Female Infertility and Treatment

Pregnancy and carrying the growing baby over the gestation period involves complex changes in the female body. The processes involved in the reproduction are itself complicated. From the earliest step of menarche that is the first-ever menstrual cycle happening in a woman’s life to the

1. Ovulation
2. Fertilisation of the produced ova
3. Implantation of the embryo
4. Developmental changes in the foetus.
5. Gestation and
6. labour time of delivering the baby.

There are a lot of changes and phases involved all through pregnancy and prior to getting conceived. Anything can go wrong during all these processes at any point, which can lead to abortion and infertility.

Infertility can be defined in simple words as difficulty in becoming pregnant even after a half-year and more.

Whereas the reason for infertility can be different from one woman to the other. In some cases of infertility in spite of becoming pregnant, the things don’t go well and can’t stay up with pregnancy. This can lead to stillbirths and abortions.

Spoke about what the problem of infertility is, let’s look into some numbers that can amplify how problematic it actually is. The prevalence of infertility in our country lies in between 4 per cent to 17 per cent as per government records. It is highest in the northernmost states like Kashmir with 15 per cent and almost 8.8 per cent in the Himachal Pradesh, Uttar Pradesh and Maharashtra states. In Andhra Pradesh, 3 per cent of married couples are carrying the burdens of infertility.

Studies as in 2018 stated that 27.5 millions of Indian couples are suffering from infertility. Alarmingly the spread of this phenomenon has become still more rapid with growing generations and changing lifestyles of the younger generations.

Taken worldwide consideration, for every 10 per cent of women living in the united states of America, 15 to 44 women are facing this inability to become pregnant according to the centre for disease control and prevention. These numerical can establish how common infertility is all over the continents. Recent studies showed that in 2020 above 30 millions of Indian couples may have faced infertility.

  Moving on let us discuss infertility in further levels. There are two types of infertility

1. Primary infertility.
2. Secondary infertility.

primary infertility is when a couple fails to conceive their first child after a period of using contraceptives or without using any such contraception.

Secondary infertility is when there is an inability to conceive the second child.

However, both of them come under infertility indeed. Not always female infertility can be a reason for the pregnancy to happen. The chances of conception depend both on male fertility and female fertility levels. As we are talking about in women, in particular, let’s dig into the reasons or causes behind female infertility.

Ovulatory issues:

Ovulation is a process in which the ovaries release the ovum or the egg. This ovum gets fertilised by a sperm which is called fertilisation. This leads to the implantation of the embryo which can be said as pregnancy or ‘got pregnant ‘ time.

Elsewhere the production and development of the ova start right from the foetal stage. Later on, this ova when fully developed are released from the ovaries at one each for every menstrual cycle. Ovulation occurs before two weeks at least from the start of periods.

Takes place for about 10 to 18 days in a menstrual cycle. A menstrual cycle lasts for 28 days. Ovulation is the time when the ova get released from the ovary. The ova thus released is said to be in it’s the most fertile phase during ovulation. Two phases of ovulation exist:

1. Follicular phase
2. Luteal phase.

The ova that are formed during the fetal stage as said above needs to get matured before they are released.

Follicular phase can be said as the maturation phase of the ovarian follicles. This goes from the start of menstruation to the start of ovulation. As said the ovarian follicles finish maturation prior to the ovulation. Next comes the release of the secondary follicle from those matured ovarian follicles. This is the point called ovulation. Ovulation takes from 24 to 36 hours.

The secondary follicle that is released through this, should reach the uterus through the fallopian tube alongside undergoing a transformation into the oocyte. This happens by meiosis I and meiosis II. The secondary oocyte leaves the follicle traverses through the fallopian tube and reaches the uterus.

If the coitus during this phase of the menstrual cycle becomes successful in fertilising the ova, the implantation occurs. If not, the ova will degrade within 12 to 24 hours after the ovulation. In general, only one oocyte is released per ovulation. But sometimes more than one ova can be released. If more than two ova get fertilised by two sperm, it results in the twin pregnancy called fraternal twins.

