1. MEDICAL BACKGROUND
During the first meeting with the specialized gynecologist, you will need to state your medical background with information concerning your general health condition, such as potential chronic or hereditary diseases, allergies, medication intake, previous surgeries, etc. Emphasis will be placed on your personal gynecological background (age of the first menstruation, duration of the menstrual cycle and menstruation, pregnancy history, abortion or termination of pregnancy, fibroids, polyps, etc).
It is important to establish a sense of confidence between the gynecologist and the couple from the very first visit so that no important information is omitted and in order to ensure that the couple complies with the doctor’s recommendations and instructions. The detection and subsequently the solution of any infertility problem requires cooperation, teamwork, and trust between the couple and the gynecologist. This is only achieved gradually, but it can be inspired by the very first meeting.
2. MANUAL PELVIC EXAMINATION
After taking your medical history, the gynecologist continues with the gynecological examination, which is performed by meticulously checking external genitalia, the vagina and the cervix and then by taking a pap smear and vaginal-cervical fluid for culture.
3. PAP TEST
The pap smear is taken on a day where you are not menstruating; you should also avoid sexual intercourse the day before. You should begin having a pap smear taken on the onset of sexual activity (regardless of age) and then once a year.
4. VAGINAL CULTURAL TEST
If the clinical examination shows a picture of vaginitis cervicitis, the gynecologist shall take vaginal and cervical smear for the detection of the cause of inflammation (fungus, bacteria, mycoplasma, etc.) and in order to pursue targeted medical treatment and therapy. During infertility testing, it is required to have all examinations performed as stated above, as it is known that certain microorganisms such as mycoplasma, ureaplasma, and chlamydia are causes of infertility.
5. VAGINAL ULTRASOUND
Ultrasonography is the simplest way to diagnose and exclude gynecological diseases, such as uterine fibroids, endometriosis cysts, polycystic ovaries, adenomyosis, ovarian cysts, polyps, endometrial hyperplasia, anatomical abnormalities, tumors of the internal genitalia, etc. All the above are important information for both the diagnosis of infertility and for further treatment.
6. PALPATION OF THE BREAST
The gynecological examination should always include the palpation of the breasts by the gynecologist to detect any palpable formations or other pathological conditions (inflammation-mastitis, nipple sagging, skin lesions, etc.).
Depending on the findings of the specific clinical examination-palpation, your doctor will recommend a further examination with ultrasound and (or) mammography. In particular, in women with a hereditary history of breast cancer, obesity, polycystic ovaries, and diabetes, mammography should be performed for the first time at the age of 35, while it is mandatory every year for all women over 40 years. Breast palpation completes the first contact with your doctor. But the most important thing is that this first meeting defines a relationship of mutual trust between the couple and the doctor, in order to achieve the goal of having a healthy child.
7. HORMONAL CONTROL
It is performed with blood tests that are done from the 2nd to the 5th day of the cycle. The 1st day of the cycle is considered the 1st day of the period. The hormones that are controlled are:
- FSH, LH, E2
These three hormones give us all the necessary information about a woman’s ovarian function and fertility levels.
It’s about an hormone that shows us the adequacy of the ovaries in the number of eggs and at the same time the quality of the eggs they produce.
It’s the hormone through which the function of the thyroid gland is controlled and is directly related to both fertility and menstrual disorders.
Disorders in the production of this hormone are associated with infertility and possible problems in the period.
- DHΕA S
The hormone-indicator of the function of the adrenal glands, the proper functioning of which is essential for fertility.
- Δ4 ΑΝDR
It is an androgen produced by the ovaries with its increased values being associated with infertility.
