The subfertile couple

Subfertile couples by definition require medical help to get pregnant after trying unsuccessfully for a variable period of time. Although the term subfertility is also occasionally used in the context of women who can conceive, but suffer recurrent miscarriages, this broad aspect is outside the scope of this chapter. Subfertility can seriously affect mental and social well-being, although not generally viewed as a disease that significantly causes physical ill health. On the contrary, subfertility may in fact be the early manifestation of serious co-existing disease. Advances in assisted reproductive technology in the last 25 years have simplified and diversified treatment options, thereby rendering the terms infertility and sterility unfashionable. As a result, there is now an unfortunate trend for couples to be subjected to superficial medical history and only perfunctory physical examinations, occasionally missing the presentations and implications of associated co-morbidities, with devastating implications. There are now many guidelines on the initial investigations and subsequent management of the subfertile couple. It is therefore now relatively easy to assist a couple achieve a pregnancy. However, dealing with the devastating news of causative factors like azoospermia, genetic disease, congenital anomaly or premature ovarian failure can be very difficult. To discuss these sympathetically, professionals require interpersonal skills in breaking bad news. Finally, a multidisciplinary team approach should be adopted to cater for the long-term health consequences, whenever co-morbidities are detected.     

The subfertile couple

Subfertile couples by definition require medical help to get pregnant after trying unsuccessfully for a variable period of time. Although the term subfertility is also occasionally used in the context of women who can conceive, but suffer recurrent miscarriages, this broad aspect is outside the scope of this chapter. Subfertility can seriously affect mental and social well-being, although not generally viewed as a disease that significantly causes physical ill health. On the contrary, subfertility may in fact be the early manifestation of serious co-existing disease. Advances in assisted reproductive technology in the last 25 years have simplified and diversified treatment options, thereby rendering the terms infertility and sterility unfashionable. As a result, there is now an unfortunate trend for couples to be subjected to superficial medical history and only perfunctory physical examinations, occasionally missing the presentations and implications of associated co-morbidities, with devastating implications. There are now many guidelines on the initial investigations and subsequent management of the subfertile couple. It is therefore now relatively easy to assist a couple to achieve a pregnancy. However, dealing with the devastating news of causative factors like azoospermia, genetic disease, congenital anomaly or premature ovarian failure can be very difficult. To discuss these sympathetically, professionals require interpersonal skills in breaking bad news. Finally, a multidisciplinary team approach should be adopted to cater for the long-term health consequences, whenever co-morbidities are detected.     

Management of recurrent early pregnancy loss

Recurrent pregnancy loss is a devastating health problem that affects many couples who are trying to establish a family. Evaluation depends on a number of factors, including the pattern of pregnancy loss, underlying medical disease and life-style issues. A detailed obstetric history, including gestational age at the time of death, ultrasound, pathology and cytogenetic results, is key in the evaluation and management of recurrent pregnancy loss. This complex reproductive disorder requires a multidisciplinary approach since genetic, endocrinologic, anatomic, immunologic, infectious, thrombophilic and iatrogenic factors may require evaluation and management. Monitoring of subsequent pregnancies requires close supportive care.     

Fertility-related knowledge and information-seeking behaviour among people of reproductive age: a qualitative study

Some potentially modifiable factors adversely affect fertility and pregnancy health. To inform a fertility health promotion programme, this study investigated fertility knowledge and information-seeking behaviour among people of reproductive age. This was a qualitative study involving six focus group discussions with women and men who intended to have children in the future and eight paired interviews with couples who were actively trying to conceive. Participants (n?=?74) themselves generally claimed ‘low’ to ‘average’ levels of knowledge about fertility. Most of them overestimated women’s reproductive lifespan and had limited knowledge about the ‘fertile window’ of the menstrual cycle. The Internet was a common source of fertility-related information and social media was viewed as a potential effective avenue for dissemination of messages about fertility and how to protect it. Most participants agreed that primary health care providers, such as general practitioners (GPs), are well placed to provide information regarding fertility and pregnancy health. This study identified several gaps in knowledge among people of reproductive age about factors that influence fertility and pregnancy health negatively. Addressing these knowledge gaps in school curricula, primary care and health promotion would assist people to realize their reproductive goals and reduce the risk of infertility and adverse obstetric outcomes.     

