Infertility is defined as the absence of children despite the desire of couples for one year without protection, affects 10-15% of couples in the reproductive age group, one out of every 6 women receives professional help due to infertility.
An unprotected couple has a 20-25% chance of conceiving in a month. This rate reaches 85-90% in 12 months. However, age is an important factor, as women get older, the chance of conceiving gradually decreases. This decline begins in the early 30s and accelerates in the 40s.
After the age of 40, the monthly pregnancy rate can decrease to approximately 1.5%. For these reasons, while the waiting period to achieve pregnancy in young patients is one year, it is 6 months due to psychological and biological effects over the age of 30. For this reason, the age of the patient should be taken into consideration and unnecessary hope should not be given to the patient or interventions that will waste time should not be taken.
The reasons that may lead to infertility should be discussed in detail with the obstetrician. Infertility period, previous pregnancies if any, treatments applied, operations (laparoscopy, laparotomy, etc.), menstruation pattern, age of first menstruation, painful menstruation, milky white fluid coming from the nipple, drug use, contraception methods used to date, past infections (tuberculosis, hepatitis, etc.), habits (alcohol, smoking, etc.) are evaluated. General examination and examination of reproductive organs are of great importance in the evaluation of women. In the examination, findings that may constitute a clue in terms of determining the cause of infertility can be detected.
For this purpose, during the examination, samples are taken from the cervix and inside the vagina and examined.
In ultrasonography, the structure of the reproductive organs, uterus and ovaries is evaluated. Diseases or changes that may take place in these organs or their neighborhoods are identified and their relationship with infertility is investigated. Problems that hinder treatment are resolved. During ultrasonography, “ovarian reserve” is evaluated, which plays an important role in the selection of the treatment to be applied in the future and in determining the chance of success of the treatment. In addition, hormone tests (FSH, LH, E2, Prolactin and TSH) to be performed on the 2nd or 3rd day of menstruation, and when necessary, AMH test, the reserve of the ovaries and their response to the drug warning are evaluated.
About 45% of infertility causes can be caused by male-related problems. The most basic laboratory method in the research of men is semen analysis. Since this test is cheap and easy, it should be performed on all patients presenting with infertility. The fact that the woman or man has had a child before does not change the necessity of doing sperm analysis. Operations (such as hernia surgery, varicocele surgery) related to the childhood and developmental periods of the man are questioned. In the examination of systemic diseases, diabetes (diabetes), diseases of the nervous system and their previous and current treatments are learned. Causes of infection such as febrile diseases, testicular inflammation (orchitis) due to mumps in adolescence, sexually transmitted diseases, tuberculosis are investigated.
In addition, chemicals, toxic gases, drugs (chemotherapy drugs, cimetidine, sulfasalazine, nitrofurantoin, testosterone preparations), frequently taken hot baths or hot working environments, radiation, alcohol and smoking are investigated. These factors are important as they adversely affect sperm production.
Can Infertility Be Treated?
In order to reveal the causes of infertility, it is necessary to conduct various studies and evaluate the test results. The most important factor in the treatment of infertility is the correct diagnosis and accordingly choosing the right treatment methods.
Among the problems related to infertility, 45 percent of the problems originate from men and 45 percent of those that originate from women. In the remaining 10 percent, no cause can be found. This is called ‘unexplained infertility’. The most important elements that determine the roadmap of infertility treatment are; The age of the woman, how long she has been infertile, the general condition of her ovaries and the sperm count of the man are the qualities of the sperm. After all these are evaluated, infertility treatment can be planned. Causes of Infertility Infertility rates are observed to be increasing worldwide. Although infertility occurs as a result of genetic reasons and various diseases, it can also lead to infertility due to reasons such as malnutrition, smoking and alcohol use, and stress.
Age is an important factor in infertility. If we look at the general average, it has been observed that the probability of getting pregnant in 35-year-old women decreases slightly, and decreases significantly after the age of 40. In addition, women after the age of 40 are more likely to have a miscarriage.
