female infertility
Introduction
Introduction to female infertility Infertility refers to a condition in which a couple has a normal sexual life after marriage, is not contraceptive, and has not conceived for 2 years. Those who have never been pregnant 2 years after marriage are called infertility, have had fertility or miscarriage, and have been infertile for more than 2 years, called secondary infertility. Absolute infertility refers to a serious anatomical abnormality or physiological defect in which both sides of the couple have congenital or acquired nature. No matter what method is used, the treatment can not be successfully treated, and a clinical sign of infertility is caused. For example, congenital absence of uterus, relative infertility refers to a cause of difficulty in conception, which reduces fertility, resulting in patients being temporarily unable to conceive, but still able to conceive through treatment, such as uterine dysplasia. basic knowledge The proportion of sickness: 0.4% Susceptible people: good for young women Mode of infection: non-infectious Complications: Infertility
Cause
Causes of female infertility
Endometriosis (20%):
The traditional view is that endometriosis is the external growth of the endometrium beyond the uterine cavity (excluding the myometrium), when the endometrial tissue with growth function appears in the body other than the uterine cavity covering the mucosa. At the site, called endometriosis (endometriosis), endometriosis and infertility, according to Tianjin and Shanghai reported that endometriosis patients with primary infertility accounted for 41.5% ~ 43.3 %, secondary infertility is 46.6% ~ 47.3%, while the normal population infertility rate is 15%, severe endometriosis causes adhesions, affecting ovarian function, hindering the maturation and release of egg cells.
Ovarian local factors (23%):
Congenital ovarian hypoplasia, polycystic ovary syndrome, premature ovarian failure, functional ovarian tumors such as granule-ovarian cell tumor, testicular blastoma, etc. affect ovarian ovulation; ovarian endometriosis not only destroys ovarian tissue, and Can cause severe pelvic tissue adhesion and cause infertility.
Mental factors (7%):
Some scholars have found that mental stress or excessive anxiety, anxiety, women's emotional disorders and various psychological disorders, and then through the neuroendocrine system on the endocrine balance between the hypothalamic-pituitary-ovary, resulting in non-ovulation and amenorrhea without pregnant.
Vaginal inflammation (9%):
Mainly trichomonas vaginitis and fungal vaginitis, light does not affect pregnancy, severe white blood cells consume the energy substances in the semen, reduce sperm activity, shorten the survival time, and even engulf sperm and affect fertilization.
Luteinized unruptured follicular syndrome (10%):
Brosen speculated that LUFS is one of the causative factors of endometriosis. According to the fact that LUFS is not broken due to follicles, 17- estradiol and progesterone in ascites are less than normal, and the inhibition of ectopic endometrial cells is lost. Force, the patient's ovary has no ovulation.
(1) Causes of the disease
The cause of infertility may be in the woman, the man or the man and the woman, which is about 60% of the female factor, about 30% of the male factor, and about 10% of the factors of both parties.
1. Female infertility factors
(1) vulvovaginal factors:
1 vulva, vaginal abnormalities: hermaphroditism includes true hermaphroditism and pseudohermaphroditism, the latter such as testicular feminization, congenital adrenal hyperplasia, ovarian masculinization.
Hymen dysplasia: hymen atresia, hard hymen and so on.
Vaginal dysplasia: congenital vaginal complete or partial atresia, double vagina or vaginal septum.
2 scar stenosis: the formation of adhesion scars after vaginal injury, affecting sperm into the cervix, affecting insemination.
(2) Cervical factors: The cervix is the way sperm enters the uterine cavity. The amount and nature of cervical mucus can affect whether sperm can enter the uterine cavity.
1 Cervical dysplasia: congenital cervical stenosis or atresia, poor menstrual blood exclusion, reduced menstrual flow, dysmenorrhea, may be complicated by endometriosis, cervical dysplasia, slender, affecting sperm passage; cervical mucosal development Poor glandular secretion.
2 Cervical inflammation: In severe cases, the purulent leucorrhea in the cervical canal is increased, sticky, affecting sperm penetration.
3 Cervical neoplasms: Cervical polyps, cervical fibroids and other obstruction of the cervical canal affect fertilization.
(3) Uterine factors:
1 Congenital malformation of the uterus: abnormal uterine development such as congenital uterus deficiency, residual uterus, double-horned uterus, mediastinal uterus, etc. all affect pregnancy.
2 endometrial abnormalities: endometritis, endometrial tuberculosis, endometrial polyps, endometrial adhesions or poor endometrial secretion response affect fertilized eggs implantation.
