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,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Infertility and,Assisted Reproductive Technologies,不孕症与,辅助生殖技术,XIN LU,Obstetrics & Gynecology Hospital,Fudan University,Contents,Infertility,Definition;,Causes;,Examinations and Diagnosis;,Treatment;,Assisted Reproductive Technologies (ART) ;,Intrauterine insemination ( IUI);,In vitro fertilization and embryo transfer (IVF-ET);,Intracytoplasmic sperm injection (ICSI);,Gamete intrafallopian transfer (GIFT);,Definition of Infertility,不孕症定义,Infertility is defined,two years,of unprotected intercourse without pregnancy.,(,WHO, one year,),Primary Infertility,:,no previous pregnancies,原发不孕,have occurred;,Secondary Infertility:,a prior pregnancy has,继发不孕,occurred;,Female Reproductive duct anatomy,女性生殖道解剖,Female,ovary,卵巢,fallopian,输卵管,uterus,子宫,cervix,宫颈,Vagina,阴道,女性生殖生理,1. 下丘脑-垂体-卵巢轴内分泌调节,Femal,Male,(,H-P-O) (H-P-T),GnRH,GnRH,FSH,LH,FSH,LH,E/P,T,4.,3.输卵管,2. 卵巢周期性排卵 5. 宫颈,6. 下生殖道,下丘脑,卵巢,垂体,子宫,卵巢,4.,子宫,Causes,原因,Causes Percentage,Female factors 40-55 %,Male factors 25-40 %,Both male and,female factors 20 %,Immunologic,unexplained factors 10 %,1,.,Hypothalamic dysfunction;,2.,Pituitary Insufficiency;,3.,Ovarian factor (peripheral defect);,4.,Others: thyroid or adrenal dysfunction;,Ovulatory dysfunction,排卵障碍,hypothalamus,pituitary,ovary,Pelvic factors,盆腔因素,1.,Tubal factors:,injury, blockage, adhesion,2.,Uterine factors:,cogenital anatomic abnormalities,endometrium disorder, tumor,3.,Cervical factors:,infection, cogenital abnormalities,4.,Extra-genital tract factors;,infection, cogenital abnormalities,Male Factors,男方因素,1. Abnormal spermatogenesis,congenital;,chronic diseases;,infectious factors;,2.,Obstructive: sperm transport,abnormalities,;,3. Immunologic factors;,4.,Endocrine disorders;,5. Sexual dysfunction;,Both Male and Female Factors,1. No demonstrable cause;,2.,Psychological factors;,3. Immunologic,factors;,count for,10%;,autoimmune response;,auto-antibodies;,Examination and Diagnoses,检查和诊断,Initial Visit,初诊,The initial visit is the most important;,The infertility is a problem of couple;,The male partner should be present;,History: both male and female;,The guide to diagnostic and treatment plans;,Examinations,检查,History collection；,Female,Physical examination;,Bimanual examination双合诊;,Rectal-Vaginal-examination (三合诊；,Laboratory;,Assistant imaging;,Male,Physical examination;,Laboratory-Semen analysis;,Examinations (for female),女方检查,Special Laboratory Examinations:,semen analysis精液分析;,hormone measurement;,sperm penetration assay (SPA)精子穿透试验;,postcoital examinition of cervical mucus,性交后宫颈粘液试验,anti-sperm immunologic examination;,Assistant imaging :,Unltrasound 超声;,Hysterosalpingogram 子宫输卵管碘油造影;,Hysteroscopy 宫腔镜;,Laparoscopy 腹腔镜；,Methods to monitor ovulation,监测排卵的方法,Luteinizing Hormone monitoring:,LH surge;,after 34-36 hr occur ovulation;,Basal Body Temperature:,simple, cheap, biphasic pattern;,Mid-luteal serum progesterone: 3ng/mL, peak;,Premenstrual molimina: 95% presence;,Mucus change: thick and cellular, no crystalline fern;,Ultrasound monitoring:,follicle size 21-23 mm, fluid in the cul-de-sac.,Normal Values for Semen Analysis,精液分析正常值,volume,2.0 mL,sperm concentration,20 x 10,6,/mL,motility,50 %,normal morphology,15 %,WBC, 1x,10,6,/mL,Data from WHO, 1999,Please keep in mind:,1. Cycle of Spermiogenesis takes about 74 days;,2. Semen parameters in males may vary;,3. Abnormal semen analysis should repeat at least once;,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,Treatment principle for female factors,Causes,Treatment,induction of ovulation；,tuboplasty,microsurgery；,medication or surgery；,immune inhibition；,anovulation,Tubal factor,Anatomic factor,immunologic,azoospermia,genetic disease,after surgery,Failure above,Assisted Reproductive