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It is estimated that one in six couples all over the world experience infertility problems at some point in their lives. This is almost the same in women and men. Treatment options for both women and men vary according to the type of infertility diagnosed. A couple in their 20s who have regular reproductive ability with normal reproductive ability have a chance of having a quarter of pregnancy every month. This means that about nine out of ten couples trying to have a baby will encounter pregnancy within a year. However, one in ten couples will not be able to conceive and will require treatment. Doctors often describe infertility as a condition of not being able to conceive after at least one year of trial. This shows us that newly married couples need not worry if pregnancy does not occur within a few months. 93% of these couples can become pregnant at the end of the second year
Alcohol, smoking, external factors, especially in men today is affected by sperm rates and infertility cases are becoming important. A woman's chance of getting pregnant decreases with her advanced age, especially after 39 years of age. The chances of getting pregnant after the age of 40 decrease by 60% and result in 50% miscarriage in the pregnancies that occur. Besides all these
• OVER WEIGHT
• OVER EXERCISE
• CANCER TREATMENT RAYS
• CANCER TREATMENT MEDICINES
• AGRICULTURAL DRUGS
• INSECT POISONS
• LEAD AND HEAVY METALS
They are great risk factors for infertility. However, the newly developed micro injection has revolutionized male infertility. It allows pregnancy even if there is no sperm in the semen. Infertility issues will be discussed in the following major.
Today's medical approach accepts infertility research in couples who do not develop pregnancy without protection for a year. A general gynecological examination, ultrasound and gynecological history to be performed in women; In men, a general urological examination is the first step.
The researches to be done are as follows:
Evaluation of female reproductive organs
Cervix (Cervix): When evaluating the cervix, the semi-fluid fluid (mucus) is permeable to the male sperm and is examined by postcoital test. However, this method has lost its importance today.
UTERUS: There are four methods used to examine the uterus.
Histerosalfingograf of: We can call this examination a womb film. It is based on the withdrawal of the uterus after giving the woman a liquid substance seen on the X-ray from the cervix within 5-7 days after the end of menstruation. This method is used to determine whether the inside of the uterus is normal and whether the tubes are open.
Hysteroscopy: Endoscopic under general anesthesia (with a thin tube) is entered through the cervix to examine the intrauterine wall directly. The disadvantages are that it is painful and expensive method.
Histerosonograf of: In this method, a special fluid is given to the uterus and examined by ultrasound. Today, this method is becoming more and more important in terms of both being less painful and cheaper.
Falloskop of: In this method, endoscopic examination of the tubes with a special optic tube and the uterus is in question.
TUBES (Fallopian tubes): The most critical step in the diagnosis of infertility is the examination of the tubes. In this examination, whether the tubes are permeable, the adhesion and the function of the tubes are examined. The most common method is to examine the hysterosalfingography (HSG) tubes mentioned earlier. It is checked whether the fluid given to the uterus from the cervix is poured into the uterus from the tubes. Thus, it is understood whether the tubes are open to allow the passage of the egg. Laparoscopy is another tube examination method. In this method, a pathology in the tubes can be seen directly with the eyes of the physician. In this method, under general anesthesia, a 1 cm hole is opened from the navel and a thin optical tube is inserted and the tubes are directly observed from a camera.
Hormonal status of woman
Female reproduction is directly and indirectly affected by many hormone secretions in the body. These hormones carry orders from the brain, uterus and ovaries, about ovulation and menstruation. The increase or decrease in these hormones prevents female ovulation and reproduction. They can be diagnosed simply by blood level measurements. The most important of these hormones are the following.
FSH, LH: These two hormones are secreted from the brain, allowing egg maturation and excretion.
OSTROGEN, PROGESTERONE: These two hormones are released from the ovaries and allow the uterine wall to mature.
Evaluation of ovulation
The regular ovulation and fertilization of a mature egg in women during each period can be determined as follows.
