What is sono hysterosalphingogram? 

Sono hysterosalphingogram (Hydroscan) refers to a procedure in which fluid is instilled into the cavity of the uterus during transvaginal ultrasound examination. The technique improves detection of endometrial pathology, such as polyps, fibroids and adhesions.In addition, it can help avoid invasive diagnostic procedures under anesthesia in some patients as well. It is easily and rapidly performed at minimal cost, well-tolerated by patients, and is virtually devoid of complications.

What are the indications for doing hydroscan?

Hydroscan is often used to investigate uterine abnormalities in women who experience infertility or multiple miscarriages. It is also a valuable 
technique for evaluating unexplained vaginal bleeding that may be the result of uterine abnormalities such as:

	Congenital defects
	Congenital defects
	masses
	adhesions (or scarring)
	polyps
	Fibroids

How should I prepare for the procedure?

You should wear comfortable, loose-fitting clothing for your ultrasound.It is best to perform hydroscan one week after menstruation to avoid the risk of infection. At this time in the menstrual cycle, the lining of the uterus is at its thinnest, which is the best time to determine if the endometrium is normal. The timing of the exam may vary, however, depending on the symptoms and their suspected origins. Hydroscan should not be performed if you are pregnant.

How does the procedure work?

For hydroscan, sterile saline is injected into the uterus by using a small, lightweight catheter distending or enlarging the uterine (endometrial) cavity. The saline outlines the cavity of the uterus and fallopian tubes which is easily seen by a transvaginal scan. Following the baseline exam, the transvaginal probe will be removed, and a sterile speculum will be inserted. The cervix will be cleansed, and a catheter will be inserted into the  uterine cavity. Once the catheter is in place, the speculum will be removed, and the transvaginal probe will be re-inserted into the vaginal canal. Sterile saline will then be injected into the catheter as ultrasound is being performed.

This ultrasound examination is usually completed within 10 minutes.

Will there be pain?

Most ultrasound examinations are painless, fast and easy. During the hydroscan, you may feel occasional cramping as a result of the introduction of the saline. Over-the-counter medication should be sufficient to minimize any discomfort associated with the procedure After an ultrasound exam, you should be able to resume your normal activities.

Risks

There are very few risks

1.	Discomfort
2.	Pelvic infection. This can be significantly reduced by giving you a short course of antibiotics after the procedure.

Intrauterine insemination (IUI)

Intrauterine insemination (IUI) is a laboratory procedure to separate fast moving sperm from sluggish or non-motile sperm which are then inserted into the uterus by a very fine catheter at the time of ovulation. If conception occurs it does so naturally inside the body

Who can be helped by IUI?

We offer IUI when we know the woman’s fallopian tubes are open and:

	no cause can be found for your delay in conception
	the female partner does not regularly release eggs, often due to polycystic ovary syndrome (PCOS)
	there are very mild abnormalities of the sperm.

What normally happens in an IUI cycle?

If the female partner does not normally ovulate, we will prescribe tablets called clomiphene and/or hormone injections to stimulate the ovaries to produce one or two follicles. If you normally ovulate, doctor will discuss whether to give you more medicine to stimulate the ovaries further. This may improve the chances of becoming pregnant but also increases the risk of a multiple pregnancy. If additional medicine is used, an injection is given to mature the eggs when the follicle(s) reach a certain size on the ultrasound scan. The IUI is performed later that day or on the next day.

What is the success rate of IUI?

The success rate of having a live birth with IUI is 11% per cycle. We recommend that you try a maximum of three cycles of treatment before considering other options. We do not recommend IUI to women 40 years or above as we have had limited success in this group.

Laparoscopy is a procedure to look inside your abdomen by using a laparoscope. A laparoscope is like a thin telescope with a light source. A small incision is made in the abdominal wall and a laparoscope is passed through it into the abdomen to look at the abdominal organs, take tissue samples (biopsy) and even carry out small operations (this is known as keyhole surgery). The images seen by the laparoscope are played on a television monitor so that doctors and nurses  can see what’s happening in real time.

Why should I need a laparoscopy?

A laparoscopy may be done to find a cause of your infertility.It may also help to find the cause of symptoms such as abdominal pain, pelvic pain, or swelling of the abdomen or pelvic region or if a previous test such as an x-ray or scan has identified a problem within the abdomen or pelvis.

Some common conditions which can be seen by laparoscopy include:

• Endometriosis
• Pelvic inflammatory disease
• Pelvic pain
• Ectopic pregnancy
• Ovarian cysts

How is it performed?

A laparoscopy is a fairly short operation. It’s normally carried out while you are under general anesthetic, which means you’re unconscious for the whole procedure. While you are under anesthetic, a catheter (small flexible tube) is passed through the urethra (urine tube) into your bladder. This is used to keep the bladder empty during the operation so it is out of the way. For the operation itself, a small incision is made just above or below your belly button. A hollow needle is put into this cut, and carbon dioxide gas is pumped into your abdomen. The gas is harmless – it’s used to slightly inflate the abdominal wall and separate the organs so they can be seen more easily. A second cut in the abdomen is then made, through which the laparoscope is gently pushed. The position of the cut depends on what’s being done – for example – women having a gynaecological investigation will usually have the incision below the belly button. If you had a large cut on your abdomen, the incision may be under the left rib (Palmer point) to avoid injury to the bowel . If the laparoscopy is done as part of another surgical procedure (such as removing the cyst in the ovary or the fallopian tube ), then one or more further incisions will be made in your abdomen. Small surgical instruments can be pushed through these cuts and the surgeon guides them into the right place using the view from the laparoscope. Once in place, the instruments can be used to carry out minor surgery inside the abdomen.

After the operation, the gas is let out of your abdomen and the small cuts are sewn up. Diagnostic laparoscopy is normally carried out as an outpatient appointment. This means you don’t have to stay in hospital overnight and you should be able to return to work after a couple of days. In some cases, you may have to stay in hospital for a night or two – it depends on the exact procedure being carried out.

Are there any possible complications from a laparoscopy? 

Possible problems which may occur include the following.

-Some minor bleeding or bruising around the skin incisions – Accidental damage to structures inside the abdomen such as the intestines or certain blood vessels. This is rare, but if it occurs an emergency traditional operation may be needed to correct the damage.
– Complications of anaesthesia.
– Occasionally, the incision becomes infected which may require a course of antibiotics.

If you have laparoscopic surgery, the risk of complications may increase, depending on what operation is performed. Occasionally the surgeon may need to convert the operation to an open laparotomy, which involves making a larger incision in the abdomen. This can happen if the operation can’t be carried out properly or safely using the laparoscope, and the surgeon needs a better view and more direct access to the organs. It happens in about 3-5% of operations.

