Fertility and Infertility

• In recent years, high-risk pregnancies have increased by 15-20%.
• Women aged 30-38 are typically at high risk of pregnancies

Assessment of Risk Factors

• Demographic factors are important to note
• Socioeconomic status plays a role
• The obstretic history is important to note
• Determine the current OB status
• Past maternal medical history/status may highlight risk factors
• Consider habits and habituation

Management at Antenatal Clinic

• Complications can occur during pregnancy, affecting the health and survival of both the mother and the fetus.
• Every pregnant woman needs at least 4 checkups during pregnancy.
• Registration and the 1st checkup should occur within 12 weeks.
• Additional checkups should be at the 14 - 26 weeks.
• Furthermore checkups should be at 28-32 weeks.
• The fouth checkup should be at 36-40 weeks.
• A proper and complete history should be taken.
• General physical, systemic, and abdominal examinations must be done during each ANC visit.

High Risk Conditions of Pregnancy Not to Be Missed

• Severe anemia is a concern if Hb is less than 7 mg/dL.
• Pregnancy-induced hypertension, pre-eclampsia, and pre-eclamptic toxemia are dangerous
• Syphilis and HIV positive status causes risks
• Gestational diabetes mellitus is a risk factor
• Hypothyroidism is a factor that raises the risk
• Being a young primigravida (less than 20 years) or an elderly gravida (more than 35 years) can cause complications
• Menopause and other underlying complications can affect pregnancy
• Carrying twin multiple pregnancies raises the risk
• Malpresentations of the foetus must be considered
• Previous lower segment cesarean sections can be relevant
• Low-lying placenta or placenta previa.
• A positive bad OB history can raise the risk
• This could include a prior History of stillbirth, Abortion, or Congenital malformation
• Or a prior history of Obstructed labor, or Premature birth
• An RH negative blood type raises risk
• Note any current systemic illnesses or past medical history of illness.

Warning Signs to Be Explained to Each Pregnant Woman

• Fever above 38.6C for more than 24 hours indicates possible infection.
• Headache or blurring of vision
• Generalized swelling of the body and puffiness of the face
• Palpitations, easy fatigability, and breathlessness at rest
• Pain in the abdomen
• Vaginal bleeding or watery discharge
• Reduced fetal movements

Prenatal Diagnostic Examinations

• Screening identifies apparently healthy people who may be at increased risk of a disease or condition.
• Screening provides information, further tests, and appropriate treatment to reduce risk and/or complications.
• Assessment defines the nature of the problem, determines the diagnosis, and develops specific treatment recommendations.
• A diagnostic test establishes the presence or absence of disease as a basis for treatment decisions.
• Diagnostic tests are conducted for treat symptomatics or screen positive individuals for confirmatory testing.

Non-Invasive Diagnostic Tests

• A fetal ultrasound uses reflected sound waves to produce a picture of a fetus, placenta, and amniotic fluid.
• The fetal ultrasound images are displayed on a TV screen that can be in black and white or in color.
• Other names for a fetal ultrasounds are a sonogram, echogram, or scan

1st Trimester Fetal Ultrasound Uses

• Determines how the pregnancy is progressing
• Finds out if pregnant with more than 1 foetus
• Estimates the age of the fetus (gestational age)
• Estimates the risk of a chromosome defect, such as Down syndrome
• Checks for birth defects that affect the brain or spinal cord

2nd Trimester Fetal Ultrasound Uses

• Estimates the age of the fetus (gestational age).

• Determines size and the position of the fetus, placenta, and amniotic fluid levels

• Determines position of the foetus, umbilical cord, and placenta during a procedure, such as an amniocentesis or umbilical cord blood sampling.

• Detects major birth defects, such as a neural tube defect or heart problems.

• Cardiotocography (CTG) technically records (-graphy) the fetal heartbeat (cardio-) and the uterine contractions (-toco-) during pregnancy, typically in the 3rd trimester.

• The machine used to perform the monitoring is called a cardiotocography, more commonly known as an electronic fetal monitor (EFM).

• A nonstress test is a common prenatal test used to check on a baby's well being.

• During a nonstress test, also known as fetal heart rate monitoring, a baby's heart rate is monitored to see how it responds to the baby's movements.

• Nonstress Test are Recommended for women at increased risk of fetal death, and are done after week 26 of pregnancy

• Results might necessitate further monitoring, testing or special care.

