Conservative treatment male infertility. In hypogonadotropic hypogonadism, preparations of human chorionic and menopausal gonadotropin (pregnyl, profazi, pergonal) are used to compensate for the lack of LH and FSH in the body. To increase the production of gonadotropins, estrogen antagonists clomiphene and tamoxifen are used, which block the action of the latter at the level of the pituitary gland. With congenital adrenal hyperplasia, glucocorticoid therapy may be necessary, with testosterone deficiency, exogenous administration of this hormone. In this case, one should be aware of the possibility of further inhibition of testosterone production in the testicles. If the patient's tests indicate elevated levels of prolactin (hyperprolactinemia), dopamine antagonists (bromocriptine or cabergoline) should be prescribed, considering the possibility of surgical treatment of pituitary adenoma.
With a pronounced negative effect of antisperm antibodies, a course administration of corticosteroids may be useful. With retrograde ejaculation, not associated with surgical interventions on the bladder neck, the antidepressant imipramine or cc-agonists are used. In patients who have undergone such operations, the introduction of collagen into the bladder neck is effective.
Surgical treatment is also common for male infertility.
With varicocele, which negatively affects the quality of sperm due to a local increase in temperature, open operations are performed by retroperitoneal and transperitoneal access, as well as endoscopic interventions.
In case of violation of the patency of the seminal ducts, a vasovaso- or vasoepididymoanastomosis is applied with the imposition of 2-row sutures. These operations cannot be performed simultaneously with the elimination of varicocele due to the high risk of testicular atrophy.
With obstruction of the ejaculatory duct, transurethral resection of its terminal part is indicated.
Sperm collection methods. Sperm can be obtained from the epididymis by puncture or open method using microsurgical techniques. For the convenience of re-sampling, a spermatocele is formed from natural or artificial materials.
Artificial insemination. The simplest methods of artificial insemination involve the introduction of sperm into the cervix or into the uterine cavity with or without pre-treatment (washing of spermatozoa, dilution with isotonic sodium chloride solution, liquefaction with chymotrypsin) or without it. If 3-6 procedures are unsuccessful, in vitro fertilization is indicated. To do this, about 12 eggs are taken from a woman and placed in a nutrient medium. After 3-6 hours, spermatozoa are added to the medium at the rate of approximately 100 thousand per 1 egg. After 48 hours, two to four 3-8-cell embryos are implanted, the rest are frozen for further use. Spermatozoa, fertilized eggs or embryos at an early stage of development are delivered to the fallopian tubes in an open way or during a laparoscopic operation. With the ineffectiveness of these methods, extremely unfavorable spermatogram parameters (the number of spermatozoa is less than 2 × 106 / ml; the proportion of cells with normal morphology is less than 4%), the most expensive method of intracytoplasmic sperm injection is used, in which one male gamete is introduced into the egg treated with hyaluronidase using a micropipette . After 48 hours of incubation, the embryos are implanted as described above. In severe forms of male infertility, the pregnancy rate after intracytoplasmic sperm injection reaches 10%. If all of the above approaches fail, artificial insemination using donor sperm is indicated. Many authors believe that it is possible to resort to it at earlier stages of treatment, since more complex methods are characterized by low cost-effectiveness, and the ethical problems associated with them are ambiguously assessed by society.
male infertility. The inability of a man's body to produce or deliver enough healthy sperm to a woman's body to conceive. In rare cases, the cause of the disease is a chromosomal pathology. Risk factors include smoking and alcohol abuse. Age doesn't matter.
In about one in three couples who have difficulty conceiving a child, the male suffers from infertility. A man's ability to reproduce depends in part on producing enough healthy sperm that one of them has a high probability of fertilizing an egg; and partly from the ability to deliver sperm to the vagina during intercourse. If problems occur at any of these stages, a man can become infertile.
In contrast to female infertility, the causes of which can be relatively easily identified, the causes of male infertility are less easily identified. In the course of a medical examination, the cause of infertility can be found out only in 1 out of 3 applied patients.
