Reproductive medicine is a branch of medicine concerning the male and female reproductive systems. It encompasses a variety of reproductive conditions, their prevention and assessment, as well as their subsequent treatment and prognosis.
Reproductive medicine has allowed the development of artificial reproductive techniques (ARTs) which have allowed advances in overcoming human infertility, as well as being used in agriculture and in wildlife conservation. Some examples of ARTs include IVF, artificial insemination (AI) and embryo transfer, as well as genome resource banking.
The study of reproductive medicine is thought to date back to Aristotle, where he came up with the “Haematogenous Reproduction Theory”. [1] However, evidence-based reproductive medicine is traceable back to the 1970s. [2] Since then, there have been many milestones for reproductive medicine, including the birth of Louise Brown, the first baby to be conceived through IVF in 1978. [3] Despite this, it was not until 1989 that it became a clinical discipline thanks to the work of Iain Chalmers in developing the systematic review and the Cochrane collection. [2]
Reproductive medicine addresses issues of sexual education, puberty, family planning, birth control, infertility, reproductive system disease (including sexually transmitted infections) and sexual dysfunction. [4] In women, reproductive medicine also covers menstruation, ovulation, pregnancy and menopause, as well as gynecologic disorders that affect fertility. [5]
The field cooperates with and overlaps mainly with reproductive endocrinology and infertility, sexual medicine and andrology, but also to some degree with gynecology, obstetrics, urology, genitourinary medicine, medical endocrinology, pediatric endocrinology, genetics, and psychiatry.
Reproductive medicine deals with prevention, diagnosis and management of the following conditions. This section will give examples of a number of common conditions affecting the human reproductive system.
Reproductive tract infections (RTIs) are infections that affect the reproductive tract. There are three types of RTIs: endogenous RTIs, iatrogenic RTIs and sexually transmitted infections. [6] Endogenous RTIs are caused by an overgrowth of bacteria which is normally present. An example of an endogenous RTI is bacterial vaginosis.
Iatrogenic RTIs are infections contracted as a result of a medical procedure.
Sexually transmitted infections (STIs) are infections spread by sexual activity, usually by vaginal intercourse, anal sex, oral sex, and rarely manual sex. Many STIs are curable; however, some STIs such as HIV are incurable. STIs can be bacterial, viral or fungal and affect both men and women. Some examples of STIs are listed below: [7]
Many parts of the Reproductive system can be affected by cancer. Below are some examples of Reproductive cancers:
A significant part of reproductive medicine involves promoting fertility in both men and women.
Assessment and treatment of reproductive conditions is a key area of reproductive medicine.
Female assessment starts with a full medical history (anamnesis) which provides details of the woman's general health, sexual history and relevant family history. [12] A physical examination will also take place to identify abnormalities such as hirsutism, abdominal masses, infection, cysts or fibroids. A blood test can inform the clinician of the endocrine status of the patient. Progesterone levels are measured to check for ovulation, and other ovulatory hormones can also be measured. Imaging techniques such as pelvic ultrasounds can also be used to assess the internal anatomy. [13]
Male assessment also starts with a history and physical examination to look for any visible abnormalities. Investigations of semen samples also take place to assess the volume, motility and number of sperm, as well as identifying infections. [14]
Once the investigations are complete, treatment of identified conditions can occur. For fertility issues, this may involve assisted reproductive technology (ART) such as in-vitro fertilisation (IVF) or fertility medication. There are surgical methods that can be used as treatment however these are now performed less frequently due to the increasing success of the less invasive techniques. [13] Treatment is also required for sexually transmitted infections (STIs). These can take the form of antibiotics for bacterial infections such as chlamydia [15] or highly active anti-retroviral therapy (HAART) for the HIV virus. [16]
Before starting a career in reproductive medicine, individuals must first obtain an undergraduate degree. The next step is medical school, where they earn a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree. Specialists in reproductive medicine usually undergo medical residency training in obstetrics and gynecology followed by medical fellowship training in reproductive endocrinology and infertility. An alternative path to practicing reproductive medicine after medical school involves a medical residency in urology, followed by a medical fellowship in male infertility. The education and training required to practice reproductive medicine is typically 15-16 years in duration. [17] [18] [19] After completing medical fellowship, physicians can obtain board certification and must maintain continuing medical education (CME). [20] CME is necessary in reproductive medicine as advancements in technology and treatment options require ongoing learning and skill development.
