Cervical insufficiency

Cervical insufficiency also known as incompetent cervix or weakened cervix, means your cervix opens (dilates) too early during pregnancy, usually without pain or contractions (painless cervical dilatation). Cervical insufficiency or cervical incompetence is the inability of the uterine cervix to retain a pregnancy in the second trimester. Cervical insufficiency can cause premature birth and miscarriage. Premature birth is when your baby is born too early, before 37 weeks of pregnancy. Miscarriage is when a baby dies in the womb before 20 weeks of pregnancy.

In a normal pregnancy, the cervix stays firm, long, and closed until late in the 3rd trimester. In the 3rd trimester, the cervix starts to soften, get shorter, and open up (dilate) as a woman’s body prepares for labor.

A cervical insufficiency may begin to dilate too early in pregnancy. If there is an cervical incompetence, the following problems are more likely to occur:

• Miscarriage in the 2nd trimester
• Labor begins too early, before 37 weeks
• Bag of waters breaks before 37 weeks
• A premature (early) delivery

When you are told that you have an incompetent cervix, it simply means that your cervix begins to open up (dilates) too early during pregnancy, when you are between four and six weeks of your pregnancy. In case you do not know, the cervix mostly remains closed during the 9 months of pregnancy. An incompetent cervix can be thin and widen without any contractions or pain. This causes the amniotic fluid sac to bulge downwards into the cervix opening until it breaks. This leads to premature delivery or miscarriage. Contractions are when the muscles of your uterus get tight and then relax. They help push your baby out of your uterus during labor and birth.

An incompetent or weakened cervix happens in about 1-2% of pregnancies. Almost 25% of babies miscarried in the second trimester are due to incompetent cervix.

Doctors don’t always know why incompetent cervix happens. You’re more likely than other women to have it if:

• You have defects in your uterus, like if it’s split into two sections.
• You’ve had surgery on your cervix.
• You have a short cervix. The shorter the cervix, the more likely you are to have cervical insufficiency.
• You’ve had injuries to your uterus that happened during a previous birth.

A cervical incompetence or cervical insufficiency, can be treated with an operation to put a small stitch of strong thread around your cervix to keep it closed.

This is usually carried out after the first 12 weeks of your pregnancy.

What is a cervix

The cervix is the opening in the lower part of the uterus (womb) that opens to the top of the vagina (birth canal).  The lumen (internal cavity) of the uterus communicates with the vagina by way of a narrow passage through the cervix called the cervical canal.

During pregnancy, the cervix stays firm and closed until late in the third trimester. It opens, shortens and gets thinner and softer so your baby can pass through the birth canal during labor and birth. In some women, the cervix opens too early during pregnancy or is shorter than normal. These conditions can cause problems during pregnancy.

Cervix function

The cervical canal contains cervical glands that secrete mucus, thought to prevent the spread of microorganisms from the vagina into the uterus. Near the time of ovulation, the mucus becomes thinner than usual and allows easier passage for sperm.

The cervix has two different parts and is covered with two different types of cells.

1. The part of the cervix closest to the body of the uterus is called the endocervix and is covered with glandular cells.
2. The part next to the vagina is the exocervix (or ectocervix) and is covered in squamous cells.

These two cell types meet at a place called the transformation zone. The exact location of the transformation zone changes as you get older and if you give birth.

The cervix and superior part of the vagina are supported by cardinal (lateral cervical) ligaments extending to the pelvic wall.

Figure 1. Cervix position

Figure 2. Cervix location

Causes of cervical incompetence

Cervical incompetence may be congenital or acquired ¹. The most common congenital cause is a defect in the embryological development of Mullerian ducts. In Ehlers-Danlos syndrome or Marfan syndrome, due to the deficiency in collagen, the cervix is not able to perform adequately, leading to insufficiency.

The most common acquired cause is cervical trauma such as cervical lacerations during childbirth, cervical conization, LEEP (loop electrosurgical excision procedure), or forced cervical dilatation during the uterine evacuation in the first or second trimester of pregnancy.

However, in most patients, cervical changes are the result of infection/inflammation, which causes early activation of the final pathway of parturition ².

Doctors don’t always know why incompetent cervix happens. You’re more likely than other women to have it if:

• You have defects in your uterus, like if it’s split into two sections.
• You’re pregnant with more than 1 baby like twins or triplets
• You’ve had surgery on your cervix.
• You have a short cervix. The shorter the cervix, the more likely you are to have cervical insufficiency.
• You’ve had injuries to your uterus that happened during a previous birth.

The competent human cervix is a complex organ that undergoes extensive changes throughout gestation and parturition. A complex remodeling process of the cervix occurs during gestation, involving timed biochemical cascades, interactions between the extracellular and cellular compartments, and cervical stromal infiltration by inflammatory cells. Any disarray in this timed interaction could result in early cervical ripening, cervical insufficiency, and preterm birth or miscarriage. Current evidence suggests that cervical incompetence functions along with a continuum that is influenced by both endogenous and exogenous factors, such as uterine contraction and decidual/membrane activation ³.

Cervical insufficiency risk factors

No one knows for sure what causes ancervical insufficiency, but these things may increase a woman’s risk:

• Being pregnant with more than 1 baby (twins, triplets)
• Having a cervical insufficiency in an earlier pregnancy
• Having a torn cervix from an earlier birth
• Having past miscarriages by the 4th month
• Having past first or second semester abortions
• Having a cervix that did not develop normally
• Having a cone biopsy or loop electrosurgical excision procedure (LEEP) on the cervix in the past due to an abnormal Pap smear

Cervical insufficiency symptoms

If your have an incompetent cervix, you may not develop any symptoms or signs early on in pregnancy. Your cervix simply begins to open before 9 months are over without pain or contractions. Some women may feel very mild discomfort or spotting for a few days, but this is only possible if you are between 14 to 20 weeks of pregnancy. However, look out for the following signs and symptoms, because they may indicate you’ve got an incompetent cervix ²:

• A feeling of pelvic pressure
• A new backache
• Mild cramps in your belly (abdomen)
• A change in vaginal discharge which changes from clear to pink
• Light vaginal bleeding or spotting

If your health care provider thinks you may have cervical insufficiency, she may check you regularly during pregnancy with transvaginal ultrasound starting at 16 to 20 weeks of pregnancy. Transvaginal ultrasound is an ultrasound in the vagina, not on the outside of your belly. An ultrasound is a prenatal test that uses sound waves and a computer screen to show a picture of your baby in the womb.

Cervical incompetence diagnosis

Often, you will not have any signs or symptoms of cervical insufficiency unless you have a problem it might cause. That is how many women first find out about it. Cervical incompetence is primarily a clinical diagnosis characterized by recurrent painless dilatation and spontaneous midtrimester birth, usually of a living fetus. The presence of risk factors for structural cervical weakness supports the diagnosis. The challenges in making the diagnosis are that relevant findings in prior pregnancy are often not well-documented and only a subjective assessment.

The diagnosis of cervical insufficiency is challenging because of the lack of objective findings and clear diagnostic criteria. Cervical ultrasound has emerged as a proven, clinically useful screening and diagnostic tool in the selected population of high-risk women based on an obstetrical history of a prior (early) spontaneous preterm birth. The transvaginal ultrasound typically shows a short cervical length, less than or equal to 25 mm, or funneling, ballooning of the membranes into a dilated internal os but with the closed external os.

The diagnosis of incompetent cervix is usually made in three different settings:

1. Women who present with a sudden onset of symptoms and signs of cervical insufficiency
2. Women who present with a history of second-trimester losses consistent with the diagnosis of cervical incompetence (history-based)
3. Women with endovaginal ultrasound findings consistent with cervical incompetence (ultrasound diagnosis)

The digital or speculum examination reveals a cervix that is dilated 2 cm or more, effacement greater than or equal to 80%, and the bag of waters visible through the external orifice or protruding into the vagina. The diagnosis is frequently made on the basis of history retrospectively after multiple poor obstetrical outcomes have occurred ⁴.

If you have any of the risk factors for cervical incompetence:

• Your health care provider may do a transvaginal ultrasound to look at your cervix when you are planning a pregnancy, or early in your pregnancy.
• You may have physical exam and ultrasounds more often during your pregnancy.

A cervical insufficiency may cause these symptoms in the 2nd trimester:

• Abnormal vaginal spotting or bleeding
• Increasing pressure or cramps in the lower abdomen and pelvis

Cervical insufficiency treatment

Many nonsurgical and surgical modali­ties have been proposed to treat cervical insufficiency. Certain nonsurgical approaches, including activity restriction, bed rest, and pelvic rest have not proven effective in the treatment of cervical incompetence and their use is discouraged. Another nonsurgical treatment to be considered in patients at risk of cervical insufficiency is the vaginal pessary. The evidence is limited for a potential benefit of pessary placement in select high-risk patients ³.

Serial Ultrasounds

If you suffer from premature births, your doctor may recommend ultrasounds after every two weeks to monitor the cervix. This is done from the 15th week to the 26th week. If the cervix is seen to become weaker or open, your doctor may recommend cervical cerclage.

Medication

Some doctors may also recommend taking a medication like progesterone, a hormone that may help prevent premature birth. Progesterone supplementation can be recommended if you have had a history of premature births. Your doctor will recommend weekly shots of progesterone hormone on your 2nd trimester. However, further research is required to prove that progesterone can help women with the risk of cervix incompetence. Talk to your doctor if you have questions about progesterone.

Cerclage is also recommended as a form of treatment. This is especially if you suffered preterm labor when you were between sixteen and thirty four weeks of pregnancy. This procedure can be done on an outpatient basis. You’re required to relax after the treatment.

Steroids are also prescribed together with other drugs to prevent preterm labor. However, this can only be done after the 24 weeks mark where the child has a chance of survival. Steroids also help the baby’s lungs to develop quicker, which helps if the baby is to be born prematurely.

Cervical incompetence cerclage

Your doctor may recommend a cerclage ⁵. This is a stitch your doctor puts in your cervix to help keep it closed. If your pregnancy has not reached the 26th week mark and you have a history of early births, cerclage can prevent a premature birth. You can get a cerclage as early as 13 to 14 weeks of pregnancy, and your doctor removes the stitch at about 37 weeks of pregnancy. Cerclage may be right for you if you’re pregnant now with just one baby and:

• You had a cerclage in a past pregnancy.
• You’ve had one or more pregnancy losses in the second trimester.
• You had a spontaneous premature birth before 34 weeks in a past pregnancy with a cervix shorter than 25 millimeters (about 1 inch) before 24 weeks of pregnancy. Spontaneous means that labor began on its own.
• In this pregnancy, your cervix is opening in the second trimester.

However, this procedure is not ideal for every woman at risk of premature labor. It is important to talk to your doctor concerning the benefits and risks of cerclage.

A cerclage is NOT recommended if you’re pregnant with twins, even if your cervix is shorter than 25 millimeters.

A woman would not be eligible for a cerclage if:

• There is increased irritation of the cervix
• The cervix has dilated 4cm
• Membranes have ruptured

Possible complications of cervical cerclage include uterine rupture, maternal hemorrhage, bladder rupture, cervical laceration, preterm labor and premature rupture of the membranes. The likelihood of these risks is very minimal, and most health care providers feel that a cerclage is a life saving procedure that is worth the possible risks involved.

Transvaginal and transabdominal cervical cerclage

Surgical approaches include transvaginal and transabdominal cervical cerclage. The two types of this commonly used vaginal procedure include McDonald and modified Shirodkar. McDonald involves taking four or five bites of number 2 monofilament suture as high as possible in the cervix, trying to avoid injury to the bladder or the rectum, with a placement of a knot anteriorly to facilitate the removal. The Shirodkar procedure involves the dissection of the vesical-cervical mucosa in an attempt to place the suture as close to the cervical internal os as close, otherwise, as possible. The bladder and rectum are dis­sected from the cervix in a cephalad manner, the suture is placed and tied, and mucosa is replaced over the knot. Nonresorbable sutures should be used for cer­clage placement using the Shirodkar procedure.

During an emergency, the cerclage patient is placed in Trendelenburg position and a bag of membranes is deflected cephalad back into the uterus by placing a Foley catheter with a 30 mL balloon through the cervix and inflating it. The balloon is deflated gradually as the cerclage suture is tightened ⁶.

Transabdominal cerclage with the suture placed at the uterine isthmus is used in some cases of severe anatomical defects of the cervix or cases of prior transvaginal cerclage failure. It can be performed laparoscopically, but it generally requires laparotomy for initial suture placement and subsequent laparotomy for removal of the suture, delivery of the fetus, or both ⁷.

Bed rest

Instead of the cerclage, some doctors will recommend bed rest. Also, bed rest can be recommended together with the different medical options. Even so, there is no substantial evidence to prove that bed rest works to prevent preterm labor, it works with the theory that relieving the cervix of the pressure can help.

1. Thakur M, Davis DD, Mahajan K. Cervical Incompetence. [Updated 2020 May 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525954
2. Wei M, Jin X, Li TC, Yang C, Huang D, Zhang S. A comparison of pregnancy outcome of modified transvaginal cervicoisthmic cerclage performed prior to and during pregnancy. Arch. Gynecol. Obstet. 2018 Mar;297(3):645-652.
3. Wang HL, Yang Z, Shen Y, Wang QL. [Clinical outcome of therapeutic cervical cerclage in short cervix syndrome]. Zhonghua Fu Chan Ke Za Zhi. 2018 Jan 25;53(1):43-46.
4. Lee KN, Whang EJ, Chang KH, Song JE, Son GH, Lee KY. History-indicated cerclage: the association between previous preterm history and cerclage outcome. Obstet Gynecol Sci. 2018 Jan;61(1):23-29.
5. Practice bulletin no. 142: cerclage for the management of cervical insufficiency. Obstet Gynecol. 2014 Feb. 123(2 Pt 1):372-9.
6. Negrete LM, Spalluto LB. Don’t be short-sighted: cervical incompetence in a pregnant patient with acute appendicitis. Clin Imaging. 2018 Sep – Oct;51:35-37.
7. Mönckeberg M, Valdés R, Kusanovic JP, Schepeler M, Nien JK, Pertossi E, Silva P, Silva K, Venegas P, Guajardo U, Romero R, Illanes SE. Patients with acute cervical insufficiency without intra-amniotic infection/inflammation treated with cerclage have a good prognosis. J Perinat Med. 2019 Jul 26;47(5):500-509.

How to detect ovulation

Ovulation occurs each month when an egg is released from one of your ovaries. Occasionally, more than one egg is released, usually within 24 hours of the first egg. Ovulation usually happens at around the same time each month.

Ovulation occurs though a sequence of hormonal responses. Located deep within your brain, the pituitary gland releases the follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which travel through your blood stream to your ovaries. These hormones signal the development and release a single egg cell from one of your ovaries. The sweeping motion of the fimbriae draws the egg cell through a very small space in the open body cavity into the uterine tube or fallopian, tube. The egg may be fertilized here if there is sperm in the fallopian tube. At the same time, the lining of your womb begins to thicken for the egg to be implanted in it after it has been fertilized and the mucus in your cervix becomes thinner, so that sperm can swim through it more easily. An unfertilized egg may live for up to 12 hours. If your egg is not fertilized, it passes out of your body during the your monthly period, along with the lining of your womb. The egg is so small that it cannot be seen.

Ovulation depends on the activity of various glands and their hormones, including:

• Hypothalamus – located within the brain. The hypothalamus uses hormones to communicate with the pituitary
• Pituitary gland – known as the ‘master gland’ of the hormone (endocrine) system. It is located within the brain, at the base of the skull, and is connected to the hypothalamus by a thin stalk. The pituitary uses chemicals to prompt the ovaries to produce their hormones
• Ovaries – the two almond-shaped glands located within a woman’s pelvis that contain the ova. The ovaries make the two female sex hormones estrogen and progesterone.

Common causes of ovulatory problems include:

• Hypothalamus – conditions that can alter the functioning of the hypothalamus include polycystic ovary syndrome (PCOS), overexercising, poor nutrition and chronic stress
• Pituitary gland – conditions that can prevent the pituitary gland from producing enough hormones include benign pituitary tumors or direct injury to the pituitary itself
• Ovaries – conditions that can prevent the ovaries from releasing ova include early menopause (also known as ovarian failure), or damage to or removal of the ovaries.

If you want to find out when you ovulate, there are a number of things you can use:

1. The length of your menstrual cycle – A menstrual cycle is counted from the first day of one period to the first day of the next period. Some women have shorter and some have longer cycles and timing of ovulation depends on the length of the cycle. A normal menstrual cycle is between 28 to 32 days. The day a woman starts her period is considered to be cycle day 1. Ovulation often occurs around day 14 of your cycle (ovulation usually occurs around 10 to 16 days before your period starts), so you may be able to work out when you’re likely to ovulate if you have a regular menstrual cycle. If on average you have a period every 28 days you ovulate around day 14 and your best chance of conceiving is between days 11 and 14. But if you have a shorter interval between periods, say 24 days, ovulation happens around day 10 and your ‘fertile window’ is between days 7 and 10 (see Figure 6 below). If on the other hand you have 35 days between periods, you should focus your baby making efforts between days 18 and 21.
   • One way to calculate your estimated time of ovulation is as follows:
     • Work out the length of your average menstrual cycle. Day one is the first day of the menstrual period and the last day is the day before your next period begins. Let’s say your menstrual cycle is 28 days long.
     • Subtract 17 days. In our example, 28 days minus 17 days equals day 11.
     • Use the ovulation predictor kit on day 11. Continue testing daily until the test comes back positive. A positive result means you are going to ovulate within the next 24 to 36 hours.
     • Having sex around the time of ovulation means that the sperm and ovum have a good chance of meeting in the fallopian tube.
2. Changes in your cervical mucus (mucus method) – During ovulation, your cervical mucus is stretchy, clear, and slick. You may notice wetter, clearer and more slippery mucus around the time of ovulation. It looks and feels like an uncooked egg white.
3. Changes in your body temperature (symptothermal method) – there’s a small rise in your body temperature after ovulation takes place, which you may be able to detect with a thermometer. You can take your body temperature in your mouth, vagina, or rectum. A regular basal body temperature is between 97°F and 98°F (36.1° C to 36.7° C). At the time of ovulation, your basal body temperature will rise between 0.5 and 1 degree. You should take your basal body temperature in the morning before you have moved or get out of bed. Ideally, it should be the same time of day. You should use the thermometer the same way each day to get accurate results.
4. Ovulation predictor kits – hormone levels increase around the time of ovulation and this can be detected using ovulation predictor kits also known as luteinizing hormone urine test (LH urine test) that measure the level of luteinizing hormone (LH) in your urine

Using a combination of these methods is likely to be most accurate. In all 4 methods, you must use a calendar or chart to track the data and changes. This predicts when you ovulate, so you can partake in (or abstain from sex). You may notice other symptoms you can track. These include bloating, backache, tender breasts, or pain in your ovaries.

Some women may experience other symptoms when they’re ovulating, including breast tenderness, bloating and mild one-sided pain in their lower abdomen, but these are not a reliable way of predicting ovulation.

Ovulation pain also called mittelschmerz (German for “middle pain” or “pain in the middle of the month”) happens about 14 days before your period, when your ovary releases an egg as part of your menstrual cycle.

Figure 1. Female reproductive organs

Menstrual cycle

Ovulation is part of the menstrual cycle. This cycle is caused by the complex and interrelated activity of various hormones. The cycle includes:

• Menstruation – the shedding of the uterine lining (also known as menstrual bleeding or having your period)
• Follicular phase – the hypothalamus triggers the pituitary gland to release follicle stimulating hormone (FSH), which prompts the ovaries to produce up to 20 follicles. Each follicle contains an immature ovum. Usually, only one follicle survives to maturity. Assuming the menstrual cycle is around 28 days long, a single ovum matures at about day 10. This event also prompts the thickening of the uterine lining (endometrium) in preparation for a fertilised ovum
• Ovulation – the maturing follicle prompts the release of higher amounts of oestrogen. The hypothalamus responds by secreting a chemical known as gonadotrophin-releasing hormone (GnRH), which makes the pituitary produce luteinizing hormone (LH) and follicle stimulating hormone (FSH). High levels of LH trigger ovulation within about two days. The mature follicle releases the ovum into the peritoneal cavity; it is then drawn into the open end of the fallopian tube. Small hair-like structures within the fallopian tube wave or ‘massage’ the ovum towards the uterus. Unless the ovum encounters a sperm within 24 hours, it will die
• Luteal phase – the follicle becomes the corpus luteum, a structure that makes the hormone progesterone. Unless a fertilised ovum implants into the uterine lining, the corpus luteum dies. Without its contribution of progesterone, the uterus can’t maintain the thickened uterine lining, and menstruation occurs.

Figure 2. Menstrual cycle

Figure 3. Pituitary gland hormones under the influence of the hypothalamus controlling the ovaries production of egg cell, ovulation and development of the female secondary sex characteristics

Abbreviations: GnRH = Gonadotropin-Releasing Hormone; FSH = Follicle-Stimulating Hormone; LH= Luteinizing Hormone

Figure 4. Ovarian Follicle Maturation

Figure 5. Ovarian activity during the Menstrual cycle

Footnote: Major events in the female menstrual cycle. (a) Plasma hormonal concentrations of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) affect follicle maturation in the ovaries. (b) Plasma hormonal concentrations of estrogen and progesterone influence changes in the uterine lining.

Abbreviations: FSH = Follicle-Stimulating Hormone; LH= Luteinizing Hormone

How does ovulation relate to my periods?

Ovulation is the release of an egg from one of your ovaries. The same hormones that cause the uterus lining to build up also cause an egg to leave one of the ovaries. The egg travels through a thin tube called a fallopian tube to the uterus.

If the egg is fertilized by a sperm cell, it attaches to the wall of the uterus, where over time it develops into a baby. If the egg is not fertilized, the uterus lining breaks down and bleeds, causing a period.

When am I are most fertile?

The five days before ovulation, together with the day you ovulate, are the days when you are most likely to conceive. Sperm can live up to five days inside your body, so if you have sex up to five days before your egg is released, you can get pregnant. After ovulation, though, your egg can only live for 12 to 24 hours. After this time is up, your time for getting pregnant has gone for now till the following month.

Your chances of getting pregnant are at their highest in the three days leading up to and including ovulation.

Do periods happen regularly when my menstruation starts?

For the first few years after a girl starts her period, it may not come regularly. This is normal at first. By about 2–3 years after her first period, a girl’s periods should be coming around once every 4–5 weeks.

Can a girl get pregnant as soon as her period starts?

Yes, a girl can get pregnant as soon as her period starts. A girl can even get pregnant right before her very first period. This is because a girl’s hormones might already be active. The hormones may have led to ovulation and the building of the uterine wall. If a girl has sex, she can get pregnant, even though she has never had a period.

How to detect fertile days

Knowing when ovulation happens is critical when you want to get pregnant because the window of opportunity to conceive is fairly small every month. As shown in the graph below (Figure 6), conception is only possible from about five days before ovulation through to the day of ovulation. These six days are the “fertile window” in a woman’s cycle and reflect the lifespan of sperm (five days) and the lifespan of the egg (24 hours). But the likelihood of conceiving is dramatically increased if sex occurs in the three days leading up to and including ovulation. If a woman has sex six or more days before she ovulates, the chance she will get pregnant is virtually zero. Then, the probability of pregnancy rises steadily and is 27-33% in the three days leading up to and including ovulation. From that point, the probability of pregnancy declines rapidly. Twelve to 24 hours after ovulation, a woman is no longer able to get pregnant during that cycle.

If all this seems too complicated, an alternative is to have sex every two to three days. That way all bases are covered without getting too technical about when the chance of conceiving is greatest.

Figure 6. Fertile window

Signs and symptoms of ovulation

The female body shows several signs of ovulation. You may experience some or all of these signs, including:

• regular menstrual cycles – menstrual periods that arrive every 24–35 days are more likely to be ovulatory than periods that occur more or less often
• mucus changes – about two weeks before menstruation, if you are ovulating you may notice slick and slippery cervical mucus
• abdominal pain – some women experience pain during ovulation. The pain may be general or localised to one side of the abdomen
• premenstrual symptoms – ovulation may accompany premenstrual symptoms such as breast enlargement and tenderness, abdominal bloating and moodiness
• temperature rise – women who use a natural family planning method of contraception will notice a small rise in their basal temperature after ovulation has occurred. The temperature rise is about half a degree Fahrenheit (Celsius). This temperature rise does not predict ovulation – it suggests that ovulation has already taken place.

How to detect ovulation at home

There are many different kinds of ovulation predictor kits on the market. Most work by measuring the level of luteinizing hormone (LH) in your urine (LH urine test). Luteinizing hormone (LH) levels rise about 24 to 36 hours before ovulation takes place.

An ovulation home test also known as luteinizing hormone urine test (LH urine test) is used by some women to detect ovulation. The LH urine test involves normal urination. There is no pain or discomfort. Ovulation home test helps you to determine the time in your menstrual cycle when getting pregnant is most likely. This at-home ovulation test is often used by women to help predict when an egg release is likely. This is when pregnancy is most likely to occur. These kits can be bought at most drug stores.

The ovulation test detects a rise in luteinizing hormone (LH) in the urine. A rise in this hormone signals the ovary to release the egg. A positive result indicates an “LH surge.” This is a sign that ovulation may soon occur. Talk to your doctor if you are unable to detect an “LH surge” or do not become pregnant after using the kit for several months. You may need to see an infertility specialist.

Luteinizing hormone (LH) urine tests are not the same as the home fertility monitors. Fertility monitors are digital handheld devices. They predict ovulation based on electrolyte levels in your saliva, luteinizing hormone (LH) levels in your urine or your basal body temperature. These devices can store ovulation information for several menstrual cycles.

How the ovulation test is performed

Ovulation prediction test kits most often come with five to seven sticks. You may need to test for several days to detect a surge in luteinizing hormone (LH).

The specific time of month that you start testing depends on the length of your menstrual cycle. For example, if your normal cycle is 28 days, you’ll need to begin testing on day 11. That is, the 11th day after you started your period. If you have a different cycle interval than 28 days, talk to your doctor about the timing of the test. In general, you should begin testing 3 to 5 days prior to the expected date of ovulation.

You will need to urinate on the test stick, or place the stick into urine that has been collected into a sterile container. The test stick will turn a certain color or display a positive sign if a surge is detected.

A positive result means you should ovulate in the next 24 to 36 hours, but this may not be the case for all women. The booklet that is included in the kit will tell you how to read the results.