Next comes the luteal phase, this is the end phase of the ovulation. The follicle that has released the ova transforms into corpus luteum by folding in. This release the hormones called estrogen and progesterone. This reacts on the site of embryonic growth where the implantation is meant to occur. When these hormones act upon, the endometrium which is already established proliferates into secretory endometrium. This marks the onset of menses by removing from the body as blood and scar tissue.

Signs of ovulation:

Ovulation can be noticed by some signs and symptoms by a woman herself. Rather it is described to be concealed ovulation. The cervical mucus thickness changes, the temperature of the body increases. In some women facing secondary infertility, ovulation can bring in some pain. In most women, libido is said to be high during the ovulation phase.

Issues in ovulation:

In women suffering from infertility, there can be problems during ovulation too.

They are

1. Oligoovulation which is the occurrence of irregular ovulation or infrequent ovulation. It can fall back to 8cycles/year.
2. A ovulation is an absence or 0 occurrences of any ovulation. Both of these can lead to excessive bleeding called dysfunctional uterine bleeding and secondary amenorrhea. Unpredictable periods, bleedings and longer and short menstrual cycle durations make it impossible to become pregnant. To treat these issues ovulation suppression and ovulation induction are done.

Menstrual cycle:

After having a little knowledge of ovulation, let us discuss the menstrual cycle. The menstrual cycle involves a series of changes from the building of the uterine layers called endometrial linings, releasing of ova, and shredding of the secondary endometrium.

The premenstrual syndrome commonly called PMS involves the symptoms that show up before the periods begin. Acne, bloating, mood swings, tiredness, irritation, tender breasts are a few which can be more severe in approximately 3 to 8% of women. The first period of a teenage girl is called menarche and ends with menopause in an elderly lady of 45 to 55 years old.

The periods begin after the corpus luteum formed in the luteal phase stimulates a sharp drop of estrogen and progesterone. This induces the thickened uterine layers to remove off through menstrual bleeding. The menstrual flows take 5-6 days on average. The average cycle lasts for 28days.

The menstrual cycle is called irregular if it takes a too long or too short cycle. The shortest cycle is when the variation between the cycles is just 4 days and longer is more than 8 to 20 days or anywhere in between. It is said to be normal if the variation is 8 days on average.

The disturbances through the menstrual cycle at any point can be listed as these. Amongst those infertility occupies the top place.

wherein does a menstrual cycle affect the fertility of women?

For a woman to conceive there lies a fertile period specific to herself. The fertile period of a cycle is during ovulation. It starts from 5 days before the ovulation to 2 days after it. Sexual intercourse during this time brings the highest likelihood of pregnancy. This may change in women if disturbances happen in ovulation or menstrual cycles like unpredictable ovulation, prolonged and heavy bleeding, irregularities in the menses, too long or too short menstrual cycles, etc., are a few reasons for infertility.

In women, the total egg reserve is formed in the fetal stage which will get depleted with age.

• The menstrual issues cause dysmenorrhea which means severe and unbearable menstrual cramps.
• Behavioural changes like empathy, emotional sensitivity, irritability, stress and also fear response variations
• Experiencing attraction to different types of men during changing phases of the menstrual cycle. Some women get attracted to the deep voice of men at certain phases. Normal and fertile woman’s voice is more attractive than infertile women. This attraction towards men with different personalities may sometimes lead to polygamous relations.
• Eating habits of women will be changing A lot during the periods. Cravings for sugars, carbs, and fats get higher during PMS and ends with no hunger by the end of menstruation.
• Weight loss and irregularities in the diet raises in the diet.
• Hypomenorrhea which is a decreased menstrual flow of less than 10ml.
• Menorrhoea in which the bleeding exceeds 80ml.
• Oligomenorrhea in which prolonged bleeding occurs more than 34 days.
• Amenorrhea is the absence of periods completely.

