When investigating the reasons for infertility in women in couples who apply for a child, their history is first questioned by taking into account the following factors.
- How old the woman is
- Duration of wanting a child and previous evaluations and results of treatments
- Menstrual cycle (regularity of menstruation, ovulation pain, breast tenderness, mid-menstrual spotting may suggest ovulation, while painful menstruation may suggest endometriosis)
- Medical, surgical and gynecological history (sexually transmitted disease, history of pelvic inflammatory disease, treatment of abnormal pap smear, previous abdominal surgery). At least while the systems are being reviewed, patients should be questioned about thyroid diseases, breast milk discharge, hirsutism, pelvic or lower abdominal pain, menstrual pain and pain during sexual intercourse.
- Pregnancy stories (pregnancy, birth, pregnancy outcomes and related complications).
- Sexual history (frequency of intercourse, sexual dysfunctions)
- Family history (whether there is an infertile member in the family, family history of early menopause, birth defects, genetic disorders, mental retardation)
- Lifestyle (work, exercise, stress factors, weight changes, smoking and alcohol use)
Things Investigated in Physical Examination and Gynecological Examination
- Weight and body mass index (while increased body mass index is associated with decreased fertility, abdominal circumference obesity is associated with insulin resistance)
- Development of secondary sex characters, body type (while development of secondary sex characters is inadequate in hypogonadotropic hypogonadism, short stature in Turner syndrome , mane and neck are seen)
- Thyroid gland diseases (nodule in the thyroid gland, sensitivity, size of the gland), milk discharge from the breasts, hair growth, acne suggest an endocrine disorder, while adrenal gland diseases, polycystic ovary syndrome, high prolactin, hyperthyroidism, -requires evaluation for hypothyroidism.
- Sensitivity on examination is significant in terms of chronic pelvic pain and endometriosis.
- Structural anomalies of the vagina and cervix, discharges, congenital anomalies of the uterus and tubes, infection and cervix. It requires evaluation in terms of the factor.
- On examination, the abnormal size of the uterus, its irregular structure, and its lack of mobility may be significant in terms of uterine anomalies, endometriosis and adhesions in the pelvis.
Evaluation of Ovulation
- Menstrual pattern. (in women with ovulation, menstruation is regular, constant in amount and duration, and is accompanied by premenstrual or menstrual complaints)
- Serum progesterone measurement: Serum progesterone levels reach the highest level 7-8 days after ovulation. In a menstrual cycle lasting 28 days, a serum progesterone level of > 3 ng/mL supports ovulation, but does not enlighten us about the quality of the luteal period. During a normal menstrual period, Day 21 progesterone levels > 10 ng/mL indicate a normal and healthy ovulation.
- Urine LH test: Ovulation can be monitored at home with urine LH test kits and information about ovulation time is available. can obtain information. Generally, urine that is not too concentrated or too watery is checked in the evening, starting from the 10th day of the menstrual period. Ovulation is expected 24-48 hours after the color change is detected.
Evaluation of the Tubes
Hysterosalpingography (HSG): While providing information about the passage of the contrast material through the tubes and its distribution into the abdominal cavity after exiting the tube ends, it also detects congenital anomalies and pathologies of the inner wall of the uterus. defines polyps, myomas, uterine inner wall adhesions). If there is sufficient experience, hysterosalpingo-contrast-ultrasonography is another effective method for HSG. It should be done within 1-2 days following the end of menstruation. It does not provide information about adhesions around the tube and endometriosis. It is necessary to repeat uterine implants that are older than 2 years. HSG may also have a therapeutic role. Tubes that are closed with mucus plugs can be opened with pressure while contrast material is administered during the shooting.
Chlamydia Ig G Antibodies: It is a painless, inexpensive, easy test that provides information about the presence of damage in the tubes. In many studies conducted in recent years, it has been shown that Chlamydia infections can cause damage to the tubes without causing pelvic inflammatory disease. It is thought to cause infertility. In the world's leading infertility guidelines (RCOG guideline), it is recommended that all women be tested for chlamydia antibodies before HSG or any invasive procedure to be performed on the uterus.
Evaluation of the Inner Walls of the Uterus
With ultrasonography examination performed with physiological serum. Polyps, myomas on the inner wall of the uterus, adhesions on the inner wall of the uterus, and congenital disorders in the structure of the uterus can be diagnosed. In addition to the pathology in the tubes, subsequent or congenital disorders in the uterine structure can also be evaluated with HSG. Abnormal HSG finding requires further examination such as hysteroscopy or laparoscopy.
The Role of Laparoscopy
The role of laparoscopy in the evaluation of infertility is controversial. Laparoscopy may be performed when endometriosis is suspected (painful menstruation, pelvic pain, deep pain during sexual intercourse), in the presence of pelvic adhesions and a history of disease in the tubes (history of pelvic pain, complicated appendicitis, pelvic infection, pelvic surgery, previous ectopic pregnancy), abnormal physical examination and HSG. In patients diagnosed with unexplained or male infertility, the opinion is that there is no need for laparoscopy, as it does not change the treatment plan.
Tests Not Commonly Used in the Clinic
Poscoital Test: Defines the relationship between changes in the menstrual cycle in the mucus in the cervix and sperm. It should be done 2-12 hours after intercourse, just before the expected ovulation. It is not a routinely recommended test in the investigation of couples applying for children. It has no proven diagnostic value.
Endometrial Biopsy: Provides information about whether there is ovulation in the menstrual cycle and luteal phase defect. It is done 2-3 days before the expected menstruation. It is an expensive, invasive, unnecessary test that does not provide information about the inner wall of the uterus for the implantation of the embryo in the uterus and is unnecessary for the evaluation of ovulation.
Basal Body Temperature: During the entire menstrual cycle, body temperature is measured and noted in the morning without any activity. The increase in basal temperature correlates with the LH curve, starting to rise two days before the LH curve. Although it provides guidance about ovulation, it is difficult It is a test that can be affected by many factors and vary depending on the observer.
Caryotype Analysis: For women diagnosed with early menopause (under 40), men with severe oligospermia, and for both men and women in couples with a history of recurrent pregnancy loss. Karyotype analysis is recommended.
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