The Female Factor

Evaluation of female infertility is much more complex as compared to evaluation of male infertility. This is because of the complexity of the female reproductive system.

The man has a simple role- ie. Deposition of a large nimber of good quality sperm in the vagina

The woman on the other hand has to-

- produce eggs in her ovaries

- have patent functioning tubes for fertilisation to occur between the egg and the sperm and to carry the embryo to the uterus.

- normal uterus to nurture the embryo

Evaluation of the female partner includes testing for all the above functions. Some of these tests are invasive.

This includes:

-  Detailed history

-  Complete physical examination

-   Tests to evaluate:   A) Ovarian function

-                                      B) Tubal patency

-                                      C) Uterus

A) There are various tests to detect the ovarian reserve:

1)   Cycle day3 serum FSh concentration-

2)  Currently, in most laboratories, levels above 10-15 IU/L are considered abnormal.  As values increase, the number of oocytes retrieved and the probability for pregnancy or live birth steadily decline.

3)   Cycle day 3 estradiol concentration-

A high cycle day 3 estradiol concetration ( greater than 80 pg/ml predicts low fecundability.

4)   Measurement of both FSH and estradiol on cycle day 3

5)   Clomiphene citrate challenge test-

This involves measuring a day3 FSH; and a day 10 FSH, afetr administering clomiphene citrate ( 100mg ) from day 5 to day 9. If the sum of the FSH level is more than 25, it suggests a poor ovarian reserve.

6)   Inhibin B-

Inhibin B is a protein hormone produced by the ovaries. It acts to inhibit the FSH production. Inhibin B level decreases with decreasing ovarian reserve.

7)   Anti-mullerian hormone-

AMH, or anti-mullerian hormone is produced by granulosa cells in ovarian follicles. It is made in the smallprimary follicles and antral follicles.

Production decreases and then stops as the follicles grow larger. There is almost no AMH made in human follicles over 8mm in size. Because of this, the levels are quite constant and the AMH test can be done on any day of a woman's cycle.

Since AMH is produced only in small ovarian follicles, blood levels of this substance have been used to attempt to measure the size of the pool of growing follicles in women.

Therefore, AMH blood levels are thought to reflect the size of the remaining egg supply - or ovarian reserve.

With advancing age, the size of the pool of the remaining follicles decreases. Therefore, the blood AMH level and the number of antral follicles seen on ultrasound also decreases.

8)  Transvaginal ultrasound for ovarian volume and antral follicle count

Ovarian reserve testing is strongly justified for women with any of the following characteristics:

-  Age older than 35

-  Unexplained infertility, regardless of age

-  Family history of earky menopause

-  Previous ovarian surgery ( ovarian cystectomy or drilling, unilateral oophorectomy ), chemotherapy or radiation

-  Smoking

-  Demonstrated poor response to exogenous gonadotropin stimulation

B) Tests to evaluate the fallopian tubes and the uterus:

1) Hysterosalpingogram (HSG) - an x-ray of the uterine cavity and fallopian tubes using a radiographic dye to detect structural abnormalities of the uterine cavity fallopian tubes, as well as tubal patency.

2) Diagnostic laparohysteroscopy - a minimally invasive surgical procedure typically performed in an outpatient day surgery setting. It permits direct visual assessment of the uterus, fallopian tubes, ovaries, and lower pelvis. It is particularly useful in diagnosing endometriosis, tubal disorders or pelvic adhesions and generally is performed at the end of a work-up, but may be performed earlier if deemed appropriate by the patient's history and referral diagnosis.

3) Ultrasound - performed seven to nine days after ovulation to reveal the thickness of the uterine lining (the endometrium) and its response to hormonal stimulation.

4) Endometrial biopsy - used to determine if the endometrium, the lining of the uterus, has responded appropriately for implantation of the embryo. This is obtained as a tiny tissue sample from the endometrium.