Why do couples discontinue in vitro fertilization treatment? A cohort study

OBJECTIVE: To investigate reasons for discontinuation of IVF treatment. DESIGN: Prospective, cohort study. SETTING: Center for reproductive medicine at a large university hospital. PATIENT(S): The 450 couples of a cohort of 974 couples who started IVF treatment between January 1996 and December 1997 and did not achieve childbirth. INTERVENTION(S): The reasons for ceasing treatment were evaluated by scrutinizing the medical records for all couples (n = 288) who did not achieve live birth and who did not complete three stimulated IVF cycles. A questionnaire was sent to all patients for whom the reason for discontinuation was not obvious from the medical records (n = 211). MAIN OUTCOME MEASURE(S): Reasons for discontinuing IVF. RESULT(S): Of 450 couples not achieving live birth, 208 completed their subsidized cycles, whereas 242 discontinued IVF. In 192 (79%) of the 242 cases, the reasons for ceasing treatment could be identified from records or questionnaires. The reason for discontinuation was psychological burden in 26%, a poor prognosis in 25%, spontaneous pregnancy in 19%, physical burden in 6%, serious disease in 2%, and other reasons in 7%. CONCLUSION(S): An unexpectedly high percentage of couples who performed IVF discontinued the treatment before the three cycles that were offered to a majority of the couples. A majority of these discontinuations were due to psychological stress. This information is of importance when counseling patients during treatment.     

The examination and investigation of the subfertile couple

The World Health Organization (WHO) defines infertility as the ‘inability of a sexually active, non-contracepting couple to achieve pregnancy in one year’. It is estimated that this can affect 8–12% of couples worldwide Many couples will demonstrate female and male causes for infertility and will seek assistance from clinicians to achieve pregnancy. The assessment of the infertile couple should include detailed history, focused examination and appropriate investigations prior to any intervention. Clinicians with a specialist interest in infertility should perform this evaluation, as part of their regular practice. The aetiology of female and male infertility is broad and can provide a challenge for experienced clinicians. It is important that patients are evaluated in a structured and sequential manner. This article will review and discuss the evaluation of both the infertile female and infertile male.     

心脏病史女性孕前保健和管理

心脏病女性在妊娠期易发生心血管并发症,是孕产妇非产科因素死亡的重要原因,应加强孕前保健和管理。结合患者病史和检查进行孕前风险评估,能够手术矫正者建议其孕前手术治疗,不宜妊娠者应建议其避孕,允许继续妊娠者孕期应联合多学科管理,提高妊娠分娩安全性。     

Human leukocyte antigen compatibility and failure to achieve a viable pregnancy with assisted reproductive technology.

Many couples fail to achieve a viable pregnancy with multiple attempts of Assisted Reproductive Technology (ART). Immunologic rejection of the embryo may be a factor in these couples. We evaluated shared human leukocyte antigen (HLA) antigenicity in 10 couples who failed multiple ART cycles and compared them with 10 couples who achieved a viable pregnancy with their first ART attempt. Study couples shared a statistically significant greater number of HLA antigens than control couples. Leukocyte immunotherapy is discussed. We conclude that couples who share multiple HLA antigens may have an immunologic basis for failing to achieve a viable pregnancy with multiple ART cycles.     

