Polycystic ovarian syndrome is the most common hormonal abnormality affecting women of reproductive age group (15-30%). It interferes with the growth of follicle (nest for the egg/oocyte), causes irregular cycles,excess hair growth, acne, and obesity eventually resulting in infertility.

PCOS is diagnosed if 2 of the following 3 criteria are met.

• Irregular cycles/ Very Minimal bleeding.
• Excess hair growth, acne, excess hair loss, elevated male hormone levels in the blood in women.
• Cystic appearance of ovaries on scan.

Like most hormonal condition, PCOS can only be MANAGED for the symptoms and not cured completely. Medication can be given for egg development (ovulation induction) and management of other symptoms.

• Most women who have PCOS can benefit from losing weight both by inculcating moderate to vigorous exercise and low glycemic index diet plans.
• Losing as low as about 5% of the current body weight may greatly help in re-establishing hormone balance and regulate your menstrual cycle.

Tablets: Clomiphene citrate / Tamoxifene / Anastrazole

Injections: Gonadotrophins (Follicle stimulating hormone-FSH, Human menopausal gonadotrophins-HMG)

Surgery: Laproscopic ovarian drilling

Adjuvants that support in establishing ovulation: Metformin, Myoinositol, N-Acetyl cysteine. Notably these adjuvants are not effective in inducing ovulation when used alone.

Here is a link to a PCOS diet plan: http://www.thefitindian.com/pcos-diet-plan/

Endometriosis is a painful disorder in which, tissue that normally lines the inside of your uterus — the endometrium — grows outside your uterus. Endometriosis commonly affects your ovaries, fallopian tubes and the tissue lining your pelvis. Rarely, endometrial tissue may spread beyond pelvic organs.

It maybe suspected in the presence of symptoms like moderate to severe pain during menstruation, intercourse and intermittent abdominal pain. The diagnosis is made by detecting an ovarian cyst on scan or during diagnostic laparoscopy.

Endometriosis on Laproscopy

Endometriosis cyst on USG

Endometriosis staging is done after a diagnostic laparoscopy based on the findings as follows

The fact that the chances for pregnancy in endometriosis are significantly decreased is non-debatable.Women with Stage I or II endometriosis have an approximately 2% chance for conceiving in any given menstrual cycle (cycle fecundity rate). That chance is less than 1% for women with Stage III or IV disease. By comparison, age-dependent cycle fecundity rates in healthy fertile women range between 15 and 25%Due to its negative impact on the ovary and pelvic environment, the chances of pregnancy decreases progressively with the magnitude of endometriosis.

Based on the stage and other fertility factors, you may be advised for surgery, IUI or IVF with or without Gonadotrophin agonist injections for reducing the ill effects of endometriosis and improving chances of pregnancy.

Here’s a link to know more about endometriosis:

Female reproductive aging is a process that follows the largely accepted concept that over time, oocytes decrease in quantity and quality and do not regenerate. All women are born with approximately 1–2 million oocytes at birth. This reduces to 300,000–500,000 at the start of puberty, and when it further reduces to about 1000, the women reach menopause and their menstrual cycle stops.

Various factors such as genes, lifestyle, environment, and medical issues, including endometriosis, ovarian surgery, chemotherapy, and radiation, can influence this plunge in the numberof woman’s oocytes. Although the reproductive decline occurs with age, all the above mentioned factors can cause significant disparity in fertility potential among women of similar age.This further highlights the unpredictability and individuality of the reproductive aging process.

Once depleted, the ovarian reserve cannot be regenerated. Hence assessment of your ovarian reserve will give you an idea of your reproductive aging process. This will enable you to plan conception- either hasten the treatment or wait for natural course to fall in place.

DHEA-S, testosterone gel, growth hormone and various other medications have been tried to improve the available ovarian reserve. However none of them have a definite role and their impact is limited.

Link for further information
http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Ovarian-Reserve-Testing

Despite all superficial factors being normal, some couples fail to conceive. Poor egg (oocyte) quality can be an important cause of female infertility. Low quality oocytes may be associated with several problems like, they may not divide properly, or they may be missing certain chromosomes. Egg quality also declines with age, and certain medical conditions, such as PolyCystic Ovarian Syndrome, can lead to poor quality eggs.

Women with poor oocyte quality can be categorized into 2 groups. The first group are older women with abnormal blood investigations like FSH, Estradiol, AMH and low ovarian reserve. The second group are younger women with normal blood parameters. Although the above mentioned blood tests can project the quality, none of them are diagnostic of poor oocyte quality.

The final assessment of oocyte quality can be made only while examining under a microscope, after egg pick up during IVF.