Technologies,(ART),辅助生育技术,unexplained,Induction of ovulation,诱发排卵-1,1.,Clomiphen,氯米芬：,ER binding GnRH , FSH/LH,dosage：50 mg, period day 5th，,5,days；,2.,Gonadotropin therapy,促性腺激素治疗：,Indications: Hypogonadotropic hypogonadism;,Pituitary dysfunction;,COH in IVF;,(COH : controlled ovarian hyperstimulation),HMG,: human menopausal gonadotropins;,FSH 75 IU/LH 75 IU, IM or SC;,Recombinant FSH: 75 IU, SC;,3.,HCG,绒毛膜促性腺腺激素,: 5000-10000 IU;,Induction of ovulation,诱发排卵,-2,4.,Gonadotropin releasing hormone agonist,(GnRH-,a,),：hypothalamic factor, as COH;,protocol: according the every GnRH-,a,component and feature, the time of,start and discontinuation are different;,zoladex; decapeptyl, dipherenline,enantone;,5.,Bromocriptine,溴隐停:,high PRL;,Assisted Reproductive Technologies (ART),辅助生育技术,Intrauterine insemination ( IUI);,宫腔内人工授精;,In vitro fertilization and embryo transfer,(IVF-ET);,体外受精与胚胎移植;,Intracytoplasmic sperm injection (ICSI);,单精子卵泡浆注射；,Gamete intrafallopian transfer (GIFT);,配子输卵管移植;,Intrauterine insemination ( IUI),人工授精,Indications:,1. as treatment of male factor infertility;,2. psychological factors;,3. unexplained infertility;,4. genetic defects;,Types:,1. artificial insemination with husbands sperm,(AIH),;,2. artificial insemination by donor,(AID),;,Method:,placement of about 0.3 ml of washed, processed,and concentrated sperm into the intrauterine cavity,by trans-cervical catheterizaion.,In vitro fertilization and embryo transfer (IVF-ET),体外受精与胚胎移植,Indications:,1. tubal factor;,2. endometriosis;,3. unexplained infertility;,4. IUI failure;,5. Immunologic factors;,Method:,1. Superovulation: COH, GnRH-,a/,FSH(HMG)/HCG;,2. Aspiration of eggs;,3. Fertilization with capacitated sperm;,4. Culture of fertilized egg in the lab;,5. Replacement of fertilized egg into the uterus;,Intracytoplasmic sperm injection,单精子卵泡浆注射,(ICSI),Micromanipulation technique;,Indications:,1. as treatment of male factor infertility: epididyma,obstruction, azoospermia, retrograde ejaculation;,2. IVF failure;,Surgical sperm recovery for ICSI:,1. Percutaneous epididymal sperm aspiration (PESA);,2. Percutaneous testicular sperm fine-needle,aspiration (TESA);,Complications:,karyotypic abnormalities;,other genetic defects;,Gamete intrafallopian transfer (GIFT),配子输卵管移植,Indications:,1. unexplained infertility;,2. endometriosis;,3. IUI failure;,4. Premature ovarian failure (POF);,5. Immunologic factors;,Method:,1. Superovulation is induced as IVF-ET;,2. HCG injection is given;,3. Follicle are aspirated via laparoscopy;,4. Sperm mixed with egg;,5. Replacement of fertilized egg into fallopian tube;,ART Complications,辅助生育技术并发症,Multiple gestations 多胎妊娠;,Pre-eclampsia 产前子痫;,Ovarian hyperstimulation syndrome (OHSS),卵巢过激综合征;,Premature birth 早产;,Low birth weight 出生低体重;,Long term emotional, social and psychological impact 长期影响情绪，社会，精神;,Ovarian HyperStimulation Syndrome (OHSS),卵巢过度刺激综合征,Causes:,1. HCG injection-trigger;,2. VEGF,3. high estrogen level,4. Inflammatory media and cytokines,Patho-physiological mechanism:,local and systemic increase in capillary permeability,Clinical finding:,1. abdominal discomfort, nausea, vomiting, pain,2. pleural effusion, chest pain, shortness of breath,3. ascites, increased abdominal girth, weight gain,4. decreased urine output, oliguria,5. liver and renal function failure,Ovarian HyperStimulation Syndrome (OHSS),卵巢过度刺激综合征,Examinations:,1. Complete blood account, liver function, BUN,2. Prothrombin time, partial thromboplastin time,3. Chest X-ray,4. Transvaginal ultrasound,5. Oxygen saturation,6. Fluid balance,7. Serum HCG measurement,8.,Pelvic exam is contraindicated,;,Treatment:,1. Prevention of OHSS,2. Follow-up: Vital signs, fluid intake and output measurement,3. Admission to hospital,Welcome to OB & GYN HOSPITAL,
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