Cause of Female Infertility
FEMALE INFERTILITY

Recent studies have shown that about 1 in 6 couples are faced with fertility-related problems. This means that approximately 60-80 million couples around the world are experiencing infertility (Deyhoul, 2017). 

A couple is said to have infertility problems when they have been unsuccessful in efforts to conceive over the course of one full year of regular unprotected sexual intercourse. 

Ratio of Male - Female infertility

Research estimates show that: 
  • the female-related factors accounts for 35%-40% of cases of couple's infertility
  • the male-related factors accounts for 35%-40% of cases of the couple's infertility
  • the remaining 20%-30% of cases are related to the combination of other factors
This means that though the male and female factors account for greater percentage (70%-80%) of the reported cases of fertility, a relatively larger proportion of the causes of the couple's infertility are linked to other factors. 

This is a very vital information that clinicians need to  relay to couples faced with infertility problems. Many couples with infertility problems (especially the females) are often burdened with guilt for not being able to conceive and bear children. They tend to personalise every form of infertility, hence running the risk of developing mental health problem in addition to the existing infertility!!
Female Infertility
 Females infertility is described as the inability of woman of reproductive age to conceive and bear children. As mentioned early, female infertility is shown to explain around one-third of all cases investigated. It has also been shown that almost all cases of female infertility are amenable to treatment. 

This is a very good news; females do not have to die in silence!! They need to seek for help and do something about their infertility problems!!!
Causes of Female Infertility 
A number of factors have been identified to be associated with female infertility. 

Below are some of the commonly associated factors:
  1. Age
  2. Hereditary 
  3. Lifestyle
  4. Timing
  5. Medical conditions
  6. Inject-able birth control 
  7. Household chemicals
1. Age: 
Age is a consistent singular factor that affect females' infertility. There is an inverse relationship between a woman's age and her fertility. As a woman ages, her fertility naturally tends to decrease until she reaches menopause (which can occur any time from late 30s) when she no longer ovulates and consequently unable to get pregnant. Studies showed that fertility begins to stall after the age of 35, and by the age of 40 it is in a steep decline. 

Increasing number of women are delaying their child birth so as to establish their career or get onto property leader. As good as this current trend, may be, the flip side to it is that this is often at the expense of their natural fertility. Each woman has fix number of eggs which when they are gone, can not be replaced. It is therefore important that women need to know what their 'ovarian reserve' is before delaying their child-bearing. The ‘ovarian reserve’ (a measure of female fertility during the reproductive years) can be tested. 

A fertility test for women includes: 
  • Blood test. The blood test will measure some relevant hormonal levels. E.g. hormone known as Anti Mullerian Hormone (AMH), which will give an indication of your ovarian reserve will be tested. 
  •  Pelvic ultrasound scan. The scan will check for any polyps, Fibroids, cysts or other problems likely to affect fertility. 

During her child-bearing age, a woman can experience fertility problems as her ovulation becomes less regular and her egg count declines. This is known as peri-menopause and can be characterised by
  •  irregular menstrual periods 
  • heavy periods
  • frequent hot-flashes, 
  • mood swings etc. 
Although there is no set age when fertility begins to go down, recent evidence show that women seem to experience increasingly difficulty in getting pregnant after age 35. The turning point for this downward spiral of fertility in women may be different for every woman. This explains why many women seem to experience the peri-menopause earlier in their 30s, while others remain fertile through their 40s and even 50s. 

Alarmingly, from our experience at ASSIST-Fertility UK, the age of peri-menopause is consistently getting lower into the mid 20s bracket!! 

It is important for women to keep accurate record of their menstrual history and discuss with their GP if they notice any significant change in their regular patterns. 

2. Hereditary 

It has been suggested that early menopause may run in families, hence, if the lady's mother had early menopause, the young lady is likely to have early menopause. This is attributed to the genetic factors which are passed down to the family members and predispose the women in the family to have more or less eggs than the average population of women of similar age. Some gynaecological issues which affect fertility (see section on medical conditions) have been shown to run in the family and so it is important for the young lady to screen for such problems and seek professional help as soon as possible.

Though this might be the case in some instances, environmental (external) factors such as change in life-style can modify the presentation of such family genetic connections to menopause or infertility.

It is therefore worth-the-while to find out your family history regarding menopause, infertility and other genetic problems. 
3. Lifestyle 
 Lifestyle is one of the major situational (external) factors that affect fertility of women and men. Some of these lifestyles are discussed below:

a) Weight 
Being overweight (or obese) or underweight can affect your fertility.
Obesity
Excess body weight as been shown to affect the production of many hormones such as reproductive hormones. The hormonal imbalance and dysfunction tend to decrease female ovarian functions, consequently reducing the woman's chance of getting pregnant. Recent studies found that women who were obese at age 18 are more likely to develop Polycystic Ovary Syndrome (PCOS) and have problems with infertility. PCOS is the most common hormonal disorder among women of reproductive age, and the leading cause of infertility.

