Female Infertility

1 What is Female Infertility?

Female infertility means not being able to get pregnant after at least one year of trying (or 6 months if the woman is over age 35).

A woman of reproductive age who has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility, should be offered further clinical assessment and investigation along with her partner.

According to the World Health Organization (WHO), infertility can be described as the inability to become pregnant, maintain a pregnancy, or carry a pregnancy to live birth.

A clinical definition of infertility by the WHO and ICMART is “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.”

Infertility can further be broken down into primary and secondary infertility. Primary infertility refers to the inability to give birth either because of not being able to become pregnant, or carry a child to live birth, which may include miscarriage or a stillborn child.

Secondary infertility refers to the inability to conceive or give birth when there was a previous pregnancy or live birth.

2 Symptoms

In women, changes in the menstrual cycle and ovulation may be a symptom of a disease related to female infertility. Symptoms include:

  • Abnormal periods. Bleeding is heavier or lighter than usual.
  • Irregular periods. The number of days in between each period varies each month.
  • No periods. You have never had a period, or periods suddenly stop.
  • Painful periods. Back pain, pelvic pain, and cramping may happen.

Sometimes, female infertility is related to a hormone problem. In this case, symptoms can also include:

  • Skin changes, including more acne
  • Changes in sex drive and desire
  • Dark hair growth on the lips, chest, and chin
  • Loss of hair or thinning hair
  • Weight gain

Other symptoms include:

  • Milky white discharge from nipples unrelated to breastfeeding
  • Pain during sex

Many other things can lead to infertility in women, and their symptoms vary.

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3 Causes

There are several causes of female infertility.

Causes of Failure to Ovulate

Ovulatory disorders are one of the most common reasons why women are unable to conceive, and account for 30% of women's infertility. Fortunately, approximately 70% of these cases can be successfully treated by the use of drugs such as Clomiphene and Menogan/Repronex.

The causes of failed ovulation can be categorized as follows:

Hormonal Problems

These are the most common causes of anovulation. The process of ovulation depends upon a complex balance of hormones and their interactions to be successful, and any disruption in this process can hinder ovulation. There are three main sources causing this problem:

  • Failure to produce mature eggs: In approximately 50% of the cases of anovulation, the ovaries do not produce normal follicles in which the eggs can mature. Ovulation is rare if the eggs are immature and the chance of fertilization becomes almost nonexistent. Polycystic ovary syndrome, the most common disorder responsible for this problem, includes symptoms such as amenorrhoea, hirsutism, anovulation and infertility. This syndrome is characterized by a reduced production of FSH, and normal or increased levels of LH, oestrogen and testosterone. The current hypothesis is that the suppression of FSH associated with this condition causes only partial development of ovarian follicles, and follicular cysts can be detected in an ultrasound scan. The affected ovary often becomes surrounded with a smooth white capsule and is double its normal size. The increased level of oestrogen raises the risk of breast cancer. 
  • Malfunction of the hypothalamus: The hypothalamus is the portion of the brain responsible for sending signals to the pituitary gland, which, in turn, sends hormonal stimuli to the ovaries in the form of FSH and LH to initiate egg maturation. If the hypothalamus fails to trigger and control this process, immature eggs will result. This is the cause of ovarian failure in 20% of cases.
  • Malfunction of the pituitary gland: The pituitary's responsibility lies in producing and secreting FSH and LH. The ovaries will be unable to ovulate properly if either too much or too little of these substances is produced. This can occur due to physical injury, a tumor or if there is a chemical imbalance in the pituitary.

Scarred Ovaries

Physical damage to the ovaries may result in failed ovulation. For example, extensive, invasive, or multiple surgeries, for repeated ovarian cysts may cause the capsule of the ovary to become damaged or scarred, such that follicles cannot mature properly and ovulation does not occur. Infection may also have this impact.

Premature Menopause

This presents a rare and as of yet unexplainable cause of anovulation. Some women cease menstruation and begin menopause before normal age. It is hypothesized that their natural supply of eggs has been depleted or that the majority of cases occur in extremely athletic women with a long history of low body weight and extensive exercise. There is also a genetic possibility for this condition.

