Male factor Infertility – Causes and Treatment

Male factor Infertility – Causes and Treatment

 

How common is male factor infertility and what proportion of infertility in the couple is attributable to the male?

Of all infertility cases, approximately 40–50% is due to “male factor” infertility and as many as 2% of all men will exhibit suboptimal sperm parameters.

The rates of infertility in less industrialised nations are markedly higher and infectious diseases are responsible for a greater proportion of infertility.

The fertility rate in men younger than age 30 years has also decreased worldwide by 15%.

Male infertility

Male infertility

Is it necessary for all infertile men to undergo a thorough evaluation?

 If you are facing difficulty in conceiving then semen analysis should be done at the earliest.

Male infertility is commonly due to deficiencies in the semen, and semen quality is used as a surrogate measure of male fecundity.

Males with sperm parameters below the WHO normal values are considered to have male factor infertility.

The most significant of these are low sperm concentration (oligospermia), poor sperm motility (asthenospermia), and abnormal sperm morphology (teratospermia).

Semen analysis remains the single most useful and fundamental investigation with a sensitivity of 89.6%, that it is able to detect 9 out of 10 men with a genuine problem of male infertility.

 

What is the clinical value of traditional semen parameters?

Males with sperm parameters below the WHO normal values are considered to have male factor infertility.

The most significant of these are low sperm concentration (oligospermia), poor sperm motility (asthenospermia), and abnormal sperm morphology (teratospermia).

What key male lifestyle factors impact on fertility (focusing on obesity, heat and tobacco smoking)?

Cigarette smoke is a common somatic cell carcinogen and mutagen, and may adversely affect male reproduction factors.

Obesity is also linked to subfertility due to alteration in the hormone environment. Constant exposure to lead for instance, without safety measures, predisposes such individuals to low fertility.

Men who are exposed to high temperature at their workplace – welders, dyers, blast furnace workers and those employed in cement and steel factories – are more prone to infertility. A 1° elevation in testicular temperature leads to 14% depression of spermatogenesis.

Do supplementary oral antioxidants or herbal therapies significantly influence fertility outcomes for infertile men?

 Oxidative stress in the seminal fluid causes damage of the sperm plasma membrane and loss of its DNA integrity. Normally, a balance exists between concentrations of reactive oxygen species and antioxidant scavenging systems. If oxidative damage exceeds natural scavenging capacity then it affects sperm parameters. High dosage of vitamin C & E may rescue from such damage and increase fertility in male factor infertility.

 

What are the evidence-based criteria for genetic screening of infertile men?

Genetic testing is required in all severely oligospermic and non-obstructive azoospermic men. Such men demonstrate small testes and increased FSH. Chromosome structural and numeric abnormalities, YCMD, and other genetic mutations have been implicated in male subfertility. These men may benefit from genetic testing.

How does a history of neoplasia and related treatments in the male impact on reproductive health and fertility options?

Cancer, or post cancer treatments, can interfere with male factor fertility and reduce the ability to have children. Different types of treatments can have different effects.

Higher doses of cancer drugs are more likely to cause permanent fertility changes. The combinations of drugs can have greater effects. The risks of permanent infertility are even higher when males are treated with both chemo and radiation therapy.

 

What is the impact of varicocele on male fertility and does correction of varicocele improve semen parameters and/or fertility?

Varicocele is among the most common causes of male infertility. Varicocele affects fertility and sperm quality in some, but not in all men. The adverse effect of varicocele on sperm parameters may be due to increased testicular temperature, increased pressure, or reduced blood flow.

Male Fertility

Male Fertility

 

 

Effectiveness of varicocelectomy is however not proved and hence not practiced in many infertility setup.

Revolution in IVF Treatment: Towards better techniques & Success in IVF

Revolution in IVF Treatment: Towards better techniques & Success in IVF

Success in IVF Treatment

Lesley Brown was a patient with nine years of primary infertility who sought the assistance of Patrick Steptoe and Robert Edwards at the Oldham General Hospital in England in 1970’s. At that time, she was unaware of the historical revolution in IVF treatment she was going to be associated with. Fertilisation of oocytes outside the human body, a process known as in vitro fertilisation (IVF), was considered entirely experimental and unsuccessful around that period. Without using medications to stimulate her ovaries, Lesley Brown underwent laparoscopic egg retrieval, with her single egg fertilised in the laboratory, and later transferred back into the uterus. The embryo transfer resulted in the first live birth from IVF, a daughter Louise Brown, who was born in July 1978.

Fertility Breakthrough

Fertility Breakthrough

Introduction of ovarian stimulation and Success with traditional IVF

 The success of IVF treatment with unstimulated cycles yielded on average 0.7 oocytes per retrieval and an overall pregnancy rate of 6% per initiated cycle at that time. Stimulated IVF cycles with human menopausal gonadotropin (hMG) prior to laparoscopic egg retrieval was extensively studied at the Jones Institute after 5 years. Its widespread use led to dramatic improvement in oocyte yield per retrieval and pregnancy rates. Between 1980 and 1983, the use of hMG with IVF treatment resulted in an average recovery of 2.1–2.6 oocytes per retrieval and increasing pregnancy rates of 23.5% per retrieval in 1982 and 30% in 1983.

Pituitary desensitisation by administration of gonadotropin releasing hormone agonist (long protocol) prior to ovarian stimulation with hMG was first reported in 1984. Effective suppression with this protocol decreased the incidence of premature ovulation to about 2% and significantly improved overall pregnancy rates with IVF.

Pregnancy rates in women using donor oocytes are known to be as high as 50% per embryo transfer in recipients across all age groups. Indeed, women in their sixties have also given birth with donor oocytes, demonstrating that the postmenopausal uterus maintains the capacity to support pregnancies if provided adequate hormonal support. Despite these unresolved issues, donor IVF remains an integral part of modern ART, and accounts for 11.6% of the IVF treatment cycles.

 

Development of different types of protocol

Development of different types of protocol

Freezing techniques in IVF

Intense efforts to develop various freezing/thawing techniques and cryoprotective agents eventually resulted in the first reported human pregnancy from a frozen embryo in 1983, which unfortunately ended in premature rupture of the membranes and termination of pregnancy at 24 weeks of gestation. Despite the initial set back, technology in cryopreservation continued to improve throughout the 1980s, leading to an increase in embryo survival rate and pregnancy rates. During the initial years of experimentation, at best approximately 50% of embryos survived the freeze/thaw process and resulted in a pregnancy rate of 13.4% per embryo transfer procedure, as only 4.6% of the individual thawed embryos implanted

 

Freezing Techniques

Freezing Techniques

ICSI revolutionised Artificial Reproductive Techniques

As the pregnancy rate of IVF improved over the last decade from 22.3% in 1995 to 33% in 2003. In 2003, GIFT and ZIFT were used in only 0.1% and 0.4% of ART cycles, while IVF represented the remaining 99.5% of cases.

 

The first pregnancies using embryos generated by ICSI were reported in 1992 (Palermo et al 1992) and the procedure has been applied increasingly from 11% of IVF treatment cycles in 1995 to 55.6% in 2003. Fertilisation rates as high as 70% can be achieved with testicular sperm extraction (TESE) despite only using a few poor-quality sperm. The first clinical application of the procedure called preimplantation genetic diagnosis (PGD) was used in 1990 to prevent the transmission of two X-linked conditions: adrenoleukodystrophy and X-linked mental retardation

Better Freezing success with Vitrification

 Currently, each thawed oocyte has a mean survival rate of 47%, fertilisation rate of 52%, but pregnancy rate of only 1.52% . Other methods to circumvent oocyte damage caused by the freeze/thaw process include vitrification and cryopreservation of germinal vesicles. Vitrification uses high concentration of cryoprotectants to solidify the cell into a glass-like state without the formation of ice. Based on a small study, post-thaw survival rates and pregnancy rate of this approach were 68.8% and 21.4%,

Fertility Preservation is a breakthrough in IVF treatment

Ovarian tissue cryopreservation, achieved by biopsy and cryopreservation of ovarian cortex containing primordial follicles, followed by thawing and transplanting the autograft after completion of cancer treatment offers a potential solution in those circumstances. Transplantation can be either orthotopic (in close proximity to the infundibulo-pelvic ligament) or heterotopic (ie, forearm or abdomen). improving the efficiency of oocyte cryopreservation and of ovarian tissue transplantation promises to provide options to women who must delay childbearing.

 

 

Thyroid Hormone in Fertility and Pregnancy

Thyroid Hormone in Fertility and Pregnancy

 

Thyroid hormone  is produced by the thyroid gland present at the neck and is controlled by Thyroid Stimulating Hormone (TSH)  to produce more hormones when needed. Elevated TSH levels can be a sign that the thyroid gland is under-active. When thyroid function is not sufficient to meet, your body’s needs it is called hypothyroidism.

Hypothyroidism can lead to infertility, increased miscarriage risk, and complications in both mother and baby. 50 to 70% of hypothyroid female patients have menstrual abnormalities. Many present with oligo menorrhea (scanty bleeding during cycle). Severe hypothyroidism is commonly associated with failure of ovulation and infertility. Ovulation and conception can occur in mild hypothyroidism. But these pregnancies are at risk of abortions, stillbirths, or prematurity.

If you are trying to conceive then proper evaluation of thyroid hormone function is essential. In fact, thyroid tests are included in basic hormone tests for infertility.

 

What is subclinical hypothyroidism?

