Causes for Infertility
Infertility has several different causes. Many couples may experience more than one cause. Some infertility causes can be overcome through lifestyle changes, hormone therapy and/or medical intervention such as in vitro fertilization, while other couples may need to take other measures, such as a surrogate mother or even adoption.
Whatever your choice, remember that if you and your partner want a baby, there is one for you, just waiting to be chosen or conceived, taken home and loved.
This article outlines several common causes for infertility and possible treatments. It explains the concepts without jargon so you can have an educated discussion with your doctor about your challenges in trying to conceive.
* Ovulation Factors
Ovulation – the release of an egg into the fallopian tube – is required for conception. Most women ovulate about once a month or approximately every 28 to 31 days.
Oligoovulation means a woman ovulates irregularly. If you suffer from oligoovulation, it will be hard to predict your ovulation by tracking your menstrual cycle, but measuring basal body temperature along with tracking cervical mucus changes may be more effective, as will over-the-counter ovulation predictor kits.
Anovulation means a woman isn’t ovulating at all – either permanently or temporarily. Drastic changes in diet or eating disorders such as anorexia and bulimia can cause temporary anovulation, as can excessive exercise, stress, and breastfeeding. Amenorrhea, also caused by these factors, refers to a lack of a menstrual cycle. Every so often, a woman can get her period but not release an egg during that cycle. This is called an anovulatory cycle.
Some diseases also cause anovulation. These include:
- Pituitary problems
- Polycystic ovarian syndrome (PCOS)
- Hypothalamic dysfunction
- Luteal phase defects
- Pituitary gland, adrenal gland or ovarian tumors
Hormonal imbalances are the number one cause of anovulatory cycles.
Replacement hormones and drug therapy can often induce ovulation, but in some cases, lifestyle changes – such as stress management, reducing strenuous exercise, or stopping breastfeeding – will bring back a normal menstrual cycle complete with regular ovulation.
* Cervical / Uterine Factors
If a woman is diagnosed with cervical infertility – usually done by means of a cervical exam – it means sperm is unable to pass through the cervix and into the uterus. Cervical infertility may be caused by:
- Cervical mucus too thick to allow sperm to pass through;
- A lack of cervical mucus to transport sperm;
- A narrow cervix, also called “stenosis”;
- A cervix infection, sometimes caused by sexually transmitted diseases;
- A sperm “allergy,” where the woman’s immune system attacks the sperm as a foreign body.
Uterine abnormalities are not a common cause of infertility; they are more closely associated with recurrent miscarriages. However, a number of uterine abnormalities may contribute to infertility. Often, these are not the primary cause of infertility but a factor to consider during in vitro fertilization to avoid pre-term pregnancy or miscarriage.
Abnormalities your doctor may check for include:
- congenital malformations;
- leiomyomas (fibroids);
- intrauterine adhesions (scarring)
- endometrial polyps.
* Tubal & Peritoneal Factors
- Completely blocked fallopian tubes
- One blocked tube
- Tubal scarring
- Tubal damage
- Tubal ligation (performed intentionally as permanent birth control)
A tubal blockage located close to the uterus is called “proximal” tubal blockage, while a blockage locating further away is called distal tubal blockage.
Making up about 25 percent of all infertility cases, tubal damage or blockage is one of the most prevalent causes of infertility. It is often caused by pelvic infections, including pelvic inflammatory disease (PID) or pelvic endometriosis, but can also be caused by scar tissue that forms after pelvic surgery. Some STDs, including gonorrhea and Chlamydia, cause pelvic infections that lead to tubal blockages.
Since tubal damage is such a common cause of infertility, most doctors will test for it using a special X-ray called a hysterosalpingogram (HSG) and/or a diagnostic laparoscopy.
Most blockages can be treated with surgery – even in the case of previous tubal ligation patients – but if surgery doesn’t work, in vitro fertilization remains an option for women with tubal infertility issues.
The peritoneum is a thin membrane that lines the pelvic cavity. Problems with this membrane, sometimes caused by endometriosis, ruptured appendicitis, pelvic inflammatory disease and scar tissue, can contribute to infertility.
Several immunological factors may lead to infertility. They include anti-sperm antibodies present in the male or female partner.
These anti-bodies can:
- immobilize sperm;
- make them clump together;
- limit their ability to pass through the cervical mucus or
- stop them from binding to and penetrating the egg.
