Infertility | Female Infertility
General information about infertility
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What is infertility?
Infertility, whether male or female, can be defined as 'the
inability of a couple to achieve conception or to bring a
pregnancy to term after a year or more of regular, unprotected
2. What is the incidence of infertility
The World Health Organization (WHO) estimates that approximately
8-10% of couples experience some form of infertility problems.
On a worldwide scale, this means that 50-80 million people
suffer from infertility. However, the incidence of infertility
may vary from region to region.
3. Is infertility exclusively a female
No. The incidence of infertility in men and women is almost
identical. Infertility is exclusively a female problem in
30-40% of the cases and exclusively a male problem in 30-40%
of the cases. Problems common to both partners are diagnosed
in 10-15% of infertile couples. After thorough medical investigations,
the causes of the fertility problem remain unexplained in
only a minority of infertile couples (5-10%). This is called
4. What are the most common causes
The most common causes of female infertility are ovulatory
disorders and anatomical abnormalities such as damaged fallopian
tubes. Less frequent causes include, for example, endometriosis
and hyperprolactinemia, thyroid gland related problems.
In developing countries like India, infections of the womb
such as gonorrhoea, chlamydia and tuberculosis significantly,
contribute to infertility.
Causes of male infertility can be divided into three main
Sperm production disorders affecting the quality and/or the
quantity of sperm;
Other factors such immunological disorders.
Approximately a third of all cases of male infertility can
be attributed to immune or endocrine problems, as well as
to a failure of the testes to respond to the hormonal stimulation
triggering sperm production. However, in a great number of
cases of male infertility due to inadequate spermatogenesis
(sperm production) or sperm defects, the origin of the problem
still remains unexplained.
5. Ectopic Pregnancy
When a pregnancy is not located in the uterus it is called
an Extra Uterine Pregnancy (EUG) or ectopic pregnancy.
The most common place for an EUG is the fallopian tube but
sometimes the ectopic pregnancy is located elsewhere, such
as in the cervix, the ovary or in the abdomen. EUG is a rare
disease and occurs in 1% of all pregnancies. With IVF treatment
the risk can increase. Risk factors for EUG are a history
of infection of the tubes (Salpingitis), Chlamydia infection,
Pelvic Inflammatory Disease (PID), genital tuberculosis, former
EUG, operation on the tubes or in the lower abdomen, endometrioses
The symptoms of ectopic pregnancy are often similar to those
of a normal miscarriage and may include a positive pregnancy
test together with or without vaginal bleeding and abdominal
pain. Although it is not common, the possibility of EUG has
to be considered in patients with the symptoms and one (or
more) of the risk factors for EUG. Diagnoses is made by questioning
the patient on the risk factors, physical examination, vaginal
ultrasound and laboratory findings, especially the serum BHCG
Depending on the size and the location of the EUG, different
treatments can be given. Nowadays, most of the ectopic pregnancies
can be removed surgically by Laparoscope, without opening
the abdomen. But occasionally medical treatment in the form
of Methotrexate injection or expectant treatment is offered
when the pregnancy is very small and thorough control of the
patient is possible. Alternatively, one can directly inject
drugs into the ectopic pregnancy, making use of a thin needle,
under the guidance of Tranvaginal Sonography.
Polycystic ovary syndrome or shortly PCOS, is an ovulation
disorder which affects 4-6% of all women. Several factors
contribute to the disease. At this moment researchers think
that the cause of the disease is genetic.
The major features of this syndrome are irregular or no menstruation,
Hirsutism and acne due to high levels of male hormones, obesity
(40-50%), high insulin levels with risk for developing diabetes
and large polycystic ovaries shown on ultrasound.
Women with PCOS usually present at fertility clinics for counseling.
To increase fecundity the treatment possibilities are mostly
focused on regulation of the menstrual cycle. For this, several
drugs are used (Clomiphene Citrate, Bromocriptine, Gonadotrophins)
and weight loss is strongly advised.
