Endocrine sterility is a condition in which hormonal disorders affect reproductive function. There are problems with conception: the quality of sperm is reduced, there are failures in the menstrual cycle, which provoke the irregularity of ovulation. Endocrine disorders affecting fertility usually occur in the thyroid gland, adrenal glands, hypothalamus and pituitary gland, sex glands. Every third patient with a diagnosis of infertility suffers precisely from problems with the endocrine system.
Endocrine sterility is a group dysfunction - a combination of hormonal disorders that affect the menstrual cycle in women and the quality of sperm in men. However, all these disorders lead to one thing - the malfunction of the ovaries and the lack of ovulation (or its irregularity).
Treatment of endocrine sterility consists of three stages:
- root cause elimination
- hormonal correction,
- control of hormonal background.
The prognosis after endocrine disorders is 70-80% of successful pregnancies. The remaining couples can turn to modern reproductive technologies that allow you to have children, even with a serious dysfunction of the reproductive system.
Who is at risk
Biological risk factors:
- age from 25 years
- the presence of cysts and tumors in the genitals,
- early onset or delay of the first menstruation,
- regular failures in the menstrual cycle,
- artificial termination of the first pregnancy
- bad heredity
- misuse of combined oral contraceptives,
- concomitant endocrine disorders
- urogenital diseases in history.
Social risk factors:
- harmful working environment
- the presence of industrial organizations in the village,
- bad habits,
- combination of work and study (in parallel with marriage),
- uncontrolled sex.
Causes and symptoms of endocrine disorders
The main symptom of endocrine infertility will be the absence of pregnancy with problems with the menstrual cycle: delays, severe pain, reduction or increase in the volume of discharge, metrorrhagia. More than 30% of women with this diagnosis do not ovulate, although the menstrual cycle is normal. In this case, you can talk about bleeding that mimic menstruation, but have a different nature.
Often women complain of pain in the abdomen and back, various discharge, cystitis, pain during sex. With an increase in the level of prolactin, there is tension in the mammary glands, and colostrum is released. Symptoms of PMS are worse.
If the cause of endocrine infertility is a high level of sex hormones, the symptoms will be as follows: acne, excess hair, baldness, drops in blood pressure, obesity, the appearance of stretch marks on the skin.
Causes of endocrine sterility
- Incorrect work of the hypothalamus and pituitary due to head and chest injuries, neoplastic processes in the brain, increased prolactin levels. The hormone prolactin inhibits the secretion of follicle-stimulating and luteinizing hormones, as well as the ovaries, which leads to a reduction in secretions in the menstrual cycle, the lack of ovulation.
- The predominance of male hormones in the female body (dysfunction of the ovaries and adrenal glands). A small amount of male hormones is necessary for a woman’s body, but their predominance leads to endocrine infertility, polycystic ovary, obesity, bleeding, absence of menstruation. If the level of male hormones grows under the influence of the adrenal glands, there is often a problem in the growth of the organ bark.
- With a deficiency of the luteal phase, a shortage of progesterone and estrogen develops. With a reduction in the level of female sex hormones, the natural process of endometrial transformation changes, and there is dysfunction of the fallopian tubes.
- Thyroid dysfunction. Lack of hormones of this gland and excessive hormone production by diffuse tissue (diffuse toxic goiter) lead to endocrine sterility due to the lack of ovulation.
- Obesity or thinness. Adipose tissue is part of the endocrine system. It takes part in the metabolism in tissues, in particular, the tissues of the reproductive system. Excess fatty tissue can cause an imbalance of hormones, which leads to disruptions in the menstrual cycle, and the lack of - problems with the ovaries.
- Premature menopause. Termination of menstruation (due to ovarian exhaustion) for a certain period in women 36-38 years old can cause menopause and endocrine infertility.
- Resistant ovarian syndrome (loss of connection between the pituitary and the ovaries). The syndrome is that the ovarian receptors stop responding to gonadotropins, which stimulate the release of the egg from the follicle. The syndrome develops after viral diseases, pathologies of pregnancy, stress, malnutrition, lack of vitamins.
- Chromosomal mutations. Diseases that occur as a result of pathologies at the genetic level, cause a shortage of female sex hormones, the absence of menstruation, sexual infantilism.
- Somatic pathologies such as cirrhosis, tuberculosis, malignant tumors, hepatitis, autoimmune diseases.
Diagnosis of the causes of endocrine infertility
General and gynecological examinations, as well as the study of history, help to find out many of the causes of endocrine sterility. Analyzes and tests are often needed only to confirm the diagnosis. Among the tests for endocrine sterility, measure basal temperature, ovulation tests, and ultrasound of the genitals.
General and gynecological examinations
When making a diagnosis, the doctor first of all clarifies the information on the menstrual cycle (duration, intensity of ICP, abundance of secretions). It is important to analyze the hereditary pathology. It also takes into account pregnancy history, the outcome of conception, complications after childbirth, the condition of the child. Be sure to consider all surgical interventions in the genitals and other manipulations, their nature and duration. The doctor separately considers the role of contraceptives in the patient's sexual life.
General inspection is aimed at assessing:
- female growth
- body mass
- mammary glands,
- sexual signs.
Gynecological examination is:
- determining the size of the vagina, uterus,
- assessing the condition of the cervix,
- assessment of the state of appendages.
Basal Temperature Measurement
A graph of basal temperature allows you to diagnose the absence of ovulation (anovulation). This temperature indicates the intensity of progesterone production by the ovaries. Progesterone is responsible for the transformation of the endometrium in the uterus, which is needed for better attachment of a fertilized egg. Basal temperature is measured in the morning by inserting a thermometer into the anus. In order for the graph to correctly display the state of the body, it is necessary to measure the temperature in the rectum every day.