What should I expect during the recovery period? 

After a laparoscopy, it’s normal to feel some pain and discomfort around the cuts in your abdomen – this will get better after a couple of days.

You may feel some pain in your shoulders. Your abdomen may also feel uncomfortable for a day or two afterwards, which happens if there is any carbon dioxide gas remaining.

The gas is gradually absorbed by the abdomen lining. You may also feel the need to  urinate more often because the gas puts increased pressure on the bladder.

Before you go home the hospital staff will advise you how to keep the wounds clean and when to come back for a follow-up appointment or to have stitches removed. If you go home the same day, it’s a good idea to have somebody with you for the first 24 hours after the operation, just in case you experience any problems, such as fever, chills,vomiting or severe pain. It’s important to contact your doctor straightaway if this happens.

It takes a few days to recover from a diagnostic laparoscopy, and up to 12 weeks if surgery has also been carried out. Follow your surgeon’s advice about physical activity, rest and returning to work.If you wound is stitched with dissolvable stitches these do not need removing and it can be left uncovered, if it is dry.

What are the advantages of laparoscopy over traditional surgery? 

-less invasive and fewer side effects
-small scars and less pain
– faster recovery time
What is ‘lap and dye’ test

A ‘lap &dye’ test involves the injection of dye up through the neck of the womb using a fine tube. Via the laparoscope, it is possible to observe the flow of the dye out of the ends of the Fallopian tubes, if they are clear. If they are blocked, no dye is seen.

If you are having a ‘lap & dye’ test, it is important that you are not menstruating at the time of your operation and you should wear a sanitary towel to protect your clothing from the discharge of the blue.

Why I was prescribed Clomiphine tablets?

Clomiphine tablets are used to stimulate your ovaries to produce eggs. This is then carefullymonitored by ultrasound during the treatment cycle 
to pinpoint ovulation and allows the correct timing of sexual intercourse. Clomiphine will induce ovulation successfully in 70-80% of properly selected women.

When should I start taking Clomiphine?

Please start taking Clomiphine tablet/s 50 or 100 mg orally daily from the 2nd or 3rd Day of your periods for five days.

How follow up is done?

You will be given a scan appointment between 10th to 14th day of your period. At this appointment the doctor will do an internal scan and plan further scans if necessary and will tell you the approximate time of ovulation.

What are the side effects of taking Clomiphine? 

You may expect headaches, stomach upset and nausea as a result of Clomiphine treatment side effects. Very rarely you may experience visual disturbances. If you get the visual disturbances, please report this to the team and we may have to stop prescribing this treatment to you in this situation.

What will happen if the treatment fails?

If your response is below expectations (no follicles seen on scan with poor womb lining), a doctor will discuss the way forward with you prior to the next attempt at treatment.

What happens if too many follicles are formed in the ovaries?

If your response is above expectation (more than 3 follicles on scan above 14mm), you may be asked to refrain from intercourse and stop the treatment to prevent the possibility of multiple pregnancy. The overall risk of multiple pregnancy is increased approximately 7-10%.

Is there increased chance of having abnormal babies if I fall pregnant with Clomiphine?

There is no evidence that Clomiphine treatments increases the overall risk of birth defects or of any one anomaly in particular.

What is polycystic ovary syndrome?

What are polycystic ovaries?

What are the symptoms of PCOS?

What causes PCOS?

The cause of PCOS is not yet known. PCOS sometimes runs in families. If any of your relatives (mother, aunts, sisters) are affected with PCOS, your own risk of developing PCOS may be increased.

The symptoms of PCOS are related to abnormal hormone levels. Hormones are chemical messengers which control body functions. Testosterone is a hormone which is produced by the ovaries. Women with PCOS have slightly higher than normal levels of testosterone and this is associated with many of the symptoms of the condition.

Insulin is a hormone which regulates the level of glucose (a type of sugar) in the blood. If you have PCOS, your body may not respond to the hormone insulin (known as insulin resistance), so the level of glucose is higher. To prevent the glucose levels becoming higher, your body produces more insulin. High levels of insulin can lead to weight gain, irregular periods, infertility and higher levels of testosterone.

How is PCOS diagnosed?

Women with PCOS often have different signs and symptoms and sometimes these come and go. This can make PCOS a difficult condition to diagnose. Because of this, it may take a while to get a diagnosis.

A diagnosis is usually made when you have any two of the following:

1. Irregular, infrequent periods or no periods
2. More facial or body hair than is usual for you and/or blood tests which show higher testosterone levels than normal
3. An ultrasound scan which shows polycystic ovaries
4. When a diagnosis is made, you may be referred to a gynaecologist (a doctor who specialises in caring for a woman’s reproductive system) or an endocrinologist (a doctor who specialises in the hormonal system).
5. An ultrasound scan which shows polycystic ovaries

1. Are over 40 years of age
2. Have relatives with diabetes
3. Developed diabetes during a pregnancy (known as gestational diabetes)
4. Are obese (body mass index or BMI over 30)

If you are diagnosed with diabetes, you will be given dietary advice and may be prescribed tablets or insulin injections.

High blood pressure

Women with PCOS tend to have high blood pressure, which is likely to be related to insulin resistance and to being overweight, rather than the PCOS itself. High blood pressure can lead to heart problems and should be treated.

Heart disease in later life

Developing heart disease is linked to health conditions such as diabetes and high blood pressure. If you do not have these conditions, there is no clear evidence that, just because you have PCOS, you are more likely to die from heart disease than women who do not have PCOS. If you have a high cholesterol level you may be advised to take medication (statins) to reduce the risk of heart problems. If you are trying for a baby, you should seek specialist advice about the use of statins.

Cancer

With fewer periods (less than three a year), the endometrium (lining of the womb) can thicken and this may lead to endometrial cancer in a small number of women. There are different ways to protect the lining of the womb using the hormone progestogen. Your doctor will discuss the options with you. This may include a five-day course of progestogen tablets used every three or four months, taking a contraceptive pill or using the intrauterine contraceptive system (Mirena®). The options will depend on whether you are trying for a baby. PCOS does not increase your chance of breast, cervical or ovarian cancer.

Depression and mood swings

The symptoms of PCOS may affect how you see yourself and how you think others see you. It can lower your self-esteem.

Snoring and daytime drowsiness

PCOS can lead to fatigue or sleepiness during the day. It is also associated with snoring.

What can I do to reduce long-term health risks?

