1FEMALE INFERTILITY- IN GENERAL

• Infertility is a condition in which successful pregnancy has not occurred, despite normal intercourse over 12 months. The cause of female infertility is multifactorial 
• Infertility in women who have never been pregnant is primary infertility and infertility in women who have previously conceived is termed secondary infertility
• In nearly 30 % of the cases, the cause of infertility may be attributed to the female partner

Ovarian factors

• Hypothalamic Amenorrhoea
• Hyperprolactinemia
• Pituitary adenoma
• Primary hypothyroidism
• Impaired ovum transport in fallopian tubes 
• PCOD
• Subclinical adrenal failure
• Diabetes mellitus
• Leutinized unruptured follicles
• Luteal phase deficiency
• Premature ovarian failure
• Resistant ovary syndrome
• Luteal phase defect

Cervical factors

• Cervical stenosis
• The Faulty direction of cervix
• Impenetrable cervical mucous -Local anti sperm antibodies or Low pH mucous
• Loss of mucous due to amputation of the cervix- Cone biopsies

Vaginal factors:-

• Purulent discharge
• Vaginal tumours
• Vaginal septa

Peritoneal factors:- 

• Infection
• Adhesions
• Adnexal masses
• Endometriosis
• PID

Tubal factors

• Partial or complete bilateral tubal obstruction from salpingitis associated infection

Uterine factors

• Congenital uterine anomaly
• Fibroids
• Polyps
• Poor cervical mucous quality
• Uterine synechiae
• Pinhole os
• Intrauterine adhesions
• Tuberculous endometritis

Unexplained or psychological factors

• 15% of infertility is of unknown etiology

• Depends on the underlying condition
• Symptoms of anovulation, amenorrhoea, irregular menses

Examinations

• General physical examination to see the fragments of amenorrhoea

Abdominal examination: 

• Masses felt in the hypogastrium could be arising from the pelvic region

Per speculum examination:

• The distribution of hair pattern in the external genitalia
• Inspection of vaginal mucosa to detect abnormalities such as deficiency of oestrogen or the presence of infection
• Cervical abnormalities should be ruled out like cervical stenosis

Pelvic examination:

• Various pelvic pathologies like fibroids, adnexal masses, tenderness or pelvic nodules indicative of infection or endometriosis, uterine defects (such as absence of the vagina and uterus, Presence of vaginal septum, etc) can be detected on bimanual examinationBMI

Increased BMI (>28) found to be associated with 

• Hyperinsulinemia
• Oligomenorrhoea
• Anovulation
• PCOS

Basal Hormone Evaluation

• Usually done between the third and fifth day of the menstrual cycle – Hormone levels vary the least during this period in the cycle. Irregular hormone levels in this phase suggest a disorder in follicular maturation
• Elevated FSH indicates diminished ovum reserve
• Elevated LH deteriorates oocyte quality
• Serum progesterone on D21-D23 of a 28-day cycle at a level of 10 ng/mL indicate adequate ovulation and adequate luteal phase
• TFT (Thyroid Function test)
• Serum prolactin and androgen levels – elevated levels suppress ovulation
• Antimullerian hormone (AMH) - For quantitative prediction of ovarian reserve

Ultrasonography

• To detect patency of uterus and ovary
• Follicular study to confirm ovulation (Dominant follicle is 17 mm in diameter, Diagnosis of leutinized unruptured follicle can be diagnosed)

Endometrial biopsy

• 2 days prior to the onset of cycle
• A secretory endometrium and subnuclear vacuolation is pathognomic of ovulation
• Endometrium showing 2 days lag is suggestive of LPD(Luteal phase defect)
• Bacteriological evaluation to rule out tuberculosis

Hysterosalpingogram

• To test the tubal patency
• Usually done on 7th -10th day of a cycle

Hysteroscopy

• To assess the pelvic organs and tubal patency

Mandatory when HSG reveals intrauterine lesions like 

• Fibroids
• Endometrial polyps
• Congenital uterine anomaly
• Intrauterine adhesions
• Women undergoing IVF
• Failure of implantation after three cycles

Laparoscopy

Mandatory in the presence of 

• Pelvic diseases
• Endometriosis
• Unexplained infertility
• Tubal block in HSG

Ovarian factors evaluation 

• Follicular study
• Serum progesterone level on 21st day of the cycle
• Clomiphine citrate challenge test
• USG to diagnosis PCOD
• Basal body temperature charting

• Treatment plan should be based onthe duration of infertility and Women’s age
• Patient counseling - counsel about fertile period of cycle, intercourse in every 2-3 days, mind factors
• Life tyle changes -BMI should be achieved between 20-25, Stop alcohol consumption and smoking

Treatment for Cervical factors

• Chronic cervicitis - Antibiotics
• IUI can be an alternative for cervical factors of infertility

Treatment for uterine factors

• Lysis of uterine sepatate and uterine synechiae
• Surgical treatment of uterine abnormalities
• Hysteroscopic removal of endometrial polyps
• Treatment for uterine fibroids

Treatment for tubal factors of infertility

• Microsurgery and laparoscopy
• Electrocautery
• Endocoagulation
• Lasers
• Selective salpingography and tubal catheterisation
• Hysteroscopic tubal canulation

Treatment for ovarian factors

• PCOS- Weight loss through diet and exercise, ovulation induction, Dietary changes, and surgery
• Ovulation inducing drugs like clomiphine citrate, hMGs, and synthetic GnRH analogues
• ART- Assisted reproductive techniques like IVF, ICSI, etc