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Publication Ref No.

: IJPRD/2009/PUB/ARTI/VOL-8/OCT/010

ISSN 0974 9446

FEMALE INFERTILITY CAUSES AND THEIR DIAGNOSTIC TESTS: A REVIEW


Merekar Abhijit N.1*, Pattan S. R. 2, Dighe N. S .2, Kuchekar.B. S. 3 Parjane. S. K. 2, Gaware. V. M.2, Deithankar. A. S.1 Department of Pharmaceutics, Pravara Rural College of Pharmacy, Pravaranagar, A/P-Loni (413736), Tal- Rahata, Dist.-Ahmednagar, Maharashtra, India. 2 Department of Pharmaceutical Chemistry, Pravara Rural College of Pharmacy, Pravaranagar, A/P-Loni (413736), Tal- Rahata, Dist.-Ahmednagar, Maharashtra, India. 3 Department of Pharmaceutical Chemistry, M.I.T College of Pharmacy, Pune, Maharashtra, India.
1

ABSTRACT Female infertility is the major disorder which has altered the man kind foe lack of conception and reproducibility, stressful world, excess radiation, lack of biological food, genetical disorder , changing life style, increased electronic discharge have resulted the female infertility. In the present review we have discussed causes, diagnostics tests and hormonal problems, preconceptional failure and major reasons for female infertility.

KEYWORDS Genetical Disorder, Preconceptional Failure, Follicle Problem.

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Publication Ref No.: IJPRD/2009/PUB/ARTI/VOL-8/OCT/010

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INTRODUCTION AND MATERIAL METHOD Infertility is the failure of a couple to become pregnant after one year of regular, unprotected intercourse. In both men and women the fertility process is complex. Infertility affects about 10% of all couples. Even under ideal circumstances, the probability that a woman will get pregnant during a single menstrual cycle is only about 30%. And, when conception does occur, only 50 - 60% of pregnancies advance beyond the 20th week [1]. (The inability of a woman to produce a live birth because of abnormalities that cause miscarriages is called infecundity and is not discussed in detail in this report.)About a third of infertility problems are due to female infertility and another third are due to male infertility. In the remaining cases, infertility affects both partners or the cause is unclear. Although this report specifically addresses infertility in women, it is equally important for the male partner to be tested at the same time. [2]

INFERTILITY HISTORY [3] (Table 1)


CAUSES FEMALE INFERTILITY I) CAUSES OF FAILURE TO OVULATE Ovulatory disorders are one of the most common reasons why women are unable to conceive and account for 30% of women's infertility. Fortunately, approximately 70% of these cases can be successfully treated by the use of drugs such as Clomiphene and Menogan/Repronex. The causes of failed ovulation can be categorized as follows: Hormonal Problems: These are the most common causes of anovulation. The process of ovulation depends upon a complex balance of hormones and their interactions to be successful and any disruption in this process can hinder ovulation. There are three main sources causing this problem. [3, 4, 5, 6] (Table 2) Scarred Ovaries: Physical damage to the ovaries may result in failed ovulation. For example, extensive, invasive, or multiple surgeries, for repeated ovarian cysts may cause the capsule of the ovary to become damaged or scarred, such that follicles cannot mature properly and ovulation does not occur. Infection may also have this impact. [7, 8] Premature Menopause This presents a rare and as of yet unexplainable cause of an ovulation. Some women cease menstruation and begin menopause before normal age. It is hypothesized that their natural supply of eggs has been depleted or that the majority of cases occur in extremely athletic women with a

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Publication Ref No.: IJPRD/2009/PUB/ARTI/VOL-8/OCT/010