Structural problems of female reproductive system:

1. Blockages:
   The female reproductive system has a complex of the fallopian tubule, uterus, vagina etc. If any obstacle arises ok he path of ova from the overs to the uterus at any point the fertility chances go down. This happens if there is a blockage to and if the tubules in the transport.
2. Endometriosis:
   Endometriosis is a condition in which the uterine endometrium grows in n parts other than the uterus. But the menstrual bleeding takes place as usual. This causes severe bleeding, lesions, inflammation, swelling, abdominal pain,  lower back and pelvic pain. Women suffering from endometriosis put on weight, withstands hormonal imbalance, and prominently infertility. About 30-40 per cent of women with endometriosis are infertile. The severity of endometriosis ranges from tiny lesions of mm size to deeper implants. This makes the uterus unsuitable for pregnancy.
3. Uterine fibroids:
   These are tumours that are benign which develop from the uterus. The reason behind this is not exactly known but has an adverse effect on female fertility. The symptoms are heavy bleeding, severe pain in the abdomen, lower back and spine, constipation, nausea, longer periods etc. The fibroids are the masses of smooth tissue and are fibrous. There are various types of fibroids depending on the location. Eg: subserosal fibroids are located in the uterine serosa, submucosal fibroids are located inside the uterine cavity, intramural fibroids are located in the walls of the uterus and pedunculated fibroids are located outside the uterus respectively. The treatment for this fibroids is either by surgeries and uterine artery embolization. Tiny fibroids don’t need treatment and leaves on their own. Oral contraception medication can be given. The problem with uterine fibroids is that they make the uterus unfit for any pregnancy and implantation.
4. Uterine polyps:
   These are also the non-cancerous growths with a stalk. Generally occurs in women closer to their menopause. Obesity, using steroids, high blood pressure, being treated for cancers, the menopausal stage can be the reasons for these. Yet the signs include abnormal bleeding, crampings, prolonged menses. Surgically they can be removed.
5. scarring:
   scarring caused infertility. Any remains from the injury, infection, surgery, trauma to the uterus or any part of the reproductive system adheres to the organs. This tissue is called scar tissue. This gets on to the surface of the organs and interferes with their function. Thus scar tissue makes it impossible to conceive. Sometimes the scar tissue also inhibits the entry of sperm into the uterus.
6. Shape of the uterus:
   The shape of the uterus also manipulates the chances of pregnancy. The distorted uterus is a condition which is congenital. The uterus doesn’t fully develop during the fetal stage. This later in reproductive age becomes a problem in pregnancy.
7. Gonorrhoea and chlamydia:
   These are the sexually transmitted diseases. They inhabit the urethra, rectum and cervix and genital tract. Babies developed inside a woman with these STDs are likely to get blinded. The adverse effects of these diseases include abdominal pain, infertility, vaginal bleeding, swelling, vaginal discharge with the smell, pus formation, thickness of the cervical mucus changes, ph and consistency changes. All these changes make the pregnancy difficult.

Functional problems of the female reproductive system:

1. Immature follicles:
   A follicle undergoes meiosis and mitotic divisions to form secondary oocyte. It decreases the number of chromosomes obtained from both the parents. This is necessary because the chromosomal number becomes so much. Some follicles do not undergo these divisions. And those cannot be fertilised by a sperm cell because they are not mature. A girl child when born will have about 1million egg cell reserve in the ovaries, which remains out of 6-7 million in the fetal stage. These eggs will be lost in thousands every menstrual cycle that is ovulation. By the age of 20s, she will have only 2lakhs of eggs available. Lately, this number drops down with age going towards menopause.
   In every ovulation in each menstrual cycle, the eggs go through developmental changes and divisions to become a mature egg cell. Such that fertilisation may occur after ovulation. But in immature follicles, they do not mature completely those changes do not occur. Also to mention, that an immature follicle releases even before the actual ovulation time. To set this right, hormone therapy and other procedures are done.
2. Implantation failure:
   Even after both the sperm and egg cell undergoes fertilisation the implementation issues are seen in most infertility cases. This happens because of the various factors such as endometriosis, adenomyosis, and embryo development issues and hormonal balance.
3. PCOS:
   The biggest cause of infertility. The production of androgens or male hormones will be in surge the male characters grow to appear dominantly than female characters. Facial hair, masculine stature are seen. It’s the most common disorder with almost 10 of 100 women facing this. Fluid-filled cysts are formed, develop inside the ovaries thus interfering with the development and releasing of the ova.
4. Primary ovary insufficiency:
   The ovaries stop releasing any more eggs during ovulation. This brings on so many risks of infertility. If at all an egg cell is even released, being through irregular cycles can’t get a pregnancy.
5. Autoimmune disorders
   Autoimmune disorders such as lupus, thyroid, rheumatoid arthritis, Hashimoto’s disease can create inflammation, swelling in the uterus and placenta. Production of antibodies during these diseases and using immunosuppressants to treat those diseases can affect the reproductive organs and their egg cell production.

