infertility; It is the inability of couples to have children despite having regular sexual intercourse for at least one year without using any birth control method. Actually INFERTILITY IS A DISEASE . If the history or physical examination findings require early diagnosis or treatment, diagnostic procedures can be started before the one year period expires. infertility; It can be caused by problems of women, men or both. ~ 30-40% men, ~ 40-50% women are responsible for infertility. In ~ 15-20% couples, the cause cannot be found or there are problems arising from both sides. As the causes of infertility from a different perspective; 25% ovulation disorder, 15% tuberculosis problems, 10% endometriosis-chocolate cyst, 25% male factor, 20% unexplained infertility can be mentioned.
TIME REQUIRED FOR COUPLE PREGNANCY
duration probability of pregnancy
3 months 57%
6 months 66%
1 year 85%
2 years 92%
infertility; It affects 1 in 7 couples. The frequency in Europe is around 14%. In the USA, 6.1 million women (1995), 7.3 million women (2002) are infertile.
Many factors can cause infertility:
History of infection in the female reproductive organs (The risk of infertility increases as the number of attacks increases)
sexually transmitted diseases
Irregular or no periods
Endometriosis (Chocolate cysts)
Polycystic Ovary Syndrome
Congenital anomalies of the uterus and other reproductive organs
Advanced age, smoking, alcohol or drug use
Causes leading to infertility in men (history of infection in the testicles and sperm ducts, history of mumps, chronic trauma to the testis, chemotherapy, radiotherapy treatment, etc.)
If the infertile couple has one of the following factors, it is more appropriate to start examination and treatment without waiting for the end of one year:
Female age ≥35
Absence of menstruation or irregular menstruation
History of previous abdominal or intra-abdominal surgery
History of intra-abdominal infection, known uterine-tube disease or endometriosis-chocolate cyst
Abnormal examination findings
Having previous cancer treatment
Recognizing that the spouse has an infertility problem
History of sexually transmitted disease n
History of previous urogenital surgery-undescended testis
Abnormal examination findings
Having previous cancer treatment
It is necessary to mention some important factors in infertility and its treatment.
Female age negatively affects fertility. Although not all women aged 35 years, it should be considered the beginning of the transition to the period of decreased fertility. When it comes to conceiving and giving birth, there is no test that shows fertility better than a woman’s age. For example, it is very rare for a woman aged 44 or more who has not given birth to conceive and give birth with IVF with her own eggs.
The frequency of weekly intercourse is also important in the probability of conception. The chance of pregnancy is optimal with intercourse every 2-3 days. Again, as the woman’s weight increases, the time until conception becomes longer, and ovulation and menstrual disorders begin. Therefore, if these patients lose weight and approach the ideal weight, their chances of conceiving will increase.
Excessive alcohol consumption negatively affects fertility in both men and women. Alcohol intake can impair sperm quality. women who smoke; be warned that fertility will decrease. Passive smoking also reduces the chances of getting pregnant. Again, smoking impairs sperm quality.
The couple should be evaluated together before treatment. Efforts are made to eliminate any pathology detected after taking a history and examination, which may cause problems in terms of infertility. Before treatment; Sperm examination of the man by looking at all parameters (pre-wash count, pre-wash motility, post-wash count, post-wash motility, stained sperm morphology analysis), 2-3. Hormone evaluation and uterine film-HSG taken at the end of menstruation have priority. For those with abnormal uterine film; Other upper examinations such as hysteroscopy, laparoscopy may also be required.
We can summarize the features to be considered during the man’s sperm delivery as follows:
There should be an average of 3-5 days of sexual abstinence.
The ejaculate should be given by masturbation.
The semen sample should be collected in a screw-cap polystyrene container.
Ensure that all ejaculate is contained in the container.
Ejaculate should not be brought from outside the unit.
If it is necessary to bring the semen sample from outside the laboratory; It should be delivered to the laboratory within maximum 30 minutes by keeping it at body temperature and protecting it from ultra violet light.
