Infertility is defined when a couple not being able to get pregnant after at least 1 year of unprotected sex (using no birth control methods) .Infertility affects about 10% of people in the reproductive age. Men and women both affects equally.

What causes the Infertility ?

There are different causes of infertility in men and female.

Infertility in female is due to following reasons:

1. Unable to survive fertilized egg or embryo in the uterus
2. Unable to move eggs from the ovary.
3. Unable to produced eggs

Infertility in men is due to following reasons : .

1. Low sperm count
2. Decreased movement of sperm

Causes of infertility in female includes :

1. Polycystic ovary syndrome(POCS)
2. Ovarian cysts
3. Myomas or fibroid
4. Polyps
5. Antiphospholipid syndrome
6. Anorexia nervosa( an eating disorder consisting of loss of appetite due to and emotional states such as anxiety,irritation , anger or fear. In anorexia nervosa there is no real loss of appetite, but rather a refusal to eat or an aberration in eating patterns, so that the term anorexia may be misnomer)
7. Obesity
8. Stress, depression
9. Excessive exercise
10. Dyspareunia
11. Turners syndrome
12. Defects of the uterus and cervix
13. Endometriosis
14. Pelvic inflammatory disease
15. Adrenal hormone deficiency
16. Thyroid hormone deficiency
17. Prolactinoma
18. Autoimmune disease
19. Scar tissue after surgery
20. Diabetes
21. Hypertension
22. Urinary tract infection
23. Smoking, heroin, cocaine and heavy alcohol consumption
24. Antibiotics , Antidepressants , acetaminophen , estrogen supplement
25. Chemotherapy
26. Radiation
27. Premature menopause

Causes of infertility in male includes :

1. Genetic abnormalities
2. Erectile dysfunction
3. Dyspareunia
4. Impotence
5. Retrograde ejaculation
6. No sperm
7. Anti-sperm antibodies
8. Cystic fibrosis
9. Varicocele
10. Undescended testis
11. Deficiency of testosterone
12. Klinefelter,s syndrome
13. Sexually transmitted disease includes chlamydia and gonorrhea.
14. Exposure to radiation and chemical
15. Smoking, heroin, cocaine and heavy alcohol consumption
16. Chemotherapy
17. Post operation scar
18. Hypothyroidism
19. Diabetes
20. Hypertension
21. Urinary tract infection
22. Spinal cord injuries
23. Drugs such as cimetidine, nitrofurantion, spironolactone

What are the signs and symptoms of infertility ?

Main signs and symptoms of infertility is the inability for a couple to get pregnant after at least 1 year of unprotected sex (using no birth control methods).

How is a infertility diagnosed ?

Diagnosis relies on clinical findings ,laboratory tests and radiological imaging.

Laboratory tests includes :

1. Serum progesterone analysis
2. Thyroid function tests
3. Luteinizing hormone test
4. Testosterone level
5. FSH and LH level
6. Estrogen level
7. Genetic testing
8. Blood glucose analysis
9. Complete blood test

Radiological imaging includes:

1. Hysterosalpingography
2. Pelvic ultrasound
3. Scrotal ultrasound
4. Pelvic CT scan
5. Laparoscopy

How is a infertility managed?

Management of infertility depends upon causes , duration of infertility and age of the women.

Treatment of infertility in women :

1. Drugs used for those who have ovulation disorders includes clomiphene, hMG( human menopausal gonadotropin , FSH( follicle-stimulation hormone), HCG(Human chorionic gonadotropin hormone), Gn-RH ( Gonadotropin-releasing hormone), metformin, Bromocriptine.
2. Treatment of STD s
3. Treatment of diabetes, hypertension, hypothyroidism.
4. Surgical management of tumors, Myomas , fibroid and Polyps
5. Assisted reproductive technology (ART is the procedure that involves manipulation of eggs or sperm to establish pregnancy) is indicated when women has a healthy uterus but medical treatment fails to achieve a pregnancy. ART includes IVF( in vitro fertilization, surgical sperm aspiration , ICSI( intracytoplasmic sperm injection), ZIFT( zygote intrafallopian transfer).

Treamtment of infertility in men :

1. Treatment of impotence
2. Treatment of STD s
3. Treatment of diabetes, hypertension and hypothyroidism
4. Surgical management of undescended testis, Varicocele .
5. ART

What is the prognosis of infertility?

About 60 % of couple become pregnant after appropriate treatments( exclude ART techniques) . Couple who are candidate of ART success rate is up to 27%.