Have a healthy lifestyle

The main ways to reduce your overall risk of long-term health problems are to:

1. Eat a healthy balanced diet.

 

1. This should include fruit and vegetables and whole foods (such as wholemeal bread, whole grain cereals, brown rice, wholewheat pasta), lean meat, fish and chicken. You should decrease sugar, salt, caffeine and alcohol (14 units is the recommended maximum units a week for women)

 

1. Eat meals regularly especially including breakfast

 

1. Take exercise regularly (30 minutes at least three times a week)

 

You should aim to keep your weight to a level which is normal (a BMI between 19 and 25).

If you are overweight, it would be helpful to lose weight and maintain your weight at this new level. If you are obese (BMI greater than 30), discuss strategies for losing weight, including weight-reducing drugs, with your GP, practice nurse or pharmacist.

The benefits of losing weight include:

1. A lower risk of insulin resistance and developing diabetes

 

1. A lower risk of heart problems

 

1. A lower risk of cancer of the womb

 

1. More regular periods

 

1. An increased chance of becoming pregnant

 

1. Reduction in acne and a decrease in excess hair growth over time

 

1. Improved mood and self-esteem

 

What are fibroids?

How common are fibroids?

What are different types of fibroid?

What are the symptoms of fibroid?

The majority of women with fibroids show no symptoms. Many women are unaware that they have fibroids. However, if symptoms develop, you may experience one or more of the following:

1. Heavy or painful periods in some cases this can lead to anaemia
2. Discomfort, or swelling, in your lower abdomen, particularly if your fibroids are large
3. Backache, or pains in your legs
4. Urinating frequently, usually if your fibroids are pressing on your bladder
5. Constipation which can be caused by the fibroids pressing on your rectum (large intestine leading to your anus)
6. Pain or discomfort during sex this is usually if your fibroids are growing near your vagina (or lower part of your cervix)
7. Infertility

In some cases, you may have repeated miscarriages or infertility problems. Very rarely fibroids can cause problems during pregnancy and labour. Diagnosis

As fibroids rarely have symptoms, they are often found during a routine gynaecological (vaginal) examination.If fibroids are suspected, an ultrasound scan can be used to confirm a diagnosis. It can also rule out any other possible causes for your symptoms. Treatment Options

With Medication The most effective medication to treat fibroids is an injected hormone medicine called gonadotropin releasing hormone agonist (GnRHa). This causes your body to release a very low amount of oestrogen, causing your fibroids to shrink. GnRHa works by preventing your menstrual cycle (period), but it is not a form of contraceptive. However, it does not affect your chances of becoming pregnant after you stop using it. If you are prescribed GnRHa, it can help ease your heavy periods and any pressure felt on your abdomen. Common side effects include menopause-like symptoms, such as hot flushes, increased sweating, and vaginal dryness. Osteoporosis (thinning of the bones) is a less common side effect. GnRHa is not prescribed for long term use, and is often used to shrink fibroids prior to surgery. A combination of GnRHa and low doses of Hormone Replacement Therapy (HRT) can be used to shrink your fibroids, whilst preventing the side effects of the menopause. Other medicines can be used to treat heavy periods, but they are less effective the larger your fibroids are. These include:

Tranexamic acid these tablets are taken from the start of your period for up to four days. However, treatment should be stopped if your symptoms have not improved within three months. The tablets work by helping the blood in your womb to clot, which reduces the amount of bleeding. Tranexamic acid tablets are not a form of contraception and will not affect your chances of becoming pregnant once you stop taking them

Anti-inflammatory medicines such as ibuprofen and mefanamic acid help to ease your periods and are taken for a few days during your period. They work by reducing your bodys production of a hormone-like substance, called prostaglandin, which is linked to heavy periods. They are also painkillers but are not a form of contraceptive. Common side effects include indigestion and diarrhoea.

The contraceptive pill is often taken, during your period, to prevent your menstrual cycle (period) from occurring. Some contraceptive pills also help to reduce any period pain you may experience. See your GP to discuss which contraceptive pill you should use Levonorgestrel intrauterine system (LNG-IUS) is a small plastic device that is placed in your womb and slowly releases the progestogen hormone called levonorgestrel. It prevents the lining of your womb from growing quickly so your bleeding becomes lighter. Possible side effects of LNG-IUS include; having irregular bleeding that may last for more than six months, acne (inflamed skin on the face), headaches, and breast tenderness. It may also stop you having periods at all, although this is rare

Surgical Procedures
Surgical procedures, for treating fibroids, are usually only considered if all other medications are ineffective. There are a number of different surgical procedures that can be carried out to treat fibroids. Common surgical procedures that are used to treat fibroids include:

1. Hysterectomyinvolves surgery to remove the womb. A hysterectomy is not usually necessary unless the fibroids are very large or you have severe bleeding. A hysterectomy may be advised in order to prevent fibroids recurring. Having a hysterectomy can lead to early menopause and some women experience problems with a reduced libido

 

1. Myomectomy involves surgery to remove the fibroids from the wall of your womb. A myomectomy is an alternative to having a hysterectomy, particularly for women still wishing to have children. However, the procedure may not always be possible as it depends on your individual circumstances, such as the size, number and position of your fibroids

 

1. Endometrial ablationis removal of the womb lining. It is usually only carried out if your fibroids are near the inner surface of your womb. The affected womb lining is removed, which may be done in a number of ways, including using laser energy, a heated wire loop, microwave heating, or hot fluid in a balloon. Endometrial ablation can be used as an alternative to a hysterectomy

 

1. Uterine artery embolisation (UAE) is a new treatment used to block the blood supply to fibroids. This is done by injecting a chemical through a small tube (catheter) that has been guided by X-ray scans into a blood vessel in your leg. This is usually used in women with large fibroids, and has been known to shrink fibroids by up to 60%. There are reservations about using this procedure in women who want to get pregnant

 

Abdominal Myomectomy

What is it?
Open surgery to remove fibroids (also called laparotomy)

What types of fibroids does it treat?
Can remove fibroids in the wall of the womb (intramural) and in the outer layer of the womb (subserous)

How is it done?
A 15cm cut is made in the abdomen for the doctor to shell out the fibroids. This is done with a looped wire, knife or laser. Once the fibroids have been removed, the uterus and abdomen are stitched up. The operation requires general anaesthetic and you will be in hospital for a few days.

What is the recovery period afterwards?
It will take about a month or more to recover at home. You will probably feel tired and weak and will need to regain your strength by walking and doing specific exercises. Do not lift heavy objects while recovering.

Will the fibroids come back?
Some studies show a 10 to 15% chance of fibroid regrowth, while others estimate 30%.

Will I still be able to get pregnant?
Most women can still become pregnant after a myomectomy, but in some cases scarring in the womb can cause fertility problems.

What are the advantages of this procedure?
Advantages: your womb is left intact and you may still be able to have children.

What are the possible complications and other disadvantages? Complications: bleeding that can lead to an emergency hysterectomy. Infection; damage to surrounding organs.

