For a pregnancy to occur, the woman releases an egg from either ovary every month, which is called ovulation. This released egg travels towards the Fallopian tube. The end of the tube is shaped like the fringes of a dress. These fringes continually move in a wave like manner, to pull the egg into the tube, from where it begins to travel towards the uterus. At the end of the tube, just before it enters the uterus, it is met by a healthy sperm, which are contained in the ejaculate released during intercourse. The sperm travel upwards through the vagina into the cervix, and then into the uterus Female Infertility
The sperm and the egg fuse together in a process called fertilization, and an embryo is formed. The embryo then continues the journey into the uterus and attaches to the uterine wall, in a process called implantation. Once implantation has occurred, the body starts to release more hormones that will aid in the growth of the baby, and the woman will discover that she is pregnant.
Anything that causes an interruption at any point in this process can cause Female Infertility.
Causes of Female infertility
- Impaired production of eggs – Factors that can cause this include age related decline, premature ovarian failure, endometriosis or medical conditions like diabetes
- Disorders of ovulation – These are caused by abnormalities in the production of hormones, and common causes include Polycystic Ovarian Syndrome (PCOS), hyperprolactinaemia, thyroid problems, adrenal problems, stress, being underweight or overweight, and certain medications
- Dysfunction of the Fallopian tubes – The tubes can become damaged by anything that causes it to be inflamed or scarred. Common causes include Pelvic Inflammatory Disease (PID, usually a consequence of a sexually transmitted infection) and adhesions (scar tissue) caused by endometriosis or previous surgery inside the uterus or the abdomen. Also, fibroids can cause a blocked tube if it is lying across the tube.
- Implantation problems – These are problems with the structure of the uterus or cervix which make it difficult for the fertilized egg to be implanted on the lining of the uterus. They include: fibroids, endometrial polyps, adenomyosis, and intrauterine adhesions
In up to 20% of cases, no definite cause can be found in either the man or the woman for infertility, when all tests done show normal results. Making an accurate diagnosis of the underlying issue usually involves a series of investigations, which might be time consuming. For the woman, the tests may need to be done at specific times of the menstrual cycle. You will need to be mentally and emotionally prepared for this, and try to adjust your schedule as much as possible, so that there aren’t too many interruptions to your daily routine. While there are a number of tests that can be done, the specific tests you will have done and their sequence will depend on your individual case, and the decision will be made after your doctor has seen you and you both have come to an agreement.
Investigations of Female Infertility
- Ultrasound scan: This is done to examine the uterus and the ovaries and can be used to pick up things like fibroids, polycystic ovaries, adhesions, and in some cases, endometriosis
- Hormonal tests: These are blood tests that are done to measure the amount of specific hormones in the body to check for deficiency, excess, or imbalance. Some of them are done on specific days of the cycle in order to make an accurate assessment. Some of the hormones tested for include LH, FSH, Prolactin, Progesterone, AMH, Thyroid hormones, and Testosterone. This is sufficient to make diagnoses of PCOS, Hyperprolactinaemia, Ovarian Failure, Hyper- or Hypo- thyroidism, anovulation.
- Hysterosalpingography: It is commonly called a HSG and is a radiological test that is done to determine whether or not the tubes are patent. A dye in inserted into the uterus through the vagina, after which a series of X-rays are taken of the pelvic area. Demonstrating spillage of the dye through the tubes confirms that they are patent. A HSG can also show intrauterine adhesions, and determine the way a fibroid affects the uterine cavity.
- Magnetic Resonance Imaging (MRI): This is a very sensitive imaging technique which is more accurate than a conventional ultrasound scan. An MRI of the abdomen and pelvis can be used to make a more specific diagnosis of some identified problems like fibroids (shows the numbers, size, and location), endometriosis (shows the extent and stage), and adenomyosis (shows the size and location). It also helps in determining what kind of surgical treatment can be used for treatment.
- Hysteroscopy: Hysteroscopy is a method of visualizing the inside of the womb with a special tiny camera called a hysteroscope, which is fitted with a light source and passed from the vagina, through the cervix, and into the womb. The images are magnified and projected on a screen for the doctor to see and make assessments. It is used to identify any abnormality on the inside of the uterine cavity, like fibroids, polyps, and intrauterine adhesions (scar tissue). It is also used as a method of treating these issues.
- Laparoscopy: Laparoscopy is a type of surgical procedure in which the inside of the abdomen and pelvis is accessed by laparoscopic instruments, which include a laparoscope – a thin telescope fitted with a light source and a camera. They are passed into the abdomen through small cuts on the skin (about 1-2 cm long), and the images are then magnified and projected on a screen for the doctor to see. Laparoscopy can be used to check the patency of the tubes, confirm endometriosis, abdominal adhesions (scar tissue), polycystic ovaries, and fibroids. It can also be used to treat these conditions.
Treatment of Female Infertility
The results of the investigations done will be explained to you, and a treatment plan will be outlined, depending on what is found. Sometimes, all that is necessary is for you to monitor your menstrual cycle and determine when you usually ovulate, so that you can have timed intercourse. Treatment options include:
- Ovulation induction and follicular tracking: This is used to address infertility that is caused by PCOS. Medications (tablets or injections) are given to stimulate the ovaries to ovulate (i.e to release an egg). After this, the ovaries are scanned regularly to monitor the growth of the follicle (the small sac on the ovary that contains the egg), and to confirm when ovulation occurs, so that sexual intercourse can be timed.
- Surgical treatment: You might require a surgery to treat problems like uterine fibroids, polyps, intrauterine and abdominal adhesions, and endometriosis. This can be done by hysteroscopy, laparoscopy, or laparotomy (abdominal surgery).
- Medical treatment: In some cases, issues like hyperprolactinaemia, and endometriosis can be managed with the use of some tablets and injections.
- Assisted Reproduction