Infertility in women

Female infertility - a woman's inability to conceive in childbearing age.

Infertile is considered to be a marriage in which, with regular sexual life and the absence of contraception within 1 year, pregnancy does not occur.

[1], [2], [3], [4],

Epidemiology

The frequency of infertile marriages is 15-17%, 40-60% of them are female infertility. The most common forms of female infertility are tubal peritoneal (50-60%) and anovulatory (endocrine) (30-40%) forms, as well as external genital endometriosis (25%); combined forms of infertility are 20-30%. In 2-3% of cases, the cause of infertility can not be established.

At each site of the reproductive system of the male and female body pathological processes may occur, violating the complex biological mechanism of their work and leading to infertility.

Allocate primary and secondary infertility. Primary infertility - infertility in women (or men) who live a regular sexual life without protection and without pregnancy (in men - nonfertile semen). Secondary infertility is the absence of pregnancy (the ability to fertilize in men) during the year of regular sexual activity after advancing pregnancies. Absolute infertility is infertility associated with the absence or abnormality of the development of the genital organs.

The presence of one of the partners of various forms of infertility, is defined as combined infertility, the presence of factors of infertility in both partners - a combined form of infertility in a pair.

One of the most important problems in gynecology and reproductive technology is infertile marriage. A fruitless marriage, representing 15% of married couples in Russia, is related to the problem of the childless future of millions of citizens, the reduction and loss of the nation's gene pool. Maybe. This problem is more urgent than many others in medicine, for only after the birth of a person can we talk about the importance and significance of providing him with one or another medical aid. 

• Reproductive quality is the ability to reproduce to oneself such individuals, ensuring the continuity and continuity of life.
• Reproductive health is defined by WHO as the absence of diseases of the reproductive system or reproductive harm if reproductive processes are possible with complete physical, mental and social well-being.
• Sexual health is a combination of physical, emotional and social aspects of sexual life, which positively enriches the person, promotes mutual understanding and love.
• Family planning is a set of socio-economic, legal, medical measures aimed at the birth of children desired by the family, healthy prophylaxis, the prevention of abortion, the preservation of reproductive health, the achievement of harmony in marriage.
• Fertility - the ability to reproduce offspring.
• Sterility - lack of ability to reproduce offspring.
• Infertile marriage is the absence of pregnancy within 12 months. Regular sexual life without the use of any contraceptive, provided that the spouses (sexual partners) are of childbearing age (WHO).

[5], [6], [7], [8], [9], [10], [11],

Causes of the infertility in women

Female infertility can be a consequence of many diseases and conditions.

Primary infertility in women

• Genital infantilism, anomalies in the development of female genital organs.
• Dysregulation of hormonal function of the ovaries, functional lack of gonads.
• Diseases of the uterus and appendages of the uterus, preventing the onset of pregnancy.

[12], [13]

Secondary infertility in women

• Inflammatory diseases of female genital organs, complications after abortion, IUD.
• Diseases of the endocrine system.
• Tumors of the genital organs.
• Ectopic pregnancy.
• Somatic diseases (tuberculosis, collagenoses, blood diseases, etc.).
• Traumatic damages of the vagina, cervix, perineum.
• Chronic intoxication (alcohol, nicotine, salts of heavy metals, etc.).
• Industrial-professional factors (microwave field, small doses of ionizing radiation).
• Defective food.

The main cause of female infertility are inflammatory diseases of female genital organs or their consequences (in 60-70% of cases). Among the inflammatory processes most often infertility accompanied by inflammation of the uterine appendages, which cause obstruction of the fallopian tubes, various violations of the functional state of the ovaries.

Especially often obstruction of the fallopian tubes occurs with gonorrheal salpingitis, but it can also be a consequence of nonspecific inflammation. Infertility often occurs after abortion or pathological birth. The consequence of abortion can be salpingitis with the development of obstruction of the fallopian tubes and damage to the mucous membrane of the uterus

Salpingitis leads not only to obstruction of the fallopian tubes, but also to the disturbance of their motor activity, to dystrophic changes in the mucous membrane of the uterine tube, which prevents fertilization.

