Primary and secondary infertility. Laboratory and instrumental examination methods

In women, the following types of infertility are distinguished: primary and secondary; absolute and relative; congenital and acquired, temporary and permanent; physiological and pathological.

Primary infertility - when a woman cannot become pregnant, and secondary - when the pregnancy took place and ended in an abortion, ectopic pregnancy, childbirth, etc., but after that the woman cannot become pregnant again. The causes of primary infertility are often endocrine diseases (60-80%), and secondary - inflammatory diseases of the female genital organs (80-90%).

Congenital infertility is caused by hereditary and congenital pathology (many endocrine diseases, malformations of the genital organs, etc.). Acquired infertility is most often secondary, associated with previous diseases after birth.

The concepts of "absolute" and "relative" infertility may change in the process of development of medical science and practice. For example, in the absence of tubes, infertility was previously considered absolute, but now, when in vitro fertilization is used, it has become relative. The absence of ovaries or uterus and currently leads to absolute infertility (not subject to treatment).

Temporary infertility is due to passing causes (anovulatory cycles during lactation, in early puberty), and permanent infertility is due to permanent causes (absence of fallopian tubes).

Physiological infertility is considered in women in the prepubertal and postmenopausal periods, during lactation. Knaus and Ogino in this group attributed the state of sterility from the 1st to the 12th and from the 17th to the 28th day of the 28-day menstrual cycle. Pathological infertility is associated with all etiological factors of primary and secondary infertility.

Recently, there are also such concepts as voluntarily conscious and forced infertility. Voluntarily conscious infertility is such situations when, due to socio-economic or other factors (nuns), a woman consciously does not want to become pregnant and give birth not only to the second, third, but also the first child. And forced infertility is associated with certain restrictive measures for childbearing.

The diagnosis of infertility can be qualified even at the first visits of a woman to a doctor. For example, this may be in a married woman, when tubo-ovarian formations, amenorrhea, etc. are detected. In such situations, one should not wait for a year or more to perform an examination for infertility, but should begin immediately after the diagnosis of such a pathology.

Examination of a woman is always fraught with certain difficulties and is often risky. In this regard, the husband is first examined, the infection is detected in both spouses. If it is available, only after that a detailed examination of the woman is carried out for the endocrine or inflammatory etiology of infertility, as well as other possible factors. In a clinical study, the anamnesis takes the first place. When collecting it, the following basic data should be clarified: age, profession and material and living conditions; duration of marital life and data on sexual function (frequency and circumstances in which sexual intercourse occurs, libido, orgasm, contraceptives used and used); menstrual function and a woman's knowledge of the days of the cycle likely to become pregnant; outcomes of previous pregnancies; transferred gynecological and extragenital diseases, their treatment; surgical interventions in the past, their volume, outcomes; detailed data on inflammatory and endocrine diseases; genealogical history; carefully collected information about possible complaints - pain, leucorrhea, bleeding, etc.

Somatic and gynecological status is determined by the length and weight of the body, constitution; basic anthropometric indicators; the severity of secondary sexual characteristics, their abnormalities, the presence of hypertrichosis, hirsutism; functional state of the cardiovascular, urinary, respiratory and other systems and organs; gynecological examination with an assessment of the external genitalia, vagina, cervix and body of the uterus, appendages and uterus; special attention is paid to the condition of the mammary glands and possible galactorrhea.

If necessary, an examination is carried out by related specialists (oculist, endocrinologist, therapist, etc.). It is advisable for all women suffering from infertility to conduct the following special studies: bacterioscopic and, if necessary, bacteriological; colpocytological; assessment of the cervical number; colposcopy simple or extended; ultrasound. Hormonal, immunological and radiological studies are performed according to indications.

It is important to assess the penetration of spermatozoa through the cervical canal into the uterine cavity. For this purpose, spermatozoa are examined in the vagina and cervical canal (postcoital test in the preovulatory period), a test for the penetration of spermatozoa through the cervical mucus on a slide is determined, “spermoantibodies” are detected in women by the sperm microagglutination reaction.

The study of the patency of the fallopian tubes using hysterosalpingography is carried out in the 2nd phase of the cycle, during which contraception must be observed. There are a number of other methods for assessing the functional state of the fallopian tubes (using ultrasound, laparoscopy, metrosalpingospinography, etc.).

Hysterography with a histological examination of the endometrium is performed for infertility only for special indications.

A special place in the examination of women with infertility is occupied by laparoscopy. It has found wide distribution for both diagnostic and therapeutic surgical purposes. It can be considered correct to use laparoscopy only for diagnostic purposes after all other methods have been performed.

After examining women with infertility using the above research methods, it is usually possible to establish its endocrine or infectious genesis. To clarify the cause of infertility, various additional research methods are required, which are determined individually in each specific case.

Hormonal examination includes an assessment of thyroid function by blood levels of thyroid hormones (T3 and T4), thyroglobulin (TG) - the limiting substrate of thyroid hormones and thyroxin-binding globulin (TSG) - the main protein that binds thyroid hormones. The morphological structure of the thyroid gland is assessed according to ultrasound, thermography, and tomography. For topical diagnosis of the source of hormonal disorders (hyperandrogenemia, etc.), hormonal tests are performed. In general, the complex of the stated research methods determines the usefulness of the phases of the menstrual cycle, ovulation, the nature of the transformation of the endometrium, the violation of each of which or their combination can be the cause of infertility. Assessment of the functional state of the pituitary gland is carried out by the level of gonadotropic hormones (FSH, LH), prolactin, TSH, ACTE Determination of the concentration of liberins and statins of the hypothalamus, as well as neurotransmitters, as well as endogenous opiates to determine the functional state of the hypothalamus and the central structures of the regulation of the reproductive system in wide practice is limited due to methodological difficulties. Various functional hormonal tests are used for this purpose. The morphological characteristics of the central structures and the hypothalamic-pituitary region are obtained with the help of X-ray studies (survey x-ray of the skull, x-ray of the Turkish saddle), computed tomography, and magnetic nuclear resonance imaging. Hormonal studies allow you to evaluate those changes in the content of hormones that are characteristic of ovulation. 1-2 days before it, an increase in progesterone levels is noted, which increases in the next three days after ovulation. A corresponding increase in the excretion of pregnandiol follows a day after the peaks of progesterone in the blood. The peak content of estrogen in the blood is observed 36-48 hours before ovulation. It coincides with the LH peak, but is more often observed 1-1.5 days earlier than it. The days of maximum increase in estrogen are the terms of the greatest probability of pregnancy.

The conducted surveys allow diagnosing variants of infertility by genesis: endocrine (secretory); tubal, peritoneal, uterine, cervical (excretory); immunological, psychogenic-sexual, etc.

The clinical picture of female infertility is characterized by the pathological manifestations that cause it.

Tubal infertility may be due to organic or functional pathology. Organic damage to the fallopian tubes is characterized by their obstruction. Most often, it occurs due to inflammatory diseases of the genital organs, including STDs. Postpartum and post-abortion complications of inflammatory or traumatic origin often lead to obstruction of the tubes. Transferred appendectomy, especially in complicated forms of appendicitis (phlegmonous, perforative, gangrenous), can cause tubal obstruction. Tubal endometriosis and other variants of external endometriosis contribute to the development of tubal infertility. Finally, various other surgical and gynecological diseases, accompanied by peritonitis and pelvioperitonitis, cause tubal obstruction.

Functional disorders of the fallopian tubes are associated with the pathology of the neuroendocrine system of regulation of reproductive function, the processes of steroidogenesis and prostaglandinogenesis. It is known that a fertilized egg enters the uterus 5-7 days after fertilization. Promotion of spermatozoa and ovum through the tube before and after fertilization is under neuroendocrine control. Important factors in this case are the contraction of the muscles of the tubes, fimbriae, the movement of cilia and the flow of fluid. Their directions and nature change according to the phases of the cycle and especially in connection with ovulation. Therefore, along with inflammatory processes, violations of hormonal and other regulatory factors can cause pathology of the secretory and motor activity of the fallopian tubes, even while maintaining its anatomical patency.

The peritoneal form of infertility develops for the same reasons as tubal infertility, and is a consequence of adhesive processes caused by inflammatory diseases, surgical interventions on the genitals and in the abdominal cavity.

A special place in the genesis of infertility is given to endometriosis. Although there are ambiguous opinions about the role of endometriosis in the development of infertility, according to most authors and our observations, we can assume that endometriosis leads to infertility due to the development of tubal and peritoneal factors, as well as hormonal disorders. Among infertile women, 30% or more are diagnosed with endometriosis. Often this disease is asymptomatic, and only during surgical interventions are pronounced adhesive changes in the pelvic organs that caused infertility. It should be taken into account that both inflammatory diseases of the genital organs and endometriosis contribute to the development of functional disorders of the fallopian tubes, their obstruction and hormonal changes, i.e. determine combined forms of infertility.

