The female causes of infertility are anovulation and tubal/uterine factor. Each of these two factors is responsible in 10-15% of the infertile couples.
Anovulation refers to the absence of ovulation and characterized by irregular menses. There are 3 types;
- World Health Organization (WHO) Group I: There are no signals from the brain to stimulate the ovaries. The serum FSH and LH levels, as well as Estradiol levels are very low. Imaging of the brain is conducted to rule out the very rare organic causes. Excessive weight loss and/or excessive physical activity may also trigger it. Patients with this type of anovulation respond very well to medical treatment, that is exogenous gonadotropin (FSH) treatment, achieving a monthly fecundity rate of 20-25%. If such medical treatment fails, results with IVF are also very satisfactory.
- WHO Group II: Polycystic ovary syndrome (PCOS). Please refer to the PCOS section.
- WHO Group III: Ovarian failure. The serum FSH and LH levels are high (35 IU/L). Unfortunately, neither ovulation induction therapy nor IVF are helpful for these patients.
- Hyperprolactinemia: Elevated serum prolactin levels are also associated with anovulation. Since prolactin level is a very labile hormone and may be elevated in several physiologic circumstances (e.g., following protein enriched diet, sleeping, exercise, stress etc.), it is of critical importance that the prolactin measurement is done in late morning, without protein-enriched prior diet and repeated 2-3 times. Medical treatment very promptly restores ovulation and is associated with the return of cyclic menses.
B. Tubal-uterine factor
In 10-15% of the infertile couples, tubal and uterine factor is responsible for the infertility. The risk factors for the development of tubal factor infertility are: prior history of sexually transmitted disease, previous pelvic surgery (e.g. myoma surgery, tubal surgery etc.), endometriosis (chocolate cyst) and prior history of appendicitis. Based on the extent and severity of tubal damage, either reconstructive tubal surgery or IVF can be considered. Nowadays, more and more couples undergo IVF rather than surgery to attain live birth.
Congenital or acquired anatomical lesions of the uterus may also result in infertility. Among the acquired lesions, the most important one is intrauterine adhesions most commonly developing following curettage following miscarriage, delivery or myoma surgery. Such adhesions may be surgically treated in an effective manner. However, dense and extensive adhesions may recur following hysteroscopic surgery and may also be associated with thin endometrium, which might be an important obstacle for success. The experience of the surgeon is of critical importance for the success of the surgery.
Myoma are, in general, not considered to result infertility. Myomas growing to the inner lining might be an exception; such myomas should and are effectively treated by hysteroscopy on an ambulatory basis.