BREAST CANCER & 21 FACTS

One out of every ten women develops cancer of the bosom (an incidence of 10%)

Among women who are 25 – 74 years of age, bosom cancer is the leading cause of cancer mortality.
Cancinoma of the bosom is more common on the left bosom than the right. It is more common in the outer than the inner quadrant.
Cancer of the bosom is commoner in women who have no children and in women who have not bosom fed.
Cancer of the bosom is 5 times more likely to occur in women who have family history of bosom cancer.
Cancer of the bosom is one of the leading causes of death from all causes of death in women between ages 39 to 44 years.

The typical presentation of bosom cancer is that of a lump in the bosom which in the early stages is isolated, movable and painless.
As the cancer advances, fixation, retraction of skin or Tip, ulceration, pain, redness and ancillary masses may appear.
EARLY detection depends on SELF examination by women at monthly intervals and twice yearly by physicians. bosom self examination (BSE) should be performed monthly, one week after the menses.
To make an early diagnosis the DOCTOR must have a high degree of suspicion regarding all bosom lumps as well as a basic knowledge of bosom problems.

The most common type of bosom lesions and their frequencies are: fibrocystic disease 34% bosom cancer 27% fibroadenoma 19% intraductal papilloma 6%, duct ectasia 4% other types of bosom lesions 11%.

Patients at high risk of bosom cancer are:

• Those over the age of 40 years
• Those with a family history of bosom cancer
• Women who have never been pregnant or never had children.
• Women having their first baby after age 35 years.
• Women with a previous history of cancer in one bosom
• Women with explosure of bosom to excessive ionizing radiation.
• Women with endometrial or ovarian cancer
• Women with high dietary intake of fat.
• Women with chronic psychological stress.
• Women leaving in the western hemisphere of Europe or America.
• White women in the upper socio economic group.

Biopsy is mandatory in bosom lumps, any suspicion found by mammogram or bosom scan even if there are no clinical findings. It is also mandatory in any serous or bloody Tip discharge even if there are no lumps, and mammograms are negative. A woman should have a baseline mammogram between age 35 to 40 years of age. Between 40 and 50 years, mammogram are recommended every other year, after 50 years of age, yearly mammogram are recommended.
15% of patients who survive treatment of the initial bosom cancer for 3 or more years develop cancer in the opposite bosom.

Contralateral hidden cancers are seen in about 25% of patients with bosom cancer recently proved on one side.35% of women with untreated bosom cancer are known to survive for 5 years.
Irrespective of all diagnosis, techniques including mammogram, some cancers still unfortunately still elude early detection. Reliance for early detection of bosom cancer must be placed on self examination.
Recommendations for surgery, radiation and chemotherapy depends on the type, size, location and the extent of the tumour, the patient’s age, relation to the menopause and other factors.
bosom monthly self examination (BSE), bosom scan and mammogram in those of high risk group aids early detection and treatment.

What is bosom Cancer?

bosom cancer is a malignant tumour (a collection of cancer cells) arising from the cells of the bosom. Although bosom cancer predominantly occurs in women, it can also affect men.
What Causes bosom Cancer

There are many risk factors that increase the chance of developing bosom cancer. Some of the bosom cancer risk factors can be modified (such as alcohol) while other cannot be influenced (such as age).

Age: -
The chances of bosom cancer increases as you get older.

Family: -
The risk of bosom cancer is higher among women who have relatives with the disease. Having a close relative with the disease (sister, mother, daughter) doubles a woman’s risk.

Previous bosom Cancer: -
Having been diagnosed with bosom cancer in one bosom increases the risk of cancer in the other bosom or a recurrence in the same bosom.

Menstruation: -
Women who started their menstruation as a younger age (before 12) or went through menopause later (after 55 years have a slightly increased risk.

Bosom Tissue: -
Women with dense bosom tissue on mammogram have a higher risk of bosom cancer.

Race:-
White women have a higher risk of developing bosom cancer, but African Americans and black women have more aggressive tumours when they do develop bosom cancer.
Exposure to previous chest radiation increases the risk of bosom cancer.
Having no children or the first child after age 30 increases the risk of bosom cancer.
bosom feeding for one and a half to 2 years slightly lowers the risk of bosom cancer.
Being overweight or obese increases the risk of bosom cancer.

Bosom Cancer Symptoms and Signs

The most common signs of bosom cancer are a new lump or mass in the bosom. In addition, the following are possible signs of bosom cancer:
Tip discharge or redness
bosom or Tip pain
Swelling of part of the bosom or dumpling.


How is bosom Cancer Diagnosed?

Although bosom cancer can be diagnosed by the above signs and symptoms, the use of screening MAMMOGRAM has made it possible to detect many of the cancers early before they cause any symptoms.
Women age 40 years and older should have a screening MAMMOGRAM every year and should continue to do so as long as they are in good health.
Women in their 20s and 30s should have a clinical and self bosom examination regularly by their gynaecologist during any gynaecological encounters.


What is Treatment of bosom Cancer?

Patients with bosom cancers have many treatment options. Most treatments are adjusted to the type of cancer and the staging group.

Surgery: -
Most women with bosom cancer will require surgery. The surgery could be bosom conserving surgery or mastectomy.
bosom conserving surgery will only remove part of the bosom. (Partial Mastectomy) and usually followed by radiation therapy.
Mastectomy means all the bosom tissues are removed.
Radical mastectomy means the whole bosom tissue is removed in addition to the axillary lymph nodes and the chest wall muscles.

Radiation Therapy: -
Destroys cancer through external beam radiation or through branchy therapy.

Chemotherapy: -
chemotherapy is the treatment of bosom cancers with medications given either through intravenous injections or orally.

Adjuvant Chemotherapy means chemotherapy is given after the surgery.
Neo adjuvant Chemotherapy means it is given before the surgery.

Hormone Therapy: -
This is usually used to prevent or reduce the risk of bosom cancer recurrence. Tamoxifen prevents oestrogen from binding to oestrogen receptors on the bosom cells. Other hormones that can be used are Fulvestrant, Aromatase inhibitors such as letrozole, anatrozole and exemestane.

FIBROID

Uterine fibroid is the most common benign (not cancerous) tumour of a woman uterus (womb). Fibroids are tumours of the smooth muscle that is normally found in the wall of the uterus. 
They can develop within the uterine wall or attaché to it. They may grow as single tumours or in clusters.
Uterine fibroids can cause excessive menstrual bleeding, pelvic pain and frequent urination. Even though they are called benign (not cancerous) tumours, fibroids potentially can cause many health problems.
Fibroid growth occurs in up to 50% of all women and they are a leading cause of hysterectomy (removal of uterus) in Europe and America.
Fibroids starts in muscle tissues of the uterus they can grow into uterine cavity (submucosal) into the thickness of the uterine wall (intramural) or on the surface of the uterus (subserosal) into the abdominal cavity. Some may occur as pedunculated masses.

Uterine Fibroid Causes.

The exact reasons why some women develop fibroids are unknown. Fibroids tend to run in families. Women of Africa descent (blacks) are 2 0r 3 times more likely to develop fibroids than women of other races.
Fibroids grow in response to stimulation by the female hormone (oestrogen) produced naturally in the body. These growths can show up as early as 20 and shrink after menopause when the body stops producing large amount of oestrogen.
Fibroids can be small and cause no problems, but they can also grow to weigh several kilograms. Fibroids generally grow slowly.