If the hormone values of the woman, the uterine film and the sperm parameters of the man are within normal limits; The type of treatment is planned, especially with the age of the woman in the foreground and the other characteristics of the couple are also evaluated. This treatment; It can be in the form of waiting treatment, intercourse with clomiphene (ovulation-enhancing pill) or vaccination, intercourse with gonadotropins (ovulation-enhancing injection) or vaccination. If the woman’s ovarian-ovarian reserve is low, her tubes are clogged or her age is advanced, if the sperm values of the man (after at least 3 tests performed at certain intervals) are at values that do not give a chance for pregnancy with intercourse or vaccination, direct in vitro fertilization (IVF-ICSI) without these treatments. can also be treated.
It may be required to be performed together with some surgical treatments before or during infertility treatment. To summarize them briefly:
Bilateral Tube Occlusion-Tube surgery
It is preferred in young patients and in tube blockages close to the ends. If there is no pregnancy for 6 months after surgery, the tubal passage should be re-evaluated. Advances in in vitro fertilization technologies have put the role of tubal surgery on the back burner.
Hydrosalpinx-Tubes filling with liquid
Tubes are taken especially before IVF treatment .
Intrauterine pathologies (myoma, polyp, adhesions)
Myomas in the body of the uterus and close to the outside (>5 cm) may adversely affect the passage in the tubes. Intrauterine fibroids of all sizes and in the large uterine body adversely affect the adhesion of the embryo to the uterus and increase the likelihood of miscarriage. All these types of fibroids may need to be removed before treatment. Endometrial-intrauterine membrane polyps may need to be removed because they adversely affect the adhesion of the embryo to the uterus. Adhesions in the intrauterine cavity reduce the possibility of pregnancy. These adhesions must be removed.
Congenital Uterine Abnormalities
Plastic surgery may be required. Absence of uterus is the anomaly that affects fertility worst.
Even if they do not disrupt the anatomy of the intra-abdominal cavity, they can negatively affect the fertility potential. Surgical treatment (laparoscopy) in early stage endometriosis may increase the probability of pregnancy. During the removal of chocolate cysts, the possibility of decreased ovarian reserve should be considered.
Polycystic Ovary Syndrome (PCOS)
In cases resistant to all medical treatments and before IVF treatment, ovarian drilling can be considered with laparoscopy to restore ovulation.
Vaccination (Intrauterine Insemination – IUI)
Vaccination is the placement of a sufficient number of healthy motile sperm directly into the uterus with the help of a special cannula. In this process; It is aimed to remove the acidic environment harmful to the sperm, to select fast-moving healthy sperm and to ensure that these sperm reach the tubes more easily. With Butedavi ; The mucus barrier in the cervical-cervix is bypassed and the germ cell density in the fertilization-fertilization area is increased.
Before the procedure, the sperm is prepared in the laboratory by going through different medical processes. The optimal sperm preparation technique is selected according to the characteristics of the sperm, equipment and laboratory conditions.
Although obtaining at least 5 million motile sperm after preparation is considered as the minimum required sperm count for vaccination, there are centers that accept this number as 1 million.
In the case of mild disorders in sperm count, movement and shape, some anatomical (hypospadias, spinal canal injuries) or psychological (impotence) problems in men, unexplained infertility or immunological infertility cases where there are substances called anti-sperm antibodies in the cervix that impair sperm movement, insemination is primarily performed. The patient is given drugs (gonadotropins) that provide egg development for 9-20 days (sometimes this period can even reach 35 days in polycystic ovary cases). When egg development is evaluated intermittently with hormone tests and ultrasonography and egg development is achieved, hCG (Pregnyl or Ovitrelle) is administered to perform ovulation. Vaccination process is applied once 33-36 hours after these drugs or 2 times, 24. and 72. hours later. It is accepted that vaccination once or twice does not make any difference in terms of pregnancy probability.
Failure to achieve success in vaccination treatment with gonadotropins 3 times is the reason for switching to IVF-ICSI treatment.