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Infertility. He-Feng Huang Women’s Hospital, School of Medicine, Zhejiang University. Where we come from?. Infertility. Definition: The inability to achieve pregnancy after regular unprotected intercourse for a period of 1 year. - PowerPoint PPT Presentation
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InfertilityHe-Feng HuangWomens Hospital, School of Medicine, Zhejiang University
Where we come from?
Infertility Definition: The inability to achieve pregnancy after regular unprotected intercourse for a period of 1 year.
Primary infertility: never conceived within 1 yearSecondary infertility: after a previous pregnancy, unable to conceive again within a 1 year period.
EtiologyFemale factorsMale factorsFemale and male factors
Female FactorOvulatory disordersTubal factors Uterine factorsCervical factorsVulval and vaginal factors
Ovulatory disordersHypothalamic dysfunctionPituitary dysfunction Ovarian factor OthersHypothalamic-pituitary-ovary axis
Hypothalamic dysfunctionPsychological factors: Stress, Disturbance, Anorexia derived from mental stimulus
Chronic consumptive diseases: Tuberculosis , Severe malnutrition, Anorexia nervosa
Pituitary dysfunction Pituitary tumors: Pituitary adenomaPituitary lesions: Empty sella syndromeSheehans Syndrome
Ovarian factorsPCOSLUFSPOFOvary insensitivity syndrome Congenital abnormalitySurgery or X-rayOvarian endometriosisOvarian tumor
PCOSSymptom Menses disturbance and infertility hirsutism, acne, obesity (BMI 25)Diagnosis1irregular menses or anovulation2experimental or clinical hyperandrogenism3polycystic ovarian morphology observed by ultrasound Accord with 2 points of the three. Follow-up for whole life
OthersThyroid disorder Adrenal dysfunction
Tubal factors
InflammationSurgery of ectopic pregnancy
Tubal ovarian effusion Ectopic pregnancyTubal blockage, hydrosalpinx (HSG
Tubal ligationTubal abnormality
Tubal factorsTubal ligationTuberculosis fallopian tube
Increase of tubal factorsSTDRepeated intro-uterine manipulationRepeated drug abortion
Uterine factorsUterine developmental abnormality Congenital absence of the uterus Uterine malformationEndometrial abnormality Endometrial tuberculosis Asherman syndromeUterine tumor
Uterine developmental abnormality
Intrauterine adhesions fibroid
Male factorsSemen abnormality Oligospremia, Aspermia, Asthenospermia Sperm transport abnormalityEndocrine disordersSexual dysfunction Immunological factors
Male and female factorsPsychological factorsSubfertilityImmunological factors
Classification
Investigation and DiagnosisMale investigationHistory: general health, medications, lifestyle and reproductive healthGeneral examinationSpecific examination abnormality of genitals seminal analysis
Volume 2.0mlPH 7.2~7.5Density 2010 /mlCount 4010 /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 110666Normal Seminal analysisFourth/Fifth versionVolume 1.5mlPH 7.2~7.5Density 1510 /mlCount 3910 /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 110666Fourth versionFifth version
Female InvestigationHistory General examinationSpecific examinationOthers
Specific examinationOvarian examinationOvulation monitor Luteal function Ovarian reserve
Ovarian functionOvulation monitor 1Basic body temperature 2Cervical mucus 3Vaginal cytological test 4Ultrasound monitor 5Serum or urinary LH peak 6Serum E2 and P levels 7Endometrial biopsy 8Laparoscopy
Follicular development and ovulation
Biphasic basal body temperature
monophasic basal body temperature
Low estrogenHigh estrogen
Cervical mucus
Fern crystallization
Proliferative endometriumSecretory endometrium
Luteal function
1BBT 2Endometrial biopsy 3Serum E2 and P levels
Ovarian reserve1Age2Antral follicle count (AFC)3Basic FSHE24CC stimulating test5GnRH-a stimulating test6AMHInhibin B
Tubal investigationHydrotubation Hysterosalpinography (HSG)LaparoscopyHysterosalpingography by Ultrasound
Hydrotubation
HSG normal figure
Laparoscopy methylene blue liquid
Postcoital testCervical hostility Hysteroscope Laparoscopy
Postcoital test
Postcoital testCervical hostility Hysteroscope Laparoscopy
