Female Infertility
Definition of infertility in woman
Generally infertility is defined as not being able to conceive after 12 months of unprotected frequent sex. This condition affects about 10-15% of couples. It can be due to female factors, male factors and a combination of both partners' factors. Causes of male infertility will be discussed on another page. Some causes of infertility conditions are treatable and there are treatments for infertility. Most couples up to 95% will get pregnant after trying for 24 months therefore some doctors will not usually diagnose a couple as infertile until 24 months have passed without conception despite regular unprotected sex.
Risk factors of infertility
Generally infertility is defined as not being able to conceive after 12 months of unprotected frequent sex. This condition affects about 10-15% of couples. It can be due to female factors, male factors and a combination of both partners' factors. Causes of male infertility will be discussed on another page. Some causes of infertility conditions are treatable and there are treatments for infertility. Most couples up to 95% will get pregnant after trying for 24 months therefore some doctors will not usually diagnose a couple as infertile until 24 months have passed without conception despite regular unprotected sex.
Risk factors of infertility
- Age: The quality and quantity of a woman's eggs begin to decline with increasing age. By mid-30s, the woman will have fewer and poorer quality eggs. Hence with increasing age, the chance of pregnancy decreases and the risk of miscarriage/ genetic abnormality in fetus increases.
- Smoking: increases the risk of infertility in both men and women. Smoking damages the cervix and fallopian tubes, depletes the eggs prematurely and increases your risk of miscarriage/ectopic pregnancy.
- STD: Sexually transmitted diseases such as chlamydia and gonorrhea can damage the fallopian tubes and increases risk of infertility
- Alcohol consumption: excessive alcohol consumption reduces male's fertility and increases risk of miscarriage/deformity
- Weight: An overweight lady will have increase risk of infertility and in overweight men it affects the sperms. Underweight ladies who have eating disorders may have fertility issues too.
- Excessive exercise: woman who overexercise over 7 hours per week will have ovulation problems and result in amenorrhoea.
- Mental stress - excessive stress can affect female ovulation and sperm production
Causes of female infertility
There are many possible causes of infertility. There is about one-third of cases whereby no cause is ever identified. Woman needs a functioning womb, fallopian tubes and ovulation to get pregnant. So the possible causes can be any of this parts.
1. Ovulation disorders
Ovulation is the monthly release of an egg that induces the monthly menstrual cycle. In some patients they ovulate infrequently or not at all resulting in irregular menses or no menses (amenorrhoea). With reduced frequency of ovulation it can increases the risk female infertility. Ir-regulation of reproduction hormones in the pituitary gland, hypothalamus and problems in ovary glands can cause ovulation disorders.
- Polycystic Ovary syndrome (PCOS): It's the most common cause of female infertility. It is because of raised levels of androgens (testosterones) which cause hormone imbalance hence affecting ovulation. This results in irregular ovulation or no ovulation. PCOS is associated with insulin resistance (diabetes), obesity, male pattern hair growth on the face or body and acne.
- Premature ovarian failure: Also known as premature ovarian insufficiency whereby the ovaries stop producing eggs before age 40. It can be caused by an autoimmune response or by premature loss of eggs from your ovary either due to genetics or post-chemotherapy. Sometimes the cause is unknown. The estrogen levels drop drastically and patients will experience early menopause.
- Hypothalamic and pituitary gland dysfunction: The hypothalamus produce the hormone Gonadotropin releasing hormone which controls the pituitary gland. The Pituitary gland produces two hormones FSH and LH which are responsible for stimulating ovulation each month. Excess physical exercise, emotional stress, a very high BMI or very low BMI, or a recent substantial weight gain or loss can disrupt the production of these hormones and affect ovulation. In addition, the pituitary gland may cause excess prolactin hormone in a condition called hyperprolactinemia which reduces estrogen production and may cause infertility as a result.
2. Damaged fallopian tubes (Infertility due to "faulty" fallopian tubes)
Blocked or damaged fallopian tubes will prevent a fertilized egg to move to the uterus or it may prevent the sperms from reaching the egg. Causes of damaged fallopian tubes are:
- Previous abdomen or pelvic surgery including surgery for previous ectopic pregnancy results in scarring and damage to the fallopian tubes. This results in blocked tubes which prevents the sperm to reach the egg or the fertilized egg from implantation in the uterus.
- Previous sterilization treatment - previously woman may have chosen sterilization to have her fallopian tubes blocked. It is possible to reverse this process but the chances of pregnancy will not be high.
- Pelvic tuberculosis: It is a cause of tubal infertility in countries whereby tuberculosis is prevalent especially in developing countries.
