Infertility Or, in common words, infertility may occur as a result of no pregnancy occurring before, or a pregnancy occurring at first, but not being able to become pregnant later. Approximately 25% of all women will experience infertility at some point in their lives.
The age at which women are most productive in terms of fertility is around the age of 25 and especially from the age of 35 This results in a significant decrease in fertility. The average chance of a couple achieving pregnancy in a 3-month period is 57%, in 6 months this rate is 72%, after 1 year it is 85%, and after 2 years it is 93%. In other words, especially for young couples, one should not be in a hurry.
Couples younger than 25 may wait up to 2 years to start infertility tests. For couples over the age of 30, not having a pregnancy within a period of 6 to 12 months, depending on the situation, may be considered sufficient to start infertility tests. On the other hand, in the treatment of infertility, it is necessary to continue a treatment protocol for at least 6 months. Moreover, what couples need to know above all else is that this treatment process patience is what it requires. The effect of age on fertility in men is controversial. Although male productivity reaches its highest values around the age of 35 and shows a significant decline after the age of 45, men who can become fathers even in their 80s are known and this issue is not as important as the female age.
Causes of infertility:
Causes related to men are 25-40%, reasons related to women are 40-55%, reasons related to both are 10-15%, and unexplained reasons are 10-15%. In other words, both couples are almost equally responsible for infertility.
Approach to a childless couple:
It is possible to reveal some of the reasons from the beginning with a detailed interview and examination with the couple. After this meeting, basic examinations are carried out:
• First of all, it is an easy examination. your man sperm analysis for evaluation spermiogram is done. After approximately 2-5 days of sexual abstinence, the man gives a sperm sample by masturbation and it is evaluated in the laboratory according to the World Health Organization criteria. Number, motility, viability rate and shapes of sperms is examined. It is investigated whether there are inflammatory cells and whether there is anything that can be done with medical treatment.
In a sperm analysis that can be considered normal, according to the criteria of the World Health Organization, there must be 20 million sperm per milliliter, at least half of them must be motile (live), or the rate of forward-moving sperm must be at least 25% of all sperm, and normally shaped sperm must be at least 14% and above, with detailed evaluation by staining (Kruger Criteria).
It should not be forgotten that it is not appropriate to diagnose male infertility with a single abnormal spermiogram.
Since men's sperm results fluctuate, in case of abnormality, the examination must be repeated at least 2 times with an interval of 4-6 weeks.
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EVALUATION OF WOMEN
• Then, the woman's uterus and ducts are evaluated by taking a medicated film (HSG).
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This film evaluates whether the channels are open and whether they appear normal. If both channels appear to be blocked, then it is not possible for the sperm to pass through these channels and fertilize the egg, and to find out whether they are really blocked, a procedure called Laparoscopy is usually performed to look inside the abdomen. If the canals are found to be closed during this procedure and can be repaired by surgery, they can be repaired, but if they cannot be repaired, there is nothing to do but resort to in vitro fertilization.
INFERTILITY DUE TO ONE OR BOTH TUBES BEING CLOSED (TUBAL FACTOR)
An important part of the causes of female infertility problems in the tubes constitutes. If this situation cannot be overcome with surgery, it may be necessary to proceed directly to in vitro fertilization treatments.
In couples applying for infertility, if the sperm analysis requested after examination and ultrasonography gives normal results, it is recommended to evaluate the condition of the ducts by taking a uterine film (hysterosalpingography). There is a high possibility of problems with the tubes, especially in women who have frequent vaginal infections (inflammation) with discharge, who have previously been diagnosed with tuberculosis (TB), who have had more than one abortion, who have had intra-abdominal surgery such as cesarean section or ruptured appendicitis.
Generally, if an obstruction is detected in one or two of the tubes on the uterine film or if there is a suspicion that it is closed, the next step is laparoscopy It is a surgery called. In fact, laparoscopic surgery is a method that is performed under anesthesia but does not require hospitalization afterwards. It is entered through the navel with a lighted device, which allows us to see whether the tubes are open or not by the passage of the medicine given into the abdomen. It also makes it possible to detect intra-abdominal adhesions, if any, and even to intervene in these adhesions. In evaluating the permeability of tubes laparoscopy It is considered the gold standard, that is, the best method.
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If one of the tubes is determined to be open and the other closed by canal film or laparoscopy, vaccination can be tried as it can be one of the treatment methods. In fact, if only one tube is open, there is a chance of spontaneous pregnancy, although the success rate is low. However, it is not recommended to leave it alone for long periods of time or spend time with vaccinations. It should not be forgotten that the reason that causes one tube to close may also have affected it to a greater or lesser extent, even if the other tube appears open.
