Infertility investigations

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The woman and her partner should be present at the initial evaluation for infertility. The doctor will obtain a full clinical history from the couple and then proceed on to a physical examination. The initial investigations that need to be performed will be based on these assessments. Sometimes, the cause of the infertility may be found at this visit. Further evaluation and clinic visits may be necessary for other couples. It may take several weeks. This is because some of the tests may have to be repeated for verification at different specific times in her menstrual cycle. The initial workup of a man usually can be done faster, because men have no monthly cycles and because there are fewer tests for men.

COMMON INVESTIGATIONS IN FEMALE

Ultrasound scan of the pelvic organs
Ultrasound is used to detect abnormalities in the uterus (such as fibroids, polyps, abnormal shape) or the ovaries (such as cysts). The ultrasound is usually done vaginally as this is gives a better image quality and more sensitive in picking up abnormalities. Antral follicle count may be done using the ultrasound scan and this assessment can be helpful in predicting the likely response to the various treatment options. It is a measurement of the number of egg-containing follicles that are developing in the ovaries. A high numbers of antral follicles count indicates a greater ovarian reserve and more likely to respond better to ovarian stimulation.

Hormone tests
Laboratory blood studies to measure certain hormones that play a role in fertility is not routinely done if the woman has a regular menstrual cycle. Indications will depend on the woman’s menstrual pattern, her age, and other clinical features that may suggest an endocrine abnormality. The tests include luteinizing hormone (LH), follicle-stimulating hormone (FSH), oestradiol, Anti-Mullerian hormone (AMH), prolactin, thyroid and male hormones (such as testosterone). The Anti-Mullerian hormone (AMH) is a test to assess ovarian reserve.

Health screening
This should include screening for infections such as syphilis, hepatitis B and C, human immunodeficiency virus (HIV) and cervical cancer (with test such as Pap smear/Thin prep or test to detect Human Papilloma virus). A full blood count is also important to exclude thalassemia and other blood disorders.

Hysterosalpingogram (HSG)

Normal HSG

Hysterosalpingogram (HSG) is an x-ray examination that is used to evaluate the uterine cavity and to check for patency of the fallopian tubes (whether the tubes are blocked). It is done just after a woman’s menstrual period, so there is no danger of her being pregnant and thereby exposing the fertilized egg or embryo to radiation. A dye (technically called a contrast medium) is injected through the cervix. It spreads into the uterus and the fallopian tubes, allowing them to be visualized on x-ray. X-rays are taken during the injection of dye. There may be some cramping or discomfort felt as the dye is injected. You may be asked to change positions for different x-ray views. The x-rays will show the outline of the uterus and fallopian tubes as the dye fill them and spill into the abdominal cavity. Conditions detected by the hysterosalpingogram may require further testing for confirmation; this may include a laparoscopy or hysteroscopy (use of a small lighted telescope to view internal organs).

Saline Infusion sonohysterography (SIS)
Saline infusion sonohysterography (SIS) is also sometimes called saline infusion hysterogram (SHG). It is an investigative procedure to assess the uterus cavity to ascertain the shape and look for any abnormalities within it. It incorporates an ultrasound scan and instillation of sterile fluid into the uterus to show the uterine cavity and endometrial layers. With the use of an ultrasound scan, the uterine wall and the ovaries can be visualized as well.

Hysteroscopy
The hysteroscope is a small-lighted telescope used for visual examination of the cervix and the uterus to help diagnose and treat abnormalities in the cervical canal or the uterine cavity. Saline fluid is used to distend (expand) the uterine cavity to improve visualization and allow any operative manipulations to be achieved. Video monitoring is often used at the same time. It is sometimes performed in combination with a laparoscopy. Hysteroscopy can be used for the removal of intrauterine growths (such as endometrial polyps or fibroids), a biopsy of the endometrium, removal of the lining or separation of adhesions.

