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FEMALE INFERTILITY

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DEFINITION

Infertility means that couples have been trying to get pregnant with frequent intercourse for at least a year with no success. Female infertility, male infertility or a combination of the two affects millions of couples in the United States. An estimated 10 to 15 percent of couples have trouble getting pregnant or getting to a successful delivery.

Infertility results from female infertility factors about one-third of the time and male infertility factors about one-third of the time. In the rest, the cause is either unknown or a combination of male and female factors.

The cause of female infertility can be difficult to diagnose, but many treatments are available. Treatment options depend on the underlying problem. Treatment isn’t always necessary — many infertile couples will go on to conceive a child spontaneously.

SYMPTOMS

The main symptom of infertility is the inability of a couple to get pregnant. A menstrual cycle that’s too long (35 days or more), too short (less than 21 days), irregular or absent can be a sign of lack of ovulation, which can be associated with female infertility. There may be no other outward signs or symptoms.

WHEN TO SEE A DOCTOR

When to seek help depends, in part, on your age.

If you’re in your early 30s or younger, most doctors recommend trying to get pregnant for at least a year before having any testing or treatment.

If you’re between 35 and 40, discuss your concerns with your doctor after six months of trying.

If you’re older than 40, your doctor may want to begin testing or treatment right away.

Your doctor also may want to begin testing or treatment right away if you or your partner has known fertility problems, or if you have a history of irregular or painful periods, pelvic inflammatory disease, repeated miscarriages, prior cancer treatment, or endometriosis.

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CAUSES

To become pregnant, each of these factors is essential:

  • YOU NEED TO OVULATE. Achieving pregnancy requires that your ovaries produce and release an egg, a process known as ovulation. Your doctor can help evaluate your menstrual cycles and confirm ovulation.
  • YOUR PARTNER NEEDS SPERM. For most couples, this isn’t a problem unless your partner has a history of illness or surgery. Your doctor can run some simple tests to evaluate the health of your partner’s sperm.
  • YOU NEED TO HAVE REGULAR INTERCOURSE. You need to have regular sexual intercourse during your fertile time. Your doctor can help you better understand when you’re most fertile during your cycle.
  • YOU NEED TO HAVE OPEN FALLOPIAN TUBES AND A NORMAL UTERUS. The egg and sperm meet in the fallopian tubes, and the pregnancy needs a healthy place to grow.

For pregnancy to occur, every part of the complex human reproduction process has to take place just right. The steps in this process are as follows:

  • One of the two ovaries releases a mature egg.
  • The egg is picked up by the fallopian tube.
  • Sperm swim up the cervix, through the uterus and into the fallopian tube to reach the egg for fertilization.
  • The fertilized egg travels down the fallopian tube to the uterus.
  • The fertilized egg implants and grows in the uterus.

In women, a number of factors can disrupt this process at any step. Female infertility is caused by one or more of these factors.

OVULATION DISORDERS

Ovulation disorders, meaning you ovulate infrequently or not at all, account for infertility in about 25 percent of infertile couples. These can be caused by flaws in the regulation of reproductive hormones by the hypothalamus or the pituitary gland, or by problems in the ovary itself.

  • POLYCYSTIC OVARY SYNDROME (PCOS). In PCOS, complex changes occur in the hypothalamus, pituitary gland and ovaries, resulting in a hormone imbalance, which affects ovulation. PCOS is associated with insulin resistance and obesity, abnormal hair growth on the face or body, and acne. It’s the most common cause of female infertility.
  • HYPOTHALAMIC DYSFUNCTION. The two hormones responsible for stimulating ovulation each month — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — are produced by the pituitary gland in a specific pattern during the menstrual cycle. Excess physical or emotional stress, a very high or very low body weight, or a recent substantial weight gain or loss can disrupt this pattern and affect ovulation. The main sign of this problem is irregular or absent periods.
  • PREMATURE OVARIAN INSUFFICIENCY. This disorder is usually caused by an autoimmune response where your body mistakenly attacks ovarian tissues or by premature loss of eggs from your ovary due to genetic problems or environmental insults such as chemotherapy. It results in the loss of the ability to produce eggs by the ovary, as well as a decreased estrogen production under the age of 40.
  • TOO MUCH PROLACTIN. Less commonly, the pituitary gland can cause excess production of prolactin (hyperprolactinemia), which reduces estrogen production and may cause infertility. Most commonly this is due to a problem in the pituitary gland, but it can also be related to medications you’re taking for another disease.

