There are primary and secondary female infertility. Primary infertility is spoken of if a woman has not had a single pregnancy, despite regular sexual activity for a year in the absence of contraception, secondary – if there is a pregnancy earlier, that is, if it is impossible to conceive a child after an abortion, ectopic pregnancy, miscarriage, or the birth of a child. Voluntary infertility can be called a situation if pregnancy is undesirable and a woman is protected using contraceptives. There are also absolute infertility, when conception is impossible due to congenital pathology or irreversible changes in the woman’s body, and relative infertility, when the ability to fertilize is not impaired; in such cases, it is appropriate to talk about reduced fertility.
The inability of a mature woman’s body to conceive is due to the following reasons:
- endocrine disorders – anovulation) – 40%;
- tubal-peritoneal factor-30%;
- gynecological diseases – 15-25%;
- immunological factor – 3%;
- unidentified factors-2-3%.
The main cause of ovarian infertility is anovulation – a violation of the menstrual cycle, as a result of which the maturation and release of the egg from the follicle does not occur. Endocrine (anovulatory) infertility can have different origins: hypothalamic, hypothalamic-pituitary, ovarian, thyroid and adrenal gland diseases, chromosomal abnormalities, violation of implantation of a fertilized egg, violation of the function of the fallopian tubes, etc.
Etiological factors of anovulatory infertility
Hypothalamic causes. Hypothalamic gonadoliberin deficiency (gonadotropin-releasing hormone-GnRH) leads to a violation of the regulation of the gonadotropic function of the pituitary gland and, accordingly, ovarian function; clinically manifested by anovulation. Violation of GnRH secretion can occur with emotional overstrain, weight loss, under the influence of medications.
Pituitary causes. Micro-and macroadenomas of the anterior pituitary lobe, prolactinomas can lead to pathological hyperprolactinemia. In all cases, if a pituitary adenoma is suspected, magnetic resonance imaging (MRI) is necessary. A slight increase in the level of prolactin, most often temporary, can occur with emotional overstrain.
Ovarian causes. There are primary and secondary ovarian insufficiency. The cause of primary ovarian insufficiency is ovarian pathology, secondary-a decrease in the secretion of GnRH in the hypothalamus or gonadotropin hormones in the adenohypophysis. Premature ovarian insufficiency may have a genetically determined, autoimmune, idiopathic, functional (weight loss, physical activity, medications) origin.
The most common cause of ovarian anovulation (female infertility) is polycystic ovary syndrome. Often, the syndrome of luteinization of a non-ovulated follicle is detected. This condition can be caused by some medications (prostaglandin synthetase inhibitors), it is often observed in endometriosis, stress, hyperandrogenism, hyperprolactinemia, inflammatory processes in the ovaries. The diagnosis is established on the basis of ultrasound (ultrasound) or laparoscopy data.
The thyroid gland and the adrenal glands. Hypothyroidism or hyperthyroidism is accompanied by a violation of the function of the pituitary gland, ovaries, which leads to anovulation. In Itsenko-Cushing’s disease and other cases of hypercortisolemia, elevated levels of testosterone and cortisol cause suppression of the gonadotropic function of the pituitary gland, as well as ovarian dysfunction, while secondary polycystic ovaries may develop.
Chromosomal abnormalities lead to amenorrhea and are also accompanied by infertility.
Violation of the implantation of a fertilized egg occurs as a result of a decrease in the level of progesterone; it can be caused by deformation of the uterine cavity with submucosal uterine fibroids.
Violation of the function of the fallopian tubes can be a consequence of inflammatory processes of the uterine appendages, which lead to a violation of the capture of the oocyte as a result of the formation of peritubar adhesions and damage to the fimbria, as well as damage to the epithelium of the tubes. The function of the fallopian tubes can be impaired with endometriosis, destructive appendicitis, suppuration after surgery on the pelvic organs or abdominal cavity.
Smoking, alcohol abuse, drug use, psychological factors, and adverse environmental effects can contribute to a decrease in fertility.
Female infertility: Diagnostics
To determine the cause of female infertility, it is necessary to study the hormonal status, conduct ultrasound of the pelvic organs, adrenal glands, analyze the physical, mental and social health of the patient and compare it with the course of the disease, as well as with the results of the treatment. The study of the quality of life allows us to optimize tactics and strategy in the treatment of women with various diseases of the reproductive system.
