Rhesus Disease

Introduction 

Rhesus disease is a condition where antibodies in a pregnant woman's blood destroy her baby's blood cells. It's also known as haemolytic disease of the foetus and newborn (HDFN).
Rhesus disease doesn't harm the mother, but it can cause the baby to become anaemic and develop a yellow discoloration of the skin and eyes referred to as jaundice.

 

Causes of rhesus disease 

Rhesus disease is caused by a specific mix of blood types between a pregnant mother and her unborn baby.
Rhesus disease can only occur in cases where all of the following happen:

• the mother has a rhesus negative (RhD negative) blood type
• the baby has a rhesus positive (RhD positive) blood type
• the mother has previously been exposed to RhD positive blood and has developed an immune response to it (known as sensitisation)

These are explained in more detail below.

Blood types
There are several different types of human blood, known as blood groups, with the four main ones being A, B, AB and O. Each of these blood groups can either be RhD positive or negative.
Whether someone is RhD positive or RhD negative is determined by the presence of the rhesus D (RhD) antigen. This is a molecule found on the surface of red blood cells.
People who have the RhD antigen are RhD positive, and those without it are RhD negative. In the UK, around 85% of the population are RhD positive.

How blood types are inherited
Your blood type depends on the genes you inherit from your parents. Whether you're RhD positive or negative depends on how many copies of the RhD antigen you've inherited. You can inherit one copy of the RhD antigen from your mother or father, a copy from both of them, or none at all.
You'll only have RhD negative blood if you don't inherit any copies of the RhD antigen from your parents.
A woman with RhD negative blood can have an RhD positive baby if her partner's blood type is RhD positive. If the father has two copies of the RhD antigen, every baby will have RhD positive blood. If the father only has one copy of the RhD antigen, there's a 50% chance of the baby being RhD positive.

Sensitisation
An RhD positive baby will only have rhesus disease if their RhD negative mother has been sensitised to RhD positive blood. Sensitisation occurs when the mother is exposed to RhD positive blood for the first time and develops an immune response to it.
During the immune response, the woman’s body recognises that the RhD positive blood cells are foreign and creates antibodies to destroy them.
In most cases, these antibodies aren't produced quickly enough to harm a baby during the mother's first pregnancy. Instead, any RhD positive babies the mother has in the future are most at risk.

How does sensitisation occur?
During pregnancy, sensitisation can happen if:

• small numbers of foetal blood cells cross into the mother’s blood
• the mother is exposed to her baby's blood during delivery
• there's been bleeding during the pregnancy
• an invasive procedure has been necessary during pregnancy – such as amniocentesis, or chorionic villus sampling (CVS)
• the mother injures her abdomen (tummy)

Sensitisation can also occur after a previous miscarriage or ectopic pregnancy, or if a RhD negative woman has received a transfusion of RhD positive blood by mistake (although this is extremely rare).

How sensitisation leads to rhesus disease
If sensitisation occurs, the next time the woman is exposed to RhD positive blood her body will produce antibodies immediately.
If she's pregnant with an RhD positive baby, the antibodies can lead to rhesus disease when they cross the placenta and start attacking the baby's red blood cells.

Symptoms of rhesus disease 

Rhesus disease only affects the baby, and the mother won't experience any symptoms.
The symptoms of rhesus disease depend on how severe it is. Around 50% of babies diagnosed with rhesus disease have mild symptoms that are easily treatable.

Signs in an unborn baby
 Anaemia because red blood cells are being destroyed faster than usual by the antibodies.
If your baby is anaemic, their blood will be thinner and flow at a faster rate. This doesn't usually cause any noticeable symptoms, but it can be detected with a type of ultrasound scan known as a Doppler ultrasound.
If the anaemia is severe, complications of rhesus disease, such as internal swelling, may be detected during scans.

Signs in a newborn baby
The two main problems caused by rhesus disease in a newborn baby are haemolytic anaemia and jaundice. In some cases, the baby may also have low muscle tone (hypotonia) and they may be lacking in energy.
If a baby has rhesus disease, they won't always have obvious symptoms when they're born. Symptoms can sometimes develop up to three months afterwards.

Haemolytic anaemia
Haemolytic anaemia occurs when red blood cells are destroyed. This happens when the antibodies from the mother’s RhD negative blood cross the placenta into the baby’s blood. The antibodies attack the baby’s RhD positive blood, destroying the red blood cells.
In the newborn baby, this may cause pale skin, increased breathing rate, poor feeding or jaundice (see below).

Jaundice
Jaundice in newborn babies turns their skin and the whites of their eyes yellow. In babies with dark skin, the yellowing will be most obvious in their eyes or on their palms and soles.
Jaundice is caused by a build-up of a chemical called bilirubin in the blood. Bilirubin is a yellow substance that's made naturally in the body when red blood cells are broken down. It's normally removed from the blood by the liver, so it can be passed out of the body in urine.
In babies with rhesus disease, the liver cannot process the high levels of bilirubin that build up as a result of the baby's red blood cells being destroyed

 

 

 

 

Diagnosing rhesus disease 

Rhesus disease is usually diagnosed during the routine screening tests you're offered during pregnancy.

Blood tests
A blood test should be carried out early on in your pregnancy to test for conditions such as anaemia, rubella, HIV and hepatitis B.
Your blood will also be tested to determine which blood group you are, and whether your blood is rhesus (RhD) positive or negative (see causes of rhesus disease for more information).
If you're RhD negative, your blood will be checked for the antibodies (known as anti-D antibodies) that destroy RhD positive red blood cells. You may have become exposed to them during pregnancy if your baby has RhD positive blood.
If no antibodies are found, your blood will be checked again at 28 weeks of pregnancy and you'll be offered an injection of a medication called anti-D immunoglobulin to reduce the risk of your baby developing rhesus disease (see preventing rhesus disease for more information).
If anti-D antibodies are detected in your blood during pregnancy, there's a risk that your unborn baby will be affected by rhesus disease. For this reason, you and your baby will be monitored more frequently than usual during your pregnancy.
In some cases, a blood test to check the father's blood type may be offered if you have RhD negative blood. This is because your baby won't be at risk of rhesus disease if both the mother and father have RhD negative blood.

Checking your baby's blood type
It's possible to determine if an unborn baby is RhD positive or RhD negative by taking a simple blood test during pregnancy.
Genetic information (DNA) from the unborn baby can be found in the mother's blood, which allows the blood group of the unborn baby to be checked without any risk. It's usually possible to get a reliable result from this test after 11-12 weeks of pregnancy, which is long before the baby is at risk from the antibodies.
If your baby is RhD negative, they're not at risk of rhesus disease and no extra monitoring or treatment will be necessary. If they're found to be RhD positive, the pregnancy will be monitored more closely so that any problems that may occur can be treated quickly.
In the future, RhD negative women who haven't developed anti-D antibodies may be offered this test routinely, to see if they're carrying an RhD positive or RhD negative baby, to avoid unnecessary treatment.

