hy does one want to have a child ? Is it true that all women have a maternal instinct, which demands that she should become a mother, so that she showers all her love to her offspring? This may not be the only reason. As a matter of fact, a mother is only responsible for carrying the baby for 9 months and delivering it to the outside world
Press Release Body: FRCS ( Edin), FRCOG (Lond) W
hy does one want to have a child ? Is it true that all women have a maternal instinct, which demands that she should become a mother, so that she showers all her love to her offspring? This may not be the only reason. As a matter of fact, a mother is only responsible for carrying the baby for 9 months and delivering it to the outside world. Once that has happened, the father is as much involved with the safe keeping, nurture, health needs, physical, emotional and educational needs of the child. Most fathers share the care of children equally with the mothers. So the problem of infertility is one of the couple not any one of them; it is common knowledge that a woman alone is responsible for the infertility problem may be in about 40% of the cases and the man is responsible in an equal number of cases. It is very likely that they are both responsible in the remaining 20% of the cases. The man and woman get married for fulfillment of physical and emotional love. The nature of self-esteem an individual acquires when he or she is admired and sought after by a person of the opposite sex itself is a boon in life. Marriage results in culmination of their expectations from one another until they gradually settle down to the humdrum of daily life in due course.
The baby is only an offshoot of marriage and every couple takes it for granted that it can be created at will. In today's world, the babies should be created when you want them, and not at any time.
The start with, the desire to have a child is born out of the common belief that every couple after marriage should have a child to show that they are truly married, to show that their marriage has been consummated, and to show their masculinity and the femininity to each other and the rest of the world. But, when the pregnancy does not occur, after a few months of trail at conception, the couple suddenly gets a new sense of disappointment, which leads in course of time to frustration and fear. This finally causes a big dent in their self-esteem.
A wish for a child in the family further gets exaggerated because of socio-cultural processes, family pressure caused by the disappointed grandparents, disputes in dividing - the family legacy, business, profession etc. Thus childlessness causes a breach in the family dynamics.
The individual partners of the marriage express feeling of guilt. Men may attribute this to some of their innocent habits of masturbation during their post pubertal era. Some cannot forgive themselves if they have procured abortion in their previous pregnancies voluntarily because of unsuitable socio-economic factors. Some partners blame themselves and others blame each other. In either case, marital harmony is the casualty.
Roughly about 80 to 85% of couples produce a pregnancy before the end of the first year of marriage or before the first year of trying for pregnancy. Normally, we expect the couple to get investigated for the infertility problems after such a period of failed trial. The couple who has been married late in life should start getting investigated much earlier. The treating physician who is normally a gynaecologist well versed in taking care of infertile folks, should tailor the level of investigations according to the age of the woman. A woman in early twenties needs to have a very conservative approach for evaluation of the cause of infertility. But a woman of thirty years who is married only 6 - 8 months requires more aggressive approach in both investigation and treatment.
History taking is the first line of approach. When one asks them how long they have been "trying for pregnancy", it is frequently observed that a woman who has been married for 5 years, says that she has been trying only since 2 - 3 months. By this she means that she has been taking medical help since only so many months. In actual fact, what we have asked them to mention is how long has the woman been exposed to unprotected sex. Probably, in this couple it may be all the 5 years. This would really give a very serious dimension to the status of infertility. A general history of the female should take note of the following; genitourinary tract problems in the family, regularity or irregularity of periods, quantity of bleeding and abdominal pain in relation to menses. One must also think on the frequency of sexual activity and if it is free from pain. When one is interrogating a woman on her sexual problems, not infrequently she complains that all the semen that is ejaculated leaks out of the vagina. This is not at all an unusual phenomenon. Some men produce about only 0.5 - 1 ml of semen and some others might produce 5 ml of semen. Viscous semen that does not flow out of the vagina may not be very helpful for fertility. High viscosity of semen itself can be a barrier for sperm motility. But on the other hand, if one thinks that the vagina is not deep enough to hold a required quantity of semen at its depth, one may advise her to have a pillow beneath her buttocks after sexual intercourse so that the vagina takes a deep downward direction thus preventing the leak.
General examination of the female consists of noting the height and weight, examination of breast whether there is any secretion of milk by pressing the areolar region. One must look for male distribution of hair, which is often associated with obesity and irregular periods. Some women complain that the periods appear once in 2 - 3 months, another may state that she has to take 5 - 7 tablets every month to get a period; otherwise she may not get periods for years together. Many women think that if only their periods become regular, they would automatically become pregnant. So they insist that no investigations should be done on them with regard to their infertile status and all they want is regularization of periods. This is also a wrong impression. Irregularity of periods is caused by so many conditions like the disturbance of ovarian function, increased production of prolactin hormone by the pituitary gland and thyroid disturbances. Extreme obesity and disproportionately low body mass index can also cause loss of menses.
