Acupuncture, a form of alternative medicine is the stimulation of specific acupuncture points along the skin of the body using thin needles. It is commonly used for pain relief, though it is also used to treat a wide range of conditions. Acupuncture is rarely used alone but rather as an adjunct to other treatment modalities. In Western settings acupuncture is used as a primary intervention for fertility problems. Acupuncture is increasingly used as an adjunct to assisted reproductive technologies and more widely in the complementary health care system.
The Western medical acupuncture approach involves using acupuncture after a medical diagnosis. In traditional acupuncture, the acupuncturist decides which points to treat by observing and questioning the patient to make a diagnosis according to the tradition used.
This method has always been applied to reproductive treatment in China. Western medicine may exert influence on neuroendocrine system, immunological functions and even signal pathway in consideration when discussing the efficacy of acupuncture and these still continue to be studied. The Chinese medicine evaluates the effect of acupuncture from an overall perspective. In Chinese medicine, reproductive function relates not only to reproductive organs, but also to the kidney, the liver, and the heart.
Acupuncture can be used as an adjuvant treatment for unexplained infertility. Although acupuncture did not increase the cumulative pregnancy rate, it decreased the number of control ovarian hyperstimulation (COH) cycles and more patients got pregnant in natural cycles after receiving acupuncture (Tab. 1).
Acupuncture treatment procedures should happen once or twice a week, and will continue for anywhere from a few weeks to a few months. Remember the process may take more time than just twice a week if you are combining it with medical infertility treatments, like IVF. In general, the acupuncture treatment can be completed in 12 appointments. At each appointment, your acupuncturist will most likely take additional time to discuss your current condition and answer any questions that you may have.
Anorexia nervosa (AN) is a complex and frequently intractable illness of unknown etiology that is often chronic and disabling. It is characterized by aberrant feeding behaviors, an extreme pursuit of thinness and emaciation, and body image distortions. Onset tends to occur during adolescence.
AN is often associated with denial of illness and resistance to treatment. Consequently it is difficult to engage individuals with AN in treatment, including nutritional restoration, and weight normalization. The continuous restrictive eating and malnutrition result in pervasive disturbances of most organ systems including cardiovascular and gastrointestinal complications, endocrine disorders (i.e. osteopenia (bone weakening) and amenorrhea), and other metabolic alterations.
It is well known that patients with AN, compared to healthy controls, tend to eat significantly fewer calories by restricting caloric intake and avoiding calorie dense foods. Individuals with AN show many unusual eating behaviors like slow and irregular eating, vegetarianism, and choosing a narrow range of foods.
Without weight restoration, patients may face serious or even fatal medical complications of severe starvation. However, the process of nutritional rehabilitation can also be risky to the patient. The refeeding syndrome, a problem of electrolyte and fluid shifts, can cause permanent disability or even death. It is essential to identify at-risk patients, to monitor them carefully, and to initiate a nutritional rehabilitation program that aims to avoid the refeeding syndrome. A judicious, slow initiation of caloric intake, requires daily management to respond to entities such as liver inflammation and hypoglycemia that can complicate the body's conversion from a catabolic to an anabolic state.
Administration of nutrients (Tab. 1) should be done slowly, starting with no more than 500 kcal/day in the form of a complete liquid diet for several days, then gradually increasing the caloric load in a step-wise mater. People at high risk are those with BMI < 12, those who vomit, abuse laxatives and binge and those with physical comorbidity. In such severe cases, strict monitoring is required, and it may take a month or more to restore body weight, not necessarily to normal weight, but to an acceptable level (usually a 10% gain in weight) that can be followed by oral feeding on an outpatient basis.
Caloric requirements in AN patients are high and vary between 30–40 kcal/kg/day (up to 70–100 kcal/kg/day) for inpatients, and 20 kcal/kg/day for outpatients; after the first phase of treatment it is possible to achieve a weight gain of 1–1.5 kg/week in the inpatient setting and of 0.5 kg/week in the outpatient setting. Also, for maintenance, AN patients need higher caloric amounts - around 50–60 kcal/kg/day - than the general population. This increased caloric requirement may be due both to exercise – often a hallmark of this illness - and metabolism.
It has been suggested that the AN patient should be eating calorie dense food to replenish the necessary nutrients. Daily intake of foods containing protein of high biological value, such as whey and casein, and egg whites, that contain a high concentration of essential amino acids per gram and calorie density, should be recommended. Consuming small amounts of protein of high biological value, in conjunction with the protein source foods that are perceived as less challenging by AN patients (usually of a vegetable source), can help assure a faster restoration of nutrient status even in a continued state of reduced body weight. Additionally, a variety of protein food sources including fleshy fish and poultry should be encouraged.
Recommended Daily Allowances (RDA’s) for vitamins and minerals vary by age and gender, but can be met by intake of a multivitamin/multimineral tablet or liquid. Placing the emphasis on nutrient requirements, achieved through food intake, as opposed to caloric intake, may help to lessen the anxiety and resistance to refeeding observed in AN patients.
Nutrition restoration is a core element in treatment because of the need to restore weight in order to avoid severe physical complications and to improve cognitive function to make psychological interventions useful and effective.
Weight loss or anorexia can also cause hormonal imbalance. Sex hormones are affected in both male and female patients with anorexia nervosa. These patients have low levels of hypothalamic gonadotropin releasing hormone (GnRH) and low levels of pituitary luteinizing (LH) and follicle stimulating hormone (FSH), estrogen and testosterone. These abnormalities affect potency, fertility. It is possible that this mechanism evolved to protect the mother’s health. A pregnancy where the mother is weak could pose a risk to the baby’s and mother’s health.
Hallmark of anorexia nervosa is secondary amenorrhea too and weight restoration is the mainstay of treatment for amenorrhea in the setting of anorexia nervosa. However lack of menses, it is possible for women with anorexia nervosa to become pregnant.
