|ICD-10||N 46 46., N 97.0 97.0|
|ICD-9||606 606 , 628 628|
|eMedicine||med / 3535 med / 1167 med / 1167|
|Wikimedia Commons Media Files|
Infertility - in biology - the loss by plants and animals of the ability to reproduce sexually.
Infertility (Lat. Sterilitas) - in medicine - the inability of a couple at childbearing age to conceive a child with regular sex life.
A married couple is considered infertile if the woman’s pregnancy does not occur within a year of regular sexual activity (sexual intercourse at least 2 times a week) without the use of contraceptive methods and methods. According to the World Health Organization, “... about 8% of couples during the reproductive period of life face the problem of infertility”. A person is distinguished by absolute infertility, predetermined by incurable changes in the sexual apparatus of a man or woman (developmental defects, surgical removal of the genital glands, injuries and others) , and relative, the causes of which can be eliminated. Infertility is called primary if there has never been a pregnancy, and secondary if earlier the woman had at least one pregnancy, no matter what it ended (in childbirth, ectopic pregnancy, miscarriage, etc.).
The causes of female infertility can be:
1) Obstruction or absence of the fallopian or fallopian tubes into which the egg enters after ovulation and in which it occurs with sperm. In the distal parts of the fallopian tubes, the sperm meets and merges with the egg, that is, fertilization occurs, as a result of which an embryo is formed. The embryo moves along the tube into the uterine cavity due to contractions of the muscular wall of the tube (peristalsis) and cilia (the epithelium lining the tube from the inside), which “drive” the embryo into the uterus. Obstruction of the fallopian tubes, as a rule, is the result of an adhesive (adhesive) process, which leads to inflammation of the tubes (salpingitis). Sometimes this is the result of a woman's sterilization (dressing or crossing the fallopian tubes). The absence of fallopian tubes is observed after surgical removal of the tube, for example, in connection with an ectopic (tube) pregnancy or purulent process in it (pyosalpinx).
2) Adhesive process in the small pelvis (peritoneal factor of infertility) is the result of operations, the inflammatory process, endometriosis. Adhesions can envelop the ovary or be located between the tube and the ovary, preventing the egg from entering the tube. With a combination of tubal and peritoneal factor, they speak of tubal-peritoneal infertility.
3) Endocrine (hormonal) disorders - may be a consequence of the pathology of the ovaries (their depletion, polycystic ovary syndrome, etc.) and other endocrine (hypothalamus, pituitary, adrenal glands, thyroid gland) and non-endocrine organs (liver, kidneys, etc.). Disorders of metabolic processes, mental stress, etc. can lead to endocrine infertility. Whatever the cause of endocrine infertility, its key point is always the breakdown of the ovulation mechanism (anovulation).
4) Pathology or absence of the uterus - the organ in which the implantation of the embryo and gestation occurs. Uterine pathology can be congenital (intrauterine septum, bicornuate uterus, doubling of the uterus, etc.) and acquired (removal or scarring of the uterus after operations, uterine fibroids, endometritis, adenomyosis, polyposis, endometrial hyperplasia, etc.).
5) Endometriosis, which is expressed in the growth of the uterine mucosa (endometrium) beyond. Adhesions arise between the foci of endometriosis, which are the cause of tubal-peritoneal infertility.
6) Immunological infertility - is associated with the presence in a woman of antibodies to sperm (antisperm antibodies).
7) Chromosomal pathology can lead to sterility in women.
8) Psychological infertility is considered as the result of a conscious or unconscious unwillingness of a woman to have a child. Sometimes it is a fear of pregnancy and childbirth, sometimes unwillingness to have a child from a given man, sometimes resistance to changes in appearance that pregnancy can lead to, and so on.
Male infertility is the inability of a man to fertilize a woman.
The cause of male infertility may be:
1) Ejaculatory disorders, including the absence of ejaculate, retrograde ejaculation, which occurs due to impaired innervation of the genitourinary organs, others.
3) Anatomical changes in the structure of the male genital organs (hypospadias - when the external opening of the urethra is not opened in the glans penis but at the root of the scrotum, as a result of which sperm does not enter the woman’s vagina. Another option for anatomical infertility is obstruction or congenital absence of the vas deferens Obstruction is most often associated with the inflammatory process in the male genital tract, sometimes it is the result of an accumulation of thick secretion (with a genetic disease, ovistsidoz or Fibrocystic breast disease) or the result of surgery, such as the intersection of the seminiferous tubules with the purpose of male contraception.
