Treatment

Diagnosing female infertility

Disturbances in the Ovulation

Norm: The menstrual cycle is a period of time that begins with the commencing of menstruation. The usual duration of the cycle is 28 days, but 21-35-day intervals are also considered normal. In this period, the female reproductive system undergoes different endocrine and morphological changes.

The menstrual cycle is usually divided into three stages:

Follicle phase: the oocyte undergoes development and maturity before being fertilized. Along with the surrounding cells and liquids, it forms a small cyst, called a follicle. The basic hormones that are being produced in this phase are the estrogens that cause endometrium growth.

Ovulation phase: the follicle ruptures and the oocyte is excreted.

Luteal phase: after ovulation, the cells that surround the oocyte undergo change and form a structure, called a “yellow body” (corpus luteum). It has different sizes and secretes progesterone that reshapes the endometrium and prepares it for the implantation of the embryo. The duration of this phase is usually 12-14 days.

Abnormalities: irregular menstruation or lack thereof (amenorrhea) usually lead to a lack of ovulation. Other abnormalities in ovulation are the so-called LUF syndrome (non-ruptured follicle after induced by the endocrine system ovulation) and a corpus luteum deficiency.

Tests:

  • Determining the basal body temperature;
  • Determining the ovulation through a urine test;
  • Ultrasound examination (folliclemetry);
  • Dynamic determination of the hormonal balance through blood tests.

Treatment: Drugs or surgical treatment with the aim of recovering the normal ovulation process. If unsuccessful, a more specific type of treatment is usually applied:

  • Replacement, increase, or decrease of the secretion of Gonadotropin Releasing Hormone (GnRH);
  • Replacement and increase of the secretion of the Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH);
  • Replacement or increase of the Progesterone serum levels during the Luteal phase;
  • If the ovarial reserves are decreased or an early failure of the ovarial function is present, a treatment programme is being applied that encompasses in vitro fertilization with donor oocytes.

Cervical Factors

Norm:

In the normal ovulatory menstrual cycle, the estrogens that are being synthesized by the so-called granulose cells, increase the quantity of the cervical mucus and change its characteristics. This allows the sperm cells to easily move and infiltrate the woman’s reproductive tract.

Abnormalities: Innate abnormalities of the endometrium, endometrium treatment as a result of abnormal PAP test results (cryo-, laser treatment, connisatio), and the application of certain medications play a role in the quality of the cervical mucus.

Tests:

Post-coital test (PCT): evaluates the interactions between the cervical mucus and the semen after coitus. In this test, the cervical mucus is isolated from the cervical canal and is being microscopically examined.
The pH of the cervical mucus is an important factor for the sperm cells’ survival rate. Low pH values do not allow the sperm cells to pass this first physiological barrier of the female reproductive system.

Treatment: Various hormonal and nonhormonal methods are applied:

  • Bypassing the cervical mucus through an intrauterine insemination;
  • Conservative treatment, meaning a discontinuation of the applied medications and replacing them with new ones. For example: substitution of CC (clomiphene citrate) for aromatase inhibitor after inducing ovulation.

Uterine Body

Norm: The normal uterus cavity provides implantation conditions for the developing embryo. The endometrium undergoes change thanks to the estrogen and progesterone and prepares to receive the developing new organism.

Abnormalities: The normal endometrium development is hindered by the abnormalities in the ovulation or the application of certain drugs. Innate anatomical abnormalities in the uterine body or the uterus cavity can also hinder the normal embryo implantation. Other negative factors are the intrauterine accretions of prior surgical procedures or tumor formations that stem from the endometrium or the uterine body.

Tests:

Hysterosalpingography (HSG), hydrotubation under ultrasound control (sonohystrerography) and hysteroscopy.

Treatment:

A replacement of the type of medications that are used for inducing ovulation or the use of additional hormonal therapy which could improve the inadequate endometrium development.
Surgical treatment of any underlying anatomical defects and pathological changes in the endometrium and/or the uterine body.

Tubular Factor

Norm: The basic function of the fallopian tubes is the transport of the fertilized egg to the uterine body.

Abnormalities: Factors that hinder the acquiring of the oocyte by the tube, the sperm cells reaching the fertilized egg or its transport towards the uterine cavity.

Tests: Hysterosalpingography (HSG), hydrotubation under ultrasound control (sonohysterography), laparoscopy, or laparotomy.

Treatment:

Surgical treatment: Recommended if the normal-sized adhesions are present in the distal end of the fallopian tubes. For the last 25 years, IVF treatment has been applied as a basic form of treatment of tubular factor in infertility.
Peritoneal factors

Norm:

The peritoneal cavity is a part of the human body that contains the organs of the digestive and reproductive systems. It creates the environment, where the oocytes normally develop and the interaction between the fallopian tubes and the ovary takes place. This interaction leads to the oocyte’s infiltration in the fallopian tube and its subsequent fertilization by the sperm cell.

Abnormalities: Factors that could cause infertility:

  • Adhesions as a result of a surgical treatment;
  • Adhesions as a result of a prior inflammatory process in the pelvis;
  • Endometriosis (the presence of cells in the endometrium outside of their normal location in the uterine cavity) can lead to adhesions that obstruct the interaction between the ovary and the fallopian tubes.

Tests: Laparoscopy is a leading factor in diagnostics.

Treatment:

  • Surgical – removal of the adhesions caused by endometriosis;
  • Combined – surgical and conservative treatment;
  • IVF treatment – the method of choice when the previous techniques prove to be unsuccessful.
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