What is Infertility?
Barren marriage – the absence of pregnancy in women of childbearing age for 1 year of regular sexual life without the use of any contraceptive means. The frequency of infertile marriage, according to various sources, ranges from 10 to 20%.
Causes of Infertility
The cause of infertility can be abnormalities in the reproductive system in one or both spouses. Infertility in 45% of cases is associated with disorders in the sexual sphere in women, in 40% – in men, in the remaining cases infertility is caused by disorders in both spouses.
In women, primary and secondary infertility are distinguished in the absence of pregnancy in history and in the past, as well as relative infertility when the probability of pregnancy persists, and absolute sterility when the possibility of becoming pregnant naturally is completely excluded (in the absence of uterus, fallopian tubes, ovaries, and also in case of abnormal development of the genital organs).
Psychogenic factors of infertility
Conflict situations in the family, at work, dissatisfaction with sex life, as well as the persistent desire to have a child or, conversely, the fear of pregnancy can cause ovulation disorders that mimic endocrine sterility. Similarly, stress-induced autonomic disturbances can lead to the discoordination of the smooth muscle elements of the fallopian tubes with functional tubular obstruction.
Patients with infertility are prescribed a neuropsychiatric consultation. A specialist can apply tranquilizers, sedatives, as well as psychotherapeutic procedures. In some cases, such therapy is effective without the use of ovulation stimulants.
Infertility Diagnosis
Infertile spouses must be examined simultaneously.
Examination of men begin with the analysis of sperm. If no pathology has been identified, then at this stage no other studies are carried out in the man.
Normal spermogram according to the WHO criteria: the total number of spermatozoa in the ejaculate is not less than 20×106 / ml; mobility – more than 25% of active-mobile ones with direct access after 60 minutes from the moment of receiving the ejaculate; morphology – more than 50% of normal forms; no agglutination; ejaculate volume not less than 2 ml; normal viscosity, pH 7.2-7.8; leukocytes not more than 1.0 x106 / ml.
The postcoital test is used to confirm / exclude immunological infertility associated with antisperm antibodies in a woman, as well as suspected sexual dysfunction. Postcoital test allows to assess the quality of cervical mucus and the number of motile sperm in it after intercourse. If spermatozoa are immobile or perform pendulum movements, the test must be repeated. When re-obtaining negative or doubtful results, additional diagnostic methods are used to confirm / exclude immunological infertility.
The examination of women is carried out in two stages. At the first stage, standard methods of examination are used, which allow pre-diagnosing the 3 most common causes of female infertility: ovulation disorders (endocrine infertility) (35-40%); tubal and peritoneal factors (20-30%); various gynecological diseases that affect fertility (15-25%).
The studies of the second stage are always individual, and the set and use of diagnostic procedures are always determined by the results of the survey conducted at the first stage. At the second stage, the preliminary conclusion is clarified (the nature and severity of the existing pathology).
In 48% of infertile women, one factor of infertility is revealed, in the remaining 52%, two or more.
Standard methods of examination of women (first stage)
Anamnesis
It is advisable to interview women according to the scheme recommended by WHO.
- The number and outcome of previous pregnancies and childbirth, post-abortion and postpartum complications, the number of living children.
- The duration of infertility.
- Used methods of contraception, the duration of their use.
- Extragenital diseases (diabetes mellitus, tuberculosis, pathology of the thyroid gland, adrenal glands, etc.).
- Drug therapy (cytotoxic drugs, psychotropic drugs and tranquilizers).
- Surgery to promote infertility (surgery on the uterus, ovaries, fallopian tubes, urinary tract and kidneys, intestines, appendectomy).
- Inflammatory processes in the pelvic organs and sexually transmitted diseases, the causative agent, the duration and nature of therapy.
- Diseases of the cervix uteri and their treatment (conservative treatment, cryo-or laser therapy, electrocoagulation).
- Galactorrhea and its connection with lactation.
- Epidemic, production factors, bad habits (smoking, use of alcohol, drugs).
- Hereditary diseases in relatives of I and II degrees of kinship.
- Menstrual history (age of menarche, nature of the cycle, its violations, intermenstrual discharge, painful menstruation).
- Sexual function – pain during intercourse.
Objective examination
- Determine growth, body weight and body mass index (BMI) by the formula:
BMI = body weight (kg): [height (m) • height (m)]Normally, a BMI is 20–26 kg / m2. For obesity (BMI> 30 kg / m2), it is necessary to establish the time of its onset, possible causes and speed of increase in body weight.
