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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.
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Ovarian
Failure
|
|
Diagnosis
|
Treatment
|
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. |
| Treatment |
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.
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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. |
| Treatment |
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.
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Mechanical
Obstruction
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Diagnosis
|
Treatment
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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. |
| Treatment |
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.
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| 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.
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Problems
With The Cervix And Uterus
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Diagnosis
|
Treatment
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Hostile
Cervical
Mucus |
Explanation |
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. |
| Treatment |
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.
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Incompetent
Cervix |
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. |
| Symptoms |
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. |
IUD's
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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