MINISTRY OF HEALTH OF UKRAINE
Bukovinsky State Medical University
“Approved”
on methodological meeting
of Department of Obstetrics and Gynecology
with course of Infant and Adolescent Gynecology
“___”______________________ 201_ year
protocol #
T.a.the Head of the department
Professor
________________ O.A. Andriyets
Methodical development
practical exercises
"Medical and social meaning of infertility problems in marriage.
Etiopathogenetical factors for infertility examination couple with infertility.
Modern principles and methods of treatment of female infertility. Assisted
reproductive technologies "
Module 4. Obstetrics and Gynecology
Semantic module 13. Infertility in marriage. Family Planning.
Academic Discipline: Obstetrics and Gynecology
Course: 6
Faculty: Medicine
Specialty: General Medicine
Hours - 5.5
Developed by
assits.prof. A. Berbets
Chernivtsi, 2010
1. Research topics and methodological basis.
Knowledge of obstacles occur physiologically pregnancy is relevant, because the frequency of
infertility is increasing year after year and now stands at 10-15% and only 30% - women
recovering. Svoyechana correct diagnosis and treatment of infertility algorithm is the key to
stabilize the demographic situation in Ukraine.
2. Study objective: To study the causes of infertility in marriage (the frequency, etiology, clinical
picture, treatment). Deepen knowledge on prevention of infertility and family planning in the
district doctor clinics.
The student must:
2.1. Know:
1. What mean by infertility?
2. What types of infertility?
3. Qualitative and quantitative indicators of fertile sperm.
4. The causes of female infertility.
5. Methods for diagnosing tubular sterility.
6. Methods of diagnosis of endocrine infertility.
7. Test Algorithm couple with immunological infertility.
8. Indications and contraindications for surgical treatment of tubular infertility.
9. Indications for extracorporeal fertilization.
10. Principles of endocrine infertility therapy.
2.2. Able:
1. Assess results of the functional state of ovaries.
2. Assess results of laboratory, cytological, radiological examination methods, ultrasound.
3. Make plan of examination of patients with suspected pipe genesis of infertility.
4. Choose from anamnesis data that indicate the cause of infertility.
5. Perform inspection of the cervix in the mirror, vaginal studies and put the preliminary diagnosis.
6. Make plan of endocrine infertility treatment, depending on its origin.
7. Spermogram interpret the results.
2.3. Fall into practical skills: α = III
1. Anatomy of the female genital organs.
2. Key terms fertility and fertilization.
3. Basic and additional special methods, their diagnostic value.
4. Methods of functional ovaries.
5. Neuroendocrine regulation of menstrual cycle.
6. Normal and abnormal results of laboratory research methods (blood, urine, separation of the
vagina, etc.).
3. Educational goal: The specific examples demonstrate the principles of medical ethics and
deontology. Promote clinical skills in medical thinking in the process of communicating with
patients, take into account not only the nature of the disease, but also the individual characteristics
of the patient.
4. Intersubject integration (basic level of training).
Names of previous subjects received skills
Normal anatomy of the human determine anatomic structure of external and internal genital organs
Biological chemistry describe features steroyidohenezu
Histology describe the structure of reproductive cells, endometrial, ovarian, Uterus and uterine
tubes
Normal and Pathological Physiology define physiological characteristics of changes in women
depending on the phases of the menstrual cycle. Hold a collection of material for biochemical and
hormonal studies
Propaedeutics collect anamnesis internal diseases, conduct surveys fizykalnyh ¬ tion, recognize
clinical syndromes and symptoms to determine the required amount and sequence ¬ NIST test
methods, Evaluate the results of paraclinical methods
Topographic anatomy and operative surgery determine anatomic structure of external and internal
genital organs
5. PLAN AND ORGANIZATION Practical exercises
Milestones number Rozpodilchasu classes and levels
Types of learning control Educational and methodological support
1. Preparatory stage: 50 minutes. oral interviews, written for standardized lists of questions or
computer testing. table tests, dummies, calendar, stethoscope, tape centimetric
1.1 Organizational issues;
1.2 Formation of motivation
1.3 Control of entry-level training L = II-III
2. Main Stage:
independent work of students under the supervision of a teacher:
- During history taking and examination fee (with her consent) students gulf ¬ yut attention to
complaints, changes in physiological parameters of the test.