In contrast to the occurrence of amenorrhea in females, males have changes in sexual functioning, including a decrease in sexual drive. With decreasing weight is also reduced testosterone levels.
Given the lack of clear correlation between features of anorexia nervosa and subsequent pregnancy complications, there is no clear treatment or preventative measure for this issue, other than treatment of the underlying eating disorder and nutritional deficiencies.
Lifestyle is a term to describe the way individuals, family circles, and societies live and which behavior they manifest in coping with their physical, psychological, social, and economic environments on a day-to-day basis.
Lifestyle is expressed by daily work and leisure profiles, including activities, attitudes, interests, opinions, values, and allocation of income. Lifestyle is a composite of motivations, needs, and wants and is influenced by factors such as culture, family, reference groups, and social class.
The leading causes of global deaths today are largely lifestyle related. A healthy lifestyle is an important predictor of future health, productivity and life expectancy. It has been found to reduce the factors which contribute to health risks.
The combination of the main healthy lifestyle factors-maintaining a healthy weight, exercising regularly, following a healthy diet, and not smoking-seem to be associated with as much as an 80% reduction in the risk of developing the most common and deadly chronic diseases.
Lifestyle diseases or chronic diseases are associated with the way a person or group of people lives on a daily basis. In other words, lifestyle diseases characterize those diseases whose occurrence is primarily based on the daily habits of people and are a result of an inappropriate relationship of people with their environment.
Lifestyle is associated with the development of many chronic diseases. The World Health Organization (WHO) has recognized diabetes, hypertension, stroke, diabetes, obesity, high cholesterol, cardiovascular disease and stroke, cancer and chronic lung disease as major non-communicable diseases (NCDs). There are many other conditions associated with modern living like stress, depression and substance abuse are important factors also contributing to lifestyle related morbidity and mortality like suicides. These major NCDs share common lifestyle related risk factors like physical inactivity, unhealthy diet, tobacco use and harmful use of alcohol. Globally, the current scenario of NCDs is the major cause of morbidity and mortality.
Recently, the pivotal role that lifestyle factors play in the development of infertility has generated a considerable amount of interest. Lifestyle factors are the modifiable habits and ways of life that can greatly influence overall health and well-being, including fertility. Many lifestyle factors such as the age at which to start a family, nutrition, weight, exercise, psychological stress, environmental and occupational exposures, and others can have substantial effects on fertility; lifestyle factors such as cigarette smoking, illicit drug use, and alcohol and caffeine consumption can negatively influence fertility while others such as preventative care may be beneficial. A summary table of each lifestyle and the associated relative risk (RR) and odds ratio (OR) is provided (Tab. 1).
Physical exercise is performed for various reasons, including strengthening muscles and the cardiovascular system, honing athletic skills, weight loss or maintenance, and merely enjoyment. Frequent and regular physical exercise boosts the immune system and helps prevent the "diseases of affluence" such as heart disease, cardiovascular disease, Type 2 diabetes, and obesity. It may also help prevent depression, help to promote or maintain positive self-esteem, improve mental health generally, and can augment an individual's sex appeal or body image, which has been found to be linked with higher levels of self-esteem. Childhood obesity is a growing global concern, and physical exercise may help decrease some of the effects of childhood and adult obesity. Health care providers often call exercise the "miracle" or "wonder" drug—alluding to the wide variety of proven benefits that it can provide.
With use, muscles consume energy derived from both fat and glycogen. Due to the large size of leg muscles, walking, running, and cycling are the most effective means of exercise to reduce body fat.
Traditional Chinese medicine (TCM) is a style of traditional Asian medicine informed by modern medicine but built on a foundation of more than 2,500 years of Chinese medical practice that includes various forms of herbal medicine, acupuncture, massage (tui na), exercise (qigong), and dietary therapy. It is primarily used as a complementary alternative medicine approach. TCM is widely used in China and is becoming increasingly prevalent in Europe and North America.
One of the basic tenets of TCM "holds that the body's vital energy (chi or qi) circulates through channels, called meridians, that have branches connected to bodily organs and functions." Concepts of the body and of disease used in TCM reflect its ancient origins and its emphasis on dynamic processes over material structure, similar to European humoral theory. Scientific investigation has found nohistological or physiological evidence for traditional Chinese concepts such as qi, meridians, and acupuncture points. The TCM theory and practice are not based upon scientific knowledge, and its own practitioners disagree widely on what diagnosis and treatments should be used for any given patient. The effectiveness of Chinese herbal medicine remains poorly researched and documented. There are concerns over a number of potentially toxic plants, animal parts, and mineral Chinese medicinals. A review of cost-effectiveness research for TCM found that studies had low levels of evidence, but so far have not shown benefit outcomes. Pharmaceutical research has explored the potential for creating new drugs from traditional remedies, with few successful results. A Nature editorial described TCM as "fraught withpseudoscience", and said that the most obvious reason why it hasn't delivered many cures is that the majority of its treatments have no logical mechanism of action. Proponents propose that research has so far missed key features of the art of TCM, such as unknown interactions between various ingredients and complex interactive biological systems.
TCM's view of the body places little emphasis on anatomical structures, but is mainly concerned with the identification of functional entities (which regulate digestion, breathing, aging etc.). While health is perceived as harmonious interaction of these entities and the outside world, disease is interpreted as a disharmony in interaction. TCM diagnosis aims to trace symptoms to patterns of an underlying disharmony, by measuring the pulse, inspecting the tongue, skin, and eyes, and looking at the eating and sleeping habits of the person as well as many other things.
The fundamental principles of TCM are based on the Yin-Yang doctrine, the symbolic way of designating opposing forces, and the five element theory that everything in the Universe is dominated and balanced by the five elements, wood, fire, earth, metal and water. The therapeutic mechanism of TCM focuses on enhancing human body's resistance to diseases by improving the inter-connections among self-controlled systems and integrating the human body with the environment. The practice of TCM involves physical therapy such as acupuncture and chemical therapy using materials originating from plants, minerals and animals, while TCM natural products may comprise one or more herbs in the form of decoctions.
