Pregnancy: before, during, and after

By Alfredo Germain

In this comprehensive book, future parents will find up-to-date information on a wide range of familiar topics, including preconception assessment, prenatal care, recommended medical examinations, nutritional plans, and exercise guidelines for expectant mothers, among others. The book also offers detailed insights into caring for newborns and babies during their crucial first year of life.

• Language: English
• Publisher: EDP SUD
• Release date: Mar 26, 2024
• ISBN: 9789566230168

Book preview

PROFESSIONALS WHO CONTRIBUTED TO THE CONTENT OF THIS EDITION.

Susana Aguilera P. | Physician, Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Clínica Las Condes.

Verónica Álvarez V. | Physician, Nutrition, Advanced Center of Metabolic Medicine and Nutrition (CAMMYN).

Carlos Barrera H. | Physician, Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Clínica Las Condes.

Eugenio Canessa B. | Physician, Anesthesiology, Department of Anesthesiology, Clínica Las Condes.

Sofía Castro L. | Clinical Lactation Specialist, Department of Pediatrics, Clínica Las Condes.

Elizabeth Chong K. | Physician, Gynecology and Obstetrics, Department of Obstetrics and Gynecology, Clínica Las Condes.

Fanny Cortés M. | Physician, Genetics, Department of Genetics, Clínica Las Condes.

Javier A. Crosby R. | PhD, Reproductive Medicine Unit, Department of Obstetrics and Gynecology, Clínica Las Condes.

Ada Cuevas M. | Physician, Nutrition, Department of Nutrition, Advanced Center of Metabolic Medicine and Nutrition (CAMMYN), Adjunct Associate Professor, Universidad Finis Terrae.

Carlos Díaz M. | Physician, Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Clínica Las Condes.

María Jesús Estay S. | Nutritionist, Advanced Center of Metabolic Medicine and Nutrition (CAMMYN).

Cecilia Fabres V. | Physician, Reproductive Medicine, Department of Obstetrics and Gynecology, Clínica Las Condes.

Emilio Fernández O. | Physician, Reproductive Medicine, Department of Obstetrics and Gynecology, Clinica las Condes

Alfredo Germain A. | Physician, Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Clínica Las Condes.

Jorge Gigoux M. | Physician, Anesthesiology, Department of Anesthesiology, Clínica Alemana.

Rogelio González P. | Physician, Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Clínica Las Condes.

Miguel Guelfand C. | Physician, Pediatric and Neonatal Surgery, Department of Pediatric Surgery, Clínica Las Condes.

Enrique Guiloff F. | Physician, Department of Obstetrics and Gynecology, Clínica Las Condes.

Paula Gutiérrez M. | Midwife.

Stefan Hosiasson S. | Physician, Neonatology, Department of Pediatrics, Clínica Las Condes.

Enrique Jadresic M. | Physician, Psychiatry, Associate Professor at the University of Chile.

Catalina Larraín F. | Psychologist, Maternal-Infant and Perinatal Mental Health, Cryas Team.

Juan Luis Leiva B. | Physician, Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Clínica Las Condes.

Marcela Moyano O. | Midwife, Clínica Las Condes.

Hernán Muñoz S. | Physician, Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Clínica Las Condes.

Mauricio Pinto C. | Physician, Neonatology, Department of Pediatrics, Clínica Las Condes.

Andrés Pons G. | Physician, Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Clínica Las Condes.

Lorena Quiroz V. | Physician, Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Clínica Las Condes.

Gustavo Rencoret P. | Physician, Maternal-Fetal Medicine, Clínica Alemana.

Jorge Andrés Robert S. | Physician, Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Clínica Las Condes.

Maureen Rossel G. | Physician, Pediatrics, Department of Pediatrics, Clínica Las Condes.

Marta Sánchez M. | Nurse-Midwife, Clínica Alemana.

Eduardo Sepúlveda | Physician, Maternal-Fetal Medicine, Clínica Alemana

Jennifer Silva R. | Clinical Lactation Specialist, Department of Pediatrics, Clínica Las Condes.

Mariana Valenzuela Cruz. | Lawyer, Council for the Defense of the State.

Hernán Villalón U. | Physician, Neonatology, Department of Pediatrics, Clínica Las Condes.