On the day of the release of the egg from the follicle, the basal temperature indicators drop by 0.2-0.3 ° C. In the second phase, the temperature rises by 0.5-0.6 ° C. If there is no ovulation, then the basal temperature is kept below 37 ° C throughout the cycle (in combination with a reduction in the second phase).
Determination of hormone levels
You can confirm the presence of ovulation by determining the level of progesterone in the blood (less than 15 nmol / l), as well as pregnandiol in the urine. In a cycle without ovulation, indicators in the second, luteal phase will be low. Home tests for ovulation can determine the concentration of luteinizing hormone in the urine a day before the release of the egg.
To determine the causes of endocrine sterility allow tests for levels:
- follicle-stimulating hormone,
- luteinizing hormone
- thyroid stimulating hormone
- thyroid hormones (T3, T4),
- dehydroepiandrosterone sulfate.
The results can be considered correct only when taking tests for several cycles in a row. It is better to determine hormone levels on the 5th, 6th or 7th day of the cycle.
Ultrasound and postcoital test
Ultrasound helps to assess the process of maturation of the eggs in the follicles, determine the dominant follicle and find out the time of release of the egg. They also conduct an ultrasound of the adrenal glands and the thyroid gland. The postcoital test makes it possible to determine the characteristics of cervical mucus. When anovulating, the cervical number will be less than 10 points.
Biopsy and scraping
The condition of the endometrium depends on the work of the ovaries. In the absence of ovulation, an endometrial biopsy will show hyperplasia (excessive cell growth) or a lack of excretion of compounds by tissue cells. This is provided that the analysis is carried out 2-3 days before the expected onset of menstruation. Also on anovulation accompanies the absence of endometrial transformation.
Hormonal tests help determine the functionality of the genital organs at different stages of the menstrual cycle. The essence of the method consists in determining the natural hormonal background of a woman after stimulation with various drugs.
Types of samples:
- Progesterone test. Determination of estrogen levels in the absence of menstruation. Evaluation of the reaction of the endometrium of the uterus to the effects of progesterone. Determination of endometrial rejection at lower doses of the hormone.
- Dexamethasone test. Analysis of genesis in the excessive production of male hormones (adrenal glands or ovaries).
- Clomiphene test. Relevant for failures of the menstrual cycle and the absence of ovulation. The sample allows you to determine the concentration of steroid hormones in the follicle, as well as to assess the ability of the pituitary to form reserves.
- Test with tiroliberin. Analysis of the thyroid gland.
- Test with cercukal. Monitoring reactions between functional and organic increase in prolactin levels.
Other methods for diagnosing the causes of endocrine infertility:
- X-ray of the skull
- laparoscopy (diagnostic).
Talking about female endocrine infertility is possible only after exclusion of factors from the partner and vice versa. You should also study the functionality of the uterus, fallopian tubes and the immunity of the woman as a whole (immunological infertility).
Hyperprolactinemia can be diagnosed by two blood samples. Excessive production of prolactin often accompanies the pathologies of the pelvic organs (often caused by genital endometriosis). Treatment of endometriosis contributes to the settlement of prolactin and the onset of pregnancy.
An overabundance of prolactin on an ongoing basis can be combined with thyroid insufficiency. The lack of thyroid hormones, as the cause of hyperprolactinemia, is detected by examining gland hormones (levels T3, T4). The lack of thyroid hormones is eliminated with levothyroxine sodium. Treatment leads to the resolution of prolactin and spontaneous pregnancy.
Constant excessive production of prolactin may indicate a pituitary tumor (hormonally active prolactinoma). Diagnosis of the condition is performed by CT or MRI. Prolactinoma is eliminated surgically, by radiation or by medication. Even after the tumor is eliminated and prolactin levels return to normal, infertility may persist in patients. Further elimination of infertility depends on the symptoms.
Effect of gonadotropins and estradiol
Hypergonadotropic amenorrhea is a common cause of infertility - the absence of menstruation, an increase in FSH levels and a lack of estradiol. This phenomenon may be a manifestation of premature depletion of the ovaries or their changes, the underdevelopment of the sex glands or the insensitivity of the ovaries to gonadotropins.
Hypergonadotropic amenorrhea is diagnosed using ultrasound of the ovaries, studying the history, as well as karyotype studies and consulting genetics (in case of suspicion of underdevelopment of the sex glands). If the glands are developed and there are no age-related pathologies, the gonad biospia is used. The procedure makes it possible to investigate the follicular reserves for resistant ovarian syndrome (insensitivity to gonadotropins) or ovarian depletion syndrome.
A decrease in estradiol, FSH and LH levels indicates hypothalamic-pituitary insufficiency - destruction of the anterior pituitary, termination of secretion of tropic hormones and dysfunction of the peripheral glands (thyroid, parathyroid, adrenal). If the condition is caused by hereditary causes or has developed in childhood, there may be underdevelopment of secondary sexual characteristics, proliferation of the genitals, the absence of menstruation. This failure in the reproductive age stops menstruation or significantly reduces it.
With excessive production of male sex hormones, it is necessary to estimate the concentration of androgens. With a slight increase in testosterone, one can speak of hyperandrogenism caused by ovarian dysfunction. Often the disease develops on the background of obesity or sclerosis of the ovaries.
