Female Infertility
Infertility means you cannot get pregnant (conceive). Primary Infertility refers to couple who have not become pregnant after at least 1 year having sex without using birth control methods.
About
Other causes like Fibroid, Uterine Anomaly, etc.
Female infertility contributes to about 50 % of causes of infertility.
Being infertile is often a social stigma and is associated with lot of social pressure and psychological issues.
Causes
Ovulatory Disorders
- It affects 25 % of female infertile population. In this the women don’t spontaneously achieve ovulation.
Endometriosis
- It affects approximately 15 % of female infertile women. It invloves presence of endometrial tissue growing outside the uterus, most commonly the ovaries and the peritoneum leading to adhesion, distortion in anatomy and infertility.
Pelvic Adhesion
- Pelvic adhesions distort the normal anatomy and hence affect fertility.
Tubal blockage
- For natural pregnancy, patent and functional tubes are a must, as fertilization of the egg and sperm takes place in the tubes.In India, Tuberculosis is the leading cause of tubal damage.
Hyperprolactinemia
Unexplained
Tests
Detailed menstrual, medical, surgical and sexual history is taken.
After a detailed history, pelvic ultrasound is performed to assess the uterus and ovaries. Ultrasonography mainly transvaginal can help in detecting the cause behind infertility in some cases.
Uterus is assessed for the size, endometrial lining, blood flow and any other abnormalities like Abnormal uterine shapes (Septate uterus, bicornuate uterus), Fibroid uterus, Endometrial polyp, Calcifications, Adhesions or Ashermann syndrome.
Ovaries are assessed for the volume and follicle count which gives an estimate of the ovarian reserve or to detect any other abnormalities like Polycystic ovaries, Ovarian cyst (Endometrioma, Dermoid cyst, Simple cyst, corpus luteal cyst etc.), Poor ovarian reserve, ovaries stuck to uterus as in PID.
A) Follicular Monitoring
- Follicular study is done in a fertility clinic. It is better done transvaginal then trans abdominally. It can be done in a natural as well as a stimulated cycle.
- It is ideally started from D2 when the women is menstruating to assess the AFC (Antral Follicle Count).
- Then it is repeated on D 8/9 and then every alternate day to monitor the growth of follicle (Egg in the ovary) and its rupture (Ovulation) and also the endometrial lining in response to follicle.
- One of the important tests to asses ovarian reserve is serum AMH i.e. Anti-Mullerian Hormone and AFC.
- After that, the couple is explained about normal fertility and advice given based on the reports.
Certain blood tests may be advised to find out any hormonal problems.
Abnormal tubal pathology like Hydrosalpinx (fluid filled in the tube), Pyosalpinx (pus filled in the tube) , Ectopic pregnancy can also be diagnosed with TVS.
B) What is AFC?
- AFC is Antral follicle count.It is assessed by transvaginal ultrasonography on second or third day of your periods.
- It gives an estimate of the follicles that can be recruited in that menstrual cycle. Normal AFC should be 3-8 follicles less than 10mm in each ovary.
- Total AFC less than 5 indicates poor ovarian reserve.
- AFC of 5-15 indicate normal reserve.
- AFC of more than 15 indicates polycystic ovaries.
C) What is AMH?
- AMH that is Anti-Mullerian hormone is a hormone secreted by granulosa cells of pre-antral and antral follicles of the ovary. It gives an estimate of ovarian reserve (that is no of eggs remaining) which determines fertility.
- It is blood tests which can be performed on any day of menstrual cycle.
- They decrease with increasing age of the women.
- If AMH count is good, it indicates good fertility status.
- A woman is born with fixed no. of eggs for her lifetime which only reduce with age. Hence it is important to complete the family in time before the reproductive potential of women diminishes.
- It is important to remember that AMH levels decline and FSH levels increase as women ages. In other words, normal AMH and FSH levels change depending on a woman’s age. Because of this, focusing on age-specific AMH and FSH levels allows us to best assess awoman’s ovarian reserve, devise an appropriate treatment plan and estimate her IVF pregnancy chances.
