I. Ovulation disorders
Normal ovulation cycle requires normal function of the hypothalamic-pituitary-ovarian axis. Dysfunction in any one of these parts can lead to anovulation and thus cause infertility such as anovulation, scanty menstruation, and gonorrhea.
Causes of anovulation.
1. Hypothalamic disorders are divided into two categories: functional and organic. The former includes idiopathic mesencephalic anovulation, psychogenic anovulation, functional hyperprolactinemia, and anorexia nervosa; the latter includes mesencephalic tumors, post-encephalitis, and post-traumatic head injury. Jiang Qiaoyan, Department of Traditional Chinese Medicine, Sanming Second Hospital
2, pituitary dysfunction Pituitary adenoma, Silhan syndrome, tuberculosis or syphilitic granuloma.
3.Ovarian dysfunction includes primary amenorrhea of the ovaries and secondary amenorrhea. The former includes Turner syndrome and others. The latter includes premature ovarian failure, organic damage to the ovaries, such as loss of function after radiation exposure, destruction due to tumor or inflammation.
Amenorrhea
There are many causes of amenorrhea. However, from the point of view of infertility it is most important to determine the degree of amenorrhea in order to induce ovulation and make it pregnant. It is divided into two types.
1. First degree amenorrhea: Patients without menstruation should first undergo a progesterone test at the initial consultation to differentiate their degree of amenorrhea. Progesterone 20mg intramuscular injection for 5~7d or Angioprogesterone 10mg for 5~7d. Observe for withdrawal bleeding, the presence of withdrawal bleeding indicates that the endometrium is changing in the proliferative phase, there is a certain level of estrogen in the body, there is some degree of development of follicles, the pituitary gland has the function to secrete FSH, suggesting that amenorrhea may be due to hypothalamic dysfunction.
2, the second degree of amenorrhea: amenorrheic patients who have no withdrawal bleeding after giving progestin, and then give combined estrogen and progestin sequential therapy before they have withdrawal bleeding is called second degree amenorrhea. At this time, the estrogen level in the body is very low, the endometrium has no proliferative changes, and the follicles basically do not develop.
Polycystic ovary syndrome
Clinical symptoms: infertility, hirsutism, obesity, amenorrhea, masculinization, etc. (not necessarily all of them), elevated LH/FSH, elevated prolactin and/or testosterone.
IV. Hyperprolactinemia
Hyperprolactinemia refers to higher than normal blood prolactin (PRL). It is now mostly considered to include overt hyperprolactinemia and underlying hyperprolactinemia. The former refers to a persistent elevation of PRL in 24h blood, while latent refers to a transient elevation of PRL values above the physiological range during sleep at night or at a certain period of the cycle. Clinical symptoms: lactation; abnormal menstruation; infertility; other disorders.
V. Premature ovarian failure
Premature ovarian failure refers to amenorrhea due to ovarian dysfunction under the age of 40 (or 35). It specifically includes normal menarche, amenorrhea within 40 years of age, high gonadotropin, low estrogen, and no follicles present on ovarian biopsy.
VI. Dysfunctional uterine bleeding
Excluding organic lesions and blood abnormalities, abnormal uterine bleeding caused by disorders in the regulation of the neuroendocrine system is called dysfunctional uterine bleeding.
1. Pathophysiology: Due to the dysfunction of hypothalamic-pituitary-ovarian gonadal axis, the endometrium reacts abnormally and its histological changes lose regularity, which can be at any stage from the proliferative phase to the secretory phase.
Most of those with dysfunctional uterine bleeding are anovulatory bleeding, where follicles have some degree of development and persist, but there is no ovulation nor corpus luteum formation, and the endometrium, which has been subjected to estrogen for a long time, bleeds in the form of ruptured bleeding or receding bleeding, the amount and duration of which are uncertain.
2. Symptoms.
Ovulatory bleeding: A small amount of vaginal bleeding is seen during ovulation due to the low estrogen level before ovulation.
Pre-menstrual bleeding: It is caused by luteal insufficiency and insufficient secretion of estrogen and progesterone.
Postmenstrual bleeding: caused by slow regression of the corpus luteum and continuous secretion of progesterone.
Bleeding caused by endometrial hyperplasia: due to abnormal proliferation of the endometrium caused by the persistence of follicles and secretion of a certain amount of estrogen, the endometrium is mostly glandular cystic hyperplasia overgrown.
Bleeding due to incomplete endometrial maturation: caused by imbalance of estrogen and progesterone secretion.
VII. Luteinization of unruptured follicles
Luteinization of unruptured follicles (LUF) is an anovulatory phenomenon in which luteinization is endocrinologically indicated, but the egg cannot be expelled because the follicle does not rupture.
Luteinizing Insufficiency
Luteal insufficiency refers to insufficient secretion of estrogen and progesterone by the corpus luteum and inadequate secretory changes in the endometrium. Luteal insufficiency often leads to luteal bleeding, obstructed egg deposition, non-pregnancy, and habitual abortion.
Etiology: The maintenance of normal luteal function depends on the perfect functioning of the hypothalamic-pituitary-ovarian gonadal axis, and abnormalities not only in the luteal phase but also in the follicular phase can lead to luteal dysfunction. It is now generally accepted that luteal insufficiency is associated with the following factors.
1, insufficient FSH secretion during the follicular phase, low values of FSH and estradiol in the follicular fluid.
2. Inadequate LH peak during ovulation.
3, Insufficient secretion of LH in the luteal phase or its pulsatile secretion.
4, Abnormal endometrial cell steroid hormone receptors and low responsiveness to hormones secreted by the corpus luteum, even if the corpus luteum functions normally and the endometrium is poorly developed.
IX. Hypertestosteronemia
In the follicular phase of normal menstrual cycle, the average serum testosterone concentration is 0.43ng/ml, with a high limit of 0.68ng/ml. If it exceeds 0.72.44nmol/L, it is called hypertestosteronemia, or hyperandrogenemia.
Etiology: about 34% originate from polycystic ovary syndrome, followed by hyperadrenocorticism, accounting for 29%, and a few are seen in follicular membrane hyperplasia and adrenocortical hyperplasia; about 28% are of unknown origin. Recently, it has been reported that hyperinsulinemia can stimulate the ovaries to secrete large amounts of androgens, resulting in hypertestosteronemia.