Female Infertility, its causes and treatments

One of the most important symptoms of infertility is the inability of getting pregnant. Also the menstrual cycle of 35 days or more, or less than 21 days, and irregular or absent menstrual cycle can also mean that you have problems with ovulation

When Is The Right Time To See An Infertility Specialist?

When you notice the above symptoms it is very much needed to visit your gynecologist. The time to see a doctor depends on your age and let us discuss what your doctors recommend according to your age:

• If you are 30 to 35 years, your doctor will ask you to try for pregnancy for at least one year before he starts you with fertility tests or treatments.
• If your age falls between 35 and 40, you can talk to your doctor after trying for six months.
• If you are above 40 years, your doctor will start fertility tests and treatments as soon as possible.

If you or your partner has a history of fertility problems, or if you have issues of irregular periods, pelvic inflammatory disease, previous miscarriage, endometriosis, or cancer treatment, your doctor might suggest fertility tests and treatments right away.

Discuss with your doctor about pre-existing medical conditions: If you have long-term medical conditions like asthma, diabetes, epilepsy and mental health-related disorders, you should talk to your doctor and inform them about medicines taken for these conditions. Because the medicines that you take to treat these diseases make it harder for you to get pregnant. Without discussing it with a doctor, you should not stop taking these medicines.

There are many reasons that may cause your infertility. The most common factors for reduced fertility [1] are as follows:

Problems With Ovulation

• Polycystic ovarian syndrome: This is considered as the most common cause of your infertility and is said to interfere with the normal ovulation process. It causes a hormonal imbalance that causes ovulatory problems. Abnormal hair growth on face and body, acne formation, obesity, and insulin resistance are caused due to PCOS.
• Primary ovarian insufficiency POI: POI is another cause of problems with ovulation. It is a condition in which your ovaries stop working normally before you reach 40 years and is not the same as early menopause [2].
• Excess production of prolactin-hyperprolactinemia: The pituitary gland causes an excess of prolactin which in turn reduces your estrogen levels resulting in your infertility.
• Problems related to the thyroid gland: Hypothyroidism is seen in 2-4% of women in their reproductive age and it affects your fertility causing anovulatory cycles, luteal phase defects, hyperprolactinemia, and an imbalance of sex hormones [3].

Problems with Uterus

• Fibroids of the uterus: About 35% to 77% [4] of women are affected by fibroids in their reproductive age. Myomectomy is preferred for your fibroid-related infertility and helps to have children and to maintain your fertility.
• PID Pelvic Inflammatory Disease: According to a study, 19 out of 48 women who do not take contraceptive care are said to be unknowingly affected with infertility after an index episode of PID [5].
• Uterine polyps: Overgrowth of endometrial tissue on the surface of your uterus results in the formation of uterine polyps. They cause irregular or heavy vaginal bleeding.
• Uterine septum: A congenital defect where your uterus is divided by a longitudinal septum. When the embryo gets settled on the lining of the divided uterine wall, it can lead to miscarriage. Studies show that congenital uterine anomalies are present in 7.3% of the infertile population.
• Cysts of the ovaries: If you have ovarian cysts that are filled with endometrial tissue then you may have infertility issues. They can be drained or removed surgically. Cysts on ovaries may sometimes get infected causing pelvic inflammation and scarring of fallopian tubes and ends up in fertility problems.

Cervix Problems

• Stenosis of the cervix: If you have a narrowed cervix that is inherited or acquired, then sperms cannot reach ovaries and can cause fertility problems.
• Sometimes, your cervix may produce an abnormally thick and sticky type of mucus that makes it difficult for the sperm to travel to your uterus.

Fallopian Tubes Problems

If your fallopian tubes are blocked or damaged, the sperm of your partner cannot reach your egg or your fertilized egg cannot implant onto your uterus. Tubal damage or blockage is due to:

1. Pelvic inflammatory disease of fallopian tubes caused by infection with chlamydia, gonorrhea, or other infections that are transmitted sexually.
2. Prior surgery of your abdomen or pelvic region like for the ectopic pregnancy. Here, the fertilized egg develops in a fallopian tube and it is an emergency surgical condition.
3. Another major cause of fallopian tubal blockage is tuberculosis of pelvis, which damages your tubes and causes infertility.