You may miss your surge if you miss a day of testing. You may also not be able to detect a surge if you have an irregular menstrual cycle.

How to prepare for the ovulation test

DO NOT drink large amounts of fluids before using the test.

Drugs that can decrease luteinizing hormone (LH) levels include estrogens, progesterone, and testosterone. Estrogens and progesterone may be found in birth control pills and hormone replacement therapy.

The drug clomiphene citrate (Clomid) can increase luteinizing hormone (LH) levels. This drug is used to help trigger ovulation.

Why the ovulation test is performed?

The ovulation test is most often done to determine when a woman will ovulate to assist in difficulty in getting pregnant. For women with a 28-day menstrual cycle, this release normally occurs between days 11 and 14.

If you have an irregular menstrual cycle, the kit can help you tell when you are ovulating.

The ovulation home test may also be used to help you adjust doses of certain medicines such as infertility drugs.

Medical tests for ovulation

Medical tests can check whether or not ovulation took place. These tests can include:

• blood test – to check for the presence of progesterone. A level greater than 20 nmol/L indicates that ovulation took place. This test must be taken about three to 10 days before the first day of the next expected period
• pregnancy ultrasound – the presence of a fetus is the only absolute proof that ovulation took place. Medical tests such as ovulation predictor kits and blood tests can only ascertain that ovulation probably – not definitely – occurred.

How to increase your chances of ovulation

Ways to increase your chances of ovulation include:

• Women who are seriously obese or underweight may have problems with ovulation. Try to keep your weight around the average for your height and build.
• Excessive exercise can prevent ovulation. Ease back on your physical activity levels – this may require expert help if your desire to exercise is actually a form of bulimia.
• Repeated crash dieting, fasting, skipping meals and other disordered eating habits can hamper your body’s ability to regularly ovulate. Make sure to eat properly and regularly. Once again, you may need expert help if these habits are associated with an eating disorder such as anorexia or bulimia nervosa.
• Chronic emotional stress can play havoc with your menstrual cycle. Try to reduce the amount of stress in your life, and learn ways to better cope with stress. For example, relaxation training may be helpful.

Some women who aren’t ovulating regularly can be helped by reproductive technologies including tablets and injections to trigger higher production of ovulatory hormones. The dosage needs to be carefully monitored, because ovulation induction can trigger the maturation of a number of ova, which could lead to a multiple pregnancy.

The best time to get pregnant

You’re most likely to get pregnant if you have sex within a day or so of ovulation (releasing an egg from the ovary). This is usually about 14 days after the first day of your last period, if your cycle is around 28 days long. An egg lives for about 12-24 hours after being released. For pregnancy to happen, the egg must be fertilized by a sperm within this time. Sperm can live for up to 7 days inside a woman’s body. So if you’ve had sex in the days before ovulation, the sperm will have had time to travel up the fallopian tubes to “wait” for the egg to be released. When the egg and sperm meet, it’s called fertilization. The fertilized egg also called an embryo moves through your fallopian tubes and attaches to the wall of your uterus where it grows and develops into a baby. When the embryo attaches to the uterus, it’s called implantation.

It’s difficult to know exactly when ovulation happens, unless you are practising natural family planning, or fertility awareness.

If you want to get pregnant, having sex every 2 to 3 days throughout the month will give you the best chance.

You don’t need to time having sex only around ovulation.

To get pregnant:

1. A woman’s body must release an egg from one of her ovaries (ovulation).
2. A man’s sperm must join with the egg along the way (fertilize).
3. The fertilized egg must go through a fallopian tube toward the uterus (womb).
4. The fertilized egg must attach to the inside of the uterus (implantation).
5. Infertility may result from a problem with any or several of these steps.
6. If you want to get pregnant, having sex every 2 to 3 days throughout the month will give you the best chance. You don’t need to time having sex only around ovulation.

Getting pregnant (conception) happens when a man’s sperm fertilizes a woman’s egg. For some women this happens quickly, but for others it can take longer.

You can get pregnant if you have unprotected sex any time from 5 days before and the day of ovulation. The more often you have sex during this time, the more likely you are to get pregnant. Your egg is fertile (can become an embryo) for 12 to 24 hours after ovulation. Your partner’s sperm can live inside you for up to 72 hours after you have sex.

However, it’s difficult to know exactly when your ovulation happen, unless you are practising natural family planning, or fertility awareness.

Out of every 100 couples trying for a baby, 80 to 90 will get pregnant within 1 year. The rest will take longer, or may need help to conceive.

To understand getting pregnant (conception) and pregnancy, it helps to know about the male and female sexual organs, and to understand how a woman’s monthly menstrual cycle and periods work.

The menstrual cycle is counted from the first day of a woman’s period (day 1). Some time after her period she will ovulate, and then around 12-16 days after this she’ll have her next period.

The average menstrual cycle lasts 28 days. But normal cycles can vary from 21 to 35 days. The amount of time before ovulation occurs is different in every woman and even can be different from month to month in the same woman, varying from 13 to 20 days long. Learning about this part of the cycle is important because it is when ovulation and pregnancy can occur. After ovulation, every woman (unless she has a health problem that affects her periods or becomes pregnant) will have a period within 14 to 16 days.

Being aware of your menstrual cycle and the changes in your body that happen during this time can help you know when you are most likely to get pregnant. See how the menstrual cycle works by watching the video below. Each month your ovaries release an egg about 14 days before the first day of your period. This is called ovulation. When you and your partner have unprotected sex around the time of ovulation, his sperm swim to meet your egg. Unprotected sex means you don’t use any kind of birth control to help prevent pregnancy.

Trouble getting pregnant

Trouble getting pregnant, difficulty conceiving is also known as infertility, which is usually defined as not being able to get pregnant after 12 months of unprotected sexual intercourse. A broader view of infertility includes not being able to carry a pregnancy to term. Finding out that you or your partner are unable to fall pregnant can be upsetting and difficult to deal with.

Because fertility in women is known to decline steadily with age, some health providers evaluate and treat women aged 35 years or older after just 6 months of unprotected sex. Women with infertility should consider making an appointment with a reproductive endocrinologist—a doctor who specializes in managing infertility. Reproductive endocrinologists may also be able to help women with recurrent pregnancy loss, defined as having two or more spontaneous miscarriages.

Pregnancy is the result of a process that has many steps.

To get pregnant:

1. A woman’s body must release an egg from one of her ovaries (ovulation).
2. A man’s sperm must join with the egg along the way (fertilize).
3. The fertilized egg must go through a fallopian tube toward the uterus (womb).
4. The fertilized egg must attach to the inside of the uterus (implantation).

Infertility may result from a problem with any or several of these steps.

Impaired fecundity (the ability to produce new offspring or fertility) is a condition related to infertility and refers to women who have difficulty getting pregnant or carrying a pregnancy to term.

• About 6% of married women aged 15 to 44 years in the United States are unable to get pregnant after one year of trying (infertility). Also, about 12% of women aged 15 to 44 years in the United States have difficulty getting pregnant or carrying a pregnancy to term, regardless of marital status (impaired fecundity).
• Infertility is not always a woman’s problem. Both men and women can contribute to infertility. Many couples struggle with infertility and seek help to become pregnant, but it is often thought of as only a woman’s condition. However, in about 35% of couples with infertility, a male factor is identified along with a female factor. In about 8% of couples with infertility, a male factor is the only identifiable cause.
• Almost 9% of men aged 25 to 44 years in the United States reported that they or their partner saw a doctor for advice, testing, or treatment for infertility during their lifetime.

For couples trying for a baby, it is normal to have feelings of uncertainty, disappointment and anxiety. It may affect a couple the same way or in different ways.

It is good to talk through any problems, and have both of you talk about how you feel.

If there are difficulties between you, talk to your doctor as a couple. Your doctor may refer you both to a counsellor if necessary.

There are many causes of infertility. For about 4 couples in 10 it will relate to a sperm problem. In another 4 couples in 10 there will be a female reproductive cause. Sometimes there is a combination of factors.

Treatment for infertility is available and can bring hope to people wanting to have a baby, but it also has financial, physical and emotional costs. And success is not guaranteed.

What is a natural birth

Natural childbirth can refer to many different ways of giving birth without using pain medication, either in the home or at the hospital or birthing center ¹.

Natural childbirth is a way of giving birth by letting nature take its course. This may include:

• going through labor and delivery without the help of medications, including pain relievers such as epidurals
• using few or no artificial medical interventions such as continuous fetal monitoring or episiotomies (when the area between the vagina and anus, called the perineum, is cut to make room for the baby during delivery)
• allowing the woman to lead the labor and delivery process, dealing with it in any way she is comfortable

Many women with low-risk pregnancies choose to go through natural childbirth to avoid any possible risks that medications could pose for the mother or baby. Pain medications can affect your labor — your blood pressure might drop, your labor might slow down or speed up, you might become nauseous, and you might feel a sense of lack of control.

But many women choose natural childbirth to feel more in touch with the birth experience and to deal with labor in a proactive manner.

Preparation for birth can help to reduce the experience of pain and reduce anxiety, which can help you to better cope with labor.

There are a number of methods you can use to help you cope with your labor pain.

Like the labor experience, this is an individual decision. Some women are keen to avoid medications, others are happy to consider all available options. You need to choose the best coping technique or combination that suits you and your needs. Remember, your plan may change when you are in labor. Labor might hurt more than you had anticipated. Some women who had previously said they want no pain medicine whatsoever end up changing their minds once they’re actually in labor. This is very common and completely understandable.

During your labor, your midwife will continue to guide you and work with you according to your wishes.

How Is Natural Childbirth Done?

How you choose to work through the pain is up to you. Different women find that different methods work best for them. Many can control the pain by channeling their energy and focusing their minds on something else. The two most common childbirth philosophies in the United States are the Lamaze technique and the Bradley method.

The Lamaze technique teaches that birth is a normal, natural, and healthy process but takes a neutral position toward pain medication, encouraging women to make an informed decision about whether it’s right for them.

The Bradley method (also called Husband-Coached Birth) emphasizes a natural approach to birth and the active participation of a birth coach. A major goal of this method is the avoidance of medications unless absolutely necessary. The Bradley method also focuses on good nutrition and exercise during pregnancy and relaxation and deep-breathing techniques as a method of coping with labor. Although the Bradley method advocates a medication-free birth experience, the classes do prepare parents for unexpected complications or situations, like emergency C-sections.

Women who choose natural childbirth can use a number of natural ways to ease pain. These include ², ³:

• Emotional support
• Relaxation techniques
• A soothing atmosphere
• Moving and changing positions frequently (such as walking around, showering, rocking, or leaning on birthing balls)
• Using a birthing ball
• Using soothing phrases and mental images
• Placing a heating pad or ice pack on the back or stomach
• Massage or counterpressure
• Taking a bath or shower
• Hypnosis (also called “hypnobirthing”)
• Using soothing scents (aromatherapy)
• Acupuncture or acupressure
• Applying small doses of electrical stimulation to nerve fibers to activate the body’s own pain-relieving substances (called transcutaneous electrical nerve stimulation, or TENS)
• Injecting sterile water into the lower back, which can relieve the intense discomfort and pain in the lower back known as back labor.
• Yoga
• Meditation
• Walking
• Immersion in warm water or a jacuzzi
• Distractions via activities that keep the mind otherwise occupied
• Listening to soothing music
• Visual imagery.

What If I Can’t Handle the Pain?

Every woman experiences pain in a different way. The way you experience pain depends on your emotional, psychological, social, motivational and cultural circumstances. Every woman responds and copes differently with the pain of labor and childbirth.

Labor might hurt more than you had anticipated. Some women who had previously said they want no pain medicine whatsoever end up changing their minds once they’re actually in labor. This is very common and completely understandable.

You should be applauded for your willingness and enthusiasm to try to deliver naturally. But if it turns out that the pain is too much to bear, don’t feel bad about requesting medications. And if something doesn’t go according to plan, you may need to be flexible as circumstances change. That doesn’t make you any less brave or committed to your baby or the labor process. Giving birth is a beautiful and rewarding experience, with or without medical intervention.

Natural pain relief

• Relaxation: Being relaxed in labor has many benefits. Your body will work better if you’re relaxed. Your natural hormones that help your labor progress (oxytocin), and those ‘natural pain-relief hormones’ (endorphins) that help you cope with labor, will be released more readily. Fear, tension and resistance are a normal response when you feel out of control or you are not sure what to expect next. On the other hand, relaxing and trusting that your body knows what to do will help you manage your pain. Learn how to relax, stay calm and breathe deeply. Breathing techniques may help you to ‘ride the waves’ of each contraction. Remember that a relaxed mind is a relaxed cervix. If your face is relaxed, the muscles through your pelvis are too.
• Active birth: Moving around and changing positions is one of the most helpful things you can do to manage the pain of labor and birth. Being able to move freely and rocking your pelvis can help you to cope with the contractions. If you stay upright, gravity will also help your baby to move down through your pelvis.
• Heat and water: The use of heat can help to ease tension and discomfort in labor. Both hot and cold packs are useful, as is being immersed in water in either a shower or a bath. Healthy women with uncomplicated pregnancies may find that having a warm bath in labor helps with relaxation and pain relief. A warm bath increases relaxation and production of endorphins (your body’s natural pain relief hormone). It reduces the pain of contractions and the pressure on your pelvis and muscles.
• Touch and massage: Feeling stressed and anxious makes pain seem worse. Massage can reduce muscle tension as well as providing a distraction between and during contractions. Practise with your partner during your pregnancy and find out how you like to be massaged. At different stages during labor, massage and touch will feel good and at other times you may find it distracting or annoying.
• Complementary therapies: Alternative therapies such as acupuncture, acupressure or aromatherapy can also be very effective, but should only be practised by qualified practitioners.

Non-medical pain relief​

• TENS (Transcutaneous electrical nerve stimulation) also called electrotherapy: A TENS machine delivers a small electrical current to your body through electrodes attached to your skin. It does not involve medicines or injections. The TENS machine is a small, portable, battery-operated device that is worn on your body. The box is attached by wires to sticky pads that are stuck to the skin on your back. The machine has dials that you can adjust to control the frequency and strength of small electrical pulses that are transmitted to your body. These pulses stimulate your body to release your endorphins.
• Water injections for back pain: Many women have lower back pain that persists throughout their labor. Midwives can use a technique where sterile water injections are given in four different places in your lower back, just beneath the skin. The injections cause a strong stinging sensation, like a bee sting. The sting will last for up to 30 seconds before disappearing along with the back pain. The injections can provide a few hours of pain relief to your lower back without any side effects for you or your baby.

Medical pain relief

• Nitrous oxide gas also known as ‘laughing gas’, women in labor can breathe a mixture of nitrous oxide and oxygen through a mouth piece or mask. The gas is inhaled during a contraction and helps take the edge off your pain. Many women choose the gas as it makes them feel in control of their pain-relief and provides them with something to focus on to get through each contraction. There are no after-effects for you or your baby. The mixture of gas can be changed during different stages of your labor to provide better pain relief or if you feel a little nauseous or light-headed.
• Pethidine or morphine injection: Pethidine and morphine are strong painkillers given by injection. You may be offered one of these medications, which work by mimicking the effects of endorphins. Although they help reduce the severity of the pain, they do not take it away completely. Women have varying responses to morphine and pethidine. Some women will say the injection provided pain relief, while others will say it had no effect at all on their level of pain. The injections can take up to 30 minutes to work and can make you feel quite nauseated. Because these drugs cross the placenta to your baby, your baby may become sleepy. Sometimes pethidine may contribute to breathing problems in your baby if given within two hours of birth. For this reason and due to its relatively short period of effect, it is mostly helpful for women who are in well-established labor but not too close to giving birth.
• Epidural: An epidural is a procedure where an anesthetic (a drug that gives either partial or total loss of sensation) is injected into the small space in your back near your spinal cord by a specialist anaesthetist. After an epidural, you will have altered sensation from your waist down. How much you can move your legs after an epidural will depend on the type and dose of anaesthetic used. A very thin tube will be left in your back so the anaesthetic can be topped up. Sometimes the tube is attached to a machine so that you have control over when the epidural is topped up. The benefits of an epidural are that it takes away the pain of contractions, it can be effective for hours and can be increased in strength if you need to have an emergency cesarean. In a long labor, it can allow you to sleep and recover your strength. Epidurals can cause a fall in blood pressure, so you will usually have an intravenous drip (a bag of liquid that enters your body through a tube) put into your arm or the back of your hand, and your blood pressure will be monitored more closely. You may also lose the sensation to pass urine, so you will have a catheter tube inserted into your bladder to drain your urine. Because of the potential side effects such as low blood pressure, the baby’s heart rate will need to be continuously monitored by a cardiotocography (CTG) machine following an epidural. The chance of you needing assistance with the birth of your baby increases once you have had an epidural. A stronger epidural or ‘top up’ will help relieve the pain of these procedures.

Not all birth places can offer every method of pain management. You might like to talk to your care provider about the pain relief options available to you at your planned place of birth and which methods of pain relief can and can’t be used together. You can choose one method or a few, or you change from one to another during labor. Remember it is important to keep an open mind and have a positive attitude and confidence in your ability to labor.

Dealing With Pain During Childbirth

If you’re like most women, the pain of labor and delivery is one of the things that worry you about having a baby. This is certainly understandable, because labor is painful for most women.

It’s possible to have labor with relatively little pain, but it’s wise to prepare yourself by planning some strategies for coping with pain. Planning for pain is one of the best ways to ensure that you’ll stay calm and be able to deal with it when the time comes.

Pain During Labor and Delivery

Pain during labor is caused by contractions of the muscles of the uterus and by pressure on the cervix. This pain can be felt as strong cramping in the abdomen, groin, and back, as well as an achy feeling. Some women experience pain in their sides or thighs as well.

Other causes of pain during labor include pressure on the bladder and bowels by the baby’s head and the stretching of the birth canal and vagina.

Pain during labor is different for every woman. Although labor is often thought of as one of the more painful events in human experience, it ranges widely from woman to woman and even from pregnancy to pregnancy. Women experience labor pain differently — for some, it resembles menstrual cramps; for others, severe pressure; and for others, extremely strong waves that feel like diarrheal cramps.

It’s often not the pain of each contraction on its own that women find the hardest, but the fact that the contractions keep coming — and that as labor progresses, there is less and less time between contractions to relax.

Preparing for Pain

To help with pain during labor, here are some things you can start doing before or during your pregnancy:

Regular and reasonable exercise (that your doctor says is OK) can help strengthen your muscles and prepare your body for the stress of labor. Exercise also can increase your endurance, which will come in handy if you have a long labor. The important thing to remember with any exercise is not to overdo it — and this is especially true if you’re pregnant. Talk to your doctor about what he or she considers to be a safe exercise plan for you.

If you and your partner attend childbirth classes, you’ll learn different techniques for handling pain, from visualization to stretches designed to strengthen the muscles that support your uterus. The two most common childbirth philosophies in the United States are the Lamaze technique and the Bradley method.

The Lamaze technique is the most widely used method in the United States. The Lamaze philosophy teaches that birth is a normal, natural, and healthy process and that women should be empowered to approach it with confidence. Lamaze classes educate women about the ways they can decrease their perception of pain, such as through relaxation techniques, breathing exercises, distraction, or massage by a supportive coach. Lamaze takes a neutral position toward pain medication, encouraging women to make an informed decision about whether it’s right for them.

The Bradley method (also called Husband-Coached Birth) emphasizes a natural approach to birth and the active participation of the baby’s father as birth coach. A major goal of this method is the avoidance of medicines unless absolutely necessary. The Bradley method also focuses on good nutrition and exercise during pregnancy and relaxation and deep-breathing techniques as a method of coping with labor. Although the Bradley method advocates a medication-free birth experience, the classes do do discuss unexpected complications or situations, like emergency cesarean sections.

Some ways to handle pain during Natural Birth: see above.

Pain Medications

A variety of pain medications can be used during labor and delivery, depending on the situation. Talk to your health care provider about the risks and benefits of each.

Analgesics. Pain medicines can be given many ways. If they are given intravenously (through an IV) or through a shot into a muscle, they can affect the whole body. These medicines can cause side effects in the mother, including drowsiness and nausea. They also can have effects on the baby.

Regional anesthesia. This is what most women think of when they consider pain medication during labor. By blocking the feeling from specific regions of the body, these methods can be used for pain relief in both vaginal and cesarean section deliveries.

Epidurals, a form of local anesthesia, relieve most of the pain from the entire body below the belly button, including the vaginal walls, during labor and delivery. An epidural involves medicine given by an anesthesiologist through a thin, tube-like catheter that’s inserted in the woman’s lower back. The amount of medication can be increased or decreased according to a woman’s needs. Very little medication reaches the baby, so usually there are no effects on the baby from this method of pain relief.

Epidurals do have some drawbacks — they can cause a woman’s blood pressure to drop and can make it difficult to urinate. They can also cause itching, nausea, and headaches in the mother. The risks to the baby are minimal, but include problems caused by low blood pressure in the mother.

Tranquilizers. These drugs don’t relieve pain, but they may help to calm and relax women who are very anxious. Sometimes they are used along with analgesics. These drugs can have effects on both the mother and baby, and are not often used. They also can make it difficult for women to remember the details of the birth. You should discuss the risks of taking tranquilizers first with your doctor.

Things to Consider

Here are some things to think about when considering pain control during labor:

• Medicines can relieve much of your pain, but probably won’t relieve all of it.
• Labor may hurt more than you anticipated. Some women who have previously said they want no pain medicine whatsoever end up changing their minds once they’re actually in labor.
• Certain medications can affect your baby, causing the baby to be drowsy or have changes in the heart rate.

Talking to Your Health Care Provider

You’ll want to review your pain control options with the person who’ll be delivering your baby. Find out what pain control methods are available, how effective they’re likely to be, and when it’s best not to use certain medications.

If you want to use pain-control methods other than medication, make sure your health care provider and the hospital staff know. You might want to also consider writing a birth plan that makes your preferences clear.

Remember, too, that many women make decisions about pain relief during labor that they abandon — often for very good reason — at the last minute. Your ability to endure the pain of childbirth has nothing to do with your worth as a mother. By preparing and educating yourself, you can be ready to decide what pain management works best for you.

Where is Natural Birth Done ?

Some women who opt for natural childbirth choose to deliver in a non-hospital setting such as a birth center, where natural childbirth is the focus. Women are free to move around during their labor, get in positions that are most comfortable to them, and spend time in the tub or jacuzzi. The baby is monitored frequently, often with a handheld ultrasound device. Comfort measures such as hydrotherapy, massage, warm and cold compresses, and visualization and relaxation techniques are often used. The woman is free to eat and drink as she chooses.

A variety of health care professionals may work in the birth center setting — such as registered nurses, certified nurse midwives, and doulas (professionally trained providers of labor support and/or postpartum care) who act as labor assistants.

Studies indicate that getting continuous support during labor from a trained and experienced companion, such as a midwife or doula, can mean shorter labor, less (or no) medications, less chance of needing a C-section, and a more positive feeling about the labor when it’s over.

These days, it’s also possible to have a more natural childbirth in many hospitals. Some hospitals have birth centers, where a natural approach is taken, but medical intervention is available if needed. Many hospitals have modified their approach for low-risk births, and have rooms with homelike settings where women can labor, deliver, and recover without being moved. They may take their cues from the laboring woman, allowing labor to proceed more slowly and without intervention if all seems to be going well. They may use alternative pain-management techniques if requested and welcome the assistance of labor assistants like midwives or doulas.

In addition to the father, other children, grandparents, and friends may be allowed to attend the births (which is also common practice at birth centers). After birth, babies might remain with the mother longer. In its fullest form, this approach is sometimes called family-centered care.

What Will Natural Birth Feel Like ?

Although labor is often thought of as one of the more painful events in human experience, it varies widely from woman to woman and even from pregnancy to pregnancy. Women experience labor pain differently — for some, it resembles menstrual cramps; for others, severe pressure; and for others, extremely strong waves that feel like diarrheal cramps. First-time mothers are more likely to give their pain a higher rating than women who’ve had babies before.

How Long Will Natural Birth Take ?

There’s no magic timetable when you’re giving birth. For some women, the baby comes in a few hours; for many others it may take all day (or longer). Whether you opt for medications or not, every woman’s body reacts to labor differently.

Risks and Precautions of Natural Birth

Natural childbirth is, in general, very safe. But it becomes risky when a woman ignores her health care provider’s recommendations or if she refuses medical intervention if everything doesn’t go as planned.

It’s important for the well-being of you and your baby to be open to other options if complications occur. In an emergency, refusing medical help could put your life and your baby’s at serious risk.

After Natural Birth Delivery

Like any woman who’s given birth, you’ll probably feel:

• exhausted — both you and your baby will probably want to sleep as much as possible
• shaky or cold — many women shiver after delivery; this is a natural reaction
• sore — you’ll probably feel cramping in your uterus, especially with breastfeeding, and you’ll have some pain and discomfort in and around your vagina
• elated and empowered — you may feel an overwhelming sense of accomplishment knowing that you did it

Natural birth plan

A birth plan is a set of instructions you make about your baby’s birth. Fill out this plan with your partner. Then share it with your provider, your family and other support people. It’s best for everyone to know ahead of time how you want labor and birth to be.

• For a free copy of a birth plan get it here: ⁴

A birth plan tells your provider how you feel about things like who you want with you during labor, what you want to do during labor, if you want drugs to help with labor pain, and if there are special religious or cultural practices you want to have happen once your baby is born.

• Important: the goal of a birth plan isn’t for you and your partner to decide exactly how the birth of your child will happen — labor involves so many variables, you can’t predict exactly what will happen. A birth plan isn’t a binding agreement — it’s just a guideline.

Note: How can you use your birth plan

Fill out a birth plan with your partner. While completing a birth plan, you’ll be learning about, exploring, and understanding your labor and birthing options well before the birth of your child. This can also improve your communication with the people who’ll be helping during your delivery. By sharing your birth plan with your provider and with the nurses at the hospital or birthing center where you plan to have your baby – you’re letting everyoneknow ahead of time how you want labor and birth to be. Share it with your family and other support people, too.

Your doctor or health care provider may know, from having seen you throughout the pregnancy, what you do and don’t want. But, if you go into labor when there’s an on-call doctor who you don’t know well, a well thought-out birth plan can help you communicate your goals and wishes to the people helping you with the labor and delivery.

Figure 1. Birth Plan

Things to Consider

Before you make decisions about each of your birthing options, you’ll want to talk with your health care provider and tour the hospital or birthing center where you plan to have your baby.