Diagnosis of infertility:

When a woman finds it’s difficult to become pregnant after a year or more with a successful sexual life, then a look into her reproductive health can be suggested. The history of reproductive health, prior pregnancies in case of secondary infertility, prior miscarriages and abortions, injuries and traumas, surgeries to the pelvic region will be asked.

Menstrual summary and ovulation periods are evaluated. A vaginal examination will be done. Physical examination of a vaginal and pelvic examination, pap test, blood test and ultrasound comes in the primary diagnosis. Tests that test for the levels of follicle-stimulating hormones and AMH in the blood are done to assess the production of eggs and the presence of follicles in the ovaries.

Optimal presence of these hormones in the blood indicates a healthy reproductive life. For testing, the amount of progesterone and date of ovulation, a 23rd-day blood sample is collected. Laparoscopy is done to evaluate any blockages in the fallopian tubes. Alongside x-ray hysterosalpingogram which is a dye.

X-ray is taken from cervix the to view the fallopian tube blockages. For visualising the nature of uterine polyps, uterine and endometrial fibroids, scar tissue ultrasound is done. Hysteroscopy and saline sonohysterogram examines the peritoneal cavity. Ovulation testing for prediction of ovulation and fertile phase. This can be predicted with testing for luteinizing hormone surge. Imaging testing that looks for disease in fallopian tube and uterus. Sonohysterogram is also called a saline infusion sonogram. Genetic testing is done to determine genetic defects that are responsible for infertility.

Treatment for Female Infertility:

To talk about the treatment for PCOS, after testing for the ovulation and egg cell reserves. Tests will be done for hormones, sonohysterogram and genetic testing. There are many treatments to restore fertility. Fertility Restoration will be done by fertility drugs. Clomiphene citrate is an oral medication given to stimulate the release of FSH and LH. These hormones stimulate the growth of a follicle.

Letrozole works similar to the clomiphene and induces ovulation. Bromocriptine is a dopamine antagonist that inhibits problems caused by excess prolactin, metformin is used in treating diabetes if insulin is a hurdle for fertility.

Gonadotropin medications are used to mature the immature follicles and in stimulation to release the ova. These are a few fertility drugs prescribed. But there are certain risks associated with them. Surgical fertility restoration includes fallopian tubal surgeries and stereoscopic surgeries are done to correct or remove any abnormalities and obstructions.

Tubal surgeries are done if the fallopian tubes are blocked or filled with fluid. Laparoscopy is used to remove the blockages or to dilute the tubes. These are rarely adopted as most IVFs are successful. This takes several blood tests and daily hormone injections for a few weeks.

Intrauterine insemination is another prominent treatment that allows compulsory insemination. In this process during a period prior to ovulation, sperm is placed into the uterus.

Under the assisted reproductive technology, in vitro fertilisation comes. This involves a complex of procedures that helps to conceive a child. Eggs will be collected from the ovaries and fertilised in the laboratory by insemination. Later on, the fertilised embryo is transplanted in the uterus. Treating endometriosis, tubal pregnancies, removal of fibroids and lesions etc. Is primary to maintain a healthy uterus condition.

Also Read about Male Infertility and Treatment.

Reference:

1. Polycystic Ovary Syndrome (PCOS) – NICHD – NIH
2. Female infertility – Symptoms and causes – Mayo Clinic
3. http://nichd.nih.gov/health/topics/poi
4. Infertility and Fertility – NICHD – NIH
5. Women’s Health – NICHD – NIH.