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Exams to assess a couple’s fertility

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In fertility research, factors are studied taking into consideration each step in the reproduction process. Basic exams exist for each one of them which must be requested at the first doctor’s appointment in order to dismiss or confirm diagnostic hypotheses. In a didactic way, there are five factors that must be examined and can prevent a couple from having children. Nevertheless, it should be considered that some couples are unable to become pregnant during a determined period and cannot find medical justifications for this difficulty, the so-called Unexplained Infertility or Sterility Without Apparent Cause (SWAC). The infertility factors are:

I. Hormonal Factor and Ovarian Factor: female hormonal and ovulation problems;

II. Anatomical Factor: examination of the entire anatomy of the uterus, tubes, cervix, and adhesions;

III. Endometriosis Factor;

IV. Male Factor;

V. Immunological Factor: examination of the incompatibility between the cervical mucus and the spermatozoa, the embryo and the uterus, or the female and male gametes, caused by hostility, a type of “allergy”. However, this factor has no scientific evidence that confirms the results and benefits in the chances of fertilization. Therefore, it should only be required in specific situations.

VI. Unexplained Infertility – Sterility Without Apparent Cause (SWAC)

I. Hormonal factor and ovarian factor

This factor accounts for 50% of infertility cases, for total lack of ovulation (anovulation) or by a similar defect (ovulation problems – luteal phase defect). The study of ovulation is done through indirect methods, which together give the diagnosis of whether or not ovulation exists. Treatment depends on the observed changes.

Hormone dosages: They take place during the menstrual cycle, in order to evaluate the actual existence, quality, and time of ovulation. Dosages should be made at the appropriate time, prescribed by the physician, and the following hormones are usually measured: FSH, LH, estrogênio, progesterone and prolactin, and others that may be listed in accordance with the suspected diagnosis (thyroid, etc.).

Serial transvaginal ultrasound: Through this examination, which is repeated several times during the ovulatory cycle, one can foresee the rupture of the follicle (ovulation). In the moments leading up to ovulation, the follicle containing the egg reaches its maximum size, about 20 mm, forming a small cyst (functional cyst). Ovulation is nothing more than to rupture this “cyst” with the expulsion of the egg, which will be forwarded to the uterus through the fallopian tube, where it should be fertilized, in order to become an embryo. Finally, the ultrasound monitoring of ovulation easily provides the most fertile day of the woman in any given month.

Endometrial biopsy: It provides material for microscopic examination and can be performed in the doctor’s office during a video hysteroscopy (see next chapter) examination, around the 24th day of the menstrual cycle. The examination of this material also allows us to evaluate the effective action of hormones, indicating that the endometrium is in sync with the menstrual cycle.

II. Anatomical factor

It is the research of changes in the reproductive organ, which can prevent the meeting of sperm with the egg in the tubes and subsequent fertilization. The uterus and fallopian tubes should exhibit normal morphology and operation.

The changes occur in 20 to 30% of infertility cases. Besides causes such as inflammatory, traumatic, surgical, malformations, myoma, etc., it should be noted the role of emotional factors. Stress can cause changes in peristalsis (movement) of the tubes, compromising the capture and transport of the egg. Some tests may help to better detect possible problems. These are:

Hysterosalpingography: It is an X-ray procedure using a contrast dye. It is an important test for the physician to evaluate whether the patient has intact fallopian tubes and uterine cavity, which is essential to assess her fertility. The physician should be directly involved in the interpretation and, whenever possible, monitor the actual procedure. The assessment of the X-rays should be cautious, noting the presence of stenoses, synechiae (adhesions), septa, polyps, uterine malformations, tubal obstructions, and minor tubal injuries. The cases showing abnormality may follow a diagnostic laparoscopy and hysteroscopy for further evaluation. It is interesting to note that up to 20% of normal hysterosalpingograms showed abnormality in video laparoscopy.

Uterus:

  • uterine myomas (size and location);
  • structural anomalies, such as uterine malformations (bicornuate uterus or uterus didelphys);
  • anatomical alterations of the endometrium.

