Uterine infertility is the impossibility of the desired pregnancy in a woman of childbearing age due to the existing pathology of the uterus. The causes of uterine infertility may be submucous fibroids, intrauterine synechiae, abnormalities of the structure of the uterus, adenomyosis, endometrial polyps, etc. Ultrasound of the pelvic organs, hysteroscopy, and hysterosalpingography help to confirm this or that uterine pathology. Treatment of uterine infertility depends on the nature of the detected changes; it may include surgical methods (myomectomy, removal of polyps, dissection of synechiae, metroplasty, etc. D.), cyclic estrogen-progestogenic therapy.
General information
Uterine infertility is a form of female infertility caused by congenital anatomical abnormalities or acquired diseases of the uterus. In gynecology, the uterine factor, as the cause of infertility, is detected in about 15% of women who are unable to conceive during a year of regular sexual activity without the use of contraception. In other cases, endocrine (35%), tubal/tubal-peritoneal (30%), immunological (5%), cervical (5%), psychogenic (3%) infertility or infertility of unknown origin is diagnosed. Thus, the uterine factor is assigned the third position in the structure of the causes of female infertility. Within the uterine form of infertility, its various variants are distinguished, due to different reasons and having a different prognosis for the possibility of conception and bearing a child.
Causes of uterine infertility
The causes of fertility disorders associated with the uterine factor can be congenital and acquired; in accordance with this, primary or secondary infertility is diagnosed.
The causes of congenital order include congenital uterine anomalies: uterine atresia, doubling of the uterus, a change in its shape (saddle-shaped, two-horned), the presence of an septate uterus. In some cases, uterine infertility may result from the incorrect position of the organ – retroflexia of the uterus. Much more often, uterine infertility is based on acquired diseases caused by hormonal, tumor, infectious, post-traumatic changes in the endometrium and uterine cavity.
The most common etiofactor of uterine infertility is the pathology of the inner layer of the uterus, which can be represented by glandular, glandular-cystic, atypical hyperplasia or endometrial polyps. Hyperplastic processes are based on increased proliferative activity of the endometrium associated with hyperestrogenism. Insufficient secretory transformation of the endometrium makes it impossible to attach a fertilized egg and further development of the embryo in the uterine cavity. In addition, endometrial polyps can create mechanical obstacles to implantation of the fetal egg.
Myomatous nodes, as a factor of uterine infertility, are detected in every fifth infertile patient. The connection between uterine fibroids and infertility confirms the fact that after conservative myomectomy, the possibility of conception in such women is often restored. The immediate cause of uterine infertility in uterine fibroids can be both progesterone deficiency and deformation of the uterine cavity by submucous and uterine leiomyoma, which causes difficulties in implanting a fertilized egg.
The frequency of endometriosis among infertile women reaches 20-48%. The mechanisms of infertility development against the background of adenomyosis are multifaceted: they are associated with hyperestrogenism, gonadotropin imbalance, inferiority of cyclic transformation of the endometrium, and immune reactions that disrupt the process of implantation of blastocysts into the endometrium. Endometrial hyperplasia, uterine fibromyoma and adenomyosis often accompany each other, causing the complexity and duration of treatment of patients with uterine infertility.
In Asherman syndrome, uterine infertility is explained by obliteration of the uterine cavity and tubal angles by synechiae (splices). This pathology is usually associated with injury to the basal layer of the endometrium with the subsequent development of the infectious process. Complicated abortions, hysteroresectoscopies, diagnostic curettage, endometritis, genital tuberculosis, and the use of intrauterine contraceptives can lead to the formation of intrauterine synechiae.
Uterine infertility induced by the presence of foreign bodies in the organ cavity is rare. Mechanical interference for implantation in this case can create intrauterine spirals and their individual parts, ligatures, fetal bone remains. Uterine infertility is often combined with cervical factors – cervical hypertrophy, atresia and polyps of the cervical canal, cervical endometriosis, changes in the properties of cervical mucus, etc.