生殖相关输卵管疾病的微创手术进展

任何不孕夫妇都希望通过寻求一切合理的治疗手段来实现妊娠。其中20%以上夫妇是由于输卵管因素导致的不孕,这部分患者面临的治疗选择有：微创手术和体外受精（IVF）。大多数情况下,在这一决策过程中必须切实有效地比较这两种方法的疗效、不良反应及费用。目前证据显示,微创手术对于输卵管疏松粘连、轻微的远端输卵管梗阻、近端输卵管梗阻及输卵管妊娠的治疗更加有效。一个成功的输卵管修复手术不仅可以使不孕夫妇避免进一步的治疗,而且也获得了能够自然妊娠的心理优势。在IVF治疗前或过程中,根据输卵管病变进行个体化的微创手术治疗,可以提高IVF疗效、宫内妊娠率及活产率。IVF周期中异位妊娠的发病率高于自然人群,微创手术治疗异位妊娠不但创伤小,而且可以尽量减小对后续IVF疗效的影响。目前认为将微创手术和IVF综合运用,才能使不孕患者获得最佳的生育结局。     

Barrier contraception

Barrier contraception is a safe, effective, reversible form of contraception acceptable to many couples. The use of barrier contraception may protect against carcinoma of the cervix and sexually transmitted diseases. Distribution and education in the use of barrier contraception does not always require medical supervision. This must make it an attractive form of contraception for agencies supporting family planning programmes in developing countries. The only marketed recent advance in barrier contraception is the collatex sponge. Effectiveness rates range between 9 and 27 pregnancies per 100 woman-years. This is unlikely to make it the first choice of contraception for couples who would find an unintended pregnancy a severe problem, but the sponge will be acceptable to couples who are simply trying to delay a pregnancy. The new surge of interest in barrier contraception could lead to safer more effective forms of contraception being made available to women without medical supervision. This would have many advantages, but could also detract from the ability of family planning clinics to play an important role in preventative medicine for women.     

Optimizing use of assisted reproduction

Infertile couples who have failed to achieve pregnancy now have new options that have become available in the last two decades. The costs are generally large and frequently not covered by insurance. Risks include multiple pregnancy and hyperstimulation syndrome. Evidence concerning results of several treatment options is presented. The large difference in success between age groups is displayed. Results to be expected from donor eggs to overcome the low success in older age groups (>38 years) are presented.     

Couples sérodifférents dont l’homme est infecté par le VIH et Assistance médicale à la procréation : le désir d’enfant et la grossesse aux prises avec la réalité de la maladie

Assisted Reproductive Technologies for serodiscordant couples with HIV-infected male partner has been possible since 2000 in French centres such as the CECOS in Toulouse. From the outset, couples in the program meet psychologists or psychiatrists. In the first instance, the results from 40 psychologist led interviews with serodiscordant couples held at the CECOS in Toulouse, identified several challenging ideas. Couples who plan to have children were in a stable long-term relationship and both were involved in managing the illness. Medically assisted procreation awakens in the women a strong desire for children and enables the couples to make plans for the future. But it also reminds the men of their reliance on medical assistance because of the demands made by the medical program, and in case of failure it can destabilise the couples’ way of coping with HIV. Subsequently, interviews with 12 couples during pregnancy revealed the overbearing presence of the illness, despite the imminent birth of the desired child. In their responses, women express their anxiety concerning the risk of contamination, and the defences that the men had built up to cope with HIV appeared destabilised, now that the idea of their death is rekindled.     

Candidate selection and psychosocial considerations of in-vitro fertilization procedures

The psychological impact of the new reproductive technology should not be understated. The history of infertility treatment and failure to achieve pregnancy that most couples bring to the program, along with their hopes and expectations for success, makes them extremely vulnerable to anxiety, unrealistic expectations, and grief reactions. When a cycle of IVF fails, the intensity of the experience and the disappointment may be overwhelming for a while, but most couples are willing to try it again. One patient wrote about her feelings after IVF treatment after having read comments in a popular magazine which implied that medical science was taking control of reproduction. Those of us who go through in-vitro fertilization think long and hard about what we are doing. Most of us weigh the pros and cons very thoroughly. We weigh the risks to our potential children just as people who have genetically linked diseases do before they conceive. (Our fetuses are not "bombarded" by ultrasound procedures any more than many other pregnant women's fetuses are these days.) Most of us are thankful that the technology is now available to us, if we choose to participate. Physicians who work with IVF patients do realize that the procedure is stressful. Often the stress is viewed as primarily the patients', and we are asked to study the level of stress. To a large extent that is the subject matter of this chapter. Nevertheless, the stress is perceived because the physicians and staff are also under stress. The failure of an IVF cycle is immediately known to the health care givers.(ABSTRACT TRUNCATED AT 250 WORDS)     