In Chinese philosophy, the concept of yin yang sometimes referred to in the west as yin and yang) is used to describe how polar or seemingly contrary forces are interconnected and interdependent in the natural world, and how they give rise to each other in turn. Many natural dualities — e.g. dark and light, female and male, low and high, cold and hot — are thought of as manifestations of yin and yang (respectively).
Yin yang are complementary opposites within a greater whole. Everything has both yin and yang aspects, although yin or yang elements may manifest more strongly in different objects or at different times. Yin yang constantly interacts, never existing in absolute stasis. The concept of yin and yang is often symbolized by various forms of the Taijitu symbol, for which it is probably best known in western cultures. There is a perception (especially in the West) that yin and yang correspond to good and evil. However, Taoist philosophy generally discounts good/bad distinctions as superficial labels, preferring to focus on the idea of balance.
In TCM, there are five diagnostic methods: inspection, auscultation, olfaction, inquiry, and palpation.
Inspection focuses on the face and particularly on the tongue, including analysis of the tongue size, shape, tension, color and coating, and the absence or presence of teeth marks around the edge.
Auscultation refers to listening for particular sounds (such as wheezing). Olfaction refers to attending to body odor. Inquiry focuses on the "seven inquiries", which involve asking the person about the regularity, severity, or other characteristics of: chills, fever, perspiration, appetite, thirst, taste, defecation, urination, pain, sleep, menses, leukorrhea. Palpation which includes feeling the body for tender A-shi points, and the palpation of the wrist pulses as well as various other pulses, and palpation of the abdomen. Examination of the tongue and the pulse are among the principal diagnostic methods in TCM.Certain sectors of the tongue's surface are believed to correspond to the zàng-fŭ. For example, teeth marks on one part of the tongue might indicate aproblem with the Heart, while teeth marks on another part of the tongue might indicate a problem with the Liver. Pulse palpation involves measuring the pulse both at a superficial and at a deep level at three different locations on the radial artery (Cun, Guan, Chi, located two fingerbreadths from the wrist crease, one fingerbreadth from the wrist crease, and right at the wrist crease, respectively, usually palpated with the index, middle and ring finger) of each, for a total of twelve pulses, all of which are thought to correspond with certain zàng-fŭ. The pulse is examined for several characteristics including rhythm, strength and volume, and described with qualities like "floating, slippery, bolstering-like, feeble, thready and quick"; each of these qualities indicate certain disease patterns. Learning TCM pulse diagnosis can take several years.
Chinese medicine therapies
Yoga is a mind-body exercise that combines spiritual traditions with physical movements. It was first practiced by Hindus in India more than 5,000 years ago. These movements, known as "postures," involve deep stretching and meditation (Pic. 1). The word yoga means "union" in the ancient Indian language of Sanskrit (ancient Indian language).
Yoga in Indian traditions, however, is more than physical exercise, it has a meditative and spiritual core. One of the six major orthodox schools of Hinduism is also called Yoga, which has its own epistemology (branch of philosophy concerned with the theory of knowledge) and metaphysics, and is closely related to Hindu Samkhya philosophy (one of the six orthodox schools of Hindu philosophy).
Many studies have tried to determine the effectiveness of yoga as a complementary intervention for cancer, schizophrenia, asthma, heart disease and infertility. The results of these studies have been mixed and inconclusive, with cancer studies suggesting none to unclear effectiveness, and others suggesting yoga may reduce risk factors and aid in a patient's psychological healing process.
It appears that there is a burgeoning number of women who struggle to get pregnant naturally. As a result of infertility problem, many mothers experience chronic stress. It can wreck havoc on body, change mood and depress the immune system. In this case, yoga not only increases blood flow and strengthens pelvic region but also addresses the root cause of stress.
Some major ways in which yoga can effect and treat infertility:
As mentioned before, stress plays a major role in slowing down your fertility. Yoga is a great way to beat stress and achieve peace of mind. Yoga is not just about the body it is also about breathing. The breathing techniques associated with yoga can help lower the stress hormone cortisol in the body. This in turn can increase chances of conceiving.
Detoxifies the body
Certain yoga poses can help detoxify the body and help boost fertility. Yoga can also help relax tight muscles and connective tissues.
Many infertility issues arise due to blockages. With yoga, it is possible to increase blood circulation and ensure that it reaches the reproductive organs. This can help create a positive environment for a pregnancy.
Works on immune system
Yoga is great way to boost immunity. Practicing yoga helps find inner calm, which in turn can help raise the number of white blood cells in the body. This not just helps keeping common diseases at bay but can also help beat infertility.
Helps keep the ovaries healthy
Certain yoga poses reroute the blood flow to reach the ovaries. This helps to provide these specific organs with more oxygen, making them healthier. It is important to note that ovarian dysfunction is a common cause of infertility in women. So, yoga can be a great tool for women with ovary related issues.
Helps deal with hormonal treatment better
With all those hormones in the body, it is easy to fall into the depths of physical and mental distress. This negative energy in the body can reduce chances of conceiving. With yoga, it is possible to minimize these side effects and increase chances of becoming pregnant.
Yoga involves a lot of stretching poses and exercises, thus strengthening reproductive muscles and organs which play a major role both in pregnancy and delivery. Fertility yoga is gentle and not demanding. An example of fertility yoga is Hatha which is slow-pacing.
These simple yet powerful fertility yoga poses should be practiced on a routine basis. Learning from a good yoga teacher is advised to get the pose right. These are some of the poses advisable for increasing fertility.(Pic.2)
• Cobra pose
• Lotus pose
• Legs up the wall pose
• Bridge pose
• Cobbler´s pose
• Supported head stand
• Supported shoulder stand
There is no need to be experienced in these practices to try fertility yoga. Doing these special poses can help women to gain more confidence about themselves and help towards parenthood. It can also help through reproductive difficulties.
