Infertility is defined as cohabitation after marriage, normal sexual intercourse, and failure to conceive without contraception for more than 1 year. It can be divided into primary infertility and secondary infertility according to whether or not a pregnancy has occurred after marriage. Primary infertility is defined as never having had a pregnancy; secondary infertility is defined as having had a pregnancy and then not having another pregnancy without contraception for more than one year. Relative infertility can be divided into relative infertility and absolute infertility according to the cause of infertility: relative infertility refers to temporary infertility caused by one of the couple preventing conception or reducing fertility for some reason, and if the factor is corrected, pregnancy is still possible. There are many causes of infertility, like ovulation disorder or non-ovulation, tubal incompetence, poor function, inflammation, tuberculosis or endometriosis in the female partner, immune factors, and oligospermia or weak sperm in the male partner.
Main factors of male infertility
The main factors are sperm production disorder and sperm delivery disorder, which require examination of external genitalia and semen. These include.
1. abnormal semen: no sperm, low sperm count, reduced activity and abnormal morphology. Semen is discharged once 4 to 5 days before the examination, followed by abstinence and sperm retrieval using the masturbation method. The normal general semen discharge is 2-6 ml each time, the number should be more than 20 million/ml, more than 200 million/ml, and the active sperm should be >50%. Among them, fast linear motion sperm has the ability to fertilize. It is better to have two semen laboratory tests within six months.
2. For example, cryptorchidism causes atrophy of the varicocele, or congenital testicular hypoplasia, as well as mumps complicating orchitis and tuberculosis invading the testicles, all of which affect sperm production. Chronic intoxication (smoking, alcoholism), excessive mental tension and excessive sexual life can affect sperm count.
3, sperm transport obstruction: obstruction of the epididymis or vas deferens due to inflammation and trauma, or sexual life disorders such as impotence and premature ejaculation, often do not allow sperm to enter the female reproductive tract.
4, immune factors: men themselves produce anti-sperm antibodies, and semen self-coagulation cannot cross the female cervical mucus, producing infertility.
5. Endocrine dysfunction: men suffering from hypothyroidism, hyperadrenocorticism and hypopituitarism can cause infertility.
The main factors of female infertility
1. Ovulation dysfunction, manifested as no ovulation in the menstrual cycle or luteal dysfunction after ovulation although there is ovulation.
2. Congenital abnormalities in the development of reproductive organs or acquired reproductive organ lesions that hinder the smoothness and function of the reproductive channel from the vulva to the fallopian tubes and prevent the sperm from meeting the egg, resulting in infertility.
3. Immunological factors: The presence of anti-sperm antibodies in the female reproductive tract or serum causes sperm agglutination, loss of vitality or death, resulting in infertility or sterility. In addition, some infertile women have antibodies to their own egg zona pellucida in their serum, which can prevent sperm from penetrating the egg for fertilization and can cause infertility.
Infertility caused by sexual disorders, lack of sexual knowledge, systemic diseases and unknown causes account for about 1/3 of the causes of infertility.
5. Infertility caused by habitual abortion refers to the phenomenon of fetal abortion or stillbirth occurring more than twice in a row during the same pregnancy, which belongs to the category of infertility and is a common outcome of many diseases affecting pregnancy.
Clinical manifestations
1. Sexually transmitted diseases infertility
Diseases transmitted by sexual intercourse are called diseases, including gonorrhea, syphilis, chlamydial infection, mycoplasma infection and toxoplasma infection. Some of these diseases can cause tubal obstruction, some cause endometritis, uterine wall damage, endocrine dysfunction, etc. and lead to infertility; some cause damage to important organs and endanger life; some pregnancy during the disease can occur miscarriage, premature birth or stillbirth.
2.Immune infertility
Under the condition of normal sexual life, the body produces spontaneous immunity to any part of the reproductive process and delays conception for more than two years, which is called immune infertility. Immune infertility has a broad sense and a narrow sense. Immune infertility in the broad sense refers to the body’s immunity to any tissue antigen in the hypothalamic-pituitary-ovarian (testicular) axis, which may manifest as anovulation and amenorrhea in women and reduced spermatozoa or sperm motility in men. Immune infertility is usually referred to in a narrow sense, that is, the infertile couple is normal except for the presence of anti-sperm immunity or anti-clear band immunity.
