Female Infertility

Infertility means you cannot get pregnant (conceive).
Primary infertility refers to couples who have not become pregnant after at least 1 year of having sex without using birth control methods.
Female infertility contributes to about 50% of causes of infertility.
Being infertile is often a social stigma and is associated with a lot of social pressure and psychological issues.
Infertility in women mainly occurs because of the inability to produce enough healthy eggs for fertilization.
Age, physical problems, hormonal changes, or environmental changes can also contribute to female infertility.

Ovulatory Disorders

It affects 25% of the female infertile population. In this the women don’t spontaneously ovulate.

This is more common in women suffering from polycystic ovarian syndrome (PCOS).

Endometriosis

It affects 25% of the female infertile population. In this the women don’t spontaneously ovulate.

This is more common in women suffering from polycystic ovarian syndrome (PCOS).

Pelvic Adhesion

Pelvic adhesions distort the normal anatomy and hence affect fertility.

They can be secondary to pelvic infections.

Tubal blockage or damage

For natural pregnancy, patent and functional tubes are a must, as fertilization of the egg and sperm takes place in the tubes.
Any reason leading to blockage in the tube affects fertilization.
Pelvic surgery, pelvic infections, and endometriosis can cause scarring and damage to these tubes and stop sperms from entering the fallopian tubes.
In India, Tuberculosis is the leading cause of tubal damage.

Hyperprolactinemia

Poor ovarian reserve:

As the age advances, the number and quality of eggs go on declining. Poor ovarian reserve is one of the leading causes of infertility, especially in older women.

Cervical issues:

Certain cervical issues, like infection, etc., cause thickening of the cervical mucus. This doesn’t allow the sperms to enter and fertilize the eggs, which are important for the woman to get pregnant.

Uterine problems:

Uterine polyps and fibroids can also interfere in the fertilization and implantation process.
Polyps occur when there is too much growth in the lining of the uterus, while fibroids grow in the wall of the uterus.
These cause difficulties when sperms try to enter and fertilize the eggs and also when embryos try to implant in the uterus.

Mullerian Anomalies

Bicornuate uterus, Septate uterus, T shaped uterus etc are congenital anomalies which may contribute to infertility.

Of these,uterine septum is a congenital abnormality where the uterine cavity is divided in two halves by a remnant septum. This usually leads to difficulty in implantation or repeated abortions.

Asherman’s syndrome

Here the lining of the uterus fails to grow due to adhesions in the endometrial cavity. These adhesions are usually due to previous curettages or infections and need surgical correction.

Unexplained

Detailed menstrual, medical, surgical, and sexual history is taken.
The female partner has to undergo a few tests if they fail to get pregnant even after a year of unprotected sexual intercourse.

A) Pelvic Ultrasound:

Ultrasonography, mainly transvaginal, can help in detecting the cause behind infertility in some cases.
The uterus is assessed for size, endometrial lining, blood flow, and any other abnormalities like abnormal uterine shapes (septate uterus, bicornuate uterus), fibroid uterus, endometrial polyp, calcifications, adhesions, or Asherman syndrome.
Ovaries are assessed for the volume and follicle count, which gives an estimate of the ovarian reserve or detects any other abnormalities like polycystic ovaries, ovarian cysts (endometrioma, dermoid cyst, simple cyst, corpus luteal cyst, etc.), poor ovarian reserve, and ovaries stuck to the uterus as in PID.
Abnormal tubal pathology like hydrosalpinx (fluid-filled in the tube), pyosalpinx (pus-filled in the tube), and ectopic pregnancy can also be diagnosed with TVS.

B) Follicular Monitoring

Follicular study is done in a fertility clinic. It is better done transvaginally than transabdominally. It can be done in a natural as well as a stimulated cycle.
It is ideally started from Day 2 when the woman is menstruating to assess the AFC (Antral Follicle Count).
Then it is repeated on Day 8/9 and then every alternate day to monitor the growth of the follicle (egg in the ovary) and its rupture (ovulation) and also the endometrial lining in response to the follicle.