3 uterine tumors: endometrial cancer causes infertility, most of the infertility of patients with endometrial atypical hyperplasia, uterine fibroids can affect pregnancy, submucosal fibroids can cause infertility or miscarriage after pregnancy.
(4) Fallopian tube factors: The fallopian tube has the function of transporting sperm, picking up eggs and transporting fertilized eggs to the uterine cavity. Fallopian tube lesions are the most common factor of infertility, and any factors affecting the function of fallopian tubes affect insemination.
1 fallopian tube hypoplasia: tubal dysplasia affects peristalsis, is not conducive to the delivery of sperm, eggs and fertilized eggs, prone to tubal pregnancy; congenital tubal excessive slender distortion affects the operation of sperm or egg.
2 fallopian tube inflammation: fallopian tube inflammation can cause umbrella end adhesion or lumen obstruction, adhesion between the fallopian tube and surrounding tissue affects peristalsis and infertility, tubal tuberculosis causes tubal stiffness, ramp and so on.
3 lesions around the fallopian tube: endometriosis is more, ectopic endometrium in the fallopian tube to form nodules or pelvic ectopic endometrium caused tubal adhesions.
(5) Ovarian factors:
1 ovarian dysplasia: polycystic ovary, ovarian undeveloped and ovarian hypoplasia.
2 luteal function is insufficient: ectopic disease in the luteal phase of the lack of secretion affect pregnancy.
3 ovarian tumors.
(6) Ovulation disorders: factors that cause ovarian dysfunction and cause ovulation can cause infertility.
1 central effect: hypothalamic-pituitary-ovarian function axis disorder, causing menstrual disorders, such as anovulatory menstruation, amenorrhea, etc.; pituitary tumors cause ovarian dysfunction and cause infertility; mental factors such as excessive tension, anxiety on the hypothalamus - The pituitary-ovarian axis can have an effect that inhibits ovulation.
2 systemic diseases: severe malnutrition, excessive obesity or lack of certain vitamins in the diet, especially E, A and B, can affect ovarian function; endocrine and metabolic diseases such as hyperthyroidism or hypothyroidism, adrenal hyperfunction or low, Severe diabetes can also affect ovarian function leading to infertility.
2. Male infertility factors are mainly due to spermatogenic disorders and infertility disorders. The examination of external genitalia and semen should be performed to determine whether there is any abnormality.
(1) Abnormal semen: If there is no sperm or too few sperm, the vitality is weakened and the morphology is abnormal.
Factors that affect sperm production are:
1 congenital dysplasia: congenital testicular hypoplasia can not produce sperm; bilateral cryptorchidism leads to atrophy of the seminiferous tube and other obstacles to sperm production.
2 systemic factors: chronic wasting diseases, such as chronic malnutrition, chronic poisoning (smoking, alcohol abuse), excessive mental stress may affect sperm production.
3 local causes: mumps complicated with orchitis leading to testicular atrophy; testicular tuberculosis destroys testicular tissue; varicocele sometimes affects sperm quality.
(2) Sperm transport is blocked: epididymis and vas deferens tuberculosis can block the vas deferens, hinder the passage of sperm; impotence, premature ejaculation can not make sperm into the female vagina.
(3) Immunity factors: sperm and seminal plasma produce antibodies against self-sperm in the body, which can cause male infertility. The injected sperm will self-aggregate and cannot pass through the cervical mucus.
(4) Endocrine dysfunction: male endocrine regulation by the hypothalamic-pituitary-testicular axis, pituitary, thyroid and adrenal dysfunction may affect sperm production and cause infertility.
(5) abnormal sexual function: genital dysplasia or impotence caused by sexual intercourse difficulties.
3. Both men and women
(1) Lack of basic knowledge of sexual life.
(2) Both men and women are eager to create excessive mental stress.
(3) Immune factors: In recent years, studies on immune factors suggest that there are two kinds of immune conditions affecting conception.
1 Alloimmunization: Sperm, seminal plasma or fertilized egg is an antigenic substance. After being absorbed by the vagina and endometrium, the antibody substance is produced by an immune reaction, so that the sperm and the egg cannot be combined or the fertilized egg cannot be implanted.
2 autoimmune: It is believed that the presence of zona pellucida autoantibodies in the serum of infertile women can prevent sperm from penetrating the egg after reacting with the zona pellucida, thus preventing insemination.
4. Influencing factors The general factors affecting conception are to exclude reproductive system abnormalities or organic diseases in the reproductive system and affect fertility. The following factors may affect conception.
(1) Age: The male fertility is the strongest age of 24 to 25 years old, and the female is 21 to 24 years old. According to some scholars, there is no significant difference in fertility between men and women before the age of 35, and their fertility gradually gradually after 35 years old. Decline, infertility can rise to 31.8%, infertility can reach 70% after 40 years old, and rarely reach pregnancy after 45 years old.
