How Do I Choose the Best Infertility Treatment?

Infertility is medically defined as the absence of any contraceptive measures for more than one year, and normal sexual life without successful pregnancy. Mainly divided into primary infertility and secondary infertility. Primary infertility is never conceived; secondary infertility is infertility after having been pregnant. According to this strict definition, infertility is a common problem that affects at least 10% to 15% of couples of childbearing age. The causes of infertility are divided into male infertility and female infertility.

Basic Information

English name: infertility
Visiting department: Obstetrics and Gynecology
Common locations: Female reproductive system

Common causes: Ovulation disorders, abnormal semen, abnormal fallopian tubes, unexplained infertility, endometriosis, immunological infertility, etc.
Common symptoms: Not contraceptive and not pregnant
Contagious: no

Causes of Infertility

The causes of infertility are divided into male infertility and female infertility. In 1992, the classification was most widely used by the World Health Organization in the diagnosis and treatment of infertility. The primary etiology diagnoses are: ovulation disorder, semen abnormality, fallopian tube abnormality, infertility of unknown cause, endometriosis and other infertility such as immunology. Another factor is cervical factors, including cervical stenosis, which accounts for more than 5% of all cervical factors. Female infertility is mainly due to ovulation disorders, fallopian tube factors, and endometrial receptive abnormalities. Male infertility is mainly due to abnormal spermatogenesis and dysfertility. ^[1]

1. female infertility

(1) Fallopian tube infertility The fallopian tube plays an important role in collecting eggs and transporting eggs, sperm and embryos; the fallopian tube is also the place where sperm is capable, sperm and eggs meet and fertilize. Infection and surgical operations can easily cause damage to the fallopian tube mucosa, resulting in the disappearance of cilia, peristalsis, and blockage or adhesion to surrounding tissues, affecting the unobstructed function of the fallopian tube. Therefore, blocked or unobstructed fallopian tubes are an important cause of female infertility. Infection Pelvic infection is the main cause of tubal infertility. Infection not only causes the fallopian tube to be blocked, but also because of scar formation, the fallopian tube wall is rigid and the fallopian tube is adhered, which changes its relationship with the ovary and affects the fallopian tube's egg collection and transport functions. Infected pathogens can be caused by aerobic and anaerobic bacteria, as well as by chlamydia, tuberculosis, gonorrhoeae, mycoplasma, and the like. Endometriosis, pelvic endometriosis, and ovarian endometriosis can form peritoneal adhesions, causing external adhesion of the fallopian tube end or adhesion around the ovary, preventing mature eggs from being taken into the fallopian tube; Extensive adhesions can also affect the operation of fertilized eggs. tubal tuberculosis tubal tuberculosis is the most common in genital tuberculosis, which manifests as thickening and hypertrophy of fallopian tubes, umbrella-shaped eversion like pipe-shaped, or even umbrella-end closed; fallopian tubes are stiff and nodular, and cheese-like masses or miliary peritoneum can be seen in some cases Nodule. About half of patients with tubal tuberculosis have endometrial tuberculosis at the same time. Hydrosalpinx caused by fallopian tube sterilization is more common, which becomes an important factor affecting function after fallopian tube recanalization. The lesions of the proximal tubal tissue and cells after sterilization are related to the length of sterilization. Therefore, the longer the time after sterilization, the lower the success rate of recanalization.