Ovaries:

  • cysts;
  • tumors;
  • polycystic appearance.

Hysterosonography: It is an examination that can be done in a doctor’s office. A special catheter is placed in the uterus through the vagina. Through it, a fluid is injected which dilates the uterine cavity, moves towards the tubes, and reaches the pelvic cavity. This procedure is monitored by ultrasound and allows to evaluate the anatomy of the uterine cavity and, indirectly, gives an idea of tubal patency by the accumulation of intra-abdominal fluid behind the uterus. Nevertheless, this exam does not replace the hysterosalpingography for the evaluation of the tubes.

Endovaginal ultrasound: It is an important tool in the initial evaluation of the infertile patient. In the past, it took more aggressive procedures to determine ovarian and uterine abnormalities. With the use of vaginal ultrasound, today is safer and easier to evaluate these structures by the physician. One can use vaginal ultrasound to diagnose a variety of problems.

The examination can reach the following organs of the reproductive system:

The vaginal ultrasound can also diagnose ovarian problems and, as described in the previous section, is very useful when accompanying a patient through the ovulatory phase of her cycle and evaluate the presence of the dominant follicle. Diagnoses such as ovarian cysts and endometriomas can easily be visualized with the use of vaginal ultrasound.

Anatomical alterations that can compromise fertility: myomas, malformations, endometriosis, adhesions, and hydrosalpinx.

Video laparoscopy: It is a very useful and sophisticated exam, done in the hospital under general anesthesia. Through a micro video camera, introduced into the abdomen through a minimal incision in the navel, the reproductive organs are visualized: uterus, fallopian tubes, ovaries, and surrounding organs. With this device, a “walk” through the abdominal cavity is conducted, in an extraordinary live panoramic view and in color. It is possible to see everything, in superb detail, on the monitor screen. Changes in tubal patency, adhesions and endometriosis are diagnosed this way and can at the same time be treated surgically without cutting the abdomen. This equipment allows the introduction of special tweezers to perform acts and surgery, correcting many of the alterations, such as releasing adhered tissues, cauterizing and vaporizing endometrial sites, coagulating bleeding, and even performing major surgeries if necessary (myomas, cysts, etopic pregnancy, etc.).

Diagnosis and surgical treatment by VIDEO LAPAROSCOPY must be done by professionals with experience in infertility and microsurgery. Once a certain alteration is detected during an examination, the specialized surgeon in Human Reproduction must have experience and ability to discern the real benefits of a surgical treatment. Otherwise, the trauma of surgery may further worsen the reproductive health of this patient.

Video hysteroscopy: It can done in the doctor’s office and allows, without any incisions, to examine the interior of the uterus (endometrium). Using the same micro camera of the previous exam, it is possible to diagnose, in the uterine cavity, the existence of abnormalities, such as myomas, polyps, malformations, and adhesions, that are surgically corrected, when necessary, the same way.

Cervix: Cervical mucus, as previously described, is extremely important in the fertilization process, for that is where the sperm “swims” towards the egg to be fertilized. Alterations in the cervix account for 15 to 50% of the causes of infertility. The analysis of this factor is made by evaluating the cervical mucus, video hysteroscopy, and colposcopy.

Adhesions: They constitute the factor caused by the presence of obstructions (adhesions) in the capture of the eggs by the tube(s), that should be unobstructed throughout its length. Often the organs stick together, preventing them from exercising their proper function. Generally, this is a result from pelvic infections, endometriosis, or surgeries in this area. The initial diagnosis is indicated by hysterosalpingography, but the confirmation is done by video laparoscopy, the only exam that allows for a definitive diagnosis and, concomitantly, the surgical treatment. When the endoscopic resolution is not possible, surgery should be done by conventional techniques, taking into account the principles of microsurgery.

