Female Infertility - Symptoms, Causes and Treatment

What is Female Infertility?

Female infertility refers to the condition of not getting pregnant even after trying to conceive for at least a year. Infertility can be a result of male factors or female factors, or in some cases, it can be a result of both male and female factors.

Is this Infertility in women a medical emergency?

Female infertility is not a medical emergency.

What are the causes of female infertility? 

In a few cases, the exact cause of infertility cannot be determined, but some of the more common causes include

• Problems with ovulation: Women may ovulate infrequently or not at all. Certain factors that cause problems with ovulation include
  • Polycystic ovary syndrome (PCOS): Hormone imbalance that affects ovulation
  • Premature ovarian failure
  • Hypothalamic dysfunction: Improper production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) by the pituitary gland
  • Excess production of prolactin hormone - reduces estrogen production and causes infertility.
• Damaged or blocked fallopian tubes: Fallopian tubes are long, slender tubes connecting ovaries to the uterus. Fertilized eggs pass from the ovaries through the fallopian tubes into the uterus. Damaged or blocked fallopian tubes prevent sperm from reaching the egg or block the passage of the fertilized egg into the uterus. Damage of fallopian tubes can be due to an infection of the uterus or fallopian tubes or due to pelvic tuberculosis.
• Endometriosis: Endometriosis is a condition in which the endometrial tissue that lines the inner surface of the uterus grows outside the uterus. Endometriosis causes scarring and blockage of the fallopian tube, which ultimately causes infertility. Endometriosis also affects the inner lining of the uterus, which disrupts the implantation of the fertilized egg.
• Polyps or tumors in the uterus interfere with implantation and cause infertility.
• Uterus abnormalities: Some abnormalities of the uterus can be present even at the time of birth.
• Cervical abnormalities: Such as cervical stenosis, can interfere with the passage of sperm through the cervix to the uterus, leading to infertility.

Risk factors 

Certain factors that increase the probability of infertility include:

• Age: As the age of a woman increases, the quantity and quality of eggs decrease, making it difficult to become pregnant. Also, as the age increases, the chances of miscarriages would be higher.
• Obesity: Being overweight affects normal ovulation. Being underweight also has the same effect.
• Tobacco smoking and alcohol consumption. Smoking increases the risk of miscarriages as well as ectopic pregnancy. Excess consumption of alcohol also can increase the risk of infertility in women. Alcohol consumption during pregnancy can also lead to miscarriage.
• Sexually transmitted infections: The presence of sexually transmitted infections such as chlamydia and gonorrhea can damage the fallopian tubes and increase the risk of infertility.

Symptoms & signs

The primary sign of infertility is not getting pregnant. There are no other outward signs and symptoms to define infertility. A menstrual cycle that is too long, such as lasting more than 35 days between each cycle, or a menstrual cycle that is too short, such as only 21 days between each cycle, can indicate an abnormality. These kinds of menstrual cycle patterns indicate that the woman is not ovulating, which may result in infertility.

Investigations

There are certain investigations that are performed to confirm infertility in females as well as to determine the exact cause of infertility. They include the following:

• Ovulation testing: It is a test that helps to detect the surge in luteinizing hormone (LH) that occurs before ovulation. The level of luteinizing hormone (LH) in urine is tested. A rise in this hormone normally signals the ovary to release the egg.
• Ovarian reserve testing is performed to determine the quality and quantity of eggs available for ovulation.
• Hysterosalpingography: An x-ray procedure performed to investigate the shape of the uterus and the shape and patency of the fallopian tubes.
• Hormone testing is performed to check the levels of ovulatory, thyroid, and pituitary hormones that all play a role in the reproductive process.
• Imaging tests like pelvic ultrasound and sonohysterogram are performed to see the details of the uterus and fallopian tubes and to identify the presence of any disease. Hysteroscopy is also performed to check for any uterus or fallopian tube abnormalities.
• Laparoscopy is also performed in a few cases to examine the uterus, ovaries, and fallopian tubes. With the help of laparoscopy, conditions like endometriosis, scarring, and blockages can be identified.
• Genetic testing is also performed to check if there is any genetic factor present that is causing infertility.

Diagnosis

A diagnosis of infertility in a woman is established based on medical history, clinical evaluation, and results of the investigations done.

Treatment options

Treatment of infertility depends on the age of the individual and the duration of infertility. A woman requires physical and physiological strength to undergo infertility treatment. Treatment may be either medical or surgical or, in a few cases, a combination of both.

Medical treatment

Fertility drugs are prescribed to regulate or stimulate ovulation. These drugs work like natural hormones to trigger ovulation. Some of these drugs include clomiphene citrate, gonadotropins, metformin, letrozole, and bromocriptine.

Interventional treatment including surgery and indications for surgery

Surgical treatment for infertility is not usually done as the first line of treatment, but surgeries are performed to correct uterus or fallopian tube abnormalities. Laparoscopic or hysteroscopic surgeries involve:

• Correcting an abnormal uterine shape
• Removing endometrial polyps
• Removing fibroids
• Removing pelvic or uterine adhesions
• Fallopian tube surgeries are also performed to dilate the fallopian tubes, to clear the blocked fallopian tubes, or to create a new tubal opening

Other treatments that may be advised for infertility include:

• Intrauterine insemination (IUI): In this procedure, millions of healthy sperm are placed inside the uterus close to the time of ovulation.
• Assisted Reproductive Technology: These are medical procedures used to treat infertility. Procedures include in vitro fertilization, intracytoplasmic sperm injection (ICSI), and cryopreservation of gametes or embryos.

Role of Diet/Exercise/Lifestyle changes/Preventive measures

Certain measures that need to be taken to optimize fertility include:

• Maintaining an ideal body weight
• Discontinue tobacco smoking
• Avoid or limit alcohol consumption
• Avoid or limit caffeine intake
• Maintain low-stress levels
• Consume fiber-rich foods and maintain a healthy diet

Complications

Complications that are associated with infertility are:

• Inability to become pregnant
• Depression
• The use of fertility drugs can lead to the risk of getting pregnant with twins or triplets or even more
• Injecting fertility drugs to induce ovulation can cause swollen and painful ovaries. It can cause weight gain, fluid accumulation in the abdomen, and shortness of breath
• The use of fertility drugs can increase the risk of developing ovarian tumors later in life

Prognosis

The overall prognosis of female infertility is good. In the majority of cases, infertility treatments are successful; however, there may be underlying untreatable factors that reduce the overall success in the management of infertility.

Medical consultation is recommended under the following circumstances:

• History of irregular or painful periods
• Repeated miscarriages
• Being 35 to 40 years old and not having conceived yet
• Having a history of pelvic inflammatory disease or endometriosis
• Having undergone prior cancer treatment

Indications for hospitalization

Treatment for female infertility is generally provided on an outpatient basis and does not require any hospitalization.

Suggested clinical specialists/departments to consult for infertility in women

• Obstetrics and Gynecology