Conditions treated

In this section Raj Mathur describes the conditions for which he provides specialised and individualised care.

What is infertility?

The desire to have a child is one of the most fundamental and powerful drives in humans. This does not mean that everyone, always wants to have children – in fact many people spend large parts of their life avoiding pregnancy for very good reasons! However, when individuals wish to have a child and this does not happen, this can cause great and profound unhappiness. This sadness can extend beyond the individual concerned to their partners and loved ones. Couples may need to revise their life-plans and learn to deal with a ‘child-shaped hole’ in their lives. Contrary to the opinions of bar-room philosophers and some parts of the tabloid media, infertility is a real and serious condition, and medical authorities world-wide recognise it as such.

The best definition of infertility that I know of is the one used by the American Society of Reproductive Medicine, which states

‘Infertility is a disease defined by the failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse.’

I like this definition because it is a relatively precise way of deciding when a couple trying to have a baby should seek medical advice. Research tells us that as many as 1 in 7 couples may suffer from this problem and need advice or assistance.

Of course, the desire to have a child is not restricted to those in a relationship or to heterosexual people – single persons and same-sex couples can also have a powerful desire to have offspring.

What are the causes of infertility?

Investigations uncover a cause in roughly 8 out of 10 couples with infertility. This diagram, from the  HFEA shows the distribution of causes of infertility among patients having fertility treatment in the UK in a typical year.

 

Broadly speaking in about 3 out of 10 couples a cause is found in the man alone and in another 3 out of 10 couples in the woman alone. Both male and female causes are found in roughly 2 out of 10 couples, while no cause can be ascertained in another 2 out of 10.

What tests are recommended if we have been trying to conceive without success?

I would always advise that couples speak to a professional in whose expertise they trust before doing any tests, so that they can be guided to what tests are best for them. In most cases, the doctor will take a history from both partners, trying to pick up on features that may have implications for your fertility, such as whether you have regular cycles or not, whether there has been any evidence of a pelvic infection (such as Chlamydia), whether one or both partners smokes etc. In most cases, the female partner should be examined by the doctor; the man may also need to be examined depending on his medical history.

As a first step, tests are carried out to check if the woman is ovulating and if her tubes are open. To this, in my practice, I add an assessment of the woman’s ovarian reserve. For ovulation, a simple blood test is carried out to measure levels of the hormone progesterone about 7 days before the expected date of the next period is carried out. I am often asked by patients how to time this test if their cycles are a bit irregular – the best course of action is to develop psychic powers, so you know exactly when your next period is going to start! Failing that, it is reasonable to do the test on a couple of occasions 5 to 7 days apart, in the second half of your menstrual cycle. Tests that you can buy at the chemists that measure LH in the urine are also helpful. The progesterone level in blood should be tested seven days after your first positive stick test.

Testing the fallopian tubes can be done by a number of methods, and the choice between these will depend on the features on your history and examination. In cases where there is no great fear that there is a problem with the tubes, a test called Hysterosalpingogram (HSG) is advised. This does not require anaesthesia and is carried out in the X-Ray department in the first 10 days of your cycle. It is advisable to take some paracetamol or Ibuprofen as pain relief 30 minutes before the test, as it can be uncomfortable.

In women where there are features that raise the suspicion of tubal problems or where we suspect endometriosis, a laparoscopy is usually advised. This is a procedure done under general anaesthetic. A small cut is made in your belly-button and a telescope is inserted into your tummy. A further cut is made lower down on the tummy to allow a device to be inserted that enables the surgeon to move the organs around and get a good view of the tubes, ovaries and womb.

A laparoscopy is specially useful in finding out if you have endometriosis, which can be associated with infertility and pelvic pain. Find out more about endometriosis and the treatments available by clicking here

Ovarian reserve testing is done by measuring the levels of a hormone in your blood called AMH (Anti-Mullerian Hormone) and by a an ultrasound scan to count the number of small follicles in your ovaries (Antral Follicle Count or AFC). These tests can be done at any time in your cycle. Simply put, AMH is a hormone produced by cells in your ovaries that surround the developing egg. As the woman ages, the number of eggs declines and so do the levels of AMH in her blood. By measuring the AMH level, we can tell whether a woman has an ‘average’ egg reserve for her age or not. This information is particularly helpful in women having IVF, as it helps plan their treatment. It is not known at present whether AMH or AFC predict whether a woman will conceive naturally – research is ongoing in this area, but it is a complex subject.