Endometriosis

You may suffer infertility if you have endometriosis, as it affects the embryos and gametes, transport of embryos, and causes fallopian tube abnormalities. Fallopian tubes are the places where your egg meets with the sperm and gets fertilized. When they get blocked due to endometriosis, you cannot achieve pregnancy. Abnormal endometrial tissue develops outside of your uterus in various other organs like ovaries and fallopian tubes and causes obstruction for the passage of egg and sperm. Surgical treatment of endometriosis includes [6] surgical ablation or resection and this improves your ability to give birth to a baby.

Lifestyle-related Issues

• Smoking: If you have a habit of smoking. It can lead to ovulatory problems and hormonal imbalance.
• Stress: If you have increased stress, there is a release of cortisol, a stress hormone which shows a negative impact on your fertility.
• Poor diet: The diet that you take if it does not include essential vitamins and nutrients, causes reduced fertility or poor functioning of reproductive organs.
• Anorexia or bulimia: An eating disorder causing infertility as you cannot eat essential foods that are needed to boost your immune system as well as your fertility.
• Athletic training: When you over-exercise, you lose significant body fat, which is not good.
• Addiction to alcohol or other drugs: Over intake of alcohol or any other recreational drugs lower your chances of conceiving.
• Overweight: You may have a high chance of facing menstrual dysfunction and anovulation if you are overweight [7].
• Age: Your age plays a major role in your fertility, and fertility tends to decrease with your age

Evaluation of your infertility is needed if you face issues to become pregnant after trying for more than 12 months having unprotected sex. Testing should be done in a cost-effective and focused way so that all relevant factors are known. Those tests that are less invasive and most commonly used are done first to know causes for your infertility. The speed and limitation of the tests should be based on your and your partner’s preferences, your age, duration of infertility and features of your medical and physical examination.

There are many tests that can help you analyze your infertility

Tests For Ovulation At Home

When you have trouble conceiving you should first check for ovulation whether it is happening or not. Following steps can help you to know your ovulation process

There are a few steps that you can do at home that help you know whether you are ovulating:

1) Write down alterations in your morning body temperature for a period of a few months.

2) Note down the appearance of your cervical mucus for a couple of months.

3) Nowadays a home ovulation kit is available at drug stores that help you to know your ovulation time.

Test of Ovarian Reserve

The egg quality and quantity that is needed for ovulation is checked by this test. If you are aged above 35 years, your egg quality may be reduced. Testing of follicle-stimulating hormone (FSH), estradiol, anti-Mullerian hormone (AMH) and ovarian antral follicle count (AFT) is done by your doctor to check your ovarian reserve.

Test For Evaluating Uterus

• Hysteroscopy: Your doctor will identify abnormalities of your uterus by inserting a hysteroscope, a tiny tube with a small camera at one end.
• Vaginal or abdominal ultrasound: It is done to look inside of your uterus and ovaries for any blocks, fibroids, or tumours.
• Sonohystogram: It is an ultrasound test that is done by injecting saline into your uterus helps to identify abnormalities like fibroids of the uterus.

Test for fallopian tube evaluation

1. Hysterosalpingogram (HSG): With the help of this specialized x-ray your doctor will spot blocks in your fallopian tubes by injecting a dye.
2. Laparoscopic examination of your abdomen helps in evaluating the condition of your reproductive organs, determining blockages of fallopian tubes, any scar tissues that may be present, or any adhesions within pelvic organs.

Test of Cervical Mucus

Testing of your cervical mucus and tissue, helps you to know whether ovulation is occurring or not.

You can check the cervical mucus texture by wiping it with toilet paper at the vaginal opening. If your mucus is stretchy, slippery, and watery kind, resembling raw egg white your ovulation time is nearing. You can have intercourse at this time for conceiving.

Other Hormonal Tests

Progesterone is a hormone that is produced by your body after ovulation. So, a blood test done to check its production helps to document your ovulation.

Luteinizing hormone LH, the level of this hormone is raised in your urine when the ovary releases the egg.

Other hormones like prolactin, can also be checked for confirming your ovulation. Urine and blood tests are done to check for any infection or for any hormonal problem including that of thyroid function.

Genetic Test

This helps to know whether you have any genetic related factor that is causing infertility. Here the DNA is examined to know any gene changes that are causing your infertility.

