By Zaira Salvador BSc, MSc (embryologist), Ana Mª Villaquirán Villalba MD, MSc (gynecologist) and Mark P. Trolice MD, FACOG, FACS, FACE (reproductive endocrinologist).
Last Update: 09/24/2018

The womb or uterus is, along with the ovaries, the most important organ of the female reproductive system. Its function is activated thanks to the influence of sex hormones, which play a major role on the menstrual cycle. Moreover, it is home for the developing baby during the 9 months of pregnancy.

Morphological and/or functional abnormalities in the uterus can lead to female infertility.

Depending on the seriousness or the type of abnormality, the woman may experience issues in achieving pregnancy or carrying a child until birth, to the point that she may have no choice but to give up on her dream of getting pregnant and delivering a child.

Uterine causes of female infertility

Uterine anomalies can be present from birth (congenital) or appear during adulthood.

In either case, uterine factor infertility (UFI) is likely to lead to sterility/infertility issues of varied severity in the affected woman. For example, it is possible that an embryo is able to attach to your womb, but that it cannot lead to an ongoing pregnancy. Oftentimes, this type of anomaly ends up in recurrent miscarriages.

In short, the following is a classification of the most common types of uterine causes of infertility in females:

Müllerian duct anomalies

They are caused by anomalies during fetal development, particularly between weeks 8 and 17 of pregnancy.

The name Müllerian duct anomalies, also known as uterine anomalies or malformations, is due to the fact that the origin of these abnormalities can be found at the stage where development and/or fusion of Müllerian duct occurs in female babies.

Müllerian ducts are a pair of structures of embryonic origin that develop into the uterus (womb), Fallopian tubes, cervix, and part of the vagina during embryogenesis.

Uterine anomalies that can be present in young girls from birth due to defects in the development of Müllerian ducts are listed below:

Müllerian agenesis
The development Müllerian ducts is interrupted at some stag, which result in the absence of uterus. It is also known as Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome.
Arcuate or septate uterus
Due to defects in the lateral fusion of the Müllerian ducts. As a consequence, the uterus develops with a septum that divides it in two.
Unicornuate uterus
Only one Müllerian duct develops fully, which causes the uterus to have half the normal size. Only one Fallopian tube develops.
Bicornuate uterus
The fusion process of the Müllerian ducts is not fully completed. The result is a heart-shaped uterus.
Uterus didelphys
Also known as uterus didelphis or double uterus, Müllerian ducts finish their development, but don’t fuse together, which results in two independent uterine cavities, with two cervices and two vaginas.

Oftentimes, women with uterine anomalies do not realize that they have one until they undergo an ultrasound scan in their first gynecological consultation.

Müllerian duct anomalies are rarely accompanied by symptoms, but in some cases they may come with pelvic pain or absence of menstrual periods (amenorrhea).

Check out this for more information: What Are Müllerian Duct Anomalies? – Classification with Pictures.

Synechiae

Uterine synechiae are adhesions or lesions that occurs in the walls of the uterus, causing morphological alterations.

This pathology is known as Asherman’s syndrome and the causes are varied:

  • Previous D&C procedures that may have caused damage to the uterine wall
  • Bleeding after a C-section or vaginal birth
  • Myomectomy or fibroid removal surgery
  • Endometritis (infection of the endometrium)

Contrary to Müllerian duct anomalies, the Asherman’s syndrome is an acquired cause of female infertility.

Tumors

Usually, tumors that appear in the uterus are benign. The following are the most common ones:

Fibroids
Tumors that form in the muscular layer of the womb: the myometrium. Out of the different types of fibroids, the submucosal is the one that can alter the morphology of the uterine cavity and cause infertility.
Adenomyosis
The inner lining of the uterus (endometrium) breaks through the muscle wall of the uterus (myometrium).
Uterine polyps
Endometrial tissue that grows outside the uterine cavity and difficults embryo implantation.

