Infertility at women
Female infertility – is shown by lack of approach of pregnancy throughout 1,5 - 2 years and more at the woman leading regular sex life without use of contraceptives. Allocate the absolute infertility connected with the irreversible pathological states excluding conception (anomaly of development of a female genital), and the relative infertility which is giving in to correction. Also distinguish primary (if the woman had no pregnancy) and secondary infertility (if there was pregnancy in the anamnesis). Female infertility is a severe psychological injury both for the man, and for the woman.
Infertility at women
The diagnosis "infertility" is made to the woman on that basis if for the 1st year and more at the regular sexual relations without use of methods of protection at her there does not occur pregnancy. Speak about absolute infertility in case the patient has irreversible anatomic changes making conception impossible (lack of ovaries, uterine tubes, a uterus, serious anomalies of development of genitals). At relative infertility, the reasons which caused it can be subjected to medical correction.
Also allocate infertility primary – at absence in the anamnesis of the woman of pregnancies and secondary – at impossibility of approach of repeated pregnancy. Infertility in marriage occurs at 10-15% of couples. From them in 40% of cases of the reason of infertility are covered in the man's organism (impotence, defective sperm, violations of an ejaculation), in other 60% - it is about female infertility. The violations connected with health of one of spouses or both of them therefore inspection of each of partners is necessary can be the reasons of infertility. Except a factor of physical health, can lead family mental and social trouble to infertility. For the choice of the correct tactics of treatment of infertility it is necessary to define the reasons which caused it.
Reasons of female infertility
In marriage treat female factors of infertility:
- the increased Prolactinum secretion;
- tumoral formations of a hypophysis;
- various forms of violation of a menstrual cycle (, , etc.) caused by violation of hormonal regulation;
- congenital defects of anatomy of genitals;
- bilateral pipe impassability;
- adhesive processes in a small basin;
- the acquired malformations of genitals;
- tubercular damage of genitals;
- system autoimmune diseases;
- negative result of the postkoitalny test;
- psychosexual violations;
- not clear reasons of infertility.
Depending on the reasons leading at women to problems with conception classify the following forms of female infertility:
- Endocrine (or hormonal) infertility form
- Pipe infertility form
- Uterine form of infertility
- The infertility caused by endometriosis
- Immune form of infertility
- Infertility of unspecified genesis
The endocrine form of infertility is caused by violation of the hormonal regulation of a menstrual cycle providing an ovulation. The anovulyation, i.e. lack of an ovulation owing to not ripening of an ovum or absence of a mature ovum from a follicle is characteristic of endocrine infertility. It can be caused by injuries or diseases of gipotalamo-hypophysial area, excess secretion of hormone of Prolactinum, a syndrome of polycystous ovaries, insufficiency of progesterone, tumoral and inflammatory damages of ovaries etc.
Tube infertility arises when there are anatomic obstacles in a way of advance of an ovum on uterine tubes in a uterus cavity, i.e. both uterine tubes are absent or are impassable. At peritonealny infertility the obstacle arises not in uterine tubes, and between pipes and ovaries. Pipe infertility usually arises owing to adhesive processes or an atrophy of the eyelashes in a pipe providing advance of an ovum.
The uterine form of infertility is caused anatomic (congenital or acquired) by defects of a uterus. Congenital anomalies of a uterus are its underdevelopment (hypoplasia), doubling, existence of a saddle uterus or an intrauterine partition. The acquired defects of a uterus are intrauterine sinekhiya or its cicatricial deformation, tumors. The acquired defects of a uterus develop as a result of intrauterine interventions to which also surgical termination of pregnancy - abortion belongs.
The infertility caused by endometriosis is diagnosed approximately for 30% of the women having this disease. The mechanism of influence of endometriosis on infertility is finally not clear, however it is possible to note that sites of endometriosis in pipes and ovaries interfere with a normal ovulation and movement of an ovum.