Treatment for your infertility mainly depends on the cause, your age, duration of your infertile period.

Some of the methods include:

• Surgical treatment
• Inducing ovulation through hormonal therapy
• ART(assisted reproductive technology) that includes IVF.
• Fertility enhancing drugs or supplements.
• Control of infections by using antibiotics.

Surgical Methods for treating Female Infertility

If there are blocks or obstructions in your major reproductive organs they cause infertility.

Surgery can remove uterine polyps and fibroids, correct any abnormal uterine shape, and remove any pelvic or uterine adhesions.

Advanced technology has given way to treat most of the problematic issues of the reproductive system like the above-mentioned ones. A simple keyhole surgery or an operative Laparoscope (done through making small cuts on the abdomen) or an operative hysteroscope (a small tube having a camera and light is sent into the cervix and uterus) are done to evaluate and treat the above-mentioned issues.

Sometimes, if the above is not possible due to various reasons, then there is a need for open surgery where a long cut is made on the abdomen.

Hormonal Therapy for treating Female Fertility

when you have irregular or no periods, it indicates that your ovulation process is also irregular or absent. There may be chances of missed ovulation even if you have regular and uninterrupted periods.

There are a number of fertility medicines that are used to treat problems of ovulation. It is important for you to know about the pros and cons of these fertility medicines and should discuss with your doctor to get a better understanding of any dangers, side effects, and benefits.

A wide range of medicines in the form of tablets or injections are used to induce ovulation such as:

• Clomid or Clomiphene citrate: A doctor recommends this if you have the polycystic ovarian syndrome. It induces ovulation by acting on the pituitary gland and you are supposed to take it by mouth.
• Metformin or Glucophage: This is used when you have insulin resistance Diabetes and PCOS. It helps to lower your male hormones that are present in excess when you have PCOS and causes ovulation. You take it by mouth and few times in combination with clomiphene citrate or FSH.
• Human menopausal gonadotropin or hMG: This is suggested if you have pituitary gland problems and cannot ovulate because of it. It is given as injection and acts on your ovaries to cause ovulation (Repronex, Pergonal).
• FSH or follicle-stimulating hormone: They are injectable medicines making your ovaries to ovulate and act just like hMG. Examples are Gonal-F, Follistim.
• Gn-RH analog: If your ovulation is irregular, then these analogues act on your pituitary gland and make ovaries to produce eggs. You may show unpredictable responses when taking these medicines and so you should be closely observed. You take them as nasal spray or as injections.
• Bromocriptine: Sometimes your ovulation problem may be due to high levels of prolactin hormone that causes the production of milk. In such a case, this medicine is given to inhibit the secretion of prolactin. (Parlodel)

Assisted Reproductive Technology for treating Female Infertility

ART is a group of procedures that involves the removal of eggs from a woman’s body. These eggs are then mixed up with the sperm to develop into an embryo. These embryos are then carefully placed back into your uterus. Though it is very expensive and time-consuming, ART procedures help many of the Couples to conceive.

Success of ART: It largely varies and depends on:

• Your cause of infertility
• Your age and your partner's age- Advanced female age[8] has a negative impact on ART outcomes. So, if you are above 42 years then you should go for other options like oocyte donation or adoption.
• Type of clinic where you get treatment
• Type of ART suggested for you
• Whether the egg that is used for your ART is fresh or frozen.
• Whether the embryo that is used is fresh or frozen.

ART methods that are commonly followed:

Known methods of ART are:

