Female Reproductive System Female Reproductive System is the most complex. Most of the women are unaware of their own bodies. The modern women should be aware of the anatomy of her reproductive system. Women are the one who has to provide nutrition, give birth and nourish her infant. Here we have explained the external parts as well as the internal parts of the female reproductive system. It is very important for every women and girl to understand the menstrual cycle, physiology of pregnancy, birth and lactation.
External Genitalia
The vulva consists of the mons veneris (mons pubis), the clitoris, the labia majora and labia minora, Vestibule which has four parts : The urethral opening, the vaginal opening, hymen and Opening of the Bartholin’s ducts.
Mons Pubis
This is a pad of fibro–fatty tissue in the pubic area. It is covered with pubic hair. The skin of this part is coarse. It contains sweat glands, sebaceous gland and hair follicle.
Labia Majora
These are two folds of skin and fat below the mons pubis. Labia majora are more prominent after childbirth and are closed in women who have not given birth. The surface is pigmented and hairy. The inner part contains sebaceous (sweat) glands and is hairless. They become atrophic in menopausal age and is very thin during puberty.
Labia Minora
These are two folds of skin which lie inside each labia majora. It contains sweat and sebaceous glands. They are more prominent before puberty. It has no hair.
Clitoris
This is a small, sensitive area in the females just as in males there is penis. It has a rich nerve supply. It plays an important part in female arousal during sex.
Vestibule
This is a triangular area which extends from the labia minora and the Hymen.
Hymen
The hymen closes the vaginal opening partially. It has a small outlet for the passage of blood. In some cases, the outlet through which blood can pass at puberty is not there. This leads to the accumulation of blood in the vagina. This condition is a type of amenorrhea (absence of periods) and it requires medical attention. The hymen is usually ruptured during sex. However, gymnastic exercise and horse riding may also rupture the hymen. After childbirth, it more or less disappears. A woman who has never had sex has an unruptured hymen and this state is commonly referred to as virginity.
Bartholin’s Glands
These are two glands which are 1–1.5 cm in size and are yellowish white in color. They lie deep inside the vestibular bulb. The glands produce special watery secretions during coitus.
Internal Genitalia
The Internal Reproductive Organs
Vagina
It lies between the urinary bladder and the rectum. This is the three–inch long passage that leads from the uterus to the exterior. It does not contain hair follicles, sweat and sebaceous glands. The vaginal secretions are very small in amount but it may be excess during sexual activity, in menstruation and during pregnancy. The mucus is secreted by Bartholin’s glands which lubricates the vagina. There occur changes in the mucous membrane of the vagina during menstrual cycle which is mainly due to estrogenic hormones. The vagina has Doderlein’s bacilli during child–bearing age. This organism acts on the glycogen to produce lactic acid and hence due to this acidity in the secretions in vagina it acts as a defensive barrier for vaginal infections. The opening to the vagina is partially covered by the hymen.
Uterus
The uterus is a hollow, muscular organ that lies in the pelvis between the rectum and the urinary bladder. The cervix is the lowermost part of the uterus. A pair of Fallopian tubes extend from each of its sides. It is the main organ of the reproductive system in which a fertilized ovum gets implanted and develops into a fetus through the period of pregnancy. The mucous membrane of the body of the uterus is called the endometrium. It provides a position for implantation of the fetus. The lining of the uterus is shed every month as a menstrual period, if conception does not occur.
Cervix
The lower third of the uterus is called the cervix. It is approximately 2.5 cm in length. It projects into the vault of the vagina. Nearly half of the cervix lies in the vagina. It is called the portiovaginalis. It provides an alkaline secretion, which helps the penetration of sperm for the purpose of fertilization. It acts as a sphincter for the uterus and plays a very important part during pregnancy and child birth. Cancer of the cervix and chronic cervicitis are diseases of the cervix.
Fallopian Tubes
These are two delicate tubes that join to the uterus at its sides on one end. They extend up to the ovaries at the other end. The tubes measure approximately 10 cm in length. They carry the ova from ovaries to the uterus. Fertilization of the ovum actually occurs in the tubes. Hence obstruction of the tubes may prevent conception and lead to infertility. If fertilization occurs, the fertilized ovum gets implanted in the uterus on the fifth or sixth day after fertilization. A tubal (ectopic) pregnancy results if the zygote gets implanted in the tubes instead of passing to the uterus. The infection of the fallopian tubes is known as Salpingitis.
Ovaries
The two almond–shaped ovaries are attached to the ends of the fallopian tubes on either sides of the uterus. They are approximately 4 cm in length, 2.5 cm in breath and 1.5 cm in thickness. They contain thousands of ova or eggs in various stages of development. These ova are present in the ovaries before puberty. After puberty, they become what are known as graafian follicles, under hormonal stimulation. The ovaries also produce the sex hormones estrogen and progesterone.
Ovulation
Each month one or more eggs get released from the ovary, this is known as ovulation and it is the part of the woman’s menstrual cycle. Ovulation does not take place when the women is pregnant.
Corpus Luteum
The corpus luteum is a part of the ovary. After ovulation, the graafian follicle ruptures to develop corpus luteum.
Puberty is the period which links childhood to adulthood, which is at 12–14 years of age and is characterized by increased body growth. Puberty leads to fully maturation with various biological and psychological changes. It is brought about by the start of the ovarian activity and production of hormones.
Before puberty begins, the anterior pituitary produces growth and other tropic hormones and does not produce gonadotrophins. The ovaries are not active. At puberty, production of the gonadotrophins starts due to increased activity of the anterior pituitary. Maturation takes place and primordial follicles is changed into graafian follicles. The graafian follicles produce estrogens. The body undergoes various changes due to the hormones which are mainly seen in the breast, pubic and axillary hair growth, commencement of menstruation, growth in height and general metabolism of the body.
Development of the Secondary Sexual Characters
The secondary sexual characters develop in the following order
Pubic and Axillary hair
The growth of hair on the mons veneris and in the axillae starts at puberty. Pelvis
It becomes wide.Menarche
The menarche occurs at puberty. The ovarian hormones, estrogens and progesterone, act on the endometrium. The endometrium becomes thick, and is shed cyclically on withdrawal of these hormones.
Skin Changes
They change their shape and becomes elongated. They become bulky and oval.Uterus
The body of the uterus increases in size and changes form the immature type to the adult type.Vagina
The changes are seen more over here. The vaginal epithelium increases in thickness due to storage of glycogen in its superficial and intermediate zones. Doderlein’s bacilli appear in the vagina, and its pH becomes acidic. The labia majora become more prominent due to deposition of subcutaneous fat. The vulva becomes more reactive. The mons pubis and labia minora increases in size. Psychological Changes
At puberty, girls become more shy, reserved, and blush easily. They also become sensitive and at times moody.
Delayed Puberty
Puberty may be delayed when breast tissues or pubic hair have not appeared by 13–14 years and menarche is late and appears by the age of 17 to 18 years. Generally there is a family history of delayed menarche. In some cases the delay may be because of environmental influence on the hypothalamus, or due to some endocrinal or systemic insufficiency. Usually, in a case of delayed menarche, the menstruation is irregular and infrequent. The girl may have prolonged periods of amenorrhea or sparse menstrual flow. These women do not need any treatment. Only reassurance and follow up is enough in a most of these cases.
Precocious Puberty
This is early onset of puberty. In this, the girl exhibits secondary sex characters at the age of 8 years or start menstruation at the age of 10 years. It may happen as early as 2nd or 3rd year of life. The physical growth is usually stunted due to early closure of epiphyses. In a majority of these cases no cause is found. There is no organic lesion seen.
The following lesions may cause precocious puberty:
Menstruation is monthly uterine bleeding out flowing through the vagina during reproductive life of a woman i.e. from menarche to menopause. It contains blood, cervical mucus, endometrial fragments & vaginal epithelium.
Women have two ovaries, the organs that hold the ova, or eggs. There are thousands of eggs in each ovary. One egg is about as big as the tip of a pin.
One of the first things to happen in the menstrual cycle is that an egg pops out of one of the ovaries. The egg travels from the ovary through the fallopian tube to the uterus, or womb. It is in the uterus where an egg grows into a baby.
About the time the egg is traveling to the uterus, the uterus is building up a lining of healthy tissue and blood. If the egg reaches the uterus and is fertilized, it will remain there and become a baby. The lining is there to help the baby stay healthy and comfortable.
But most of the time, the egg only “Visits” the uterus, then passes through. If the egg doesn’t remain in the uterus, the lining of blood and tissue is not needed and so it passes out through the vagina. It may seem like a lot of blood, but it's not. There is less than a half cup over the course of an entire period.
About two weeks later, another egg works its way out and the entire cycle begins again. The whole menstrual cycle usually takes about one month from one period to the next.
Irregular Periods
Periods can be irregular at extremes of the reproductive life i.e. after menarche & nearing menopause. Otherwise periods should be regular.
Dysmenorrhoea
Dysmenorrhoea means painful menstruation. It is usually seen as stomach ache & backache. This is a normal phenomenon, which is a result of progesteron secretion. Occasionally there may be associated disorders like endometriosis, pelvic inflammation, fibroids etc.
Heaviness & tenderness in the breasts during menstruation
Some women do have heaviness & tenderness in the breasts during menstruation while some may have it premenstrually. If it is mild, only reassurance is the treatment.
Sex during menstruation
It is safe to have sex during menstruation since there are no chances of conception, however it is not hygienic.
Physical Activities during menstruation
It is advisable to restrict vigorous physical activities during menstruation but routine activities should be continued.
How Your Menstrual Cycle Works
Menstrual CycleThe key to getting pregnant is understanding how your monthly ovulation cycle works, so you can better determine when you’re most likely to conceive and can schedule intercourse accordingly.
The Menstruation cycle for most women varies between 27 and 32 days. If it’s regular, you and your partner are not using any method of birth control and are having sex at least twice a week, there’s an 85 percent chance that you’ll get pregnant within a year. If pregnancy does not occur, then you and/or your partner may have a fertility problem. On the first day of your menstrual period, the hypothalamus (a small area in the brain behind the eyes) detects that the level of the female hormone estrogen is low.
It then sends a chemical signal to the pituitary gland (a pea–sized structure that hangs from the base of the brain) that it’s time to stimulate the ovaries to produce an egg. The pituitary reacts by sending a fertility hormone called follicle–stimulating hormone (FSH) into your bloodstream. One of your two ovaries responds by summoning anywhere from eight to 15 eggs from your total available lifetime supply of 40,000 (reduced at adolescence from approximately 2 million in the ovaries of a newborn––the fact that all the woman’s eggs are present from birth contributes to an increased risk of genetic abnormalities after age 35.) For unknown reasons, although suspected to be hormonal, only one of these eggs (or two in the case of fraternal twins) ripens completely each month, while the rest fail to mature and ultimately die. During the first 2 weeks of your Menstruation cycle, spurred on by FSH, the dominant egg develops and forms a blister–like egg sac known as a follicle near the surface of the ovary.
When the egg is almost ripe enough to be fertilized, FSH tells the ovary to release a surge of estrogen, which in turn signals the pituitary gland to produce large amounts of a second fertility hormone––Lutenizing Hormone (LH). Within 24 to 48 hours, the follicle releases a mature egg in response to LH and it makes its way to one of your two fallopian tubes. This is the big moment which you’ve been waiting for–Ovulation, when your body is ready to become pregnant. It’s here in the fallopian tube that the egg meets one of the approximately 200 to 600 millions of sperm from a single ejaculation and fertilization takes place. In the next 3 days, the fertilized egg travels down the tube to the uterus where it implants on day 5 to 6, in the uterine lining, which has been prepared to receive it during the first half of the menstrual cycle. If the egg isn’t fertilized, the lining sloughs resulting in the menstrual period.