Anomalies of endometrial origin

The endometrial or uterine lining is, as the name suggests, the inner layer of the womb, where embryo implantation occurs.

The endometrium has a proliferative nature. As such, it changes as a response to hormone levels of estrogen and progesterone, increasing its thickness as the menstrual cycle comes to its end.

For this reason, alterations in the endometrial lining can affect embryo implantation and cause female infertility. Some of these alterations include:

Endometritis
Systemic inflammation of the endometrial lining due to infections caused by microorganisms like chlamydia, mycoplasma, gonococcus, or streptococcus.
Endometrial atrophy
The endometrial lining is too thin or even absent due to the absence of estrogens in the organism. It may be due to primary or secondary ovarian failure.
Endometrial hyperplasia
Increased endometrial thickness due to overstimulation caused by too high estrogen levels. The cause may be due to alterations in the functioning of the ovaries or anovulatory cycles.

Endometrial thickness varies during the cycle. Having the right thickness at each phase is crucial, especially if you are trying to get pregnant.

Get more info by clicking the following link: What’s the Role of the Endometrium? – Function & Thickness.

Treatment

In cases of UFI, the first thing your doctor will do is to evaluate if it is still possible for you to recover fertility with a pharmacological or surgical treatment.

Should this not be possible, that is, if pregnancy is not achieved even after surgery, you may have no alternative but to turn to Assisted Reproductive Technology (ART) to have a baby.

Pharmacological treatment

Infections that cause acute or chronic endometritis are usually treated with antibiotics based on a previous bacteriological evaluation.

In case trophic alterations of the endometrium are present, a hormone treatment based on female sex hormones like estrogens, progesterone, and FSH is effective to improve endometrial thickness.

Surgery

It is usually the first option in cases of Müllerian duct anomalies. The following are the different surgical procedures used to treat uterine anomalies:

Hysteroscopy
To correct septa in the uterus. It is used to remove small submucosal fibroids as well as synechiae.
Laparoscopy
Used in the same cases as hysteroscopy but when the procedure is expected to be more challenging. Also, for the resection of horns with malformations in order to avoid the complete removal of the uterus (hysterectomy).
Gynecological surgery
In those cases where using endoscopic techniques is not possible. For instance, behind the presence of large subserosal fibroids.

In most cases, once the uterine abnormality has been surgically removed, the pregnancy success rates, both naturally and via fertility treatment, increase substantially.

Fertility treatments

In case a fertility treatment was needed to achieve pregnancy, your doctor will consider whether pregnancy is possible by means of Intrauterine Insemination (IUI) or via In Vitro Fertilization (IVF):

IUI
After processing the sperm sample, it is inserted into the uterine fundus, as it occurs during intercourse. Prior to this day, the woman undergoes mild ovarian stimulation to enhance the pregnancy chances.
IVF
The woman is stimulated using fertility drugs to cause the production of multiple mature eggs at the same time. Then, they are fertilized in the laboratory using the partner’s sperm if possible, or donor sperm. The resulting embryos are transferred back to the womb of the intended mother after a few days of embryo culture.

If you need to undergo IVF to become a mother, we recommend that you generate your Fertility Report now. In 3 simple steps, it will show you a list of clinics that fit your preferences and meet our strict quality criteria. Moreover, you will receive a report via email with useful tips to visit a fertility clinic for the first time.

Using IUI or IVF will depend on factors such as the cause of infertility, age, sperm quality, egg count, etc.

You may also enjoy some further information reading this: Intrauterine Insemination or In Vitro Fertilization?

Surrogacy

Surrogacy, also called surrogate motherhood, is the unique reproductive option for women who don’t have a womb or have a serious Müllerian duct anomaly that prevents pregnancy.

Thanks to surrogacy, the pregnancy is carried by another woman (the gestational carrier) until birth. In countries where this technique is allowed, the intended or commissioning parents become the rightful parents right after delivery.