• IUI Intrauterine insemination: This is an important treatment method for infertility. Here, specially prepared healthy sperm is injected directly into your uterus. You will be given ovulation stimulating drugs before starting IUI. This method treats mild infertility factors in males, couples with idiopathic or unexplained infertility, and women having problems with the viscosity of her cervical mucus.
• IVF: In-vitro fertilization, which means fertilization, is done outside the body and is the most effective of ART methods. If your partner has less sperm count or your fallopian tubes are blocked, this ART method is often helpful. First, you will be given medicines to increase egg production and these eggs are removed from your uterus once when they are matured. These matured eggs are then combined with the sperm of your partner to promote fertilization in a dish of a lab. In 3 to 5 days this fertilization results in the formation of healthy embryos which are then implanted into your uterus.
• (ZIFT) Zygote Intrafallopian Transfer or Tubal Embryo Transfer: All the steps in this process are similar to that of IVF, but after fertilization, the embryos are implanted into your fallopian tubes and not in the uterus.
• (ICSI) Intracytoplasmic sperm injection: Here a mature egg is fertilized by injecting only a single sperm and the embryo thus developed is then transferred into your uterus or fallopian tubes. This method is quite beneficial for those having serious sperm abnormalities, for older couples and for those with repeated failure of IVF attempts.
• Gamete Intrafallopian Transfer (GIFT): Here fertilization is made to occur inside your body by transferring eggs and sperm into your fallopian tubes.
• Surrogacy: This method is often considered beneficial if you have no eggs or if you have severe medical issues that cause unhealthy egg production. In such conditions, you can consider having a baby through Surrogacy. A woman is said to be a Surrogate mother when she agrees legally to bear the baby in her womb using the man’s sperm and her own egg. Due to her egg sharing, she becomes the biological mother of the baby. Once the baby is born, this surrogate mother will give up the baby for the intended parents.

Other treatments for Female Infertility

Apart from the mainstream treatments mentioned above, there are some other treatments for infertility available as well. They are:

Fertility Enhancing Supplements for Female Infertility

There are few herbs and supplements that can boost your fertility levels. Even though they are marketed as natural, you should consider whether they have FDA approval and any serious side effects they cause.

Some of the herbs and supplements are Vitamin B, C, D and E. Calcium, folic acid and folate, fish oil, and magnesium.

Control of Infections by Using Antibiotics

If you have a history of pelvic inflammatory disease, antibiotics are prescribed by gynecologists to control your infection and they are to be taken under prescription only.

The ability of you to conceive, your fertile future, and the regularity of your menstrual cycle are determined by the healthy eggs that your ovaries will produce. We all know that there is a wide range of factors that highly influence the quality and health of eggs a woman produces. Factors like diet and nutrition, your social life, the environment in which you live, your hormones, amount of stress, and rest in daily life and circulation in the overall body do impact the health of eggs.

If you have enough knowledge of these factors, you can increase your chances of getting pregnant by modifying your lifestyle, planning, and following a strict and healthy diet. This will help to improve your quality of eggs.

There are a number of things that a woman at the age of 35 or above can do to improve her egg quality. Because after 35 years, egg quality gets reduced. Very simple tweaks to your lifestyle like taking vitamin supplements and herbal concoctions could show a tremendous impact on your ability to get pregnant.