Premenstrual syndrome or PMS as it is commonly known is a medical condition wherein there is change in the mood or behavior of some abnormal symptoms usually experienced in the second half of the cycle. Women become too ‘fussy’ and get anxious or depressed easily. These symptoms may also continue even after the period starts. Premenstrual symptoms vary from women to women and can get worse as she gets older i.e. in her 20’s and 30’s. These symptoms usually disappears after menopause.
Causes of Premenstrual Syndrome
The exact cause is not known, but it is supposed to be related to hormonal changes during the menstrual cycle. It has shown that women who have some deficiencies like zinc, magnesium, Vitamins E and B6, or certain fatty acids in their diet suffer from PMS. It also maybe due to alteration in the levels of hormones, estrogen and progesterone.
Symptoms of Premenstrual Syndrome
Dysmenorrhea literally means painful menstruation. Many women get some discomfort during menstruation. It is known as dysmenorrhea if the pain is severe and the woman has to take bed–rest and analgesic.
Types of Dysmenorrhea
Primary (spasmodic)
Secondary
Primary (Spasmodic)
This is the commonest type of dysmenorrhea. In primary dysmenorrhea there is no certain pelvic pathology involved.
Age
Primary dysmenorrhea is predominantly confined to adolescent girls, 15–18 years of age. It usually appears within 2 years of menarche. There may be a family history of dysmenorrhea in the mother or sister.
Clinical Features of Dysmenorrhea
The pain begins a few hours before or just about with the onset of menstruation. The severity of pain usually lasts for few hours, it may extent to 24 hours but can persist beyond 48 hours.
The pain is spasmodic and confined to the lower abdomen, it may radiate to the back and medial aspect of thighs.
Systemic discomforts like nausea, vomiting, fatigue, diarrhea and headache may be associated.
It may be accompanied by symptomatic changes causing pallor, cold sweats and occasional fainting.
Rarely, fainting and collapse in severe cases may be associated.
Abdominal or pelvic examination does not reveal any abnormal findings.
Causes of Pain
The exact cause of spasmodic dysmenorrhea is unknown.
The possible cause is that the uterine muscles get into a spasm and this in turn produces ischemia of the muscle. The pain is the result of this ischemia.
The pain is related to dysrhythmic uterine contraction and uterine hypoxia (lack of oxygen).
Psychosomatic factor due to tension and anxiety during adolescents or lower pain threshold is often attributed as an aggravating factor in pain perception. This may explain in part, the disappearance of pain with advancing age.
Treatment of Dysmenorrhea
Measures include improvement of general health and simple psychotherapy in terms of explanation and assurance. It should be explained to young girls that menstruation is a physiological phenomenon and not a disease. The girl should be taught the hygiene of menstruation. The patient should be reassured that the pain is short lived.
She may use a hot water bottle for fomentation of the lower abdomen. Usual activities including sports are to be continued. During period, bowel should be kept empty and mild analgesics and antispasmodics may be prescribed. With these simple measures, the pain is relieved in majority.
In severe cases
It is done under general anesthesia. Dilatation should be slow and gradual. If the pain recurs after being cured for few months, repeat dilatation is indicated. Sufficient dilatation is done with Hegar’s dilators upto 8–10 mm. Late sequels may be cervical incompetence. Cervical dilatation relieves pain by–i) stretching of the fibro muscular tissues at the level of internal os and ii) by causing injury to the sensory nerve endings cutting down the pain pathway. Curettage is unnecessary; may be of help if associated with menstrual abnormality or in membranous dysmenorrhea.Bilateral block of the pelvic plexus
Paracervical block with alcohol may be carried out along with dilatation of the cervix to improve the result. It may be employed as a therapeutic test before a major operation like presacral neurectomy is undertaken.Presacral neurectomy –(Cotte’s operation)
It can only be done in a hopeless case of a neurotic type of patient when all the other measures fail. The objective is to cut down the sensory pathway from the uterus. Secondary (Congestive) Dysmenorrhea
Secondary dysmenorrhea is normally considered to be period–associated pain occurring in the presence of pelvic pathology.
Age
The patients are usually in thirties; more often parous (have had previous deliveries) and unrelated to any social status.
Clinical Features of Secondary Dysmenorrhea
The pain is dull, situated in the back and in front without any radiation. It usually appears 3–5 days prior to the period and relieves with the start of bleeding. The onset and duration of pain may vary. There is no systemic discomfort unlike primary dysmenorrhea. The patients may have got some discomfort even in between periods. There are symptoms of associated pelvic pathology. Abdominal and vaginal examinations usually reveal a lesion. At times, the lesion is revealed by laparotomy or laparoscopy.
Cause Of Pain
The pain may be related to increased vascularity in the pelvic organs. Common lesions are–chronic pelvic inflammatory disease, pelvic endometriosis, adenomyosis, uterine fibroid, endometrial polyp, IUCD etc.
Treatment of Secondary Dysmenorrhea
The type of treatment depends on the severity, age and parity of the patient. Analgesics provide temporary relief.
Amenorrhea means absence of menstruation. It is a symptom, please do not take it as a disease. Depending on the causes, Amenorrhea could be of various types.
Types Of Amenorrhea
False Amenorrhea (Cryptomenorrhea)
True Amenorrhea
Physiological.
Pathological–Primary Secondary
False Amenorrhea (Cryptomenorrhea)
In this condition, there is periodic shedding of the endometrium and bleeding but the menstrual blood fails to come out from the genital tract due to obstruction in the passage.
This Obstruction Could be Due to
Vagina
Imperforated hymen.
Vaginal septum.
Absence of vagina.
Cervix
Could be congenital or acquired atresia.
Treatment
Simple dilatation of the cervix so as to drain the collected blood is enough. In cases of secondary atresia of the vagina, reconstructive surgery is to be done.
True Amenorrhoea
Physiological
Physiological causes of amenorrhea indicate the absence of menstruation due to natural conditions.
Before Puberty
The age of puberty is 12–14 years. The physiological amenorrhea is before the pubertal age. It is because the pituitary gonadotrophins are not adequate enough to stimulate the ovarian follicles for effective steroidogenesis and the estrogen levels are not sufficient enough to cause bleeding from the endometrium.
During Pregnancy
If a women of child bearing age complains of amenorrhea then it is likely that she is pregnant. During this period large amount of estrogens and progesterone are secreted from the trophoblasts (Link to glossary) which suppresses the pituitary gonadotrophins hence no maturation of the ovarian follicles.
During Lactation
Due to high levels of some hormones and low levels of others, there is no menstruation. If the patient does not breast feed her baby, the menstruation returns by 6th week following delivery in about 40 percent and by 12th week in 80 percent of cases. If the patient breast feeds her baby, the menstruation may be suspended in about 70 percent until the baby stops breast feeding.
Following Menopause
The menopausal age is 45–50 years. During this period no more follicles are available in the ovaries for the gonadotrophins to act. Due to which there is cessation of estrogen production from the ovaries with rise of pituitary gonadotrophins.
Pathological
Pathological causes indicate amenorrhea due to abnormal conditions.
Primary Amenorrhea
Young girls who have not menstruated by the age of 17 years could be having primary amenorrhea rather than delayed menarche.
Cause of Amenorrhea
Due to Some Medical Diseases
Genital tuberculosis or diabetes could be the reason in some cases. Such type of amenorrhea is usually associated with hypogonadism. Abnormal loss or gain in weight within short span of time shows some metabolic disorders.
Secondary Amenorrhea
When there is absence of periods for 6 months following normal menstruation, it is called secondary amenorrhea. It may be physiological, concealed (cryptomenorrhea) or true secondary amenorrhea. No matter what the type of amenorrhea, it requires proper diagnosis and treatment in due course of time.
Menopause
Hormone changes in a woman such as estrogen decline, the aging process itself and stress occur between the ages of 45 and 55. A woman’s menstrual periods stop altogether. This signals the end of fertility.
Emotional changes associated with menopause are
Irritability
Mood changes
Lack of concentration, difficulty with memory
Tension, anxiety, depression
Insomnia
Physical signs and symptoms associated with menopause are:
Hot flashes, which are sudden waves of heat that can start in the waist or chest and work there way to the neck and face and sometimes the rest of the body. Sometimes heart palpitations accompany hot flashes.
Irregular periods that vary and can include:
Periods that stop for a few months and then start up again and are more widely spaced.
Periods that bring heavy bleeding and/or the passage of many or large blood clots. (This can lead to anemia).
Loss of bladder tone, which can result in stress incontinence (leaking urine when you cough, sneeze or exercise).
Headaches, dizziness.
There may be a growth of facial hair but a thinning of hair in the temple region.
Breast tenderness.
Bloating in upper abdomen.
Loss of some strength and tone of muscles.
Bones becoming more brittle, increasing the risk for osteoporosis.
Increased risk for heart attack when estrogen levels drop.
Medication to treat depression and/or anxiety may be warranted in some women. Also, certain sedative medicines can help with hot flashes.
Infertility is defined as a failure to conceive within one or more years of regular unprotected coitus. Primary infertility denotes those patients who have never conceived. Secondary infertility indicates previous pregnancy but failure to conceive subsequently within one or more years of unprotected regular intercourse. A healthy couple, on an average takes a year to achieve pregnancy. If the couple fails to conceive for two years, after regular sexual intercourse without contraception, they could be a case of infertility.
80 percent of the couples achieve conception if they so desire, within one year of having regular intercourse with adequate frequency (4–5 times a week). Another 10 percent will achieve the purpose by the end of second year. As such, 10 percent remain infertile by the end of second year.
Factors Responsible of Fertility are:
The normal count of spermatozoa is 100 million/ml. The minimum count for fertility is 20 million/ml. The production of healthy spermatozoa is necessary to be deposited in vagina.
The spermatozoa remain healthy and penetrate into the uterine cavity and into the uterine tubes.
Production of ova is vital. The ovum finds its way into the uterine tube where it can be fertilized by a spermatozoon.
The fertilized ovum migrates into the uterus and the endometrium should be hospitable for the spermatozoa for the implantation of fertilized ovum.
Causes of Infertility
The numerous reasons that lead to infertility can be broadly categorized to be related to the anatomy ( physiological causes) or due to some kinds of infections (pathological causes).
Physiological
Infertility is the rule prior to puberty and after menopause. But it should be remembered that the girl may be pregnant even before the menarche and pregnancy is possible within few months of menopause. Fertility is lower until the age of 16–17 years and after 35 years. Conception is impossible during pregnancy as the hormone Human Chorionic Gonadotrophin HCG is suppressed and hence no ovulation. During lactation, infertility is said to be relative. Inspite of the fact that the patient is amenorrhagic during lactation, ovulation and conception can occur. However, in fully lactating women (breast feeding 5–6 times a day and spending 60 minutes in 24 hours), pregnancy is unlikely up to 10 weeks postpartum.
Pathological
Conception depends on the fertility of both the male and female partner. It is also emphasized that the relative infertility of one partner may sometimes be counter balanced by the high fertility of the other.
Faults in the Female Ovarian Factors
Anovulation and Oligo–ovulation (infrequent ovulation)
Corpus Luteum Insufficiency (CLI)
Lutinization of Unruptured Follicle (LUF)
Anovulation or Oligo–ovulation
In the absence of ovulation, conception cannot take place. This is quite frequent during adolescence or premenopausal period. Hypothalamic or Cortical factors
Pituitary Gonadal
Others Factors are
Thyroid dysfunction.
Substantial weight loss (anorexia nervosa).
Diabetes mellitus.
Adrenal hyperfunction.
Pelvic endometriosis.
As there is no ovulation, there is no corpus luteum formation. In the absence of progesterone, there is no secretary endometrium in the second half of the cycle. The other features of ovulation are absent.
