Female infertility

An estimated 10 percent to 15 percent of couples are classified as infertile, which means that they’ve been trying to get pregnant with frequent, unprotected intercourse for at least a year with no success.  Of all couples classified as infertile, female infertility accounts for about 40 percent to 50 percent. In 30 percent to 40 percent of infertile couples, the man’s sperm is the cause, while the remaining 10 percent to 30 percent either is attributed to both male and female infertility or is unexplained. The cause of female infertility can be difficult to diagnose, but there are many resources and therapies available to treat it. And sometimes, treatment isn’t necessary: Half of all infertile couples will go on to conceive a child spontaneously within the next 36 months.

The main symptom of infertility is the inability of a couple to get pregnant. An abnormal menstrual cycle, either too long or too short, can be a sign of female infertility. There may be no other outward signs or symptoms.

Ovulation disorders account for infertility in 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. You have an ovulation disorder if you ovulate infrequently or not at all.

Abnormal FSH and LH secretion. 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 or a very high or very low body weight can disrupt this pattern and affect ovulation. The main sign of this problem is irregular or absent periods. Much less commonly, specific diseases of the pituitary, usually associated with other hormone deficiencies, may be the cause.
Polycystic ovary syndrome (PCOS). In PCOS, complex changes occur in the hypothalamus, pituitary and ovary, resulting in overproduction of male hormones (androgens), which affects ovulation. PCOS can also be associated with insulin resistance and obesity.
Luteal phase defect. Luteal phase defect happens when your ovary doesn’t produce enough of the hormone progesterone after ovulation. Progesterone is vital in preparing the uterine lining for a fertilized egg.
Premature ovarian failure. This disorder is usually caused by an autoimmune response, where your body mistakenly attacks ovarian tissues. It results in the loss of the eggs in the ovary, as well as in decreased estrogen production.

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

  • Inflammation of the fallopian tubes (salpingitis) due to chlamydia or gonorrhea
  • Previous ectopic pregnancy, in which a fertilized egg becomes implanted and starts to develop in a fallopian tube instead of in the uterus
  • Previous surgery in the abdomen or pelvis

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 impairs fertility. Researchers think that the excess tissue may also produce substances that interfere with conception.    Also called cervical stenosis, this can be caused by an inherited malformation or damage to the cervix. The result is that the cervix can’t produce the best type of mucus for sperm mobility and fertilization. In addition, the cervical opening may be closed, preventing any sperm from reaching the egg. Benign polyps or 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. However, many women who have fibroids can become pregnant. Scarring within the uterus also can disrupt implantation, and some women born with uterine abnormalities, such as an abnormally shaped (bicornate) uterus, can have problems becoming or remaining pregnant.  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. The good news is that couples with unexplained infertility have the highest rates of spontaneous pregnancy of all infertile couples.

Some things may put you at higher risk of infertility. They include:

Age. After age 32, the quantity and the quality of a woman’s eggs begin to decline. In your mid-30s, the rate of follicle loss accelerates, resulting in fewer and poorer quality eggs, making conception more challenging. Women over 35 are also at a higher risk of miscarriage and babies with chromosomal abnormalities.
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, reducing your ability to get pregnant. Many fertility specialists recommend setting a quit date before beginning fertility treatment.
Weight. If you’re overweight or significantly underweight, it may inhibit 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 diseases like 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.
Alcohol. Heavy drinking is associated with an increased risk of ovulation disorders and endometriosis.
Caffeine. Consuming more than the equivalent of six cups of coffee a day (900 milligrams of caffeine) may decrease your fertility.

Fertility tests may include:

Ovulation testing. A blood test for progesterone, a hormone produced after ovulation, can document that you are ovulating. You can also check for this at home. Over-the-counter ovulation prediction kits can detect ovulation in most women.
Hysterosalpingography. This test evaluates the size and contour of your uterine cavity and checks whether your fallopian tubes are open. Fluid 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 into 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.
Laparoscopy. Typically done on an outpatient basis and under general anesthesia, laparoscopy allows your doctor to view your ovaries, fallopian tubes and uterus to check for endometriosis, scarring, blockages or irregularities. First, your doctor makes a small incision (8 to 10 millimeters) beneath your navel, and inserts a needle into your abdominal cavity. A small amount of gas (usually carbon dioxide) is inserted into the abdomen to create space for entry of the laparoscope — an illuminated, fiber-optic telescope. If you give consent before the procedure, your doctor can remove endometriosis or adhesions, or treat scarring or other problems with lasers or ablation during the same procedure.
Ovarian reserve testing. Women at risk of a depleted egg supply — including women over age 35, those with autoimmune disease and smokers — may have this series of blood and imaging tests, which are performed on specific days of the menstrual cycle. They include blood tests of FSH concentration on day three of your cycle; clomiphene citrate challenge test (CCCT), in which you receive five doses of the ovary-stimulating drug clomiphene citrate preceded and followed by a blood test to assess your response; ultrasound imaging of the ovaries to determine ovarian volume or follicle count; and blood tests to detect inhibin-B, a possible marker of ovarian reserve.
Hormone testing. Testing for specific hormones, such as FSH and prolactin, can determine whether an undiagnosed medical condition might be interfering with your fertility.

