According to the World Health Organization, in the 21st century, infertility will become the third most common disease after tumors and cardiovascular diseases. At present, the incidence of infertility in China is increasing year by year, accounting for about 5-15% of the total population. According to survey statistics, among all infertility diseases.
The main causes of male and female infertility can be summarized into five categories: the main causes of female infertility are: first, ovulatory dysfunction, second, tubal factors, third, abnormal development of reproductive organs, fourth, reproductive tract infections, and fifth, immunological factors; the main causes of male infertility are: first, sexual dysfunction, second, abnormal semen quality, third, varicocele, fourth, immunological factors, and fifth, reproductive tract infections such as orchitis, vesiculitis and prostatitis, etc.
Section I. Interventional treatment of tubal incompetence
I. Overview
Among the many factors that cause female infertility, tubal obstruction is one of the most common causes of female infertility, and its incidence has been reported in the literature as a percentage of female infertility patients. Proximal tubal obstruction, which accounts for about tubal infertility, is mostly due to non-specific inflammatory diseases, such as inflammation of the reproductive system, tuberculosis, and post-abortion infection.
Diagnosis
However, due to tubal spasm, membranous adhesions, mucus plug obstruction, operation and other reasons, routine tubal iodography has up to 30% false positive results.
III. Treatment
Tubal factors are a common treatment problem in infertility. There are many clinical methods used to treat tubal obstruction, and their diagnostic accuracy and efficacy vary. Due to the special anatomical location and morphology of the fallopian tubes, it is difficult to achieve satisfactory results with drug treatment; laparoscopic examination and dissection are technically complicated and traumatic, and their application is limited; lavage test and anti-inflammatory treatment have unsatisfactory effects.
Tubal recanalization is an emerging technology combining traditional hysterosalpingography with modern interventional radiology technology, which loosens and separates the adhesions in the tubal lumen with the mechanical movement of the guidewire and can be treated by microcatheter injection. Interventional recanalization opens up a new treatment route for patients with obstruction and is an effective, simple, safe and economical method.
Interventional recanalization has visualization, which avoids the blindness and illusion of the previous traditional tubal lavage, which was judged only by the subjective feeling, drug injection resistance and experience of the doctor, so it helps to diagnose the site, degree and nature of tubal obstruction, and enables most of the obstructed tubes to be recanalized to achieve therapeutic effect, and greatly improves the conception rate of patients after recanalization. However, for the distal part of the jugular abdomen and the umbilical segment obstruction, recanalization by guidewire is not recommended. Interventional tubal revascularization is contraindicated in cases of severe occlusion at the uterine horn, obstruction after tubal anastomosis, severe heart failure, active tuberculosis, and iodine allergy. If the patient is in an acute episode of genital inflammation, fever, menstrual period, or if tubal tuberculosis has been diagnosed, the patient should not be recanalized with a guide wire because of decreased tubal compliance.
Generally, interventional recanalization is performed within the 5th-7th day after menstruation. Pre-operative routine blood tests, chest X-ray, ECG, pelvic ultrasound or CT examination should be done if necessary. A preoperative iodine allergy test must also be performed.
The operation should be performed gently and skillfully to prevent subplasmic perforation of the fallopian tube and injury to the muscle wall. At the same time, prolonged operation time should be avoided, causing uterine cavity infection, and postoperative anti-infection treatment should be given. After the operation, the patient should be asked to lie down and observe for 1-2h and leave only when there is no special discomfort. Abdominal pain and small amount of vaginal bleeding may also occur after surgery. These symptoms usually disappear within 2-5 days after the operation and should be treated symptomatically.
In order to prevent tubal re-adhesion after surgery, post-operative lavage treatment is very necessary, and anti-infection treatment should be strengthened at the same time. And perform uterine lavage 3-7 days after menstruation for 3 consecutive months, 2 times a month to consolidate the patency of the fallopian tubes. For eugenics and prevention of ectopic pregnancy. We ask patients to wait 3 months after the intervention before getting pregnant.