Laparoscopy and tubal patency test
Laparoscopy is a procedure that allows visual examination and treatments of the pelvic and abdominal organs. The procedure is performed with a laparoscope, which is a small-lighted telescope. This is performed under general anesthesia. It is often necessary to place an instrument on the cervix and uterus in order to help move the uterus around. A small incision is made in or below the patient’s navel. A needle is inserted to inflate the abdomen with carbon dioxide. Following this, the laparoscope is inserted and used to examine the abdomen visually. It is connected to a high intensity light and a high-resolution television camera so that the doctor can see what is happening inside of you. Instruments are inserted through additional tiny incisions in the abdomen if necessary and are used to treat pelvic abnormalities. A colored solution (usually blue dye) is injected into the uterus via the cervix to assess whether the fallopian tubes are blocked.

Investigations that are not necessary anymore
• Basal body temperature
• Post-coital test

COMMON INVESTIGATIONS IN MALE

Semen analysis
It is almost always the first test done on men and may be repeated several times. After abstaining from intercourse for about 3 – 5 days, the man collects a semen sample via masturbation, into a clean container that is provided by the laboratory. The sample is microscopically examined to determine the number, activity and shape of individual spermatozoa (sperm cells) and the characteristics of the fluid part of the semen. A normal and healthy ejaculate typically contains more than 2 ml of semen, and each ml will contain an average of 20 million sperm that look to be of normal size, shape and behavior. If the specimen markedly differs on any of these factors, further tests may be done.

Hormone tests
The commonest hormone tests include measurements of luteinizing hormone (LH), follicle-stimulating hormone (FSH) and testosterone levels. However, this is not routinely done unless there is abnormalities of the semen analysis or positive physical findings.

Health screening
This should include screening for infections such as syphilis, hepatitis B and C, human immunodeficiency virus (HIV).

Testicular biopsy
This is a minor operation—performed with a local or general anaesthetic—in which a small amount of tissue from the testes is removed for laboratory studies. This test is done only when the semen analysis does not show any sperm at all.

 

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Stress and hormonal imbalance in women

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Life is full of stress. It is common to everyone. Some people are able to handle stress better than others while many cannot cope with the stress that comes with everyday modern living. Stress can affect the well-being of both one’s physical and mental health. Physical stress occurs when a person does not have enough rest, engaging in exercises to the extreme limit of bodily endurance, has a poor diet, or suffers from illness and disease. Mental stress may arise from worries about matters such as money, jobs, retirement, marriage, or the death of loved ones. Sometimes the stress that arises is subtle, and a person may not even realize she is experiencing it. For example, one may feel tired and overwhelmed after a hard day’s work. This fatigue may be a result of either physical or mental stress or a combination of both. Either way, the body is taxed to some degree.

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Premenstrual Syndrome (PMS)

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Premenstrual syndrome (PMS) involves symptoms that begin 7 to 14 days prior to the next menses and usually disappear when men­struation flow begins. A significant proportion of women experience PMS at some point in time; some more frequent than others. The severity can range from mild only to very severe form. Luckily, this is only seen in a small proportion of women. For some women, it may get worse as they age and will disappear once they reach menopause. However, during this transition period, it may overlap with the menopause symptoms.

 Symptoms and signs

  •  Physical changes such as fatigue, lack of energy, tender and/or swollen breasts, fluid retention causing puffiness in ankles, hands, and face.
  • Dizziness or fainting, headaches.
  • Digestive issues such as constipation, diarrhoea, bloating, heartburn, food cravings, increased appetite or overeating.
  • Psychological symptoms – such as mood changes, pronounced tension, and anxiety, sleeping difficulty, depression, difficulty concentrating, less interest in work or the usual activities.
  • Skin changes such as acne outbreaks.
  • Sexual issues.

These are the common ones and there are many other symptoms that may be attributed to PMS as well. If you think you have PMS, you should keep track of your symptoms and assess the severity for at least 2 months. The use of the PMS symptoms diary is very useful and you can show this diary to the doctor during the consultation. It is a useful aid for the diagnosis and for assessment of response to treatment. You can download one example from this link.

