What is Infertility?
The first concept that we must have is that the fertility of the human being is relatively low. A couple has a chance of getting pregnant about 20% a month. So it is common to have some time between the beginning of the attempts to get pregnant and the pregnancy, which raises the first question: when a couple should think about infertility?
Marital infertility is defined as the absence of pregnancy after 12 months of regular intercourse without the use of a contraceptive method. This time limit is important because, after 1 year without being able to get pregnant, the couple should seek medical care for an appropriate evaluation. Obviously, there are situations in which this time should be shorter. For example, when the woman is 35 or older she should seek help after 6 months of trying. Other examples are in those couples where there is a suspected initial change, such as irregular menses, Polycystic Ovarian Syndrome, endometriosis, previous pelvic infection, previous ectopic gestation, tubal ligation or vasectomy.
Infertility is not a rare problem and affects about 15% of couples.
Causes
The stages of the reproductive process need to be in perfect working order to occur during pregnancy. The main phases are ovulation, the capture of the egg by the tuba, the fertilization of this by the spermatozoon and, finally, the implantation of the embryo formed in the uterus.
Therefore, the main causes of infertility are:
The first concept that we must have is that the fertility of the human being is relatively low. A couple has a chance of getting pregnant about 20% a month. So it is common to have some time between the beginning of the attempts to get pregnant and the pregnancy, which raises the first question: when a couple should think about infertility?
Marital infertility is defined as the absence of pregnancy after 12 months of regular intercourse without the use of a contraceptive method. This time limit is important because, after 1 year without being able to get pregnant, the couple should seek medical care for an appropriate evaluation. Obviously, there are situations in which this time should be shorter. For example, when the woman is 35 or older she should seek help after 6 months of trying. Other examples are in those couples where there is a suspected initial change, such as irregular menses, Polycystic Ovarian Syndrome, endometriosis, previous pelvic infection, previous ectopic gestation, tubal ligation or vasectomy.
Infertility is not a rare problem and affects about 15% of couples.
Causes
The stages of the reproductive process need to be in perfect working order to occur during pregnancy. The main phases are ovulation, the capture of the egg by the tuba, the fertilization of this by the spermatozoon and, finally, the implantation of the embryo formed in the uterus.
Therefore, the main causes of infertility are:
- Women's Factors
- Problems with ovulation (ovulatory factor)
- Tubal changes (tubal factor)
- Changes in uterus (uterine factor)
- Endometriosis.
- Male Factors
- Problems in the formation, transport or ejaculation of spermatozoa.
Women's Factors
Ovulation is the process in which the ovum, stored inside the ovaries, is released monthly. Women who ovulate normally have regular menses, often preceded by pre-menstrual symptoms (known as premenstrual tension or PMS). On the other hand, those that do not ovulate adequately, present irregular menstruations, associated, in some cases, with the increase of hairs and acne. The latter situation is typically found in women with Polycystic Ovarian Syndrome (lack of ovulation and ovaries with multiple microcysts). Other diseases may also be involved, such as prolactin-producing tumors, hypothyroidism, androgen producing tumors and rare enzyme deficiencies.
In addition, reducing the quantity and quality of the eggs is also a major cause of difficulty in getting pregnant. This process is directly related to age because the ovules, unlike the spermatozoa, do not multiply and they are exhausted. Nowadays, when pregnancy is increasingly delayed, this problem is extremely important.
After ovulation, the latter is picked up by the uterine tube. It is in the tuba that the fertilization occurs, that is, the encounter of the spermatozoid with the ovum. The embryo is formed and transported to the uterus. This stage depends on the perfect functioning of the tubas, extremely delicate organs. Tubal changes may be evident, such as in bilateral obstruction, or more subtle, such as in adhesions and distortions. These changes are secondary to inflammatory/infectious processes or endometriosis.
In the womb, implantation of the embryo will occur. The most common problems that can affect this stage are the presence of fibroids, polyps, uterine malformations and adhesions (or uterine synechiae). Less common causes of infertility.