Dehydroepiandrosterone (DHEAS) is an adrenal androgen. Its increase suggests that the problem lies precisely in this body. A slight increase in the hormone indicates congenital hyperplasia of the adrenal cortex. The disease interferes with cortisol synthesis, which leads to excessive use of steroids in the process of androgen formation.
High levels of DHEAS in combination with severe symptoms of hyperandrogenism indicate a tumor in the adrenal glands or ovaries. To determine the localization of the tumor and its type, resorted to ultrasound and CT, hormonal tests (dexamethasone and tetracosactide), tissue biopsy.
To diagnose endocrine infertility on the background of hyperandrenogeny (without increasing testosterone and DHEAS levels), globulins that bind sex hormones, as well as fractions of free and bound testosterone, are examined. The analysis helps to determine the effect of globulins on androgens (the deficiency of the first intensifies the influence of the second). With the reduction of globulins worth checking liver. Other diseases that can reduce the level of globulins are usually detected in the early stages of diagnosing the causes of hyperandrogenism. This may be hypothyroidism, a surplus of cortisol in Itsenko-Cushing syndrome.
When identifying the causes of endocrine infertility in obese women, it is necessary to resort to standard glucose tolerance tests. Anomalies of glucose tolerance can cause infertility.
These disorders include:
- Hypothalamic-pituitary dysfunction. The hypothalamus and pituitary are responsible for the regulation of the menstrual cycle. Failure of these parts of the brain leads to impaired hormone production. In particular, there is an increase in prolactin levels.
- Polycystic Ovary Syndrome. The ovaries produce too many male hormones, which leads to the impossibility of ovulation and the formation of cysts.
- Hyperandrogenism. In this case, the number of male sex hormones in the woman’s body is higher than normal.
- Malfunctioning thyroid.
- Early menopause (ovarian depletion).
- Resistant ovarian syndrome. The ovaries stop responding to the action of hormones that stimulate the timely maturation of the egg.
Diagnosis of hormonal infertility
Functional diagnostic tests are used in medicine to determine the hormonal activity of the ovaries.
They also reveal the presence of ovulation. The attending physician may prescribe a calculation of the basal temperature schedule, ultrasound monitoring and ovulation test.
To determine if a woman has problems with ovulation, make a basal temperature chart. Today it is the easiest and cheapest way to reflect the production of progesterone by the ovaries, which should prepare the uterine mucosa for further development of the egg.
In order to make an accurate linear graph of basal temperature, the patient, immediately after waking up, measures the temperature in the rectum at the same time. The received data is recorded daily.
If the schedule is made correctly, analyzing its information, you can determine the beginning of ovulation (the first phase of the menstrual cycle with a temperature drop of 0.2 / 0.3 g. C).
The temperature in the second phase of the cycle should differ from the first one by 0.5 / 0.6 g. The duration of the second phase of the schedule is at least 12-14 days.
If ovulation is absent, the graph will turn out to be single phase. However, the two-phase graph of basal temperature does not provide a 100% guarantee that there was ovulation. However, the same can be said about the negative result of a single-phase graph. The basal temperature is greatly influenced by external factors: elementary fatigue, cold, etc. The graph will show whether it was ovulation or not. But, these results will be past.
To confirm ovulation can progesterone levels in the blood, which is determined in the 28-day menstrual cycle from the 19th to the 23rd day. With normal ovulation, the maximum level of progesterone will fall on the seventh day after ovulation. Usually, a doctor prescribes several blood tests for progesterone during one menstrual cycle. Только повышение содержание прогестерона точно скажет, была ли овуляция или нет.
Существуют и более точные методы определения наличия овуляции.
- тест на овуляцию – назначается анализ мочи на наличие лютеинизирующего гормона (ЛГ),
- ultrasound monitoring - ultrasound helps to determine the state of the dominant follicle and the possibility of its rupture (ovulation),
- endometrial biopsy.
The procedure takes about 10 minutes and is carried out in the usual gynecologist's office. Endometrial changes occur in response to progesterone production. Therefore, their presence indicates the beginning of ovulation. The tissue for analysis is taken from the uterus before the start of the menstrual cycle. It is processed in a special way and examined under a microscope.
Endometrial biopsy can be performed on the 26th day of the normal menstrual cycle or on the 12-13th day, when the peak of LH reaches its maximum.
In case of hormonal infertility, tests reveal various degrees of endometrial hyperplasia (growth of its structure with a change in glands).
To identify the causes of endocrine infertility in women, additional examinations are prescribed, including:
- Measurement of hormone levels: LH, prolactin, testosterone, FSH, thyroid. The analysis is assigned to 5/7 days of the menstrual cycle.
- Determination of progesterone levels. With the help of this survey determine the functional abilities of the corpus luteum. The analysis is scheduled for the 19/23 day of the menstrual cycle.
- Examination of the function of the adrenal cortex. The level of dehydroepiandrosterone sulfate is investigated.
A single determination of the amount of hormones in the blood sometimes gives incomplete information. Therefore, if any abnormalities are detected, repeat tests are assigned.
Doctors to diagnose hormonal disorders in the reproductive system prescribed hormonal tests. Their essence lies in the fact that the patient takes certain hormonal drugs and the reaction of their own hormones can be judged on the state of the reproductive system. For analysis, blood is taken and the level of hormone production is assessed by the body.
Treatment of hormonal infertility
Treatment of hormonal (endocrine) infertility in the first stage should normalize the endocrine system.
For example, the function of the adrenal glands, the thyroid gland is being adjusted, the treatment of diabetes mellitus, etc. The second stage of treatment is aimed at stimulating follicle maturation and stimulating ovulation. Therapy is carried out drugs.
