Causes of female infertility
Fallopian tube damage or blockage. This condition usually results from inflammation of the fallopian tube (salpingitis). Chlamydia is the most frequent cause. Tubal inflammation may go unnoticed or cause pain and fever.
Tubal damage with scarring is the major risk factor of a pregnancy in which the fertilized egg is unable to make its way through the fallopian tube to implant in the uterus (ectopic pregnancy). One episode of tubal infection may cause fertility difficulties. The risk of ectopic pregnancy increases with each occurrence of tubal infection.
Endometriosis: Endometriosis occurs when the tissue that makes up the lining of the uterus grows outside of the uterus. This tissue most commonly is implanted on the ovaries or the lining of the abdomen near the uterus, fallopian tubes and ovaries. These implants respond to the hormonal cycle and grow, shed and bleed in sync with the lining of the uterus each month, which can lead to scarring and inflammation. Pelvic pain and infertility are common in women with endometriosis.
Infertility in endometriosis also may be due to
Ovarian cysts (endometriomas): Ovarian cysts may indicate advanced endometriosis and often are associated with reduced fertility. Endometriomas can be treated with surgery.
Scar tissue: Endometriosis may cause rigid webs of scar tissue between the uterus, ovaries and fallopian tubes. This may prevent the transfer of the egg to the fallopian tube.
Ovulation disorders: Some cases of female infertility are caused by ovulation disorders. Disruption in the part of the brain that regulates ovulation (hypothalamic-pituitary axis) can cause deficiencies in luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Even slight irregularities in the hormone system can affect ovulation.
Elevated prolactin (hyperprolactinemia): The hormone prolactin stimulates breast milk production. High levels in women who aren’t pregnant or nursing may affect ovulation. An elevation in prolactin levels may also indicate the presence of a pituitary tumor. In addition, some drugs can elevate levels of prolactin. Milk flow not related to pregnancy or nursing (galactorrhea) can be a sign of high prolactin.
Polycystic ovary syndrome (PCOS): In PCOS, increased androgen production prevents the follicles of the ovaries from producing a mature egg. Small follicles that start to grow but can’t mature to ovulation remain within the ovary. A persistent lack of ovulation may lead to mild enlargement of the ovaries. Without ovulation, the hormone progesterone isn’t produced and estrogen levels remain constant. Elevated levels of androgen may cause increased dark or thick hair on the chin, upper lip or lower abdomen as well as acne and oily skin.
Early menopause (premature ovarian failure): Early menopause is the absence of menstruation and the early depletion of ovarian follicles before age 35.
Benign uterine fibroids: Fibroids are benign tumors in the wall of the uterus and are common in women in their 30s. Occasionally they may cause infertility by interfering with the contour of the uterine cavity, blocking the fallopian tubes.
Pelvic adhesions: Pelvic adhesions are bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery. They may limit the functioning of the ovaries and fallopian tubes and impair fertility. Scar tissue formation inside the uterine cavity after a surgical procedure may result in a closed uterus and ceased menstruation (Asherman’s syndrome). This is most common following surgery to control uterine bleeding after giving birth.
Medications: Temporary infertility may occur with the use of certain medications. In most cases, fertility is restored when the medication is stopped.
Thyroid problems: Disorders of the thyroid gland, either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism), can interrupt the menstrual cycle and cause infertility.
Cancer and its treatment: Certain cancers — particularly female reproductive cancers — often severely impair female fertility. Both radiation and chemotherapy may affect a woman’s ability to reproduce. Chemotherapy may impair reproductive function and fertility more severely in men than in women.
– Cushing’s disease
– Sickle cell disease
– Kidney disease
If you and your partner are unable to achieve conception within a reasonable time and would like to do so, seek help. The woman’s gynecologist, the man’s urologist or your family doctor can determine whether there’s a problem that requires a specialist or clinic that treats infertility problems.
Some infertile couples have more than one cause of their infertility. Thus, your doctor will usually begin a comprehensive infertility examination of both you and your partner.
