7% of women in Pakistan are infertile, which causes problems in conceiving. Adequate treatment of infertility in women following a fertility test can help them conceive.

Infertility In Women

A. JABBAR DENTAL CLINIC KARACHI

Sadia Khan

Overview

Infertility is defined as the inability to conceive a child over the course of 1 year of unprotected intercourse in women under age 35 or 6 months of unprotected intercourse in women over the age of 35 years. 
&nbsp;

Infertility affects 1 out of every 6 couples<a href="#accordion">[2]</a>. It can be damaging to the patient&rsquo;s mental, psychological, spiritual and physical well-being. Moreover, it is often a long road to finding the correct diagnosis. However, many infertile couples may go on to conceive without treatment later. 
&nbsp;

According to the Centers for Disease Control and Prevention (CDC), 6.1 million women in the United States aged 15 to 44 experience difficulties becoming pregnant or maintaining pregnancy<a href="#accordion">[3]</a>. In a study carried out in Pakistan, of 7,628 female patients examined over a period of 3 years for different problems, 534 women were found with the complaint of infertility<a href="#accordion">[4]</a>. The frequency of infertility was 7%<a href="#accordion">[4]</a>. 
&nbsp;

Infertility can be divided into two types - primary and secondary. 
&nbsp;

1. Primary Infertility: When someone who has never conceived previously is unable to conceive, it is called primary infertility. 
&nbsp;

2. Secondary Infertility:&nbsp;This is defined as difficulty conceiving in those who have previously had 1 or more pregnancies. 
&nbsp;

Signs and Symptoms

The inability to get pregnant is the main sign of infertility. However other signs and symptoms are mostly a product of the underlying condition causing failure of conception. If you experience any of these signs, it is best to get an evaluation from your doctor to discover the cause. 
&nbsp;

1. Irregular Menstrual Cycle: If your cycle is such that you are unable to calculate when your period may arrive, you most likely have an irregular cycle - It can be a common sign of polycystic ovarian syndrome (PCOS). 
&nbsp;

2.&nbsp;Heavy Or Painful <a href="https://merisehat.pk/disease/first-period-no-worries-we-got-you-covered">Periods</a>:&nbsp;If your period is so painful that it interferes with your daily life tasks, it could be a sign of endometriosis. 
&nbsp;

<ul>
	<li>No Periods: If you are not getting your periods consistently for months, you may need a fertility evaluation. 
	&nbsp;</li>
	<li>Hormonal Imbalance: Some signs that your hormones could be out of proportion are a decreased sex drive, thinning hair, skin problems, facial hair, and weight gain. 
	&nbsp;</li>
	<li>Painful Intercourse: Pain during intercourse signals an underlying problem such as hormonal imbalance or endometriosis. 
	&nbsp;</li>
</ul>

Please Note: Consult your doctor if you are experiencing any of these symptoms. Also speak to your health care provider, if you experience any unusual discharge, fever, itching in the vaginal area, abnormal bleeding or pain. 
&nbsp;

Causes

Pregnancy requires multiple steps. These involve: 
&nbsp;

<ol>
	<li>&nbsp;Release of an egg from one of the two ovaries present in the female body</li>
	<li>&nbsp;Fertilization - the fusion of a man&rsquo;s sperm with the egg</li>
	<li>&nbsp;Movement of the fertilized egg through the fallopian tube toward the uterus</li>
	<li>&nbsp;Implantation - attachment of the embryo to the uterus 
	&nbsp;</li>
</ol>

A dysfunction of any of these steps can cause difficulty conceiving. Female infertility commonly results from the following factors: 
&nbsp;

<h5>1. Ovulation Disorders</h5>

Infrequent or absence of ovulation is accountable for most infertility cases in women. The following are the disorders caused by problems with ovulation: 
&nbsp;

