When love does not yield results - possible causes of undesired childlessness.
There are diverse causes of undesired childlessness and these rarely
arise from real illnesses such as diabetes or other metabolic illnesses.
Of course, personal circumstances such as stress, smoking or obesity
can influence the chances of becoming pregnant. In 80% of cases,
both partners are factors which compound the difficulty of conceiving.
As a result, a lot of small problems can sometimes lead to one big
problem….
Examination of the woman:
Female cycle
In order to help you to better understand the complicated processes
which are necessary in the lead up to implantation in the endometrium,
we will now give you an overview of the natural course of the female
cycle.
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The female menstrual cycle normally lasts 28 days, beginning on
the first day of menstrual bleeding (period) and ending on the day
before the start of the following period. A dominant egg follicle
begins to grow in one of the ovaries
during the woman’s period, which can last between 3 and 7
days.
A single follicle grows throughout the monthly cycle through the minutely
synchronized interaction between the ovary and the pituitary gland
(hypophysis)
An ultrasound scan in the vagina can provide a detailed image of
the ovary and the number of follicles present can be counted. Based
on this number of follicles, the doctor can estimate how well the
ovaries will react to possible
future hormone stimulation.
The follicles generally contain one egg cell. As a result of the
release of hormones through the pituitary gland (hypothalamus),
just one follicle containing a fertile egg cell matures monthly.
This one follicle can open at the right moment (ovulation)
and release its contents along with follicle fluid and egg (oocyte).
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Ovulation may not occur if the follicle has not reached the required
size. In terms of reproductive medicine, this is often the case
in older women. Conversely, ovulation often does not occur in young
women because the pituitary gland is not yet capable of supporting
the maturing of the follicle to the extent needed.
After ovulation, the follicle becomes a so-called corpus
luteum. The function of this corpus luteum is to influence the
implantation conditions in the womb so that pregnancy can occur.
In healthy women, the lifespan and function of the corpus luteum
is aligned to support the beginning of the pregnancy in the first
twelve days. Should the lifespan of the corpus luteum be shortened
(less than ten days) as a result of unhealthy circumstances or if
the function of the corpus luteum
is reduced to the extent that the endometrium can not be sufficiently
prepared for the implantation of an embryo, then this is referred
to as corpus luteum weakness or
luteal insufficiency.
Hormones:
Hormones
are signals which are sent out by one of the body´s organs
to have an effect on another organ. The following hormones play
a role in assessing the menstrual cycle:
Hormones
Oestradiol is the main female sex hormone. It is produced
in growing follicles and released into the blood. The larger
the follicle grows during its development, the more this hormone
is distributed through the blood. If several follicles mature
in both ovaries (for example through hormonal stimulation
of the ovaries) then the concentration of oestradiol is higher
in relation to this.
Progesterone is the corpus luteum hormone. It is mainly
produced through the corpus luteum in the second half of
the cycle and initiates the release of special nutrients
through the endometrium.
FSH is the hormone which
stimulates the follicle. It is produced in the front part
of the pituitary gland and is responsible for the maturing
of the follicle. On the one hand, FSH stimulates the creation
of oestrogen in the follicle and on the other, it stimulates
the creation and activity of cells in the inner follicle (granual
layer cells) that are connected to the egg cell and provide
the latter with nutrients.
LH is the luteinising hormone. Like FSH, it is produced
in the front part of the pituitary gland and ensures both
the production of small amount of male sex hormone in the
inner ovary and the release of a mature follicle in the
middle of the cycle. In the second half of the cycle (luteal
phase), it stimulates the production of progesterone through
the corpus luteum.
Prolactin is the hormone
which stimulates the production of milk. It induces the production
of milk in the female breast following childbirth. Like FSH
and LH, it is produced in the pituitary gland. In some infertile
women and men, this hormone is overproduced and thus leads
to irregularities in the progress of the cycle or to weakness
in the ovaries or testicles. Prolactin is a hormone which
can be released in larger amounts as a result of internal
or external stress.
HCG is the pregnancy hormone. This hormone is produced
by cells in the "Schwangerschaftshülle" (not
by the embryo itself) and stimulates the release of progesterone
in the corpus luteum of the ovary. A sufficient supply of
progesterone in early pregnancy can only be guaranteed through
a steady and dynamic increase in the amount of HCG released.
Examination of the womb and the fallopian tubes
Ultrasound: Should
an ultrasound examination reveal irregularities in the endometrium,
then this could signal a benign change in the membrane. Such a so-called
polyp can alone be a factor which prevents the implantation of the
embryo. A further examination is necessary in order to confirm this
diagnosis and to establish the size, number and position of the
polyps. This second examination involves viewing the womb cavity
with the aid of sterile cooking salt.
During this examination, a narrow tube is inserted through the cervical
canal and into the womb cavity. Then the sterile water is injected
into the womb cavity whilst being viewed through the ultrasound.
