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Female Fertility


Causes

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 right. In women, a number of factors can disrupt this process at any stage leading to difficulty in conception. They include:

Disorders of The Ovary

Ovulation disorders constitute one of the most common causes. Most of them are treatable. You have 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 and body hair, obesity to name a few.
  • Hormonal Imbalances: Production of appropriate amounts of hormones: FSH (Follicle Stimulating Hormone) and LH (Lutenizing 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.
  • Luteal phase defect: It occurs due to insufficient progesterone levels, which again maybe due to a variety of causes. This leads to the uterine lining being inadequately prepared for implantation of the fertilized egg. Such women usually have normal periods and hence, remains undetected till being investigated for infertility.
  • Premature ovarian failure: This occurs when the ovary fails to produce eggs before the time of menopause. 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.
  • Un-ruptured follicle syndrome: A normal follicle, with an egg inside of it is produced every month yet the follicle fails to rupture. The egg, therefore remains inside the follicle and ovulation does not occur.

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, termination of pregnancy (MTP) or IUD (intrauterine device) insertion
  • Post-operative 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.

More often than not, PID is a silent disease.

Endometriosis

Endometriosis occurs when present on the inner lining of the uterus grows outside the uterus, usually on the surfaces of organs in the pelvic and abdominal areas, in places that it is not supposed to grow. When the ovaries are involved, it leads to formation of "chocolate cysts". The symptoms include heavy, painful and long menstrual periods, urinary urgency, rectal bleeding and premenstrual spotting and infertility. 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.

Uterine Causes

Benign tumors (fibroids or myomas) in the uterus, common in women in their 30s, can impair fertility by blocking the fallopian tubes or by disrupting implantation.

Unexplained Infertility

In some instances, a cause for infertility is never found. It's possible that combinations of minor factors in both partners underlie these unexplained fertility problems.

Miscellaneous Causes

Other than the common causes mentioned above, infertility can occur due to vast number of medical and surgical abnormalities. In many cases, it may be due to abnormalities in both the partners to some extent. Some of the causes include:

  • Congenital abnormalities, such as septate uterus, unicornuate uterus
  • Abnormalities of Cervical mucus
  • Adverse lifestyle and behavioral factors

Evaluation

Some infertile couples have more than one cause of their infertility. In some cases, the cause of infertility may be unclear, or it may take a number of tests to determine the cause. They include:

Medical history

This includes questions about illnesses and surgeries that could affect fertility. Medications, menstrual history and sexual habits are also evaluated. Sexual development and whether one has had any signs of hormonal imbalances are also looked for.

General Physical Examination

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.

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 tubes are open. The laparoscope can also be used to look for other problems that may affect fertility, such as adhesions (scar tissue) or endometriosis.

Hysteroscopy

In this procedure, a small scope is inserted into the uterus through the vagina to look inside of the uterus. This test is done if uterine abnormalities are seen during the HSG (tubogram),for suspected scars or polyps

Hormone testing for FSH, LH, Prolactin,T3,74,TSH

Endometrial Biopsy

It involves scraping and examining a sample of tissue from the lining of the uterus. One can then determine if ovulation has occurred, any infection, whether the lining of the uterus has undergone the changes necessary for the implantation of a fertilized egg and support of an early pregnancy. An endometrial biopsy can also detect an infection or inflammation of the endometrium (endometriosis).

Pelvic Ultrasound

Ultrasound is the standard technique for evaluating the uterus and ovaries, detecting fibroids/polyps, ovarian cysts and tumors. Transvaginal sonohysterography uses ultrasound along with saline infused into the uterus, which enhances the visualization of the uterus.

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.