SCH is classically defined as a thyrotropin (TSH) level above the upper limit of normal range (4.5−5.0 mIU/L) with normal free thyroxine

(FT4) levels. Women with unexplained infertility more commonly present with this condition than women with infertility due to a known cause.

Should non-pregnant women be treated for SCH (subclinical Hypothyroidism)?

There is no benefit from the standpoint of lipid profile or alteration of cardiovascular risk in non-pregnant women. The risk of over-treatment with thyroid hormone can result in bone loss. Hence refrain from self-treatment with thyroid hormone and consult your doctor for proper advice.

How does your thyroid affect your pregnancy?

 TSH levels outside the normal pregnancy range are associated with an increased risk of pregnancy complications as placental abruption, preterm birth, foetal death, and preterm breaking of waters (premature rupture of membranes). If you are taking thyroid medications then you should continue the treatment during pregnancy. Regular tests will guide you to dosage adjustments in pregnancy.

Can you get pregnant if you have thyroid problems?

Unexplained infertility and ovulatory disorders can cause infertility in patients with low thyroid hormone levels. But you can still conceive with thyroid problem. In this scenario, you must consult you treating doctor for prevention of complications in pregnancy.

Can a thyroid problem cause a miscarriage?

Low thyroid hormone is associated with adverse reproductive outcomes. The problems include miscarriage, pregnancy complications, and delayed foetal neurodevelopment. There is fair evidence that thyroid autoimmunity (positive thyroid antibody) is associated with miscarriage and infertility. Treating TSH levels >4.0 mIU/L is associated with improved pregnancy and miscarriage rates.

What should be the thyroid level during pregnancy?

The Endocrine Society recommends the following pregnancy trimester guidelines for TSH levels: 2.5 mIU/L is the recommended upper limit of normal in the first trimester,

3.0 mIU/L in the second trimester, and 3.5 mIU/L in the third trimester.

 

Should there be universal screening for hypothyroidism in the first trimester of pregnancy?

The American College of Obstetricians and Gynaecologists does not recommend routine screening for hypothyroidism in pregnancy unless women

have risk factors for thyroid disease. During your pregnancy, a thyroid test may not be advised if you don’t have any symptoms or risk factors. But women

at high risk for thyroid disease should be screened.

Does thyroid affect pregnancy baby?

Untreated maternal hypothyroidism can cause delayed foetal neurologic development. Children delivered to mother with untreated hypothyroid may show impaired school performance, and lower intelligence quotient (IQ).

 Can thyroid cause birth defects?

Delayed foetal neurodevelopment can result from thyroid deficiency in pregnancy. Thyroid maternal under function, even when considered mild (or subclinical), may be associated with an impairment of brain development of the baby.

If you are taking thyroid hormone you will need regular checks to adjust dosage. You should not discontinue treatment without proper advice form physician. During pregnancy, you may have to alter the dosage. Regular pregnancy checks are required to prevent any complications in mother and baby.

 

Eating during Pregnancy, Food & Diet Plans

Eating during Pregnancy, Food & Diet Plans

food in pregnancy

food in pregnancy

Eating during Pregnancy

 A balanced diet provides all of necessary nutrients in proper proportions for adequate nutrition, function and development of body. In pregnancy, balanced diet is essential for growth of the baby and wellbeing of mother. Without good nutrition mother is more prone to disease, infection and restriction of growth of foetus.

 

Extra calories / eating for two

 During the first three months’ calorie needs of pregnant mothers are basically the same as they were before pregnancy. However, pregnant women should add 200 calories to their usual dietary intake during the second trimester, and 300 calories during their third trimester when the baby is growing quickly.

 

Brain growth of baby

 Baby’s brain starts forming just three weeks after conception and it undergoes rapid changes during pregnancy. Majority of brain growth is completed when the baby is born and later it undergoes few fine changes only. Food containing docosahexaenoic acid (DHA) is important in pregnancy for helping the brain and central nervous system mature. Iodine deficiency during pregnancy is the leading cause of preventable mental health.

 

Foods to avoid

 Avoiding certain foods in pregnancy is recommended for maternal and fetal well-being. Pregnancy is a state of lower immunity and pregnant women catch infections easily. Moreover, not all medications can be used to treat diseases in pregnancy. Hence it is safer to avoid certain foods in pregnancy which can give rise to food poisoning or infections. Fish such as shark, swordfish, king mackerel, and tilefish have high mercury levels and must be avoided. Smaller fish have less mercury content can be chosen instead as their longevity in water is short such as fresh water fish. Similarly, smoked meat or fish should be avoided as they can cause infections. Raw uncooked eggs or poultry, unpasteurised milk and milk products, raw sprouts, unwashed fruits or vegetables are not advisable as well. Pregnant women should carefully avoid excess caffeine, alcohol or tobacco as these could harm the baby. Artificial sweetners, sugar rich foods, canned foods and foods containing nitrates as in frozen meat are better avoided in pregnancy.

 

Vegetarian diet in pregnancy

 Vegetarians can meet their protein needs by eating select milk and egg foods, protein-rich vegan foods like nuts, hummus, and beans, soy milk, soy cheese, soy yogurt, and tofu. Pregnant women require an additional 45 grams of carbohydrates per day which can be obtained from fruits, vegetables, grains, and several dairy products. Nuts and vegetable oils can provide the dietary fat requirement for pregnant women. Carbohydrates enriched with folic acid reduce the rate of birth defects. Milk, yogurt, dark green leafy vegetables such as spinach, dried beans and peas and cheese are good sources of calcium.

 

Role of dietary fibres in pregnancy

 Dietary fibre is a nutrient that cannot get digested by human gastrointestinal tract. It absorbs water and helps bowel movements. Insoluble fibre like vegetables (especially dark green leafy ones), root vegetable skins, fruit skins, whole wheat products are essential during pregnancy to prevent constipation. Soluble fibres absorb water, bind to fatty acids and slow down sugar absorption. Some types of soluble fibres are: kidney beans, sprouts, broccoli, spinach, apple, orange, grapefruit, grapes, prunes, grains, oatmeal etc.

 

Choosing fruits and vegetables

Pregnant women need at least 70 mg of Vitamin C daily, which is contained in fruits such as oranges, grapefruits and honeydew, and vegetables such as broccoli, tomatoes, and sprouts. At least 2-4 servings of fruit and 4 or more servings of vegetables daily is recommended during pregnancy. Fresh fruit contains lots of essential vitamins and nutrients and eating plenty of fresh fruit during pregnancy can help wellbeing of mother and baby. Broccoli and dark, green vegetables, such as kale and spinach, contain vitamin C, vitamin K, vitamin A, calcium, iron, folate and potassium which are essential in pregnancy.

 

 

Planning meals in pregnancy

 Pregnant women should plan for small frequent meals. Lighter meals help prevent gastrointestinal upsets like abdominal distension and vomiting. Fatty foods like fried, baked snacks can be replaced by servings of fruits and nuts. Drinking 3-4 litres of water daily is essential during pregnancy.

 

Foods to avoid vomiting of pregnancy

Foods with high content of sugar, fat or salt lead to vomiting in pregnancy. A large evening meal can give rise to morning sickness. Having small and frequent meals and drinking a lot of cold water suppresses vomiting sickness of pregnancy. At times, fast foods and street foods can cause food poisoning and better be avoided in pregnancy.

 

Vitamins and minerals in pregnancy

 The lack of calcium, iron, iodine and other vitamins lead to baby’s learning disabilities, delay in language development, behavioural problems, delayed motor skill development, and a lower I.Q. Deficiency of Folic acid in pregnancy leads to severe malformations of the brain and spinal cord.  Folic acid is found in green leafy vegetables, broccoli, beans, citrus fruits and liver.

 Eating well during pregnancy is essential and the guidelines for eating well for a healthy pregnancy are simple and easy to follow. Healthy eating keeps the mother safe throughout pregnancy and provides baby the essential nutrients they need inside the uterus.

 

Fertility Enhancing Surgeries

Fertility Enhancing Surgeries

 

Surgeries that can enhance fertility

Fertility enhancing surgeries are usually advised to young women with suspected minimal to moderate disease of tubes, ovaries or uterus. These surgeries may enhance the rate of spontaneous pregnancy or IUI treatment. Usually such surgeries are done by experts through laparoscope to prevent damage to pelvic organs.

Fertility enhancing surgeries in female infertility

Myomectomy :

Uterine fibroids are the most common tumours in the female. Fibroids in infertile women undergoing assisted reproductive treatment can decrease success rates than do age-matched women with no fibroid. Removal of fibroids(myomectomy) can help these cases. However, myomectomy is restricted to women with unexplained infertility. If you have fibroids growing into the uterine cavity then you are more likely to benefit after myomectomy. Higher pregnancy rates can be achieved after laparoscopic removal than open surgery. This procedure can be considered if you are suffering from infertility for long years.

Tubal anastomosis:

Tubal sterilization is one of the most commonly used contraceptive methods worldwide. Approximately 1% of the women who undergo this procedure may request reversal of the procedure to restore fertility. However, if you are going for this procedure you must be aware of its cost benefit analysis. Due to its low success rate, often IVF is preferred to tubal anastomosis. Tubal anastomosis by the laparoscopic approach has the advantages over open surgery. Less postoperative discomfort and fewer complications, a smaller incisional scar, a shorter recovery time, and earlier resumption of normal activities are the advantages of laparoscopic procedure. This could be especially beneficial for a patient who previously has undergone a laparotomy or caesarean section because it allows her to avoid a second surgery.

Patient selection as well as meticulous surgical technique are key factors in achieving satisfactory pregnancy rates.

