The incapability to produce a live birth after appropriate sexual exposure without the use of contraception is called infertility. It can affect both men and women. According to WHO, most infertile couples around the world suffer from two types of Infertility – Primary infertility & Secondary infertility. Primary infertility is a condition when the woman has never conceived. Secondary infertility is a condition that may occur anytime in a woman’s life after her first pregnancy. Infertility is rising at a rapid rate. It is estimated that globally 60-80 million couples suffer from infertility every year, of which probably between 15-20 million (25%) are in India alone. As per the WHO Study (2012), one in every four couples in developing countries had been found to be affected by infertility.
What is the background, present statistics & scenario of Women Infertility in India?
Nowadays, couples plan their life and make decisions about having a baby very carefully. They wait until the time is just right to expand their family. Most of them assume that by discontinuing birth control pills, pregnancy would happen right away. Although this is somewhat true and happens without any difficulty for a majority of couples, there are some who face problems. At least 15% of couples experience some degree of infertility. Those who are unable to conceive easily have specific problems causing infertility. These problems can be related to the woman, the man or both partners.
Traditionally, infertility has largely been attributed to the female and it has been a common belief that women are the culprits. However, in reality, it affects men and women almost equally.
- Problems with Male-40%
- Problems with Female-40%
- Unexplained -10%
Therefore, it is important for both partners to be aware of the causes of infertility and discuss the problems together with the doctor.
What Is Infertility in women?
Infertility is defined as the inability of a woman to become pregnant (conceive) after one year (or longer) of unprotected intercourse. Some doctors evaluate and treat women aged 35 years or older after 6 months of unprotected intercourse as female fertility is known to decline steadily with age.
In order to conceive, what are the things crucial for women?
Pregnancy is the result of a process that has many steps. Women require the following things to conceive:
- An egg must be released from one of her ovaries (ovulation).
- Sperm must fuse with the egg along the way (fertilize).
- The fertilized egg must go through a fallopian tube towards the uterus (womb).
- The fertilized egg must get attached to the inside of the uterus (implantation).
Is infertility a common problem?
The answer is yes. In India, the infertility problem experienced by currently married women is 8.8%, of which 6.7% of women have experienced primary infertility and 2.1% of women have experienced secondary infertility. The prevalence of currently infertile women is 4.6%. The prevalence of infertility in Eastern India is high whereas in the states of the west (such as Rajasthan, Gujarat, etc.), and the north (Assam, Meghalaya, Arunachal Pradesh, etc.) the prevalence of infertility is low. In the central Indian states (Madhya Pradesh, Maharashtra, etc.) a moderate (7-10%) rate of infertility prevalence has been observed. Among all the states, West Bengal has the highest prevalence (14.8%) of infertility experienced by women. In the states like Bihar, Goa, Haryana, Chhattisgarh, Kerala, Andhra Pradesh, and Uttar Pradesh infertility prevalence was found above 10%.
Is this just a woman’s problem?
It is not always a woman’s problem. Both men and women can contribute to infertility. Nowadays, many couples suffer from infertility and seek help to become pregnant, but it is often thought to be only a woman’s condition. Recent statistics show that in about 35% of couples with infertility, a male factor is identified along with a female factor. A male factor is the only identifiable cause in about 8% of couples with infertility. It is observed that 9% of men aged 25 to 44 years in the US reported that they or their partner saw a doctor for advice, testing, or treatment for infertility during their lifetime.
How does the female reproductive system work?
The female reproductive system is mainly responsible for producing eggs (ova) which are fertilized later, and for providing the space and conditions to allow a baby to develop. In order to maintain the sequence, the female reproductive system also has the structures necessary to allow sperm from a man to meet the ova of a woman.
Different hormones are released into the reproductive system that helps to control a woman’s monthly cycle. The process is called ovulation. Pregnancy happens when ova are fertilized by a sperm. The hormones are also responsible for creating the right conditions in the womb (uterus) for fetus development and blocking ovulation during pregnancy.
What is a female reproductive system composed of?
Ovaries: The ovaries are a pair of small glands similar to the size and shape of almonds. It is located on the left and right sides of the pelvic body cavity lateral to the superior portion of the uterus. Female sex hormones such as oestrogen and progesterone as well as ova (commonly called “eggs”), the female gametes are produced by the ovaries. Ova are produced from oocyte cells that slowly develop throughout a woman’s early life and reach maturity after puberty. Every month during ovulation, a mature ovum is released. The ovum moves from the ovary to the fallopian tube and may be fertilised there before reaching the uterus.