Follicle Problems

Although currently unexplained, "unruptured follicle syndrome" occurs in women who produce a normal follicle, with an egg inside of it, every month yet the follicle fails to rupture. The egg, therefore, remains inside the ovary and proper ovulation does not occur.

Causes of Poorly Functioning Fallopian Tubes

Tubal disease affects approximately 25% of infertile couples and varies widely, ranging from mild adhesions to complete tubal blockage.

Treatment for tubal disease is most commonly surgery and, owing to the advances in microsurgery and lasers, success rates (defined as the number of women who become pregnant within one year of surgery) are as high as 30% overall, with certain procedures having success rates up to 65%.

The main causes of tubal damage include:

  • Infection: Caused by both bacteria and viruses and usually transmitted sexually, these infections commonly cause inflammation resulting in scarring and damage. A specific example is Hydrosalpinx, a condition in which the fallopian tube is occluded at both ends and fluid collects in the tube.
  • Abdominal Diseases: The most common of these are appendicitis and colitis, causing inflammation of the abdominal cavity which can affect the fallopian tubes and lead to scarring and blockage.
  • Previous Surgeries: This is an important cause of tubal disease and damage. Pelvic or abdominal surgery can result in adhesions that alter the tubes in such a way that eggs cannot travel through them.
  • Ectopic Pregnancy: This is a pregnancy that occurs in the tube itself and, even if carefully and successfully overcome, may cause tubal damage and is a potentially life-threatening condition.
  • Congenital Defects:: In rare cases, women may be born with tubal abnormalities, usually associated with uterus irregularities.

Endometriosis

Approximately 10% of infertile couples are affected by endometriosis.

Endometriosis affects five million US women, 6-7% of all females. In fact, 30-40% of patients with endometriosis are infertile. This is two to three times the rate of infertility in the general population.

For women with endometriosis, the monthly fecundity (chance of getting pregnant) diminishes by 12 to 36%. This condition is characterized by excessive growth of the lining of the uterus, called the endometrium.

Growth occurs not only in the uterus but also elsewhere in the abdomen, such as in the fallopian tubes, ovaries and the pelvic peritoneum.

A positive diagnosis can only be made by diagnostic laparoscopy, a test that allows the physician to view the uterus, fallopian tubes, and pelvic cavity directly.

The symptoms often associated with endometriosis include heavy, painful and long menstrual periods, urinary urgency, rectal bleeding and premenstrual spotting. Sometimes, however, there are no symptoms at all, owing to the fact that there is no correlation between the extent of the disease and the severity of the symptoms.

The long term cumulative pregnancy rates are normal in patients with minimal endometriosis and normal anatomy. Current studies demonstrate that pregnancy rates are not improved by treating minimal endometriosis.

Additional Factors

Other variables that may cause infertility in women:

  • At least 10% of all cases of female infertility are caused by an abnormal uterus. Conditions such as fibroid, polyps, and adenomyosis may lead to obstruction of the uterus and Fallopian tubes.
  • Congenital abnormalities, such as septate uterus, may lead to recurrent miscarriages or the inability to conceive.
  • Approximately 3% of couples face infertility due to problems with the female cervical mucus. The mucus needs to be of a certain consistency and available in adequate amounts for sperm to swim easily within it. The most common reason for abnormal cervical mucus is a hormone imbalance, namely too little estrogen or too much progesterone.

Behavioral Factors:

It is well-known that certain personal habits and lifestyle factors impact health; many of these same factors may limit a couple's ability to conceive. Fortunately, however, many of these variables can be regulated to increase not only the chances of conceiving but also one's overall health.

  • Diet and Exercise: Optimal reproductive functioning requires both proper diet and appropriate levels of exercise. Women who are significantly overweight or underweight may have difficulty becoming pregnant.
  • Smoking: Cigarette smoking has been shown to lower sperm counts in men and increases the risk of miscarriage, premature birth, and low-birth-weight babies for women. Smoking by either partner reduces the chance of conceiving with each cycle, either naturally or by IVF, by one-third.
  • Alcohol: Alcohol intake greatly increases the risk of birth defects for women and, if in high enough levels in the mother’s blood, may cause Fetal Alcohol Syndrome. Alcohol also affects sperm counts in men.
  • Drugs: Drugs, such as marijuana and anabolic steroids, may impact sperm counts in men. Cocaine use in pregnant women may cause severe retardations and kidney problems in the baby and is perhaps the worst possible drug to abuse while pregnant. Recreational drug use should be avoided, both when trying to conceive and when pregnant.