The following factors have been associated with the presence of fibroids:

• Being overweight (obesity).
• Never having given birth to a child.
• Onset of menstruation period before age 10.
• African and African heritage (3 – 9 times often than in Caucasian women). 
• Uterine Fibroid Symptoms.

Most fibroids, even large ones, produce no symptoms. These masses are often found incidentally during a normal pelvic examination.

When women do experience symptoms, the most common are the following:
Irregular vaginal bleeding or an increase in menstrual bleeding known as menorrhagia, sometimes with blood clots.
Pressure on the bladder which may cause frequency in urination and a sense or urgency to urinate and very rarely inability to urinate.
Pressure in the rectum, resulting in constipation.
Pelvic pressure, resulting in lower abdominal pain.
Increase in size around the waist and abdominal swelling. Some women need to increase their cloth size but not because of significant weight gain.
Infertility
Pelvic mass during a physical examination.

When to Seek Medical Help

If a woman has any of the following, she should see her gynaecologist.
Irregular heavy menstrual bleeding. Menstrual bleeding soaking though more than 3 pads per hour requires your gynaecologist attention.
Severe or prolonged pelvic or abdominal pain.
Dizziness, light headedness, shortness of breath or chest pain associated with excessive vaginal bleeding.
Vaginal bleeding associated with pregnancy.
Infertility with long standing fibroid.
Uterine Fibroid Diagnosis
When uterine fibroid is suspected, your gynaecologist can arrive at a diagnosis by various methods:
A physical examination including a pelvic examination can reveal an irregularly shaped uterus when fibroids are present.
An abdominal, or transvaginal ultrasound san can help indentify the numbers, size and shape of most fibroid.
A hysteroscopic look at the uterus by passing a small fibreoptic camera through the cervix can confirm a submucous fibroid.
Hystero salpingogram (HSG) during infertility working sometimes gives an indication about the presence of a fibroid. It helps in distinguishing those fibroids that cause tubal blockage from those that do not.
Laparscopy is a minor surgical procedure to have a direct view of the pelvic. It is procedure done during routine infertility work up to confirm tubal patency. It can detect subserous and intra mural fibroids sometimes incidentally.

Uterine Fibroid Treatment

Uterine fibroid treatment depends on the symptoms, the size, and the location of the fibroids, the age (How close to menopause) and the patients desire to have children and the patients’ general health.

Medical Treatment

In most cases of fibroid, treatment is not necessary particularly if the woman has no symptoms, has small tumours, or has gone through menopause.
Abnormal vagina bleeding caused by fibroids may require surgical scrapping of the uterine cavity by D&C (Dilatation & Curettage). If no malignancy found, the bleeding can be controlled by hormonal medications. Observation every 6 months to check for changes in the size and symptoms is advisable.

Medication

Women with heavy bleeding, pains and fibroids may be given non-steroidal anti inflammatory drugs (NSAIDs) oral contraceptive (birth control pills) gonadotrophin releasing hormone agonists and anti hormonal drug mifepristone.
Non steroidal drugs such as ibuprofen have been shown to relieve pelvic pain associated with fibroids.
Oral contraceptive pills are also commonly used in women with fibroids. They often decrease perceived menstrual blood flow and help with pelvic pain.
Gonodotrophin releasing hormone agonists are medications that act on the pituitary gland to decrease oestrogen produced by the body. A decrease in oestrogen causes fibroids to decrease in size. These medications are usually used prior to surgery to shrink the fibroid, to decrease the amount of blood loss during surgery to improve pre-operative blood count. The size of fibroid can be reduced up to 50% in 3 months, but the fibroids can re-grow once treatment is stopped.
Long term treatment with these drugs is limited by the side effects of low oestrogen (much like menopause) which includes decreased bone density (osteoporosis) hot flushes and vaginal dryness.
Mifepristone has also been shown to reduce fibroid size by about half. It has also been shown to reduce pelvic pain, bladder pressure and lower back pain. Mifepristone can induce miscarriage so it should be used with caution if a woman is trying to conceive.
Danazol has been used to reduce bleeding in women with fibroids. It causes the menstruation to stop but does not shrink the size of the fibroid. Danazol is an androgenic (male hormone) drug that can cause side effects such as weight gain and muscular cramps decreased breast size, acne (oily skin) mood changes depression etc.

Surgery

Myomectomy is the surgical removal of the fibroid only. It can be accomplished by open surgery, hysteroscopy or laparoscopically depending on the size and location of the fibroid.
The uterus is left intact and the patient may be able to become pregnant. It is the most common surgical procedure in the treatment of fibroid in Nigeria.
Hysterectomy is the surgical removal of the uterus (and fibroids). It is the most common performed surgical procedure in the treatment of fibroid in the UK and USA and it is considered a cure, but at the expense of fertility. Depending on the size and location of the fibroid, it can be performed abdominally, vaginally or laparoscopically.
Uterine artery embolization or clotting of the arterial blood supply to the fibroid is an innovative approach that has shown promising results. This procedure is done by inserting a catheter (small tube) into an artery of the leg (femoral artery) using special X-ray video to trace the arterial blood supply to the uterus, then clotting the artery with tiny plastic or gelatine sponge particles the size of grains of sand. This material blocks blood flow to the fibroid and shrinks it. Interventional radiologist performs their procedures.

Uterine Fibroid Prevention

Women should avoid weight gain after age 18 and maintain a normal body weight compared to height. Body weight tends to increase oestrogen production thus aggravating fibroid growth.
Exercise can help women control weight and additionally decrease hormone production that stimulates fibroid growth.
In conclusion, treatment success and future outcome in fibroid depends on the severity of the fibroid prior to treatment and the chosen treatment. Fibroids may affect fertility, but it depends on the size and location of the fibroids.
Many women with fibroids are older than 35 years. This and other factors such as decreased egg quality and decreased ovulation contribute to their inability to become pregnant.
Fibroids rarely turn into cancer.

MENSTRUAL CRAMPS (DYSMENORRHEA)

 

Menstrual cramps are pain in the belly and pelvic areas that are experienced by a woman as a result of her menstrual period. Menstrual cramps are not the same as the discomfort felt during premenstrual syndrome (PMS). Although the symptoms of both disorders can sometimes be experienced as a continual process. Many women suffers from both PMS and menstrual cramps

How Common is Menstrual Cramps?

Menstrual cramps of some degree affects more than an estimated 50% of women and among these up to 15% would describe their menstrual cramps as severe. Nearly 90% of adolescent girls report having menstrual cramps.

What is Dysmenorrhea?

The medical term for menstrual cramps is dysmenorrhea. There are 2 types of dysmenorrhea primary and secondary.
In primary dysmenorrhea, there is no underlying gynaecological problem causing the pain. This type cramping may begin within 6 months to a year following menarche (the beginning of menstruation), the time when a girl starts having menstrual periods. Menstrual cramps typically do not begin before the onset of ovulation. Therefore, an adolescent girl may not experience dysmenorrhea until months to year following the onset of menstruation.
In secondary dysmenorrhea, some underlying abnormal conditions (usually involving a womans reproductive system), contributes the menstrual pain. Secondary dysmenorrhea may be evident at menarche, but more often the condition develops later.