4) Endocrine disorders (hyper- and hypogonadotropic hypogonadism, hyperprolactinemia, others) can lead to impaired spermatogenesis. To diagnose this cause of infertility, it is necessary to determine hormones: prolactin, testosterone, FSH, LH.
5) Damage to spermatogenic epithelium, for example, as a result of irradiation, chemotherapy, exposure to toxic substances or high temperatures, infection, scrotal injury, dropsy of the testicles, etc. As a result of all these factors, sperm production decreases or stops in the testes. It can be a reversible and irreversible process.
6) Genetic, chromosomal disorders, as a result of which spermatogenesis does not occur.
7) Inflammatory process, including sexually transmitted diseases.
8) An immunological factor when the formation of autoimmune antibodies against sperm (antisperm antibodies) is observed.
Whatever male infertility is caused by, it will always be reflected in the spermogram. That is why it is necessary to begin the examination of a childless couple with a spermogram of a man. The following variants of sperm pathology are distinguished:
1) Anejaculation - the absence of ejaculate (sperm).
2) Azoospermia - the absence of sperm in the ejaculate. There are secretory azoospermia when spermatozoa are not formed in the testes, and obstructive azoospermia when spermatozoa are formed but are not erupted due to obstruction of the vas deferens.
3) Oligospermia - insufficient amount (volume) of sperm. According to WHO standards, the volume is at least 1.5 ml.
4) Oligozoospermia - insufficient sperm count in semen. According to WHO standards, the concentration of sperm in semen is at least 15 million / ml.
5) Asthenozoospermia - insufficient sperm motility. According to WHO standards, the proportion of motile spermatozoa of category A + B + C in semen is at least 40%.
6) Necrospermia - the absence of live sperm
7) Cryptospermia - the presence of single motile sperm in the ejaculate
8) Teratozoospermia - an increased number of morphologically abnormal spermatozoa. According to WHO standards, the proportion of morphologically normal sperm in the semen is at least 4%.
9) Pyospermia - an increased number of leukocytes in semen due to the inflammatory process.
Analysis of the ejaculate (spermogram) characterizes the sperm fertility in men. For ejaculate with normal values of sperm count, motility and morphology, the term “normospermia” is used. Excess sperm in the ejaculate (more than 200 million in 1 ml) are referred to as polyspermia.
Combined and combined infertility
A woman’s combination of several causes of infertility is called “combined infertility”. For example, one and the same woman may have impassable tubes, anovulation, antisperm antibodies, and endometriosis. Combined infertility should be distinguished from “combined”, in which both man and woman have problems with reproductive health.
The field of medicine that studies reproduction is called reproduction. Gynecologists deal with female infertility, andrologists deal with male infertility. Distinguish infertility treatment and overcoming infertility.
Under infertility treatment It implies the use of all possible methods, which will lead to its overcoming, that is, the onset of pregnancy and the birth of a child. Methods for treating infertility include, for example, surgical restoration of the patency of the fallopian tubes in a woman, or surgical restoration of the vas deferens in a man, or surgical treatment of varicocele in a man, as well as IVF and other assisted reproductive technologies.
Definition of the disease. Causes of the disease
Under infertility understand the lack of conception in a couple living a regular sexual life without the use of contraception for more than one year. About 15% of couples planning to conceive experience infertility each year.
Infertility can be caused by reproductive dysfunction in one of the partners (men or women) or in both partners. The latter is observed most often, since impaired fertility (the ability to have children) of one of the partners can be compensated by the preserved fertility of the other.
Male factor, or male infertility, is said to be given if a man has changes in sperm parameters or its delivery mechanism that impedes conception. This situation is observed in half of the men examined for infertility in marriage. The causes of male infertility are quite diverse and include medical factors:
- Varicocele - This is the varicose veins of the scrotum, which disrupts the blood supply to the testicle. The most common reversible cause of male infertility. The exact reason why varicocele causes infertility is unknown, probably due to an increase in the temperature of the scrotum, leading to impaired spermatogenesis and a decrease in sperm quality. Treatment of varicocele can improve sperm parameters, increase the chances of natural conception and conception as a result of the use of assisted reproductive methods (IVF / ICSI).