The following diagnostic tests are performed:
- determination of functional changes in the ovaries and uterus;
- detection of urogenital tract infection;
- assessment of the state of the uterine cavity and patency of the fallopian tubes;
- identification of an immunological conflict between spouses.
The most informative studies of the hormonal function of the ovaries are ultrasound and hormonal monitoring, supplemented by basal temperature measurement. In infertility, the examination of patients should begin with determining the level of luteinizing (LH) and follicle-stimulating (FSH) hormones in the blood. In the early follicular phase of the cycle, the level of FSH should be below 3-5 IU/l. Exceeding the standard values indicates that the biological age of the ovaries is older than the chronological age of the woman. The study of the FSH content should be carried out together with the determination of the level of estradiol, since at the concentration of estradiol above 250 pmol/l, the level of FSH decreases (by the negative feedback mechanism). To exclude polycystic ovary syndrome, the ratio of LH/FSH is additionally calculated.
To assess the state of carbohydrate metabolism, you should measure the level of glucose and insulin in the blood on an empty stomach. If necessary, a glucose tolerance test is performed. In the middle of the luteal phase of the cycle, the level of progesterone is determined (5-7 days after the basal temperature rises). The function of the thyroid gland and the level of blood prolactin are studied.
Recently, it is recommended to start the examination of patients with infertility with a study of the content of prolactin in the blood, since an increased level of prolactin is diagnosed in 20-25% of patients with infertility and various menstrual cycle disorders, and in 40-45% of them, macro – and micro-tumors of the pituitary gland are the cause of hyperprolactinemia.
Ultrasound of the pelvic organs is performed at the initial stages of examination of patients with infertility, and hysterosalpingography – in the follicular phase of the cycle.
Female infertility: Treatment of hormonal infertility
In the treatment of anovulatory infertility, clomiphene citrate or gonadotropin preparations prepared from the urine of pregnant or postmenopausal women, and in recent years – obtained by genetic engineering, are prescribed to restore fertility.
Clomiphene citrate is an antiestrogenic drug that has the ability to bind estradiol receptors in all target organs, including the hypothalamus, at the site of GnRH synthesis, which causes an increase in the secretion of gonadotropins and especially FSH. An increase in the level of FSH stimulates the maturation of follicles in the ovaries and leads to an increase in the concentration of estradiol. By suppressing the regulatory effect of endogenous estrogens, clomiphene citrate blocks the normal feedback mechanism, which causes an increase in the frequency of cyclic GnRH secretion. The drug is prescribed from the 2nd day of the menstrual cycle for 25-50 mg or 100 mg for 5 days, and in the case of amenorrhea – from the 2nd day of the induced menstrual cycle. Patients with polycystic ovary syndrome have an increased sensitivity to drugs that stimulate ovulation, so such patients are prescribed clomiphene citrate at a dose of no more than 25-50 mg. The effectiveness of treatment is evaluated using ultrasound. From the 9th-10th day of the menstrual cycle, the diameter of the dominant follicle should be monitored, and on the 13th-14th day – the preovulatory follicle, which should have a size of 16-26 mm. If the disappearance or gradual decrease of the dominant follicle is recorded during ultrasound, ovulation has occurred. If three or more follicles with a size of 18-22 mm are detected according to ultrasound data, sexual contact should be avoided. The level of serum progesterone exceeding 20 nmol/l on the 21st day of the menstrual cycle indicates ovulation.
Currently, ovulation stimulation is recommended for no longer than 6 months, which is associated with an increased risk of ovarian cancer when taking clomiphene citrate for more than 12 months. In real practice, due to frequent dose adjustment, the drug is often used for a longer time.
Of the side effects of clomiphene citrate, hot flashes are most often noted, which occur in 10% of cases and disappear after stopping taking the drug. Sometimes, against the background of clomiphene citrate therapy, an increase in the size of the ovaries may occur. Rarely, patients note such undesirable phenomena as nausea, vomiting, depression, nervousness, fatigue, insomnia, headache, weight gain, pain in the mammary glands. When prescribing high doses of the drug to patients with polycystic ovary syndrome, the frequency of side effects increases. In the absence of the effect of the use of clomiphene citrate in such patients, laparoscopic diathermocoagulation of the ovaries or the appointment of gonadotropins is necessary.
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