Environmental and Occupational Factors:

The ability to conceive may be affected by exposure to various toxins or chemicals in the workplace or the surrounding environment. Substances that can cause mutations, birth defects, abortions, infertility or sterility are called reproductive toxins.

Disorders of infertility, reproduction, spontaneous abortion, and teratogenesis are among the top ten work-related diseases and injuries in the U.S. today. Despite the fact that considerable controversy exists regarding the impacts of toxins on fertility, four chemicals are now being regulated based on their documented infringements on conception.

  • Lead: Exposure to lead sources has been proven to negatively impact fertility in humans. Lead can produce teratospermia (abnormal sperm) and is thought to be an abortifacient, or substance that causes artificial abortion.
  • Medical Treatments and Materials: Repeated exposure to radiation, ranging from simple x-rays to chemotherapy, has been shown to alter sperm production, as well as contribute to a wide array of ovarian problems.
  • Ethylene Oxide: A chemical used both in the sterilization of surgical instruments and in the manufacturing of certain pesticides, ethylene oxide may cause birth defects in early pregnancy and has the potential to provoke early miscarriage.
  • Dibromochloropropane (DBCP): Handling the chemicals found in pesticides, such as DBCP, can cause ovarian problems, leading to a variety of health conditions, like early menopause, that may directly impact fertility.

4 Making a Diagnosis

Making a diagnosis of female infertility is done by performing several tests.

In any fertility work-up, both male and female partners are tested if pregnancy fails to occur after a year of regular unprotected sexual intercourse.

Fertility testing is particularly important if a woman is over 35 years old or if either partner has known risk factors for infertility. An analysis of the man's semen should be performed before the female partner undergoes any invasive testing.

Medical History and Physical Examination

The first step in any infertility work up is a complete medical history and physical examination. The doctor will ask about the patient's history of sexual activity, especially frequency and timing of intercourse. Menstrual history, lifestyle issues (smoking, drug and alcohol use, and caffeine consumption), any medications being taken, and a profile of the patient's general medical and emotional health can help the doctor decide on appropriate tests.

Easy Preliminary Steps

Before beginning an expensive fertility work-up, you can try the following steps. They are are free or low-cost and can be helpful:

  • Monitor basal body temperature. This is accurate in determining if ovulation is actually taking place.
  • Test the consistency of your cervical mucus. Collect some mucus between two fingers and stretch it apart. If you are near the time of ovulation, the mucus will stretch more than 1 inch before it breaks. As an alternative, at-home kits can test saliva as substitute for checking cervical mucus.
  • Use an over-the-counter urine test to detect luteinizing hormone (LH) surges. This helps determine the day of ovulation. Tests are also available to measure levels of follicle-stimulating hormone (FSH). However, these at-home tests may not be as accurate as those performed in a doctor’s office.

Laboratory Tests

Several laboratory tests may be used to detect the cause of infertility and monitor treatments:

Hormonal Levels: Blood and urine tests are taken to evaluate hormone levels. Hormonal tests for ovarian reserve (the number of follicles and quality of the eggs) are especially important for older women.

Examples of possible results include:

  • High follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels and low estrogen levels suggest premature ovarian failure.
  • High LH and low FSH may suggest polycystic ovary syndrome or luteal phase defect.
  • High FSH and high estrogen levels on the third day of the cycle predict poor success rates in older women trying fertility treatments.
  • LH surges indicate ovulation.
  • Blood tests for prolactin levels and thyroid function are also measured. These are hormones that may indirectly affect fertility.

Clomiphene Challenge Test

Clomiphene citrate (Clomid, Serophene, generic), a standard fertility drug, may be used to test for ovarian reserve. With this test, the doctor measures FSH on day 3 of the cycle. The woman takes clomiphene orally on days 5 and 9 of the cycle. The doctor measures FSH on the tenth day. High levels of FSH either on day 3 or day 10 indicate a poor chance for a successful outcome.

