is a condition of the reproductive system that impairs the
ability to achieve pregnancy. Primary infertility is the
inability to conceive a child after regular intercourse for
at least 1 year. Secondary infertility occurs in couples who
have previously been pregnant at least once, but are unable
to achieve another pregnancy.
Infertility affects men and women equally. About one-third
of the cases are due to a male factor, one-third to the
female and the remaining to the combination of both
partners. Causes of infertility include a wide range of
physical as well as emotional factors.
For a woman to be fertile, her reproductive organs must be
healthy and functional. To conceive a child, the ovaries
must release healthy eggs regularly and her reproductive
tract must allow the eggs and sperm to pass into her
fallopian tubes for a possible union 50%
of the infertile cases are due to a problem in the woman.
The problem could either be a hormonal one or an anatomical
one or a pathological one. The most common causes of female
infertility are listed here and each one is linked to a very
simple explanation of the causes, the symptoms, the
diagnostic tests and the treatment modalities. In addition
we have filtered the hundreds of web sites on the related
topics and have provided links to a select few.
Premature Ovarian Failure
Poly Cystic Ovarian Disease
Disorders of the Fallopian Tube
What is Premature ovarian Failure?
Every woman is born with a finite stock of oocytes (eggs) at
the time of her birth. After she attains puberty, every
month, some of the egg-containing follicles start growing.
Some release an egg while the others die a natural death
mid-way through their growth phase. Thus, this stock of eggs
depletes as a woman ages and very few eggs remain in the
ovary when a woman is in her forties. This is natural
phenomenon of menopause also resulting in a cessation of
menstruation. However, some women attain menopause much
earlier in their life and this state is known as "premature
How is it diagnosed?
The first indication of premature ovarian failure would be
absence of menstruation for several months or several years.
In normal women in the reproductive age group, the pituitary
gland in the brain secretes hormones, follicle stimulating
hormone (FSH) and Luteinizing hormone (LH) which
specifically binds to the receptors on the ovarian cells,
stimulates them to grow and in turn produce the hormone
estradiol. This estradiol enters the blood stream and as its
concentration in the blood increases, it sends a message to
the pituitary, preventing it from secreting any more FSH and
Now, in women with premature ovarian failure, the FSH and LH
cannot bind to its specific receptors in the ovary because
of the diminished reserve of such cells. Therefore, there is
no estradiol produced to send a negative feed-back message
back to the pituitary. In the absence of any feedback from
the ovary, the pituitary continues secreting large
quantities of both FSH and LH.
Therefore, pituitary ovarian failure can be identified by
testing the concentrations of hormones FSH and LH in the
blood. Very high concentrations of these hormones in the
blood similar to that found in menopausal women confirms
premature ovarian failure.
What are the causes of premature ovarian failure?
In half the women with premature ovarian failure, the cause
remains unclear. While in the other half, premature ovarian
failure is a result of destruction of the ovaries either by
chemotherapy, radiation therapy or surgery. Cancers may
necessitate treatment with chemo-therapeutic agents which
can damage the ovaries. Tumours of the ovaries or of other
abdominal organs may need irradiation therapy which also
result in the destruction of the ovarian cells. Certain
infections of the ovaries may need removal of the ovary.
Damage to the ovaries results in premature ovarian failure.
Can premature ovarian failure be reversed?
Pre-mature ovarian failure is irreversible. As the cause of
premature ovarian failure is unknown in more than half of
such patients, the day we are able to decipher the cause,
will any treatment be possible. But at the moment this
disorder of the ovaries is irreversible.
Can a woman with premature ovarian failure ever be able to
bear a child?
Advances in assisted reproductive technologies has made it
possible even for women with premature ovarian failure to
bear a child. This is possible only if woman’s general
health is fine and her uterus responds to external hormones.
However, since there are no eggs in the woman’s ovaries, she
would need "oocyte donation". These donated oocytes are
fertilized in the laboratory with her husband’s sperms and
the resultant embryo is transferred into the uterus. The
patient would need to take hormone supplements daily for
more than 3 months if she does conceive following embryo
The woman can have the joy of a pregnancy and giving birth
to a child although the child may not have her genetic
What are poly cystic ovaries (PCO)?
