Female infertility is manifested by the absence of pregnancy for 1.5 – 2 years or more in a woman who lives a regular sexual life, without the use of contraceptives. There are absolute infertility associated with irreversible pathological conditions that exclude conception (anomalies in the development of the female genital sphere), and relative infertility that can be corrected. There is also a distinction between primary (if the woman did not have any pregnancies) and secondary infertility (if there was a pregnancy in the anamnesis). Female infertility is a severe psychological trauma for both men and women.
The diagnosis of “infertility” is made to a woman on the basis that for 1 year or more, with regular sexual relations without the use of methods of prevention, she does not become pregnant. Absolute infertility is spoken of if the patient has irreversible anatomical changes that make conception impossible (absence of ovaries, fallopian tubes, uterus, serious abnormalities of the development of the genitals). With relative infertility, the causes that caused it can be subjected to medical correction.
Also, primary infertility is distinguished – in the absence of a woman’s history of pregnancies and secondary – if it is impossible to get pregnant again. Infertility in marriage occurs in 10-15% of couples. Of these, in 40% of cases, the causes of infertility lie in the male body (impotence, defective sperm, ejaculation disorders), in the remaining 60% – we are talking about female infertility. The causes of infertility may be disorders related to the health of one of the spouses or both of them, so it is necessary to examine each of the partners. In addition to the factor of physical health, family mental and social problems can lead to infertility. To choose the right tactics for infertility treatment, it is necessary to determine the causes that caused it.
Female factors of infertility in marriage include:
- increased secretion of prolactin;
- tumor formations of the pituitary gland;
- various forms of menstrual cycle disorders (amenorrhea, oligomenorrhea, etc.) caused by hormonal regulation disorders;
- congenital defects of the anatomy of the genitals;
- double-sided pipe obstruction;
- adhesive processes in the pelvis;
- acquired malformations of the genitals;
- tuberculous lesion of the genitals;
- systemic autoimmune diseases;
- negative result of the postcoital test;
- psychosexual disorders;
- unclear causes of infertility.
Depending on the causes that lead women to problems with conception, the following forms of female infertility are classified:
- Endocrine (or hormonal) form of infertility
- Tubal-peritoneal infertility
- Uterine form of infertility
- Infertility caused by endometriosis
- Immune form of infertility
- Infertility of unknown origin
The endocrine form of infertility is caused by a violation of the hormonal regulation of the menstrual cycle, which ensures ovulation. Endocrine infertility is characterized by anovulation, i.e. the absence of ovulation due to the non-maturation of the egg or the absence of a mature egg from the follicle. This can be caused by injuries or diseases of the hypothalamic-pituitary region, excessive secretion of the hormone prolactin, polycystic ovary syndrome, progesterone deficiency, tumor and inflammatory lesions of the ovaries, etc.
Tubal infertility occurs when there are anatomical obstacles to the advancement of the egg through the fallopian tubes into the uterine cavity, i.e. both fallopian tubes are absent or impassable. In peritoneal infertility, the obstacle occurs not in the fallopian tubes themselves, but between the tubes and the ovaries. Tubal-peritoneal infertility usually occurs due to adhesions or atrophy of the cilia inside the tube, ensuring the advancement of the egg.
The uterine form of infertility is caused by anatomical (congenital or acquired) defects of the uterus. Congenital anomalies of the uterus are its underdevelopment (hypoplasia), doubling, the presence of a saddle uterus or intrauterine septum. Acquired defects of the uterus are intrauterine synechiae or its scar deformation, tumors. Acquired uterine defects develop as a result of intrauterine interventions, which include surgical termination of pregnancy – abortion.
Infertility caused by endometriosis is diagnosed in approximately 30% of women suffering from this disease. The mechanism of the effect of endometriosis on infertility is completely unclear, however, it can be stated that the areas of endometriosis in the tubes and ovaries prevent normal ovulation and the movement of the egg.