Tissue Samples:

To rule out luteal phase defect, premature ovarian failure, or absence of ovulation, the doctor may take tissue samples of the uterus 1 - 2 days before a period to determine if the corpus luteum is adequately producing progesterone. Samples taken from the cervix may be cultured to rule out infection.

Tests for Autoimmune Disease

Tests for autoimmune disease, such as hypothyroidism and type 1 diabetes, should be considered in women with recent ovarian failure that is not caused by genetic abnormalities.

Imaging Tests and Diagnostic Procedures.

If an initial fertility work-up does not reveal abnormalities, more extensive tests may help reveal abnormal tubal or uterine findings. The four major approaches for examining the uterus and fallopian tubes are:

  • Ultrasound (particularly a variation called saline-infusion sonohysterography)
  • Hysterosalpingography
  • Hysteroscopy
  • Laparoscopy

Combinations of these imaging procedures may be used to confirm diagnoses.

Ultrasound and Sonohysterograph

Ultrasound is the standard imaging technique for evaluating the uterus and ovaries. It is also used for detecting fibroids, ovarian cysts and tumors, and obstructions in the urinary tract.

Transvaginal sonohysterography uses ultrasound along with saline infused into the uterus, which enhances the visualization of the uterus. This technique is proving to be more accurate than standard ultrasound in identifying potential problems. It is currently the gold standard for diagnosing polycystic ovaries.

Hysteroscopy

Hysteroscopy is a procedure that may be used to detect the presence of endometriosis, fibroids, polyps, pelvic scar tissue, and blockage at the ends of the fallopian tubes. Some of these conditions can be corrected during the procedure by cutting away any scar tissue that may be binding organs together or by destroying endometrial implants.

Hysteroscopy may be done in a doctor’s office or in an operating room, depending on the type of anesthesia used. The procedure uses a long flexible or rigid tube called a hysteroscope, which is inserted into the vagina and advanced through the cervix to reach the uterus.

A fiber-optic light source and a tiny camera in the tube allow the doctor to view the cavity. The uterus is filled with saline or carbon dioxide to inflate the cavity and provide better viewing. This can cause cramping.

There are small risks of bleeding, infection, and reactions to anesthesia. Many patients experience temporary discomfort in the shoulders after the operation due to residual carbon dioxide that puts pressure on the diaphragm.

Hysterosalpingography

Hysterosalpingography is performed to discover possible blockage in the fallopian tubes and abnormalities in the uterus:

  • The doctor inserts a tube into the cervix through which a special dye is injected. (The patient may experience some cramping and discomfort.)
  • The dye passes into the uterus and up through the fallopian tubes.
  • An x-ray is taken of the dye-filled uterus and tubes.
  • If the dye is seen emerging from the end of the tube, no blockage is present. (In some cases, hysterosalpingography may even restore fertility by clearing away tiny tubal blockages.)
  • If results show blockage or abnormalities, the test may need to be repeated. In case of blockage, hysterosalpingography may reveal a number of conditions, including endometrial polyps, fibroid tumors, or structural abnormalities of the uterus and tubes.

There is a small risk of pelvic infection, and antibiotics may be prescribed prior to the procedure.

Laparoscopy

Laparoscopy is a minimally invasive surgical procedure. It requires general anesthesia and is performed in an operating room. The surgeon makes a very small incision below the belly button and inserts an instrument called a laparoscope, which is similar to a hysteroscope. Through the laparoscope, the surgeon can view the uterus, fallopian tube, and ovaries. Laparoscopy is most helpful for identifying endometriosis or other adhesions that may affect fertility.

5 Treatment

The major approaches to treat female infertility can be grouped into three categories:

  • Medicines to improve fertility - these are sometimes used alone but can also be used in addition to assisted conception.
  • Surgical treatments - these may be used when a cause of the infertility is found that may be helped by an operation.
  • Assisted conception - this includes several techniques such as:
  • Intrauterine insemination (IUI).
  • In vitro fertilisation (IVF).
  • Gamete intrafallopian transfer (GIFT).
  • Intracytoplasmic sperm injection (ICSI).

Medicines that may improve fertility:

Medicines are mainly used to help with ovulation. Ovulation is the name for the process where the ovary makes and releases an egg (ovum). Women normally ovulate about once a month until the menopause. For various reasons, ovulation may not occur at all, or it may occur less often than normal.

