The Causes of Female infertility
There are various causes of female infertility, which include the ovulation problems and polycystic ovary syndrome (PCOS), poor egg quality, anatomical problems, endometriosis, genetic cause, or unexplained condition.
1. Ovulation problem and PCOS
Ovulatory dysfunction can be caused by many factors. The most common cause is polycystic ovary syndrome (PCOS). The other potential causes of the ovulation problem are obesity, too low body weight, extreme exercise, hyperprolactinemia, premature ovarian failure, advanced maternal age, thyroid dysfunction, stress, etc. Women with anovulation cannot get pregnant because there is no egg grows and to be fertilized. If women have irregular ovulation, they will have lower chance to conceive because the ovulation occurs less frequently, and also the quality of the egg may not quite good.
2. Poor egg quality
Advanced age is the most important factor that related to the egg quality. Chromosomal abnormalities in eggs increase significantly with age, which in turn, determining the chromosomal status of the embryos. Even they have regular monthly menstrual cycle, but the poor quality egg may not able to be fertilized, or if fertilization occurs, embryo may not properly develop to blastocyst stage. Even implantation can occur, the embryo that not healthy enough may result in a miscarriage.
3. Anatomical problems
The most common anatomical problem that leads to infertility is tubal blockage, which can be the consequences of inflammation in the pelvic organ, adhesion from previous surgery or endometriosis, thus fertilization cannot be occurred. Other common causes are scar, polyps, or myomas in the uterine cavity that interfere or disturb the implantation process.
During menstruation, the endometrial tissue that lines the inside of the uterus, migrate through the fallopian tubes and attaches to other organs in the abdominal cavity, such as the ovaries and fallopian tubes. Scarring or adhesions are formed in the pelvis, ovaries, and fallopian tubes, resulting in the tube blockage, and restricting the tube movement. Implantation process in endometriosis is also impaired because the imbalances of the hormones and prostaglandin productions.
5. Genetic causes
Abnormality of X chromosome and some gene mutation can lead to infertility. In women with Turner syndrome (45,X), the follicles in their ovaries are atretic, so there is no egg grows. Women with triple X syndrome (47,XXX) are fertile but reach the menopause prematurely, and they can transmit the extra chromosome to the offsprings.
6. Unexplained condition
In case that the cause of infertility cannot be identified after standard investigation of both female and male partner, unexplained Infertility is what remains. It doesn’t mean that there is no reason for the infertility, but that the reason is not found at that time. Recent research indicates that pregnancy rates with infertility treatment are equal to or higher than pregnancy rates of couples with other infertility diagnoses.
Investigation for female infertility
After consultation with the fertility specialist, history taking and physical examination will be done : 1. History taking and physical examination
The doctor will take patient’s history, menstrual history, lifestyle issues (smoking, drug and alcohol use, and caffeine consumption), any medications being taken, and a profile of the patient’s general medical and emotional health. The relevant physical examination will be performed.
2. Ovulation test
Various methods are used to test the ovulation :
- Monitor basal body temperature : This is accurate in determining if ovulation is actually taking place.
- Cervical mucus consistency : By collecting some mucus between two fingers and stretch it apart. If you are near the time of ovulation, the mucus will stretch more than 1 inch before it breaks. As an alternative, at-home kits can test saliva as substitute for checking cervical mucus.
- Use an over-the-counter urine test to detect luteinizing hormone (LH) surges. This helps determine the day of ovulation. However, these at-home tests may not be as accurate as blood LH level.
3. Laboratory tests
Ovarian Reserve Test Ovarian reserve can be estimated by female’s age, ultrasonography for antral follicle count, and hormone assays, which are AMH and FSH.
- Anti-Mullerian Hormone : AMH
What is AMH?
- AMH is a hormone secreted by cells in the follicles. The level of AMH in the blood is a good indicator of women’s ovarian reserve and potential response to the IVF drugs. But AMH cannot indicate the quality of the eggs.
- If the AMH levels are within the normal range, your ovaries may response well to the stimulation medications. Too low or too high levels of AMH are not so good.
- Normal range of AMH levels :
– Very low fertility 0.0 – 0.3 ng/ml – Reduced fertility 0.3 – 0.7 ng/ml – Satisfactory fertility 0.7 – 3.5 ng/ml – High fertility > 3.5 ng/ml
How can I get the AMH test?
- AMH level can be checked anytime, because there is no significant variation within a menstrual cycle and not affected by using hormonal medication.
- SAFE Fertility Center has a service to check the AMH level. For more information, please contact email : email@example.com
What can I do if I have too low or too high AMH?
- Low AMH level indicates the poor egg reserve. If your AMH is low, you should consult a fertility specialist for further explanation. You can book the appointment with our fertility specialist at SAFE Fertility Center.
- High AMH level indicates that many eggs in the ovaries will be responded to the stimulation medications. Women with high AMH level have a better chance of giving birth after IVF treatment. However, AMH levels are not associated with the egg’s quality. And women with high AMH levels have a higher risk of ovarian hyperstimulation syndrome (OHSS) Please see details in patient information (link to patient information: complication from IVF treatment: OHSS). at SAFE Fertility Center, we are OHSS-free clinic. We use the stimulation protocol that prevent the moderate to severe OHSS. For more information, please contact email : firstname.lastname@example.org
Follicle Stimulating Hormone (FSH), Estradiol (E2)
What is FSH and Estradiol?
