Chapter 11, Page 5

Fibroids may grow larger during pregnancy, but usually pregnancy and delivery are uneventful. In rare cases, after a myomectomy, uterine rupture may occur during pregnancy or delivery, and this complication may result in severe blood loss, fetal loss and even maternal death. Because of the potential for catastrophic results, it is recommended that women have cesarean deliveries in the following circumstances:

when the myomectomy involved full-thickness incision of the uterine wall or multiple deep uterine incisions, or
when myomectomy was complicated by infection which may have weakened the uterine wall, or
when there is doubt regarding the adequacy or extent of the uterine repair.

The uterus was often a neglected organ in the infertility workup, partly because we did not have the tools to study it properly. Hysteroscopy, hysterosalpingography and vaginal ultrasound are all complementary procedures for evaluating the uterine cavity in the infertile woman. The HSG is good for looking for polyps, adhesions and septa that appear as "filling defects" on the X-ray. However, careful radiologic technique is a must. Vaginal ultrasound is excellent for detecting submucosal fibroids or polyps, which can be missed on hysteroscopy and HSG. Of course, the major advantage of hysteroscopy is it offers the chance of treating the problem as well!

We are now also developing newer techniques to study the uterus. One of our major areas of ignorance today is the complex process of embryo implantation. It is obvious that the endometrium has a key role to play in this process, in which the embryo has to appose and attach itself to the maternal endometrium and invade into it. The normal endometrium contains cell adhesion proteins called integrins, which allow the embryo to interact with it. Studies have shown that the endometrium of some infertile women is deficient in some of these integrins, and this deficiency may be responsible for failure of the embryo to implant successfully. Thus, testing the endometrium for beta integrin can be a useful marker for uterine receptivity. This test involves doing an endometrial biopsy at a specific point in the menstrual cycle, and evaluating this with special staining techniques, but is only available on a research basis so far.

Next Chapter

Credits: How to Have a Baby: Overcoming Infertility