Emergence of an immune form of infertility is connected with presence at the woman of antispermalny antibodies, that is the specific immunity developed against spermatozoa or an embryo. In more than a half of cases, infertility is caused not by a single factor, but a combination of 2-5 and more reasons. In some cases the reasons which caused infertility remain unspecified, even after full inspection of the patient and her partner. Infertility of unspecified genesis occurs at 15% of the surveyed couples.
Diagnosis of infertility
Poll method in diagnosis of infertility
Consultation of the gynecologist is necessary for diagnostics and identification of the reasons of infertility for the woman. Collecting and assessment of information about the general and gynecologic health of the patient is important. At the same time become clear:
- Complaints (health, duration of lack of pregnancy, a pain syndrome, its localization and communication with periods, changes in body weight, existence of allocations from mammary glands and a genital tract, psychological climate in a family).
- Family and hereditary factor (infectious and gynecologic diseases at mother and the immediate family, age of mother and father at the patient's birth, a condition of their health, existence of addictions, the number of pregnancy and childbirth at mother and their current, health and age of the husband).
- Diseases of the patient (the postponed infections, including sexual, operations, injuries, the gynecologic and accompanying pathology).
- The nature of menstrual function (age of approach of the first periods, assessment of a regularity, duration, morbidity of periods, amount of the blood lost at periods, prescription of the available violations).
- Assessment of sexual function (age of the beginning of sex life, the number of sexual partners and marriages, character of the sexual relations in marriage - a libido, a regularity, an orgasm, discomfort at sexual intercourse, earlier applied contraception methods).
- Detorodnost (existence and the number of pregnancies, features of their course, an outcome, the course of childbirth, existence of complications in childbirth and after them).
- Methods of inspection and treatment in case they were carried out earlier, and their results (laboratory, endoscopic, radiological, functional methods of inspection; medicamentous, operational, physiotherapeutic and other types of treatment and their shipping).
Methods of objective inspection in diagnosis of infertility
Methods of objective inspection are divided into the general and special:
Methods of the general inspection in diagnosis of infertility allow to estimate the general condition of the patient. They include survey (definition like a constitution, assessment of a condition of skin and mucous membranes, character of pilosis, a state and extent of development of mammary glands), a palpatorny research of a thyroid gland, stomach, measurement of body temperature, arterial pressure.
Methods of special gynecologic inspection of patients with infertility are numerous and include laboratory, functional, tool and other tests. At gynecologic survey pilosis, features of a structure and development of external and internal genitals, the copular device, allocation from a genital tract is estimated. From functional tests the following is the most widespread in diagnosis of infertility:
- construction and the analysis of a temperature curve (on the basis of data of measurement of basal temperature) - allow to estimate hormonal activity of ovaries and commission of an ovulation;
- definition of a tservikalny index - the definition of quality of cervical slime in points reflecting organism saturation degree estrogen;
- the postkoitusny (postkoitalny) test – is carried out for the purpose of studying of activity of spermatozoa in a secret of a neck of a uterus and definition of existence of antispermalny bodies.
From diagnostic laboratory methods at infertility researches of content of hormones in blood and urine have the greatest value. It is not necessary to conduct hormonal tests after gynecologic and mammology examinations, sexual intercourse, right after morning awakening as the level of some hormones, in particular Prolactinum, at the same time can change. It is better to carry out hormonal tests several times for obtaining more reliable result. At infertility the following types of hormonal researches are informative:
- the research of the DGEA-S level (degidroepiandrosteron of sulfate) and 17 ketosteroids in urine – allows to estimate function of bark of adrenal glands;
- research of level of Prolactinum, testosterone, cortisol, tireoidny hormones (TZ, T4, TTG) in blood plasma for 5-7 day of a menstrual cycle - for assessment of their influence on a follicular phase;
- progesterone level research in blood plasma for 20-22 day of a menstrual cycle - for assessment of an ovulation and functioning of a yellow body;
- research of level of follikulostimuliruyushchy, lyuteiniziruyushchy hormones, Prolactinum, estradiol, etc. at violations of menstrual function (oligomenory and amenory).
