Causes of Infertility in Women

Infertility is defined as the inability to get pregnant after 1 year of unprotected intercourse. It is estimated that 10% of couples of reproductive age in the US are affected by infertility. Both men and women can experience infertility. We equally share the diagnosis, as men and women each represent one third of the cases of infertility. The last third is the cases where it is a combination of both the man and the woman. In almost 20% of infertility cases the cause can not be determined.

Infertility and Age

Age is a major factor in women’s fertility. A woman’s fertility peaks in her early 20’s and begins a decline that gets much steeper after 35. It is estimated that by age 35 a woman has lost over 90% of her eggs. As women are waiting longer and longer to begin to start a family, infertility is becoming a bigger and much more common issue. While age is one of the main determinants of fertility in women, there are various other conditions and occurrences that affect it as well. We’ll talk about some of them here.

Tubal Occlusion

This is an obstructed fallopian tube. It is the most common cause of infertility in women, as about 20% of cases can be attributed to this condition. If the tube or tubes are blocked the fertilized egg cannot reach the uterus. Blockages are often caused by pelvic inflammatory disease (PID), endometriosis, infections after previous childbirth, and intra-abdominal infections like appendicitis and peritonitis.

Treatment

One form of treatment is a tuboplasty which is a surgery to remove the blockage. You may choose to forgo surgery and attempt to overcome tubal infertility but using IVF to conceive. It is actually less expensive and less invasive (hard to imagine for those who have or are going through IVF!) than the tuboplasty. There are laparoscopic options, but this not a perfect fix as an increased risk for ectopic pregnancies has been seen in postsurgical women. The technology is quickly improving and the risks may change. At this point, you should look at the options with your doctor and determine which is right for you.

Endometriosis

Endometriosis occurs when the tissue that lines the uterus (the endometrium) grows outside the uterus on other organs. It can be found growing on the ovaries, fallopian tubes, the lining of the pelvic and abdominal cavities, vagina, cervix, bowel or bladder. As the uterine lining prepares itself monthly for fertilization, the tissue that has grown outside the uterus can over time begin to do the same. It can thicken and cause the other organs to crowd or fuse together, and cysts to form. It is estimated that 5 million women in the US have endometriosis. It is one of the most common health problems in women.

Symptoms of endometriosis include painful menstrual periods, chronic pain in the lower back and pelvis, pain during or after sex, spotting or bleeding in between periods, and infertility. If you have any of these symptoms, talk to you doctor or OB/GYN.

There is no real way to lower your chances of getting endometriosis, except to keep lower estrogen levels in your body. You can do this by exercising regularly, maintaining a low amount of body fat, and avoiding large amounts of alcohol and caffeine.

Testing for Endometriosis

  • Pelvic Exam – During a normal pelvic exam your doctor can look for large cysts or scars behind the uterus.
  • Ultrasound – With an ultrasound your doctor can determine whether there are any ovarian cysts. It will be either a vaginal ultrasound where a wand scanner is inserted through the vagina, or an abdominal ultrasound. These are the more common imaging tests that will be done, but a magnetic resonance imaging test (MRI) may also be performed.
  • Laparoscopy – The only way your doctor can determine for sure whether there is endometriosis is to look inside. While under general anesthesia, you will have your abdomen expanded by a gas so your organs will be easier to look at. Through a small cut in the abdomen, a lighted tube will be placed inside with a scope to observe. Your doctor will be able to diagnose by seeing growths this way, or they may take a sample to observe under a microscope.

Treatment

Unfortunately there is no cure for endometriosis, but there are ways to manage pain and the infertility that it causes. The treatments will depend on your age and your plans for having children. As always, talk to your doctor about what treatment is right for you.

Pain Medications

These are either over the counter or prescription medications used to alleviate the pain associated with endometriosis. They will not treat the problem and will not improve your chances of having children if that is your goal.

Hormone Treatment

These treatments will only be for women who do not want to get pregnant during the time of treatment. These can be in the form of:

  • Birth Control Pills – these will decrease the heaviness of your period.
  • GnRH Agonists & Antagonists – these are hormones that reduce the amount of estrogen in your body. You are effectively putting your body into menopause, and you will experience the symptoms associated with it (hot flashes, bone loss, vaginal dryness). It is common to undergo this treatment for endometriosis in preparation for IVF, in an attempt to keep quick-growing endometriosis at bay to create a window for conception.
  • Progestins – These hormones work against the effects of estrogen to shrink endometriosis. They will completely stop menstruation, but may cause irregular bleeding. A common progestin is Depo-Provera, a commonly used injectable birth control method.
  • Danazol– This is a weak male hormone that lowers estrogen and progesterone levels in a woman’s body. Menstruation will stop. Danazol is not used often due to its side effects (weight gain, breast shrinking, facial hair growth). Also, it does not prevent pregnancy and the presence of the hormone would be harmful to a baby in the event of a pregnancy.