Problems with sperm production. The production of non-viable, slow-moving spermatozoa or an insufficient number of healthy spermatozoa can have various causes. Normally, testicular temperature is about 1°C lower than body temperature. Any factor that raises the temperature of the testicles can lead to a decrease in the number of sperm produced.
Some lifestyle habits, such as smoking, drinking alcohol, using certain medications or mild drugs and even wearing tight clothing can reduce the quality and quantity of sperm produced. The function of sperm production can be impaired as a result of some chronic diseases. Diseases that affect the urethra, such as hypospadias, or the scrotum, such as varicocele, can also reduce a man's fertility. In addition, male infertility can develop as a result of medical procedures such as surgery, chemotherapy, or radiotherapy for serious conditions such as testicular cancer.
A decrease in sperm production can also occur with hormonal disorders or chromosomal defects. Insufficient production of the male sex hormone testosterone by the testicles can lead to a decrease in the number of healthy sperm in the semen. Since the secretion of testosterone is under the control of the pituitary gland, diseases of this organ, such as its tumor, can also reduce the reproductive functions of a man. In rare cases, low testosterone levels can be due to a chromosomal abnormality such as Klinefelter's syndrome. The most common cause of low sperm count is idiopathic oligospermia, in which the sperm count in semen is reduced for unknown reasons.
Problems with the delivery of sperm. Spermatozoa may not enter the vagina due to many factors. The most obvious reason for this is erectile dysfunction, the inability to achieve and maintain an erection. Other causes include damage to the epididymis or the vas deferens (the ducts that carry sperm). Such lesions are often the result of sexually transmitted diseases such as gonorrhea. Infertility can occur in men who have retrograde ejaculation, in which the flow of seminal fluid is directed back to the bladder if the bladder valve does not close completely, which can occur after prostate surgery.
The doctor will ask the patient about their general health, sex life, and perform a thorough examination, including examination of the genital area. In addition, a man may be required to provide a semen sample. If the number of spermatozoa is insufficient or if they are characterized by inactivity or non-viability, further tests will be carried out, such as a blood test that establishes the level of hormones.
The choice of treatment method depends on the diagnosis. If testosterone levels are low, injections of this hormone may be given. In case of impotence or retrograde ejaculation, artificial insemination can be used, in the latter case, sperm can be isolated from the urine. Damage to the epididymis or vas deferens can be corrected by microsurgical surgery. If the body produces only a small amount of healthy sperm, they can be collected directly from the epididymis. The egg will then be fertilized in a process called intracytoplasmic injection.
female infertility- the inability of a woman to naturally conceive a child. The risk increases with age, with women over the age of 35 most often affected. In rare cases, the disease is caused by a chromosomal pathology. Risk factors include stress, as well as increased physical activity and being overweight or underweight.
In about half of the cases in couples who do not have the opportunity to conceive a child, the woman is infertile. The ability to conceive decreases with age, in most cases falling by the age of 35, which makes it difficult for women older than this age to get pregnant.
There are a number of women's diseases that can affect one or more of the processes necessary for pregnancy.
Problems with ovulation. common cause female infertility is the impossibility of releasing a mature egg from the ovary, which normally occurs every monthly cycle. Ovulation is controlled by a complex interaction of hormones produced by the hypothalamus (a part of the brain), the pituitary gland, and the thyroid gland. A common and highly treatable disease leading to female infertility, is polycystic ovary syndrome, which can be accompanied by hormonal imbalance, which makes ovulation impossible. Diseases thyroid gland, such as hypothyroidism, can also lead to the development of hormonal imbalance, which affects the frequency of ovulation. A similar imbalance can be observed in diseases of the pituitary gland, such as prolactinoma, a benign tumor of the pituitary gland. The causes of ovulation disorders are different and not always known at this point in time. Sometimes women who have taken oral contraceptives for many years may need some time to restore their normal hormonal cycle after giving up contraception. Heavy exercise, stress, obesity, or being underweight can also affect hormone levels.
Early menopause is also accompanied by ovarian failure. Ovarian dysfunction sometimes develops for no apparent reason, but may also be the result of surgery, chemotherapy, or radiotherapy. In rare cases, there is a pathology of ovarian development due to a chromosomal abnormality, such as, for example, Turner's syndrome.
