Female Infertility

CONDITION

What is female infertility?

Fertility is the ability of a woman to achieve pregnancy. Infertility is usually defined as not being able to get pregnant despite trying for one year. A broader view of infertility includes not being able to carry a pregnancy to term and having a baby. Women under 35 years old who fail to conceive after 12-months of contraceptive-free intercourse are considered infertile.

What is the percentage of population affected by female infertility?

According to the World Health Organization (WHO), one in every four couples suffer from infertility.

How does female infertility affect you?

Pregnancy results from a chain of events. A woman’s fertility often depends on her body’s ability to release an egg from one of her ovaries (ovulation). The egg must travel through a fallopian tube toward her uterus (womb). A man’s sperm must join with (fertilise) the egg along the way. The fertilised egg must then attach itself to the inside of the uterus. Female infertility can affect any of these processes and prevent you from conceiving and giving birth to a baby.

Which part of the body is affected?

The female reproductive system is made up of the following parts:

  • Vagina: opening of the reproductive system, which allows the entry of sperm towards the uterus
  • Cervix: narrow region that connects the vagina to the uterus
  • Uterus or womb: where a fertilised egg implants and grows to develop into a baby
  • Ovaries: organs on either side of the uterus, which release an egg each month to fertilise with sperm
  • Fallopian tubes: narrow tubes that open out at the ovaries to pick up the released egg for fertilisation

These events are controlled by hormones secreted by the ovaries and the brain. Female infertility can affect the ability of these hormones or the reproductive system to function normally to allow and sustain a pregnancy.

What are the causes of female infertility?

About one-third of infertility cases are due to problems with the man (male factors) and one-third are due to problems with the woman (female factors). Some of the causes of female fertility may include:

  • Problems with ovulation account for most women’s fertility problems. Without ovulation, eggs are not available for fertilisation. Ovulation problems can be caused by:
    • Simple lifestyle factors: Stress, diet or athletic training can affect the hormonal balance.
    • Polycystic ovarian syndrome (PCOS): This is the most common cause of female infertility, where multiple cysts form in the ovaries.
    • Hypothalamic dysfunction: Excess stress, being underweight or overweight, or a recent significant weight gain or loss disrupt the balance of the hormones that control the functions of the ovaries.
    • Premature ovarian failure: The ovaries stop producing eggs very early, either because of an autoimmune disorder or following cancer treatment.
    • Excess prolactin: When prolactin is produced in excess by the pituitary gland, the ovaries’ secretion of oestrogen hormone reduces.
    • Pituitary gland tumour: A hormonal imbalance from a serious medical problem such as a tumour can cause ovulation problems.
  • Aging is an important factor in female infertility. The ability of a woman’s ovaries to produce eggs declines with age, especially after age 35. About one-third of couples where the woman is over 35 will have problems with fertility. By the time she reaches menopause, when her monthly periods stop for good, a woman can no longer produce eggs or become pregnant.
  • Certain structural deformities in the female reproductive system can also lead to complications with fertility.
    • If the fallopian tubes are blocked at one or both ends, the egg can’t travel through the tubes into the uterus. Blocked tubes may result from pelvic inflammatory disease, endometriosis, or surgery for an ectopic (tubal) pregnancy.
    • The cervical tissue may be preventing the sperm from entering the womb for fertilisation.
    • Extra growths such as polyps and fibroids in the uterus can interfere with pregnancy.
    • Endometriosis can interfere with implantation and its surgical removal can lead to the formation of scar tissue which can block the fallopian tubes.
    • An abnormally shaped uterus will not support a healthy pregnancy.
  • Sometimes the cause of infertility is unknown and may be governed by a combination of many minor factors.

Who is at risk of female infertility?

