Infertile marriage is the absence of pregnancy in a woman of childbearing age within 1 year of regular sexual activity without the use of any contraceptives. The frequency of infertile marriage is from 10 to 20%.
The cause of infertility can be disorders in the reproductive system in one or both spouses. Infertility in 45% of cases is associated with disorders in the sexual sphere in a woman, in 40% - in a man, in other cases, infertility is caused by disorders in both spouses.
In women, primary and secondary infertility are distinguished in the absence of a pregnancy history and in the presence of it in the past, as well as relative infertility, when the likelihood of pregnancy remains, and absolute infertility, when the possibility of becoming pregnant naturally is completely excluded (in the absence of the uterus, fallopian tubes, ovaries, as well as with abnormal development of the genital organs).
Infertile spouses must be examined at the same time.
A) examination of a man– start with sperm analysis. If no pathology is detected, then at this stage no other studies are carried out in men (spermogram - see 119).
B) postcoital test– used to confirm/exclude immunological infertility associated with antisperm antibodies in a woman, as well as if sexual dysfunction is suspected. The postcoital test allows you to evaluate the quality of cervical mucus and the number of motile sperm in it after sexual intercourse. If the sperm are motionless or make pendulum-like movements, the test must be repeated. If negative or questionable results are repeatedly obtained, additional diagnostic methods are used to confirm/exclude immunological infertility.
B) examination of a woman– carried out in two stages. At the first stage, standard examination methods are used to preliminarily diagnose the 3 most common causes of female infertility: ovulation disorders (endocrine infertility) (35-40%); tubal and peritoneal factors (20-30%); various gynecological diseases that negatively affect fertility (15-25%).
It is advisable to interview women according to the scheme recommended by WHO.
1. The number and outcome of previous pregnancies and births, post-abortion and postpartum complications, the number of living children.
2. Duration of infertility.
3. Contraceptive methods used, duration of their use.
4. Extragenital diseases (diabetes mellitus, tuberculosis, pathology of the thyroid gland, adrenal glands, etc.).
5. Drug therapy (cytotoxic drugs, psychotropic drugs and tranquilizers).
6. Surgeries that promote infertility (surgeries on the uterus, ovaries, fallopian tubes, urinary tract and kidneys, intestines, appendectomy).
7. Inflammatory processes in the pelvic organs and sexually transmitted diseases, pathogen, duration and nature of therapy.
8. Diseases of the cervix and their treatment (conservative treatment, cryo- or laser therapy, electrocoagulation).
9. Galactorrhea and its connection with lactation.
10. Epidemic, industrial factors, bad habits (smoking, drinking alcohol, drugs).
11. Hereditary diseases in relatives of the 1st and 2nd degree of kinship.
12. Menstrual history (age of menarche, nature of the cycle, its disorders, intermenstrual discharge, painful menstruation).
13. Sexual function - pain during sexual intercourse.
Objective examination
1 . Height, body weight and body mass index (BMI) are determined. Normal BMI is 20-26 kg/m2. In case of obesity (BMI >30 kg/m2), it is necessary to establish the time of its onset, possible causes and the rate of increase in body weight.
2. Assess the condition of the skin (dry, moist, oily, acne, stretch marks), hair growth, hypertrichosis and its severity (according to the D. Ferriman, J. Galwey scale). In case of excess hair growth, the time of its appearance is specified.
3. Study the condition of the mammary glands (development, nipple discharge, space-occupying formations).
4. A bimanual gynecological examination and speculum examination of the cervix, colposcopy, and cytological examination of smears are performed.
5. An ultrasound of the uterus and ovaries is performed. If there are clinical signs of hyperandrogenemia, an ultrasound scan of the adrenal glands is additionally prescribed. It is also advisable to use ultrasound of the mammary glands to clarify their condition and exclude tumor formations.
A standard first-stage examination also includes a consultation with a therapist to identify contraindications to pregnancy. If signs of endocrine and mental diseases, as well as developmental defects, are detected, consultations with specialists of the relevant profile are prescribed - endocrinologists, psychiatrists, geneticists.
Research The second stage is always individual, and the set and order of use of diagnostic procedures are always determined by the results of the examination conducted at the first stage (see question 118). At the second stage, the preliminary conclusion (the nature and severity of the existing pathology) is clarified.