Yes we can! Successful examples of disallowing ‘conscientious objection’ in reproductive health care

Reproductive health care is the only field in medicine where health care professionals (HCPs) are allowed to limit a patient’s access to a legal medical treatment – usually abortion or contraception?– by citing their ‘freedom of conscience.’ However, the authors’ position is that ‘conscientious objection’ (‘CO’) in reproductive health care should be called dishonourable disobedience because it violates medical ethics and the right to lawful health care, and should therefore be disallowed. Three countries – Sweden, Finland, and Iceland – do not generally permit HCPs in the public health care system to refuse to perform a legal medical service for reasons of ‘CO’ when the service is part of their professional duties. The purpose of investigating the laws and experiences of these countries was to show that disallowing ‘CO’ is workable and beneficial. It facilitates good access to reproductive health services because it reduces barriers and delays. Other benefits include the prioritisation of evidence-based medicine, rational arguments, and democratic laws over faith-based refusals. Most notably, disallowing ‘CO’ protects women’s basic human rights, avoiding both discrimination and harms to health. Finally, holding HCPs accountable for their professional obligations to patients does not result in negative impacts. Almost all HCPs and medical students in Sweden, Finland, and Iceland who object to abortion or contraception are able to find work in another field of medicine. The key to successfully disallowing ‘CO’ is a country’s strong prior acceptance of women’s civil rights, including their right to health care.     

Early pregnancy complications

The early pregnancy period can be complicated by a range of symptoms varying from nausea, vomiting, vaginal spotting and pelvic pain, to more severe conditions such as hyperemesis gravidarum, early embryonic demise, mental health problems and either molar or ectopic pregnancies. Some of these conditions require hospital admission and multidisciplinary team management, whilst others can be managed in an outpatient setting after the appropriate investigations. Complications early on in the pregnancy can be distressing, therefore women who experience such symptoms require close monitoring, reassurance and information on how to access help. Early pregnancy units have been specifically designed to serve patients with complications in early pregnancy and the health professionals are trained to support women during their treatment, whilst helping these patients make informed decisions about their care. This review summarises the key presentations, investigations and management of the most common complications that can arise in early pregnancy.     

Challenges imposed by scientific development in ART

The primary goal of ART is to produce a healthy baby which will develop into a healthy adult. There are a number of challenges which must be met in order to achieve this goal, with possibly two foremost at the present time. The first is to eliminate multiple pregnancy by transfer of a single embryo, and the second is to understand the risks involved in ART. In recent years spin-out technologies have also developed from ART, first the diagnosis of genetic disease in the embryo, and now the derivation of embryonic stem cell lines with the potential to treat a range of human health disorders. Current and future scientific developments can help achieve all of these aims, but present a number of challenges to the ART community and regulatory bodies.     

Possible Relationship of Post-Partum Psychiatric Symptoms to Childbirth Education Programmes

Following the publication of Lamaze's ‘Painless Childbirth’ in 1958 [1] and Le-boyer's ‘Birth Without Violence’ in 1975 [2], pregnant women and their partners have become increasingly interested in ‘natural childbirth.’ The term natural childbirth is a popular and highly emotional concept that means different things to different people, but it is increasingly coming to mean that the pregnant woman and her partner assume maximum responsibility during normal labour and delivery, with medical intervention being kept to an absolute minimum. It often includes the presence of the partner and parent-infant contact immediately after delivery. Many women and their partners interested in natural childbirth enroll in prenatal classes, whose primary focus is to maximize the woman's participation and minimize medical intervention in the normal birthing process. There is now a vast and rapidly growing literature describing the positive effects of pregnant women maintaining control over their pregnancy, labour, and delivery and one cannot help but feel enthusiastic about the overall positive effects [2,3,5,6]. However, we have recently had cause to wonder if there are negative sequelae for some women and their partners [7].     

