Infertility

Infertility is the failure to conceive within one year with regular sexual intercourse and no contraception. In general, frequent unprotected sexual intercourse results in fertilization of the egg in 50% of couples within 3 months, in 75% within 6 months, and in 90% within 1 year. The incidence of infertility increases in older women. Cases of primary infertility are associated with sperm disorders (35% of couples), decreased ovarian reserve or ovulatory dysfunction (20%), tubal dysfunction and pelvic lesions (30%), abnormal 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 intercourse with each other for several days in the middle of the menstrual cycle, when ovulation is most likely. Daily morning basal body temperature measurements can help determine the onset of ovulation in women with regular menstrual cycles. A decrease in temperature suggests the onset of ovulation, and an increase of more than 0.5 "C indicates the end of ovulation. Using a test to determine LH helps identify the surge of this hormone in the middle of the menstrual cycle, which also helps to determine the time of ovulation. Use of caffeine and tobacco impairs fertility.

The diagnosis is established based on the medical history, examination and consultation of both partners. In men, a spermogram is determined to identify disorders, and women are examined for ovulatory, tubal dysfunction and changes in the pelvic organs.

There are support groups for infertile couples (eg, American Fertility Association, RESOLVE). If the chance of conception is low (usually after 2 years of treatment), the clinician should recommend adoption.

Infertility: Causes and Diagnostic Tests

Infertility can be devastating for any partner, and examinations can be extremely stressful. A caring attitude towards partners on the part of the doctor can be crucial.

90% of young couples who have regular sex conceive within the first year. The ability to conceive increases with the length of the marriage. High ability in one partner can compensate for the lack of ability in the other, so many of the remaining 10% have subfertile partners. Find out the following:

• Is the egg produced by a woman healthy?
• Is a man producing enough healthy sperm?
• Do eggs and sperm meet?
• Is the embryo implanted?

Unexplained infertility

Infertility is considered unexplained if the man's sperm, ovulation and fallopian tubes in the woman are normal.

Fertility can be increased by inducing ovulation of multiple follicles (controlled ovarian hyperstimulation), with the aim of obtaining more than one oocyte (hyperovulation). Initially, the woman is given clomiphene for 3-4 menstrual cycles and ovulation is induced with hCG. Intrauterine insemination of sperm is performed on the following 2 days. If pregnancy does not occur, the woman is given gonadotropins to treat ovulatory dysfunction, followed by hCG and insemination on the following 2 days. Additionally, progesterone is given in the luteal phase of the menstrual cycle. The day of onset of menstruation and the dose of gonadotropin may vary depending on the patient's age and ovarian reserve. With clomiphene and gonadotropin treatment, the pregnancy rate is 10-15% per cycle during 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 multiple embryonic pregnancy.

History: It takes two to fertilize. Both partners should be examined.

Ask your partner about her menstrual history, previous pregnancies and contraceptive use, history of pelvic infections and abdominal surgery.

Ask your partner about the specifics of puberty, previous fatherhood, previous surgeries (herniorrhaphy, orchidopexy, bladder neck surgery), illnesses (sexually transmitted diseases and mumps in adolescence), medications, alcohol, work (is he at home when his partner ovulates).

Ask both partners about sexual activity - frequency, timing, technique (incomplete intercourse is a problem in 1% of couples); feelings about infertility and failure to father a child; previous examinations.

Examination: Check the woman's general health and sexual development, and examine the abdomen and pelvis.

If the partner has an altered spermogram, he must undergo an examination to identify endocrine dysfunction, penile pathology, varicocele. It is also necessary to confirm the presence of two normal-sized testicles (3.5-5.5 x 2.1-3.2 cm).

Ovulation tests. With regular cycles, ovulation is most likely not altered. The only proof that ovulation is normal is pregnancy. Luteinization of an unovulated follicle is possible, in which case functional diagnostic tests may be positive in the absence of an egg. Any changes in test results imply an ovulation disorder.