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The diagnosis of infertility is made after 12 months of unsuccessful attempts to become pregnant while being sexually active and without contraception. According to statistics, 20% of couples face this problem. But this diagnosis is not a death sentence. In most cases the situation is fixable. It is necessary to identify the cause of infertility as soon as possible and prescribe treatment, which will result in a long-awaited pregnancy and the birth of a child.
Infertility (lat. sterilitas) is the inability of women and men to fertilize.
Infertility can be:
- absolute – the presence of a pathology that excludes the possibility of conception (in women – absence of the uterus, ovaries; in men – absence of sperm, testicles);
- relative - the presence of a cause that can be eliminated.
Also distinguished:
- primary infertility – failure to conceive in a sexually active couple;
- secondary infertility – failure to conceive after pregnancy.
The main causes of infertility include:
- hormonal imbalance;
- infectious diseases;
- abnormal structure of the genital organs;
- genital injuries;
- immunological problems;
- psychological problems.
Methods for diagnosing infertility
Infertility is most often blamed on the woman. But this is a deep misconception. According to studies, 40% of infertility cases are diagnosed in women, 40% in men. The remaining 20% includes combined and unknown causes. Therefore, it is important to diagnose infertility in both women and men. Moreover, it is worth starting the examination with the man, because there are fewer factors influencing male infertility and this diagnosis is simpler.
Diagnosis of infertility in men
Examination of a man for infertility takes place in several stages. First, the main studies are ordered. If after them the doctor still has some questions, then additional ones are prescribed.
The main methods for diagnosing male infertility include the following steps.
- Consultation with an andrologist or reproductive specialist.
Survey. Past illnesses, pregnancies of other partners, characteristics of sexual life and the degree of influence of negative factors (harmful industries, smoking, alcohol) are clarified.
Inspection. The degree of expression of secondary sexual characteristics is determined, the scrotum is palpated.
- Laboratory diagnosis of infertility.
Spermogram is a study of ejaculate. Preparation for the analysis is very important and begins a week before the test. Following a diet, avoiding alcohol consumption, visiting the sauna and bathhouse, stress, and no sexual intercourse for two days. If a man has a cold, the test should be postponed until complete recovery. The research procedure takes place in three stages: masturbation (in a specially designated room in a medical institution or at home), sample collection, and analysis. The ejaculate must reach the laboratory within an hour and must be at room temperature during transportation. Based on the results of the spermogram, the volume of ejaculate, the number of sperm, their motility, morphology and several other indicators are assessed. If deviations from the norm are detected, the analysis is repeated 2 more times to exclude errors or the influence of other factors.
Analysis of hormone levels. These are mainly follicle-stimulating hormone (FSH), testosterone, luteinizing hormone (LH) and prolactin. If these hormones are abnormal, we can talk about endocrine disorders.
- Ultrasound examination (ultrasound).
Ultrasound and Dopplerometry of the scrotal organs. It is used to assess the structure and pathology of the testicles and their appendages.
TRUS (transrectal ultrasound) is performed to assess the condition of the prostate gland and seminal vesicles.
Additional diagnostics of infertility in men includes the following studies:
- genetic tests are prescribed for disorders of sperm maturation and production or their absence;
- analysis for sexually transmitted diseases (STDs) is carried out in case of inflammation combined with an abnormal spermogram;
- prostate secretion excludes or confirms inflammation of the prostate;
- determination of tumor markers is prescribed in case of suspected malignancy;
- an immunological study (MAR test) should reveal the presence or absence of antisperm antibodies;
- testicular biopsy is indicated in the absence of sperm or a serious decrease in their number;
- a study of post-orgasmic urine is carried out in the absence of ejaculation or its small volume to exclude or confirm the reflux of sperm into the bladder.
Each of the additional methods for diagnosing the causes of infertility has serious indications for research and should be carried out by experienced specialists.
Diagnosis of infertility in women
Female infertility requires more serious research than male infertility. After all, the female body must not only form a high-quality egg, but also create special conditions for fertilization, gestation and birth of a child.
As with the examination of male infertility, the diagnosis of female infertility is carried out in stages.
- Consultation with a gynecologist or reproductive specialist.
Survey. The list of past diseases, operations (especially on the pelvic organs), genetic abnormalities in the family, the presence of pregnancies, characteristics of sexual life and the menstrual cycle, and the influence of harmful factors is specified.