Every woman is born with millions of eggs at the time of
birth. Each of these eggs is covered by specialised cells
and this entire unit is called as a "follicle". After the
woman attains puberty, every month a few of these follicles
start growing of which one ruptures to release the egg while
the others whither away. However, in some women several
follicles start growing and then remain static in that
state. Such ovaries which have these "cystic" follicles are
termed as poly cystic ovaries.
What are the symptoms that indicate that a woman could have
Women with PCO have irregular menstrual cycles, are
generally obese, have a high waist to hip ratio; excess hair
growth on the face, abdomen limbs and other parts of the
body. Ultra-sonographic scanning of the ovaries show the
presence of several small follicles. The concentration of
reproductive hormones in the blood is also altered. The
hormone luteinising hormone (LH) is present in high
concentration while the ratio of the hormones LH and FSH is
also high. Both these hormones are produced by the pituitary
gland and is responsible for the timely growth of the
follicles and the release of the eggs. Some of the women may
also have high concentrations of the hormone insulin in the
blood and also excess of male hormones (androgens). Not all
women will exhibit all these criteria associated with PCO.
How is it diagnosed?
PCO can be diagnosed by ultrasonography of the ovaries which
clearly shows several hypoechogenic regions in the ovaries
forming what has often been termed as "pearly necklace
Blood tests for determining the concentrations of the
pituitary hormones FSH and LH, the concentration of insulin
and also the androgens. These tests has to be done
preferably on the second or third day after menstruation. A
thorough clinical examination for any evidence of hirsuitism
- excess of hair growth in the woman; a waist to hip ratio
and the body mass index also has to be noted.
Does PCO affect a woman’s fertility?
The fertility of a woman with PCO is compromised especially
if she has irregular menstrual cycle. These women often have
anovulatory cycles (i.e., cycles where the follicles do not
ovulate and release an egg.). These women also have abnormal
hormone profiles and all this together results in
What are the treatment options for a woman with PCO to
The first line of treatment for women with PCO would be
"ovulation induction". Since these women often do not
ovulate spontaneously, medications like clomiphene citrate
are given to stimulate the growth of the follicle and then
timing them to rupture by administering another hormone
"human chorinoc gonadotropin". In case the women are
resistant to clomiphene citrate and do not respond to it
then they are directly injected with gonadotropins to
stimulate the growth of follicles and their rupture.
One has to be extremely cautious while administering
fertility drugs especially gonadotropins to women with PCO.
In response to the gonadotropins, the multiple cysts present
in these women can flare and lead to a condition known as
"Ovarian hyperstimulation syndrome" which can become
life-threatening. Careful ultrasonographic monitoring and
measuring the concentration of the hormone estradiol in the
blood in such women is very helpful to adjust the dose of
gonadotropins being administered and minimise the risk of
ovarian hyperstimulation syndrome.
Another option for women with PCO is "operative laparoscopy"
where these cysts can be cauterised or burned. It is very
important that this procedure is also carried out by a very
experienced and skilled surgeon to ensure that no part of
the ovary is damaged. Only the cysts have to be cauterised
and that too till the right depth to ensure that the rest of
the ovarian cells are not damaged.
There have been some recent reports on the successful use of
an anti-diabetic drug, "metformin" for the treatment of PCO.
This drug reduces the insulin levels and thereby may improve
the hormone profile in such women. Strict monitoring is
essential while the woman is on metformin and this drug
should not be taken unless under medical supervision.
What is endometriosis?
The inner lining of the uterus is called as the "endometrium".
Every month, in response to the hormones estradiol and
progesterone produced by the ovary, this lining forms into a
"bed" of cells. If the egg has been fertilized by the sperms
then the resultant embryo attaches or implants on the
endometrium. In case, the egg is not fertilized in that
month then this lining of the uterus is shed resulting in
In some women, the endometrium grows at places other than in
the uterus. The endometrium can be present near or on the
ovaries, the fallopian tubes or any other part of the
abdomen. There is no outlet for the endometrium formed at
locations others than within the uterus and this tissue
accumulates within the body. Such a condition is called as
What is the cause of endometriosis ?
The exact cause of endometriosis is not yet known. There are
a number of theories which have been postulated to explain
It is postulated that in women who have anomalies of the
reproductive tract, retrograde menstruation occurs i.e.,
there is a backward flow of menstrual discharge. These
endometrial cells implant on the ovaries or any part of the
pelvic cavity where is grows and regresses every month in
response to the menstrual changes.