The occurrence of an immune form of female infertility is associated with the presence of antisperm antibodies in a woman, that is, specific immunity produced against sperm or embryo. In more than half of cases, infertility is caused not by a single factor, but by a combination of 2-5 or more causes. In some cases, the causes of infertility remain unidentified, even after a full examination of the patient and her partner. Infertility of unknown origin occurs in 15% of the surveyed couples.
The survey method in the diagnosis of infertility
To diagnose and identify the causes of infertility, a woman needs a gynecologist’s consultation. It is important to collect and evaluate information about the general and gynecological health of the patient. At the same time , it becomes clear:
- Complaints (well-being, duration of absence of pregnancy, pain syndrome, its localization and connection with menstruation, changes in body weight, the presence of secretions from the mammary glands and genital tract, psychological climate in the family).
- Family and hereditary factor (infectious and gynecological diseases in the mother and immediate relatives, the age of the mother and father at birth of the patient, their health status, the presence of bad habits, the number of pregnancies and childbirth in the mother and their course, the health and age of the husband).
- Diseases of the patient (transferred infections, including sexual, operations, injuries, gynecological and concomitant pathology).
- The nature of menstrual function (age of onset of the first menstruation, assessment of the regularity, duration, painfulness of menstruation, the amount of blood lost during menstruation, the prescription of existing disorders).
- Evaluation of sexual function (age of sexual initiation, number of sexual partners and marriages, nature of sexual relations in marriage – libido, regularity, orgasm, discomfort during sexual intercourse, previously used methods of contraception).
- Childbearing (the presence and number of pregnancies, the peculiarities of their course, the outcome, the course of childbirth, the presence of complications in childbirth and after them).
- Methods of examination and treatment, if they were carried out earlier, and their results (laboratory, endoscopic, X-ray, functional methods of examination; medical, surgical, physiotherapy and other types of treatment and their tolerability).
Methods of objective examination in the diagnosis of infertility
Methods of objective examination are divided into general and special:
Methods of general examination in the diagnosis of infertility allow to assess the general condition of the patient. They include examination (determination of body type, assessment of the condition of the skin and mucous membranes, the nature of hair loss, the condition and degree of development of the mammary glands), palpatory examination of the thyroid gland, abdomen, measurement of body temperature, blood pressure.
Methods of special gynecological examination of patients with infertility are numerous and include laboratory, functional, instrumental and other tests. During a gynecological examination, hair loss, features of the structure and development of external and internal genitalia, ligamentous apparatus, discharge from the genital tract are evaluated. Of the functional tests, the most common in the diagnosis of infertility are the following:
- construction and analysis of the temperature curve (based on basal temperature measurement data) – allows you to evaluate the hormonal activity of the ovaries and ovulation;
- determination of the cervical index – determination of the quality of cervical mucus in points, reflecting the degree of saturation of the body with estrogens;
- postcoital (postcoital) test – is carried out in order to study the activity of spermatozoa in the secret of the cervix and determine the presence of antisperm bodies.
Of the diagnostic laboratory methods, the most important in infertility are studies of the content of hormones in the blood and urine. Hormonal tests should not be carried out after gynecological and mammological examinations, sexual intercourse, immediately after waking up in the morning, since the level of some hormones, especially prolactin, may change at the same time. It is better to conduct hormonal tests several times to get a more reliable result. In infertility, the following types of hormonal studies are informative:
- examination of the level of DHEA-C (dehydroepiandrosterone sulfate) and 17- ketosteroids in urine – allows to evaluate the function of the adrenal cortex;
- the study of the level of prolactin, testosterone, cortisol, thyroid hormones (TK, T4, TSH) in blood plasma on the 5-7 day of the menstrual cycle – to assess their effect on the follicular phase;
- the study of progesterone levels in blood plasma on the 20th- 22nd day of the menstrual cycle – to assess ovulation and functioning of the corpus luteum;
- study of the level of follicle-stimulating, luteinizing hormones, prolactin, estradiol, etc. with menstrual function disorders (oligomenorrhea and amenorrhea).