- Assess the re ¬ zultaty provided laboratory blood tests (clinical, biochemical, hormonal), urine,
etc. koagulogrammy.
• - Collect general and gynecologic anamnesis.
• Perform general and gynecological examination.
• assesses the functional diagnostic tests, laboratory data.
• Perform differential diagnosis of disorders of menstrual function and uterine bleeding associated
with abortion, and of early tumors.
• put the diagnosis of endometriosis, abnormalities of ZHSO.
• Obhruntuvuyut pathogenetic and symptomatic treatment of endometriosis, abnormalities of
ZHSO.
• Obhruntuvuyut indications for surgical treatment method (vyshkribuvannya, amputation of the
uterus, resection yayeshnykiv, etc.).
• Evaluate laboratory data, renthenolo ¬ logical, ultrasound methods.
2 hours. 10 min.
L = III Practical tasks Audios, tables, dummies, menstrualyoho cycle regulation schemes, tables,
slides, demo equipment, or medical history and laboratory data extract, mirror, gloves, specimen,
tweezers or spoons Folkmana, skull X-rays, uterus, medical packaging means, the control problem,
Microscope, a set of glasses with vaginal epithelial cells - four estrogenic saturation degree, a
symptom of a fern. In studies to prepare at least 2 patients.
3. Final stage: 60 min.
L = III
3.1 Controlling the final level of training. Solving clinical problems, a written test.
3.2 Motivated the overall assessment of training each student.
3.3 Informing students about the topic next
5.1. Preparatory stage - at the beginning of training the instructor will disclose urgency of their
main aims and objectives of training, to control output level of knowledge, to give problems for
independent work.
5.2. Main Stage: Infertility - a marriage in which during the year with the regular sex life without
the use of contraceptives, no pregnancy occurs. The frequency of infertility - 10-15% curable with
them - 30% of women.
We must remind students of basic research methods, disassemble fertility conditions. Fertility cycle,
when ovulation is, optimal transport mechanisms sperm and ova, normal implantation.
The structure of male infertility infertility ranked first - 52%.
Causes of male infertility: chronic stress, prostatitis, varicocelle. 70% of prostate chlamydia nature.
Female infertility:
1). Primary: Genetic, endocrine.
2). Recycled - inflammatory and endocrine genesis.
Structure of female infertility: primary - 50%, secondary - 50%.
Type of infertility: tubal - 50-60%, endocrine - 30%, immune - 5%, -2% peritoneal.
Causes of infertility in the family
1. Inflammatory processes genitals.
2. Infantilism and genital hypoplasia.
3. Diseases of the endocrine glands.
4. Injuries and the displacement of genital organs.
5. Genital tumors.
6. Fallopian tube obstruction.
7. Causes of the male sperm (azospermiya, olihospermiya, aspermiya, nekrospermiya).
8. Causes of the men and women that prevents ejection of semen in the vagina or the flow of sperm
in the upper female genital organs.
9. Causes of the ovaries. Lack of ovulation or the disabled ovaries produce eggs that can not be
fertilized.
10. No implantation dysfunction and yellow body.
11. Immune incompatibility between sperm and egg.
Particular attention should be paid to students' methods of inspection of men and women. Necessary
spermogram 3 times a month, measurement of basal temperature in women, colposcopy, samples
Shuvarskoho, histerosalpinhohrafiya, hormonal testing (17 CC, prolactin, FSH, LH, testosterone,
estrogen, progesterone), laparoscopy, pertubatsiya, research level of endogenous prostaglandins ,
thyroxin, tyreoyidynu.
Pipe infertility
There are two forms of tubular infertility:
- As a result of dysfunction of the uterine tubes (hypertonus, hipotonus, dyskoordynatsiya)
- As a result of organic lesions of uterine tube (obstruction, adhesions, kink, sterilization).
Methods of diagnosis
1. Histerosalpinhohrafiya (held in the first phase of the menstrual cycle).
2. Laparoscopy - because it conducted 1-3 months after questionable histerosalpinhohrafiyi (HSH),
and after 6 months at HSH normal data.