Infertility of endocrine genesis is observed in all forms of primary and secondary amenorrhea, insufficiency of the follicular and luteal phases of the cycle, hyperandrogenemia of ovarian and adrenal origin, hyperprolactinemia, and certain rare types of endocrine pathology (luteinization syndrome of the unovulated follicle, iatrogenic diseases, etc.). Anovulation and disturbances in the cyclic transformation of the endometrium most often lead to the development of endocrine infertility. In turn, they are caused by numerous varieties of endocrine pathology in women of central and peripheral origin.

Immunological infertility is associated with the antigenic properties of sperm and egg, as well as with immune responses against these antigens. There are also data on the role of incompatibility of blood groups of spouses according to the AB0 system in the development of infertility. Antisperm antibodies are found not only in the blood serum of male or female partners, but also in cervical mucus extracts. The presence of antibodies in the blood serum does not always coincide with their presence in the mucus of the cervix. It is believed that cervical mucus antibodies can be of both systemic origin (penetrate into the cervical mucus from the circulating blood) and locally synthesized. Antisperm antibodies can form in men and cause sperm agglutination and possible infertility. Antibodies are also formed in women to the husband's sperm (antibodies to sperm isoantigens), and they are detected both in the blood serum and in the secrets of the reproductive system. In the female genital organs, the most significant area for the development of immunological activity is the cervix, the endometrium, fallopian tubes and vagina are less involved in this. Immune mechanisms for the interaction of antisperm antibodies with sperm antigens also change significantly in the phases of the menstrual cycle, especially in the periovulatory period. Diagnosis of infertility of immune origin is based on postcoital tests.

Infertility associated with malformations and anatomical disorders in the reproductive system. The causes of infertility in this group are: atresia of the hymen, vagina and cervical canal; acquired infection of the cervical canal; vaginal aplasia (Rokitansky-Kuster syndrome); doubling of the uterus and vagina; traumatic injuries of the genital organs; hyperanteflexia and hyperretroflexia of the uterus; tumors of the uterus and ovaries, in which, in addition to anatomical changes, there are also hormonal disorders.

Infertility of a psychogenic nature is associated with various disorders of the psycho-emotional sphere, stressful situations with prolonged psychosomatic stress.

The uterine form of infertility, in addition to the cervical factor, includes multiple degenerative changes in the endometrium due to inflammatory processes and traumatic injuries.

Extragenital diseases lead to infertility. They can directly affect the generative function or indirectly through developing hormonal disorders.

Principles of treatment of female infertility. Infertility treatment is carried out after establishing its form, exclusion or confirmation of combined causes, as well as confidence in the good health of the husband.

When determining infertility of endocrine origin, treatment is prescribed taking into account the cause and nature of the violations. The duration of the disease and the presence of concomitant pathology are important when choosing treatment tactics. Based on this, a number of stages in the treatment of infertility of endocrine origin can be distinguished. At the first stage, it is necessary to eliminate metabolic disorders (obesity), carry out therapy for extragenital diseases, and correct possible disorders of the thyroid gland and adrenal glands. This can contribute to the normalization of menstrual function and the onset of pregnancy. At the second stage, differentiated therapy is carried out.

Treatment of ovarian hypofunction, as a cause of infertility, is carried out taking into account the severity of the pathology. General strengthening measures, physiotherapy procedures using natural and preformed factors are carried out, aimed at improving the blood circulation of the pelvic organs. Then, according to indications, estrogen compounds or cyclic hormone therapy (estrogens with progesterone) are prescribed immediately. To induce ovulation, clomiphene citrate and gonadotropic hormones are used. In the process of hormonal therapy, before stimulating ovulation, you should make sure that the fallopian tubes are full and exclude the cervical factor (if this has not been done before). It is not advisable to use synthetic progestins. Clomiphene citrate is prescribed on the 5-9th day of the cycle at a dose of 50 mg to 150-200 mg / day. The dose is regulated by the effectiveness of the previous course of taking clomiphene.

Insufficiency of the luteal phase of the menstrual cycle is a polyetiological disease and is treated after the establishment and, if possible, elimination of the underlying cause (hyperandrogenemia, ovarian hypofunction, etc.). Progesterone is prescribed in the second phase of the cycle for 8-10 days with the introduction of the last dose 3-4 days before the expected menstruation. It is considered inappropriate to use norsteroids (norcolut, etc.), since they have a luteolytic effect. After 2-3 months from the start of treatment with progesterone, it is possible, according to indications, to use clomiphene citrate and gonadotropic drugs. There is a positive effect in this pathology of prostaglandinogenesis blockers (naprossin, aspirin, indomethacin), as well as luliberin (10-20 mcg subcutaneously or intravenously every 2-3 hours two nights a week during the 2nd phase of the cycle).

Treatment of infertility caused by hyperandrogenemia of ovarian origin (ovarian scleropolycystosis) is carried out by conservative and surgical methods.

The detection of hyperprolactinemia in infertility is the basis for treatment with Parlodel according to the schemes in accordance with the form of pathology. With a prolonged course of the disease and developed amenorrhea, after 2-3 months of using the drug, it is possible to conduct cyclic hormonal therapy (estrogens with gestagens) followed by stimulation of ovulation.

In the treatment of infertility due to hyperandrogenemia of adrenal origin (variants of AGS), the use of glucocorticoids (hydrocortisone, dexamethasone) is indicated, and then after 2-3 months of cyclic therapy - sex hormones. The final step will be the use of clomiphene and gonadotropic hormones to stimulate ovulation.

In case of endocrine pathology of tumor genesis (adrenal glands, pituitary gland), infertility treatment is carried out after a preliminary surgical intervention.

Infertility caused by the syndrome of luteinization of a non-ovulated follicle is insufficiently studied. This pathology is associated with hyperandrogenemia, hyperprolactinemia, stress and inflammatory processes. Therapy involves the elimination of the alleged cause, since there is no special therapy due to an unidentified etiology.

To assess the effectiveness of the treatment of all types of infertility of endocrine origin, a thorough examination is indicated. The same methods are used as for the diagnosis of this pathology. Particular attention is paid to the processes of maturation of follicles (ovulation) and transformation of the endometrium. Literature data and our observations indicate that the restoration of generative function in infertility of endocrine origin is achieved within 30-60% (depending on the form of pathology), although the restoration of menstrual function with ovulation is observed more often (up to 70-90%). In women with endocrine forms of infertility after treatment with clomiphene citrate, multiple pregnancies are often (up to 10%) observed. All of them belong to the risk group for the pathological course of pregnancy and childbirth (miscarriage, gestosis, anomalies of birth forces, bleeding, congenital malformations in fetuses and newborns, etc.).

Treatment of tubal and peritoneal infertility can be conservative and surgical. Conservative treatment for functional inferiority of the fallopian tubes can be carried out in the absence of anatomical changes, endocrine diseases and pathology in the husband, when an idiopathic form of infertility is established (without specific reasons). In this case, some drugs are used (antispasmodics, sedatives, tranquilizers, prostaglandin inhibitors), cyclic hormone therapy with estrogens and progestogens, psychotherapy, physiotherapy procedures (ultrasound, amplipulse therapy, ultrasound, hydrotherapy) are carried out. Such therapy is also the final stage after anti-inflammatory treatment for peritoneal infertility. Treatment of tubal and peritoneal infertility with anatomical changes involves the relief of the inflammatory process, the restoration of tubal patency and their functional usefulness. Initially, anti-inflammatory therapy is carried out using antibacterial agents (antibiotics, antiseptics, etc.), vitamins, physiotherapy procedures, prodigiosan. The choice of antibacterial agents depends on the results of bacteriological and bacterioscopic studies that determine the sensitivity of the genital tract flora to drugs. More often, broad-spectrum antibiotics are used (a combination of two drugs for two courses lasting 7-10 days). Such therapy should be carried out periodically for 6-10 months. When prescribing intensive courses of antibiotic therapy, it is important to prevent dysbacteriosis, candidiasis by introducing nystatin and enzymes. At the same time, intensive physiotherapeutic treatment is prescribed in outpatient, inpatient and sanatorium conditions. In most cases, in the presence of an adhesive process, balneo-mud treatment, hydromassages and gynecological massage can be effective. Restoration and assessment of the patency and functional state of the fallopian tubes are the final stage. For a long time, hydrotubation was considered the leading method. Various mixtures (enzymes, glucocorticoids, antiseptics) were used for its implementation. Hydrotubation is combined with antibiotic therapy and physiotherapy. However, the attitude towards this procedure has recently changed. This is due to frequent complications - the attachment of infection and damage to the fallopian tubes and the widespread introduction of laparoscopy for diagnostic and therapeutic purposes. Modern diagnostic methods make it possible to quickly resolve the issue of surgical treatment. It is believed that in the presence of saccular formations in the tubes (hypo-, hydrosalpinxes), even the restoration of their patency during treatment will not contribute to the rehabilitation of the generative function, and therefore timely surgical treatment is advisable. At the same time, the fact of possible fertilization in a test tube does not exclude the possibility of pregnancy even with functional inferiority of the tubes and with various damage to them.

