Infertility is the inability of a mature organism to conceive.

Barren marriage- absence of pregnancy after 12 months of regular unprotected sexual activity.

Distinguish masculine And female infertility. It can be absolute relative. Absolute infertility means that the possibility of pregnancy is completely excluded (absence of organs, abnormal development of the genital organs).

Infertility can be primary, when there is no indication in the anamnesis of the presence of at least some pregnancy, subject to regular unprotected sexual activity, and secondary, when there have been previous pregnancies (even ectopic, non-developing), but confirmed either visually (presence of a fetus) or histologically, or according to ultrasound examination (ultrasound), but after these pregnancies for 1 year with regular unprotected sexual activity, the next pregnancy does not occur.

Organization of medical care for infertile marriage

As a rule, in the absence of children in a marriage, the woman almost always takes full responsibility for this, but experience shows that in a married couple both partners may be equally unable to conceive. According to WHO, male infertility currently occurs in 50-60% of cases of infertile marriage, and in some regions of our planet this figure is close to 70%. Therefore, examination of both partners and the search for all possible diagnostic and treatment options should be simultaneous. An obstetrician-gynecologist and an andrologist simultaneously examine the spouses and assess the state of their reproductive function. Working with a married couple allows you to outline a general examination plan, the sequence of diagnostic procedures and avoid possible mistakes.

The duration of the examination should not exceed 6 months, and treatment should preferably be carried out for no more than 2 years, taking into account all the most modern methods (laparoscopy, reconstructive plastic surgery, IVF).

At the same time, specialists must warn their patients that even with the most thorough examination, correct diagnosis and application of all necessary and most modern treatment methods, the pregnancy rate is about 50-70%. Despite the vast accumulated experience, advanced technologies, and the perfection of operational techniques, in 5-10% of married couples the cause remains unclear.

Conditions that ensure pregnancy

1. Spermatogenesis (male factor).
2. Insemination (coital factor).
3. Ovulation (ovarian factor).
4. Interaction of cervical mucus and sperm (cervical factor).
5. Normal pH of the environment in the uterine cavity, ensuring active movement of sperm.
6. Integrity of the endometrium, normal size and shape of the uterine cavity (uterine factor).
7. Patency of the fallopian tubes and their anatomical relationship with the ovaries (tubal factor).
8. Necessary conditions for cell fusion inside the fallopian tube.

To identify all the factors that ultimately lead to infertility, a complete clinical and laboratory examination is necessary. Having made a diagnosis of primary or secondary infertility, it is necessary to note what causes it.

Female infertility

Classification of female infertility

1. Endocrine factor infertility - disruption of ovulation processes due to damage to the hypothalamic-pituitary-ovarian system (HPO) or general and systemic diseases.
2. Pipe factor infertility - a change in the patency and/or contractile activity of the fallopian tubes.
3. Peritoneal factor infertility - peritubar adhesions, changing the ratio of the fimbrial sections of the tubes and ovaries, interfering with the transport of gametes.
4. Uterine factor infertility - pathological conditions of the endometrium, malformations of the uterus.
5. Cervical factor infertility - anatomical and functional changes in the cervix that impede the movement of sperm or lead to their death.
6. Immunological factor infertility - the production of antisperm antibodies (ASAT) in a woman to the sperm of her partner.
7. Unidentified forms of infertility.

Examination methods for female infertility

Anamnesis data are of great importance. From the anamnesis, the doctor learns about the developmental characteristics of the patient, the age of her parents, and diseases suffered by herself and her parents in childhood. Information about tuberculosis in the family, the presence of neoplasms, and mental illness may be important. Smoking and alcohol abuse by the patient herself or her parents may also be important in making a diagnosis. The specialist must pay attention to the patient’s complaints (pain, weakness, fatigue, changes in the menstrual cycle, body weight, condition of the mammary glands), and determine the psychological situation in the family.

Particular importance is attached to the study of menstrual function. In case of any violation (in terms of duration, amount of bleeding, etc.), it is necessary to indicate when the deviations first appeared and, if possible, what they are associated with.

Regular menstrual cycle- the interval between menstruation is 21 - 35 days.

Primary amenorrhea- absence of spontaneous menstruation during the entire period of a woman’s life.

Secondary amenorrhea- absence of spontaneous menstruation for 6 or more months.

Oligomenorrhea- spontaneous menstruation with an interval of 36 days to 6 months.

Polymenorrhea- the interval between menstruation is less than 21 days.

Dysmenorrhea- painful menstruation.

The characteristics of sexual life (libido, orgasm, frequency of sexual intercourse, pain during sexual intercourse, contraception and duration of its use) and reproductive function are also taken into account.

Information about the presence or absence of infection is a priority in the list of examinations for infertile marriages. For each examined patient, the nature of the vaginal and cervical contents must be established. It is mandatory to conduct a study for the presence of gonorrhea, trichomonas, chlamydia, ureomycoplasma, gardnerella, viruses, fungi, syphilis, tuberculosis, toxoplasmosis, AIDS, etc. When a certain type of infection is identified, it is necessary to decide on the feasibility and scope of treatment.

Colposcopy- an endoscopic method that allows you to assess the condition of the vulva, vaginal walls and the vaginal part of the cervix.

Colposcopy is indicated for all women who are being examined for infertility problems. In cases where any changes are detected, patients must undergo adequate treatment, since the identified pathology may be the only reason leading to infertility.

Metrosalpingography(MSG) - is carried out to determine the patency of the fallopian tubes, identify anatomical changes in the uterus, as well as the adhesive process.

To determine the patency of the fallopian tubes, it is most advisable to carry out MSG in phase I (days 7-9) of the menstrual cycle, although this study can be carried out in phase II.

During the cycle when MSG is performed, patients are recommended to use contraception. MSG is indicated no earlier than 2 months after the last exacerbation of existing chronic salpingoophoritis or any acute inflammatory process. Hemogram indicators, urine tests, and smears to determine the degree of vaginal cleanliness should be within normal limits.

Hysteroscopy(GS) - the main advantage of this invasive examination method is the ability to identify intrauterine pathology. Hysteroscopes provide magnification of 5 times or more.

Laparoscopy(LS) - used as a diagnostic method, as well as treatment for infertility.

Ultrasound examination (ultrasound) is a non-invasive examination method and can be performed on almost any patient, regardless of her condition.

There are no contraindications to this diagnostic method. Using ultrasound, you can determine the presence of organs, their sizes, the changes that may occur, observe folliculogenesis, and the dynamics of tumor growth (fibroids, cysts).

The study of functional diagnostic tests (FDT) is used to determine the functional state of the reproductive system. TFD also talks about the patient’s hormonal status.

Basal temperature(BT) of the body - measured daily at the moment of waking up before getting out of bed. The thermometer is inserted into the rectum to a depth of 3-5 cm, the measurement continues for 4-8 minutes. The temperature is recorded to the nearest tenth on the menocyclogram.

