In order to talk about the difficulties in conceiving for a couple, we recommend trying to achieve pregnancy with regular sexual intercourse for 1 year under the age of 35 and for 6 months above the age of 35. However, if the woman has menstrual irregularity, a known genital anomaly, a history of tube obstruction, or a diagnosis of chocolate cyst (endometriosis), I recommend earlier evaluation.
In a couple who applied with inability to conceive;
A detailed history should be taken:
- period of inability to conceive,
- The order of menstrual cycles should be questioned. Regular menstruation and the feeling of tightness and swelling in the breasts in the period close to menstruation can be considered as an indicator of ovulation.
- A medical and surgical resume should be obtained. Past diseases, operations, infections, drug use, chemotherapy and radiotherapy history should be questioned.
- Pregnancy history, if any
- The frequency of sexual intercourse and whether there is difficulty in intercourse should be asked.
- Having trouble conceiving, congenital problems or individuals diagnosed with a genetic disease in the family,
- Lifestyle, smoking, alcohol use, eating habits, rapid weight gain or loss should be questioned.
- Being too low or overweight can adversely affect the ability to conceive.
- It should be noted that the woman does not have menstruation, secondary sexual characteristics such as hair growth in the genital area and under the armpits, absence of breast development, and short stature. These findings may be the findings of hypogonadotropic gonadism and Turner Syndrome, which is a problem of FSH and LH secretion from the brain.
- In terms of hormonal irregularity, increased hair growth in male-pattern areas of the body, milk or fluid coming out of the breasts or spontaneously are also important findings.
- Examination can reveal the presence of congenital anomalies involving the uterus, tubes and ovaries.
- Regular menstruation is almost always an indication of regular ovulation.
- In order to determine the ovarian reserve, counting the egg sacs with a diameter of 2-9 mm, which we call antral follicles in transvaginal ultrasonography, allows us to understand the ovarian reserve. In case of less than 6-8 antral follicles in total in both ovaries, reserve deficiency can be mentioned. AMH is a hormone secreted from follicles with a diameter of 2-8 mm, and its level in the blood gives information about the ovarian reserve. The blood level is not affected by the menstrual cycle and a result below 1 ng/ml indicates a low reserve. A value of 1-2 ng/ml is considered the lower limit of normal, a value between 2-4 ng/ml is considered normal reserve, and values above 4ng/ml are considered high reserve. Antral follicle count in ultrasonography and AMH measurement in the blood will enable us to understand the equivalent amount of reserve. Therefore, it is not necessary to measure AMH in every patient. It can be done if there is difficulty in visualizing the ovaries in ultrasonography due to overweight or the presence of a large chocolate cyst.
- If there is a suspicious finding in the examination or history, uterine tube film (HSG) may be requested if necessary. However, it is not necessary in every case.
- Chromosome analysis can be performed in necessary cases (short stature, severe reserve deficiency, ovarian failure, external genitalia abnormality, abortion).
- Progesterone measurement can be made in the blood to determine whether there is spontaneous ovulation or not in those whose menstrual intervals are less than 35 days. For this purpose, the progesterone level is 21-24 days according to the first day of menstruation. Between days 28-30. between days 35-38 if menstruation does not start. can be viewed between days. Detection of the value above 3 ng/ml is considered as the presence of ovulation.
Causes of Female Infertility
Conditions that may cause difficulties in conceiving in women:
- Ovulation disorders
- Chocolate cyst (endometriosis)
- Problems involving tubes
- Problems with the uterus
Infrequent ovulation (oligo-ovulation) or not ovulating (anovulation) can cause difficulties in getting pregnant.
In women, ovulation problems can also be seen in hypogonadotropic hypogonadism, which causes problems in the secretion of GnRH, FSH or LH from the brain. This condition can occur without intense exercise, weight loss, eating disorders, previous surgeries involving the area, genetic mutation, stress, or an identifiable cause (idiopathic).
In the presence of high prolactin level, squeezing from the breasts or spontaneous milk or liquid discharge, in addition to opening between menstruation and ovulation problems may be seen in some patients.
