Female Fertility

Question 1

Definition of infertility

Answer 1

Lack of pregnancy
after one year of unprotected intercourse
If over the age of 36, fertility investigations will take
place after 6 months of unprotected intercourse.

Question 2

Factors involved in successful conception

Answer 2

• Release of a healthy, non-damaged oocyte.
• Production of sperm with adequate motility,
  DNA integrity, count and morphology.
• Adequate transport of sperm and egg to the
  fallopian tubes where fertilisation occurs.
• Penetration of the sperm into the oocyte.
• Implantation of the embryo
  into a healthy uterus lining.
• Normal development of the embryo into a foetus.

Question 3

Structural abnormalities — females

Answer 3

• Cervical stenosis: Narrow / closed cervix.
• Uterine septum: Poor environment for
  embryo to implant due to poor vascular
  supply of blood (and hence nutrients).
• Uterine polyps and fibroids: May disrupt
  implantation. Usually due to oestrogen dominance.
• Fallopian tube / obstruction: Pelvic inflammation, STDs
  (e.g., chlamydia), endometriosis (scar tissue that can obstruct the
  fallopian tubes), abdominal / pelvic surgeries, ectopic pregnancy.
• Ovarian cysts: Can cause infection and scars of fallopian tubes.

Question 4

Hormonal issues - female

Answer 4

• Polycystic Ovarian Syndrome — elevated androgens, anovulation,
  irregular cycles, ↓ uterine lining development, implantation issues.
• Hyper or hypothyroidism — irregular cycles, ovulatory
  disorders, miscarriage, pre-term birth, pre-eclampsia.
• Amenorrhoea— due to hypothalamic dysfunction, pituitary tumours,
  excess exercise, undereating, low BMI, high stress (ACTH / cortisol).
• Obesity / insulin resistance — lack of ovulation / ↑ androgen levels.
• Premature ovarian failure— loss of ovarian function
  < 40 due to chemotherapy / radiotherapy, genetic,
  SLE. Rare condition and can be overcome with ART

Question 5

Oestrogen:

Answer 5

• Highest in first half of the
  menstrual cycle.
• Creates proliferative
  endometrium.
• Important for ovulation.

Question 6

Progesterone

Answer 6

• Highest in second half of
  menstrual cycle.
• Maintains secretory endometrium.
• Important for implantation and
  the survival of the embryo.

Question 7

Oestrogen and Progesterone

Answer 7

• Both hormones are produced in the ovaries, adrenals and placenta.
• Both are stored in the adipose (fat) tissue.
• However, women are more
  susceptible to oestrogen dominance
  (i.e., high oestrogen: progesterone ratio).

Question 8

Symptoms and signs of oestrogen dominance

Answer 8

• Fibroids and uterine polyps
• Endometriosis
• PCOS
• Heavy bleeding and clotting
• Fibrocystic breasts
• Tender and swollen breasts
• PMS and irritability
• Headaches
• Shorter menstrual cycles
  (esp. luteal phase)
• Poor memory
• Brain fog
• Hypothyroidism
• Hair loss
• Insomnia
• Fatigue
• Mood swings
• Gallbladder disease
• Swelling and bloating
• Miscarriages

Question 9

Symptoms and signs of progesterone dominance

Answer 9

• Breast tenderness
• Water retention
• Bloating
• Shortness of breath
• Dizziness
• Drowsiness / lack
  of concentration
• Sense of physical instability
• Long luteal phase
• Discomfort or pain in the legs
• Decreased libido
• Anxiety / panic attacks
• Weight gain
• Insomnia
• Light periods

Question 10

Optimising oestrogen / progesterone ratio

Answer 10

• Reduce stress — regular healthy meals, optimise
  sleep, ↓ over-exercising, address emotional stressors.
• Optimise liver function — to detoxify excess oestrogen.
• Avoid endocrine disruptors (e.g., home / personal products).
• Avoid alcohol — ↑ oestrogen levels by promoting the induction
  of aromatases and by impairing hepatic oestrogen metabolism.
• Reduce body weight if obese — oestrogen
  is stored and produced in fat cells.
• Optimise digestion and elimination —to excrete excess oestrogen.
• Consider herbs such as Vitex agnus castus.

Question 11

Effect of Medications and drugs on fertility

Answer 11

• NSAIDs (long-term use or ↑ dosage) — inhibit
  ovulation and lower progesterone levels.
• Chemotherapy— damage / depletion of oocytes.
• Antipsychotic medicines — increase prolactin
  levels leading to anovulation and amenorrhoea.
• Corticosteroids — suppress immune function, affect gut
  microbiome, elevate blood pressure and blood sugar levels.
• Antihistamines— dry the mucous membranes.
• Toxic effects of tobacco, recreational drugs, marijuana (shown
  to correlate with poorer quality oocytes) and other medical drugs.

Question 12

Environmental effect on fertility

Answer 12

• Excessive radiation (mobile phones, x-rays and
  radiotherapy, frequent flying) — damages oocytes.
• Environmental toxin exposure (e.g., mercury, lead, phthalates,
  solvents)— associated with infertility and miscarriage.
• Chronic alcohol consumption — leads to diminished
  ovarian reserve and ovulatory dysfunction.
• Caffeine— increases cortisol production,
  slows COMT (→ oestrogen dominance).
• Xenoestrogens, pesticides and endocrine disruptors (e.g.,
  plastics, cans, detergents, candles, flame retardants, cosmetics)

Question 13

Immunological factors

Answer 13

Immunological factors ― because a foetus is not genetically
identical to its mother, there are immunological
events that must occur to prevent foetal rejection

Question 14

Example of Immunological factors

Answer 14

• Tissue type compatibility — if mother’s immune
  system responds negatively to paternal HLA proteins,
  this can affect implantation / pregnancy outcome.
• Blood clotting defects — ↑ risk of early / late term loss, risk of
  maternal embolism / stroke, placental blood flow restriction.
• High uterine NK cells — can trigger ↑ TNF-alpha, cytokines (→
  early pregnancy loss). High BPA exposure linked to NK cell activity.
• Autoimmunity— immune system rejects the embryo