- Reproductive system infections which are accompanied by the ingestion of various products of inflammation into the sperm that interfere with the functioning of sperm, which leads to a deterioration of sperm parameters. These include: inflammation of the epididymis (epididymitis) or the testicle itself (orchitis), prostate gland (prostatitis) and some sexually transmitted infections, including chlamydial infection, gonorrhea, trichomoniasis.
- Ejaculation Disorders. Most often, retrograde ejaculation leads to infertility - a condition when semen during an orgasm does not exit through the urethra, but moves in the opposite direction and enters the bladder. Retrograde ejaculation can lead to diabetes mellitus, spinal injuries, the use of certain medications, as well as surgery on the prostate gland or bladder. Delay of ejaculation is much less common when a man during an intercourse cannot reach an orgasm or reaches, but not in all sexual intercourse, and it takes a considerable amount of time (sometimes more than an hour).
- Immune factors. Sperm, unlike other cells in the body, contain half the set of chromosomes, so the immune system perceives them as foreign cells. Upon contact with sperm, the immune system produces special proteins - antibodies that are fixed to sperm and interfere with their functioning. Normally, this does not happen, since the testes are arranged in a special way, and the sperm during maturation are protected from interacting with the cells of the immune system by a special structure - the hematotesticular barrier. But any violation of the structure of the testis (trauma, varicocele, impaired patency of the vas deferens) can lead to damage to the hematotesticular barrier and the formation of antisperm antibodies.
- Undescended testicles (cryptorchidism). In some men, one or both testicles at birth are not lowered into the scrotum, but are located in the inguinal or abdominal cavity. Outside the scrotum, the testes cannot fully function, since spermatogenesis requires a temperature below body temperature. This leads to an irreversible violation of spermatogenesis, which persists even after the surgical descent of the testicles into the scrotum. The likelihood of infertility is significantly higher in men with bilateral cryptorchidism than with unilateral cryptorchidism.
- Hormonal disorders. Thyroid diseases (hyper- and hypothyroidism), adrenal gland diseases, low testosterone (male hypogonadism) negatively affect spermatogenesis. The most serious violations of spermatogenesis are observed with a deficiency of the main hormone that stimulates spermatogenesis - FSH (follicle-stimulating hormone), but such conditions are rarely observed.
- Tumors Benign and malignant tumors of the testicle itself and the structures that regulate spermatogenesis, for example, the pituitary or hypothalamus, are often accompanied by severe violations of sperm production. Methods used to treat tumors also negatively affect sperm quality: chemotherapy, radiation therapy, and surgery.
- Obstruction of the vas deferens. The vas deferens along which spermatozoa move can be blocked at different levels: inside the testis, in the epididymis, vas deferens, at the level of the prostate gland or in the urethra. Causes include damage during surgery (for example, due to inguinal hernia), infections, injuries, or malfunction as a result of hereditary diseases.
- Chromosomal defects. Congenital diseases, for example, Klinefelter’s syndrome, in which men are born with two X chromosomes and one Y chromosome (instead of one X and one Y), lead to the malfunctioning of male reproductive organs. Other genetic syndromes associated with infertility include cystic fibrosis, Kalman syndrome, and Cartagener syndrome.
- Sexual problems. These may include problems with maintaining or maintaining an erection sufficient for sexual intercourse (erectile dysfunction), premature ejaculation, painful intercourse, anatomical abnormalities (location of the external opening of the urethra on the lower surface of the penis (hypospadias), or psychological problems and problems of interpersonal relationships that impede a full regular sexual life.
- Taking medications. Testosterone replacement therapy, prolonged use of anabolic steroids, drugs for cancer treatment (chemotherapy), antifungal drugs, drugs used to treat peptic ulcer disease, and some other drugs can reduce sperm quality.
- Postponed operations. Some operations may prevent sperm from entering the ejaculate.This is a vasectomy (the intersection of the vas deferens for contraception), surgery for an inguinal hernia, surgery for the scrotum or testicles, surgery for the prostate and large operations on the abdomen for cancer of the testicle and rectum.
Environmental factors, such as:
- Industrial chemicals. Long-term exposure to benzene, toluene, xylene, pesticides, herbicides, organic solvents, paints and lead adversely affects sperm quality and quantity.
- Heavy metals. Exposure to lead or other heavy metals can also inhibit spermatogenesis.
