REPRODUCTIVE

Reproductive Issues

Infertility

  • Definition: Inability to conceive despite engaging in unprotected sexual intercourse for a prolonged period, typically defined as at least 12 months.

  • Common factors associated with infertility:   - Decreased sperm production   - Endometriosis   - Ovulation disorders   - Tubal occlusions

Subfertility

  • Definition: Infertility may be referred to as subfertility.

  • Types:   - Primary Infertility: Happens when a woman has never been pregnant.   - Secondary Infertility: Occurs when a woman has been pregnant in the past.

  • Factors associated with infertility:   - Delaying pregnancy   - Sexually Transmitted Infections (STIs)

Reproductive Alternatives

Assisted Reproductive Therapies (ART)

  • Definitions and types of treatments:   - In Vitro Fertilization (IVF)   - Gamete Intrafallopian Transfer (GIFT)   - Intra-uterine Insemination (IUI)   - Ovulation Induction (hyperstimulation)   - Adoption   - Surrogate mothers/Gestational carrier   - Donor oocyte (egg donor)

Contraception: Voluntary Prevention of Pregnancy

Factors that influence contraceptive choices:

  • Religious beliefs

  • Cognitive ability

  • Cost

  • Ease of use

  • Effect on sexual sensation

  • Health factors/side effects

  • Prescription availability

Types of Contraception

  • Permanent sterilization:   - Bilateral tubal ligation   - Vasectomy

  • Periodic abstinence: Abstaining from sexual intercourse.

  • Coitus interruptus: Withdrawal method where the man withdraws his penis from the vagina before ejaculation; noted as the most ineffective method of contraception.

  • Abortion: May be medical or surgical.

Fertility Awareness Methods

  • Develop “fertile awareness” by noting:   - Cervical mucus changes   - Menstrual cycle patterns   - Basal temperature

  • Usage: Track fertile days and can avoid fertile periods.

Hormonal Contraceptives

  • Oral contraceptives:   - Composed of hormonal contraceptives either with estrogen and progesterone or progestin-only pills.   - Administration: Pill taken daily.   - Adverse effects:     - Breast tenderness     - Spotting     - Nausea   - Special consideration: Patients should avoid smoking; increased risk of Deep Vein Thrombosis (DVT) for those older than 35, which needs assessment for leg pain; increasing risk for stroke and myocardial infarction.

  • Ethinyl estradiol and norelgestromin (Ortho Evra): Contraceptive patch that requires replacement each week for 3 weeks with a period starting on week 4 (no patch).

Implants and Injections

  • Etonogestrel implant:   - A tiny, thin rod about the size of a matchstick inserted into a woman’s arm by a healthcare provider.   - Prevents pregnancy by thickening cervical mucus and preventing ovulation.

  • Medroxyprogesterone (Depo-Provera):   - Injection administered every 3 months.   - Backup form of birth control needed for 7 days after the first injection.   - Fertility typically returns approximately 1 year after stopping.   - Can be used during breastfeeding.

Emergency Contraception

  • Involves taking a larger-than-normal dose of oral contraceptive no later than 72 hours after unprotected sex, with a second dose repeated 12 hours later.

  • Not intended as a primary method of birth control.

Barrier Methods

  • Condoms (male and female): Effective when used with spermicide and also protect against STIs.

  • Intrauterine device (IUD):   - Contraindicated for women with diabetes or previous history of Pelvic Inflammatory Disease (PID).   - Associated with high risk of infection and may cause heavy periods.   - Effectiveness ranges from 3 to 10 years.   - Copper IUDs contain no hormones.

  • Cervical diaphragm:   - Should be used with spermicide.   - Needs fitting by a prescriber and must be left in place for 6 hours after intercourse; should be refitted in case of weight loss or gain.

Sexual Maturity Across the Lifespan

  • Onset of physiological changes begins around the age of 9 years, particularly in girls.

  • Notable differences in growth and maturation appear between boys and girls.

Sexual Maturation in Females

  • Signs include:   - Breast development   - Pubic hair growth   - Axillary hair growth   - Menstruation

Sexual Maturation in Males

  • Signs include:   - Testicular enlargement   - Pubic hair growth   - Penile enlargement   - Axillary hair growth   - Facial hair growth   - Vocal changes

Secondary Sexual Characteristics

  • Physical changes not directly linked to reproduction but signal sexual maturity, e.g., a lower voice in males and broader hips in females.

Menopause

  • Definition: Absence of menses for 12 months.

  • Generally begins between ages 45 to 55.