In the diagnosis of infertility, hormonal tests are widely used to more accurately determine the state of individual parts of the reproductive apparatus and their reaction to taking a particular hormone. Most often, in infertility is carried out:
- progesterone test (with norcolut) is carried out in order to determine the level of saturation of the body with estrogens in amenorrhea and the reaction of the endometrium to the introduction of progesterone;
- cyclic or estrogen-progestogenic test with one of the hormonal drugs: gravistat, non-ovlon, marvelon, ovidon, femoden, silest, demulene, triziston, triquilar – to determine the reception of the endometrium to steroid hormones;
- clomiphene test (with clomiphene) – to assess the interaction of the hypothalamic-pituitary-ovarian system;
- a test with metoclopramide – in order to determine the prolactinosecretory ability of the pituitary gland;
- a dexamethasone test was performed in patients with an increased content of male sex hormones to identify the source of their production (adrenal glands or ovaries).
To diagnose immune forms of infertility, the content of antisperm antibodies (specific antibodies to spermatozoa – ASAT) in the blood plasma and cervical mucus of the patient is determined. Of particular importance in infertility is the examination for sexual infections (chlamydia, gonorrhea, mycoplasmosis, trichomoniasis, herpes, cytomegalovirus, etc.) affecting a woman’s reproductive function. Informative diagnostic methods for infertility are radiography and colposcopy.
Patients with infertility caused by intrauterine fusion or adhesive obstruction of the tubes are shown to be examined for tuberculosis (lung radiography, tuberculin tests, hysterosalpingoscopy, endometrial examination). To exclude neuroendocrine pathology (pituitary lesions), patients with impaired menstrual rhythm are X-rayed with a skull and a Turkish saddle. The complex of diagnostic measures for infertility necessarily includes colposcopy to detect signs of erosion, endocervicitis and cervicitis, serving as a manifestation of a chronic infectious process.
Hysterosalpingography (rengenogram of the uterus and fallopian tubes) reveals abnormalities and tumors of the uterus, intrauterine fusion, endometriosis, obstruction of the fallopian tubes, adhesions, which are often the causes of infertility. Ultrasound allows you to examine the patency of the winding pipes. To clarify the condition of the endometrium, diagnostic curettage of the uterine cavity is performed. The obtained material is subjected to histological examination and assessment of the correspondence of changes in the endometrium to the day of the menstrual cycle.
Surgical methods of infertility diagnosis
Surgical methods for the diagnosis of female infertility include hysteroscopy and laparoscopy. Hysteroscopy is an endoscopic examination of the uterine cavity using an optical device–a hysteroscope inserted through the external uterine pharynx. In accordance with the recommendations of WHO – the World Health Organization, modern gynecology has introduced hysteroscopy into the mandatory diagnostic standard for patients with uterine infertility.
Indications for hysteroscopy are:
- infertility primary and secondary, habitual miscarriages;
- suspected hyperplasia, endometrial polyps, intrauterine fusion, abnormalities of uterine development, adenomyosis, etc.;
- violation of menstrual rhythm, heavy menstruation, acyclic bleeding from the uterine cavity;
- fibroids growing into the uterine cavity;
- unsuccessful IVF attempts, etc.
Hysteroscopy allows you to consistently examine from the inside the cervical canal, the uterine cavity, its anterior, posterior and lateral surfaces, the right and left mouths of the fallopian tubes, assess the condition of the endometrium and identify pathological formations. Hysteroscopic examination is usually performed in a hospital under general anesthesia. During hysteroscopy, the doctor can not only examine the inner surface of the uterus, but also remove some neoplasms or take a fragment of endometrial tissue for histological analysis. After hysteroscopy, the discharge is carried out in the minimum (from 1 to 3 days) terms.
Laparoscopy is an endoscopic method of examining organs and the pelvic cavity using optical equipment inserted through a micro-incision of the anterior abdominal wall. Laparoscopic diagnostic accuracy is close to 100%. Like hysteroscopy, it can be performed with infertility for diagnostic or therapeutic purposes. Laparoscopy is performed under general anesthesia in a hospital setting.