Constanza Von Dessauer G. | Psychologist, Doula.

ALFREDO MANUEL GERMAIN ARAVENA

Graduated with a degree in Medicine from the University of Chile and completed his studies in Obstetrics and Gynecology at the Pontifical Catholic University of Chile. He further pursued a postgraduate program in Maternal-Fetal Medicine at the University of Texas, Southwestern Medical Center in Dallas, United States.

Between 1986 and 2004, he served as a Professor in the Department of Obstetrics and Gynecology at the Pontifical Catholic University of Chile, specializing in Maternal-Fetal Medicine and dedicating his efforts to preventing and treating medical problems related to pregnancy. He is recognized for his contributions through numerous publications in basic and clinical research in complex pregnancies.

In 2004, he founded the Maternal-Fetal Surveillance Specialized Center (CEVIM) at Clínica Las Condes, where he held the director position for 8 years. Alfredo is an esteemed member of the certification panel for the sub-specialty of Maternal-Fetal Medicine of CONACEM. He actively participates in major Chilean and American societies related to Obstetrics, Gynecology, and Maternal-Fetal Medicine. Additionally, he remains an integral part of the Maternal-Fetal Medicine Unit in the Department of Obstetrics and Gynecology at Clínica Las Condes.

Alfredo's passion lies in focusing on preventing, caring, and treating pregnancies with difficulties, making a significant impact in the field of Maternal-Fetal Medicine.

Content

Prologue

| Aníbal Llanos M. | María J. Serón - Ferré |

Presentation

| Alfredo Germain A. |

1. Pregnancy: How and When

| Cecilia Fabres V. | Emilio Fernández O. | Javier A. Crosby R. | Alfredo Germain A. |

2. Preconception Assessment

| Alfredo Germain A. | Gustavo Rencoret P. | Rogelio González P. |

3. What to do After Confirming Pregnancy

| Alfredo Germain A. | Marta Sánchez M. | Hernán Muñoz S. | Carlos Díaz M. |

| Rogelio González P. |

4. Fetal Development

| Alfredo Germain A. | Marta Sánchez M. | Juan Luis Leiva B. |

| Rogelio González P. |

5. Ultrasounds During Pregnancy

| Alfredo Germain A. | Carlos Díaz M. | Hernán Muñoz S. | Rogelio González P. |

6. Structural Analysis in Newborns – A Guide on What to Do

| Fanny Cortés M. | Susana Aguilera P. | Alfredo Germain A. |

7. Fetal Assessment and Therapy

| Hernán Muñoz S. | Alfredo Germain A. | Carlos Barrera H. | Carlos Díaz M. |

8. Twin and Multiple Pregnancy

| Susana Aguilera P. | Alfredo Germain A. |

9. Changes and Maternal Care During Pregnancy

| Alfredo Germain A. | Susana Aguilera P. | Hernán Muñoz S. |

10. Mental Health During Pregnancy

| Catalina Larraín F. | Alfredo Germain A. | Enrique Jadresic M. |

11. Legal Aspects of Pregnancy

| Mariana Valenzuela C. | Paula Gutiérrez M. | Marta Sánchez M. | Marcela Moyano O. |

12. Eating Habits During Pregnancy

| Ada Cuevas M. | Verónica Álvarez V. | María Jesús Estay S. |

13. Physical Activity During Pregnancy

| Carlos Díaz M. | Alfredo Germain A. | María Jesús Estay S. |

14. Complex Pregnancies

| Alfredo Germain A. | Juan Luis Leiva B. | Andrés Pons G. | Rogelio González P. |