• A contraction stress test (CST) is Performed near the end of pregnancy to determine how well the fetus will cope with the contractions of childbirth.

• The aim is to induce contractions and monitor the foetus to check for heart rate abnormalities using a cardiotocograph.

Interpretation of the CST

• NEGATIVE indicates no late decelerations and adequate FHR recording
• POSITIVE indicates late decelerations present with the majority of contractions (without excessive uterine activity)
• Equivocal test results are deemed suspicious, and the test as hyperstimulation and unsatisfactory

Invasive Pregnancy Diagnostic Test

• Chorionic villi are small structures in the placenta that act like blood vessels that contain cells from the developing foetus.

• A Chorionic villus sampling (CVS) test removes a sample of these cells through a needle

• CVS Determines chromosomal or genetic disorders in the foetus,. by sampling the chorionic villus (placental tissue) and testing it for chromosomal abnormalities, usually done at 10-12 or before 15 weeks' gestation.

• Amniocentesis removes some fluid from around the sac surrounding the baby inside the uterus to determine birth defects and genetics

• Amniocentesis is done between 14 and 20 weeks of gestation.

• Amniocentesis is offered to women who are at increases risk for bearing a child with birth defects

• This involves all women who:

  • Will be 35 or older when they give Birth
  • Had a screening test result that indicates there may be a birth defect or other problem
  • Have had babies with birth defects in other pregnancies
  • Have a family history of genetic disorders

• Down syndrome, Anencephaly, and Rare metabolic disorders are the reasons

• Embryoscopy examines the embryo at 9-10 weeks' gestation through the intact membranes by introducing an endoscope into the exocoelomic space transcervically or transabdominally.

• Embryoscopy allows Management of early pregnancy in selected families affected by recurrent genetic syndromes.

• An Embryoscopy can identity recognizable external foetal abnormalities.

• The procedure-related risk of Embryoscopy foetal loss around 12 per cent

• Fetoscopy examines the foetus after 11 weeks gestation

• Cordocentesis or percutaneous umbilical cord blood sampling is diagnostoc to examine blood from the foetus to detect foetal abnormalities.

• An advanced imaging UTZ guides a thin needle through the abdomen and uterine walls to the umbilical cord to retrieve a small sample of foetal blood.

• Samples are sent to the laboratory for analysis, and results are usually available within 72 hours

• Cordocentesis is similar to amniocentesis except the goal is to retrieve blood

• Cordocentesis is done after 17 weeks of pregnancy, when there are cases where when diagnostic information can not be obtained through amniocentesis, CVS, ultrasound or the results of these tests were inconclusive.

• Cordocentesis detects chromosome abnormalities ((i.e. Down Syndrome blood disorders (i.e. foetal hemolytic disease.)

• Cordocentesis can detect Malformations of the foetus such as Fetal infection ((i.e. toxoplasmosis or rubella) with tests for foetal platelet count in the mother, Foetal anemia with Isoimmunisation

Causes of Subfertility

• Male causes 30%
• Female causes 30%
• Mixed causes 30%
• Unexplained causes 10%

Factors Affect the Natural Conception Rate

• For females, >35 years, there is a decline in oocyte quality and number

• For males, semen quality tends to fall in men over the age of 50, while frequency of intercourse tends to fall in men over the age of 40

• Smoking reduces fertility in female and cement quality in males

• Alcohol is harmful to the foetus and can affect cement quality

• Stress and anxiety affect libido and coital frequency

• Recommended coital frequency is 2 to 3 times per week

• Being over or underweight an affect ovulation

• Women with a BMI of >29 or <19 will find it hard to conceive

• Non steroidal anti inflammatory drugs (inhibit ovulation)

• Chemotherapy destroys rapidly dividing cells

• Some drugs effect cement quality

• Exposure to chemicals and radiation has a negative affect on male and female fertility rates

• Ovum life expectancy is about 1 day if not fertilized

• The sperm should be available in the female genital tract at or shortly before ovulation

Factors Affecting Fertility: STIs and Other Infections

• Gonorrhea and chlamydia can cause infertility

• In women, can cause Pelvic inflammatory diseases (major cause of tubal infertility) and cervicitis

