Primary infertility is a woman’s inability to conceive from the very beginning of the reproductive period. The criteria for primary infertility are unsuccessful attempts to get pregnant during a year of regular sexual activity with a healthy partner without the use of contraception. To identify the causes of primary infertility, a complete gynecological examination is performed (examination, functional tests, ultrasound, tests for infections and hormones, ultrasound and HSG, hysteroscopy, laparoscopy). Treatment – medical or surgical elimination of factors of primary infertility; if natural conception is impossible, the use of IVF or surrogacy services.
Primary infertility is the impossibility of pregnancy associated with congenital or pre-puberty pathology of the female body. It is necessary to differentiate the concepts of “infertility” and “childlessness”: in the first case, we are talking about complete infertility (the absence of pregnancies in any form – uterine and ectopic), in the second – about the inability of a woman to endure pregnancy and complete it with the birth of a viable fetus (this category includes cases of ectopic pregnancy, spontaneous miscarriages, stillbirth, etc.). According to researchers in 2010, 1.5% of women aged 20 to 44 suffer from primary infertility in the world, and in the USA – 1.9% of women of the same age range. It is believed that primary disorders of childbearing function in women are 1.5-2 times more common than secondary ones.
In gynecology, primary infertility is divided into congenital and acquired, temporary and permanent, absolute and relative. Congenital infertility is caused by the pathology that a woman has from the moment of birth (endocrine disorders, malformations of the genitals), acquired – is associated with diseases suffered after birth, but before the beginning of sexual life (attempts to get pregnant). Temporary infertility is a transient condition (for example, early puberty in girls, lactation amenorrhea or anovulation) and does not require special medical intervention, permanent – due to reasons that cannot be resolved independently.
Absolute infertility is understood as the complete exclusion of the possibility of conception due to irreversible pathological changes in the sexual apparatus; relative – the impossibility of pregnancy for reasons that can be eliminated. However, the criteria for absolute and relative primary infertility may change as reproduction develops. Thus, the advent of IVF made it potentially possible for women with the absence of fallopian tubes to become pregnant, and experimental uterus transplantation operations made it possible for women with the absence of this organ to have children – that is, in those patients who a few years ago were considered absolutely infertile.
In addition to female infertility, primary infertility is also found in men: as a rule, it is caused by non-fertile sperm or abnormalities of the reproductive system that prevent normal ejaculation (for example, violation of the patency of the seminal tract). In rare cases, the factors of infertility are determined in both spouses (sexual partners) – this form of pathology is regarded as combined infertility.
Possible causes of primary infertility may be neuroendocrine disorders, abnormalities in the development of the reproductive apparatus, complications of diseases of the reproductive organs suffered before the onset of sexual activity or active attempts to become pregnant. Primary infertility may be based on uterine, endocrine, tubal, and immunological factors.
Endocrine dysfunction is detected in 60-80% of women suffering from primary infertility. This may be an ovulation disorder caused by stress, mental and physical fatigue, alimentary dystrophy (including anorexia), polycystic ovary syndrome, hypothyroidism, adrenogenital syndrome, obesity. Uncontrolled use of COCs, as well as emergency contraception (for example, postinor) can also lead to a violation of the regulation of the menstrual cycle. Less often, the factors of primary infertility are genital infantilism caused by a tumor or inflammatory lesion of the hypothalamic-pituitary region, head injuries; various forms of gonadal dysgenesis (Swyer syndrome, Shereshevsky—Turner syndrome) caused by chromosomal abnormalities, etc.
The congenital causes of primary infertility include anatomical defects of the pelvic organs: for example, the absence of the uterus (including Rokitansky-Kustner syndrome), ovaries and fallopian tubes; hyperretroflexia and hyperanteflexia of the uterus. Anomalies such as gynatresia, hymen atresia, vaginal and uterine atresia are usually detected during puberty due to the inability of menstrual blood outflow and the development of hematocolpos, hematometers, hematosalpinx. Similar defects in the structure of the genitals occur at an early stage of embryonic development (up to 12 weeks. pregnancy) and may be associated with toxicosis, viral infections, endocrine disorders, occupational and household intoxication of the mother.
However, even with a normally formed sexual apparatus, common infections suffered in childhood (diphtheria, scarlet fever), and later – STDs, genital tuberculosis, nonspecific inflammations (adnexitis, salpingitis, endometritis, pelvioperitonitis, etc.) may lead to primary infertility in the future. The result of the severe course of these diseases may be blocked fallopian tubes, creating obstacles. for the onset of pregnancy. Past infections or intoxication can cause damage to the follicular apparatus of the ovaries, resulting in a decrease in the hormonal function of the glands, ovulatory disorders. Primary immunological infertility is associated with the antigenic properties of the egg and sperm and the resulting immune reaction against these antigens.
The main clinical manifestation of primary infertility in women is the absence of pregnancies for a year or more from the beginning of sexual life, if the male sexual partner is healthy, and the couple does not use any means and methods of prevention. Most often, patients have amenorrhea, irregular menstrual cycle, hypomenstrual syndrome, and menstrual-cramps. The remaining symptoms correspond to the underlying disease.