15. Preparing for Delivery

| Alfredo Germain A. | Marcela Moyano O. |

16. Anesthesia During Labor

| Eugenio Canessa B. | Jorge Gigoux M. |

17. The Moment of Childbirth

| Alfredo Germain A. | Jorge Andrés Robert S. | Eduardo Sepúlveda S. |

18. The Doula: a New Partner

| Constanza Von Dessauer G. | Alfredo Germain A. |

19. The First Days of Life of the Newborn

| Stefan Hosiasson S. | Catalina Larraín F. | Hernán Villalón U. |

Mauricio Pinto C. |

20. Neonatal Surgery

| Miguel Guelfand C. |

21. Newborn Care at Home

| Hernán Villalón U. | Stefan Hosiasson S. | Mauricio Pinto C. |

22. Breastfeeding

| Maureen Rossel G. | Elizabeth Chong K. | Sofía Castro L. | Jennifer Silva R. |

23. Postpartum: Adapting to Motherhood

| Alfredo Germain A. | Enrique Jadresic M. | Marcela Moyano O. |

24. The Newborn’s First Year of Life

| Hernán Villalón U. | Stefan Hosiasson S. | Enrique Jadresic M. |

25. Myths of Pregnancy and Childbirth

| Enrique Guiloff F. | Marta Sánchez M. |

26. Responsible Parenthood and Fertility Regulation

| Lorena Quiroz V. | Alfredo Germain A. |

27. Choosing the Baby's Name

| Alfredo Germain A. | Marta Sánchez M. |

Glossary

| Alfredo Germain A. |

Prologue

Composing this Prologue, which we could call variations for keyboard with four hands on a work by Alfredo Germain Aravena, is a great privilege. The performers, María Serón - Ferré and Aníbal Llanos Mansilla, wholeheartedly commit to bearing witness to some of Alfredo's knowledge adventures and his latest work, a new book.

First movement: Ephemeral youth. We knew him as a 2nd-year medical student and later as a Student Assistant for the following 5 years. He proved to be one of the most productive researchers in the laboratory, studying cardio-respiratory responses to fetal oxygen deficiency. Even back then, he displayed a gift for writing, being the author and co-author of several published works. With many attributes, he transformed from a timid start to becoming a dedicated, inquisitive, and involved student. Upon graduating, he earned a scholarship in Obstetrics and Gynecology at the Pontifical Catholic University, initiating a collaboration with Dr. María Serón.

Second movement: The age of reason. From the dedicated, inquisitive, and involved student emerged a comprehensive academician who combined active teaching and clinical work with significant contributions to knowledge through various publications cited worldwide. Without abandoning these pursuits and paraphrasing Nicanor Parra, Germain stepped down from Olympus and wrote about a subject immortalized by Leonardo da Vinci with La Gioconda, which masterfully portrays the phenomenology of a pregnant woman, the paradox of the enigmatic smile alongside the beatitude in her bodily expression. Thus, Alfredo and a select group of collaborators wrote Embarazo y Recién Nacido. Guía para futuros padres, an extraordinary and much-needed book.

Third movement: The current work, Embarazo: antes, durante y después. Todo lo que los futuros padres deben saber. Over the years, Alfredo maintains his spirit and graciously transfers his knowledge and that of his collaborators to his readers, accompanying them like an expert sherpa through one of the most mysterious and profound journeys of our species: the creation of a new human being. Quoting Jacques L. Monod, Nobel Prize in Medicine, A dream written n our genes. This edition, from the very first chapter, updates and expands on the topics covered in previous editions, incorporating others such as assisted fertilization, support during gestation, and contemporary approaches to genetic problems. This is a formidable work, a comprehensive vision of a complex biological process useful not only for mothers and fathers but also, as predicted by Dr. Wild in the prologue of Germain's first book, a work for students and academia. Undoubtedly, a necessary opus to keep at hand.

Presentation

Before you were conceived

You were desired

Before you were born

You were already loved

Even an hour before you were here

I would have given my life for you

This is the miracle of life

MAUREEN HAWKINS, THE MIRACLE.

The intrauterine period plays a vital role in shaping our lives. Most of a person's characteristics, from food preferences to language sounds and even the predisposition to certain chronic diseases, originate during our time in the mother's womb. This has transformed what was once considered a mystery into a profoundly meaningful period.

In recent years, there has been an unprecedented expansion in our understanding of the reproductive process. This has significantly impacted the development of assisted reproduction techniques and the comprehension, prevention, and treatment of pregnancy-related diseases. Today, motherhood can happen in previously unthinkable situations, such as in individuals born without a uterus, who can now experience motherhood through a uterine transplant. Moreover, genetic diagnosis of embryos at a preimplantation stage has become possible, and advances in preventing fetal diseases and genetic treatments have brought this once distant and mysterious period closer and more illuminated, fostering a strong connection and affectionate interaction between parents, the medical team, and the unborn child.

