Female Infertility

Posted December 29, 2014 by NRM

While not often discussed, Infertility is diagnosed in as many as 15% of couples attempting conception. Common female causes of infertility include ovulatory dysfunction, older age of the female, tubal factors, and uterine or pelvic factors (such as fibroids, polyps, or endometriosis). In this article you will find more information on each factor’s causes, diagnostic evaluation, and potential therapies.

What is the definition of infertility?

• Women <35: no pregnancy after 12 months or more of regular, unprotected intercourse
• Women >35: no pregnancy after 6 months of regular, unprotected intercourse

What are the causes of Infertility?

1. Ovulatory Function
   • Evaluation of ovulation (release of the egg from a growing follicle in the ovary) should be an initial diagnostic step for all infertile women. Menstrual regularity and predictability (occurring at intervals of 25-35 days), consistent menstrual flow, and consistent “moliminal” symptoms (symptoms you routinely experience telling you that your period is about to start) strongly suggest normal ovulation.
   • Objective measures of ovulation include basal body temperature measurements, use of ovulation predictor kits, and/or assessment of serum progesterone levels.
   • Women with lack or ovulation or experiencing irregular, unpredictable ovulation (such as women with PCOS) may be candidates for ovulation induction. See more about Basic Fertility Therapy.
2. Diminished ovarian reserve (“DOR”)
   • Ovarian reserve is directly related to age, and refers to the quantity and quality of functional oocytes (eggs) remaining in a woman’s ovary. Women with diminished ovarian reserve may have regular menstrual cycles and overall be very healthy, but may have difficulty conceiving.
     • Women at risk for DOR:
       • Age >35
       • Family history of premature menopause
       • History of ovarian surgery
       • History of chemotherapy
       • Unexplained infertility
   • While no test can define your ovarian reserve, the following measures help to predict response to fertility medications and successful conception with therapy. These tests are common to perform in a basic fertility evaluation and include:
     1. Day 3 Labs- including FSH, LH and Estradiol.
     2. Antimullerian Hormone (AMH).
     3. Ultrasound assessment of antral follicle count.
   • Women with concerns for DOR may be treated with Basic Fertility Therapy for a short period of time, or move directly to Advanced Fertility Therapy such as IVF. When the reserve is significantly diminished, IVF with egg donor is the best option.
3. Uterine Abnormalities
   • The size or shape of the uterine cavity can be abnormal, either from a birth defect (such as a uterine septum, unicornuate or bicornuate uterus) or an abnormality may grow over time (such as fibroids, polyps, or scar tissue from a previous surgery).
   • Your uterine cavity may be evaluated by Ultrasound, 3D ultrasound, saline sonohystogram, HSG, or hysteroscopy.  Click to learn about our diagnostic techniques.
   • Fibroids, polyps and uterine septum may be surgically removed to help restore the uterine cavity to a more normal shape.
4. Tubal blockage
   • Tubal disease represents a significant cause of infertility and is routinely evaluated during an initial infertility work-up.
   • Women at risk for tubal disease include women with a history of a sexually transmitted infection such as Chlamydia or those who had a previous tubal ligation
5. Peritoneal Factors are factors in the pelvis and abdomen that may affect the transport of the egg into the fallopian tube, and therefore inhibit fertilization of an egg by sperm. Women at risk for peritoneal disease or scar tissue include:
   • Previous abdominal or pelvic surgery
   • Previous abdominal or pelvic infection (such as appendicitis)
   • Endometriosis

Ultrasound or HSG may show abnormalities suspicious for peritoneal disease. Laparoscopy may be warranted to further evaluate scar tissue in patients with pelvic pain, or history of surgery or infection, or to treat suspected scar tissue.

For more information, the American Society for Reproductive Medicine provides free online access: learn more at http://www.reproductivefacts.org/