So, with genital infantilism, there is an absence or weak severity of pubic hair and armpits, hypoplasia of the mammary glands, the absence of menarche at the age of 15-16 years. Gynecological examination reveals underdevelopment of the external and internal genitalia: large labia do not cover the small, short and narrow vagina, the body of the uterus is small cylindrical, the neck is long conical.
In the case of uterine and vaginal agenesis, secondary sexual characteristics are sufficiently pronounced, the external genitalia are formed normally. Primary amenorrhea is noted. Sexual contacts due to the underdevelopment of the vagina are sharply painful or impossible. More than a third of these patients are diagnosed with abnormalities of the urinary system: aplasia / dystopia of the kidney, doubling of the ureters, horseshoe kidney.
Some disorders of menstrual function (for example, anovulatory menstrual cycles) are not accompanied by any external signs: menstruation occurs at the expected time, proceeds with the usual duration and with moderate blood loss. In this case, the only symptom of primary infertility is the inability of a woman to conceive. The psychological aspect of primary infertility of any genesis is associated with dissatisfaction due to unrealized maternal potential, which is accompanied by the development of neuroses, depression, low self-esteem, and a decrease in social activity. According to statistics, childless marriages break up more often than those in which children are born.
Patients who have complained about the absence of pregnancies are examined according to an extended scheme. At the first visit to the gynecologist, the clinical and anamnestic data are clarified, and an examination is performed. It turns out the general and gynecological anamnesis, the nature of menstrual function, how long unsuccessful attempts at conception have been noted. Objective examination includes determination of height, weight, BMI; assessment of hair loss and condition of the mammary glands; rectal or bimanual examination. Already at this stage, sexual infantilism, anomalies of the structure of the genitals may be suspected or revealed.
The second stage of examination of women with primary infertility is performed using laboratory and instrumental techniques. Functional diagnostic tests (colpocytology, examination of cervical mucus, analysis of the basal temperature graph) help to assess the nature of the menstrual cycle. In addition, to study the functional state of the reproductive system, it is advisable to examine the hormonal status, the most important indicators of which are the levels of prolactin, gonadotropins (FSH and LH), estradiol, testosterone, cortisol, thyroid hormones (TSH, T3, T4), etc. It is advisable for all patients to examine a smear on the flora, according to the indications, to conduct a bacteriological examination of the discharge from the genital tract, PCR and ELISA.
It is difficult to overestimate the informative value of ultrasound of the pelvic organs in the diagnosis of structural defects, post-inflammatory changes, volumetric formations of the uterus and ovaries. Folliculometry is used to track folliculogenesis and ovulation. In the diagnosis of primary uterine and tubal infertility, the role of ultrasound and hysterosalpingography is invaluable. Endovideosurgical examination (laparoscopy) is usually performed at the final stage of diagnosis.
To determine the causes of infertility, it may be necessary to perform ultrasound of the thyroid gland, Rg of the Turkish saddle, examination of the fundus, determination of visual fields, consultation of an endocrinologist, ophthalmologist, geneticist. In order to exclude the male factor of primary infertility, simultaneous examination of the sexual partner is recommended (spermogram, ultrasound of the scrotum, assessment of the androgenic status). The postcoital test suggests the immunological nature of primary infertility.
The possibility and effectiveness of primary infertility treatment is determined by a number of factors: the identified underlying and concomitant pathology, the potential elimination of the cause, the possibility of using assisted reproductive technologies. It should be noted that in some cases (for example, in the absence of ovaries and uterus), the birth of her own child becomes impossible, therefore, a woman is recommended to resort to surrogate motherhood using donor oocytes or adoption.
Treatment of primary endocrine infertility varies depending on the nature of the disorder. Patients with obesity are prescribed dietary correction, dosed physical activity, and medication. Primary infertility associated with genital infantilism requires the appointment of cyclic hormone therapy with estrogens and progestogens, vitamin therapy, physiotherapy (electrophoresis on the pelvic organs, gynecological massage, balneotherapy). With anovulation caused by hyperprolactinemia, bromocriptine is prescribed, etc. With polycystic ovarian changes, they resort to their wedge-shaped resection or cauterization. If pregnancy does not occur after the measures taken, drug stimulation of ovulation can be applied according to generally accepted protocols.
Treatment of tubal infertility can be conservative and surgical. At the first stage, physiotherapy, treatment with natural factors is applied; enzyme therapy, anti-inflammatory and immunomodulatory therapy is carried out; hydrotubation with the use of enzymes and corticosteroids is performed. In the absence of the expected effect, laparoscopic adhesiolysis, salpingectomy, plastic fallopian tubes are performed.
In the immunological form of primary infertility, it is recommended to use condoms for 4-6 months; in some cases, pregnancy can be achieved only with the help of artificial insemination, which excludes contact of spermatozoa with cervical mucus. In all forms of primary infertility, regardless of the causes, psychotherapy, phytotherapy, acupuncture is indicated. An alternative method of restoring fertility when it is impossible to conceive naturally is IVF.