Fundamental Causes of Infertility in Women

Men’s infertility issues seem easy to figure out at first because it all comes down to sperm: Whether they are produced, can they move, and can they fertilize when they get to the egg? Women’s infertility issues are more complex due to so many different things that can be at fault. Those problems can cause difficulty in inducing pregnancy.

Uterus

Perhaps you had a hysterosalpingogram (HSG) to evaluate your uterus and fallopian tubes or maybe a hysteroscopic surgery for more detailed examination into the uterus. Examining the uterus is an important part of any fertility analysis because it sustains and holds the fetus during pregnancy.

Uterus fibroids

Fibroids are benign tumors and commonly found outside or inside the uterus. They’re very common, with forty percent of women before 55 having at least one. They have high incidence in African-American women about fifty percent. Fibroids may cause bladder or bowel problems, serious bleeding, or discomfort. Fibroids can be either outside or inside the uterine cavity; their exact locations determine whether they can cause fertility problem. Fibroids which are completely outside the uterus, like pedunculated fibroids, are often attached by a stem to the uterus, they don’t usually cause an infertility problem.

Subserosal fibroids are found at the outer uterus wall and typically don’t disturb the cavity.

Intramural fibroids are found within the uterus wall and can cause problem if they grow too large.

Submucosal fibroids are found on the inner wall lining and may make the cavity too cramped for a fetus to gestate completely for nine months. Overall, there is a forty percent chance of miscarriage on women with submucosal fibroids.

Fibroids can be removed surgically (myomectomy). Small fibroids found inside the uterus are usually removed with hysteroscopy, a thin telescope is inserted into the vagina to reach the uterus. It is an outpatient procedure and is often atraumatic. In contrast, bigger intramural fibroids require a real surgery and hospital stay. People generally need to have caesarean delivery after undergoing an abdominal myomectomy.

Removing polyps

These are tiny fleshy benign growths located on the endometrium surface. Very small polyps typically do not cause problem on pregnancy, but multiple polyps or larger polyps can interfere with delivery. Polyps may cause bleeding and should be diagnosed via hysteroscopy or sonohysterogram and can be safely scraped off the endometrium in a process called polypectomy.

Fallopian tubes

Most women have a couple of fallopian tubes, next to the ovaries, at each side of the uterus. Because those tubes are direct path for reaching the uterus, a problem on one or both tubes may have a huge impact on your chance of getting pregnant.

Sometimes one tube is surgically removed due to an ectopic pregnancy, (a pregnancy that grows in the fallopian tube instead of in the uterus). If ectopic pregnancy is found early enough, doctors may perform a treatment with a substance called methotrexate. In some cases, fetus can grow large enough in the tube. There is a risk that tube can burst, causing severe bleeding. The only way to deal with this life-threatening condition is to remove the fallopian tube.

Women can get pregnant with just one tube, but it should be understood that, someone who once had ectopic pregnancy have a higher risk of getting another.

Investigating damaged tubes

Women must at least have one fallopian tube and ovary each to get pregnant as the egg may still “float” to the remaining fallopian tube. One study showed that an egg has 30 percent chance of getting picked up by an opposite fallopian tube. Occasionally fallopian tubes are noticeably enlarged when observed by ultrasound. In women with really swollen tubes which prevent dye from flowing through them, may have a hydrosalpinx, it is the medical term for a badly infected tube. Women with dilated tubes are known to have hydrosalpinges.

A hydrosalpinx can interfere with the possibility of getting pregnant in two ways:

The egg can’t be picked up by a significantly dilated tube, whose end (fimbriae) is blocked by scars.

Even if the embryo can make it to the uterus from a fallopian tube or after being placed there with an in vitro fertilization (IVF) procedure, it may not be able to last long because some infected materials from the tube flows into the uterus, making it an inhospitable environment for any embryo to grow.

Hydrosalpinx can only be surgically treated. In mild cases, the problematic tube is peeled back by the surgeon like a flower. Unfortunately, in severe cases, it may still fail to work. The only way is to remove both tubes and an IVF procedure is needed to achieve pregnancy as eggs can no longer reach the uterus. This situation is a difficult thing for most women to accept because it practically ends any chance of having a natural pregnancy. In some cases, some women don’t have fallopian tubes since birth; overall, external sex organs may appear to be normal, but the fallopian tubes, uterus, and vagina are missing. Certainly, if you’ve had ectopic pregnancies a couple of times, both fallopian tubes must be surgically removed.

Occasionally fallopian tubes look good on an X-ray photograph but may have plenty of scarring (or adhesions) that prevent the egg from being picked up. Tissue growths that are found around the pelvis, also grow around or even inside the fallopian tubes, generally it is a common cause of scarring around fallopian tubes. Normal tubes can’t be visualized by ultrasound. Due to fallopian tubes’ role in making it possible for women to get pregnant, IVF is necessary if there are problems in those tubes. Blockages on the tubes can make IVF inevitable on women who are trying to get pregnant.

Effects of scarring

Adhesions or scar tissue can form in the reproductive system. Any woman who had more than one cesarean section tend to have scar tissue throughout their pelvis that must be cut away before doctor could get to the uterus. Scarring forms when plasma and blood from surgery trauma form fibrin deposits, they are threadlike strands that tightly bind an organ. Doctors can remove them with a surgery but as you may have guessed it – it creates more adhesions.

Pelvic adhesions are common after a surgery, such as fibroid removal, appendectomy or fallopian tube removal after an ectopic pregnancy. About 75 percent of surgeries cause adhesions which may cause pelvic pain; about a third of women with severe pelvis pain have scarring, and about 15 percent women have severe pelvic pain. Cesarean sections tend to cause adhesions, however they tend to be in front of the uterus (anterior), and thus may cause trouble during the next C-section. Fortunately, C-sections don’t usually disturb the fallopian tubes (which are located behind the uterus), and will not cause infertility.

Your windows of opportunity of getting pregnant after scarring removal is about six months, after that scar tissue will form again. Adhesions may damage ovaries or fallopian tubes, and you may need IVF to achieve pregnancy.

If there are adhesions in the uterus, it could be Asherman’s syndrome (or uterine synechiae). With Asherman’s, the scar tissue crisscrosses the whole cavity and makes it harder, if not impossible, for fertilized egg to implant.

Asherman’s can happen after a D&C (dilation and curettage), a uterine infection or an abortion. It can be observed with an HSG but should be diagnosed with a hysteroscopy, which allows visualization of the uterus. Asherman’s is also possible if you have recurrent miscarriages after a uterine trauma; or no or scant menstrual flow. If you have mild to moderate adhesions and they are removed surgically, there is a good chance, about 75 percent or higher, of getting pregnant. Severe scarring may destroy almost all uterine lining, which make pregnancy unlikely.

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