Type I - normal two-phase cycle; temperature rise in the second phase by 0.4°C or more; there is an “ovulatory” and “premenstrual” drop in temperature;

Type II - insufficiency of corpus luteum function; the temperature rise in the second phase is weakly expressed (0.2-0.3°C); the cycle is usually two-phase;

Type III - shortening and insufficiency of the second phase; the temperature rises shortly before menstruation, the second phase is shorter by 10 days; there is no “premenstrual” drop in temperature;

Type IV - anovulatory cycle; single-phase menstrual cycle, monotonous temperature curve;

Type V - severe estrogen deficiency; large temperature ranges are observed, there is no noticeable rise in the second phase, the graph does not fit into the previous 4 types; may be the result of incorrect measurement or depend on random reasons.

A fairly accurate method for assessing ovarian function is histological examination. endometrial scraping.

When curettage of the endometrium for diagnostic purposes, one should take into account the characteristics of the menstrual cycle and the clinical picture of the disease.

However, all of the above examination methods allow us to only indirectly judge the state of the hormonal status of patients. And only the study of the quantitative content of hormones in the blood of women according to the phases of the menstrual cycle can accurately characterize one or another hormonal status at the time of the study.

Cytogenetic studies are carried out by specialist geneticists. In patients, sex X- and Y-chromatin is determined by studying cell nuclei obtained by scraping the mucous membrane of the inner surface of the cheek. Determination of sex chromatin allows you to assess the state of sex chromosomes in the patient being examined. If there are deviations in the amount of sex chromatin, the karyotype should be examined. These studies are indicated in the presence of short stature of patients, multiple, often erased, somatic developmental anomalies, dysplasia, in cases where anemnesis reveals developmental defects in the patients' relatives, multiple deformities or spontaneous miscarriages in early pregnancy.

Postcoital test(PCT) provides rich information regarding the reproductive capacity of a married couple. This makes it possible to evaluate the correctness of coitus technique, sperm quality, quantity and characteristics of the cerebral cyst, the presence of antibodies, and obtain indirect information about the presence of ovulation.

The purpose of PCT is not only to determine the number of actively motile sperm in the CC, but also to assess the cervical scale, sperm survival, and determine the immunological aggression of the CC by the presence of the “swinging phenomenon”. The presence of an adequate number of actively motile sperm in endocervical mucus allows us to exclude cervical factors as a possible cause of infertility. It is rational to record the number of sperm and an assessment of their motility in the table. PCT can be assessed:

A) great- if the endocervical mucus contains more than 10 sperm with active forward motility; the number of sperm with the “swinging phenomenon” is less than 25%;

b) satisfactory- the number of sperm in endocervical mucus is 6-10; “swinging phenomenon” less than 25%;

V) bad- number of sperm less than 5;

G) doubtful- if the number of sperm exceeds 5 and sperm with the “swinging phenomenon” is more than 25% - the appearance of immunological aggression of the CC;

d) negative- no sperm.

Examination plan for a married couple for infertility

Consultations: therapist, ophthalmologist, genetic endocrinologist, medical genetic examination, psychoneurologist, sex therapist, neurosurgeon.

Special examination methods include: RW, HIV; blood type and Rh factor; general blood and urine analysis, blood sugar, sugar curve; infectious screening (examination with provocation for gonorrhea, trichomonas, chlamydia, ureomycoplasma, gardnerella, fungi, viruses); examination for tuberculosis (fluorography, samples, blood culture, scraping culture); postcoital test or cervical mucus-sperm contact test on a glass slide; functional diagnostic tests 3 cycles; colpocytology; Ultrasound of the pelvic organs; Ultrasound control of folliculogenesis 2-3 cycles; colposcopy; blood hormone studies (FSH, LH, TSH, T4, T3, prolactin, cortisol, estrogens, progesterone, testosterone); urine test for 17-KS; craniogram; electroencephalography; MSH with water-soluble contrast; radioisotope metrosalpingostincigraphy; hysteroscopy; laparoscopy with chromohydrotubation; data from conclusions after surgical interventions, histological responses; spermogram.

One of the first of a large list of examinations for an infertile marriage is male ejaculate analysis.

Secretory infertility: a) secretory-endocrine; b) secretory-toxic.

Extretor infertility: a) extretor-toxic; b) extretor-obstructive.

Combined infertility.

Immunological infertility.

The rules that must be followed before taking the test remain unchanged. It is necessary to abstain from sexual activity for 4-5 days, smoking, and alcohol consumption. In addition, the examination of ejaculate is not performed during the period of exacerbation of any diseases of the genital organs or any other. It is advisable that there be no significant stress during this period. Sperm is collected by masturbation in a medical institution, where the study will be carried out, preferably in a Petri dish. If the last condition is not met, time and temperature conditions may be violated, so the reliability of the analysis is very relative.

Microscopic and macroscopic data of the ejaculate are assessed.

The normal volume is 2-5 ml, if it is more than 5 ml, then this indicates the presence of an inflammatory process (inflammatory exudate in the sperm), which reduces fertility.

The smell of semen is specific, close to the smell of raw chestnut. The normal pH of ejaculate is 7-8. A shift in the reaction either to the acidic or alkaline side leads to a decrease in fertilizing function. The sperm liquefaction time is also estimated, which is normally 15-45 minutes, possibly up to 60 minutes. An increase in this time, as a rule, indicates a deficiency in the secretion of the prostate gland of enzymes, such as fibrinolysin, fibrogenase. A decrease in the viscosity of the secretion indicates an insufficient content of seminal vesicles in the ejaculate, which provide the energy potential of sperm.

The indicators of fertile sperm are as follows:

1) quantity - 2-5 ml;

3) liquefaction time - 15-60 minutes;

4) amount in 1 ml - 40-60 million or more;

5) mobile forms 70% or more;

6) actively mobile forms 50% or more;

7) pathological forms - 30-35%;

8) living forms - 70-80%;

9) agglutination - absent;

10) red blood cells - absent;

11) leukocytes - 6-8 in the field of view;

12) lecithin grains - in large quantities;

13) microflora is absent.

Endocrine infertility is characterized by disruption of the ovulation process. Anovulation is the most common cause of infertility and is a group of pathological conditions accompanied by disruption of cyclic processes in the hypothalamic-pituitary-ovarian system: polycystic ovary syndrome (PCOS), hyperprolactinemia syndrome (HPS), amenorrhea (A), dysfunctional uterine bleeding (DUB), congenital adrenal cortex dysfunction (CAD).

The cause may be disturbances in the rhythm and release of gonadotropic releasing hormones and/or gonadotropins, while its only manifestation is infertility.

The diagnosis of such anovulation is established on the basis of:

— monophasic basal temperature;

- absence of a dominant follicle with a diameter of 18-20 mm on days 12-14 of the cycle (ultrasound);

- monotonously low level of progesterone (P) without increasing it by 5-7 times on the 16-22nd day of the cycle.

