Reproductive medicine

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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.

Contents

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.

Aristotle Aristotle Altemps Inv8575.jpg
Aristotle

History

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 wasn't 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]

Scope

Reproductive medicine addresses issues of sexual education, puberty, family planning, birth control, infertility, reproductive system disease (including sexually transmitted diseases) 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.

Conditions

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.

Infectious Diseases

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 or oral 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]

Cancer

Many parts of the Reproductive system can be affected by cancer. Below are some examples of Reproductive cancers:

Reproductive Cancers affecting Women

Reproductive Cancers affecting Men

Conditions affecting Fertility [8]

A significant part of Reproductive Medicine involves promoting fertility in both men and women.

Causes of Infertility or Subfertility in Women

Causes of Infertility or Subfertility in Men

Disorders of Sex Development

Congenital Abnormalities

Congenital Abnormalities of the Female Reproductive system [9]

Congenital Abnormalities of the Male Reproductive system [10]

Endocrine Disorders [11]

Disorders due to hormone excess

Disorders due to hormone deficiency

Disorders due to hormone hypersensitivity

Disorders due to hormone resistance

Non-functioning endocrine tumours

Secondary Endocrine disorders (originating in the pituitary gland)

Assessment and treatment

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]

Education and training

Specialists in reproductive medicine usually undergo training in obstetrics and gynecology followed by training in reproductive endocrinology and infertility, or in urology followed by training in andrology. 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). [17]

Anamnesis

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, he or she often doesn't start talking about such an issue without the physician initiating the subject by a specific question about sexual or reproductive health. [18] 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. [18] 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. [18]

Ethical and medicolegal issues

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. [19] 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 [20]

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.

Related Research Articles

Cervix The lower part of the uterus in the human female reproductive system

The cervix or cervix uteri is the lower part of the uterus in the human female reproductive system. The cervix is usually 2 to 3 cm long and roughly cylindrical in shape, which changes during pregnancy. The narrow, central cervical canal runs along its entire length, connecting the uterine cavity and the lumen of the vagina. The opening into the uterus is called the internal os, and the opening into the vagina is called the external os. The lower part of the cervix, known as the vaginal portion of the cervix, bulges into the top of the vagina. The cervix has been documented anatomically since at least the time of Hippocrates, over 2,000 years ago.

Vagina part of the female genital tract

In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vulva to the cervix. The outer vaginal opening is normally partly covered by a membrane called the hymen. At the deep end, the cervix bulges into the vagina. The vagina allows for sexual intercourse and birth. It also channels menstrual flow (menses), which occurs in humans and closely related primates as part of the monthly menstrual cycle.

In vitro fertilisation Assisted reproductive technology procedure

In vitro fertilisation (IVF) is a process of fertilisation where an egg is combined with sperm outside the body, in vitro. The process involves monitoring and stimulating a woman's ovulatory process, removing an ovum or ova from the woman's ovaries and letting sperm fertilise them in a liquid in a laboratory. After the fertilised egg (zygote) undergoes embryo culture for 2–6 days, it is implanted in the same or another woman's uterus, with the intention of establishing a successful pregnancy.

Infertility is the inability of a person, 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.

Delayed puberty is when a person lacks or has incomplete development of specific sexual characteristics past the usual age of onset of puberty. The person may have no physical or hormonal signs that puberty has begun. In the United States, girls are considered to have delayed puberty if they lack breast development by age 13 or have not started menstruating by age 16. Boys are considered to have delayed puberty if they lack enlargement of the testicles by age 14. Delayed puberty affects about 2% of adolescents.

Hypogonadism means diminished functional activity of the gonads—the testes or the ovaries—that may result in diminished production of sex hormones.

Kallmann syndrome (KS) is a genetic disorder that prevents a person from starting or fully completing puberty. Kallmann syndrome is a form of a group of conditions termed hypogonadotropic hypogonadism. To distinguish it from other forms of hypogonadotropic hypogonadism, Kallmann syndrome has the additional symptom of a total lack of sense of smell (anosmia) or a reduced sense of smell. If left untreated, people will have poorly defined secondary sexual characteristics, show signs of hypogonadism, almost invariably are infertile and are at increased risk of developing osteoporosis. A range of other physical symptoms affecting the face, hands and skeletal system can also occur.

Assisted reproductive technology methods used to achieve pregnancy by artificial or partially artificial means

Assisted reproductive technology (ART) includes medical procedures used primarily to address infertility. This subject involves procedures such as in vitro fertilization, intracytoplasmic sperm injection (ICSI), cryopreservation of gametes or embryos, and/or the use of fertility medication. When used to address infertility, ART may also be referred to as fertility treatment. ART mainly belongs to the field of reproductive endocrinology and infertility. Some forms of ART may be used with regard to fertile couples for genetic purpose. ART may also be used in surrogacy arrangements, although not all surrogacy arrangements involve ART.

