Do you understand the diagnosis and treatment of infertility?

1.
Definition and Epidemiology

1.
Definition and Epidemiology

Infertility refers to not conceiving after 12 months of unprotected intercourse
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Among pregnant women, 50% are pregnant within 3 months, 75%-82% are pregnant within 6 months, and 85%-92% are pregnant within 12 months

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Infertility refers to not conceiving after 12 months of unprotected intercourse

2.

3.
Treatment methods for infertile patients

3.
Treatment methods for infertile patients

1.
Initial assessment

1.
Initial assessment

The initial assessment of all infertile couples should include a discussion of reasonable intercourse time and changeable risk factors such as smoking, drinking, caffeine, and obesity
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The survey should also discuss infertility treatment options, including adoption

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Discuss reasonable intercourse time and risk factors that can be changed such as smoking, drinking, caffeine, obesity, etc.

2.

3.
Female reasons

3.
Female reasons

Abnormal menstrual function is the most common cause of female infertility
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These abnormalities include abnormal ovulation function and abnormalities of the offspring or outflow tract , which can be manifested as amenorrhea or irregular or shortened menstrual cycles

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Abnormal menstrual function is the most common cause of female infertility

4.

Measuring FSH on the third day of the menstrual cycle is the most effective and economical way to detect the response of FSH to clomiphene , the number of cystic follicles and anti-Miller hormone by ultrasound.

By changing negative feedback regulation to increase FSH drugs, gonadotropins, pulsed GnRH

Fetal pregnancy and ovarian hyperstimulation

5.
Fallopian tube disease

5.
Fallopian tube disease

Abnormal fallopian tube function may be due to pelvic inflammatory disease (PID), appendicitis, endometriosis, pelvic adhesions, fallopian tube surgery, previous use of the internal contraceptive device (IUD), history of ectopic pregnancy
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However, the cause of 50% of patients with clear fallopian tube infertility cannot be determined

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Pelvic Inflammatory Disease (PID), appendicitis, endometriosis, pelvic adhesions, fallopian tube surgery, previous use of the internal contraceptive device (IUD), history of ectopic pregnancy

Laparoscopic tubal lavage isrecommended when the hysterosalpingogram shows abnormal fallopian tube or uterine cavity or the patient's initial assessment age is ≥35 years old
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Although tubal reconstruction can be tried when tubal disease is clear, VF is usually used
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These patients have an increased risk of ectopic pregnancy
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Laparoscopic tubal lavage and tubal reconstruction

6.
Endometriosis

6.
Endometriosis

    Endometriosis refers to the appearance of endometrial glands or stroma outside the endometrial cavity or myometrium, which accounts for 40% of infertility other than ovulation abnormality, fallopian tube obstruction, and male factors
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The clinical manifestations are dyspareunia (dyspareunia), usually pre-menstrual, progressively worsening dysmenorrhea, thickened vaginal rectal lacuna or cervical deviation during pelvic examination
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Mild endometriosis does not impair fertility.
Moderate and severe endometriosis can cause infertility due to many factors, including follicle formation, fertilization, implantation, and adhesion damage
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Endometriosis usually has no clinical manifestations, but it can be clearly ruled out by endoscopy
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The clinical manifestations are dyspareunia (dyspareunia), usually pre-menstrual, progressively worsening dysmenorrhea, thickened vaginal rectal lacuna or cervical deviation during pelvic examination
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Impaired follicle formation, fertilization, planting, and adhesion

    For women with mild endometriosis, 60% will become pregnant within 1 year without treatment.
Laparoscopic resection or ablation can improve the probability of pregnancy
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In the advanced stage of endometriosis, drug therapy is widely used to control symptoms, but it has not been shown to improve infertility
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For moderate and severe endometriosis, the pregnancy rates after conservative surgery are 50% and 39%, respectively, while the pregnancy rates for expectant treatment alone are 25% and 5%
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For some patients IVF can be used as a treatment option
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7.
Male reasons

7.
Male reasons

     The known causes of male infertility include primary testicular disease, genetic abnormalities (especially Y chromosome microdeletion), sperm transport disorders, hypogonadism caused by hypothalamic pituitary disease
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However, the cause of up to half of the suspected male infertility factors cannot be clarified
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An important initial diagnostic test is sperm analysis
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Testosterone levels should be tested when sperm counts are repeatedly decreased or have clinical manifestations of hypogonadism
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Gonadotropin levels can help determine whether it is gonadogenesis or central hypogonadism
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Hypogonadism caused by primary testicular disease, genetic abnormalities (especially Y chromosome microdeletion), sperm transport disorder, hypothalamic pituitary disease

     Gonadotropin or pulsed gonadotropin releasing hormone (GnRH) can significantly improve secondary hypogonadism
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The initial treatment plan depends on sperm concentration and mobility
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Men with mild male infertility can initially choose to expect treatment with sperm count (15-20)×10/ml and normal mobility]
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Moderate male factor infertility [sperm count (10～15)×10/ml, activity of 20%～40%, IUI alone or combined with female partner for ovulation induction therapy should be started, but with or without intracytoplasmic sperm Inject (CS1) IVF
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For men with severe defects (sperm count <10×10/ml, mobility 10%), IVF with ICS or donor sperm should be used
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When applying ICSI to azoospermia caused by congenital bilateral absence of vas deferens, genetic testing and counseling should be carried out to be alert to the risk of cystic dimension
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Gonadotropin or Pulsed Gonadotropin Releasing Hormone

8.
Assisted reproductive technology

8.
Assisted reproductive technology

   The development of assisted reproductive technology (ART) has brought about significant changes in the treatment of male and female infertility
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When multiple conservative methods are unsuccessful, IVF can be used for infertility patients with multiple reasons
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VF or CS is usually used for couples with male factors or fallopian tube disease.
IVF using donor eggs is used for premature egg aging and elderly female patients
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The success rate is affected by the cause of infertility and age, usually 15% to 40%
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The success rate is highest in anovulatory women and lowest in women with reduced ovarian reserve
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In the United States, the success rate of whites is higher than that of black, Asian or Hispanic women
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Although IVF is highly effective, it is expensive and requires close monitoring of ovulation and invasive techniques, including multiple follicular puncture
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IVF is associated with a significant increase in the risk of multiple pregnancy, especially in women under 35 years of age, the risk is as high as 30%.
Therefore, it is recommended to judge the number of implanted embryos or embryo sacs based on age and special prognostic factors
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Original source

Dennis L.
Kasper, Anthony S.
Fauci, Stephen L.
Hauser, et al, HARRISON'S PRINCIPLES OF INTERNAL MEDICINE, 19th Edition.

Dennis L.
Kasper, Anthony S.
Fauci, Stephen L.
Hauser, et al, HARRISON'S PRINCIPLES OF INTERNAL MEDICINE, 19th Edition.
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