3. Laparoscopy combined with hromosalpinhoskopiyeyu.
4. Renthenokimohrafiya.
5. Kimohrafichna pertubatsiya.
6. Radioisotope scanning.
7. Mikrobiopsiya uterine tubes.
8. Bacterioscopic, bacteriological research genital tract.
Treatment. Trumpet Functional infertility treated through psychotherapy, avtosuhestiyi, sedative
drugs, tranquilizers, antispasmodic drugs, prostaglandin blockers in peredovulyatorni days
(naprosyn, indomethacin). Widely used balneological therapy - sulfur-water bath and performovani
physical factors - in a pulse mode ultrasound, electrostimulation uterine tubes.
Trumpet organic infertility treated by conducting a comprehensive anti-inflammatory therapy. In
the absence of the effect of complex conservative treatment for infertility pipe 1,5-2 years show
microsurgical treatment (salpinhostomiya).
Absolute contraindications for Microsurgical plastic operations on the uterine tube:
1. Genital tuberculosis.
Relative contraindications for Microsurgical plastic operations on the uterine tubes:
1. Age women older than 35 years.
2. Duration of tube 2-3 years of infertility and hopeless conservative treatment of more than 1,5-2
years.
3. Frequent exacerbation of inflammation in the uterus recent (year) acute inflammation.
4. The presence of large hidrosalpinksiv, which remains when you remove no more than 5 cm pipe.
5. Pronounced (third degree) adhesive process in small tazi.
Postoperative rehabilitation after Microsurgical plastic operations on pipes should include
rozsmoktuvalnu therapy - electrophoresis of zinc and copper, magnetic, ultrasound, enzyme, direct
elekrostymulyatsiyu uterine tubes after salpinhostomiyi and early hidrotubatsiyi without
hydrocortisone. After surgery recommended konratseptsiya within 3-4 months.
Endocrine infertility - infertility is characterized violation ovulation processes. The causes of
endocrine infertility is hyperandrogenia, NLF, gonadotrophic insufficiency, hyperprolactinemia,
thyroid dysfunction.
When endocrine infertility test a couple should be held within 3-6 months.
Necessarily hyperandrogeny differential diagnosis of adrenal and ovarian origin (of
deksametazonovoyi tests).
Treatments anovulyatsiyi - endocrine causes of infertility:
1. When hyperprolactinemia treatment recommended by parladelom 2,5-7,5 mg / day for 4-6
months after normalization of prolactin appoints Clomifenum, HG, perhonal;
Classical scheme Clomifenum ovulation stimulation with 5-to 9-day cycle of 50 mg, with
insufficient effect to increase the drug dose of 100-150 mg per day, for 3 cycles.
2000-3000 IU of HCG at 2-4-6-day increase of basal temperature.
2. When dysfunction of hypothalamic-pituitary system anovulyatsiyeyu and low LH, a positive test
using hestahenovym Clomifenum, HG, perhonal.
3. When loss of certain functions of hypothalamic-pituitary system with low estrogen negative test
conducted hestahenovym therapy HCG and perhonalom; reactivity only when using WP-pituitary
LH.
4. When hyperandrogenia splinter nadnyrnykovoho genesis appoint corticosteroids (dexamethasone
on 0,25-0,5 mg daily) combined with Clomifenum, HG or perhonalom.
5. When ovarian hyperandrogeny high excretion of estrogen, LH and polycystic ovaries used in
combination with gestagens or Clomifenum perhonalom and HCG, and WP-LH and its agonists,
which allow to stimulate follicular maturation in the ovaries.
Immune infertility associated with the presence of antibodies in cervical names to sperm that result
in a violation of fertilization. There are several hypotheses of immunological infertility. One of
them may be a genetic predisposition to sensitization ejaculate antigens. Such sensitization may
occur in the second phase of the menstrual cycle when natural barrier to foreign proteins decreased,
and the background of the inflammatory process increases penetration of cervical canal. Proved that
the semen fluid are inhibiny immune response that impede women's genital response to sperm. In
the men's possible violation of these inhibiniv secretion. Antyspermatozoyidnyy effect such
reactions could occur: 1) formation of humoral antibodies, 2) formation of tissue antibodies, and 3)
enhanced phagocytosis of sperm in the cervix or uterine cavity, 4) delayed reactionWhich manifests
itself in violation of blastocyst implantation in the endometrium due to prior sensitization inner wall
of the uterus with sperm, 5) emission of ejaculate sensitized uterine cavity through strengthened its
contractile movements.
