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Reviewed by the Faculty of Harvard Medical School

Female Infertility

What Is It?

For a man and a woman who are having frequent intercourse without using any birth control, the average amount of time it takes to conceive is six months. Most couples are able to achieve a pregnancy within one year if they have intercourse twice a week or more often. Between 10% and 15% of couples will continue to have difficulty conceiving after one year of trying. When pregnancy is this slow to occur, the man and woman are diagnosed as infertile.

Infertility can be caused by health problems in the man, the woman or both partners. In some infertile couples, no cause can be found to explain the problem. In approximately 20% of couples, there is more than one cause of the infertility. The cause of infertility occurs about as often in men as in women.

Normal aging reduces a woman's ability to become pregnant. Ovulation, the process of forming and releasing an egg, becomes slower and less effective. Aging begins to reduce fertility as early as age 30, but pregnancy rates are very low after age 44, even when fertility medications are used. Even though fertility is less reliable for women of older ages, approximately 20% of women in the United States have their first child at or after age 35.

Symptoms

The primary symptom of infertility is difficulty getting pregnant. Various causes of infertility may result in additional symptoms. Any of the following problems may cause infertility:

  • Infrequent ovulation (egg release from the ovary) accounts for 20% of female infertility problems. If you're ovulation is infrequent, your periods will be spaced apart by longer than a month, or they will be absent. Common causes of infrequent ovulation include body stresses such as eating disorders, unusually ambitious exercise training, rapid weight loss, low body weight and obesity. Some hormonal abnormalities such as thyroid problems, pituitary gland problems, adrenal gland problems and polycystic ovary syndrome can delay or prevent the ovaries from releasing an egg. Some symptoms that might suggest a hormone abnormality include unexpected weight loss or gain, fatigue, excessive hair growth or hair loss, acne and ovarian cysts. Cysts in the ovary can cause pelvic pain and also can interfere with the normal process of ovulation.
  • Scarring in the fallopian tubes can prevent pregnancy because it stops the egg from traveling into the uterus. Fallopian tube problems are the cause in approximately 30% of female infertility problems. Damage can be from a previous surgery, a previous ectopic (tubal) pregnancy, tubal scarring from endometriosis or from pelvic inflammatory disease. Pelvic inflammatory disease is a bacterial infection in the pelvis, caused by sexually transmitted bacteria such as gonorrhea or chlamydia. It often scars, damages or blocks the fallopian tubes. A history of pelvic pain, with or without fever, may suggest a diagnosis of endometriosis or pelvic infection.
  • Abnormalities in the shape or lining of the uterus account for almost 20% of female infertility problems. Fibroid tumors or uterine polyps sometimes result in heavy menstrual bleeding, pelvic pain or enlargement of the uterus. Scar tissue can develop within the uterine cavity as a complication of uterine infections, miscarriages, abortions or surgical procedures such as a dilation and curettage (D&C). Such scar tissue can lead to infrequent periods, scanty menstrual flow.
Diagnosis

An important first step in diagnosing female infertility is figuring out whether ovulation is occurring at predictable intervals. When an egg is released, it causes shift in the body's sex hormones. This shift in sex hormones can be detected with these tests:
  • The body's early-morning core body temperature is affected by hormone shifts. By using a precise thermometer (called a basal body thermometer) to take your temperature every day when you first wake up in the morning, you will be able to detect a slightly higher temperature during the second half of your monthly cycle. This slight temperature change occurs after ovulation.
  • An ovulation predictor test is an over-the-counter urine test that can predict egg release. The urine test checks for high levels of luteinizing hormone. A positive test near the middle of your cycle means it is likely you will have ovulated or are about to ovulate. The ovulation predictor test kit is available at most drug stores and pharmacies, and can be performed in your home.
  • You also can examine your vaginal mucus at home. With careful instruction, some women are able to interpret changes in the appearance of the vaginal mucus and consistency of the cervix as a sign of hormone shifts that show ovulation has occurred.

