Infertility is defined as the situation where pregnancy does not occur within one year despite regular unprotected sexual intercourse 2-3 times a week. Infertility can be caused by the male or the female; there may be problems in both, or there may be no identifiable cause at all. In terms of proportions, infertility causes can be expressed as 40-50% related to the woman, 40-50% related to the man, and 10% as unexplained infertility where no cause can be found.
Infertility in Women
While investigating the cause of infertility in women, a gynecological examination and ultrasonography are performed. This evaluation can take place on any day of the menstrual cycle. Apart from problems like discharge or cervical erosion, the examination and ultrasonography can identify conditions that lead to infertility, such as endometriosis (chocolate cyst disease), polycystic ovary syndrome, decreased ovarian reserve, swellings due to tubal blockage (hydrosalpinx), intrauterine polyps, myomas, and uterine anomalies. During the examination, the thickness and regularity of the endometrium, the inner wall of the uterus, should also be examined. This is because the embryo will implant here, and a thin endometrium may indicate intrauterine adhesions.
Certain hormone tests are also requested from the woman while investigating the cause of infertility. Leading these are TSH (thyroid gland analysis) and Prolactin (milk hormone). Additionally, depending on the examination, FSH, estradiol, AMH, blood sugar, and insulin tests may be requested. In women with a history of miscarriages, coagulation tests and genetic tests should also be performed.
One of the procedures requested from the woman is a uterine film (HSG). HSG should be taken within one week after the end of menstruation. The uterine internal cavity is seen in detail in the film, providing information about polyps, myomas, and uterine anomalies. During the uterine film, the passage of the administered dye through the tubes is examined; at this stage, we can see blockages in the tubes and associated swellings (hydrosalpinx). Therefore, the uterine film is an important diagnostic tool showing both the tubes and the uterine internal cavity. Contrary to popular belief, it is not a painful procedure; when performed by a skilled professional, it does not cause pain or any problems.
Infertility in Men
A semen analysis should be performed on the male while investigating the cause of infertility. The man is asked to provide a sperm sample after 3-4 days of sexual abstinence, and the sample is evaluated in terms of count, motility, and morphology. In couples where a sperm problem is detected, IVF treatment can be initiated directly depending on the level of the problem, or ovulation tracking or intrauterine insemination (IUI) may be recommended for mild issues. Cases with no sperm in the semen are called azoospermia, and a microTESE surgery is recommended to find sperm in the testes under a microscope. In half of the cases with no sperm in the semen, sperm can be found in the testes, and pregnancy can be achieved through IVF treatment. Occasionally, there may be blockages in the sperm ducts; in couples where there is no sperm in the semen due to blockage, sperm can be obtained with just a needle without the need for surgery. IVF treatment is then applied to the couple using the sperm obtained this way.
What Needs to Be Done for Infertility Treatment?
First, the woman visits a doctor and is examined. As in other branches of medicine, there are sub-specialties in obstetrics and gynecology, and couples with infertility problems should apply to gynecologists with knowledge and experience in this field. Otherwise, we occasionally see couples in our daily practice who lose time with ovulation-stimulating medications for long periods, thereby decreasing their chances of conceiving.
However, semen analysis should be the first test performed in an infertility investigation. Today, the rate of the male factor has risen to 60%. Azoospermia, the problem of having no sperm in the semen, is seen in approximately 10% of infertile couples.
Sometimes we see that women undergo ovulation tracking for long periods, but in reality, there is a problem with their partner’s sperm. Late performance of sperm analysis leads to such unnecessary follow-ups. Of course, infertility treatments do not consist solely of IVF treatment. Significant pregnancy rates can also be achieved through ovulation tracking, IUI, or endoscopic surgical methods.
However, evaluation by an experienced physician at IVF centers where all these treatments are performed together will prevent both time and financial loss, and the chance of achieving pregnancy will be high.
How is Infertility Treated?
In the last 20 years, infertility problems and treatments have been discussed more frequently. In fact, it is suggested that the rate of infertility has not increased, but it is now being voiced more by society. Consequently, applications to physicians to solve the problem have also increased. Infertility is a sterility problem.
Today, infertility issues are investigated like other diseases, and treatment is possible through both medication and surgical methods. Especially in countries like ours, the primary role in the infertility treatment process seems to belong to the woman.
First, the woman visits a doctor and is examined. However, semen analysis should be the first test performed in an infertility investigation. Today, the rate of the male factor has risen to 60%. Azoospermia is seen in approximately 10% of infertile couples. Sometimes we see that women undergo ovulation tracking for long periods, but there is actually a problem with their partner’s sperm. Late sperm analysis leads to such unnecessary follow-ups.
As a result of all these detailed examinations, the cause of infertility is attempted to be identified. After revealing the cause, we discuss treatment alternatives with the couple. When deciding on the type of infertility treatment, it is correct to consider the woman’s age, the duration of the couple’s marriage, and the woman’s ovarian reserve, and to choose the treatment method accordingly.
If the woman’s age is over 35 and the marriage duration exceeds five years, it is necessary to turn to assisted reproductive treatments, IUI, and IVF as much as possible. Similarly, if the woman’s egg reserve is decreased, it is best to switch to assisted reproductive treatments to speed up the process. Patients for whom we recommend ovulation tracking and timed intercourse are generally young and newly married couples; polycystic ovary patients can also conceive during these follow-ups.
