Causes of Female Infertility

1. Normally cervix produces mucus that helps spermatozoa to move up the cervical canal.
2. Cervical causes of infertility may be
   • Poor quality mucus
   • Thick viscid mucus and mucus plug
   • Long standing infection with large number of (Phagocytic cells) WBCs
   • Low pH
   • Presence of anti-sperm antibodies.

1. Uterine malformations are seen 2-3% of female newborn babies and are a frequent cause of mid trimester pregnancy losses.
2. Uterine fibroids particularly submucosal ones create a hostile condition so that implantation is difficult and fibroids which block the fallopian tube also hinder establishment of pregnancy.
3. Endometritis-inflammation of endometrium may result from infection. Infertility can arise through the effect of toxins produced by the organisms and abnormal secretions from the infected endometrial glands.
4. Asherman's syndrome is a condition in which parts of the uterine walls adhere together. Implantation is prevented because of little or no endometrium.

Ovaries

1. Anovulation is found in more than a quarter of infertile women and it may be due to one of the following reasons:
   • Hypogonadotropic hypogonadism— Gonado­tropin release is deficient in these patients leading to decreased stimulation of ovaries which in turn causes failure of ovulation.
   • Ovarian failure—In certain women ovaries fail to ovulate at an earlier age. This may be due to chromosomal abnormalities like Turner's syndrome, autoimmune disorders, infections like mumps, previous surgeries around the ovaries and anti cancer drugs.
   • Polycystic ovarian syndrome—Characterized by infertility, multiple cysts in ovaries, failure of ovarian follicles to develop, menstrual irregularity, hirsutism and acne.
   • Weight loss—Fat content of a female's body has an influence on her ovarian function. Females who are underweight often fail to ovulate and menstruate. FSH and LH secretions fall in such females and there is little or no development of ovarian follicles.

Management algorithm of female factors

• • Strenuous exercise—leads to loss of body fat below critical levels necessary for normal ovarian function.
  • Hyper prolactinemia—High blood levels of prolactin interfere with GnRH secretion from hypothalamus which in turn leads to failure of ovulation and menstruation.

1. Presence of endometrium outside the uterine cavity is termed as endometriosis. This condition is associated with adhesions in the pelvis. Endometriosis when affects tubes and ovaries may lead to infertility (Fig).

Assess severity, may benefit from diathermy or laser ablation, medical suppression not helpful for fertility, and may need in vitro fertilization.

Fig.  Management of endometriosis

No Detectable Problems

• About 17% of females among infertile couples reveal no demonstrable problems that can cause or contribute to their infertility.