Infertility in Women

The leading cause of infertility in women is obstruction of the fallopian tubes usually arising from infections. This means that the eggs (ova) cannot meet with the sperms, presenting a mechanical basis for infertility.

If during a normal delivery the internal genital organs have an infection, this can lead to infection of the fallopian tubes and thus cause blockage.

The infection normally affects the lower part of the uterus (the cervix). Gradually the infection ascends to the uterine cavity and the fallopian tube,s where it causes scarring of the internal and external parts of the fallopian tubes- thereby causing obstruction.

Abortion

Abortion sometimes is an indirect cause of infertility, if the woman gets an infection as a complication of the abortion. The infection can lead to blockage of the fallopian tubes.

Sexually transmitted infections can also cause infertility arising from blocked fallopian tubes.

Lack or relative absence of ovulation

The second common cause of infertility in women is the lack or relative absence of ovulation. The eggs do not mature frequently enough, to enable conception within an acceptable time frame. If a couple has been having regular sex without protection for more than a year and are unable to conceive, then the couple is technically infertile and they need a diagnosis.

Hostile cervical mucous or sperm allergy

Another cause of infertility in women that is not very common, is hostile cervical mucous or sperm allergy. In that case the woman’s cervical mucous is hostile to sperm, making her develop antibodies that prevent the free movement and progression of sperm within her cervix and uterus.

Sometimes a man forms antibodies against his own sperm. The standard way of managing this problem, is through artificial insemination. Sperms are cleaned and prepared in the laboratory and then inserted directly into the woman’s uterus so they do not have to travel through the cervix. This preparation involves washing and removing of sensitive substances, stimulating the formation of antibodies.

Sperm allergy is only detectable through medical investigations. Once your health care provider has conducted investigations which have established that your fallopian tubes are normal, and you are ovulating regularly- and that your partner has healthy sperm, then the health care provider will conduct further tests to determine whether there is production of antibodies against the man’s sperm. This is called a sperm mucous interaction test, in which the health care provider checks if the sperm is behaving normally, when placed within the cervical mucous.

Other rare causes of infertility are described below.

•  A woman with fibroids may occasionally develop infertility.
• A woman with inadequate levels of progesterone—the hormone which helps to sustain pregnancy in the early stages— may conceive but lose the pregnancy, when the embryo or foetus is still very small. In majority of such cases, a woman may not even be aware that she was pregnant. She may think that her period delayed but she actually had an early miscarriage. This is referred to as luteal phase insufficiency.
• A couple may have infertility of uncertain cause. These are couples who upon investigation for the various causes of infertility, have normal examination findings yet they are not able to have a child. Ten percent of all infertile couples suffer this type of infertility.
• Sometimes damage to the cavity of the uterus may cause it to become fibrous, and compromise its ability to hold a pregnancy.
• In very rare cases, congenital malformations such as absence of some genital structure are present. These include, for example; a woman who is born with malfunctioning ovaries, or a woman who doesn’t have a uterus. However, these disorders are rare.

Menstruation and infertility

Women can still menstruate even when they are infertile, except in inovular infertility—that is infertility resulting from lack of ovulation, or development of an egg.

Diagnosing infertility

There are no clinical or social symptoms to show that one is infertile. It is generally not advisable to pursue a diagnosis of infertility on demand without having reasonable basis for suspicion. A woman who has been married or has been actively seeking to have a child, and has not been able to conceive for the past one year, has every reason to pursue an explanation on why she may not have conceived.

A woman’s menstrual history may cause concern about her fertility. For example, irregular periods with long intervals between the periods of more than three months may suggest that ovulation is not consistent. Conception cannot occur in the absence of an egg.

Treating infertility

Treatment usually depends on the cause of infertility. If a woman has blocked fallopian tubes, an operative procedure known as laparoscopic toboplasty is performed. Through a small opening in the abdomen, the doctor looks inside to assess the damage to the fallopian tubes. Through the same procedure the doctor can open up the blocked fallopian tubes, If the woman’s tubes are severely damaged and surgery is not technically feasible, then the other option is to have in vitro fertilisation (IVF).

Artificial insemination helps manage cases of hostile cervical mucous.

Women who have a problem with ovulation normally use fertility drugs for treatment. However some of the patients may require surgical intervention particularly women who have a condition referred to as polycystic ovarian disease or syndrome (POS).

These are ovaries that are larger than the average size. There are no known causes of POS but it is associated with difficulties in ovulation. These cases are manageable surgically, through a procedure involving drilling of ovaries. This is a simple procedure done through laparoscopy, where the patient is operated under anaesthesia.

Women with infertility of uncertain cause normally use fertility drugs. If this is not successful, the next level of intervention is artificial insemination. This involves collecting sperm from the spouse and processing them before putting them directly into the uterine cavity.

Treating infertility often takes a long time because several attempts are needed, with either medication or through surgery. For example if medication fails, the doctor can turn to surgery and if that fails the doctor can try in vitro fertilisation, depending on the specific cause of infertility. Hence patience by the couple is vital.

When all these options have failed the couple is can consider adoption.

Does age affect success of the treatment?

The age of a woman is an important factor. Success rate is higher with younger women who are in their twenties, than in women above 35 years of age. This is because at 35, the fertility rate in the woman declines.

Dr. David Kiragu is a gynaecologist/obstetrician based at KAM Health Services, IPS Building, Nairobi

END: PG MAY 07/7