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Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
Infertility 不孕症 2006网上教材
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Infertility 不孕症 2006网上教材

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  • 1. Infertility and Assisted Reproductive Technologies 不孕症与 辅助生殖技术 XIN LU Obstetrics & Gynecology Hospital Fudan University 2006-5-11/19
  • 2. Contents <ul><li>Infertility </li></ul><ul><ul><li>Definition; </li></ul></ul><ul><ul><li>Causes; </li></ul></ul><ul><ul><li>Examinations and Diagnosis; </li></ul></ul><ul><ul><li>Treatment; </li></ul></ul><ul><li>Assisted Reproductive Technologies (ART) ; </li></ul><ul><ul><li>Intrauterine insemination ( IUI); </li></ul></ul><ul><ul><li>In vitro fertilization and embryo transfer (IVF-ET); </li></ul></ul><ul><ul><li>Intracytoplasmic sperm injection (ICSI); </li></ul></ul><ul><ul><li>Gamete intrafallopian transfer (GIFT); </li></ul></ul>
  • 3. DEFINITION of Infertility 不孕症定义 <ul><li>What is Infertility? </li></ul><ul><li>Infertility is defined two years of unprotected intercourse without pregnancy. </li></ul><ul><li>( WHO, one year ) </li></ul><ul><li>Primary Infertility : no previous pregnancies </li></ul><ul><li>原发不孕 have occurred; </li></ul><ul><li>Secondary Infertility: a prior pregnancy has </li></ul><ul><li>继发不孕 occurred; </li></ul>
  • 4. Female Reproductive duct anatomy 女性生殖道解剖 <ul><li>Female </li></ul><ul><li>ovary 卵巢 </li></ul><ul><li>fallopian 输卵管 </li></ul><ul><li>uterus 子宫 </li></ul><ul><li>cervix 宫颈 </li></ul><ul><li>Vagina 阴道 </li></ul>
  • 5. Female Reproductive Physiology 女性生殖生理 <ul><li>1. 下丘脑 - 垂体 - 卵巢轴内分泌调节 Femal Male </li></ul><ul><li>( H-P-O) (H-P-T) </li></ul><ul><li>GnRH GnRH </li></ul><ul><li>FSH,LH FSH,LH </li></ul><ul><li>E/P T </li></ul><ul><li>4. 3. 输卵管 </li></ul><ul><li>2. 卵巢周期性排卵 5. 宫颈 </li></ul><ul><li>6. 下生殖道 </li></ul>hypothalamus ovary pituitary 子宫 ovary 4. 子宫
  • 6. Causes 原因 <ul><li>Causes Percentage </li></ul><ul><li>Female factors 40-55 % </li></ul><ul><li>Male factors 25-40 % </li></ul><ul><li>Both male and </li></ul><ul><li>female factors 20 % </li></ul><ul><li>Immunologic </li></ul><ul><li>unexplained factors 10 % </li></ul>
  • 7. Female Factors 女方因素 <ul><li>Ovulatory dysfunction </li></ul><ul><li>( 排卵障碍 ) </li></ul><ul><li>Pelvic factors </li></ul><ul><li>( 盆腔因素 ) </li></ul>
  • 8. <ul><li>1 . Hypothalamic dysfunction; </li></ul><ul><li>2. Pituitary Insufficiency; </li></ul><ul><li>3. Ovarian factor (peripheral defect); </li></ul><ul><li>4. Others: thyroid or adrenal dysfunction; </li></ul>Ovulatory dysfunction 排卵障碍 hypothalamus pituitary ovary
  • 9. Pelvic factors 盆腔因素 <ul><li>1. Tubal factors: </li></ul><ul><li>injury, blockage, adhesion; </li></ul><ul><li>2. Uterine factors: </li></ul><ul><li>cogenital anatomic abnormalities; </li></ul><ul><li>endometrium disorder, tumor; </li></ul><ul><li>3. Cervical factors: </li></ul><ul><li>Infection, cogenital abnormalities; </li></ul><ul><li>4. Extra-genital tract factors; </li></ul><ul><li>Infection, cogenital abnormalities; </li></ul>
  • 10. Female Factors Summary Follopian tube Uterine ovary oocyte Cervix Extra-genital tract sperm Hypothalamus Pituitary Thyroid Adrenal
  • 11. Male Factors 男方因素 <ul><li>1. Abnormal spermatogenesis </li></ul><ul><li>congenital; </li></ul><ul><li>chronic diseases; </li></ul><ul><li>infectious factors; </li></ul><ul><li>2. Obstructive: sperm transport </li></ul><ul><li>abnormalities; </li></ul><ul><li>3. Immunologic factors; </li></ul><ul><li>4. Endocrine disorders; </li></ul><ul><li>5. Sexual dysfunction; </li></ul>
