Counselling about risk in Gyanecology

Presenting information on risk :

 

Term	Numerical ratio	Colloquial description
Very common	1/1 to 1/10	A person in family
Common	1/10 to 1/100	A person in street
Uncommon	1/100 to 1/1000	A person in village
Rare	1/1000 to 1/10 000	A person in small town
Very rare	Less than 1/10 000	A person in large town

 

 

 

 

RCOG Consent Advice 9 - Perineal Tears Following Childbirth :

 

Serious risks -

1. Incontinence of stools and/or flatus - 
 Common

1/10 to 1/100

A person in street

 
2. Delivery by caesarean section in future pregnancies may be recommended if symptoms of incontinence persist or investigations suggest abnormal anal sphincter structure or function.

Uncommon:

1/100 to 1/1000

A person in village

  
 3. Haematoma. 
 4. Consequences of failure of the repair requiring the need for further interventions in the future such as secondary repair or sacral nerve stimulation.

Rare:

1/1000 to 1/10 000

A person in small town

5.  Rectovaginal fistula.

Very rare:

Less than 1/10 000

A person in large town

 

 

RCOG Consent Advice 10 - Surgical evacuation of the uterus :

 

Serious risks include:

• Uterine perforation, up to five in 1000 women (uncommon-A person in village)
• Significant trauma to the cervix (rare-A person in small town)

Frequent risks include:

• Bleeding that lasts for up to 2 weeks is very common but blood transfusion is uncommon (1–2 in 1000 women)
• Need for repeat surgical evacuation, up to five in 100 women (common)
• Localised pelvic infection, three in 100 women (common).

RCOG Consent Advice 12 - CS for placenta previa :

 

In all women with placenta praevia:

• Emergency hysterectomy, up to 11 in 100 women (very common)
• Massive obstetric haemorrhage, 21 in 100 women (very common).
• Need for further laparotomy during recovery from the caesarean, 75 in 1000 women (common)
• Thromboembolic disease, up to three in 100 women (common)
• Bladder or ureteric injury, up to six in 100 women (common)
• Future placenta praevia, 23 in 1000 women (common)

Links for cancer information

For detailed & well-presented information about cancers -
 Must read  -  
 Cervical cancer
 Endometrial cancer

Anorexia nervosa

• Onset typically before the age of 25 years
• One of the most important causes of secondary amenorrhoea in adolescents
• Amenorrhoea frequently pre-dates weight loss

• Weight loss >25% original body weight
• Distorted body image with implacable attitude towards eating

• Exclude medical illness that could cause weight loss
• Exclude other psychiatric disorders

• Associated with lanugo hair, bradycardia , hypotension, constipation, hypothermia, vomiting (may be self-induced) and periods of over-activity

• Psychiatric referral required  

• May occur in adolescents and present with primary amenorrhoea

• FSH and LH levels are low and may be undetectable

• Oestradiol and progesterone low. Progesterone challenge test typically negative

• Cortisol elevated

• Prolactin normal

• TSH and T4 levels are normal but T3 and reverse T3 are elevated

• Changes revert to normal with weight gain but 30% remain amenorrhoeic

• Response to GnRH is regained at ~15% below the ideal body weight and occurs before the resumption of menses

Causes of azoospermia

1) Hypothalamic-pituitary failure: (Hypogonadotrophic hypogonadism)

2) Primary testicular failure (nonobstructive azoospermia)

3) Obstruction of the genital tract (obstructive azoospermia)

4) Anejaculation 

5) Retrograde ejaculation

WHO reference values for semen analysis - Year 2010

Semen volume: ≥ 1.5 ml

 pH: ≥ 7.2  

Sperm concentration: ≥ 15 million spermatozoa per ml

Total sperm number: ≥ 39 million spermatozoa per ejaculate 

Total motility (percentage of progressive motility and non-progressive motility): ≥ 40% motile or ≥ 32% with progressive motility

Vitality: ≥ 58% live spermatozoa 

Sperm morphology (percentage of normal forms): ≥ 4% 

(Please note : Older values, year 2002 are different)

Causes of azoospermia - 4

4) Anejaculation: 
    - total failure of seminal emission into the posterior urethra. 
    - Rare

5) Retrograde ejaculation: 
  - substantial propulsion of seminal fluid from the posterior urethra into the bladder. 
  - Accounts for 0.3–2.0% of male fertility problems

(4) and (5) may result from:

1. Spinal cord injury
2. Transurethral prostatectomy – only 7% of men retain ejaculation
3. Retroperitoneal lymph node dissection
4. Diabetes mellitus
5. Transverse myelitis
6. Multiple sclerosis
7. Psychogenic / idiopathic disorders

Causes of azoospermia - 3

3) Obstruction of the genital tract (obstructive azoospermia): 

Prevalence < 2%

Diagnosis is based on normal testis size and normal serum FSH levels.
Causes include :
Congenital bilateral absence of vas deferens 
(associated with cystic fibrosis mutations or renal tract abnormality)

Causes of azoospermia - 2

2) Primary testicular failure (nonobstructive azoospermia): 

The diagnosis is based on reduction in testicular size and elevation of serum FSH levels. 