For men, the fertility test is less complicated. A sample of semen is examined in the laboratory and the scientist counts the number of sperm per ml of semen, the proportion of sperm that appear normal and the proportion that are swimming around actively. The result can be compared against the numbers we know are compatible with ‘normal’ fertility from research done on men whose partners conceived within 12 months of starting to try to conceive.

Can we do anything to boost our chances of conceiving?

There is a lot of interest in ‘lifestyle’ factors and fertility. Quite a bit is known from research regarding the impact of smoking and alcohol intake on fertility. We are also finding out more about matters such as exercise, body weight, the composition of your diet and drugs such as cannabis and anabolic steroids. For a presentation explaining the effect of lifestyle on fertility, click here. This is a presentation I did to the Irish Fertility Society in 2012 on this topic and is really directed at professionals, but in my experience most fertility patients actually have a very good understanding of these issues and should be able to follow the information in the presentation.

It might seem sometimes, that everything that is enjoyable in life, with the obvious exception of sex, is bad for your fertility! I think it is important not to set ridiculously high standards for yourself. Take time to relax and if the odd glass of wine should pass your lips, try not to worry too much about it. Infertility can be stressful enough, and you need to ensure you make some me-time and couple-time when you are not just focussing on procreation.

Endometriosis can cause pain and subfertility over many years, affecting well-being and quality of life. Several treatments are available, but it is vital to work together to choose the best approach for your situation.

What is endometriosis?

Endometriosis is a condition in which tissue similar to the lining of the womb starts to grow in parts of the body outside the womb. Most commonly, it grows on the ovaries and on the surfaces of organs near the womb, but occasionally endometriosis can affect organs quite far removed from the womb, for instance the lungs. This tissue is sensitive to female hormones produced by the ovaries – just as the normal lining of the womb. Hence we find that endometriosis typically affects women in their reproductive years (when their ovaries are active) but ceases to be a problem after the menopause (when the ovaries stop releasing hormones to the same extent).

Women with endometriosis may suffer from a number of problems. It may cause pelvic and lower abdominal pain and be associated with difficulty in conceiving. Some women may suffer from very severe pain, including pain during and before periods and during intercourse. Some may find it very painful to open their bowels. Many women find they are tired all the time, despite leading a healthy lifestyle and others find their personal, social and work lives are badly affected by their symptoms.

I believe that endometriosis can have a serious damaging effect on a woman’s physical and emotional well-being. Accordingly, it is important to confirm a diagnosis of endometriosis at an early stage, establish the full extent of the disease and use all applicable measures at our disposal to help the woman.

Support for women living with Endometriosis can be found at http://www.endometriosis-uk.org/

How is endometriosis diagnosed?

In many cases, a suspicion of endometriosis is raised by the patient’s complaints of significant pain. Gynaecological examination may also provide useful information, particularly if areas of endometriosis (called ‘nodules’) can be felt by the doctor. However, some women with endometriosis find internal examinations very painful and I do not always perform one for this reason. In some women with endometriosis, the ovaries develop cysts filled with altered blood – these can be seen by a simple ultrasound scan, which may be helpful in diagnosis. These days, more and more reliance is placed on a method of imaging the body called MRI (Magnetic Resonance Imaging) which allows ‘pictures’ of the internal organs with great clarity. This can identify, not only cysts but also more subtle areas of endometriosis and in particular whether the bowel is likely to be involved.

The procedure that can diagnose, or rule out, endometriosis with the most reliability is Laparoscopy. This involves a general anaesthetic and the insertion of a camera through the belly button into the tummy. The doctor can examine the ovaries, fallopian tubes, womb and other organs. If endometriosis is present, it can be diagnosed and the full extent mapped. A major advantage of laparoscopy is that it allows the doctor to treat the endometriosis at the same time (provided of course the patient is prepared for this). However, laparoscopy is invasive and, like any surgical procedure, it carries a risk of complications. The balance of risk versus benefit varies from one individual to another, and my approach is to individualise the plan of investigation and treatment to suit your needs and clinical features.

How is endometriosis treated?

Surgery:

What does it involve?

All stages of endometriosis can be treated by operation, although it may not always be the best option. In most cases, operations can be carried out by the ‘keyhole’ method, using laparoscopy. This usually involves an incision within the bellybutton and two smaller cuts lower down, one on each side. The endometriosis can either be removed entirely, or destroyed by heat energy. In most cases this involves an overnight hospital stay, followed by a few weeks recovery. The small skin incisions are closed with absorbable sutures which do not need removal, but if they are irritating you skin they can be taken out after a week.

What are the risks?