 

Monitoring during pregnancy

If your baby is at risk of developing rhesus disease, they'll be monitored by measuring the blood flow in their brain. If your baby is affected, their blood may be thinner and flow more quickly. This can be measured using a type of ultrasound scan called a Doppler ultrasound.
If a Doppler ultrasound shows your baby’s blood is flowing faster than normal, a procedure called fetal blood sampling (FBS) can be used to check whether your baby is anaemic. This procedure involves inserting a needle through your abdomen (tummy) to remove a small sample of blood from your baby. The procedure is performed under local anaesthetic, usually on an outpatient basis, so you can go home on the same day.
There's a small (usually 1-3%) chance that this procedure could cause you to lose your pregnancy, so it should only be carried out if necessary.
If your baby is found to be anaemic, they can be given a transfusion of blood through the same needle. This is known as an intrauterine transfusion (IUT) and it may require an overnight stay in hospital.
FBS and IUT are only carried out in specialist units, so you may need to be referred to a different hospital to the one where you were going to have your baby.

 

Diagnosis in a newborn baby

If you're RhD negative, blood will be taken from your baby’s umbilical cord when they're born. This is to check their blood group and see if the anti-D antibodies have been passed into their blood. This is called a Coombs test.
If you're known to have anti-D antibodies, your baby’s blood will also be tested for anaemia and jaundice.




 

Treating rhesus disease 

Treatment for rhesus disease depends on how severe the condition is. In more severe cases, treatment may need to begin before the baby is born.
Around half of all cases of rhesus disease are mild and don't usually require much treatment. However, your baby will need to be monitored regularly, in case serious problems develop.
In more severe cases, a treatment called phototherapy is usually needed and blood transfusions may help to speed up the removal of bilirubin (a substance created when red blood cells break down) from the body.
In the most serious cases, a blood transfusion may be carried out while your baby is still in the womb and a medication called intravenous immunoglobulin may be used when they're born if phototherapy isn't effective.
If necessary, the baby may be delivered early using medication to start labour (induction) or a caesarean section, so treatment can start as soon as possible. This is usually only done after about 34 weeks of pregnancy.

Phototherapy
Phototherapy is treatment with light. It involves placing the newborn baby under a halogen or fluorescent lamp with their eyes covered.
Alternatively, they may be placed on a blanket containing optical fibres through which light travels and shines onto the baby's back (fibre optic phototherapy).
The light absorbed by the skin during phototherapy lowers the bilirubin levels in the baby’s blood through a process called photo-oxidation. This means that oxygen is added to the bilirubin, which helps it to dissolve in water. This makes it easier for the baby’s liver to break down the bilirubin and remove it from the blood.
During phototherapy, fluids will usually be given into a vein (intravenous hydration) because more water is lost through your baby's skin and more urine is produced as the bilirubin is expelled.
Using phototherapy can sometimes reduce the need for a blood transfusion.

Blood transfusions
In some cases, the levels of bilirubin in the blood may be high enough to require one or more blood transfusions.
During a blood transfusion, some of your baby’s blood is removed and replaced with blood from a suitable matching donor (someone with the same blood group). A blood transfusion normally takes place through a tube inserted into a vein (intravenous cannula).
This process helps to remove some of the bilirubin in the baby’s blood and also removes the antibodies that cause rhesus disease.
It's also possible for the baby to have a transfusion of just red blood cells to top up those they already have.

Blood transfusion to an unborn baby
If your baby develops rhesus disease while still in the womb, they may need to be given a blood transfusion before birth. This is known as intrauterine foetal blood transfusion.
An intrauterine foetal blood transfusion requires specialist training and is not available in all hospitals. You may therefore be referred to a different hospital for the procedure.
A needle is usually inserted through the mother's abdomen (tummy) and into the umbilical cord, so donated blood can be injected into the baby. An ultrasound scanner is used to help guide the needle to the right place.
Local anaesthetic is used to numb the area, but you'll be awake during the procedure. A sedative may be given to keep you relaxed and your baby may also be sedated to help stop them moving during the procedure.
You may need more than one intrauterine foetal blood transfusion. Transfusions can be repeated every two to four weeks until your baby is mature enough to be delivered. They may even reduce the need for phototherapy after birth, but further blood transfusions could still be necessary.
There's a small risk of miscarriage during an intrauterine foetal blood transfusion, so it's usually only used in particularly severe cases.

Intravenous immunoglobulin
In some cases, treatment with intravenous immunoglobulin (IVIG) is used alongside phototherapy if the level of bilirubin in your baby’s blood continues to rise at an hourly rate.
The immunoglobulin is a solution of antibodies (proteins produced by the immune system to fight against disease-carrying organisms) taken from healthy donors. Intravenous means that it's injected into a vein.
Intravenous immunoglobulin helps to prevent red blood cells being destroyed, so the level of bilirubin in your baby’s blood will stop rising. It also reduces the need for a blood transfusion.
However, it does carry some small risks. It's possible that your baby may have an allergic reaction to the immunoglobulin, although it's difficult to calculate how likely this is or how severe the reaction will be.
Concerns over possible side effects, and the limited supply of intravenous immunoglobulin, mean that it's only used when the bilirubin level is rising rapidly, despite phototherapy sessions.
Intravenous immunoglobulin has also been used during pregnancy, in particularly severe cases of rhesus disease, as it can delay the need for treatment with intrauterine foetal blood transfusions.




 

Complications of rhesus disease 

Although rhesus disease is rare and most cases are successfully treated, there are some risks to both unborn and newborn babies.

Unborn babies
If rhesus disease causes severe anaemia in an unborn baby, it can lead to:

• foetal heart failure
• fluid retention and swelling (foetal hydrops)
• stillbirth 

Blood transfusions given to a baby in the womb (intrauterine transfusions [IUT]), can be used to treat anaemia in an unborn baby. However, this treatment also carries some risks of complications. It can lead to an early labour that begins before the 37th week of pregnancy and there's a 2% risk of miscarriage or stillbirth.

Newborn babies
Rhesus disease causes a build up of excessive amounts of a substance called bilirubin. Without prompt treatment, a build-up of bilirubin in the brain can lead to a neurological condition called kernicterus. This can lead to deafness, blindness, brain damage, learning difficulties or even death.
Treatment for rhesus disease is usually effective in reducing bilirubin levels in the blood, so these complications are uncommon.

Blood transfusions
The risk of developing an infection from the blood used in blood transfusions is low, because all the blood is carefully screened. The blood used will also be matched to the baby’s blood type, so the likelihood of your baby having an adverse reaction to the donated blood is also low.
However, there may be a problem with the transfusion itself. For example, the tube (catheter) used to deliver the blood can become dislodged, causing heavy bleeding (haemorrhage) or a blood clot.
Generally, the risks associated with blood transfusions are small and don't outweigh the benefits of treating a baby with anaemia




 

Preventing rhesus disease 

Rhesus disease can largely be prevented by having an injection of a medication called anti-D immunoglobulin.
This can help to avoid a process known as sensitisation, which is when a woman with RhD negative blood is exposed to RhD positive blood and develops an immune response to it.
Blood is known as RhD positive when it has a molecule called the RhD antigen on the surface of the red blood cells.

Anti-D immunoglobulin
The anti-D immunoglobulin neutralises any RhD positive antigens that may have entered the mother’s blood during pregnancy. If the antigens have been neutralised, the mother’s blood won't produce antibodies.
You'll be offered anti-D immunoglobulin if it's thought there's a risk that RhD antigens from your baby have entered your blood – for example, if you experience any bleeding, if you have an invasive procedure (such as amniocentesis) or if you experience any abdominal injury.
Anti-D immunoglobulin is also administered routinely during the third trimester of your pregnancy if your blood type is RhD negative. This is because it's likely that small amounts of blood from your baby will pass into your blood during this time.
This routine administration of anti-D immunoglobulin is called routine antenatal anti-D prophylaxis, or RAADP (prophylaxis means a step taken to prevent something from happening).