Thanks to advances in diagnostic imaging, we can now see and appreciate the unborn child from as early as 25 days post-conception. This closeness allows the child to become a part of the family life early. It is a marvel to witness this once-unreachable process, which, in my opinion, is unparalleled in the history of prenatal care.

Twenty years ago, I wrote the first version of this book in collaboration with a dear friend and an excellent healthcare professional. The book was updated in 2012 and 2018, enabling me to share my experience on pregnancy and newborn care with parents. It aimed to provide a simple, clear, updated, and detailed understanding of these topics. The acceptance and demand for this idea were gratifying, with multiple reprints and thousands of copies reaching families.

Technological advancements in diagnostic evaluation and treatment for both mothers and babies have been significant in recent years. Alongside the increasing desire for patient information, I created this new text, nearly doubling the previous editions' length. It comprehensively and clearly, covers everything necessary to know before, during, and after pregnancy.

The chapters have been written by professionals who have worked together for several years. They are esteemed in the country and have kindly supported me in this task. In addition to being gynecologists, some of them are close collaborators, friends, and specialists in Maternal-Fetal Medicine. Together, we form the most extensive team in the country in this subspecialty.

This edition marks a significant change as the text, now updated in nearly all chapters, is available in Spanish and English. It can be acquired in the traditional printed format upon request and is also available in a user-friendly electronic format accessible on all platforms and electronic libraries worldwide. This accessibility allows sharing this text with approximately 1.9 billion Spanish and English speakers—a dream come true.

I sincerely thank those who have made this new book version possible. Firstly, to the Chilean Atherosclerosis Working Group corporation, for their support in preparing and disseminating this book. Secondly, to the Chilean Society of Obstetrics and Gynecology (SOCHOG), who have supported this project for the past 15 years. Their endorsement again places this book among the few on this topic worldwide and the only one in Chile with the backing of the respective Medical Society.

A special mention goes to my family for their understanding and support during the time dedicated to this project.

Lastly, I express my heartfelt thanks to all my patients and their families, who have entrusted me with their medical care during one of the most significant periods of human life: the arrival of a child.

ALFREDO GERMAIN ARAVENA

Gynecologist-Obstetrician / Maternal-Fetal Medicine

Clínica Las Condes

1.

Pregnancy: How and When

| Cecilia Fabres V. | Emilio Fernández O. | Javier A. Crosby R. | Alfredo Germain A. |

HAVING A CHILD: A TURNING POINT

Becoming parents is one of the most significant events in a couple's married life. The arrival of a child to the family is a couple's decision, but above all, it is a gift that changes their lives forever. In this context, children are unique, unrepeatable, independent persons who should be expected with love, welcomed, and respected from the onset of pregnancy.

To ensure a pleasant experience, future parents should visit their doctor to confirm their suitable physical condition and, if necessary, make lifestyle changes that can contribute to a normal pregnancy.

FINDING THE RIGHT TIME

Determining the most appropriate time for pregnancy can be challenging. The childbearing age for women ranges from 15 to 42 years old. However, it is crucial to balance age, health, emotional and work conditions, and the couple's situation. The decision should be mutual. Ideally, women should aim to have their first pregnancy between 25 and 35 years old. Delaying the decision for too long can make conception increasingly tricky, especially after age 38, when the rate of spontaneous abortions rises due to chromosomal abnormalities in the ova. Typically, a healthy couple in which the woman is under 35 years old and has an active sexual life has an 80% chance of pregnancy within a year without using fertility methods. This probability increases to 90% after two years. However, this period decreases to 6 months for women over 35. It is recommended for couples who have been actively trying to conceive for 12 months without success to undergo a medical evaluation, as it is considered infertility after that period. There are various situations in which it could be beneficial to consider the appropriateness of getting pregnant. Here are some examples.

DOES THE PARENT'S AGE MAKE A BIG DIFFERENCE?