Inspection. First, the ratio of height and weight and the development of secondary sexual characteristics are assessed. Then a gynecological examination of the vagina and cervix and a two-handed examination of the uterus and ovaries are performed.
- Laboratory diagnostics.
Smear. Analysis of discharge from the cervical canal will indicate the presence of an inflammatory process or STD.
Blood test for hormones (FSH, LH, estrogens, progesterone and androgen), infections and increased clotting.
- Ultrasound diagnosis of the condition of the uterus and ovaries. Ultrasound is the most informative and reliable way to determine ovulation. In addition, you can evaluate the condition of the uterus and ovaries, monitor the growth of the endometrium and determine the causes of menstrual irregularities.
- Rectal temperature measurement. This additional research method is carried out over a period of 3 months and assesses the presence (37°C) or absence (<37°С) овуляции. Наблюдение и измерение женщина проводит самостоятельно.
- Hysterosalpingography (HSG). This is an x-ray examination aimed at diagnosing tubal infertility and assessing the condition of the uterus. This research method is carried out on days 5-7 of the cycle by injecting a contrast agent into the uterus and assessing its movement through the fallopian tubes. This method is not always informative in assessing the patency of the fallopian tubes, because the patient experiences discomfort, which may affect the result. This method is more suitable for identifying uterine pathologies. And the most reliable way to assess the patency of the fallopian tubes is laparoscopy.
- Laparoscopy. This type of examination is performed under general anesthesia using a special apparatus through small holes in the abdominal cavity. The undoubted advantage of this study is not only its high information content, but also the possibility of correcting identified disorders (restoration of fallopian tube function, removal of fibroids and ovarian formations).
- Hysteroscopy. This method of endoscopic examination of the uterus not only evaluates its condition, but also allows for treatment of almost any uterine pathology.
- Tomography of the skull and sella turcica is prescribed if endocrine infertility is suspected.
- Spiral computed tomography of the pelvic organs is prescribed to clarify pathologies of the internal genital organs.
Diagnostics of partner compatibility
There are cases when conception does not occur due to incompatibility of partners. There are several methods for diagnosing such cases of infertility.
- Karyotyping is a study of the genetic compatibility of partners. The material for analysis is blood from a vein.
- HLA typing – assessment of immunological compatibility. The more antigens that react aggressively to foreign cells, the less chance of pregnancy.
- Kurzrock-Miller test. This diagnostic method examines the interaction of male and female germ cells. The specialist places cervical fluid and sperm in one test tube and observes the behavior of the cells.
- Shuvarsky's test. This method is similar to the previous one, but the combination of cervical fluid and sperm occurs naturally. A woman takes this test no more than 6 hours after sexual intercourse.
There are many reasons why problems with conception occur. Conducting timely diagnosis and prescribing treatment for infertility in most cases can eliminate them. The main thing is to conduct a comprehensive study of both men and women. As a result, even already desperate couples have a high probability of becoming happy parents of a long-awaited child.
Infertility is the inability of a woman or man to conceive. There is also a distinction between the concept of infertile marriage - this is the absence of pregnancy after a year of sexual activity without the use of contraception on a regular basis. According to various sources, the frequency of infertile marriages varies from 10% to 20%.
According to the World Health Organization, “about 8% of married couples experience the problem during their reproductive years.”
General information
There are many reasons for female infertility: from any gynecological pathology to immunological reasons. Diagnosis of infertility in women is a serious issue in reproductive medicine. According to statistics, the cause of infertile marriages in an average of 70% of cases is female infertility.
The procedure for carrying out diagnostic activities is systematized and includes a number of standard and sequential procedures, which will be discussed in the article. Examination for infertility in women begins after excluding possible causes of impaired sperm fertility in a man. This is due to the fact that establishing the causes of female infertility is a longer and more labor-intensive process.
It is important that at the time of examination there are no inflammatory diseases of the vagina and cervix. To do this, you need to undergo a preliminary examination by a gynecologist in the clinic, and, as prescribed by the doctor, undergo the appropriate tests, including for sexually transmitted infections. In addition, after curing acute inflammation or exacerbation of the chronic course of the disease, at least 4 months should pass (some experts recommend at least six months).