(2) Nutrition: Nutrition and reproductive function are closely related. According to the literature, women with severe malnutrition after marriage, anemia, weight loss and economic backwardness have lower fertility or infertility, but the other extreme is overnutrition. Excessive obesity can also cause hypogonadism, leading to infertility or decreased fertility.
(3) Trace elements and vitamins: In recent years, many domestic and foreign scholars have noticed trace elements such as zinc, manganese, selenium, copper and other elements, as well as vitamin E, A, C, B12 and other sexual functions of men and women, secretion of sex hormones. Closely related, these trace elements and vitamins play an important role in maintaining the function of human reproductive endocrine and the coordination of hypothalamic-pituitary-gonadal axis function. If the trace elements are seriously insufficient or even vitamin deficiency, the ability to conceive or cause infertility can also be reduced.
(4) Other aspects: Both men and women, if they have bad habits, will also affect their fertility, such as long-term smoking, alcohol abuse or exposure to narcotic drugs, toxic substances, adverse effects on the fertility of men and women, as well as environmental and occupational Pollution, such as noise, chemical dyes, mercury, lead, cadmium, etc., can also affect women's fertility.
(two) pathogenesis
Infertility is caused by a variety of diseases and causes, so the pathogenesis is not the same.
Prevention
Female infertility prevention
1. Menarche at the beginning of menstruation: When a woman is around 14 years old, menstruation will be menarche. This is a normal physiological phenomenon. It symbolizes that the reproductive system has gradually matured, and there is no need to make a fuss. However, some lack of physiology. The young girl of knowledge is shy about this, and she is carrying a bag of thoughts. Whenever she is in the menstrual period, she is worried, and cant even eat, sleepless. In the long run, the so-called qi stagnation of Chinese medicine will occur; qi stagnation is bloody, blood will damage the cell line, the cell line is damaged, and it is infertile after marriage. Therefore, when men and women have menarche, they should pay attention to understanding the physiological knowledge and treatment methods in this aspect, which will eliminate the concern and naturally become pregnant after marriage.
2, pay attention to menstrual hygiene: during the menstrual period, if you do not pay attention to health, it is very easy to get a variety of women's diseases, such as irregular menstruation, dysmenorrhea, vulvitis, vaginitis, cervicitis, endometritis, annexitis, pelvic Inflammation, etc., these conditions will hinder pregnancy after pregnancy, then, how to pay attention to health during menstruation, in general, in the spirit to maintain optimism and comfort; physical attention should be paid to rest, avoid fatigue; Heat, avoid cold and cold; in the daily life should be regular, comfortable, avoid sitting in wetlands or rain wading, in addition, menstrual belt should be washed frequently, underwear and toilet paper should be changed frequently) body shower should not be too frequent, so as not to catch a cold.
3, menstruation does not adjust early treatment: irregular menstruation refers to menstruation, menstruation, changes in menstrual flow, or amenorrhea, dysmenorrhea, uterine bleeding, etc., infertile women have these phenomena to varying degrees, so it can be said Irregular menstruation is a sign that it is difficult to conceive. The reason why girls suffer from irregular menstruation is relatively simple, and treatment is relatively easy. Therefore, when a girl suffers from irregular menstruation, she should be treated early, fight for a cure, and stay in China for treatment. The general effect is better.
4, menstruation is late to marry late: Some girls have a late menarche, until menstruation after 18 to 20 years old, and the amount is small, pale, thin, which indicates that the function of the reproductive system is relatively low, not only after marriage Can not be pregnant, and menstrual conditions go from bad to worse, until amenorrhea or other diseases, therefore, any girl who is late in menstruation, development is relatively slow, should be seriously exercised, appropriate supplemented with drug conditioning.
Complication
Female infertility complications Complications, infertility
1. Female complications: endocrine disorders, tubal obstruction, sputum dysfunction, uterine dysplasia and malformation, uterine fibroids, endometritis, endometrial tuberculosis, cervix stenosis adhesion, cervix both fluid volume and trait abnormalities The congenital piece has no vagina and the vagina is separated.
2. Male complications: congenital testicular dysplasia, stagnation, testicular tuberculosis, post-mastitis orchitis, vas deferens, genital dysplasia, impotence, premature ejaculation.