<ul>
	<li><a href="https://merisehat.pk/disease/polycystic-ovary-syndrome-pcos">Polycystic Ovary Syndrome (PCOS)</a>: Ovulation is impacted by a hormonal imbalance brought on by PCOS. PCOS is linked to insulin resistance, obesity, abnormal body or facial hair development, and acne. It is the most frequent reason for infertility in women. 
	&nbsp;</li>
	<li>Dysfunction Of The Hypothalamus: Each month, the pituitary gland releases two hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), to promote ovulation. A very high or extremely low body weight or excessive physical or mental stress can all interfere with the synthesis of these hormones and impair ovulation. The most typical symptoms are irregular or absence of menstruation. 
	&nbsp;</li>
	<li>Primary Ovarian Insufficiency: Also known as premature ovarian failure, it is frequently brought on by an autoimmune reaction or the early loss of eggs from your ovaries, mostly due to genetics or chemotherapy. Simply put the ovaries stop functioning as they should before age 40 in primary ovarian failure. 
	&nbsp;</li>
	<li>Excessive Prolactin: Prolactin can be produced in excess by the pituitary gland (hyperprolactinemia), which inhibits the production of estrogen and may result in infertility. Certain medications can also increase prolactin levels in the body. 
	&nbsp;</li>
	<li><a href="https://merisehat.pk/disease/menopause">Menopause</a>:&nbsp;Ovarian function naturally declines throughout menopause, which typically happens around age 50. A woman who has entered menopause has, by definition, been without a period for at least a year. Hot flashes, mood swings, insomnia, and other symptoms are also common among women. 
	&nbsp;</li>
	<li>Diminished&nbsp;Ovarian Reserve (DOR): All of a woman&#39;s eggs are present at birth, and over time, her egg supply naturally decreases. In DOR, there are fewer eggs in the ovaries than would be expected for a person of a certain age. Congenital (condition present at birth), medicinal, surgical, or unknown factors may all contribute to its occurrence. Natural conception may be possible for women. It is also possible that a poorer response is seen in case of fertility treatment due to production of fewer eggs. 
	&nbsp;</li>
</ul>

<h5>2. Problems In The Fallopian Tube (tubal infertility)</h5>

Fallopian tubes that are damaged or blocked prevent sperm from reaching the egg or prevent the fertilized egg from entering the uterus. Various factors might lead to fallopian tube injury or obstruction: 
&nbsp;

<ul>
	<li>Pelvic Inflammatory Disease: infection in the uterus due to sexually transmitted diseases such as gonorrhoea and chlamydia can cause pelvic inflammatory disease. 
	&nbsp;</li>
	<li>Surgery: previous abdominal or pelvic surgeries, such as surgery for an ectopic pregnancy (a fertilized egg implants and grows outside of the uterus, typically in a fallopian tube) 
	&nbsp;</li>
</ul>

<h5>3. Endometriosis</h5>

When tissue that normally develops in the uterus implants and expands in other areas, it is known as endometriosis. The surgical excision of this excess tissue development may result in scarring and obstruction of fallopian tubes, preventing fertilization. Endometriosis can also cause implantation problems. 
&nbsp;

<h5>4. Cervical Or Uterine Causes</h5>

<ul>
	<li>Tumors or polyps: fibroids or myomas may be common in the uterus, and some can obstruct the fallopian tube interfering with implantation. However; some women still do conceive 
	.</li>
	<li>Shape of the uterus: the shape of the uterus might be such from birth that it can cause difficulty in conception. 
	&nbsp;</li>
	<li>Cervical stenosis: cervical narrowing either inherited or caused by cervical damage can impair fertility. 
	&nbsp;</li>
</ul>

<h5>5. Medications </h5>

Certain drugs can have side effects that reduce fertility. These include:<a href="#accordion">[6]</a>

<ul>
	<li>Non-steroidal anti-inflammatory drugs (NSAIDS)</li>
	<li>Chemotherapy</li>
	<li>Neuroleptic medications</li>
	<li>Spironolactone</li>
	<li>Illegal drugs like marijuana and cocaine. 
	&nbsp;</li>
</ul>

<h5>6. STDs</h5>

Some sexually transmitted diseases such as chlamydia, if left untreated, can cause pelvic inflammatory disease leading to the blockage of the fallopian tubes, preventing fertilization<a href="#accordion">[8]</a>.