Infertility is one of the most complex problems in medicine, which requires complex and often lengthy examination. What tests and procedures should a married couple who consults a doctor about infertility undergo?

According to WHO definition, a marriage is considered infertile in which pregnancy does not occur within one year with regular sexual activity without the use of any means of contraception. Women over 35 years of age are recommended to consult a doctor after 6-7 months of absence of pregnancy.

First of all, it is worth remembering that in the absence of children in a marriage, the examination should be started by both spouses at the same time, since the causes of this condition can be either male or female, or combined, that is, occur in both spouses at the same time. Therefore, even if at one of the stages a pathology is detected in one of the partners, the second partner needs to be examined completely. In this case, you can start with a man, because... Male infertility accounts for the same percentage of cases as female infertility, and examining a man is much faster and easier. For examination, the future dad needs to contact a urologist or urologist-andrologist.

Examination of a man

Visit to a urologist-andrologist

The first examination by a urologist-andrologist allows you to diagnose malformations of the male genitourinary system, varicose veins of the scrotum (varicocele). With varicocele, due to the presence of varicose veins and stagnation of blood in the scrotum, a significant increase in local temperature occurs, which disrupts the process of sperm maturation. During the questioning, the doctor pays attention to ejaculation disorders (ejaculation), the presence of concomitant diseases, and the use of medications, since they can affect the ability to conceive.

Analyzes

Assessment of the functioning of the male reproductive system begins with a study spermograms - sperm analysis. It takes into account physical parameters: the volume of sperm, its color, viscosity - and microscopic parameters: the number and motility of sperm, the content of other cells, etc. Based on the data obtained, we can make assumptions about male infertility, prostatitis, and possible infections.

The fundamental factor in male fertility (the ability to conceive a child) is the production of normal sperm in sufficient quantities. The entire process of sperm formation (spermatogenesis) takes 72 days; the formation of sperm occurs in the testicles and is regulated primarily by hormones produced in the man’s body. During the production process, male reproductive cells enter the epididymis, where they are nourished and matured. There, sperm acquire motility. Then, through the vas deferens, mature sperm enters the seminal vesicles and is stored there until ejaculation. During ejaculation, the secretions from the seminal vesicles mix with the thick fluid from the prostate to form seminal fluid.

After ejaculation, sperm lives in a woman’s body and retains the ability to fertilize an egg for 48 to 72 hours. In order for fertilization to occur, there must be a sufficient number of sperm in the ejaculate and their good mobility. The ability to conceive can be affected by the immaturity of sperm, the presence of a large number of cells with an irregular structure, as well as the volume and composition of seminal fluid.

In addition to a spermogram, it is also recommended to carry out MAP test- a test for the determination of antisperm antibodies in the sperm of specific proteins formed in the male body that affect sperm and lead to their death. The analysis can be performed from the same portion of sperm as the spermogram.

If an inflammatory process is suspected, the doctor will prescribe tests for sexually transmitted infections, bacteriological culture of sperm or prostate juice. Juice is collected after rectal massage of the prostate gland. To collect prostate juice, the patient is asked to lie on his right side, press his legs to his stomach, or, while standing, bend forward. Detection of sexually transmitted infections is carried out by collecting smears from the urethra. To perform bacterial cultures, sperm or prostatic fluid is placed in a special nutrient medium and bacterial growth is assessed after 7-10 days. This analysis also makes it possible to determine the sensitivity of the isolated microorganism to the action of antibiotics, that is, to select a drug that will cure this infection. The fact is that men's fertility may suffer due to the presence of a chronic or acute inflammatory process in the prostate gland (prostatitis), because As a result of this disease, the quality of the sperm produced decreases, and with a long-term process, blockage of the channels through which sperm moves occurs is possible.

Ultrasound

In case of chronic inflammatory processes in the organs of the reproductive system, the presence of varicose veins of the scrotum, or suspected developmental defects, an ultrasound scan of the prostate and testicles is performed.

In difficult cases, the doctor may, in addition to ultrasound, recommend magnetic resonance imaging (computer image) of the genital organs.

If a man has any reproductive system disorders, the woman’s examination plan may be changed. But this can only be decided by the attending physician based on the examination data of the man and his diagnosis. In any case, the discovery of certain violations during the examination of a man does not negate the need to examine a woman.

Examination of a woman

Visit to the gynecologist

During the initial visit to the gynecologist, it is necessary to tell the doctor as fully and honestly as possible about all past illnesses, injuries, operations, the presence or absence of previous pregnancies, abortions, miscarriages. Equally important is heredity in the family through the female line, especially if relatives have experienced infertility or spontaneous abortion or early menopause. During the first appointment, the doctor usually asks the patient many questions. But this is not at all idle curiosity. Detailed and honest answers to these questions help make the correct diagnosis and often significantly save examination time.

After examining the woman, the doctor will outline a rough plan for the upcoming examination. Already during the first examination, the doctor can exclude or confirm the presence of some malformations of the genital organs - anomalies in the structure of the uterus, vagina, suspect the presence of an inflammatory process, and identify indirect signs of existing hormonal disorders. Also, during the first examination, the doctor takes smears that can identify acute or chronic inflammatory diseases of the genital organs.

Screening for sexually transmitted infections is mandatory. Sometimes the only complaint a woman has is a prolonged absence of pregnancy. This happens because chronic, sluggish infections lead to inflammatory processes in the pelvis, as a result of which inflammation of the fallopian tubes develops and adhesions are formed, which can close the lumen of the fallopian tube and prevent the penetration of the egg into it. This condition is called tubal-peritoneal infertility and ranks first among the factors preventing conception.

Ultrasound

Ultrasound is mandatory for all patients. The use of modern equipment and vaginal sensors allows not only to avoid the unpleasant procedure of preparing for the study - filling the bladder, but also provides good visualization of the structure of the internal genital organs. Using ultrasound, you can identify congenital anomalies of the structure of the uterus and ovaries, fibroids, endometriosis, and ovarian cysts. Uterine fibroids are a benign tumor of the ovaries, endometriosis is a pathology in which the inner layer of the uterus (endometrium) grows in uncharacteristic places - in the muscular layer of the uterus and even outside it, for example in the ovaries. These diseases, as well as ovarian cysts, can cause infertility. Several ultrasound examinations during, for example, one menstrual cycle are used to monitor the onset of ovulation (the release of an egg from the ovary, which occurs in the middle of the menstrual cycle). The first ultrasound is best performed immediately after the end of menstruation - on the 5-7th day of the cycle. For certain indications, repeat studies are prescribed in the middle and at the end of the cycle.