One of the most reliable methods of diagnosis of immunological infertility is postkoyitalnyy test.
For research conducted along the rear fence material vault and cervical canal. A study assessed the
following indicators: Assessing the quality of cervical mucus (volume density of mucus
crystallization effect and stretching, the presence of cells), the presence of mobile forms of sperm.
In normal mucus must be liquid, transparent, and demonstrate atselyulyarnym "fern test" and
stretching. The presence of cervical names> 20 sperm moving says the absence of immunologic
incompatibility. Antibodies can also detect fluorestsentynymy methods with monoclonal
antysyrovatkamy. Artificial fertilization (IVF) - is introducing alien genetic material in the form of
sperm in sexual ways of women to pregnancy. There are sperm artificial insemination husband
(SHZCH) and the sperm donor (SHZD), depending on the input path of sperm - pihvynnyy,
intratservikalnyy way and uterine artificial insemination. SHZCH used for Hypospadias urethra,
impotence, lack of ejaculation, when olihospermiyi with preserved normal sperm mobility and the
absence of these morphological changes in vahinizmi.
Absolute indications for SHZD is azoospermiya. Relative - olihospermiya olihostenospermiya and
morphological changes in sperm motility and their violation, not to treat; incompatibility of
marriage by Rh factor; hereditary diseases in men, which can be transmitted to descendants.
Organization, structure and objectives of family planning services
In a worsening demographic situation in the country, lowering living standards of most of the
population, deterioration of reproductive health issues deserve special emphasis on family planning
as a reserve to reduce maternal and infant mortality, Disease prevention, sexually transmitted
diseases and preserving health.
In modern conditions, a sharp decline in fertility in Ukraine the problem of family planning has a
greater medical and social importance. Abortion in Ukraine remains the main method of birth
control. In this post-abortion complications observed in one third of women in their primigravides
frequency reaches 40%. The main complications of abortion is infertility, miscarriage, pelvic
inflammatory disease, endocrine disorders, complications during pregnancy and following
childbirth.
Family planning as an essential element of primary health care in many countries and in Ukraine
includes the following main activities:
• Information and counseling people with family planning;
• organization of family planning;
• the population means of contraception,
• treatment of infertility and sexual disorders;
• public opinion in the process ofAimed at changing the established notions of family planning on a
purely medical problem or intrafamily;
• increase knowledge and skills on this issue not only of Obstetricians and Gynecologists and other
medical specialties, and nurses, especially, Midwives health posts;
• deepening and extending the work on sexual education of children and adolescents, training of
teachers and parents on sexual development of children;
• involvement of the media to cover the problem of family planning, sexual culture, Family and
marital relations;
• increase the availability and quality of health services in family planning services.
Family Planning (PS) Ukraine belongs to one of the youngest subsystems Health of Ukraine.
Designed for world model airplane system, including complex medical and organizational activities
aimed at developing people safe sexual behavior, interest in maintaining and improving personal
health and fundamentals of responsible parenthood, Became the basis for the formation of the
younger generation reproductive function and reproductive health in adults. That is, the basis of the
airplane service relies primarily focused work with young people in the formation of sexual culture
and prepare them to create healthy families.
Organization of structural units of the airplane is in accordance to the level of consultative care for
AC.
And to level ascribed - obstetrical and medical items, district hospitals, medical dispensaries and
dispensaries family doctor and community organizations settlements.
At the family level and district doctor, medical assistants, midwives provide the following services
with AC:
• Conduct health education work on healthy lifestyles, sex education;
• disease preventionThat sexually transmitted diseases;
• organization of preventive examination of the female population while individual counseling or
selection method of preventing unwanted pregnancy;
• Organization and training of families to the methods of family planning according to WHO
recommendations;
• early detectionpregnant women and the dynamic oversight in collaboration with a physicianobstetrician-gynecologist; early detection of women with severe pathology degree to which the
pregnancy threatens the health or life, to their referral to a higher level of assistance.
Medical assistance on an airplane to provide level II in district offices and central district hospitals,
city offices, women's consultations, maternity, obstetric and gynecological department, service,
child and adolescent gynecology, child health clinics, Office / study of medical and social help to
children and young people clinic, youth-friendly, interested associations.