Tests: monitoring follicle development or changes in the secretory endometrium using ultrasound; detecting “ovulatory” mucus in the middle of the cycle (like the white of a raw chicken egg); detecting the LH peak (for example, using the Clearplan kit); determining the increase in basal body temperature in the middle of the cycle (plotting a temperature curve is a complex procedure and can be uncomfortable).

Functional diagnostic tests. Check if the patient is vaccinated against rubella virus, if not, provide vaccination. Check blood prolactin level if anovulation is suspected (high values may indicate prolactinoma, take an X-ray), determine FSH content (elevated in primary ovarian failure) and LH (to detect polycystic ovary syndrome), and conduct thyroid function tests.

Sperm examination.

If the postcoital test is normal, it is necessary to determine the spermogram, antisperm antibodies and infection. (Normal spermogram - > 20 million spermatozoa/ml, > 40% motile and > 60% normal forms). If the above indicators decrease, a specialist consultation is required.

Infertility: Diagnostic Tests and Treatment

Determining the patency of pipes.

1. Laparoscopy and dye test (chromopertubation). The pelvic organs are visualized and methylene blue is introduced through the cervical os. If the patency is obstructed in the proximal part, the tubes are not filled with dye. If the obstruction is distal, there is no "release" of dye into the pelvic cavity.
2. Hysterosalpingography (with contrast agent) allows to determine the structure of the uterus, tubal “filling” and “exit” of the contrast agent.

Postcoital test. Conducted during the ovulation period, 6-12 hours after intercourse: cervical mucus is collected from the cervix and counted in the fields of vision at high magnification. A positive test (the ovulatory mucus contains more than 10 motile spermatozoa in the field of vision) indicates that the sperm is normal, ovulation may have occurred, intercourse was effective, and the cervical mucus does not contain antibodies.

Treatment for infertility. Treatment is aimed at removing the underlying cause. Azoospermia is not treatable. To improve low sperm counts, the partner should be advised to quit smoking and drinking alcohol, and to ensure a lower testicular temperature (do not take hot baths or wear tight pants). Medications such as tamoxifen can be prescribed, but treatment is not always effective. Will the couple agree to donor sperm? (AID - artificial insemination by donor).

Impaired sperm secretion (e.g. impotence). In this case, artificial insemination with the partner's sperm may be recommended.

Hyperprolactinemia is treated by eliminating the cause, if one is found (adenoma, medications); if not, bromocriptine is prescribed at a dose of 1 mg every 24 hours orally with a gradual increase in the dose until normal prolactin levels in the blood are achieved.

Anovulation is treated by stimulating follicle formation with clomiphene citrate at a dose of 50-200 mg every 24 hours orally, starting on the 5th day of the cycle for 5 days. Side effects: visual disturbances, abdominal pain due to ovarian hyperstimulation. Human chorionic gonadotropin (hCG) is similar in structure to LH and its administration may be required to initiate rupture of a mature follicle. If clomiphene citrate does not help to eliminate infertility, injections of gonadotropin or LH-releasing hormone analogues can be used.

Antisperm antibodies - this condition cannot be corrected. It is necessary to try to transplant gametes directly into the fallopian tube.

Obstruction of the tubes can be treated surgically, but the results are disappointing.

Assistance with fertilization. The couple needs psychological (and financial) stability. Ectopic pregnancy, obesity, multiple pregnancy and fetal abnormalities are much more common than in normal pregnancies.

In vitro fertilization is used for blocked tubes and other problems. The patient's ovaries are stimulated, the egg is removed, fertilized in vitro and implanted into the uterus.

Gamete transplantation into the fallopian tube can be recommended for patients without fallopian tube pathology, for example, in cases of “unexplained infertility” (20%).

The need for adaptation should not be forgotten. Infertile couples can seek help from a psychotherapist or self-help groups.

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