While technology offers ways to achieve pregnancy at later maternal and paternal ages, it is crucial to understand the biological limitations involved. For women, the efficiency of the reproductive process declines after age 35 due to the quality of the oocytes. Fertility decreases spontaneously, and the frequency of miscarriages increases from 20% at age 35 to 50% at 40 and 90% at 45. The global risk of chromosomal abnormalities at these ages is 1/92, 1/66, and 1/21, respectively. Moreover, advanced maternal age is associated with a higher likelihood of developing adverse health conditions during pregnancy, such as high blood pressure and diabetes mellitus. However, with proper medical care from specialists in Maternal-Fetal Medicine, successful pregnancies can be achieved in most cases. As for the father, the risk of infertility doubles at age 40, and there is an increased risk of early miscarriage and premature labor. Research also suggests a correlation between fathers aged 50 and certain rare health conditions in newborns, including congenital syndromes, bone development abnormalities (achondroplasia and osteogenesis imperfecta), and neurologic development alterations such as autism spectrum disorders. Fortunately, modern embryo analysis technology detects many complications, especially chromosomal abnormalities, before implantation. We will delve into this topic further in this chapter. In summary, while achieving a successful pregnancy later in life is possible, it should be a carefully considered decision supported by a medical team who can provide advice on effective measures to ensure a joyful and medically safe experience for both the mother and the baby.

WHAT IS THE RECOMMENDED TIMEFRAME BETWEEN PREGNANCIES?

Several factors influence this decision, but waiting at least 12 months between one pregnancy and the next is advisable. This interval allows the mother to fully recover physically and mentally from the demands of breastfeeding and caring for a child.

HOW LONG SHOULD A WOMAN WAIT AFTER A CESAREAN SECTION?

Recovering from a cesarean delivery, an abdominal surgery, requires ample time for proper healing. It is advisable to wait at least 12 months, or potentially longer, depending on the number of previous c-sections.

HOW LONG SHOULD A WOMAN WAIT AFTER A MISCARRIAGE?

It is common for women to conceive in the menstrual cycle immediately following a miscarriage. However, most obstetricians recommend waiting for at least two menstrual cycles before attempting to conceive again.

In cases of frequent miscarriages (two or more consecutive losses), it is advisable to undergo further medical evaluations before considering another pregnancy.

HOW LONG SHOULD A WOMAN WAIT AFTER BEING VACCINATED AGAINST MEASLES?

Before attempting to conceive, it is crucial to verify immunity against measles through IgG (indicating immunity) and IgM (indicating recent infection) antibody tests. If both tests yield negative results, it is recommended that the mother-to-be receive the measles vaccine.

After vaccination, it takes approximately three months to develop immunity against the disease. Hence, during this period, the woman must avoid measles exposure and postpone pregnancy. If she is already pregnant, it is advised to delay vaccination until after childbirth while taking precautions to prevent measles infection.

HOW TO CONCEIVE

FEMALE REPRODUCTIVE SYSTEM

The female genital system consists of both internal and external parts. The external part includes the labia majora, labia minora, and clitoris, while the internal part comprises the vagina, uterus, fallopian tubes, and ovaries.

The vagina, approximately 7.5 cm long, is a tubular organ composed of elastic fibromuscular tissue covered by pluristratified epithelium. It responds to ovarian hormones, specifically estradiol and progesterone. Besides facilitating sexual intercourse and acting as the receptacle for seminal fluid, the vagina also serves as the birth canal through which a baby is delivered during normal or vaginal childbirth. At the end of the vagina is the uterine neck.

The uterus is a muscular organ with two parts: the cervix and the uterine corpus. Made of stretchable smooth muscle fibers, it can expand and accommodate the growing fetus during pregnancy. The uterus provides a sufficient blood supply to the placenta through uterine arteries, nourishing the developing pregnancy. During labor, it contracts to enable cervical dilation and facilitate childbirth.

The ovaries on each side of the uterus and connected to the distal end of the fallopian tubes serve as the female gonads. They contain ova and female gametes. Within the ovaries, follicles develop and mature, releasing a mature egg during each menstrual cycle. This egg is fertilized and implanted in the uterus, initiating pregnancy or released unfertilized.

THE OVARIAN CYCLE OR MENSTRUAL CYCLE

The menstrual cycle typically lasts between 28 and 30 days. During this cycle, the pituitary gland stimulates the ovaries through the Gonadotropin hormone, aiding in the development, maturation, and release of an egg from the ovary around day 14, known as ovulation. Throughout the egg's growth and maturation, estrogen levels increase. Estrogen is necessary to produce cervical mucus and the thickening of endometrial glands, which support embryo development.