Routine antenatal anti-D prophylaxis (RAADP)
There are currently two ways you can receive RAADP:

• a one-dose treatment: where you receive an injection of immunoglobulin at some point during weeks 28 to 30 of your pregnancy
• a two-dose treatment: where you receive two injections; one during the 28th week and the other during the 34th week of your pregnancy

There doesn't seem to be any difference in the effectiveness between the one-dose or two-dose treatments. Your local clinical commissioning group (CCG) may prefer to use a one-dose treatment, because it can be more efficient in terms of resources and time.

When will RAADP be given?
RAADP is recommended for all pregnant RhD negative women who haven't been sensitised to the RhD antigen, even if you previously had an injection of anti-D immunoglobulin.
As RAADP doesn't offer lifelong protection against rhesus disease, it will be offered every time you become pregnant if you meet these criteria.
RAADP won't work if you’ve already been sensitised. In these cases, you'll be closely monitored so treatment can begin as soon as possible if problems develop.

Anti-D immunoglobulin after birth
After giving birth, a sample of your baby's blood will be taken from the umbilical cord. If you're RhD negative and your baby is RhD positive, and you haven't already been sensitised, you'll be offered an injection of anti-D immunoglobulin within 72 hours of giving birth.
The injection will destroy any RhD positive blood cells that may have crossed over into your bloodstream during the delivery. This means your blood won't have a chance to produce antibodies and will significantly decrease the risk of your next baby having rhesus disease.

 

Complications from anti-D immunoglobulin

Some women are known to develop a slight short-term allergic reaction to anti-D immunoglobulin, which can include a rash or flu-like symptoms.
Although the anti-D immunoglobulin, which is made from donor plasma, will be carefully screened, there's a very small risk that an infection could be transferred through the injection.
However, the evidence in support of RAADP shows that the benefits of preventing sensitisation far outweigh these small risks.
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Gestational Diabetes

Definition

Gestational diabetes develops during pregnancy (gestation). Like other types of diabetes, gestational diabetes affects how your cells use sugar (glucose). Gestational diabetes causes high blood sugar that can affect your pregnancy and your baby's health.
Any pregnancy complication is concerning, but there's good news. Expectant moms can help control gestational diabetes by eating healthy foods, exercising and, if necessary, taking medication. Controlling blood sugar can prevent a difficult birth and keep you and your baby healthy.
In gestational diabetes, blood sugar usually returns to normal soon after delivery. But if you've had gestational diabetes, you're at risk for type 2 diabetes. You'll continue working with your health care team to monitor and manage your blood sugar.

Symptoms

For most women, gestational diabetes doesn't cause noticeable signs or symptoms.

Causes

Researchers don't know why some women develop gestational diabetes. To understand how gestational diabetes occurs, it can help to understand how pregnancy affects your body's glucose processing.
Your body digests the food you eat to produce sugar (glucose) that enters your bloodstream. In response, your pancreas — a large gland behind your stomach — produces insulin. Insulin is a hormone that helps glucose move from your bloodstream into your body's cells, where it's used as energy.
During pregnancy, the placenta, which connects your baby to your blood supply, produces high levels of various other hormones. Almost all of them impair the action of insulin in your cells, raising your blood sugar. Modest elevation of blood sugar after meals is normal during pregnancy.
As your baby grows, the placenta produces more and more insulin-blocking hormones. In gestational diabetes, the placental hormones provoke a rise in blood sugar to a level that can affect the growth and welfare of your baby. Gestational diabetes usually develops during the last half of pregnancy — sometimes as early as the 20th week, but generally not until later.\

Risk factors

Any woman can develop gestational diabetes, but some women are at greater risk. Risk factors for gestational diabetes include:

• Age greater than 25. Women older than age 25 are more likely to develop gestational diabetes.
• Family or personal health history. Your risk of developing gestational diabetes increases if you have prediabetes — slightly elevated blood sugar that may be a precursor to type 2 diabetes — or if a close family member, such as a parent or sibling, has type 2 diabetes. You're also more likely to develop gestational diabetes if you had it during a previous pregnancy, if you delivered a baby who weighed more than 9 pounds (4.1 kilograms), or if you had an unexplained stillbirth.
• Excess weight. You're more likely to develop gestational diabetes if you're significantly overweight with a body mass index (BMI) of 30 or higher.
• Nonwhite race. For reasons that aren't clear, women who are black, Hispanic, American Indian or Asian are more likely to develop gestational diabetes.

Complications

Most women who have gestational diabetes deliver healthy babies. However, gestational diabetes that's not carefully managed can lead to uncontrolled blood sugar levels and cause problems for you and your baby, including an increased likelihood of needing a C-section to deliver.
Complications that may affect your baby
If you have gestational diabetes, your baby may be at increased risk of:

• Excessive birth weight. Extra glucose in your bloodstream crosses the placenta, which triggers your baby's pancreas to make extra insulin. This can cause your baby to grow too large (macrosomia). Very large babies — those that weigh 9 pounds or more — are more likely to become wedged in the birth canal, sustain birth injuries or require a C-section birth.
• Early (preterm) birth and respiratory distress syndrome. A mother's high blood sugar may increase her risk of early labor and delivering her baby before its due date. Or her doctor may recommend early delivery because the baby is large.
  Babies born early may experience respiratory distress syndrome — a condition that makes breathing difficult. Babies with this syndrome may need help breathing until their lungs mature and become stronger. Babies of mothers with gestational diabetes may experience respiratory distress syndrome even if they're not born early.
  
• Low blood sugar (hypoglycemia). Sometimes babies of mothers with gestational diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own insulin production is high. Severe episodes of hypoglycemia may provoke seizures in the baby. Prompt feedings and sometimes an intravenous glucose solution can return the baby's blood sugar level to normal.
• Type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a higher risk of developing obesity and type 2 diabetes later in life.

Untreated gestational diabetes can result in a baby's death either before or shortly after birth.

Complications that may affect you

Gestational diabetes may also increase the mother's risk of:

• High blood pressure and preeclampsia. Gestational diabetes raises your risk of high blood pressure, as well as, preeclampsia — a serious complication of pregnancy that causes high blood pressure and other symptoms that can threaten the lives of both mother and baby.
• Future diabetes. If you have gestational diabetes, you're more likely to get it again during a future pregnancy. You're also more likely to develop type 2 diabetes as you get older. However, making healthy lifestyle choices such as eating healthy foods and exercising can help reduce the risk of future type 2 diabetes.
  Of those women with a history of gestational diabetes who reach their ideal body weight after delivery, fewer than 1 in 4 eventually develops type 2 diabetes.
  
  
  

  Tests and diagnosis

  Medical experts haven't agreed on a single set of screening guidelines for gestational diabetes. Some question whether gestational diabetes screening is needed if you're younger than 25 and have no risk factors. Others say that screening all pregnant women is the best way to identify all cases of gestational diabetes.
  

  When to screen

  Your doctor will likely evaluate your risk factors for gestational diabetes early in your pregnancy.
  If you're at high risk of gestational diabetes — for example, your body mass index (BMI) before pregnancy was 30 or higher or you have a mother, father, sibling or child with diabetes — your doctor may test for diabetes at your first prenatal visit.
  If you're at average risk of gestational diabetes, you'll likely have a screening test during your second trimester — between 24 and 28 weeks of pregnancy.
  

