COUPLES WHO WISH CHILDREN
[Full descripsion]
BACKGROUND.
Reproductive and sexual health are at the core of people’s lives and well-being. The ability to develop in a supportive environment and grow into a sexually responsive and responsible adult, the ability to enjoy one’s sexuality without harming or infecting oneself or one’s partner, and the ability to have children by choice are among the unique attributes that define us as human..
A strong focus on reproductive and sexual health is justified not only on the ground of human right, equity, and social justice. There are strong public health argument, too, since reproductive ill-health contribute in such large measure to global burden of disease.
The purpose of this writing is to give information on reproductive ill-health in popular style, rather than technical style about the topic:
COUPLES WHO WISH CHILDREN.
BACKGROUND.
Reproductive and sexual health are at the core of people’s lives and well-being. The ability to develop in a supportive environment and grow into a sexually responsive and responsible adult, the ability to enjoy one’s sexuality without harming or infecting oneself or one’s partner, and the ability to have children by choice are among the unique attributes that define us as human..
A strong focus on reproductive and sexual health is justified not only on the ground of human right, equity, and social justice. There are strong public health argument, too, since reproductive ill-health contribute in such large measure to global burden of disease.
The purpose of this writing is to give information on reproductive ill-health in popular style, rather than technical style about the topic:
COUPLES WHO WISH CHILDREN.
This writing is based on the experience of the writer to help and to treat the COUPLES WHO WISH CHILDREN to have children since 1969,40 years ago, while the writer was a physician [MD] in Sibolga General Hospital and Chief of Municipality Health Services in Sibolga City,Tapanuli,North Sumatra, Indonesia.
Emphasis has always been placed upon the clinical application of knowledge derived from anatomy, physiology, pathology, pharmacology, and others medical references, as well as the experience of the writer as a physician [MD] since 1965.”Experience is the best teacher” as the saying goes.
The basic principle of writing is in popular style have been based on situation, problem, solution and evaluation. Be this is may be writing has been of value for reviewing by the postgraduate physician, and it also served the “just graduate “physicians the nurses, the midwifes, paramedical workers, and to whom it may concern.
I am grateful to many associates, students, and correspondents from many parts of the world who have made helpful criticisms and suggestions. Thanks are due to my colleague Dr Halim Wibisono, Drs Sutejo Muliodiharjo, Mudiyono and Arif for reviewing portion of the manuscript and computer processing.
THE SITUATION.
There are 14 % of reproductive-age women; 5 million couples in the United States of America are childless or infertile. Infertility is defined as the inability to conceive after 12 months of unprotected sexual intercourse.[Harrison's. Manual of Medicine, 2005, p 846].
A study in South-eastern Bangladesh, examined the extent to which couples preference for male babies could be preventing a further decline in fertility through an impact on contraceptive use that determines fertility rates. Married couples-over 7500 “just married” couples,
in fact were also the subject of a prospective study carried out in Shanghai, China. Results published in 2000 showed that despite a high rate of contraceptive use [about 80 % of married couples], half of the couples with one child had experienced one or more unintended pregnancies following the birth of their first child . It may be because of sex preference male or female babies birth and contraceptive failure. [WHO Geneva.2002, p 11].
In patriarchal culture societies there are the tendencies of couples preference for male babies; and in matriarchal culture societies the tendencies of couples preferences for female babies.
Picture: "Just married" couple want child soon or
birth spacing, honey year instead of honey
moon ?
birth spacing, honey year instead of honey
moon ?
Source: B.P.S.,SDKI, Indonesia, 2007, P 4.
Picture: A beautiful bride with a nice traditional
dress; is she a matriarchal bride ?
Source:B.P.S.,SKRRI, Indonesia, 2007, p cover.
What are we talking about? In these texts we are talking about:
Infertility, childless, couples who wish children.
Couples preference for male babies.
Couples preference for female babies.
Couples "just married" after birth spacing or honey year wish or want children.
THE PROBLEM
What is the problem ? Einstein once said that the most important act of thinking a person can do is to define a problem, because anyone can work out a solution.
Can we help or treat the infertile couples to have children births ? Yes, we can.
Can we help or treat the couples preference male births? Yes, we can.
Can we help or treat the couples preference female births ? Yes, we can.
How serious a problem is it ?
There are 14 % of reproductive age women infertility in USA, it is estimated about 120 million couples are infertile in the worldwide.
Every year about 210 million women become pregnant, it is estimated that more than a half or about 110 million couples preference male births and less than a half or 100 million preference female as well as preference indifference births.
Some 340 million cases of curable sexually transmitted infections [STIs] caused mainly by bacteria, are estimated to occur worldwide every year, the STIs may cause the infertility for the couples transmitted infections. In many countries, STIs are among the top five conditions for which men and women seek care and thus considerable drain on resource-strapped health services.
[WHO.Geneva, 2002, p 31].
THE SOLUTION
How to solve the problems? What is to be has been done ?
Theoretical problems in the sciences [physics, chemistry etc. ] have exact solutions which can eventually be found. However, with real life problems, an absolute solutions not always possible; a compromise or partial solution often to be found, according to the methods and technologies available. The approach and steps of solution reflect our common efforts providing people with the information and services need to manage their fertility or infertility,
depict as follows: Picture: A Balinese Barong dancer
with a nice funny dress, Bali,
Indonesia; is he a patriarchal man?