Problems with fertilization and egg movement. The path of the egg from the ovary to the uterus can be blocked if the fallopian tube is damaged. Damage to the fallopian tube can occur as a result of an inflammatory process in the pelvic region, which, in turn, can develop as a complication of sexually transmitted diseases, such as chlamydial cervicitis. Such infections can occur without symptoms and can only be diagnosed when you see a doctor about infertility.
Endometriosis, a disease characterized by the formation of fibrous tissue and cysts in the pelvic region, can also affect the fallopian tubes, which blocks the path of the egg to the uterus.
In some women, fertilization of an egg by a spermatozoon is impossible, because. the mucus normally produced by the cervix contains antibodies that destroy the partner's sperm before they can reach the egg, or is too viscous to prevent the fertilized egg from passing into the uterus.
Problems with the introduction of the egg into the lining of the uterus. If the uterine lining becomes damaged as a result of an infection, such as gonorrhea, implantation of a fertilized cell may not be possible. Hormonal problems can also cause the lining of the uterus to be insufficiently prepared to receive the egg.
Most of the reasons for female infertility, these days it is possible to identify during the survey. A woman can determine when she ovulates, and if she ovulates at all, using a special device available on the market, or by keeping daily records of basal temperature. If the doctor suspects that the patient is ovulating irregularly, she may periodically take a blood test for the level of the hormone progesterone during the menstrual cycle (it normally increases after ovulation). In addition, a series of ultrasound scans of the ovaries during the menstrual cycle can be carried out, which allows you to determine whether ovulation occurs, and a sample of uterine tissue can be taken from the woman to rule out the presence of pathology.
If the examination shows that the woman is not ovulating, she may have additional blood tests to determine the level of thyroid hormones and other hormones. To stimulate ovulation, the patient may be prescribed a drug course of treatment.
If the woman is ovulating normally and her partner's seminal fluid is also normal, the doctor will check for problems that may interfere with the fertilization of the egg by the sperm. For example, the patient may be asked if she is having sex while she is ovulating, and a sample of cervical mucus (collected no later than a few hours after intercourse) will be taken to test for sperm antibodies. If the test reveals the presence of antibodies, several treatment options are possible. For example, the partner's sperm can be injected directly into the uterine cavity, which prevents it from coming into contact with the mucus.
If the cause of infertility cannot be determined, further examination will be aimed at determining the presence of blockage of the fallopian tubes or uterine pathology. Methods used include laparoscopy. The choice of treatment method depends on the existing problem; microsurgery can be used for blocked tubes, and for endometriosis, a course of drug treatment is selected.
There are two main types of male and female infertility - primary and secondary infertility.
The first diagnosis is made if a woman cannot become pregnant, while she did not have such a condition before. Secondary infertility is a type of infertility in which it is not possible to become pregnant again.
Female primary infertility - what is it?
According to ICD 10, primary infertility is divided into several forms, each of which differs in its course and manifestations.
From a medical point of view, this diagnosis means the inability to conceive a child due to congenital or acquired pathologies of the organs of the reproductive system.
Such pathologies are:
- uterine fibroids;
- Cyst;
- Cervical erosion;
- Gynecological diseases of various etiologies.
There is another pathology that affects the inability to get pregnant - this is ovarian disease. Due to their malfunctioning, the egg does not mature and, accordingly, conception does not occur. This condition may be accompanied by the absence of menstruation or heavy and long menstrual flow.
The diagnosis of primary infertility according to ICD 10 may indicate the presence of the consequences of abortions or other methods of terminating a previous pregnancy. After an artificial or natural abortion, the hormonal background of a woman is disturbed, which is an obstacle to the successful conception of a child.
Primary infertility according to the ICD can be explained by the consequences of gynecological diseases, as well as injuries to the internal organs of the reproductive system. A woman can get such injuries during an abortion.
Adhesions in the fallopian tubes are also the reason for the lack of pregnancy. Since the path of advancement of the egg is closed, its fertilization does not occur.