The fallopian tubes are pipe like structures that connects the ovary (where the egg is released) to the uterus (womb). The fallopian tube picks up an egg after it is ovulated (released) from the ovary and are the site of fertilization, the process in which a man’s sperm joins with an egg. Tubal factor infertility accounts for about 25-30% of all cases of infertility

A blockage in the fallopian tubes prevents the sperm from meeting the egg and fertilizing it.

The tubes may be completely blocked on both sides or in certain cases where just one is blocked or the pipe is narroweddue to scarring.

https://fertilitynj.com/infertility/female-infertility/structural-causes/hydrosalpinx/

Pelvic infections, previous gynaecological surgery, ectopic pregnancy, casarean, ruptured appendix, tubectomy (family planning surgery), endometriosis are some of the most common causes of tubal block.

Although a HSG or a SSG can detect possible tubal block, it always confirmed using a diagnostic laparoscopy.

If the extent of tubal damage is mild to moderate, surgery might be suggested to you by your doctor. The only advantage of surgery is that you may subsequently try to get pregnant naturally. The chance of a successful surgery is better if you are young, having minimal amount of scar tissue blocking the tubes, and if your male partner has healthy sperm. The biggest risk after tubal surgery is the possible development of a tubal (ectopic) pregnancy.

A hydrosalpinx is a distally blocked fallopian tube that is substantially distended with fluid. The fluid in the hydrosalphinx is toxic to the oocyte, sperms and specially the embryo. Leakage of this fluid into the womb can prevent implantation of embryo even after an IVF. Hence a hydrosalphinx, diagnosed on a laparoscopy, should always be disconnected from the uterus.

http://www.fullcirclehealthcareinc.com/hydrosalpinx.html

The uterus is the female reproductive organ with a single broad fundus and single cavity that is wider above and narrower below (like an inverted triangle). Any deviation from this shape is called a uterine malformation.

Although they may be suspected on HSG and USG, a diagnostic hystero-laparoscopy (DHL) is required to make a diagnosis.

Malformations may be associated with decreased pregnancy rates, recurrent abortions or even preterm delivery. Hence diagnosis and appropriate management is essential.

Reproductive outcomes in women with uterine malformations:

http://www.momjunction.com/articles/uterine-abnormalities-during-pregnancy_00398428/#gref

Fibroids are benign (noncancerous), slow growing tumours of muscle tissue in the uterus. Based on their location there can be 4 different types of fibroids.

• Subserosal are in the outer wall of the uterus (55%)
• Intramural are found in the muscular layers of the uterine wall (40%)
• Submucosal protrude into the uterine cavity (5%)

Fibroids can be easily diagnosed on an baseline ultrasound.

Fibroids that are inside the uterine cavity (submucosal) or very large (>6 cm in diameter) within the wall of the uterus (intramural) can adversely influence pregnancy chances and hence should be removed prior to fertility treatment.

Based on the location, fibroids can be removed either laparoscopically (intramural) or hysteroscopically (submucosal)

http://www.nhs.uk/conditions/fibroids/pages/introduction.aspx

Adenomyosis is a benign (non-cancerous) condition in which the inner lining of the uterus (the endometrium) breaks through the muscle wall of the uterus (the myometrium). It is diagnosed on ultrasound, MRI or while doing a diagnostic hysteroscopy. It is essential to differentiate between a fibroid, which is more localized, and adenomyosis as the line of treatment is different.

Presence of adenomyosis decreases the chance of embryo implantation. Medical treatment with gonadotrophin agonists for 1 or 2 months improves pregnancy rates.

http://www.yapspecialist.com.au/information/?cat_id=1&info_id=37

Endometrial hyperplasia occurs when the endometrium, the lining of the uterus, becomes too thick. It is not cancer, but in some cases, it can lead to cancer of the uterus. As the lining is too thick it may further interfere with the implantation of embryo. It is more common in women with PCOS as they have infrequent menstrual cycles and diagnosed by histopathology examination of endometrial biopsy.

Medical treatment with prolonged progesterone supplementation for a minimum 2-3 months is essential before initiating fertility treatment.

Infection of the uterine lining (endometrium) or the entire female reproductive tract is called genital tuberculosis. Genital tuberculosis is a common cause of thin endometrium specially in Indian women and prevents embryo implantation. It is diagnosed by doing a TB PCR or TB culture test on the endometrial biopsy obtained during a hysteroscopy. Women who are diagnosed with tuberculosis should be treated with anti-tubercular antibiotics for a minimum of 6 months before initiating fertility treatment.

- Scar tissue can grow b/w two organs in pelvic area around bladder, bowel, uterus and Ovaries.

- It may be asymptomatic or cause pelvic pain, GI problems, Infertility. Treatment requires if they cause bothersome symptoms.

- Adhesions are m/c in women with endometriosis after surgical procedure like myomectomy, endometriosis surgery, LSCS.