Indonesia; is he a patriarchal man?
1. The sex chromosomes.
2. Male reproductive system.
3. Female reproductive system.
4. Fertilization and pregnancy.
5. Infertility in the female.
6. Infertility in the male.
7. Examination and diagnosis.
8. Treatment of infertility in the female.
9. Treatment of infertility in the male.
10. Advise for couples to have children births.
11. Advise for couples to have preference male births.
12. Advise for couples to have preference female births.
13. Making pregnancy saver.
14. Normal pregnancy and delivery
15. Curable sexual transmitted infections [STIs].
1.THE SEX CHROMOSOMES.
Sex is determined genetically by 2 chromosomes called the sex chromosomes to distinguish them from the other somatic chromosomes [autosomes]. It is now clear that in man there are 46 chromosomes : in males, there are 22 pairs of autosomes plus a large X chromosome and a small Y chromosome ; in females, there are 22 pairs of autosomes plus 2 X chromosomes.
When a sperm [male gamete cell] containing a Y chromosome fertilize an ovum [woman egg cell], an XY pattern results an the zygote develops into a genetic male. When fertilization occurs with an X-containing sperm, an XX pattern and a genetic female result.
Because the human Y chromosome is smaller than the X chromosome, it has been hypothesized that the sperms containing the Y are lighter and able to “swim” faster up the female genital tract, thus reaching the ovum more rapidly. This supposedly accounts for the fact that the number of males born is slightly greater than the number of females.
2.THE MALE REPRODUCTIVE SYSTEM.
The testes are made up a series of convoluted seminiferous tubules along the wall of which the spermatozoa are formed from the primitive germ cells [spermatogenesis]. The tubules drain into a network of ducts in epididymis. From there , spermatozoa pass into the vas deferens. They enter through the ejaculatory ducts into the urethra in the body of the prostate at the time of ejaculation. Between the tubules in the testes are nests of cells containing lipid granules, the interstitial cells of Leydig, which secrete testosterone into the blood stream.
Effect of temperature
Picture:The male reproductive system Source:William F. Ganong.
Medical Physiology,
California,1971, p 318
Spermatogenesis requires a temperature considerably lower than that of the interior of the body .When testes are in the scrotum, they are kept cool enough for spermatogenesis to proceed normally. When they are retained in the abdomen or when, in
Spermatogenesis requires a temperature considerably lower than that of the interior of the body .When testes are in the scrotum, they are kept cool enough for spermatogenesis to proceed normally. When they are retained in the abdomen or when, in
experimental animals, they are held close
to the body by tight cloth binders, degeneration of the tubular walls and sterility
result.
Spermatozoa are first produced at puberty and spermatogenesis activity is maintained into old age, so that there is no definite end to reproductive life in the male.
Semen
The fluid that is ejaculated at the time of orgasm, the semen, contains sperms and the secretions of the seminal vesicles, prostate, Cowper’s glands, and the urethral glands. The volume per ejaculate is 2-5 ml after 3 days of continence. There are normally about 80-120 million sperms / ml of semen, even though it takes only one sperm to fertilize the ovum. Human sperms move at the speed of 3 mm/ min through the female genital tract.
Composition of human semen:
result.
Spermatozoa are first produced at puberty and spermatogenesis activity is maintained into old age, so that there is no definite end to reproductive life in the male.
Semen
The fluid that is ejaculated at the time of orgasm, the semen, contains sperms and the secretions of the seminal vesicles, prostate, Cowper’s glands, and the urethral glands. The volume per ejaculate is 2-5 ml after 3 days of continence. There are normally about 80-120 million sperms / ml of semen, even though it takes only one sperm to fertilize the ovum. Human sperms move at the speed of 3 mm/ min through the female genital tract.
Composition of human semen:
Picture: The structure of the testis
Color: White opalescent. Specific gravity: 1.028.pH: 7.3-7.5.
Sperm count: Average about 100 million/ ml, .with fewer than 20 % abnormal forms.
Other components: Fructose, ascorbic acid from seminal vesicle [60 % of total volume]. Citric acid , cholesterol, phospholipids, fibrinolysin, fibrinogenase and prostaglandins from prostate [20 % of total volume]. Phosphate and bicarbonate as buffers.
Fructose is an important constituent of the medium in which spermatozoa are stored in vitro for use in artificial insemination.
Sperm count: Average about 100 million/ ml, .with fewer than 20 % abnormal forms.
Other components: Fructose, ascorbic acid from seminal vesicle [60 % of total volume]. Citric acid , cholesterol, phospholipids, fibrinolysin, fibrinogenase and prostaglandins from prostate [20 % of total volume]. Phosphate and bicarbonate as buffers.
Fructose is an important constituent of the medium in which spermatozoa are stored in vitro for use in artificial insemination.
The key diagnostic test in a semen analysis: Sperm counts of less than 13 million /ml, motility of less than 32 % , and less than 9 % normal morphology are associated with subfertility. Testosteron levels should be measured if the sperm count is low on repeated exam.
[Source:Harrison's Manual of Medicine.2005,p 837.]
[Source:Harrison's Manual of Medicine.2005,p 837.]