If the intended mother is able to contribute her eggs because she still has functional ovaries, the baby born via surrogate will be biologically hers. Should this not be possible, donor eggs would be used. By no means will the eggs of the surrogate be used.

FAQs from users

What are the different types of surrogacy?

By Mark P. Trolice MD, FACOG, FACS, FACE (reproductive endocrinologist).

There are two types of surrogacy:

  • Traditional surrogacy involves the woman who will carry the pregnancy also to be the source of the egg. She usually will ovulate naturally and undergo intrauterine insemination (IUI). Countries vary in their laws overseeing this arrangement so it is imperative that you consult, in advance of your treatment cycle, with an attorney who is well versed in this area.
  • IVF surrogacy is the process of using an egg donor and a separate gestational carrier. Following hormonal stimulation of the egg donor and egg retrieval, the eggs are fertilized with the sperm of one or both partners in a reproductive laboratory through IVF. The embryo is then transferred into the gestational carrier’s uterus, previously prepared hormonally to synchronize optimal receptivity. The resulting baby is genetically unrelated to the carrier.

Can obesity increase the chances of having adenomyosis?

By Ana Mª Villaquirán Villalba MD, MSc (gynecologist).

Adenomyosis, also known as endometriosis interna, is a uterine condition that causes tissue from the inner layer of the uterus (endometrium) to grow in its muscle layer (myometrium). The causes of this condition are unclear, but we know that it is dependent on the hormone estrogen. Amongst the factors that increase the chances for it to develop, we can find having had at least one pregnancy, and previous surgery to the uterus (C-section, D&C, hysteroscopy, etc.). It is associated with age as well, especially in women over 40. Certain types of adenomyosis can only me detected using special techniques such as 4D ultrasound or MRI. In the mildest cases, there exist few treatments with proven effectiveness, and there is still no proof that it diminishes the pregnancy rates of patients. However, in severe cases like T-shaped uteri, it requires surgery through hysteroscopy.

What is absolute uterine factor infertility?

By Zaira Salvador BSc, MSc (embryologist).

Absolute uterine factor infertility (AUFI) is defined as a type of female infertility that is 100% due to conditions that originate in the uterus and cause the woman to be childless.

Can a woman have a baby without a womb?

By Zaira Salvador BSc, MSc (embryologist).

No, it’s not possible. Embryo implantation cannot take place if there’s no uterus and subsequently uterine lining to attach to. The only option for these women is to use a gestational surrogate.

Suggested for you

When a woman is trying to conceive, having a functional, healthy womb is essential. But having a good ovarian reserve, as well as egg quality, is crucial too. To learn more about this, read: How Many Eggs Does a Woman Have? – Your Egg Count by Age.

To get a much deeper insight on all the fertility treatments available today to get pregnant, continue reading about them here: What Are Infertility Treatments? – Definition, Types & Costs.

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Authors and contributors

 Zaira Salvador
BSc, MSc
Embryologist
Bachelor's Degree in Biotechnology from the Polytechnic University of Valencia (UPV). Embryologist specializing in Assisted Procreation, with a Master's Degree in Biotechnology of Human Assisted Reproduction from the University of Valencia (UV) and the Valencian Infertility Institute (IVI). More information
License: 3185-CV
 Ana Mª Villaquirán Villalba
Bachelor's Degree in Medicine from the University of Valle, Colombia. Specialist in Obstetrics & Gynecology. Master's Degree in Human Reproduction from the University of Valencia and IVI. Currently, she is the medical director of Tahe Fertilidad. More information
License: 303007571
 Mark P. Trolice
MD, FACOG, FACS, FACE
Reproductive Endocrinologist
Mark P. Trolice is the Director of Fertility CARE – The IVF Center and Clinical Associate Professor in the Department of Obstetrics & Gynecology (OB/GYN) at the University of Central Florida College of Medicine. He is Board-certified in REI and OB/GYN, and maintains annual recertification. His colleagues select him as Top Doctor in America® annually, one among the top 5% of doctors in the U.S. More information
License: ME 78893
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