In this way, the shape of the womb cavity as well as possible irregularities
in the endometrium can be assessed. This examination is almost always
painless. Polyps in the endometrium are found in around 5% of women
who are childless for unknown reasons.
Hysterosalpingo-contrast sonography
(echovist):
In a similar examination, a possible blockage of one or both fallopian
tubes is tested through the use of a sugar-based contrast substance.
In such cases, the possibility of opening a blocked fallopian tube
through an operation or of carrying out test-tube
fertilisation from the outset exists. It is particularly important
to weigh up the risks here because the fallopian tube can be opened
through an operation but the price is an increased danger of ectopic
pregnancy.
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Laparoscopy: A detailed
examination of the fallopian tube function is possible through laparoscopy.
An optic with a camera is inserted through the navel into the abdominal
cavity after this cavity has been filled with carbon dioxide using
a needle. This operation, which can only take place under full anesthetic,
allows a direct examination of the abdominal area including the
fallopian tubes. In addition, this method provides the opportunity
of carrying out operative measures simultaneously. In this way,
blockages of the fallopian tubes, which restrict their mobility
and thus prevent the collection of the egg cell during ovulation,
can be overcome. Abnormal changes such as endometriosis
can in some cases be diagnosed and removed.
Transvaginal endoscopy (laparoscopy):
This operation method (endoscopy)
does not involve making a hole in the navel. In this case, the surgeon
inserts the optic through a tiny opening in the vagina and can thus
examine the fallopian tubes and the womb. It is an uncomplicated
process. Nevertheless, one must be aware of the limitations of this
method, as complex removal of concretions in the abdominal cavity
and other large operative measures remain beyond the scope of the
classic laparoscopy.
Examination of the man:
Certain factors which prevent pregnancy occurring can just as often
be attributed to the man as to the woman. The examination of male
fertility takes place through a spermiogram
(ejaculate analysis). Here, the number, movement and shape of the
semen cells (sperm) in the seminal
discharge are assessed. The diagnosis of factors leading to male
infertility is not only drawn from the analysis of the spermiogram
but also from the further examination of the male genital organs.
Male genital organs::
The assessment of the male genital organs with the aid of ultrasound
plays an important role here, although the volume of the testicles
is also examined (amongst other factors). In addition, the possibility
of the existence of a tumour can in this way be eliminated. Furthermore,
the vascular consistency of the testicles and penis can be examined
through the Doppler method. The physical examination, which is undertaken
by an urologist, pays particular attention to the following:
Testicle volume and consistency (firm or soft), the presence of varicose
veins next to the left testicle, the shape of the penis (particularly
the position of the urethra) and possible cysts in the scrotum or
in the epididymis. The results of this clinical examination can
validate and enhance the interpretation of the spermiogram and can
be compared to the results of the laboratory tests and thus better
assessed. The spermiogram only reflects the current state of the
man`s fertility. As a result of this, it is worthwhile to repeat
the spermiogram analysis after a reasonable time period.
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Sperm sample, spermiogram:
The analysis of your semen sample in the laboratory comprises the assessment
of a diversity of elements, which are considered as a whole in order
to evaluate the quality of the semen. The three most important factors
here are:
- the concentration of sperm (the number of sperm per ml of seminal
discharge)
- the movement of the sperm in the liquid semen
- the shape of the sperm
As well as these three factors, a large amount of additional data is
measured as part of the seminal discharge. This data allows us to
assess the quality of sperm in detail and thus to also recognize
rare forms of male infertility.
Explanation of terms related to sperm analyses
The following terms are often used in the assessment of male infertility
and are therefore explained here:
Sperm analysis
1. Oligozoospermia: Too few sperm are present in the seminal discharge: less than twenty million semen cells are found in one milliliter of seminal fluid.
2. Asthenozoospermia: The movement of the sperm is impaired:
less than half the sperm move forwards in the ejaculation
fluid
3. Teratozoospermia: Less than 30% of the semen cells in the seminal discharge have a normal shape. This can apply to deformities of the sperm tail, middle part or head.
4. OAT-Syndrome: (Oligoasthenoteratozoospermia) a term which is often used to describe difficulties in all three parameters.
5. Azoospermia: No sperm can be identified in the seminal discharge. In order to be absolutely certain that no sperm are present, a concentrate of the fluid is created using centrifugal force (spinning). The concentrate is then carefully examined under a microscope. Azoospermia occurs if sperm are not produced in the testicles or if there is a complete closure of the urethra.
6. Parvisemia: The volume of the seminal discharge amounts to less than two milliliters. Parvisemia can indicate a blockage in the prostate or in the semen sacs. Even if a large amount of sperm is present, parvisemia leads to a lower ability to conceive, as fewer sperm find their way into the womb or fallopian tubes.
Hormone Test:
A hormone test is done in addition to consultation with the doctor,
the physical examination and the microscopic examination of the
sperm quality. For this, we take a blood sample, in which the concentration
of a number of hormones which are important for the assessment of
your fertility is analysed: e.g. LH, FSH and testosterone. LH,
FSH and Testosterone.
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