Acquiring a child is undoubtedly one of the most desired goals, a lifelong dream, for most couples. However, in our country, over one in six couples face fertility problems, meaning they fail to conceive even with regular sexual intercourse without the use of any contraceptive method for at least a year.

Infertility can be attributed to one-third of cases in women, one-third in men, while the remaining cases either have unexplained causes or involve issues present in both prospective parents.

Causes of female infertility

Achieving pregnancy requires the ovaries to produce and release eggs.

Additionally, open fallopian tubes and a healthy uterus are necessary, as pregnancy requires a healthy environment to develop.

 

The complex process of human reproduction follows these steps:

  • One of the two ovaries releases a mature egg.
  • The egg travels to the fallopian tube.
  • Sperm “swims” through the fallopian tubes to reach and fertilize the egg.
  • The fertilized egg then travels to the uterus through the fallopian tubes, where it eventually implants and develops.

Several factors can disrupt this process at any stage.

 

Ovarian Dysfunction

 

Ovarian Dysfunction occurs when a woman has rare or no ovulation due to problems caused by reproductive hormones from the hypothalamus or pituitary gland, or issues within the ovary itself.

 

Polycystic Ovary Syndrome (PCOS)

In polycystic ovary syndrome, the hormonal balance is disrupted, leading to infrequent or absent ovulation. The ovaries become enlarged and filled with small cysts. PCOS is associated with insulin resistance and obesity, abnormal hair growth on the face or body, and acne. It is the most common cause of female infertility.

 

Hypothalamic Dysfunction

Two hormones responsible for stimulating ovulation each month – follicle-stimulating hormone (FSH) and luteinizing hormone (LH) – are produced by the pituitary gland in a specific pattern during the menstrual cycle. Excess physical or emotional stress, very high or very low body weight, or significant recent weight loss or gain can disrupt this pattern and affect ovulation. The main indicator of this problem is irregular or absent periods.

 

Premature Ovarian failure

Premature ovarian failure or insufficiency is usually caused by an autoimmune reaction in which the body mistakenly attacks ovarian tissues. It can also be caused by premature loss of eggs from the ovaries due to genetic problems or chemotherapy. Other factors that can be toxic to the ovaries include:

  • Pelvic radiation
  • Infections, such as those caused by certain viruses like mumps, CSV, or HIV
  • Autoimmunity, either isolated or as part of an autoimmune polyendocrine syndrome (coexistence with adrenal insufficiency, autoimmune thyroid disease, type 1 diabetes, systemic lupus erythematosus, myasthenia gravis, etc.)
  • Causes that lead to diminished stimulation and dysfunction of the ovarian follicles
  • Intra-ovarian factors that modify ovarian function
  • Gene mutations related to gonadotropins (FSH, LH) or their receptors

 

Hyperprolactinemia

Less commonly, the pituitary gland may cause excessive prolactin production (hyperprolactinemia), which reduces estrogen production and can lead to infertility. This is often due to a problem with the pituitary gland but can also be associated with medications for other conditions.

 

Problems with the fallopian tubes

Any abnormality in the fallopian tubes can result in fertility problems, as the egg will not be able to pass through them, be fertilized, and then implant in the uterus.

Factors that can affect and create issues in the fallopian tubes include:

 

  • Infections
  • Previous surgeries on the reproductive organs and abdominal cavity
  • Ectopic pregnancies
  • Fallopian tube abnormalities
  • Endometriosis
  • Hydrosalpinx

 

These conditions can disrupt the normal functioning of the fallopian tubes, leading to blockages, scarring, or structural abnormalities. As a result, the eggs may not be able to meet the sperm or be transported to the uterus properly, causing infertility or an increased risk of ectopic pregnancy.

 

Endometriosis

Endometriosis is a common gynecological condition. In women with endometriosis, the endometrial tissue, which normally lines the uterus and is shed during menstruation, grows in areas outside the uterus, such as:

  • On or inside the ovaries
  • Behind the uterus, on the ligaments that support the uterus
  • On the peritoneum, which is the lining of the abdominal cavity
  • On the intestines, bladder, or rectum

Endometriosis can be caused by specific genes or abdominal scars from previous surgeries like cesarean section or other procedures. Another theory suggests that remnants of embryonic tissues from when the woman was an embryo can later develop into endometriosis.

