Management of Infertility in Rural Areas

10/20/2015

Courses: Management of Infertility in Rural Areas Lesson 1 | mdCurrent India

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Management of Infertility in Rural Areas - Lesson 1 - Relevant Anatomy and Physiology, Part 1: The Female Reproductive Anatomy It is important to understand the relevant anatomy and physiology while evaluating and managing infertility. They are described in a very simplified way so that any of the hospital staff can understand them. Introduction THE FEMALE REPRODUCTIVE ANATOMY The following are the brief description of the relevant areas Ovary: Two ovaries are present on either side of the Uterus and they produce female eggs/ovum and female hormones (estrogen, progesterone). Their blood supply is mostly from the lateral pelvic wall but also has vessels from the Uterus. Ovum: These are the female reproductive cells that contribute X chromosomes. Fallopian tubes: These tubes on either side transport ovum to the uterus. It is the passageway where fertilization occurs. It could be the site of ectopic pregnancy. It is the site where tubal ligation (sterilization) is carried out.

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Uterus: when an egg is fertilized and implants in the lining of the uterus; when no fertilized egg is present the lining of the uterus sheds for the menstrual cycle. Cervix: lower end of the uterus; an opening between the uterus and vagina that passes sperm, menstrual fluid, and a fetus. Vagina: pathway for menstrual flow, birth canal, sperm, and STIs. Opening for sexual intercourse and contains vaginal secretions/lubrication. Urethra: opening for urine. Clitoris: sensitive tissue with sole purpose for sexual stimulation.

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Passageway of Ovum: Ovary Fallopian tube Uterus Cervical Opening Vagina Menstruation When the ovaries are formed in the fetus, there are approximately 6,000,000 primordial follicles, which will then decrease to about 600,000 at birth. Then they will decrease to 300,000 at the first menstrual cycle and then at the time of menopause they will decrease to 10,000. The Cycle The average cycle is 28 days and has two distinct phases

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The Follicular Phase The follicular phase starts on day one of the menstrual cycle (the first full day of bleeding). This is due to the release of gonadotropinreleasing hormone (GnRH) from the brain which causes the secretion of follicle stimulating hormone (FSH) from the pituitary gland. The FSH stimulates the eggs inside the ovaries to grow and about 20 immature eggs respond and begin to develop within sacs known as follicles. The follicles provide nourishment to the eggs. As the eggs develop, the ovaries release estrogen. Estrogen signals the pituitary gland to reduce FSH production and this leads to sufficient FSH to stimulate only one egg to continue developing and the rest of the eggs shrivel away. The Estrogen also stimulates the lining of the uterus to thicken. The primary follicle contains the egg that has grown the most rapidly. Estrogen continues to rise until it triggers a surge of luteinizing hormone (LH) from the pituitary gland which then stimulates ovulation. The follicle ruptures and the egg is released along with the follicular fluid onto the surface of the ovary.


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The Luteal Phase The ruptured follicle continues to receive LH which enables the follicle to turn into a small cyst known as the corpus Luteum which produces progesterone. The Progesterone further thickens the endometrium and develops glandular structures and blood vessels that supply nutrients to the developing embryo. It also switches off FSH an LH and it raises the basal body temperature (BBT) by half a degree, warming the uterus and fertilized egg. The Journey of the Egg The egg is surrounded by the zona pellucida, which is a protective shell. The shell is surrounded by a mass of sticky cells called the cumulus oophorus. These sticky cells allow the finger like projections at the end of each fallopian tube, to pick up the egg and sweep it into the tube. The channel from the fimbriae to the uterus is lined with cilia, which together with muscular contractions move the ovum along the tube to the uterus. The journey from the ovary to the uterus takes about 6 days and if the egg is not fertilized it will disintegrate and is absorbed.

