Uterine Fibroids Overview

Introduction

Infertility is a disease defined as the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination. Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after 6 months for women over age 35 years.

A woman's fertility declines from her mid-30s into her 40s, as her egg supply ages. At the same time, her risk of miscarriage increases. Although a man's sperm count decreases with age, male fertility is not known to be greatly affected by age. (www-obsgynhelathcenteronlin e. com. 2016)

Definition

Infertility: means inability to conceive after one year or 6 months for women over age 35 years of regular intercourse without the use of contraception.

Sterility: means inability to conceive due to a cause which can't be treated as absence of uterus, 10-15% of married couple is infertile.

Types:

·        Primary infertility: it means conception has never occurred.

·        Secondary infertility: it means failure of conception after one or more previous successful pregnancy.

Etiology of infertility:

To conceive, certain things have to happen: vaginal intercourse must take place around the time when an egg is released from woman ovary; the system that produces eggs has to be working at optimum levels; and her hormones must be balanced. Causes of infertility are:

1. Female actors:

Female infertility may be caused by blockage of the Fallopian tube due to malformations, infections such as chlamydia and/or scar tissue. For example, endometriosis can cause infertility with the growth of endometrial tissue in the Fallopian tubes and/or around the ovaries. The following causes of female infertility include:

Figure: Shows causes of female infertility

Ovulatory disorders; to be pregnant, a woman need to ovulate. This is defined as a process of producing and releasing an egg. These ovulatory disorder may be a result of:

1.      Polycystic ovary syndrome (PCOS), that is one of the most common hormonal disorders among female affecting approximately 6%-12% of women all over the world. In addition to other symptoms (abnormal menstrual periods, central obesity, hair loss, acne, hirsutism, etc.), PCOS results in anovulation (absence of ovulation).

2.      Other disorder is premature ovarian insufficiency (POI). This condition is also known as premature menopause and refers to the loss of function of the ovaries before the age of 40. POI leads to anovulation and decreased estrogen production.

Figure : Shows The view of the polycystic ovary.

Endometriosis; is a disorder when tissue that belongs to the uterus grows in other locations for example:

1-ovaries                                                   2- Fallopian tubes

3-tissues surrounding uterus                   4- pelvic cavity

About 30% -50% of women with endometriosis are infertile. In addition to infertility, endometriosis is accompanied by other symptoms including painful and heavy periods, pain at the ovulation and pain during sexual intercourse.

Figure: Shows Endometriosis – inner layer of the uterus   growing in abnormal locations.

Pelvic adhesions; are strings or bands of scar tissue that develop around the Fallopian tubes, ovaries, uterus and bowel. These adhesions occur as a result of:

1-      Pelvic inflammatory disease (PID). PID refers to an infection of reproductive organs (uterus, tubes, etc.) that is accompanied by lower abdominal pain. It is a complication of sexually transmitted diseases (chlamydia and gonorrhea) that can lead to infertility,

2-       Ectopic pregnancy and chronic pelvic pain.

3-       Also be caused by endometriosis, ruptured appendicitis and previous surgeries, particularly on the ovaries, tubes and uterus. Pelvic adhesions may result in tubal blockage and interfere with the ovulation process causing infertility.

Tubal blockage; when the tubes are blocked or damaged, the sperm cannot reach the egg and conception is not possible.** Causes of tubal blockage vary from

1.      Anatomical abnormalities

2.      Previous surgeries in uterus or tubes

3.      Infection due to sexually transmitted diseases, especially chlamydia or gonorrhea.

Figure: Shows tubal blockage prevents the sperm from fertilizing the egg.

Hyperprolactinemia; is defined as a condition of abnormally high level of prolactin in the blood, excessive amount of prolactin causes infertility by interfering with ovulation process. Other symptoms of hyperprolactinemia in women include loss of periods, breast milk secretion (galactorrhea), loss of libido and breast pain.  Most commonly hyperprolactinemia is associated with disorders of the pituitary gland, however it also can accompany the use of certain medications (antipsychotics, antidepressants, antihypertensive, etc.).

Other causes; infertility may be a result of some factors as

1-      Uterine factors (malformations, Asherman's Syndrome, uterine fibroids (also known as myomas) and polyps).

2-      Cervical factors (Cervical stenosis, antisperm antibodies and non-receptive cervical mucus).