- Pelvic inflammatory disease: infection of the uterus and fallopian tubes due to previous sexually transmitted diseases like chlamydia, gonorrhea causes scarring and damage to the fallopian tubes.
- Endometriosis - cells that are normally found within the lining of the uterus start to implant and grow elsewhere in the body.The lining of uterus is affected and hence it disrupts the implantation of the fertilized egg. Some people go through surgery to emove the extra tissue growth and surgery will result in adhesion, scarring and blocked fallopian tubes.
3. Abnormal uterine and cervical causes
Some uterine and cervical conditions can affect implantation hence affecting fertility and also increases the risk of miscarriage.
- Uterine polyps or fibroids: These growths are usually benign but they can block fallopian tubes or interfere with implantation hence causing sub-fertility. However, many women who have such conditions can still get pregnant.
- Congenital uterine abnormalities: for example an abnormally shaped uterus can result in infertility or difficulty to carry on pregnancy to term.
- Endometriosis: as above
- Cervical sternosis: narrowing of cervix either as a result of damage to cervix due to infections or congenital abnormality.
sometimes the cause is never found or it could be a combination of both male and female factors.
There are many possible causes of infertility. There is about one-third of cases whereby no cause is ever identified. Woman needs a functioning womb, fallopian tubes and ovulation to get pregnant. So the possible causes can be any of this parts.
1. Ovulation disorders
Ovulation is the monthly release of an egg that induces the monthly menstrual cycle. In some patients they ovulate infrequently or not at all resulting in irregular menses or no menses (amenorrhoea). With reduced frequency of ovulation it can increases the risk female infertility. Ir-regulation of reproduction hormones in the pituitary gland, hypothalamus and problems in ovary glands can cause ovulation disorders.
- Polycystic Ovary syndrome (PCOS): It's the most common cause of female infertility. It is because of raised levels of androgens (testosterones) which cause hormone imbalance hence affecting ovulation. This results in irregular ovulation or no ovulation. PCOS is associated with insulin resistance (diabetes), obesity, male pattern hair growth on the face or body and acne.
- Premature ovarian failure: Also known as premature ovarian insufficiency whereby the ovaries stop producing eggs before age 40. It can be caused by an autoimmune response or by premature loss of eggs from your ovary either due to genetics or post-chemotherapy. Sometimes the cause is unknown. The estrogen levels drop drastically and patients will experience early menopause.
- Hypothalamic and pituitary gland dysfunction: The hypothalamus produce the hormone Gonadotropin releasing hormone which controls the pituitary gland. The Pituitary gland produces two hormones FSH and LH which are responsible for stimulating ovulation each month. Excess physical exercise, emotional stress, a very high BMI or very low BMI, or a recent substantial weight gain or loss can disrupt the production of these hormones and affect ovulation. In addition, the pituitary gland may cause excess prolactin hormone in a condition called hyperprolactinemia which reduces estrogen production and may cause infertility as a result.
2. Damaged fallopian tubes (Infertility due to "faulty" fallopian tubes)
Blocked or damaged fallopian tubes will prevent a fertilized egg to move to the uterus or it may prevent the sperms from reaching the egg. Causes of damaged fallopian tubes are:
- Previous abdomen or pelvic surgery including surgery for previous ectopic pregnancy results in scarring and damage to the fallopian tubes. This results in blocked tubes which prevents the sperm to reach the egg or the fertilized egg from implantation in the uterus.
- Previous sterilization treatment - previously woman may have chosen sterilization to have her fallopian tubes blocked. It is possible to reverse this process but the chances of pregnancy will not be high.
- Pelvic tuberculosis: It is a cause of tubal infertility in countries whereby tuberculosis is prevalent especially in developing countries.
- Pelvic inflammatory disease: infection of the uterus and fallopian tubes due to previous sexually transmitted diseases like chlamydia, gonorrhea causes scarring and damage to the fallopian tubes.
- Endometriosis - cells that are normally found within the lining of the uterus start to implant and grow elsewhere in the body.The lining of uterus is affected and hence it disrupts the implantation of the fertilized egg. Some people go through surgery to emove the extra tissue growth and surgery will result in adhesion, scarring and blocked fallopian tubes.
3. Abnormal uterine and cervical causes
Some uterine and cervical conditions can affect implantation hence affecting fertility and also increases the risk of miscarriage.
- Uterine polyps or fibroids: These growths are usually benign but they can block fallopian tubes or interfere with implantation hence causing sub-fertility. However, many women who have such conditions can still get pregnant.
- Congenital uterine abnormalities: for example an abnormally shaped uterus can result in infertility or difficulty to carry on pregnancy to term.
- Endometriosis: as above
- Cervical sternosis: narrowing of cervix either as a result of damage to cervix due to infections or congenital abnormality.
sometimes the cause is never found or it could be a combination of both male and female factors.
