Female Infertility

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Infertility (the inability to conceive a child) is a reproductive problem that can cause a lot of distress.1,2,3 Many women around the world struggle with it.2 Research shows that one in six people experience infertility at some point in their lifetime.2

Female reproductive system

The uterus, fallopian tubes and ovaries form part of the female reproductive system. During a process called ovulation,5 an ovary releases an egg into one of the fallopian tubes every month, where it could potentially be fertilised by sperm.5

 

If the egg is fertilised, it will implant itself in the uterus and the woman will become pregnant.5  This is called conception.6 If the egg is not fertilised, the woman will have her monthly period.5

 

The journey of the egg being released by the ovary (ovulation) and becoming fertilised by sperm (conception) is illustrated below. The fertilised egg develops into a blastocyst, which, if it successfully implants in the uterus, is the beginning of a potentially successful pregnancy.6

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Female Infertility: Causes and Risk Factors

Infertility in women can be caused by:

  • Problems with ovulation, like polycystic ovarian syndrome (PCOS).1,3
  • Illnesses affecting the reproductive organs, like endometriosis.3
  • Pelvic adhesions (bands of scar-like tissue, often caused by infection or inflammation).3,7
  • Blocked fallopian tubes, which may prevent the egg from being released properly or prevent the sperm from reaching the egg.3
  • Abnormalities in the uterus or the cervix (the lower end of the uterus).1
  • High levels of prolactin hormones in the blood.3
  • Damage to the reproductive organs caused by untreated sexually transmitted diseases (STDs).8
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Did You Know? Tubal factor infertility (TFI), which is often caused by STDs, makes up more than 85% of female infertility cases in parts of sub-Saharan Africa, compared to only 33% of cases worldwide.9 HIV infection can also reduce fertility.11

Untreated STDs are a major health problem among South African women in rural communities.8,10

Factors that may increase the risk of infertility in women include:

  • Age over 35 years.1
  • A history of STDs.1
  • Previous pelvic surgery, like the removal of ovarian cysts.1
  • Irregular or missed periods.1
  • Cigarette smoking.1
  • Stress.1
  • Very high or very low body fat.1
  • A history of autoimmune disease, like lupus.1,12
  • A history of appendicitis, which can lead to adhesions or blocked fallopian tubes.1,13
  • Taking certain medications, including non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, or antipsychotics.1,14
  • Consuming cannabis (weed), alcohol or caffeine.1

Symptoms of Female Infertility

If a woman of reproductive age has been unable to conceive a baby after one year of unprotected sex or after artificial insemination, she is considered to be suffering from infertility.1 Reproductive age is defined by the World Health Organisation as 15 to 49 years.15

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Diagnosing Female Infertility

Infertility and its underlying cause may be diagnosed through a variety of tests, including:16

  • Pelvic examination: The pelvic area is examined for infection, lumps or tenderness which could be a sign of problems like fibroids, ovarian tumours, endometriosis or pelvic inflammatory disease.
  • Blood tests: Blood samples can be tested for progesterone hormone levels to find out whether the patient is ovulating.
  • Ultrasound: A non-invasive scan is used to check the condition of the ovaries, uterus and fallopian tubes.
  • Hysterosalpingo-contrast-ultrasonography: This type of ultrasound is used to check the fallopian tubes for blockages or abnormalities which could cause a problem with ovulation or fertilisation.
  • Hysterosalpingogram: An X-ray of the uterus and fallopian tubes is taken, using a special dye to find blockages or abnormalities.
  • Laparoscopy: This is usually only used in patients with a history of pelvic inflammatory disease or a likelihood of fallopian tube blockages. It is a keyhole surgery that uses a tiny camera to examine the uterus, fallopian tubes and ovaries. A dye may also be injected into the fallopian tubes to highlight any blockages.
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Impact of Female Infertility

Struggling with infertility can have a major psychological impact on a woman, causing feelings of:17

