Female Fertility
For you to conceive, your body must produce precisely the right balance of fertility hormones to ovulate regularly, and you must have at least one open Fallopian tube and a healthy uterus. The most common reasons for infertility in women are:
- Ovulatory disorders
- Fallopian tube disease
- Uterine disorders
- Endometriosis
In about 20% of couples with infertility problems, no diagnosis can be made for the cause of the fertility problem — this is called unexplained infertility. Fortunately, advances in reproductive medical care have made it possible to treat most explained and unexplained fertility problems.
See the video Merissa’s Story.
OVULATORY DISORDERS
Ovulatory disorders are the most common cause of infertility in women. For you to successfully produce an egg each month requires a complex interaction between hormones produced by your brain and your ovaries. In the first part of your cycle, your hypothalamus — a region of your brain responsible for the regulation of hormones — produces a fertility hormone called gonadotropin releasing hormone (GnRH). This signals the pituitary — a small gland in your brain — to release a hormone called FSH that tells your follicles (or egg sacks) to start developing.
In a normal cycle, these follicles produce estrogen, which in turn signals the pituitary to produce another hormone called luteinizing hormone (LH) to stimulate ovulation.
After ovulation, the remains of the egg sac form a small yellow body called the corpus luteum, which then starts producing the hormone progesterone, whose job is to increase the blood supply to the lining of your uterus, making it the ideal environment for a fertilized egg.
If your body doesn’t produce enough hormones, or if the timing is off, or if your ovaries don’t respond to the signals from the hormones at any step during this process, you either won’t ovulate or the lining of your uterus won’t develop properly. In any case, you won’t be able to get pregnant. A number of conditions can interfere with ovulation or prevent ovulation all together. However, many ovulatory problems are treatable, and most women will be able to become pregnant.
ANOVULATION
Anovulation is simply the medical term used to describe when a woman does not ovulate.
Symptoms
The most common sign of anovulation is irregular or absent menstrual periods. Some women may have excess hair growth or produce breast milk even though they are not nursing or pregnant.
Causes
Anovulation can result from several factors, including:
- Polycystic ovarian disease
- Thyroid disease
- Elevated prolactin (hyperprolactinemia), a hormone that stimulates milk production and suppresses ovulation
- Low levels of the fertility hormones (FSH and LH) produced by the pituitary gland
- Premature ovarian failure
- Certain other medical conditions and medications
- Extreme weight loss or weight gain
- Excessive exercise
- Eating disorders
- Unexplained
Treatment
Depending on the cause, the treatment of anovulation can include medications stimulate ovulation (e.g. clomiphene), medications to correct a thyroid hormone imbalance, lifestyle changes, and such.
POLYCYSTIC OVARIAN SYNDROME (PCOS)
Polycystic ovary syndrome (PCOS), also know as polycystic ovary disease (PCOD), is the most common hormone problem in women of reproductive age, affecting 5% to 10% of women in this age group. The principal features are weight problems, lack of regular ovulation and/or menstruation, and excessive amounts or effects of androgenic (male) hormones. The symptoms and severity of the syndrome vary greatly among women. While the causes are unknown, insulin resistance, diabetes, and obesity are all strongly correlated with PCOS.
The hormone imbalance seen in women with PCOS interferes with the normal monthly production of eggs. This results in the ovaries containing many small follicles or cysts that contain eggs that are not released regularly.
Symptoms and tests
Some women with PCOS have no symptoms. More often, however, women will experience all or some of the following symptoms:
- Weight gain or obesity
- Excessive hair growth (hirsutism) and/or abnormal hair growth
- Irregular periods or complete absence of menstruation (amenorrhea)
- Acne
- Enlarged ovaries covered with cysts
- Insulin resistance/hyperinsulinemia
If your doctor suspects PCOS, he or she may recommend that you have a blood test to determine if your levels of androgens and other hormones such as LH (luteinizing hormone) which can be abnormal in women with PCOS.
Treatment
Treatment depends on the severity of the condition. With some women, reducing insulin levels and improving insulin sensitivity through weight loss, a low calorie diet and exercise may restore normal ovulation. For more severe cases, treatment may also include:
- Fertility drugs like clomiphene citrate that can help the ovaries to release egg
- Insulin-regulating drugs such as metformin
- Surgery (ovarian drilling)
- Assisted reproductive technologies like superovulation or IVF
See the video Hilary’s Story.
ELEVATED PROLACTIN (HYPERPROLACTINEMIA)
Hyperprolactinemia is the excessive production of prolactin (the hormone responsible for milk production). High levels of prolactin can suppress ovulation or cause irregular menstrual cycles.