  Routine screening for gestational diabetes

Screening for diabetes mellitus during pregnancy

Gestational diabetes
The following 2-step screening system for gestational diabetes is currently recommended in the United States:

• 50-g, 1-hour glucose challenge test (GCT)
• 100-g, 3-hour oral glucose tolerance test (OGTT) - For patients with an abnormal GCT result

Alternatively, for high-risk women or in areas in which the prevalence of insulin resistance is 5% or higher (eg, the southwestern and southeastern United States), a 1-step approach can be used by proceeding directly to the 100-g, 3-hour OGTT.
The US Preventive Services Task Force (USPSTF) recommends screening for gestational diabetes mellitus after 24 weeks of pregnancy. The recommendation applies to asymptomatic women with no previous diagnosis of type 1 or type 2 diabetes mellitus.^{[4, 5]} The recommendation does not specify whether the 1-step or 2-step screening approach would be preferable.
Type 1 diabetes

• The disease is typically diagnosed during an episode of hyperglycemia, ketosis, and dehydration
• It is most commonly diagnosed in childhood or adolescence; the disease is rarely diagnosed during pregnancy
• Patients diagnosed during pregnancy most often present with unexpected coma - Early pregnancy may provoke diet and glycemic control instability in patients with occult diabetes

Type 2 diabetes
According to the American Diabetes Association’s "Standards of Medical Care in Diabetes--2010,"^{[6, 7]} the presence of any one of the following criteria supports the diagnosis of diabetes mellitus:

• Hemoglobin A1C (HbA1C) = 6.5%
• Fasting plasma glucose = >126 mg/dL (7.0 mmol/L)
• A 2-hour plasma glucose level = 200 mg/dL (11.1 mmol/L) during a 75-g OGTT
• A random plasma glucose level = 200 mg/dL (11.1 mmol/l) in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis

In the absence of unequivocal hyperglycemia, a diagnosis based on any of the first 3 criteria should be confirmed by repeat testing on a different day.
Prediabetes
Women with prediabetes identified before pregnancy should be considered at extremely high risk for developing gestational diabetes mellitus during pregnancy. As such, they should receive early (first-trimester) diabetic screening.

Postdiagnostic testing

Once the diagnosis of diabetes is established in a pregnant woman, continued testing for glycemic control and diabetic complications is indicated for the remainder of the pregnancy.
First-trimester laboratory studies

• HbA1C
• Blood urea nitrogen (BUN)
• Serum creatinine
• Thyroid-stimulating hormone
• Free thyroxine levels
• Spot urine protein-to-creatinine ratio
• Capillary blood sugar levels

Second-trimester laboratory studies

• Spot urine protein-to-creatinine study in women with elevated value in first trimester
• Repeat HbA1C
• Capillary blood sugar levels

Ultrasonography

• First trimester - Ultrasonographic assessment for pregnancy dating and viability
• Second trimester - Detailed anatomic ultrasonogram at 18-20 weeks and a fetal echocardiogram if the maternal glycohemoglobin value was elevated in the first trimester
• Third trimester - Growth ultrasonogram to assess fetal size every 4-6 weeks from 26-36 weeks in women with overt preexisting diabetes; perform a growth ultrasonogram for fetal size at least once at 36-37 weeks for women with gestational diabetes mellitus

Electrocardiography
If maternal diabetes is longstanding or associated with known microvascular disease, obtain a baseline maternal electrocardiogram (ECG) and echocardiogram.

Blood sugar testing after you give birth

Your doctor will check your blood sugar after delivery and again in six to 12 weeks to make sure that your level has returned to normal. If your tests are normal — and most are — you'll need to have your diabetes risk assessed at least every three years.
If future tests indicate diabetes or prediabetes — a condition in which your blood sugar is higher than normal, but not high enough to be considered diabetes — talk with your doctor about increasing your prevention efforts or starting a diabetes management plan.

Treatments and drugs

It's essential to monitor and control your blood sugar to keep your baby healthy and avoid complications during pregnancy and delivery. You'll also want to keep a close eye on your future blood sugar levels. Your treatment strategies may include:

• Monitoring your blood sugar. While you're pregnant, your health care team may ask you to check your blood sugar four to five times a day — first thing in the morning and after meals — to make sure your level stays within a healthy range. This may sound inconvenient and difficult, but it'll get easier with practice.
  To test your blood sugar, you draw a drop of blood from your finger using a small needle (lancet), then place the blood on a test strip inserted into a blood glucose meter — a device that measures and displays your blood sugar level.
  Your health care team will monitor and manage your blood sugar during labor and delivery. If your blood sugar rises, your baby's pancreas may release high levels of insulin — which can cause low blood sugar in your baby right after birth.
  Follow-up blood sugar checks are also important. Having gestational diabetes increases your risk of developing type 2 diabetes later in life. Work with your health care team to keep an eye on your levels. Maintaining health-promoting lifestyle habits, such as a healthy diet and regular exercise, can help reduce your risk.
  
• Healthy diet. Eating the right kinds of food in healthy portions is one of the best ways to control your blood sugar and prevent too much weight gain, which can put you at higher risk of complications. Doctors don't advise losing weight during pregnancy — your body is working hard to support your growing baby. But your doctor can help you set weight gain goals based on your weight before pregnancy.
  A healthy diet focuses on fruits, vegetables and whole grains — foods that are high in nutrition and fiber and low in fat and calories — and limits highly refined carbohydrates, including sweets. No single diet is right for every woman. You may want to consult a registered dietitian or a diabetes educator to create a meal plan based on your current weight, pregnancy weight gain goals, blood sugar level, exercise habits, food preferences and budget.
  
• Exercise. Regular physical activity plays a key role in every woman's wellness plan before, during and after pregnancy. Exercise lowers your blood sugar by stimulating your body to move glucose into your cells, where it's used for energy. Exercise also increases your cells' sensitivity to insulin, which means your body will need to produce less insulin to transport sugar.
  As an added bonus, regular exercise can help relieve some common discomforts of pregnancy, including back pain, muscle cramps, swelling, constipation and trouble sleeping. Exercise can also help get you in shape for the hard work of labor and delivery.
  With your doctor's OK, aim for moderately vigorous exercise on most days of the week. If you haven't been active for a while, start slowly and build up gradually. Walking, cycling and swimming are good choices during pregnancy. Everyday activities such as housework and gardening also count.
  
• Medication.  Insulin
  The goal of insulin therapy during pregnancy is to achieve glucose profiles similar to those of nondiabetic pregnant women. In gestational diabetes, early intervention with insulin or an oral agent is key to achieving a good outcome when diet therapy fails to provide adequate glycemic control.
  Glyburide and metformin
  The efficacy and safety of insulin have made it the standard for treatment of diabetes during pregnancy. Diabetic therapy with the oral agents glyburide and metformin, however, has been gaining in popularity. Trials have shown these 2 drugs to be effective, and no evidence of harm to the fetus has been found, although the potential for long-term adverse effects remains a concern.
  
• Close monitoring of your baby. An important part of your treatment plan is close observation of your baby. Your doctor may monitor your baby's growth and development with repeated ultrasounds or other tests. If you don't go into labor by your due date — or sometimes earlier — your doctor may induce labor. Delivering after your due date may increase the risk of complications for you and your baby.

Prevention

There are no guarantees when it comes to preventing gestational diabetes — but the more healthy habits you can adopt before pregnancy, the better. If you've had gestational diabetes, these healthy choices may also reduce your risk of having it in future pregnancies or developing type 2 diabetes down the road.