The second level of care on the airplane requires a normative definition of the specialist responsible
for the airplane, which relies on the organizational and methodological guide for the prevention of
STDs and pregnancy neplanovanoyi:
• providing public information and services from the airplane;
• a system of contraceptives population;
• creating conditions accessibility to services for the aircraft to the region;
• a register of women from extragenital pathology of severe degreeThat the pregnancy threatens the
health or life to them free of effective modern contraception types;
• cooperation with NGOs, educational institutions, law enforcement agencies and care institutions
in implementing the information component of AC in schools with issues of sexual education,
Health, development and reproductive health;
• Conduct pislyaabortnoho, postpartum counseling and individual selection of AC method of
contraception.
At level III aircraft providing services to Ukrainian State Centre of Family Planning Consultative
diagnostic, information and analysis units and training centers, educational institutions III-IV
accreditation levels, associations, regional centers of family planning with consulting and
diagnostic, Stationary (day stay patient), information and analysis units and training centers,
prevention of HIV / AIDS, health, medical genetics, regional STI and drug dispensaries,
associations.
The Ukrainian State Centre of Family Planning organized, methodical, consultative ¬ tive,
educational and highly specialized medical care.
Subdivisions of AC III level of service provided:
• provide advice and medical and diagnostic assistance on issues related to reproductive health of
families, family planning;
• prevention of infections, sexually transmitted infections (STIs);
• Andrology assistance to the population,
• prevention, Diagnosis and treatment of infertility;
• organization of health education work among the population and educational work among medical
experts, social experts, psychologists and educators regarding family planning foundations,
pediatric gynecology, sexology, Andrology;
• analysis of the demographic situation in the region and state of reproductive health, reproductive
epidemiology research costs and medical factors that violate the reproductive healthAnd
development activities and specific recommendations to address regional problems of family
planning and reproductive rights based on modern advances in medical science and practice;
• organizational and methodical work of family planning services and other preventive obstetric and
gynecologic medical zaklaSee also the region;
• introduction of modern methods of prevention, diagnosis and treatment of disorders and disorders
of reproductive function;
• training doctors of various specialties and nurses and nurse specialists from these problems;
• cooperation with local authorities, social security, Youth and Family Service, agencies and
educational institutions, government agencies of civil registration, law enforcement and other
agencies, media organizations, religious denominations on social health protection and rights of
families and their members, reproductive health I populationAnd to identify needs of the region in
various means and methods of contraception;
• collaboration with regional dermato-lock-, drug dispensaries, centers and prevention of HIV,
health centers, social services for young people to integrate services on aircraft.
Organization of the airplane in Ukraine on the formation of reproductive health services carried out
together with education in any structural-organizational level through the creation and adoption of
joint programs under age children.
5.3. Control issues:
1. What mean by infertility?
2. What types of infertility?
3. Qualitative and quantitative indicators of fertile sperm.
4. The causes of female infertility.
5. Methods for diagnosing tubular sterility.
6. Methods of diagnosis of endocrine infertility.
7. Test Algorithm couple with immunological infertility.
8. Indications and contraindications for surgical treatment of tubular infertility.
9. Indications for extracorporeal fertilization.
10. Principles of endocrine infertility therapy.
11. Organization, structure and objectives of family planning services.
5.4. Final stage. Monitoring learning through situational problem solving, oral communications
students about their work. Assessed the work of each student, the teacher makes generalizations
comments for swing classes in assessing students on ethics, provides job home.
6. Materials methodological support classes:
Venue: study rooms, viewing room gynecologic department, office of functional diagnosis,
manipulation, visualization study, women's consultation.
Equipment: Study table, slides, case histories or extracts from them, mirrors, tweezers, subject
glasses, skull X-rays, histerohramy, packaging hormones, microscope, a set of glasses with klityka,
diagnosis and treatment ppohonadotropnoyi Perk, Diagnosis and treatment hiperhonadotropnoyi
Pernod vaginal epithelium (four estrogenic saturation degree). A set of control questions, situational
problems, tasks for students' independent work.
6.1. Appendices. Means for control:
Checklists of questions.