Diagnostic stages
Diagnosis of female infertility, like diagnosis of any other disease, goes through a number of stages and uses methods such as:
- collection of complaints and medical history;
- objective examination;
- laboratory and instrumental research methods.
When collecting an anamnesis during an examination for infertility, the doctor pursues a number of tasks, among which are clarification of several issues: the presence of pregnancies, the duration of the period of infertility, contraceptive methods used, the presence of systemic and inflammatory diseases, surgical or drug treatment, exposure to external factors. Regarding previous pregnancies, their number and outcomes, the presence of previous abortions (spontaneous and artificial), children, as well as ectopic pregnancy and any complications (postpartum and post-abortion are taken into account) are important.
Among systemic diseases, endocrine diseases play a role: diabetes mellitus, pathology of the pituitary gland, thyroid gland and adrenal glands, and infectious diseases (tuberculosis and others). If there is a pathology of an inflammatory nature, it is necessary to establish the type of pathogen, the fact of treatment and its duration. It is also important to inform your doctor about existing sexually transmitted diseases, including past ones.
The woman’s history should indicate the presence of surgical interventions that could affect the development of infertility. Such operations include:
- appendectomy;
- gynecological operations (on the uterus, ovarian resection);
- surgery for ulcerative colitis;
- other interventions.
Taking medications can also affect the ovulation process. The impact may be short-term or long-term. Among medications, the most significant role can be played by psychotropic drugs and cytostatics. In addition, other types of treatment are also important, for example, X-ray therapy of the abdominal organs. Therefore, it is important to inform your doctor of all data related to existing diseases and their treatment.
It is possible to be exposed to external factors, which include habits such as alcohol abuse, smoking, as well as harmful industrial and environmental agents. Thus, all possible external influences and working and living conditions are clarified.
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Mandatory to clarify is the question of the menstrual cycle: time of onset of menstruation, regularity, duration, first day of the last menstruation. The doctor will also find out about sexual function and any disorders thereof. In addition to the above points, important factors are hereditary, including family history.
An objective examination includes examination, anthropometric data (body weight, height, body mass index); assessment of the nature of hair growth, condition of the skin and mammary glands; systematic examination with blood pressure measurement; gynecological status. During the examination, the patient is given a typobiological assessment: a male or eunuchoid type of structure is possible.
Laboratory and instrumental methods include blood tests, radiography of the skull and targeted examination of the sella turcica (for the diagnosis of neuroendocrine diseases), hysterosalpingography, study of the fundus and visual fields. Also, according to indications, a cytogenetic study is prescribed to determine sex chromatin (more often performed in patients with spontaneous miscarriages in early pregnancy).
Diagnostic algorithms
There are several examination algorithms for testing for infertility in women. The division is based on two main indicators:
- cycle regularity;
- the presence or absence of endocrinopathies, that is, any disorders or diseases of the endocrine glands.
Based on these clinical data, three groups of patients are formed, which is necessary to select the most effective and informative examination methods. The first group includes patients with a regular cycle and no manifestations of endocrinopathies. The examination in this group begins with a postcoital test. Many people are interested in what the post-coital test is called? Shuvarsky's test or compatibility test are synonyms for one study. The essence of the method is to study cervical mucus. Parameters such as viscosity, acidity, sperm count and activity are assessed. The test is carried out within 4-6 hours after sexual intercourse. For proper implementation, several rules must be observed:
- after sexual intercourse, a woman should be in a horizontal position for half an hour;
- abstinence from sexual activity for two to three days;
- The use of vaginal medicinal and hygiene products is prohibited.
A negative test indicates immunological infertility. This is a fairly rare (approximately 2% of cases) cause of infertility and is also one of the least studied.
If the test is positive, the next stage of diagnosis is hysterosalpingography. This is a method for assessing the patency of the fallopian tubes, otherwise called metrosalpingography. Refers to x-ray research methods. If the fallopian tubes are passable, then diagnostic laparoscopy is indicated to identify possible non-inflammatory diseases (for example, endometriosis). When the fallopian tubes are obstructed, infertility is called tubo-peritoneal.