The main causes of pathology
Primary and secondary infertility have similar causes, so the following list is applicable for these two forms of pathology:
- The lack of ovulation may be due to hormonal failure. In this condition, a woman is alarmed by a violation of the menstrual cycle and severe bleeding. Treatment of pathology - medication;
- The loss of qualitative characteristics of the egg can occur with the age of a woman. For example, at the age of 40, female germ cells become abnormal. You can solve the problem of conception with the help of a donor egg and surrogate motherhood;
- Primary infertility is a diagnosis that can be made on the basis of endometriosis. A characteristic feature of this disease is the pathological growth of the endometrium outside the uterus. This condition is accompanied by severe menstrual pain. Elimination of pathology is possible by surgical method.
- Obstruction of the fallopian tubes can occur against the background of inflammation or STDs;
- Due to polycystic ovaries, the hormonal system is disrupted, as a result of which the menstrual cycle and ovulation are delayed. Polycystic ovaries may be accompanied by an increase in body weight. Hair also grows rapidly and skin problems appear. To treat this condition, drugs are prescribed to stimulate ovulation.
Primary infertility - a diagnosis for men
As mentioned earlier, such a pathology can be diagnosed not only in women, but also in men. The reasons for its development will be in such moments:
- Urinary tract infection. When inflammation occurs, the production of antisperm antibodies. The inflammatory process can be caused by pathogenic fungi, bacteria and viruses. The effectiveness of treatment depends on finding the source of the problem;
- Venous expansion of the vas deferens or, in other words, varicocele. Primary or secondary infertility can be diagnosed due to overheating of the testicles, as well as due to an autoimmune reaction;
- Genetic anomalies that affect the possibility of bearing a child by a surrogate mother. Since the risk of disease transmission by heredity is high, it is recommended to use donor biomaterials for IVF;
- Male infertility can be explained by frequent illnesses, in particular, tuberculosis, bronchial asthma, diabetes mellitus, cirrhosis of the liver, diseases of the gastrointestinal tract and pancreas. Also important are hormonal disorders;
- Bad habits are one of the main causes of male infertility, they include addiction to alcohol, smoking and drug use;
- Regular contact with chemical compounds, work in bad environmental conditions;
- Frequent stress, constant fatigue and malnutrition - all this affects the production of male sex hormones.
Effective treatment
Depending on what primary infertility according to the ICD, the most effective treatment. In modern medicine, there are several methods that give good results, This:
- Therapeutic treatment with the use of medications, as well as chemotherapy and radiation therapy;
- Surgical intervention, for example, removal of hernias, correction and elimination of trauma to the scrotum, etc.;
- IVF - this method of infertility treatment is safe and especially effective.
What methods of pathology diagnostics are applicable?
In order to make an accurate diagnosis, the patient must undergo a comprehensive examination. It is also necessary to identify the cause of primary infertility. The complex of diagnostic measures includes tests, as well as instrumental and laboratory studies.
Based on the results of the tests and the information collected about the patient's life, the doctor draws conclusions regarding the diagnosis. If primary infertility is confirmed, then appropriate treatment is prescribed, based on the cause of the identified pathology.
Due to the method of modern medicine, this diagnosis is not a sentence for childless couples. Depending on the situation, you can always find the right solution.
ICD-10 CODE N46 Male infertility.
EPIDEMIOLOGY OF MALE INFERTILITY
Infertility in men- manifestation of various pathological conditions, and not their nosological form. However, due to its clear delineation and clinical significance, this phenomenon has acquired independent clinical significance. The cause of 40% of infertile marriages is a violation in the male reproductive system, 45% in the female and 5–10% is a combination of male and female factors of infertility. Often, the survey does not reveal any changes in the spouses.
ETIOLOGY (CAUSES) OF MALE INFERTILITY
Causes of male infertility can be classified based on the nature of the pathological changes (eg, genetic, endocrine, inflammatory, traumatic) and their location (hypothalamus, pituitary, testes, vas deferens, androgen target organs). All etiological factors are divided into three groups: pretesticular, testicular and posttesticular.
MAIN CAUSES OF MALE INFERTILITY
Pretesticular disorders (pathology of the hypothalamus, pituitary gland).
♦ Congenital defect in GnRH secretion (eg, Kallmann syndrome, Prader-Willi syndrome).