Symptoms and tests
The main symptoms that women experience are producing breast milk without being pregnant or nursing, and irregular or absent menstrual periods. A blood test can detect elevated prolactin levels.
Causes
Hyperprolactinemia can be caused by several factors, including:
- Tumors in the pituitary gland (called prolactinomas)
- Thyroid disorders
- Surgical scars on the chest wall and other chest wall irritations (such as shingles)
- Medications, including some tranquilizers, antidepressants, antihypertensives, and antinausea drugs
- Oral contraceptives and recreational drugs (such as marijuana)
Treatment
Both drugs and surgery are used to treat hyperprolactinemia:
- Bromocriptine or cabergoline are medications that reduce high prolactin levels
- Clomiphene citrate can induce ovulation
- Surgery may rarely be required for a very large pituitary tumour that has not responded to medications such as bromocriptine
THYROID DISEASE
The thyroid is a small gland in your neck, just above your breast bone. The thyroid is controlled by the pituitary gland which releases thyroid stimulating hormone (TSH). This hormone tells the thyroid gland to release thyroid hormone.
Both ovaractive (hyperthyroid) and underactive (hypothyroid) thyroid glands can cause changes in the menstrual cycle and prevent egg release.
Symptoms and tests
Excessive thyroid hormone production (hyperthyroidism) causes symptoms such as anxiety, tremors, weakness, rapid heart beat, weight loss and frequent bowel movements. Low thyroid hormone (hypothyroidism) causes symptoms such as dry skin, fatigue, weight gain and constipation.
The first test of thyroid function is a blood test for your TSH level. All Genesis patients have this test performed.
Causes
Thyroid disease is common and affects women eight times more often than men.
Thyroid disease has a variety of causes. Medications, infections, immune diseases, radiation, and growth in the thyroid gland can all affect how the thyroid gland functions.
Treatment
Hyperthyroidism and hypothyroidism are both treated with medications. Surgery is rarely necessary.
PREMATURE OVARIAN FAILURE
Premature ovarian failure (POF), or early menopause, happens when a woman under the age of 40 stops producing eggs. While the average age of natural menopause is approximately 51 years (range 40 to 55 years), some women with POF can go into early menopause in their twenties.
Symptoms and tests
Women with POF may have any of the natural signs and symptoms of menopause. These include:
- Irregular or absent periods
- Hot flashes
- Sleeping problems
- Mood swings
- Problems with concentration or memory
- Vaginal dryness
- Painful intercourse
- Low sex drive
- Loss of energy
Often, the symptoms are more severe in young women than in women who go through menopause in their 50s.
The diagnosis of POF usually requires at least three months without a period and two elevated follicle stimulating hormone (FSH) blood tests at least one month apart.
A high FSH level indicates that the ovaries no longer contain eggs capable of ovulating. A high FSH level is a marker of aging ovaries. For women with POF, this happens much earlier than usual. Depending on the laboratory, normal FSH levels are usually less than 12 IU/L, while elevated levels are greater than 20 to 40 IU/L.
Causes
Between 5% and 30% of women with POF will have at least one other affected relative, usually a sister or mother. Other causes of POF include:
- Genetics (missing part of an X chromosome, extra X chromosome)
- Autoimmune disorders
- Cancer treatments (radiation therapy or chemotherapy)
- Surgery
- Toxins
For nearly two-thirds of women with POF, however, the cause remains unknown. Regardless of the underlying reason, POF occurs when the ovaries run out of eggs, or when something happens to make the remaining eggs unresponsive.
Treatment
While the symptoms of POF can be treated with hormone replacement therapy, there’s no medical treatment to restore the function of a women’s ovaries once she stops ovulating. Occasionally, women experience a spontaneous remission, and they begin ovulating again. However, for women trying to get pregnant, the only reliable way of conceiving is to have IVF using donor eggs from a young healthy donor.
POF can be a devastating diagnosis. If POF is the result of cancer treatment, you may be coping with the trauma of your illness as well as the loss of fertility. We understand that women may need support to cope with this condition and to explore what options are available for them.
We strongly recommend that you contact local and national infertility support groups such as IAAC, as they provide invaluable support and general information. For more specific resources, see the POF Support Group at www.pofsupport.org. Their website hosts various discussion groups and offers factual medical information, reading lists, and useful links.
FALLOPIAN TUBE BLOCKAGE
Tubal blockage is a common form of infertility where the Fallopian tubes are blocked or scarred. Consequently, sperm and egg may never meet, embryos can be trapped in the tube (ectopic pregnancy) or tubal fluid can flow back into the uterus preventing embryos from implanting.
