FEMALE FACTOR INFERTILITY
She looked at me in desperation, as if to say ‘’Give me a child now or I die here, because I cannot go home without one. I cannot afford to fail the second time’’.
Her case is like the plight of so many infertile African women.
She had been married to her first husband for over 10 years without giving him a child. When the man got tired of waiting , he decided to test his manhood by playing an away game with his secretary, and scored, she became pregnant for him.
As if that was not enough problem for the poor lady, her mother in-law and sisters in-law came over , beat her thoroughly then threw her out of her matrimonial home to make way for the new pregnant secretary/wife to take over.
Luckily she was such a pretty and desirable lady, so not long she had remarried to another man.
She is now married to her new husband for 4 years without giving him any child.
Now she is desperate.
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INFERTILITY: is usually defined as no pregnancy after one year of unprotected intercourse. This is a relative measurement. Over time, many couples may achieve pregnancy. In five years, nearly one half of "infertile" couples will conceive.
SUBFERTILITY: is used to describe gradations between normal fertility and sterility, often used interchangeably with infertility.
FECUNDABILITY: is the pregnancy rate from one menstrual cycle. The normal rate in humans is 20%. Seventy-five percent of normally fertile couples are expected to have conceived in six months and almost 100% by one year.
STERILITY: is the absolute inability to procreate: an absent uterus in women, absent testes in men. In years past, a woman with blocked fallopian tubes or man with an obstructed vas deferens would be sterile. But with assisted reproductive technology (ART), this is no longer the case.Normal fertility can be considered from several different points of view: the couple, the female and the male. In this article, we are going to look at female fertility: the biological steps and mechanisms, the defects, the causes of the defects and what to do.
THREE BASIC QUESTIONSThere are really three basic questions that have to be answered when doctors try to determine why a woman is having problems getting pregnant.
[1]Is she ovulating?
[2]Is there a clear passage from the ovary to the uterus?
[3]How old is she?
A similar set of questions has to be answered in men. Is there sperm? Can it be delivered to the female? Is the sperm normal? In the male these questions are answered in a preliminary and rather thorough way by semen analysis. With women the process is more complicated.
FEMALE INFERTILITYFemale factor infertility is the inability to conceive or carry a pregnancy to term due to one or more problems specific to females. For example, if a couple is struggling to achieve pregnancy and the male has adequate sperm count, motility, and shape, but the woman has polycystic ovarian syndrome, then their inability to conceive is likely due to female factor infertility.
FEMALE FERTILITY PROBLEMS
There are several conditions that contribute to female factor infertility, including uterine and pelvic abnormalities, secondary infertility, polycystic ovarian syndrome, and hostile cervical mucus. It is important to understand, however, that infertility, whether male infertility or female infertility, is not the same thing as sterility - conception and successful pregnancy are possible in many cases. Likewise, secondary infertility (the inability of a couple to conceive after having already achieved a successful pregnancy or pregnancies) can often be treated.
[1] Abnormal Uterine/Pelvic Area
[2] Blocked Fallopian Tubes
[3] Endometriosis
[4] Hostile cervical mucus. This is a condition in which the cervical mucus creates a thick barrier that sperm cannot penetrate.
[5] Irregular Ovulation
[6] Medications/Contraceptives and Infertility
[7] Polycystic Ovarian Syndrome
[8] Premature Ovarian Failure
[9] Uterine Fibroids
[10] High levels of the hormone prolactin
[11] Galactorhoea (milk leaking from the breasts).
[12] Amennorhoea [absence of periods]
[13] The production of sperm antibodies (when a woman develops antibodies to her partner’s sperm).
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INFERTILITY AFTER MISCARRIAGEThe termination of a pregnancy is devastating to couples who wish to have a baby; worse yet is the prospect of female infertility after miscarriage. Unfortunately, such a fate is possible. This form of female factor infertility can be caused by hormonal, environmental, immunological, and even physiological problems. There is hope, however, with treatment from a female fertility specialist.
