Standards of infertility treatment
Infertility treatment protocols
Infertility
Profile: obstetrics and gynecology
Stage: polyclinic (outpatient).
Purpose of the stage: Diagnosis of infertility depending on the cause, carrying out a full range of therapeutic and rehabilitation measures; timely hospitalization of the patient in a hospital for invasive diagnostic and therapeutic methods.
Duration of treatment: no more than 1 year.
ICD codes:
N97 Female infertility
N97.0 Female infertility associated with lack of ovulation
N97.1 Female infertility of tubal origin N97.2 Female infertility of uterine origin
N97.3 Female infertility of cervical origin
N97.4 Female infertility associated with male factors
N97.8 Other forms of female infertility
N97.9 Female infertility, unspecified.
Definition: Infertility is the absence of pregnancy for 12 menstrual cycles or a year with regular sexual activity without the use of contraception.
Classification:
1. Based on the presence of previous pregnancies:
- primary - there was no pregnancy in the anamnesis;
- secondary - a history of at least one pregnancy, regardless of its outcome.
2. Due to:
- endocrine genesis;
- tubo-peritoneal origin;
- acquired pathology (tumors of the uterus and ovaries);
- congenital pathology of the genitals;
- genital tuberculosis;
- negative postcoital test (PCT);
- iatrogenic causes;
- sexual dysfunction;
- unspecified (diagnosis unknown, endoscopic examination not performed);
- unexplained (absence of visible causes when using all examination methods, including endoscopic).
3. If natural conception is possible:
- Absolute - natural conception is not possible.
- Relative - with reduced fertile function, natural conception is possible.
Risk factors:
1. disturbance of the ovulation process (27%);
2. decreased sperm count or motility (19%);
3. damage to the fallopian tubes (14%);
4. presence of endometriosis (5%);
5. other factors (5%).
Diagnostic criteria:
Lack of pregnancy for 1 year or more.
1. Clinical and anamnestic data:
- complaints;
- features of family history and heredity;
- past illnesses;
- the nature of menstrual function;
- the course and outcome of previous pregnancies;
- previously used contraceptive methods;
- history of infections;
- presence of pain in the lower abdomen (endometriosis);
- carrying out gynecological and other operations;
- rhythm of sexual life.
2. Clinical examination:
- body type;
- weight-height coefficient (weight/height 2), norm - 23;
- degree of hair growth - according to the Ferriman et Gallwey scale, norm - 4.5;
- degree of development of the mammary glands - according to the Tanner scale;
- presence of galactorrhea.
3. Gynecological examination:
- a gynecological examination reveals various anatomical changes in the reproductive tract.
- the condition of the cervix is assessed using colposcopy.
4. Infectious screening:
5. Hormonal screening:
- prolactin;
- thyroid-stimulating hormone (TSH);
- estradiol;
- testosterone, cortisol, DEAS
- triiodothyronine (T3);
- thyroxine.
6. Immunological screening: postcoital test (PCT).
7. Husband's spermogram.
Additional examination:
- Ultrasound of the pelvic organs.
- Hysterosalpingography.
- Ultrasound of the mammary glands according to indications
- Mammography according to indications
- X-ray of the skull and sella turcica if necessary.
- Computed tomography and nuclear magnetic resonance as indicated.
- Ultrasound of the thyroid gland according to indications.
Endoscopic examination methods, laparoscopy and hysteroscopy, are performed in a hospital setting.
List of main diagnostic measures:
1. Infectious screening:
- vaginal smear to assess the degree of vaginal cleanliness.
- a smear from the cervical canal to detect chlamydia, ureaplasma, mycoplasma, herpes simplex virus, cytomegalovirus using PCR;
- blood for toxoplasmosis with a history of recurrent miscarriage.
2. Hormonal screening:
Examination of women with a regular menstrual cycle:
- on days 5-7 of the menstrual cycle, the levels of basal secretion of the following hormones are determined in the blood plasma: prolactin, testosterone and dehydroepiandrosterone (DEAS).
- on the 20-22nd day - progesterone.
Examination of women with menstrual irregularities:
on days 5-7 of your own or gestagen-induced cycle, determine:
- prolactin;
- follicle-stimulating hormone (FSH);
- luteinizing hormone (LH);
- thyroid-stimulating hormone (TSH);
- estradiol;
- testosterone, cortisol, DEAS
- triiodothyronine (T3);
- thyroxine.