(2) Infertility Chronic ovulation disorder caused by ovulation disorder is a common manifestation of many endocrine diseases, accounting for 20% to 25% of women. The clinical manifestations are mainly irregular menstruation and even amenorrhea. Cycles shorter than 26 days or longer than 32 days indicate abnormal ovulation. The medical history can also reflect signals of endocrine disorders such as hirsutism, virilization, galactorrhea, and low estrogen. In 1993, the World Health Organization (WHO) developed a classification standard for anovulation, which is divided into three categories. WHO type I (low gonadotrophic anovulation), WHO type II (normal gonadotrophic anovulation), WHO type III (high gonadotrophic anovulation). WHO type I: Including hypothalamic amenorrhea (stress, weight loss, exercise, anorexia nervosa and others), Kallmann syndrome (abnormal gonadotropin-releasing hormone precursor cell migration), and gonadotropin deficiency. Typical manifestations are hypogonadotrophic hypogonadism: low FSH, low E2 and normal prolactin and thyroxine. WHO type II: Most patients encountered clinically. That is, ovarian dysfunction with normal gonadotropins, with varying degrees of anovulation or thin menstruation. Includes: PCOS, follicular membrane hyperplasia, and HAIRAN syndrome (hairy, anovulatory, insulin resistance, and acanthosis nigricans). Typical manifestations are: FSH, E2, and prolactin are normal, but LH / FSH is often abnormally elevated. WHO type III: Patients are mainly deficient or resistant to terminal organs and present with high gonadotropin hypogonadism, including premature ovarian failure and hypogonadism (ovarian resistance). Typical manifestations are elevated FSH and LH and low E2. These patients are characterized by poor response to induced ovulation and impaired ovarian function. ^[2]

(3) Immune infertility At present, autoantibodies related to infertility are divided into two categories: non-organ specific autoantibodies and organ specific autoantibodies. The former refers to antibodies against common antigens present in different tissues, such as anti-phospholipid antibodies (APA), anti-nuclear antibodies (ANA), anti-DNA antibodies, etc .; the latter refers to antibodies that only target the autoantigen of a specific organ or tissue, such as anti-sperm. Antibodies (ASAb), anti-ovarian antibodies (AOVAb), anti-endometrial antibodies (AEMAb), and anti-chorionic gonadotropin antibodies (AhCGAb). At present, the nature of the antigens targeted by non-organ specific autoantibodies is relatively well understood. The technologies for detecting APA and ANA are relatively mature and standard, and the clinical data are rich. The antigen components targeted by organ specific autoantibodies are complex and the standardization of detection is low. The relationship with infertility is also difficult to determine due to difficult analysis of statistical data and statistics, which affects the treatment of infertile patients with autoantibody positive.

(4) Unexplained infertility When the indicators examined by an infertile couple are normal, and the cause of infertility cannot be explained, it is diagnosed as unexplained infertility. It is speculated that the etiology of infertility of unknown cause may have the following aspects: bad cervical secretion effects; endometrium's poor acceptance of early embryos; poor peristaltic function of the fallopian tube; defect of the egg collection function of the fallopian tube Luteinized non-rupture syndrome; Slight hormone secretion is poor, such as insufficient corpus luteum function; Sperm and egg fertilization ability is impaired; Mild endometriosis; Immune factors such as anti-sperm antibody, anti-sperm Zona pellucida antibodies or anti-ovarian antibodies; dysfunction of peritoneal macrophages; impaired antioxidant function in peritoneal fluid.

2. Male infertility

(1) Reproductive organs and other abnormalities Congenital abnormalities: Congenital abnormalities of the testicles include testis-free disease, seminiferous tubule dysplasia (Klinefelter), XYY syndrome, and male pseudohermaphroditism. Klinefelter syndrome has a chromosome karyotype of 47, XXY; the patient's breasts are feminized; the testicles are small and hard, and the seminiferous tubules are hyalinized and fibrotic; spermatogenesis is completely stopped or severely reduced. Abnormal testicular decline is also an important cause of male infertility. When the testicle drops abnormally, the number of germ cells in the seminiferous tubules decreases, the testicles shrink in size, and the weight also decreases. The higher the position of the testicle in the abdominal wall or abdominal cavity, the greater the damage to the seminiferous tubules. Patients with abnormal testicular decline in both sides are less likely to have children if left untreated. Vascular obstruction: The congenital absence of the vas deferens and seminal vesicles is characterized by a small amount of semen, often less than 1 ml, and no fructose in the seminal plasma; inflammatory obstructions, such as bilateral epididymal tuberculosis; ejaculatory duct obstruction is rare. Surgical injury or vas deferens ligation, etc .; and prostatitis, seminal vesiculitis can cause a significant decrease in semen quality. Varicocele: It can cause testicular blood stasis, reduce effective blood flow, and disrupt the normal microenvironment of spermatogenesis, eventually degenerating and shrinking spermatogonia, reducing sperm production, weakening vitality, and increasing abnormal sperm. Azoospermia. Androgen target organ lesions are divided into two types: completeness such as feminization of testis; incompleteness such as Reifenstein syndrome.

