Authors: Deputy Chief Physician Zhu Xiaodan, Department of Obstetrics and Gynecology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine.
At present, the global fertility problems are increasing day by day, and the overall fertility of women is on the decline. Women are facing various pressures in modern society, including occupational pressure, family pressure, social expectations, and the unhealthy lifestyle that follows, which makes the fertility of contemporary women decline more and more "younger". At present, the incidence of infertility is as high as 10%~18%. In 2023, the birth rate in China was as low as 6.4‰.
National birth rate
In the reproductive endocrinology clinic, patients often ask: How is my fertility? Can you still be born? Faced with such a question, today, let’s talk about this topic.
As we all know, to complete a successful pregnancy, women need the cooperation of the whole reproductive system and all organs of the whole body. Therefore, the evaluation of female fertility is divided into three parts: the first part is the evaluation of ovarian reserve function, the second part is the evaluation of the structure and function of uterus and fallopian tube, and the third part is the evaluation of general state.
First, the ovarian reserve function
The ovarian reserve function of women refers to the quantity and quality of eggs, that is, the "inventory" of follicles with growth and development functions. The number of follicles in women has been determined at birth and is non-renewable. With the increase of age and the progress of menstrual cycle, the number of eggs gradually decreases. So how do we evaluate how much "inventory" there is in the ovaries?
1. Age
Age is the primary factor to evaluate fertility, and the best reproductive age for women is 23~32 years old. With the increase of age, fertility gradually decreases, pregnancy rate and live birth rate decrease, and abortion rate increases. With the increase of age, ovarian function declines irreversibly, and the number of follicles and the quality of eggs decrease. Age-related abnormal vascularization, oxidative stress and free radical imbalance in the ovary will lead to the decline of oocyte quality, which will lead to fertilization failure or abnormal embryo development.
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2. Basic follicle stimulating hormone (bFSH)
BFSH is the level of serum FSH on the second to fourth day of menstruation, and it is one of the indexes to evaluate ovarian reserve function. The main reasons for the increase of bFSH level are the aging, the decline of ovarian function, the decrease of E2 secretion, the weakening of negative feedback on hypothalamus-pituitary-ovarian axis, and the subsequent increase of FSH. When the serum level of bFSH is higher than 10u/L, the ovarian reserve function is decreased, and when the serum level of bFSH is higher than 18u/L, the live birth rate is almost zero.
3. Basic estradiol (bE2)
BE2 refers to the level of serum E2 on the 2nd to 4th day of menstrual cycle, which can be used as an index to evaluate ovarian reserve function. When the bE2 value is more than 74.9 pg/ml (274.134 pmol/L), the ovarian function is decreased or the pregnancy outcome is poor when in vitro fertilization (IVF) is performed, and the number of embryos obtained is small.
4. FSH/LH (follicle stimulating hormone/luteinizing hormone) ratio
FSH/LH ratio can be used as an index to reflect ovarian function, and can also be used as a sign of ovarian response to gonadotropin to predict pregnancy outcome. When FSH/LH > 2, it is suggested that the ovary may have a bad reaction to gonadotropin in assisted reproductive technology. When FSH/LH > 3.6, the ovarian function is obviously decreased, and the cancellation rate of IVF ovulation cycle is high.
5. Anti-Miller hormone (AMH)
AMH is mainly produced by primary follicles, preantral follicles, sinus follicles, etc. It regulates the growth and development of follicles and is not regulated by hypothalamus-pituitary-ovary axis. As a reliable index of ovarian reserve function, it can be detected on any day of menstrual cycle. Serum AMH concentration was negatively correlated with age. AMH value reaches its peak in adulthood (about 25 years old), generally drops significantly after 36 years old, and approaches zero when approaching menopause.
6. Inhibin B(INH-B)
INH-B appears from the pre-antral follicular phase and is regulated by FSH. INH-B level, as a direct index to predict ovarian reserve function, reflects ovarian reserve. On the third day of menstruation, the blood INH-B < 45 ng/L indicates that ovarian function is decreased.
7. Sinus follicle count (AFC) and ovarian volume
AFC, ovarian volume and ovarian interstitial blood flow parameters can be used as evaluation indexes of ovarian reserve function and responsiveness. AFC is significantly correlated with age and basic hormones. With age, the number of follicles decreases exponentially. Ovarian volume can reflect the number of follicles and the situation of ovarian reserve pool from another angle. With the increase of age, ovarian function declines and ovarian volume shrinks. The most commonly used parameters of ovarian stromal blood flow are the peak velocity of ovarian stromal blood flow (PSV) and resistance index (RI). High PSV and/or low RI indicate that the ovarian interstitial blood supply is abundant and the ovary responds well to gonadotropin.
Second, the evaluation of the structure and function of reproductive tract
Because of the special anatomical structure and physiological function of female reproductive tract, the evaluation of reproductive tract structure and function is also an important link in fertility evaluation, including vagina, cervix, uterus, fallopian tube and pelvic cavity.