References:

• http://www.emedicinehealth.com
• http://en.wikipedia.org
• http://www.mayoclinic.com
• http://www.medicinenet.com
• http://www.ncbi.nlm.nih.gov
• http://www.ehealthmd.com
• http://www.umm.edu
• http://www.fertilitycommunity.com
• http://www.cdc.gov

Related posts:

1. Premature ovarian failure
2. In vitro fertilization
3. HELLP Syndrome

Premature ovarian failure is the condition characterized by infertility, amenorrhea, hot flashes, night sweat, mood swings, irritability due to a loss of normal function of ovary before 40 years of old.

What cause the premature ovarian failure?

The exact causes of premature ovarian failure is still unknown but believed that it is associated with genetic disorder which include Turner’s syndrome .

What are the risk factors of premature ovarian failure?

1. Long term chemotherapy or radiation therapy
2. Smoking
3. Chemicals
4. Pesticides
5. Infection
6. Autoimmune disease

What are the signs and symptoms of premature ovarian failure ?

1. Irregular periods (amenorrhea) is the most common and first symptom
2. Hot flashes
3. Irritability
4. Night sweats
5. Difficulty concentration
6. Pain during sexual intercourse
7. Decreased sexual desire
8. Dryness of vagina
9. Fracture of bone
10. infertility

How is premature ovarian failure  diagnosed ?

Diagnosis relies on clinical presentation and laboratory tests .

Laboratory tests includes:

1. Follicle-stimulating hormone(FSH) level: FSH level is abnormally high in POS.
2. Luteinizing hormone (LH)level: LH level is lower than FSH in POS.
3. Serum estradiol level: Serum estradiol is low in POS.

How is premature ovarian failure managed?

The main goal is to prevent osteoporosis and relive symptoms of estrogen deficiency .Treatments includes :

1. Hormone replacement therapy(HRT) : HRT contain the combination of the hormones estrogen and progesterone and need to take till 50 years old .
2. Calcium and vitamin D: To prevent the osteoporosis.
3. In vitro fertilization may help in some people who have infertility.

What is the prognosis of premature ovarian failure ?

Prognosis of premature of premature ovarian failure is unpredictable.

References:

• http://www.emedicinehealth.com
• http://www.mayoclinic.com
• http://www.webmd.com
• http://www.nlm.nih.gov
• http://en.wikipedia.org
• http://www.medicinenet.com

Related posts:

1. Infertility
2. Meigs Syndrome
3. Dysmenorrhea( menstrual cramps)

Almost every menstruating women experience mild pain during mensuration ,but when the pain is severe enough that hampers the daily normal activities is diagnosed as dysmenorrhea. Dysmenorrhea , also called menstrual cramps is the pain in the pelvis and abdomen which are experienced by the women during her menstrual period .
Dysmenorrhea is divided into primary and secondary based on the absence or presence of underlying abnormal condition( usually involving a woman’s reproductive system) respectively.

What is the pathophysiology of dysmenorrhea ?
During mensuration prostaglandins is produced which causes the uterine muscles ischemia through vasocontriction and myometrial contraction. These constriction resulting temporary oxygen deprivation to tissue are the responsible for the pain in the primary dysmenorrhea.
Secondary dysmenorrhea is caused inflammation or infection in the woman’s reproductive organs .

What causes the dysmenorrhea?
Risk factors :
Primary dysmenorrhea:

1. Early age of menarche
2. Heavy or prolonged menstrual flow
3. Smoking
4. Positive family history
5. Obesity
6. Nulliparity
7. Lack of exercise
8. Retroverted uterus
9. Emotional stress

Secondary dysmenorrhea:

1. Endometriosis
2. Leiomyoma
3. Ovarian cysts
4. Adenomyosis
5. Pelvic Inflammatory disease
6. Presence of Intrauterine device.
7. Ovarian torsion
8. Tubo-ovarian abscess

What are the symptoms and signs of dysmenorrhea ?

1. Lower abdominal/pelvis pain during anytime of means and lasts 8-72 hours . Pain may radiate to the thighs or lower back.
2. Headache
3. Nausea , vomiting
4. Diarrhea
5. lower abdominal tenderness in physical examination .
6. Heavy menstrual flow or irregular bleeding .(secondary dysmenorrhea)
7. Dyspareunia ( Secondary dysmenorrhea)
8. Vaginal Discharge (Secondary dysmenorrhea)
9. Palpable uterine masses
10. Cervical motion tenderness ( Pelvic inflammatory disease)

How to diagnosed dysmenorrhea?
Primary dysmenorrhea is diagnosed by patients signs and symptoms, whether as secondary dysmenorrhea needs Laboratory studies and Imaging studies to find the disease that causes the dysmenorrhea.

