Causes of Female Infertility: A Patient's Guide to Understanding the Female Factor

In short: Infertility means no pregnancy after at least a year of regular intercourse, and the cause may lie with the woman, the man or both. The main causes in women are ovulation disorders and polycystic ovaries, blocked fallopian tubes, endometriosis, abnormalities and adhesions of the uterus, and problems of the cervix. The chance of pregnancy falls gradually with age, so early medical advice is recommended.

Infertility is defined as the inability to conceive despite trying with regular, unprotected intercourse for one year. If you and your partner are facing this challenge, please know that you are not alone — infertility is a common issue affecting many couples, and understanding its causes is the first step toward finding the right solution.

The causes of infertility can come from female factors, male factors, or a combination of both. This article focuses on the female factors, to help you better understand what might be happening and what can be done.

Female factors:

Multiple studies have shown that a woman’s natural fertility gradually decreases with increasing age, which is why timely evaluation and treatment can make a real difference.

1- Vaginal Causes of Infertility in Women

Blockage of the vagina which will interfere with the entrance of the male organ such as imperforate hymen, or extremely narrow vagina, or painful infections in the vagina.

2- Cervical Causes of Infertility in Women

• Previous cone biopsy or laser conization. This might cause a decreased amount of mucous. This will affect sperm movement.
• Presence of anti-sperm antibodies.
• Closed cervix (very rare condition).

3- Uterine Causes of Infertility in Women

• a. Congenital anomalies: Most of them precipitate from abortions, but some of them affect fertility and can be corrected surgically, such as a septate or divided uterus, which can be removed by hysteroscopy. Anomalies such as bicornuate uterus, rudimentary horn and T-shaped uterus. These anomalies are sometimes associated with kidney and urinary tract anomalies, and some of them increase the risk of miscarriage, preterm birth and abnormal position of the baby, so they should be assessed by 3D ultrasound or MRI before deciding on treatment.

• b. Asherman Syndrome: In this syndrome intra uterine adhesions form either after repeated curettage, severe endometritis, or due to scars from previous uterine surgery. Women with this syndrome usually complain of decreased amount of blood loss during menstruation. It may be suspected on hysterosalpingogram or 3D ultrasound, but it is confirmed and treated by hysteroscopy. Hysteroscopic resection of the adhesions may need more than one session, and some doctors give estrogen and/or place a temporary barrier after surgery to reduce recurrence, although the evidence for these measures is still limited.

• c. Fibroids: Fibroids are a benign uterine tumor that might cause irregularities in the intrauterine cavity. They usually do not cause infertility unless they distort the uterine cavity. Fibroids that bulge into the cavity (submucosal) should be removed before trying to conceive, while the benefit of removing fibroids in the wall that do not affect the cavity is uncertain, so the decision is individualized according to their size, number and symptoms. Myomectomy can be done by hysteroscopic resection for fibroids inside the cavity, or by laparoscopy or laparotomy (an abdominal incision) for fibroids in the wall or on the outside of the uterus.
• d. Fibrosis: This may happen after endometritis and can be diagnosed using HSG, hysteroscopy can help in treatment.
• e. Endometrial polyp: Its presence mimics IUCD, polyps can be diagnosed by HSG, ultrasound or hysteroscopy then polypectomy (removing the polyp) can be done easily.
• f. Adenomyosis: Symptoms include secondary dysmenorrhea and heavy periods, and it is diagnosed by ultrasound or MRI. Hormonal treatments such as progestins or GnRH analogues (for example before a frozen embryo transfer) may be helpful; the decision for this treatment should be taken by the treating physician.