Symptom
Female infertility symptoms common symptoms uterine adhesions uterus transposition menstrual flow less amenorrhea dysmenorrhea secondary infertility uterus vaginal discharge vaginal discharge anti-sperm antibody positive
Patients with amenorrhea, dysmenorrhea, thin menstruation or oligo menstruation, irregular vaginal bleeding or cervix, vaginal inflammatory disease caused by increased vaginal discharge, attachment mass, thickening and tenderness; abnormal hair distribution; breast and abnormal secretion; uterus Intimal developmental delay, uterine dysplasia and malformation; severe malnutrition, body mass and body mass index (BMI), ie weight (kg) / height (m2) abnormalities.
The diagnosis and judgment of infertility can be divided into three aspects: 1 to find the cause of infertility. 2 judge the prognosis. 3 develop a treatment plan.
1. Woman examination
(1) Ask about medical history:
1 chief complaint: time of infertility, menstrual conditions, obesity, with or without galactorrhea.
2 current medical history: menstrual abnormalities and treatment, sexual life history, and previous examinations and results about infertility.
3 growth and development history: whether there is growth retardation puberty development is normal, genital and secondary sexual development and the presence or absence of congenital malformations.
4 menstrual birth history: menarche, menstruation, menstruation and menstrual volume, with or without dysmenorrhea and the extent of the last three menstrual periods; and asked about the age of marriage, with or without contraceptive history (including contraceptive methods and duration of contraception), Unmanned history (specific surgery time, method and gestational age at the time of surgery), history of remarriage, past fertility, dystocia and postpartum hemorrhage.
5 history of infertility: primary infertility, secondary infertility, infertility years, whether to receive treatment and efficacy.
6 past history: whether there are endocrine diseases, metabolic diseases, mental illness, hypertension and digestive diseases and medication history; history of infection, such as inflammation, tuberculosis; exposure to harmful chemicals, radioactive substances; history of surgery Wait.
7 family history: whether there are congenital hereditary diseases, understand the birth of brothers and sisters.
(2) Total physical examination: check the development, height, arms spacing, weight, cardiopulmonary, endocrine organs, abdominal examination, special examination of the development of secondary sexual characteristics and the presence or absence of galactorrhea.
(3) gynecological examination: check the development of the vulva, the distribution of pubic hair, the size of the clitoris, whether the labia majora is fused; whether the vagina is patency, vaginal mucosa color, vaginal discharge or secretion traits; whether the cervix has inflammation, such as erosion, polyps; Size, location and activity; whether there is thickening in the attachment area, whether there is a lump, the size of the lump, the texture, the degree of activity, and whether there is tenderness.
2. Male inspection
Ask about the existence of chronic diseases, such as tuberculosis, mumps and other sexual life conditions, whether there is difficulty in sexual intercourse, after a general examination, focus on the genital presence or absence of deformities and lesions, especially to check semen.
Examine
Female infertility check
[Laboratory Inspection]
1. Progesterone test to determine whether the ovarian has a progesterone test for estrogen secretion.
METHODS: 20 mg of progesterone was intramuscularly injected daily for 3 days, or 10 mg intramuscularly every day for 5 days; or 5 mg of megestrol acetate per day for 5 days.
If vaginal bleeding occurs 3 to 7 days after stopping the drug, it indicates that the woman has certain estrogen in the body, which is I degree amenorrhea; if there is no bleeding, it is negative, probably because the estrogen level in the body is extremely low, the endometrial hyperplasia, the uterus The endometrium is destroyed or absent (such as severe endometrial tuberculosis, intrauterine adhesions or naive uterus, etc.).
2. Estrogen test Progesterone test negative can be tested by estrogen to determine whether the progesterone test negative cause is low estrogen levels.
METHODS: Oral diethylstilbestrol 1 mg/d for 20 days. After cessation of vaginal bleeding, it was II degree amenorrhea, indicating that the level of estrogen in the body was low, and its etiology was dysfunctional in the ovary, pituitary or hypothalamus. If the GnRH pituitary stimulation test was done, there was no vagina. Bleeding can confirm uterine amenorrhea.
3. FSH, LH, PRL determination of various hormone levels in the blood when appropriate, can obtain more information on the functional status of the ovary and its affected links, detection of serum FSH, LH, PRL, E2 can identify the ovaries or Pituitary ovulation disorders in amenorrhea, such as determining whether the ovary has lost the ability to secrete estrogen, or lack of gonadotropin and the ovary does not secrete steroid hormones, radioimmunoassay for gonadotropin, according to serum FSH, LH, PRL, E2 values were used to identify ovarian or pituitary ovulatory disorders and amenorrhea (Table 1).
(1) PRL: normal value is 0-20g/L, PRL>25g/L, and low FSH/LH level is hyperprolactinemia. When the PRL is elevated, further X-ray film should be taken. Or CT examination to exclude pituitary tumors.