Causes

 The cause is unknown but may be due to fluctuations in the circulating level of hormones in the regular menstrual cycles (especially oestrogen and progesterone). These fluctuations cause retention of sodium in the blood­stream, resulting in oedema in body tissues and contributing to some of the physical symptoms. There may be other contributing factors such as psychiatric, endocrinologic, diet, and changes in the chemical’s levels in the body (endorphin, sero­tonin, prostaglandin).

Risk increases with:

  • Increased levels of stress.
  • Caffeine and high fluid intake seem to worsen symptoms.
  • Smoking may also intensify or increase symptoms.
  • PMS increases with age.
  • PMS can occur with other disorders such as depression.

Diagnosis

A physical examination and other investigations will be done to rule out other disorders. Diagnosis usually depends on a history of symptoms and their relationship to the menstrual cycle. Keeping a menstrual diary to monitor and record symptoms severity is helpful. This is also essential for diagnosis and assessment of improvement to treatment.

Prevention

No specific preventive measures but you can try to avoid stressful situ­ations at the expected time of PMS. Support from close friends or spouse will be helpful.

Expected outcome

Lifestyles and behavioural modifications, with or without medications can adequately control PMS symptoms.

Complications

Physical and psychological symptoms may be severe enough to disrupt a woman’s life.

Treatment

General

  • Treatment steps involve education and understanding of the problem faced by the woman. Begin a regular, aerobic exercise program (such as walking, biking, swimming etc) and learn relaxation techniques. These are beneficial in general and both are encouraged as part of stress reduction. Meditation or yoga may be helpful. If feasible, reduce activities during symptomatic days if it helps.
  • Stop smoking.
  • Get regular sleep.
  • Cognitive behavioural therapy (CBT) may provide some relief for some women. This can be done concurrently with other therapy for more effective relief of PMS.

Dietary changes

  • Decrease salt intake during the premenstrual phase.
  • Eat a balanced diet with plenty of fiber (fruits and vegetables), whole grains varieties, and food rich in calcium and vitamins B.
  • Eat regular meals and snacks throughout the day. Skipping a meal may make you more miserable due to low blood sugar or hungry pang.
  • Limit or abstain intake of alcohol, caffeine, and sodas.
  • Keep well hydrated

Medications

These are used with varying degrees of success. Treatment should be individualized, based on the main presenting symptoms and the woman’s reproductive needs at that point in time.

  • Complementary medicine such as Vitex agnus castus (chasteberry) can be tried in mild PMS and can be effective in some women. There are also many vitamins and supplements that are popular as a treatment for PMS such as primrose oil (for breast tenderness), vitamin B6, calcium and vitamin D. These may be helpful in relieving a few symptoms but may not work for everyone. It is generally not prescribed as a routine. If you are taking any complementary medicine or supplements, please inform your doctor about it because some of these may interact with the prescribed medications. The role of acupuncture is still uncertain.
  • Diuretics pills can help you to pass out more urine to reduce fluid retention.
  • Pain medications such as paracetamol, ibuprofen or celecoxib.
  • Medications are used to suppress the cyclical hormonal change and these include the combined oral contraceptive pills (COCs) and gonadotropin-releasing hormone agonists (GnRH agonist). COCs pills will be a good option for those who require contraception as well. Drospirenone-containing COCs are effective and licensed to be used for PMS. GnRH agonist injection will suppress the ovarian hormone production, leading to a state of low oestrogen or pseudo-menopausal state. However, for long term use, the oestrogen-progestin combinations pills need to be given as add-back therapy to avoid menopausal symptoms and estrogen-deficiency complications such as bone loss
  • Selective serotonin reuptake inhibitors (SSRIs) are a group of drugs that target the serotonin system by increasing the level in the brain. Serotonin is one of the chemicals that is important in the transmission of signals between brain nerve cells (neurons). Elevated levels will improve the transmission of signals among the neurons in the brain and help to improve mood and sense of well-being.

