TREATMENT OF INFERTILITY.

The treatment of infertility should be tailored to the problems unique to each couple. Even so, a woman above 30 years is treated hastily because the biological clock is closer to menopause and also because epidemiological studies have proven the increasing health risks associated with increased age of  mother at birth of the baby.

Ovulatory Dysfunction

Treatment of ovulatory dysfunction should first be directed at identification of the etiology of the disorder to allow specific management when possible. Dopamine agonists, for example, may be indicated in patients with hyperprolactinemia while life-style modification may be successful in women with low body weight or a history of intensive exercise.

Medications used for ovulation induction include clomiphene citrate, gonadotropins, and pulsatile GnRH.

1.       Clomiphene citrate is a nonsteroidal estrogen antagonist that increases FSH and LH levels by blocking estrogen negative feedback at the hypothalamus. The efficacy of clomiphene for ovulation induction is highly dependent on patient selection. It induces ovulation in 70 to 80% of women with PCOS and is the initial treatment of choice in these patients.

2.       Gonadotropins are highly effective for ovulation induction in women with hypogonadotropic hypogonadism and PCOS and are used to induce multiple follicular recruitment in unexplained infertility and in older reproductive-aged women. Disadvantages include a significant risk of multiple gestation and the risk of ovarian hyperstimulation, but careful monitoring and a conservative approach to ovarian stimulation reduce these risks.

3.       Pulsatile GnRH is highly effective for restoring ovulation in patients with hypothalamic amenorrhea .Pregnancy rates are similar to those following the use of gonadotropins, but rates of multiple gestation are lower and there is virtually no risk of ovarian hyperstimulation.

None of these methods are effective in women with premature ovarian failure in whom donor oocyte or adoption are the methods of choice.

Tubal Disease

If hysterosalpingography suggests a tubal or uterine cavity abnormality, or if a patient is ≥35 at the time of initial evaluation, laparoscopy with tubal lavage is recommended, often with a hysteroscopy. Although tubal reconstruction may be attempted if tubal disease is identified, IVF is often used instead, as these patients are at increased risk of developing an ectopic pregnancy.

Endometriosis

laparoscopic resection or ablation appears to improve conception rates even though most women with mild cases of endometriosis are capable of giving birth to babies within a year.

 Medical management of advanced stages of endometriosis is widely used for symptom control but has not been shown to enhance fertility.

In moderate to severe endometriosis, conservative surgery is associated with pregnancy although some patients prefer IVF as the treatment of choice.

 Though often effective, IVF is expensive and requires careful monitoring of ovulation induction and invasive techniques, including the aspiration of multiple follicles. IVF is associated with a significant risk of multiple gestation (31% twins, 6% triplets, and 0.2% higher order multiples).

Assisted Reproductive Technologies

The development of assisted reproductive technologies (ART) has dramatically altered the treatment of male and female infertility. IVF is indicated for patients with many causes of infertility that have not been successfully managed with more conservative approaches. IVF or ICSI is often the treatment of choice in couples with a significant male factor or tubal disease, whereas IVF using donor oocytes is used in patients with premature ovarian failure and in women of advanced reproductive age. Success rates depend on the age of the woman and the cause of the infertility.

Amenorrhea

This complex termonlogy literally means no menstruation (a- no; menorrhea- menstruation).

There are several  pathologies and physiologic states that alter the menstruation cycle and they do so at different stages. This one for one, is regarded as primary when a female well into her teenage years hasn’t bled yet i.e menarche. The usual cause is delayed puberty but it may also occur secondary to anatomical defects in the development of the reproductive system.

Other causes include anorexia nervosa, the eating disorder that creates bony skeletons out of beautiful girls.

The secondary type is generally cessation of menstruation. A common physiologic cause is menopause in the 4th to 5th decades of life. Another such cause is pregnancy.

Cases for concern are underlying ovarian  (such as in auto-immune ovarian failure )or uterine dysfunction and hormone (pituitary or hypothalamic) failure.

Some diseases such as tuberculosis(TB) and malabsorption disorders are also involved in the etiology of amenorrhea. PCOS-polycystic ovarian syndrome is another but it has characteristics i.e, Hirsutism (male-like hair distribution in a female), obesity and long-standing irregular periods which are specific to it.

As we all know, it isn’t normal for a woman in their reproductive age to miss a monthly visit from their “Aunt”. If you didn’t know why it is very important, well now you do.

CAUSES OF FEMALE INFERTILITY

Haven’t  you ever wondered what causes a woman to be unable to conceive a child within a whole year of frequent unprotected sex? Here are some of the reasons.

PSYCHOLOGICAL ASPECTS OF INFERTILITY

Infertility is invariably associated with psychological stress.When extreme, stress can contribute to infertility; for example, stress may impair hypothalamic control of ovulation.

OVULATORY DYSFUNCTION

Amenorrhea (absence of menses) or as irregular or short menstrual cycles may be taken very lightly but may be symptoms of an issue that is more grave.

You never know, maybe your ovary is dysfunct.

TUBAL DISEASE

Tubal disease may result from pelvic inflammatory disease (PID), appendicitis, endometriosis, pelvic adhesions, tubal surgery, and previous use of an intrauterine device (IUD). However, a specific cause is not identified in up to 50% of patients with documented tubal factor infertility.

