Fertility Endometriosis Dialogues

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SERVICES EXTENDED

SERVICES EXTENDED

Fertility

Fertility assessment
We pride ourselves as a one-stop clinic for fertility assessment. This includes comprehensive pelvic ultrasound scanning by the fertility specialist that also involves checking fallopian tubes for patency with the HyCoSy technology. Hormone profile as well as semen analysis are undertaken, and results discussed in the single visit. You will have the opportunity to leave the clinic with a proper diagnosis and complete plan of management. It is important that both partners attend together.

Ovulation induction
The commonest cause of lack of ovulation is polycystic ovarian syndrome. A dedicated team of specialists will monitor ovulation induction to ensure that other than achieving a pregnancy, the risk of multiple pregnancy is minimized. Specialised treatment for rare cases of lack of ovulation such as pituitary failure is carefully administered by the fertility specialist.

Intrauterine insemination
In the event natural conception is rendered unlikely, intrauterine insemination is a suitable alternative. It is important that the fallopian tubes are patent and the sperm parameters are normal. This is either done in a natural cycle or following ovulation induction treatment.

In vitro fertilization (IVF)
Damaged fallopian tubes as well as very poor sperm count account for the commonest indication for in vitro fertilization. This also includes unexplained subfertility of a duration longer than 2 years. Considering the complexity of IVF treatment, each couple are treated differently with an
individualized treatment plan tailored to their unique situation. Either the long agonist or antagonist protocol is chosen for each individual case. Every effort is put in to optimise a live birth outcome as well as conscientiously reducing risks of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy. The process of IVF starts with pretreatment planning and counselling. Important tests include hormone profile, ovarian reserve testing and semen analysis. A pelvic ultrasound scan checking to ensure that the uterus is normal for implantation is done in clinic. There is no programming of the cycle and patients book treatment at their convenient time. When ready, a typical cycle starts by switching off the hormones (called down-regulation). This is then followed by injections to stimulate the eggs to grow and it may take about 10 days on average. Stimulation is monitored to ensure appropriate response and minimize risk of poor response or ovarian hyperstimulation syndrome. When the follicles reach the desired size, a late night injection (trigger) is given to cause the eggs to mature. This is then followed by oocyte (egg) retrieval, a process undertaken under light sedation using ultrasound scanning. In the IVF laboratory, the oocytes are examined for maturity and sperm is mixed or injected directly into the eggs for fertilization. We then grow the fertilized embryos in the incubator for up to 5 days when the top quality embryos are selected for transfer. Spare embryos are frozen at will for future use. Following embryo transfer, luteal support is provided using progesterone and a pregnancy test is taken in a couple of weeks. If pregnant, a pregnancy scan is planned for around 7 weeks of gestation. In the unfortunate event that a pregnancy does not arise, a follow-up medical consultation is with the Consultant is arranged as soon as possible and the whole cycle is reviewed to understand any possible explanations. As the process of IVF is daunting, counselling is always to hand.

Fertility preservation
Treatment for cancer now guarantees long-term survival when diagnosis is made at early stage. Unfortunately, chemotherapy or radiotherapy may cause irreversible damage to the ovaries or testes. We offer the opportunity to discuss fertility preservation for sperm, oocytes or embryos. Duration of storage may be up to an initial 10 years. Once cancer treatment is completed and the all clear is given by the cancer specialist,fertility treatment may be commenced. Age related fertility decline also constitutes a valid reason for fertility preservation. There needs to be a candid discussion with our fertility specialist to understand the pros and cons of this strategy.

Pre-implantation Genetic Testing
Some couples may be unfortunate to have rare genetic conditions that cause a significant quality of health compromise and require lifelong treatment of the offspring. The commonest disease is sickle cell anaemia. In this situation, specilialised testing of embryos created using IVF technology is offered to identify unaffected embryos giving them a chance for a healthy child.

Oocyte, sperm and embryo donation
Unfortunately, some couples may be faced with childlessness without the chance to be able to have biological children. This include women with ovarian insufficiency, men where sperm has not been retrieved surgically from the testes and cases of severe genetic conditions. Our team of experts will offer the needed support and professionalism to navigate through the difficult ethical, moral and legal intricacies that comes with the donation programme.

Surrogacy
Rarely women may lose the capacity to carry a pregnancy following a hysterectomy or damaged womb lining. In some cases, this is due to the womb not forming from birth. In order to complete a family, surrogacy arrangements are made where the woman’s oocytes are fertilized and an embryo transferred into a gestational surrogate. Legal complexities mean that a clear plan of transfer from the birth mother is put in place
before starting the process.

