Infertility is divided into infertility and sterility. A couple of childbearing age who have lived together for more than one year, have normal sexual intercourse, and have not used any contraceptive measures, but have not succeeded in conceiving, is called infertility. Those who are able to conceive but cannot obtain a viable baby due to miscarriage or stillbirth for various reasons are called infertility. Early evaluation is necessary as women’s fertility decreases with age after the age of 40. The causes of infertility are extremely varied, and overall infertility is caused unilaterally by the wife in 50% of cases, unilaterally by the man in 30% of cases, and jointly by both partners in 20% of cases. Since male fertility tests are simple and convenient, painless, non-invasive and less costly, infertility tests are performed on men first, checking whether the male internal and external genitalia are developing normally, and if there is no abnormality in the genital fertility test and the sexual function is normal, the next step is to do a semen test on the male side. If the semen test is normal, the male partner can basically be ruled out as the cause of infertility, and then the female partner can be started to find the cause.
This article is a 2015 ASRM committee guideline for the diagnosis and evaluation of female infertility. We recommend the diagnosis and evaluation of infertility in women who have failed to conceive spontaneously within the first half of their 35 years of age, and the conditions that need to be evaluated include the following
1. history of menorrhagia or irregular menstruation
2. presence of known or suspected uterine, tubal or peritoneal pathology or endometriosis stages III-IV
3. a known or suspected low fertility of the partner.
Evaluation for infertility should be done in both spouses. Women may be considered for artificial insemination if they wish to become pregnant.
I. Medical history and physical examination
Diagnosis should include a comprehensive assessment of the patient’s substance use history, fertility history, and family history, followed by a thorough physical examination. The relevant medical history should include the following.
1. duration of infertility, prior evaluation and treatment.
2. history of menstruation (age at menarche, cycle characteristics, presence of discomfort, degree of dysmenorrhea)
3. history of pregnancy (number of pregnancies, pregnancy outcome, live birth rate and associated complications)
4. the contraceptive methods used.
5. frequency of sexual life and sexual dysfunction.
6. history of surgery (procedure, indications and outcome), whether hospitalized, serious illness or injury, inflammatory pelvic disease or history of contact infection
7. thyroid disease, breast overflow, hirsutism, pelvic or abdominal pain, painful intercourse
8. abnormal cervix and subsequent treatment.
9. history of previous medications and allergies.
10. family history of birth defects, delayed development, early menopause or infertility
11, occupational exposure to known environmental hazards.
12. smoking, alcohol or drug use.
The patient’s physical examination should document the following indicators.
1. weight, body mass index (BMI), blood pressure, and pulse rate.
2. enlargement and nodularity of the thyroid gland and the presence of pressure pain.
3. characteristics of breast secretions.
4. the phenomenon of excessive androgen secretion
5, vaginal or cervical secretions.
6. pelvic or abdominal tenderness, organ enlargement or presence of masses.
7. the size, shape, position and mobility of the uterus
8. adnexal masses or pressure pains.
9, rectal uterine trap masses, pressure pain and nodules.
II. Ovarian function
Ovulation disorders account for 15% and 40% of spousal infertility and female infertility, respectively. Ovulation disorders can lead to significant menstrual disturbances (scanty or amenorrhea), and the most common causes include polycystic ovary syndrome (PCOS), obesity, weight gain or loss, strenuous exercise, hypothyroidism, and hyperprolactinemia. Methods to assess ovulatory function include.
1. Menstrual history. For most women who ovulate, the menstrual cycle is regular, usually between 21-35 days. Studies have shown that some degree of variation in menstrual cycle and cycle length is completely normal. Patients with abnormal uterine bleeding, menorrhagia or amenorrhea generally do not require special diagnostic tests for anovulation.
2. Continuous basal body temperature (BBT) measurement. BBT provides a simple and inexpensive method of assessing ovulatory function. Based on cycle monitoring of BBT, ovulation can be found to occur generally within the time frame of a 7-day temperature rise on continuous basal body temperature testing. However, BBT is not the best or preferred method for ovulatory function assessment because of its lack of reliability.
Serum progesterone: A reliable, objective ovulation test. Within the normal range of variability, serum progesterone is usually measured approximately 1 week prior to the next menstrual period, rather than at any particular time. Progesterone concentrations greater than 3 mg/ml provide reliable evidence that recent ovulation is presumed. (incoherent)
4. Urinary luteinizing hormone (LH). A mid-cycle surge in LH levels occurs 1-2 days prior to ovulation and the test may yield false positive and false negative results.