It is a simple radiological examination, which is performed without anesthesia between the 6th and 11th day of the cycle. It gives us very important information about:
- the permeability of the fallopian tubes (if they are blocked or if there is a fallopian tube, you have a major cause of infertility)
- the intrauterine cavity, ie the place where the fetus will be implanted
- the existence of congenital abnormalities that exist from the birth of a woman, such as the bicornuate uterus, the existence of an endometrial septum, and acquired abnormalities (eg polyps of the endometrial cavity, submucosal fibroids, endometrial adhesions)
- when hysterosalpingography is performed, may be fallopian tube spasm, the use of antispasmodics and non-steroidal anti-inflammatory drugs is prophylactically recommended. Antibiotics are also given prophylactically starting one day before, or on the same day as the test.
9. VITAMIN D MEASUREMENT
Vitamin D deficiency can contribute to infertility. To measure the levels of vitamin D in the body, the “25 hydroxyvitamin D” blood test is always used, which measures the stored form of vitamin D. Normal values should range from a minimum of 40 to 50 nanograms per milliliter.
Depending on the results of the above examinations, the gynecologist may consider appropriate a series of additional examinations, which are the following:
Α. THROMBOPHILIC CONTROL
Thrombophilia is the increased chance of thrombosis in conditions that increase blood clotting and is divided into hereditary or acquired. Hereditary Thrombophilia can occur if there are mutations in genes that are detected by special blood tests, known as molecular or genetic thrombophilic tests. Some of these genes are factor v Leiden, variant G 20210, factor FVIII, and the MTHFR genes. Acquired Thrombophilia refers to the presence in the body of diseases or substances that increase blood clotting and can cause thromboses, such as antibodies against cardiolipin and B2 glycoprotein and the presence of Lupus anticoagulant, Protein C, Protein S, or ATIII, APCR, and Homocysteine.e.
It is a small operation that allows immediate examination of the uterine cavity with a hysteroscope and is performed only when there is any indication. It does not require admission and stay in the clinic, while it can be done with or without anesthesia. The hysteroscope is inserted through the cervix into the uterine cavity and with the camera it has, it offers the possibility of its immediate overview. If endometrial polyps or adhesions are detected, they can be removed during the same examination if necessary. Also, any submucosal fibroids are detected which may show signs of endometrial inflammation in the endometrial cavity.
C. MOLECULAR DETECTION (PCR) OF CHLAMIDS, UREOPLASMA, MYCOPLASMA
Chlamydia (and more specifically those of the genus chlamydia trachomatis), ureaplasmas, and mycoplasmas are the most common sexually transmitted diseases. Mycoplasma, mainly mycoplasma hominis, and ureaplasma urealyticum, are bacteria that are often detected in a woman’s genitals and transmitted through sexual contact. Their existence can reduce fertility. Although their presence can be detected by culturing vaginal and cervical fluid, their detection by culture gives false-negative results in a percentage of 40%. The most reliable method is the detection of DNA and these microorganisms, with a special polymerase chain reaction (PCR) in a sample of vaginal and cervical fluid or tissue from the endometrial cavity.
Laparoscopy does not need to be performed in all women, but only in cases where there is enough evidence. It is a surgery that allows immediate examination and complete control of the internal genitals of the woman (ovaries, uterus, fallopian tubes), as well as other intra-abdominal organs (intestine, liver, gallbladder, etc.), in order to detect and potential in order to spot and solve a problem. Laparoscopy achieves an accurate diagnosis of conditions that often cause infertility problems, such as endometriosis, adhesions (internal scars from previous surgeries or inflammation), ovarian cysts, or fibroids.
Indications for laparoscopy:
- adhesion solution
- removal of endometriotic cyst
- fibroid removal
- removal of ovarian cysts
- laparoscopic removal of hydrocephalus
During laparoscopic surgery, 3 to 4 very small incisions (half to one cm) are made in the abdomen to allow the laparoscopic instruments and the high-definition camera to pass through. In order to have an intra-abdominal organs preview, sufficient space is required, which is ensured by the introduction of carbon dioxide into the peritoneal cavity. The image from the laparoscope camera is projected onto monitors and the doctor has a magnified, high-resolution image of the intra-abdominal organs so that he can be able to check and correct any abnormal findings.
