With the advent of the second child, infertility is becoming more common. What exactly is considered infertility and what tests should be done?
Definition of infertility: A woman who has been sexually active without contraception for at least 12 months without becoming pregnant is said to be infertile.
In infertility, male factor alone accounts for about 40%, female factor alone accounts for about 40%-55%, both factors account for 10%-20%, and unknown causes account for about 10%. Because male fertility tests are convenient, non-invasive and inexpensive, men are generally examined first and are not detailed here. And female examination in principle from simple to complex, from non-invasive to invasive, from economic to expensive.
1, medical history taking
(1)Duration of non-contraceptive and non-pregnancy: this is the main complaint of infertility.
(2) Menstrual history: including age at menarche, menstrual cycle, menstrual volume, duration, accompanying symptoms and the first day of last menstruation, etc., which is important for diagnosing the presence or absence of ovulation, endometriosis or inflammation.
(3) Marital history: age of marriage, number of marriages, history of miscarriage, preterm birth, stillbirth, ectopic pregnancy and gravidity; for those who have given birth at full term, we should know whether there are any abnormalities during pregnancy, delivery and postpartum, lactation, contraceptive history and contraceptive methods and time, etc. The patient should be given the opportunity to confide in the patient alone.
(4) Sexual life history: frequency and duration of sexual life, any sexual disorders and abnormal sexual desire.
(5) In addition to the past medical history, drug treatment history, and the occupation of both patients, etc., all need to be asked in detail.
2.Physical examination
(1) General examination: height, weight, hair distribution, whether there is nipple discharge, etc. Primary amenorrhea with short stature suggests turner syndrome; high stature is alert to testicular feminization. Excessive hair may be associated with excessive androgen production. Nipple overflow, suggesting abnormal secretion of lactogen.
(2) Gynecological examination: pay attention to the clitoris for enlargement, the development of labia majora and minora; the nature of vaginal secretions, the presence of vaginal transverse septum and longitudinal septum; peer into the position of the cervix, the size of the cervical orifice, the nature of cervical mucus, the presence of hypertrophy, erosion and other chronic inflammatory changes; double consultation to understand the size, position and mobility of the uterus, the presence of painful nodules in the fornix, and the presence of thickening, masses and pressure pain in the bilateral adnexal area.
3.Examination of ovulation disorder
(1) Ultrasound monitoring of follicular development: The best way to monitor ovulation is transvaginal ultrasonography, which is usually started on the 8th day of the normal menstrual cycle.
The follicle diameter at ovulation is 20-24mm. The possibility of pregnancy with follicle diameter less than 17mm is very small. 5 days before ovulation, the dominant follicle grows 2-3mm per day and grows rapidly within 24 hours of ovulation. After ovulation the follicles disappear and fluid appears in the pelvis.
(2) Diagnostic scraping: This provides information on the function of estrogen and progesterone, whether ovulation occurs and whether there are organic lesions in the endometrium.
If exogenous progesterone has not been used recently, the endometrium shows secretory phase changes suggesting ovulation, while the endometrium shows proliferative phase changes suggesting anovulation. Care should be taken to exclude the possibility of pregnancy in the patient to avoid causing a medically induced abortion.
(3) Vaginal cytology: This test must be performed before and after ovulation with serial smears and in comparison with basal body temperature and cervical mucus examination to be more accurate.
(4) Basal body temperature: biphasic body temperature suggests ovulation but is not accurate.
(5) Cervical mucus examination: It is valuable for estimating the degree of oocyte maturation and predicting ovulation.
4.Endocrine examination
(1) Sex hormone 6: Blood is collected on the 3rd day of menstrual cycle for examination.
Follicle-maturing hormone (FSH): FSH>20U/L indicates a decrease in ovarian reserve, which is seen in premature ovarian failure, ovarian insensitivity syndrome, primary amenorrhea, etc.
Luteinizing hormone (LH): FSH and LH are both less than 5U, suggesting hypothalamic pituitary hypofunction, seen in Silhan syndrome; FSH and LH are both >40>U, suggesting ovarian failure; LH/FSHR2, suggesting possible PCOS.
Prolactin (PRL): PRL >25μg/ml is considered hyperprolactinemia. PRL is affected by many factors and should be measured repeatedly. High PRL can cause ovarian dysfunction, abnormal menstruation, overflow of breast milk and infertility in women.
Estradiol (E2): 48-52lpmol/L in preovulation, 370-1835pmol/L in ovulation, 272-793pmol/L in late ovulation. low values are seen in ovarian hypofunction, premature ovarian failure, and Silhan syndrome.
Progesterone (P): 0-4,8mnol/L in preovulation and 7,6-97,6nmol/L in late ovulation. low values of blood P in late ovulation are seen in luteal insufficiency and ovulatory uterine dysfunctional bleeding.
Testosterone (T): normal is 0, 7-2, 1 nmol/L. Hypertestosteronemia can cause female infertility.
(2) Hormone function test: This test is mostly used in patients with amenorrhea.
Luteinizing hormone test: positive indicates that there is still a certain amount of estrogen in the body, is a first degree amenorrhea, such as negative, must be done again artificial cycle test.
Artificial cycle test: Withdrawal bleeding indicates no endometrial problems and is a degree II amenorrhea. No bleeding suggests problems with the endometrium, which mainly occurs after endometrial tuberculosis or multiple scrapings with scarring of the endometrium or uterine adhesions.
Pituitary excitation test: generally used to identify whether the pituitary gland or hypothalamus has a problem, abnormal indicates that pituitary function is impaired.
5.Fallopian tube patency test
The examination of tubal function is the most important part of the infertility examination and is a prerequisite for choosing the correct treatment for infertility patients. It is usually performed on 3-7 days after the patient’s menstruation. The following methods are now mainly used.
(1) Ultrasound-guided tubal lavage: it is more commonly used and less invasive, but the internal and external appearance of the uterine cavity and fallopian tubes cannot be seen, and the site of obstruction, if any, is not known. Therefore, it is generally not recommended.
(2) Tubal iodine contrast (HSG): 5ml of iodine oil is injected into the uterine cavity through the catheter under fluoroscopy. If no filling of the fallopian tubes is seen, wait for 3-5 minutes and then inject the contrast agent and take a film afterwards. The site of tubal obstruction can be known, and the morphology of the uterus and fallopian tubes can be understood. Nowadays, this method is usually used
(3) Laparoscopic examination.
If the tubal obstruction is caused by pelvic inflammatory disease, if the tubal appearance is normal, it is simple intraluminal obstruction; it may also manifest as tubal inflammatory mass, tubal umbilical end curling or adhesion with surrounding tissues; if there is tubal effusion, the tubal thickens, the wall is thin and there is fluid retention in the tubal lumen. Pelvic tuberculosis manifests as yellowish-white corn nodules on the peritoneum, caseous necrotic-like lesions, and calcified spots; endometriosis manifests as small rice-sized bleeding spots in the pelvis, small granulomas, or peritoneal defects.
It is also important to note that tubal strictures and tubal convolutions can also cause infertility. Laparoscopic tubal lavage allows direct visualization of methylene blue flow from the umbilical end and tubal dilatation, which is more accurate than tubal lavage under ultrasound.
(4) Tuboscopy: It can directly see whether there are anatomical changes in the whole fallopian tube, whether there are adhesions and damages in the mucosa, and biopsy and separation of adhesions can be performed, so that the diagnosis and treatment of tubal infertility can be significantly improved.
6.Post-coital test
After intercourse near ovulation, the posterior fornix and cervical mucus are taken. The post-coital test is a test to detect the penetration of sperm to the cervical mucus and the acceptability of the cervical mucus to sperm (i.e. compatibility).
7.Hysteroscopy
The ultimate means of evaluating the uterine cavity and identifying associated lesions, hysteroscopy can be done from 3 days after menstrual cleansing to preovulation. To clarify the cause of infertility, such as uterine adhesions, endometrial polyps, submucosal fibroids, uterine longitudinal septum, etc. and restore the normal anatomical structure and function.
8.Immunological examination
Such as anti-hyaline band antibody, ovarian autoimmune antibody, intra-serum antiphospholipid antibody, cervical mucus sperm antibody, endometrial antibody.
9.Chromosome examination
Special indications are needed for blood karyotype examination, such as primary amenorrhea or abnormal genital development. If repeated miscarriage or output abnormal children, both couples should be examined.
10.Other monitoring
Such as thyroid function, adrenal gland disease, diabetes and other disease screening.