Ovulation is stimulated by clomifencitrate (drugs clomid and clostilbegit). Clostilbegit fits most patients. In addition, it is not only effective, but also inexpensive. Klomifentsitrat affects the pituitary gland and causes an increase in the amount of the hormone FSH. In 10% of patients after treatment with this drug, pregnancy begins with two fruits. Three or more fetuses are extremely rare.
Treatment with clomiphenigrate does not always lead to ovulation. When you can not get pregnant during the three cycles of ovulation, then another drug is prescribed - gonadotropin. It can be used alone or in combination with other medicines.
Types of gonadotropin may be different:
- human menopausal (menogon and menopur),
- recombinant follicle-stimulating hormone (gonal-f and puregon),
- human chorionic gonadotropin (choragon and pregnil).
Treatment with gonadotropin is more expensive than clomifencitrate. In addition, there is a risk of side effects. Multiple pregnancy with this drug is also more likely.
Auxiliary methods of reproductive technology for hormonal infertility
With endocrine infertility, about 80% of all patients who go to the doctor and take stimulating drugs, mark the onset of ovulation.
Of these, more than 50% become pregnant during the first six months of therapy.
But there are always a number of women who have received stimulant therapy and surgical treatment with no positive result. In such cases, experts recommend turning to the help of in vitro fertilization (IVF). It stimulates superovulation and leads to the maturation of a large number of follicles. IVF has helped many women for whom the endocrine genesis of infertility has become an obstacle to conception.
Drug effects on the predominant follicle in order to induce ovulation. For stimulation, clomiphene citrate is suitable, which causes the pituitary gland to produce follicle-stimulating hormone. It is worth noting that the treatment of clomiphene citrate often causes multiple pregnancy (in 10% of pregnancies after stimulation).
In the absence of pregnancy (after treatment with clomiphene citrate for six cycles), gonadotropins are prescribed:
- human menopausal gonadotropins (menogon, menopur),
- recombinant follicle-stimulating hormones (gonal-f, puregon),
- chorionic gonadotropin (pregnil, choragon).
Gonadotropins also cause multiple pregnancies. Treatment with these drugs may cause side effects.
Endocrine sterility is successfully treated by correcting hormonal levels, but sometimes surgical intervention is required. In case of polycystic ovaries, a wedge-shaped resection is necessary, or laparoscopic thermocautery. It is noteworthy that after thermo cautery, the pregnancy forecast is up to 90%. This is due to the fact that the procedure eliminates the possibility of adhesions in the pelvis.
In endocrine infertility, in vitro fertilization is recommended in combination with other pathologies. Samples are taken from partners, the egg is fertilized “in vitro” and the embryo is transplanted into the woman’s uterus. The method allows to bypass those processes that occur in the pipes during natural conception.
Forecast for endocrine infertility in women
Modern medicine successfully treats endocrine sterility. Drugs alone can cure up to 80% of women with this diagnosis. After treatment, if ovulation has recovered (and new factors of infertility have not appeared), half of the pregnancy begins in the first six menstrual cycles of hormonal stimulation. Less chance of pregnancy in women whose endocrine sterility is caused by problems with the hypothalamus or pituitary gland.
Pregnant women who have undergone a course of stimulation with hormones for endocrine infertility are registered by a gynecologist and observed by an endocrinologist. With symptoms of miscarriage (discoordination, weak labor activity) women are urgently hospitalized.
Preventing endocrine sterility is quite simple - to monitor your health since childhood. It is necessary to prevent any pathologies that may affect the ovaries and the hypothalamic-pituitary region of the brain. Parents should pay attention to infectious diseases to which children are prone, to treat acute respiratory viral infections and flu. The cause of endocrine sterility may be chronic tonsillitis, toxoplasmosis, rheumatism.
It is also important to keep the psycho-emotional and physical state under control. Infertility often develops after chronic fatigue, overexertion, trauma (both psychological and sexual).
In adult women, endocrine infertility is often the result of abortions, pregnancy pathologies, difficult childbirth, intoxication, chronic inflammation in the genitourinary system. Separately, it is worth paying attention to the medications that a woman takes and the proper management of pregnancy.
Endocrine sterility - a complex of hormonal disorders leading to the irregularity of ovulation or its absence in women and impaired sperm quality in men. It can be based on dysfunctions of the thyroid gland, gonads, and hypothalamic-pituitary regulation. Normalization of impaired functions leads to pregnancy in 70-80% of cases of endocrine infertility. In other cases, at present, the elimination of endocrine sterility by IVF is considered promising. Every third infertile woman causes infertility lies in the pathology of the endocrine system.
The concept of “endocrine infertility” is collective, including various violations of the mechanisms of hormonal regulation of the menstrual cycle: at the hypothalamic-pituitary-ovarian level, in the TSH systems the thyroid gland, ACTH - the adrenal cortex, etc. Regardless of the causes of endocrine infertility, it is based on dysfunction of the ovaries, manifested by persistent anovulation (lack of ovulation) or its irregularity.
Symptoms of endocrine infertility
The main manifestations of endocrine infertility are the impossibility of pregnancy and abnormalities in the menstrual cycle. Menstruation may occur with delays of varying severity (from a week to six months), accompanied by pain and abundant secretions, or be absent altogether (amenorrhea). Often marked spotting in the intermenstrual period.
In 30% of patients with endocrine infertility, the menstrual cycles are anovulatory in nature and correspond to the normal menstrual cycle (21-36 days) in their duration. In such cases, it is not menstruation, but menstrual bleeding.