3-      Vaginal factors (vaginismus and vaginal obstruction), these congenital reproductive tract abnormalities may cause infertility.

2- Male factor

Role of male (30- 40 %) of infertility

·        Spermatonesis: is a continuous process since puberty and take 72 days by testes stimulated by FSH and completed by spermogenesis.

·        Sperm Transport: epidermises, vas defence, ejaculatory duct passing through the prostate and lastly through the urethra.

·        Sperm Deposition: coitus and ejaculation with adequate seminal fluid.

Imperfect Spermatonesis: A-testicular causes

·        Congenital: undescend testes (cryptochidism)

·        Traumatic: direct trauma tight clothes or varicocele

·        Inflammatory: mumps, T.B, syphilis, orchitis

·        Neoplastic: exposure to radiation that destroy your testes

B-central cause

·        CNS causes as Meningitis

·        Pituitary causes as adenoma

C- General causes

·        Endocrinal causes as D.M, hypo or hyper thyrodism.

·        Aging (fertility decrease with age), over or under WT.

·        Some Drugs, Stress, Excessive alcohol intake.

Obstruction in sperm transport:

·        Congenital: Absent or hypoplastic of vas deference or testes.

·        Traumatic: surgical trauma e.g. accidental vas ligation during hernia repair.

·        Inflammatory: Epidimitis and prostatitis (due to gonorrhea, T.B, or Bilharzias)

·        Neoplastic: tumor of epididmis or prostate.

Failure of sperm deposition:

·        Congenital: Epispadius or Hypospadius

·        Impotence and Premature ejaculation

·        Retrograde ejaculation into urinary bladder (due to spinal cord injury, D.M, nephropathy).

Causes in seminal fluid:

·        Abnormal high or low volume (less than 2ml or greater than 7ml) low volume may be too small to allow adequate contact with cervix, high volume dilutes sperm concentration so insufficient number comes in contact with cervix.

·        Azoospermia: complete absence of spermatozoa in the seminal fluid.

·        Polyspermia: marked increase in the number of Spermatozoa more than 250.000000/ml.

·        Oligospermia: marked diminution in the number of Spermatozoa less than 15.000000/ml.

·        Necrospermia: all spermatozoa are dead.

·        Asthenospermia: reduction or loss of motility of spermatozoa.

·        Agglutination: more than 10% of sperm show agglutination.

·        Low fructose or low prostaglandin content (fructose is essential for metabolism and prostaglandin for motility of spermatozoa).

·        Antibodies: male produce antisperm antibodies to his sperm.

Coital factor:

·        Apareunia and Dyspareunia.

·        Vaginismus.

·        Flour seminis which means abnormal escape of semen from vagina after coitus.

·        Infrequent intercourse or poor timing of intercourse.

·        Vaginal washing immediately after intercourse washes away the sperm.

·        The use of lubricant when coitus is difficult this interfere sperm motility and migration.

Immunological Factor:

·             The wife produces antibodies to her husband spermatozoa.

·             The husbands produce antibodies to his own sperm.

Idiopathic or Unexplained:

·        NO cause is found it about 10%

Diagnosis of Infertility:

Investigation for female: A- History:

·        Personal history

·        Menstrual history

·        Obstetric history

·        Past history

·        Family history

·        Sexual history

B- Examination:

·        General (general health status, thyroid function, breast for galactorrhea, chest, heart, presence of secondary sex characters distribution of hair and fat)

·        Abdominal (for pelvicabdominal swilling e.g fibroid

·        Pelvic exam. To detect abnormality in the pelvic organ e.g. uterine hypoplasia.

C- Special Investigation:

Detection of ovulation (ovarian factors)

·        Basal Body Temperature

·        Premenstrual Endometrial Biopsy

·        Examination of Cervical Mucus

·        Vaginal Smear

·        Hormonal Assays

·        Ultrasound

Investigation for tubal potency

·        Hysterosalpigography (HSG)

·        Laprascopy

·        Sonohysterosalpigography

·        Direct transcervical cannulation of the fallopian tube.

Investigation of the uterine factor

·        Endometrial Biopsy to detect secretory change or endometritis.

·        Sonography show uterine anomalies , fibroid or adhesion

·        Hysterosalpigography shows anomalies and fibroid.

Investigation of cervical factors

Postcoital test: the test performed just before ovulation when cervical mucus is excessive (12th or 13th day) sample of cervical mucus is examined microscopically to detect characteristics that enhance sperm survival and to assess adequacy of estrogen production.

