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 failed to conceive, is called infertility. Those who are able to conceive but cannot obtain a surviving baby due to miscarriage or stillbirth for various reasons are called infertility. As women’s fertility decreases with age, after the age of 40, early evaluation is essential.
This article is a guideline for the diagnosis and evaluation of female infertility published by the ASRM committee in 2015. We recommend infertility diagnosis and evaluation for 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 (but are not limited to 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.
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.
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 and usually ranges from 21-35 days. Studies have shown that a certain 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, it can be found that ovulation generally occurs within the time when a 7-day temperature rise occurs with continuous basal body temperature testing. However, BBT is not used as the best or preferred method for ovulatory function assessment because of its lack of reliability.
3. Serum progesterone measurement: a reliable and objective ovulation detection method. Within the normal range of variability, serum progesterone testing is usually performed approximately 1 week before 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. (incommensurate)
4. Urinary luteinizing hormone (LH). A mid-cycle surge in LH levels occurs 1-2 days prior to ovulation and the test may produce false positive and false negative results.
5. Endometrial biopsy (EBM). It allows to understand the secretion of endometrial tissue, secretion is produced by progesterone stimulation and thus implies 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 reproductive potential in terms of the number and quality of the primordial follicles. 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) statistics and mullerian hormone (AMH) concentrations to assess ovarian reserve. Any single test result, even if poor, 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) can be considered as failure to conceive. (change again)
2. Clomiphene excitation test (CCCT): serum FSH levels were measured before and after clomiphene treatment, respectively. Increased FSH concentration after clomiphene stimulation reflects reduced ovarian reserve function.
3. Sinus follicle count. The sinus follicle count counts follicles with two cavities in the ovaries of 2-10 mm in diameter bilaterally. If the number of sinus follicles is less than 3-6, it can be considered as reduced ovarian reserve function.
4. Serum mullerian hormone (AMH) level: AMH <1ng/mL can be considered as reduced ovarian reserve function.
Uterine abnormalities
Uterine abnormalities can be divided into morphological abnormalities and functional abnormalities, both of which can lead to female infertility. The methods of uterine assessment are as follows.
1, Ultrasound, 3D ultrasound and MRI: can detect uterine fibroids, congenital malformations of the uterus and ovaries.
2. Hysterosalpingogram: The size and shape of the uterine cavity can be measured to determine the presence of developmental abnormalities and the presence of other causes of uterine pathology leading to infertility.
3.Transvaginal uterine ultrasonography.
4.Hysteroscopy: As an economical and minimally invasive diagnostic and therapeutic method, hysteroscopy plays an important role in the evaluation of the uterus.
Fallopian tube patency
Fallopian tube disease is an important cause of female infertility and requires special attention. Accurate diagnosis and effective treatment require a variety of methods such as
1. Hysterosalpingogram: Tuberosalpingogram can observe the obstruction of the proximal and distal tubules and show isthmus nodular tubal inflammation. However, the proximal obstruction needs to be further evaluated and artifacts produced by tubal or myometrial contraction or transient tubal position change need to be excluded.
2.Saline oxygen contrast ultrasonography of the fallopian tubes: the patency of the fallopian tubes can be determined.
3.Laparoscopy and tubal passage pigmentation method: to detect obstruction in the proximal or distal tubal area.
4.Hysteroscopy.
5.Chlamydia antibody test: Chlamydia infection has been shown to be possibly associated with tubal disease.
Peritoneal factors
Peritoneal factors such as endometriosis, pelvic or adnexal adhesions may lead to female infertility.
1. Transvaginal ultrasound can detect unidentifiable pelvic pathologies 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, their male partner’s should be evaluated. Women under 35 years of age who have not been able to conceive spontaneously without any contraceptive measures for one year should promptly seek medical evaluation for infertility and be treated according to the results of the evaluation. women over 35 years of age who have received treatment and are able to ovulate successfully and who have not been able to conceive spontaneously without contraceptive measures for 6 months may be considered for assisted reproduction.