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Dr. Jones: The mammalian miracle of growing babies inside you is amazing. Yeah, that's a lot of M's in one sentence, but what do we know and what don't we know about implantation? And what do couples do and doctors do to try to make it work better?

Announcer: Covering all aspects of women's health, this is the "Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: In humans, eggs are sort of squished out of the follicle, and that's the cyst that has the egg in it in the ovary when ovulation occurs. Okay. It usually works. It's not too hard to understand, and we can study it in other mammals like lab mice. The fallopian tube picks up the egg, which is surrounded by a cloud of sticky cells, and moves the egg and its cells into the tube. Okay. I got that.

Sperm, which were deposited in the vagina, swim up the cervix, uterus, and out the tube and meet the egg. Okay. That seems hard and a long way for the tiny guys, but there are so many of them. The egg and sperm recognize each other as human, and only one sperm gets in the egg. Now, that's amazing, and there are so many of them. And the egg gets fertilized.

Okay. We understand that mostly, and we can watch it happen in the IVF lab with human eggs and sperm. We do know that a lot of eggs and sperm and a lot of fertilized eggs are not normal, so there are lots of time that the process doesn't go much farther than this. But if things are normal enough, the fertilized egg starts to divide, wanders down the fallopian tube with a little help of tiny little fingers on the cells of the fallopian tube and arrives in the uterus at the time that the embryo has developed enough to have over 100 cells and specialized cells that can settle into the uterus lining and start to burrow under the lining. And, after that, we really don't have a clue as to what happens at all.

The human process of implantation is not necessarily like mice or cows. We actually are much less efficient. Removing the uterus of women at various stages of implantation to study what's going on is not going to be done. The primates that we share our genes and our reproductive biology with are increasingly rare and are protected from this kind of research. Implantation, the process of the embryo burrowing under the uterus lining, capturing some of the blood supply of the uterus lining, and growing enough to make a placenta, which then grows to feed the embryo and fetus, is mostly a mystery.

It is thought that about one in five fertilized eggs goes on to make a baby to viability in fertile couples. In infertile couples, it doesn't happen that often, and sometimes we don't know why or what to do about it. So many couples who are not getting pregnant move to in vitro fertilization. It is thought about 1% of all the babies born in the U.S. were conceived with IVF, and that makes about a million babies in the U.S. over the years. Hundreds of thousands of cycles of IVF are done each year in the U.S. But you can put lovely looking embryos into the uterus of a woman and not get pregnant for no good reason.

This leads doctors and patients to try to come up with strategies to increase the chance of implantation. In the old days, we had a woman in bed tipped upside down for a day after putting the embryo in her uterus with hopes that it wouldn't fall out. Then we had women rest for hours, then an hour, then 15 minutes, and then not at all because randomized trials showed that laying down flat after an embryo transfer didn't seem to make a difference in implantation. Some people have tried acupuncture with the hope that it might help implantation through some ancient wisdom that we understand about as well as we understand implantation. Randomized trials showed that acupuncture didn't work better than fake acupuncture and implantation, but doctors and patients were desperate to make this very expensive and life-consuming process work.

Some years ago, someone came up with the idea that if you disrupted the uterus lining the month before IVF, maybe it would cause a reaction in healing that might increase the chance of implantation. Given that we have no clue about implantation, it seemed like an idea. And some early studies suggested it might have a small effect, increasing the likelihood that the embryo would successfully implant and grow. Now, this isn't like gardening where you scratch the earth and then put the seeds down in hopes that they will grow better than just dropping the seeds on the ground, although it sort of sounds like that.

The endometrial disruption called endometrial scratching actually happens the month before the IVF cycle. It can be done in several ways, but the most common is to put a small tube with a sharp edge at the tip into the uterus, through the cervix, and move it around back and forth, sort of scuffing up or scratching the uterus lining. So does it work? Some people thought it did. Some studies suggested it might, and patients and doctors were desperate.

In a widely read medical journal, the "New England Journal of Medicine," a large randomized trial of endometrial scratching versus no scratching before an IVF cycle reported that it didn't help. There was no difference. Not exactly a surprise. At least it didn't hurt. Well, actually, it did hurt. Putting a tube in the uterus and swirling it around is uncomfortable to most women. And for doctors who charge for this procedure, it could be 200 to 600 bucks, so scratch that. Well, no, don't scratch that.

Lots of things have been tried. Word gets out on the web, and patients request some intervention or another that might increase the chance of getting pregnant. I will admit to some magical thinking of my own that I did after putting embryos back in the uterus of patients undergoing IVF in my years as an IVF doctor. There are a couple of minutes between putting a tiny drop of fluid with embryos, or better one embryo, into the top of the uterus. And when the embryologist in the lab checks the tube and makes sure that the embryos are gone, it's a couple of minutes. I would practice deep breathing and imagine the embryo in the uterus happy and implanting, and growing, and seeing children at our IVF picnic. I didn't tell patients that I did this little exercise, but it seemed like a good use of a few quiet minutes. Magical thinking. What I really wanted was some kind of tissue super glue, but somebody actually tried that, and it didn't work.