- Radiation or X-rays. Exposure to radiation can significantly reduce sperm count in semen. As a rule, the effect is reversible, and after a while the sperm parameters are restored to normal values. At high radiation doses, sperm production may be irreversibly impaired.
- Testicular overheating. An increase in scrotum temperature negatively affects spermatogenesis. Frequent use of saunas, baths can impair sperm quality. A prolonged sitting position, tight underwear and clothing, working with a laptop lying on your knees can also increase the temperature of the scrotum and adversely affect sperm production.
Lifestyle, bad habits and conditions of professional activity also affect male fertility:
- Drug use. Cocaine and marijuana have a reversible negative effect on the quantitative and qualitative parameters of sperm.
- Excessive alcohol consumption. Alcohol abuse can lower testosterone levels, cause erectile dysfunction, and decrease sperm production. Liver diseases caused by excessive alcohol consumption also lead to fertility problems.
- Tobacco smoking. In men who smoke, sperm quality is significantly worse than in non-smoking men. Secondhand smoke can also affect male fertility.
- Emotional stress. Hormones produced during stress inhibit the secretion of spermatogenesis stimulating substances. Prolonged and severe stress can lead to significant changes in sperm parameters.
- Overweight.Obesity introduces an imbalance in normal male hormonal status, which leads to a decrease in male fertility.
- Occupational hazard. Men in certain occupations, such as drivers or welders, are at greater risk of infertility than other men.
In 30% of men with impaired sperm parameters, it is not possible to establish the cause; this form of male infertility is called idiopathic (causeless).
The pathogenesis of male infertility
The process of creating sperm (spermatogenesis) occurs in the testicle. 90-95% of the testicular volume is represented by special tubes - the seminiferous tubules, in which the process of creating spermatozoa occurs - spermatogenesis. The process of creating one sperm takes about 70 days.
The process of creating sperm is stimulated by follicle-stimulating hormone (FSH), which is produced in the area of the brain - the pituitary gland. In the absence of FSH, spermatogenesis does not proceed, and spermatozoa do not form.
Spermatogenesis is a delicate process. Many factors can disrupt its normal course (increased scrotum temperature, medication, x-ray radiation) and lead to the creation of spermatozoa with irregular structure (morphology), poor mobility and defective genetic material that are not capable of fertilization.
After exiting the testicle, the sperm enter a long, sinuous tube called the epididymis. As a result of the passage of the epididymis, which takes about a week, spermatozoa improve their mobility, and there is also a change in the molecules on the surface of the sperm, which is necessary for interaction with the egg.
Against the background of inflammatory processes in the epididymis, the process of sperm maturation can be disrupted, and they will not be able to fertilize the egg. In some cases, as a result of the inflammatory process or after operations on the appendage, an obstacle to the passage of spermatozoa is formed, as a result of which they do not enter the semen.
After passing the epididymis, sperm can be stored in the body of a man for several weeks, while maintaining the ability to fertilize. But if sperm is stored for too long, sperm cells begin to degrade and die.
Destructive sperm can damage new sperm, preventing them from leaving the epididymis. Men are recommended to ejaculate every two or three days to maintain sperm quality in optimal condition.
During ejaculation, about 250 million sperm cells begin to move through the vas deferens and the urethra (urethra) to the outside. The movement of sperm is provided by the contraction of the muscles of the vas deferens and the urethra, which are accompanied by pleasant orgasmic sensations. As a rule, the release of sperm occurs in several portions. Most sperm are contained in the first portion, the second and third contain mainly the secret of the additional male sex glands - the prostate and seminal vesicles.
The secret of the additional gonads (prostate and seminal vesicles) is necessary to ensure the vital activity of sperm after ejaculation. With an inflammatory or other pathological process in the prostate or seminal vesicles, the composition of their secretion can change, which disrupts the functioning of sperm and reduces the likelihood of conception.
After getting into the vagina, the sperm should leave it within a few minutes and move to the cervix. The fact is that the vaginal environment is acidic, which is necessary to protect the female body from bacteria and viruses. However, the acidic environment quickly destroys the sperm, if the sperm is in it for more than two minutes, it dies. According to statistics, only one out of 100 sperm can manage to leave the vagina and move to the cervix.
In this regard, it is very important that spermatozoa get as close to the cervix as possible during ejaculation, which is not possible with anomalies such as hypospadias (the external opening of the urethra is on the lower surface of the penis).