Basal body temperature measurement: In this method, the woman's body temperature is measured every morning from the first day of menstruation until the first day of the other menstrual period without getting out of bed. In the middle of the menstrual period, the temperature increases by 0.3-0.5 degrees.
Endometrial biopsy: by this method, a small sample is taken from the intrauterine membrane to check whether the membrane is mature enough for the embryo to settle.
Urine tests: It is based on measuring the levels of certain hormones that need to increase the time of ovulation in the urine.
Causes of Infertility in Women
Infertility studies have not been able to find the cause of approximately 15%. However, in general, the most important reasons of female infertility are ovulation disorder, endometriosis, damaged and occluded tubes. Ovulation disorder is the most common cause of women, but is usually based on hormone deficiency.
Endometriosis is the presence of the intrauterine membrane in other regions outside the uterus. These regions are the most common tubes and ovaries. Bleeding, inflammation and adhesion occur in all these areas with menstrual bleeding. This especially affects the tubes and does not allow the egg to reach the uterus and causes infertility.
The most important symptoms of endometriosis are pain before and after menstruation, pain during and after intercourse, irregular severe periods and infertility. When infertility cases were examined, 25% endometriosis was detected. The most common causes of damaged and occluded tubes are infections, endometriosis, previous intra-abdominal surgery and gay-transmitted diseases.
Causes of Infertility in Men
The first step to determine the causes of infertility in men begins with a general urological examination. A couple in their 20s who have regular sex with normal reproductive ability have a one-quarter pregnancy chance each month. This means that about nine out of ten couples trying to have a baby will experience pregnancy within a year. However, one in ten couples will not be able to achieve pregnancy and will require treatment. Doctors usually describe infertility after at least one year's trial.
Estimates show that around 40 per cent of all infertility cases are men. This is often related to male partnerinsperm quality and number. Research by a family doctor or specialist clinic will reveal a clear diagnosis of male infertility in most cases (although no test can predict predetermined total reproductive ability). Since the sperm characteristics required for “normal” fertilization (fertilization) are well known, abnormal results from a sperm test indicate a problem in men. These tests, carried out on a semen sample, reveal abnormalities in sperm count, movement and shape.
In recent years, specialized infertility clinics have also used in vitro fertilization (in vitro fertilization) as a diagnostic test. Often, inability to fertilize healthy egg cells under laboratory conditions is due to abnormal sperm characteristics. Therefore, unsuccessful IVF (in vitro fertilization) may provide more definitive evidence of kon male factor ”infertility.
The abnormalities that can be detected by the tests are as follows: Low sperm count, normally at least 20 million sperm should be found in a milliliter of semen (sperm fluid). Those below this number may lead to impaired fertility. Lack of sperm production due to insufficiency in the testicles or failure of sperm to come out due to a blockage. Poor sperm motility; sperm cannot swim through the cervix to meet the eggs in the celiac tube. Bad form (known as morphology); a sperm cannot pass through the outer layer of the egg and fertilization does not occur.
All these requirements have their own scientific names; most known is oligospermia (very few sperm) and azoospermia (no sperm) .However, sperm abnormalities are not the only cause of infertility in men. Difficulties in sexual intercourse may be - ejaculation disorders or sexlessness. Especially nowadays, vasectomy (ligation of sperm channels for birth control) increases the number of neutered men. It is only possible to some extent that men who have been neutered by vasectomy can have children again.
There is no simple solution to infertility in men. Treatment is based on results from research and depends on how serious it is to achieve a buoyant result. Depending on the severity of the disease, doctors can try a range of treatments ranging from simple to complex. However, it would be appropriate to say that the most stubborn causes of male infertility even eventually responded to medical treatment. Up to a few years ago, even the most serious cases where the only solution was donor fertilization or donation can be successfully treated with new sperm microinjection techniques.
Since the range of options is wide and some treatments are not available everywhere, the decisions that patients and doctors have to make are important. If treatment is given as necessary, the options available are only drug therapy, in vitro fertilization (IVF), sex cell transfer (GIFT), superovulation and artificial insemination (IUI) and intracytoplasmic sperm injection technique (ICSI).
