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Female infertility

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Overview

Female infertility is difficult in getting pregnant despite engaging in regular, unprotected sexual intercourse for at least 12 months. Infertility includes having miscarriages or unsuccessful pregnancy. About 10% of women experience infertility. It is one of the most common diseases in women.

For heterosexual couple, it is considered female infertility or female factor if the infertility comes from the woman. Generally, infertility is usually one-third male factor, one-third female factor and one-third combination of both or unknown factor.

Several causes of female infertility include problems with reproductive system organs, age, genetics, among others. The treatment plan is usually developed based on the cause of the infertility. Although it can be challenging to treat female infertility, some women eventually become mothers without any intervention.

Symptoms

For a woman to get pregnant, the body has to go through lengthy process. It starts with releasing an egg from the ovaries, a man’s sperm fertilizes the egg, then it proceeds to the fallopian tube and towards the womb. Lastly, the embryo must be implanted inside the uterus. Any problems within the process may prevent pregnancy, resulting in infertility.

Inability to conceive is the main sign of infertility. A menstrual cycle that is overly lengthy (35 days or more), too short (less than 21 days), irregular, or nonexistent may indicate that the patient are not ovulating. There might be no additional symptoms or indicators.

Women’s fertility declines with age and therefore women should:

  • Up to age 35, with no known health or fertility issues should try conceiving for at least one year before seeing a doctor.
  • Between ages 35 and 40, should try getting pregnant for 6 months and seek medical advice if unsuccessful.
  • Older than 40, is recommended to have immediate assessment and necessary treatment.

Couples who have health problems should consult an infertility specialist before trying to get pregnant to ensure a healthy pregnancy. If the couple has a history of known fertility issues, irregular or painful periods, pelvic inflammatory disease, recurrent miscarriages, cancer treatment, endometriosis or other suspected diseases, the doctor may require testing and treatment immediately.

Causes

For a woman to become pregnant, she must have healthy ovaries, fallopian tubes, and uterus. Female infertility can be caused by illnesses that affect any one of these organs. The main cause of infertility can sometimes be difficult to identify. In some, it can be unexplained. The common causes of female infertility are:

  • Ovulation disorders: Most cases of infertility are caused by irregular or absent ovulation. Ovulation abnormalities can be brought on by issues with the ovary, the pituitary gland, or the hypothalamus, which regulate reproductive hormones.
    • Polycystic ovary syndrome (PCOS): PCOS is a common cause of female infertility. It contributes to the abnormal levels of androgen hormone which affects ovulation. Common related conditions are insulin resistance and obesity, hirsutism, acne, and irregular periods.
    • Hypothalamic dysfunction: Follicle-stimulating hormone (FSH) and luteinizing hormone (LH), two hormones made by the pituitary gland, are in charge of triggering ovulation each month. The production of these hormones can be disturbed and impair ovulation by excessive physical or emotional stress, extremely high or extremely low body weight, or a recent major weight gain or decrease. The most frequent signs are irregular or missed periods.
    • Primary ovarian insufficiency (POI): Or premature menopause is a condition where the woman’s ovaries stop functioning and reduce estrogen production before the age of 40. POI can be caused by a variety of medical disorders, certain exposures (such as chemotherapy or pelvic radiation therapy), and other factors, although the exact cause is frequently unknown.
    • High prolactin levels: Or hyperprolactinemia, this reduces the production of estrogen and may result in infertility. Paitent may be taking drugs for another condition, which could possibly be the cause of this.
  • Endometriosis: This is when tissue that normally grows in the uterus implants and grows in other areas such as the fallopian tube, pelvic cavity, or ovaries. The surgical excision of this excess tissue growth may result in scarring, which may obstruct fallopian tubes and prevent the process of fertilization of an egg and sperm. Endometriosis can prevent a fertilized egg from implanting properly.
  • Damage to fallopian tubes (tubal infertility): The fallopian tube is where the sperm and the egg meet. It also brings the fertilized eggs to the uterus. Obstruction or damage in the tubes will prevent the natural process of pregnancy. Some factors that may contribute to the injury or obstruction of the fallopian tube are:
    • History of pelvic inflammatory disease such as chlamydia, gonorrhea, or other sexually transmitted infections
    • Prior abdominal or pelvic surgery such as surgery for ectopic pregnancy
  • Uterine or cervical causes: Problems with the uterine and cervix can prevent successful pregnancy in women.
    Common issues include:

    • Uterine fibroid or polyps which reduce fertility by preventing implantation or blocking fallopian tubes. The excessive cell growth in the endometrium results in uterine polyps, whereas fibroids develop in uterine wall. Successful pregnancy in still in this case.
    • Uterine issues that are present at birth, such as an abnormally shaped uterus, might make it difficult to get pregnant or maintain a pregnancy.
    • A cervical injury or congenital abnormality can lead to cervical stenosis. In this condition, the cervix is narrowed or completely closed which impacts natural fertility.
    • Inability of the cervix to produce a good mucus that will allow sperm to pass through and enter the uterus.
  • Unexplained infertility: Approximately 20% of couples have difficulty in determining the main cause of infertility. In some cases, unexplained infertility can be multifactorial infertility such as a combination of multiple small factors present in both partners. However, treatment, lifestyle changes or medication can still be beneficial.