- Assess the condition of the skin (dry, moist, oily, acne, stretch bands), hairiness, hypertrichosis and its severity (according to the scale D. Ferriman, J. Galwey). In case of excessive hair growth, they specify the time of its appearance.
- Examine the state of the mammary glands (development, discharge from the nipples, volume formation).
- Carry out bimanual gynecological examination and examination of the cervix in the mirrors, colposcopy, cytological examination of smears.
- Conduct an ultrasound of the uterus and ovaries. In case of clinical signs of hyperandrogemia, an additional ultrasound of the adrenal glands is prescribed. It is also advisable to use breast ultrasound to clarify their condition and exclude tumor formations.
A standard examination of the first stage also includes a consultation with a therapist to identify contraindications to pregnancy. When detecting signs of endocrine and mental diseases, as well as malformations, consult the relevant specialists – endocrinologists, psychiatrists, geneticists.
Specialized methods of examination of women (second stage)
Specialized examination methods vary depending on the intended cause of infertility.
Endocrine infertility can be suspected in infertile women with menstrual disorders (oligo, opso-, amenorrhea), clinical signs of hyperandrogenesis, hyperprolactinemia, hypoestrogenia, metabolic disturbances (obesity, marked weight deficit), as well as in illness and Itco-K syndrome, as well as in case of illness and Syndrome-K-disorders (obesity, marked weight deficit), as well as in illness and Syndrome Icene-K-disorders (obesity, marked weight deficit), as well as in case of illness and Syndrome Icene-K, and obesity (obesity, marked weight loss), as well as in case of illness and Syndrome Icene-K, i.e. hypo-, hyperthyroidism, etc.
Diagnosing this form of infertility involves measuring the basal temperature in 2-3 consecutive cycles.
After the establishment of endocrine infertility proceed to clarify its causes. It is advisable to start the examination with determining the level of prolactin. If hyperprolactinemia is detected, it is necessary to exclude a pituitary tumor (macro-, microprolactinoma) and thyroid pathology.
To clarify the condition of the pituitary region perform a radiography of the skull with the visualization of the Turkish saddle. In the absence of changes on the craniogram, a computed tomography or magnetic resonance imaging is additionally prescribed to detect or exclude microadenomas.
Hypothyroidism is excluded based on the determination in the blood of the content of thyroid hormones (T3, T4) and thyroid stimulating hormone.
If the content of prolactin is not increased, it is necessary to determine the basal level of FSH. With its increase, infertility associated with ovarian pathology (primary or secondary ovarian form of infertility) can be assumed.
At normal or low FSH concentrations, hypothalamic-pituitary insufficiency or dysfunction can be suggested, as well as a destructive tumor of the hypothalamic-pituitary area.
Examination of women with endocrine infertility in combination with clinical signs of hyperandrogenemia complements the determination of testosterone and dehydroepiandrosterone sulfate plasma levels.
In obese women, it is recommended to additionally use the standard glucose tolerance test to detect carbohydrate metabolism disorders.
Infertility Treatment
Treatment of endocrine sterility. Hormonal imbalances are normalized by adequately selected treatment of identified endocrinopathies, and in case of obesity body mass correction is indicated.
Treatment supplement the use of drugs that stimulate ovulation. Ovulation stimulants are used not only for endocrine infertility, but also as an independent therapy for infertile women with ovulatory disorders for an unidentified cause (estrogen-progestin drugs, clomiphene, exogenous gonadotropins, GnRH agonists).
For women with endocrine sterility who have not become pregnant within 1 year after hormonal therapy, laparoscopy is recommended to exclude obstruction of the tubes.
Tubal and peritoneal infertility is caused by anatomical and functional disorders of the fallopian tubes, adhesions in the pelvic region, or their combination.
In refining the diagnosis of tubal-peritoneal infertility, laparoscopy with methylene blue chromosalpingoscopy is currently used.
Treatment of tubal-peritoneal infertility. To restore the anatomical patency of the fallopian tubes, operative laparoscopy is indicated. In peritoneal infertility, adhesions are separated and coagulated according to indications. In parallel, detectable concomitant surgical pathology (endometrioid heterotopies, subserous and intramural myomas, retention formations of the ovaries) are eliminated.
Contraindications to surgical treatment of tuboperitoneal infertility: age over 35 years, duration of infertility more than 10 years, acute inflammatory diseases of the internal genital organs; ovulatory disorders that are not amenable to correction, etc.