Finally, endometriosis is an increasingly relevant disease, since its frequency has been increasing in the last decades. It is characterized by the presence of endometrium outside the uterus. The endometrium is the inner lining of the uterus and where the implantation of the embryo takes place. When there is no pregnancy, the endometrium is discharged, and menstruation occurs. The problem occurs when the endometrium develops in other places. The organs where most of these implants are found are the ovaries, tubes, and peritoneum (inner lining of the abdomen), but they can also reach the intestine, ureter, and bladder. The two main symptoms of endometriosis are pain and infertility. The pain usually occurs during menstruation and/or sexual intercourse.
Ovulation is the process in which the ovum, stored inside the ovaries, is released monthly. Women who ovulate normally have regular menses, often preceded by pre-menstrual symptoms (known as premenstrual tension or PMS). On the other hand, those that do not ovulate adequately, present irregular menstruations, associated, in some cases, with the increase of hairs and acne. The latter situation is typically found in women with Polycystic Ovarian Syndrome (lack of ovulation and ovaries with multiple microcysts). Other diseases may also be involved, such as prolactin-producing tumors, hypothyroidism, androgen producing tumors and rare enzyme deficiencies.
In addition, reducing the quantity and quality of the eggs is also a major cause of difficulty in getting pregnant. This process is directly related to age because the ovules, unlike the spermatozoa, do not multiply and they are exhausted. Nowadays, when pregnancy is increasingly delayed, this problem is extremely important.
After ovulation, the latter is picked up by the uterine tube. It is in the tuba that the fertilization occurs, that is, the encounter of the spermatozoid with the ovum. The embryo is formed and transported to the uterus. This stage depends on the perfect functioning of the tubas, extremely delicate organs. Tubal changes may be evident, such as in bilateral obstruction, or more subtle, such as in adhesions and distortions. These changes are secondary to inflammatory/infectious processes or endometriosis.
In the womb, implantation of the embryo will occur. The most common problems that can affect this stage are the presence of fibroids, polyps, uterine malformations and adhesions (or uterine synechiae). Less common causes of infertility.
Finally, endometriosis is an increasingly relevant disease, since its frequency has been increasing in the last decades. It is characterized by the presence of endometrium outside the uterus. The endometrium is the inner lining of the uterus and where the implantation of the embryo takes place. When there is no pregnancy, the endometrium is discharged, and menstruation occurs. The problem occurs when the endometrium develops in other places. The organs where most of these implants are found are the ovaries, tubes, and peritoneum (inner lining of the abdomen), but they can also reach the intestine, ureter, and bladder. The two main symptoms of endometriosis are pain and infertility. The pain usually occurs during menstruation and/or sexual intercourse.
Male Factors
The function of the male reproductive system is to produce and transport the spermatozoa. Changes in this system may reduce the amount, movement, shape, and fertilization capacity of sperm. The main causes that we find to explain these problems are varicocele, infectious processes, exposure to toxins, genetic factors, hormonal changes and obstruction of transport ducts. In addition, most men with a change in semen have no identifiable reason to explain it.
Varicocele is the presence of varicose veins in the testicles. Many men have some degree of varicocele, but when this degree is important (veins visible on clinical examination), it results in increased temperature and accumulation of toxic substances in this region, harming the production of spermatozoa. Other symptoms are the feeling of weight and pain in the area.
Infections lead to an inflammatory process, which can impair the production of spermatozoa and/or increase the oxidative stress to which they are subjected. Several toxins can lead to temporary or definitive impairment of sperm production. The main ones are drugs used in chemotherapy, radiation, heat or exogenous hormones. Genetic alterations may also explain the testicular insufficiency, being necessary to investigate them when there is a considerable reduction in the number of spermatozoa. Finally, the main cause of obstruction of the ducts is vasectomy or ligation of the vas deferens for contraception.
Risk factors
Based on the main factors of infertility, the American Society of Reproductive Medicine has established four main care:
Age: do not let to get pregnant late
Sexually transmitted diseases: prevent and treat rapidly
Weight: avoiding low weight or obesity
Smoking: stop smoking, because smoking reduces fertility.