You may be at a risk of female infertility if you have the following factors:

  • Age: With age, the quality and quantity of the eggs produced by the ovaries declines. By mid-30, your body begins to produce fewer and poorer quality eggs.
  • Smoking: Smoking increases your risk of ectopic pregnancy and miscarriage, damages your fallopian tubes and cervix, and ages your ovaries, reducing the number of eggs that it produces prematurely.
  • Weight: A healthy weight is important for pregnancy. Being underweight or overweight affects normal ovulation.
  • Sexual history: Practicing unprotected sex with multiple partners can increase your risk of contracting sexually transmitted infections, which can in turn damage the fallopian tubes and lead to fertility problems later.
  • Alcohol: Excessive alcohol intake can also affect your fertility.

What are the signs and symptoms of female infertility?

The primary sign of female infertility is the inability to conceive and sustain a pregnancy. Some of the symptoms of associated conditions that affect your menstrual cycle and ovulation may include:

  • Very long (35 days or more) or very short (21 days or less) menstrual cycles
  • Abnormal, irregular or no periods
  • Painful periods
  • Acne, male pattern hair growth on face and thinning of hair
  • Weight gain
  • Changes in sex drive and pain during sex
  • White discharge from breasts

What are the related disorders that occur with female infertility?

Female infertility can be associated with many other conditions such as PCOS, endometriosis, uterine polyps, pituitary tumours, premature ovarian failure, hyperprolactinemia and cervical stenosis.

What are the stages of female infertility?

There are 2 types of female infertility:

  • Primary infertility: you are unable to become pregnant after a minimum of 1 year of having unprotected sex.
  • Secondary infertility: you have been able to conceive at least once, but are now unable.

When should I seek help for my infertility?

You may have reason to be concerned if you have been trying to get pregnant for at least one year and:

  • You are in your late 30s and have been trying to get pregnant for six months or longer
  • Your menstrual cycles are either irregular or absent
  • You have painful periods
  • You have a known history of fertility problems
  • You have a history of pelvic inflammatory disease or endometriosis
  • You have had multiple miscarriages
  • You have been treated for cancer with drugs and radiation

How is female infertility diagnosed?

When you visit the clinic for infertility problems, your doctor will review your medical and sexual histories, and perform a thorough physical examination.

The first step in testing is to find out if you are ovulating each month. There are several ways to do this. For example, you can keep track of changes in your morning body temperature and texture of your cervical mucous. Another tool is a home ovulation test kit, which can be bought at a pharmacy. Checks of ovulation can also be done in your doctor’s office, using blood tests for hormone levels or ultrasound imaging of the ovaries. If you are ovulating, more tests will need to be done.

Some common female tests include:

  • Hysterosalpingogram: This is an X-ray of the fallopian tubes and uterus after they are injected with a dye. It shows if the tubes are open and the shape of the uterus.
  • Laparoscopy: An exam of the tubes and other female organs for disease. An instrument called a laparoscope is used to look inside the abdomen.
  • Biopsy: A test done to remove a sample of the inner lining of the uterus for evaluation.
  • Ovarian reserve testing: This is performed to determine the number and quality of eggs ready for ovulation.

TREATMENT

What are the consequences of not treating female infertility?

Left untreated, you may not be able to get pregnant and have a baby.

What are the treatment options for female infertility?

Depending on the test results, different treatments can be suggested. Eighty-five to 90% of infertility cases are treated with drugs or surgery.

Various fertility drugs may be used for women with ovulation problems. It is important to talk with Dr Alex Polyakov about the drug to be used. You should understand the drug’s benefits and side effects. Depending on the type of fertility drug and the dosage of the drug used, multiple births (such as twins) can occur in some women.

If needed, surgery can be done to repair damage to a woman’s ovaries, fallopian tubes, or uterus.

Your doctor may even suggest assisted reproductive techniques (ART) to assist with a particular step in the reproductive process.

What is assisted reproductive technology?

Assisted reproductive technology (ART) uses special methods to manage infertility. Success rates vary and depend on many factors. ART can be expensive and time-consuming. But ART has made it possible for many to have children that otherwise could not have been conceived.

In vitro fertilisation (IVF)

In vitro fertilisation (IVF) is a procedure made famous with the 1978 birth of Louise Brown, the world’s first “test-tube baby.” IVF is often used when your fallopian tubes are blocked or when a man has low sperm count. A drug is used to stimulate the ovaries to produce multiple eggs. Once mature, the eggs are removed and placed in a culture dish with the man’s sperm for fertilisation. After about 40 hours, the eggs are examined to see if they are fertilised by the sperm and are dividing into cells. These fertilised eggs (embryos) are then placed in your uterus, thus bypassing the fallopian tubes.