If we examine the other reasons that cause infertility in women, in addition to blockages in the tubes, various infections and sexually transmitted diseases can also prevent natural conception. Monogamy is important to prevent such diseases. Obesity in women can also cause infertility. For this reason, when pregnancy is decided, weight control should be ensured and a healthy diet should be provided. There are many reasons that can cause infertility in men. Radiotherapy or chemotherapy used to treat cancer can seriously damage sperm.
Infertility Treatment Methods
Infertility (infertility) is an expression used when a woman has never been pregnant before, or if she has not been able to get pregnant ‘again’ even once.
Women may experience infertility at some point in their lives. On average, this can be seen in 25 percent of women. Although fertility characteristics vary from person to person, women generally experience their most fertile period for pregnancy around the age of 25.
In addition, after 35, women’s fertility begins to decrease gradually. However, the age factor is not an obstacle to having healthy children.
If the couple does not use any contraception, but pregnancy does not occur, ‘infertility’ may be suspected. Newly married couples may be worried if pregnancy has not occurred for several months after marriage. Young couples should not rush to suspect infertility. Couples should wait for a minimum of 1 year and if pregnancy does not occur, they should start investigating the underlying causes. Couples with a healthy sex life (average sexual intercourse 2 times a week) should continue to try for 1 year.
Infertility is a very common problem today. Infertility can be caused by a man, a woman, or both at the same time.
In cases of infertility, no symptoms can be mentioned in people. Infertility does not cause any discomfort in people. When the generality of the couples is evaluated, 15 percent of them cannot have a child. While planning the treatment of infertility, the age of the people, how long they have not been able to have children, and whether they have any health problems are taken into consideration.
A factor of 45 percent in general infertility problems is caused by men. Especially in recent years, the incidence of male infertility has increased. There are several treatments for male infertility. It is also possible for a man with very few sperm to have children.
There are various treatment options for infertility experienced by women. More detailed and challenging treatments are applied compared to men.
Factors Affecting Infertility Treatment
- The age of the expectant mother is one of the factors affecting the treatment of infertility. It should be noted that fertility begins to decline after the age of 35.
- Expectant mothers and fathers should avoid environments that will adversely affect the treatment. Especially hot environments such as baths, spas and saunas cause deterioration in sperm.
- Heavy exercise and sports should be stopped 3 months before starting infertility treatment.
- The expectant mother should pay attention to her nutrition.
Researched in Physical Examination and Gynecological Examination
Weight and body mass index (Increased body mass index is associated with decreased fertility, while abdominal circumference obesity is associated with insulin resistance)
Development of secondary sex characters, body type (in hypogonadotropic hypogonadism, development of secondary sex characters is insufficient, whereas in Turner syndrome, short stature and mane neck are seen)
- Thyroid gland diseases (nodule in the thyroid gland, tenderness, gland size), milk coming from the breasts, 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 (menstruation is regular in women with ovulation, 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. In a 28-day menstrual cycle, a serum progesterone level > 3 ng/mL per day 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 learn 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 agent to the abdominal cavity after passing through the tubes and exiting from the tube ends, it also defines the congenital anomalies and pathologies of the inner wall of the uterus (polyps, fibroids, uterine inner wall adhesions). 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 even without pelvic inflammatory disease. In the world’s leading infertility guidelines (RCOG guideline), it is recommended that all women should be tested for chlamydia antibodies before any interventional procedure to the uterus or HSG.
Evaluation of the Inner Walls of the Uterine
The diagnosis of polyps, fibroids in the inner wall of the uterus, adhesions in the inner wall of the uterus, congenital defects in the structure of the uterus can be made 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. It is an expensive and invasive examination. 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 identifies the relationship between changes in the menstrual cycle in mucus in the cervix and 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.
During the entire menstrual cycle, body temperature is measured and noted in the morning without any activity. 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: Karyotype analysis is recommended for women diagnosed with early menopause (under 40 years of age), men with severe oligospermia, and couples with a history of recurrent pregnancy loss.