Noninflammatory disorders of the uterus

Disease Description (Causes and Symptoms)

• Definition summary: Noninflammatory disorders of the uterus collectively refer to uterus-related problems caused by factors other than inflammatory diseases, mainly including recurrent miscarriage, infertility (female factors), and complications related to assisted reproductive technology (ART).
• Main causes and pathophysiology
  • Recurrent miscarriage: Consecutive pregnancy losses (generally two or more before 20 weeks of pregnancy, or three or more according to some guidelines), often with no clear cause. Possible causes include chromosomal abnormalities (such as a balanced translocation in either partner), immunological abnormalities (such as antiphospholipid antibodies), endocrine abnormalities (thyroid function and progesterone deficiency), uterine structural abnormalities (uterine malformations and adhesions), cervical insufficiency, and congenital or acquired abnormalities.
  • Female infertility (noninflammatory origin): Possible causes include ovulatory disorders (anovulation), intrauterine structural abnormalities (uterine fibroids, polyps, and congenital uterine malformations), cervical mucus abnormalities, tubal dysfunction and obstruction (tubal occlusion or stenosis), hormonal abnormalities (imbalances in thyroid and ovarian hormones), and other systemic or medical conditions.
  • Complications related to assisted reproductive technology (ART): Infection, ovarian hyperstimulation syndrome (OHSS), problems related to intrauterine embryo transfer after in vitro fertilization, and the risk of multiple pregnancy.
• Main symptoms
  • Repeated pregnancy loss (recurrent miscarriage) and inability to maintain a pregnancy
  • Difficulty becoming pregnant (no pregnancy after trying for more than one year, with age-based criteria applied)
  • Symptoms of complications after ART, such as abdominal pain, abdominal distension, bleeding, and fever

Treatment Methods

• General principles: Identify the cause and apply cause-specific treatment. When the cause is unclear, consider symptom relief and assisted reproductive technology.
• Recurrent miscarriage
  • Cause-specific treatment after basic testing (chromosome testing of both partners, antiphospholipid antibody testing, thyroid and hormone testing, etc.).
  • Chromosomal abnormalities: Consider genetic counseling and, if necessary, ART with preimplantation genetic diagnosis (PGD).
  • Antiphospholipid antibody syndrome: Combined treatment with an antiplatelet agent (low-dose aspirin) and low-molecular-weight heparin (LMWH) is standard practice (according to the physician’s judgment).
  • Uterine structural abnormalities (adhesions, malformations, polyps, etc.): Corrective surgery using hysteroscopy or laparoscopy.
  • Cervical insufficiency: Cervical cerclage (such as a cerclage clip) may be performed during pregnancy according to the indications.
  • Hormonal support: Progesterone supplementation (for the purpose of supporting treatment or maintaining early pregnancy) — used according to the indications and supporting evidence.
• Female infertility (by cause)
  • Ovulatory disorders: Ovulation-inducing agents (letrozole (letrozole/letrozole-based), clomiphene citrate, behavioral modification, and weight management). Metformin may be considered in cases related to insulin resistance.
  • Intrauterine structural problems: Resection of uterine fibroids or polyps (laparoscopy/hysteroscopy) and corrective surgery for uterine malformations (according to the indications).
  • Tubal problems: In cases of tubal obstruction or adhesions, laparoscopic adhesiolysis/reconstructive surgery or bypass through IVF (in vitro fertilization).
  • Cervical problems (mucus abnormalities): Consider intrauterine insemination (IUI) or IVF.
  • When male factors are also present, semen testing and, if necessary, concurrent treatment of the male partner.
• Management of ART-related complications
  • Ovarian hyperstimulation syndrome (OHSS): Prevention of excessive ovarian stimulation (mild stimulation protocols, use of GnRH antagonists, and adjustment of trigger medication); if symptoms occur, treatment according to symptoms, such as hospitalization, fluid and electrolyte management, coagulation monitoring, and paracentesis for ascites.
  • Infection management: Aseptic procedures and antibiotic treatment when necessary.
  • Prevention of multiple pregnancy: Reduce the number of embryos transferred (single embryo transfer is recommended), etc.
• Lifestyle management and general precautions
  • Maintain an appropriate weight (BMI management), do not smoke or drink excessively, take folic acid (before and after pregnancy), and manage stress.
  • Properly control chronic diseases (such as thyroid disease and diabetes).

Checklist Before an Outpatient Visit (Including Example Questions)

• Items to prepare
  • A list of medications currently being taken (including prescriptions, OTC medications, and herbal medicines) and recent medication history
  • Previous obstetric and gynecologic medical records (previous HSG, ultrasound, ovarian stimulation/ART-related records, and surgical records)
  • The husband’s (or partner’s) semen analysis results, if available
  • Pregnancy loss records: number of miscarriages, gestational weeks, and related tests and treatments (evaluations, surgery, and medications)
  • Recent menstrual history and whether ovulation occurs (menstrual cycle chart, basal body temperature chart, and ovulation test records)
  • Test results for existing chronic diseases (thyroid disease, diabetes, antiphospholipid antibodies, etc.)
• Information to tell the doctor in advance during the outpatient visit
  • Whether oral contraceptives were taken recently, history of surgery (related to the uterus or fallopian tubes), history of infectious diseases (e.g., pelvic inflammatory disease), and the duration and methods of attempts to become pregnant (whether IUI/IVF procedures were performed)
• Example questions (useful for patients to write down in advance)
  • "How many miscarriages have occurred recently, and what was the average timing of the pregnancies?"
  • "Prepare copies of the results of recent tests (e.g., HSG, ultrasound, and blood tests) to bring with you."

Examples of General Questions to Ask the Doctor

• "What are the possible causes in my case, based on the test results?"
• "What additional tests are recommended, and why?"
• "What are the advantages, disadvantages, and success rates of the recommended treatment options (surgery, medication, and ART)?"
• "What side effects and complications can be expected during treatment, and how should they be managed if they occur?"
• "Which lifestyle improvements could help increase the chances of becoming pregnant?"

Examples of Condition-Specific Questions

• Regarding recurrent miscarriage:
  • "How likely is it that the tests performed so far will identify the cause, and what additional tests do you recommend?"
  • "If antiphospholipid antibodies or a genetic cause is identified, how will the treatment and prognosis change?"
• Regarding infertility/ART:
  • "Given my situation (or our situation as a couple), what is the first recommended treatment, and when would IVF be necessary?"
  • "Can procedures to reduce the risk of OHSS (such as a mild stimulation protocol or embryo freezing) be used?"

(Note: The recommended tests and treatments vary depending on the individual case. The final decision should be made in consultation with the treating physician, taking into account the indications, test results, age, and other factors.)