Assessment of hormonal levels

A consultation with a gynecologist-endocrinologist and an assessment of hormonal levels are necessary to determine the hormonal causes of infertility. These tests are required. Hormones of the brain, ovaries and adrenal glands are studied - LH, FSH, estradiol, testosterone, cortisol, prolactin, 17-hydroxyprogesterone, DHA-sulfate, progesterone, as well as thyroid hormones - TSH, free thyroxine (free T4), free triiodothyronine (T3 free). In the presence of hormonal changes, the egg does not mature. This occurs in many diseases, for example, when there is a violation of the production of hormones in the adrenal cortex, polycystic ovary syndrome - increased production of male sex hormones in the ovaries, and increased production of the hormone prolactin in a woman’s body. A decrease in the production of female sex hormones is also possible under other circumstances, for example, against the background of a low-calorie diet, intense exercise, or regular stress. Overweight, dysfunction of the thyroid gland, taking certain medications, tumor processes and brain injuries can also lead to disruption of the ovulation process.

In the first phase of the cycle, blood hormones are usually donated on the 3-5th day of the cycle, in the second - on the 20-23rd day of the cycle. Some hormones are tested once, while others will have to be tested several times.

Magnetic resonance imaging

For patients with elevated levels of prolactin in the blood, the doctor may recommend magnetic resonance imaging of the brain, most often with contrast enhancement of blood vessels. This procedure is performed to exclude a pituitary tumor (adenoma), which often causes similar hormonal imbalances. Prolactin is produced in the endocrine gland of the brain - the pituitary gland. This hormone is responsible for the production of milk after childbirth, then its amount in the blood increases significantly. Prolactin prevents the egg from maturing and leaving the ovary.

Basal temperature measurement

Another hormonal disorder that can result in infertility is a decrease in the synthesis of the hormone progesterone, produced by the corpus luteum, which forms at the site of the follicle from which the egg was released. This hormone supports the development of pregnancy in the early stages, before the formation of the placenta. Under conditions of reduced progesterone secretion, fertilization occurs, but the fertilized egg cannot attach and develop in the uterus. This condition is called luteal phase deficiency of the menstrual cycle.

In diagnosing this condition, measuring basal temperature (temperature in the rectum) over several menstrual cycles can complement the diagnostic picture, and ultrasound and hormonal examination data help the doctor make the correct diagnosis. Basal (rectal) temperature is measured daily. The measurement time should be the same throughout the entire examination (5-7 minutes); the difference in measurement time should not exceed 30 minutes. Having woken up, but without getting out of bed, without making sudden movements, the woman takes a thermometer and carefully inserts its narrow part into the anus for 5-7 minutes. Then he notes the thermometer readings on a special graph.

With correct and regular measurement of basal temperature, it is possible to diagnose a violation or absence of ovulation, as well as a decrease in the hormonal activity of the corpus luteum formed after ovulation.

Hysterosalpingography

This examination is prescribed for suspected tuboperitoneal infertility (presence of adhesions in the abdominal cavity).

Hysterosalpingography (HSG) is the introduction of a radiopaque contrast agent into the uterine cavity and fallopian tubes, followed by assessment of its passage through the fallopian tubes using a series of x-rays. A radiopaque contrast agent is injected into the uterus through the cervical canal.

HSG is most often performed in the first half of the menstrual cycle, but in some cases the study is indicated in the second phase. In this case, mandatory protection is necessary during this cycle, since the introduction of a contrast agent increases the likelihood of attachment of a fertilized fertilized egg outside the uterus, that is, an ectopic pregnancy. This feature occurs only in the menstrual cycle in which the examination was carried out.

This research is somewhat painful, but sometimes simply irreplaceable. Usually, before undergoing HSG, the patient is given antispasmodic drugs, which somewhat anesthetize the procedure.

An alternative to HSG is echohysterosalpingoscopy (ESH), a method in which a saline solution or contrast agent is injected into the uterus, and the movement of fluid through the fallopian tubes is assessed using ultrasound. Due to the different composition of the injected liquid, this procedure is painless, but slightly less informative than HSG. In addition, there is no radiation exposure in this study.

Postcoital test

The cause of infertility can be a violation of the composition of mucus in the cervical canal of the cervix, the presence of antibodies to sperm in it. Normally, this mucus plays a protective role in the fight against infectious agents living in the vagina, and prevents their spread to the uterus and further into the fallopian tubes and pelvis. If the chemical composition of cervical mucus is disrupted, it can be harmful to sperm and prevent them from penetrating towards the egg. In some cases, changes in the physicochemical composition of cervical mucus can be facilitated by the presence of cervical erosion - a change in the mucous membrane of the cervix. In this case, changes in the composition of the mucus may occur.

If cervical factor infertility is suspected, a postcoital test is prescribed. During the period of ovulation, 5-6 hours after sexual intercourse, mucus is taken from the woman’s vagina and cervix. Sperm motility is determined under a microscope. If they are less mobile in the cervix than in the usual spermogram of a given man, then they conclude that cervical mucus has a negative effect.

Blood test for antisperm antibodies

Sometimes you can find couples in whom the disease is caused by incompatibility, i.e. immunological factor. Antibodies produced by the female body to the partner’s sperm (antisperm antibodies) do not allow sperm to fertilize the egg - the antibodies bind sperm. Determination of antisperm antibodies is possible in cervical (cervical) mucus.

Hysteroscopy

If intrauterine pathology is suspected (the presence of fibroid nodes protruding into the lumen of the uterus, adhesions inside the uterus, endometriosis), the doctor may recommend hysteroscopy.

This procedure is performed under anesthesia and consists of examining the uterine cavity using a special device - a hysteroscope. During hysteroscopy, intrauterine adhesions, endometrial polyps, and fibroids protruding into the uterine cavity can be diagnosed and removed. After hysteroscopy, curettage of the uterine cavity is usually performed, followed by histological examination of the endometrium to identify pathological changes in the inner layer of the uterus.

Laparoscopy

This study is the most reliable and informative diagnostic method. This method makes it possible to visually assess the degree of patency of the fallopian tubes, their function, and, if necessary, separate adhesions. Laparoscopy is performed in a hospital under general anesthesia.

During the operation, a thin needle is inserted into the abdominal cavity, through which a small amount of inert gas is pumped to slightly move the abdominal wall away from the internal organs. A flexible probe equipped with a video camera is then passed through the needle. Instruments are inserted through two other small incisions. During the operation, the uterus, tubes and ovaries are examined from the outside; surgical intervention can be performed - to cut adhesions, remove the capsule from the ovaries, or remove uterine fibroids.

Laparoscopy is also indispensable for the diagnosis and treatment of endometriosis, a disease in which endometrial cells (the inner layer of the uterus) grow, forming something like deep “pockets” in the thickness of the uterus, which can penetrate the fallopian tubes, ovaries and even the abdominal cavity. Endometriosis, developing in the ovaries, disrupts the maturation of the egg; in the fallopian tubes, it interferes with the fusion of the egg and sperm, and also disrupts the attachment of the fertilized egg to the wall of the uterus.

An unusual, but no less real, cause of infertility can be a psychological factor, so your doctor may also advise you to consult a psychotherapist or psychologist.

If a diagnosis of infertility is made, the success of examination and treatment depends not only on the competence of the attending doctor, but also on the clarity and timeliness of the couple’s implementation of his recommendations.

