Women’s Infertility

Polycystic ovarian syndrome (PCOS) is a common condition that affects women of childbearing age. The key factor of PCOS is hormonal imbalance.

Most, but not all women, with PCOS have many small cysts within the outer edge of their ovaries. Oocytes (eggs) develop inside of follicles, which are small fluid-filled sacs. Each follicle breaks open once the egg has matured. The egg then travels to the fallopian tube for fertilization; ovulation has taken place. However, the ovary of a woman with PCOS does not produce all the hormones needed for an egg to mature. The follicle continues to swell with fluid but never breaks open because of the lack of ovulation and progesterone. The follicle remains as a cyst on the ovary.

The ovaries of women with the condition produce more androgen (male hormone) than normal. The high levels of androgen affect egg development and ovulation. Researchers have also found that there may be a link between PCOS and insulin resistance. The abundance of insulin increases the production of androgens.

Symptoms

The symptoms of PCOS vary for each woman but all have menstrual abnormalities: heavy, irregular or absent.

  • Infertility due to irregular or lack of ovulation
  • Infrequent or absent menstrual cycle
  • Cyst on the ovaries
  • Weight gain or trouble losing weight
  • Androgenic alopecia (male-pattern baldness)
  • Hirsutism (excess facial and body hair)
  • Acne, oily skin, dandruff
  • Sleep apnea
  • Anxiety or depression

Diagnosis

There is no one specific way to diagnose PCOS. The clinician uses different tests and exams to determine if PCOS is the cause of symptoms present. Test and exams may include:

  • Blood test to check sex hormone levels or insulin
  • Physical exam
  • Pelvic exam
  • Ultrasound

Lifestyle Therapy

Restoring menstrual cycles and a healthy diet can lower blood sugar and improve insulin usage. Exercise can lower body fat, which helps lower insulin. Lower insulin levels can restore ovulation.

Medical Therapy

Metformin, a diabetic medication, can reduce the amount of androgens released by the ovaries. It also improves the body’s use of insulin. Metformin may also restore ovulation. Fertility medications, like Clomid, may be used for ovulation stimulation. Laparoscopic or minimally invasive surgery may be required. An assisted reproductive technology (ART) such as in vitro fertilization (IVF) may be used to help achieve pregnancy.

Endometriosis occurs when tissue lining the uterus grows on other nearby organs or structures. The displaced tissue continues to function as it would within the uterus. It becomes thinker and sheds with each cycle; however, there is no way for it to exit the body.

Endometriosis can affect the ovaries, fallopian tubes, tissues that hold the uterus in place, bowels and bladder. Most, but not all women with endometriosis, experience pelvic pain.

Symptoms

  • Dysmenorrhea – pelvic pain and cramping during menstrual cycle
  • Heavy bleeding
  • Bleeding between cycles
  • Pain during and after intercourse
  • Pain with urination and bowel movements
  • Bloating, constipation or nausea
  • Diagnosis

A pelvic exam or ultrasound is an option but the best way to diagnose endometriosis is through laparoscopy (minimally invasive surgery.) Adhesions caused by endometriosis are also removed with the procedure.

Medical Therapy

Conservative Surgery – is normally performed as a laparoscopic procedure. The physician removes adhesions (scar tissue) caused by endometriosis. The growth of endometriosis can distort the reproductive structures, like the fallopian tube, making it difficult for fertilization to occur. Removing the scar tissue will improve the functions of the reproductive organs.

Hormone Therapy – The patient may take fertility medication in order to induce ovulation for assisted reproductive technology (ART) procedures, like in vitro fertilization (IVF).

Amenorrhea is an absence of menstrual cycles, normally three or more. There are two types of amenorrhea: primary and secondary. Women with primary amenorrhea have never had a menstrual cycle. Women with secondary amenorrhea have had cycles in the past but no longer have them.

Possible Causes of Secondary Amenorrhea

  • Polycystic ovarian syndrome
  • Stopping the use of birth control
  • Extreme weight loss
  • Poor nutrition
  • Being overweight
  • Stress
  • Over exercising
  • Dysfunction of the uterus, ovaries or fallopian tubes
  • Premature menopause
  • Thyroid gland disorders

Symptoms

  • Breast discharge
  • Change in breast size
  • Vaginal dryness
  • Hirsutism (excess facial and body hair)

Diagnosis

A blood test is administered to check hormone levels and an ultrasound may done to check for reproductive abnormalities.

Lifestyle Therapy

Losing or gaining weight could help with irregular cycles.

Medical Therapy

Medication might be used to treat hormonal or gland-related amenorrhea. Abnormalities of reproductive structures may require surgery in order to regulate the menstrual cycle.