It has also been thought that endometriosis may have a
genetic origin as women whose mothers or sisters who suffer
from endometriosis are more prone to it.
What are the symptoms ?
Many women with endometriosis may not have any symptoms. The
type of symptoms and their intensity depends upon the
location of the endometriotic tissue and the extent to which
the disease has spread. However, the most common symptoms
associated with endometriosis are:
severe cramps during or prior to menstruation.
pain during intercourse
some women with endometriosis may complain of vaginal
bleeding at irregular intervals.
Infertility could be a result of endomtroisis.
How is it diagnosed?
The diagnosis of endometriosis cannot be made on the basis
of the patients symptoms alone and needs to be confirmed by
a diagnostic laparoscopy.
Laparoscopy is a minor surgical procedure by which a
laparoscope (a thin telescope) is inserted into the abdomen
through the navel. This enables the surgeon to directly
visualize the reproductive organs. The presence of
endometriosis and the extent to which it has spread can be
gauged by the surgeon. Whether the endometriosis is deep or
superficial and the extent of adhesions it has caused is
determined and the endometriosis is scored as minimal, mild,
moderate or severe.
Can it cause infertility?
Endometriosis on its own does not necessarily cause
infertility. However, the endometriotic tissues can hinder
conception. Endometriosis may cause adhesions around the
ovary and the fallopian tube. These adhesions may interfere
with the release of the eggs from the ovary; they may
interfere with the capturing of the eggs by the fallopian
tube. In such instances, endometriosis may be a cause of
Can it be treated with medications ?
Three different types of medications are available for the
treatment of endometriosis. Endometrial tissue, be it at its
natural site in the uterus, or the extra-uterine location of
endometrial tissue in patients with endometriosis, is under
the control of the hormones produced by the ovary. The aim
of medical treatment is to prevent the secretion of hormones
by the ovaries or negate their effect. In all these three
types of medical treatment of endometriosis, menstruation
ceases as long as the woman is on medication and the
symptoms of endometriosis can be overcome. The three types
of medications currently available are:
Oral contraceptive pills can be taken continuously without
waiting for a withdrawal bleed.
Danazol. This drug leads to a drop in the levels of the
hormone estradiol in the blood and prevents the
proliferation of the endometrial implants. Small patches
of endometriosis can be treated successfully with Danazol.
Gonadotropin releasing Hormone analogs (GnRHa). These are
the newest class of hormones that have been used to treat
endometriosis. This drug creates a pseudo-state of
menopause and as long as the woman is on GnRHa treatment,
she produce negligible amounts of reproductive hormones.
In the absence of reproductive hormones in the body, the
endometrial lining becomes very thin.
All these medications have several side effects and need to
be taken only under the supervision of a doctor.
Can endometriosis be treated surgically?
Endometriosis can also be surgically treated. If the
endometrial implants are very large then it is advisable to
surgically remove these implants. This is generally done
under laparoscopic visualisation. The endometrial implants
are "cauterised" or "ablated" with a mild degree of
electrical current. This procedure should be performed only
by a well trained endoscopic surgeon so that no part of the
reproductive tract is damaged.
What are the other options of treating infertility in spite
In women who have endometriosis and are infertile but do not
suffer from any other symptoms of endometriosis then their
problem can be treated by any of the assisted reproductive
technologies. If her fallopian tubes are not blocked then
she can be treated by
intra-uterine insemination or
transfer. If the tubes are blocked or are unhealthy
then she can be treated by
and embryo transfer.
What is a fallopian tube ?
The fallopian tubes emerge from each side of the uterus and
extend to the surface of the ovary. The ovarian end of each
of the tubes is funnel-like which surrounds the ovary. The
funnel-like end comprises many fine, delicate finger-like
projections called "fimbriae". These fimbriae "capture" the
egg as soon as it is released from the ovary. If this egg
meets the sperms, it gets fertilized in the tube and the
early stages of embryo development takes place in the
Fallopian tube. The cells of the Falopian tube provide all
the nutrition needed by the egg, the sperms and the embryos.
What can go wrong with a woman’s fallopian tube ?