Cervical hostility
Postcoital testCervical hostility Hysteroscope Laparoscopy
EndometriosisLaparoscopy)
Treatment of infertility1.Treatment of genitals organic disease2.Induction of ovulation3.Luteal support4. Improvement of cervical mucus 5.Treatment of tubal inflammation6.ART
1. Genitals organic diseaseGenital malformationsGenital inflammation Uterine MyomaEndometriosis ----Etiology combined treatment: Infection control, Surgery
2.Tubal infertilityFallopian 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
3. Asherman syndromePrinciple of Management: Separate adhesions Prevention of adhesion recurrence Promote endometrium repairMethods Hysteroscope management of intrauterine adhesion Estrogen promote endometrium regeneration Intrauterine device (IUD)
1.Reproduction-related disease2.Induction of ovulation3.Luteal support4.Improvement of cervical mucus 5.Treatment of tubal inflammation6.ART
Drugs for ovulation inductionCCHMGFSH: u-FSH, FSH-HP, r-FSHHCGGnRHLHRHGnRH analogGnRH agonist GnRH antagonistbromocriptine
The first R-GNGonal- F+Lhadi+Ovidrel=FSH+LH+HCGIVFbabySebastian 1997.5.7
1.Reproduction-related disease2.Induction of ovulation3.Luteal support4. Improvement of cervical mucus 5.Treatment of tubal inflammation6.ART
1.Reproduction-related disease2.Induction of ovulation3.Luteal support4. Improvement of cervical mucus 5.Treatment of tubal inflammation6.ART
1.Reproduction-related disease2.Induction of ovulation3.Luteal support4. Improvement of cervical mucus 5.Treatment of tubal inflammation6.ART
1.Reproduction-related disease2.Induction of ovulation3.Luteal support4. Improvement of cervical mucus 5.treatment of tubal inflammation6.ART
Summary: Infertility-treatmentAzoospermiaGenetic diseaseAfter surgeryAssisted Reproductive Technologies(ART)UnexplainedCausesTreatmentImmunologicMedication or surgeryImmune inhibition
ARTAssisted Reproductive technologyAID or AIH Artificial inseminationIVF-ET In vitro fertilization-embryo transfer
AIH or AIDAIH (artificial insemination with husband sperm) IUI (Intrauterine insemination IVI (Intravaginal insemination) ICI (Intracervical insemination) ITI (Intratubal insemination) IPI (Intraperitoneal insemination) IFI (Intrafollicle insemination)AID (artificial insemination by donor)
IVF-ETIndicationTubal infertilityEndometriosisIUI failureUnexplained infertilityImmunological infertilityOligospermia
IVF-ET
Other technology derived from IVFCrypreservation of embryosOocyte donation and embryo donationSurrogate motherGIFT (Gamete intrafallopian transfer) ZIFT (Zygote intrafallopian transfer)ICSIPGD
ICSI (Intracytoplasmic sperm injection)
PGDPreimplantation genetic diagnosis
PGD indication X-linked chromosome disease Chromosome abnormality (number/structure) Monogenic diseasesPGS: Preimplantation genetic screenAdvanced ageHistory of habitual abortionFailure of IVF for several times
PGD techniqueBlastomere BiopsyFISHSingle cell PCRInterphase nuclear conversionWhole genomic amplification,WGAComparative genomic hybridization, CGH
PGD
141413 Robertsonian translocation 13q14q
X-linked agammaglobulinemia
IVF-ET protocolPatients preparationCOHOocyte retrievalIn vitro fertilizationEmbryo trasferLuteal supportFollow up
Complication of ARTOHSSEctopic pregnancy and abortionMultiple pregnancy multiple pregnancy reduction
Transvaginal ultrasound-guided selective fetal reduction
In vitro maturation (IVM)Immature oocytes Mature oocytesembryos
Ethic of ART (Chinese government)The government does not support nor approve the practice of human clonesForbid performing ART for single womanForbid Manufacturing OocytesForbid commercial trial of zygotes and embryosForbid multiple pregnancy dominated ARTForbid gender selected ART without medical indicationForbid surrogate motherhood
Ethic of ARTChallenge the course of natural reproductionDanger of inbreedingCommercial trial of zygotes and embryosUncertainty of parenthoodRisk of oocyte donationControversy between clone and traditional family formationClone criminalityChallenge of the definition of humanART related regulations and laws
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