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long history of low body weight and extensive condition. [9, 10] Follicle Problem

exercise. There is also a genetic possibility for this

Although currently unexplained, "Unruptured follicle syndrome" occurs in women who produce a normal follicle, with an egg inside of it, every month yet the follicle fails to rupture. The egg, therefore, remains inside the ovary and proper ovulation does not occur. [11, 12] Polycystic ovary syndrome (PCOS) In PCOS, your body produces too much androgen hormone, which affects ovulation. PCOS is associated with insulin resistance and obesity. [13] II) CAUSES OF POORLY FUNCTIONING FALLOPIAN TUBES Tubal disease affects approximately 25% of infertile couples and varies widely, ranging from mild adhesions to complete tubal blockage. Treatment for tubal disease is most commonly surgery and, owing to the advances in microsurgery and lasers, success rates (defined as the number of women who become pregnant within one year of surgery) are as high as 30% overall, with certain procedures having success rates up to 65%. The main causes of tubal damage include: Infection: Caused by both bacteria and viruses and usually transmitted sexually, these infections commonly cause inflammation resulting in scarring and damage. A specific example is Hydrosalpnix, a condition in which the fallopian tube is occluded at both ends and fluid collects in the tube. [14] Abdominal Diseases: The most common of these are appendicitis and colitis, causing inflammation of the abdominal cavity which can affect the fallopian tubes and lead to scarring and blockage. [15] Previous Surgeries: This is an important cause of tubal disease and damage. Pelvic or abdominal surgery can result in adhesions that alter the tubes in such a way that eggs cannot travel through them. [16] Ectopic Pregnancy:

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This is a pregnancy that occurs in the tube itself and, even if carefully and successfully overcome, may cause tubal damage and is a potentially life-threatening condition. [17] Congenital Defects: In rare cases, women may be born with tubal abnormalities, usually associated with uterus irregularities. [18]

III) ENDOMETRIOSIS Approximately 10% of infertile couples are affected by endometriosis. Endometriosis affects five million US women, 6-7% of all females. In fact, 30-40% of patients with endometriosis are infertile. This is two to three times the rate of infertility in the general population. For women with endometriosis, the monthly fecundity (chance of getting pregnant) diminishes by 12 to 36%. [19] This condition is characterized by excessive growth of the lining of the uterus, called the endometrium. Growth occurs not only in the uterus but also elsewhere in the abdomen, such as in the fallopian tubes, ovaries and the pelvic peritoneum. A positive diagnosis can only be made by diagnostic laparoscopy, a test that allows the physician to view the uterus, fallopian tubes and pelvic cavity directly [20]. The symptoms often associated with endometriosis include heavy, painful and long menstrual periods, urinary urgency, rectal bleeding and premenstrual spotting. Sometimes, however, there are no symptoms at all, owing to the fact that there is no correlation between the extent of the disease and the severity of the symptoms. The long term cumulative pregnancy rates are normal in patients with minimal endometriosis and normal anatomy. Current studies demonstrate that pregnancy rates are not improved by treating minimal endometriosis. [21]

IV) ADDITIONAL FACTORS (1) Other variables that may cause infertility in women: At least 10% of all cases of female infertility are caused by an abnormal uterus. Conditions such as fibroid, polyps and adenomyosis may lead to obstruction of the uterus and Fallopian tubes. Congenital abnormalities, such as septate uterus, may lead to recurrent miscarriages or the inability to conceive. [22] Approximately 3% of couples face infertility due to problems with the female is cervical mucus. The mucus needs to be of a certain consistency and available in adequate amounts for sperm to swim easily within it. The most common reason for abnormal cervical mucus is a hormone imbalance, namely too little estrogen or too much progesterone. [23]

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Publication Ref No.: IJPRD/2009/PUB/ARTI/VOL-8/OCT/010