• Eat healthy foods. Choose foods high in fiber and low in fat and calories. Focus on fruits, vegetables and whole grains. Strive for variety to help you achieve your goals without compromising taste or nutrition. Watch portion sizes.
• Keep active. Exercising before and during pregnancy can help protect you from developing gestational diabetes. Aim for 30 minutes of moderate activity on most days of the week. Take a brisk daily walk. Ride your bike. Swim laps.
  If you can't fit a single 30-minute workout into your day, several shorter sessions can do just as mu

Causes of Missed monthly period in women

Definition

Amenorrhea (uh-men-o-REE-uh) is the absence of menstruation — one or more missed menstrual periods. Women who have missed at least three menstrual periods in a row have amenorrhea, as do girls who haven't begun menstruation by age 15.
The most common cause of amenorrhea is pregnancy. Other causes of amenorrhea include problems with the reproductive organs or with the glands that help regulate hormone levels. Treatment of the underlying condition often resolves amenorrhea.

 Symptoms

The main sign of amenorrhea is the absence of menstrual periods. Depending on the cause of amenorrhea, you might experience other signs or symptoms along with the absence of periods, such as:

• Milky nipple discharge
• Hair loss
• Headache
• Vision changes
• Excess facial hair
• Pelvic pain
• Acne

 Causes

Amenorrhea can occur for a variety of reasons. Some are normal during the course of a woman's life, while others may be a side effect of medication or a sign of a medical problem.

Natural amenorrhea

During the normal course of your life, you may experience amenorrhea for natural reasons, such as:

• Pregnancy
• Breast-feeding
• Menopause

Contraceptives

Some women who take birth control pills may not have periods. Even after stopping oral contraceptives, it may take some time before regular ovulation and menstruation return. Contraceptives that are injected or implanted also may cause amenorrhea, as can some types of intrauterine devices.

Medications

Certain medications can cause menstrual periods to stop, including some types of:

• Antipsychotics
• Cancer chemotherapy
• Antidepressants
• Blood pressure drugs
• Allergy medications

 

 Lifestyle factors

Sometimes lifestyle factors contribute to amenorrhea, for instance:

• Low body weight. Excessively low body weight — about 10 percent under normal weight — interrupts many hormonal functions in your body, potentially halting ovulation. Women who have an eating disorder, such as anorexia or bulimia, often stop having periods because of these abnormal hormonal changes.
• Excessive exercise. Women who participate in activities that require rigorous training, such as ballet, may find their menstrual cycles interrupted. Several factors combine to contribute to the loss of periods in athletes, including low body fat, stress and high energy expenditure.
• Stress. Mental stress can temporarily alter the functioning of your hypothalamus — an area of your brain that controls the hormones that regulate your menstrual cycle. Ovulation and menstruation may stop as a result. Regular menstrual periods usually resume after your stress decreases.

Hormonal imbalance

Many types of medical problems can cause hormonal imbalance, including:

• Polycystic ovary syndrome (PCOS). PCOS causes relatively high and sustained levels of hormones, rather than the fluctuating levels seen in the normal menstrual cycle.
• Thyroid malfunction. An overactive thyroid gland (hyperthyroidism) or underactive thyroid gland (hypothyroidism) can cause menstrual irregularities, including amenorrhea.
• Pituitary tumor. A noncancerous (benign) tumor in your pituitary gland can interfere with the hormonal regulation of menstruation.
• Premature menopause. Menopause usually begins around age 50. But, for some women, the ovarian supply of eggs diminishes before age 40, and menstruation stops.

Structural problems

Problems with the sexual organs themselves also can cause amenorrhea. Examples include:

• Uterine scarring. Asherman's syndrome, a condition in which scar tissue builds up in the lining of the uterus, can sometimes occur after a dilation and curettage (D&C), cesarean section or treatment for uterine fibroids. Uterine scarring prevents the normal buildup and shedding of the uterine lining.
• Lack of reproductive organs. Sometimes problems arise during fetal development that lead to a girl being born without some major part of her reproductive system, such as her uterus, cervix or vagina. Because her reproductive system didn't develop normally, she can't have menstrual cycles.
• Structural abnormality of the vagina. An obstruction of the vagina may prevent visible menstrual bleeding. A membrane or wall may be present in the vagina that blocks the outflow of blood from the uterus and cervix. 

Risk factors

Factors that may increase your risk of amenorrhea may include:

• Family history. If other women in your family have experienced amenorrhea, you may have inherited a predisposition for the problem.
• Eating disorders. If you have an eating disorder, such as anorexia or bulimia, you are at higher risk of developing amenorrhea.
• Athletic training. Rigorous athletic training can increase your risk of amenorrhea.

Complications

Complications of amenorrhea may include:

• Infertility. If you don't ovulate and have menstrual periods, you can't become pregnant.
• Osteoporosis. If your amenorrhea is caused by low estrogen levels, you may also be at risk of osteoporosis — a weakening of your bones.

Tests and diagnosis

During your appointment, your doctor will perform a pelvic exam to check for any problems with your reproductive organs. If you've never had a period, your doctor may examine your breasts and genitals to see if you're experiencing the normal changes of puberty.
Amenorrhea can be a sign of a complex set of hormonal problems. Finding the underlying cause can take time and may require more than one kind of testing.

Lab tests

A variety of blood tests may be necessary, including:

• Pregnancy test. This will probably be the first test your doctor suggests, to rule out or confirm a possible pregnancy.
• Thyroid function test. Measuring the amount of thyroid-stimulating hormone (TSH) in your blood can determine if your thyroid is working properly.
• Ovary function test. Measuring the amount of follicle-stimulating hormone (FSH) in your blood can determine if your ovaries are working properly.
• Prolactin test. Low levels of the hormone prolactin may be a sign of a pituitary gland tumor.
• Male hormone test. If you're experiencing increased facial hair and a lowered voice, your doctor may want to check the level of male hormones in your blood.

Hormone challenge test

For this test, you take a hormonal medication for seven to 10 days to trigger menstrual bleeding. Results from this test can tell your doctor whether your periods have stopped due to a lack of estrogen.

Imaging tests

Depending on your signs and symptoms — and the result of any blood tests you've had — your doctor might recommend one or more imaging tests, including:

• Ultrasound. This test uses sound waves to produce images of internal organs. If you have never had a period, your doctor may suggest an ultrasound test to check for any abnormalities in your reproductive organs.
• Computerized tomography (CT). CT scans combine many X-ray images taken from different directions to create cross-sectional views of internal structures. A CT scan can indicate whether your uterus, ovaries and kidneys look normal.
• Magnetic resonance imaging (MRI). MRI uses radio waves with a strong magnetic field to produce exceptionally detailed images of soft tissues within the body. Your doctor may order an MRI to check for a pituitary tumor.

Scope tests

If other testing reveals no specific cause, your doctor may recommend a hysteroscopy — a test in which a thin, lighted camera is passed through your vagina and cervix to look at the inside of your uterus.

Treatments and drugs

Treatment depends on the underlying cause of your amenorrhea. In some cases, contraceptive pills or other hormone therapies can restart your menstrual cycles. Amenorrhea caused by thyroid or pituitary disorders may be treated with medications. If a tumor or structural blockage is causing the problem, surgery may be necessary.

 Lifestyle and home remedies

Some lifestyle factors — such as too much exercise or too little food — can cause amenorrhea, so strive for balance in work, recreation and rest. Assess areas of stress and conflict in your life. If you can't decrease stress on your own, ask for help from family, friends or your doctor.
Be aware of changes in your menstrual cycle and check with your doctor if you have concerns. Keep a record of when your periods occur. Note the date your period starts, how long it lasts and any troublesome symptoms you experience.

