Congenital Disorders

• Cryptorchidism> 1 year (should be operated on at 8-12 months of age)
• "Wandering testicles"
• Hypospadias
• Phimosis
• Varicose veins of the spermatic cord in stage III
• Hydrocele of the testicles (injuries, damage to the blood/testicle barrier)

Past or ongoing diseases

• Diabetes - infections, vascular disorders
• Hypertension - medicines
• Inflammation of the genitourinary system (endotoxins, immunology)
• Chronic inflammation of the respiratory system - Kartegener syndrome
• Gastric and duodenal ulcer disease - medicines
• Parotitis - mumps during puberty

Previous surgery on the genitourinary system

• Catheterization (infections, injuries)
• Breaking stones (through the ureter, ultrasound)
• Prostate resection.
• Stimulants - steroids, alcohol, cigarettes - drugs – quantity and period of time

• Penis
• Kernels
• Varicose veins of the spermatic cord
• Hydrocele of the testicles – ultrasound

Lifestyle

• Tight underwear, tight thick pants
• Sedentary work style (desk work, driver, "busy white collar")
• Overuse of the sauna

Recommendations

• Loose underwear, looser pants, seat beads/rings, contoured seats
• Weight loss

Occupational exposure:

Chemicals

• Varnishers, painters, employees of printing houses, gas stations, car workshops (solvents, heavy metals)
• Farmers, fruit growers, greenhouse workers - without health and safety regulations
• Work at high temperatures - cooks, bakers, metallurgists

Most often we deal with idiopathic infertility, i.e. with an unknown cause.

Abnormal semen analysis results require consultation of a urologist or andrologist. Diagnosis should be extended to additional semen analysis and hormonal tests.

Medical interview

• Does he have children?
• What is their age?
• Has anything happened in man's life since their conception - illness, surgery, stimulants/addictions.
• Was he with another partner with whom he wanted to have children?
• Does the ex-partner have children with another partner?
• What is his profession? Where does he work?
• Did he have any operations?
• Does he have a chronic illness - genitourinary system diseases, hypertension, peptic ulcer disease?
• Are there Any hereditary diseases in the family?
• Does he have a brother? Does the brother have children? - exclusion of the possibility of genetic disorders.
• Does he take any medicine?
• How often does intercourse with his partner occur?
• Is he addicted? To what? For how long?

General semen analysis

Basic study in which sperm we assess a concentration in 1 ml, total sperm concentration in the entire ejaculate volume, motility, viability and sperm morphology. In addition, the concentration of round cells and leukocytes is marked.

Semen culture

In the case of a suspected genitourinary tract infection or an increased leukocyte concentration in general semen analysis it is recommended to perform cultures of semen: aerobic, anaerobic and mycogram.

Swim-up

Migration test examining the ability of sperm to transfer from semen plasma to another environment. The correct value is > 3.0 million/ml.

HBA

Hyaluronan-sperm binding assay testing the percentage of mature and functional spermatozoa. The correct value is> 80%.

MAR

Test for the presence of sperm antibodies.

Sperm Chromatin

Sperm DNA fragmentation test to determine what% sperm may have damaged genetic material.

Citric acid

Marker of prostate function.

Fructose

Seed follicle marker

Neutral alpha-glucosidase (NAG)

Epididymal marker.

Oxydoreduction potential

Test determining the ratio of free radicals to antioxidants that can neutralize them in semen.

It should be remembered that spermatogenesis, i.e. the process of sperm formation, lasts about 12 weeks. In the event of abnormal semen analysis, we recommend repeating it.

It is important to perform the test:

• while being healthy,
• after a possibly normal lifestyle.

In the event of an abnormal sperm test, the patient is usually referred to an urologist-andrologist in order to broaden diagnostics and possible treatment to improve parameters.

If azoospermia is diagnosed, the chance for these patients is to perform a classic testicular biopsy, thanks to which it is possible to obtain sperm for the IVF - ICSI procedure.

In case of an incorrect HBA test result, it is possible to use additional sperm selection, pICSI, thanks to which the embryologist selects only mature spermatozoa and fertilizes egg cells with them.

With an abnormal sperm chromatin fragmentation result, it is possible to use magnetic sperm selection, eliminating the spermatozoa in which the process of apoptosis has begun.

In the case of infertility lasting more than a year, after confirmed correct ovulation and patency of the fallopian tubes and semen> 5 million/ml, the couple may be directed to insemination (IUI).