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(2) Behavioral Factors: It is well-known that certain personal habits and lifestyle factors impact health; many of these same factors may limit a couple's ability to conceive. Fortunately, however, many of these variables can be regulated to increase not only the chances of conceiving but also one's overall health. [24, 25, 25, 26, 27] (Table 3) (3) Environmental and Occupational Factors: The ability to conceive may be affected by exposure to various toxins or chemicals in the workplace or the surrounding environment. Substances that can cause mutations, birth defects, abortions, infertility or sterility are called reproductive toxins. Disorders of infertility, reproduction, spontaneous abortion and eratogenesis are among the top ten work-related diseases and injuries in the U.S. today. Despite the fact that considerable controversy exists regarding the impacts of toxins on fertility, four chemicals are now being regulated based on their documented infringements on conception. [28, 29, 30] (Table 4) DIAGNOSTIC TESTS FOR INFERTILITY In any fertility work-up, both male and female partners are tested if pregnancy fails to occur after a year of regular unprotected sexual intercourse. Fertility testing should especially be performed if a woman is over 35 years old or if either partner has known risk factors for infertility. An analysis of the man's semen should be performed before the female partner undergoes any invasive testing. I)Medical History and Physical Examination: The first step in any infertility work up is a complete medical history and physical examination. Menstrual history, lifestyle issues (smoking, drug and alcohol use and caffeine consumption), any medications being taken and a profile of the patient's general medical and emotional health can help the doctor decide on appropriate tests. [31] II) Easy Preliminary Steps: Before embarking on an expensive fertility work-up, the following steps are free or low-cost and can be helpful: Monitor basal body temperature. This is accurate in determining if ovulation is actually taking place. Test the consistency of your cervical mucus. Collect some mucus between your two fingers and stretch it apart. If you are near the time of ovulation, the mucus will stretch more than 1 inch before it breaks. As an alternative, at-home kits can test saliva as substitute for checking cervical mucus. Take an over-the-counter urine test for detecting luteinizing hormone (LH) surges. This helps determine the day of ovulation. Tests are also available to measure levels of follicle-stimulating hormone (FSH). However, these at-home tests may not be as accurate as those performed in a doctors office. [32, 33]

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III) Laboratory Tests: Several laboratory tests may be used to detect the cause of infertility and monitor treatments: 1) Hormonal Levels: Blood and urine tests are taken to evaluate hormone levels. Hormonal tests for ovarian reserve (the number of follicles and quality of the eggs) are especially important for older women. Examples of possible results include: High follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels and low estrogen levels suggest premature ovarian failure. High LH and low FSH may suggest polycystic ovary syndrome or luteal phase defect. High FSH and high estrogen levels on the third day of the cycle predict poor success rates in older women trying fertility treatments. LH surges indicate ovulation. Blood tests for prolactin levels and thyroid function are also measured. These are hormones that may indirectly affect fertility. [34, 35, 36] 2) Clomiphene Challenge Test: Clomiphene citrate (Clomid, Serophene), a standard fertility drug, may be used to test for ovarian reserve. With this test, the doctor measures FSH on day 3 of the cycle. The woman takes Clomiphene orally on days 5 and 9 of the cycle. The doctor measures FSH on the tenth day. High levels of FSH either on day 3 or day 10 indicate a poor chance for a successful outcome. [37, 38] 3) Tissue Samples: To rule out luteal phase defect, premature ovarian failure and absence of ovulation, the doctor may take tissue samples of the uterus 1 - 2 days before a period to determine if the corpus luteum is adequately producing progesterone. Tissue samples taken from the cervix may be cultured to rule out infection. [39] 4) Tests for Autoimmune Disease: Tests for autoimmune disease, such as hypothyroidism and diabetes, should be considered in women with recent ovarian failure that is not caused by genetic abnormalities. [40, 41] IV) Imaging Tests and Diagnostic Procedures:

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If an initial fertility work-up does not reveal abnormalities, more extensive tests may help reveal abnormal tubal or uterine findings. Combinations of these imaging procedures may be used to confirm diagnoses. [42, 43, 44, 45] (Table 5)
PRECONCEPTION INTERVENTIONS FOR MEDICAL CONDITIONS ASSOCIATED WITH INFERTILITY [46, 47, 48, 49, 50, 51] (Table 6)

CONCLUSION Female infertility is the major cause of lack of reproducibility and conception. 25% of the couples are tacing this problem. Many reasons are sorted out for female infertility but through proper diagnosis and counseling for treatment of female infertility can be only ray of hope. Review reveals extensively all the major reasons and causes for infertility. All these problems can surely be sorted out to come out this problem. Female infertility can surely be treated with medicines, minor surgical operations, laparoscopic procedures, hormonal therapy and prevention of preconception failure. The review is helpful to all the scientific, medical researchers who can put efforts to put end to female infertility. ACKNOWLEDGEMENT