Diagnostic tests for female infertility
General physical examination: The gynecologist will ask the woman about her past medical history in particularly her gynecological history, menstrual cycle, previous sexual diseases, sexual habits and medications. Then she will undergo a pelvic examination.
Blood tests : to evaluate the pituitary hormones levels, the hypothalamus hormones levels, FSH, LH and thyroid hormones.
STD tests: If the woman is suspicious of having chlamydia or gonorrhea, confirmatory tests can be done.
Genetic testing: If there is genetic family history which can interfere with fertility, then relevant tests can be carried out.
Pelvic ultrasound: using ultrasound waves, a probe is put over the abdomen or in the vagina to view the uterus and ovaries, looking for abnormalities like cyst, polyps or fibroids.
Hysterosalpingography: A contrast fluid is injected into the woman's uterus and followed by x-rays to follow the flow of fluid up from uterus to the fallopian tubes to identify any blocked or damaged fallopian tubes.
Hysteroscopy: Under anesthesia, a scope with camera is inserted via the cervix into the uterus to visualize it to rule out any abnormalities.
Laparoscopy surgery: Under anesthesia, key hole incisions are made on the abdomen and flexible tube with camera is inserted into the pelvis to look for scarring, blocked or damaged fallopian tubes, endometriosis, abnormal growth and other abnormalities of uterus or ovaries.
General physical examination: The gynecologist will ask the woman about her past medical history in particularly her gynecological history, menstrual cycle, previous sexual diseases, sexual habits and medications. Then she will undergo a pelvic examination.
Blood tests : to evaluate the pituitary hormones levels, the hypothalamus hormones levels, FSH, LH and thyroid hormones.
STD tests: If the woman is suspicious of having chlamydia or gonorrhea, confirmatory tests can be done.
Genetic testing: If there is genetic family history which can interfere with fertility, then relevant tests can be carried out.
Pelvic ultrasound: using ultrasound waves, a probe is put over the abdomen or in the vagina to view the uterus and ovaries, looking for abnormalities like cyst, polyps or fibroids.
Hysterosalpingography: A contrast fluid is injected into the woman's uterus and followed by x-rays to follow the flow of fluid up from uterus to the fallopian tubes to identify any blocked or damaged fallopian tubes.
Hysteroscopy: Under anesthesia, a scope with camera is inserted via the cervix into the uterus to visualize it to rule out any abnormalities.
Laparoscopy surgery: Under anesthesia, key hole incisions are made on the abdomen and flexible tube with camera is inserted into the pelvis to look for scarring, blocked or damaged fallopian tubes, endometriosis, abnormal growth and other abnormalities of uterus or ovaries.
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Treatment for female infertility
As infertility is caused by many factors above, the treatment method depends on the cause of infertility, the age of patient , their health and preference of patient. Assisted reproductive methods can be quite costly and most countries do not provide subsidy for it. Treatments include medications, intrauterine insemination and assisted reproductive technology (ART).
1. Fertility drugs to regulate or stimulate ovulation
- As irregular ovulation or no ovulation is a commoner cause of infertility, these drugs are used to stimulate or regulate ovulation to increase the chance of pregnancy. These drugs mimic female hormones like FSH and LH to stimulate ovulation and increase number of mature eggs from the ovary
- Clomifene: This medicine is helpful for those with polycystic ovariansyndrome. It stimulates ovulation by causing the pituitary gland to release more FSH and LH. Clomifene is started early in the menstrual cycle and is taken for five days either from cycle days 3 through 7, or from day 5 through 9 of menstrual cycle. Starting dose of one tablet (50 mg ) daily is taken any time of the day. If 50 mg dose doesn't work, the dosage can be increased to 100mg. Ovulation usually occurs about 8 to 10 days after completing a 5 day course of Clomifene. If after taking for three to six cycles, still there is no result then you may consider other fertility treatments.
- Gonadotropins: These injected medicines stimulate the ovary directly to produce multiple eggs. Some examples are Human menopausal gonadotropin or hMG, (Repronex) and FSH (Gonal-F, Follistim AQ, Bravelle). Another medicine is human chorionic gonadotropin (Ovidrel, Pregnyl) which is used to mature the eggs and trigger their release at the time of ovulation.
- Gn-RH (gonadotropin-releasing hormone) analogs : These medications are in the form of nasal sprays or injectable forms. These drugs provides "external supply of Gn-RH" to the pituitary gland, which alters the FSH and LH levels, this allow the doctor to induce follicle growth during IVF treatments.
- Metformin : for those patients with PCOS and insulin resistance , metformin maybe effective when clomifene fails.