With ovarian inflammation, ovulation can be disturbed, in connection with which the egg does not enter the abdominal cavity, and when forming adhesions around the ovary (in case of normal ovulation), it can not get into the tube. In addition, oophoritis can disrupt the endocrine function of the ovaries.

The role of endocervicitis in the etiology of infertility is significant, as they alter the function of the cervical canal epithelium. Colpitis can also be the cause of infertility (changing the properties of the vaginal fluid against the background of various diseases can lead to the death of spermatozoa).

In the etiology of infertility, endocrine disorders occur in 40-60% of cases. In this case, the function of the ovaries can be disturbed primarily, which is observed in abnormalities of the development of the genital organs or in the defeat of the follicular apparatus of the ovaries in connection with the transmitted infectious diseases or intoxications (the egg maturation and ovulation are disrupted, the hormonal function of the ovaries is necessary for maturation, transport of the egg and her fertilization).

Infantilism and hypoplasia of the genitals can cause infertility in women. In this case, infertility is promoted by both anatomical and functional features of the reproductive system associated with all underdevelopment (a long narrow vagina with a shallow posterior arch, a narrow cervical canal, a decrease in the hormonal function of the ovaries, inferiority of cyclic processes in the endometrium, a violation of the function of the fallopian tubes, ).

The function of the ovaries can change again due to diseases of the pituitary gland, thyroid gland, adrenal glands. To infertility are such diseases as myxedema, hypothyroidism, severe diabetes, Itenko-Cushing's disease, obesity, etc.

Infertility can be caused by traumas and dislocations of the genitals (old gap in the perineum, gaping of the sexual gap, pubescence of the vagina, bends and displacements of the uterus, eversion of the cervix, urogenital fistulas, synechia of the uterine cavity, infection of the cervical canal).

Infertility in a number of cases is a concomitant symptom in endometriosis, tumors of female genital organs

Common diseases and intoxications (tuberculosis, syphilis, alcoholism, etc.), as well as malnutrition, avitaminosis, mental illnesses cause complex disorders leading to a disorder of ovarian function, in connection with which infertility may also occur.

The cause of infertility are immunological factors (the formation of antibodies to the sperm in the body of a woman).

Frequency of detection of various factors of reproductive harm in couples.

Infertility factors	Frequency of detection
Men's	37%
Female (total)	82%
of them:
hormonal	56%
cervical-vaginal	51%
tubal peritoneal	48%

It should be borne in mind that among women with infertility, more than 60% have two or more factors of impaired fertility.

Pathological cervical mucus

Pathological cervical mucus can worsen fertility by inhibiting penetration or increasing sperm destruction. Normally, cervical mucus changes from dense, impermeable to more fluid, transparent and stretchable by increasing levels of estradiol during the follicular phase of the menstrual cycle. Pathological cervical mucus may remain impenetrable to the sperm by the time of ovulation or can cause sperm destruction, facilitating the influx of vaginal bacteria (eg, as a result of cervicitis). Sometimes abnormal cervical mucus contains antibodies to sperm. Pathological mucus rarely significantly impairs fertility, except in cases of chronic cervicitis or cervical stenosis as a result of treatment of cervical intraepithelial neoplasia.

Women are examined for cervicitis and cervical stenosis. If they do not have any of these disorders, then perform postcoital examination of cervical mucus in order to identify infertility.

Reduced ovarian reserve

Reduced ovarian reserve is a decrease in the quantity or quality of oocytes, leading to a decrease in fertility. The ovarian reserve may begin to decline by age 30 and earlier and rapidly declines after 40 years. Ovarian lesions also reduce reserve. Although older age is a risk factor for reducing the ovarian reserve, both age and decreased ovarian reserve in themselves are indicators of infertility and lead to lower treatment efficacy.

Tests for a reduced ovarian reserve are provided for women older than 35 years who underwent ovarian surgery or who did not have the effect of stimulating the ovaries with exogenous gonadotropins. The diagnosis can be expected if FSH levels are detected more than 10 mIU / ml or estradiol levels of less than 80 pg / ml per day three times during the menstrual cycle. The diagnosis can be made with the appointment of a woman clomiphene 100 mg orally once a day in the 5-9th day of the menstrual cycle (clomiphene citrate confirms the test). A significant increase in FSH and estradiol levels from the 3rd to the 10th days of the cycle indicates a decrease in the ovarian reserve. In women over 42 years old or with a decrease in the ovarian reserve, donated oocytes can be used.

