Anovulation
Anovulation is a state in which ovulation is absent. This is a result of hormonal imbalance or due to the improper development of the ovaries. This is when the formation of the ovum (egg) in the ovary is disturbed. Approximately, 35% of women experience anovulation. The most known cause of this abnormality is the polycystic ovarian syndrome (PCOS). Polycystic Ovarian Syndrome (PCOS) is a hormonal disorder that causes irregular menstrual cycles or lack of menstruation (amenorrhea), obesity and features of hyperandrogenism like acne and hirsutism. The origin of this hormonal disorder may be in the hypothalamus, pituitary gland, or in the ovary itself.
The initiation of the treatment involves restoring weight and lifestyle changes. If normalization of menstrual cycle and ovulation is not achieved, the next step is medical treatment with medications or injectable hormones to normalize the hormonal functions and stimulate ovulation. Ovarian drilling (making small holes on the ovary’s surface by using heat or laser) is also considered to improve the ovarian hormonal microenvironment.
Pathological factors
Endometriosis
Endometriosis is a state when the tissue that lines the uterus also grows outside in organs like the ovaries, fallopian tubes, bladder and peritoneum. Women who are afflicted with endometriosis show symptoms of increasingly painful menstruation (dysmenorrheal), menstruation that is abnormal in intensity (whether heavy or light), pain during sexual intercourse (coitalgia) and infertility. Endometriosis can also cause blood cysts in the ovaries. Endometriosis might also be caused by the effect on the tubes’ functionality, which is caused by the inflammatory and wound-healing component of the endometrial tissue. However, the presence of a family hereditary factor and the possibility of poor oocyte quality might also be responsible. Nearly 35% of infertile women suffer from endometriosis.
Surgical treatment by laparoscopy (diathermy/argon/exeresis) is usually prescribed to improve the patient’s fertility.
Tubal Factors
Between 20-25 percent of all cases of infertility are related to tubal factor. Tubal factor infertility includes cases of either blocked fallopian tubes or partially blocked fallopian tubes, one of the two tubes blocked, tubal scarring and other types of damage to the fallopian tubes.
The result of endometriosis, or PCOS, tubal factor infertility is a prominent factor in problems of infertility in women. Scar tissue formed by endometrial tissue, surgery, or cysts, also create long-term difficulties when it comes to conception. Sometimes the tubal damage is not very serious. Nevertheless, when after standard fertility testing is performed there is no other obvious cause of infertility found, it is generally attributed to tubal factor infertility. Where cases of minimal scarring are found, a diagnosis of unexplained infertility is given.
Primary Cause of Tubal Factor Infertility
The primary cause of tubal factor infertility is pelvic inflammatory disease which is generally caused by either gonorrhea or Chlamydia infection that has travelled from the cervix through the uterus and into the fallopian tubes. As the body releases white blood cells to combat the infection, the tubes fill with pus and the bacteria are either brought under control or they are destroyed. Sadly, the carnage that is associated with this battle is the destruction of the inner lining of the tubes, which become permanently scarred. The end of the tube or tubes may become blocked with scar tissue as can the ovaries. Damage may be minimized if the infection is caught early enough and treated aggressively with antibiotics.
Tubo-peritoneal factors
Nearly 25% of female infertility cases occur due to a tubal factor, i.e. a disorder of the Fallopian tubes. Fallopian tubes function as an integral part in the reproduction process. The Fallopian tubes pick up the ovum released during ovulation, transport the spermatozoa towards the ovum and carry the fertilized ovum to the uterus. Damage to the Fallopian tubes will interfere in these vital functions and hence, prevent pregnancy. The tubo-peritoneal factor can cause an ectopic pregnancy (pregnancy in the Fallopian tube). Tubal damage can occur due to:
1. Genital tuberculosis
2. Infections arising from the uterine cervix or (Pelvic Inflammatory Disease, PID). The bacterial infections involved with PID are Gonorrhea and Chlamydia which produce an inflammatory reaction causing scarring and fibrosis that prevents the proper functioning of the Fallopian tubes.
3. Infections arising from the abdominal cavity, e.g. Appendicitis
4. A previous pelvic surgery can produce adhesions around the tubes or endometriosis which might cause tubal blockage.
5. The Fallopian tube gets filled with inflammatory fluids and thus, becomes a potential source of chronic infections which results in Hydrosalpinx.
Tubal damage can be treated by endoscopic surgery, tubal microsurgery and ART techniques like IVF/ICSI.
Uterine Factors
In general cases, the embryo implants in the uterine cavity, so if the cavity has fibroids, polyps or adhesions inside it, the embryo will fail to implant. In addition, some women may be born with anomalies of the uterine cavity like an intrauterine septum or bicornuate uterus . The miscarriage rate among women with a large uterine septum is quite high.
Fortunately the majority of the above conditions can be resected or corrected surgically and is usually followed by a subsequently normal implantation rate.