Risk factors

Risk for female infertility is known to increase with:

  • Age: Age-related infertility is mostly caused by deteriorating egg quality since older women have fewer eggs and are more likely to have health issues that can affect fertility. A woman’s risks of miscarriage and bearing a child with a genetic disorder both rise as she gets older.
  • Sexual history: Unprotected sexual activity with numerous partners raises one’s risk of contracting a sexually transmitted infection (STIs) that could impact female fertility. The fallopian tubes can suffer damage from STIs such chlamydia and gonorrhea.
  • Weight: Obesity and being underweight can cause hormone imbalances that affects ovulation and fertility. Maintaining a healthy weight and a healthy diet is important for women who are trying to get pregnant.
  • Smoking: It is known to prematurely age the ovaries and diminish the egg supply which makes conceiving difficult for some women. Smoking raises the risk of ectopic pregnancy and miscarriage. It is advised to stop smoking prior to starting fertility therapy.
  • Alcohol: Excessive substance use such as alcohol can decrease fertility.

Diagnosis

Fertility testing is often recommended to women who fails to get pregnant after actively trying for more than a year by having frequent unprotected sex with her spouse. Or after six months of trying for those who are 35 years of age or older. The doctor will perform a physical examination and take a thorough medical history evaluation of the couple. Determining the causes of the infertility will provide an effective treatment and give the couple the best opportunity of becoming pregnant.

Common fertility tests for women are:

  • Ovulation test:
    Over-the-counter ovulation prediction kit are also readily available. The kit can pick up the spike in luteinizing hormone (LH) that happens just before ovulation. Progesterone is a hormone released after ovulation, and a blood test for it might show whether the person is ovulating. The levels of additional hormones, such as prolactin, may also be measured.
  • Hysterosalpingography: This procedure helps locate any obstruction in the fallopian tubes. It involves injecting a dye into the uterus while watching it flow through the fallopian tubes. The process is seen and documented with an X-ray. A free-moving dye means that the fallopian tubes do not have blockages.
  • Ovarian reserve testing: This test assesses the viable number of eggs a woman has in her ovaries and determines the ovarian function. These blood and imaging tests may be administered to women who are at risk of having a diminished egg production, especially those over the age of 35.
  • Other hormone testing: The doctor may require thyroid and pituitary hormones testing. Over production and improper function of the thyroid or pituitary gland may stop ovulation. Right level of hormones is necessary to maintain the normal function of the ovaries.
  • Imaging tests: A sonohysterogram, also called saline infusion sonogram (SIS) or hysteroscopy, is a test done to check for polyps, fibroids, or other structural irregularities in the uterine lining. During a transvaginal ultrasound, the uterus is filled with saline (water), which gives a clear image of the uterine cavity. Generally, a pelvic ultrasound tests for fallopian tube or uterine disease.
  • Laparoscopy. This is commonly used to assess or treat endometriosis scarring, blockages, or abnormalities of the fallopian tubes, as well as other ovarian and uterus problems. During the procedure, a narrow-fitted tube with camera (laparoscope) is inserted into the small cut in the abdomen area which will allow doctors to see and assess the organs.
  • Genetic testing. The test identifies any gene alterations, or genetic disorders that may be contributing to infertility.

Treatment

The series of tests will help the healthcare provider determine the exact cause of female infertility and provide a range of possible treatment to increase chances of pregnancy. Typically, the cause, age, duration of infertility and couple’s preferences affects the treatment options. Infertility is a complicated condition that will requires major financial, physical, mental, and time sacrifices for the couple. In some cases, the treatment can involve more than one method.

Common treatments for female infertility are medications, surgery, intrauterine insemination, or assisted reproductive technology. Gestational surrogacy and adoption may also be an option for those who wanted to start a family.

  • Medications: Fertility drugs are the primary form of treatment for female infertility. It is used to control or induce ovulation. It also improves the quality and quantity of eggs of those who ovulates. Fertility drugs are designed like the natural chemicals, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), that promotes ovulation.