It is the most common cause of male infertility due to oligozoospermia. 

May be due to:

• Cryptorchidism
• Torsion
• Trauma
• Orchitis
• Chromosome disorders (Klinefelter’s syndrome, Y-chromosome microdeletions)
• Systemic disease
• Radiotherapy or chemotherapy
• Idiopathic (66%)

There is no effective treatment. 

Men undergoing treatments that cause infertility should be offered the opportunity to cryopreserve semen.

Causes of azoospermia - 1

1) Hypothalamic-pituitary failure: (Hypogonadotrophic hypogonadism). 

 Accounts for < 1% of male factor fertility.

 It results in a deficiency of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which is associated with -

failure of spermatogenesis and testosterone secretion.

Kallman Syndrome

 - X-linked recessive disease
- Reduced or complete absence of the sense of smell (anosmia-caused by the absence of the olfactory bulbs),  
- underdeveloped genitalia  - infertility
- lack of secondary sexual characteristics, 
- gynaecomastia, 
- short 4th metacarpal bone
- Males affected (1 in 10,000). 

- Presents at puberty

- Normal life-span 

- reduced or absent GnRH, with hypogonadotrophic hypogonadism. 

 - Hypothalamus is also affected

Anovulation in hyperprolactinemia

Hyperprolactinemic anovulation -

- 5-10% anovulation. 

- Anovulatory because hyperprolactinemia inhibits gonadotropin and therefore estrogen secretion. 

- Most have oligomenorrhea or amenorrhea. 

- Their serum gonadotropin concentrations are usually normal or decreased. 

- Hyperprolactinemia should always be confirmed by several measurements of serum prolactin. 

- An MRI of the head should be done in whom the cause is not obvious (eg, neuroleptic drug therapy, primary hypothyroidism).

WHO Group 3 ovulation disorders

Hypergonadotropic hypoestrogenic anovulation -

 - 10-30% cases of anovulation. 

- Primary causes :

1. POF (absence of ovarian follicles due to early menopause) or 
2. ovarian resistance (follicular form). 

- Many, but not all, of these women have amenorrhea.

- They usually do not respond to therapy for anovulation.

WHO Group 1 ovulation disorders

Hypogonadotropic hypogonadal anovulation -
(Hypothalamic pituitary Failure)

- 5 to 10 % of anovulation, usually amenorrhea 
(although a range of gonadal compromise can be seen)

- Low or low-normal FSH and low serum estradiol due to decreased hypothalamic secretion of GnRH or pituitary unresponsiveness to GnRH
(Low gonadotrophins
Normal prolactin
Low oestrogen)

- Causes of hypothalamic amenorrhea include :

1. stress-or exercise-related amenorrhea, 
2. anorexia nervosa, and 
3. Kallman's syndrome (isolated gonadotropin deficiency); approximately 5 to 10 percent have hypopituitarism. 

- Reversing the lifestyle factors that contribute to the anovulation (low weight, heavy exercise) should be attempted before considering intervention with medications.

Infertility & HIV

HIV: To prevent Male to female transmission :

1) Sperm washing is used to reduce the viral load in prepared sperm to a very low or undetectable level followed by IUI, IVF of ICSI

However, alternatives to sperm washing are now being proposed.

2) HAART treatment to reduce viral load to undetectable levels followed by timed intercourse – may be equally effective, less invasive and more cost effective for a specific cohort of patients. 

- Not appropriate in situations where any form of female infertility is diagnosed or suspected

• Where the man is HIV positive, the risk of HIV transmission to the female partner is negligible through unprotected sexual intercourse when all of the following criteria are met:

a)    The man is compliant with highly active antiretroviral therapy (HAART)

b)    The man has had a plasma viral load of less than 50 copies/ml for more than 6 months

c)    There are no other infections present

d)    Unprotected intercourse is limited to the time of ovulation

Infertility & HIV

HIV: 

To prevent Female to male transmission -

Use of assisted reproductive techniques (ART), such as IUI or IVF