Female factors affecting fertility

Obstructions to Fertilisation and Implantation

Damaged or blocked tubes can prevent the ova and sperm from meeting and therefore fertilisation is unable to occur. This cause of infertility is usually found during laparoscopy when dye is injected through the tubes to check patency and the pelvic organs are visualised through a laparoscope.

The main causes of tubal damage are:

• Prior infections including sexually transmitted disease or pelvic inflammatory diseases
• infection following pelvic or lower abdominal surgery
• Distortion and adhesions due to prior surgery or endometriosis
• Mechanical contraception such as IUD's and tubal sterilisation techniques

Scarring or blockage of the fallopian tubes is often irreversible. In some cases surgery (microsurgery, or laparoscopic tubal surgery using laser or diathermy) may be successful. If damage is severe, or if tubal surgery fails, referral for IVF is the best treatment option.

Endometriosis is the growth of cells of the lining of the uterus,( the endometrium ), outside the uterine cavity. Many women have some degree of endometriosis, often without any symptoms, which is found at laparoscopy. Unless the amount of endometriosis is substantial or has caused scarring it is unlikely that endometriosis alone is causing infertility.

Situations where it could be impeding fertilisation and implantation include:

• Moderate or severe endometriosis causing distortion of pelvic anatomy, or where there is widespread disease.
• Endometrial cysts on the ovary can affect the process of normal ovulation.
• With some women endometriosis can cause pain during intercourse, and they may therefore be avoiding sexual intercourse during ovulation.
• Adenomyosis, where endometrial tissue grows within the uterine muscle causing enlargement and pain of the uterus.
• There is some evidence that mild endometriosis may have subtle effects on fertility also.

Endometriosis may be treated with drugs or surgery where it is extensive or causing symptoms.

Where uterine abnormalities are present the fertilised egg (embryo) is unable to implant successfully in the uterine cavity. These abnormalities would be found during hysteroscopy, which is often done at the same time as laparoscopy, or seen on ultrasound scan.

Some of the abnormalities that may be found are:

• Fibroids and polyps
• Congenital abnormalities where the uterus is unusually shaped
• Uterine distortion due to adenomysis
• Adenomyosis does not destroy uterus

Some of these conditions can be treated surgically.

Cervical problems can prevent passage of the sperm to the uterus and fallopian tubes by anatomical or physiological obstruction. Investigations that find these problems include visualising the cervix through pelvic examination and taking a cervical specimen (post-coital test), or during hysteroscopy.

The cervix may be:

• Scarred and narrowed due to injury, perhaps from previous treatment of an abnormal smear test, and therefore mucus production may be inhibited and sperm movement through the cervix affected.

Treatment for cervical problems, particularly mucus abnormalities, depends on the cause of the problem. Surgical treatment for a narrowed cervix, such as dilatation, may be used. Hostile mucus may be treated with medications, or the problem bypassed with intra-uterine insemination or IVF treatment.

Ovulation Disorders

Hormonal imbalances can alter the normal feedback process that leads to ovulation. Hormonal assays (blood or urine tests) are used at various stages of the cycle to pinpoint these imbalances.
Hyperprolactinaemia, an excess of the hormone prolactin produced by the pituitary gland, interferes with the release of follicle stimulating hormone (FSH) and luteinizing hormone (LH) which control the development of the follicle and the release of the egg. Periods may become infrequent or cease. Treatment involves taking medication to reduce the production of prolactin.
With pituitary failure, the pituitary produces no FSH or LH, and so follicle development and ovulation do not occur. Synthetic gonadotrophin hormone preparations such as Metrodin or Puregon are are used to replace these hormones.

With ovarian failure although FSH is produced by the pituitary gland, the ovaries do not respond. FSH and LH levels become quite high, but as no follicular development is happening oestrogen levels are very low. This lack of ovarian response and hormonal imbalance generally signifies menopause in older women, but can occur in younger women leading to premature menopause. The general symptoms of menopause may be present (hot flushes, vaginal dryness) and periods cease. Usually with this infertility factor egg donation is required.

Polycystic ovaries is a common disorder in infertile women. This condition is associated to:

·  Irregular cycles.

·  Excess hauroracne

·  Alterations in metabolic and reproductive hormone properties

Often Polycystic Ovaries is triggered by weight gain so weightloss and exercise are the first lines of management. Ovulation induction may be then performed using medications, which help follicular development.

Women often present with a history of irregular cycles, and on examination may be found to be overweight and/or have increased body hair. Ovulation induction with clomiphene citrate or gonadotrophin is the ususal first-line treatment for this condition. Weight loss can also benefit women with this disorder.

Other ovulation disorders can be a result of social or environmental factors. With some women major stress, drastic dieting and extreme physical fitness can interfere with the normal neural and hormonal feedback mechanisms that maintain the normal menstrual cycle. Once their lifestyle is examined and a balanced approach to the external cause is taken, their cycle usually resumes normally.

Recurrent Miscarriage

Some couples achieve pregnancy but are unable to maintain it past a certain point.

Repeated spontaneous abortions early in the pregnancy can be a result of:

• genetic and chromosomal abnormalities
• hormonal imbalances
• uterine abnormalities
• environmental factors (drugs, infections, toxins, etc)
• immunological factors

After investigations suggest or pinpoint a cause of pregnancy loss, treatment will depend upon the diagnosis. With chromosomal abnormalities that appear to have a genetic link, the couple may need referral to a geneticist. Hormonal imbalances, infections and immunological factors may be treated with medications with varying degrees of success. Your consultant will discuss your diagnosis and the best treatment options with you for your individual case.