Investigation of vaginal factors

·        The PH of the vagina is determined by universal indicator excessive vaginal acidity kill the spermatozoa

·        Examined for vaginitis.

Investigation for the male: A- History

·        Personal history

·        Present history

·        Family history

·        Past history

·        Sexual history

·        Special habits (smoking, alcoholism)

B- Examination:

·        General examination for diseases which depress testicular activity as D.M

·        Local examination for genital organ for abnormalities as hypospadias, undescended testicle and varicocele.

C- Special Investigations:

·        Semen analysis: to show normal characteristics of it (the amount of semen is about 3-5ml in the coitus or ejaculation, the motility of sperm 90 % of them remain motile after 2hrs and about 20% of them have malformation in normal, reaction alkaline PH 7.2-8 , sperm count 20-120.000/ml).

·        Testicular biopsy to show azoospermia is due to failure of spermatogenesis.

·        Chromosomal study and testing for autoantibody husband serum.

·        Vasography: Dye is injected to determine the site of obstruction in the vas deference.

·        Scrotal ultrasound detects varicocele, small testis and epididymis anatomy.

Treatment of infertility:

Once an accurate diagnosis is made, appropriate interventions and treatment for infertility should first address any underlying medical condition that may be contributing to fertility problems. If this step does not restore fertility, there are several treatment approaches: (1) Drugs to induce ovulation, such as clomiphene and gonadotrophins, (2) Assisted reproductive technologies (ART) such as in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI), (3) Lifestyle measures (healthy lifestyle, planning sexual activity with ovulation cycle, managing stress and emotions) and Complementary and Alternative Medicine (CAM)

First treatment option: Lifestyle Changes

Lifestyle can make huge benefits in overcoming infertility, and achieving a higher overall level of health. When it comes to lifestyle changes, there are some steps you can take that are scientifically proven to affect fertility. Fundamentally, an improved diet, regular exercise, and healthy habits can do a great service. Some tips include:

1- Healthy Foods to Improve Fertility:

·         Balanced colourful diet: include various colours of fruits and vegetables. Spinach, green pepper, cucumber, apples, strawberries and red peppers. For yellow and orange, incorporate bananas, nectarines, lemons and for the blue and purple category.**

Figure: Shows the best sources of healthy foods for infertility.

·         Whole grains: lead to an improved fertility, so go ahead and include plenty of whole grains like wheat, rice, oats, cornmeal, etc., in daily diet.

·         Omega 3 fatty acids: Many fishes, Walnuts, flax seeds and whole grains are a rich source of omega 3 fatty acids, eat fishes such as catfish, salmon etc., which are known to have little or no mercury. Supplements such as fish oil which contain a mixture of omega 3, omega 6 and omega 9 fatty acids are also beneficial and the high content of omega-3 fatty acids may help to reduce inflammation, and promote the proper production of hormones.

Figure: Shows the best sources of omega 3 foods to improve fertility.

·         Dates: contain several nutrients that can help boost your ability to conceive. They are rich in vitamins A, E and B as well as iron and other minerals, also help with regular bowel movements and treat constipation.

2-Planning Sexual Activity and Monitoring Basal Body Temperature:

3-Reduce stress:

Stress can lower chances of conception. Hence, it is important to minimize stress and practice healthy coping methods like relaxation through meditation and yoga when trying to conceive.

Figure: Shows some of the stress reduction techniques

4-Exercise: exercising too much or not enough can have an adverse effect on your hormonal balance and cause sterility issues.  Medications can help with this, but changing your lifestyle to incorporate a moderate amount of exercise is preferred.

Figure: Show types of woman's exercises **

Second treatment option

Treatment for Female: (treat the cause)

·        Ovulatory Drugs for Anovulation.

·        Cervical dilatation for stenosis cervix.

·        Cauterization for non-specific chronic cervicitis

·        Excessive vaginal acidity is treated by an alkaline vaginal douche (one spoon sodium bicarbonate is one liter of water) given 30 minute before coitus.

·        Tupoplasty for the blocked tubes in the form of salpingolysis (adhesiolysis), resection and end to end anastomosis.

·        Surgical intervention for correction of anomalies, removal of obstruction as fibroid.

B- Treatment For Male: (treat the cause)

·        Early treatment of undescended testicle.