(2) The normal value of FSH in the menstrual cycle is 5-20U/L, and LH is 5-25U/L.
1FSH, LH value>40U/L, possible cases are: ovarian dysfunction, premature ovarian failure, or ovarian hypoplasia, ovarian insensitivity syndrome, gonadotropin-secreting tumor, primary priming caused by 17-hydroxylase deficiency Amenorrhea, etc., for patients with primary amenorrhea, should be karyotype analysis and zoning examination.
2LH>25U/L and the FSH value is normal, E2 is high or normal, especially when LH/FSH>3, it may be polycystic ovary syndrome. At this time, androgen can be found to increase the androstenedione.
3FSH, LH are <5U / L, indicating pituitary dysfunction, lesions may be in the pituitary or hypothalamus, and the difference between pituitary and hypothalamic lesions, need to rely on GnRH test, if the results are not clear, then doe multi-directional tomography Or CT examination for abnormalities, fundus examination when multi-directional tomographic abnormalities.
4. GnRH pituitary stimulation test GnRH pituitary excitability is the LHRH test, which can distinguish hypothalamic or pituitary amenorrhea, suggesting GnRH treatment response.
METHODS: 3 l of normal saline was added to 50 g of 10 peptide GnRH intravenously. The serum was measured at 15, 30, 60 and 120 minutes before and after injection. The peak of LH appeared 15 to 30 minutes after administration, and the peak appeared 15 to 30 minutes after administration. The value increased by 7.5 g / L or more or LH was more than 3 times higher than that before the drug was normal reaction, the pituitary function was good; the peak appeared in the delayed reaction after 60-90 min after administration; if the LH base value was low, below 6 g / L, after administration An increase in value less than 2 times the base value is a low response.
RESULTS: 1 FSH, LH was low or normal before administration, and the response was normal hypothalamic dysfunction after treatment; 2 FSH, LH was low before administration, no response to pituitary dysfunction after administration; 3 FSH, LH base value before administration More than 30U / L, the pituitary over-reaction after treatment, for ovarian insufficiency type, suggesting ovarian amenorrhea; 4 LH before treatment, double FSH, LH after treatment is excessive reaction, FSH low or normal before medication, reaction after medication Normal is polycystic ovary syndrome.
5. Clomiphene test clomiphene test method: I degree amenorrhea on the 5th day after discontinuation of vaginal bleeding oral clomiphene, 50 ~ 100mg / d, a total of 5 days, positive suggestive mild hypothalamic amenorrhea.
Clomiphene can be used to determine whether the reproductive axis of a stunted woman is normal.
6. Gonadotropin test negative for clomiphene test, progesterone test or estrogen test positive, intramuscular injection of HMG 70 ~ 150U / d on the 5th day after withdrawal of vaginal bleeding, monitoring ovulation, follicular maturation during continuous medication At the time, the intramuscular injection of HCG 5000 ~ 10000U / d, ovulation is positive for the gonadotropin test.
7. ACTH excitatory test ACTH 20mg, intramuscular injection, urine 17-ketosteroids and 17-hydroxysteroid excretion before and after 24h, PCOS responded normally, and adrenal cortical dysfunction 17-ketosteroids and 17-hydroxyl Steroids are significantly higher.
8. Dexamethasone inhibition test is suitable for amenorrhea male patients, dexamethasone 0.5mg, once every 6 hours, a total of 2 days or 7 days, compared with pre-treatment urinary 17-ketosteroids, 17-hydroxysteroids, blood testosterone, Changes in blood dehydroepiandrosterone, etc., if the pituitary-adrenal axis function is normal, the drug will inhibit ACTH, urinary 17-ketosteroids and 17-hydroxysteroids decreased due to negative feedback, but Cushing syndrome, adrenal cortical tumor The patient does not decrease.
9. Thyrotropin-releasing hormone (TRH) stimulation test TRH is a tripeptide that stimulates pituitary cells, secretes thyrotropin and prolactin patients to urinate first, rest in bed for 20 minutes, and dissolves 100 g of TRH in physiological saline. Blood was taken at 5, 10, 15, 30 and 60 minutes for determination. Prolactin (PRL) was 5 to 10 times higher than the baseline value within 15 minutes. Such patients have a tendency to hyperprolactinemia, and the general PRL is <120 g/L. For normal reaction, 120-150 g/L is suspicious, and >150 g/L is overreaction.
[Other inspections]
1. Cervical mucus changes the secretion of cervical mucus every day is 20 ~ 60ml, the mucus is alkaline, the pH value is 7 ~ 8.5, the mucus in the ovulation period is clear, which is conducive to the penetration of sperm.