Because of the exposure to X-rays during the intervention, conception after an interval of several months is beneficial for eugenics, and also after 3 months of outpatient maintenance lavage treatment, the chance of tubal pregnancy can be reduced. Intercourse is prohibited or condoms must be used for 1-2 months after treatment to prevent ectopic pregnancy.
Section II. Interventional treatment of male varicocele
I. Overview
Varicocele in men is a common disease in young adults with a prevalence of 10-15%, which refers to the abnormal tortuous and dilated trapezius plexus caused by the obstruction of blood flow in the spermatic veins. Patients mostly have no obvious symptoms, but some of them may have soreness and pain in the scrotum, which is aggravated after walking or labor and relieved after lying down. As a result of vasodilatation and stasis of blood vessels, local warming and increased concentration of catecholamines in blood affect the spermatogenic function and may also be accompanied by testicular atrophy. 39% of male infertility patients have varicocele, so varicocele is one of the important causes of male infertility.
According to the different factors of development, varicocele is generally divided into primary varicocele and secondary varicocele.
varicose veins. Primary varicocele mostly occurs at the age of 15-30 years old, which is presumed to be a period of abundant blood supply to the scrotum and its contents, high sexual desire, and excessive sexual stimulation can reflexively cause pelvic and spermatic vein congestion, thus leading to the occurrence of varicocele. In some patients, varicocele can disappear or be reduced after marriage; secondary varicocele is caused by pressure on the spermatic vein on the way of reflux, which mostly occurs above 35 years old, and common compression lesions are: renal tumor, ureteral tumor, retroperitoneal tumor, hydronephrosis, perinephric pus, vagus vessel, iliac vein obstruction, etc.
Varicocele occurs 95% on the left side for two reasons: the left internal spermatic vein is long and enters the renal vein at a right angle, and the blood flow is subject to some resistance. The left internal spermatic vein near the left renal vein has no valve, so the blood is easy to backflow; the left internal spermatic vein is located after the sigmoid colon, which is easily compressed by the intestinal feces and affects the blood return flow.
Diagnosis
The diagnosis is not difficult. During the examination, the patient is allowed to stand. The scrotum on the affected side can be seen to be markedly drooping, and there are sometimes curved veins on the skin surface. The veins in the scrotum are coiled into clusters, and the male examination can reveal tortuous and dilated spermatic veins like earthworms. On examination, a soft, compressible mass of varicose veins can be palpated in the spermatic cord above the testes. Occasionally, small nodules of thrombosis may be palpated. A mass of the same nature may also be palpated in the lower posterior aspect of the testis. The mass disappears quickly when the patient is lying down. If it does not disappear after lying down, it should be considered secondary. Appropriate investigations are required. Spermovasography is the most reliable method to diagnose primary varicocele, which can not only understand the existence, degree and anatomical variation of varicocele, but also decide whether surgery or embolization is appropriate, study the reasons for the continued existence of varicocele after surgery and decide the timing of surgery.
Treatment
1.Surgical treatment
Traditional surgical methods include retroperitoneal cluster ligation of the spermatic vessels, transinguinal high ligation of the internal spermatic veins and laparoscopic surgery. The incidence of postoperative complications such as testicular syringomyelia and testicular artery injury and the recurrence rate of varicocele are high.
2.Interventional treatment
There is extensive traffic between the spermatic vein and vas deferens vein and external spermatic vein, and there is also a lot of traffic between this deep group of veins and superficial group of veins. Embolization of the spermatic vein and trapezius plexus will not affect the blood return to the testis and the paid testis. Embolization of the seminiferous veins eliminates the backflow, which is a direct cause of varicocele, and there is little displacement of the embolized material due to the backflow. This is the basis for percutaneous puncture for spermatic vein embolization. With the development of interventional radiology, the implementation of venous embolization has replaced some of the surgical treatment, which has the advantages of simplicity, less pain, and less recurrence, reducing the recurrence rate compared to traditional surgery.
