Female Infertility

Infertility is the inability to conceive after regular intercourse for at least 1 year without contraception. Infertility affects 10% to 15% of all couples in the United States. Following extensive investigation and treatment, about half of infertile couples achieve pregnancy. Of the half who don't, roughly 10% have no pathologic basis for infertility; the prognosis in this group becomes extremely poor if pregnancy isn't achieved after 3 years.

Causes

Many factors may account for infertility: abnormalities of the uterus (such as fibroids); ovarian dysfunction; endometriosis; scar tissue from previous surgery; thyroid problems or other hormonal imbalances; sexually transmitted diseases or other infections in the man or woman; and a low sperm count.

Female reproductive problems account for 40 percent of all infertility cases; male reproductive problems account for another 40 percent; and 20 percent of the time physicians cannot determine precisely what is wrong.

Signs and Symptoms

The patient's history indicates the inability to conceive after at least 1 year of regular intercourse without contraception. The patient may also report irregular, painless menses, which may indicate anovulation, or a history of pelvic inflammatory disease. which may suggest fallopian tube blockage.

Differential medical diagnosis includes anorexia nervosa, bulimia, neoplasms, congenital anomalies, drug ingestion, polycystic ovarian disease, hypothyroidism, and hypothalamic disease.

Diagnostic tests

Basal body temperature graph shows a sustained elevation in body temperature postovulation until just before onset of menses, indicating the approximate time of ovulation.

Endometrial biopsy, done on or about day 5 after the basal body temperature elevates, provides histologic evidence that ovulation has occurred.

Progesterone blood levels measured when they should be highest can show a luteal phase deficiency. Over-the-counter ovulation predictors are less expensive and quite accurate.

Hysterosalpingography provides radiologic evidence of tubal obstruction and uterine cavity abnormalities.

Endoscopy confirms the results of hysterosal­pingography and visualizes the endometrial cavity by hysteroscopy or explores the posterior surface of the uterus, fallopian tubes, and ovaries by culdoscopy.

Laparoscopy allows visualization of the abdominal and pelvic areas.

In postcoital examination, the cervical mucus is examined for motile sperm cells following intercourse that takes place at midcycle (as close to ovulation as possible).

Immunologic or antibody testing allows detection of spermicidal antibodies in the sera of the female.

Treatment

Identification of the underlying abnormality or dysfunction is considered to determine the appropriate treatment.

• In hyperactivity or hypoactivity of the adrenal or thyroid gland, hormonal therapy is necessary; progesterone deficiency requires progesterone replacement. Anovulation necessitates treatment with clomiphene citrate, human menopausal gonadotropins, or human chorionic gonadotropin; ovulation usually occurs several days after such administration. If mucus production decreases (an adverse effect of clomiphene citrate), small doses of estrogen to improve the quality of cervical mucus may be given concomitantly.
• Surgical restoration may correct certain anatomic causes of infertility, such as fallopian tube obstruction. Surgery may also be necessary to remove tumors located within or near the hypothalamus or pituitary gland.
• Endometriosis requires drug therapy (danazol, medroxyprogesterone, or noncyclic administration of oral contraceptives); surgical removal of areas of endometriosis; or a combination of both.
• Other options, often controversial and involving; emotional and financial cost, include surrogate mothering, frozen embryos, in vitro fertilization, and gamete intra-fallopian transfer.

Prevention

• Regular exercise is important, but if you're exercising so intensely that your periods are infrequent or absent, your fertility is likely to be impaired.
• Avoid weight extremes. Being overweight or underweight can affect your hormone production and cause infertility.
• Avoid alcohol, tobacco and street drugs. These substances may impair your ability to conceive or produce a healthy child. Don't drink alcohol or smoke tobacco. Avoid illegal drugs such as marijuana and cocaine.
• The use of both prescription and nonprescription drugs can decrease your chance of getting pregnant or keeping a pregnancy. Talk with your doctor about any medications you take regularly.