Infertility is the absence of pregnancy during the year with a regular sexual life in the absence of contraception. In general, frequent unprotected sex leads to fertilization of the egg in 50% of couples for 3 months, 75% for 6 months and 90% for 1 year. The incidence of infertility is increased in older women. Cases of primary infertility are associated with impaired sperm (35% of couples), decreased ovarian reserve or ovulatory dysfunction (20%), tubal dysfunction and lesions of the pelvic organs (30%), pathological cervical mucus (<5%) and unidentified factors (10%). . Inability to conceive often leads to feelings of frustration, anger, guilt, resentment and an inferiority complex.
Couples planning a pregnancy should have frequent sexual contact with each other for several days in the middle of the menstrual cycle, when ovulation is most likely. A daily morning basal temperature measurement can help determine the onset of ovulation in women with a regular menstrual cycle. A decrease in temperature suggests the onset of ovulation, and an increase of more than 0.5 "C indicates the end of ovulation.The use of the test to determine LH helps identify the release of this hormone in the middle of the menstrual cycle, which also helps to determine the time of ovulation.Caffeine and tobacco use worsen fertility.
Diagnosis is established based on the history of the disease, examination and advice of both partners. In men, a spermogram is determined to identify abnormalities, and women are examined for ovulatory, tubal dysfunction, and pelvic organ changes.
For infertile couples, there are support groups (for example, the American Fertility Association, RESOLVE). If the probability of conception is low (usually after 2 years of treatment), the clinical doctor should recommend adoption.
Infertility: Causes and Diagnostic Tests
Infertility can make devastation in the soul of each partner, and surveys cause an exceptional nervous tension. The decisive role can be taken care of by partners on the part of the doctor.
In 90% of young couples who have a regular sexual life, conception occurs within the first year. The ability to conceive increases with the duration of the marriage. A high ability of one of the partners can compensate for the lack of ability of another, so many partners from the remaining 10% have insufficient reproductive function. Find out the following:
- Is the egg produced by a woman healthy?
- Does a man have enough healthy sperm?
- Are there eggs and sperm?
- Is the embryo implanted?
Infertility is considered inexplicable if the sperm in a man, ovulation and fallopian tubes in a woman are normal.
Fertility can be increased by stimulating the ovulation of several follicles (controlled ovarian hyperstimulation); The purpose of this is to obtain more than 1 oocyte (hyperovulation). First, during 3-4 menstrual cycles, a woman is prescribed clomiphene and stimulates ovulation with HCG. In the next 2 days, intrauterine insemination of sperm is performed. If pregnancy does not occur, a woman is prescribed gonadotropins for the treatment of ovulatory dysfunction followed by administration of hCG and insemination within the next 2 days. In addition, the luteal phase of the menstrual cycle is prescribed progesterone. The day of onset of menstruation and the dose of gonadotropin may vary depending on the age of the patient and the ovarian reserve. In the treatment with clomiphene and gonadotropin, the pregnancy rate is 10-15% for the first 4 cycles. If pregnancy does not occur after 4 cycles, it is recommended to use reproductive technologies. Controlled ovarian hyperstimulation can lead to a multiembryonic pregnancy.
Anamnesis. Two are needed for insemination. Survey follows both partners.
Ask the partner about the menstrual history, previous pregnancies and contraceptives used, the nature of pelvic infections and abdominal surgery.
Ask your partner about the peculiarities of puberty, previous paternities, previous operations (hernia repair, orchidopexy, bladder neck surgery), diseases (venereal diseases and epidemic parotitis in adolescence), drugs, alcohol, work (whether he is at home or when the partner occurs ovulation).
Ask both partners about sexual activity - frequency, time, technique (incomplete sexual intercourse - a problem in 1% of couples); feelings about infertility and unrealized paternity; previous surveys.
Examination. Check the general health of the woman and sexual development, and also examine the stomach and pelvis.
If a spermogram has been changed in a partner, he needs to undergo a test to identify a violation of the function of the endocrine system, the pathology of the penis, varicocele. It is also necessary to confirm the presence of two testicles of normal size (3.5-5.5 x 2.1-3.2 cm).
