Please remember three basic principles.
1, infertility is tried out, that is, most people are not absolutely unable to conceive or sure to conceive, the reasons found are only possible reasons, in the end is not the cause, try to know, first diagnose infertility will need to try a year.
2, not all couples are sure to have children, which is somewhat cruel, but it is true, in fact, all diseases are like this, may be cured, may not be cured, only infertility is not cured in the end eventually how can not get pregnant than other diseases are not cured the possibility of some.
3, infertility just can not conceive a child, in most cases infertility does not affect a person’s health, while certain measures to treat infertility, especially surgery, including in vitro fertilization, etc., but can personally bring harm.
1, the diagnosis of infertility
Infertility is the absence of pregnancy after 12 months of normal sexual intercourse without the use of contraception. A couple, even if nothing is wrong, in the natural state, only once a month ovulation, the chance of pregnancy is about 20% to 25%, then a year, 12 months, is about 80% to 90%. Therefore the current definition is one year, normal sex, failure to conceive, is sterile. This has taken into account that now people want children gradually advanced age, the previous definition is two years.
2.Infertility and sterility
Literally this interpretation should be infertility, while sterility can be interpreted as being pregnant but unable to have children. Currently the two are commonly referred to as infertility.
3.Classification of infertility
Primary infertility: normal sexual life for one year, no contraception, no pregnancy.
Secondary infertility: a history of pregnancy, followed by a year of normal sexual life without contraception and no pregnancy.
4.Incidence of infertility
The incidence is affected by the social environment, economic development, literacy and medical equipment. The global incidence of infertility reported in various regions is 2%-32%, generally 10%. The United States: 13% of married couples from 1965 to 1985; China, about 5% in Tianjin, Beijing and Shanghai, about 20% in the northwest, it can be seen that the incidence varies from region to region within a country.
5, the etiology of infertility
There are many causes of infertility, the World Health Organization surveyed 8,500 infertile couples in developed countries in 1992, female infertility accounted for about 37%, male infertility accounted for about 8%, the two factors account for about 35% of infertility, about 5% of unexplained infertility. Professor Xu Ling of Peking Union Medical College Hospital and others counted the causes of infertility in 1024 infertility cases in the gynecological infertility clinic from April 1986 to February 1988, of which 40.3% were organic causes, 38.3% were endocrine causes, 14.7% were multifactorial causes, and 6.7% were unknown causes.
The specific factors are as follows: ovulation disorder ② abnormal reproductive tract ③ abnormal sperm ④ abnormal implantation process.
Ovulation disorders]
(1) Hypothalamic dysfunction (38%): anorexia nervosa, excessive wasting due to malnutrition, mental stress, extreme exertion or strenuous exercise can cause amenorrhea.
(2) Pituitary dysfunction (17%): hyperprolactinemia, empty saddle syndrome, and Schine’s syndrome.
(3) Ovarian dysfunction (45%): premature ovarian failure, polycystic ovary syndrome.
Abnormalities of the reproductive tract
(1) Cervical factors: cervical insufficiency: short cervical canal, relaxed endocervical opening, cervical inflammation: severe erosion, abnormal secretions.
(2) Uterine factors: various malformations such as: saddle-shaped uterus, longitudinal uterus, bicornuate uterus, unicornuate uterus, Asherman syndrome, etc., submucosal myoma muscle of the uterus, myometrium, uterine adhesions, etc.
(3) Endometrial abnormalities: thin and thick endometrium, endometrial polyps.
(4) Ovarian duct factors: incompetence, abnormal function (umbilical end).
(5) Severe pelvic adhesions: adhesions caused by pelvic inflammatory disease, adhesions caused by pelvic surgery.
[Semen abnormalities].
The male partner cannot produce enough mature sperm with normal motility, such as: azoospermia, congenital testicular hypoplasia, orchitis. Gonadotropin deficiency, hyperprolactinemia, difficulty in intercourse with blocked vas deferens, impotence, retrograde ejaculation, autoimmune diseases, medications, stress or systemic diseases, etc.