Excision of endometriosis:

In women with minimal and mild endometriosis, surgical removal or thermal destruction(ablation) of endometriosis is recommended as first line with higher success rate.

Laparoscopic surgery for destruction of mild endometriosis almost doubles the spontaneous pregnancy rate. IVF is the best option for patients after failed primary surgery. Repeat surgery is associated with lower pregnancy rate.

The pregnancy rate after intrauterine insemination IUI may be increased after surgery for mild endometriosis. The place of IUI is limited in patients with moderate or severe endometriosis and in older women. The incidence of recurrence of endometriosis is not increased after ovarian stimulation for IVF.

Ovarian cystectomy:

Ovarian cysts commonly are simple cysts(functional)or chocolate cysts (endometrioma).

Functional cysts, unless they become very large, these types of ovarian cysts don’t affect fertility. Hence your doctor may prefer to wait and watch for growth of these cysts. Small cysts may regress on their own.

Ovarian endometriomas are managed by laparoscopic procedures, like cyst aspiration or excision.

 Distal tubal disease and tubal reconstruction:

These procedures are of minimal benefit for fertility. At times these surgeries can be done for young patients with hydro salpinx who don’t want to go for IVF. Of all surgical treatments for tubal disease, sterilization reversal results in the highest pregnancy rates. The procedure is appealing to couples who desire an extended family or who are not comfortable with IVF. The ectopic pregnancy risk and the need for future contraception are recognized disadvantages with these procedures.

 Benefits of bariatric surgery for obesity:

 Obese men and women may benefit from weight loss programme or surgical removal of fat content from body.

Female Infertility

Polycystic ovary syndrome (PCOS) is the most frequent cause of female infertility. It is often associated with obesity. PCOS, hirsutism, and menstrual irregularities improve after bariatric surgery. The increased risk of miscarriage in obese women may decline after bariatric surgery.

Male infertility 

Obesity can be associated with reduced sperm concentrations. Weight loss is the cornerstone of the treatment of obesity-related infertility. It can restore fertility and normal hormonal profiles. But effects of bariatric surgery impact on male fertility is still unclear. At times sperm counts may be adversely affected by fat loss surgery.

Adhesiolysis :

Laparoscopic adhesiolysis still remains a useful and effective procedure for infertile couples with pelvic adhesions. These adhesions may be a result of previous surgery or infections like abdominal tuberculosis.

 Septal resection:

Although septate uterus does not seem to be an infertility factor hysteroscopic septum resection is accompanied by a significant improvement in the reproductive performance. There is no adverse effect in the achievement of pregnancy in women with a history of recurrent abortions after septum removal.

Hysteroscopic septum resection in women with septate uterus significantly improves the live birth rates and future fertility is also not impaired.

Metroplasty:

Metroplasty refers to repairing the womb with birth defects like extra horn, double uterus or divided uterus. Women with uterine partition(septum) and otherwise unexplained infertility might benefit from hysteroscopic metroplasty.

Ovarian drilling:

 Ovarian drilling is done in women with PCOS to break the thick outer surface and destroy some of the testosterone producing tissue made by the ovaries. This can help the ovaries release an egg each month and start regular monthly menstrual cycles. This may reduce symptoms of excess testosterone as well.

Uterine transplantation:

The uterine transplant is the surgical procedure whereby a healthy uterus is transplanted into an individual who does have one from birth or got it removed for disease process. Although it appears as a breakthrough procedure in the field of infertility its results are yet to be studied.

Surgery for Ectopic pregnancy:

Surgery for ectopic pregnancy usually involves the fallopian tubes. It is aimed at preserving the tubes for future fertility but recurrence of ectopic is common in such situations.

Fertility enhancing surgery in male infertility

 Varicocelectomy:

Varicocele is one among the most common causes of male infertility. The adverse effect of varicocele on spermatogenesis can be attributed to an increased testicular temperature. The results of varicocele surgery are not conclusive and not encouraging for restoring fertility. Hence this is reserved for people with severe grade of the disease. ICSI is an alternative method of fertility treatment in these patients.

TESA, PESA, MESA & Testicularbiopsy:

These are procedures of sperm retrieval for patients undergoing ICSI treatment. Usually these procedures are advised in patients with azoospermia with blockage of the passage (vas deferens).

Reversal of vasectomy:

Vasectomy reversal is surgery to undo a vasectomy. Success rates with vasectomy reversal will range from about 40 percent to over 90 percent. In some cases, pregnancy, still may not happen after a vasectomy reversal, even when there is sperm. This may be due to decreased motility of sperm.

Fertility Enhancing Surgeries

Fertility Enhancing Surgeries

HSG test for infertility – Advantages and Side effects

HSG test for infertility – Advantages and Side effects

Why HSG (Hysterosalpingogram) is done?

Hysterosalpingogram ( HSG) is a type of X-Ray of abdomen to know the condition of the fallopian tubes. If the fallopian tubes are blocked then couple may have difficult in conceiving, it is required to check whether tubes are open or not in cases of infertility. It’s also used to investigate miscarriages resulting from abnormalities within the uterus such as tumour masses, adhesions and uterine fibroids.

What is HSG

What is HSG

 What is a Hysterosalpingogram (HSG)?

HSG is a diagnostic X-Ray procedure that usually takes around 15 minutes to perform. It is usually done before ovulation around 10 -12 days after menstruation. This is done on an outpatient basis.

How the patient is prepared for HSG?

The doctor usually obtains history regarding pregnancy and any allergies as HSG should not be done on a pregnant woman. Any kind of allergies should be noted as the dye used in this procedure may cause severe reactions in such people. This procedure should not be performed in inflammatory condition like chronic pelvic infection or an untreated sexually transmitted disease. Since the dye used may damage a developing foetus doctors advise to take contraceptive pills in the cycle when HSG is done in order to prevent pregnancy. The patient is also given antibiotics to prevent infection and also at times a pain killer to reduce the discomfort during the procedure.

 

How is a Hysterosalpingogram done?

Hysterosalpingography uses a real-time form of x-ray called fluoroscopy to examine the uterus and fallopian tubes

A woman is positioned under a fluoroscope (an x-ray imager that can take pictures during the study) on a table. The doctor then examines the patient’s uterus and places a speculum in her vagina. Her cervix is cleaned, and a cannula is placed into the opening of the cervix. A liquid containing iodine (a fluid that can be seen by x-ray) is slowly pushed through the cannula. The contrast is seen as white on the image and can show the contour of the uterus as the liquid travels from the cannula, into the uterus, and through the fallopian tubes. If the tubes are blocked the dye doesn’t pass through and may cause swelling of the tubes called hydrosalpinx.

After the HSG, a woman can immediately return to normal activities but refrain from intercourse for a few days.

Does HSG cause pain?

An HSG usually causes mild or moderate cramping pain for about an hour. However, some women may experience cramps for several hours. These symptoms can be greatly reduced by taking medications used for menstrual cramps like pain killers before the procedure or when they occur.

What are the risks of HSG?

HSG is considered a relatively safe procedure. However, some complications mild or serious can happen in less than 1% of the time. There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk. The effective radiation dose for this procedure varies. Special care is taken during x-ray examinations to use the lowest radiation dose possible while producing the best images for evaluation.

In the event of a chronic inflammatory condition, pelvic infection or untreated sexually transmitted disease, be certain to notify the physician or technologist before the procedure to avoid worsening of infection.

Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant.

 

  1. The most common serious problem with HSG is pelvic infection. This usually occurs when a woman has had previous tubal disease (such as a past infection of chlamydia). In rare cases, infection can damage the fallopian tubes or make it necessary to remove them. A woman should call her doctor if she experiences increasing pain or a fever within 1-2 days of the HSG.

 

  1. Fainting – Rarely, some woman may get light-headed during or shortly after the procedure and faint due to a vasovagal attack.

 

  1. Iodine Allergy – Rarely, a woman may have an allergy to the iodine contrast used in HSG. A woman should inform her doctor if she is allergic to iodine, intravenous contrast dyes, or seafood. Women who are allergic to iodine should have the HSG procedure performed without an iodine-containing contrast solution. If a woman experiences a rash, itching, or swelling after the procedure, she should contact her doctor.

 

  1. Spotting – Spotting sometimes occurs for 1-2 days after HSG. Unless instructed otherwise, a woman should notify her doctor if she experiences heavy bleeding after HSG.

What are the limitations of HSG?

Hysterosalpingography only sees the inside of the uterus and fallopian tubes. Abnormalities of the ovaries, wall of the uterus, and other pelvic structures may be evaluated with MRI or ultrasound. Alternatively, a surgical procedure to directly view the tubes (laparoscopy) can be done which is more accurate than HSG.

What is the next step if tubes are found to be blocked on HSG?

Patients may undergo revaluation of tubes with laparoscopy or may be suggested to go for IVF. In vitro fertilization (IVF) is a procedure which can bypass the function of the tubes and can achieve pregnancy in cases with the blocked fallopian tubes.

 

What is HSG

What is HSG

 

 

 

 

 

Implantation & IVF Success

Implantation & IVF Success

The Process of Implantation and IVF Success

 Implantation is referred to the stage of pregnancy at which the embryo adheres to the wall of the uterus. It helps the embryo to grow by receiving nutrients from the mother.

In humans, implantation of a fertilised ovum is most likely to occur around 6 – 9 days after ovulation. The reception-ready phase of the endometrium of the uterus is usually termed the “implantation window” and lasts about 4 days.

The term “implantation” is used to describe process of attachment and invasion of the uterus endometrium by the blastocyst (conceptus).

