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Treatment Of Infertility In Women

The medical infertility workup is usually able to diagnose the cause of a fertility problem in a woman. Identifying the problem is the first step in recommending treatment. The most common causes for female infertility are ovulatory failure, mechanical obstructions, endometriosis, cervical problems and uterine problems. These are described in the sections and tables below.

About 10 % of the time, the cause for the infertility cannot be found. Couple who face this challenge may be candidates for Assisted Reproductive Technology, while others turn to adoption or decide to live child-free.

Ovarian Failure
Between 20 - 30 % of female infertility can be blamed on ovulatory problems. Ovulation is regulated by hormone activity. Thus, several hormonal problems can prevent ovulation, fertilization or implantation of the egg. Below is a description of the most common hormone irregularities in women which cause reproductive difficulty.

Ovarian Failure
History of
Birth Control Pill Use
Explanation Birth control pills prevent pregnancy by interfering with hormonal regulation of ovulation. Going off the pill doesn't necessarily mean that a woman's cycles will return to normal immediately. In fact, up to 10 - 15 % of women experience initial trouble resuming ovulation. And about 5 % of former birth control pill users need fertility drugs to promote ovulation.
Symptoms Irregular menstrual periods after the pill is stopped.
Treatment Fertility drugs may be used to induce ovulation.
Polycystic Ovarian Syndrome (PCOS) Explanation

This syndrome is caused by hormonal imbalances. Excessively high androgen hormone levels disrupt egg maturation within the ovaries. As a result, cysts form on the ovary's surface, and ovulation does not occur. The menstrual cycle may not occur, and if the uterine lining isn't released by menstruation, abnormal uterine growths may form.

PCOS is associated with glucose intolerance and insulin resistance which can lead to elevated blood sugar levels. Insulin resistance usually leads to higher levels of circulating insulin, which in turn can cause hormonal imbalances that decrease ovulation.

Symptoms Irregular menstrual periods, elevated male hormone levels in the blood which can cause excessive facial and body hair, obesity, acne, cystic or enlarged ovaries.

Laser surgery may be used to destroy the cysts. This sometimes restores hormonal balance. Fertility drugs may be used to induce ovulation.

If glucose intolerance is diagnosed, treating elevated blood sugar levels may improve fertility. Modest weight loss in women who are overweight proves beneficial in improving insulin sensitivity and glucose tolerance. Medication used to improve blood sugar control include Metformin (glucophage), or insulin sensitizers such as Pioglitazone, Rosiglitazone, or Troglitazone.

Elevated Prolactin
Hormone Levels
Explanation Prolactin is the hormone that prepares a woman's breasts for lactation (breastfeeding). High prolactin levels can prevent ovulation. Causes for increased prolactin include; some prescription drugs (certain types of: blood pressure medications, antidepressants, and painkillers), hallucinogenic drugs, and alcohol use. Benign pituitary tumors and hypothyroidism are also causes.
Symptoms Some women with high prolactin levels have milk in their breast that can be expressed by squeezing the nipples. Other symptoms include; irregular ovulation, lack of menstrual periods, and dry vagina.
Treatment CAT (computerized axial tomography) scans can determine if a benign pituitary tumor is the cause. A drug called bromocriptine can shrink the tumor. Hypothyroidism, if the cause, can be treated with thyroid medication. If a prescription drug is likely to be causing the problem, the physician can change medications.
Absence of GnRH Explanation GnRh (gonadotropin-releasing hormone) comes from the hypothalamus and directs the other hormones (FSH, LH) responsible for ovulation. Stress (and other unknown causes) may prevent the hypothalamus from releasing GnRH, then ovulation won't occur.
Symptoms Lack of ovulation. Low blood levels of GnRH.
Treatment GnRH replacement
Premature Ovarian Failure Explanation This condition occurs when a woman's ovaries stop working long before normal menopause. This may occur because the immature eggs have been destroyed for some reason.
Symptoms Inability to get pregnant
Treatment Treatment is limited to Assisted Reproductive Technology (ART) using a donor egg, which is fertilized in the laboratory, and implanted into the uterus of the woman who cannot conceive naturally.
Luteal Phase Defect Explanation Progesterone levels are too low to stimulate the proper uterine lining (endometrium) development. Therefore, a fertilized egg cannot implant and develop. Luteal phase defects are often easy to correct.
Symptoms Possibly shorter than normal menstrual cycles. Abnormally low hormone levels of LH, FSH, estrogen, or progesterone will diagnose the cause of the defect.

