妇产科学课件：不孕英文版

Infertility

Vocabulary

Infertility不孕症Fecundability受孕力Anovulation不排卵Oligo-ovulation稀发排卵Amenorrhea闭经Oligomenorrhea月经稀发Ovarianreserve卵巢储备Clomiphenecitrate枸橼酸氯米芬Vocabulary

Gonadotropin促性腺激素Hysterosalpingography子宫输卵管造影Hysterosalpingo-contrastsonography子宫输卵管超声造影Fimbrioplasty输卵管伞部成形术Neosalpingostomy输卵管造口术Oligospermia少精子症Azoospermia无精子症Asthenospermia弱精子症Vocabulary

Teratospermia

畸精子症Assistedreproductivetechnology辅助生殖技术Artificialinsemination人工授精IVF-ET体外受精-胚胎移植ICSI单精子卵胞浆内注射FecundabilityTheprobabilityofachievingpregnancywithinasinglemenstrualcycle.Thefecundabilityofanormalcouplehasbeenestimatedat20%to25%.About90%ofcouplesshouldconieveafter12monthsofunprotectedintercourse.

Whatisinfertility?

Infertility

isdefinedastheinabilitytoconceiveafter12monthsoffrequentandunprotectedcoitus.

Primaryinfertility,inwhichnopreviouspregna-ncieshaveoccurred.

Secondaryinfertility,inwhichapriorpregnancyhasoccurred.Theepidemiologyofinfertility

Morerecentpopulation-basedstudiesfrom2009and2012reportedahigherprevalenceofinfertilitywithestimatesrangingfrom12%to24%.1.BushnikT,CookJL,YuzpeAA,etal.EstimatingtheprevalenceofinfertilityinCanada.Hum

Reprod27:738–746,2012.2.SlamaR,HansenOKH,DucotB,etal.Estimationofthefrequencyofinvoluntaryinfertilityonanation-widebasis.Hum

Reprod1489–1498,2012.3.BhattacharyaS,PorterM,AmalrajE,etal.TheepidemiologyofinfertilityintheNorthEastofScotland.Hum

Reprod24:3096–3107,2009.+HCG+HCG+HCGReproductiveProcessWhatdoespregancyrequire?1.Ovulationandproductionofacompetentoocyte2.Productionofcompetentsperms3.Transportofthesperm,oocyteandfertilizedegginthereproductivetract4.Normalfertilizationoftheoocyteandsperm5.ImplantationoftheembryoCausesofInfertilityFromCollinsJA.Unexplainedinfertility.InKeyeWE,ChangRJ,RebarRW,etal[eds].Infertility:EvaluationandTreatment.Philadelphia:WBSaunders,1995,p250Ovulatorydisordersanddecreasedovarianreserve(35%-40%)Tubalinjury,blockage,orparatubaladhesions(30%-35%）EndometriosisUterinefactorsCervicalfactorsOthers:immunologicfactors,systemicdiseasesUnexplainedfactors♀FemaleFactors1.OvulatoryDisordersFemaleFactors----OvulatoryDisorders——ClinicalSymptoms

Themostcommoncauseoffemaleinfertility，includingAnovulation——amenorrheaorsevereoligomenorrheaOligo-ovulation——oligomenorrhea（>35days)Agingoftheovarianfollicle——shortenedcyclelengthMethodsforDetectingOvulation1.Serialsonographyand

mesurementofLHD9D11D13D16Cyclelength:28-30daysMethodsforDetectingOvulation2.Basalbodytemperature(BBT)monitoring----Theleastexpensivemethodfordetectingovulation

BBTreferstothetemperatureobtainedpriortorisingfrombedinthemorning.Formostwomen,BBTislessthan36.7℃beforeovulationandover36.7℃afterovulation.Progesteroneproductionfromtheovaryapp-earstoraisethehypothalamicset-pointforBBTbyapproximately0.3-0.5℃.A

biphasicpatternisalmostalwaysassociatedwithovulation,butoccasionallyBBTrecordingsmayappearmonophasiceveninthepresenceofovulation.SoBBTisnotanabsolutelyaccuratemethod.MethodsforDetectingOvulation3.Mid-lutealprogesteronemeasurement

Thebloodsampleistakenonthe21stdayofmenstruation(ifthemenstrualcyclelengthis28days)or7daysafter

ovulation.