Implantation is a highly co-ordinated event that involves both embryonic and maternal active participation.

Initially the newly hatched blastocyst loosely adheres to the endometrial epithelium. Then it rolls over the endometrium to find a suitable place for implantation where it gets attached firmly.

 

What happens in implantation window?

Embryo–endometrial dialogue has led to the identification of a ‘window of implantation’. The implantation window is characterised by changes to the endometrium cells, which aid in the absorption of the uterine fluid. These changes bring the blastocyst nearer to the endometrium and immobilise it. The first step of implantation is the formation of foetal–maternal interface. Next crucial step is invasion of the embryo into the endometrium.

How implantation is mediated?

 Implantation is initiated when the blastocyst comes into contact with the uterine wall. Certain molecules and pinopodes are involved in bringing embryo and endometrium together and attachment in embryo implantation. The embryo produces cytokines and growth factors and receptors for endometrial signals.

Does body immunity play role in successful pregnancy?

The embryo, as a genetic product of both maternal and paternal chromosomal material, can be seen as an allograft to the uterus. The body immune system plays an important role in implantation process. The host (mother)genetically different from the transplants(foetus), raises the possibility of a graft-versus-host reaction. The immunological action against the embryo can be described as maternal restraint.

Can we calculate Implantation period?

Implantation of a fertilized ovum is most likely to occur around 6 – 9 days after ovulation. It falls around day 21 of a regular menstruation cycle. In irregular cycles, it is difficult to predict. During the female fertile age, there is an average chance of pregnancy of approximately 15% per cycle.

Does implantation process differ in IVF and natural pregnancy?

 The assisted reproduction setting for implantation is not different to a naturally conceived pregnancy.

But at times, during IVF treatment, the factors for implantation may be adversely affected. This is attributed to high level of steroid hormones and drugs used for pituitary desensitization. Imbalance in the oestrogen and progesterone interaction may result in implantation failure in a number of patients.

Can we enhance implantation by PGD?

Embryonic factors are by far the main factors determining whether or not a successful implantation and pregnancy will occur.

PGD seems to be a safe procedure that can enhance pregnancy rates by improving embryo quality by selection. Preimplantation genetic screening (PGS) enables the testing of gametes and embryos for numerical chromosomal aberrations commonly found in early pregnancy loss.

What are the early signs of implantation?

Embryonic implantation is the establishment of pregnancy, to be proven by finding human chorionic gonadotrophin (HCG) in maternal blood. Some women may experience slight bleeding and cramping pain during the process of implantation.

 What is the role of embryo transfer procedure in implantation?

The performance of an atraumatic embryo transfer is essential to implantation and IVF success. Factors such as the contamination of the catheter tip with cervical bacteria, stimulation of uterine contractions during the procedure, may significantly influence implantation rates. Usually embryo transfer is performed under ultrasound guidance by use of soft catheters for better success.

 What is recurrent implantation failure?

Recurrent implantation failure is an important cause of repeated IVF failure. It is estimated that approximately 10% of women seeking IVF treatment will experience this particular problem. It is a distressing condition for patients and frustrating for clinicians and scientists. Recurrent implantation failure refers to failure to achieve a clinical pregnancy after transfer of at least four good-quality embryos in a minimum of three fresh or frozen cycles in a woman under the age of 40 years. The failure to implant may be a consequence of embryo or uterine factors.

Premature Ovarian Failure

Premature Ovarian Failure

What is premature ovarian failure?

 

 When a woman’s ovaries stop working before age 40, she is said to have premature ovarian insufficiency (POI) or premature ovarian failure (POF) also, known as premature menopause, is a common condition, affecting 1–2% of women younger than 40 years of age and 0.1% of women, younger than 30 years of age. When this happens, a woman’s menstrual cycles become irregular and stop. Her ovaries stop making hormones such as oestrogen and progesterone and she stops releasing eggs (ovulating) regularly or at all.

Some women develop POF when they are teenagers, even before they start to have menstrual periods. If that happens, the teen will never experience normal function of her ovaries. For other women experiencing POF, their ovaries may continue to intermittently release (ovulate) eggs and make hormones; these women may continue to have menstrual cycles for months or years before their ovaries completely shut down. For this reason, the currently used term POI is preferred to the older terminology “premature ovarian failure (POF).

 Causes of Premature Menopause 

In human females, the process of ovarian follicular maturation, or maturation of eggs, is a highly organised and complex process. Maturation of Eggs is the progressive maturation of small primordial follicles that progress to become large ovulatory follicles. When follicles eventually mature, the oocytes (eggs) are released from the surface of the ovary. They are collected by the uterine tube, and  proceed to become fertilised.

The causes of POF remains unknown in most cases. A genetic cause of POF is identified in few patients, i.e. in 5-7% of the total cases, whereas causes remains most often undiscovered. Fragile X syndrome is one of the genetic causes of POF which can be transmitted in the family.

Women receiving cyclophosphamide for either kidney diseases or rheumatoid arthritis are at risk of developing POF.

Malnutrition and cigarette smoking are perhaps the only consistent environmental features associated with an earlier menopause.

The first known significant cause is damage to the ovaries, such as that caused by iatrogenic agents like chemotherapy or radiotherapy or pelvic surgery may be

associated with ovarian failure. Surgical menopause may be induced by removal of ovaries, but interestingly hysterectomy to remove the uterus is also associated with an earlier menopause.

Premature ovarian failure (POF) may be considered as an autoimmune endocrine disease. Autoantibodies and lymphocyte subset changes are associated with premature ovarian failure. This problem can run in family as well.

 

What POF women experience?

Women with POF experience menopausal symptoms,

such as hot flushes, night sweats and vaginal dryness, In addition, there is increased risk of developing osteoporosis because of the lengthened time of exposure to reduced oestrogen similar to those going through a natural menopause.

For most women, it can be an unexpected and distressing diagnosis, with unpleasant symptoms, but made worse by the fact that it coincides with infertility.

Premature ovarian failure (POF) is a disorder associated with female infertility, and it affects approximately 1% of women under the age of 40 yr . It can be attributed to two major mechanisms: follicle dysfunction and follicle depletion .

Despite having amenorrhea and markedly elevated serum gonadotropin levels, some women with karyotypically normal can go to spontaneous premature ovarian failure. Nevertheless, they have ovarian follicles that function intermittently. Graafian follicles capable of responding to these high FSH levels are faced with high serum LH levels as well, which might prevent normal follicle function.

Premenopausal women may be at risk for the development of osteoporosis. However, bone loss in women with amenorrhea from other causes has not been assessed. Women with POF have diminished general and sexual well-being and are less satisfied with their sexual lives than other women

TREATMENT

 

Many women with POF would benefit from symptom relief by the use of exogenous steroids, to compensate for the loss of ovarian hormone estrogen and possibly progesterone and androgens. Menopausal symptoms, such as hot flushes, night sweats and vaginal dryness can be relieved by oestrogen replacement, such as sequential HRT or oral contraceptive pill.

Infertility In POF

Infertility is a significant issue for most women undergoing POF. A number of treatment regimens have been evaluated with the aim of restoring fertility. However, treatments with clomiphene, Gonadotrophins, GNRH agonists or immunosuppressants do not significantly improve the chance of conception and are not used.

The only reliable fertility treatment is the use of donor eggs. It is an assisted reproductive procedure that is widely practised in most countries. At present, in vitro maturation of immature follicles is possible. But in vitro growth and maturation from stored ovarian tissue is not reliably achievable in humans. For women with impending POF, there may not be any alternatives. Young women about to begin cancer treatment are encouraged to attempt a cycle of IVF if time permits. They can go for storing  embryo or eggs  for later use.

In addition, young women may store ovarian tissue, in the hope that at a later stage their tissue can be reimplanted, or that the use of in vitro growth and maturation of immature follicles may restore fertility

Women suffering from oestrogen deficiency should be recommended a number of measures to protect against osteoporosis. It includes increased physical exercise, eating a diet rich in calcium and vitamin D and avoiding risk factors such as smoking and high alcohol intake.

Women with POF are advised to undergo HRT until the normal age of menopause addition of testosterone to HRT to improve sexual function and wellbeing.

Premature ovarian failure (POF), a major life-changing condition that affects a significant proportion of young women. It remains an enigma and the researcher’s minefield. As women increasingly survive childhood cancers due to improved iatrogenic interventions, the number of POF sufferers will inevitably increase.

Patient Counselling

When primary ovarian insufficiency is diagnosed in the adolescent female, the patient and her family are often unprepared for such news with its implications for compromised fertility and the need for long-term hormonal therapy. Adolescents may demonstrate myriad emotions ranging from apathy or denial  and these emotions may be different from those of their parents or guardians. Parents can provide valuable insights about their daughters’ ability to appreciate the significance of the diagnosis to the treating practitioner and help in managing the situation.

Ovarian Drilling  – How It Helps PCOS?

Ovarian Drilling – How It Helps PCOS?

ovarian drilling

What is ovarian drilling and how does it work?


ovarian drilling – In women with PCOS ovulation doesn’t occur regularly and usually they have ovaries with a thick outer layer. The ovaries make more testosterone, the male type of hormone. High testosterone levels lead to irregular menstrual periods, acne, and extra body hair.

Ovarian drilling is done to break the thick outer surface and destroy some of the testosterone producing tissue made by the ovaries. This can help the ovaries release an egg each month and start regular monthly menstrual cycles. This may reduce symptoms of excess testosterone

How drilling of ovary is done?