In many cases the cycle will be ovulatory and regulated by
these treatments. Newer oral anti diabetic drugs such as Metformin
are being more frequently used to treat PCOS, with very good
outcome. Alternately, one can Electrocoagulate the ovarian
surface using a laparoscope, especially in those women with
highly elevated levels of LH hormone.
If these women fail to become pregnant, they may be subjected
to Gonadotropin injections, to stimulate ovulation. This may
be combined with an Intrauterine insemination procedure (IUI)
. Resistant cases may be treated by performing ART procedures
such as IVF or ICSI.
7. What are the causes of damaged
In the beginning In Vitro Fertilisation (IVF) was developed
for patients facing infertility due to damaged fallopian tubes.
Later on the indications to perform IVF was broadened with
for example unexplained infertility and male infertility.
Nowadays tubal damage still accounts for a large number of
all IVF treatments. The main cause is abdominal infection.
In developing countries such as India, the biggest culprit
is Genital Tuberculosis, in which the womb of the patient
is infected by the tuberculosis germ. For the tubes this is
mostly due to sexually transmitted diseases (for example Chlamydia
or Gonorrhea) but complicated appendicitis or Pelvic Inflammatory
Disease (PID) can also cause damaged tubes.
Other causes are abdominal operations (gynecological operations,
cesarean section, sterilization or other) and internal diseases
like Crohn's disease. Affected patients can have fertility
problems and are at risk for having a pregnancy located in
the tubes (ectopic or tubal pregnancy).
8. Cystic fibrosis and male infertility
Men who have cystic fibrosis often have a congenital anomaly
in the male genital tract. The vas deferens, the tube connecting
the testicle and epididymis to the ejaculatory duct is congenitally
This makes it impossible for the sperm to pass through the
penis. Using testicular sperm aspiration, the urologist can
obtain sufficient sperm to allow excellent success with IVF
and ICSI (Intracytoplasmic Sperm Injection). Insufficient
numbers of sperm are obtained to make intrauterine insemination
an effective option.
As cystic fibrosis is recessive genetic disorder, abnormal
gene contributions from both parents are necessary for this
disorder to be present. Both copies of the gene are abnormal
in men with CF. While persons carrying a single copy of an
abnormal gene do not have this condition, when paired with
a partner with CF, they have a 50% chance of CF in their offspring.
This makes testing the female partner advisable. If the woman
tests normal, the children will be carriers for an abnormal
gene and although they will not likely have CF, it is advised
that their spouses be checked for CF gene abnormalities.
Cystic fibrosis is more commonly seen in European populations.
Its prevalence in Asian populations is relatively on the lower
9. What is Endometriosis?
Histologically identical to endometrium (the inner lining
of the uterine wall) outside the uterine cavity. Usually,
endometriosis is confined to the pelvic and lower abdominal
cavity; however, it has occasionally been reported to be in
other areas, as well.
Endometriosis is one of the most common problems that gynecologists
currently face. It is one of the most complex and least understood
diseases in our field and, despite many theories, we still
do not have a clear understanding of the cause or of its relationship
Since this disorder is primarily a human disease and rare
in other animal species, accumulation of the facts has been
slow. Although endometriosis has been considered a pathological
or separate disease entity, it may not be a disease at all.
It may actually be the clinical manifestation of a more basic
underlying disorder, such as a basic chemical or physiological
abnormality that affects the tubal motility or immune system
which could be responsible for the initiation or progression
of endometriosis in patients with retrograde menstrual flow.
By the same token, endometriosis may not be the cause of infertility,
but the result of it. Further technological developments may
be necessary in order for us to fully understand this problem.
Endometriosis is generally diagnosed at the time of Laparoscopy.
Nowadays one can treat it by performing advanced Laparoscpic
surgery using Lasers, electric current and scissors. In fact,
with the advent of operative Laparoscopy, very few patients
need to undergo the traditional method of opening the abdomen.