You may find that your obstetrician, nurse-midwife, or the facility where they admit patients already has birth-plan forms that you can fill out. If so, use the form as a guideline for asking questions about how women in their care are routinely treated. If their responses are not what you’re hoping for, you might want to look for a health provider or facility that better matches your goals.

And it’s important to be flexible — if you know one aspect of your birthing plan won’t be met, be sure to weigh that against your other wishes. If your options are limited because of medical needs, insurance, cost, or geography, focus on one or two areas that are really important to you. In the areas where your thinking doesn’t agree with that of your doctor or nurse-midwife, ask why he or she usually does things a certain way and listen to the answers before you make up your mind. There may be important reasons why a doctor believes some birth options are better than others.

Finally, find out if there are things about your pregnancy that might prevent certain choices. For example, if your pregnancy is considered high risk because of your age, health, or problems during pregnancy (current or previous), your health care provider may advise against some of your birthing wishes. You’ll want to discuss, and consider, this information when thinking about your options.

What Are Your Birthing Options ?

In creating your birthing plan, you’re likely to have choices in the following areas:

Where to have the baby. Most women give birth in the hospital. However, most are no longer confined to a cold, sterile maternity ward. Find out if your hospital practices family-centered care. This usually means the patient rooms will have a door, furnishings, a private bathroom, and enough space to accommodate a family.

Additionally, many hospitals now offer birthing rooms that allow a woman to stay in the same bed for labor, delivery, and sometimes, postpartum care (care after the birth). These rooms are fully equipped for uncomplicated deliveries. They’re often attractive and have gentle lighting.

But some women believe that the most comfortable environment is their own home. Advocates of home birth believe that labor and delivery can and should happen at home, but they also stress that a certified nurse-midwife or doctor should attend the birth.

An important thing to remember about home birth is that if something goes wrong, you don’t have the amenities and technology of a hospital. It can take a while to get to the hospital, and during a complicated birth those minutes can be invaluable.

For women with low-risk pregnancies who want something in between the hospital and home, birthing centers are another option. These provide a more homey, relaxed environment with some of the medical amenities of a hospital. Some birthing centers are associated with hospitals and can transfer patients if necessary. It’s a good idea to find out what happens in case of a complication: How would you get to the hospital? How long would the transfer take?

Who will assist at the birth

Most women choose an obstetrician (OB/GYN), a specialist who’s trained to handle pregnancies (including those with complications), labor, and delivery. If your pregnancy is considered high risk, you may be referred to an obstetrician who subspecializes in maternal-fetal medicine. These doctors have specialized training to care for pregnant women with medical conditions or complications, as well as their fetuses.

Another medical choice is a family practitioner who has had training and has maintained expertise in managing non-high-risk pregnancies and deliveries. In some areas of the United States, especially rural areas where obstetricians are less available, family practitioners handle most of the deliveries. As your family doctor, a family practitioner can continue to treat both you and your baby after birth.

And doctors aren’t the only health care providers a pregnant woman can choose to deliver her baby. You might decide that you want your delivery to be performed by a certified nurse-midwife, a health professional who’s medically trained and licensed to handle low-risk births and whose philosophy emphasizes educating expectant parents about the natural aspects of childbirth.

Increasing numbers of women are choosing to have a doula, or birth assistant, present in addition to the medical personnel. This is someone who’s trained in childbirth and is there to provide support to the mother. The doula can meet with the mother before the birth and can help communicate her wishes to the medical staff, should it be necessary.

Your birth plan can also indicate who else you’d like to have with you before, during, and immediately after the birth. In a routine birth, this may be your partner, your other children, a friend, or other family member. You also can make it clear at what points you want no one to be there but your partner.

More Birthing Options

Atmosphere during labor and delivery. Many hospitals and birthing centers now allow women to make some choices about the atmosphere in which they give birth. Do you want music and low lighting? How about the freedom to walk around during labor? If possible, would you like to eat or drink during labor? You might be able to request things that may make you the most comfortable — from what clothes you’ll wear to whether you’ll have a DVD player in your room.

Procedures during labor. Hospitals used to perform the same procedures on all women in labor, but many now show increased flexibility in how they handle their patients. Some examples include:

• enemas. Used to clean out the bowels, enemas used to be routine when women were admitted. Now, you may choose to give yourself an enema or to skip it entirely.
• induction of labor. At times, labor may need to be induced or sped up for medical reasons. But sometimes, practitioners will give women the option of getting some help to move things along, or giving labor a little more time to progress on its own.

• shaving the pubic area. Once routine, shaving is no longer done unless a woman requests it.

Other procedures that you can include in your birth plan are preferences about fetal monitoring, extra birthing equipment you’d like in the room, and how often you have internal exams during labor.

Pain management. This is important for most women and is certainly something you have a lot of control over. It’s also something you’ll want to discuss carefully with your health care provider. Some women change their minds about pain relief during labor only to discover that they’re too far along in their labor to use certain methods, such as an epidural. You’ll also want to be aware of alternative forms of pain relief, including massage, relaxation, breathing, and bathing. Know your options and make your wishes known to your care provider.

Position during delivery. You can try a variety of positions during labor, including the classic semi-recline with the feet in stirrups that you’ve seen in the movies. Other choices include lying on your side, squatting, standing, or simply using whatever stance feels right at the time.

Episiotomies. When necessary, doctors perform episiotomies (when the perineum — the area of skin between the vagina and the anus — is partially cut to ease the delivery). You may have one if you risk tearing or in the case of a medical emergency. But if there is an option, you can discuss your preference with your provider.

Assisted birth. If the baby becomes stuck in the birth canal, an assisted birth (i.e., using forceps or vacuum extraction) may be necessary.

Cesarean section (C-section). You might not want to think about this, but if you have to have a cesarean, you’ll need to consider a few things. Do you want your partner to be present, if possible? What about viewing the birth — do you want to see the baby coming out?

Post-birth. Decisions to be made about the time immediately after birth include:

• Would your partner like to cut the umbilical cord ?
• Does your partner want to hold the baby when the baby emerges ?
• Do you want immediate contact with the baby, or would you like the baby to be cleaned off first ?
• How would you like to handle the delivery of the placenta ? Would you like to keep the placenta ?
• Do you want to feed the baby right away ?

Communicating Your Wishes

Give your health care provider your reasons for creating a birth plan — not because you don’t trust him or her, but to help ensure cooperation and to cover the possibilities if something should go wrong. If your caregiver seems offended or is resistant to the idea of a birth plan, you might want to reconsider whether this is the right caregiver for you.

Also, think about the language of your plan. You can use many online resources to create one or you can make one yourself.

Here are some tips:

• Make your birth plan read like a list of requests or best-case scenarios, not like a set of demands. Phrases such as “I would prefer” and “if medically necessary” will help your health care provider and caregivers know that you understand that they might have to change the plan.
• Think about the other personnel who’ll be using it — hospital staffers might feel more comfortable if you call it your “birth preferences” rather than your “birth plan,” which could seem as though you’re trying to tell them how to do their jobs.
• Try to be positive (“we hope to”) as opposed to negative (“under no circumstances”).

Once you’ve made your birth plan, schedule a time to go over it with your doctor or nurse-midwife. Find out and discuss where you agree or disagree. During your pregnancy, review the birth plan with your partner periodically to make sure that it’s still in line with both of your wishes.

Strive to keep the plan as simple as possible — preferably less than two pages — and list them in order of importance. Focusing on your priorities will help ensure that the most important of your wishes are met.

You may also want to make several copies of the plan: one for you, one for your chart, one for your doctor or nurse-midwife, and one for your birthing coach or partner. And bringing a few extra copies in your labor bag is a good idea, especially if your doctor ends up not being on call when your baby is born.

Although you might not be able to control everything that happens to you during your baby’s birth, you can play a role in the decisions that are made about your body and your baby. A well thought-out birth plan can help you to do that.

Birth Is Intended to Happen Simply, Without Worry or Trouble

The physiologic process of birth is simply and carefully designed. Women’s bodies are designed to grow, birth, and nourish babies. In the last weeks of pregnancy, a series of physiologic changes occur, mostly, as evidence suggests, orchestrated by the baby. The cervix softens and may begin to dilate and efface. The uterine muscle becomes increasingly responsive to oxytocin. At first, oxytocin levels rise gradually and, when labor starts, more quickly. The pain associated with strong uterine contractions (the result of higher levels of oxytocin) sends a signal to the brain that stimulates the ongoing release of the large amounts of oxytocin required for strong, effective contractions. Coping with the increasingly strong contractions (by movement, relaxation, and other comfort measures) insures the continued release of oxytocin.

Pain plays an important role in helping labor progress by insuring that increasing amounts of oxytocin are released ⁵. When oxytocin levels are high (and the contractions are painful), beta-endorphins (“nature’s narcotic”) are released. Endorphins help women manage the pain of contractions by inducing an almost dream-like state and decreasing pain perception. In a very real sense, nature does not abandon women during labor.

Stress hormones, however, disrupt the process. Especially in early labor, stress and anxiety can stop labor; in active labor, stress can slow progress. Privacy and feeling safe and protected emotionally as well as physically help keep catecholamine levels low and labor progressing.

Women begin to have an instinctive urge to push as the baby moves down the birth canal. Following the urge, quite naturally, and changing positions in response to what the woman is feeling not only helps the baby descend and rotate but also protects the baby and the birth canal. When the baby is just ready to be born, if oxytocin and endorphin levels are high, a natural release of catecholamines gives women a surge of strength to push the baby out.

The baby is born with high levels of catecholamines and endorphins and is alert and calm. Placed skin-to-skin with his mother, the baby will find the breast and self attach. Even the small movements of the baby, when skin-to-skin with his mother, stimulate the release of maternal oxytocin. Oxytocin facilitates the separation and delivery of the placenta, decreasing the risk of maternal hemorrhage, and sets the stage for efficient milk let down and successful breastfeeding. Babies kept skin-to-skin stay warmer, are less likely to become hypoglycemic, cry less, have more stable heart rates, and breastfeed for a longer duration than babies who are separated from their mother ⁶.

Every pregnant women needs to know that labor and birth are simply and beautifully designed. In order to keep labor and birth as safe as possible, and to minimize the risk of complications, it is essential to respect the simple, natural, physiologic process of labor and birth and not interfere in any way, unless there is a clear medical indication. There is an optimal way to give birth, and this is it.

How to prepare for natural birth

Every pregnant woman needs to know that birth is intended to happen simply and easily and that six key birth practices make birth safer for mothers and babies.

The World Health Organization (WHO) identifies four care practices that promote, support, and protect normal birth ⁷. Lamaze International identifies two additional practices. Together, these six practices are supported by research, including systematic reviews from The Cochrane Library and the Coalition for Improving Maternity Services ⁸. Romano and Lothian ⁹ provide a detailed overview of the research that supports these six care practices. Written for women and their families, the Lamaze Healthy Birth Practice papers describe the importance of each of the six practices for a healthy, safe birth and provide a synopsis of the evidence that supports each practice. Every pregnant woman needs to know that these six evidence-based birth practices make birth healthier and safer for mothers and babies.

Childbirth education

Childbirth education can simplify pregnancy and birth and help women navigate the maze of modern obstetrics in order to have a safe, healthy birth. Pregnancy is complex and fraught with potential for worry and confusion. It is easy to fall into the trap of thinking that things can go terribly wrong. Excellent childbirth education can help women learn how simple birth can and should be, how to stay confident in their ability to grow and birth their babies, and how to avoid “spoiling the pregnancy” with worry and fear.

Preparation for birth and mothering starts at the beginning of pregnancy ¹⁰. It takes 9 months to grow a baby and to prepare emotionally and physically for birth and being a mother. Over the course of the pregnancy, women slowly attach to their babies, getting to know them through kicks and periods of rest and through changes to their own bodies as the pregnancy progresses. The physical growth of the baby happens simply and easily from one day to the next throughout pregnancy, but the emotional and psychological changes of pregnancy can easily be disrupted.

Childbirth education, right from the beginning of pregnancy, can help women choose health-care providers and places of birth that provide evidence-based maternity care, make thoughtful but sometimes difficult decisions about prenatal testing, and deal with fears for themselves and their babies. And, over the course of the pregnancy, childbirth education can help women develop plans for labor so that labor and birth can unfold optimally in the safest, healthiest way possible.

Childbirth education can help women connect with excellent resources and research to help them make decisions about their pregnancies and births that ultimately will make birth healthier and safer for them and their babies. Some of those resources include Lamaze’s weekly pregnancy e-mails ¹¹ and the six Lamaze Healthy Birth Practice papers. Other resources include information provided by the organizations Childbirth Connection ¹², the Coalition for Improving Maternity Services ¹³ and Choices in Childbirth ¹⁴.

Healthy Birth Practice #1: Let Labor Begin on Its Own

In most cases, the best way to insure that the baby is ready to be born and the mother’s body is ready to birth her baby is to let labor begin on its own ¹⁵. In the last weeks of pregnancy, the baby moves down into the pelvis, the cervix softens, and the uterine muscle becomes more receptive to oxytocin. The baby’s lungs mature, and he puts on a protective layer of fat. Every day makes a difference in how mature the baby is and how well he is able to make the transition to life outside the womb ¹⁶.

Elective labor induction not only increases the use of analgesia and epidural anesthesia but also the incidence of nonreassuring fetal heart rate patterns, shoulder dystocia, instrument delivery, and cesarean surgery ¹⁷. It is not without risk for the baby either, increasing the need for neonatal resuscitation and increasing the likelihood of low birth weight and admission to the neonatal intensive care unit ¹⁷. Although women are told that if a baby is thought to be large it is safer to induce labor early, this is not true. Suspected macrosomia is not an indication for induction, and induction for suspected macrosomia does not reduce the incidence of shoulder dystocia and is associated with an increased risk of cesarean ¹⁸.

Every pregnant woman needs to know that it is healthier and safer for both mother and baby to let labor begin on its own.

Healthy Birth Practice #2: Walk, Move Around, and Change Positions Throughout Labor

Moving in labor helps women cope with strong and painful contractions while gently moving the baby into the pelvis and through the birth canal ¹⁹. The pain of contractions can be a guide to the laboring woman as she moves in response to what she feels, trying to find comfort as the contractions become increasingly strong. Finding comfort in a variety of ways, including movement, helps labor progress. When women are able to cope with increasingly strong contractions, increasing amounts of oxytocin are released, and this keeps labor progressing. Movement in response to pain also protects the baby and the birth canal, especially during pushing. Research supports that walking, movement, and changing positions may shorten labor, are effective forms of pain relief, and are associated with fewer nonreassuring fetal heart rate patterns, fewer perineal injuries, and less blood loss. Walking during the first stage of labor decreases the likelihood of cesarean surgery and forceps and vacuum extraction deliveries ²⁰.

Every pregnant woman needs to know that walking, movement, and changing positions during labor help labor progress, enhance comfort, and decrease the risk of complications.

Healthy Birth Practice #3: Bring a Loved One, Friend, or Doula for Continuous Support

In labor, women feel better when cared for and encouraged by people they know and trust ²¹. For most women, that means family or close friends. Family and friends support the laboring woman in simple but important ways: protecting her privacy, helping her get comfortable, creating a cocoon that helps her feel safe and protected. This is especially important in the unfamiliar and often overwhelming hospital environment.

In recent years, doulas have provided continuous emotional and physical support for laboring women and their families. Doulas have the advantage of knowing labor and birth well and knowing countless ways of helping women find comfort and feel protected and safe in labor. This experience is a big advantage, especially in restrictive hospital environments. Research findings demonstrate that labor support reduces the likelihood of requesting pain medication, reduces the likelihood of having severe postpartum pain, and increases the likelihood of having a spontaneous vaginal birth. Women who have continuous labor support are more satisfied with the birth experience, have fewer cesareans, and are less likely to use Pitocin during labor ²².

Every pregnant woman needs to know that continuous emotional and physical support in labor makes birth safer and healthier for mother and baby.

Healthy Birth Practice #4: Avoid Interventions That Are Not Medically Necessary

In most hospitals, women routinely have an intravenous line, continuous electronic fetal monitoring, and an epidural ²³. Most hospitals also restrict eating and drinking in labor. Each of these practices has the potential to interfere with the process of labor and birth and create complications.

Intravenous lines and electronic fetal monitoring restrict women’s ability to walk, change positions, and find comfort as the contractions become increasingly painful. Food and fluids are typically restricted to prevent the extraordinarily rare occurrence of aspiration if general anesthesia is required. If women are able to eat and drink in labor, there is no need for intravenous lines. No research suggests that labor and birth are safer if food and fluids are restricted and intravenous lines are in place. In fact, increasing evidence indicates that the routine use of intravenous lines may contribute to fluid overload in labor ²⁴.

The routine use of continuous electronic fetal monitoring compared with intermittent auscultation increases the likelihood of instrument vaginal delivery and cesarean surgery but does not reduce the incidence of cerebral palsy, stillbirth, low Apgar scores, newborn death rates, or admission to the neonatal intensive care unit. In essence, the routine use of electronic fetal monitoring increases the risk of the mother having a cesarean with no difference in outcome for the baby ²⁴.

Epidurals interfere in the process of labor and birth in important ways. Because there is no pain, the brain does not get the message to keep releasing oxytocin. Consequently, contractions need to be stimulated with Pitocin. Pitocin does not pass the blood brain barrier; therefore, the body does not know to release endorphins. Women miss out on the valuable effects of endorphins during labor. Epidural use is associated with longer labors, increased likelihood of instrument delivery, more malpositioned babies, more tearing, and an increased risk of cesarean surgery, especially if the epidural is given early in labor ²⁴.

Every pregnant woman needs to know that each of these interventions has unintended effects. When interventions are used routinely, they set the stage for a cascade of other interventions, the physiologic process of labor and birth is disrupted, and women and babies are exposed to unnecessary risks.

Healthy Birth Practice #5: Avoid Giving Birth on the Back, and Follow the Body’s Urges to Push

Upright positions—including squatting, sitting, or lying on the side—make it easier for the baby to descend and move through the birth canal ²⁵. Changing positions helps wiggle the baby through the pelvis by enlarging pelvic diameters. It is also more comfortable to give birth in positions other than on the back. The use of upright or side-lying positions during second-stage labor is associated with a shorter duration of second-stage labor, fewer forceps or vacuum births, fewer episiotomies, fewer abnormal fetal heart rate patterns, and less chance of having severe pain during pushing ²⁶. The findings of this review suggest several possible benefits for upright posture in women without epidural anaesthesia, such as a very small reduction in the duration of second stage of labour (mainly from the primigravid group), reduction in episiotomy rates and assisted deliveries. However, there is an increased risk blood loss greater than 500 mL and there may be an increased risk of second degree tears, though the review authors cannot be certain of this ²⁶. In view of the variable risk of bias of the trials reviewed, further trials using well-designed protocols are needed to ascertain the true benefits and risks of various birth positions ²⁶.

Directed pushing is more stressful for the baby and is associated with increased risk of pelvic floor dysfunction ²⁷. The alternative is to wait for and follow the instinctive urges to push that happen as the baby moves down the birth canal. Even with an epidural, it is safer to wait until the baby moves through the mother’s pelvis on his own.

Every pregnant woman needs to know that it is safer and healthier for mother and baby when the laboring mother pushes in positions other than on her back and follows her own urges to push rather than pushing in a directed way.

Healthy Birth Practice #6: Keep Mother and Baby Together – It’s Best for Mother, Baby, and Breastfeeding

Physiologically, mothers and babies are meant to be together. Mothers are less likely to hemorrhage and are more satisfied. Babies stay warmer, their heart rates are more stable, and their respirations are more regular. They are less likely to become hypoglycemic or have breastfeeding difficulties ²⁸. The benefits are so clear that it is considered a harmful practice to separate mothers and babies unless there is a serious medical indication ²⁹. All the routine care of the baby right after birth can be done with the baby placed skin-to-skin with his mother.

Every pregnant woman needs to know that keeping her baby with her is not just a nice option, but keeping her baby close makes the early hours and days after birth safer for mothers and babies.

Birthing Centers and Hospital Maternity Services

You’ll make plenty of decisions during pregnancy, and choosing where to give birth — whether in a hospital or in a birth center setting — is one of the most important.

Hospitals

Many women fear that a hospital setting will be cold and clinical, but that’s not necessarily true. A hospital setting can accommodate a variety of birth experiences.

Traditional hospital births (in which the mother-to-be moves from a labor room to a delivery room and then, after the birth, to a semiprivate room) are still the most common option. Doctors “manage” the delivery with their patients. In many cases, women in labor are not allowed to eat or drink for medical reasons, and they may be required to deliver in a certain position.

Pain medications are available during labor and delivery (if the woman chooses); labor may be induced, if necessary; and the fetus is usually electronically monitored throughout the labor. A birth plan can help a woman communicate her preferences about these issues, and doctors will abide by these as much possible.

In response to a push for more “natural” birth events, many hospitals now offer more modern options for low-risk births, often known as family-centered care. These may include private rooms with baths (birthing suites) where women can labor, deliver, and recover in one place without having to be moved.

Although a doctor and medical staff are still present, the rooms are usually set up to create a nurturing environment, with warm, soothing colors and features that try to simulate a home-like atmosphere that can be very comforting for new moms. Rooming in — when the baby stays with the mother most of the time instead of in the infant nursery — also may be available.

In addition, many hospitals offer childbirth and prenatal education classes to prepare parents for the birth experience and parenting classes for after the birth.

The number of people allowed to attend the birth varies from hospital to hospital. In more traditional settings, as many as three support people are permitted to be with the mother during a vaginal birth. In a family-centered approach, more family members, friends, and sometimes even kids might be allowed. During a routine or nonemergency C-section, usually just one support person allowed.

Hospital Births

If you decide to give birth in a hospital, you will see a variety of health professionals:

Obstetrician/gynecologists (OB/GYNs) are doctors with at least 4 additional years of training after medical school in women’s health and reproduction, including both surgical and medical care. They can handle complicated pregnancies and also perform C-sections.

Look for obstetricians who are board-certified, meaning they have passed an examination by the American Board of Obstetrics and Gynecology (ACOG). Board-certified obstetricians who go on to receive further training in high-risk pregnancies are called maternal-fetal specialists or perinatologists.

If you deliver in a hospital, you also might be able to use a certified nurse-midwife (CNM). CNMs are registered nurses who have a graduate degree in midwifery, meaning they’re trained to handle low-risk pregnancies and deliveries. Most CNMs deliver babies in hospitals or birth centers, although some do home births.

In addition to obstetricians and CNMs, registered nurses (RNs) attend births to take care of the mother and baby. If you give birth in a teaching hospital, medical students or residents might be present during the birth. Some family doctors also offer prenatal care and deliver babies.

While you’re in the hospital, if you choose or if it’s necessary for you to receive anesthesia, it will be administered by a trained anesthesiologist. A variety of pain-control measures, including pain medication and local, epidural, and general anesthesia, are available in the hospital setting.

Birth Centers

Women who deliver in a birth center are usually those who have already given birth without any problems and whose current pregnancies are considered low risk (meaning they are in good health and are the least likely to develop complications).

Women giving birth to multiples, who have certain medical conditions (such as gestational diabetes or high blood pressure), or whose baby is in the breech position are considered higher risk and should not deliver in a birth center.

Women are carefully screened early in pregnancy and given prenatal care at the birth center to monitor their health throughout their pregnancy.

Natural childbirth is the focus in a birth center. Since epidural anesthesia usually isn’t offered, women are free to move around in labor, get in the positions most comfortable to them, spend time in the jacuzzi, etc. Comfort measures (such as hydrotherapy, massage, warm and cold compresses, and visualization and relaxation techniques) are often used. The woman is free to eat and drink as she chooses.

A variety of health care professionals operate in the birth center setting. A birth center may employ registered nurses, CNMs, and doulas (professionally trained providers of labor support and/or postpartum care).

Although a doctor is seldom present and medical interventions are rarely done, birth centers may work with a variety of obstetric and pediatric consultants. The professionals affiliated with a birth center work closely together as a team, with the nurse-midwives present and the OB/GYN consultants available if a woman develops a complication during pregnancy or labor that puts her into a higher risk category.

The baby’s heart rate is monitored often during labor, typically with a handheld Doppler device. Birth centers do have medical equipment available, such as IV lines and fluids, oxygen for the mother and the infant, and other equipment necessary to treat sick babies and moms.

A birth center can provide natural pain control and pain control with mild narcotic medications, but if a woman decides she wants an epidural, or if complications develop, she must be taken to a hospital.

Birth centers often provide a homey birth experience for the mother, baby, and extended family. In most cases, birth centers are freestanding buildings, although they may be attached to a hospital. Birth centers may be located in residential areas and generally include amenities such as private rooms with soft lighting, showers, and whirlpool tubs. A kitchen may be available for the family to use.

Look for a birth center that is accredited by the Commission for the Accreditation of Birth Centers (CABC). Some states regulate birth centers, so find out if the birth center you choose has all the proper credentials.

Which One Is Right for You ?

How do you decide whether a hospital or a birth center is the right choice for you? If you’ve chosen a particular health care provider, he or she may only practice at a particular hospital or birth center, so you should discuss your decision. And check with your health insurance carrier to make sure your choice is covered. In many cases, accredited birth centers as well as hospitals are covered by major insurance companies.

If you have any conditions that classify your pregnancy as higher risk (such as being older than 35, carrying multiple fetuses, or having gestational diabetes or high blood pressure, to name a few), your health care provider may advise you to deliver in a hospital where you and your baby can receive medical treatment as necessary. In fact, you might not be eligible to deliver in a birth center because of your risk factors. And if you want interventions such as an epidural or continuous fetal monitoring, a hospital is probably the better choice for you.

For a woman without significant problems in her medical history and whose pregnancy has been classified as low risk, a birth center can be an option. Women who want a natural birth with minimal medical intervention or pain control may feel more comfortable in a birth center, as may those who want friends or family members there for the birthing experience.

Once you’ve decided on either a hospital or a birth center, you may still have to choose which hospital or which birth center. Before you make a choice, be sure that your health care provider — whether he or she is a doctor or a CNM — can deliver at the facilities you’re considering.

Also, try to get a tour of the hospital or birth center so you can see for yourself if the staff is friendly and the atmosphere is one in which you’ll feel relaxed.