·        Early treatment of prostatitis before being chronic

·        Carful treatment of mumps orchitis and infection.

·        Treatment the cause as varicocele, hydrocele,

·        Treatment of obesity and avoid tight clothes.

·        Hormonal support for hormones imbalance.

·        For autoimmunity cortisone is used.

Artificial Insemination:

·        Indication of it :

o    Failure of deposition of semen into the vagina due to impotence, hypospadius, epicardia's, premature and retrograde ejaculation and presence of vaginismus.

o    Subfertile semen due to oligospermia, polyspermia and asthenspermia .

o    Hostile cervical mucus which cannot be treated.

o    Sever uterine retroversion.

o    Sterile husband (insemination with denoted semen but it is forbidden in Muslim cultures).

Techniques of it:

·        In Vitro Fertilization (IVF)

·        Embryo Transfer (ET)

·        Zygote Intrafallobian Tube Transfer (ZIFT)

·        Gamete Intrafallobian Tube Transfer (GIFT)

·        Surrogate Mothering (SM)

Prevention:

·        Avoid using of tobacco (cigarettes) and marguana which reduce fertility (decrease sperm count).

·        Avoid exposure to chemicals or radiation and toxins.

·        Avoid excessive alcohol use which damage egg or sperm.

·        Avoid tight under clothes.

·        Avoid sex partners it reduce the risk of STDS.

·        Maintain body WT close to ideal for your height to reduce the risk of hormone imbalance

·     Sex counseling to identify sexual difficulties, teach specific exercise and different coital position

·     Avoid lack of sleep

·        Psychological support is the most important factor for infertile

Advices to increase the chance of conception:

·        Remove sugar , cereals and farina from your diet

·        Use natural fats, eating more coconut, coconut oil, olives, olive oil, eggs, avocado, nuts

·        Eat lots of green leafy vegetables (lettuce, spinach, lopush), broccoli, cauliflower, cabbage and food rich in iron

·        Avoid processed dairy products (cream and ghee)

·        Drink about four liters of water a day (urine should be very bright)

·        Control the level of insulin.Introduction  

Infertility is a disease defined as the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination. Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after 6 months for women over age 35 years.

A woman's fertility declines from her mid-30s into her 40s, as her egg supply ages. At the same time, her risk of miscarriage increases. Although a man's sperm count decreases with age, male fertility is not known to be greatly affected by age. (www-obsgynhelathcenteronlin e. com. 2016)

Definition

Infertility: means inability to conceive after one year or 6 months for women over age 35 years of regular intercourse without the use of contraception.

Sterility: means inability to conceive due to a cause which can't be treated as absence of uterus, 10-15% of married couple is infertile.

Types:

·        Primary infertility: it means conception has never occurred.

·        Secondary infertility: it means failure of conception after one or more previous successful pregnancy.

Etiology of infertility:

To conceive, certain things have to happen: vaginal intercourse must take place around the time when an egg is released from woman ovary; the system that produces eggs has to be working at optimum levels; and her hormones must be balanced. Causes of infertility are:

1. Female actors:

 Female infertility may be caused by blockage of the Fallopian tube due to malformations, infections such as chlamydia and/or scar tissue. For example, endometriosis can cause infertility with the growth of endometrial tissue in the Fallopian tubes and/or around the ovaries. The following causes of female infertility include:  

Figure: Shows causes of female infertility

Ovulatory disorders; to be pregnant, a woman need to ovulate. This is defined as a process of producing and releasing an egg. These ovulatory disorder may be a result of:

1.      Polycystic ovary syndrome (PCOS), that is one of the most common hormonal disorders among female affecting approximately 6%-12% of women all over the world. In addition to other symptoms (abnormal menstrual periods, central obesity, hair loss, acne, hirsutism, etc.), PCOS results in anovulation (absence of ovulation).

2.      Other disorder is premature ovarian insufficiency (POI). This condition is also known as premature menopause and refers to the loss of function of the ovaries before the age of 40. POI leads to anovulation and decreased estrogen production.

Figure : Shows The view of the polycystic ovary.

Endometriosis; is a disorder when tissue that belongs to the uterus grows in other locations for example:

1-ovaries                                                   2- Fallopian tubes

3-tissues surrounding uterus                   4- pelvic cavity

About 30% -50% of women with endometriosis are infertile. In addition to infertility, endometriosis is accompanied by other symptoms including painful and heavy periods, pain at the ovulation and pain during sexual intercourse. 

