Fertility Disorders
Numerous studies have shown that 10 -15% of couples suffer
with a fertility disorder. These are mainly due to: a) ovulatory
dysfunction (OD) generally caused by hormonal disorders and
b) inflammatory processes usually secondary to genital tract
infections (GTI), mainly sexually transmitted diseases.
Ovulatory dysfunction is the most common disorder diagnosed
in infertile couples (37%) and is predominantly associated
with irregular menstrual cycles (IC). Irregular cycles are
present in 10% of women, but having an irregular cycle doesn’t
necessary mean having an ovulatory dysfunction. We have been
able to show according to the BOM charting that 43% of women
with irregular cycles present an ovulatory dysfunction, which
can be characterized by the absence of ovulation or abnormal
ovulatory activity, as seen in cycles with short or abnormal
luteal phases. On the other hand, young nuliparous women with
regular cycles, (i.e., cycle length between 25 and 36 days)
may also present an ovulatory dysfunction as identified by
BOM charts (32).
Ovulatory Dysfunctions
Endocrinological disorders
Endocrinological disorders are the most common cause of ovulatory
dysfunction (27, 28, and 32). They can be divided into hypothalamic
disorders, pituitary disorders, general endocrine disorders and
adrenal and/or ovarian disorders (1).
Hypothalamic disorders
Hypothalamic disorders (e.g., anorexia nervosa) are characterized
by hypo-estrogenic cycles with the persistence of “dry”
days. Amenorrhea may be present. This type of cycle is also seen
in athletes, although in this case it should be considered as a
normal part of the continuum. In the later case there is a frequent
return to regular ovarian cyclic activity as observed within three
months of less strenuous physical exercise. However, some of the
young women in this category may further develop an anorectic state
and despite discontinuation of strenuous physical activity they
do not return to normal cycles.
Hypoestrogenic cycles: Anorexia athletes
Ovarian-Adrenal dysfunctions
Adrenal and ovarian abnormalities are the most frequent cause of
ovarian dysfunctions. The most common is the polycystic ovarian
syndrome: an ovulatory dysfunction caused by hyperandrogenemia.
In these women, irregular cycles are usually present, early after
menarche (21, 22, 28).
Polycystic Ovarian Syndrome(PCO)
They can also complain because of acne and/or hirsutism
as well as increased body weight and mood changes.
Reasons for consulting a physician in women with
PCO (number of patients = 229, more than one reason for some patients)
Cycles are characterized by a hyper estrogenic state
where a continuous fertile type of mucus pattern is identified or
mucus patches are present. Cycles can be ovulatory, with a long
follicular phase or anovulatory.
Hyperestrogenic cycles
Doubtful peak
Long follicular phase
Anovulatory cycles
When a young woman complains because of menstrual
abnormalities, the teaching of self-awareness of fertility in order
to identify ovulatory dysfunctions is very important in order to
be able to rule out metabolic conditions such as hyper insulinemia.
Our studies have shown that in 86% of women who present with menstrual
irregularities, an endocrine abnormality is present of which hyperandrogenemia
is the most common (80% of cases (32). It is important to note that
an impaired insulin response to oral glucose tolerance test is a
commonly (80% of time) associated condition in these women (36).
This requires treatment to prevent the occurrence of type II diabetes
mellitus (22). Proper care, including diet, exercise and medical
treatment will restore normal cyclical ovarian activity. Women who
know how to recognize their mucus symptoms will be able to follow
the improvement of their endocrine abnormality.
Abnormal insulin response to oral glucose tolerance
test in PCO patients as compared to normal women at 0 and 180 minutes
(number of women = 94)
Hypothyroidism is a less frequent (about 2%) (32) cause of ovarian
dysfunction but it and hyperthyroidism, have to be considered. Different
types of ovarian dysfunction can be observed in patients with thyroid
disorders. Menorrhagia (15) is frequently associated to hypothyroidism.
Although there is no specific pattern of ovarian activity associated
to these endocrine abnormalities they should always be kept in mind
and eliminated as a possible cause.
Menorrhagia
Women with ovulatory dysfunctions associated to irregular cycles
and abnormal mucus patterns will not usually resume normal cycling
spontaneously without appropriate treatment. Follow up studies have
shown that in the absence of treatment these conditions only worsen
with time (22, 23).
Other conditions, such as premature ovarian failure may also be
a cause of fertility disorders presenting with irregular mucus patterns
in response to fluctuating estrogen levels. These conditions are
also observed in the perimenopausal period, where some cycles show
an ovulatory pattern. As the condition worsens, anovulatory cycles
will predominate.
In fertile women, naturally occurring midcycle cervical
mucus studied with scanning electron microscopy, shows an
arrangement of parallel fibers oriented along the main axis
of the mucus sample, probably corresponding to the S subtype
(2). Sperm transport maybe facilitated by this normally occurring
condition. At midcycle, cervical mucus is greater in quantity,
has more mucin and less protein and has higher water content
than in the luteal phase (19). This increase in the amount
of mucin in the cervical canal, because of its hydrophilic
character, probably functions to retain or hold water in place
at the cell surface, keeping in this way the cervical canal
patent for sperm migration. Also this increase in mucin at
a period of high water content could help in the protection
of the cervix. Pathogens or other toxins may be trapped by
the mucin thus preventing their entry into the uterus and
Fallopian tubes (12). Future research is needed to establish
mucus ultra structure and biochemical properties under different
endocrinological abnormalities. Also, the function of the
specific mucins and mucus types remains to be determined as
well as their possible alterations. |
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