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Human Reproductive Disorder. Xulan Dept. of G & O, the First Affiliated Hospital of Shantou University Medical College. Introduction of Infertility ※ Definition Fecund: the ability to reproduce, typically used in context of women to become pregnant.

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Human reproductive disorder
Human Reproductive Disorder

Xulan

Dept. of G & O, the First Affiliated Hospital of Shantou University Medical College


Human reproductive disorder

  • Introduction of Infertility

    ※ Definition

  • Fecund: the ability to reproduce, typically used in context of women to become pregnant.

  • Infertility: the inability to conceive after two years or more of trying with unprotected intercourse for couples.

    ( WHO, one year)


Human reproductive disorder


Human reproductive disorder

  • What are the chances of a fertile couple actively seeking pregnant in a single month or cycle? 10%-20%

  • The accumulated pregnancy rate during two years

    __chances of conceiving by 6 months: 75%

    __chances of conceiving by 1 year:90%

    __10%-15%of couples will require longer than one year to conceive.


Human reproductive disorder

Epidemiology and etiology of infertility pregnant in a single month or cycle? 10%-20%

Causes Percentage

Female factors 30-50 %

Male factors 30 %

Both male and

female factors 20 %

unexplained factors 10 %

So, the initial evaluation should include both the partners.


Human reproductive disorder

pregnant in a single month or cycle? 10%-20%Female Infertility

  • Causes

  • Ovulatory dysfunction: 25%.

  • Tubal factors: 30%-50%

    3. Pelvic factors

    4. Cervical factors

    5. Extra-genital tract factors

    6. Others


Female factors
Female Factors pregnant in a single month or cycle? 10%-20%

Hypothalamus

Pituitary

Follopian tube

Uterine

ovary oocyte

Cervix

Extra-genital tract

Fig.1sperm

Thyroid

Adrenal


Human reproductive disorder

  • Ovulatory dysfunction pregnant in a single month or cycle? 10%-20%

    1. Hypothalamus: amenarrhea or mensrtual disorder

    -- Emotional depress

    -- Psychological trauma

    -- Environmental and Climate changes

    2. Pituitary diseases:

    --Sheehan’s syndrome

    -- Pituitary tumor: Hyperprolactinemia,

    -- Empty sella syndrome


Human reproductive disorder

  • Ovary diseases: pregnant in a single month or cycle? 10%-20%

    1. Congenital dysformation:

    Turner’s syndrome(45,XO)

    2. Polycystic syndrom(PCO)

    3. Premature ovary failure(POF)

    4. Ovary functional tumors

    5. Insensitive to follicle stimulating hormones(FSH).

    6. Other endocrinologic diseases: adrenal or thyroid dysfunction


Human reproductive disorder

● Pelvic Factors pregnant in a single month or cycle? 10%-20%

Tubal factors: tubal blokage, adhension and hydrosalpinx

1. Inflammations

--Chlamydia

--Gonorrhea

--Tubercle bacillus and so on

2. Tubal dysformation

3. Pelvic adhension: endometriosis

4. Abdominal or pelvic surgery

5. Ectopic pregnancy


Human reproductive disorder

Fig.2 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

●Pelvic factors pregnant in a single month or cycle? 10%-20%

Pelvic Adhension

1.Inflammations:

--Chlamydia, turbercle bacillum, gonorrhea, staphylococci and so on

2. Pelvic endometriosis

3. Pelvic surgery

●Reproductive system dysformation

-- Mayer-Rokitansky- Kuster-Hauser syndrome: no uterus and vagina


Human reproductive disorder

-- Uterus didelphys pregnant in a single month or cycle? 10%-20%

-- Uterus bicornis

-- Uterus septus

-- Uterus unicornis

-- Rudimentary horn of uterus

-- others


Human reproductive disorder

Fig.3 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

Fig.4 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

Fig.5 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

Fig.6 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

Fig.7 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

Fig.8 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

Fig.9 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

Fig.10 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

Fig.11 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

Fig.12 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

Fig.13-1 pregnant in a single month or cycle? 10%-20%

Fig.13-2


Human reproductive disorder

  • Cervical factors pregnant in a single month or cycle? 10%-20%

    -- Cervicitis :

    cervical erosion,

    cervical polyps,

    cervical hyperplasia

    -- cervical stenosis

    -- Cervical tumors: leiomyoma

    -- Cervical cancer


Human reproductive disorder

●Extra-genital factors pregnant in a single month or cycle? 10%-20%

-- Vulvo-vaginalitis

-- Vulvo-tumors

● Others

--Immunological factors:

autoimmune response;

auto-antibodies: AsAb, ACA, ANA, etc.

