Female Infertility

FEMALE INFERTILITY

Infertility is a disease in which the ability to get pregnant and give birth to a child is impaired or limited in some way. For man and woman (heterosexual couples), this is usually diagnosed after one year of trying to get pregnant. However, the same couple may be diagnosed sooner depending on other factors. For heterosexual couples, one third of causes of infertility are due to a male problem, one third are due to a female problems, and one third are due to combination or unknown reasons. When the cause of the infertility is found to come from the female partner, it's considered female infertility or 'female factor' infertility. These problems may include uterine fibroids, ovarian cyst, endometriosis , blocked fallopian tubes, and pelvic inflammatory disease(PID).

If a woman of reproductive age is repeatedly unable to conceive a child within a year of having unprotected intercourse or donor insemination, the condition is referred to as female infertility. A doctor might also say that a woman who gets pregnant but suffers miscarriages is infertile.

There are 2 types of infertility:

• Primary infertility - Refers to couples who have not become pregnant after at least 1 year having sex without using birth control methods.
• Secondary infertility - Refers to couples who have been able to get pregnant at least once, but now are unable.

POSSIBLE CAUSES

Getting pregnant and carrying a pregnancy to term are actually very complicated processes. Many things can go wrong during these processes that would lead to infertility. For this reason, the causes listed below includes only some of the common causes of infertility in females and therefore it is by no means all-inclusive.

Women who may be having difficulty getting pregnant or carrying a pregnancy to term should talk with their doctors about possible treatments.

Some of the possible causes may include;

• Failure to ovulate
• Problems with the menstrual cycle
• Infections
• Failure to ovulate
• Problems with the menstrual cycle
• Infections
• Failure of eggs to mature
• Implantation failure
• Endometriosis
• Polycystic ovary syndrome

• Primary ovary insufficiency
• Uterine fibroids
• Auto-immune disorders

Failure to ovulate

The most common cause of female infertility is the failure to ovulate, which occurs in almost half of women with infertility issues. Not ovulating can be resultant from several causes, such as:

• Aging, including 'diminished ovarian reserve,' which refers to a low number of eggs in a woman's ovaries due to normal aging
• Ovarian or gynecological conditions, such as primary ovarian insufficiency (POI) or polycystic ovary syndrome (PCOS)
• Endocrine disorders, such as thyroid disease or problems with the hypothalamus, which affect the hormones produced by the body so that there might be too much or too little of a hormone or group of hormones
• Life style and environmental factors
• Obesity has been linked to lower sperm count and quality in men.
• Excessive exercise is known to affect ovulation and fertility in women.
• Research shows that using body-building medications or androgens can affect sperm formation.
• Among women who are obese and who have polycystic ovary syndrome (PCOS), losing 5% of body weight greatly improves the likelihood of ovulation and pregnancy.
• Being underweight is strongly linked to ovarian dysfunction and infertility in women.
• Strenuous physical labor and taking multiple medications are known to reduce sperm count in males.2
• Substance use (e.g. smoking tobacco, using other tobacco products, marijuana use, heavy drinking, and using illegal drugs such as heroin and cocaine) reduces fertility in both men and women.
• Radiation therapy and chemotherapy can cause infertility in both females and males.

Problems with the menstrual cycle

This is the process that prepares the female body for pregnancy. The menstrual cycle includes several phases, and problems at any one of the stages can lead to difficulty getting pregnant or to infertility.

Structural problems with the reproductive system

Such structural problems usually involve the presence of abnormal tissue in the fallopian tubes or uterus. If the fallopian tubes are blocked, eggs are not able to move from the ovaries to the uterus and sperm is not able to reach the egg for fertilization. Structural problems with the uterus, such as those that may interfere with implantation, can also cause infertility.

