Conceiving Naturally After Fallopian Tube Loss

Fallopian tube loss can be an emotionally distressing occurrence, particularly when it is complicated by an ectopic pregnancy loss, a complex womens’ health condition such as endometriosis or pelvic inflammatory disease. One of the questions that many women come away asking is: how will this effect my chances of having children in the future?

The Fallopian tube is an important structure residing within the pelvic cavity – it’s role is to facilitate the movement of the ovum from the ovaries to the uterus. It is also where sperm and egg meet if fertilisation is to occur and then the fertilised egg makes its way to implant in the uterine wall.

Occasionally, some women are only born with one Fallopian tube (or only one ovary for that matter), but more commonly, some women lose their Fallopian tubes as the result of an ectopic tubal pregnancy requiring its removal, or their Fallopian tube may become blocked or scarred in the context of certain condition such as endometriosis with adhesions, or untreated chlamydia, leading to pelvic inflammatory disease. The questions is, is it still possible to become pregnant with only one Fallopian tube?

The Fallopian tube is not a fixed structure – attached firmly to the ovary and immobile. Instead, the Fallopian tube is actually a hyper mobile structure within the pelvis – with little fimbriae at the end of the tube, similar to fingers on your hand – when the ovary is ready to release an egg, the Fallopian tube fimbriae “pick up” the egg, and allow it to move into the tube.

One study revealed that there was evidence that the corpus luteum was present in the opposing ovary in 32% of pregnancies in women that had a single Fallopian tube- which indicated that the opposite ovary had released the viable egg and had been collected by the Fallopian tube even though it was not on the “same side.” [1] So that represented a 1 in 3 chance of becoming pregnant from an egg released from the opposite ovary, even with only one Fallopian tube!

If you have experienced a condition resulting in the loss or damage to one of your Fallopian tubes, the good news is, it does not have to be a barrier to conceiving naturally – and optimising your reproductive health, practicing intentional preconception care for both yourself and your partner and learning to chart and understand your cycles to supercharge your chances of conceiving. If you would like to discuss these options more, and get tailored support and advice for your situation, why not book in a Nurture consultation with the Natural Fertility Collective.

[1] Jackie A. Ross, Amelia Z. Davison, Yasmin Sana, Adjoa Appiah, Jemma Johns, Christopher T. Lee, Ovum transmigration after salpingectomy for ectopic pregnancy, Human Reproduction, Volume 28, Issue 4, April 2013, Pages 937–941, https://doi.org/10.1093/humrep/det012

Caesarean Scar Isthmocele and Secondary Infertility – are we talking about this enough? 

April is Caesarean-Section Awareness Month. In 2020, 1 in 3 babies globally was delivered by C-section, and for many a C-section delivery is a life saving procedure for mother, child, or both [1]. 

I wanted to take this opportunity to discuss one increasing trend that we have seen emerge around secondary subfertility and Caesarean-scar isthmocele – if you have had a C-section in the past, and are struggling to conceive now, or are suffering from unexplained pelvic pain or abnormal uterine bleeding, C-section isthmocele might be a condition to ask about.

Unfortunately, Caesarean section isthmocele is a condition that not many women are aware of, so it can take a prolonged amount of time to identify this as the cause of their symptoms.

What is Caesarean Section Isthmocele?

Uterine isthmocele was first described in 1995, however our awareness of its relevance in fertility and future pregnancy has only come into its own over the past few years – with much more extensive research necessary and indicated. 

Diagnosis of Caesarean section isthmocele, starts with the symptoms that a woman is experiencing – after excluding other causes of abnormal uterine bleeding, a transvaginal ultrasound and hysterosonography may be undertaken. Hysteroscopy may also be implemented, as it allows a clear view of the pouch itself, and may allow its correction [2]. 

An isthmocele is a reservoir-like pouch that has formed in the front wall of the uterus at the site of the Caesarean section scar. They are bigger than 1-2mm and are usually triangular in shape, although some will be semicircular [3]. 

These pouches may contain fluid or blood, sometimes small volumes of a few ml, up to >30ml. 

Usually, a woman with a Caesarean scar isthmocele will experience no symptoms, and these require no further treatment, even if incidentally noticed on ultrasound. Unless they are causing symptoms they do not require intervention [3]. 

The most common symptoms associated with Caesarean scar isthmocele are: 

1. Abnormal uterine bleeding – particularly dark post-menstrual spotting (in the absence of other causes),

2. Pelvic pain,

3. Secondary infertility [3].

Yes, you read that right. Secondary infertility on its own is a SYMPTOM of a underlying condition.

Secondary infertility is difficulty in conceiving following previous successful pregnancy and birth – whilst the specific rates of secondary infertility are difficult to pinpoint, it is beginning to be evident in Western countries that secondary infertility can be as high as 1 in 6, the same is primarily infertility.

Sub-fertility represents one of the serious, potential long-term impacts of Caesarean section [4]. Rising numbers of C-sections may lead to rising trends in secondary infertility, if we don’t push more research and comprehensive support in this area. Despite rising numbers of C-sections, there has been little progress in raising awareness around the effects that isthmocele may have on future fertility, or the importance of its investigation in presentations of secondary infertility.