Before undergoing infertility testing, be aware that a certain amount of commitment is required. Your doctor or clinic will need to determine what your sexual habits are and may make recommendations about how you may need to change those habits. The tests and periods of trial and error may extend over several months.
Evaluation is expensive and in some cases involves operations and uncomfortable procedures, and the expenses may not be reimbursed by many medical plans. Finally, there’s no guarantee, even after all testing and counseling, that conception will occur. However, for couples who are eager to have their own child, such an evaluation is best. It may result in a successful pregnancy.
Tests for men
General physical examination. This includes examination of your genitals and questions concerning your medical history, illnesses and disabilities, medications and sexual habits. Semen analysis. Your doctor may ask for a specimen of ejaculated semen. This is generally obtained by masturbating or by interrupting intercourse and ejaculating your semen into a clean container. Your doctor will provide instructions. Such a specimen may be required more than once. A laboratory analyzes your semen specimen for quantity, color and presence of infections or blood. Detailed analysis of the sperm also is done. The laboratory will determine the number of sperm present and any abnormalities in the shape and movement (motility) of the sperm. Often sperm counts fluctuate from one specimen to the next. Hormone testing. A blood test to determine the level of testosterone and other male hormones is common.
Tests for women
Confirmation of ovulation. A blood test is sometimes performed to determine the levels of hormones involved in successful ovulation.
Hysterosalpingography: This test evaluates the condition of your uterus and fallopian tubes.
Laparoscopy: Performed under general anesthesia, this surgical procedure involves inserting a thin viewing device into your abdomen and pelvis to examine your fallopian tubes. Laparoscopy generally is done on an outpatient basis.
Basal body temperature: Although this test was once a standard, basal body temperature charting is used less often today. Charting a woman’s body temperature doesn’t give as precise time of ovulation as earlier believed.
Urinary luteinizing hormone (LH) detector kits: A number of at-home kits are available to test your LH level.
Ovarian reserve testing: Testing may be done to determine the potential effectiveness of the eggs after ovulation. This approach often begins with hormone testing early in a woman’s menstrual cycle.
In some infertile couples, no specific cause is found. Even though infertility is unexplained, the pregnancy rate for these couples is among the highest.
Treatment of infertility depends on the cause, how long this has been going on, the age of the people and other factors. Some causes of infertility can’t be corrected. However, various means of insemination or embryo transfer may be possible so that a woman can still become pregnant.
Fertility drugs (ovulation induction) include:
Clomiphene citrate (Clomid, Serophene). This drug is taken orally and stimulates ovulation in women who have PCOS or other ovulatory disorders. It causes the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg.
Human menopausal gonadotropin, or hMG (Repronex, Pergonal). This injected prescription medication is for women who don’t menstruate on their own due to the failure of the pituitary gland to stimulate ovulation. Unlike clomiphene, which stimulates the pituitary gland, hMG and other gonadotropins directly stimulate the ovaries. This drug contains both FSH and LH.
Follicle-stimulating hormone, or FSH (Gonal-F, Follistim, Bravelle). FSH is essentially hMG without the LH. Like hMG, it works by stimulating the ovaries to 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)
Gonadotropin-releasing hormone (Gn-RH) analogs. This treatment is for women with irregular ovulatory cycles or who ovulate prematurely — before the lead follicle is mature enough — during hMG treatment. Gn-RH analogs deliver constant Gn-RH to the pituitary gland, which alters hormone production, so that a physician can induce follicle growth with FSH.
Letrozole (Femara). This drug is in a class of medications called aromatase inhibitors, which are approved for treatment of advanced breast cancer. Doctors sometimes prescribe letrozole for women who don’t ovulate on their own and who haven’t responded to treatment with clomiphene citrate. Letrozole is not approved by the U.S. Food and Drug Administration for inducing ovulation. The drug’s manufacturer has warned doctors not to use the drug for fertility purposes because of possible adverse health effects. These adverse effects may include birth defects and miscarriage.