Symptoms
The uterine form of infertility is diagnosed if a woman of reproductive age, who leads a regular sexual life without the use of contraception, cannot become pregnant within a year; at the same time, other probable causes of infertility (including the male factor) are excluded, and the patient has certain diseases of the uterus that potentially prevent conception.
The absence of pregnancy may be the only obvious symptom of gynecological diseases, but it is more often combined with other signs of problems in the reproductive sphere. So, with endometrial hyperplasia, along with uterine infertility, intermenstrual spotting or anovulatory uterine bleeding may occur.
Uterine fibroids are characterized by copious prolonged menstruation and metrorrhagia, leading to anemia, pain in the lower abdomen and lower back, dysuric phenomena, constipation. When the leg of the myomatous node is twisted, a typical clinic of an acute abdomen develops. Foreign bodies of the uterus can declare themselves not only uterine infertility, but also menorrhagia, metrorrhagia, the development of chronic endometritis or pyometra.
Patients with intrauterine synechiae have a tendency to hypomenstrual syndrome or amenorrhea. With a mild form of Asherman syndrome, pregnancy may occur, but its course may be complicated by spontaneous termination, premature birth, placental pathology (low or tight attachment, presentation). Menstrual dysfunction and dyspareunia are frequent companions of congenital uterine abnormalities.
Diagnosis
One or another variant of uterine infertility is diagnosed with the exclusion of other causes of infertility and laboratory and instrumental confirmation of the existing pathology of the uterus. When collecting anamnesis, the gynecologist finds out when there were problems with conception, i.e. whether infertility is primary or secondary. Information about gynecological diseases and operations, STIs, pregnancies and their outcomes, extragenital pathology is studied in detail. Attention is paid to the analysis of menstrual function (age of menarche, duration and regularity of the cycle).
During the gynecological examination, the correctness of the development of the uterus, its position and size is determined, the absence or presence of myomatous nodes is revealed. Ultrasound of the pelvic organs allows to detect intrauterine pathology with a greater degree of reliability. Ultrasound hysterosalpingoscopy or X-ray hysterosalpingography is used in the diagnosis of polyps and assessment of the state of the uterine cavity. Direct visualization of the expected changes, clarification of their nature and location is achieved using hysteroscopy.
Laboratory research methods (smear microscopy, PCR diagnostics, colpocytology, etc.) play an auxiliary role in the diagnosis of uterine infertility. The exception is the histological examination of the scraping obtained with the SDC of the uterine cavity and the cervical canal – this analysis plays a crucial role in confirming endometrial hyperplasia and determining its shape.
Treatment
Pathogenetic therapy of uterine infertility is closely related to the treatment of the underlying disease. In case of hyperplastic transformation of the endometrium after curettage, cyclic estrogen-gestational therapy is prescribed for 3-6 months with subsequent pregnancy planning. Treatment of endometriosis is also hormonal, often long–term.
The choice of the method of treatment of uterine fibroids is determined by the localization and size of the node. Submucous fibroids are to be removed by hysteroresectoscopy, interstitial or subserous nodes are removed by conservative myomectomy with laparoscopic or laparotomic access. It is possible to embolize the uterine arteries. Pregnancy is allowed no earlier than 6 months after surgical treatment of fibroids after assessing the condition of the scar on the uterus.
Treatment of intrauterine synechiae is reduced to dissection of the splices under endosurgical control and subsequent appointment of hormone therapy for a period of 3-6 months. With the doubling of the uterus or a two-horned uterus, metroplasty is performed; the removal of the intrauterine septum is carried out by excision, laser reconstruction of the uterine cavity. Foreign bodies that caused uterine infertility are removed during hysteroscopy; in the presence of endometritis, anti-inflammatory therapy is performed.
The prognosis for the restoration of natural fertility after treatment of uterine infertility is variable. Myomectomy, removal of endometrial polyps, and courses of cyclic hormone therapy have a significant positive effect on the frequency of pregnancy. If an independent pregnancy does not occur after eliminating the cause of uterine infertility, in some cases assisted reproductive technologies can help.