SECONDARY INFERTILITY
Sometimes female infertility occurs after a woman has already given birth to one or more children. If a couple has already successfully conceived and delivered before, but is having difficulty becoming pregnant again, they may be experiencing secondary infertility.Secondary infertility can be caused by a wide range of issues, including age, irregular ovulation, endometriosis, hostile cervical mucus, and an abnormal uterus or pelvis. Scar tissue from the previous pregnancy may be causing blockage to the fallopian tubes or cervix, resulting in female factor infertility.
INFERTILITY CAUSED BY ABORTION
There is a risk of becoming infertile after an abortion, arising from various complications. If you have had a first trimester abortion (in the first 13 weeks) this is done by vacuum suction which can cause perforation of the womb. This is when the womb ruptures and causes internal bleeding. It is life threatening and the surgeon would be required to do additional surgery to repair the damage. Sometimes after this has occurred, the damage to the womb prevents another embryo from attaching. Rupture happens in about 1% of cases, so if 100 women had an abortion, one of them would have this problem.The main abortion complications that could cause infertility:90% of abortions are done in the first trimester. However, a late abortion frequently requires a material called laminaria to dilate the cervix. This makes the passage large enough to allow a suction tube to be inserted. The laminaria could weaken the cervix and conceivably cause infertility.If the physician scrapes too hard, the lower lining of the uterus can be removed. This is extremely rare.An untreated infection can scar the uterus and cause later fertility problems. The infection rate for first trimester abortions is less than 1%. Most women monitor their body temperature after an abortion to detect if an infection has occurred. Early detection should prevent any problems.
A woman who already have gonorrhea or chlamydia are very likely to suffer pelvic inflammatory disease which causes infertility. They are particularly susceptible to damage from PID after an abortion. This can be avoided by obtaining a STD test before the abortion.The suction tube can perforate both the uterus and a large blood vessel or intestine. If the latter happens, then surgery may be required. The surgery can cause infertility. Perforation of the uterus is also quite rare.
It would seem that if the physician is competent, and the woman monitors her body temperature after the procedure, that the chances of an abortion causing later infertility is quite remote.
CAUSES AND MECHANISMS OF FEMALE INFERTILITYThe main causes of female factor infertility are ovulation disorders, tubal disease and endometriosis. In a population of infertile couples, if you consider unexplained and male factor infertility at about 25% each, ovulatory disorders and tubal factors would be about 20% each and endometriosis 5-10%, with small percentages for uterine/cervical problems.3
The history and physical exam offer us many hints about the cause of infertility :
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FEMALE INFERTILITY WORK-UP: HISTORY AND PHYSICAL EXAMINATION.
HISTORY[1]Systemic illnesses: weight gain, weight loss
[2]Cancer, chemotherapy, radiation treatment, surgery
[3]Urogenital system: surgery: D & C, laparoscopy
[4]Pregnancy: outcome
[5]Menstruation: regular, irregular, absent
[6]Pelvic pain, dysmenorrhea, dyspareunia
[7]Sexual history: function, sexually transmitted disease, pelvic inflammatory disease
[8]Endocrine history: diabetes, thyroid disease
FAMILY HISTORYInfertility, cystic fibrosis, endometriosis
MEDICATIONS AND DRUGS
Prescription: endocrine, psychoactive, anti-hypertensive
PHYSICAL EXAMINATION
[1]Height & weight, neck, arms (carrying angle)
[2]Skin: hirsuitism
[3]Breasts: galactorrhea
[4]Abdomen: girth, adiposity
[5]Mass Pelvic exam: uterus, ovaries, pelvic mass, tenderness Genital ulcers, warts
QUESTIONS AND ANSWERS
[1]IS SHE OVULATING?Defects in ovulation comprise about 25% of female fertility problems. The biggest clue that ovulation is occurring is the presence of regular menstrual periods. Regular periods are almost always associated with ovulation. Irregular or scanty menstruation (oligomenorrhea) or absent periods (amenorrhea) have to be investigated by your doctor.It is impossible to describe all the conditions that affect ovulation, but let me hit the highlights and give you some examples of the mechanisms involved. Causes for ovulatory defects can be genetic, as in Turner's syndrome, or hormonal, as in prolactinoma or the polycystic ovary syndrome (PCOS). Deficient or excessive body fat can also lead to hormonal changes that stop ovulation.
