Causes of Infertility in females and Treatments

Infertility is not uncommon amongst females, but there are many new age treatments available today.

About 45% of couples who are unable to conceive are due to infertility issues in the female.

The reasons are likely to be

  • Damage to the fallopian tubes
  • Ovulatory problems
  • Endometriosis
  • Conditions affecting the uterus
  • A combination of factors
  • No identifiable reason.

Failure to Ovulate:

20% of the treatment cases for female infertility fall under this bracket (Ref. The BOSTON IVF , Handbook of Infertility, 2nd edition,page 27). There are many causes of anovulation (the absence of ovulation) and a range of symptoms. Some of the causes are treatable with drugs and sometimes lifestyle changes. Others are not treatable and pregnancy may only be possible with the help of an egg donor.

Some treatable causes are

  •  Hypothalmic anovulation – caused by exercise, stress and/or weight loss
  •  Hyperprolactinemia – raised levels of prolactin, a pituitary hormone
  •  Polycystic ovarian syndrome (PCOS).
  •  Hormonal problems(Failure to produce mature eggs due to Malfunction of the hypothalamusor the pituitary gland
  •  Scarred Ovaries -due to extensive surgeries,radiation exposure
  •  Premature Menopause ( premature ovarian failure)
  •  Follicle Problems- unruptured follicle syndrome

Poorly Functioning Fallopian Tubes

20% of the cases for female infertility fall under this bracket (Ref. The BOSTON IVF , Handbook of Infertility, 2nd edition,page 27).

1) Infection like tuberculosis, sexually transmitted diseases-causing hydrosalpinx and tubo -ovarian masses

2) Abdominal Diseases- The most common of these are appendicitis and colitis, causing inflammation of the abdominal cavity which can affect the fallopian tubes and lead to scarring and blockage

3) Previous Surgeries- Pelvic or abdominal surgery can result in adhesions that alter the tubes in such a way that eggs cannot travel through them.

4) Ectopic Pregnancy- This is a pregnancy that occurs in the tube itself and, even if carefully and successfully overcome, may cause tubal damage and is a potentially life-threatening condition

5) Congenital Defects- absence of a tube or only stump present.

Salpingitis

Inflammation of the fallopian tubes can occur from the inside, that is, from the uterus, as is the case with sexually transmitted diseases such as gonorrhoea or chlamydia. It can also come from outside the tube by the spread of infection from another organ such as the appendix. When this happens, the tube is often damaged by adhesions, where two damaged surfaces actually join together. Adhesions can also occur after pelvic surgery or as a result of endometriosis. Adhesions can obstruct in a number of ways – by separating the ovary and tube with new tissue or by blocking the outer end of the tube. In many cases, microsurgery can be helpful in clearing the blockage.

Hydrosalpinx and pyosalpinx

A hydrosalpinx is a particular type of tubal blockage in which the tube is obstructed near its fimbrial end. The tube becomes filled with clear watery fluid. Sometimes after IVF the rise in progesterone causes the tube to relax and this fluid can be passed into the uterus, washing out the transferred embryo. This process accounts for quite a few cases of persistent IVF failure.

A pyosalpinx is an acutely inflamed blocked tube filled with pus. It sometimes subsides with antibiotics, becoming a hydrosalpinx. Otherwise it can rupture and form an abscess in the pelvis, much like a burst appendix, and then requires an operation to drain both it and the abscess.

Both uterine and cervical factor

5% of the cases for female infertility fall under this bracket (Ref. The BOSTON IVF, Handbook of Infertility, 2nd edition,page 27).

UTERINE factors

  • Congenital- presence of complete or incomplete septum, bicornuate uterus
  • Pathology – fibroids, polyps, adenomyosis, Asherman’s syndrome-uterine synechiae

Cervical factors

  • Hormonal imbalance causing cervical mucus consistency to be thick thus preventing swimming of sperm to travel upto the fallopian tubes.
  • Pathology-cervical fibroid

Endometriosis and Infertility:

The long term cumulative pregnancy rates are normal in patients with minimal endometriosis and normal anatomy.

Moderate and severe endometriosis might require IUI or IVF

Approximately 10% of infertile couples are affected by Endometriosis. 30-40% of patients with endometriosis are infertile. This is two to three times the rate of infertility in the general population. For women with endometriosis, the monthly fecundity (chance of getting pregnant) diminishes by 12 to 36%.

Definition: Endometriosis is characterized by excessive growth of the lining of the uterus, called the endometrium. Growth occurs not only in the uterus but also elsewhere in the abdomen, such as in the fallopian tubes, ovaries and the pelvic peritoneum.

Diagnosis: A positive diagnosis can only be made by diagnostic laparoscopy, a test that allows the physician to view the uterus, fallopian tubes, and pelvic cavity directly.

Symptoms: includes heavy, painful and long menstrual periods, urinary urgency, rectal bleeding and premenstrual spotting.

Sometimes, however, there are no symptoms at all, owing to the fact that there is no correlation between the extent of the disease and the severity of the symptoms.

Treatment: can be medical- hormonal treatment or surgical -ablation of endometriotic spots or excision of a cyst.

Unexplained infertility-25%

The precise cause of infertility in any one couple may never be identified by any number of tests. This is the so-called broad category of unexplained infertility. Couples in this category simply have no obvious reason preventing their conception. That’s what “unexplained infertility” means. The good news is that fertility therapy works as well in couples with unexplained infertility as in those with specific causes of infertility.

Other factors that may play a part include:

  • Age – female fertility declines sharply after the age of 35
  • Polycystic Ovary Syndrome (PCOS)
  • Gynaecological problems such as previous ectopic pregnancy or having had more than one miscarriage , history of sexually transmitted diseases
  • Medical conditions such as diabetes, epilepsy, thyroid and bowel diseases
  • Lifestyle factors such as stress, being overweight or underweight, and smoking.

The decision to offer treatment in unexplained infertilty will depend on the age of the woman, how long the couple have been infertile and previous obstetric history. In this group of couples trying to conceive, if the female age allows, they can try naturally for 2-3 yrs, and if unsuccessful, then commence treatment. If the woman is older, earlier recourse to treatment is appropriate. The most successful treatment would be Gonadotrophin stimulated IUI or IVF.

Fibroids and polyps in the uterus

Fibroids are benign lumps of tissue growing in or on the myometrium (the wall of the uterus surrounding the endometrium). The closer they are to the endometrium, the more likely they are to cause symptoms such as heavy bleeding, dysmenorrhea and infertility.

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