Kegel exercises are the most popular method of reinforcing pelvic floor muscles and are noninvasive treatment such that they do not involve the placement of any vaginal weights/cones. They are the most cost-effective treatment and differ from other therapies in that the patients can do them by themselves anytime, anywhere, while doing other work, and without regular hospital visits.
The pelvic floor muscles are used in order to stop the flow of urine, grasp a penis during intercourse, or hold back a bowel movement. Since the anal sphincter is usually the strongest of these muscles, it needs very little attention, while the other two areas are usually stressed when the Kegel exercises are taught in childbirth preparation classes.
Kegel exercises are considered by childbirth educators to be essential to all women – whether or not they have borne children (Cesarean or vaginally) or intend to, and no matter what their age. Contrary to common belief, pelvic floor muscle laxity is not always associated with childbirth and can be caused by other factors, including the aging process, hormonal decreases, a woman's particular physiology, an injury or disease, or simply an unawareness of the existence of these muscles.
Though most commonly used by women, men can also use Kegel exercises. Kegel exercises are employed to strengthen the pubococcygeal muscle (the main muscle of the pelvic floor) and other muscles of thepelvic diaphragm. Kegels can help men achieve stronger erections, maintain healthy hips, and gain greater control over ejaculation. The objective of this may be similar to that of the exercise in women with weakened pelvic floor: to increase bladder and bowel control and sexual function.
The exercises consist of exercising the pubococcygeus (PC), contracting it and relaxing it repeatedly (Pic.1). This muscle is used to prevent leakage of urine, so it is possible to identify throught first making cuts during urination. Once identified, is advised start with sets of 10-20 contractions / relaxations, repeating the exercise throughout the day. Should be consistent and, if possible, to reach 200 daily repetitions spread over four sets of 50.
Pharmacotherapy of vaginismus is a type of therapy, which is focused on release of excessive tension of the pelvic floor muscles (Pic. 1).
Vaginismus is characterized by recurrent or persistent involuntary contraction of the perineal muscles surrounding the outer third of the vagina when penile, finger, tampon, or speculum penetration is attempted.
Three main types of pharmacological treatment have been proposed for vaginismus: local anesthetics (e.g., lidocaine), muscle relaxants (e.g., botulinum toxin) and anxiolytic medication.
Anesthetics
Lidocaine
Topical application of lidocaine gel can be used during finger dilatation in patients, who have associated pain or areas of hypertensia (areas with increased pressure) in the introitus of vagina (the opening that leads to the vaginal canal). Gel is often used at home before intercourse.
Muscle relaxants
Botulinum toxin injection
Botulinum toxin injection is the most used cure with promising results. Botox causes a weakening and paralysis of the target muscles of pelvic floor. Depending on how many muscles are involved in idividual, the amount of Botox is used. The dose of Botox is divided into main muscles (especially pubococcygeus), because very often these are blocking the penetration. Botox is administred to the woman under general anaesthesia, light sedation or without it, depending on patient or clinician preference. The toxin is injected into vaginal wall with a needle.
The injection of Botox and insertion of a dilator (medical implement used to expand an opening of or vaginal introitus) under anesthesia with follow up progressive dilation also has shown to be a safe and effective treatment for vaginismus. Most women are able to have pain free intercourse within 2-4 weeks after the procedure.
The effect of botox can last for up to 6 months. The effect is usually reduced over time, but the medication can be repeated. Sometimes the high doses can lead to antibody formation, which have impact on therapeutic effect. To avoid this, it is reccomended to have treatment no more frequently than every 3 months.
Anxiolytic medication
When vaginismus is accompanied by severe anxiety or panic, anxiolytic medication may be a useful adjunct to psychotherapy.
Every women can have different degree of relief and duration of medication due to severity of condition.
Psychotherapy of vaginismus is a kind of therapy used to deal with the psychological side of vaginismus causing painful intercourse. Vaginismus is an involuntary contraction of the vaginal muscles which makes sexual intercourse painful or impossible - hence interfering in personal and marital relationships. Many sexual problems arise from anxiety, mismatched expectations, and unhelpful learnt responses, rather than simply physical problems with the sexual organs. A medical evaluation of vaginosis and dyspareunia (pain during or after sexual intercourse) focuses initially on physical causes, which must be ruled out before psychogenic or emotional causes are entertained.