Damage to the fimbriae can result in them not being able to
"capture" the egg and direct it into the tube. Damage to the
inner linings of the cells of the tube can prevent
fertilization; development of the embryo and in some
instances the movement of the embryo towards the uterus
resulting in an "ectopic pregnancy". The tubes may be
blocked because of a pelvic infection and this will prevent
the sperm from fertilizing an egg. Endometriosis may also
result in tubal blockage. The fallopian tubes are surgically
severed and the ends sewn up to prevent pregnancy.
What tests can be done to determine whether a woman’s
fallopian tubes are normal ?
Three types of tests are now available for evaluating the
status of the fallopian tubes. These are :
radio-opaque dye is injected into the uterus through the
vagina and then X-rays are taken. If the tube is not blocked
then the dye can be seen emerging /spilling out of the
fallopian tube. If no dye emerges out of the tube then one
can conclude that it is blocked.
Where large amounts of fluid is injected into the uterus
through the vagina. If the tubes are not blocked then this
fluid emerges out of the fimbrial end of the fallopian
tubes. The entire procedure is performed under ultrasound
guidance and the fluid that comes out can be seen ultra-sonographically.
In this procedure, a fibre-optic telescope, a laparoscope,
is inserted into the abdomen through the navel. With the
laparoscope, the surgeon can directly visualise the status
of the fallopian tube. One can see the position of the
fimbriae and also whether the tubes are open or blocked.
Then a coloured dye such as methylene blue is injected
through the vagina. If the tubes are open (patent) then the
dye spills out of the fimbrial end of fallopian tube
immediately. No dye will spill out of the fallopian tube if
it is blocked. And if there is some damage to tube then the
dye will spill out slowly.
Can abnormalities of the fallopian tube be corrected ?
If the fallopian tube is blocked because of tubal ligation
as in cases of tubal sterilisation then it can be surgically
reversed. However, whenever the blockage of the tube is a
result of pelvic infection then surgical correction may not
be possible. No medical therapy is known as yet to correct
damaged fallopian tubes.
What are the options available for women with damaged
fallopian tubes to bear a child ?
In women where there is a pathological damage to the
fallopian tube then surgical correction of the tube is not
possible. In such women the best option for bearing a child
and embryo transfer.
What is the role of the cervix in a normal conception ?
The cervix acts a "sentry" restricting the entry of "poor
quality" sperms, cells other than sperms present in semen
and the seminal plasma from entering into the uterus. It
acts as a natural filter and only the highly motile sperms
enter into the upper reproductive tract of the women. It
also acts as a store house where the sperms are stored in
the cervical mucus.
How can one diagnose whether the cervix is hostile to sperms
The Post-Coital Test is the most apt test to detect whether
the cause of infertility in a couple is a "hostile cervix".
What is the post-coital test ?
For this test, secretions of the cervix are studied under
the microscope few hours after a couple has been advised
sexual intercourse. It is very important to perform this
test during the middle of the menstrual cycle. The specific
detailed instructions for this test would be given to you by
What are the reasons why a cervix can be hostile to sperms ?
In some women, the cervix "overdoes its sentry duty" and in
such women the cervix not only prevents but may also damage
the sperms which are trying to gain entry into the uterus.
The different reasons as to why a cervix can be hostile to
The woman’s lower reproductive tract may be infected with
microorganisms which may produce substances which are
toxic to the sperms.
Some women may produced anti-sperm antibodies which bind
to the sperms; immobilize them and prevent them from
passing through the cervix.
The cause of cervical hostility remains unknown but a
post-coital test shows the presence of non-motile sperms.
What are the treatment options available for a woman with a
hostile cervix ?
It is important to identify the cause for the cervical
hostility. If it is due to a microbial infections then the
same can be treated with appropriate antibiotics. If it is
due to anti-sperm antibodies or if the cause of a poor
post-coital test is unknown then the best treatment option
for infertility in such women would be
What is hyperprolactinemia ?
Prolactin is one of the hormones produced by the pituitary
gland located in the brain. This hormone stimulates
lactation in women and its presence in concentrations higher
than normal in non-lactating women is termed as
What is the normal function of the hormone prolactin ?