C) Ovarian reserve tests

One of the important tests to assess ovarian reserve is serum AMH, i.e., Anti-Müllerian hormone, and AFC.

What is AMH?

- AMH, which is an anti-Müllerian hormone, is a hormone measured by a blood test.
- It is secreted by granulosa cells of the preantral and antral follicles of the ovary.
- A woman is born with a fixed number of eggs for her lifetime, which only reduces with age. AMH gives an estimate of ovarian reserve (that is, the number of eggs remaining), which determines fertility.
- Hence it is important to complete the family in time before the reproductive potential of women diminishes.
- It is a blood test that can be performed on any day of the menstrual cycle.
- They decrease with increasing age of the women.
- If AMH count is good, it indicates good fertility status.

Optimal fertility	>4ng/ml
Satisfactory fertility	2.2-4ng/ml
Low fertility	0.3-2.2ng/ml
Very low/ Undetectable	<0.3ng/ml

It is important to remember that AMH levels decline and FSH levels increase as women age. In other words, normal AMH and FSH levels change depending on a woman’s age. Because of this, focusing on age-specific AMH and FSH levels allows us to best assess a woman’s ovarian reserve, devise an appropriate treatment plan, and estimate her IVF pregnancy chances.

Age	AMH level (ng/ml)
25	5.4
30	3.5
35	2.3
40	1.3
>43	0.07

What is AFC?

AFC is antral follicle count. It is assessed by transvaginal ultrasonography on the second or third day of your periods.
It gives an estimate of the follicles that can be recruited in that menstrual cycle. Normal AFC should be 3-8 follicles less than 10 mm in each ovary.
Total AFC less than 5 indicates poor ovarian reserve.
AFC of 5-15 indicates a normal reserve.
AFC of more than 15 indicates polycystic ovaries.

D) Hormonal profile

The menstrual cycle and the ovulation are regulated by hormones. Blood tests may be done to detect any hormonal imbalance.
These usually include S.FSH, S.LH, S.E2, S.P4

Tubal testing: For natural conception, tubal patency is very important.
The egg and the sperm meet in the tube for fertilization.
It may need evaluation with sonosalpingography, hysterosalpingography, or hysterolaparoscopy.

E) Tubal Patency Tests

SONOSALPHINGOGRAPHY

In sonosalpingography, tubal patency is assessed through ultrasonography.
Sonosalpingography (SSG) is a diagnostic procedure used to test tubal patency.
Firstly, Foley’s catheter is placed in the uterine cavity.
Then 10-20 ml of normal saline is injected, and the flow of saline is visualized on ultrasonography.
Patency is confirmed by observing a shower at the fimbrial end.

HYSTEROSALPINGOGRAPHY (HSG)

In Hysterosalpingography, tubal patency is assessed through X-ray or C-ARM.
Hysterosalpingography is also known as uterosalpingography. It is a radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the fallopian tubes. This means it is a special x-ray in which dye is inserted to look at the shape of the womb and fallopian tubes.
The doctor injects dye through the cervix, which travels through the fallopian tubes & helps to check if the fallopian tubes are blocked.
At the same time, X-Ray films are taken.

HYSTEROLAPAROSCOPY (HSL)

In Hysterolaparoscopy, tubal patency is assessed through laparoscopy. It is the gold standard for evaluation. It helps in assessing as well as correcting the blocked tubes at the same time.
It consists of laparoscopy, hysteroscopy, and chromopertubation to assess tubal patency.

In Laparoscopy

The doctor puts in the laparoscope, which is a slender tube fitted with a tiny camera, through a small incision made near the belly button. This allows the doctor to see the outside of the ovaries, uterus, and the fallopian tubes and detect any kind of defects in them.

In Hysteroscopy

The doctor puts in the hysteroscope, which is a slender tube fitted with a tiny camera, through the cervix. This allows the doctor to see the inside of the uterus and cornua (opening of the fallopian tubes) and detect any kind of defects in them.

In Chromopertubation

Methylene blue-stained saline is inserted through the cervix, and free flow is observed with a laparoscope. A tubal blockage, if identified, can be corrected in the same sitting.