What causes menstrual cramps

Each month the inner lining of the uterus (the endometrium) normally builds up in preparation for a possible pregnancy. After ovulation, if the egg is not fertilised by a sperm, no pregnancy will result and the current lining of the uterus is no longer needed. The woman oestrogen and progesterone  hormone and levels decline and the lining of the uterus becomes swollen and eventually shed as a menstrual flow and is replaced by a new lining in the next monthly cycle. When the old uterine lining begins to breakdown, molecular compounds called prostaglandins are released. These compounds cause the muscle of the uterus to contract. When the uterine muscles contract, they constrict the blood supply (vasoconstriction) to the endometrium. These contractions blocks the delivery of oxygen to the tissue of the endometrium which in turn breaks   down and dies and are shed as menstrual flow. Other substances known as leukotrieries are released and elevated at this time and may be related to the development of menstrual cramps.

Why are some Cramps so Painful?

Menstrual cramps are caused by uterine contractions that occur in response to prostaglandins and other chemicals. The cramping sensation is intensified when clots or pieces of bloody tissue from the lining of the uterus pass through the cervix, especially if a woman’s cervical canal is narrow.
The difference in pain may be due to the woman prostaglandins level. Women with menstrual cramps have elevated level of prostaglandins in the endometrium compared to women who do not experience cramps. Menstrual cramps are very similar to those pregnant woman experiences when she is given prostaglandin as an induction agent for labour.

What other Factors Influence Menstrual Cramps?

An unusually narrow cervical canal tends to increase menstrual cramps
A backwards tilting of the uterus (a retroverted uterus)
Lack of exercise is now recognised to contribute to painful menstrual cramps
It has long been taught that psychological factors also play a role. For example it is widely  accepted that emotional stress can increase the discomfort of menstrual cramps

What are the Symptoms of Menstrual Cramps?

Menstrual cramps are pains that begin in the lower abdomen and pelvis. The discomfort can extend to the lower back or legs. The cramps can be a quite painful or simply a dull ache. They can be periodic or continual. Menstrual cramps usually starts shortly before the menstrual period, peak within 24 hours after the onset of the bleeding and subside again after a day or two.
Menstrual cramps may be accompanied by a headache and or nausea which can lead to vomiting. Menstrual cramps can also be a accompanied by either constipation or diarrhea because the prostaplandins which cause the smooth muscles to contract are found in both the uterus and the intestinal tracts. Some women experience an urge to urinate more frequently.

How are Menstrual Cramps Diagnosed?

The diagnosis of menstrual cramps is usually made by the woman herself, and reflects her individual perception of pain once a woman has experienced menstrual cramps, usually with the adolescent onset of her monthly flow, she becomes well aware of the typical symptoms if there are other medical conditions contributing to menstrual cramps (secondary dysuenorrhea), the doctor may suggest diagnostic testing including imaging studies.

What is the Treatment for Menstrual Cramps?

Currently recommendation includes not only adequate rest and sleep but also regular exercise (walking). Some women find that abdominal message, yoga, or orgasmic sexual activity may bring relief. A heating pad applied to the abdominal area may relieve the pain and congestion and decrease the symptoms.
A number of non prescription drugs can help to control the pain as well as actually prevent the menstrual cramps themselves. For mild cramps, aspirin or paracetamol may be sufficient.
The main agent for treating moderate cramps are the non steroidal anti inflawattun of prostaglandins and lessen the effects. Such NSAIDS include ibuprofen, naproxen, ketoprofen.
A woman should start taking this medications before her pains becomes difficult to control. This might mean starting the medications 1 to 2 days before her period is due to begin and continue the medication 1-2 days into her period. The best results are obtained by taking the NSAIDs on a scheduled basis and not waiting for the pain to begin.

What if Cramps are very Severe?

If a woman’s menstrual cramps are too severe to be managed by the above strategies, then the oral contraceptive pills containing oestrogen and progesterone in a regular or extended cycle can be prescribed.
This type of approach can prevent ovulation which in turn reduces the severity of cramping and causes a light menstrual flow.
The use of intrauterine device that releases small amounts of progesterone directly into the uterine cavity has also been associated with a 50% reduction in the prevalence of menstrual cramps, in contrast, intrauterine devise that contains only copper may worsen the menstrual cramps.

Are there Surgical Solutions?

In the past, many women with menstrual cramps had an operation known as D&C to remove some of the lining of the uterus, some women even resort to the ultimate solution to menstrual problems by having a hysterectomy surgery that removes the entire uterus.

What is Treatment of Secondary dysmenorrhea

The treatment of secondary dysmenorrhea depends on the cause. There are a number of under of underlying conditions which can contribute to the pain, including endometriosis, uterine fibroids, adenonuyosis, PID, adhesions, use of intrauterine contraceptive devises (IUCD)
All of these conditions should be first diagnosed by the gynaecologist who will then recommend the optimal treatment.
If a woman notices changes in the severity of her menstrual cramps, the timing, or location, she should consult her gynaecologist especially if the changes are of sudden onset.

Prognosis for menstrual cramps

In general, a woman’s menstrual cramps do not worsen during her lifetime, infact the menstrual cramps usually diminish with age and after pregnancy.
Where there is secondary dysmenorrhea with an underlying condition contributing to the pain, the prognosis depends on the successful treatment of the underlying condition.

ENDOMETRIOSIS AND POLYCYSTIC OVARIAN SYNDROME (PCOS)

ENDOMETRIOSIS

Endometriosis is a condition where the endometrial tissue from the lining of the uterus forms and grows in places outside the uterus. Theses growth leads to pain and infertility. Up to 50% of women who have endometriosis experience infertility.
The lost endometrial cells respond to the body hormones the same way they would inside the uterus.
Normally the endometrium within the uterus thickens to prepare for an embryo. When pregnancy does not occur, the extra lining breaks down and is shed during menstruation.
With endometriosis, the endometrial tissue that is outside the uterus also thickens, break down and bleeds, except that it cannot be expelled vaginally like the endometrial tissue. Instead the endometrial tissue outside the uterus builds up over time and forms patches, scar tissues, cyst and adhesions.
Usually, these endometrial growth form in the pelvis region, near the ovaries, but can also appear in rectum, vagina, fallopian tube, urinary tracts, bowels and rarely in the lungs, arms, thighs, umbilicus e.t.c.
Beside infertility, it causes painful period and painful sexual intercourse. Other women experience no symptoms, and it is only discovered accidentally during infertility evaluation.

How Endometriosis Cause infertility

Endometriosis is believed to be involved in up to 30% of female infertility. However, not every woman with endometriosis will have trouble in conceiving, and ironically, pregnancy may help alleviate the symptoms and reduce the progress of the disease.
The connection between endometriosis and infertility isn’t completely understood. Even when there is no obvious barrier to fertilisation and the number of implants are small or not blocking the egg or sperm from meeting, infertility can still result.

However, some other ways that endometriosis can affect fertility are:-

Endometriosis scar, adhesions or cysts around the ovaries may prevent the eggs from entering the fallopian tubes and may also prevent ovulation from occurring.
Endometriosis inside the fallopian tubes may form scar and adhesions, blocking the tubes.
The cause of endometriosis is not fully known, but some researchers suspect, it is related to the body immunity, so whatever it is that causes endometriosis may also cause infertility.
Endometriosis can make sexual intercourse painful, and pain may be more around ovulation period hence interfering with ability to conceive.