After your doctor examines your vagina and pelvic organs, a sample of mucus from your cervix and vagina may be tested for possible infection. If necessary, blood tests also can be used to confirm normal ovulation by measuring a high progesterone level in the later part of your menstrual cycle. Blood levels of two additional sex hormones, follicle stimulating hormone and estradiol, can help show that the ovaries are functioning well enough to release eggs. These blood tests usually are done at specific times in your menstrual cycle. Other blood tests may be needed to measure the function of your thyroid gland, your pituitary gland and your adrenal glands.

Other tests that are used to understand the cause of infertility examine the physical structure of pelvic organs.

  • A hysterosalpingogram is an X-ray study done after a liquid X-ray dye is allowed to flow into your uterus through a slender catheter positioned just inside the cervix. The dye outlines the shape of your uterine cavity and reveals problems such as polyps, fibroid tumors or other variations in the shape of the inside of your uterus. The dye also flows through the fallopian tubes and can reveal problems such as partial or complete blockage.
  • An ultrasound reveals the shape and size of the uterus, and gives some information about the uterine cavity or inner lining. This test cannot determine if the fallopian tubes are blocked. An ultrasound can identify the ovaries, their shape and size, and the presence of developing cysts. Ultrasound of the pelvis is very safe and does not involve the use of X-rays or dye.
  • Hysteroscopy and laparoscopy are surgical procedures performed by a gynecologist. Both procedures use a small video camera to view the pelvic organs. Your gynecologist can see the inside of your uterus during a hysteroscopy procedure, obtain biopsies, and, in some cases, remove polyps, fibroids or scar tissue. Laparoscopy allows your doctor to view the outside of your uterus and to inspect your ovaries. Sometimes, it is possible to remove cysts or scar tissue from on ovary using laparoscopy.

When a couple's difficulty in getting pregnant is caused by a fertility problem in the woman, an explanation for her infertility can be found in about four out of five cases. It is important for the man in the couple to be checked for fertility problems, too. It is OK to continue sexual activity during a fertility evaluation unless your doctor advises you otherwise. With continued frequent sexual intercourse, even without treatment, you have between a 1% and 3% chance of getting pregnant during each new menstrual cycle after a single unsuccessful year.

Expected Duration

A fertility evaluation usually extends over several months because it requires numerous tests, and because some tests must be done during a specific time in the menstrual cycle. The treatments also require time, careful planning and repeated office visits. The time that it takes to complete a fertility evaluation can be frustrating, because couples who need this evaluation already have spent a full year trying for a pregnancy.

Prevention

You can optimize your chances of getting pregnant in a number of ways.
  • Exercise moderately. If you are exercising so heavily that your menstrual periods are infrequent or absent, your fertility is likely to be impaired.
  • Avoid extremes of weight. An optimum body mass index (BMI) is at least 20 and below 27.
  • Avoid alcohol, smoking and excesses of caffeine (more than one cup of coffee per day) and avoid marijuana and cocaine.
  • Review your medicines with your doctor. Drugs such as digoxin (Lanoxin); bodybuilding steroids; some drugs for treatment of thyroid conditions, depression, hypertension, seizure and asthma; and some prescription antacids can affect your ability to conceive or carry a normal pregnancy.

If you are thinking about parenthood, it is also important to optimize your health before you get pregnant by making sure that your immunizations are up to date, by avoiding alcohol, by reviewing whether any medicines you take are safe during pregnancy, and by taking 0.4 milligrams (400 micrograms) of the vitamin folic acid every day, beginning at least one month before planning to conceive. Starting to take folic acid supplements a few months before conception greatly reduces the chance of abnormal development of the baby's spinal column.

Some treatments for cancer, including chemotherapy and radiation, can cause infertility. Techniques are now available to help a woman planning to undergo these treatments to later have a baby from her own egg. Two strategies have been successful:

  • Frozen storage — The woman's eggs are removed from her ovary surgically and are frozen.
  • Ovary cell transplantation — Ovary cells are transplanted into an area of the woman's body that will not be exposed to radiation, such as the arm.

When the woman is ready to have a baby, a fertility expert can combine the egg with sperm and insert it into the woman's uterus. In some cases, if the woman's uterus has been removed by surgery, a surrogate (different) woman may volunteer to carry the pregnancy in her uterus.