In vitro fertilization using ICSI (injecting a sperm directly into an egg) has the highest success rate of any current treatments;
A woman’s body rejects the fetus as foreign tissue.
Clinics report a 70 percent success rate when treating this form of infertility by injecting the partner’s white blood cells into the woman prior to conception. When successful, the woman’s body begins to “recognize” the cells, and therefore, later identifies the fetus as “friendly.”
Antibodies in mother produce blood clots.
The prospective mother-to-be produces antibodies that cause clotting in blood vessels that lead to the fetus. Deprived of nutrients, the fetus dies in utero, triggering a spontaneous abortion or miscarriage.
Endometriosis afflicts more than 5.5 million American women and girls, and contributes to 25 to 50 percent of all infertility cases. Thirty to 40 percent of women suffering from endometriosis are infertile, so this is an important factor to look at if you have been trying unsuccessfully to conceive.
The Endometriosis Association lists several symptoms of the disease, but the disease may be asymptomic in mild cases.
- Pain before and during periods
- Pain during sex
- Painful urination during periods
- Painful bowel movements during periods
- Other Gastrointestinal upsets such as diarrhea, constipation, nausea.
What exactly is endometriosis? The Endo-Association defines it as a chronic disease that occurs “when tissue like that which lines the uterus (endometrium) is found outside the uterus, usually in the abdomen on the ovaries, fallopian tubes, and ligaments that support the uterus; the area between the vagina and rectum; the outer surface of the uterus; and the lining of the pelvic cavity.”
The tissue develops into growths or legions that—like the uterine lining—builds up, breaks down and sheds during a woman’s menstrual cycle. Since this lining has no way to leave the body, it results in internal bleeding, breakdown of the blood and tissue and painful inflammation.
*Treatment of Endometriosis
Although endometriosis has no cure, several different treatment options are available to reduce pain and symptoms, slow or shrink growths and preserve or restore fertility.
Medication: In mild cases, over-the-counter pain relievers such as aspirin and acetaminophen (Tylenol) and prostaglandin inhibitors such as ibuprofen (Advil and Motrin) can relieve pain and slow growth.
Hormone therapy: Stopping ovulation through oral contraceptives or other hormone therapy will also stop the build up and break down of legions. Obviously, this isn’t a desirable treatment option for women trying to conceive and may also cause side effects.
Surgery: Surgery – usually laparoscopy, an outpatient procedure in which surgery occurs through the belly button – can remove or destroy the growths and relieve pain. Pregnancy can often occur after such surgery. A more extensive procedure with a longer recovery time – laparotomy – involves a full incision, but is still considered “conservative” surgery, versus the alternative of a hysterectomy with removal of all growths and the ovaries.
Alternative / Natural Medicine: As with most diseases, alternative and natural treatments also exist. These can be used with traditional Western medicine treatments or alone and may include:
- nutritional changes
- homeopathic treatments
- immune therapy
- allergy management
- traditional Chinese medicine such as acupuncture and acupressure
* Pelvic Inflammatory Disease
Most infertility causes are not preventable, but Pelvic Inflammatory Disease, a bacterial infection in the upper genital tract, can be prevented by preventing STDs, including Chlamydia and Gonorrhea. A PID typically affects the uterus, fallopian tubes and ovaries and can lead to infertility. It is also the most important risk factor for ectopic pregnancies leading to miscarriages.
Since Chlamydia and Gonorrhea are transmitted through unprotected sex, use of a condom in any non-monogamous relationship can prevent the diseases and help prevent PID. If you are in a monogamous relationship, both partners should be tested to make sure they are free of STDs before they begin having unprotected sex.
Symptoms of PID include:
- lower abdominal and pelvic pain
- vaginal discharge or bleeding.
Symptoms may begin a few days after the start of your period.
When symptoms are present, doctors can diagnose PID through a bacterial culture of cervical discharge and a white blood cell count test. (Elevated levels may indicate the infection.)
PID is sometimes confused with appendicitis or a ruptured ovarian cyst, in which case a laparoscopy can confirm PID. It can be cured with antibiotics.
Only 10 to 25 percent of all single cases of PID (that is, not a recurring infection) result in damage to the fallopian tubes that cause infertility, and prompt treatment increases the odds that there will be no enduring side effects.
