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Female Infertility

Studies directed by the WHO worldwide between 1978 and 1985 found out that the major causes of infertility in sub Saharan Africa are infections, like sexually transited infections, puerperal sepsis and post arbortal sepsis ( Apter D (February 1980).
The causes of female infertility can be classified depending on whether they are acquired or inborn and also depending on the location.


Acquired causes include habits of an individual like smoking, sexually transmitted diseases and eating habits. Diseases like thrombophilia also causes acquired infertility. (Broek, R. P. G.; Kok- Krant, N.; et al.  (2012).


The following are the most common causes of infertility in females:

  1. Failure to ovulate
    Problems affecting the ovaries or the ova are the most common causes of infertility in women. Problems of ovulation include Anovulation. This is lack of ovulation or ovulation which is not frequent. This leads to oligomenorrhea which is infrequent monthly periods. Anovulation can lead to less chance to conceive, difficulty in predicting a woman’s fertile period, and the ova being unable to break through the follicles. Polycystic ovarian syndrome and poor ovarian reserve and ovarian cancers also some of the common causes infertility. The most common causes of ovulation disorders are dysfunctional hypothalamus, low levels of prolactin in the blood, defects of the luteal phase of menstruation and ovarian, pituitary and adrenal glands tumors. Polycystic ovarian s

    Oligomenorrhea problems cause 30% of infertility in women. The good news is that about 70% of ovulation related infertility can be reversed completely. This can be done by use of drugs such as Clomiphene and Menogan/Repronex.  (Hull MG, Savage PE, Bromham DR (June 1982).

    Less typical causes of ovulation disorder are:
      1. Primary ovarian failure (POF)
      2. Resistant ovary syndrome
      3. Autoimmune oophoritis

    Diagnosis of ovulation can be done by laboratory tests like the serum follicle stimulating hormone levels, serum levels of the luteinizing hormones, and serum prolactin levels, diagnosis can also be done by computed tomography (CT) scan, biopsy of the endometrium, biopsy of the ovarian tissue and antibody tests.

    Treatment depends on the diagnosis. This includes use of drugs to induce ovulation, nutritional therapy, stress management, treatment of the underlying problems and surgical procedures in cases of tumor induced infertility. In cases like primary ovarian failure, autoimmune inflammation of the fallopian tubes, no treatment has been discovered yet.
       

  2. Problems affecting the fallopian tubes

    About 20-25% of infertility is attributed to tubal problems in women. These problems range from mild adhesions or scarring of the fallopian tubes to bilateral tubal blockage or unilateral tubal blockage. The most common causes of tubal factor infertility includepelvic inflammatory disease and previous pelvic surgery. The   most common treatment for tubal problems is surgery. Adhesions can be secondary to laparotomy. [ Ten Broek, R. P. G.; Kok- Krant, N.; et al. (2012)]

    Diagnosis of tubal factor infertility is mostly done by hysterosalpingogram. Some contrast dye is injected into the cervix to get into the uterus. The dye passes out to the peritoneal cavity if the tubes are patent. The disadvantage with this test is that the dye can pass through tubes with lumens that are severely damaged. Patent tubes with scarred lumens may not be conducive for fertilization of the ova and transport of fertilized ova to the uterus for implantation. The result of such tubes may tubal pregnancies.

    Laparoscopy can also diagnose tubal damage.

    Tubal factor infertility is treated by tubal surgery like tuboplasty to repair tubal damage or to increase tubal patency. In vitro fertilization can also be used to achieve fertility

    Before deciding the therapy of choice, the fertility specialist usually considers factors like the degree of tubal damage, the age of the woman and the presence of any other infertility factors in any of the partners. All these factors are discussed with the couple
       
  3. Pelvic inflammatory disease (PID)

    Another cause of female infertility is pelvic inflammatory disease. This disease is caused by history of sexually transmitted diseases like gonorrhea or Chlamydia that spreads from the cervix to the uterus and to the fallopian tubes. This infection leads to severe inflammation of the affected tissues and fallopian tubes end up filled with fluids including pus, bacterial cells and leucocytes in response to the infection. The healing process leaves the mucosal lining of the tubes lumen scarred irreversibly. The scarring leads to blockage of the lumen. There is also formation of scar tissue on the outer layer of the ovaries. This leads to impaired function of the ovaries and the tubes and cause infertility. Early detection and treatment of pelvic inflammatory disease leads to complete healing and therefore infertility is avoided. Previous pelvic inflammatory disease also increases the possibility for tubal pregnancies.
       