Picture: Female reproductive system, side view.lateral or side view.
Source: William F.Ganong, 1971, p 324
3. FEMALE REPRODUCTIVE SYSTEM.
Picture : Female reproductive system, the right side is front view, and the upper left side is
lateral or side view.
The female reproductive organs consist of the ovary, Fallopian or uterine tube, uterus and vagina.
Menstrual cycle:
The reproductive system of the female, unlike that of male, shows regular cyclic change that happen may be regarded as periodic preparation for fertilization and pregnancy. In human being, the cycle is a menstrual cycle, and its most conspicuous feature is the periodic vaginal bleeding that occurs with the shedding of the uterine mucosa [menstruation].
The length of the cycle is notoriously variable in women, but an average figure is 28 days from the start of one menstrual period to the start of the next. By common usage, the days of the cycle are identified by number, starting with the first day of menstruation.
Ovarian cycle or ovulation:
Under the ovarian capsule there are from the time of birth many primordial follicles, each containing an immature ovum. At the start of each cycle, several of this follicles enlarge and a cavity forms around the ovum. In humans, one of the follicles in one ovary starts to grow rapidly on about the sixth day, while the others regress. At about the 14th day of cycle, the distended follicle ruptures and the ovum is extruded into the abdominal cavity. This is the process of ovulation. The ovum is pick up by the fimbriae ends of the fallopian tubes and transported to the uterus , and, unless, fertilization occurs, it goes out through the vagina. Follicle which enlarge but fail to ovulate degenerate, forming atretic follicles.
The ovum lives for approximately 72 hours after it is extruded from the follicle, and the sperms apparently survive in female genital tract for no more 120 hours. Consequently, the fertile period during a 28 day cycle [period of menses] is actually 120 hours in length; and the most fertile period is 48 hours before ovulation.
Source:William F.Ganong.Medical Physiology,California, 1971, p 324
4. FERTILIZATION AND PREGNANCY.
In human fertilization of the ovum by the sperm usually occurs in the midpoint of the uterine tube. Penetration of the ovum by the sperm and the initiation of the cell division, which begin at once, may be brought about by lysosomal enzymes in the acrosome [head] of the sperm. Only one sperm penetrate the ovum, because once the ovum has been fertilized a barrier forms around it that normally prevents other sperms from entering.
The developing embryo, now called a blastocyst, moves down the tube into the uterus. Once in contact with the endometrium [of uterus], the blastocyst becomes surrounded by the outer layer of syncytio-trophoblast, which it erodes the endometrium, and the blastocyst burrows in to it [implantation].The implantation side is usually on the dorsal wall of the uterus. A placenta then develops and the trophoblast remains associated with it.
As pregnancy advances the products of conception increase in size and eventually occupy the whole of the uterus cavity, the growing embryo [foetus] attached by its umbilical cord to the placenta is bathed by amniotic fluid which is contained within the “bag of membranes” consisting of the amnion. The function of the amniotic fluid is to provide space for embryo growth and movements and to distribute the pressure due to uterine contractions evenly over the embryo.
Endocrine change:
In women , the corpus luteum in the ovary at time of fertilization fails to regress and instead enlarges in response to stimulation by gonadotropic hormones secreted by the placenta. The placental gonadotropin in humans called human chorionic gonadotropin [hCG].The enlarged corpus luteum of pregnancy secretes estrogens and progesterone. There are degenerative changes in corpus after the fifth month, but it persists through out pregnancy; hCG secretion decreases after an initial marked rise, but estrogen and progesterone secretion increases until just before parturition.
5. INFERTILITY IN THE FEMALE.
4. FERTILIZATION AND PREGNANCY.
In human fertilization of the ovum by the sperm usually occurs in the midpoint of the uterine tube. Penetration of the ovum by the sperm and the initiation of the cell division, which begin at once, may be brought about by lysosomal enzymes in the acrosome [head] of the sperm. Only one sperm penetrate the ovum, because once the ovum has been fertilized a barrier forms around it that normally prevents other sperms from entering.
The developing embryo, now called a blastocyst, moves down the tube into the uterus. Once in contact with the endometrium [of uterus], the blastocyst becomes surrounded by the outer layer of syncytio-trophoblast, which it erodes the endometrium, and the blastocyst burrows in to it [implantation].The implantation side is usually on the dorsal wall of the uterus. A placenta then develops and the trophoblast remains associated with it.
As pregnancy advances the products of conception increase in size and eventually occupy the whole of the uterus cavity, the growing embryo [foetus] attached by its umbilical cord to the placenta is bathed by amniotic fluid which is contained within the “bag of membranes” consisting of the amnion. The function of the amniotic fluid is to provide space for embryo growth and movements and to distribute the pressure due to uterine contractions evenly over the embryo.
Endocrine change:
In women , the corpus luteum in the ovary at time of fertilization fails to regress and instead enlarges in response to stimulation by gonadotropic hormones secreted by the placenta. The placental gonadotropin in humans called human chorionic gonadotropin [hCG].The enlarged corpus luteum of pregnancy secretes estrogens and progesterone. There are degenerative changes in corpus after the fifth month, but it persists through out pregnancy; hCG secretion decreases after an initial marked rise, but estrogen and progesterone secretion increases until just before parturition.