Before your labor pains start, get answers to these questions:

If Choosing a Hospital

• Is the hospital easy to get to?
• How is it equipped to handle emergencies?
• What level nursery is available? (Nurseries are rated I, II, or III — a level III neonatal intensive care unit [NICU] is equipped to handle any neonatal emergency. A lower rating may require transportation to a level III NICU.)
• How many deliveries take place at the hospital each year? (A higher number means the hospital has more experience with various birth scenarios.)
• What is the nurse-to-patient ratio? (A ratio of 1:2 is considered good during low-risk labor; a 1:1 ratio is best in complicated cases or during the pushing stage.)
• What are the hospital’s statistics for cesarean sections, episiotomies, and mortality? (Keep in mind, though, that these numbers include high-risk and complicated deliveries.)
• How many labor and support people may be present for the birth?
• What procedures are followed after your baby’s birth? Can you breastfeed immediately if desired? Is rooming in available?
• How long is the typical postpartum stay for vaginal deliveries? For C-sections?
• Can the baby and the father stay with you in your room around the clock, if you desire?

If Choosing a Birth Center

• Is the birth center accredited by the Commission for the Accreditation of Birth Centers?
• Is the birth center easy to get to?
• What situations during labor would lead to a transfer to a hospital? How are transfers handled? What emergencies are the transfer facilities able to handle?
• What professionals (such as midwives, doctors, and nurses) are available on staff? On a consulting basis? Are they licensed?
• What childbirth and prenatal education classes are offered?
• What are the center’s statistics for hospital transfers, episiotomies, and mortality?
• What procedures are followed after your baby’s birth? How long is the typical postpartum stay and how will your baby be examined?

It’s wise to choose where to deliver your baby as early in your pregnancy as possible. That way, if complications do arise, you’ll be well informed and can concentrate on your health and the health of your baby.

What is natural water birth?

A water birth means at least part of your labor, delivery, or both happen while you’re in a birth pool filled with warm water. Water birth can take place in a hospital, a birthing center, or at home. A doctor, nurse-midwife, or midwife helps you through it. If you have any further questions or require additional information please discuss the use of water during labor and/or birth with your midwife or doctor.

The prevalence of water birth in the United States is uncertain because it has not been studied in births outside of the home and birth centers, and the data are not recorded on birth certificates ³⁰. Several professional organizations, including the British Royal College of Obstetricians and Gynaecologists and the American College of Nurse–Midwives, support healthy women with uncomplicated pregnancies laboring and giving birth in water. The United Kingdom’s National Institute for Health and Care Excellence states that women should be informed that there is insufficient high-quality evidence to either support or discourage giving birth in water ³¹.

You and your baby must fit all of the following criteria to use a bath or pool for your labor and/or birth:

• Be healthy with no complications of pregnancy
• Be having only 1 baby who is presenting head first
• Be at least 37 weeks pregnant
• Not be a carrier of, or infected with, HIV, Hepatitis B or Hepatitis C virus
• Not be excessively overweight
• Not have broken your waters for longer than 18 – 24 hours (unless antibiotics have already been started)
• The color of your broken waters must remain clear
• Your baby’s heart rate must remain within the normal range
• You must not enter water until 4 hours after receiving an injection for pain relief.

Conditions for using water during your labor:

• You must never be alone while immersed in the water.
• The midwife or doctor will advise you about the best time to enter the water, which is when labor is becoming stronger.
• The bath or pool must be filled with only pure tap water with no additives such as:
  • bath oils
  • gels
  • soaps
  • salt.
• When sitting in the bath or pool the water should reach the level of your breasts.
• You should feel comfortably warm.
• You can leave the water at any time.
• You must leave the water to urinate.
• You should keep well hydrated throughout labor to avoid dehydration.
• You must leave the water when advised to do so by the midwife and/or doctor.
• You cannot have an injection for pain relief or an epidural when in the water, but it is possible to use gas if desired.

If you choose to birth in water:

• All the conditions for using water during labor must be met at all times.
• You must leave the water if the midwife or doctor is concerned about your wellbeing and safety.
• You must be assisted when you leave the water to avoid any injury to you or your baby.
• Your baby must be brought to the surface as soon as he/she is born and the head must then remain above the water at all times.
• The baby’s umbilical cord must not be cut under water.
• The baby must be kept warm after birth using skin-to-skin contact, drying the head and keeping the rest of the body under water.
• The baby must be removed from the water immediately if he/she needs help to breathe.
• You must leave the water for the delivery of the placenta after the baby is born unless you want to have a natural third stage.
• If you require stitches this procedure will be delayed for at least 1 hour after you leave the water.

Natural water birth key points:

• Water immersion in a bath or a pool during the first stage of labor has been shown to decrease the need for pain relieving drugs ³² and make the experience more enjoyable for women.
• There are strict guidelines for keeping the water clean during labor.
• Waterbirths are associated with low-risks for both the woman and baby when care is provided by midwives and/or doctors who follow best practice guidelines.
• You must never be alone while immersed in the water.

Exploring your choices:

• Firstly find out if your maternity service offers the option of immersion in water for labor and/or birth.
• Write down what you would like in your birth plan.
• Talk to a midwife and/or doctor to find out more information, in particular:
  • whether there are any reasons why immersion in water is not advisable for you – the benefits and risks to you and your baby
  • details about when you would be required to leave the water.
• You will be asked to sign an agreement form if you choose to use water for your labor and/or birth.

Common concerns about using water for labor and/or birth

• You and your baby may get too hot: If your body overheats your baby may also get too hot and this can cause the baby’s heart rate to increase. You should feel comfortable in the water but not too hot. Your midwife will check the water temperature regularly while you are in the water during labor and/or birth.
• Your baby may develop an infection: There are strict guidelines for keeping the water clean during your labor and for cleaning the bath or pool to minimize the possibility of infection.
• Your baby may inhale water: If you choose to stay in the water to birth, your baby should be born under the water, then gently but immediately lifted out into the air. Your baby’s head should then be kept above the water so that breathing can start and potential inhalation of water can be prevented.

American College of Obstetricians and Gynecologists Recommendations

The American College of Obstetricians and Gynecologists makes the following recommendations ³³:

• Immersion in water during the first stage of labor may be associated with shorter labor and decreased use of spinal and epidural analgesia and may be offered to healthy women with uncomplicated pregnancies between 37 weeks and 41 weeks of gestation.
• There are insufficient data on which to draw conclusions regarding the relative benefits and risks of immersion in water during the second stage of labor and delivery. Therefore, until such data are available, it is the recommendation of the College that birth occur on land, not in water.
• A woman who requests to give birth while submerged in water should be informed that the maternal and perinatal benefits and risks of this choice have not been studied sufficiently to either support or discourage her request. She also should be informed of the rare but serious neonatal complications associated with this choice.
• The opinions expressed in this document should not be interpreted in such a manner as to prevent the conduct of well-designed prospective studies of the maternal and perinatal benefits and risks associated with immersion during labor and delivery.
• Facilities that plan to offer immersion during labor and delivery need to establish rigorous protocols for candidate selection; maintenance and cleaning of tubs and pools; infection control procedures, including standard precautions and personal protective equipment for health care personnel; monitoring of women and fetuses at appropriate intervals while immersed; and moving women from tubs if urgent maternal or fetal concerns or complications develop.

What is Cesarean Section (C-Section)?

Every pregnant woman hopes for a short labor and delivery with no complications — manageable contractions, some pushing, then a beautiful baby.

But it doesn’t always work out that way. Some babies need to be delivered via cesarean section (C-section).

Even if you’re hoping for a traditional vaginal birth, it may help to ease some fears to learn why and how C-sections are performed, just in case everything doesn’t go as planned.

What Is a C-Section ?

A C-section is the surgical delivery of a baby that involves making incisions in the mother’s abdominal wall and uterus. Generally considered safe, C-sections do have more risks than vaginal births. Plus, moms can go home sooner and recover quicker after a vaginal delivery.

But C-sections can help women who are at risk for complications avoid dangerous delivery-room situations and can be a lifesaver in an emergency.

C-sections are done by obstetricians (doctors who care for pregnant women before, during, and after birth) and some family physicians. Although more and more women are choosing midwives to deliver their babies, midwives of any licensing degree cannot perform C-sections.

Why Are C-Sections Needed ?

Scheduled C-Sections

Some C-sections are scheduled if the doctor knows that a vaginal birth would be risky. A doctor may schedule one if:

• the baby is in breech (feet- or bottom-first) or transverse (sideways) position in the womb (although some babies can be turned before labor begins or delivered vaginally using special techniques)
• the baby has certain birth defects (such as severe hydrocephalus)
• the mother has problems with the placenta, such as placenta previa (when the placenta sits too low in the uterus and covers the cervix)

the mother has a medical condition that could make a vaginal delivery risky for herself or the baby (such as HIV or an active case of genital herpes)
some multiple pregnancies

• the mother previously had surgery on her uterus or an earlier C-section (although many such women can safely have a vaginal birth after a C-section, called a VBAC)

Emergency C-Sections

Some C-sections are unexpected emergency deliveries done when complications arise with the mother and/or baby during pregnancy or labor. An emergency C-section might be done if:

• labor stops or isn’t progressing as it should (and medicines aren’t helping)
• the placenta separates from the uterine wall too soon (called placental abruption)
• the umbilical cord becomes pinched (which could affect the baby’s oxygen supply) or enters the birth canal before the baby (called umbilical cord prolapse)
• the baby is in fetal distress — certain changes in the baby’s heart rate may mean that the baby is not getting enough oxygen
• the baby’s head or entire body is too big to fit through the birth canal

Of course, each woman’s pregnancy and delivery is different. If your doctor has recommended a C-section and it’s not an emergency, you can ask for a second opinion. In the end, you most often need to rely on the judgment of the doctors.

How Is a C-Section Done ?

Here’s a quick look at what usually happens during a scheduled C-section.

Your labor coach, wearing a surgical mask and gown, can be right by your side during the entire delivery (although partners might not be allowed to stay during emergency C-sections). Before the procedure begins, an anesthesiologist will discuss what will be done so that you don’t feel pain during the C-section.

To prepare for the delivery, you’ll probably have:

• various monitors in place to keep an eye on your heart rate, breathing, and blood pressure
• your mouth and nose covered with an oxygen mask or a tube placed in your nostrils to give you oxygen
• a catheter (a thin tube) inserted into your bladder through your urethra (which may be uncomfortable when it’s placed, but should not be painful)
• an IV in your arm or hand
• your belly washed and any hair between the bellybutton and pubic bone shaved
• a privacy screen put around your belly

After anesthesia is given, the doctor makes an incision on the skin of the abdomen — usually horizontally (1–2 inches above the pubic hairline, sometimes called “the bikini cut”).

The doctor then gently parts the abdominal muscles to get to the uterus, where he or she will make another incision in the uterus itself. This incision can be vertical or horizontal. Doctors usually use a horizontal incision in the uterus, also called transverse, which heals better and makes a VBAC much more possible.

After the uterine incision is made, the baby is gently pulled out. The doctor suctions the baby’s mouth and nose, then clamps and cuts the umbilical cord. As with a vaginal birth, you should be able to see your baby right away. Then, the little one is handed over to the nurse or doctor who will be taking care of your newborn for a few minutes (or longer, if there are concerns).

The obstetrician then removes the placenta from the uterus, closes the uterus with dissolvable stitches, and closes the abdominal incision with stitches or surgical staples that are usually removed, painlessly, a few days later.

If the baby is doing OK, you can hold and/or nurse your newborn in the recovery room. You may need help holding the baby on the breast if you have to stay lying down flat.

Will I Feel Anything ?

You won’t feel any pain during the C-section, although you may feel sensations like pulling and pressure. Most women are awake and simply numbed from the waist down using regional anesthesia (an epidural and/or a spinal block) during a C-section.

That way, they are awake to see and hear their baby being born. A curtain will be over your abdomen during the surgery, but you may be able to take a peek as your baby is being delivered from your belly.

Sometimes, a woman who needs an emergency C-section might require general anesthesia, so she’ll be unconscious (or “asleep”) during the delivery and won’t remember anything or feel any pain.

What Are the Risks of a C-section ?

C-sections today are, in general, safe for both mother and baby. However, there are risks with any kind of surgery. Potential C-section risks include:

• increased bleeding (that could, though rarely, require a blood transfusion)
• infection (antibiotics are usually given to help prevent this)
• bladder or bowel injury
• reactions to medicines
• blood clots
• death (very rare)
• possible injury to the baby

Some of the regional anesthetic used during a C-section does reach the baby, but it’s much less than what the newborn would get if the mother had general anesthesia (which sedates the baby as well as the mother).

Babies born by C-section sometimes have breathing problems (transient tachypnea of the newborn) because labor hasn’t jump-started the clearance of fluid from their lungs. This usually gets better on its own within the first day or two of life.

Having a C-section may — or may not — affect future pregnancies and deliveries. Many women can have a successful and safe vaginal birth after cesarean. But in some cases, future births may have to be C-sections, especially if the incision on the uterus was vertical rather than horizontal. A C-section can also put a woman at increased risk of possible problems with the placenta in future pregnancies.

• In the case of emergency C-sections, the benefits usually far outweigh the risks. A C-section could be lifesaving.

What Is the Recovery Like After a C-section ?

As with any surgery, there’s usually some degree of pain and discomfort after a C-section. The recovery period is also a little longer than for vaginal births. Women who’ve had C-sections usually stay in the hospital for about 3 or 4 days.

Right after, you may feel itchy, sick to your stomach, and sore — these are all normal reactions to the anesthesia and surgery. If you needed general anesthesia for an emergency C-section, you may feel groggy, confused, chilly, scared, alarmed, or even sad. Your health care provider can give you medicines to ease any discomfort or pain.

For the first few days and even weeks, you might:

• feel tired
• have soreness around the incision (the doctor can prescribe medicines and/or recommend over-the-counter pain relievers that are safe to take if you’re breastfeeding)
• be constipated and gassy
• have a hard time getting around and/or lifting your baby

It can help if you support your abdomen near the incision when you sneeze, cough, or laugh. These sudden movements can be painful. You’ll need to avoid driving or lifting anything heavy so that you don’t put any unnecessary pressure on your incision.

Check with your health care provider about when you can get back to your normal activities (typically after about 6 to 8 weeks, when the uterus has healed). As with a vaginal delivery, you shouldn’t have sex until your doctor has given you the go-ahead, usually about 6 weeks after delivery.

Frequent and early walking may help ease some post-cesarean pains and discomfort. It also can help prevent blood clots and keep your bowels moving. But don’t push yourself — take it easy and have someone help you get around, especially up and down stairs. Let friends, family, and neighbors lend a helping hand with meals and housework for a while, especially if you have other children.

Although breastfeeding might be a little painful at first, lying on your side to nurse or using the clutch (or football) hold can take the pressure off your abdomen. Drink plenty of water to help with your milk supply and to help avoid constipation.

C-sections scars fade over time. They’ll get smaller and become a natural skin color in the weeks and months after delivery. And because incisions are often made in the “bikini” area, many C-section scars aren’t even noticeable.

What If I Don’t Feel Better ?

See your health care provider if you have:

• a fever
• signs of infection around your incision (swelling, redness, warmth, or pus)
• pain around your incision or in your abdomen that comes on suddenly or gets worse
• foul-smelling vaginal discharge
• pain when peeing
• trouble pooping
• heavy vaginal bleeding
• leg pains, or swelling or redness of your legs
• trouble breathing or chest pain
• pain in one or both breasts
• feelings of depression
• thoughts of hurting yourself or your baby

Emotionally, you may feel a little disappointed if you’d been hoping for a vaginal birth or had gone through labor that ended in a C-section. Remember that having a C-section does not make the birth of your baby any less special or your efforts any less amazing. After all, you went through major surgery to deliver your baby!

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What is fallopian tube

The fallopian tubes (uterine tubes or oviducts) open near the ovaries (Figure 1 and 2). Each fallopian tube is about 10 centimeters long and 0.7 centimeters in diameter, the middle and longest part of the fallopian tube is the ampulla and the segment near the uterus is a narrower isthmus – which passes medially to the uterus, penetrates its wall and opens into the uterine cavity. Near each ovary, a fallopian tube expands, forming a funnel-shaped infundibulum, which partially encircles the ovary. Fingerlike extensions called fimbriae fringe the infundibulum margin. Although the infundibulum generally does not touch the ovary, one of the larger fimbriae connects directly to the ovary.

The fallopian tube is enclosed in the mesosalpinx, which is the superior margin of the broad ligament.

Simple columnar epithelial cells, some ciliated, line the fallopian tube. The epithelium secretes mucus, and the cilia beat toward the uterus. These actions help draw the secondary oocyte (an immature egg cell of the female ovary) and expelled follicular fluid into the infundibulum following ovulation. Ciliary action and peristaltic contractions of the fallopian tube’s smooth muscle layer aid transport of the oocyte down the uterine tube. Fertilization usually occurs in the fallopian tube.

Figure 1. Fallopian tube

Figure 2. Fallopian tube location

Fallopian tube function

The normal epithelium of the fallopian tube is comprised of two cell types: ciliated and secretory. The ciliated cells of the fallopian tube play a major role in the transport of the ovum, the sperm cells, and the zygote (a fertilized ovum). The human ovary usually releases one egg (oocyte) per month, around day 14 of a typical 28-day ovarian cycle. This egg is swept into the fallopian (uterine) tube by the beating of cilia on the fallopian tube’s epithelial cells and begins a 3-day trip down the fallopian tube toward the uterus. If the egg is not fertilized, it dies within 24 hours and gets no more than one-third of the way to the uterus. Therefore, if a sperm is to fertilize an egg, it must migrate up the fallopian tube to meet it. The vast majority of sperm never make it. Although a typical ejaculation may contain 200 million sperm, many of these are destroyed by vaginal acid or drain out of the vagina; others fail to get through the cervical canal into the uterus; still more are destroyed by leukocytes in the uterus; and half of the survivors of all these ordeals are likely to go up the wrong fallopian tube tube. Only  about 200 (1 in a million) reach the general vicinity of the egg.

The fallopian tube secretory cells secrete mucus that slows the progression of the spermatozoa through the fallopian tube, preserves their viability and facilitates their appropriate capacitation (functional maturation of the spermatozoon and is required to render them competent to fertilize an oocyte) and activation ¹.

Figure 3. Fallopian tube ciliated epithelium

Fallopian tube cyst

Fallopian tube cysts are the remnants of the congenital paramesonephric duct and are considered benign cysts ². The prevalence of fallopian tube or paraovarian cysts in a healthy population is 7%-10% regardless of age ³. In another study involving pediatric and adolescent population, the incidence of fallopian tube cysts was 7.3% in this pediatric and adolescent population ⁴. In addition, this is the first study to confirm presence of fallopian tube cysts in prepubertal females ⁴. Surgeon should be aware of these benign cysts because they are frequently a source of abdominal pain in young girls. As nonphysiologic cysts, these will not resolve spontaneously and may increase in size and/or be at risk for adnexal torsion. Most fallopian tube and paraovarian cysts are asymptomatic and accidentally discovered, but they may occasionally give rise to clinical problems due to enlargement or torsion. Ultimately, surgical management is required for definitive resolution.

In a study ⁵ of 338 young patients with a clinical picture of acute appendicitis, 44 had acute appendicitis plus a coincidental paratubal cyst, and 2 additional cases of torsion of huge paratubal cysts (13.6%) were detected. Only 2.5% were associated with ectopic tubal pregnancy, which was seen just distal to the site of the fallopian tube cysts. The exact implication of the presence of fallopian tube cyst in the causation of ectopic pregnancy is not clear ⁶, but it may be explained by disturbed tubal motility, compression of the already narrow tubal lumen, or defective vascularization of the fallopian tubes.

In another study involving 19 women, the authors found most of the patients (84%) had adnexal (uterus appendage) torsion at the time of diagnosis of fallopian tube cyst. Irregular menses and hirsutism was found in 52.6% of the patients, among whom 36.8% were obese ³. When the patients were compared on the basis of their body mass index, the size of fallopian tube cysts was significantly larger in the overweight/obese group. The author concluded by suggesting a possible correlation exists between obesity, fallopian tube cyst size, and hyperandrogenism ³.

When a fallopian tube cyst undergoes torsion, however, it is very difficult to diagnose by ultrasonography ⁷. When ultrasonographic diagnosis of these cysts is not always feasible, and surgeons usually use laparoscopy to diagnose the cyst. Your doctor will make a small opening in your belly and insert a special telescope or laparoscope to look at your uterus and fallopian tubes. Endocysticendoscopic visualization is a simple, valuable step prior to cystectomy. Bipolar coagulation or extraction of these cysts diagnosed at laparoscopy is easy, not time-consuming, and should be routinely performed in all cases following basic laparoscopic microsurgical principles.

The treatment of complicated fallopian tube cysts is excision, either by laparotomy or by laparoscopy ⁸. Although excision of silent fallopian tube cysts has not been recommended by some authors ⁹, prophylactic fallopian tube cyst excision is a common practice in the published literature to prevent possible complications ¹⁰, ⁸. These complications include hemorrhage, perforation, tubal-ovarian torsion, recurrence of torsion and ectopic pregnancy ¹¹. Furthermore, it has been
reported that paratubal cysts can transform into malignancies (2% to 3%) ¹², ¹³, ¹⁴. The high tubal-ovarian torsion rate caused by fallopian tube cycts of up to 45% in the literature ¹² suggests that prophylactic excision is beneficial before complications occur. Theefore due to the significant effect of fallopian tube cystectomy on tubal patency supports the concept of routine removal of any fallopian tube or paraovarian cyst discovered at laparoscopy. An additional value of removal of these cysts detected at laparoscopy is the exclusion of the rare possibility of malignancy (2% to 3%) and obtaining sufficient tissues for histopathologic evaluation.

Blocked fallopian tubes

Blocked fallopian tubes is usually caused by an old infection in the fallopian tubes, sometimes a sexually transmitted infection. Other causes include previous surgery (particularly surgeries on the tube), severe adhesions of your pelvis, endometriosis, or other sources of infection such as appendicitis ¹⁵.

Damage and blockage of the end portion of a fallopian tube can cause it to become filled with fluid; the swollen and fluid-filled tube is called a hydrosalpinx. A normal pregnancy in the uterus may not occur because the tube may be severely damaged and blocked and not work properly. A pregnancy may develop in the tube (ectopic pregnancy) which can be life-threatening. In addition, as the tube is blocked, secretions that collect in the tube may backflow into the uterus and prevent a pregnancy from implanting into the uterus.

What are the symptoms of blocked fallopian tubes ?

Most women do not have any symptoms other than fertility problems. In some women, an ectopic pregnancy may be the first sign of a problem with their tubes. Occasionally, some women may complain of regular or constant pain in their pelvis or lower belly, which may get worse during and after their period. A vaginal discharge can also be associated with this condition.

How is blocked fallopian tubes diagnosed ?

There are three ways to check if one or both of your tubes are blocked and if you have hydrosalpinx; one or more may be performed:

Hysterosalpingogram (HSG) (x-ray)

The doctor will inject a special liquid that shows up on an x-ray into your uterus through your cervix (neck of the womb) and then take an x-ray (called a hysterosalpingogram or HSG) to see where the liquid goes. If your fallopian tubes are open, the liquid will flow out of the ends of the tube into the pelvic cavity. If the tubes are blocked, the liquid will be trapped and your doctor will be able to tell that you have a hydrosalpinx. However, this test can sometimes falsely suggest that the tubes are blocked and sometimes results can be difficult to interpret.

Ultrasound

Your doctor may be able to detect the presence of a hydrosalpinx on ultrasound. If your tube appears enlarged on ultrasound, this usually indicates a more severe hydrosalpinx.

Surgery (laparoscopy)

Your doctor will make a small opening in your belly and insert a special telescope or laparoscope to look at your uterus and fallopian tubes. During this surgery, the doctor can look at your fallopian tubes to see if they are blocked. Usually the doctor inserts a dye through the cervix into the uterus and fallopian tubes to confirm that the dye passes through the ends of the tubes. For more information about laparoscopy, see the ASRM booklet titled Laparoscopy and Hysteroscopy.

If you have hydrosalpinx, can you still have a baby ?

If your fallopian tubes are completely blocked, an egg cannot travel through them to your womb. You will need to be treated by a fertility specialist to become pregnant. Your doctor may occasionally be able to open the tubes with surgery.

If there is too much damage to the tube(s), you will need treatment that does not involve the tubes to help you get pregnant, such as in vitro fertilization (IVF). In this procedure, your egg is joined (fertilized) with sperm in the laboratory. Then the doctor places the fertilized eggs (embryos) into your womb. Your doctor may recommend that your hydrosalpinx is removed or separated from the womb before you start IVF treatment, as the hydrosalpinx may lower your chance of pregnancy.

You have only one fallopian tube. Is it possible to get pregnant ?

You may still be able to get pregnant with only one fallopian tube if:

• You have at least one functioning ovary
• You have monthly menstrual cycles (ovulate)
• Your remaining fallopian tube is healthy

If you’re unable to get pregnant after a year of trying to conceive, see your gynecologist or a reproductive endocrinologist for evaluation.

Fallopian tube pregnancy

The uterus, or womb, is the place where a baby grows when a woman is pregnant. Pregnancy begins with a fertilized egg. Normally, the fertilized egg attaches itself to the lining of the uterus. If you have an ectopic pregnancy, the fertilized egg grows in the wrong place, outside the uterus, usually in the fallopian tubes –fallopian tube pregnancy. The result is usually a miscarriage ¹⁶.

An ectopic pregnancy occurs when a fertilized egg implants somewhere other than the main cavity of the uterus – in this case the fallopian tube.

An ectopic pregnancy most often occurs in one of the fallopian tubes that carry eggs from the ovaries to the uterus. This type of ectopic pregnancy is known as a tubal pregnancy. In some cases, however, an ectopic pregnancy occurs in the abdominal cavity, ovary or neck of the uterus (cervix).

To date, the incidence of ectopic pregnancy has increased from 0.5% in 1970 to an estimated 20 in every 1,000 pregnancies are ectopic ¹⁷. Approximately 98% of ectopic pregnancies occur in the fallopian tube ¹⁸.

An ectopic pregnancy can’t proceed normally. The fertilized egg can’t survive, and the growing tissue might destroy various maternal structures. Left untreated, life-threatening blood loss is possible ¹⁹.

Ectopic pregnancy can be a medical emergency if it ruptures, in fact, it is the leading cause of maternal death in early pregnancy ²⁰.

Signs of ectopic pregnancy include:

• Abdominal pain
• Shoulder pain
• Vaginal bleeding
• Feeling dizzy or faint

Early treatment of an ectopic pregnancy can help preserve the chance for future healthy pregnancies.

