What is the diagnosis of Infertility?
If the couple does not use any contraceptive method for 1 year but pregnancy cannot occur, it is called infertility. The rate of infertility is 15% in almost all societies. 15 out of every 100 couples encounter this problem. They have to go through a process ranging from a simple treatment to complex treatments.
How common is it compared to spouses?
Male infertility is one of the leading causes of all infertility. It constitutes 35%. Female infertility: It alone constitutes 40% of all infertility.
The infertility problem, which is common in both men and women, constitutes 10% to 20% of all infertility; Infertility with an unexplained cause that does not cause any problems in men or women; It constitutes 10-20%.
MALE INFERTILITY
First of all, what is normal spermiogram analysis? let's talk about this. In men's semen analysis performed twice with an interval of at least 4 weeks, the volume should be 1.5-5 ml. Sperm concentration should be over 20 million/ml, motility percentage should be over 50% and morphology (structure) should be over 14% normal. Azoospermia; It is defined as the absence of any sperm in semen analysis. In such men, it is possible to have a baby by taking sperm from the testicles using micromanipulator methods called PESA, MESA, TESE and applying microinjection (ICSI).
In short, the causes of male infertility:
1- Problems with the reproductive center (hormone, chromosome)
2- Testicular causes (orchitis infection, varicocele, undescended testicle)
3- Obstructions in the post-testicular channels (infection, immunology)
FEMALE INFERTILITY
The two biggest causes of infertility in women are ovulation and tubo-peritoneal problems. Uterus (womb) and cervix (cervix) problems appear less frequently. 10% of them are unexplained infertility problems.
ovulation problems in women:
According to the classification made by the World Health Organization (WHO), they are divided into 4 groups.
Group 1: Reproductive center (hypothalamus-pituitary) deficiencies:
In this group FSH and E2 are low. Patients in this group cannot menstruate without medication.
Group 2: Disorders between the reproductive center and the ovaries:
FSH and E2 are normal in this group. An example of this group is polycystic ovary syndrome.
Group 3: Ovarian insufficiency:
In this group, FSH is high and E2 is low. Examples of this group are some chromosomal diseases and congenital absence of ovaries. Since egg donation is required for the treatment of this group and egg donation is prohibited in our country, assistance is provided abroad.
Group 4: Hyperprolactinemia:
Prolactin (milk hormone) It is a condition in which the production is more than normal.
POLY CYSTIC OVARIAN SYNDRUM (PCOS)
Disorders that we encounter very frequently and need to be followed in every period of a woman's life, apart from the problem of infertility. I would like to talk about PCOS (POLY CYSTIC OVARIAN SYNDROME) that gives birth. Although it is seen in 20% to 25% of infertile couples; In addition to infertility, menstrual irregularity, increased androgenic hair growth (excessive hair growth on the face, chin, chest and abdomen), hair loss, acne is a disorder that women who do not want to have children often consult gynecologists with these complaints. Another aspect of the matter is; PCOS (poly cystic ovary syndrome) patients have an increased risk of developing type 2 diabetes, hypertension, cardiovascular diseases, endometrium and breast cancer in the following years. For this reason, PCOS is an important general health problem.
WHAT IS PCOS?
During follicle growth, cessation of follicle development and atresia (regression and disappearance) due to increased androgenism in the environment. It is a disorder characterized by chronic anovulation (absence of ovulation) and dozens of cysts arranged like a pearl necklace with a diameter of 5-12 mm in the ovaries. There are menstrual delays due to the absence of ovulation. Excess androgen due to active theca cells in the ovaries prevents ovulation and causes hirsutism (excessive hair growth). The cause of PCOS is that, in most of these women, reduced insulin sensitivity during the rapid growth period, called pubertal adrenaline, between the ages of 13-14, continues into older ages. Hype due to insulin resistance r insulin causes hyper androgenism. In these women's later years, disorders called metabolic diseases or syndrome x are common. Increased hyperinsulinemia due to insulin resistance reduces SHBGs. Circulating testosterone increases twofold. IGF-1 increases, which increases the production of androgens in the theca cells.
HOW SHOULD PCOS BE TREATMENT?
Since PCOS has insulin resistance; Insulin sensitizing drugs such as metformin are useful in the treatment, especially in obese patients. In women who do not want children; To prevent excessive hair growth; Anti-androgenic birth control pills may be given. The progesterone in them reduces androgen production by lowering the constantly released LH. It also reduces the amount of testosterone in free circulation by increasing the synthesis of SHBGs.
PCOS (poly cystic ovary syndrome) is a WHO Group 2 ovulation disorder. The first option for patients who want to have children is a drug called clomiphene citrate, which is structurally similar to estrogen. It can stimulate ovulation by stimulating FSH in the pituitary. It should not be used for more than 6 months. If no response is obtained, it is necessary to use drugs such as FSH under the supervision of an external specialist doctor. In patients with a body mass index of more than 30, even a 5% weight loss can restore ovulation.