Secondary infertility may be caused as the collected blood/fluid in the pouch may affect the quality of cervical mucus, making it inhospitable to sperm [5].

Persistence of menstrual blood in the much may also obstruct sperm transport through the cervical canal, interfere with embryo implantation and lead to secondary infertility [6]. 

The post-menstural spotting is usually due to the accumulation of blood in the pouch during menstruation, then being discharged subsequently [3]. 

Risk factors and prevention of caesarean section isthmocele

Whilst the complication is more common in women that have a retroverted uterus and in women with multiple C-sections, the exact mechanism is not completely understood. It is thought that the tissue may have reduced healing due to poor blood circulation in that area, however other factors such as the stage of labour of the C-section, the suturing technique and a few other surgical wound closure factors, may also play a role [7]. 

Other risk factors include: premature rupture of membranes, short operation time for the C-section and the extent of cervical dilatation at time of C-Section. The short operation time was taken to indicate that more time should be taken to ensure a careful and thorough approach to uterine closure post C-section [7].

Pregnancy complications in future pregnancies may include higher rates of ectopic pregnancy and lower implantation rates [7].

Caesarean Scar Isthmocele & ART/IVF

Even within the context of IVF, women with history of an existing isthmocele from previous c-section have increased risk of developing intracavity fluid during ovarian stimulation – in fact, this may happen in 40% of cases. Presence of this endometrial fluid has an adverse effect on implantation, reducing pregnancy success rates.  However, in cases where women with isthmocele did not develop intracavity fluid, success rates were comparable to women without isthmocele [8].

Treatment

In women experiencing symptoms, including secondary infertility, treatment of the isthmocele may be necessary. 

Medical and expectant “let’s wait and see” treatment are not reflected to be effective in current research. For women wishing to conceive, or planning a future pregnancy, minimally invasive surgical correction of the isthmocele generally gives the best outcome. 

Many isthmoceles can be corrected via hysteroscopic or laparoscopic repair, with a hybrid of the two options beneficial in many cases [9]. Patient outcomes appear similar across both surgical options, with improvement of pelvic pain, abnormal bleeding and secondary infertility in significant numbers after the surgical revision [10]. 

Surgical removal of the local inflammed tissue and correction of the pouch through a minimally-invasive method can improve pelvic pain, abnormal bleeding symptoms and has been demonstrated to restore fertility in many cases [6]. 

In one very small study of hysteroscopic correction of symptomatic isthmoceles:

  • 42.8% of the participants became pregnant within 6-8 months post-surgery [2]. 
  • In another small study, 91.7% of the participants who wished to conceive did so, including 60% of those with secondary infertility. 45% of these pregnancies carried to term and had successful deliveries both via C-section and VBAC [10].  

With so many births happening via C-section, having full and frank discussion about the possibility of Caesarean Isthmocele in cases of unexplained secondary infertility can be a fruitful and viable option for many women, with minimally invasive revision a helpful option.

Charting and understanding your cycle will provide valuable additional insight into the potential for caesarean scar isthmocele, with correlation between unusual post-menstrual spotting and cyclical pelvic pain becoming clear through cycle tracking. Insight from a qualified fertility awareness educator will also help to identify and rule out any other potential barriers to conception and help you to optimise your fertility and reproductive health, irrespective of caesarean scar isthmocele. We signpost to minimally invasive surgeons in these cases also.

You can learn more about our fertility course and personalised support here: Conceiving: Naturally.

Have questions regarding this article? Or seeking personalised clinical support in this area? Please reach out to us via our contact page! We’d love to hear from you.

Reference List 

  1. Cesarean Section Awareness Month, https://www.preventaccreta.org/cesarean-awareness

2. Carrillo de Albornoz, A.V., Carrasco, I.L., Pastor, N.M., Blanco, C.M., Matos, M.M., Pacheco, L.A., Bartolome, E.M. (2019). Outcomes after hysteroscopic treatment of symptomatic isthmoceles in patients with abnormal uterine bleeding and pelvic pain: a prospective case series. International Journal of Fertility and Sterility, 13(2), 108-112. 

3. Park, IY., Kim, MR., Lee, HN., Gen, Y. (2018). Risk factors for Korean women to develop an isthmocele after a cesarean section. BMC Pregnancy & Childbirth, 18(1).

4. Sandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, Gibbons D, Kelly NM, Kennedy HP, Kidanto H et al. (2018) Short-term and long-term effects of caesarean section on the health of women and children. The Lancet, 392:1349–1357.

5. Van der Voet, L,F., Bij de Vaste, A.M., Veersema, S., Brolmann, H.A., Huirne, J.A. (2014) Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. British Journal Of Gynaecology, 121 (2), 236-244. 

6. Florio, P., Filippeschi, M., Moncini, I., Marra, E., Franchini, M., Gubini, G. (2012). Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility. Current Opinion in Obstetrics & Gynecology, 24(3), 180-186.