How to managed dysmenorrhea?

1. Adequate rest and sleep
2. Regular exercise
3. Heating pad to the site of pain may relived pain.
4. Nutritional supplement with rich of omega-3 fatty acids, magnesium, vitamin E and B1.
5. Nonsteroidal anti-inflammatory drugs( ibuprofen, naproxen, ketoprofen , diclofenac) is the first line therapy to relive pain in both primary and secondary dysmenorrhea. If NSAIDS is contraindicated acetaminophen(paracetamol) may be useful .
6. Dilation and curettage may help to relive pain in those person whose pain cant relived by medicine.
7. The treatment of secondary dysmenorrhea is to managed its causes .

What is the prognosis of Dysmenorrhea?

With the use of NSAIDs prognosis of primary dysmenorrhea is excellent.Where the prognosis of secondary dysmenorrhea depends on the underlying disease process.

References:

• http://my.clevelandclinic.org
• http://www.emedicinehealth.com
• http://www.mayoclinic.com
• http://www.webmd.com
• http://www.nlm.nih.gov
• http://en.wikipedia.org
• http://www.medicinenet.com

Related posts:

1. Mittelschmerz

It is the pain in pelvic and lower abdomen which is experience in some women during ovulation, days between menstrual periods. It is also called ovulation pain, midcycle pain, menstrual, middle pain, or cramps. The word Mittelschmerz is a German word that means middle pain.

What causes the Mittelschmerz?

The exact cause of Mittelschmerz is unknown, but believed that this is due to fluid or blood that released from the ovary during, after and before ovulation which irritate the abdominal cavity, cause pain. Pain is relived when body absorbs the fluid or blood.

What are the symptoms of Mittelschmerz?

• Pain occurs on one side of the lower abdomen (can be either side).
• Sharp, cramping, distinctive pain which occurs midway between menstrual periods
• Pain lasts anywhere from a few hours to 2-3 days.
• Fever
• Vomiting
• Difficult or painful urination.
• Swollen abdomen.
• Difficulty breathing.
• Faintness or dizziness.

How to diagnosed Mittelschmerz?

There is no any test that can diagnose Mittelschmerz. Diagnosis solely relies on patient’s history but ultrasound need to be done to exclude other diseases or the pain is severe enough.

What is the management of Mittelschmerz?

1.Change lifestyle and home treatment:

• Exercise
• Fruits
• Soaking in a hot bath
• Using heating pad

2. Medical treatment ：

• Anti-inflammatory medication likes Ibuprofen, Naproxen, aspirin, ketoprofen is prescribed for pain.
• If pain is severe and occurs every month, oral contraceptive is prescribed in some women to prevent the ovulation.

What is the prognosis Mittelschmerz?

After the proper management prognosis of Mittelschmerz is excellent.

References:

• http://my.clevelandclinic.org
• http://www.babyhopes.com
• http://www.healthcentral.com
• http://www.emedicinehealth.com
• http://www.mayoclinic.com
• http://www.webmd.com
• http://www.nlm.nih.gov
• http://en.wikipedia.org

Related posts:

1. Dysmenorrhea( menstrual cramps)

Do you feel irritated with the littlest of things? Does your temper rise up at the most unexpected of times? Do you feel that you are losing your health and energy? Are you on the wrong side of 40? Well in that case you probably are suffering from menopause. All the above are common menopause symptoms typically experienced by women. There is nothing to get freaked out about. It is a stage in life that marks the beginning of a new level of maturity for you. Most women get freaked out and insecure about them during this phase and do everything in their capacity to lock age. All sorts of surgery operations, medicines, skin damage cream etc are used by them. That is however not the healthy way of dealing with the situation. This just increases the irritation and feeling of negativity.

Well you must have seen how the most beautiful of women mange to age gracefully. Let us take the example of Julie Andrews. She still looks as ravishing as before thanks to her inner confidence. Well the first step to aging gracefully is to treat menopause in the right way. The moment you cross 30 you will find a number of problems pertaining to your body. The first sign, being excessive drying of skin leaving it vulnerable to skin damage. You might also be experiencing heat flashes and night sweats.