The cervix contains a special mucus, which, on the one hand, protects the sperm from the aggressive environment of the vagina, and on the other, it can impede their further movement. The consistency of the mucus depends on the hormonal status of the woman, and most of the time she is not permeable to even the most healthy and motile sperm. A few days before ovulation, the consistency of the mucus changes in such a way that it becomes able to skip sperm.
In some cases, the cervical mucus may contain antibodies (proteins produced by the immune system to combat foreign substances that enter the body) to sperm cells that prevent sperm cells from passing through the cervical mucus even during ovulation.
After passing the cervix, the sperm enters the uterus, and in front of it there is a dilemma - which fallopian tube to move on to: right or left. Women have two fallopian tubes (one on each side), but only one of them every month an egg leaves the ovary. In this situation, the woman’s body comes to the aid of the sperm. In the period close to ovulation, due to hormonal influences, the muscles of the uterus on the ovulation side begin to rhythmically contract, indicating the sperm to the correct opening of the fallopian tube.
The next stage for the sperm is the passage of the opening of the fallopian tube. It is very small, with a diameter of only a few sperm heads, so sperm that move randomly will not be able to enter it. Only spermatozoa with fast and rectilinear movement overcome this stage.
Once in the fallopian tube, the sperm are in a fairly favorable environment, attach to the walls of the tube and wait for the egg to exit. In this state, they can be quite long - about 48 hours.
The exit of the egg from the ovary is accompanied by an increase in temperature in the fallopian tube by 1-2 degrees, which serves as a signal for sperm hyperactivation. They begin intensive tail movements, detach from the wall and quickly move towards the egg. At this stage, 6-8 sperm remain, and they have several hours to fertilize the egg, as its life span is very short.
Compared to the sperm, the egg is a rather large cell, the largest in the human body. After exiting the ovary, it is surrounded by a cloud of cells called follicular cells, through which sperm must penetrate before they come into contact with the surface of the egg. To pass through follicular cells, sperm cells must use the intense style of movement (hyperactivation) that they used to separate from the walls of the fallopian tube.
After the follicular cells pass to the ovum, 1-2 spermatozoa get, which need to get inside. To do this, the sperm has a sac of enzymes at the very top of the head, which bursts as soon as the sperm comes into contact with the outer surface of the egg. These enzymes help dissolve the outer membrane of the egg and, combined with powerful tail movements, help the sperm to penetrate the inside of the egg. As soon as the sperm enters, the egg membrane changes its chemical properties and becomes completely impenetrable to the rest of the sperm. After the sperm merges with the egg, an embryo forms and pregnancy begins.
If the sperm is functionally immature and does not contain the necessary signaling molecules on its surface, it will not be able to come into contact with the egg, and fertilization will not occur. There is a rare anomaly - globuloseospermia, when the sperm do not have a conical, but a round head. The reason for this is the lack of a sac with enzymes (acrosomes), which also eliminates the penetration of the sperm inside the egg.
Diagnosis of male infertility
Diagnosis of male infertility includes the following required methods:
- Inspection and history taking (medical history). The doctor examines and palpates (palpating) the organs of the reproductive system, which allows you to diagnose conditions such as varicocele, cryptorchidism, developmental anomalies of the male genital organs. Using the survey, the patient is revealed to have hereditary conditions, chronic diseases, injuries and surgeries, and sexual life features that can affect the likelihood of conception.
- Sperm analysis (spermogram). A man sperm for research through masturbation. The study requires men to certain restrictions - to exclude heavy physical exertion, alcohol consumption, as well as sexual abstinence for 3-4 days before the study.
After passing the sample, the sperm is examined in the laboratory, the total number of sperm, the number of sperm with an irregular shape (morphology), as well as the speed and nature of the movement of the sperm are estimated. Sperm analysis is quite complicated, performed manually and depends on the qualifications of the specialist performing it. It is recommended to perform sperm analysis in specialized laboratories located at infertility treatment centers.
If sperm analysis does not reveal deviations from the norm, then before further in-depth examination of a man, a thorough examination of the woman should be carried out to exclude her factors that impede pregnancy.
If deviations from the norm are identified, a further examination plan is drawn up individually, depending on the results of previous studies and may include the following methods:
- Ultrasound examination of the scrotum. This test allows you to identify varicocele, changes in the structure of the appendage and testicle, indicating the presence of an inflammatory process or impaired patency of the vas deferens.
