What Is Infertility?

Infertility means failure to conceive after trying for at least one year or 6 months if a woman is over 35. It is a condition that affects both genders equally. Overall around 15% of couples struggle to conceive. It is important to remember that infertility can arise from female factors (about 35%), male factors (about 35%), a combination of both (20%), or from unknown causes (about 10%).

Types Of Infertility In Women

• Primary infertility: The couple’s inability to conceive any child at all after having regular unprotected sex.
• Secondary infertility: Couples who have already conceived a first child but have great difficulty in adding to their family.

Female infertility can arise if any problems occur in any of these steps:

• Ovulation: The ovaries must produce an egg.
• Womb: The egg must swim through the fallopian tube and enter the uterus.
• Fertilization: A man’s sperm must fertilize the egg along the way.
• Implantation: The embryo must attach inside the uterus and grow.

What Causes Infertility In Women?

A number of factors can cause female infertility. Some of these are:

1. Ovulation Disorders

Ovulation disorders account for 1/3rd of female infertility and the most common problem for unsuccessful pregnancy. The pituitary gland or the hypothalamus produces reproductive hormones, any abnormality in its regulation or complications in the ovary can cause ovulation disorders.

Symptoms

The inability to conceive is the main symptom of infertility. If your menstrual cycle is too short (under 21 days), too long (more than 35 days), irregular or altogether absent, it could mean you are not ovulating.

When to See a Doctor

Determining when to see a doctor will depend on your age.

• Up to 35 years: Most times, your doctor will suggest you to try at least 1 year before seeking treatment.
• 35 – 40 years: Consult a doctor after trying to conceive for 6 months.
• Above 40 years: Your doctor might start treatment or tests right away.

It is also possible for your doctor to suggest treatment and tests right away if either you or your partner has a history of infertility or if you have a history of endometriosis, prior cancer treatment, frequent miscarriages, pelvic inflammatory disease, painful or irregular periods.

Some causes of ovulation disorders are as follows:

Primary ovarian insufficiency (POI)

POI or premature ovarian failure causes ovulation problems. This disorder is caused when the ovary stops releasing eggs and lowers its estrogen production before she turns 40.

POI is also referred to as premature menopause, but they are both different. Women with POI  have chances of conceiving even after irregular periods for years, but those with early menopause will stop having periods nor get pregnant.

Patients with POI have deficient estrogen and as a result, cause osteoporosis. It can be improved by increasing the estrogen level. Age, family history, and ovarian surgeries can also be associated with POI.

Some symptoms of POI include; night sweats, irregular menstrual cycle, inability to conceive, hot flashes, dry vagina, low sex drive, etc. Women should see a doctor if they experience these symptoms.

What Causes POI?

A healthy ovary produces mature eggs each month for fertilization along with two essential hormones, estrogen and progesterone, to facilitate pregnancy. On the other hand, POI  prevents the ovary from working normally.

The causes of POI are:

• Genetic disorders: POI may arise due to specific genetic conditions or flaws in the chromosomes such as mosaic Turner’s syndrome, where a woman has only one X chromosome while the other one is either inactive or missing.
• Antibodies: In this case, the female’s immune system releases antibodies that affect the ovarian tissue, harm the follicles(or the sac that contains eggs) and damage the eggs.
• Toxins: Cancer treatments( chemotherapy and radiation ) are associated with toxin-induced POI. Such treatments damage the DNA in cells. Other toxic substances like pesticides, cigarette smoke, and viruses might also cause POI.

Treatment

Restoring estrogen levels is the main focus when treating POI. Some of these treatments include:

• Estrogen therapy: Such therapy can inhibit osteoporosis and can help in treating estrogen deficiency. Your doctor will prescribe estrogen with progesterone as it prevents precancerous changes induced by taking estrogen alone.
• Supplements: Vitamin D and calcium supplements can prevent osteoporosis. Your doctor will recommend a bone density testing before prescribing the supplements.

It is recommended to take 1000mg of calcium per day for females aged 19-50 while 1200mg for those above 50 years. The ideal dosage of vitamin D is not known yet, but  600-800 IU a day is a good start for adults.

Higher doses may be recommended in cases of low vitamin D.

