Infertility refers to a complex social problem that combines medical, psychosocial and economic dimensions. Although infertility is not a fatal disease, it can cause family discord and social instability. According to statistics, one out of every six to eight couples suffers from infertility, and there are about (50-80) million infertile couples worldwide, and 2 million new couples are added every year. The prevalence of infertility in China is 10% in urban areas and up to 15% in rural areas. Every year, about 60,000 patients visit our hospital for infertility. Some of these patients are blindly seeking medical treatment, choosing to visit some illegal medical institutions and undergoing a large number of unnecessary examinations, such as routine tests for chlamydia, mycoplasma, gonococcus, hysteroscopy, colposcopy, tuboscopy, dilatation of the uterine cavity, genital ultrasound of both sides, endocrine, anti-sperm antibodies, chromosomes, male semen, prostate fluid, pale mice egg penetration test and post-coital test.
The tests that cause infertility with very low incidence are also routinely performed, which not only aggravates the burden of patients but also loses or delays the best time for treatment. How to let infertility patients undergo scientific and standardized examinations, curb excessive examinations and high costs in infertility diagnosis and treatment, and let patients spend the least amount of money to obtain the most satisfactory results is an ethical and responsible doctor.
We know that the causes of infertility are complex, and the clinical symptoms are the inability to conceive or maintain a pregnancy. The main causes of female infertility are ovulation disorders (25%) and tubal disease (20%-25%) and endometriosis (10%). Male infertility as the main factor accounted for 40% and unknown causes or both factors 20%.
According to the above causes of infertility, the doctor first performs the following on the patient.
1.History taking: The purpose of history taking is to understand the patient’s personal medical and life history, including age, occupation, experience, stress, diet, smoking and drinking history and other factors affecting fertility.
2. Semen routine examination: Semen specimens (within 1 h) were collected for examination after abstinence (2-7) d. It is difficult to predict the possibility of pregnancy based on semen analysis results alone because there is a large overlap in semen parameters between normal and infertile men. If the semen analysis is abnormal, the clinician should consider whether the semen collection details and semen transit route affect the results of the test, which usually requires 2 tests. Sperm density is generally higher with computerized testing than with manual testing. For specimens with high sperm density, computerized detection of sperm viability is generally low.
3.Gynecological examination: If pressure pain in the adnexal area and posterior vault tenderness, abnormal vaginal cervix, enlarged and irregularly shaped uterus or lack of motility are found in female patients, they should be highly alert.
4. Ovulation monitoring and mid-luteal progesterone testing: For women with regular menstrual cycles, periods of (25-35)d and menstrual breast distention, laboratory confirmation of ovulation is not necessary. For irregular periods, patients are advised to monitor the LH peak with a luteinizing hormone (LH) urine test or to monitor the mid-luteal progesterone level to monitor ovulation. Progesterone levels are monitored on days 18 to 24 of menstruation and ovulation is diagnosed if progesterone levels are >3 ng/mL. In patients with more severe sporadic menstruation (menstrual cycle more than 45 d), the primary cause of the menstrual disorder should be identified clinically and the primary cause should be treated aggressively. Continuous basal body temperature (BBT) measurement in infertile patients can be used to retrospectively analyze the presence or absence of ovulation and luteal function, but continuous ultrasound monitoring is the gold standard for confirming ovulation.
If HSG diagnoses proximal tubal obstruction, proximal tubal cannulation imaging (by interventional radiography) is also feasible. Laparoscopy should be performed in patients with suspected endometriosis and pelvic adhesions. Tubal lavage, which cannot exclude hydrosalpinx and clarify the site of tubal obstruction, is only suitable for primary screening of infertility in primary hospitals.
6.Chlamydia antibody: some evidence supports Chlamydia trachomatis test as one of the methods to diagnose tubal disease.
7. Uterine cavity examination: HSG can check for uterine developmental abnormalities such as submucosal fibroids, T-shaped uterine cavity (associated with exposure to ethylene estradiol), endometrial polyps, uterine adhesions and congenital mullerian duct developmental abnormalities. Of course, HSG cannot differentiate between a longitudinal uterus and a bicornuate uterus, and hysteroscopy, laparoscopy or other imaging studies (transvaginal ultrasound or MRI) are usually required after HSG has detected an abnormality. Transvaginal ultrasound is an effective method to detect suspicious fibroids, while saline-infused ultrasonography of the uterine cavity is the most effective imaging method to diagnose submucosal fibroids and is superior to plain transvaginal ultrasound for uterine adhesions and longitudinal uterine septum . Hysteroscopy is the definitive method to examine endometrial lesions and is sometimes used for treatment.