- FSH is a hormone produced by the pituitary gland in the brain that controls the recruitment, selection, and growth of follicles in the ovaries. If the quantity of the remaining follicles in the ovaries decreases, the pituitary gland will release more FSH to stimulate the ovaries in order to produce more eggs. So when FSH level is high, it is indicated the low number of remaining follicles.
- Estradiol (E2) is a hormone produced by the cells in the follicles, which respond to the stimulation of the FSH.
- FSH should be interpreted with E2 result.
- Low FSH in good ovarian reserve or high FSH in poor ovarian reserve may reduce the pregnancy and live birth rates after IVF treatment.
How can I get the FSH and Estradiol test?
In general, FSH and E2 for ovarian reserve test are done on day 2 or 3 of the period. More information about ovarian reserve test, please contact: email (Link to contact email).
What can I do if I have high FSH level?
- Elevated FSH level on day 2 or 3 of period indicates the poor ovarian reserve. You may re-test again in the next 1 or 2 months because FSH level varies between the menstrual cycles. Persistent elevated FSH level is used as a guide for fertility treatment and to consider the alternative treatment, such as oocyte donation.
- For more information about high FSH level or poor ovarian reserve, you can book the appointment (link to make the appointment page) with our fertility specialist at SAFE Fertility Center for discussion and treatment plan.
FSH and AMH: which one is better?
For ovarian reserve test, AMH is better than FSH :
- FSH, the pituitary hormone, is an indirect measure of the ovarian activity. AMH is a direct measure of ovarian function.
- FSH is considerable variability from cycle to cycle. AMH is less variability between cycles.
- FSH is considerable variability within the cycle, so the test should be done during 2nd to 5th of the cycle. AMH has no significant variability within the cycle.
- FSH level is affected by using exogenous hormone, so the test cannot be interpreted if you use any hormone medication. AMH is not significantly affected by hormone use.
- FSH level rises when the quantity of the eggs is very low, or in late reproductive life. AMH slowly declines throughout reproductive life as the number of eggs drop, so it can be tested anytime.
- For more information about ovarian reserve test, please contact email : email@example.com
What is prolactin and how can I get the prolactin test? 1. Prolactin is a hormone produced by pituitary gland and has a role in reproduction and lactation. Normal prolactin level is 2 – 29 ng/ml or 80 – 440 mIU/ml. 2. There are various causes of elevated prolactin:
- Physiological change : Exercise, stress, breast stimulation, etc.
- Medication : antidepressants, antipsychotics, estrogen, anti-androgen, some antihypertensive drugs, etc.
- Medical illness : pituitary tumor, hypothyroidism, PCOS, chronic renal failure, etc.
3. SAFE Fertility Center has a service to check the AMH level. For more information, please contact email : firstname.lastname@example.org
Why does prolactin affect fertility?
- Elevated prolactin inhibits the growth and development of the eggs, and results in anovulation. After ovulation, progesterone production from the corpus luteum is not enough to support the pregnancy, which is known as luteal phase defect. Deficiency of progesterone produced after ovulation may result in the unsuitable endometrium for implantation.
- Hyperprolactinemia interferes the response of the uterine lining to estrogen, so it has negative effect to the implantation process. It is also found to be associated with recurrent pregnancy loss.
What can I do if I have high prolactin level?
- If you have high prolactin level, in case of mild elevated prolactin level, you should re-test the prolactin level. Investigation for persistent elevated or moderate to high prolactin level should be done. Treatment will be considered according to the cause.
- For fertility consultation, you can discuss with fertility specialists at SAFE Fertility Center
Thyroid Stimulating Hormone (TSH)
What is TSH and thyroid dysfunction?
- TSH is a hormone produced from pituitary gland that regulates the function of thyroid gland. The normal range is 0.4 – 4.4 mIU/ml.
- Thyroid dysfunction means that thyroid gland produces too much thyroid hormone, which is known as hyperthyroidism, or too less thyroid hormone, which is known as hypothyroidism. Most common cause of thyroid dysfunction is autoimmunity.
Why does thyroid dysfunction affect fertility?
- Thyroid dysfunction can cause the ovulation dysfunction, and menstrual irregularity to amenorrhea. Thyroid hormone synergize with FSH and LH to stimulate the estrogen and progesterone production from follicular cells. Hypothyroidism can cause the low production of both E2 and progesterone, which may have negative impact to the endometrial development and implantation process.
- Hypothyroidism is also found to be associated with recurrent miscarriage. After treatment to normalize the thyroid hormone level, the miscarriage rate is reduced.
- Women with high TSH level are increased risk of IVF failure because they have a higher chance that oocytes fail to be fertilized. What can I do if I have abnormal TSH?
- If you have abnormal TSH level, you should consult the doctor for fully investigation of thyroid function and treatment.