After leaving the ovary, the egg remains within the fallopian tube for approximately 24 hours, ready for fertilization. If fertilization occurs, the embryo starts to develop and migrates towards the uterus, a journey that takes about 5 to 6 days. As a blastocyst, the embryo reaches the uterus and remains free to move within the cavity for approximately 24 hours until it implants itself in the uterine endometrium. Tissues then start forming, giving rise to membranes surrounding the embryo and forming the placenta. The pregnancy is established through implantation.

The placenta, an organ developed from the outermost embryo layers, plays multiple crucial roles in pregnancy. It produces various hormones necessary for the baby's growth and development and facilitates the exchange of oxygen and nutrients between mother and child.

THE MALE REPRODUCTIVE SYSTEM

The male genital system consists of both external and internal parts. The external part includes the penis and the testicles covered by the scrotum. The internal part comprises the vas deferens, seminal vesicles, prostate, and urethra.

Sperm cells, formed in the testicles, travel through the epididymides and the vas deferens to reach the seminal vesicles and prostate. Seminal fluid, produced by these glands, is added to the sperm.

During intercourse, ejaculation expels semen through the ejaculatory ducts, reaching the urethra within the penis for external release.

ESTABLISHING PREGNANCY

Once in the vagina, sperm cells can survive and remain active for several hours, even days, with the help of cervical mucus. Cervical mucus is a transparent fluid produced by the cervical glands in the uterine neck, influenced by the action of ovarian estrogen. It reaches its peak before ovulation when women are most fertile.

When a sperm cell successfully penetrates the wall of an egg, fertilization occurs in the distal segment of the fallopian tube. The tube then facilitates the movement of the embryo through rhythmic movements on the surface of its cells, aided by cilia. The nuclei of the sperm cell and egg, known as pronuclei, interact and fuse, sharing the genetic information of both parents. This marks the beginning of embryo development, which involves cell division and takes 5 to 6 days until the embryo reaches the uterus, where it typically implants and initiates pregnancy.

In cases where the embryo implants in the fallopian tube instead of the uterine cavity, it is referred to as an ectopic or tubal pregnancy. Early diagnosis of this significant complication is crucial, as it can harm the mother's health. Ectopic pregnancies are not viable.

WHAT IF CONCEPTION IS NOT POSSIBLE?

If a woman cannot conceive after 12 months of regular sexual activity (2 to 3 times a week), it is advisable to seek a medical diagnosis to determine the underlying cause. However, it is now possible to address and resolve the issue in most cases.

Infertility can be categorized as primary, when a couple has never been able to conceive, or secondary, when they have previously had a child but cannot have another. The causes of infertility can stem from either the woman or the man, and sometimes both. Approximately 30% of infertility cases are attributed to male factors, another 30% to female factors, and around 30% to a combination of both. The remaining 10% of patients have unknown causes.

MALE INFERTILITY

1. CAUSES RELATED TO ABNORMALITIES OF SPERM CELLS OR MALE GAMETES, EITHER IN:

›Production

›Release

›Morphological Characteristics

›Functional Characteristics

The initial assessment involves analyzing a semen sample to evaluate various aspects, including the concentration of sperm cells, their progressive mobility, vitality, and the characteristics of the seminal fluid. This examination also considers factors such as the presence of round cells, debris, antibodies, and other relevant indicators.

2. MALE CAUSES ASSOCIATED WITH OTHER FACTORS

›Infectious Factors

›Inflammatory/Vascular Factors, such as Varicocele

›Hormonal Factors

These conditions can often be effectively treated with a range of interventions, including antibiotics, anti-inflammatory drugs, vitamins, hormones, and, in some cases, surgery. However, it's important to note that certain conditions currently lack effective treatment options. Fortunately, advancements in assisted reproductive techniques (ARTs) offer hope to couples facing such challenges. Sophisticated and complex procedures, such as insemination, bypass, and methods like In vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI), enable many couples to achieve pregnancy and fulfill their dream of having a child, even in the presence of these conditions.