  • Fear and worry.
  • Guilt.
  • Loneliness.
  • Depression and grief.
  • Low self-esteem.
  • Failure.
  • Helplessness.
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Did You Know? Women with a history of depression have a greater risk for infertility. This means that psychological support like counselling is an important part of the fertility journey, both before and during treatment.18

Treatment of Female Infertility

The type of treatment used will depend on the underlying cause of infertility and on the patient’s age.1 The ultimate goal of treatment is to establish a healthy pregnancy that results in a healthy delivery.1

Lifestyle habits that can improve fertility include:1

  • Maintaining a healthy weight.
  • Quitting smoking.
  • Managing stress.

Common assisted fertility treatments (AFTs) include intrauterine insemination (IUI) and in vitro fertilisation (IVF).19

  • IUI: Sperm from the partner or donor is placed directly into the uterus, giving it a better likelihood of reaching the eggs.19

 

In cases where infertility is caused by problems with ovulation like PCOS, hormone therapy or medications to stimulate ovulation can be used to restore fertility.1 This can be followed with timed sexual intercourse or IUI.1

 

  • IVF: The patient takes a high dose of injectable hormones, stimulating the ovaries to produce multiple follicles (sacs containing immature eggs).19 Once the eggs have matured, they are retrieved and combined with the sperm in a lab, and those that result in embryos (i.e. the sperm successfully joins with the egg) are transferred to the patient’s uterus.19

IVF is considered the best option for women with abnormal fallopian tubes and those with endometriosis-related infertility.1 Egg donation via IVF is also an option for women with age-related infertility and/or a low number of eggs available.1 Ovarian stimulation may also be used, although success often depends on the patient’s age.1

Unfortunately, the high cost of fertility treatments like IVF is a major barrier to those seeking treatment in developing countries.20 Infertility will continue to be a problem in countries with low resources if fertility treatments do not become more accessible.20

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1. Drakeley A, Chong D. Infertility in women – Symptoms, diagnosis and treatment. BMJ Best Practice US. Last updated December 12, 2023. Accessed August 9, 2024. https://bestpractice.bmj.com/topics/en-us/498

 

  1. 1 in 6 people globally affected by infertility. WHO. April 4, 2023. Accessed July 26, 2024. https://www.who.int/news/item/04-04-2023-1-in-6-people-globally-affected-by-infertility

 

2b. WHO. Infertility prevalence estimates, 1990–2021. 2023. Accessed July 26, 2024. https://iris.who.int/bitstream/handle/10665/366700/9789240068315-eng.pdf?sequence=1

  1. Walker MH, Tobler KJ. Female infertility. In: StatPearls. StatPearls Publishing; 2024. Accessed July 26, 2024. http://www.ncbi.nlm.nih.gov/books/NBK556033/
  2. Dyer SJ, Abrahams N, Hoffman M, et al. Infertility in South Africa: Women’s reproductive health knowledge and treatment-seeking behaviour for involuntary childlessness. Hum Reprod. 2002;17(6):1657-1662. doi:10.1093/humrep/17.6.1657

 

  1. Holesh JE, Bass AN, Lord M. Physiology, ovulation. In: StatPearls. StatPearls Publishing; 2024. Accessed August 12, 2024. http://www.ncbi.nlm.nih.gov/books/NBK441996/

 

  1. Conception. National Cancer Institute. Accessed August 12, 2024. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/conception

6b. Blastocyst: definition, stage & implantation. Cleveland Clinic. Accessed August 13, 2024. https://my.clevelandclinic.org/health/body/22889-blastocyst.