You immediately have got to read the signs correctly and start maintaining a fitness regime. Eat a full and healthy diet every day. In case you are not into physical activity you should start on immediately. You could join a gym or aerobics class. But in case you can not find a proper gym or aerobics centre close by then you could start to go out regularly for morning walks or jogs.

Slowly you will be experiencing other menopause symptoms like irregular periods or extreme cramps in the lower back region. You could also be experiencing sudden quickening of the heart rate. You are officially in your perimenopausal stage. Gradually you will stop getting your periods. In this stage your ovaries produce less estrogen.  Estrogen is the hormone which is responsible for a number of functions in a woman’s body.  The process and also the symptoms of menopause can last for several years. The average age of menopause in women is the 40s or 50s. However this time might vary. But whenever you face menopause the important thing is that you deal with it the right way.

Related posts:

1. Male Menopause

Meigs syndrome is the triad of ascites, pleural effusion and benign ovarian tumor (fibroma) which resolves after resection of the ovarian tumor. The syndrome was named for Joe Vincent Meigs (1892-1963), a professor of gynecology at Harvard Medical School.

What is the pathophysiolgy?

1. Pathophysiolgy of ascites:  Exact pathophysiolgy of ascites is still unknown but different research suggested that irritation of the peritoneal surfaces by ovarian could stimulate the production of peritoneal fluid.
2. Pathophysiolgy of pleural effusion: the exact etiology of the pleural effusion is unclear but size of the pleural effusion is largely independent of the amount of ascites.

What are the signs and symptom of Meigs syndrome?

1. Fatigue
2. Shortness of breath
3. Increased abdominal size
4. Nonproductive cough
5. Weight loss
6. Amenorrhea for premenopausal women
7. Menstrual irregularity
8. Bloating
9. Tachycardia
10. Dullness of percussion of lungs
11. Abdominal examination may felt the mass
12. Present of ascites
13. Present of pelvic mass

What is the Differential Diagnosis of Meigs syndrome?

1. Liver failure (cirrhosis)
2. Congestive heart failure
3. Renal failure
4. Metastatic tumors
5. Malnutrition
6. Tuberculosis
7. Lung Cancer, Non-Small Cell
8. Ovarian Cancer

How to diagnose Meigs syndrome?

Diagnosis of Meigs syndrome is relies on Patients history, physical exam, lab test, Imaging studies and histologic findings.

Laboratory tests:

1. CBC, sodium, potassium, chloride, bicarbonate, blood urea nitrogen, creatatine, and glucose level need to be done before operation.
2. Tumor marker serum levels of CA-125 can be elevated in Meigs syndrome.

Imaging studies:

• X-ray confirm pleural effusion
• Ultrasound confirm the ascites and ovarian mass
• CT-scan for ascites, ovarian mass, and no signs of metastasis.

Histologic studies ： Histologic studies shows different type of benign tumor.

How to manage Meigs syndrome?

Management of Meigs syndrome consists of thoracentesis and paracentesis to drain off the excess fluid for symptomatic relief.

Unilateral salpingo-oophorectomy or wedge resection is the treatment of choice for Meigs syndrome.

What is the prognosis of Meigs syndrome?

After the surgery the prognosis is excellent.

References:

• emedicine.medscape.com
• www.nlm.nih.gov
• healthguide.howstuffworks.com
• www.mayoclinic.org
• www.patient.co.uk
• www.healthcentral.com
• www.wrongdiagnosis.com
• en.wikipedia.org
• books.google.com
• www.femalepatient.com

Related posts:

1. Premature ovarian failure
2. Dysmenorrhea( menstrual cramps)
3. HELLP Syndrome

Premenstrual syndrome is a condition characterized by a combination of variety of symptoms and signs including mood swings, tenderness of breasts, fatigue, irritability and depression that occur during the days before a woman’s period starts and usually go away after the first day or two of flow. The peak age of premenstrual syndrome is late 20s and early 30s. According to research 3 out of 4 menstruating women experience some form of premenstrual syndrome.

What causes the premenstrual syndrome?

The exact cause of premenstrual syndrome is still unknown, but most evidence suggests that PMS results from the alterations in or interactions between the levels of sex hormones and brain chemicals known as neurotransmitters.

What is the risk factor of premenstrual syndrome?

• High caffeine intake
• Stress
• Increasing age
• History of depression
• Family history
• Dietary factors (Low levels of certain vitamins and minerals, particularly magnesium, manganese, and vitamin E)

What are the signs and symptoms of Premenstrual syndrome?