It is not „in the woman’s head“. Rather, it is a real physical pain from the panic reaction to penetration, the product of a fight or flight response. Psychological factors that should play a crucial role to arouse this dysfunction could be avoidance, fear of penetration, anxiety, relationship problems, chronic frustration, disappointment and depression. People with vaginismus are twice as likely to have a history of childhood sexual interference and held less positive attitudes about their sexuality, whereas no correlation was noted for lack of sexual knowledge or (non-sexual) physical abuse. In addition, poor sexual self-esteem, lack of interest, and general inability to find pleasurable sex, increasingly have been shown as psychological causes in such patients.
Psychological treatments methods:
Considering the fact that vaginismus, in the majority of of the instances, has a lot of psychological reasons, the treatment approach primarily concentrates on relaxing r mind and body. Pacient should try a few mental calming techniques. This should help to eliminate any anxiety and fearfulness.
As a psychotherapeutic approach, the CBT addresses dysfunctional emotions, maladaptive behaviours (type of behavior that is often used to reduce one's anxiety, but the result is dysfunctional and non-productive ) and cognitive processes using a number of goal-oriented, explicit systematic procedures. Adopting a blend of cognitive and behavioral therapy, the therapists deal with patients’ anxiety and depression. It is a "problem focused" and "action oriented" technique by which therapist tries to assist the client in selecting specific strategies to help address those problems.
Sex therapy is an umbrella term for a number of established psychological and behavioral treatments for sexual difficulties. Most commonly, it involves a therapist working with a couple to discuss the problem, work out what might be going wrong, and then asking the couple to try a number of approaches to improve their relationship, communication and lovemaking.
A common approach is to initially ask the couple not to have sex and simply focus on touching and intimacy (an approach known as sensate focus). This takes the pressure off, reduces anxiety, and once the couple start feeling more connected, therapy focuses on introducing sexual activities or exercises for the couple to try at home to help deal with the remaining difficulties. Similarly, the therapist might ask the couple to try new ways of communication, and consider how they understand their partner, both sexually and in everyday life.
Sex therapy includes the use of vaginal trainers (VTs). Vaginal trainers, also known as dilators, remain the most widely recommended treatment for vaginismus. They are available in graduated sizes and are used to slowly stretch the vaginal walls, making penetration and transition to intercourse more comfortable.
Hypnotherapy can provide an acceptable time and cost effective therapeutic tool that helps resolve vaginismus and improves sexual satisfaction in both spouses. Women with vaginismus can be successfully treated by hypnotherapy without simultaneous treatment of their husbands.
Generally, hypnotherapy is a situation of focused arousal in which perceptual monitoring and consciousness are dissociated so, imagination and fantasies are commonly applied by hypnotherapist. It has been expressed that Hypnosis is a deep relaxation technique that reduce stress and the intensity of emotional and psychological concentration on conception and induce trance to alleviate suffering or to promote healing.
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
Intrauterine insemination (IUI) as a type of artificial insemination involves the placement of sperm directly into the uterus at the time of ovulation, either in a natural menstrual cycle or following ovarian stimulation. The process allows the concentration of sperm in a small volume of culture media and then the concentrated sperm is placed into the uterus through a transcervical catheter. IUI has the advantages of being less invasive and more affordable than other assisted reproduction techniques such as IVF. IUI theoretically allows a relatively higher number of motile sperm to reach the oocyte. The rationale for washing sperm is to remove prostaglandins, infectious agents, and antigenic proteins as well as to remove immotile spermatozoa, leucocytes, and immature germ cells.
IUI is a more efficient method of artificial insemination. Sperm is occasionally inserted twice within a “treatment cycle“. A double intrauterine insemination theoretically increases pregnancy rates by decreasing the risk of missing the fertile window during ovulation. However, a randomized trial of insemination after ovarian hyperstimulation found no difference in live birth rate between single and double intrauterine insemination.
Unlike intracervical insemination, intrauterine insemination normally requires a medical practitioner to perform the procedure (see Tab. 1). A female under 30 years of age has optimal chances with IUI; for the man, a total motile sperm count of more than 5 million per ml is optimal. In practice, donor sperm will satisfy these criteria. A promising cycle is one that offers two follicles measuring more than 16 mm, and estrogen of more than 500 pg/mL on the day of hCG administration. A short period of ejaculatory abstinence before intrauterine insemination is associated with higher pregnancy rates. However, GnRH agonist administration at the time of implantation does not improve pregnancy outcome in IUI cycles according to a randomized controlled trial.