A minimally invasive surgery called laparoscopy is used for ovarian drilling. A thin, lighted telescope (laparoscope) is put through a small surgical cut (incision) near the umbilicus. A tiny camera is used to see the ovaries. The surgeon inserts tools through other tiny incisions in the lower belly and makes very small holes in the ovaries. This helps to lower the amount of testosterone made by the ovaries.

What are the benefits of drilling ovary?


About 50% of women get pregnant in the first year after surgery. Some women still may not have regular cycles after the surgery. Others may have other fertility problems (such as blocked tubes or a low sperm count) that can prevent pregnancy. Some women after a short period of regular ovulation may go back to previous irregular cycles.
For some women with PCOS, ovarian drilling will not fix the problems with irregular periods and ovulation, even temporarily. However, ovarian drilling can help a woman respond better to fertility medicines.

What are the risks of  drilling ovary ?


There are certain risks of the surgery done for ovarian drilling .
Some of the risks are related to surgery. As with all surgical procedures, there are risks of bleeding, anaesthesia, and infection. Also, laparoscopy can cause injury to the bowel, bladder, and blood vessels. Very rarely, there is a risk of death.
There are also risks to fertility. If there is too much damage to the ovary during the ovarian drilling procedure, a woman may enter menopause at a younger age than expected. After the procedure, adhesions (scarring) can form between the ovaries and the fallopian tubes, making it hard to get pregnant. Most important in many women the beneficial effects are for too short period and they immediately go back to the previous status.

ovarian drilling

ovarian drilling

How is ICSI treatment different from IVF?

How is ICSI treatment different from IVF?

What is intracytoplasmic sperm injection (ICSI)?

ICSI treatment is an option for conceiving with male infertility. It is an advanced fertility treatment which gives best success in the  hands of experts.

In human being formation of an embryo from a woman’s egg and a man’s sperm is a very complex phenomenon. The sperm of a man is a moving cell inside the body and it must reach to the egg at appropriate time to fertilize it as the released egg from ovary can survive for only 24 hours. At times this process doesn’t happen due to any of following problems in the man

  1. Sperm quantity may be too low – oligospermia
  2. Azoospermia- No sperms are found
  3. Defects in sperm movement – Asthenospermia
  4. Sperm cannot penetrate the egg due to a thick covering – thick zona

Before a man’s sperm can fertilize a woman’s egg, the head of the sperm must attach to the zona of the egg. Once attached, the sperm penetrates through the outer layer to the inside of the egg (cytoplasm), where fertilization takes place.

Sometimes the sperm cannot penetrate the outer layer, for a variety of reasons. The egg’s outer layer may be thick or hard to penetrate or the sperm may be unable to swim. In these cases, a procedure called intracytoplasmic sperm injection (ICSI) can be done to fertilize the egg inside the labaoratory. During ICSI, a single sperm is injected directly into the cytoplasm the egg.

 

How ICSI is different from IVF?

 

There are two ways that an egg may be fertilized in the laboratory: IVF and ICSI. In traditional IVF, 50,000 or more swimming sperm are placed next to the egg in a laboratory dish. Fertilization occurs spontaneously when one of the sperm enters into the cytoplasm of the egg. In the ICSI process, a tiny needle, called a micropipette, is used to inject a single sperm into the center of the egg. Fertilization achieved through ICSI can be up to 80-90% whereas through IVF it is aound 50 -60 %. With either traditional IVF or ICSI, once fertilization occurs, the fertilized egg (now called an embryo) grows in a laboratory for 2 to 5 days before it is transferred to the woman’s uterus (womb).

 

Why ICSI is needed?

 

ICSI helps to overcome fertility problems, such as:

  • The male partner produces too few sperm to do artificial insemination (intrauterine insemination [IUI]) or IVF.
  • The sperm may not move in a normal fashion, hence cannot reach up to the egg in time.
  • The sperm may have trouble attaching to the egg , Intra cytoplasmic sperm injection overcomes this.
  • Azoospermia due to a blockage in the male reproductive tract may keep sperm from getting out. In these couples the sperms are obtained directly from Testes through a minor procedure like PESA or TESE. ICSI helps these couples to achieve a pregnancy even though no sperms are found in semen analysis.
  • At times, traditional IVF fails to create embryos in some patients. ICSI can achieve fertilization in such patients regardless of the condition of the sperm.
  • ICSI is used along with IVM (In vitro maturation of eggs).
  • ICSI is necessary where frozen eggs are used for fertilization.

 

Does ICSI work for all?

 

ICSI fertilizes up to 80% of eggs. But certain issues may occur during or after the ICSI process:

  • Some or all of the eggs may be damaged. Hence it is advisable to take help of an expert embryology department.
  • The egg might not grow into an embryo even after it is injected with sperm. This can happen due to any inherent problem in any one of the couple.
  • The embryo may stop growing after fertilization due to several reasons.

 

Once fertilization takes place, a couple’s chance of achieving pregnancy is same for IVF and ICSI. Chances of Pregnancy in humans is up to 30-40 % even with very good embryos. This is due to the low implantation capacity of human uterus.

ICSI treatment

ICSI treatment

Can ICSI affect a baby’s development?

 

If a woman gets pregnant naturally, there is a 1.5% to 3% chance that the baby will have a major birth defect. The chance of birth defects associated with ICSI is similar to IVF, but slightly higher than in natural conception.

The slightly higher risk of birth defects may actually be due to the infertility and not the treatments used to overcome the infertility.

Certain conditions have been associated with the use of ICSI, such as Beckwith-Wiedemann syndrome, Angelman syndrome, hypospadias, or sex chromosome abnormalities. They are thought to occur in far less than 1% of children conceived using this technique.

 

Some of the problems that cause infertility may be genetic. For example, male children conceived with the use of ICSI may have the same infertility issues as their fathers. Couple should go through a counselling process at a standard ICSI center with the help of Infertility specialists and embryologists.

 

 

DEEP ENDOMETRIOSIS

DEEP ENDOMETRIOSIS

Endometriosis

Are you suffering from severe endometriosis?



 What is Endometriosis?


 Endometriosis is a common disorder of women of reproductive age. The most frequent clinical presentation of endometriosis is painful menstruation.

What are the common symptoms of endometriosis?


 Endometriosis commonly present with painful menstruation, pelvic pain, pain during intercourse, infertility, and pelvic mass.

How to know the severity of endometriosis?


The correlation between the symptoms of endometriosis and the severity of disease is poor. Currently available laboratory markers are of limited value. At present, the best marker, serum CA-125, is usually elevated only in advanced stages and therefore not suitable for routine screening. Severity of endometriosis is difficult to determine from its symptoms. Usually symptoms are expressed according to area of involvement not depth of disease.

 Who are affected by endometriosis?


Endometriosis usually starts in the ovary, it also can happen in the abdomen cavity affecting fallopian tubes, uterus and other pelvic organs like bladder and bowel. It affects women of reproductive age. Usually starts at around the age of 15 to 20 years and slowly spreads destroying nearby organs. It can subside spontaneously at menopause.

 What is the correlation of CA 125 to endometriosis?


Plasma concentrations of CA-125 are increased in women with cystic ovarian and deep endometriosis and plasma concentrations are higher during menses than during the follicular and luteal phases of the cycle.

How ultrasonography and MRI are useful in Endometriosis?

Transvaginal ultrasound and magnetic resonance imaging are often helpful, particularly in detection of endometriotic cysts. Recently, trans rectal ultrasound and magnetic resonance imaging were shown to be valuable in detection of deep infiltrating lesions, especially affecting the rectum.

What is the role of Laparoscopy in endometriosis?


Direct assessment of endometriotic foci at laparoscopy may be viewed as a “gold standard” for identifying endometriosis. Laparoscopic removal of endometriosis significantly reduces pain and improves quality of life. Early diagnosis, surgical confirmation and therapy of endometriosis by laparoscopic techniques is recommended as soon as symptoms occur, even in adolescent girls.

Can a clinical test detect deep endometriosis?


 A clinical examination during menstruation is proposed as a simple and reliable test to diagnose deep endometriosis. It also helps to decide which women may require bowel surgery. In >60% of cases deep lesions are “unexpected” findings at laparoscopy, these women are the candidates for bowel preparation before laparoscopy.

What is needed for definite diagnosis of endometriosis?


 Diagnosis of endometriosis requires a careful clinical examination in combination with judicious use and critical interpretation of laboratory tests, imaging techniques, and, in most instances, surgical evaluation combined with biopsy results of excised lesions.

Which group of patients present with less severe symptoms?


 Endometriosis, characterised by the ectopic localisation Of the endometrium, can be present as superficial implants, deep peritoneal lesions, and ovarian endometriomas, with or without associated pelvic adhesions. The frequency of dysmenorrhea and the frequency and severity of dyspareunia is less in patients with endometriosis located only on the ovaries than in patients with lesions at other sites.

What is Cystic Ovarian Endometriosis?


 In some women, more severe forms present as either cystic ovarian or deep infiltrating endometriosis. Cystic ovarian endometriosis always has been recognized as a severe form because of its association with pelvic adhesions, infertility, and pelvic pain. Clinical examination during menstruation can diagnose reliably deep endometriosis, cystic ovarian endometriosis, or cul-de-sac adhesions. This test, preferentially combined with a follicular phase CA-125 assay, should be used to decide whether a preparation for bowel surgery should be given.

 

How CA 125 helps in pre-treatment of endometriosis?