Hypothalamic dysfunction

This refers to the malfunction of the pituitary gland. The pituitary gland releases two hormones; FSH and LH, that stimulates ovulation. If excess or too less of these hormones are produced, the ovary won’t ovulate normally. This can be due to a tumor, physical injury, or an abnormality in the pituitary gland.

What Causes Hypothalamic dysfunction?

There are various causes of hypothalamic dysfunction. Some of the common causes include; head injury, surgery, radiation, and tumor. It can also be associated with Prader-Willi syndrome, a genetic condition where a person is missing some chromosomes.

Excessive bleeding, malnutrition, eating disorders, and infections are some other causes of hypothalamic dysfunction.

Polycystic Ovarian Syndrome (PCOS)

Common among women, PCOS is a hormonal imbalance that causes infrequent or longer periods of menstruation and infertility in women.

If not diagnosed and treated early, it can cause type-2 diabetes and heart disease. Some symptoms of PCOS include; Irregular menstrual cycle, polycystic ovaries, increase in androgen.

Causes Polycystic Ovarian Syndrome (PCOS)

The root cause of PCOS is not known yet, but some of these factors might be associated with it:

• Genes: report shows that PCOS might be caused due to certain genes.
• Low-grade inflammation: White blood cells release substances that fight infections. Some reports suggest women with PCOS are linked with low-grade inflammation.
• Excess androgen: High levels of male hormone(androgen) is released by the ovaries which cause hirsutism and acne
• Excess insulin: The pancreas produces a hormone known as insulin, which is used by the cells as a primary energy supply for your body. When cells become resistant to it, the sugar level in your body increases and lead to excess insulin. This might lead to the production of more androgen and cause ovulation problems.
• Hyperprolactinemia: It is a condition where a person has excess prolactin in their blood. The pituitary gland releases excess prolactin, which leads to lower production of estrogen and causes infertility. Like other pituitary gland problems, it can also be caused by certain medications used for treating another disease.

What Causes Hyperprolactinemia?

• Tumor: One major cause of hyperprolactinemia is prolactinoma( pituitary gland tumor). These tumors are more common in women than men; it produces excess prolactin and is not cancerous. Larger tumors can even cause headache and blurry vision.
• Medications: Certain drugs can also lead to excess production of prolactin. Some of these drugs are methyldopa, SSRI antidepressants, opiates, Risperdal, etc.

Hypothyroidism, chest- wall injuries, kidney and liver problems, radiation treatments are some other causes.

Treatment

The treatment for hyperprolactinemia depends on its cause. If the patient has the condition but shows no signs or symptoms, then treatment isn’t required. However, there are some options  for treating the tumor:

• Medicines: Prescription drugs such as bromocriptine and cabergoline are used to reduce the production of excess prolactin.
• Surgery: If such medicines are not effective, surgery is needed to remove the tumor.
• Radiation: In rare cases, if both the above options are not found to be ineffective, then radiation is preferred to reduce the size of the tumor.

Synthetic thyroid hormone is also used to remedy hypothyroidism and reduce excess production of prolactin.

2. Damage to Fallopian Tube

Damaged fallopian tubes are another possible cause of infertility. It keeps the embryo from entering the uterus. Main causes of fallopian tube damage include:

• Pelvic inflammatory disease: Bacteria, viruses, and STDs like Chlamydia and gonorrhea infects the fallopian tube. Sometimes women with PID don’t know that they have the condition as it rarely shows any symptoms. It is later detected when they can’t conceive or suffer from chronic pelvic pain.

Some of the symptoms are; serious pelvic pain, foul vaginal discharge, high fever(>38.3 C). It is better to consult a doctor if you experience such symptoms.

The chances of having PID is increased if a woman:

• is sexually active before 25 years
• has many sexual partners
• is sexually active with someone with multiple partners
• has unprotected intercourse
• Prior-surgeries: Pelvic or abdominal surgery can result in adhesion that stops the egg from passing through the fallopian tube. Surgery for ectopic pregnancy can also cause the embryo to implant and develop in the tubes and not the uterus.

3. Endometriosis

A painful disorder that occurs when the tissue grows elsewhere instead of the uterus(endometrium). About 10% of partners who experience infertility are related to endometriosis.