Some causes of infertility have still not been discovered which means both partners can have minor factors affecting fertility. In some cases, the problem corrects itself but an expert opinion should always be sought before deciding to wait. 
&nbsp;

Diagnosis

The fertility tests that can be carried out are: 
&nbsp;

<ul>
	<li>Ovulation Test: The increase in luteinizing hormone (LH) that takes place just before ovulation is identified using an at-home, over-the-counter ovulation prediction kit. A blood test for the hormone progesterone can also help confirm whether one is ovulating. Prolactin and other hormone levels may also be tested. 
	&nbsp;</li>
	<li>Hysterosalpingography: A procedure called hysterosalpingography involves injecting X-ray contrast into your uterus and taking an X-ray to look for any problems. The test reveals whether the fluid leaks from your fallopian tubes and leaves your uterus. If any issues are discovered, the doctor may require further evaluation. 
	&nbsp;</li>
	<li>Testing The Ovarian Reserve: The amount and quality of eggs accessible for ovulation are determined by this examination. These blood and imaging tests may be given to women who are at risk of having fewer eggs and women older than age 35. 
	&nbsp;</li>
	<li>Hormonal Tests: Other hormone tests help measure the levels of thyroid and pituitary hormones, which regulate reproductive processes, as well as ovulatory hormones. 
	&nbsp;</li>
	<li>Imaging Tests: A pelvic ultrasound helps assess for fallopian tube disease or uterine cancer/ causes. Sonohysterograms, also known as saline infusion sonograms or hysteroscopies, can sometimes be used to reveal uterine characteristics that aren&#39;t visible on a standard ultrasound. 
	&nbsp;</li>
</ul>

Some rare tests are:

<ul>
	<li>Laparoscopy: In this minimally invasive procedure, your fallopian tubes, ovaries, and uterus are examined by inserting a piece of thin viewing equipment via a tiny incision made beneath your navel. Endometriosis, scarring, blockages or abnormalities of the fallopian tubes, as well as issues with the ovaries and uterus, can all be found during a laparoscopy. 
	&nbsp;</li>
	<li>Genetic Testing: Genetic testing enables you to find out whether your genes have undergone any alterations that might be contributing to your infertility. 
	&nbsp;</li>
</ul>

Treatment

Treatment of infertility depends on the cause, the patient&#39;s age, how long the patient has been infertile, and personal preference. 
&nbsp;

<h5>Medicine To Improve Fertility</h5>

Ovulation disorders can be treated with fertility drugs which work like natural hormones to trigger ovulation. They can be used to stimulate an egg with better quality or to release more than one egg. These drugs include: 
&nbsp;

<ol>
	<li>&nbsp;Metformin: This drug improves insulin resistance which may be causing ovulation issues, such as in PCOS. 
	&nbsp;</li>
	<li>&nbsp;Clomiphene Citrate: Women younger than 39 who do not have PCOS are ideal for this treatment. This drug helps in the release of more FSH and LH by the pituitary gland, stimulating the growth of ovarian follicles containing eggs. 
	&nbsp;</li>
	<li>&nbsp;Gonadotropins: These medications include human menopausal gonadotropin (hMG)&nbsp; and FSH. They stimulate the ovary to produce multiple eggs. Moreover, the gonadotropin, human chorionic gonadotropin is responsible for maturing and triggering the release of eggs at the time of ovulation. 
	&nbsp;</li>
	<li>&nbsp;Letrozole: This is usually used by women below the age of 39 with PCOS. It works in a similar manner to clomiphene and belongs to the class of drugs known as aromatase inhibitors. 
	&nbsp;</li>
	<li>&nbsp;Bromocriptine: This is a dopamine agonist used to combat problems caused by the pituitary gland&rsquo;s overproduction of prolactin 
	&nbsp;</li>
</ol>

<h5>Surgical Procedures To Improve Fertility:</h5>

There are many surgical options available that can improve fertility, but due to the success rate of non-surgical treatments, not many people opt for surgery. Surgical procedures include:<a href="#accordion">[10]</a> 
&nbsp;