• Inflammation
• Abdominal surgery
• Fibroids
• Polyps
• Opening of the uterine cavity,
• Cervical procedures
• Ectopic pregnancies
• ▪umerous curettage of the uterine cavity

• BMI determination - PCO hazard> 30, BMI> 40 - extreme obesity.
• Scars after surgery and laparoscopy
• Features of androgenization
• Insulin resistancy - acantosis nigricans
• Changes at the entrance to the vagina
• Cervical lesions - large erosion
• Change in PH- inflammation
• Soreness/tenderness during examination - suspected endometriosis, adhesions
• Nodules behind the uterus - suspected endometriosis
• Ultrasound examination
• Uterus: fibroids, polyps, defects in septum, arcuate uterus, bicornuate 3D, adenomyosis
• Ovaries - size assessment, cysts, PCO, antral follicles
• Hydrocele of the fallopian tubes
• Fluid in the abdomen - the possibility of inflammatory lesions, endometriosis.

Medical interview

• Was the patient pregnant?
• If so, how did the pregnancy end? Miscarriages, Caesarean section, vacum, ticks, manual placenta separation, curettage after delivery, inflammation.
• Age of first menstrual period?
• Length of monthly cycle?
• <23-25 ​​means ovarian extinction, > 35 days is usually PCOS
• How long does menstruation last (up to 7 days), its flow.
• Past diseases, including chronic diseases?
• Is the patient permanently taking medication? What medication?
• Diseases in the family (e.g. diabetes - the possibility of insulin resistance)?
• Is there a galactorrhoea?
  a particularly important aspect in breastfeeding for multigravida/check yourself in a physical examination
• Previous operations?
• Past inflammation of the vagina?
• Painful intercourse?
• Has the patient been treated for infertility?
• If so, with whom (it is important) and for how long? What tests did they do?
• Have any assisted reproduction procedures been performed yet? What was the outcome?

The aim of the tests is to assess the hypothalamic-pituitary-ovarian axis.

Hormonal tests performed on the 3-5 day of the cycle: FSH, LH, E2, PRL

tests are performed between 8-10 am, preferably 2 hours after waking up.

Interpretation of FSH

FSH <12 IU norm.

FSH 15-20 IU - very little chance of getting oocytes - direct in vitro qualification.

FSH> 20 inability to obtain egg cells - qualification for a donor cell. FSH> 10 repeated 2 times in young patients may indicate extinction of ovarian function.

LH/FSH interpretation

LH/FSH = 1 - standard.

LH/FSH> 2 indicates PCO-s and the possibility of no ovulation.

Interpretation of the PRL

PRL is measured in the morning on an empty stomach 2 hours after waking up.

The PRL norm for women is 1-25 ng/ml, the PRL norm for men is 1-20 ng/ml.

About 1% of the population has hyperproalktinaemia,

5 - 14% of women with secondary amenorrhea, 75% with galactorrhoea and primary amenorrhea,

30% with pituitary microadenoma (PRL> 50-100 ng/ml).

Contrast magnetic resonance imaging (MRI) should be performed and treatment with carbergolin should be initiated

½ tabl. 2 x a week or 1 tabl. Once a week.

Tests done at any day of the cycle:

• AMH, TSH, FT4, FT3
• TPO and TG thyroid antibodies
• IgG IgM anti-cardiolipin antibodies
• Vit D3, Helicobacter pyroli
• Insulin resistancy: glucose and insulin concentration after a 75 g glucose dose consumption at 0-60-120 min.

Thrombophilia testing done for miscarriages or ineffective in vitro procedures

• Protein S, Protein C, AT III
• Mutation of the Prothrombin gene
• MTHFR mutation
• Factor V Leiden mutation
• PAI, HPA1-a
• Lupus anticoagulant

Karyotype in both partners

AMH interpretation - currently the most important ovarian reserve marker. Low

AMH depending on age indicates the extinction of ovarian function.

The norm is AMH 1.5-4.0 ng/ml,

AMH 0.5 - 1.5 ng/ml, - reduced ovarian reserve, quick diagnostics: in vitro or insemination (IUI) when the couple do not want or cannot carry out IVF.

AMH <0.5 ng/ml, - means extremely reduced ovarian reserve - difficulties in obtaining follicles in the in vitro procedure, consideration of the donor cell after unsuccessful cycles.

AMH> 4.0 ng/ml suggests suspected PCO syndrome. In older patients, PCO-s may mask ovarian reproductive failure.

Interpretation of TSH, FT4 FT3, ATA - thyroid function assessment. Frequent hypothyroidism reduces the chance of pregnancy. Antithyroid antibodies may suggest an active immune process. Properly adjusted treatment can affect a woman's fertility. Ideally, TSH values fluctuate around 1,

Vitamin D3 concentration

There was a clear seasonality in getting pregnant depending on vitamin D3 concentration. Balancing deficiencies can significantly affect fertility.

Techniques for assessing tubal patency:

Sono HSG (based on ultrasound) - good visibility of the uterus, average visibility of the fallopian tubes, no relation between the ovary and the fallopian tube, no assessment of the fallopian tubes. High costs of contrast agents. The procedure is easy to perform and not very painful for the patient.