Corpus Luteum Insufficiency (CLI)
In this condition, there is inadequate growth and function of the corpus luteum. The life span of the corpus luteum is shortened to less than 10 days. There is insufficient secretion of progesterone and hence less secretary changes in the endometrium which hinders implantation.
Luteinized Unruptured Follicular Syndrome (trapped ovum)
In this condition the ovum gets trapped inside the follicle which gets matured. The cause is obscure but may be associated with pelvic endometriosis.
Tubal Factors
The impaired tubal function (tubopathy) includes defective ovum pick up, impaired tubal motility, loss of cilia (hair like processes inside the fallopian tubes) and partial to complete obstruction of the tubal lumen. Infections like tuberculosis, gonococcal or post–partum infection can cause bilateral blockage of the fallopian tubes.
Peritoneal Factors
In addition to adhesions that surround the fallopian tubes, endometriosis is an important cause of infertility by producing ovulatory dysfunction and is responsible for changed tubal motility.
Uterine Factors
The endometrium must be sufficiently accessible enough for effective implantation and growth of the fertilized ovum. The possible factors that hinder implantation are underdeveloped uterus, inadequate secretary endometrium, fibroid uterus, endometritis, uterine adhesions or congenital malformation of uterus.
Cervical Factors
Anatomic–Anatomic defects like congenital elongation of the cervix, second degree uterine prolapse and acute retroverted uterus prevents the sperm to enter. These conditions prevent the external os to bathe in the seminal pool. Pin hole os may at times be at fault, or the cervical canal may be obstructed by a polyp .
Physiologic–In this spermatozoa fail to penetrate the mucus due to fault in the composition of the cervical mucus. The mucus may be scanty following amputation, confiscation or deep cauterization of the cervix. The abnormal constituents include excessive, viscous or purulent discharge as in chronic infection of the cervix (cervicitis).
Vaginal Factors
Absence of vagina (partial or complete), transverse vaginal septum, septate vagina (where the vaginal canal is abnormally divided by a septum) or narrow introitus causing dyspareunia included in the congenital group. Infection of the vagina and purulent discharge may at times be the cause but pregnancy can take place in presence of vaginitis specific or non–specific.
Factors causing infertility in the male and female partners
Anxiety and apprehension.
Advancing age of the wife beyond 35 is related but spermatogenesis continues throughout life although ageing reduces the fertility in the male also.
Infrequent intercourse, lack of knowledge of coital technique and timing of coitus to utilize the fertile period are very much common even amongst the literate couples.
Apareunia and dyspareunia (Painful or difficult sexual intercourse).
Use of lubricants during intercourse–which may be spermicidal.
Infertility Investigations in Female
Age, duration of marriage, history of previous marriage with proven fertility if any, are to be noted.
Age: Fertility is at its peak between the age of 20–25 years. It declines rapidly after the age of 40 years of age.
Duration of marriage: Problem regarding coitus and contraception.
A general medical history should be taken with reference to tuberculosis, sexually transmitted disease or any pelvis inflammatory diseases.
Any treatment and investigations of infertility carried out in the past. The surgical history should be directed specially towards abdominal or pelvic surgery.
Menstrual history should be taken in details.
Previous obstetric history–including number of pregnancies, the interval between the two pregnancies is to be enquired.
Sexual problems such as painful sexual intercourse and loss of libido are to be enquired. There may be some psychosomatic reason.
General, systemic and gynecological examinations are made to detect any abnormality which may hinder fertility.
General examination must be thorough–Any recent changes in weight like obesity or marked reduction in weight are to be noted. Abnormal distribution of hairs or underdevelopment of secondary sex characters are also to be noted.
Systemic examination may accidentally detect abnormalities like hypertension, organic heart disease, chronic renal lesion, endocrinopathies and alike.
Gynecological examination includes –adequacy of hymeneal opening, any vaginal infections, cervical tear or chronic infection. Undue elongation of the cervix, uterine size, position and mobility, presence of unilateral or bilateral adjoining abnormal masses. Examination may reveal abnormal cervical discharge. The discharge is to be collected for Gram stain and culture.
Special Investigations
Ovarian Factors
Ovarian dysfunctions (dysovulatory) commonly associated with infertility are:
Anovulation or Oligo–ovulation (infrequent ovulation).
Corpus Luteal Insufficiency (CLI).
Diagnosis of Ovulation
The various methods used in practice to detect ovulation are grouped as follows:
Indirect
Menstrual History.
Evaluation of peripheral or endorgan changes due to estrogen and progesterone.
Any gonadotrophins or steroid hormones preceding, coinciding or succeeding the ovulatory process.
Menstrual History:
The following should be noted:
Regular normal menstrual loss between the age of 20–35.
Mid–menstrual bleeding (spotting) or pain or excessive mucoid vaginal discharge.
Premenstrual syndrome or primary dysmenorrhoea (Painful menses).
Evaluation of Peripheral or Endorgan Changes
Basal Body Temperature (BBT)
Observation
There is “Biphasic pattern” of temperature variation in ovulatory cycle. In the 2nd half of the menstrual cycle there is rise in the body temperature by approximately 5degree C. The temperature falls 24–48 hours before the onset of menstrual flow and remains at a lower level during the first half of the cycle. But in anovulatory cycle, there is rise of temperature throughout the cycle. If pregnancy occurs, the rise of temperature sustains along with absence of the period .
Endometrial Biopsy
Endometrium showing secretary changes in the second half of the cycle gives the diagnosis of ovulation. Tuberculosis is a common reason for blockage of the fallopian tube. Curettage is to be done on 21–23rd day of the cycle. Barrier contraceptive should be prescribed during the cycle to prevent accidental conception. However, if the cycle is irregular, it is done within 24 hours of the period.
Cervical Mucus Test
Alteration in the properties of the cervical mucus occurs due to the effect of estrogen and progesterone. Disappearance of fern pattern beyond 22nd day of the cycle which was present in the mid cycle is suggestive of ovulation. Persistence of fern pattern even beyond 22nd day also suggests anovulation. Progesterone causes dissolution of the sodium chloride crystals. Following ovuation there is loss of this fern pattern which was present in the mid cycle.
Vaginal Cytology
Maturation index shifts to the left from the mid cycle to the mid second half of cycle due to the effect of progesterone. However, a single smear on day 25 or 26 of the cycle reveals features of progesterone effect if ovulation occurs.
Hormone Estimation
Serum progesterone: Estimation of serum progesterone is done on day 8th and 21st of a cycle. An increase in value from less than 1 ng/ml to greater than 5 ng/ml suggests ovulation. Serum Leutinizing Hormone– Daily estimation of Serum Leutinizing Hormone at mid cycle can detect the Leutinizing Hormone surge and the ovulation is expected within 24 hours. Serum estradiol (a hormone) attains the peak rise approximately 24 hours prior to LH surge and 48 hours prior to ovulation. The serum LH and oestradiol estimation is used for in vitro fertilization.
Sonography
Sonography during midcycle can accurately measure the Graafian follicle just before ovulation (15–20 mm). It is particularly helpful in the initiation and verification of ovulation, artificial insemination and in vitro fertilization.
Direct
Laparoscopy
Laparoscopic visualization of recent corpus luteum or detection of the ovum from the aspirated peritoneal fluid from the pouch of Douglas (pouch between rectum and uterus) is the only direct evidence of ovulation.
It is done in cases of:
Abnormal HSG findings.
Failure to conceive after reasonable period even with normal HSG.
Unexplained infertility.
Insufflation Test
In this Air or Carbon Dioxide gas is injected into the uterine cavity under pressure. If both the tubes are blocked, there is no leakage of the gas and its pressure in the manometer is maintained.
This test is carried out in the second half of the cycle.
Limitation–Not to be done in the presence of pelvic inflammatory disease.
Hysterosalpingography (HSG)
This is a test for patency of the Fallopian tubes. In this test a radio–opaque dye is injected into the uterine cavity and radiographs are taken. It is the same as insufflation test. Instead of air or C02, dye is instilled transcervically.
It is done when insufflation test is negative. It can precisely detect the side and site of block in the tube. It can reveal any abnormality in the uterus (congenital or acquired like fibroid). But it cannot be done in presence of any bacterial infection of the pelvic organ.
Treatment
This includes hormonal treatment of anovulation, corpus luteum insufficiency, hyperprolactinaemia and thyroid dysfunction. Endometriosis is to be treated. Genital tuberculosis should be treated adequately.
Surgical
Tubal surgery: Tubal plasty is done which is a finer surgery on the fallopian tubes. Uterine surgery: Operation on the uterus. Cervical operation: Cauterization of the cervix is done in cases of excessive leucorrhoea or in presence of erosion or chronic infection of cervix. (cervicitis) Also Vaginal operations.
Leucorrhoea (White P/V Discharge)
Leucorrhoea is per vaginal white discharge, which could be physiological or pathological. This is the commonest symptom with which patient presents.
Physiological Leucorrhoea
Many a times women experience excessive mucoid discharge per vaginum in premenstrual or postmenstrual period, which is normal. It can also be seen in adolescent girls or infants & with sexual excitement.
Pathological Leucorrhoea
Common causes of pathological leucorrhoea are:
Vaginal infections are of following types:
Bacterial–gonococci, tuberculosis, syphilis etc.
Parasitic–Candidial, trichomonal.
Non-specific–foreign body, senile etc.
Cervical erosion & cervicitis.
Uterine polyps, fibroids.
Fibroids are not hereditary. They do have a strange genetic pattern, however, that many fibroids are monoclonal (derived from the same cell). In other words, if a woman has multiple fibroids, sometimes all of those fibroids come from a single cell as if that cell were cloned.
This has led some people to postulate that a virus is involved in producing the fibroid cells that then grow and replicate like a cancer, but in a controlled, non–invasive fashion. If that is true, (we’re really guessing) then people in the same family could be susceptible; not because of genetics, but because of exposure to the same virus.
Smooth Muscle Tumors of the Uterus
Smooth muscle tumors of the uterus are often multiple. Here we discuss submucosal, intramural, and subserosal leiomyomata of the uterus. Fibroids are actually mostly in the muscle of the uterus (intramural) and by virtue of their size or position they “Impinge” upon the endometrium and cause bleeding. Those are the ones which need to be “Shaved” away and that is much more of a procedure than just removing ones that protrude into the endometrical cavity. One however doesn’t trust arterial embolization for fibroids because there have been major complications when blood vessels of the pelvis get embolized when they weren’t supposed to be during the procedure. Fibroids of the uterus are present in about 25% of women. They actually require no treatment in most cases. The only times they require any therapy at all are:
By position or size they cause irregular uterine bleeding that cannot be controlled with hormonal therapy or removal of a polyp–like fibroid (submucosal) from the inside of the uterus at time of hysteroscopy & D & C (an outpatient procedure).
They are so big (usually softball size or more) that they give either pelvic pressure, bladder or rectal pressure or pelvic fullness symptoms.
They are in a position (usually near the ovaries or they have grown so rapidly that there is a question they might be malignant. (Incidence of malignancy is way under 1%).
They cause recurrent pain due to the blood supply being compromised (infarction like a heart attack is felt). This is not common at all but when they cause pain, it is quite colicky like a kidney stone, not like menstrual cramps.
The fibroids cause distortion of the endometrial cavity and women have problems either during pregnancy or then they have frequent miscarriages.
FibroilTreatments can vary from just removing the fibroid’s (myomectomy or submucosal resection) to hysterectomy. There are some medicines to help shrink uterine muscle and fibroids but they are only temporary treatments. Myomectomy (cutting fibroids out of the uterus) has been the standard treatment of symptomatic fibroids when women want to preserve their ability to have children.