When to see a doctor

Consult your doctor if you've missed at least three menstrual periods in a row, or if you've never had a menstrual period and you're age 15 or older.
 
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Genital Herpes

Definition

Genital herpes is a common sexually transmitted infection that affects men and women. Features of genital herpes include pain, itching and sores in your genital area. But you may have no signs or symptoms of genital herpes. If infected, you can be contagious even if you have no visible sores.
The herpes simplex virus (HSV) causes genital herpes. Sexual contact is the primary way that the virus spreads. After the initial infection, the virus lies dormant in your body and can reactivate several times a year.
There's no cure for genital herpes, but medications can ease symptoms and reduce the risk of infecting others. Condoms also can help prevent transmission of the virus.

Symptoms

 

 

Most people who've been infected with HSV don't know they have the infection because they have no signs or symptoms or because their signs and symptoms are so mild.
When present, the symptoms of genital herpes include:

• Pain or itching that begins within two to 10 days after exposure to an infected sexual partner
• Small red bumps or tiny white blisters, which may appear several days later
• Ulcers that form when the blisters rupture and ooze or bleed
• Scabs that form as the ulcers heal

Ulcers may make it painful to urinate. You also may experience pain and tenderness in your genital area until the infection clears.
During an initial outbreak, you may have flu-like signs and symptoms such as swollen lymph nodes in your groin, headache, muscle aches and fever.

 

 

Differences in symptom location

Sores appear where the infection entered your body. You can spread the infection by touching a sore and then rubbing or scratching another area of your body, including your eyes.
Men and women can develop sores on the:

• Buttocks
• Anus
• Mouth

Women can also develop sores in or on the:

• Vaginal area
• External genitals
• Cervix

Men can also develop sores in or on the:

• Penis
• Scrotum
• Thighs
• Urethra, the channel inside the penis leading to the bladder

 

 

Recurrences are common

Genital herpes is different for each person. The signs and symptoms may recur, off and on, for years. Some people experience numerous episodes each year. For many people, however, the outbreaks are less frequent as time passes.
During a recurrence, shortly before sores appear, you may feel:

• Burning, tingling and itching where the infection first entered your body
• Pain in your lower back, buttocks and legs

However, recurrences are generally less painful than the original outbreak, and sores generally heal more quickly.

 

 

When to see a doctor

If you suspect you have genital herpes — or any other sexually transmitted infection — see your doctor.

Causes

Two types of herpes simplex virus infections can cause genital herpes:

• HSV-1. This is the type that usually causes cold sores or fever blisters around your mouth, though it can be spread to your genital area during oral sex. Recurrences are much less frequent than they are with HSV-2 infection.
• HSV-2. This is the type that commonly causes genital herpes. The virus spreads through sexual contact and skin-to-skin contact. HSV-2 is very common and highly contagious, whether or not you have an open sore.

Because the virus dies quickly outside of the body, it's nearly impossible to get the infection through contact with toilets, towels or other objects used by an infected person.

Risk factors

Your risk of becoming infected with genital herpes may increase if you:

• Are a woman. Women are more likely to have genital herpes than are men. The virus is sexually transmitted more easily from men to women than it is from women to men.
• Have multiple sexual partners. Each additional sexual partner raises your risk of being exposed to the virus that causes genital herpes.

Complications

Complications associated with genital herpes may include:

• Other sexually transmitted infections. Having genital sores increases your risk of transmitting or contracting other sexually transmitted infections, including AIDS.
• Newborn infection. Babies born to infected mothers can be exposed to the virus during the birthing process. This may result in brain damage, blindness or death for the newborn.
• Bladder problems. In some cases, the sores associated with genital herpes can cause inflammation around the tube that delivers urine from your bladder to the outside world (urethra). The swelling can close the urethra for several days, requiring the insertion of a catheter to drain your bladder.
• Meningitis. In rare instances, HSV infection leads to inflammation of the membranes and cerebrospinal fluid surrounding your brain and spinal cord.
• Rectal inflammation (proctitis). Genital herpes can lead to inflammation of the lining of the rectum, particularly in men who have sex with men.

Tests and diagnosis

Your doctor usually can diagnose genital herpes based on a physical exam and the results of certain laboratory tests:

• Viral culture. This test involves taking a tissue sample or scraping of the sores for examination in the laboratory.
• Polymerase chain reaction (PCR) test. PCR is used to copy your DNA from a sample of your blood, tissue from a sore or spinal fluid. The DNA can then be tested to establish the presence of HSV and determine which type of HSV you have.
• Blood test. This test analyzes a sample of your blood for the presence of HSV antibodies to detect a past herpes infection.

Treatments and drugs

There's no cure for genital herpes. Treatment with prescription antiviral medications may:

• Help sores heal sooner during an initial outbreak
• Lessen the severity and duration of symptoms in recurrent outbreaks
• Reduce the frequency of recurrence
• Minimize the chance of transmitting the herpes virus to another

Antiviral medications used for genital herpes include:

• Acyclovir
• Famciclovir
• Valacyclovir

Your doctor may recommend that you take the medicine only when you have symptoms of an outbreak or that you take a certain medication daily, even when you have no signs of an outbreak.

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What is infertility?

In general, infertility is defined as not being able to get pregnant (conceive) after one year of unprotected sex. Women who do not have regular menstrual cycles, or are older than 35 years and have not conceived during a 6-month period of trying, should consider making an appointment with a reproductive endocrinologist—an infertility specialist. These doctors may also be able to help women with recurrent pregnancy loss—2 or more spontaneous miscarriages.

Pregnancy is the result of a process that has many steps.

To get pregnant—

• A woman’s body must release an egg from one of her ovaries (ovulation).
• A man's sperm must join with the egg along the way (fertilize).
• The fertilized egg must go through a fallopian tube toward the uterus (womb).
• The fertilized egg must attach to the inside of the uterus (implantation).

Infertility may result from a problem with any or several of these steps.

Impaired fecundity is a condition related to infertility and refers to women who have difficulty getting pregnant or carrying a pregnancy to term.

Is infertility a common problem?

Yes. About 6% of married women 15–44 years of age in the United States are unable to get pregnant after one year of unprotected sex (infertility).
Also, about 12% of women 15–44 years of age in the United States have difficulty getting pregnant or carrying a pregnancy to term, regardless of marital status (impaired fecundity).

Is infertility just a woman's problem?

No, infertility is not always a woman's problem. Both men and women contribute to infertility.
Many couples struggle with infertility and seek help to become pregnant; however, it is often thought of as only a women’s condition. A CDC study analyzed data from the 2002 National Survey of Family Growth and found that 7.5% of all sexually experienced men younger than age 45 reported seeing a fertility doctor during their lifetime—this equals 3.3–4.7 million men. Of men who sought help, 18% were diagnosed with a male-related infertility problem, including sperm or semen problems (14%) and varicocele (6%).

What causes infertility in men?