Patients have pain in the lower abdomen or lower back, discharge from the genital tract, dyspareunia, cystitis. There may be stress and heaviness in the mammary glands, galactorrhea (colostrum discharge from the nipples) associated with an increase in prolactin levels. Characterized by premenstrual tension syndrome - deterioration on the eve of menstruation. When hyperandrogenism accompanying endocrine sterility, acne, hirsutism or hypertrichosis, alopecia develop. There are fluctuations in blood pressure, the development of obesity or weight loss, the formation of stretch marks on the skin.
Diagnosis of endocrine sterility
When collecting anamnesis in patients with endocrine infertility, the time of onset of menstruation, their abundance, pain, presence in the history (including the mother of the patient) of menstrual dysfunction, the presence and duration of the absence of pregnancies, in the presence of outcome and complications of pregnancies are specified. It is necessary to find out whether gynecological operations and manipulations were carried out earlier, the type and duration of use of contraception.
A general examination includes an assessment of the patient's height (less than 150 cm or more than 180 cm), the presence of obesity, virilism, development of the mammary glands and secondary sexual characteristics. A gynecologist is consulted, during which, during a gynecological examination, the shape and length of the vagina and uterus, the condition of the cervix, parametrium and appendages are determined. According to the general and gynecological examinations, such causes of endocrine infertility, such as sexual infantilism, polycystic ovarian disease, etc., are ascertained. Evaluation of the hormonal function of the ovaries and the presence of ovulation in endocrine infertility are determined using functional tests: construction and analysis of the basal temperature curve, urinary ovulation test, ultrasound monitoring follicle maturation and ovulation control.
According to the schedule of basal temperature is determined by the presence or absence of ovulation. The basal temperature curve reflects the level of postovulatory ovarian production of progesterone, which prepares the endometrium of the uterus for implantation of a fertilized egg. The basal curve is constructed on the basis of the morning temperature, measured daily at the same time in the rectum. In the ovulatory cycle, the temperature graph is two-phase: on the day of ovulation, rectal temperature drops by 0.2-0.3 ° C, and in the second phase of the cycle, lasting from 12 to 14 days, rises by 0.5-0 compared to the temperature of the first phase , 6 ° C. The anovulatory menstrual cycle is characterized by a monophasic temperature curve (steadily below 37 ° C), and the insufficiency of the luteal phase is manifested by shortening the second phase of the cycle in less than 11-12 days.
To confirm or deny the fact of ovulation, you can determine the level of progesterone in the blood and pregnandiol in the urine. In the anovulatory cycle, these indicators in the second phase are extremely low, and in case of insufficient luteal phase, they are reduced in comparison with the ovulatory menstrual cycle. The test for ovulation allows you to determine the increase in the concentration of LH in the urine 24 hours before the commission of ovulation. Ultrasonic monitoring of folliculogenesis makes it possible to follow the maturation of the dominant follicle in the ovary and the release of the egg from it.
A reflection of the functioning of the ovaries is the state of the endometrium of the uterus. In scraping or biopsy of the endometrium, taken 2-3 days before the expected menstruation, hyperplasia of varying severity (glandular cystic, glandular, polyposis, adenomatosis) or secretory insufficiency is detected during anovulation and endocrine infertility.
To clarify the causes of endocrine infertility determine the levels of FSH, estradiol, LH, prolactin, TSH, testosterone, T3, T4, DEA-C (dehydroepiandrosterone sulfate) on the 5-7th day for several menstrual cycles. Conducting hormonal samples allows to clarify the status of various parts of the reproductive system in endocrine infertility. The mechanism of these tests is to measure the level of the patient's own hormones after taking certain stimulating hormone preparations.
If necessary, clarify the causes of endocrine infertility is performed X-ray of the skull, ultrasound of the thyroid gland, ovaries, adrenal glands, diagnostic laparoscopy. The diagnosis of endocrine infertility to a woman is established only after exclusion of the male factor of infertility (presence of a normal spermogram), as well as pathology of the uterus, immunological and tubal forms of infertility.
Endocrine sterility treatment
The first stage of treatment of endocrine infertility includes the normalization of impaired functions of the endocrine glands (correction of diabetes mellitus, obesity, activity of the adrenal glands, thyroid gland, removal of tumors, etc.). In the future, hormonal stimulation of the maturation of the dominant follicle and ovulation is carried out. To stimulate ovulation, clomiphene citrate is prescribed, which causes an increase in the secretion of the pituitary follicle-stimulating hormone. Of clomiphene citrate after stimulation of pregnancies, 10% are multiple (often twins and triplets).
In the absence of pregnancy for 6 ovulatory cycles, when clomiphene citrate is stimulated, treatment with gonadotrophins is resorted to: CMH (human menopausal gonadotropin), r-FSH (recombinant follicle-stimulating hormone), and hCG (human chorionic gonadotropin). Treatment with gonadotropins increases the frequency of multiple pregnancies and the development of side effects.
In most cases, endocrine sterility is susceptible to hormonal correction, in the rest, surgical intervention is indicated. In polycystic ovary syndrome, laparoscopic or laparoscopic thermocautery is resorted to using their wedge resection. After laparoscopic thermocautery, the highest percentage of pregnancies is observed - from 80 to 90% of cases, since the formation of adhesions in the pelvis is excluded.
In case of endocrine infertility, aggravated by tubo-peritoneal factor or a decrease in sperm fertility, an in vitro fertilization method (IVF) with transplantation of embryos ready for development into the uterine cavity has been shown. To achieve the onset and gestation of pregnancy in women with endocrine infertility is possible only with a comprehensive solution to this problem.