Some of the other techniques used in IVF include

Intracytoplasmic Sperm Injection

Intracytoplasmic Sperm Injection

  • Intracytoplasmic sperm injection (ICSI): A single healthy sperm cell is directly injected into a mature egg.
  • Assisted hatching: The outer covering of the embryo is removed to facilitate embryo implantation into the uterus.

Gamete intrafallopian transfer (GIFT)

Gamete intrafallopian transfer (GIFT) is similar to IVF, but is performed when you have at least one normal fallopian tube. Three to five eggs are placed in the fallopian tube, along with the man’s sperm, for fertilisation inside your body.

Zygote intrafallopian transfer (ZIFT)

Zygote intrafallopian transfer (ZIFT), also called tubal embryo transfer, combines IVF and GIFT. The eggs retrieved from your ovaries are fertilised in the lab and placed in the fallopian tubes rather than the uterus.

What are the alternative treatments for female infertility?

Some of the alternative treatments for female infertility can include:

  • Gestational surrogates: If your pregnancy poses high health risks or if you have a nonfunctional uterus, your pregnancy can be carried by another woman to term.
  • Egg donation: ART procedures sometimes involve the use of donor eggs (eggs from another woman) or previously frozen embryos. Donor eggs may be used if you have impaired ovaries or a genetic disease that could be passed on to your baby.

Am I candidate for IVF?

You may be a good candidate for IVF if you any of the below conditions:

  • Ovulatory dysfunction
  • Blocked, diseased or absent fallopian tubes
  • Pelvic inflammatory disease
  • Unexplained infertility
  • Failed conventional fertility methods with injectable drugs and/or intrauterine insemination (IUI)
  • Endometriosis
  • PCOS
  • Uterine factors or cervical mucous problems

How do I prepare for IVF?

IVF involves a series of steps that are performed in accordance with your monthly menstrual cycle. Before starting IVF, you will be screened for ovarian reserve and infectious diseases, and your uterine cavity examined. Your doctor may even perform a mock embryo transfer to determine the technique that will best suit your condition.

It can be a long and laborious process for some, so it is best for you to be physically and mentally prepared for each stage of treatment as well as its outcomes. Get a clear understanding of the process so that you are well informed about the risks and side effects of the treatment, and that you are aware that you may need more than one cycle for positive results.  

Eat a healthy balanced diet, take supplements such as folic acid on a regular basis, exercise regularly, avoid excess caffeine and alcohol, and get ample amount of sleep.

How is IVF performed?

IVF involves many steps:

  • Ovulation induction: The doctor will administer fertility drugs to boost the production of your eggs. Transvaginal ultrasounds will be conducted to monitor the development of the eggs and blood tests obtained to check hormone levels.
  • Egg retrieval: Your doctor will perform a follicular aspiration, a minor surgical procedure to remove the eggs from your ovaries. An ultrasound probe is inserted through the vagina and into the follicles under ultrasound guidance. Each follicle in the ovary is pierced to retrieve the egg(s).
  • Insemination and fertilisation: The eggs are mixed with the sperm in an environmentally controlled chamber to facilitate the process of insemination. The egg is fertilised a few hours after insemination. If the chance of fertilisation is low, intracytoplasmic sperm injection (ICSI) may be used where the sperm is directly injected into the egg.
  • Embryo culture: Division of the fertilised egg forms an embryo. The development of the embryo is monitored and within 5 days, a normal embryo has several actively dividing cells.
  • Embryo transfer: Embryo transfer is performed 3 to 5 days after egg retrieval and fertilisation. A thin tube containing one or more embryos is inserted into the vagina through the cervix and into the uterus. After transfer, if an embryo attaches or sticks to the womb lining, it results in pregnancy.

IVF Procedure

IVF Procedure

What can I expect after an IVF cycle?