In the presence of polycystic ovary syndrome, insufficient functioning of the thyroid gland (hypothyroidism) or excess hormone secretion (hyperthyroidism), in the presence of hormone-secreting adrenal gland or ovarian tumors, liver or kidney disease, external hormone-containing drug intake, antidepressant use, chemotherapy and radiotherapy After its application, problems with ovulation can be seen. Apart from these, ovulation disorders can also be seen due to low reserve or ovarian failure.
Age is an important factor in terms of decreased ovarian reserve. Because when a girl is born, she is born with a fixed number of eggs in the ovarian tissue. In fact, the number of eggs, which is 7 million in the mother’s womb, decreases to 1 million at birth, decreases to 300,000 at puberty, and there is a rapid loss after the age of 35. In addition to age, genetic predisposition, heavy smoking, history of chemotherapy or radiotherapy and autoimmune diseases may accelerate this loss.
Chocolate cyst (endometriosis):
Endometriozis rahatsızlığı, karın içi organlar olan rahim, tüp ve yumurtalıkların anatomik ilişkisini bozarak ya da tüplerde tıkanıklık ve içi sıvı dolu tüp yani hidrosalpenx rahatsızlığına yol açarak gebe kalmakta güçlüğe neden olabilirler. In addition, endometriosis itself may have a reducing effect on ovarian reserve.
The tubes are a tube-shaped organ connected to the uterus, in which the egg released after ovulation meets the sperm coming after sexual intercourse and fertilization occurs. Every woman has 2 pieces and one end opens into the uterine cavity and the other end opens into the abdominal cavity. In case of a problem involving the tubes, there is a problem in the course of the egg and sperm in the tubes, and this may cause problems for spontaneous pregnancy.
Tuberculosis can also occur after infections involving the uterus, tubes and ovaries, after sexually transmitted chlamydia and gonorrhea infections, and in the presence of advanced endometriosis.
Obstruction at the exit point of the tubes from the uterus may be due to muscle spasm or mucus plug and does not always mean anatomical obstruction. However, in case of obstruction in the parts of the tubes opening into the abdominal cavity, a liquid-filled tube image, which we call hydrosalpenx, may occur. In this case, the fluid accumulated in the tube may flow backwards into the uterus, which may adversely affect the attachment of the embryo and the continuation of the development of the attached embryo and reduce the chance of delivery. In fact, it has a negative effect on the results not only in itself, but also in IVF. For this reason, it is recommended to remove it when it is detected, or to apply treatment after it is disconnected from the uterus if there is a dense intra-abdominal adhesion and technical difficulties.
Problems with the uterus:
Fibroids located in the uterus that press into the uterus may have a reducing effect on the chance of pregnancy.
-The risk of miscarriage or premature birth may increase in the presence of an intrauterine curtain, that is, a septum, which is one of the congenital anomalies that concern the uterus,
The presence of polyps or intrauterine adhesions may also have a negative effect on conception.
In the presence of chromosomal problems (Turner Syndrome, translocations), early depletion of ovarian reserve or recurrent miscarriages can be seen.
Treatment in Female Infertility
In the presence of ovulation disorder, normalization if there is a sudden weight change, or if there is no additional factor that will cause inability to conceive, ovulation-stimulating pills or daily injection treatments can be tried. If there is an additional reason for not being able to conceive or in patients who do not respond to these treatments, in vitro fertilization can be tried.
In the presence of high prolactin level, a lowering drug can be planned after imaging with cranial radiography and, if necessary, MRI.
In patients with obstruction at the exit point of the tubes from the uterus, surgical treatment has no obvious benefit and IVF treatment can be considered. However, in case of obstruction in the part where the tubes open into the abdominal cavity and fluid accumulation in the tube, that is, in the presence of hydrosalpenx, it is recommended to remove the affected tube or tubes by laparoscopic way before the treatment and then to plan IVF treatment.
In patients with chocolate cysts, we prefer to stay away from the operation unless there is severe abdominal pain or cancer suspicion. Because every intervention to the ovaries will have a reducing effect on the ovarian reserve, even if it is performed by the most experienced physicians. If there is no obstruction in the tubes and there is no additional reason for inability to conceive due to the woman or the man, ovulation vaccination treatment can be tried in these patients in the first steps. Or, in cases where vaccination is not successful or cannot be done, direct in vitro fertilization can be started.
In the presence of a curtain in the uterus, myoma uteri or endometrial polyp pressing into the uterus, corrective actions can be planned for these problems by hysteroscopic method.