Female Infertility

a) PCOS: Polycystic Ovarian Syndrome (PCOS), is an ovulation disorder which affects 7-8% of all women. The researchers claim it to be genetic condition though several factors may contribute to it. The main symptoms include irregular or no menstruation, hirsutism and acne due to high levels of male hormones, obesity, high insulin levels with risk for developing diabetes and large polycystic ovaries shown on ultrasound. To increase fertility the treatment possibilities are mostly focused on regulation of the periods in women. For this, several drugs are used (Clomiphene Citrate, Bromocriptine, Gonadotrophins) and weight loss is recommended. In many cases the cycle will be ovulatory and regulated by these treatments. Newer oral antidiabetic drugs such as Metformin are being more frequently used to treat PCOS, with very good results. Apart from this, one can electro coagulate the ovarian surface using a laparoscopic surgery, especially in those cases where women have highly elevated levels of LH hormone. In cases of failure to achieve a pregnancy to Gonadotropin injections are used to induce ovulation. This may be combined with IUI (Intrauterine insemination) procedure also. Resistant cases may be recruited for ART procedures such as IVF of ICSI.

b) Damaged fallopian tubes:

The invitrofertilisation treatment (or IVF) was initially developed for patients facing infertility due to damaged fallopian tubes. Later on the treatment indications were broadened to include cases of unexplained infertility and male infertility. Even until now, tubal damage still accounts for a large number of all IVF treatments. In developing countries like India, genital tuberculosis is a big problem which may lead to blocked tubes. In addition, tubal damage may be the result of sexually transmitted diseases (like Chlamydia or Gonorrhea). Pelvic Inflammatory Disease (PID), gynaecological surgeries, caesarean sections, tubectomy or complication of appendicitis. The patients with damaged/blocked tubes suffer from infertility and are at a high risk of having an ectopic pregnancy.

c) Endometriosis

Endometriosis itself may not be a disease in itself but may be the manifestation of a basic chemical or physiological abnormality that affects the tubal mobility or immune system resulting in endometriosis in patients with retrograde menstrual flow. Thereby endometriosis may not be the cause, but the result of it. Endometriosis is generally diagnosed at the time of laparoscopy and we can treat it simultaneously using Lasers, electric current and scissors. In fact, with the invention of operative laparoscopic surgery, very few people need to undergo the traditional method of opening the abdomen. Endometriosis can also be controlled by using various drugs such as Danazol, GnRh analogues or progesterones which help many patients to conceive. The remaining patients may have to take the help of IVF or ICSI treatment. In our unit, we have found that ICSI gives better results than IVF.

d) Age related infertility

Fertility decreases with increase in age. A woman in her 20s and 30s has a 20-25% chance of conceiving naturally but for a woman in her early 40s, the chance is only 5-10% chance. In IVF clinics, usually women over the age of 35 are seen twice as commonly as younger women. In fact, age is the single most important factor determining the outcome by IVF treatment. The main reason for decrease in fertility with age is due to declining quality of the woman's eggs. Although it is not possible to improve the quality of the eggs, women in their 40s or 50s can only conceive using the techniques which can improve IVF outcome. For example, by increasing the drugs used to induce ovulation which will increase the number of eggs that develop in a given period, thereby increasing the chances of fertilization leading to pregnancy. Egg donation is most commonly used method to increase the chance of pregnancy in women with age-related infertility problems using either a relative or anonymous donor. To predict a woman's fertility blood tests that are commonly recommended are FSH (Follicle Stimulating Hormone) and E-2 (Oestradiol) which are carried out on the third day of the menstrual cycle. The higher the FSH, the lesser are the chances of woman to achieve a pregnancy. With increasing age the FSH levels increase but sometimes high FSH levels are also seen in women who have poor quality eggs.

e) Ectopic Pregnancy

When a pregnancy does not occur in the uterus it is called an Ectopic pregnancy or Extra Uterine Pregnancy (EUG). The most common site of ectopic pregnancy is the tube but sometimes it may occur at other sites like cervix, ovary or the abdomen. The incidence of EUG is about 1% but the risk increases during IVF treatment.

The most common risk factors for EUG are PID, Genital TB, previous history of a EUG, salpingitis, Chlamydia infection, endometriosis, previous history of surgery or tubes, appendix etc.

The symptoms are similar to those of an abortion including a positive pregnancy test with or without vaginal bleeding and abdominal pain. The condition is diagnosed after a thorough examination and an ultrasound together with serum BHCG levels. The treatment depends on the size and site of ectopic. Most commonly, laparoscopy is used to remove the ectopic pregnancy but sometimes medical management may also be offered to the patient. Alternatively, drugs may be injected directly into the ectopic pregnancy under ultrasound guidance.

f) Recurrent miscarriage

Recurrent miscarriage affects 1-3% of all females. The chances of a pregnancy ending up in an abortion are about 18-20% after one and about 20-25% after two episodes of miscarriage. About 50% of pregnancies that end up in an abortion in the first three months have major chromosomal abnormalities. This incidence decreases to 30% in second trimester losses and about 5% in the last trimester. Other possibilities might be hormonal disturbances, abnormality of the immunological system, anatomical abnormality of the uterus, infections lifestyle problems like drug addiction, alcohol use, cigarette smoking, excessive caffeine intake etc. In about 50% of patients, no cause would be found. The treatment of the problem would depend on the cause. For example:

• If the patient has uterine fibroids or polyps she is advised laparoscopic surgery.
• If she has a uterine septum, it could be corrected hysterocopically
• In case of hormonal dysfunctions called luteal phase defect or LPD progesterone is prescribed.
• In case of infections, antibiotics are given.
• If there are immunologic factors, aspirin therapy is prescribed sometimes along with heparin therapy.

Recent advances in the field include injecting lymphocyte cells derived from the husband into woman's body.