<ul>
	<li>Laparoscopy: The doctor inserts a laparoscope via an incision around your belly button. It can help remove scar tissue, treat endometriosis, unblock the blocked fallopian tubes, and remove ovarian cysts. 
	&nbsp;</li>
	<li>Hysteroscopy: This involves the insertion of a hysteroscope into the uterus through the cervix. It is used to cut scar tissue, clear obstructed tubes, and remove polyps and fibroid tumours. 
	&nbsp;</li>
</ul>

<h5>Reproductive Assistance&nbsp;</h5>

<ul>
	<li>Intrauterine&nbsp;Insemination: Millions of healthy sperm are washed in a special solution after which they are delivered to the uterus. This is sometimes done in combination with medications that help release the egg.<a href="#">[9]</a> <a href="#accordion">[10]</a> 
	&nbsp;</li>
	<li>In Vitro Fertilization (IVF): This entails taking mature eggs, fertilizing them with sperm in a dish in the&nbsp;lab, and then placing the fertilized embryos in the uterus. The most successful assisted reproductive method is IVF. Multiple blood tests and daily hormone injections are necessary throughout an IVF cycle, which takes many weeks. Some embryos can be frozen for later use if both partners agree. 
	&nbsp;</li>
	<li>Intracytoplasmic Sperm Injection:&nbsp;The doctor injects the sperm directly into the egg in a dish and then releases it into the uterus. 
	&nbsp;</li>
	<li>GIFT (gamete intrafallopian tube transfer) and ZIFT (zygote intrafallopian transfer):&nbsp;These treatments work similarly to IVF in that an egg is removed, combined with sperm in a lab, and then promptly placed into the fallopian tubes. In ZIFT, the doctor immediately inserts the zygotes, which are the fertilized eggs at this stage, into the fallopian tubes. In GIFT, the sperm and eggs are mixed before being inserted by a physician. 
	&nbsp;</li>
</ul>

Complications mostly result from the medications used for infertility: 
&nbsp;

<ul>
	<li>Injectable fertility medications carry a higher chance of developing multiple fetuses, i.e. twins, triplets and sometimes even more. This can lead to preterm labour or low birth weight of the babies. 
	&nbsp;</li>
	<li>Drugs injected to stimulate ovulation can cause ovarian hyperstimulation syndrome which includes painful and swollen ovaries along with bloating, nausea, mild abdominal bloating, and vomiting. In more severe cases, there can be weight gain, fluid filling the abdomen, painful and enlarged ovaries, and breathlessness. 
	&nbsp;</li>
	<li>Women using fertility drugs for 12 or more months without being able to conceive, may be at risk for developing borderline ovarian tumours in the future. 
	&nbsp;</li>
</ul>

It is recommended that you contact your doctor in case of any unusual side effects, and have your medication and dosage evaluated every few months in case of failure in conception. 
&nbsp;

The following emotional and mental health complications are also associated with infertility:

<ul>
	<li>Depression</li>
	<li>Stress</li>
	<li>Anxiety</li>
	<li>Social stigma</li>
	<li>Relationship problems 
	&nbsp;</li>
</ul>

<ul>
	<li>Age:With time, a woman&#39;s eggs lose both quality and quantity. The rate of follicle loss accelerates towards the mid-30s, producing fewer eggs of lower quality. This raises the chance of miscarriage and makes fertilisation more challenging. 
	&nbsp;</li>
</ul>