Metformin (Glucophage). This oral drug is taken to boost ovulation. It’s used when insulin resistance is known or suspected.
Bromocriptine. This medication is for women whose ovulation cycles are irregular due to elevated levels of prolactin, the hormone that stimulates milk production in new mothers. Bromocriptine inhibits prolactin production.
Surgery may be a treatment option for infertility. Blockages or other problems in the fallopian tubes usually can be surgically repaired. Laparoscopy allows delicate operations on the fallopian tubes.
Infertility due to endometriosis often is more difficult to treat. Although hormones such as those found in birth control pills are effective for treating endometriosis and relieving pain, they haven’t been useful in treating infertility. If you have endometriosis, your doctor may treat you with ovulation therapy, in which medication is used to stimulate or regulate ovulation, or in vitro fertilization, in which the egg and sperm are joined in the laboratory and transferred to the uterus.
Assisted reproductive technology (ART). ART has revolutionized the treatment of infertility. Each year thousands of babies are born in the United States as a result of ART. Medical advances have enabled many couples to have their own biological child. An ART health team includes physicians, psychologists, embryologists, laboratory technicians, nurses and allied health professionals who work together to help infertile couples achieve pregnancy.
The most common forms of ART include:
In vitro fertilization (IVF). This is the most effective ART technique. IVF 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. IVF often is recommended as a first-line therapy and is the treatment of choice if both fallopian tubes are blocked. It’s also widely used for a number of other conditions, such as endometriosis, unexplained infertility, cervical factor infertility, male factor infertility and ovulation disorders.
Electroejaculation. Electric stimulus brings about ejaculation to obtain semen. This procedure can be used in men with a spinal cord injury who can’t otherwise achieve ejaculation.
Surgical sperm aspiration. This technique involves removing sperm from part of the male reproductive tract such as the epididymis, vas deferens or testicle. This allows retrieval of sperm if blockage is present.
Intracytoplasmic sperm injection (ICSI). This technique consists of a microscopic technique (micromanipulation) in which a single sperm is injected directly into an egg to achieve fertilization in conjunction with the standard IVF procedure. ICSI has been especially helpful in couples who have previously failed to achieve conception with standard techniques. For men with low sperm concentrations, ICSI dramatically improves the likelihood of fertilization.
Assisted hatching. This technique attempts to assist the implantation of the embryo into the lining of the uterus.
ART works best when the woman has a healthy uterus, responds well to fertility drugs, and ovulates naturally or uses donor eggs. The man should have healthy sperm, or donor sperm should be available. The success rate of ART gradually diminishes after age 32.
Certain complications exist with the treatment of infertility. These include:
Multiple pregnancies. Although the most common complication of ART is multiple pregnancies, ART isn’t the direct cause of a number of the extreme cases of septuplets or octuplets reported in the media. The number of quality embryos kept and matured to fetuses and birth ultimately is a decision made by the couple. If too many babies are conceived, the removal of one or more fetuses (multifetal pregnancy reduction) is possible to improve survival odds for the other fetuses.
Ovarian hyperstimulation syndrome (OHSS). If over stimulated, a woman’s ovaries may enlarge and cause pain and bloating. Mild to moderate symptoms often resolve without treatment, although pregnancy may delay recovery. Rarely, fluid accumulates in the abdominal cavity and chest, causing abdominal swelling and shortness of breath. This accumulation of fluid can deplete blood volume and lower blood pressure. Severe cases require emergency treatment. Younger women and those who have polycystic ovary syndrome have a higher risk of developing OHSS than do other women.
Bleeding or infection. As with any invasive procedure, there is a risk of bleeding or infection.
Low birth weight. The greatest risk for low birth weight is a multiple pregnancy. In single live births, there may be a greater chance of low birth weight associated with ART.
Birth defects. Significant concern exists regarding the possible relationship between ART and birth defects. More research is necessary to confirm these findings. Weigh this factor if you’re considering whether to take advantage of this treatment. ART is the most successful fertility-enhancing therapy to date.