Lecture of infertility

2021-03-22 12:00 AM

Normally, after a year of living together, about 80 - 85% of couples can get pregnant naturally. According to world statistics, the infertility rate accounts for about 8-15% of couples.

Preamble

Infertility is a focus on the reproductive health care program. Infertility treatment is an urgent need for infertile couples to ensure family happiness and develop harmoniously with society.

Normally, after a year of living together, about 80 - 85% of couples can get pregnant naturally. According to world statistics, the infertility rate accounts for about 8-15% of couples. In Vietnam today, infertility accounts for 12-13% of the total number of couples, equivalent to nearly one million couples.

Definition and classification of infertility 

Define

According to the World Health Organization, a couple called infertility when living together for more than a year and without using any contraception and still have no children.

Fertility peaks between 20 and 25 years old and declines after 30 years in women and after 40 years in men.

Classification of infertility

Primary Infertility (Infertility I):

The couple has never been pregnant, despite having lived together for more than a year and not using any contraception.

Secondary Infertility (Infertility II):

The couple previously had a child or became pregnant, but later could not get pregnant again despite living together for more than a year and not using any contraception.

Causes of infertility 

Conception can be achieved when these conditions are: (1) follicular development and oocyte enlargement; (2) having quality-assured spermatozoa production; (3) the sperm meets the ovule; (4) fertilization, implantation and development in the uterus for more than 37 weeks. When there is a disorder of any stage in this chain of reproductive activities, it leads to an adverse outcome. Thus an infertile couple can be caused by the husband. either by the wife or for both. The data obtained show that about 30-40% of infertility cases are caused by a single male cause, 40% due to a female, 10% a combination of a man and a female, and 10% of an unknown cause.

In general, the causes of infertility can be classified as follows:

Male infertility

Semen abnormalities: spermatogenesis due to obstruction or aplasia, decreased sperm quality (low, weak, deformed sperm) ..

Anatomic abnormalities: varicose veins, low urinary closure, high closure, testicular place.

Functional disorders: decreased libido, erectile dysfunction, ejaculation disorder, painful intercourse.

Other causes: testicular injury, urogenital surgery, male sterilization, urogenital infections or genetic causes.

The reason is female

Ovulation abnormality: The menstrual cycle does not ovulate due to the influence of the hypothalamus - pituitary - ovary.

Causes of the uterine tube: Conditions that can damage the uterine tube such as genital tract infections, sexually transmitted diseases, history of pelvic and tube surgery, endometriosis of the tube. uterus, congenital abnormality in the uterine tube or sterilization.

Causes in the uterus: uterine fibroids, uterine adhesions, congenital abnormalities (malformations of the bipedal uterus, uterus with septum, no uterus ...)

Causes of the cervix: poor mucus, anti-sperm antibodies, damage to the cervix due to surgical intervention (apical cut, electric burning ...), the cervix is ​​short.

Other causes: Psychosexuality, painful intercourse, birth defects of the lower genital tract ...

Infertility of unknown cause

About 10% of infertility cannot find the exact cause after having examined and done all the necessary tests to probe and diagnose.

Steps of examination and diagnostic exploration

Examination

The principle of infertility examination is to examine both husband and wife, ensuring privacy and confidentiality.

Asking disease:

The purpose of questioning is to collect information about both husband and wife:

Age, occupation and geography.

Time desired to have children and past course of treatment.

A history of obstetrical pregnancy, miscarriage, term birth or abortion.

Intercourse, frequency, ejaculation condition and difficulties encountered.

History of medical problems and current medications.

On the wife's side, you should ask:

Age of menstruation, nature of menstruation, period of each period, amount of menstruation more or less, have colic during menstruation.

History of genital infections and treatment.

History of gynecological diseases or surgeries especially the pelvic region.

Clinical examination:

On the wife's side, it is necessary to examine:

Body observation: stature, secondary sexual properties such as hair, hair, pubic hair, armpit hair, breast development, clitoris, large lips, baby lips ...

Gynecological examination includes breast examination, assessment of breast development, lactation, observing through the speculum for genital lesions, inflammation, paying attention to the degree of secretion of the cervix, cleanliness and development of the vaginal mucosa .... Vaginal examination combined with abdominal manipulation to detect gynecological tumors. In addition, the abnormal position of the uterus is a point to note, the uterus falling on one side is a cause that prevents sperm from penetrating the upper genital tract. Fibrous nodules in the uterus can also be a cause of infertility.

On the part of the husband that needs to be examined:

Observe the whole body: stature, secondary sexual properties such as hair, hair, pubic hair, armpit hair, voice.

History and history associated with genital infections, mumps, testicular tuberculosis. For mumps, it is important to ask about pre-pubertal or post-pubertal age, and is there accompanying testicular inflammation. In addition, they also asked about surgical conditions related to genitals such as inguinal hernia, testicular place.