On the 20-22nd day - progesterone.
3. Immunological screening: postcoital test (PCT).
4. Husband's spermogram.
List of additional diagnostic measures:
1. Ultrasound of the pelvic organs.
2. Hysterosalpingography.
3. Ultrasound of the mammary glands according to indications
4. Mammography according to indications
5. X-ray of the skull and sella turcica if necessary.
6. Computed tomography and nuclear magnetic resonance according to indications.
7. Ultrasound of the thyroid gland according to indications.
Treatment tactics:
There are no age limits for infertility treatment, with the exception of the period of normal menopause (about 50 years).
1. Consultation with a psychotherapist.
2. Pathogenetic treatment of the causes leading to infertility:
- endocrine pathology (hyperprolactinemia, hyperandrogenism, luteal phase deficiency);
- urogenital infections (gonorrhea, trichomoniasis, HSV, CMV, chlamydia, mycoplosis, ureaplasmosis, etc.);
- endometriosis;
- other reasons.
3. Induction of ovulation using:
- clomiphene citrate 50 mg (1 tablet) from days 5 to 9 of the menstrual cycle; if ineffective, the dose is increased to 100-150 mg;
- gonadotropins (FSH is preferable to human menopausal gonadotropin) - the dose is selected individually;
- agonists and antagonists of gonadotropin-releasing hormones.
4. Methods of assisted reproduction.
- Intrauterine insemination of sperm, often in combination with ovulation induction.
- In vitro fertilization (IVF): it is possible to use donor eggs; surrogacy in cases of incompetent uterine function.
List of essential medications:
1. Clomiphene 50 mg tablet.
2. Gonadotropins (FSH is preferable to human menopausal gonadotropin);
3. Agonists and antagonists of gonadotropin-releasing hormones.
Criteria for transfer to the next stage of treatment:
Lack of restoration of reproductive function.
If there are no conditions for examination and treatment in the clinic, the patient is sent for further examination and treatment to a specialized clinic.
There are two main types of male and female infertility - primary infertility and secondary.
Primary infertility is a condition in which a woman cannot become pregnant without previously having such a condition. Secondary is a type of infertility in which it is impossible to get pregnant again.
Female primary infertility – what is it?
Primary infertility according to ICD 10 is divided into several forms, each of which differs in its course and manifestations.
From a medical point of view, this diagnosis means the inability to conceive a child due to congenital or acquired pathologies of the reproductive system.
Similar pathologies are:
- Uterine fibroids;
- Cyst;
- Cervical erosion;
- Gynecological diseases of various etiologies.
There is another pathology that affects the inability to get pregnant - ovarian diseases. Due to their malfunction, the egg does not mature and, accordingly, conception does not occur. This condition may be accompanied by absence of menstruation or heavy and prolonged menstrual flow.
A diagnosis of primary infertility according to ICD 10 may mean the presence of consequences of abortion or other methods of terminating a previous pregnancy. After an artificial or natural abortion, a woman’s hormonal levels are disrupted, which is an obstacle to the successful conception of a child.
Primary infertility according to ICD can be explained by the consequences of gynecological diseases, as well as injuries to the internal organs of the reproductive system. A woman can receive such injuries during an abortion.
Adhesions in the fallopian tubes are also a cause of lack of pregnancy. Since the path of advancement of the egg is closed, its fertilization does not occur.
Main causes of pathology
Primary and secondary infertility have similar causes, so for these two forms of pathology the following list is applicable:
- The lack of ovulation may be due to hormonal imbalance. In this condition, a woman is alarmed by irregular menstrual cycles and heavy bleeding. Treatment of pathology is medication;
- Loss of quality characteristics of the egg can occur as a woman ages. For example, at the age of 40, female reproductive cells become abnormal. The problem of conception can be solved with the help of a donor egg and surrogacy;
- Primary infertility is a diagnosis that can be made based on endometriosis. A characteristic sign of this disease is the pathological growth of the endometrium outside the uterus. This condition is accompanied by severe menstrual pain. Elimination of the pathology is possible surgically.
- Obstruction of the fallopian tubes can occur due to inflammation or an STD;
- Due to polycystic ovary syndrome, the functioning of the hormonal system is disrupted, as a result of which the menstrual cycle and ovulation are delayed. Polycystic ovary syndrome may be accompanied by weight gain. Hair also grows quickly and skin problems appear. To treat this condition, medications are prescribed to stimulate ovulation.