We are very thankful to HON.Radhakrishna Vikhe Patil for his valuable guidance and support
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hormone-releasing hormone (LH-RH) in male infertility due to idiopathic azoospermia and oligospermia. Fertil Steril; 1973, 24:485-486. 6)Bchter, D, Behre, H.M, Kliesch, S. and Nieschlag, E. Pulsatile GnRH of hCG/hMG as effective treatment for men with hypogonadotropic hypogonadism: a review of 42 cases. Eur. J. Endocrinol, 139 1998, 298303. 7)Glazener, C.M.A, Kelly, N.J. and Hull, M.G.R. Prolactin measurement in the investigation of infertility in women with a normal menstrual cycle. Br. J. Obstet. Gynaecol, 94, 1987, 535538 8)Norman RJ, Dewailly D, Legro RS, Hickey TE. Polycystic ovary syndrome. Lancet. 370, 2007 Aug 25,685-97. 9)Lee, John, M.D. What Your Doctor May Not Tell You About Premenopause. 1999. 10)Wilcox LS, Mosher WD. Use of infertility services in the United States.Obstet Gynecol; 82, 1993:122-7. 11)Puri, P, Barton, D, ODonnellandB, Prepubertal testicular torsion: Subsequent fertility. J. Pediatr. Surg. 20, 1985, 598.

