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Female Infertility FAQs

FEMALE REPRODUCTIVE SYSTEM FAQs
What are the organs of Female Reproductive System?

Conception in the Female reproductive system is concerned with copulation, fertilization, growth and development of the fetus and its birth. The organs of female reproductive system are divided into:

A. External genitalia (vulva, pudendum): External genitalia include mons veneris, labia majora, labia minora, clitoris, vestibule and perineum. These organs are visible externally and are concerned with copulation and parturition.

B. Internal genitalia:These include vagina, uterus, fallopian tubes and the ovaries. These organs are placed internally and require special instruments for inspection.

Vagina: The vagina is a fibromusculo-membranous sheath communicating the uterine cavity with the exterior at the vulva. It constitutes the excretory channel for the uterine secretions and menstrual blood.

It is the organ of copulation and forms the birth canal of parturition. It is highly sensitive and has got enough power of distensibility as evident during childbirth. The diameter of vagina is about 2.5 cm, being widest at its upper part and narrowest at its introitus. Length of vagina is 7 to10 cm. Cervix, the mouth of uterus lies at the apex of vagina.

Uterus: This is the organ where pregnancy normally grows. During pregnancy, the uterus serves for reception, implantation, retention, nutrition of fetus, which it then expels during labor.

Uterus is pyriform in shape, measures about 8cm long, 5cm wide and 3cm thick. It weighs 50 to 80 grams. Uterus has triangular cavity which is lined by a lining of cells called endometrium. This endometrium normally sheds during each menses leading to periods.

Cervix: this is also called mouth of the uterus, is cylindrical in shape and measures about 2.5 cm. at its lower end it opens in the upper part of vagina. Cervix secretes important secretions and cervical mucus which has important part in passage of sperms in uterine cavity.

Fallopian tube (uterine tube, oviduct): These are paired structures, measuring about 10 cm. Each tube has got two openings, one communicating with the lateral angle of the cavity called uterine opening, measures 1 mm in diameter and the other opening on the lateral end called abdominal opening measuring about 2 mm in diameter. The lateral end of tube is called fimbrial end, as it has fingerlike projections called fimbrias that help in pick up of the oocyte after its release from the ovary after ovualation.

The important functions of tubes are transport of the gametes, to facilitate fertilization and survival of zygote through its secretions. Normally fertilization occurs in the middle part of tube (ampullary part), further development of zygote takes place upto morula and blastula stage of embryo. Gradually the embryo is transported by the cilliary actions of the lining cells towards the uterine cavity, where it gets finally implanted after three days of fertilization.

The ovary: The ovaries are paired sex gonads in female which are concerned for germ cell maturation, storage and its release during ovulation and female hormonal production. It is oval in shape, measures about 3 cm in length, 2 cm in breadth and 1 cm in thickness and weighs about 15 to 20 grams. The ovaries contain about 6 to 7 millions oocytes during the intrauterine period, at birth this reduces to 2 millions, rest become atretic. At puberty about 4 lacs of oocytes are left behind; out of these only 400 to 500 oocytes ovulate during the entire reproductive period of female.

 What are the causes for Infertility in females?

Female infertility can be caused by any abnormality in reproductive, hormonal (endocrine) system or due to systemic causes.

1. Uterine causes: absent uterus, hypoplastic uterus, septum in uterus, bicornuate uterus, fibroids, intrauterine adhesions, infection, etc.

2. Tubal factors (35 to 45%): Fallopian tube is a very important part of female reproductive system. Infection can cause serious damage to the tube causing infertility. In India, tuberculous infection is an important cause of female infertility. Also repeated curettage of uterus, abortions can cause infection of tubes & their subsequent blockage.

3. Cervical causes: The cervical epithelium secretes important secretions that are necessary for normal passage of sperm through the cervical canal. Disturbance in this process can cause infertility. Cervical stenosis, thick cervical mucus and the presence of sperm antibodies in cervical mucus can cause infertility.

4. Vaginal causes: Hymen is tight membrane that covers the vaginal outlet. Usually this ruptures during first few coital exposures. If this membrane persists, it can cause infertility.

5. Ovarian causes (25 to 40%):

a. Ovulatory dysfunction: This is a condition in which ovulation, the release of an egg from the ovary, does not occur regularly or is absent. These patients usually have irregular cycles.

b. Polycystic ovarian disease (PCOD): PCOD is an endocrine (hormonal) disorder in which the ovaries become enlarged and studded with numerous small cysts. PCOD is usually associated with ovulatory dysfunction, irregular cycles and obesity.

c. Premature ovarian failure (POF): When a female have menopause before the age of 40 years. Ovary is no more able to produce the eggs.