Surgical treatment of tubal and peritoneal infertility began to be used in the 60-70s of the XX century. with the development of microsurgical techniques. When deciding on the surgical treatment of infertility after the necessary examination, there must be confidence in the possibility of eliminating its cause. An indicator of the success of such treatment is its end result - the birth of a full-term baby. It depends on many factors, the main of which are: definition of clear indications for surgical treatment; surgical technique; subsequent rehabilitation therapy. In case of tubal and peritoneal infertility, women with various types of pathology are subject to microsurgical treatment: adhesions involving the tubes and ovaries in the process, caused by inflammations and operations; coarse adhesions that clog the fallopian tube; variants of pelvic endometriosis with impaired patency or functional activity of the tubes. Tubal surgeries for the treatment of infertility include the following: salpingolysis, fimbriolysis and fimbrioplasty, salpingoplasty or salpingostomy, tubal anastomosis, implantation of the tubal into the uterus.

Treatment of infertility in endometriosis can be conservative (hormonal), surgical and combined. This tactic is determined by the multifactorial (endocrine disorders, adhesions) genesis of infertility in endometriosis. Surgical treatment of infertility in endometriosis in recent years is considered the most effective and the only one capable of eliminating foci of endometriosis. It is performed by laparoscopy or laparotomy. Surgical intervention for endometriosis in order to treat infertility should be conservative, organ-preserving, in contrast to radical operations that are performed at an older age. Combined treatment of infertility in endometriosis is also used: hormonal and surgical. In this case, hormonal therapy (with the same drugs) can be carried out before or after surgery. It is believed that a combination in which surgical treatment is preceded by hormonal treatment is more effective. In moderate and mild forms of endometriosis, infertility treatment can begin with hormonal therapy, and then, in the absence of positive results, switch to a combined one. Severe forms of endometriosis are an indication for surgical intervention, often radical (no longer organ-preserving). Surgical treatment of infertility is also carried out with isthmic-cervical insufficiency, tumor diseases, anomalies in the development and position of the genital organs, with certain types of endocrine pathology (sclerocystosis, macroprolactinomas, etc.).

Treatment of immunological infertility is not effective enough. Glucocorticosteroids, cyclic hormone therapy with estrogen, antihistamines, anabolic hormones are used for this purpose. It is recommended to use a condom for 5-7 months in order to eliminate the entry of antigens into the body of a woman and reduce sensitization. The greatest success in the treatment of immunological infertility has been achieved with intrauterine insemination with the husband's sperm.

We can talk about infertility if a woman does not become pregnant during a year with regular sexual intercourse without using contraceptives. In 40% of cases, it is associated with diseases in men, in 45% in women. In the remaining 15 out of 100 cases of infertility, both partners have its cause.

This is a condition where a woman has never become pregnant in her life, subject to regular sexual contact and in the absence of contraception. With secondary infertility, a woman previously had a pregnancy, but subsequently, as a result of any diseases, the ability to bear a child disappeared. Among all infertile women, the primary form is observed in 60%, the secondary - in 40%.

Primary female infertility can be relative and absolute. In the first case, pregnancy is possible; in the second, conception and gestation do not occur in natural conditions. A typical example of relative primary infertility in a woman is the absence of children in a marriage with an infertile man.

What causes infertility in women?

The main causes of primary infertility are associated with anatomical disorders in the structure of the genital organs:

• infantilism (underdevelopment);
• congenital developmental anomalies;
• incorrect position of the uterus;
• sexually transmitted infections.

In addition, this form of pregnancy pathology may be associated with disruption of the ovaries, changes in ovulation and the menstrual cycle.

Inflammatory processes in the genital tract, tumors, intoxication, endocrine and other serious diseases most often cause secondary infertility.

Primary infertility is a pathology that can occur as a result of psycho-emotional changes. , in which the egg is not capable of fertilization, appear due to prolonged stress, conflicts in the family, dissatisfaction with intimate life. They can be provoked by fear of pregnancy or, on the contrary, by a passionate desire to have a child.

In addition to suppressing ovulation, these factors contribute to the release of stress hormones and change the activity of the autonomic nervous system. As a result, the contractile activity of the fallopian tubes is disrupted and functional tubal obstruction is formed. This combination of ovulation disorders and the functioning of the uterus is difficult to diagnose.

The unfulfilled desire to become a mother leads to chronic nervous tension and further reduces the likelihood of fertilization. Thus, a vicious circle of fruitless marriage is formed.

Factors that can provoke primary infertility in women:

• diseases of the endocrine glands;
• damage to the fallopian tubes or peritoneum;
• gynecological diseases;
• immune incompatibility.

Endocrine disorders can cause primary infertility if they appear at a young age before the first pregnancy. They are associated with a violation of the ovulatory cycle, which occurs for one of the following reasons:

• insufficiency of the luteal phase during the menstrual cycle;
• luteinization of the follicle without ovulation.

Anovulation is the absence of egg maturation, which can be caused by pathology of the pituitary gland, hypothalamus, ovaries, adrenal glands. The absence of ovulation leads to an increase in the content of male sex hormones in the blood - androgens, prolactin; lack of female sex hormones - estrogens; overweight or wasting. Anovulatory infertility can be caused by Itsenko-Cushing's syndrome or disease, as well as thyroid diseases with impaired production of thyroid hormones (hypo- or hyperthyroidism).

Hormonal disorders are often associated with traumatic brain injury, encephalitis, and prolonged stress. In addition to anovulation, they can provoke insufficiency of the luteal phase of the menstrual cycle. At the same time, the ovaries do not provide the production of hormones responsible for preparing the endometrium of the uterus for pregnancy. The mucous membrane of the uterus does not thicken, as a result, the embryo formed during conception cannot attach to it. Spontaneous abortion occurs even before the expected delay in menstruation.

Sometimes the follicle in which the egg matures prematurely turns into a corpus luteum, and ovulation does not occur. The reasons for this condition are unknown.

Damage to the fallopian tubes or peritoneum is more characteristic of secondary infertility. It can cause an initial inability to become pregnant if the disease develops in a girl or teenager.

Violation of the function of the fallopian tubes, not accompanied by structural changes in these organs, can occur against the background of stress, an increase in the concentration of androgens in the blood, as well as in chronic inflammatory processes in the body, in which the content of prostacyclins increases.

The main cause of primary tubal infertility is tuberculosis of the reproductive system.

Peritoneal infertility may appear as a result of a pronounced adhesive process in the abdominal cavity. Such adhesions are formed after extensive operations on the abdominal organs.

Gynecological diseases most often lead to secondary infertility, the primary form of pathology is caused by anomalies in the development of the uterus.

In rare cases, the cause of infertility is the production of antibodies in the female body that destroy the sperm of the sexual partner (). However, it has been found that such immunoglobulins can also be found in a compatible couple. Therefore, the determination of antisperm antibodies in clinical practice is not used.

One cause of the pathology is detected only in 48% of women, in other cases, primary infertility of combined genesis is recorded. This must be taken into account when planning pregnancy. The later a woman decides to become pregnant, the more likely she is to "accumulate" several risk factors for infertility.

Diagnostics

In order to make a diagnosis of "primary infertility", the doctor must ask and examine the patient.

The following questions are clarified:

• At what age did menstruation begin?
• how long the cycle lasts, whether menstruation begins regularly;
• Is there any spotting between periods?
• painful menstruation;
• whether the woman had a pregnancy in the past;
• used contraception and duration of its use;
• duration of infertility;
• regularity of sexual activity.

The doctor looks for signs of diseases of other organs: diabetes, tuberculosis, diseases of the adrenal glands and the thyroid gland. The patient is asked about possible psychogenic factors.

During an external examination, attention is paid to excess body weight, skin condition, the presence of acne, facial hair.