Today, this is done without performing large incisions by using specially designed scopes that can be inserted into the body. Treatment with drugs to temporarily shrink the tumors so pregnancy can be attempted before the shrinkage reverses has sometimes been successful. Uterine artery embolization also appears to be a possibility. Coagulation of the tumors through a laparoscope has also been used but is still considered controversial.
Sexually Transmitted
Spread of STI
STIs or sexually transmitted infections can be spread in several ways.
STI is usually spread through sex because the bacteria or viruses travel in semen, vaginal fluids, and blood.
Saliva (or spit) can sometimes spread STI if you have a tiny cut in or around your mouth. Infected blood on needles and syringes can spread STI.
Infected women who are pregnant can pass an STI to their babies during pregnancy and at childbirth.
Except for hepatitis B, there are no vaccinations to prevent STI. If you get an STI once, you can get it again.
And, you can have more than one STI at a time. Many STI’s are easily treated, but all can be dangerous if ignored. For some STI, like genital warts, genital herpes or HIV, there is no cure today.
Myth
“You can’t get an infection or get pregnant the first time you have sex or if the guy doesn’t ‘Come’ inside the woman”.
Fact
Yes, you can. And sex doesn’t have to be full intercourse: you can get an STI just by having really close genital contact with an infected partner. Infection can be spread by body fluids or by oral sex. Protect yourself and your partner by using a latex condom for any kind of sexual activity.
The most commonly found sexually transmitted infections in India is:
Gonorrhea
Gonorrhea (or “Clap”) is an infectious sexually transmitted infection that chiefly affects the mucous membrane of the urogenital tract, the rectum, and occasionally the eyes. The disease is caused by gonococci and belongs to the genera of Neisseria. Discharges from the involved mucous membranes are the source of infection and the bacteria are transmitted by direct contact, usually sexual or during passage of a newborn through the birth canal.
Causes, Incidence, and Risk Factors of Gonorrhea
This infection occurs in people who have been infected with gonorrhea. It affects women more frequently than men (4:1) and its highest incidence is among sexually active adolescent girls. There is also increased risk during menstruation and pregnancy. Two forms of arthritis exist, one with skin rashes and multiple joint involvement but no demonstrable gonococci in the joint fluid; and a second, less common form where disseminated gonococcemia leads to infection of a single joint (monoarticular) and joint fluid cultures are positive.
Single joint arthritis follows generalized spread (dissemination) of the gonococcal infection. Dissemination is associated with symptoms of fever, chills, multiple joint aches (arthralgia) and rashes (1mm–2cm red macules). This episode may end as a single joint becomes infected. The most commonly involved joints are the knee, wrist, and ankle.
In Male
Usually, suffer’s inflammation of the urethra with pus and painful urination. Fibrosis sometimes occurs in an advanced stage, causing narrowing of the urethra. There also may be involvement of the epididymis and prostate gland.
In Female
Infection may occur in the urethra, vagina, and cervix, and there may be a discharge of pus. However, infected females often harbor the disease without any symptoms until it has progressed to a more advanced stage. If the uterine (Fallopian) tubes become involved, pelvic inflammation may follow. Peritonitis, or inflammation of the peritoneum, is a very serious disorder. The infection should be treated and controlled immediately because, if neglected, sterility or death may result. Although antibiotics have greatly reduced the mortality rate of acute peritonitis, it is estimated that between 50,000 and 80,000 women are made sterile by gonorrhea every year as a result of scar tissue formation that closes the uterine tubes. If the bacteria are transmitted to the eyes of the newborn in the birth canal, blindness can result.
Prevention of Gonorrhea
Prevention consists of following safer sexual practices. Monogamous sexual relations with a known disease–free partner are considered the ideal means of prevention. The use of condoms provides the best protection against gonorrhea and other sexually–transmitted diseases. Treatment of all sexual partners of a known infected person is essential to prevent further spread or re–infection.
Symptoms of Gonorrhea
The Common Symptoms are:
Migrating joint pain for 1 to 4 days (polyarthralgia).
Single joint pain.
Fever.
Skin rash or lesion.
Vaginal or urethral discharge.
Pain or burning on urination.
Lower abdominal pain.
Signs and Tests of Gonorrhea
The Doctor may advice one or more of the following tests:
Positive cervical gram stain (positive for gonococci).
Urethral culture for gonorrhea in men.
Cervical culture for gonorrhea in women.
Throat culture for gonorrhea.
Joint fluid gram stain.
Synovial fluid culture for gonorrhea (culture of joint aspirate).
Treatment of Gonorrhea
Abstinence from coitus until the infection is eradicated. Patients are advised bed–rest and analgesics. Various antibiotics are prescribed.
Medication Include:
Injections.
Ceftriaxone 125 mg IM (injected into a muscle).
Spectinomycin 2 grams IM (injected into a muscle).Oral (by mouth) one–time dose.
Cefixime 400 mg.
Ciprofloxacin 500 mg.Ofloxacin 400 mg.
Cefuroxime Axotal 1 gram.
Cefpodoxime proxetil 200 mg.
Enoxacin 400 mg.Oral (by mouth) multiple dose.
Erythromycin 500 mg, four times per day, for one week.A follow–up visit 7 days after treatment to recheck cultures and confirm the cure of infection is important.
Complications
If untreated, Gonorrhea may lead to: persistent discomfort, other gonorrhea complications, such as disseminated gonorrhea (spread throughout the body). Hence, immediate diagnosis and treatment of gonorrhea is essential.
STIs and Pregnancy
Women who are pregnant can become infected with the same sexually transmitted infections (STIs) as women who are not pregnant. Pregnancy does not provide women or their babies any protection against STIs .In fact, the consequences of an STI can be significantly more serious–even life threatening–for a woman and her baby if the woman becomes infected with an STI while she is pregnant. As the list of diseases known to be sexually transmitted continues to grow, it is increasingly important that women be aware of the harmful effects of these diseases and know how to protect themselves and their children against infection.
STIs during pregnancy
STIs can have many of the same consequences for pregnant women as for women who are not pregnant. STIs can cause cervical and other cancers, chronic hepatitis, cirrhosis, and other complications. Many STIs are silent–or present without symptoms–in women. Among the additional consequences pregnant women may suffer from STIs are early onset of labor, premature rupture of the membranes surrounding the baby in the uterus, and uterine infection after delivery.
Infection from the pregnant woman to her fetus
STIs can be transmitted from a pregnant woman to the fetus, newborn, or infant before, during, or after birth. Some STIs (like syphilis) cross the placenta and infect the fetus during its development. Other STIs (like gonorrhea, chlamydia, hepatitis B, and genital herpes) are transmitted from the mother to the infant as the infant passes through the birth canal. HIV infection can cross the placenta during pregnancy, infect the newborn during the birth process, and, unlike other STIs, infect an infant as a result of breast–feeding.
STIs affecting the fetus or newborn
Harmful effects on the baby may include stillbirth, low birth weight, conjunctivitis (eye infection), pneumonia, neonatal sepsis (infection in the blood stream), neurologic damage (such as brain damage or motor disorder), congenital abnormalities (including blindness, deafness, or other organ damage), acute hepatitis, meningitis, chronic liver disease, and cirrhosis. Some of these consequences may be apparent at birth, others may not be detected until months or even years later.
Treatment of STI during pregnancy
Bacterial STIs (like chlamydia, gonorrhea, and syphilis) can be treated and cured with antibiotics during pregnancy. There is no cure for viral STIs such as genital herpes and HIV, but antiviral medication for herpes and HIV may reduce symptoms in the pregnant woman. In addition, the risk of passing HIV infection from mother to baby is dramatically reduced by treatment. For women who have active genital herpes lesions at the time of delivery, a cesarean section may be performed to protect the newborn against infection.
Protection of pregnant women against infection
Although a woman may be monogamous during her pregnancy, she can remain at risk of STIs if her partner is not monogamous. For this reason, she may want to consider consistent and correct use of latex condoms for every act of intercourse. Protection is critical throughout a woman’s pregnancy, including the last trimester when active infection can present a great threat to the health of a woman and her baby.
Various Sexually Transmitted
Gonorrhea
Gonorrhea (or “Clap”) is an infectious sexually transmitted infection that chiefly affects the mucous membrane of the urogenital tract, the rectum, and occasionally the eyes. The disease is caused by gonococci and belongs to the genera of Neisseria. Discharges from the involved mucous membranes are the source of infection and the bacteria are transmitted by direct contact, usually sexual or during passage of a newborn through the birth canal.
In Males
Usually suffer inflammation of the urethra with pus and painful urination. Fibrosis sometimes occurs in an advanced stage, causing narrowing of the urethra. There also may be involvement of the epididymis and prostate gland.
In Females
Infection may occur in the urethra, vagina, and cervix, and there may be a discharge of pus. However, infected females often harbor the disease without any symptoms until it has progressed to a more advanced stage. If the uterine (Fallopian) tubes become involved, pelvic inflammation may follow. Peritonitis, or inflammation of the peritoneum, is a very serious disorder. The infection should be treated and controlled immediately because, if neglected, sterility or death may result. Although antibiotics have greatly reduced the mortality rate of acute peritonitis, it is estimated that between 50,000 and 80,000 women are made sterile by gonorrhea every year as a result of scar tissue formation that closes the uterine tubes. If the bacteria are transmitted to the eyes of the newborn in the birth canal, blindness can result.
Treatment of Gonorrhea
Abstinence from coitus until the infection is eradicated. Patients are advised bed–rest and analgesics. Various antibiotics are prescribed.
Syphilis
Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. The highest incidence is in the 20 to 39 years old age group. It is acquired through sexual contact or transmitted through the placenta to a fetus. The disease progresses through several stages: primary, secondary, latent, and sometimes tertiary.
Primary Stage
During the primary stage, the chief symptom is an open sore, called a chancre (pronounced SHANKG–ker), at the point of contact. The chancre heals within one to five weeks.
Secondary Stage
In secondary stage, from 6 to 24 weeks later, symptoms such as a skin rash, fever, and aches in the joints and muscles usher.
Latent Stage
In latent stage, the symptoms eventually disappear (in about 4 to 12 weeks), and the disease ceases to be infectious, but a blood test for the presence of the bacteria generally remains positive. During this “Symptomless” period, the bacteria may invade body organs.
Tertiary Stage
In the tertiary stage, signs of organ degeneration appear.
If the syphilis bacteria attack the organs of the nervous system, the tertiary stage is called neuro–syphilis. Neurosyphilis may take different forms, depending on the tissue involved. For instance, about two years after the onset of the disease, the bacteria may attack the meninges, producing meningitis. The blood vessels that supply the brain may also become infected. In this case, symptoms depend on the parts of the brain destroyed by oxygen and glucose starvation. Cerebellar damage is manifested by un–coordinated movements in such activities as writing. As the motor areas become extensively damaged, victims may be unable to control urine and bowel movements. Eventually, they may become bedridden, unable even to feed themselves. Damage to the cerebral cortex produces memory loss and personality changes that range from irritability to hallucinations.
During Pregnancy
Infection of the fetus with syphilis can occur after the fifth month. Infection of the mother is not necessarily followed by fetal infection, provided that the placenta remains intact. But once the bacteria gains access to fetal circulation, there is nothing to hinder their growth and multiplication. As many as 80 percent of children born to untreated syphilitic mothers will be infected in the uterus if the fetus is exposed at the onset or in the early stages of the disease. About 25 percent of the fetuses will die within the uterus. Most of the survivors will arrive prematurely, but 30 percent will die shortly after birth. Of the infected and untreated children surviving infancy, about 40 percent will develop symptomatic syphilis during their lifetimes.
Treatment of Syphilis
Syphilis can be treated with antibiotics during the primary, secondary, and latent periods. Certain forms of neurosyphilis may also be successfully treated, but the prognosis for others is very poor. Noticeable symptoms do not always appear during the first two stages of the disease. Syphilis, however, is usually diagnosed through a blood test whether noticeable symptoms appear or not. Some evidence suggests that AIDS may alter the course of neurosyphilis by accelerating its progression, possibly by impairing macrophages and antibody production and facilitating penetration of the AIDS virus into the central nervous system.
