Female infertility

Introduction to infertility

Primary infertility is said to occur when a couple has never achieved a pregnancy despite at least one year of uninterrupted and adequate unprotected sexual intercourse.
Secondary infertility implies that there has been a previous pregnancy.
It is often necessary to evaluate both partners simultaneously and to elicit sexual, menstrual and obstetric history.
A past history of Pelvic Inflammatory Disease (PID) and Sexually Transmitted Infections (STIS), contraception use and other significant past medical history are also necessary.

Causes of infertility

Female factors 

Female infertility are caused by the following factors:

  1. Ovulation failure
  2. Polycystic ovarian syndrome (PCOS)
  3. Hyperprolactinaemia
  4. Pelvic factors
  5. Congenital malformations of uterus etc.
  6. Tubal disease
  7. Pelvic adhesions
  8. Uterine fibroids
  9. Endometriosis
  10. Cervical factors

Male factors 

Male infertility are caused by the following factors:

  1. Oligospermia
  2. Azoospermial
  3. Penile and testicular abnormalities
  4. Erectile dysfunction

Symptoms of infertility

The following are common symptoms of infertility:

  1. Inability to achieve pregnancy despite regular unprotected sex at least 2-3 times weekly
  2. Amenorrhoea (females)
  3. Impotence (males)

Signs of infertility

Female

  1. Absence of secondary sexual characteristics
  2. Virilisation changes (hirsutism, clitoromegaly, deepening of voice etc.)
  3. Galactorrhoea
  4. Abdominal masses due to uterine or ovarian enlargement

Male

  1. Abnormal vaginal discharge indicative of infection
  2. Abnormal penile discharge indicative of infection
  3. Absence of secondary sexual characteristics
  4. Testicular abnormalities e.g. varicocoeles, small or absent testes

Investigations

  • FBC,
  • Sickling
  • High vaginal swab
  • Blood glucose
  • Hystero-Salpingogram (best done under fluoroscopic guidance).
  • Semen analysis
  • Serum progesterone level in mid-luteal phase (day 21-23 of menstrual cycle) to check for ovulation
  • Thyroid function tests
  • Further hormonal studies e.g. Serum LH, FSH, Serum Testosterone, Prolactin to be done by specialist

Treatment for female infertility

Treatment objectives

Treatment objectives of infertility include the following:

  1. To treat the underlying cause of the infertility if possible
  2. To achieve pregnancy within the shortest possible time

Non pharmacological treatment

Non Pharmacological method of treating infertility include the following:

  1. Counselling
  2. Uterine, Tubal and Testicular surgery where needed
  3. Assisted Reproduction Technologies e.g. Artificial insemination, Invitro-fertilization with embryo transfer where indicated

Pharmacological treatment

A. Failure of ovulation

1st Line Treatment
Evidence Rating: [A]
Clomifene citrate, oral,

  • 50 mg daily for 5 days, starting between the 2nd and 5th day of the menstrual cycle.

B. Hyperprolactinaemia

1st Line Treatment
Evidence Rating: [A]
Bromocriptine, oral,

  • 1.25 mg nocte for 7 days (with the evening meal or at bedtime).
  • Increase weekly to a max. of 2.5 mg 8 hourly

C. Polycystic Ovarian Syndrome (PCOS)

Evidence Rating: [A]
Metformin (PO)

  • 500 mg 8hourly, alone or along with fertility drugs

Surgeries:

  • Tubal surgery for Tubal blockage
  • Myomectomy for uterine fibroids
  • Ovarian drilling is a possible surgical treatment for PCOS-related infertility

Referral Criteria

Early referral of all patients with infertility to a specialist is preferred, particularly women with uterine, ovarian or tubal disease requiring surgery or who require ovulation induction not responsive to clomifene citrate.
Also refer male partners for review by a urologist.