A) Planned Relation

Natural cycle follicular monitoring followed by planned relationships.
With ultrasonography, the growth of the follicle and endometrial response is monitored, and ovulation is confirmed.
Couple is asked to have a relationship around the ovulatory period.

B) Ovulation Induction

Certain tablets may be given to form a good single follicle, and its growth monitored on USG.
Couples will be asked to have relationships around the ovulatory period.

C) Ovarian Hyperstimulation

Certain tablets and injections may be given to form more than one follicle, and their growth monitored with USG.
When follicles would be optimally formed, injection is given to induce ovulation.
Couples will be asked to have a relationship around the ovulation period, or IUI may be done.

D) Intrauterine Insemination (IUI)

Intrauterine insemination (IUI), also known as artificial insemination, is a process in which the washed/processed semen is placed into the uterine cavity with the help of a catheter in and around the time of ovulation (release of egg from the ovary).
It is usually accompanied with ovulation induction or hyperstimulation.

E) ART (Artificial Reproductive Technology)

In couples who can’t conceive naturally due to blocked or damaged tubes, poor ovarian reserve, low sperm count, or motility, one can conceive through test tube baby treatment.
In this way, using a woman’s egg and husband’s sperm, the embryo is formed in the specialized laboratory and then transferred back to the uterus at an appropriate time.
ART involves IVF, ICSI, a donation program, and a freezing program

IVF stands for in-vitro fertilization. It is the process of fertilizing the eggs and sperms in a laboratory and inserting these fertilized eggs (that is, embryos) into the uterus of the female partner.

ICSI or Intracytoplasmic sperm injection, is a technique where a single sperm is injected directly into the center of the egg.

F) Fertility-Enhancing Surgeries

1) Diagnostic Hysterolaparoscopy

Laparoscopy involves visualization of the uterus, tubes, and ovaries through a laparoscope inserted through the abdomen through a small incision.
Any abnormality or pathology can be detected and corrected accordingly.
It also involves visualization of the uterus from within with the help of a hysteroscope.
Tubal anatomy and functionality can be tested with the help of methylene blue-stained saline, in which it is inserted into the uterus, and tubal patency is confirmed by visualizing its flow through the fimbrial end through the laparoscope.

2) Fibroid surgery

Fibroids are abnormal growths that develop in or on the uterus.
Depending on the location, it can give rise to symptoms like pain, heavy bleeding, etc., or it may be asymptomatic.
Depending on the size and location, it can hinder fertility and implantation and may need surgery.
Surgery can be performed laparoscopically or through a hysteroscope depending on the location.

3) Endometriosis Surgery

Endometriosis involves the presence of endometrial tissue growing outside the uterus, most commonly the ovaries and the peritoneum, leading to adhesion, distortion in anatomy, and infertility. It usually causes painful periods and painful intercourse.
It also depletes the egg count and affects its quality. Surgery in the form of drainage of a chocolate cyst, correction of anatomy, and fulguration of endometriosis may be required.
It is usually done laparoscopically.

4) Polyp Removal

Endometrial polyp is due to overgrowth of the endometrium.
It can cause heavy and irregular bleeding or can be asymptomatic.
It affects the implantation of embryos.
It can be resolved with medical treatment.
If not resolved, it needs to be removed hysteroscopically.

5) Uterine Septum Removal

A uterine septum is a congenital anomaly in which the uterine cavity is divided into two halves by a septum.
If associated with infertility, it needs hysteroscopic correction.
The septum that divides the uterine cavity is excised with scissors under hysteroscopic guidance.

6) Tubal Reconstruction

If the women have undergone tubal ligation to achieve pregnancy naturally, tubal reconstruction needs to be done.

Infinity fertility centre is considered as the best female infertility center in manpada, Thane. We have the best infertility specialist in thane, who is the best in the field of infertility and she has many years of experience in treating all types of infertility problems. The female infertility problems can be overcome by using IUI, IVF, ICSI, Laparoscopy, Iysteroscopy, and other fertility treatments for women.

Customization is the key to success.