In diagnosis of infertility the hormonal tests allowing to define more precisely a condition of separate links of the reproductive device and their reaction to reception of this or that hormone are widely used. Most often at infertility carry out:
- progesteronovy test (with norkoluty) – for the purpose of clarification of level of a saturation of an organism estrogen at amenory and reactions of endometrium to progesterone introduction;
- cyclic or estrogen-gestagennuyu test with one of hormonal medicines: , non-ovlon, , , , , , , – for definition of reception of endometrium to hormones steroids;
- klomifenovy test (with clomifene) – for interaction assessment - hypophysial systems;
- test with metoklopramidy – for the purpose of definition of prolaktinosekretorny ability of a hypophysis;
- test with dexamethasone - at patients with the increased content of male sex hormones for identification of a source of their development (adrenal glands or ovaries).
For diagnostics of immune forms of infertility determination of content of antispermalny antibodies (specific antibodies to spermatozoa - ASAT) in plasma of blood and tservikalny slime of the patient is carried out. Special value at infertility has inspection on the sexually transmitted infections (clamidiosis, gonorrhea, mycoplasmosis, trichomoniasis, herpes, a cytomegalovirus, etc.) influencing reproductive function of the woman. Informative methods of diagnostics at infertility are the X-ray analysis and a kolposkopiya.
Carrying out inspection on tuberculosis (a X-ray analysis of lungs, tuberkulinovy tests, a gisterosalpingoskopiya, an endometrium research) is shown to patients with the infertility caused by intrauterine unions or adhesive impassability of pipes. For an exception of neuroendocrine pathology (damages of a hypophysis) to patients with the broken menstrual rhythm the X-ray analysis of a skull and the Turkish saddle is carried out. The complex of diagnostic actions at infertility surely includes carrying out a kolposkopiya for the identification of symptoms of an erosion, an endotservitsit and a tservitsit serving as manifestation of chronic infectious process.
By means of a gisterosalpingografiya (the roentgenogram of a uterus and uterine tubes) anomalies and tumors of a uterus, intrauterine unions, endometriosis, impassability of uterine tubes, the adhesive processes which often are the reasons of infertility come to light. Performing ultrasonography allows to investigate passability of uterine tubes. For specification of a condition of endometrium the diagnostic scraping of a cavity of a uterus is carried out. The received material is exposed to a histologic research and assessment of compliance of changes in endometrium to day of a menstrual cycle.
Surgical methods of diagnosis of infertility
Hysteroscopy and laparoscopy belong to surgical methods of diagnosis of infertility. Hysteroscopy is an endoscopic survey of a cavity of a uterus by means of the optical device hysteroscope entered through an external uterine pharynx. According to WHO recommendations - World Health Organization the modern gynecology entered carrying out hysteroscopy into the obligatory diagnostic standard of patients with a uterine form of infertility.
Serve as indications to carrying out hysteroscopy:
- infertility primary and secondary, habitual abortions;
- suspicions on a giperplaziya, endometrium polyps, intrauterine unions, anomalies of development of a uterus, , etc.;
- violation of a menstrual rhythm, plentiful periods, acyclic bleedings from a uterus cavity;
- the myoma growing in a uterus cavity;
- unsuccessful attempts of EKO etc.
Hysteroscopy allows to examine consistently from within the tservikalny channel, a uterus cavity, its lobby, back and the side surfaces, the right and left mouths of uterine tubes, to estimate a condition of endometrium and to reveal pathological educations. The Gisteroskopichesky research is usually conducted in a hospital under the general anesthesia. During hysteroscopy the doctor can not only examine the internal surface of a uterus, but also remove some new growths or take an endometrium fabric fragment for the histologic analysis. After hysteroscopy the extract is made in minimum (from 1 to 3 days) terms.
The laparoscopy is an endoscopic method of survey of bodies and cavities of a small pelvis by means of the optical equipment entered through a microsection of a forward belly wall. Accuracy of laparoscopic diagnostics is close to 100%. As well as hysteroscopy, can be carried out at infertility with the diagnostic or medical purpose. The laparoscopy is carried out under the general anesthesia in the conditions of a hospital.