If both tubes are detected to be closed with the uterine film and it is observed that the tubes have become fluid-filled structures called hydrosalpinx and these structures can be monitored with ultrasound, the chance of opening them with surgery and pregnancy occurring is extremely low. Therefore in vitro fertilization process should be implemented.
However, in such a case, before proceeding with in vitro fertilization treatment, these damaged, fluid-filled parts of the tubes must be removed by laparoscopy. It is suggested that this liquid content may have adverse effects on the settlement and development of the embryo in the uterus after the embryos are transferred to the uterus. Therefore, these parts of the tubes filled with liquid, namelyhydrosalpinx The structures we mentioned negatively affect the success of in vitro fertilization treatment.
If there is a duct obstruction from the beginning of the point where the tubes leave the uterus, a certain chance of success is possible with microsurgery. In addition, if the tubes can be opened successfully with the operation, other pregnancies may occur spontaneously after pregnancy and birth. However, this kind of blockage in channels In order for the opening operation to be successful and pregnancy to occur, the surgeon who will perform this operation must have received special training (micro surgery training) on this subject.
However, today, repairing damaged sections of the tubes or correcting them with surgery is not widely accepted, and since the chance of success will not increase much due to new adhesions that may occur with surgery, it is more preferred in such cases. IVF It is recommended to switch to treatments.
Another reason for this is that today's in vitro fertilization treatments are success rates is that it has increased even more than before. The first periods when pregnancy occurs in our patients who were diagnosed with a problem in one or both of the tubes and were taken to both insemination and in vitro fertilization treatments. ectopic pregnancy Therefore, one should be skeptical and remember that this possibility is higher than the rate in normal society.
As it is known, early diagnosis of ectopic pregnancy is life-saving.
• If the channels are open and look normal, it is investigated whether the woman ovulates normally. Although many methods are used, today it is most commonly investigated with blood tests (day 21 of menstruation) and ultrasonography.
If there is an ovulation problem and it is permanent, then the doctor applies medication to ensure ovulation. The most common reason for lack of ovulation is Polycystic ovary disease. For more detailed information about polycystic ovary, please Click here.
How is ovulation treatment done?
Treatment of women with ovulation difficulties varies depending on the underlying cause. The aim of this treatment is to try to mimic natural physiology as much as possible. What is natural is that an egg matures during a menstrual period and begins on the 12th-14th day of menstruation. It cracks in its days. Therefore, treatments that develop eggs from the ovaries must parallel this natural development.
I said that the most common problem in women with ovulation problems is Polycystic ovary disease. It would be a logical approach to treat these women with simple and cheap pills for 3-6 months without doing detailed examination at the beginning.
The main drugs used for this purpose are pills containing clomiphene. It is generally used starting on the 5th day of the menstrual period and lasting for five days. It would also be appropriate to monitor the development of the ovaries while using this medication. Treatment can be started from the lowest dose and the dose can be increased by one pill until ovulation is achieved. However, there is generally little chance of a response to more than 3 pills a day.
After the dose that ensures ovulation is determined, the woman is expected to become pregnant after at least 3 menstrual cycles with the same dose to ensure ovulation. In women with Polycystic Ovary who have ovulation problems, although ovulation is achieved at a rate of 75% with pills containing clomiphene, the pregnancy rate does not exceed 30%. In other words, achieving ovulation is not a guarantee for pregnancy.
If ovulation cannot be achieved with clomiphene or if pregnancy does not occur despite ovulation, what should be done?
In these women, injection treatment, which is usually the second option, should be started. The needles used for this purpose contain reproductive hormones that stimulate the female hormone estrogen.
Needle treatment is done daily. During this treatment, it is necessary to closely monitor the development of the eggs. Physicians who do not have sufficient experience in this field may use these injections unnecessarily or in excessively high doses in order to get results as soon as possible. Thus, these treatments eventually lead to conditions called hyperstimulation syndrome or multiple pregnancies, which are sometimes reported in the media (as in the case of septuplets). For this reason, the physician should be patient in injection treatment and adjust the dose according to the development of the eggs over certain periods of time, starting from the lowest dose. Sometimes this type of adjustment can take up to 3-4 weeks.
Sometimes the reason for not ovulating is inadequate secretion of hormones that need to be released from the hypothalamus or pituitary region in the brain or hyperprolactinemia (high milk hormone) or hypothyroidism There may be another hormonal problem such as underactivity of the thyroid gland. The treatment methods for each of these problems are different.
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If the woman cannot become pregnant within 2-3 months even though ovulation is achieved with the treatment given, then vaccination method is used. The chance of success of vaccination for each attempt is around 10-15%. If success is not achieved with this procedure (even though it is done 3-4 times), then IVF It is recommended to try.
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