Fertility medications for women are:

    • Clomiphene citrate: Targets the pituitary gland which aims to increase the hormones necessary to assist the development and release of a mature egg (ovulation). This drug is not advisable to women who have primary pituitary or ovarian failure. Clomiphene is taken orally. In most cases, this is the first line of treatment for women under the age of 39 without PCOS.
    • Gonadotropins: Instead of releasing one egg every month, this treatment stimulates the ovary to release multiple eggs which gives higher chances for pregnancy. However, known concerns of using gonadotropins is the increased risk of multiple pregnancies and premature deliveries.

Human menopausal gonadotropin, or hMG (Menopur), and FSH (Gonal-F, Follistim AQ, Bravelle) are examples of gonadotropin-containing drugs. Human chorionic gonadotropin (Ovidrel, Pregnyl), a different gonadotropin, is used to mature the eggs and cause their release at the time of ovulation. These medications are administered through injection.

    • Metformin: Prescribed to women diagnosed with PCOS, insulin resistance which can be a contributing factor to infertility. The likelihood of ovulation may increase as a result of metformin’s ability to reduce insulin resistance.
    • Letrozole: Letrozole is an oral medication, ovulation-inducing drug widely used outside of its approved uses. It functions by briefly reducing the level of progesterone in a woman, which stimulates the brain to naturally produce more follicle-stimulating hormone (FSH). It is a member of the class of medications known as aromatase inhibitors and functions similarly to clomiphene.

It is frequently used to enhance the number of mature eggs generated in the ovaries in women with normal ovulation as well as to induce ovulation in women with PCOS.

    • Bromocriptine. Bromocriptine are drugs prescribed to women who experience ovulation issues as a result of excessive prolactin levels. These prescription drugs are consumed orally.
  • Risks of fertility drugs: The infertility specialist will discuss the potential risks with using fertility medications, such as:
    • Pregnancy with multiples. A lot of fertility medications raise a woman’s chance of conceiving twins, triplets, or other multiples which can cause extra complications for the mother. The likelihood of premature birth (too early) is increased among multiple fetuses. There is also a higher risk of health and developmental issues in premature infants.

Statistically, injectable drugs improve one’s chance of multiples by up to 30%. The substantial risk of triplets or more is prevalent with injectable fertility drugs. However, less than 10% of multiple births are caused by oral drugs. If it happens, it is mostly twin pregnancies.

    • Ovarian hyperstimulation syndrome (OHSS). Few women may experience a reaction to the injected fertility drugs which can result in over production of eggs in the ovaries. The condition can develop from mild to severe OHSS.

In mild cases, swollen and uncomfortable ovaries are one of the signs and symptoms, along with mild abdomen discomfort, bloating, nausea, vomiting, and diarrhea. These symptoms typically resolve on its own. In severe cases, common symptoms are sudden weight gain, swollen, painful ovaries, fluid in the belly, and shortness of breath.

    • Long-term risks of ovarian tumors. According to some research, the duration of fertility drug use particularly one year or more without successful pregnancy may contribute to a higher chance of developing borderline ovarian tumor.

Further studies suggest that fertility drug use does not significantly contribute to risk of ovarian tumor. Careful assessment of drug use every few months and focusing on those that have the highest success rates is important especially in the first few treatment cycles.

  • Surgery: If the medications and other treatments fail to fix the fertility issues, surgical treatment may be recommended. These are:
    • Laparoscopic or hysteroscopic surgery: This is a minimally invasive procedure to correct problems that cause infertility or miscarriage by have visibility go the organs and being able to repair the uterus when needed. The procedure can also remove endometrial polyps, fibroids tumors, scar tissues, and ovarian cysts.
    • Tubal surgeries. This procedure aims to repair or open blocked fallopian tubes. The doctor might advise a laparoscopy to remove scar tissues and repair the tubes. This surgery is not commonly recommended since in vitro fertilization (IVF) often results in higher pregnancy rates. The chances of getting pregnant with IVF after this operation may be increased by having your tubes near your uterus removed or blocked.
  • Reproductive assistance: reproductive assistance methods are:
    • Intrauterine insemination (IUI). During the ovulation, the doctor will inject sperm into the uterus after washing it with a specific solution. This is often done while taking medications that triggers ovulation.
    • Assisted reproductive technology (ART). In vitro fertilization (IVF) is the most common ART. The embryos are produced in a lab by combining sperm and mature eggs. The embryo (or embryos) transferred into the woman’s uterus after three to five days. Embryos may also be kept for a later transfer.

ART can be financially and time consuming. Multiple blood tests and daily hormone injections are necessary during an IVF cycle. Success rates of IVF generally depends on the specialist, infertility diagnosis and age.

Doctors who treat this condition

Diseases & Conditions Female infertility