Performed and gynecological organs. Within 3 months, a woman should measure her basal body temperature. A study of smears from the vagina, from the surface of the cervix. If necessary, prescribe seeding for microflora, polymerase chain reaction to identify possible infectious factors.

If endocrine infertility is suspected, it is necessary to find the affected link in the "hypothalamus - pituitary gland - ovaries" system. For this purpose, x-rays are prescribed, computer or magnetic resonance imaging of the skull and the Turkish saddle, the fundus is examined, ultrasound of the thyroid gland, ovaries and adrenal glands is performed.

Analyze the hormonal background in detail:

• follicle stimulating hormone;
• luteinizing hormone;
• prolactin;
• thyroid-stimulating hormone;
• adrenocorticotropic hormone;
• estradiol;
• progesterone;
• thyroxine and triiodothyronine;
• cortisol;
• testosterone;
• DHEA-S.

With concomitant obesity, a glucose tolerance test is prescribed to detect diabetes mellitus.

Insufficiency of the luteal phase is diagnosed according to the measurement of basal temperature. With this pathology, the second phase of the cycle is shortened to 10 days, and the temperature difference before and after ovulation does not exceed 0.6 ° C. The diagnosis is confirmed by detecting a reduced level of progesterone one week after ovulation (day 21 of the cycle).

Luteinization of a non-ovulated follicle is recognized by repeated ultrasounds. According to this study, the follicle first increases in size, then its growth stops. Ovulation does not occur, the follicle shrinks.

Tubal-peritoneal and gynecological infertility is most often secondary. For its diagnosis use:

• hysterosonography;

Using these methods, it is possible to find structural changes that prevent the development of pregnancy. The same studies are often prescribed for primary infertility.

One of the best research methods to detect a violation of the structure of the genital organs is a spiral computed tomography of the pelvic organs. Magnetic resonance imaging of this area is also used, but its diagnostic value is somewhat lower.

For the diagnosis of immunological infertility, a postcoital test is performed. To do this, determine the number and nature of the movements of spermatozoa in the cervical mucus on the 12-14th day of the cycle. If the spermatozoa are immobile or not detected, this may be a sign of the immune incompatibility of the sexual partners.

In rare cases, the content of antisperm antibodies is determined in the blood or cervical mucus; however, this test is non-specific and should not be used.

Simultaneously with the examination, women take a semen analysis from her partner to rule out male infertility.

Treatment

Therapy begins with attempts to normalize the emotional state of the patient. Consultation of a medical psychologist, psychotherapist is appointed. In some cases, seeing a psychiatrist and prescribing sedatives or tranquilizers is helpful. Sometimes these measures help to solve the problem of infertility without stimulating ovulation.

It is important to normalize body weight. In some cases, weight loss contributes to the onset of pregnancy, as this normalizes the production of gonadotropic hormones from the pituitary gland.

If sexually transmitted infections are detected, the woman is prescribed appropriate antibiotics.

If the cause of infertility is a pituitary tumor, the woman is referred to a neurosurgeon. Functional hormonal disorders require the appointment of appropriate drugs.

If the cause of infertility is infantilism, the patient is prescribed physiotherapy and gynecological massage. In the first phase of the cycle, B vitamins should be taken, folic acid in primary infertility is necessary to prevent congenital pathology in the fetus. In the second phase, vitamins A and E are shown. In addition, a course of oral contraceptives is prescribed. If these measures do not help, ovulation is stimulated, and if it is ineffective, assisted reproductive technologies are used.

With endocrine infertility, ovulation stimulation is often used. Such treatment of primary infertility is carried out using the following drugs:

• monophasic combined oral contraceptives for 3 cycles;
• Clomiphene from 5 to 9 days of the cycle;
• preparations of gonadotropins (follicle-stimulating, luteinizing hormones, followed by the introduction of chorionic gonadotropin).

Ovulation stimulation is a complex procedure, its plan is formed individually for each patient. What helps one woman can only hurt another. Therefore, for all questions related to this method of treatment, you need to personally consult with a qualified gynecologist.

If pregnancy has not occurred within a year of treatment, the patient is referred for laparoscopy.

Treat with laparoscopic intervention, for example, dissect adhesions in the abdominal cavity. In case of severe obstruction of the tubes, it is carried out, and IVF is used for pregnancy.

If immunological infertility is diagnosed, the couple is advised to use contraception with condoms for six months. Within 3 days before ovulation, the patient is prescribed estrogenic drugs. After the termination of barrier contraception, a desired pregnancy often occurs.

Primary infertility in men requires, first of all, stopping smoking, drinking alcohol, normalizing the regimen and physical activity. The patient is examined by an andrologist, after which appropriate therapy is prescribed. In case of pathology of the vas deferens, it is proposed to take sperm directly from the epididymis or the testicle itself, followed by artificial insemination (introduction into the woman's uterus).

If therapy is ineffective for 2 years, assisted reproductive technologies are used - artificial insemination or. If at the time of the diagnosis of "primary infertility" the woman is already 35 years old, conservative methods of treatment should not be used at all. In these cases, it is necessary to use assisted reproductive technologies as soon as possible.

The success of treatment depends on many factors and cannot be predicted in advance. It must be remembered that the psychological state of a woman is very important in her fertility. On average, as a result of treatment with ovulation stimulation, pregnancy occurs within a year in about half of patients with primary infertility. The prognosis is worse for diseases such as those accompanied by a lack of egg maturation and menstruation. In this case, modern medical technologies help.

male infertility

If the couple does not have children, both partners should be examined.

Primary male infertility can be caused by such reasons:

• varicocele;
• orchitis transferred in childhood, for example, with mumps (mumps);
• anomalies in the development of the reproductive system;
• endocrine diseases in a child or adolescent.

The main method for diagnosing such a condition is. This biological fluid is examined according to the protocol approved by the World Health Organization. An andrologist or urologist should interpret the results.

If the spermogram is within the normal range, the man is considered healthy. If abnormalities are detected, the patient is prescribed a urological examination. Sometimes it is necessary to consult an endocrinologist or geneticist.

Primary infertility in women is a condition in which a woman has never had a pregnancy, and we are talking about any pregnancy (ectopic, spontaneous miscarriage, abortion or childbirth). The prevalence of this pathological condition is steadily increasing, leading to serious socio-medical consequences. Therefore, it is necessary to examine a married couple in order to establish the cause of infertility and conduct targeted treatment.

Causes of infertility

The primary absence of pregnancies in history may be due to the following causative factors:

• endometriosis and infertility is a frequent tandem, as it has a complex mechanism of fertility disorders (it is associated with the development of adhesions, immune changes, hormonal imbalance, etc.);
• the consequences of abortions, in which there is often a cervical and uterine factor of infertility;
• hormonal disorders that develop after emergency contraception (postinor is a drug with a large dose of hormones that prevents the implantation of a fertilized egg);
• inflammatory processes of the genital organs in women;
• the consequences of operations that lead to obstruction of the fallopian tubes;
• immune infertility, which may be associated with damage to the egg, sperm or fertilization processes;
• hormonal disorders against the background of various genital and extragenital causes, in which there is no ovulation;
• idiopathic infertility, in which it is not possible to establish the possible cause of this pathological condition. In this case, most likely, we are talking about the lack of a complete examination of women and men as a result of various reasons (imperfection of the diagnostic base).

Diagnostic search for infertility

Anovulation (lack of ovulation) is the most common cause of infertility. Therefore, the diagnostic search for primary infertility begins with this causal factor. On this basis, three fundamentally different forms are distinguished, which determine one or another treatment tactic. With this in mind, it is customary to distinguish:

• normogonadotropic anovulatory infertility - the level of luteinizing and follicle-stimulating hormones produced by the pituitary gland remains within the normal range;
• hypogonadotropic anovulatory infertility - the level of tropic pituitary hormones is reduced;
• hypergonadotropic anovulatory infertility, in which there is an increase in the level of hormones synthesized by the pituitary gland.

Therefore, at the first stage of diagnosing infertility, it is shown to determine the blood levels of luteinizing and follicle-stimulating hormones, as well as progesterone and estradiol, taking into account the phase of the menstrual cycle. Hormonal disorders are usually associated with certain clinical and anamnestic data. This may be a postinor taken for the purpose of emergency contraception, menstrual disorders, etc.

Principles of infertility treatment

The treatment of the primary depends on the causative factor. Taking into account the main treatment tactics, it is advisable to distinguish the following categories of primary infertility:

• anovulatory, including postinor-associated infertility;
• infectious-dependent;
• adhesive;
• endometriosis-associated;
• idiopathic infertility.