• Say “no '' to smoking: Once you plan to conceive it is better to quit smoking, as it has a major negative impact on the fertility rates of both males and females. You will definitely have improved chances of getting conceived once you stop smoking. Smoking has been proved to cause serious damage to your baby by affecting its DNA.
• Several studies[9]noticed the harmful effects of tobacco in women as reduction of pregnancy rate, early spontaneous abortions are increased and there is a drastic alteration of ovarian reserves.
• Cut short on your “caffeine” intake: A meta-analysis study[10] result shows that there is significant evidence of an association between caffeine intake and the risk of having a spontaneous abortion. If you and your partner have a habit of consuming high doses of caffeine, while planning to get pregnant, it can result in your increased risk of miscarriage. It is proved through studies that caffeine intake would double the negative effects of alcohol and impact your probability of conception.
• A Big “no” to a glass of alcohol: Studies[11] show that if you have a habit of drinking alcohol, you will have 50% fewer chances to conceive during your menstrual cycle. So when you are trying to conceive you better avoid having alcohol. Alcohol can cause serious complications to the developing brain of your baby especially during the first three months of pregnancy.
• Stress management: Try managing stress at home, work, and with other kids. Because stress causes the release of cortisol and prolactin, the hormones that can hamper your ovulation. Focus on doing activities like yoga, swimming, meditation, gentle dancing, etc that gives energy and positive thoughts.
• Studies [12 ] have shown a possible relationship between high levels of stress and higher levels of stress hormones like cortisol, causing infertility.
• Focus on a healthy diet: A diet loaded with leafy vegetables, nuts, fruits, healthy and organic fish, meat, lentils, beans, and whole grains is the best natural remedy for a good quality egg and helps in boosting up your fertility levels. It is advised to stay away from deep-fried foods, processed meats, excessive salts, and sugars.
• Maintain ideal BMI (body mass index): By calculating your height and weight, BMI is estimated and this tells you about the ideal healthy weight. A BMI of 18.5-24.9 is said to be ideal before you conceive. Overweight causes increased oxidative stress and hasten reproductive processes. Studies have proved that overweight women have increased risk of miscarriages, pregnancy complications, and a lowered conception rate. They show poor outcomes both in natural as well as assisted conception. A high BMI (25) and a lower than normal BMI (18.5 or less) affect your fertility and cause complications of your pregnancy. Eating the right food and focusing on a regular exercise regimen helps you maintain a healthy weight.
• Aim to improve healthy blood circulation: Ovaries will produce healthy eggs when they get sufficient oxygen-rich blood. This is possible if you keep dehydration away by having good amounts of water, as dehydration decreases blood flow. Also, practising yoga regularly before you plan to conceive helps to improve overall blood circulation and is very effective to deal with fertility issues of female reproductive organs. Some of the yoga poses that help to boost up your fertility are child pose, lotus pose, reclining hero and seated forward bend pose.
• Take folic acid supplements: Your baby will have good protection from neural tube defects if you take enough folic acid. It is ideal to take a folic acid supplement two months prior you plan your pregnancy and should continue even after. Do visit your gynecologist to get an idea of best-suited supplements.
• Do not take non-prescribed medicines of your own.
• Get your cervical screening test done: If you are aged between 25 to 49, then you should undergo cervical screening tests every 3 years. It helps to identify any infections associated with the cervical region that may interfere with your pregnancy.
• Freezing of eggs: Some of the women have plans to delay their pregnancy due to personal and medical reasons. The best way to preserve your fertility is to get your eggs frozen for future use. Freezing eggs defy the biological clock and you can boost your chances of pregnancy with cryopreservation of your eggs.
• Give a try to Acupuncture: This is an ancient Chinese technique that helps to improve egg quality. By reducing stress, acupuncture aids in the stimulation of healthy egg production from your ovaries. Before you plan for acupuncture, do visit your doctor for better suggestions.
• Get tested for sexually transmitted infections STIs: if there is any chance that you or your partner have an STI, it is better to get tested as STIs affect your fertility. Your future pregnancy and your baby will also have to face serious issues if you left your STIs untreated.

When trying to get conceived, you should take care of your diet and nutrition. Wholesome and balanced foods will give you all the nutrition that is needed for maintaining a healthy reproductive system, to keep your hormones stable and improve your circulation.

Fertility boosting nutrients, in short, are iron, fibre, carbohydrates, good fats, high-fat dairy, vegetable protein, and folic acid, and plenty of vitamins.

Below is given a list of superfoods that you should include in your diet if you are planning to get pregnant:

• Bananas: Enriched with potassium and Vitamin B6, banana helps in improving egg quality by regulating reproductive hormones.
• Beans: When the iron level in your body is low, there is a production of unhealthy or less healthy eggs. Beans, which are full of protein and iron are known to increase women's fertility and libido.
• Complex carbs: According to studies, it is known that high insulin levels inhibit the ovulation process. Bad carbs that are taken by us are quickly digested and cause an increase in blood sugar levels. Complex carbs, also known to be good carbs, are digested slowly and show a gradual effect on your blood sugar levels.
• Greens: Ovulation is enhanced by folate and Vitamin B, which are abundantly present in green leafy vegetables. Greens also increase your libido.
• Berries: Being rich in antioxidants, berries, specifically strawberries, protects eggs from ageing and from getting damaged and even improves libido.
• Potatoes: Vitamin C is abundantly available in potatoes when they are taken in baked form. They are said to treat luteal phase defects, where your ovaries do not produce enough progesterone.
• Pumpkin seeds: They are a rich source of non-heme iron. It was found by a study that women who consume this iron regularly have 40% less trouble in getting pregnant, than those who do not consume it.
• Olive oil: Rich in monounsaturated fats, olive oil helps to reduce inflammation in the body, which is said to interfere with the ovulation process and early development of the embryo.
• Whole dairy products: It has been found that consuming full-fat dairy products help with less trouble in getting pregnant.
• Dates: Iron and folate play a major role during your conception and pregnancy. Dates are rich in iron, folate, potassium, Vitamins B and K, antioxidants, and other essential nutrients.
• Sesame seeds: They are rich in zinc and produce hormones that are responsible to maintain good health of your eggs.
• Pomegranates: They are power storages of antioxidants, Vitamins C and K, folate, and potassium, and are effective to improve blood flow to the pelvic region. They increase female fertility and help in thickening the lining of the uterus and this helps in reduced chances of miscarriage.
• Cinnamon: This keeps female infertility at bay by making your ovaries function normally. Polycystic ovarian syndrome PCOS, which is one of the major causes of female infertility is treated by consuming cinnamon. Drink tea for a few months, by adding a teaspoon of cinnamon powder in a cup of warm water.
• Nutmeg: It enhances your fertility and increases the chances of getting pregnant. Equal quantities of nutmeg powder and sugar powder are taken with a cup of cow’s milk during your periods’ help to fasten your conceiving process.
• Holy basil leaves: Chewing 3 to 4 basil leaves followed by a glass of milk improves the chances of getting pregnant. It has been proved that consuming holy basil effectively cures female infertility.

