Female Factor Infertility

Ovarian Factors - Egg Timer Troubles

• Age: Primary factor; oocyte quantity/quality ↓ significantly, impacting fecundity.
• Diminished Ovarian Reserve (DOR):
  • Reduced oocyte pool. Markers:
    • AMH < 1.1 ng/mL
    • Antral Follicle Count (AFC) < 5-7 (total via TVS)
    • Basal FSH > 10-12 mIU/mL (Day 2/3)
• Premature Ovarian Insufficiency (POI):
  • Ovarian failure < 40 yrs.
  • Amenorrhea, hypoestrogenism, ↑FSH (>25-40 mIU/mL, 2 occasions >4 wks apart).
• Anovulation/Oligo-ovulation (WHO Classification):
  • Gr I: Hypothalamic failure (e.g., anorexia). ↓FSH, ↓LH, ↓E2.
  • Gr II: HPO dysfunction (PCOS commonest).

    ⭐ PCOS is the most common cause of anovulatory infertility (WHO Group II).

    • Normo/↑LH, Normo FSH.
  • Gr III: Ovarian failure (e.g., POI). ↑FSH, ↑LH, ↓E2.

Tubal & Peritoneal Factors - Pipeline Predicaments

• Contribute to ~30-40% of female infertility. Key culprits:
  • Pelvic Inflammatory Disease (PID) (e.g., Chlamydia).
  • Endometriosis.
  • Post-surgical adhesions (e.g., myomectomy).
  • Previous tubal surgery (ligation, ectopic).
• Pathophysiology:
  • Mechanical blockage (distal/proximal).
  • Impaired ciliary motility.
  • Hydrosalpinx: fluid accumulation toxic to embryos.
  • Peritubal adhesions distorting tubo-ovarian anatomy.
• Investigations:
  • Hysterosalpingography (HSG): initial screening.
  • Laparoscopy with chromopertubation: definitive diagnosis.
  • Sonohysterosalpingography (SHG).
• Management:
  • Tubal reconstructive surgery (e.g., fimbrioplasty).
  • In Vitro Fertilization (IVF): often the preferred treatment.

  ⭐ Pre-IVF salpingectomy or proximal tubal occlusion is advised for hydrosalpinx (diameter >3 cm) to improve implantation rates. ​

Uterine & Cervical Factors - Womb & Neck Niggles

• Uterine Anomalies:
  • Congenital (Müllerian): Septate (↑RPL, commonest), bicornuate, arcuate. DES exposure → T-shaped uterus.
  • Acquired: Submucosal/intramural fibroids (distort cavity, ↓implantation), endometrial polyps, Asherman’s syndrome (intrauterine adhesions, often post-D&C/infection), adenomyosis.
• Cervical Factors:
  • Stenosis (post-surgery/congenital), impedes sperm transport.
  • Hostile mucus (e.g., clomiphene effect, infection, anti-sperm Ab).
• Dx: TVS, HSG, Saline Infusion Sonography (SIS), Hysteroscopy (gold standard for intrauterine lesions).
• Rx: Hysteroscopic surgery (septoplasty, myomectomy, adhesiolysis), IUI (bypasses cervical factor), IVF.

  ⭐ Submucosal leiomyomas most significantly impair implantation and pregnancy outcomes. Gynaecology Infertility

Diagnostic Workup - Clue Quest Central

• Foundation: Comprehensive history (menstrual cycle, coital frequency, medical/surgical past), targeted physical exam (BMI, signs of androgen excess, thyroid).
• Ovulation Check:
  • Mid-luteal serum progesterone (Day 21 of 28-day cycle; >3 ng/mL suggests ovulation, >10 ng/mL adequate).
  • Urinary LH ovulation predictor kits.
  • TVS for follicular monitoring.
• Ovarian Reserve (ORT):
  • Day 2/3 FSH, LH, Estradiol.
  • Anti-Müllerian Hormone (AMH): reflects primordial follicle pool.
  • Antral Follicle Count (AFC) via TVS (5-10 follicles per ovary normal).
• Anatomical Assessment:

⭐ AMH is a reliable marker of ovarian reserve, less prone to cycle-to-cycle variability than FSH.

High‑Yield Points - ⚡ Biggest Takeaways

• Polycystic Ovary Syndrome (PCOS) is the leading cause of anovulatory infertility.
• Tubal factors, especially blockage from Pelvic Inflammatory Disease (PID), are common.
• Endometriosis contributes through inflammation, adhesions, and altered folliculogenesis.
• Diminished Ovarian Reserve (DOR) is marked by ↓AMH and ↑FSH.
• Uterine issues like submucosal fibroids or polyps can hinder implantation.
• Advanced maternal age (>35 years) critically reduces oocyte quality and quantity.
• Ovulation induction (clomiphene, letrozole) is first-line for anovulatory patients.