- Dopplerography of the scrotum vessels - a method for assessing blood flow through the vessels of the testis, the most accurate method for diagnosing varicocele.
- Transrectal ultrasound - allows you to evaluate the structure of the prostate gland, which is important in the diagnosis of infections of the additional male glands and obstruction of the vas deferens.
- Urethral swabs for urogenital infection. Some urogenital infections, such as chlamydia, can occur secretly, but at the same time have a negative effect on sperm parameters.
- Bacteriological examination of sperm. The study reveals the presence of bacterial infection in semen. A mandatory research method for suspected infection of additional male genital glands.
- Determination of blood hormone levels. Used with low sperm count. Hormones affecting spermatogenesis are evaluated: follicle-stimulating hormone, luteinizing hormone, testosterone, estradiol. According to special indications, hormones of the thyroid gland and adrenal glands are determined.
- Genetic tests. A mandatory study in the absence of sperm in semen or their extremely low concentration. The study may include analysis of deletions in the Y chromosome (absence of specific regions on the Y chromosome), assessment of the karyotype (number of chromosomes), assessment of mutations in the gene responsible for cystic fibrosis (CFTR).
- Biochemical study of sperm. Allows you to evaluate the concentration in the semen of substances secreted by a particular gland. For the epididymis, this is alpha-glycosidase, for the seminal vesicles - fructose, for the prostate - zinc and citric acid. The absence of one or more of these substances allows you to confirm the diagnosis of obstruction of the vas deferens and suspect its level.
- Testicular biopsy. Used to assess the preservation of spermatogenesis in the testis in the absence of sperm in the semen. In the case of sperm obtained as a result of a biopsy, they must be cryopreserved to avoid repeated operations. Biopsy techniques are discussed below.
- Assessment of sperm DNA fragmentation. The method allows you to estimate the number of sperm containing damaged genetic material (DNA with breaks). The use of this method is indicated for pregnancy loss (miscarriage, missed pregnancy) in the early stages, as well as in the absence of conception against the background of normal spermogram indicators.
- HBA test. The test allows you to evaluate the functional maturity of spermatozoa, if possible bind to hyaluronic acid. Hyaluronic acid mimics the surface of the egg, if the sperm does not bind to hyaluronic acid, then it cannot interact with the egg.
Male Infertility Treatment
The tactics for treating male infertility depend on the cause that caused it.
- Varicocele - the elimination of this cause of male infertility is possible only through surgical treatment. The best results with regard to the frequency of pregnancy and the level of postoperative complications are shown by microsurgical subinguinal varicocelectomy.
- Vas deferens - In some cases, impaired patency of the vas deferens can be restored surgically.The best results have the following operations: vasovasoanostomosis (they connect the ends of the crossed vas deferens).
For obstruction at the level of the epididymis, vasoepididyimanastomosis (the connection of the vas deferens with the duct of the epididymis) is used. The effectiveness of this approach is 60-87% and largely depends on the experience of the surgeon and the time elapsed since the formation of obstruction.
- Testicular biopsy - Surgical extraction of sperm from the testis and epididymis. This approach is mainly used for obstructive and non-obstructive azoospermia to obtain spermatozoa with the aim of their subsequent use in the IVF / ICSI procedure. The following testicular biopsy methods are used:
Fine needle testicular biopsy (TESA)
A thin needle is passed through the skin into the testicular tissue and aspiration (absorption) of the testicular tissue is performed, from which sperm are subsequently removed. The advantage of this technique is low trauma for the patient. The disadvantage is the low probability of detecting sperm with non-obstructive azoospermia (20-30%), which makes this technique justified only with proven obstructive azoospermia, when the probability of sperm is close to 100%.
Open testis biopsy (TESE)
A small incision is made in the skin of the scrotum - 1.5-2 cm, the testicle is secreted, its shell is dissected for a short distance. A small fragment of tissue is taken from the resulting hole, the incisions are sutured, and the resulting material is examined for sperm. The average probability of sperm detection in nonobstructive azoospermia for TESE is 40-50%.