(2) Endocrine abnormalities The main reason is dysfunction of gonadotropin synthesis or secretion. Kallmann syndrome, also known as selective hypogonadism hypogonadism, is a pulsed dysfunction of GnRH in the hypothalamus and is an autosomal recessive genetic disease. Clinical features are sexual maturity disorder with loss of smell, small testes, abnormal testicular decline, small penis, and hypospadias. Serum testosterone levels are low, and LH and FSH levels are at the lower limit of normal values for the same age group. Selective LH deficiency: Patients have normal serum FSH levels, low LH and testosterone levels, insufficient virilization, and breast development, but the testes are normal in size and there are a small amount of sperm in the semen. Pituitary tumors have the most significant effect on LH secretion. Pituitary tumors are the most common cause of hyperprolactinemia. Excessive PRL can cause patients with hyposexuality, erectile dysfunction, breast development, and dysplasia. Infertility is often associated with infertility in 21-hydroxylase, reduced corticosteroid synthesis, and increased ACTH. The adrenal cortex is stimulated by ACTH to synthesize a large amount of testosterone, which inhibits the secretion of pituitary gonadotropin This leads to infertility.

(3) Sexual dysfunction includes hyposexuality, erectile dysfunction, premature ejaculation, non-ejaculation and retrograde ejaculation, etc., semen cannot be normally injected into the vagina.

(4) Immune factors are divided into two categories, antisperm autoimmunity generated by males and antisperm alloimmunity generated by females. Sperm and the immune system are isolated by the blood-testis barrier, so whether it is male or female, sperm antigens are foreign antigens and have strong antigenicity. The blood testis barrier and seminal plasma immunosuppressive factors and other factors have jointly established a complete immune tolerance mechanism. When orchitis, epididymitis, prostatitis, seminal vesicle inflammation, or vasectomy and other operations occur, the above immune tolerance The mechanism is destroyed, that is, an anti-sperm immune response may occur.

(5) Infectious factors Mumps virus can cause orchitis, severe cases can cause permanent tubule destruction and atrophy and testicular failure; Treponema pallidum can also cause orchitis and epididymitis; gonorrhea, tuberculosis, filariasis Can cause vas deferens obstruction; chronic bacterial infection of semen, or mycoplasma and chlamydia infection can increase the white blood cell count in semen, reduce semen quality and increase immature sperm.

(6) Physicochemical factors and environmental pollution Spermatogenic epithelium is a rapidly dividing cell, so it is easy to accept damage caused by chemical factors. Heat, radiation and toxic substances can shed spermatogenic epithelium, or affect the function of interstitial cells and support cells, hindering the spermatogenic process. Spermatogenic epithelium is sensitive to radiation. Cyclophosphamide, nitrogen mustard and other chemotherapeutic drugs directly damage spermatogenic epithelial and mesenchymal cell functions. Certain environmental toxins have similar effects or structures with natural hormones, such as polychlorinated biphenyls (PCB), tetrachlorobiphenyl (TCDD), dichlorodiphenyldichloroethane (DDT), and diethylstilbestrol (DES). These toxins affect human health by contaminating the air, water and food chain, including the continued decline in the quantity and quality of male sperm.

(7) History of drug surgery Opiates, anticancer drugs, chemotherapy and antihypertensive drugs can directly or indirectly affect spermatogenesis. A history of previous pelvic surgery, bladder and prostate surgery may cause hypoejaculation; hernia repair or testicular fixation may affect spermatic cord or testicular blood supply.

(8) About 31.6% of infertile males of unknown cause are unable to find out the exact cause through the currently used examination methods. ^[3]

Clinical manifestations of infertility

The common clinical manifestation of infertility is that the couple lives regularly for 1 year, without contraception and pregnancy. Infertility caused by different causes may be accompanied by clinical symptoms of the corresponding cause.