 The presence of pelvic nodularity during menstruation or a CA125 concentration higher than 35 U/mL can be used to decide in which women bowel pre-treatment should be given with a sensitivity of 87%, whereas <13%, will get an unnecessary bowel pre-treatment.

How deep endometriosis is treated?


Deep pelvic endometriosis may lead to severe pain, the treatment of which may require complete surgical resection of lesions. Infiltration of bowel is a difficult therapeutic problem. Preoperative diagnosis is difficult and digestive infiltration may remain unknown before surgery. This may cause damage to the gut with incomplete resection during surgery and sometimes may require repeated surgery. Both magnetic resonance imaging (MRI) and endoscopic ultrasonography are able to detect rectal infiltration but their usefulness in the preoperative staging is still not evaluated.

Can Endometriosis affect fertility?


Endometriosis is a chronic, progressive disease and may lead to severe destructions of reproductive organs and infertility in advanced stages.

Approximately 30% to 50% of women that have the diagnosis of endometriosis also struggle with infertility. Twenty five percent to 50% of women diagnosed with infertility also have endometriosis, but the endometriosis may not be severe enough to be the primary cause of infertility. White women have been reported to be more likely than African American women to have endometriosis. In addition, risk factors for endometriosis include below average body mass index, smoking, and alcohol use.

How ovulation is affected by endometriosis?


After ovulation, peritoneal fluid contains concentrations of progesterone and of 17 beta-estradiol that are 5 to 20 times higher than plasma concentrations in women with ovulatory cycles but not in women with unruptured luteinized follicles. Since viable endometrial cells were found in the peritoneal fluid of over 50% of women, both with and without endometriosis, a new hypothesis is presented about the cause of pelvic endometriosis and the association of pelvic endometriosis and infertility: pelvic endometriosis could be the consequence of infertility caused by the unruptured luteinized follicle.

Endometriosis

Endometriosis

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What happens in Silent endometriosis?


Many times, a woman who has difficulty conceiving will have a case of endometriosis that does not come with severe symptoms. This is known as silent endometriosis. These silent sufferers eagerly crowd into the waiting rooms of in vitro fertilisation (IVF) clinics and reproductive specialists with the hope of conceiving. However, these women may have endometriosis, and the in vitro attempts they take may fail.

How endometriosis can lead to infertility in a woman and how it is treated?


Infertility due to endometriosis could be due to several abnormalities like tubal dysfunction, impaired ovarian reserve, worsening egg quality, defect in implantation and decreased sperm motility inside the female reproductive system. Infertility due to endometriosis at the earlier stages can be treated by simpler treatment like ovulation induction and IUI. However, at advanced stages it requires IVF / ICSI as the disease spreads rapidly and destroys the ovaries. At later stages, usually the women are completely depleted of their eggs and have to go through egg donation programme.

What are the precautions for women trying to conceive with endometriosis?


If you are experiencing severe pain during cycles it may be due to endometriosis, you must consult local gynaecologist. Diagnosis of endometriosis is usually done with pelvic ultrasound which may show chocolate cysts in the ovaries. It is always better to undergo a laparoscopy to check patency of tubes at this stage . If you are trying to conceive then it is a better option. If you are diagnosed as mild to moderate case of endometriosis you should regularly follow up with AMH levels. This can indicate extent of destruction of ovaries. Severe endometriosis needs immediate attention for fertility preservation, you may need IVF at this stage for optimum results.



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PCOS

PCOS

Polycystic Ovary Syndrome (PCOS)



Which is the most common hormone disorder found in women?


PCOS  is extremely prevalent and probably constitutes the most frequently encountered endocrine (hormone) disorder in women of reproductive age. Having the disorder may significantly impact the quality of life of women during the reproductive years, and it contributes to morbidity and mortality by the time of menopause.


What are the disorders associated with PCOS?


Polycystic ovary syndrome women are at increased risk for coronary heart disease and type 2 diabetes mellitus. Their risk factors include central obesity, hypertriglyceridemia, low levels of high-density lipoprotein (HDL) cholesterol, hypertension, and elevated fasting plasma glucose concentrations. Polycystic ovary syndrome women should undergo screening for hypertension, abnormal lipid profiles, insulin resistance, and reproductive disorders including cancer of endometrium.


What is PAO?


A subgroup of women (up to 30%) may have subtle abnormalities resembling Polycystic ovary syndrome  called PAO. While PCOS occurs in at least 5% of the population, the isolated finding of polycystic-appearing ovaries (PAO), which meets the classic ultra-sonographic criteria, occurs in 16–25% of the normal population without evidence of the full-blown syndrome. These characteristics include androgenic ovarian responses to stimulation with gonadotropins, as well as metabolic changes such as lowered high density lipoprotein-C levels and evidence of insulin resistance. While these data generated by our group need further assessment, these findings suggest that important yet silent abnormalities may exist in otherwise normal women who have a trait of Polycystic ovary syndrome (namely PAO).


What is the most important reproductive concern in women with PCOS?


The most frustrating reproductive concern for women with PCOS is pregnancy loss. The spontaneous abortion rate in Polycystic ovary syndrome is approximately one third of all pregnancies. This is at least double the rate for recognized early abortions in normal women (12–15%). Reasons for this are unclear although hypotheses include elevated LH levels, deficient progesterone secretion, abnormal embryos from atretic oocytes, and an abnormal endometrium.


How PCOS negatively impact psychosocial development of young women?


Women with PCOS, particularly those with hirsutism, have an increased prevalence of reactive depression and minor psychological abnormalities. There is also evidence of increased psychological stress and an increased catecholamine response to provoked stress. The overall quality of life is decreased in hirsute women. The presence of hirsutism and menstrual irregularities, especially in younger patients, is extremely distressing and has a significant negative impact on their psychosocial development.


Which cancer has increased risk in women with PCOS?


Women with Polycystic ovary syndrome are at increased risk of endometrial cancer. Chronic unopposed estrogen exposure is probably the proximate risk factor. This may be confounded by obesity, hypertension, and diabetes, which are known correlates of endometrial cancer risk. It is imperative to screen all women with Polycystic ovary syndrome, even those who are considered too young to develop endometrial hyperplasia and carcinoma.


Can low grade inflammation be a risk factor of PCOS?


Women with Polycystic ovary syndrome have significantly increased CRP concentrations relative to those in healthy women with normal menstrual rhythm and normal androgens. Inflammatory marker like CRP concentrations is more with PCOS. It correlates with the degree of obesity and inversely with insulin sensitivity, although not with total testosterone concentrations.

PCOS

PCOS


Which is a better predictor of metabolic syndrome in PCOS?


Obesity, a key determinant of insulin concentrations, appeared to have an independent effect on risk for the metabolic syndrome. In Anovulatory Polycystic ovary syndrome women a waist circumference of >83.5 cm along with biochemical evidence of hyperandrogenism is a powerful predictor of the presence of metabolic syndrome and insulin resistance. Age and central obesity (waist-hip ratio/waist circumference) are better predictors of metabolic syndrome in women with Polycystic ovary syndrome compared to other parameters including BMI.


How Metformin helps in PCOS?


Metformin is the most thoroughly investigated insulin-lowering agent used to treat PCOS; it enhances insulin sensitivity in the liver, where it inhibits hepatic glucose production, and in muscle, where it improves glucose uptake and use.

The persistence of regular ovulatory menstrual cycles in the 6 months after the end of treatment demonstrates that metformin treatment provides lasting benefits. All girls maintain a BMI <25 kg/m2, and this can play a role in normal ovulation menstrual cycles.


What is the role of AMH in diagnosis of Polycystic ovary syndrome ?


Serum anti-Mullerian hormone (AMH), produced in the ovaries by small follicles, is usually elevated in women with PCOS and correlates with the severity of this syndrome. AMH plays an important role in inhibiting follicular development by decreasing the sensitivity of the follicles to FSH and by inhibiting granulosa cell aromatase. Serum AMH appears as a sensitive and specific parameter that predict Polycystic ovary syndrome than antral follicle count and ovarian volume.

 


What is the source of DHEA in Polycystic ovary syndrome ?


Serum DHEAS has been found to be elevated in some women with polycystic ovary syndrome  . In Polycystic ovary syndrome , it has been found that there are actually two different sources of androgens, the ovary and the adrenal. In women with PCOS, the theca cells are overactive and proliferate excessively, producing too much testosterone. Unfortunately, in 40-50% of women with PCOS, there is also another source of androgens, which is the adrenal glands. The adrenal glands produce all of the DHEA in the body.


What causes PCOS in non-obese women?


All women with PCOS are not obese. Between 20–50% of women with PCOS are normal weight or thin, and the pathophysiology of the disorder in these women may differ from that in obese women. It has been suggested that PCOS develops in non-obese women because of a hypothalamic-pituitary defect that results in increased release of LH, and that insulin plays no role in the disorder.

These women tend to have an increased waist to hip ratio and are insulin resistant and hyperinsulinemic compared to their normal counterparts.


How the lean PCOS are treated?


Even normal weight and thin women with PCOS respond to pharmacological measures to improve insulin sensitivity, such as administration of agents like metformin, with decreases in ovarian androgen production and serum androgens. Administration of myoinositol (3 g per day) reduce luteinizing hormone (LH), high-sensitivity C-reactive protein (hs-CRP) (inflammation), and androgens, as well as improve insulin tolerance test, in lean patients with PCOS.


How infertility in PCOS treated?


