Reproductive Endocrinology and Infertility
The subspecialty of reproductive endocrinology and infertility (REI) is fascinating and challenging. It includes both male and female reproductive disorders associated with the relevant endocrine systems and the hormones they produce. It covers conditions such as polycystic ovarian syndrome, hyperprolactinemia, thyroid conditions, hyperandrogenism, and many more (eg. See PCOS).
Polycystic Ovarian Syndrome (PCOS)
This condition produces irregular cycles in females, signs of over production of androgens, weight gain, acne, increase hair growth and is often accompanied by infertility. It sometimes is part of a greater picture, which is called Metabolic Syndrome, which includes hypertension. There is often a link to diabetes, with a family history of such. An ultrasound of the ovaries displays multiple small cysts in the ovaries, which are follicles, which have not fully ovulated. The ovary is enlarged and dense. A blood test reveals a number of changes of the major female hormone, FSH (follicle stimulating hormone), and LH (luteinizing hormone). When this condition is diagnosed there are many areas requiring attention and treatment.
The second part of the sub-specialty is that of infertility. Often reproductive endocrine problems lead to this. Infertility is now being broken down into many areas. Male factor, female factor and sometimes unexplained.
Female infertility may include problems with ovulation (eg. PCOS), excessive exercise, fallopian tubes, uterus or even as a result of other illnesses.
Male factor infertility is a multiple and varied field. Causes may range from low sperm counts through to blocked vas, systemic illness or anatomical problems. Medications can affect male fertility as can illnesses and many other factors.
I often apply a simple list to questions on infertility.
This simple mnemonic which I call the South CCOOAASSTT principle, gets me through many of the causes of infertility, but of course it could be used anywhere.
C Cervical - Previous surgery and congenital problems with
C Coital (sex) - Not enough and problems with
O Ovulation - Not enough or never
O Other - Covers many other areas such as lifestyle, illnesses and family history.
A Anatomy - Both male and female
A Age - Female age is a significant factor. Male, not so much.
S Sperm - A semen analysis answers most male factor questions
S Sex (Coitus)
T Tubes - Where egg and sperm have to meet to fertilize
T Timing - When coitus takes place is vital
Once I have taken a thorough history from my patients (that means the couple) and I have examined them both, I know in what direction to move forward. Sometimes it is straightforward, i.e. previous vasectomy; sometimes it is not so obvious.
Treatments can be extremely varied. Once I have a diagnosis, I can then look at the treatment/s required. Often reassurance is all that is required for a couple, however, sometimes IVF is the treatment. Between reassurance and IVF there are many options. These range from surgery on the tubes, ovulation treatments, lifestyle changes, intrauterine insemination, excision of endometriosis and so forth.
Microsurgery such as tubal re-anastomosis or vasectomy reversal is also one area of my sub-specialty. This is far less common now than previously with the success of IVF, but still has a place.
Miscarriage Investigations Program (MIP)
In 2002 I put together a comprehensive program dedicated to miscarriage. This is a difficult area of reproductive disorders. Investigations, treatment and then careful management of the ongoing pregnancy are all part of this program. This program is particularly useful for couples having recurrent IVF failure also.
This is a particular area of interest to me. Known as keyhole surgery it allows many operations to be undertaken using small incisions and an operating system linked to a large TV monitor. Recovery times are reduced enormously and the surgery has many advantages over the traditional open approach.
I have a day only list at the Wollongong Day Surgery once a fortnight where I do diagnostic laparoscopies often with a hysteroscope to look inside the uterus. I have a theatre list at Wollongong Private Hospital once a month where I can see to some of these larger cases with significant disease needing advanced laparoscopic surgery.
Advanced Laparoscopic Surgery
Advanced Laparoscopic surgery requires a great deal of training and there are now a limited number of experienced endoscopic surgeons in Australia. I manage some of these on my monthly Wollongong Private Hospital list. Some of the more complex cases are referred on to the experts in Sydney. Dr Geoff Reid and Dr David Kowalski are amongst these.
A particular interest of mine is endometriosis, which can be the cause of infertility and or pelvic pain. Excision surgery has excellent results for this condition. Other conditions I have managed are fibroids, adhesions and ovarian cysts.