Abnormal implantation process]
Defective early development of the fertilized egg, abnormal interaction between the embryo and the endometrium.
[Other].
Endometriosis, immune diseases, systemic diseases, etc.
Overall, ovulation disorders account for 27% of infertility, semen abnormalities account for 25%, fallopian tube problems account for 22%, endometriosis accounts for 5%, and unexplained infertility accounts for 17%.
6, infertility examination methods
Any one or several links abnormal can affect the fertility process, infertility can be caused by a single factor, but also by multiple factors, a comprehensive analysis of the causes of infertility in both couples, the development of a practical treatment plan is the prerequisite for targeted treatment of infertility.
Medical history taking]
Present medical history: the number of years of infertility, whether to take contraceptive measures, whether sex 1-2 times / week, if the couple is two places, to understand the time of cohabitation per month or per year, but also to understand the details of the previous pregnancy, such as: the history of abortion, scraping history, the history of bleeding or infection after delivery.
Menstrual history: age of menarche, menstrual cycle, menstrual volume, whether dysmenorrhea, what kind of medication is taken for dysmenorrhea, if menstruation is sporadic or amenorrheic, ask about the time of menstrual change, whether there is functional bleeding and anemia, what kind of medication is taken and how effective it is. Progesterone test for withdrawal bleeding, whether artificial cycles are used, and when the last medication was used.
Past history: whether she has undergone any examination about infertility, whether she has monitored ovulation, whether she has ovulated, whether she has done tubal lavage, tubal angiography, hysteroscopy, laparoscopy, etc., and what are the results. Any gynecological diseases such as uterine fibroids, endometriosis or pelvic inflammatory disease. Any other systemic medical history such as tuberculosis or surgical history.
[Physical examination].
Measure height and weight for possible abnormal sexual development. If there is poor development, consider the possibility of low estrogen level in the body. If there is hairiness in the areola or umbilicus, consider the presence of high androgen level or polycystic ovary syndrome. If there is lactation, consider the possibility of hyperprolactinemia and vacuolar saddle and pituitary prolactinoma.
Gynecological conditions: vulva and vagina: congenital malformation, vaginal inflammation, cervix: cervical atresia, erosion, polyps and cysts, nature and amount of cervical mucus, uterus: size, position, morphology, softness, mobility, tenderness; bilateral adnexa: mass, tenderness and inflammation, uterosacral ligament with or without painful nodules to palpation.
Semen examination for male]
The normal value of semen examination: sperm concentration of 20 × 106/ml or more, activity rate of 75% or more, viability within 60 minutes after ejaculation for fast forward motion (grade a) 25% or more, forward motion (grade a + b) 50% or more, white blood cells should be less than 1 × 106/ml. To diagnose male factor infertility, repeat the measurement of semen routine. Determination method: 3-5 days without semen discharge, two semen collections should not be less than 7 days or more than 3 months.
Some common questions in semen examination
(1) The first thing to check is the male semen. This is because this test is non-invasive, simple and inexpensive. There are many female patients who have even had laparoscopic surgery without any problems, but the semen is very poor once checked; other couples say that they have been pregnant before and their semen must be fine. The woman was also pregnant at the time. How can you not think that the woman has no problem? Both sides need to be checked.
（The actual fact is that you can find a lot of people who are not able to get a good deal on this. But one thing is for sure, the so-called normal value is calculated according to the average distribution in the population, it does not mean that a little lower than the normal value is completely impossible to get pregnant. The actual low is actually not a standard, for example, there is no definition of the commonly referred to less weak sperm and severe less weak sperm.
(3) Theoretically, 4% of normal sperm is not considered aberrant sperm. In fact, the sperm look a little different from the normal sperm form, the genetic material and sperm inside the fertilization ability of the oocyte is not necessarily poor, so it can only be called abnormal form sperm. This is again in line with what I said earlier, infertility is tried out.
