Female infertility

SHAMS ATRASH
DEFINTION
Infertility is defined as not being able to get pregnant (conceive) after one year (or longer) of
unprotected sex, However, for women aged 35 and older, the inability to conceive after 6
months is generally considered infertility.
CAUSES OF FEMALE
INFERTILITY:
1. Ovulation problems:
 PCOS
 Thyroid issues
 premature ovarian failure
 Hypothalamic dysfunction.
 Prolactin excess
2. Scarring from surgery
3. Uterine or cervical causes
4.Damage to fallopian tubes
5. Fibroids
6. Endometriosis
7. Pelvic inflammatory disease
8. Sterilization
9. Medicines and drugs 
10. Infections
11. Idiopathic
 OVULATION PROBLEMS
PCOS
PCOS is one of the most common causes of female infertility.
OVERVIEW AND MECHANISM:
a condition in which the ovaries produce an abnormal amount of
androgens, male sex hormones that are usually present in women in small
amounts.
 Polycystic ovaries contain a large number of harmless follicles that are
up to 8mm (approximately 0.3in) in size. 
 The follicles are underdeveloped sacs in which eggs develop, these sacs
are often unable to release an egg, which means ovulation does not take
place.
 The exact cause of PCOS is unknown, but it often runs in families.
IS IT A DEAD END?
 Women with PCOS are three times more likely to have a
miscarriage, as compared to women who don’t have PCOS. They are
also more likely to develop preeclampsia, gestational diabetes, and
have a larger baby and premature delivery. This could lead to difficulty
during delivery or cesarean delivery.

BUT!!
  clomiphene may be the first treatment recommended for women with
PCOS who are trying to get pregnant.
 Clomiphene encourages the monthly release of an egg from the ovaries
(ovulation).
 If clomiphene is unsuccessful in encouraging ovulation, another
medicine called metformin may be recommended, encouraging regular
monthly periods and lowering the risk of miscarriage, metformin
can also have other long-term health benefits, such as lowering 
high cholesterol levels and reducing the risk of heart disease.
HYPO/HYPER THYRODISM
Both hypothyroidism and hyperthyroidism can cause infertility by affecting ovulation. Women
with these conditions may not release an egg once a month during menstruation; in fact, they
may not release an egg at all. This makes it difficult to conceive.
 PRIMARY OVARIAN
INSUFFICIENCY
/PREMATURE OVARIAN
FAILURE
 Ovarian insufficiency is a failure of the ovary to function adequately in a woman younger than
40 years, in its role either as an endocrine organ or as a reproductive organ.
 is a condition characterized by amenorrhea, hypoestrogenism, and elevated serum
gonadotropin levels in women younger than 40 years. 
 POI is rare, typically affecting about 1% of women or people assigned female at birth (AFAB)
between ages 15 to 44.
  Losing estrogen can have side effects similar to those that occur with menopause, such as hot
flashes, decreased sex drive and mood changes. It also increases risk for osteoporosis, heart
disease and other conditions.
 In fact, around 5% to 10% of those with a diagnosis of POI will spontaneously get pregnant
without treatment for infertility. For this reason, POI is often also called “decreased ovarian
reserve.”
UTERINE CAUSES OF
INFERTILITY
 Uterine polyps
 Uterine fibroids
 Asherman’s Syndrome
 bicornuate uterus *
 Luteal phase defect 
 Thin endometrial lining
 absolute uterine factor infertility
UTERINE POLYPS
 These polyps are usually noncancerous (benign), although some can be cancerous or can
eventually turn into cancer (precancerous polyps).
 Uterine polyps most commonly occur in women who are going through or have
completed menopause, although younger women can get them, too.
 Uterine polyps are estrogen-sensitive

Signs and symptoms of uterine polyps include:
 Irregular menstrual bleeding
 Bleeding between menstrual periods
 Excessively heavy menstrual periods
 Vaginal bleeding after menopause
 Infertility
risk of developing uterine polyps is higher in:
1.Overweight patient
2.Approaching the age of menopause or are experiencing
menopause
3.Suffering from hypertension
4.Receiving treatment for breast cancer
5.Taking medication that blocks estrogen
polyps may contribute to infertility because:
 They make it more difficult for a fertilized egg to attach to the uterine walls
 They block sperm from joining with an egg
 They block sperm from entering the uterus