Infertility check

Examination of female infertility

1. Examination of tubal infertility

(1) Fallopian tube drainage is relatively blind, and it is difficult to make a more accurate judgment of tubal morphology and function, but it can be used as a screening test because of the simple method. The examination time should be arranged 3 to 7 days after menstruation is clean, without gynecological inflammation and sexual life.

(2) Fallopian tube perfusion (SSG) under ultrasound monitoring can observe the changes in the sound and image of the fluid flowing through the fallopian tube after the injection of liquid (optional ultrasound diagnostic contrast agent can also be selected ) under ultrasound monitoring. There is no blindness of traditional fallopian tube drainage, and the coincidence rate with laparoscopy is 81.8%; and it has no damage to the uterus and fallopian tube mucosa and has mild side effects. The operation method is similar to tubal perfusion, and B-ultrasonic monitoring is used before, during and after the injection of fluid. Result evaluation: unobstructed: seeing the formation of non-echoic areas in the uterine cavity and moving towards the bilateral fallopian tubes, liquid dark areas can be seen in the posterior fornix. Unsuccessful: there is resistance when bolus fluid is injected. Repeatedly pressurize the bolus slightly to see the fluid flow through the fallopian tube. Obstruction: The bolus resistance is large, and the dark area of the uterine cavity is enlarged. The patient complains of abdominal pain. There is no liquid dark area in the posterior fornix.

(3) Hysterosalpingography (HSG) also has a comprehensive understanding of the uterine cavity, and can determine lesions 5mm in the uterine cavity, which is easy to operate. Contrast agent can use 40% iodinated oil or 76% diatrizoate; there may be iodine allergies, skin tests need to be done before surgery. The patient was supine on the X-ray examination table, and the diatrizoate was injected into the uterine cavity. Take the first film to understand the uterine cavity and fallopian tubes, continue to inject the contrast agent and take the second film, and observe whether the contrast agent has entered the pelvic cavity and diffused in the pelvic cavity; if using lipiodol, take the second one after 24 hours sheet. The patency of the fallopian tube was analyzed according to the radiograph, and the accuracy rate was 80%.

(4) Hysteroscopic tubal intubation and drainage of the interstitial area often results in the phenomenon of obstruction during the fluid test due to spasm, residual tissue debris, mild adhesions, and scarring. Under hysteroscopic direct vision from the fallopian tube Intubation or angiography at the opening of the uterine cavity can directly dredge and lavage the interstitial area, and is a reliable method for diagnosis and treatment of tubal interstitial obstruction.

(5) Laparoscopy can directly look at the pelvic internal organs, and can comprehensively, accurately and timely judge the nature and extent of pathological changes in various organs. The fluid flow test under the microscope can dynamically observe the patency of the fallopian tube, and at the same time it plays the role of dredging the fallopian tube cavity, which is one of the best methods for female infertility examination.

2. Examination of ovulation dysfunction infertility

Determine anovulation and its cause. Basal body temperature (BBT) measurement table can help judge, the increase of basal body temperature of 0.5 to 1.0 degrees indicates the presence of ovulation and the length of the luteal phase. Although this test is simple and low-cost, patients spend more energy, and about 20% of cases with a single temperature are tested for ovulation by other methods. The second method to determine ovulation is urine LH measurement, which is tested during the 10th to 16th day of menstruation (most patients ovulate during this window period). The detection of LH peak is more accurate than the BBT measurement, but the measurement The cost of LH is large. The presence of LH indicates the possibility of ovulation, but some patients show LH peaks but do not ovulate, which may be related to unruptured follicular luteinization syndrome. Other methods for detecting ovulation include: measuring the level of progesterone (P greater than 3ng / ml) in the middle corpus luteum, the appearance of mature follicles in the middle of menstruation (1.6-2.2cm), free fluid in the pelvic cavity during ovulation, endometrial biopsy (the first day of menstruation or cycle 23 Day) The endometrium changes during the secretory phase.