The second group includes women with irregular cycles and without clinical manifestations of endocrinopathies. In this group, tests for infertility begin with determining the level of prolactin. If the values are normal, it is necessary to examine the level of thyroid-stimulating hormone (TSH). If TSH is elevated, this indicates the need to confirm hypothyroidism. If prolactin levels are elevated, the patient is prescribed an X-ray of the skull and, if necessary, a computed tomography scan of the skull. According to the results of these studies, it is possible to detect a space-occupying formation in the pituitary gland, or hyperprolactinemia is functional in nature.
The third group contains patients with irregular cycles and clinical symptoms of endocrinopathies. The latter include, for example, virilization (a set of symptoms reflecting an increase in the content of male sex hormones in the female body), obesity, hypertrichosis (excessive hair growth). Diagnostic procedures begin with an ultrasound examination of the pelvic organs. When one ovary is enlarged, the presence of a virilizing tumor is most likely. If the size and structure of the ovaries are normal, or an increase is detected on both sides, then there is only one tactic: donate blood to study the level of testosterone, dihydroepiandrosterone (DHEA) and 17-hydroxyprogesterone (17-OHP), followed by a test with dexamethasone. If a decrease in all indicators by 75% is detected, the cause of infertility is diagnosed as adrenal hyperandrogenism. When testosterone levels decrease by 25%, polycystic ovary disease occurs. If the test result is negative, a computed tomography scan is prescribed to look for a virilizing adrenal tumor.
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When analyzing the results of clinical data, the following cause-and-effect patterns were identified:
- in group 1, the cause of infertility is diseases of an inflammatory or non-inflammatory nature;
- in group 2 – absence of ovulation of various origins;
- in group 3 – hormonal dysfunction of the ovaries and/or adrenal glands. An interesting fact is that “the frequency of this form of infertility ranges from 4 to 40%.”
For infertility in women, one of the diagnostic stages is to determine the presence and time of ovulation.
Methods for determining ovulation
Determining ovulation is a mandatory test for infertility. There are several possible ways. In patients with a regular cycle, one option is long-term measurement of rectal temperature (for 3 months). The essence of the method is a jump in basal temperature during ovulation by approximately 0.3 degrees. To record temperature changes, it is necessary to measure daily in the morning and record the temperature on a graph. However, it should be noted that not all women have ovulation accompanied by a noticeable change in basal temperature. In addition, the change may be due to other factors (stress, illness, measurement error, etc.). Therefore, measuring basal temperature is a simple, low-cost, but not effective method for determining ovulation.
In addition to this method, you can use:
- ultrasound examination in the middle of the cycle and 2 days before the start of menstruation;
- study of progesterone levels in the blood in the middle of the 2nd phase of the cycle.
Ultrasound examination is indicated to determine the presence of a dominant follicle, as well as to measure endometrial thickness.
What tests do women undergo for infertility and when? There are recommendations for the timing of a particular examination for infertility to ensure that it is as informative as possible. For example, hysterosalpingography is recommended to be performed a week after the start of menstruation. Postcoital test – two weeks from the start of the cycle. It should be remembered that the beginning of the cycle is considered the first day of menstruation. Endometrial biopsy is performed only under strict indications in the premenstrual phase.
Conclusion
Thus, tests for infertility are prescribed individually, taking into account the medical history, complaints and manifestations of the disease in each specific case. After an examination, the doctor at the reproduction center will prescribe the necessary list of studies and tests to establish a diagnosis. Examination for female infertility usually takes a long period of time. For optimization purposes, an examination procedure has been developed, where the choice of diagnostic measures depends on the clinical picture.
Remember that nowadays the diagnosis of infertility is not a death sentence, and there are many effective treatment methods. Good luck to you and your loved ones. Take care of yourself!
Higher medical education, venereologist, candidate of medical sciences.
Diagnosis of infertility in women is an important step towards determining the cause of an infertile marriage. Today there are many diagnostic methods and in this article we will talk about them in great detail.
Diagnosis of female infertility begins with a preliminary examination of the patient in the clinic and antenatal clinic. In some cases, after this stage it is possible to identify the problem and prescribe effective therapy. In outpatient settings, types of infertility caused by ovulation disorders and gynecological diseases not associated with occlusion of the fallopian tubes respond well to treatment.
If there are indications, they proceed to the second stage of examination. The patient is prescribed specialized diagnostic methods (non-invasive hardware, endoscopy, hormonal studies). Treatment in such cases, depending on the identified pathology, can be either conservative or surgical (using laparoscopic, laparotomic and hysteroscopic methods).