Laparoscopic surgery is usually safe, but like any operation, it does carry some risks. In general, serious complications occur in around 1 in 1000 cases (0.01%), but in some women the risk is greater. This is especially so in women who have had previous operations on their abdomen or who are obese or very thin. Some types of endometriosis surgery, particularly where the surgeon is attempting to remove endometriosis from around the bowel or ureter, is also more likely to be associated with injury to these organs, which then requires major emergency surgery to put right.

Is it right for me?

My approach is to enable you to consider your options after being fully informed about them. If you are trying to conceive, hormone treatment is not appropriate as it prevents conception. In such cases, surgery is likely to be the better option. The same applies when there are large endometriotic cysts (‘chocolate cysts’) – drug treatment is unlikely to lead to these disappearing completely and surgery is usually needed. On the other hand, if you have previously had several operations for endometriosis or have other risk factors, then drug treatment may carry fewer risks than surgery. Like in most areas of life, the aim should be to work out the best choice for your needs, in your particular situation

Drug treatment

What does it involve?

Endometriosis is sensitive to the hormones produced by the ovaries and this means that manipulating these hormones can suppress the symptoms of endometriosis. A relatively simple hormonal treatment is the oral contraceptive pill, which has been shown to improve the pelvic pain and heavy periods associated with endometriosis. Similar benefits can also be obtained from using the Mirena Intra-Uterine System, a coil that releases a small amount of hormone within the womb.  A more profound suppression of the ovaries can be achieved by using drugs called GnRH analogues. These block the release of hormones from the pituitary gland that ‘drive’ the ovaries. An example of this type of drug is Zoladex and this is given by injection every 4 weeks for 6 injections.

What are the risks?

The combined pill and Mirena coil are widely used for contraception, but do carry a small element of risk. For instance, the pill should not be used in women over 35 who smoke, or those with focal migraines, liver problems or thrombosis.  Drugs like Zoladex can cause hot flushes and other menopause-like symptoms, as well loss of minerals from the bones. However, these problems can be largely avoided by using supplementary hormones tablets – this is called ‘add-back’ and makes the Zoladex easier to tolerate and safer, without compromising its efficacy.

Is it right for me?

Once again, this depends entirely on your situation and clinical features and my approach is help you individualise the treatment regime that suits your particular case. Clearly, if you are trying for a baby, drug treatment is not a good idea as it is contraceptive. However, in some cases where you are about to commence IVF treatment, a few months of GnRH analogue pre-treatment has been shown to improve the chance of a successful outcome. If contraception is needed, a trial of drug treatment is often a better and safer option than surgery.

What are fibroids?

The wall of the uterus (womb) is made up mainly of muscle. In some women there is an overgrowth of these muscle cells, forming 'lumps' called fibroids. These are benign and can vary in size from microscopic to huge - some can grow to fill the entire abdomen! Often, fibroids are multiple and it is quite common to have more than one.

Fibroids are very common, with around 1 in 4 women in the reproductive age group having at least one. Women of an African-Caribbean ethnicity are more likely to develop them and often develop them at a younger age than other ethnic groups. Fibroid growth depends on hormones produced by the ovary, so when ovarian hormone production declines at the menopause, fibroids usually shrink and cause less of a problem.

In many women, fibroids cause no problems and the woman may not even know she has a fibroid. In other women, however, fibroids can be associated with heavy periods, pelvic pain and infertility. Symptoms depend on the size of the fibroids, with larger ones more likely to cause pressure symptoms due their sheer size, and on the exact location of the fibroid. A fibroid that protrudes into the inner lining of the womb (also called 'submucous' fibroid) is more likely to be associated with infertility and pregnancy loss than one that does not affect the lining of the womb. For this reason, a full assessment of the womb by means of tests such as hysteroscopy and MRI scanning is important and is part of my care pathway.

 

Treatments available

  • Drugs and hormone treatments

Pain and heavy bleeding can often be managed by the use of Tranexamic Acid and Mefenamic Acid taken during the period. These medications will not cause the fibroid to shrink or stop growing, but they can improve your quality of life significantly.

A number of hormone-related treatments have been developed to help with fibroids, but none of them is as yet approved for long-term use. These include GnRH analogues (such as Zoladex) and Ulipristal. Ulipristal ('Esmya') is particularly effective in stopping bleeding within days, but can only be used for 3 months and only prior to surgery. 

A lot of research is being carried out to test newer drugs in patients with fibroids, with some very exciting prospects. CLICK HERE for a recent presentation I did on this topic to the Ulster Obstetrical and Gynaecological Society. Scientists are looking at a variety of products, including components of your diet such as Vitamin D and curcumin (the chemical that gives turmeric its distinctive yellow colour).