12)van de Vrie W, Baggen MG, Visser W, Derkx FH, Morrel B, OuwendijkRJ. High renin and prorenin in plasma and pleural exudate of a patient withthe ovarian hyperstimulation syndrome. Neth J Med. 51, 1997, 232-6. 13)Dahlgren E, Johansson S, Lindstedt G, Knutsson F, Oden A, JansonPO, et al. Women with polycystic ovary syndrome wedge resected in 1956 to1965: a long-term follow-up focusing on natural history and circulating hormones.Fertil Steril. 57, 1992:505-13. 14)Shevell T, Malone FD, Vidaver J, Porter TF, Luthy DA, Comstock CH, et al. Assisted reproductive technology and pregnancy outcome. Obstet Gynecol, ; 106, 2005 Nov,103945. 15)Healy DL, Trounson AO, Andersen AN. Female infertility: causes and treatment. Lancet. 343, 1994; 1539-44. 16)Belker, A.M, et al. Results of 1,469 microsurgical vasectomy reversals by the
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Vasovasostomy Study Group. J. Urol, 145, 1991, 505. 17)Steptoe PC, Edwards RG, Purdy JM. Clinical aspects of pregnancies established with cleaving embryos grown in vitro. Br J Obstet Gynaecol, ; 87: 1980,757-68. 18)Visscher RD. Economic implications of assisted reproductive technology.N Engl J Med. 331, 1994; 1588-9. 19)Hoxsey R, Rinehart JS. Infertility and subsequent pregnancy. Clin Perinatol, 24,1997, 321- 4 20)Trickey, Ruth. Women, Hormonesandthe Menstrual Cycle. 2003. 21)Chehval, MJandPurcell, MH, Varicocelectomy,Incidence of external spermatic vein involvement in the clinical varicocele. Fertil. Steril, 39, 1992,573. 22)Rao, MandRao, D, Cytogenetic studies in primary infertility. Fertil. Steril, 1977, 28:209. 23)Goldenberg, R.LandWhite, R, The effect of vaginal lubricants on sperm motility in vitro. Fertil. Steril, 1975, 26:872. 24)Honig, S.CandOates, R.D, Infertility. In: Clinical Urology. Edited by R.J. Krane, M.B. SirokyandJ.M. Fitzpatrick. Philadelphia: J.B. Lippincott, 1994. 25)Birdsall M, Kennedy S. The risk of aortic dissection in women with Turner syndrome [Letter]. Hum Reprod, 11, 1996, 1587. 26). Pryor, JLandHowards, S.S, Varicocele. Urol. Clin. North Am, 1987, 14:499. 27)Schormeyer, T, Knuth, U.AandBelken, L, Reversible azoospermia induced by anabolic steroid 19-nortestosterone. Lancet, 1984, 1:417. 28)Lantz, G.D, et al, Recovery of severe oligospermia after exposure to dibromochloropropane (DMCP). Fertil. Steril, 1981, 35:46. 29)Greene MF, Hare JW, Cloherty JP, Benacerraf BR, Soeldner JS. First trimester hemoglobin A1 and risk for major malformation and spontaneousabortion in diabetic pregnancy. Teratology, 39,1989,225-31.20 30)Teitze C. Reproductive spans and rate of reproduction among Hutteritewomen. Fertil Steril,8 1957,89-97. 31)Annas GJ. The shadowlands secrets, liesandassisted reproduction. N EnglJ Med. ,
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3391998,935 32)Lee, John, MD. Hormone Balance Made Simple. 2006 33)Buyalos RP, Lee CT. Polycystic ovary syndrome: pathophysiology and outcomewith in vitro fertilization. Fertil Steril. 65, 1996; 1-10. 34) Amowitz LL, Sobel BE. Cardiovascular consequences of polycystic ovarysyndrome. Endocrinol Metab Clin North Am. 28, 1999; 439-58. 35)Beerendonk CC, van Dop PA, Braat DD, Merkus JM. Ovarian hyperstimulationsyndrome: facts and fallacies. Obstet Gynecol Surv, 53, 1998,439-49. 36)Marks, JL, MacMahon, RandLipshultz, L.I, Predictive parameters of successful varicocele repair. J. Urol, 136, 1986,:609. 37)Mellinger, RCandThompson, R.J, The effect of clomiphene citrate in female infertility. Fertil. Steril, 17, 1966,:94. 38)Charny, CWandBaum, S, Varicocele and infertility. J.A.M.A, 204, 1968: 1165. 39)Franks S. Polycystic ovary syndrome. N Engl J Med, 333 1995;853-61. 40)Hwang WJ, Lai ML, Hsu CC, Hou NT. Ischemic stroke in a young woman with ovarian hyperstimulation syndrome. J Formos Med Assoc. 97, 1998; 503-6. 41)Legro RS, Kunselman AR, Dodson WC, Dunaif A. Prevalence and predictorsof risk for type 2 diabetes mellitus and impaired glucose tolerance inpolycystic ovary syndrome: a prospective, controlled study in 254 affectedwomen. J Clin Endocrinol Metab, 84 1999; 165-9. 42)Belker, AMandSteinbock, GS, Transrectal prostate ultrasonography as a diagnostic and therapeutic aid for ejaculatory duct obstruction. J. Urol, 1990, 144:356. 43)Carter, SC, Shinohara, KandLipshultz, L.I, Transrectal ultrasonography in disorders of the seminal vesicles and ejaculatory ducts. Urol. Clin. North Am, 1989, 16:773. 44)Griffin, JEandWilson, JD, Disorders of sexual differentiation. In Walsh, P.C, et al. (eds.): Campbells Urology, Volume 2. Edited by P.C. Walsh, et al. Philadelphia: W.B. Saunders, 1992. 45)Abramov Y, Elchalal U, Schenker JG. Obstetric outcome of in vitro fertilize d pregnancies complicated by severe ovarian hyperstimulation syndrome: amulticenter
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study. Fertil Steril, 70, 1998, 1070-6. 46)Delgado-Escueta AV, Janz D. Consensus guidelines: preconception counseling,managementandcare of the pregnant woman with epilepsy. Neurology, 42(4 Suppl 5):1992; 149-60. 47)Hanson RG, Powrie RO, Lawson L. Diabetes insipidus in pregnancy: a treatable cause of oligohydramnios. Obstet Gynecol, 89(5 Pt 2), 1997; 816-7. 48)Kallen BA, Carlsson SS, Bengtsson BK. Diabetes insipidus and use ofdesmopressin (Minirin) during pregnancy. Eur J Endocrinol. ; 132, 1995:144-6. 49)Dunaif A. Insulin action in the polycystic ovary syndrome. Endocrinol MetabClin North Am. 28, 1999; 341-59. 50) Wolfe HM, Gross TL. Obesity in pregnancy. Clin Obstet Gynecol. 37, 1994; 596-604. 51)Stewart JA, Hamilton PJ, Murdoch AP. Thromboembolic disease associated with ovarian stimulation and assisted conception techniques. Hum Reprod, 12, 1997; 2167-73.