III. Endometriosis factor

Endometrium is the tissue that lines the uterus internally and is formed between menstrual cycles. This “layer” becomes loose and comes out along with blood each time the woman menstruates. For reasons not yet defined, this coating can migrate and lodge in other organs, such as ovaries, fallopian tubes, intestines, bladder, peritoneum, and even within the uterus, within the muscle. When this happens, it is given the name of endometriosis (when lodged into the muscles of the uterus, it is called adenomyosis); that is, the endometrium is outside its usual area. Endometriosis accounts for about 40% of the causes of female infertility. The disease is not malignant, and some patients manifest only slightly, with a slight increase in the intensity of menstrual cramps. In others, they can feel miserable, with severe pain and heavy bleeding (severe endometriosis). In either situation, whatever the degree of endometriosis, fertility may be compromised. The evidence for this disease can be given, in addition to clinical history, by measuring levels in the blood of a substance called CA125, and a suspicious image seen by ultrasound with bowel preparation performed by professionals and specialists in this disease. In more advanced cases, one should be asked to do a magnetic resonance imaging, colonoscopy and excretory urography. New tests, such as CRP, SAA, anticardiolipin IgG, IgA and IgM, and other markers represent an option for future research and immunological treatments for this pathology. To confirm the diagnosis and grade the impairment of organs affected by the disease, video laparoscopy is essential and can, through it, also get cured with cauterization and resection of the foci. A specialist in endometriosis should assess the case. The medicinal treatment is an additional alternative that should be evaluated on a case by case basis.

IV. Male factor

The research of male fertility is an important chapter in Human Reproduction, both for participating in the couple’s difficulties in having children, and for the embarrassment and the manner of collecting the material (by masturbation), and the prejudices that still exist involving possible diagnoses (as absurd as it may seem).

IN CASES WHERE RELIGION CONDEMNS MASTRUBATION. THE SEMEN IS COLLECTED DURING THE SEXUAL ACT USING A SPECIAL TYPE OF CONDOM. THE COLLECTED MATERIAL IS FORWARDED TO THE LABORATORY SOON AFTER INTERCOURSE.

Research of male fertility is always much simpler than the female. It is fundamental to know what is relevant in this research, so that superficial results do not lead the couple to waste time and money, in addition to psychological distress involved in this type of treatment. The male factor is responsible, alone, for 30 to 40% of infertility cases, and associated with the female factor for 20% more; an accomplice, therefore, for 50% of the couples having difficulty to conceive. Since the assessment of this factor is relatively simple and inexpensive, it should be performed in all the cases before any therapeutic recommendations. This study is based on clinical history (past history of infection, traumas, prior surgeries, impotence, habits such as alcoholism, smoking, etc.), physical exam, sperm analysis and, in special cases, genetic exams.

Causes of male infertility

  • Low sperm count.
  • Poor motility of spermatozoa.
  • Abnormal spermatozoa.
  • Lack of sperm production.
  • Vasectomy.
  • Difficulties in sexual intercourse.

Most common diseases

  • Varicocele
  • Infections
  • Chromosomal/genetic problems
  • Malformations

Most common abnormalities in a sperm analysis

Asthenospermia: It is when the motility of the spermatozoa is reduced. According to some researchers, it is the most common abnormality in a sperm analysis. The most common causes are immunological infections, varicocele, smoking, alcoholism, medicine, psychiatric problems, endocrines, stress, and professional diseases.

Oligospermia: It is the reduction in the number and motility of the spermatozoa. The causes are the same as cited in the two previous items.

Teratospermia: They are the abnormalities in the shape of the spermatozoa. The main causes for these abnormalities are: inflammations, certain drugs, congenital origin, and varicocele. Spermatozoa capable of fertilization must have perfect shape. The ideal shape is oval.

NOMENCLATURE
SCIENTIFIC NAME QUANTITY OF SPERMATOZOA
AZOOSPERMIA ABSENCE OF SPERMATOZOA
OLIGOSPERMIA LESS THAN 20 MILLION/ML
SEVERE OLIGOSPERMIA LESS THAN 05 MILLION/ML
POLYSPERMIA MORE THAN 250 MILLION/ML
NECROSPERMIA DEAD SPERMATOZOA MORE THAN 30%

 

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