- solution of adhesions
- removal of endometrial cyst
- fibroid removal
- removal of ovarian cysts
- laparoscopic removal of fallopian tubes
During the laparoscopic operation, 3 to 4 tiny incisions are made in the abdomen (half to one centimeter), so that the laparoscopic instruments and the high-definition camera can pass. In order to be able to review the intra-abdominal organs, sufficient space is required which is ensured by the introduction of carbon dioxide into the peritoneal cavity. The image from the laparoscope camera is projected on screens and the doctor has the image of the intra-abdominal organs enlarged and with great clarity, in order to check and correct the pathological findings that he will find.
Laparoscopy is indicated because it offers:
- short-term hospitalization (usually without overnight in the clinic)
- fast recovery and return to daily activities (work, family obligations, etc.)
- less postoperative pain
- best aesthetic result safety with a much lower incidence of postoperative infections
- simultaneous detailed examination of the abdomen and its organs (due to the magnification and high resolution of the image).
Ε. KARYOTYPE BLOOD EXAMINATION
The representation of the set of chromosomes of an individual is called a karyotype. The normal human karyotype contains 46 chromosomes (23 pairs), including the two sex-determining chromosomes. The karyotype of peripheral blood lymphocytes enables the control of all chromosomes for the possible existence of numerical and structural chromosomal abnormalities and rearrangements. As cytogenetic abnormalities are associated with both male and female infertility, the classic karyotype concerns couples with infertility problems, with two or more first-trimester miscarriages and previous failed IVF attempts. The detection of such abnormalities is crucial for the proper planning of a subsequent pregnancy that can occur either spontaneously or by assisted reproduction methods. Peripheral blood karyotype must be submitted to couples who have a family history:
a. Individuals with:
- chromosomal abnormalities
- mental retardation of unknown cause
- multiple miscarriages and neonatal death
- primary or secondary amenorrhea
- premature menopause
- abnormalities in sperm (azoospermia, oligospermia)
- abnormal clinical phenotype (delayed or excessive physical development, deformity, mental retardation).
b. Couples with:
- infertility of an unknown cause (inability to conceive naturally or through assisted reproduction procedures)
- multiple miscarriages or a history of undetected neonatal death
- child with a diagnosed chromosomal abnormality
- diagnosed chromosomal abnormality of a structural nature in the karyotype of fetal amniotic fluid during pregnancy.
F. CYSTIC FIBROSIS TESTING
Cystic fibrosis is the second most common genetic disease in Greece, after Mediterranean anemia, and the first in the Caucasian race. The disease is due to mutations in the CFTR (cystic fibrosis transmembrane conductance regulator) gene and is inherited in its residual nature. This means that the carriers of the mutated gene are perfectly healthy, but have a 50% chance of passing on their mutated gene to their offspring. The disease has a wide range of symptoms both in severity and extent (respiratory, digestive, and other systems). This means that there are variants in the CFTR gene that are considered mild and do not bring about the characteristic pathological phenotype of the disease, they are simply related to hypersensitivity of the respiratory system (eg frequent respiratory infections). In addition, men with cystic fibrosis are sterile and 20-40% are often carriers of a single abnormal CFTR gene and are therefore considered clinically healthy. With the current data in our country, the screening test should be applied to all high-risk groups, but also to all couples who are going to have a child, at the level of prenatal control. In the latter case, the test can be started first by the mother, to investigate whether she is a carrier of a mutation in the fibrocystic disease. If the mother is found to be a carrier of such a mutation, then it is necessary to examine the father with extended mutation control, since the risk of giving birth to a child with the disease increases greatly. It should be noted here that a large number of couples with male infertility should undergo genetic testing for cystic fibrosis-related mutations at the same time: a significant proportion of men with obstructive azoospermia undergo micro fertilization techniques. carriers of mutations in the CFTR gene.
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