8. Diagnostic laparoscopy: laparoscopy is controversial in infertility screening because of its invasive nature, high price and inability to perform treatment. Laparoscopy is usually used for unexplained infertility, suspected endometriosis or pelvic adhesions with pelvic pain and complications of appendicitis, pelvic infection, pelvic surgery or history of ectopic pregnancy. Laparoscopy is able to diagnose unexplained infertility but not to treat the pathological lesions present.
Infertility tests with clinical limitations.
1. Post-coital test: The post-coital test is often used to check the amount of cervical mucus and its interaction with sperm. After intercourse in the late follicular phase, a small amount of cervical mucus is taken for examination of its lacrimation and microscopic examination of its amniotic crystals and motile sperm (at least 5 motile sperm per high magnification is considered normal). Its diagnostic value is limited and it is poorly predictive. The number of sperm present per high-powered microscope considered as normal sperm function has been controversial so far, and the results of the experiment are unstable and poorly reproducible. Therefore, there are studies that have raised many questions about the validity of this test. In addition, various treatments for abnormal sperm function have not been proven to be effective; therefore, the addition of this test to the routine tests for infertility has failed to improve pregnancy rates.
2.Endometrial biopsy: Endometrial biopsy reveals secretory phase endometrium, which is reliable evidence of ovulation, but this test is used to detect ovulation, which is invasive and more expensive unnecessarily.
3. Basal body temperature measurement: (basal body temperature chart), is the cheapest method to detect ovulation. Its results can predict the time of progesterone rise. However, it is difficult to read the meter and the results of the meter reader, there is a large error. In a normal menstrual cycle, the basal body temperature starts to rise (2-3) d after the peak of serum LH and continues for at least 10 d. Therefore, the basal body temperature changes retrospectively to determine the time of ovulation is reliable, but it is too late to use it to guide intercourse.
4. Hamster egg penetration test: This test checks sperm penetration. Controversy exists as to whether hamster eggs can predict fertilization of human eggs. The results are partly dependent on laboratory manipulation. This test is not included in the initial screening for the cause of infertility because the results do not affect clinical treatment.
5. Mycoplasma culture: This test is not routinely recommended for primary screening for infertility because there is only minimal evidence for its role in female infertility screening.
Antibody testing: The available evidence does not support the routine use of antiphospholipid, antisperm, antinuclear and antithyroid antibodies in the initial screening for infertility. Antiphospholipid antibodies have been shown to be associated with early pregnancy loss, while testing for other immune factors can be performed after failure of infertility treatment.
7. Chromosome examination: there is a consensus to perform this examination in patients with severe oligospermia. Patients with severe oligospermia are at high risk for y-chromosome microdeletions or other abnormalities. This test is also recommended for women with early menopause and recent miscarriage. In most cases, chromosomal testing is not used as a primary screening test for the cause of infertility because the incidence of chromosomal abnormalities is extremely low in women with unexplained infertility, endometriosis, and tubal infertility. Those patients who have failed initial infertility treatment and are ready to enter an in vitro fertilization (IVF) cycle may undergo chromosomal testing. Although the validity analysis of pre-IVF chromosomal testing has not been elucidated to date.
Currently, we at the Institute of Reproduction have developed a clinical pathway for primary screening of infertility etiology as follows.
① A detailed history of the infertile patient and a physical examination.
② Infertility screening tests include: semen analysis, ovulation testing, HSG for patients with abnormal fallopian tubes or presence of uterine cavity development, and follicle stimulating hormone (FSH) levels on day 3 of menstruation for women over 35 years of age or at risk of premature ovarian failure. The evidence-based rationale includes.
(i) tests directly related to pregnancy outcome: semen analysis; mid-luteal progesterone measurement and ultrasound monitoring of ovulation during ovulation; and hysterosalpingography: for tubal patency.
② Tests not directly related to pregnancy outcome: post-coital test; hamster egg penetration test; cervical mucus penetration test; anti-sperm sperm antibody assay; endometrial diagnostic scraping, spermatozoa, chlamydia, and tuboscopy. These results have been shown to be unrelated to pregnancy outcomes or lack follow-up information
Gansu Province is located in the west, and compared with developed provinces and cities, medical institutions are relatively backward in terms of treatment technology and medical equipment. Some individuals of childbearing age in remote places lack scientific understanding of reproductive health and infertility, and there is no unified and standardized pathway of infertility etiology examination in relevant medical institutions so far. This has led to many infertility patients not receiving timely and standardized treatment. To effectively relieve the reproductive diseases and infertility problems of individuals of reproductive age, and to curb the phenomena of excessive examination, treatment and high costs, confusion in diagnosis and improper treatment in infertility diagnosis and treatment, it is crucial to standardize the clinical pathways of primary medical units for primary screening of infertility etiology. Therefore, we can finally realize that infertility patients can take the lead in obtaining scientific and standardized diagnosis and treatment in our province, so that patients can obtain satisfactory results with minimal cost.