Other causes of female infertility

• Problems with ovulation

A menstrual cycle lasting less than twenty-one days and more than thirty-five can signal the inability of the egg to fertilize. If ovulation does not occur, the ovaries are unable to produce mature follicles, and accordingly, eggs that can be fertilized. This cause of female infertility - of the most common.

• Dysfunction of the ovaries

Disruption of hormone production in the "hypothalamus-pituitary" system can sometimes cause dysfunction of the ovaries. Luteotropin and follitropin are produced either in very large or very small amounts, and their ratio is also violated, and as a result, the follicle does not mature enough, the egg cell is non-viable or does not mature at all. The cause of this dysfunction can be trauma to the head, swelling, etc. Disorders in the lower cerebral appendage.

• Hormonal disbalance

Hormonal failure in the body can lead to the disappearance of menstruation or unmatched egg. This disorder has many causes, including genetic predisposition, transferred infectious diseases, weakening of the immune system, endocrine diseases, surgical interventions and injuries of the abdominal and urogenital organs.

• Genetic predisposition

Female infertility can be caused by genetic factors, hereditary predisposition, in which the egg can not ripen.

• Polycystic ovary

With polycystic disease, follicotropin production declines, while the level of luteotropin, estrogen and testosterone remains normal or exceeds it. There is an opinion that a reduced level of follicotropin provokes inadequate development of follicles, which are produced by the ovaries. As a result, multiple follicular cysts (up to six to eight millimeters) are formed, which are diagnosed by ultrasound. The affected ovary is usually enlarged, on its surface a white capsule is formed, through which an egg can not pass, even if it is ripe.

• Cervical Dysfunction

As a result of such disorders, spermatozoa are unable to penetrate the uterine mucosa, which causes their death.

• Cervical erosion

The cause of female infertility may be such a pathology as erosion - ulcerous formations on the mucous membrane of the cervix, which is congenital or arise due to infections and injuries. The development of pathology contributes to hormonal disorders, the failure of the menstrual cycle, the earlier onset of sexual relations, the lack of a regular sexual partner, weak immunity. As a rule, such pathology proceeds asymptomatically and is determined when examined by a gynecologist. Sometimes, discharge from the sexual organs of brown shade and pain during sexual intercourse may appear.

• Scars on the ovary

This pathology leads to the fact that the ovaries lose the ability to produce follicles, as a result of which there is no ovulation. Scars can appear after operations (for example, with the removal of cysts) and infectious pathologies.

• Syndrome of unexploded follicle

With this syndrome, the ripened follicle is not torn and transformed into a cyst. The causes of such a disorder may be hormonal problems, ovary capsule consolidation or pathology of its structure. However, until the end of such a phenomenon is not investigated.

• Endometriosis

With this disease, endometrial cells begin to expand and form polyps that penetrate not only into the fallopian tubes and ovaries, but into the abdominal cavity. Such a disease prevents the egg from ripening and prevents its fusion with the sperm, and in case of fertilization it prevents the egg from gaining a foothold on the uterine wall.

• Psychological factor

Frequent stressful situations can lead to a violation of natural physiological functions, which has a negative effect on the process of fertilization. Psychological factors include female infertility of unknown origin (about ten percent of couples do not show any female infertility provoking disorders).

• Pathology of the uterus

Any deformities of the uterus have an effect like the IUD - preventing the egg from gaining a foothold on the endometrium. Such pathologies include polyps and uterine myoma, endometriosis, as well as congenital pathologies of the structure.

Diagnostics of the infertility in women

When conducting the diagnosis, both partners should be examined regardless of the complaints presented. First of all, it is necessary to exclude the presence of sexually transmitted diseases, hereditary pathologies and diseases of the endocrine system. After all the necessary information on the presence or absence of concomitant diseases is collected, the patient is examined for secondary sexual characteristics, rectal examination and pelvic examination are performed.

