Female Infertility: Causes, Diagnosis, and Treatment

Infertility is defined as the inability to conceive after one year of regular, unprotected intercourse. About 15% of couples worldwide are affected, and in roughly half of those cases, the issue originates with the woman.

Definition: Primary vs. Secondary Infertility

Primary infertility refers to couples who have never achieved pregnancy. Secondary infertility applies when a couple cannot conceive despite having had at least one prior pregnancy.

Main Causes

Female infertility has multifactorial origins—hormonal, anatomical, genetic, and environmental.

1. Polycystic Ovary Syndrome (PCOS)

PCOS affects 6–10% of women of reproductive age. Insulin resistance and elevated androgen levels disrupt or halt ovulation.

• Diagnosis: Rotterdam criteria – irregular cycles, hyperandrogenism, polycystic ovarian morphology on ultrasound.
• Treatment:
  • 5–10% weight loss significantly lowers androgen levels.
  • Metformin improves cycle regularity in insulin-resistant patients.
  • Letrozole boosts live birth rates (27.5% vs. 19.1% with clomiphene; Legro et al. 2014).

2. Ovulation Disorders without PCOS

Thyroid dysfunction (hypothyroidism or hyperthyroidism) and hyperprolactinemia can inhibit ovulation.

• Testing (cycle days 2–5): TSH, free T3/T4, prolactin.
• Treatment: Levothyroxine for hypothyroidism; dopamine agonists (e.g., bromocriptine) restore ovulation in up to 70% of cases (PubMed 2006).

3. Endometriosis

Endometrial tissue implants outside the uterus, causing inflammation and adhesions.

• Diagnosis: Laparoscopy with histological confirmation.
• Treatment: Minimally invasive excision improves pregnancy rates by 20–30% (WHO 2013).

4. Tubal Factor

Fallopian tube damage or blockage—often from infection—prevents egg and embryo transport.

• Diagnosis: Hysterosalpingography (sensitivity 65–95%) (Study 2012).
• Treatment: Tubal flushing or surgical repair restores patency in 40–60%; severe blockages often require IVF.

5. Uterine Anomalies and Fibroids

Structural uterine issues—such as septa or fibroids—can impair implantation.

• Diagnosis: 3D ultrasound, hysteroscopy.
• Treatment: Hysteroscopic resection increases live birth rates by 30–40% (RCOG Guideline No. 24).

6. Genetic and Immunological Factors

Balanced chromosomal rearrangements and antiphospholipid antibodies can prevent successful implantation.

• Diagnosis: Karyotyping, autoimmune antibody panel.
• Treatment: Low-dose heparin plus aspirin improves implantation rates in antiphospholipid syndrome (Cochrane Review).

7. Idiopathic Infertility

No cause is found in up to 15% of patients despite extensive evaluation. IUI offers 10–15% success per cycle; IVF yields 30–35% per cycle.

8. Male Factor

A male factor contributes to infertility in about 40% of couples.

• Semen Analysis (WHO 2021): >15 million sperm/mL, >40% motility, >4% normal forms (WHO 2021).

Diagnostic Workup

1. Medical history and cycle charting (cycle length, symptoms, lifestyle)
2. Hormonal panel (days 2–5: FSH, LH, AMH, TSH, prolactin, estradiol)
3. Transvaginal ultrasound (antral follicle count, fibroids, cysts)
4. Hysterosalpingography (tubal patency assessment)
5. Laparoscopy if endometriosis or adhesions are suspected
6. Genetic testing for recurrent pregnancy loss

Success Rates by Age

The German IVF Register (D·I·R) reported (2023) per embryo transfer:

• Under 35 years: 30% live birth rate
• 35–39 years: 20% live birth rate
• 40+ years: 10% live birth rate

Assisted Reproductive Techniques: IUI vs. IVF

IUI: 10–15% success per cycle; cost approx. €300–500
IVF: 25–35% live birth rate per cycle; cost approx. €3,000–5,000
Source: ESHRE ART Guidelines

Evaluation Timeline

– Women ≥35 years: begin evaluation after 6 months of trying
– Women <35 years: begin evaluation after 12 months
Source: ESHRE 2015

Clinical Checklist

• Record cycle details (basal temperature, cervical mucus, ovulation signs)
• Gather medical records and current medication list
• Schedule ultrasound and HSG appointments
• Confirm insurance coverage for fertility procedures

Lifestyle and Nutrition

A BMI of 20–24 kg/m² and a Mediterranean-style diet support reproductive health.

• 400 µg folic acid daily and 1 g omega-3 fatty acids (Study 2016)
• 150 minutes of moderate aerobic exercise per week
• Avoid trans fats and heavily processed foods

Environmental Toxins

Endocrine disruptors such as BPA and phthalates can damage egg quality.

• Use glass or stainless steel containers instead of plastic
• Opt for organic produce to minimize pesticide exposure
• Drink filtered water to reduce PCBs and heavy metals (EFSA 2024)

Conclusion

Female infertility is complex and often multifactorial. A thorough evaluation, evidence-based treatments, and tailored lifestyle changes can greatly improve your chances of a successful pregnancy. Collaborate closely with your fertility center and follow established guidelines on your journey to parenthood.