Symptoms and tests
Often, there are no symptoms of blockage. In many cases, the blockage is the result of a past infection or surgery that has caused scar tissue to form in the fallopian tubes. This condition is usually diagnosed in women by one of the following:
- Hysterosalpingogram (HSG)—an X-ray test that looks at the inside of the uterus and fallopian tubes
- Laparoscopy —a surgery where a thin, telescope is inserted through a tiny incision in the belly to look at female pelvic organs
Causes
The main cause of damage to tubes is an infection. The most common infections are chlamydia and gonorrhea.
Other causes of tubal damage include:
- Appendicitis
- Previous ectopic pregnancy
- Endometriosis
- Scar tissue from abdominal surgery
- Tuberculosis
- Congenital conditions
Tubes can be blocked in several locations along the length of the tube. If the tube is blocked at the end, closest to the ovary, it is called a hydrosalpinx. The tube may fill up with secretions, resulting in a hydrosalpinx (water-filled tube). Stagnant fluid from the hydrosalpinx can slowly drain into the uterus and interfere with implantation of an embryo. Several studies have shown that the presence of a hydrosalpinx can reduce IVF success rates by as much as 50%.
Treatment
The treatment of tubal infertility depends on many factors including the cause and location of the damage. If only one tube is blocked and no hydrosalpinx is present, no treatment may be necessary. Laparoscopic surgery or tubal cannulation procedures may be used try to open or repair the tubes.
If a hydrosalpinx is present we recommend the tube(s) be blocked with a clip, opened or removed. This will prevent the fluid in the tube from draining back into the uterus.
If both tubes are blocked and cannot be repaired, in vitro fertilization (IVF) is the best treatment option.
UTERINE DISEASE
UTERINE ABNORMALITIES
Many women have uterine abnormalities with no negative effect on their fertility. In some cases, however, an abnormality of the uterus can affect a woman’s ability to get pregnant or carry a pregnancy to term.
Abnormalities include:
- Fibroids
- Polyps
- Scarring of the uterine cavity (aka Asherman syndrome) — Scarring can result from uterine surgery (e.g. a D&C) or infection.
- Septate uterus – The uterus is divided in half by a thin wall.
- Bicornuate uterus—The uterus is heart-shaped and the cavity is divided into two chambers by a thick muscular wall.
- Unicornuate uterus—Only half the uterus has formed. The uterus is small and located on one side of the pelvis only. There is usually only one Fallopian tube.
Symptoms and tests
Often, women have no symptoms of a uterine abnormality aside from difficulty in getting pregnant or recurrent miscarriages. Some women will have painful or heavy periods. Physicians have several tests they can use to diagnose these conditions, such as a hysterosalpingogram, laparoscopy, hysteroscopy, ultrasound and MRI.
Causes
Uterine abnormalities can be genetic or drug-induced. In the 1950s, the drug diethylstilbestrol (DES) was prescribed to prevent miscarriages, and many of the daughters of women who took DES were born with these uterine defects. Currently, very few women of reproductive age have been exposed as DES was withdrawn from the market in the early 1970s.
Treatment
Some uterine conditions can be corrected with surgery; however, for others, there is no treatment that can improve fertility or pregnancy outcomes.
UTERINE FIBROIDS
One out of every four or five women in their 30s and 40s has a uterine fibroid. Fibroids are benign growths of the uterus also known as myomas. They are dense growths of muscle cells of the uterus somewhat like a knot in a piece of wood. They may protrude from the inside or outside surface of the uterus. They are often multiple and can vary in size from quite small to up to 10 cm or more in diameter. Fibroids can impair fertility by:
- Large fibroids in the wall of the uterus can occasionally block the Fallopian tubes
- Growing into the uterine cavity preventing an embryo from implanting or causing early miscarriage
The impact that fibroids have on fertility depends upon their size and location.
Symptoms and tests
Fibroids are often asymptomatic. The most common symptoms women experience include:
- Painful and heavy periods
- Pressure or pelvic pain
- Sensation of a mass
Fibroids are diagnosed using tools such as pelvic ultrasound, a special x-ray called a hysterosalpingogram, a hysteroscopy, or a laparoscopy .
Causes
Although the exact cause of fibroids is unknown, their growth seems to be related to the hormones estrogen and progesterone. When these hormone levels decline at menopause, many fibroid-related symptoms begin to resolve. However, it is not clear that hormones actually cause the fibroids. As an example, women who have had high levels of both of these hormones as a result of pregnancy or taking birth control pills have a lower incidence of fibroids later in life.