Women are unique individuals and the desire to reproduce can be over-whelming. Never is that yearning more magnified then when they are unable to accomplish getting pregnant. Yoga can get women to the place they need to be so that they can free their hearts and prepare for a baby.
Endometrial ablation is the procedure in which is removed or destroyed the endometrium (the inner layer of uterus) and superficial myometrium (the middle layer of the uterine wall, consisting mainly of uterine smooth muscle cells). The main purpose is to destroy the basal layer of endometrium and inhibit its regeneration, hence preventing blood loss during menses. Women who suffer from excessive menstrual bleeding (Pic. 1) and who have failed medical therapy and do not wish to undergo a hysterectomy (surgical removal of the uterus) are reccomended to undergo endometrial ablation.
Endometrial ablation has been explored and many devices and techniques have been developed and have been found to be effective. The procedure is almost always performed as an outpatient treatment, either at the hospital, ambulatory surgery center, or physician office. The endometrial ablation procedure is primarily performed while patients are under local and/or light sedative anesthesia, or if necessary, general or spinal anesthesia. Patients normally leave the treatment facility within one hour following the procedure and generally spend one day resting at home, before returning to the activities of daily living.
A number of treatment options are available (Pic. 2):
Endometrial Ablation System (Minerva Surgical), Minerva works by generating heat from plasma energy that is created and contained inside a leak-proof ablation array that takes the shape of the uterine cavity. The hot membrane surface of the array ablates (destroys) the endometrium.
The Minerva procedure is the fastest FDA (Food and Drug Administration) approved treatment, average procedure time is 3.1 minutes from device insertion to removal, and is usually performed under local and/or conscious sedation anesthesia. Most patients leave the treatment center within one hour of treatment.
Endometrial Ablation System, utilizes a metallized mesh electrode array that is introduced into the uterine cavity, applying bipolar electrical energy that creates heat to ablate (destroy) the endometrium.
The Novasure average procedure time is 5 minutes from device insertion to removal and is usually performed under local and/or conscious sedation anesthesia. Most patients leave the treatment center within one hour of treatment.
The Genesys HTA
Hydro-Thermal Ablation System, uses a hysteroscope device (Pic. 3) which is inserted into the uterus through the cervical canal, to help doctors safely confirm proper probe placement and to see the area they are treating. In this procedure, the doctor looks at the inside of the uterus with the hysteroscope and then fills the uterus with saline fluid. The fluid is then slowly heated and the lining of the uterus is burned so that menstrual bleeding periods become less heavy and, in some cases, even stops. The fluid is then cooled and removed by special tubing to protect the external areas of the body from any burns.
The average procedure time is 26 minutes.
The Her Option
Endometrial Ablation System, is a treatment that creates sub-zero temperatures to freeze and ablate the endometrium. Following the application of local anesthetic around the cervix, a physician uses ultrasound to guide the placement of a cryoprobe (a long slender pointed surgical instrument, used to apply extreme cold to tissues) to the right uterine horn (cornua). The cryoprobe is activated, reducing its temperature to minus 60°C. The cryoprobe is kept in place while ice is formed in the uterine cavity, under ultrasound observation. Once the appropriate time has passed and/or the appropriate depth of ice has been achieved, the cryoprobe is warmed to 37°C. The cryoprobe is then repositioned to the untreated left uterine horn and the procedure is repeated. Finally, the cryoprobe is warmed and removed.
Transcervical Resection of the Endometrium (TCRE) or Loop Resection with Rollerball
Ablation as it is commonly called, utilizes a hysteroscope, through which a bi-polar radio frequency electrocautery cutting loop is deployed to resect (remove) the superficial endometrium, followed by a bi-polar radio frequency rollerball tool to ablate the remaining underlying endometrium via cauterization. It is a proven procedure, being a day-care procedure with rapid recovery.
The 'Thermachoice III '- balloon
This system utilized a heated saline filled balloon which was inserted into the uterine cavity to ablate the endometrium. The fluid was safely contained in a flexible and non-allergenic Silastic membrane that conformed to most uterine cavity shapes and sizes.
After the procedure, the endometrium heals by scarring over, thus reducing or eliminating future uterine bleeding. The patient's hormonal functions will remain unaffected because the ovaries are left intact.
Medical nutrition therapy (MNT) is a therapeutic approach to treating medical conditions and their associated symptoms via the use of a specifically tailored diet devised and monitored by a medical doctor, registered dietitian or professional nutritionist. The diet is based upon the patient's medical record, physical examination, functional examination and dietary history.
The role of MNT when administered by an MD or DO physician, dietitian or professional nutritionist is to reduce the risk of developing complications in pre-existing conditions such as type 2 diabetes as well as ameliorate the effects any existing conditions such as high cholesterol.
Ovarian drilling is a surgical technique of puncturing the membranes surrounding the ovary with a laser beam or a surgical needle using minimally invasive laparoscopic procedures. It differs from ovarian wedge resection, because resection involves the cutting of tissue. Ovarian drilling is often preferred to wedge resection because cutting in to the ovary can cause adhesions which may complicate postoperative outcomes.
Anovulation (absence of ovulation) is a major cause of female infertility, and polycystic ovary syndrome (PCOS) is the leading cause of anovulation. While undergoing drug-induced ovulation, women with PCOS usually have a satisfactory response recruiting follicles, but some are unable to recruit follicles or often produce an excessive number of follicles, which can result in ovarian hyper-stimulation syndrome and/or multiple pregnancy. Surgical laparoscopy with ovarian drilling may prevent or reduce the need for drug-induced ovulation.