Prevention of endocrine sterility
Taking care of the prevention of endocrine forms of infertility is necessary from childhood. Reduction and prevention of childhood infections, chronic tonsillitis, rheumatism, influenza, toxoplasmosis in childhood and adolescence will avoid dysfunction of the ovaries and the processes of the hypothalamic-pituitary regulation.
Preventive importance is the correct emotional and physical education of girls, because the ovarian function often suffers as a result of mental overstrain, psychological and sexual trauma. It is undeniable that often endocrine infertility develops after pathological delivery, abortion, intoxication, inflammatory infections of the female reproductive system, therefore, attention should be paid to the prevention of these conditions.
Proper management of pregnancy, the reasonable use of certain drugs, especially hormones during pregnancy, will help to avoid congenital ovarian hypofunction and adrenal hyperplasia in girls.
To identify endocrine infertility, the following diagnostic measures are carried out.
1. Determination of the characteristics of the menstrual cycle.
• Normal cycle. Monthly pass regularly, with intervals from 21 to 35 days. But it is often found that the luteal phase is incomplete.
• Primary amenorrhea. Inhibition of ovarian function, which leads to the absence of at least one spontaneous menstruation.
• Amenorrhea secondary. In this case, the monthly does not occur for six months or longer. This condition is caused by chronic anovulation.
Если у женщин с первичной аменореей наблюдается двухфазный цикл, можно говорить об аномалиях влагалища и матки. А при вторичной аменорее такой цикл свидетельствует об атрезии цервикального канала или маточных синехиях.
• Опсоменорея. Увеличение промежутков между менструациями в пределах от 36 суток до полугода. В подобных случаях аменорея и НЛФ отмечаются с одинаковой частотой.
• Пройоменорея. The opposite condition, when menstruation is repeated too often. The interval between them is less than 21 days.
• Hypomenorrhea. Too scanty during menstruation. This is due to abnormalities in the ovaries or endometrial pathologies. Usually is a transitional stage to amenorrhea.
• Hypermenorrhea - too much secretion.
• Oligomenorrhea. In this condition, the monthly lasts less than two days.
• Polymenorrhea. Long periods of the week - and longer.
• Metrorrhagia. The complete absence of a regular cycle. Allocations are irregular, have different intensity and duration. This is due to the fact that cyclical changes do not occur in the endometrium.
2. Study of ovarian function and ovulation assessment
• Monitoring basal temperature. With NLF, the 2nd phase of the cycle becomes shorter. The temperature difference between the phases does not reach 0.6 degrees.
• Progesterone blood test, urine dignandiol excretion study. The procedure is prescribed not earlier than on the 4th or 5th day after the rectal temperature rises. Since the content of progesterone reaches its maximum value a week after ovulation. When NLF revealed a shortage of progesterone. Its normal rate is 9–80 nmol / l. The rate of pregnandiol in the urine is above 3 mg / day.
• Endometrial biopsy. It is performed 2 or 3 days before menstruation. In this case, the secretory transformation of the endometrium is insufficient.
• Cervical number. Estimate the volume of mucus, its consistency and crystallization.
• Ultrasonic dynamic monitoring of the growth of follicles and endometrium during the cycle.
3. Hormonal tests.
For the study of hormonal background, blood for analysis is taken in the morning between 9 and 11 o'clock. Before this, the patient has an easy breakfast. If a woman has a regular cycle, conduct a study on such hormones: cortisol, testosterone, LH, FSH, estradiol, dehydroepiandrosterone sulfate (5-7 days of the cycle), as well as progesterone and prolactin (6-7 days after the basal temperature rises ). In addition, on 5-7 and 21-22 days of the cycle, an indicator of 17-COP in the urine is assessed.
If such violations of the cycle as oligomenorrhea or amenorrhea take place, blood analysis is performed for FSH, LH, TSH, estradiol, cortisol, dehydroepiandrosterone sulfate, TZ, T4 testosterone, cortisol. Also find out the level of 17-KS in daily urine. With a two-phase basal temperature curve, progesterone levels are determined.
When prolactin is elevated in the blood, the analysis is repeated from the 5th to the 7th day of the cycle (this applies to women with a normal cycle or oligomenorrhea). If the patient suffers from amenorrhea, the analysis is repeated after 7 days.
Samples (hormonal and functional)
For the diagnosis of conditions associated with endocrine sterility, use such tests:
• Progesterone. It is used in the examination of patients with amenorrhea. It consists in the assessment of estrogen saturation, the reaction of the endometrium to progesterone, the study of the characteristics of its rejection with a shortage of progesterone.
• Clomiphenic. It is indicated for patients with amenorrhea or a broken cycle. Before it causes a menstrual-like reaction. With this study, you can determine the level of production in the follicles of steroid hormones and assess the reserve capacity of the pituitary gland.
• Dexamethasone. It is performed for women who suffer from hirsutism. It provides an opportunity to accurately determine the nature of hyperandrogenism (ovarian or adrenal).
• With the use of cerukala. Allows to differentiate organic and functional hyperprolactinemia.
• Using thyroliberin. It is used to assess the performance of the thyroid gland.
The presence of anovulation in a patient is indicated by the results of functional tests:
• The cervical number does not reach 10.
• Monophasic basal temperature.
• Endometrium does not undergo secretory transformation.
• Progesterone levels fall below 15 nmol / l.
