Causes of Female Infertility

When investigating the causes of female infertility in couples who apply with the desire to have children, first of all, the history of the woman is questioned by considering the factors mentioned below.

  • How old is the woman
  • The length of time to ask for a child and the results of previous assessments and treatments
  • menstrual cycle ( regular menstruation, ovulation pain, breast tenderness, mid-menstrual spotting may suggest ovulation, while painful menstruation may suggest endometriosis.)
  • Medical, surgical and gynecological history (sexually transmitted disease, history of pelvic inflammatory disease, treatment of abnormal pap smear, previous abdominal surgery) . At the very least, when reviewing the systems, patients should be questioned in terms of thyroid diseases, lactation, hair growth, pelvic or lower abdominal pain, menstrual cramps, and pain during sexual intercourse.
  • Pregnancy histories (pregnancy, delivery, pregnancy outcomes and associated complications)
  • sexual story ( frequency of intercourse, sexual dysfunctions)
  • family history ( family history of infertility, family history of early menopause, birth defects, genetic disorders, mental retardation)
  • Life style (work, exercise, stress factors, weight changes, smoking and alcohol use))

Researched in Physical Examination and Gynecological Examination

  • Weight and body mass index ( An increased body mass index is associated with decreased fertility, whereas abdominal circumference obesity is associated with insulin resistance.)
  • Development of secondary sex characters, body type ( In hypogonadotropic hypogonadism, development of secondary sex characteristics is insufficient, whereas in Turner syndrome, short stature and mane neck are seen)
  • Thyroid gland diseases ( Nodule in the thyroid gland, tenderness, size of the gland), breast milk, hair growth, acne suggest an endocrine disorder, while adrenal gland diseases, polycystic ovary syndrome, high prolactin, and hyper-hypothyroidism require evaluation.
  • Tenderness on examination is significant in terms of chronic pelvic pain and endometriosis.
  • Structural anomalies of the vagina and cervix, discharges, congenital anomalies of the uterus and tubes require evaluation in terms of infection and cervix factor.
  • On examination, abnormal size of the uterus, irregularity of its structure, lack of mobility may be significant in terms of uterine anomalies, endometriosis and adhesions in the pelvis.

Evaluation of Ovulation

  • Menstrual pattern (in women with ovulation, menstruation is regular, constant in terms of quantity and duration, with premenstrual or menstrual period complaints.)
  • Serum progesterone measurement: Serum progesterone levels reach the highest level 7-8 days after ovulation. A serum progesterone level > 3 ng/mL per day in a 28-day menstrual cycle supports ovulation, but does not enlighten us about the quality of the luteal period. Day 21 progesterone levels > 10 ng/mL in a normal menstrual period indicate a normal and healthy ovulation.
  • Urine LH test: The person can monitor ovulation with urine LH test kits at home and get information about the time of ovulation. In general, starting on the 10th day of the menstrual period, urine that is not very dense or very watery is checked in the evening hours. Ovulation is expected 24-48 hours after the color change is detected.

Evaluation of Tubes

Hysterosalpingography (HSG): While giving information about the distribution of the contrast material to the abdominal cavity after passing through the tubes and exiting the tube ends, it also detects congenital anomalies and pathologies of the inner wall of the uterus. (polyp, fibroids, uterine inner wall adhesions) ) defines. If there is sufficient experience, hysterosalpingo-contrast-ultrasonography is another effective method for HSG. It should be done within 1-2 days after the end of menstruation. It does not provide information about adhesions and endometriosis around the tube. It is necessary to repeat the uterine films older than 2 years. HSG may also have a therapeutic role. Tubes closed with mucus plugs can be opened with pressure while contrast material is administered during extraction.

Chlamydia Ig G Antibodies: It is a painless, inexpensive, easy test that gives information about the presence of damage to the tubes. In many studies conducted in recent years, it is thought that Chlamydia infections cause infertility by causing damage to the tubes without pelvic inflammatory disease. In the world’s leading infertility guidelines (RCOG guideline) It is recommended that all women be tested for chlamydia antibodies before any HSG or uterine interventional procedure.

Evaluation of the Inner Walls of the Uterine

Polyps, fibroids in the inner wall of the uterus, adhesions in the inner wall of the uterus, congenital disorders in the uterine structure can be diagnosed with the ultrasound examination performed with saline. In addition to the pathology in the tubes, subsequent or congenital uterine disorders can also be evaluated with HSG. Abnormal HSG finding requires further examination such as hysteroscopy or laparoscopy.

The Role of Laparoscopy

The role of laparoscopy in the evaluation of infertility is controversial. Laparoscopy can be performed when endometriosis is suspected (painful menstruation, pelvic pain, deep pain during sexual intercourse), in the presence of pelvic adhesions and tuberculosis disease (history of pelvic pain, complicated appendicitis, pelvic infection, pelvic surgery, previous ectopic pregnancy), abnormal physical examination and HSG. In patients diagnosed with unexplained or male-caused infertility, it is widely believed that laparoscopy is not needed because it does not change the treatment plan.

Tests Uncommon in Clinical Use

Poscoital Test: It describes the relationship of changes in the menstrual cycle in mucus in the cervix to sperm. It should be done 2-12 hours after intercourse, just before the expected ovulation. It is not a routinely recommended test in the investigation of couples who apply with a desire to have a child. It has no proven diagnostic value.

Endometrial Biopsy: It gives information about whether there is ovulation in the menstrual cycle and luteal phase defect. It is done 2-3 days before the expected period. It is an expensive, invasive, unnecessary test for the evaluation of ovulation, which does not provide information about the inner wall of the uterus for the embryo to implant in the uterus.

Basal Body Temperature: It is recorded by measuring body temperature in the morning without any activity during the entire menstrual cycle. The baseline temperature rise correlates with the LH curve, starting to rise two days before the LH curve. Although it is a guide about ovulation, it is a difficult test that can be affected by many factors and may vary according to the observer.

Karyotype Analysis: Early menopause ( under 40Karyotype analysis is recommended for women diagnosed with ), men with severe oligospermia, and couples with a history of recurrent pregnancy loss.

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