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Conception and your gynaelogical history

How your gynae history may affect your fertility and pregnancy, and when you should have no cause for concern


Posted: 6 August 2007
by ThinkBaby

Until we decide that we're ready to start a family we are usually so preoccupied with avoiding conception that we may not think about how our gynaelogical health may affect our fertility. Once we've embarked upon the road to conception however, it's easy to see every past gynaecological experience as a potential threat to our chances, so what in our gynaecological history do we not need to worry about, and what may be a cause for concern? Here we look at some of the most common causes of worry for women trying to conceive or newly pregnant.

Ovarian cysts
Ovarian cysts are very common, usually benign and nothing to worry about. In many cases women aren't even aware that they have a cyst and they may disappear and reappear with no impact on your fertility at all. If you have a cyst that is large enough to cause pain, then you may have been referred for an ultrasound and diagnosis by your doctor. Even in these cases cysts are usually nothing to worry about and if they don't disappear by themselves within a few cycles then a course of contraceptive pills will usually be effective in shrinking the cyst. In this case your fertility will only be affected while you are taking the contraceptive pill.

In some cases an ovarian cyst may be more problematic and complex cysts that don't disappear on their own or with several months of contraceptive pills may need to be removed surgically and sometimes the whole ovary will also need to be removed. In a small number of cases ovarian cysts may be cancerous, in which case urgent treatment is vital and at least one ovary will probably need to be removed. If you have already had an ovary removed for one of these reasons then see below for how this may affect fertility.

For polycystic ovarian syndrome see below.

Polycystic Ovarian Syndrome (PCOS)
Women with PCOS have multiple small cysts on their ovaries which cause irregular menstrual cycles and can disrupt ovulation, or cause anovulation. The condition is consequently a common cause of infertility, but it is also quite common and can usually be treated successfully and most women with the condition will eventually be able to become pregnant.

If you have already been diagnosed with PCOS and now want to start a family then speak to your doctor right away about treatment, rather than waiting the usual twelve months as the chances are that you may have difficulties conceiving. Medications, usually oral, can be given to stimulate ovulation and most women are able to get pregnant in this way within about 6 to 9 months. For those women who don't become pregnant with the help of medication, IVF will probably be successful.

Removal of an ovary
If you have had one ovary removed (whether due to ovarian cancer or an ovarian cyst) then your fertility will depend fully on the health of the other ovary. If the other ovary is healthy then it will take over the role of both ovaries, releasing an egg every month instead of every two months, and your fertility levels will be unaffected.

For women with ovarian cancer, early diagnosis and treatment raises the possibility of the surgery leaving one healthy ovary intact, although in many cases surgeons may not know until they operate how much tissue they will have to remove. Where fertility-sparing surgery is possible there is still a chance of cancer recurring in the second ovary at a later stage.

There is a chance that your fertility may be lowered following surgery to remove an ovary if the surgery results in uterine adhesions. You should also be aware that the removal of one ovary will bring your menopause forward by about a year.

Endometriosis
Endometriosis is a condition where the tissue of the womb lining, the endometrium, grows outside of the womb, attaching itself to organs including the ovaries and fallopian tubes. The relationship between endometriosis and infertility is not fully understood, while almost half of all infertile women have endometriosis, most women with endometriosis have only a mild case, are not infertile and will fall pregnant with no medical intervention.

If you have been treated for mild endometriosis your chances of conceiving will probably not have been affected either positively or negatively by the treatment for endometriosis: There's no need to worry about the condition causing infertility, although if you do have difficulties conceiving then you should raise the issue with your doctor. If you have severe endometriosis and the condition causes large cysts on the ovaries or blockage of the fallopian tubes then your chances of conceiving may be lower than normal - surgery to remove the endometriosis may help raise you fertility levels, but not to normal levels.

If you are having problems conceiving and suffer from endometriosis then may be treated in several ways. If the condition is interfering with ovulation but your fallopian tubes are healthy you may be given ovulation boosting drugs. If the endometriosis involves a physical block to the establishment of a pregnancy then surgery may be recommended to remove the blockage. In cases where such treatment is not successful, conception assistance techniques such as IVF have a good chance of success.

Fibroids
Fibroids are non-cancerous growths in the uterus that can cause heavy menstrual bleeding and irregular periods and they may obstruct the passage of the egg to the uterus and prevent a fertilised egg from implanting in the womb, so reducing fertility. However, in many cases fibroids don't affect fertility at all and may not even be diagnosed until a woman is already pregnant.