Diagnosis of infertility in women is an important step towards determining the cause of an infertile marriage. Today there are many diagnostic methods and in this article we will talk about them in great detail.

Diagnosis of female infertility begins with a preliminary examination of the patient in the clinic and antenatal clinic. In some cases, after this stage it is possible to identify the problem and prescribe effective therapy. In outpatient settings, types of infertility caused by ovulation disorders and gynecological diseases not associated with occlusion of the fallopian tubes respond well to treatment.

If there are indications, they proceed to the second stage of examination. The patient is prescribed specialized diagnostic methods (non-invasive hardware, endoscopy, hormonal studies). Treatment in such cases, depending on the identified pathology, can be either conservative or surgical (using laparoscopic, laparotomic and hysteroscopic methods).

In some cases, the only option for the patient is assisted reproductive technologies (ART). These include IVF procedures, as well as artificial insemination (these activities can be performed in different modifications).

Specialized medical care can be obtained at the state center for reproduction and family planning, gynecological departments of medical institutions, at private infertility treatment centers, at the clinical bases of research institutes and departments dealing with these problems.

Diagnosis plan for infertility in women

1. Collection of a woman’s medical history (somatic, gynecological and reproductive).

2. General examination (weight, height, skin, examination of the mammary glands).

3. Gynecological examination.

4. Husband's sperm analysis.

5. Blood test: general and biochemical blood test, coagulogram, RW, HIV, HbsAg, blood test for glucose, blood group and Rh factor.

6. General urine analysis.

7. Comprehensive examination for STDs.

8. Ultrasound of the pelvic organs.

9. Colposcopy.

10. Hysterosalpingography.

11. Functional diagnostics of ovarian activity:

Measuring basal temperature for 2-3 months;

Weekly hormonal colpocytology;

Daily study of the phenomenon of mucus arborization;

To determine the diameter of the follicle, an ultrasound is performed on the 12-14-16th day of the cycle;

The levels of estrogen, testosterone, prolactin, FSH, LH are determined in the blood plasma;

On days 3-5 of the menstrual cycle, in the middle of the cycle and in phase 2, the level of progesterone in the blood and pregnanediol in the urine is determined;

The level of 17-KS in the urine is determined 2 times a month.

12. Hormonal tests.

13. Application of additional research methods according to indications:

Hormonal examination: cortisol, DHEA-S (dehydroepiandrosterone - sulfate), insulin, T3, T4, TSH, antibodies to thyroglobulin;

Shuvarsky-Guner postcoital test;

Determination of antisperm antibodies in women in the mucus of the cervical canal on preovulatory days (the levels of immunoglobulins IgG, IgA, IgM are determined);

Kurzrock-Miller test (penetration of sperm into the cervical mucus of a woman during ovulation);

Friberg test (determination of antibodies to sperm using a microagglutination reaction);

Kremer's test (detection of local antibodies in the husband during contact of sperm with cervical mucus;

Izojima immobilization test;

Immunological tests.

14. Examination by a mammologist, mammography.

15. X-ray of the sella turcica and skull.

16. Examination of the fundus and visual fields.

18. Laparoscopy.

Taking anamnesis for female infertility

The examination of a woman suffering from infertility begins with a thorough history taking. The first conversation with the patient is carried out in accordance with WHO recommendations. In this case, the doctor should clarify the following points:

Does the patient have children and how many there are at the moment.

How long does infertility last?

How many pregnancies and births have you had in the past and what was their outcome.

Complications after childbirth and abortion.

What methods of contraception did the woman use and for how long?

Do you have any chronic diseases (problems in the functioning of the adrenal glands, thyroid glands, diabetes mellitus, tuberculosis, etc.).

What medications have you taken or are you taking (tranquilizers, psychotropic drugs, cytotoxic drugs).

Have you undergone operations associated with the risk of adhesions (interventions on the ovaries, uterus and its tubes, kidneys, urinary tract, intestines, surgery for appendicitis).

Have you had pelvic inflammation or sexually transmitted infections in the past? (If such diseases have occurred, it is necessary to clarify the type of pathogen and details of treatment).

Has galactorrhea been observed and was it associated with lactation?

Have there been any sexual dysfunctions such as contact bleeding or dyspareunia?

What cervical diseases were diagnosed and what therapy was prescribed (conservative, electrocoagulation, cryotherapy, laser).

It is also necessary to inquire about the patient’s lifestyle, the presence of bad habits (smoking, addiction to alcohol or drugs), to clarify the influence of industrial, epidemic and hereditary factors (find out the presence of hereditary diseases in the patient’s 1st and 2nd degree relatives).

When diagnosing female infertility, the menstrual history of an infertile woman (menarche, cycle features, cycle disorders, discharge between menstruation, sensations during menstruation) is also of great importance.

Physical examination in women with infertility

At this stage of the examination, the following diagnostic measures are carried out:

The patient's height and weight are measured.

Body mass index is calculated (weight in kilograms divided by the square of height in meters). Normal values ​​for this indicator are from 20 to 26. If obesity is noted (mass index exceeds 30), find out when obesity appeared, how quickly it developed and what could have been the cause.

Carefully study the condition of the skin (dry skin or oily, moist), pay attention to the presence of traces of stretch marks and acne. Assess the nature of hair growth. If there is hypertrichosis, its degree is determined using the D. Ferriman, J. Galwey scale. Find out when excess hair growth occurred.

The mammary glands are examined, the degree of their development is assessed, and a study is carried out for discharge from the nipples and palpable formations.

A bimanual gynecological examination is performed, the condition of the cervix is ​​examined using mirrors, and colposcopy is performed.

At this stage, a medical opinion from a therapist is also required about the possibility of a successful pregnancy and successful childbirth. If signs of mental, endocrine or any other diseases, developmental defects are detected, then consultation with a specialized doctor - psychiatrist, endocrinologist, geneticist, etc. will be necessary.

Laboratory diagnostic methods for female infertility

Infectious screening for infertility in women

In accordance with the order of the Ministry of Health of the Russian Federation No. 572n, infectious screening is performed. It involves the following activities:

Taking a smear from the cervix for cytological analysis.

- Flora smear from the cervical canal and urethra.

Examination of the degree of vaginal cleanliness.

PCR analysis for 12 infections: chlamydia, human papillomavirus infection, mycoplasmosis, ureaplasmosis, trichomoniasis, gonorrhea, etc. For this, a smear is taken from the cervical canal.

The use of a cultural method (when samples from the vagina and cervical canal are inoculated to study the flora and assess its sensitivity to antibacterial drugs).

Blood tests for HIV, syphilis, hepatitis B and C.

If the patient has been diagnosed with one of the infections mentioned above, a course of etiotropic therapy will be required, followed by another (control) examination. At this stage, the patient may be referred for specialized treatment to an immunologist (if HIV is detected) or a dermatovenerologist (in the case of gonorrhea or syphilis).