[2]IS THERE A CLEAR PASSAGE FROM THE OVARY TO THE UTERUS?The two main conditions that can affect the fallopian tubes are endometriosis and tubal infection.
[A] ENDOMETRIOSISIn this condition, implants of endometrial tissue are found outside the uterine cavity, primarily in the pelvis, on the ovaries, tubes, body linings and adjacent organs of the GI and GU tracts. This extra endometrial tissue responds to cyclical estrogen and progesterone in the same way the uterine endometrium does -- proliferating, swelling and bleeding. The implants can invade the surrounding tissues, affect nerve endings, and cause scarring and adhesions on adjacent peritoneal surfaces. The most common symptoms of endometriosis are pelvic pain, painful periods (dysmenorrhea) and painful sexual intercourse (dyspareunia). These symptoms generally coincide with menstruation but can become chronic. That said, there are women who have had no complaints at all and are found to have endometriosis at laparoscopy or surgery.
[B] PELVIC INFLAMMATORY DISEASE [PID] / SALPINGITIS
PID is the most common cause of tubal factor infertility. The infection involves the upper genital tract (the uterus, the fallopian tubes and the ovaries) and structures around these organs. The infection of the fallopian tube (salpingitis) is the most crucial element causing infertility. The fallopian tube is lined with special, ciliated cells that direct the egg toward the sperm and the fertilized egg into the uterine cavity. Infection can destroy these cells and distort and/or block the tube.
The main bacterial culprits are Neisseria gonococcus (NG) and Chlamydia trachomatis (CT). NG is directly kills the special cells; CT probably destroys cells through immunological mechanisms. With the infection, the tubes can become thickened, distorted and blocked. Abscesses can form between the tube and the ovary or in the adjacent pelvis, and can be life threatening. This condition requires prompt, broad-spectrum antibiotic treatment. Interestingly, in about half of cases of tubal infertility secondary to PID, there is no history of acute infection. Chlamydia in particular can linger in the genital tract, causing ongoing subclinical damage. Chronic pelvic pain, infertility and ectopic pregnancy (where the pregnancy develops in the tube instead of the uterus) are the serious consequences of PID.
[3]HOW OLD IS SHE?
Fertility decreases with age. Nationally, in assisted reproductive technology facilities, live birth rates are 37% for women <35>42. As mentioned earlier, there are only so many primordial follicles present in the ovary at birth and they decrease steadily until the time of menarche, from 2-4 million to 400,000. With every cycle, primordial follicles are lost. As women age, more chromosomal abnormalities occur during cell division of the ova. The decreasing numbers of follicles, cycles without ovulation (anovulatory) and poor quality of the ova all combine to diminish the chances of older women, especially after age forty, becoming pregnant.While age is the strongest predictor of a women's ovarian function, there are some tests that are also helpful. They are the follicle count, which is determined by ultrasound, and blood tests for follicle stimulating hormone (FSH) and estradiol. All these tests are performed on or about the third day of the menstrual cycle. Follicle count is used because the number of small follicles seen on Day 3 gives a good idea about ovarian reserve.The hormone levels give indirect evidence about ovarian reserve because inhibin, secreted by cells of the follicles, effects the hormone FSH. As the follicle number diminishes, there are fewer cells producing inhibin and FSH increases. As the specialized cells, called granulosa cells, continue to diminish, ovarian estrogen decreases despite elevated FSH. A high FSH and a low estrogen indicate severe loss of follicles.
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INFERTILITY DIAGNOSTIC TESTS
The Female Work-up (Diagnostic Tests)
[1] ULTRASOUND : Ultrasound scan is a simple and easy outpatient procedure to examine the internal reproductive organs. It can clearly show the position and size of uterus, endometrial lining and the ovaries. Certain abnormal conditions such as fibroid, double uterus and ovarian cyst can be diagnosed through ultrasound scan alone. In addition, ultrasound scan can be used for the diagnosis of ovulation.