5. INFERTILITY IN THE FEMALE.
A couple is said to be infertile:
1. If pregnancy does not result after one year of normal marital relations
without contraceptives;
2. if the woman conceives but aborts repeatedly;
3. if the woman bears one child but aborts repeatedly or fails to conceive
2. if the woman conceives but aborts repeatedly;
3. if the woman bears one child but aborts repeatedly or fails to conceive
thereafter.
14 % [10-15 %] of marriages are childless. In about 58 % of cases this is attributable to the female partner, 25 % attributable to the male partner and 17 % unexplained. Treatment may correct infertility but not sterility, which is absolute inability to reproduce.
Ovulation and conception may occur at any time from the menarche to the menopause. Conception is most likely to occur during the period of reasonably regular ovulation, which begin after adolescence and usually terminate before the menopause.
Female infertility may be due to the following causes:
Nutritional: Hypovitaminosis, protein deficiency, and iron deficiency anemia may cause infertility.
Endocrine : Hypopituitarism/hypothalamic may causes ovary failure to ovulate. Hypothyroidism results in anovulation , infertility, and abortion.
Infections: Vaginitis, cervicitis, endometritis of uterus mucosa and tuba uterine infection.
Tumor: Cervical tumors [polips, myomas]; uterine tumors [polyps, myomas]; ovarian tumors [follicle cysts, corpus luteum cysts] may disrupt function or destroy the ovary.
Congenital:uterine hypoplasia, tubal congenital atresia, ovarian agenesis.
6. INFERTILITY IN THE MALE.
14 % [10-15 %] of marriages are childless. In about 58 % of cases this is attributable to the female partner, 25 % attributable to the male partner and 17 % unexplained. Treatment may correct infertility but not sterility, which is absolute inability to reproduce.
Ovulation and conception may occur at any time from the menarche to the menopause. Conception is most likely to occur during the period of reasonably regular ovulation, which begin after adolescence and usually terminate before the menopause.
Female infertility may be due to the following causes:
Nutritional: Hypovitaminosis, protein deficiency, and iron deficiency anemia may cause infertility.
Endocrine : Hypopituitarism/hypothalamic may causes ovary failure to ovulate. Hypothyroidism results in anovulation , infertility, and abortion.
Infections: Vaginitis, cervicitis, endometritis of uterus mucosa and tuba uterine infection.
Tumor: Cervical tumors [polips, myomas]; uterine tumors [polyps, myomas]; ovarian tumors [follicle cysts, corpus luteum cysts] may disrupt function or destroy the ovary.
Congenital:uterine hypoplasia, tubal congenital atresia, ovarian agenesis.
6. INFERTILITY IN THE MALE.
Male reproductive ability begins at about age 16.After approximately age 45 , fertility decreases, although men over 80 have fathered children.
Male infertility may due to the following causes:
1. Spermatozoal abnormalities :.The normal values of semen [spermatic fluid] are as follows:
Volume:2.5-5 ml; pH:7.4; viscosities: moderate thin after 30 minutes. Motility [26.5 degree C] : More than 70 % motile at ejaculation; 60 % at 2 hours;25-40 % at 6 hours. Count: 50-120 million / ml. Morphology: Fewer than 30 % abnormal spermatozoal head. Color: Whitish, semi-gelatinous fluid.
Key diagnostic test is a semen analysis: Sperm counts of less than 13 million / ml, motility of less than 32 %, and less than 9 % normal morphology are associated with subfertility.[Harrison’s Manual of Medicine, 2005, p 837] .
High fertility is assume to exist when the sperm count approaches 185 million / ml.[Ralph C. Benson .Obstetrics & gynecology, 1971, p667].
Spermatozoa survive longest in alkaline cervical secretions and are destroyed quickly if they remain in the acid vaginal fluid. Motility is arrested at pH 6.0 and motility does not return after sperms have been exposed to a pH less than 4 and will die.
2. Endocrine: Hypopituitarism or Hypogonadism and hypothyroidism are associated with infertility.
3. Most instances of mechanical obstruction [congenital, inflammatory, or traumatic] in epididymides and vas deferens occur here.
4. Varicocele may increase scrotal temperature and thus impair spermatozoal maturation.
5. Infection: Sexually transmitted disease such as gonorrhoe, syphilis, chlamydia, trichomoniasis may cause infertility.
6. Erectile dysfunction [ED] is the failure to achieve erection, ejaculation or both..
It effects 10-25 % of middle age and elderly men. Diabetic, atherosclerosis and drug related cause account for more than 80 % of cases of ED in older men.
7. EXAMINATION AND DIAGNOSIS
Successful treatment of infertility is possible only if an early and accurate diagnosis can be established. This requires an energetic and systematic approach by the clinician and the cooperation of both partners over a period of at least 3 months, with 4 office visits for the wife and 2-3 for the husband, both partners usually can be evaluated and the cause of infertility
Male infertility may due to the following causes:
1. Spermatozoal abnormalities :.The normal values of semen [spermatic fluid] are as follows:
Volume:2.5-5 ml; pH:7.4; viscosities: moderate thin after 30 minutes. Motility [26.5 degree C] : More than 70 % motile at ejaculation; 60 % at 2 hours;25-40 % at 6 hours. Count: 50-120 million / ml. Morphology: Fewer than 30 % abnormal spermatozoal head. Color: Whitish, semi-gelatinous fluid.