Subclinical infection with Chlamydia trachomatis may be an underdiagnosed cause of tubal infertility and requires the treatment of both partners.

ENDOMETRIOSIS

Endometriosis is defined as the presence of endometrial glands or stroma outside the endometrial cavity and uterine musculature. Its presence is suggested by a history of dyspareunia (painful intercourse) and worsening dysmenorrhea that often begins before menses.

It could be another cause of infertility.

When should I see a doctor about my period?

See your doctor about your period if:

• You have not started menstruating by the age of 15.
• You have not started menstruating within 3 years after breast growth began, or if breasts haven't started to grow by age 13.
• Your period suddenly stops for more than 90 days.
• Your periods become very irregular after having had regular, monthly cycles.
• Your period occurs more often than every 21 days or less often than every 35 days.
• You are bleeding for more than 7 days.
• You are bleeding more heavily than usual or using more than 1 pad or tampon every 1 to 2 hours.
• You bleed between periods.
• You have severe pain during your period.
• You suddenly get a fever and feel sick after using tampons.

STIs MANAGEMENT

THE 4 C's OF STI MANAGEMENT

Each and every treatment of STI must include the 4 C's:

1.      Compliance to the full drug course &

              follow−up

2.      Counselling: On safer sexual behaviour

3.      Condom: Ensure proper use

4.      Contact tracing, partner treatment and

Notification

Patient Education

·         Avoid multiple or anonymous partners, prostitutes or any other person with multiple sex

·         partners

·         Use condoms correctly

·         Avoid alcohol or drug abuse which may lead to irresponsible sexual behaviour.

·         Seek urgent medical attention when you suspect symptoms of S.T.I’s.

·         Observe high standard of hygiene – do not share private items such as sharp objects.

N/B. Sexually transmitted diseases can also be transmitted through other means other than sexual contact:

-          Infected panties

-          Blood products

-          Contact with infected body fluids

-          Contaminated instrument.

                       Common Conditions Occurring at Menopause

Cardiovascular system:  palpitations, high blood pressure, hot flashes (the major symptom)

Musculoskeletal:  aches and pains (not osteoporosis, as it is usually symptomless), but usually a form of arthritis.

Genital:  irregular bleeding, decreased libido, vaginal dryness

General:  dryness and wrinkling of the skin

Neurological:  nausea, dizziness, mood changes, irritability, depression, insomnia, numbness, tingling

Cause of Hot Flashes

Unknown but two theories merit mention.

1.      Inadequate breathing efforts. Lose weight, if necessary, to reduce the metabolic rate and to make each breath deeper.  Practice deep breathing daily.

2.        Blood vessel tone. Women with hot flashes tends to lack the normal tightening of blood vessels

DYSMENORRHEA

Painful menstruation is difficult to treat, not because the disorder will not yield to therapy, but because women have about the worst record of noncompliance to medical counsel with this disorder that with any other. The reason for noncompliance will become obvious as the causes of dysmenorrhea are discussed. 

One important cause of dysmenorrhea is that of wearing improper clothing. Tight bands around the waist, hips, or thighs impede the circulation to the pelvic organs and increase the likelihood of painful menstruation. Also, the clothing of the extremities must be proper. There should not be one inch of chilled skin on the extremities any time during the month, not only during the menstrual period itself. The extremities should be covered with as many layers of clothing as is the trunk. To fail to do so is to cause the circulation to be imbalanced, and increases the likelihood of pelvic congestion and painful menstruation.

Posture is also important as a cure for painful menstruation. The contracted ligaments give rise to compression of the nerves which increases the symptoms of painful menstruation.

Dietary measures can be of great benefit, particularly since many of the things that irritate the gastrointestinal tract reflexively irritate the genitourinary tract. All irritants in the gastrointestinal tract such as spices, alcohol, aspirin, other drugs, hot pepper, vinegar, overeating, failure to chew properly, and any other matter known to irritate the gastrointestinal tract should be eliminated. Constipation should be corrected, particularly just prior to the onset of the menstrual period.

Rest and regularity are mandatory for the sufferer from dysmenorrhea. After the age of 20, eight hours of sleep or bed rest daily should be obtained. From childhood a pattern of regular bedtime and rising time without weekend or seasonal variation is the ideal order of life. Such a person rarely has difficulty with relaxing or sleeping. Regularity in all things is essential. 

At least one bowel movement daily is ideal, two or more bowel movements being preferred. Fruits, vegetables, and whole grains are helpful in maintaining good bowel health. The avoidance of oil is advisable, particularly, since oil tends to cause red blood cell clumping, creating circulatory problems through the rich meshwork of tiny capillaries found in the reproductive organs. Fats also alter the platelet function of the blood, causing clotting of the blood to be improper, a condition which may lead to painful menstruation.

One should develop a good emotional outlook. A mature, vigorous, and healthy adult should be able to cope with any problems that are presented to her during a 24-hour day. With Divine aid and sympathetic understand of family and friends, the individual should have the emotional equilibrium to cope with all of life's trials.

When the painful menstruation occurs, a "hot half bath" in a bathtub, or a hot foot bath up to the upper portions of the calf muscles using a deep bucket, tub or trash can will very often provide complete relief. Warm or hot water as determined by experimentation are both acceptable for the hot water baths.