The diagnostic procedures also include hysterosalpingography (performed on the sixth-eighth day from the beginning of the cycle). With the help of hysterosalpingography determine the state of the uterine cavity and tubes. Through the cervical canal they are filled with contrast medium. If the fallopian tubes have normal patency, then this solution does not retain in them and penetrates into the abdominal cavity. Also, with the help of hysterosalpingography, it is possible to diagnose other pathologies of the uterus. To diagnose the disease, ultrasound biometry of follicle growth (on the eighth to fourteenth day of the cycle), hormonal examination (luteotropin, follitropin, testosterone on the third or fifth day of the cycle) is also used, the level of progesterone is determined on the nineteenth to twenty-fourth day of the cycle, in two to three day before the start of menstruation, an endometrial biopsy is performed.

Diagnosis of infertile marriage involves the examination of both sex partners, diagnostic measures should be carried out in full to identify all possible factors of infertility in both women and men.

In accordance with the recommendations of the WHO when examining infertile women should be installed and conducted: In the study of anamnesis:

• number and outcomes of previous pregnancies: spontaneous and induced abortions, including criminal ones; ectopic pregnancy, bladder skidding, the number of live children, postpartum and post-abortion complications;
• duration of primary or secondary infertility;
• the contraceptive methods used and the duration of their use after the last pregnancy or with primary infertility;
• systemic diseases: diabetes, tuberculosis, thyroid gland diseases, adrenal cortex, etc .;
• medication that may have a short-term or long-term adverse effect on ovulation: cytotoxic drugs and X-ray therapy of the abdominal cavity; psychopharmacological agents such as tranquilizers;
• operations that could contribute to infertility: appendectomy, sphenoid resection of the ovaries, operations on the uterus and others; postoperative period;
• inflammatory processes in pelvic organs and sexually transmitted diseases, type of pathogen, duration and nature of therapy;
• endometriosis disease;
• the nature of vaginal discharge, examination, treatment (conservative, cryo- or electrocoagulation);
• presence of secretions from mammary glands, their connection with lactation, duration;
• production factors and the environment - epidemic factors; alcohol abuse, taking toxic drugs, smoking, etc .;
• hereditary diseases with regard to relatives of the first and second degree of kinship;
• menstrual and ovulatory anamnesis; polymenorea; dysmenorrhea; the first day of the last menstruation;
• sexual function, soreness in sexual life (dyspareunia).

Objective examination

• height and weight of the body; weight gain after marriage, stressful situations, climate change, etc .;
• development of mammary glands, the presence of galactorrhea;
• hairiness and the nature of its distribution; skin condition (dry, oily, aspae vulgaris, striae);

Examination of body systems:

• measurement of blood pressure;
• X-ray of the skull and Turkish saddle;
• eye fundus and field of view.

[14], [15], [16]

Gynecological examination data

During the gynecological examination, the day of the cycle, corresponding to the date of the study, is taken into account. The degree and peculiarities of the development of external genitalia, the size of the clitoris, the nature of the embryo, the vagina, the cervix, the uterus and appendages, the condition of the sacro-uterine ligaments, the presence and nature of the discharge from the cervical canal and vagina are assessed.

Colposcopy or microscope examination is the obligatory method of examination at the first examination of the patient, reveals the signs of colpitis, cervicitis, endocervicitis and erosion of the cervix, which can cause infertility and can be a sign of chronic genital infection.

Laboratory and instrumental methods of examination

Great importance in the correct diagnosis of infertility in women has the implementation of additional laboratory and instrumental methods of examination. Compliance with the timing of the main methods of examining women can avoid false-positive and false-negative results of these studies. WHO recommends the following frequency and timing of a laboratory examination of women with infertility:

• functional diagnostics tests - 2-3 cycles;
• hormonal studies (LH, FSH, prolactin, testosterone, DEA) on the 3-5th day of the menstrual cycle; in the middle of the cycle and in the second phase;
• Hysterosalpingography on the 6th-8th day of the menstrual cycle; kymopertubation - in days of ovulation;
• US-biometry of follicle growth on the 8-14th day of the menstrual cycle;
• Immunological tests - on the 12-14th day of the menstrual cycle.

Immune forms of infertility are caused by the appearance of antisperm antibodies, more often in men and less often in women.