3. Examination of immune infertility

(1) Sperm immunoassay is divided into three parts: AsAb test, seminal plasma immunosuppressive substance test and sperm cell immune test. AsAb test is still commonly used in clinical practice. There are many methods for detecting AsAb, and the current methods are limited to the detection of immunoglobulins (IgG, IgA, and a few IgM). The first is to detect AsAb attached to sperm (direct method); the second is to detect AsAb in serum, semen, and female reproductive tract secretions (indirect method). The direct method is more reliable, and the results obtained by the indirect method are often low in validity and high in variability.

(2) Cervical mucus test after sexual intercourse test (PCT): It is performed during the predicted ovulation period. Intercourse is prohibited for 3 days before the test. Avoid vaginal medication or irrigation. If the cervix has inflammation, mucus is thick and has white blood cells, this test is not suitable. , Need to do after treatment. Within 2 to 8 hours after intercourse, the subject's cervical mucus was smeared and examined on a glass slide. It is normal if there are 20 active spermatozoa per high power field of vision; if the sperm has poor ability to pass through the mucus or the sperm does not move, it is abnormal. When the PCT is normal, the couple's sexual life is normal, the ovarian estrogen secretion and cervical mucus are normal, and the sperm can penetrate the cervical mucus. The couple has fertility, which can exclude the female cervical factor and the male sperm survival rate and penetration. Factors cause infertility.

4. Examination of unexplained infertility

Prior to the diagnosis of unexplained infertility, a basic infertility assessment should confirm ovulation, unobstructed fallopian tubes, normal uterine cavity, and normal semen analysis. Infertility under these conditions is classified as unexplained infertility.

Examination of male infertility

Physical examination

(1) Blood pressure, height, weight, nutritional status and secondary sexual characteristics including body size, bone, fat distribution, body hair distribution, male breast development (klinefelter syndrome), and olfactory abnormalities (kallman syndrome) Sign) and so on.

(2) Reproductive organ examination to check the testicle size, texture, tenderness, etc .; whether the epididymis is tender, indurated, the presence or absence of the vas deferens; whether the varicocele veins are varicose and the extent of varicose veins; penis size and development. Digital rectal examination should pay attention to the size and texture of the prostate. Normally, the seminal vesicle cannot be touched. When the seminal vesicle is diseased, it may be touched.

(3) Laboratory inspection Semen inspection: Including the evaluation of sperm and seminal plasma. Semen routine is the most commonly used and most important test to evaluate male fertility in infertile couples. Normal semen is a mixture of testicular and epididymal secretions and sperm. During the ejaculation, the secretions of the prostate, seminal vesicle and urethral glands are mixed. Formation of a viscous projectile. Analysis indicators include: semen volume, sperm density, viability, vitality, morphology, and presence or absence of white blood cells. Semen biochemical examination: -glucosidase and carnitine in seminal plasma are characteristic products of epididymis; fructose is a characteristic product of seminal vesicles; acid phosphatase, citric acid, zinc, etc. are characteristic products of prostate. Testing these items can help determine the functional status of male accessory gonads. Pathogen examination: the detection of pathogenic bacteria or mycoplasma and chlamydia in prostate fluid or semen has guiding significance for treatment. Semen cytology: According to the proportion and morphology of germ cells at all levels, valuable information about the spermatogenic function of the testes can be obtained. If more spermatogonia and spermatocytes are found without spermatozoa, it indicates that the spermatogenic process is impeded.

(4) Endocrine examinations include T, FSH, LH, PRL, etc., and evaluate the function of hypothalamus, pituitary, and testis through measurement, and provide a basis for analyzing the cause of testicular failure. High FSH and low T levels indicate hypogonadism due to testis, which is seen in azoospermia caused by Klinefelter syndrome, severe varicocele, actinomyopathy, and drug damage. FSH is lower than normal, indicating that there is a central lesion, whether it is a thalamus lesion or a pituitary lesion, and a pituitary examination, GnRH challenge test, or testicular biopsy is required to identify it. PRL was significantly increased, and the normal values of FSH and LH were low or low, accompanied by decreased sexual function, oligospermia, impotence, etc., which was hyperprolactinemia, with the possibility of pituitary adenomas or microadenomas. Because testicular volume is negatively correlated with FSH, T and LH reflect the function of testicular mesenchymal cells and are not directly proportional to testicular volume. Therefore, sex hormone determination also provides a basis for testicular biopsy. Although FSH and LH are secreted in pulses, FSH serum levels fluctuate little, so to a certain extent: serum FSH levels can reflect the spermatogenic function of the testes, but FSH measurements cannot completely replace testicular biopsies.