The excision of the extra tissue causes scarring, which can lead to fallopian tube blockage and stop the sperm from interacting with the egg. Recent studies reveal that treating minimal endometriosis does not accelerate the rate of a successful pregnancy.

4. Uterine Or Cervical Causes

Most uterine causes can affect fertility by interfering with the implantation of the sperm and accelerating the chances of miscarriage. Some of these causes include:

• Fibroids and polyps tumors in the uterus can cause an obstruction in the womb or the fallopian tubes.
• An estimated 3% of couples who experience infertility are related to cervix mucus problems.
• Congenital abnormalities can cause repeated miscarriages and unsuccessful pregnancy.
• An inherited abnormality or damaged cervix can cause cervical stenosis ( narrowing of the cervix)

5. Unidentified Infertility

Sometimes, the exact cause of infertility can be hard to identify. Both male and female factors combined can cause unexplained infertility. Although the exact reason for infertility is hard to identify, it is not recommended to delay its diagnosis and treatment.

Risk Factors

Certain personal and lifestyle choices affect health; most of these factors also limit the couple’s ability to conceive.

• Diet and exercise: Both overweight and underweight women may have difficulty conceiving, which is why a proper diet and training is recommended for optimum reproductive functioning.
• Smoking: It reduces sperm counts and reduces sperm growth and increases the risks of miscarriage and premature birth for women.
• Alcohol and drugs: Consumption of both alcohol and drugs significantly raises the chances of infertility in women.

Prevention of female infertility

If you want to get pregnant soon or in the near future, here are some ways to increase your normal fertility:

• Maintain a healthy weight: If you are underweight or overweight, it will increase your chance of ovulation disorders. Exercise moderately if you want to lose weight. Intense, strenuous exercise lasting for over 5 hours is also associated with a decrease in ovulation.
• Quit smoking: Besides affecting your general health, tobacco also affects the fertility of a woman in many ways, including the health of the fetus. If you are a smoker and is looking to conceive, quit immediately.
• No alcohol: Excessive alcohol consumption leads to decreased fertility. Drinking alcohol while pregnant will also negatively affect the developing fetus. It is important to avoid alcohol if you are trying to conceive.
• Reduce stress: Studies show that couples that experience psychological stress have a lower chance of getting successful outcomes in their fertility treatment. Before trying to conceive, find a way to create a stress-free environment.
• Lower caffeine intake: Research has suggested that your ability to conceive will increase when you limit your caffeine intake by 200 milligrams per day. This is about 1-2 cups of 6-8 ounce coffee cups per day.

Environmental And Occupational Factors of female infertility

Overexposure to harmful toxins or chemicals present in the workplace and the surrounding can cause infertility.

• Lead: Lead can negatively impact human fertility. It can lead to abortion.
• Medical treatments and materials: Frequent exposure to radiation (x-ray, chemotherapy) alters sperm production and contributes to ovarian problems.
• Ethylene oxide: Using ethylene oxide (a chemical used in sterilization) causes complications in the early stage of pregnancy and can even cause a miscarriage.
• Dibromocholoropropane (DBCP): Handling DBCP (chemicals found in pesticide) can cause ovarian disorders and directly impact fertility.

Age as a cause of female infertility

Age is a major cause of fertility problems. About 1/3rd  partners in which the women are over 35 experience infertility. Age reduces a woman’s chance of getting pregnant because of the following reasons:

• As the female ages, her ovaries release fewer eggs
• The quality of her eggs decreases with age
• Health problems may occur leading to fertility issues
• More likely to experience a miscarriage

Diagnosis For Infertility In Women

Usually, doctors recommend getting an infertility checkup; a physical exam, questions about your medical and sexual history. Sometimes an infertility checkup can identify the cause. However, doctors will need to perform tests to find the cause. Some of these tests include:

Hysterosalpingography

This is an x-ray of the uterus and fallopian tubes. A special dye is inserted into the uterus through the vagina. This helps the doctors to see if the dye can move freely into the uterus and also the fallopian tube.

It helps in detecting physical blockage that can cause infertility. These blocks keep the eggs from passing through the fallopian tubes and into the uterus. It can also stop the sperm from swimming towards the egg.

