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Infertility Facts

Infertility Cause

Normal PREGNANCY Care

Effective antenatal care (ANC) can improve the health of the mother and give her a chance to deliver a healthy baby. Regular monitoring during PREGNANCY can help detect complications at an early stage before they become life-threatening emergencies. However, one must realize that even with the most effective screening tools currently available, one cannot predict which woman will develop pregnancy-related complications. Hence, every pregnant woman needs special care

The important components of ANC are discussed below.

• Early registration

Timing of the first visit/registration

The first visit or registration of a pregnant woman for ANC should take place as soon as the pregnancy is suspected. Every married woman in the reproductive age group should be encouraged to visit her health provider or inform you if she believes herself to be pregnant. Ideally, the first visit should take place in the first trimester, before or at the 12th week of pregnancy.

Importance of early registration

Early registration is required to:

Assess the health status of the mother and obtain baseline information on blood pressure (BP), weight, haemoglobin, etc.
Screen for complications early and manage them appropriately by referral as and when required.
Help the woman recall the date of her last menstrual period (LMP).
Give the woman the first dose of tetanus toxoid injection (Inj. TT) well in time (after 12 weeks of pregnancy).
Help the woman access facilities for an early and safe abortion if she does not want to continue with the pregnancy. Be alert to the possibility that the abortion might be an attempt at female foeticide.
Build a good rapport with the pregnant woman. Allow plenty of time to counsel the woman and her family.
Start the woman on a regular dose of iron folic acid during the first trimester

Record-keeping

Complete the antenatal card for every woman registered/examined by you. Hand over the card to the woman.Instruct her to bring the card with her for all subsequent check-ups/visits, and carry it along with her at thetime of delivery.
Record this information in the PHC/CHC antenatal register.

Antenatal check-up

Number and timing of visits

Ensure that every pregnant woman makes at least 4 visits for ANC, including the first visit/registration andany home visits by the ANM/lady health visitor (LHV). These are sufficient and, for pregnancies withoutcomplications, studies have shown that additional visits do not improve the maternal or perinatal outcome.

The first visit is recommended as soon as the pregnancy is suspected. This is meant for registration of the pregnancy and the first antenatal check-up. The second visit should be scheduled between the 4th and 6th month (around 26 weeks). The third one should be planned in the 8th month (around 32 weeks), and the fourth one in the 9th month (36-40 weeks).

Preparing for the ANC Clinic

Before beginning each ANC Clinic, ensure that all the required instruments/equipment, e.g. stethoscope, sphygmomanometer, weighing scale, inch tape, are available and in working condition.
Greet every pregnant woman in a friendly manner at each visit.

Listen to the woman's problems and concerns and offer advice or refer to a CHC or a first referral unit
(FRU), as appropriate. Remember, every woman needs social support during pregnancy.

Confirm that pregnancy is wanted. If not, and the woman wishes to go in for an abortion, offer her manual vacuum aspiration (MVA)/MTP services if they are available at your PHC/CHC, or refer her to the nearestCHC/FRU where safe abortion services are available. (You are advised to follow the GoI guidelines for theMedical Termination of Pregnancy.) This is important, especially during the first visit whenMTP is still feasible.

Conduct the antenatal examination in a room/enclosure that allows privacy for conducting an abdominal
palpation.Record all findings accurately on the antenatal card, and in the antenatal register.

History-taking

During the antenatal visits, take a detailed history of the woman (i) to diagnose the pregnancy (first visit only,if required); (ii) to identify any complications during previous pregnancies which may have a bearing on thepresent one; and (iii) to identify any medical or obstetric condition(s) that may complicate the presentpregnancy (first and subsequent visits).
While taking the history, ask the following questions:

Date of the last menstrual period

Remember that the LMP refers to the FIRST day of the woman's last menstrual period. Ensure that the woman, while telling you her LMP, is NOT referring to the date of the first MISSED PERIOD. This mistake will lead to a miscalculation of the gestational age and expected date of delivery (EDD)
by 4 weeks

The following formula for calculation of the EDD is based on the assumption that the menstrual cycle of thewoman was regular before conception and it was a 28-30 days' cycle. If the period of the menstrual cycle ismore than 30 days, add the additional number of days in the cycle (beyond 28 days) to the EDD calculated below.

EDD = LMP + 9 months + 7 days (+ additional days, if any)

Age of the woman

This is required as women below 16 years of age or above 40 years have greater chances of having pregnancy related complications.

Order of the pregnancy

Primigravidas and those who have had 4 or more pregnancies are at a higher risk of developing complications during pregnancy and labour.

