Infertility:Women

What causes infertility in women?

Causes of infertility in women
Adhesions and scarring: Can be caused by sexually transmitted diseases left untreated, Chlamydia being the most common. Scarring can lead to blockage of the fallopian tubes, or damage to the delicate membranes within the tubes. It can also be formed by endometriosis and prior surgeries in the abdominal area.

Age: A woman's fertility begins falling off after the age of 25, though pregnancy can be achieved and maintained for most women into their early 40s. The rate of miscarriage and birth defects increases after 35. See noah.cuny.edu

Asherman's Syndrome: This is a condition where the walls of the uterus adhered to each other. Usually caused by uterine inflammation.

Cancer treatment: Chemotherapy and radiation can cause early menopause. Information on how cancer treatment affects fertility is posted at upenn.edu

DES (diethylstilbestrol) exposure: Synthetic estrogen used in the 50s and 60s to prevent miscarriage. Can cause abnormalities in the reproductive organs such as shortened cervix, deformities of the vagina or cervix, T-shaped uterus, abnormal fallopian tubes, ovulation problems, increased risks of ectopic pregnancy, repeated miscarriage, and premature delivery. See this site

Endometriosis: Growth of endometrial tissue outside the uterus. Can cause blockage of the fallopian tubes and adhesions. May not cause any symptoms beyond infertility, but could cause crampy periods and painful intercourse. FAQ posted at bioscience.org.

Environmental hazards: Pesticides may damage a woman's eggs leading to early menopause. Some materials are linked to early miscarriage. Ethylene oxide, used in chemical sterilization of surgical instruments. Exposure by healthcare professionals (including veterinary) to nitrous oxide. Vinyl chloride, used in plastics, and metallic compounds including manganese, arsenic, and nickel.

Hyperprolactinemia (elevated levels of the hormone prolactin): Can be caused by pituitary tumors, and breast milk production after giving birth. May lead to weak or skipped ovulation. Lowering prolactin levels can be achieved with Bromocriptine (Parlodel).

Hypothyroid: Underactivity of the thyroid gland. Symptoms include low basal body temperature and unexplained weight gain. Can throw off the endocrine system leading to ovulation problems and to miscarriage. An article about thyroid disease and pregnancy, fertility and pregnancy loss is posted in two parts at fertility and pregnancy loss (part 1) and fertility and pregnancy loss (part 2).

Immunological problems: The most common immune problems, testing positive for anti-phospholipid antibodies or the lupus anticoagulant, can lead to blood clots in the placenta that prevent nourishment from reaching a fetus. There are other more controversial causes of immunological fertility problems -- please check immunological fertility problems for more information.

Luteal phase defect (LPD): There are two types of luteal phase problems that fall under the category of LPD. One is a short luteal phase -- 10 days or less. The second is when the length of the phase is not necessarily shorter than the standard 12-16 days, but it is out of phase and progesterone production is low. Typical treatment is to enhance ovulation and/or to use hCG or progesterone support after ovulation.

Luteinized unruptured follicle syndrome (LUFS): Failure of the follicle to release an egg even though it has reached maturity. Commonly seen when an LH surge is not followed by ovulation. Can be confirmed with ultrasound. May account for 5-30% of women with unexplained infertility.

Medication: Non-steroidal anti-inflammatory drugs (NSAIDs -- see fertilityplus.org), radiation and chemotherapy for cancer treatment, antihistamine and decongestants may lead to fertility problems. Vitamin C in large doses is also considered an antihistamine - which can lead to cervical mucus drying out.

Menopause: When a woman stops having regular ovulation and menses. Pregnancy may still be achieved through drug therapy and perhaps IVF with donor egg.

Obesity: Excess weight can lead to elevated estrogen levels which act as birth control and prevent a woman from ovulating. Drugs to induce ovulation can bypass this problem. For more information on weight and infertility, please check fertilityplus.org/faq.