Disadvantages: 20 to 25% of women undergo additional surgery, usually hysterectomy, to stop symptoms. Possible weakening of the womb wall and scarring may cause complications during pregnancy such as rupturing of the womb wall.

Laparoscopic Myomectomy

What is it?

Keyhole surgery (through the abdomen) to remove fibroids.

What types of fibroids does it treat?
Recommended for fewer than three fibroids and fibroids that are less than 5cm wide.

How is it done? A laparoscope (telescope) is inserted into the womb through a tiny cut in the abdomen. Other small cuts are made in the same area to insert instruments that slice up and remove the fibroids. This is done under general anaesthetic and you will be in hospital for a day or two. It is a difficult, often long, procedure and requires a highly skilled surgeon.

What is the recovery period afterwards?
The surgery may take longer but recovery is much quicker than abdominal myomectomy. Recovery at home takes 7 to 14 days.

Will the fibroids come back?
This procedure may not remove all fibroids. Any missed fibroids are likely to continue to grow. New fibroids may also develop.

Will I still be able to get pregnant?
Laparoscopic myomectomy does not usually interfere with fertility.It may improve your fertility if no other cause is found.

What are the advantages of this procedure?
Advantages: less invasive than other surgical options; small abdominal scars and little scarring inside the womb.

What are the possible complications and other disadvantages?
Complications: unexpected complications may require an abdominal myomectomy or emergency hysterectomy.

Disadvantages: there may be an increased risk of your womb rupturing during pregnancy.

Disadvantages:
20 to 25% of women undergo additional surgery, usually hysterectomy, to stop symptoms. Possible weakening of the womb wall and scarring may cause complications during pregnancy such as rupturing of the womb wall.

Hysteroscopic Myomectomy

What is it?
Removal of small fibroids through the vagina.

What types of fibroids does it treat?
Can remove only small submucous fibroids.

How is it done?
A small hysteroscope (telescope) is inserted into the womb through the vagina and cervix. A laser or wire loop is then inserted through the hysteroscope to remove the fibroids. You will be given a general anaesthetic and will probably be able to go home the same day.

What is the recovery period afterwards?
It should take 2 to 7 days to recover at home.

Will the fibroids come back?
There is a 20 to 30% chance of fibroids growing back.The fibroids which are partially in the muscle of the womb are likely to slip into the uterine cavity and a 2nd procedure may be needed .Very large fibroids may need 2 procedures . 

Will I still be able to get pregnant?
Hysteroscopic myomectomy may improve your chances of getting pregnant 

What are the advantages of this procedure?
Advantages: no incisions; recovery is less than a week; little scarring. You will still have your womb and may be able to have children.

What are the possible complications and other disadvantages?

Complications:

possible damage to the womb wall.

Disadvantages:

symptoms may continue: Perforation of the uterus leading to the procedure being abandoned and a laparoscope(a small scope through the abdomen) may need to be inserted to look at any possible damage that may have occurred. You may be in hospital overnight to check for any complications. It is likely that the procedure may have to be repeated on another day 

Hysterectomy

What is it?
Removal of the uterus (womb). In some cases, the fallopian tubes, cervix and/or ovaries are also removed.

What types of fibroids does it treat?
Removes all fibroids. Should only be done if fibroids are very large or cause problems that cannot be treated in other ways.

How is it done?
The uterus is removed either through a cut in the abdomen (if fibroids are large) or through the vagina (if fibroids are small). Both are major operations. Abdominal hysterectomy can take one hour or several depending on the size of fibroids. You will be in hospital for 5 to 7 days. Vaginal hysterectomy takes about an hour and you will be in hospital for 2 to 3 days.

What is the recovery period afterwards?
Abdominal hysterectomy – Recovery will take 6 to 8 weeks at home. Vaginal hysterectomy – Recovery should take about five weeks at home. You will feel tired, but try to walk as much as possible.

Will the fibroids come back?
Fibroids will not grow back.

Will I still be able to get pregnant?
If you have a hysterectomy you will not be able to have children

What are the advantages of this procedure?
Advantages: all of your fibroids will be gone and will never grow back.

What are the possible complications and other disadvantages?
Complications: possible damage to your bladder or bowel; infection; risk of bleeding heavily during or after the operation, which may require a blood transfusion. Disadvantages: you will no longer have your womb or be able to have children. Can lead to an early menopause 

Complications

1. Heavy periods (menorrhagia) this does not necessarily mean that there is anything seriously wrong, but it can disrupt your everyday life and make you feel miserable. In some cases, menorrhagia can lead to anaemia, causing fatigue and breathlessness. See the separate health encyclopaedia topic for further information about heavy periods.
2. Abdominal pains you may experience discomfort or bloating (swelling) to your lower abdomen, particularly if your fibroids are large. You may also find you need to urinate frequently if your fibroids are pressing on your bladder. This pressure may also mean you have painful bowel movements or feel constipated.

 

1. Miscarriage and premature birth during pregnancy the levels of oestrogen in a woman’s body can increase by as much as five times. Because fibroids are thought to be produced by high levels of oestrogen this may lead to complications with the development of the baby, or cause pain and discomfort. In rare cases, fibroids could block the passage of the birth canal causing possible complications during labour

 

1. Miscarriage and premature birth during pregnancy the levels of oestrogen in a woman’s body can increase by as much as five times. Because fibroids are thought to be produced by high levels of oestrogen this may lead to complications with the development of the baby, or cause pain and discomfort. In rare cases, fibroids could block the passage of the birth canal causing possible complications during labour

 

1. Infertility is more common in women with large fibroids as they can interfere with the fertilised egg attaching to the lining of your womb……

What is endometriosis?

What could endometriosis mean for me?

What causes endometriosis?

Why does endometriosis occur?

It is not yet known why endometriosis occurs. A number of theories have been suggested but none has been proved. The most commonly accepted theory is that, during a period, light ‘backward’ bleeding carries tissue from the womb to the pelvic area via the fallopian tubes. This is called ‘retrograde menstruation’. How soon can I expect to get a diagnosis?

For many women, it can take years to get a diagnosis. Doctors say that this is because:

no one symptom or set of symptoms can definitely confirm a diagnosis of endometriosisthe symptoms of endometriosis are common and could be caused by a number of other conditions such as irritable bowel syndrome (IBS) and pelvic inflammatory disease (PID) (for further information see Acute pelvic inflammatory disease: what the RCOG guideline means for you)
Different women have different symptoms

Some women have no symptoms at all There is no simple test for endometriosis. The only way to make a definite diagnosis is by a small surgical operation known as laparoscopy (see What treatment can I get?). This is not performed on every woman.
If you have painful periods and no other symptoms, your GP may suggest that you try pain relief before having further surgical investigation or treatments.

