Infertility, female
Infertility, female: Excerpt from Handbook of Diseases
Infertility affects 10% to 15% of all couples in the United States. About 40% of all infertility is attributed to the female. (See also “Infertility, male,” page 446.) After extensive investigation and treatment, about 50% of these infertile couples achieve pregnancy. Of the 50% who don’t, 10% have no pathologic basis for infertility; the prognosis in this group becomes extremely poor if pregnancy isn’t achieved after 3 years.
Causes
The causes of female infertility may be functional, anatomic, or psychological.
Functional causes
Complex hormonal interactions determine the normal function of the female reproductive tract and require an intact hypothalamic-pituitary-ovarian axis, a system that stimulates and regulates the production of hormones necessary for normal sexual development and function.
Any defect or malfunction of this system can cause infertility due to insufficient gonadotropin secretions (luteinizing hormone [LH] and follicle-stimulating hormone). The ovary controls and is controlled by the hypothalamus through a system of negative and positive feedback mediated by estrogen production. Insufficient gonadotropin levels may result from infections, tumors, or neurologic disease of the hypothalamus or pituitary gland. Hypothyroidism also impairs fertility.
Anatomic causes
The anatomic causes of female infertility include the following:
❑ Ovarian factors related to anovulation and oligo-ovulation (infrequent ovulation) are a major cause of infertility. Presumptive signs of ovulation include regular menses, cyclic changes reflected in basal body temperature readings, postovulatory progesterone levels, and endometrial changes due to the presence of progesterone. The absence of presumptive signs suggests anovulation.
Ovarian failure, in which the ovaries produce no ova, may result from ovarian dysgenesis or premature menopause. Amenorrhea is commonly associated with ovarian failure. Oligo-ovulation may be due to a mild hormonal imbalance in gonadotropin production and regulation and may be caused by polycystic disease of the ovary or abnormalities in the adrenal or thyroid gland that adversely affect hypothalamic-pituitary functioning.
❑ Uterine abnormalities may include a congenitally absent uterus, bicornuate or double uterus, leiomyomas, or Asherman’s syndrome, in which the anterior and posterior uterine walls adhere because of scar tissue formation.
❑ Tubal and peritoneal factors are due to faulty tubal transport mechanisms and unfavorable environmental influences that affect the sperm, ova, or recently fertilized ovum. Tubal loss or impairment may occur secondary to ectopic pregnancy.
For many patients, tubal and peritoneal factors result from anatomic abnormalities: bilateral occlusion of the tubes due to salpingitis (resulting from gonorrhea, tuberculosis, chlamydia, or other organisms), peritubal adhesions (resulting from endometriosis, pelvic inflammatory disease [PID], or childhood rupture of the appendix), and uterotubal obstruction due to tubal spasm.
❑ Cervical factors may include a malfunctioning cervix that produces deficient or excessively viscous mucus impervious to sperm, preventing entry into the uterus. The cervix may also be stenotic or dilated.
Clinical tip If the patient’s cervix is dilated, make sure she isn’t pregnant.
With cervical infection, viscous mucus may contain spermicidal macrophages. Some cervical antibodies do immobilize sperm.
Psychological problems
Such problems probably account for relatively few cases of infertility. Occasionally, ovulation may stop because of stress, which results in failure of the body to release LH. Marital discord may affect the frequency of intercourse. Typically, psychological problems result from — rather than cause — infertility.
Signs and symptoms
The inability to achieve pregnancy after having regular intercourse without contraception for at least 1 year suggests infertility. For women older than age 35, this time factor is usually reduced to 6 months.
Diagnosis
Diagnosis requires a complete physical examination and health history, including specific questions on the patient’s reproductive and sexual function, past diseases, mental state, previous surgery, types of contraception used in the past, and family history. Irregular, painless menses may indicate anovulation. A history of PID may suggest fallopian tube blockage.
Clinical tip Infertility is a disorder of couples, so both partners should be evaluated.
Tests that assess ovulation
❑ Basal body temperature graph shows a sustained elevation in body temperature after ovulation until just before onset of menses, indicating the approximate time of ovulation. Oral temperatures are taken every morning before rising. This method isn’t as diagnostically useful as other methods.
❑ Endometrial biopsy, done on or about day 5 after the basal body temperature rises, provides histologic evidence that ovulation has occurred.
❑ Progesterone blood levels, measured when they should be highest, can show a luteal phase deficiency. Over-the-counter ovulation predictor kits are less expensive and quite accurate.
Procedures that assess structural integrity
❑ Hysterosalpingography provides radiologic evidence of tubal obstruction and abnormalities of the uterine cavity by injecting radiopaque contrast fluid through the cervix.
❑ Endoscopy confirms the results of hysterosalpingography and visualizes the endometrial cavity by hysteroscopy or explores the posterior surface of the uterus, fallopian tubes, and ovaries by culdoscopy. Laparoscopy allows visualization of the abdominal and pelvic areas.
Male-female interaction studies
❑ Postcoital test (Sims-Huhner test) examines the cervical mucus for motile sperm cells after intercourse that takes place at midcycle (as close to ovulation as possible).
❑ Immunologic or antibody testing detects spermicidal antibodies in the sera of the female. Further research is being conducted in this area.
Treatment
Effective treatment depends on identifying the underlying abnormality.
Functional infertility
With hyperactivity or hypoactivity of the adrenal or thyroid gland, hormone therapy is necessary; a progesterone deficiency requires progesterone replacement. Anovulation necessitates treatment with clomiphene, human menopausal gonadotropins, or human chorionic gonadotropin; ovulation usually occurs several days after such treatment.
If mucus production decreases (an adverse effect of clomiphene), small doses of estrogen may be given to improve the quality of cervical mucus.
Anatomic infertility
Surgical restoration may correct certain anatomic causes of infertility such as fallopian tube obstruction. Surgery may also be necessary to remove tumors located in or near the hypothalamus or pituitary gland. Endometriosis requires drug therapy (danazol or medroxyprogesterone, or noncyclic administration of hormonal contraceptives), surgical removal of areas of endometriosis, or both.
Other options, typically controversial and involving emotional and financial cost, include surrogate mothering, frozen embryos, zygote intrafallopian transfer, in vitro fertilization, and artificial insemination.
Special considerations
❑ Management includes providing the infertile couple with emotional support and information about diagnostic and treatment techniques.
❑ Encourage the patient and her partner to talk about their feelings, and listen to what they have to say with a nonjudgmental attitude.
❑ If the patient requires surgery, tell her what to expect postoperatively; this depends on which procedure is to be performed.
❑ Encourage the couple to contact their health insurance company to determine what type of infertility treatments are covered.
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
More About Female conditions
More Medical Textbooks Online about Female conditions
Review other book chapters online related to Female conditions:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
|
|
More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
|
|
» Next page: Recognize the female athlete triad (Avoiding Common Pediatric Errors)
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
