Female Infertility

Infertility can result from ovulatory or uterine problems; mechanical problems, including obstruction of the fallopian tubes; male fertility factors; or multiple factors in either sex or combined female and male factors. Ovulatory problems are the most common cause of female infertility. Polycystic ovarian syndrome (PCOS) affects up to 5% of reproductive-age women. It is the most common cause of ovulatory infertility. PCOS is a condition characterized by multiple ovarian cysts, often found in a row, resembling a "string of pearls." Ovarian cysts are fluid-filled sacs arising from follicles swollen with fluid that are prevented from producing mature oocytes. Patients with PCOS also have hormonal imbalances, including decreased levels of LH, FSH, and progesterone and increased androgen production, including excess testosterone and DHEAS causing hirsutism or male facial patterns of hair growth. Insulin resistance is a common associated condition. PCOS is generally diagnosed when two of the following three criteria are present and other possible causes can be ruled out: clinical or laboratory results showing excess androgen secretion, decreased or absence of ovulation, and ovaries found by imaging techniques such as ultrasound to contain many cysts. Although the exact etiology of the problem is still unknown, genetic factors may be involved.17

Around the time of menopause, impairment of ovulation may cause infertility with adverse effect on follicle size and oocyte quality despite regular ovulation and normal gonadotropin levels. These factors are considered when treating older women with infertility. Serum levels of LH, FSH, and inhibin A and B may be helpful in assessing infertility and treatment options.18,19 Infertility diagnostic testing is as varied as treatment options. The patient workup for infertility includes a careful, detailed history, which can help to limit the number of laboratory tests required. Availability of tests varies from center to center, so availability is one of the considerations for infertility testing. Typical laboratory tests ordered are FSH on day three of the ovulatory cycle, LH, estradiol, prolactin, and TSH levels. Measurement of ovarian and adrenal androgens such as testosterone and DHEAS should be decided on the basis of ovulatory status of the patient and the clinical picture.

Treatment for Infertility

In the past 25 years, treatment for infertility has changed significantly and is dependent on whether the origin is within the reproductive organs, hormonal, or a combination of several factors. In vitro fertilization (IVF) has become commonplace. This technique involves using agents to induce ovulation, stimulating the ovaries to produce several mature follicles, removing multiple oocytes, and allowing fertilization to occur outside of the body in a controlled in vitro environment. The zygote undergoes divisions in the laboratory, and the blastocyst (or earlier state embryo) is then transferred to the woman's uterus for implantation and, hopefully, a resulting pregnancy. Initially, IVF was performed without giving medication to simulate the ovaries to develop multiple follicles. New medication options make the IVF procedure much more efficient, some improving uterine blood flow and endometrial development, and pregnancy rates have continued to increase.20,21

Case Scenario 12-2 Infertility and Polycystic Ovarian Disease: "String of Pearls" in a Bearded Lady

Follow-Up

The special chemistry section had received laboratory requests for several hormone levels on a 23-year-old African-American female with a preliminary diagnosis of hirsutism and infertility. Previously laboratory results showed a slightly elevated 8:00 a.m. plasma cortisol level, but a low-dose overnight dex-amethasone test showed normal cortisol suppression. This corresponds with mild hypercortisolism typical of obesity. The patient was found to be 70 pounds overweight. The initial laboratory results obtained from the special chemistry section showed slightly elevated LH at midfollicular cycle; normal FSH, prolactin, and estradiol at midcycle; and normal initial results for the androgens testosterone and DHEAS.

Case Scenario 12-2 Infertility and Polycystic Ovarian Disease: "String of Pearls" in a Bearded Lady (continued)

Test Result Reference Range

Testosterone, total (ng/dL) 65 15-70

Estradiol, midcycle (pg/mL) 151 150-750

Prolactin (ng/mL) 14 < 20 in nonpregnant women

Results from the reference laboratory showed increased free testosterone of 11.5 pg/mL (reference range, 1.1 to 6.3 pg/mL), increased androstenedione of 315 ng/dL (85 to 175 ng/dL), increased androstandiol glucuronide of 540 ng/dL (60 to 300 ng/dL), and decreased sex hormone-binding globulin level. An ultrasound revealed a normal-sized uterus and multicystic ovaries with "string of pearls" appearance. A diagnosis of polycystic ovarian disease was made and treatment was begun. The tumors produced increased amounts of male hormones, which stimulated an elevated LH level and lowered production of sex hormone-binding globulin. Progesterone values are often abnormal in these cases. This condition and the resulting male hormone levels are one of the more common causes of ovarian infertility. It is associated with male pattern hair distribution in women.

Infertility of Multiple Causes

Around 15% of all couples in the United States experience infertility, with roughly half of cases due to a male factor. Analysis of semen is one of the first steps in assessing infertility and in treatment strategies. Semen analysis involves sperm concentration (number per milliliter) and vitality, morphology and motility testing, and viscosity and volume of seminal fluid. Obtaining a semen sample is less invasive than many of the procedures for assessing male fertility and is necessary at some point to help determine the type of medical intervention needed to assist in reproduction. Infection and anatomic problems can be common causes of male infertility, affecting the sperm cells or seminal fluid. Generally these conditions can be easily treated.22 Endocrine and immunologic parameters are measured in both male and female infertility to determine cause and direct treatment.4 Hormone treatments or surgeries, when indicated, can also be used to address male fertility factors, including sperm motility and seminal fluid viscosity.

100 Pregnancy Tips

100 Pregnancy Tips

Prior to planning pregnancy, you should learn more about the things involved in getting pregnant. It involves carrying a baby inside you for nine months, caring for a child for a number of years, and many more. Consider these things, so that you can properly assess if you are ready for pregnancy. Get all these very important tips about pregnancy that you need to know.

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