WHAT IS INFERTILITY?
The WHO (World Health Organization) defines infertility as the absence of pregnancy after a year of attempts (sexual intercourse) well distributed throughout the menstrual cycle (that is, in the fertile period) and in the absence of contraceptive methods.
Infertility is very common, you are not alone. It is estimated that 15% of couples will present some type of infertility during their reproductive life.
I AM INFERTILE, WHAT NOW?
You should talk to your partner, and both should seek evaluation specialist in human reproduction (reproductive medicine).
Infertility isn’t a problem exclusive in the women. In about 40% of infertility cases, main cause is female, 40% male and 20% the association of both sexes. As well the man as the woman must be evaluated from the beginning.
The choice of the doctor or the human reproduction clinic must be judicious. The couple must feel freely, talk frankly with the doctor and have a team of professionals at your disposal that, working together, are ready to answer your questions, and whenever possible to anticipate solutions, preventing problems from arising.
All professionals in the clinic play an essential role in helping the couple and must be in total harmony with the wishes of the people involved, so that there is no mismatched information and the couple doesn’t feel confused.
The initial concern is to objectively diagnose the causes of infertility and then propose the treatment that can eliminate them, if this isn’t possible, search the best treatment, with the best cost-benefit ratio to accomplish the dream of have a child.
The doctor will talk a lot to find out their health history and then probably will order a series of exams.
HOW TO DIAGNOSE INFERTILITY?
To help the couple know if need medical treatment or not, I asked some questions with answers below and other useful information.
HOW IS INFERTILITY CLINICALLY DIAGNOSED? HOW DO WE KNOW THAT WE NEED TREATMENT?
Infertility is defined as the inability to conceive in one year of attempts (sexual intercourse well distributed throughout the month), without using contraceptive methods. Is condition that can result from physiological factors present in men and women.
IF I AND MY HUSBAND (OR WIFE) ARE WITH PROBLEMS TO HAVE A CHILDREN, WHAT IS THE FIRST STEP TO BE TAKEN
If the previous question is in line with the problems you are facing, you can need medical help to have a child. Get in touch with a professional specialist in Human Reproduction to evaluate your case.
WHAT IS THE TOTAL COST OF TREATMENT?
Each couple has a special and specific treatment indication. The various possible treatments present different costs, classified in degrees of complexity and intervention. During the consultation, the couple will be evaluated and depending on the proposed treatment, the cost will be informed.
WHAT ARE THE MAIN DISEASES MAY LEAD TO INFERTILITY?
- Uterine tubes obstruction
- Ovulation problems (polycystic ovaries)
- Ovarian cyst
- Ovarian failure (early menopause)
- Luteal Phase Deficiency
- Hostile cervical mucus
- Hyperandrogenic disorders
- High prolactin
- Uterine tube ligation
- Couples with recurrent pregnancy losing (Anti- phospholipid antibody syndrome, etc.)
- Anatomical defects of the uterus (bicornuate uterus, unicorn, didelfo, etc)
- Embryo implantation problems
- Immunological infertility
- Thyroid disorders
- Genetic problems
- Defective sperm
- Testicular failure
- Anti-sperm antibodies
- Absence of deferent duct (congenital)
- Testicular cancer
In addition, these factors, couples with infertility can have experience problems with egg quality or it is release, immunological problems blocking fertilization or implantation or secretion abnormal hormones.
And after you look for a professional, what is done?
Initially, the couple will be asked about their personal and family history o obtain a diagnostic determination. The following couple will be examined and later (if necessary) exams additional information will be requested. After these initial steps, all results will be evaluated and analyzed critically in search of the possible causes of infertility. Finally, appropriate treatment will be proposed.
TO IDENTIFY THE PROBLEM, THE FOLLOWING QUESTIONS MUST BE ANSWERED:
- Are there problems with ovulation?
- Are there problems with sperm production or function?
- Is there a possibility of fertilization between the egg and the sperm?
- Can the implantation happen and be kept?
We usually find infertility in women (female factor) in 40% of cases, others 40% are due to the male factor; 10% due to both (couple) and the remaining 10% are classified as not identifiable (ISCA – Infertility without Apparent Cause).
The couple must be evaluated simultaneously, starting with an interview, complete history and exam detailed physics. Then you will pass the more specific tests, according to the needs of each couple
EVALUATION OF THE WOMAN
To determine if the woman has problems such as ovulation, egg transport, fertilization or deployment, several tests can be done. Between them:
Urine LH test: detects the increase in LH that occurs before ovulation. The luteinizing hormone s secreted by the pituitary gland during the menstrual cycle, but increases in the middle of the cycle to induce the release of the egg (oocyte).
