Female infertility refers to infertility in female humans.

[edit] Causes

Factors relating only to female infertility are:

[edit] General factors

According to the American Society for Reproductive Medicine (ASRM), Age, Smoking, Sexually Transmitted Infections, and Being Overweight or Underweight can all affect fertility. ^[1]

[edit] Age

Fertility starts declining after age 27 and drops at a somewhat greater rate after age 35.^[2] In terms of ovarian reserve, a typical woman has 12% of her reserve at age 30 and has only 3% at age 40^[3]. 81% of variation in ovarian reserve is due to age alone^[3], making age the most important factor in female infertility.

A study commissioned by RESOLVE ^[4], a non-profit patient advocacy organization, states that both three out of four men and three out of four women overestimate by five years the rapid decline in female fecundity with prime childbearing age occurring up to age 32 for females and a rapid decline at 35 instead of 40 as most people commonly believe.^[5] The American Society for Reproductive Medicine (ASRM) states, "...women in their 20's to early 30's are most likely to conceive."^[6] (More detailed booklet: ^[7]). Elite egg donor agencies such as A Perfect Match that advertise in places such as Ivy League student newspapers offering up to $20,000 or even $50,000 for donor eggs seek donors under the age of 29. ^{[8] [9]}

Fertility specialist and book author Dr. Sherman Silber ^[10] puts it a different way: "Only 1% of women in their early 20's are infertile but by their late 20's, 16% [one in six] are infertile, and by their mid-30's almost 25% [one in four] are infertile. By age 40, 60% [three in five] are infertile and by age 43 it would be a rare woman who is still fertile."^[11] Because one in six can be infertile (before treatment) by their late 20's Dr. Silber recommends that a woman who expects to delay childbirth beyond age 30 have her gynecologist perform an antral follicle count ultrasound at about age 25.^[12] Other fertility specialists such as book author Dr. Daniel Potter ^[13] recommend an FSH (Follicle-stimulating hormone) or other laboratory test instead of the antral follicle count ultrasound.^[12]

The issues of age need to be taken up with a qualified fertility specialist such as a reproductive endocrinologist. Standard of care: Women over 35 who are attempting to conceive should seek the advice of a fertility specialist after six months of unprotected intercourse, or after one year if under the age of 35.^[14]

[edit] Smoking

Smoking is harmful to the ovaries, and the degree of damage is dependent upon the amount and length of time a woman smokes. Nicotine and other harmful chemicals in cigarettes interfere with the body's ability to create estrogen, a hormone that regulates folliculogenesis and ovulation, and cause egg cells to be more prone to genetic abnormalities. Some damage is irreversible, but stopping smoking can prevent further damage.^[15][16] Smokers are 60% more likely to be infertile than non-smokers.^[17] Smoking reduces the chances of IVF producing a live birth by 34% and increases the risk of an IVF pregnancy miscarrying by 30%.^[17]

[edit] Sexually transmitted infection

Sexually transmitted infections are a leading cause of infertility. They often display few, if any visible symptoms, with the risk of failing to seek proper treatment in time to prevent decreased fertility.^[15]

[edit] Body weight and eating disorders

Twelve percent of all infertility cases are a result of a woman either being underweight or overweight. Fat cells produce estrogen,^[18] in addition to the primary sex organs. Too much body fat causes production of too much androgen and the body begins to react as if it is on birth control, limiting the odds of getting pregnant.^[15] Too little body fat causes insufficient production of estrogen and disruption of the menstrual cycle.^[15] Both under and overweight women have irregular cycles in which ovulation does not occur or is inadequate.^[15]

A study in the US indicated that approximately 20% of infertile women had a past or current eating disorder, which is five times higher than the general lifetime prevalence rate.^[19]

A review from 2010 concluded that overweight and obese subfertile women have a reduced probability of successful fertility treatment and their pregnancies are associated with more complications and higher costs. In hypothetical groups of 1000 women undergoing fertility care, the study counted approximately 800 live births for normal weight and 690 live births for overweight and obese anovulatory women. For ovulatory women, the study counted approximately 700 live births for normal weight, 550 live births for overweight and 530 live births for obese women. The increase in cost per live birth in anovulatory overweight and obese women were, respectively, 54 and 100% higher than their normal weight counterparts, for ovulatory women they were 44 and 70% higher, respectively.^[20]

