Normal Menstrual cycle: The length of the menstrual cycle is calculated by counting the number of days from day one of menses (period) until day one of the next menses. Although a 28-day cycle is considered normal, cycle intervals of 21-35 days may also be normal. The normal menstrual cycle is the result of a carefully coordinated interaction between the brain, the pituitary, the ovary, and the uterus.

The normal menstrual cycle can be considered as consisting of 3 parts:

• Follicular phase: When the egg plus the surrounding cells and fluid make up a cyst, which is known as a follicle. The dominant hormone is estrogen and causes the lining of the uterus (the endometrium) to thicken or proliferate.
• Ovulation: When the follicle ruptures and the egg is released.
• Luteal phase: After the follicle ruptures, the cells that originally surrounded the egg undergo changes and form a structure called the corpus luteum. The corpus luteum may exist as a cystic structure of varying sizes and primarily secretes the hormone, progesterone, which causes the endometrium to change and become secretory. The length of the luteal phase is usually 12-14 days.

Abnormal menses and ovulation: Absence of menses (amenorrehea) or menses occurring ar irregular intervals implies absent or infrequent ovulation. Other abnormalities of ovulation are LUF syndrome (luteinized unruptured follicle) and the luteal phase defect.

Tests for determine the ovulation:

• Basal body temperatures;
• Ovulation predictor kits – urinary tests;
• Ultrasound monitoring and measurement of hormones.

Treatment: The initial consideration for the treatment of defects of ovulation is to utilize medications or surgical procedures that restore a normal hormonal environment that will hopefully result in spontaneous ovulation. If this treatment is unsuccessful the other specific treatment is applied:

• Replace, icrease, or decrease the release of Gonaditropin Releasing Hormone (GnRH);
• Replace or increase the release of Follicle stimulating hormone and Luteinizing hormone (FSH and LH);
• Replace or increase Progesterone during the luteal phase;
• Diminished ovarian reserve or premature ovarian failure will require Assisted Reproductive Technologies including donor oocytes.

Cervical factors

During a normal ovulatory cycle, the estrogen that is produced by the cells surrounding the egg causes an increase in the amount of cervical mucus and causes the mucus to become thin and watery. These changes allow the sperm to more easely penetrate and move within the mucus.

Abnormal:
Birth defects involving the cervix, prior treatment of abnormal PAP smear (cryotherapy, laser therapy, cone biopsies) or exposure to specific medications can have an adverse impact upon the cervical mucus.

Tests:

• The postcoital test test is intended to evaluate the interaction between the cervical mucus and the semen. After the couple has intercoutse, the patient comes to the clinic where mucus id removed from the cervz and observed under a microscope.
• pH of the cervical mucus is an important factor for sperm survival. The lowest pH values do not allow the sperm to proceed this first physiological barrier in the female reproductive system.

Treatment: Various hormonal and non-hormonal therapies have been suggested.

• Bypassing the cervix by performing intrauterine insemination;
• Discontinuation of offending medications or adding other medications. Par example: in a case with induction of ovulation to replace CC (clomiphenе citrate) with aromatase inhibitor.

Uterine factors

Normal: A normal uterine cavity is essential to allow implantation of the fertilized egg. The lining of the uterus (endometrium) must be exposed to appropriate levels of estrogen and progesterone in order to adequately development.

Abnormal: Defects of ovulation or exposure to certain medications may interfere with this normal endometrial development. Anatomic problems with the uterine wall or the endometrial cavity may also prevent normal implantation. Such abnormalities include birth defects, intrauterine scarring from prior surgical procedures, or tumors of the uterine lining or uterine wall.

Tests: Hysterosalpingogram (HSG), Sonohysterography, Hysteroscopy.

Treatment:

• Changing the type of medications used to treat abnormalities of ovulation or using additional hormonal therapy can treat inadequate endometrial development;
• Surgical therapy is required for treating anatomical abnormalities.

Tubal factor

Normal: The most important role of the fallopian tubes is to transport the fertilized egg to the uterus.

Abnormal: Any condition that prevents the tube from picking up the egg, prevents the sperm from reaching the egg, or prevents the fertilized egg from reaching the uterine cavity will result in infertility.

Tests: Hysterosalpingogram (HSG), Sonohysterography, Laparoscopy, Laparotomia.

Treatment:

• Surgical therapy – when there is the possibility to reopen blocked tubes and restore normal pelvic anatomy.
• When other procedures are unsuccessful or are felt to have poor potential for success, then Assisted Reproductive Technologies are required.

Peritoneal factors

Normal: The peritoneal cavity is the area in human body that contains the intestines and reproductive organs. The role of the cells that line this cavity in normal reproduction are uncertain; but can be considered to provide an environment where normal development of the egg can occur, where the tube and the ovary can interact to allow the egg to be picked up, and the sperm and egg can interact within the fallopian tube.

Abnormal: These are factors that might interfere with infertility

• The presence of scar tissue (adhesions) that have developed as a result of prior pelvic surgery;
• The presence of scar tissue as a result of prior pelvic infections;
• Endometriosis (the presence of endometrial tissue outside of its usual location within the uterine cavity) may lead to scar tissue that prevents the normal interaction between the tubes and ovaries. Endometriosis also appears to be able to interfere with fertility even when the tubes are open. This interference would appear to be due to inflammatorychemicals that are secreted by endometriosis and in response to the presence of endometriosis.

Tests: Laparoscopy is usually required to diagnose peritoneal factors.

Treatment:

• Surgical therapy is used to treat adhesions;
• Surgical and hormonal therapy can be used in the treatment of endometriosis;
• When other procedures are unsuccessful or are felt to have poor potential for success, then Assisted Reproductive Technologies are required.