TORCH-complex

The TORCH complex includes:

Detection of antibodies (immunoglobulins - Ig) G and M to rubella, cytomegalovirus, toxoplasmosis, herpes simplex virus (type 1 and 2). If IgG antibodies to rubella are not detected, the patient needs vaccination.

Hormonal screening

In order to confirm or exclude the endocrine nature of the pathology (anovulatory infertility), hormonal screening is performed as part of a standard outpatient examination program. In case of cycle disorders and ovulatory function disorders, a study of hormonal levels helps to identify the cause of the pathology.

Hormonal screening includes assessment of the level of the following hormones: luteinizing and follicle-stimulating hormones, prolactin, estradiol, cortisol, testosterone, 17-hydroxyprogesterone, thyroid-stimulating hormone, dehydroepiandrosterone sulfate, free thyroxine (on the 2nd or 3rd day in a normal cycle and at any time in case of a broken cycle) and progesterone (on the 21st–23rd day of the cycle).

If studies have shown abnormalities in hormone levels, the patient will need further diagnostics aimed at identifying the causes of the hormonal imbalance. At this stage, specialized instrumental and laboratory diagnostic methods can be used:

Computed tomography of the sella turcica area.

Ultrasound examination of the thyroid gland.

Hormonal tests.

Such diagnostics falls within the competence of a specialized specialist – a gynecologist-endocrinologist. The same doctor, based on the results of examinations, determines the treatment regimen.

Immunological methods for diagnosing female infertility

Also, to diagnose infertility in women, they resort to immunological studies - identifying antibodies in samples from the cervical canal (IgG, IgM, IgA).

Instrumental methods for diagnosing infertility in women

During the outpatient examination of infertile patients, a mandatory method is pelvic ultrasound. Ultrasound examination is also recommended for assessing the condition of the mammary glands and excluding neoplasms in them (up to 36 years). If indicated, an ultrasound scan of the thyroid gland is performed.

If intrauterine or tubal causes of infertility are suspected, the patient undergoes hysterosalpingography (HSG). The study is performed from the 5th to the 7th day of the cycle with normal menstruation or oligomenorrhea. In patients with amenorrhea, HSG can be performed at any time.

At the same time, the diagnostic capabilities of HSG in the study of fallopian tubes cannot be considered satisfactory. The fact is that during the study of tubal patency, there is a significant discrepancy between the results (up to 50%) of HSG and laparoscopic examination, supplemented by chromosalpingoscopy with methylene blue. This means that diagnosing tubal-peritoneal infertility (TPI) and completely clarifying the picture of tubal changes can only be done using the laparoscopic method. As for HSG, this method is informative in the diagnosis of intrauterine diseases.

X-ray diagnostic methods for female infertility include:

Tomography (computer or magnetic resonance imaging).

Craniogram.

Hysterosalpingography.

Mammography (after 36 years).

Tomography of the skull and sella turcica is performed for endocrine infertility, which is associated with hyperprolactinemia or pituitary insufficiency (with low FSH levels). This method allows doctors to detect macro- and microprolactinomas of the pituitary gland. In addition, it makes it possible to diagnose empty sella syndrome.

If there is a suspicion of surgical pathology of the genital organs, the patient may be referred to a spiral CT scan of the pelvis. Such a study allows you to obtain complete information about the condition of the organs, after which you can plan surgical intervention. Instead of spiral tomography in such cases, the use of MRI is also allowed. However, it must be taken into account that the diagnostic potential of this method is not as high, and obtaining images will take longer.

Patients who, due to endocrine infertility, exhibit signs of hypo- or hyperthyroidism, abnormalities in the level of thyroid hormones, and hyperprolactinemia are referred for an ultrasound examination of the thyroid gland.

Ultrasound of the adrenal glands is indicated for elevated levels of adrenal androgens and hyperandrogenism. If necessary, a CT scan of the adrenal glands is performed.

Endoscopic diagnosis of female infertility

Endoscopic diagnosis involves laparoscopy and hysteroscopy. If there is pathology of the endometrium, a biopsy is performed during the procedure.

Laparoscopy is considered the most informative method for peritoneal and tubal factors of infertility. Moreover, it makes it possible to correct detected pathologies: restore tubal patency, separate adhesions, remove fibroids (intramural, subserous) and retention formations in the ovaries, and perform coagulation of endometrioid heterotopias.

The hysteroscopy method is used in the following cases:

Suspicions of intrauterine pathology based on the results of a survey, examination and ultrasound examination.

The patient has dysfunctional uterine bleeding, regardless of its intensity.

Hysteroscopy of the uterus helps to identify many different pathologies: polyps, adenomyosis, myomatous nodes, GPE, chronic endometritis, synechiae, malformations, and the presence of a foreign body. During this procedure, a specialist may perform curettage of the cervical canal and uterine cavity for diagnostic purposes. In addition, under hysteroscopic control, surgical interventions can be performed for various intrauterine pathologies.

Diagnosis of sexual partner

In parallel with the examination, the patient is also referred for diagnostics to her partner. This is necessary in order to exclude the possibility of male infertility. The main study in this case is spermogram. If the analysis shows abnormalities in sperm parameters, the man must be examined by an andrologist. After this, you can decide on possible ways to solve the problem (treatment of the man or IVF).

In addition to the spermogram, when examining men, the MAP test method (detection of antibodies to sperm) is used. If the rate of this test exceeds 30%, we can say that a man’s infertility is of an immune nature. In such cases, IVF or the method of artificial insemination is indicated.

If there is a suspicion of one of the surgical pathologies (ovarian cyst, tubal occlusion, uterine malformations, endometrioid or myomatous process, intrauterine synechiae, peritoneal adhesions), the patient should be referred to a specialized medical institution. There they will conduct further diagnostics, make a final diagnosis and carry out the necessary treatment (surgical or endoscopic method). The diagnosis of male infertility is described in detail in another article on our website.

If a woman has not undergone the full range of necessary studies, it is impossible to make a final diagnosis. Consequently, the therapy will be ineffective. It is important to take into account this point: the maximum duration of any conservative treatment is two years (this also applies to treatment after surgical interventions to eliminate a particular gynecological pathology). If after two years of therapy pregnancy does not occur, the woman is sent without delay to an ART center. There is also no point in postponing a visit to the center because the patient’s age (over 35 years old) may make it difficult to successfully use such techniques. It must be remembered: in infertile women of this age category, the stage of therapy, which involves the use of techniques aimed at restoring the natural ability to conceive (outpatient stage), should be excluded altogether.

Married couple- this is a single whole from the point of view of reproductive health.

Therefore, if a man consults an andrologist due to the absence of pregnancy in his sexual partner, his reproductive function should be assessed taking into account the reproductive function of the sexual partner.

This must be done for two reasons:

1. There is a high probability of the presence of factors of marital incompatibility in primary infertility.
2. To assess the “infertility formula” of a given couple, which will help to offer optimal treatment options and give a realistic prognosis. It must be remembered that when prescribing treatment for infertility in marriage to a man, the ultimate goal of this treatment is to achieve pregnancy in the sexual partner, and improving seminal fluid parameters is only a step towards achieving this goal.