3.Endocrine disorders of infertility
The establishment of normal ovulation cycle requires normal function of hypothalamus-pituitary-ovarian axis. The dysfunction of any one of these parts may lead to non-ovulation, thus causing anomenorrhea, scanty menstruation, gonorrhea, etc., leading to infertility. Menorrhagia can be caused by many factors. However, the most important thing from the perspective of infertility is to determine the degree of amenorrhea in order to induce ovulation and make it pregnant.
4. Ovarian infertility
The ovary is a gonadal organ that is 2.5 to 5.0 cm long, 1.5 to 3.0 cm wide, and 0.6 to 1.5 cm thick during the fertile age. normally, the ovary is located in the ovarian fossa. The main functions of the ovaries are to produce and discharge oocytes and to secrete steroid hormones. If the ovaries are underdeveloped, dysfunctional or have tumors, they can affect human development, health and fertility.
5. Tubal infertility
Tubal inflammation is a common clinical disease in gynecology and is one of the main causes of female infertility. In recent years, the incidence of tubal inflammation caused by sexually transmitted diseases (STD), gonorrhea and Chlamydia trachomatis has been increasing significantly, and the prevention and control of reproductive tract infections is crucial to infertility. 2nd Fallopian tube developmental abnormalities Fallopian tube developmental abnormalities are less common and not easily detected, and often coexist with abnormal reproductive tract development, leading to infertility or ectopic pregnancy.
6. Endometriosis infertility
Endometriosis is a gynecological disease caused by the endometrium growing in any part of the body other than the uterine cavity. For example, it occurs in the ovaries, uterosacral ligament, plasma membrane layer of the lower posterior wall of the uterus, pelvic peritoneum of the rectal fossa and sigmoid colon, and also in the myometrium, so clinically endometriosis is divided into extrinsic endometriosis and intrinsic endometriosis. Patients often present with complaints of infertility, dysmenorrhea and pelvic pain. The infertility rate of endometriosis patients is reported to be about 40% at home and abroad.
7.Uterine infertility
Uterine malformation, dysplasia, endometritis, uterine fibroids, adhesions in the uterine cavity, abnormal position of the uterus and endometrial insufficiency can affect the operation of sperm, the fertilized egg and the development and growth of the fetus, resulting in infertility or miscarriage.
8.Cervical infertility
Infertility caused by cervical disease accounts for 5% to 10% of infertility. The morphology of the cervix and the function of the cervical mucus directly affect whether a significant number of sperm can swim into the uterine cavity and be able to do so. Organic or functional diseases of the cervix affect the entry and storage of semen or sperm in the cervical canal. As the first barrier for sperm to pass, any anatomical and physiological changes in the cervix can affect the passage of sperm and cause infertility.
9. Vulvar and vaginal infertility
Infertility caused by vulvar and vaginal diseases accounts for 1% to 5% of infertility. Certain organic or functional diseases of the vulva and vagina affect the entry and storage of semen or sperm in the vagina, or affect the function of normal sperm due to changes in the environment, resulting in infertility.
10. Excessive weight loss can cause infertility
A proper fat intake is essential for the maintenance of fertility function. In order to lose weight, eating only vegetarian food leads to nutritional imbalance and a sharp decrease in protein intake, which can affect the reproductive function and lead to ovulation arrest. Severe deficiencies in trace elements can also affect fertility, such as iron deficiency, which makes it difficult to maintain normal menstrual volume and cycles, zinc deficiency, which can lead to ovarian insufficiency, and iodine deficiency, which may cause amenorrhea.
11. Infertility of unknown origin
Infertility can be infertility for many years without any of the above-mentioned causes.
12.Psychological infertility
Psychological factors are also an important cause of female infertility, which requires early treatment and the care and love of family members. In order to find targeted treatment measures more accurately, it requires us to read the psychology of female infertility.
The psychological factors of female infertility patients are mainly reflected in: inferiority complex, restlessness, nervousness, reduced socialization, lack of interest in life, restlessness and anxiety, sense of loss, and their reluctance and taboo to talk to others about fertility, which is more prominent among infertility patients with low literacy level in rural areas. heavy, thus losing their confidence in healing.
Although infertility is not a fatal disease, it not only has a serious impact on the physical and mental health of the patient, but also brings about a series of social problems, such as the breakdown of the couple’s relationship, family discord and divorce. For most infertile couples, “infertility” is one of the most stressful events in their lives, and they are prone to emotional instability and mental stress. Therefore, infertility is not only a disease but also a psychological trauma.
Infertility tests
Infertility tests are mainly used to observe the shape of the fallopian tubes, whether there are adhesions around them and whether the umbilical ends are atretic; to observe the shape of the ovaries, whether there are adhesions and whether there are signs of ovulation, and to perform minor surgery such as separating adhesions and dilating the umbilical ends of the fallopian tubes. In addition, laparoscopic aspiration of eggs from the ovaries can be performed for in vitro fertilization to produce “test tube babies”.
Comparison of screening methods for fallopian tube failure
In recent years, with the massive application of obstetrical and gynecological endoscopy, new methods for tubal patency examination have been introduced, including laparoscopic direct vision tubal lavage examination, hysteroscopic intubation through the fallopian tube, combined laparoscopic and hysteroscopic examination, and tuboscopy, among which the accuracy rate of laparoscopic direct vision tubal lavage examination can reach 90-95%. However, due to the high requirements of endoscopic surgery for instruments, laparoscopy is still an invasive surgery, and it can only understand whether the fallopian tubes are patent and the obstruction at the umbilical end of the fallopian tubes and the adhesions around the fallopian tubes, but there is no way to understand the specific site and nature of blockage in the fallopian tube cavity. It should be the first choice for patients with tubal blockage because it can not only determine whether the fallopian tubes are blocked, but also the nature of the blockage and the specific location of the blockage.
Laparoscopic tubal patency examination and treatment can only be performed when the site of tubal blockage is identified as tubal umbilical obstruction and peri-fallopian tube adhesions are suspected after hysterosalpingography. It is usually only when the cause of infertility is not clearly identified by all conventional methods that tubal lavage (with melanin dye) is performed during endoscopy.
Hysteroscopy is an examination method mainly used to understand the internal situation of the uterine cavity, it can clearly understand the microscopic lesions in the uterine cavity under direct vision through the combination of cold light source and endoscopy, which is a microscopic examination, but there is no way to understand the situation outside the uterine cavity, because the fallopian tube is a tube structure along the uterus and is located outside the uterus. It is the wrong place to use hysteroscopy.
The combined hysteroscopy and laparoscopy is also very limited to check the patency of the fallopian tubes, because hysteroscopy can only understand the internal situation of the uterus, while laparoscopy can only understand the specific situation in the abdominal cavity and the tissue structure around the fallopian tubes and the presence of adhesions, i.e., the blockage of adhesions at the umbilical end of the fallopian tubes and the effect of adhesions around the fallopian tubes on the peristaltic function of the fallopian tubes. In other words, by these two methods, we can only know the situation at the ends of the fallopian tubes and their surroundings, but we cannot know the specific location and nature of the blockage in the fallopian tube lumen.
Tubal lavage has a very poor chance of correctly diagnosing the patency of the fallopian tubes, with a correct diagnosis rate of less than 50%, because this method is only a blind pass.
Interventional methods of selective tubal imaging and recanalization not only clarify the specific site and nature of tubal blockage, but can also accurately understand the patency of the tubes while detecting the presence of tubal blockage and allowing simultaneous recanalization treatment, but are not recommended as the first choice because of the high economic cost and the replacement of inexpensive transx-ray hysterosalpingography.
Tuboscopy is an endoscopic examination instrument for microscopic examination of the internal structure of the tubal lumen. Through tuboscopy, local microscopic lesions inside the tubal lumen can be directly observed, such as lesions of the tubal mucosa and tubal cilia immobility syndrome. Usually, this test is only a final screening of the etiology of infertility when the cause of infertility cannot be determined through various methods of infertility examination and laparoscopy, in order to rule out infertility caused by abnormalities in the internal structure and function of the tubal lumen.
Prevention and care
Important points
Any couple who have lived together for more than 1 year without using contraception and have failed to conceive is said to be infertile. Those who have never conceived after 2 years of marriage are called primary infertility; those who have had births or miscarriages and have been infertile for more than 2 consecutive years are called secondary infertility.
According to the statistics, a normal couple of childbearing age, with normal couple life without any contraceptive measures, about 60%-70% of women will conceive within 3 months; about 75%-80% of women will conceive within 6 months; and the conception rate will be more than 85% within 12 months. Some statistics also show that 60% of women conceive within 1 year; 80% within 2 years; and about 90% within 3 years. From the statistical results, the conception rate is the highest within 1 year after marriage, therefore, some people advocate the time frame for infertility as 1 year.
Infertility has not been unified in terms of the standard of time. The International Federation of Obstetrics and Gynecology has set the standard of infertility at 2 years after marriage according to the opinion of most scholars, and most scholars in China also advocate a limit of 2 years. The American Infertility Society’s standard is 1 year. All the above-mentioned various regulations are artificially formulated. Combined with our situation, the year limit for infertility is set at 2 years, so that we can avoid premature conclusions about infertile people and not delay the diagnosis and treatment. However, those who marry late (e.g. over 30 years old) should be examined in advance to detect the problem early and treat it in time.
The cause of infertility lies 2/3 in the female partner, and tubal obstruction has always been the main cause, but since the general emphasis on infection prevention and the introduction of broad-spectrum antibiotics, obstetric and gynecological inflammatory diseases causing tubal obstruction have been greatly reduced; on the other hand, the understanding of endocrine diseases and the continuous progress of examination techniques have improved the diagnosis rate of infertility due to ovarian insufficiency, so ovarian infertility also plays an important role.
Local ovarian factors: such as congenital absence of ovaries or infantile ovaries, premature ovarian failure, polycystic ovaries, certain ovarian tumors such as granulosa-follicular membrane cell tumors and testicularoblastoma can affect ovarian hormone secretion and ovulation.
2, systemic diseases: such as severe malnutrition or lack of certain important nutritional factors in the diet can affect ovarian function and cause infertility; chronic diseases, metabolic diseases such as hypo- or hyperthyroidism, diabetes, adrenal dysfunction, etc. can also lead to infertility.
3. Central influences: imbalance of endocrine balance among the hypothalamus, pituitary gland and ovaries, pituitary tumor or scar can cause ovarian dysfunction and infertility; mental factors such as mental stress or excessive anxiety can affect the hypothalamus-pituitary-ovarian axis and inhibit ovulation.
Infertility caused by vulvovaginal factors: congenital anomalies such as non-porous hymen, transverse vaginal septum and congenital absence of vagina can prevent sexual life; in case of severe vaginal inflammation, a large number of white blood cells can engulf sperm, reduce sperm motility and shorten their survival time and affect conception.
Infertility due to uterine factors: about 10%-15% of infertility. The normal uterus is forward leaning and forward flexing, the cervical opening is backward, and the cervical opening is immersed in semen after intercourse, which is conducive to conception. If the uterus is posteriorly tilted and flexed, the cervical opening is forward, which can affect conception; due to insufficient ovarian progesterone secretion, the endometrial secretion response is poor; uterine insufficiency and endometrial inflammation such as tuberculous endometritis, submucosal fibroids, etc. can affect the implantation of pregnant eggs.
Infertility due to cervical factors: It is a more important cause of infertility, accounting for about 10-20% of infertility. During ovulation, the ectocervix opens up from 1mm to 3mm in diameter after menstruation, and the cervical mucus increases during ovulation, with a clear and transparent pH value of 7.0-8.2, which neutralizes the acidity of the vagina and facilitates the movement and passage of sperm. Due to chronic cervicitis or low estrogen level, the cervical mucus can be viscous or contain a large number of white blood cells, which is not conducive to the activity and passage of sperm and can affect conception. In addition, cervical polyps or cervical fibroids can block the cervical canal, affecting the passage of sperm, and the narrowing of the cervical opening may also be a cause of infertility.
4. Infertility caused by tubal factors: Inflammatory adhesions of the fallopian tubes cause tubal obstruction, which prevents the egg and sperm from meeting and causes infertility. Endometriosis in the pelvic cavity can also cause tubal adhesions and distortion, resulting in infertility.
5. Other factors: After systematic examination, about 10% of both men and women are not found to have obvious causes of infertility. In recent years, it is thought to be related to immune factors. In some infertile women, anti-sperm antibodies are found in the serum, and such antibodies can agglutinate with semen, and these infertile couples can make these antibodies disappear after a period of contraception with condoms and pregnancy. Other factors, such as blood group incompatibility between the couple, have also been suggested as possible causes of infertility. Sex chromosome aberrations such as karyotype 45XXO or 46XXP- or chimerism, sometimes the patient has a normal appearance, but the ovaries are underdeveloped and there is no ovulation or amenorrhea, and most of them require consultation and treatment for infertility.