Common questions
1. What is infertility?
The function of the male reproductive system is to produce and transport the spermatozoa. Changes in this system may reduce the amount, movement, shape, and fertilization capacity of sperm. The main causes that we find to explain these problems are varicocele, infectious processes, exposure to toxins, genetic factors, hormonal changes and obstruction of transport ducts. In addition, most men with a change in semen have no identifiable reason to explain it.
Varicocele is the presence of varicose veins in the testicles. Many men have some degree of varicocele, but when this degree is important (veins visible on clinical examination), it results in increased temperature and accumulation of toxic substances in this region, harming the production of spermatozoa. Other symptoms are the feeling of weight and pain in the area.
Infections lead to an inflammatory process, which can impair the production of spermatozoa and/or increase the oxidative stress to which they are subjected. Several toxins can lead to temporary or definitive impairment of sperm production. The main ones are drugs used in chemotherapy, radiation, heat or exogenous hormones. Genetic alterations may also explain the testicular insufficiency, being necessary to investigate them when there is a considerable reduction in the number of spermatozoa. Finally, the main cause of obstruction of the ducts is vasectomy or ligation of the vas deferens for contraception.
Risk factors
Based on the main factors of infertility, the American Society of Reproductive Medicine has established four main care:
Age: do not let to get pregnant late
Sexually transmitted diseases: prevent and treat rapidly
Weight: avoiding low weight or obesity
Smoking: stop smoking, because smoking reduces fertility.
Common questions
1. What is infertility?
A: Marital infertility is defined as the absence of pregnancy after 12 months of regular intercourse without the use of a contraceptive method. It is important to note that infertility is not equal to impossibility, but the difficulty to get pregnant, which can be of varying degrees.
2. How many women are currently suffering from the problem?
A: Infertility is not a rare problem. Quite the contrary, it reaches about 15% of couples.
3. Is infertility an exclusively female problem?
No, it's a couple problem. The data are clear: in 30% of couples, the problem is found in men, and in 20%, the problem is in both men and women. Thus, we can say that in 50% of infertile couples, man is involved in the cause of infertility.
No, it's a couple problem. The data are clear: in 30% of couples, the problem is found in men, and in 20%, the problem is in both men and women. Thus, we can say that in 50% of infertile couples, man is involved in the cause of infertility.
4. What causes infertility in women?
A: The main causes of female infertility are dysfunctions in ovulation (ovulatory factor), changes in tubas (tubal factor) and uterus (uterine factor). Another important cause of infertility is endometriosis, an increasingly common disease in our midst.
A: The main causes of female infertility are dysfunctions in ovulation (ovulatory factor), changes in tubas (tubal factor) and uterus (uterine factor). Another important cause of infertility is endometriosis, an increasingly common disease in our midst.
5. Are there factors that increase the risk of female infertility?
A: Of course. Becoming pregnant, obesity or low birth weight, exposure to sexually transmitted diseases, and smoking are clear examples of situations that increase the risk of infertility and should be avoided.
Another situation we see in clinical practice is when the woman undergoes chemotherapy or radiotherapy in the treatment of cancer. In this case, depending on the scheme used, there is a loss of eggs and high risk of infertility.
6. How does age interfere with a woman's fertility?
A: Age is the single most important variable in a woman's fertility. The big problem is that the eggs, unlike the spermatozoa, do not multiply. The woman's egg cell is established before it is born, while it is in her mother's belly, and only reduces it ever since! The problem is that, in addition to the loss in quantity, there is also the loss of egg quality, which leads to a lower chance of becoming pregnant and a greater chance of miscarriage. We know that in general there is a greater chance of pregnancy before the age of 35 and that this chance decreases with age, with a significant drop after 37 years. However, this can vary greatly from woman to woman.
7. Can pregnancy anxiety hinder this process? In what way?
A: Anxiety can get in the way, especially for bringing suffering to the couple. However, it cannot be overvalued: most women who want to get pregnant have some degree of anxiety and only a small part will have problems.