Ovulation is partly controlled by hormones called gonadotropins. These are made in a gland just under the brain (the pituitary gland). A gonadotrophin is a hormone that stimulates the activity of the gonads (the ovaries in women and the testicles in men).

The main gonadotrophins made by the pituitary gland are called follicle-stimulating hormone (FSH) and luteinising hormone (LH). These pass into the bloodstream and travel to the ovaries.

  • Clomifene is a medicine that has been used to help with fertility for many years. It is taken as a tablet. It works by blocking a feedback mechanism to the pituitary gland. This results in the pituitary making and releasing more gonadotrophin hormones than normal. The extra amount of gonadotrophin hormones may stimulate the ovaries to ovulate.
  • Medicines that contain gonadotrophins are another type of treatment. These need to be injected. They are sometimes used when clomifene does not work. They may also be used prior to assisted conception techniques to trigger ovulation. Gonadotrophin medicines may also improve fertility in men with certain types of hormonal problems that can affect sperm count.
  • Medicines that contain gonadotrophin-releasing hormone are sometimes used. These stimulate the pituitary to release gonadotrophins (which in turn stimulate the ovaries).
  • Metformin may be offered to women with polycystic ovary syndrome (PCOS) who have trouble conceiving. Metformin is a medicine that is commonly used to treat some people with diabetes. Some studies have suggested that metformin may help to improve fertility in some women with PCOS, usually in addition to clomifene.

Surgical treatments:

The situations where an operation may be an option include:

  • Fallopian tube problems - surgery may help some women with infertility caused by Fallopian tube problems. For example, if your Fallopian tubes have been blocked or scarred from a previous disease, infection, or other problem. Some women who have had a tubal tie (sterilisation) in the past for contraception may be able to have their fertility restored by tubal surgery. These days, most surgery to the Fallopian tubes is done by keyhole surgery.
  • Endometriosis - this is a condition that occurs when cells from the lining of the womb (uterus) grow in other areas of the body. Surgery may help to improve fertility in women with endometriosis.
  • Polycystic ovary syndrome (PCOS) - an operation on the ovaries may be suitable for some women with PCOS. The procedure is sometimes called ovarian drilling or ovarian diathermy. Again keyhole surgery is used. A heat source (diathermy) is usually used to destroy some of the tiny cysts (follicles) that develop in the ovaries. It may be done if other treatments for PCOS haven't worked.
  • Fibroids - for women with fibroids, surgery (to remove the fibroid) may be considered if there is no other explanation for the infertility. However, small fibroids may not cause infertility.

Assisted conception:

Intrauterine insemination (IUI).

This is the process by which sperm are placed into the woman's womb (uterus). It is done by using a fine plastic tube which is passed through the neck of the womb (the cervix) into the womb.

Sperm are passed through the tube. It is a relatively straightforward procedure. It can be timed to coincide with ovulation (about halfway through a monthly cycle) in women who are still ovulating. Fertility medicines may also be given beforehand, to maximize the chance of ovulation occurring.

Women who have this procedure need to have healthy Fallopian tubes to allow the egg to travel from the ovary into the womb. If successful, fertilization takes place within the womb.

The sperm used can be either from the male partner, or from a donor:

  • The male partner's sperm can be used when the cause of the infertility is unexplained and the sperm test results are normal. It may also be useful for cases where the female cervical mucus seems to block or kill the sperm. Sperm is obtained by the male partner masturbating just prior to the IUI procedure.
  • Donor sperm are obtained from a sperm bank of frozen sperm provided by donors. It may be considered as an option in a number of circumstances - for example:
  • Where the male partner has no or very few sperm, or the sperm are not normal.
  • Where the male partner has had a sterilization (vasectomy) but reversal has failed.
  • Where the male partner has an infectious disease such as HIV.
  • Where there is a high risk of transmitting a genetic disorder (a disease that is caused by an abnormality in either partner's DNA) to a baby.

If IUI does not work, couples tend to move on to try other methods described below.

In vitro fertilization (IVF).

IVF means fertilization outside of the body. In vitro literally means in glass (that is, in a laboratory dish or test tube).

