What is Infertility?
Infertility is defined as the inability to conceive within 1 year despite the regular and unprotected intercourse of the couple. However, if pregnancy does not occur despite regular and unprotected intercourse in women over the age of 35, the necessary examinations and treatments can be started earlier.
Infertility can occur in 10 to 20 out of every 100 couples in reproductive diameter. The incidence increases with increasing age. Infertility is a health problem related to the reproductive system. As it may depend on a single reason; It can also happen with the combination of several factors. Infertility is a disease of the reproductive system that impairs the body's ability to perform its reproductive function.
Although having a child is perceived as a simple and natural function, this process is actually quite complex. In order for pregnancy to occur, all of the following factors must be met:
- Healthy egg production by the woman,
- Quality sperm production by the male,
- Healthy fallopian tubes that allow the sperm to reach the egg,
- Sperm fertilizes the egg
- The ability of the fertilized egg to hold in the uterus,
- Adequate embryo quality.
What is Infertility in Women?
Female infertility, male infertility, or a combination of both affects millions of people worldwide. Approximately 10-15% of couples are unable to conceive, despite having regular unprotected sex for a year.
Overall, one-third of infertility is due to men and one-third to women, with other factors unknown or a combination of both.
Although the diagnosis of infertility in women is difficult, many treatments are possible. Treatment is often not necessary. More than half of infertile couples can spontaneously have children within 24 months.
Infertility Symptoms in Women?
The main symptom of infertility is the inability to get pregnant. A menstrual cycle that occurs at intervals of more than 35 days or less than 21 days can be a sign of infertility. Other than these, there are no signs or symptoms.
If you're in your 30s or younger, most obstetricians will recommend that you try to get pregnant for at least a year before testing or treatment.
If you're between the ages of 35 and 40, it's a good idea to talk to your doctor after trying to get pregnant for six months.
If you are older than 40 years of age or have irregular, painful periods, have pelvic inflammatory disease (PID), have been treated for cancer or endometriosis before, you should seek treatment and testing immediately.
Causes of Infertility in Women
In order for you to become pregnant, you must meet the following factors:
You must enter the ovulation period. In order for you to get pregnant, you must have regular menstrual periods, known as the ovulation period, in which the egg is released. Your doctor can help with your menstrual cycle and let you know if you are ovulating.
Your partner needs health sperm. For most couples, this is not a problem if the men have not had an illness or surgery. Your doctor can do simple tests about your partner's sperm health.
You must have regular sexual intercourse. You should have regular sexual intercourse between your periods. Your doctor can help you determine your most fertile period between your cycles.
For pregnancy to occur, the entire complex reproductive process of man, from the release of the mature egg to the implantation of the fertilized egg and the fertilization of the growing egg in the uterus, must develop correctly. In the case of female infertility, some of these formations may be interrupted. Male infertility can affect one or more of these factors and prevent pregnancy.
Female Infertility Test
Since the most common cause of infertility problem in women is ovulation disorders, it is first checked whether the normal ovulation process takes place. The absence of the ovaries, the irregularity of the hormones required for ovulation and secreted from the brain, or various ovarian diseases constitute approximately 25% of the causes of infertility in women. In women, the hormone level control on the first day of the menstrual cycle, the endometrial biopsy sample taken from the inner surface of the uterus a few days before the start of menstruation, and the development of the ovary by ultrasonography are examined to obtain information about the healthy ovulation process.
It can be said that another common cause of infertility is the problem of obstruction in the tubes. Partial or complete blockage of the tubes causes infertility by preventing the egg from reaching the uterus. In order to detect this situation in women with suspected infertility, special drugs are sent to the tubes through the uterus, and then it is evaluated whether there is any obstruction problem in the tubes, thanks to the x-ray taken. In addition to this method, the fallopian tubes can be viewed in detail with a closed surgical procedure called laparoscopy, which allows viewing the inside of the abdomen with a camera.
About 5% of infertility problems in women are caused by structural defects, adhesions, fibroids or polyps in the uterus. Fibroids that cause miscarriage or infertility by preventing the embryo from holding in the uterus can be easily identified by gynecological examination and ultrasonography methods. It is known that structural problems such as the uterine veil and the presence of double uterus that occur in the uterus while still in the mother's womb cause infertility and can be diagnosed with an imaging method called Hysterosalpingography. A fiber optic light imaging device called a hysteroscope allows you to easily diagnose polyps and fibroids as well as structural disorders by entering the uterus.
What Causes Infertility in Men?
One-third of infertility causes are male, one-third female, and the remaining one-third are both male and female. Therefore, almost 50% – 60% male factors play a role.