A: Anxiety can get in the way, especially for bringing suffering to the couple. However, it cannot be overvalued: most women who want to get pregnant have some degree of anxiety and only a small part will have problems.
8. After how many attempts to get pregnant should a woman seek medical advice?
After 1 year without getting pregnant, the couple should seek medical care for an appropriate evaluation. This period should be shorter, 6 months, when the woman is 35 years or older. Other examples are in those couples where there is a suspected initial change, such as irregular menses, Polycystic Ovarian Syndrome, endometriosis, previous pelvic infection, previous ectopic gestation, tubal ligation or vasectomy.
After 1 year without getting pregnant, the couple should seek medical care for an appropriate evaluation. This period should be shorter, 6 months, when the woman is 35 years or older. Other examples are in those couples where there is a suspected initial change, such as irregular menses, Polycystic Ovarian Syndrome, endometriosis, previous pelvic infection, previous ectopic gestation, tubal ligation or vasectomy.
9. What kind of procedures do doctors use to diagnose infertility in women?
A: The procedures we do to find a specific cause of infertility include evaluation of ovulation (menstrual history and hormone dosages), tubal (hysterosalpingography), and uterus evaluation (transvaginal ultrasonography). Endometriosis is diagnosed through blood tests (CA-125) and imaging tests (specialized transvaginal ultrasonography and magnetic resonance imaging).
A: The procedures we do to find a specific cause of infertility include evaluation of ovulation (menstrual history and hormone dosages), tubal (hysterosalpingography), and uterus evaluation (transvaginal ultrasonography). Endometriosis is diagnosed through blood tests (CA-125) and imaging tests (specialized transvaginal ultrasonography and magnetic resonance imaging).
10. Are fertility problems inherited among women?
A: The vast majority of problems are not hereditary, but there are exceptions.
In relation to women, there are families with Polycystic Ovarian Syndrome, fibroids, endometriosis and early egg loss (premature ovarian failure).
Men may have genetic alterations that lead to reduced semen quality. Another rare but important situation is when there are no bilateral vas deferens (ducts that carry the sperm from the testis to the ejaculatory duct). This problem is related to mutation of the cystic fibrosis gene, a serious disease that should be evaluated.
A: The vast majority of problems are not hereditary, but there are exceptions.
In relation to women, there are families with Polycystic Ovarian Syndrome, fibroids, endometriosis and early egg loss (premature ovarian failure).
Men may have genetic alterations that lead to reduced semen quality. Another rare but important situation is when there are no bilateral vas deferens (ducts that carry the sperm from the testis to the ejaculatory duct). This problem is related to mutation of the cystic fibrosis gene, a serious disease that should be evaluated.
11. What are the main means currently used to treat infertility in women?
A: There are currently several treatments for infertility. They can be divided into surgical procedures or human reproduction treatments (scheduled sexual intercourse, intrauterine insemination, and IVF).
A: There are currently several treatments for infertility. They can be divided into surgical procedures or human reproduction treatments (scheduled sexual intercourse, intrauterine insemination, and IVF).
12. Is it possible to treat infertility with the use of medications? What are the main ones?
A: Yes. In women who have Polycystic Ovarian Syndrome (ovulation dysfunction), ovulation induction is done with medications. In this case, the first choice is clomiphene citrate, oral medication, practical and with low cost.
A: Yes. In women who have Polycystic Ovarian Syndrome (ovulation dysfunction), ovulation induction is done with medications. In this case, the first choice is clomiphene citrate, oral medication, practical and with low cost.
13. What are human reproduction techniques?
A: Human reproduction techniques include: scheduled intercourse (scheduled intercourse), intrauterine insemination, and IVF. These treatments are arranged in degrees of complexity (less complex to more complex) and indicated for different problems of the couple.
A: Human reproduction techniques include: scheduled intercourse (scheduled intercourse), intrauterine insemination, and IVF. These treatments are arranged in degrees of complexity (less complex to more complex) and indicated for different problems of the couple.