 Lifestyle modification is very important in the treatment for PCOS, because weight loss and exercise have been shown to lead to improved fertility and the lowering of androgen levels. Ovarian stimulation along with insulin sensitizers help in many instances. IVF is an alternative option in Polycystic ovary syndrome . GnRH antagonist protocol appears to significantly reduce the rate of severe OHSS in these women. The average number of oocytes recovered is higher but rate of immature oocytes is more and fertilization rate is lower in the PCOS group.


Does IVM help in PCOS?


In-vitro maturation treatment can now be offered as a successful option to infertile women with polycystic ovaries or polycystic ovary syndrome. It is possible to combine natural cycle in-vitro fertilization with immature oocyte retrieval followed by in-vitro maturation, and thus offer women with various causes of infertility reasonable pregnancy and implantation rates without recourse to ovarian stimulation.


What is the effect of bariatric surgery in PCOS?


Bariatric surgery has been increasingly popular to treat morbid obesity associated with PCOS. In the larger population as the surgery has become safer with primarily a laparoscopic approach and selection of a healthier population for surgery, long-term survival is now superior with versus without the surgery.



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Heart Disease in Women

Heart Disease in Women

Heart Disease in Women


Ischaemic heart disease and stroke are the world’s biggest killers. These diseases have remained the leading causes of death globally in the last 15 years.


Why we should be worried about heart disease?


Ischaemic heart disease and stroke are the world’s biggest killers, accounting for a combined 15.2 million deaths in 2016. These diseases have remained the leading causes of death globally in the last 15 years.

Leading cause of death is Heart Disease

Leading cause of death


What are the traditional risk factors for Heart disease in women?


  • Diabetes mellitus
  • Hypertension
  • Dyslipidemia
  • Obesity
  • Physical inactivity
  • Smoking

What are the Non-traditional risk factors for Heart disease in women?


  • Pregnancy-Related Disorders and CVD Risk Association
    • Preterm Delivery
    • Hypertensive Pregnancy Disorders
    • Persistence of Weight Gain After Pregnancy
  • Autoimmune Diseases: Rheumatoid Arthritis and Systemic Lupus Erythematosus
  • Radiation and Chemotherapy for Breast Cancer
  • Depression

Symptoms of heart disease in women can also be confused with other conditions, such as depression, menopause, and anxiety.


What are the symptoms of heart disease in women?


Symptoms of heart disease in women can also be confused with other conditions, such as depression, menopause, and anxiety.

Common heart disease symptoms in women include:

  • indigestion or gaslike pain in the chest and stomach
  • cold sweats
  • dizziness
  • paleness
  • shortness of breath or shallow breathing
  • lightheadedness
  • fainting or passing out
  • anxiety
  • nausea
  • vomiting
  • Neck, jaw, back pain

What is Broken Heart Syndrome?


Stress-induced cardiomyopathy was first described in Japan in 1990 and was named after the octopus trapping pot with a round bottom and narrow neck, which resembles the left ventriculogram during systole in these patients.

It mainly affects postmenopausal women and is often preceded by extreme physical or emotional triggers. The clinical presentation, electrocardiographic findings, and biomarker profiles are often similar to those of ACS, but the coronary artery anatomy is found to be without significant obstructive disease at angiography.

The cause of Takotsubo cardiomyopathy remains unknown, but is thought to be related to a disproportionate distribution and activation of myocardial sympathetic receptors. The ventricular dysfunction, which usually involves the left, but may also involve the right ventricle, generally resolves within several weeks with supportive therapy, including β-blockade; however, especially in the presence of significant comorbidities, the outcome may not be benign.

Heart disease in women

Heart disease in women


What is the summary of  healthy diet ?


A healthy diet is low in:

  • sodium (salt),
  • added sugars,
  • solid fats,
  • refined grains.

Solid fats are saturated fat and trans fatty acids. Refined grains come from processing whole grains, which results in a loss of nutrients (such as dietary fiber).


What is DASH diet or eating plan?


The DASH eating plan requires no special foods and instead provides daily and weekly nutritional goals. This plan recommends:

  • Eating vegetables, fruits, and whole grains
  • Including fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils
  • Limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils
  • Limiting sugar-sweetened beverages and sweets.

How to choose healthy foods ?


When following the DASH eating plan, it is important to choose foods that are:

  • Low in saturated and trans fats
  • Rich in potassium, calcium, magnesium, fiber, and protein
  • Lower in sodium

What are the symptoms should not be ignored in women as warning of heart disease?


Dramatic chest pain may not be there for a women.

1.Unusual fatigue:

  • You are suddenly worn out after your typical exercise routine.
  • You aren’t exerting yourself, but have fatigue or a “heavy” chest.
  • Simple activity like making the bed, walking to the bathroom or shopping makes you excessively tired.
  • Although you feel exceptionally tired, you also experience sleep disturbance.

2. Sweating and/or shortness of breath:

  • Sudden sweating or shortness of breath without exertion
  • Breathlessness that continues to worsen over time after exertion
  • Shortness of breath that worsens when lying down and improves when propping up.

What are the symptoms you should look out for heart disease?

Chest pain may not be there for a women. If it is there it may suggests heart disease. If chest pain is not there then it does not exclude heart disease.There may be only discomfort , heaviness, sense of pressure or heavy weight.

You should carefully look out  for the following findings:

  • Women, in particular, can have pain in either arm — not just the left one like many men.
  • Pain in the lower or upper back often starts in the chest and spreads to these areas.
  • The pain is sometimes sudden, not due to physical exertion, and can wake you up at night.
  • You may feel pain that is specific to the left, lower side of the jaw.

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What is the right age for IVF ?

What is the right age for IVF ?

 What is the right age for IVF ?

Pregnancy Risk increases with age . IVF Success rate decreases with age.

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Success rate is less for women with IVF at  age more than 40 years because the quality of the eggs harvested in assisted techniques such as IVF deteriorates with age.

 

After which age fertility of a woman starts to fall by IVF and natural process ?


The ability to conceive starts to fall around the age of 32 years.  IVF Pregnancy risk  increases with age.

What are the chances of getting pregnant without IVF with respect to age?


  • After the age 32, a woman’s chances of conceiving decrease gradually and significantly.
  • After age of 35, the fertility reduces fast
  • By age 40, fertility has fallen by 50%.
  • At the age of 30 years, the chance of conceiving is about 20%.
  • At the age of 40 the chance of conceiving is around 5% only.

What are the risks of Pregnancy for older mothers?


Evidence demonstrates that it is increasingly difficult for women to become pregnant after the age of 35. It also said that women over 35 have a higher risk of miscarriage.

As women get older the number and quality of egg cells that are produced by the ovaries declines.

How successful is IVF for older women?


While in vitro fertilisation (IVF) can potentially help many women conceive, much like unassisted conception it is far less successful as women get older. The live birth rate for women under 35 undergoing IVF is 31%, but the success rate is less than 5% for women over 42 years of age.

Why success rate is less for women with IVF at  age more than 40 years?


Success rate is less for women with IVF at  age more than 40 years because the quality of the eggs harvested in assisted techniques such as IVF deteriorates with age. These techniques stimulate the release of more egg cells but cannot compensate for the effects of reproductive ageing on egg quality.

Can I postpone my pregnancy for few years


Newer preservation techniques are designed to freeze eggs from younger women and allow postponed pregnancy at a later age. Human oocyte cryopreservation (egg freezing) is a procedure to preserve a woman’s eggs (oocytes). This technique was mainly developed to enable women who, due to studies or any other complication can´t deal with pregnancy during their most fertile years, to postpone their maternity until their personal situation is the right to form a family.

 

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What are the health risks of late pregnancy?


  • Greater difficulty in initially conceiving a child.
  • Personal and psychological difficulties.
  • Increased risk of complications for both mother and infant during pregnancy and delivery .
  • Greater risk of general maternal health problems, such as high blood pressure, which can contribute to complications.
  • Higher risk of miscarriage in women above the age of 35.
  • Higher risk of having twins or triplets, which is itself associated with higher risk of complications.
  • More chance of having a baby with a congenital abnormality, such as Down’s syndrome.
  • Elevated risk of pre-eclampsia.
  •  Higher risk of complications during delivery, such as prolonged labor.
  •  Need for assisted delivery or Cesarean section is more.
  • Higher chances of stillbirth.
  • The risks of pregnancy and birth complications, caesarean section, increase with age.
  • Complications include-
    • gestational diabetes,
    • placenta praevia,
    • placenta abruption.
  • Older women are more likely to have a baby with birth defects or genetic abnormalities.
  • A woman over 35 is nearly 2.5 times more likely than a younger woman to have a stillbirth.
  • By age 40, she is more than five times more likely to have a stillbirth than a woman under 35.
  • For a woman aged 40 the risk of miscarriage is greater than the chance of a live birth.

Why risk of cesarean section is higher in elderly pregnant women?


Most older mothers experience normal labor and delivery. However, certain problems are more common in this age group, for example, placental abruption (premature separation of the placenta). Therefore, the rate of cesarean section is somewhat higher in older mothers.

What are the Genetic risks associated with pregnancy of elderly women?


Certain genetic risks present more often in pregnancy as women age. For example, the rate of having a baby with Down syndrome accelerates with maternal age.

While the rate of an embryo having Down syndrome at the 10-week mark of pregnancy is 1 in 1,064 at age 25, this rises to 1 in 686 at age 30 and 1 in 240 by the age of 35 years. At the age of 40, the Down syndrome rate increases still to 1 in 53, and down to 1 in 19 embryos at age 45.

What are the indications of egg freezing?