This procedure probably reduces the need for clinical induction of ovulation, or facilitates its use. The procedure can be performed with admission in "day hospitals", with very little surgical trauma compared to the initial laparotomy technique. Laparoscopic drilling is a minimally invasive surgery in which the ovaries are treated with small perforations using heat or laser. The mechanism by which partial destruction results in ovarian follicular development and ovulation is unknown. Despite the contribution of hormonal changes caused by the procedure, such as the reduction of serum androgens, it is not clear whether this is the basis of the ovulation restoration mechanism. The most plausible theory involves the sharp drop in intraovarian androgens (and perhaps estrogens) resulting in an increase in the secretion of follicle-stimulating hormone (FSH) and an intra-follicular environment more conducive to normal follicular maturation and ovulation.
Many forms of ovarian drilling are described, including electrocautery or laser use. All of these share a common goal, which is creating focal areas of damage in the ovarian cortex. There is no evidence that one method consistently produces results superior to another. Nevertheless, the use of laser therapy has become less popular. The method most commonly used worldwide at the moment is monopolar needle or hook due to ease of installation and the wide availability of the necessary equipment.
Standardization of the surgical techniques is lacking. Reproductive outcomes are comparable with laser and diathermy. Electrocautery, using an insulated unipolar needle electrode with a non-insulated distal end measuring 1-2 cm, is the most commonly used method, although few authors have reported similar ovulation and pregnancy rates with bipolar energy.
The number of punctures is empirically chosen depending on the ovarian size. In the original procedure, 3-8 diathermy punctures (each of 3 mm diameter and 2-4 mm depth) per ovary were applied, using power setting of 200-300 W for 2-4 s. Most surgeons perform four punctures per ovary, each for 4 s at 40 W (rule of 4), delivering 640 J of energy per ovary (the lowest effective dose recommended). Nevertheless, clinical response is dose-dependent, with higher ovulation and pregnancy rates observed by increasing dose of thermal energy up to 600 J/ovary, irrespective of ovarian volume. Conversely, adjusting thermal dose based on ovarian volume (60 J/cc) has better reproductive outcomes with similar postoperative adhesion rates than fixed dose of 600 J/ovary. Despite lack of convincing evidence and significant reduction in operative time, most gynecologists still perform bilateral over unilateral drilling.
Different modifications of the classic needle electrode technique such as laparoscopic ovarian multi-needle intervention, ovarian drilling using a monopolar hook electrode, ovarian drilling using the harmonic scalpel and office microlaparoscopic ovarian drilling are proposed. Various transvaginal methods such as transvaginal hydrolaparoscopy (fertiloscopy) and transvaginal sonography - guided ovarian interstitial laser treatment are also developed. However, larger prospective studies are needed to validate the use, safety, efficacy and long-term effects of these alternate techniques.
Although oral contraceptives can causes menses to return, oral contraceptives should not be the initial treatment as they can mask the underlying problem and allow other effects of the eating disorder, like osteoporosis, continue to develop. Weight recovery, or increased rest does not always catalyze the return of a menses. Recommencement of ovulation suggests a dependency on a whole network of neurotransmitters and hormones, altered in response to the initial triggers of secondary amenorrhoea. To treat drug-induced amenorrhoea, stopping the medication on the advice of a doctor is a usual course of action.
As for physiological treatments to hypothalamic amenorrhoea, injections of metreleptin (r-metHuLeptin) have been tested as treatment to oestrogen deficiency resulting from low gonadotropins and other neuroendocrine defects such as low concentrations of thyroid and IGF-1. R-metHuLeptin has appeared effective in restoring defects in the hypothalamic-pituitary-gonadal axis and improving reproductive, thyroid, and IGF hormones, as well as bone formation, thus curing the amenorrhoea and infertility. However, it has not proved effective in restoring of cortisol and adrenocorticotropin levels, or bone resorption.
Looking at hypothalamic amenorrhoea, studies have provided that the administration of a selective serotonin reuptake inhibitor (SSRI) might correct abnormalities of Functional hypothalamic Amenorrhoea (FHA) related to the condition of stress-related amenorrhoea. This involves the repair of the PI3K signaling pathway, which facilitates the integration of metabolic and neural signals regulating gonadotropin releasing hormone (GnRH)/luteinizing hormone (LH). In other words, it regulates the neuronal activity and expression of neuropeptide systems that promote GnRH release. However, SSRI therapy represents a possible hormonal solution to just one hormonal condition of hypothalamic amenorrhoea. Furthermore, because the condition involves the inter workings of many different neurotransmitters, much research is still to be done on presenting hormonal treatment that would counteract the hormonal affects.
Clomid (Clomiphene citrate)
Clomifene is useful in those who are infertile due to anovulation or oligoovulation. Evidence is lacking for the use of clomifene in those who are infertile without a known reason. In such cases, studies have observed a clinical pregnancy rate 5.6% per cycle with clomifene treatment vs. 1.3%–4.2% per cycle without treatment.
Clomifene has also been used with other assisted reproductive technology to increase success rates of these other modalities.
2. Oral antidiabetic agents
Metformin was recommended as treatment for anovulation in polycystic ovary syndrome.
3. Selective estrogen receptor modulator (SERM)
Tamoxifen may be used an alternative to clomiphene citrate for ovulation induction in women with anovulatory infertility. A dose of 10–40 mg per day is administered in days 3–7 of a woman's cycle.
Human chorionic gonadotropin (hCG)
A molecule which is structurally similar to luteinizing hormone (LH). LH is secreted by the pituitary just before ovulation occurs, whereas hCG is released during pregnancy. On its own, hCG is not very effective in inducing ovulation, but when combined with clomifene citrate, it is much more effective.
Human menopausal gonadotropin (hMG)
A very powerful treatment for infertility. It consists of a combination of LH (luteinizing hormone) and FSH (follicle-stimulating hormone). From menopause onwards, the body starts secreting LH and FSH in large quantities due to the slowing down of the ovarian function. This excess of hormones is not used by the body and is expelled in the urine. HMG is therefore collected from the urine of menopausal women. The urine then undergoes purification and a chemical treatment. The resulting hMG induces the stimulation of several ovarian follicles. This increases the risk of producing several oocytes during the same cycle, and thus the risk of multiple pregnancies.