14. What are the risks of each of them?
A: The main risk related to all human reproduction techniques is multiple gestations. As all of these treatments involve the induction of ovulation, we increase the chance of multiple ovules and, consequently, multiple embryos. Thus, the doctor should exercise caution when performing them. Another important problem is Ovarian Hyperstimulation Syndrome when there is an exaggerated response to the medications used to induce ovulation.
A: The main risk related to all human reproduction techniques is multiple gestations. As all of these treatments involve the induction of ovulation, we increase the chance of multiple ovules and, consequently, multiple embryos. Thus, the doctor should exercise caution when performing them. Another important problem is Ovarian Hyperstimulation Syndrome when there is an exaggerated response to the medications used to induce ovulation.
15. Is the generation of multiple babies still a common factor for this type of gestation?
A: Yes. Human reproduction treatments increase the chance of multiple pregnancies (twins, trigemelars, etc.) by inducing the production of a larger number of ova and embryos. However, much has been done to mitigate this risk. In addition, it is always good to point out that the chance of multiple gestations is less than the chance of single gestation.
A: Yes. Human reproduction treatments increase the chance of multiple pregnancies (twins, trigemelars, etc.) by inducing the production of a larger number of ova and embryos. However, much has been done to mitigate this risk. In addition, it is always good to point out that the chance of multiple gestations is less than the chance of single gestation.
16. Do babies born of assisted reproduction techniques tend to be born preterm?
A: Prematurity is related to multiple pregnancies (twins, trigemelars, etc.). Thus, a single pregnancy after in vitro fertilization has no increased risk of prematurity. But multiple gestations, both post-fertilization and spontaneous, is at increased risk.
A: Prematurity is related to multiple pregnancies (twins, trigemelars, etc.). Thus, a single pregnancy after in vitro fertilization has no increased risk of prematurity. But multiple gestations, both post-fertilization and spontaneous, is at increased risk.
17. Are assisted reproduction techniques efficient? What factors undermine the success of this type of treatment?
A: There has been a great improvement in the results of human reproduction techniques. IVF, for example, has a 40% chance of success on average. Although not look great, it represents twice the chance of a couple with no problems getting pregnant. However, much needs to be done to achieve even better results.
The two main factors that hamper the success of the treatment go hand in hand: the woman's age and the quantity and quality of the eggs. Women over 40 years of age, for example, have a considerably lower chance than those under 40. Other important factors are low sperm quantity and quality, the presence of severe endometriosis, and association of multiple causes of infertility.
A: There has been a great improvement in the results of human reproduction techniques. IVF, for example, has a 40% chance of success on average. Although not look great, it represents twice the chance of a couple with no problems getting pregnant. However, much needs to be done to achieve even better results.
The two main factors that hamper the success of the treatment go hand in hand: the woman's age and the quantity and quality of the eggs. Women over 40 years of age, for example, have a considerably lower chance than those under 40. Other important factors are low sperm quantity and quality, the presence of severe endometriosis, and association of multiple causes of infertility.
18. What causes infertility in a man?
A: The main causes that we find in men are: varicocele, infectious processes, exposure to toxins, genetic factors, hormonal changes and obstruction of transport ducts. However, most men with a change in semen have no identifiable reason to explain it.
A: The main causes that we find in men are: varicocele, infectious processes, exposure to toxins, genetic factors, hormonal changes and obstruction of transport ducts. However, most men with a change in semen have no identifiable reason to explain it.
19. Is there any relationship between fertility and sexual potency?
A: In the vast majority of men, no. The production of sperm (fertility) and testosterone (sexual potency) is made by different cells in the testis. Thus, what occurs most frequently is the change in semen with normal testosterone level.
A: In the vast majority of men, no. The production of sperm (fertility) and testosterone (sexual potency) is made by different cells in the testis. Thus, what occurs most frequently is the change in semen with normal testosterone level.
20. Is it possible to have good sex and not to conceive a woman?
Of course. Getting pregnant is only part of what is expressed in sexual intercourse. In addition, there are several reasons that explain infertility, and the immense minority of these involve the loss of the sexual potency of men or women.