Genital Herpes
Unlike syphilis and gonorrhea, genital herpes is incurable. Type I herpes simplex virus is the virus that causes the majority of infections above the waist such as cold sores. Type II herpes simplex virus causes most infections below the waist such as painful genital blisters on the prepuce, glands, penis, and penile shaft in males and on the vulva or sometimes high up in the vagina in females. The blisters disappear and reappear in most patients, but the virus itself remains in the body. Genital herpes virus infection causes considerable discomfort, and there is an extraordinarily high rate of recurrence of the symptoms. The infection is usually characterized by fever, chills, flu like symptoms, lymphadenopathy, and numerous clusters of genital blisters. For pregnant women with genital herpes symptoms at the time of delivery, a cesarean section will usually prevent complications in the child. Complications range from central nervous system damage to death.
Treatment of Genital Herpes
Pain medication, saline compresses, sexual abstinence for the duration of the eruption, and use of some oral drugs. These drugs interfere with viral DNA replication but not with host cell DNA replication. A topically applied ointment that contains Inter Vir–A (Immuvir), an antiviral substance, is another drug used to treat genital herpes. Inter Vir–A provides rapid relief for the pain, itching, and burning associated with genital herpes. An experimental genital herpes vaccine will involve human testing shortly.
Chlamydia
Chlamydia (kla–MID–e–a) is a sexually transmitted infection caused by the bacterium Chlamydia Trachomatis (chlamys = cloak, the bacterium cannot grow outside the body; it cloaks itself inside cells to divide). At present, chlamydia is the most prevalent and one of the most damaging of the sexually transmitted infections. It affects between 3 and 5 million persons annually.
In Males
Urethritis (inflammation of the urethra) is the principal result. It is characterized by burning on urination, frequency of urination, painful urination, and low back pain.
In Females
Urethritis may spread through the reproductive tract and develop into inflammation of the uterine (Fallopian) tubes, which increases the risk of ectopic pregnancy and sterility. As in gonorrhea, the organism may be passed from mother to infant during childbirth, infection the eyes. Treatment consists of the administration of specific antibiotics.
Trichomoniasis
The microorganism Trichomonas vaginalis, a flagellated protozoan (one–celled animal), causes trichomoniasis, an inflammation of the mucous membrane of the vagina in females and the urethra in males. If the normal acidity of the vagina is disrupted, the protozoan may overgrow the normal microbial population and cause trichomoniasis. Symptoms include a yellowish vaginal discharge with a particularly offensive odor and severe vaginal itch in women. Men can have it without symptoms but can transmit it to women none–the–less.
Treatment of Trichomoniasis
Sexual partners must be treated simultaneously. The drug of choice is metronidazole.
Genital Warts
Warts are an infectious disease caused by viruses. Sexual transmission of genital warts is common and is caused by the Human Papilloma Virus (HPV). It is estimated that nearly 1 million persons a year develop genital warts. Patients with a history of genital warts may be at increased risk for certain types of cancer (cervical, vaginal, anal, vulval, and penile). There is no cure for genital warts.
Treatment of Genital Warts
It consists of cryotherapy with liquid nitrogen, electrocautery, excision, laser surgery, and topical application of podophyllin in tincture of benzoin. Alpha interferon is also used to treat genital warts.
STI and Pregnancy.
MTP (Medically Terminated Pregnancy).
Medical Termination of Pregnancy (MTP)
MTP is Medical Termination of Pregnancy. It also called induced abortion. It is the medical way of getting rid of unwanted pregnancy. Any qualified gynecologist (MD/DGO) can perform MTP. Any MBBS Doctor, who has obtained training in MTP, is allowed to perform this procedure. However, MTP should always be performed at a place recognized by government authorities.
Following are the Indications for Medical Termination of Pregnancy
Failure of contraception.
Possible hazards on physical/mental health of the mother.
Pregnancy caused by rape.
Possible hazard to the health of growing fetus.
Medical Termination of Pregnancy is legally permitted up to 20 weeks of gestation. Pregnancy termination performed in first trimester is safer than in second trimester since it has fewer complications. It is illegal to perform MTP after determining sex of the child as Government of India has banned sex determination.
Complications of Medically Terminated Pregnancy
Medical Termination of Pregnancy(MTP) is a procedure that is carried out under anesthesia & increases the risk for the procedure. Patient can have lot of bleeding during & after the procedure. There are high chances of patient having recurrent abortions. Rarely, patient may not conceive again if infection sets in.
Pregnancy
Pregnancy is a new phase in a woman’s life. She gives birth to a bundle of joy, which she has to nourish and cherish. Pregnancy constitutes of joy and hope along with pain and agony during child birth. The mother–to–be needs to be given proper guidance and consultation for a successful and a healthy delivery.
The First Trimester (First 12 Weeks)
The first trimester is a time of profound changes inside your body, and you’ll experience these changes in your own individual way. The first trimester may bring increased energy and a sense of well–being; yet other women may feel increasingly tired and emotional; still others don’t notice many changes until much later in pregnancy.
Although the physical changes of early pregnancy may make you uncomfortable, they don’t endanger your health or the health of your baby. Each pregnancy, of course, is unique, and you may experience many, some or none of the changes and symptoms described here.
Nausea and Vomiting
Nausea and vomiting in early pregnancy may be due to hormone changes produced by the placenta and the fetus. Changes in your gastro–intestinal system may also play a role–the stomach empties somewhat more slowly under the influence of the hormones of pregnancy. Nausea and vomiting may also be aggravated by emotional stress and fatigue.
Even though it is commonly called “Morning sickness”, the nausea and vomiting in early pregnancy can occur at any time of day. It can be more severe in a first pregnancy, in young women and in women carrying multiple fetuses. Usually, it begins at four to eight weeks of gestation and subsides by 14 to 16 weeks. Some women have nausea and vomiting beyond the first trimester, and a few even throughout their entire pregnancy.
In rare instances, nausea and vomiting may be so severe that a pregnant woman cannot maintain proper nutrition and fluids or gain enough weight. This condition is known as hyperemesis gravid arum. Eating smaller meals more frequently throughout the day often helps alleviate nausea. Drinking less fluid with meals may also provide relief. The idea behind these measures is to avoid having your stomach completely empty or completely full, either of which can make nausea worse.
Breast Tenderness
The increased production of the hormones estrogen and progesterone is the primary reason for the changes in a pregnant woman’s breasts. By a few weeks of gestation, you may notice tingling sensations in your breasts, and they may feel heavy, tender and sore.
Weight Gain
Although you’ll probably gain about 25 to 30 pounds (11 to 14 kilograms) during the course of your pregnancy, you’ll put on only a small percentage of this amount during the first trimester. A normal weight gain during the first trimester is only about 2 pounds (about 1 kilogram).
Second Trimester (13th to 28th Weak)
The second trimester, lasts from the beginning of the 13th week of pregnancy until the end of the 27th week, and is sometimes called the “Golden period” of pregnancy. This is when many of the side effects of early pregnancy have diminished. Also you are likely to find that your nausea is easing off, you are sleeping better and your energy is returning. The risk of miscarriage is lower than that in the first trimester. Your enlarging abdomen will begin to be much more noticeable by four or five months.
Now is the time you’ll also want to think about childbirth classes for you and your partner. During the mid–trimester, more blood is produced to supply the placenta with oxygen and nutrients for your baby’s growth. Your digestive system slows the rate at which food moves through your system. And every organ system in your body continues to adapt to pregnancy under the influence of increasing hormone levels. These and other changes may give rise to some of the signs and symptoms described here.
Back Pains
During pregnancy this period the joints between your pelvic bones begin to soften and loosen in preparation for the baby to pass through your pelvis during birth. In the second trimester, your uterus becomes heavier, changing your center of gravity. Gradually–and perhaps without even noticing it–you begin to adjust your posture and the ways in which you move. Another reason for the back pain may be separation (diastases) of the muscles along the front of the abdomen (the rectus abdominis muscles).
These two parallel sheets of muscles run from the rib cage to the pubic bone. As the uterus expands, these muscles sometimes separate along the center seam, and back pain can then become worse. Your doctor can tell whether the amount of separation is more than usual and may suggest ways to remedy the separation after your baby is born.
Abdominal Pain
Pain in the lower abdomen during the second trimester is often related to the stretching of ligaments and muscles around the expanding uterus. Although this cause of abdominal pain doesn’t pose a threat to you or your baby, it’s important to report it to your doctor.
A fairly common cause of abdominal or groin pain in mid–pregnancy is stretching of the round ligament. Actually made of muscle cells, the round ligament is a cord–like structure that supports the uterus. Before pregnancy, the round ligament is less than a quarter of an inch thick. By the end of pregnancy, it has become longer, thicker and more taut. A sudden movement or reach can stretch the round ligament, causing a pulling or stabbing pang in your lower pelvic area or groin or a sharp cramp down your side. The discomfort usually lasts several minutes and then goes away.
Third Trimester (29th to 40th Weak)
The third trimester begins at the 28th week of pregnancy and lasts until birth. This usually is a time of excitement and anticipation of the baby’s arrival. Like many women during late pregnancy, you may be tired of being pregnant, thinking about when labor will start and how your delivery will go. At term, it will weigh about a little over one kilogram, and will have stretched to hold your baby, the placenta and about a liter of amniotic fluid. Nearly all of the physical symptoms of late pregnancy arise from this increase in the size of the uterus.
Shortness of Breath
If you’re like many women in late pregnancy, you may be experiencing some amount of breathlessness. This is because your diaphragm–the broad, flat muscle that lies under your lungs–is being pushed up out of its normal place by the expanding uterus. The diaphragm rises about 4 centimeters from its usual position during pregnancy.
At the same time, though, the hormone progesterone acts on the respiratory center in the brain, causing you to breathe more deeply. As a result, although your total lung capacity is decreased, the volume of air you are taking in with each breath is actually increased during pregnancy. So, despite your own discomfort, the baby’s need for oxygen and blood are being taken care of.
Hip Pain
The increased hormones of pregnancy tend to cause the connective tissue in your body to soften and loosen up. One result is that the joints between the bones of your pelvis become more relaxed. The greater flexibility of these bones makes it easier for the baby to pass through them during birth. Unfortunately, it can also have the added effect of producing hip pain. Hip pain in late pregnancy usually occurs on one side. The changes in your posture, along with lower back pain, that result from the heavier uterus can add to your discomfort.
Sciatica
Pain, tingling or numbness running down the buttock, hip and thigh is called sciatica. It can be caused by the pressure of the pregnant uterus on the sciatic nerve. Two sciatic nerves run from your lower back down your legs to your feet.
Vaginal Pain
Some women occasionally feel a sharp, stabbing pain inside the vagina during late pregnancy. This is probably linked to the cervix starting to dilate, which can happen weeks, days or hours before labor begins. It is usually nothing to be concerned about, but tell your doctor if it causes a great deal of discomfort. Any severe pain in the lower abdomen should be reported to your doctor right away.
.Nausea Heartburn Fainting and Dizziness Leg CrampsConstipation and Hemorrhoids Backaches Coughs and Colds VaricositySkin Changes Stretch Marks High Blood Pressure Pelvic PainInsomnia Bladder Problems Headaches Anemia
Pregnancy Complaints
Nausea
This is also known as morning sickness, but can strike at anytime of the day. These symptoms of nausea and vomiting generally go away by the end of the first three months. Things that irritate the condition: low blood sugar, low blood pressure, hormonal changes, emotional ambivalence, deficiency of vitamin B6 and iron, or excessive amounts of grease or certain spices. Remember, vomiting that is excessive needs medical attention.