Polycystic Ovary Syndrome (PCOS): Symptoms include infertility, irregular cycles, obesity, acne, excess facial and body hair, obesity, skin tags, dark skin patches (back of neck, under arms, under breasts, groin), cystic ovaries, excess male hormones, insulin resistance, and dyslipidemia. It should be diagnosed through a combination of a physcial exam, ultrasound evaluation to look for possible cysts in the ovaries or ovarian enlargment, and blood tests to check LH and FSH (check ratio as well as levels on these two as LH higher than FSH is indicative of PCOS, especially when 2:1 or 3:1), testosterone, DHEAS, SHBG, androstenedione, prolactin, TSH, fasting glucose and insulin testing. Check inciid.org/faq and pcosupport.org for lots of information and support options.

Premature ovarian failure (POF): Characterized by high FSH in a younger woman (usually in her 30s). Cancer treatment and environmental hazards may play a role in the development of POF.

Recurrent miscarriage/pregnancy loss (RPL): When a woman miscarries more than one pregnancy. Testing can be done to try to determine the cause of such losses. If an underlying condition is found, the woman may need to be treated for the problem before a pregnancy can be carried to term. Testing information can be found at fertilityplus.org/faq/miscarriage.

Smoking: Associated with an approximately 5% increase in miscarriage rate. Smoking also doubles the chances of an ectopic pregnancy by damaging the cilia in the tubes. Studies have shown a marked decrease in effectiveness of IVF and GIFT. More information on smoking and GIFT can be found in the April 2, 1997 section of 'What's up Doc?' at ivf-et.com

Tubal ligation (and failed surgery to reverse): Surgical sterilization of a woman by obstructing or tying of the fallopian tubes. May be reversed surgically with varying degrees of success.

Turner's Syndrome: Women should have cells that are 46XX, but Turner's women are missing an X -- hence a karyotype of 45XO or a mosaicism of 46XX and 45XO. Turner's women with a 45XO karyotype are sterile while those with a mosaicism may be able to get pregnant and carry to term. Women tend to be ultra-feminine and small in stature. Check onr.com/ts-texas.

Uterine abnormalities: Include problems from DES exposure, septums, T-and heart-shaped uterus.

Vegetarian lifestyle: Vegetarians may experience irregular ovulation that reduces the chances of conception.

Evaluation process for women

Hormone tests: These are simple blood tests to check if there is a hormonal imbalance. These tests may include any or all of the following hormones:
- luteinizing hormone (LH)
- follicle stimulating hormone (FSH)
- estradiol (E2)
- progesterone
- prolactin
- thyroid stimulating hormone (TSH)
- free T3
- free thyroxine
- total testosterone
- DHEAS
- androstenedione
- sex-hormone binding globulin

- 17-Hydroxyprogesterone

A chart of hormone levels is posted here.

Insulin resistance (IR) testing: Insulin resistance is precursor to diabetes that can cause weight gain and is often seen in those with PCOS. Testing should be done on overweight infertility patients and anyone suspected of having PCOS, What happens is that the body starts producing excess insulin (hyperinsulinemia) in order to keep glucose levels normal. Testing glucose levels alone won't indicate insulin resistance until it is fairly advanced -- what's needed is fasting glucose and insulin levels, or a glucose tolerance test (preferrably also checking insulin). More info is at . Pelvic exam: A physical exam to check for signs of infection as well as obvious physical abnormalities. Pretty much the standard feet-in-stirrups event.

Abdominal ultrasound: A transducer is passed over the bare skin of the abdomen in order to view the uterus and ovaries. Cysts, fibroids and uterine abnormalities may be visible.

Trans-vaginal ultrasound: A transducer wand is inserted into the vagina to view the cervix, uterus and ovaries. Provides greater detail than abdominal ultrasound.

Post-coital test (PCT): A sample of cervical fluid is obtained by gently scraping the cervix within a few hours of intercourse. The fluid is checked under a microscope to see if motile sperm are present. Must be done with fertile mucus at ovulation time.

Endometrial biopsy (EMB): Used to 'date' the lining in relation to ovulation and to test for infection or pre-cancerous cells. To date the lining, the test is generally performed a few days prior to expected menses. A thin catheter is inserted through the cervix and a small sample of the uterine lining is removed.