Of course. Getting pregnant is only part of what is expressed in sexual intercourse. In addition, there are several reasons that explain infertility, and the immense minority of these involve the loss of the sexual potency of men or women.
21. Are there factors that increase the risk of male infertility?
A: Yes, mainly related to exposure to toxic substances. Among the most common examples are drugs used in chemotherapy, ionizing radiation, heat or exogenous hormones. In addition, infections that lead to inflammation of the testicles (orchid-epididymitis) may also be involved.
A: Yes, mainly related to exposure to toxic substances. Among the most common examples are drugs used in chemotherapy, ionizing radiation, heat or exogenous hormones. In addition, infections that lead to inflammation of the testicles (orchid-epididymitis) may also be involved.
22. How does age interfere with man's fertility?
A: Age interferes with a man's fertility, but in a much less important way than in a woman. There are studies that show a reduction in concentration and motility of sperm, others an increase in genetic problems with age. However, the evidence demonstrates little or no influence on the ability to generate a pregnancy.
A: Age interferes with a man's fertility, but in a much less important way than in a woman. There are studies that show a reduction in concentration and motility of sperm, others an increase in genetic problems with age. However, the evidence demonstrates little or no influence on the ability to generate a pregnancy.
23. What kind of procedures do doctors use to diagnose infertility in men?
A: The main test in man is sperm. It should be done after sexual abstinence of 2 to 5 days and, ideally, repeated with an interval of 15 to 30 days (two programs). This test evaluates the semen volume, number, concentration, motility, and shape (morphology) of sperm and the presence of inflammation. It shows good correlation with pregnancy and should always be performed!
Diagnostic and exams
Infertility Diagnosis
Although it seems complicated, the couple's investigation must be objective and focused on the main causes that lead to infertility. In addition, it is worth mentioning: research is always on the couple, never just the woman or the man.
In women, the basic tests we do include the evaluation of ovulation (menstrual history and dosages of hormones), the study of tubas (hysterosalpingography) and evaluation of the uterus (transvaginal ultrasonography). The diagnosis of endometriosis, when suspected, involves blood and imaging tests (ultrasonography with intestinal preparation).
Only when necessary can we make use of more advanced tests such as magnetic resonance imaging, laparoscopy, hysteroscopy and genetic evaluation.
In man, we evaluated sperm production through semen analysis (sperm count). The program evaluates the semen volume, number, concentration, movement (motility) and shape (morphology) of spermatozoa and the presence of inflammation.
When indicated, we request other tests such as hormonal dosages, pelvic ultrasonography, testicular biopsy and genetic studies of man, among others.
Treatment and care
Infertility Treatment
Guidelines
Before thinking about any human reproduction treatment, there are fundamental guidelines for any couple wanting to get pregnant. Initially, it is necessary to perform ante-natal examinations, such as serologies for HIV, hepatitis B and C, syphilis, and rubella. In addition, in order to reduce the risk of some malformations, supplementation with folic acid for women is universally indicated. In relation to fertility, we should guide the couple to maintain an adequate weight, healthy habits of life and, in case of smoking, try to stop.
After the investigation of the cause of infertility, appropriate treatment is started. This can be done through surgeries or clinical procedures. The nomenclature of the procedures we use to treat the infertile couple varies according to each service or Medical Society. For educational purposes, we believe that human reproduction techniques include: programmed intercourse (scheduled intercourse), intrauterine insemination and IVF. In many situations, there is more than one treatment option. In these cases, among the factors that determine the choice we have: age of the woman, time of infertility, associated factors and desire of the couple.
Surgical treatment
Surgical treatment is indicated for some causes of infertility. Examples are fibroids, polyps or uterine malformations, correctable tubal changes and endometriosis. Currently, preference is given to minimally invasive procedures, such as laparoscopy and hysteroscopy.
Regarding the man, one can consider to treat varicocele surgically or to perform the vasectomy reversal. In addition, when there are no spermatozoa in ejaculated semen (azoospermia), surgical procedures may be required to collect spermatozoa from the testis (testis puncture or microdissection of the testis) or the epididymis.