Follicle-stimulating hormone (FSH or recombinant FSH)
Now used as a replacement for hMG (human menopausal gonadotropin). Although hMG is a combination of FSH and LH (luteinizing hormone), FSH is the only active component that has an effect on ovulation. However, until recently, it was not possible to produce pure FSH. FSH is now administered in a similar way as hMG, at a specific point during the cycle, and it requires medical monitoring. It is therefore important to fully understand a woman’s cycle, and to be able to accurately anticipate menstruation and ovulation dates. FSH is also sometimes useful for women who are suffering from PCOS (Polycystic ovary syndrome).
Menstrual disorders include several conditions of menstrual cycle (Pic. 1) irregularity, which can be treated pharmacologicaly. Disorders can be divided into two main categories- disorders of menstrual lenght and disorders of menstrual flow.
Disorders of menstrual lenght
Disorders of menstrual lenght include polymenorrhea (cycles with intervals of 21 days or fewer), oligomenorrhea (infrequent menstruation) and amenorrhea (the absence of menstruation).
Hormonal imbalance can be the cause of polymenorrhea. Depending on which hormon is decreased during menstrual cycle, the replacement takes place.
In case of estrogen deficiency and shor follicular phase (the phase of the menstrual cycle during which follicles in the ovary mature) the option is to use an estrogen substitution of 4-10 day cycle or ovulation induction with clomiphene. Usually, the menstrual cycle is stabilized in 2-3 months.
Another problem might be an insufficient function of the luteum body (progesterone and estrogen secreting body in the female reproductive system), so the estrogen-progesteorne substitution is needed during the second phase of the cycle- from 14th to 25th day of cycle.
Very often more frequent menstrual bleeding can cause anemia, so it is necessary to start substitution therapy with an iron.
As for physiological treatments to hypothalamic amenorrhoea (absence of menstrual periods due to disorder of hypothalamus), injections of metreleptin (a synthetic analog of the hormone leptin used to treat diabetes) have been tested as treatment to estrogen deficiency resulting from low gonadotropins (follicle stimulating hormone and luteinizing hormone which are made in the pituitary which stimulates the sex glands). Metreleptin has appeared effective in restoring defects in the hypothalamic-pituitary-gonadal axis (controls development, reproduction, and aging) and improving reproductive hormones.
Looking at hypothalamic amenorrhoea, studies have provided that the administration of a selective serotonin reuptake inhibitor (SSRI) might correct abnormalities of functional hypothalamic amenorrhoea (FHA) related to the condition of stress-related amenorrhoea.
However, SSRI therapy represents a possible hormonal solution to just one hormonal condition of hypothalamic amenorrhoea. Furthermore, because the condition involves the inter workings of many different neurotransmitters, much research is still to be done on presenting hormonal treatment that would counteract the hormonal affects.
Disorders of flow
Disorders of menstrual flow include hypomenorrhea (extremely light menstrual blood flow), menorrhagia (menstrual periods with abnormally heavy or prolonged bleeding) and dysmenorrhea (painful periods, or menstrual cramps, is pain during menstruation).
Hypomenorrhea can be caused by hormonal imbalance of estrogen and progesterone. If there are low levels of estrogen, the innner lining of the uterus is thin, which leads to light menstrual blood flow during period.
Hormonal imbalance can be treated with oral contraceptives, which restore the natural cycle of hormonal release and contain both hormones.
In case of hypothyroidism, the scanty menstruation can be one of the signs. Due to lower levels of thyroid hormones produced by the thyroid gland, they must be supplement pharmacologically.
Causes may be due to abnormal blood clotting, disruption of normal hormonal regulation of periods or disorders of the endometrial lining of the uterus. Depending upon the cause, it may be associated with abnormally painful periods. Excessive bleeding can lead to anaemia (low concentration of red blood cells in blood) which presents as fatigue, shortness of breath and weakness.
If the degree of bleeding is mild, all that may be sought by the woman is the reassurance that there is no sinister underlying cause. If anaemia occurs then iron tablets may be used to help restore normal hemoglobin levels (the levels of the molecule in red blood cells that carries oxygen). Treatment may be given for a fixed period of time to replenish the body stores. Alternatively therapy may be continued long-term, often in a cyclical regimen on the days of menstruation.
The condition is often be treated with hormones, particularly as dysfunctional uterine bleeding commonly occurs in the early and late menstrual years when contraception is also sought. Usually oral combined contraceptive or progesterone only pills may be taken for a few months, but for longer-term treatment the alternatives of injected Depo Provera or the more recent progesterone releasing IntraUterine System may be used.
Fibroids may respond to hormonal treatment, else require surgical removal.
Many therapies are proposed for dysmenorrhea and include the use of non-steroid anti-inflammatory drugs (NSAIDs; used to treat inflammation, mild to moderate pain, and fever), oral contraceptives, vitamins and tocolytic agents (reduce or stop uterine contractions).
Egg donation is the process by which a woman donates eggs for purposes of assisted reproduction or biomedical research. For assisted reproduction purposes, egg donation typically involves IVF technology, with the eggs being fertilized in the laboratory; more rarely, unfertilized eggs may be frozen and stored for later use. Egg donation is a third party reproduction as part of ART.
Egg donor may have several reasons for donate her eggs:
First step is choosing the egg donor by a recipient from the profiles on or clinic databases (or, in countries where donors are required to remain anonymous, they are chosen by the recipient's doctor based on recipient woman’s desired trait). This is due to the fact that all of the mentioned examinations are expensive and the agencies/clinics must first confirm that a match is possible or guaranteed before investing in the process.