  • 12. Both Male and Female Factors <ul><li>1. No demonstrable cause; </li></ul><ul><li>2. Psychological factors; </li></ul><ul><li>3. Immunologic factors; </li></ul><ul><li>count for 10%; </li></ul><ul><li>autoimmune response; </li></ul><ul><li>auto-antibodies; </li></ul>
  • 13. Examination and Diagnoses 检查和诊断 <ul><li>Initial Visit 初诊 </li></ul><ul><ul><li>The initial visit is the most important; </li></ul></ul><ul><ul><li>The infertility is a problem of couple; </li></ul></ul><ul><ul><li>The male partner should be present; </li></ul></ul><ul><ul><li>History: both male and female; </li></ul></ul><ul><ul><li>The guide to diagnostic and treatment plans; </li></ul></ul>
  • 14. Examinations 检查 <ul><li>Female </li></ul><ul><ul><li>Physical examination; </li></ul></ul><ul><ul><li>Bimanual examination (双合诊) ; </li></ul></ul><ul><ul><li>Rectal-Vaginal-examination ( 三合诊); </li></ul></ul><ul><ul><li>Laboratory; </li></ul></ul><ul><ul><li>Assistant imaging; </li></ul></ul><ul><li>Male </li></ul><ul><ul><li>Physical examination; </li></ul></ul><ul><ul><li>Laboratory-Semen analysis; </li></ul></ul>
  • 15. Examinations (for female) 女方检查 <ul><li>Special Laboratory Examinations: </li></ul><ul><li>semen analysis (精液分析) ; </li></ul><ul><li>hormone measurement; </li></ul><ul><li>sperm penetration assay (SPA) 精子穿透试验 ; </li></ul><ul><li>postcoital examinition of cervical mucus </li></ul><ul><li>(性交后宫颈粘液试验) </li></ul><ul><li>anti-sperm immunologic examination; </li></ul><ul><li>Assistant imaging : </li></ul><ul><li>Unltrasound 超声 ; </li></ul><ul><li>Hysterosalpingogram 子宫输卵管碘油造影 ; </li></ul><ul><li>Hysteroscopy 宫腔镜 ; </li></ul><ul><li>Laparoscopy 腹腔镜; </li></ul>
  • 16. Examination and Diagnoses Initial evaluation History Physical exam Irregular menses No ovulation HSG or Hysteroscopy Abnormal of uterine Normal evaluation HSG Tubal blockage Abnormal Semen analysis anovulation Tubal factor unexplained Uterine factor Male factor Further Investigate and Treatment
  • 17. Normal Values for Semen Analysis 精液分析正常值 <ul><li>volume ≥ 2.0 mL </li></ul><ul><li>sperm concentration ≥ 20 x 10 6 /mL </li></ul><ul><li>motility ≥ 50 % </li></ul><ul><li>normal morphology ≥ 15 % </li></ul><ul><li>WBC < 10 6 /mL </li></ul><ul><li>Data from WHO, 1999 </li></ul><ul><li>Please keep in mind: </li></ul><ul><li>1. Cycle of Spermiogenesis takes about 74 days; </li></ul><ul><li>2. Semen parameters in males may vary; </li></ul><ul><li>3. Abnormal semen analysis should repeat at least once; </li></ul>
  • 18. Methods to monitor ovulation 监测排卵的方法 <ul><li>Luteinizing Hormone monitoring: </li></ul><ul><li>LH surge; </li></ul><ul><li>after 34-36 hr occur ovulation; </li></ul><ul><li>Basal Body Temperature: </li></ul><ul><li> simple, cheap, biphasic pattern; </li></ul><ul><li>Mid-luteal serum progesterone: > 3ng/mL, peak; </li></ul><ul><li>Premenstrual molimina: 95% presence; </li></ul><ul><li>Mucus change: thick and cellular, no crystalline fern; </li></ul><ul><li>Ultrasound monitoring: </li></ul><ul><ul><li>follicle size 21-23 mm, fluid in the cul-de-sac. </li></ul></ul>
  • 19. Treatment principle for female factors <ul><li>Causes Treatment </li></ul><ul><li>induction of ovulation ; </li></ul><ul><li>tuboplasty, </li></ul><ul><li>microsurgery ; </li></ul><ul><li>medication or surgery ; </li></ul><ul><li>immune inhibition ; </li></ul>anovulation Tubal factor Anatomic factor immunologic azoospermia genetic disease after surgery Failure above Assisted Reproductive Technologies (ART) 辅助生育技术 unexplained