Hysterosalpingogram (HSG): People often call this the dye test. A catheter is inserted through the cervix and a small amount of dye is pushed into the uterus while x-rays are being taken (usually continuous motion as well as a few stills). The shape of the uterus is observed, as well as how the dye flows through the fallopian tubes.

Laparoscopy: This surgery is usually done under general anesthesia to look for structural abnormalities, endometriosis and adhesions as well as possibly repair any problems found. The abdomen is inflated with carbon dioxide and a scope is inserted through a small incision below the navel. A second incision just above or below the pubic hairline is used to insert a tool to help manipulate the organs for better viewing with the scope. Patients may be able to get a videotape of the surgery.

Hysteroscopy: The cervix is dilated just enough to insert a small scope used for viewing the inside of the uterus. Minor abnormalities can be fixed during this procedure, which can be done under local or general anesthesia. Often done in conjunction with a laparoscopy.

Infectious disease testing: Some physicians will test for a variety of sexually transmitted and other infectious diseases including ureaplasma, mycoplasma, gonorrhea, chlamydia, syphilis, toxoplasmosis, rubella (German measles), cytomegalovirus virus, Hepatitis b&c and HIV I & II.

Immune testing: Some of the tests mentioned below are still controversial, but more and more doctors are seeing the benefits of checking into and treating immune disorders which affect fertility.

Lupus (SLE) tests (includes commonly tested for lupus anti-coagulant):
- Activated Partial Thromboplastin Time (APTT)
- Kaolin clotting time
- Platelet Neutralization Assay
- Dilute Russel viper venom time
- Anti-phospholipid antibodies (APA) tests (includes IgM,
- IgG and IgA markers):
- Anticardiolipin antibodies (ACA)
- Phosphoethanolamine
- Phosphoinositol
- Phosphatidic acid
- Phosphoglycerol
- Phosphoserine
- Phosphocholine

Anti-nuclear antibodies (ANA) tests:
- ssDNA
- dsDNA
- Sm
- RNP
- SSA
- SSB
- Histone
- Scl-70

Anti-thyroid antibodies (ATA):
- Thyroglobulin
- Thyroid microsomal (thyroid peroxidase) autoantibodies

Anti-sperm antibodies (ASA): These can be either autoimmune or alloimmune. They are a blood test, usually indicated by a specimen at IUI-time behaving abnormally. If it's autoimmune (the male has them) then the sperm are healthy looking, but they clump together and make knots that don't make satisfactory progression in great looking mucus. If it is alloimmune (the woman has them) then they are usually healthy looking but mostly dead on arrival or all of the live ones are incredibly slow. It's at IUI time that most of us get sent for the full range of tests, but many of us are treated without testing (testing cost is high, treatment cost is low). Treatment is usually prednisone for the party doing the antibodies. Dose is dependent on severity. Prednisone is very inexpensive -- about $5.00/month each.

Alloimmune tests:
- Leukocyte Antibody Detection (LAD or HLA sharing)
- Natural Killer Cells (CD56+)
- Full Reproductive Immunophenotype (include NK cells)
- Embryo Toxicity Factor (ETF)

MRI or CT scan: One of these might be done if elevated prolactin is found. This is to look for a pituitary tumor.

Comments: Infertility - Women

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BonnieLeigh - 1184 days ago.
Hey! I am 30 years old. I have endometriosis and hypothyroidism. My husband and I have been trying to conceive for 3 years. We started seeing a fertility doctor in December. The first month I had an ovarian cyst, so they could not give me fertility medication. The next month was right after Christmas, so we decided to try on our own for financial reasons. This past month the ovarian cyst was gone so I took medication, had a HCG shot, and thought everything was right on track. Nope I started my period, but it is very light and I have little to no cramps. I am so disappointed!!! MY doctor told me to do a test because light bleeding is considered fairly normal, but I know what the results will be. I am so pissed that insurance does not cover infertility procedures, and meanwhile my tax dollars can go to every hoodlum that has a child that cannot take care of it. I am needing suggestions and words of encouragement. I want to have a baby more than anything in the world. Pray for me!!!