♦ Acquired defect in GnRH secretion, hypopituitarism (due to tumor, trauma, ischemia, radiation).
♦ZPR.
♦ Isolated LH deficiency (Pasqualini's syndrome).
♦ Hyperprolactinemia (due to pituitary adenoma, exposure to medicines).
♦ Violation of the functions of other endocrine glands, taking hormonal drugs.
testicular disorders.
♦Chromosomal abnormalities (Klinefelter's syndrome).
♦ Congenital and acquired anorchism.
♦ Isolated aplasia of the spermatogenic epithelium (Sertoli cell or Del Castillo syndrome).
♦ Cryptorchidism.
♦ Varicocele.
♦ Injury to the testicle (trauma, torsion, orchitis).
♦ Disorders caused by systemic diseases or exogenous factors.
♦Androgen deficiency or resistance to them.
Posttesticular disorders.
♦Obstruction of the seminal ducts (congenital, acquired).
♦Hypospadias.
♦Sperm function or motility disorders (eg, autoimmune disorders, adnexal infections).
PATHOGENESIS OF MALE INFERTILITY
Infertility due to hypogonadism occurs as a result of a violation of generative (spermatogenesis) and hormonal (steroidogenesis) functions, less often - only generative. Infertility is often combined with manifestations of androgen deficiency. Hypogonadism may be present from birth or develop during puberty, adulthood, or old age.
DIAGNOSIS OF MALE INFERTILITY
In case of infertility, an examination of two partners is mandatory (and it is better to start with an examination of a man). The goal is to establish infertility and determine its cause. Evaluation of male fertility is not difficult, however, it is not easy to identify the cause of infertility, and in 15–20% of cases this cannot be done and infertility is recognized as idiopathic. The diagnostic process for male infertility consists of several successive stages. It should be carried out with minimal economic costs and include predominantly non-invasive means.
HISTORY Includes clarification of the characteristics of sexual life, pregnancy in sexual partners, as well as information about previous diseases, operations, and negative factors.
PHYSICAL EXAMINATION FOR MALE INFERTILITY
During a physical examination, the degree of severity of secondary sexual characteristics is determined (androgen deficiency is manifested by a eunuchoid physique, poor hair growth, gynecomastia). Palpation of the scrotum reveals the presence of the testicles, their size (average: length - 4.6 cm, width - 2.6 cm, volume - 18.6 ml) and consistency (normally densely elastic), as well as changes in the epididymis and varicose veins spermatic cord (varicocele). Exclude inflammatory lesions of the prostate and seminal vesicles.
LABORATORY STUDIES FOR MALE INFERTILITY
Ejaculate examination (spermogram)- the main stage in the diagnosis of male infertility. Ejaculate for research is obtained after 2-3 days of abstinence by masturbation (preferably) or interrupted sexual intercourse. The ejaculate is delivered to the laboratory at room temperature no later than 1 hour after collection. The normative indicators currently accepted for evaluating sperm are presented in Table. 19-1.
Table 19-1. Normal values for ejaculate parameters (WHO Guidelines, 1999)
| Index | Characteristic |
| ejaculate volume | ≥2.0 ml |
| pH | ≥7,2 |
| Sperm concentration | ≥20 million/ml |
| Total sperm count | ≥40 million/ejaculate |
| Sperm motility | ≥50% forward movement (category a+b) or 25% rapid forward movement (category a) within 60 minutes of ejaculation |
| Morphology | 30% normal sperm |
| Viability | 50% live sperm |
| MAR test | <50% подвижных сперматозоидов с прилипшими частицами |
| Leukocytes | <1 млн/мл |
| α-glucosidase (neutral) | 11 honey/ejaculate |
| Lemon acid | 52 µmol/ejaculate |
| Acid phosphatase | 200 U/ejaculate |
| Fructose | 13 µmol/ejaculate |
| Zinc | 2.4 µmol/ejaculate |
It is important to distinguish between aspermia - the absence of ejaculate, azoospermia - the absence of spermatozoa in the ejaculate, oligozoospermia (<20 млн сперматозоидов/мл), астенозооспермию (<50% подвижных сперматозоидов), тератозооспермию (<30% сперматозоидов нормальной морфологии) или их сочетание - олигоастенотератозооспермию.