IVF is used in couples whose infertility is caused by blocked Fallopian tubes, or where their infertility is unexplained. It may also be used where there are certain problems with ovulation or a combination of factors causing infertility.

IVF involves taking fertility medicines to stimulate the ovaries to make more eggs than usual. When the eggs have formed, a small operation is needed to harvest them (egg retrieval). Each egg is mixed with sperm. This is obtained either by the male partner masturbating, or from a donor. The egg/sperm mixture is left for a few days in a laboratory dish. The aim is for sperm to fertilize the eggs to form embryos.

One or two embryos which have formed are then placed into the woman's womb using a fine plastic tube passed through the cervix. Any other embryos which have formed in the dish are either discarded or, if you wish, frozen for further attempts at IVF at a later date.

Around one in four IVF procedures result in a successful pregnancy. Your chance of success with IVF may be higher if:

  • The female partner is under the age of 37.
  • The female partner has been pregnant before.
  • The female partner has a body mass index (BMI) between 19 and 30 (they are a good weight).

It is recommended that when IVF is used:

  • Three cycles are offered to women aged under 40 years
  • One cycle is usually offered to women aged 40-42 years if they have not had IVF in the past

Gamete intrafallopian transfer (GIFT).

A gamete is an egg or sperm. Eggs and sperm are collected in the same way as for IVF. The eggs are mixed with sperm. The mixture of eggs and sperm is then placed into one of the woman's Fallopian tubes. Therefore, unlike IVF, the sperm fertilizes the egg naturally inside the woman's Fallopian tube or womb, and not outside the body in a laboratory dish. GIFT is no longer recommended to be used instead of IVF.

Intracytoplasmic sperm injection (ICSI).

This technique involves an individual sperm being injected directly into an egg. (It is injected into the outer part of the egg - the cytoplasm.)

This method bypasses any natural barriers that may have been preventing fertilization. For example, some cases of infertility are due to the sperm of a male partner not being able to penetrate the outer part of the egg to fertilize the egg. ICSI can also be used when a male partner has a low sperm count, as only one sperm is needed.

If needed, a sperm can also be obtained by a small operation to the testicle (testis). This may be done when sperm cannot be produced in the usual way; for example, if the male partner has a blocked vas deferens, or has had a vasectomy.

The egg containing the sperm is then placed in the womb in the same way as with IVF. ICSI is used for couples who have failed to achieve fertilization through IVF, or where the quality or number of sperm is too low for normal IVF to be likely to succeed.

Egg donation.

This involves stimulating the ovaries of a female donor with fertility medicines, and collecting the eggs which form. The eggs are mixed with and fertilised by sperm of the recipient's partner (similar to IVF). After 2-3 days, embryos are placed in the womb of the recipient via the cervix.

This method is an option in a number of circumstances - for example, it may be used:

  • For women who have ovarian failure and cannot produce eggs.
  • For women who have had their ovaries removed.
  • For women who have conditions where the ovaries do not work (for example, in Turner syndrome).
  • Where there is a high risk of transmitting a genetic disorder to the baby.
  • In some cases of IVF failure.

Embryo donation.

Couples who have had successful IVF treatment may decide to donate any spare embryos to help other infertile couples.
Possible complications of infertility treatments:

Multiple pregnancies.

Twins and multiple pregnancies are more common in some forms of infertility treatment including medication treatment - for example, with clomifene.

This is because in some of the treatments using medication, the ovaries may be stimulated so that more than one egg is released and therefore more than one egg may be fertilized. Also, in some assisted conception treatments, more than one embryo is put back into the woman's womb (uterus) and therefore more than one pregnancy can develop.

This occurs less commonly now as latest guidelines advise that in most cases only one embryo is put into the womb.
Having twins or triplets may be a great thing for some couples. However, it should be explained that it does carry an increased risk of problems during a woman's pregnancy, such as high blood pressure and diabetes.

There is also a higher risk of other complications such as a having a small baby or going into premature labor.

Pregnancy in the Fallopian tube.

A pregnancy which develops in the Fallopian tube (an ectopic pregnancy) may be a little more likely in women who are undergoing treatment for infertility. This is especially if the cause of infertility is due to a problem with the Fallopian tubes.

Stress.

Going through investigations and treatment for infertility can be a very stressful thing and can put a strain on many relationships. It is important to discuss your feelings with your partner, doctor, nurse or counselor.