Primary infertility - diagnosis for men
As stated earlier, this pathology can be diagnosed not only in women, but also in men. The reasons for its development will be the following:
- Urinary tract infection. During inflammation, antisperm antibodies are produced. The inflammatory process can be caused by pathogenic fungi, bacteria and viruses. The effectiveness of treatment depends on finding the source of the problem;
- Venous dilatation of the vas deferens or, in other words, varicocele. Primary or secondary infertility can be diagnosed due to overheating of the testicles, as well as due to an autoimmune reaction;
- Genetic abnormalities that affect the possibility of a surrogate mother carrying a child. Since the risk of transmitting diseases by heredity is high, it is recommended to use donor biomaterials for IVF;
- Male infertility can be explained by frequent illnesses, in particular, tuberculosis, bronchial asthma, diabetes mellitus, liver cirrhosis, gastrointestinal and pancreatic diseases. Hormonal disorders are also important;
- Bad habits are one of the main causes of male infertility, these include addiction to alcohol, smoking and drug use;
- Regular contact with chemical compounds, work in poor environmental conditions;
- Frequent stress, constant fatigue and poor nutrition - all this affects the production of male sex hormones.
Effective treatment
Depending on the primary infertility according to the ICD, the most effective treatment will be selected. In modern medicine there are several methods that give good results, these are:
- Therapeutic treatment using medications, as well as chemotherapy and radiation therapy;
- Surgical intervention, for example, removal of hernias, correction and elimination of scrotal injury, etc.;
- IVF – this method of infertility treatment is safe and particularly effective.
What pathology diagnostic methods are applicable?
In order to make an accurate diagnosis, the patient must undergo a comprehensive examination. This is also necessary to identify the cause of primary infertility. The complex of diagnostic measures includes tests, as well as instrumental and laboratory studies.
Based on the test results obtained and the information collected about the patient’s life, the doctor draws conclusions regarding the diagnosis. If primary infertility is confirmed, then appropriate treatment is prescribed based on the cause of the identified pathology.
Thanks to modern medicine, this diagnosis is not a death sentence for childless couples. Depending on the situation, you can always find the right solution.
One of the important problems of our time is infertility. According to statistics, about 10-15% of married couples suffer from this condition. The reasons may lie both in the body of a woman and in the body of a man. In any case, infertility is not a death sentence; pregnancy is possible.
This article will help you understand the reasons for infertility and what treatment is needed in each specific situation.
Diagnosis of primary stage infertility: what is it?
Primary infertility is the absence of pregnancy after 12 months of regular sexual activity without the use of contraceptive methods, and there is no history of previous pregnancies.
Primary infertility code according to ICD 10:
- Female infertility – N97.
- Male infertility – N46.
Among women
Infertility in women has its own causes, symptoms and treatment tactics.
Causes
Factors in the development of female infertility of the 1st degree include:
- Endocrine diseases. May result from malfunction of the ovaries (eg, malnutrition, polycystic ovary syndrome), other endocrine (eg, adrenal, pituitary, hypothalamus), and nonendocrine (eg, liver, kidney) organs. Endocrine-type infertility can be a consequence of severe stress and metabolic disorders in the body. There is a breakdown in the ovulation process, which is manifested by the absence of an egg release.
- Violation of the patency of the fallopian tubes. After ovulation, the egg enters these tubes, where it normally merges with the sperm. In the absence of patency (for example, due to the adhesive process), there is no meeting of the sperm and the egg, fusion does not occur, and there is no fertilization.
- Endometriosis. This pathology is characterized by excessive growth of the uterine mucosa outside its boundaries, the result is the formation of adhesions that prevent implantation of the embryo.
Important! Uncontrolled use of combined oral contraceptives and postinor-based emergency contraceptives can cause the endocrine form of primary infertility.
We bring to your attention a video on the topic of female infertility:
Symptoms
The main clinical picture of infertility is presented:
With insufficient development of the genital organs there may be:
- Weak or absent hair growth in the armpits and pubic area.
- Underdevelopment of the mammary glands.
- Lack of menstrual cycle at 15-16 years of age.
- Dyspareunia (painful sexual intercourse).
Diagnostics
The beginning of diagnostic measures is based on clarifying the obstetric and gynecological history. Rate:
- Height.
- Body mass index.
- Character of hair growth.