* Polycystic Ovarian Syndrome
The single-most common cause of female infertility, according to Women’s Health, the Federal Government Source for Women’s Health Information, is Polycystic Ovarian Syndrome. PCOS afflicts one in 10 women of childbearing age, although it can begin in young girls as early as age 11.
The syndrome occurs due to high levels of androgens (male hormones, although females also produce them in smaller quantities) in the body, leading to missed or irregular periods, baldness, excessive facial and/or body hair, cysts in the ovaries, and often, infertility.
A number of other symptoms and disorders are linked to the disease, including:
- pelvic pain
- sleep apnea
PCOS also carries with it an increased risk of:
- Type 2 diabetes
- high cholesterol
- high blood pressure
- heart disease
Why DOES PCOS cause infertility?
The follicles within a woman’s ovaries contain fluid and multiple eggs, which begin to mature each month. Usually only one egg matures fully, and the follicle breaks open to release the egg, which travels down the fallopian tube ready to be fertilized. This process is called ovulation.
PCOS prevents the ovary from making all the hormones it needs for an egg to fully mature. Instead, follicles grow and build up fluid, remaining as cysts. Without ovulation, the woman’s body doesn’t produce progesterone, and the menstrual cycle become irregular or non-existent (called anovulation). Obviously, without ovulation, pregnancy cannot occur by natural methods.
Treatments for PCOS
No cure exists for the syndrome but treatment and lifestyle changes designed to manage the illness can reduce the risk of complications, minimize symptoms and also increase the chances of a successful conception and pregnancy.
Unfortunately, one of the most common forms of PCOS treatment is the use of birth control pills to regulate menstrual cycles and reduce the presence of male hormones. This is not a permanent fix, however, and lasts only as long as the woman is on the Pill, so is not a desired treatment for women trying to conceive.
Diabetes medications: Diabetes medications, including Glucophage (metformin) lowers testosterone production and controls the way the insulin controls blood sugar levels. PCOS is linked to insulin production, making this an effective treatment. Glucophage, according to an article in the New England Journal of Medicine, was recently found safe for pregnant women to treat gestational diabetes, and so may be a good option to discuss with your doctor if you trying to conceive with PCOS.
Fertility medications: Since anovulation causes infertility – and is a common symptom of PCOS – medicines designed to stimulate ovulation may help a woman with PCOS become pregnant. Clomiphene citrate, under the brand names Clomid or Serophene, usually works. Sometimes metformin will be added, which may help a woman ovulate with on a lower dose of both medications. Gonadrotropins – a fertility medicine taken by injection – may also be used, but carries a greater risk of multiple births. Finally, in vitro fertilization remains an option for women trying to conceive with PCOS.
Surgery: When fertility medicines don’t work, “ovarian drilling” – a laparoscopic procedure – may be used as a last effort to stimulate ovulation. The surgeon punctures an ovary with a small needle and uses an electric current to destroy a small portion of the ovary. There is a risk of scar tissue developing on the ovary, but the surgery may lower male hormone levels, stimulating ovulation. Effects may last a few months, creating a small window during which a woman may conceive naturally or through artificial insemination. The treatment typically doesn’t help with cosmetic symptoms of PCOS, such as baldness or body and facial hair growth.
Lifestyle modification: Often, women can manage the symptoms and risks of PCOS with lifestyle changes, including regular exercise and a healthy diet rich in fruits, vegetables and whole-grain products. By following a diet similar to what a diabetic should eat, a woman with PCOS can improve her body’s use of insulin and normalize hormone levels, which may stimulate ovulation and even create regular menstrual cycles, leading to the possibility of a healthy pregnancy.
*Premature Ovarian Failure
According to the International Premature Ovarian Failure Association, approximately one to four percent of the female population suffers from Premature Ovarian Failure, sometimes called premature menopause.
Premature Ovarian Failure typically occurs in women under 40; it can happen as early as the teen years. POF may be caused by certain syndromes, diseases, genetic disorders or even radiation treatment or chemotherapy, although in many patients, doctors can’t identify a specific cause at all.