Suggestions
Relaxation and deep breathing exercises do help. A protein snack before bed will help lower blood sugar in the morning. In the morning, get off the bed slowly. Take a walk everyday. Sea bands on both wrists for acupressure points also do help. Anise, dried peach tree leaves, fennel seed, red raspberry or ginger teas are home remedies for nausea. Infusion of ginger root and smelling ground ginger help reduce symptoms. Increase iron rich foods in your diet. For those who want to try homeopathy, Ipecac 6X three times daily for 5 days, Nux vomica 6X, Slippery Elm tablets, two before each meal do work. Aromatherapy: lavender, rose, or chamomile for a massage oil.
Diet during Pregnancy
Smart nutritional choices can help make sure that you and your baby start out with the nutrients you both need. You need to make changes during pregnancy to get the extra calories. The key to good nutrition is balance.
Meat, Poultry, Fish, Dry Beans, Eggs and Nuts during Pregnancy
These foods provide B vitamins, protein, iron and zinc. One serving equals 2 to 3 ounces of cooked lean meat, poultry or fish. For the other foods in this group, one ounce of lean meat equals ½ cup of cooked dry beans, one egg or two tablespoons of peanut butter.
Milk, Yogurt and Cheese during Pregnancy
This group is a major source of protein, calcium, phosphorus and vitamins. One serving equals one cup of milk or yogurt, 1½ ounces of natural cheese, or two ounces of processed cheese. Whenever possible, choose items that are made with low–fat, part–skim or skim milk. If you don't like milk or are lactose–intolerant, modified–milk products are available at your supermarket. These include yogurt–milk in cultured form and low–lactose substitutes. If you feel that you are not getting enough milk products, you should talk to your doctor about other sources of calcium.
Fruits during Pregnancy
This group provides vitamins A and C, potassium and fiber. One serving equals one medium apple, banana or orange, ½ cup of chopped, cooked or canned fruit, or one 6–ounce cup of fruit juice. Good sources of vitamin C include berries, citrus fruits or juices, melon and other fruits. Also good are dried fruits such as raisins and prunes.
Vegetables during Pregnancy
These foods contain vitamins A and C, folate, and minerals such as iron and magnesium. They are also low in fat and contain fiber, which helps to alleviate constipation. One serving equals one cup of raw, leafy vegetables (spinach, romaine lettuce, broccoli), ½ cup of other cooked or raw vegetables (carrots, sweet potatoes, corn, peas, potatoes), or ¾ cup of vegetable juice.
Breads, Cereals, Rice and Pastas during Pregnancy
This group provides complex carbohydrates (starches), an important source of energy, in addition to vitamins, minerals and fiber. One serving equals one slice of bread, one ounce of cereal, or ½ cup of cooked cereal, rice or pasta. Try to choose from whole–grain products and foods made with less sugar.
Fats, Oils and Sweets during Pregnancy
Use sparingly, since these products contain calories, but few vitamins or minerals. Fats should not make up more than 30 percent of your daily calories. Try to select low–fat foods.
Iron–Rich Foods during Pregnancy
Since many women are slightly anemic (from monthly blood loss, improper diet or previous pregnancies), you may want to fortify your iron levels even before becoming pregnant with such foods as meat, raisins and prunes or beans, soy products, spinach and cream of wheat. During pregnancy, the daily requirement of iron doubles from 15 mg to 30 mg as blood volume increases and to help the developing fetus. Your body is better able to absorb iron when consumed with foods rich in vitamin C, such as citrus fruits, potatoes and broccoli.
Folic Acid during Pregnancy
Research suggests that folic acid supplementation during the weeks leading up to and following conception may help prevent neural tube defects. Foods rich in folic acid include liver, deep green leafy vegetable.
Investigation during Pregnancy
Beta HcG (Human Chorionic Gonadotropin) Levels During Pregnancy
An HcG Beta Blood test is a sensitive test and can detect pregnancy as early as 10 days after fertilization. Upon conception, a woman’s body starts to produce a “Pregnancy hormone” called the Human Chorionic Gonadotropin, commonly referred to as HcG. HcG production begins approximately 8–10 days after conception when the embryo starts to implant itself into the uterine lining (implantation).
As the embryo grows, the level of HcG rises, and generally should double every two to three days. A dramatic decrease in the levels may indicate a miscarriage. HcG beta levels can also be used to identify a multiple pregnancy. The Beta HcG chart is to be used only as a guideline. Please consult your doctor for further information.
Weeks from the Last Menstrual Period (LMP) Amount of hCG in mIU/ml
3 5–50
4 3–426
5 19–7,340
6 1,080–56,500
7–8 7,650–229,000
9–12 25,700–288,000
13–16 13,300–254,000
17–24 4,060–165,400
25–40 3,640–117,000
Urine Human Chorionic Gonadotropin (HCG Pregnancy Test)
Where is test performed?
Commercial laboratory, hospital, doctor’s office. Test requires only a few minutes in the laboratory. Collect a urine specimen of at least 15ml (about 1 tablespoon) or more. If possible, collect the first–voided morning urine.
Seeing
Urine color varies greatly, whether you’re healthy or ill. Tell the technician, nurse or doctor if urine appears red, cloudy, smoky or has any other strange appearance or color.
Smelling
Urine may have a noticeably abnormal odor if it is concentrated. Many drugs and foods affect the smell and other characteristics of urine. Report any unusual odors to the technician, nurse or doctor.
Feeling
Collecting a urine specimen should not cause pain. If it does, notify the technician, nurse or doctor. Test results are determined by hemagglutination inhibition.
Normal Values
If agglutination fails to occur, test results are positive, indicating pregnancy.
After delivery, hCG levels decline rapidly, within a few days they are undetectable.
Measurable hCG should not be found in the urine of men or non–pregnant women.
What HIGH or INCREASED levels may indicate.
During pregnancy, elevated levels may indicate multiple pregnancy or Erythroblastosis Fetalis.
Choriocarcinoma in men and non–pregnant women.
Ovarian or testicular tumors in men and non–pregnant women.
Melanoma in men and non–pregnant women.
Multiple myeloma in men and non–pregnant women.
Gastric, hepatic, pancreatic or breast cancer in men and non–pregnant women.
What LOW or DECREASED level may indicate.
Threatened abortion.
Ectopic pregnancy.
Taking these drugs may affect test results
Carbamazepine.
Chlorpromazine.
Phenothiazines.
Promethazine.
Other factors that may affect test results
Early pregnancy.
Threatened abortion.
Tap water or soap in the specimen.
Protein or blood in the urine.
Elevated erythrocyte sedimentation rate.
Failure to collect all urine during the test period.
Failure to store the specimen properly.
Pap Smears
Pap Smears Can Save your Life
No cancer screening test in medical history is as effective for early detection of cancer as the Pap examination. Sadly, 80 percent of women who die of cervical cancer have not had a Pap examination in five years or more.
A Pap examination is a simple procedure in which your physician painlessly obtains cells from the surface of your cervix, often using a special brush to sample the area where most cancers begin to develop. The cells are placed on a glass slide, which is sent to a laboratory. At the laboratory, the cells are stained and then examined under a microscope by specially trained cytotechnologists. If an abnormality is found, a pathologist, a physician who specializes in laboratory medicine, studies the cells and makes the final interpretation.
Its primary purpose is to detect early cervical cancer and pre–cancerous conditions. An abnormal Pap smear often means pre–cancer, a change that can lead to cervical cancer if left untreated.
If cancerous or pre–cancerous cells are found, the next step is a more thorough examination of your cervix, during which your physician will obtain tissue biopsies for a pathologist to study.
Sometimes, an abnormal Pap smear means there are uncertain cell changes that could be pre–cancerous or could be entirely benign, needing no further investigation. A Pap examination also may detect infections such as bacteria, yeast or viruses. One kind of sexually transmitted virus is important to detect because of its link to cervical cancer. This virus is Human Papillomavirus (HPV), sometimes called “Condyloma” or genital warts.
Every woman should have an annual Pap examination when she becomes sexually active or turns 18 years old – whichever comes first. Regular Pap examinations should continue after menopause and after a hysterectomy (removal of the uterus).
To ensure that the cells your physician obtains during the exam are adequate for evaluation, you should abstain from sexual activity and avoid using vaginal douches or lubricants for 48 hours before the examination.
Pathologists recommends that you have yearly Pap and pelvic examinations. Cervical cancer takes time to develop into a deadly disease. The pelvic exam is added insurance, it can help detect signs of cancer in female organs other than the cervix.
Any woman can develop cancer of the cervix, but you are at a higher risk if: You have had multiple sex partners or a male partner who has had multiple female partners. If your partner has had sex with other women, you are at high risk even if you have had only one partner.
Antenatal Care Services Provided
Promotion of maternal and child health has been one of the most important components of the Family Welfare Programme of the Government of India and the National Population Policy–2000 (Ministry of Health and Family Welfare 2000).
In 1996, safe motherhood and child health services were incorporated into the Reproductive and Child Health Programme. (Ministry of Health and Family Welfare, 1997, 1998b)
The important components of this programme are
Provision of antenatal care, including at least three antenatal care visits, iron prophylaxis for pregnant and lactating mothers, two doses of tetanus toxoid vaccine, detection and treatment of anaemia in mothers, and management and referral of high–risk pregnancies.
Encouragement of institutional deliveries or home deliveries assisted by trained health personnel.
Provision of postnatal care, including at least three postnatal visits.
Identification and management of reproductive tract and sexually transmitted infections.
Despite the national programmes for improving maternal and child health in India, maternal mortality and morbidity continue to be high (Agarwal et al., 2007).
One of the important reasons for this is under–utilisation or non–utilisation of the maternal health care services due to lack of awareness in the rural and slum population in India.
It is a known fact that education has an important influence on awareness. The lack or low rates of literacy are a major obstacle to health awareness in this area. Due to lack of education, the rural population and the poor urban population still prefer the deliveries performed at home by the Dais (nannies who are not medically trained, but are known for their experience in performing deliveries and are preferred to doctors in rural areas). A study by Ray et al. (1993) showed that practices of delivery at home in slums were found to be 34.7%, which corroborated with the findings of another study (31.7%) by Agarwal et al.(2007). Yet another study of urban slums identified prolonged waiting time, heavy workload at home and long distance as reasons for non–utilization. Women from this population tend not to use antenatal care services due to the traditional belief that medical attention is not required during pregnancy (Jejeebhoy 1997).
Health care–seeking attitudes and age and parity of the pregnant women are co–related. According to a study published in the Journal of Obstetrics and Gynaecology of India (Chandhiok et al., 2006), there was a statistically significant reduction in the proportion of women obtaining antenatal care services with increasing age, parity, and number of living children. In short, awareness and accessibility of health care services heavily influence the health care–seeking behaviour of pregnant women from the rural and urban poor population. According to WHO (1994), most maternal deaths are preventable if women have access to basic medical care during pregnancy, delivery and post partum period.
The antenatal care facilities provided by the government can be accessed by visiting a health centre that provides such facilities or from health workers during their visits. To ensure better health care–seeking attitudes of pregnant women, it is important to create awareness of the possible complications during pregnancy and their management and hence the need for care during pregnancy. This can reduce maternal mortality and morbidity.
A survey commissioned by Department of Family Welfare, Ministry of Health and Family Welfare, Govt. of India and conducted by ICMR (Indian Council Of Medical Research), looked at the immunisation of children and pregnant women including antenatal care of pregnant women. The conclusion of this study from the result was that the literacy of women in rural areas is an important key to improve accessibility of antenatal services provided by the government (Singh & Yadav 2007). Improvement in literacy is estimated to have an effect not just on the initial accessibility of the services but also on the over all compliance with the antenatal care programmes.
