Infertility in Women
Infertility is the inability to conceive after 12 months of unprotected intercourse. Basic fertility testing should begin no later than 12 months of trying for young women, and no later than 6 months of trying in women who are over 35 years old. Women over 35 have a more rapid decline in their egg supply and quality, so testing should begin earlier to avoid losing precious time. Fertility testing should begin even earlier if there is an obvious problem, such as irregular periods, ovulation problems, or uterine problems such as fibroid tumors.
The following medical conditions often contribute to difficulties conceiving:
Causes of female infertility
So many things have to go just right in a woman’s body in order to achieve fertilization, successful implantation, and a sustained pregnancy. It’s a wonder any of us are here at all! We can correct many aspects of the female cycle that may not be functioning properly. Sometimes this is all a couple needs to become and stay pregnant.
Common problems that cause infertility in women include abnormalities in ovarian function or anatomical abnormalities of the uterus or fallopian tubes.
There are many different forms of ovarian dysfunction, which result in ovulation problems or abnormal hormone production throughout the menstrual cycle. Evaluation is primarily through hormone testing. Often thyroid hormone abnormalities, prolactin abnormalities, polycystic ovary syndrome, hypothalamic amenorrhea, and decreased ovarian reserve are discovered. Some of these underlying conditions can be treated to restore normal ovarian function and ovulation but others require the use of fertility medications. Understanding the underlying cause enables us to choose the most effective treatment option.
Many women who experience infertility have hormones that are not functioning properly, are not ovulating at the right time, or are not ovulating at all.
Understanding how your own body works becomes even more essential when you start trying to build your family. There are four phases to your menstrual cycle, including:
Begins on cycle day 1, the first day of your period. While your body is shedding the lining and nutrients of uterus that were not used to sustain a pregnancy last month, it also begins to develop follicles (each containing an egg) in the ovaries when the pituitary gland releases the hormone FSH, follicle stimulating hormone. As the days pass, one follicle becomes dominant and prepares to release one mature egg, ready for fertilization. The developing follicle makes estrogen, which causes the lining of the uterus (endometrium) to grow.
This occurs after a surge in the level of luteinizing hormone (LH) – which tells the dominant follicle to release its mature egg into the fallopian tube. This part of the cycle begins around cycle day 14, typically lasts for 16-32 hours, and ends after the egg has been released. Properly timed intercourse needs to occur here or just prior to ovulation in order to achieve pregnancy.
This phase begins around day 15 and lasts until pregnancy occurs or the next period begins (around 14 days later). The egg that has been released will stay in the fallopian tube for around 24 hours awaiting fertilization. Once fertilization occurs, the fertilized egg develops into an embryo and travels down the tube to the uterus over the next 4-5 days. An unfertilized egg will disintegrate quickly if it does not become fertilized. The ovary makes a combination of estrogen and progesterone during the luteal phase. These hormones cause the lining to undergo changes, and become prepared to have an embryo implant. If pregnancy does not occur, the ovary stops making hormones which causes the lining to become unstable and menses begins.
Problems with the fallopian tubes are very common.
Blockages of the fallopian tubes can prevent the egg from entering the tube after ovulation, or prevent sperm from ascending into the tube to reach the egg. Fallopian tubes can also become swollen and accumulate fluid (also known as a Hydrosalpinx) which is unhealthy for a developing embryo.
The fallopian tubes are very delicate structures and are easily damaged when there is inflammation within the pelvis. The most common causes of tubal damage include prior pelvic surgery, endometriosis, or a sexually transmitted infection such as chlamydia or gonorrhea. Damaged fallopian tubes are also a risk factor for an ectopic pregnancy.
Tubal abnormalities also increase the risk of having an ectopic pregnancy, where an embryo implants inside the fallopian tube, which is not viable and also dangerous because the tube can rupture. Women with endometriosis, pelvic adhesions, and prior sexually transmitted infections are at increased risk of having tubal abnormalities.