Some specific structural problems that can cause infertility include:

• Polyps, noncancerous growths on the inside surface of the uterus. Polyps can interfere with the function of the uterus and make it difficult for a woman to remain pregnant after conception. Surgical removal of the polyps can actually increase the chances for a woman to get pregnant.
• An unusually shaped uterus, which does affect implantation and the ability to carry a pregnancy to term
• Endometriosis, when the tissue that normally lines the inside of the uterus is found in other places, especially when it blocks the fallopian tubes,
• Uterine fibroids, growths that appear within and around the wall of the uterus. Most women with fibroids do not have problems with fertility and can get pregnant, however some women with fibroids may not be able to get pregnant naturally or may have multiple miscarriages or preterm labor.
• Scarring in the uterus from previous injuries, infections, or surgery. Scarring may increase the risk of miscarriage and may interfere with implantation, thus leading to infertility.

Infections

Gonorrhea and chlamydia in women that are left untreated can lead to pelvic inflammatory disease, which might cause scarring that blocks the fallopian tubes. Untreated syphilis increases the risk for a pregnant woman to have a stillbirth.

Chronic infections in the cervix and surgical treatment of cervical lesions associated with human papillomavirus (HPV) infection can also reduce the amount or quality of cervical mucus. The presence of this sticky or slippery substance that collects on the cervix and in the vagina can make it difficult for women to get pregnant.

Failure of eggs to mature

Eggs may not mature properly for a variety of reasons, ranging from conditions such as PCOS, to obesity, to a lack of specific proteins needed for the egg to mature.

An immature egg may not be released at the correct time, thus may not make it down the fallopian tubes, and/or may not be able to be fertilized.

Implantation failure

Implantation failure refers to the failure of a fertilized egg to implant in the uterine wall to begin pregnancy. While the specific cause of implantation failure are often unknown, possibilities include;

• Genetic defects in the embryo
• Thin endometrium
• Embryonic defects
• Endometriosis
• resistance to progesterone
• Scar tissue in the endometrial cavity

Endometriosis

Current theories on how endometriosis causes infertility include the following:

Changes in the structure of the female reproductive organs may occur. Endometriosis can cause pelvic adhesions made of scar tissue to form between nearby structures, such as between the ovary and pelvic wall. This can obstruct and affect the release of the egg after ovulation. Scarring in the fallopian tube can interrupt block the egg's movement through the fallopian tube. The lining of the abdomen, which is called the peritoneum may go through changes that affect its function:

In women with endometriosis, the amount of fluid inside the peritoneum often increases.

The fluid in the peritoneum contains substances that can negatively affect the functions of the egg, sperm, and fallopian tubes.

Chemical changes in the lining of the uterus that occur as a result of endometriosis may affect an embryo's ability to implant properly and make it difficult for a woman to stay pregnant even after conception.

Polycystic ovary syndrome

One of the most common causes of female infertility is PCOS. It is a condition in which a woman's ovaries and, in some cases, adrenal glands produce more androgens (a type of male hormone) than normal. High levels of these hormones interfere with the development of ovarian follicles and release of eggs during ovulation. As a result, fluid-filled sacs, or cysts, can develop within the ovaries. Current research suggests that a combination of genetic and environmental factors leads to the disease however as at now, the exact cause of PCOS is unknown.

Primary ovary insufficiency

POI occurs when a woman's ovaries stop producing hormones and eggs at a young age. Women with POI ovulate irregularly, if they do at all. They may have abnormal levels of ovarian and pituitary hormones due to problems with their ovaries.

Pregnancy is still possible, though quite rare among women with POI who often have trouble getting pregnant.

Uterine fibroids

These are noncancerous growths that form in the inside of the uterus. Uterine fibroids can cause symptoms in some cases, depending on their size and location. Scientists do not know what causes fibroids to form, but it is widely believed that there may be a genetic basis.

Fibroids are found in 5% to 10% of infertile women actually contribute to infertility. Fibroids located in the uterine cavity as against to those that grow within the uterine wall, or those that are larger than 6 centimeters in diameter are more likely to have a negative effect on fertility.