Key diagnostic test is a semen analysis: Sperm counts of less than 13 million / ml, motility of less than 32 %, and less than 9 % normal morphology are associated with subfertility.[Harrison’s Manual of Medicine, 2005, p 837] .
High fertility is assume to exist when the sperm count approaches 185 million / ml.[Ralph C. Benson .Obstetrics & gynecology, 1971, p667].
Spermatozoa survive longest in alkaline cervical secretions and are destroyed quickly if they remain in the acid vaginal fluid. Motility is arrested at pH 6.0 and motility does not return after sperms have been exposed to a pH less than 4 and will die.
2. Endocrine: Hypopituitarism or Hypogonadism and hypothyroidism are associated with infertility.
3. Most instances of mechanical obstruction [congenital, inflammatory, or traumatic] in epididymides and vas deferens occur here.
4. Varicocele may increase scrotal temperature and thus impair spermatozoal maturation.
5. Infection: Sexually transmitted disease such as gonorrhoe, syphilis, chlamydia, trichomoniasis may cause infertility.
6. Erectile dysfunction [ED] is the failure to achieve erection, ejaculation or both..
It effects 10-25 % of middle age and elderly men. Diabetic, atherosclerosis and drug related cause account for more than 80 % of cases of ED in older men.
7. EXAMINATION AND DIAGNOSIS
Successful treatment of infertility is possible only if an early and accurate diagnosis can be established. This requires an energetic and systematic approach by the clinician and the cooperation of both partners over a period of at least 3 months, with 4 office visits for the wife and 2-3 for the husband, both partners usually can be evaluated and the cause of infertility
Picture:Tubal insufflation test [Rubin test]
The first picture, both tuba uterin are patent, front view.
The second picture, right tube is occluded, and left tube is patent, front view.
The third picture is lateral or side view,with stethoscop on the left side.
Source: Ralph C. Benson.OBSTETRICS &GYNECOLOGY, 4th edition, 1971, p 670-671
determined. Obscure or multiple causes of infertility may require more time and special technique of investigati
on.
The initial evaluation include discussion on the appropriate timing of intercourse, semen analysis in the male, confirmation of ovulation in the female, and, in majority of situations documentation of tuba uterine patency in the female.
A history of regular, cyclic, predictable, spontaneous menses usually indicates ovulatory cycles, which may be confirmed by urinary ovulation predictor kids, basal body temperature [BBT] graphs, or plasma progesterone measurements during the luteal phase of the cycle.
Tubal insufflation [Rubin test] to the wife..
The test is a safe office procedure in properly selected patients if CO2 [carbon dioxide] is employed and if the pressure is kept below 200 mm Hg [mercury]. Tubal insufflation [TI] at or about the time of ovulation is most likely to be revealing and successful. Auscultation over the lower abdomen during insufflation may disclose the whistle of gas passing through one tubal ostium or the other.
TI is indicated in the investigation of:
1.Primary or secondary infertility and
2.As a means of nonoperative tubolysis well after subsidence of salpingitis, appendicitis etc.
If tests of tubal patency were unsatisfactory, hysterosalpingography is done.
Utero-tubal insufflation in infertile patients has both diagnostic and therapeutic value. Reported successful TI is known to enhance the likelihood of pregnancy.
Contraindications of TI are pregnancy, recent genital tract infection, uterine bleeding, recent dilatation and curettage or other uterine surgery, and serious cardiopulmonary disease
The woman receives a complete physical and pelvic examination.
The husband’s general physical examination, with emphasis on the genital and rectal examination, is done next. Penile, urethral, testicular, epididymal , and prostatic abnormalities are sought. Spermatozoal analysis is repeated on the third visit if the previous study was abnormal.
Testicular biopsy is indicated if oligospermia or azoospermia [very low sperm count analysis] is present.
8. TREATMENT OF INFERTILITY IN THE FEMALE.
The treatment of infertility should be tailored to the problems unique to each couple, treatment in all cases depend upon correction of the underlying disorder or disorders suspected of causing infertile and wishing children.
Nutritional : protein, energy, vitamin and mineral deficiencies must be corrected
Good nutrition for stability of body weight, requires that energy and protein intake, vitamins and minerals are balanced over time. The average energy intake is about 2800 kcal/ day for men and about 1800 kcal/ day for women, the protein need is about one gram/ kg body weight per day, though these estimates vary with age, body size and activity level.
on.The initial evaluation include discussion on the appropriate timing of intercourse, semen analysis in the male, confirmation of ovulation in the female, and, in majority of situations documentation of tuba uterine patency in the female.
A history of regular, cyclic, predictable, spontaneous menses usually indicates ovulatory cycles, which may be confirmed by urinary ovulation predictor kids, basal body temperature [BBT] graphs, or plasma progesterone measurements during the luteal phase of the cycle.
Tubal insufflation [Rubin test] to the wife..
The test is a safe office procedure in properly selected patients if CO2 [carbon dioxide] is employed and if the pressure is kept below 200 mm Hg [mercury]. Tubal insufflation [TI] at or about the time of ovulation is most likely to be revealing and successful. Auscultation over the lower abdomen during insufflation may disclose the whistle of gas passing through one tubal ostium or the other.
