Infertility is one of the most urgent problems of modern medicine. The impossibility of conception is noted in 15-20% of married couples. According to the WHO definition, a marriage is considered infertile if pregnancy does not occur with regular sexual activity (at least 4 times a month) for a year without the use of contraceptives. What to do if the spouses are unable to conceive a child? Where to start the survey? A gynecologist tells Goodshapetips about this.
In 40-50% of cases, the causes of infertility in marriage are associated with impaired male reproductive function, therefore, the examination should always begin with a spermogram! In the spermogram determine:
semen volume (normally more than 1 ml),
total sperm count (in 1 ml – more than 20 million),
the number of active-motile and normal spermatozoa (at least 50%),
white blood cell count (0-1 in view).
Recently, given the increasing role of the immune factor of “male” infertility, WHO recommends that as a routine screening conduct an extended spermogram, including a MAR test (mixed antiglobulin test, mixed antiglobulin reaction) for the presence of antisperm antibodies (ASAT). They cover the spermatozoa, reducing their viability and mobility.
If deviations in the extended spermogram are detected, an in-depth examination is performed to determine the causes of spermatogenesis disorders (morphological and bacteriological analysis of sperm, examination blood for infections definition of hormones, etc.). Examination and treatment of men is carried out by an andrologist or urologist.
At the next stage, the woman needs to exclude endocrine pathology, which is the second most common cause of infertility in marriage (30%). For this it is necessary to carry out the following procedures:
ultrasound examination of the pelvic organs, it allows you to evaluate the function of the ovaries: the presence of a dominant follicle, corpus luteum, signs of ovulation that has occurred;
measurement of rectal temperature within 3-6 monthsit provides indirect information about endocrine dysregulation;
hormonal examination: determination of plasma concentration of luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, estradiol (E2), testosterone, progesterone, cortisol, 17-hydroxyprogesterone, dehydroepiandrosterone, TSH, T3, T4.
The most common causes of endocrine infertility are:
“polycystic ovary syndrome” (PCOS) is a dishormonal disease that leads to the formation of a dense membrane around the ovaries, preventing the release of an egg (ovulation). PCOS is characterized by the absence menses (amenorrhea) or infrequent or irregular periods, excess body hair growth, obesity.
An ultrasound examination reveals a bilateral increase in the ovaries by 2-6 times compared with the norm. In the blood, there is an increase in LH, a normal or elevated level of FSH, an increase in the ratio of LH and FSH, a normal or low level of estradiol.
Treatment is selected individually and is carried out either with the appointment of hormone therapy (estrogen-progestin drugs, ovulation stimulants), or surgery is performed: wedge resection or ovarian cauterization.
“luteal phase deficiency” which is diagnosed according to basal temperature and hormonal profile. The treatment for this disorder is hormonal.
ovarian failure (Shereshevsky-Turner syndrome, resistant ovary syndrome, ovarian exhaustion syndrome), in which estrogens are not produced by the ovaries; at the same time, the level of gonadotropins increases and amenorrhea is noted. So far, the treatment of infertility in this group of patients is unpromising.
hyperprolactinemia (high levels of prolactin in the blood). To determine the tactics of treatment in such cases, it is necessary to do computed tomography (CT) of the Turkish saddle.
Causes of hyperprolactinemia can be:
pituitary microadenoma, for the treatment of which Parlodel is prescribed with careful monitoring of an obstetrician-gynecologist, neurosurgeon and oculist;
pituitary macroadenoma, the presence of which involves surgery and / or radiotherapy;
functional disorders, corrected by the appointment of Parlodel;
Pregnancy after endometriosis and fibroids
Next, you need to exclude tubal-peritoneal infertility, caused by a violation of the patency of the fallopian tubes against the background of adhesions in the small pelvis. The main reasons are:
inflammatory diseases of the genital organs,
intrauterine manipulations (abortions, diagnostic curettage, the introduction of an intrauterine device, etc.),
Infectious screening when examining a couple with infertility should include:
vaginal smear for flora, which allows you to assess the presence of inflammation, as well as to identify a number of pathogens (Trichomonas, candida, gonococcus);
examination for the presence of chlamydia, ureaplasmas, mycoplasmas, herpes simplex viruses (HSV), cytomegalovirus (CMV) using PCR diagnostics (polymerase chain reaction) or enzyme immunoassay (ELISA).
