Major causes of female infertility

Painful and irregular periods may give an indication of female infertility, but many women have no symptoms until they try to conceive. Fertility testing of both partners together is highly recommended as only one third of infertility cases are caused by female factors, a third are male and the remainder a combination of factors or the reason is unexplained.

Endometriosis and PCOS are among the common reasons for female infertility which include:

Polycystic ovary syndrome (PCOS)

A common cause of irregular periods is PCOS. This is caused by a hormone imbalance that disrupts ovulation. The ovaries develop many small cysts instead of ripening and maturing one egg each cycle. Although women with PCOS may have a high Body Mass Index (BMI), not all with this condition are overweight.

Symptoms may include: Irregular menstrual periods, excessive hair growth, acne and weight gain.

Diagnosis: Scan of ovaries, hormone testing.

Possible solutions: Changes to diet and lifestyle if overweight, weight loss of just five per cent can re-start regular ovulation in obese women. Ovulation stimulating drugs such as clomiphene or gonadotrophins may be prescribed but care is needed as women with PCOS can overstimulate. If these measures are unsuccessful then IVF with fertility drugs are recommended.

More information about PCOS.

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POOR EGG QUANTITY

Age is the biggest factor as egg quantity and quality declines significantly with age from late 30s. Although this may also be an issue for younger women when eggs are damaged (chemotherapy) or develop chromosomal abnormalities. Symptoms include: difficulty conceiving and recurrent miscarriage.

Diagnosis: Anti-Mullerian Hormone (AMH) is a substance produced by small ovarian follicles. In a natural conception, one of these follicles will mature to become an egg. AMH test is commonly used to assess the number of eggs available and to predict response to ovarian stimulation. Although not a measure of egg quality, if more eggs are available there is a greater chance that one will be of sufficient quality.

Research has shown that the number of the growing follicles is related to the size of the pool of remaining primordial follicles (microscopic follicles in “deep sleep”). Therefore, AMH blood levels give an indication of the remaining egg supply – or “ovarian reserve” but as the release of eggs is not consistent the AMH reading should not be used to predict future fertility. Women with many small follicles, such as those with polycystic ovaries, have high AMH hormone values and women that have few remaining follicles and those that are close to menopause have low AMH levels.

Possible solutions: IVF with own eggs (if of sufficient quality) or with egg or embryo donation. Success rates for older women with donated eggs are equivalent to those of women under 35. Surrogacy where another woman carries the baby with donated eggs fertilised by the partner’s sperm may also be an option.

Premature ovarian failure

Premature ovarian failure is failure of egg production in women under the age of 40. A woman would normally release eggs throughout her lifetime until the age of about 52 when she reaches menopause, although loss is rapid from the age of 35. Sometime this happens more rapidly perhaps as a result of genetics or chemotherapy.

Symptoms: Periods have ceased.

Diagnosis: Elevated FSH and AMH testing as above.

Treatment: IVF with donated eggs or embryos.

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BLOCKED FALLOPIAN TUBES

The egg travels from the ovary to the uterus through the fallopian tube. If the tubes are damaged they can become blocked so the sperm is prevented from reaching the egg and fertilising it. Blocked tubes can be caused by pelvic inflammatory disease, sexually transmitted diseases such as chlamydia, and previous sterilisation surgery.

Symptoms: There are no symptoms.

Diagnosis: Hycosy diagnostic test is where a dye is inserted into the tubes and followed using an ultrasound scan. If the dye travels through the tubes to the uterus then tubal patency is confirmed and the tubes are clear. This test can be performed at any time of the cycle assuming the couple have not had unprotected sex.

Possible treatment: In a small minority of cases, laparoscopic surgery can be used to open tubes, but more often IVF is recommended as the eggs are generally unaffected.

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ENDOMETRIOSIS

Endometriosis is a condition where the endometrial tissue (the uterine lining that sheds with each monthly period) grows outside the uterus. It is an important factor in infertility, as it can cause tubal blockages and ovulation problems.

Symptoms may include: Painful periods, deep pain during penetrative sex, chronic pelvic pain, painful bowel motions or urination during menstruation. However, there may be no symptoms other than difficulty getting pregnant.

Diagnosis: Laparoscopy is used for both diagnosis and treatment if tissue is seen to be blocking the tubes.

Treatments: Laparoscopic surgery to remove abnormal tissue. Fertility drugs with intrauterine insemination (IUI) for mild endometriosis or in vitro fertilisation (IVF) for more severe cases.

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UTERINE OR CERVICAL CAUSES

A normal uterine cavity (womb) and endometrial lining is essential for a woman to be able to conceive and carry a pregnancy to term. Conditions such a congenital abnormalities can impact the uterus and cervix. In some countries, health professionals still check the cervical mucus but this is no longer considered relevant in the UK, as IVF or IUI treatment overcomes any issues with the mucus.

Fibroids

Fibroids are non-cancerous growths that develop in or around the womb (uterus) they do not always cause a problem, it depends where they are located. They are made of muscle and fibrous tissue and vary in size. It is thought that their formation is linked to the hormone oestrogen. Other names include uterine myomas or leiomyomas. They most commonly occur in women over 30 of African- Caribbean origin but not exclusively.

Symptoms: Many women are unaware they have fibroids because they don’t have any symptoms. But symptoms in about 1 in 3 women include heavy periods or painful periods, lower back pain, pain or discomfort during sex.

Diagnosis: By a routine gynaecological examination or scan.

Treatment: Fibroids often shrink and disappear without treatment but if they are causing discomfort there are medications available or surgery is an option.

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UNEXPLAINED INFERTILITY

Sometimes the reason for the infertility cannot be detected and for a small minority of people it is found that the egg and sperm are ‘incompatible’ and when put together do not form an embryo, however the latter can be overcome with intracytoplasmic sperm injection (ICSI), an IVF technique in which an individual sperm is introduced directly into an egg cell.

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FERTILITY TESTING

Bourn Hall provides comprehensive fertility testing, available as a suite of tests or individually, to assist diagnosis. It is highly recommended that both partners are checked at the same time.  This may reveal a male infertility issue or influence the decision of which person in a same-sex relationship should be provided with sperm or carry the baby.

Testing includes:

• Screening for infection
• Blood tests for hormone levels and ovarian reserve
• Ultrasound scans
• Tubal patency assessment.
• Semen analysis

A complete assessment can be completed with 6 weeks and includes a consultation with a fertility specialist.

Fertility medicine is moving towards using testing more as a way to determine if treatment is required and what is most appropriate, than to pinpoint the exact cause. Rapid testing that provides the desired information quickly is therefore highly beneficial.

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