Uterine fibroids are tumors that arise from the smooth muscle of the uterus. They normally grow during a woman’s childbearing years. It is not clear what causes fibroids. Factors that may contribute to them include a family history of fibroids or ovaries that produce an abundance of estrogen or progesterone. Most fibroids are benign and it is possible to have multiple fibroids in the uterus at one time. They also vary in size ranging from the size of a pea to that of a volleyball.

Types of Fibroids

Fibroids are categorized by their locations in the uterus.

  • Submucosal – grow in the uterus
  • Intramural – grow within the wall of the uterus
  • Subserosal – grow on the outside of the uterus

Symptoms

Uterine fibroids can cause the following symptoms; however, not all women may experience them:

  • Heavy menstrual cycles
  • Cramping
  • Bleeding between cycles
  • Pressure in lower abdomen
  • Lower back pain
  • Pain during intercourse
  • Frequent urination

Diagnosis

  • Pelvic Exam
  • Ultrasound

Treatment

Laparoscopic surgery can remove fibroids from the uterus.

Luteal phase defect (LPD) is the inability to produce enough progesterone during the luteal phase, which disrupts the monthly menstrual cycle. The luteal phase is the two-week period between ovulation and menstruation. The ovaries release progesterone during this phase, aiding in the thickening of the uterus lining for pregnancy. Progesterone levels remain high in order to support the developing baby. A drop in progesterone levels will lead to a miscarriage.

The lining sheds during menstruation, if pregnancy does not occur. A woman with LPD experiences her menstrual cycle earlier than usual due to the low production or premature drop of progesterone.

LPD may occur if the ovaries do not produce enough progesterone or if the lining of the uterus does not respond to the progesterone.

Symptoms

  • Frequent, short menstrual cycles
  • Spotting between cycles
  • Miscarriages

Diagnosis

Blood tests are used to check hormone levels, including the follicle-stimulating hormone, the luteinizing hormone and progesterone. If an endometrial biopsy is needed, it take place a day or two before the next menstrual cycle to observe the development of the lining of the uterus.

Medical Therapy

  • Clomiphene citrate (Clomid) is used to stimulate ovulation and release more eggs.
  • Human chorionic gonadotropin (hCG)is used to stimulate ovulation of mature eggs and produce more progesterone.
  • Progesterone injections, pills, or suppositories assist with uterine lining growth.

Premature menopause is a condition in which a woman’s egg supply shrinks earlier than usual. Some women can have a low egg supply as early as 30 years of age. The number of eggs a woman has decreases as she ages. The reserve of eggs is nearly gone at the age of 40 and by her 50s it is obsolete, resulting in menopause.

Intrauterine insemination (IUI) and in vitro fertilization (IVF) are typical fertility options for women with premature menopause.

Uterine malformations occur during embryonic development in which the Müllerian ducts do not fuse together properly. The fusion of the Müllerian ducts should result in the formation of the uterus, ovaries, fallopian tubes, cervix and upper portion of the vagina. Malformation of the ducts can have varying results.

Types of malformations:

Müllerian Agenesis

The uterus is absent

Unicornuate Uterus

Only half of the uterus forms; one fallopian tube is present

Uterus Didelphys

There are two uterine cavities and two cervixes

Bicornuate Uterus

The upper chamber of the uterus does not fuse properly leaving an indentation at the top of the uterus, giving it a heart shape.

Septated Uterus

This is the most common uterine malformation. A septum made of fibrous tissue partially or completely separates the uterus into two. It is a result of the Müllerian ducts combining but the septum created remains. The newly formed uterus should reabsorb the tissue after the two ducts have fused together. The physician performs hysteroscopy to remove the septum.

Blockage within the fallopian tubes due to scarring or damage can make conception difficult. Sperm is unable to fertilize the egg or the fertilized eggs are can’t travel through the tubes to the uterus for implantation.

Possible Causes of Damaged or Abnormal Fallopian Tubes

  • Endometriosis
  • Sexually transmitted infections (STI) or pelvic inflammatory disease (PID)
  • Ectopic pregnancy
  • Previous C-section
  • Tubal ligation

Diagnosis

Dye is injected in the uterus with a catheter inserted through the cervix during a test called a hysterosalpingogram (HSG). The dye passing through the fallopian tubes is confirmation that there is no blockage. The dye will not pass through blocked or misshapen tubes. Occasionally, laparoscopic surgery is required to make an accurate diagnosis.

Medical Therapy

Laparoscopic surgery is used to remove scar tissue and reconstruct the area for normal function. In vitro fertilization (IVF) is an option to attain pregnancy when there is a great amount of scar tissue or damage to the tubes.