Fibroids are more likely to affect a woman's fertility if:

• They interfere with blood flow to the uterus, which can prevent the embryo from implanting
• They change the position of the cervix, which may reduce the number of sperm that enter the uterus
• They change the shape of the uterus, which can interfere with the movement of sperm or implantation
• They block the fallopian tubes, which prevents sperm from reaching the egg and keeps a fertilized egg from moving to the uterus

Auto-immune disorders

Autoimmune disorders cause the body's immune system to attack normal body tissues it would normally ignore. Autoimmune disorders, such as lupus and other types of thyroiditis, or rheumatoid arthritis, may affect fertility. The reasons for this are not fully understood and differ between diseases, however they are thought to involve inflammation in the uterus and placenta or medications used to treat the diseases.

SYMPTOMS

Irregular periods

The average woman's cycle is 28 days long on the average, anything within a few days of that can be considered normal, as long as those cycles are consistent. For example, a woman who has a 33-day cycle one month, a 31-day cycle the next month, and a 35-day cycle after that, would still be having normal periods.

Conversely, a woman whose cycles vary so greatly that she cannot even begin to estimate when her period might arrive is experiencing irregular periods. This can be related to issues with hormones, or to polycystic ovarian syndrome (PCOS). Both of which can contribute to infertility.

Painful or heavy periods

Most women experience cramps with their supposedly normal periods however, painful periods that interfere with daily life may be a symptom of endometriosis.

No periods

It's perfectly normal for women to have an off-month here and there. Factors like stress or heavy workouts can cause one's period to temporarily disappear. But if periods disappear for months, it may be time to get one's fertility checked.

Symptoms of hormone fluctuations

Signs of hormone fluctuations in women could indicate potential issues with fertility. People should talk to their doctor if they experience:

• Problems with skin
• Reduced sex drive
• Hair growth in the Face
• Hair thinning
• Weight gain

Pain during sex

Some women may have experienced painful sex their entire lives, such women would have convinced themselves that it's normal. But it's not. It could be related to hormone issues, to endometriosis, or to other underlying conditions that could also be contributing to infertility.

RISK FACTORS

Many factors can increase a woman's risk of female infertility. General health conditions, genetic (inherited) traits, lifestyle choices and age can all contribute to female infertility. Specific factors can include:

• Uterine fibroids.
• Hormonal issues that prevents ovulation.
• Sexually transmitted infections (STIs).
• Abnormal menstrual cycle.
• Being underweight.
• Polycystic Ovary Syndrome (PCOS).
• Having a low body-fat content from extreme exercise.
• Primary Ovary Insufficiency (POI).
• Structural problems (problems with the fallopian tubes, uterus or ovaries).
• A past ectopic (tubal) pregnancy.
• Autoimmune disorders (lupus, rheumatoid arthritis, Hashimoto's disease, thyroid gland conditions).
• Excessive substance use (heavy drinking).

WHEN TO SEE A DOCTOR

After one year of unsuccessfully trying to conceive, speak with a physician. At this point, one may want to begin an infertility evaluation.

Women over age 35, should consider consulting their physicians after four to six months of trying to conceive. At that age, pregnancy is less likely to occur without fertility treatment.

DIAGNOSIS

Fertility tests may include:

Ovulation testing. A blood test for progesterone, a hormone that is produced after ovulation can also document the fact that a person is ovulating. Other hormone levels, such as prolactin, also may be checked.

Hysterosalpingography. During this test, X-ray contrast is injected into the uterus and an X-ray is taken to detect abnormalities in the uterine cavity. The test also determines whether the fluid passes out of the uterus and spills out of the fallopian tubes. If abnormalities are found, the patient will most likely need further evaluation. In a few women, the test itself may improve fertility, possibly by flushing out and opening the fallopian tubes.

Ovarian reserve testing. This testing helps to determine the quality and quantity of eggs that are available for ovulation. Women at risk of a depleted egg supply (including women older than 35) may have this series of blood and imaging tests.

Other hormone testing. Other hormone tests will check levels of ovulatory hormones as well as thyroid and pituitary hormones that control reproductive processes.

Imaging tests. A pelvic ultrasound looks for uterine or fallopian tube disease. Sometimes a sonohysterogram, is used to see details inside the uterus that cannot be seen on a regular ultrasound.