Before the IUI
Before artificial insemination is turned to as the solution to impregnate a woman, doctors will require an examination of both the male and female involved in order to remove any and all physical hindrances that are preventing them from naturally achieving a pregnancy. The couple is also given a fertility test to determine the motility, number, and viability of the male's sperm and the success of the female's ovulation (see Tab. 2). From these tests, the doctor may or may not recommend a form of artificial insemination (intrauterine insemination or intracervical insemination).
The sperm used in artificial insemination may be provided by either the woman's partner sperm or by a sperm donation (donor sperm). Though there may be legal, religious and cultural differences in these and other characterizations, the manner in which the sperm is actually used in artifical insemination would be the same, If the procedure is successful, the woman will conceive and carry a baby to term in the normal manner (see Tab. 1). A pregnancy resulting from artificial insemination will be no different from a pregnancy achieved by sexual intercourse. In all cases, the woman would be the biological mother of any child produced by AI, and the male whose sperm is used would be the biological father.
IUI process
Timing is critical, as the window and opportunity for fertilization is little more than twelve hours from the release of the ovum. To increase the chance of success, the woman's menstrual cycle is closely observed, often using ovulation kits, ultrasounds or blood tests, such as basal body temperature tests over, noting the color and texture of the vaginal mucus, and the softness of the nose of her cervix. To improve the success rate of artifical insemination, drugs to create a stimulated cycle may be used, but the use of such drugs also results in an increased chance of a multiple birth.
Sperm can be provided fresh or washed. The washing of sperm increases the chances of fertilization. Pre- and post-concentration of motile sperm is counted.
When ovarian stimulation is used, patients underwent afirst cycle with orally administered 50 mg/day clomiphene citrate, from days 3 to 7 of the menstrual cycle, along with subcutaneous human menopausal gonadotropin or recombinant FSH at days 3, 5 and 7 of the cycle. The follicular development is monitored by transvaginal ultrasound at days 2 (basal) and 8 of the cycle. Subsequently, daily monitoring is performed until follicular diameter measured 18 to 20 mm and thickness of the endometrium was greater than 7 mm. When one or (at most) three follicles measured the expected mean diameter, hCG or recombinant hCG is administered. IUI is scheduled 36 to 40 hours after hCG or r-hCG administration and confirmation of follicular rupture.
The patient is on bed rest for 20 minutes, and the supplementation of the luteal phase is administered orally with natural progesterone at a dose of 200 mg every 12 h from the day after IUI until confirmation of the embryonic heartbeat using an ultrasound.
Legal aspects of artificial insemination
Some countries restrict artificial insemination in a variety of ways. For example, some countries do not permit AI for single women, and some Muslim countries do not permit the use of donor sperm. As of May 2013, the following European countries permit medically assisted AI for single women: Armenia, Belarus, Belgium, Bulgaria, Cyprus, Denmark, Estonia, Finland, Germany, Greece, Hungary, Iceland, Republic of Ireland, Latvia, Republic of Macedonia, Moldova, Montenegro, Netherlands, Romania, Russia, Spain, Ukraine, United Kingdom.
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.
Due to the discomfort when attempting penetration for some women entry of the penis may be impossible, thus, women suffering from vaginismus might be also struggling with infertility. Also, they may fail to consummate their marriage and inability to conceive can lead to even greater pain and depression. Since the woman cannot have sexual intercourse with partner, she may perceive herself as a failure and feel even more pressured and anxious. It is important not to blame yourself for this condition and it is highly recommended to seek a professional advice. With professional advice and help women can cure vaginismus and could even conceive.
Variety of techniques involving techniques that consists of a series of instrictions for touching activities can help couples to overcome anxiety and increase comfort with intercourse. The focus is placed on touch rather than on performance. To resolve the vaginismus and become fertile, women can either achieve sexual intercourse with intravaginal deposition of semen or try the natural way or assisted reproduction techniques.
Vaginismus may present certain complications during gynaecological exams mainly due to pelvic tightness. Therefore, it is recommended to undergo treatment of vaginismus as soon as it is detected. If the treatment does not eliminate the problem, explaining the problem to physician and agreeing on next steps can reduce the feelings of discomfort. As for the delivery, the hormones released during the delivery widen woman’s body, thus the vaginismus should not have negative effect on delivery.