NLF is diagnosed based on the following results:
• The second phase of the cycle is too short - its duration is less than 10 days.
• The difference in basal temperature between the phases of the cycle is less than 0.4-0.6 degrees.
• A blood test reveals a drop in progesterone during the heel of the corpus luteum.
• Histology shows the inferiority of the secretion phase in the endometrium.
The luteinization of a neovulatory follicle is determined by an ultrasound method and a laparoscopic procedure. From 9 to 11 day of the cycle, you can see the first ultrasound signs of an increasing follicle. On the eve of ovulation, it reaches a size of 2 cm. And if the cycle has been stimulated, then its diameter can be up to 3 cm. Every day the follicle should increase by 2-3 mm. A sign of ovulation held is the absence of its image in the middle of the cycle. And with FLNP, the follicle gradually shrinks. Laparoscopically, this condition manifests itself as a hemorrhagic body with no ovulation stigma.
Endocrine sterility treatment methods
Treatment of endocrine sterility may be surgical or conservative. The decision on what method to resort, the endocrinologist takes. The same specialist prescribes a supportive drug treatment regimen using one or another drug (levothyroxine sodium, dexamethasone, bromocriptine). A course of hormone therapy usually lasts several months, usually from 3 to 4. If the pregnancy has not come, hormone therapy is supplemented with drugs that induce ovulation.
At the first stage of therapy it is necessary to normalize the endocrine system. This includes such activities as the fight against obesity, lowering the level of sugar, the elimination of tumor formations. Treatment of pathologies of the adrenal glands and thyroid.
Then carry out activities for hormonal stimulation. To successfully stimulate ovulation, patients are prescribed clomiphene citrate. It has the ability to affect the work of the pituitary gland and increase the production of follicle-stimulating hormone. A feature of this therapy is the increased likelihood of multiple pregnancy. In 1 out of 10 cases, the patient has twins or triplets.
If after 6 cycles the pregnancy has not come, the treatment tactics change. A woman is prescribed a course of gonadotropins (HMG, r-FSH, hCG). After this treatment, the likelihood of multiple pregnancy increases and the risk of complications increases.
The chances of success of hormonal correction are quite high. But there are cases when patients are recommended a surgical procedure. Thus, women with polycystic cysts perform a wedge-shaped resection of the ovaries using laparoscopic technology. The most effective technique is laparoscopic thermocautery. Pregnancy statistics after it is very high - up to 90%. This is because the formation of adhesions does not occur in the small pelvis.
If endocrine sterility is accompanied by aggravating factors (tubal-peritoneal pathology, insufficient sperm fertility), the patient is recommended IVF.
Women suffering from endocrine infertility are shown such physiotherapy methods:
• Quantum therapy. The procedure is carried out in this way. Using a peristaltic pump, blood is drawn from a vein into a sterile container, which contains 50 ml of 0.9% sodium chloride solution and 5000 IU of heparin. After exposure to the blood by KUV-radiation, it is returned to the vein. Just spend a few sessions with an interval of 2 or 3 days.
• Reflexology. The use of acupuncture or exposure to shock, heat or laser on acupuncture points. Such procedures relieve the patient from inflammation in the appendages and improve the motility of the tubes. Patients with ovarian hypofunction are prescribed exposure to a biologically active helium-neon laser. Procedures begin on the 5th day of the cycle. The full course consists of 10 sessions. With amenorrhea and rare menstruation, the laser is prescribed on the 5th day after the curettage procedure.
• Sauna. Procedures can be weak (at 60 degrees) or moderate (70 degrees). In the first case, the relative humidity reaches 10-20%, the concentration of 02 - 26%. In the second case, these figures reach 10-18% and 30%. Sauna procedures relax, relieve stress, improve the immune system, activate the excretory function, and normalize thermoregulation.
• Ozone therapy. Such procedures are carried out every other day from the 3rd to the 11th day of the cycle. For this, the ozone-acid gas mixture is passed through a container containing 0.9% sodium chloride solution (200 ml) for 15 minutes. Then the ozonated solution is administered to the patient drip.
Today, thanks to the development of medical technology, endocrine sterility is treatable. Good results can be achieved in 80% only with the help of conservative therapy.
With the restoration of ovulation and the absence of other pathologies, conception occurs rather quickly - during the first 6 cycles of stimulation.
If infertility is associated with the hypothalamic-pituitary factor, drug therapy is less effective.
When a patient becomes pregnant, she must be under strict medical supervision. At the slightest suspicion of the possibility of miscarriage, a woman is hospitalized. The probability of discoordination is rather high, weakness of labor activity is possible.
Prevention of hormonal infertility in women
Prevention of endocrine infertility problems begins in childhood. Important role played by the prevention and timely treatment of influenza, tonsillitis, rheumatism, toxoplasmosis and other diseases. If this is not done, ovarian function or the mechanism of the hypothalamic-pituitary regulation may be impaired.
Girls can not be subjected to stress or excessive mental stress, because ovarian function depends largely on psychogenic factors.
In addition, it is necessary to monitor women's health, in time to treat inflammatory diseases of the genital organs. It is also necessary to take into account that the risk factors determining the possibility of infertility in the future are interrupted pregnancies and pathological deliveries.
It also matters competent management of pregnancy, the correct use of drugs, primarily hormonal. This will help prevent the pathologies of the ovaries and adrenal glands in newborn girls.
What is endocrine sterility
The collective term “endocrine” (or hormonal) is understood to mean several types of disease that are different in their etiology. Their similarity lies in the fact that they are all associated with too low or high content in the female body of thyroid hormones, hypothalamus and pituitary, as well as the sex glands.
