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About Fertility
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Female reproductive system |
The Anatomy
A healthy fertile woman has a uterus and ovaries with eggs. The uterus is connected to the ovaries by two fallopian tubes. Her fertile partner makes healthy sperm in his testicles which is then expelled in adequate numbers during ejaculation. This is just the beginning - much more is required to conceive a child.
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Laparoscopic view of ovulation in progress |
Eggs and Ovulation
An egg inside a fluid-filled ovarian follicle is nurtured by the granulosa cells and has to develop and mature during the first 10-14 days of the menstrual cycle (day 1 being the 1st day of the menstrual period). Several follicles are usually recruited during each cycle but only one becomes dominant. That follicle contains an egg destined for ovulation during that cycle.
The Hormones
Granulosa cells surrounding the egg produce nutrients and estrogen which prepare the female reproductive system for conception. The estrogen level should be high enough to build up an adequate thickness of the uterine lining (endometrium) for embryo implantation, to make cervical mucous receptive to sperm penetration, and to induce many other changes in the female reproductive system which facilitate sperm, egg, and embryo transport and implantation. An estrogen signal is also necessary for ovulation. A high level of estrogen in the circulation (above 250 pg/mL) tells the pituitary gland that there is a mature egg in the ovarian follicle. The pituitary then sends a signal in the form of an LH surge (detected by ovulation predictor kits). The LH signal initiates luteinization of the granulosa cells (they can now start producing progesterone) and activates enzymes which digest the wall of the follicle. This, in turn, leads to the follicular rupture and release of the follicular fluid with the egg surrounded by cumulus-granulosa cells (ovulation). The egg is then picked up by the fimbria (finger-like projections) of the fallopian tube and is squeezed by the tubal musculature into the portion of the tube called the ampulla.
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Egg-sperm interaction |
Fertilization
In the meantime, about a hundred million motile sperm deposited during sexual intercourse in the vagina work their way up to the egg in the tubal ampulla. However, sperm transport to a great extent depends on the contractions of the female reproductive system and has relatively little to do with sperm swimming abilities. Only 10% of motile sperm pass through the cervix and enter the uterine cavity and only 1% (or about 1 million) end up in the fallopian tube. That million sperm in the tubal ampulla is necessary to disperse the cumulus of granulosa cells so that ultimately one sperm can fertilize the egg. The egg and the sperm have to be in the fallopian tube at about the same time. The egg cannot wait for the sperm for more than 24 hours and the sperm that spends several days in the female reproductive system loses its fertilizing potential.
Embryo Implantation
The fertilized egg, or pre-embryo, begins to divide and is gradually squeezed by the fallopian tube towards the uterus. It arrives in the uterus 5-7 days after ovulation in the form of a tiny cyst containing a small amount of fluid and surrounded by a layer of about 100 cells. The cyst (a blastocyst) is the same size as the egg and is surrounded by the same membrane (shell) which initially surrounds the egg (zona pellucida). In order to implant, the blastocyst has to digest that shell and create an opening through which it hatches. After hatching, the blastocyst attaches itself to the surface of the endometrium, then burrows under, taking nourishment from the invaded endometrial cells and ruptured blood vessels. The process of attachment and implantation involves Velcro-like molecules called integrins as well as many other substances produced both by the embryo and the uterine lining. Subsequent development of the embryo and continuation of the pregnancy depend on embryo quality and on the intrauterine environment.
How Often Does It Work?
This brief description in many ways over-simplifies the complexity of events that lead to conception and pregnancy. The process of reproduction is extremely inefficient. The fecundity (chances for pregnancy) in a given cycle are low - only between 5 and 25%. They are the highest (about 25%) in women during their late teens and early 20s and decrease to about 5% at the age of 40. Nevertheless, about 8 of 10 couples conceive a child during the first 12 months of attempting pregnancy; the remaining two couples are considered infertile and should be evaluated by a physician specializing in Reproductive Endocrinology/Infertility (RE/I).
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