Professor of Anatomy/Consultant Reproductive Endocrinologist,
[email protected] 0700 MARTCENTER
Recently, a consortium of fertility experts from various international organisations both in Europe and Africa met under the auspices of the World Health Organisation and came up with a new definition of “Infertility” which was published in the Fertility and Sterility Journal, September, 2017.
In the new definition, infertility is the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse due to impairment of a person’s capacity to reproduce either as an individual or with his/ her partner.
Furthermore, they opine that fertility interventions may be less than one- year based on medical, sexual and reproductive history, age, physical findings and diagnostic test.
The most common cause of infertility in female is the inability to produce eggs that are normal. Disorders of egg production accounts for more than 30 per cent of infertility in women. Fortunately, 70 per cent of these cases can be successfully treated with the use of drugs that support ovulation.
Drugs like clomid, gonadotropins; menogon, follitrope, folligraft, gonal F and several other FSH (follicle stimulating hormone) help to stimulate the growth of follicles. Anovulation (inability to ovulate) can be due to four major factors:
These are the most common causes of anovulation. The ovulatory mechanism is controlled by the complex balance of hormones and I liken it to an orchestra in the symphony, any disruption in this process can hinder ovulation. Three main factors causing this are:
Failure to produce mature eggs
In about 50 per cent 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 fertilisation becomes almost non-existent. Even when a substantial amount of ovulatory support hormones like FSH are given, and we obtain like 12 eggs, seven of the eggs would be fully matured while five eggs are immature and cannot be fertilised even using “brute force” with Intra cytoplasmic sperm injection.
Polycystic ovary syndrome is the most common disorder responsible for this problem. Symptoms such as amenorrhoea, hirsutism, anovulation and infertility are evident in polycystic ovary syndrome.
This syndrome is characterised by a reduced production of FSH, and normal or high levels of LH, estrogen, and testosterone. The current hypothesis is that the suppression of FSH associated with this condition causes partial development of ovarian follicles, and follicular cysts can be detected in an ultrasound scan.
The affected ovary often becomes surrounded by a smooth white capsule and doubles its normal size. The increased level of oestrogen raises the risk of breast cancer. This condition has also been linked with the inadequate carbohydrate metabolism especially with resistance to insulin.
Insulin is the hormone produced by the body to help us to manage our sugar intake. This can be successfully managed by dietary regulation, detoxification and the use of anti-diabetic drugs like metformin. The thyroid gland and the adrenal gland also play a significant role in the manifestations of some of the infertility problems at this level.
Malfunction of the hypothalamus
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. It can be regarded as the director of music for the symphony orchestra for ovulation.
If the hypothalamus fails to trigger and control this process, immature eggs will result. This amounts to 20 per cent of cases with ovarian failure. We now know that some of the malfunctions of the hypothalamus can be due to poor diet: malnutrition, bad eating habits, stress, and some environmental and occupational toxins.
Malfunction of the pituitary gland
The pituitary’s responsibility lies in producing and secreting FSH and LH. It is easily termed as the musical conductor. The ovaries will be unable to ovulate properly if either too much or too little of these substances are produced. This can occur due to physical injury, a tumour or chemical imbalance in the pituitary.
Also, physical damage to the ovaries may result in failed ovulation. For instance, 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.
In Nigeria, a great number of ladies had been sent into premature ovarian failure because they were attempting to terminate a pregnancy. A termination of pregnancy by D and C (dilatation and curettage) by unskilled hand with excess bleeding may lead to ovarian short down and scarring.
Another rare case and an unexplainable cause of anovulation. Some women cease menstruating and begin menopause before normal age. It is hypothesised that their natural supply of eggs has been depleted. A majority of cases occur in extremely athletic women with a long history of low body weight and extensive exercise.
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