6. Endometriosis (1 to 10%): Endometrial tissue spreads to the ovary or elsewhere in the abdominal cavity and cause damage to the organs. Common site for endometriosis is ovary.

7. Immunological causes: In this disease antibodies develop in female against the sperms or oocytes. This can result in failure of fertilization, implantation or abortion.

8. Hormonal (endocrine) causes: Endocrine system produces very important hormones that are necessary for normal human reproduction. Abnormal hormonal production can result in infertility. In female FSH, LH, PRL (prolactin) (from pituitary glands), estrogen, progesterone, DHEA (from ovaries), insulin (from pancreas), thyroid hormones (from thyroid gland) & GnRh from hypothalamus are important. Common endocrine diseases associated with infertility are thyroid disorders (hypothyroidism, hyperthyroidism), diabetes, and Cushing's disease.

9. Genetic causes: Certain genetic diseases cause hormonal imbalance, anovulation, failure of fertilization or implantation or abortion. Common genetic abnormalities are Turner's syndrome, Down's syndrome, etc.

10. Mental Stress: Sound mind is necessary for normal process of hormonal production, ovulation, fertilization, implantation & future pregnancy outcome. Excessive mental stress can cause disturbances in above process of reproduction leading to infertility to some extent.

11. Systemic causes: Obesity, malnutrition, smoking, alcohol intake, kidney disease, sickle cell disease, chemotherapy, HIV/AIDS can lead to infertility.

12. Unexplained infertility: Some couples are unable to conceive in spite of normal reports. In these couples more extensive work up and advanced form of infertility treatment may be necessary.

Risk factors life style issues that affect fertility:
1. Age: the probability of having a baby decreases with increasing age.
2. Alcohol intake & smoking: increases the risk of infertility
3. Prolonged exposure to high temperatures, industrial chemicals and radiation.
4. Depression and stress: may impact the hormones that regulate ovulation.
5. Unprotected sex: may increase the risk of sexually transmitted diseases that can lead to pelvic inflammatory disease.

Ovulation

When does ovulation occur in female?

Timing of ovulation depends upon the duration and regularity of menstrual cycle of female partner. If cycles are regular i.e. 28 to 30 days, usually, in normal circumstances, ovulation occurs fourteen days prior to expected periods. If cycles are irregular then prediction of ovulation is difficult, in such cases you can take help of ovulation tests or consult your gynecologist.

Which tests are available for detection of ovulation?

Normal ovulation is defined as rupture of the ovarian follicle with release of an oocyte. The most common means of assessing ovulation in the menstruating woman include basal body temperature (BBT) recordings, cervical mucus changes, testing of luteinising hormone (LH) surge and serial ultrasound scans.

What should be the time of intercourse to achieve a pregnancy?

Timing of intercourse depends upon the duration and regularity of menstrual cycle of female partner. Usually, in normal circumstances, ovulation occurs fourteen days prior to expected periods. So, in general if a female partner is having a regular cycle of 28 to 30 days, she should have intercourse daily or alternate day from day 12 to day 18 of menstrual cycle to have a pregnancy. If cycles are irregular then prediction of ovulation is difficult, in such cases you can take help of ovulation tests or consult your gynecologist.

What is Superovulation?

In this treatment medicines like Clomiphen Citrate, Letroze & hormonal injections of FSH & LH or recombinant FSH are given daily to get more than one follicle which then are made to rupture by giving injection of HCG. This process increases chances of pregnancy by 30-40%. The risk of multiple pregnancy & ovarian hyperstimulation syndrome (OHSS) is there, so this is to be done judiciously.

After intercourse why semen comes out of vagina?

Normally vagina can accommodate upto half to one milliliter semen which is sufficient for normal reproduction. When husband's semen volume is more than this amount, the remaining semen may come out of vagina after intercourse. This will be not the cause of your infertility.

Age

Most women over age 30 also have healthy pregnancies and healthy babies. Recent studies suggest, however, that older moms do face some special risks. Since the late 1970s, birth rates for women in their late 30s and 40s have increased dramatically. The birth rates for women age 35 to 39 and 40 to 44 more than doubled.