There is no simple medication that increases sperm concentrations or corrects the shape of each sperm cell. Some medications have been used successfully to assist in cases of impotence, especially when impotence is associated with male sex hormone testosterone deficiency.
In addition, supportive hormones may be given to stimulate the testes in cases where the male partner has a condition known as hypogonadotropic hypogonadism (the hypothalamus or the hypophaletic glands in the brain cannot produce sperm due to insufficient or no hormonal stimulation in the testes). These “reproductive” hormones are known as gonadotropins and can be given to both men and women to stimulate the development of eggs in females and sperm cells in men.
In Vitro Fertilization
IVF is the original “test-tube” technique and is an assisted reproductive technique that finds application in the world. In simple terms, IVF takes one or more eggs from the ovary, fertilizes them in the laboratory with male sperm and transfers the selected embryos to the uterus for implantation and pregnancy. Although IVF has been developed for couples with tube obstruction in women, the main causes of infertility, however, have been found to be useful in patients with problems with a lower sperm count or poor morphology. Modern sperm preparation techniques (washing and culture) can improve the viability of sperm samples and increase the probability of fertilization.
Recently developed techniques such as ICSI provide satisfactory fertilization and pregnancy rates below average sperm concentrations, which increases the chance of treatment with sperm from the male partner.
The best results are obtained by synchronizing ovulation with fertilization medications at the same time. However, it is important that doctors who begin this drug treatment ensure that no more eggs develop in the ovary. Too many eggs increase the risk of multiple pregnancies. All artificial insemination procedures are intended to form a single mature egg. This is much less than the number of eggs obtained for IVF, but minimizes the risk of multiple pregnancy.
At the time scheduled for ovulation, a fresh sperm fluid sample (produced on the same day) is prepared and delivered to the uterus of the female partner via a thin catheter. This procedure is called intrauterine fertilization or IUI. Since fertilization takes place in a natural environment (ie in the uterus), at least one channel of the female partner must be open.
Success rates from IUI following ovarian stimulation are between 10 and 15% per menstrual period, but may reach 50% after several attempts within one year. It is important that the male partner's sperm count is in a wide ”normal sperm range and that the female's channels are healthy.
Step by Step IUI
1. Drug treatment to stimulate the maturation of a single egg
• Gonadotropins that will generally stimulate the growth of follicles and cause ovulation.
2. Measuring the growth of follicles, separation of drug doses and monitoring of treatment to prevent serious side effects.
• Transvaginal ultrasound scan (two or three times in one treatment period)
• Sometimes a blood sample is taken by hormone therapy.
3. The sperm sample obtained on the morning of ovulation is prepared and then applied on the same day.
4. Pregnancy test, observation.
Fertilization by microinjection has been regarded as a revolution over the past few years and has offered promising treatments, even in the most difficult situations of male infertility. New microinjection techniques, such as ICSI, are now a real treatment solution when doctors cannot offer any advice other than adoption or donor fertilization. ICSI uses the most powerful microscopes and micromanipulators. For example, embryologists holding a single human egg at the end of a thin tube can insert sperm into the egg seven or more times with the help of a fine needle. can be transferred.
In a normal fertilization, a single ejaculation of the semen can have more than 200 million live sperm, but only a few hundred of these sperm reach the released egg cell in the uterine tube and fertilize. It was thought that it was impossible until some time before the treatment of men with very low total sperm counts was possible, but now ICSI makes fertilization possible even with only one sperm cell.
The results from ICSI have been remarkable so far and have achieved significant success even in very low numbers of males with poor quality. In Brussels, where this technique was first applied, close to 70% of the eggs injected with this method were fertilized with sperm cells obtained from specimens, although it did not seem very difficult to find live sperm. When ICSI fertilized eggs were transferred to a female partner, pregnancy and birth rates were as high as in routine IVF.