Ultrasound scan appears as a routine practice in the management of infertility, from the initial stages of diagnosis of the cause of infertility, to the eventual confirmation of pregnancy, including routine monitoring of early pregnancy. Ultrasound scan is probably the most important test in investigation of infertility. A well-preformed and detailed ultrasound scan of the female pelvis will give more information than any other single test.
Ultrasound is the only definitive way to tell you have ovulated. Especially TRANSVAGINAL ULTRASOUND SCAN. This can tell if you have LUFS (Lutenized Unruptured Follicle Syndrome), which looks exactly like you are ovulating in every way except the egg is not released.
[2] HORMONAL BLOOD TESTS: perform some basic hormone blood tests. Here is a list of the common blood tests performed. FSH (Follicle Stimulating Hormone)LH (Lutenizing Hormone)EstrogenProgesterone
including estradiol, inhibin B, Pooled progesterone, prolactin,thyroid stimulating hormone, testosterone.
[3] POSTCOITAL TEST: This test will tell if you and your partner's cervical mucus and sperm are compatible. During the fertile time of your cycle, the doctor will take a sample of the female's cervical fluid withintwo hours of intercourse. If the sperm survive and move forward in the cervical fluid, you will know the sperm andcervical mucus are compatible.
[4] HSG (Hysterosalpingogram) : This is a Special X-Ray examination. This will tell if your fallopian tubes are open by injecting dyethrough the cervix. Blocked tubes and lesions or polyps on the uterine cavity can be foundwith this method.
TRANSVAGINAL ULTRASOUND SCAN
Definition
Transvaginal ultrasound is a imaging technique used to create a picture of the genital tract in women. The hand-held device that produces the ultrasound waves is inserted directly into the vagina, close to the pelvic structures, thus often producing a clearer and less distorted image than obtained through transabdominal ultrasound technology, where the probe is located externally on the skin of the abdomen.
Purpose
Transvaginal ultrasound can used to evaluate problems or abnormalities of the female genital tract. It may provide more accurate information than transabdominal ultrasound for women who are obese, for women who are being evaluated or treated for infertility , or for women who have difficulty keeping a full bladder. However, it does provide a view of a smaller area than the transabdominal ultrasound.
Types of conditions or abnormalities that can be examined include:
[a]the endometrium of women with infertility problems or who are experiencing abnormal bleeding
[b]sources of unexplained pain
[c]congenital malformations of the ovaries and uterus
[d]ovarian cysts and tumors
[e]pelvic infections, such as pelvic inflammatory disease
[f]bladder abnormalities
[g]a misplaced IUCD (intrauterine contraceptive device)·
[h]other causes of infertility
Transvaginal ultrasound can also be used during pregnancy. Its capability of producing more complete images means that it is especially useful for identifying ectopic pregnancy, fetal heartbeat, and abnormalities of the uterus, placenta, and associated pelvic structures.
FOLLICULOMETRY [ULTRASOUND]
Ultrasound Folliculometry is a serial Transvaginal ultrasound scan test carried out to monitor follicular growth . Ovulation/Follicular growth can be best monitored by ultrasound folliculometry, providing 40–60% effectiveness.
Folliculometry is one of the most accurate method for determining ovulation. Ovulation scans allow the doctor to determine accurately when the egg matures; and when you ovulate. This is often the basic procedure for most infertility treatment since the treatment revolves around the wife's ovulation. Daily scans are done to visualize the growing follicle, which looks like a black bubble on the screen. Most women can see the follicle clearly for themselves - and know by the scans when the egg has ruptured.
Other useful information which can be determined by these scans is the thickness of the uterine lining - the endometrium. The ripening follicle produces increasing quantities of estrogen, which cause the endometrium to thicken.
The doctor can get a good idea of how much estrogen you are producing (and thus the quality of the egg) based on the thickness and brightness of the endometrium on the ultrasound scan. Ultrasound Folliculometry is started from day 6 – 8 counting from the first day of menstruation. Folliculometry is performed every 2 or 3 days in the initial stages and can be done daily from the day 12, till after the follicle ruptures [post ovulation]. So in a routine ultrasound folliculometry the lady could be scanned transvaginally for between 3 to 6 sessions.
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