One of the tests that allow one to assume an immunological incompatibility is the postcoital test (PKT), known as the Sims-Juner trial or the Shuvarskiy trial. The test allows you to indirectly judge the presence of antisperm antibodies. The most significant manifestation of immunological disorders in the clinic is the presence of specific antibodies to spermatozoa. In women, antisperm antibodies (ACAT) may be present in serum, mucus of the cervical canal and peritoneal fluid. The frequency of their detection varies from 5 to 65%. In the examination of a married couple, the definition of antisperm antibodies should be included already in the first stages and primarily in the husband, since the presence of antisperm antibodies in the ejaculate testifies to the immune factor of infertility.

Postcoital test (Shuvarskiy-Sims-Juner test) - is performed to determine the number and mobility of spermatozoa in cervical mucus. Before postcoital testing, partners should abstain from sexual intercourse for 2-3 days. Forward-moving spermatozoa can be detected and cervical mucus within 10-150 min. After sexual intercourse. The optimal interval before the sample is 2.5 hours. The cervical mucus is removed by pipetting. If at normozoospermia in each field of vision you can see 10-20 advancing spermatozoons, then the cervical factor as the cause of infertility can be excluded.

Determination of antisperm antibodies in women in the mucus of the cervical canal: on preovulyatornye days, mucus is taken from the cervical canal for quantitative determination of antibodies of three classes - IgG, IgA, IgM. Normally, the amount of IgG does not exceed 14%; IgA - 15%; IgM - 6%.

• laparoscopy with the determination of patency of the fallopian tubes - on the 18th day of the menstrual cycle;
• determination of the level of progesterone on the 19th-24th day of the menstrual cycle;
• biopsy of the endometrium 2-3 days before the onset of menstruation.

Complex clinical and laboratory examination of women consisting of infertile marriage, allows to identify the following causes of infertility:

• Sexual dysfunction.
• Hyperprolactinemia.
• Organic disorders of the hypothalamic-pituitary region.
• Amenorrhea with elevated FSH.
• Amenorrhea with a normal level of estradiol.
• Amenorrhea with a decreased level of estradiol.
• Oligomenorrhoea.
• Irregular menstrual cycle and (or) anovulation.
• Aiovulation with regular menstruation.
• Congenital anomalies of genital organs.
• Two-sided obstruction of the fallopian tubes.
• Adhesive process in a small pelvis.
• Endometriosis disease.
• Obtained pathology of the uterus and cervical canal.
• Acquired violations of patency of the fallopian tubes.
• Tuberculosis of genital organs
• Iatrogenic causes (surgical interventions, medications).
• System causes.
• Negative postcoital test.
• Unidentified causes (when laparoscopy was not performed).
• Infertility of unclear genesis (when applying all methods of examination, including endoscopic).

Treatment of the infertility in women

Treatment of female infertility, first of all, should be aimed at eliminating the main cause, which provokes a malfunction of the reproductive function, as well as correction and elimination of any accompanying pathologies. Simultaneously with the basic treatment, general strengthening procedures, psychocorrection, are carried out. Treatment of the female must necessarily be comprehensive, in order to resume the normal functioning of the reproductive system as soon as possible.

If the tubes are obstructed, anti-inflammatory therapy is carried out, which is aimed not only at eliminating the inflammatory process and resuming the patency of the fallopian tubes, but also in activating the functions of the "hypothalamus-pituitary-ovary" system. From physiotherapeutic methods of treatment appoint radon or hydrogen sulphide baths, the use of therapeutic mud. To correct the work of the body's immune system, antihistamines are prescribed (suprastin, tavegil, dimedrol), immunomodulating drugs. Treatment is done with small doses of drugs for two to three months or with shock doses for a week.

Women with obstruction or complete absence of fallopian tubes, as well as the presence of such diseases as polycystosis, endometriosis, etc., can be offered a technique of in vitro fertilization. Women are prescribed drugs to enhance the growth and maturation of eggs. Then, with a special needle, the mature eggs are removed and fertilization is carried out in a test tube. On the third or fifth day, embryos are placed in the uterus, and the patient is prescribed special preparations to make the embryos take root. Two weeks after the procedure, a blood test is administered to determine if a pregnancy is developing. On the fifth or sixth week, an ultrasound is performed.