Figure: Shows Endometriosis – inner layer of the uterus   growing in abnormal locations.

Pelvic adhesions; are strings or bands of scar tissue that develop around the Fallopian tubes, ovaries, uterus and bowel. These adhesions occur as a result of:

1-      Pelvic inflammatory disease (PID). PID refers to an infection of reproductive organs (uterus, tubes, etc.) that is accompanied by lower abdominal pain. It is a complication of sexually transmitted diseases (chlamydia and gonorrhea) that can lead to infertility,

2-       Ectopic pregnancy and chronic pelvic pain.

3-       Also be caused by endometriosis, ruptured appendicitis and previous surgeries, particularly on the ovaries, tubes and uterus. Pelvic adhesions may result in tubal blockage and interfere with the ovulation process causing infertility. 

Tubal blockage; when the tubes are blocked or damaged, the sperm cannot reach the egg and conception is not possible.** Causes of tubal blockage vary from

1.      Anatomical abnormalities

2.      Previous surgeries in uterus or tubes

3.      Infection due to sexually transmitted diseases, especially chlamydia or gonorrhea. 

Figure: Shows tubal blockage prevents the sperm from fertilizing the egg.

Hyperprolactinemia; is defined as a condition of abnormally high level of prolactin in the blood, excessive amount of prolactin causes infertility by interfering with ovulation process. Other symptoms of hyperprolactinemia in women include loss of periods, breast milk secretion (galactorrhea), loss of libido and breast pain.  Most commonly hyperprolactinemia is associated with disorders of the pituitary gland, however it also can accompany the use of certain medications (antipsychotics, antidepressants, antihypertensive, etc.).

Other causes; infertility may be a result of some factors as

1-      Uterine factors (malformations, Asherman's Syndrome, uterine fibroids (also known as myomas) and polyps).

2-      Cervical factors (Cervical stenosis, antisperm antibodies and non-receptive cervical mucus).

3-      Vaginal factors (vaginismus and vaginal obstruction), these congenital reproductive tract abnormalities may cause infertility.

2- Male factor

Role of male (30- 40 %) of infertility

·        Spermatonesis: is a continuous process since puberty and take 72 days by testes stimulated by FSH and completed by spermogenesis.

·        Sperm Transport: epidermises, vas defence, ejaculatory duct passing through the prostate and lastly through the urethra.

·        Sperm Deposition: coitus and ejaculation with adequate seminal fluid.

Imperfect Spermatonesis: A-testicular causes

·        Congenital: undescend testes (cryptochidism)

·        Traumatic: direct trauma tight clothes or varicocele

·        Inflammatory: mumps, T.B, syphilis, orchitis

·        Neoplastic: exposure to radiation that destroy your testes

B-central cause

·        CNS causes as Meningitis

·        Pituitary causes as adenoma

C- General causes

·        Endocrinal causes as D.M, hypo or hyper thyrodism.

·        Aging (fertility decrease with age), over or under WT.

·        Some Drugs, Stress, Excessive alcohol intake.

Obstruction in sperm transport:

·        Congenital: Absent or hypoplastic of vas deference or testes.

·        Traumatic: surgical trauma e.g. accidental vas ligation during hernia repair.

·        Inflammatory: Epidimitis and prostatitis (due to gonorrhea, T.B, or Bilharzias)

·        Neoplastic: tumor of epididmis or prostate.

Failure of sperm deposition:

·        Congenital: Epispadius or Hypospadius

·        Impotence and Premature ejaculation

·        Retrograde ejaculation into urinary bladder (due to spinal cord injury, D.M, nephropathy).

Causes in seminal fluid:

·        Abnormal high or low volume (less than 2ml or greater than 7ml) low volume may be too small to allow adequate contact with cervix, high volume dilutes sperm concentration so insufficient number comes in contact with cervix.

·        Azoospermia: complete absence of spermatozoa in the seminal fluid.

·        Polyspermia: marked increase in the number of Spermatozoa more than 250.000000/ml.

·        Oligospermia: marked diminution in the number of Spermatozoa less than 15.000000/ml.

·        Necrospermia: all spermatozoa are dead.

·        Asthenospermia: reduction or loss of motility of spermatozoa.

·        Agglutination: more than 10% of sperm show agglutination.