. TABLES AND FIGURES : Infertility History Table 1: History of Infertility [3]


History of Infertility Duration Prior pregnancies Present partner Another partner Previous treatments Evaluation and treatment of wife Medical History Systemic illness (i.e, diabetes mellitus, multiple sclerosis Previous/current therapy sulfasalazine, nitrofurantoin, alcohol marijuana, androgenic steroids) Thermal exposure Gonadotoxins Chemicals (pesticides) Drugs (chemotherapeutic, cimetidine,

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Radiation Smoking Family History Cystic fibrosis Androgen receptor deficiency Retroperitoneal injury Timing of intercourse Pelvic injury Frequency of intercourse Frequency of masturbation Pelvic, inguinal, or scrotal surgery Herniorrhaphy Y-V plasty, transurethral resection of the prostate Infections Viral, febrile Mumps orchitis Venereal Tuberculosis, smallpox (rare) Infertile first-degree relatives

Sexual History Potency Lubricants

Surgical History Orchiectomy (testis cancer, torsion)

Childhood & Development GU congenital anomalies Undescended testes, orchiopexy Herniorrhaphy Y-V plasty of bladder Testicular torsion Testicular trauma Onset of puberty

Review of Systems Respiratory infections Anosmia Galactorrhea Impaired visual fields

Table 2: Hormonal Problems of Female Infertility

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Failure to produce mature eggs

Malfunction of the hypothalamus Malfunction of the pituitary gland

In approximately 50% of the cases of anovulation, the ovaries do not produce normal follicles in which the eggs can mature. Ovulation is rare if the eggs are immature and the chance of fertilization becomes almost nonexistent. Polycystic ovary syndrome, the most common disorder responsible for this problem, includes symptoms such as amenorrhea, hirsuitism, an ovulation and infertility. This syndrome is characterized by a reduced production of FSH and normal or increased levels of LH, oestrogen and testosterone. The current hypothesis is that the suppression of FSH associated with this condition causes only partial development of ovarian follicles and follicular cysts can be detected in an ultrasound scan. The affected ovary often becomes surrounded with a smooth white capsule and is double its normal size. The increased level of oestrogen raises the risk of breast cancer. The hypothalamus is the portion of the brain responsible for sending signals to the pituitary gland, which, in turn, sends hormonal stimuli to the ovaries in the form of FSH and LH to initiate egg maturation. If the hypothalamus fails to trigger and control this process, immature eggs will result. This is the cause of ovarian failure in 20% of cases. The pituitary's responsibility lies in producing and secreting FSH and LH. The ovaries will be unable to ovulate properly if either too much or too little of these substances is produced. This can occur due to physical injury, a tumor or if there is a chemical imbalance in the pituitary.

Table 3: Behavioral Factors for Female Infertility Diet and Exercise Optimal reproductive functioning requires both proper diet and appropriate levels of exercise. Women who are significantly overweight or underweight may have difficulty becoming pregnant Cigarette smoking has been shown to lower sperm counts in men and increases the risk of miscarriage, premature birth and low-birth-weight babies for women. Smoking by either partner reduces the chance of conceiving with each cycle, either naturally or by IVF, by one-third. Alcohol intake greatly increases the risk of birth defects for women and, if in high enough levels in the mother is blood, may cause Fetal Alcohol Syndrome. Alcohol also affects sperm counts in men. Drugs, such as marijuana and anabolic steroids, may impact sperm counts in men. Cocaine use in pregnant women may cause severe retardations and kidney problems in the baby and is perhaps the worst possible drug to abuse while pregnant. Recreational drug use should be avoided, both when trying to conceive and when pregnant.