So what do we do when we don't know what to do? The world of infertility and early pregnancy loss has been filled with well-meaning therapies to try to help people have the children that they hope for. Most, at least, haven't been harmful -- acupuncture to increase IVF implantation, aspirin to prevent miscarriage, and many others. But before we suggest it or offer it to patients who want it, we should at least know that it won't hurt physically, emotionally, or financially. Large, well-done randomized trials are very expensive, and in the IVF world, usually not funded by our government, but they need to be done. As patients and consumers of reproductive health care, we should try to get the best information from our physicians and take a deep breath and do the best we can. And thanks for joining us on The Scope.

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My patients tell me that they've had an ovarian cyst. "What kind?" I ask. "I don't remember," is the common answer. Well, that's not a helpful answer.

Ovarian cyst comes in two flavors, functional cysts and nonfunctional cysts. Functional cysts are usually the good kind. They arise from the function of the ovary. A woman who ovulates makes a cyst about one inch in diameter every month. And there are a lot of smaller cysts every month that go along for the ride. These functional cysts come in two types. Follicular cysts that have the eggs and corpus luteum cysts that the follicular cyst turns into after ovulation.

Now the Follicular cyst is filled with clear fluid, doesn't have much of a blood supply, and occasionally can get pretty big, as big as four inches. Getting that big isn't common, but it happens. And unless there's a lot of pain with this big cyst, the important thing is to leave it alone. These cysts go away after a few weeks. How do you know if you have one? Well, every woman with functional cysts has these, and they usually don't know about them unless they're getting an ultrasound for some reason.

We watch these cysts grow with great interest and hope in infertility therapy and in vitro fertilization. Sometimes a woman can learn she has one because it becomes bigger and causes pain. Follicular cysts can look a certain way on ultrasound, clear fluid, with a very thin cyst wall. So we know for pretty sure that these are good cysts, and we try to wait and let them go away.

After ovulation, the follicular cyst becomes a corpus luteum cyst. This is a progesterone factory whose job it is to make the hormones to prepare the uterus for pregnancy. If no pregnancy occurs with the ovulation, then these cysts go away in about two weeks. These cysts are very active making hormones, and they have a rich blood supply. If they get bumped, and you can figure out ways that they could get bumped, they can bleed and grow rapidly with blood and can hurt.

Women who have a corpus luteum cyst that bleeds a lot can come to the doctor or the emergency room and an ultrasound can usually make the diagnosis because they look like a cyst with new blood in it. We try not to operate and let the cyst go away on its own, which may take a month or so. Sometimes there's so much bleeding into the abdomen that it requires surgery, but we try not to operate and leave scars on the ovary if possible. So when a woman can tell me that she had a functional cyst or a corpus luteum cyst that required surgery or a follow-up, I know I don't have to worry because these are the good cysts.

Now, the bad cysts. There are nonfunctional cysts or neoplastic new tissue cysts new tissue cysts. Any of the tissues in the ovary can grow to make a cyst and some of these cysts can get big, really, really, really big. The biggest neoplastic cyst in recorded history was 328 pounds. That is really big. These cysts come in different types, depending on the kind of cells that made these cysts. Serous cysts, mucinous cysts, dermoid cysts, I could go on.

We usually operate to remove these cysts when they get bigger than two inches because they can grow and it's much easier to remove a cyst when it's two inches than when it's 20 inches or bigger, bigger, bigger. We cannot tell exactly what kind of cyst it is some of the time just by looking at an ultrasound, but we do know what it is when the pathologist looks at it. Some cysts are made out of egg tissue make hair and teeth and other kinds of tissues, and they look a certain way on ultrasound. But usually, we give them to the pathologist and let them figure it out. Why should you know what kind of cyst you had removed? Because some cysts tend to predict that you'll get another one.

Now, for the ugly. Some nonfunctional cysts are ovarian cancer. This is another reason that we remove nonfunctional cysts when they grow and look different on ultrasound than functional cysts. Ovarian cancer is not terribly common. About 10 per 100,000 women per year or a little more than 1% risk in a woman's lifetime.

Ovarian cancer has no symptoms when it's very small so it can be hard to catch early. When a cancerous ovarian cyst gets bigger, it can cause pain, and pressure and a feeling of abdominal fullness because we cannot always tell which cysts or cancerous on ultrasound. Although cancer cysts do tend to look quite different from functional cysts, we tend to want to remove cysts when they grow, and especially if we find them in women who are post-menopausal and shouldn't be making cysts.

So if you've had surgery or medical care for an ovarian cyst, you should keep a record of what kind of cyst it was. Get a copy of the report from your doctor and keep it in your medical records. Ovarian cysts come in different types, and we have different concerns, and different follow-up, for women with some cysts. In fact, any woman who has had surgery on her reproductive organs should have a copy of her operative report and pathology in her permanent medical records.

Maybe someday, we'll have a universal electronic medical record and all of it will be there for your doctor to help you. But until then, keep your own copies on file and thanks for joining us on The Scope.

updated: July 9, 2020
originally published: August 11, 2016