It should be noted that female infertility is caused by more than twenty reasons. Therefore, in order to conduct correct treatment, you need a thorough and sometimes lengthy examination in order to identify the reasons that prevent a woman from becoming pregnant. Only after detailed and complete diagnosis by the attending physician can be appointed a qualified treatment, which in each case is strictly individual.

The goal of infertility treatment in women is the restoration of reproductive function.

The main principle of infertility treatment is early detection of its causes and sequential stages of treatment.

Modern and highly effective methods of infertility treatment include medical and endoscopic methods and methods of assisted reproductive technologies. The latter are the final stage of infertility treatment or an alternative to all existing methods.

The tactics of therapy depend on the form and duration of infertility, the age of the patient, the effectiveness of the previously used methods of treatment. If there is no positive effect of traditional treatment within 2 years, it is advisable to use methods of assisted reproductive technologies.

The choice of treatment methods for infertility and the determination of their sequence in each case depend on such factors as the duration of the disease, the severity of changes in the fallopian tubes, the degree of spread of the adhesion process, the age and the somatic state of the patient.

Treatment of tubal peritoneal infertility

Treatment of tubal infertility with organic lesions of the fallopian tubes is quite difficult. Among the conservative methods, the priority for today is a complex anti-inflammatory, resorptive treatment conducted against the background of an exacerbation of the inflammatory process. Conducted therapy consists in the induction of exacerbation of the inflammatory process according to indications followed by complex antibacterial and physiotherapy, sanatorium treatment.

Reconstructive tubular microsurgery, introduced into gynecological practice in the 60s of the XX century, has become a new stage in the treatment of tubal infertility, allowing to perform such operations as salpingoovariolysis and salpingostomatoplasty. The improvement of endoscopic technique made it possible to perform these operations in a number of cases during laparoscopy. This method allows to diagnose other pathology of the pelvic organs: endometriosis, fibroids of the uterus, cystic ovarian formations, polycystic ovaries, etc. It is very important to have a simultaneous surgical correction of the pathology revealed during laparoscopy.

Treatment of endocrine infertility

Therapy given to patients with endocrine infertility forms is determined by the level of damage to the system of hormonal regulation of the ovulation process. Based on a certain level, the following groups of patients with hormonal forms of infertility are distinguished:

The first group is highly polymorphic, conditionally united by a common name - "polycystic ovary syndrome". This group is characterized by an increase in blood LH, a normal or elevated FSH level, an increase in the ratio of LH and FSH, a normal or decreased level of estradiol.

Treatment should be chosen individually and can consist of several stages:

• use of estrogen-progestogen drugs by the principle of "rebound effect";
• application of indirect stimulants of ovarian function - clomiphen citrate (clostilbegit).

In the presence of hyperandrogenism appoint in combination with dexamethasone;

• application of direct stimulants of the ovaries - metodine HG.

2-nd group - patients with hypothalamic-pituitary dysfunction.

Women with various disorders of the menstrual cycle (insufficiency of the luteal phase, anovulatory cycles or amenorrhea), with severe ovarian estrogen secretion and a low level of prolactin and gonadotropins. The sequence of application of drugs that stimulate ovulation in this group of patients is as follows: gestagen-estrogen preparations, clomiphen citrate (clostilbegite), possibly in various combinations with dexamethasone, parlodel (bromocriptine) and / or CG. With inefficiency - menopausal gonadotropins, HG.

3rd group - patients with hypothalamic-pituitary insufficiency. Women with amenorrhea, who have little or no estrogen of ovarian genesis; The level of prolactin is not increased, the level of gonadotropins is low or can not be measured. Treatment is possible only with menopausal gonadotropins HG or analogs of LH-RG.

4-th group - patients with ovarian insufficiency. Women with amenorrhea, in which estrogens are not produced by the ovaries, the level of gonadotropins is very high. Until now, infertility treatment in this group of patients is unpromising. For relief of subjective sensations in the form of "hot flashes", hormone replacement therapy is used.

