标签： 2021魔都新茶论坛

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.

The picture comes from the Internet.

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!

Zhidian Travel obtained the real car map and related information of JAC brand-new pure electric car EV3. JAC EV3 adopts the layout of 4 doors and 5 seats, and its size is much larger than that of Wuling Bingo. The new car adopts a brand-new LOGO and English logo. The front face is highly similar to that of Euler Good Cat. The side of the car is equipped with a hidden door handle, and the taillights are rounded rectangular. Judging from the declaration time node, JAC EV3 is expected to start at the Shanghai Auto Show in April.

Jianghuai EV3 has a length, width and height of 4025×1770×1560mm and a wheelbase of 2620mm. The new car is equipped with a single motor (low/high power) with the maximum power of 70kW and 100kW respectively, and is equipped with lithium iron phosphate batteries. The new car also provides panoramic canopy, two-color body, front windshield camera, exterior rearview mirror camera and other configurations.

　　On November 28th, according to the WeChat official account of the Ministry of Transport, on the morning of the 28th, the Ministry of Transport held a news conference on the inspection of the special project of the online car ride-hailing type safety, in conjunction with the Central Network Information Office, the Ministry of Public Security and other departments, reported the inspection work. According to the report, Didi has 7 main problems, and continues to remove the Didi ride-hailing business before completing the rectification of potential safety hazards.

　　Check the basics

　　Since the beginning of this year, there have been cases of passengers being killed in Didi Hitch in Zhengzhou, Wenzhou and other places. The central leadership has attached great importance to it, and the social impact has been very bad.

　　After the inter-ministerial joint meeting on the coordinated supervision of new business models of transportation, the Ministry of Transport, the Central Political and Legal Committee, the Central Network Information Office, the Development and Reform Commission, the Ministry of Industry and Information Technology, the Ministry of Public Security, the Ministry of Justice, the Ministry of Emergency Management, the People’s Bank of China, the General Administration of Market Supervision and other 10 departments formed a special project inspection working group for safety. From September 5th to 15th, Didi, Shouqi, Shenzhou, Cao Cao, Yidao, Meituan, TikTok, Autonavi and other 8 major online car-hailing and ride-hailing platform companies carried out joint security project inspections and went to Zhengzhou and Wenzhou to learn about the case.

　　At the same time, all localities have also carried out safety inspections on other online car-hailing and ride-hailing platform companies in the region with reference to the form and content of ministerial-level inspections.

　　In accordance with the decision-making and deployment of the State Council, the Ministry of Transport, together with relevant departments, has always adhered to the basic principles of people-centered and "encouraging innovation and standardized development" for new forms of transportation services such as online car-hailing, and implemented inclusive and prudent supervision. The special project inspection work adheres to the problem-oriented and goal-oriented, and in accordance with the principle of "comprehensive coverage and key points", "check the pulse of the physical examination and prescribe the right medicine" for the platform company, focusing on the platform company’s existing problems affecting public safety, passenger personal safety, information and other issues. At the same time, adhere to the rectification while inspection, urge and guide the platform company to check the problem, analyze the cause, make immediate changes, block security bugs, and effectively protect the safety of people’s lives and property.

　　The main issues identified

　　From the inspection, Didi mainly has the following seven problems:

　　First, there are major security risks in Hitch products. There are risks of user personal information leakage and security risks, product "social" positioning induces major security risks, Hitch rules violate relevant national and local regulations, are suspected of illegally operating road passenger transportation, and the business fund settlement model is not compliant.

　　The second is that the main responsibility for safety production is not in place. The safety management organization is not perfect, the safety management system has major deficiencies, the safety production responsibility system and the accident hidden danger investigation and management system have not been implemented, and the safety production costs have not been fully guaranteed. Safety management personnel have not passed the assessment and have not carried out driver training and education as required.

　　Third, the problem of illegal operation of online car-hailing is prominent. There are a large number of unqualified illegal operations of platform companies, vehicles and drivers.