[edit] Other general factors

Chemotherapy poses a high risk of infertility. Antral follicle count decreases after three series of chemotherapy, whereas follicle stimulating hormone (FSH) reaches menopausal levels after four series.^[21] Other hormonal changes in chemotherapy include decrease in inhibin B and anti-Müllerian hormone levels.^[21]

• Significant liver or kidney disease
• Thrombophilia^[22][23]

[edit] Hypothalamic-pituitary factors

• Hypothalamic dysfunction
• Hyperprolactinemia^[24]

[edit] Ovarian factors

• Polycystic ovarian syndrome

• Anovulation

• Diminished ovarian reserve, also see Poor Ovarian Reserve

• Premature menopause

• Menopause

• Luteal dysfunction^[25]

• Gonadal dysgenesis (Turner syndrome)

• Ovarian cancer

[edit] Tubal (ectopic)/peritoneal factors

• Endometriosis^[26]

• Pelvic adhesions

• Pelvic inflammatory disease (PID, usually due to chlamydia)^[27]

• Tubal occlusion^[28]

• Tubal dysfunction

[edit] Uterine factors

• Uterine malformations^[29]

• Uterine fibroids (leiomyoma)

• Asherman's Syndrome^[30]

[edit] Cervical factors

• Cervical stenosis^[31]

• Antisperm antibodies^[32]

• Non-receptive cervical mucus^[33]

[edit] Vaginal factors

• Vaginismus
• Vaginal obstruction

[edit] Genetic factors

• Various intersexed conditions, such as androgen insensitivity syndrome

[edit] Diagnosis

Diagnosis of infertility begins with a medical history and physical exam. The healthcare provider may order tests, including the following:

• Lab tests
  • hormone testing, to measure levels of female hormones at certain times during a menstrual cycle
  • day 2 or 3 measure of FSH and estrogen, to assess ovarian reserve
  • measurements of thyroid function^[34] (a thyroid stimulating hormone (TSH) level of between 1 and 2 is considered optimal for conception)
  • measurement of progesterone in the second half of the cycle to help confirm ovulation

• Examination and imaging
  • an endometrial biopsy, to verify ovulation and inspect the lining of the uterus
  • laparoscopy, which allows the provider to inspect the pelvic organs
  • fertiloscopy, a relatively new surgical technique used for early diagnosis (and immediate treatment)
  • Pap smear, to check for signs of infection
  • pelvic exam, to look for abnormalities or infection
  • a postcoital test, which is done soon after intercourse to check for problems with sperm surviving in cervical mucous (not commonly used now because of test unreliability)
  • special X-ray tests

Diagnosis and treatment of infertility should be made by physicians who are fellowship trained as reproductive endocrinologists. Reproductive Endocrinologists are usually Obstetrician-Gynecologists with advanced training in Reproductive Endocrinology & Infertility (in North America). These highly educated professionals and qualified physicians treat Reproductive Disorders affecting not only women but also men, children, and teens.

Prospective patients should note that reproductive endocrinology & infertility medical practices do not see women for general maternity care. The practice is primarily focused on helping their patients to conceive and to correct any issues related to recurring pregnancy loss.

[edit] Prevention

Some cases of female infertility may be prevented through identified interventions:

• Maintaining a healthy lifestyle. Excessive exercise, consumption of caffeine and alcohol, and smoking are all associated with decreased fertility. Eating a well-balanced, nutritious diet, with plenty of fresh fruits and vegetables (plenty of folates), and maintaining a normal weight are associated with better fertility prospects.
• Treating or preventing existing diseases. Identifying and controlling chronic diseases such as diabetes and hypothyroidism increases fertility prospects. Lifelong practice of safer sex reduces the likelihood that sexually transmitted diseases will impair fertility; obtaining prompt treatment for sexually transmitted diseases reduces the likelihood that such infections will do significant damage. Regular physical examinations (including pap smears) help detect early signs of infections or abnormalities.
• Not delaying parenthood. Fertility does not ultimately cease before menopause, but it starts declining after age 27 and drops at a somewhat greater rate after age 35.^[2] Women whose biological mothers had unusual or abnormal issues related to conceiving may be at particular risk for some conditions, such as premature menopause, that can be mitigated by not delaying parenthood.

[edit] References