Let's look at how infertility treatment looks like in each of these groups. With anovulatory infertility, which also develops if postinor is taken to prevent unwanted pregnancy, treatment is based on the following principles:

• correction of existing hormonal changes;
• after that, ovulation is stimulated so that several eggs mature and one of them comes out;
• support for the second phase of the menstrual cycle, as well as when pregnancy occurs, it is indicated to continue taking hormone therapy.

Treatment of infertility caused by infectious and inflammatory processes involves the appointment of the following drugs:

• broad-spectrum antibiotics, taking into account the sensitivity of microorganisms that are pathogens;
• immunostimulating agents;
• vitamin preparations;
• hormonal agents, if there are certain violations in the hormonal background, especially if Postinor was previously taken after unprotected intercourse.

In the event that there is adhesive obstruction of the fallopian tubes, then a laparoscopic intervention is indicated. Its purpose is to dissect adhesions that compress the fallopian tube from the outside, and plastic surgery is also performed for deformities of the fallopian tube. The effectiveness of the treatment in this case depends on the degree of adhesions. The higher it is, the less chance of pregnancy.

Primary infertility associated with endometriosis implies complex therapy aimed at eliminating existing disorders. The main principles of treatment in this case are:

• treatment of hormonal disorders (combined oral contraceptives, purely progestogen drugs, gonadoliberin agonists, antigonadotropins may be prescribed);
• dissection of adhesions, if any;
• ovulation stimulation and support of the second phase of the menstrual cycle, since there is almost always a relative or absolute progesterone deficiency.

However, the greatest difficulties arise in the treatment of immune and idiopathic infertility. Usually in such a situation, the use of assisted reproduction methods is indicated.

Prevention of infertility in women

A large place in the preservation of women's reproductive health is given to preventive measures. These include the following:

• treatment of concomitant diseases in women;
• normalization of the menstrual cycle;
• protection from unwanted pregnancy (postinor is not recommended for this purpose, it is necessary to give preference to planned contraception);
• prevention of abortions (both medical and traditional), the consequences of which in relation to reproductive function are extremely negative;
• exclusion of hypothermia;
• observance of sexual culture, which reduces the risk of inflammatory diseases of the female genital area;
• timely treatment and observation by a gynecologist and other specialists.

Summing up all of the above, it should be noted that primary infertility is a serious problem that has severe medical and social consequences. Therefore, it is necessary to start a diagnostic search as early as possible, which allows you to clarify the possible cause of this pathological condition. Having found out the underlying disease, it is possible in most cases to conduct effective treatment.

The real scourge of gynecology is infertility. Symptoms of this diagnosis are manifested in the inability of a woman to become pregnant within 1 year of active sexual activity with a healthy man without the use of contraception. Primary infertility is the inability of a woman to become pregnant from the beginning of her reproductive years. That is, conception never occurred. Unfortunately, this diagnosis is not rare for modern couples. A woman with 1st degree infertility has neither the experience of pregnancy nor a single child yet. The suppressed feeling of the impossibility of becoming a mother causes only apathy for everything that happens around. But do not despair. Today, there are not many diseases left that forever deprive a woman of the opportunity to find parental happiness. This article presents the main causes and methods of treatment for primary infertility.

Causes of infertility of the 1st degree. Treatment

A woman is not able to conceive a child subsequently due to congenital or acquired pathology, as well as due to experienced infectious diseases of the internal genital organs. For example, among the pathologies that develop in women are uterine fibroids, cervical erosion, cysts and other gynecological diseases. Ovarian pathologies are also very common. When the ovarian follicles do not work properly, there may be problems with the maturation of the egg. Such diseases are manifested by a prolonged absence of menstruation and prolonged bleeding when they appear.

Infertility of the 1st degree can occur after the termination of the first pregnancy in a woman. As a result of abortion, the female hormones produced during the process of conception and the formation of the fetus turned out to be unnecessary and provoked a hormonal failure in the body.

Another cause of primary infertility in this case is the possible traumatization of the internal genital organs due to abortion. Adhesions that cause obstruction of the fallopian tubes are possible. Because of this, the egg simply cannot pass into the uterine cavity and be fertilized. Read more about all the causes of infertility below.

1. Ovulation does not occur. The hormonal failure that occurs in the body of a woman prevents the release of a healthy egg. This is manifested by a failure of menstruation, an abnormal amount of bleeding. Treatment consists in therapy with medications that stimulate ovulation.
2. Poor quality egg. The older the woman, the worse the quality of the egg becomes. In women who want to become pregnant after age 40, the egg that is released may be abnormal. The way out of the situation: a surrogate mother or implantation of an egg from a donor.
3. Endometriosis. The disease consists in the growth of endometrial tissue outside the uterus. Endometriosis is manifested by quite painful sensations during menstruation. Is fraught with miscarriages. Treatment is surgical only. The overgrown tissue is removed and the patency of the fallopian tubes is restored.
4. . Obstruction is said to be when the egg is unable to reach the uterus. In this way, the sperm will not reach the egg. Infertility of the 1st degree in women of this nature can be the cause of inflammatory processes in the genital organs, as well as sexually transmitted infections.
5. Polycystic ovaries. Multiple cysts in the ovaries cause a hormonal imbalance, a delay in menstruation, and, consequently, ovulation. Polycystic disease is manifested by an unexpected increase in body weight, rapid growth of body hair, and acne. Treatment consists of taking drugs that stimulate ovulation.

Diagnosis performed by a specialist will help to find out the cause and begin to determine the path of treatment. Primary infertility can be overcome. Modern medicine is able to work miracles in the truest sense of the word. An extreme solution to the problem of infertility of the 1st degree may be IVF or surrogacy. A good mood, the belief that everything will work out and the fulfillment of all the requirements of the attending physician - these are the components of success on the path to motherhood.

Obstetrician-gynecologist Andreeva O.V. speaks of primary and .

Female infertility is the inability of a woman to conceive at childbearing age.

ICD-10 code

N97 Female infertility

Epidemiology

The frequency of infertile marriages is 15-17%, of which female infertility accounts for 40-60%. The most common forms of female infertility are tubal-peritoneal (50–60%) and anovulatory (endocrine) (30–40%) forms, as well as external genital endometriosis (25%); combined forms of infertility account for 20-30%. In 2–3% of cases, the cause of infertility cannot be determined.

At each site of the reproductive system of the male and female body, pathological processes can occur that disrupt the complex biological mechanism of their work and lead to infertility.

There are primary and secondary infertility. Primary infertility - infertility in women (or men) who live a regular sexual life without contraception and without the onset of pregnancy (in men - infertile sperm). Secondary infertility is the absence of pregnancy (the ability to fertilize in men) within a year of regular sexual activity after previous pregnancies. Absolute infertility is infertility associated with the absence or anomalies in the development of the genital organs.

The presence of various forms of infertility in one of the partners is defined as combined infertility, the presence of infertility factors in both partners is a combined form of infertility in a couple.

One of the most important problems in gynecology and reproduction is infertile marriage. Barren marriages, which make up 15% of married couples in Russia, are associated with the problem of the childless future of millions of citizens, the decline and loss of the nation's gene pool. Maybe. this problem is more relevant than many others in medicine, because only after the birth of a person can we talk about the importance and significance of providing him with one or another medical care.

• Reproductivity is the property of reproducing similar individuals to itself, which ensures the continuity and continuity of life.
• Reproductive health is defined by WHO as the absence of diseases of the reproductive system or disorders of the reproductive function, with the possibility of carrying out reproductive processes in complete physical, mental and social well-being.
• Sexual health is a combination of physical, emotional and social aspects of sexual life, which positively enriches the personality, promotes mutual understanding and love.
• Family planning is a set of socio-economic, legal, medical measures aimed at the birth of healthy children desired by the family, the prevention of abortions, the preservation of reproductive health, and the achievement of harmony in marriage.
• Fertility is the ability to reproduce offspring.
• Sterility is the inability to reproduce offspring.
• Infertile marriage is the absence of pregnancy within 12 months. regular sexual life without the use of any means of contraception, provided that the spouses (sexual partners) are of childbearing age (WHO).

Causes of infertility in women

Female infertility can be the result of many diseases and conditions.

Primary infertility in women

• Genital infantilism, anomalies in the development of female genital organs.
• Dysregulation of the hormonal function of the ovaries, functional insufficiency of the sex glands.
• Diseases of the uterus and uterine appendages that prevent pregnancy.

Secondary infertility in women

• Inflammatory diseases of the female genital organs, complications after abortion, IUD.
• Diseases of the endocrine system.
• Tumors of the genital organs.
• Ectopic pregnancy.
• Somatic diseases (tuberculosis, collagenosis, blood diseases, etc.).
• Traumatic injuries of the vagina, cervix, perineum.
• Chronic intoxication (alcohol, nicotine, salts of heavy metals, etc.).
• Industrial and professional factors (microwave field, low doses of ionizing radiation).
• Inadequate nutrition.