Microsurgical testicular biopsy (microTESE)
The technique differs from TESE by the use of an operating microscope with a 15-20-fold increase, which requires a larger incision in the testicle, but will allow a detailed study of its tissue to detect and extract the expanded seminiferous tubules, which most likely contain sperm. The presented approach significantly increases the chances of sperm detection in comparison with random biopsy techniques (TESA, TESE). The average probability of obtaining sperm with nonstructural azoospermia for microTESE is 60-70%.
Drug therapy has several directions:
- Antibacterial drugs used in patients with additional male genital gland infection.
- Sexual Dysfunction Correction Drugs used if the patient has erectile dysfunction or premature ejaculation.
- Hormone therapy used if the cause of infertility is a violation of the level of sex hormones: low FSH, testosterone or high prolactin.
- Antioxidant therapy It is also used for idiopathic male infertility, since oxidative is the most common factor leading to impaired sperm quality.
Lifestyle correction - The main approach in the correction of idiopathic male infertility and an important complement in the treatment of the established causes of impaired fertility. The patient receives individual recommendations based on the characteristics of his life:
- normalization of work and rest (8 hours of sleep), avoid stressful situations,
- increase the amount in the diet of products containing polyunsaturated fatty acids (sea fish, seafood),
- minimize consumption of fried foods,
- caffeine consumption not more than 100 mg / day (1 cup of coffee),
- exclude cola consumption,
- minimize alcohol consumption, not more than 5 units (1 unit - 10 grams of pure alcohol) per week,
- exclude smoking / reduce the number of cigarettes consumed per day,
- increase physical activity (jogging, moderate physical activity),
- to exclude factors that heat the scrotum (hot baths, saunas, baths, working with a laptop lying on your knees, do not wear tight underwear),
- regular sexual life - after 1-2 days (3 times a week), do not use lubricants (lubricants) containing spermicides.
Assisted Reproductive Technology (ART)
The use of these methods is shown if pregnancy without the use of ART is impossible (azoospermia, ejaculation disorders), or infertility cannot be treated for 12 months from the date of diagnosis. Assisted reproductive methods include the following techniques:
- Artificial insemination with husband's sperm (IMSM) - it is used for violation of ejaculation (delayed ejaculation), impaired sperm penetration through cervical mucus, and as the first stage of assisted reproductive technologies prior to IVF. During this procedure, the husband’s sperm is inserted directly into the woman’s uterus through a catheter during ovulation.
- In Vitro Fertilization (IVF) - a procedure during which the interaction of the egg and sperm is carried out not in the body of a woman, but in a special vessel. At the same time, if for a man it requires only sperm delivery, the procedure for preparing a woman for IVF is much more complicated - hormonal stimulation is carried out, as a result of which several follicles containing ova mature in the ovary. To obtain the eggs, the follicles are punctured with a needle under ultrasound guidance. The interaction of sperm and egg can lead to the formation of embryos. Embryos are kept for some time in special conditions, 1-2 best ones are selected and transferred to the woman’s uterus. The remaining embryos can be cryopreserved and re-transferred to the uterus if the first procedure is unsuccessful. Pregnancy as a result of one IVF procedure develops in approximately 30% of women.
- Intracytoplasmic Sperm Injection (ICSI) - during this procedure, one sperm is taken and transferred through the needle into the egg. The rest of the procedure is similar to IVF. The main indications for using this method are low sperm quality (low quantity, low motility and a large number of spermatozoa with an abnormal morphology. The effectiveness of ICSI is higher than IVF - the pregnancy rate is 45%, but the safety of this method for posterity raises questions and has not been finally determined.
The prognosis for male infertility is mostly favorable. The use of modern treatment methods, including assisted reproductive technologies, in most cases allows to overcome the male factor and achieve pregnancy. An unfavorable prognosis for a man regarding the possibility of having children is usually associated with a complete absence of sperm, not only in the ejaculate, but also in the testicle (according to the results of a biopsy or in the presence of genetic factors that preclude the preservation of spermatogenesis).
Not all forms of male infertility can be prevented through prevention. But compliance with these simple recommendations can significantly reduce the likelihood of this condition:
- do not smoke, do not use drugs,
- drink alcohol in moderation, not systematically,
- active, active lifestyle (moderate physical activity) / maintaining normal body weight, avoid factors contributing to the heating of the testicles (tight underwear, laptop on your knees),
- avoid strong and prolonged stress,
- minimize / eliminate contact with harmful substances: pesticides, heavy metals and other toxins.