1. Tension
2. Anxiety
3. Depressed mood
4. Mood swings and irritability
5. Anger
6. Depression
7. Insomnia
8. Dysmenorrhea
9. Poor concentration
10. Headache
11. Fatigue
12. Weight gain
13. Fluid retention
14. Abdominal bloating
15. Breast tenderness
16. Acne
17. Constipation or diarrhea
18. Frequent urination

How is Premenstrual syndrome diagnosed?

Diagnosis of premenstrual syndrome only relies on patients history .There are no unique physical findings or laboratory tests to diagnose the premenstrual syndrome.

How to managed premenstrual syndrome?

1.Diet and changes of life style :

• Small and frequent meals
• Limit salt
• Food rich in calcium
• Avoid caffeine and alcohol
• Regular exercise
• Enough sleep

2.Medical treatment:

Medical care of premenstrual syndrome (PMS) is primarily pharmacological and behavioral, with an emphasis on relief of symptoms, including:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen sodium to reduce the pain
• Antidepressants including fluoxetine, paroxetine, sertraline.
• Diuretics to reduce the weight gain and swelling which include Spironolactone
• Oral contraceptives are used to stop ovulation and stabilized hormone level.
• Gonadotropins-releasing hormone (GnRH) agonists to suppress the ovulation.
• Medroxyprogesterone acetate (Depo-Provera) is used in severe PMS to stop the ovulation.

3.Surgical Care:

In women who are severely affected, bilateral oophorectomy has been effective to alleviate symptoms because it renders the patient postmenopausal.

Reference:

• www.emedicinehealth.com
• emedicine.medscape.com
• www.medicinenet.com
• en.wikipedia.org
• www.nlm.nih.gov
• www.google.com/health

Related posts:

1. Mittelschmerz
2. HELLP Syndrome
3. Seasonal affective disorder (SAD)

HELLP syndrome is serious complication of pre-eclampsia or eclampsia.  HELLP syndrome is stands for Hemolysis, Elevated Liver enzyme levels and a Low Platelet count characterized by bleeding diathesis, liver problems and increased blood pressure. HELLP syndrome can threatens both mother and fetus.

The exact cause of HELLP syndrome is unknown but thought to be that it is due to activation of the coagulation cascade this leads to a microangiopathic hemolytic anemia. In HELLP syndrome not only RBC is consumed but also platelet consumed. Due to blood clot in small arteries, blood supply to liver cells is decreased and suffers ischemia, leading to periportal ischemia. HELLP syndrome leads to a variant form of disseminated intravascular coagulation (DIC), leading to paradoxical bleeding, which can make emergency surgery a serious challenge.

What are the symptoms of HELLP syndrome?

1. High blood pressure during pregnancy
2. Pain or tenderness in the upper right side of the stomach
3. Nausea or vomiting
4. Headache
5. Blurred vision
6. seizure
7. abnormal bleeding or clot formation due to DIC
8. oliguria or anuria due acute renal failure
9. Shortness of breath due to pulmonary embolism
10. coma

How HELLP syndrome diagnosed?

HELLP syndrome is diagnosed by patient’s history, physical examination and lab tests.

Lab tests includes:

1. Full blood count shows anemia and decreased platelets count.
2. Liver function test shows elevated levels of LDH, asparate aminotransferase (AST) ,alanine aminotransferase (ALAT) , glutathione S-transferase-a1 (α-GST or GST-a1) and bilirubin .

How to managed HELLP syndrome ?

Patient with HELLP syndrome need ICU setup. Several treatment strategies have been considered to be beneficial in stabilization of the disease but the only effective treatment is prompt delivery of the baby. Patient’s presents with seizure is managed with giving intravenous magnesium sulfate or diazepam. DIC is managed with fresh frozen plasma or fresh blood transfusion. In mild cases, corticosteroids and antihypertensive (hydralazine, and nifedipine) may be sufficient. One of the latest research shows that administration of postpartum dexamethasone resulted in the rapid resolution of the HELLP syndrome as measured by increasing platelet counts and decreasing LDH, AST, and ALT levels. Recurrence in the abnormalities in platelet counts and liver functions was not noted after completion of therapy in patients.

What is the prognosis of HELLP syndrome?

If HELLP syndrome is not treated properly up to 25% of women develop serious complication and a small number of women may die.

