Module on “Infertility (Part- 2)” by Dr. Vishwesh BN

CAUSES OF FEMALE INFERTILITY

The causes of female infertility can be – Tubal and peritoneal factors (25–35%), Ovulatory factor (30–40%) and Endometriosis (1–10%).

Ovarian factors: The ovulatory dysfunctions (dysovulatory) encompass:

• Anovulation or oligo-ovulationy
• Decreased ovarian reserve
• Luteal phase defect (LPD)
• Luteinized unruptured follicle (LUF).

Anovulation or Oligo-Ovulation:

The ovarian activity is totally dependent on the gonadotropins and the normal secretion of

gonadotropins depends on the pulsatile release of GnRH from hypothalamus. As such, ovarian dysfunction is likely to be linked with disturbed hypothalamo-pituitary-ovarian axis either primary or secondary from thyroid or adrenal dysfunction. Thus, the disturbance may result not only in anovulation but may also produce oligomenorrhea or even amenorrhea. Anovulatory cycles usually represent a lesser degree of disturbance with these normal pathways than does amenorrhea. As there is no ovulation, there is no corpus luteum formation. In the absence of progesterone, there is no secretory endometrium in the second half of the cycle. The other features of ovulation are absent.

Luteal Phase defect (LPD):

In this condition, there is inadequate growth and function of the corpus luteum. There is inadequate progesterone secretion. The lifespan of corpus luteum is shortened to less than 10 days. As a result, there is inadequate secretory changes in the endometrium which hinder implantation. LPD is due to defective folliculogenesis which again may be due to varied reasons. Drug induced ovulation, decreased level of FSH and/or LH, elevated prolactin, subclinical hypothyroidism, older women, pelvic endometriosis, dysfunctional uterine bleeding are the important causes.

Luteinized unruptured follicular syndrome (trapped ovum):

In this condition, the ovum is trapped inside the follicle, which gets luteinized. The cause is obscure but may be associated with pelvic endometriosis or with hyperprolactinemia. Tubal and peritoneal factors are responsible for about 30–40 percent cases of female infertility.

The obstruction of the tubes may be due to

(a) Pelvic infections causing: (i) Peritubal adhesions (ii) Endosalpingeal damage.

(b) Previous tubal surgery or sterilization.

(c) Salpingitis isthmica nodosa

(d) Tubal endometriosis and others.

(e) Polyps or mucous debris within the tubal lumen, or tubal spasm.

Peritoneal factors: In addition to peritubal adhesions, even minimal endometriosis may produce infertility. Deep dyspareunia too often troubles the patient.

Tubal Factors: Peritoneal and tubal factors may account for up to 35% of all cases of infertility. Partial or complete bilateral tubal obstruction results from previous salpingitis. Most commonly this is postabortal, puerperal, gonococcal, chlamydial or tuberculous in nature.

Uterine factors: The endometrium must be sufficiently receptive enough for effective nidation and growth of the fertilized ovum. The possible factors that hinder nidation are uterine hypoplasia, inadequate secretory endometrium, fibroid uterus, endometritis (tubercular in particular), uterine synechiae or congenital malformation of uterus. Uterine absence, atrophy or hypoplasia of a degree sufficient to bar the ascent of spermatozoa causes

amenorrhoea as well as infertility. Tuberculous endometritis , Intrauterine adhesions (Asherman’s syndrome) due to previous overzealous curettage or previous surgery on the uterus, Submucous polyp , Uterine leiomyomas etc are some other uterine causes.

Cervical factors:

Anatomic: Anatomic defects preventing sperm ascent may be due to congenital elongation of the cervix, second degree uterine prolapse and acute retroverted uterus. These conditions prevent the external os to bathe in the seminal pool. Pinhole os may at times be implicated, or the cervical canal may be occluded by a polyp.

Physiologic: The fault lies in the composition of the cervical mucus, so much that the spermatozoa fail to penetrate the mucus. The mucus may be scanty following amputation, conisation or deep cauterization of the cervix. The abnormal constituents include excessive, viscous or purulent discharge as in chronic cervicitis. Presence of antisperm or sperm immobilizing antibodies may be implicated as immunological factor of infertility.

