Obstetrics and Gynecology: Common disease sites: Common causes of female reproductive system: ovulation disorder, abnormal semen, abnormal fallopian tubes, unexplained infertility, endometriosis, immune infertility and other common symptoms: no contraception, no pregnancy, contagiousness: no etiology, clinical manifestations, examination, diagnosis, treatment and etiology. The causes of infertility are divided into male infertility and female infertility. This classification is widely used by the World Health Organization in the diagnosis and treatment of 1992 infertility. The main causes are ovulation disorder, abnormal semen, abnormal fallopian tubes, unexplained infertility, endometriosis and other infertility such as immunology. Another factor is the cervical factor, including cervical stenosis, which accounts for more than 5% of all cervical factors. Female infertility is mainly caused by ovulation disorder, tubal factor and abnormal endometrial receptivity, while male infertility is mainly caused by abnormal spermatogenesis and nocturnal emission. 1. Female infertility (1) Tubal infertility plays an important role in taking eggs and transporting eggs, sperm and embryos; The fallopian tube is also the place where sperm can be capacitated, sperm and eggs meet and fertilize. Infection and operation are easy to damage tubal mucosa, and then cilia disappear, peristalsis is damaged, and obstruction or adhesion with surrounding tissues occurs, which affects tubal patency. Therefore, tubal obstruction or obstruction is an important cause of female infertility. ① Pelvic inflammatory disease is the main factor leading to tubal infertility. Infection not only causes tubal obstruction, but also causes tubal wall stiffness and adhesion around fallopian tube due to scar formation, which changes its relationship with ovary and affects the collection and transportation function of fallopian tube eggs. The pathogens of infection can be caused by aerobic and anaerobic bacteria, and can also be caused by chlamydia, mycobacterium tuberculosis, Neisseria gonorrhoeae and mycoplasma. ② Endometriosis: Pelvic endometriosis and ovarian endometriosis can form a peritoneal adhesion zone, causing adhesion outside the umbrella end of the fallopian tube or around the ovary, so that mature eggs cannot be ingested into the fallopian tube; Extensive adhesion can also affect the operation of fertilized eggs. ③ tubal tuberculosis tubal tuberculosis is the most common case of genital tuberculosis, which is characterized by thickening and hypertrophy of fallopian tubes, eversion of umbrella ends like buckets, and even closure of umbrella ends; The fallopian tube is stiff and nodular, and there are some caseous masses or miliary nodules in the peritoneum. About half of tubal tuberculosis's patients suffer from endometrial tuberculosis. ④ Hydrosalpingosis is common after tubal sterilization, which is an important factor affecting the function after tubal recanalization. The pathological changes of proximal tubal tissues and cells after sterilization are related to the length of sterilization, so the longer the sterilization time, the lower the success rate of recanalization. (2) Infertility caused by ovulation disorder and chronic ovulation disorder are the same manifestations of many endocrine diseases, accounting for about 20% ~ 25% of women. The main clinical manifestations are irregular menstruation or even amenorrhea, and the cycle shorter than 26 days or longer than 32 days indicates abnormal ovulation. Medical history can also reflect the signals of endocrine disorders, such as hirsutism, masculinity, galactorrhea and low estrogen. 1993 the world health organization (who) has formulated the classification standard of anovulation, which is divided into three categories. Who type ⅰ (low gonadotropin anovulation), who type ⅱ (normal gonadotropin anovulation) and who type ⅲ (high gonadotropin anovulation). Who type ⅰ: including hypothalamic amenorrhea (stress, weight loss, exercise, anorexia nervosa, etc.), Kalman syndrome (abnormal migration of gonadotropin-releasing hormone precursor cells) and gonadotropin deficiency. The typical manifestation is hypogonadism: FSH is low, E2 is low, and prolactin and thyroxine are normal. Who ⅱ ⅱ: the most frequently encountered patients in clinic. That is, ovarian dysfunction with normal gonadotropin, accompanied by different degrees of anovulation or scanty menstruation. Including PCOS, follicular cell proliferation and Hercynian syndrome (hirsutism, anovulation, insulin resistance and acanthosis nigricans). The typical