2 Literature Review
2.2 Aetiology
The causes of infertility are variable with
regard to the social and demographic profile of the individuals. The WHO
provides a statistical analysis about the causes of infertility.
This study will concentrate mainly on the
female pelvic causes of infertility rather than including all the general
causes.
2-2-1.Uterine factors
Uterine factors represent 2-3% of the
incidence of infertility and intrauterine pathology is the much more common in
infertile women (40-50%) (Niknejadi & Haghighi 2012), therefore, female
reproductive tract should be examined for any probable causes of infertility
first part of the reproductive tract is the cervical canal. An irregular
cervical mucus component, which interacts with the sperm, is not often regarded
as one of the leading causes of infertility. However, the postcoital test
(pct), the measurement and observance of the presence of the active sperm in
the cervical mucus is still one of the infertility evaluation tests. Coussein
and Vlahos (2012) identified that the uterine abnormality is relatively
uncommon causes of female reproductive failure. Uterine malformation caused by mu¨llerian fusion defects are the most
common types of congenital anomalies of the reproductive system (Homer et al 2000).
This type of anomalies may occur during the Mu¨llerian
developmental process (Saravelos, Cocksedge & Li 2008), (Wold, Pham, and Arici 2006).
Furthermore, American Society of Reproductive Medicine developed specific
calcification of the uterine malformation regarding the degree of failure of
development of the Mu¨llerian duct. This calcification has become the most
widely accepted and used globally, their calcification consist of seven
regions
(1) Mu¨llerian hypoplasia which may include
the vagina, the cervix, the fundus, the tubes, or combined
(2)
Unicornuate uterus hypoplasia of one of the two Mu¨llerian ducts and this could
be subdivided according to the present or absence of the rudimentary horn
(3)
Didelphys uterus (failure of lateral fusion of the vagina and uterus Mu¨llerian
ducts)
(4) Bicornuate uterus (incomplete fusion of
the uterine horns at the level of the fundus), which may be partial or
Complete.
(5) Septate uterus (absent or incomplete
resorption of the uterovaginal septum), ether Complete or Partial
(6) Arcuate uterus (a mild indentation at
the level of the fundus)
(7) Diethylstilbestrol (DES) exposed uterus
(T-shaped uterus resulting from DES exposure of the patient in utero)
Inthis calcification, there is no specific
procedure or criteria for the diagnosis of each anomalies and the result will
depend on the clinician impression (Woelfer et al 2001).It is important to know
that this calcification exclude some of the other anomalies such as cervical atresia, vaginal anastomosis and
vaginal septum (Pavone et al 2006).The diagnosis and indications for the
treatment vary according to the different types of malformation. The septet
uterus is the most common uterine anomalies among the other kind of anomalies
(Homer et al 2000).
Calcification of the uterine malformation according to the American
Society of Reproductive Medicine ( Lee
& Ku 2011).
Repair of these
Müllerian anomalies or Caesarean section may result in synergy Uterine
synechiae or uterine atresis and these can be defined as the presence of
intrauterine adhesions (IUAs) or combined of fibrotic tissue can be either
partial or complete (serious and severe adhesions resulting in menstrual
dysfunction and infertility) (Ahmadi & Javam
2014).Imaging methods used in the
diagnosis of these anomalies will be discussed in details in the next section.
2.2.2.
Tubal-peritoneal factors.
In about 25–35 % of women, the risk factors
for infertility are the result of the tubal peritoneal pathology. Pelvic
inflammatory disease (PID) is the most common disease .In more than half of the
these cases, tubal peritoneal factor infertility may occur as a result of
ectopic pregnancy, pelvic PID, endometriosis, and pelvic or adnexal
adhesions. These factors may reveal some
sort of pathology but cannot adequately specify the diagnosis (Coussein and
Vlahos 2012). The outer end or ampullar section is responsible for
Fertilization and the Fallopian tubes are responsible for oocyte uptake. For this reason, any change in anatomical or physiological aspect of the tubes is usually associated with the
cause of the infertility. For example, contraceptives have a certain effect on
fertility. Brugo-Olmedo, Chillik and
Kopelman (2002) also emphasised on this fact that there is an association
between endometriosis and infertility. Their study demonstrated approximately 48%
infertile patients were found to have endometriosis compared with 5% of the
normal fertile patient.Also, another study also found that 30-50 % of the
patient with endometriosis were infertile (Bulletti et al 2010). Endometriosis is actually the condition which
is identified as the presence of endometrial tissue, stroma or glandes out of
the uterine cavity, which leads to the onset ofchronic inflammatory reaction.
It may affect about5-15% of women in their reproductive period. Bulletti et al (2010) did an extensive research
to explain the relation between infertility and endometriosis. They found that the
prevalence of infertility in the females with endometriosis may relate to
several situations such as anatomical disorders, anovulation and changing of
the luteal phase. Abrao (2013) was also of the similar opinion. Some authors
have identified that the changes in receptivity of endometriosis may affect on
uterine implantation
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