TI is indicated in the investigation of:
1.Primary or secondary infertility and
2.As a means of nonoperative tubolysis well after subsidence of salpingitis, appendicitis etc.
If tests of tubal patency were unsatisfactory, hysterosalpingography is done.
Utero-tubal insufflation in infertile patients has both diagnostic and therapeutic value. Reported successful TI is known to enhance the likelihood of pregnancy.
Contraindications of TI are pregnancy, recent genital tract infection, uterine bleeding, recent dilatation and curettage or other uterine surgery, and serious cardiopulmonary disease
The woman receives a complete physical and pelvic examination.
The husband’s general physical examination, with emphasis on the genital and rectal examination, is done next. Penile, urethral, testicular, epididymal , and prostatic abnormalities are sought. Spermatozoal analysis is repeated on the third visit if the previous study was abnormal.
Testicular biopsy is indicated if oligospermia or azoospermia [very low sperm count analysis] is present.
8. TREATMENT OF INFERTILITY IN THE FEMALE.
The treatment of infertility should be tailored to the problems unique to each couple, treatment in all cases depend upon correction of the underlying disorder or disorders suspected of causing infertile and wishing children.
Nutritional : protein, energy, vitamin and mineral deficiencies must be corrected
Good nutrition for stability of body weight, requires that energy and protein intake, vitamins and minerals are balanced over time. The average energy intake is about 2800 kcal/ day for men and about 1800 kcal/ day for women, the protein need is about one gram/ kg body weight per day, though these estimates vary with age, body size and activity level.
Additional vitamins which support better fertility is better gives to the women as such as:
1.Vitamin A 20 000 IU per oral [PO] daily. Since the lack of vit A interferes with the process of ovulation, an adequate dietary supply of this vitamin necessary for normal fertility.
2.Vit E-alpha tocopherol 100 IU , per oral once daily. If vit E deficiency in female, ovarian function is normal but uterine physiology is disturbed. There is partial failure of implantation, and the fertilized ova implanted grow and develop only to a certain stage , at which time the embryo show generalized hemorrhage, die, and is aborted or resolved. Administration of vit E during the first half of gestation permits normal embryo development and parturition.
3.Vit C 500 mg , per oral once daily. Vit C is concerned fundamentally with the formation of intercellular substances, including the collagen of fibrous tissue structures, the matrices of bone, cartilage, and dentin, and all non epithelial cement substance, including of vascular endothelium. Administration of vit C, within a few hours rapid repair of tissues in wounds and bone fractures, and is an important factor in determining resistance to infection.
Source: Philip B. Hawk, Ph.D., Sc. D. [Hon].Practical Physiological Chemistry, McGraw-Hill, New York, 1954, p 1104-1296.
Treatment of endocrine disorders.
1. Estrogenic hormone: Estradiol 1 mg once daily for the 6th-11h day of the woman menses, this hormone will stimulate the ovulation on the 14th day of menses, and hope the next menses on the 28th day of menses.
2. Clomiphene citrate is administered in dose of 100 mg/ day for 5 days. Clomiphene is used in the treatment of disorder of ovulation in patient who wish children. Usually, a single ovulation is induced by a single course of therapy, and the patient must be treated repeatedly until pregnancy is achieved. The compound is no of value in patients with pituitary failure.
3. The gonadotropins are produced by a single type of pituitary cell..These hormones serve complementary functions in the reproductive process. The follicle stimulating hormone [FSH] and luteinizing hormone [LH] from anterior pituitary gland control the function of ovary. The FSH is responsible for the early maturation of the ovarian follicles; that FSH and LH together are responsible for their final maturation. The doses begin with 75 IU FSH plus 75 IU LH [one ampule] intramuscular daily for 9-12 days. If pregnancy still does not result, increase the dose to 2 ampules daily for 9-12 days.Human menopausal gonadotropins [hMG] is known as menotropins consist of
4 Human menopausal gonadotropins [hMG] is known as menotropins consist of FSH 75 IU and LH 75 IU for subcutaneous or intramuscular injection. Its mechanism of action is to induce maturation of follicles and expulsion of ova.
5. Treatment of hypothyroidism with combination of levothyroxin[TY] and liothyronine [T3].Levothyroxine 25 microgram per oral daily for 2 weeks, increasing the daily dose by 25 microgram for the next 2 weeks. Liothyronine 5 microgram daily for 2 weeks such as levothyroxine.
Surgical measures correction of congenital, tumors, for the lower genital tract. Surgical
excision of ovarian tumors restore fertility. Surgical relief of tuba uterine
obstruction due to salpingitis will reestablish fertility.
Sodium bicarbonate 500 mg two times one gram per oral daily will induce the secretion of cervix, uterus and tuba uterine become base or alkaline which are favorable media for sperma to “swim” which facilitate fertilization.
Base-forming foods.Diet with a large amount of vegetables and fruits on burning outside or inside the body leave an ash or residue in which the basic elements [sodium, potassium, calcium, and magnesium] predominate; where as cereals, meat, and fish foods leave an ash in which the acid forming elements [chlorine, phosphorus, and sulfur] predomite.Such foods are spoken of a base forming and acid forming foods, respectively, and will influence the acid-base balance of the body, particularly [the cervix, uterus, and tuba uterine] can produce the alkaline secretion , which favorable for sperms life and motility, and then facilitate fertilization and pregnancy.
