For a normal pregnancy to occur a mature egg must be released from ovaries and this egg must travel through the normal tubes . At the same time,a man’s sperms must travel along the way to fertilise the egg and the fertilized egg must implant inside the uterus. Pregnancy is the result of these steps. Any deviation leads to female infertility.
Achieving pregnancy requires regular menstrual cycles during which an egg is released , a process known as ovulation. The fertilized egg implants and grows in the uterus for a pregnancy to occur. Ovulation disorders account for infertility in 25 percent of infertile couples. These can be caused by any defect in the regulation of reproductive hormones by the hypothalamus or the pituitary gland, or by problems in the ovary itself.
(1) Failure to produce mature eggs:
In 50% of the cases of anovulation, the ovaries do not produce normal follicles in which the eggs can mature. Polycystic ovary syndrome, the most common disorder responsible for this problem, includes symptoms such as amenorrhoea, hirsutism, anovulation and infertility.
(2) Damage to the Ovaries
Physical damage like extensive, invasive, or multiple surgeries, for repeated ovarian cysts,infections may cause the capsule of the ovary to become damaged or scarred and impair normal ovulation .
(3) Premature Menopause
This presents a rare cause of anovulation where some women cease menstruation and begin menopause before normal age . It results in depletion of eggs .There is also a genetic possibility for this condition.
(4) "Unruptured follicle syndrome" occurs in women who produce a normal follicle, but the egg remains trapped inside the ovary.
(5) Luteal phase defect
Luteal phase defect happens when the ovary doesn't produce enough of the hormone progesterone after ovulation for uterine support.
Tubal factors : When fallopian tubes become damaged or blocked, they keep sperm from getting to the egg or close off the passage of the fertilized egg into the uterus. Causes of fallopian tube damage or blockage can include :
Optimal reproductive functioning requires both proper diet and appropriate levels of exercise. Women who are significantly overweight or underweight may have difficulty in becoming pregnant.
Cigarette smoking has been shown to lower sperm counts in men and increases the risk of miscarriage, premature birth, and low-birth-weight babies for women. Smoking by either partner reduces the chance of conceiving with each cycle, either naturally or by IVF.
Alcohol intake greatly increases the risk of birth defects if high level of alcohol is found in the mother’s blood, may cause Fetal Alcohol Syndrome.
Recreational drug,anabolic steroids,marijuana,cocaine use should be avoided, both when trying to conceive and when pregnant.
The ability to conceive may be affected by exposure to various toxins in environment. Reproductive toxins like lead ,radiation exposure like x-rays , chemotherapy may cause mutations, birth defects, abortions, infertility or sterility and they have been shown to alter sperm production, as well as contribute to a wide array of ovarian problems.
An infertility evaluation is usually initiated after one year of regular unprotected intercourse in women under age 35 and after six months of unprotected intercourse in women age 35 and older. However, the evaluation may be initiated sooner in women with irregular menstrual cycles or known risk factors for infertility such as endometriosis, a history of pelvic inflammatory disease, or reproductive tract malformations.
The initial approach should be with both the partners so that the cause can be discussed and prepare them mentally for the appropriate evaluation .The basic infertility evaluation for women includes a history and a physical examination.
Menstrual history which helps in detecting ovulatory status, normal regular cycle with premenstrual symptoms suggest normal ovulation with good fertility. Any history of irregular cycle with severe dysmenorrhoea may suggest endometriosis and anatomical abnormalities. Absence of ovulation may suggest premature menopause.
Medical history suggestive of sexually transmitted diseases, pelvic inflammatory disease, thyroid disease, h/o galactorrhoea, insulin resistance, should be extracted. Equal importance should be given to sexual history such as dyspareunia, failure of ejaculation, retrograde ejacualtion, any sexual dysfuction , frequency of coitus and their knowledge about the fertile period.
History of cervical surgery or any H/O abnormal pap smear.
A general review of symptoms suggestive of other endocrine abnormalities which might be contributing to infertility is done .
A careful social history to evaluate for any environmental exposures or social habits (such as smoking, drinking alcohol, drug usage or extreme exercise) which can contribute to infertility.
Duration of infertility, the details of previous treatment and evaluation are very important to gather enough information and avoid unnecessary intervention and also give some useful information from where to get started.
Physical examination: A physical examination usually includes a general examination, with special attention to any signs of hormone deficiency or signs of other conditions that might impair fertility.