(4) Do some minor abnormalities in the sperm affect pregnancy or not? It depends on whether one has tried with all other factors being normal. If one has tried for a year without conceiving, then it is considered to be a problem. The actual fact is that you will be able to have a child as soon as possible, not to the advanced age, the economic conditions are ready, the physical conditions are expired, and then try to try again, it really can not breed.
Fallopian tube examination
Tubal lavage: the advantages are simple, safe and effective, with an accuracy of up to 70%. Disadvantages: it cannot distinguish between one side or both sides or which side is open; it does not help to diagnose the cause of the disease; enlargement of the uterine cavity or tubal cavity can cause the illusion of a patent fallopian tube; tubal spasm can also cause the illusion of an incomplete fallopian tube.
Hysterosalpingography with iodine oil: advantages: it can show the internal conditions of the uterine cavity and fallopian tube cavity comprehensively; it can help to diagnose such as: uterine adhesions, genital tract abnormalities, submucosal fibroids, uterine myometriosis, reproductive tract tuberculosis, etc.; the film can be taken for long-term preservation. Disadvantages: cannot accurately reflect pelvic lesions, cannot accurately reflect the degree of adhesions, allergy test should be done before examination.
Ovulation test for infertility]
Basal body temperature (BBT) measurement: biphasic for ovulation, 10% for possible follicular non-rupture luteinization. Monophasic for non-ovulation.
Progesterone level measurement: mid-luteal serum progesterone level greater than 3ng/ml indicates ovulation.
Ultrasound: monitor follicle size, endometrial thickness, and the presence of fluid in the posterior fornix. Monitoring follicular growth and rupture of the dominant follicle can be used as evidence of ovulation. In addition, the size of the uterus, the presence of malformations, uterine fibroids, the size of the ovaries, the presence of polycystic ovaries and pelvic masses can also be observed.
Ovulation test paper to detect ovulation: Using ovulation test paper before and after ovulation helps to determine the presence of ovulation and the time of ovulation, and to understand the time of ovulation by measuring the LH peak in urine.
【Laparoscopy】.
Under general anesthesia, a 1.0 cm and two 0.5 cm small incisions are made in the umbilicus and bilateral lower abdomen respectively, and laparoscopes and operating instruments are inserted to observe the appearance, shape and color of the pelvic organs, whether they can move, and whether there are adhesions, tuberculosis and endometriosis lesions in the pelvis. The accuracy rate is up to 90%. Some operations are also performed: separation of pelvic adhesions, tubal ostomy, removal of cysts, cauterization of endometriosis lesions, ovarian perforation, etc. The disadvantages are: surgical complications include bleeding, wound infection, damage to the organs, and the possibility of surgical failure.
7. Choice of tubal examination methods
In principle, in order of simplicity to complexity: lavage – hysterosalpingography – laparoscopy. If pregnancy is still not possible after six months of a certain tubal examination, the next examination should be performed. If uterine malformation or tuberculosis is suspected, priority can be given to imaging. If endometriosis or pelvic adhesions are suspected, priority can be given to laparoscopy. In vitro fertilization-embryo transfer (IVF-ET) can be considered if the operation fails or if postoperative infertility remains after ovulation promotion therapy.
8. Infertility tests related to menstruation
In early follicular phase: blood sampling for FSH, LH, PRL, E2, T0 on 2-4 days of menstruation. follicular phase: ultrasound monitoring of follicles and endometrial and fallopian tube examination. Ovulation phase: ultrasound monitoring of follicles and uterine? Endometrial coitus test. Luteal phase: ultrasound for endometrial thickness and blood sampling for E2 and P.