High FSH levels, small and hard testicles (<6ml), and azoospermia are important diagnostic indicators of Klinefelter syndrome; if the testicle volume is 6ml, it may be primary or idiopathic spermatogenic disorders; there are two possibilities One is testicular spermatogenic epithelial injury, and the other is the lowering of the gonadotropin releasing factor (GnRH) pulse efficiency in the lower thalamus. If the FSH is normal and the testicles are small, a pituitary examination, GnRH challenge test, or testicular biopsy should be performed for identification. If there are many reasons for azoospermia with normal testicular volume, check the urine sample after ejaculation to exclude retrograde ejaculation. Check sperm berry sugar, if sperm berry sugar is negative, consider whether there is a lack of vas deferens and seminal vesicles; also seen in Sertoli cell syndrome only. If the vas deferens are normal, it may be an acquired ejaculation obstruction. If there is no obstruction of the spermatic tract, further testicular biopsy is needed to determine whether it is the primary testicular spermatogenesis disorder.

(5) Immunological examination When unexplained sperm motility, spontaneous sperm agglutination, chronic reproductive system infection and other cases are encountered, anti-sperm antibodies in serum and semen and cervical mucus of both spouses can be detected.

(6) Genetic examination The following patients should be considered for genetic testing. Routine use of chromosomal banding technology, FISH technology, and Y-chromosome microdeletion examination should be considered. People with congenital reproductive system abnormalities; Obstructive or non-obstructive azoospermia or severe oligozoospermia; Couples with infertility of unknown reasons for many years; FSH levels increased with small testes; Need to accept ICSI technology helps pregnant women.

(7) imaging examination is suspected of intracranial pituitary lesions, CT or MRI can be performed. Doppler ultrasound can help identify varicocele. Vasectomy and seminal vesicle angiography: It is an invasive test that will not only cause pain to the patient, but the careless operation during the test may even cause the obstruction to worsen the condition, so the indication should be strictly selected. For patients who have no spermatozoa or very few spermatozoa, if there is no abnormality during physical examination, and testicular biopsy shows the presence of spermatogenesis. You need to know more about the situation of the insemination pipeline to perform this inspection.

(8) Traumatic azoospermia is the most serious type of male infertility. The etiology is more complicated. The incidence is about 10% of male infertility patients. It can be divided into obstructive azoospermia (OA) and azoospermia. Non-obstructive azoospermia (NOA). The former is caused by obstruction of the sperm tract, not the testis does not produce spermatozoa; the latter is caused by testicular spermatogenesis dysfunction. Scrotal exploration: in patients with azoospermia, the testis volume is above 15mL, the vas deferens are normal, and the sex hormone levels are normal. In order to identify whether azoospermia is caused by OA or NOA, scrotal exploration is feasible. During the operation, vas deferens angiography . Indications for diagnostic percutaneous epididymal sperm extraction (PESA): the volume of at least one side of the bilateral testis is 12ml; the texture of the testis is medium or above; the serum FSH level is 2.5 to 40 IU / L. Contraindications: Both testicular volumes are 40 IU / L; history of tuberculosis, epididymitis and beaded changes; acute epididymitis, orchitis, seminiferitis, seminal vesiculitis, prostatitis, or scrotal skin infection or eczema; abnormal coagulation function. It can replace the relatively damaged testicular biopsy to distinguish OA and NOA in patients with azoospermia. Testicular biopsy: It is a traumatic diagnostic method, but it is an indispensable technique in andrology research and disease diagnosis. Testicular biopsy is to take biopsy testicular tissue for histological examination, in order to understand testicular pathological changes, spermatogenesis, clarify the lesion site, perform quantitative histological analysis, evaluate the prognosis, and decide to use ART technology.