The general physical examination should include height,weight of the patient giving an estimate of Body Mass Index (BMI) . Overweight and underweight also cause irregular cycles, hormonal imbalance and anovulation .
Incomplete development of secondary sexual characteristics is a feature of hypogonadotrophic hypogonadism. A body habitus that is short and stocky, with a squarely shaped chest suggests Turner syndrome.
Other examinations include features of thyroid abnormalities, galactorrhoea or signs of excess male hormones like hirsutism , acne, male pattern baldness, virilization suggest the presence of an endocrinopathy .
Examination is incomplete without local and internal examination .During internal examination mass palpable in the fornices and adnexa might be suggestive of chronic inflammatory diseases or severe endometriosis. Vaginal and cervical structural abnormalities and discharge should be noted and treated. Abnormal Uterine enlargement , irregularity, lack of mobility are signs of a uterine anomaly, leiomyoma, endometriosis, or pelvic adhesions.
Ovulation predictors:
1. Normal menstruation history suggests ovulation. Other predictors being basal body temperature (BBT) around the time of ovulation which is biphasic. It is a rough estimation of ovulation if not the perfect time of ovulation.
2. Serum progesterone concentration of 3ng/ml suggestive of ovulation which is reliable.
3. LH kits are available to predict the LH surge and to assess the fertility period
Ovulation reserve should be assessed in women who are anovulatory in nature and also who have high risk of premature menopause.
How to check for ovulation reserve?
1. Day 3 FSH Measurement
2. Serum Estradiol
3. Antimullerian hormone (AMH)
4. Clomiphene challenge test
5. Antral follicle count (AFC)
Endometrial dating is not a valid method anymore to assess luteal phase dysfunction. According to ASRM, it has a role only in detecting endometrial pathology and also Post coital test should no longer be included in the list of female infertility evaluation anymore.
IMAGING IN THE EVALUATION OF FEMALE INFERTILITY
It gives a complete evaluation of female reproductive system. Several congenital and aquired causes can be diagnosed.
The main tests are:
Hysterosalpingogram (HSG)
Ultrasound / Ultrasonogram (USG)
SonoSalineHysterogram (SSG)
Hysteroscopy
Laparoscopy
HYSTEROSALPINGOGRAM( HSG ) :
It is a simple office procedure which doesn’t need anesthesia where liquid media is introduced into the uterus and series of x-rays are taken .It helps in delineating the abnormalities of uterine cavity and the tubes. Historically, it’s the main stay of evaluation.
ULTRASOUND (USG)
It’s the more simple and non invasive imaging with no radiation exposure ,helps in identifying uterine fibroids, polyps, adnexal pathology,and features of ovulation .
Sonosalinehysterogram(SSG)
It’s a combination of ultrasound and HSG where liquid media is introduced into the uterine cavity to delineate uterine wall abnormalities and tubal patency.
It is also a simple minimally invasive procedure which doesn’t need anesthesia.
HYSTEROSCOPY
It is an endoscopic office procedure where sterile saline solution is introduced into the uterine cavity to diagnose the intrauterine pathology like polyp,submucous fibroids ,intrauterine adhesions , septal abnormalities . It can be done under regional or general anesthesia .The advantage of hysteroscopy is the simultaneously intrauterine pathology can be corrected .It can also be combined with laparoscopy.
Patients with repeated history of abortions should be subjected for hysteroscopy.
LAPAROSCOPY
It is an minimally invasive endoscopic procedure to visualize the abdominal and pelvic organs to diagnose uterine abnormalities, adnexal pathology like tubal adhesions,tubo –ovarian mass,ovarian cyst,endometriosis. When laparoscopy is done chromopertubation is done simultaneously to know the tubal patency.
Advantages of laparoscopy: it is minimally invasive, diagnostic and operative at the same time. In cases of PCOD drilling can be done to enhance the pregnancy rates. In cases of endometriosis as much as possible endometriotic patches can be removed ovarian cyst can be excised.
According to ASRM (American Society of Reproductive medicine) laparoscopy is indicated clearly in patients with abnormal HSG and ultrasound, unexplained infertility and in cases of endometriosis. In special cases, there may be a place for laparoscopy in young women with a period of infertility of more than 3years with no recognised abnormalities.
Anovulatory patients not responding to medical line of treatment for more than 3-6 cycles should also be considered for additional investigations along with laparoscopy.
Combined Hysteroscopy and Laparoscopy:
Both are complimenatary to each other in diagnosing the intrauterine and exrauterine abormalities and treating the cause simultaneously.