·        Low fructose or low prostaglandin content (fructose is essential for metabolism and prostaglandin for motility of spermatozoa).

·        Antibodies: male produce antisperm antibodies to his sperm.

Coital factor:

·        Apareunia and Dyspareunia.

·        Vaginismus.

·        Flour seminis which means abnormal escape of semen from vagina after coitus.

·        Infrequent intercourse or poor timing of intercourse.

·        Vaginal washing immediately after intercourse washes away the sperm.

·        The use of lubricant when coitus is difficult this interfere sperm motility and migration.

Immunological Factor:

·             The wife produces antibodies to her husband spermatozoa.

·             The husbands produce antibodies to his own sperm.

Idiopathic or Unexplained:

·        NO cause is found it about 10%

Diagnosis of Infertility:

Investigation for female: A- History:

·        Personal history

·        Menstrual history

·        Obstetric history

·        Past history

·        Family history

·        Sexual history

B- Examination:

·        General (general health status, thyroid function, breast for galactorrhea, chest, heart, presence of secondary sex characters distribution of hair and fat)

·        Abdominal (for pelvicabdominal swilling e.g fibroid

·        Pelvic exam. To detect abnormality in the pelvic organ e.g. uterine hypoplasia.

C- Special Investigation:

Detection of ovulation (ovarian factors)

·        Basal Body Temperature

·        Premenstrual Endometrial Biopsy

·        Examination of Cervical Mucus

·        Vaginal Smear

·        Hormonal Assays

·        Ultrasound

Investigation for tubal potency

·        Hysterosalpigography (HSG)

·        Laprascopy

·        Sonohysterosalpigography

·        Direct transcervical cannulation of the fallopian tube.

Investigation of the uterine factor

·        Endometrial Biopsy to detect secretory change or endometritis.

·        Sonography show uterine anomalies , fibroid or adhesion

·        Hysterosalpigography shows anomalies and fibroid.

Investigation of cervical factors

Postcoital test: the test performed just before ovulation when cervical mucus is excessive (12th or 13th day) sample of cervical mucus is examined microscopically to detect characteristics that enhance sperm survival and to assess adequacy of estrogen production.

Investigation of vaginal factors

·        The PH of the vagina is determined by universal indicator excessive vaginal acidity kill the spermatozoa

·        Examined for vaginitis.

Investigation for the male: A- History

·        Personal history

·        Present history

·        Family history

·        Past history

·        Sexual history

·        Special habits (smoking, alcoholism)

B- Examination:

·        General examination for diseases which depress testicular activity as D.M

·        Local examination for genital organ for abnormalities as hypospadias, undescended testicle and varicocele.

C- Special Investigations:

·        Semen analysis: to show normal characteristics of it (the amount of semen is about 3-5ml in the coitus or ejaculation, the motility of sperm 90 % of them remain motile after 2hrs and about 20% of them have malformation in normal, reaction alkaline PH 7.2-8 , sperm count 20-120.000/ml).

·        Testicular biopsy to show azoospermia is due to failure of spermatogenesis.

·        Chromosomal study and testing for autoantibody husband serum.

·        Vasography: Dye is injected to determine the site of obstruction in the vas deference.

·        Scrotal ultrasound detects varicocele, small testis and epididymis anatomy.

Treatment of infertility:

Once an accurate diagnosis is made, appropriate interventions and treatment for infertility should first address any underlying medical condition that may be contributing to fertility problems. If this step does not restore fertility, there are several treatment approaches: (1) Drugs to induce ovulation, such as clomiphene and gonadotrophins, (2) Assisted reproductive technologies (ART) such as in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI), (3) Lifestyle measures (healthy lifestyle, planning sexual activity with ovulation cycle, managing stress and emotions) and Complementary and Alternative Medicine (CAM)

First treatment option: Lifestyle Changes

Lifestyle can make huge benefits in overcoming infertility, and achieving a higher overall level of health. When it comes to lifestyle changes, there are some steps you can take that are scientifically proven to affect fertility. Fundamentally, an improved diet, regular exercise, and healthy habits can do a great service. Some tips include:

1- Healthy Foods to Improve Fertility:                                                                                           

·         Balanced colourful diet: include various colours of fruits and vegetables. Spinach, green pepper, cucumber, apples, strawberries and red peppers. For yellow and orange, incorporate bananas, nectarines, lemons and for the blue and purple category.**

Figure: Shows the best sources of healthy foods for infertility.