Each egg donor is first referred to a psychologist who will evaluate if she is mentally prepared to undertake and complete the donation process. These evaluations are necessary to ensure that the donor is fully prepared and capable of completing the donation cycle in safe and success manner. The donor is then required to undergo a thorough medical examination, including a pelvic exam, blood tests to check hormone levels and to test for infectious diseases, Rh factor, blood type, and drugs and an ultrasound to examine her ovaries, uterus and other pelvic organs. A family history of approximately the past three generations is also required, meaning that adoptees are usually not accepted because of the lack of past health knowledge. Genetic testing is also usually done on donors to ensure that they do not carry mutations (e.g., cystic fibrosis) that could harm the resulting children; however, not all clinics automatically perform such testing and thus recipients must clarify with their clinics whether such testing will be done. During the process, which usually takes several months, the donor must abstain from alcohol, sexual intercourse, cigarettes, and drugs, both prescription and non-prescription.
Once the screening is complete and a legal contract signed, the donor will begin the donation cycle, which typically takes between three and six weeks. An egg retrieval procedure comprises both the egg donor's cycle and the recipient's cycle. Birth control pills are administered during the first few weeks of the egg donation process to synchronize the donor's cycle with her recipient's, followed by a series of injections which halt the normal functioning of the donor's ovaries. These injections may be self-administered on a daily basis for a period of one to three weeks. Next, FSH is given to the donor to stimulate egg production and increases the number of mature eggs produced by the ovaries. Throughout the cycle the donor is monitored often by a physician using blood tests and ultrasound exams to determine the donor's reaction to the hormones and the progress of follicle growth.
Once the doctor decides the follicles are mature, the doctor will establish the date and time for the egg retrieval procedure. Approximately 36 hours before retrieval, the donor must administer one last injection of hCG to ensure that her eggs are ready to be harvested. The egg retrieval itself is a minimally invasive surgical procedure lasting 20-30 minutes, performed under sedation (but sometimes without any). A small ultrasound-guided needle is inserted through the vagina to aspirate the follicles in both ovaries, which extracts the eggs. After resting in a recovery room for an hour or two, the donor is released. Most donors resume regular activities by the next day.
Laws by state
The legal status and compensation of egg donation has several models across states with examples:
During ICSI just one sperm is injected directly into the egg cytoplasm using a micromanipulative apparatus that transforms imperfect hand movements into fine and precise movements of micromanipulation tools.
Intracytoplasmic Sperm Injection (ICSI) is an assisted reproductive technique (ART) initially developed by Dr. Gianpiero D. Palermo in 1993 to treat male infertility. It is most commonly used in conjunction with in vitro fertilization (IVF). Following IVF procedure, the physician places the fertilized egg into the female’s uterus for implantation. Sperm are obtained by the same methods as with IVF: either through masturbation, by using a collection condom, or by surgically removing sperm from a testicle through a small incision (MESA, TESE). The females are treated with fertility medications for approximately two weeks prior to oocyte retrieval to stimulate superovulation, where the ovaries produce multiple oocytes rather than the normal one oocyte. The oocytes are retrieved by either laparoscopy, or more commonly, transvaginal oocyte retrieval. In the latter procedure, the physician inserts a thin needle through the cervix, guided by a sonogram and pierces the vaginal wall and then the ovaries to extract several mature ova. Before the embryologist can inject the sperm into the oocyte, the sperm must be prepared by washing and exposing it to various chemicals to slow the sperm movement and prevent it from sticking to the injection plate. Also, the oocytes are treated with hyaluronidase to single out the oocyte ready for fertilization by the presence of the first polar body. Then, one prepared sperm is injected into an oocyte with a thin needle. Often, embryologists try to fertilize several eggs so they can implant more than one into the uterus and increase the chance of at least one successful pregnancy. This also allows them to save extra embryos, using cryopreservation, in case later IVF rounds are needed.
After the embryologist manually fertilizes the oocytes, they are incubated for sixteen to eighteen hours and develop into a pronucleate eggs (successfully fertilized eggs about to divide into an embryo). The egg then grows for one to five days in the laboratory before the physician places it in the female’s uterus for implantation.
The chance of fertilization increases dramatically with ICSI compared to simply mixing the oocytes and sperm in a Petri dish and waiting for fertilization to occur unaided (classical IVF procedure). Studies have shown that successful fertilizations occur 50% to 80% of the time. Since the introduction of ICSI, intrauterine insemination (IUI) has decreased in popularity by 80%.See full description of ICSI
Sperm donation is the donation by a male (known as a sperm donor) of his sperm (known as donor sperm), principally for the purpose of inseminating a female who is not his sexual partner. Sperm donation is a form of third party reproduction including sperm donation, oocyte donation, embryo donation, surrogacy, or adoption. Number of births per donor sample will depend on the actual ART method used, the age and medical condition of the female bearing the child, and the quality of the embryos produced by fertilization. Donor sperm is more commonly used for artificial insemination (IUI or ICI) than for IVF treatments. This is because IVF treatments are usually required only when there is a problem with the female conceiving, or where there is a “male factor problem” involving the female's partner. Donor sperm is also used for IVF in surrogacy arrangements where an embryo may be created in an IVF procedure using donor sperm and this is then implanted in a surrogate. In a case where IVF treatments are employed using donor sperm, surplus embryos may be donated to other women or couples and used in embryo transfer procedures.
On the other hand, insemination may also be achieved by a donor having sexual intercourse with a female for the sole purpose of initiating conception. This method is known as natural insemination.
Donor sperm and fertility treatments using donor sperm may be obtained at a sperm bank or fertility clinic. Here, the recipient may select donor sperm on the basis of the donor's characteristics, e.g. looks, personality, academic ability, race, and many other factors. Sperm banks or clinics may be subject to state or professional regulations, including restrictions on donor anonymity and the number of offspring that may be produced, and there may be other legal protections of the rights and responsibilities of both recipient and donor. Some sperm banks, either by choice or regulation, limit the amount of information available to potential recipients; a desire to obtain more information on donors is one reason why recipients may choose to use a known donor and/or private donation.
