Infertility is a group of fertility disorders caused by a variety of etiologies, and is a reproductive ill health event for couples of reproductive age. With the rapid development of assisted reproductive technology and the improvement of related clinical treatment techniques, it has helped many infertile couples to obtain offspring. However, many patients seek medical care blindly and do not know enough about the disease, which delays the condition and the best chance of conception.
Infertility is called infertility when a woman has had sex without contraception for at least 12 months without conceiving, and in men it is called infertility. Infertility is divided into two categories: primary and secondary. Those who have never had a history of pregnancy without contraception and have never been pregnant are called primary infertility; those who have had a history of pregnancy and have not been pregnant for 12 consecutive months without contraception are called secondary infertility. The necessary conditions for conception are normal ovulation, the union of egg and sperm to form a fertilized egg, and the implantation of the egg in the uterus. Female infertility factors mainly include pelvic factors, ovulation disorders, immune factors, and other unknown causes.
I. Pelvic factors
1. Fallopian tube factor
The fallopian tubes are a pair of long, thin, curved muscular ducts that serve as a place for the union of egg and sperm and a channel for the transport of fertilized eggs, and are divided into four parts from the inside out: the interstitial part, the isthmus, the abdomen and the umbrella part, with a total length of 8-350 px. Abnormalities of the fallopian tubes (tubal distortion, uplift, congenital malformation, etc.), chronic tubal inflammation (infection by Neisseria gonorrhoeae, Mycobacterium tuberculosis, Mycoplasma trachomatis, etc.) cause umbilical atresia or destruction of the mucous membrane of the fallopian tubes, resulting in complete obstruction of the fallopian tubes or fluid accumulation, leading to infertility.
For infertile couples with normal semen indicators in the male partner and good ovarian function in the female partner, they can have a tubal iodography after 3-7 days of menstruation with no intercourse. Young couples who have been infertile for years can first try expectant treatment with Chinese herbal medicine. Combining with tongue and pulse symptoms, the treatment is based on evidence. Chinese herbs are often combined with Lonicera japonica, Lobelia vine, Lutong and Daxuetong to promote pain relief and clear heat and detoxification; Ghost arrow feather, piercing stone, stone see-through, piercing sorrel and ground dragon to break blood and dysmenorrhea; honeysuckle, dandelion and earth shell, etc. to clear heat and detoxify.
For obstruction or adhesions in different parts of the fallopian tubes, laparoscopic tubostomy, plastic surgery, anastomosis and tubal uterine transplantation are feasible for the purpose of tubal recanalization. The tubal resection or blockage should pay attention to protect the ovarian blood supply, preserve the structure of the umbilical end of the fallopian tube as much as possible, and keep the length of the fallopian tube not less than 100 px. tubal effusion with a diameter greater than 75 px, tuberculosis, and total obstruction are not suitable for tubal unblocking surgery, and currently resection or ligation is advocated to block the inflammatory effusion from interfering with the endometrial environment This can create conditions for assisted reproductive technology.
Bilateral hydrocele in the fallopian tubes
2.Pelvic adhesions
Pelvic adhesions, pelvic inflammatory disease, endometriosis, tuberculous pelvic inflammatory disease, etc. can cause local or extensive loose or dense adhesions, resulting in destruction of pelvic and tubal function and outcome. Pelvic adhesions are also related to surgeries on adjacent organs. Common pelvic surgeries include appendectomy, uterine fibroid surgery or ovarian surgery, which are likely to be infected if not treated with regular anti-inflammatory therapy after surgery, and pelvic adhesions are one of the most common complications of these surgeries. The abdominal pain caused by pelvic adhesions can be treated with Chinese herbal medicine. If the effect of Chinese herbal medicine is not good, young couples with long-term infertility can undergo combined uterine and abdominal surgery, pelvic adhesions decomposition + bilateral tubal Melanoplasty.
3.Endometriosis
When the endometrial tissue (glands and mesenchyme) appears outside the body of the uterus, it is called endometriosis. Ectopic endometrium can invade any part of the body, but most of them are located in the pelvic organs and wall peritoneum, with the ovaries and uterosacral ligament being the most common. Clinical patients are often seen for menstrual irregularities, infertility, lower abdominal pain or dysmenorrhea, etc. Ultrasound is checked to detect ectopic lesions. Internationally, laparoscopy is the standard method to confirm the diagnosis of pelvic endometriosis, except for direct visualization of lesions in the vagina or other areas.
