Ji Keon LOOI
FELDA and other government settings in rural Malaysia
Outline
•FELDA (main emphasis)
•MARA
•RISDA
•FELCRA
Federal Land Development Authority
•A.k.a. FELDA
Summary
•Basically, FELDA plays an important role in assisting the development of rural areas in Malaysia. It has introduced a diversity of activities which the settlers can venture into.
•Will not be examined.
Vision and Mission
VISION
•FELDA as a leading world oil palm industry and the settlers community becoming middle class in 2010.
MISSION
•FELDA's Management achieving world class and becoming global player.
•Oil palm and rubber production comparable to the best producers in the world.
•Settlers obtaining stable income.
•Settler families acquiring suitable level of education.
•Enjoying modern infrastructure facilities.
•Owing harmonious and perfect environment.
Objectives
FELDA was established with the following objectives:
•To develop plantation areas in a productive way by adopting effective agricultural management practices such as good field maintenance, maximizing production with lower cost of production.
•To encourage the development of a progressive, productive and discipline settlers' community.
•To build an excellent and dedicated management machinery based on "Professionalism with Social Development Orientation".
History of FELDA
•established on 1st July 1956
•under the Land Development Act 1956
•Reasons for establishment
–help the government carried out rural land development schemes
>manage and channel financial aids to the state Government to carry out land development schemes in the respective states
>coordinating land development in these states which include the movement of population within the states
–uplift the economic status as well as living standard of the rural community
•Since 1961, FELDA was entrusted to carry out on its own development and settlement schemes throughout the country.
Achievements
•Has developed 480 new areas totalling 853,313 hectares which became plantation and settlement areas.
•Settlers: 112,635 people from rural poor and landless community.
•Together with their families, they were resettled in the new settlement.
•Brings economic and social development as well as political stability
•Uplifts the living standard of the rural community
•Narrows the gap in the quality of the life between the urban and rural population
Settlers
•mainly homeless rural people and ex-security personnel
•Criteria:
–Citizen of Malaysia
–Married
–Does not own more than 2 acres of land
•Settler is given one plot of agricultural land (~10 acres) and one plot of housing land (1/4 acre) and is to be registered in the Owner's Registrar.
Settlers’ income
•Farms Production - Income from oil palm and rubber estates production.
•Alternative Sources - Economic activities. (eg agriculture, livestock)
•Investment – KPF (Felda Investment Co-op), Others – ASN, ASB and others.
FELDA Housing project
•To develop suitable vacant lots and already given titles to FELDA so that efforts to increase the quality of life of the scheme community are more effective.
•To ensure that settler's children in the low-income group have the opportunity to own residential houses of good quality.
•To provide opportunity to the settler's children to continue residing in the schemes to help in the growth and economic activities in the schemes.
• To help strengthen settler's family institution.
• To help the government's efforts to expedite housing development in the rural areas.
Agricultural activities
•Oil palm*
•Rubber*
•Boef goat
•Feedlot Cattle
•Bamboo
•Tongkat Ali
•Alfafa
•Kenaf*
•Guinea Grass
The Council of Trust for Indigenous People
•Majlis Amanah Rakyat (MARA)
Objective
–To encourage, guide, train and assist Bumiputera to enable them to participate actively and progressively in small and medium scale commercial and industrial enterprises towards creating a strong and viable Bumiputera Commercial and Industrial Community (MPPB).
Strategies of MARA
•Produce Bumiputera entrepreneurs in the small and medium scale commercial and industrial enterprises
•Participate actively in commercial and industrial enterprises through investments and management in companies of the Bumiputeras
•Increase the number of trained Bumiputera manpower
•Provide facilities and services and become trustee to help raise the social and economic standard of the bumiputera community
RISDA
•Rubber Industry Smallholders Development Authority
Functions
•Allows small farmers to replant their old and non-economical rubber tree with new clons that provide better harvests and returns
•Under this programme, small farmers are also able to replace their non-productive rubber trees with other plants such as oil palm, fruits, logs etc.
•Translated from Malay
Federal Land Consolidation and Rehabilitation Authority
•FELCRA
•The rehabilitation of unsuccessful state-managed schemes
•The consolidation of unused government land fringing villages for the purpose of providing additional land to small farmers so as to enable them to possess economic size land holdings
•Youth land development programme to develop unused marginal government land to provide land to unemployed rural youths
•In situ development project
Sunday 26 August 2007
Saturday 25 August 2007
Other causes of short stature
* Down syndrome (trisomy 21)
Silver-Russell (Russell-Silver) syndrome
Hypochondroplasia
* SHOX gene mutations
* Turner’s Syndrome (50% - 45XO; remainder are mosaics with structural abnormalities of either X or Y)
Leri-Weill dyschondrosteosis
Growth hormone (GH) receptor gene mutations (Laron syndrome)
IGF1 gene mutation
IGF1R gene mutation
PROP1 gene mutations
POU1F1 gene mutations
GHRH gene mutations
GH gene mutations
Insulin receptor gene mutations (leprechaunism)
* These are the more popular/well-known genetic causes
The other causes mentioned below may also overlap with some chronic causes.
Pulmonic causes
Cystic Fibrosis
Severe asthma
Chronic obstructive pulmonary disease
Restrictive lung disease
Cardiac causes
Hypoxemia
Congestive heart failure
Low cardiac output states
Renal causes
Chronic renal insufficiency
Renal failure
Renal tubular acidosis
Psychosocial causes (placing in different environment would allow catching up)
Chronic neglect
Starvation
Gastrointestinal causes
Sprue (gluten intolerance)
Protein-losing enteropathy
Malnutrition related:
Inflammatory bowel disease - Crohn disease, ulcerative colitis
Mechanical - e.g. pyloric stenosis
Chronic bowel infection
Protein or caloric deprivation associated with enzyme deficiencies
(In the developed world, malnutrition may occur as part of more complex disease - for example, inflammatory bowel disease, or anorexia nervosa, rather than frank malnutrition.)
Malabsorption related:
Cystic fibrosis
Celiac (Coeliac) Disease
Skeletal causes
Rickets (Vit D deficiency)
Chondrodystrophies
Drug-related causes
Steroids
Another reasoning for short stature may be a constitutional delay of growth and sexual development (i.e. delayed puberty), but this is normally corrected by itself later on.
Friday 24 August 2007
Research Tasks for RURAL PCL
Rural vs Urban
1) Behaviour & Attitude differences
- include Gender bias (domestic violence/ sexual abuse)
{Shantz}
2) Spectrum of diseases and stage of presentation
- include occupational and health hazards (gender differences?) / mortality and morbidity rates
{Sri}
3) Availability of resources and accessbility - Challenges a rural doctor faces
{Chris}
4) Expectations on a rural doctor (focus on social role)
- include issues like acceptance into the community and prejudices against women doctors
{Christine}
5) Healthcare delivery system
- talk about delivery system for children and adults
{John}
6) FELDA & other government settings for rural development
{JK}
7) Government help and rights of people (especially women)
{Vivian}
8) Socio-economic-environmental challenges of the rural community
{Lawrence}
9) Role of traditional healers in rural community
{Madhura}
1) Behaviour & Attitude differences
- include Gender bias (domestic violence/ sexual abuse)
{Shantz}
2) Spectrum of diseases and stage of presentation
- include occupational and health hazards (gender differences?) / mortality and morbidity rates
{Sri}
3) Availability of resources and accessbility - Challenges a rural doctor faces
{Chris}
4) Expectations on a rural doctor (focus on social role)
- include issues like acceptance into the community and prejudices against women doctors
{Christine}
5) Healthcare delivery system
- talk about delivery system for children and adults
{John}
6) FELDA & other government settings for rural development
{JK}
7) Government help and rights of people (especially women)
{Vivian}
8) Socio-economic-environmental challenges of the rural community
{Lawrence}
9) Role of traditional healers in rural community
{Madhura}
Management and Prognosis
Most cases of short stature due to genetic short stature and constitutional delay.
Generally do not require any treatment unless psychological well-being is affected.
Treatment is directed at the underlying cause of short stature.
Medical Care
Medical care depends on the etiology of the short stature.
• Recombinant human growth hormone (rhGH) administration has not been proven to remarkably improve final adult height in children with normal variant short stature.
o A recent study from the National Institutes of Health was double blinded randomly and suggests GH has a small effect on adult height in children with normal short stature if they are treated with GH injections for many years.
o In the absence of better clinical outcomes, do not use rhGH therapy to treat children with normal variant short stature.
Medication administered depends on the etiology of the short stature.
Drug Category: Growth Hormone
These agents improve symptoms associated with GHD. Also used in Turner syndrome, Prader Willi syndrome, chronic renal failure, IUGR.
Daily subcutaneous injections. 3 monthly follow up to monitor height/ weight and side effects.
Drug Name: Somatropin (Humatrope, Nutropin, Genotropin, Saizen)
hGH produced via recombinant DNA technology in Escherichia coli; widely available since 1985. Currently, only 1 of the 10 largest reported clinical studies has demonstrated that therapy can increase final adult height in patients with normal variant short stature. This most recent NIH-funded study was randomized, placebo controlled, and took place over 14 y. Investigators demonstrated average gain in height did not exceed 4 cm when rhGH treatment of normal variant short stature began prior to puberty and continued through completion of puberty. Whether several years of daily injections are worth the potential, but not promised, relatively small increase in final adult height remains a personal and individual decision involving the patient, patient's family, and physician.
Drug Category: Insulin-like growth factor-I
Indicated for long-term treatment of severe, primary insulin-like growth factor-I (IGF-I) due to mutations of the growth hormone receptor (GH-R) or GH-R downstream signaling pathways.
Drug Name: Mecasermin (Increlex)
Recombinant human insulinlike growth factor-1 (rhIGF-1) indicated for long-term treatment of GF in children with severe primary IGFD. IGF-I is essential for normal growth of children's bones, cartilage, and organs by stimulating uptake of glucose, fatty acids, and amino acids into tissues. IGF-I is the principal hormone for linear growth and directly mediates GH actions. Primary IGFD is characterized by absent IGF-I production despite normal or elevated GH release.
For severe constitutional delay, a short course of low dose sex hormones can be used to promote pubertal growth.
Surgical Care
• Surgical care depends on the underlying cause of short stature.
• Brain tumors that cause hyposomatotropism may require neurosurgical intervention, depending on the tumor type and location.
• Limb-lengthening procedures have been performed but carry enormous morbidity and mortality risks and are not recommended.
Diet
• Optimize nutrition in patients with GI disease.
• Obtain psychologic or psychiatric consultation for patients with eating disorders.
• Forced energy intake in children with normal variant short stature has not been demonstrated to improve short-term growth or final adult height. .
Prognosis
• Individuals with normal variant short stature have an excellent prognosis.
• Treatment of patients with classic GHD with rhGH can be expected to yield a height consistent with genetic potential, provided that therapy is initiated at least 5 years prior to the onset of puberty.
• Treatment of hypothyroidism at least 5 years before the onset of puberty is essential to attain a height consistent with the genetic potential.
• Any chronic illness can reduce the adult height achieved if treatment of the condition is initiated late.
Sources
http://www.emedicine.com/ped/topic2087.htm#section~Treatment
http://www.fmshk.org/database/articles/mb05drcheng.pdf
Lecture Notes: Short Stature: A practical approach and Treatment by Dr YS Choy
Contributed by John Lee
Generally do not require any treatment unless psychological well-being is affected.
Treatment is directed at the underlying cause of short stature.
Medical Care
Medical care depends on the etiology of the short stature.
• Recombinant human growth hormone (rhGH) administration has not been proven to remarkably improve final adult height in children with normal variant short stature.
o A recent study from the National Institutes of Health was double blinded randomly and suggests GH has a small effect on adult height in children with normal short stature if they are treated with GH injections for many years.
o In the absence of better clinical outcomes, do not use rhGH therapy to treat children with normal variant short stature.
Medication administered depends on the etiology of the short stature.
Drug Category: Growth Hormone
These agents improve symptoms associated with GHD. Also used in Turner syndrome, Prader Willi syndrome, chronic renal failure, IUGR.
Daily subcutaneous injections. 3 monthly follow up to monitor height/ weight and side effects.
Drug Name: Somatropin (Humatrope, Nutropin, Genotropin, Saizen)
hGH produced via recombinant DNA technology in Escherichia coli; widely available since 1985. Currently, only 1 of the 10 largest reported clinical studies has demonstrated that therapy can increase final adult height in patients with normal variant short stature. This most recent NIH-funded study was randomized, placebo controlled, and took place over 14 y. Investigators demonstrated average gain in height did not exceed 4 cm when rhGH treatment of normal variant short stature began prior to puberty and continued through completion of puberty. Whether several years of daily injections are worth the potential, but not promised, relatively small increase in final adult height remains a personal and individual decision involving the patient, patient's family, and physician.
Drug Category: Insulin-like growth factor-I
Indicated for long-term treatment of severe, primary insulin-like growth factor-I (IGF-I) due to mutations of the growth hormone receptor (GH-R) or GH-R downstream signaling pathways.
Drug Name: Mecasermin (Increlex)
Recombinant human insulinlike growth factor-1 (rhIGF-1) indicated for long-term treatment of GF in children with severe primary IGFD. IGF-I is essential for normal growth of children's bones, cartilage, and organs by stimulating uptake of glucose, fatty acids, and amino acids into tissues. IGF-I is the principal hormone for linear growth and directly mediates GH actions. Primary IGFD is characterized by absent IGF-I production despite normal or elevated GH release.
For severe constitutional delay, a short course of low dose sex hormones can be used to promote pubertal growth.
Surgical Care
• Surgical care depends on the underlying cause of short stature.
• Brain tumors that cause hyposomatotropism may require neurosurgical intervention, depending on the tumor type and location.
• Limb-lengthening procedures have been performed but carry enormous morbidity and mortality risks and are not recommended.
Diet
• Optimize nutrition in patients with GI disease.
• Obtain psychologic or psychiatric consultation for patients with eating disorders.
• Forced energy intake in children with normal variant short stature has not been demonstrated to improve short-term growth or final adult height. .
Prognosis
• Individuals with normal variant short stature have an excellent prognosis.
• Treatment of patients with classic GHD with rhGH can be expected to yield a height consistent with genetic potential, provided that therapy is initiated at least 5 years prior to the onset of puberty.
• Treatment of hypothyroidism at least 5 years before the onset of puberty is essential to attain a height consistent with the genetic potential.
• Any chronic illness can reduce the adult height achieved if treatment of the condition is initiated late.
