FEMALE INFERTILITY

Ovulation Problems

Anovulation means lack of ovulation or absent ovulation. Ovulation is the release of an egg from the ovary. This must happen in order to achieve pregnancy. If ovulation is irregular but not completely absent, this is called Oligovulation. Both anovalation and oligovulation are kinds of ovulatory dysfunction.
Ovulatory dydfunction is a common cause of female infertility occurring in 30 -40% of infertile women. Fortunately, approximately 70% of these cases can be treated with ovulation medications.

Symptoms

Usually women with anovulation will have irregular periods or in most case they may not get their cycles at all.
If your cycle is shorter than 21 days or longer than 36 days, then you may have ovulatory dysfunction.
If your cycle falls within normal range of 21 to 31 days but the length of your cycle varies widely month to month, it may also be a sign of ovulatory dysfunction (e.g. one month your period is 22 days and the next 35 days).
It is possible to get your cycle on an almost normal schedule and not ovulate, but it is not common.
A menstrual cycle where ovulation does not occur is called an anovulatory cycle.

How Does Anovulation Cause Infertility?

For a couple without infertility, the chances of conception are 25% each month, so even if ovulation occurs there is no guarantee to conceive in a month.
When a woman is anovulatory, she cannot get pregnant because there is no egg to be fertilized. If a woman has irregular ovulation, she has fewer chances to conceive since she ovulates less frequently. Late ovulation doesn’t produce best quality egg which again makes fertilisation less likely.
Irregular ovulation means the hormones in the woman’s body are not quite right. These irregular hormones can lead to other issues such as lack of fertile cervical mucus, thinner or thickened endometriom (where fertilised egg need to implant) abnormally low level of progesterone or shorter luteal phase.

Causes of Anovulation

Anovalution and ovulatory dysfunction can be caused by a number of factors. The most common cause is polycystic ovarian syndrome (PCOS)
Other potential causes of irregular or absent ovulation are:

• Obesity
• Too low body weight
• Hyper prolactineamia
• Premature ovarian failure
• Advanced maternal age or low ovarian reserve.
• Thyroid dysfunction
• Extremely high level of stress.

Diagnosis of Anovalution

Your doctor will ask about your menstrual cycle, and if you report irregular or absent cycle, ovulation dysfunction will be suspected.
Your doctor will ask for your day 21 progesterone blood test. After ovulation, progesterone level rises.If your progesterone level does not rise, then you are probably not ovulating.
Your doctor will also order for an ultrasound to check out the shape and size of your uterus and ovaries, and also to see if your ovaries are polycystic, a symptom of polycystic ovarian syndrome.
Ultrasound can also be used to track follicle development and ovulation.

Treatment of Anovulation

The treatment will depend on the cause of anovulation. Many ovulation problems can be treated by lifestyle changes and diet. If low body weight and extreme exercise is the cause, gaining weight or reducing exercise may be enough to restart ovulation. The same goes for obesity. If you are overweight, loosing 10% of your current weight is enough to restart ovulation.

The most common treatment for anovulation is fertility drug, usually Clomid. (It is well abused in Nigeria and many substandard versions are available. You are well advised to see a fertility doctor before self medication) It triggers ovulation in 80% of anovulatory women and helps about 45% to get pregnant within 6 months of treatment. If Clomid does not work, there are other drugs worth trying.

For polycystic ovarian syndrome (PCOS) women, insulin sensitizing drugs like Metformin may help to restart ovulation. Usually 6 months of treatment with Metformin is required to know if Metformin works. If anovulation is due to premature ovarian failure or low ovarian reserve, fertility drugs are less likely to work, in which case IVF with Donor eggs or adoption might be suggested by your doctor.


Blocked Fallopian Tube

The fallopian tubes are 2 thin tubes one on each side of the uterus. They help lead the mature egg from ovaries to the uterus.
When an obstruction prevents the egg from travelling down the tube, the woman has blocked fallopian tubes. It can occur on one or both sides. This is also known as Tubal Factor Infertility. It is the cause in 40% of infertile women.

How Does Blocked Fallopian Tube Cause Infertility?

Each month, when ovulation occurs, an egg is released from one of the ovaries. The egg travels from the ovary through the tubes and into the uterus. The sperm also need to swim their way from the cervix through the uterus and through the fallopian tubes to get to the egg. Fertilisation usually takes place while the egg is travelling through the tubes.
If one or both fallopian tubes are blocked, the egg cannot reach the uterus and the sperm cannot reach the egg, preventing fertilization and pregnancy.
It is possible for the tube not to be blocked totally but only partially. This can increase the risk of a tubal pregnancy or ECTOPIC pregnancy.
What is Hydrosalpinx?
A specific kind of blocked fallopian tube, hydrosalpinx is when a blockage causes the tube to dilate and fill with fluids. The fluid blocks the egg and sperm, preventing fertilization and pregnancy.

Can Pregnancy occur with Blocked Fallopian Tube?

If only one fallopian tube is blocked, it may still be possible to achieve pregnancy. It depends on how well the ovaries are functioning and also what caused the blocked tube in the first place.

Symptoms of Blocked Fallopian Tubes
Unlike ovulation problems, where irregular menstrual cycle may hint at the problem, blocked fallopian tubes rarely cause any symptoms.
A specific type of blockage called hydrosalpinx may cause lower abdominal pain and unusual vaginal discharge, but not every woman has this symptom.
Some causes of blocked tubes might lead to a hint of the problems, for example, endometriosis and pelvic inflammatory disease (PID) may cause painful menstruation and painful sexual intercourse, but the symptoms don’t necessary point to blocked tubes.


What causes Blocked Fallopian Tubes?

The most common cause of blocked fallopian tubes is pelvic inflammatory disease (PID).
PID is the result of sexually transmitted disease, (STD) but not all PID are related to STD.
Other causes of blocked tubes include:-
Current or history of STD, specifically Chlamydia or Gonorrhoea. History of uterine infection caused by ABORTION or MISCARRIAGE. History of ruptured Appendix, history of abdominal surgery, previous ectopic pregnancy, prior surgery of the fallopian tubes and endometriosis.
How is Blocked Fallopian Tube Diagnosed?
Blocked fallopian tube is usually diagnosed with a specialised X-ray called Hystero Salpingogram (HSG). The test involves placing a dye through the cervix using tiny tube. Once dye is given, the X-rays are taken.
15% of women have a false positive result. Other tests are Saline Sono Hysterogram, Ultrasound, Laparoscopy or Hysteroscopy.

Treatment of Blocked Fallopian Tubes

If one tube is open and otherwise healthy you might get pregnant without help or at worse your doctor may give fertility drugs to increase ovulation on the side of the open tube.
If both tubes are blocked, the options are Laparoscopic surgery to open blocked tubes or remove the scars causing the blockage.
Unfortunately, the surgery rarely works. The chance of success depends on how old you are, how bad the blockage is and the cause of the blockage. The risk of ectopic pregnancy rises after surgery.
The definitive treatment of bilateral blocked fallopian tube is invitro fertilisation (IVF).
I would continue on female infertility next week, by discussing Endometriosis and Polycystic Ovarian Syndrome (PCOS).