During intercourse, sperm are ejaculated into the vagina and must travel through the vaginal canal, past the cervix and into the uterine cavity to the fallopian tubes. The cervical glands produce mucus that nourishes and serves as a transport medium for sperm. If the mucus is too thick or absent, it can impede the progress of the sperm.

Sometimes a woman will produce antibodies to her partner’s sperm. This means that her immune system mistakenly identifies sperm as an invading pathogen (like a virus or bacteria) and produces antibodies to destroy it. The post coital (after intercourse) test is used to diagnose cervical factor infertility by some physicians.

In the post coital test, sample of the cervical mucus is taken from the vagina, after intercourse, and examined under the microscope. Numerous dead or non-motile sperm indicate a cervical mucus problem. Furthermore, it is possible that a woman will have no cervical mucous because of past surgery to the cervix (such as cone biopsy for abnormal Pap Smears).

The cervical canal may then be narrowed (stenosis). Many reproductive endocrinologists do not perform the post coital test because most treatments offered (such as IUI and IVF) bypass the cervix and cervical mucous.

Intrauterine insemination (IUI) is often the first line treatment for cervical factor infertility. In IUI, the partner’s specially washed, prepared, and concentrated sperm are inserted directly into the uterus using a catheter. This process bypasses the cervix and is often successful.

The uterus must be normally shaped and free of large obstructions in order to support a developing fetus. The uterus is lined with endometrial cells that rapidly divide, under the influence of estrogen and progesterone, during the ovulatory cycle. This cell division increases the width and vascularity of the uterus preparing it to nourish the embryo and later the fetus.

Some women are born with congenital abnormalities of the uterus including conditions such as the unicornuate uterus (half uterus) and uterine septum (vertical barrier inside uterus).

A uterine septum may cause repeat miscarriages if the embryo implants on the septum. Uterine abnormalities can be diagnosed by hysterosalpingogram, ultrasound, sonohystogram, MRI, or hysteroscopy with laparoscopy.

At the time of hysteroscopy, a reproductive endocrinologist, infertility specialist can cut a uterine septum and reduce the repeat miscarriage tendency. If other uterine abnormalities such as a unicornuate uterus are diagnosed, your physician may choose to replace fewer embryos at the time of IVF, for example, because the size of the uterine cavity is smaller.

Large polyps, fibroids, or scar tissue may also obstruct the uterus. In most instances, times these conditions can be corrected by hysteroscopic surgery. Reproductive endocrinologists at UAB have expertise in correcting these conditions.

Uterine fibroids are common, non-cancerous growths of the muscle wall of the uterus that can cause symptoms such as heavy vaginal bleeding, anemia, and pressure on the bladder leading to frequent urination. As many as 25-50% of all women may have fibroids, but not all of these women have fibroids that are large enough or in a location in the uterus that causes symptoms or problems. It is important to have a physician who understands your symptoms and evaluates them in order to understand if any treatment is needed for your fibroids.

Fibroids may be located inside the uterus (submucosal), within the muscle wall of the uterus (intramural), or on the outside surface of the uterus (subserosal). Women may have one or multiple fibroids. Generally an ultrasound of the pelvis, in concert with saline infused into the cavity (sonohysterogram), are valuable in determining the size and location of all fibroids.

The ultrasound is very important for the physician in that the best surgical approach to the fibroids can be determined from the ultrasound if the patient desires to retain the uterus and if surgery is indicated. Fibroids located on the inside of the uterus tend to cause the most problems with bleeding and fertility.

However, large fibroids within the muscle wall of the uterus may also be a problem during pregnancy, particularly if the placenta implants over the fibroid. If the placenta is located over a large transmural fibroid, a miscarriage could result.

If you have a fibroid inside the uterine cavity and are experiencing infertility or heavy vaginal bleeding, a surgical approach whereby the cervix is dilated and the fibroid is resected using a resectoscope may be possible. An Ob/Gyn with advanced training in hysteroscopy using the resectoscope is required to perform this surgery. Physicians in Reproductive Endocrinology and Infertility at UAB have received this advanced training as part of their subspecialty fellowship training following their Ob/Gyn residency training.

The advantage to this surgical approach is that you will go home the same day, have no abdominal incisions, and will likely be back at work within one week. Chances for successful pregnancy and reduction in vaginal bleeding are excellent following the hysteroscopic resection of a fibroid.

If you have a large fibroid within the muscle wall of the uterus and have had a miscarriage or problem in a prior pregnancy, it is possible that the fibroid played a role. Your physician can help evaluate this with you. Some women benefit from having an abdominal myomectomy. If multiple fibroids are removed and the uterine cavity is entered, your physician may recommend that you have a cesarean section for a pregnancy following this procedure to reduce the chances for the uterus to rupture during labor.

Hysterectomy has been done traditionally for fibroids. Since the recurrence rate for fibroids is about 15%, a hysterectomy may be preferred by women with symptoms who wish to avoid a possible recurrence and when childbearing is complete.

Uterine artery embolization is a radiologic procedure that may also be recommended for a large fibroid that causes heavy bleeding. The radiologist places a catheter through a small incision in the upper leg that is directed toward the uterine arteries. Small pellets are inserted through the catheter which are designed to reduce blood supply to a large fibroid, which leads to a reduction in size of the uterus with reduced bleeding. Because the pellets can also reach the ovaries and cause ovarian failure, this procedure is not generally recommended for those women who wish to become pregnant in the future.

Medical therapy, including oral contraceptives, progestins, and Lupron, are also used to treat fibroids. These treatments can often help with heavy bleeding symptoms, but are not considered permanent treatment. Fibroids do not go away with any of these treatments. Medical treatment often allows patients to be stabilized before surgery can be performed or until menopause occurs and fibroids naturally shrink.

Many more options exist now than in the past for treating uterine fibroids. A visit to your Ob/Gyn should help clarify the best treatment for you.