Taking into account all of the above, the entire diagnostic algorithm and treatment plan for male factor infertility should be constantly linked to the treatment and diagnostic plan of the sexual partner, based on the current “infertility formula”.

The diagnostic algorithm for examining a man should consist of three stages.

The purpose of the first stage examination is to assess the state of fertility of a man and a married couple as a whole.
The purpose of the second stage examination is to prescribe treatment for infertility. At this stage, the reasons for the decrease or absence of fertility are diagnosed and the degree of decrease in the fertility of the sexual partner is assessed. All this allows you to clarify the “formula for an infertile marriage” and draw up a treatment plan.
Third stage examinations are carried out after each course of treatment. At the same time, the state of fertility in the couple is re-evaluated, the “infertility formula” is again clarified, and the treatment program is changed if necessary.

The first stage of the examination includes:

Assessment of medical history, including a history of pregnancies from a given man and previous diseases related to fertility
. physical examination of the patient
. exclusion of inflammatory pathology of the genital organs (examination of a smear from the mucous membrane of the urethra and examination of prostate secretions)
. examination of seminal fluid with analysis of spermogram, physicochemical properties of seminal fluid, markers of accessory sex glands).
. examination of seminal fluid for the presence of antisperm antibodies (MAP test).
This stage of examination should be carried out for all patients who contact a specialist about an infertile marriage. To complete the entire examination complex, 2 visits to the clinic with an interval of 24 hours are sufficient. This survey answers a number of fundamental questions.
. Allows you to assess the degree of fertility of a given man.
. Allows you to create a diagnostic program and outline a treatment plan when identifying any degree of infertility in a man.
. In the absence of signs of infertility, it gives the value “Fertile man” in the formula for an infertile marriage.
A “fertile man” can be considered an individual who shows satisfactory spermogram parameters, in the absence of signs of inflammation in the genitals and low values ​​of antisperm antibodies.
An individual can be considered a “subfertile man” if the following parameters are present:
. spermogram indicators are satisfactory, but there is an inflammatory pathology of the genital organs and/or urogenital infection or a significantly increased level of antisperm antibodies
. at least one spermogram indicator is close to the lower limit of the reference value based on the results of two or more studies
An “infertile man” can be considered an individual whose spermogram has at least one indicator below the reference value based on the results of two or more studies, provided there is no pregnancy in a regular sexual partner with regular sexual activity without contraception for more than 1 year.

Second stage of examination includes a diagnostic search for the causes of reduced fertility and prediction of the likelihood of improved fertility when these causes are eliminated.

At this stage of the examination, the patient undergoes a full range of diagnostic measures - determination of hormonal status, ultrasound of the scrotum and transrectal ultrasound (TRUS), determination of causative agents of urogenital infections, genetic studies, study of sperm function, post-orgasmic urine, necessary general clinical studies, testicular biopsy if indicated.
We prescribe testing of testosterone, TSH and prolactin fractions to all patients with reduced fertility. A study of pituitary hormones is prescribed if there are signs of hypogonadism. It is advisable to determine prolactin if a pituitary tumor is suspected. At high FSH levels, it is advisable to study the level of inhibin and anti-Mullerian hormone.

If there are signs of inflammation in the genital organs and if an excretory form of male infertility is suspected, ultrasound of the scrotum and TRUS are prescribed. An ultrasound examination reveals structural changes and pathological formations in the testicles and their appendages. The absolute indication for TRUS is low-volume azoospermia. This method makes it possible to detect changes in the seminal vesicles with obstruction of the distal sections of the vas deferens or their absence with congenital agenesis of the vas deferens.
Sowing of ejaculate and diagnosis of STIs is carried out in case of pyospermia, when the concentration of leukocytes is more than 1 million/ml, as well as in case of any inflammatory diseases of the genital organs. Infections such as human herpes simplex virus or chlamydia can affect sperm, leading to their immobilization, the formation of antisperm antibodies and miscarriage, as well as congenital abnormalities of the fetus. It should be noted that the diagnosis of sexually transmitted infections should be carried out using the enzyme-linked immunosorbent assay (ELISA) in combination with PCR.

Genetic studies should be undertaken in case of azoospermia and severe pathospermia. In addition to its diagnostic value, genetic studies can provide information about the possibility of transmitting a genetic disease to male offspring, which patients must be informed about.

The study of post-orgasmic urine is carried out during retrograde ejaculation.

Testicular biopsy cannot be performed for diagnostic purposes only; it should only be used while obtaining testicular tissue for cryopreservation for the purpose of its further use in in vitro fertilization cycles.

The result of the second stage of the survey is:

If significant causes of decreased fertility are identified and the prognosis is favorable, treatment is prescribed. The goal of treatment is to achieve pregnancy in a sexual partner or improve the parameters of seminal fluid, which will allow for a “simpler” method of artificial insemination or improve its effectiveness.
. If the prognosis for treatment of reduced fertility is unfavorable, the issue of the optimal program of assisted reproduction methods should be decided.
. If there are no significant reasons for the failure of pregnancy in both partners, an examination for incompatibility is required.

Third stage of examination carried out after each course of infertility treatment.

Control studies are carried out based on the results of the treatment (monitoring the cure of infections, inflammatory diseases, antisperm antibodies, control levels of blood testosterone, prolactin, etc.). A control examination of the seminal fluid is required.
All this allows you to re-evaluate the situation, clarify the “infertility formula” and correct the treatment plan.

If conception does not occur within a year of regular sexual activity without the use of contraception, then the couple is declared infertile. Naturally, many questions immediately arise: who to contact, what examination to undergo for infertility in order to find out the cause and begin treatment. Cm. " " .

The main thing you need to know is that the couple is infertile, and not specifically the woman or the man, so both need to be examined. It is better to contact a special clinic for the treatment of infertility or state human reproduction centers, which are located in large cities.

You need to come to the first appointment together, taking with you all previous tests, ultrasound data, and so on. First, a survey is conducted (collection of data on the health of both spouses, past illnesses, surgical interventions), and then a physical examination of the man and woman.

Taking an anamnesis and examination allows you to correctly determine the examination tactics. Invasive and complex examinations, for example, laparoscopy, hysteroscopy, are usually carried out after other examinations.

There are also examination algorithms for infertility that allow you to find the reason for the lack of pregnancy as quickly as possible and begin treatment.

Examination of a man for infertility.

The evaluation of the man includes an interview focusing on systemic diseases and exposures, pelvic or groin surgery, and a physical examination. Some pathologies can be identified or suspected during examination, for example, varicocele (dilation of the testicular veins) or cryptorchidism (undescended testicles into the scrotum).

Then the man must take a semen analysis (spermogram) and if it is normal, then the examination of the man ends. If there are deviations in the spermogram, even minor ones, it is recommended to take the test again, preferably after two to three months.