Sources
http://www.emedicine.com/ped/topic2087.htm#section~Treatment
http://www.fmshk.org/database/articles/mb05drcheng.pdf
Lecture Notes: Short Stature: A practical approach and Treatment by Dr YS Choy
Contributed by John Lee
Intrauterin Growth Restriction (IUGR)
Intrauterine Growth Restriction (IUGR)
= condition where the fetus is smaller than expected for the number of weeks of
pregnancy (small for gestational age)
- estimated fetal weight less than the 10th percentile
- may be born at term (after 37 weeks of pregnancy) or prematurely (before 37 weeks)
- babies often appear thin, pale, and have loose dry skin.
umbilical cord is often thin and dull-looking rather than shiny and fat.
hypoglycaemia, hypothermia, polycythemia
Causes:
- occurs when a problem or abnormality prevents cells and tissues from growing or
causes cell to decrease in size.
- due to fetus not receiving the necessary nutrients and oxygen needed for growth and
development of organs and tissues, or because of infection.
• Maternal factors:
o high blood pressure
o chronic kidney disease
o advanced diabetes
o heart or respiratory disease
o hypoxemia (high altitude, cyanotic cardiac, pulmonary disease)
o malnutrition, anemia
o infection
o substance abuse (alcohol, drugs)
o cigarette smoking
• Factors involving the uterus and placenta:
o decreased blood flow in the uterus and placenta
o decrease in surface area, infarction
o decreased placental weight or cellularity or both
o placental abruption (placenta detaches from the uterus)
o placenta previa (placenta attaches low in the uterus)
o tumour (chorioangioma, hydatiform mole)
o infection in the tissues around the fetus
• Factors related to the developing baby (fetus):
o multiple gestation (twins, triplets, etc.)
o infection (CMV, Rubella, Syphilis, Toxoplasmosis)
o birth defects (congenital heart defect, diaphragmatic hernia)
o chromosomal abnormality (Trisomy 21 & 18)
o radiation
o familial and racial background
http://pediatrics.aappublications.org/cgi/content/full/112/1/150
(Posted by: Vivian)
= condition where the fetus is smaller than expected for the number of weeks of
pregnancy (small for gestational age)
- estimated fetal weight less than the 10th percentile
- may be born at term (after 37 weeks of pregnancy) or prematurely (before 37 weeks)
- babies often appear thin, pale, and have loose dry skin.
umbilical cord is often thin and dull-looking rather than shiny and fat.
hypoglycaemia, hypothermia, polycythemia
Causes:
- occurs when a problem or abnormality prevents cells and tissues from growing or
causes cell to decrease in size.
- due to fetus not receiving the necessary nutrients and oxygen needed for growth and
development of organs and tissues, or because of infection.
• Maternal factors:
o high blood pressure
o chronic kidney disease
o advanced diabetes
o heart or respiratory disease
o hypoxemia (high altitude, cyanotic cardiac, pulmonary disease)
o malnutrition, anemia
o infection
o substance abuse (alcohol, drugs)
o cigarette smoking
• Factors involving the uterus and placenta:
o decreased blood flow in the uterus and placenta
o decrease in surface area, infarction
o decreased placental weight or cellularity or both
o placental abruption (placenta detaches from the uterus)
o placenta previa (placenta attaches low in the uterus)
o tumour (chorioangioma, hydatiform mole)
o infection in the tissues around the fetus
• Factors related to the developing baby (fetus):
o multiple gestation (twins, triplets, etc.)
o infection (CMV, Rubella, Syphilis, Toxoplasmosis)
o birth defects (congenital heart defect, diaphragmatic hernia)
o chromosomal abnormality (Trisomy 21 & 18)
o radiation
o familial and racial background
http://pediatrics.aappublications.org/cgi/content/full/112/1/150
(Posted by: Vivian)
Endocrine Causes of Short Stature
JK Looi
Monash Malaysia
Aug 24, 2007
Sources
•Evaluation of short stature
–http://student.bmj.com/issues/00/05/education/143.php
•Short Stature
–http://www.emedicine.com/ped/topic2087.htm
•Monash Lectures by Dr Choy and Prof Khalid
•Mauriac’s syndrome revisited
–http://www.springerlink.com/content/k50324232m4m874n/fulltext.pdf
Background
•Causes of short stature IS NICE
Endocrine causes
•growth hormone deficiency
congenital or acquired
(meningitis, trauma, irradiation)
•Hypopituitarism
•Hypothyroidism
•congenital adrenal hyperplasia
•diabetes mellitus
•pseudohypoparathyroidism
N.B.: Less common of non-endocrine causes
Revision
Let’s see what you can remember about Growth Hormone
•Patterns of GH secretion
•Biological effects
Patterns of release
•Episodic/pulsative/circardian secretion by ant pituitary gland
•Hypothalamic control on adeno-hypophysis
–GHRH stimulates
–Somatostasin inhibits
•Bound to GH binding protein in plasma
•Raised after meals, during deep sleep, exercise
Biological effects of GH
•Liver
–Stimulation of insulin-like growth factor (IGF-I)
•Body composition
–Lipolytic
–promotes retention of nitrogen
–protein anabolism (reducing plasma protein concentration)
–Improve muscle mass and strength
•Opposes function of insulin
GH insufficiency
•Slow growth velocity, delayed skeletal maturation, often overweight, dry skin, increase sc fat, crowding of facial features (maxillary hypoplasia, poor nasal bone development, delayed closure of fontanelles), delayed puberty
Laron dwarfism
•familial disorder; autosomal recessive
•Consanguinity a major contributor
•Lack of responsiveness of GH receptors
•Assay results:
–low serum IGF-I, but increased serum GH
Primary hypothyroidism
•Function of thyroid hormone in embryo/fetus/neonate/infant
–Brain maturation and skeletal development
•Low growth hormone pulsatility
•Slow growth, immature and delayed puberty
•Marked delay in bone age
Congenital Adrenal Hyperplasia
•Lack cortisol, lack aldosterone, excess androgen (21 hydroxylase deficiency)
•NB: In virilising form of CAH
•Testosterone leads to early growth plate fusion OR
•Administration of excess glucocorticoid for growth
Diabetes Dwarfism
•A.k.a. Mauriac syndrome
•low levels of insulin, inadequate diet and poorly controlled DM, with hepatosplenomegaly
Pathophysiology
•Inadequate control of the diabetes mellitus results in insufficient available tissue glucose.
•Gluconeogenesis and fat metabolism result in a catabolic state.
•Also, hyperglycemia has been associated with diminished somatomedin formation and somatomedin inhibitors in diabetic rats.
•Increased glycogen and fat storage in liver - hepatosplenomegaly
See you all in Segamat!!!
•Any questions?
Monash Malaysia
Aug 24, 2007
Sources
•Evaluation of short stature
–http://student.bmj.com/issues/00/05/education/143.php
•Short Stature
–http://www.emedicine.com/ped/topic2087.htm
•Monash Lectures by Dr Choy and Prof Khalid
•Mauriac’s syndrome revisited
–http://www.springerlink.com/content/k50324232m4m874n/fulltext.pdf
Background
•Causes of short stature IS NICE
Endocrine causes
•growth hormone deficiency
congenital or acquired
(meningitis, trauma, irradiation)
•Hypopituitarism
•Hypothyroidism
•congenital adrenal hyperplasia
•diabetes mellitus
•pseudohypoparathyroidism
N.B.: Less common of non-endocrine causes
Revision
Let’s see what you can remember about Growth Hormone
•Patterns of GH secretion
•Biological effects
Patterns of release
•Episodic/pulsative/circardian secretion by ant pituitary gland
•Hypothalamic control on adeno-hypophysis
–GHRH stimulates
–Somatostasin inhibits
•Bound to GH binding protein in plasma
•Raised after meals, during deep sleep, exercise
Biological effects of GH
•Liver
–Stimulation of insulin-like growth factor (IGF-I)
•Body composition
–Lipolytic
–promotes retention of nitrogen
–protein anabolism (reducing plasma protein concentration)
–Improve muscle mass and strength
•Opposes function of insulin
GH insufficiency
•Slow growth velocity, delayed skeletal maturation, often overweight, dry skin, increase sc fat, crowding of facial features (maxillary hypoplasia, poor nasal bone development, delayed closure of fontanelles), delayed puberty
Laron dwarfism
•familial disorder; autosomal recessive
•Consanguinity a major contributor
•Lack of responsiveness of GH receptors
•Assay results:
–low serum IGF-I, but increased serum GH
Primary hypothyroidism
•Function of thyroid hormone in embryo/fetus/neonate/infant
–Brain maturation and skeletal development
•Low growth hormone pulsatility
•Slow growth, immature and delayed puberty
•Marked delay in bone age
Congenital Adrenal Hyperplasia
•Lack cortisol, lack aldosterone, excess androgen (21 hydroxylase deficiency)
•NB: In virilising form of CAH
•Testosterone leads to early growth plate fusion OR
•Administration of excess glucocorticoid for growth
Diabetes Dwarfism
•A.k.a. Mauriac syndrome
•low levels of insulin, inadequate diet and poorly controlled DM, with hepatosplenomegaly
Pathophysiology
•Inadequate control of the diabetes mellitus results in insufficient available tissue glucose.
•Gluconeogenesis and fat metabolism result in a catabolic state.
•Also, hyperglycemia has been associated with diminished somatomedin formation and somatomedin inhibitors in diabetic rats.
•Increased glycogen and fat storage in liver - hepatosplenomegaly
See you all in Segamat!!!
•Any questions?
Epidemiology of Short Stature
Frequency:
In the US: In 1994, Lindsay et al studied 114,881 school children in Utah. After 1 year, 79,495 of the original group were available for evaluation. Of these, 555 (0.7%) had heights that were below the third percentile and a growth rate that was fewer than 5 cm/y. When examined further, causes for short stature within this group of children included familial short stature (37%), constitutional delay (27%), a combination of familial short stature and constitutional delay (17%), other medical causes (10%), idiopathic short stature (5%), GH deficiency (3%), Turner syndrome (3% of girls), and hypothyroidism (0.5%).
Internationally:
General
Several studies have been conducted to determine the frequency of various causes of short stature. In 1974, Lacey and Parkin evaluated children in Newcastle upon Tyne in England. They studied 2256 children, of whom 111 were below the third percentile in stature. Of the 98 children that they were able to examine, only 16 had evidence of organic disease causing their short stature. Diagnoses included Down syndrome, cystic fibrosis, chronic renal insufficiency, GH deficiency, juvenile rheumatoid arthritis (treated with glucocorticoid), and Hurler syndrome.
Short stature due to growth hormone deficiency (GHD)
Frequency of isolated GHD has been reported to range from 1 case per 1,800 children in Sri Lanka (a probable overestimate due to liberal diagnostic criteria) to 1 case per 30,000 children in Newcastle, UK (a probable underestimate due to its reliance on referral rates to a growth clinic).
Mortality/Morbidity:
General
Short stature has been shown to have far-reaching effects on psychological well-being, including poor academic achievement (despite normal intelligence, healthy family dynamics, and high socioeconomic status) and behavioral problems (eg, anxiety, attention-seeking actions, poor social skills). Morbidity related to the underlying cause of the growth failure may also be present.
Mortality rates in children with growth failure relate to the underlying cause of the growth failure. Mortality is not related to growth failure itself; rather, it is related only to the cause of the growth failure.
Short stature due to growth hormone deficiency (GHD)
Mortality in children with GHD is due almost entirely to other pituitary hormone deficiencies. These children have an increased relative risk of death in adulthood from cardiovascular causes resulting from altered body composition and dyslipidemia.
Most morbidity in children with GHD relates to short stature. Average adult height for untreated patients with severe isolated GHD is 143 cm in men and 130 cm in women. Approximately 5% of children with GHD also have episodes of hypoglycemia, particularly in infancy, which resolve with GH therapy.
Adults with untreated GHD have altered body composition (eg, excess body fat, lower lean body mass), decreased bone mineralization, cardiovascular risk factors (in particular, altered blood lipids), and decreased exercise tolerance. In addition, these patients may be socially isolated.
Sex: The sex distribution of patients with idiopathic GHD in the National Cooperative Growth Study is 73% male and 27% female. Among patients with organic GHD, in which no sex difference should be present, the ratio is 62% male to 38% female.
Age: Although most cases of idiopathic GHD are thought present at birth, diagnosis often is delayed until concern is raised about short stature. Diagnosis of GHD is made during 2 broad age peaks. The first age peak occurs at 5 years, a time when children begin school and the height of short children probably is compared to that of their peers. The second age peak occurs in girls aged 10-13 years and boys aged 12-16 years. This second peak possibly relates to the delay in puberty associated with GHD. Children with GHD may seem to grow at a slower rate than their peers, because their peers are in the midst of the pubertal growth spurt, while children with GHD have not yet entered this phase.
Contributed by Lawrence Oh
Reference:
http://www.emedicine.com/ped/topic1810.htm
http://www.emedicine.com/ped/topic902.htm
In the US: In 1994, Lindsay et al studied 114,881 school children in Utah. After 1 year, 79,495 of the original group were available for evaluation. Of these, 555 (0.7%) had heights that were below the third percentile and a growth rate that was fewer than 5 cm/y. When examined further, causes for short stature within this group of children included familial short stature (37%), constitutional delay (27%), a combination of familial short stature and constitutional delay (17%), other medical causes (10%), idiopathic short stature (5%), GH deficiency (3%), Turner syndrome (3% of girls), and hypothyroidism (0.5%).
Internationally:
General
Several studies have been conducted to determine the frequency of various causes of short stature. In 1974, Lacey and Parkin evaluated children in Newcastle upon Tyne in England. They studied 2256 children, of whom 111 were below the third percentile in stature. Of the 98 children that they were able to examine, only 16 had evidence of organic disease causing their short stature. Diagnoses included Down syndrome, cystic fibrosis, chronic renal insufficiency, GH deficiency, juvenile rheumatoid arthritis (treated with glucocorticoid), and Hurler syndrome.
Short stature due to growth hormone deficiency (GHD)
Frequency of isolated GHD has been reported to range from 1 case per 1,800 children in Sri Lanka (a probable overestimate due to liberal diagnostic criteria) to 1 case per 30,000 children in Newcastle, UK (a probable underestimate due to its reliance on referral rates to a growth clinic).
Mortality/Morbidity:
General
Short stature has been shown to have far-reaching effects on psychological well-being, including poor academic achievement (despite normal intelligence, healthy family dynamics, and high socioeconomic status) and behavioral problems (eg, anxiety, attention-seeking actions, poor social skills). Morbidity related to the underlying cause of the growth failure may also be present.
Mortality rates in children with growth failure relate to the underlying cause of the growth failure. Mortality is not related to growth failure itself; rather, it is related only to the cause of the growth failure.
Short stature due to growth hormone deficiency (GHD)
Mortality in children with GHD is due almost entirely to other pituitary hormone deficiencies. These children have an increased relative risk of death in adulthood from cardiovascular causes resulting from altered body composition and dyslipidemia.