 Most polyps can be removed with hysteroscopic polyp removal. 

 there is no guarantee of conceiving after polyp removal, some studies suggest higher
pregnancy rates in women who undergo polyp removal.

sonohysterogram, or
hydrosonography
 UTERINE FIBROIDS
 sometimes known as uterine myomas or leiomyomas.
 Fibroids usually develop during a woman's reproductive years (from around the age of 16 to 50) when
oestrogen levels are at their highest.
 Many women are asymptomatic.
 Women who do have symptoms (around 1 in 3) may experience:

1. Heavy periods or painful periods

2. tummy (abdominal) pain
3. Back pain
4. a frequent need to urinate
5. constipation
6. pain or discomfort during sex
 In rare cases,  can affect pregnancy or cause infertility.
UTERINE FIBROIDS
There are several ways uterine fibroids can reduce fertility: 
 Changes in the shape of the cervix can affect the number of sperm that can
enter the uterus.
 Changes in the shape of the uterus can interfere with the movement of the
sperm or embryo.
 Fallopian tubes can be blocked by fibroids.
 They can impact the size of the lining of the uterine cavity.
 Blood flow to the uterine cavity can be affected. This can decrease the ability
of an embryo to stick (implant) to the uterine wall or to develop.

Most women with fibroids will not be infertile. Women with fibroids and
their partners should be thoroughly evaluated to find other problems with
fertility before fibroids are treated. A fertility specialist can help assess if
fibroids might be hampering conception.
 ASHERMAN’S SYNDROME
 The condition of scarring within the endometrial cavity of the uterus is often referred to as
Asherman’s Syndrome.
 A normal uterine cavity and endometrial lining is necessary in order to conceive and maintain a
pregnancy. Scar tissue within the uterine cavity can partially or completely obliterate the
normal cavity and can interfere with conception, or increase the risk for miscarriage or other
complications later in the pregnancy.
Causes
1. most commonly caused by the trauma to the lining from a D&C (dilation and curettage)
2. A recently pregnant uterus is much more susceptible to developing Asherman’s after D&C
compared to a non-pregnant uterus
3. It is sometimes caused by scarring after uterine surgeries such as Cesarean section or
myomectomy for fibroid tumors
4. In rare cases it is caused by infection, such as genital tuberculosis 
5. Unknown

Intrauterine adhesions can be cut during hysteroscopy to improve chances for 

embryo implantation (pregnancy) and to reduce the risk of miscarriage.
BICORNUATE UTERUS
 BICORNUATE UTERUS
 A bicornuate uterus results from failure of the Müllerian ducts to completely fuse. 
 A heart-shaped uterus probably won’t affect your fertility. In fact, studies have shown that having a bicornuate
uterus doesn’t lessen a woman’s chances of becoming pregnant.
 But, some older researchs suggests that this abnormality is more common in women who are infertile.
 But a bicornuate uterus raises your risk of having a miscarriage later
 Strassman metroplasty
STRASSMAN METROPLASTY

(A) Bicornuate uterus with recto-vesical (RV) band; (B) dissected RV band and uterovesical fold; (C) incised medial side of
cornua by harmonic scalpel and cornua supported with Hegar's dilators; (D) end result of unification after suturing with V-
LOC and vicryl
 LUTEAL PHASE DEFECT 
 a luteal phase defect inhibits uterine lining growth, which is required for egg implantation and fetal development.
 The luteal phase is the period of time between ovulation and menstruation. The duration of the luteal phase is typically
12 to 16 days. During this time, progesterone levels increase and the uterine lining thickens to create a healthy
environment for potential egg implantation.
 Most women with luteal phase defect do not realize they have the condition until they try to conceive and find it
challenging. 
common symptoms of luteal phase defect, including:
 Spotting between periods
 Early menstrual cycles
 Difficulty becoming pregnant
 Miscarriage
LUTEAL PHASE DEFECT
Any woman can develop a short luteal phase Treatment:
when her body does not produce enough
progesterone. Certain health conditions can put a 1.Clomiphene citrate it triggers your ovaries to make
woman a higher risk for a short luteal phase, more follicles, which release eggs.
including:
 Stress 2.Human chorionic gonadotropin (hCG). It may help start 
ovulation and make more progesterone.
 Underactive or overactive thyroid
 Endometriosis 3.Progesterone injections, pills, or suppositories. They may be
used after ovulation to help the lining of your uterus grow.
 PCOS
 Excessive exercise
 Anorexia
 Obesity
 Age
 THIN ENDOMETRIAL LINING
 For an Embryo to go be implanted in the endometrium, it should be in optimal condition, that is, and it
should be thick and trilaminar with a good blood supply.
 As the pregnancy progresses, all the nourishment that is required for the growth of a baby is supplied by the
glands present in the uterine lining. And in the absence of a proper thick endometrial lining, it would be
difficult to hold a pregnancy.
 Causes:

1. Low estrogen
2. C&D
3. Poor blood flow
4. Infection & PID
5. Birth control bills
6. clomid 
 ABSOLUTE UTERINE FACTOR INFERTILITY
 Absolute uterine factor infertility is a condition where a woman cannot get pregnant because she
either doesn’t have a uterus or her uterus is no longer functioning correctly.
 Acquired absolute factor infertility is caused when the uterus is surgically removed
 Congenital:

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome: is a rare disorder that affects women. It is

characterized by the failure of the uterus and the vagina to develop properly in women who have
normal ovarian function and normal external genitalia. Women with this disorder develop normal
secondary sexual characteristics during puberty, but do not have a menstrual cycle (primary
amenorrhea). Often, the failure to begin the menstrual cycle is the initial clinical sign of MRKH
syndrome.  
MAYER-ROKITANSKY-KÜSTER-
HAUSER SYNDROME (a) Trans-abdominal pelvic ultrasound
image in the longitudinal plane shows
absent uterus but a vaginal stripe is present
(arrowhead). (b) Trans-abdominal split-
screen pelvic ultrasound images of the
adnexae show normal ovaries bilaterally.
(c) Sagittal T2-weighted MR image of the
pelvis confirms the absence of a normal
uterus. (d) Coronal T2-weighted MR
image of the pelvis shows bilateral normal
ovaries (arrows)
TUBULAR FACTORS
 Tubal factor infertility is often caused by pelvic infection, such as pelvic inflammatory
disease (PID), or endometriosis, or scar tissue that forms after pelvic surgery.
PID
 Untreated STD can cause pelvic inflammatory disease (PID), a serious condition, in women.
 1 in 8 women with a history of PID experience difficulties getting pregnant. 
 GETTING PID VIA THOSE MEANS:

1. Have an STD and do not get treated;

2. Have more than one sex partner;
3. Have a sex partner who has sex partners other than you;
4. Have had PID before;
5. Are sexually active and are age 25 or younger;
6. Douche
7. Use an intrauterine device (IUD) for birth control.
PID
Some women with pelvic inflammatory disease don’t have symptoms. For the women who do have symptoms, these
can include:
 Lower abdominal pain (the most common symptom)
 Upper abdominal pain
 fever
 Painful sex
 Painful urination
 Irregular bleeding
 increased or foul-smelling vaginal discharge
 tiredness

PID if diagnosed early, can be treated. However, treatment won’t undo any damage that has already happened to the
reproductive system. The longer you wait to get treated, the more likely the complications from PID. While taking
antibiotics, symptoms may go away before the infection is cured. Even if symptoms go away, you should finish taking
all of the medicintion.
 PID
 Some of the complications of PID are

1. Formation of scar tissue both outside and inside the fallopian tubes that can lead to
tubal blockage;
2. Ectopic pregnancy (pregnancy outside the womb);
3. Infertility (inability to get pregnant);
4. Long-term pelvic/abdominal pain.
ENDOMETRIOSIS
 Patients with endometriosis have endometrial-type tissue outside of the uterus
 Women with endometriosis are more likely to have infertility
  It most often occurs on or around reproductive organs in the pelvis or abdomen, including:

1. Fallopian tubes
2. Ligaments uterosacral
3. Lining of the pelvic cavity
4. Ovaries
5. Outside surface of the uterus
6. Space between the uterus and the rectum or bladder
 More rarely, it can also grow on and around the:

1. Bladder endometriosis may prevent a pregnancy because

the abnormal tissue may:
2. Cervix
3. Intestines 1. block the ovary from releasing eggs
4. Rectum 2. block the fallopian tubes
3. stop the fallopian tubes working properly
5. Stomach (abdomen)
4. stop a fertilised egg from attaching to the uterus
6. Vagina or vulva
 ENDOMETRIOSIS
 Common signs and symptoms of endometriosis include:

1. Painful periods (dysmenorrhea).

2. Pain with intercourse.
3. Pain with bowel movements or urination. 
4. Excessive bleeding.
5. Infertility, Sometimes, endometriosis is first diagnosed in those seeking treatment for
infertility.
6. Other signs and symptoms. fatigue, diarrhea, constipation, bloating or nausea, especially
during menstrual periods.
 INFECTIONS
 Chlamydia (chlamydia trachomatis)In females, chlamydia can cause damage and scarring to the
uterus or fallopian tubes if left untreated, resulting in a decreased chance of becoming pregnant. 
 Gonorrhea can thrive in a female’s reproductive tract, specifically in the uterus and the fallopian tubes
causing PID and tubal factor infertility.
 Human papillomavirus some strains of HPV can increase the possibility of a woman developing
precancerous cells and cervical cancer. The process of removing cancerous and precancerous cells from
the cervix can affect fertility. The procedures to remove these cells can change the production of
cervical mucus, affecting a woman’s ability to conceive.
 HSV can have an indirect effect on fertility by causing a couple to avoid sexual contact during
outbreaks, which can prolong the process of trying to conceive.
 Syphilis: Women with untreated syphilis who become pregnant have a 50% chance of miscarriage or
stillbirth, which has a direct impact on the ability to have a child.
SOURCES
 Infertility | Reproductive Health | CDC
 causes of infertility - NHS - NHS (www.nhs.uk)
 What are some possible causes of female infertility? | NICHD - Eunice Kennedy Shriver National Institute of Child Health and Human Development (nih.gov)
 Polycystic Ovary Syndrome (PCOS) | Johns Hopkins Medicine
 Polycystic Ovarian Syndrome (PCOS) and Pregnancy: Symptoms (healthline.com)
 Polycystic ovary syndrome - Treatment - NHS (www.nhs.uk)
 Early miscarriage rate in lean polycystic ovary syndrome women after euploid embryo transfer - a matched-pair study. | Semantic Scholar
 Thyroid Disorders - Infertility in Women - Hypothyroidism (dallasfertility.com)
 Ovarian Insufficiency: Practice Essentials, Background, Pathophysiology (medscape.com)
 https://my.clevelandclinic.org/health/diseases/17963-primary-ovarian-insufficiency
 Uterine polyps - Symptoms and causes - Mayo Clinic
 Uterine Problems Can Cause Infertility or Miscarriage - Advanced Fertility Center of Chicago
 Uterine Polyps | Fertility Center of San Antonio (fertilitysa.com)
 Uterine Polyps Can Cause Infertility or Miscarriage - Advanced Fertility Center of Chicago
 Fibroids - NHS (www.nhs.uk)
 Fibroids and Fertility (reproductivefacts.org)
 Uterine Fibroids and Infertility - PMC (nih.gov)
 Laparoscopic view during Strassmann's metroplasty: (A) Bicornuate... | Download Scientific Diagram (researchgate.net)
 Luteal Phase Defect (LPD): Symptoms, Causes, and Treatment (webmd.com)
 Thin Endometrium | Symptoms, Causes & Treatments (medicoverfertility.in)
 Mayer-Rokitansky-Küster-Hauser Syndrome - NORD (National Organization for Rare Disorders) (rarediseases.org)
 Mayer–Rokitansky–Kuster–Hauser syndrome in a 18-year-old presenting... | Download Scientific Diagram (researchgate.net)
 STD Facts - Pelvic Inflammatory Disease (cdc.gov)
 Pelvic Inflammatory Disease: Risk Factors, Symptoms & Treatments (healthline.com)
 Pelvic Inflammatory Disease (PID) (jhmi.edu)
 Endometriosis - Symptoms and causes - Mayo Clinic
 Treatment — Nuffield Department of Women's & Reproductive Health (ox.ac.uk)
 How endometriosis affects pregnancy | Pregnancy Birth and Baby (pregnancybirthbaby.org.au)
 STDs Affecting Fertility | Loma Linda Univ. Fertility & IVF | CA (lomalindafertility.com)