DAMAGE TO FALLOPIAN TUBES (TUBAL INFERTILITY)

When fallopian tubes become damaged or blocked, they keep sperm from getting to the egg or block the passage of the fertilized egg into the uterus. Causes of fallopian tube damage or blockage can include:

  • Pelvic inflammatory disease, an infection of the uterus and fallopian tubes due to chlamydia, gonorrhea or other sexually transmitted infections
  • Previous surgery in the abdomen or pelvis, including surgery for ectopic pregnancy, in which a fertilized egg becomes implanted and starts to develop in a fallopian tube instead of the uterus
  • Pelvic tuberculosis, a major cause of tubal infertility worldwide, although uncommon in the United States

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ENDOMETRIOSIS

Endometriosis occurs when tissue that normally grows in the uterus implants and grows in other locations. This extra tissue growth — and the surgical removal of it — can cause scarring, which may obstruct the tube and keep the egg and sperm from uniting. It can also affect the lining of the uterus, disrupting implantation of the fertilized egg. The condition also seems to affect fertility in less-direct ways, such as damage to the sperm or egg.

 

UTERINE OR CERVICAL CAUSES

Several uterine or cervical causes can impact fertility by interfering with implantation or increasing the likelihood of a miscarriage.

  • Benign polyps or tumors (fibroids or myomas) are common in the uterus, and some types can impair fertility by blocking the fallopian tubes or by disrupting implantation. However, many women who have fibroids or polyps can become pregnant.
  • Endometriosis scarring or inflammation within the uterus can disrupt implantation.
  • Uterine abnormalities present from birth, such as an abnormally shaped uterus, can cause problems becoming or remaining pregnant.
  • Cervical stenosis, a cervical narrowing, can be caused by an inherited malformation or damage to the cervix.
  • Sometimes the cervix can’t produce the best type of mucus to allow the sperm to travel through the cervix into the uterus.

UNEXPLAINED INFERTILITY

 

In some instances, a cause for infertility is never found. It’s possible that a combination of several minor factors in both partners underlie these unexplained fertility problems. Although it’s frustrating to not get a specific answer, this problem may correct itself with time.

RISK FACTORS

Certain factors may put you at higher risk of infertility, including:

  • With increasing age, the quality and quantity of a woman’s eggs begin to decline. In the mid-30s, the rate of follicle loss accelerates, resulting in fewer and poorer quality eggs, making conception more challenging and increasing the risk of miscarriage.
  • Besides damaging your cervix and fallopian tubes, smoking increases your risk of miscarriage and ectopic pregnancy. It’s also thought to age your ovaries and deplete your eggs prematurely, reducing your ability to get pregnant. Stop smoking before beginning fertility treatment.
  • If you’re overweight or significantly underweight, it may hinder normal ovulation. Getting to a healthy body mass index (BMI) has been shown to increase the frequency of ovulation and likelihood of pregnancy.
  • SEXUAL HISTORY. Sexually transmitted infections such as chlamydia and gonorrhea can cause fallopian tube damage. Having unprotected intercourse with multiple partners increases your chances of contracting a sexually transmitted disease (STD) that may cause fertility problems later.
  • Heavy drinking is associated with an increased risk of ovulation disorders and endometriosis.

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TESTS AND DIAGNOSIS

If you’ve been unable to conceive within a reasonable period of time, seek help from your doctor for further evaluation and treatment of infertility.

Fertility tests may include:

  • OVULATION TESTING. An over-the-counter ovulation prediction kit — a test that you can perform at home — detects the surge in luteinizing hormone (LH) that occurs before ovulation. If you have not had positive home ovulation tests, a blood test for progesterone — a hormone produced after ovulation — can document that you’re ovulating. Other hormone levels, such as prolactin, also may be checked.
  • During hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee), X-ray contrast is injected into your uterus and an X-ray is taken to determine if the uterine cavity is normal and whether the fluid passes out of the uterus and spills out of your fallopian tubes. If abnormalities are found, you’ll likely need further evaluation. In a few women, the test itself can improve fertility, possibly by flushing out and opening the fallopian tubes.
  • OVARIAN RESERVE TESTING. This testing helps determine the quality and quantity of eggs available for ovulation. Women at risk of a depleted egg supply — including women older than 35 — may have this series of blood and imaging tests.
  • OTHER HORMONE TESTING. Other hormone tests check levels of ovulatory hormones as well as thyroid and pituitary hormones that control reproductive processes.
  • IMAGING TESTS. Pelvic ultrasound looks for uterine or fallopian tube disease. Sometimes a hysterosonography (his-tur-o-suh-NOG-ruh-fee) is used to see details inside the uterus that are not seen on a regular ultrasound.