(1) classification of cervical mucus crystallization: the most typical fern plant crystal, the trunk is thick, the branches are dense and long, atypical, the branches are short and short or the branches are fuzzy, or only the ellipsoid is seen in the mucus.
(2) Changes in anterior ovulation: increased mucus volume, thin mass, increased stringiness, up to the vaginal opening, 10cm long, typical fern plant-like crystal under the microscope, affected by progesterone after ovulation, gradually closed cervix, mucus The amount is reduced, and the fern-like crystals are gradually replaced by ellipsoids.
(3) Post-intercourse test: After ovulation period, 30s to 1h after bedtime, check the cervical mucus, check whether the sperm in the cervical mucus survives, the normal value is 10~15 live sperm/HP, sperm survival rate is cervix Mucus properties, with or without anti-sperm antibodies and semen itself.
2. Vaginal smears generally take the scraping of the upper side of the vagina, fixed with 95% ethanol, pasteurized, observe the layers of the vagina, including the bottom layer, the middle layer, the proportion of the surface layer, the surface layer of keratinized and keratinocytes, in Under the influence of mild estrogen, keratinocytes account for less than 20%; moderate estrogen effects, keratinocytes account for 20% to 60%; high estrogen effects, keratinocytes account for more than 60%, have exceeded normal ovulation Level, generally reported by the maturity index (MI): bottom layer % / middle layer % / surface layer %, such as the left digit increase is the "left shift phenomenon", indicating that the estrogen level is decreased, as the number on the right increases The "right shift phenomenon" indicates that the level of estrogen is increased, and the vaginal smear can be continuously observed in order to understand the changes in estrogen in the body.
3. Progesterone test for progesterone patients with progesterone 20mg, intramuscular injection 1 / d, a total of 3 to 5 days, such as the endometrium has been prepared by estrogen stimulation, withdrawal bleeding occurred more than 2 days to 2 weeks Positive test indicates that there is still a certain amount of estrogen produced in the body, which is a degree of amenorrhea. If it is negative, it must be tested manually.
4. Artificial cycle test first use estrogen, such as daily oral administration of 0.5 to 1 mg of ethyl phenol or 0.625 to 1.25 mg of estrogen for 21 consecutive days, the last 7 days to add progesterone, stop for 2 days to 2 weeks to see No withdrawal bleeding, if there is bleeding, the endometrium has no problem, it responds to female and progesterone, but the ovary can not produce enough female, progesterone, II degree amenorrhea, such as no withdrawal bleeding, suggesting endometrial The problem is mainly caused by endometrial tuberculosis or multiple curettage, intimal scar formation or intrauterine adhesions (Asherman syndrome).
5. Pituitary stimulation test can be used domestic GnRH-a9 peptide - alarin (alarelin) 25g, LH (luteinizing hormone) increased 2.5 times after intravenous injection for 15min, increased 3.1 times after 60min, if abnormal may indicate pituitary function got damage.
6. Blood hormone determination, chromosome analysis and immunology generally adopt radioimmunoassay, including pituitary follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), progesterone (P), testosterone (T) Prolactin (PRL), the cyclical changes of the first four hormone levels were obvious, the LH and FSH peaks appeared 24 hours before ovulation, and the E2 peak appeared 24 hours before the LH peak. The P value increased after ovulation, and the measured value was certain. To indicate the number of days in the menstrual cycle, to understand the basic state of the ovary or its reserve capacity, blood should be collected on the third day of the menstrual cycle. Increased FSH in the near menopause indicates decreased ovarian reserve capacity, LH/FSF, T and PRL values in the diagnosis of PCOS. And the significance of amenorrhea lactation syndrome is as described above.
When there are special indications, such as primary amenorrhea or genital dysplasia, karyotype should be performed.
Women's anti-sperm antibody and anti-cardiolipin antibody test, enzyme-linked immunosorbent assay (ELISA) can be used to measure antibodies in the blood, positive for pregnancy has an adverse effect.
7. Continuous B-ultrasound monitoring follicular development and ovulation V-ultrasound probe close to the pelvic organs, without filling the bladder, can accurately observe follicular development, endometrial thickness and characteristics, generally starting on the 8th day of the menstrual cycle, dominant follicle diameter When the ovulation is close to 18~22mm, the follicle disappears, the liquid appears in the pelvic cavity, and the dominant follicle does not rupture and suddenly increases. It may be LUFS. If it is gradually reduced, it is follicular atresia.
8. Semen test
(1) Sperm density: Calculated with a blood cell counter and a number of 10 squares at 1 million/ml.