Symptoms of ectopic pregnancy

At first, an ectopic pregnancy might not cause any signs or symptoms. In other cases, early signs and symptoms of an ectopic pregnancy might be the same as those of any pregnancy — a missed period, breast tenderness and nausea.

If you take a pregnancy test, the result will be positive. Still, an ectopic pregnancy can’t continue as normal.

Light vaginal bleeding with abdominal or pelvic pain is often the first warning sign of an ectopic pregnancy. If blood leaks from the fallopian tube, it’s also possible to feel shoulder pain or an urge to have a bowel movement — depending on where the blood pools or which nerves are irritated. If the fallopian tube ruptures, heavy bleeding inside the abdomen is likely — followed by lightheadedness, fainting and shock.

Seek emergency medical help if you experience any signs or symptoms of an ectopic pregnancy, including:

• Severe abdominal or pelvic pain accompanied by vaginal bleeding
• Extreme lightheadedness or fainting
• Shoulder pain.

Causes of ectopic pregnancy

A fallopian tube pregnancy — the most common type of ectopic pregnancy — happens when a fertilized egg gets stuck on its way to the uterus, often because the fallopian tube is damaged by inflammation or is misshapen. Hormonal imbalances or abnormal development of the fertilized egg also might play a role.

Various factors are associated with ectopic pregnancy, including:

• Previous ectopic pregnancy. If you’ve had one ectopic pregnancy, you’re more likely to have another.
• Inflammation or infection. Inflammation of the fallopian tube (salpingitis) or an infection of the uterus, fallopian tubes or ovaries (pelvic inflammatory disease) increases the risk of ectopic pregnancy. Often, these infections are caused by gonorrhea or chlamydia.
• Fertility issues. Some research suggests an association between difficulties with fertility — as well as use of fertility drugs — and ectopic pregnancy.
• Structural concerns. An ectopic pregnancy is more likely if you have an unusually shaped fallopian tube or the fallopian tube was damaged, possibly during surgery. Even surgery to reconstruct the fallopian tube can increase the risk of ectopic pregnancy.
• Contraceptive choice. Pregnancy when using an intrauterine device (IUD) is rare. If pregnancy occurs, however, it’s more likely to be ectopic. The same goes for pregnancy after tubal ligation — a permanent method of birth control commonly known as “having your tubes tied.” Although pregnancy after tubal ligation is rare, if it happens, it’s more likely to be ectopic.
• Smoking. Cigarette smoking just before you get pregnant can increase the risk of an ectopic pregnancy. And the more you smoke, the greater the risk.

Complications of ectopic pregnancy

When you have an ectopic pregnancy, the stakes are high. Without treatment, a ruptured fallopian tube could lead to life-threatening bleeding.

Seek emergency medical help if you develop any signs or symptoms of an ectopic pregnancy, including:

• Severe abdominal or pelvic pain accompanied by vaginal bleeding
• Extreme lightheadedness or fainting

If you have possible signs or symptoms of an ectopic pregnancy — such as light vaginal bleeding or abdominal pain — see your doctor. He or she might recommend an office visit or immediate medical care.

How is ectopic pregnancy diagnosed ?

If your doctor suspects an ectopic pregnancy, he or she might do a pelvic exam to check for pain, tenderness, or a mass in the fallopian tube or ovary. A physical exam alone usually isn’t enough to diagnose an ectopic pregnancy, however. The diagnosis is typically confirmed with blood tests and imaging studies, such as an ultrasound.

With a standard ultrasound, high-frequency sound waves are directed at the tissues in the abdominal area. During early pregnancy, however, the uterus and fallopian tubes are closer to the vagina than to the abdominal surface. The ultrasound will likely be done using a wandlike device placed in your vagina (transvaginal ultrasound).

Sometimes it’s too soon to detect a pregnancy through ultrasound. If the diagnosis is in question, your doctor might monitor your condition with blood tests until the ectopic pregnancy can be confirmed or ruled out through ultrasound — usually by four to five weeks after conception.

In an emergency situation — if you’re bleeding heavily, for example — an ectopic pregnancy might be diagnosed and treated surgically.

How is ectopic pregnancy treated

A fertilized egg can’t develop normally outside the uterus.

• To prevent life-threatening complications, the ectopic tissue needs to be removed.

If the ectopic pregnancy is detected early, an injection of the drug methotrexate is sometimes used to stop cell growth and dissolve existing cells. It’s imperative that the diagnosis of ectopic pregnancy is certain before this treatment is undertaken.

After the injection, your doctor will monitor your blood for the pregnancy hormone human chorionic gonadotropin (HCG). If the HCG level remains high, you might need another injection of methotrexate.

In other cases, ectopic pregnancy is usually treated with laparoscopic surgery. In this procedure, a small incision is made in the abdomen, near or in the navel. Then your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the area.

Other instruments can be inserted into the tube or through other small incisions to remove the ectopic tissue and repair the fallopian tube. If the fallopian tube is significantly damaged, it might need to be removed.

If the ectopic pregnancy is causing heavy bleeding or the fallopian tube has ruptured, you might need emergency surgery through an abdominal incision (laparotomy). In some cases, the fallopian tube can be repaired. Typically, however, a ruptured tube must be removed.

Your doctor will monitor your HCG levels after surgery to be sure all of the ectopic tissue was removed. If HCG levels don’t come down quickly, an injection of methotrexate may be needed.

Prevention of ectopic pregnancy

You can’t prevent an ectopic pregnancy, but you can decrease certain risk factors. For example, limit your number of sexual partners and use a condom when you have sex to help prevent sexually transmitted infections and reduce the risk of pelvic inflammatory disease. Quitting smoking before you attempt to get pregnant may also reduce your risk.

Fallopian tube removal

The surgical removal of the fallopian tube, also called salpingectomy is largely used in case of fallopian tube pregnancy (ectopic pregnancy) and hydrosalpinx in infertile women scheduled for assisted reproductive technologies. Salpingectomy was the standard procedure for ectopic pregnancy ²¹ until 1978, when laparoscopic salpingotomy was first reported by Bruhat et al. ²².

In clinical practice for ectopic pregnancy, the choice of salpingotomy versus salpingectomy depends on many factors, including patient age, tube condition, serum human chorionic gonadotropin (hCG) levels, and patient’s future fertility desire. The decision of whether to preserve or remove the tube when treating women with tubal pregnancy has been debated for many years, and controversy remains. Previous trials have resulted in different conclusions ²³, ²⁴, ²⁵, ²⁶. Whether salpingotomy improves postoperative fertility outcomes compared with salpingectomy remains unclear.

The results of the randomized clinical trials showed that preservation of the tube via salpingotomy did not provide improved fertility ²⁷. This lack of an effect is largely because the transport function of the tube is damaged by the mechanical damage, and the tube is burned by bipolar electric coagulation during the course of the operation. Although the anatomical structure of the tube is preserved, the preserved tube might not be available. In addition, as a result of the operation-induced wound, secretion of cytokines, prostaglandin and leukocyte chemotactic factors by the tubal tissues would exert a negative effect on the reflux in the capillaries and lymphatic system, leading to postoperative tubal adhesion and hydrosalpinx. Consequently, future pregnancies would be affected.

Salpingectomy might decease the ovarian function ²⁸. Most recent studies on this subject have focused only on fertility outcomes after surgery. Furthermore, the effects of salpingectomy on ovarian function have not been taken into account. The blood supply of the ovary originates from both the ovarian artery and the ovarian branch of the uterine artery. These branches of arteries anastomose into nets in the mesosalpinx. Blood circulation is easily damaged during salpingectomy, and the destruction of the ovarian blood supply can lead to ovarian dysfunction ²⁹; however, no information was provided regarding the effect that the two procedures have on ovarian function. The effects of salpingectomy on ovarian function should also be considered when determining the surgical regimen.

One disadvantage of salpingotomy is the increased risk of persistent ectopic pregnancies. A previous study indicated that persistent ectopic pregnancies after salpingotomy occurred in 5% to 20% of cases via laparoscopic surgery and 3% to 5% of cases via laparotomy ³⁰.

According to the recent meta analysis and systematic review, the authors believe that for patients with a healthy contralateral tube operated for tubal pregnancy, the subsequent fertility after salpingectomy and salpingotomy are similar in the long term ²⁷. However, additional multi-center, high quality randomzied  clinical trials with large samples are required for further verification. As for the case where both fallopian tubes are blocked with or without hydrosalpinx, further trials aimed at confirming both the positive effects of tubal surgery before assisted reproductive technologies (IVF) and the safety of bilateral salpingectomy are necessary to definitively state when and why unilateral rather than bilateral salpingectomy are recommended ³¹. This 2010 Cochrane review now provides evidence that laparoscopic tubal occlusion is an alternative to laparoscopic salpingectomy in improving IVF pregnancy rates in women with hydrosalpinges ³².

What is fallopian tube pain ?

Pain in the fallopian tube area (fallopian tube pain) is commonly called pelvic pain – which is pain in the lowest part of your abdomen and pelvis ³³.

Fallopian tube pain is a general term used to describe pain that occurs mostly or only in the region below a woman’s belly button. This region includes the lower stomach, lower back, buttocks, and genital area ³⁴.

Fallopian tube pain is chronic if it lasts for more than 6 months and affects a woman’s quality of life ³⁵. This condition is a common reason why women seek medical care ³⁶.

There are many possible causes of pelvic pain, and it may be difficult to figure out the specific cause or causes ³⁴. A woman’s pelvic pain may result from multiple causes occurring all at the same time. In many cases, pelvic pain indicates a problem with one or more of the organs in the pelvic area, such as the uterus, vagina, intestine, bladder or from musculoskeletal sources. Problems may include infection, inflammation, or conditions such as endometriosis. And a woman with one chronic pain condition is at increased risk for other types of chronic pain.

The intensity of a woman’s pelvic pain may not relate to the severity of the problem or condition causing the pain ³⁷. For example, a woman with only small areas of endometriosis may experience intense pain.

How many women have pelvic pain ?

Researchers are not sure exactly how many women in the United States have chronic pelvic pain.

Because it is often linked to other disorders, such as endometriosis or vulvodynia, chronic pelvic pain may be misdiagnosed as another condition, making it difficult to estimate reliable prevalence rates for pelvic pain ³⁸. According to one study, about 15% of women of childbearing age in the United States reported having pelvic pain that lasted at least 6 months ³⁹. Worldwide, the rates of chronic pelvic pain for women of childbearing age range from 14% to 32% ³⁹. Between 13% and 32% of these women have pain that is severe enough to cause them to miss work ⁴⁰.

How Do Doctors Narrow the Diagnosis to Focus on Important Common Conditions of Fallopian Tube Pain ?

Doctors usually categorize female patients presenting with uterus pain (acute pelvic pain) according to age (e.g., is she in her reproductive years or postmenopausal ?). If the patient is of reproductive age, possible diagnoses are next categorized by whether she is pregnant or attempting pregnancy.

Non-pregnant Reproductive Aged-Women

The typical diagnoses made in nonpregnant reproductive-aged women who present with acute pelvic pain include the following (from most to least common) ⁴¹, ⁴²:

1. Idiopathic (unknown cause or origin) pelvic pain,
2. Pelvic inflammatory disease.  Pelvic inflammatory disease is an infection and inflammation of the uterus, ovaries, and other female reproductive organs. It is usually caused by sexually transmitted infections e.g. gonorrhea and chlamydia
3. Acute appendicitis,
4. Conditions related to ovarian cysts, and
5. Endometriosis.

Other less common causes of acute pelvic pain in this population are listed in Table 1 below.

Table 1. Conditions Causing Acute Pelvic Pain in Different Populations

Figure 4. An algorithm for using physical examination findings to evaluate selected common causes of pelvic pain in non-pregnant women

Note: McBurney’s point = is the name given to the point over the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus (navel), this point roughly corresponds to the most common location of the base of the appendix where it is attached to the cecum, deep tenderness at McBurney’s point, known as McBurney’s sign, is a sign of acute appendicitis; Rovsing sign = is a sign of appendicitis, if palpation of the left lower quadrant of a person’s abdomen increases the pain felt in the right lower quadrant, the patient is said to have a positive Rovsing’s sign and may have appendicitis; Positive Carnett’s sign = is a finding on clinical examination in which (acute) abdominal pain remains unchanged or increases when the muscles of the abdominal wall are tensed. A positive test increases the likelihood that the abdominal wall and not the abdominal cavity is the source of the pain (for example, due to rectus sheath hematoma instead of appendicitis).

Reproductive-aged women who are pregnant or attempting pregnancy

Women who are pregnant or attempting pregnancy through fertility treatments have other common causes of acute pelvic pain (Table 1). For pregnant women, the clinical scenario narrows the list of possible causes, but it is critical to detect serious or life-threatening conditions, such as ectopic pregnancy in the early weeks of pregnancy and placental abruption in the later stages of pregnancy. Nongynecologic conditions, such as appendicitis, can also occur during pregnancy.

Women undergoing infertility treatments through ovarian stimulation or in vitro fertilization have unique risks, such as ovarian hyperstimulation syndrome (i.e., ovarian enlargement with multiple ovarian cysts and leakage of fluid from the ovary into the abdominal/pelvic space), ovarian torsion, and heterotopic pregnancy (i.e., simultaneous ectopic and intrauterine pregnancy) ⁴⁴.

Postmenopausal women

Cancer must be primarily considered in a postmenopausal woman with acute pelvic pain. Other rare causes are postmenopausal endometriosis ⁴⁵ and, on occasion, a retained intrauterine device that the patient had forgotten to remove ⁴⁶.

Which History and Physical Examination Findings Are Most Helpful in Evaluating Acute Pelvic Pain ?

Several findings in the patient’s history can help guide laboratory testing and imaging to confirm a suspected diagnosis (Table 2). Relevant historical features include whether the patient is sexually active (e.g., pain related to a complication of pregnancy), specific symptoms (e.g., description of the pain; changes in menstrual pattern; the presence of vaginal discharge, dysuria, hematuria, or nausea), and whether she has had intra-uterine instrumentation or pelvic surgery. A recent study reported rare occurrences of pelvic inflammatory disease in women who denied ever having sexual intercourse, illustrating the need for a high index of suspicion for this condition ⁴⁷.

Table 2. History and Physical Examination Findings Are Most Helpful in Evaluating Acute Pelvic Pain

Fallopian tube cancer

Fallopian tube cancer is a disease in which malignant (cancer) cells form in the tissue covering the lining the fallopian tube ⁴⁸.

The fallopian tubes are a pair of long, slender tubes, one on each side of the uterus. Eggs pass from the ovaries, through the fallopian tubes, to the uterus. Cancer sometimes begins at the end of the fallopian tube near the ovary and spreads to the ovary.

Fallopian tube cancer, ovarian epithelial cancer and primary peritoneal cancer form in the same type of tissue and are treated the same way ⁴⁸. The hypothesis that many high-grade serous ovarian cancers (the most common histologic subtype) may arise from precursor lesions that originate in the fimbriae of the fallopian tubes has been supported by findings from risk-reducing surgeries in healthy women with BRCA1 or BRCA2 mutations ⁴⁹. In addition, histologically similar cancers diagnosed as primary peritoneal carcinomas share molecular findings, such as loss or inactivation of the tumor-suppressor p53 and BRCA1 or BRCA2 proteins ⁵⁰. Therefore, high-grade serous adenocarcinomas arising from the fallopian tube and elsewhere in the peritoneal cavity, together with most ovarian epithelial cancers, represent extrauterine adenocarcinomas of Müllerian epithelial origin and are staged and treated similarly to ovarian cancer ⁴⁸. Regardless of the site of origin, the hallmark of these cancers is their early peritoneal spread of metastases. Since 2000, fallopian tube cancer and primary peritoneal cancer have usually been included in ovarian cancer clinical trials ⁵¹.

Clear cell and endometrioid ovarian cancers that are linked to endometriosis have different gene-expression signatures, as do mucinous subtypes ⁵⁰.

Stromal and germ cell tumors are relatively uncommon and comprise fewer than 10% of cases.

Incidence and Mortality

Epithelial carcinoma of the ovary is one of the most common gynecologic malignancies, with 50% of all cases occurring in women older than 65 years. It is the fifth most frequent cause of cancer death in women ⁵².

Estimated new cases and deaths from ovarian cancer in the United States in 2017 ⁵³:

• New cases: 22,440.
• Deaths: 14,080.

Risk Factors

Family history and genetic alterations

Women who have a family history of ovarian cancer are at an increased risk of ovarian cancer.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. Talk with your doctor if you think you may be at risk.

The most important risk factor for ovarian cancer is a history of ovarian cancer in a first-degree relative (mother, daughter, or sister). This risk is higher in women who have one first-degree relative and one second-degree relative (grandmother or aunt) with a history of ovarian cancer. This risk is even higher in women who have two or more first-degree relatives with a history of ovarian cancer. Approximately 20% of ovarian cancers are familial, and although most of these are linked to mutations in either the BRCA1 or BRCA2 gene, several other genes have been implicated ⁵⁴. The risk is highest in women who have two or more first-degree relatives with ovarian cancer ⁵⁵. The risk is somewhat less for women who have one first-degree relative and one second-degree relative (grandmother or aunt) with ovarian cancer.

Some ovarian, fallopian tube, and primary peritoneal cancers are caused by inherited gene mutations (changes).

The genes in cells carry the hereditary information that is received from a person’s parents. Hereditary ovarian cancer makes up about 20% of all cases of ovarian cancer. There are three hereditary patterns: ovarian cancer alone, ovarian and breast cancers, and ovarian and colon cancers.

In most families affected with breast and ovarian cancer syndrome or site-specific ovarian cancer, genetic linkage to the BRCA1 locus on chromosome 17q21 has been identified ⁵⁶. BRCA2, also responsible for some instances of inherited ovarian and breast cancer, has been mapped by genetic linkage to chromosome 13q12 ⁵⁷.

The lifetime risk for developing ovarian cancer in patients harboring germline mutations in BRCA1 is substantially increased over that of the general population ⁵⁸. Two retrospective studies of patients with germline mutations in BRCA1 suggest that the women in these studies have improved survival compared with BRCA1 mutation–negative women ⁵⁹. Most women with a BRCA1 mutation probably have family members with a history of ovarian and/or breast cancer; therefore, the women in these studies may have been more vigilant and inclined to participate in cancer screening programs that may have led to earlier detection.

For women at increased risk, prophylactic oophorectomy may be considered after age 35 years if childbearing is complete. In a family-based study among 551 women with BRCA1 or BRCA2 mutations, of the 259 women who had undergone bilateral prophylactic oophorectomy, 2 (0.8%) developed subsequent papillary serous peritoneal carcinoma, and 6 (2.8%) had stage I ovarian cancer at the time of surgery. Of the 292 matched controls, 20% who did not have prophylactic surgery developed ovarian cancer. Prophylactic surgery was associated with a reduction in the risk of ovarian cancer that exceeded 90% (relative risk, 0.04; 95% confidence interval, 0.01–0.16), with an average follow-up of 9 years ⁶⁰; however, family-based studies may be associated with biases resulting from case selection and other factors that influence the estimate of benefit. After a prophylactic oophorectomy, a small percentage of women may develop a primary peritoneal carcinoma that is similar in appearance to ovarian cancer ⁶¹.

There are tests that can detect gene mutations. These genetic tests are sometimes done for members of families with a high risk of cancer. Women with an increased risk of ovarian cancer may consider surgery to lessen the risk.

Some women who have an increased risk of ovarian cancer may choose to have a risk-reducing oophorectomy (the removal of healthy ovaries so that cancer cannot grow in them). In high-risk women, this procedure has been shown to greatly decrease the risk of ovarian cancer.

Signs and symptoms of ovarian, fallopian tube, or peritoneal cancer

Signs and symptoms of ovarian, fallopian tube, or peritoneal cancer include pain or swelling in the abdomen.

Ovarian, fallopian tube, or peritoneal cancer may not cause early signs or symptoms. When signs or symptoms do appear, the cancer is often advanced. Signs and symptoms may include the following:

• Pain, swelling, or a feeling of pressure in the abdomen or pelvis.
• Vaginal bleeding that is heavy or irregular, especially after menopause.
• Vaginal discharge that is clear, white, or colored with blood.
• A lump in the pelvic area.
• Gastrointestinal problems, such as gas, bloating, or constipation.

These signs and symptoms also may be caused by other conditions and not by ovarian, fallopian tube, or peritoneal cancer. If the signs or symptoms get worse or do not go away on their own, check with your doctor so that any problem can be diagnosed and treated as early as possible.

How is fallopian tube, ovarian and peritoneal cancer diagnosed

Tests that examine the ovaries and pelvic area are used to detect (find) and diagnose ovarian, fallopian tube, and peritoneal cancer.

The following tests and procedures may be used:

• Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Pelvic exam : An exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. A speculum is inserted into the vagina and the doctor or nurse looks at the vagina and cervix for signs of disease. A Pap test of the cervix is usually done. The doctor or nurse also inserts one or two lubricated, gloved fingers of one hand into the vagina and places the other hand over the lower abdomen to feel the size, shape, and position of the uterus and ovaries. The doctor or nurse also inserts a lubricated, gloved finger into the rectum to feel for lumps or abnormal areas.
• CA-125 assay.
• Ultrasound exam (pelvic or transvaginal).
• Computed tomography (CT) scan.
• Positron emission tomography (PET) scan.
• Magnetic resonance imaging (MRI).
• Chest x-ray.
• Biopsy.

CA-125 levels can be elevated in other malignancies and benign gynecologic problems such as endometriosis. CA-125 levels and histology are used to diagnose epithelial ovarian cancer ⁶².

Prognostic Factors

Prognosis for patients with ovarian cancer is influenced by multiple factors. Multivariate analyses suggest that the most important favorable prognostic factors include the following ⁶³:

• Younger age.
• Good performance status.
• Cell type other than mucinous or clear cell.
• Well-differentiated tumor.
• Early-stage disease.
• Absence of ascites.
• Lower disease volume before surgical debulking.
• Smaller residual tumor after primary cytoreductive surgery.
• BRCA1 or BRCA2 mutation carrier.

For patients with stage I disease, the most important prognostic factor associated with relapse is grade, followed by dense adherence and large-volume ascites ⁶⁴. Stage I tumors have a high proportion of low-grade serous cancers. These cancers have a derivation distinctly different from that of high-grade serous cancers, which usually present in stages III and IV. Many high-grade serous cancers originate in the fallopian tube and other areas of extrauterine Müllerian epithelial origin.

If the tumor is grade III, densely adherent, or stage IC, the chance of relapse and death from ovarian cancer is as much as 30% ⁶⁵.

The use of DNA flow cytometric analysis of tumors from stage I and stage IIA patients may identify a group of high-risk patients ⁶⁶. Patients with clear cell histology appear to have a worse prognosis ⁶⁷. Patients with a significant component of transitional cell carcinoma appear to have a better prognosis ⁶⁸.

Case-control studies suggest that BRCA1 and BRCA2 mutation carriers have improved responses to chemotherapy when compared with patients with sporadic epithelial ovarian cancer. This may be the result of a deficient homologous DNA repair mechanism in these tumors, which leads to increased sensitivity to chemotherapy agents ⁶⁹.

Figure 4. Fallopian tube cancer

Fallopian tube cancer prevention

Should prophylactic surgery be limited to the fallopian tubes or can one or both ovaries be spared in BRCA mutations carriers ?

Several germ-line mutations and copy number variations that harbor increased risk for high-grade serous ovarian carcinomas have been reported, BRCA1 and BRCA2 being the most prevalent ones, accounting for 5% to 10% of the cases with up to 54% lifetime risk ⁷⁰. Women recognized to have BRCA mutations are currently treated with risk-reducing (prophylactic) excision of the adnexa (bilateral salpingo-oophorectomy). This practice, which targets healthy women, has provided most of the emerging data in the study of early serous carcinomas. Currently there is no data to support or reject such a practice ⁷¹. Removing the fallopian tubes with surgery carries an obvious decrease in early menopause–related morbidity and an improvement in quality of life, including preservation of fertility, but evidence supporting this approach is still limited in terms of the number of prospectively accrued cases.

Is there hope for early detection of intraepithelial carcinomas as one strategy to reduce serous cancer mortality ?

One might expect that the practice of more complete fallopian tube examination will uncover more early serous carcinomas and provide more information as to their prognosis. Whether such tumors can be identified by noninvasive (serologic) assays or imaging will not be known until such techniques are developed. Of the few cases of stage 0 (intraepithelial) fallopian tube serous cancers diagnosed prospectively in BRCA-positive women, no recurrences have been documented. However, higher stage fallopian tube cancer is associated with relatively poor prognosis despite adjuvant therapy.107,108 Larger studies devoted to detailed examination of the distal fallopian tube will expand the database of stage 0 fallopian tube serous cancer cases and provide greater insight into the potential value of early detection, the prognosis, and the appropriateness of postoperative therapy in these cases.

Is fimbriectomy a viable alternative to tubal ligation that will significantly reduce serous cancer risk ?

The current data indicates that a significant percentage of serous carcinomas arise from a precursor condition in the distal fallopian tube. It is reasonable to expect that sterilization practices that targeted the fimbria would maximize the protective effect of tubal sterilization on serous cancer prevention. However, the value of such a practice must be evaluated in the context of the safety and feasibility of fimbriectomy and the fact that such a strategy precludes so-called tubal reversal procedures in the future for the patient. Nevertheless, barring the emergence of a successful chemopreventive or early detection algorithm, removing fimbrial tissue is the most obvious, albeit yet unproven, surgical approach to pelvic serous cancer prevention.

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What is a cervix

The cervix is part of the lower end of the uterus. The cervix is the opening in the lower part of the uterus (womb) that opens to the top of the vagina (birth canal). The lumen (internal cavity) of the uterus communicates with the vagina by way of a narrow passage through the cervix called the cervical canal.

During pregnancy, the cervix stays firm and closed until late in the third trimester. It opens, shortens and gets thinner and softer so your baby can pass through the birth canal during labor and birth. In some women, the cervix opens too early during pregnancy or is shorter than normal. These conditions can cause problems during pregnancy.

Cervix function

The cervical canal contains cervical glands that secrete mucus, thought to prevent the spread of microorganisms from the vagina into the uterus. Near the time of ovulation, the mucus becomes thinner than usual and allows easier passage for sperm.

The cervix has two different parts and is covered with two different types of cells.

1. The part of the cervix closest to the body of the uterus is called the endocervix and is covered with glandular cells.
2. The part next to the vagina is the exocervix (or ectocervix) and is covered in squamous cells.