Symptoms of endocrine disorders
The main symptom of the disease - the impossibility of pregnancy. However, there are other symptoms, the combination of which varies depending on the cause of endocrine infertility:
- complete absence of menstruation or their long delays,
- abnormal flow of menstruation itself (too painful, scanty, copious, thick, with blood clots),
- severe condition during PMS,
- the normal menstrual cycle is accompanied by anovulation, which means that this is not about menstruation, but about imitating their bleeding,
- heaviness in the mammary glands and the release of colostrum from the nipples,
- dirty brown discharge in the middle of the menstrual cycle
- frequent cystitis
- sudden and unexplainable change in weight (in any direction),
- skin and hair problems: the appearance of acne and stretch marks, hypertrichosis, hirsutism or, on the contrary, alopecia (hair loss).
The presence of the symptoms described depends on the specific hormones the body has problems with. They are valuable diagnostic signs of endocrine sterility in women.
Decreased secretion of progesterone and estrogen
If the body does not have enough female sex hormones, then this is fraught with a change in the state of the endometrium, which is transformed and begins to prevent egg transplantation into it. Another consequence of progesterone deficiency is reduced peristalsis of the fallopian tubes. As a result, the luteal phase of the cycle (NLF) is diagnosed.
Typically, this pathology is accompanied by hyperprolactinemia, as a result of which the egg simply does not come out of the mature follicle due to the depressed ovarian function. Factors contributing to the emergence of this pathology are injuries of the skull and chest, tumors in the area of the pituitary gland. The monthly cycle in this case is characterized by the absence of ovulation, and the menstruation itself is characterized by long delays.
How to diagnose a problem
When you first visit, the doctor must take anamnesis, that is, find out:
- which gynecological diseases the patient suffered earlier,
- were there surgical interventions
- are there menstruations, how regular, long and abundant are they,
- Is there any experience of pregnancies, as well as their course and outcome (if any)?
Further, the body’s metric parameters, such as height and weight (based on their BMI), the degree of development of secondary sexual characteristics are examined. In addition, the gynecologist will identify the presence or absence of virilism - the presence of male-type hair distribution (mustache, beard, hair around the nipples).
After an external examination, the doctor proceeds to the examination on the gynecological chair, during which he assesses the metric parameters of the uterus and vagina of the patient, the state of the remaining internal genital organs. Already at this stage such causes of infertility, such as polycystic ovary or hypoplasia of the genital organs, can be identified.
Ultrasound monitoring is the process of maturation in the ovaries of the follicles (folliculometry). In order to find out whether there is maturation of the egg, tests are conducted to identify ovulation. Usually, ultrasonic monitoring is used for this, but methods such as the urinary test and regular basal temperature measurement are also informative. Ovulation is also characterized by an increase in the amount of progesterone in the blood, and in the urine - pregnandiol.
If the doctor deems it necessary, then in addition he can prescribe an X-ray of the skull and laparoscopy, and also send the patient to an ultrasound of various endocrine glands.
In this way, all the components of the female reproductive system are gradually investigated. Depending on what the main causes of female infertility are, the types of treatment can also be different.
How is endocrine sterility treated?
If during the diagnostics it was revealed that some types of hormones are produced by the body in excess, then drugs are prescribed that reduce this function of the glands. If it turned out that the secretion of the hormone is too low, then, on the contrary, the patient is prescribed hormone replacement therapy or drugs that stimulate the production of scarce substances.
If endocrine sterility is associated with somatic problems (obesity, the appearance of tumors, the development of diabetes), then it is these disorders that are first corrected. In some cases, it may even require surgical intervention.
In case of polycystic ovaries, wedge-shaped resection or thermocautery is most often performed by the lasroscopic method.
In each case, the set of applied methods of treatment can be different even when the causes of the pathological impossibility of pregnancy are the same. Only an individual and comprehensive approach to therapy can be a guarantee of recovery.
Forecast for a happy pregnancy with the disease
With the modern development of medicine, it is possible to completely cure endocrine sterility in approximately 80% of all cases. This is a merit of not only gynecologists, but also endocrinologists. If the reason for the non-occurrence of pregnancy was impaired ovulation, then when restoring this function, women can become pregnant in the first six months after the start of hormone replacement therapy.
The most difficult to treat is hormonal sterility, caused by hypothalamic-pituitary dysfunction, but even here the recovery rate is quite high.
As soon as a woman manages to become pregnant, she is shown careful monitoring by the gynecologist and endocrinologist. At the first suspicion of the threat of miscarriage or premature birth, hospitalization is indicated. A history of patients with endocrine infertility often diagnosed with weak labor activity and discoordination.
Preventing the occurrence of hormonal disruptions
What can cause infertility in women? First of all, these are various diseases of the genital organs and deviations in their work. Therefore, special attention should be paid to the gynecological health of girls, observing all hygienic requirements. If mom had previously been diagnosed with endocrine infertility, regular visits to the pediatric gynecologist and control of the main hormones become mandatory.
Ecology and lifestyle are also very important. It is necessary to try to avoid stress, even eliminate passive smoking, not to drink alcohol. Proper nutrition will help to avoid problems with weight, which also serves as the prevention of hormonal infertility.
Remember that there are no hopeless situations, and sterility is no longer a sentence for a married couple. Of course, one should not give up and give up, even if the doctor makes disappointing forecasts. Лечитесь, планируйте и верьте в то, что скоро все получится! Ведь, как известно, мысли имеют свойство материализоваться!