Smoking

Alcohol

Drugs

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Stress and Fertility

Neurotransmitters (chemical messengers) act in the hypothalamus gland, which controls both reproductive and stress hormones. Severely elevated levels of stress hormone can, in fact, shut down menstruation. Whether stress has any significant effect on fertility or fertility treatments is unclear.

Table 4: Environmental and Occupational Factors for Female Infertility Lead Exposure to lead sources has been proven to negatively impact fertility in humans. Lead can produce teratospermias (abnormal sperm) and is thought to be an abortifacient, or substance that causes artificial abortion. Repeated exposure to radiation, ranging from simple x-rays to chemotherapy, has been shown to alter sperm production, as well as contribute to a wide array of ovarian problems. A chemical used both in the sterilization of surgical instruments and in the manufacturing of certain pesticides, ethylene oxide may cause birth defects in early pregnancy and has the potential to provoke early miscarriage. Handling the chemicals found in pesticides, such as DBCP, can cause ovarian problems, leading to a variety of health conditions, like early menopause, that may directly impact fertility.

Medical Treatments and Materials Ethylene Oxide

Dibromochloropropane (DBCP)

Table 5: Imaging Tests and Diagnostic Procedures for female infertility.

Ultrasound and Sonohysterography

Ultrasound is the standard imaging technique for evaluating the uterus and ovaries, detecting fibroids, ovarian cysts and tumors and also obstructions in the urinary tract. It uses sound waves to produce an image of the organs and entails no risk and very little discomfort. Transvaginal sonohysterography uses ultrasound along with saline infused into the uterus, which enhances the visualization of the uterus. This technique is proving to be more accurate than standard ultrasound in identifying potential problems. It is currently the gold

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standard for diagnosing polycystic ovaries. Hysteroscopy Hysteroscopy is a procedure that may be used to detect the presence of endometriosis, fibroids, polyps, pelvic scar tissue and blockage at the ends of the fallopian tubes. Some of these conditions can be corrected during the procedure by cutting away any scar tissue that may be binding organs together or by destroying endometrial implants. Hysteroscopy may be done in a doctors office or in an operating room, depending on the type of anesthesia used. The procedure uses a long flexible or rigid tube called a hysteroscope, which is inserted into the vagina and through the cervix to reach the uterus. A fiber optic light source and a tiny camera in the tube allow the doctor to view the cavity. The uterus is filled with saline or carbon dioxide to inflate the cavity and provide better viewing. This frequently causes cramping. There are small risks of bleeding, infection and reactions to anesthesia. Many patients experience temporary discomfort in the shoulders after the operation due to residual carbon dioxide that puts pressure on the diaphragm. The wound itself is minimally painful Hysterosalpingography is performed to discover possible blockage in the fallopian tubes and abnormalities in the uterus: The doctor inserts a tube into the cervix through which a special dye is injected. (The patient may experience some cramping and discomfort.) The dye passes into the uterus and up through the fallopian tubes. An x-ray is taken of the dye-filled uterus and tubes. If the dye is seen emerging from the end of the tube, no blockage is present. (In some cases, hysterosalpingography may even restore fertility by clearing away tiny tubal blockages.) If results show blockage or abnormalities, the test may need to be repeated. In case of blockage, hysterosalpingography may reveal a number of conditions, including endometrial polyps, fibroid tumors, or structural abnormalities of the uterus and tubes. There is a small risk of pelvic infection and antibiotics may be prescribed prior to the procedure. Laparoscopy is a minimally invasive surgical procedure. It requires general anesthesia and is performed in an operating room. The surgeon makes a very small incision below the belly button and inserts an instrument called a laparoscope, which is similar to a hysteroscope. (The difference is that a laparoscope is inserted through the abdomen, while a hysteroscope is inserted through the cervix.) Through the laparoscope, the surgeon can view the uterus, fallopian tube and ovaries. Laparoscopy is most helpful for identifying