Scheduled sexual intercourse (scheduled intercourse)
Scheduled intercourse is indicated for the woman who has problems with ovulation. It is the simplest treatment in human reproduction. The first step is the induction of ovulation, which is done with medications taken orally or applied by subcutaneous injections. In this period, the growth of ovarian follicles (each follicle contains an ovum) is controlled by ultrasound examinations. When the follicles reach a suitable size, one last medication is applied, which deflagrates the actual ovulation. Sexual intercourse is scheduled and the pregnancy test is done after 14 days.
The chance of pregnancy with this treatment is around 15% per cycle (or trial). Although it seems limited, it should be remembered that it is a simple treatment and it almost equals the chance of getting an infertile couple from a fertile couple.
Intrauterine insemination
Intrauterine insemination is indicated for the couple in which the man has a mild to moderate alteration of the semen. It can also be used in cases where there is no infertility factor (infertility without apparent cause) or when there are minor changes. It is an intermediate treatment in human reproduction. The induction of ovulation is done in a manner similar to scheduled sexual intercourse. However, instead of sexual intercourse itself, the processed semen is injected into the woman's uterus using a delicate catheter. The seminal processing aims to separate the spermatozoa with good motility. The pregnancy test is done after 14 days.
The chance of pregnancy with this treatment is around 15 to 20% per cycle (or trial). Again, it is similar to the chance per cycle of a couple with no changes.
In vitro fertilization (IVF)
A: The main test in man is sperm. It should be done after sexual abstinence of 2 to 5 days and, ideally, repeated with an interval of 15 to 30 days (two programs). This test evaluates the semen volume, number, concentration, motility, and shape (morphology) of sperm and the presence of inflammation. It shows good correlation with pregnancy and should always be performed!
Diagnostic and exams
Infertility Diagnosis
Although it seems complicated, the couple's investigation must be objective and focused on the main causes that lead to infertility. In addition, it is worth mentioning: research is always on the couple, never just the woman or the man.
In women, the basic tests we do include the evaluation of ovulation (menstrual history and dosages of hormones), the study of tubas (hysterosalpingography) and evaluation of the uterus (transvaginal ultrasonography). The diagnosis of endometriosis, when suspected, involves blood and imaging tests (ultrasonography with intestinal preparation).
Only when necessary can we make use of more advanced tests such as magnetic resonance imaging, laparoscopy, hysteroscopy and genetic evaluation.
In man, we evaluated sperm production through semen analysis (sperm count). The program evaluates the semen volume, number, concentration, movement (motility) and shape (morphology) of spermatozoa and the presence of inflammation.
When indicated, we request other tests such as hormonal dosages, pelvic ultrasonography, testicular biopsy and genetic studies of man, among others.
Treatment and care
Infertility Treatment
Guidelines
Before thinking about any human reproduction treatment, there are fundamental guidelines for any couple wanting to get pregnant. Initially, it is necessary to perform ante-natal examinations, such as serologies for HIV, hepatitis B and C, syphilis, and rubella. In addition, in order to reduce the risk of some malformations, supplementation with folic acid for women is universally indicated. In relation to fertility, we should guide the couple to maintain an adequate weight, healthy habits of life and, in case of smoking, try to stop.
After the investigation of the cause of infertility, appropriate treatment is started. This can be done through surgeries or clinical procedures. The nomenclature of the procedures we use to treat the infertile couple varies according to each service or Medical Society. For educational purposes, we believe that human reproduction techniques include: programmed intercourse (scheduled intercourse), intrauterine insemination and IVF. In many situations, there is more than one treatment option. In these cases, among the factors that determine the choice we have: age of the woman, time of infertility, associated factors and desire of the couple.
Surgical treatment
Surgical treatment is indicated for some causes of infertility. Examples are fibroids, polyps or uterine malformations, correctable tubal changes and endometriosis. Currently, preference is given to minimally invasive procedures, such as laparoscopy and hysteroscopy.
