Infertility Female - Female Infertility
What is female infertility
The definition of infertility is when a couple have not conceived after 12 -18 months of unprotected intercourse. Normally, after one year of trying 95% of normal fertile couples will have conceived. Infertility is said to affect about 1 in 7 couples in the UK.
Why does it occur
In about one in four of all couples investigated for infertility, no definite diagnosis can be reached and one can only refer to this as 'unexplained' infertility. Women generally become less fertile as they get older and as couples delay starting a family until much later so the treatment may be correspondingly less successful.
How does it occur
The main causes of infertility in women are the following:
Failure of ovulation
This occurs when the ovaries fail to produce eggs each month and can be due to of a problem within the ovary itself, for example, when the ovary has developed many cysts within it (polycystic disease). Alternatively there may be a hormonal cause where the chemical messengers produced in the brain's master gland (the hypothalamus) do not provide the correct hormones to trigger off ovulation in the ovary. The functioning of the hypothalamus can be affected by outside factors such as severe dieting, chronic stress and chronically poor nutrition which in turn can affect the ability to ovulate.
Blocked Fallopian Tubes
These are very delicate complex structures which transport eggs, sperm and early embryos. They can become narrowed or blocked by scar tissue formed as a result of inflammation within the tubes. This prevents fertilisation and embryo transport. If only one tube is blocked the woman may still be fertile but it may take longer to achieve a pregnancy.
This may occur due to adhesions or 'bands of scar tissue' caused by previous surgery or infection. These may 'kink' the tubes and so prevent egg transport. Specific infection with an organism called chalmydia can cause pelvic inflammatory disease which can disturb normal function of the tubes.
Damage can be caused to the ovary, tubes, or other organs in the pelvic area when endometrial tissue (which is normally confined to the lining of the uterus) grows outside the uterus, and damages these organs and affects ability to conceive.
These are benign fibrous growths occurring outside, within, or inside the wall of the uterus which can interfere with implantation of the embryo.
Failure of fertilisation and implantation
This can occur if the body produces special proteins (antibodies) which render the sperm less motile (active) and therefore less able to fertilise the egg.
problems with intercourse
This may be because the male is impotent or alternatively it may arise because intercourse itself is painful for the woman (because of a physical problem) and therefore an unpleasant experience. This may cause fear and the associated anxiety can prevent a couple from relaxing.
What are the tests
Investigations usually commence when the woman has tried unsuccessfully to become pregnant after 18-24 months of unprotected intercourse and these can be initiated by the family doctor.
Some doctors ask women to keep a temperature chart for 3 -6 months. A mid cycle temperature "spike" indicates ovulation. This can be accompanied by a blood test to check the serum progesterone hormone level at Day 21 of the cycle. If the level is sufficiently high on this day then this indicates satisfactory ovulation.
Seminal fluid analysis
This is described in detail in the ppp healthcare fact sheet - Male Infertility.
post coital test
Cervical mucus is taken from the vagina around the time of ovulation and about 8 hours after intercourse. The mucus is examined under a microscope for evidence of satisfactory sperm activity.
Investigation of mucus
Cervical mucus is present throughout the menstrual cycle but greatly increases in quantity at ovulation Mucus taken at ovulation is placed in contact with the male sperm to check whether the mucus prevents sperm penetration.
A tiny sample of the womb lining (endometrium) is taken to check if it has responded to hormonal cycle changes and is free from infection.
Assessment of tubal patency
A telescope instrument is inserted into the abdomen through a small cut made beneath the navel (laparoscopy). This procedure can establish if scar tissue, fibroids or other anatomical problems are affecting the womb, ovary, or fallopian tubes. By passing a blue dye through the tubes (hydrotubation) blockages in the tubes can be discovered. An ultrasound scan can assess the shape of the uterus and establish any physical abnormality.
What is the treatment
The type of treatment will vary according to the underlying cause, but in all cases this should be part of a shared programme between the doctor and the couple.
Treatment with a special drug (clomiphene) will help, by stimulating ovulation. Fifty percent of women will become pregnant within six months. The tablet is taken on day 2-5 of each cycle.
This can be corrected surgically, but success is more usual in women with only minor tubal damage.
This may be treated surgically if confined to the fallopian tube but if it is widespread in the pelvis then a hormone treatment (with a drug called danazol) for a 6-9 month period will help cure the problem.
Couples who are not suitable or who have been unsuccessful with other methods may be offered assisted conception (known as IVF or GIFT).
In-vitro fertilisation (IVF)
The ovaries are artifically stimulated by hormones and (under scan control in an IVF unit) several eggs are collected or harvested. After fertilisation outside the womb, 3-4 eggs are transferred back into the womb for attempted implantation. pregnancy rates for IVF from established centres approach 30% per cycle and birth rates of around 25% per cycle can now be expected in women under 40 years old (assuming that the sperm function of the partner is normal).
Gamete Infusion (GIFT)
Sperm and egg are transferred into the fallopian tube where fertilisation and implantation occur naturally.
These techniques are not simple and several attempts may be needed as assisted conception does not always result in pregnancy. Full counselling by the doctors is very important as the programme may be stressful to the couple especially if several failed attempts occur.
Where can I get further information
Apart from contacting your Gp, the following organisations may be of further help:
Family planning Association
2-12 pentonville Road
Helpline: 020 7837 4044 (9.00-19.00 Mon-Fri)
CHILD Self Help Support Group
43 St Leonards Road
Bexhill on Sea
Telephone: 01424 732361
Web page: http://www.child.org.uk
- SHUSHAN, A., EISENBERG, V.H., SCHENKER, J.G. (1995) Subfertility in the era of assisted reproduction. Fertility and Sterility, 64(3) pp.459-69
- MARSHALL, K., SENIOR, J., CLAYTON, J. (1996) Womens Health: 2. Infertility. pharmaceutical Journal, 256(6881) pp.303-307