The male reproductive system actually starts from the hypothalamus region in the lower part of the brain; it continues in the head with the pituitary gland in the lower part of the brain and ends in the testicles. The causes of infertility are evaluated by dividing these regions into sections according to the anatomical localization of the reproductive system:
- Decreased sperm production and sperm motility
- abnormal sperm function
- Absence of any sperm cells in the semen (Azospermia)
- Varicocele (enlargement of the veins leading to the testicles)
- channel blockages
- Hormonal disorders and genetic diseases
- Sperm shape (morphology) disorder
- Congenital anatomical problems (undescended testis, etc.)
- immune system problems
- Sexual dysfunctions (such as erectile dysfunction and premature ejaculation)
- Some febrile diseases in childhood and adolescence
- Previous cancer treatment
- drug use
- Excessive smoking, alcohol and caffeine use
Symptoms of Infertility in Men
There are no specific symptoms of infertility. Inability to have a child within 1 or 2 years despite regular unprotected sexual intercourse is considered a sign of infertility. However, some additional symptoms may occur depending on the underlying disease that may cause male infertility. If these symptoms are not directly in the testicles, it is very unlikely that the patient will associate them with infertility. However, pain in the testicles, swelling; Findings such as penile discharge may also be a warning for the patient as they may be a sign of infertility.
Male Infertility Test
The first examination to be performed on a man with suspected infertility is the sperm count test, which is usually called a spermiogram. This examination is performed by examining a semen sample taken from a man who has not had any sexual activity such as intercourse and masturbation for 3 days. The sperm count, motility and shape in the sample taken are evaluated in detail and compared with the criteria determined by the World Health Organization.
Antisperm Antibody Test is performed to detect the presence of antibodies against sperm in the semen sample or blood taken.
Spermiogram alone is not a sufficient test to obtain definitive results. Therefore, although the spermiogram test gives normal results, other applications are required for the suspicion of male infertility. However, since spermiogram is considered as an easy and useful infertility test, it is preferred to be applied.
While investigating the causes of male infertility, structural dysfunctions in the reproductive organs should also be evaluated. With the Ultrasonography test to be performed, information about the structure and size of the testicles in men, the enlargement problems called Varicocele in the testicular vessels and the stenosis in the sperm ducts are obtained.
If all these test results are in normal values, the infertility test of the female partner is started.
Infertility Treatment Methods
IVF (in-vitro fertilization) is the most well-known fertility treatment. However, there are different treatment methods to be offered to couples who have difficulties in conceiving naturally.
The decision of which method to recommend is made after the evaluation of the woman's fallopian tubes and egg quality and the sperm of the man, accompanied by information such as the age of the partners, whether there is a previous pregnancy, how long they have been trying to get pregnant.
Pregnancy (Fertility) Medicines
If the pregnancy (fertility) problem is due to the lack of regular ovulation, egg development can be achieved by fertility drugs that can be given in the form of tablets or injections.
While the treatment given in the form of medicine enables the natural fertility mechanisms in your body to work more effectively, the treatment given in the form of injection directly stimulates the ovaries and realizes ovulation.
Possible side effects encountered during drug therapy may manifest themselves as hot flushes, breast tenderness, nausea and emotional fluctuations, and allergic reactions, although rare, can be seen in injection therapy.
After pregnancy (fertility) treatment aimed at increasing the number of eggs, the risk of multiple pregnancy may increase, and although rare, the ovaries may be overstimulated, called 'ovarian hyperstimulation'.
Pregnancy treatment under close supervision is very important in terms of minimizing possible side effects. These drugs, which regulate and increase ovulation, are also frequently used in other pregnancy treatments.
Vaccination Treatment (Insemination)
Vaccination treatment is applied by placing your partner's sperm into the uterus with a simple method during the ovulation period when fertility is at its highest. This method is recommended in cases where the tubes are healthy and the cause of unexplained infertility problems.
It is also used effectively in couples where the sperm count or motility decreases before it reaches very low levels, the passage of sperm through the cervix is prevented or sexual intercourse cannot take place due to reasons such as vaginismus, premature ejaculation, erectile dysfunction.
The most mobile sperms selected from the sperm sample given by your spouse and the most likely to fertilize the egg are passed through the cervix with the help of a plastic tube and released into the uterus.
Vaccination treatment is not a painful method and is generally applied with drugs that support pregnancy formation. The success rate of the treatment is approximately 15%, and it varies according to the age of the woman, the sperm values of the man and the health status of the tubes.
In Vitro Fertilization (IVF) Treatment
Regularly menstruating women produce a single egg each month. In IVF treatment, it is aimed to increase this number with externally given hormone drugs. Although each treatment protocol differs, basically two parallel hormone treatments are applied that provide egg development and prevent early ovulation.