  4. Endometriosis-associated infertility

    This is the abnormal proliferation of uterine cells outside the uterus. These cells are usually shed from the uterus during menses and they attach themselves elsewhere. These are called endometriosis implants. Most implantations take place in the fallopian tubes, on the ovaries, on the perimetrium, on the surfaces lining, the pelvic cavity and on the intestines. Implantation can also occur on the vagina, bladder and cervix. It is believed that the implants release factors that can destroy  gametes and fertilized ova.[ Speroff L, Glass RH, Kase NG (1999)]

    It is estimated that about 10% of infertility is caused by endometriosis. Approximately 30-40%of women with endometriosis are infertile. With endometriosis, a woman’s chances of conceiving reduce by 12 to 36%. The diagnosis of endometriosis is done bydaignostic laparoscopy whereby the doctor is able to visualize the uterus, fallopian tubes, and pelvic cavity. Endometriosis can be asymptomatic but the most common symptoms of endometriosis are menorrhagia, dysmenorrhoea, urgency of micturition, bleeding from the rectum and spotting before menses. The severity of the symptoms does not necessary reflect the extent of the disease process.
       
  5. Other causes of infertility

    Other causes of infertility in women are:
    1.  Uterine abnormalities like uterine fibroids and uterine polyps. These cause 10% of all infertilities in women by obstructing the uterine cavity and the lumen of the fallopian tubes.
    2. Congenital anomalies like septet uterus cause inability to conceive and miscarriages.
    3. Hormonal imbalance can alter the consistency and amount of cervical mucus so that sperms are unable to swim through it. This can be caused by increased levels of progesterone or reduced levels of estrogen.
    4. The health habits and lifestyle of the woman can also lead to infertility.  These cause 12% of female infertility. Consumption of too much fats lead to increased production of estrogen and this leads to contraception. On the other hand too little fats lead to reduction of estrogen. In both cases ovulation is altered. Malnutrition in early ages of life can also cause infertility in adult life. (Sloboda, D. M.; Hickey, M.; Hart, R. (2010).   Tobacco smoking and exposure to smoky environment can cause damage to the ovaries. Nicotine in cigarettes alter estrogen production, reduce uterine perfusion. The risk of infertility in smokers is 60% more than for nonsmokers. Smoking also causes early menopause.  (Dechanet C, Anahory T, etal (2011)
    5. Exposure to toxins either at work or in the environment can cause mutation of genes and arbortions. Drugs used for chemotherapy like procarbazine and cyclphosphamide can cause infertility due to premature ovarian failure. (Rosendahl, M.; Andersen, C etal. (2010)..
    6. Diseases like diabetes mellitus can reduce infertility by delaying the onset of the first menstrual period (menarche), and can also cause early menopause, and oligomenorrhea. Other diseases with an effect on fertility include liver and kidney diseases.
    7. The age of the woman can also affect fertility. The fertility rates are high in the early and mid-twenties. The fertility rates are greatly reduced after 35 years of age (Anderson SE, Dallal GE, Must A (April 2003).
    8. Genetic factors like chromosomal anomalies, mutation can cause infertility in women Sultan C, Biason-Lauber A, Philibert P (January 2009).
    9. Unexplained infertility is whereby the standard evaluation results are normal and yet the couple does not conceive. 
    10. Cervical factors like cervical stenosis and non-receptive cervical mucosa can also lead to infertility.
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