- Condition of the mammary glands.
- Condition of the genital organs.
Check availability:
- Complicated obstetric history.
- Endocrine diseases.
- Somatic pathologies.
- STD.
- Tuberculosis, HIV and other especially dangerous infections.
- Psychogenic factors.
Conduct laboratory and instrumental studies:
Treatment
The possibility and effectiveness of treatment for type 1 infertility is determined by the following factors:
- The main pathology.
- Concomitant diseases.
- Possibility of eliminating the cause.
- Possibility of using assisted reproductive technologies.
Reference! If infertility has developed due to endocrine pathology, then therapy is prescribed depending on the diagnosed pathology. If there is excess body weight, diet, physical activity, and medications are prescribed.
If it is determined that the cause of the underlying disease is underdevelopment of the genital organs, then the following is prescribed:
- Drug therapy with hormonal agents (gestagens, estrogens).
- Vitamin therapy.
- Physiotherapy (gynecological massage, balneotherapy).
If there is obstruction of the fallopian tubes, treatment can be either conservative or surgical. Conservative treatment includes:
Surgical treatment is performed if there is no effect from conservative therapy. It consists in:
- Laparoscopic lysis of adhesions.
- Resection of part of the fallopian tubes.
- Fallopian tube plastic surgery.
Forecast
If the reasons that caused primary infertility are reversible, then the prognosis is favorable. With appropriate therapy, pregnancy can occur and become pregnant. If this pathology depends on genetic factors, chromosomal abnormalities, then pregnancy is unlikely.
In men
Infertility in males also has its own characteristics.
Causes
The causative factors of first degree infertility in males are:
- Infectious and inflammatory diseases of the urinary tract. During the inflammatory process, antibodies are produced, which lead to the emergence of an antisperm immune status. Inflammation can be of viral, fungal, bacterial etiology. Before starting treatment for the disease, it is necessary to find the source of the infection and find out the causative agent.
- Varicocele. Is a dilatation of the veins of the spermatic cord. Overheating of the testicles occurs, as a result of which an autoimmune reaction directed against sperm may occur.
- Somatic systemic diseases. Tuberculosis, diabetes mellitus, bronchial asthma, cirrhotic liver disease, respiratory tract diseases, traumatic brain injuries, pathology of the digestive system, hormonal imbalances can cause disruption of spermatogenesis, the structure of sperm and their fertilizing ability.
- Hormonal imbalance. Stressful situations, overwork, violation of diet and nutritional balance are the reasons for changes in the ratio of hormones in a man’s body. Options for changing the balance of hormonal substances can be hypogonadism, hyperestrogenism, hyperprolactinemia.
Symptoms
Often no specific clinical picture is observed in primary male infertility. Symptoms can be very variable, depending on the factor that caused the primary form of infertility.
Diagnostics
Diagnostic measures begin with the mandatory collection of a life history, illness, and concomitant pathologies that could serve as a factor in this pathology. An examination is performed to identify anatomical abnormalities.
The main diagnostic method is a spermogram. The analysis must be carried out several times (about 2-3), before the procedure they abstain from sexual intercourse and masturbation for 3 days. The shape, size, mobility, and maturity of spermatozoa are assessed.
Ultrasound examination is also valuable. Using it, you can visualize the anatomy of the genital organs and diagnose possible pathologies. It is mandatory to eliminate hormonal imbalance in the body. The concentration of follicle-stimulating, luteinizing hormones, testosterone and progesterone in the blood is determined.
Infertility, or otherwise infertility, can occur due to the influence of many factors. Female and male infertility may differ in their mechanism of development, the likelihood of conception and the duration of infertility.
To make a correct diagnosis and predict further treatment actions, WHO specialists use the generally accepted classification of the disease.
Classification helps to reveal the patient’s history and determine the nature of the problem: congenital or acquired infertility.
Types of pathological conditions by degree
Primary
A patient is diagnosed with first-degree infertility if she does not become pregnant within 12 months of regular sexual activity and provided that the woman has not previously become pregnant or given birth. The primary form can be triggered by a number of unfavorable factors, such as a malfunction of the endocrine system and abnormal structure of the reproductive organs.
Secondary
Second degree of infertility is given to women who have been pregnant before. In this case, the outcome of the previous conception does not matter (direct birth, abortion, ectopic or frozen pregnancy). Secondary infertility can develop for the same reasons as primary.
