Female infertility
Female infertility: Excerpt from Professional Guide to Diseases (Eighth Edition)
Primary infertility is the inability to conceive after regular intercourse for at least 1 year without contraception. Secondary infertility occurs in couples who have previously been pregnant at least once, but are unable to achieve another pregnancy. About 30% to 40% of all infertility is attributed to the male, and 40% to 50% to the female; about 10% to 30% is due to a combination of male and female factors. Following extensive investigation and treatment, approximately 50% of these infertile couples achieve pregnancy. Of the 50% who don’t, 10% have no pathologic basis for infertility; the prognosis for this group becomes extremely poor if pregnancy isn’t achieved within 3 years.
Causes and incidence
The causes of female infertility may be functional, anatomic, or psychosocial:
❑ Functional causes: complex hormonal interactions determine the normal function of the female reproductive tract and require an intact hypothalamic-pituitary-ovarian axis — the system that stimulates and regulates the hormone production necessary for normal sexual development and function. Any defect or malfunction of this axis can cause infertility due to insufficient gonadotropin secretions (both luteinizing hormone [LH] and follicle-stimulating hormone). The ovary controls, and is controlled by, the hypothalamus through a system of negative and positive feedback mediated by estrogen production. Insufficient gonadotropin levels may result from infections, tumors, or neurologic disease of the hypothalamus or pituitary gland. Hypothyroidism also impairs fertility.
❑ Anatomic causes include the following:
– Ovarian factors are related to anovulation and oligo-ovulation (infrequent ovulation) and are a major cause of infertility. Pregnancy or direct visualization provides irrefutable evidence of ovulation. Presumptive signs of ovulation include regular menses, cyclic changes reflected in basal body temperature readings, postovulatory progesterone levels, and endometrial changes due to the presence of progesterone. Absence of presumptive signs suggests anovulation. Ovarian failure, in which no ova are produced by the ovaries, may result from ovarian dysgenesis or premature menopause. Amenorrhea is often associated with ovarian failure. Oligo-ovulation may be due to a mild hormonal imbalance in gonadotropin production and regulation and may be caused by polycystic disease of the ovary or abnormalities in the adrenal or thyroid gland that adversely affect hypothalamic-pituitary functioning.
– Uterine fibroids or uterine abnormalities rarely cause infertility; however, uterine abnormalities may include congenitally absent uterus, bicornuate or double uterus, leiomyomas, or Asherman’s syndrome, in which the anterior and posterior uterine walls adhere because of scar tissue formation.
– Tubal and peritoneal factors are due to faulty tubal transport mechanisms and unfavorable environmental influences affecting the sperm, ova, or recently fertilized ovum. Tubal loss or impairment may occur secondary to ectopic pregnancy.
Frequently, tubal and peritoneal factors result from anatomic abnormalities: bilateral occlusion of the tubes due to salpingitis (resulting from gonorrhea, tuberculosis, or puerperal sepsis), peritubal adhesions (resulting from endometriosis, pelvic inflammatory disease [PID], diverticulosis, or childhood rupture of the appendix), and uterotubal obstruction (due to tubal spasm).
– Cervical factors may include malfunctioning cervix that produces deficient or excessively viscous mucus and is impervious to sperm, preventing entry into the uterus. In cervical infection, viscous mucus may contain spermicidal macrophages. Cervical antibodies have also been found to immobilize sperm.
❑ Psychosocial problems probably account for relatively few cases of infertility. Occasionally, ovulation may stop under stress due to failure of LH release. The frequency of intercourse may be related. More often, however, psychosocial problems result from, rather than cause, infertility.
About 10% to 20% of couples will be unable to conceive after 1 year of attempting to become pregnant. Healthy couples who are younger than age 30 and having intercourse regularly only have a 25% to 30% change of getting pregnant each month. A woman’s peak fertility is in her early 20s. As a woman ages beyond 35 (and particularly beyond 40), the likelihood of conception is less than 10% per month.
Diagnosis
Inability to achieve pregnancy after having regular intercourse without contraception for at least 1 year suggests infertility. (In women older than age 35, many clinicians use 6 months rather than 1 year as a cutoff point.)
Diagnosis requires a complete physical examination and health history, including specific questions on the patient’s reproductive and sexual function, past diseases, mental state, previous surgery, types of contraception used in the past, and family history. Irregular, painless menses may indicate anovulation. A history of PID may suggest fallopian tube blockage. Sometimes PID is silent, and no history may be known.
The following tests assess ovulation:
❑ Basal body temperature graph shows a sustained elevation in body temperature postovulation until just before the onset of menses, indicating the approximate time of ovulation.
❑ Endometrial biopsy, done on or about day 26, provides histologic evidence that ovulation has occurred. However, endometrial biopsy is retrospective, which diminishes its utility.
❑ Progesterone blood levels, measured when they should be highest, can show a luteal phase deficiency or presumptive evidence of ovulation.
The following procedures assess structural integrity of the fallopian tubes, the ovaries, and the uterus:
❑ Urinary LH kits, available without a prescription, can sensitively detect the LH surge about 24 hours preovulation, allowing couples to time coitus.
❑ Hysterosalpingography provides radiologic evidence of tubal obstruction and uterine cavity abnormalities by injecting radiopaque contrast fluid through the cervix.
Male-female interaction studies include the following:
❑ Postcoital test (Sims’-Huhner test) examines the cervical mucus for motile sperm cells following intercourse that takes place at midcycle (as close to ovulation as possible).
❑ Immunologic or antibody testing detects spermicidal antibodies in the female’s sera.
Treatment
Treatment depends on identifying the underlying abnormality or dysfunction within the hypothalamic-pituitary-ovarian complex. In hyperactivity or hypoactivity of the adrenal or thyroid gland, hormone therapy is necessary; progesterone deficiency requires progesterone replacement. Anovulation necessitates treatment with clomiphene, human menopausal gonadotropins, or human chorionic gonadotropin; ovulation usually occurs several days after such administration. If mucus production decreases (an adverse effect of clomiphene), small doses of estrogen to improve the quality of cervical mucus may be given concomitantly; however, such intervention remains unproven.
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 or medroxyprogesterone, or noncyclic administration of hormonal 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, or in vitro fertilization (IVF). In view of the good success rate of IVF (about 20%), IVF may be used instead of surgery in many cases.
Special considerations
Management includes providing the infertile couple with emotional support and information about diagnostic and treatment techniques.
❑ An infertile couple may suffer loss of self-esteem; they may feel angry, guilty, or inadequate, and the diagnostic procedures for this disorder may intensify their fear and anxiety. You can help by explaining these procedures thoroughly. Above all, encourage the patient and her partner to talk about their feelings, and listen to what they have to say with a nonjudgmental attitude.
❑ If the patient requires surgery, tell her what to expect postoperatively; this, of course, depends on which procedure is to be performed.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Infertility (Field Guide to Bedside Diagnosis)
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