  • Uterine Artery Embolisation

This is a treatment carried out in the X-Ray department. A tube is passed through one of the blood vessels in the groin and guided into the uterine artery (which is the major source of blood supply to the womb). Special particles are injected to block the uterine artery.Starved of blood, the fibroids die and symptoms are reduced. The rest of the womb can develop a new blood flow from the ovaries and survives as before.

One advantage of this treatment is that it requires only a small cut in the groin to introduce the tube. However, it can cause quite severe pain for the first day or so after the procedure and for this reason, hospital admission and strong pain relief is advised for a day. Some women will have lower abdominal pain, vaginal discharge and a low-grade fever after the procedure. This is called 'post-embolisation syndrome' and can persist for several weeks.

It is not clear at present whether this procedure is right for women trying to conceive or those who wish to retain their fertility. The worries are as follows: a small proportion of women (around 7%) may fine that their periods completely stop after embolisation. This is more likely in women over 40. Hence, there may be difficulty in falling pregnant. Additionally, the risk of some pregnancy complications, such as miscarriage, may also be increased. However, it must be recognised that all fibroid treatments carry some risks and this is where it is important to individualise the care offerred. In some women with subfertility, uterine artery embolisation MAY be the best option available, if the fibroids have to be treated and the surgical risks are significant.

  • Surgery

An operation can be performed to either remove just the fibroid ('Myomectomy') or the entire womb ('Hysterectomy'). Myomectomy is an option for women who are trying to conceive or wish to keep this option open, while hysterectomy may make sense if your family is complete. Depending on the size of the fibroids, it is sometimes possible to do these operations through the laparoscope ('key hole surgery'), but in other cases a cut on the tummy is required. You can expect to be in hospital between 1 and 3 nights and it can take upto 4 weeks to be back doing your normal activities.

Heavy periods can have a severe effect on the quality of life for some women. Fortunately, there are now a number of effective treatment options, from medications to surgery.

 

Some women with heavy periods have a condition such as fibroids or endometriosis that accounts for these. In others, no visible cause is found, but the impact on your wellbeing can be just as severe. My approach is to carry out investigations to rule out any obvious cause and then work with you to decide on a treatment option that suits your needs.

The investigations that may help find a cause for heavy periods include blood tests to check for bleeding disorders, hormone levels and ultrasound scan. In some women a hysteroscopy may be advised; this involves passing a telescope through the neck of the womb into the womb and allows the lining of the womb to be examined. Most women are able to have this in the outpatient clinic without any special pain relief, but it can also be done under anaesthetic if required. If you are having a hysteroscopy, it is important to ensure that you are not pregnant at the time by not having unprotected sexual intercourse in that menstrual cycle.

Your treatment options include non-hormonal and hormonal medicines and surgery. The choice of treatment depends on your medical history, whether or not you need contraception and whether or not you are trying to conceive. The advantage of non-hormonal treatments is that they can be used by women who are trying to have a baby, whereas the hormonal medications are contraceptive (for instance, the contraceptive pill and Mirena coil). 

Surgery should be considered where your family is complete and we are unable to manage your period with medications and the Mirena coil. In the past, the only real option used to be a hysterectomy. This is still used by some women, but increasingly i find that women who have completed their family opt to have Endometrial Ablation - a procedure in which the lining of the womb is destroyed using Radio Frequency energy. This causes the periods to either stop or become much lighter. The procedure is done under a short anaesthetic and you can go home the same day. No cuts are needed on the tummy. Of course, once the lining of the womb is destroyed, pregnancy should not be attempted and some form of long-term contraception must be followed after an ablation. One option for this is a laparoscopic sterilisation, which can be done at the same time as the ablation. I offer Novasure Endometrial Ablation. You can read more about it here http://www.novasure.com/uk/

 

Losing pregnancies repeatedly is heart-breaking. Although most miscarriages occur without a detected cause, repeated pregnancy loss should be investigated to find out if it is due to conditions that can be treated.

 

Miscarriages are common, with as many as 1 in 3 pregnancies ending in a miscarriage. In most instances, there is no detectable causes for the miscarriage and, although it causes genuine distress, there is not much to be gained from detailed testing. However, if 3 or more pregnancies are lost, particularly if this happens consecutively, tests are indicated to try and determine a cause. In women of 40 and above, it may be reasonable to do these tests after 2 miscarriages. 