9. Treatment of ovulation disorders
Simple ovulation disorder: anovulatory patients who have an intact hypothalamic-pituitary-ovarian axis and certain endogenous estrogen levels in the body, that is, those who can retreat from bleeding with progesterone alone, can apply clomiphene citrate (clomiphene), which is taken: the general starting dose is 50 mg orally daily, on menstrual day If there is no ovulation, the dose will be increased to 100mg in the next cycle. If there is still no ovulation when 150mg is used, it is called clomiphene resistance. Clomiphene is easy, inexpensive, effective and safe, with ovulation rate up to 70% and pregnancy rate up to 30%, with low risk of multiple pregnancy and ovarian hyperstimulation. Clomiphene side effects: vasodilatory symptoms, adnexal pain, nausea, headache and, rarely, blurred vision or flash points. Polycystic ovary syndrome is often associated with increased insulin levels, increased LH, and increased androgens. Severe endocrine metabolic disorders should be corrected before ovulation promotion. Metformin can be applied simultaneously during ovulation promotion, commonly used dose is 50mg~150mg orally daily.
Hypogonadotropic hypogonadism: apply gonadotropin to promote ovulation, inject FSH or FSH/LH 75~150IU daily starting from day 2~3 of menstrual cycle, meanwhile there must be ultrasound to monitor follicle development, if follicle development is not satisfactory, the dose can be increased until the dominant follicle grows to 18mm, MCG 5000-10000IU can be injected intramuscularly, 36 hours later Sexual intercourse or artificial insemination. This is a highly individualized ovulation promotion protocol with no definite rules. During its implementation, special attention should be paid to adjust the protocol according to the individual and the time, and to the risk of ovarian hyperstimulation.
Ovulation treatment for hyperprolactinemia and pituitary microadenoma: treatment with bromocriptine can restore ovulation while lowering prolactin.
10. Surgical treatment of uterine anomalies and tubal obstruction
For patients with tubal blockage diagnosed by fluid or imaging, laparoscopic surgical treatment can be considered to separate the adhesions and sort out the oviducts to make them unblocked. In case of hydrosalpinx, the patient’s age, ovulation status, male partner’s semen routine and the patient’s wish should be taken into consideration when choosing between a tubal stoma or a tubal root dissection. This is because after the dissection, the patient can only rely on assisted reproduction, while the stoma can still try to conceive on its own. However, in severe hydrocele, the function of the fallopian tube has been basically lost, especially if the umbilical end has been destroyed, the tube has basically lost the ability to pick up eggs, so it is unnecessary to keep the tube open, and the chance of pregnancy is very small after surgery, and new adhesions and hydrocele will occur soon. However, it is very difficult for the patient to accept it psychologically and requires detailed communication.
In the case of endometrial polyps, submucosal fibroids, and uterine adhesions, hysteroscopic surgery is performed; laparoscopic surgery is used to remove myomas (>4 cm) in the myometrium, which cause infertility, and hysteroscopic surgery is performed for uterine malformations such as longitudinal diaphragm or bowed uterus.
11. Rules of surgical treatment for infertility
The need for wedge resection and perforation of the ovaries is currently debated due to the development of ovulation-promoting drugs, and adhesions are separated as much as possible, and fluids are routinely passed during surgery.
12. Abnormal semen in the male partner
The normal value of semen test is calculated according to the average distribution in the population, it does not mean that if the value is slightly lower than normal, it is impossible to get pregnant. But there is no standard for how low it is, for example, there is no definition for what is often referred to as low and weak sperm and severe low and weak sperm. Theoretically, 4% of normal sperm is not considered teratospermia. In fact, the sperm look a little different from the normal sperm form, the genetic material and sperm fertilization ability of the oocyte is not necessarily poor, so it can only be called abnormal form sperm. Does a slight abnormality in the sperm affect pregnancy or not? It depends on whether one has tried with all other factors being normal, and if one has tried for a year without conceiving, then it is considered to be a problem. So here again, I urge people of childbearing age to have children as soon as possible, not to the advanced age, the economic conditions are ready, the physical conditions are overdue, and then try to try, it really can not breed. Most pregnancies can be obtained through IUI if the male partner has abnormal semen.