- TSH level should be normalized before IVF treatment. For fertility issue, please consult fertility specialists (Link to inquiry or email).
Autoimmune disease is the condition in which the immune response of the body attacks and damages the normal substances or tissues. More than 80 types of autoimmune diseases and some of them can contribute toward fertility or pregnancy loss. Certain autoimmune diseases are associated with infertility including diabetes and lupus, which have been associated with both difficulty conceiving and recurrent pregnancy loss. Ovarian autoimmune disease is associated with premature ovarian failure. Antiphospholipid antibody syndrome (APAS) is another cause of fertility problem. Women with APAS is not difficult to get conceive, but they will have recurrent miscarriage because the blood is more likely to clot, especially in the placenta. So the pregnancy ends up with recurrent miscarriage, fetal growth restriction, preterm births, and/or preeclampsia.
How can I get the diagnosis of autoimmune diseases or APAS?
- There are various kinds of autoimmune diseases, and each of them is unique. However, if you have some suspicious symptoms, such as fatigue, dizziness, and low-grade fever, you can consult the doctor for proper investigation.
- Antiphospholipid antibodies are recommended to test in women with history of thrombosis or obstetric complication. The following blood tests will be done: – Lupus anticoagulants – anticardiolipin antibody – β2-glycoprotein1 antibody If you have positive results, you should re-test again at least 6-8 weeks apart. Once you have been diagnosed with APAS, you have to use medicines to prevent blood clots during IVF program and throughout pregnancy course. For more information about autoimmune diseases and APAS, please contact: email (Link to email or inquiry page).
- Karyotype analysis Karyotyping is a highly useful test in infertile couples. Karyotype analysis determines the number of chromosomes in the cells and whether there are any pieces of chromosomal material that are missing, extra or rearranged. The most common genetic cause of female infertility are quantitative, structural chromosome aberrations, and Fragile X syndrome. Knowledge of chromosomal abnormalities can prevent the use of treatments with a high chance of failure and lead us to strategies, such as PGD, more likely to produce a healthy baby.
4. Imaging and diagnostic procedures
- Ultrasonography An ultrasound scan provides the detailed information of the uterus, fallopian tubes, and both ovaries. Doctor can assess: Thickness of endometrial lining : in general, 8 – 13 mm thickness during mid cycle is good. Too thin endometrial lining indicates the adhesion inside the endometrial cavity; too thick endometrial lining might possibly reduce chance of successful pregnancy. Intrauterine polyp is a common cause of thick endometrium. Uterine myoma (fibroid), which distorts the endometrial cavity, decreases the fertility by 70%, and may cause miscarriage. It may change the environment of the uterus in the way that can interfere with embryo implantation. Congenital uterine abnormalities, such as unicornuate or bicornuate uterus, uterine didelphys, can be seen by ultrasound scan. These can cause miscarriage, preterm labor, and preterm birth. Hydrosalpinx, is a blocked fallopian tube that is filled with fluid. The most common cause is tubal infection. Hydrosalpinx lowers the IVF success rate because of 1. Toxins in the fluid has a negative impact to the embryos 2. Reduced implantation potential by altering endometrial receptivity and uterine contractility pattern 3. Flushing embryos from the fluid on the embryos Ovaries : Ovarian reserve test can be checked by antral follicle counts (AFC). The number of these follicles that are found in the ovary at the beginning of a cycle is an indicator of the size of the follicle pool in general. The average AFC for any age is as follow: – Age 25 years : median AFC = 14 – Age 30 years : median AFC = 12 – Age 35 years : median AFC = 10 – Age 40 years : median AFC = 8 – Age 45 years : median AFC = 6Ovarian cyst : is a fluid-filled sac that forms in the ovaries. Ovarian cysts can be benign or cancerous but most of them in women younger than 35 years are likely to be benign. They affect fertility if they interfere with normal ovulation or represent a mechanical obstacle for the fertilization process. Polycystic ovary : is the ultrasound scan finding of a typical characteristic of enlarged ovaries with multiple small sized cysts at the periphery of the ovaries.
- Hysterosalpingography HSG is an X-ray procedure that is used to view inside of the uterus and fallopian tubes. It can show the patency of fallopian tubes, as well as size and shape of the uterine cavity.
- Hysteroscopy Hysteroscopy is the procedure used to diagnose or treat problems of the uterus, and is done under anesthesia. A hysteroscope is a thin, lighted telescope-like device. It is inserted through your vagina into the uterus. The hysteroscopy transmits the image onto a screen, so the condition in womb can be clearly assessed. Some treatment can be done via hysteroscopy, such as polypectomy, adhesiolysis, myomectomy, etc.
- Magnetic Resonance Imaging MRI is a useful investigation for scanning and detection of abnormalities in soft tissue structures. Some women are in doubt with the abnormalities in the womb, fallopian tubes, or ovaries, MRI can be used to confirm the diagnosis and plan of treatment before IVF.
- Laparascopy Laparoscopy is a surgical procedure, which is often used to diagnose and treat the infertility causes. at SAFE Fertility Center, our fertility specialists