For reproductive medicine specialists in contraception, other methods of training are possible. Specialists tend to be organized in specialty organizations such as the American Society for Reproductive Medicine (ASRM) and European Society of Human Reproduction and Embryology (ESHRE).
The anamnesis or medical history taking of issues related to reproductive or sexual medicine may be inhibited by a person's reluctance to disclose intimate or uncomfortable information. Even if such an issue is on the person's mind, they often do not start talking about such an issue without the physician initiating the subject by a specific question about sexual or reproductive health. [21] Some familiarity with the doctor generally makes it easier for person to talk about intimate issues such as sexual subjects, but for some people, a very high degree of familiarity may make the person reluctant to reveal such intimate issues. [21] When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level. [21]
There are many ethical and legal issues surrounding reproductive medicine. In the UK the Human Fertilisation and Embryology Authority (HEFA) regulates many aspects of reproductive medicine in the UK, including IVF, Artificial Insemination, storage of reproductive tissue and research in this field. HEFA was established due to the Human Fertilisation and Embryology Act (1990). This act was reviewed and the Human Fertilisation and Embryology Act (2008) was passed through parliament as an update to the 1990 act.
For therapies such as IVF, many countries have strict guidelines. In the UK, referrals are only given to women under 40 who have either undergone 12 cycles of artificial insemination, or have tried and failed to conceive for 2 years. [22] While NICE recommends NHS clinical commissioning groups (CCGs) to provide 3 NHS funded cycles of IVF, many only offer 1 cycle, with some only offering IVF in exceptional circumstances on the NHS. If an individual does not meet the criteria or has gone through the maximum number of NHS-funded cycles, the individual will have to pay for private treatment [23]
Many reproductive technologies are seen to have ethical problems, including IVF, mitochondrial replacement therapy, germline modification, preimplantation genetic diagnosis.
There are many groups around the world which oppose to ARTs, including religious groups and pro-life charities such as LIFE.
The cervix or cervix uteri is a dynamic fibromuscular sexual organ of the female reproductive system that connects the vagina with the uterine cavity. The human female cervix has been documented anatomically since at least the time of Hippocrates, over 2,000 years ago. The cervix is approximately 4 cm long with a diameter of approximately 3 cm and tends to be described as a cylindrical shape, although the front and back walls of the cervix are contiguous. The size of the cervix changes throughout a woman's life cycle. For example, during the fertile years of a woman's reproductive cycle, females tend to have a larger cervix vis á vis postmenopausal females; likewise, females who have produced offspring have a larger sized cervix than females who have not produced offspring.
Pelvic inflammatory disease, also known as pelvic inflammatory disorder (PID), is an infection of the upper part of the female reproductive system, namely the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there may be no symptoms. Signs and symptoms, when present, may include lower abdominal pain, vaginal discharge, fever, burning with urination, pain with sex, bleeding after sex, or irregular menstruation. Untreated PID can result in long-term complications including infertility, ectopic pregnancy, chronic pelvic pain, and cancer.
Infertility is the inability of an animal or plant to reproduce by natural means. It is usually not the natural state of a healthy adult, except notably among certain eusocial species. It is the normal state of a human child or other young offspring, because they have not undergone puberty, which is the body's start of reproductive capacity.
Hypogonadism means diminished functional activity of the gonads—the testicles or the ovaries—that may result in diminished production of sex hormones. Low androgen levels are referred to as hypoandrogenism and low estrogen as hypoestrogenism. These are responsible for the observed signs and symptoms in both males and females.
Sexual medicine or psychosexual medicine as defined by Masters and Johnsons in their classic Textbook of Sexual Medicine, is "that branch of medicine that focuses on the evaluation and treatment of sexual disorders, which have a high prevalence rate." Examples of disorders treated with sexual medicine are erectile dysfunction, hypogonadism, and prostate cancer. Sexual medicine often uses a multidisciplinary approach involving physicians, mental health professionals, social workers, and sex therapists. Sexual medicine physicians often approach treatment with medicine and surgery, while sex therapists often focus on behavioral treatments.