Treatment
Fibroids can be treated by medications or by surgery. Several medications can be used to shrink fibroids temporarily however the medications usually prevent pregnancy at the same time and the fibroids almost always regrow when the medications are stopped.
Except surgery, there are no fibroid treatments that will improve fertility.
Surgery is not always recommended for fibroids. The decision to remove a fibroid depends on their location, size, rate of growth and and other factors.
There are three ways fibroids can be removed, depending on their location and size:
- Hysteroscopy to remove fibroids on the inner wall of the uterus
- Laparoscopy to remove fibroids growing on the outside of the uterus
- Laparotomy to remove larger or multiple fibroids
RECURRENT PREGNANCY LOSS
Miscarriage is extremely common: 15% of women under 35 experience miscarriage, and up to 50% of women over 42 miscarry. Most women (70%) who miscarry once or twice can expect to go on to carry a child to full term.
Recurrent miscarriage is defined as three or more consecutive miscarriages.
Symptoms and tests
The reasons for recurrent miscarriage are often complex. The most common cause of a miscarriage is a genetic abnormality in the embryo that prevents it from growing normally. Recurrent miscarriage however is a more complex problem that has a variety of possible causes:
- Chromosomal abnormality in one or both partners
- Structural problems of the uterus
- Immune system abnormalities
- Blood clotting disorders
- Hormonal imbalances
- Infections of the uterine lining
In approximately 30% of couples no cause can be identified.
Experiencing recurrent miscarriage can be devastating, and the fact that the doctor often cannot find any single cause can make this even more difficult for couples to cope with. After thoroughly investigating your situation, the doctor will meet with you to discuss your treatment options.
Emotional support
For many women, each miscarriage is a loss and can bring about intense feelings of grief. These feelings may go on for a long time, and you may feel very alone. Our counselors have experience in helping women and couples cope with their feelings. There are also a number of support groups for couples dealing with recurrent miscarriage.
ENDOMETRIOSIS
Each month your body, in preparation for pregnancy, creates a lining for the uterus called the endometrium. If pregnancy does not occur, the uterus sheds the lining and the tissue passes through the body in the form of menstrual bleeding. Endometriosis is a common condition in which the endometrium grows and spreads outside the uterus. The endometrial tissue may then implant on the ovaries, the outside of the uterus, and other abdominal organs. These deposits bleed every month with the menses and are quickly surrounded by an inflammatory reaction as the body tries to “wall off” the bleeding deposit. The inflammation and bleeding around the deposits of endometriosis create an unfavourable environment for eggs and sperm. The inflammation may cause scar tissue (adhesions) to form that can prevent the eggs from reaching the Fallopian tubes or even block the tubes.
Althought some women with endometriosis have no symptoms and can conceive normally, many have difficulty conceiving.
Symptoms and tests
Women with endometriosis often experience painful intercourse and painful, heavy menstrual periods. Some women, however, have no symptoms. A surgical procedure called laparoscopy, where a thin, telescope-like instrument is inserted just beneath the navel to examine the reproductive organs, can confirm the diagnosis of endometriosis.
Causes
The cause of endometriosis is unknown, but it has been suggested that it is a disease of angiogenesis (the formation of new blood vessels). This is because, in this disorder, the endometrium, as well as endometriotic plaques, seems to have a greater tendency to form new blood vessels than the endometrium of normal women.
Treatment
Endometriosis can be treated in several ways, depending on the severity of the condition. These include:
- Medications to suppress the pituitary gland and the secretion of female hormones that control menstrual cycles (while this therapy may reduce the endometriosis, it also stops the menstrual periods thereby preventing conception).
- Surgical procedures such as laparoscopy or laparotomy to cauterize the areas of endometriosis and surgically remove the scars and adhesions that result from endometriosis.
- Fertility drugs (e.g. clomiphene, superovulation) after surgery to help stimulate the ovaries and increase the chances of conception.
- Assisted reproductive technologies like in vitro fertilisation (IVF) when drugs or surgery are not effective. IVF may offer the best chance of pregnancy especially if the Fallopian tubes have been damaged.
UNEXPLAINED INFERTILITY
Up to 10% of infertile couples are diagnosed with unexplained infertility. This simply means that conventional fertility tests for both partners don’t reveal the cause of the couple’s infertility. This is an extremely frustrating diagnosis. But just because we are unable to diagnose the cause of your infertility doesn’t mean we can’t treat it.
There are a range of treatment options, including:
- Fertility drugs such as clomiphene citrate, or follicle-stimulating hormone (FSH)
- Intrauterine insemination (IUI) (artificial insemination of sperm into the uterus)
- In vitro fertilization (IVF)