Physical examination of the female may give away the diagnosis in some cases. Absence of breast development associated with scanty hair in the armpits and pubic region may be a fairly serious problem. It may denote a condition known as ovarian dysgenesis. This is frequently due to chromosomal abnormalities like for eg., having one sex chromosome less or one sex chromosome more than what is required. Any woman who has not started menstruating by the age of 15 should be considered as a case of primary amenorrhoea. These girls should be investigated.
Some girls may get what is known as hidden menses or cryptomenorrhoea. This is frequently due to the presence of hymen, which has no natural opening at all. When the first menses appears in a little girl, the bleeding flows out of the uterine cavity and through the cervix. But it gets retained in the vagina as the hymenal membrane has closed the introitus. (See Figure)
A normal woman bleeds roughly about 80 ml during the whole menses. The vagina itself can hold up to 500 ml without causing any discomfort. So a little girl may not know that she has already attained menarche about six months ago and that the menstrual fluid is collecting inside the vagina without her knowledge. After a couple of months, the vagina cannot distend anymore; the menstrual fluid starts escaping in a retrograde fashion through the fallopian tube and starts trickling into the pelvis. The distension of the vagina may cause obstruction of the urethra and the little girl is frequently brought for inability to pass urine. This condition is known as hematocolpos. One when examines the introitus, one can see a purplish discolored bulging hymenal membrane.
This condition is easily treated by making an incision over the bulging, bluish discoloured hymenal membrane. This will result in a gush of dark coloured tarry, viscous old blood amounting to 500 - 600 ml of fluid. The membrane will again close up if one does not follow up with a second operation after 2 - 3 days so as to exise the hymen (Picture B) all along the margin of introitus and entering the raw margin (Picture C) so as to keep the opening patent.
When a young girl of 15 - 16 years of age has been brought to the clinic for non - occurrence of menstrual bleeding, it may be much more serious than cryptomenorrhoea. If she has developed all the secondary sexual characters, it is possible that she may not have the uterus or she may not even have a vagina. This becomes obviously on examining the vulval region carefully.
Congenital absence of vagina - also called, as Rokitonsky Syndrome, is a condition where the patient's chromosomal components are all normal. Examination of the vulval area shows that there is no vaginal opening. These women usually do not have a uterus. If one examines the inside of pelvis by a laparoscope, one only sees well developed tubes and ovaries on either side with the uterus represented by a band of fibrotic structure in mid line. Such women have normally functioning ovaries, which are capable of producing ova (eggs) cyclically. They also produce female hormones, which will help in formation of secondary sexual characters like development of breasts, female distribution of fat on shoulder, waist and hips and growth of axillary and pubic hair. For these women an artificial vagina can be constructed.
The operation consists of dissecting out a space between the rectum and urinary passage from the level of hymenal membrane to the level of pelvic peritoneum, which is the lower, most portion of the membranous sac containing abdominal and pelvic organs. While this is being created by the Gynaecologist, a Plastic Surgeon will shave off a thin layer of patient's skin from the inner aspect of the thigh. The skin is wrapped over a sterile spongy mould measuring about 4" in length and 1 ½" in diameter. This is placed inside the space that has been artificially created, and the hymenal orifice is temporarily closed (see picture).
The mould can be removed after 6 days gently freeing it from the skin graft, which has already got adhered to the wall of the space created. Post - operatively, care is taken to keep the space open by advising the patient to insert a condom covered teakwood mould in the space created, so that the space does not collapse. The patient is taught to take it out, in the morning - wash it - and replace it in a fresh condom into the vagina. In course of time, the space will get stabilized. The mould can only be inserted for a few hours in the night when the patient goes to sleep. It is very important to counsel the patient and parents before hand that she will never be able to menstruate or bear a child. The operation is entirely meant for sexual activity. Such a person should be encouraged to marry a widower or divorcee who has already produced a few children through his first marriage.
Congenital absence of vagina is not a case of total infertility. The woman's ovaries can produce eggs. The eggs can be collected for the purpose of fertilization outside the body by her husband's sperm. The embryos formed thereof can be grown in another woman's uterus who will act as a surrogate or a gestational carrier for the genetic mother.
(The above article has been written by Dr. Sulochana Gunasheela, India's leading infertility expert and to more details one can visit the website www.gunasheelahospital.org or call on 080 - 26673585)
2022