Fallopian tubes: It connects the ovaries to the uterus. The released egg moves along a fallopian tube.
Uterus (womb): A hollow, pear-shaped organ where the fetus develops. It’s divided into 2 parts: the cervix, which is the lower part that opens into the vagina, and the corpus, which is the main body of the uterus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit.
Vagina: The area between the lower part of the womb (the cervix) and the outside of the body. The vagina receives the penis during sexual intercourse and is a passageway for childbirth.
Hymen: It covers the opening of the vagina. It is a thin piece of tissue that has one or more holes in it. On using a tampon or during a first sexual experience, sometimes the hymen may be stretched or torn. If it does tear, it may bleed a little bit.
Vulva: It covers the entrance to the vagina. The vulva has five parts: mons pubis, labia, clitoris, urinary opening, and vaginal opening.
Mons pubis: It’ is the fatty bulge above the labia which is covered with hair after puberty.
Labia: There are two sets of skin folds (often called lips) on either side of the opening of the vagina. The labia majora are the outer lips, and the labia minora are the inner lips. It is normal for the labia to look different from each other.
Clitoris: It’s a small, sensitive bump at the bottom of the mons pubis that is covered by the labia minora.
Urinary opening: It’s below the clitoris from where your urine leaves the body.
Vaginal opening: It’s the entry to the vagina and is found below the urinary opening.
Which anatomical parts play an important role for a woman to conceive?
- Functioning ovaries
- Fallopian tubes
Conditions that affect the normal functioning of the above-mentioned organs can contribute to female infertility.
What are signs & symptoms of infertility in women?
- Women experienced the problem of irregular cycles as one of the most important symptoms of infertility (40%).
- Women who had extremely heavy or light bleeding during the menstrual cycle (34.2%).
- Women who had earlier miscarriages (25.6%).
- Women who were underweight(21% )
- Women, trying to conceive were older than 35 years (18.4%).
- Respondents were overweight (14.6%).
- Women who suffered from thyroid, diabetes, and hypertension like diseases (13.1%).
- Women who had faced some kind of sexually transmitted disease (9%).
- None of the above sins as a hint of infertility (6.8%).
- Women who said that their partner experienced impotency during sex (5.6%).
What are the causes of infertility in women?
Causes identified for infertility in women:
- Poor egg quality (47%) was found as the main cause of infertility.
- Women had problems in their uterus and fallopian tube (37.5%). This was identified as the second major cause of infertility among women.
- Women who were above 35 years of age (29%).
- Women had ovulation disorders (20.6%)
- Women who had a uterine problem and premature ovarian failure problem (16.8%).
- Women who suffered from endometriosis(14.5% )
- The pelvic inflammatory disease was the cause of infertility in (7.4%) of women.
- Submucosal fibroids in (5%) cases.
- Side effects of medications (0.7%).
- Chemotherapy (0.2%) was found to cause infertility in rare cases.
Disruption of ovarian function (presence or absence of ovulation (anovulation) and effects of ovarian “age”)
Usually, an average menstrual cycle is 28 days long. Day 1 is referred to as the first day of “full flow.” Regular predictable periods occur every 24 to 32 days likely reflecting ovulation. A woman with irregular periods is likely not ovulating. When a woman doesn’t ovulate during a menstrual cycle, it’s called anovulation. Important causes of anovulation include the following:
- Polycystic ovary syndrome (PCOS): PCOS is a condition when women are unable to ovulate or to ovulate irregularly. Some women with PCOS have elevated levels of testosterone, which can cause acne and excess hair growth. PCOS is the most common cause of female infertility.
- Diminished ovarian reserve (DOR): Diminished ovarian reserve is a condition in which there are fewer eggs remaining in the ovaries than normal. The number of eggs declines naturally as a woman ages. Decreasing egg count occurs due to congenital, medical, surgical, or unexplained causes. Women with diminished ovarian reserve may be able to conceive naturally but will produce fewer eggs in response to fertility treatments.
- Functional hypothalamic amenorrhea (FHA): FHA occurs due to excessive exercise, stress, or low body weight. Sometimes it is associated with eating disorders such as anorexia (lack or loss of appetite for food).
- Improper function of the hypothalamus and pituitary glands: The hypothalamus and pituitary glands in the brain controls hormones that maintain normal ovarian function. A benign pituitary gland tumour, improper function of the hypothalamus or pituitary gland results in improper levels of a hormone which may cause a woman not to ovulate.