3. DONATION OF SPERM CELLS

Sperm cell donation is recommended for men who do not produce sperm or have low-quality sperm cells that cannot fertilize oocytes, even with techniques like IVF or ICSI. It is also used in cases where men have a hereditary disease that could potentially impact the quality of life in their offspring or make conception impossible.

In such situations, the complexity of the treatment for the male partner does not necessarily reflect the complexity of the woman's treatment, particularly if she is healthy. Ovulation stimulation can be achieved through echography monitoring to identify the fertile period when she can be inseminated with the donated sample.

FEMALE INFERTILITY

1. OVULATORY FACTOR OR GONADAL ENDOCRINE: Causes related to developmental abnormalities and maturation of oocytes.

The ovulatory factor is connected to the functionality of the ovary. As the ovary is a gland of the endocrine system, regulated by the pituitary gland, a well-balanced female endocrine system is essential for its proper functioning. Therefore, women can experience ovulation disorders if their thyroid or adrenal glands malfunction.

The ovary serves two primary functions:

›Maturing and releasing an oocyte in every menstrual cycle is known as ovulation.

›Producing and secreting hormones that support pregnancy and other tissues is called the endocrine function.

Both functions are interdependent, meaning that if one fails, it can affect the other.

Today, accurate assessment of ovarian function is possible through an ovulation study, which involves echographic monitoring of the developing follicle and measuring specific hormones in the blood to identify any disorders and address them appropriately. Additionally, the quality of the endometrium's thickening and characteristics and the quality of cervical mucus can be evaluated throughout the cycle.

These analyses help identify the underlying causes and guide the treatment options. Depending on the specific alterations observed, the treatment may involve correcting ovulation or restoring general hormonal function. The medical team discusses various options with the patient, ranging from dietary changes to medication use.

Different methods exist to correct the ovulatory factor, and numerous drugs are available to stimulate ovulation. Selecting the most suitable treatment depends on the patient's diagnosis and individual characteristics. Typically, treatment begins with non-invasive and cost-friendly oral medications. However, injectable drugs can also be considered if the patient does not respond favorably or the diagnosis necessitates it.

The most common procedure involves conducting 3 to 5 cycles of ovulation stimulation, with echographic monitoring, to identify the fertile period and indicate the timing of intercourse. Before starting stimulation, it is recommended to perform an x-ray of the uterus and tubes (hysterosalpingography, HSG). In some cases, a procedure known as intrauterine insemination (IUI) or bypass may be performed. If pregnancy is not achieved after this initial low complexity treatment, the doctor may proceed with further tests such as endometrial biopsy, immunological exams, laparoscopy, or hysteroscopy. These surgical procedures can diagnose and correct conditions such as endometriosis, a secondary adherence syndrome caused by inflammation, myomas, polyps, and other factors.

While medical records or ultrasound findings can suggest some of these conditions, laparoscopy is required for accurate diagnosis and correction.

Once the correct diagnosis has been made and all the factors have been addressed, and if the desired pregnancy has not been achieved after completing the low-complexity treatment stage, it is time to consider high-complexity treatments or Assisted Reproductive Techniques (ARTs).

The timing of when a doctor offers this type of treatment to a couple depends on several factors, with the woman's age, duration of infertility, ovarian reserve, previous surgery records, and associated male factors being among the most important considerations.

2. OVARIAN RESERVE

Ovarian reserve refers to the number of follicles or eggs a woman has at a specific time. It is highest at birth and gradually declines over time through a natural biological process called atresia or programmed cell death and through successive ovulations throughout a woman's life, starting from menarche or the first menstruation.

At birth, a baby girl typically has around 500 to 800 thousand follicles or ova in both ovaries, but by menarche, this number decreases to around 200 to 250 thousand. The ovarian reserve continues to decrease progressively until menopause.

The ovarian reserve can be measured or estimated by assessing the plasma levels of Anti-Mullerian Hormone (AMH), which is produced by the ovarian follicles, or by counting the Antral Follicles in both ovaries through transvaginal ultrasound during the early days of the menstrual cycle (around day 2-3), along with the measurement of FSH and Estradiol.

