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Why can’t I have a child naturally?

Girofiv

The first step in determining the cause of sterility and in choosing the best treatment is to study the couple and the reports submitted, with a view to compiling all the necessary information in each event.

There is, however, no failsafe test indicating the couple’s capacity to reproduce. Only the age of the woman is a proven prognostic factor, because the older she is, the less chance there is of achieving natural pregnancy.

Although each case is different, the gynaecologist will normally ask couples visiting GIROFIV for the first time to do some basic tests. When more specific tests are required, a complementary study is usually requested.

Basic sterility test (1st visit)

WOMAN
MAN
MEDICAL HISTORY
GYNAECOLOGICAL EXAMINATION AND ULTRASOUND
BASAL HORMONE TEST

MEDICAL HISTORY
Detailed anamnesis to determine the patient’s medical history. It covers factors such as:

  • Age
  • Duration of sterility
  • Family history
  • Previous diseases or operations
  • Previous pregnancies
  • Evaluation of the number and moment of sexual relations

GYNAECOLOGICAL EXAMINATION AND ULTRASOUND
For evaluating the anatomy and functionality of the female reproductive system. If performed at the start of the cycle, it provides information on the ovarian reserve, as the number of follicles in each ovary can be quantified.

BASAL HORMONE TEST
This test determines specific hormones in the blood such as FSH, LH, estradiol, progesterone, AMH, etc. with a view to evaluating ovarian function.

MEDICAL HISTORY
SEMEN ANALYSIS / SPERM RETRIEVAL TEST

MEDICAL HISTORY
Detailed anamnesis to determine the patient’s medical history. It covers factors such as:

  • Age
  • Duration of sterility
  • Family history
  • Previous diseases or operations
  • Evaluation of the number and moment of sexual relations

SEMEN ANALYSIS / SPERM RETRIEVAL TEST
This is a basic analysis of semen performed to determine its quality. It looks specifically at volume, the sperm count, motility and morphology.

CONSULT WORLD HEALTH ORGANISATION TABLE

Complementary sterility test (specific tests)

WOMAN
MAN
KARYOTYPE
HYSTEROSALPINGOGRAPHY
LAPAROSCOPY
HYSTEROSCOPY
ENDOMETRIAL RECEPTIVITY ARRAY (ERA)

KARYOTYPE

This is a study of the number and the structure of the chromosomes present in the nuclei of cells. It involves extraction of blood.

Each cell of the body should have a total of 46 chromosomes, organised into 22 pairs of autosomes and 1 pair of allosomes, which determine gender. The only cells of the body that contain half the chromosomes (23) are eggs and spermatozoa, because when they join to form the embryo, together they add up to a total of 46 chromosomes.

An alteration in a patient’s karyotype increases the risk of gametes (eggs) with an anomalous genetic load. This increases the production of embryos with genetic problems and prompts cases of sterility or recurrent miscarriages.

HYSTEROSALPINGOGRAPHY

This technique is used to evaluate Fallopian tube permeability.
It involves injecting a radio-opaque material into the cervical canal while taking serial X-rays to observe how it flows through the uterine cavity, from the Fallopian tubes to the abdominal cavity.

This study allows for the diagnosis, for example, of uterine pathologies (malformations, synechaie or adhesions, tumour masses), tubal pathologies (obstructions, stenosis, polyps, hydrosalpinx) and peritoneal adhesions.

Whenever the Fallopian tubes are affected, the first-choice treatment is in vitro fertilisation (IVF).

LAPAROSCOPY

This technique is used to observe the interior of the abdominal cavity using fibre optic cables that are inserted through the abdomen. This surgery involves a general anaesthetic and admission to hospital for a few hours, even though it is a minimally invasive technique.
This surgical technique offers a direct view of the external surface of the uterus, the ovaries, the pelvic cavity and the Fallopian tubes, which may be moved using special forceps, and to detect the existence of adhesions that are preventing them from moving. It also allows for evaluation of their permeability using a positive contrast medium.

Its use is limited to cases involving factors of risk and in which hysterosalpingography is not conclusive.

In some cases, the examination may also be used to treat and to repair some pathologies observed.

HYSTEROSCOPY

This technique is used to evaluate the uterine cavity and the endometrium.
It entails introducing a fibre optic cable into the uterine cavity through the cervical canal to yield a direct view of the endometrial lining and allows for diagnosis of any anomaly in the walls of the uterine cavity such as polyps, myomata, synechaie, etc.