In some cases, the only option for the patient is assisted reproductive technologies (ART). These include IVF procedures, as well as artificial insemination (these activities can be performed in different modifications).
Specialized medical care can be obtained at the state center for reproduction and family planning, gynecological departments of medical institutions, at private infertility treatment centers, at the clinical bases of research institutes and departments dealing with these problems.
Diagnosis plan for infertility in women
1. Collection of a woman’s medical history (somatic, gynecological and reproductive).
2. General examination (weight, height, skin, examination of the mammary glands).
3. Gynecological examination.
4. Husband's sperm analysis.
5. Blood test: general and biochemical blood test, coagulogram, RW, HIV, HbsAg, blood test for glucose, blood group and Rh factor.
6. General urine analysis.
7. Comprehensive examination for STDs.
8. Ultrasound of the pelvic organs.
9. Colposcopy.
10. Hysterosalpingography.
11. Functional diagnostics of ovarian activity:
Measuring basal temperature for 2-3 months;
Weekly hormonal colpocytology;
Daily study of the phenomenon of mucus arborization;
To determine the diameter of the follicle, an ultrasound is performed on the 12-14-16th day of the cycle;
The levels of estrogen, testosterone, prolactin, FSH, LH are determined in the blood plasma;
On days 3-5 of the menstrual cycle, in the middle of the cycle and in phase 2, the level of progesterone in the blood and pregnanediol in the urine is determined;
The level of 17-KS in the urine is determined 2 times a month.
12. Hormonal tests.
13. Application of additional research methods according to indications:
Hormonal examination: cortisol, DHEA-S (dehydroepiandrosterone - sulfate), insulin, T3, T4, TSH, antibodies to thyroglobulin;
Shuvarsky-Guner postcoital test;
Determination of antisperm antibodies in women in the mucus of the cervical canal on preovulatory days (the levels of immunoglobulins IgG, IgA, IgM are determined);
Kurzrock-Miller test (penetration of sperm into the cervical mucus of a woman during ovulation);
Friberg test (determination of antibodies to sperm using a microagglutination reaction);
Kremer's test (detection of local antibodies in the husband during contact of sperm with cervical mucus;
Izojima immobilization test;
Immunological tests.
14. Examination by a mammologist, mammography.
15. X-ray of the sella turcica and skull.
16. Examination of the fundus and visual fields.
18. Laparoscopy.
Taking anamnesis for female infertility
The examination of a woman suffering from infertility begins with a thorough history taking. The first conversation with the patient is carried out in accordance with WHO recommendations. In this case, the doctor should clarify the following points:
Does the patient have children and how many there are at the moment.
How long does infertility last?
How many pregnancies and births have you had in the past and what was their outcome.
Complications after childbirth and abortion.
What methods of contraception did the woman use and for how long?
Do you have any chronic diseases (problems in the functioning of the adrenal glands, thyroid glands, diabetes mellitus, tuberculosis, etc.).
What medications have you taken or are you taking (tranquilizers, psychotropic drugs, cytotoxic drugs).
Have you undergone operations associated with the risk of adhesions (interventions on the ovaries, uterus and its tubes, kidneys, urinary tract, intestines, surgery for appendicitis).
Have you had pelvic inflammation or sexually transmitted infections in the past? (If such diseases have occurred, it is necessary to clarify the type of pathogen and details of treatment).
Has galactorrhea been observed and was it associated with lactation?
Have there been any sexual dysfunctions such as contact bleeding or dyspareunia?
What cervical diseases were diagnosed and what therapy was prescribed (conservative, electrocoagulation, cryotherapy, laser).
It is also necessary to inquire about the patient’s lifestyle, the presence of bad habits (smoking, addiction to alcohol or drugs), to clarify the influence of industrial, epidemic and hereditary factors (find out the presence of hereditary diseases in the patient’s 1st and 2nd degree relatives).
When diagnosing female infertility, the menstrual history of an infertile woman (menarche, cycle features, cycle disorders, discharge between menstruation, sensations during menstruation) is also of great importance.
Physical examination in women with infertility
At this stage of the examination, the following diagnostic measures are carried out:
The patient's height and weight are measured.