Source: Philip B.Hawk et al. Practical Physiological Chemistry, McGraw-Hill, NewYork, 1954, p 1097 and Appendix IV, p 1357-1364.
The best position of the wife in intercourse on fertile period is genu-pectoral or knee-chest following by the husband on the upperside. The reason is that the semen ejaculated directly to the cervix hole and go down to the uterine cavity on the lower than normal position.
9. TREATMENT OF INFERTILITY IN THE MALE
Androgenic preparations are used when normal spermatogenesis is to be achieved. Androgen preparation for replacement therapy:
Methyltestosteron per oral 25-50 mg daily; sublingual ] 5-10 mg /day.
Fluoxymesterone per oral 10 mg / day or;
Testosterone, transdermal 2.5-10 mg/ day; or
Testosterone topical gel [1 %] 5-10 g gel / day; or
Testosteron intramuscular [IM] 30-60 mg daily for the husband, on the 5th day-11th day of the menses of his wife. Large dose of testosterone depress spermatogenesis, but if stop or intermittent low dose may be of value of some patients or relief the oligosperm. Harvey and Jackson have attributed the beneficial effect to more efficient erection and ejaculation and to improvement in the quality of the semen. Androgen therapy is contraindicated in patients with carcinoma of the prostate .
Source: Cecil & Loeb. A Textbook of Medicine, W.B. Saunders Company, USA, 1959, p 753.
Human chorionic gonadotropin [hCG] is injected IM at a dose of 75-150 units three times per week.
Treatment hypothyroidism with levothyroxine 50-100 microgram per day and liothyronine 10 microgram per day.
Sodium bicarbonate 500 mg per oral one gram twice daily, has the effect to induce alkaline the secretion of seminal vehicle, prostate and Cooper's gland which is favorable for spermatozoa media to move or propulsion.
Vitamin support spermatogenesis and strength of sperm motility:
Vitamin A 20 000 IU per oral daily and vitamin E 100 IU per oral daily , the purpose of these two vitamns are to stimulate spermatogenesis in the testes.
Neurotropic and neuronmyalgic vitamins such as tablet neurodex, consist of vitamin B1 100 mg, B6 200 mg and B12 250 microgram. The purpose of these vitamins are to strengthen motility of sperms in the semen of the husband and in the secretion of genital tract of his wife, and then to facilitate fertilization.
All of these vitamins can strengthen the health of the husband too.
Treatment of erectile dysfunction with testosreron 30-60 mg IM injecton or sildenafil [viagra brand name of Pfizer] per oral one hour before intercourse.
10.ADVICE FOR COUPLES TO HAVE CHILDREN BIRTHS.
Ovulation occurs approximately 14 days before the onset of the next menstrual period regardless of the length of time between period; when the cycle is regular, the time of ovulation and the fertile period can be anticipated.
The ovum lives for approximately 72 hours after it is extruded from the follicle and the sperms survive in female genital tract no more 120 hours [5 days].Consequently, the fertile period during in 28 day cycle [period of menses]is actually 120 hours [5 days] and the most fertile period is 24 hours [one day] at the day of ovulation .
The couple intercourse on the day of ovulation is most likely to result in pregnancy.
What does it mean?
The couple intercourse in the 5 days fertile period or in 10-14th day of menses may result fertilization, and in 14th day of menses is the most fertile period result of fertilization or pregnancy. The writer advice the couples to do a few intercourses on the day of ovulation if the couples fit to do , the more ejaculated hundreds million sperms on ovulation day will result of pregnancy.
If the menses cycle is 30 days, the fertile period is in the 12-16th days, and the most fertile period is on the 16th day, please do a few intercourse as you always fit to do, hopeful result pregnancy.
If oligosperm is present, the artificial insemination usually results in pregnancy, assuming female reproductive system is normal.
If medication treatment to the couples have not responded, the next step is to consult the patient to the Gynecologist for assisted reproductive technologies [ART] treatment. What are the ART ? The ART are techniques involving the direct retrieval of eggs from the ovary. Most of these procedures require ovarian stimulation with timed retrieval of oocytes [ova].
What is in vitro fertilization [IVF] ? the IVF is extraction of oocytes [through the vaginal wall under ultrasound guidance], fertilization in vitro in the laboratory, and trans-cervical transfer of the embryo into the uterus 2 days later. Usually requires 100 000 to 200 000 sperm per egg.
What are the indication of the IVF ? Previously damaged tubes, immunologic infertility [anti-sperm antibodies], extreme male factor infertility and unexplained infertility.
What is intracytoplasmic sperm injection [ICSI]?
Retrieval of oocytes followed by the injection of a single spermatozoon into the egg with a micropipette: embryos are then transferred to the uterus 2 days later.
What is indication for ICSI ? Oligospermia, sperm motility disorders.
The information of couples preference male or female, it seems not yet available in ART, IVF and ICSI.
Source: F. John Bourgeois et al. Obstetrics and Gynecology Recall, Virginia, 2008, p 509.
If treatment is not successful within 3 years, the physician must consider whether he should recommend adoption.