ENDOMETRIAL RECEPTIVITY ARRAY (ERA)

The endometrium is receptive when it is ready for embryo implantation to occur. This usually takes place around day 21 of all the menstrual cycles of a fertile woman.
An ERA involves molecular-level evaluation of the status of endometrial receptivity. This molecular tool makes it possible to diagnose whether or not there is a receptive endometrium through analysis of the expression of a group of genes responsible for this function. This requires the performance of an endometrial biopsy, usually on an outpatient basis, as it does not require sedation.

KARYOTYPE
SPERM DNA FRAGMENTATION
FISH
OTHER

KARYOTYPE

This is a study of the number and the structure of the chromosomes present in the nuclei of cells. It involves extraction of blood.

Each cell of the body should have a total of 46 chromosomes, organised into 22 pairs of autosomes and 1 pair of allosomes, which determine gender. The only cells of the body that contain half the chromosomes (23) are eggs and spermatozoa, because when they join to form the embryo, together they add up to a total of 46 chromosomes.

An alteration in a patient’s karyotype increases the risk of gametes (spermatozoa) with an anomalous genetic load. This increases the production of embryos with genetic problems and prompts cases of sterility or recurrent miscarriages

SPERM DNA FRAGMENTATION

This is the study of the genetic material of the spermatozoa in the ejaculate. It is a parameter that is independent from and complementary to traditional tests such as semen analysis.
DNA may sometimes have break points or losses of genetic material in the DNA chains of the spermatozoon. The more break points there are, the worse the prospects of reproduction, as the embryos generated with these sperm will more likely be of a lower quality and/or will have low implantation potential. In some cases, such damage may be repaired by the egg, although this mainly depends on its quality. Hence, the greater the oocyte quality, the higher the capacity to repair sperm damage.

Different factors may cause fragmentation. They are classified as follows:

  • Internal factors (primary fragmentation)
    Fragmentation is caused by abnormal maturation of spermatozoa in the epididymis, or because the control mechanisms in the testicle do not work properly, are unable to eliminate these abnormal sperm and allow them to continue to ejaculation. This could explain why there is a greater incidence of DNA fragmentation in men of over 45 years old.
  • External factors (secondary fragmentation)
    Several factors may induce DNA breakage. They may be either pathological (cancer, inflammatory processes, varicoceles, cryptorchidism or stress) or external factors (such as pollution, tobacco, some drugs, advanced age or metabolic alterations due to excess weight). In some cases, damage is permanent: for example after radiotherapy or chemotherapy treatments. In others it may be temporary, as is the case of testicular varicocele, exposure to high temperatures (either for occupational causes or as a result of an episode of high fever), inflammatory processes and/or infectious testicular processes (orchitis).

A fragmentation test is recommended in the following cases:

  • Varicocele
  • Cryptorchidism
  • Serious seminal factor
  • Chemotherapy
  • Diabetes mellitus
  • Idiopathic sterility
  • Recurrent miscarriages
  • Recurrent IVF failure
  • Exposure to toxic substances or to high temperatures
  • BMI > 25
  • Age > 45 years old
  • Smokers ( >10 c/day)
  • Alcohol ( > 6 units/week)

FISH

FISH (fluorescent in situ hybridisation) is a molecular cytogenetic technique based on the hybridisation of two chains of DNA when their sequence is complementary.
It is a sensitive method for evaluating the normal chromosomal complement of a cell.
FISH in spermatozoa is suitable in those patients with abnormal karyotypes, alterations of meiosis and abnormalities in the semen.
Genetic and chromosomal anomalies could cause sterility or infertility because of alteration in the production of spermatozoa or of alteration in seminal tracts and, therefore, in the transport of the sperm.

One characteristic of this technique, however, is that it only allows for the study of a limited number of chromosomes. Normally, a study of 5 chromosomes is required: X, Y, 13, 18 and 21. It may therefore yield a normal result in those chromosomes that have been studied, but show chromosomal anomaly in others. It is also of limited use in patients with a low sperm count, as this technique cannot yield a result because of a lack of material. To perform it, a sperm count should contain at least one million spermatozoa/ml.

OTHER

In the event of dysfunctional sexual relations, testicular pain or the suspected presence of varicoceles, an andrologist should be consulted.