How is Endometriosis Diagnosed?

The only way to confirm a diagnosis of endometriosis is with a direct view diagnostic laparoscopy or accidentally during open pelvic surgery for other ailments.
Laparoscopy is an outpatient procedure that involves making a small incision in the abdomen, through which the gynaecologist inserts a tube with special camera and instruments to see the pelvis.
Because the use of laparoscopy is not widespread in Nigeria, the diagnosis of endometriosis is underreported. Its symptom is similar to that of pelvic infection (PID), hence pelvic infection (PID) is over diagnosed instead.

How is Endometriosis Treated?

Treatment of endometriosis is dependent on its severity, if the patient is experiencing pain, the patient’s age, and whether pregnancy is desirable.
Some treatment of endometriosis will lead to decreased fertility, which would not be an option if pregnancy is desirable are:
Laparoscopic surgery to remove the endometrial growth, scar, and adhesions caused by the endometriosis.
This is not a cure as the endometriosis may return later.
However, some women will have increased fertility for up to 9 months after the surgery.
IVF treatment is an option pre or post surgery.
In mild to moderate endometriosis, intrauterine insemination (IUI) along with fertility drugs may be used. The pain of endometriosis may be treated with pain relieving medications, acupuncture, and lifestyle changes such as regular exercises and diet changes.
If you do not wish to get pregnant, the treatment options may include hormonal treatments which stops ovulation and prevents pregnancy.
In severe cases the removal of the womb (Hysterectomy) and ovaries might be the only solution.

POLYCYSTIC OVARIAN SYNDROME (PCOS)

Polycystic ovarian syndrome is an endocrine disorder and a common cause of infertility in women.
In PCOS, hormones that affect the reproductive system are abnormal leading to irregular or absent ovulation. PCOS is a common disorder affecting up to 10% of women.
Women with PCOS often have polycystic ovaries. This means that the ovaries have many tiny, benign and painless cysts. During an ultrasound examination, the tiny cysts resemble a string of PEARLS.
A common finding with PCOS is abnormal high levels of Androgens (male) hormones. Whilst Androgens are found in both men and women, they are considered to be primarily male hormone.
High Androgen (male hormone) levels are associated with some of the more distressing symptoms of PCOS such as ACNE, and abnormal hair growth in women.
What are the Symptoms of Polycystic Ovarian Syndrome (PCOS)?
Some of the symptoms of PCOS include:

• Infertility
  
• Irregular or absent ovulation
  
• Absence of monthly menstrual cycle (Amenorrhea)
  
• Irregular monthly cycle (Oligomenorrhea)
  
• Recurrent miscarriage
  
• Abnormal hair growth on upper lip, chin, around nipple or on abdomen (Hirsutism)
  
• Acne
  
• Especially oily skin and hair
  
• Male pattern balding
  
• Obesity
  
• Insulin resistance
  
• High level of androgens
  
• Elevated LH hormone level (making ovulation prediction kits unreliable)
  

PCOS does not present in the same way for all women. A woman does not need all those symptoms to be present, before a diagnosis of PCOS is made.
For example, many women with PCOS do not have abnormal hair growth or obesity.

How Does PCOS Cause Infertility?

The abnormal hormone level associated with PCOS leads to problems with ovulation. These irregularities in ovulation are the main cause of infertility.
PCOS is associated with a higher risk of early miscarriages, which may be as high as 20-40%, nearly twice as high as in the general population.
Some of the reasons for the higher miscarriage rate are; poor egg quality related to premature or late ovulation. A less favourable environment for an embryo to implant in the uterine lining due to the abnormal hormone levels is another reason for the higher miscarriage rate.
Another reason has to do with the insulin resistance associated with PCOS.

How is PCOS Diagnosed?

Not every doctor agrees on the criteria for diagnosing PCOS. Its definition has been changed over the years.
However, the commonly used diagnostic criteria currently used require 2 out of the 3 of the following:

• Irregular or absent menstrual cycle caused by chronic anovulation.
• Either blood test confirmation or outward signs of high level of androgens (abnormal hair growth)
• The presence of polycystic ovaries as seen by ultrasound scan.

Taking a detailed history is an important part of PCOS diagnosis. Your doctor will want to know about how regular your menstrual cycles are and will ask about any unwanted hair growth. You may be tempted not to mention the unwanted hair growth because of embarrassment, but it is important you tell your doctor this problem if you have it.

Treatment of PCOS

Treatment of PCOS will depend on whether or not you are trying to get pregnant. If pregnancy is not a priority, the birth control pill (contraceptive) will help to regulate your cycle and help to reduce ACNE and unwanted hair growth.
For those trying for pregnancy, the treatment of PCOS is similar to the treatment used for treating anovulation.
The first line of treatment is ovulation drugs such as CLOMID which is used to help stimulate ovulation.
Metformin (Glucophage) a drug usually used to treat insulin resistance is sometimes used for treatment, even if you do not have insulin resistance.
If these medications do not help, then Gonadotrophins injections may be tried.
If drugs alone do not work or there are other factors leading to infertility, IVF treatment may be recommended.
Studies have shown that women who are overweight with PCOS may be able to restart ovulation naturally by loosing just 10% of their current weight. A healthy diet and regular exercise may also help to restore ovulation in some but not all women with PCOS.

GUILDE TO INFERTILITY INVESTIGATIONS

The philosophy of care in any infertility clinic should be a success oriented approach (getting infertile couples pregnant) rather than the usual problem oriented approach (doing endless, useless and unnecessary investigations) as is the norm in our environments these days.
In a problem oriented approach, a lot of time, money and effort would be wasted by the doctors concentrating on a long list of useless and fanciful tests and investigations. Many of these investigations do not affect the treatment or the outcome of the treatment options.
It is bad enough being infertile, but for the infertile couples to go through endless tests and investigations that add no value to the outcome of any treatment option DRAINS them emotionally and financially.
Keeping the investigations complex however helps some clinics to justify the abnormally high fees they charge to reach a diagnosis.
Couples that come to doctors for infertility want to have babies, not unnecessary extended investigations and having to wait too long in achieving their objectives.
Every infertility investigations protocol should ideally be easy, simple, safe and less stressful with a proper diagnosis and successful treatment (having babies) achieved.

Criteria for Getting Pregnant Naturally.

There are basically 5 criteria for achieving pregnancy naturally.

• The sperm of the man must be of adequate quantity and quality.

• Sex should occur around the ovulation period (fertile period) of the woman.

• The inside of the woman’s womb should be able to keep and maintain a pregnancy. Nothing inside should be able to disrupt a pregnancy.

• The fallopian tubes should be open on both sides, so that the eggs produced on the ovary can meet with the sperm.

• The ovaries must be producing quality eggs regularly (monthly)

From the above criterion, it would be easy to see that the essence of any infertility investigation is to check out these 5 requirements and confirm they are all working well.
About 95% of infertile couples would first see their general practitioners before seeing an infertility expert. It is therefore important that there is a guide on what the GP should do at this level as frontline doctors.
About 45% of infertile couples will get pregnant by themselves, by changes in their lifestyles and by the standard gynaecological treatment. However, 60% will require some form of assisted conception such as Intrauterine Insemination (IUI), Invitro fertilisation (IVF) etc at a specialised infertility centre. It is important for the GP to know when to refer to an infertility specialist so that time, money and effort are not wasted.