If you are not pregnant, breastfeeding or menopausal and your periods have stopped or become irregular, it could be due to POF. You may also experience other symptoms of menopause, including:
- Hot flashes
- Vaginal dryness
- Lack of sex drive
- Painful sex
- Bladder control problems
- Mood swings
- Energy loss
Unfortunately, only about six to eight percent of women with POF will be able to successfully conceive. No treatments exist to restore fertility in women with POF, but you should still seek treatment for the disorder, because it carries several other health risks including an increased risk of osteoporosis, and heart disease.
A doctor may diagnose POF with two FSH tests done approximately a month apart. If FSH (Follicle Stimulating Hormone) levels are normal, it typically indicates the ovaries are working correctly. Women with POF will show FSH levels in the post-menopausal range.
According to the International POF Association, many doctors misdiagnose POF or blame the symptoms on stress. Insist on diagnostic testing to either rule out or diagnose the disorder so that you can begin treatment promptly. Treatment may include hormone replacement therapy and lifestyle changes to manage symptoms and decrease the health risks of complications associated with POF, such as osteoporosis and heart disease.
* Fibroid Tumors
Fibroid tumors by themselves are a primary cause of fertility in only three to 12 percent of women who have them. If fibroid tumors block the fallopian tubes, they can cause infertility.
However, treatments for fibroid tumors, including myomectomy – a surgical procedure in which fibroids are removed but the uterus remains intact – and hysterectomy can cause permanent infertility. In many cases, fibroid tumors return after a myomectomy and the surgery must be repeated. This repeated procedure can cause uterine scarring leading to infertility. If conception occurs, however, 85 to 90 percent of all women will have a successful pregnancy without complications.
Female Alternative Surgery, which uses lasers to remove the fibroid tumors without damaging the uterus or ovaries and preserving fertility, should be discussed with your doctor, as well.
What are Fibroid Tumors?
Fibroid tumors are benign masses which grow in the uterus. They can be hard and stony or soft and rubbery. Nearly 25 percent of all women of childbearing age have fibroids. They are typically identified during a gynecological exam when a doctor may feel a mass in the uterus; this diagnosis may be confirmed by an ultrasound.
Some women won’t have any symptoms from fibroid tumors and, chances are, without any symptoms, the fibroids also won’t create problems with conception. However, if you are having fertility issues and have any of the following symptoms, fibroid tumors blocking the fallopian tubes may be a cause.
Symptoms of Fibroid Tumors
- Pelvic Pain
- Increased menstrual cramps
- Increased menstrual flow
- Irregular or painful periods
- Increased urinary frequency
A hormonal disordered characterized by unusually high levels of prolactin in the blood in non-pregnant, non-breastfeeding women or in men.
This disorder occurs in approximately 10 percent of the population and can result in infertility in males or females. In women, it can cause irregular or non-existent menstrual periods.
Stress, sex, exercise, sleep, nipple stimulation, certain prescription drugs and even eating certain foods can also increase prolactin levels temporarily. If one blood test shows elevated levels of prolactin, a follow-up test should be ordered to confirm the diagnosis.
If hyperprolactinemia is causing infertility, it can be treated with prescription drugs.
* Luteal Phase Defect
The luteal phase of a woman’s menstrual cycle begins immediately after ovulation and continues for approximately 12 to 14 days. If the luteal phase lasts 10 days or less, it is considered a Luteal Phase Defect. Some doctors believe any luteal phase shorter than 12 days can cause problems. This shortened time period may not allow the uterine lining to develop enough for the embryo to fully implant, and often leads to an early miscarriage or a failure to conceive.
LPD occurs because of inadequate progesterone stimulation; it is a hormonal imbalance. You may discover a Luteal Phase Defect while charting your fertility. A time frame between ovulation and menstruation of less than 12 days may indicate an LPD. A doctor can discover an LPD with a simple blood test that detects progesterone levels in your body seven days after ovulation.
It is often treated with vitamin B6 and progesterone cream, which help lengthen the luteal phase.
If over-the-counter treatments don’t work, a reproductive endocrinologist may prescribe Clomid or progesterone suppositories.
* Other Causes of Infertility
Several other causes of infertility exist. A reproductive endocrinologist may explore some of these possible causes with you.
Anything that effects your menstrual cycle, including stress, rapid weight loss or gain, travel, and intense exercise can cause temporary infertility. These are all factors to consider when you are trying to conceive.
Additionally, some medical conditions can lead to infertility. Some diseases associated with infertility, pregnancy complications or miscarriage include:
- Thyroid Disease
Author: Dawn Allcot
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