• In men, can cause Urethritis, Epididymitis, Accessory gland infections

• Mumps can lead to orchitis, which may cause secondary testicular atrophy

• Other infections: Tuberculosis

Main General Health Factors Which Affect Fertility

• Consider 24-hour food intake, alternative therapies (herbs), alcohol, recreational drugs, and smoke Congenital health problems, UTIs, and STDs
• Radiation to his testes, X-rays, or an industrial accident
• Surgical repair of a hernia or torsion of the testes
• Job or lifestyle involving sitting for long periods
• Sexual practices, such as frequency of coitus, and Masturbation

Health History Which May Effect Fertility

• In coital position, failure to achieve ejaculation

• Use of douches or sprays can interfere with vaginal pH levels

• In Females, consider Past pregnancies, miscarriages, or abortions

• Hx contraceptive use can be a factor

• Current or past reproductive tract problems (infections) are important

• Endocrine problems such as Galactorrhea (breast nipple secretions),thyroid dysfunction

• Abdominal or pelvic operations can restrict blood-flow

• Hx childhood cancer treated with radiation that reduced ovarian function

Factors That Cause Male Subfertility

• Disturbance in spermatogenesis

• Inadequate production of FSH and LH in the pituitary, which stimulates sperm productio

• Obstruction that prevents movements

• Qualitative/quantitative changes inhibit motility

• Development of autoimmunity

• Problems in ejaculation or deposition sperm from getting close enough to the cervix

• Chronic or excessive exposure to X-rays or radioactive substances

• General ill health, poor diet

Limited Cement Count

• The cement count is the number of cement in a single ejaculation or in a milliliter of cement.

• Normal is considered to have 30-46 million cement per ml or >50million cemem per ejactulation

• 50% of cement that are motile

• 30% that are normal

• Diseases such as Mumps, Orchitis, Epididymitis or ascending urethral infection due to gonorrhea,

• Benign hypotrophy will make it likely after 50

• Anomalies of the penis, or hypospadias.

• Obesity can affect sperm in males

Ejaculation Problems

• Medical issues such as cardiovascular and Parkinson's
• finasteride used for male pattern baldness may result in hormonal imbalances
• Premature ejaculation can also be psychological

Factors of Female Subfertility

• Anovulation can be the primary cause
• Cervical or vaginal matters that immobilize spermatozoa
• Poor nutrition in general

Subfertility: Polycystic Ovary Syndrome

• Excess testosterone levels

• Irregular or unpredictable menstruation

• Reduce weight to have benefits

• Tubal transport are a factor for subfertility

• Stenotic cervical or obstruction can halt sperm

• D&C procedures

• Detailed history and physical examinations

• cement examination

• Checking tubes

General and Sexual

• Occupation
• Medications
• Prior operations

Female

-Past pregnancies

• Curent issues

Tests for Ovarulation

• Checking cervical fluid

Low Validity Testing:

• To check for sperm to penetrate

• In women , use medications to induce ovarulation

Procedures

• Inject sperm

Noncoital Methods

• In virto fertilization (IVF)
• ZIF
• GIFT

Vitro Fertilization

• Retrieve sperm (for males too)
• Stimulate to make sure to grab eggs
• 20% result

Intra Fallopian

• 28% rates

• Tubal embryo and is more rare

Intracypalasmic

4 Common Problems of the Gynecological System:

• Cysts, especially in the ovaries

Ovarian Cyst

• Semi soild fillded in the ovary

Etiology

• Caused by cell growth

• Common among menstrual cycles

• Pathological and caused by abnormal cell growth

• Endometriosis and pelvis pain

• Causes egg folicles Bloating, pain and breast tender ness are symptoms

• Sharp or sudden abdominal pain

• Ultrasound, MRI tests are used to analyze

Management

• Check frequently for changes

• Hormone medicines and pills used

Anagelsics

• NSAIDs like Ibruprofen

• Laparoscopy allows the doctor to see

• Reomoval is needed and required

Complications

• Affects infertility

Endrometrium is a type of uterine wall

• Deep is near the bowel and bladders

Retrograde means blood goes the other way through the fallopian tubes

Symptoms

• Pains can be present throughout periods

• Hormone pills can help

• Uerterial fibroids often are not malignant

• Check urine, blood is needed

• Poly cist will increase the testosterone levels

• Vitamins often required

• Heavy or painful periods

• Bleeding can happen due to pregnancy or periods

• Use birth pills for reduction

• Disruptions can cause hormonal changes

Questions about fertility testing, factors affecting fertility (lifestyle, age), and classifications of subfertility. Also tests of knowledge of cordocentesis and gestational diabetes risks. Includes questions on male and female infertility factors.