Questions on cysts, fibroids, cycles & PCOS that were not answered during Know Your Fertility Wellness Seminar on 3 March 2023? Dr Lim Whui Whui Associate Consultant, Obstetrics ＆ Gynaecology, Singapore General Hospital answers those questions in this article.
1. Is there any way to prevent or remove fibroid naturally? How would the size of cyst or fibroid impact/affect the chance of pregnancy?
As the cause of fibroids are currently unknown although they do carry a genetic component to it (i.e. if you have a family history of fibroids, then you will be at a higher risk of getting them as well), there are no clear ways to prevent fibroids from forming or removing them naturally. Your lifestyle may affect fibroid formation and hence sticking to a healthy diet and exercise may help reduce your risk of getting fibroids. However, the good news is that most fibroids do not cause symptoms and will not need to be removed surgically.
The location of the fibroid plays a large part in whether it impacts fertility – if the fibroid grows into the uterine cavity or on the uterine lining and distorts it, it can affect implantation of the embryo. Large fibroids that grow in the muscle of the uterus may also play a part in reducing implantation rates and hence fertility.
Cysts generally do not affect fertility especially if they are functional cysts which are part of our menstrual cycle. However, endometriosis which causes endometriotic cysts can affect fertility through various mechanisms, such as distortion of the pelvic anatomy, reducing egg quality and causing an inflammatory response.
Women who undergo multiple surgeries for large cysts may also experience a reduction in egg quantity through the inadvertent removal of ovarian tissue during the surgery. This can lead to subfertility.
2. Will ladies with a high body fat percentage (but normal BMI) affect fertility?
Hormonal balance is very important for the regulation of your menstrual cycles. Having a body fat percentage which is too high can result in a hormonal imbalance and insulin resistance. These cause your menstrual cycles to become irregular and hence ovulation is affected, resulting in fertility issues. A high body fat percentage can also increase your risks of getting other conditions such as diabetes and cardiovascular diseases. Likewise, having too low a body fat percentage will result in changes such as irregular or a cessation of your menstruation. Hence, it is important to maintain a healthy body fat percentage.
3. Do bad cramps that occur during menstruation a concern, and if it reduces the chances of getting pregnant?
Cramps during menstruation, otherwise known as dysmenorrhea, can be due to a primary or secondary cause. A primary cause is the contraction of muscles and blood vessels in the uterus caused by natural chemicals in the uterus lining. A secondary cause is due to medical conditions such as endometriosis and adenomyosis.
Depending on the reason behind your painful cramps, your fertility may be affected. Endometriosis (where endometrial tissue grows outside the uterus) may result in reduced fertility from a distortion of pelvic anatomy and other mechanisms. Adenomyosis (where endometrial tissue grows into the muscular wall of the uterus) can alter endometrium receptivity and reduce embryo implantation rates. If the cramps are affecting your quality of life, you should definitely seek advice from your gynaecologist.
4. Is it better to remove small polyps before IUI?
The effect of asymptomatic endometrial polyps (polyps growing on the lining of the uterus) on fertility is still unclear. However, depending on their size, number and location, they may cause some interference to sperm transportation, embryo implantation and endometrial receptivity. Your fertility specialist will be able to advise on whether to remove the polyps, if necessary to do so, prior to IUI or any other fertility treatments.
5. How do I track my ovulation if I have PCOS and irregular periods?
If you have irregular periods from PCOS, it can be very difficult to track your ovulation. Ovulation kits test for a raised level of a hormone, called Luteinizing Hormone(LH), during your menstrual cycle. In some women with PCOS, their baseline LH may already be high and hence a false positive result may occur. It will also not be feasible to do daily testing if your periods are spaced further apart. The best way to get pregnant should you have PCOS and irregular periods would be to have regular sex every 2 to 3 days to ensure the highest probability of the sperm meeting the egg should ovulation occur. If you are unsuccessful after 6 months, it is worth visiting your fertility specialist to obtain ovulation induction medications like letrozole and clomifene to help you ovulate.
6. How does letrozole help with fertility for ladies with PCOS?
Women with PCOS may not be able to ovulate and release an egg regularly. Letrozole can be used as an ovulation induction medication by blocking oestrogen production. This causes the body to react by releasing higher levels of another hormone called Follicle Stimulating Hormone (FSH). FSH will then stimulate the follicles in the ovary to develop and mature, eventually leading up to ovulation.
7. Will exercises such as jogging or jumping affects implantation?
There have not been any studies proving that exercises which as jumping or jogging affect implantation. Exercising however can help relieve stress and anxiety which has a negative impact on fertility. However, if you have just undergone IVF, caution should be placed on strenuous activities as the ovaries are enlarged from stimulation drugs and can twist upon their blood supply resulting in an emergency called ovarian torsion.
8. Is taking anti-depressants safe while trying to conceive? Will it affect fertility or hurt the chances to conceive?
There are a wide range of anti-depressants available, with different potential side effect profiles depending on the dose and duration of treatment. Some medication may cause a dysfunction in the hypothalamic-pituitary-ovarian (HPO) axis which causes menstrual irregularity and hence, problems with ovulation and fertility. Some studies have also shown that certain anti-depressants like the selective serotonin reuptake inhibitors (SSRIs) may affect certain sperm parameters, but this is usually short-term and reversible. Whether these changes in sperm parameters translate to a lower fertility rate is still unknown. Other studies on the other hand, demonstrate that the use of SSRIs do not affect fertility outcome in those undergoing IVF, and that the pregnancy rate for those on treatment and those without, is not significantly different.
Overall, data is sparse and much research still needs to be conducted to gain a better understanding on the impact of anti-depressants on fertility. However, it is important that mental health problems are well treated during and after pregnancy as this can affect both you and your baby’s well-being and bonding. Depression and anxiety may also worsen after pregnancy and hence it is important to continue your regular medication and attend regular checkups with your doctor. Do not stop your medication suddenly and if you are unsure whether the medication you are on affects your fertility or pregnancy, it is important to seek pre-conception advice from your doctor or gynaecologist.
9. What vaccines should the women get before getting pregnant?
Before getting pregnant, it is important to make sure your vaccinations are up to date. It is worth checking your rubella and varicella-zoster virus (chickenpox) immunity prior to pregnancy so that you can get your Mumps, Measles and Rubella (MMR) vaccination and chickenpox vaccination respectively. This is important as you should not get pregnant for 4 weeks after receiving these vaccines.
10. What supplements should women take to improve egg quality? Can you provide the recommended dosage?
Based on current available evidence, it is not known whether supplements play a large role in improving egg quality. Co-enzyme Q10, an antioxidant agent, can play a role in protecting the oocytes from oxidative stress. The recommended dosage varies according to the formulation and there is controversy regarding the right dosage and formulation for fertility indications. Some studies have also shown that for women undergoing IVF with a poor ovarian reserve, DHEA at a dose of 25mg three times a day may improve prognosis. In women with PCOS, myo-inositol may help to improve insulin sensitivity and hormonal balance, allowing ovulation to occur.
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