Some studies suggest that the rate of follicle loss accelerates around the age of 36-37. Other factors can also contribute to a decreased ovarian reserve, such as extensive ovarian surgery (due to endometriosis or ovarian cysts), certain autoimmune diseases affecting the ovaries, or exposure to toxic agents or radio/chemotherapy treatments.

When the ovarian reserve is low, particularly in older women, achieving spontaneous pregnancy becomes more challenging, and there is an increased risk of miscarriage due to the decreased quantity and quality of oocytes. However, in young women with low ovarian reserve resulting from extensive surgery where only a portion of the ovarian tissue is removed, the number of oocytes may be decreased while preserving their quality relative to the woman's age, leading to a better reproductive prognosis.

On the other hand, women with Polycystic Ovary Syndrome (PCOS) are born with a higher number of follicles or ova, resulting in a greater ovarian reserve compared to individuals of the same age without this condition.

Various treatment strategies are currently available to address decreased ovarian reserve. One such approach involves supplementation with different combinations of vitamins/antioxidants, which has shown promising results in improving the quality of oocytes obtained through in vitro fertilization procedures. Another experimental technique being explored is injecting stem cells or culture medium directly into the ovaries, aiming to promote the rejuvenation of the remaining follicles. These innovative methods hold potential for enhancing ovarian function and optimizing fertility outcomes. However, further research is required to fully understand these approaches' efficacy and safety.

3. TUBOPERITONEAL FACTOR: Causes related to abnormal transport of sperm cells to the distal portion of the tubes and the fertilized oocyte to the uterine cavity.

The tuboperitoneal factor may be suspected if there is a history of pelvic inflammatory/infectious disease or abdominal conditions (such as severe appendicitis, peritonitis, or adnexitis), as well as prior use of intrauterine devices or uterine/tubal surgeries (such as curettages or previous ectopic pregnancy). The presumptive diagnosis is typically conducted using a radiologic exam called hysterosalpingography (HSG), where X-ray images of the tubes and uterus are taken. At the same time, a water-soluble radiopaque contrast medium is introduced through the uterine cervix. Another diagnostic method involves a thin tube inserted through the navel to directly observe the pelvic organs (laparoscopy) or an ultrasound exam where a physiological solution is administered through the cervix to assess the shape of the uterine cavity and fallopian tube permeability.

4. UTERINE FACTOR: Causes related to abnormalities or anatomical defects of the uterine cavity.

Uterine abnormalities can be either congenital (complete or incomplete walls) or acquired diseases of the uterine wall, such as myomas, or abnormalities in endometrial thickness (pathological reduction) that can result in adhesions or pathological thickening, such as endometrial hyperplasia or polyps. Uterine abnormalities can be diagnosed through a transvaginal ultrasound, but confirmation and treatment are typically performed using hysteroscopy. During hysteroscopy, a thin tube called a hysteroscope is inserted through the cervical canal to visualize and treat any surface abnormalities within the uterine cavity..

5. CERVICAL FACTOR: Causes related to abnormalities of the uterine neck that can be anatomical or inflammatory.

The cervical factor refers to the disturbance in the normal function of the uterine cervix. The cervix acts as a barrier that sperm cells must cross to reach the oocytes, and it produces cervical mucus that aids in sperm transport during different phases of the menstrual cycle. Various factors can contribute to cervical factor infertility, including cervical infections, birth traumas, previous surgeries, or antisperm antibodies in the cervical mucus. In many cases, this issue can be resolved; otherwise, intrauterine insemination (IUI) can be utilized. During IUI, selected sperm cells from the partner or donor are placed directly into the uterine cavity using a thin catheter. The sperm cells used in IUI are carefully chosen based on quality and mobility through laboratory procedures.

6. PELVIC ENDOMETRIOSIS

Pelvic endometriosis has an estimated incidence of 40% among infertile women. It should be suspected in cases of dysmenorrhea or severe and progressive menstrual pain that is not alleviated with typical painkillers. Symptoms such as dyspareunia (painful intercourse) or chronic pelvic pain have also been associated with endometriosis. This condition can be diagnosed through laparoscopy, ultrasound, or pelvic magnetic resonance imaging. Persistent ovarian cysts with a finely granulated or lumpy appearance may indicate endometriosis. Endosonography can also be used for diagnosis. Laparoscopic surgery is the primary treatment for endometriosis. When