The main cause of female infertility is inflammatory diseases of the female genital organs or their consequences (in 60-70% of cases). Among the inflammatory processes, infertility is most often accompanied by inflammation of the uterine appendages, in which there is obstruction of the fallopian tubes, various violations of the functional state of the ovaries.

Especially often, obstruction of the fallopian tubes occurs with gonorrheal salpingitis, but it can also be the result of nonspecific inflammation. Infertility often occurs after an abortion or pathological childbirth. Abortion may result in salpingitis with the development of obstruction of the fallopian tubes and damage to the uterine mucosa

Salpingitis leads not only to obstruction of the fallopian tubes, but also to a violation of their motor activity, to degenerative changes in the mucous membrane of the fallopian tube, preventing fertilization.

With inflammation of the ovaries, ovulation can be disturbed, in connection with which the egg does not enter the abdominal cavity, and when adhesions form around the ovary (in the case of normal ovulation), it cannot enter the tube. In addition, oophoritis can disrupt the endocrine function of the ovaries.

The role of endocervicitis in the etiology of infertility is significant, since they change the function of the epithelium of the cervical canal. Colpitis can also be the cause of infertility (changes in the properties of the vaginal fluid against the background of various diseases can lead to the death of spermatozoa).

In the etiology of infertility, endocrine disorders occur in 40-60% of cases. In this case, the function of the ovaries can be impaired primarily, which is observed with abnormalities in the development of the genital organs or with damage to the ovarian follicular apparatus due to infectious diseases or intoxications (the process of maturation of the egg and ovulation is disturbed, the hormonal function of the ovaries decreases, which is necessary for maturation, transport of the egg and her fertilization).

Infantilism and hypoplasia of the genital organs can cause infertility in women. At the same time, both anatomical and functional features of the reproductive system associated with its underdevelopment contribute to infertility (a long narrow vagina with a shallow posterior fornix, a narrow cervical canal, a decrease in ovarian hormonal function, inferiority of cyclic processes in the endometrium, impaired function of the fallopian tubes, etc. ).

Ovarian function may change secondarily due to diseases of the pituitary gland, thyroid gland, adrenal glands. Diseases such as myxedema, hypothyroidism, severe forms of diabetes mellitus, Itsenko-Cushing's disease, obesity, etc., lead to infertility.

Infertility can be caused by injuries and displacements of the genital organs (old rupture of the perineum, gaping of the genital slit, pubescence of the walls of the vagina, kinks and displacements of the uterus, eversion of the cervix, urogenital fistulas, synechia of the uterine cavity, infection of the cervical canal).

Infertility in some cases is a concomitant symptom of endometriosis, tumors of the female genital organs.

General diseases and intoxications (tuberculosis, syphilis, alcoholism, etc.), as well as malnutrition, beriberi, mental illness cause complex disorders leading to ovarian dysfunction, in connection with which infertility can also occur.

The cause of infertility is immunological factors (the formation of antibodies to spermatozoa in a woman's body).

The frequency of detection of various factors of reproductive dysfunction in married couples.

It should be taken into account that among women suffering from infertility, more than 60% have two or more factors of impaired fertility.

Pathological cervical mucus

Abnormal cervical mucus can impair fertility by inhibiting penetration or increasing sperm destruction. Normally, cervical mucus changes from thick, impenetrable to thinner, clearer, and more stretchable by increasing estradiol levels during the follicular phase of the menstrual cycle. Abnormal cervical mucus may remain impervious to sperm by the time of ovulation or may cause sperm destruction, facilitating the influx of vaginal bacteria (eg, as a result of cervicitis). Sometimes abnormal cervical mucus contains antibodies to sperm. Pathological mucus rarely significantly impairs fertility, except in cases of chronic cervicitis or cervical stenosis as a result of treatment for cervical intraepithelial neoplasia.

Women are examined for cervicitis and cervical stenosis. If they do not have any of these disorders, then a postcoital examination of cervical mucus is performed to detect infertility.

Decreased ovarian reserve

Reduced ovarian reserve is a decrease in the number or quality of oocytes, resulting in reduced fertility. Ovarian reserve may begin to decline by age 30 or earlier, and decline rapidly after age 40. Ovarian lesions also reduce the reserve. Although older age is a risk factor for reduced ovarian reserve, both age and reduced ovarian reserve are in themselves indicators of infertility and result in poorer treatment outcomes.

Tests for reduced ovarian reserve are available for women over 35 years of age who have had ovarian surgery or who have not responded to exogenous gonadotropin ovarian stimulation. Diagnosis can be suggested by detecting FSH levels greater than 10 mIU/ml or estradiol levels less than 80 pg/ml per day three times during the menstrual cycle. Diagnosis can be made by giving a woman clomiphene 100 mg orally once a day on days 5-9 of the menstrual cycle (clomiphene citrate confirms the test). A significant increase in FSH and estradiol levels from days 3 to 10 of the cycle indicates a decrease in ovarian reserve. In women over 42 years of age or with a decrease in ovarian reserve, donor oocytes may be used.

Other causes of female infertility

• Problems with ovulation

A menstrual cycle lasting less than twenty-one days and more than thirty-five may signal the inability of the egg to be fertilized. If ovulation does not occur, the ovaries are not able to produce mature follicles, and, accordingly, eggs that can be fertilized. This cause of female infertility is one of the most common.

• Ovarian dysfunction

Violation of hormone production in the hypothalamus-pituitary system can sometimes cause ovarian dysfunction. Luteotropin and follitropin are produced either in very large or in very small quantities, their ratio is also disturbed, and, as a result, the follicle does not mature enough, the egg is not viable or does not mature at all. The cause of such dysfunction may be a head injury, a tumor, or other disorders in the lower cerebral appendage.

• Hormonal disbalance

Hormonal failure in the body can lead to the disappearance of menstruation or the immaturity of the egg. Such a disorder has many causes, including genetic predisposition, past infectious diseases, weakened immune system, endocrine diseases, surgical interventions and injuries of the abdominal organs and the genitourinary system.

• genetic predisposition

Female infertility can be caused by genetic factors, a hereditary predisposition in which the egg cannot mature.

• Polycystic ovaries

With polycystic disease, the production of follitropin decreases, while the level of luteotropin, estrogen and testosterone remains normal or exceeds it. There is an opinion that a reduced level of follitropin provokes insufficient development of follicles, which are produced by the ovaries. As a result of this, the formation of multiple follicular cysts (up to six to eight millimeters) occurs, which are diagnosed by ultrasound. The affected ovary is usually enlarged, a white capsule forms on its surface, through which the egg cannot pass, even if it is ripe.

• Cervical canal disorders

As a result of such violations, spermatozoa are not able to penetrate the uterine mucosa, which causes their death.

• Cervical erosion

The cause of female infertility can be such a pathology as erosion - ulcerative formations on the mucous membrane of the cervix, which can be congenital or occur due to infections and injuries. The development of pathology is facilitated by hormonal disorders, menstrual cycle failure, earlier onset of sexual relations, the absence of a permanent sexual partner, and weak immunity. As a rule, such a pathology is asymptomatic and is determined during examination by a gynecologist. Sometimes there may be discharge from the genital organs of a brown hue and pain during intercourse.

• Scars on the lining of the ovaries

This pathology leads to the fact that the ovaries lose the ability to produce follicles, resulting in no ovulation. Scars can appear after operations (for example, when removing cysts) and infectious pathologies.

• Unexploded follicle syndrome

With this syndrome, the mature follicle does not rupture and is converted into a cyst. The causes of such a disorder may be hormonal disorders, thickening of the ovarian capsule, or pathology of its structure. However, this phenomenon has not been fully investigated.

• endometriosis

With such a disease, endometrial cells begin to grow and form polyps that penetrate not only into the fallopian tubes and ovaries, but into the abdominal cavity. Such a disease does not allow the egg to mature and prevents its fusion with the sperm, and in case of fertilization, it prevents the egg from attaching to the uterine wall.

• Psychological factor

Frequent stressful situations can lead to disruption of natural physiological functions, which has a negative impact on the fertilization process. Psychological factors also include female infertility of unknown origin (approximately ten percent of couples do not show any disorders provoking female infertility).

• Pathology of the structure of the uterus

Any deformation of the uterus has an effect like an IUD - it prevents the egg from gaining a foothold on the endometrium. Such pathologies include polyps and uterine fibroids, endometriosis, as well as congenital pathologies of the structure.