Prolactin stimulates production of breast milk in women
after the delivery of a child. This hormone prevents the
secretion of hormones, follicle stimulating hormone and
Luteinising hormone which are essential for normal growth of
egg-containing follicles in the ovaries. Therefore,
lactating women do not ovulate or menstruate. Presence of
higher than normal concentrations of prolactin in the blood
of non-lactating women affects normal ovulation in these
women and can be one of the causes of infertility.
What are the tests performed to diagnose hyperprolactinemia
Hyperprolactinemia can be detected by estimating the
concentration of the hormone "prolactin" in the blood. This
blood test need not be done on an empty stomach. In cases
where the concentration of prolactin in the blood is in the
borderline state, it is advisable to repeat the test and see
what is the average concentration of the hormone before
embarking on any treatment.
Some of the women who have hyper-prolactinemia may have some
breast secretions. Observations of these secretions under
the microscope show the presence of fat globules.
What are the causes of hyperprolactinemia ?
High prolactin levels in the blood in non-lactating women
may be due to several factors:
The prolactin producing cells in the pituitary may be
Certain drugs such as tranquilizers, pain killers and
alcohol may cause a rise in prolactin levels.
Stress also induces hyperprolactinemia.
Prolactin producing cells in the pituitary form a cluster
– a benign (non canerous) tumour resulting in excess
production of prolactin. In cases of very high
concentrations of prolactin in non-lactating women, a
computed tomography scan needs to be carried out to rule
out a pituitary adenoma.
Can hyperprolactinemia affects a woman’s fertility ?
Lactating women do not ovulate. Therefore women with
hyperprolactinemia also have ovulatory disorders and
therefore compromised fertility.
What are fibroids ?
The outer wall of the uterus (the womb) in the woman is
covered by a thick muscular layer. The presence of abnormal
masses of smooth muscle tissue on the uterine wall is termed
as fibroids. There may be one large fibroid or several small
ones. These fibroids generally form in women who are in
their 30s or 40s and regress with menopause. These fibroids
may result in excessive uterine bleeding, abdominal pain, a
feeling of great pressure in the lower abdomen, infertility,
miscarriages or premature delivery while some women may have
no symptoms associated with the fibroid. Fibroids are also
termed as leimyomas or myomas.
Are there different types of fibroids ?
Fibroids are termed as "sub-serous", "intramural" or
submucous" depending upon their location in the uterine
cavity. Sub-serous and intramural are the most common types
of fibroids and are located beneath the outer peritoneal
covering of the uterus and in the muscular uterine wall
respectively. The sub-mucous fibroids are present in the
How can these fibroids be detected ?
Large fibroids are easily visualized by ultra-sonography.
The high frequency waves create an image of the pelvic
organs and presence of an abnormal mass in the abdomen
clearly indicate the presence of fibroids.
The presence of the fibroids can be confirmed by a
diagnostic laparoscopy and a
Are these fibroids cancers ?
These fibroids are not cancerous.
Can these fibroids affect a woman’s chance of conceiving ?
The presence of a fibroid by itself may not necessarily
interfere with the chances of a woman conceiving but will
depend upon the location and the size of the fibroid.
Can fibroids be treated with medications ?
The size of the fibroid can be temporarily reduced by the
administration of a drug called gonadotropin releasing
hormone analogue (GnRHa). Long term administration of this
drug stops the pituitary from secreting hormones which in
turn prevents the ovaries from secreting its hormones. The
absence of ovarian hormones results in the shrinkage of the
uterine fibroids. These medication cannot be used for
extended periods of time and therefore GnRHa is used
primarily to decrease the size of fibroid prior to surgery
and in women who have become anemic due to excessive
bleeding and cannot be operated to remove the fibroid.
Should these fibroids be removed ?
It is not always necessary to remove the fibroids. If a
woman is not having excessive bleeding, or abdominal pain
i.e., if the fibroid is not bothering her then it is not
important to remove the fibroid. The decision on whether to
remove the fibroid or not depends upon the location and size
of the fibroid and if the woman has had any history
Depending upon the location of the fibroid, it can be
removed either laparoscopically or hysteroscopically.
If a woman is pregnant, can the fibroid interfere with her
The fibroid does not always interfere with pregnancy.
However, if the fibroid is present very close to the fetus
or the embryo then it can lead to a miscarriage or abortion.
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