These two cell types meet at a place called the transformation zone. The exact location of the transformation zone changes as you get older and if you give birth.

The cervix and superior part of the vagina are supported by cardinal (lateral cervical) ligaments extending to the pelvic wall.

Figure 1. Cervix position

Figure 2. Cervix location

What is short cervix ?

The cervix is the opening to the uterus (womb) that sits at the top of the vagina (birth canal). It opens, shortens and gets thinner and softer so your baby can pass through the birth canal during labor and birth.

In some women, the cervix opens too early during pregnancy or is shorter than normal. These conditions can cause problems during pregnancy.

A short cervix means the length of your cervix (also called cervical length) is shorter than normal. You may find out that you have a short cervix during an ultrasound that you get as part of your regular prenatal care. Prenatal care is medical care you get during pregnancy.

Checking for a short cervix is not a routine prenatal test. Your healthcare provider probably doesn’t check your cervical length unless:

• She has a reason to think it may be short.
• You have signs of preterm labor. This is labor that begins too soon, before 37 weeks of pregnancy.
• You have risk factors for premature birth, like you had a premature birth in the past or you have a family history of premature birth (premature birth runs in your family).

If your healthcare provider thinks you have a short cervix, she may check you regularly with ultrasound.

If you have a short cervix, you have a 1-in-2 chance (50 percent) of having a premature birth ¹. If you have a short cervix and you’re pregnant with just one baby, your health care provider may recommend these treatments to help you stay pregnant longer:

• Cerclage: cervical cerclage is a procedure in which stitches are used to close the cervix during pregnancy to help prevent pregnancy loss or premature birth.
• Vaginal progesterone. Progesterone is a hormone that helps prepare your body for pregnancy. It may help prevent premature birth only if you have a short cervix and you’re pregnant with just one baby. You insert it in your vagina every day starting before or up to 24 weeks of pregnancy, and you stop taking it just before 37 weeks.

Many things can affect the length of your cervix, including:

• Having an overdistended (stretched or enlarged) uterus
• Problems caused by bleeding during pregnancy or inflammation (irritation) of the uterus
• Infection
• Cervical insufficiency

Figure 3. Short cervix

What is incompetent cervix ?

When you are told that you have an incompetent cervix, it simply means that your cervix begins to open up (dilates) too early during pregnancy, when you are between four and six weeks of your pregnancy. In case you do not know, the cervix mostly remains closed during the 9 months of pregnancy. An incompetent cervix can be thin and widen without any contractions or pain. This causes the amniotic fluid sac to bulge downwards into the cervix opening until it breaks. This leads to premature delivery or miscarriage. Contractions are when the muscles of your uterus get tight and then relax. They help push your baby out of your uterus during labor and birth.

Incompetent cervix can cause premature birth and miscarriage. Premature birth is when your baby is born too early, before 37 weeks of pregnancy. Miscarriage is when a baby dies in the womb before 20 weeks of pregnancy.

An incompetent or weakened cervix happens in about 1-2% of pregnancies. Almost 25% of babies miscarried in the second trimester are due to incompetent cervix.

Doctors don’t always know why incompetent cervix happens. You’re more likely than other women to have it if:

• You have defects in your uterus, like if it’s split into two sections.
• You’re pregnant with more than 1 baby like twins or triplets
• You’ve had surgery on your cervix.
• You have a short cervix. The shorter the cervix, the more likely you are to have cervical insufficiency.
• You’ve had injuries to your uterus that happened during a previous birth.

Cervical insufficiency risk factors

No one knows for sure what causes ancervical insufficiency, but these things may increase a woman’s risk:

• Being pregnant with more than 1 baby (twins, triplets)
• Having a cervical insufficiency in an earlier pregnancy
• Having a torn cervix from an earlier birth
• Having past miscarriages by the 4th month
• Having past first or second semester abortions
• Having a cervix that did not develop normally
• Having a cone biopsy or loop electrosurgical excision procedure (LEEP) on the cervix in the past due to an abnormal Pap smear

What Are the Symptoms of an Incompetent Cervix ?

If your have an incompetent cervix, you may not develop any symptoms or signs early on in pregnancy. Your cervix simply begins to open before 9 months are over without pain or contractions. Some women may feel very mild discomfort or spotting for a few days, but this is only possible if you are between 14 to 20 weeks of pregnancy. However, look out for the following signs and symptoms, because they may indicate you’ve got an incompetent cervix ²:

• A feeling of pelvic pressure
• A new backache
• Mild cramps in your belly (abdomen)
• A change in vaginal discharge which changes from clear to pink
• Light vaginal bleeding or spotting

If your health care provider thinks you may have cervical insufficiency, she may check you regularly during pregnancy with transvaginal ultrasound starting at 16 to 20 weeks of pregnancy. Transvaginal ultrasound is an ultrasound in the vagina, not on the outside of your belly. An ultrasound is a prenatal test that uses sound waves and a computer screen to show a picture of your baby in the womb.

How is an Incompetent Cervix Diagnosed ?

Often, you will not have any signs or symptoms of cervical insufficiency unless you have a problem it might cause. That is how many women first find out about it. Cervical incompetence is primarily a clinical diagnosis characterized by recurrent painless dilatation and spontaneous midtrimester birth, usually of a living fetus. The presence of risk factors for structural cervical weakness supports the diagnosis. The challenges in making the diagnosis are that relevant findings in prior pregnancy are often not well-documented and only a subjective assessment.

The diagnosis of cervical insufficiency is challenging because of the lack of objective findings and clear diagnostic criteria. Cervical ultrasound has emerged as a proven, clinically useful screening and diagnostic tool in the selected population of high-risk women based on an obstetrical history of a prior (early) spontaneous preterm birth. The transvaginal ultrasound typically shows a short cervical length, less than or equal to 25 mm, or funneling, ballooning of the membranes into a dilated internal os but with the closed external os.

The diagnosis of incompetent cervix is usually made in three different settings:

1. Women who present with a sudden onset of symptoms and signs of cervical insufficiency
2. Women who present with a history of second-trimester losses consistent with the diagnosis of cervical incompetence (history-based)
3. Women with endovaginal ultrasound findings consistent with cervical incompetence (ultrasound diagnosis)

The digital or speculum examination reveals a cervix that is dilated 2 cm or more, effacement greater than or equal to 80%, and the bag of waters visible through the external orifice or protruding into the vagina. The diagnosis is frequently made on the basis of history retrospectively after multiple poor obstetrical outcomes have occurred ³.

If you have any of the risk factors for cervical incompetence:

• Your health care provider may do a transvaginal ultrasound to look at your cervix when you are planning a pregnancy, or early in your pregnancy.
• You may have physical exam and ultrasounds more often during your pregnancy.

A cervical insufficiency may cause these symptoms in the 2nd trimester:

• Abnormal vaginal spotting or bleeding
• Increasing pressure or cramps in the lower abdomen and pelvis

What Are the Risk Factors for Incompetent Cervix ?

You are at a higher risk of having this condition if:

• You have had a 2nd trimester miscarriage without known cause or if you have had an early spontaneous preterm delivery which was not caused by a placenta abruption or preterm labor.
• You have undergone a procedure like loop electrosurgical excision procedure (LEEP) or a cone biopsy on your cervix.
• Your mother used DES drugs while pregnant with you. This is a drug that was prescribed to expectant mothers to prevent miscarriage. Later it was found to be ineffective and it caused abnormalities in the reproductive tract of the fetus.
• You underwent a previous dilation and curettage or birth where your cervix was damaged or you have terminated several pregnancies.
• Your cervix is unusually shorter.
• You have undergone cervical insufficiency in previous pregnancies.

How Can an Incompetent Cervix Be Treated ?

If your health care provider thinks you may have cervical insufficiency, she may check you regularly during pregnancy with transvaginal ultrasound starting at 16 to 20 weeks of pregnancy. Transvaginal ultrasound is an ultrasound in the vagina, not on the outside of your belly. An ultrasound is a prenatal test that uses sound waves and a computer screen to show a picture of your baby in the womb.

Medication

Progesterone supplementation can be recommended if you have had a history of premature births. Your doctor will recommend weekly shots of progesterone hormone on your 2nd trimester. However, further research is required to prove that progesterone can help women with the risk of cervix incompetence.

Cerclage is also recommended as a form of treatment. This is especially if you suffered preterm labor when you were between sixteen and thirty four weeks of pregnancy. This procedure can be done on an outpatient basis. You’re required to relax after the treatment.

Steroids are also prescribed together with other drugs to prevent preterm labor. However, this can only be done after the 24 weeks mark where the child has a chance of survival. Steroids also help the baby’s lungs to develop quicker, which helps if the baby is to be born prematurely.

Serial Ultrasounds

If you suffer from premature births, your doctor may recommend ultrasounds after every two weeks to monitor the cervix. This is done from the 15th week to the 26th week. If the cervix is seen to become weaker or open, your doctor may recommend cervical cerclage.

Cerclage

If your pregnancy has not reached the 26th week mark and you have a history of early births, cerclage can prevent a premature birth. This procedure involves the stitching of the cervix to close it. The stiches can be removed during labor or the last month of your pregnancy. Your doctor can also recommend this procedure even before your cervix opens. This is mostly done before 14 weeks.

However, this procedure is not ideal for every woman at risk of premature labor. It is important to talk to your doctor concerning the benefits and risks of cerclage.

You can get a cerclage as early as 13 to 14 weeks of pregnancy, and your provider removes the stitch at about 37 weeks of pregnancy. Cerclage may be right for you if you’re pregnant now with just one baby and:

• You had a cerclage in a past pregnancy.
• You’ve had one or more pregnancy losses in the second trimester.
• You had a spontaneous premature birth before 34 weeks in a past pregnancy with a cervix shorter than 25 millimeters (about 1 inch) before 24 weeks of pregnancy. Spontaneous means that labor began on its own.
• In this pregnancy, your cervix is opening in the second trimester.

A cerclage is not recommended if you’re pregnant with twins, even if your cervix is shorter than 25 millimeters.

A woman would not be eligible for a cerclage if:

• There is increased irritation of the cervix
• The cervix has dilated 4cm
• Membranes have ruptured

Possible complications of cervical cerclage include uterine rupture, maternal hemorrhage, bladder rupture, cervical laceration, preterm labor and premature rupture of the membranes. The likelihood of these risks is very minimal, and most health care providers feel that a cerclage is a life saving procedure that is worth the possible risks involved.

Bed Rest

Instead of the cerclage, some doctors will recommend bed rest. Also, bed rest can be recommended together with the different medical options. Even so, there is no substantial evidence to prove that bed rest works to prevent preterm labor, it works with the theory that relieving the cervix of the pressure can help.

Pregnant cervix

When a woman becomes pregnant, the narrow opening of the cervix is sealed with a mucus plug, which forms a protective barrier for the cervical canal. During pregnancy, a lot of changes occur in the cervix, as it softens, becomes longer, then shortens, dilates and becomes thinner as pregnancy progresses. Why do these things happen, and what is the role of the cervix during pregnancy ? Here is some information to answer this question about your reproductive anatomy.

During pregnancy, the position of your cervix will change, but this happens at various times for different women.

The cervix rises a little bit and becomes softer as early as the 12th day after ovulation or a bit later, when your home pregnancy test becomes positive. For some women, this occurs just before they are expecting their period, while for others it happens just when their pregnancy is confirmed by a doctor.

Thickening of the cervix is usually the first change observed, since it produces more glandular cells that form the mucus plug. It may also become inflamed, appearing red on examination, and sometimes allowing some bleeding (spotting).

Thickening of the cervix serves to protect the uterus, but when your date of delivery is near, it starts to prepare for childbirth. Your cervix will slowly dilate, which causes the mucus plug to be lost. This may occur a few weeks before your expected date of delivery, but in other women, it may happen just as labor commences. However, physical examination alone cannot provide information if you are close to delivery.

The cervix is rigid and closed before pregnancy, but it softens and elongates during pregnancy. However, during labor, the cervix shortens and dilates to allow the passage of your baby.

Cervical shortening before 37 weeks of pregnancy increases your risk of giving birth to a premature baby. A baby is usually born about 38 weeks after conception. Although the cervix gradually softens and effaces (decreases in length) as the baby grows bigger in the uterus, it does not open or dilate until you are ready to give birth. If your cervix is short before the 37th week, you may go into preterm labor. If premature birth occurs even earlier, your baby may have greater health risks.

Factors that influence the length of your cervix during pregnancy include:

• Biological differences among women
• Uterine activity of unknown origin
• Overdistended or overstretched uterus
• Complications related to bleeding during your pregnancy
• Inflammation
• Infection
• Weak cervix (incompetent cervix)

Signs and symptoms that you are experiencing preterm labor include frequent or regular uterine contractions, vaginal spotting, pelvic pressure, or constant low back ache. Consult your health care provider to determine by pelvic examination, if your cervix is beginning to open. An ultrasound examination may be done to measure the length of your cervix.

The health care provider will explain the risks and benefits of treatments to try to stop your preterm labor. However, if you are not in active labor but you are still in early pregnancy and in danger of premature labor, your doctor may suggest that you have a cervical cerclage. This surgical procedure closes the cervix by stitching it with strong sutures. This is usually done in women who have a history of giving birth prematurely and has an ultrasound showing the cervix beginning to open.

Other forms of treatment involve the use of a hormone (progesterone) or a pessary (a silicone device), which is placed around your cervix to prevent premature birth.

If you have a history of premature birth and are concerned about the length of your cervix during pregnancy, consult your doctor to know more about promoting healthy pregnancy.

What is low cervix soft closed cervix ?

If you find your cervix low and soft, it could mean many different things. The most common explanation is that you are pregnant. A cervix that is softening, otherwise known as “ripening”, tends to happenafter a successful ovulation. You might also be at the end of your ovulation cycle.

During ovulation, a low soft cervix is very common. In addition, you might notice more vaginal discharge at that point, which will help the sperm move toward the egg. Also, the cervix will open just slightly. If you feel your cervix low and soft, it means you might be ready to get pregnant, while high and hard means you are at the start of ovulation, and not yet ready to release the egg.

However, checking your cervix is very important, as each woman is different. Some women can tell when they have a low soft closed cervix that they are definitely pregnant. For others, the cervix doesn’t do that at all. You may need several months to test out yourself.

Table 1 below shows the cervical positions for many women and what they mean. Use this as a rough guide until you figure out your own cervical position schedule throughout your cycle.

Table 1. Cervix position and what they mean

How to Check Your Cervical Position

Always wash your hands before checking your cervix. Try to find a comfortable position for yourself, either sitting on the toilet or standing near the bathtub with one leg on the edge. Slide your middle finger inside your vagina slowly and gently. The cervix is usually three to six inches inside the vagina. You might also notice some clear mucus on your fingers after you check it – this is entirely normal.

Tips: To get the best idea of where and how your cervix lies, check it once a day after your period has stopped. Check your cervix at the same time every day, and always empty your bladder first. Use the same position to check it each time, as changing position can affect the height of your cervix.

Other Ways to Tell Your Ovulation

When you are trying to get pregnant, there is much more than a low soft closed cervix position to help you determine ovulation. Be aware that your fertility takes many forms. Track your menstrual cycle to find the most fertile days. Check your cervical mucus for thickness. Monitor your hormones with at-home kits. Tracking your basal body temperature to find the days when hormones make it go up and down. Look for physical symptoms, such as mood swings and breast changes which indicate that ovulation is on the way. Many women choose to use all these methods together to ensure pregnancy.

What is effaced cervix ?

The words effacement, being effaced and effacing are terms that you will hear often as you approach your last trimester of your pregnancy. These terms are used to describe the process that the cervix prepares itself for delivery and it is measured by percentage. If you are told that you are 50% effaced, this means that you are half way from complete effacement. 100% effacement or complete effacement tells you that your cervix is quite thin and you are about to get into labor.

Cervical effacement is the “ripened” or thinned stage of the cervix ⁵. Normally, the cervix of a woman who isn’t pregnant is thick and long. A normal cervix will measure between 3 to 5 centimeters in length. However, when you are pregnant and near the end of your pregnancy, the cervix will begin thinning out and becoming shorter. This process is what is referred to as effacement. The cervix naturally starts to become shorter and it begins to pull up to a point where it seems to disappear, becoming a part of the lower uterus.

Labor progression is described by the stretching and opening of the cervix. Throughout your pregnancy, your cervix will remain as normal before starting to thin out as labor nears. The cervix is estimated to dilate by a centimeter during each hour of labor. However, this should not be generalized because different women will dilate differently. A dilation of 0 – 4 centimeters is regarded to as early labor and this will progress as the woman nears child birth. It is rare for a woman to be dilated by up to 2 centimeter several weeks to giving birth. When cervix dilation measures between 4 and 7 centimeters, the woman is in active labor. At 7 to 10 centimeters, the woman is at the transition stage which is the final stage of labor. When the cervix is at 10 centimeters, this is considered full dilation and the woman is ready to give birth. 10 centimeters is about the size of the head of the newborn child.

As the expectant mother’s due date approaches, the baby’s head will drop down causing the uterus to contract. This contraction combined with the effacement going on and dilation will lead to cramping. These cramp pains and contraction may feel like active labor and this is actually described as false labor. It is also called Braxton Hicks contraction and these are merely signs of the labor process. This process will take a few weeks before the cervix is effaced fully. In first time pregnancies, the cervix can become effaced even before it is dilated but in subsequent pregnancies, dilation will occur before effacement.

In the last weeks of pregnancy, your doctor will examine your cervix to identify any changes that are occurring in preparation for birth. The cervical effacement will be measured to identify how ready the body is for delivery. 0% effacement would mean that your cervix has had no changes, while 50% effacement would mean that your cervix is half its ordinary thickness. When you are 100% effaced, your cervix is thinned out completely leaving only the uterus opening for delivery. At this stage, you will be going into labor in no time.

Figure 4. Cervix effacement

How to Efface the Cervix Naturally

The American Pregnancy Association makes it clear that complete effacement occurs when the baby is engaged to the mother’s pelvis. When 100% effaced, the cervix will soon start to push outward. Though this occurs naturally, effacement can also be induced medically when labor appears to have stalled using the methods below.

• Evening primrose oil

Evening primrose oil is recommended by a lot of midwives as a herbal treatment. The oil acts as prostaglandin which helps ripen the cervix. These oil capsules can be taken orally or rubbed on the cervix in the final weeks of pregnancies. These capsules can also be placed inside the woman’s vagina at bedtime. Evening primrose oil is not recommended for women who have had vaginal infections, placenta previa and other pregnancy complications.

• Sex

Sex in the last trimester can boost dilation in the cervix. Sperms have prostaglandins which can help thin out the cervix. However, this dilation encouragement method should not be practiced by women who have already lost their mucus plug. The mucus plug protects the cervix from infections caused by harmful bacteria which could affect the baby.

• Keep in a good position

The weight of the baby also could encourage dilation. Dilation will occur naturally when the baby drops down in preparation for birth. There are positions that also could encourage dilation and these include sitting on an exercise ball or sitting with your legs spread wide apart. Walking also could encourage dilation. Another technique you can use is getting on your hands and knees as this shifts the baby’s weight forward. In a nut shell, all positions that include opening up the pelvis or shifting the weight of the baby forward should help encourage dilation.

How do you know if and when your cervix is effaced ?

As mentioned above, first time pregnancies become effaced before the cervix is dilated. However, the reverse occurs for subsequent pregnancies. Towards the end of the pregnancy, your effacement progress will be checked by your doctor through routine prenatal visits and the doctor may have to take an internal examination to identify the extent of dilation. Based on the results, your doctor should be able to guess when you will deliver. However, this doesn’t mean that you should race to the delivery room because the prediction is as good as a guess meaning it may be much sooner that your actual due date. Chances that your doctors educated guess is accurate are quite rare and hundreds of women give birth weeks after the guess, so don’t be impatient.

The cervix will continue to dilate even when on labor and full dilation will occur towards the end of the transitional phase when dilation will be at 10 centimeters. There are three labor phases and the third stage is when the cervix completely opens up meaning your body is ready for delivery.

What is cervix dilation

When you are getting closer to your due date, you will notice your cervix dilating and softening to prepare for giving birth and this happens even before labor pains begin. The cervical dilation will happen during labor and is crucial in letting your baby pass out via the birth canal. Both cervical dilation and the other necessary changes for birth will be encouraged by your baby’s head putting pressure against your cervix and uterine contractions. You may be stressing when you are only, let’s say, 1 cm dilated. Whether you are a first time mom or have given birth before, you should know how you can dilate faster to fasten labor.

How to Dilate Your Cervix Faster

Notes and Precautions: You should always talk with your midwife or doctor ahead of time so they know what procedures you would be fine with and which ones you want to avoid. Each labor happens differently and in some cases you will need flexibility, but having a plan can still help.

You should always go with the natural method first, allowing your cervix to naturally dilate. Every mechanical or medical intervention will have a small risk and may even increase the risk of a cesarean section. Because of this, most doctors will only encourage you to speed up the dilation process or induce labor when they feel it is necessary.

Walk

When you are in labor you should try to walk as much as you can. The combination of body movement and gravity will help your baby descend down into your birth canal. In addition, the pressure that the baby’s head exerts on the cervix may help with dilation and even effacement (thinning) of your cervix. It can also help encourage contractions which in turn further help with dilation. You should ask someone to walk next to you and provide support and keep walking for as long as it is tolerable.

Use Birth Balls

Another option is to sit on a birth ball with your legs spread apart. Use a bed or chair to rest your upper body and then squat on the ball as this will relax your pelvic muscles and widen your pelvis. You can also gently rock and use gravity to bring your baby’s head down to your cervix to encourage dilation.

Do Gentle Exercises

Sometimes doing gentle exercises like walking a short distance, as mentioned above, can help with dilation. Another great idea is to go up then down stairs but be sure to do so in long and slow strides. This will help stretch and dilate your cervix. Walking wider and slower than normal increases the stretch of the cervix, encouraging dilation.

Relax with Warm Shower

Try either standing or sitting in a warm shower to help yourself relax. By relaxing, you prevent tense muscles which would make the physical work harder. Using a warm shower can ease tension while helping with cervical dilation and contractions. You can also lie in warm water, but make sure someone helps you get in and out.

If you are looking for other ways to relax, try listening to some soothing music. You can also ask someone to give you a gentle massage. No matter the way you relax, it will produce the same beneficial effects in terms of cervical dilation.

Empty Your Bladder

When your bladder is full, this inhibits contractions so there will be less pressure on your cervix, resulting in a slower dilation. Instead, be sure to urinate regularly.

Stimulate Your Nipples or Have Sex

Stimulation is one of the effective methods to dilate your cervix. It varies from woman to woman and sometimes simply rubbing your nipples will help, while other women find having sexual intercourse works best. This is considered a low-risk and safe option. The hormones found in semen (prostaglandins) will help your cervix efface and dilate. In fact, doctors will sometimes administer these hormones to encourage labor. After you orgasm, your body will release oxytocin which is another hormone capable of encouraging cervical dilation. You can also release this hormone by stimulating your nipples.

Try Acupressure

Acupressure is related to acupuncture but instead of applying needles to the pressure points, you simply apply pressure. You only need to understand anatomy and don’t need any special training to perform it. The most important pressure point for dilation is located on your hand, specifically the webbing between your forefinger and thumb. It should feel slightly tender when pressed. Apply the pressure for a minute or less then give it a break for two minutes and repeat on the other hand.

Medical Methods

You can also consider using a medication that is applied to your cervix by your doctor to dilate and soften your cervix.

• Misoprostol is a prostaglandin and can soften the cervix when placed within the vagina. It is safe, relatively inexpensive, and commonly used by doctors.
• Dinoprostone is similar and also a prostaglandin. You can either have it squirted into the cervical opening or inserted into your vagina in the form of a suppository.
• The enzyme hyaluronidase is produced from bovine testes. It can be injected into your cervix to help soften and dilate it. It will sometimes be used in cases when a woman’s cervix hasn’t dilated or ripened at all.

What is Tilted cervix

A tilted uterus, also called a tipped uterus, retroverted uterus or retroflexed uterus, is a normal uterus anatomical variation ⁶. It shouldn’t interfere with your ability to fall pregnant and have a baby.

In most women, the uterus tips forward at the cervix. About 1 in 4 women, however, has a uterus that leans backward, or tilts, at the cervix. In the past, doctors thought that a tilted uterus might have contributed to infertility. But experts now know that the position of the uterus doesn’t affect the ability of sperm to reach an egg.

Occasionally, a sharply tilted uterus may happen when scar tissues (adhesions) form due to conditions such as endometriosis, infection or prior surgery. Although this may make it more challenging for sperm to reach an egg, conception can still occur. However, in these cases, you may benefit from seeing a fertility specialist.

Figure 5. Tipped (tilted) uterus

Causes of tilted uterus

Tilted uterus or retroversion of the uterus is common ⁷. One in 4 women has this condition. The problem may also occur due to weakening of the pelvic ligaments at the time of menopause. An enlarged uterus can also be caused by pregnancy or a tumor.

Scar tissue in the pelvis (pelvic adhesions) can also hold the uterus in a retroverted position. Scarring may come from ⁷:

• Endometriosis
• Infection in uterus or tubes
• Pelvic surgery

Symptoms of tilted uterus

Tilted uterus almost never causes any symptoms.

Rarely, it may cause pain or discomfort.

How is tilted uterus diagnosed ?

A pelvic exam will show the position of the uterus. However, a tilted uterus can sometimes be mistaken for a pelvic mass or a growing fibroid. A rectovaginal exam may be used to distinguish between a mass and a tilted uterus.

An ultrasound test can be used to see the exact position of the uterus.

Treatment for tilted uterus

Treatment is not needed most of the time. Underlying disorders, such as endometriosis or adhesions, should be treated as needed.

Outlook (Prognosis) for tilted uterus

In most cases, the condition does not cause problems.

Possible Complications of tilted uterus

Atypical positioning of the uterus may be caused by endometriosis, salpingitis, or pressure from a growing tumor.

When to Contact a Medical Professional

Call your health care provider if you have ongoing pelvic pain or discomfort.

Prevention of tilted uterus

There is no way to prevent the problem. Early treatment of uterine infections or endometriosis may reduce the chances of a change in the position of the uterus.

Tilted uterus and getting pregnant

Tilted uterus shouldn’t interfere with your ability to conceive ⁶.

What Is Cancer of the Cervix ?

Cancer starts when cells in the body begin to grow out of control. Cells in nearly any part of the body can become cancer, and can spread to other areas of the body.