HSG (based on x-ray image) - good visibility of the uterine cavity and fallopian tubes. Time-lapse photography possible. No relation between the ovary and the fallopian tube, hyphae fallopian tubes not documented, low cost of contrast media, high cost of x-ray equipment. The need for an X-ray technician. Irradiation.

Hydrolaproscopy - (HSC and hydrolaproscopy). Great visualization of the uterine cavity, the possibility of visualization of the fallopian tubes and the relationship between them and the ovaries. The possibility of visualization of adhesions, endometriosis. No knowledge of the inside of the fallopian tube - assessment of post-inflammatory changes. Cannot be done with a rear bent uterus, pelvic adhesions. Poor documentation capability, need for intravenous anesthesia (anaesthesiologist, nurse, instrumentalists), expensive equipment (HSC, hydroaproscope, video track). Possibility of intestinal and vascular complications. The procedure requires high operator skills.

Laparoscopy with HSC – excellent visualization of the uterine and abdominal cavities. Opportunity to visualize the ovary - oviduct relationship. Tubal hyphae evaluation.

Assessment of endometriosis, adhesions, fallopian tube patency. Lack of knowledge about the inside of the fallopian tube.

• assessment of post-inflammatory changes. The possibility of visual documentation. Necessity of an operating room, endotracheal anesthesia. Possibility of intestinal and vascular complications. Expensive equipment.
• laparoscope, hysteroscope, operating room. A large and expensive operational team.
• anesthesiologist, nurse, instrumentalist, assistance.

Preparation for HSG:

Vaginal culture with antibiogram. in the preceding cycle In the case of infection, treatment - the need to repeat, postponing in the event of inflammation.

From the 15th day of the cycle preceded by rinsing with Tantum Rosa 2 times a day (irrigator) + Metronidazole 0.5 twice a day for 10 days or Gynalgin 2 x1 into the vagina.

Having sex after menstruation before HSG procedures is prohibited.

HSG is performed on a fasting patient.

Anesthesia for any of the procedures requires biochemical blood tests as determined by the anaesthesiologist. All procedures require testing for infectious diseases, HBC, HCV, HIV, WR

Obstruction of both fallopian tubes is a direct indication for the in vitro procedure. In people who do not accept in vitro, sometimes, attempts are made to unclog the fallopian tubes with various techniques, but the effectiveness of these procedures is negligible.

Tubal patency does not mean its proper functioning.

The fact that the contrast passes through the fallopian tube is encouraging, but we still know nothing about the hyphal apparatus, the ciliary system in the fallopian tube and their relationship to the ovary. Our knowledge is slightly higher if patency is checked by hiseterolaparoscopy.

One blocked fallopian tube

One obstructed fallopian tube is an indication for intrauterine insemination (IUI) in a cycle where ovulation occurs in the ovary on the patent side.

It is appropriate to use slight ovarian stimulation to increase the chance of ovulation on the patent side. We then use cheap drugs such as clomiphene or letrozole. It makes no sense to carry out more than 4-6 inseminations because the total costs of these procedures outweigh the in vitro cost.

Lack of ovulation in hyperprolactinemia

There is often no ovulation in hyperprolactinemia. Lowering prolactin using carbergoline usually normalizes the cycle. Light stimulation with clomiphene or letrozole improves the results. It is necessary to exclude pituitary adenoma by MRI. We apply the procedure to patients up to approximately 33 years of age.

Lack of ovulation - PCO-s

As treatment for PCO, the following is recommended:

• Weight reduction in cooperation with a dietitian. This gives greater effectiveness than self-control, but still the effectiveness of therapy is low.
• At BMI> 35, bariatric surgery should be considered.
• Myo-inositol 2 x 1 dietary supplement - as an element supporting treatment.
• Metformin - additional support, especially with insulin resistancy.
• In the absence of ovulation in PCO-s, clomiphene stimulation is used 1x 1/2 tabl. 2-6 d.c. and ovulation monitoring.
• HCG chorionic gonadotropin is administered subcutaneously to burst the Graff follicle.

Lack of ovulation

Lack of ovulation is an indication for laparoscopic ovarian cauterization with a thin needle, not a spatula or hook. The cauterization procedure is not recommended for patients >38 years of age because it reduces the ovarian reserve.

After cauterization, the patient undergoes re-stimulation with Clomiphene. If there is no effect, we combine Klomifen and FSH (37.5-75IU). In the absence ofan effect, we recommend in vitro stimulation and the IVF procedure.

STIMULATION FOR IN VITRO

The goal of ovarian stimulation is to increase egg cell production.

Preparation for stimulation:

Irrigation Tantum Rosa 2 x plot + Metronidazole 2 x 1/10 days