　　Fourth, the foundation of emergency management is weak and inefficient. The formulation of emergency plans is unscientific, the system is not perfect, the emergency drills are not in place, the emergency management personnel are seriously insufficient, the customer service personnel are seriously insufficient, the emergency response efficiency is low, and the linkage mechanism with relevant departments is not perfect.

　　Fifth, the risk of social stability is prominent. To promote the "rent-based purchasing" business, the operating rules such as order dispatch and distribution mechanism are opaque, and orders are changed day by day, which poses hidden dangers of instability.

　　Sixth, the problem of public safety hazards is relatively large. The driver’s qualification and background review are not in place, the company’s offline management of people and vehicles is out of control, criminal security cases occur from time to time, the main responsibility of comprehensive social security management is missing, the early warning and cleaning of high-risk drivers are not in place, the abnormal itinerary and abnormal order cancellation are not effectively monitored and managed, and the APP safety function settings are not perfect.

　　Seventh, there are hidden dangers in Internet information security. There are loopholes in information systems, hidden dangers and risks of being attacked by external hackers and unauthorized access by internal employees; data grading and classification management requirements are not strictly implemented, and user personal information is stored in plain text; information security responsibilities of employees in important departments and positions are not implemented effectively, and specific measures are not enough; Insufficient management and training of employees in information security.

　　For the other seven platform companies, the main issues identified during the inspection included:

　　First, the compliance rate of online car-hailing is still insufficient. Some "asset-heavy" platform companies have high compliance rates for their own vehicles, but some "asset-light" companies have low compliance rates. Second, safety production management needs to be strengthened urgently. There are problems to varying degrees in implementing the main responsibility of safety production, signing safety production responsibility letters at every level, and strengthening safety production education and training.

　　Third, there are deficiencies in public security prevention. There is a general lack of dynamic management of the background situation of vehicles and drivers, and security protection technology needs to be improved. Fourth, there are hidden risks in Internet information security. Some companies have not implemented the relevant work of grade protection as required, the data grading classification management regulations are not clear, and the management and training of internal information security of enterprises are insufficient. Fifth, some product capital settlement models are not compliant, and there are capital security risks.

　　Handling opinions on relevant responsible units and responsible personnel

　　In response to the problems discovered by the inspection team, the inspection team formed opinions on the handling of relevant responsible units and responsible persons according to law, mainly including the following aspects:

　　The first is to continue to remove Didi Hitch from the shelves before completing the rectification of potential safety hazards. For Didi, there are serious illegal acts of wantonly engaging in illegal business activities in the name of Hitch, endangering social and public interests, and major liability accidents and multiple safety production accidents have occurred, resulting in serious consequences. The company is ordered not to continue to carry out Hitch business until the rectification of potential safety hazards is completed.

　　The second is to deal with illegal operations in accordance with the law. The relevant territorial management departments shall, in accordance with the "Interim Measures for the Administration of Online Booking Taxi Business Services" and the relevant requirements of the local implementation rules, severely crack down on online car-hailing platforms and private passenger car sharing information service platforms for illegally engaging in taxi business activities, and increase penalties for platform companies and other enterprises.

　　The third is to impose administrative penalties on the relevant responsible persons in accordance with the law. The relevant territorial management departments shall impose administrative penalties such as fines on the main responsible persons and legal representatives of Didi Chuxing Technology Co., Ltd. in accordance with the relevant provisions of the "Safety Production Law". At the same time, the company is required to handle the internal responsible persons according to the list of problems.

　　The fourth is to deal with suspected acts of excluding and restricting competition and publishing illegal advertisements. For Didi’s suspected use of market dominance to obtain improper benefits, in accordance with the Antimonopoly Act and other laws and regulations, the market supervision department will take the lead in organizing interviews and issuing reminders. For Didi Hitch’s previous propaganda advertisements suspected to contain content that obstructs social public order and violates good social customs, interviews will be conducted and disposed of according to law.