Fibroids of some size are very common in women of reproductive age, and there may be no symptoms at all. Consequently fibroids may not be diagnosed until a woman undergoes investigations for infertility, or until a woman is scanned during pregnancy. If you have already had an operation to remove fibroids in the past then your chances of conceiving are good. However, the fibroids may return in time and may again affect fertility, also, surgery to remove fibroids may result in uterine scarring or damage to the fallopian tubes, and there is a very small chance that your fertility may be affected by a post-surgical infection.

Once a pregnancy is established, higher levels of oestrogen and increased blood flow may encourage the fibroids to grow more quickly, but they usually return to their normal size after birth. Most women who fall pregnant when they have fibroids are able to carry their babies to term, but if the fibroids are very large and restrict the baby's growth in-utero then early delivery may be necessary. The position of the fibroid(s) may also necessitate a c-section birth if the birth canal is blocked or the baby can't turn into a good birthing position.

Previous miscarriage
Having a miscarriage does not affect your chances of conceiving again. In cases where a Dilation and Curettage (D&C) is necessary to clean out the womb following a miscarriage there is a small chance that the procedure may result in pelvic inflammatory disease and some scarring of the uterus, which may affect fertility but such scarring in the uterus can usually be surgically repaired.

If you have experienced a miscarriage with a previous pregnancy your chances of having a second miscarriage are not any higher for future pregnancies. If you have two miscarriages then your chances of a further miscarriage are slightly higher, however. Women who experience repeated miscarriage, which is termed as three or more consecutive miscarriages, may have a structural problem preventing the successful establishment of a pregnancy. It's usually only after two or three miscarriages that your doctor will look into the causes of the miscarriages - if not obvious - so that treatment can be recommended to prevent the problem recurring.

Sometimes a structural problem is evident with a first miscarriage, and if so, doctors may be able to make special recommendations or offer preventative treatment for subsequent pregnancies.

Previous abortions
Many women who have previously chosen to have an abortion worry that the procedure will have affected their fertility, particularly if they subsequently have difficulties trying to conceive. Before abortion became legal in the UK there was a correlation between illegal abortions and later fertility problems, however, with legally conducted abortions there is only a very small chance of fertility being affected. There is a small chance that, as after a miscarriage, the cleaning out of the uterus in a D&C may lead to pelvic inflammatory disease and scarring inside the uterus, but this can usually be surgically repaired.

Abortions usually involve dilation of the cervix, which may weaken the cervix if repeated several times and make the pregnancy complication of incompetent cervix, where the cervix dilates prematurely in pregnancy leading to miscarriage, more likely.

If you have had a past abortion then there's no reason to worry that this might make you infertile, but the information will be relevant to your doctor if you are undergoing fertility tests.

Genital warts
In themselves, genital warts are not associated with infertility, and if you have suffered from them in the past then you shouldn't worry that your fertility will have been affected. However, genital warts are associated with pre-cancerous changes in the cervix, and with some STIs such as chlamydia which can lead to infertility if left untreated, so they should always be checked by a doctor, whenever they occur.

Vaginal infections

Thrush
Thrush is a common vaginal infection where the balance of candida, an organism naturally present in the vagina of most women, is disrupted. The infection usually causes irritation of the vulva, making both sex and urination painful, and there may also be a thick white vaginal discharge. While unpleasant, the infection does not spread beyond the cervix and so has no impact on fertility. Thrush infections are very common during pregnancy but the usual treatments are not appropriate for pregnant women.

Pelvic inflammatory disease (PID)
PID is infection and inflammation of the female upper genital tract that can be treated quickly and effectively with antibiotics once diagnosed, but if left untreated can lead to scarring of the uterus, fallopian tubes and ovaries and so cause infertility and raise the likelihood of ectopic pregnancy. It is believed that around 10% of women with mild PID are made infertile by the disease and as many of 50% of women with severed PID are rendered infertile. However, these figures are based on diagnosed cases of PID, and given that the condition often has very mild, or even no symptoms, it's difficult to know exactly how common the disease is.

The most common cause of PID is one of the sexually transmitted infections listed below, but there are other sources of infection. In some women PID may result from the termination of a pregnancy, or even childbirth itself, and women who use the contraceptive coil have a raised risk of contracting PID. Where symptoms of the disease do occur they can include: a thick vaginal discharge, unusual vaginal bleeding, heavier menstrual periods than is usual, discomfort or pain during sex, pain in the lower back and abdomen and fever. In severe cases there may be severe abdominal pain, severe vomiting and high fever.