Blood Hormone Test: measures Luteinizing Hormone (LH), Follicle Hormone Stimulant (FSH) levels, Prolactin, Progesterone and Stimulating Thyroid Hormone (TSH). The FSH is produced by the anterior pituitary and stimulates the ovary to develop a follicle for ovulation. Progesterone is produced after ovulation and prepares the uterus for pregnancy.
The levels of the hormones Luteinizing and Follicle Hormone Stimulating are checked to see if there are any dysfunction of the pituitary gland. Levels of prolactin (a hormone that stimulates milk production are checked to see if there is an excess, causing hyperprolactinemia, a condition that interferes in the ovulation. Progesterone levels are checked to determine if there is an alteration, causing interference with the development of the endometrium, layer that lines the uterus, preparing it for implantation of the embryo. The TSH is verified as a measure normal for thyroid gland function.
Anti-Müllerian Hormone (HAM or AMH): today it is the best marker of the ovarian reserve, that is, can indirectly determine how many eggs a woman has in her ovaries and can help in predicting the age of menopause. It is also used to calculate the dose of medications needed for ovulation induction.
Hysterosalpingography (HSG): x-ray of the uterine cavity and fallopian tubes using a substance which is visible on the x-ray, to determine if there are structural defects in the uterine cavity and tubes uterine.
Diagnostic laparoscopy: minimally invasive surgical procedure. Allows viewing direct from the uterus, fallopian tubes, ovary and lower pelvis. It is very useful particularly in the diagnosis of endometriosis, disturbances in the fallopian tubes, pelvic adhesion, among others.
Hysteroscopy: usually done in conjunction with laparoscopy to visually examine the interior uterine cavity in search of wounds, adhesions, polyps, tumors and other abnormalities and to eliminate endometriosis.
Endovaginal ultrasound: performed between two to four days before ovulation, to observe the endometrial thickness (uterine lining layer) and it is response to stimulation hormonal, in addition to the presence of the dominant follicle (inside which we will find the egg).
Endometrial biopsy: used to determine if the endometrium, the inner lining layer of the uterus, will respond adequately to the embryo implantation, obtaining a sample of endometrium tissue
EVALUATION OF THE MAN
The man may have infertility problems related to: problems with production or secretion of sperm, anatomical problems, previous testicular lesions, problems hormonal. The man provides one or more semen samples that will be analyzed in advanced testings.
Analysis of normal semen: The man’s semen is analyzed in several tests, such as for counting sperm, motility, morphology and concentration. Other tests can be done:
- Semen culture to detect infections
- Tests to check the possibilities of in vitro fertilization or intrauterine insemination (seminal processing)
- Test for anti-sperm antibodies and for types of antibodies IgC, IgM and IgA
- Long term survival studies
- Detection of biochemical markers in semen, for example, fructose, as a test accessory diagnosis in men with severe infertility problems.
In cases where semen analysis is normal, treatment will be based on the woman’s analysis. The normal semen includes:
- Sperm concentration over than or equal to 15 million/mL
- Progressive motility (movement) equal to or over than 32%
- Volume equal to or over than 1.5 mL
- Kruger morphology equal to or over than 4%
- Vitality equal to or over than 58% live sperm
Abnormal semen analysis: If any abnormality occurs in the semen tests, it is repeated for confirmation. Depending on each type of alteration found, a specific conduct will be indicated. For example, sperm with good motility and concentration over 5 million, are a good indication of intrauterine insemination. If the number is less than 5 million, in vitro fertilization (IVF) would be the best option for treatment.
If the morphology is less than 4% (Kruger) or the concentration is less than 3 million, there is an indication to do IVF – ICSI treatment.
Azoospermia: Azoospermia is a condition where we can’t find sperm in the liquid seminal. In many cases it is due to insufficiency primary testicular, hormonal, chromosomal or obstructive. Patients can to need hormonal, urological, genetic or ultrasound tests for further assessments of the problem.
Anti-sperm antibodies: These are substances that bind to the surface of sperm and may interfere with their movement, their penetration into the cervical mucus or their ability to fertilize the egg (oocyte).
References in Medical Literature:
Several authors. “Assisted Human Reproduction”. Publisher Atheneu. São Paulo, 2003.