Most morbidity in children with GHD relates to short stature. Average adult height for untreated patients with severe isolated GHD is 143 cm in men and 130 cm in women. Approximately 5% of children with GHD also have episodes of hypoglycemia, particularly in infancy, which resolve with GH therapy.
Adults with untreated GHD have altered body composition (eg, excess body fat, lower lean body mass), decreased bone mineralization, cardiovascular risk factors (in particular, altered blood lipids), and decreased exercise tolerance. In addition, these patients may be socially isolated.
Sex: The sex distribution of patients with idiopathic GHD in the National Cooperative Growth Study is 73% male and 27% female. Among patients with organic GHD, in which no sex difference should be present, the ratio is 62% male to 38% female.
Age: Although most cases of idiopathic GHD are thought present at birth, diagnosis often is delayed until concern is raised about short stature. Diagnosis of GHD is made during 2 broad age peaks. The first age peak occurs at 5 years, a time when children begin school and the height of short children probably is compared to that of their peers. The second age peak occurs in girls aged 10-13 years and boys aged 12-16 years. This second peak possibly relates to the delay in puberty associated with GHD. Children with GHD may seem to grow at a slower rate than their peers, because their peers are in the midst of the pubertal growth spurt, while children with GHD have not yet entered this phase.
Contributed by Lawrence Oh
Reference:
http://www.emedicine.com/ped/topic1810.htm
http://www.emedicine.com/ped/topic902.htm
Thursday 23 August 2007
Psychosocial aspects for short stature
The psychosocial disadvantages may be more distressing than the physical symptoms, especially in childhood and adolescence, but people with dwarfism vary greatly in the degree to which social participation and emotional health are affected.
-Social prejudice against extreme shortness may reduce social and marital opportunities.
-Numerous studies have demonstrated reduced employment opportunities. Severe shortness is associated with lower income.
-Self-esteem may be reduced and family relationships affected
-Extreme shortness (in the low 2–3 foot [60–90 cm] range) can interfere with ordinary activities of daily living, like driving or even using countertops built for taller people.
Chris.
-Social prejudice against extreme shortness may reduce social and marital opportunities.
-Numerous studies have demonstrated reduced employment opportunities. Severe shortness is associated with lower income.
-Self-esteem may be reduced and family relationships affected
-Extreme shortness (in the low 2–3 foot [60–90 cm] range) can interfere with ordinary activities of daily living, like driving or even using countertops built for taller people.
Chris.
Monday 20 August 2007
Tasks For PCL 6
Growth Chart (How to interpret?)
- Definition of centile
- What's normal
- Criteria for short stature
{Shantz}
Endocrine causes of Short Stature
{JK}
Chronic diseases related to short stature
- include chronic infections
{Christine}
Intrauterine Growth Retardation
- causes/ pathophysiology
{Vivian}
Other causes of Short Stature
-Genetic causes of Short Stature (Hereditary and Non-hereditary)
- Malabsorption
- Malnutrition
{Madhura}
Investigations for causes of Short Stature
- focus on endocrine system
{Sri}
Management and prognosis of Short Stature
- focus on endocrine system
{John}
Psychosocial factors related to Short Stature
{Chris}
Epidemiology of Short Stature
- In Malaysia vs the rest of the world
{Lawrence}
- Definition of centile
- What's normal
- Criteria for short stature
Endocrine causes of Short Stature
Chronic diseases related to short stature
- include chronic infections
Intrauterine Growth Retardation
- causes/ pathophysiology
Other causes of Short Stature
-Genetic causes of Short Stature (Hereditary and Non-hereditary)
- Malabsorption
- Malnutrition
Investigations for causes of Short Stature
- focus on endocrine system
Management and prognosis of Short Stature
- focus on endocrine system
Psychosocial factors related to Short Stature
Epidemiology of Short Stature
- In Malaysia vs the rest of the world
{Lawrence}
Friday 17 August 2007
Post Partum Management and Breastfeeding
Defining the postpartum period
The words "postpartum" and "postnatal" are sometimes used interchangeably. The postpartum period (also called the puerperium) according to Western textbook definitions starts shortly after the birth of the placenta. Neither "postpartum period" nor "puerperium” is officially defined. WHO has, however, formally designated the first 28 completed days after birth of the infant as the neonatal period. Although not officially sanctioned, traditionally the postpartum period is supposed to end 6 weeks after birth.
Aims and timing of postpartum care
The words "postpartum" and "postnatal" are sometimes used interchangeably. The postpartum period (also called the puerperium) according to Western textbook definitions starts shortly after the birth of the placenta. Neither "postpartum period" nor "puerperium” is officially defined. WHO has, however, formally designated the first 28 completed days after birth of the infant as the neonatal period. Although not officially sanctioned, traditionally the postpartum period is supposed to end 6 weeks after birth.
Aims and timing of postpartum care
The aims of care in the postpartum period are:
- support of the mother and her family in the transition to a new family constellation, and response to their needs
- prevention, early diagnosis and treatment of complications of mother and infant, including the prevention of vertical transmission of diseases from mother to infant
- referral of mother and infant for specialist care when necessary
- counselling on baby care
- support of breastfeeding
- counselling on maternal nutrition, and supplementation if necessary
- counselling and service provision for contraception and the resumption of sexual activity
- immunization of the infant.
The first hours after birth
The baby
The care in the first hours or first day includes meeting the physiological needs of the newborn and assessing the baby carefully. The physical assessment of the newborn has two purposes: to determine the anatomic normality for the first time in a new life and to determine the state of health.
Care in the first hours includes:
- thermal protection by providing a warm environment and not separating the mother and the newborn to prevent hypothermia of the baby.
- supporting frequent and exclusive breastfeeding and assisting the mother if necessary to adopt correct breastfeeding practice.
- cleanliness and clean cord care.
- weighing the baby.
- examination of the newborn for health in order to reassure the mother and to recognize problems early.
- frequent observation by the mother who knows about the danger signs.
- administering vitamin K to the baby if country policy prescribes it, either by injection or orally. However, the evidence for routine administration of vitamin K to all newborns to prevent the relatively rare haemorrhagic disease of the newborn is still lacking.
- starting immunization with BCG and hepatitis B vaccine, and the first dose of oral poliomyelitis vaccine, as recommended. In countries and populations at high risk of tuberculosis infection, infants receive BCG as soon as possible after birth.
The mother
The first hours postpartum are extremely important.
During this time caregivers should:
- assess maternal well-being, measure and record blood pressure and body temperature.
- assess for vaginal bleeding, uterine contraction and fundal height regularly.
- identify signs of serious maternal complications, in particular haemorrhage, eclampsia and
- infections and instigate treatment.
- suture the perineum where necessary
The first week postpartum
Maternal and newborn assessment and advice
In the first week postpartum assessment of the condition of mother and baby is important, together with appropriate advice and counselling, particularly where this is the woman’s first child. The postpartum visit during the first week should include:
The Mother
- General well-being, micturition (especially the first 8-12 hours, see ), possible complaints.
- Abdomen: fundal height, distended bladder?
- Perineum, vaginal haemorrhage, lochia, haemorrhoids.
- Legs: thrombophlebitis, signs of thrombosis?
- Temperature, if there is reason to suspect infection. Body temperature of 38.0°C is abnormal, especially during the first days after delivery.
- Assessment and help with breastfeeding, to prevent problems.
Assessing the baby
A routine neonatal examination does not take more than 5-10 minutes and should be done in a quiet, warm and clean environment, preferably in daylight and with parents present.
Assessment should include:
- asking the mother how she feels about the baby, how the baby is feeding and about any concerns
- general condition: is the baby active, feeding well and frequently? (be alert for the "too good baby", who never cries)
- if necessary, observing breastfeeding and helping the mother to improve the technique
- skin: is it clean (no pustules), not jaundiced?
- are eyes clean (not draining pus)?
- if the baby is not active, not feeding well or other abnormalities are observed more thorough examination should be done.
The first months
If mother and baby are healthy, after the first week frequent support by a caregiver is no longer necessary. Traditionally, the mother is asked to come back for a check-up 6 weeks after birth. However, in the meantime she will need advice on the condition of the baby, and possibly on breastfeeding or other problems that may arise. At the age of 6 weeks, the baby receives a second dose of OPV and the first dose of the diphtheria/pertussis/tetanus (DPT) vaccine.
Baby’s growth should be assessed.
What should be done at the check-up consultation of the mother 6 weeks after delivery?
First of all the caregiver should ask the woman about her well-being and possible complaints or problems. There is more maternal morbidity in the postpartum period than most caregivers are aware of. Traditionally a vaginal examination is performed to check the healing of a large tear, or if the woman complains about pain or other discomfort. Haemoglobin may be measured, especially if anaemia has occurred during pregnancy or in the postpartum period, and if necessary a prescription of iron may again be given. It is important, if possible, to involve the husband or partner in the consultation. Often women and their partners feel the need to discuss the course of labour, and events that occurred at that time. Questions should be answered, and information given.
Integrated care
Traditionally, after 6 weeks the postpartum period ends. However, the care should not end then: in many countries follow-up consultations for baby care are organized; at 10 and 14 weeks after birth further immunizations of the baby are planned. If baby health care clinics are available, the immunizations are best integrated in the care of these clinics. Theoretically, the best time to end postpartum care is 6 months after birth.
Breastfeeding
The establishment and maintenance of breastfeeding should be one of the major goals of good postpartum care. Human breast milk is the optimal food for newborn infants.
Through the ages the human species has been dependent on it for its reproduction, animal milk being used only as an emergency measure if no human milk was available, usually with disastrous consequences. Only in the second half of the 20th century have modified cow’s milk preparations or "formula" become readily available which are closer to human milk in nutrient quantity, but still very different in quality, and lacking in immune factors. In developed countries, differences in mortality between breastfed and artificially fed infants are small, but there is an abundance of literature on the advantages of breastfeeding for the prevention of infant and later morbidity (Howie 1990). In developing countries artificial feeding is associated with a much higher infant morbidity and mortality than breastfeeding, primarily caused by infections and malnutrition (Habicht 1986, Victora 1986, Feacham and Koblinsky 1984).
The immunological properties of breast milk are unique (Welsh & May 1979). Immunoglobulin A (IgA) is of major importance, and is present in particularly high concentration in the colostrum produced during the first few days. IgA probably acts by preventing bacterial adherence to epithelial cell surfaces in the gut and upper respiratory tract (Cravioto et al 1991). Human milk contains both T and B lymphocytes, another mechanism by which the neonate benefits from maternal immunological experience (Bertotto et al 1990). Apart from its immunological qualities, breast milk also contains essential amino acids, and long chain polyunsaturated fatty acids which are not present in animal milks and which may be of great importance for the developing brain (Van Biervliet et al 1992).
Source: http://www.who.int/reproductive-health/publications/msm_98_3/msm_98_3_6.html
Contributed by John Lee
Thursday 16 August 2007
Physiology of pregnancy
The hormones with the strongest influence on pregnancy are HCG, estrogen, progesterone, HCS. These are secreted primarily by the placenta, but the corpus luteum is an important source of hormones in first 7-12 weeks.
Adjustment to pregnancy
Digestive System, Nutrition and Metabolism
morning sickness
- one of the first sign of pregnancy
- the cause is still unknown but there are several hypothesis.
- Hypothesis 1: reduced intestinal motility caused by steroid of pregnancy
- Hypothesis 2: evolutionary adaptation to protect fetus from toxin. Fetus is most vulnerable to toxin at the peak of morning sickness. Women with morning sickness tend to prefer bland food rather than spicy and pungent foods which are toxic to the baby
Constipation and heartburn
- Constipation: result from reduced intestinal motility
- Heartburn: result from enlarging uterus pushing upward on stomach, causing the reflux of gastric contents into the esophagus
Increase basal metabolic rate
- Thus pregnant mother often feel hot
- Appetite might be strongly stimulated ,causing mother to overeat when they only need an extra 300kcal/day.
Nutrition
- During last trimester, fetus needs more nutrients than the mother digestive tract can absorb. In preparation to this, the placenta stores nutrients early in gestation and release them in the last trimester
- Nutrition such as iron, calcium, vitamin K and D as well as folic acid are important for the development of fetus
Circulatory System
- The mother blood volume will rises about 30% during pregnancy because of fluid retention and hemopoeisis to supply blood to the placenta for the fetus
- Cardiac output rises about 30% to 40% above by 27 weeks and return to normal in the last 8 week
- Uterus puts pressure on the large pelvic blood vessels. It interferes with the venous return thus cause varicose vein, oedema and hemorrhoid
Respiratory System
- minute ventilation increase about 50%
- this is because: 1. oxygen demand are about 20% higher to supply the fetus and support the mother increase metabolic rate. 2. progesterone increase sensitivity of respiratory chemoreceptors to carbon dioxide and ventilation is adjusted to keep the arterial co2 at low level. 3.expanding uterus push the abdominal viscera up towards the diaphragm and interferes with the normal breathing
Urinary System
- aldosterone and steroids of pregnancy promote water and salt retention by kidneys. GFR increase by 50% and urine output is slightly elevated so that the mother can dispose of both her own and fetus metabolic waste.
- Expanding uterus also compress on the bladder reducing its capacity, the urination become more frequent and mother might experience uncontrollable leakage of urine
Integumentary System
- skin must grown to accommodate the expansion of the abdomen and breasts and added fat deposition on the hips and thighs/
- stretching of dermis can always cause striae or scretch marks
- melanocyte activity increase in some areas and darkens the areolae and linea alba. The latter often becomes a dark line ‘linea nigra’ a line from umbilical to pubic region.
- Some mother also require temporary blotchy darkening of the skin over the nose and cheeks called the ‘ mask of pregnancy’
Adjustment to pregnancy
Digestive System, Nutrition and Metabolism
morning sickness
- one of the first sign of pregnancy
- the cause is still unknown but there are several hypothesis.
- Hypothesis 1: reduced intestinal motility caused by steroid of pregnancy
- Hypothesis 2: evolutionary adaptation to protect fetus from toxin. Fetus is most vulnerable to toxin at the peak of morning sickness. Women with morning sickness tend to prefer bland food rather than spicy and pungent foods which are toxic to the baby
Constipation and heartburn
- Constipation: result from reduced intestinal motility
- Heartburn: result from enlarging uterus pushing upward on stomach, causing the reflux of gastric contents into the esophagus
Increase basal metabolic rate
- Thus pregnant mother often feel hot
- Appetite might be strongly stimulated ,causing mother to overeat when they only need an extra 300kcal/day.