Aspiration/Vaccination treatment (IUI) is generally recommended for couples where at least one tube is open, there is no serious sperm problem, and the woman is under 38-40 years of age. Ovulation tracking, IUI, and IVF treatments all start on the 2nd-3rd day of the period. The ovulation tracking process lasts 10-12 days, and during this period, different drugs or injections are applied according to the treatment method. At the end of this process, if spontaneous ovulation tracking was performed, intercourse is recommended. If IUI is planned, the sperm is prepared in the laboratory at the exact time of ovulation and administered into the uterus with a thin catheter. It is expected that the sperm will find and fertilize the egg spontaneously. The sperm sample is prepared by selecting the best sperm in the laboratory and these selected sperm are left in the uterus. In IUI, the sperm finds the egg spontaneously, and fertilization occurs in the woman’s tubes. Therefore, IUI is not recommended if there are serious problems in the woman’s tubes or the sperm. IUI treatment ends in 15 days, and coming to the hospital or clinic 2-3 times in total is sufficient. Since the ovaries are only mildly stimulated, the woman’s daily life is not affected. Rest is not required after IUI, and it is even recommended to continue sexual life.
IVF (In Vitro Fertilization) treatment is also started on the 2nd-3rd day of the period. In this treatment, which is completed within 20 days in total, the first part is the section where the ovaries are stimulated; the hospital is visited 3-4 times, and the ovaries are stimulated with injections during this process. This stage is important because there may be a risk of ovarian hyperstimulation, and when we see this situation, it is necessary to take some precautions and postpone the embryo transfer. After the ovaries are stimulated, the eggs that reach sufficient size are collected under anesthesia. The egg collection process takes 15-30 minutes, and a sperm sample is taken from the male on the same day. The mature eggs obtained are fertilized with the best selected sperm; this process is called microinjection (ICSI). If fertilization occurs the next day, embryos are formed, and the embryos are monitored in the laboratory for 3-5 days. At the end of this monitoring process, one or two of the best embryos are selected and placed into the uterus with a thin catheter. This procedure is the embryo transfer process, which takes 5 minutes and is performed in the normal gynecological examination position; as it is performed with a full bladder, there may be discomfort from that. Since the uterine cavity is seen more clearly when the bladder is full, the bladder should be full during embryo transfer. A pregnancy test is performed in the blood 10-12 days after the embryo transfer to determine whether pregnancy has occurred. Using certain medications after embryo transfer increases the probability of pregnancy; therefore, attention should be paid to the use of medications.
In summary, infertility treatments and IVF treatment are planned as a result of a detailed examination of couples and are no longer difficult to apply today. Detailed examination performed before starting these treatments, whose success rates vary between 20-80%, increases the probability of getting a positive result. Correcting the problems detected during these examinations will increase treatment success. In fact, sometimes spontaneous pregnancies can occur after correcting these problems even before starting treatment.
What are Infertility Rates?
When looked at as a ratio, causes of infertility can be expressed as 40-50% belonging to the woman, 40-50% belonging to the man, and 10% as unexplained infertility where no cause can be found.
What Other Treatments are Applied in Infertility Treatment?
Ovulation tracking, IUI treatment, endoscopic operations (concerning the uterus, tubes, and ovaries), genetic examinations, evaluation and follow-up for healthy pregnancy in couples with recurrent pregnancy loss, evaluation of secondary infertile couples seeking a second child, and egg and sperm freezing methods for cases undergoing cancer treatment are successfully performed in IVF centers.
Of course, the medical staff and technical equipment of the center become important at this point. What should be done to be successful in infertility treatments? First of all, the woman’s age is very important. Especially today, since the age of marriage and the age of having children have advanced, the group of advanced-age female patients has increased. As the woman’s age advances, it becomes more difficult to achieve pregnancy in these couples because ovarian capacity decreases and egg quality drops. The number of treatments increases, and consequently, the financial burden also increases.
Generally, couples wait until the woman reaches age 40 and go to IVF centers at age 40 or when irregularities in menstruation start. However, when the woman’s age advances, the success of IVF and infertility treatments also decreases, falling below 20%. Contrary to popular belief, it is often difficult to obtain results with these treatments, and multiple treatment attempts may occur. Therefore, if a couple wants a child and pregnancy has not occurred within 6 months, they should apply to an IVF center and first investigate the cause. If no problem is detected in the first evaluation, the couple can wait according to the physician’s recommendation, or infertility treatment stages can be initiated.
However, evaluating the woman’s ovarian capacity is especially important; leaving it to time and waiting can lead to results that may be impossible to compensate for in the future.
In which situations should one switch to IVF treatment in infertility treatment?
Couples with serious sperm problems, blockage of both tubes in the woman, a woman’s age of 38 or older, genetic problems, or advanced-age women with borderline ovarian capacity should switch directly to IVF treatment.
How Many Times at Most Can IVF Treatment Be Performed?
Although the generally accepted number is 3, this number increases as the woman’s age advances. While more than 10 IVF treatments are performed in some other countries, there is no medically determined upper limit for this number; the family’s financial and moral characteristics determine this number. It is known that high numbers of attempts do not threaten women’s health.
Do Medications Used in Infertility and IVF Treatments Put the Woman into Early Menopause? Do Eggs Deplete Early?
This is a misconception. Normally, at least 10 eggs grow in a woman every month, and only one of them becomes mature for ovulation that month while the others regress and stop growing. The injections used in IVF treatments allow these eggs that would otherwise regress to continue growing, thus ensuring the development of many eggs that month.
How Long Do Infertility Treatment and the IVF Treatment Process Last?
This process varies according to the woman’s ovarian capacity and age, and treatment is completed within 15-40 days. Spouses do not always need to accompany the woman; the woman can come to the center alone or with a close friend during follow-ups. Infertility investigation and treatment is a process. In fact, it is the infertility problem itself and this process that cause stress in couples. However, staying calm during this process is constructive for the couple’s health and family relationship. It is recommended to get help from the treatment center on this matter. Sharing the treatment process with your family and surroundings can occasionally increase your stress; it would be more appropriate to share your treatment process with as few people as possible.
Prof. Dr. Banu Kumbak Aygün
