1. Infertility He-Feng Huang Women’s Hospital, School of Medicine, Zhejiang University

2. Endocrine disease Infertility ： The inability to achieve pregnancy after regular unprotected intercourse for a period of 1 year. Dysfunctional uterine bleeding ： Abnormal uterine bleeding caused by hormonal mechanism, with no organic disease of reproductive tract and internal medical disease. Amenorrhea ： Absence or cessation of menstruation lasted more than 3 cycles or 6 months.

3. Normal menstruation mechanism ▷ Regulation and feedback of hypothalamus-anterior pituitary- ovary ▷ Normal ovarian function ▷ Complete uterine, normal reaction of endometrium to estrogen and progesterone ▷ Unobstructed reproductive tract

4. Where we come from?

6. Infertility Definition: The inability to achieve pregnancy after regular unprotected intercourse for a period of 1 year. Primary infertility: never conceived within 1 year Secondary infertility: after a previous pregnancy, unable to conceive again within a 1 year period.

7. Etiology Female factors Male factors Female and male factors

8. Female Factor Ovulatory disorders Tubal factors Uterine factors Cervical factors Vulval and vaginal factors

9. Ovulatory disorders Hypothalamic dysfunction Pituitary dysfunction Ovarian factor Others

10. Hypothalamic dysfunction Psychological factors: Stress, Disturbance, Anorexia derived from mental stimulus Chronic consumptive diseases: Tuberculosis, Severe malnutrition, Anorexia nervosa

11. Pituitary dysfunction Pituitary tumors Pituitary lesions Sheehan’s Syndrom

12. Ovarian factors PCOS LUFS POF Ovary insensitivity syndrome Congenital abnormality Surgery or X-ray Ovarian endometriosis Ovarian tumor

13. PCOS Diagnosis （ 1 ） irregular menses or anovulation （ 2 ） experimental or clinical hyperandrogenism （ 3 ） polycystic ovarian morphology observed by ultrasound Accord with 2 points of the three. Symptom Menses disturbance and infertility hirsutism, acne, obesity ( BMI ≥ 25 ) Follow-up for whole life

14. Others Thyroid disorder Adrenal dysfunction

15. Tubal factors Inflammation Surgery of ectopic pregnancy Tubal ligation Tubal abnormality

16. Increase of tubal factors STD Repeated intro-uterine manipulation Repeated drug abortion

18. Tubal blockage, hydrosalpinx (HSG ）

19. Ovarian and Fallopian tube conglutination

20. Uterine factors Uterine developmental abnormality Congenital absence of the uterus Uterine malformation Endometrial abnormality Endometrial tuberculosis Asherman syndrom Uterine tumor

23. Male factors Semen abnormality Oligospremia, Azoospermia, Asthenospermia Sperm transport abnormality Endocrine disorders Sexual dysfunction Immunological factors

25. Male and female factors Psychological factors Subfertility Immunological factors

26. Classification

27. Investigation and Diagnosis Male investigation History: general health, medications, lifestyle and reproductive health General examination Specific examination ： abnormality of genitals seminal analysis

29. Volume ≥ 2.0ml PH 7.2~7.5 Density ≥ 20×10 /ml Count ≥ 40×10 /every ejaculation Motility within 60 min after ejaculation ≥ 50% sperm progressive motility (grade a+b) or ≥ 25% sperm rapid progressive motility (grade a) Grade a: rapid progressive motility Grade b: slow progressive motility Morphology ≥ 30% normal head Survive rate ≥ 75% WBC ≤ 1×10 6 6 6 Normal Seminal analysis

30. Female Investigation History General examination Specific examination Others

31. Specific examination Ovarian examination Ovulation monitor Luteal function Ovarian reserve

32. Ovarian function Ovulation monitor 1 、 Basic body temperature 2 、 Cervical mucus 3 、 Vaginal cytological test 4 、 Ultrasound monitor 5 、 Serum or urinary LH peak 6 、 Serum E 2 and P levels 7 、 Endometrial biopsy 8 、 Laparoscopy

33. Follicular development and ovulation

34. 2. 基础体温测定 biphasic basal body temperature

35. monophasic basal body temperature

36. Low estrogenHigh estrogen

37. Cervical mucus

39. Proliferative endometrium

40. Secretory endometrium

42. Luteal function 1 、 BBT 2 、 Endometrial biopsy 3 、 Serum E2 and P levels

43. Ovarian reserve 1 、 Age 2 、 CC stimulating test 3 、 GnRH-a stimulating test 4 、 Antral follicle count (AFC) 5 、 Basic FSH 、 E2 6 、 AMH 、 Inhibin B