D) Sonosalphingography
- Sonosalpingography (SSG) is a diagnostic procedure used to test tubal patency.
- Firstly, Foleys catheter is placed in uterine cavity.
- Then 50-100 ml of normal saline is injected and flow of saline is visualized on ultrasonography.
- Patency is confirmed by observing a shower at the fimbrial end.
- It can also be used to delineate submucous fibroid and detect intra-uterine lesions.
Surgeries
A) Diagnostic Hysterolaparoscopy
- Hysterolaparoscopy involves visualization of the uterus, tubes and ovaries through a laparoscope inserted through the abdomen through a small incision.
- Any abnormality or pathology can be detected and corrected accordingly.
- It also involves visualization of the uterus from within with help of a hysteroscope.
- Tubal anatomy and functionality can be tested with the help of methylene blue stained saline, in which it is inserted into the uterus and tubal patency is confirmed by visualizing its flow through the fimbrial end through the laparoscope.
B) Fibroid surgery
- Fibroids are abnormal growth that develop in or on the uterus.
- Depending on the location, it can give rise to symptoms like pain, heavy bleeding etc or may be asymmtomatic.
- Depending on the size and location, it can hinder fertility and implantation and may need surgery.
- Surgery can be performed laparoscopically or through hysteroscope depending on the location.
C) Endometriosis Surgery
- Endometriosis involves presence of endometrial tissue growing outside the uterus, most commonly the ovaries and the peritoneum leading to adhesion, distortion in anatomy and infertility. It usually causes painful periods and painful intercourse.
- It also depletes the egg count and affects its quality. Surgery in form of drainage of chocolate cyst, correction of anatomy and fulguration of endometriosis may be required.
- It is usually done laparoscopically.
D) Polyp Removal
- Endometrial Polyp is due to overgrowth of the endometrium.
- It can cause heavy and irregular bleeding or can be asymptomatic.
- It affects implantation of embryo.
- It can be resolved with medical treatment.
- If not resolved, it needs to be removed hysteroscopically.
E) Uterine Septum Removal
- Uterine septum is a congenital anomaly in which uterine cavity is divided into two halves by a septum.
- If associated with infertility, it needs hysteroscopic correction.
- The septum which divides the uterine cavity is excised with scissors under hysteroscopic guidance.
F) Tubal Reconstruction
- If the women have undergone tubal ligation to achieve pregnancy naturally, tubal reconstruction needs to be done.
Treatments
A) Planned Relation
- Natural cycle monitoring followed by planned relationship.
- With Ultrasonography, the growth of the follicle and endometrial response is monitored and Ovulation is confirmed.
- Couple is asked to have relationship around the ovulatory period.
B) Ovulation Induction
- Certain tablets may be given to form a good single follicle and its growth monitored on USG.
- Couple will be asked to have relationship around ovulatory period.
C) Ovarian Hyperstimulation
- Certain tablets and injections may be given to form more than one follicle and their growth monitored with USG.
- When follicles would be optimally formed, injection given to induce ovulation.
- Couple will be asked to have relationship around ovulation period or IUI may be done.
D) Intra-Uterine Insemination (IUI)
- Intra-uterine insemination (IUI) also known as Artificial Insemination is a process in which the washed/processed semen is placed into the uterine cavity with the help of a catheter in and around the time of ovulation (release of egg from the ovary).
- It is usually accompanied with ovulation induction or hyperstimulation.
E) ART (Artificial Reproductive Technology)
- In couples who can’t conceive naturally due to blocked or damaged tubes, poor ovarian reserve, low sperm count or motility, one can conceive through Test tube baby treatment.
- In this using women’s egg and husband’s sperm, embryo is formed in the specialized laboratory and then transferred back to the uterus at appropriate time.
- ART involves IVF, ICSI, Donation program, Freezing Program.