Female Subfertility
Subfertility may be due to problems with one or both partners.

  • Natural female fertility seems to decline quite rapidly after the age of 35, but this is just an average and the actual point of decline for any individual may vary significantly.
  • Increasing maternal age occurs with increased obstetric risks and risk of miscarriage. This should be noted by women who choose to delay their family. Some of the causes of failure of ovulation are relative rather than absolute which is why the term subfertility may be preferable, and these include problems of lifestyle. Infrequent ovulation carries a poor prognosis for conception, but is not a total bar. Causes of female infertility Disorders of ovulation They may occur at the level of pituitary or hypothalamus as well as at the level of the ovary. Pituitary tumours will displace or destroy normal tissue , and the production of folliclestimulating hormone (FSH) and luteinising hormone (LH) are often the first to be affected.
  • Sheehan’s disease is pituitary infarction following postpartum haemorrhagic shock.
  • Hyperprolactinaemia may present with galactorrhoea or amenorrhoea. The control of prolactin is unlike the other releasing factors in that it is controlled by an inhibiting rather than a releasing factor from the hypothalamus into the hypothalamic-pituitary portal circulation. It is also released in response to thyrotrophin-releasing factor, as is thyroid-stimulating hormone (TSH), and so it is elevated if thyroxine is low.
  • The pituitary gland may be responsible for other disorders such as Cushing’s syndrome.
  • A number of chromosomal disorders result in inadequate ovaries and usually primary amenorrhoea. These include Turner’s syndrome in which the ovaries are just streaks. The condition may be a mosaic. In testicular feminisation there is primary amenorrhoea. The karyotype is XY but there is androgen insensitivity. XXY or Klinefelter’s syndrome appears as a male. The XXX karyotype is sometimes called super-female, but is anything but super.
  • Premature ovarian failure or premature menopause causes secondary amenorrhoea. Premature ovarian failure occurs in about 1% of women and, in the majority of cases, no cause is found.
  • Polycystic ovarian syndrome is usually, but not always, associated with obesity. Sclerocystic ovaries fail to ovulate but they can be very sensitive to clomifene. Problems of tubes, uterus or cervix
  • The Fallopian tubes are delicate structures whose cilia waft the ovum, or even early embryo, to its destination for implantation – more correctly called nidation. Damage to the tubes may occur as a result of infection: A history of pelvic inflammatory disease (PID) is highly suggestive of damage to tubes. A medical or spontaneous abortion can lead to infection of retained products of conception. Postpartum infection can also affect fertility. Previous Caesarean section does not impair fertility. Infection with an intrauterine contraceptive device (IUCD) in situ is also less common nowadays. They are rarely used in the nulliparous and modern devices are changed after 5 years, whereas the worst infections were often with plastic devices that had been in place for many years. However, insertion of an IUCD is a high-risk time for introducing infection.
  • Sexually transmitted diseases may cause infertility, largely through associated PID. Chlamydia and gonorrhoea are the most important.
  • Infection may be less direct, and spread from appendicitis is possible, even without overt peritonitis. Risk factors include: Late diagnosis Having the disease before puberty – as the peritoneum in a little girl is less extensive and does not wall off the infection so readily
  • Female sterilisation operations involve disruption of the tube and results of attempted reversal are poor. Laparoscopic proof of patency of the tubes is not evidence that they function normally.
  • Infection can also damage the uterus.