How your infertility is treated depends on the cause, your age, how long you’ve been infertile, and personal preferences. 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.

Using fertility drugs increases your chances of getting pregnant with twins or other multiples. Oral medications carry a fairly low risk of multiples (5 percent to 8 percent), but your chances increase by about 20 percent with injectable medications. Generally, the more fetuses you’re carrying, the greater the risk of premature labor, low birth weight and later developmental problems. Sometimes the amount or timing of the medications will be altered in an attempt to lower the risk of multiples.

There are several fertility drugs for abnormal LH and FSH production. These drugs include:

Clomiphene citrate (Clomid, Serophene). This drug is taken orally and stimulates ovulation in women who have PCOS or other ovulation disorders. It causes the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg. Clomiphene citrate also improves fertility in normally ovulating women, and is often used as an initial treatment for unexplained infertility.

Gonadotropins. Instead of stimulating the pituitary gland to release more hormones, these treatments increase the production of LH and FSH from other sources. Gonadotropin medications include:

Human menopausal gonadotropin, or hMG, (Repronex). This injected medication is for women who don’t ovulate on their own due to the failure of the pituitary gland to stimulate ovulation. HMG and other gonadotropins contain both FSH and LH, and directly stimulate the ovaries to ovulate.
Follicle-stimulating hormone, or FSH, (Gonal-F, Follistim, Bravelle). FSH works by stimulating the ovaries to produce mature egg follicles.
Human chorionic gonadotropin, or HCG, (Ovidrel, Pregnyl). Used in combination with clomiphene, hMG and FSH, this drug stimulates the follicle to release its egg (ovulate).

Metformin (Glucophage). This oral drug is used when insulin resistance is a known or suspected cause of infertility, usually in women with a diagnosis of PCOS. Metformin improves insulin resistance, normalizing ovulation.

Aromatase inhibitors (Letrozole). These drugs, also used to treat some breast cancers, may induce ovulation. However, the effect the medication has on early pregnancy isn’t yet known.

Several surgical procedures can correct problems or otherwise improve female fertility. They include:

Tissue removal. This surgery removes endometriosis or pelvic adhesions with lasers or ablation, which can improve your chances of achieving pregnancy.
Tubal reversal surgery (microscopic). After a woman has had her tubes cut and tied for permanent contraception, surgery may be done to reconnect them and restore fertility. Your doctor will determine whether you’re a good candidate for the surgery.
Tubal surgeries. If your fallopian tubes are blocked or filled with fluid (called hydrosalpinx), tubal surgery may improve your chances of becoming pregnant. Laparoscopic surgery is performed to remove adhesions, dilate a tube or create a new tubal opening. Tubal surgery is more successful when the blocked or narrowed part of the tube is closer to the ovary than to the uterus. Tubal blockage close to your uterus may increase your risk of ectopic pregnancy. In these and other severe cases of blockage or hydrosalpinx, removal of your tubes (salpingectomy) can improve your chances of pregnancy with in vitro fertilization.

Reproductive assistance: In vitro fertilization
This highly effective technique involves retrieving mature eggs from a woman, fertilizing them with a man’s sperm in a dish in a laboratory and implanting the embryos in the uterus three to five days after fertilization. In vitro fertilization (IVF) often is recommended when both fallopian tubes are blocked. It’s also widely used for a number of other conditions, such as endometriosis, unexplained infertility, cervical factor infertility and ovulation disorders. IVF increases your chances of having twins or other multiples because multiple fertilized eggs may be implanted into your uterus so that there is a greater chance that at least one will develop into a baby. IVF also requires frequent blood tests and daily hormone injections.

If you’re a woman thinking about getting pregnant soon or in the future, there are a few ways you can improve your chances of having normal fertility:

Maintain a normal weight – Overweight and underweight women are at increased risk of ovulation disorders. If you need to lose weight, exercise moderately. Strenuous, intense exercise of more than seven hours a week has been associated with decreased ovulation.

Quit smoking – Tobacco has multiple negative effects on fertility, not to mention your general health and the health of a fetus. If you smoke and are considering pregnancy, quit now.
Reduce stress – Some studies have shown that couples experiencing psychological stress had poorer results with infertility treatment. If you can, find a way to reduce stress in your life before trying to become pregnant.
Limit caffeine – Cut your caffeine intake to less than six cups of coffee each day.