WHAT IS POLY CYSTIC OVARY (PCO)?
Coincidentally, during ultrasound checks; Cysts in the ovaries with a diameter of around 10-12 mm, such as a string of prayer beads or a necklace of pearls; The disorder that causes menstrual delays and ovulation laziness, as well as masculine hairiness (hyper andronegenism), that is, the absence of hair on the face, chin, moustache, nipples and abdomen, is called Poly Cystic Ovary. If there is no pubescence or egg laying laziness, no treatment is required. Only; Annual checks are required to determine whether the cysts are growing or not. If there is masculine hair growth (face, chin, moustache, nipples, abdominal area) and ovulation laziness and desire to have children (in which case the diagnosis is called PCOS, not PCO), treatment is required.
WOMEN. TUBAL FACTORS ARE A LARGE GROUP IN INFERTILITY:
They constitute approximately 35% of all infertile couples.
Causes:
1- Previous surgical operations
2- Previous pelvic infections
3- Endometrium cells, called endometriosis, passing out of the uterus and causing some ectopic inflammatory formations in the pelvis, abdominal membrane, and ovaries.
4- Tuberculosis disease, which is common in our country
Diagnosis: 1-HSG (hysterosalpingo graphy) = medicated canal uterine film: It is performed with 90% local anesthesia. It can be performed under general anesthesia for patients who are very nervous. The process is as follows; The water-soluble opaque substance is injected into the uterus by the gynecologist with a special cannula (Rubin cannula) with slight pressure. The point that needs to be paid attention to here is that applying too much pressure is very dangerous. The drug either bursts the closed tubes or enters the uterine muscle tissue, and this process is monitored live under scopy and pressure application is adjusted. In this way, unnecessary excessive pressure is not applied and too much medication is not administered into the abdomen.
2-LAPAROSCOPY: Laparoscopy is used both for diagnostic purposes and especially in patients whose diagnosis cannot be made in HSG or whose tubes are obstructed. It is a surgical operation that has been used mostly for therapeutic purposes in recent years. Under general anesthesia, the abdomen is inflated by first entering the abdomen with a Veres needle 2 cm below the navel and administering 3 liters of carbon dioxide gas. A space is created between the intestines and other organs and the abdominal wall. Then, the needle site is widened with a size 10 trocar and this space is entered. A light device that will show the camera is inserted through the trocar, and then a surgical intervention is performed by entering the abdominal cavity from both groins with 5 mm trocars and the conditions of the tubes, ovaries and uterus are evaluated. Adhesions are opened with cutting cautery. Stenosis and blockages at the end of the tube can be opened. Apart from tubes, laparoscopy can also be used in other operations related to infertility such as cystectomy, myomectomy and ectopic pregnancy for therapeutic purposes.
In treatment; If the obstruction is at the end of the tube (distal) and there is no excessive adhesion and the mucosa is not destroyed, it can be corrected with laparoscopic surgery. Problems in other areas; Thanks to the widespread use of microinjection in the world and in our country, surgery has remained in the background. Microinjection; energy It has been a savior in the treatment of azoospermia in women and tubal problems in women.
Factors related to the uterus (womb) in female infertility: Congenital anomalies (septum), myomas, adhesions that develop later; It can be easily corrected with a surgical technique called hysteroscopy and taken into in vitro fertilization programs.
We briefly talked about male and female infertility. We briefly explained the first and second step treatments. In cases where these treatment methods cannot be achieved, we resort to what we call assisted reproductive techniques.
ASSIGNED REPRODUCTION TECHNIQUES
1-Intrauterine insemination
2-Tube Baby
1-VACCINATION: (intrauterine insemination) method. In this treatment, semen analysis in men requires around 10 million/ml sperm and around 14% normal morphology.
To Whom IUI Is Performed?
For women; Good answers are being received.
How is Vaccination Done? (Intra uterine insemination)
With the controlled ovarian hyperstimulation described above, insemination is performed 36 hours after HCG 10000 units are administered intramuscularly after 4 to 5 women have grown eggs. After semen is collected from the man, it is first rested for 15 minutes, then the semen is centrifuged at 2000 rpm for 20 minutes in concentration (gradient system) and then the prostate fluid and dead sperm collected above are removed. Then, it is centrifuged again with HEPES solution for 10 minutes at 2000 rpm. The first quality and motile live sperms that settle at the bottom are then injected into the uterus with the help of ultrasound, through a special plastic and sterile insemination cannula to the woman taken to the gynecological table. The patient is removed after resting on the table for 15 minutes.
When we cannot get an answer to all these, we resort to the IVF method. In vitro fertilization was achieved for the first time in England in 1978 and LUİSE BROWN was born. With the discovery of microinjection (ICSI) in Belgium in 1992, it became possible to treat infertility cases such as azoospermia.
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