  • 20. Induction of ovulation 诱发排卵 -1 <ul><li>1. Clomiphen 氯米芬: ER binding GnRH , FSH/LH </li></ul><ul><li>dosage : 50 mg, period day 5th , 5 days ; </li></ul><ul><li>2. Gonadotropin therapy 促性腺激素治疗: </li></ul><ul><li>Indications: Hypogonadotropic hypogonadism; </li></ul><ul><li>Pituitary dysfunction; </li></ul><ul><li>COH in IVF; </li></ul><ul><li>(COH : controlled ovarian hyperstimulation) </li></ul><ul><li>HMG : human menopausal gonadotropins; </li></ul><ul><li>FSH 75 IU/LH 75 IU, IM or SC; </li></ul><ul><li>Recombinant FSH: 75 IU, SC; </li></ul><ul><li>3. HCG 绒毛膜促性腺腺激素 : 5000-10000 IU; </li></ul>
  • 21. Induction of ovulation 诱发排卵 -2 <ul><li>4. Gonadotropin releasing hormone agonist </li></ul><ul><li>(GnRH-  ) : hypothalamic factor, as COH; </li></ul><ul><li>protocol: according the every GnRH-  </li></ul><ul><li>component and feature, the time of </li></ul><ul><li>start and discontinuation are different; </li></ul><ul><li>zoladex; decapeptyl, dipherenline, </li></ul><ul><li>enantone; </li></ul><ul><li>5. GnRH antagonist; </li></ul><ul><li>6. Bromocriptine 溴隐停 : high PRL; </li></ul>
  • 22. Assisted Reproductive Technologies (ART) 辅助生育技术 <ul><li>Intrauterine insemination ( IUI); </li></ul><ul><li>宫腔内人工授精 ; </li></ul><ul><li>In vitro fertilization and embryo transfer </li></ul><ul><li>(IVF-ET); 体外受精与胚胎移植 ; </li></ul><ul><li>Intracytoplasmic sperm injection (ICSI); </li></ul><ul><li>单精子卵泡浆注射; </li></ul><ul><li>Gamete intrafallopian transfer (GIFT); </li></ul><ul><li>配子输卵管移植 ; </li></ul>
  • 23. Intrauterine insemination ( IUI) 人工授精 <ul><li>Indications: </li></ul><ul><li>1. as treatment of male factor infertility; </li></ul><ul><li>2. psychological factors; </li></ul><ul><li>3. unexplained infertility; </li></ul><ul><li>4. genetic defects; </li></ul><ul><li>Types: </li></ul><ul><li>1. artificial insemination with husband’s sperm (AIH) ; </li></ul><ul><li>2. artificial insemination by donor (AID) ; </li></ul><ul><li>Method: </li></ul><ul><li>placement of about 0.3 ml of washed, processed </li></ul><ul><li>and concentrated sperm into the intrauterine cavity </li></ul><ul><li>by trans-cervical catheterizaion. </li></ul>
  • 24. In vitro fertilization and embryo transfer (IVF-ET) 体外受精与胚胎移植 <ul><li>Indications: </li></ul><ul><li>1. tubal factor; </li></ul><ul><li>2. endometriosis; </li></ul><ul><li>3. unexplained infertility; </li></ul><ul><li>4. IUI failure; </li></ul><ul><li>5. Immunologic factors; </li></ul><ul><li>Method: </li></ul><ul><li>1. Superovulation: COH, GnRH-  FSH(HMG)/HCG; </li></ul><ul><li>2. Aspiration of eggs; </li></ul><ul><li>3. Fertilization with capacitated sperm; </li></ul><ul><li>4. Culture of fertilized egg in the lab; </li></ul><ul><li>5. Replacement of fertilized egg into the uterus; </li></ul>
  • 25. Gamete intrafallopian transfer (GIFT) 配子输卵管移植 <ul><li>Indications: </li></ul><ul><li>1. unexplained infertility; </li></ul><ul><li>2. endometriosis; </li></ul><ul><li>3. IUI failure; </li></ul><ul><li>4. Premature ovarian failure (POF); </li></ul><ul><li>5. Immunologic factors; </li></ul><ul><li>Method: </li></ul><ul><li>1. Superovulation is induced as IVF-ET; </li></ul><ul><li>2. HCG injection is given; </li></ul><ul><li>3. Follicle are aspirated via laparoscopy; </li></ul><ul><li>4. Sperm mixed with egg; </li></ul><ul><li>5. Replacement of fertilized egg into fallopian tube; </li></ul>
  • 26. ART Complications 辅助生育技术并发症 <ul><li>Multiple gestations 多胎妊娠 ; </li></ul><ul><li>Pre-eclampsia 产前子痫 ; </li></ul><ul><li>Ovarian hyperstimulation syndrome (OHSS) </li></ul><ul><li>卵巢过激综合征 ; </li></ul><ul><li>Premature birth 早产 ; </li></ul><ul><li>Low birth weight 出生低体重 ; </li></ul><ul><li>Long term emotional, social and psychological impact 长期影响(情绪,社会,精神) ; </li></ul>
  • 27. 复习思考题 <ul><li>1. 不孕症应如何进行诊断; </li></ul><ul><li>2. 女性不孕的特殊检查有哪些; </li></ul>

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