Gynaecology Thrissur

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Information for patients

 Fibroids

Infertiity 

Ovarian cysts 

Menopause  Normal pregnancy Abnormal uterine bleeding


   

 

Q:When should a couple worry about infertility?  

 

A:Ordinarily, if a couple stays together for 6 months without using contraceptive methods unable to conceive, it may be time to investigate for infertility.  If the woman has grossly abnormal menstrual periods, investigations may be started much earlier.

 

Q:What is the normal physiology of fertilization?  

 

A: Normally, a woman produces ova from her ovary. The ova are extruded out  every month at about the 14th to 16th day of the cycle. This process is called ovulation.  These ova are picked up by finger like tubular organs attached to the womb (uterus) called fallopian tubes. The ovum travels through the fallopian tube to reach the uterus.  The sperm from the man enters the woman’s vagina , uterus and from there, goes into the fallopian tube to meet the ovum to form a zygote, which is  the smallest form of the beginning of human life.  This zygote then enters the uterus and lodges there to develop into a foetus and gradually grows there till the woman delivers the baby. 

 

Q:Why does conception not occur in the first cycle after marriage in all couples?

 

A: All couples who cohabitate together do not conceive immediately after marriage even if they have not been using contraception for the following reasons:

A woman may not ovulate in all cycles.

The sperm may not meet the ova in spite of being near it.

The zygote  may not lodge properly in the uterus.

   This fact is  important to remember in patients with infertility.  When a couple starts infertility treatment, they should not be disappointed unduly in case they do not get positive results  in the first or second cycle of trying for a conception.  

 

Q: What are the causes of infertility?

 

A:  The main causes of infertility are:

    1. Poor quality of the husband’s sperms. Normally there are 20million sperms per ml of   

        semen.  Decrease or absence in count, motility etc of sperms may result in infertility.

    2.Anovulation, meaning lack of regular ovulation occurring from the woman’s ovary. 

        Usually such women have irregular periods.

    3. Block in the fallopian tubes due to birth defects or infections.

    4. Abnormalities in the cervix which is the mouth of the uterus.

    5. Some  immulogical problem, by which the man or the woman may produce antibodies  

         against the sperms or ova which render them ineffective.

 

Q: What are the social causes of infertility?

 

A: 1.Poor quality of sperms can be worsened by smoking and alcoholism.

     2.Excessive heat can be a deterrent for the production of sperms.

     3.Excessive weight gain as well as excessive weight loss in the female can lead to 

        hormonal disturbances which can lead to anovulation or oligoovulation.

        Overweight women would do well to cut down on sweets and fatty foods and to

        exercise regularly . These simple and cheap measures could go a long way in

         regularizing ovulation.

     4.Infertility causes a lot of mental tension. Mental tension can affect the hypothalamus, 

        an organ in the brain which controls the production of all female reproductive

        hormones necessary for proper ovulation and conception.  This is the reason why a lot

        of women conceive spontaneously when they are not on any treatment and are not

        planning actively for conception.  The tension release in these months probably

        removes any hypothalamic block that may be posing a problem for conception.

      5.Long working hours prevent couples from cohabitating normally, thus causing apparent infertility.  Similarly, couples,

        where the husband is staying abroad, or in another part of the country also suffer from apparent infertility.  The couple

        start trying for conception in the 2 or 3 months that the husband is in station, which may prove inadequate for normal

        conception.  This leads to over treatment for infertility as fertility has to be artificially enhanced in the months that the

        husband is in station.

 

Q:What are the basic evaluations a couple will have to undergo in case of infertility?

 

A: The basic evaluations in a case of infertility are

  1. Clinical history and examination

  2. Blood tests

  3. Semen Analysis.

  4. Specialised investigations.


  5.                                                 Clinical history and examination

    Male:Since 50% of infertility is caused due to poor quality of semen, a semen analysis is mandatory in all cases of infertility. If there are abnormalities in the semen, the man should by evaluated by way of history and physical examination.  History might reveal noxious factors like smoking, alcoholism, working in an overheated environment,erectile dysfunction, etc, which could be remedied.  Physical examination may reveal enlarged veins near the scrotum which is called varicocoel.  The presence of significant varicocoel may mandate surgical correction. 
    Female: The main points in clinical history of a female are menstruation, coital history and history of abnormal vaginal discharge.
     
    Menstruation: Irregularities in menstruation could be an indication of hormonal imbalance. Hormonal imbalance results in anovulation, where the ovum required for fertilisation is not released by the ovary.
     Regular coital history: Infrequent coitus may lead to infertility if the couple co-habitate in the nonfertile periods of the cycle.  This is particulary important in couples with different working hours or couples who stay separately and meet only occasionally.  Care should be taken to see that the couple are together in the fertile period of the cycle. 