Nutrition
- During last trimester, fetus needs more nutrients than the mother digestive tract can absorb. In preparation to this, the placenta stores nutrients early in gestation and release them in the last trimester
- Nutrition such as iron, calcium, vitamin K and D as well as folic acid are important for the development of fetus
Circulatory System
- The mother blood volume will rises about 30% during pregnancy because of fluid retention and hemopoeisis to supply blood to the placenta for the fetus
- Cardiac output rises about 30% to 40% above by 27 weeks and return to normal in the last 8 week
- Uterus puts pressure on the large pelvic blood vessels. It interferes with the venous return thus cause varicose vein, oedema and hemorrhoid
Respiratory System
- minute ventilation increase about 50%
- this is because: 1. oxygen demand are about 20% higher to supply the fetus and support the mother increase metabolic rate. 2. progesterone increase sensitivity of respiratory chemoreceptors to carbon dioxide and ventilation is adjusted to keep the arterial co2 at low level. 3.expanding uterus push the abdominal viscera up towards the diaphragm and interferes with the normal breathing
Urinary System
- aldosterone and steroids of pregnancy promote water and salt retention by kidneys. GFR increase by 50% and urine output is slightly elevated so that the mother can dispose of both her own and fetus metabolic waste.
- Expanding uterus also compress on the bladder reducing its capacity, the urination become more frequent and mother might experience uncontrollable leakage of urine
Integumentary System
- skin must grown to accommodate the expansion of the abdomen and breasts and added fat deposition on the hips and thighs/
- stretching of dermis can always cause striae or scretch marks
- melanocyte activity increase in some areas and darkens the areolae and linea alba. The latter often becomes a dark line ‘linea nigra’ a line from umbilical to pubic region.
- Some mother also require temporary blotchy darkening of the skin over the nose and cheeks called the ‘ mask of pregnancy’
Management of preterm labor
Contextualised By: Chris
Source: http://www.aafp.org/afp/990201ap/593.html
Tocolysis
- offer some short-term benefit in the management of preterm labor.
-A delay in delivery can be used to administer corticosteroids to enhance pulmonary maturity and reduce the severity of fetal respiratory distress syndrome, and to reduce the risk of intraventricular hemorrhage.
-The delay can also be used to facilitate transfer of the patient to a tertiary care center. –
-Tocolytic therapy also has potential for maternal complications. These agents should be used only when the perceived benefits outweigh the risks.
-Contraindications to tocolysis include nonreassuring fetal heart rate tracing, eclampsia or severe preeclampsia, fetal demise (singleton), chorioamnionitis, fetal maturity and maternal hemodynamic instability.
Corticosteroid Therapy
-Dexamethasone and betamethasone are the preferred corticosteroids for antenatal therapy. Corticosteroid therapy for fetal maturation reduces mortality, respiratory distress syndrome and intraventricular hemorrhage in infants between 24 and 34 weeks of gestation..
-Maternal pulmonary edema can occur when antenatal corticosteroids are used in combination with tocolytic agents. This complication is more commonly associated with maternal infection, fluid overload and multiple gestation. Pulmonary edema has not been reported when corticosteroids are used alone.
-In women with PPROM, antenatal corticosteroid therapy reduced the risk of respiratory distress syndrome. The magnitude of the reduction in this group is not as great as in women with intact membranes. In women with PPROM at less than 30 to 32 weeks of gestation, in the absence of clinical chorioamnionitis, antenatal corticosteroid use is recommended because of the high risk of intraventricular hemorrhage at this early gestational age. Although the risk of maternal and fetal infection may increase with corticosteroid use, the increased risk is small.
Antibiotic Therapy
-Group B streptococcal disease continues to be a major cause of illness and death among newborn infants and has been associated with preterm labor, although data supporting this association are weak. A gestational age of less than 37 weeks is one of the major risk factors for group B streptococcal disease.
- Recent data suggest that poor fetal outcome (death, respiratory distress, sepsis, intraventricular hemorrhage or necrotizing colitis) occurred less frequently in women receiving antibiotics (average gestational age: 24 to 32 weeks). In addition, women who received antibiotics sustained pregnancy approximately twice as long as those who did not receive antibiotics and also had a lower incidence of clinical amnionitis.
Source: http://www.aafp.org/afp/990201ap/593.html
Tocolysis
- offer some short-term benefit in the management of preterm labor.
-A delay in delivery can be used to administer corticosteroids to enhance pulmonary maturity and reduce the severity of fetal respiratory distress syndrome, and to reduce the risk of intraventricular hemorrhage.
-The delay can also be used to facilitate transfer of the patient to a tertiary care center. –
-Tocolytic therapy also has potential for maternal complications. These agents should be used only when the perceived benefits outweigh the risks.
-Contraindications to tocolysis include nonreassuring fetal heart rate tracing, eclampsia or severe preeclampsia, fetal demise (singleton), chorioamnionitis, fetal maturity and maternal hemodynamic instability.
Corticosteroid Therapy
-Dexamethasone and betamethasone are the preferred corticosteroids for antenatal therapy. Corticosteroid therapy for fetal maturation reduces mortality, respiratory distress syndrome and intraventricular hemorrhage in infants between 24 and 34 weeks of gestation..
-Maternal pulmonary edema can occur when antenatal corticosteroids are used in combination with tocolytic agents. This complication is more commonly associated with maternal infection, fluid overload and multiple gestation. Pulmonary edema has not been reported when corticosteroids are used alone.
-In women with PPROM, antenatal corticosteroid therapy reduced the risk of respiratory distress syndrome. The magnitude of the reduction in this group is not as great as in women with intact membranes. In women with PPROM at less than 30 to 32 weeks of gestation, in the absence of clinical chorioamnionitis, antenatal corticosteroid use is recommended because of the high risk of intraventricular hemorrhage at this early gestational age. Although the risk of maternal and fetal infection may increase with corticosteroid use, the increased risk is small.
Antibiotic Therapy
-Group B streptococcal disease continues to be a major cause of illness and death among newborn infants and has been associated with preterm labor, although data supporting this association are weak. A gestational age of less than 37 weeks is one of the major risk factors for group B streptococcal disease.
- Recent data suggest that poor fetal outcome (death, respiratory distress, sepsis, intraventricular hemorrhage or necrotizing colitis) occurred less frequently in women receiving antibiotics (average gestational age: 24 to 32 weeks). In addition, women who received antibiotics sustained pregnancy approximately twice as long as those who did not receive antibiotics and also had a lower incidence of clinical amnionitis.
Pregnancy Period
NORMAL - Traditionally a human pregnancy is considered to last approximately 40 weeks (280 days) from the LMP, or 38 weeks (266 days) from the date of fertilization.
TWINS/ TRIPLETS - The length of pregnancy decreases with each additional baby. On average, most singleton pregnancies last 39 weeks; for twins, 35 weeks; for triplets, 33 weeks; and for quadruplets, 29 weeks.
Fraternal twins- separate placenta
Identical twins- share the same placenta
TWINS/ TRIPLETS - The length of pregnancy decreases with each additional baby. On average, most singleton pregnancies last 39 weeks; for twins, 35 weeks; for triplets, 33 weeks; and for quadruplets, 29 weeks.
Fraternal twins- separate placenta
Identical twins- share the same placenta
- What is effacement, and how significant is 2cm dilation?
Effacement - thinning of the cervix
2cm dilation is an indicator for labour (first stage of labour)
- What does the urinalysis suggest?
Rachel: Blood + protein in urine - suggestive for UTI
↑Glucose level -gestational diabetes
protein - suggestive for eclampsia
- Why MSU? - to reduce contamination
For every sample, these are performed: Microscopic, sensitivity, culture (basic histology test)
To detect the specific bacteria thus MSU is taken first before administering ampicilin
Can choose which antibiotic to be used
Antibiotic can only be given if bacteria presence
prepared by: SRI MURNIATI ROSLI
Tuesday 14 August 2007
Causes and Risk Factors for Premature birth
Ji Keon LOOI
17 August 2007 (First Draft: 14 Aug)
MBBS / MED2042
Week 5: An early arrival
Causes and Risk Factors for Premature birth
What is preterm birth?
•A.k.a. Premature birth
•the birth of a baby before the standard period of pregnancy is completed.
•< 37 weeks since last menstrual period
•Note: standard length of a human gestation is 266 days
•postmature birth is defined as birth more than 42 weeks after the LMP
What causes preterm labour?
•The mechanism that causes normal term labor to begin is not completely understood, so the actual cause of premature labor is also unknown. However, there are some factors that may increase a woman's risk for premature labor.
~ ehealthMD
Factors related to maternal diseases that increases risk of preterm birth
•Idiopathic
•Low socioeconomic status
•high blood pressure
•preeclampsia
•Short interval between pregnancies (< 3 months)
•Age: <18> 40
•weak cervix
–Previous surgery involving the cervix (D+C / Cone Biopsy)
–Cervix dilatation and effacement in the third trimester are at increased risk for preterm birth
•maternal diabetes
•Periodontal disease
–Oral bacteria, especially Fusobacterium nucleatum and Capnocytophaga species, have been associated with upper genital tract infection in pregnant women
•Exposure to diethylstilbestrol (DES)
Factors related to pregnancy history that increases risks of preterm birth
•prior preterm delivery
•prior induced abortion
•antepartum hemorrhage / vaginal bleeding during labor
•prior miscarriage
Others
•Multiple pregnancy
•Sexually transmitted diseases
•Urinary tract infections ( risk of preeclampsia)
•Tobacco and alcohol use
The symptoms of an imminent premature birth
•Four or more uterine contractions in one hour, before 37 weeks' gestation.
•A watery discharge from the vagina which may indicate premature rupture of the membranes surrounding the baby.
•Pressure in the pelvis or the sensation that the baby has "dropped".
•Menstrual cramps or abdominal pain.
•Pain or rhythmic tightening in lower abdomen or back.
•Vaginal spotting or bleeding.
Nice to know
•While it is normally desirable for a pregnancy to reach its full term, there are circumstances in which obstetricians must induce preterm delivery for the safety of the mother, the child, or both.
Induction of premature labor is necessary under:
•Severe hypertension or eclampsia
•a seizure or coma in a woman with pre-eclampsia
•Preterm premature rupture of the membranes (PPROM).
–ruptured amniotic sac prior to the 37th week of pregnancy
•Fetal stress
Have a nice weekend!!!
17 August 2007 (First Draft: 14 Aug)
MBBS / MED2042
Week 5: An early arrival
Causes and Risk Factors for Premature birth
What is preterm birth?
•A.k.a. Premature birth
•the birth of a baby before the standard period of pregnancy is completed.
•< 37 weeks since last menstrual period
•Note: standard length of a human gestation is 266 days
•postmature birth is defined as birth more than 42 weeks after the LMP
What causes preterm labour?
•The mechanism that causes normal term labor to begin is not completely understood, so the actual cause of premature labor is also unknown. However, there are some factors that may increase a woman's risk for premature labor.
~ ehealthMD
Factors related to maternal diseases that increases risk of preterm birth
•Idiopathic
•Low socioeconomic status
•high blood pressure
•preeclampsia
•Short interval between pregnancies (< 3 months)
•Age: <18> 40
•weak cervix
–Previous surgery involving the cervix (D+C / Cone Biopsy)
–Cervix dilatation and effacement in the third trimester are at increased risk for preterm birth
•maternal diabetes
•Periodontal disease
–Oral bacteria, especially Fusobacterium nucleatum and Capnocytophaga species, have been associated with upper genital tract infection in pregnant women
•Exposure to diethylstilbestrol (DES)
Factors related to pregnancy history that increases risks of preterm birth
•prior preterm delivery
•prior induced abortion
•antepartum hemorrhage / vaginal bleeding during labor
•prior miscarriage
Others
•Multiple pregnancy
•Sexually transmitted diseases
•Urinary tract infections ( risk of preeclampsia)
•Tobacco and alcohol use
The symptoms of an imminent premature birth
•Four or more uterine contractions in one hour, before 37 weeks' gestation.
•A watery discharge from the vagina which may indicate premature rupture of the membranes surrounding the baby.
•Pressure in the pelvis or the sensation that the baby has "dropped".
•Menstrual cramps or abdominal pain.
•Pain or rhythmic tightening in lower abdomen or back.
•Vaginal spotting or bleeding.
Nice to know
•While it is normally desirable for a pregnancy to reach its full term, there are circumstances in which obstetricians must induce preterm delivery for the safety of the mother, the child, or both.
Induction of premature labor is necessary under:
•Severe hypertension or eclampsia
•a seizure or coma in a woman with pre-eclampsia
•Preterm premature rupture of the membranes (PPROM).
–ruptured amniotic sac prior to the 37th week of pregnancy
•Fetal stress
Have a nice weekend!!!
Monday 13 August 2007
tasks for pcl 5
SRI (10min max)
pregnancy period (briefly)
* normal
* fraternal twins
* identical
cervix
*significance of 2cm dilatation of cervix
Investigations
*urinalysis
*bacteriological swab
PRETERM LABOUR
VIVIAN (10min)
Maturation of vital organs
*enbryogenesis, organogenesis
JIKEON ,IMP(15min)
causes and RF
complications
CHRIS (10min)
management
*as well as why doc needs to delay labour
pharmacology mx
*salbutamol
*dexmethasone
*ampicillin
SHANTZ (10min)
different stages of normal labour
*various complications that can occur at each stage
*endocrine component
LAWRENCE *(10min)
physiology of pregnancy
JOHN (10min)
post partum mx of mother and benefits of breast feeding
CHRISTINE (10min)
antenatal mx of mother
MADHURA (15min)
psychosocial issues(IMP)
*clinical care of pregant mothers in a rural setting
*transfer of mother from rual clinics to hospitals(challenges)
*if transfer of mother is not possible, what other solutions are available in a rural setting?
*stresses and financial difficulties of a padi farmer
pregnancy period (briefly)
* normal
* fraternal twins
* identical
cervix
*significance of 2cm dilatation of cervix
Investigations
*urinalysis
*bacteriological swab
PRETERM LABOUR
VIVIAN (10min)
Maturation of vital organs
*enbryogenesis, organogenesis
JIKEON ,IMP(15min)
causes and RF
complications
CHRIS (10min)
management
*as well as why doc needs to delay labour
pharmacology mx
*salbutamol
*dexmethasone
*ampicillin
SHANTZ (10min)
different stages of normal labour
*various complications that can occur at each stage
*endocrine component
LAWRENCE *(10min)
physiology of pregnancy
JOHN (10min)
post partum mx of mother and benefits of breast feeding
CHRISTINE (10min)
antenatal mx of mother
MADHURA (15min)
psychosocial issues(IMP)
*clinical care of pregant mothers in a rural setting
*transfer of mother from rual clinics to hospitals(challenges)
*if transfer of mother is not possible, what other solutions are available in a rural setting?