(1) Indications
Male infertility patients with severe clinical symptoms or varicocele with sperm abnormalities are all indications for embolization. Recently, treatment of varicocele in childhood and adolescence has been advocated in order to improve fertility.
(2) Contraindications
Embolization is contraindicated in cases of complications caused by obstruction of the left common iliac vein or compression of abdominal organs and tumors. Embolization will aggravate the obstruction of blood return and worsen testicular damage.
(3) Precautions
Before the operation, explain the significance of embolization to the patient and obtain the cooperation of the patient. Apply lead skin to cover the scrotal area of the patient during the operation to avoid excessive X-ray exposure. Select the appropriate embolization material according to the imaging results and the degree of catheter super-selection. If the side branch vessels are fine and widely distributed use sclerosing agent. In the case of single, non-side-branched spermatic veins, sclerosing agent, stainless steel ring or detachable balloon can be chosen. The catheter must be inserted to the appropriate position before releasing the embolic material, and the embolic material should be pushed slowly. Do not pull the floating catheter at will during the embolization test to avoid premature dislodgement of the balloon.
(4) Complications
As long as the embolization material is selected appropriately and the size is suitable, there are generally no serious complications and sequelae. Fever, pain at the lumbar abdomen and scrotum are common adverse reactions, which can be treated symptomatically and generally disappear 2-3 days after surgery. Stainless steel ring or balloon dislodged into the renal vein or pulmonary artery is a more serious complication, very rare, mostly due to improper operation, if necessary, surgical removal.
(5) Efficacy and limits
The discomfort of scrotal swelling disappeared 24 hours after the operation, and the varicose spermatic vein retracted compared with the preoperative one, and various embolization agents achieved good results. The success rate of percutaneous puncture spermatic vein embolization was 59%-93%, the embolization efficiency was 96.2%-98.7%, and the postoperative recurrence rate was 1.4%-2.5%. After treatment, the semen improved by 50%-80%, and 30%-50% of patients regained their fertility. Since spermatic vein embolization is an intravascular operation, if the open segment of the spermatic vein is a multi-branched fine vessel and it is difficult to implement catheter embolization, it should be terminated promptly and surgical treatment should be performed instead.
Section III. Interventional treatment of vascular impotence
I. Overview
Patients with impotence account for about 37%-42% of male sexual dysfunction. Relevant domestic surveys show that impotence occurs in about 10% of adult men, and the incidence of impotence increases with age. Therefore, impotence has become a common disease that seriously endangers male patients and families.
Impotence is the inability of the penis to get an erection or an erection that is not hard enough to complete normal sexual intercourse. The physiological process of erection is a vascular response regulated by nerves. The erection of the penis after filling with blood, its hardness and duration are related to the degree of filling of the penile corpus cavernosum and venous return.
The arteries supplying blood to the penis mainly come from the internal iliac artery and the internal pubic artery. When these vessels are affected by trauma, pelvic surgery, atherosclerosis and endocrine disorders, they can cause vascular impotence; some drugs such as blood pressure and blood sugar lowering drugs like reserpine, guanethidine, digoxin, valium, tachyphylaxis and gastrodia can cause impotence. Neurological and urinary system lesions can also cause impotence: localized brain damage, such as limited epilepsy, encephalitis, cerebral hemorrhage compression, spinal cord injury, spinal cord tumors, chronic alcoholism, multiple sclerosis, pelvic surgery damage to peripheral autonomic nerves, etc. can cause impotence.
