Search for tag: "uterus"

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

Dr. Jones: As human beings have evolved, our big brains evolved to be bigger than our pelvis has evolved to be bigger. So births have become a little harder with a few more long-term consequences for women. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Healthcare and this is the scope of the problem of getting the baby out.

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: It has clearly been an advantage for humans to have a big brain. So with the big brain comes a big head. Today in The Scope studio I'll be talking to an expert on the pelvic floor, Dr. Ingrid Nygaard. She is a professor at the University of Utah and a urogynecologist, a gynecologist who specializes in pelvic floor problems. So what is the pelvic floor really? Not something you scrub with Ajax or something but give it to us.

Dr. Nygaard: No, definitely not. It's one of those important structures that we appreciate only really when it's not functioning as well as we wish it would. The pelvic floor is made up of the muscles, ligaments, connective tissues and nerves that support our internal organs, like the bladder, the uterus, the vagina, rectum. The pelvic floor muscles run from your pubic bone at the front to the base of your spine at the back. They're shaped like a sling and they hold your pelvic organs in place.

Dr. Jones: So it's kind of like a sling or a hammock but you don't want it too sling-y. You don't want it too hammock-y. You want it to be strong. So all these muscles and connective tissues keep our insides in. What happens when a baby comes out that way?

Dr. Nygaard: Well, as you can probably imagine, to allow the baby to pass through, the structures in the pelvic floor all have to stretch quite a bit. Luckily our body starts preparing for this long before labor even starts. But the pelvic floor muscles sometimes weaken after childbirth and then they weaken further as we get older.

Dr. Jones: Well, women give birth vaginally all over the world but why do some women have problems after vaginal birth and some don't?

Dr. Nygaard: Well, we know that weakened or dysfunctional pelvic floor muscles can cause problems down the road, like bothersome leakage of urine or pelvic organ prolapse where one or more of the pelvic organs bulges into the vagina. But for most women these conditions don't happen until they're middle aged or older. We don't know very much about how young women experience changes in their pelvic floor function after childbirth. It's probably fair to say that most women notice some minor changes after giving birth but the fact that most women who deliver vaginally don't have long lasting problems speaks, I think, to how amazing our bodies really are.

Dr. Jones: So as young women they may have the original insult or the original maybe even damage but that really doesn't show up until ageing and gravity and time adds its little mix to the potion. Is that how it goes?

Dr. Nygaard: Right exactly.

Dr. Jones: Right. So if women have a problem after vaginal birth, could it get better on? And so you're suggesting that these they don't notice it or maybe it gets better on its own?

Dr. Nygaard: No, absolutely it could get better on its own. A lot of processes go on in our bodies that encourage healing and recovery after childbirth. Over the first couple of months for example, the uterus goes back down to normal size and the pelvic floor muscles start regaining their strength, and this means that symptoms that some women notice after childbirth often go away within a few months. If it doesn't get better, is there anything we can do to help? Well, we're lucky that time alone helps many women recover well after childbirth but we don't know very much about other factors that might help women recover well after vaginal delivery. But one thing women can do to help get the pelvic floor back in shape after delivery is pelvic muscle exercises. Some people call those Kegel exercises. I encourage women who notice some urinary leakage for example, to do these. It's a good idea to have someone give you some guidance to make sure you do these correctly and effectively, and a great resource for this is a women's health physical therapist and you can also ask your doctor or nurse for tips.

Dr. Jones: Oh and they're really easy to do. I just did them. I can do them while I'm even talking on The Scope radio right now and I don't have to hold my breath and my face isn't getting red.

Dr. Nygaard: It's not getting red.

Dr. Jones: But someone in the studio is kind of laughing. Oh, okay, well let's talk about does childbirth cause any problems over the long-term? We talked about that a little bit.

Dr. Nygaard: Well, over the course of her lifetime about one in five women undergoes treatment, often surgery, for pelvic floor disorders. Childbirth is one thing that can contribute to this but there are many other factors too from ageing to nerve problems like strokes to obesity and genetics plays a role as well.

Dr. Jones: I read somewhere that female paratroopers had a little more prolapse but that's just an aside. So what kind of research are you involved with regarding these problems in childbirth?