*stresses and financial difficulties of a padi farmer
Friday 10 August 2007
Causes And Risk Factors for Infertility
30 - 40% of all infertility - "male" factor
1. Hormonal problem:
o Quite rare & represent only 1% of all male infertility disorders
o Pituitary tumour & other conditions where the pituitary gland is affected
2. Sperm production problem:
o Sertoli cell-only syndrome
o Maturation arrest à precursor cells are unable to complete their development to sperm in the testis.
o Hypospermatogenesis
o Cryptochisism – Undescended testis
o Genetic causes – Klinefelter’s Syndrome, Down’s Syndrome, etc
o Orchitis – Testes infection, can be viral (Mumps orchitis) or bacterial (epididymo-orchitis)
o Heat:
– Temp: 1-1.5 °c < than body temp (achieved by pampiniform plexus)
– Fever, excessive external heat eg: hot spa, underwear style (tight or loose? Still in reaserch)
o Anti-Sperm antibodies – damaging effect on sperm
o Torsion of testis – blood vessels that supply the testis become twisted
o Varicocele - varicose condition of spermatic cord veins, abnormal valves & dilatation, ¯ sperm count , ‘bag of worms’
o Drugs – anti-cancer drugs, chemicals: pesticides, etc
o Radiation damage – in radiation therapy
3. Sperm blockage:
o Congenital absence of vas deferens – common in Cystic Fibrosis
o Congenital absence of seminal vesicle - acidity of semen
o Infection – eg: gonorrhoea, chlamydia, cause inflammation of reproductive ducts
o Obstruction in region of prostate – infection, ‘cyst’ in prostate gland (congenital)
o Vasectomy
4. Ejaculatory problem:
o Damage to nerve ( pudendal n.) – caused by spinal cord injury, diabetes (neuropathy) & surgery - erectile dysfunction
o Surgery to nerves in pelvis & prostate surgery – may cause damage to sphincter muscle of bladder, lead to retrograde ejaculation
o Timing of intercourse – ref to ovarian & menstrual cycle of female
o Medication – anti hypertensive & anti depression drugs
5. Others:
o Smoking
o Stress
o Excessive alcohol
o Idiopathic – 15%
o 2° causes: Diabetes, obesity, sicke cell disease, chronic renal failure, liver disease, usage of lubricants
· 40 - 50% of infertility - "female" factor
1. Ovulation causes
a. Abnormalities of the thyroid gland
Hypothyroidism leads to increased prolactin release, leading to galactorrhoea. The high prolactin level may prevent normal ovulation, causing decreased fertility, sometimes with irregular or absent menses.
Hyperthyroidism patients have variable menstrual patterns
b. Excessive male hormone (androgens)
Excess androgens in the woman may lead to the formation of male secondary sex characteristics and the suppression of LH and FSH production by the pituitary gland. Elevated levels of androgens may be found in women with polycystic ovaries, or with a tumor in the pituitary gland, adrenal gland, or ovary.
c. Physical stress, psychological stress and extreme lifestyle changes
Stress in women disrupts the hormonal communication between the brain, the pituitary, and the ovary, interfering with both the maturation of an egg and the ovulation process.
d. Poor egg quality
Eggs that become damaged or develop chromosomal abnormalities cannot sustain a pregnancy. This problem is usually age-related -- egg quality declines significantly in the late 30s and early 40s.
2. Cervical causes
This involves inability of the sperm to pass through the mouth of the uterus due to damage of the cervix. Causes include the following:
a. Inadequate or inhospitable cervical mucous
Destroys partner’s sperm
b. Cervical narrowing or "stenosis"
Impedes the passage of semen into the uterus
c. Infections of the cervix
Commonly due to sexually transmitted diseases
d. Immunological infertility
Immune attack of sperm or "sperm allergy" is sometimes diagnosed when the woman's immune system produces "anti-sperm antibodies" that attack her partner's sperm.
3. Pelvic causes
These include any disruption of the normal pelvic anatomy:
a. Scar tissue or "adhesions"
Usually caused by surgery or infection. Pelvic adhesions are actually scar tissue that forms between two or more internal organs. Infertility can occur when the adhesions attach to the ovaries or fallopian tubes.
b. Endometriosis
Endometrial tissue (the uterine lining that sheds with each monthly period) grows outside the uterus
c. Blocked, scarred, or distorted fallopian tubes
Pelvic inflammatory disease (PID) - an infection of the reproductive tract that usually is caused by a sexually transmitted disease but can also stem from a miscarriage, abortion, childbirth or an intrauterine device (IUD).
d. Benign tumors (fibroids) of the uterus
Can interfere with embryo implantation or fetal growth. At least 40 percent of women have these benign uterine tumors, or myomas.
e. Poly cystic ovarian syndrome
Patients whose ovaries contain many small cysts have hormone imbalances and do not ovulate regularly.
4. Uterine causes
a. Thin or abnormal uterine lining
Implantation cannot occur
b. Anatomic problems
Polyps, uterine fibroids, abnormal shape of the uterus, septum or "dividing wall" within the uterus
c. Diethylstilbestrol (DES)
A synthetic oestrogen was given to some women who were at risk for miscarriage during the 1950s and 1960s. Women and men whose mothers took DES while pregnant with them are at high risk for certain reproductive tract cancers and menstrual irregularities. Many DES daughters have an abnormally shaped uterus that can lead to repeated miscarriages. DES sons are prone to cysts in their reproductive tract, undescended testicles and other fertility problems.
· Remaining 10 -30% of infertility - contributing factors from both partners/ or idiopathic
*Estimated that 10 - 20% of couples will be unable to conceive after 1 year of trying to become pregnant.
*Important that pregnancy be attempted for at least 1 year.
- Chance for pregnancy occurring in healthy couples who are both under the age of 30 and having intercourse regularly is only 25 - 30% per month. A woman's peak fertility occurs in her early 20s.
- As a woman ages beyond 35 (and particularly after age 40), the likelihood of getting pregnant drops to less than 10% per month.
Risk factors for infertility:
Multiple sexual partners (increases risk for sexually transmitted diseases)
Sexually transmitted diseases
History of PID (pelvic inflammatory disease)
History of orchitis (Testis infection) or epididymitis in men
Mumps (men)
Varicocele (men)
A past medical history that includes DES exposure (men or women)
Eating disorders (women)
Anovulatory menstrual cycles
Endometriosis
Defects of the uterus (myomas) or cervical obstruction
Long-term (chronic) disease such as diabetes
Source:
Medline - http://www.nlm.nih.gov/medlineplus/ency/article/001191.htm,
advanced infertility institute web site – http://www.fertilitydocs.com/causesof.html
And health A to Z website – http://www.healthatoz.com
Contributed by John Lee
1. Hormonal problem:
o Quite rare & represent only 1% of all male infertility disorders
o Pituitary tumour & other conditions where the pituitary gland is affected
2. Sperm production problem:
o Sertoli cell-only syndrome
o Maturation arrest à precursor cells are unable to complete their development to sperm in the testis.
o Hypospermatogenesis
o Cryptochisism – Undescended testis
o Genetic causes – Klinefelter’s Syndrome, Down’s Syndrome, etc
o Orchitis – Testes infection, can be viral (Mumps orchitis) or bacterial (epididymo-orchitis)
o Heat:
– Temp: 1-1.5 °c < than body temp (achieved by pampiniform plexus)
– Fever, excessive external heat eg: hot spa, underwear style (tight or loose? Still in reaserch)
o Anti-Sperm antibodies – damaging effect on sperm
o Torsion of testis – blood vessels that supply the testis become twisted
o Varicocele - varicose condition of spermatic cord veins, abnormal valves & dilatation, ¯ sperm count , ‘bag of worms’
o Drugs – anti-cancer drugs, chemicals: pesticides, etc
o Radiation damage – in radiation therapy
3. Sperm blockage:
o Congenital absence of vas deferens – common in Cystic Fibrosis
o Congenital absence of seminal vesicle - acidity of semen
o Infection – eg: gonorrhoea, chlamydia, cause inflammation of reproductive ducts
o Obstruction in region of prostate – infection, ‘cyst’ in prostate gland (congenital)
o Vasectomy
4. Ejaculatory problem:
o Damage to nerve ( pudendal n.) – caused by spinal cord injury, diabetes (neuropathy) & surgery - erectile dysfunction
o Surgery to nerves in pelvis & prostate surgery – may cause damage to sphincter muscle of bladder, lead to retrograde ejaculation
o Timing of intercourse – ref to ovarian & menstrual cycle of female
o Medication – anti hypertensive & anti depression drugs
5. Others:
o Smoking
o Stress
o Excessive alcohol
o Idiopathic – 15%
o 2° causes: Diabetes, obesity, sicke cell disease, chronic renal failure, liver disease, usage of lubricants
· 40 - 50% of infertility - "female" factor
1. Ovulation causes
a. Abnormalities of the thyroid gland
Hypothyroidism leads to increased prolactin release, leading to galactorrhoea. The high prolactin level may prevent normal ovulation, causing decreased fertility, sometimes with irregular or absent menses.
Hyperthyroidism patients have variable menstrual patterns
b. Excessive male hormone (androgens)
Excess androgens in the woman may lead to the formation of male secondary sex characteristics and the suppression of LH and FSH production by the pituitary gland. Elevated levels of androgens may be found in women with polycystic ovaries, or with a tumor in the pituitary gland, adrenal gland, or ovary.
c. Physical stress, psychological stress and extreme lifestyle changes
Stress in women disrupts the hormonal communication between the brain, the pituitary, and the ovary, interfering with both the maturation of an egg and the ovulation process.
d. Poor egg quality
Eggs that become damaged or develop chromosomal abnormalities cannot sustain a pregnancy. This problem is usually age-related -- egg quality declines significantly in the late 30s and early 40s.
2. Cervical causes
This involves inability of the sperm to pass through the mouth of the uterus due to damage of the cervix. Causes include the following:
a. Inadequate or inhospitable cervical mucous
Destroys partner’s sperm
b. Cervical narrowing or "stenosis"
Impedes the passage of semen into the uterus
c. Infections of the cervix
Commonly due to sexually transmitted diseases
d. Immunological infertility
Immune attack of sperm or "sperm allergy" is sometimes diagnosed when the woman's immune system produces "anti-sperm antibodies" that attack her partner's sperm.
3. Pelvic causes
These include any disruption of the normal pelvic anatomy:
a. Scar tissue or "adhesions"
Usually caused by surgery or infection. Pelvic adhesions are actually scar tissue that forms between two or more internal organs. Infertility can occur when the adhesions attach to the ovaries or fallopian tubes.
b. Endometriosis
Endometrial tissue (the uterine lining that sheds with each monthly period) grows outside the uterus
c. Blocked, scarred, or distorted fallopian tubes
Pelvic inflammatory disease (PID) - an infection of the reproductive tract that usually is caused by a sexually transmitted disease but can also stem from a miscarriage, abortion, childbirth or an intrauterine device (IUD).
d. Benign tumors (fibroids) of the uterus
Can interfere with embryo implantation or fetal growth. At least 40 percent of women have these benign uterine tumors, or myomas.
e. Poly cystic ovarian syndrome
Patients whose ovaries contain many small cysts have hormone imbalances and do not ovulate regularly.
4. Uterine causes
a. Thin or abnormal uterine lining
Implantation cannot occur
b. Anatomic problems
Polyps, uterine fibroids, abnormal shape of the uterus, septum or "dividing wall" within the uterus
c. Diethylstilbestrol (DES)
A synthetic oestrogen was given to some women who were at risk for miscarriage during the 1950s and 1960s. Women and men whose mothers took DES while pregnant with them are at high risk for certain reproductive tract cancers and menstrual irregularities. Many DES daughters have an abnormally shaped uterus that can lead to repeated miscarriages. DES sons are prone to cysts in their reproductive tract, undescended testicles and other fertility problems.
· Remaining 10 -30% of infertility - contributing factors from both partners/ or idiopathic
*Estimated that 10 - 20% of couples will be unable to conceive after 1 year of trying to become pregnant.
*Important that pregnancy be attempted for at least 1 year.
- Chance for pregnancy occurring in healthy couples who are both under the age of 30 and having intercourse regularly is only 25 - 30% per month. A woman's peak fertility occurs in her early 20s.
- As a woman ages beyond 35 (and particularly after age 40), the likelihood of getting pregnant drops to less than 10% per month.
Risk factors for infertility:
Multiple sexual partners (increases risk for sexually transmitted diseases)
Sexually transmitted diseases
History of PID (pelvic inflammatory disease)
History of orchitis (Testis infection) or epididymitis in men
Mumps (men)
Varicocele (men)
A past medical history that includes DES exposure (men or women)
Eating disorders (women)
Anovulatory menstrual cycles
Endometriosis
Defects of the uterus (myomas) or cervical obstruction
Long-term (chronic) disease such as diabetes
Source:
Medline - http://www.nlm.nih.gov/medlineplus/ency/article/001191.htm,
advanced infertility institute web site – http://www.fertilitydocs.com/causesof.html
And health A to Z website – http://www.healthatoz.com
Contributed by John Lee
Thursday 9 August 2007
types of infertility
Male infertility
Sperm defects
A low sperm count is the most common cause of male infertility. Abnormalities in sperm shape or their ability to swim can also cause infertility problems. These can be due to hormonal imbalances, infection, or testicular varicocele.
A total absence of sperm (known as 'azoospermia') in the ejaculate can be caused by testicular damage, mumps, anatomical disorders, or lack of hormones.
Immunological factors
Some men produce antibodies to their own sperm, which prevent the sperm from penetrating the egg. The exact cause is not known but may be due to infection or vasectomy.
Spermatic cord occlusion
The spermatic cord is the tube that transports the sperm from each testis to the penis and any blockages will cause infertility. Common causes are vasectomy, infection and some sexually transmitted diseases.
Ejaculation disorders
Some ejaculation disorders such as retrograde ejaculation – where the semen is ejaculated backwards into the bladder – can prevent proper transfer of sperm into the vagina without the man being aware of the problem.
Erectile dysfunction and lack of libido( impotence)
there are many causes of this. The man loses his sexual desire leading to ED. The causes maybe psychological, neurogenic, vascular, endocrine or related to drugs and often includes contributions from various causes. ED is often a common symptom of hyponadism.
Endocrine disorders
such as male hypogonadism resulting in small and soft testes, poor libido, impotence and loss of secondary hair, and deficiency of semen production
Ageing
Until recently, ageing was considered a risk factor only for female fertility. However, recent research shows ageing affects sperm function too. Sperm that swim in a straight line have a far better chance of making their way through the female reproductive tract to reach the egg. But this swimming ability declines as a man ages. At the same time, the chance of genetic abnormalities in the sperm also increases
Female infertility
Ovulation disorders
A delicate balance of sex hormones (oestrogen, progesterone, luteinizing hormone and follicle stimulating hormone) is needed for the timely growth and release of the egg from the ovary (ovulation).
Hormone imbalances can cause ovulation disorders in women and are the most common cause of infertility in women.