Living without a diagnosis can be distressing. Many women may fear the worst about why they are in pain or why they are having problems becoming pregnant. They may think that they have cancer.

What happens when I see a specialist?

At your appointment, you may be asked specific questions about your periods and your sex life. It is important that you provide as much information as possible, as this will help your doctor find the correct diagnosis. You may find it helpful to write down your symptoms beforehand and take your notes along to the appointment with you. In this way, you will be sure to provide all the information required. Some women find it helpful to take a friend or partner along with them as well.
Your gynaecologist may examine your pelvic area, this will include an internal examination. Your doctor will discuss the best time to do this. This may be when you are having your period. If you have concerns about this, you should have an opportunity to discuss them.

What types of tests might I be offered?

You should be given full information about the tests that are available. These may include:

Ultrasound
You may be offered a scan. This can identify whether there is an endometriosis cyst in the ovaries. A normal scan does not rule out endometriosis.

Laparoscopy
For most women, having a laparoscopy is the only way to get a definite diagnosis; because of this, it is often referred to as the ‘gold standard’ test. A laparoscopy is a small operation which is carried out under general anaesthesia. A small cut is made in your abdomen near your tummy button (navel), then a telescope (known as a laparoscope), which is about the width of a pen, is inserted. This allows the gynaecologist to see the pelvic organs clearly and look for any endometriosis. This is usually carried out as day surgery. If you have a laparoscopy, you should be given full information about your results.

Making a decision about treatment
You should be given full information about your options for treatment. This should also include information about the risks and benefits of each option. Several factors may influence your decision about treatment. These include:

How you feel about your situation
Your age
Whether your main symptom is pain or problems getting pregnant
Whether you want to become pregnant – some hormonal treatments which help to reduce the pain will stop you from becoming pregnant
How you feel about surgery
What treatment you have had before
How effective certain treatments are
You may decide that no treatment is the best way forward. This could be because your symptoms are mild, you have not had problems getting pregnant or you are nearing the menopause, when symptoms may get better.

What treatment can I get?
The options for treatment may be:

Pain relief
Pain-relieving drugs reduce inflammation and help to ease the pain.
Hormone treatments

There is a range of hormone treatments to stop or reduce ovulation (the release of an egg) to allow the endometriosis to shrink or disappear.

The hormonal methods below are contraceptives and will prevent you from becoming pregnant:
The combined oral contraceptive (COC) pill or patch: These contain the hormones estrogen and progestogen and work by preventing ovulation and can make your periods lighter, shorter and less painful.
The intrauterine system (IUS): this is a small T-shaped device which releases the hormone progestogen. This helps to reduce the pain and makes periods lighter. Some women get no periods at all.

The hormonal methods below are non-contraceptive, so contraception will be needed if you do not want to become pregnant:

Use of hormonal progestogens or testosterone derivatives
GnRH agonists – these drugs prevent estrogen being produced by the ovaries and cause a temporary and reversible menopause

Surgery

Surgery can be used to remove areas of endometriosis. Surgery including hysterectomy does not always successfully remove the endometriosis. There are different types of surgery, depending on where the endometriosis is and how extensive it is. How successful the surgery is can vary and you may need further surgery. Your gynaecologist will discuss this with you before any surgery.

Laparoscopic surgery: The gynaecologist removes patches of endometriosis by destroying them or cutting them out.
Laparotomy: If the endometriosis is severe and extensive, you may be offered a laparotomy. This is major surgery which involves a cut in the abdomen, usually in the bikini line.
Hysterectomy: Some women have surgery to remove their ovaries or womb (a hysterectomy). Having this surgery means that you will no longer be able to have children after the operation.
Depending upon your own situation, your doctor should discuss hormone replacement therapy (HRT) with you if you have your ovaries removed.

What if I am having difficulty getting pregnant?
Getting pregnant can be a problem for some women with endometriosis. Your doctor should provide you with full information about your options such as assisted conception.
Living with endometriosis
Not all cases of endometriosis can be cured and for some women there is no long-term treatment that helps. With support many women find ways to live with and manage this condition.

What is an ectopic pregnancy?

An ectopic pregnancy is when a pregnancy starts to grow outside the uterus (womb). One in 90 (just over 1%) pregnancies is an ectopic pregnancy. When you become pregnant, the sperm and egg meet in the fallopian tube (the tube that carries the egg from the ovary to the uterus). Usually, the fertilised egg moves into the uterus for the pregnancy to grow and develop. If this does not happen, an ectopic pregnancy may start to develop in a fallopian tube (sometimes known as a tubal pregnancy). An ectopic pregnancy can occur in places other than a fallopian tube, such as in the ovary (rarely) or inside the abdomen (very rarely).

What are the symptoms of an ectopic pregnancy?

Each woman is affected differently by an ectopic pregnancy. Some women have no symptoms, some have a few symptoms while others have many symptoms. Because symptoms vary so much, it is not always straightforward to make a diagnosis of an ectopic pregnancy. The symptoms of an ectopic pregnancy may include:

Abnormal bleeding

You may have some spotting or bleeding that is different from your normal period. The bleeding may be lighter or heavier than normal. The blood may be darker and more watery.

Pain in your lower abdomen

This may develop suddenly for no apparent reason or may come on gradually over several days. It may be on one side only.

Pain in the tip of your shoulder

This occurs due to blood leaking into the abdomen. This pain is there all the time and may be worse when you are lying down. It is not helped by movement and may not be relieved by painkillers.

Upset tummy

You may have diarrhoea or pain on opening your bowels.

Severe pain/collapse

If the fallopian tube ruptures and causes internal bleeding, you may develop intense pain or you may collapse. This is an emergency situation. In rare instances, collapse is the first sign of an ectopic pregnancy.

Should I seek medical advice immediately?

Yes! An ectopic pregnancy can pose a serious risk to your health. If you have had sex within the last 3 to 4 months (even if you have used contraception) and are experiencing these symptoms, get medical help immediately. Seek advice even if you do not think you could be pregnant.

Am I at increased risk of an ectopic pregnancy?

Any woman of childbearing age who is having sex could have an ectopic pregnancy. You are at an increased risk of an ectopic pregnancy if:

A	You have had a previous ectopic pregnancy
B	you have a damaged fallopian tube. The main causes of damage are:
C	previous surgery to your fallopian tubes, including sterilisation
D	previous infection in your fallopian tubes
E	you become pregnant when you have an intrauterine device (IUD/coil) or if you are on the progesterone-only contraceptive pill (mini-pill)
F	Your pregnancy is an in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) pregnancy.
G	you are over 40 years old
H	you smoke.

How do I get a diagnosis?