Second, diagnosis
The diagnosis of impotence must be made carefully. The doctor should take a detailed medical history and conduct relevant examinations, including marital history, sexual history, possible reasons for failure to have intercourse, specific circumstances at home, lifestyle habits, history of trauma, treatment process, and assessment of the patient’s mental and psychological condition. At the same time, the patient should be examined for diseases such as cardiovascular disease, endocrine defeat, and genitourinary system, so that a comprehensive analysis can first distinguish between mental impotence and organic impotence. Organic impotence is characterized by the inability of the penis to move at any time, neither erection during sexual excitement, nor spontaneous erection. Functional impotence, on the other hand, has a spontaneous erection, but the erection fails again in the immediate room. It must be remembered that the vast majority of people have psychogenic impotence, and only after the nature of impotence is clarified can the appropriate treatment be given.
For organic cases, vascular tests such as ultrasound or angiography can also be performed, which can help to clarify the blood supply and venous drainage of the penis. The first test is usually performed using Doppler ultrasound to measure the penile artery/brachial blood pressure index (PBI), which is normal when the PBI is >0.75 and diagnosed as arterial impotence when the PBI is <0.6. When the PBI is between 0.6 and 0.75 then the diagnosis is not clear and other tests are needed. Alternatively, the diagnosis can be confirmed by testing the diameter of the penile arteries and the blood flow rate. In addition, angiography (DSA) can confirm the diagnosis of vascular impotence, but angiography is an invasive test. If ultrasound suggests the possibility of vascular impotence, DSA can be performed if treatment is proposed at the same time.
III. Treatment
The treatment of impotence requires different treatment according to the cause of impotence. Psychological impotence can be treated with good results through psychological guidance and other measures. For organic diseases, the corresponding treatment should be carried out for the primary cause.
1.Traditional treatment
Including psychotherapy, drug treatment, surgery. Psychological treatment is mainly to provide psychological guidance to the patient, and if necessary, use the corresponding drugs for treatment. Here we must remind patients must go to a large hospital for the corresponding examination and treatment, many fraudsters may use partial prescriptions, ancestral secret recipes and other fraudulent activities, they often take advantage of the patient with this disease is very difficult to talk about the psychology of fraudulent money. Surgical treatment is mainly for vascular factors, such as penile artery revascularization, cavernous artery anastomosis, penile cavernous implantation and so on. There are many surgical methods and the success rate of surgery varies, domestic information reported in the range of 25%-90%, must be cautious, it is best to go to a large hospital for treatment.
2.Interventional treatment: endovenous angioplasty (PTA) treatment
Interventional technology provides a powerful treatment tool for vascular impotence. PTA is very effective for stenosis caused by large blood vessel stenosis, and may solve the problem of insufficient blood supply to the penile corpus cavernosum without incision through small balloon expansion. However, for patients with atherosclerosis or post-diabetic stenosis, it must be noted that even if the problem of large-vessel stenosis is solved, the small cavernous vessels may still have the problem of stenosis, and it is necessary to make sure that the distal small vessels are open, and if they are not open, even if the large-vessel stenosis is solved, the effect may not be good. If the distal small vessels are not very patent, we can still choose a balloon of a certain size for dilation and angioplasty. At this time, the dilation and angioplasty must be combined with certain medications, such as blood-stasis activating drugs, vasodilating drugs, thrombolytic drugs, etc., and postoperative anticoagulation therapy. Therefore, the selection of indications is very important.
The indications for endoluminal arterioplasty are currently considered to include.
(1) Complete arteriogenic impotence.
(2) Those without occlusive lesions in the proximal great vessels.
(3) Those without penile venous fistula.
(4) Bilateral arterial lesions, angioplasty is performed on the side with the less severe lesion.
1.Penile drainage vein embolization
Interventional treatment not only can solve impotence caused by arterial stenosis, but also can solve venous fistula impotence through penile drainage vein embolization. If a fistula is found in the veins of the penis on imaging, embolization can be performed with a spring coil, but care must be taken to protect the testicles because they are sensitive to radiation.
In conclusion, the treatment of impotence must first identify the cause, and then choose the best treatment, interventional therapy is a very important tool, but it must be grasped the indications.