Related posts:

1. Meigs Syndrome
2. Premenstrual syndrome(PMS)

Nausea and vomiting (morning sickness) is common symptoms in any pregnancy. When these symptoms are severe which hampers the daily life and requiring hospital admission is called hyperemesis gravidarum.Hyperemesis gravidarum, also called HEG, is severe nausea and vomiting during pregnancy. Its results in dehydration, weight loss, unable to eat, and a disturbance in the acid-base balance in the body.

The exact cause of HEG is unknown but some studies shows that ,there may be a link between high level of estrogen or human chrionic gonadotrion , a hormone that helps the unborn bady to developed which is produced by placenta .

The risk of HEB seems less in elder women than the younger one .first pregnancy, twin , triplets pregnancy, previous HEG, overweight and trophoblastic disease of the womb are some risks factor for hyperemesis gravidarum

Symptoms or HEG are at peak at 8 to 12 weeks of pregnancy (high level of human chrionic gonadotrion in 8-12 weeks) and usually resolve by the 16^th to 17^th week. Commonly patients present with the long-lasting vomiting but some patients also have the symptoms like excess of saliva, weight loss, fatigue, headache, fainting, syncope, and weakness, loss of appetite, decreased concentration, irritability, mood changes, and impaired sense of taste.

Hyperemesis gravidarum is diagnosed by taking complete  history, Lab tests (Complete blood count, serum electrolytes liver enzymes and bilirubin, and urinalysis for ketone and specific gravity, ketone are a sign or starvation) and ultrasound to exclude and trophoblastic disease of the womb.

When patient is diagnosed as HEG admission is needed for further management. Patient is managed with giving nothing from mouth and giving IV fluid with adding vitamins and antiemetics drugs likes promethzine, hydroxyzine, prochlorperazine (2 -3 times a day ). In some refractory severe cases of hyperemesis gravidarum, if maternal survival is threatened, or if hyperemesis gravidarum is causing severe physical and psychological burden, termination of the pregnancy should be considered.When urine ketone is nil stop IV fluid and allows small meals per mouth and discharged with giving oral antiemetics drugs.

Hyperemesis gravidarum is self-limited and improves by the end of the first trimester but in some case symptoms may persist through 20-22 week of pregnancy, in rare cases, until delivery.

Reference:

• www.emedicinehealth.com
• emedicine.medscape.com
• www.medicinenet.com
• en.wikipedia.org
• www.nlm.nih.gov
• www.google.com/health

No related posts.

What is MRKH?

MRKH is a congenital disorder that affects the female reproductive tract. Congenital means that it is there at birth. About 1 in every 5,000-10,000 female babies has this condition. MRKH is a syndrome (group of symptoms). We do not know the cause of this syndrome but we do know that when a baby grows in the mother’s uterus (womb), systems develop. One of the systems is called the reproductive system, which includes the uterus, vagina, fallopian tubes, and ovaries. The reproductive system is formed during the first few months of “fetal” life (while a baby is still in her mother’s womb). With MRKH, the reproductive system starts to develop but doesn’t completely finish.

Girls with MRKH have normal ovaries and fallopian tubes. Most often the uterus is absent or tiny. The vagina is typically shorter and narrower than usual or it may be absent. Sometimes, there may be one kidney instead of two. About 3% of girls will have a minor hearing loss and some may have spinal problems such as scoliosis (curvature of the spine).

When is a girl likely to find out she has MRKH?

The most common age for MRKH to be diagnosed is when a young woman is between 15 and 18 years old. That’s when a young woman is likely to see her health care provider because she hasn’t started her period. Some girls may find out at an earlier age or when they are older.

What will happen at my doctor’s appointment?

Your doctor will probably ask you questions such as: “When did you notice that your body was changing…going through puberty?” Next, he/she may want to take a look at your outer female organs and also check to see how long your vagina is. Your doctor will gently put a Q-tip or gloved pinky finger at the opening of your vagina and then very slowly and carefully put it into the vagina to see how deep your vagina is. If your doctor thinks you might have MRKH, he/she will probably order a test called an ultrasound or an MRI (magnetic resonance imaging). These tests do not hurt and are similar to having an x-ray. Usually your doctor will have you see a specialist who has experience taking care of young women with MRKH. A pediatric and adolescent gynecologist is a doctor with special training in young women’s reproductive health.

What can a pelvic ultrasound or MRI show?

A pelvic ultrasound is usually the first test to check to see if a uterus or womb is present. This test can also confirm that you have two ovaries and two kidneys. Sometimes a very tiny uterus can be seen. A tiny uterus is called a “uterine horn or remnant”. You may need to have an MRI so that your doctor can see your female organs in more detail.