Antenatal care has an effect on the health care seeking attitude of women during delivery/ child birth. The results from NFHS–2(National Family Health Survey 2) show that women who received three or more antenatal care visits (as recommended) were more than twice as likely to receive professional assistance for home delivery.
The primary aim of antenatal care is to achieve, at the end of pregnancy, a healthy mother and a healthy baby (Park & Park 2002). With government antenatal care services in place, it is important to look at the reasons for under/ non–utilisation of these services. Addressing these issues will ensure increase in utilisation of these services and in turn decrease maternal and child mortality.
From the above discussion it is clear that public health interventions need to concentrate on literacy of the pregnant women in rural areas and slums in cities and on ensuring sufficient staff in Antenatal Care services to reach out to this population.
Reference
Agarwal P, Singh MM, Garg S. Maternal health–care utilization among women in an urban slum in Delhi. Indian J Community Med 2007,32:203–5.Chandhiok N, Dhillon B.S, Kambo I, Saxena N C. 2006 Determinants of antenatal care utilization in rural areas of India : A cross–sectional study from 28 districts (An ICMR (Indian Council Of Medical Research) task force study) Journal of Obstetrics and Gynecology of India Vol. 56, No. 1: January/February 2006 Pg 47–52.Jejeebhoy SJ. 1997 Maternal mortality and morbidity in India: priorities for social sciences research. J Family Welfare 42(2): 30–51.Mother–baby package: Implementing safe motherhood in countries. World Health Organization: Geneva, 1994.National Population Policy – 2000. Department of family welfare. Ministry of Health and Family Welfare. Government of India, New Delhi.
Park JE, Park K. Text Book of Preventive and Social Medicine, 18th edition M/s. Banarsidas Bhanot Publishers: Jabalpur, 2002: 386.Ray SK, Mukherjee B, Dobe M, Sengupta D, Ghosh M, Chaudhuri N. Utilization of maternal services in West Bengal. Indian Pediatr 1993,30:351–4. [PUBMED].Singh P, Yadav RJ. 2000 Antenatal care of pregnant women in India. Indian J Com Med, 25(3): 112–17.
Unborn Child & Labor
Profile of an Unborn Child
Five Week OldFive Week Old Fetus
A five week old fetus. The baby is about 1/2 inch long, and his heart has been beating for about a week The black circle is the eye and just below is his hand.
His neural tube (later known as the spinal cord) begins to fuse. From now on his nervous system and heart develops. In the next 2 weeks his oral and nasal cavities will form.
Eight to Ten Week OldEight to Ten Week Old Fetus
An eight to ten week old fetus, now longer than an inch with a heartbeat that can be heard for the first time with the help of a Doppler. His muscles are already starting to exercise a little. And his sleepy looking eyelids seem to be falling into a peaceful sleep.
Fourteen Week OldFourteen Week Old Fetus
A fourteen week old fetus. By now he’s grown to 4 inches and weighs an ounce. Facial features become more refined and he’s growing hair. You will soon be able to determine the sex of the child.
Sixteen to Eighteen Week OldSixteen to Eighteen Week Old Fetus
A sixteen to eighteen week old fetus. At this point, he is between four to six inches long and weighs between three to four ounces. His face is much more detailed as are his hands. His head is quite large compared to the rest of his body, specially his eyes. You can now see the details on his face.
Twenty Week OldTwenty Week Old Fetus
A twenty week old fetus. He is nearly ten to eleven inches long now and weighs about 10.6 ounces. That soft, downy hair (lanugo) that he started to grow earlier now covers his entire body, although his skin is still pinkish and translucent. He will be able to hear his mother’s stomach and heartbeat in a couple of weeks, and may even blink and become startled if he hears a loud noise.
Twenty–Six Week OldTwenty–Six Week Old Fetus
A twenty–Six week old fetus now weighing about one pound now and even be viable outside of the womb. The second trimester is coming to a close. His lungs start to make surfactant which helps to keep the lung tissues from sticking together.
He is even engaging in such activities as sleeping, turning, sucking, and kicking.
Thirty Week OldThirty Week Old Fetus
A thirty–week old fetus. At this point, he is nearly fifteen inches long and weighs about 3.1 pounds. Only ten short weeks and it’ll be time to move out. His face and body are just about fully developed, and now he is working on strengthening his organs.
Even his brain is beginning to develop faster than ever. He is even becoming familiar with voices he hears often. And now you know that the baby’s a ‘he’.
Thirty–two to Forty Weeks Old Fetus
A picture taken later than thirty to thirty–two weeks would be difficult to see clearly being as the baby takes up the entire womb at this point. He weighs about 3.85 pounds and is 15.7 inches long, but by the time he is term (forty weeks), he will weigh an average of 7.1 pounds and be about 19.7 inches in length. But from now to the time of birth, the baby is busy hiccupping, responding to outside stimuli, directing body functions, developing sleeping patterns, rolling, and maybe even occasionally giving a swift kick to the ribs.
Cesarean Delivery
A Cesarean section is a surgical method of delivering a baby (or babies) through an incision made in the abdomen and then the uterus. The incision is usually made at the pubic hair line, horizontally and is popularly known as a “Bikini cut” (since the scar is usually below the area that would be covered by a bikini). In a few cases, the older vertical incision may be used. In this case the scar runs from the lower uterus to the upper part of the abdomen.
Sometimes a Cesarean Section is made before labor begins.
There are many reasons for e.g.
Females with placenta previa
Pre–ecclampsia.
Diabetes (if the baby is very big).
A pelvis that’s too small for the baby’s head to fit through.
Rh (Rhesus) factor disease.
Cesarean sections are also done when the baby is not in the typical "head down" position.
Vertex Position or Breech Baby
Vertex PositionThis could be in the breech position, when a baby is delivered buttocks first.
Actually, there are several variations of a breech birth:
The baby may be in a sitting position with both legs crossed (complete breech), have one foot dangling below the rest of the body (footling breech), or have both legs stretched up toward the head (frank breech). The transverse lie, an even rarer position in which the baby’s lies sideways across the uterus, usually with a shoulder resting on your pelvic opening.
How a C–section is performed
If a cesarean section wasn’t planned in advance, your doctor will explain why it’s needed now, as well as the risks of this procedure. Many hospitals will allow your childbirth partner to be present for a cesarean birth. The operation takes about one hour and involves these steps:
Drawing blood for cross–matching and other tests.
Sterilizing the lower abdomen and shaving pubic hair.
Inserting an IV into your arms for medications, if needed, to be given during surgery.
Inserting a catheter into the bladder to drain urine during surgery.
Administering anesthesia which can be spinal, epidural or general.
Making incisions into the abdomen and uterus.
Delivering the baby and placenta through the incision.
Sewing the incision closed.
Who’s at risk?
What are your chances of having a repeat cesarean?
About one–third of all cesarean sections are done on women who have had the procedure in a previous pregnancy. A repeat cesarean section is usually scheduled at some predetermined point in your pregnancy. Many women who had a cesarean section may be candidates for vaginal delivery. VBAC is short for vaginal birth after cesarean section, and is now encouraged for most women who previously delivered a baby by cesarean section. You may be a candidate for VBAC if the condition that necessitated your previous cesarean section isn’t present in this pregnancy (such as your first baby was in the breech position while your second one is head down); you had a low transverse incision in your cesarean section, or you haven’t developed any new condition that would rule out vaginal birth, such as placenta previa.
Other times, the decision for a cesarean section isn’t made until you’re in labor, such as when labor fails to progress, there’s an incomplete opening of the cervix, fetal distress, prolapsed cord, active genital herpes or profuse bleeding.
RH factor
A blood type with a positive Rh factor will produce a protein that inhibits the surface of red blood cells. Rh–negative red blood cells lack this protein. The Rh factor is critical for the sake of an unborn child. The prenatal blood screen performed during the first prenatal visit will determine Rh status.
If an Rh negative woman and an Rh positive man conceive a child, the fetus’ Rh factor will be positive or negative, with no harm to an Rh negative baby and most likely no harm to a Rh positive baby.
However, if the baby’s Rh factor is positive, during delivery the fetus’ Rh–positive blood cells may enter the mother’s bloodstream. In very rare situations, this can happen during pregnancy. Since an Rh–negative mother’s bloodstream does not contain the Rh factor, her body will produce antibodies to fight off the foreign red blood cells, thus threatening the red blood cells of future unborn children. If an Rh–negative mother conceives an Rh–negative baby, there are no foreign red blood cells present and no threat of future fetal blood cell destruction.
An injection of Rh immunoglobulin (Rhlg) given to the mother during the 28th week of pregnancy can usually prevent harm to a developing fetus. If the baby is born with an Rh–positive factor, the mother will receive a second injection within 72 hours after birth to protect the next baby. If the new baby is Rh–negative, no second injection is necessary.
Pune Fertility Center
. Pune Fertility CenterPune Fertility Center is one of its own kind being the only referral center and will be an exclusive center for the treatment of infertility under one roof in our own city of Pune thus providing that ray of hope to the innumerable couples desiring a child. The center has state–of–art facilities for In–Vitro–Fertilization, Micro–manupulation, (ICSI), Assisted Hatching, Sperm & Embryo Cryopreservation, a fully functional endocrinology laboratory for diagnostic & therapeutic tests & facilities for genetic testing such as pre–implantation and prenatal testing for chromosomal & genetic disorders.
Beginning infertility treatment is like entering a new world with its own language. The IVF–In–Vitro Fertilization or Test Tube Baby Treatment is a procedure where the human ovum and spermatozoa are placed in a petri–dish to fertilize outside the woman’s body & then the resulting embryo is transferred to her uterus. IVF effectively overcomes a variety of infertility problems, particularly tubal problems & sperm deficiencies. IVF is a four stage process. During the first phase gonadotropines hormones are used to stimulate the growth of as many eggs as possible. This multiple development increases the chances for fertilization and pregnancy. In stage two the drugs/injections are used to stimulate the release of mature eggs, which are removed or retrieved from the woman's ovaries using a fine needle. The eggs are then transferred to a laboratory dish in the third phase, where the sperms & eggs are combined for fertilization. In the final step a number of fertilized eggs or embryos are inserted back into the uterus.
Intra Cytoplasmic Sperm Injection (ICSI) is useful in men who have inadequate, weak sperms. This procedure involves the micro–manupulation of a single sperm, which is directly injected in a single egg. If the egg is fertilized , the embryo is then transferred back into the uterus using normal IVF procedure.
For the first time a lady gynecologist & embryologist (pathologist) have come together to give this specialized services to the infertile couples in the city.
The team consists of Dr. Bharati Dhorepatil and Dr. Shehbaaz Daruwala.
Dr. Bharati Dhorepatil, Gynecologist & Infertility Specialist is a practicing gynecologist for more than 15 yrs, has undergone special training in Assisted Reproductive Technologies at National University Hospital, Singapore and Augusta Reproductive Biology Associates at Medical College of Georgia, USA. She completed Diploma in Gynecologic Endoscopy at Kiel, Germany.
Dr. Shehbaaz Daruwala, Pathologist & Embryologist is a practicing pathologist for 10 yrs, has undergone special training of Basic Embryology at CRAFT IVF Center, Mumbai and Advanced Embryology training (ICSI) at Schoysman Infertility Management & Foundation, Belgium & Franenklinik, Inselspital, Bern, Switzerland.
The Pune Fertility Center will also introduce the concept of IVF Coordinator & Infertility Support Group.
Pune Fertility Center We Help Bring Dreams ToThe Infertility Coordinator will be a person who will bridge the gap between the patients & specialists. Understanding the psychology of the patients & educating them about their problems is as important as the treatment itself. The patients will not feel like they have been left alone in the world of hi–tech medicine.