Being over-weight also increases the risk of insulin resistance. Having a high level of insulin in your blood can cause metabolic disturbances that can affect ovulation. Insulin resistance, as well as defects in insulin secretion, have been associated with polycystic ovarian syndrome (PCOS), which can also lead to fertility issues. The exact cause of PCOS is unknown, but excess insulin might result in increased androgen production which can be a problem for ovulation.

Being too thin
Underweight has also been shown to have negative effect on female fertility. It is shown that women with low BMIs (body mass index) tend to be deficient in leptin, the hormone that controls hunger and feelings of satiety. The reduction in Leptin level is also associated with reduced or absence of menstrual periods. 

Most people know that their ovaries produce oestrogen, however, a lot of people do not know that adipose tissue (fat cells) also produces some oestrogen. When you are at a healthy body weight, you have a higher probability of producing an appropriate amount of oestrogen, but when you are overweight or obese, your adipose tissue produces more oestrogen than necessary—which can prevent regular ovulation. Your body requires a fine balance of hormones to ovulate properly, and having too much oestrogen can throw off that balance.

The reverse is also true, when you are underweight your ovaries make less oestrogen, which can also impact ovulation (at ovulation, you need your oestrogen levels to rise, helping along the release of the egg from its follicle).  In addition to the fact that being significantly underweight can affect hormone production and inhibit normal ovulation, it can stop menstruation altogether. This is known as amenorrhea.

Maintaining a healthy body weight (normal BMI range), which is reached through a healthy diet and moderate exercise, is one of the most important lifestyle change a woman can make to increase her chances of getting pregnant (Arredondo, 2017).

  b) Smoking
Study showed that smoking is associated to 13% of the 'other factor' causes of infertility in male and females (American Society for Reproductive Medicine, 2014). The study highlighted that a woman's smoking may also affect the fertility of her sons.

 Smoking is associated with the following fertility problems:
  • Problems with the Fallopian tubes, including blockages (preventing egg and sperm from meeting) and an increased risk of ectopic pregnancy
  • Cervical changes, specifically an increased risk of developing cervical cancer
  • Damage to the eggs as they develop in the ovaries
  • Increased risk of miscarriage, possibly due to damaged eggs, damage to the developing fetus, or unfavourable changes in the uterine lining, which may make healthy implantation of an embryo less likely
Some studies have shown that smoking can cause not only problems with fertility while you're smoking, but can lead to lowered fertility in the future. While males tend to produce new sperm throughout their lives, women are believed to be born with all the eggs they will ever have. Once those eggs are damaged, there's no going back. Smoking may decrease the total number of eggs a woman has in her ovaries and cause the ovaries to age prematurely.

Toxins in cigarettes may also lead to DNA damage to the ovarian follicles, where the eggs normally develop to maturity. This premature aging of the ovaries and decrease in eggs may lead to earlier menopause, as much as four years earlier than normal. While smoking can lead to some long-term fertility damage, studies have also shown that fertility rates can improve after one year of quitting. It is best for you and your future baby if you quit before you achieve pregnancy.

c) Alcohol
Although there is not yet any established direct association between alcohol intake and infertility, it is advisable to avoid heavy drinking. This is because drinking during the early stages of pregnancy (and possibly even before conception) has been linked to premature births. As for whether it's safe to drink later in pregnancy, the jury's still out. Though some clinicians would suggest that a small amount of alcohol is OK, many healthcare professionals and clinicians would firmly offer that it is best not to indulge since there is no concrete proof that it is not harmful to the baby.

d) Caffeine 
There are debates regarding whether or not caffeine intake is associated with infertility. Nevada School of Medicine (2011) found that caffeine interferes with the muscle contractions that help eggs travel from the ovaries and through the Fallopian tubes to the womb. Another study  revealed that drinking five or more cups of coffee a day may cut a woman's chances of successful in vitro-fertilisation by half (Danish, 2012) . Other studies, however, suggested caffeine plays no role in fertility. Either way, if you're struggling to conceive, it is worth taking a look at your caffeine intake and cutting back if you are drinking more than 200 milligrams a day—that's 1 to 28-ounce cups of coffee.

e) Extreme exercise
Working out helps keep you slim, strong, and full of energy—all important when you're trying to get pregnant. Excessive exercising can have a negative impact on ovulation: women who performed high-frequency, high-intensity exercise for more than five hours a week had a harder time getting pregnant. Women who were active on most days of the week were 3.2 times more likely to be infertile than inactive women. Women who exercised 'to exhaustion' were 2.3 times more likely to be infertile than women who said they 'take it easy.