Endometriosis can also be controlled (if not totally cured)
by using various drugs such as Danazol, GnRh analogues or
progesterones. The above mentioned treatments help many patients
to become pregnant. The remaining patients may have to resort
to IVF or ICSI. In our unit, we have found that ICSI gives
better results than IVF.
10. What does Laparoscopy involve?
The laparoscope allows visual inspection of the pelvic organs
through a very tiny incision. Abnormalities that lead to infertility
can be treated surgically through additional small incisions
to remove scar tissue, laser, coagulate, or excise endometriosis,
and repair tubes blocked at the fimbrial end. Many types of
female reproductive surgery can be performed Laparoscopically,
in the outpatient setting.
11. What causes recurrent miscarriage
Recurrent miscarriage affects 1% of all women. The incidence
of pregnancy loss among all women is about 15%. If the first
pregnancy ended in miscarriage, there is only a slightly increased
chance (18%) of this happening again second time round. However,
after two miscarriages, this risk rises to 25-30%. For this
reason, most doctors now recommend that a woman see a fertility
specialist if she has experienced two miscarriages in a row.
At least 50% of pregnancies that miscarry in the first three
months are believed to have a major chromosomal abnormality.
This rate remains high for pregnancies lost during the second
trimester (30%) and drops to 5% for those lost in the last
trimester. Other possible causes include problems relating
to the immune system, hormone imbalances, abnormally shaped
uterine cavity, and pelvic infections.
Studies have also linked the use of alcohol, cigarettes, and
excessive caffeine consumption to an increased risk of miscarriage.
For some 50% of couples with recurrent miscarriage no explanation
will be found for the problem. When a woman consults a specialist
about her recurring miscarriages, the doctor will first try
to diagnose the cause. The treatment will depend on what was
found. If, for example, the woman is found to have uterine
fibroids or polyps (two types of benign growths) surgery may
be performed to remove these. Similarly, if she has a uterine
septum (a congenital condition in which the uterus has a wall
through the middle of it), surgery can correct this. If blood
tests find that she has a hormonal dysfunction known as "luteal
phase defect" (not producing enough of the hormone progesterone
to support an early pregnancy), she can be given progesterone
vaginal suppositories. If the presence of an organism called
"Ureaplasma" is found, an antibiotic will be prescribed. If
there are immunologic factors, aspirin therapy in early pregnancy
may be prescribed. And, although controversial due to possible
side effects, some doctors use "heparin" therapy - a series
of injections which lowers the body's immunity to the fetus.
The other newer advance in the treatment, is in the form of
immunotherapy, where the women are injected with the lympocyte
cells derived from the husband.
12. Infertility after 40
It is generally accepted that fertility decreases with age.
A woman in her twenties and thirties has a 20-25% chance of
a naturally occurring pregnancy, but for a woman in her early
forties this possibility decreases to 5%. In IVF therapy women
over the age of 35 are seen twice as frequently compared with
younger women. In fact, age is the most important factor in
IVF success rates. Research has recently revealed that fertility
decreases with age because of the declining quality of the
Although it is not possible to improve the quality of the
eggs, women in their forties (and fifties and sixties) can
become pregnant using techniques which can improve IVF outcome.
For example, increasing the doses of drugs used to induce
ovulation will increase the number of eggs that develop in
a given month, thereby increasing the chance that at least
one egg will be fertilized and develop into a viable pregnancy.
The most consistently successful method to increase the chance
of pregnancy in women with age-related infertility is egg
donation from a relative or anonymous donor. To predict a
woman's fertility two blood tests - FSH (Follicle Stimulating
Hormone) and E-2 (Oestradiol) - can be carried out on the
third day of the menstrual cycle. These assess a woman's "ovarian
reserve", in other words whether she is still producing eggs
and whether these are able to produce a pregnancy.
The higher the FSH, the less capable a woman's eggs are of
producing a pregnancy. As a woman ages, her FSH levels increase,
but younger women with poor quality eggs can also have high