Hormone replacement with/without fertility drug treatment.

Cervical Mucus Problems Explanation Cervical mucus is suppose to become thinner, clearer, more alkaline, and easier for the sperm to swim through when a woman is ovulating. Estrogen is the hormone responsible for transforming the cervical mucus. Some women don't produce mucus that is hospitable to the sperm and the sperm are more likely to die than to reach the egg.
Symptoms Scant, thick, sticky cervical mucus even during ovulation.
Treatment Estrogen therapy to stimulate production of mucus that aids the sperm in reaching the egg. ART is another option. Sperm are collected and injected directly into the uterus (intrauterine insemination), bypassing the vagina and the cervix.

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Mechanical Obstruction
Mechanical obstructions account for up to 25 - 40 % of female infertility problems. Adhesions, scar tissue and blockages that affect the fallopian tubes and uterine cavity can prevent fertilization and implantation.

Mechanical Obstruction
Pelvic Inflammatory
Disease (PID)
Explanation Infections that invade the pelvic cavity are usually transmitted through sexual contact. Untreated infections often lead to infertility problems. Common venereal diseases include gonorrhea, chlamydia, streptococcus, and enterococcus. The bacteria can cause damage to the reproductive tract, particularly the fallopian tubes, including scarring and adhesions (scar tissue that binds two surfaces together). Tuberculosis and severe appendicitis are other diseases that can damage and scar the reproductive tract. About 1 % of women who use IUD's for contraception get infections that lead to pelvic inflammatory disease.
Symptoms Fever, abdominal pain, bloody spotting, and/or vaginal discharge may indicate an infection. Sometimes symptoms are mild and go unnoticed, or the symptoms resolve and go untreated. Unfortunately many venereal diseases have no symptoms at all.

The best treatment is prevention. The more sexual partners a person has, the more likely that person is to contract a venereal disease. Condoms provide a protective barrier which minimizes risk. Seek medical attention for diagnostic tests and evaluation if you have any symptoms, concerns or fear that you have been exposed. Most bacterial infections can be treated with antibiotics.

Scarring and damage can be seen with dye studies, a hysteroscope (to view the inside of the reproductive organs) and a laparoscope (to view the outside of the reproductive organs). Repairing damage involves microsurgery or laser surgery to remove scar tissue and reconstruct damaged areas.

Endometriosis Explanation Endometrial tissue is the tissue that lines the uterus and creates a plush environment for a fertilized egg to implant into. Endometriosis is a disease where the endometrial cells that are suppose to stay in the uterus, somehow find their way to the outside of the uterus and proceeds to grow on the ovaries, tubes, the bowel, or in the abdominal cavity. Monthly hormone cycles that regulate normal menstruation also cause this displaced tissue to grow, bleed and form cysts throughout the abdominal cavity. The result is scarring of the reproductive organs that can cause infertility and miscarriage.
Symptoms Severe cramping around the menstrual cycle, heavy menstrual bleeding, painful intercourse, pain with bowel movements or urination. However, some women have no symptoms at all.
Treatment Drug therapy can shrink the abnormal growths. Surgery can be performed to remove the abnormal endometrial tissue and growths.

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Cervix and the Uterus
Other conditions can cause fertility problems with the cervix, fallopian tubes and the uterus. Up to 10-15 % of female infertility is a result of cervical problems, and a small percentage of infertility is due to uterine defects.

Problems With The Cervix And Uterus
Hostile Cervical

Cervical mucus must be of the right consistency and pH to welcome sperm and help the sperm travel from the vagina into the uterus. If the mucus becomes too acidic it will kill the sperm. Cervical mucus can become hostile to the sperm as a result of infections, trauma or antibodies.