Cervical cancer starts in the cells lining the cervix — the lower part of the uterus (womb). This is sometimes called the uterine cervix. The fetus grows in the body of the uterus (the upper part). The cervix connects the body of the uterus to the vagina (birth canal).

Most cancer of the cervix begin in the cells in the transformation zone ⁸. These cells do not suddenly change into cancer. Instead, the normal cells of the cervix first gradually develop pre-cancerous changes that turn into cancer. Doctors use several terms to describe these pre-cancerous changes, including cervical intraepithelial neoplasia (CIN), squamous intraepithelial lesion (SIL), and dysplasia ⁸. These changes can be detected by the Pap test and treated to prevent cancer from developing.

Although cervical cancers start from cells with pre-cancerous changes (pre-cancers), only some of the women with pre-cancers of the cervix will develop cancer ⁸. It usually takes several years for cervical pre-cancer to change to cervical cancer, but it also can happen in less than a year. For most women, pre-cancerous cells will go away without any treatment. Still, in some women pre-cancers turn into true (invasive) cancers. Treating all cervical pre-cancers can prevent almost all cervical cancers.

Types of cancer of the cervix

Cervical cancers and cervical pre-cancers are classified by how they look under a microscope. The main types of cervical cancers are squamous cell carcinoma and adenocarcinoma.

• Most (up to 9 out of 10) cervical cancers are squamous cell carcinomas. These cancers develop from cells in the exocervix and the cancer cells have features of squamous cells under the microscope. Squamous cell carcinomas most often begin in the transformation zone (where the exocervix joins the endocervix).
• Most of the other cervical cancers are adenocarcinomas. Adenocarcinomas are cancers that develop from gland cells. Cervical adenocarcinoma develops from the mucus-producing gland cells of the endocervix. Cervical adenocarcinomas seem to have become more common in the past 20 to 30 years.
• Less commonly, cervical cancers have features of both squamous cell carcinomas and adenocarcinomas. These are called adenosquamous carcinomas or mixed carcinomas.

Although almost all cervical cancers are either squamous cell carcinomas or adenocarcinomas, other types of cancer also can develop in the cervix. These other types, such as melanoma, sarcoma, and lymphoma, occur more commonly in other parts of the body.

Risk Factors for cancer of the cervix ?

A risk factor is anything that changes your chance of getting a disease such as cancer. Different cancers have different risk factors. For example, exposing skin to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for many cancers. But having a risk factor, or even several, does not mean that you will get the disease.

Several risk factors increase your chance of developing cervical cancer. Women without any of these risk factors rarely develop cervical cancer. Although these risk factors increase the odds of developing cervical cancer, many women with these risks do not develop this disease. When a woman develops cervical cancer or pre-cancerous changes, it might not be possible to say that a particular risk factor was the cause.

In thinking about risk factors, it helps to focus on those you can change or avoid (like smoking or human papilloma virus infection), rather than those you cannot (such as your age and family history). However, it is still important to know about risk factors that cannot be changed, because it’s even more important for women who have these factors to get regular Pap tests to detect cervical cancer early.

Cancer of the cervix risk factors include:

Human papilloma virus (HPV) infection

Infection by the human papilloma virus (HPV) is the most important risk factor for cervical cancer. HPV is a group of more than 150 related viruses. Some of them cause a type of growth called papillomas, which are more commonly known as warts.

• HPV can infect cells on the surface of the skin, and those lining the genitals, anus, mouth and throat, but not the blood or internal organs such as the heart or lungs.
• HPV can spread from one person to another during skin-to-skin contact. One way HPV spreads is through sex, including vaginal, anal, and even oral sex.
• Different types of HPV cause warts on different parts of the body. Some cause common warts on the hands and feet; others tend to cause warts on the lips or tongue.

Certain types of HPV may cause warts on or around the female and male genital organs and in the anal area. These are called low-risk types of HPV because they are seldom linked to cancer.

Other types of HPV are called high-risk types because they are strongly linked to cancers, including cancer of the cervix, vulva, and vagina in women, penile cancer in men, and cancers of the anus, mouth, and throat in both men and women.

Doctors believe that a woman must be infected with HPV in order to develop cervical cancer. Although this can mean infection with any of the high-risk types, about two-thirds of all cervical cancers are caused by HPV 16 and 18.

Infection with HPV is common, and in most people the body can clear the infection by itself. Sometimes, however, the infection does not go away and becomes chronic. Chronic infection, especially when it is caused by certain high-risk HPV types, can eventually cause certain cancers, such as cervical cancer.

Although there is currently no cure for HPV infection, there are ways to treat the warts and abnormal cell growth that HPV causes.

Smoking

When someone smokes, they and those around them are exposed to many cancer-causing chemicals that affect organs other than the lungs. These harmful substances are absorbed through the lungs and carried in the bloodstream throughout the body.

Women who smoke are about twice as likely as non-smokers to get cervical cancer. Tobacco by-products have been found in the cervical mucus of women who smoke. Researchers believe that these substances damage the DNA of cervix cells and may contribute to the development of cervical cancer. Smoking also makes the immune system less effective in fighting HPV infections.

Having a weakened immune system

Human immunodeficiency virus (HIV), the virus that causes AIDS, damages a woman’s immune system and puts them at higher risk for HPV infections. This might explain why women with AIDS have a higher risk for cervical cancer.

The immune system is important in destroying cancer cells and slowing their growth and spread. In women with HIV, a cervical pre-cancer might develop into an invasive cancer faster than it normally would.

Another group of women at risk for cervical cancer are those taking drugs to suppress their immune response, such as those being treated for an autoimmune disease (in which the immune system sees the body’s own tissues as foreign and attacks them, as it would a germ) or those who have had an organ transplant.

Chlamydia infection

Chlamydia is a relatively common kind of bacteria that can infect the reproductive system. It is spread by sexual contact. Chlamydia infection can cause pelvic inflammation, leading to infertility.

Some studies have seen a higher risk of cervical cancer in women whose blood tests and cervical mucus showed evidence of past or current chlamydia infection. Women who are infected with chlamydia often have no symptoms. In fact, they may not know that they are infected at all unless they are tested for chlamydia during a pelvic exam.

A diet low in fruits and vegetables

Women whose diets don’t include enough fruits and vegetables may be at increased risk for cervical cancer.

Being overweight

Overweight women are more likely to develop adenocarcinoma of the cervix.

Long-term use of oral contraceptives (birth control pills)

There is evidence that taking oral contraceptives (OCs) for a long time increases the risk of cancer of the cervix. Research suggests that the risk of cervical cancer goes up the longer a woman takes OCs, but the risk goes back down again after the OCs are stopped, and returns to normal about 10 years after stopping.

The American Cancer Society believes that a woman and her doctor should discuss whether the benefits of using OCs outweigh the potential risks.

Intrauterine device ( IUD) use

Some research suggests that women who had ever used an intrauterine device (IUD) had a lower risk of cervical cancer. The effect on risk was seen even in women who had an IUD for less than a year, and the protective effect remained after the IUDs were removed.

Using an IUD might also lower the risk of endometrial (uterine) cancer. However, IUDs do have some risks. A woman interested in using an IUD should first discuss the possible risks and benefits with her doctor. Also, a woman with multiple sexual partners should use condoms to lower her risk of sexually transmitted illnesses no matter what other form of contraception she uses.

Having multiple full-term pregnancies

Women who have had 3 or more full-term pregnancies have an increased risk of developing cervical cancer. No one really knows why this is true. One theory is that these women had to have had unprotected intercourse to get pregnant, so they may have had more exposure to HPV. Also, studies have pointed to hormonal changes during pregnancy as possibly making women more susceptible to HPV infection or cancer growth. Another thought is that pregnant women might have weaker immune systems, allowing for HPV infection and cancer growth.

Being younger than 17 at your first full-term pregnancy

Women who were younger than 17 years when they had their first full-term pregnancy are almost 2 times more likely to get cervical cancer later in life than women who waited to get pregnant until they were 25 years or older.

Economic status

Many low-income women do not have easy access to adequate health care services, including Pap tests. This means they may not get screened or treated for cervical pre-cancers.

Diethylstilbestrol

Diethylstilbestrol is a hormonal drug that was given to some women between 1940 and 1971 to prevent miscarriage. Women whose mothers took diethylstilbestrol (when pregnant with them) develop clear-cell adenocarcinoma of the vagina or cervix more often than would normally be expected. These types of cancer are extremely rare in women who haven’t been exposed to diethylstilbestrol. There is about 1 case of vaginal or cervical clear-cell adenocarcinoma in every 1,000 women whose mothers took diethylstilbestrol during pregnancy. This means that about 99.9% of “diethylstilbestrol daughters” do not develop these cancers.

Diethylstilbestrol-related clear cell adenocarcinoma is more common in the vagina than the cervix. The risk appears to be greatest in women whose mothers took the drug during their first 16 weeks of pregnancy. The average age of women diagnosed with diethylstilbestrol-related clear-cell adenocarcinoma is 19 years. Since the use of diethylstilbestrol during pregnancy was stopped by the FDA in 1971, even the youngest diethylstilbestrol daughters are older than 40 − past the age of highest risk. Still, there is no age cut-off when these women are felt to be safe from diethylstilbestrol-related cancer. Doctors do not know exactly how long these women will remain at risk.

Diethylstilbestrol daughters may also be at increased risk of developing squamous cell cancers and pre-cancers of the cervix linked to HPV.

Having a family history of cervical cancer

Cervical cancer may run in some families. If your mother or sister had cervical cancer, your chances of developing the disease are 2 to 3 times higher than if no one in the family had it. Some researchers suspect that some instances of this familial tendency are caused by an inherited condition that makes some women less able to fight off HPV infection than others. In other instances, women in the same family as a patient already diagnosed could be more likely to have one or more of the other non-genetic risk factors previously described in this section.

What Causes cancer of the cervix ?

In recent years, there has been a lot of progress in understanding what happens in cells of the cervix when cancer develops. In addition, several risk factors have been identified that increase the odds that a woman might develop cervical cancer.

The development of normal human cells mostly depends on the information contained in the cells’ DNA. DNA is the chemical in our cells that makes up our genes, which control how our cells work. We look like our parents because they are the source of our DNA. But DNA affects more than just how we look.

Some genes control when cells grow, divide, and die:·

• Genes that help cells grow, divide, and stay alive are called oncogenes.
• Genes that help keep cell growth under control or make cells die at the right time are called tumor suppressor genes.

Cancers can be caused by DNA mutations (gene defects) that turn on oncogenes or turn off tumor suppressor genes.

Human papilloma viruses (HPV) cause the production of two proteins known as E6 and E7 which turn off some tumor suppressor genes. This may allow the cervical lining cells to grow too much and to develop changes in additional genes, which in some cases will lead to cancer.

But HPV is not the only cause of cervical cancer. Most women with HPV don’t get cervical cancer, and certain other risk factors, like smoking and HIV infection, influence which women exposed to HPV are more likely to develop cervical cancer.

Cervix Cancer Prevention

The most common form of cervical cancer starts with pre-cancerous changes and there are ways to stop this disease from developing. The first way is to find and treat pre-cancers before they become true cancers, and the second is to prevent the pre-cancers.

Finding cervical pre-cancers

A well-proven way to prevent cervical cancer is to have testing (screening) to find pre-cancers before they can turn into invasive cancer. The Pap test (or Pap smear) and the human papilloma virus (HPV) test are used for this. If a pre-cancer is found it can be treated, stopping cervical cancer before it really starts. Most invasive cervical cancers are found in women who have not had regular Pap tests.

The Pap test is a procedure used to collect cells from the cervix so that they can be looked at under a microscope to find cancer and pre-cancer. These cells can also be used for HPV testing. A Pap test can be done during a pelvic exam, but not all pelvic exams include a Pap test.

An HPV test can be done on the same sample of cells collected from the Pap test.

The most important thing you can do to prevent cervical cancer is to be tested according to American Cancer Society guidelines.

The American Cancer Society recommends that women follow these guidelines to help find cervix cancer early ⁹. Following these guidelines can also find pre-cancers, which can be treated to keep cervical cancer from forming.

• All women should begin cervical cancer testing (screening) at age 21. Women aged 21 to 29, should have a Pap test every 3 years. HPV testing should not be used for screening in this age group (it may be used as a part of follow-up for an abnormal Pap test).
• Beginning at age 30, the preferred way to screen is with a Pap test combined with an HPV test every 5 years. This is called co-testing and should continue until age 65.
• Another reasonable option for women 30 to 65 is to get tested every 3 years with just the Pap test.
• Women who are at high risk of cervical cancer because of a suppressed immune system (for example from HIV infection, organ transplant, or long-term steroid use) or because they were exposed to diethylstilbestrol in utero may need to be screened more often. They should follow the recommendations of their health care team.
• Women over 65 years of age who have had regular screening in the previous 10 years should stop cervical cancer screening as long as they haven’t had any serious pre-cancers (like CIN2 or CIN3) found in the last 20 years (CIN stands for cervical intraepithelial neoplasia). Women with a history of CIN2 or CIN3 should continue to have testing for at least 20 years after the abnormality was found.
• Women who have had a total hysterectomy (removal of the uterus and cervix) should stop screening (such as Pap tests and HPV tests), unless the hysterectomy was done as a treatment for cervical pre-cancer (or cancer). Women who have had a hysterectomy without removal of the cervix (called a supra-cervical hysterectomy) should continue cervical cancer screening according to the guidelines above.
• Women of any age should NOT be screened every year by any screening method.
• Women who have been vaccinated against HPV should still follow these guidelines.

Some women believe that they can stop cervical cancer screening once they have stopped having children. This is not true. They should continue to follow American Cancer Society guidelines.

Although annual (every year) screening should not be done, women who have abnormal screening results may need to have a follow-up Pap test (sometimes with a HPV test) done in 6 months or a year.

The American Cancer Society guidelines for early detection of cervical cancer do not apply to women who have been diagnosed with cervical cancer, cervical pre-cancer, or HIV infection. These women should have follow-up testing and cervical cancer screening as recommended by their health care team.

Screening tests offer the best chance to have cervical cancer found early when successful treatment is likely. Screening can also actually prevent most cervical cancers by finding abnormal cervical cell changes (pre-cancers) so that they can be treated before they have a chance to turn into a cervical cancer.

If it’s found early, cervical cancer is one of the most successfully treatable cancers. In the United States, the cervical cancer death rate declined by more than 50% over the last 30 years. This is thought to be mainly due to the effectiveness of screening with the Pap test.

Despite the recognized benefits of cervical cancer screening, not all American women get screened. Most cervical cancers are found in women who have never had a Pap test or who have not had one recently. Women without health insurance and women who have recently immigrated are less likely to have cervical cancer screening.

Things to do to prevent pre-cancers

There are also some things you can do to prevent pre-cancers, such as:

• Avoiding exposure to HPV
• Getting an HPV vaccine
• Not smoking

Tests for cervix cancer

The first step in finding cervical cancer is often an abnormal Pap test result. This will lead to further tests which can diagnose cervical cancer.

Cervical cancer may also be suspected if you have symptoms like abnormal vaginal bleeding or pain during sex. Your primary doctor or gynecologist often can do the tests needed to diagnose pre-cancers and cancers and may also be able to treat a pre-cancer.

If there is a diagnosis of invasive cancer, your doctor should refer you to a gynecologic oncologist, a doctor who specializes in cancers of women’s reproductive systems.

Tests for women with symptoms of cervix cancer or abnormal Pap results

Medical history and physical exam

First, the doctor will ask you about your personal and family medical history. This includes information related to risk factors and symptoms of cervical cancer. A complete physical exam will help evaluate your general state of health. The doctor will do a pelvic exam and may do a Pap test if one has not already been done. In addition, your lymph nodes will be felt for evidence of metastasis (cancer spread).

The Pap test is a screening test, not a diagnostic test. It cannot tell for certain if you have cervical cancer. An abnormal Pap test result may mean more testing, sometimes including tests to see if a cancer or a pre-cancer is actually present. The tests that are used include colposcopy (with biopsy), endocervical scraping, and cone biopsies.

Colposcopy

If you have certain symptoms that are suggestive of cancer or if your Pap test result shows abnormal cells, you will need to have a test called colposcopy. You will lie on the exam table as you do with a pelvic exam. A speculum will be placed in the vagina to help the doctor see the cervix. The doctor will use a colposcope to examine the cervix. The colposcope is an instrument that stays outside the body and has magnifying lenses. It lets the doctor see the surface of the cervix closely and clearly. Colposcopy itself is usually no more uncomfortable than any other speculum exam. It can be done safely even if you are pregnant. Like the Pap test, it is better not to do it during your menstrual period.

The doctor will put a weak solution of acetic acid (similar to vinegar) on your cervix to make any abnormal areas easier to see. If an abnormal area is seen, a biopsy (removal of a small piece of tissue) will be done. The tissue is sent to a lab to be looked at under a microscope. A biopsy is the best way to tell for certain if an abnormal area is a pre-cancer, a true cancer, or neither. Although the colposcopy procedure is usually not painful, the cervical biopsy can cause discomfort, cramping, bleeding, or even pain in some women.

Cervical biopsies

Several types of biopsies can be used to diagnose cervical pre-cancers and cancers. If the biopsy can completely remove all of the abnormal tissue, it might be the only treatment needed.

Colposcopic biopsy

For this type of biopsy, first the cervix is examined with a colposcope to find the abnormal areas. Using a biopsy forceps, a small (about 1/8-inch) section of the abnormal area on the surface of the cervix is removed. The biopsy procedure may cause mild cramping, brief pain, and some slight bleeding afterward. A local anesthetic is sometimes used to numb the cervix before the biopsy.

Endocervical curettage (endocervical scraping)

Sometimes the transformation zone (the area at risk for HPV infection and pre-cancer) cannot be seen with the colposcope and something else must be done to check that area for cancer. This means taking a scraping of the endocervix by inserting a narrow instrument (called a curette) into the endocervical canal (the part of the cervix closest to the uterus). The curette is used to scrape the inside of the canal to remove some of the tissue, which is then sent to the laboratory for examination. After this procedure, patients may feel a cramping pain, and they may also have some light bleeding.

Cone biopsy

In this procedure, also known as conization, the doctor removes a cone-shaped piece of tissue from the cervix. The base of the cone is formed by the exocervix (outer part of the cervix), and the point or apex of the cone is from the endocervical canal. The tissue removed in the cone includes the transformation zone (the border between the exocervix and endocervix, where cervical pre-cancers and cancers are most likely to start).

A cone biopsy can also be used as a treatment to completely remove many pre-cancers and some very early cancers. Having had a cone biopsy will not prevent most women from getting pregnant, but if a large amount of tissue has been removed, women may have a higher risk of giving birth prematurely.

The methods commonly used for cone biopsies are the loop electrosurgical excision procedure (LEEP), also called the large loop excision of the transformation zone (LLETZ), and the cold knife cone biopsy.

Loop electrosurgical procedure (LEEP, LLETZ): In this method, the tissue is removed with a thin wire loop that is heated by electricity and acts as a small knife. For this procedure, a local anesthetic is used, and it can be done in your doctor’s office.
Cold knife cone biopsy: This method is done in a hospital. A surgical scalpel or a laser is used to remove the tissue instead of a heated wire. You will receive anesthesia during the operation (either a general anesthesia, where you are asleep, or a spinal or epidural anesthesia, where an injection into the area around the spinal cord makes you numb below the waist). Having any type of cone biopsy will not prevent most women from getting pregnant, but if a large amount of tissue has been removed, women may have a higher risk of giving birth prematurely.

Pre-cancerous changes in a biopsy are called cervical intraepithelial neoplasia (CIN). Sometimes the term dysplasia is used instead of CIN. CIN is graded on a scale of 1 to 3 based on how much of the cervical tissue looks abnormal when viewed under the microscope.

How biopsy results are reported

• In CIN1, not much of the tissue looks abnormal, and it is considered the least serious cervical pre-cancer (mild dysplasia).
• In CIN2 more of the tissue looks abnormal (moderate dysplasia)
• In CIN3 most of the tissue looks abnormal; CIN3 is the most serious pre-cancer (severe dysplasia) and includes carcinoma in situ).

If a biopsy shows a pre-cancer, doctors will take steps to keep an actual cancer from developing. Treatment of women with abnormal pap results is discussed in

Cervix cancer Prevention and Early Detection

Diagnostic tests for women with cervical cancer

If a biopsy shows that cancer is present, your doctor may order certain tests to see how far the cancer has spread. Many of the tests described below are not necessary for every patient. Decisions about using these tests are based on the results of the physical exam and biopsy.

Cystoscopy, proctoscopy, and examination under anesthesia

These are most often done in women who have large tumors. They are not necessary if the cancer is caught early.

In cystoscopy a slender tube with a lens and a light is placed into the bladder through the urethra. This lets the doctor check your bladder and urethra to see if cancer is growing into these areas. Biopsy samples can be removed during cystoscopy for pathologic (microscopic) testing. Cystoscopy can be done under a local anesthetic, but some patients may need general anesthesia. Your doctor will let you know what to expect before and after the procedure.

Proctoscopy is a visual inspection of the rectum through a lighted tube to check for spread of cervical cancer into your rectum.

Your doctor may also do a pelvic exam while you are under anesthesia to find out if the cancer has spread beyond the cervix.

Imaging studies

If your doctor finds that you have cervical cancer, certain imaging studies may be done to look inside the body. These tests can show if and where the cancer has spread, which will help you and your doctor decide on a treatment plan.

Chest x-ray

Your chest may be x-rayed to see if cancer has spread to your lungs. This is very unlikely unless the cancer is far advanced.

Computed tomography (CT)

CT scans are usually done if the tumor is larger or if there is concern about cancer spread. For more information, see CT Scan for Cancer.

Magnetic resonance imaging (MRI)

MRI looks at soft tissue parts of the body sometimes better than other imaging tests. Your doctor will decide which imaging test is best for your situation.

Intravenous urography

Intravenous urography (also known as intravenous pyelogram, or IVP) is an x-ray of the urinary system taken after a special dye is injected into a vein. This test can find abnormal areas in the urinary tract, caused by the spread of cervical cancer. The most common finding is a blockage of the ureters (tubes that connect the kidneys to the bladder) by the cancer. IVP is rarely used for patients with cervical cancer because CT and MRI are also good at finding abnormal areas in the urinary tract, as well as others not seen with an IVP.

Positron emission tomography (PET scan)

PET scans use glucose (a form of sugar) that contains a radioactive atom. Cancer cells in the body absorb large amounts of the radioactive sugar and a special camera can detect the radioactivity.

This test can help see if the cancer has spread to lymph nodes. PET scans can also be useful if your doctor thinks the cancer has spread but doesn’t know where, because they scan your whole body.

PET scans are often combined with CT scans using a machine that can do both at the same time. The combined PET/CT test is rarely used for patients with early cervical cancer, but may be used to look for more advanced cancer or if radiation treatment is a possibility.

General treatment information for cancer of the cervix

The options for treating each patient with cervical cancer depend on the stage of disease. The stage of a cervical cancer describes its size, depth of invasion (how far it has grown into the cervix), and how far it has spread.

After establishing the stage of your cervical cancer, your cancer care team will recommend your treatment options. Think about your options without feeling rushed. If there is anything you do not understand, ask for an explanation. Although the choice of treatment depends largely on the stage of the disease at the time of diagnosis, other factors that may influence your options are your age, your general health, your individual circumstances, and your preferences. Cervical cancer can affect your sex life and your ability to have children. These concerns should also be considered as you make treatment decisions.

Depending on the type and stage of your cancer, you may need more than one type of treatment. Doctors on your cancer treatment team may include:

• A gynecologist: a doctor who treats diseases of the female reproductive system
• A gynecologic oncologist: a doctor who specializes in cancers of the female reproductive system
• A radiation oncologist: a doctor who uses radiation to treat cancer
• A medical oncologist: a doctor who uses chemotherapy and other medicines to treat cancer

Many other specialists may be involved in your care as well, including nurse practitioners, nurses, psychologists, social workers, rehabilitation specialists, and other health professionals.

Common types of treatments for cervical cancer include:

• Surgery
• Radiation therapy
• Chemotherapy (chemo)
• Targeted therapy

For the earliest stages of cervical cancer, either surgery or radiation combined with chemo may be used. For later stages, radiation combined with chemo is usually the main treatment. Chemo (by itself) is often used to treat advanced cervical cancer.

It is often a good idea to get a second opinion, especially from doctors experienced in treating cervical cancer. A second opinion can give you more information and help you feel more confident about choosing a treatment plan. Some insurance companies require a second opinion before they will agree to pay for certain treatments. Almost all will pay for a second opinion. Still, you might want to check your coverage first, so you’ll know if you will have to pay for it.

It is important to discuss all of your treatment options, including their goals and possible side effects, with your doctors to help make the decisions that best fit your needs. It’s also very important to ask questions if there’s anything you’re not sure about.

Your recovery is the goal of your cancer care team. If a cure is not possible, the goal may be to remove or destroy as much of the cancer as possible to help you live longer and feel better. Sometimes treatment is aimed at relieving symptoms. This is called palliative treatment.

Considering complementary and alternative methods

You may hear about alternative or complementary methods that your doctor hasn’t mentioned to treat your cancer or relieve symptoms. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.

Complementary methods refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctor’s medical treatment. Although some of these methods might be helpful in relieving symptoms or helping you feel better, many have not been proven to work. Some might even be dangerous.

1. Cervical insufficiency and short cervix. March of Dimes Foundation. https://www.marchofdimes.org/complications/cervical-insufficiency-and-short-cervix.aspx
2. Wei M, Jin X, Li TC, Yang C, Huang D, Zhang S. A comparison of pregnancy outcome of modified transvaginal cervicoisthmic cerclage performed prior to and during pregnancy. Arch. Gynecol. Obstet. 2018 Mar;297(3):645-652.
3. Lee KN, Whang EJ, Chang KH, Song JE, Son GH, Lee KY. History-indicated cerclage: the association between previous preterm history and cerclage outcome. Obstet Gynecol Sci. 2018 Jan;61(1):23-29.
4. Low Soft Closed Cervix http://www.newkidscenter.com/Low-Soft-Closed-Cervix.html
5. What Does Effacement Mean? Newkids Center. http://www.newkidscenter.com/What-Does-Effacement-Mean.html
6. Tilted uterus: Can it lead to infertility? Mayo Clinic. https://www.mayoclinic.org/tilted-uterus/expert-answers/faq-20058485
7. Retroversion of the uterus. Medline Plus. https://medlineplus.gov/ency/article/001506.htm
8. What Is Cervical Cancer ? American Cancer Society. https://www.cancer.org/cancer/cervical-cancer/about/what-is-cervical-cancer.html
9. The American Cancer Society Guidelines for the Prevention and Early Detection of Cervical Cancer. American Cancer Society. https://www.cancer.org/cancer/cervical-cancer/prevention-and-early-detection/cervical-cancer-screening-guidelines.html

What is uterus

The uterus is a hollow, muscular organ shaped somewhat like an inverted pear. The uterus receives the embryo that develops from an oocyte fertilized in the uterine tube, and sustains its development.