Laparoscopy

A minor surgery which involves a small incision to see inside the abdomen and inserts a small tool (laparoscope) to examine the ovaries, fallopian tubes, and uterus for any signs of disease or physical problems. A laparoscopy usually detects scarring, endometriosis, and blocks in the fallopian tubes.

Ovulation Tests And Ovarian Reserve Testing

This can be done at home using an ovulation test kit. It can detect a sudden increase in Luteinizing Hormone (LH). Blood tests can also show signs of ovulation problems. Ovarian reserve testing helps in determining the condition of the eggs available.

Treatments Available For Female Infertility

Infertility can be corrected with a combination of medicines, surgery, artificial reproductive technology, or ARTs. Doctors suggest treatments based on:

• Laboratory test results
• How long the couples have been struggling to conceive
• Age of both genders
• The health of both partners
• Personal preferences

Medications (Fertility Drugs)

Fertility drugs are fundamental treatments for females who have fertility problems due to ovulation disorders. Such drugs improve ovulation by helping to produce natural hormones ( FSH and LH).  Some of these fertility drugs are:

Clomiphene

Clomiphene (or Clomid) is very effective in treating fertility problems. It should be taken orally, like tablets and pills (50mg) every day for 5 days and then observe the result. These drugs make the pituitary gland to release more LH and FSH and thereby stimulates ovulation.

Some side effects include drying of the vagina, irritation, vomiting, and nausea.

Gonadotropins

These treatments are injected to stimulate the ovary directly to release more eggs. Gonadotropin medications include HMG (Menopur), FSH ( Bravelle, Gonal-F, Follistim AQ) and human chorionic gonadotropin (Pregnyl, Ovidrel).

However, gonadotropin usage can increase the risks of having multiples and premature births.

Bromocriptine

Bromocriptine ( Cycloset) is used when the pituitary gland produces excess prolactin.

Letrozole (Ferama)

An aromatase inhibitor (similar to clomiphene) that is used to stimulate ovulation. However, it isn’t used much like the others since the effects it has on early pregnancy is not known.

Metformin

It is used by patients diagnosed with PCOS or when the problem is due to insulin resistance.

Risks of Using Fertility Drugs

• Increases the risks of conceiving twins.
• It can cause Ovarian Hyperstimulation Syndrome (OHS), swollen and painful ovaries.
• Long-term risks of tumors

Surgical Treatments

There are several surgical procedures available to treat infertility problems and restore fertility. The success rates of other treatments are higher, so surgical treatments are rarely preferred nowadays.

Tubal Surgeries

Laparoscopic surgery is done to remove adhesions, create new tubal openings, and remove blocks or fluids in the fallopian tubes. As IVF produce better results, laparoscopic surgery is rarely done.

Laparoscopic or Hysteroscopic Surgery

These surgeries improve the chances of conceiving. Surgery involves removing polyps and fibroids that causes abnormality in the uterus, uterine adhesion removal.

Reproductive Assistance

Common methods used in reproductive assistance technology (ART) include:

Intrauterine Insemination (IUI)

This treatment involves the transfer of healthy sperm inside the uterus. IUI accelerate the chances of ovulation. IUI treatments are cheaper compared to IVF.

Assisted Reproductive Technology

The sperm cell and the egg cell are kept together in a lab dish for fertilization. After fertilization, the embryo is transferred to the uterus for implantation. IVF is one major and effective method of assisted reproductive technology. It requires multiple blood tests and hormone injections and can take several weeks.

Preparing Before The Appointment

These are some of the steps you can follow before your infertility tests:

1. Note down your menstrual cycles and related symptoms, days you have sex with your partner, etc.
2. List the number of medications, supplements you take, its doses, and mention how often you consume them.
3. Document your medical history and carry it along with you during your appointment.
4. Carry a notepad to note down relevant pieces of information at your visit.
5. Make a list of the important questions you’ll ask.

References:

https://www.mayoclinic.org/diseases-conditions/female-infertility/symptoms-causes/syc-20354308

https://web.stanford.edu/class/siw198q/websites/reprotech/New%20Ways%20of%20Making%20Babies/Causefem.htm

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