5. Endometrial biopsy (EBM). It allows to understand the secretion of endometrial tissue, the secretion is produced by progesterone stimulation, thus implying ovulation. Traditional histological periodic endometrial biopsy has long been considered the ‘gold standard’ for evaluating luteal function and diagnosing luteal phase defects (LPD).
6, Transvaginal ultrasound: It can show the size and number of dominant follicles, while clinicians can presume ovulation and luteal formation by the growth of follicles, whether the follicles rupture, the appearance of internal luteal echogenicity and rectal uterine trap fluid.
7. Hormone measurements: Serum thyroid stimulating hormone (TSH) and prolactin measurements can determine thyroid disease and hyperprolactinemia, both of which may require special treatment. In women with amenorrhea, serum follicle stimulating hormone (FSH) and estradiol levels are measured to identify hypothalamic amenorrhea (low or normal FSH, low estradiol) and premature ovarian failure (high FSH, low estradiol) to determine the need for exogenous gonadotropin stimulation for ovulation or assisted reproductive technology.
If a woman is treated and does not have a successful pregnancy within 3-6 menstrual cycles after successful ovulation stimulation, further evaluation is needed to select other treatment options.
Ovarian reserve
Ovarian reserve reflects the reproductive potential in terms of the number and quality of the follicles in the primordial follicle. Decreased ovarian reserve (DOR) results in reduced fertility. We usually use serum FSH and estradiol measurements on day 3 of the menstrual cycle, clomiphene excitation test (CCCT), sinus follicle count (AFC) and mullerian hormone (AMH) concentrations to assess ovarian reserve. A poor result of any single test does not mean that pregnancy is not possible.
1. Serum FSH and estradiol measurement: Measurement of serum FSH levels on days 2-4 of the menstrual cycle can reflect ovarian reserve. High levels (>10-20 IU/L) may be considered a failure to conceive.
2. Clomiphene excitation test (CCCT): serum FSH levels were measured before and after clomiphene treatment, respectively. An increase in FSH concentration after clomiphene stimulation reflects reduced ovarian reserve function.
3. Sinus follicle count. The sinus follicle count counted follicles with two cavities of 2-10 mm in diameter in the ovaries bilaterally. If the number of sinus follicles is less than 3-6, the ovarian reserve function can be considered to be reduced.
Patency of the fallopian tubes
Fallopian tube disease is an important cause of female infertility and requires special attention. Accurate diagnosis and effective treatment require a variety of methods as follows.
1. Hysterosalpingogram: Tuberosalpingogram can observe the obstruction of the proximal and distal tubules and show isthmus nodular tubal inflammation. However, the proximal obstruction needs further evaluation and artifacts produced by contraction of the fallopian tubes, myometrium or transient changes in the position of the fallopian tubes need to be excluded.
2. saline oxygen contrast ultrasonography of the fallopian tubes: the patency of the tubes can be determined.
3. laparoscopy and tubal pigmentation: to detect proximal or distal obstruction of the fallopian tubes
4, hysteroscopy.
5. chlamydia antibody test: chlamydia infection has been shown to be possibly associated with tubal disease.
v. peritoneal factors
Peritoneal factors such as endometriosis, pelvic or adnexal adhesions may lead to female infertility.
1. Transvaginal ultrasonography can detect unidentifiable pelvic lesions such as endometriosis. Mild endometriosis has less impact on fertility. Most women who are infertile do so because of the presence of severe adnexal adhesions and other risk factors, such as pelvic pain, moderate or severe endometriosis, pelvic infection or a history of surgery.
2. Laparoscopy provides the clearest examination of the patient’s symptoms and risk factors for peritoneal disease.
The diagnostic evaluation of female infertility includes a detailed medical history and physical examination. In addition to this, the male partner’s should be evaluated. Women under 35 years of age who are unable to conceive spontaneously without any contraceptive measures for one year should be evaluated for infertility and treated according to the results of the evaluation. women over 35 years of age who have been treated and are able to ovulate successfully and who are unable to conceive spontaneously without contraceptive measures for 6 months may be considered for assisted reproduction.