With a standard ultrasound examination, the adhesions themselves are extremely rare. Only in combination with special ultrasound tests can reveal indirect signs of the adhesive process: a change in the anatomy of the internal genital organs, thickening of their contours.
Recently, modern modifications of ultrasound have been widely used: echohysterosalpingoscopy, fertiloscopy, which are highly informative non-invasive methods for detecting tubal-peritoneal factor.
Hystersalpingography to detect obstruction of the fallopian tubes is currently practically not used due to low efficiency and an increased risk of complications.
The main diagnostic method for suspected tubal obstruction is laparoscopy, which allows you to evaluate the localization of adhesions, as well as to separate them. Restoration of reproductive function is noted in 25-45% of cases.
Treatment of the adhesive process in the small pelvis with exclusively conservative methods (lidase, Vishnevsky ointment, prodigiosan, etc.) is considered outdated due to inefficiency!
One of the most common causes of infertility is external endometriosis. This is an overgrowth of tissue similar in structure to the uterine mucosa, in atypical localization: on the peritoneum, in the ovaries, fallopian tubes.
Diagnosis is based on ultrasound data and the determination of a specific tumor marker CA-125, which increases with endometriosis.
With laparoscopy, you can not only see the foci of endometriosis, but also treat them – their thermal destruction, removal of endometrioid ovarian cysts. At the second stage it is necessary hormonal treatment within 6 months.
After the end of the course, pregnancy occurs in 52-73% of women, in the majority – in the first 6-8 months.
Uterine fibroids involves a comprehensive examination using ultrasound, hydrosonography, hysteroscopy, CT to clarify the possibility of using one of the organ-preserving methods of treatment:
laparoscopic removal of a single subserous myoma node (myomectomy),
uterine artery embolization (UAE)in which the arteries supplying the uterus and myoma uterus, a special substance (embolizate) is injected, which completely blocks the blood circulation of the uterus; myomatous nodes decrease and are then released through the cervix.
Folk remedies (upland uterus, Maryin root, etc.) are ineffective for uterine myoma. Rare positive results can be explained by the placebo effect (self-hypnosis).
In case of underdevelopment, absence or after surgical removal of the uterus (the so-called absolute infertility), the program of “surrogate mothers” is recommended. In this case, the eggs and sperm of an infertile couple are used. The resulting embryos are transferred into the uterine cavity of a healthy woman – a “surrogate mother”.
In some cases, a woman has an excessive activity of the immune system, in which she develops antisperm antibodies in the cervical mucus that prevent the advancement of spermatozoa. In this case, the partner’s spermatozoa are perceived as foreign and destroyed. In such circumstances conception is very difficult.
To study compatibility, a test should be performed to determine sperm motility (Shuvarsky test, Kurzrock-Miller test, Kremer test), as well as an analysis to determine the titer of antisperm antibodies in cervical mucus (indirect MAR test).
The most modern method of treating various types of infertility, including incompatibility of partners, is artificial insemination:
fertilization in vitro (in vitro) wife’s eggs or a donor egg with the husband’s or donor’s sperm, followed by the transfer of embryos into the mother’s uterus (in vitro fertilization – IVF);
injection of sperm into an egg using microsurgical instruments in vitro followed by transfer of embryos into the mother’s uterus (intracytoplasmic sperm injection – ICSI).
The efficiency of in vitro fertilization in the world reaches 30-40%.
Sometimes a psychological factor acts as the cause of infertility, when stress or previous emotional trauma causes a woman’s conscious or unconscious reluctance to have children. Doctors divided these women into three groups:
the first included women with a weak psychological blockade of conceptionim for offensive pregnancy it is enough to establish relationships in the family and find peace of mind;
the second group included the fair sex with a more persistent blockadeprovoked by frequent stressful situations in the family, at work (“career infertility”);
the third group included women whose infertility is considered persistentsince it is caused by psychogenic fears, for example, fear of upcoming childbirth, fear of changing appearance, sometimes the onset of pregnancy is “slowed down” by memories of previous abortions, painful childbirth.
To eliminate such blocks, you need to contact a psychologist. In any case, women who cannot get pregnant for a long time are advised to remove the importance from the problem and stop unsuccessful attempts to get pregnant for a while, relax and live for their own pleasure. For many, the problem will be solved by itself!