But there are also a number of factors that provoke this pathology. Such factors of female illness are:
- artificial termination of pregnancy and the development of complications;
- endometriosis;
- hormonal disorders;
- injury to the pelvic organs;
- damage to the fallopian tubes as a result of surgery;
- inflammation and infection of the genital organs;
- obstruction of the fallopian tubes;
- early menopause
Absolute (3rd degree)
What is it - 3rd degree of infertility in women?
The third degree includes the case when women are unable to conceive naturally, and men are unable to fertilize an egg due to sperm abnormalities.
Female absolute infertility occurs for the following reasons:
- absence of reproductive organs;
- abnormalities of their development, leading to the inability to conceive and bear a child.
The causes of absolute male infertility are azoospermia, meaning the absence of sperm in the seminal fluid due to congenital anomalies or inflammatory processes resulting from previous chemotherapy or after surgery on the scrotum.
The diagnosis of absolute infertility is very rare, and science does not stand still, trying to minimize the inability to have children. This includes surrogacy and test tube babies.
What are the different forms called based on etiology?
Of unknown origin
Infertility of unknown origin belongs to ICD-10 code No. 97.9 and is detected in 5–10% of cases. This form of infertility is diagnosed by doctors if its cause cannot be determined. However, a couple wishing to conceive a child cannot do so for one year.
During the examination, specialists cannot identify any obstacles to fertilization or congenital pathologies in partners. Even with the most advanced diagnostic methods, it is sometimes impossible to identify functional and anatomical defects in the reproductive system of both patients.
Endocrine
In case of disruption of the egg maturation process, a diagnosis of endocrine infertility is made according to ICD-10 code No. 97.0, which manifests itself in 30 - 40% of cases. Violation of a woman's reproductive function may be caused by a lack of normal folliculogenesis in the ovaries.
The causes of the pathology may be:
- disruption of the thyroid gland and adrenal glands;
- functional failure in the reproductive system.
Endocrine infertility manifests itself in the absence of ovulation and disruptions in the menstrual cycle.
Cervical origin
Polyps in the cervical canal or its erosion can cause infertility of cervical origin (ICD code 97.3). The mucus becomes so thick that it cannot allow sperm to enter the uterus.
Even if sperm manages to penetrate the uterine cavity, the mucus, which is poisonous in its chemical composition, leads to the inevitable death of sperm.
Pipe origin
Infertility of tubal origin occurs in 20–60% of cases and is ICD code 97.1. It is characterized by adhesions in the pelvic area and pathologies of the fallopian tubes. All this leads to blocking the free movement of the egg and the impossibility of its penetration into the uterus.
The following reasons can lead to tubal infertility:
- congenital anomalies;
- genital endometriosis;
- tuberculosis of the genital organs;
- salpingitis;
- surgical operations in the abdominal cavity or pelvic organs;
- abortions.
We invite you to watch a video about tubal infertility:
Royal
Infertility of uterine origin (ICD code 97.2) can be caused by:
- Birth defects. Underdevelopment of the uterus, its duplication, saddle shape or complete absence of this organ.
A pathology in the form of a septum may develop in the uterine cavity, which blocks the penetration of sperm into its cavity.
- Acquired vices. They arise as a result of intrauterine interventions or after suffering inflammatory processes of the endometrium, which subsequently lead to cicatricial deformities of the uterine cavity, intrauterine adhesions (synechia).
With this form of infertility, a woman, as a rule, experiences periodic pain in the lower abdomen, regardless of the regularity of the menstrual cycle.
Associated with male factors
According to the ICD code, this pathology is numbered 97.4 and is diagnosed in married couples if the woman does not have any deviations in sexual reproductive function, and men have these deviations. In this case, the spermogram reveals low fertilizing ability.
The causes of the pathology may be:
- environmental pollution;
- malnutrition;
- obesity;
- bad habits (alcohol and smoking abuse);
- constant depression and anxiety;
- long-term use of hormonal drugs and some antibiotics;
- colds and hypothermia;
- harmful factors at work;
- sexually transmitted infections;
- testicular injuries;
- varicocele;
- endocrine disorders in the body;
- passive lifestyle.
The potency of a man with this pathology may not be impaired, but the likelihood of conception is greatly reduced. In order to exclude that female infertility is associated with male factors, a man needs to be examined for possible infections and take a post-coital test and spermogram.