Most ectopic pregnancies are suspected between 6 and 10 weeks of pregnancy. Sometimes the diagnosis is made quickly, but if you are in the early stages of pregnancy, it can take longer (a week or more) to make a diagnosis of an ectopic pregnancy.

Your diagnosis will be confirmed by the following:

Consultation and examination

The doctor will ask about your medical history and symptoms. The doctor willexamine your abdomen and may also do a vaginal (internal) examination.If you have not already had a positive pregnancy test, you will be asked for a urine sample so this can be tested for pregnancy. If the pregnancy test is negative, it is very unlikely that your symptoms are due to an ectopic pregnancy.

Ultrasound scan

Most women are offered a transvaginal scan (where a probe is gently inserted into your vagina) to look at the uterus, ovaries and fallopian tubes. If you are in the early stages of pregnancy, you may be offered another scan after a few days when it may be easier to see the pregnancy.

Blood tests

1)	A test for the level of the pregnancy hormone human chorionic gonadotrophin (hCG) or a change in this level every few days  may help to give a diagnosis.
2)	A test for the level of the hormone progesterone may be taken.

Laparoscopy

If the diagnosis is still unclear, an operation called a laparoscopy may be necessary. This operation takes place under a general anaesthetic. 
The doctor uses a small telescope to look at your pelvis by making a tiny cut usually into the umbilicus (tummy button). This is also called keyhole surgery.If an ectopic pregnancy is detected, treatment may take place during the same operation.

What are the options for treatment?

Because an ectopic pregnancy cannot lead to the birth of a baby, all options end the pregnancy in order to reduce the risks to your own health. 

Your options depend on:

1)	how many weeks pregnant you are
2)	your symptoms
3)	if there has been a lot of bleeding inside your abdomen
4)	the level of hCG
5)	your scan result
6)	your general health
7)	your personal views and preferences – this should involve a discussion about your future pregnancy plans
8)	the options available at your local hospital. The options for treatment are listed below – not all will be suitable for you.

Expectant management (wait and see)

Ectopic pregnancies sometimes end on their own – similar to a miscarriage. Depending on your situation, it may be possible to monitor the hCG levels with blood tests every few days until these are back to normal. 

Expectant management is not an option for all women. It is usually only possible when the pregnancy is still in the early stages and when you 
have a few or no symptoms. Up to 29 in 100 (29%) women undergoing expectant management may require additional medical or surgical management.

Medical treatment

In certain circumstances, an ectopic pregnancy may be treated by medication (drugs). The fallopian tube is not removed. A drug (methotrexate) prevents the pregnancy from developing and so the ectopic pregnancy gradually disappears.

The drug is given as an injection. If your pregnancy is beyond the very early stages or the hCG level is high, methotrexate is less likely to succeed. Many women experience some pain in the first few days, but this usually settles with paracetamol or similar pain relief. Although long-term treatment with methotrexate for other illnesses can cause significant side effects, this is rarely the case with one or two injections to treat ectopic pregnancy.

You may need to stay in hospital overnight and then return to the clinic or ward a few days later. It may be sooner if you have any symptoms. It is 
very important that you attend your follow-up

A	Fifteen in 100 (15%) women need to have a second injection of methotrexate.
B	Seven in 100 (7%) women will need surgery, even after medical treatment.

Surgery

The aim of surgery is to remove the ectopic pregnancy. The type of operation you have will depend on your wishes or plans for a future pregnancy and what your surgeon finds during the operation (laparoscopy).

To have the best chance of a future pregnancy inside your uterus, and to reduce the risk of having another ectopic pregnancy, you will usually be advised to have your fallopian tube removed (salpingectomy).

If you only have one tube or your other tube does not look healthy, this already affects your chances of getting pregnant. In this circumstance, you may be advised to have a different operation (salpingotomy). This operation aims to remove the pregnancy without removing the tube. It carries a higher risk of a future ectopic pregnancy but means you retain the possibility of a pregnancy in the uterus in the future. Some women may need to have a further operation to remove the tube later if the pregnancy has not been completely removed.

An operation to remove the ectopic pregnancy will involve a general anaesthetic. The surgery will be either:

1.	Laparoscopy – the stay in hospital is about 1 to 2 days and the recovery is about 2 to 4 weeks
2.	Open surgery – known as a laparotomy – is performed through a larger cut in your lower abdomen. It is usually done if severe internal bleeding is suspected. You will need to stay in hospital for 2 to 4 days. It usually takes about 4 to 6 weeks to recover.

There are risks associated with any operation. This may be due to the use of an anaesthetic or the operation itself. Your surgeon and  anaesthetist will discuss these with you.

What do I need to know to make an informed decision?

When an ectopic pregnancy is confirmed, and if the fallopian tube has not ruptured, your doctor should discuss your options with you.

Make sure you:

1)	fully understand all your options
2)	ask for more information if there is something you do not understand
3)	raise your concerns
4)	understand what each option means for your fertility
5)	have enough time to make your decision.

In an emergency situation

If the fallopian tube has ruptured, emergency surgery is needed to stop the bleeding. This is achieved by removing the ruptured fallopian tube and pregnancy. This operation is often life-saving. Your doctors will need to act quickly and this may mean that they have to make a decision on your behalf to operate. In this situation you may need a blood transfusion (see RCOG patient information 

Follow-up appointments: what happens next?

It is important that you attend your follow-up appointments. The check-ups and tests you have will depend on the treatment you received.

Expectant management

Your doctor will need to check your blood levels of hCG every few days until normal levels are reached. This is to ensure that the pregnancy has completely ended. You may need further ultrasound scans.

Medical management

You will need to return twice in the first week and then once a week to check your blood levels of hCG. It may take a few weeks to ensure the pregnancy has completely ended and you may need further ultrasound scans. During this time, you should not have sex. You should avoid getting pregnant by using reliable contraception for at least 3 months.

Surgical management

You may be offered a follow-up appointment with your gynaecologist, particularly if you have had an emergency operation. If you have not had your fallopian tube removed, you will need to have your hCG level checked until this is back to normal.

What about future pregnancies?

For most women an ectopic pregnancy occurs as a ‘one off’ event and does not occur again. Even if you have only one fallopian tube, your chance of conceiving is only slightly reduced.The overall chance of having an ectopic pregnancy next time is between 7 and 10 in 100 (7–10%). However, this depends on the type of surgery you had and any underlying damage to the remaining tube(s). In a future pregnancy, you may be offered an ultrasound scan at 6 to 8 weeks to confirm that the pregnancy is developing in the womb.

If you do not want to become pregnant, seek further advice from your doctor or family planning clinic as some forms of contraception may be more suitable after  an ectopic pregnancy.

How will I feel afterwards?