GP Guideline in Infertility Management

The frontline general practitioner should try as much as possible to see the couples together. Both should be involved in the management of their infertility.
A detailed history including drug and examination of the couple is mandatory.
The GP should advise every woman presenting with infertility to take folic acid as a supplement whilst they are trying to conceive and at least during the first 12 weeks of a pregnancy in order to prevent neural tube defects. The dose should be increased in women who have previously had an infant with neural tube defect or who have epilepsy and are on medications.
Environmental factors can affect infertility and therefore an occupational history should be taken as part of infertility investigations.

General Advice GP Should Give to Infertile Couples.

Women complaining of infertility should be advised to give up smoking if they do smoke.
Men who smoke should be advised to stop in order to remove one variable that may affect their infertility.Women should be advised not to drink more than one or two units of alcohol once or twice a week when trying to become pregnant.
In men there is evidence that excessive drinking can adversely affect reproductive function and general health, therefore men who drink excessively should be advised to limit their drinking.Any woman with a body mass index > 30 should be advised to loose weight whether ovulating or not.
Although weight loss in overweight men will improve their general health, there is little evidence to suggest that this will improve fertility.
Men with poor quality sperm should be advised to wear loose fitting underwears and trousers and avoid occupational or social situations that might cause testicular overheating.There is no evidence that the use of temperature charts and ovulation kits to time intercourse improves infertility outcome. There use should be discouraged. Couples should be advised instead to have REGULAR intercourse 2-3 times a week throughout their cycle.

Initial Investigation at GP Clinic

The male partner should have 2 semen analysis performed during the initial investigation. The laboratory that performs the semen analysis should undertake the analysis according to recognised WHO methodology. The laboratory should also practice internal quality control. The GP should try and send the sample to the same laboratory used by specialist infertility clinics.
Whilst regular menstruation is strongly suggestive of ovulation, this should be confirmed by the measurement of serum progesterone in the mid luteal phase (Day 21 progesterone)
There is no VALUE in measuring thyroid function or prolactin in women with a regular menstrual cycle, in the absence of galactorrhea (milk from the breast)
or symptoms of thyroid diseases.

When Should a GP Refer to Infertility Specialist?

For the sake of the infertile couples a general practitioner should consider an early referral to infertility specialist if the woman is aged 35 years and above. An early referral to an infertility specialist is required when the woman is not seeing her periods, or when her period is scanty and irregular (amenorrhea & oligomenorrhea). The GP should refer if the woman has a previous history of abdominal or pelvis surgery (e.g. fibroid opx), if there is a history of sexually transmitted diseases and if there is an abnormal pelvic examination.
The GP should consider early referral when the man has a previous genital disease, a previous urinary or genital surgery. A previous sexually transmitted disease, a varicocele or any significant systemic illness and if there is an abnormal genital examination.
Further Investigation in a Specialised Infertility Clinic
Further management of infertile couple should be in a specialised infertility clinic staffed by an appropriately trained multi professional team with facilities for investigating and managing problems in both partners.
GPs should endeavour to refer patients to such clinics and patients should request that they be referred to such clinics. GPs should continue to offer ongoing support to the couples after the referral.
The female should normally have a test of tubal patency. A Hysterosalpingogram (HSG) or a salime Sono Hysterogram may be used as a screening test for tubal patency. A diagnostic laparoscopy and dye test is however the procedure of choice to properly evaluate the pelvis.
Before any uterine instrumentation at the GPs or infertility centres, a screening for sexually transmitted diseases especially Chlamydia should be performed and any infection should be appropriately treated.
An Ultrasound scan (Abdominal and Vaginal) to properly evaluate the uterus and the ovaries is very essential.

Non Essential Investigation in Routine Infertility Management

An endometrial biopsy (D&C) to evaluate luteal phase should not be performed as part of routine investigation of the infertile couple.
The so called “Tubal flushing” or Hydrotubation has no place in the modern investigation or treatment of infertile couple. Apart from the fact that it is rarely successful, it causes discomfort and could actually disseminate genital infection into full blown PID
The post coital test is not recommended in the routine investigation of infertile couples.
Sperm function test are specialised tests and should not be used in routine investigations of infertile couple (Routine semen analysis is sufficient)
Routine testing for antisperm antibodies in semen is not recommended.
Hysteroscopy should not be considered in routine investigation.

Guide to Semen Collection and Normal Values

Before the man goes for his semen collection, he should have abstained for 2 to 3 days. The sample is preferably produced by masturbation, rather than by coitus interruptus. The sample should not be collected in condoms. A wide mouthed sterile plastic specimen pot should be used in the collection. The plastic container should be marked with the name, date and time of production. Delivery of the specimen to the laboratory as soon as possible within one hour is essential. The sample should be protected from the extreme of temperatures e.g less than 15oc or above 38oc during the transportation.

WHO values for ‘normal’ semen analysis
The WHO values should be the basis of any referrals from GP to the infertility specialist.
The volume should be between 2 to 5 mils.
The liquefaction time should be within 30mins.
The sperm concentration (or count) should be above 20 million per ml.
The sperm motility should be over 50% having progressive motility.
The shape (morphology) of the sperm should at least be over 30% with normal forms.
The white blood cells suggestive infections should be less than 1 million per mil.
In conclusion, with these basic investigations a diagnosis of the cause of infertility should easily be reached and an appropriate management options outlined for the couples. There is no need for endless repetitive investigations that wear out the couples and sometimes the medical team.
The philosophy of care must always remain success oriented rather than problem oriented.

......Continuation on FEMALE FERTILITY

PELVIC INFLAMMATORY DISEASE (PID)



Pelvic inflammatory disease (PID) is an infection of the reproductive organs occurring when bacteria travels through cervix to the uterus and the fallopian tubes.

PID can cause infertility, ectopic pregnancy, chronic pelvic pain, tubal or ovarian abscess, adhesions, peritonitis and perihepatitis. In rare cases, untreated PID can lead to death.

Pelvic inflammatory disease can be acute (sudden severe symptoms) or chronic (Long term with less intense symptoms) or silent (no symptoms).

With PID, the presence or lack of symptoms does not indicate how much damage the reproductive organs sustain. It is possible to have no symptoms and have serious blockages and adhesions leading to infertility. Some women will only discover they have PID after trying to conceive unsuccessfully or after experiencing an ectopic pregnancy.

Because many cases of PID are silent and involve no symptoms, PID is often missed or undiagnosed. The actual number of PID is likely to be higher than diagnosed.



What Causes PID

PID is caused by sexually transmitted diseases (STD). Common causes include Chlamydia and gonorrhoea. Chlamydia is a common cause of silent PID which means many women do not know they are infected.

If you have undiagnosed STD, your risk of PID is higher any time the cervix is open and infection can potentially enter the uterus.

You have a higher risk of PID after childbirth, miscarriages, abortion, endometrial biopsy, IUD insertion, HSG, Hysteroscopy.



How Does PID cause Infertility?

Between 10 – 15% of women with acute PID become infertile. If a woman has multiple episodes of acute PID, her risk of developing infertility rises.

The most common cause of PID related infertility is blocked fallopian tube. The tube typically becomes blocked from adhesions caused by the inflammation, and the blockage is usually found closer to the ovaries than the uterus.

When the blockage is near the ovaries, it is more difficult to treat surgically.