Quality of life during the transition to parenthood in Hong Kong: a longitudinal study

Abstract

Objective: Quality of life has emerged as an important health outcome in the care of perinatal families. This study was designed to examine the changes in quality of life among Chinese couples during the transition to parenthood.

Methods: A longitudinal design was used. Participants comprised a convenience sample of 203 Chinese-childbearing couples attending the antenatal clinics, who completed data collection during pregnancy and at six weeks and six months postpartum. At each point, couples completed the Medical Outcomes Study Short Form 12-Item Health Survey.

Results: The results showed that women experienced substantial changes in their quality of life during pregnancy and postpartum, whereas the changes in their partners’ quality of life were less noteworthy. Women had a poorer quality of life than their partners during the early postpartum period. The mental health component of women’s quality of life was closely related to their partners’ across the perinatal period.

Conclusions: The findings of the present study highlight the need for more attention to a couple’s quality of life during the transition to parenthood. Couple-based and culturally relevant interventions should be developed to assist both parents to cope with the new challenges and demands of parenthood, and thus achieve a better quality of life.     

Childbearing motivational patterns of primiparous women of advanced age and their partners

Objective: This study aimed to: (1) describe the positive and negative childbearing motivations of primiparous women of advanced maternal age and their partners (AMA group) compared with their younger counterparts (comparison group) during pregnancy; (2) identify distinct childbearing motivational patterns in the AMA group; and (3) to explore their correlates. Background: First childbirth at advanced maternal age is a growing social concern, but few studies have explored couples’ childbearing motivational patterns, challenging the stereotypes that presuppose that this reproductive trend reflects ambivalent motivations. Methods: Forty-six couples in the AMA group and 44 couples in the comparison group responded to the Childbearing Motivations Scale during the third trimester of pregnancy. Results: The AMA group differed from the comparison group in positive but not negative childbearing motivations. Two childbearing motivational patterns were identified in the AMA group. The ‘realistic childbearing motivational pattern’ was characterised by highly positive motivations that coexisted with moderate negative motivations. The ‘disengaged childbearing motivational pattern’ was characterised by moderate positive motivations that coexisted with low negative motivations. These two patterns had comparable frequencies for women and men. Women who were less satisfied with their professional life and experienced prior adverse pregnancy outcomes and men who reported a higher deviation from child-timing expectations were more likely to report a ‘realistic childbearing motivational pattern’. Conclusion: Healthcare providers should avoid stereotyped views and develop couple-focused interventions across the reproductive lifespan and during antenatal care to promote satisfactory decisions and to prepare couples for the positive aspects and demands of childrearing.     

Gestational Diabetes Mellitus: Insulinic Management

Diabetic pregnancies have attendant risks. Adverse fetal, neonatal, and maternal outcomes in a diabetic pregnancy can be avoided by optimum glycemic control. Most pregnancies with GDM can be managed with non-insulinic management, which includes medical nutrition therapy. However, many necessitate concomitant insulinic management. The new insulin analogs present undoubted advantages in reducing the risk of hypoglycemia, mainly during the night, and in promoting a more physiologic glycemic profile in pregnant women with diabetes. Rapid-acting insulin analogs seem to be safe and efficient in reducing postprandial glucose levels more proficiently than regular human insulin, with less hypoglycemia. The long-acting insulin analogs do not have a pronounced peak effect as NPH insulin, and cause less hypoglycemia, mainly during the night. The review focuses on glycemic goals in pregnancy, insulinic management of GDM, and posology of insulin and its analogs. Clear understanding of the insulinic management of GDM is essential for women’s health care providers to provide comprehensive care to women whose pregnancies are complicated with diabetes and rechristen the ‘‘diabetic capital of the world’’ to the ‘‘diabetic care capital of the world.’’