If deviations from the norm are detected, then the analysis is repeated 1-2 times.
The study of hormone levels contributes to the evaluation of spermatogenesis and the identification of endocrine causes of infertility.
It may be limited to the determination of FSH, LH, testosterone and prolactin. Determination of hormone levels (primarily FSH and testosterone) is especially indicated for severe oligozoospermia. The results of hormonal tests give grounds to differentiate obstructive and secretory azoospermia, as well as infertility on the basis of primary (hypergonadotropic) and secondary (hypogonadotropic) hypogonadism.
If the above methods fail to establish the cause of infertility, then additional studies are used.
Identification of inflammatory changes and infectious agents is indicated for leukocytospermia, signs of sexually transmitted diseases, as well as inflammatory lesions of the urethra and accessory sex glands.
Cytogenetic analysis is appropriate for azoospermia and severe oligoastenoteratozoospermia. Klinefelter's syndrome (karyotype 47, XXY) is the most common chromosomal anomaly in infertile men.
Attempts to identify antisperm antibodies are justified in case of infertility due to testicular injury, orchitis, vasectomy.
INSTRUMENTAL STUDIES FOR MALE INFERTILITY
To clarify the state of the scrotum, the structure of the prostate, seminal vesicles and ejaculatory ducts, ultrasound is used.
Testicular biopsy is often the only way to differentiate secretory and excretory forms of azoospermia with normal testicular size and FSH content. This method can be used in azoospermia to detect spermatozoa in the convoluted seminiferous tubules and subsequent in vitro fertilization - injection of the spermatozoon into the cytoplasm of the egg. A testicular biopsy can be combined with an x-ray examination of the patency of the vas deferens (vasography).
TREATMENT OF MALE INFERTILITY
GOALS OF TREATMENT
Treatment of the underlying disease and stimulation of spermatogenesis. It is necessary to exclude factors that negatively affect the generative function of a man: alcohol and nicotine abuse, thermal effects, and taking certain medications.
MEDICAL TREATMENT OF MALE INFERTILITY
It is generally accepted (although its expediency has not been proven) infertility therapy for 2.5–3 months. The terms of treatment are set, taking into account the duration of the cycle of spermatogenesis (72-76 days) and the period of maturation of spermatozoa in the epididymis (about 2 weeks).
In hypogonadotropic hypogonadism, hCG preparations are prescribed to compensate for FSH function, and hCG preparations or combinations thereof are prescribed to compensate for LH function. GnRH agonists are less commonly used. Antiestrogens (clomiphene, tamoxifen) are prescribed to increase the level of gonadotropin production. In hyperprolactinemia, dopaminergic drugs (bromocriptine) are highly effective.
Infertility due to hypergonadotropic hypogonadism is resistant to drug therapy. In such cases, testosterone preparations are necessary to maintain its physiological concentration and level the manifestations of androgen deficiency.
Antiestrogens and antioxidants are prescribed to stimulate spermatogenesis in patients with idiopathic oligoasthenoteratozoospermia. If an inflammatory lesion of the urethra and accessory sex glands is detected, they are sanitized.
SURGICAL TREATMENT OF MALE INFERTILITY
Varicocele in men under 25–30 years of age is subject to surgical elimination. The patient must be informed that there is no guarantee of success.
Microsurgical restoration of the patency of the seminal ducts is carried out with their obstruction and preserved spermatogenesis, according to the results of a testicular biopsy.
The discovery and widespread use of the ICSI method led to the development of methods for obtaining spermatozoa directly from the testicle or its epididymis. For this, microsurgical epididymal sperm aspiration, testicular sperm extraction (similar to testicular biopsy) and percutaneous epididymal sperm aspiration are used. Obviously, each of these methods of obtaining spermatozoa involves a subsequent ICSI.
PREVENTION OF MALE INFERTILITY
Prevention of infertility is to reduce the risk of diseases leading to infertility, as well as to exclude factors that inhibit spermatogenesis.