Birth interval

Research shows that women who have spaced their children less than 36 months apart have greater chances ofdelivering a premature and low birth-weight (LBW) baby, with consequently increased risk of infant mortality.An interval of less than 2 years from the previous pregnancy or 3 months from the previous abortion increases the chances of the mother developing anaemia.

Symptoms during the present pregnancy

You must ask for symptoms that might be causing the woman some discomfort, and also for symptoms which indicate that a complication may arise. Ask the woman for the following symptoms in the present pregnancy:

Symptoms that indicate discomfort

nausea and vomiting
heartburn
constipation
increased frequency of micturition

Symptoms which indicate that a complication may arise

Fever
Vaginal discharge
Palpitations, easy fatiguability and breathlessness at rest
Generalized swelling of the body; puffiness of the face
Vaginal bleeding
Decreased or absent foetal movements
Leaking of watery fluid per vaginum (P/V)
Decreased urinary output

Previous pregnancies

It is essential to ask a woman about her previous obstetric history, especially if she had suffered from any complications. This is important as some complications may recur during the present pregnancy.

Ask the woman about:

the total number of previous pregnancies (including the present one, "gravida") and deliveries("parity")
abortion(s)
premature birth(s)
stillbirth(s) or neonatal loss
hypertensive disorders of pregnancy (if not known, ask for a history of convulsions in previous pregnancies)
prolonged labour
obstructed labour
malpresentation, such as breech delivery
antepartum haemorrhage (APH)
postpartum haemorrhage (PPH)
assisted delivery (forceps or vacuum extraction)
delivery by caesarean section
birth weight of the previous baby
any surgery on the reproductive tract (e.g. myomectomy, removal of the septum, cone biopsy, cervical cerclage, uterine perforation following an MTP, etc.)
isoimmunization (Rh -ve) in the previous pregnancy (history of [h/o] any costly injection given within 72 hours of the previous delivery)

History of any systemic illness(es)

Rule out any personal history of systemic illnesses such as

hypertension
diabetes
heart disease
tuberculosis
renal disease
epilepsy
asthma
rashes
jaundice

Family history of systemic illness

If the woman does not have any of the above-mentioned systemic illnesses, ask for a family history of
hypertension, diabetes and tuberculosis. If present, such a history predisposes the woman to developing the same herself during pregnancy (e.g. hypertensive disorders of pregnancy, gestational diabetes, etc.). As pregnancy is a physiologically stressful period in a woman's life, it can unmask the underlying tendency to develop these disorders.

Also ask for a family history of thalassaemia, or whether anybody in her family has received blood
transfusions. You must also ask for a family history of delivery of twins and/or the delivery of an infant with congenital malformation, as the presence of such a history in the family increases the chances of the woman giving birth to a child with the same defect.

History of drug intake or allergies

It is important to find out whether the woman is allergic to any drug, or if she is taking any drug that might be harmful to the foetus. Find out whether she had undergone any treatment or taken drugs for Infertility. If yes, then the woman has a higher chance of having twins and other multiple pregnancies

Physical examination

This activity will be nearly the same during all the visits. Initial readings may be taken as a baseline and
compared with the later readings.

General examination

Weight : A pregnant woman's weight should be taken AT EACH VISIT. The weight taken during the first visit/registration should be treated as the baseline weight. Normally, a woman should gain 9-11 kg during her pregnancy. After the first trimester, a pregnant woman gains around 2 kg every month or 0.5 kg per week. To calculate the expected weight gain since her previous visit, multiply the number of weeks elapsed since the previous visit by 0.5 kg. This should be compared with the actual weight gained. If the diet is inadequate, with less than the required amount of calories, the woman might gain only 5-6 kg during her pregnancy. Suspect an inadequate dietary intake if the woman gains less than 2 kg per month. Put her on food supplementation. Take the help of the ANM or refer the woman to the anganwadi worker (AWW) of her village for food supplementation, especially for those categories of women who need it the most A low weight gain usually points towards intrauterine growth retardation (IUGR) and results in an LBW baby.

Excessive weight gain (more than 3 kg in a month) should arouse the suspicion of pre-eclampsia/twins
(multiple pregnancy). Check the woman's BP, and test her urine to check if she has proteinuria.
Keep the following points in mind while taking the weight:

The weighing machine should be checked for "zero error" before taking the weight.
The woman should be wearing light clothing.
She should stand erect on the weighing machine, in such a way that her weight is evenly distributed on the platform.
The weight must be measured to the nearest 100 g.

Blood pressure : Measure the BP of pregnant women AT EVERY VISIT to rule out hypertensive disorders ofpregnancy If the BP is high (more than 140/90 mmHg; or diastolic more than 90 mmHg), check the BP again after 1hour. If it is still high, test the woman's urine for the presence of albumin, as the combination of a high BP and proteinuria is sufficient to categorize the woman as having pre-eclampsia.