Dr. Nygaard: That's amazing to consider the fact that even though nearly four million women deliver baby in the US every year, most of them vaginally, there really hasn't been much research about how to maximize recovery after childbirth in terms of pelvic floor health. So we are conducting a study called the MAPH study, which is short for Motherhood And Pelvic Health, and the goal of the study is to find out what we can recommend to help women recover well after vaginal delivery. We're specifically looking at how things like physical activity, intra-abdominal pressure and muscular strength influence pelvic floor support and symptoms during that first postpartum year. We see this research as an important step in crafting prenatal and postnatal regimens that will promote better pelvic floor health. We're planning to enroll about 1,500 women across the Salt Lake Valley. Our participants are all first time new moms and we're so grateful to them for lending us their time and involvement to help us learn about pelvic floor health after childbirth.

Dr. Jones: So for those of you who are still having babies or about to have your first, the good news is that it goes mostly just fine and for you ladies who have some long-term consequences of getting those babies out, there's hope and there's help, and thanks for joining us on The Scope.

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Interviewer: You are about to go into labor, your husband's nowhere to be found, you can't get to the hospital in time. What do you do? We'll tell you coming up next on The Scope.

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

Interviewer: We're here with Dr. Kirtly Parker Jones. I'm sure that if you're about to give labor at home with nobody there to help you or you're stuck in an elevator or somewhere, you're not going to pull out the internet and listen to this podcast. You know, to conscience people, what can women do who are about to go into labor?

Dr. Jones: About to give birth.

Interviewer: About to give birth. There we go, labor's different. About to give birth, with nobody around to help or inexperienced people around how to help

Dr. Jones: There are those women who have very rapid labors and lucky for them, but it is a little scary. Some women who have 15 minute labors or they have their first contraction and then they have their second contraction and then all of a sudden they feel the baby coming. Now this is not something that usually happens to first time moms. It's more likely to happen to women who've given birth before, meaning the pathway through the pelvis has been stretched a little, the baby can come out a little faster.

Interviewer: Now you've mentioned that, I remember my mom because I was about six when she had my little baby brother and she literally had the baby, she literally had him in the elevator. But she was surrounded by people. They were rolling her into the delivery room and he just came out before they even got there.

Dr. Jones: You got her on a stretcher, so at least she's lying down. The baby is not going to fall on the floor.

Interviewer: Doctor's with her.

Dr. Jones: Let's say you have fast labors and you feel your water break and you have your first contraction and then you know the baby's coming. Maybe you have time to grab your phone for 911, but the first thing is, don't try to get in the car and drive. Just don't do that.

The first thing is to get at ground level. Could be a bed if you want to or it could be the floor. If you're going to give birth that fast, it's often that you've had a baby before and that's a good thing. The baby is not going to get stuck. If you feel the baby is coming, then the head is already on the pelvic floor. It is way down.

Interviewer: It is less pain for you.

Dr. Jones: You know have the urge to push, that baby is on its way. That's the good news and the urge to push is uncontrollable. What do you need to do? First of all, the baby is going to come out. The baby is coming out you can, when the baby is out, you'll know the baby is out. The placenta isn't out yet.

But what you really need to do is to have some kind of cloth or a towel so that you could wipe the baby dry because if it's chilly, and the baby is wet, which it will be, then it will get cold. You want to dry off the baby and then put the baby skin to skin with you. It is not your job and you should not pull on the placenta. Hopefully you're not going to be there by yourself for the next three days.

Interviewer: Hopefully not.

Dr. Jones: Hopefully that's not going to happen.

Interviewer: Maybe 30 minutes.

Dr. Jones: The placenta itself is a very risky time for mom. With the baby, it's risky for the mom and the baby if the baby gets stuck. But of course it's not getting stuck if the baby is on its way and then we worry about the placenta coming out. But the best thing to do would be to actually dry the baby off if you can.

If you've got a towel, put the baby skin to skin on your chest. If you want, you can put the baby to your breast. The baby, if he's breathing well or if she's breathing well, may actually grab onto a nipple and suck a little bit.

Interviewer: That early?

Dr. Jones: Yes, and that would be great because it will help your uterus contract. Stimulation of the nipple releases oxytocin, which makes your uterus contract. And that's really what you want to expel the placenta. You need to wipe the baby off, put it skin to skin. If the baby isn't breathing, then you can give a little spank if you want to.

Interviewer: Just to hear it cry.

Dr. Jones: You can give it a blow in the face, that sometimes can stimulate a baby to breathe. If the baby is really tiny then that's even more important that it keep warm. And you can breathe in the baby's nose or face, put your mouth over the baby's nose or face and give it a little breath if it's not breathing. But mostly the issue is getting it close and warm.