　　Requirements for rectification of platform companies

　　According to the problems found in the inspection, the Joint Inspection Unit put forward rectification requirements for Didi Company. The specific requirements are as follows:

　　The first is to strengthen the safety management of hitchhiking. Offline rectification of hitchhiking hidden dangers, comprehensive self-inspection and rectification of hidden dangers, before the rectification of hidden dangers is completed, the hitchhiking business will be stopped indefinitely, and the privacy protection of users’ personal information will be strengthened. Strengthen new product security evaluation.

　　The second is to implement the main responsibility of safety production. Strictly implement the "Safety Production Law" and other laws and regulations, establish and improve the company’s safety production management rules and regulations, strengthen the construction of offline safety forces, improve the cooperation mechanism between government and enterprises, implement the safety production responsibility system, strengthen the investigation and management of hidden dangers, and strengthen Security Training education.

　　The third is to operate in full compliance with the law. In accordance with relevant regulations, comprehensively promote the compliance of online car-hailing, remove non-compliant vehicles and drivers on the platform as soon as possible, and connect the online car-hailing operation information data to the national online car-hailing supervision information exchange platform according to regulations, and ensure data quality.

　　The fourth is to improve emergency response capabilities. Improve and perfect the company’s emergency plan system, enhance the pertinence, practicality and operability of emergency plans, improve the emergency response mechanism for emergencies, and effectively achieve responsive and efficient handling. Increase customer service force allocation and handling capabilities. Strengthen customer service personnel training, strengthen complaint handling capabilities, and improve customer service personnel response capabilities. Improve the linkage mechanism with relevant management departments to ensure rapid response and handling of emergency incidents.

　　The fifth is to implement the main responsibility for social stability. Take the initiative to implement the main responsibility for social stability of enterprises, respond to drivers’ demands for enterprises in a timely manner, resolve conflicts in a timely manner, strengthen the education and management of connected drivers, and cooperate with relevant departments to maintain industry stability.

　　The sixth is to strengthen the governance of public safety issues. Take good care of the access of vehicles and drivers, strengthen the dynamic verification of vehicle and driver qualifications, strengthen the dynamic risk management and control of vehicle operation, strengthen the consistency review of online and offline people and vehicles, resolutely block "impostor" security bugs, and implement the main responsibility of comprehensive social security management.

　　The seventh is to improve the level of Internet information security management. Conduct an overall investigation of the internal information system,. Further improve the data grading classification management measures and strictly implement them to strictly prevent information leakage. Improve the company’s information security management system, clarify the information security post responsibilities of key departments and key personnel, formulate a systematic Internet Information Security Training plan, and urge employees to further enhance their awareness of information security responsibility.

　　For the other 7 platform companies, the rectification requirements put forward by the inspection team mainly include: First, comprehensive compliance with the law. Accelerate the progress of vehicle and driver license applications in accordance with relevant regulations, and realize all legal compliance of vehicles and drivers under the platform as soon as possible. Remove non-compliant vehicles and drivers, and standardize the product fund settlement model. The second is to improve the level of safety production management. Implement the main responsibility of safety production in accordance with relevant laws and regulations, strengthen customer service team building, improve customer service team awareness and handling capabilities, and conduct regular training to continuously improve the platform company and driver emergency response capabilities. The third is to improve offline management and service capabilities. Improve vehicle and driver management mechanisms, improve offline service quality, and ensure that various safety and security measures are in place. The fourth is to strengthen the governance of public safety issues. Do a good job in security risk investigation, improve the platform APP function settings and strengthen vehicle risk management and control, and deal with vehicle dynamic risk hazards in a timely manner. Fifth, improve the level of Internet information security management. Do a good job in level protection related work, and regularly carry out information security threat and risk assessment and hidden danger investigation work. Perfect data grading classification management methods, key data should be encrypted and stored to prevent the leakage of user personal information.

　　Regarding the above existing problems, handling measures and rectification requirements, the Joint Inspection Unit has sorted out the relevant list and formally provided face-to-face feedback to the relevant platform companies.

　　In the next step, the Joint Inspection Team will guide the relevant departments of the territory to follow the requirements of relevant laws and regulations and the list of issues reported by the inspection team, and urge the platform company to seriously implement the rectification and put it in place to better ensure the safety of people’s travel.