manifestations are: FSH, E2 and prolactin are normal, but LH/FSH is often abnormally increased. WHO Type III Type III: The patient is mainly the defect or resistance of the end organ, which is characterized by hypogonadism with high gonadotropin, including premature ovarian failure and gonadal hypoplasia (ovarian resistance). The typical manifestations are the increase of FSH and LH, and the decrease of E2. These patients are characterized by poor response to ovulation induction and decreased ovarian function. (3) Immune infertility At present, there are two kinds of autoantibodies related to infertility: non-organ specific autoantibodies and organ specific autoantibodies. The former refers to antibodies against * * * antigens existing in different tissues, such as antiphospholipid antibodies (APA), antinuclear antibodies (ANA), anti-DNA antibodies, etc. The latter refers to antibodies that only target the autoantigen of a specific organ, such as anti-sperm antibody (ASAb), anti-ovarian antibody (AOVAb), anti-endometrial antibody (AEMAb) and anti-chorionic gonadotropin antibody (AhCGAb). At present, the properties of antigens targeted by non-organ specific autoantibodies have been well understood, and the techniques for detecting APA and ANA are mature and standard, with abundant clinical data. However, the antigen components targeted by organ-specific autoantibodies are complex and the standardization of detection is low. Their relationship with infertility is also difficult to be clarified because the test data is difficult to analyze and count, thus affecting the treatment of infertility patients with autoantibodies. (4) Unexplained infertility is diagnosed as unexplained infertility when all the indicators examined by infertile couples are normal and the cause of infertility cannot be explained. It is speculated that the causes of unexplained infertility may be: ① the adverse effect of cervical secretion; ② The endometrial receptivity to early embryos is poor; ③ Tubal peristalsis disorder; (4) The function of collecting eggs at the umbrella-shaped end of fallopian tube is defective; ⑤ luteinized unruptured syndrome; ⑥ Mild hormone secretion is poor, such as luteal insufficiency; ⑦ Impaired fertilization ability of sperm and eggs; 8 mild endometriosis; Pet-name ruby immune factors, such as anti-sperm antibody, anti-zona pellucida antibody or anti-ovarian antibody; Attending the abnormal function of peritoneal macrophages; The antioxidant function in peritoneal fluid is impaired. 2. Male infertility (1) reproductive organs and other abnormalities ① Congenital abnormalities: testicular congenital developmental abnormalities include azoospermia, Creutzfeldt-Jakob syndrome, XYY syndrome and male pseudohermaphroditism. The karyotype of Creutzfeldt-Jakob syndrome is mostly 47, XXY；; The patient's breasts are feminine; Testicles are small and hard, seminiferous tubules are glassy and fibrotic, and spermatogenesis is completely stopped or seriously reduced. Abnormal testicular descent is also an important cause of male infertility. When the testicular descent is abnormal, the number of germ cells in seminiferous tubules decreases, and the volume and weight of testis decrease. The higher the position of testis in abdominal wall or abdominal cavity, the greater the damage of seminiferous tubule. Patients with abnormal bilateral testicular descent are unlikely to have children without treatment. ② Obstruction of vas deferens: Congenital absence of vas deferens and seminal vesicles, characterized by low semen volume, often less than 65,438+0 ml, and no fructose in seminal plasma; Inflammatory obstruction, such as bilateral epididymal tuberculosis; Ejaculatory duct obstruction is rare. Surgical injury or vasectomy, etc. And prostatitis and seminal vesiculitis. ③ Varicocele: It can lead to testicular congestion, decrease the effective blood flow, destroy the normal spermatogenic microenvironment, and finally make spermatogonia degenerate and shrink, reduce spermatogenesis, weaken vitality, abnormally increase sperm, and in severe cases, azoospermia may occur. ④ Androgen target organ lesions can be divided into two types: complete feminization of testis; Incompleteness such as Reifenstein syndrome. (2) Endocrine abnormality ① The main reason is the dysfunction of gonadotropin synthesis or secretion. Kallmann syndrome, also known as selective hypogonadism, is an autosomal recessive genetic disease and a dysfunction of hypothalamic GnRH pulse release. The clinical feature is sexual maturity disorder, accompanied by loss of sense of smell, small testis, abnormal