Penis size, urinary location, inflammatory manifestations.

Examination of the scrotum, testicular presence in the scrotum as well as size and density, examination of the spermatic cord, epididymis.

Subclinical

Survey in women:

Hormonal tests: gonadotropic hormones (LH, FSH), sex hormones (estrogen, progesterone), pregnancy endocrine (hCG) ... Conduct hormonal tests to evaluate the function of hypothalamus - the pituitary or ovaries through a hormonal response.

Ovulation probe: Baseline body temperature measurement, uterine index, endometrial biopsy dated ... When oocyte ejaculation occurs, the body temperature curve has 2 times, the cervical index after the release. The oocyte for several days must be reduced to 0.0.0.0 due to the presence of progesterone secreted from the system. Biopsy of the endometrium from day 21-24 of the 28-day menstrual cycle, found secretory images, used only 1 time before the birth treatment diagnosis when the above tests are not clear.

Post-sex test: The survival of the sperm in the female genital tract depends on the rapid movement of the sperm into the cervical mucus. This is the basis of the post-intercourse test (Huhner test). From 2-10 hours after intercourse suck fluid from the cervical canal. Positive test if at least 5 healthy sperm is found in one medium on the objective x 40. The simple post-intercourse test does not evaluate the fertility of the husband and does not replace the semen test. . Vaginitis, cervical inflammation can lead to erroneous assessment of a clinical trial, requiring treatment from the infection before trying a test.

Imaging diagnostics: gynecological ultrasound, ultrasound monitoring of follicular development, uterine imaging, routine X-ray pituitary imaging or computer tomography.

Diagnostic and intervention laparoscopy: diagnosis of genital anomalies, oviductal removal endoscopy, ovarian catheterization, oviductal catheterization, ovarian spot burning ...

A chromosome test detects genetic abnormalities.

Survey in men:

Endocrine tests:

Quantification of gonadotropic hormones (LH, FSH), sex hormones (testosteroids) ...

Semen tests:

Semen map analysis according to the requirements and standardized techniques of the World Health Organization in order to objectively evaluate semen on parameters such as semen volume, mass, density, mobility, billion Survival rate, sperm morphology ...

Normal map semen parameters:

Volume: 2- 6ml.

Lysates on average after 15 minutes, opaque white or ash gray.

PH: 7,2 -7,8.

Quantity: 20 x 106 / ml or more.

Sperm motions: 25% or more in rapid straight movements (type a) or 50% or more forward within 60 minutes of collection.

Appearance: 30% or more of normal appearance.

Survival rate: 50% or more of live spermatozoa.

Leukocytes: less than 1 x 106 / ml

Supersonic:

Examine the scrotum, testicles, and spermatic cord through ultrasound.

Biopsy:

Testicular, epididymis, and spermatic cord look for the presence of sperm in the case of a sterile semen sample.

Chromosome examination:

Detect genetic abnormalities

Treatment Methods
Depending on the cause of infertility of the husband or wife, corresponding treatment.

Some basic treatments:

Towards the wife

If there is an abnormality of oocyte: indicated to stimulate the ovaries according to many different regimens to increase follicular development, maturation and oocysts.

Tubal occlusion: surgery to open the tubes through the abdomen or endoscopy.

Treat for genital tract infections, if any, before investigating the cause of infertility. Approximately 5% of infertility patients get pregnant spontaneously after treatment with vaginitis, cervix or changes in vaginal environment.

Other necessary supportive treatments such as indications of Bromocriptin in case of lactation amenorrhea, insulin hypersensitivity preparations (metformin) in polycystic ovary syndrome ...

Surgery can be indicated such as opaque endoscopy, polycystic ovary burning, removal of endometriosis, repair of genital deformities ...

On the husband's side

Semen abnormalities: depending on the severity of the abnormality, only the intervention method is indicated.

Hormonal: It is possible to improve sperm quality in cases of hormonal causes, which are abnormally abnormal, but the course of treatment is often long, expensive and does not improve much.

Artificial insemination with post-dialysis sperm injection into the uterine cavity is preferred in the case of moderate sperm abnormality. This is a simple method, easy to perform, closest to physiological and pretty good cumulative pregnancy rate.

In vitro fertilization: is an achievement in infertility treatment with maximum intervention potential, especially in those with low, weak, and severely malformed sperm. In cases of obstructive infertility, sperm can be extracted from the testicles and crest to be injected into the oocyte.

Abnormal sexual function: exclude physical causes (diabetes, vascular abnormalities, nerves, prostate enlargement ...), psychotherapy, aphrodisiac preparations only is indicated after exclusion of physical diseases and limited use only under the supervision of a physician.

Surgical repair may be indicated in varicose veins, low urinary closure, testicular place.