Diagnosis of infertility in women

When conducting a diagnosis, it is necessary to examine both partners, regardless of the complaints. First of all, it is necessary to exclude the presence of sexually transmitted diseases, hereditary pathologies and diseases of the endocrine system. After all the necessary information about the presence or absence of concomitant diseases is collected, the patient is examined according to secondary sexual characteristics, a rectal examination and an examination of the pelvic organs are performed.

Diagnostic procedures also include hysterosalpingography (performed on the sixth to eighth day from the start of the cycle). With the help of hysterosalpingography, the condition of the uterine cavity and tubes is determined. Through the cervical canal they are filled with a contrast agent. If the fallopian tubes have normal patency, then this solution is not retained in them and penetrates into the abdominal cavity. Also, with the help of hysterosalpingography, other pathologies of the uterus can be diagnosed. To diagnose the disease, ultrasonic biometry of follicle growth is also used (on the eighth to fourteenth day of the cycle), hormonal research (luteotropin, follitropin, testosterone - on the third to fifth day of the cycle), on the nineteenth to twenty-fourth day of the cycle, the level of progesterone is determined, in two to three days before the onset of menstruation, endometrial biopsy is performed.

Diagnosis of an infertile marriage involves the examination of both sexual partners, diagnostic measures should be carried out in full to identify all possible factors of infertility in both women and men.

• the number and outcomes of previous pregnancies: spontaneous and induced abortions, including criminal ones; ectopic pregnancy, hydatidiform drift, number of live children, postpartum and post-abortion complications;
• duration of primary or secondary infertility;
• the methods of contraception used and the duration of their use after the last pregnancy or in case of primary infertility;
• systemic diseases: diabetes, tuberculosis, diseases of the thyroid gland, adrenal cortex, etc.;
• drug treatment that can have a short-term or long-term negative effect on the processes of ovulation: cytotoxic drugs and radiotherapy of the abdominal organs; psychopharmacological agents such as tranquilizers;
• operations that could contribute to the occurrence of infertility: appendectomy, wedge resection of the ovaries, operations on the uterus and others; during the postoperative period;
• inflammatory processes in the pelvic organs and sexually transmitted diseases, type of pathogen, duration and nature of therapy;
• endometrioid disease;
• the nature of vaginal discharge, examination, treatment (conservative, cryo- or electrocoagulation);
• the presence of secretions from the mammary glands, their relationship with lactation, duration;
• production factors and the environment - epidemic factors; alcohol abuse, taking toxic drugs, smoking, etc.;
• hereditary diseases, taking into account relatives of the first and second degree of kinship;
• menstrual and ovulatory history; polymenorrhea; dysmenorrhea; the first day of the last menstruation;
• sexual function, pain during sexual activity (dyspareunia).

Objective examination

• height and body weight; weight gain after marriage, stressful situations, climate change, etc .;
• development of the mammary glands, the presence of galactorrhea;
• hair growth and the nature of its distribution; skin condition (dry, oily, aspae vulgaris, striae);

Examination of body systems:

• measurement of blood pressure;
• X-ray of the skull and Turkish saddle;
• fundus and visual fields.

Gynecological examination data

When conducting a gynecological examination, the day of the cycle corresponding to the date of the study is taken into account. The degree and features of the development of the external genital organs, the size of the clitoris, the nature of hair growth, the characteristics of the vagina, cervix, uterus and appendages, the state of the sacro-uterine ligaments, the presence and nature of discharge from the cervical canal and vagina are assessed.

Colposcopy or microcolposcopy is a mandatory method of examination at the first examination of the patient, it allows to identify Signs of colpitis, cervicitis, endocervicitis and cervical erosion, which can cause infertility and be a sign of chronic infection of the genitals.

Laboratory and instrumental examination methods

Of great importance in the correct diagnosis of infertility in a woman is the implementation of additional laboratory and instrumental methods of examination. Compliance with the timing of the main methods of examination of women allows you to avoid false-positive and false-negative results of these studies. WHO recommends the following frequency and terms of laboratory examination of women with infertility:

• functional diagnostic tests - 2-3 cycles;
• hormonal studies (LH, FSH, prolactin, testosterone, DEA) on the 3rd–5th day of the menstrual cycle; in the middle of the cycle and in the second phase;
• hysterosalpingography on the 6-8th day of the menstrual cycle; kymopertubation - on the days of ovulation;
• Ultrasound biometrics of follicle growth on the 8th-14th day of the menstrual cycle;
• immunological tests - on the 12-14th day of the menstrual cycle.

Immune forms of infertility are caused by the appearance of antisperm antibodies, more often in men and less often in women.

One test that suggests immunological incompatibility is the postcoital test (PCT), known as the Sims-Huner test or the Shuvarsky test. The test allows you to indirectly judge the presence of antisperm antibodies. The most significant clinical manifestation of immunological disorders is the presence of specific antibodies to spermatozoa. In women, antisperm antibodies (ASAT) may be present in serum, cervical mucus, and peritoneal fluid. The frequency of their detection ranges from 5 to 65%. The examination of a married couple should include the determination of antisperm antibodies already at the first stages, and first of all in the husband, since the presence of antisperm antibodies in the ejaculate is evidence of the immune factor of infertility.

Postcoital test (Shuvarsky-Sims-Huner test) - is performed to determine the number and motility of spermatozoa in the cervical mucus. Before the postcoital test, partners should abstain from sexual activity for 2-3 days. Advancing spermatozoa can be detected in cervical mucus within 10-150 minutes. after sexual intercourse. The optimal interval before the test should be 2.5 hours. Cervical mucus is taken with a pipette. If, with normozoospermia, 10–20 advancing spermatozoa can be seen in each field of view, then the cervical factor as the cause of infertility can be excluded.

Determination of antisperm antibodies in women in the mucus of the cervical canal: on preovulatory days, mucus is taken from the cervical canal to quantify antibodies of three classes - IgG, IgA, IgM. Normally, the amount of IgG does not exceed 14%; IgA - 15%; IgM - 6%.

• laparoscopy with the determination of the patency of the fallopian tubes - on the 18th day of the menstrual cycle;
• determination of the level of progesterone on the 19-24th day of the menstrual cycle;
• biopsy of the endometrium 2-3 days before the onset of menstruation.

A comprehensive clinical and laboratory examination of women in infertile marriages reveals the following causes of infertility:

• sexual dysfunction.
• Hyperprolactinemia.
• Organic disorders of the hypothalamic-pituitary region.
• Amenorrhea with elevated FSH levels.
• Amenorrhea with normal estradiol levels.
• Amenorrhea with reduced estradiol levels.
• Oligomenorrhea.
• Irregular menstrual cycle and/or anovulation.
• Aiovulation with regular menstruation.
• Congenital anomalies of the genital organs.
• Bilateral obstruction of the fallopian tubes.
• Adhesive process in the small pelvis.
• endometrial disease.
• Acquired pathology of the uterus and cervical canal.
• Acquired violations of the patency of the fallopian tubes.
• Tuberculosis of the genital organs
• Iatrogenic causes (surgical interventions, drugs).
• systemic reasons.
• Negative postcoital test.
• Unidentified causes (when laparoscopy was not performed).
• Infertility of unknown origin (when using all methods of examination, including endoscopic).

Treatment of infertility in women

Treatment of female infertility, first of all, should be aimed at eliminating the main cause that provokes reproductive dysfunction, as well as correcting and eliminating any accompanying pathologies. Simultaneously with the main treatment, general strengthening procedures and psychocorrection are carried out. The treatment of the female must necessarily be comprehensive in order to resume the normal functioning of the reproductive system as soon as possible.

In case of tube obstruction, anti-inflammatory therapy is carried out, which is aimed not only at eliminating the inflammatory process and resuming the patency of the fallopian tubes, but also at activating the functions of the hypothalamus-pituitary-ovaries system. Of the physiotherapeutic methods of treatment, radon or hydrogen sulfide baths, the use of therapeutic mud are prescribed. To correct the functioning of the body's immune system, antihistamines (suprastin, tavegil, diphenhydramine), immunomodulatory drugs are prescribed. Treatment is carried out with small doses of drugs for two to three months or shock doses for a week.

Women with obstruction or complete absence of the fallopian tubes, as well as the presence of such diseases as polycystic, endometriosis, etc., may be offered the method of in vitro fertilization. A woman is prescribed drugs to enhance the growth and maturation of eggs. Then, mature eggs are removed with a special needle and fertilization is carried out in a test tube. On the third or fifth day, the embryos are placed in the uterus, and the patient is prescribed special drugs so that the embryos take root. Two weeks after the procedure, a blood test is ordered to see if a pregnancy is developing. At the fifth or sixth week, an ultrasound examination is performed.