Tests for ovulation. With regular cycles, ovulation is probably not changed. The only evidence that ovulation is normal is pregnancy. Luteinization of the neovulating follicle is possible, in which case functional diagnostic tests can be positive in the absence of the oocyte. Any change in test results implies a violation of ovulation.
Tests: monitoring the development of the follicle or changes in secretory endometrium in ultrasound; the detection of "ovulatory" mucus in the middle of the cycle (like the protein of a raw chicken egg); detection of the peak of LH (for example, using the Clearplan whale); determination of the increase in basal body temperature in the middle of the cycle (the construction of a temperature curve is a complicated procedure and can cause inconvenience).
Tests of functional diagnostics. Check if the patient is vaccinated against the rubella virus, if not, provide vaccination. Check the blood prolactin level if you suspect anovulation (high values may indicate the presence of prolactinoma, take an X-ray), determine the content of FSH (it is increased in the primary failure of the ovaries) and LH (for detection of polycystic ovary syndrome), and perform tests for thyroid function glands.
Study of sperm.
If the postcoital test is normal, it is necessary to determine spermogram, antisperm antibodies and infection. (Normal spermogram -> 20 million spermatozoa / ml,> 40% of mobile and> 60% of normal forms). If these indicators are lowered, a specialist consultation is required.
Infertility: diagnostic tests and treatment
Determination of the patency of pipes.
- Laparoscopy and dye test (chromotubutation). The pelvic organs are visualized and the methylene blue is injected through the uterine pharynx. If the patency is broken in the proximal part, the tubes are not filled with a dye. With distal obstruction there is no "ejection" of the dye into the pelvic cavity.
- Hysterosalpingography (with contrast material) allows to determine the structure of the uterus, the tube "filling" and "exit" of the contrast medium.
Postcoital test. Carried out during the ovulation 6-12 h after sexual intercourse: cervical mucus is taken from the cervix and counted in the fields of vision with a strong increase. Positive test (in ovulatory mucus contains more than 10 mobile spermatozoa in the field of vision) indicates that sperm is normal, ovulation may be taking place, sexual intercourse is effective and cervical mucus does not contain antibodies.
Treatment for infertility. Treatment is aimed at removing the underlying cause. Azoospermia does not respond to treatment. To improve the low sperm count, the partner should be advised to stop smoking and drinking alcohol, ensure a lower temperature of the testicles (do not take hot baths or wear tight trousers). You can prescribe medications, such as tamoxifen, but the treatment is not always effective. Will the spouse agree to donor sperm? (AID is artificial insemination by donor, artificial insemination by donor sperm).
Violation of sperm excretion (eg, impotence). In this case, artificial insemination by the partner's sperm can be recommended.
Hyperprolactinemia is treated by eliminating the cause, if one is found (adenoma, drugs), if not, bromocriptine is administered at a dose of I mg every 24 hours, with a gradual increase in the dose until the normal prolactin level in the blood is reached.
Anovulation is treated by stimulating the formation of the follicle with clomiphen citrate in a dose of 50-200 mg every 24 hours, starting from the 5th day of the cycle for 5 days. Side effects: visual impairment, abdominal pain as a result of ovarian hyperstimulation. Human chorionic gonadotropin (hCG) is similar in structure to LH, and its administration may be required to initiate rupture of the mature follicle. If clomiphene citrate is not conducive to the elimination of infertility, injections of gonadotropin or analogues of LH-releasing hormone can be used.
Antisperm antibodies - this state of correction is not subject. You should try to transplant the gametes directly into the fallopian tube.
The obstruction of the tubes can be attempted to be surgically eliminated, but the results are disappointing.
Help with fertilization. The couple needs psychological (and financial) stability. Ectopic pregnancy, obesity, multiple pregnancy and abnormalities in the fetus are much more common than with normal pregnancy.
Fertilization in vitro is used for tube obstruction and other problems. The ovaries of the patient are stimulated, the egg is taken away, fertilized in vitro and placed in the uterus.
Transplantation of gametes into the fallopian tube can be recommended to patients without pathology of the fallopian tubes, for example, with "unexplained infertility" (20%).
Do not forget about the need for adaptation. Infertile couples can resort to the help of a psychotherapist or self-help groups.
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