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Tan Xiaojun
·Senior reproductive medicine expert
·Postdoctoral fellow at Peking University
·PhD candidate at Xiangya School of Medicine, Central South
University
·Master’s tutor at Central South University
· Master's degree candidate in reproductive
medicine at the University of South China
· Professional training at Huazhong University
of Science and Technology and Tongji
Hospital Reproductive Center
Expertise:
diagnosis and treatment of infertility, first/second/third generation IVF (including
egg/sperm donation), microsperm retrieval, embryo freezing and resuscitation, artificial
insemination (including husband's sperm and sperm donation), paternity testing, chromosomal
disease
diagnosis, high-throughput gene sequencing, endometrial receptivity gene testing and other
clinical
technology applications. Many of these technologies are at the leading level both domestically
and
internationally.
Both husband and wife are healthy, but they have no children for a long time. Where is it stuck? Beijing infertility examination, IVF, salpingography process, reasons for delayed pregnancy, normal infertility of husband and wife in physical examination, ovulation monitoring, reproductive outpatient consultation process
Husband and wife are healthy but have no children? Six common card points and a set of ideas for medical examination
Many couples have normal physical examinations, but they still have no children. Around "both husband and wife are healthy, but they have no children for a long time. Where is it stuck?" This problem is structured from ovulation, sperm, fallopian tube, timing of sexual intercourse and medical treatment process.
Why "look healthy", but still may not be pregnant?
Many couples will have a typical confusion: usually the physical examination is normal, life is regular, and both sides have no obvious diseases. Why are they still not pregnant?
From the medical definition, regular and unprotected sexual life is not pregnant for 12 months, and it usually enters the scope of infertility assessment; If the woman's age is **≥35 years old * *, it is generally recommended to start the evaluation after trying for 6 months without being pregnant; If the woman is older, or has abnormal menstruation, pelvic inflammatory disease history, previous surgery history, male semen problems, etc., it is often necessary to check earlier. This standard is not to "exaggerate the problem", but to avoid missing the window of fertility decline.
Looking further, the World Health Organization points out that about one in every six adults in the world has experienced infertility in his life. This means that "not being pregnant" is not a rare situation of individual people, nor does it mean that anyone is "obviously sick", nor does it mean that one party must have a problem alone.
First-principles look at this problem, there are only three things in essence:
Are there any mature eggs discharged?
Are there enough normal sperm to reach the egg?
Can fertilized eggs form smoothly and enter the uterine environment suitable for implantation?
As long as any one of these three links is deviated, there may be a situation that "husband and wife are healthy, but they just can't conceive".
Crowd: Which couples are most likely to appear "seemingly healthy, but actually stuck"?
It is not only people who are "clearly sick" who need to be vigilant. Clinically, the following types of couples are particularly prone to "no big problems in physical examination, but no results in pregnancy preparation":
1. People who have normal routine physical examination, but have not done special fertility assessment.
General physical examination is more inclined to general health screening, such as liver and kidney function, blood pressure, blood sugar and routine items of B-ultrasound.
However, fertility evaluation focuses on another system: whether ovulation is regular, whether semen quality reaches the standard, whether fallopian tubes are unobstructed, and whether uterine cavity environment is suitable for implantation. This is not the same as "normal physical examination". Both ASRM and ACOG list ovulation assessment, semen analysis and fallopian tube/uterus assessment as important components of infertility examination.
2. People whose menstruation "looks ok" but whose ovulation may not be stable.
Some women's menstruation is not completely disordered, even coming every month, but it does not mean that ovulation can be stable every cycle.
ACOG pointed out that in infertility evaluation, whether ovulation occurs is often judged by urine LH monitoring and progesterone detection in luteal phase. In other words, the existence of menstruation does not mean that the quality of ovulation must be ideal.
3. The man is "in good health", but there are hidden problems in sperm function.
The man has no discomfort symptoms, and it cannot be directly inferred that the semen is completely normal. According to WHO and ACOG data, the common causes of male infertility involve sperm quantity, vitality, morphology and semen excretion. Many men are in good daily condition, but their semen parameters may not be ideal.
4. People whose women are getting older but feel in good health.
Medically, age is not equal to "physical feeling". Both ASRM and ACOG pointed out that after the age of 35, women's fertility will decline, and the risk of abortion and chromosomal abnormalities will gradually increase. In other words, a "healthy-looking" person may also face age-related changes in egg quality.