The main indications to carrying out a laparoscopy in gynecology are:
- infertility primary and secondary;
- extra-uterine pregnancy, ovary apopleksiya, perforation of a uterus and other medical emergencies;
- impassability of uterine tubes;
- uterus myoma;
- cystous changes of ovaries;
- adhesive process in a small basin, etc.
Indisputable advantages of a laparoscopy are the operation beskrovnost, absence of the expressed pains and rough seams in the postoperative period, the minimum risk of development of adhesive postoperative process. Usually in 2-3 days after carrying out a laparoscopy the patient is subject to an extract from a hospital. Surgical endoscopic methods are low-traumatic, but highly effective both in diagnosis of infertility, and in its treatment therefore are widely applied to inspection of women of reproductive age.
Treatment of female infertility
The decision of a question of treatment of infertility is made after receiving and assessment of results of all conducted examinations and establishment of the reasons which caused it. Usually treatment is begun with elimination of the paramount reason of infertility. The medical techniques applied at female infertility are directed on: restoration of reproductive function of the patient by conservative or surgical methods; use of auxiliary reproductive technologies in cases if natural conception is impossible.
At an endocrine form of infertility correction of hormonal frustration and stimulation of ovaries is carried out. Treat non-drug types of correction normalization of weight (at obesity) by a dietotherapy and increase in physical activity, physical therapy. A main type of drug treatment of endocrine infertility is hormonal therapy. Process of maturing of a follicle is controlled by means of ultrasonic monitoring and dynamics of maintenance of hormones in blood. At the correct selection and observance of hormonal treatment at 70-80% of patients with this form of infertility there occurs pregnancy.
At a pipe peritonealnoy to an infertility form the purpose of treatment is restoration of passability of uterine tubes by means of a laparoscopy. Efficiency of this method in treatment pipe infertility makes 30-40%. At it is long the existing adhesive impassability of pipes or at inefficiency of earlier performed operation, artificial insemination is recommended. At an embryological stage the cryopreservation of embryos for their possible use in need of repeated EKO is possible.
In cases of a uterine form of infertility – anatomic defects of its development - reconstructive plastic surgeries are performed. The probability of approach of pregnancy in these cases makes 15-20%. At impossibility of surgical correction of uterine infertility (lack of a uterus, the expressed defects of its development) and independent incubation of pregnancy by the woman resort to surrogacy services when replanting of embryos is carried out in a uterus of the substitute mother who underwent special selection.
The infertility caused by endometriosis is treated by means of laparoscopic endocoagulation during which the pathological centers are removed. The result of a laparoscopy is fixed by a course of medicamentous therapy. The percent of approach of pregnancy makes 30-40%.
At immunological infertility artificial insemination by an artificial insemination is usually used by the husband's sperm. This method allows to pass an immune barrier of the tservikalny channel and promotes approach of pregnancy in 40% cases of immune infertility. Treatment of unspecified forms of infertility is the most complex problem. Most often in these cases resort to use of auxiliary methods of reproductive technologies. Besides, indications to performing artificial insemination are:
- pipe impassability or lack of uterine tubes;
- state after the carried-out conservative therapy and a medical laparoscopy concerning endometriosis;
- unsuccessful treatment of an endocrine form of infertility;
- absolute male infertility;
- exhaustion of function of ovaries;
- some cases of a uterine form of infertility;
- the accompanying pathology at which pregnancy is impossible.
The main methods of artificial insemination are:
- method of an intrauterine insemination donor sperm or sperm of the husband (IISD, IISM);
- method of extracorporal fertilization (EKO);
- intracellular injection of a spermatozoon in an ovum (IKSI, IMSI method);
- use of a donor ovum or donor embryo;
Efficiency of treatment of infertility is influenced by age of both spouses, especially women (the probability of approach of pregnancy sharply decreases after 37 years). Therefore it is necessary to start treatment of infertility as it is possible earlier. And it is never necessary to despair and lose hope. Many forms of infertility give in to correction in the traditional or alternative ways of treatment.