13. Unexplained infertility
The diagnostic criteria for unexplained infertility are: a couple with normal ovarian function, normal ovulation, normal uterus and patent oviducts in the female partner; normal semen routine in the male partner and no organic disease such as endometriosis detected under laparoscopy, and still no pregnancy after 12 months of efforts. Unexplained infertility is actually caused by multiple factors, such as minor alterations in follicular development, ovulation, oocyte function, luteal phase, and sperm function or male semen analysis at the low end of the normal range. A single factor has little effect on infertility, but when more than one factor is present, the pregnancy rate decreases.
14.The process of examination and treatment of infertility
The first thing to check is the male semen, as this test is non-invasive, simple and inexpensive. There are many female patients who have even undergone laparoscopic surgery without any problems, but the semen turns out to be very poor; other couples say that they have been pregnant before and their semen must be fine. The woman was also pregnant at the time. The woman was also pregnant at the time. How can you not think that the woman has no problem? That’s why both partners need to be checked. The male partner can obtain a pregnancy through artificial insemination (IUI), and laparoscopy can solve most female infertility problems and confirm unexplained infertility. Unexplained infertility needs to be treated with ovulation monitoring and IUI first, and then in vitro fertilization (IVF) if infertility persists for 2-3 times. IVF and ICSI should be strictly controlled for indications. Traditional IVF is mainly for female factors and ICSI is mainly for male factors. See the chapter on assisted reproduction for more details.
15.Treatment of endometriosis
About half of the cases of endometriosis are associated with infertility, and about 1/3 of patients with unexplained ectopic lesions are found during laparoscopy. In severe cases, the cause of infertility can be explained by lesions such as sterile pelvic masses or adhesions, but the mechanism by which infertility occurs in mild endometriosis is not well understood. Currently, the causes of infertility in patients with endometriosis have been explored from a pathophysiological perspective: the prostate theory, the autoimmune response theory and the endocrine theory.
In patients with endometriosis who are infertile, the first step is a thorough examination of both sexes: ovulation of the female partner, semen of the male partner, and assessment of the uterine tubes. Combining the patient’s wishes, age, and economic status, we decide on surgical, pharmacological, and fertility treatment to minimize the interval between diagnosis and treatment, individualize the treatment plan, and laparoscopic surgery is the best treatment.
(1) Clear diagnosis, clinical staging, pregnancy assessment.
(2) separation of adhesions, restoration of anatomy, and stoma.
(3) Repeated surgery is undesirable.
(4) When dealing with chocolate cysts, puncture is not acceptable without pathological evidence, laparoscopy should be performed for the first operation, and transvaginal ultrasound-guided cyst puncture is feasible for recurrent coeliacs, which can be followed by injection of anhydrous alcohol and other drugs and extraction in 3 minutes.
(5) assisted conception technique is the best treatment, active assisted conception after laparoscopy to improve conception rate, higher pregnancy rate within six months, and significantly lower success rate of IVF/ET than patients with simple tubal incompetence.
(6) Multiple factors to consider: medication: medication alone does not improve fertility; high recurrence rate, can only relieve symptoms, surgery + medication can reduce recurrence, GnRHa is an important option for treatment of severe endometriosis and preparation for assisted conception. Mild endometriosis with more complete lesion removal, short-term (about 3 months) observation after surgery, if not pregnant, COH/IUI for 3 cycles, still unsuccessful then IVF. recurrence of endometriosis: transvaginal ectopic cyst puncture, 2-3 cycles of GnRHa treatment after puncture, IVF.
(7) Patients with adenomyosis, with a low pregnancy rate, need to explain their condition to the patient. If the lesion is limited, GnRHa is given after surgical treatment to shrink the uterus and avoid recurrence, and if it is diffuse, GnRHa medication is given directly, with the duration of medication depending on the uterine morphology, until the uterine morphology returns to normal and IVF is performed immediately.