Body mass index is calculated (weight in kilograms divided by the square of height in meters). Normal values for this indicator are from 20 to 26. If obesity is noted (mass index exceeds 30), find out when obesity appeared, how quickly it developed and what could have been the cause.
Carefully study the condition of the skin (dry skin or oily, moist), pay attention to the presence of traces of stretch marks and acne. Assess the nature of hair growth. If there is hypertrichosis, its degree is determined using the D. Ferriman, J. Galwey scale. Find out when excess hair growth occurred.
The mammary glands are examined, the degree of their development is assessed, and a study is carried out for discharge from the nipples and palpable formations.
A bimanual gynecological examination is performed, the condition of the cervix is examined using mirrors, and colposcopy is performed.
At this stage, a medical opinion from a therapist is also required about the possibility of a successful pregnancy and successful childbirth. If signs of mental, endocrine or any other diseases, developmental defects are detected, then consultation with a specialized doctor - psychiatrist, endocrinologist, geneticist, etc. will be necessary.
Laboratory diagnostic methods for female infertility
Infectious screening for infertility in women
In accordance with the order of the Ministry of Health of the Russian Federation No. 572n, infectious screening is performed. It involves the following activities:
Taking a smear from the cervix for cytological analysis.
- Flora smear from the cervical canal and urethra.
Examination of the degree of vaginal cleanliness.
PCR analysis for 12 infections: chlamydia, human papillomavirus infection, mycoplasmosis, ureaplasmosis, trichomoniasis, gonorrhea, etc. For this, a smear is taken from the cervical canal.
The use of a cultural method (when samples from the vagina and cervical canal are inoculated to study the flora and assess its sensitivity to antibacterial drugs).
Blood tests for HIV, syphilis, hepatitis B and C.
If the patient has been diagnosed with one of the infections mentioned above, a course of etiotropic therapy will be required, followed by another (control) examination. At this stage, the patient may be referred for specialized treatment to an immunologist (if HIV is detected) or a dermatovenerologist (in the case of gonorrhea or syphilis).
TORCH-complex
The TORCH complex includes:
Detection of antibodies (immunoglobulins - Ig) G and M to rubella, cytomegalovirus, toxoplasmosis, herpes simplex virus (type 1 and 2). If IgG antibodies to rubella are not detected, the patient needs vaccination.
Hormonal screening
In order to confirm or exclude the endocrine nature of the pathology (anovulatory infertility), hormonal screening is performed as part of a standard outpatient examination program. In case of cycle disorders and ovulatory function disorders, a study of hormonal levels helps to identify the cause of the pathology.
Hormonal screening includes assessment of the level of the following hormones: luteinizing and follicle-stimulating hormones, prolactin, estradiol, cortisol, testosterone, 17-hydroxyprogesterone, thyroid-stimulating hormone, dehydroepiandrosterone sulfate, free thyroxine (on the 2nd or 3rd day in a normal cycle and at any time in case of a broken cycle) and progesterone (on the 21st–23rd day of the cycle).
If studies have shown abnormalities in hormone levels, the patient will need further diagnostics aimed at identifying the causes of the hormonal imbalance. At this stage, specialized instrumental and laboratory diagnostic methods can be used:
Computed tomography of the sella turcica area.
Ultrasound examination of the thyroid gland.
Hormonal tests.
Such diagnostics falls within the competence of a specialized specialist – a gynecologist-endocrinologist. The same doctor, based on the results of examinations, determines the treatment regimen.
Immunological methods for diagnosing female infertility
Also, to diagnose infertility in women, they resort to immunological studies - identifying antibodies in samples from the cervical canal (IgG, IgM, IgA).
Instrumental methods for diagnosing infertility in women
During the outpatient examination of infertile patients, a mandatory method is pelvic ultrasound. Ultrasound examination is also recommended for assessing the condition of the mammary glands and excluding neoplasms in them (up to 36 years). If indicated, an ultrasound scan of the thyroid gland is performed.
If intrauterine or tubal causes of infertility are suspected, the patient undergoes hysterosalpingography (HSG). The study is performed from the 5th to the 7th day of the cycle with normal menstruation or oligomenorrhea. In patients with amenorrhea, HSG can be performed at any time.