 

Endometriosis

Overview
Diagnosis of endometriosis
Endometriosis commonly presents with pain, which could be cyclic and related to the menstrual cycle. This manifests as painful periods, bowel or bladder pain. Pain may also be non-cyclic or continuous. Whereas symptoms may be suggestive of endometriosis, they are not specific.

On examination, there may be detectable pelvic nodules or a mass around the ovary and often areas of tenderness. We perform a detailed ultrasound scan looking for features of endometriosis including a cyst in the ovary, nodules between the bowel and vaginal wall or scarring. Other suggestive signs include areas of discomfort during scanning. Availability of magnetic resonance imaging (MRI) provides additional information that is particularly helpful when planning complex surgery to excise disease from bowel, ureters or bladder. Definitive diagnosis is made following laparoscopic surgery. We are privileged to perform excision surgery when endometriosis is found on laparoscopy so you do not have to go through multiple surgeries. This is likely to be suspected on pre-operative assessment with ultrasound scan or MRI. Endometriosis presenting in other parts of the body is suspected from frequency of symptoms associated with menses. This includes chest pain with thoracic endometriosis or bleeding from the belly button. Definitive diagnosis is made by taking tissue during surgery for analysis.

Management of pain
Endometriosis related pain may be amenable to hormone treatment using either the combined contraceptive pill or progesterone only preparations. This may be a sensible option when surgery is not immediately desirable. It is most effective where pain is strongly correlated with the periods. Other medications may include suppressing ovarian hormones to mimic the menopause. Ideally, this option must only be offered where surgery has confirmed endometriosis and symptoms haven’t improved following excision or it is dangerous to excise without damaging vital structures such as nerves or blood vessels. We offer add-back therapy to counteract the symptoms of the menopause that accompany ovarian suppression.

Management of Fertility
Most women with endometriosis will have no problems conceiving, however, nearly 50% of women with delayed conception may have endometriosis.
Fully fertility evaluation must be completed to determine the probable cause of delay in conception. This includes confirmation of ovulation, semen analysis and tubal patency testing. Where endometriosis is suspected, performing laparoscopy to ascertain tubal patency provides the unique chance to treat the disease and release adhesions that may hold the fallopian tubes down. There is good evidence to show that laparoscopic treatment of endometriosis increases the odds of achieving a pregnancy. This includes excision of ovarian endometrioma. Care is taken to reduce the inadvertent risk of ovarian damage when the cyst wall is excised.

It is important that semen analysis is done prior to undertaking laparoscopy as this is invasive and costly. When semen parameters are severely abnormal, offering assisted reproductive treatment in the form of IVF affords better chances to achieving a pregnancy. Intermediate treatments such as intrauterine insemination may not particularly be cost-effective.

Endometriosis Surgery
The most beneficial surgical treatment of endometriosis is excision preferably performed during the first surgery. It requires expertise and experience in complex laparoscopic surgery as disease may involve the bowel, ureters, bladder or the recto-vaginal space. Laparoscopic surgery has the benefit of shorter hospital stay, earlier return to normal activities, reduced complication rates and better visualisation for the operating surgeon. Pre-operative planning and appropriate imaging guides and prepares the patient and surgical team of the expectations during surgery.

Multidisciplinary Care Concept
Endometriosis is a complex condition that may have effects in more than one symptom presentation. Due to its chronic nature, the effect on quality of life is often significant with impact on psychological well-being, social relations and occupational disruption. This is worsened by poor understanding of endometriosis amongst the general public. Whereas the gynaecologist is likely the first point of contact with health care, a coordinated multidisciplinary team sets the goals of care for the patient. At FED, we have a fertility specialist also doubling as endometriosis specialist which brings the advantage of a balanced professional able to navigate through the patient journey prioritizing care goals. We also work in close collaboration with the pain specialist, psychotherapy and social departments, physiotherapy and rehabilitation and a dedicated radiologist specializing in female gynaecological imaging. Other members called upon include urological, bowel and cardiothoracic surgeons.

This one-stop multidisciplinary team convenes weekly to discuss complex cases and make plans under the leadership of the endometriosis specialist. We welcome colleagues from other institutions to join the virtual ward rounds to discuss cases prior to making appropriate referrals. This approach is endeared to the patients who feel always at the center of the discussion and being involved in every step of their care. Decisions for specific
treatment options are weighed against best practice and potential benefit for the prioritized symptoms.

 Endometriosis Research
Whereas endometriosis has gained significant attention in the recent past, there remains a lot of work to be done to understand the disease and develop innovative treatments. We have various ongoing research projects whose success has depended on the willingness of our patients to participate and the great partnership of our collaborators. We remain indebted to you all. To take part in any of our research projects, please contact Dr Charles Muteshi for further details.

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