Depending on the patient's situation, the testing regime may rarely include:

Other imaging tests. Depending on the symptoms, the doctor may request a hysteroscopy to look for uterine or fallopian tube disease.

Laparoscopy. This minimally invasive surgery involves making a small incision beneath the navel and inserting a thin viewing device to examine the fallopian tubes, ovaries and uterus. A laparoscopy may identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.

Genetic testing. Genetic testing helps determine whether there's a genetic defect causing infertility.

TREATMENT

Fertility restoration: Surgery

Several surgical procedures can correct problems or otherwise improve female fertility. However, surgical treatments for fertility are rare these days due to the success of other treatments.

They include:

• Laparoscopy. If someone has been diagnosed with tubal or pelvic disease, one option is to get surgery to reconstruct the reproductive organs. The doctor puts a laparoscope through a cut near the belly button to get rid of scar tissue, treat endometriosis, open blocked tubes, or remove ovarian cysts, which are fluid-filled sacs that can form in the ovaries.
• Hysteroscopy. In this procedure, the doctor places a hysteroscope into the uterus through the cervix. It's used to remove polyps and fibroid tumors, divide scar tissue, and open up blocked tubes.
• Tubal surgeries. If the fallopian tubes are blocked or filled with fluid (hydrosalpinx), the doctor may recommend laparoscopic surgery to remove adhesions, dilate a tube or create a new tubal opening.

This surgery is rare, as pregnancy rates are usually better with IVF. For hydrosalpinx, removal of the tubes (salpingectomy) or blocking the tubes close to the uterus can improve the chances of pregnancy with IVF.

Medication.

If one has ovulation problems, she may be prescribed drugs such as clomiphene citrate (Clomid, Serophene), gonadotropins (such as Gonal-F, Follistim, Humegon and Pregnyl), or Letrozole.

Gonadotropins can trigger ovulation if Clomid or Serophene don't work. These drugs also can also help a person get pregnant by causing the ovaries to release multiple eggs. Normally, only one egg is released each month. The doctor may suggest that the patient takes gonadotropin if she has unexplained infertility or when other kinds of treatment haven't helped her get pregnant.

Metformin (Glucophage) is another type of medication that may help a woman ovulate normally if she has insulin resistance or PCOS (polycystic ovarian syndrome).

Intrauterine insemination. For this procedure, after semen gets rinsed with a special solution, a doctor places it into the uterus when the patient is ovulating. It's sometimes done while she is taking medications that help trigger the release of an egg.

In vitro fertilization (IVF). In this technique, the doctor places embryos that were fertilized in a dish into the patient's uterus.

Patient takes gonadotropins that trigger the development of more than one egg. When the eggs are mature, the doctor uses an ultrasound for guidance and collects them with a needle.

Sperm is then collected, washed, and added to the eggs in the dish. Several days later, embryos (or fertilized eggs) are put back into the uterus with a device called an intrauterine insemination catheter.

If both partners agree, extra embryos can be frozen and saved to use later.

Intracytoplasmic sperm injection (ICSI). A doctor injects sperm directly into the egg in a dish and then places it into the uterus.

PREVENTION

One can optimize the chances of getting pregnant in a number of ways.

• Exercise moderately. Do not exercise so heavily that menstrual periods are infrequent or absent.
• Review medicine prescriptions with the doctor. Some medications can affect one's ability to conceive or carry a normal pregnancy Maintain a healthy weight.
• Avoid smoking.
• Limit caffeine. High intake of caffeinated drinks may impair fertility.
• Consider following a fertility diet.

Women who do the following may have better rates of fertility:

• Eating more beans, nuts and other fertility-boosting plant protein
• Eating more whole grains
• Avoiding sugary sodas
• Having a glass of whole milk and other full-fat dairy food every day (even including an occasional small bowl of ice cream)

Some treatments for cancer can cause infertility. Certain techniques allow a woman planning to undergo chemotherapy or radiation to later have a baby from her own egg.

It will be prudent to discuss these with the doctor before beginning cancer treatment.