Infertility in men can be caused by different factors and is typically evaluated by a semen analysis. A specialist will evaluate the number of sperm (concentration), motility (movement), and morphology (shape). A slightly abnormal semen analysis does not mean that a man is necessarily infertile. Instead, a semen analysis helps determine if and how male factors are contributing to infertility.
Conditions that can contribute to abnormal semen analyses include— 

• Varicoceles, a condition in which the veins on a man’s testicles are large and cause them to overheat. The heat may affect the number or shape of the sperm.
• Medical conditions or exposures such as diabetes, cystic fibrosis, trauma, infection, testicular failure, or treatment with chemotherapy or radiation.
• Unhealthy habits such as heavy alcohol use, testosterone supplementation, smoking, anabolic steroid use, and illicit drug use.
• Environmental toxins including exposure to pesticides and lead.

What causes infertility in women?

Women need functioning ovaries, fallopian tubes, and a uterus to get pregnant. Conditions affecting any one of these organs can contribute to female infertility. Some of these conditions are listed below and can be evaluated using a number of different tests.
Ovarian Function (presence or absence of ovulation and effects of ovarian “age”):

• Ovulation. Regular predictable periods that occur every 24–32 days likely reflect ovulation. Ovulation can be predicted by using an ovulation predictor kit and can be confirmed by a blood test to see the woman’s progesterone level. A woman’s menstrual cycle is, on average, 28 days long. Day 1 is defined as the first day of “full flow.”
• A woman with irregular periods is likely not ovulating. This may be because of several conditions and warrants an evaluation by a doctor. Potential causes of anovulation include the following:
  • Polycystic ovary syndrome (PCOS). PCOS is a hormone imbalance problem that can interfere with normal ovulation. PCOS is the most common cause of female infertility.
  • Functional hypothalamic amenorrhea (FHA). FHA relates to excessive physical or emotional stress that results in amenorrhea (absent periods).
  • Diminished ovarian reserve (DOR). This occurs when the ability of the ovary to produce eggs is reduced because of congenital, medical, surgical, or unexplained causes. Ovarian reserves naturally decline with age.
  • Premature ovarian insufficiency (POI). POI occurs when a woman’s ovaries fail before she is 40 years of age. It is similar to premature (early) menopause.
  • Menopause . Menopause is an age-appropriate decline in ovarian function that usually occurs around age 50. It is often associated with hot-flashes and irregular periods.
• Ovarian function. Several tests exist to evaluate a woman’s ovarian function.
• No single test is a perfect predictor of fertility.
• The most commonly used markers of ovarian function include follicle stimulating hormone (FSH) value on day 3–5 of the menstrual cycle, anti-mullerian hormone value (AMH), and antral follicle count (AFC) using a transvaginal ultrasound.

Tubal Patency (whether fallopian tubes are open, blocked, or swollen):

• Risk factors for blocked fallopian tubes (tubal occlusion) can include a history of pelvic infection, history of ruptured appendicitis, history of gonorrhea or chlamydia, known endometriosis , or a history of abdominal surgery.
• Tubal evaluation may be performed using an X-ray which is called a hysterosalpingogram (HSG), or by chromopertubation (CP) in the operating room at time of laparoscopy, a surgical procedure in which a small incision is made and a viewing tube called a laparoscope is inserted.
  • Hysterosalpingogram (HSG) is an X-ray of the uterus and fallopian tubes. A radiologist injects dye into the uterus through the cervix and simultaneously takes X-ray pictures to see if the dye moves freely through fallopian tubes. This helps evaluate tubal caliber (diameter) and patency.
  • Chromopertubation is similar to an HSG but is done in the operating room at the time of a laparoscopy. Blue-colored dye is passed through the cervix into the uterus and spillage and tubal caliber (shape) is evaluated.

Uterine Contour (physical characteristics of the uterus):

• Depending on a woman’s symptoms, the uterus may be evaluated by transvaginal ultrasound to look for fibroids or other anatomic abnormalities. If suspicion exists that the fibroids may be entering the endometrial cavity, a sonohystogram (SHG) or hysteroscopy (HSC) may be performed to further evaluate the uterine environment.

What things increase a woman's risk of infertility?

Female fertility is known to decline with—

• Age. Many women are waiting until their 30s and 40s to have children. In fact, about 20% of women in the United States now have their first child after age 35, and this leads to age becoming a growing cause of fertility problems. About one-third of couples in which the woman is older than 35 years have fertility problems. Aging not only decreases a woman's chances of having a baby but also increases her chances of miscarriage and of having a child with a genetic abnormality.
• Aging decreases a woman's chances of having a baby in the following ways—
  • Her ovaries become less able to release eggs.
  • She has a smaller number of eggs left.
  • Her eggs are not as healthy.
  • She is more likely to have health conditions that can cause fertility problems.
  • She is more likely to have a miscarriage.
• Smoking.
• Excessive alcohol use.
• Extreme weight gain or loss.
• Excessive physical or emotional stress that results in amenorrhea (absent periods).

How long should women try to get pregnant before calling their doctors?

Most experts suggest at least one year for women younger than age 35. However, women aged 35 years or older should see a health care provider after 6 months of trying unsuccessfully. A woman's chances of having a baby decrease rapidly every year after the age of 30.
Some health problems also increase the risk of infertility. So, women should talk to a health care provider if they have—

• Irregular periods or no menstrual periods.
• Very painful periods.
• Endometriosis.
• Pelvic inflammatory disease.
• More than one miscarriage.

It is a good idea for any woman and her partner to talk to a health care provider before trying to get pregnant. They can help you get your body ready for a healthy baby, and can also answer questions on fertility and give tips on conceiving. Learn more at the CDC's Preconception Health Web site. 

How will doctors find out if a woman and her partner have fertility problems?

Doctors will begin by collecting a medical and sexual history from both partners. The initial evaluation usually includes a semen analysis, a tubal evaluation, and ovarian reserve testing.

How do doctors treat infertility?

Infertility can be treated with medicine, surgery, intra-uterine insemination, or assisted reproductive technology. Many times these treatments are combined. Doctors recommend specific treatments for infertility based on—

• The factors contributing to the infertility.
• The duration of the infertility.
• The age of the female.
• The couple’s treatment preference after counseling about success rates, risks, and benefits of each treatment option.

What are some of the specific treatments for male infertility?

Male infertility may be treated with medical, surgical, or assisted reproductive therapies depending on the underlying cause. Medical and surgical therapies are usually managed by an urologist who specializes in infertility. A reproductive endocrinologist may offer intrauterine inseminations (IUIs) or in vitro fertilization (IVF) to help overcome male factor infertility.

What medicines are used to treat infertility in women?

Some common medicines used to treat infertility in women include—

• Clomiphene citrate (Clomid®*) is a medicine that causes ovulation by acting on the pituitary gland. It is often used in women who have polycystic ovarian syndrome (PCOS) or other problems with ovulation. This medicine is taken by mouth.
• Human menopausal gonadotropin or hMG (Repronex®*; Pergonal®*) are medicines often used for women who don't ovulate because of problems with their pituitary gland—hMG acts directly on the ovaries to stimulate ovulation. It is an injected medicine.
• Follicle-stimulating hormone or FSH (Gonal-F®*; Follistim®*) are medicines that work much like hMG. It causes the ovaries to begin the process of ovulation. These medicines are usually injected.
• Gonadotropin-releasing hormone (Gn-RH) analog are medicines often used for women who don't ovulate regularly each month. Women who ovulate before the egg is ready can also use these medicines. Gn-RH analogs act on the pituitary gland to change when the body ovulates. These medicines are usually injected or given with a nasal spray.
• Metformin (Glucophage®*) is a medicine doctors use for women who have insulin resistance and/or PCOS. This drug helps lower the high levels of male hormones in women with these conditions. This helps the body to ovulate. Sometimes clomiphene citrate or FSH is combined with metformin. This medicine is usually taken by mouth.
• Bromocriptine (Parlodel®*) is a medicine used for women with ovulation problems because of high levels of prolactin. Prolactin is a hormone that causes milk production.