4- Tubal factors causing Infertility in Women:

• a. Chronic pelvic infections: This problem will cause tubal congestion. If the cross section reaches more than 3cm, tubal obstruction results in impeding of the oocyte transfer, chronic pelvic infections may also result in pelvic adhesions that will affect tubal movement. Slowing it so inappropriate time for oocyte transfer interferes with fertilization. Pelvic inflammatory disease will result in tubal occlusion or pelvic adhesions that cause inability for the fimbrial ends to catch the oocyte from the ovary or as mentioned before abnormal movement of the tubes and oocyte transfer. The most common causes of PID are sexually transmitted infections, mainly Chlamydia and Gonorrhoea, and less often other bacteria. PID affects ovarian function and tubal movement. And it may be severe enough to destruct the tubes requiring surgical resection.

If the tube is blocked and filled with fluid (hydrosalpinx), this fluid can reduce the chance of IVF success, so removing or clipping the affected tube by laparoscopy is recommended before IVF.

• b. Destruction of the fimbrial ends: Disabling its function in catching oocytes into the tubes, PID or endometriosis can cause this.
• c. Adhesions: Caused by tubal surgery done for ectopic pregnancy, pelvic surgery done to the tubes or due to appendicitis.
• d. Short tubes (less than 4cm).
• e. Tubal Tumors affecting its function.

5- Ovarian dysfunction:

• A. Polycystic ovarian disease: 20% of females have what is called polycystic ovary which involves having follicles consisting of more than the normal condition. In this case the woman has normal fertility but if it is associated with some of the following conditions, it is called polycystic ovarian syndrome and it is pathological. Please press on the link to read more about Polycystic ovarian disease.

What about the possibility of doing IVF for these women?

IVF was first done for women who have tubal occlusion or male abnormal semen analysis.

But the decision, whether women with PCOD will need IVF, should be individualized as said earlier.

For most women with PCOS who do not ovulate, the first step is lifestyle and weight optimization, then letrozole tablets, which are now the first-line medication for ovulation induction; injections or ovarian drilling come second, and IVF is usually reserved for women who do not conceive with these steps or have other causes of infertility.

-For hirsuitism treatment for women, seeking pregnancy is different from those who are not.

Most of the time, treatment of hormonal imbalance is the best thing.

-Regarding recurrent miscarriage in PCOS patients, a raised LH level was once thought to be the cause, but lowering LH before ovulation induction has not been shown to reduce miscarriage; the recommended approach is a full recurrent miscarriage work-up and optimizing weight, insulin resistance and general health. Ovarian diathermy (drilling) lowers LH levels and may be used as a second-line option to restore ovulation in women who do not respond to tablets, but it is not recommended as a treatment to prevent miscarriage.

Repeated pregnancy loss is discussed in more detail in our dedicated article on recurrent miscarriage.

• B- Failure of the ovary to perform its normal function:

  

  • 1- Ovarian failure:
    • A- Congenital causes.
      • 1- Genetic and chromosomal causes.
        • Ovarian agenesis.
        • Hereditary causes for accelerated loss of ovarian reserve.
        • Familial premature ovarian failure.
        • Chromosomal abnormalities, most commonly Turner syndrome (45,X or mosaic forms), and less often 47,XXX; a Fragile X (FMR1) premutation is another important genetic cause.
      • 2- Congenital enzymatic dysfunction.
        • 17-α Hydroxylase Deficiency.
        • Galactosemia.
    • B- Exposure to certain factors:
      • Large amount of radiation exposure.
      • Chemotherapeutic agents as in cancer treatment.
      • Viruses such as mumps.
      • Heavy smoking.
    • C- Autoimmune causes: Presence of ovarian antibodies.
    • D- Lack of (or dysfunction) of LH, FSH ovarian receptors.
    • E- Idiopathic causes.
    • F- Surgical oopherectomy.
  • 2- Physiological ovarian failure. Such as luteinized unruptured follicle (the follicle does not release the egg). Corpus luteum insufficiency was once considered a cause, but there is no reliable test for it and it is no longer regarded as a separate cause of infertility.