Fallopian tube damage
The fallopian tube is where fertilisation takes place, after the egg is released from the ovary into the tube and is met by sperm. Full or partial blockage of the fallopian tubes will prevent fertilisation.
Damage to the fallopian tubes can be caused by inflammation as a result of viral or bacterial infections, some types of sexually transmitted diseases, or complications of surgery such as adhesions or scarring.
Uterus and cervical disorders
Benign growths on the uterine wall, such as fibroids or polyps, can contribute to infertility as they interfere with the attachment of the embryo to the wall of the uterus.
Abnormalities in the shape of the cervix or changes in the texture of the cervical mucus can make it difficult for the sperm to move from the vagina into the uterus.
Endometriosis
Endometriosis is a condition where the lining of the uterus forms at inappropriate places within and outside of the reproductive tract. It can block the fallopian tubes and/or disrupt ovulation. It occurs in about 10 per cent of women.
Immunological factors
The presence of antibodies to sperm in cervical mucus can cause infertility. In other cases, the mother's immune system prevents the embryo from attaching to the wall of the uterus and so causes a miscarriage.
Polycystic ovaries
Polycystic ovaries contain lots of small cysts, making the ovary larger than normal. The condition, called polycystic ovarian disease (PCOD), is also associated with high levels of androgen and oestrogen. Women with PCOD have irregular periods and may not ovulate, resulting in infertility.
Ovarian failure
Ovarian failure can be a consequence of medical treatments (for ovarian tumours for instance), or the complete failure of the ovaries to develop or contain eggs in the first place (for example, Turner's Syndrome).The treatment for ovarian tumours may involve surgical removal of all or part of the ovary. Ovarian failure can also occur as a result of treatments such as chemotherapy and pelvic radiotherapy for cancers in other body areas. These therapies destroy eggs in the ovary.
Ageing
Age is a critical factor affecting the fertility of a woman and many women today are delaying having children. Some of the common reasons include education and career demands, financial stability, second marriages and relationships, and waiting for a suitable partner.
Reproductive function declines as a woman ages, particularly after the age of 35. Women are born with a finite number of eggs, unlike men who produce sperm most of their adult life. In the years approaching menopause, there are fewer and fewer eggs left in the ovary. The quality of eggs also diminishes as a woman gets older. By the late thirties, there is an increase in chromosome abnormalities that can result in birth defects like Down's syndrome.
Ageing can also affect other reproductive organs and functions, such as the uterus, hormone production, and ovulation. There is also a higher incidence of miscarriage in women in their late thirties.
Delaying children isn't always avoidable, but infertility treatments cannot reverse the ageing process and should not be thought of as a safeguard that will ensure a pregnancy at some point in the future. The success rates of IVF for women over 35 are much lower than for younger women
Sperm defects
A low sperm count is the most common cause of male infertility. Abnormalities in sperm shape or their ability to swim can also cause infertility problems. These can be due to hormonal imbalances, infection, or testicular varicocele.
A total absence of sperm (known as 'azoospermia') in the ejaculate can be caused by testicular damage, mumps, anatomical disorders, or lack of hormones.
Immunological factors
Some men produce antibodies to their own sperm, which prevent the sperm from penetrating the egg. The exact cause is not known but may be due to infection or vasectomy.
Spermatic cord occlusion
The spermatic cord is the tube that transports the sperm from each testis to the penis and any blockages will cause infertility. Common causes are vasectomy, infection and some sexually transmitted diseases.
Ejaculation disorders
Some ejaculation disorders such as retrograde ejaculation – where the semen is ejaculated backwards into the bladder – can prevent proper transfer of sperm into the vagina without the man being aware of the problem.
Erectile dysfunction and lack of libido( impotence)
there are many causes of this. The man loses his sexual desire leading to ED. The causes maybe psychological, neurogenic, vascular, endocrine or related to drugs and often includes contributions from various causes. ED is often a common symptom of hyponadism.
Endocrine disorders
such as male hypogonadism resulting in small and soft testes, poor libido, impotence and loss of secondary hair, and deficiency of semen production
Ageing
Until recently, ageing was considered a risk factor only for female fertility. However, recent research shows ageing affects sperm function too. Sperm that swim in a straight line have a far better chance of making their way through the female reproductive tract to reach the egg. But this swimming ability declines as a man ages. At the same time, the chance of genetic abnormalities in the sperm also increases
Female infertility
Ovulation disorders
A delicate balance of sex hormones (oestrogen, progesterone, luteinizing hormone and follicle stimulating hormone) is needed for the timely growth and release of the egg from the ovary (ovulation).
Hormone imbalances can cause ovulation disorders in women and are the most common cause of infertility in women.
Fallopian tube damage
The fallopian tube is where fertilisation takes place, after the egg is released from the ovary into the tube and is met by sperm. Full or partial blockage of the fallopian tubes will prevent fertilisation.
Damage to the fallopian tubes can be caused by inflammation as a result of viral or bacterial infections, some types of sexually transmitted diseases, or complications of surgery such as adhesions or scarring.
Uterus and cervical disorders
Benign growths on the uterine wall, such as fibroids or polyps, can contribute to infertility as they interfere with the attachment of the embryo to the wall of the uterus.
Abnormalities in the shape of the cervix or changes in the texture of the cervical mucus can make it difficult for the sperm to move from the vagina into the uterus.
Endometriosis
Endometriosis is a condition where the lining of the uterus forms at inappropriate places within and outside of the reproductive tract. It can block the fallopian tubes and/or disrupt ovulation. It occurs in about 10 per cent of women.
Immunological factors
The presence of antibodies to sperm in cervical mucus can cause infertility. In other cases, the mother's immune system prevents the embryo from attaching to the wall of the uterus and so causes a miscarriage.
Polycystic ovaries
Polycystic ovaries contain lots of small cysts, making the ovary larger than normal. The condition, called polycystic ovarian disease (PCOD), is also associated with high levels of androgen and oestrogen. Women with PCOD have irregular periods and may not ovulate, resulting in infertility.
Ovarian failure
Ovarian failure can be a consequence of medical treatments (for ovarian tumours for instance), or the complete failure of the ovaries to develop or contain eggs in the first place (for example, Turner's Syndrome).The treatment for ovarian tumours may involve surgical removal of all or part of the ovary. Ovarian failure can also occur as a result of treatments such as chemotherapy and pelvic radiotherapy for cancers in other body areas. These therapies destroy eggs in the ovary.
Ageing
Age is a critical factor affecting the fertility of a woman and many women today are delaying having children. Some of the common reasons include education and career demands, financial stability, second marriages and relationships, and waiting for a suitable partner.
Reproductive function declines as a woman ages, particularly after the age of 35. Women are born with a finite number of eggs, unlike men who produce sperm most of their adult life. In the years approaching menopause, there are fewer and fewer eggs left in the ovary. The quality of eggs also diminishes as a woman gets older. By the late thirties, there is an increase in chromosome abnormalities that can result in birth defects like Down's syndrome.
Ageing can also affect other reproductive organs and functions, such as the uterus, hormone production, and ovulation. There is also a higher incidence of miscarriage in women in their late thirties.
Delaying children isn't always avoidable, but infertility treatments cannot reverse the ageing process and should not be thought of as a safeguard that will ensure a pregnancy at some point in the future. The success rates of IVF for women over 35 are much lower than for younger women
Treatment option for infertility
What is assisted reproductive technology (ART)?
Assisted reproductive technology (ART) is a term that describes several different methods used to help infertile couples. ART involves removing eggs from a woman's body, mixing them with sperm in the laboratory and putting the embryos back into a woman's body.
The U.S. Centers for Disease Prevention (CDC) collects success rates on ART for some fertility clinics. According to the 2003 CDC report on ART, the average percentage of ART cycles that led to a healthy baby were as follows:
37.3% in women under the age of 35
30.2% in women aged 35-37
20.2% in women aged 37-40
11.0% in women aged 41-42
IVF
In vitro fertilization (IVF) means fertilization outside of the body. IVF is the most effective ART. It is often used when a woman's fallopian tubes are blocked or when a man produces too few sperm. Doctors treat the woman with a drug that causes the ovaries to produce multiple eggs. Once mature, the eggs are removed from the woman. They are put in a dish in the lab along with the man's sperm for fertilization. After 3 to 5 days, healthy embryos are implanted in the woman's uterus.
# Who are the best couples for I.V.F. treatment ?
1-Couples with unexplained failure of conception
2-Patients with blocked tubes (the sperm cannot reach the oocytes to fertilize them)
3-Patients with poor semen analysis.
4-Patients with severe polycystic ovarian syndrome and dysfunctional ovulation
5-Patients with endometriosis
6-Patients with anti-sperm antibodies (both male and female)
There are basically five steps in the IVF and embryo transfer process which include the following:
1.Monitor and stimulate the development of healthy egg(s) in the ovaries.
2.Collect the eggs.
3.Secure the sperm.
4.Combine the eggs and sperm together in the laboratory and provide the appropriate environment for fertilization and early embryo growth.
5.Transfer embryos into the uterus.
GIFT & ZIFT
Gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT) are two procedures related to IVF.
GIFT is similar to IVF, but the gametes (egg and sperm) are transferred to the fallopian tubes rather than the uterus, and fertilization takes place in the tubes rather than in the laboratory. GIFT also involves a laparoscopic surgical procedure to transfer the sperm and egg into the tubes. GIFT accounts for approximately 2% of assisted reproductive technology (ART) procedures in the United States.
ZIFT differs from GIFT in that the fertilization process still takes place in the laboratory versus the fallopian tubes. It is similar to GIFT in that the fertilized egg is transferred into fallopian tubes, and it involves a laparoscopic surgical procedure. ZIFT accounts for less than 1.5% of assisted reproductive technology (ART) procedures in the United States.
IUI
Intrauterine insemination (IUI) is a procedure in which sperm are placed in a woman's uterus through artificial means. IUI is most often recommended for couples with unexplained infertility or male factor infertility — such as a low sperm count or poor sperm motility. For many couples, intrauterine insemination is a more affordable and less invasive alternative to in vitro fertilization (IVF). However, IUI is not effective for infertility associated with blocked or damaged fallopian tubes.
Intrauterine insemination involves injecting sperm directly into your uterus at the time of ovulation. This can be done using either your partner's sperm or a donor's sperm. Before the procedure, the sperm are "washed" and prepared for injection. Your doctor uses a soft tube (catheter) to deposit the sperm through your cervix and into your uterus at the time of ovulation. Fertility drugs that stimulate ovulation may be used in conjunction with intrauterine insemination. Success rates for IUI depend on many factors, including your age and the duration and cause of infertility.
Why is ‘sperm washing’ necessary
Sperm must be washed in order to be used with IUI. Raw semen cannot be inserted directly into a woman’s uterus. This is because semen contains chemicals called prostaglandins. Prostaglandins cause muscular contractions and are responsible for cramps during menstruation and pregnancy. If raw semen is inserted directly into your uterus, rather than going through the cervix first, it could cause severe pain and cramping. It could also cause your uterus to collapse, causing severe complications.
Sperm is also washed in order to increase your chances of becoming pregnant. Sperm washing can remove dead sperm and those sperm with poor motility. This leaves behind sperm that can swim faster and that are more likely to fertilize your egg. Sperm washing can also get rid of the white blood cells, mucous and seminal fluid surrounding the sperm, which can also interfere with fertility.
Male Infertility Treatment
Assisted reproductive technologies such as in vitro fertilization (IVF), GIFT, ZIFT, and intracytoplasmic sperm injection (ICSI) can be used when either the man or the woman is infertile. When male factor infertility is solely responsible for a couple’s inability to conceive (usually due to low sperm count or poor sperm quality) there are several techniques and male infertility treatment options designed to collect and process sperm to improve the chances of fertilization with the egg.
Sperm Retrieval Procedures
One of the most common causes of male infertility is low sperm count. Treatment for low sperm count usually involves some type of sperm retrieval procedure. These less invasive treatment options are designed to obtain sperm from a man who would otherwise have trouble producing it.
Percutaneous Epididymal Sperm Aspiration (PESA)
Percutaneous Epididymal Sperm Aspiration (PESA) is a male infertility and low sperm count treatment option to pursue if there is no sperm in the semen. During this minimally invasive sperm retrieval procedure, a needle is inserted through the scrotum and into the epididymis and the sperm cells are removed.
This virtually pain-free treatment commonly lasts between 10 and 20 minutes and requires only a local anesthetic.
Testicular Sperm Extraction (TESE)
TESE is another male infertility treatment reserved for men who have a blockage which prevents sperm from entering their epididymis. In this method, small amounts of testicular tissue are removed via a needle inserted into the testis. The tissue is processed and the sperm is eventually extracted.
This male infertility treatment involves a general anesthetic. Side effects include pain and soreness, which will usually diminish within a few days.
Microepididymal Sperm Aspiration (MESA)
MESA is a sperm retrieval treatment employing microsurgery techniques to collect sperm near blocked portions of the epididymis. Microepididymal sperm aspiration requires a tiny incision in the scrotum. Fluid is then recovered from the epididymal tube and analyzed for sperm content.
This type of male infertility treatment is performed under general anesthetic. Pain and discomfort are common after the procedure, but can be relieved with prescribed pain medication.
Sperm Preparation Methods
Sperm preparation methods are designed to enhance sperm function and increase the chances of conception. Each of the methods below ensures the sperm are ready to be used as part of fertility treatment with IVF, artificial insemination, and other assisted reproductive technologies.
Swim-Up Technique
The swim-up technique is widely used in fertility clinics. It is based on the fact that sperm need to swim up to reach the uterus and only the healthiest and most active sperm can do that. This preparation method involves placing a culture medium on top of semen in a tube. The healthy, active sperm swim up into the culture medium, leaving behind seminal fluid and debris such as white blood cells, dead sperm, and bacteria. As the sperm swim up to and reach this culture, they are collected and used in a fertilization treatment.
Cryopreservation
Cryopreservation of semen involves collecting and freezing sperm for later use. During this male infertility treatment, sperm is collected and mixed with a freezing medium that allows the sperm to survive the freezing process.
Some men who wish to undergo a vasectomy opt for cyropreservation treatment beforehand to ensure they have active sperm to use in the future, if need be.
Surgical Infertility Solutions for Men
In addition to the male infertility treatment methods used for assisted reproductive technology, there are a several surgical infertility solutions available to treat specific anatomical problems:
Vasoepididymostomy
Vasoepididymostomy is a surgical procedure designed to treat an epididymal obstruction, such as scarring or cysts, which can block the sperm from traveling into the vas deferens.
This male infertility treatment is a difficult microsurgical procedure, requiring a skillful and experienced surgeon.
