不孕症与辅助生殖技术

InfertilityandAssistedReproductiveTechnologies不孕症与辅助生殖技术XINLUObstetrics&GynecologyHospitalFudanUniversity2006-5-11/19ContentsInfertilityDefinition;Causes;ExaminationsandDiagnosis;Treatment;AssistedReproductiveTechnologies(ART);Intrauterineinsemination(IUI);Invitrofertilizationandembryotransfer(IVF-ET);Intracytoplasmicsperminjection(ICSI);Gameteintrafallopiantransfer(GIFT);DEFINITIONofInfertility不孕症定义WhatisInfertility?Infertilityisdefinedtwoyearsofunprotectedintercoursewithoutpregnancy.(WHO,oneyear)PrimaryInfertility:nopreviouspregnancies原发不孕haveoccurred;SecondaryInfertility:apriorpregnancyhas继发不孕occurred;FemaleReproductiveductanatomy女性生殖道解剖Femaleovary卵巢fallopian输卵管uterus子宫cervix宫颈Vagina阴道FemaleReproductivePhysiology女性生殖生理1.下丘脑-垂体-卵巢轴内分泌调节FemalMale(H-P-O)(H-P-T)GnRHGnRHFSH,LHFSH,LHE/PT4.3.输卵管2.卵巢周期性排卵5.宫颈6.下生殖道hypothalamusovarypituitary子宫ovary4.子宫Causes原因CausesPercentageFemalefactors40-55%Malefactors25-40%Bothmaleandfemalefactors20%Immunologicunexplainedfactors10%FemaleFactors女方因素Ovulatorydysfunction（排卵障碍）Pelvicfactors（盆腔因素）1.Hypothalamicdysfunction;2.PituitaryInsufficiency;3.Ovarianfactor(peripheraldefect);4.Others:thyroidoradrenaldysfunction;Ovulatorydysfunction排卵障碍hypothalamuspituitaryovaryPelvicfactors盆腔因素1.Tubalfactors:injury,blockage,adhesion;2.Uterinefactors:cogenitalanatomicabnormalities;endometriumdisorder,tumor;3.Cervicalfactors:Infection,cogenitalabnormalities;4.Extra-genitaltractfactors;Infection,cogenitalabnormalities;FemaleFactorsSummaryFollopiantubeUterineovaryoocyteCervixExtra-genitaltractspermHypothalamusPituitaryThyroidAdrenalMaleFactors男方因素1.Abnormalspermatogenesiscongenital;chronicdiseases;infectiousfactors;2.Obstructive:spermtransportabnormalities;3.Immunologicfactors;4.Endocrinedisorders;5.Sexualdysfunction;BothMaleandFemaleFactors1.Nodemonstrablecause;2.Psychologicalfactors;3.Immunologicfactors;countfor10%;autoimmuneresponse;auto-antibodies;ExaminationandDiagnoses检查和诊断InitialVisit初诊Theinitialvisitisthemostimportant;Theinfertilityisaproblemofcouple;Themalepartnershouldbepresent;History:bothmaleandfemale;Theguidetodiagnosticandtreatmentplans;Examinations检查FemalePhysicalexamination;Bimanualexamination（双合诊）;Rectal-Vaginal-examination(三合诊）；Laboratory;Assistantimaging;MalePhysicalexamination;Laboratory-Semenanalysis;Examinations(forfemale)女方检查SpecialLaboratoryExaminations:semenanalysis（精液分析）;hormonemeasurement;spermpenetrationassay(SPA)精子穿透试验;postcoitalexaminitionofcervicalmucus（性交后宫颈粘液试验）anti-spermimmunologicexamination;Assistantimaging:Unltrasound超声;Hysterosalpingogram子宫输卵管碘油造影;Hysteroscopy宫腔镜;Laparoscopy腹腔镜；ExaminationandDiagnosesInitialevaluationHistoryPhysicalexamIrregularmensesNoovulationHSGorHysteroscopyAbnormalofuterineNormalevaluationHSGTubalblockageAbnormalSemenanalysisanovulationTubalfactorunexplainedUterinefactorMalefactorFurtherInvestigateandTreatmentNormalValuesforSemenAnalysis精液分析正常值volume≥2.0mLspermconcentration≥20x106/mLmotility≥50%normalmorphology≥15%WBC106/mLDatafromWHO,1999Pleasekeepinmind:1.CycleofSpermiogenesistakesabout74days;2.Semenparametersinmalesmayvary;3.Abnormalsemenanalysisshouldrepeatatleastonce;Methodstomonitorovulation监测排卵的方法LuteinizingHormonemonitoring:LHsurge;after34-36hroccurovulation;BasalBodyTemperature:simple,cheap,biphasicpattern;Mid-lutealserumprogesterone:3ng/mL,peak;Premenstrualmolimina:95%presence;Mucuschange:thickandcellular,nocrystallinefern;Ultrasoundmonitoring:folliclesize21-23mm,fluidinthecul-de-sac.TreatmentprincipleforfemalefactorsCausesTreatmentinductionofovulation；tuboplasty,microsurgery；medicationorsurgery；immuneinhibition；anovulationTubalfactorAnatomicfactorimmunologicazoospermiageneticdiseaseaftersurgeryFailureaboveAssistedReproductiveTechnologies(ART)辅助生育技术unexplainedInductionofovulation诱发排卵-11.Clomiphen氯米芬：ERbindingGnRH,FSH/LHdosage：50mg,periodday5th，5days；2.Gonadotropintherapy促性腺激素治疗：Indications:Hypogonadotropichypogonadism;Pituitarydysfunction;COHinIVF;(COH:controlledovarianhyperstimulation)HMG:humanmenopausalgonadotropins;FSH75IU/LH75IU,IMorSC;RecombinantFSH:75IU,SC;3.HCG绒毛膜促性腺腺激素:5000-10000IU;Inductionofovulation诱发排卵-24.Gonadotropinreleasinghormoneagonist(GnRH-a)：hypothalamicfactor,asCOH;protocol:accordingtheeveryGnRH-acomponentandfeature,thetimeofstartanddiscontinuationaredifferent;zoladex;decapeptyl,dipherenline,enantone;5.GnRHantagonist;6.Bromocriptine溴隐停:highPRL;AssistedReproductiveTechnologies(ART)辅助生育技术Intrauterineinsemination(IUI);宫腔内人工授精;Invitrofertilizationandembryotransfer(IVF-ET);体外受精与胚胎移植;Intracytoplasmicsperminjection(ICSI);单精子卵泡浆注射；Gameteintrafallopiantransfer(GIFT);配子输卵管移植;Intrauterineinsemination(IUI)人工授精Indications:1.astreatmentofmalefactorinfertility;2.psychologicalfactors;3.unexplainedinfertility;4.geneticdefects;Types:1.artificialinseminationwithhusband’ssperm(AIH);2.artificialinseminationbydonor(AID);Method:placementofabout0.3mlofwashed,processedandconcentratedspermintotheintrauterinecavitybytrans-cervicalcatheterizaion.Invitrofertilizationandembryotransfer(IVF-ET)体外