It should be noted that female infertility is caused by more than twenty reasons. Therefore, in order to carry out the correct treatment, a thorough, and sometimes long-term examination is necessary in order to identify the reasons that prevent a woman from becoming pregnant. Only after a detailed and complete diagnosis by the attending physician can a qualified treatment be prescribed, which in each case is strictly individual.

The goal of infertility treatment in women is to restore reproductive function.

The basic principle of infertility treatment is the early detection of its causes and the consistent implementation of treatment stages.

Modern highly effective methods of infertility treatment include medical and endoscopic methods and methods of assisted reproductive technologies. Moreover, the latter are the final stage of infertility treatment or an alternative to all existing methods.

The tactics of therapy depend on the form and duration of infertility, the age of the patient, the effectiveness of previously used methods of treatment. In the absence of a positive effect of traditional treatment within 2 years, it is advisable to use the methods of assisted reproductive technologies.

The choice of methods of treatment for infertility and the determination of their sequence in each specific case depend on such factors as the duration of the disease, the severity of changes in the fallopian tubes, the degree of spread of the adhesive process, the age and somatic condition of the patient.

Treatment of tubal-peritoneal infertility

Treatment of tubal infertility with organic lesions of the fallopian tubes is quite difficult. Among conservative methods, the priority today is a complex anti-inflammatory, absorbable treatment, carried out against the background of an exacerbation of the inflammatory process. The ongoing therapy consists in inducing an exacerbation of the inflammatory process according to indications, followed by complex antibacterial and physiotherapy, and spa treatment.

Reconstructive tubal microsurgery, introduced into gynecological practice in the 60s of the XX century, has become a new stage in the treatment of tubal infertility, making it possible to perform such operations as salpingo-ovariolysis and salpingostomatoplasty. Improvement in endoscopic techniques has made it possible to perform these operations during laparoscopy in some cases. This method allows diagnosing other pathologies of the pelvic organs: endometriosis, uterine fibromyoma, cystic ovarian formations, polycystic ovaries, etc. The possibility of simultaneous surgical correction of the pathology detected during laparoscopy is very important.

Treatment of endocrine infertility

The therapy prescribed for patients with endocrine forms of infertility is determined by the level of damage to the system of hormonal regulation of the ovulation process. Based on a certain level, the following groups of patients with hormonal forms of infertility are distinguished:

The 1st group is extremely polymorphic, conditionally united by a common name - “polycystic ovary syndrome”. This group is characterized by an increase in LH in the blood, a normal or elevated level of FSH, an increase in the ratio of LH and FSH, a normal or low level of estradiol.

Treatment should be selected individually and may consist of several stages:

• the use of estrogen-gestagenic drugs according to the principle of "rebound effect";
• the use of indirect stimulants of ovarian function - clomiphene citrate (clostilbegit).

In the presence of hyperandrogenism, it is prescribed in combination with dexamethasone;

• the use of direct ovarian stimulants - metrodyne hCG.

Group 2 - patients with hypothalamic-pituitary dysfunction.

Women with various disorders of the menstrual cycle (insufficiency of the luteal phase, anovulatory cycles or amenorrhea), with pronounced secretion of estrogen by the ovaries and low levels of prolactin and gonadotropins. The sequence of use of drugs that stimulate ovulation in this group of patients is as follows: progestogen-estrogenic drugs, clomiphene citrate (clostilbegit), possibly in various combinations with dexamethasone, parlodel (bromocriptine) and / or hCG. With inefficiency - menopausal gonadotropins, hCG.

Group 3 - patients with hypothalamic-pituitary insufficiency. Women with amenorrhea who have little or no ovarian estrogens; the level of prolactin is not elevated, the level of gonadotropins is low or cannot be measured. Treatment is possible only with menopausal hCG gonadotropins or LH-RH analogs.

Group 4 - patients with ovarian failure. Women with amenorrhea, in whom estrogens are not produced by the ovaries, have very high levels of gonadotropins. So far, the treatment of infertility in this group of patients is unpromising. Hormone replacement therapy is used to stop subjective sensations in the form of "hot flashes".

Group 5 - women who have a high level of prolactin. This group is heterogeneous:

• patients with hyperprolactinemia in the presence of a tumor in the hypothalamic-pituitary region. Women with various disorders of the menstrual cycle (insufficiency of the luteal phase, anovulatory cycles or amenorrhea), the level of prolactin is elevated, there is a tumor in the hypothalamic-pituitary region. In this group of patients, it is necessary to single out patients with pituitary microadenoma, for whom treatment with parlodel or norprolact is possible with careful monitoring of an obstetrician-gynecologist, neurosurgeon and oculist, as well as patients with pituitary macroadenomas, who should be treated by a neurosurgeon, either by radiotherapy of the pituitary gland or by tumor removal;
• patients with hyperprolactinemia without damage to the hypothalamic-pituitary region. Women with menstrual disorders similar to the subgroup with clear ovarian estrogen production, elevated prolactin levels. The drugs of choice for this form are parlodel and norprolact.

Treatment of immunological infertility

To overcome the immune barrier of cervical mucus, condom therapy, nonspecific desensitization, some immunosuppressive agents and assisted reproduction methods (artificial insemination with the husband's sperm) are used.

Assisted reproduction methods

In cases where the treatment of infertility in a married couple using methods of conservative therapy and, if necessary, surgical treatment does not bring the desired results, it is possible to use assisted reproduction methods. These include:

• Artificial insemination (AI):
  • husband's sperm (IISM);
  • donor sperm (IISD).
• In vitro fertilization:
  • with embryo transfer (IVF ET);
  • with oocyte donation (IVF OD).
• Surrogacy.

The use and application of these methods is in the hands of specialists from the centers of reproduction and family planning, however, practitioners should be aware of the possibilities of using these methods, indications and contraindications for their use.

Assisted reproductive technologies include in vitro manipulation of sperm and egg to create an embryo.

Assisted reproductive technologies (ART) can lead to multiple embryonic pregnancies, but the risk is lower than with controlled ovarian hyperstimulation. If the risk of genetic defects is high, then the embryo should be examined for defects before implantation.

In Vitro Fertilization (IVF) can be used to treat infertility resulting from oligospermia, the presence of sperm antibodies, tubal dysfunction or endometriosis, as well as unexplained infertility. The procedure includes controlled ovarian hyperstimulation, oocyte retrieval, fertilization, embryo culture and embryo transfer. For ovarian hyperstimulation, clomiphene in combination with gonadotropins or gonadotropins alone can be prescribed. GnRH agonists or antagonists can often be given to prevent premature ovulation.

After sufficient growth of the follicle, hCG is prescribed to induce the final maturation of the follicle. Oocytes are collected 34 hours after hCG administration by follicle puncture, transvaginally under ultrasound guidance, or, less commonly, laparoscopically. Oocytes are inseminated in vitro.

The semen sample is usually washed several times with tissue culture medium and concentrated to increase sperm motility. Sperm is additionally added, then the oocytes are cultured for 2-5 days. Only one or a few resulting embryos are placed in the uterine cavity, minimizing the chance of developing a multi-embryonic pregnancy, which is highest with in vitro fertilization. The number of embryos transferred is determined by the woman's age and likely response to in vitro fertilization (IVF). Other embryos may be frozen in liquid nitrogen and transferred to the uterine cavity in a subsequent cycle.

Transfer of gametes into fallopian tubes (GIFT) is an alternative to IVF but is used infrequently in women with unexplained infertility or normal tubal function associated with endometriosis. Several oocytes and sperm are obtained in the same way as in IVF, but the transfer is transvaginally under ultrasound guidance or laparoscopically to the distal fallopian tubes where fertilization occurs. The success rate is approximately 25-35% at most fertility centers.

Intracytoplasmic sperm injection is used when other technologies have failed, and also in cases where severe impairment of sperm function has been noted. Sperm is injected into the oocyte, then the embryo is cultured and transferred in the same way as in in vitro fertilization (IVF). In 2002, more than 52% of all artificial cycles in the US were performed by intracytoplasmic sperm injection. More than 34% of artificial cycles led to pregnancy, in which 83% of cases were born live children.

Other procedures include a combination of in vitro fertilization and gamete intrafallopian tube transfer (GIFT), use of donor oocytes, and frozen embryo transfer to a surrogate mother. Some of these technologies have moral and ethical issues (for example, the legality of surrogacy, the selective reduction in the number of implanted embryos in multi-embryonic pregnancy).