• C- Pituitary failure:

  • 1- Secondary disorder of Gonadotrophin Regulation. High prolactine level either due to pituitary adenoma, idiopathic hypothyroidism or as a side effect to medication, which affects follicular maturation.
    • Suprapituitary Tumors.
    • Pituitary Tumors, trauma such as in RTA, radiation exposure to the pituitary.
    • Idiopathic causes.
  • 2- LH and FSH gonadotrophin Deficiency due to:
    • Pituitary tumors.
    • Destructive pituitary lesion.
    • Pituitary ablation.

• D- Hypothalamic failure. Which could be as a result of:

  • Rapid and sudden increase or decrease in body weight.
  • Severe psychological and neurological stress strenuous exercises.
  • Radiation exposure.
  • Medications that cause hypothalamic failure.
  • Tumors.
  • Unknown causes.

• E- Endocrinopathy: Such as Adrenal gland dysfunction which lead to hyperandrogenic state, and Thyroid gland problems. Hypothyrodism causes hyperprolactinemia and hyperthyroidism affects hormones necessary for follicular maturation, pancreatic problems such as diabetes.

6- Endometriosis:

Which is the presence of endometrial tissues outside endometrial cavity it affects pregnancy either by forming chocolate cyst (or endometrioma) or by causing adhesions. Please press on the link to read more about Endometriosis

Diagnosis is now usually made by symptoms, examination and ultrasound or MRI, and laparoscopy is reserved for selected cases. When surgery is needed, it includes laparoscopic excision or cauterization of endometriosis and division of adhesions; depending on age, ovarian reserve and tubal condition, IVF may be a better option than repeated surgery.

The keyhole surgery used for this procedure is described in our guide to gynecological laparoscopy.

In cornual obstruction (the area where the tube is connected to the uterus), tubal catheterization opens the tube in most cases, but the chance of natural pregnancy afterwards is only around 20–30%, and it is lower after reconstruction of badly damaged tubes; for this reason IVF is often the better option, especially in older women or when the male partner also has a problem.

Cornular Dilatation is done by passing a special tube through the cervix to the tube.

In cases of ovarian cysts (hemorrhagic cyst) surgical intervention is needed. Treatment of chronic PID causing adhesions, is similar to treatment of endometriosis, that is adhesiolysis and tubal reconstruction.

7- Unexplained Infertility:

Inability to conceive after one year of regular intercourse (six months if the woman is 35 or older) when the standard tests — ovulation, tubal patency and semen analysis — are all normal. Multiple researches have been done with multiple theories attempting to explain it.

• Presence of certain amounts of fatty acids in the sperm
• Cervical leucocytosis.
• Psychological causes.

It is said that stress and strenuous exercise, and unstable changes in weather may cause oligospermia but there is lack of strong evidence for this. But, psychological causes might affects premature ejaculation or erectile dysfunction. The best psychological support for the male is from his wife regarding psychological causes. In women, it affects sexual function and ovulatory failure. In our society, most females, after marriage, will find problems in proper sexual intercourse that is related to the way that most of them are raised, and psychotherapy is helpful in these cases.

• Some hypotheses say that stress and worries may affect hormones and sexual function, for example causing painful intercourse from vaginal muscle spasm; however, stress does not block the fallopian tubes, and a tubal blockage seen on testing needs medical evaluation.

Stress also has its effects on the hypothalamus and ovarian function.

So we advise each couple seeking pregnancy to try, as much as possible, to alleviate stress and worries as much as possible and have trust in god and trust their treating physician.

• Genetic causes.
• Endometrial Immunity.
• Lack of some vitamins and ferritine level.

It should be said that these causes are rare and not that familiar, researchers are doing their best to identify and treat these causes.

If you recognize any of these signs or have been trying to conceive without success, a thorough evaluation with an experienced fertility specialist can help identify the underlying cause and the most suitable path forward for you.

Dr. Najeeb Layyous and his team are available to guide you through diagnosis and personalized treatment options.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist