At present, the incidence of infertility in China is about 15-20%, there are nearly 40 million infertility patients, and the rate of increase by hundreds of thousands each year, infertility is not a mere family problem, according to survey reports, 30% of people divorce due to infertility. Infertility refers to a couple’s normal sexual life for one year without contraception without pregnancy, which by normal sexual life means two to three times a week, too often or too little, is not conducive to fertility. In fact, infertility is considered a condition causing disease. If there is a requirement for fertility, then it is an infertility condition. If there is no requirement for fertility, infertility is not considered a disease.
For the treatment of infertility, the most important thing is to find the cause of infertility and then treat the cause. The causes of infertility are complex and varied. For example, female side: ovulation disorder, fallopian tube disorder, benign or malignant tumor of reproductive tract, endocrine abnormality, excessive obesity, excessive wasting, thyroid abnormality, adrenal abnormality, insulin abnormality, etc. may cause infertility; male side: abnormal semen vitality, abnormal quantity, sperm malformation, acrosome enzyme deficiency, chromosome abnormality, varicocele, vas deferens obstruction, spermatogenic disorder, endocrine abnormality, etc. may also cause infertility.
Because of the many causes, the examination is tedious and the treatment is complicated and varies from person to person. The most important thing is that for women, the best age for fertility should be before 30 years old. It is best not to go beyond 35 years old. Since when a woman’s ovarian function decreases cannot be estimated from a physical examination alone. From the analysis of a large global sample, ovarian function declines significantly after the age of 37-38 years in women. The first clinical manifestation of declining ovarian function in women is not menstrual disorders, but a significant decrease in fertility. Therefore, the treatment of infertility cannot be delayed. For women, the younger they are, the better. Treatment options for infertility are numerous and vary from person to person.
They include ovulation promotion treatment for those who do not ovulate; for those with hydrosalpinx, combined hysteroscopic surgery, and depending on the surgery, consider whether to preserve the fallopian tubes and try to conceive after surgery or have surgery on the fallopian tubes and perform IVF after surgery; for those with endocrine abnormalities, such as pituitary, thyroid, adrenal and pancreatic problems, endocrine treatment is needed; for abnormal semen conditions in the male partner, artificial insemination, In vitro fertilization, oral medication and surgical treatment are available for abnormal male semen. IVF is the last step in the treatment of infertility, and it is the last thing that has to be done after all other assisted reproduction methods have been used and no pregnancy has occurred. The success rate of IVF is not 100%.
There are many people who mistakenly believe that children born naturally are not as good as IVF, or that children born naturally are better than IVF, but this is not true. Natural pregnancies are the result of superiority, natural miscarriages, fetal abnormalities, etc. IVF is now divided into three techniques: one is sperm and eggs put together, natural selection for fertilization, and natural pregnancy is not very different (commonly known as the first generation of IVF); one is oocyte plasma single sperm injection, injection of a single sperm into the follicular plasma, artificially assisted fertilization (only suitable for abnormal sperm-egg union, very low sperm count or people with chromosomal abnormalities, commonly known as the second generation of IVF); three is oocyte Plasma single sperm injection followed by genetic diagnosis, that is, the second generation of IVF technology embryo development first after taking embryo cells for chromosome culture, the embryo with no abnormal chromosome development will be implanted in the uterus (commonly known as the third generation of IVF). IVF still inevitably results in miscarriage or failure, and even in some cases, ectopic pregnancy, ovarian hyperstimulation syndrome, and life-threatening pleural fluid and ascites. There is also no good or bad difference between the first, second and third generation of IVF, but only different indications.
Here are some infertility-related issues.
I. Basic infertility-related tests
Basic examinations are performed for different aspects of factors, such as routine semen examination on the male side; on the female side: check ovulation, fallopian tubes, and uterine cavity.
A. Male side examination.
Many people think that having a child is a woman’s business and has nothing to do with the male partner, but in fact, according to a study by the World Health Organization, 20% of infertility cases have the problem on the male side, 38% have the cause on the female side, 27% have the problem on both sides of the couple, and the remaining 15% are unexplained infertility. In reality, the male factor is increasingly high in infertile couples. The reason for this is nothing but the continuous deterioration of the environment on which human beings live and the increase in bad habits, which make men suffer from azoospermia, oligospermia, weak sperm, such as men who smoke and drink to affect sperm, overwork, have suffered from testicular tuberculosis, mumps, varicose veins of the spermatozoa, etc., all of which can affect the quality of sperm. The male side examination is very simple, checking semen, non-invasive and is the primary examination item.
B. Checking ovaries on the female side.
To find out whether there is ovulation, you can check the blood progesterone. Normally, progesterone reaches its peak 7 days before the expected next menstruation, so check progesterone to understand whether there is ovulation and luteal function. This is a relatively accurate way to know whether ovulation is occurring or not. However, for invasive testing, we have a simple, convenient and effective way, which is to take basal body temperature or ultrasound follicle monitoring every morning. For ultrasound follicle monitoring, you should not just see the follicle increase to 2cm and then stop doing it, you should do it again and see the enlarged follicle disappear before ovulation is considered. It is a good idea to retest the blood progesterone again 7 days after ovulation to know what the value is and to be able to assess the luteal function. Of course, if the patient can insist on measuring the basal body temperature, it is also a more ideal way to understand the function of the ovaries and, save money (the cost is 3 yuan for the thermometer).
C. Checking the fallopian tubes on the female side.
According to statistics, about 1/3 of infertility patients are infertile due to fallopian tubes. fallopian tubes have the ability to transport sperm, eggs and fertilized eggs etc. The most common tubal incompetence is tubal infection and tuberculosis infection. Sexually transmitted diseases are increasingly causing pelvic adhesions, resulting in infertility. In particular, inflammatory infections after abortion, childbirth, surgery, inflammatory infections of the urinary system, sexual intercourse during menstruation, endometriosis, and severe appendicitis may also affect the fallopian tubes and cause blockage, adhesions, and fluid collection resulting in tubal incompetence. In addition, congenital malformation, tubal dysplasia, distortion, dysfunction and polyps can all cause tubal incompetence. For tubal examination, most patients choose lumpectomy. In fact, there are many methods to check whether the fallopian tubes are patent, such as: tubal iodine oil imaging, hysteroscopic intubation and lavage, laparoscopic tubal lavage and so on. Nowadays, it is believed that as far as possible, fluid should not be done because it will not open the blocked fallopian tubes, and the pressure will increase and rupture, and repeated fluidization of the blocked tubes may cause inflammation or even water retention. Usually, hysterosalpingogram is used, which can clearly show the shape of the uterus and fallopian tubes. For fluid-filled fallopian tubes, many patients like to consider herbal treatment first, which is actually useless and laparoscopic surgery should be performed to deal with the fluid. If the test is unilateral incompetent, or open but not smooth, pregnancy can be tried for 3-6 months, and if it fails or ectopic pregnancy, hysteroscopy is needed. Repeated tubal angiograms are not recommended. If tubal angiography has been done in the past with no obvious abnormalities and you are still not pregnant after 6 months of trying to conceive, you do not need to have another angiography and you should have hysteroscopy. Hysteroscopic tubal cannulation to understand the patency of the fallopian tubes is not recommended and is not as simple and convenient as angiography.
II. Indications for hysteroscopy and laparoscopy for infertility
Hysteroscopy is an important part of the infertility treatment process, but it is also a part that is ignored by many people. Many people think that hysteroscopy is highly invasive and costly, so it is better to use it to treat infertility than to do in vitro fertilization directly. This is actually a very wrong idea. Hysteroscopy is not only to find out the condition of the fallopian tubes and the pelvis, but also to provide the appropriate treatment based on the results of the examination. For example, recanalization of tubal effusion, release of pelvic adhesions, removal of pelvic endometriosis lesions, release of uterine adhesions, etc. More valuable is the possibility of providing guidance for future infertility treatment based on the morphology of the patient’s pelvis, uterine cavity and fallopian tubes, whether to continue natural conception? Should we continue to conceive naturally? Or should we do IVF as soon as possible? Those who have undergone hysteroscopy will have this answer. What is the biggest influence on a woman’s pregnancy rate? It is age. Hysteroscopy can buy the most time to find the cause of infertility and make the right guidance for fertility treatment. In cases of hydrosalpinx and uterine adhesions, direct IVF without hysteroscopic treatment will make it difficult to get pregnant, which will cost a lot and yield little results, making it more expensive than it is worth.
Laparoscopy is needed for infertility caused by incompetent oviducts, fluid retention, endometriosis, unexplained pelvic masses, fibroids larger than 4 cm in diameter, suspected pelvic lesions, etc. Hysteroscopy is needed for longitudinal uterus, endometrial polyps or submucosal fibroids, etc., or problems with the endometrium.
If the sperm, ovulation and tubal examination are normal and still no pregnancy within six months, hysteroscopy is also needed to exclude the cause of pelvic endometriosis, pelvic adhesions, etc. Those who have undergone tubal angiography and no problems were found, or those who are incompetent after trying to conceive also need to undergo hysteroscopy as soon as possible.
Assisted reproduction: artificial insemination, in vitro fertilization
The indications for artificial insemination include: low male fertility, cervical factors, ejaculation disorders, idiopathic/unexplained infertility, immune infertility, and endometriosis. The prerequisite for choosing IUI is patency of the female partner’s fallopian tubes. If the female partner has ovulation disorder, ovulation promotion + IUI can be performed to increase the pregnancy rate.
The indications for IVF are: ovulation disorders, endometriosis, tubal obstruction, severe semen abnormalities, unexplained infertility, and immune infertility. IVF techniques include controlled ovulation promotion (10-20 follicles at a time), transvaginal ultrasound guided puncture for egg retrieval, in vitro fertilization with sperm, in vitro culture of fertilized embryos for 3-5 days, transfer of cultured embryos into the uterine cavity, and application of progesterone for fetal preservation.
The treatment of infertility is a cycle of finding the cause – treatment – trying to conceive – pregnancy or finding the cause – treatment – trying to conceive – infertility – continuing to find the cause -The cycle process of treatment. There are many causes of infertility, and some people cannot find the cause at all, i.e., unexplained infertility. Therefore, the infertility treatment cycle is long and requires patients to have good compliance and come to the hospital for relevant examinations and treatment in strict accordance with the doctor’s advice. After regular examination and treatment, a decision is usually given within six months or a year as to whether one can continue to try to conceive or IVF as early as possible. The treatment of infertility is also a matter of early rather than late. A woman’s ovarian function will not regress, but only deteriorate day by day, and the sooner you get pregnant, the better.