All the above-listed foods and remedies help to improve the chances of getting pregnant. You may try these remedies to enhance your fertility level but before adopting them, it is suggested to consult your doctor.

The food that you take in your pregnancy will directly impact the health of your growing baby. So it is more important for you to be very careful when it comes to your food habits.

Health practitioners and nutritionists say that it is good to avoid all kinds of packages and adulterated food items while you plan for having a baby.

Some of the Indian foods that should be avoided are:

• Fish and seafood: Pregnant women are highly recommended to avoid intakes of large fish like tuna, walleye, marlin, shark, and swordfish, as they have high mercury levels that are harmful to the growing baby. Fresh and clean water fish rich in omega 3 fatty acids like shrimp, salmon, and tilapia can be consumed.
• Brinjal: The King of vegetables in Indian cuisine is the name given to brinjal and all of us are very well-known about brinjal. Though it is good in treating disorders of amenorrhoea and premenstrual disorders, amid pregnancy it should not be eaten.
• Milk and its products that are unpasteurized: Milk, that too well-pasteurized milk should be consumed by pregnant women.
• Papaya: Strictly should avoid taking unripe papaya during pregnancy planning, as unripe papaya has latex that causes uterine contractions resulting in abortions. Baby growth is restricted by papain and pepsin that are present in papaya.
• Ajinomoto: It is widely used in Indian-Chinese street foods nowadays. It affects brain development in the baby, so it should be avoided.
• Pineapple: There is an increased chance of getting an abortion or miscarriage or premature birth with an intake of pineapple. It has bromelain that makes the cervix much softer leading to a miscarriage.
• Refined products of flour: Items made of refined flour like bread, pasta, noodles, etc should not be taken as they contain chemical preservatives that cause harm to fetal development.
• Grapes: Due to an abnormal increase of body temperature and a hormonal imbalance caused by a compound called Resveratrol that is present in grapes, they should be kept away particularly at the last phases of conception.

• You should nor blame yourself: Infertility is caused by both of the partners and is not only a woman's issue. You can sort out your fertility issues by reaching a doctor.
• Seeking support: When a woman has issues of getting pregnant, she becomes overstressed. This stress in return worsens your health. Get support from family and friends.you can reach to online fertility groups and get your questions answered.
• Don’t be alone: Out of unknown jealousy of other women getting pregnant, some women stay at home, isolating themselves from society. This social isolation cannot solve your problem. Get interacted with a friend or a trusted family member and reduce your social phobia.
• Communicate closely with the partner: Both the partners are put under equal stress and they start ignoring each other. There is increased stress and tension in their relationship. The best way is to work along with your partner and talk to each other to sort out the issue.
• Stop feeling ashamed: Manu couples are being ashamed of their infertility status. Experts say that you should accept your condition, get help and treated for having a happy family with a baby,
• Empowering self: Infertility makes you feel that there is no longer control of yourself on your partner, your job, and your life as well. So, experts say to overcome this you should start focusing on what you can control. Adopt lifestyle changes that help you to get pregnant like quitting smoking, stop the use of alcohol and caffeine, doing exercises, and maintaining ideal body weight.
• Have strong hope: Make sure that infertility does not show a permanent impact on your life. Many of the couples having problems with infertility end up having a healthy baby. So, do not let go of your hope.