Determining the number of embryos to be transferred may directly affect the chance of pregnancy and the risk of multiple pregnancy. Once the embryo quality has been determined, the number of embryos will be discussed in detail with the couples prior to transfer. Embryo transfer does not require anesthesia except in very rare cases.
- Surgical Methods in Infertility Treatment
- Some surgical interventions before IVF treatment increase the chance of pregnancy.
- Treatment of endometriosis disease
- Removal of fibroids or polyps that disorganize the lining of the uterus
- Opening of intrauterine adhesions
- Removal of blocked and enlarged fallopian tubes with fluid accumulation
- Surgical treatments that can be done in women with polycystic ovary disease and suppressed ovulation
- Surgical removal of sperm from the testis (TESE, TESA) or epididymis (MESA, PESE) in men without sperm
Diseases or problems related to the uterus, ovaries and tubes can be directly observed and surgical intervention can be performed if necessary, with instruments inserted through holes of 3-5 mm in the lower abdomen with laparoscopy.
The situations in which laparoscopy is applied are as follows:
- Intra-abdominal adhesions
- Opening the tubes
- Removal of damaged tubes
- Myoma surgery
- Chocolate cyst surgery
A hysterectopia is a tube-shaped device with a camera at the end. It is placed inside the vagina and extends from the cervix to the uterus and allows the physician to detect intrauterine problems. If your doctor deems it necessary, they may take a small tissue sample.
With the hysteroscope device, the inside of the uterus can be viewed, and the diagnosis of problems such as uterine fibroids, polyps and intrauterine curtains can be diagnosed and treated with simultaneous intervention. Situations where hysteroscopy examination is performed include:
How is Hysterectomy Done?
In hysteroscopic observation, a small telescopic camera system is sent through the cervix into the uterus. No incision is required for this surgery. In the hysterectomy procedure, sterile fluid is injected into the uterus through this telescope, and the inner wall of the uterus is reviewed, problems such as fibroids, polyps, adhesions, septum can be detected, and biopsy can be taken if necessary.
It is also possible to treat the problems detected after this diagnostic procedure with surgical hysteroscopy in the same session. If necessary, your doctor can perform the procedure under general anesthesia, local anesthesia or sedation (calming). Postoperative discharge is usually provided, except for large fibroid removal surgeries.
Mild vaginal bleeding and menstrual-like abdominal pain may occur after hysteroscopy. Your doctor may recommend some medications for pain. The bleeding will subside within a few days. As long as it doesn't get heavy and turn into an uncomfortable smelly discharge, this bleeding is not a problem.
Myomectomy – Myoma Surgery
Myomectomy is the removal of uterine fibroids that can prevent pregnancy. It is performed by open or closed surgery method. Before IVF treatment, a series of examinations and tests are performed to prevent embryo implantation and pregnancy. These examinations also determine whether the expectant mother has fibroids and polyps. If surgery is decided in the treatment of uterine fibroids, general anesthesia is applied to the patients, and the uterine fibroids are removed one by one. Although these operations are usually performed by the open method from the abdomen, they can be performed using the laparoscopic or hysteroscopic method.
Increasing the number of uterine fibroids can make treatment more difficult. In some cases, patients may need to be reoperated. Not all fibroids pose great risks to pregnancy, so a treatment is planned according to the doctor's opinion.
During pregnancy, fibroids can settle inside and on the outer wall of the uterus. When these fibroids grow or multiply, they cause the inner wall of the uterus to become blocked. They can negatively affect the development of the baby as well as cause premature birth.
In the intervention of fibroids, the decision of surgery is made according to the complaints of the person. Myoma surgery (myomectomy) is considered necessary in one out of every 10 women. In other patients, fibroids are kept under control with regular follow-up.
Robotic surgery is performing laparoscopic (closed) surgeries under a 3D image with the help of a robot named da Vinci. When it comes to robotic surgery, there is a misconception that the operation is performed by a robot. However, it is not the robot that performs the surgery, but the surgeon himself who controls the robot's arms.
The following procedures can be performed with robotic surgery and the chance of pregnancy can be increased.
- Myoma surgery
- tube surgery
- Chocolate cyst surgery
What is the Vaccination Method?
If the number of sperm in the semen is over 10 million and there is no morphologically severe sperm defect, the method of grafting can be applied. The sperm taken from the man is washed and dead cells and toxic wastes are removed from the environment. The rate of motile, quality sperm is increased and this sperm is introduced through the woman's cervix through a special catheter. Sperms reach the egg by moving themselves.
In order to apply this method;
- Having morphologically normal, motile sperm
- Absence of any obstruction factor in the woman
- It is necessary for the woman to have normal ovulation and egg quality.
- It is a method recommended only for cases with borderline problems. It is the easiest method, but the probability of success is low. The chance of pregnancy success varies between 10-15%.