These techniques can be used not only to produce poor sperm, but also to treat infertility in men who cannot produce any sperm due to other testicular disorders (or vasectomy). (extraction of sperm from the sperm duct) and extraction of sperm from the testis (TESE) - are used regularly. The sperms are then used by the ICSI to fertilize the eggs.
Injection of sperm cells into oocytes
|Verification of fertilization|
Again, encouraging results were obtained indicating that men who could not provide ejaculation for various reasons or who could not produce sperm in their testis could now supply sperm to fertilize their partner's eggs.
Despite the remarkable success of ICSI, most centers agree that the technique remains relatively experimental. There are doubts that some hereditary disorders associated with male factor infertility (such as cystic fibrosis) can be transmitted to any male child. Because of this reason, most ICSI centers insist on extensive counseling before treatment, some genetic screening and follow-up before and after conception. For this reason, vicious pairs accepted in ICSI programs are carefully chosen. Most of these men have severe sperm defects and usually have failed IVF records. Of course, when obtaining a sperm sample from the male partner, the female partner must undergo routine procedures for stimulation of the ovary and egg collection.
1. Drug treatment that stimulates the maturation of many eggs
• GnRH agonists to stop all other hormone activities (usually two weeks before injections / nasal spraying and then an additional 10-14 days depending on the clinical response).
• Gonadotropins, which stimulate the growth of follicles and ovulate.
2. To measure the growth of follicles, to determine drug doses to the individual and to monitor the treatment to prevent serious side effects.
• With transvaginal ultrasound scanning (two or three times in one treatment period)
• Sometimes by measuring the hormones in a blood sample.
3. Egg collection, usually lasting 10 to 20 minutes under local anesthesia
• Transvaginal ultrasound guidance.
• Entered through the vagina 32-36 hours after the last hormone injection.
4. Sperm sample provided on the same day as egg collection. This sample can be obtained by natural way or by aspiration from the epididymis (MESA) or testis extraction (TESE).
• A single sperm cell is injected into a single egg cell.
• The eggs are examined the next day under a microscope to see if fertilization has occurred.
6. Embryo transfer (usually two or three days after fertilization)
• Transfer of up to three embryos to the uterus
• Excess embryos are stored frozen and then transferred if necessary.
7. Pregnancy test / Observation
The vital point in the success of ICSI is the preparation and selection of sperm cells by washing and grading. These sperm preparation methods allow several viable cells to be obtained in the sperm sample which cannot be used otherwise.
In most countries, counseling should be provided for all couples undergoing assisted pregnancy. For most of those who come to this stage, the frustration of childlessness has created serious emotional tensions, so guidance and assistance is often necessary to overcome this difficult period.
In addition, assisted assisted pregnancy as a medical treatment has its own needs which make counseling even more important. The passage of a period of treatment for a period is not always as easy as the statistics show, and success cannot be guaranteed. Even in couples where pregnancy occurs, serious frustrations may be encountered on the loss of this pregnancy.
Some couples also found that dilemmas in assisted reproductive techniques, such as what to do with frozen embryos that were kept substitutes, how to face treatment failure, could be solved more easily after consultation with a specialist counselor.
A Real Chance of Success?
It is easy to talk about failure, as about four out of five couples who have been treated with one-term assisted reproductive techniques have no children. But the reality is that the overall success rates of assisted reproductive techniques are as good as and even better in nature. Moreover, since the chances of success are the same for each treatment period, couples who register for assisted reproductive treatment see a significant decrease in their number after several periods. However, these are general rates, and all studies have shown that the probability of conception is poor if the female partner is 40 or older or the male partner has abnormal sperm. The results obtained from fertilization experiments by giving sperm into the uterus after ovarian stimulation show approximately 15% pregnancy and 10% baby acquisition rate. However, the latest success of ICSI in the treatment of male infertility means that men with sperm disorders are now more likely to be paternity of their own children. Pregnancies in the rate of 25% are recorded with a slightly lower rate of pregnancy ending with a healthy birth.