Female causes

Problems with Ovulation

Polycystic ovaries

The commonest cause of ovulation problems is Polycystic Ovaries. This is a common condition, affecting one in ten women. It usually presents as irregular periods, weight gain and hirsutism (excessive hair growth). On transvaginal pelvic ultrasound scan it is possible to see the small cysts (around 0.5 cm. diameter each) around the ovaries. The diagnosis is made on the physical findings, hormone blood tests and a pelvic scan. Women who have polycystic ovary syndrome do not ovulate and require treatment to help them get pregnant. This could be in the form of life-style changes to lose weight, fertility drugs (given in the form of tablets such as Metformin or Clomid), or a day-case key-hole operation called laparoscopic ovarian drilling (where the inside of the abdomen is examined with a small scope and heat is applied to both ovaries in certain points).

Other causes of not ovulating

There are many other causes of not ovulating. Investigations include pelvic scan and blood tests for hormone levels. Depending on the type of problem, other investigations may sometimes be required. Treatment is often in the form of fertility drugs and is targeted at correcting the underlying condition.

Premature menopause

This occurs when the ovaries stop working before the age of 40. The diagnosis is made on blood hormone tests. The main fertility treatment is egg donation. It is also important to be aware of the longer term implications for your health. These will be discussed with you in detail.

Tubal blockage

Tubal blockage can affect the tube at the point at which it joins the womb (known as proximal blockage), or at the end of the tube (known as distal blockage). If the tube is blocked at its end, it can swell up with secretions, and is called a hydrosalpinx. Tubal disease is diagnosed by either a laparoscopy (a day case key-hole surgery under general anaesthetic where the inside of the abdomen is examined with a small scope), or by an outpatient X-ray procedure called a hysterosalpingogram or HSG. If, on HSG proximal blockage is found, it can often be treated at the same time by passing a wire into the tube and through the blockage. This is called selective salpingography. Distal tubal disease can be seen on HSG, but can only definitively be diagnosed by laparoscopy. Sometimes it is possible to open the tube surgically. If it is not possible to repair the tube, then in vitro fertilisation (IVF), otherwise known as test-tube bay treatment can help.

In IVF the woman's eggs are taken outside the body and mixed with her partner's sperm in a test tube in the laboratory. The resulting embryos are transferred to her womb.

Another cause of tubal blockage is previous female sterilisation. Up to 1 in 10 women who have been sterilised consider having more children, and reversal of sterilisation operation is a realistic option. The procedure involves an abdominal operation with a 3-4 day stay in hospital. The results are good, and depend on the method used for sterilisation, and the presence of any other fertility factors. Your consultant will discuss all these issues with you and advice you appropriately.

Pelvic adhesions (scar tissue)

Scarring around the tubes and ovaries are usually caused by previous pelvic surgery, such as appendicectomy, or ovarian cysts being removed, or from pelvic infection. It can only be reliably diagnosed at laparoscopy. If pelvic adhesions are found, it is usually possible to divide them surgically.

Endometriosis

The endometrium is the term used for the lining of the womb. When it is found outside of the lining of the womb it is called endometriosis and is associated with infertility with an approximate halving of the chances of conceiving naturally. Many women with endometriosis will have heavy painful periods and deep pain on intercourse. However, many women suffer no symptoms at all, apart from infertility. Laparoscopy is needed to diagnose endometriosis. In many cases, during the laparoscopy, endometriosis can be treated either by removal or ablation (burning away). Other cases may require open surgery or in vitro fertilisation (IVF).

Problems with the Uterus

Fibroids

Fibroids are overgrowth of part of the muscle of the womb. They are very common (present in 1 in 2 women) and can be small or very large. If they are large (over 5 cm in diameter) or if they bulge into the inside of the womb they could lead to infertility or miscarriage. They could also lead to heavy painful periods. In those circumstances it may be appropriate to remove the fibroid, an operation called a myomectomy. Another option is to have the fibroid removed by blocking off its blood supply (called embolisation). Currently, this treatment is not recommended for women who are trying to conceive.

Intra-uterine adhesions (Asherman's syndrome)

This is scar tissue inside the cavity of the womb. It causes the walls of the womb to stick together leading to infertility. Asherman’s syndrome can occur after a scrape of the womb following a pregnancy, particularly if there has been some infection. Sometimes the scar tissue can reduce the normal menstrual loss, or stop it altogether. The condition is diagnosed by looking in the cavity of the womb, either with an X-ray called a hysterosalpingogram (HSG), or an operation called a hysteroscopy (a day-case key-hole operation where the inside of the womb is examined with a small scope). Treatment can be given at the same time by cutting the scar tissue.

Congenital malformations of the Uterus

These are abnormalities that the woman is born with, such as a uterine septum or double uterus. There are many different types, and each will have different implications. The condition is diagnosed by looking in the cavity of the womb, either with an operation called a hysteroscopy, or with an X-ray called a hysterosalpingogram (HSG).

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