You will be able to empty your bladder after the procedure. You can continue with your normal activities, but refrain from vigorous activities. It is normal to pass some clear or bloody fluid after the procedure.

What are the advantages and disadvantages of IVF?

The primary advantage of IVF is the achievement of a successful pregnancy and a healthy birth. It allows couples who are otherwise unable to get pregnant, to have a baby.

Other advantages include:

  • It is more successful than other assisted reproductive technology methods and these success rates have been increasing since its conception.
  • It is especially useful in single women and same-sex couples.
  • It can help identify fertilisation problems in those with unexplained infertility.
  • It can help screen for inherited diseases.

The disadvantages of IVF include:

  • You may have to undergo multiple cycles before you can become pregnant and have a healthy live birth.
  • It is associated with side effects such as ovarian hyper-stimulation syndrome (OHSS), multiple pregnancies and ectopic pregnancy.
  • IVF can cause a lot of stress and affect your emotional and psychological wellbeing.
  • It can be expensive for many.
  • The act of discarding extra embryos may pose ethical issues of destroying a potential life.

Describe the stages of recovery and care plan?

You may experience:

  • Breast tenderness as a result of the high levels of oestrogen
  • Mild bloating and cramping
  • Constipation

These are normal, but contact your doctor immediately if you experience moderate to severe pain following the embryo transfer.

After 12 days to two weeks from the time of egg retrieval, you will be tested for pregnancy. If you test positive, you will be referred to an obstetrician for prenatal care. If you test negative, your medications will be stopped to allow your menstrual cycle to occur and your case will be reassessed to consider alternate methods to improve your chances of success. Following 3 months, another cycle will be started.

What are the outcomes of IVF?

The outcomes of IVF are greatly affected by many factors such as:

  • Age
  • BMI
  • Ovarian reserve
  • Reproductive history including previous miscarriages
  • Cause of infertility
  • Lifestyle factors

IVF success is not only restricted to the attainment of pregnancy but also the birth of a healthy child without any related complications. According to the Centers for Disease Control and Prevention (CDC), IVF results in an average of 29.4% pregnancy and 22.4% live births.

What are the potential complications of IVF?

As with most therapeutic procedures, IVF may be associated with certain risks and complications such as:

  • Multiple births
  • Premature and low birth weight baby
  • Ovarian hyper stimulation syndrome (OHSS): a condition of ovarian enlargement accompanied by fluid accumulation in the abdominal cavity
  • Miscarriage
  • Bleeding
  • Infection
  • Damage to the bowel, bladder or blood vessels
  • Possibility of ectopic or tubal pregnancy

What is the downtime of IVF?

IVF is performed in cycles, with each cycle lasting for about 6-9 weeks until you confirm on your pregnancy. You are given about 3 months to physically and emotionally recover from a failed pregnancy before you start with the next cycle. Some would require 3 such cycles for a positive pregnancy. However, you will be able to continue with your normal activities after the procedure, with caution against vigorous activities.

What is the cost of IVF?

Any costs involved will be discussed with you prior to the procedure.

How can female infertility be prevented?

Some forms of infertility cannot be prevented, but there are a few factors that may increase your chances of becoming pregnant:

  • Avoid smoking, drugs and alcohol.
  • Limit your intake of caffeine.
  • Exercise regularly in moderation.
  • Avoid being overweight or underweight.
  • Practice safe sex and limit the number of sex partners.
  • Consider ways of protecting your fertility from cancer treatment.

What is the current research regarding female infertility?

Extensive research is being done to find better treatment options for female infertility. Some of the recent studies are listed below:

  • Vanni VS, Viganò P, Papaleo E, Mangili G, Candiani M, Giorgione V. Advances in improving fertility in women through stem cell-based clinical platforms. Expert Opin Biol Ther. 2017 May;17(5):585-593.
  • Melin J, Madanat-Harjuoja L, Heinävaara S, Malila N, Gissler M, Tiitinen A. Fertility treatments among female cancer survivors giving birth – a Finnish register-based study. Acta Oncol. 2017 Mar 24:1-5.