·         Whole grains: lead to an improved fertility, so go ahead and include plenty of whole grains like wheat, rice, oats, cornmeal, etc., in daily diet.

·         Omega 3 fatty acids: Many fishes, Walnuts, flax seeds and whole grains are a rich source of omega 3 fatty acids, eat fishes such as catfish, salmon etc., which are known to have little or no mercury. Supplements such as fish oil which contain a mixture of omega 3, omega 6 and omega 9 fatty acids are also beneficial and the high content of omega-3 fatty acids may help to reduce inflammation, and promote the proper production of hormones.

Figure: Shows the best sources of omega 3 foods to improve fertility.

·         Dates: contain several nutrients that can help boost your ability to conceive. They are rich in vitamins A, E and B as well as iron and other minerals, also help with regular bowel movements and treat constipation.

2-Planning Sexual Activity and Monitoring Basal Body Temperature: 

3-Reduce stress:    

Stress can lower chances of conception. Hence, it is important to minimize stress and practice healthy coping methods like relaxation through meditation and yoga when trying to conceive.  

Figure: Shows some of the stress reduction techniques

4-Exercise: exercising too much or not enough can have an adverse effect on your hormonal balance and cause sterility issues.  Medications can help with this, but changing your lifestyle to incorporate a moderate amount of exercise is preferred.

Figure: Show types of woman's exercises **

Second treatment option

Treatment for Female: (treat the cause)

·        Ovulatory Drugs for Anovulation.

·        Cervical dilatation for stenosis cervix.

·        Cauterization for non-specific chronic cervicitis

·        Excessive vaginal acidity is treated by an alkaline vaginal douche (one spoon sodium bicarbonate is one liter of water) given 30 minute before coitus.

·        Tupoplasty for the blocked tubes in the form of salpingolysis (adhesiolysis), resection and end to end anastomosis.

·        Surgical intervention for correction of anomalies, removal of obstruction as fibroid.

B- Treatment For Male: (treat the cause)

·        Early treatment of undescended testicle.

·        Early treatment of prostatitis before being chronic

·        Carful treatment of mumps orchitis and infection.

·        Treatment the cause as varicocele, hydrocele,

·        Treatment of obesity and avoid tight clothes.

·        Hormonal support for hormones imbalance.

·        For autoimmunity cortisone is used.

Artificial Insemination:

·        Indication of it :

o    Failure of deposition of semen into the vagina due to impotence, hypospadius, epicardia's, premature and retrograde ejaculation and presence of vaginismus.

o    Subfertile semen due to oligospermia, polyspermia and asthenspermia .

o    Hostile cervical mucus which cannot be treated.

o    Sever uterine retroversion.

o    Sterile husband (insemination with denoted semen but it is forbidden in Muslim cultures).

Techniques of it:

·        In Vitro Fertilization (IVF)

·        Embryo Transfer (ET)

·        Zygote Intrafallobian Tube Transfer (ZIFT)

·        Gamete Intrafallobian Tube Transfer (GIFT)

·        Surrogate Mothering (SM)

Prevention:

·        Avoid using of tobacco (cigarettes) and marguana which reduce fertility (decrease sperm count).

·        Avoid exposure to chemicals or radiation and toxins.

·        Avoid excessive alcohol use which damage egg or sperm.

·        Avoid tight under clothes.

·        Avoid sex partners it reduce the risk of STDS.

·        Maintain body WT close to ideal for your height to reduce the risk of hormone imbalance

·     Sex counseling to identify sexual difficulties, teach specific exercise and different coital position

·     Avoid lack of sleep

·        Psychological support is the most important factor for infertile 

Advices to increase the chance of conception:

·        Remove sugar , cereals and farina from your diet

·        Use natural fats, eating more coconut, coconut oil, olives, olive oil, eggs, avocado, nuts

·        Eat lots of green leafy vegetables (lettuce, spinach, lopush), broccoli, cauliflower, cabbage and food rich in iron

·        Avoid processed dairy products (cream and ghee)

·        Drink about four liters of water a day (urine should be very bright)

·        Control the level of insulin.

Explore the characteristics, growth mechanisms, and risk factors related to uterine fibroids, noncancerous tumors commonly affecting women during their childbearing years. This quiz delves into the hormonal influences and statistics surrounding the incidence of fibroids.