    Stress: Stress can cause anovulation and a couple desiring pregnancy should learn to cope up with the stress inherent in the investigation of infertility.  It is easier said than done, as there is a lot of pressure from social and family circles when the couple do not concieve for a long time.  This coupled with the tedious investigations and frequent visits to the gynaecologist can be stressful.  However, it is important for the couple to find some ways to let out their emotions and remain stressfree, so that they get better results out of their infertility treatment. 

    Abnormal vaginal discharge: At the time of first visit, gynaecologist are generally very diligent and look for abnormal vaginal discharge and ask for presence of itching or copious vaginal discharge.  The clear watery discharge coming about 15 days before menstruation is normal and is helpful for sperms to reach the uterus.. However, if there is foul smelling discharge, or itching in  the private parts, it is indicative of infection in the vagina or cervix.  This may be harmful for the sperms entering the vagina and will contribute to infertility.  This is usually taken care of by many gynaecologists by routinely prescribing a course of antibiotics, antifungal and antitrichomonal agents, which are tablets which kill organisms causing vaginal infections. 

    However, when the couple have been infertile for a long time, this aspect tends to get forgotten.  This may be a reason why when some major factors contributing to infertility have been treated, the couple continues to remain childless, as this minor factor is forgotten.  Thus it is important for the infertile couple to report to the gynaecologist any change in her vaginal secretions, at any point during the treatment for infertiliy. 


                                                             Clinical examination:

    A good clinical examination by the infertiliy specialist can detect many abnormalities, which may then be corroborated with findings of investigations.  Some factors that doctors detect through clinical examination are as follows:
    Improper intercourse: Surprisingly, some couples who come for infertility treatment are found to  not even have undergone normal coitus. This happens sometimes because, they are either unaware of how intercourse should be done or sometimes because the man has difficulty in attaining erection.  Embarassment prevents them from disclosing this to their doctors and in this era where many doctors rely more and more on investigations and less and less on clinical examination, this deficit remains undiagnosed, specially when some glaring deficits like low sperm count or very irregular periods is present.  When gross abnormalities are present, the onus of investigations shift to correct these abnormalities and sometimes the lack of intercourse remains undetected!!!
    Polyps: Simple growths like polyps near the mouth of the uterus could be revealed by a proper clinical examination.
    Galactorrhoea:Expression of milk or a watery discharge from the breasts (Galactorrhoea) could be an indication of increased levels of a hormone called prolactin , which could cause infertility.
    Hirsuitism:  Presence of hair on the upper lip, or a male distribution of hair on the abdomen, could be an indication of abnormal hormone levels in the body.  However, it must be remembered that not all women with hair on the upper lip have abnormal hormone levels.  Some could be having just familial hirsuitism. 
    Body weight: Both excessive weight gain, as well as excessive weight loss are deterrants for normal ovulation . 

                                                                   Investigations

    After a good clinical examination, investigations will have to be done on the husband and wife to detect abnormalities which need attention.  The following investigations will need to be done in the male and the female.
     
    Semen Analysis
    Male infertility affects almost 50% of  infertile couples.  A simple semen analysis would rule out male factor straight away.
    Semen should be collected in a clean, dry, wide mouthed container after 2 days of abstinence.  The specimen is collected after masturbation in the laboratory.  Some men prefer to collect it at home and in that case, the specimen should be handed over to the labarotary within half an hour noting the time of collection.
     

                                                                 Female factors
     
    Ovulation studies:

    Various tests can be done to find out if a woman is ovulating or not. 
    BBT: Basal body temperature:A woman is asked to record her temperature first thing in the morning, before getting up or having any beverages.  The temperature varies mildly over the days.  If the temperature rises and falls twice in the month, around midcycle, the temperature chart is said to be biphasic and indicative of ovulation.  However, this is a retrospective test and can only tell that ovulation has occurred/not occurred.  It cannot predict when ovulation will occur and thus it is not helpful in planning intercourse. 
     
    Ultrasonography:
    A woman is asked to undergo ultrasonography every two days ,starting from the 10th day onwards till ovulation is confirmed.  The ultrasonogram documents the growth of the follicle in the ovaries.  The follicle gradually grows from a size of 8 mm till it reaches 18mm and in a couple of days is seen no more.  This is indicative of ovulation. . Doctors use this modality of testing quite frequently to know whether a patient is ovulating , so that intercourse can be timed appropriately and also sometimes to find out if medications given for inducing ovulation are working properly or not. 
     