- Bromocriptine: this drug is effective for patient's whose pituitary over produce prolactin (hyperprolactinemia). Patients have high levels of prolactin they may have irregular ovulation cycles and thus have fertility problems. This drug inhibits prolactin production.
- Letrozole (Femara): is a drug known as aromatase inhibitors which is similar function as clomiphene. It is sometimes used as an off label drug to induce ovulation. It lowers a woman’s progesterone level which induces the pituitary to make more FSH to induce ovulation which is effective in women with PCOS. However, the effect this medication has on early pregnancy isn't yet known so it is less frequently used
Side effects and risks of drugs above:
- Multiple pregnancies: chances higher especially with injectable drugs rather than oral medications as it induces more mature eggs to ovulate . Multiple pregnancies will result in increasing risk of premature births, low birth weight and possible development issues.
- Ovarian hyperstimulation syndrome (OHSS). Injectable fertility drugs are used to induce ovulation and in turn it can cause OHSS, which causes painful and swollen ovaries. Some other symptoms are bloatedness, nausea, vomiting, diarrhea and mild abdomen pain. The symptoms will go away without treatment but sometimes may last for several weeks. Very rarely, it can cause a more-severe form of OHSS which may result in rapid weight gain, enlarged painful ovaries, ascites and shortness of breath.
- Long-term risks of development of ovarian tumors. If women take fertility drugs for more than a year without a successful pregnancy, there may be an increased risk of developing ovarian tumors later on. Hence always follow up with the gynecologists and do not buy any medications over counter yourself.
2. Surgery to restore fertility
- Fallopian tubal surgery - if the cause of infertility is due to blocked or scarred fallopian tubes, surgery is an option to repair them. After surgery, the eggs will find it easier to pass through the unblocked tubes. But surgery is less frequently carried out as pregnancy rates are better with IVF treatment.
- Laparoscopic surgery: Under anesthesia, key hole incisions are made on the abdomen and flexible tube with camera is inserted into the pelvis to look for scarring, blocked or damaged fallopian tubes, endometriosis, abnormal growth and other abnormalities of uterus or ovaries.Surgery can help to correct an abnormal uterine shape, remove any endometrial polyps/fibroids that misshape the uterine cavity and also to remove any pelvic or uterine adhesions that could have cause blockage.
3. Assisted reproductive conception
The methods and techniques used for assisted reproduction includes:
- Intrauterine insemination (IUI): It is a form of artificial insemination. The sperms from the husband are washed and the best are selected. After which using a fine catheter, the sperms are inserted through the cervix into the uterus during ovulation period. The woman may be given some ovulating inducing drugs first. This method is common when the man is found to have low sperm count or decreased sperm motility or if they have erectile dysfunction. It is also a useful method for those with unknown cause of infertility. The success rate is about 7-16% when used together with fertility drugs.
- In-Vitro Fertilization (IVF) : This method involves extracting mature eggs from the woman's ovary and placed in a Petri dish with the man's sperms for fertilisation to take place outside the womb (in the laboratory). The embryo is then transferred back into the uterus after fertilization to begin a pregnancy. Sometimes the embryo maybe frozen for future use (cryopreserved). An IVF cycle takes several weeks, it requires frequent blood tests and daily hormone injections. Success rates depend on many factors and it varies, the factors include the clinic performing the procedure, the cause of infertility and the age of the woman undergoing the procedure. The success rate is about 20-35% in woman less than 40 years old but with increasing age the success rate decreases, it can be as low as 1% for those above 44 years of age.
- ICSI (Intracytoplasmic sperm injection) : A single sperm is injected into an egg to achieve fertilization during an IVF procedure. It is suitable for men with low sperm counts, when the male factor is the main cause of infertility.
- Using donor eggs/sperms/embryos: These assisted reproduction conception procedures sometimes involve the use of donor eggs (eggs from another woman), donor sperms ( sperms from another man), or previously frozen embryos (for woman who freeze the embryos before chemotherapy). Donor eggs are used when the women who cannot produce eggs likewise donor sperms are used for man who has o sperms (azoospermia). Sometimes donor eggs or donor sperm are used when the woman or man has a genetic disease that they do no wise to be passed on to the baby. An infertile woman or couple may also use donor embryos. created using sperms and eggs from donors, the embryo is then transferred to the uterus. The child in this case will not be genetically related to either parent.
- Surrogate mother: Women with ovaries but no uterus because of previous operation can engage surrogate mother especially for women who cannot get pregnant because of a serious health conditions that may jeopardize her life. In this case, the woman uses her own egg which is fertilized by her partner’s sperm and the embryo is placed inside the surrogate mother's uterus. The surrogate mother will go through the pregnancy and deliver the baby on the parents' behalf.