Number 1. Dvatsyatydvorichna patient asked the doctor for advice, because married over 5 years,
but there was no pregnancy. This means of preventing pregnancy does not use about 6 - 7 months.
Diagnosis? What to do?
Number 2. Dvatsyatydevyatyrichna patient asked the doctor complaining that 2 years ago
underwent artificial abortion at will, and last year of pregnancy is not reached. Second marriage.
Diagnosis? Which test should be carried out to establish cause infertility?
Number 3. Dvatsyatysemyrichna patient asked the doctor complaining of lack of pregnancy during
6 years of marriage without means of prevention. Man of 35 years. Diagnosis? A plan examination
infertility.
№ 4. Trytsyatyp'yatyrichna patient came advice that can be done to calm pregnancy. In the past, she
underwent two operations on ectopic pregnancy, both uterine tubes removed during operations.
Diagnosis? What are the possible methods should be applied in this patient?
Number 5. A woman aged in 47 years lost a single daughter from serious infectious diseases.
Patient wants to consult, or may even come in her pregnancy. What advice should provide a doctor?
What reservations should be made
of late pregnancy?
Tests.
1 Frequency of infertility:
A. 5-10%.
B. 15-20%.
Of 5-20%.
G. 35-40%.
D. More than 40%.
2. Can cause infertility colpitis?
A. Yes.
B. No.
3. It may change the pH of cervical mucus to be the only cause of infertility?
A. No.
B. Yes.
4. What forms of female infertility prevail in Ukraine?
A. Endocrine.
B. inflammatory genesis.
Of mixed origin.
G. Nez 'cleared genesis.
5. A survey of spouses with infertility should I do:
A. From the survey women.
B. On the test man.
A survey of women and men simultaneously.
6. In a survey of spouses in infertility, which test is first?
A. endometrial biopsy at 22 to 24-day cycle.
B. Pertubatsiya.
V. spermogram man.
G. Histerosalpinhohrafiya.
D. bacteriological examination of a couple.
7. Does the contractile activity of uterine tubes on the generative function?
A. Yes.
B. No.
8. For the diagnosis of infertility in women is necessary to conduct such an examination:
A. Measurement of basal temperature, MSH, kolpotsytolohiya.
B. ultrasound measurement of basal temperature, kolpotsytolohiya.
V. Kolpotsytolohiya, MSH, and bacteriological research bacterioscopic flora, measuring basal
temperature.
G. Tests of functional hormonodiahnostyky, MSH, determine the degree of purity of vaginal flora,
pH of cervical mucus, endometrial histological study of 22-24-day cycle.
9. To confirm the nature of the hypothalamic-pituitary infertility need to conduct research:
A. estrogen, progesterone, prolactin.
B. Testosterone, cortisol, estrogen and progesterone.
Of FSH, LH, TSH, prolactin.
H. 17-CS and 11-OKS, aldosterone.
D. ST, prolactin, ACTH.
10. What hormonal studies argue halaktoreyu as the cause of infertility?
A. estrogen, progesterone, prolactin.
B. Testosterone, ACTH, cortisol.
In. Prolactin, prolaktoliberynu, prolaktostatynu, T3, T4, TSH, TG, ST.
G. cortisol, 11-OKS, aldosterone.
True answers to self tests:
1.B, 2.A, 3.B, 4.B, 5.B, 6.A, 7.H, 8.B, 9.A, 10.A.
7. Tasks NDRS
1. And perform a bibliographic search on "Use of endoscopic methods in the treatment of
endometriosis.
2. Writing papers on the issue.
3. Plan review of literature.
4. Production of tables, slides, drawings.
8. Recommended readings.
8.1. General:
1. Gryshchenko VI "Gynaecology. / VI Gryshchenko - Berlin: Basis, 2000.
2. Order number 582 of Health of Ukraine "On approval of clinical protocols for obstetric and
gynecological care. Protocol "tactic of women with infertility.
3. Kulakov VI Operative Gynecology. / VI Kulakov .- M., 1990.
4. Tymoshenko LV Practical Gynecology. / LV Said. - K.: "Health", 1988.
MORE:
1. Smetnyk VP, LG Tumilovich Neoperatyvnaya lead researches: A Guide for doctors. / V.P
Smetnyk, LG Tumilovich .- S-Pb, SOTYS, 1995. - 224 pp.