44. Tubal investigation Hydrotubation Hysterosalpinography (HSG) Laparoscopy Hysterosalpingography by Ultrasound

46. Normal figure

48. Postcoital test Cervical hostility Hysteroscope Laparoscopy

50. Postcoital test Cervical hostility Hysteroscope Laparoscopy

52. Postcoital test Cervical hostility Hysteroscope Laparoscopy

53. Endometriosis （ Endometriosis （ Laparoscopy)

54. Treatment of infertility 1.Treatment of genitals organic disease 2.Induction of ovulation 3.Luteal support 4. Improvement of cervical mucus 5.Treatment of tubal inflammation 6.ART

55. 1. Genitals organic disease Etiology combined treatment: Infection control, Surgery 1. Genital malformations, Genital inflammation Uterine Myoma, Endometriosis

56. 2.Tubal infertility Fallopian tube obstraction: Fallopian tube glue loose solution operation Salpingostomy Tubo-uterine implantation Tubal anastomosis Fallopian tubes were partial unobstructed: Liquid instillation Physical therapy Traditional Chinese Medicine

57. 3. Asherman syndrome Principle of Management: Separate adhesions Prevention of adhesion recurrence Promote endometrium repair Methods Hysteroscope management of intrauterine adhesion Estrogen promote endometrium regeneration Intrauterine device (IUD)

58. 1.Reproduction-related disease 2.Induction of ovulation 3.Luteal support 4.Improvement of cervical mucus 5.Treatment of tubal inflammation 6.ART

59. Drugs for ovulation induction CC HMG FSH: u-FSH, FSH-HP, r-FSH HCG GnRH （ LHRH ） GnRH analog ： GnRH agonist GnRH antagonist bromocriptine

60. The first R-GN （ Gonal- F+Lhadi+Ovidrel=FSH+LH+HCG ） IVFbaby—Sebastian （ 1997.5.7 ）

61. 1.Reproduction-related disease 2.Induction of ovulation 3.Luteal support 4. Improvement of cervical mucus 5.Treatment of tubal inflammation 6.ART

62. 1.Reproduction-related disease 2.Induction of ovulation 3.Luteal support 4. Improvement of cervical mucus 5.Treatment of tubal inflammation 6.ART

63. 1.Reproduction-related disease 2.Induction of ovulation 3.Luteal support 4. Improvement of cervical mucus 5.Treatment of tubal inflammation 6.ART

64. 1.Reproduction-related disease 2.Induction of ovulation 3.Luteal support 4. Improvement of cervical mucus 5.treatment of tubal inflammation 6.ART

65. Treatment-female factor Causes Treatment induction of ovulation ； tuboplasty; microsurgery ； medication or surgery ； immune inhibition ； anovulation Tubal factor Anatomic factor immunologic azoospermia genetic disease after surgery Assisted Reproductive Technologies (ART) unexplained

66. ART （ Assisted Reproductive technology ） AID or AIH (Artificial insemination ， AI ) IVF-ET (In vitro fertilization-embryo transfer IVF-ET ）

67. AIH or AID AIH(artificial insemination by husband semen) IUI (Intrauterine insemination ） IVI (Intravaginal insemination) ICI (Intracervical insemination) ITI (Intratubal insemination) IPI (Intraperitoneal insemination) IFI (Intrafollicle insemination) AID (IUI)

68. IVF-ET Indication Tubal infertility Endometriosis IUI failure Unexplained infertility Immunological infertility Oligospremia

69. IVF-ET

71. Other technology derived from IVF Crypreservation of embryos Oocyte donation and embryo donation Surrogate mother GIFT (Gamete intrafallopian transfer) ZIFT (Zygote intrafallopian transfer) ICSI PGD

72. ICSI (Intracytoplasmic sperm injection)

74. PGD Preimplantation genetic diagnosis

75. PGD indication ★ X -linked chromosome abnormality ★ Chromosomal (numerical/structural) ★ Monogenic diseases

76. PGD technique Blastomere Biopsy FISH

77. PGD

79. 14 三体 正常 14 三体， 13 单体 Robertsonian translocation （ 13q14q ）

80. X-linked agammaglobulinemia

82. IVF-ET protocol Patients preparation COH Oocyte retrieval In vitro fertilization Embryo trasfer Luteal support Follow up

84. Complication of ART OHSS Ectopic pregnancy and abortion Multiple pregnancy － multiple pregnancy reduction

85. Transvaginal ultrasound-guided selective fetal reduction

86. In vitro maturation (IVM) Immature oocytes Mature oocytes embryos Intracytoplasmic implantation

87. Ethic of ART (Chinese government)  The government does not support nor approve the practice of human clones;  Forbid performing ART for single woman;  Forbid Manufacturing Oocytes;  Forbid commercial trial of zygotes and embryos;  Forbid multiple pregnancy dominated ART;  Forbid gender selected ART without medical indication;  Forbid surrogate motherhood

88. Ethic of ART Challenge the course of natural reproduction Danger of inbreeding Commercial trial of zygotes and embryos Uncertainty of parenthood Risk of oocyte donation Controversy between clone and traditional family formation Clone criminality Challenge of the definition of “human” ART related regulations and laws