Expert tips
"Good health" and "normal fertility" are not completely equivalent concepts. General physical examination focuses on general health, while fertility assessment focuses on eggs, sperm, fallopian tubes, uterine environment and time window.
Technology: What are the six common links?
If this problem is disassembled from the perspective of reproductive medicine, it usually focuses on the following six links.
1. The timing of the same room is wrong, and the real coverage of ovulation window is insufficient
Many couples don't have the same room, but they don't cover the real pregnancy window. ACOG pointed out that pregnancy may occur from 5 days before ovulation to 1 day after ovulation, and the highest chance of pregnancy is a few days near ovulation.
In other words, if the frequency of sexual intercourse is low and the ovulation window is always staggered, even if the physical condition is generally good, it will be "invalid for pregnancy" for a long time.
Advantages:
This is the easiest factor to adjust.
Does not involve invasive treatment.
Disadvantages (risks):
The error in calculating ovulation date by App alone may be large.
Menstrual regularity does not mean that ovulation day is fixed.
2. Ovulation, but insufficient support for ovulation quality or luteal function.
Some women have the problems of unstable ovulation, unsatisfactory follicular development or insufficient support in luteal phase.
The common manifestation of this situation is not necessarily typical, and sometimes it is just the prolonged pregnancy preparation time. ACOG explicitly mentioned that infertility assessment will use hormone detection and ovulation monitoring to judge this link.
Advantages:
More problems can be found through monitoring.
In some cases, we can start with lifestyle and cycle monitoring.
Disadvantages (risks):
A single test cannot fully represent the overall cycle.
Overreliance on one result is easy to misjudge.
3. Abnormal semen parameters or sperm function of the man.
Many couples only stare at the woman when they are pregnant, which is a typical misunderstanding.
According to WHO data, male factors often involve low sperm count, abnormal morphology, insufficient exercise ability, etc. ACOG also pointed out that the common problem of male infertility is abnormal sperm cells and their functions.
Advantages:
Semen analysis is usually a relatively basic and important first step.
Can quickly screen out obvious problems.
Disadvantages (risks):
The single result is influenced by abstinence time, fever and living habits.
"Within the normal range" does not mean that you must have the ideal pregnancy efficiency.
4. The fallopian tube is not smooth, or there are pelvic factors.
Tubal problems do not necessarily cause obvious pain or symptoms.
ACOG introduced that * * salpingography (HSG)** can be used to observe the uterine cavity and fallopian tubes, and it is one of the common tools for infertility assessment. ASRM also lists tubal patency and pelvic evaluation as the core content.
Advantages:
The patency can be judged directly.
It has reference value for subsequent selection of natural pregnancy preparation, ovulation promotion, artificial insemination or test tube.
Disadvantages (risks):
It belongs to the examination with certain discomfort.
"unobstructed" does not mean that the oviduct's egg picking and transportation functions are completely normal.
5. There are hidden problems in uterine environment.
For example, endometrial polyps, submucosal fibroids, intrauterine adhesions, chronic inflammation, etc., may not be fully exposed in general physical examination.
In the opinion of female infertility evaluation, ASRM emphasized that the evaluation of uterus and pelvic structure is very important for clarifying pregnancy obstacles.
Advantages:
Image and uterine cavity evaluation can help identify some structural problems.
After the cause is clear, the path is clearer.
Disadvantages (risks):
There is no absolute cause and effect between some mild abnormalities and infertility.
Examination and treatment should be combined with symptoms, age and pregnancy duration.
6. Unexplained infertility: The examinations are almost normal, but they are still not pregnant.
NICE pointed out that unexplained infertility refers to the fact that no clear reason has been found after examination. In other words, there is indeed a situation in medicine that "looks normal, but still can't conceive". NICE also pointed out that taking oral drugs alone does not necessarily improve the chances of pregnancy and live birth in this group, and the treatment path needs to be combined with age, time and overall evaluation.
Advantages:
At least some clear organic problems are ruled out.
It is helpful for doctors to make the next strategy according to age and duration.
Disadvantages (risks):
Psychological pressure is often greater.
It is easy to fall into repeated waiting, repeated examination and vacillation of treatment direction.