Infertility diagnosis

Diagnosis is based on the patient's clinical manifestations, medical history, and various laboratory tests.

Infertility treatment

1. Treatment of tubal infertility

According to the lesion site, the degree of adhesion, the extent of involvement, the number of years of infertility, whether it is combined with other causes of infertility, and the patient's willingness to choose the appropriate method of treatment of tubal infertility.

(1) Treatment of bilateral tubal obstruction According to the site and degree of tubal obstruction, different treatment options are selected. The blocking and blocking of the fallopian tube can be achieved by pelvic adhesion release and fallopian tube angioplasty. If a tubal ostomy is feasible for mild tubal effusion, it may have less impact on ovarian function than tubal resection. On the one hand, it not only drains harmful tubal effusion, but also hopes that the tubal function will be restored through the body's reconstruction, thereby The possibility of spontaneous pregnancy is retained; however, there is a possibility that hydrops may form again after surgery. Salpingectomy is feasible for severe hydronephrosis and its function has been completely lost and cannot be preserved. The mesangium should be kept as much as possible during resection to reduce the possible impact on ovarian blood supply. Recanalization of tubal interstitial obstruction is difficult and the recombination rate is low. It is recommended to perform IVF-ET directly. Gap obstruction after simple fallopian tube ligation can be considered end-to-end anastomosis of the fallopian tube after ligation.

(2) The treatment of unobstructed fallopian tubes is caused by partial obstruction of the umbrella end and obstruction of unilateral fallopian tube isthmus, which can be treated according to the method of bilateral obstruction of fallopian tubes; In patients, laparoscopy may not be positive, and can be treated with hysteroscopic fallopian tube intubation.

(3) The treatment of chronic inflammation of the fallopian tube is only applicable to those with fallopian tube adhesion, less obstruction, short lesion time, etc. Otherwise, the treatment effect is not good. It is feasible to take traditional Chinese medicine for promoting blood circulation and removing blood stasis. The traditional Chinese medicine retains enema and acupoint injection, and cooperates with ultra-short wave physical therapy to promote local blood circulation, which is conducive to the elimination of inflammation.

(4) In vitro fertilization-embryo transfer (IVF-ET) patients who have not been able to obtain a natural pregnancy after 6 months to one year after tubal and pelvic plastic surgery, the chance of obtaining a natural pregnancy is very low, and it is generally not advisable to reshape Surgery, and IVF-ET is recommended. Patients with infertility due to fallopian tubes tend to use IVF, especially when they are older, have infertility years, combine other infertility factors, or when the above surgical and non-surgical treatments are not effective, IVF should be used as soon as possible to avoid missing the best female fertility. Period, leading to a decline in pregnancy rates.

2. Treatment of ovulation disorder infertility

Ovulation induction is commonly known as ovulation promotion, which is the main method of treating anovulatory infertility. It refers to the use of drugs or surgical methods to induce ovulation in the ovary of patients with ovulation disorders. The purpose is generally to induce the development of a single follicle or a few follicles. It is mainly used in the treatment of ovulation disorder infertility and / or combined with intrauterine artificial fertilization technology.

3. Treatment of immune infertility

Can start from reducing AsAb production, inhibiting AsAb production, removing AsAb that binds sperm, and overcoming AsAb interference.

(1) AsAb production-Isolation therapy uses condom contraception for a period of more than 6 months, which reduces or eliminates the original antibody titer in the body, and prevents semen antigens from entering the female reproductive tract to produce new antibodies. The efficacy is uncertain. At present, it is generally used in combination with other treatment methods, or the condom is used only during the non-ovulation period.

(2) Inhibition of AsAb production-drug treatment is divided into the following types: According to the cause of immune infertility, such as reproductive system infection, prostatitis, seminal vesiculitis, epididymitis, etc., use appropriate antibacterial drugs. Immunosuppressive therapy, mainly using corticosteroids, such as prednisone, methylprednisolone, betamethasone, dexamethasone, etc., the general course of treatment is about six months.