If you have been treated for PID in the past then there is a chance that your fertility may have been affected and if you are having trouble conceiving then it's important that you tell your doctor about this part of your gynaecological history as it may help him or her narrow down possible causes of infertility. However, having had PID in the past does not mean that you will necessarily have difficulty conceiving, and many women who have had a past PID infection conceive with no problems at all.

Contracting PID in pregnancy is relatively rare, however, if you do think that you may have contracted the disease and are pregnant, then it's important that you seek medical help as soon as possible, as PID in pregnancy raises the risks of miscarriage, premature birth, and stillbirth if left untreated.

Bacterial vaginosis (VB)
VB is one of the most common vaginal infections and like Trichomoniasis it requires prompt medical treatment. Symptoms include a whitish vaginal discharge, an unpleasant vaginal odour, vaginal itchiness and pain during urination. In most cases BV is a relatively mild infection and doesn't lead to complications, however, if left untreated the infection can have serious consequences. The infection increases your risk of pelvic inflammatory disease, which can lead to infertility and an increased risk of ectopic pregnancy. It can also increase your susceptibility to sexually transmitted diseases such as chlamydia and HIV.

During pregnancy, BV can lead to premature delivery and low birth-weight babies if left untreated. As with trichomoniasis, the usual treatment is a course of antibiotics, usually metronidazole.

Sexually transmitted infections

Chlamydia
Chlamydia is a vaginal infection that is transmitted sexually and is more common for women who do not use barrier methods of contraception. The likelihood of contracting chlamydia also rises the more sexual partners you have. If untreated the infection can lead to pelvic inflammatory disease which may lead to infertility in about one tenth of mild cases, and also raises the risk of ectopic pregnancy. Chlamydial infection is a real concern for fertility, partly because many women experience no symptoms of infection, so go untreated, and it is the most common cause of PID among women.

When symptoms do occur they include vaginal discharge and pain in urinating, sometimes developing to abdominal pain and fever. A course of antibiotics is required to clear up the infection. The risk of damage to the fallopian tubes, and possible infertility, is raised with every infection if chlamydia is contracted repeatedly.

If you think you may have had chlamydia in the past your doctor can check for a previous infection with a blood test.

Trichomoniasis
Trichomoniasis is a sexually transmitted vaginal infection that is associated with fertility, premature labour and low birth-weight babies if left untreated. The infection can both impede the progress of sperm to an egg, preventing conception, and can result in an under-developed womb lining, lessening the chances of implantation if an egg is successfully fertilised.

For nearly half of women and more than half of men the infection shows no symptoms, where symtoms are in evidence for women they include a foul-smelling vaginal discharge, irritation of the vulva, pain during intercourse and sometimes pelvic pain.

If you think you may have been exposed to the infection then it's important that you tell your doctor, who will be able to conduct tests to check. Trichomoniasis can usually be successfully treated with a course of antibiotics, metronidazole is the antibiotic usually prescribed.

If you contract the infection during pregnancy it is particularly important that you seek treatment given the association with pre-term delivery and low birth-weight. The infection can also be passed along to the infant at birth, but won't adversely affect your baby's health.

Gonorrhoea
Gonorrhea is another infection that may lead to pelvic inflammatory disease, raising the risk of infertility and ectopic pregnancy if left untreated. The infection also increases the risk of infertility in men if left untreated. Gonorrhea can be contracted during pregnancy and may be passed on to the baby at birth resulting in an eye infection known as conjunctivitis.

Around half of women with gonorrhea display no symptoms, but if you do have symptoms then these are likely to include a yellow or green vaginal discharge which may be thin or watery, pain when urinating and lower abdominal pain. Most men with gonorrhea will have similar symptoms including a white, yellow or green discharge from the penis, pain when urinating and sore testicles, but about 10% of men will be asymptomatic (displaying no symptoms).

The infection can be successfully treated with antibiotics whether or not you are pregnant, and if you think you may have the infection it's important that you and your partner are treated as soon as possible. If you are worried that a previous gonorrhea infection may have affected your fertility then you should speak to your doctor.

Crabs
Crabs are lice that infect the pubic area and are usually passed from person to person through sexual contact. If you have been treated for crabs in the past then there is no cause for concern that it will have infected your fertility. However, if you find that you have crabs while trying to conceive or while pregnant then you should probably also be tested for other STIs that you may have picked up at the same time and which may have an impact on fetility or on your pregnancy.


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