Oocyte cryopreservation can increase the chance of a future pregnancy for three key groups of women:

  1. those diagnosed with cancer who have not yet begun chemotherapy or radiotherapy;
  2. those undergoing treatment with assisted reproductive technologies who do not consider embryo freezing an option; and
  3. those who would like to preserve their future ability to have children, either because they do not yet have a partner, or for other personal or medical reasons.

What is the success rate of egg freezing followed by IVF?


The percentage of transferred cycles is lower in frozen cycles compared with fresh cycles (approx. 30% and 50%). Such outcomes are considered comparable.

Is genetic defect affected with egg freezing and IVF ?


Two recent studies showed that the rate of birth defects and chromosomal defects when using cryopreserved oocytes is consistent with that of natural conception.


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HIRSUTISM, EXCESS BODY HAIR IN FEMALE

HIRSUTISM, EXCESS BODY HAIR IN FEMALE

 

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By Femelife Fertility

Excessive growth of facial or body hair on women may be symptom of an underlying disorder. Dark and coarse hair may appear on the face, chest, abdomen, back, upper arms, or upper legs due to excess androgens in blood. Most common medical disorder causing hirsutism is PCOS (Polycystic Ovary Syndrome) accounting up to 10% of all cases.

Excessive growth of facial or body hair on women may be symptom of an underlying disorder.

Excessive growth of facial or body hair on women

 

Excessive growth of facial or body hair on women may be symptom of an underlying disorder. Dark and coarse hair may appear on the face, chest, abdomen, back, upper arms, or upper legs due to excess androgens in blood. Most common medical disorder causing hirsutism is PCOS (Polycystic Ovary Syndrome) accounting up to 10% of all cases. Prompt medical attention often improves the condition whereas delaying medication makes the treatment more difficult and may have long-term health consequences.

The Human Hair

The human hair follicle is a complex structure and much has not been learnt about it. The hair follicle can be divided into 3parts: the lower segment (bulb and suprabulb), the middle segment (isthmus), and the upper segment (infundibulum). The lower segment around 4mm in length stays below the skin surface. The middle segment is a short section and the upper segment extends from the entrance to the skin to outside. Hair grows continuously in a cyclical fashion and rate of hair growth differs according to its position. Human body is covered by small vellus hair throughout except the palm and sole. In contrast the scalp is covered by lengthy terminal hair. The number of hair follicle at birth is fixed for life and it is around 100000 follicles in the scalp and 50 million on the body on an average.

Growth Cycle of Hair

 Each hair grows from a follicle deep inside skin. Hair continues to grow even if it is plucked or removed as long as hair follicles are not completely destroyed. The number of hair follicles slowly begins to decrease at around age 40. Hair density varies by ethnic origin. Men and women of the same ethnic group have similar numbers of hair follicles and similar hair patterns. Asians and American Indians generally have less body hair than people of Mediterranean descent. Excessive hair that is due to genetic and ethnic variation is typically located on the arms, hands, legs, and feet, whereas hirsutism typically affects the face, abdomen, chest, inner thighs, and back.

Adults have two types of hair, vellus and terminal Vellus hair is soft, fine, generally colourless, and usually short. In most women, vellus hair covers the face, chest, and back and gives the impression of “hairless” skin. Terminal hair is long, coarse, dark, and sometimes curly and covers the face and body of men. Terminal hair grows on the scalp, pubic, and armpit areas in both men and women. A mixture of vellus and terminal hair covers the lower arms and legs in both men and women.

Hair growth occurs in cycles. While some hair follicles grow, others rest, and still others are shed. Hormonal changes, such as those associated with oral contraceptives (birth control pills) or pregnancy, may synchronize hair growth and make it appear to grow and shed more than usual. However, hair growth patterns usually return to normal within 6 to 12 months.

EFFECTS OF ANDROGENS ON HAIR GROWTH

Terminal hair that covers the face and body of men is usually the result of androgens. In men, androgens are produced primarily by the testes and the adrenal glands. In women, androgens are also produced but at a lower amount by the ovaries and the adrenal glands. Oestrogens, the female hormone reduces the effect of androgens in women. If vellus hair in women are sensitive to androgen then it may change to thick coarse terminal hair which grows faster. Once a vellus hair has changed to a terminal hair, usually it does not change back and is called hirsutism. Androgens increase sebum production, which results in oily skin and acne. Excess androgens in women can cause irregular or absent ovulation and menstruation. Extremely high androgen levels, such as when a tumor is present, may cause male-like balding, deepening of the voice, increased muscle mass, enlargement of the clitoris, and decreased breast size. These effects of excess androgens are called virilisation.

What causes hirsutism?

  1. Excessive production of androgens by the ovaries (polycystic ovary syndrome, tumor)
  2. Excessive sensitivity of hair follicles to androgens (genetic)
  3. Excessive production of androgens by the adrenal glands (non-classical adrenal hyperplasia [NCAH])
  4. Insulin resistance
  5. Hyperandrogenism, insulin resistance, acanthosis nigricans (HAIR-AN syndrome)
  6. Excessive production of cortisol by the adrenal glands (Cushing syndrome)
  7. Menopause
  8. Medications

Polycystic ovary syndrome is the most common cause of hirsutism and it is due to associated hormonal imbalances that cause the ovaries to overproduce androgens.

Unexplained Hirsutism

For unknown reasons, some women have hair follicles that are abnormally sensitive to androgens. Androgen levels are normal and menstrual periods occur regularly in these patients. This tendency to develop hirsutism is clearly genetic, but the exact abnormality is not known.

Ovarian or Adrenal Tumors

On rare occasions, an androgen-producing tumor may develop in the ovaries or adrenal glands. This tumor may produce extremely high androgen levels. Symptoms, such as hirsutism, usually appear suddenly and progress quickly. Very high androgen levels may cause male-like balding, deepening of the voice, and increased muscle mass. Fortunately, most of these tumors are not cancerous.

Menopause 

 Around the time of menopause, the ovaries stop producing estrogen but continue to produce androgens. The decreased levels of estrogen may allow the androgens to have a greater impact, leading to an increase in 8 the number of dark terminal hairs, especially on the face. For this reason, many menopausal women complain of new facial hair (moustache and whiskers) and mild balding.

Which drugs may cause hirsutism?

Drugs with characteristics of androgens may cause hirsutism. Anabolic steroids used to increase muscle mass in chronically ill and debilitated people and by some bodybuilders, are chemically related to androgens. Natural supplements such as DHEA may cause hirsutism. Danazol, phenytoin, minoxidil, and diazoxide are other medications associated with increased hair growth.

How Hirsutism is diagnosed?

Physicians trained to treat hirsutism and related problems generally include reproductive and medical endocrinologists. Some gynecologists, dermatologists, and general practitioners also have acquired the necessary expertise. After identifying the causes of hirsutism, physician can recommend appropriate treatment. Any unwanted hair remaining after treatment may be removed by a variety of cosmetic treatments, including laser and electrolysis.

Doctors might recommend an ultrasound or a CT scan to check ovaries and adrenal glands for tumours or cysts. Tests that measure the amount of certain hormones in blood, including testosterone or other testosterone-like hormones, might help determine whether elevated androgen levels are causing hirsutism.

What laboratory tests should be ordered for a patient with hirsutism?

Laboratory testing depends on the symptoms expressed by patients. Cases of mild hirsutism may be left alone without any investigations. However, serum levels of total and free testosterone, DHEAS, and 17-OHP can be useful tests, depending on the individual patient. Patients with signs or symptoms of hypothyroidism,

hyperprolactinemia, acromegaly, or Cushing syndrome also should be evaluated with serum thyroid-stimulating hormone (TSH), prolactin, IGF-I, or 24-hour urine cortisol testing, respectively.

How is hirsutism treated?

  1. Treatment of hirsutism is usually with a combination of oral contraceptive pills, spironolactone, other drugs like eflorinithine and cosmetic measures; however, other antiandrogens and gonadotropin-releasing hormone agonists can be used.
  2. Patients with polycystic ovary syndrome may have improvement of symptoms if they are treated with insulin sensitizers.
  3. Treatment of virilization is surgical removal of the tumor or steroid treatment for congenital adrenal hyperplasia.

How do you choose the appropriate therapy for hirsutism?

Most patients are given a trial of OCPs, with or without spironolactone, and are advised to use cosmetic measures while waiting for the medications to work. The topical cream eflornithine HCl may be used alone or in combination with other measures. Because of their more serious side effects and higher cost, the other medications are reserved for the most severe cases in which OCPs and spironolactone fail.

Whatever therapy may be chosen, the results do not last for more than 3 to 6 months. Although many medications and combinations have been used, only topical eflornithine HCl is currently approved by the Food and Drug Administration for treatment of hirsutism. Unfortunately, most patients have a relapse of hirsutism approximately 12 months after discontinuation of medical therapy.

What cosmetic measures can be used for the treatment of hirsutism?

Bleaching, shaving, plucking, waxing, depilating, and electrolysis are effective measures that can be used alone or in combination with medications. By these procedures terminal hair that is already present is removed. Simultaneous use of medications decrease new growth and rate of transformation to terminal hair. Laser-assisted hair removal is a commonly used method of treatment for hirsutism. It is done on outpatient basis using intense pulsed light therapy which cause thermal injury to the hair follicle. At least three to six treatments about 2 to 2.5 months apart are required. The techniques result in removal of hair, and a period of 2 to 6 months before the regrowth of hair, which is thinner and lighter. Patients with light skin and dark hair have the best results with the fewest side effects. The side effects include minimal discomfort, local swelling and redness lasting 24 to 48 hours.

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