Advances in medical care now help women in their late 30s and 40s have safer pregnancies than in the past. However, women should be aware of the risks associated with later childbearing so that they can make informed decisions about their pregnancies.

How much does age effect fertility ?

Women generally have some decrease in fertility starting in their early 30s. It is not unusual for a woman in her mid-30s or order to take longer to conceive than a younger women.

Age-related declines in fertility may be due, in part, to less frequent ovulation or to problems such as endometriosis, in which tissue similar to that lining the uterus attaches to the ovaries or fallopian tubes and interferes with conception.

If conception has not taken place after six months of trying, a women over age 35 should consult her Doctor. About one-third of women between age 35 and 39 and two-thirds of women over 40 have fertility problems. Many cases of infertility can be treated successfully.

IUI, IVF and ICSI
What is the success rate of IUI treatment?Success rate of IUI treatment varies greatly depending upon the age of both partners, cause of infertility, duration of infertility, type of treatment and sperm parameters. On an average the success rate of IUI is 10 to 20% depending on the couple's profile.

What is IVF-ET (In Vitro Fertilization - Embryo Transfer) Test-Tube baby? When is this needed to be done?

IVF-ET is needed to be done is patients with blocked fallopian tubes. It may also be done in other forms of infertility where IUI super ovulation has failed. In this, the woman is subjected to controlled ovarian hyperstimulation using hormonal injections. Injections are required to retrieve as many eggs as possible. Once the follicles have reached an appropriate size, vaginal ovum aspiration is done and the ova are collected in a petridish with a media. Capacitated sperms are then mixed with oocytes and fertilisation is achieved into the uterus. Once embryos are formed then they (2-3 embryos) are transferred into the uterus. Progesterone support is then given chemical pregnancy is diagnosed by B-HCG. Live pregnancy is confirmed in few weeks by seeing a live foetal heart on vaginal sonography.

What is the success rate of pregnancy after IVF?The success of conception depends on causes of infertility in a couple, age of female partner, number and grade of embryos transferred, experience of treating doctors, IVF lab standard and many other factors. Success rates range from 25-45%

Can we have intercourse (IC) after embryo transfer in IVF cycle?

IC should be avoided during embryo transfer in IVF cycle. Intercourse can cause implantation failure or abortion.

How many cycles of IVF are required to get pregnant?

Number of cycles required depends on the age of the patient, general health of the patient, cause of infertility, quality of the oocyte, quality of the semen, etc. Usually two to four cycles are tried.

What are causes of IVF failure?

Success rate of IVF depends upon the age, general condition of female partner, cause of infertility in couple, response to fertility drugs, number of eggs retrieved and fertilized, number of embryos transferred, condition of uterus, laboratory standard and experience of center.

a) Maternal age: Success rate of IVF decreases with increasing maternal age as number of eggs produced and their fertilization rate decreases with increasing age. Success rate of IVF is 53% for women in age group of 25 to 35 years, where as it is 18% for woman in the age group of 40 to 44 years.

b) Cause of infertility: This is another important factor deciding the outcome of IVF cycle. Highest success rates are found in patients having tubal damage with good uterine cavity and lowest among those with male factor infertility. Infection of uterus causes adhesions or scarring in uterine cavity or decreased endometrial thickness that can cause implantation failure. Also general ill health, debility and systemic diseases decrease the chance of conception.

c) Failure of response to drugs: In spite of giving daily injections of fertility drugs some patients respond poorly to produce sufficient number of eggs. This can be due to increasing age of patient or resistance to the drugs.

d) Failure of fertilization: Failure of fertilization may be due to poor quality oocytes, sperms, genetic diseases or improper culture conditions in the laboratory.

e) Number and grade of embryos transferred: Pregnancy rate increases with increasing number of grade 1 embryos transferred. But this also increases the risk of multiple pregnancies. Good quality grade 1 embryos have good potential for implantation and further development than grade 2, 3, 4 embryos.

f) Genetic disease: Genetic diseases in a couple can cause fertilization failure, cessation of growth of embryo or abortion. Karyotyping of couple, at least in high risk cases, is necessary before IVF, ICSI treatment to rule out genetic diseases.

g) Male factor infertility: Extremely low sperm count, impaired motility or poor sperm morphology represent main causes of failed fertilization in conventional IVF. Now days these factors are tackled by ICSI to some extent.

h) Excessive mental stress: Excessive stress can cause hormonal imbalance and altered body response to fertility drugs. This can lead to reduced number of oocytes, implantation failure or abortion. So during treatment the couple should be mentally and physically relaxed and should have positive thinking and attitude towards their treatment.

i) Unexplained causes: Some times failure can occur even if everything goes uneventful during whole treatment cycle. Here we are at the end of the beginning rather than at the beginning of the end. We need more research in this area to rule out much more causes.