The most obvious sign of a potential problem is a change in menstrual cycle. If you notice that it becomes lighter or shorter, you should talk to your doctor about the implications for your fertility and your health.

f) Stress
While the exact pathways between fertility and stress is still unknown. It is believed that hormones such as cortisol or epinephrine, which rise and often remain high during times of chronic stress, could play a significant role. Some research shows that stress may also affect testosterone levels and sperm production in men. Other research indicates that stress may have an impact on other aspects of fertility beyond ovulation, including problems with fertilisation and implantation in the uterus. Stress reduction may help enhance proteins within the uterine lining that are involved in implantation. It can also increase blood flow to the uterus, which also affects conception. 

g) Diet

Foods for Fertility
According to a study of diet and fertility from Harvard Medical School, unlike other factors that you cannot control—such as age and genetics—eating certain foods and avoiding others is something you can do yourself, without medical intervention, to help improve your ovulatory function.

1. Complex Carbs
Eat more complex ("slow") carbs and limit highly processed ones.
Your body digests bad carbs (like cookies, cakes, white bread and white rice) quickly, and turns them into blood sugar. To drive down the blood-sugar spike, the pancreas releases insulin into the bloodstream. Good carbs (those containing fibre, such as fruits, vegetables, beans and whole grains) are digested slowly and have a more gradual effect on blood sugar and insulin. Studies have found that high insulin levels appear to inhibit ovulation.

2. Unsaturated Fats
Avoid all trans fats and eat more healthy unsaturated fats.
Trans fats (found primarily in foods such as commercial baked and snack foods, animal products, french fries and some margarine) increase insulin resistance. Insulin helps move glucose from the bloodstream to the cells; resistance means it's harder to move glucose into the cells. The pancreas keeps pumping out more insulin anyway, and the result is more insulin in your bloodstream. High insulin levels cause a lot of metabolic disturbances that affect ovulation.

3. Protein
Get more protein from plant foods like beans and less from red meat.
Plant protein (from beans, nuts, seeds and tofu) comes with healthy fats and is relatively low in calories and can be helpful for weight loss.

4. Whole Milk
Consume one or two servings a day of whole milk or other full-fat dairy foods, such as yogurt, and less non- and low-fat dairy.

5. Multivitamins
Take a daily multivitamin that contains at least 400 micrograms of folic acid and 40 to 80 milligrams of iron.

Women that took daily multivitamins containing 400 micrograms of folic acid were shown to be 40 percent less likely to experience ovulatory infertility than women who did not.
4. Timing: Missing the "fertile window" in a woman's cycle.
Pregnancy is practically possible between 5 days earlier and a day after ovulation. These six days are referred to as the ‘fertile window’ in a woman’s cycle. These correspond to the lifespan of sperm (5 days) and the lifespan of the ovum (24 hours). outside of these days, the chance of the woman becoming pregnant is literally 0%. 

5. Medical conditions
        a) Female Health Issues
Female health issues such as Polycystic Ovary Syndrome (PCOs), endometriosis, Pelvic Inflammatory Disease (PID), and uterine fibroid etc can affect a woman's chances of getting pregnant or successfully carrying a pregnancy to term. 

Women with Autoimmune Disorders (such as lupus or rheumatoid arthritis) may also have trouble conceiving, since their bodies may reject a fertilised egg or attack her partner's sperm. With appropriate medical care, however, many women with these health conditions tend to have increased chance of successfully getting pregnant and having healthy babies.  

     b) Sexual health Issues
Sexually transmitted infections like chlamydia and gonorrhea can cause pelvic inflammatory disease and cause fertility problems, even years after a woman contracts them. In fact, chlamydia can cause damage to the fallopian tubes without any other symptoms, and many women may not know they had the disease until they experience trouble getting pregnant. It's important to note, though, that vaginal infections (like yeast infections) have no effect on fertility. 

   c) Thyroid disease
The Obstetrician & Gynecologist (2015) supports the long-suspected theory that thyroid disorders can contribute to ovulation and pregnancy problems, and suggests that women having trouble conceiving be tested for over- or under-active thyroid.  It is shown that people with significant thyroid disease typically have some obvious symptoms, but sub-clinical, undiagnosed hypothyroidism is certainly a recognised problem which can have subtle effects on fertility without a woman knowing it. 
6. Inject-able birth control
Usually, you can get pregnant once you stop taking most forms of hormonal birth control. One exception to this is the Depo-Provera, the injectable birth control. Each Depo-Provera injection prevents pregnancy for 12 to 14 weeks—and while some women do get pregnant in as little as one month after that protection wears off, it can take other women up to a year to conceive. It is recommend that women stop using injectable birth control several months before they hope to get pregnant. 
             

7. Household Chemicals

According to the Environmental Health perspective (2013), exposure to pollutants, pesticides, and industrial compounds can fertility of couples up to 29%.  About 15 common chemicals were found to be associated with early menopause and these chemicals include 
  • nine PCBs (which have been banned since 1979 but still exist in older products), 
  • three pesticides,
  •  two forms of plastics called phthalates (often found in personal care items and beauty products like perfumes and nail polishes),
  • the toxin furan, a byproduct of industrial combustion.
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