Varicocelectomy
Varicocelectomy is the most common procedure performed for male infertility. This treatment is essentially a surgical procedure to repair varicoceles (varicose veins of the testicles). The additional blood from varicoceles can raise the temperature of the testes and impair sperm production, causing low sperm count. Treatment to repair this condition requires that veins are cut to eliminate blood flow to the varicocele, improving fertility and increasing the chances of conception.
Female Infertility Treatment
Natural Treatments
Female infertility treatment commonly involves assisted reproductive technologies such as IVF, GIFT, ZIFT, and ICSI to improve the chances of conception, but there are also a variety of structural causes of female factor infertility that have surgical solutions, including endometriosis treatment. Reproductive surgery and diagnostic procedures (particularly diagnostic hysteroscopy) can correct tubal obstruction, endometriosis, uterine fibroids, and scarring from pelvic inflammatory disease.
Endometriosis and Infertility – Treatment Options
Endometriosis is one of the most common causes of female factor infertility, affecting nearly 5 million women in the United States each year. Endometriosis is a chronic disease that causes tissue to build up outside of a woman’s uterus. The tissue can attach to the ovaries, uterine wall, and fallopian tubes causing severe abdominal pain. Endometriosis can also result in significant scarring of the reproductive organs, which sometimes contributes to female infertility. Endometriosis treatment includes several non-surgical and surgical options.
Hormonal medications can be used to halt or slow the progression of endometriosis. A common prescription used for endometriosis treatment is Gn-RH agonists, which control estrogen production – a contributing factor in the growth of endometrial tissue. Other prescription options can be discussed with your doctor or fertility specialist.
There are other effective, but more invasive female infertility and endometriosis treatment options. Read below to learn more.
Other Reproductive Surgery
Reproductive and female infertility treatment options often involve surgical procedures, including:
Laparotomy Microsurgery
This female infertility treatment involves the use of a microscope to perform reproductive surgery. Laparotomy microsurgery can be used for endometriosis treatment or to remove scar tissue and reconstruct fallopian tubes. This procedure is more invasive than most, but it is an excellent option for many women facing fertility problems.
Laparoscopy
This procedure entails the use of a laparoscope to perform surgery. The laparoscope is inserted through a small incision in order to view the pelvic organs. Operating through additional small incisions, scar tissue can be removed and damaged fallopian tubes can be repaired. This procedure is commonly used for female infertility and endometriosis treatment.
Diagnostic Hysteroscopy
Diagnostic hysteroscopy is an important tool used to diagnose female infertility. This treatment involves the use of a fiber optic scope to inspect the uterus for abnormal uterine conditions such as fibroids, polyps, and scarring. Diagnostic hysteroscopy is performed by stretching the cervical canal and using the scope to view the internal structure of the uterus.
Diagnostic hysteroscopy is commonly performed on an outpatient basis and recovery time is typically between two and three days.
Falloposcopy
This female infertility treatment is used to inspect the fallopian tubes for abnormalities such as tube obstruction, scarring, and damage to the inner lining. The falloscopy procedure entails the use of a fiber optic scope to inspect the fallopian tubes and correct any of the above conditions. It will also allow your physician to determine and recommend other female infertility treatment if the damage is too severe.
Contributed by Lawrence Oh
Assisted reproductive technology (ART) is a term that describes several different methods used to help infertile couples. ART involves removing eggs from a woman's body, mixing them with sperm in the laboratory and putting the embryos back into a woman's body.
The U.S. Centers for Disease Prevention (CDC) collects success rates on ART for some fertility clinics. According to the 2003 CDC report on ART, the average percentage of ART cycles that led to a healthy baby were as follows:
37.3% in women under the age of 35
30.2% in women aged 35-37
20.2% in women aged 37-40
11.0% in women aged 41-42
IVF
In vitro fertilization (IVF) means fertilization outside of the body. IVF is the most effective ART. It is often used when a woman's fallopian tubes are blocked or when a man produces too few sperm. Doctors treat the woman with a drug that causes the ovaries to produce multiple eggs. Once mature, the eggs are removed from the woman. They are put in a dish in the lab along with the man's sperm for fertilization. After 3 to 5 days, healthy embryos are implanted in the woman's uterus.
# Who are the best couples for I.V.F. treatment ?
1-Couples with unexplained failure of conception
2-Patients with blocked tubes (the sperm cannot reach the oocytes to fertilize them)
3-Patients with poor semen analysis.
4-Patients with severe polycystic ovarian syndrome and dysfunctional ovulation
5-Patients with endometriosis
6-Patients with anti-sperm antibodies (both male and female)
There are basically five steps in the IVF and embryo transfer process which include the following:
1.Monitor and stimulate the development of healthy egg(s) in the ovaries.
2.Collect the eggs.
3.Secure the sperm.
4.Combine the eggs and sperm together in the laboratory and provide the appropriate environment for fertilization and early embryo growth.
5.Transfer embryos into the uterus.
GIFT & ZIFT
Gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT) are two procedures related to IVF.
GIFT is similar to IVF, but the gametes (egg and sperm) are transferred to the fallopian tubes rather than the uterus, and fertilization takes place in the tubes rather than in the laboratory. GIFT also involves a laparoscopic surgical procedure to transfer the sperm and egg into the tubes. GIFT accounts for approximately 2% of assisted reproductive technology (ART) procedures in the United States.
ZIFT differs from GIFT in that the fertilization process still takes place in the laboratory versus the fallopian tubes. It is similar to GIFT in that the fertilized egg is transferred into fallopian tubes, and it involves a laparoscopic surgical procedure. ZIFT accounts for less than 1.5% of assisted reproductive technology (ART) procedures in the United States.
IUI
Intrauterine insemination (IUI) is a procedure in which sperm are placed in a woman's uterus through artificial means. IUI is most often recommended for couples with unexplained infertility or male factor infertility — such as a low sperm count or poor sperm motility. For many couples, intrauterine insemination is a more affordable and less invasive alternative to in vitro fertilization (IVF). However, IUI is not effective for infertility associated with blocked or damaged fallopian tubes.
Intrauterine insemination involves injecting sperm directly into your uterus at the time of ovulation. This can be done using either your partner's sperm or a donor's sperm. Before the procedure, the sperm are "washed" and prepared for injection. Your doctor uses a soft tube (catheter) to deposit the sperm through your cervix and into your uterus at the time of ovulation. Fertility drugs that stimulate ovulation may be used in conjunction with intrauterine insemination. Success rates for IUI depend on many factors, including your age and the duration and cause of infertility.
Why is ‘sperm washing’ necessary
Sperm must be washed in order to be used with IUI. Raw semen cannot be inserted directly into a woman’s uterus. This is because semen contains chemicals called prostaglandins. Prostaglandins cause muscular contractions and are responsible for cramps during menstruation and pregnancy. If raw semen is inserted directly into your uterus, rather than going through the cervix first, it could cause severe pain and cramping. It could also cause your uterus to collapse, causing severe complications.
Sperm is also washed in order to increase your chances of becoming pregnant. Sperm washing can remove dead sperm and those sperm with poor motility. This leaves behind sperm that can swim faster and that are more likely to fertilize your egg. Sperm washing can also get rid of the white blood cells, mucous and seminal fluid surrounding the sperm, which can also interfere with fertility.
Male Infertility Treatment
Assisted reproductive technologies such as in vitro fertilization (IVF), GIFT, ZIFT, and intracytoplasmic sperm injection (ICSI) can be used when either the man or the woman is infertile. When male factor infertility is solely responsible for a couple’s inability to conceive (usually due to low sperm count or poor sperm quality) there are several techniques and male infertility treatment options designed to collect and process sperm to improve the chances of fertilization with the egg.
Sperm Retrieval Procedures
One of the most common causes of male infertility is low sperm count. Treatment for low sperm count usually involves some type of sperm retrieval procedure. These less invasive treatment options are designed to obtain sperm from a man who would otherwise have trouble producing it.
Percutaneous Epididymal Sperm Aspiration (PESA)
Percutaneous Epididymal Sperm Aspiration (PESA) is a male infertility and low sperm count treatment option to pursue if there is no sperm in the semen. During this minimally invasive sperm retrieval procedure, a needle is inserted through the scrotum and into the epididymis and the sperm cells are removed.
This virtually pain-free treatment commonly lasts between 10 and 20 minutes and requires only a local anesthetic.
Testicular Sperm Extraction (TESE)
TESE is another male infertility treatment reserved for men who have a blockage which prevents sperm from entering their epididymis. In this method, small amounts of testicular tissue are removed via a needle inserted into the testis. The tissue is processed and the sperm is eventually extracted.
This male infertility treatment involves a general anesthetic. Side effects include pain and soreness, which will usually diminish within a few days.
Microepididymal Sperm Aspiration (MESA)
MESA is a sperm retrieval treatment employing microsurgery techniques to collect sperm near blocked portions of the epididymis. Microepididymal sperm aspiration requires a tiny incision in the scrotum. Fluid is then recovered from the epididymal tube and analyzed for sperm content.
This type of male infertility treatment is performed under general anesthetic. Pain and discomfort are common after the procedure, but can be relieved with prescribed pain medication.
Sperm Preparation Methods
Sperm preparation methods are designed to enhance sperm function and increase the chances of conception. Each of the methods below ensures the sperm are ready to be used as part of fertility treatment with IVF, artificial insemination, and other assisted reproductive technologies.
Swim-Up Technique
The swim-up technique is widely used in fertility clinics. It is based on the fact that sperm need to swim up to reach the uterus and only the healthiest and most active sperm can do that. This preparation method involves placing a culture medium on top of semen in a tube. The healthy, active sperm swim up into the culture medium, leaving behind seminal fluid and debris such as white blood cells, dead sperm, and bacteria. As the sperm swim up to and reach this culture, they are collected and used in a fertilization treatment.
Cryopreservation
Cryopreservation of semen involves collecting and freezing sperm for later use. During this male infertility treatment, sperm is collected and mixed with a freezing medium that allows the sperm to survive the freezing process.
Some men who wish to undergo a vasectomy opt for cyropreservation treatment beforehand to ensure they have active sperm to use in the future, if need be.
Surgical Infertility Solutions for Men
In addition to the male infertility treatment methods used for assisted reproductive technology, there are a several surgical infertility solutions available to treat specific anatomical problems:
Vasoepididymostomy
Vasoepididymostomy is a surgical procedure designed to treat an epididymal obstruction, such as scarring or cysts, which can block the sperm from traveling into the vas deferens.
This male infertility treatment is a difficult microsurgical procedure, requiring a skillful and experienced surgeon.
Varicocelectomy
Varicocelectomy is the most common procedure performed for male infertility. This treatment is essentially a surgical procedure to repair varicoceles (varicose veins of the testicles). The additional blood from varicoceles can raise the temperature of the testes and impair sperm production, causing low sperm count. Treatment to repair this condition requires that veins are cut to eliminate blood flow to the varicocele, improving fertility and increasing the chances of conception.
Female Infertility Treatment
Natural Treatments
Female infertility treatment commonly involves assisted reproductive technologies such as IVF, GIFT, ZIFT, and ICSI to improve the chances of conception, but there are also a variety of structural causes of female factor infertility that have surgical solutions, including endometriosis treatment. Reproductive surgery and diagnostic procedures (particularly diagnostic hysteroscopy) can correct tubal obstruction, endometriosis, uterine fibroids, and scarring from pelvic inflammatory disease.
Endometriosis and Infertility – Treatment Options
Endometriosis is one of the most common causes of female factor infertility, affecting nearly 5 million women in the United States each year. Endometriosis is a chronic disease that causes tissue to build up outside of a woman’s uterus. The tissue can attach to the ovaries, uterine wall, and fallopian tubes causing severe abdominal pain. Endometriosis can also result in significant scarring of the reproductive organs, which sometimes contributes to female infertility. Endometriosis treatment includes several non-surgical and surgical options.
Hormonal medications can be used to halt or slow the progression of endometriosis. A common prescription used for endometriosis treatment is Gn-RH agonists, which control estrogen production – a contributing factor in the growth of endometrial tissue. Other prescription options can be discussed with your doctor or fertility specialist.
There are other effective, but more invasive female infertility and endometriosis treatment options. Read below to learn more.
Other Reproductive Surgery
Reproductive and female infertility treatment options often involve surgical procedures, including:
Laparotomy Microsurgery
This female infertility treatment involves the use of a microscope to perform reproductive surgery. Laparotomy microsurgery can be used for endometriosis treatment or to remove scar tissue and reconstruct fallopian tubes. This procedure is more invasive than most, but it is an excellent option for many women facing fertility problems.
Laparoscopy
This procedure entails the use of a laparoscope to perform surgery. The laparoscope is inserted through a small incision in order to view the pelvic organs. Operating through additional small incisions, scar tissue can be removed and damaged fallopian tubes can be repaired. This procedure is commonly used for female infertility and endometriosis treatment.
Diagnostic Hysteroscopy
Diagnostic hysteroscopy is an important tool used to diagnose female infertility. This treatment involves the use of a fiber optic scope to inspect the uterus for abnormal uterine conditions such as fibroids, polyps, and scarring. Diagnostic hysteroscopy is performed by stretching the cervical canal and using the scope to view the internal structure of the uterus.
Diagnostic hysteroscopy is commonly performed on an outpatient basis and recovery time is typically between two and three days.
Falloposcopy
This female infertility treatment is used to inspect the fallopian tubes for abnormalities such as tube obstruction, scarring, and damage to the inner lining. The falloscopy procedure entails the use of a fiber optic scope to inspect the fallopian tubes and correct any of the above conditions. It will also allow your physician to determine and recommend other female infertility treatment if the damage is too severe.
Contributed by Lawrence Oh
Psychosocial Factors In Infertility
Social factors that play a part in infertility:
- Current social phenomena: tendency for marriage to occur at a later age, therefore couples trying to start families at later age. Fertility in women decreases with increasing age.
- Smoking: decreases libido, has been linked to infertility in both males and females, while both cigarettes and marijuana lead to a decrease in sperm density, motility, and morphology
- Alcohol: interferes with the synthesis of testosterone in males and has an impact on sperm concentration. Alcoholism may delay the sexual response and may be conducive to impotence
- Stress: Stress hormones have an impact on the hypothalamus gland, which produces reproductive hormones. Severely elevated levels can even shut down menstruation.
One interesting small study reported a significantly higher incidence of pregnancy loss in women who experienced both high stress and prolonged menstrual cycles.
Another reported that women with stressful jobs had shorter periods than women with low-stress jobs.
In males, stress causes a blunted GnRH release, leading to hypogonadism.
However, while stress does not cause infertility, infertility most definitely causes stress. The stress and deep emotions one feels are the result of infertility, not the cause of it.
