Infertility can be defined as the inability of a couple to become pregnant (regardless of cause) after one year of unprotected sexual intercourse (using no birth control methods).
In approx. 40% of couples, the female factor is the cause, whereas 30 – 40% cases are due to a cause in the male partner. Combination of male and female factors accounts for the remaining 20% to 30% of cases.
Causes of Female Infertility
For a successful pregnancy to occur, every step of the complex human reproductive process— from the release of a mature egg from the ovary to the fertilization of the egg to the implantation of the fertilized egg and growth of embryo in the uterus has to take place perfectly. In women, a number of factors can disrupt this process at any stage leading to difficulty in conception. They include:-
1. Failure of Ovulation
Ovulation disorders constitute one of the most common causes. Most of them are treatable. You must suspect an ovulation disorder if you ovulate infrequently or not at all.
Polycystic ovary syndrome (PCOS): It occurs due to overproduction of male hormone- androgen which adversely affects ovulation. Infertility is just one of the symptoms. Other symptoms include menstrual irregularities, acne, excess facial, body hair and obesity.
Hormonal Imbalances: Production of appropriate amounts of hormones: FSH (Follicle Stimulating Hormone) and LH (Luteinizing Hormone) through the month is essential for ovulation. Any abnormality due to endocrine gland disorders, stress, and excessive weight loss/gain amongst many other factors can adversely affect their production leading to ovulation disorders.
Some women produce excess amounts of prolactin, (a hormone that stimulates production of breast milk) which prevents ovulation.
Premature ovarian failure: This occurs when the ovary fails to produce eggs. It can be genetic (Turner’s syndrome) or acquired (following radiation or chemotherapy for cancers; surgery to remove the ovaries for treating ovarian cancer or severe endometriosis or autoimmune ovarian failure) or unexplained reasons.
2. Disorders of the Fallopian Tubes:
Tubal diseases vary widely, ranging from mild adhesions to complete tubal blockage. Tubal damage occurring through pelvic infection is called pelvic inflammatory disease (PID). It can occur due to numerous causes such as,
- Sexually transmitted diseases (e.g. Gonorrhea, Chlamydia)
- Infection after childbirth, miscarriage, medical termination of pregnancy (MTP) or intrauterine device (IUD) insertion
- Postoperative pelvic infection (e.g. perforated appendix, ovarian cysts)
- Severe endometriosis
- Tuberculosis: It can manifest as tuberculous endometritis (infection of uterus) or/and salpingitis (infection of tubes).
- Other reasons for tubal damage include: tubal surgery, abdominal surgery and previous tubal or pelvic pregnancy.
Endometriosis is a chronic disease. The symptoms include painful, heavy and long menstrual periods, urinary urgency, rectal bleeding, premenstrual spotting and infertility.
3. Uterine causes
Benign (non aggressive) tumors in the uterus, common among women in their 30s, can impair fertility by blocking the fallopian tubes or by disrupting implantation.
4. Unexplained infertility
In some instances, cause for infertility is never found. It’s possible that combinations of factors in both partners underlie these unexplained fertility problems.
How will you evaluate the cause of Female Infertility
Some infertile couples have more than one cause for their infertility. In some cases, cause of infertility may be unclear, or it may take a number of tests to identify the cause. They include:
- Hysterosalpingogram (HSG)
During this x ray procedure. a speculum is used to open the vagina, a liquid is injected into the cervix (opening into the uterus) so that it flows into the uterus. The extent to which the liquid comes out of the tubes is used to determine if one or both of the tubes are open.
- Diagnostic Laparoscopy
In this minimally invasive procedure, a laparoscope is inserted through a small incision below your belly button. The surgeon can determine if one or both of the tubes are open.
- Diagnostic Hysteroscopy
In this procedure, a small scope is inserted into the uterus through the vagina to look inside the uterus.
- Hormone testing for FSH, LH, Prolactin, T3,74,TSH
- Pelvic Ultrasound
Ultrasound is a standard technique for evaluating the uterus and ovaries, detecting fibroids/polyps, ovarian cysts and tumors. Transvaginal sonohysterography uses ultrasound with saline infused into the uterus, that enhances the visualization of the uterus.
- Semen Analysis is done in every couple to evaluate the partner/husband’s sperm quality and quantity
- Other tests
These include tests for Infections (tuberculosis, syphilis or other sexually transmitted infections), genetic testing (Turner syndrome, testicular feminization syndrome) may also be required to be conducted.
Treatment of Female infertility
Treatment has to be carefully selected keeping in mind the age, years since marriage and the exact cause of infertility.
- Medical Treatment
Medical treatment has to be provided for any infection of the genital tract like tuberculosis. or Pelvic Inflammatory Disease. Drug therapy is used to correct ovulation. If there are no underlying causes of ovulation problems (such as thyroid disease), the first line of treatment is oral medication. If oral medication fails to correct the problem other treatment options are considered.
- Surgical treatment
The vast majority of surgical procedures used to treat infertility can now be performed on an outpatient basis using a Laparoscope or Hysteroscope. The surgeon can remove scar tissue, treat endometriosis, remove cysts, fibroids, polyps and unblock the fallopian tubes. Laparotomy may still be required for reversing tubal ligations and removing large fibroid tumors, but even these procedures can usually be performed through a small incision as an outpatient.
- Intrauterine insemination (IUI)
Intrauterine insemination has been shown to increase the chances of pregnancy in women undergoing induced ovulation. During this procedure, the partner’s sperm is placed directly into the uterine cavity near the time of ovulation. IUI is generally performed in the case of a low sperm count, abnormalities of ejaculation (retrograde ejaculation, impotence,), when the cervix prevents sperm from entering the uterus, or with donor sperm.
- Assisted Reproductive Techniques
Rapid advancements in the field have enabled individuals with a variety of disorders to successfully become proud parents, a situation relatively uncommon in the past. The various options available are:
- In vitro fertilization (IVF)
IVF is the most common method and is the treatment of choice if both fallopian tubes are found to be blocked. It is a process where the mature eggs (oocyte) are aspirated from the ovaries under anaesthesia. (OPU). The eggs are combined with healthy sperm in the laboratory and the resulting fertilized egg (embryo) is placed back into the uterine cavity. (ET)
IVF is also popular for conditions such as:
- Unexplained infertility
- Cervical factor infertility
- Male factor infertility
- Ovulation disorders
- Immunologic infertility (the presence of anti-sperm antibodies)
- Adjunct to Clomiphene or FSH therapy
- Intracytoplasmic sperm injection (ICSI)
ICSI is recommended for couples in whom the sperm characteristics are too poor to perform traditional IVF, high levels of antispam antibodies are present or if prior IVF attempts have failed. A sperm is injected into the egg using a special microscope. ICSI can improve the likelihood of fertilization when male infertility disorders such as low sperm counts, low sperm motility or high number of abnormally shaped sperm are present.
- Blastocyst transfer
Blastocyst transfer helps to identify a single embryo most likely to result in pregnancy. The technique allows embryos to mature longer, usually five to six days, before transfer. Embryos that progress to the blastocyst stage may have a higher chance of pregnancy than those transferred earlier.
- Donor Oocytes
The use of donor oocytes (eggs) is for patients who cannot become pregnant using their own eggs. They allow recipients to experience pregnancy and deliver a healthy child who is biologically related to one parent.