The 5th group is women who have a high level of prolactin. This group is not homogeneous:

• Patients with hyperprolactinemia in the presence of a tumor in the hypothalamic-pituitary region. Women with various disorders of the menstrual cycle (insufficiency of the luteal phase, anovulatory cycles or amenorrhea), prolactin level is elevated, there is a tumor in the hypothalamic-pituitary region. In this group of patients it is necessary to isolate patients with pituitary microadenoma, for which treatment with parlodel or norprolact is possible with careful monitoring of the obstetrician-gynecologist, neurosurgeon and ophthalmologist, as well as patients with macroadenoma pituitary gland, which the neurosurgeon should treat, either by radiotherapy of the pituitary gland or removal of the tumor;
• Patients with hyperprolactinemia without lesion of the hypothalamic-pituitary region. Women with menstrual disorders similar to the subgroup with a clear production of estrogen of ovarian origin, an increase in the level of prolactin. The drugs of choice for this form are parlodel and norprolact.

Treatment of immunological infertility

To overcome the immune barrier of cervical mucus used: condom therapy, nonspecific desensitization, some immunosuppressors and methods of assisted reproduction (artificial insemination with the husband's semen).

Methods of assisted reproduction

In cases where infertility treatment in a married couple using conservative therapy methods and, if necessary, surgical treatment does not bring the desired results, it is possible to use methods of assisted reproduction. These include:

• Artificial insemination (AI):
  • sperm of the husband (IISM);
  • donor sperm (IISD).
• In Vitro Fertilization:
  • with embryo transfer (ECO PE);
  • with donation of oocytes (IVF OD).
• Surrogacy.

The use and application of these methods is in the hands of specialists in reproductive and family planning centers, but practical doctors should know the possibilities of using these methods, indications and contraindications to their use.

Auxiliary reproductive technologies include manipulation of sperm and an egg in vitro to create an embryo.

Auxiliary reproductive technologies (ART) can result in a multiembryonic pregnancy, but the risk is lower than with controlled ovarian hyperstimulation. If the risk of genetic defects is high, then before embryoation, the embryo needs to be inspected for defects.

In vitro fertilization (IVF) can be used to treat infertility due to oligospermia, the presence of sperm antibodies, tubal dysfunction or endometriosis, and also with unexplained infertility. The procedure includes controlled ovarian hyperstimulation, oocyte search, fertilization, embryo culture and embryo transfer. For hyperstimulation of the ovaries, clomiphene can be administered in combination with gonadotropins or gonadotropins alone. Often GnRH agonists or antagonists can be prescribed to prevent premature ovulation.

After sufficient growth of the follicle, HCG is prescribed to induce the final maturation of the follicle. Thirty-four hours after the application of HCG, oocytes are taken by follicle puncture, transvaginally under ultrasound control or less often laparoscopically. Insemination of oocytes in vitro is carried out.

The sperm sample is usually washed several times with tissue culture media and concentrated to increase sperm motility. Additionally, sperm is added, then the oocytes are cultured for 2-5 days. Only one or more embryos obtained are placed in the uterine cavity, minimizing the chance of developing a multiembryonic pregnancy, which is highest in in vitro fertilization. The number of displaced embryos is determined by the age of the woman and the likely response to in vitro fertilization (IVF). Other embryos can be frozen in liquid nitrogen and transferred to the uterine cavity in a subsequent cycle.

The transfer of gametes into the fallopian tubes (GIFT) is an alternative IVF method, but is used infrequently in women with unexplained infertility or with normal tube function in combination with endometriosis. Several oocytes and semen are obtained in the same way as in IVF, but transduction is carried out transvaginally under ultrasound control or laparoscopically - to the distal parts of the fallopian tubes where fertilization takes place. The success rate is approximately 25-35% in most infertility treatment centers.

Intracytoplasmic sperm injection is used when other technologies are not successful, as well as in cases where severe impairment of sperm functions has been noted. The sperm is injected into the oocyte, then the embryo is cultured and transferred in the same manner as in vitro fertilization (IVF). In 2002, more than 52% of all artificial cycles in the US were carried out by intracytoplasmic sperm injection. More than 34% of artificial cycles led to pregnancy, in which 83% of cases gave birth to live children.

Other procedures include a combination of in vitro fertilization and gamete transfer to the fallopian tubes (GIFT), the use of donor oocytes, and the transfer of frozen embryos to a surrogate mother. Some of these technologies have moral and ethical problems (for example, the lawfulness of surrogate motherhood, selective reduction of the number of implanted embryos in a multiembryonic pregnancy).