PID may also cause hydrosalpinx. This occurs when a tube is blocked near the ovary and then dilates and fills with fluid. The presence of hydrosalpinx can decrease the chances of a successful IVF treatment.

Ectopic pregnancy can also be caused by PID related damages. If you undergo surgery to repair tubal damage caused by PID, your risk of ectopic pregnancy will also be higher.

In the past, some doctors treat chronic PID with hysterectomy, but this is less frequently necessary. If your doctor suggests hysterectomy for chronic PID, you should seek a 2nd opinion.



Symptoms of PID

Symptoms of PID differ from person to person depending on whether or not they are experiencing acute, chronic or silent PID. The most common symptom is pelvic pain. Pelvic pain during intercourse (dyspareunia), lower back pain, irregular menstrual bleeding, unusual vaginal discharge, problem with urination, flu like symptoms, fatigue, fever, chills, weakness or swollen lymph node, lack of appetite, diarrhoea and vomiting and infertility.

Many of the symptoms can be mistaken for other diseases such as endometriosis, appendicitis and urinary tract infection. It is important to be upfront with your doctor if you suspect you may have contracted STD or you have other risk factors for PID, like a recurrent miscarriage, abortion, childbirth or IUD insertion.

If you are experiencing regular pelvic pain or pain during intercourse, and your doctor has not been able to diagnose or treat the problem successfully, you may wish for a 2nd opinion.

Keep pushing until you find appropriate treatment for your symptoms because your future fertility and overall health depends on it.


How is PID Diagnosed?

Doctors diagnose PID by assessing your signs and symptoms, analysing vaginal and cervical cultures, conducting urine and blood tests. Performing pelvic examination and evaluating vaginal discharge.

Whilst vaginal culture will usually uncover STD, or other bacterial infection, they will not always detect infection in fallopian tubes and uterus.

Other tests include pelvic ultrasound and diagnostic laparoscopy.



Prevention of PID

Since PID is caused by sexually transmitted disease (STD), it is preventable.

Unprotected sex with multiple partners increases your risk of getting PID.

If you are not in a committed and stable relationship with a partner who has tested for STD, practising safe sex by condom and regular STD testing is essential.

Testing for STD before insertion of IUD is important as insertion can lead to PID if you already have an STD.

Douching increases the risk of PID. Douching alters the natural flora and pit of the vagina, thus increasing the risk of vaginal infection. Douching also negatively imparts cervical mucus which is important when trying to conceive.

Invasive fertility testing like HSG, Hysteroscopy and fertility treatment involving the cervix and uterus can lead to PID if you have undiagnosed STD. This is the reason most fertility clinics conducts STD testing and vaginal culture before fertility testing and treatment.




Treatment of PID

Oral antibiotics are most often used to treat PID.

Determining which organism is causing PID might be difficult and sometimes more than one kind of bacteria may be involved. For these reasons, you may be prescribed two or more antibiotics to take at once.
Because of serious complications and damages to your fertility, treatment is often started before all the results are back. The results may however indicate a different antibiotic is necessary for treatment, so your doctor may change your treatment midway.

Antibiotic may be given by injection as well. Whilst you may feel better after a few days of antibiotics, it is important that you complete your antibiotics regimen days. Not doing so may lead to the bacteria becoming resistant and difficult or impossible to treat.




Your sexual partner must also be treated to prevent re-infection even if they have no symptoms.
Use a condom during the treatment of you and your partner.In some cases surgery may be necessary to treat abscess or particularly painful adhesions.

FEMALE INFERTILITY

Ovulation Problems

Anovulation means lack of ovulation or absent ovulation. Ovulation is the release of an egg from the ovary. This must happen in order to achieve pregnancy. If ovulation is irregular but not completely absent, this is called Oligovulation. Both anovalation and oligovulation are kinds of ovulatory dysfunction.
Ovulatory dydfunction is a common cause of female infertility occurring in 30 -40% of infertile women. Fortunately, approximately 70% of these cases can be treated with ovulation medications.

Symptoms

Usually women with anovulation will have irregular periods or in most case they may not get their cycles at all.
If your cycle is shorter than 21 days or longer than 36 days, then you may have ovulatory dysfunction.
If your cycle falls within normal range of 21 to 31 days but the length of your cycle varies widely month to month, it may also be a sign of ovulatory dysfunction (e.g. one month your period is 22 days and the next 35 days).
It is possible to get your cycle on an almost normal schedule and not ovulate, but it is not common.
A menstrual cycle where ovulation does not occur is called an anovulatory cycle.

How Does Anovulation Cause Infertility?

For a couple without infertility, the chances of conception are 25% each month, so even if ovulation occurs there is no guarantee to conceive in a month.
When a woman is anovulatory, she cannot get pregnant because there is no egg to be fertilized. If a woman has irregular ovulation, she has fewer chances to conceive since she ovulates less frequently. Late ovulation doesn’t produce best quality egg which again makes fertilisation less likely.
Irregular ovulation means the hormones in the woman’s body are not quite right. These irregular hormones can lead to other issues such as lack of fertile cervical mucus, thinner or thickened endometriom (where fertilised egg need to implant) abnormally low level of progesterone or shorter luteal phase.

Causes of Anovulation

Anovalution and ovulatory dysfunction can be caused by a number of factors. The most common cause is polycystic ovarian syndrome (PCOS)
Other potential causes of irregular or absent ovulation are:

• Obesity
• Too low body weight
• Hyper prolactineamia
• Premature ovarian failure
• Advanced maternal age or low ovarian reserve.
• Thyroid dysfunction
• Extremely high level of stress.

Diagnosis of Anovalution

Your doctor will ask about your menstrual cycle, and if you report irregular or absent cycle, ovulation dysfunction will be suspected.
Your doctor will ask for your day 21 progesterone blood test. After ovulation, progesterone level rises.If your progesterone level does not rise, then you are probably not ovulating.
Your doctor will also order for an ultrasound to check out the shape and size of your uterus and ovaries, and also to see if your ovaries are polycystic, a symptom of polycystic ovarian syndrome.
Ultrasound can also be used to track follicle development and ovulation.

Treatment of Anovulation

The treatment will depend on the cause of anovulation. Many ovulation problems can be treated by lifestyle changes and diet. If low body weight and extreme exercise is the cause, gaining weight or reducing exercise may be enough to restart ovulation. The same goes for obesity. If you are overweight, loosing 10% of your current weight is enough to restart ovulation.

The most common treatment for anovulation is fertility drug, usually Clomid. (It is well abused in Nigeria and many substandard versions are available. You are well advised to see a fertility doctor before self medication) It triggers ovulation in 80% of anovulatory women and helps about 45% to get pregnant within 6 months of treatment. If Clomid does not work, there are other drugs worth trying.

For polycystic ovarian syndrome (PCOS) women, insulin sensitizing drugs like Metformin may help to restart ovulation. Usually 6 months of treatment with Metformin is required to know if Metformin works. If anovulation is due to premature ovarian failure or low ovarian reserve, fertility drugs are less likely to work, in which case IVF with Donor eggs or adoption might be suggested by your doctor.


Blocked Fallopian Tube

The fallopian tubes are 2 thin tubes one on each side of the uterus. They help lead the mature egg from ovaries to the uterus.
When an obstruction prevents the egg from travelling down the tube, the woman has blocked fallopian tubes. It can occur on one or both sides. This is also known as Tubal Factor Infertility. It is the cause in 40% of infertile women.