Treatment

Treatment depends on the results of your infertility evaluation. Some causes of infertility have a specific treatment, such as surgery to remove a fibroid tumor or medicines to treat a thyroid problem.

Infertility associated with infrequent or absent ovulation often can be treated with various hormone medications called fertility drugs. All fertility medications have potential side effects, and can cause twins or even more than two babies in one pregnancy. Most fertility treatments require the supervision of a fertility specialist. Examples of fertility medicines include:

  • Clomiphene citrate (Clomid, Milophene, Serophene) is a medicine that stimulates the ovary to release one or more eggs. This medicine works indirectly by adjusting levels of your natural hormones.
  • Injected forms of luteinizing hormone and follicle-stimulating hormone may be used when supervised by an infertility specialist. These medications encourage the ovaries to release more than one egg at a time. This is known as superovulation, or ovulation induction. These medicines are sometimes given after a course of treatment by another hormone medicine, known as a GnRH analogue, that quiets down all natural hormone stimulation to the ovary in preparation for a precisely timed cycle of ovulation.

After fertility drug treatment, the eggs that mature in your ovary can be allowed to travel naturally into the uterus if the fallopian tubes are healthy. Sometimes surgery is used to harvest the eggs that mature after fertility drug treatment, so they can be fertilized with greater certainty and placed into the uterus. Procedures that can help you start a pregnancy include:

  • Intrauterine insemination is a procedure in which sperm are inserted into the uterus directly. Semen is collected by the man, usually after he stimulates himself to ejaculate, and is inserted into the uterus using a special catheter or a syringe.
  • In vitro fertilization (commonly called IVF, and known in the early days of the procedure as "test tube baby") combines egg and sperm in a laboratory dish. Surgery is required to collect the eggs that your ovary has been stimulated to release. The eggs and sperm are combined in the laboratory, and the embryos are inserted into your uterus. Multiple embryos may be placed inside the uterus, but IVF does not guarantee that a pregnancy will result. Sometimes, more than one embryo implants itself in the uterus, which can result in twins, triplets or higher-order multiple pregnancies. This procedure requires treatment with hormones beforehand.
  • Zygote intrafallopian transfer (ZIFT) and gamete intrafallopian transfer (GIFT) are variations of the surgical IVF procedure and require the presence of at least one healthy fallopian tube. In ZIFT, eggs are removed from the ovary by surgery and are combined with sperm in a laboratory. The resulting embryos are placed in the fallopian tube. GIFT is when eggs and sperm are placed in the fallopian tube before the sperm and egg have fertilized together, allowing the eggs and sperm to fertilize inside the woman. As with IVF, these procedures require hormone pretreatment.

It is important for you to get counseling about all options for parenthood, including procedures for adoption. Some health insurance plans do not pay for infertility treatment.

When To Call A Professional

Although it may be possible to become pregnant on your own after one year of trying to conceive, it is wise to speak with a physician after one year and possibly begin an infertility evaluation. If you are over 35 and want to become pregnant, you may want to consult your physician after four to six months of trying to conceive because pregnancy is less likely to occur without fertility treatment at your age.

If you are undergoing fertility treatment, including taking medications to stimulate your ovaries, it is important for you to notify your infertility specialist about symptoms of pelvic pain and abdominal swelling. Unusually stimulated ovaries can lead to significantly enlarged ovaries and cause excessive accumulation of fluid in your pelvic area and abdomen as a complication of treatment.

Prognosis

The chance of any woman having a successful pregnancy depends on the cause of her infertility problem. It is currently possible for more than half of couples who seek infertility treatments to eventually have a pregnancy.

Additional Info

American Society for Reproductive Medicine
1209 Montgomery Highway
Birmingham, AL 35216-2809
Phone: (205) 978-5000
Fax: (205) 978-5005
E-Mail: asrm@asrm.org
http://www.asrm.org

RESOLVE
The National Infertility Association
7910 Woodmont Ave.
Bethesda, MD 20814
Phone: (301) 652-8585
E-Mail: info@resolve.com
http://www.resolve.org/

Last updated December 7, 2008




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