testicular descent, small penis and hypospadias. Serum testosterone level is low, and LH and FSH levels are at the lower limit of normal values of the same age group. ② Selective LH deficiency: The patient's serum FSH level is normal, LH and testosterone levels are low, the breast is not masculine, but the testis size is normal, and there are a few sperm in the semen, so it is also called "reproductive azoospermia". ③ Pituitary tumor has the most obvious effect on LH secretion. Pituitary tumor is the most common cause of hyperprolactinemia. Excessive PRL will lead to decreased sexual desire, erectile dysfunction, galactorrhea and spermatogenesis dysfunction. ④ In adrenal hyperplasia, infertility is often related to the deficiency of 2 1- hydroxylase, and the decrease of corticosteroid synthesis leads to the increase of ACTH. The adrenal cortex is over-stimulated by ACTH to synthesize a large amount of testosterone, which inhibits the secretion of pituitary gonadotropin, thus leading to infertility. (3) Sexual dysfunction includes hyposexuality, erectile dysfunction, premature ejaculation, non-ejaculation and retrograde ejaculation. Semen cannot be injected into vagina normally. (4) Immune factors can be divided into two categories: anti-sperm autoimmunity produced by men and anti-sperm alloimmunity produced by women. Sperm and immune system are separated by blood-testis barrier, so sperm antigen is an exogenous antigen, which has strong antigenicity for both men and women. The blood-testis barrier, immunosuppressive factors in seminal plasma and other factors have established a complete immune tolerance mechanism. When orchitis, epididymitis, prostatitis, seminal vesiculitis or vasectomy occur, the above immune tolerance mechanism is destroyed, that is, anti-sperm immune response may occur. (5) Mumps virus can cause orchitis, and in severe cases, it can cause permanent destruction and atrophy of seminiferous tubules, leading to testicular failure; Treponema pallidum can also cause orchitis and epididymitis; Gonorrhea, tuberculosis and filariasis can cause obstruction of vas deferens; Chronic bacterial infection of semen, or mycoplasma and chlamydia infection can increase the white blood cell count in semen, decrease the quality of semen and increase immature sperm. (6) Physical and chemical factors and environmental pollution The spermatogenic epithelium is a fast splinter cell, so it is easily damaged by chemical factors. ① Heat, radiation and toxic substances can make spermatogenic epithelium fall off, or affect the functions of interstitial cells and sertoli cells, and hinder the spermatogenic process. Spermatogenic epithelium is sensitive to radiation. Chemotherapeutic drugs such as cyclophosphamide and nitrogen mustard directly damage the function of spermatogenic epithelium and interstitial cells. ② Some environmental toxins have similar functions or structures with natural hormones, such as polychlorinated biphenyls (PCB), tetrachlorobiphenyls (TCDD), dichlorodiphenyl dichloride (DDT) and diethylstilbestrol (DES). These toxins affect human health by polluting air, water and food chain, including the continuous decline in the number and quality of male sperm. (7) History of drug operation Opioid drugs, anticancer drugs, chemotherapy drugs and antihypertensive drugs can directly or indirectly affect sperm production. Previous pelvic surgery, bladder and prostate surgery may lead to ejaculation dysfunction; Hernia repair or testicular fixation may affect the blood supply of spermatic cord or testis. (8) About 365,438+0.6% of unexplained infertility patients, the exact cause can not be found by the commonly used examination methods at present. Clinical manifestations The clinical manifestations of infertility are the sexual life regularity of husband and wife 1 year, no contraception and no pregnancy. Infertility caused by different causes may be accompanied by clinical symptoms of corresponding causes. Examination of female infertility 1. Examination of tubal infertility (1) Tubal hydrotubation is blind, and it is difficult to make a correct judgment on the shape and function of fallopian tubes, but the method is simple and can be used as a screening test. The examination time should be arranged in 3 ~ 7 days after clean menstruation, no gynecological inflammation and no sexual life. (2) Tubal hydrotubation (SSG) under the supervision of B-ultrasound can observe the ultrasonic changes after injecting liquid (or special ultrasonic diagnostic contrast agent) through the fallopian tube under the supervision of ultrasound. There