The Miscarriage Association is a great source of support and information http://www.miscarriageassociation.org.uk/

My approach is to offer a detailed consultation looking at your pregnancy and medical history (for both partners) to see if any indications can be found as to what might be causing the miscarriages. A number of tests are available including chromosome tests for both partners. I would normally recommend a full thrombophilia screen, thyroid tests and ultrasound for the woman. In some cases, ovarian reserve assessment is advisable and some men may benefit from a sperm DNA assessment.

The aim of testing is to identify any potentially treatable conditions. If a clotting disorder is found (such as Anti-phospholipid syndrome), specific treatment is available to reduce the risk of another miscarriage occurring. In other women, support and care during early pregnancy with an early ultrasound scan and perhaps progesterone supplements is advised. There may be a role for IVF treatment in some couples where recurrent miscarriage co-exists with difficulty in conceiving. If appropriate, Il discuss this option, including cutting-edge measures such as IMSI for miscarriages that may relate to sperm problems.

Individualised advice for women with Polycystic Ovaries, Premature Menopause and Pre-Menstrual Syndrome

 

I specialise in gynecological hormonal problems and am able to offer care tailored to your needs for these, using medical and surgical options and considering fertility and wider health issues as appropriate.

Polycystic Ovary Syndrome (PCOS) is the most frequent cause of irregular or absent periods. I can provide advice and treatment for all aspects of this condition, including excessive hair growth, period problems and subfertility. Importantly, I stress a holistic approach and try and keep your long-term health in mind. It is important to understand what you can do to help yourself in some circumstances, particularly when it comes to weight management and exercise. My approach is to empower and support women in taking charge of their own health, stepping in with medical intervention where indicated. This is specially important with PCOS as it has implications beyond periods and fertility. It is often diagnosed for the first time in teenage years and this is a crucial time when your own self-confidence in maintaining a healthy lifestyle should be supported.

An invaluable source of information and support for people affected by PCOS is Verity - http://www.verity-pcos.org.uk/

 

Premature Menopause (Premature Ovarian Failure) is a condition where the ovaries stop working before the age of 40 and affects around 1 in 100 women. In some cases, a cause is detectable - genetic problems, previous cancer treatment, operations that have led to loss of ovarian tissue or auto-immune problems. I offer advice and treatment for women with this condition. Support is also available from http://www.daisynetwork.org.uk/

 

 

Laparoscopic surgery is possible for many conditions and is associated with quicker recovery and a rapid return to normal activity

 

I offer laparoscopic surgery for a number of common gynaecological conditions, such as endometriosis, ovarian cysts, pelvic adhesions and hydrosalpinges. Laparoscopy is done under general anaesthetic. A telescope is inserted through the belly button into the tummy. Gas (carbon dioxide) is inflated into the tummy to separate the organs and allow them to be examined closely. One or two further small cuts are made on the sides of the tummy to introduce instruments that can move and hold organs as needed. 

A major advantage of this type of surgery over the conventional open operation is that the size of incision is small - barely a centimetre. This means that teh amount of pain after operation s much less and you recover sooner. You may even be able to go home the same day as your operation. In most cases you are back to normal within a week.

Like any operation, laparoscopic surgery carries a risk of complications and these can be more likely in women with obesity, previous surgery and severe endometriosis. Complications include a small risk of injury to organs inside the abdomen, such as bowel, ureter or bladder. If an injury occurs, it is an emergency and a major operation may be needed to out right the damage. However, the chances of this are low in most cases, probably less than 1 in a 100. I always discuss the specific risks and benefits of surgery with you before your operation, to enable you to make an informed decision about whether it is right for you.

More information about Laparoscopy can be obtained here - http://www.nhs.uk/conditions/Laparoscopy/Pages/Introduction.aspx

Donor Egg IVF provides hope to women with very low ovarian reserve

IVF using eggs from a fertile donor is an option for women whose own ovaries produce very few eggs despite stimulation. Like other forms of IVF, this is regulated by the HFEA in the UK. There is a shortage of egg donors in the UK, which means that many couples travel abroad for this treatment.

Mr Mathur is able to offer donor egg IVF in co-ordination with a reputable European clinic with excellent success rates. Donors are young fertile women who are screened to standards accepted in UK practice. Mr Mathur provides all the care and treatment needed in the UK, so that you only have to travel abroad for a short period of time. Follow-up appointments and early pregnancy ultrasound are offered as part of the package.

An important point to consider is that, if treatment is carried out in a UK clinic, children born from treatment can find out the identity of the donor when they reach the age of 18. In certain other countries the rules are different - here the identity of the donor is anonymous and cannot be revealed.

Please get in touch on cambridgefertility@gmail.com if you would like more information