Infections: Bacteria or viruses can invade the cervix and the infected cervical mucus becomes a barrier to the sperm's travel.

Trauma: Past procedures or surgeries to the cervix can scar the mucus producing glands of the cervix.

Antibodies: Antibodies are our body's natural defense to invaders. Antibodies cling to invaders and immobilize the invaders. For unknown reasons, some women create antibodies that attack sperm.

Symptoms Infections may produce symptoms of fever, pain, or discharge. Some infections don't produce any symptoms at all. If trauma or antibodies are to blame for the cervical mucus, there probably won't be any symptoms and diagnosis will require specific tests.

Many infections are treatable with drugs/antibiotics. Cough syrups that contain glyceryl guaiacolate can improve secretion of cervical mucus, in some cases, where trauma has decreased the production of cervical mucus.

In the case of antibodies, or when other treatments don't resolve cervical mucus problems, sperm can be collected, and then with medical assistance, the sperm can be injected into the uterus through a process called insemination.

Explanation Once a pregnancy is achieved, it is the job of the cervix to hold the uterus closed and keep the developing baby safely inside the womb. An incompetent cervix is too weak to support the growing baby, and the result can be miscarriage or premature labor and delivery.
Symptoms A cervix that thins and dilates too early. Diagnosis often isn't made until a woman has had more than one miscarriage.
Treatment An incompetent cervix can be sutured (stitched closed) in a procedure called a cerclage, to provide additional strength and support. Bedrest is often indicated to reduce pressure on the cervix. Once the cervix has been sutured, delivery of the baby may be done by cesarean section.
Fibroid Tumors Explanation Non-cancerous tumors develop within the walls of the uterus. These common growths can interfere with implantation of a fertilized egg and cause spontaneous abortions.
Symptoms Usually none. Large tumors can cause pain and frequent menstrual bleeding.
Treatment Microsurgery and laser surgery are used to remove tumors. Severe cases may require hysterectomy. (Removal of the uterus).
Developmental Defects
Of The Uterus
Explanation Rarely a female baby is born without a uterus. Other developmental defects include a heart-shaped uterus that has a septum that partially divides the uterus into two compartments. If the compartment is too small to expand during a full term pregnancy, then the pregnancy can end in a miscarriage.
Symptoms No obvious symptoms for uterine deformities. Problems would be discovered during the infertility work up. If a uterus is missing completely, there would be no menstrual cycle.
Treatment Surgery to repair certain structural abnormalities can be done using a hysteroscope. Other defects require major surgery.
DES Exposure (diethylstilbestrol) Explanation From 1941-1972 DES was prescribed to pregnant women to prevent miscarriage. DES exposure proved to be detrimental to the unborn child. DES offspring may have infertility problems related to abnormalities of the vagina, cervix, tubes or uterus. DES daughters still have a good chance at becoming pregnant, but have an increased risk of tubal pregnancy, and because of weaker cervical muscles, they have an increased risk of preterm labor due to a weak cervix.

The symptoms will vary according to the abnormality in the reproductive system. Tubal pregnancy is a serious and painful condition that requires immediate medical attention. When the fertilized egg implants and starts to grow in the fallopian tube, there is risk of rupturing the tube.

Preterm labor (PTL) symptoms should be immediately reported to the health care provider.

Treatment DES daughters may need assistance in becoming pregnant, and once achieving pregnancy, they need to be monitored closely. Women are trained to spot the signs and symptoms of PTL.
Intrauterine Devices
Explanation The Dalkon Shield was a specific brand of IUD that impaired fertility in many women. Some professionals believe other brands of IUD's may also cause fertility problems. Besides the risk of infection, there is a small risk of the IUD puncturing the uterine wall, resulting in scarring and infertility.
Symptoms Symptoms of infection such as pain and fever may occur. But problems may go unnoticed.
Treatment Options depend on the type of problem imposed by the IUD use. Infections are usually treatable. Scar tissue may require surgical removal.

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