    LH kits: Urine is tested on alternate days and a special paper is inserted into it.  The change in colour in the dipstick is used to indicate ovulation.  This can be done by the patient at home itself and avoids the necessity of visiting the doctor every 2 days.  But the overall cost of testing per cycle would be higher than that of serial ultrasonography done by most sonology centers.
     

                                                                        Tubal studies:
    As mentioned before, the uterus is connected by two tubes which communicate with the abdominal cavity.  These tubes are responsible for the transport of the ovum , the sperm and in case of successful fertilization, the transport of the embryo into the uterus.  It is done rather invasively by vaious modalities.
     
    Tube testing:
    It is the local language used for testing the tubal patency by injecting air into the uterus.  The gush of air in the abdomen in the case of patent tubes can be heard through the stethoscope.  It is a very crude form of investigation . It is hardly ever performed in full-fledged institutions.  
    Hysterosalpingogram: In this test, a radio-opaque dye is injected into the uterus.  The path of the dye is recorded on an X-ray film.  The dye normally passes through the uterus into the tubes and finally into the abdomen proving that the tube is open.  This test can be done on a day care basis, but if there is block in one of the tubes, it can be quite painful. 
     
    Sonosalpingogram: Any plain fluid is pushed into the uterus and the ejection of the fluid into the abdomen is recorded on sonography. Unless very high resolution ultrasonograhy machines are used, it may not be as accurate as the hysterosalpingogram.
     
    Laparoscopy: Generally in current practice, laparoscopy is not used as a routine investigation to test the patency of the tube.  But if a patient does not conceive after a reasonable period of time inspite of treatment, a laparoscopy is done.  A fluid with or without dye is injected into the uterus and the flow of dye through the tubes is observed through the laparoscope.  Any abnormalities in the abdomen can be corrected at the same sitting.
     
    Laparoscopy in infertility:
    Laparoscopy is an important modality of investigation in the investigation and treatment of infertility.  Laparoscopy is used to diagnose any subtle causes for infertility.
    Tubal disease:

    Any factor that affects the motility or patency of the fallopian tube can cause infertility.  Tubal disease has been implicatedin 15-20% of couples presenting with infertility.  The tubal ends are some times closed because of agglutinations.  These can be released through laparoscopic instruments. Releasing adhesions between the tube, ovary, and the uterus can improve the motility of the tube
    Ovarian cysts:

    Sometimes in a condition called the polycystic ovarian disease, medical treatment might fail.  In such cases making tiny holes in the ovary might help enhance fertility. Picture on the right shows multiple punctures made into the ovary of a woman with this problem. 
    Endometriosis:

     Resection and vaporization of endoetriosis is the most common indication for laparoscopy in infertility.  Laparoscopic treatment of endometriosis yields a pregnancy rate of upto 60%.  

     

 

 

  Laparoscopic puncture of ovaries can cure some cases of Polycystic ovaries, one of the causes of infertility.

 

Hysteroscopy: Usually at the time of laparoscopy itself, a scope is passed into the uterus to make sure there are no abnormalities inside the uterine cavity.  In case of blocks in the tubal opening into the uterus, a cannula is passed into the opening to remove the block.  

Sometimes there are polyps or fingerlike growths in the uterus, which prevent normal conception.

Presence of adhesions or small flimsy bands in the uterus can also be picked up using hysteroscopy.  Correction of these abnormalities could lead to fertility. 

Hysteroscopy is also useful in patients who get pregnant, but continously have abortions.  One of the reasons could be presence of congenital walls dividing the cavity, called uterine septum.  This can be cut using hysteroscope.  Infections can also cause the walls of the uterus to stick together and this can be cut using the hysteroscope.

 

Q: What are polycystic ovaries: what are the options available for treatment

Normally, women develop many follicle, about 8-9mm in her ovaries.  One of them become dominant and ovulate.  In women with polycystic ovaries, none of the follicle are able to attain a size capable of ovulating. These women also have excess of oestrogen in them.  Most of them are associated with obesity.  The androgen level is quite often high in these women and they have excess hair on their upper lip and hair may grow in a slightly male pattern.  there may be light pigmentation on the back, called acanthosis nigricans.  Many of them have cells which are resistant to the hormone insulin, which normally digests glucose in cells.  as a result some of them have excess glucose in their blood. 

Treatment options; 1.drugs like Clomiphene citrate can be given for 3- 6 months.  giving it for more than 6 months may be harmful . 

2. Hormone injections can be given

3.Drugs like metformin and Pioglitazone can reduce insulin levels

4. In patients who cannot concieve on clomiphene, laparoscopic puncture of the ovaries is an option.  This is an alternative to hormone therapy as hormone therapy is expensive.

 


 

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