Currently, in the case of lesions of the fallopian tubes in the isthmic and interstitial parts, as well as in absolute tubal infertility, in vitro fertilization is possible.
Infertility in gynecological diseases can cause endometriosis, uterine myoma, polycystic ovary syndrome, anatomical and functional changes in the uterus, endometrium, cervical factors.
These diseases are diagnosed at the first stage of the survey.
Immunological infertility is diagnosed only after exclusion: tubal-peritoneal infertility; endocrine sterility and intrauterine pathology. After exclusion of all factors proceed to the formulation of postcoital test. The frequency of immunological infertility is 2%.
Treatment of immunological infertility. In women, it is preferable to use assisted reproductive technologies – artificial insemination with the husband’s sperm or in vitro fertilization. To achieve spontaneous pregnancy, treatment of latent infection of the genital tract is carried out. Within 2-3 days of the preovulatory period, preparations of pure estrogens are prescribed, it is recommended to use a condom for at least 6 months (weakening the sensitization of female immunocompetent cells to sperm antigens with prolonged absence of contact), and pregnancy often ceases after mechanical contraception ceases.
The proposed use of glucocorticosteroids did not get widespread due to the high frequency of adverse reactions and extremely low therapeutic efficacy.
Infertility of unknown origin (“unexplained” infertility) is diagnosed only after a standard examination and the use of specialized methods.
Infertility treatment of unclear genesis is currently in vitro fertilization. Only when it is impossible to use this method, one can try to restore the natural fertility by ovulation stimulants.
The use of assisted reproductive technologies in the treatment of female and male infertility
Artificial insemination – the introduction of sperm into the female genital tract to induce pregnancy. You can use the sperm of a husband or donor.
Insemination is carried out on an outpatient basis 2-3 times during the menstrual cycle on its 12-14th day (with a 28-day cycle).
Donor sperm is obtained from men younger than 36 years old, physically and mentally healthy, without hereditary diseases and developmental disorders and without cases of fetal loss and spontaneous abortion in relatives.
According to the literature, the frequency of pregnancy after artificial insemination is 10-20%. During pregnancy and childbirth are similar to those in natural conception, and fetal malformations are recorded no more often than in the general population.
In vitro fertilization – in vitro fertilization of eggs, the cultivation and transfer of embryos to the uterus.
At present, in vitro fertilization is carried out using ovulation inducers in order to obtain quite a lot of mature oocytes.
Auxiliary reproductive technologies allow the use of cryopreservation programs not only of sperm, but also of oocytes and embryos, which reduces the cost of IVF attempts.
The standard IVF procedure consists of several steps. First, folliculogenesis is activated in the ovaries using superovulation stimulants according to some schemes, then all follicles with a diameter of more than 15 mm are punctured under the control of ultrasound ovarian scanning and insemination of oocytes by introducing at least 100,000 spermatozoa into the medium. After embryo cultivation for 48 hours, no more than 2-3 embryos are transferred using a special catheter into the uterus (the remaining embryos with normal morphology can be cryopreserved for further use in repeated IVF cycles).
In vitro fertilization with single spermatozoa, oocyte fertilization is possible (intracyoplasmic injection of spermatozoa – ICIS).
In ICIS, the single sperm is micromanipulated under visual control into a mature oocyte under metaphase II of meiosis. All other stages of the procedures are similar to IVF.
In azoospermia, methods are used within the framework of the IVF + + ICIS program, which allows the production of sperm from the epididymis and testicle.
Ovarian hyperstimulation syndrome is one of the complications of the IVF procedure. This is a complex of pathological symptoms that occur during the use of ovulation stimulants (abdominal pain, ovarian enlargement, in severe cases, the picture of “acute abdomen”).
Indications for surgical treatment of ovarian hyperstimulation syndrome are signs of internal bleeding due to an ovary rupture. The volume of surgery should be gentle, with maximum preservation of ovarian tissue.
Features of the course and management of pregnancy after in vitro fertilization due to the high probability of its interruption, premature birth and the development of severe forms of gestosis. The frequency of these complications depends primarily on the nature of the infertility (purely female, combined, or only male), as well as on the characteristics of the IVF procedure.
In children born as a result of in vitro fertilization, the frequency of congenital anomalies is not higher than that in the general population of newborns.
The frequency of multiple pregnancy in vitro fertilization is 25-30%.