There are both congenital and acquired problems of the uterus. Some problems with the uterus can cause infertility or increase the chance of adverse pregnancy outcomes. Common uterine abnormalities include fibroids, polyps and scar tissue within the uterine cavity. Fibroids are benign tumors originating from the muscle cells within the walls of the uterus. If they grow and protrude into the cavity of the uterus, there is a clear reduction in fertility and increase in miscarriage rates. These fibroids require surgical removal via hysteroscopy. Endometrial polyps are benign growths that originate from the endometrium, which lines the uterine cavity. Large polyps will also reduce fertility and require removal by hysteroscopy. Intrauterine adhesions (Ashermans syndrome) or scar tissue, signifies damage to the endometrial tissue, usually as a result of a prior surgery within the uterus or infection. Scar tissue can be removed by hysteroscopy but some severe cases cannot be repaired and a gestational carrier may be needed.
Ovulation disorders and PCOS
Problems with ovulation often result in irregular and unpredictable menstrual cycles. Women with irregular menses do not need to wait for a fertility evaluation and should proceed with hormone testing to identify the root cause of the irregular cycles. Irregular periods indicates that ovulation is not predictable or is not occurring at all. Common hormonal problems that cause ovulation problems include thyroid disorders, hyperprolactinemia, and polycystic ovary syndrome (PCOS). Almost 10% of reproductive age women have PCOS, which is characterized by ovulation problems, irregular cycles, and manifestations of high male hormone (androgen) levels. The high androgens often cause oily skin, acne, and facial hair. Most women with PCOS also have insulin resistance, which causes difficulty maintaining a healthy body weight.
This condition occurs when the endometrial tissue that lines the interior of the uterine cavity spreads outside of the uterus and starts growing in an abnormal location. Endometriosis commonly occurs on the ovaries, behind the uterus and cervix, or in front of the uterus. Over time, the tissue proliferates and behaves as if it were in the uterus, bleeding during each menses. This causes inflammation in the pelvis, leading to adhesion (scar tissue) formation and pelvic pain. Endometriosis can distort the normal anatomy of the pelvis and create a hostile environment for eggs and sperm. Unfortunately there are no good tests for endometriosis and it usually cannot be seen by X-ray or ultrasound. Only surgery with laparoscopy can be done to make a definitive diagnosis.
Decreased ovarian reserve
As women age, there is a decrease in the supply of eggs in the ovaries. Women are born with a finite supply of eggs and those eggs do not replicate to make new eggs. As time goes on, eggs are continuously dying and we have no way to stop or reverse the process. Not only does the supply decline over time, but the quality of the remaining eggs declines as well. Older eggs are less likely to fertilize normally and produce a normal embryo. The decline in egg quality and quantity results in lower fertility, higher miscarriage rates, and higher rates of chromosomal abnormalities.
Female fertility tests
Ovarian reserve testing is important for all patients, even if ovarian function appears to be normal. Ovarian reserve refers to the remaining egg supply in the ovaries and is closely correlated with fertility potential using treatment. Women are born with a finite supply of eggs and the supply declines over time.
There is a great deal of individual variation in the rate of decline of the egg supply, and of concern is that some women will have decreased ovarian reserve. Most forms of fertility treatment require medications to stimulate the ovaries, but with low ovarian reserve there is a lower chance that the ovaries have the desired response to medications. We typically use blood levels of AMH to assess ones ovarian reserve, but we also use ultrasound to perform an antral follicle count of the ovaries.
Hysterosalpingogram (HSG) test
The fallopian tubes are evaluated by the HSG test. In most cases, the diagnosis of a tubal problem is made through an HSG.
The HSG test or saline ultrasound (sonohysterogram) is used to reveal structural abnormalities of the uterus.
Endometrial Receptivity Analysis (ERA) trst
Failure of implantation is another cause of infertility in a small percentage of patients. Implantation can be impaired when there are structural problems of the uterus, but some patients appear to have a problem with the function of the uterine lining, and a less hospitable environment for implantation of an embryo. The Endometrial Receptivity Analysis (ERA) test evaluates the endometrium (uterine lining) to see if it is receptive for embryo implantation.
When the female and male fertility evaluations ordered by your physician are complete and results are back, you will meet with your physician again in person or by scheduled phone consultation to review what everything means and create a treatment plan together.
Sometimes a couple tests “normal” for their fertility evaluations, yet still experiences difficulty conceiving or sustaining a pregnancy. A completely normal workup results in the diagnosis of unexplained infertility. When this is the case, we consider looking for more answers from genetics and exploratory minimally invasive surgery.