Over-stimulation of the ovaries.

There is a small risk that some of the medicines used to treat infertility, such as the gonadotrophin medicines, can over-stimulate the ovaries. This may lead to a condition known as ovarian hyper stimulation syndrome. In this condition, the ovaries can swell due to a number of cysts that develop on the ovaries.

Symptoms can include tummy (abdominal) pain and swelling (distension), feeling sick (nausea) and being sick (vomiting). The condition can usually be treated easily and does not lead to any major problems. However, occasionally it can be more serious and can lead to liver, kidney and breathing problems or a blood clot in an artery or vein (a thrombosis).

Close monitoring using ultrasound scans is often used when women are given medicines to stimulate the production of eggs by the ovaries. The numbers and size of the sac containing an egg (the follicle) can be measured.

This helps to reduce the risk of multiple pregnancy and also ovarian hyperstimulation.

Other side-effects.

Some of the medicines used to treat infertility - for example, the gonadotrophins - may cause hot flushes and menopause-type symptoms.

Before deciding to go ahead with any treatment, you should have a discussion with your infertility expert on the pros and cons of the treatment proposed and the risk of problems and side-effects.

6 Prevention

For some, adopting a healthier lifestyle through simple lifestyle changes, or staying up to date with regular health checks and tests, may help to prevent infertility.

You can optimize your chances of getting pregnant in a number of ways.

  • Exercise moderately. Do not exercise so heavily that your menstrual periods are infrequent or absent.
  • Avoid extremes of weight. An optimum body mass index (BMI) is at least 20 and below 27.
  • Avoid alcohol, smoking and drugs.
  • Avoid too much caffeine. Do not drink more than one cup of coffee per day.
  • Review your medicines with your doctor. Some medications can affect your ability to conceive or carry a normal pregnancy.
  • A "fertility diet". The following nutritional advice seems to be associated with improved fertility:
  • Avoiding trans fats
  • Eating more beans, nuts and other fertility-boosting plant protein
  • Eating more whole grains
  • Avoiding sugary sodas
  • Having a glass of whole milk and other full-fat dairy food every day (even including an occasional small bowl of ice cream)

Some treatments for cancer can cause infertility. Certain techniques allow a woman planning to undergo chemotherapy or radiation to later have a baby from her own egg. Discuss these with your doctor before beginning cancer treatment.

7 Lifestyle and Coping

Lifestyle modifications are necessary in order to cope with female infertility.

Although there are no dietary or nutritional cures for infertility, a healthy lifestyle is important. Some ovulatory problems may be reversible by changing behavioral patterns. Some tips include:

  • Maintain a healthy weight. Women who are either over- or underweight are at risk for fertility failure, including a lower chance for achieving success with fertility procedures.
  • Stop smoking. Smoking may increase the risk for infertility in both men and women. Everyone should quit.
  • Avoid excessive exercise if it causes menstrual irregularity. However, moderate and regular exercise is essential for good health.
  • Avoid or limit caffeine and alcohol.
  • Avoid any unnecessary medications.

PLANNING SEXUAL ACTIVITY AND MONITORING BASAL BODY TEMPERATURE

Both male and female hormone levels fluctuate according to the time of day, and they vary from day to day, month to month, and seasonally. Some timing tips might be helpful.

Monitoring Basal Body Temperature: To determine the most likely time of ovulation and therefore the time of fertility, a woman should take her body temperature, called her basal body temperature. This is the body's temperature as it rises and falls in accord with hormonal fluctuations.

  • Each morning before rising, the woman takes her temperature with a specialized basal body thermometer and marks the result on a graph-paper chart.
  • The woman also notes the days of menstruation and sexual activity.
  • The so-called "fertile window" is 6 days long, starts 5 days before ovulation, and ends the day of ovulation.
  • The chances for fertility are considered to be highest between days 10 and 17 in the menstrual cycle (with day 1 being the first day of the period, and ovulation occurring about 2 weeks later). However, cycles vary from woman to woman.
  • Immediately after ovulation the body temperature increases sharply in about 80% of cases. (Some women can be ovulating normally yet not show this temperature pattern.)

By studying the temperature patterns after a few months, couples can begin to anticipate ovulation and plan their sexual activity accordingly. Couples should try to avoid becoming fixated on the chart, however, in scheduling their sexual activity.

Frequency of Intercourse: It is not clear how often a couple should have intercourse in order to conceive. Some doctors think that having sex more than 2 days a week adds no benefits. In addition, frequent sexual activity lowers sperm count per ejaculation.

Some studies have indicated, however, that having intercourse every day, or even several times a day, before and during ovulation, improves pregnancy rates. Although sperm count per ejaculation is low, a constantly replenished semen supply is more likely to result in a fertilized egg.

DEALING WITH STRESS

The fertility treatment process presents a roller coaster of emotions. There are almost no sure ways to predict which couples will eventually conceive. Some couples with multiple problems will overcome great odds, while other, seemingly fertile, couples fail to conceive. Many of the new treatments are remarkable, but a live birth is never guaranteed. The emotional burden on the couple is considerable, and some planning is helpful.

  • Decide in advance how many and what kind of procedures will be emotionally and financially acceptable and attempt to determine a final limit. Fertility treatments are expensive. A successful pregnancy often depends on repeated attempts.
  • Prepare for multiple births as a possible outcome for successful pregnancy (especially if assisted reproductive technologies are used). A pregnancy that results in a multiple birth introduces new complexities and emotional problems
  • Determine alternatives (adoption, donor sperm or egg, or having no children) as early as possible in the fertility process. This can reduce anxiety during treatments and feelings of disappointment in case conception does not occur.

8 Risks and Complications

Some female infertility treatments can cause complications, including side effects from medication, multiple pregnancy and stress.

Side Effects of Medication

Some medications used to treat infertility can cause side effects. These may include:

Ovarian Hyperstimulation Syndrome

Ovarian hyperstimulation syndrome (OHSS) is a rare complication of in-vitro fertilization (IVF). It occurs in women who are very sensitive to the fertility drugs taken to increase egg production. Too many eggs develop in the ovaries, which become very large and painful.

OHSS is more common in women under 30 and in women who have polycystic ovary syndrome (PCOS). OHSS generally develops in the week after egg collection.

The symptoms of OHSS are pain and bloating low down in your tummy (abdomen), nausea or vomiting. Severe cases can be dangerous. Contact your clinic if you have any of these symptoms.

You may need to go to hospital, so your condition can be monitored and treated by healthcare professionals.

Ectopic Pregnancy

If you have IVF, you have a slightly higher risk of an ectopic pregnancy, where the embryo implants in the fallopian tubes rather than in the womb.

If you have a positive pregnancy test, you'll have a scan at six weeks to make sure the embryo is growing properly and that the pregnancy is normal.

Tell your doctor if you experience vaginal bleeding or stomach pain after having IVF and a positive pregnancy test.

Pelvic Infection

The procedure to extract an egg from an ovary may result in a painful infection developing in your pelvis. However, the risk of serious infection is very low. For example, there is likely to be less than one serious infection for every 500 procedures performed.

Multiple Pregnancies

If more than one embryo is replaced in the womb as part of IVF treatment, there's an increased chance of producing twins or triplets.

Having more than one baby may not seem like a bad thing, but it significantly increases the risk of complications for you and your babies. These include:

  • having a higher risk of miscarriage, anemia and heavy bleeding; you are also more likely to go into early labor and need a caesarean section or assisted ventouse or forceps delivery
  • up to 25% of multiple pregnancies cause pregnancy-related high blood pressure
  • being two to three times more likely to develop gestational diabetes during pregnancy if you're carrying more than one baby
  • the risk of pre-eclampsia is three times higher for twin pregnancies and nine times higher for triplets
  • The 2013 NICE fertility guidelines recommend that double embryo transfers should only be considered during treatment in women aged 40-42. Younger women should only be considered for a double embryo transfer if there are no top-quality embryos.

Stress

Infertility can be stressful and put a strain on relationships. It may be helpful to join a support group, where you can talk through your feelings with others experiencing similar problems.

Finding out you have a fertility problem can be traumatic, and many couples find it helpful to talk to a counselor. They can discuss treatment options, how they may affect you and the emotional implications. Your GP should be able to refer you to a counselor as part of your fertility treatment.

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