Intraoperatively, purple-brown bleeding spots or granular nodules, adhesions between the posterior wall of the uterus and the anterior wall of the rectum, shallowing and disappearance of traps, and adhesions of surrounding tissues are seen. For women with fertility requirements, all ectopic endometriotic lesions seen should be excised or destroyed during the procedure, preserving ovarian tissue and separating adhesions as much as possible. For stage I and II patients with no obvious tubal occlusion and less than 30 years of age, although the literature reports that the natural pregnancy rate of stage I and II is as high as 60% within 8 or 5 months after surgery, but then the pregnancy rate decreases significantly with the passage of time. The pregnancy rate should be improved by ART as soon as possible if pregnancy does not occur during the “golden time” after stage I and II EMs.
Ovarian chocolate cysts
4. Endometrial lesions
The fertilized egg is formed by the union of sperm and egg, and the process of implantation is completed through positioning, adhesion and invasion. Endometrial lesions, such as uterine polyps, submucosal fibroids, adenomyoma, endometritis, adhesions, etc., can affect the fertilization of the egg, and hysteroscopy is feasible for such infertility patients.
5. Reproductive tract anomalies
Congenital abnormal development of fallopian tubes, uterine malformation (such as septum uteri, bicornuate uteri, etc.), congenital vaginal atresia, hymenal defects, etc. can cause infertility and miscarriage.
6.Uterine fibroids
Uterine fibroids are the most common benign tumor in female reproductive organs and one of the most common tumors in human body, also known as fibromyoma and uterine fibroids. Some patients with fibroids are infertile or prone to miscarriage. The impact on conception and pregnancy outcome may be related to the location, size and number of fibroids. Large fibroids can cause deformation of the uterine cavity, preventing the implantation of the gestational sac and the growth of the embryo; compression of the fallopian tubes by fibroids can lead to lacunae; submucosal fibroids can prevent the implantation of the gestational sac or affect the entry of sperm into the uterine cavity. The rate of spontaneous abortion is higher in patients with leiomyoma than in the normal population, with a ratio of about 4:1.
Ovulation disorders
Persistent anovulation, polycystic ovary syndrome, premature ovarian failure, congenital gonadal dysgenesis, hypogonadotropic gonadal dysfunction, hyperprolactinemia, luteinized ovary non-rupture syndrome, and psychological factors can cause ovulation disorders. Ovulation can be monitored clinically by basal body temperature measurement and follicle testing.
The basal body temperature can reflect the ovarian function, roughly estimate the ovulation date and reflect the whole process of luteal production and decline, which provides some scientific basis for clinical diagnosis and treatment of ovulatory disorders of infertility. ultrasound was first applied to the treatment of infertility in 1972, etc. The “high temperature phase” and “low temperature phase” on the basal body temperature chart reflect the different phases of an ovarian cycle.
The low-temperature phase is the follicular growth phase and the high-temperature phase is the luteal phase. A long hypothermic phase (>16 days) indicates a slow follicular growth rate; a short phase (<12 days) indicates a fast follicular growth rate. Too short a hyperthermia period suggests insufficient luteal function. A slow rise in the hyperthermia period, or an unstable rise in body temperature, with fluctuating highs and lows, indicates luteal malfunction. Whether the follicle growth is fast or slow, it indicates poor ovarian function.
Also observe whether the follicles are synchronized with the endometrial development. If the endometrium is not synchronized with the development of the embryo, it will be difficult for the embryo to implant, which may lead to biochemical pregnancy or even preterm abortion. When the follicle develops to about 18 mm, the endometrial thickness is less than 7 mm, which is considered too thin; more than 14 mm, which is too thick; or poor endometrial typing, such as type III or C, which makes it difficult for the embryo to implant and the pregnancy rate is almost zero.
Clinically, surgical or non-surgical treatment (ovulation induction) is feasible for patients with ovulation disorders. Commonly used ovulation-promoting drugs include clomiphene and letrozole (taken on the 5th day of menstruation for 5 consecutive days). Patients with thin endometrium can be supplemented with estrogen such as tretinoin to promote endometrial growth is the synchronization of follicles and endometrium.