Endometriosis

Endometriosis is a common disorder that affects women during their reproductive years. It occurs when endometrial tissue, which lines the uterus, grows outside the uterine cavity, or rarely in distant sites such as the navel or lungs. This tissue may grow in small, superficial patches called implants: in thicker, penetrating nodules: or it may form cysts in the ovary called endometriomas.

Endometriosis is highly unpredictable. Some women may have a few isolated implants that never spread or grow, while in others the disease may spread throughout the pelvis. Endometriosis irritates surrounding tissue and may produce web-like growths of scar tissue called adhesions. This scar tissue can bind any of the pelvic organs to one another and may sometimes cover them entirely.

Many women who have endometriosis experience few or symptoms. In fact, it is often diagnosed when a patient is undergoing pelvice surgery for other reasons. However, in some women, endometriosis may cause severe menstrual cramps, pain during intercourse, infertility, or other symptoms.

Many specialists feel that endometriosis is more likely to be found in women who have never been pregnant. For this reason, the condition is sometimes labeled a "career woman's disease, " because working women often delay pregnancy. But endometriosis cannot be so easily generalized. Sometimes it affects women who have had children and it can also occur in teenagers.

CAUSES OF ENDOMETRIOSIS

Several theories exists as to how endometriosis occurs

Moderate Endometriosis:

The "chocolate cysts" of endometriosis amy be smaller than a beans or larger than a large orange. The leading theory is retrograde menstruation, the backward flow of menstrual discharge through the fallopian tubes into the pelvis. According to this theory, the endometrial cells may implant on the ovaries or elsewhere in the pelvic cavity. There is support for this theory, because women with reproductive tract abnormalities that prevent the normal outflow of menstrual blood have an increased chance of developing endometriosis. However, retrograde flow has been noted in many women who never develop endometriosis, so there may be other mechanisms involved.

Severe Endometriosis:

In some cases bands of fibrous scar tissue (adhesions) bind the pelvic organs together or larger than an orange. Sudden pain may occur when a large cysts bleeds into itself or bursts. The spilled fluid may cause further inflammation and the development of scar tissue.

What are the after effects of hormonal treatment?

Hormonal treatment at the most influences weight gain by half to one kilogram; other than that there are no drastic hormonal effects incurred in the patient.

What precautions are taken to prevent mixing up of the semen and oocyte samples in the laboratory?

Semen samples of every male patient are washed in separate tubes that are labelled with their first and second names at every step. Oocytes retrieved after ovum pick-up are stored in disposable plastic petridishes labelled with the female patient's name and surname and the stage of the oocyte or embryo that results in culture. Throughout the procedure honest and accurate identification of the specimen is maintained.

 What is egg donation? Who can be the donor / recipient?

Egg donation is performed when a female patient has ovulation problems or if she produces bad quality oocytes after ovulation induction as for IVF. This procedure is done after the oral and written consent of the donor, and the recipient and her husband. This procedure is performed in absolute confidentiality with the physicians and the staff and the donor and the recipient. The recipient's menstrual cycle is coordinated with that of the donor's to enable fresh embryo transfer. All the eggs produced by the donor are inseminated with the recipient's husband sperms and the resulting embryos are transferred to the recipient's uterus. Excess embryos are cryopreserved so that they may be used for following attempts when in case pregnancy fails at the first attempt. Healthy women can opt for egg donation. They should be not more than 40 years of age. They are required to undergo psychological, medical and genetic testing. The centre maintains the data of the donor's height, hair color and type, blood type, ethnic background including caste and religion, educational qualifications, occupation, etc. The centre also accepts donor's that have been chosen by the recipients. The egg recipient is a woman whose medical and / or genetic tests indicate the use of donor eggs for achieving pregnancy.

What is host uterus and surrogacy?

For those biological mothers (egg donors) who are capable of ovulating and forming normal embryos but are diagnosed medically unfit to carry out the gestation (absent uterus, uterine synechie, damaged uterus) can hire/borrow gestational carrier (host) for her embryos to develop into a fetus. In this process, eggs from a biological mother is retrieved and fertilized in vitro, after which it is transferred to host uterus to complete gestation.
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