When to contact a specialist?
The diagnosis of "infertility" is made only if pregnancy does not occur within one year of unprotected regular sexual intercourse. But, if a woman is over 35 years old, it is worth actively looking for reasons and doing examinations after six months of unsuccessful attempts.
In Latvia there is a program according to which all women up to 37 years of age (included), after being diagnosed with infertility, can undergo examinations and an in vitro fertilization (IVF) procedure at the expense of the state budget.
Infertility today is far from uncommon - about 15% of couples face this problem. Of these, 10-15% are diagnosed with the so-called unexplained infertility, when it is impossible to find the cause of infertility using available diagnostic methods. In the remaining 85-90%, the causes of infertility are divided equally into male and female factors. And this is especially important: infertility is a diagnosis in which both a woman and a man must be examined!
How to understand the reasons?
To do this, you need to understand what processes must occur in the body of a healthy woman in order for pregnancy to occur. The first day of the period is the starting point for a new cycle. At this time, the ovary begins to "prepare" the egg. The place where it is located for the first half of the cycle is called the follicle. It gradually increases in size and bursts 12-14 days before the onset of menstruation, allowing the egg to "exit" from the ovary into the fallopian tube - ovulation occurs.
Ovulation is a process completely controlled by hormones and is possible only with "flawless", well-coordinated work. For example, the follicle-stimulating hormone - FSH affects the growth of the follicle in the first half of the cycle, while the lutein hormone - LH, directly kickstarts the ovulation.
Then, the egg gradually moves along the fallopian tube, and it is usually there that the conception occurs - the sperm, having passed all the way from the vagina, through the cervix and uterus, reaches the egg and fertilizes it: the genetic composition of the two cells merges, forming the so-called zygote - unicellular stage of embryo development.
At this time, a corpus luteum is formed in the ovary at the site of the bursting follicle. Its task is to produce progesterone, which, while the fertilized egg moves towards the uterus, prepares its inner layer - the endometrium.
The zygote continues to move towards the uterus, gradually increasing in size, and, approximately on the 6th day after conception, implantation occurs - the cells of the future embryo are attached to the endometrium. After successful implantation, the first embryonic tissues begin to develop on days 6-12 - those from which the fetus will subsequently form.
This is what the ideal pregnancy scenario looks like. But in each of the stages, there are a lot of things that could possibly go wrong.
- The first group of causes of female infertility - disorders of the ovaries
In this case, the main task of the doctor is to understand whether ovulation is occurring. The absence of ovulation can be affected by hormonal imbalance, endometriomas, polycystic ovary syndrome, in which the follicles increase in size, but do not burst.
To exclude the factor of an "incorrect" ovarian function, the doctor will prescribe a series of examinations, which may include:
- Ovulation test.
The test records the peak levels of progesterone - as a rule, it rises sometime in the 48 hours before ovulation. If the test is positive, then within a few days the chance of getting pregnant is especially great.
Ultrasound can detect pathologies such as polycystic ovary, single cysts (for example, endometrioma), which can interfere with ovulation. It is also possible with the USG to confirm ovulation - see the corpus luteum in the second half of the cycle.
A dynamic examination is possible, when the patient comes in the middle of the cycle every 2 days - this will allow to find out with maximum accuracy on which day of the cycle ovulation has occurred.
- Hormonal profile (FSH, LH, thyroid hormones, etc.).
- The second group of reasons – problems with the patency of the fallopian tubes.
The reason for obstruction in most cases is adhesions - special "threads" of connective tissues that close the passage in the fallopian tube, preventing sperm from fertilizing the egg (because most often it happens in the fallopian tube), or not allowing the fertilized egg to reach the uterus. The second case is also dangerous because it increases the risks of ectopic - tubal pregnancy with all the ensuing consequences.
Adhesions, in turn, can appear due to chronic inflammation, endometriosis, pelvic surgery, sexually transmitted diseases (especially chlamydia).
The tactics that the doctor chooses depends on the patient: if she does not have a history of factors affecting the forming of adhesions, the likelihood of fallopian tube pathology is very small, obstruction as a cause of infertility can be practically excluded. But to be sure, following examinations can be assigned:
- Sonohysterosalpingography (SHSG)
The patency of the tubes is checked by ultrasound by introducing a special contrast agent, usually in the first phase of the menstrual cycle - on the 8-9th day. The procedure is outpatient and does not require any pain relief. But, if, according to the results of the SGSG, permeability is impaired, this does not mean that the tubes are impassable, since they may have a mucous plug or they may be compressed, "stuck together" during the procedure, and the pressure of the contrast fluid being inserted is insufficient to open the tube. Therefore, if an obstruction is diagnosed on ultrasound, it is still worth doing additional examinations, for example, laparoscopy.
- Hysterosalpingography (HSG)
Similar in principle - the patency is checked using a contrast agent and X-ray. It is prescribed less frequently than SHSG, since X-ray radiation is used.
Recommended as the first diagnostic method for patients with a "complicated history" - pelvic surgery, endometriosis, inflammation, etc. At the same time it is also a form of treatment - for example, it will be possible to remove adhesions on the fly. In some cases, it is impossible to predict the state of the tubes before the start of the surgery - therefore, the doctor always discusses with the patient possible scenarios for the development of events: if the tube cannot be quickly restored, it will have to be removed.
It is important to understand that the chances of getting pregnant in a woman with one fallopian tube are the same as with two, but if you leave a defective tube filled with adhesions, fluid will accumulate in it, which can also interfere with the onset of pregnancy.
It should also be borne in mind that after laparoscopic removal of adhesions in the fallopian tube, the most successful time for conception is the first six months, since adhesions tend to reappear over time.
It has been proven that if the cause of infertility is a surgically solvable problem (endometrioma, adhesions, etc.), then surgical treatment has similar results as with the IVF procedure - the chances of pregnancy within a year after the surgery are the same as after IVF without preliminary surgical treatment.
- The third group of reasons - problems of the uterus and the cervix.
It can be a congenital anatomical anomaly of the uterus, for example, a bicornuate uterus or uterine septum, fibroids, polyps, hyperplasia (thickening) of the endometrium, or, conversely, a layer that is too thin and prevents the embryo from implanting. Adhesions can also form in the uterus - especially if the patient has a history of instrumental abortion or uterine inflammation.
In these cases, these kinds of diagnostics will help:
- Ultrasonography (especially 3D);
The procedure is simultaneously diagnostic and therapeutic - a hysteroscope is inserted into the uterus - a tube with a micro-video camera, which will allow to assess the uterus visually and, if possible, remove the defect with a special tool;
It is important to understand: having children from a previous relationship does not guarantee that at present time a man cannot have problems with infertility. The spectrum of causes of infertility in men is narrower than in women - most often, it is a matter of general health, addictions or sexually transmitted diseases.
Excess weight, especially abdominal obesity, affects the chances to conceive, since the process of synthesis of female sex hormones occurs in the adipose tissue, disrupting the healthy male hormonal background.
Also, constant stress - physical and psychological, significantly affects spermatogenesis (i.e. sperm production).
To assess the "male" health, a gynecologist may prescribe a semen analysis - spermogram, tests for infections, but in most cases the man will be sent to consult an urologist or andrologist.
There are times when a patient becomes pregnant even though there is a medical "problem" or immediately after she begins to look for the causes of infertility in the doctor's office. Therefore, we can always tell her only that, yes, perhaps, the probability of getting pregnant is less than that of others, but the most important thing is to understand that there are always chances!