Aserumprogesteronelevelgreaterthan3ng/ml

isadiagnosticofovulation.Themostcommoncausesofadult-onsetanovulationare

hypothalamicdysfunction(35%)pituitarydisorders(10%)

thyroiddisease(5%)ovariandysfuntion（50%）polycysticovarysyndrome,ovarianfailure

abnomalitiesinweight,stress,eatingdisorders,strenuousexerciseprolactinoma,

Sheen’ssyndrome,Cushing'sdiseasehyperthyroidism,hypothyroidismOvulatorydisordersEvaluationofOvarianFunction1.Baselinesexhormone(FSH,LH,E2,P,PRL,T)FSH>10mIU/ml,orE2>80pg/ml,orFSH/LH>3.6:diminishedovarianreserveFSH>40mIU/ml:prematureovarianfailureLH/FSH>2-3and/orT:PCOS2.Baselineantralfolliclecount(AFC)

AFC<5:

diminishedovarianreserve

Thefollowingtestsaremadeondays2to4ofthecycle.TreatmentofOvulatoryDisordersCommonTreatment:1.Interventionstomodulateweight

increasethechanceofconception2.Clomiphenecitrate

(D3-7orD5-9,50-100mgdaily)※standardtreatmentforovulationinduction※bindingtohypothalamicestrogenreceptorsahypoestrogenicstateinthe

hypothalamusGnRHFSH,LH※onlyeffectiveinwomenwithendogenousestrogenproduction※risksofmultiplepregnancy

※

ovarianultrasoundmonitoringisnecessary

Patientswithanovulationhavethegreatestsuccesswithinfertilitytherapy.Thechoiceoftreatmentisdependentonthecause.

Mostly,treatmentofanovulatorydisorderscanresultinfecundabilitysimilartothatobservedinnormalcouples.TreatmentofOvulatoryDisorders3.Gonadotropin(Gn)treatmentGonadotropins:FSH,hMG,hCG,LH

ThemainindicationsforGninductionofovulation:

※patientswithlowlevelsofendogenousgonadotropinsandlittleendogenous

estrogenactivity※womenwithPCOSwhofailclomipheneinductionofovulation※unexplainedinfertilityorearlystageendometriosis※womeninprogramsofassistedreproduction,suchasIVFandIUI

4.Pulsatilegonadotropin-releasinghormone(GnRH)※forWHOGroupIanovulation(lowlevelsofendogenousgonadotropinsand

decreasedendogenousestrogenproduction)※areducedneedforcyclemonitoringandareducedriskofmultiplegestation※pulsatileGnRHforovulationinductionisnotpopularinChina5.Bromocriptine※forinfertilewomenwithhyperprolactinemiaandanovulation※2.5to7.5mgdaily

※

oftenachievepregnancyaftertreatmentwithbromocriptine

TreatmentofOvulatoryDisorders2.TubalFactorInfertilityFemaleFactors----MajorContributorstoTubalDiseasePelvicinflammatorydisease(PID)TheoccurenceoftubalinfertilityhasbeenreportedtobeassociatedwithPID.PreviouspelvicsurgeryFollowingpelvicsurgery,adhesionsdevelopinapproximately75%ofwomen.AppendicitisAhistoryofappendicitisappearstoincreasetheriskoftubalfactorinfertiliy.Septicabortion

Tubalorperitonealdiseaseisidentifiedinapproximately30%-35%ofthefemalepartnersofinfertilecouples.TestsofTubalPatencyHSGLaparoscopy

Thetwomostcommonlyutilizedtestsoftubalpatencyarehysterosalpingography(HSG)andlaparoscopy.Thehyperechoicinvertedtriangleistheimageofuterus.Thethinandwindingtubesonboth

sidesofuterusareoviducts.Afreeflowofcontrastmediacomesfromtheoviducts,sobothofthemareunobstructed.Animageofoviductandpelvisunderlaparoscopy.Hydrotubationunderlaparoscopy

canbemadetomakeclearwhetheroviductsareobstructedornot.

HSGLaparoscopyAdvantages1.Utilizingfewresourses2.Producingdataconcerningtheshapeofuterinecavity1.Highersensitivityandspecificity2.Withoutpainduringtheperformanceoftheprocedure3.Diagnosingendometriosisandpelvicadhesions,etc.4.TreatingabnormalitiesobservedatthetimeofprocedureDisadvantages1.Causingpain2.Providingnoinformationconcerningthepresenceofperitonealdiseases3.Lowersensitivityandspecificity1.Moreexpensive2.Moreinvasive

HSGVS

Laparoscopy

TestsofTubalPatency

3Dhysterosalpingo-contrastsonographyInrecentyears,thethreedimensionalhysterosalpingo-contrastsonography(HyCoSy)hasbeenappliedinthetestsoftubalpatency.Treatment