is no blindness of traditional tubal intubation, and the coincidence rate with laparoscopy is 8 1.8%. And has no damage to uterus and fallopian tube mucosa, and little side effect. The operation method is similar to tubal hydrotubation, and the whole process is monitored by B-ultrasound before and after liquid injection. Results evaluation: patency: no echo area formed in the uterine cavity and moved to the direction of bilateral fallopian tubes, and liquid dark area could be seen in the posterior fornix. Obstruction: there is resistance when injecting liquid. After repeated injection with a little pressure, it can be seen that the liquid flows through the fallopian tube and the dark area of the liquid can be seen in the posterior vault. Obstruction: the injection resistance is large, and the dark area of uterine cavity is enlarged. The patient complained of abdominal pain, and no fluid dark area was found in the posterior fornix. (3) Hysterosalpingography (HSG) also has a comprehensive understanding of the uterine cavity, and can judge the lesions with a size of 5mm in the uterine cavity, which is simple to operate. The contrast agent can be 40% iodized oil or 76% meglumine diatrizoate; There is the possibility of iodine allergy, and a skin test is needed before the operation. The patient lay on his back on the X-ray examination table and injected meglumine diatrizoate contrast agent into the uterus. Take the first film to understand the uterine cavity and fallopian tube, then continue to inject contrast agent, and take the second film at the same time to observe whether the contrast agent enters the pelvic cavity and spreads in the pelvic cavity; If iodized oil is used, a second film will be taken after 24 hours. According to the analysis of tubal patency, the accuracy rate is 80%. (4) Hysteroscopic tubal intubation often causes the illusion of interstitial obstruction due to spasm, residual tissue fragments, mild adhesion and scar. Intubation or angiography from fallopian tube to uterine cavity opening under hysteroscopy can directly dredge and flush interstitial part, which is a reliable method for diagnosis and treatment of interstitial obstruction of fallopian tube. (5) Laparoscopy can directly look at pelvic organs, and can comprehensively, accurately and timely judge the nature and degree of pathological changes of various organs. Dynamic observation of fallopian tube patency and dredging fallopian tube cavity is one of the best methods for female infertility examination. 2. The examination of anovulatory infertility can determine anovulation and its etiology. Basic temperature measurement table (BBT) can help to judge. The basal body temperature rises by 0.5 ~ 65438 0.0 degrees, indicating whether there is ovulation and the length of luteal phase. Although this kind of examination is simple and low-cost, patients spend a lot of energy, and about 20% of cases with single body temperature ovulate by other methods. The second method to determine whether there is ovulation is urine LH measurement, which is detected during menstrual period 10 ~ 16 (most patients ovulate during this window). The accuracy of detecting LH peak is higher than BBT measurement, but the high cost of LH measurement means ovulation is possible, but some patients have LH peak but do not ovulate, which may be related to luteinization syndrome of unruptured follicles. Other methods to detect ovulation include: determination of progesterone level in the middle luteal phase (P > 3ng/ml), appearance of mature follicles in the middle menstrual period (1.6 ~ 2.2 cm), pelvic free fluid during ovulation, endometrial biopsy (on the 23rd day of menstrual period 1 day or cycle), and endometrial changes in the secretory phase. 3. Examination of Immune Infertility (1) Sperm immune detection is divided into three parts: AsAb detection, seminal plasma immunosuppressant detection and sperm cell immune detection. AsAb detection is still a common clinical method. There are many methods to detect AsAb, and the current methods only focus on detecting immunoglobulins (IgG, IgA and a few IgM). One is to detect AsAb attached to sperm (direct method); The second is to detect AsAb in serum, semen and female genital secretions (indirect method). The direct method is more reliable, and the results obtained by indirect method are often inefficient and variable. (2) Sperm cervical mucus test Post-coital test (PCT): It is performed in the predicted ovulation period, and sexual intercourse is prohibited 3 days before the test to avoid vaginal medication or irrigation. If the cervix is