(2) Sperm activity: The number of active sperm in the 20 squares, if less than 10 million/ml, should be 100 squares, including the total number of active sperm and sperm, and the activity is the number of active sperm (20 to 100 cells) × 100/the total number of sperm (20~100 grids as above), the activity level is divided into 4 levels: the grade III straight forward; the grade II straight forward; the grade I in situ; the level 0 is inactive, the results of each experiment are inconsistent, The Macleod algorithm is 0 to 4, with 0 indicating inactivity, 1 indicating that the activity is not moving forward, 2 indicating progress but slow, 3 being normal forward activity, and 4 being fast forward.
(3) Sperm morphology: 1 drop of semen plus PBS 1% formaldehyde (formaldehyde), stained with 1% Eosin, counterstained with 10% Nigrosin, observed 200 sperm, divided into sperm head abnormalities, sperm tail abnormalities, middle segment abnormalities.
Normal semen test results: count > 20 million / ml, activity (III + II) > 40% (within 2h), normal morphology > 30%, anti-sperm antibody test (-), at least 10 million per specimen Active sperm, 7-8 active sperm can be seen under the microscope at high magnification, and there is no agglutination, the amount of seminal plasma is 2.0ml, the pH value is 7.2-7.8, the white blood cells are <1×106/ml, and the high power microscope is <3~4.
9. Hysterosalpingography is selected 2 to 7 days after menstruation cleansing, avoiding strenuous activities 24 hours after angiography, such as local contrast agent accumulation, indicating adhesion in the pelvic cavity, severe systemic disease, uterine bleeding, curettage after curettage Item check.
10. Laparoscopy was performed under laparoscopic direct observation of the pelvic cavity, and 20 ml of diluted methylene blue solution was injected through the cervix, and the fallopian tube was passed through. The smoothness was injected into the blue liquid without resistance, that is, the blue liquid was discharged from the umbrella end. There is mild resistance when pushing the liquid, the fallopian tube first expands, and the buckling, goodbye, the blue liquid flows out from the umbrella end, the impediment of the push liquid is large, and the blue liquid does not flow out from the umbrella end, but leaks from the cervix. The pelvic lesions indicate that the fallopian tube is unreasonable and the cause of patency is pelvic tuberculosis, endometriosis and pelvic inflammation caused by various causes, pelvic tuberculosis, tubal swelling, extensive adhesion with surrounding tissues, or ovary and fallopian tubes Wrap, pelvic cavity is completely closed or semi-closed, other tuberculosis features such as the above, and some are accompanied by fallopian tube fistula, endometriosis manifested as pelvic peritoneal implantation, ovarian chocolate cyst, uterine posterior wall and rectum close Adhesive, the pelvic inflammatory disease caused by the fallopian tube is impassable or unobstructed, the appearance of the fallopian tube is normal, and some manifest as the tubal ovarian inflammatory mass, the fallopian tube umbrella curl or surrounding tissue Adhesion, there are tubal accumulation of water, the tubal thickening, thin wall, liquid retention in the uterine cavity, and some simple fallopian tube end of the adhesion.
11. Hysteroscopy to examine the uterine cavity under direct vision, endometrial polyps, intimal hyperplasia, submucosal small uterine fibroids, early endometrial cancer, intrauterine adhesions, uterine scars, uterine insufficiency mediastinum The diagnosis of endometrial calcification is intuitive and effective, and if necessary, concurrent with laparoscopy, it is more conducive to a comprehensive evaluation of the patient's condition.
12. Fallopian tube Fallopian tube can directly enter the fallopian tube. The examination can not only accurately understand the location and extent of tubal obstruction and the tubal peristalsis, but also the polyposis, adhesions, scars and other organic lesions in the fallopian tube.
13. Endometrial histological examination Endometrial histological examination can reflect the ovarian function and endometrial response to ovarian hormones, and can find endometrial lesions, such as endometrial tuberculosis, polyps, inflammation, etc., ovulation after ovulation Endometrial progesterone changes in the secretory phase, such as the luteal phase in the luteal phase of the secretory gland secretion or less than normal 2 days, combined with BBT rise <12 days, suggesting that the corpus luteum function is insufficient, the uterus on the 5th to 6th day of the menstrual cycle The endometrium is still in the secretory phase and should be noted for luteal atrophy.
14. Basal body temperature measurement ovulation is generally on the 14th day of the cycle, the luteal phase should last (14 ± 2) days, the body temperature is tested in a quiet state before getting up every day, the temperature table is placed under the tongue for 5 ~ 10s, the body temperature is recorded, and the body temperature is connected every day. Line, such as biphasic, that is, after ovulation, the body temperature rises by 0.3-0.6 °C, and the body temperature drops again after menstruation.
