Female

Investigations for infertility

The Female

Female age

Female fertility is age dependent. Unlike men who may remain fertile into old age, a women's fertility potential (fecundity) begins to decline at the age of 35. Age has become one of the primary causes of infertility because women are increasingly postponing child bearing to after the age of 30. Many reasons for this decline have been suggested:

• Ovarian reserve - at the start of puberty a women has a fixed number of oocytes per ovary which will normally last until the women's early forties accepting normal ovulatory function during this period.
• Poor ovulatory function, both spontaneous and induced.
• Increased incidence of genetic and cytoplasmic abnormalities affecting fertilization success in oocytes, embryo development and implantation potential.
• Increased incidence of pregnancy loss.

Possible sequence of investigations

• Gynaecological (menstrual) history.
• PAP smear to identify cancer of the cervix.
• Tests of ovulation.
  • Cycle length.
  • Cervical mucus quality.
  • Hormone levels during the cycle
  • Monitoring of cycle (oocyte development and ovulation) by ultrasound.
• Theatre examinations of the reproductive organs.
• Endoscopic surgery.

Ovulation (the release of an oocyte)

The normal female reproductive cycle (menstrual cycle) is a complex process of regeneration and degeneration regulated by hormones (chemical messengers). These messengers are released from a number of organs (hypothalamus and pituitary gland and the ovaries) during the cycle. The hormones released in the first half of the cycle control the maturation of the oocyte within a follicle (on the ovary) and the release of the oocyte at maturity, as well as the development of the endometrium (uterus cavity). During the second half of the cycle the hormones will deregulate resulting in the shedding of the endometrium (menstruation) or the hormones would continue to maintain the endometrium and the conceptus (pregnancy). Anovulation a common cause of infertility is a disorder where no or inadequate hormonal control exists to induce ovulation. Most of these disorders can be overcome by drug therapy.

Cervical mucus

Cervical mucus, mucus secreted by the cervix (mouth of uterus), also falls under the control of the hormones (cyclical changes). One of the primary purposes of cervical mucus is to facilitate the entry of sperm into the reproductive pathways. Maximal penetration therefore occurs at ovulation.

Menstrual cycle

The name refers to all the processes that take place within the female reproductive organs from one menstruation to the next.

• Development of a mature follicle with oocyte (ovulation).
• Hormonal secretions.
• Regeneration and degeneration of the endometrium (uterus cavity).

Menstruation

Menstrual bleeding is the shedding of the endometrial lining which developed during the menstrual cycle.

Endometriosis

This is a pathological condition in which tissue resembling the normal lining of the cavity of the uterus (endometrium) is found outside the cavity of the uterus. It may occur in and on any of the reproductive organs as well as the pelvic cavity (lining) and organs in the pelvic cavity. Depending on the degree of endometriosis it can be associated with an increased risk of infertility, abdominal pain during menstruation and pain during sexual intercourse. Endometriosis can be successfully treated with surgery.

Polycystic ovarian syndrome (PCO)

Polycystic ovarian syndrome is a relatively common cause of infertility. In this condition, the ovaries contain many small cysts. The symptoms of PCO are:

• Irregular menstrual cycles.
• Excessive growth of body and facial hair.
• Acne and oily skin.
• Obesity.

Hysterosalpingography, Hysteroscopy, Laparoscopy

Are all procedures that are used to examine the normality of the reproductive organs and pathway:

• The uterus.
• The Fallopian tubes.
• The ovaries.

Endoscopic surgery

Endoscopic surgery is performed with either a laparoscope or hysteroscope to operate conditions in the pelvis, on the ovaries, around the Fallopian tubes or in the uterus (i.e. removal of septums, polyps or fibromas). This type of surgery has the advantage of only requiring the making of small incisions to access the abdominal cavity and therefore can be performed as a day-case procedure. New developments with regards instruments and techniques have markedly increased the scope of endoscopic surgery.

Microsurgery

This type of surgery is performed under magnification using special techniques to, for example, correct Fallopian tubes after sterilizations. If microsurgical rules are followed the chances of the formation of adhesions are markedly reduced, thereby increasing post-operative pregnancy potential.

Ultrasound

Ultrasound is a technique used to visualise structures with the use of sound waves. As the technique does not involve the use of radiation it has no harmful effects. For infertility it is used to examine:

• The uterus and ovaries for abnormalities.
• Monitor the development of the endometrium and the follicles.
• Confirm ovulation.
• Confirm a pregnancy - presence of a fetal sac and heart beat.

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