Surgery

Surgery is the last resort. This is rarely required because generally, medical therapy is usually effective in relieving symptoms of PMS. This type of surgery is a major operation and will involve the removal of both ovaries and the fallopian tube, usually in conjunction with the removal of the uterus (hysterectomy).

You should see your doctor immediately if you have:

  •  You or a family member has symptoms of PMS that interfere with normal activities or relationships.
  • Symptoms do not improve, despite treatment.
  • New or unexplained symptoms develop. Medications used in treatment may produce additional new side effects.

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Bacterial vaginosis (BV)

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Bacterial vaginosis (BV) is caused by an overgrowth of certain types of bacteria, which results in vaginal inflammation.  With BV, there is a shift in the bacterial ecosystem, favouring the “not so good or healthy” type such as Gardnerella vaginalis, Mycoplasma hominis and Mobiluncus species and a corresponding reduction in the healthy types such as lactobacillus. There is also a disturbance of the vaginal pH. Bacterial vaginosis most often occurs during reproductive years. It is not regarded as a sexually transmitted infection, but sexual activity has been linked to the development of this infection.

Symptoms and signs

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Myths and facts of combined oral contraceptive (COC) pills

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Currently, there is a wide selection of contraceptive methods available to suit the various reproductive needs of couples. Despite these, there is still a huge unmet need with regards to contraception. There are 123 million women around the world who are not receptive to contraception. In the 2015 United Nations Population Fund (UNFPA) report, 15 million adolescent girls in developing countries gave birth and 13 million lacked access to contraceptives. WHO estimated that approximately 214 million women of reproductive age, in developing regions, who want to avoid pregnancy are not using a modern contraceptive method and between 2015 and 2019, almost half of all pregnancies were unintended.

The combined oral contraceptive (COC) pills are readily available in the markets and yet women avoid them due to their belief in the myths surrounding them. Following are some common myths regarding the combined oral contraception pills and the facts to dispel them.

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Vulval Care

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The female external genitalia area (also called the vulval area) is particularly susceptible to skin disorders since this area is warm, sweaty, and moist. The wearing of undergarments in this type of condition can predispose the area to constant irritations and possible infections. Many types of irritants can aggravate the skin such as vaginal and menstrual discharge, use of sanitary pads or panty liner, synthetic undergarments, and vaginal lubricants. Chemicals used in the manufacturing of the undergarments, sanitary pads, and panty liners may act as irritants and sensitizing allergens. In postmenopausal women, lack of oestrogen can cause atrophy of the skin, with gradual loss of subcutaneous fat and skin elasticity. The labia fold (external skin fold at the side) will also shrink in size. This thinning of the skin will predispose to irritation and may lead to various skin disorders.

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Heavy Menstrual Bleeding (HMB)

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menstrual bleedingHeavy menstrual bleeding or HMB (previously called menorrhagia) is a significant cause of morbidity in women of reproductive age. It often involves soaking through ten or more sanitary napkins in a day, a menstrual flow that lasts for seven to 14 days or even longer. The presence of “flooding” or clots is indicative of heavy bleeding. Normal menstrual blood flows freely without clotting. This is because of the presence of an anti-clotting agent produced by the uterus. However, if the bleeding is excessive and far exceeds the amount of anti-clotting agent available, then the remaining blood that flows out will form clots. Bleeding between menstrual cycles is also abnormal. The presence of other clinical signs such as anaemia will further support the diagnosis and indicate the severity of the bleeding

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Endometrial polyps

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Endometrial polyps are growths that arise from the inner walls that lined the uterine cavity. It is sometimes called uterine polyps. It is believed to arise from the overgrowth of endometrial tissue. It may range in size from a few millimetres only to a few centimetres. Sometimes, there can be several polyps present at the same time. It may have a long stalk and can extends through the cervix into the vagina.
An endometrial polyp is usually a non-cancerous growth. However, in a small proportion of women, some of these polyps can lead to cancer (called pre-cancerous type). The risk of cancer in a polyp is increased in post-menopausal women. It can arise at any age but rarely occur in women under 20 years old.

Cause and risk factors

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