Fertilization & Implantation


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The genetic material from a sperm cell (spermatozoon) and secondary oocyte merge into a single nucleus and this fertilization normally occurs in the Fallopian tube 1224 hours after ovulation. The ejaculated sperm can remain viable for about 48 hours and a secondary oocyte is viable for about 24 hours after ovulation. The peristaltic contractions and the action from the cilia transport the oocyte through the tube while the sperm swim to the oocyte by whiplike movements from its tail. The sperm produce an enzyme (acrosin) that stimulates sperm motility and migration. The uterine contractions stimulated by the prostaglandins in semen aids sperm movement. The sperm also undergo functional changes (capacitation) in the female reproductive tract: the membrane around the acrosome becomes fragile so that several destructive enzymes are released. These enzymes help penetrate the ring of cells (corona radiate) that surround the oocyte. One sperm penetrates and enters a secondary oocyte, this is called syngamy. Syngamy causes depolarization, which triggers the release of calcium ions into the cell which then stimulate the release of granules, that in turn, promote change changes in the zona pelllucida to block entry of the other sperms. The oocyte completes equatorial division (meiosis ll) in which the nucleus from the sperms head and the nucleus from the ovum fuse to produce segmentation nucleus. The segmentation nucleus contains 23 chromosomes from the male pronucleus and 23 chromosomes from the female pronucleus. The fertilized ovum is now called a zygote. Rapid mitotic cell divisions of the zygote (called cleavage) are completed 30 hours after fertilization. Successive cleavages produce a solid sphere of cells called morula. The morula is the same size as the original zygote. However after 4 to 5 days the dense cluster of cells has developed into a hollow ball of cells and enters the uterine cavity, it is now called a blastocyst. Implantation The blastocyst remains free within the uterine cavity for a short period of timer receiving nourishment from glycogen rich secretions from the uterine glands. Six days after fertilization the blastocyst attaches to the endometrium usually on the posterior wall of the fundus. It develops two layers in the region of the area of contact between the blastocyst and endometrium the synctiotrophoblast and the cytotrophobast. The synctiotrophoblast secretes enzymes that enable the blastocyst to penetrate the uterine lining; the enzymes digest and liquefy the endometrial cells. The trophoblast secretes hCG that rescues the corpus luteum from degeneration and sustains its secretions of progesterone and estrogens, thus menstruation does not begin. Embryonic Development The inner cell mass of the blastocyst begins to differentiate into three primary germ layers: ectoderm, endoderm, and mesoderm. Within 8 days after fertilization the cells of the cytotrophoblast proliferate and form a fetal membrane called amnion. About the 12th day after fertilization a yolk sac is forming and on the 14th day cells differentiates into three distinct layers: ectoderm, endoderm, and mesoderm. As the embryo develops, the endoderm becomes the epithelial lining of the GI tract, respiratory tract and several other organs. The mesoderm forms muscle, bone, and other connective tissue, the ectoderm develops into the skin and nervous system. The formation of the embryonic membranes protects and nourishes the embryo and later the fetus. The membranes are the yolk sac (the primary source of nourishment for the embryo), amnion (protective membrane) Chorion (the structure for exchange of materials between mother and fetus, produces hCG), and Allantois (serves as an early site of blood formation). The placenta is formed by the Chorion of the embryo and a portion of the endometrium of the mother. The placenta allows oxygen and nutrients to diffuse into fetal blood from maternal blood: carbon dioxide and wastes diffuse from fetal blood into maternal blood. The umbilical cord is a vascular connection between mother and fetus and consists of 2 umbilical arteries, and surrounded by a layer of amnion. Image: Uterus and right broad ligament, seen from behind. The broad ligament has been spread out and the ovary drawn downward. Source: Henry Gray (1918) Anatomy of the Human Body. before 1858. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Gray1161.png Image: Diagram of the menstrual cycle (based on several different sources). Author: Isometrik. 8 December 2009. Access the original Image information here: https://commons.wikimedia.org/wiki/File:MenstrualCycle2_en.svg Image: Human Fertilization. The sperm and ovum unite through fertilization, creating a zygote that (over the course of 89 days) will implant in the uterine wall, where it will reside over the course of 9 months. Author: Ttrue12. 31 May 2012. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Human_Fertilization.png

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