Female Infertility
FEMALE INFERTILITY

Causes of Failure to Ovulate

Ovulatory disorders are one of the most common reasons why women are unable to conceive, and account for 30% of women’s infertility. The causes of failed ovulation can be categorized as follows:

(1) Hormonal Problems

These are the most common causes of anovulation.  The process of ovulation depends upon a complex balance of hormones and their interactions to be successful, and any disruption in this process can hinder ovulation.  There are three main sources causing this problem:

Failure to produce mature eggs

In approximately 50% of the cases of anovulation, the ovaries do not produce normal follicles in which the eggs can mature.  Ovulation is rare if the eggs are immature and the chance of fertilization becomes almost non existent.  Polycystic ovary syndrome, the most common disorder responsible for this problem, includes symptoms such as amenorrhoea, hirsutism, anovulation and infertility.  This syndrome is characterized by a reduced production of FSH, and normal or increased levels of LH, oestrogen and testosterone.  The current hypothesis is that the suppression of FSH associated with this condition causes only partial development of ovarian follicles, and follicular cysts can be detected in an ultrasound scan.  The affected ovary often becomes surrounded with a smooth white capsule and is double its normal size.  

Malfunction of the hypothalamus

The hypothalamus is the portion of the brain responsible for sending signals to the pituitary gland, which, in turn, sends hormonal stimuli to the ovaries in the form of FSH and LH to initiate egg maturation.  If the hypothalamus fails to trigger and control this process, immature eggs will result.  This is the cause of ovarian failure in 20% of cases. Excess physical or emotional stress, a very high or very low body weight, or a recent substantial weight gain or loss can disrupt production of these hormones and affect ovulation. Irregular or absent periods are the most common signs.

Malfunction of the pituitary gland

The pituitary’s responsibility lies in producing and secreting FSH and LH.  The ovaries will be unable to ovulate properly if either too much or too little of these substances is produced.  This can occur due to physical injury, a tumor or if there is a chemical imbalance in the pituitary.

Too much prolactin. The pituitary gland may cause excess production of prolactin (hyperprolactinemia), which reduces estrogen production and may cause infertility. Usually related to a pituitary gland problem, this can also be caused by medications you're taking for another disease.

(2) Scarred Ovaries

Physical damage to the ovaries may result in failed ovulation. For example, extensive, invasive, or multiple surgeries, for repeated ovarian cysts may cause the capsule of the ovary to become damaged or scarred, such that follicles cannot mature properly and ovulation does not occur. Chronic inflammation may also have this impact.

(3) Premature Menopause

This is quite often  the cause of anovulation.  Some women cease menstruation and begin menopause before normal age. Also called Premature ovarian failure or  Primary ovarian insufficiency, this disorder is usually caused by an autoimmune response or by premature loss of eggs from your ovary (possibly from genetics or chemotherapy). The ovary no longer produces eggs, and it lowers estrogen production in women under the age of 40.

(4) Follicle Problems

Although currently unexplained, “unruptured follicle syndrome” occurs in women who produce a normal follicle, with an egg inside of it, every month yet the follicle fails to rupture.  The egg, therefore, remains inside the ovary and proper ovulation  does not occur.

Causes of Poorly Functioning Fallopian Tubes

Tubal disease affects approximately 25% of infertile couples and varies widely, ranging from mild adhesions to complete tubal blockage. 
Damaged or blocked fallopian tubes 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 implants and develops in a fallopian tube instead of the uterus
•    Pelvic tuberculosis, a major cause of tubal infertility worldwide, 

Endometriosis

Approximately 10% of infertile couples are affected by endometriosis.  In fact, 30-40% of patients with endometriosis are infertile.  This is two to three times the rate of infertility in the general population.  This condition is characterized by excessive growth of the lining of the uterus, called the endometrium.  Growth occurs not only in the uterus but also elsewhere in the abdomen, such as in the fallopian tubes, ovaries and the pelvic peritoneum.  The symptoms often associated with endometriosis include heavy, painful and long menstrual periods, urinary urgency, rectal bleeding and premenstrual spotting.  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. 

Problems with the uterus causing female infertility

The fertilised egg lodges (implants) in the lining of the uterus. Some uterine problems that can hamper implantation include: 
•    fibroids – non-malignant tumours inside the womb
•    polyps – overgrowths of the endometrium, which can be prompted by the presence of fibroids
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Problems with the cervix causing female infertility

At the top of the vagina is the neck or entrance to the uterus, called the cervix. Ejaculated sperm must travel through the cervix to reach the uterus and fallopian tubes. 

Cervical mucus around the time of ovulation is normally thin and watery so that sperm can swim through it. However, thick or poor quality cervical mucus can hinder the sperm.

Diagnosis of infertility begins with a medical history and physical exam. The tests, usually include the following:

Lab tests

hormone testing, to measure levels of female hormones at certain times during a menstrual cycle
day 2 or 3 measure of FSH and estrogen, to assess ovarian reserve
measurements of thyroid function .Tthyroid stimulating hormone (TSH) level of between 1 and 2 is considered optimal for conception
measurement of progesterone in the second half of the cycle to help confirm ovulation
Anti-Müllerian hormone to estimate ovarian reserve.

Examination and imaging

laparoscopy, which allows the provider to inspect the pelvic organs
Pap smear to check for signs of infection
pelvic exam, to look for abnormalities or infection
a postcoital test, which is done soon after intercourse to check for problems with sperm surviving in cervical mucous 
Hysterosalpingography or sonosalpingography, to check for tube patency
Sonohysterography to check for uterine abnormalities.
There are also genetic testing techniques under development to detect any mutation in genes associated with female infertility.

Risk factors

Certain factors may put you at higher risk of infertility, including:
•    Age. The quality and quantity of a woman's eggs begin to decline with increasing age. In the mid-30s, the rate of follicle loss speeds, resulting in fewer and poorer quality eggs. This makes conception more difficult, and increases the risk of miscarriage.
•    Smoking. 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. Stop smoking before beginning fertility treatment.
•    Weight. Being overweight or significantly underweight may affect normal ovulation. Getting to a healthy body mass index (BMI) may increase the frequency of ovulation and likelihood of pregnancy.
•    Sexual history. Sexually transmitted infections such as chlamydia and gonorrhea can damage the fallopian tubes. Having unprotected intercourse with multiple partners increases your risk of a sexually transmitted infection that may cause fertility problems later.
•    Alcohol. Stick to moderate alcohol consumption of no more than one alcoholic drink per day.