Based on the evaluation of the above various examinations, ventilation is not suitable as a means of diagnosis of tubal patency. It has been basically abandoned. It is difficult to use carbon dioxide (CO2), and there is a possibility of air embolism when using air. The accuracy rate is only 50. %, the results of the liquid is not objective enough, but sometimes it can also play a role of mild adhesion, can be used as a primary screening, uterine tubal iodine angiography can show the internal structure of the uterus and fallopian tubes, morphology, nodular beaded, curl increase Thick, stiff, stagnant water, etc., X-ray film can also be used for reference analysis by others. For example, although lipiodol has a dispersion at the end, the diffusion limitation indicates that there is adhesion in the pelvic cavity, or the increase in the umbrella end indicates that the umbrella has resistance adhesion, water and oil beads Indicates that there is fluid in the fallopian tube.
The World Health Organization believes that laparoscopy can observe the pelvic conditions, there are advantages, liquid, ventilation and lipiodol angiography have false negative and false positive, but the accuracy of iodized oil angiography and laparoscopy are more than 90%, sometimes two The results are also inconsistent.
Laparoscopy still belongs to the scope of minor surgery. Small pelvic diseases such as endometriosis can be found, and lesion resection and adhesion separation should be performed. The tubal patency test should be based on the condition and initial treatment effect from simple examination to more complicated examination. The false negatives in the ventilation test were 63.0%, the false positives were 26.7%, the false negatives were 6.3%, and the false positives were 27.7%. Laparoscopy showed more abnormalities in the fallopian tube in the infertile women. The fallopian tube anatomical lesions such as the fallopian tubes Paraclinal cysts, fallopian tube sac formation, tubal diverticulum, etc. do not affect pregnancy; while fallopian tube stenosis and fallopian tube curl are only seen in infertile women, most of the fallopian tube deformation is due to pelvic adhesions.
Diagnosis
Diagnosis of female infertility
Tubal tube fluid
There is a large blindness, it is difficult to make a more accurate judgment on the morphological function of the fallopian tube, but because of the simple method, it can be used as a screening test. The examination time should be arranged 3 to 7 days after the menstruation is clean, without gynecological inflammation and sexual life.
2. B-supervised tubal fluid
Ultrasound monitoring can be observed under the ultrasound monitoring (and special ultrasound diagnostic contrast agents can be used) after the injection of the sound changes through the fallopian tubes. The blindness of traditional tubal drainage is 81.8% with laparoscopic examination; it has no damage to the uterus and fallopian tube mucosa, and the side effects are light. The operation method is similar to that of tubal fluid, and B-ultrasound monitoring is used before and after the injection of liquid. RESULTS: Unobstructed: See the anechoic area in the uterine cavity and move toward the bilateral fallopian tubes. The posterior humerus can be seen in the dark area. It is not smooth: there is resistance when pushing liquid, repeated liquid pressure pushes the liquid through the fallopian tube, and the posterior canal is visible in the dark area. Obstruction: The resistance of the push is large, and the dark area of the uterine cavity is enlarged. The patient complains of abdominal pain, and there is no dark area in the posterior fornix.
3. Hysterosalpingography
The uterine cavity also has a comprehensive understanding, can determine the lesion within 5mm of the uterine cavity, easy to operate. The contrast agent may be 40% iodized oil or 76% diatrizoate; there may be iodine allergy, and a skin test is required before surgery. The patient was placed supine on the X-ray examination table and injected with diatrizoate contrast agent in the uterine cavity. First take the first piece to understand the uterine cavity and fallopian tube, continue to inject contrast medium and take a second piece to observe whether the contrast agent enters the pelvic cavity and diffuse in the pelvic cavity; if iodized oil is used, take a second shot after 24 hours sheet. According to the radiograph, the tubal patency was analyzed, and the accuracy rate was 80%.
4. Hysteroscopic tubal intubation
The interstitial part often has the illusion of obstruction during the liquid-passing test due to sputum, tissue debris residue, mild adhesion and scar. Under the hysteroscopic direct vision, the cannula or angiography can be intubated from the fallopian tube to the uterine cavity opening. The interstitial part directly acts as a dredge and lavage, and is a reliable method for diagnosing and treating tubal interstitial obstruction.
5. Laparoscopy
It can directly look at the pelvic internal organs, and can comprehensively, accurately and timely judge the nature and extent of various organ lesions. Through the microscopic fluid test, the degree of tubal patency can be dynamically observed, and at the same time it plays the role of dredging the fallopian tube lumen. It is one of the best means of female infertility examination.
Diagnosis of ovulatory dysfunction infertility.