<ul>
	<li>Smoking:Smoking damages the cervix and fallopian tubes, increases the risk of miscarriage and ectopic pregnancy, and ages the ovaries which may reduce the number of eggs. Before starting your fertility treatment, it is best to quit smoking. 
	&nbsp;</li>
	<li>Sexual History:STDs like gonorrhoea and chlamydia may damage the fallopian tubes. Having multiple sexual partners can increase the risk of acquiring an STD. 
	&nbsp;</li>
	<li>Weight:Being overweight or underweight may affect ovulation, so it is beneficial to maintain a healthy BMI to increase the chances of pregnancy. 
	&nbsp;</li>
	<li>Alcohol:Consuming alcohol may reduce fertility. It is best to quit drinking alcohol. 
	&nbsp;</li>
	<li>Stress:Stress can cause a disturbance in your menstrual cycle which can lead to irregular or missed periods. 
	&nbsp;</li>
	<li>Exposure to Toxins:Environmental toxins like lead and pesticides may cause fertility issues. 
	&nbsp;</li>
	<li>Radiation:Exposure to cancer treatments and radiation therapy can also have a negative impact on fertility. 
	&nbsp;</li>
	<li>Thyroid Disease:An imbalance of thyroid hormones can also affect fertility. 
	&nbsp;</li>
	<li>Pituitary Gland Disorders:Such as Cushing&#39;s syndrome. 
	&nbsp;</li>
	<li>Past ectopic Pregnancy:A history of ectopic pregnancy is associated with infertility in women 
	&nbsp;</li>
</ul>

Females trying to conceive should: 
&nbsp;

<ul>
	<li>Maintain a healthy BMI and not use strenuous exercises for rapid weight loss.</li>
	<li>Quit smoking and alcohol.</li>
	<li>Reduce their stress levels. 
	&nbsp;</li>
</ul>

To investigate the distribution of gender and the causes of infertility, the World Health Organization (WHO) conducted a significant international investigation. Female infertility was the cause of infertility in 37% of infertile couples; male and female factors were found in 35% of couples, and male factor infertility was present in 8% of couples. The study showed the most common causes of female infertility to be: 
&nbsp;

<ol>
	<li>Ovulation disorders: 25%</li>
	<li>Endometriosis: 15%</li>
	<li>Pelvic adhesions: 12%</li>
	<li>Tubal blockage: 11%</li>
	<li>Uterine or tubal abnormalities: 11%</li>
	<li>Hyperprolactinemia: 7% 
	&nbsp;</li>
</ol>

In a research by the National Survey of Family Growth, which surveyed 12,000 American women, the prevalence of infertility was directly proportional to age.Infertility rates for women between the ages of 15 and 34 varied from 7.3% to 9.1%. The infertility rate increased to 25% in women aged 35 to 39. Lastly, there was a 30% likelihood of infertility for women between the ages of 40 and 44. Eastern Europe, North Africa, and the Middle East have greater global infertility rates than other regions. In the world, 11% of women who had a prior live birth were unable to have another, and 2% of women aged 20 to 44 were unable to have a live delivery at all. 
&nbsp;

Key Points

<ul>
	<li>Infertility is defined as the inability to conceive a child over 1 year of unprotected intercourse in females younger than 35 years, or 6 months of unprotected intercourse in women over the age of 35 years. </li>
	<li>1 out of every 6 couples is affected by infertility.</li>
	<li>Primary and secondary infertility are the two types of infertility.</li>
	<li>The main sign of infertility is the failure to conceive after a year of unprotected intercourse.</li>
	<li>Causes of female infertility include ovulatory disorders, blockage in the fallopian tubes, cervical or uterine causes, STDs, and medication.</li>
	<li>Diagnosis is done by ovulation test, hysterosalpingography, hormonal tests, testing of the ovarian reserve, genetic testing, imaging test and laparoscopy.</li>
	<li>Treatment includes fertility drugs such as metformin, clomiphene, gonadotropins, letrozole, and bromocriptine. Surgical procedures are laparoscopy, and hysteroscopy. Reproductive assistance involves intrauterine insemination, in vitro fertilization, and gamete/zygote intrafallopian tube transfer.</li>
	<li>Complications of fertility medication can be multiple pregnancies, ovarian hyperstimulation syndrome, and borderline ovarian tumours.</li>
	<li>Risk factors are age, smoking, sexual history, weight, alcohol consumption, stress, exposure to toxins, radiation exposure, thyroid disease, pituitary gland disorders, and past ectopic pregnancy.</li>
	<li>Prevention includes, maintaining a healthy weight, quitting smoking, quitting alcohol, and reducing stress levels. 
	&nbsp;</li>
</ul>