The support group will help the infertile couples to have the exchange of thoughts & experiences from the couples who have undergone IVF/ICSI treatment. These support groups will be supervised by specialists & coordinator. The patients will always find warmth, reassurance, support & invaluable guidance from fellow members. This support group will meet once in a month at Pune Fertility Center on every fourth Thursday between 5–6 pm.
For more information contact:
Pune Fertility Center,
Cresent Exclusee,
1162/3, Shivajinagar,
Opp. Akashvani,
Pune 411005, Maharashtra India.
Tel. no: 91 20 5512550
Mobile: +91 9822043112
E–mail: info@aarogya.com
Glossary
A - B - C - D - E - F - G - H - I - J - K - L - M - N - O - P - Q - R - S - T - U - V - W - X - Y - Z
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Acne : (AK–ne)
Inflammation of sebaceous (oil) glands that usually begins at puberty; the basic acne lesions in order of increasing severity are comedones, papules, pustules and cysts.
Acquired Immune Deficiency Syndrome (AIDS) :
A disorder characterized by a positive HIV–antibody test and certain indicator diseases (Kaposi’s sarcoma, Pneumocystis carinii pneumonia, tuberculosis, fungus diseases, etc.). A deficiency of helper T cells and a reversed ratio of helper T cells to suppressor T cells that results in fever or night sweats, coughing sore throat, fatigue, body aches, weight loss, and enlarged lymph nodes. Caused by a virus called Human Immunodeficiency Virus (HIV).
Amenorrbea (a–men–o–RE–a)
Absence of menstruation.
Amniocentesis (am’–ne–o–sen–TE–sis)
Removal of amniotic fluid by inserting needle trans–abdominally into the amniotic cavity.
Amnion (AM–ne–on)
The innermost fetal membrane; a thin transparent sac that holds the fetus suspended in amniotic fluid. Also called the “bag of water.”
Amniotic Fluid (am’–ne–OT–ik)
Fluid in the amniotic cavity, the space between the developing embryo (or fetus) and amnion; the fluid is initially produced as a filtrate from maternal blood and later from fetal urine.
Androgen (AN–dro–jen)
Substance producing or stimulating male characteristics, such as the male hormone testosterone.
Apgar Score (AP–gar)
A method for assessing the overall status of an infant soon after birth based on evaluation of heart rate, respiratory effort, muscle tone, reflex irritability, and color.
Areola (a–RE–o–la)
Any tiny space in a tissue. The pigmented ring around the nipple of the breast.
Atresia (a–TRE–ze–a)
Abnormal closure of a passage, or absence of a normal body opening.
Axilla (ak–SIL–a)
The small hollow beneath the arm where it joins the body at the shoulders. Also called the armpit.
FAQs
This diagnostic test is usually performed between 8 and 11 weeks gestation, sometimes as late as 13 weeks. This is generally a test for people who have a high risk of genetic abnormalities. Test results are available within 7 to 14 days. Miscarriage rate from CVS is about 4%, recent studies indicate that if the CVS is done before 10 weeks gestation there is an added risk (.5% to 1.7%) of limb deformity, and about 3% CVS is associated with serious decline in amniotic fluid protection.
There is a greater incidence of false positives because of the differences between the cellular genetic material of the choirionic villi and the fetus. There is a small chance that the sex they determine is wrong as well.
Amniocentesis
This diagnostic test is performed as early as 9 weeks and for diagnostic purposes, 18 weeks gestation. There is a risk of 1–1.5% miscarriage and 1% chance of other pregnancy complications (infection, premature labor, injury to the fetus, cord, or placenta, rupture of membranes, etc.). The tests take about 2–4 weeks to run. There is a small chance that the sex they tell you is incorrect.
Ultrasound
While ultrasound can be performed at any stage of pregnancy for the purpose of finding out the sex it is best done between 18 and 26 weeks. Most care providers will not give an ultrasound for the specific purpose of finding out the sex, and the American College of OB/GYNs has issued a statement against routine ultrasound exposure during pregnancy. However, most physicians do not heed this warning. Adequate studies on ultrasound safety have not been done, but we do know that ultrasound exposure can change the way the cell reproduces and moves. There have also been studies indicating that ultrasound heats up the cells. This method is the most frequent for finding out the sex of a baby, however, it is the least accurate. Accuracy depends on several factors: baby’s cooperation, gestational age, technician’s ability, etc.
There are many decisions to be made and everyone has their “Reasons” for whichever way they choose. I will try and list a few:
Reasons to find out the Baby’s Sex
Pick only one name.
Buy sex specific clothes.
Decorate the nursery.
Bonding with a specific baby.
Why not?
Reasons to Wait
Like the surprise.
Help make the last few weeks of pregnancy bearable, not knowing.
Could have fantasies about either sex.
To annoy relatives.
Did not have the need for the technology.
What are some reasons that would mean I would need a cesarean?
Prolapsed cord (where the cord comes down before the baby), Placenta Abruptio (where the placenta separates before the birth), Placenta Previa (where the placenta partially or completely covers the cervix), Fetal Malpresentation (transverse lie, breech (breech can sometimes be managed by External Version, exercises or a vaginal breech birth), or Asynclitic Position), Cephalopelvic Disproportion (CPD, meaning that the head is too large to fit through the pelvis.
This can also be over diagnosed, it can be caused by maternal positioning either from restraint to bed, lack of mobility or anesthetics.), Maternal medical conditions (active herpes lesion, severe hypertension, diabetes, etc. (please note that these conditions do not ALWAYS mean a cesarean.), Fetal Distress (This is a hot topic with the recent studies indicating that continuous electronic fetal monitoring increases the cesarean rate and does not show a relative increase in better outcomes. Discuss with your care provider how they define fetal distress and what steps are used to remedy the situation before a cesarean.), Maternal Exhaustion, and Repeat Cesarean, these are the main reasons for cesareans.
What type of pain relief is offered before and after a cesarean?
If you have not already had a epidural or spinal anesthesia for labor, or this is a scheduled cesarean, and not an emergency cesarean, you will most likely be given a regional anesthetic (epidural or spinal). If there is a reason that you can’t get regional anesthesia or it is an emergency you will be given a general anesthetic. You may be offered or want to watch for someone giving you a pre–operative sedative. If you are not particularly nervous about the cesarean, you may want to forego this medication. It can reach the baby and make it harder to start the baby breathing after a narcotic (usually), and it can make you groggy and unaware during the birth. After the birth your regional anesthesia will help you be pain free for a few hours, after which you will be prescribed some other type of pain medication (narcotic or otherwise).
What is the procedure for a cesarean?
Cytochem Laboratories Semen Bank
Cytochem laboratories is a well equipped Pathology Laboratory operational in the city of Pune since 1990. Cytochem Laboratories commenced its Semen Bank in the year 1992 after a steady and increasing demand for Semen Samples for Artificial Insemination of Donor Samples (AID) in infertile couples with a Male Factor.
AID or Artificial Insemination by a Donor sample is a simple procedure whereby a woman whose husband has no sperms in his Semen sample or has Sub fertile sperms, is inseminated with a Semen characteristics.
Strict selection criteria are laid down and followed for including an individual as a Donor in this Program. Educational qualifications, family background, Medical history and screening for any hereditary diseases are recorded. A record of Physical characteristics and Blood Group is maintained for matching with recipient’s features and Group Blood Tests for HIV, VDRL and Hepatitis B are carried out initially and repeated after 3 months.
Strict confidentiality is maintained. Both Recipient and Donor need to sign a Consent form. All records are Computerized and coded for strict confidentiality.
Individuals interested in becoming Donors can contact Cytochem Laboratories and speak to Dr. Mirashi or Dr. Thakar on 4475580 or write.
In addition to Donor samples, Cytochem Laboratories Semen Bank also stores samples for Patients undergoing treatment for infertility and where the Husband is schedules to go out of station for a long time, or for patients who need to store their samples before undergoing surgery, Chemotherapy or Radiotherapy.
Cytochem, the semen bank at Tilak Road, Pune’s only sperm bank who do much more than just sell sperms.
Shocking as it may sound, a few years ago, the semen samples that came for regular testing at the pathology labs in the city were taken and used for artificial insemination. No tests were done to check for HIV and venereal diseases. Neither was one sure if the sperm sample had enough motile (alive) sperms for fertilization with the egg.
The request for sperm samples became so frequent that Dr. Milind Mirashi and Pravin Thakar decided to extend their laboratory to include a bank where sperm samples could be frozen and quality controlled; so that tested samples could be made available to infertile couples of the city. Cytochem, Pune’s first and only sperm bank was established in 1992. Explaining the rising number of requests for these samples, Dr. Thakar says, “Ten to fifteen percent of Indian couples face infertility, and in most cases, the cause is the husband’s inadequate sperm count. In such cases, the two options available to these couples are adoption and Donor Insemination”.
AID or Artificial Insemination by the Donor is a simple procedure whereby a woman whose husband has no sperms in his semen or has sub–fertile sperms, is inseminated with a semen sample from a man with normal semen characteristics. Even though the subject remains taboo in the country, more and more couples are now willing to undergo the procedure.
In Pune, gynecologists and infertile couples have responded positively to the idea. Importing semen samples from Mumbai involves getting them in special cylinders which becomes an expensive venture. “Moreover, once the samples are de–freezed, they have to be used within an hour to retain quality,” adds Dr. Mirashi. For rupees four hundred, getting quality samples so close to home is like a miracle for the couples.
“Other than the quality of the samples, the time factor is extremely important in infertility cases,” notes Dr. Thakar. A woman undergoing treatment has to be artificially inseminated exactly on the fourteenth day of the cycle or within twenty–four hours of ovulation. Otherwise, she would lose an entire cycle and would have to prolong her treatment to the next one. Since the infertility treatment costs a lot for the patient, availability of samples at any given time of the day and month is of great importance, a requirement that the lab fulfills.
Dr. Thakar explains the procedure of freezing samples, “After three days of abstinence, donors are asked to give the semen samples in a sterile container. This sample is allowed to liquefy and one drop is taken on a slide for route examination. The remaining sample is mixed with a series of buffers and chemicals, aliquoted into 0.5 ml vials and frozen at ‘196 degrees centigrade in nitrogen cylinders’. The donors are strictly screened, their family history is looked into and they are questioned about any history of illness so as to prevent transmission of hereditary disease. A record of physical characteristics and blood groups are maintained so that it can later be matched with the recipient couple. Tests for HIV, VDRL and Hepatitis B are carried out and tests are repeated after three months so as to ensure that the samples are positively free from diseases especially AIDS.
According to the doctors, the process is not all that complicated as it sounds. What they say is complicated and difficult in this business, is to get the donors to give their samples.
“Donors have to be made aware of the physical and psychological problems of the couple under treatment. The trauma they undergo and the society’s attitude towards them realize that the act of donating a sample will go a long way in bringing happiness in someone’s life,” emphasizes Dr. Thakar. He continues, “It should also be clear to the donor that complete secrecy will be maintained regarding his identity. Once the donor signs a consent form, the information is fed into the computer in a coded form, accessible only to the two doctors. Both the doctors feel that providing samples for needy couples is not merely business, but also social work and it is this philosophy that they want to extend to the donors.
Dr. Sunita Tandulwarkar, gynecologist who has been regularly taking samples from the lab opines, “The success rate for my patients (with no female infertility factor) is as high as sixty to seventy percent after I started taking the samples from Cytochem.” Remarks like these have been a big boost to the work done in the lab. The duo have simultaneously started storing samples for patients who have been prescribed to undergo treatments like chemotherapy or radiotherapy, so that the samples can be used later by their wives when they want to conceive.
However the focus continues to be on motivating donors, so that one day, the doctors can have enough samples to provide options to the recipient couple to choose the characteristics they want for their baby. (Dr. Pravin Thakar and Dr. Milind Mirashi can be contacted on 4475580).
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