If the diastolic BP of the woman is above 110 mmHg, it is a danger sign pointing towards severe eclampsia.A woman with pregnancy-induced hypertension (PIH)/pre-eclampsia requires hospitalization for daily/ alternate day monitoring of BP, the level of protein in the urine and foetal condition

Pallor : Pull down the lower eyelid and look at the lower palpebral conjunctiva, and also the nails, palms, tongue and oral mucosa of the woman for the presence of pallor. If present, it is an indication that the woman is anaemic. Investigate her haemoglobin (Hb) level [see later in this chapter under Investigation for "Haemoglobin estimation"].

Respiratory rate (RR) : It is important to check the RR, especially if the woman complains of breathlessness. If the RR is more than 30 breaths/minute and pallor is present [see above in this chapter under Examination for "Pallor"], it indicates that she has severe anaemia If the RR of the woman is >30 breaths/minute, and she has other associated medical problems, refer her to the specialist at the FRU for further investigation and management of any systemic illness, if present.

Generalized oedema : The presence of generalized oedema or puffiness of the face should arouse the suspicion of pre-eclampsia.

Breast examination

Observe the size and shape of the nipples for the presence of inverted or flat nipples. Try and pull out the nipples to see if they are protractile (i.e. can be pulled out easily). Flat nipples that are protractile do not interfere with breastfeeding. However, truly inverted nipples might create a problem in carrying out successful breastfeeding.

If the nipples are inverted, advise the woman to roll her nipples between the thumb and the index finger, pulling at the nipples simultaneously.

Vaginal examination

Vaginal examination is required, especially during the first visit, to confirm the pregnancy.
This is also used to measure the gestational age, by estimating the size of the uterus during the first trimester of pregnancy, before the uterus becomes an abdominal organ.
A per speculum (P/S) examination may be done during the first and last antenatal visit, especially if the woman complains of discharge P/V. This would help in defining whether it is a vaginal or a cervical discharge, and the type of discharge, thus assisting you in making a diagnosis of reproductive tract infection (RTI), and managing the case accordingly.

Abdominal examination

Examine the abdomen to monitor the progress of the pregnancy and foetal growth, and to check the foetal lie and presentation.

Fundal height: The fundal height indicates the progress of the pregnancy and foetal growth. The uterus becomes an abdominal organ after 12 weeks of gestation. The gestational age (in weeks) can be estimated from the fundal height (in cm) after 12 weeks of gestation : Palpate for the foetal lie and assess whether it is longitudinal, transverse or oblique. Remember, if a malpresentation is diagnosed before 36 weeks, no active management or intervention is recommended at that point of time

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Facts Of Infertility

FACT : It is only partly true. Most of the patients either needs only medical advice or small procedures like IUI, laparoscopy, ultrasound monitoring, which are well within the reach of a common man.

However ART (assisted reproduction and technology) like Test Tube Baby and ICSI are costly. But only 10-15% of patients needs ARTs, Moreover, due to the globalization of world market, ART is becoming popular, acceptable and cost effective.

FACT : Infertility is a medical problem.

Approximately 35% of Infertility is due to female factor and 35% is due to male factor. In the balance of cases, Infertility results from problems in both partners or the cause of the infertility cant be explained.

FACT : Removing sugars from the diet, (e.g., caffeine, white flour, white sugar, white corn, white rice, etc.), will improve ovulation and regularity. Foods that are broken down quickly raise insulin levels too quickly and disrupt delicate hormonal values in the ovaries causing more testosterone to be produced, impairing egg quality and thus possibly lowering the chance of conception. In some women, high insulin levels may cause irregular ovulation, irregular periods, or polycystic ovarian syndrome (PCOS).

FACT : In a study of more than 2,000 women, " lengthy Infertility treatment " was listed as one of the four key causes of sexual aversion. (The other three were childhood sex abuse, rape, and painful labor ad delivery.) Most couples report a decrease in the frequency of sexual relations after a diagnosis of Infertility. What was once a source of emotional intimacy often becomes " love by the calender, "and infertile couple say they feel a loss of privacy, sometimes even envisioning a doctor in the room during sexual intimacy. Both male and female infertility patients report a decrease in their level of sexual satisfaction, with the women also reporting that they feel less comfortable with their sexuality. More than one infertility counselor has told us, "I've never seen a couple going through fertility treatments who felt they had a great sex life."