 

Problems with the uterus and cervix

Several issues with the uterus or cervix can affect fertility by interfering with embryo implantation or increasing the risk of miscarriage. These include:

 

  • Non cancerous growths or tumors (fibroids) often reduce fertility by blocking the fallopian tubes or disrupting implantation. However, many women with fibroids or polyps can still conceive normally.
  • Scarring from endometriosis or inflammation inside the uterus can disrupt implantation.
  • Genetic abnormalities of the uterus, such as an abnormal shape.
  • Cervical stenosis, which can be caused by an inherited malformation or damage, results in the lack of production of mucus that allows sperm to travel through the cervix to the uterus.

 

Age

The age of the prospective mother is undoubtedly a significant factor in fertility. The relative chance of natural conception per cycle drops from 25% in women up to the age of 30 to 18% at the age of 35 and approximately 12% at the age of 38. The rates are in single digits beyond this age.

 

Other factors

Other factors of infertility include smoking, excessive weight or anorexia, stress, increased stress and fatigue, and health problems such as diabetes. These are just some of the factors that can cause infertility.

 

Unexplained infertility

In some cases, the cause of infertility is not fully determined. It is possible that a combination of various minor factors may contribute to problems that, in some cases, resolve over time.

 

Diagnostic tests

If pregnancy has not been achieved within a reasonable period of free sexual intercourse, it is necessary to seek the assistance of a specialist for evaluation and treatment of infertility. Fertility tests may include:

  • Ovarian reserve testing: This is an examination that detects the increase in luteinizing hormone (LH) that occurs before ovulation. The levels of other hormones, such as prolactin, are also checked.
  • Hysterosalpingography: The function of the fallopian tubes is assessed, and a clearer image of the endometrial cavity is obtained. If abnormalities are found, further evaluation is needed.
  • Depending on the case, additional tests may be recommended, such as endometrial biopsy, chlamydia testing, etc.
  • Screening tests: Pelvic ultrasound examines possible damage to the uterus or fallopian tubes. Depending on the symptoms, the doctor may request hysteroscopy to check for any abnormalities in the uterus or fallopian tubes.
  • Laparoscopy: A minimally invasive surgical procedure to examine the fallopian tubes, ovaries, and uterus. Laparoscopy can detect endometriosis, scars, obstructions, or abnormalities of the fallopian tubes.
  • Genetic testing: Genetic testing confirms if there is a genetic defect that causes infertility.

 

Ovarian Reserve Assessment

This refers to the evaluation of the number and quality of remaining eggs in the ovaries. It is done through ultrasound or blood tests and provides an indication of a woman’s ovarian age.

When to Begin Investigation:

If you are under 35 years old and have been having regular unprotected sexual intercourse, approximately two to three times a week, during fertile days, for at least one year without achieving pregnancy, it is recommended to consult a fertility specialist.

If you are 35 years old or above, it is advisable to seek specialist consultation earlier, around the six-month mark of trying to conceive.

Even earlier than the six-month mark, inform your doctor if you smoke, take certain medications like steroids or antidepressants, or if you have a 25% excess or deficiency in body weight. In these cases, waiting for six months or a year to conceive naturally may be a waste of time, as your biological clock continues to tick.

Additionally, seek your doctor’s advice earlier if you have a history of:

 

  • Pelvic inflammatory disease
  • Fibroids
  • Endometriosis
  • Irregular menstrual cycles
  • Sexually transmitted infections such as chlamydia or gonorrhea
  • Polycystic ovary syndrome
  • Reproductive organ surgeries
  • Chronic conditions like diabetes or thyroid

 

The Impact of Age on Pregnancy Rates

A woman’s fertility is at its highest levels between 20-25 years old, then gradually decreases until the age of 35. After that, it declines significantly until the age of 40.

From the age of 40 and onwards, fertility declines at an even faster rate, and by the age of 45, it is nearly negligible.

It is important to note that in some cases, a woman’s “ovarian age” may differ from her “birthdate age.”