Surgery

Surgery is usually the best choice for women with serious endometriosis. There are generally three surgical options:

  • Laparoscopy – Growths are removed or burned away. Can effectively treat endometriosis without harming surrounding tissue. It is minimally invasive and the recovery is quick.
  • Laparotomy – This is major abdominal surgery through with doctors can reach and remove growths inside the pelvis or abdomen. Recovery is that of longer than that of a laparoscopy.
  • Hysterectomy – The removal of the uterus, and, in some cases, the ovaries as well. This is only done when endometriosis has severely damaged these organs. It is a last resort as a woman can no longer become pregnant after the procedure.

Polycystic Ovarian Syndrome (PCOS)

PCOS affects 5-10% of women of reproductive age and is one of the leading causes of infertility in women. This syndrome causes high levels of androgens (male hormones), especially testosterone, to develop. This stops the ovaries from producing healthy, mature eggs, resulting in anovulaton, irregular menstruation, amenorrhea, and ovulation-related infertility. There are secondary effects of the male hormones as you would expect, including acne, hirsuitism, and obesity. It should be noted that not all women with PCOS have difficulties getting pregnant.

Treatment

If you are overweight and anovulatory, then weight loss and changing your diet can restore natural ovulation. The next step if weight and diet are not the issue, or are already addressed, is the introduction of Clomid. This is a medication used to stimulate ovulation. It is widely used to treat infertility in women and sometimes men, and is taken by itself or in conjunction with a cycle of IVF or IUI. Read more about Clomid here. If you do not respond to Clomid, more intensive assisted reproductive technologies may be attempted. These include controlled ovarian hyperstimulation, follicle-stimulating hormone (FSH) injections, followed by IVF. Surgery is not typically performed to reverse PCOS, but there is a laparoscopic procedure called “organ drilling”, in which a few small follicles in an ovary are punctured with a laser or electrocautery with the goal of resuming normal ovulation. There are concerns in the medical community about the long term effects or the procedure. Talk to your doctor about whether it is right for you.

Early Menopause

Early menopause is premature ovarian failure resulting in the absence of menstruation prior to reaching 40 years old. It can be a result of low ovarian growth hormone levels, exposure to radiation or chemotherapy, or an autoimmune disease where your body produces antibodies that attack the ovaries.

The symptoms associated with early menopause are the same as those with natural menopause. As the ovaries are producing less estrogen, you will experience irregular or missed periods. You may also experience vaginal dryness, hot flashes, bladder irritability and incontinence, changes in mood, sleeplessness, and decreased sex drive.

Treatment

Once early menopause has started in is unlikely to be reversed. Women experiencing it can take hormone replacement therapy to replace the estrogen that is lost. If you experience early menopause and you want to attempt to conceive a child, talk to a reproductive specialist about what assisted reproductive technologies are available to you.

Luteal Phase Defect (LPD)

The luteal phase of your menstrual cycle is the phase between ovulation and the start of the next menses. The phase normally lasts 12 days. During this phase, progesterone is produced and the uterine lining thickens and develops extra blood vessels in preparation for the fertilized egg. A defect in this phase occurs when the correct amount of progesterone is not produced after ovulation, or if the uterus does not respond to the progesterone.

The diagnosis of LPD is easiest done by tracking the basal body temperature (BBT). It is the progesterone that is responsible for the rise in BBT after ovulation, and failure of the BBT to rise can be an indication of hormonal deficiency. An extremely close monitoring of the menstrual cycle will tell a woman if their next cycle is starting less than 12-14 days after ovulation, an additional sign that the luteal phase is defective.

Treatment

Women can take a progesterone supplement during the luteal phase if the problem is the hormone release. If there is a deeper problem with the follicle development, then an ovulatory stimulant like Clomid may be prescribed. In most cases, LPD is extremely responsive to treatment.

 

Conclusion

There are many causes of infertility in women. While age is a major factor, any woman of reproductive age is can experience these conditions. The difficult thing is that most of us don’t know there is a problem until we decide we want to try to start a family. There are plenty of resources out there to help you navigate the tricky waters of infertility. You are not alone, and help is out there.