Müllerian agenesis, also known as Mayer–Rokitansky–Küster–Hauser syndrome (MRKH) or vaginal agenesis, is a congenital malformation characterized by a failure of the Müllerian duct to develop, resulting in a missing uterus and variable degrees of vaginal hypoplasia of its upper portion. Müllerian agenesis is the cause in 15% of cases of primary amenorrhoea. Because most of the vagina does not develop from the Müllerian duct, instead developing from the urogenital sinus, along with the bladder and urethra, it is present even when the Müllerian duct is completely absent. Because ovaries do not develop from the Müllerian ducts, affected people might have normal secondary sexual characteristics but are infertile due to the lack of a functional uterus. However, parenthood is possible through use of gestational surrogates.

Male infertility refers to a male's inability to cause pregnancy in a fertile female. In humans it accounts for 40–50% of infertility. It affects approximately 7% of all men. Male infertility is commonly due to deficiencies in the semen, and semen quality is used as a surrogate measure of male fecundity.

Female infertility Diminished or absent ability of a female to achieve conception

Female infertility refers to infertility in women. It affects an estimated 48 million women, with the highest prevalence of infertility affecting people 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 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.

A vaginal disease is a pathological condition that affects part or all of the vagina.

Sexually transmitted infection Infection transmitted through human sexual behavior

Sexually transmitted infections (STIs), also referred to as sexually transmitted diseases (STDs), are infections that are commonly spread by sexual activity, especially vaginal intercourse, anal sex and oral sex. Many times STIs initially do not cause symptoms. This results in a greater risk of passing the disease on to others. Symptoms and signs of disease may include vaginal discharge, penile discharge, ulcers on or around the genitals, and pelvic pain. STIs can be transmitted to an infant before or during childbirth and may result in poor outcomes for the baby. Some STIs may cause problems with the ability to get pregnant.

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, is a condition which is characterized by hypogonadism 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 and elevated gonadotropin levels. HH may present as either congenital or acquired, but the majority of cases are of the former nature.

Leydig cell hypoplasia human disease

Leydig cell hypoplasia (LCH), also known as Leydig cell agenesis, is a rare autosomal recessive genetic and endocrine syndrome affecting an estimated 1 in 1,000,000 genetic males. It is characterized by an inability of the body to respond to luteinizing hormone (LH), a gonadotropin which is normally responsible for signaling Leydig cells of the testicles to produce testosterone and other androgen sex hormones. The condition manifests itself as pseudohermaphroditism, hypergonadotropic hypogonadism, reduced or absent puberty, and infertility.

Hypogonadotropic hypogonadism (HH), is due to problems with either the hypothalamus or pituitary gland affecting the hypothalamic-pituitary-gonadal axis. Hypothalamic disorders result from a deficiency in the release of gonadotropic releasing hormone (GnRH), while pituitary gland disorders are due to a deficiency in the release of gonadotropins from the anterior pituitary. GnRH is the central regulator in reproductive function and sexual development via the HPG axis. GnRH is released by hypothalamic neuroendocrine cells into the hypophyseal portal system acting on gonadotrophs in the anterior pituitary. The release of gonadotropins, LH and FSH, act on the gonads for the development and maintenance of proper adult reproductive physiology. LH acts on Leydig cells in the male testes and theca cells in the female. FSH acts on Sertoli cells in the male and follicular cells in the female. Combined this causes the secretion of gonadal sex steroids and the initiation of folliculogenesis and spermatogenesis. The production of sex steroids forms a negative feedback loop acting on both the anterior pituitary and hypothalamus causing a pulsatile secretion of GnRH. GnRH neurons lack sex steroid receptors and mediators such as kisspeptin stimulate GnRH neurons for pulsatile secretion of GnRH.

Vaginal anomalies congenital defect; abnormal or absent vagina

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. When present, they are often found with uterine, skeletal and urinary abnormalities. This is because these structures, like the vagina, are most susceptible to disruption during crucial times of organ-genesis. Many of these defects are classified under the broader term Müllerian duct anomalies. Müllerian duct anomalies are caused by a disturbance during the embryonic time of genitourinary development. The other isolated incidents of vaginal anomalies can occur with no apparent cause. Oftentimes vaginal anomalies are part of a cluster of defects or syndromes. In addition, inheritance can play a part as can prenatal exposure to some teratogens. Many vaginal anomalies are not detected at birth because the external genitalia appear to be normal. Other organs of the reproductive system may not be affected by an abnormality of the vagina. The uterus, fallopian tubes and ovaries can be functional despite the presence of a defect of the vagina and external genitalia. A vaginal anomaly may not affect fertility. Though it depends on the extent of the vaginal defect, it is possible for conception to occur. In instances where a functional ovary exists, IVF may be successful. Functioning ovaries in a woman with a vaginal defect allows the implantation of a fertilized ovum into the uterus of an unaffected gestational carrier. A successful conception and can occur. Vaginal length varies from 6.5 to 12.5 cm. Since this is slightly shorter than older descriptions, it may impact the diagnosis of women with vaginal agenesis or hypoplasia who may unnecessarily be encouraged to undergo treatment to increase the size of the vagina. Vaginal anomalies may cause difficulties in urination, conception, pregnancy, impair sex. Psychosocial effects can also exist.

References

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  3. Clarke, Gary N. (July 2006). "A.R.T. and history, 1678-1978". Human Reproduction (Oxford, England). 21 (7): 1645–1650. doi:10.1093/humrep/del067. ISSN   0268-1161. PMID   16606642.
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Literature