If I have an incomplete vagina, what are my options?

If you have been told that you have MRKH and your vagina is incomplete or absent, you have some options.

You can create a vagina without surgery using dilators
You can have a surgical procedure
You can do nothing
Creating a vagina with dilators

Most of the time girls with MRKH choose to make a vagina by using vaginal dilators. This treatment is very effective and “noninvasive” (does not have the risks of an operation). There are different kinds of dilators available and they come in different sizes. The most commonly used dilators look like a think plastic tube similar to a slender tampon. Starting with the smallest dilator you will learn how to hold the dilator and apply pressure to stretch your vagina. In the beginning, most of the dilator will be on the “outside” and used as a “handle” (as it can only go in so far). You will use the dilator for about 15-20 minutes, twice a day. Over time, you will begin to notice that the dilator is able to go into your vagina a bit further. This means you have made progress! As your vagina stretches, your doctor will know when to give you the next size. The next size will be slightly wider.

Surgery to create a vagina

McIndoe procedure- This is the most common surgical procedure to make a vagina. A vagina is created with a skin graft usually from your buttocks (bottom) or with a special skin-like material and a vaginal mold. Young women who have this procedure must stay in bed, in the hospital for about a week so that the newly created vagina will heal. A soft dilator must be worn all the time for a while, taking it out only to pass urine or poop. Even though a vagina is created faster with surgery, it is still necessary to use a dilator. Surgery to create a vagina should not be thought of as a “quick fix solution”.

Bowel vagina- This is a major operation which involves making a vagina using a section of the bowel. The advantage of this procedure over the McIndoe operation is that you don’t have to stay on bed rest for a week. The disadvantage is that girls who opt for this procedure will likely have chronic vaginal discharge.

Other surgical procedures to create a vagina include:

the Frank technique
Willams vulvovaginoplasty
the Vecchietti procedure
Waiting or doing nothing

You are the one who should be in control of your body. Deciding to make or not make a vagina should be your decision and if you decide you want to, when should be your decision too! If you are not planning to have vaginal intercourse, it is not something you need to do. If you plan to have vaginal intercourse now or in the future, making a vagina is something you might want to do.

How often do I need to see my doctor?

It is VERY important to keep appointments with your doctor so he/she can check your progress (whether you have decided to use dilators or have surgery). If you decide to use dilators, your doctor will need to check that you are applying pressure in the right place. As your vagina stretches, your doctor will give you the next (slightly bigger) dilator.

How long will it take to create a vagina with dilators?

The average amount of time it takes to create a vagina (if the dilator is used at least 15-20 minutes, twice a day) is about 3-14 months. It can take less time for some young women or more time for others. If the dilators are not used every day, it can take a year or more. For more information, read the following guide: Instructions on the Use of Vaginal Dilators.

A recent study done at Children’s Hospital Boston found that 88% of girls who chose to use dilators consistently to make a vagina, were able to do so within a year and a half.

Do the dilators hurt?

Using dilators to create a vagina shouldn’t hurt. Remember, you have control over the amount of pressure that you apply. You should get used to applying enough pressure so the skin will stretch but you should not be in pain.

When should I start to create a vagina?

There is no right or wrong time to create a vagina. The decision to start or not to start should be yours. You may be ready to start using dilators when you are in high school or you may decide to wait until you are older. Some questions to ask yourself: Do I have time in my day to use the dilator?”; “Do I have privacy?”; “Am I comfortable touching myself?”, “When do I plan to become sexually active?”

What if the dilators don’t work or I just can’t use them?

Most girls can learn to use a dilator and have success in creating a vagina. Sometimes, it can take a while until you feel comfortable using it. If you have any questions or wonder if you are using the dilator correctly, be sure to ask your doctor or nurse specialist. In some cases, if your doctor feels that little progress has been made, he or she may suggest that you take a break for a while and try again later. Dilator treatment is the standard, most efficient and nonsurgical treatment for MRKH; it is recommended by the American College of Obstetricians and Gynecologists (ACOG) as the first choice of treatment to create a vagina for girls with MRKH. Surgery should only be considered if dilators have been tried (under the supervision of a gynecologist who specializes in treating young women with MRKH).

Why might I have pelvic (belly) pain each month?