FACT : Approximately one in ten married women has never experienced an orgasm, and millions of these women have conceived. Additionally, many people believe that when a woman achieves climax-especially after the man does-fertility may be slightly increased due to enhanced sperm movement created by a small suction effect that's thought to pull sperm into the women's uterus. There's a certain logic behind this theory. Yet while studies have shown that such a "vacuum effect" exists, whether it actually brings about a higher PREGNANCY rate is as of yet unproven

FACT : According to the National Survey of Family Growth, more than one million couples experience " secondary Infertility." A previously fertile partner may be trying to have a child with a new spouse, or one or both partners in an existing relationship may have developed fertility problems since their last child was conceived, (e.g., endometriosis - one of the most frequent causes of secondary Infertility in women), irregular ovulation, or fallopian tube disease. Or, a Man might have had a decline in the concentration or motility of his sperm. Other factors can involve age (even one or two years can make a big difference in a woman's fertility cycle and a man's sperm count), scarring after childbirth, or hormonal changes, which can affect ovulation and sperm production.

FACT : Position makes no difference Sperm have to reach cervical mucus within five minutes, or they are inactivated by the active PH of the vagina. Hips resting on a pillow or staying in the position at the time of ejaculation will not enhance fertility.

FACT : Abnormal level of stress hormones in the body system can affect sperm production and prevent of delay ovulation or poor implantation of the foetus. Nearly 20%-40% of all pregnancies end in a miscarriage, most of these during the first trimester.

FACT : There is evidence linking reproductive impairment with exposure to aclochol, tobacco & caffeine. Alcohol and tobacco use have been demonstrated to affect the reproductive capacities of both men and women, and tobacco is an especially potent reproductive toxin. It is wise to be in the best physical shape possibel while you attempt to conceive and, of course, to ensure a healthy PREGNANCY and baby.

FACT : Currently the success rate per oocyte retrieval cycle is 35-40% all over the world. Ther patients are advised to be mentally prepared to avoid bitter disappointment and depression case the procedure fails. However the chance of pregancy is 60-70% within 3-4 attempts of IVF. The cryopreservation of embryos eliminates the need of stimulation for future cycles which dramatically reduces the cost of procedure.

FACT : Body fat within normal range, which is between 20 and 24 percent of body weight for women, is very important in making sure that the reproductive system functions normally. A Simple way to assess appropriate weight in relation to height to measure the height of woman.

For first 5 Feet, the woman should way 45kg. For each inch over 5 feet, add 2kg. Ideal body weight should fall between 95% to 129% of predicted ideal weight. Reproduction is impaired both if ideal weight is abnormally low or high.

FACT : It is good idea to have intercourse every other day around the time you ovulate. (Day 10, 12, 14 and 16) Remember, every woman is different, and may not ovulate exactly on"Day14". And, just because you ovulate on "Day 14" this month, doesn't mean it you will next month.

It is preferable to have intercourse every other day rather than every day so that sufficient sperm will be available. To increase your chances of the egg becoming fertilized, do not douche or use lubricants immediately before having intercourse.

FACT : Yes, High temperature can kill sperms.

That is why the scrotum is located inside the body - to act as kind of "Refrigerator" to keep sperm cool. So, it is a good idea to avoid hot tubs. Saunas and steam rooms. Wear loose pants and under-wears.

FACT : The simple, inexpensive way of finding out the approximate time when you ovulate is to take your basal temperature (that is, your body temperature at rest) every morning and record it on a chart.

You can buy a basal body Thermometer at any drug store. Save all your charts so you can review them with your doctor. Three or four months of charting should be adequate.

FACT : The most fertile time of the month is just before or at ovulation. Ovulation usually occurs two weeks before a period starts, so it is necessary to count backwards from the anticipate start of the next period in order to find the most fertile time.

Take the number of days in the usual cycle (from beginnings of one period to the beginning of the next) and subtract 14. For example, a woman with a 32 day period would likely to ovulate around day 18 (32-14=18), while a woman with a 28 day cycle would ovulate around day 14 (28-14=14).

Because the sperm live longer than the egg does, it is best to have intercourse before ovulation rather than afterwards, so a woman who ovulates on day 14 would have a good chance of conceiving if she has intercourse on eitherday 13 or 14.

FACT : This cannot be said with certanly as no regular record of past is available. However, the said decline is attributed to the delayed age of marriage of the woman due to carrier settlement, excessive use of drugs, rising obesity, stress and strain of modern life style, occupational factors etc.

Moreover, because of media participation more people are reporting for medical help.

FACT : Most common cause are: Ovulation Problem / Tubal Infertility / Sperm Problem / Unexplained Infertility / Age related factors / Egg quality problems, Obesity Stress, Environmental & occupational factors.

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