If the spermogram is not ideal, you need to consult an andrologist - a doctor who deals with issues of male reproductive health. The andrologist prescribes further examination.

If a high level of FSH and a low or normal level of testosterone are determined, genetic counseling and analysis for microdeletions (loss of certain sections) of the Y chromosome are suggested.

For example, a reduced sperm count and normal semen volume are observed in Kleifelter syndrome, a genetic disease that causes hormonal disorders and infertility.

With low FSH and testosterone, diseases of the pituitary gland (part of the diencephalon) can be suspected, so it is recommended to check prolactin levels and do an MRI. If a pathology is detected, drug therapy is generally prescribed.

If hormone levels are normal and the testicles are normal size, a testicular biopsy is recommended. A testicular biopsy is a tissue collection for further diagnosis of infertility, as well as to obtain sperm for IVF.

If the spermogram result is a low semen volume, then a post-ejaculatory urine test (urinalysis after ejaculation) is recommended. In some diseases, part of the sperm after ejaculation ends up in the bladder.

If ejaculation is impaired and sperm volume is low, ultrasound of the pelvic organs, scrotum and thyroid gland may also be recommended.

Male factor infertility is treated with medication and surgery, for example, for varicocele or obstruction of the vas deferens. Sometimes methods such as washing and thickening the sperm are used. Quitting bad habits often improves sperm quality.

To improve sperm quality, supplements such as zinc, vitamin E, and L-carnitine (a natural substance involved in metabolism) are also prescribed.

Female infertility: examination.

Examination of a woman for infertility begins with a survey: history of menstruation, contraception, previous pregnancies, their outcome (childbirth, abortion, miscarriages), use of medications, occupational exposure, bad habits, surgeries on the reproductive organs and pelvic infections.

Then a physical examination is carried out with an assessment of the physique, calculating the body mass index, as well as examination of the mammary glands and gynecological examination. Based on these data, the doctor prescribes additional examination and laboratory tests.

An approximate examination algorithm for female infertility includes the following studies.

1. Ovulation assessment. Basal body temperature is not considered a reliable indicator of ovulation and is not recommended for assessing ovulation in infertility.

In women with a regular cycle, ovulation usually occurs, but to confirm it, a blood test for progesterone is performed on the 21st day of the cycle (with a 28-day cycle). If the cycle is irregular or more (less than) 28 days, then the analysis is carried out 7 days before the expected menstruation.

Folliculometry (ultrasound of the reproductive organs throughout the cycle) is considered too expensive and time-consuming and is considered inappropriate for routine assessment of ovulation.

In the absence of ovulation, additional examination must be carried out: blood tests for FSH (usually on the third day of the cycle), extradiol, prolactin, TSH (thyroid hormone). Causes of infertility such as hyperprolactinemia (increased levels of prolactin, which suppresses ovulation) and disorders of the thyroid gland can be easily corrected, which allows restoring a woman’s fertility.

Sometimes ovulation disorders occur due to low body weight and excessive physical activity or, conversely, excess weight. Such women are advised to achieve normal body weight and change their lifestyle in order to achieve restoration of ovulatory cycles. Ovulation induction medications may also be used.

If, based on the test results, ovulatory insufficiency is suspected, then additionally the following can be performed: a Clomid test (measuring FSH before and after stimulation of ovulation), counting antral follicles (2-8 mm in size) using ultrasound, and analyzing the level of anti-Mullerian hormone. Women with ovulatory insufficiency can only become pregnant through egg donation and in vitro fertilization.

2. Assessing the patency of the tubes and the condition of the uterus.

An assessment of the uterus and tubes is carried out after confirming the fact of ovulation using: hysterosalpingography, hysteroscopy, laparoscopy. Sometimes, before choosing a method for assessing the fallopian tubes, a chlamydia antibody test is performed - a simple test to predict the presence of tubal disease.

Hysterosalpingography is a minimally invasive procedure to screen for structural abnormalities of the uterus and tubal patency. If there are no obvious factors for blocking the tubes, then hysterosalpingography is used - an x-ray examination in which a contrast agent is injected into the uterus and x-rays are taken.

For women with risk factors for tubal blockage (endometriosis, ectopic pregnancy, pelvic infections), hysteroscopy or laparoscopy is recommended, as these tests are more sensitive and allow simultaneous treatment of some pathologies.

Hysteroscopy- a minimally invasive operation in which a special device is inserted into the uterine cavity and an examination is performed, and, if necessary, the removal of adhesions, removal of fibroids or polyps, and dissection of the uterine septum. If pathology, chronic endometritis or neoplasia is suspected, an endometrial biopsy is performed (taking a piece of the inner lining of the uterus for analysis).

Laparoscopy- a surgical method in which the outer part of the uterus and fallopian tubes are examined, at the same time treatment can be carried out, namely, the elimination of foci of endometriosis, excision of adhesions, reconstruction (plasty) of the fallopian tubes, and so on.

Laparoscopy is an invasive procedure and can also lead to the formation of adhesions. Before prescribing an invasive examination method, the doctor must weigh the pros and cons.

3. Assessment of cervical factor of infertility.

To assess the cervical factor of infertility, a postcoital test is usually used, which allows you to determine how sperm behave in the mucus of the cervix. If the mucus is very viscous, it is difficult for sperm to penetrate through it into the cervix. If the environment is too acidic, then sperm lose their activity.

The postcoital test is carried out approximately on the 14th day of the menstrual cycle (maybe later or earlier depending on the length of the cycle) and consists of the fact that 8-12 hours after sexual intercourse without using contraception, the doctor takes the woman’s cervical mucus for analysis with a special pipette. Then the specialist evaluates the consistency, pH of the mucus and the number of sperm in it.

Cervical factor is rarely the only cause of infertility. In addition, the assessment of cervical mucus is not very accurate. It is now believed that the postcoital test has poor predictive value in diagnosing infertility.

Tests such as the TORCH infection test and histological examination of the endometrium do not help in the treatment of infertility. Tests for antisperm bodies are also of little value in diagnosing infertility.

If a woman has patent tubes, no ovulation disorders, no diseases or abnormalities of the uterus, and a man has a good spermogram, then they usually talk about unexplained infertility. Such a couple may be recommended ovulation induction with intrauterine insemination (sperm are injected directly into the uterus on the desired day of the cycle) for 3-4 cycles.

If pregnancy still does not occur, the use of in vitro fertilization is considered. If conservative treatment methods do not provide an effect for ovulation disorders, the issue of using assisted reproductive technologies is also addressed.

It is known that in case of infertility, time works against us, that is, age is one of the main factors in deteriorating fertility. Therefore, if a married couple regularly has sexual intercourse, does not use protection, and pregnancy does not occur within one year, then you need to contact a specialist.

An earlier examination for infertility should be done if a woman is over 35 years old, has amenorrhea (lack of ovulation) or oligomenorrhea (infrequent menstruation), or has factors of damage to the fallopian tubes (ectopic pregnancy, infections and pelvic surgery).