How Does Blocked Fallopian Tube Cause Infertility?

Each month, when ovulation occurs, an egg is released from one of the ovaries. The egg travels from the ovary through the tubes and into the uterus. The sperm also need to swim their way from the cervix through the uterus and through the fallopian tubes to get to the egg. Fertilisation usually takes place while the egg is travelling through the tubes.
If one or both fallopian tubes are blocked, the egg cannot reach the uterus and the sperm cannot reach the egg, preventing fertilization and pregnancy.
It is possible for the tube not to be blocked totally but only partially. This can increase the risk of a tubal pregnancy or ECTOPIC pregnancy.
What is Hydrosalpinx?
A specific kind of blocked fallopian tube, hydrosalpinx is when a blockage causes the tube to dilate and fill with fluids. The fluid blocks the egg and sperm, preventing fertilization and pregnancy.

Can Pregnancy occur with Blocked Fallopian Tube?

If only one fallopian tube is blocked, it may still be possible to achieve pregnancy. It depends on how well the ovaries are functioning and also what caused the blocked tube in the first place.

Symptoms of Blocked Fallopian Tubes
Unlike ovulation problems, where irregular menstrual cycle may hint at the problem, blocked fallopian tubes rarely cause any symptoms.
A specific type of blockage called hydrosalpinx may cause lower abdominal pain and unusual vaginal discharge, but not every woman has this symptom.
Some causes of blocked tubes might lead to a hint of the problems, for example, endometriosis and pelvic inflammatory disease (PID) may cause painful menstruation and painful sexual intercourse, but the symptoms don’t necessary point to blocked tubes.


What causes Blocked Fallopian Tubes?

The most common cause of blocked fallopian tubes is pelvic inflammatory disease (PID).
PID is the result of sexually transmitted disease, (STD) but not all PID are related to STD.
Other causes of blocked tubes include:-
Current or history of STD, specifically Chlamydia or Gonorrhoea. History of uterine infection caused by ABORTION or MISCARRIAGE. History of ruptured Appendix, history of abdominal surgery, previous ectopic pregnancy, prior surgery of the fallopian tubes and endometriosis.
How is Blocked Fallopian Tube Diagnosed?
Blocked fallopian tube is usually diagnosed with a specialised X-ray called Hystero Salpingogram (HSG). The test involves placing a dye through the cervix using tiny tube. Once dye is given, the X-rays are taken.
15% of women have a false positive result. Other tests are Saline Sono Hysterogram, Ultrasound, Laparoscopy or Hysteroscopy.

Treatment of Blocked Fallopian Tubes

If one tube is open and otherwise healthy you might get pregnant without help or at worse your doctor may give fertility drugs to increase ovulation on the side of the open tube.
If both tubes are blocked, the options are Laparoscopic surgery to open blocked tubes or remove the scars causing the blockage.
Unfortunately, the surgery rarely works. The chance of success depends on how old you are, how bad the blockage is and the cause of the blockage. The risk of ectopic pregnancy rises after surgery.
The definitive treatment of bilateral blocked fallopian tube is invitro fertilisation (IVF).
I would continue on female infertility next week, by discussing Endometriosis and Polycystic Ovarian Syndrome (PCOS).

MALE INFERTILITY

Reproduction is a normal human event for the survival of the human race. Infertility affects 25% of couples of reproductive age.
Around 50% of infertility has a male factor as a cause. Many men are in denial. They equate good erection and great sexual prowess with fertility. Many men tend to believe that infertility problems are more likely to be women’s fault.
Male fertility is on the decline markedly as a result of modern lifestyle. There is increasing evidence that the quality and the quantity of sperm that men produce has declined over the past 30 years due to many causes such as environmental pollution, stress, alcohol, smoking and increased incidence of sexually transmitted diseases. The advent of IVF and other Assisted Reproductive Techniques (ART) has helped several thousand otherwise infertile couples to have children. However, about 10% of couples will still be left with the inability to have children because IVF does not work for everyone.


Causes of Male Infertility
Infections:
It was previously thought that mumps infection is an important cause of male infertility but recent evidence suggests that it is rare for mumps to lead to sterility. Other infective causes of male infertility include STDs like gonorrhoea, Chlamydia and inflammation of the prostate gland (prostatis). Infected semen can cause infertility.

Testicular Heat:
Heat reduces sperm production. This is the reason why the testicles are outside the body in the scrotum rather than in the abdomen like the ovaries in women. Some men have frequent use of Sauna, use hot baths, jobs where long hours of sitting causes over heated testicles, wearing too tight fitting clothing, prolonged bicycling. Some obese men can become sterile because the sagging layers of fat can overheat the testicles.
Varicocele of the testes also affects sperm production and motility based on the excess heat generated by the varicoceles.

Frequent Sex:
Very frequent intercourse can lead to dramatic reduction in sperm count, and cause the man to be effectively infertile. If a man ejaculates as much as 2 to 3 times a day, they are likely to have a problem. If a man wants to be at his most fertile, he has to wait at least 2 to 3 days between each ejaculation.

Cigarette Smoking:
Cigarette smoking of over 20 per day has been shown to reduce the sperm count, sperm production and sperm motility.

Alcohol Abuse:
Excessive alcohol intake can lead to low sperm count, it can result in lower male hormone (testosterone) and cause erectile dysfunction.

Illegal Drug Use:
Anabolic steroids to stimulate muscle strength can cause testicular shrinkage and reduce sperm production. Cocaine and marijuana temporarily reduces the quantity and the qualities of sperm.

Retrograde Ejaculation:
This is a rare condition when semen is ejaculated backwards into the bladder. It is seen in severe diabetes, multiple sclerosis, spinal cord injury and surgery to the bladder or prostate.

Stress:
Emotional stress and workaholic can result in fatigue and lack of interest in sex. Increasing age can also lead to infertility because of lack of interest in sex and less frequency.

Environmental:
Environmental causes of male infertility could arise from issues such as chemicals, toxins and heat. Pesticides such as ethylene dibromide and organophosphates affect sperm production. Exposures to heavy metals such as lead also affect the quality and quantity of sperm. Excessive exposure to radiation and X-ray are harmful to the testis and sperm production.

Sexual Dysfunction:
Psychological or relationship problems that interfere with sex, erectile dysfunction, premature ejaculation, painful intercourse can all result in infertility if not well handled.

Risk Factors Linked to Male Infertility

35 years
Tobacco
Alcohol
Illegal drug use
Overweight
Underweight
STD infections
Undescended testicules
Vasectomy
Family history of fertility problem
Bicycling.

Semen Analysis
Semen analysis is always done when assessing male infertility.
The sperm is evaluated for sperm count, sperm motility, sperm shape (morphology) and other elements such as blood or white cells which can provide evidence of damage or infection.

Semen analysis is important in infertility work up, because the male partner contributes to almost 50% of all infertility problems that couples face, and yet many men refuse to think they may be the possible cause of the couples’ failure to conceive.
10-20% of men have sperm count below the WHO cut off level and about 2% of all men are completely infertile and produce no sperm at all.
Sadly, many men resist being tested and in many cases it means the women go through years of unnecessary treatment. This also means that the couple can go through a lot of unnecessary emotional turmoil and anxiety.