The impact of an ectopic pregnancy can be very significant. It can mean coming to terms with the loss of a baby, with the potential impact on future fertility or with the fact you could have lost your life.

It is important to remember that the pregnancy could not have continued without causing a serious risk to your health.

Before trying for another baby, it is important to wait until you feel ready emotionally and physically.Your the possibility of a normal pregnancy next time is much greater than the possibility of having another ectopic pregnancy. 

Sources and acknowledgements

This information is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline Tubal Pregnancy (published by the RCOG in April 2008).

Key points:

1)	A miscarriage is the early loss of a pregnancy.
2)	Recurrent miscarriage is when this happens three or more times.
3)	Around one woman in every 100 has recurrent miscarriages.
4)	Most couples who have had recurrent miscarriages still have a good chance of a successful birth in future.
5)	If you have had recurrent miscarriages, you may be offered blood tests or a pelvic ultrasound scan to try to identify the reason for them.
6)	In spite of careful investigations, it is often not possible to find the reason for recurrent miscarriages.
7)	Your doctors will not be able to tell you for sure what will happen if you become pregnant again.

What is recurrent miscarriage?

A miscarriage is when you lose a pregnancy at some point in the first 23 weeks. When this happens three or more times doctors call this recurrent miscarriage. Around one woman in every 100 has recurrent miscarriages. This is about three times more than you would expect to happen just by chance, so it seems that for some women there must be a specific reason for their losses. For others, though, no underlying problem can be identified; their repeated miscarriages may be due to chance alone.

Why does it happen?

Often, in spite of careful investigations, the reasons for recurrent miscarriages cannot be found.

There are a number of things which may play a part in recurrent miscarriage. It is a complicated problem and more research is still needed.

1) Your age and past pregnancies

The older you are, the greater your risk of having a miscarriage. The more miscarriages you have had already, the more likely you will be to have another one.

2) Genetic factors

For around three to five in every 100 women who have recurrent miscarriages, they or their partner have an abnormality on one of their chromosomes (the genetic structures within our cells that contain our DNA and the features we inherit from our parents). Although such abnormalities may cause no problem for you or your partner, they may sometimes cause problems if passed on to your baby.

3) Abnormalities in the embryo

An embryo is a fertilised egg. An abnormality in the embryo is the most common reason for single miscarriages. However, the more miscarriages you have, the less likely this is to be the cause of them.

4) Autoimmune factors

Antibodies are substances produced in our blood in order to fight off infections. Around 15 in every 100 women who have had recurrent miscarriages have particular antibodies, called antiphospholipid (aPL) antibodies, in their blood; fewer than two in every 100 women with normal pregnancies have aPL antibodies. Some people produce antibodies that react against the body’s own tissues; this is known as an autoimmune response and it is what happens to women who have aPL antibodies. If you have aPL antibodies and a history of recurrent miscarriage, your chances of a successful pregnancy may be only one in ten.

5) Womb structure

It is not clear how far major irregularities in the structure of your womb can affect the risk of recurrent miscarriages. Estimates of the number of women with recurrent miscarriage who also have these irregularities range from two out of 100 to as many as 37 out of 100. Women who have serious anatomical abnormalities and do not have treatment for them seem to be more likely to miscarry or give birth early. Minor variations in the structure of your womb  do not cause miscarriages.

6) Weak cervix

In some women, the entrance of the womb (the cervix) opens too early in the pregnancy and causes a miscarriage in the third to sixth month. This is known as having a weak (or ‘incompetent’) cervix. It is overestimated as a cause of miscarriage because there is no really reliable test for it outside of pregnancy.

7) Polycystic ovaries

If you have polycystic ovaries your ovaries are slightly larger than normal ovaries and produce more small follicles than normal. This may be linked to  an imbalance of hormones. Just under half of women with recurrent early miscarriages have polycystic ovaries; this is about twice the number of women in the general population.

Having polycystic ovaries is not a direct cause of recurrent miscarriage and it does not mean that you are at any greater risk of further miscarriages. We are not sure what the link is.

Many women with polycystic ovaries and recurrent miscarriage have high levels of a hormone called luteinising hormone (LH) in their blood. Reducing the level of LH before pregnancy, however, does not improve your chances of a successful birth.

8) Hyperprolactinaemia

Prolactin is a hormone which prepares a pregnant woman’s breasts to produce milk. When a woman produces too much prolactin, this is known as hyperprolactinaemia.  It is not yet clear whether this condition plays a role in recurrent miscarriage because the evidence is conflicting.

9) Infections

If a serious infection gets into your bloodstream it may lead to a miscarriage. If you get a vaginal infection called bacterial vaginosis early in your pregnancy, it may increase the risk of having a miscarriage around the fourth to sixth month or of giving birth early. It is not clear, though, whether infections cause recurrent miscarriage; for this to happen, the bacteria or virus would need to be able to survive in your system without causing enough symptoms to be noticed. This rules out illnesses like measles, herpes, listeria, toxoplasmosis and cytomegalovirus (so you do not need to be tested for them if you have recurrent miscarriages).

10) Blood conditions

Certain inherited conditions mean that your blood may be more likely to clot than is usual. These conditions are known as thrombophilia. They do 
not, though, mean that a serious blood clot will inevitably develop. Although thrombophilia has been thought to play some part in miscarriage, 
we do not yet know enough about how or why that is.

11) Alloimmune reaction

Some people have suggested that some women miscarry because their immune system does not respond to the baby in the usual way. This is known as an alloimmune reaction. There is no clear evidence to support this theory.

12) Diabetes and thyroid problems

Diabetes or thyroid disorders can be factors in single miscarriages. They do not cause recurrent miscarriage, as long as they are treated and kept under control.

What can be done?

Supportive antenatal care

Women who have supportive care from the beginning of a pregnancy have a better chance of a successful birth. There is some evidence that attending an early pregnancy clinic (if there is one in your area) can reduce the risk of further miscarriages.

Screening for abnormalities in the structure of your womb
You should be offered a pelvic ultrasound scan to check for and assess any abnormalities in the structure of your womb, so that they can be treated if necessary. Another method of screening using hysterosalpingography (an X-ray of the fallopian tubes using fluid injected through the entrance of the womb) has no advantages over pelvic ultrasound and causes more discomfort, so it is not usually necessary.

Screening for genetic problems

Couple should be offered a blood test to check for chromosome abnormalities; the test is known as karyotyping. If either or both of you turn out to have an abnormality you should be offered the chance to see a specialist called a clinical geneticist. They will tell you what your chances are for future pregnancies and will explain what your choices are. This is known as genetic counselling.

