INFERTILITY (FEMALE) DEFINITION
If getting pregnant has been a challenge for you and your partner, you’re not alone. Ten to 15 percent of couples in the United States are infertile. Infertility is defined as not being able to get pregnant despite having frequent, unprotected sex for at least a year for most people and six months in certain circumstances.
Infertility may be due to a single cause in either you or your partner, or a combination of factors that may prevent a pregnancy from occurring or continuing. Fortunately, there are many safe and effective therapies for overcoming infertility. These treatments significantly improve the chances of becoming pregnant.
INFERTILITY (FEMALE) CAUSES
There are many possible causes of infertility. Unfortunately, in about one-third of cases no cause is ever identified.
Problems with ovulation are the most common cause of infertility in women, experts say. Ovulation is the monthly release of an egg. In some cases the woman never releases eggs, while in others the woman does not release eggs during come cycles.
Ovulation disorders can be due to:
Premature ovarian failure – the woman’s ovaries stop working before she is 40.
PCOS (polycystic ovary syndrome) – the woman’s ovaries function abnormally. She also has abnormally high levels of androgen. About 5% to 10% of women of reproductive age are affected to some degree. Also called Stein-Leventhal syndrome.
Hyperprolactinemia – if prolactin levels are high and the woman is not pregnant or breastfeeding, it may affect ovulation and fertility.
Poor egg quality – eggs that are damaged or develop genetic abnormalities cannot sustain a pregnancy. The older a woman is the higher the risk.
Overactive thyroid gland
Underactive thyroid gland
Some chronic conditions, such as AIDS or cancer.
INFERTILITY (FEMALE) PATHOPHYSIOLOGY
- Ovulatory dysfunction
o Hypo-gonadotrophic anovulation occurs as a result of hypothalamic or pituitary abnormalities.
o Hyper-gonadotrophic anovulation occurs as a result of ovarian failure.
o Polycystic ovarian syndrome is the most common cause of eugonadotrophic anovulation.
- Tubal disease
o Most often caused by gonorrhoea and chlamydia infection. Chlamydia trachomatis is obligate intracellular parasite that invades the cervix, uterus, and fallopian tubes. This organism is the leading cause for acute salpingitis worldwide. The manifestation of this disease is varied, ranging from sub-clinical to an acute tubo-ovarian abscess that can include peritonitis and peri-hepatitis. High anti-chlamydial antibody titres highly correlate to abnormal tubal pathology. The risk of tubal occlusion has been approximated as 10% for an initial episode of salpingitis, and then doubled with every subsequent infection.
o Any pelvic infection, including appendicitis and diverticulitis, can damage the fallopian tubes.
o Endometriosis can cause intra-abdominal inflammation and scar tissue.
o This growth of hormonally responsive endometrial tissue outside the uterus may cause anatomical obstruction of the fallopian tubes. It may also lead to infertility by producing cytokines that may be toxic to sperm or embryos.
o Age-related decreases in fecundity are caused by declining oocyte numbers and poorer oocyte quality. Oogenesis begins in utero. By month 7 of gestation, mitosis completes and the peak number of oocytes (approximately 7 million) is achieved. Hormone-independent apoptosis begins at this time and continues until menopause, regardless of factors such as contraceptive use and pregnancy. Although the number of oocytes remaining in the ovary (ovarian reserve) impact on pregnancy rates, age also leads to a higher rate of oocyte aneuploidy due to decreased chromosomal crossover, meiotic spindle fragility, and telomeric shortening. This leads to a high likelihood of implantation failure, miscarriage, and chromosomally abnormal offspring (e.g., trisomy 21).
o Unexplained infertility or subfertility is defined as the failure to conceive after 2 years of regular unprotected sexual intercourse in the face of normal investigations (namely normal ovulation, normal semen analysis, patent fallopian tubes).
o As couples go through the diagnostic and treatment pathways, an increasing number will acquire some form of diagnosis so that the proportion of couples with so-called unexplained subfertility will decline.
o The label of unexplained subfertility recognises that there are numerous candidate sites for abnormalities causing reduced fertility that cannot be recognised by standard diagnostic tests, but that, ultimately, treatment may improve the chance of a pregnancy.
- Uterine abnormalities
o Uterine abnormalities can be congenital or acquired. Failure of Müllerian duct fusion results in uterine malformations including uterine didelphys, bicornuate or unicornuate uterus, and uterine septum. Submucosal or large intramural leiomyomata may have an impact on implantation or cause tubal obstruction. Endometritis, particularly when associated with a dilation and curettage procedure, can destroy the endometrial lining and cause Asherman’s syndrome (intrauterine adhesions).
- Cervical abnormalities
o Cervical mucus is critical to facilitate sperm entry into the uterus and to initiate sperm capacitation, the final step in sperm maturation. During the peri-ovulatory period the mucus becomes abundant, thin, and stretchable. Cervical maladies such as surgery or infection can disrupt the cervical glands and/or mucus production.
INFERTILITY (FEMALE) SYMPTOMS
Most couples achieve pregnancy within the first six months of trying. Overall, after 12 months of frequent unprotected intercourse, about 90 percent of couples will become pregnant. The majority of couples will eventually conceive, with or without treatment.
The main sign of infertility is the inability for a couple to get pregnant. There may be no other obvious symptoms.
