WHAT IS INFERTILITY? Infertility is the inability to conceive after one year of regular, unprotected sex.
WHEN TO BEGIN STUDYING? Usually only after one year of regular unprotected sex, should the study begin. There are however some situations where the study has to begin earlier (6 months):
• Age over 35 years
• Absent or irregular menses
• Abnormalities of the uterus
• Nipple discharge
• History of infection in the Fallopian tubes
The following table briefly discriminates the main causes, tests that may be needed to make the diagnosis and treatment options available. However, each case is different and each couple should have an individualized approach.
|Ovulation problems||Hormonal study||Ovulation induction|
|Premature menopause||Hormonal study||Egg donation|
|Obstruction of the fallopian tubes||Hysterosalpingosonography||IVF|
|Surgical / laser treatment|
|Hostile Cervical Mucus||Postcoital test||Medical treatment|
|Absence of spermatozoa||Hormonal analysis||TESE / ICSI|
|(azoospermia)||Testicular biopsy||Sperm donation|
|Absence/Obstruction of the vas deferens||Scrotal examination||TESE / ICSI|
|Screening for cystic fibrosis gene|
|Low number of spermatozoa||IUI|
|Reduced motility of spermatozoa||IUI|
|High percentage of abnormal forms of EZ||IUI|
|Antisperm antibodies||Search anti-EZ antibodies||Preparation of Sperm / IUI|
SPERMATOZOA COLLECTION METHODS
In cases of obstructive azoospermia (and not only), sperm collection may be performed in various ways, the most used are:
TESE: testicular sperm extraction
TESA: testicular sperm aspiration
MESA: microsurgical epididymal sperm aspiration
The study of man should include a complete medical and reproductive history, physical examination by a andrologist and at least two semen studies.
The objectives of this assessment are the identification of potentially correctable situations, irreversible situations that can be resolved by techniques of Medically Assisted Procreation, irreversible conditions for which the sperm donation or adoption may be an option to detect serious medical situations they have arisen by an infertility problem.
LACK OF SPERM IN EJACULATION (AZOOSPERMIA)
This problem affects 1% of all men (and 10 to 15% of infertile men) may be due to two causes:
• The testicle is unable to produce spermatozoa.
• There is a blockage to the passage of spermatozoa (congenital absence or obstruction of the vas deferens).
In the case of non-obstructive azoospermia it is necessary to make some hormonal assays (FSH, LH, testosterone). High FSH values are indicated to continue the study with the realization of a karyotype and microdeletions research of Y chromosome. Low values of FSH and testosterone involve assay of prolactin and assessment of pituitary imaging.
In the case of obstructive azoospermia due to congenital absence of the vas deferens, 2/3 of men have the cystic fibrosis gene, which also involves research of mutation in woman.
Testicular biopsy may be indicated in patients with azoospermia with normal testicular volume, with at least one palpable vas deferens, normal FSH and also to confirm the presence of obstruction in patients with low volume of ejaculated and palpable vas deferens.
WEAKNESSES IN QUANTITY AND / OR QUALITY OF SPERM
These weaknesses can have several causes: hormonal problems, varicocele, infection, certain medications and drugs.
The varicocele consists of dilated veins similar to varicose veins into the scrotum and are found in 15% of the normal population and 40% of men with infertility. In his presence is assigned a deleterious effect on spermatogenesis. Although controversial, treatment of varicocele (surgical or percutaneous embolization) is advised when it is palpable, when the couple has documented infertility, the woman has a normal or potentially correctable fertility and the spouse has changes in semen. Instead of the surgical treatment of varicocele can use immediately to IVF / ICSI when these techniques are needed to address woman's issues or when the age of this preclude more waiting time.
WEAKNESSES IN FERTILIZER CAPACITY OF SPERMATOZOA
The genesis of the weaknesses may be problems in the acrosome, inability of sperm to join the zona pellucida, etc ...
INABILITY TO EJACULATE IN THE VAGINA
This inability may be due to premature ejaculation, retrograde ejaculation or to the impossibility to achieve orgasm.
The study of woman implies first of all a medical history and physical examination, with special emphasis on history and gynecological examination. In addition to the infertility problem we have to see further and detect situations that may compromise the future pregnancy.
Ovulation problems are the most common cause of female infertility.
Simultaneously it is also the cause that the probability of successful treatment is increased. In most cases the woman has irregular cycles or is not menstruating. May also have hirsutism, acne or milk discharge from the nipples (galactorrhea).
The ovulation problems may reside in the ovary:
• The woman has polycystic ovaries • The ovaries contain few oocytes (situations of premature menopause) • There are no ovaries because they were surgically removed or woman born without ovaries
PROBLEMS IN THE FALLOPIAN TUBES
The problems in the tubes are also a common cause of infertility.
These problems may be due to injury of the fimbriae, the cells lining the inside of the tubes, obstruction or adhesions that distort the tubes. The effects of these injuries range from capturing inability of the oocyte and the inability of spermatozoa and the oocyte meet.
These injuries can have several causes:
• Infections are the most common cause and between these Sexually Transmitted Diseases (Chlamydia and Gonorrhoea) are the most frequently implicated.
• Endometriosis can also cause scar tissue, adhesions and in more severe cases obstruction of the fallopian tubes.
Endometriosis is an extremely common benign disease in which cells similar to those lining the uterus and peel off at the time of menses, developed in other locations. The most common areas are the pelvis, the ovaries (giving rise to so-called chocolate cysts) and the tubes. Like the endometrial cells also slough off at the time of menstruation, but these have no way out, eventually cause adhesions and formation of cysts.
Endometriosis is responsible for 4-8% of infertility cases. The majority of women with endometriosis have, however, problems in getting pregnant.
While one might suspect of its existence, the diagnosis requires the realization of a laparoscopy.
HOSTILE CERVICAL MUCUS
Cervical mucus is a gelatinous substance produced by glands in the cervical canal, whose characteristics change over the cycle. In the ovulation time exhibits special characteristics, which allow an easier spermatozoa migration through the uterus. At the same time also functions as a reservoir of spermatozoa.
It is said that the cervical mucus is hostile when it is too thick (for poor estrogenization, infection, etc.), or when it contains antibodies, anti-sperm.
The majority of women with uterine problems do not usually have problems conceiving, but in maintaining pregnancy.
However, in some situations (submucosal fibroids, endometrial polyps, intrauterine adhesions and malformations) may be interference with the implantation of the embryo.