Regarding the man, one can consider to treat varicocele surgically or to perform the vasectomy reversal. In addition, when there are no spermatozoa in ejaculated semen (azoospermia), surgical procedures may be required to collect spermatozoa from the testis (testis puncture or microdissection of the testis) or the epididymis.
Scheduled sexual intercourse (scheduled intercourse)
Scheduled intercourse is indicated for the woman who has problems with ovulation. It is the simplest treatment in human reproduction. The first step is the induction of ovulation, which is done with medications taken orally or applied by subcutaneous injections. In this period, the growth of ovarian follicles (each follicle contains an ovum) is controlled by ultrasound examinations. When the follicles reach a suitable size, one last medication is applied, which deflagrates the actual ovulation. Sexual intercourse is scheduled and the pregnancy test is done after 14 days.
The chance of pregnancy with this treatment is around 15% per cycle (or trial). Although it seems limited, it should be remembered that it is a simple treatment and it almost equals the chance of getting an infertile couple from a fertile couple.
Intrauterine insemination
Intrauterine insemination is indicated for the couple in which the man has a mild to moderate alteration of the semen. It can also be used in cases where there is no infertility factor (infertility without apparent cause) or when there are minor changes. It is an intermediate treatment in human reproduction. The induction of ovulation is done in a manner similar to scheduled sexual intercourse. However, instead of sexual intercourse itself, the processed semen is injected into the woman's uterus using a delicate catheter. The seminal processing aims to separate the spermatozoa with good motility. The pregnancy test is done after 14 days.
The chance of pregnancy with this treatment is around 15 to 20% per cycle (or trial). Again, it is similar to the chance per cycle of a couple with no changes.
In vitro fertilization (IVF)
IVF is indicated for numerous serious problems that lead to infertility, such as tubal alterations, endometriosis, poor egg quality and significant alteration of semen. It is a high-tech treatment in human reproduction.
The stages of IVF are the induction of ovulation, a collection of eggs, a collection of sperm, fertilization in the laboratory and transfer of embryos.
The induction of ovulation is performed in a manner similar to scheduled sexual intercourse. However, we preferentially use medications injected subcutaneously and in larger doses to produce a larger number of eggs. When the follicles reach a suitable size, seen ultrasonographically, the last medication, which deflagrates the maturing of the eggs, is applied. On average, this stage lasts around 10 days.
The uptake of the eggs is performed 35 hours after the last medication. It is done by puncture of each follicle with a fine needle through transvaginal. The procedure is done under ultrasound vision and anesthesia. Sperm collection is performed by masturbation on the same day of collection. When there are no spermatozoa in the ejaculated semen (azoospermia), other procedures may be necessary to obtain the spermatozoa (puncture of the testis or epididymis, for example).
In the laboratory, the collected eggs are fertilized by the spermatozoa, forming the embryos. Currently, in most cases, fertilization is done by injecting the sperm directly into the egg (ICSI).
Embryos develop in the laboratory for 3 to 5 days. After this period, they are transferred into the womb of the woman. This procedure is performed with a delicate catheter and there is no need for anesthesia. The pregnancy test is done after 9 to 11 days.
There are some risks associated with this treatment. The most common of these are multiple gestations, which is associated with higher rates of miscarriage, prematurity, and low birth weight newborns. Ovarian Hyperstimulation Syndrome is rare and results from the hormonal medications used to induce ovulation. The characteristic event is an exaggerated response to inducer drugs, which can lead to abdominal pain, edema, and fluid retention. In extreme cases, there is a need to stop treatment and even hospital care. Other complications are bleeding after an ovarian puncture, post-puncture infection and ovary torsion.
This treatment offers a pregnancy chance of around 40%.
Medications for Infertility
Only a doctor can tell you which drug is most appropriate for your case, as well as the correct dosage and duration of treatment. Always follow your doctor's guidelines carefully and NEVER self-medicate. Do not stop using the medication without first consulting a doctor and if you take it more than once or in much larger amounts than prescribed, follow the instructions in the package insert.
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