoot

Many people advise on taking clomid at night–this way they say that the hot flashes are less severe and generally do not interrupt their sleep. I get dizzy and feel ‘stoned’ while on clomid and find that I actually like to take it in the morning. For me, those side effects don’t get too bad until the afternoon. Also, the hot flashes at night are an annoyance but don’t bother me as much as the other side effects. I think the ‘stoned’ effect of clomid lasts for me for the time while I am taking it until a day or two after finishing the pills. I usually get very weepy after taking the last pill. I always get very bad PMS while taking clomid too.