inflamed, the mucus is sticky and there are white blood cells, this test is not suitable, and it needs treatment before doing it. Within 2 ~ 8 hours after sexual intercourse, the cervical mucus of the subjects was sucked out and coated on a glass slide for examination. It is normal if there are 20 active sperm in each high-powered field of vision; If the ability of sperm to pass through mucus is poor, or the sperm does not move, it is abnormal. When PCT is normal, it means that the couple's sexual life is normal, ovarian estrogen secretion and cervical mucus reactivity are normal, and sperm can penetrate cervical mucus. Couples have fertility, which can rule out infertility caused by female cervical factors and male sperm survival rate and penetration. 4. Examination of unexplained infertility Before the diagnosis of unexplained infertility, the basic infertility assessment should confirm ovulation, tubal patency, normal uterine cavity and normal semen analysis. Only when these are normal can infertility be classified as unexplained infertility. Male sterility test 1. Physical examination (1) generally examines blood pressure, height, weight, nutritional status, secondary sexual characteristics, including body shape, bone, fat distribution, body hair distribution, whether there is male breast development (suggesting Creutzfeldt-Jakob syndrome), whether there is olfactory abnormality (suggesting Kalman syndrome), etc. (2) The size, texture and tenderness of testicles are examined by reproductive organs; Whether there is tenderness and induration in epididymis and whether there is vas deferens; The existence and degree of varicocele; Penis size and development, etc. The size and texture of prostate should be paid attention to in rectal digital examination. Under normal circumstances, the seminal vesicle is invisible, but it may be felt when the seminal vesicle is diseased. (3) Laboratory examination ① Semen examination: including the evaluation of sperm and seminal plasma. Semen routine is the most commonly used and important test to evaluate male fertility of infertile couples. Normal semen is a mixture of testicular and epididymal secretions and sperm, which is mixed with the secretions of prostate, seminal vesicle and urethral gland during ejaculation, and finally forms a viscous ejection. Analysis indicators include: semen volume, sperm density, motility, vitality, morphology, presence or absence of white blood cells, etc. ② Biochemical examination of semen: α -glucosidase and carnitine in seminal plasma are characteristic products of epididymis; Fructose is the characteristic product of seminal vesicle; Acid phosphatase, citric acid and zinc are characteristic products of prostate. The detection of these items is helpful to judge the functional state of male accessory gonads. ③ Pathogen examination: It is instructive to detect pathogens or mycoplasma and chlamydia in prostatic fluid or semen. ④ Cytological examination of semen: According to the proportion and morphology of germ cells at all levels, valuable information about spermatogenic function of testis can be obtained. If more spermatogonia and spermatocytes are found, but no sperm is found, it means that the spermatogenesis process is blocked. (4) Endocrine examination includes T, FSH, LH, PRL, etc. By measuring and evaluating the functions of hypothalamus, pituitary and testis, it provides basis for analyzing the causes of testicular failure. ① High FSH and low T suggest testicular hypogonadism, which is seen in azoospermia caused by Creutzfeldt-Jakob syndrome, severe varicocele, radiation sickness and drug injury. ②FSH is lower than normal, indicating that there is a central lesion, whether it is thalamic lesion or pituitary lesion. Pituitary examination, GnRH provocation test or testicular biopsy are needed to differentiate. ③PRL is obviously increased, and the normal values of FSH and LH are low or low, accompanied by sexual dysfunction, oligospermia and impotence. It is hyperprolactinemia, which may be pituitary adenoma or microadenoma. ④ Testicular volume is negatively correlated with FSH, while T and LH reflect the function of leydig cells in testis, but not directly proportional to testicular volume. Therefore, the determination of sex hormones also provides a basis for testicular biopsy. Although FSH and LH are secreted in pulses, the serum FSH level fluctuates slightly, so the serum FSH level can reflect the spermatogenic function of testis to some extent, but FSH measurement can not completely replace testicular biopsy. FSH level is high, testicles are small and hard (