- Premature ovarian insufficiency (POI): POI or premature menopause, occurs when a woman’s ovaries fail before she is 40 years of age. Exposure to chemotherapy or pelvic radiation therapy, and certain medical conditions may cause POI, the cause is often unexplained. It is also observed that 5% – 10% of women with POI conceive naturally and have a normal pregnancy.
- Menopause: Menopause is a condition which is defined as an age-appropriate decline of ovarian function. During such conditions, women experience hot flashes, mood changes, difficulty in sleeping and other symptoms as well.
- Follicle Problems: “Unruptured follicle syndrome” is currently unexplained & occurs in women who produce a normal follicle, with an egg inside it, every month yet the follicle fails to rupture. The egg, therefore, remains inside the ovary and proper ovulation does not occur.
Fallopian tube obstruction (whether fallopian tubes are open, blocked, or swollen)
Blocked fallopian tubes (tubal occlusion) occur due to a history of pelvic infection, history of ruptured appendicitis, history of gonorrhea or chlamydia, known as endometriosis, or a history of abdominal surgery.
Normal pregnancies develop inside the uterus after a fertilized egg travels through the fallopian tube and gets attached to the uterine lining. Whereas in Ectopic pregnancy, the fertilized egg gets attached somewhere else in the body (fallopian tube, abdominal cavity, or cervix). Usually, it gets attached to the fallopian tube so it’s also called “tubal pregnancy.” Ectopic pregnancies are rare. It happens in about 2 out of every 100 pregnancies. Untreated ectopic pregnancy can be dangerous. In a stretched condition (with growing pregnancy), the fallopian tube can break. This condition is called ruptured ectopic pregnancy which can cause internal bleeding, infection, and in some cases death.
Abnormal uterine contour (physical characteristics of the uterus)
Uterine fibroids, also known as uterine leiomyomas, are benign smooth muscle tumours of the uterus. A transvaginal ultrasound is done to evaluate the uterus and look for fibroids or other anatomic abnormalities, depending on the symptoms.
The endometrium is the tissue that forms the inner lining of the womb (uterus). Endometriosis is a condition where endometrial tissue is found outside the uterus. It is “trapped” in the pelvic area and lower tummy (abdomen) and, rarely, in other areas of the body. It may lead to painful periods, painful sex, pain in the lower abdomen & pelvic area, reduced fertility, and other menstrual symptoms.
What increases a woman’s risk of infertility?
The important risk factors that can cause infertility in women are:
- Age: The ability to conceive starts to fall around the age of 32 years. Ageing not only decreases a woman’s chances of having a baby but also increases her chances of a miscarriage and of having a child with a genetic abnormality. Ageing decreases a woman’s chances of having a baby as the number of eggs left is less & they aren’t very healthy.
- Smoking: Smoking significantly increases the risk of infertility. It also affects fertility treatment. Smoking habit during pregnancy increases the chance of pregnancy loss. Passive smoking also increases the chance of lower fertility.
- Excessive alcohol use: It can affect the chances of conceiving.
- Obese or Overweight: Increases the chance of infertility.
- Eating disorders: Weight loss due to eating disorders, may cause fertility problems. A lack of folic acid, iron, zinc, and vitamin B-12 can affect fertility.
- Exposure to some chemicals: Some pesticides, herbicides, metals, such as lead, and solvents are sometimes responsible for infertility.
- Mental stress: This may affect female ovulation and can lead to reduced sexual activity. Excessive physical or emotional stress causes amenorrhea (absent periods).
How is infertility treated in women nowadays?
Nowadays Infertility can be treated with:
- Intrauterine insemination
- Assisted reproductive technology(IVF)
Doctors recommend specific treatments for infertility on the basis of:
- Contributing factors for infertility.
- The duration or time range of infertility.
- The female age.
- The couple’s treatment – counseling about success rates, risks, and benefits of each treatment option.
What are the suitable measures to prevent infertility in women?
- Avoid caffeine, drugs, smoking, and alcohol.
- Try to get pregnant before 35.
- Develop a healthy lifestyle
- Maintain a healthy body weight
- Minimise exposure to toxic chemicals
- Avoid junk food
- Maintaining a safe sexual lifestyle
- Not avoiding earlier sins of infertility
- Use contraceptives under the guidance of a doctor
- Avoid stress
- Go for routine check-ups
Some effective steps are being made in the diagnosis and treatment of infertility. It is shown that 65% of the couples who seek medical help eventually succeed in having children. In concern of modern medical development, some simple and affordable procedures are available to treat infertility. If females are having trouble conceiving, consult a physician or infertility expert with a special interest and expertise in the area of infertility. The treatment for infertility depends on the diagnosis and possible cause of infertility.