Depending on your situation, rarely your testing may include:

  • OTHER IMAGING TESTS. Depending on your symptoms, your doctor may request a hysteroscopy to look for uterine or fallopian tube disease.
  • This minimally invasive surgery involves making a small incision beneath your navel and inserting a thin viewing device to examine your fallopian tubes, ovaries and uterus. Laparoscopy may identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.
  • GENETIC TESTING. Genetic testing helps determine whether there’s a genetic defect causing infertility.

TREATMENTS AND DRUGS

How your infertility is treated depends on the cause, your age, how long you’ve been infertile and personal preferences. Because infertility is a complex disorder, treatment involves significant financial, physical, psychological and time commitments. Although some women need just one or two therapies to restore fertility, it’s possible that several different types of treatment may be needed before you’re able to conceive.

Treatments can either attempt to restore fertility — by means of medication or surgery — or assist in reproduction with sophisticated techniques.

FERTILITY RESTORATION: STIMULATING OVULATION WITH FERTILITY DRUGS

Fertility drugs, which regulate or induce ovulation, are the main treatment for women who are infertile due to ovulation disorders. In general, they work like the natural hormones — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — to trigger ovulation. They are also used in women who ovulate to try to stimulate a better egg or an extra egg or eggs. Fertility drugs may include:

  • CLOMIPHENE CITRATE. Clomiphene citrate (Clomid, Serophene) is taken by mouth and stimulates ovulation by causing the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg.
  • Instead of stimulating the pituitary gland to release more hormones, these injected treatments stimulate the ovary directly. Gonadotropin medications include human menopausal gonadotropin or hMG (Repronex, Menopur) and FSH (Gonal-F, Follistim AQ, Bravelle). All act to stimulate production of multiple eggs. Another gonadotropin, human chorionic gonadotropin (Ovidrel, Pregnyl), is used to mature the eggs and trigger their release at the time of ovulation.
  • Metformin (Glucophage, others) is used when insulin resistance is a known or suspected cause of infertility, usually in women with a diagnosis of PCOS. Metformin helps improve insulin resistance, which can make ovulation more likely to occur.
  • Letrozole (Femara) belongs to a class of drugs known as aromatase inhibitors and works in a similar fashion to clomiphene. Letrozole may induce ovulation. However, the effect this medication has on early pregnancy isn’t yet known, so it isn’t used for ovulation induction as frequently as others.
  • Bromocriptine (Parlodel, Cycloset) may be used when ovulation problems are caused by excess production of prolactin (hyperprolactinemia) by the pituitary gland.

FERTILITY RESTORATION: SURGERY

Several surgical procedures can correct problems or otherwise improve female fertility. However, surgical treatments for fertility are rare these days now that other fertility treatments have high success. They include:

  • LAPAROSCOPIC OR HYSTEROSCOPIC SURGERY. These surgeries can remove or correct abnormalities that decrease pregnancy rates. This can include correcting an abnormal uterine shape, removing endometrial polyps and some types of fibroids that misshape the uterine cavity or pelvic or uterine adhesions. This can improve your chances of achieving pregnancy.
  • TUBAL LIGATION REVERSAL SURGERY (MICROSCOPIC). After a woman has had her tubes tied for permanent contraception (tubal ligation), surgery may be done to reconnect them and restore fertility. Your doctor can determine whether you’re a good candidate for this or whether in vitro fertilization (IVF) might be a better choice for you.
  • TUBAL SURGERIES. If your fallopian tubes are blocked or filled with fluid (hydrosalpinx), laparoscopic surgery may be performed to remove adhesions, dilate a tube or create a new tubal opening. However, this is rarely done, as pregnancy rates are usually better with IVF. For hydrosalpinx, removal of your tubes (salpingectomy) or blocking the tubes close to the uterus can improve your chances of pregnancy with IVF.

SUMMARY

Infertility means not being able to get pregnant after at least one year of trying (or 6 months if the woman is over age 35). If a woman keeps having miscarriages, it is also called infertility. Female infertility can result from age, physical problems, hormone problems, and lifestyle or environmental factors.

Most cases of infertility in women result from problems with producing eggs. In premature ovarian failure, the ovaries stop functioning before natural menopause. In polycystic ovary syndrome (PCOS), the ovaries may not release an egg regularly or they may not release a healthy egg.

About a third of the time, infertility is because of a problem with the woman. One third of the time, it is a problem with the man. Sometimes no cause can be found.

If you think you might be infertile, see your doctor. There are tests that may tell if you have fertility problems. When it is possible to find the cause, treatments may include medicines, surgery, or assisted reproductive technologies. Happily, many couples treated for infertility are able to have babies.