- Loss of the parenthood experience - full adult status, a fulfilling and "usual" life experience, the satisfaction of nurturing a young child all the way up to adulthood, and a sense of living on through them and their children after we die
- Affects self-esteem, self-image, feelings about femininity or masculinity, and sexual attractiveness
- Sense of disappointment, and the feeling of emotions and events being out of control
- Denial, shock and numbness – After trying repeatedly unsuccessfully, feelings of "This can't be happening to us" or "I know next month we will be successful"
- Anger - usually results from feeling vulnerable or helpless or both.
- Helpless feelings result from the lack of control that you may feel over your life plan, your body, and your future.
- A sense of vulnerability evolves from feeling "jinxed," or feeling that life isn't fair. You may feel as if you can no longer count on anything good happening in your life.
- Shame - associated with faltering self-esteem, and a sense of inadequacy, defectiveness and helplessness.
- As repeated attempts to get pregnant fail, self-image affected
- Anguish, self-doubt, and chronic sadness converge as couples come to think of themselves as failing, not only in realizing their own dream to reproduce and nurture, but failing their spouse, parents, and siblings as well.
- Rejection: In many cultures, inability to conceive bears a stigma. In closed social groups, a degree of rejection (or a sense of being rejected by the couple) may cause considerable anxiety and disappointment.
- Depression
- Infertile women report higher levels of stress and anxiety than fertile women, and there is some indication that infertile women are more likely to become depressed.
- Women trying to conceive often have clinical depression rates similar to women who have heart disease or cancer.
- Fear and frustration – lack of information about the situation
- Seeking help – a big decision in itself, requires acknowledgement of a problem, very private issue that you can’t talk to everyone about, pride issues to be contended with
- Desperation for a child drives the couple to seek help
Individually:
The wife may feel the problem lies with her, feels sorry for the husband (“If he had married someone else, he would have children”), feels inadequate, less of a woman.
The husband may not know how to deal with the problem, middle-class men are most likely to respond by avoiding the issue altogether, lack of communication may make problem worse.
Work – co-workers who keep questioning “Why haven’t you had a child yet?”; feelings of depression (emotional stress) regarding oneself affects work performance
Family – parents who are clamouring for grandchildren, become irritable towards other family members due to emotional stress
Sex – becomes a chore, no longer enjoyable
There are emotional ups and downs relating to medical treatment, the uncertainty about outcomes, and the challenge of having to make important decisions such as when 'enough is enough.'
- Afraid to proceed with IVF - “playing God?”, “morally right?”
- Financial issues – treatment plans require a lot of financial planning; “investment”, risky endeavour, how to obtain money (personal sacrifices, loans?)
- Going through an IVF cycle, getting your hopes up, and then for it to come crashing down again a few weeks later – repeatedly going through this rollercoaster takes a toll (depression)
- When to stop, or other treatment options – require a lot of soul searching, “Should we adopt?”, feelings similar to above (fear, frustration, disappointment)
Domar AD, Zuttermeister PC, Friedman R. The psychological impact of infertility: a comparison with patients with other medical conditions. J Psychosom Obstet Gynaecol. 1993;14 Suppl:45-52. PMID 8142988.
Schmidt et al. "The Social Epidemiology of Coping with Infertility." Human Reproduction. 20 (2005): 1044-1052.
http://www.emedicine.com/med/topic1167.htm
http://www.emedicine.com/med/topic3535.htm
http://www.icaa.cc/WCI/articles/000022_3.htm
http://www.fcsupport.org/
http://www.resolve.org/
Investigations for infertility
by Chris
source: http://www.babyworld.co.uk/information/trying/infertilityinvestigations.asp
Hormone tests
The levels of most of the hormones known to play a part in fertility can be checked with a simple blood test. For a woman, this test is usually carried out around Day 21 of the cycle, when the levels of hormones can indicate whether ovulation has occurred and also where any problem might lie. Hormone test levels vary and you need to discuss carefully with your doctor not only what each hormone level means on its own, but also in combination, before moving on.
Sometimes the man is tested too, as hormone problems can affect sperm production.
Semen analysis
For this test, a man will need to deliver a sample of his semen into a sterile container. A ‘good’ test will show that he is producing enough seminal fluid, that there are more than 20 million sperm per ml, that more than 40 per cent of these are moving forward and that at least 70 per cent of them are not abnormally shaped. If the sperm count is poor, another test will probably be carried out since sperm counts can vary.
If the sperm seem to ‘clump together’, further tests may be carried out to check for anti-sperm antibodies. Two additional tests may also be used: the ‘swim-up’ test, which allows the percentage of normal sperm to be established, and microscopic photography, which checks the distance the sperm travel.
Post-coital test
In this test, a couple needs to have intercourse around the time of ovulation, when a woman has ‘fertile’ mucus. A sample of cervical fluid is then obtained from the cervix a few hours later and checked under a microscope to see if motile sperm are present. If a large proportion are moving through, it shows that there is no ‘hostile’ reaction taking place.
However, if sperm aren’t getting through, this test may be followed by the sperm invasion test. A sample of the woman’s fertile cervical mucus is mixed with the man’s semen and examined under a microscope to see how far the sperm penetrate into the mucus.
If they clump together and don’t move forward, or if they die off inside the mucus, this may be because one of the couple is producing antibodies to the sperm. In such cases, a ‘crossover’ test may be done, in which the man’s semen is put on a slide with someone else’s mucus and the mucus is put on a slide with someone else’s semen. This can show where the problem might lie.
Cervical mucus can also be analysed to see if it ‘ferns’ under a microscope. Ferning is a characteristic pattern of fertile mucus and shows whether it is as stretchy as it needs to be to let sperm through.
Physical investigations
Sometimes a woman will know that she has had an infection which may have caused damage to her fallopian tubes, sometimes she won’t. Chlamydia, for example, sometimes produces no discernible symptoms, so the fact that it has damaged the tubes may come as a complete surprise. This is why a check on the state of the fallopian tubes is essential in any investigation of infertility, and there are several ways in which this can be done:
Laparoscopy test
In a laparoscopy, carried out under general anaesthetic, a viewing tube is inserted through a small incision in the woman’s abdomen. The abdomen is inflated with carbon dioxide, which makes it easier for the surgeon to check the uterus, ovaries and fallopian tubes for structural abnormalities, endometriosis and adhesions, as well as possibly repair any problems at the same time. Some surgeons also use a laparoscopy to assess whether the fallopian tubes are open: dye is injected through the cervix and should flow out of the ends of the tubes; if it doesn’t, they are blocked.
A laparoscopy is usually carried out as a day procedure, but it carries the small risks and potential side effects of any operation which requires a general anaesthetic. Some women take several days to recover and can suffer soreness as the carbon dioxide tries to escape again. Despite these drawbacks, the procedure can provide a great deal of useful information, and the tiny scar will fade.
X-ray Test (hysterosalpingography)
Another standard test to assess whether the fallopian tubes are open is hysterosalpingography. Dye is injected through the woman’s cervix into the uterus. This dye shows up on X-rays, so a series of X-rays is taken to check how it is flowing through the fallopian tubes and whether there are any blockages.
Any problems show up immediately, which makes this a useful procedure, but it can cause mild to severe cramps. Another advantage of this test is that you avoid having to have a general anaesthetic and surgery; it is usually done in the hospital’s X-ray department and you can go home soon afterwards, though you may need someone to drive you.
Ultrasound tests (hysterosalpingo-contrast sonography)
A relatively new test for assessing whether the fallopian tubes are open is hysterosalpingo-contrast sonography. A contrast solution is injected through the cervix and ultrasound scanning allows its flow along the tubes to be traced. The procedure takes between 15 and 30 minutes and you can go home straight afterwards. However, it is not suitable for everyone and a laparoscopy may also be recommended for a full assessment of your pelvic cavity.
Ultrasound scanning
Ultrasound scanning is also sometimes used as a diagnostic test. Abdominal ultrasound can give a picture of a woman’s uterus and ovaries and show any fibroids, uterine abnormalities or polycystic ovaries. Ultrasound can also monitor whether eggs are developing and being released from the ovaries. One uncomfortable aspect of abdominal ultrasound is that a full bladder is necessary to allow the ovaries to be seen more clearly. Sometimes transvaginal ultrasound is used and a full bladder is then not needed.
For a man, ultrasound can show whether the sperm are being stored and passed on through the system as they should be.
Endometrial biopsy
If there is doubt whether a woman’s endometrium (lining of the womb) is thickening as it should be in preparation for a developing embryo, an endometrial biopsy can be undertaken. A catheter is inserted through the cervix and a small sample (biopsy) of the uterine lining removed. If the endometrium has not developed as expected for that phase of your cycle, this can indicate a problem with hormone levels. The test can also be used to check for infection and if this is discovered a D&C (dilatation and curettage of the endometrium under general anaesthetic) may be needed.
Surgical exploration of the testes
This is done if no other reason can be found for a man’s infertility. It can check for blockages or infections, and a biopsy may be taken to check whether sperm are being produced and are maturing properly. If the sperm-producing tubules and the sperm in them are normal but a semen analysis shows no sperm, the problem is likely to be a blockage. A vasogram may be performed to pinpoint the blockage: dye is injected and X-rays will outline the ducts and pinpoint any obstructions.
source: http://www.babyworld.co.uk/information/trying/infertilityinvestigations.asp
Hormone tests
The levels of most of the hormones known to play a part in fertility can be checked with a simple blood test. For a woman, this test is usually carried out around Day 21 of the cycle, when the levels of hormones can indicate whether ovulation has occurred and also where any problem might lie. Hormone test levels vary and you need to discuss carefully with your doctor not only what each hormone level means on its own, but also in combination, before moving on.
Sometimes the man is tested too, as hormone problems can affect sperm production.
Semen analysis
For this test, a man will need to deliver a sample of his semen into a sterile container. A ‘good’ test will show that he is producing enough seminal fluid, that there are more than 20 million sperm per ml, that more than 40 per cent of these are moving forward and that at least 70 per cent of them are not abnormally shaped. If the sperm count is poor, another test will probably be carried out since sperm counts can vary.
If the sperm seem to ‘clump together’, further tests may be carried out to check for anti-sperm antibodies. Two additional tests may also be used: the ‘swim-up’ test, which allows the percentage of normal sperm to be established, and microscopic photography, which checks the distance the sperm travel.
Post-coital test
In this test, a couple needs to have intercourse around the time of ovulation, when a woman has ‘fertile’ mucus. A sample of cervical fluid is then obtained from the cervix a few hours later and checked under a microscope to see if motile sperm are present. If a large proportion are moving through, it shows that there is no ‘hostile’ reaction taking place.
However, if sperm aren’t getting through, this test may be followed by the sperm invasion test. A sample of the woman’s fertile cervical mucus is mixed with the man’s semen and examined under a microscope to see how far the sperm penetrate into the mucus.
If they clump together and don’t move forward, or if they die off inside the mucus, this may be because one of the couple is producing antibodies to the sperm. In such cases, a ‘crossover’ test may be done, in which the man’s semen is put on a slide with someone else’s mucus and the mucus is put on a slide with someone else’s semen. This can show where the problem might lie.
Cervical mucus can also be analysed to see if it ‘ferns’ under a microscope. Ferning is a characteristic pattern of fertile mucus and shows whether it is as stretchy as it needs to be to let sperm through.
Physical investigations
Sometimes a woman will know that she has had an infection which may have caused damage to her fallopian tubes, sometimes she won’t. Chlamydia, for example, sometimes produces no discernible symptoms, so the fact that it has damaged the tubes may come as a complete surprise. This is why a check on the state of the fallopian tubes is essential in any investigation of infertility, and there are several ways in which this can be done:
Laparoscopy test
In a laparoscopy, carried out under general anaesthetic, a viewing tube is inserted through a small incision in the woman’s abdomen. The abdomen is inflated with carbon dioxide, which makes it easier for the surgeon to check the uterus, ovaries and fallopian tubes for structural abnormalities, endometriosis and adhesions, as well as possibly repair any problems at the same time. Some surgeons also use a laparoscopy to assess whether the fallopian tubes are open: dye is injected through the cervix and should flow out of the ends of the tubes; if it doesn’t, they are blocked.
A laparoscopy is usually carried out as a day procedure, but it carries the small risks and potential side effects of any operation which requires a general anaesthetic. Some women take several days to recover and can suffer soreness as the carbon dioxide tries to escape again. Despite these drawbacks, the procedure can provide a great deal of useful information, and the tiny scar will fade.
X-ray Test (hysterosalpingography)
Another standard test to assess whether the fallopian tubes are open is hysterosalpingography. Dye is injected through the woman’s cervix into the uterus. This dye shows up on X-rays, so a series of X-rays is taken to check how it is flowing through the fallopian tubes and whether there are any blockages.
Any problems show up immediately, which makes this a useful procedure, but it can cause mild to severe cramps. Another advantage of this test is that you avoid having to have a general anaesthetic and surgery; it is usually done in the hospital’s X-ray department and you can go home soon afterwards, though you may need someone to drive you.
Ultrasound tests (hysterosalpingo-contrast sonography)
A relatively new test for assessing whether the fallopian tubes are open is hysterosalpingo-contrast sonography. A contrast solution is injected through the cervix and ultrasound scanning allows its flow along the tubes to be traced. The procedure takes between 15 and 30 minutes and you can go home straight afterwards. However, it is not suitable for everyone and a laparoscopy may also be recommended for a full assessment of your pelvic cavity.
Ultrasound scanning
Ultrasound scanning is also sometimes used as a diagnostic test. Abdominal ultrasound can give a picture of a woman’s uterus and ovaries and show any fibroids, uterine abnormalities or polycystic ovaries. Ultrasound can also monitor whether eggs are developing and being released from the ovaries. One uncomfortable aspect of abdominal ultrasound is that a full bladder is necessary to allow the ovaries to be seen more clearly. Sometimes transvaginal ultrasound is used and a full bladder is then not needed.
For a man, ultrasound can show whether the sperm are being stored and passed on through the system as they should be.
Endometrial biopsy
If there is doubt whether a woman’s endometrium (lining of the womb) is thickening as it should be in preparation for a developing embryo, an endometrial biopsy can be undertaken. A catheter is inserted through the cervix and a small sample (biopsy) of the uterine lining removed. If the endometrium has not developed as expected for that phase of your cycle, this can indicate a problem with hormone levels. The test can also be used to check for infection and if this is discovered a D&C (dilatation and curettage of the endometrium under general anaesthetic) may be needed.
Surgical exploration of the testes
This is done if no other reason can be found for a man’s infertility. It can check for blockages or infections, and a biopsy may be taken to check whether sperm are being produced and are maturing properly. If the sperm-producing tubules and the sperm in them are normal but a semen analysis shows no sperm, the problem is likely to be a blockage. A vasogram may be performed to pinpoint the blockage: dye is injected and X-rays will outline the ducts and pinpoint any obstructions.
Monday 6 August 2007
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