Other forms of pathology
Immunological
Immunological infertility occurs in 2–3% of cases. The reproductive function of a woman or man is impaired due to damage to sperm by antisperm antibodies.
In the stronger sex, immunological infertility can occur as a result of exposure to the following factors:
In relation to sperm, women may experience immunosuppression in the following cases::
- sexually transmitted infections (gonorrhea, chlamydia and others);
- inflammation of the genital organs of a chronic nature;
- genital endometriosis;
- allergic diseases.
We invite you to watch a video about immunological infertility:
Psychological
Fatigue, stressful conditions of the nervous system, various fears (family conflicts, financial difficulties, fear of motherhood and others) can affect the possibility of conception. The emotions of the weaker sex are more subtle in their manifestations and internal experiences than those of men. Psychological blocks can affect any area of life, including those coming from childhood.
The influence of the psyche on the physiology of the body has not yet been fully studied. But it has been absolutely established that negative psychological feelings on a subconscious level can lead to anovulatory cycles, spasms of the fallopian tubes and myometrial hypertonicity in women, and to a deterioration in the quality of sperm, a decrease in the sensitivity or activity of sperm in men.
We invite you to watch a video about psychological infertility:
Genetic
Genetic infertility is diagnosed in 20% of married couples, and treatment is quite difficult and long. Moreover, this problem occurs more often in the male population than in women.
The causes of the genetic form of infertility can be:
Genetic infertility in the weaker sex can be indicated by factors such as primary or secondary amenorrhea, delayed puberty (the onset of the first menstrual cycle after 17 years, miscarriages in the early stages of pregnancy, stillbirth or a frozen fetus in the womb). At the same time, attempts to conceive using IVF end in failure.
Male signs of genetic infertility may include a delay in the development of primary or secondary sexual characteristics, for example, a high pitch of voice, short stature, underdeveloped testicles, wide hips and narrow shoulders.
In order to make a correct diagnosis and determine the cause of infertility, it is necessary to know the types of male and female infertility. Doctors have established a special ICD code for each form of pathology. The classification of infertility allows you to select effective treatment and achieve the fastest possible fertilization of a woman.
Possible causes of primary infertility may include neuroendocrine disorders, abnormalities in the development of the reproductive system, complications of diseases of the reproductive organs suffered before the onset of sexual activity or active attempts to get pregnant. Primary infertility may be based on uterine, endocrine, tubal, and immunological factors.
Endocrine dysfunction is detected in 60-80% of women suffering from primary infertility. This may be an ovulation disorder caused by stress, mental and physical fatigue, nutritional dystrophy (including Anorexia), polycystic ovary syndrome, hypothyroidism, adrenogenital syndrome, obesity. Uncontrolled use of COCs, as well as emergency contraception (for example, Postinor) can also lead to disruption of the regulation of the menstrual cycle. Less common factors of primary infertility are genital infantilism caused by tumor or inflammatory lesions of the hypothalamic-pituitary region, head injuries; various forms of gonadal dysgenesis (Swyer syndrome, Shereshevsky-Turner syndrome), caused by chromosomal abnormalities, etc.
Congenital causes of primary infertility include anatomical defects of the pelvic organs: for example, the absence of the uterus (including Rokitansky-Kustner syndrome), ovaries and fallopian tubes; hyperretroflexia and hyperanteflexia of the uterus. Anomalies such as gynathresia, hymenal atresia, vaginal and uterine atresia are usually detected during puberty due to the impossibility of outflow of menstrual blood and the development of hematocolpos, hematometra, hematosalpinx. Such defects in the structure of the genitals occur at an early stage of embryonic development (up to 12 weeks of pregnancy) and can be associated with toxicosis, viral infections, endocrine disorders, professional and household intoxications of the mother.
However, even with a normally formed reproductive system, primary infertility can later be caused by general infections suffered in childhood (diphtheria, scarlet fever), and later by STDs, genital tuberculosis, nonspecific inflammation (adnexitis, salpingitis, endometritis, pelvioperitonitis, etc.) The result of a severe course These diseases can cause obstruction of the fallopian tubes, creating obstacles to pregnancy. Past infections or intoxications can cause damage to the follicular apparatus of the ovaries, resulting in a decrease in the hormonal function of the glands and ovulatory disorders. Primary immunological infertility is associated with the antigenic properties of the egg and sperm and the resulting immune reaction against these antigens.