  1. Abdominal adhesions. NIDDK. Accessed August 12, 2024. https://www.niddk.nih.gov/health-information/digestive-diseases/abdominal-adhesions
  2. Preventing sexually transmitted infections: Why South Africa isn’t winning. NICD. Published March 4, 2019. Accessed July 26, 2024. https://www.nicd.ac.za/preventing-sexually-transmitted-infections-why-south-africa-isnt-winning/

 

  1. Tsevat MDG, Wiesenfeld HC, Parks C, et al. Sexually transmitted diseases and infertility. AJOG. 2017;216(1):1. doi:10.1016/j.ajog.2016.08.008

 

  1. Wilkinson D, Karim SS, Harrison A, et al. Unrecognized sexually transmitted infections in rural South African women: A hidden epidemic. Bulletin of the World Health Organization. 1999;77 1:22-28. Accessed July 26, 2024. https://consensus.app/papers/unrecognized-sexually-infections-south-women-hidden-wilkinson/5e523ead667958cfa9cf6acbbddca89f/

 

  1. Basu D, Basu JK, Ellison GTH. The burden of infertility among HIV-positive couples in South Africa: The available evidence. SAMJ. 2010;100(6):354-356. doi:10.7196/SAMJ.3111

 

  1. Khizroeva J, Nalli C, Bitsadze V, et al. Infertility in women with systemic autoimmune diseases. Best Pract.Res. Clin. Endocrinol. Metab. 2019;33(6):101369. doi:10.1016/j.beem.2019.101369

 

  1. Männistö J, Sammalkorpi H, Niinimäki M, et al. Association of complicated appendicitis on the risk of later in vitro fertilization treatment requirement and ectopic pregnancy: A nationwide cohort study. Acta Obstet Gynecol Scand. 2021;100(8):1490-1496. doi:10.1111/aogs.14165

 

  1. Causes of infertility. NHS.UK. Page last reviewed: October 23 2017. Accessed August 12, 2024. https://www.nhs.uk/conditions/infertility/causes/
  2. Women of reproductive age (15-49 years) population (thousands). WHO Data. Accessed July 26, 2024. https://platform.who.int/data/maternal-newborn-child-adolescent-ageing/indicator-explorer-new/mca/women-of-reproductive-age-(15-49-years)-population-(thousands)
  3. Diagnosis of infertility. NHS.UK. Page last reviewed: 09 August 2023. Accessed July 26, 2024. https://www.nhs.uk/conditions/infertility/diagnosis/

 

  1. Hasanpoor-Azghdy SB, Simbar M, Vedadhir A. The emotional-psychological consequences of infertility among infertile women seeking treatment: Results of a qualitative study. Iran J Reprod Med. 2014;12(2):131-138

 

  1. Treating infertility. SASOP. Accessed July 26, 2024. https://www.sasop.co.za/treating-infertility

 

  1. What’s the difference between IVF and IUI? Cleveland Clinic. January 31, 2022. Accessed July 26, 2024. https://health.clevelandclinic.org/iui-vs-ivf

 

  1. Dewi AK1, Wicaksana A, Muhammad L. The barriers of joining in vitro fertilization programs among infertile couples in developing countries: A scoping review. Asian Pac J Reprod. 2023;12(4):147. doi:10.4103/2305-0500.380981

 

  1. Zegers-Hochschild F, Adamson GD, Dyer S, et al. The international glossary on infertility and fertility care, 2017. Hum Reprod. 2017;32(9):1786-1801. doi:10.1093/humrep/dex234

 

  1. Fibroid. National Cancer Institute. Accessed August 12, 2024. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/fibroid

 

  1. Ovarian follicle. National Cancer Institute. Accessed August 12, 2024. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/ovarian-follicle

 

  1. Laparoscopic surgery. National Cancer Institute. Accessed August 12, 2024. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/laparoscopic-surgery

 

  1. Pelvic inflammatory disease. National Cancer Institute. Accessed August 12, 2024. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/pid

 

  1. Progesterone. National Cancer Institute. Accessed August 12, 2024. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/progesterone

 

  1. Prolactin. National Cancer Institute. Accessed August 12, 2024. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/prolactin

 

  1. Ultrasound. National Cancer Institute. Accessed August 12, 2024. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/ultrasound

 

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