Vaginal factors:

Atresia of vagina (partial or complete), transverse vaginal septum, septate vagina, or narrow introitus causing dyspareunia are included in the congenital group. Vaginitis and purulent discharge may at times be implicated but pregnancy too often occurs in presence of vaginitis, specific, or nonspecific. However, dyspareunia may be the real problem in such cases.

Combined factors

These include the presence of factors both in the male and female partners causing infertility.

General factors:

• Advanced age of the wife beyond 35 years is related but spermatogenesis continues throughout life although aging reduces the fertility in male also.
• Infrequent intercourse, lack of knowledge of coital technique and timing of coitus to utilize the fertile period are very much common even amongst the literate couples.
• Apareunia and dyspareunia
• Anxiety and apprehension.
• Use of lubricants during intercourse, which may be spermicidal.
• Immunological factors.

Assessment Questions (MCQs)

1. In LPD, the lifespan of corpus luteum is shortened to less than _______ days.
a) 10
b) 15
c) 23
d) 5

2. _____________ is a major factor for infertility in women.
a) Age
b) Weight
c) Anovulation
d) All of the above

3. Women who are trying to conceive should boost their intake of ______________.
a) Nickel
b) Lycopene
c) Potassium
d) Folic acid

4. The normal secretion of gonadotropins depends on the pulsatile release of _______ from hypothalamus. AT
a) GnRH
b) CRH
c) GHRH
d) TRH

5. Women should avoid pregnancy for three months after discontinuing birth control pills.
a) True
b) False

6. It is necessary for the woman to experience orgasm in order to conceive.
a) True
b) False

7. Which sexually transmitted disease can result in infertility in women?
a) Human papillomavirus (HPV)
b) Genital herpes
c) Pelvic inflammatory disease
d) All of the above

8. If a couple is infertile, this means the couple…
a) Will never be able to have children
b) Could not conceive after 12 months of unprotected sex
c) Should look into adoption
d) All of the above

9. A 35-year-old woman is considered infertile after ____ of trying to conceive.
a) 1 month
b) 2 months
c) 4 months
d) 6 months

10. The major causes of infertility in females include all of the following, EXCEPT
a) Obstructions of the reproductive tract.
b) An irregularly shaped uterus.
c) Endometriosis.
d) Declining hormone levels.

Answers:

1. a
2. d
3. d
4. a
5. b
6. b
7. c
8. b
9. d
10. b 

References:

1. Hiralal Konar Editor: Textbook of DC Dutta’s obstetrics. 8^th New Delhi: Jaypee Brothers Medical Publishers; 2015.
2. Narendra Malhotra, Pratap Kumar, Jaideep Malhotra, Neharika Malhotra Bora and Parul Mittal M. Revised and updated. Jeffcoate’s Principles Of Gynaecology. Eighth Edition New Delhi: Jaypee Brothers Medical Publishers; 2014.
3. Cecilia Bottomley and Janice Rymer. 100 cases in Obstetrics and Gynaecology. 2^nd Series editor: Janice Rymer. CRC Press: Taylor & Francis Group; 2015.
4. Andrew T. Raftery, Michael S. Delbridge, Marcus J.D. Wagstaff and Katherine I. Bridge, Editors: Churchill’s Pocketbooks Surgery. 5^th Elsevier; 2017
5. Hiralal Konar Editor: Dutta’s Bedside Clinics and Viva-Voce in Obstetrics and Gynecology. Sixth Edition. New Delhi: Jaypee Brothers Medical Publishers; 2016.
6. Sakshi Arora. Pre Neet Obstetrics and Gynaecology. First Edition. New Delhi: Jaypee  Brothers Medical Publishers; 2013.
7. Sarala Gopalan, S.Rathnakumar and Vanita Jain editors. Mudaliar and Menons Clinical Obstetrics. 7^th Revised Edition. Orient Longman, Bombay.
8. Cunningham, Leveno, Bloom, Spong, Dashe, Hoffman, Casey, Sheffield. Williams Obstetrics. 24^th McGraw Hill Education; 2014.
9. Keith Edmonds. Editor .Dewhurst’s Textbook of Obstetrics & Gynaecology. Seventh edition, Blackwell Publishing; 2007.
10. World Health Organization. Infertility. 2013.