Female Causes of Infertility

History and Examination of Female

• Menstrual cycle (regular, irregular), Previous infections & PID, Hirsutism, Dysmenorrhea, Prolactinoma & Galactorrhea, Contraception history, Family Hx of the same problem, previous marriage and children, previous infertility investigations and management.
• Sexual history (Q for both couple)

A- Anovulation/Oligoovulation (Ovarian)

Causes:

1. Physiological: Post OCPs, Lactation.

2. Pathological:

   A. General causes: as amenorrhea and in addition:

   • Age, Weight (fertility with age and overweight/obesity)
   • Psychological
   • Cigarettes smoking and addiction.
   • Environmental toxins

   B. Hypothalamic and pituitary causes (= all causes of amenorrhea).

   C. Ovarian causes:

   • Premature ovarian failure
   • PCO
   • Luteal phase defect

Diagnosis

1. Clinical

   • A-Symptoms: absence of normal symptoms of ovulation which are (any one or more):
     • Regular cyclic menstruation.
     • Ovulation pain = mid-cyclic pain ”= MiettleSchmerz pain”.
     • Ovulation spotting.
     • Premenstrual mastalgia.
   • B-Signs:
     • Signs Document ovulation
       1. increase basal body temperature early in the morning.
       2. Changes in characters of cervical mucous (become slippery)

2. Investigations:

   • A- Lab: Hormonal assay

     • Day 3 FSH & LH
     • Day 21 Progesterone level in blood
     • L.H level in plasma and urine.
     • E2
     • Prolactin
     • Testosterone, and its derivatives in hyperandrogenism.
     • TFT
     • Anti-müllerian hormone (AMH) levels can also be helpful in predicting ovarian reserve

   • B- Radiological:

     • U.S For serial measurements of follicular growth and maturation, “the mature Graffian follicle is about 18-25 mm”.

   • C- Histopathological:

     • Premenstrual endometrial biopsy show NO secretory changes OR luteal phase defect.

Treatment of Ovarian Factor

1. Correction of general condition:

   • Treatment of general causes e.g., D.M, T.B, etc.
   • Treatment of hypothyroidism
   • Treatment of hypothalamic and pituitary causes.
   • Treatment of hyper-prolactinemia (Bromocriptine and Cabergolin as anti-prolactin).
   • Progesterone for luteal phase defect in the second half of the cycle.

2. Induction of ovulation:

   • Clomiphene citrate (Clomid) = antiestrogen: oral 50-100 mg/day from the 3^rd day for 5-7 days (first-line medication).
     • Mechanism: By blocking the receptors of estrogen so blocking the negative feedback mechanism on the hypothalamus and pituitary with subsequent increase in F.S.H & L.H and thus ++follicular growth and ovulation.
     • It increases the sensitivity of the ovary to gonadotrophins.
   • Gonadotrophins. (FSH OR HMG)
   • H.C.G = human chorionic gonadotrophins. (injection to trigger ovulation)
   • Tamoxifen as selective direct estrogen receptor inhibition.
   • Metformin as anti-insulin in PCOS.

Ovarian Hyper-stimulation

• It is a common complication of induction of ovulation as the ovaries may enlarge up to 12 cm OR more with a risk of peritoneal irritation and OR ovarian rupture.
• It may be mild, moderate, or severe.
• In mild form; there is abdominal distension, pain, sickness, and diarrhea.
• In moderate form; there may be excess fluid in the abdomen leading to more pain and discomfort.
• In severe form; the case may be life-threatening as there may be free fluid in the abdomen (low albumin), hemoconcentration, and hypercoagulability.
  Ascites

B- Tubal Factor of Infertility

Causes:

1. Congenital: tubal aplasia, hypoplasia, diverticulum.
2. Traumatic: trauma during operation followed by adhesions.
3. Inflammatory: following P.I.D ---: “adhesions the commonest cause in the tube”.
4. Neoplastic: e.g., small cornal fibroid closing the tubal ostia.
5. Endometriosis: causing pelvic adhesions.
6. Disturbed physiology: e.g., Poor ciliary movement.

Diagnosis/Investigations:

• A-Hysterosalpingography = H.S.G: the main line used for diagnosis by “tubal patency tests”.

  • The idea: Inject radio-opaque dye in the uterus to pass through the tubes to the peritoneal cavity.

  • Then the lower abdomen and pelvis are photographed.

  • Timing of the test: it should be done post-menstrual to minimize chances of interrupting a pregnancy.

  • Complications:

    • Neurogenic shock, hemorrhage due to trauma,
    • Infection, perforation of uterus, endometriosis, oil embolism, dye allergy.

Values of HSG:

1. Diagnostic for: intrauterine and tubal disorder
2. Therapeutic for:
   • Removal of mucous plug that may close the tube.
   • Removal or absorption of thin adhesions.
   • Straightening of kinked tube or relief of uterotubal spasm.

B-Laparoscopy with Dye Injection:

• By injection of methylene blue dye through the cx if passed from the fimbrial end = patent tubes.

Treatment:

• IVF

C- Cervical Factor of Infertility

Causes:

1. Congenital:
2. Traumatic
3. Inflammatory: endocervicitis, “common organisms are chlamydia and gonorrhea”.
4. Neoplastic: cervical fibroid and masses blocking or distorting the cx.
5. Immunological i.e., presence of anti-sperm antibodies.
6. Hormonal: especially decreased estrogen causing decreased mucous and rendering it thick.

Diagnosis:

• Cervical culture
• Postcoital tests: for patients with history or physical exam findings suggestive of cervical factor.
  • The validity of the test is controversial.

Treatment:

• Treat underlying cause

D- Uterine Factor of Infertility

• Uterine factors include leiomyomata, intrauterine synechiae (Asherman syndrome), septae, and other müllerian anomalies.
  • Fibroid - Adhesions

Investigation:

• Pelvic US
• Saline infusion ultrasonography (sonohysterography [SHG])
• HSG
• Hysteroscopy: Reserved for those patients with HSG or SHG results that need further evaluation.
• Laparoscopy: Septate and bicornuate uterus are similar in HSG and differentiate between them by Laparoscopy.

Treatment:

• According to Cause.
  • Surgery, adhesiolysis in Asherman’s.
  • Polypectomy OR myomectomy in fibroid.
  • Removal of septum if septate uterus.

F- Pelvic and Peritoneal Factor

• Any gross pathology in the pelvis may disturb the function/movement of tubes/ovaries like endometriosis, adhesions, or PID.

Diagnosis:

• Laparoscopy.
• Ultrasound can diagnose endometrioma / hydrosalpinx

Treatment:

• Treatment of the cause.
  • Endometriosis: remove endometrioma > 3 cm if present, lysis and excision of endometriosis if indicated.

    • mild endometriosis >> ovulation induction +/- IUI.

    • if failed or moderate/severe endometriosis >> IVF.