-- Genetic factors

-- Psychological factors:

-- Unexplained causes


Human reproductive disorder

  • Evaluation and diagnosis pregnant in a single month or cycle? 10%-20%

    Initial evaluation

    The initial visit is the most important; the infertility is a problem of both of the couple; so, the male partner should be present at the beginning.


Human reproductive disorder

1. Taking history: pregnant in a single month or cycle? 10%-20%

-- marriage, menarche, menstruation

-- duration of sexual relationships with or without birth control

-- methods of birth control

-- reproductive history of both partners (ie: children with previous partners/marriages)


Human reproductive disorder

2. Physical examination (PE) pregnant in a single month or cycle? 10%-20%

--General development

-- Secondary sexual characteristics

3. Pelvic examination (PV)

-- Bimanual exam

-- Rectal-vaginal exam


Human reproductive disorder

4. Breast exam: masses and galactorrhea pregnant in a single month or cycle? 10%-20%

5. Laboratory:

-- hormonal testing:

-- urinary LH surge test

-- vaginal shedding cells test

-- cervical mucus test

-- post-coital sperm—cervical mucus test

6. Assisted imaging examination

-- Ultrasound B continuous monitoring

-- HSG

-- Hysteroscopy

-- Laparoscopy


Human reproductive disorder

  • Treatment for female fertility pregnant in a single month or cycle? 10%-20%

  • General therapy

    -- Watchful waiting (provide more time for unassisted conception)

    -- more frequent intercourse at mid-cycle

    -- emotional support


Human reproductive disorder

2. Special therapy pregnant in a single month or cycle? 10%-20%

-- treatment of pelvic inflammation disease(PID)

-- hydrotubation:

-- selective salpingogram and recanalization: to make the obstructed site of the tube reopen under X-ray guidance

-- hysteroscopy:removal of submucous leiomyoma, endometrial polyps, complete or incomplete uterus septum and separation of the cavity adhension.

-- laparoscopy: adhension separation, ovarian tumors and leiomyoma removal


Human reproductive disorder

  • Surgical approaches: pregnant in a single month or cycle? 10%-20%

    -- ovary cysts and tumors

    -- severe pelvic adhension

    -- Leiomyomas out of uterus wall

  • Physical treatment for cervical erosion:

    -- laser light

    -- crpyotherapy

    -- electrotherapy

  • Anti-tuberculosis:

    -- endometrial tuberculosis

    -- salpingotuberculosis.


Human reproductive disorder

Medication therapy pregnant in a single month or cycle? 10%-20%

  • Ovulation induction

  • Clomiphene citrate(CC)

    M5 50-150mg qn×5

    2. CC/HMG/HCG

    M5-9 CC 50-150mg

    M10-11 HMG 75IU qd

    3. LHRH pulsive therapy

    4. Bromocriptine---hyperprolactinemia

    5. Metformin---PCO


Human reproductive disorder

6. HMG/HCG pregnant in a single month or cycle? 10%-20%

M3 HMG 75IU qd

F 18-25mm, EN 8-10mm

HCG10000IU qd

● Progesterone supplement

1. Post-ovulation, progesterone 10-20mg

qd×7-10 days

2. HCG 2000IU-5000IUq3d82

3. Low dosage thyroid 20mg qd

● Assisted reproductive technology (not discussed here)


Human reproductive disorder

  • Methods to monitor ovulation pregnant in a single month or cycle? 10%-20%

    -- Luteinizing Hormone monitoring:

    LH surge-- ovulation occurs after 34-36 hr,

    BBT--simple, cheap, biphasic pattern,

    -- Mid-luteal serum progesterone: > 15.7nmol/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.


Human reproductive disorder

pregnant in a single month or cycle? 10%-20%Male infertility

  • Causes

    1. PRE-TESTICULAR CAUSES OF INFERTILITY

    a. Hypothalamic disease

  • Isolated gonadotropin deficiency (Kallmann's syndrome) 

  • Isolated LH deficiency ("Fertile eunuch") 

  • Isolated FSH deficiency Congenital hypogonadrotropic syndromes


Human reproductive disorder

b. Pituitary disease pregnant in a single month or cycle? 10%-20%

  • Pituitary insufficiency (tumors, infiltrative processes, operation, radiation) 

  • Hyperprolactinemia 

  • Hemochromatosis 

  • Exogenous hormones (estrogen-androgen excess, glucocorticoid excess, hyper and hypothyroidism).