7. Setubal, A., Alves, J., Osorio, F., Guerra, A., Fernandes, R., Albornoz, J., Sidiroupoulou, Z. (2018) Treatment of uterine isthmocele, a pouchlike defect at the site of a cesarean section scar. Journal of Minimally Invasive Gynecology, 25(1), 38-46.

8. Lawrenz, B., Melado, L., Garrido, N, Coughlan, C., Markova, D., Fatemi, Hm. (2020). Isthmocele and ovarian stimulation for IVF: considerations for a reproductive medicine specialist. Human Reproduction, 35(1), 89-99.

9. Vervoot, A., Vissers, J., Hehenkamp, W., Brolmann, H., Huirne, J. (2018). The effect of laparoscopic resection of large niches in the uterine caesarean scar on symptoms, ultrasound findings and quality of life: a prospective cohort study. British Journal of Gynaecology, 125(3), 317-325.

10. Enderle, I.,Dion, L., Bauville, E., Moquet, PY., Leveque, J., Lavoue, V., Lous, ML., Nyangoh-Timoh, K. (2020). Surgical management of isthmocele symptom relief and fertility. European Journal of Obstetrics & Gynaecology & Reproductive Biology, 245. 

The Pill, lean muscle development & fertility awareness: could contraception be impairing your gains?

Muscle mass growth and the Pill: could contraception be impairing your gains?

It’s no secret that hormonal contraception can impact the body in a variety of ways. While some women may experience positive impacts from birth control, others are left with less than desirable side effects.

If you’re on the pill or another form of hormonal birth control, did you know that it could be negatively impacting your muscle growth?

That’s right, your contraception could be impairing your gains!

The Pill and muscle gains

The Pill may affect your muscle gains by affecting fat metabolism. It’s been shown that the Pill can alter energy levels, and this can slow down fat-burning. An insulin-like growth factor (IGF-1) is known to help build muscle, but the Pill can lower its production, as well as lowering estrogen and testosterone production. What’s more, the Pill can also interfere with growth hormone release—one of its main functions is to stimulate muscle growth. All of these factors combined means that the Pill could potentially have a negative impact on your muscle mass development.

The Pill, training and fitness

The Pill is no stranger to controversy. For example, there’s the long-standing speculation that hormones in birth control could lead to weight gain (which we’ve debunked with science). But one of the most common complaints you’ll hear from women who use oral contraception is that they notice a dip in strength, muscle mass, and general fitness levels after starting the pill.

While it can be difficult to separate out the effects of birth control from all the other factors that influence your training—like diet, stress and sleep—we wanted to find out if there’s any truth to this particular claim. We looked at the evidence to find out what kind of impact hormonal contraceptives can have on your fitness levels and how you might be able to minimise them.

If you’re serious about building muscle, some forms of hormonal birth control could be holding you back.

If you’re a female athlete, training with weights can be a crucial part of your fitness routine. Strength training is essential for building muscle mass and optimising your metabolism. Women need to maintain muscle mass as they age to avoid osteoporosis, frailty, and sarcopenia (loss of muscle mass). The ability to build muscle also declines as we age.

Interestingly a study released last year demonstrated the impact of hormonal contraception on lean muscle mass might be more profound than we have previously realised. It compared two groups of women both on and off hormonal contraception over a 10 week strength building program. The women that were taking hormonal contraception had significantly lower lean muscle mass gains, and higher levels of cortisol (the stress hormone), as well as lower levels of IGF-1.

The reason for the impairment of muscle growth appears to be related to the Pill impairing the anabolic and catabolic hormones that regulate muscle development, and possibly the effects of synthetic progestin on androgen receptors.

“Oral contraceptive use impaired lean mass gains in young women after RET and was associated with lower DHEA, DHEAS, and IGF-1 and higher cortisol”

Reichmann & Lee, 2021

The pill or other hormonal contraceptives may not be suitable for all women who want to build lean body mass or get serious about their fitness. The first step is to evaluate your goals and what you are hoping to achieve with exercise and proper nutrition while taking oral contraception or other types of hormonal birth control. Some forms of contraception could affect gains if you have specific fitness or health goals.

Natural birth control

If you’re concerned with how your birth control may be affecting your muscle mass, it’s important to understand the benefits of non-hormonal contraception. These are methods of avoiding pregnancy that don’t require a prescription or implantation, and they can help you understand and embrace your cycle with no side effects. To begin with, there are two primary types of natural birth control: barrier methods, which prevent sperm from entering the woman’s body (such as condoms), and fertility awareness-based methods, which involve tracking fertile biomarkers and ovulation, so that you know when not to have sex, or to use a barrier method.

These options may seem less convenient than popping a pill or having an IUD implanted in your uterus, but for those who want more control over their hormonal health without any added chemicals like estrogen and progestin from synthetic HBCs, these options may be empowering.

To learn more about the Symptothermal Method of Fertility awareness for contraception, check out our free resources or our comprehensive course Contraception: Naturally.

References

  • Riechman SE, Lee CW. Oral Contraceptive Use Impairs Muscle Gains in Young Women. J Strength Cond Res. 2021 May 14. doi: 10.1519/JSC.0000000000004059. Epub ahead of print. PMID: 33993156.