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Overview - Evaluation - Treatment Options - Diagnosis

Treatment of Cervical Problems

Tetracyclines
The presence of white blood cells suggesting an infection can usually be resolved by treating the woman with an antibiotic. Tetracyclines are most commonly used for this purpose.

Cough Medicines
In certain individuals, there may be some role for cough medicines. Certain cough medicines (e.g., Robitussin) contain substances (e.g., guaifenesin) that actually do help thin out the cervical mucus. Taking a teaspoon three or four times a day for the two or three days before ovulation may result in some thinning of the mucus.

Estrogen
If a woman is on a certain dose of clomiphene and seems to be ovulating well but the cervical mucus is poor, some physicians will prescribe small doses of estrogen. The thinking here is that giving some additional estrogen may override the blocking effect of the clomiphene and improve cervical mucus production. While this approach is safe and easy, if it does not result in significant improvement (as checked by the post-coital test), inseminations should be considered instead.

Inseminations
Inseminations are a means of bypassing the cervical mucus altogether. A semen sample is provided by masturbation and then prepared by the laboratory so that a pure preparation of sperm is suspended in a specially prepared salt buffer. This preparation is then placed in a small syringe that is attached to a small plastic catheter. A speculum is placed in the vagina and the catheter is gently guided through the cervix and into the uterus. This is a painless, nonsurgical procedure and is particularly useful if the mucus producing cells of the cervix are destroyed or nonfunctional. The cervical mucus is, in essence, bypassed by placing the sperm beyond the cervix and into the uterus.

TREATMENT OF UTERINE PROBLEMS

Most of these problems can be adequately evaluated and treated with a hysteroscopy. There are many instruments, including scissors and lasers, that can be inserted through the hysteroscope and used to operate. Scarring and polyps can certainly be addressed in this fashion, as can pedunculated fibroids. Some smaller fibroids can also be removed in this fashion, but at times larger ones require major abdominal surgery for removal.

Uterine septums, as depicted above, can be removed quite adequately by hysteroscopy, often times by just incising them with scissors. Some of the other anomalies, such as a bicornuate uterus, require major surgery for reconstruction.

FUNCTIONAL UTERINE PROBLEMS

Knowledge in much of this area is being gained rapidly, but is relatively new. There are a few problems that can be discussed.

Luteal Phase Defect
This is a defect in which the endometrium either is not exposed to enough progesterone or does not respond properly to the progesterone that is produced. As a result, the cells of the endometrium do not undergo the very orderly series of changes that they must undergo to allow implantation to occur. Consequently, even if a conception does occur, the endometrium may not be ready to accept it and, therefore, implantation will not occur. In the past, this has been diagnosed by an endometrial biopsy, an invasive and sometimes painful procedure in which a small piece of the lining of the uterus is removed and analyzed for proper development under the microscope.
You do not necessarily need to have an endometrial biopsy for purposes of diagnosing a luteal phase defect. Adequate progesterone production can be very easily diagnosed with a simple blood test. Even if there may be some rare individuals whose endometrium does not mature properly even with normal progesterone levels, the treatment is the same as that for patients who have unexplained infertility. Therefore, there is really no need to have a biopsy. Furthermore, if you do have a biopsy and some treatment is initiated to correct a problem, a repeat biopsy to evaluate the effectiveness of that treatment is needed. Don't do it! Rather than having multiple biopsies to establish the diagnosis of luteal phase defect, serum progesterone levels can be used.

Thin Endometrium
The endometrium is another tissue that grows in response to estrogen. If the effect of estrogen is blocked, the endometrium may not develop adequately. This can sometimes occur as a result of the use of clomiphene. Normal endometrium usually develops to a thickness, as measured by ultrasound, of around ten millimeters. If it develops to only seven millimeters or less, pregnancy is extremely rare. The tissue just hasn't developed enough to allow it to accept a pregnancy. Endometrial development should be assessed by ultrasound in women on clomiphene, particularly if higher doses are being used, and any time gonadotropins are used.

Integrins
Integrins are proteins that are very sticky. They play a role in the adhesion of one cell to the next and are important in the implantation process. Although a defect in their production appears to be a rare phenomenon, it apparently can occur. Assays for integrins may soon be available. This test does require an endometrial biopsy, and in couples with difficult unexplained infertility, this may be worthwhile.