At the same time, the diagnostic capabilities of HSG in the study of fallopian tubes cannot be considered satisfactory. The fact is that during the study of tubal patency, there is a significant discrepancy between the results (up to 50%) of HSG and laparoscopic examination, supplemented by chromosalpingoscopy with methylene blue. This means that diagnosing tubal-peritoneal infertility (TPI) and completely clarifying the picture of tubal changes can only be done using the laparoscopic method. As for HSG, this method is informative in the diagnosis of intrauterine diseases.
X-ray diagnostic methods for female infertility include:
Tomography (computer or magnetic resonance imaging).
Craniogram.
Hysterosalpingography.
Mammography (after 36 years).
Tomography of the skull and sella turcica is performed for endocrine infertility, which is associated with hyperprolactinemia or pituitary insufficiency (with low FSH levels). This method allows doctors to detect macro- and microprolactinomas of the pituitary gland. In addition, it makes it possible to diagnose empty sella syndrome.
If there is a suspicion of surgical pathology of the genital organs, the patient may be referred to a spiral CT scan of the pelvis. Such a study allows you to obtain complete information about the condition of the organs, after which you can plan surgical intervention. Instead of spiral tomography in such cases, the use of MRI is also allowed. However, it must be taken into account that the diagnostic potential of this method is not as high, and obtaining images will take longer.
Patients who, due to endocrine infertility, exhibit signs of hypo- or hyperthyroidism, abnormalities in the level of thyroid hormones, and hyperprolactinemia are referred for an ultrasound examination of the thyroid gland.
Ultrasound of the adrenal glands is indicated for elevated levels of adrenal androgens and hyperandrogenism. If necessary, a CT scan of the adrenal glands is performed.
Endoscopic diagnosis of female infertility
Endoscopic diagnosis involves laparoscopy and hysteroscopy. If there is pathology of the endometrium, a biopsy is performed during the procedure.
Laparoscopy is considered the most informative method for peritoneal and tubal factors of infertility. Moreover, it makes it possible to correct detected pathologies: restore tubal patency, separate adhesions, remove fibroids (intramural, subserous) and retention formations in the ovaries, and perform coagulation of endometrioid heterotopias.
The hysteroscopy method is used in the following cases:
Suspicions of intrauterine pathology based on the results of a survey, examination and ultrasound examination.
The patient has dysfunctional uterine bleeding, regardless of its intensity.
Hysteroscopy of the uterus helps to identify many different pathologies: polyps, adenomyosis, myomatous nodes, GPE, chronic endometritis, synechiae, malformations, and the presence of a foreign body. During this procedure, a specialist may perform curettage of the cervical canal and uterine cavity for diagnostic purposes. In addition, under hysteroscopic control, surgical interventions can be performed for various intrauterine pathologies.
Diagnosis of sexual partner
In parallel with the examination, the patient is also referred for diagnostics to her partner. This is necessary in order to exclude the possibility of male infertility. The main study in this case is spermogram. If the analysis shows abnormalities in sperm parameters, the man must be examined by an andrologist. After this, you can decide on possible ways to solve the problem (treatment of the man or IVF).
In addition to the spermogram, when examining men, the MAP test method (detection of antibodies to sperm) is used. If the rate of this test exceeds 30%, we can say that a man’s infertility is of an immune nature. In such cases, IVF or the method of artificial insemination is indicated.
If there is a suspicion of one of the surgical pathologies (ovarian cyst, tubal occlusion, uterine malformations, endometrioid or myomatous process, intrauterine synechiae, peritoneal adhesions), the patient should be referred to a specialized medical institution. There they will conduct further diagnostics, make a final diagnosis and carry out the necessary treatment (surgical or endoscopic method). The diagnosis of male infertility is described in detail in another article on our website.
If a woman has not undergone the full range of necessary studies, it is impossible to make a final diagnosis. Consequently, the therapy will be ineffective. It is important to take into account this point: the maximum duration of any conservative treatment is two years (this also applies to treatment after surgical interventions to eliminate a particular gynecological pathology). If after two years of therapy pregnancy does not occur, the woman is sent without delay to an ART center. There is also no point in postponing a visit to the center because the patient’s age (over 35 years old) may make it difficult to successfully use such techniques. It must be remembered: in infertile women of this age category, the stage of therapy, which involves the use of techniques aimed at restoring the natural ability to conceive (outpatient stage), should be excluded altogether.