11. ADVISE FOR COUPLES TO HAVE PREFERENCE MALE BIRTHS.
Advise to the couples with 28 days of menstrual cycle. The ovulation occurs approximately on the 14th day of menses, the fertile period is in the 10-14th day of menses cycle, the last intercourse after wife menses is on the 8th day; please stop intercourse in 9-13th day of menses, and do intercourse a few times on the 14th day or on ovulation day as the couple feel fit , hopeful result male pregnancy. The reason is that the motility of the male genetic 22Y sperms are faster move than the female genetic 22X sperms to meet and fertilize the ovum on the ovulation day.
If the menses cycle is 30 days, the fertile period is in the 12-16th day of menses, the ovulation occurs on the 16th day, the last intercourse after wife menses is on the 10th day, please stop intercourse in 11-15th day of menses; and do intercourse a few times on the 16th day or on ovulation day, hopeful result male pregnancy.
12. ADVISE FOR COUPLES TO HAVE PREFERENCE FEMALE BIRTH.
Advise to the couples with 28 days of menstrual cycle. The ovulation occurs approximately on the 14th day of menses, the fertile period is in the 10-14th day of menses cycle, the last intercourse after wife menses is on the 8th day; please stop intercourse in 9-13th day of menses, and do intercourse a few times on the 14th day or on ovulation day as the couple feel fit , hopeful result male pregnancy. The reason is that the motility of the male genetic 22Y sperms are faster move than the female genetic 22X sperms to meet and fertilize the ovum on the ovulation day.
If the menses cycle is 30 days, the fertile period is in the 12-16th day of menses, the ovulation occurs on the 16th day, the last intercourse after wife menses is on the 10th day, please stop intercourse in 11-15th day of menses; and do intercourse a few times on the 16th day or on ovulation day, hopeful result male pregnancy.
12. ADVISE FOR COUPLES TO HAVE PREFERENCE FEMALE BIRTH.
Advice to the couples with 28 days of menstrual cycle. The ovulation occurs on the 14th day of menses, the fertile period is 10-14th day, the life of genetic male 22Y sperms is approximately 3 days, the life of female genetic 22X sperm is 5 days. The couple last intercourse after menses is on 10th day, please stop intercourse in 11-15th day, hopeful result female pregnancy. The reason is that the life of genetic male 22Y is 3 days, while stop intercourse in 11-15th day, the 22Y male sperms die on 13th day of menses, but the female genetic 22X sperms still live for next 2 days on 14-15th day, wait and fertilize the ovum on the 14th day of ovulation, hopeful result female pregnancy.
Advise to the couples with 30 days of menstrual cycle. The ovulation occurs on the 16th day of menses. The last intercourse after menses is on 12th day, please stop intercourse in 13-17th day, hopeful result female pregnancy. The reason is that the life of genetic 22Y male sperm is 3 days will die on the 15th day , but the genetic female 22X sperms are still live for the next 2 days in 16-17th day, wait and fertilize the ovum on the 16th day of ovulation, hopeful result female pregnancy.
EVALUATION.
Advise to the couples with 30 days of menstrual cycle. The ovulation occurs on the 16th day of menses. The last intercourse after menses is on 12th day, please stop intercourse in 13-17th day, hopeful result female pregnancy. The reason is that the life of genetic 22Y male sperm is 3 days will die on the 15th day , but the genetic female 22X sperms are still live for the next 2 days in 16-17th day, wait and fertilize the ovum on the 16th day of ovulation, hopeful result female pregnancy.
EVALUATION.
The evaluation answers the questions:
How good is the solution?
What is the comments of the reader ?
What is the answers of the writer ?
The answers of the writer for problems solutions are:
1. Can we help or treat the infertile couples to have children? Yes, we can ! How do we help them? The details of the solution were described on the steps [5-10] about the cause and treatment of infertility in the male and female; and then give advice to the couples to do the intercourse in the period of fertile 5 days before ovulation [extruded of female egg], and to do a few intercourses on the ovulation day 14th day of menses as the couples always feel fit, the most fertile day and the most likely result pregnancy. The others day are usually non fertile and free to do intercourse.
2. Can we help or treat the couples preference male births? Yes, we can! How do we help the couples? The details of the solution were described on the step 11 of solution, and give advice to the couples to stop intercourses 5 days before ovulation, and to do a few intercourses on the ovulation day, the most likely result of male pregnancy. The reason is that the genetic male 22Y is faster move than the genetic sperm 22X to the uterus and tuba uterine to meet and fertilize the ovum on the ovulation day and result male pregnancy. The others day are usually non fertile, and free to do intercourse.
3. Can we help or treat the couples preference female births ? Yes, we can ! The details of the solution were described on the step 12 of solution; and give advice to stop intercourse for 5 days [3 days before ovulation plus on the day of ovulation and one day after ovulation], hopeful result of female pregnancy .The others day are usually non fertile, and free to do intercourse.
4. What is the data of the treatment? The writer has experiences to help or treat the couples who wish children since 40 years ago, but no statistical data available. There is information, it is said that experience of Jules Black from Australia had the statistic said that the success of the treatment is 85%.
Source: VCD, PC. SOFTWARE .”Kesehatan Keluarga” [Family’s health]
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