Carolinas HealthCare System

Female Factors

Tubal Disease
The fallopian tubes are necessary for transporting the fertilized egg to the uterus. Fallopian tube abnormalities are responsible for about 35 percent of infertility. Fallopian tube abnormalities include tubal scarring or blockage (most commonly from pelvic infections), prior abdominal surgeries and endometriosis. The fallopian tubes are initially evaluated by an hysterosalpingogram (HSG) and can, if necessary, be more thoroughly evaluated with a laparoscopy. A laparoscopy may correct fallopian tube damage and improve fertility. If the fallopian tubes are severely damaged or surgery does not enable conception, in vitro fertilization (IVF) to bypass the tubes may be recommended. In cases of blocked and dilated fallopian tubes, patients may consider surgery to open or remove fallopian tubes before IVF to improve their chances of pregnancy.

Abnormal Ovulation
Ovulation (release of the egg from the ovary) typically occurs between days 12 to 16 of a woman's menstrual cycle. An abnormal menstrual pattern includes cycles that occur less than every 21 days or more than every 35 days. Abnormal ovulation occurs in about 25 percent of patients with infertility. Methods for ovulation evaluation include basal body temperature charting (BBT), ovulation predictor kits, endometrial biopsy, ultrasound and blood progesterone testing. BBT charting does not directly detect ovulation but it helps indirectly to confirm or disprove ovulation.

Ovulation causes the release of progesterone and increases temperature by 0.5 to 1.0 degree Fahrenheit. Ovulation predictor kits detect lutenizing hormone (LH) in the urine. LH is the brain hormone that stimulates the ovary to release the egg. It is another indirect way to evaluate for ovulation. Endometrial biopsy (removing a piece of tissue from the uterus) will determine ovulation but may produce some discomfort, and isn't routinely recommended. Ultrasound can detect egg production, but blood progesterone testing is the definitive method for determining ovulation. Blood is drawn for progesterone one week after ovulation.

Cervical Factor
The cervix is the lowest portion of the uterus. The cervix produces clear and watery mucus at ovulation allowing sperm to pass into the uterus. Cervical factor infertility is a rare cause of infertility; however, prior cervical surgery (cervical biopsy, cone biopsy, LEEP, freezing and/or laser treatments for abnormal Pap smears, for instance) may contribute to cervical factor infertility. There are no predictive tests for it. Post-coital testing -- taking a sample of mucus during ovulation to evaluate for cervical factor -- is poor at predicting true cervical abnormalities, and isn't routinely performed. Typically, intrauterine sperm insemination (IUI) to bypass any potential cervical factors is recommended.

Uterine Factor
Uterine factor is another infrequent (five percent) cause of infertility. Causes of uterine factor include uterine polyps (benign growths of endometrium lining the uterus), uterine scarring from prior infection or surgery, fibroids or abnormal uterine cavity shape. These are initially evaluated with a hysterosalpingogram (HSG) and/or a hydrosonography. Hysteroscopy may be recommended to further evaluate and treat uterine abnormalities. Uterine fibroids are benign uterine tumors that, depending on size and location, may interfere with fertility. Surgery may be recommended if indicated, but fibroids are common and may not necessarily require treatment.

Peritoneal Factor
The peritoneum is the lining of the abdominal cavity and pelvic organs. The peritoneum may be scarred, producing adhesions, most commonly from infections, prior abdominal surgeries and/or endometriosis. Endometriosis occurs when tissue lining the uterus (endometrium) is growing outside the uterus. Endometriosis often results in painful menstrual cycles. And, while the cause is unknown, endometriosis is found in approximately 35 percent of infertile women. A laparoscopy to evaluate for endometriosis and/or adhesions as a cause for infertility may be recommended.

Unexplained Infertility  
Many women delay childbearing until their 30s or 40s based on a variety of factors -- among them career, finances or simply personal choice. Roughly 20 percent of women in the United States do not attempt pregnancy until age 35 or later. Biologically, fertility decreases with age. While women under age 30 have about a 20 percent per month chance of conceiving, only five percent of women over age 40 will conceive. Although women continue to have regular menstrual cycles until sometime near menopause, this doesn't necessarily mean they remain fertile. Regardless of the woman's cycle, fertility declines with the reduction in ovarian function and egg quality as women age.

Testing for Age-Related Fertility

Several tests may help gauge a patient's fertility potential, also known as ovarian reserve:

  • Day 3 levels of FSH and Estradiol
    Follicle stimulating hormone (FSH) is a hormone released from the brain that triggers egg development by the ovary. Estradiol is the hormone produced by the ovary as the egg develops. Patients with an elevated estradiol and/or FSH level on the third day of a menstrual cycle have poor pregnancy rates with both ovulation induction and in vitro fertilization.
  • Clomiphene Citrate Challenge Test (CCT)
    The day 3 FSH and estradiol levels may be normal in patients with decreased ovarian reserve. The CCT is another test to more thoroughly evaluate fertility potential. Clomiphene citrate is an oral medication given orally on menstrual days five through nine. Estradiol and FSH are measured on day three and day 10 of the cycle. Elevated blood levels of these hormones are associated with very low pregnancy rates with fertility treatment.
  • Response to Fertility Medications
    The response to injectable high-dose fertility medications is another method for determining ovarian reserve. Patients with decreased ovarian reserve require larger amounts of medication to produce eggs and generally have lower pregnancy rates with ovulation induction and in vitro fertilization. Egg donation is an option for those patients who do not conceive with other therapies or have abnormal ovarian reserve testing. Egg donation involves using eggs donated by another woman. Patients may provide a donor (typically a sister or close friend) or an anonymous donor may be provided.

Chromosomal abnormalities in eggs is one of the main causes of decreased fertility and increased miscarriage risk. This also increases the risk of miscarriage if a couple does conceive. A patient age 40 or older has up to a 50 percent risk of miscarriage. Genetic counseling is offered to women who conceive and will deliver at age 35 or older. Prenatal testing may be considered with amniocentesis or chorionic villus sampling to test for chromosomal abnormalities.

Women who conceive after age 35 also experience greater risk of pregnancy complications, including diabetes and high blood pressure. Pre-existing medical conditions may worsen in pregnancy and require special monitoring. Health problems should be treated before attempting pregnancy.

Patients should discuss these issues with their physician. An obstetrician/gynecologist will often initiate an infertility evaluation at 12 months of infertility. For older patients, however, this may be initiated after six months. If the presumed cause of infertility is age-related, ovulation induction or IVF may be recommended. Even with infertility treatment, age affects the chance for pregnancy and this should be discussed with your physician.

In up to 10 percent of couples, infertility's cause is inexplicible. Typically, physicians recommend empiric treatment with fertility medications (ovulation induction) and/or intrauterine insemination for three to six treatment cycles. Depending on several factors including patient age and duration of infertility, other options may be recommended, including in vitro fertilization (IVF), particularly if pregnancy does not occur with ovulation induction. IVF can increase chances for pregnancy. In some cases, however, IVF helps determine a cause for infertility by evaluating egg quality, sperm and egg interaction and embryo development.