1. Detection of vaginal microecology
Female reproductive tract flora is closely related to every step of ovulation, sperm transport, fertilized egg implantation, pregnancy and delivery. Reproductive tract infection of women of childbearing age affects their reproductive health, damages their reproductive function and increases the risk of infertility.
2. Detection of cervical lesions
Cervical diseases tend to be younger, which are closely related to fertility and pregnancy outcome. Regular gynecological physical examination, cervical liquid-based thin-layer cytology (TCT) and human papillomavirus (HPV) screening should be conducted to detect cervical diseases as soon as possible.
3. Detection of uterine abnormalities
Non-invasive ultrasound, such as hysteromyoma and endometrial polyp, is the most widely used examination method to evaluate the receptivity of uterus and endometrium, and to evaluate the shape, thickness, volume, peristalsis wave, uterine artery and hemodynamic parameters of endometrium. Hysteroscopy is the gold standard for the diagnosis of endometrial lesions, which can accurately identify cervical lesions, intrauterine lesions, abnormal endometrial morphology and abnormal tubal opening through endoscopy. Endometrial biopsy can also be performed. At present, there are cytokines, various receptors, endometrial receptivity chips and other detection methods to evaluate endometrial receptivity, and the research on endometrial receptivity is constantly expanding.
4. Tubal patency test
Including salpingostomy, hysterosalpingography/contrast-enhanced ultrasound and laparoscopic salpingostomy. At present, hysterosalpingography has become a research hotspot with its unique advantages (real-time dynamic, visualization and no radiation), and has gradually become the first choice for tubal patency examination. Liquid drainage has some shortcomings, such as invisibility, blindness and great difference. X-ray radiography, as a traditional method of tubal patency examination, mainly has the disadvantages of adverse reaction of contrast agent and radiation damage. Laparoscopic salpingostomy is the "gold standard", but it is not the first choice for the time being because of invasion, hospitalization, high cost, surgery and anesthesia.
The picture comes from the Internet.
5. Detection of pelvic factors
Pelvic diseases are closely related to female fertility, such as pelvic endometriosis, pelvic tuberculosis, pelvic adhesion, tubal diseases, hysteromyoma, ovarian tumors and pelvic inflammatory diseases. Laparoscopic surgery can find and diagnose abnormal pelvic conditions in time. For infertility caused by fallopian tube factors or uterine cavity factors, hysteroscopy combined with laparoscopy can treat pelvic cavity, fallopian tube and uterine cavity diseases accordingly, which has important clinical value for female fertility evaluation, diagnosis and treatment.
6. Female reproductive tract dysplasia
Abnormal development of female reproductive tract includes abnormal development of vagina, cervix, uterine body and fallopian tube, with or without abnormalities of ovary and urinary system. The combination of pelvic ultrasound and MRI examination is the best examination method for reproductive tract dysplasia.
Third, the general state assessment
In terms of systemic diseases, we should evaluate whether there are diseases that affect fertility or are not suitable for fertility, such as thyroid diseases, familial genetic diseases, blood system diseases, cardiopulmonary diseases and tumors.
1. Thyroid diseases
Abnormal thyroid function can lead to infertility and poor pregnancy outcome, so it is suggested that women with family planning should monitor thyroid function. Clinical hyperthyroidism can lead to abortion, premature delivery and thyroid crisis, and timely treatment can significantly reduce these risks; Infertile women with subclinical hypothyroidism should be treated with levothyroxine (LT4).
2. Hereditary diseases
According to the etiology, it can be divided into monogenic diseases, polygenic diseases, chromosomal diseases, mitochondrial genetic diseases and somatic genetic diseases, which have the characteristics of congenital, lifelong and familial. It is suggested that couples with rare diseases or couples who have given birth to rare diseases should have genetic testing and genetic counseling, reproductive risk assessment and guide reproductive decisions. The genetic diagnosis (PGD) before embryo implantation was provided after the pathogenic gene locus and genetic mode of the family were clarified.
3. Other general conditions
Nutritional status is a very important factor in regulating reproductive process, which is closely related to female reproductive function. For example, obesity and malnutrition have adverse effects on internal environment, egg quality and embryo development. In addition, mental state, living environment and systemic factors also need comprehensive consideration. Whether a woman’s whole system can withstand pregnancy is also the concern of fertility evaluation, including whether she is complicated with diabetes, hypertension, heart disease and tumor.
4. Who needs fertility assessment?
1. Couples who have been pregnant for more than 1 year without pregnancy;
2. People who have had many bad pregnancies in the past;
3. People who have had multiple abortions or ectopic pregnancy in the past;
4. Women of childbearing age with less menstrual flow, irregular menstrual cycle and dysmenorrhea;
5. Obese or thin people (BMI>24 or BMI<18.5);
6. White-collar workers who stay up late and work overtime for a long time;
7. People who use computers and mobile phones for a long time to work in a radiation environment;
8. People with smoking, drinking, drug addiction and other habits.
In a word, fertility assessment can help women understand their fertility potential and possible fertility problems. In fact, whether you have the desire to have children at present or not, regular fertility assessment can help you plan your birth plan reasonably, receive corresponding medical help in time, and don’t leave regrets for your life!