(3) Overcoming AsAb interference Conservative treatment with assisted reproductive technology (ART) is ineffective and viable intrauterine artificial insemination and assisted pregnancy treatment to avoid the cervical mucus barrier. For those with unknown causes of infertility and a high degree of suspicion of immune problems, and those who have failed the above treatments, it is recommended to use appropriate ART technology (IVF) as soon as possible.

4. Treatment of Unexplained Infertility

(1) There is no research data on the long-term prognosis of the natural process of infertility due to anticipatory treatment . Most existing studies are short-term observations. Long-term observations may prove that the prognosis is good. When couples with unexplained infertility come to consult, it is important to inform them that there may be a better chance of pregnancy without treatment. For this baseline assessment of untreated pregnancy rate, clinical trials found that couples with unexplained infertility were When assigned to the control group (without treatment), the pregnancy rate was 3% to 4% per month. When infertile couples consult, they generally hope that they can be treated directly. The diagnosis of unexplained infertility is not a sentence of infertility, and their doubts should be dispelled. The probability of unexplained infertility naturally depends largely on the woman's age, duration of infertility, and previous pregnancy history. Over the years, many different populations have confirmed that infertility is negatively related to age. Natural pregnancy decreases with age, and it decreases rapidly when women are nearly 39 to 40 years old. Therefore, for the treatment of unexplained infertility, young women have a higher cumulative pregnancy rate than older women, and the probability of pregnancy also decreases with the duration of infertility, which may be due to increasing age and having arrived Low fertility. Past pregnancy history is also important. Couples with secondary infertility are more likely to have a natural pregnancy than those with primary infertility.

(2) Drug treatment should be given to younger couples who are younger and have a shorter gestation period, usually at least 2 years. During this period, attention should be paid to other health issues related to pregnancy, such as quitting smoking, reducing overweight weight, and improving original bad habits. The treatment steps for unknown causes of infertility are summarized as "three steps": induction of ovulation, intrauterine insemination, in vitro fertilization-embryo transfer.

Regarding the treatment of unexplained infertility, ovulation-promoting combined or non-combined intrauterine artificial insemination (IUI) started in the mid-1980s and is still being used with a significant increase. Clomiphene (CC) and gonadotropins Application in the treatment of ovulation.

With regard to ovarian stimulation, ovulation promotion allows the number of fertilized eggs to increase the likelihood of pregnancy. It is inconclusive how many dominant follicles are needed for IUI to promote ovulation. Generally, 1 to 2 follicles are considered to be the optimal number. Similarly, increasing the density of motile sperm through artificial insemination may further increase the probability of monthly pregnancy. To some extent, ovulation promotion and / or IUI increase the monthly pregnancy rate, which will have a cumulative effect after a period of treatment.

In vitro fertilization and embryo transfer (IVF-ET), if the ovulation-promoting and IUI treatments that last more than 3 cycles are still unsuccessful, it means that the effect of the treatment is not very optimistic. IVF also provides a diagnosis of the cause of unexplained infertility to see if the problem of infertility occurs in the fertilization stage. When couples of unexplained infertility use IVF conventional fertilization, there is a 11% to 22% risk of fertilization failure. In these patients, a higher pregnancy rate can be achieved by switching to a single spermatozoa intra-follicular injection (ICSI) fertilization method.

5. Treatment of male infertility

Different treatment methods should be adopted according to different pathogenic factors. If the cause is clear, corresponding measures should be actively adopted to improve the quality of semen. For poor sperm quality caused by unknown causes, you can try to use Chinese medicine to adjust the mental state and living habits to improve the quality of semen. If the effect is not obvious, or combine other causes of infertility, the woman is older, the length of infertility, etc., it should be used in a timely manner. Assisted Reproductive Technology.

1.MaroulisGB. Effect ofaging on fertility and pregnancy: SeminReprod Endocrinol, 1991: 9: 165-179.

2.WHO Scientific Group Report: RecentAdvancesinMedicallyAssistedConception.WHOTechnicalReportSeries820.Geneva, WHO, 1992.

3.IsidoriAM, PozzaC, GianfrilliD, etal. Medical treatmenttoimprovespermquality: ReprodBiomedOnline, 2006: 12 (6): 704-714.