*Note: Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
Many fertility drugs increase a woman's chance of having twins, triplets, or other multiples. Women who are pregnant with multiple fetuses have more problems during pregnancy. Multiple fetuses have a high risk of being born prematurely (too early). Premature babies are at a higher risk of health and developmental problems.

What is intrauterine insemination (IUI)?

Intrauterine insemination (IUI) is an infertility treatment that is often called artificial insemination. In this procedure, specially prepared sperm are inserted into the woman’s uterus. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI.
IUI is often used to treat—

• Mild male factor infertility.
• Couples with unexplained infertility.

What is assisted reproductive technology (ART)?

Assisted Reproductive Technology (ART) includes all fertility treatments in which both eggs and sperm are handled outside of the body. In general, ART procedures involve surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman. The main type of ART is in vitro fertilization (IVF).

How often is assisted reproductive technology (ART) successful?

Success rates vary and depend on many factors, including the clinic performing the procedure, the infertility diagnosis, and the age of the woman undergoing the procedure. This last factor—the woman’s age—is especially important.
CDC collects success rates on ART for some fertility clinics. According to the CDC’s 2012 ART Success Rates, the average percentage of fresh, nondonor ART cycles that led to a live birth were—

• 40% in women younger than 35 years of age.
• 31% in women aged 35–37 years.
• 22% in women aged 38–40 years.
• 12% in women aged 41–42 years.
• 4% in women aged 43–44 years.
• 2% in women aged 44 years and older.

Success rates also vary from clinic to clinic and with different infertility diagnoses
also vary from clinic to clinic and with different infertility diagnoses.
ART can be expensive and time-consuming, but it has allowed many couples to have children that otherwise would not have been conceived. The most common complication of ART is a multiple fetus pregnancy. This is a problem that can be prevented or minimized by limiting the number of embryos that are transferred back to the uterus. For example, transfer of a single embryo, rather than multiple embryos, greatly reduces the chances of a multiple fetus pregnancy and its risks such as preterm birth.

What are the different types of assisted reproductive technology (ART)?

Common methods of ART include—

• In vitro fertilization (IVF), meaning fertilization outside of the body. IVF is the most effective and the most common form of ART.
• Zygote intrafallopian transfer (ZIFT) or tubal embryo transfer. This is similar to IVF. Fertilization occurs in the laboratory. Then the very young embryo is transferred to the fallopian tube instead of the uterus.
• Gamete intrafallopian transfer (GIFT), involves transferring eggs and sperm into the woman's fallopian tube. Fertilization occurs in the woman's body. Few practices offer GIFT as an option.
• Intracytoplasmic sperm injection (ICSI) is often used for couples with male factor infertility. Sometimes it is also used for older couples or for those with failed IVF attempts. In ICSI, a single sperm is injected into a mature egg as opposed to “conventional” fertilization where the egg and sperm are placed in a petri dish together and the sperm fertilizes an egg on its own.

ART procedures sometimes involve the use of donor eggs (eggs from another woman), donor sperm, or previously frozen embryos. Donor eggs are sometimes used for women who cannot produce eggs. Also, donor eggs or donor sperm are sometimes used when the woman or man has a genetic disease that can be passed on to the baby. An infertile woman or couple may also use donor embryos. These are embryos that were either created by couples in infertility treatment or were created from donor sperm and donor eggs. The donated embryo is transferred to the uterus. The child will not be genetically related to either parent.
Surrogacy
Women with no eggs or unhealthy eggs might also want to consider surrogacy. A surrogate is a woman who agrees to become pregnant using the man's sperm and her own egg. The child will be genetically related to the surrogate and the male partner.
Gestational Carrier
Women with ovaries but no uterus may be able to use a gestational carrier. This may also be an option for women who shouldn't become pregnant because of a serious health problem. In this case, a woman uses her own egg. It is fertilized by her partner’s sperm and the embryo is placed inside the carrier's uterus.

Related Links

• How Do I Know If I Have an Infertility Problem? (Resolve: The National Infertility Association)
• Trying to Get Pregnant? (March of Dimes)
• Infertility (MedlinePlus)
• American Fertility Association The American Fertility Association (AFA) is a national consumer organization that offers support for men and women dealing with infertility. Their purpose is to educate the public about reproductive disease, and support families during struggles with infertility and adoption.
• RESOLVE: The National Infertility Association RESOLVE is a national consumer organization that offers support for men and women dealing with infertility. Their purpose is to provide timely, compassionate support and information to people who are experiencing infertility and to increase awareness of infertility issues through public education and advocacy.
• American Society for Reproductive Medicine The American Society for Reproductive Medicine (ASRM) is a multidisciplinary organization that provides information, education, advocacy, and standards in reproductive medicine.
• Society for Assisted Reproductive Technology The Society for Assisted Reproductive Technology (SART) promotes and advances the standards for the practice of assisted reproductive technology to the benefit of patients, members, and society at large.
• Human Cell, Tissues and Cellular and Tissue-Based Products Listing of ART clinics registered with FDA. 

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How to get all Gynaecology Services - including emergencies

The gynaecology service at Gyncentre Clinics provide comprehensive care for women with a wide range of gynaecology issues. The service provides inpatient, outpatient and emergency services through its mobile doctors and consultants country wide.

Outpatient clinics

We run a wide range of general and specialist clinic including:

• suspicion of cancer rapid access clinic (strict referral criteria)
• cancer follow-up clinic 
• Pregnancy crisis including termination of pregnancy with fetal abnormalities after imaging.
• multi-disciplinary oncology clinic
• colposcopy clinics
• continence and urodynamic service
• reproductive medicine clinic
• recurrent miscarriage service
• outpatient procedure clinics
• menopause clinic for women experiencing a problematic menopause or those requiring HRT (hormone replacement therapy) advice 
• laparoscopic sterilisation clinic offeings counselling to women requesting sterilisation as a contraception option
• hormone dysfunction clinic
• minimally invasive surgery
• endometriosis clinics

Emergency services clinic

 It provides assessment and treatment for women presenting with complications of early pregnancy and acute gynaecological conditions.

The majority are managed on an outpatient basis, but can be admitted to the Gynaecology Ward or the Day Surgery Unit as appropriate.

Services we offer

• Conservative and surgical management of miscarriage
• Surgical and medical management of ectopic pregnancy
• Investigation and management of all gynaecological emergencies.

Early pregnancy complications (Usually 5 to 16 weeks gestation)

• Any Vaginal bleeding or abdominal pain
• Miscarriage
• Ectopic pregnancy
• Post termination complications
• Pregnancy of unknown location

Gynaecological causes of acute abdominal pain

• PID (if too acute to be managed by GUM)
• Ovarian cyst accidents
• Abdominal / pelvic masses (associated with acute pain)

Very heavy vaginal bleeding

• Severe menstrual bleeding
• Associated with all genital tract pathology

Others

• Bartholin’s / vulval abscess
• Post gynaecological surgery complications. (within six
  weeks of surgery).

• Pregnancy complications occurring beyond the first 16 weeks and before six weeks post-partum.
• Hyperemesis/vomiting in pregnancy.
• For termination of pregnancy.
• For STI screening.

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               :  Call           0753321312

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