Hysterosalpingography

Laparoscopy

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endometriosis or other adhesions that may affect fertility. Blood tests Blood tests that measure the levels of various hormones, such as luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (PRL), estradiol and progesterone, aid greatly in determining the cause of infertility. Because changes in pituitary or thyroid function can also affect the menstrual cycle and ovulation, blood tests that measure thyroid function (TSH and/or T4) and steroids, such as testosterone and DHEA-S (dehydroepiandrosterone sulfate is used in creating androgens and estrogens), are also informative. This painless office procedure should be done the day you ovulate and several hours after sex. A small amount of cervical mucus is removed and examined under a microscope. The PCT determines how compatible a man's sperm is with his partner's cervical mucus. A sample of the endometrium (tissue lining the inside of the uterus) is removed and studied under a microscope. Problems with the endometrium are called luteal phase defect. The test checks to see if the endometrium can support implantation and growth of a fertilized egg. The test must be done about three days before your period starts. A woman may also get the test if she is having irregular periods or none at all. Testosterone levels can rise in women because of tumors that develop in the ovaries or PCOS.

Post-coital test

Endometrial biopsy

Testosterone testing

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Publication Ref No.: IJPRD/2009/PUB/ARTI/VOL-8/OCT/010

ISSN 0974 9446

Table 6: Preconception Interventions for Medical Conditions Associated with Infertility Illness Autoimmune disorder Intervention Evaluate associated renal, cardiopulmonary and thromboembolic disease Measure antiphospholipids and other auto antibodies. Discuss relative safety of most immunosuppressants (with the exception of methotrexate) Perform echocardiography to assess extent of lesion; document stenos sand assess pulmonary pressure. Evaluate for coronary artery disease if multiple risk factors are present. Consider prophylaxis against sub acute bacterial endocarditis for valvular disease. Discuss risk for preeclampsia and fetal growth disorders; if risk is moderate to severe, discuss 50% perinatal mortality rate Discontinue therapy with angiotensin-converting enzyme inhibitors .Control hypertension Avoid infection Control brachial hypertension (without compromising uterine flow) Advise patient of increased risk for aortic dissection Note that risk for malformations is two to three times Higher Aim for monotherapy Use supplemental folate If patient is seizure-free for 2 years, consider withdrawal of antiepileptic drugs. Modify drugs as needed Discuss risk for superimposed preeclampsia, abruption, fetal growth disorder and premature birth. Assess risk for recurrence and the effect of pregnancy on this risk Determine the effect of therapy on fetus and Pregnancy Assess organ damage (for example, cardiomyopathy) Advise patient of increased pregnancy loss in the case of pelvic irradiation Discuss maternal longevity. Advise weight loss before conception if possible Discuss risk for macrosomia, hypertension, cesarean delivery, infection and thrombosis For diabetes insipid us, desmopressin acetate is the treatment of choice Continue cortisol replacement unchanged except in the case of illness, stress, or labor Continue treatment for macroadenoma (size increased by estrogen) Consider thrombophilia evaluation, especially for factor V Leiden mutation Discuss need for heparin prophylaxis or treatment Discontinue warfarin therapy by 4 weeks because of teratogenic effects

Cardiac disease

Chronic renal disease

Coarctation of the aorta Epilepsy

Hypertension Malignant conditions

Obesity Pituitary disorders

Thromboembolic disease

International Journal of Pharma Research and Development Online www.ijprd.com

Publication Ref No.: IJPRD/2009/PUB/ARTI/VOL-8/OCT/010

ISSN 0974 9446

Turner syndrome

Type 1 or 2 diabetes

Assess cardiac echocardiography Determine fasting glucose level Determine thyroid-stimulating hormone level Assess for genitourinary anomalies Normalize hemoglobin A1c level before conception to decrease risk for congenital anomalies.Obtain remission of proliferative retinopathy, which may worsen during pregnancy Assess renal and vascular disease After missed period, discontinue angiotensin-converting enzyme inhibitor therapy, which causes fetal renal failure and oliguria

Figure 1: Female Reproductive System

International Journal of Pharma Research and Development Online www.ijprd.com

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