Some women with MRKH may have a tiny uterus called a “uteri or uterine remnant”. The uterus or womb is not big enough to carry a baby but it can cause pelvic pain if blood from this small uterus goes into the belly. Your doctor will be able to tell if you have a small uterus and if it needs to be taken out. If you have belly pain, it is important to tell your doctor.

Can anyone tell that I have MRKH?

Some young women wonder if anyone can tell if they have MRKH. The answer is no. No one, except you and your doctor, can tell that you were born with an incomplete vagina and following treatment, with dilators or surgery, your sexual partner will not be able to feel any difference.

Will I be able to have children?

If you were born with an incomplete vagina but have a normal size uterus, it is likely that you will be able to become pregnant and deliver a baby.

If you were born without a uterus or if your uterus is tiny, you will not be able to “carry” a pregnancy. Since your ovaries are normal and make eggs, an egg can be fertilized with your partners’ sperm. Someone else such as; your sister, friend, or another person you choose, could be the surrogate mother. Surrogate mothers are women who agree to carry a pregnancy for a couple. You and the baby’s father would be the biological parents of this child. Adoption is another choice for some couples. Fertility options are improving every day. By the time you are ready to have children, there may be more options available to you.

Is there anyone else I can talk to about having MRKH?

Some young women find it helpful to talk with a parent(s), while other girls prefer to talk with a counselor or a close friend. We know that it can be very helpful to talk with someone your own age that has MRKH. The Center for Young Women’s Health at Children’s Hospital Boston offers free monthly chats for young women with MRKH.

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Several drugs are currently used to assist in the therapeutic induction and augmentation of labor. Therapeutic induction implies that labor is initiated by the use of a drug. Augmentation indicates that labor has stared and that process is further stimulated by a therapeutic agent.

Oxytocin, the natural hormone produced for the posterior pituitary, is widely used to induce and augment labor .Several synthetic forms of oxytocin can be used by intravenous routes. Recently prostaglandins (F2α and E2) have also been used to induce and augment labor and cervical ripening .prostaglandins promote dilatation and effacement of the cervix and can be used for various reasons intravaginally, intravenously, or intra-aminiotiacally. An other therapeutic agent being tested for efficacy in labor induction and augmentation is mifepristone (RU-4860, a progesterone receptor blocker (used as abortive drugs in first trimester) .It is used to induce labor and to increase the sensitivity of the uterus to oxytocin and prostaglandins. An additional and interesting feature of these drugs is that they reduce postpartum hemorrhage by causing muscle contractions.

References:

• Harrison’s Principles of Internal Medicine, 17th edition.
• Davidson’s Principles and Practice of Medicine, 20th Edition
• Medical physiology, Lippincott Williams & Wilkins 3rd edition

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Candidates for vitro fertilization (IVF) are women with disease of the oviducts, unexplained infertility, or endometriosis (occurrence of endometrial tissue outside the endometrial cavity, a condition that reduces fertility), and those whose male partners are infertile (e.g., low sperm count). Follicular development is induced with one or a combination of GnRH analogs, clomiphene, recombinant FSH, and Menopausal gonadotropins (a combination of LH and FSH). Follicular growth is monitored by measuring serum estradiol concentration and by ultrasound imaging of the developing follicles. When the leading follicle is 16 to 17 mm in diameter and/or the estradiol level is greater the 300 pn/mL, hCG is injected to mimic an LH surge and induced final follicular maturation, including maturation of the oocyte. Approximately, 34 to 36 hours later, oocytes are retrieved from the larger follicles by aspiration using laparoscopy or a transvaginal approach. Oocyte maturity is judged from the morphology of the cumulus (granulose) cells and the presence of the germinal vesicle and first polar body. The mature oocytes are then placed culture media.

The donor’s sperm are prepared by washing, centrifuging, and collecting those that are most motile. About 1000,000 spermatozoa are added for each oocyte. After 24 hours, the eggs are examined for the presence of two pronuclei (male and female). Embryos are grown to the four-to eight- cell stage; about 60 to 70 hours after their retrieval form the follicles. Approximately three embryos are often deposited in the uterine lumen in order to increase the chance for a successful pregnancy. To ensure a receptive endometrium, daily progesterone administrations begin on the day of retrieval. A successful pregnancy rate of 15 to 25% has been reported by many groups, which compares favorably with that of natural human pregnancy.

References:

1. Medical physiology, Lippincott Williams & Wilkins 3rd edi.
2. Harrison’s Principles of Internal Medicine, 17th edition.
3. Davidson’s Principles and Practice of Medicine, 20th Edition

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