Get down, get comfortable. The baby's going to come, lucky you, unfortunately. Put the baby to breast if you can and that will help the uterus contract. People do this all over the world. Babies that come out too fast are probably better than babies that get stuck.

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Dr. Jones: When is a human uterus like a horse or a cat uterus? Well, it's not, except when it is. This is Dr. Kirtly Jones from obstetrics and gynecology at the University of Utah Health and we're talking about uterine anomalies today on the Scope.

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: The human uterus is shaped sort of like a light bulb, the old-fashioned kind. The metal part at the bottom is the cervix, which keeps the uterus anchored in the pelvis and keeps the baby in. The bulb part is the actual uterus. Inside the bulb is the uterine cavity where the baby grows and it's normally shaped like an upside down triangle. Two corners at the top of the triangle point into the fallopian tubes and one corner points down into the cervix. The uterine cavity is flat like an envelope until it's filled with the pregnancy.

Congenital uterine anomalies, malformations of the uterus that occur during fetal development, are common. About five percent of women, one in 20, will have some kind of uterine abnormality. Although many women have a uterus that slightly abnormally shaped and they may never know about or have any problems. Some uterine shapes can cause recurrent miscarriages or premature births or infertility.

Rarely, about one in 5,000, women have two uteruses and two cervices and two vaginas and about one in 1000 women have no uterus, no cervix, and no vagina. Understanding how the uterus develops is helpful here. In human and mammal development, there are two tubes that come together in the pelvis. These two tubes fuse together at the lower end and the middle of the fuse two tubes dissolves to make one uterine cavity and one cervix with the two fallopian tubes at the top.

Now, this is something that's really better on video than audio. So let's do an experiment. Imagine yourself taking two foam tubes, one in each hand. The kind of floppy foam tubes. So you're holding these foam tubes, you bring your hands together and the foam tubes in your hands at the lower part of these tubes fuse and the upper parts are kind of floppy on the sides. Those are the fallopian tubes so where they fused together, that makes the uterus.

Now if that fusion doesn't happen normally, if you got those two foam tubes in your hands, you get to uteruses and two cervices. If at all fuses and dissolves, your hands come together and you get no uterus or cervix. If it fuses but doesn't dissolve completely, you can have a uterus that's Y shaped with two horns or uterus with the wall down the middle.

Men, by the way, had these two tubes when they were developing but males make a chemical that makes the entire uterine system disappear well before they're born. That's why guys don't have a uterus.

Women without a uterus or cervix don't have periods so that's usually discovered when they're teenagers. We want to end with just a little dent on the top of the triangular uterine cavity, like horses, have about we call arcuate uterus or heart-shaped uterus and they may never know it as it doesn't cause problems.

Women with the Y-shaped uterus, we call it bicornuate, and that's the normal shape for mammals to have lots of little babies like cats, may find out that this is the uterus when they have premature babies. Women with the wall in the uterine cavity, called a septum, may find out that they when they have recurrent miscarriages.

There are many other less common uterine anomalies, but what do we do about this? Well, the majority of women with uterine anomalies have no problems except with pregnancy. We don't recommend that all baby girls or young women have imaging of the uterus to find out if it's normally shaped or not.

Some women find out that they have an abnormally shaped uterus when they have a cesarean section, maybe for a breech baby, and an abnormally shaped uterus is more likely to lead to a breech presentation of the baby.

Women who have had a very premature baby for no good reason may be advised to get imaging of their uterus. Depending on the problem, this might be done with a special kind of ultrasound or an X-ray that puts a special fluid in the uterus so the uterine cavity can be evaluated on a screen or an MRI.

Women with recurrent miscarriages usually get some kind of imaging to see if they might have a septum or wall down the middle of their uterus. The good news is that reproductive medicine specialists can surgically remove this wall with excellent results for the next pregnancy.

If someone has a uterine anomaly, what kind of doctor should they see? At the U, we have a team of reproductive endocrinologists, specialists in reproductive problems, who often team up with our high-risk pregnancy specialists to work out a plan for each woman and her uterine problem.

Surgical correction of the problem is often is an option. When there's no way to correct the problem, we often talk about gestational surrogacy where we use someone else's uterus to carry your biological baby, which we can do at the University of Utah Hospital in our Center for Reproductive Medicine.

Human development is amazing and interesting and, of course, I think the reproductive system is the coolest. But when things don't go exactly right, there are specialists who have experience and probably they can help you out. And thanks for joining us on The Scope.

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