1.Laparoscopy——distaltubaldisease

Fimbrioplasty:lysisoffimbrialadhesionsordilatationoffimbrialstricturesNeosalpingostomy:thecreationofanewtubalopeninginafallopiantubewithadistalocclusion2.IVF-ET——※proximaltubaldisease

※unsuccessfulsurgery

※withoutpregnancymorethan1yearaftersurgery3.Endometriosis

FemaleFactors----EndometriosisTreatment

※Drugtherapy(GnRH-a)

※

Surgery(mainlylaparoscopic)

※IUIorIVF-ETExaminations

SerumCA125

Ultrasound

LaparoscopySymptom

Dysmenorrhea4.Uterinefactors

FemaleFactors----UterineFactorsEndometrialpolypsIntrauterineadhesionsEndometritisortuberculosisCongenitalmalformationsUterinetumorsMostendometrialpathologiesimplicatedininfertility,suchas,Examinations

Ultrasound

Hysteroscope

EndometrialbiopsyTreatmentcorrectionoftheseanomalies5.

CervicalFactors

FemaleFactors----CervicalFactorInfertilitySevereinflammation(mostcommon)TumorPolypsCongenitalmalformationTreatment※Eliminatingtheaboveinfertilityfactors※Intrauterineinsemination(IUI)Inthenormalcervix,thesecretedcervicalmucushasphysiochemicalpropertiesthatfacilitatesthetransportofsperms.Thefollowingconditionsmayimpairtheabilitytoproducenormalmucus.♀MaleFactorsAbnormalsemen:asthenospermia,oligospermia/azoospermiateratospermia

lowspermmotilitylowspermconcentrationnospermabnormalmorphologyAssociatedfactors:undescendedtestes,parotitis,testitis,smoking,excessivealcoholconsumption,environmentaltoxins,drugs,etc.

Abnormal

sexualfunction:

Immunologicfactor:antispermantibody(AsAb)erectiledysfunction,premature

ejaculation,retrogradeejaculation

MalefactorsCommondisordersMalefactoristheonlycauseofinfertilityin20%ofinfertilecouples,butitmaybeacontributingfactorinasmanyas30%ofcases.RaredisordersObstructionofductusdeferensAzoospermiaTesticulartraumaDamageofblood-testisbarrierEndocrinediseasesChromosomalabnormalityDisordersofpituitary,thyroid

oradrenalgland

Notcurable！MalefactorsSemenEvaluationMajorParametersVolume≥1.5mlConcentration≥15×106/ml(<15×106/ml:oligospermia,

0:azoospermia)

PR(Progressivemotility)

≥32%(<32%:asthenospermia)Theratioofnormalsperm≥4%(<4%:teratospermia

)Thesemenanalysis,ifabnormal,suggeststhattheprobabilityofachievingfertilityislowerthannormal.Twosemenanalyses,performedafter2to7daysofsexualabstinence,aresoughtowingtothelargebiologicvariabilityinsemenquality.TreatmentPrinciplesTreatmentofinfertilityGeneraltreatment

※Exercise※Giveupsmoking,alcohol※ModulateWeight

※MastertheoptimumtimingforintercourseEliminatingthefactorscontributingtoinfertilityAssistedreproductivetechnology(ART)AssistedReproductiveTechnology(ART)AssistedReproductiveTechnologyArtificialinsemination(AI)

※Artificialinseminationbyhusband(AIH)

※Artificialinseminationbydonor(AID)Invitrofertilizationandembryotransfer(IVF-ET）Intracytoplasmicsperminjection(ICSI)Manytechniquesarecurrentlyutilizedthatinvolvemanipulationofoocytes,sperm,andembryostoimprovetheprobabilityofasuccessfuloutcome.IVF/ICSI-ET

IVF-ET

isthemostcommonlyperformedassistedreproductivetechnology,involvingthelaboratorycultureofaspiratedoocytesandspermatozoainvitro,followedbythetranscervicalreplacementoftheresultlingembryo(s)intotheuterinecavity.

ICSI-ETisonevariationofIVF-ET.Fertilizationisachievedbyinjectionofaspermintotheoocyte.IndicationsforIVFTubalfactorinfertilityPCOSwithoutpregnancyafterdrugtherapyorAIHEndometriosisModeratecasesofmalefactorinfertilityUnexplainedinfertilityMajorstepsinIVF

1.Ovarianstimulation:Gn(FSH,hMG,hCG,LH),CC,GnR