  • Symptoms may last up to 10 years and include:   - Hot flashes   - Bladder control issues   - Sleep issues   - Mood changes   - Vaginal dryness   - Weight gain

Gender Identity and Sexual Orientation

  • Critical concepts in adolescent health influenced by culture include:   - Biological sex: Assigned at birth based on anatomical characteristics and chromosomes.   - Gender identity: An individual’s innate sense of being male, female, androgenous, nonbinary, or a preference to reject gender designation.   - Gender expression: A person’s outward demonstration of gender concerning societal norms.   - Transgender: A person whose gender identity does not correspond with the gender assigned at birth.

Gender Dysphoria

  • Characteristics include:   - A strong desire to be of the other gender.   - Preference for clothing stereotypical of the other gender.   - Rejection of toys, games, and activities stereotypical of their assigned gender.   - Preference for cross-gender roles during play.   - Dislike of one’s sexual anatomy.

Reproductive Screening Guidelines

Cervical Cancer Screening

  • Important for women’s health.

  • Initiation: Begins at age 21, regardless of the age of first intercourse.

  • Frequency and methods for cervical screening based on age and health history:   - Women aged 21 to 29: Pap test every 3 years.   - Women aged 30 to 65:     - Pap test and HPV test every 5 years.     - Pap test alone every 3 years.     - HPV testing alone every 5 years.

Mammograms

  • For women at average risk of breast cancer: screening mammography is recommended every 1–2 years beginning at age 40 years; if not started in their 40s, should start no later than age 50 years.

  • Screening should continue until at least age 75 years.

  • Routine breast examinations may occur during physical checkups to assess any changes.

  • Clinical breast exam suggested for:   - Every 1–3 years for women aged 25–39 years.   - Annually for women 40 years and older.

Testicular Exam

  • Recommended as part of the general physical exam.

  • Many men seek medical attention for symptoms such as lumps or swelling.

STIs: Common Infections

Chlamydia

  • Many infected individuals are asymptomatic and can unknowingly transmit the infection.

  • Symptoms: Abnormal vaginal discharge with a strong smell; burning sensation during urination.

  • Screening recommendations:   - All sexually active women younger than 25 years (including pregnant women).   - Not recommended for women older than 24 without risk factors.   - Screen sexually active men with risk factors.

  • Treatment: Antibiotics.

Gonorrhea

  • Present with mild, nonspecific symptoms often confused with bladder or vaginal infections.

  • Complications include:   - Premature rupture of membranes   - Preterm birth   - Chorioamnionitis   - Neonatal sepsis   - Intrauterine growth restriction (IUGR)   - Maternal postpartum infection.

  • Treatment: Intramuscular injection of antibiotics.

Human Papillomavirus (HPV)

  • Symptoms: Mostly asymptomatic; may cause raised or flat lesions resembling cauliflower (genital/venereal warts).   - Lesions may increase or decrease during pregnancy.   - Prolific lesions may necessitate Cesarean birth.

  • Management: No cure exists; HPV vaccine recommended.

Herpes Simplex Virus (HSV)

  • Primary infection during the first trimester linked to miscarriage.

  • Symptoms: Vesicles on or around the genitals, rectum, or mouth.

  • Risk: Greatest if primary infection occurs near term, can lead to neonatal infection; Cesarean birth is indicated if lesions are present during labor.

  • Management: No cure; antiviral medications may shorten or prevent outbreaks.

Syphilis

  • Diagnosed through blood tests (RPR, VDRL).

  • Symptoms: Painless sores where syphilis introduced to the body.

  • Complications include neurovascular complications, late miscarriage, stillbirth, and potential transmission to neonate.

  • Screening recommended for all women during the first OB visit.

Hepatitis A, B, C

  • Hepatitis B is the most threatening to fetus and neonate.

  • All women screened for HBsAg during the first prenatal visit.

Human Immunodeficiency Virus (HIV)

  • Women represent the fastest-growing population with HIV, particularly among women of color.

  • HIV screening is recommended, though not all are screened during the first prenatal visit. Informed consent is required prior to testing.

  • Perinatal transmission can decrease significantly with treatment.

  • Breastfeeding is contraindicated for those with HIV.

Vaginal Infections (Not Sexually Transmitted, except Trichomoniasis)

  • Bacterial Vaginosis (BV): Associated with increased risk of preterm labor and birth.

  • Candidiasis (Yeast Infection): May cause thrush in newborns.

  • Trichomoniasis: Symptoms include itching, irritation, burning, and redness of the genitals. Complications include premature rupture of membranes and postpartum endometritis (infection).

  • Group B Streptococcus (GBS): Considered normal flora in non-pregnant women but associated with neonatal morbidity and mortality. Screening recommended between 35 – 37 weeks gestation.