In some cases, an infertile woman may have irregular or absent menstrual periods. An infertile man may have signs of hormonal problems, such as changes in hair growth, sexual function, reduced sexual desire, or problems with ejaculation. He may also have small testicles or a swelling in the scrotum.
INFERTILITY (FEMALE) DIAGNOSIS
Most people will visit their GP (general practitioner, primary care physician) if there is no pregnancy after 12 months of trying. For anybody who is concerned about fertility, especially if they are older (women over 35), it might be a good idea to see a doctor earlier. As fertility testing can sometimes take a long time, and female fertility starts to drop when a woman is in her thirties, seeing the doctor earlier on if you are over 35 makes sense.
A GP can give the patient advice and carry out some preliminary assessments. As it takes two to make a baby it is better for both the male and female to see the doctor together.
Before undergoing testing for fertility it is important that the couple be committed. The doctor will need to know what the patients’ sexual habits are, and may make recommendations regarding them. Tests and trials might extend over a long period. Even after thorough testing, no specific cause is ever found for 30% of infertility cases.
In some countries where universal healthcare cover does not exist, evaluation and eventual treatment may be expensive.
INFERTILITY (FEMALE) TREATMENT
Treatment of infertility depends on the cause, how long you’ve been infertile, your age and your partner’s age, and many personal preferences. Some causes of infertility can’t be corrected. However, a woman may still become pregnant with assisted reproductive technology. Infertility treatment involves significant financial, physical, psychological and time commitment.
Although a woman may need just one or two therapies to restore fertility, it’s possible that several different types of treatment may be needed before she’s able to conceive.
- Stimulating ovulation with fertility drugs. Fertility drugs are the main treatment for women who are infertile due to ovulation disorders. These medications regulate or induce ovulation. Talk with your doctor about fertility drug options — including the benefits and risks of each type.
- Intrauterine insemination (IUI). During IUI, healthy sperm that have been collected and concentrated are placed directly in the uterus around the time the woman’s ovary releases one or more eggs to be fertilized. Depending on the reasons for infertility, the timing of IUI can be coordinated with your normal cycle or with fertility medications.
- Surgery to restore fertility. Uterine problems such as endometrial polyps, a uterine septum or intrauterine scar tissue can be treated with hysteroscopic surgery.
Assisted reproductive technology
Assisted reproductive technology (ART) is any fertility treatment in which the egg and sperm are handled. An ART health team includes physicians, psychologists, embryologists, lab technicians, nurses and allied health professionals who work together to help infertile couples achieve pregnancy.
In vitro fertilization (IVF) is the most common ART technique. IVF involves stimulating and retrieving multiple mature eggs from a woman, fertilizing them with a man’s sperm in a dish in a lab, and implanting the embryos in the uterus three to five days after fertilization.
Each year thousands of babies are born in the United States as a result of ART. The success rate of ART is lower after age 35.
Other techniques are sometimes used in an IVF cycle, such as:
- Intracytoplasmic sperm injection (ICSI). In ICSI, a single healthy sperm is injected directly into a mature egg. ICSI is often used when semen quality is a problem, there are few sperm, or if fertilization attempts during prior IVF cycles failed.
- Assisted hatching. This technique attempts to assist the implantation of the embryo into the lining of the uterus by opening the outer covering of the embryo (hatching).
- Donor eggs or sperm. Most ART is done using the woman’s own eggs and her partner’s sperm. However, if there are severe problems with either the eggs or sperm, you may choose to use eggs, sperm or embryos from a known or anonymous donor.
- Gestational carrier. Women who don’t have a functional uterus or for whom pregnancy poses a serious health risk might choose IVF using a gestational carrier. In this case, the couple’s embryo is placed in the uterus of the carrier for pregnancy.
Complications of treatment
Complications of female infertility treatment may include:
- Multiple pregnancy. The most common complication of infertility treatment is a multiple pregnancy — twins, triplets or more. Generally, the greater the number of fetuses, the higher the risk of premature labor and delivery. Babies born prematurely are at increased risk of health and developmental problems. The goal of infertility treatment should be a single healthy pregnancy, and preventing multiple pregnancies should be discussed before treatment starts. In some cases, fetal reduction can be used to help a woman deliver fewer babies with lower health risks. Pursuing fetal reduction, however, is a major decision with ethical, emotional and psychological consequences.
- Ovarian hyperstimulation syndrome (OHSS). Use of injectable fertility drugs to induce ovulation can cause OHSS, in which the ovaries become swollen and painful. Symptoms may include mild abdominal pain, bloating and nausea that lasts about a week, or longer if you become pregnant. Rarely, a more severe form causes rapid weight gain and shortness of breath requiring emergency treatment.
- Bleeding or infection. As with any invasive procedure, there is a rare risk of bleeding or infection with assisted reproductive technology.
- Premature delivery or low birth weight. The greatest risk factor for low birth weight is a multiple fetus pregnancy. In single live births, there may be a greater chance of preterm delivery or low birth weight associated with IVF.
- Birth defects. Some research suggests that babies conceived using IVF might be at increased risk of certain birth defects, such as heart and digestive problems and cleft lip or cleft palate. However, most studies conclude that this appears to be related to why couples need infertility treatment and not the IVF procedures themselves.