A sperm donor will usually donate sperm to a sperm bank under a contract, which typically specifies the period during which the donor will be required to produce sperm, which generally ranges from 6–24 months depending on the number of pregnancies which the sperm bank intends to produce from the donor. Donors may or may not be paid for their samples, according to local laws and agreed arrangements. Even in unpaid arrangements, expenses are often reimbursed. Depending on local law and on private arrangements, men may donate anonymously or agree to provide identifying information to their offspring in the future. Private donations facilitated by an agency often use a "directed" donor, when a male directs that his sperm is to be used by a specific person. Non-anonymous donors are also called known donors, open donors or identity disclosure donors.
A sperm donate must generally meet specific requirements regarding age (most often up to 40) and medical history. Potential donors are typically screened for genetic diseases, chromosomal abnormalities and sexually transmitted infections that may be transmitted through sperm. The donor's sperm must also withstand the freezing and thawing process necessary to store and quarantine the sperm. Samples are stored for at least 6 months after which the donor will be re-tested for sexually transmitted infections. This is to ensure no new infections have been acquired or have developed during the period of donation. If the result is negative, the sperm samples can be released from quarantine and used in treatments.
Preparing the samples
A sperm donor is usually advised not to ejaculate for two to three days before providing the sample, to increase sperm count and to maximize the conception rate. A sperm donor produces and collects sperm by masturbation or during sexual intercourse with the use of a collection condom.
Sperm banks and clinics usually "wash" the sperm sample to extract sperm from the rest of the material in the semen. A cryoprotectant semen extender is added if the sperm is to be placed in frozen storage in liquid nitrogen, and the sample is then frozen in a number of vials or straws. One sample will be divided into 1-20 vials or straws depending on the quantity of the ejaculate and whether the sample is washed or unwashed. Following the necessary quarantine period, the samples are thawed and used to inseminate women through artificial insemination or other ART treatments. Unwashed samples are used for ICI treatments, and washed samples are used in IUI and IVF procedures.
Anonymous sperm donation occurs where the child and/or receiving couple will never learn the identity of the donor, and non-anonymous when they will. Non-anonymous sperm donors are, to a substantially higher degree, driven by altruistic motives for their donations.
Even with anonymous donation, some information about the donor may be released to the female/couple at the time of treatment. Limited donor information includes height, weight, eye, skin and hair color. In Sweden, this is all the information a receiver gets. In the US, on the other hand, additional information may be given, such as a comprehensive biography and sound/video samples.
Information made available by a sperm bank will usually include the race, height, weight, blood group, health, and eye color of the donor. Sometimes information about his age, family history and educational achievements will also be given.
Different factors motivate individuals to seek sperm from outside their home state. For example, some jurisdictions do not allow unmarried women to receive donor sperm. Jurisdictional regulatory choices as well as cultural factors that discourage sperm donation have also led to international fertility tourism and sperm markets.
A sperm donor is generally not intended to be the legal or de jure father of a child produced from his sperm. Depending on the jurisdiction and its laws, he may or may not later be eligible to seek parental rights or be held responsible for parental obligations. Generally, a male who provides sperm as a sperm donor gives up all legal and other rights over the biological children produced from his sperm. However, in private arrangements, some degree of co-parenting may be agreed, although the enforceability of those agreements varies by jurisdiction.
Laws prohibits sperm donation in several countries: Algeria, Bahrain, Costa Rica, Egypt, Hong Kong, Jordan, Lebanon, Lithuania, Libya, Maldives, Oman, Pakistan, Philippines, Qatar, Saudi Arabia, Syria, Tajikistan, Tunisia, Turkey, UnitedArab Emirates, and Yemen.See full description of Sperm donation
In vitro fertilization (IVF) is a process by which an egg is fertilised by sperm outside the body: in vitro . The process involves monitoring and stimulating a woman's ovulatory process, removing an ovum or ova (egg or eggs) from the woman's ovaries and letting sperm fertilise them in a liquid in a laboratory. The fertilised egg (zygote) is cultured for 2–6 days in a growth medium and is then implanted in the same or another woman's uterus, with the intention of establishing a successful pregnancy.
IVF techniques can be used in different types of situations. It is a technique of assisted reproductive technology for treatment of infertility. IVF techniques are also employed in gestational surrogacy, in which case the fertilised egg is implanted into a surrogate's uterus, and the resulting child is genetically unrelated to the surrogate. In some situations, donated eggs or sperms may be used. Some countries ban or otherwise regulate the availability of IVF treatment, giving raise to fertility tourism. Restrictions on availability of IVF include to single females, to lesbians and to surrogacy arrangements. Due to the costs of the procedure, IVF is mostly attempted only after less expensive options have failed.
The first successful birth of a "test tube baby", Louise Brown, occurred in 1978. Louise Brown was born as a result of natural cycle IVF where no stimulation was made. Robert G. Edwards, the physiologist who developed the treatment, was awarded the Nobel Prize in Physiology or Medicine in 2010. With egg donation and IVF, women who are past their reproductive years or menopause can still become pregnant. Adriana Iliescu held the record as the oldest woman to give birth using IVF and donated egg, when she gave birth in 2004 at the age of 66, a record passed in 2006.
Some conditions associated with heavy bleeding, such as ovulation abnormalities, fibroids, or endometriosis, are important contributors to infertility.
Many conditions that cause absence of a menstrual period (amenorrhea), such as ovulation abnormalities and PCOS (Polycystic Ovarian Syndrome), can also cause infertility. Asymmetrical periods from any cause may make it more difficult to conceive.
Sometimes treating the underlying condition can resume fertility. In other cases, specific fertility treatments that use ART may be helpful.