Azoospermia
Azoospermia is a medical term of a man not having any measureable level of sperm in his semen.
Azoospermia could be obstructive, where the sperm are produced but cannot be mixed with the rest of the ejaculatory fluid due to a physical obstruction, or non obstructive azoospermia where there is a problem of spermatogenesis.

A diagnosis of azoospermia is sometimes still made even though as many as 500,000 sperm per ml of semen may have been seen in the sample because it is extremely unlikely that a man will be able to father a child naturally with this number of sperm.
Azoospermia occurs in about 2% of the general population and many men suffering from it appear normal and healthy.

Oligospermia
Oligospermia means few spermatozoa in the semen. Oligaspermia is related to sample with less than 20 million spermatozoa per ml of ejaculated sperm.

Teratospermia
Teratospermia is characterised by presence of sperm with many abnormal shape (morphology) and it results in infertility.

Asthenospermia
Asthenospermia refers to reduced sperm motility. It decreases sperm quality and it is one of the major causes of infertility.

Aspermia
Aspermia is a complete absence of semen. It should not be confused with azoospermia which is absence of sperm cells. One of the causes of aspermia is retrograde ejaculation which can occur as a result of excessive drug use or prostate surgery.

Varicocele

Presence of varicocele (varicose vein in the testicles) is a correctible cause of low sperm count. It is the most commonly identified correctible abnormality that is associated with male infertility.
A varicocele is an abnormal dilatation of testicular veins. 15% of healthy fertile men in the general population have a detectable varicocele. In the infertile population up to 40% of men have it, so there seems to be an association with infertility.

Treatment
The treatment of male infertility is individualized and dependent on the cause and the abnormal parameters in the semen analysis.

Surgery
Varicocele can often be surgically corrected and an obstructed vas deferens repaired.

Infection
Treating infection will cure the infection but it rarely restores fertility.

Sexual intercourse Problems
Treatment of erectile dysfunction or premature ejaculation can improve fertility. Medication and psycho sexual counselling is important.
Hormonal deficiencies can easily be corrected but, they are rarely the only underlying problems in male infertility.
Assisted reproductive techniques (ART) such as Intrauterine Insemination (IUI), In-vitro fertilization (IVF) and Intracytoplasmic Sperm Injection (ICSI) are usually the definitive mainstay of treatment in severe male infertility.
Donor Sperm and adoption are also viable alternative treatment options.
Many mild problems in semen analysis that has underlying lifestyle and environmental issues, can be corrected by lifestyle changes in the male e.g. stop smoking, reduce alcohol intake, etc.

ANOTHER 53 YEAR OLD WOMAN IVF SUCCESS STORY @ The St. Ives Specialist Hospital

Read a 53-year old woman's story below.

It was boundless joy at St Ives Hospital Lagos when a 53-year-old woman was recently delivered of two bouncing baby boys. The woman was conceived through Invitro Fertilisation (IVF), having waited for over 20 years in humiliation and agony...

IVF is a process by which an egg is fertilised by sperm outside the body. The process involves monitoring a woman’s ovulatory process, removing ovum or ova (egg or eggs) from the woman’s ovaries and letting sperm fertilise them in a fluid medium in a laboratory.

The fertilised egg (zygote) is then transferred to the patient’s uterus (womb) after three to five days of being in the incubator, with the intention of establishing a successful pregnancy.

In a chat with Vanguard in Lagos, the elated woman, who pleaded anonymity, probably for cultural reasons, described it as “20 years of tensed waiting for her marriage to produce fruits.”

The jubilant nursing mother and her husband said they were not after publicity but decided to speak to the press in order to encourage couples who are presently facing similar challenges in their marriage not to give up, adding that it is never too late for anyone.

She admitted that she has almost given up when it was obvious that menopause had set in but continued to exercise her religious faith, until according to her, God directed her to St Ives Centre, even when she was not having the required money to carry out the IVF circle.

“ If one is in a marriage for two – three years, and has no child to show for it, as an African, there will be pressure, so mine was not exceptional. Though my people respected my person, there were pressures both from within and outside. But l held on to God because I’m a strong Christian and l know He never fails. I serve a living God who is faithful despite our unfaithfulness.

“I heard about St Ives just by chance. That was in September last year. Coincidentally, l did my Masters programme at Obafemi Awolowo University (OAU), very close to the hospital, and l never knew this place existed. It was divine and all things work together for those that love God.

“My advice to every woman wanting fruit of the womb is that they should hold on to God and l pray for them that their joy should come into manifestation soon. There is nothing impossible for God, it could be difficult with man but certainly not with God. If He can do mine at 53, it shows no case is concluded.

“For me, l see it as a reward for my past shame. God has given me double glory, my two boys. It is more than a miracle. And for the management of St Ives, l keep praying for them because they are not after one’s money, if they were, l couldn’t have registered.

“People used to call me Big Mummy, but God has given me a new and better name, ‘mummy twins’. l am now a fulfilled woman,” she narrated.

Her husband, who claimed to be four months older than his wife, said he knew his wife at age 12 when they were in secondary school but time and space set them apart for separate marriages where the man was fortunate to have children unlike the woman.

Fate however reunited them to become a happy family today having known each other for over 40 years.

He said the joy that the twins brought to the family had overridden their past apprehension; trauma and agony all through the years of his wife’s infertility, adding that she might have wept secretly on countless occasions.

“Today, all we are saying is thank you God. My wife had fasted and prayed and l believed that is why you see her looking like under sixteen now. I must confess that everybody is happy,” he said.

Reacting on the feat, Chief Medical Director of St Ives Hospital, Babatunde Okewale said the hospital’s Fertility Unit adopts a success-oriented approach towards infertility, focusing on solution for infertile couples at an affordable cost rather than doing endless investigation and tests.

The cost of IVF in most Nigerian hospitals, he said, was relatively between N650,000 and 1 million per circle and that was largely dependent on an individual patient. He noted that it was never a cheap process globally as it costs about 10, 000 dollars and above 5, 000 pounds in the United States of America and United Kingdom respectively.

Dr. Okewale pointed out that there were other procedures in medicine that were more expensive than IVF, giving kidney transplant and hip replacement that cost over N1 million as examples. He maintained that the procedure was affordable by most Nigerians.

He revealed that through IVF, about 550 babies have been delivered at his hospital which was established five years ago. He said St Ives does a half price promo once a year, in collaboration with some Non-Governmental Organisations.

Dr. Okewale further stated that the hospital is highly specialised in treating repeated IVF failure, provides treatment for men diagnosed with sperm problems and in elderly patients with a success of about 30 percent, including the conception and delivery by a 57-year-old woman.

As infertility continues on the rise worldwide, he enumerated some of the causes as urbanization, pollution, stress, chemical exposure, career orientation, late settlement in life, non-properly treated infections, obesity and abuse of antibiotics.

Urging Nigerian women to start bearing children earlier, he also said that the success of IVF was determined by age and the earlier the better.

Source:

St. Ives Specialist Hospital,

Vanguard,

http://ladunliadi.blogspot.com/2013/06/waiting-to-get-pregnant-try-ivf.html#more

Visit St Ives Specialist Hospital @ 6, Maitama Sule street, off Awolowo Road, Ikoyi, Lagos or

12, Salvation Road, Opebi Ikeja Lagos,

4, Mojidi Street, Off Toyin Ikeja

Tel:08039494531, 07088727358

Website: www.stivesng.com