Fertility medications, also known as fertility drugs, are medications which enhance reproductive fertility. For women, fertility medication is used to stimulate follicle development of the ovary. There are very few fertility medication options available for men.
Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.
Female infertility refers to infertility in women. It affects an estimated 48 million women, with the highest prevalence of infertility affecting women in South Asia, Sub-Saharan Africa, North Africa/Middle East, and Central/Eastern Europe and Central Asia. Infertility is caused by many sources, including nutrition, diseases, and other malformations of the uterus. Infertility affects women from around the world, and the cultural and social stigma surrounding it varies.
A reproductive system disease is any disease of the human reproductive system.
Hematocolpos is a medical condition in which the vagina is pooled with menstrual blood due to multiple factors leading to the blockage of menstrual blood flow. The medical definition of hematocolpos is "an accumulation of blood within the vagina". It is often caused by the combination of menstruation with an imperforate hymen. It is sometimes seen in Robinow syndrome, uterus didelphys, or other vaginal anomalies.
Hematometra is a medical condition involving collection or retention of blood in the uterus. It is most commonly caused by an imperforate hymen or a transverse vaginal septum.
Reproductive endocrinology and infertility (REI) is a surgical subspecialty of obstetrics and gynecology that trains physicians in reproductive medicine addressing hormonal functioning as it pertains to reproduction as well as the issue of infertility. While most REI specialists primarily focus on the treatment of infertility, reproductive endocrinologists are trained to also test and treat hormonal dysfunctions in females and males outside infertility. Reproductive endocrinologists have specialty training (residency) in obstetrics and gynecology (ob-gyn) before they undergo sub-specialty training (fellowship) in REI.
A sexually transmitted infection (STI), also referred to as a sexually transmitted disease (STD) and the older term venereal disease (VD), is an infection that is spread by sexual activity, especially vaginal intercourse, anal sex, oral sex, or sometimes manual sex. STIs often do not initially cause symptoms, which results in a risk of transmitting them on to others. The term sexually transmitted infection is generally preferred over sexually transmitted disease or venereal disease, as it includes cases with no symptomatic disease. Symptoms and signs of STIs may include vaginal discharge, penile discharge, ulcers on or around the genitals, and pelvic pain. Some STIs can cause infertility.
Female genital disease is a disorder of the structure or function of the female reproductive system that has a known cause and a distinctive group of symptoms, signs, or anatomical changes. The female reproductive system consists of the ovaries, fallopian tubes, uterus, vagina, and vulva. Female genital diseases can be classified by affected location or by type of disease, such as malformation, inflammation, or infection.
Reproductive surgery is surgery in the field of reproductive medicine. It can be used for contraception, e.g. in vasectomy, wherein the vasa deferentia of a male are severed, but is also used plentifully in assisted reproductive technology. Reproductive surgery is generally divided into three categories: surgery for infertility, in vitro fertilization, and fertility preservation.
The following outline is provided as an overview of and topical guide to obstetrics:
Hypergonadotropic hypogonadism (HH), also known as primary or peripheral/gonadal hypogonadism or primary gonadal failure, is a condition which is characterized by hypogonadism which is due to an impaired response of the gonads to the gonadotropins, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), and in turn a lack of sex steroid production. As compensation and the lack of negative feedback, gonadotropin levels are elevated. Individuals with HH have an intact and functioning hypothalamus and pituitary glands so they are still able to produce FSH and LH. HH may present as either congenital or acquired, but the majority of cases are of the former nature. HH can be treated with hormone replacement therapy.
Postcoital bleeding (PCB) is non-menstrual vaginal bleeding that occurs during or after sexual intercourse. Though some causes are with associated pain, it is typically painless and frequently associated with intermenstrual bleeding.
Müllerian duct anomalies are those structural anomalies caused by errors in Müllerian duct development as an embryo forms. Factors contributing to them include genetics and maternal exposure to substances that interfere with fetal development.
Vaginal anomalies are abnormal structures that are formed during the prenatal development of the female reproductive system and are rare congenital defects that result in an abnormal or absent vagina.