Human reproductive disorder

2. pregnant in a single month or cycle? 10%-20%TESTICULAR CAUSES OF INFERTILITY

  • Chromosomal abnormalities: Klinefelter's syndrome (XXY, karayotype), XX disorder (sex reversal syndrome), XYY syndrome

  • Noonan's syndrome (male Turner's syndrome)

  • Myotonic dystrophy- Bilateral anorchia (vanishing testes syndrome)

  • Sertoli-cell-only syndrome (germinal cell aplasia)


Human reproductive disorder

  • Gonadotoxins (drugs, radiation) pregnant in a single month or cycle? 10%-20%

  • Orchitis

  • Trauma

  • Systemic disease (renal failure, hepatic disease, sickle cell disease)

  • Defective androgen synthesis or action

  • Cryptorchidism

  • Varicocele


Human reproductive disorder

3. pregnant in a single month or cycle? 10%-20%POST-TESTICULAR CAUSES OF INFERTILITY

a. Disorders of sperm transport

● Congenital disorders 

● Acquired disorders 

● Functional disorders

b. Disorders of sperm motility or function

● Congenital defects of the sperm tail 

● Maturation defects 

● Immunologic disorders 

● Infection

3. Sexual dysfunction


Human reproductive disorder

Fig.14 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

Fig.15 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

Fig.16 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

Fig.17 pregnant in a single month or cycle? 10%-20%


Human reproductive disorder

pregnant in a single month or cycle? 10%-20%Evaluation and diagnoses

1.History collection:

-- period of infertility without protected intercourse

-- present and previous marriage,

-- previous fertile history with partners,

-- frequency of intercourse,

-- method of birth control,

-- harmful habits: cigarette, alcohol, drug-injection


Human reproductive disorder

2. pregnant in a single month or cycle? 10%-20%Physical examination

-- development of body: height and ratio of

upper body sigment to low body sigment

-- Secondary sexual characteristics

Inadequate body hair

atypical genital hair distribution

gynecomastia


Human reproductive disorder

-- Exam of reproductive system pregnant in a single month or cycle? 10%-20%

Size, masses (length, volume and mass) of scrotum

Use orchidometer if possible

Epididymis for scarring ,absence or induration

Vas deferense for absence or nodules

Varicocele

3. Laboratory test

-- Semen analysis

-- Karyotype (chromosome)


Human reproductive disorder

Normal Values for Semen Analysis pregnant in a single month or cycle? 10%-20%

Volume > 2.0 mL

Sperm concentration > 20 million/mL

Motility >50 %

A >25%

A+B >50%

morphology >30 % normal

Data from WHO, 1992


Human reproductive disorder

Abnormal Values for Semen Analysis pregnant in a single month or cycle? 10%-20%

azoospermia—no sperm found under microscope for at twice SA at two weeks interval

oligospermia—sperm count less than 20 million per 1mL

asthenospermia—the percentage of normal morphology sperm less than 30%


Human reproductive disorder

-- Endocrine test: <3% pregnant in a single month or cycle? 10%-20%

FSH,LH,T,PRL,E2,T3,T4,ACTH,TSH,GH

hyperprolactinemia--MR

-- Blood biochemistry

Liver enzymes and blood lipid

-- Immunologic antibody: AsAb

-- Special and sperm function tests

Sperm-Cervical mucus interaction

Sperm penetration assays

Acrosome evaluation

Hypoosmotis swelling


Human reproductive disorder

-- Bacteriologic test pregnant in a single month or cycle? 10%-20%

Bacterial culture for urine or prostate gland fluid

and drug sensitive test

Chlamydia trachomatis

Mycoplasma hominus

Ureaplasma urealyticulum

● Treatment

1. Surgical measures

-- Varicocelectomy—varicocele

-- Transurethral resection of ejaculatory duct


Human reproductive disorder

-- Microsurgical epididymal sperm aspiration pregnant in a single month or cycle? 10%-20%

-- Ablation of pituitory Adenomas

-- Prophylactic surgical measures—undescended testes

2. Medical measures

--Endocine therapy

HMG,HCG,CC,Bromocriptine

-- Treatment of infection

antibiotics

-- Empiric therapy—herbal treatment

3. Assisted reproductive techniques treatment