Infertility

1. Infertility He-Feng Huang Women’s Hospital, School of Medicine, Zhejiang University

2. Where we come from?

4. Infertility Definition: The inability to achieve pregnancy after regular unprotected intercourse for a period of 1 year. • Primary infertility: never conceived within 1 year • Secondary infertility: after a previous pregnancy, unable to conceive again within a 1 year period.

5. Etiology • Female factors • Male factors • Female and male factors

6. Female Factor • Ovulatory disorders • Tubal factors • Uterine factors • Cervical factors • Vulval and vaginal factors

7. Ovulatory disorders • Hypothalamic dysfunction • Pituitary dysfunction • Ovarian factor • Others Hypothalamic-pituitary-ovary axis

8. Hypothalamic dysfunction • Psychological factors: Stress, Disturbance, Anorexia derived from mental stimulus • Chronic consumptive diseases: Tuberculosis , Severe malnutrition, Anorexia nervosa

9. Pituitary dysfunction • Pituitary tumors: Pituitary adenoma • Pituitary lesions: Empty sella syndrome • Sheehan’s Syndrome

10. Ovarian factors • PCOS • LUFS • POF • Ovary insensitivity syndrome • Congenital abnormality • Surgery or X-ray • Ovarian endometriosis • Ovarian tumor

11. PCOS Symptom Menses disturbance and infertility hirsutism, acne, obesity (BMI ≥ 25) Diagnosis （1）irregular menses or anovulation （2）experimental or clinical hyperandrogenism （3）polycystic ovarian morphology observed by ultrasound Accord with 2 points of the three. Follow-up for whole life

12. Others • Thyroid disorder • Adrenal dysfunction

13. Tubal factors • Inflammation • Surgery of ectopic pregnancy Tubal ovarian effusion Tubal blockage, hydrosalpinx (HSG） Ectopic pregnancy

14. Tubal factors • Tubal ligation • Tubal abnormality Tubal ligation Tuberculosis fallopian tube

15. Increase of tubal factors • STD • Repeated intro-uterine manipulation • Repeated drug abortion

16. Uterine factors • Uterine developmental abnormality Congenital absence of the uterus Uterine malformation • Endometrial abnormality Endometrial tuberculosis Asherman syndrome • Uterine tumor

17. Uterine developmental abnormality

18. Intrauterine adhesions fibroid 

19. Male factors • Semen abnormality Oligospremia, Aspermia, Asthenospermia • Sperm transport abnormality • Endocrine disorders • Sexual dysfunction • Immunological factors

21. Male and female factors • Psychological factors • Subfertility • Immunological factors

22. Classification

23. Investigation and Diagnosis • Male investigation History: general health, medications, lifestyle and reproductive health General examination Specific examination： abnormality of genitals seminal analysis

24. Normal Seminal analysis（Fourth/Fifthversion） • Volume ≥ 1.5ml • PH 7.2~7.5 • Density ≥ 15×10 /ml • Count ≥ 39×10 /every ejaculation • ≥ 32% sperm progressive motility (grade a+b) Grade a: rapid progressive motility Grade b: slow progressive motility • Morphology ≥ 4% • Survive rate ≥ 50% • WBC ≤ 1×10 • Volume ≥ 2.0ml • PH 7.2~7.5 • Density ≥ 20×10 /ml • Count ≥ 40×10 /every ejaculation • ≥ 50% sperm progressive motility (grade a+b) or ≥ 25% sperm rapid progressive motility (grade a) Grade a: rapid progressive motility Grade b: slow progressive motility • Morphology ≥ 15% • Survive rate ≥ 58% • WBC ≤ 1×10 6 6 6 6 6 6 Fourth version Fifth version

25. Female Investigation • History • General examination • Specific examination • Others

26. Specific examination Ovarian examination • Ovulation monitor • Luteal function • Ovarian reserve

27. Ovarian function Ovulation monitor 1、Basic body temperature 2、Cervical mucus 3、Vaginal cytological test 4、Ultrasound monitor 5、Serum or urinary LH peak 6、Serum E2 and P levels 7、Endometrial biopsy 8、Laparoscopy

28. Follicular development and ovulation

29. Biphasic basal body temperature

30. monophasic basal body temperature

31. Low estrogen High estrogen

32. Cervical mucus

33. Fern crystallization

34. Proliferative endometrium Secretory endometrium

36. Luteal function 1、BBT 2、Endometrial biopsy 3、Serum E2 and P levels

37. Ovarian reserve 1、Age 2、Antral follicle count (AFC) 3、Basic FSH、E2 4、CC stimulating test 5、GnRH-a stimulating test 6、AMH、Inhibin B

38. Tubal investigation • Hydrotubation • Hysterosalpinography (HSG) • Laparoscopy • Hysterosalpingography by Ultrasound

39. Hydrotubation

40. HSG normal figure

41. Laparoscopy ：methylene blue liquid

42. Postcoital test • Cervical hostility • Hysteroscope • Laparoscopy

43. Postcoital test

44. Postcoital test • Cervical hostility • Hysteroscope • Laparoscopy

45. Cervical hostility

46. Postcoital test • Cervical hostility • Hysteroscope • Laparoscopy

47. Endometriosis（Laparoscopy)

48. Treatment of infertility • 1.Treatment of genitals organic disease • 2.Induction of ovulation • 3.Luteal support • 4. Improvement of cervical mucus • 5.Treatment of tubal inflammation • 6.ART

49. 1. Genitals organic disease Genital malformations Genital inflammation Uterine Myoma Endometriosis ----Etiology combined treatment: Infection control, Surgery

50. 2.Tubal infertility • Fallopian tube obstraction: Fallopian tube glue loose solution operation Salpingostomy Tubo-uterine implantation Tubal anastomosis • Fallopian tubes were partial unobstructed: Liquid instillation Physical therapy Traditional Chinese Medicine