婦產(chǎn)科學(xué)英語課件之鹿欣infertility and assisted reproductive technologies

1、Infertility and Infertility and Assisted Assisted Reproductive Technologies Reproductive Technologies 不孕癥與不孕癥與輔助生殖技術(shù)輔助生殖技術(shù)XIN LUXIN LUObstetrics & Gynecology Hospital Fudan University ContentsContentsnInfertilitynDefinition;nCauses;nExaminations and Diagnosis;nTreatment;nAssisted Reproductive Te

2、chnologies (ART) ;nIntrauterine insemination ( IUI);nIn vitro fertilization and embryo transfer (IVF-ET);nIntracytoplasmic sperm injection (ICSI); nGamete intrafallopian transfer (GIFT); Definition of Infertility Definition of Infertility 不孕癥定義不孕癥定義 Infertility is defined two years of unprotected in

3、tercourse without pregnancy. (WHO, one year)Primary Infertility : no previous pregnancies 原發(fā)不孕原發(fā)不孕 have occurred; Secondary Infertility: a prior pregnancy has 繼發(fā)不孕繼發(fā)不孕 occurred;Female Reproductive duct Female Reproductive duct anatomy anatomy 女性生殖道解剖女性生殖道解剖Female Female ovary 卵巢卵巢fallopian 輸卵管輸卵管 ut

4、erus 子宮子宮cervix 宮頸宮頸Vagina 陰道陰道女性生殖生理女性生殖生理n1. 下丘腦下丘腦-垂體垂體-卵巢軸內(nèi)分泌調(diào)節(jié)卵巢軸內(nèi)分泌調(diào)節(jié) Femal Male ( H-P-O) (H-P-T) GnRH GnRH FSH,LH FSH,LH E/P T 4. 3.輸卵管輸卵管 2. 卵巢周期性排卵卵巢周期性排卵 5. 宮頸宮頸 6. 下生殖道下生殖道下丘腦下丘腦卵巢卵巢垂體垂體卵巢卵巢Causes Causes 原因原因Causes PercentageFemale factors 40-55 %Male factors 25-40 %Both male and female f

5、actors 20 %Immunologic unexplained factors 10 % 1. Hypothalamic dysfunction; 2. Pituitary Insufficiency; 3. Ovarian factor (peripheral defect); 4. Others: thyroid or adrenal dysfunction;Ovulatory dysfunctionOvulatory dysfunction排卵障礙排卵障礙hypothalamuspituitaryovaryPelvic factors Pelvic factors 盆腔因素盆腔因素

6、 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 abnormalitiesMale Factors Male Factors 男方因素男方因素 1. Abnormal sper

7、matogenesis congenital; chronic diseases; infectious factors; 2. Obstructive: sperm transport abnormalities; 3. Immunologic factors; 4. Endocrine disorders; 5. Sexual dysfunction; Both Male and Female FactorsBoth Male and Female Factors 1. No demonstrable cause; 2. Psychological factors; 3. Immunolo

8、gic factors; count for 10%; autoimmune response; auto-antibodies; Examination and Diagnoses檢查和診斷檢查和診斷nInitial Visit 初診初診nThe initial visit is the most important;nThe infertility is a problem of couple;nThe male partner should be present;nHistory: both male and female;nThe guide to diagnostic and tre

9、atment plans; Examinations 檢查檢查nHistory collection；nFemalenPhysical examination;nBimanual examination（雙合診）雙合診）;nRectal-Vaginal-examination (三合診）；三合診）；nLaboratory;nAssistant imaging;nMalenPhysical examination;nLaboratory-Semen analysis; Examinations (for female) 女方檢查女方檢查nSpecial Laboratory Examinatio

10、ns: semen analysis（精液分析）精液分析）; hormone measurement; sperm penetration assay (SPA)精子穿透試驗(yàn)精子穿透試驗(yàn); postcoital examinition of cervical mucus （性交后宮頸粘液試驗(yàn)）（性交后宮頸粘液試驗(yàn)） anti-sperm immunologic examination;nAssistant imaging : Unltrasound 超聲超聲; Hysterosalpingogram 子宮輸卵管碘油造影子宮輸卵管碘油造影; Hysteroscopy 宮腔鏡宮腔鏡;nLaparo

11、scopy 腹腔鏡；腹腔鏡； Methods to monitor ovulation監(jiān)測(cè)排卵的方法監(jiān)測(cè)排卵的方法nLuteinizing Hormone monitoring: LH surge; after 34-36 hr occur ovulation;nBasal Body Temperature: simple, cheap, biphasic pattern;nMid-luteal serum progesterone: 3ng/mL, peak;nPremenstrual molimina: 95% presence;nMucus change: thick and cellu

12、lar, no crystalline fern;nUltrasound monitoring: follicle size 21-23 mm, fluid in the cul-de-sac. Normal Values for Semen AnalysisNormal Values for Semen Analysis 精液分析正常值精液分析正常值volume 2.0 mLsperm concentration 20 x 106 /mLmotility 50 %normal morphology 15 %WBC 1x106 /mLData from WHO, 1999 Please kee

