The uterine factor in infertility

The major functions of the uterus in reproduction are sperm transport, implantation of the blastocyst, nourishment of the conceptus, fetal growth and development, and finally, parturition.

To determine the presence or absence of a uterine factor in infertility, any or all of the following diagnostic procedures may be performed:

• Endometrial biopsy: determines the occurrence and time of ovulation, detects inadequate luteal phase, presence of infection, endometrial polyps or hyperplasia, and rules out intrauterine adhesions (Asherman’s Syndrome).

• Postcoital test: determines cervical mucus receptivity and ability of sperm to survive in mucus.

• Hysterography/hysterosonography and hysteroscopy: diagnoses uterine anomalies, submucous myoma, polyps, neoplasia, synechiae, cervical incompetence and occult retained IUD. Operative hysteroscopy can correct these conditions, except cervical incompetence.

• Laparoscopy: diagnoses and corrects external uterine factors such as endometriosis.

Congenital anomalies of the uterus are associated with increased incidence of fetal wastage, midtrimester abortion, premature labor and breech presentation. Treatment will depend upon the type of anomaly and after ruling out other causes of infertility. A bicornuate uterus is corrected by abdominal metroplasty. Intrauterine synechiae and septate uterus are approached by hysteroscopic surgery.

Incompetent cervix, a cause of repeated second trimester and early third trimester pregnancy loss, is managed by cerclage of the cervix.

Leiomyomas do not always cause infertility. About 40 percent of patients with myomas may have reproductive problems depending upon the location and type. Submucous myoma is more associated with infertility problems. Myomectomy is the treatment if other causes of infertility have been ruled out. A cesarean section may be anticipated if pregnancy occurs. Uterine rupture during pregnancy and labor may be a complication.

The most common cause of endometritis in the Philippines is tuberculosis. Treatment involves anti-tuberculous medications. Prognosis for fertility may be poor because of the involvement of the fallopian tubes. Chlamydial and other infections may be treated with doxycyline or erythromycin for two weeks.

Endometrial polyps are removed hysteroscopically.

Intrauterine synechiae (adhesions) is removed hysteroscopically, with post-operative high estrogen doses and intrauterine Pediatric foley catheter. Adequate treatment will result in a 50 percent success rate.

Poor cervical mucus is treated with antibiotics if infection is the cause. The most logical approach to overcome a thick cervical mucus is intrauterine insemination with washed sperm.

(The author is the medical director of the FEU-NMRF Medical Center. She is a professor of the FEU-NMRF’s Department of Obstetrics and Gynecology and is the incumbent president of the Philippine Society of Reproductive Endocrinology and Infertility.)