The main indications for laparoscopy in gynecology are:
- infertility primary and secondary;
- ectopic pregnancy, ovarian apoplexy, uterine perforation and other urgent conditions;
- obstruction of the fallopian tubes;
- uterine fibroids;
- cystic ovarian changes;
- adhesive process in the pelvis, etc.
The undeniable advantages of laparoscopy are the bloodlessness of the operation, the absence of pronounced pain and rough sutures in the postoperative period, and the minimal risk of developing the adhesive postoperative process. Usually, 2-3 days after laparoscopy, the patient is subject to discharge from the hospital. Surgical endoscopic methods are low-traumatic, but highly effective both in the diagnosis of infertility and in its treatment, therefore they are widely used for the examination of women of reproductive age.
The decision on the treatment of infertility is made after receiving and evaluating the results of all examinations and determining the causes that caused it. Usually, treatment begins with the elimination of the primary cause of infertility. Therapeutic techniques used in female infertility are aimed at: restoring the reproductive function of the patient by conservative or surgical methods; the use of assisted reproductive technologies in cases where natural conception is impossible.
In the endocrine form of female infertility, hormonal disorders are corrected and ovarian stimulation is performed. Non-drug types of correction include weight normalization (in case of obesity) through diet therapy and increased physical activity, physiotherapy. The main type of medical treatment of endocrine infertility is hormone therapy. The process of follicle maturation is controlled by ultrasound monitoring and the dynamics of hormone levels in the blood. With proper selection and compliance with hormonal treatment, 70-80% of patients with this form of infertility become pregnant.
In the tubal-peritoneal form of infertility, the goal of treatment is to restore the patency of the fallopian tubes using laparoscopy. The effectiveness of this method in the treatment of tubal-peritoneal infertility is 30-40%. If there is a long-term adhesive obstruction of the tubes or if the previously performed operation is ineffective, artificial insemination is recommended. At the embryological stage, cryopreservation of embryos is possible for their possible use if repeated IVF is necessary.
In cases of uterine infertility – anatomical defects of its development – reconstructive plastic surgery is performed. The probability of pregnancy in these cases is 15-20%. If it is impossible to surgically correct uterine infertility (absence of the uterus, pronounced malformations of its development) and self-gestation by a woman, they resort to the services of surrogate motherhood, when embryo transplanting is carried out into the uterus of a surrogate mother who has undergone a special selection.
Infertility caused by endometriosis is treated with laparoscopic endocoagulation, during which pathological foci are removed. The result of laparoscopy is fixed by a course of drug therapy. The percentage of pregnancy is 30-40%.
In immunological infertility, artificial insemination by artificial insemination with the husband’s sperm is usually used. This method allows you to bypass the immune barrier of the cervical canal and contributes to the onset of pregnancy in 40% of cases of immune infertility. Treatment of unidentified forms of infertility is the most difficult problem. Most often, in these cases, they resort to the use of assisted methods of reproductive technologies. In addition, indications for artificial insemination are:
- tubal obstruction or absence of fallopian tubes;
- condition after conservative therapy and therapeutic laparoscopy for endometriosis;
- unsuccessful treatment of endocrine infertility;
- absolute male infertility;
- depletion of ovarian function;
- some cases of uterine infertility;
- concomitant pathology, in which pregnancy is impossible.
The main methods of artificial insemination are:
- the method of intrauterine insemination with donor sperm or husband’s sperm (IISD, IISM);
- in vitro fertilization (IVF) method;
- intracellular injection of sperm into the egg (ICSI, IMSI method);
- using a donor egg or a donor embryo;
- surrogate motherhood.
The effectiveness of female infertility treatment is influenced by the age of both spouses, especially women (the probability of pregnancy decreases sharply after 37 years). Therefore, infertility treatment should be started as early as possible. And one should never despair and lose hope. Many forms of infertility can be corrected by traditional or alternative methods of treatment.