13、p 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 evaluationHistoryPhysical examIrregular mensesNo ovulation HSG orHysteroscopyAbnormal of uterineNormalevaluation

14、HSGTubal blockageAbnormal Semen analysisanovulation Tubal factorunexplainedUterine factorMale factorFurther Investigate and Treatment Treatment principle for female factors Causes Treatment induction of ovulation； tuboplasty, microsurgery； medication or surgery； immune inhibition； anovulationTubal f

15、actorAnatomic factorimmunologicazoospermiagenetic diseaseafter surgeryFailure aboveAssisted Reproductive Technologies(ART) 輔助生育技術(shù)輔助生育技術(shù)unexplained Induction of ovulationInduction of ovulation 誘發(fā)排卵誘發(fā)排卵-1-1 1. Clomiphen 氯米芬：氯米芬：ER binding GnRH , FSH/LH dosage：50 mg, period day 5th， 5 days； 2. Gonadotr

16、opin therapy 促性腺激素治療：促性腺激素治療： 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 絨毛膜促性腺腺激素絨毛膜促性腺腺激素: 5000-10000 IU; Induction

17、of ovulationInduction of ovulation 誘發(fā)排卵誘發(fā)排卵-2-24. Gonadotropin releasing hormone agonist (GnRH-a a)：hypothalamic factor, as COH; protocol: according the every GnRH-a a component and feature, the time of start and discontinuation are different; zoladex; decapeptyl, dipherenline, enantone;5. Bromocrip

18、tine 溴隱停溴隱停: high PRL; Assisted Reproductive Assisted Reproductive Technologies (ART) Technologies (ART) 輔助生育技術(shù)輔助生育技術(shù)nIntrauterine insemination ( IUI); 宮腔內(nèi)人工授精宮腔內(nèi)人工授精;nIn vitro fertilization and embryo transfer (IVF-ET); 體外受精與胚胎移植體外受精與胚胎移植;nIntracytoplasmic sperm injection (ICSI); 單精子卵泡漿注射；單精子卵泡漿注射；

19、nGamete intrafallopian transfer (GIFT); 配子輸卵管移植配子輸卵管移植; Intrauterine insemination Intrauterine insemination ( IUI) ( IUI) 人工授精人工授精nIndications: 1. as treatment of male factor infertility; 2. psychological factors; 3. unexplained infertility; 4. genetic defects;nTypes: 1. artificial insemination with

20、 husbands sperm (AIH); 2. artificial insemination by donor (AID); nMethod: 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 In vitro fertilization and embryo transfer (IVF-ET) transfe

21、r (IVF-ET) 體外受精與胚胎移植體外受精與胚胎移植nIndications: 1. tubal factor; 2. endometriosis; 3. unexplained infertility; 4. IUI failure; 5. Immunologic factors;nMethod: 1. Superovulation: COH, GnRH-a/a/FSH(HMG)/HCG; 2. Aspiration of eggs; 3. Fertilization with capacitated sperm; 4. Culture of fertilized egg in the

22、 lab; 5. Replacement of fertilized egg into the uterus;Intracytoplasmic sperm injection 單精子卵泡漿注射單精子卵泡漿注射 (ICSI)nMicromanipulation technique;nIndications: 1. as treatment of male factor infertility: epididyma obstruction, azoospermia, retrograde ejaculation; 2. IVF failure;nSurgical sperm recovery fo

23、r ICSI: 1. Percutaneous epididymal sperm aspiration (PESA); 2. Percutaneous testicular sperm fine-needle aspiration (TESA); nComplications: karyotypic abnormalities; other genetic defects;Gamete intrafallopian Gamete intrafallopian transfer (GIFT) transfer (GIFT) 配子輸卵管移植配子輸卵管移植nIndications: 1. unexp

24、lained infertility; 2. endometriosis; 3. IUI failure; 4. Premature ovarian failure (POF); 5. Immunologic factors;nMethod: 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 fallo

25、pian tube;ART Complications輔助生育技術(shù)并發(fā)癥輔助生育技術(shù)并發(fā)癥nMultiple gestations 多胎妊娠多胎妊娠;nPre-eclampsia 產(chǎn)前子癇產(chǎn)前子癇;nOvarian hyperstimulation syndrome (OHSS) 卵巢過激綜合征卵巢過激綜合征; ;nPremature birth 早產(chǎn)早產(chǎn);nLow birth weight 出生低體重出生低體重;nLong term emotional, social and psychological impact 長期影響（情緒，社會(huì)，精神）長期影響（情緒，社會(huì)，精神）; Ovarian HyperStimulation Syndrome (OHSS)卵巢過度刺激綜合征卵巢過度刺激綜合征nCauses: 1. HCG injection-trigger; 2. VEGF 3.