Screening for abnormalities in the embryo

If you have a history of recurrent miscarriage and you lose your next baby,your doctors may suggest checking for abnormalities in the embryo or the placenta afterwards. They will do this by checking the chromosomes of the embryo through karyotyping, although it is not always possible to get a result. They may also examine the placenta through a microscope. The results of these tests may help them to identify and discuss with you your possible choices and treatment.

Screening for vaginal infection

If you have had miscarriages in the fourth to sixth month of pregnancy or if you have a history of going into labour prematurely, you may be offered tests (and treatment if necessary) for an infection known as bacterial vaginosis (BV).

If you have BV, treatment with antibiotics may help to reduce the risks of losing your baby or of premature birth. There is not enough evidence to be sure that it makes any difference to the chances of a baby surviving.

Treatment for aPL antibodies

There is some evidence that if you have aPL antibodies and a history of recurrent miscarriages, treatment with low-dose aspirin tablets and low-dose heparin injections in the early part of your pregnancy may improve your chances of a live birth up to about seven in ten (compared with around four in ten if you take aspirin alone and just one in ten if you have no treatment).

Even with treatment, you will have a risk of extra problems during pregnancy (including pre-eclampsia, restriction in the baby’s growth and premature birth). You should be carefully monitored so that you can be offered appropriate treatment for any problems that arise.

Steroids (certain sorts of natural or synthetic hormones) have been used to treat aPL antibodies in recurrent miscarriage, but they do not seem to improve the chances of a successful delivery and they carry significant risks for you and your baby, compared with aspirin and heparin.

Treatment for thrombophilia

Although you may have a higher risk of miscarriage if you have an inherited tendency to blood clotting (thrombophilia), you may still have a healthy and successful pregnancy. At present there is no test available to identify whether you will miscarry if you have thrombophilia. You may, though, be offered treatment to reduce the risk of a blood clot.

Tests and treatment for a weak cervix

If you have a weak cervix, a vaginal ultrasound scan during your pregnancy may indicate whether you are likely to miscarry.

If you have a weak cervix, you may be offered an operation to put a stitch in your cervix, to make sure it stays closed. It is usually done through the vagina, but occasionally it may be done through a ‘bikini line’ cut in your abdomen, just above the line of the pubic hair.

Although having a cervical stitch after the third month of pregnancy slightly lowers your risk of giving birth early, it has not been proved to improve the chances of your baby surviving. Because all operations involve some risk, your doctors should only suggest it if you and your baby are likely to benefit. They should discuss the risks and benefits with you.

Hormone treatment

It has been suggested that taking progesterone or human chorionic gonadotrophin hormones early in pregnancy could help prevent a miscarriage. There is not yet  enough evidence to prove whether this works.

Immunotherapy

Treatment to prevent or change the response of the immune system (known as immunotherapy) is not recommended for women with recurrent miscarriage. It has not been proven to work, does not improve the chances of a live birth and it may carry serious risks (including transfusion reaction, allergic shock and hepatitis).

What could it mean for me in future?

Your doctors will not be able to tell you for sure what will happen if you become pregnant again. However, even if they have not found a definite reason for your miscarriages, you still have a good chance (three out of four) of a healthy birth. Sources and acknowledgements

This information is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline The Management of Recurrent Miscarriage (last revised in May 2003).

What does vaginal bleeding and pain mean?

Vaginal bleeding in the early stages of pregnancy is common and does not always mean there is a problem. However, bleeding can be a warning sign of a miscarriage. If all the tests are normal and no cause for the bleeding has been found, then you need not worry.

Both ectopic and molar pregnancy can cause bleeding and pain but these are much less common pregnancy problems. An ectopic pregnancy is when the pregnancy is growing outside the womb (uterus), usually in the fallopian tube. A molar pregnancy is a much rarer condition where the placenta is abnormal.

See your doctor or midwife if you:
– experience bleeding
– feel pain
– stop feeling pregnant.

How can I get help?

Contact your doctor or get yourself checked in Emergency department of a hospital.

Consultation and examination

You will be asked about your symptoms, the date of your last period and your medical history. A vaginal examination may be carried out to see where the bleeding is coming from. A vaginal examination will not cause you to miscarry.

Test

A urine sample to confirm a positive pregnancy test.

Blood test(s) to check your blood group and/or pregnancy hormone levels. If you have a Rh (rhesus) negative blood group, then you may be given an injection of anti-D immunoglobulin to protect future pregnancies.

Ultrasound scan

Most women are offered a transvaginal scan (where a probe is gently inserted in your vagina) or a transabdominal scan (where the probe is placed over your abdomen). You may be offered both. Both scans are safe and will not make you miscarry. A repeat scan may be necessary after 7 to 10 days if the pregnancy is very small or has not been seen.

Medical terms that may be used to describe what is happening

	A threatened miscarriage – bleeding or cramping in a continuing pregnancy.
	An incomplete miscarriage – a miscarriage has started but there is still some pregnancy tissue left inside the womb.
	A complete miscarriage – when all the pregnancy tissue has been passed and the womb is empty.
	A delayed miscarriage/missed miscarriage/silent miscarriage – the pregnancy has stopped developing but is still inside the womb. This will be diagnosed on the scan.

What is an early miscarriage?

Early miscarriage is when a woman loses her pregnancy in the first three months Many early miscarriages occur before a woman has missed her first period or before her pregnancy has been confirmed. Once you have had a positive pregnancy test, there is around a one in five (20%) risk of having a miscarriage in the first three months. Most miscarriages occur as a ‘one-off’ (sporadic) event and there is a good chance of having a successful pregnancy in the future.

Sources and acknowledgements

This information is based on the Royal College of Obstetricians and Gynaecologists’ (RCOG) guideline on Management of Early Pregnancy Loss (which was published in October 2006).

Infertility often creates one of the most distressing life crises that a couple has ever experienced together. The long term inability to conceive a child can evoke significant feelings of loss. Coping with the multitude of medical decisions and the uncertainties that infertility brings can create great emotional upheaval for most couples. If you find yourself feeling anxious, depressed, out of control, or isolated, you are not alone.

Why would we need counselling?

There are certain points during infertility treatment when discussion with a health professional of various options and exploration of your feelings about these options can help facilitate clarification of your thinking and help with your decision making. For example,

	To help manage the stress of investigations and treatments
	To help manage the stress of investigations and treatments
	To support your relationship with your husband and your joint decisions
	To help you think through the different treatment options and their implications for your future
	To understand conflicting thoughts and feelings.
	To cope with disappointments when treatments don’t work
	To talk with someone who has the objectivity to listen without judging

WHO IS THE SERVICE FOR?

Any individual or couple, who are undergoing fertility treatment.

HOW CONFIDENTIAL IS IT?

All personal information disclosed during counselling is strictly confidential.