Expert tips
"Normal examination" does not mean "no problem", which may also mean that the existing examination has not captured the factors that really affect the pregnancy efficiency, or that the problem lies in the superposition of multiple mild factors, rather than a single big problem.
Q&A: Couples are healthy but have no children. The four most common questions.
Question 1: The physical examination is normal at ordinary times. Do you still need to go to the fertility clinic?
It needs to be judged according to the length of pregnancy and age.
If the woman is less than 35 years old, she has regular unprotected sex for 12 months and is not pregnant; Or the woman is over 35 years old and has not been pregnant for 6 months, usually she should enter the evaluation process. If menstruation is obviously irregular, previous pelvic infection, history of uterine cavity operation after abortion, and the risk of abnormal male semen is high, you should see a doctor in advance.
Question 2: Is the woman's problem more serious?
This premise is inaccurate.
WHO clearly pointed out that infertility can be caused by female factors, male factors or unexplained factors. Only focusing on the woman is unscientific and will delay the inspection efficiency.
Question 3: I'm young, can I wait forever?
Waiting indefinitely is not recommended.
Waiting is not a strategy in itself. For most couples, time is not only a natural opportunity to try, but also a variable of fertility. The closer you are to 35 years old and above, the more you need to pay attention to the evaluation time.
Question 4: Do we have to make test tubes directly?
Not necessarily.
Whether to enter assisted reproductive technology depends on age, ovarian reserve, semen condition, tubal status, previous pregnancy duration and treatment response. Some people are suitable to improve the assessment first and then continue to prepare for pregnancy naturally or carry out more basic intervention; Some people need to enter the next stage faster because of the time window or the clear cause.
Basis: This conclusion is consistent with the idea of clinical guidelines-first make clear the cause and stratification, and then decide the path, instead of everyone directly entering the same technical route.
Process: a set of more practical ideas for examination and treatment.
The following set of procedures is more suitable for people who "both husband and wife feel healthy, but pregnancy has never been successful".
Basic evaluation process of delayed pregnancy
Step key content function
Step 1: Evaluate whether age, pregnancy duration and sexual frequency have entered the medical evaluation window.
Step 2: Check the male factors by analyzing the male semen, and avoid only checking the female.
Step 3: Ovulation and hormone evaluation of women to see whether ovulation is regular and follicular development is appropriate.
Step 4: Uterus and fallopian tubes are examined to evaluate patency and uterine cavity environment.
The fifth step is to judge whether there are pelvic, intimal or immune-related risks combined with medical history, so as to improve the etiological location.
Step 6: According to the age and results, decide to continue natural pregnancy preparation, further monitor or enter assisted reproduction to improve decision-making efficiency.
This process is consistent with the core framework of ACOG and ASRM on infertility evaluation: first, make a systematic, layered and detour-free evaluation, and then decide the treatment path.
Suggested information before seeing a doctor.
How long have you been pregnant?
Is menstruation regular?
Does the frequency of sexual intercourse cover ovulation period?
Previous pregnancy, abortion, uterine cavity operation, pelvic inflammatory disease or surgical history.
Has the man had a semen test?
Do both parties have long-term staying up late, smoking, drinking, obesity, recent high fever, etc.
This information will directly affect the doctor's judgment that "the problem is stuck at the level of screening, function or time window".
Summary: Both husband and wife are healthy, but they have no children for a long time. What really sticks is often not "whether they are sick" but "whether they have found the right link"
Core conclusion:
Normal physical examination does not mean that all fertility links are normal.
Delayed pregnancy, common sticking points focus on ovulation, sperm, fallopian tube, uterine environment and the timing of sexual intercourse.
If the woman is less than 35 years old and has not been pregnant for 12 months, or more than 35 years old and has not been pregnant for 6 months, the assessment should usually be started.
Unexplained infertility is an objective medical situation, which does not mean "thinking too much" or "nothing".
There are two cognitive biases that are most likely to occur on this issue:
One is to mistake "feeling good" for "fertility must be no problem";
The second is to take "wait" as a solution.
From the perspective of medical logic, what really matters is not blind anxiety or procrastination, but taking apart the pregnancy chain as soon as possible: eggs, sperm, channels, environment and time. * * Only by finding specific points, natural pregnancy preparation, monitoring cycle and further treatment can there be a basis for discussion.
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