In its nonpregnant, adult state, the uterus is about 7 centimeters long, 5 centimeters wide (at its broadest point), and 2.5 centimeters in diameter. The size of the uterus changes greatly during pregnancy and it is somewhat larger in women who have been pregnant. The uterus is located medially in the anterior part of the pelvic cavity, superior to the vagina, and usually bends forward over the urinary bladder (see Figure 3).

The upper two-thirds or body (corpus), of the uterus has a domeshaped top called the fundus (see Figure 1). The uterine tubes (also called Fallopian tubes) connect at the upper lateral edges of the uterus. The lower third of the uterus is called the cervix. This tubular part extends downward into the upper part of the vagina. The cervix surrounds the opening called the cervical orifice, through which the uterus opens to the vagina.

The uterine wall is thick and has three layers (Figure 1). The endometrium, the inner mucosal layer, is covered with columnar epithelium and contains abundant tubular glands. The myometrium, a thick, middle, muscular layer, consists largely of bundles of smooth muscle cells. During the monthly female menstrual cycles and during pregnancy, the endometrium and myometrium change extensively. The perimetrium consists of an outer serosal layer, which covers the body of the uterus and part of the cervix.

Uterus anatomy

The uterus is supported by the muscular floor of the pelvis and folds of peritoneum that form supportive ligaments around the organ, as they do for the ovary and uterine tube. The broad ligament has two parts: the mesosalpinx mentioned earlier and the mesometrium on each side of the uterus. The cervix and superior part of the vagina are supported by cardinal (lateral cervical) ligaments extending to the pelvic wall. A pair of uterosacral ligaments attaches the posterior side of the uterus to the sacrum, and a pair of round ligaments arises from the anterior surface of the uterus, passes through the inguinal canals, and terminates in the labia majora.

As the peritoneum folds around the various pelvic organs, it creates several dead-end recesses and pouches (extensions of the peritoneal cavity). Two major ones are the vesicouterine pouch, which forms the space between the uterus and urinary bladder, and rectouterine pouch between the uterus and rectum (see Figure 3).

The uterine blood supply to the uterus is particularly important to the menstrual cycle and pregnancy. A uterine artery arises from each internal iliac artery and travels through the broad ligament to the uterus (Figure 2). It gives off several branches that penetrate into the myometrium and lead to arcuate arteries. Each arcuate artery travels in a circle around the uterus and anastomoses with the arcuate artery on the other side. Along its course, it gives rise to smaller arteries that penetrate the rest of the way through the myometrium, into the endometrium, and give off spiral arteries. The spiral arteries wind tortuously between the endometrial glands toward the surface of the mucosa. They rhythmically constrict and dilate, making the mucosa alternately blanch and flush with blood.

Figure 1. Uterus anatomy

Figure 2. Blood supply to the uterus

Figure 3. Uterus location

Figure 4. Uterus location in the female pelvis

What is the function of the uterus ?

The lumen of the uterus is roughly triangular, with its two upper corners opening into the uterine tubes. In the nonpregnant uterus, the lumen isn’t a hollow cavity but rather a potential space; the mucous membranes of the opposite walls are pressed against each other with little room between them. The lumen communicates with the vagina by way of a narrow passage through the cervix called the cervical canal. The superior opening of this canal into the body of the uterus is the internal os and its opening into the vagina is the external os. The canal contains cervical glands that secrete mucus, thought to prevent the spread of microorganisms from the vagina into the uterus. Near the time of ovulation, the mucus becomes thinner than usual and allows easier passage for sperm.

The uterine wall consists of three layers. The outermost layer, the perimetrium, is a thin serosa of simple squamous epithelium and loose connective tissue. The middle and thickest layer is the myometrium, about 1.25 cm thick in the nonpregnant uterus. It is composed mainly of bundles of smooth muscle that sweep downward from the fundus and spiral around the body of the uterus. The myometrium is less muscular and more fibrous near the cervix; the cervix itself is almost entirely collagenous. The muscle cells of the myometrium are about 40 μm long immediately after menstruation, but they are twice this long at the middle of the menstrual cycle and 10 times as long in pregnancy. The function of the myometrium is to produce the labor contractions that help to expel the fetus.

The innermost layer is a mucosa called the endometrium. It has a simple columnar epithelium, compound (branching) tubular glands, and a lamina propria populated by leukocytes, macrophages, and other cells. The superficial half to two-thirds of it, called the functional layer (stratum functionalis), is shed in each menstrual period. The deeper layer, called the basal layer (stratum basalis), stays behind and regenerates a new functional layer in the next cycle. When pregnancy occurs, the endometrium is the site of attachment of the embryo and forms the maternal part of the placenta from which the fetus is nourished.

Figure 5. Endometrium of the uterus and its blood supply

What is Inverted uterus ?

Inversion of the uterus is a very serious and fortunately relatively rare complication of delivery (at childbirth). A non-puerperal (non-childbirth) uterine inversion is even more uncommon, with only 150 cases published between 1887 and 2006 ¹, ². In the vast majority the incidence was observed in women older than 45 years. 85% of uterine inversion was caused by benign pathology, only 15% was associated with cancer ³.

Uterine inversions are classified into two groups, including (a) puerperal (childbirth) that is due to obstetric problem and (b) non-puerperal (non-childbirth) inversions that is due to gynecological problem ⁴. The diagnosis can be difficult even on physical examination. Most non-puerperal (non-childbirth) uterine inversions are caused by benign submucous myomas, while other causes are leiomyosarcoma, rhabdomyosarcoma, malignant mixed müllerian tumour and endometrial polyp. Women of reproductive age who present with the rare finding of non-puerperal uterine inversion are likely to have a malignancy. Most cases have reported puerperal uterine inversion as a rare condition ⁵. Leiomyomas (uterine fibroids – benign tumor of the uterus) are considered as the most frequent gynecologic problems. A report has been shown that submucosal leiomyoma dilated cervix and prolapsed into the vagina ⁶. Furthermore, some cases of prolapsed cervical myoma may show some malignancy features that lead to differential diagnoses, and frozen section analysis during surgery is considered as a logical action ⁷.

The cause of uterine inversion is not clearly defined. Possible explanations could be a thin uterine wall, rapid growth of the tumour, tumour size, fundic localisation of the tumour, tumour attachment to the uterine wall with a thin pedicle, dilatation of the cervix by distension of the uterine cavity, and sudden expulsion of the tumour ², ⁸.

Non-puerperal uterine inversion caused by submucousal leiomyoma has been more frequently reported in African women ⁹. The clinical diagnosis of non-puerperal uterine inversion is divided into (a) chronic signs including irregular vaginal bleeding, anemia, and a feeling of mass coming down in vagina and (b) acute signs including pelvic pain and heavy vaginal bleeding ¹⁰. Some literatures have also pointed to vaginal discharge, urethrovaginal fistula and intermittent acute urinary retention ¹¹.

Imaging procedures such as ultrasound and magnetic resonance imaging will contribute to the diagnosis ¹². Unfortunately, because of the rare nature of the disorder, uterine inversion frequently goes undetected until surgery unless a high index of suspicion is maintained.

Types of treatment vary greatly from case to case. Abdominal and vaginal hysterectomies are recommended for women who have completed their family size. Vaginal myomectomy is suggested for the cases showing no malignancy. Finally, for uterine inversion caused by malignancy, advanced surgery such as radical abdominal hysterectomy is indicated.

What is Tipped uterus ?

Tipped uterus, also called tilted uterus or retroverted uterus is a condition where the woman’s uterus (womb) tilts backward rather than forward ¹³.

Causes of tipped uterus

Tipped uterus or retroversion of the uterus is common. One in 5 women has this condition. The problem may also occur due to weakening of the pelvic ligaments at the time of menopause. An enlarged uterus can also be caused by pregnancy or a tumor.

Scar tissue in the pelvis (pelvic adhesions) can also hold the uterus in a retroverted position. Scarring may come from:

• Endometriosis
• Infection in uterus or tubes
• Pelvic surgery

Symptoms of tipped uterus

Tipped uterus almost never causes any symptoms.

Rarely, it may cause pain or discomfort.

How is tipped uterus diagnosed ?

A pelvic exam will show the position of the uterus. However, a tipped uterus can sometimes be mistaken for a pelvic mass or a growing fibroid. A rectovaginal exam may be used to distinguish between a mass and a tipped uterus.

An ultrasound test can be used to see the exact position of the uterus.

Treatment for tipped uterus

Treatment is not needed most of the time. Underlying disorders, such as endometriosis or adhesions, should be treated as needed.

Outlook (Prognosis) for tipped uterus

In most cases, the condition does not cause problems.

Possible Complications of Tipped uterus

Atypical positioning of the uterus may be caused by endometriosis, salpingitis, or pressure from a growing tumor.

When to Contact a Medical Professional

Call your health care provider if you have ongoing pelvic pain or discomfort.

Prevention of tipped uterus

There is no way to prevent the problem. Early treatment of uterine infections or endometriosis may reduce the chances of a change in the position of the uterus.

What is irritable uterus ?

In general, a normal human pregnancy lasts about 40 weeks, or just more than 9 months, from the start of the last menstrual period to childbirth ¹⁴. Labor that begins before 37 weeks is called preterm labor (or premature labor). When birth occurs between 20 weeks of pregnancy and 37 weeks of pregnancy, it is called preterm birth ¹⁴.

Irritable uterus (preterm labor uterus contractions) is the regular contractions of the uterus, every 10-15 minutes or more often, that start before 37 weeks of pregnancy resulting in changes in the cervix ¹⁵. Changes in the cervix include effacement (the cervix thins out) and dilation (the cervix opens so that the fetus can enter the birth canal) ¹⁶.

What are the signs and symptoms of irritable uterus (preterm labor uterus contractions) and what should you do if you have any of them ?

See your obstetrician or other health care professional right away if you notice any of these signs or symptoms:

• Leaking fluid or bleeding from the vagina (watery, mucus, or bloody)
• Increase in amount of discharge
• Feeling of pressure in the pelvis or or lower abdomen
• Constant low, dull backache
• Cramps that feel like menstrual cramps
• Abdominal cramps with or without diarrhea
• Ruptured membranes (your water breaks with a gush or a trickle of fluid)

Causes of irritable uterus (preterm labor)

Factors associated with irritable uterus (preterm labor uterus contractions) ¹⁷:

• Maternal factors
• Low socioeconomic status
• Nonwhite race
• Maternal age ≤18 or ≥40 years
• Low pre-pregnancy weight
• Smoking during pregnancy
• Substance abuse during pregnancy
• Certain pregnancy complications, such as multiple pregnancy and vaginal bleeding.

Maternal history

• Previous history of preterm delivery
• Previous history of a second-trimester abortion
• Short interval between pregnancies

Uterine factors

• Having a short cervix: Cervical incompetence from trauma or exposure to diethylstilbestrol can lead to painless cervical dilation and preterm labor. Both of these conditions may respond to the placement of a cerclage (this is a stitch that your provider puts in your cervix); however, no controlled trials have been conducted to support this approach.
• Uterine volume increased
• History of certain types of surgery on the uterus or cervix
• Uterine anomalies: Uterine malformations that predispose a patient to preterm labor include a bicornate or unicorn uterus, and uterine fibroids, particularly submucosal and subplacental fibroids. Women who are diagnosed with uterine malformations before conception may be given the option of birth control or surgery, if applicable.
• Trauma
• Infection: Infections of the genitourinary tract are an important and treatable factor associated with preterm labor. Women with Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, Trichomonas vaginalis, Gardnerella vaginalis or group B streptococci infections have higher rates of preterm births. Although cause and effect have not yet been conclusively defined, diagnosis and treatment of these infections are necessary to prevent perinatal transmission ¹⁸. Therefore, women with sexually transmitted diseases, urinary tract infections, severe respiratory infections and vaginitis should be treated appropriately. Patients with intact amniotic membranes and a history of positive group B streptococcal culture are usually treated with intravenous penicillin. This approach is based on the rationale that treatment will prevent perinatal transmission, although this approach is not substantiated in the prevention of preterm labor. Pregnancy and delivery may be prolonged in women treated with erythromycin, ampicillin and clindamycin (Cleocin) ¹⁹.

In most cases, the cause of preterm labor is not diagnosed, and the etiology is likely to be multifactorial.

Can anything be done to prevent preterm birth if you’re at high risk ?

If you have had a prior preterm birth and you are planning another pregnancy, a preconception care checkup can help you get in the best possible health before you become pregnant. When you become pregnant, be sure to start prenatal care early. You may be referred to a health care professional who has expertise in managing high-risk pregnancies. In addition, you may be given certain medications or other treatment to help prevent preterm birth if you have risk factors. Treatment is given based on your individual situation and your risk factors for preterm birth.

Why is irritable uterus (preterm labor uterus contractions) a concern ?

Irritable uterus (preterm labor uterus contractions) can lead to preterm birth, which is a concern for the babies because babies who are born too early may not be fully developed. They may be born with serious health problems. Some health problems, like cerebral palsy, can last a lifetime. Other problems, such as learning disabilities, may appear later in childhood or even in adulthood.

The risk of health problems is greatest for babies born before 34 weeks of pregnancy. But babies born between 34 weeks of pregnancy and 37 weeks of pregnancy also are at risk ¹⁶.

If you have preterm labor, will you have a preterm birth ?

It is difficult for health care professionals to predict which women with preterm labor will go on to have preterm birth. Only about 10% of women with preterm labor will give birth within the next 7 days. For about 30% of women, preterm labor stops on its own.

How is preterm labor diagnosed ?

Preterm labor can be diagnosed only when changes in the cervix are found. Your obstetrician or other health care professional may perform a pelvic exam to see if your cervix has started to change. You may need to be examined several times over a period of a few hours. Your contractions also may be monitored.

Your obstetrician or other health care professional may do certain tests to determine whether you need to be hospitalized or if you need immediate specialized care. A transvaginal ultrasound exam may be done to measure the length of your cervix. The level of a protein called fetal fibronectin in the vaginal discharge may be measured. The presence of this protein is linked to preterm birth.

What happens if your preterm labor continues ?

If your preterm labor continues, how it is managed is based on what is thought to be best for your health and your baby’s health. When there is a chance that the baby would benefit from a delay in delivery, certain medications may be given. These medications include corticosteroids, magnesium sulfate, and tocolytics.

What are corticosteroids ?

Corticosteroids are drugs that cross the placenta and help speed up development of the baby’s lungs, brain, and digestive organs. Corticosteroids are most likely to help your baby when they are given between 24 weeks of pregnancy and 34 weeks of pregnancy, but consideration can also be given to providing corticosteroids between 23 and 24 weeks of pregnancy.

Corticosteroid therapy is presently the only treatment shown to improve fetal survival when given to a woman in preterm labor between 24 and 34 weeks of gestation ²⁰. Studies have shown a decrease in intraventricular hemorrhage, respiratory distress syndrome and mortality even when treatment lasts for less than 24 hours, although optimal benefits begin 24 hours after therapy and last for seven days ²⁰. Corticosteroid therapy is also beneficial in pregnant women of less than 30 to 32 weeks of gestation with preterm premature rupture of membranes and no evidence of chorioamnionitis. Treatment regimens include betamethasone, in a dosage of 12 mg given intramuscularly every 24 hours for two days, or dexamethasone, in a dosage of 6 mg given intramuscularly every 12 hours for two days..

What is magnesium sulfate ?

Magnesium sulfate is a medication that may be given if you are less than 32 weeks pregnant, are in preterm labor, and are at risk of delivery within the next 24 hours. This medication may help reduce the risk of cerebral palsy that is associated with early preterm birth.

Magnesium sulfate acts centrally to decrease seizures and blocks neuromuscular transmission. The mechanism for preventing uterine contraction is unknown but may be related to calcium antagonist activity ²¹.

Complications associated with the use of magnesium sulfate are ²²:

• Maternal side effects include nausea, vomiting, hypotension, headache and the more severe effects of respiratory depression and pulmonary edema.
• Because magnesium sulfate crosses the placenta, fetal side effects include decreased muscle tone and lethargy. An immediate antidote to magnesium toxicity is an infusion of calcium gluconate.

What are tocolytics ?

Tocolytics are drugs used to delay delivery for a short time (up to 48 hours). They may allow time for corticosteroids or magnesium sulfate to be given or for you to be transferred to a hospital that offers specialized care for preterm infants. In addition to its role in protecting against cerebral palsy, magnesium sulfate also can be used as a tocolytic drug.

Drugs used for tocolysis include magnesium sulfate, ritodrine (Yutopar), terbutaline, nifedipine (Adalat, Procardia) and indomethacin (Indocin) ²³. Recent studies have shown that antocin (Atosiban), an oxytocin receptor inhibitor (not labeled by the FDA for this purpose) may also be effective ²⁴.

It is difficult to evaluate the efficacy of these drugs because of the inability to establish a definitive diagnosis of labor and the lack of consensus regarding the definition of successful treatment of preterm labor. However, it should be emphasized that tocolytic therapy has not been definitively shown to improve fetal outcome.

Oxytocin inhibitors offer a potential new therapeutic agent for the treatment of preterm labor. Although the exact mechanism of action is not known, uterine oxytocin receptors and/or oxytocin may have etiologic roles in uterine hyperactivity in women with preterm labor. Studies of the two oxytocin antagonists, antocin ²⁴ and an orally active nonpeptidyl oxytocin antagonist ²⁵, have suggested a high level of efficacy and few side effects (primarily nausea and vomiting). Phase III trials are currently being conducted to examine the effect of antocin on preterm uterine activity.

What happens if your labor does not stop ?

If your labor does not stop and it looks like you will give birth to your baby early, you and the baby usually will be cared for by a team of health care professionals. The team may include a neonatologist, a doctor who specializes in treating problems in newborns. The care your baby needs depends on how early he or she is born. High-level neonatal intensive care units provide this specialized care for preterm infants.

What is uterus transplant ?

In the year 2000, in Jeddah, Saudi Arabia, the first uterus transplant was attempted using a living donor in a woman submitted to emergency peripartum hysterectomy. Although the transplant did not result in pregnancy, it is credited with having achieved living-donor and recipient surgeries without major complications ²⁶. However, the uterus in the recipient only remained viable for 100 days ²⁷; the donor had a perioperative ureteral lesion, and it is questionable whether the uterus was correctly perfused. A necrotic uterus was removed after three months ²⁸.

In 2011, a second human uterus transplant was attempted. In Antalya, Turkey, a 21-year-old patient with MRKH – Mayer-Rokitansky-Küster-Hauser syndrome, a rare congenital condition that significantly impacts the lives of affected women, received a uterus from a deceased 22-year-old donor ²⁹. The donor’s multi-organ retrieval surgery lasted two hours, and the uterus was the first organ to be procured. The transplant procedure lasted six hours and included bilateral end-to-side anastomosis of the graft common iliac vessels to the external iliac vessels. The immunosuppression protocol included thymoglobulin for ten days and maintenance suppressive therapy with a triple-drug regimen with prednisolone, mycophenolate mofetil, and tacrolimus. Eighteen months after uterine transplant, the embryo-transfer attempts began. The patient attempted IVF multiple times, but only two very early miscarriages were observed ³⁰. The reasons for the failed pregnancies are unknown in this case; however, it is important to bear in mind that a nulliparous uterus was transplanted and that its capacity to carry a pregnancy to term had not been demonstrated.

Mayer–Rokitansky–Küster–Hauser Syndrome is characterized by the presence of only a rudimentary solid bipartite uterus in combination with absence of the upper third of the vagina. The syndrome accounts for <3% of Müllerian malformations ³¹, and it is seen in 1:4500 females ³². Three Mayer–Rokitansky–Küster–Hauser Syndrome subtypes exist: (i) the typical form, with no extra genital malformation (50% of patients); (ii) the atypical form, with associated malformations in the renal system (20% of patients) and (iii) the severe form, with associated renal and skeletal malformations. This type is also known as MURCS (Müllerian duct aplasia, Renal aplasia and Cervicothoracic Somite dysplasia) and is found in around 30% of these patients ³³. So far, Mayer–Rokitansky–Küster–Hauser Syndrome has been the main indication for uterus transplantation with nine patients being transplanted ³⁴.

Uterus transplantation is now a new type of quality of life enhancing as well as a life-giving transplantation, which is the first potential treatment for absolute uterine factor infertility ³⁵. This affects around 1 in every 500 women of fertile age,1 which on a worldwide base would be around 1.5 million women.

A unique feature of modern uterus transplantation is that it is temporary, since the allograft (the donated uterus) would be kept for a restricted time, until the recipient has delivered the desired number of children. The uterus would then be removed by hysterectomy or by discontinuing immunosuppression. This restricted time on immunosuppressive medications would minimize the long-term side effects of these potent pharmaceuticals ³⁶.

There were several mild rejection episodes, although subclinical, which were diagnosed on protocol cervical biopsies (1, 2, 4 weeks after surgery and thereafter monthly) in five out of the seven patients ³⁴. All the rejection events were effectively reversed by 2 weeks treatment of corticosteroid or tacrolimus dose increments. During the first post transplantation year, the uterine artery blood flow was within normal ranges ³⁴.

Single embryo transfers to achieve pregnancies were initiated 12 months after uterus transplantation, and the first live birth from our human clinical trial took place in September 2014 ³⁷. This is the first successful human uterus transplantation procedure, since the goal of the uterus transplantation is a healthy baby. The recipient had an uneventful pregnancy until she was admitted at 31 full weeks and 5 days due to headache, high blood pressure and pre-eclampsia was diagnosed. An abnormal fetal cardiotocography showing fetal distress was registered the following night, and a cesarean section was performed and a healthy and normal-sized (1.8 kg) male baby was delivered. The cause of pre-eclampsia may be related to her unilateral renal ageneneis ³⁸. Subsequently, three more uterus recipients have given birth (unpublished observations). All these, in total, four boys are developing in good health and thriving. Interestingly, in another one of these pregnancies, pre-eclampsia was developed and that patient had also a single kidney. The other two patients had double kidneys and did not develop pre-eclampsia. Additionally, there is presently, as of October 2015, one more ongoing pregnancy and doctors estimate that more live births will follow.

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24. Goodwin TM, Paul R, Silver H, Spellacy W, Parsons M, Chez R, et al. The effect of the oxytocin antagonist atosiban on preterm uterine activity in the human. Am J Obstet Gynecol. 1994;170:474–8.
25. Pettibone DJ, Clineschmidt BV, Kishel MT, Lis EV, Reiss DR, Woyden CJ, et al. Identification of an orally active, nonpeptidyl oxytocin antagonist. J Pharmacol Exp Ther. 1993;264:308–14.
26. Castellón LAR, Amador MIG, González RED, et al. The history behind successful uterine transplantation in humans. JBRA Assisted Reproduction. 2017;21(2):126-134. doi:10.5935/1518-0557.20170028. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5473706/
27. Transplantation of the human uterus. Fageeh W, Raffa H, Jabbad H, Marzouki A. Int J Gynaecol Obstet. 2002 Mar; 76(3):245-51. https://www.ncbi.nlm.nih.gov/pubmed/11880127/
28. Uterine transplantation research: laboratory protocols for clinical application. Díaz-García C, Johannesson L, Enskog A, Tzakis A, Olausson M, Brännström M. Mol Hum Reprod. 2012 Feb; 18(2):68-78. https://www.ncbi.nlm.nih.gov/pubmed/21900333/
29. Preliminary results of the first human uterus transplantation from a multiorgan donor. Ozkan O, Akar ME, Ozkan O, Erdogan O, Hadimioglu N, Yilmaz M, Gunseren F, Cincik M, Pestereli E, Kocak H, Mutlu D, Dinckan A, Gecici O, Bektas G, Suleymanlar G. Fertil Steril. 2013 Feb; 99(2):470-6. https://www.ncbi.nlm.nih.gov/pubmed/23084266/
30. Clinical pregnancy after uterus transplantation. Erman Akar M, Ozkan O, Aydinuraz B, Dirican K, Cincik M, Mendilcioglu I, Simsek M, Gunseren F, Kocak H, Ciftcioglu A, Gecici O, Ozkan O. Fertil Steril. 2013 Nov; 100(5):1358-63. https://www.ncbi.nlm.nih.gov/pubmed/23830110/
31. Clinical implications of uterine malformations and hysteroscopic treatment results. Hum Reprod Update. 2001 Mar-Apr;7(2):161-74. https://www.ncbi.nlm.nih.gov/pubmed/11284660
32. Müllerian agenesis: etiology, diagnosis, and management. Obstet Gynecol Surv. 2000 Oct;55(10):644-9. https://www.ncbi.nlm.nih.gov/pubmed/11023205
33. Clinical aspects of Mayer-Rokitansky-Kuester-Hauser syndrome: recommendations for clinical diagnosis and staging. Hum Reprod. 2006 Mar;21(3):792-7. Epub 2005 Nov 10. https://www.ncbi.nlm.nih.gov/pubmed/16284062
34. Uterus transplantation trial: 1-year outcome. Fertil Steril. 2015 Jan;103(1):199-204. doi: 10.1016/j.fertnstert.2014.09.024. Epub 2014 Oct 22. https://www.ncbi.nlm.nih.gov/pubmed/25439846
35. Pernilla Dahm-Kähler, Cesar Diaz-Garcia, Mats Brännström; Human uterus transplantation in focus, British Medical Bulletin, Volume 117, Issue 1, 1 March 2016, Pages 69–78, https://doi.org/10.1093/bmb/ldw002
36. Pernilla Dahm-Kähler, Cesar Diaz-Garcia, Mats Brännström; Human uterus transplantation in focus, British Medical Bulletin, Volume 117, Issue 1, 1 March 2016, Pages 69–78, https://doi.org/10.1093/bmb/ldw002
37. Livebirth after uterus transplantation. Lancet. 2015 Feb 14;385(9968):607-616. doi: 10.1016/S0140-6736(14)61728-1. Epub 2014 Oct 6. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61728-1/fulltext
38. Livebirth after uterus transplantation – Authors’ reply. Lancet. 2015 Jun 13;385(9985):2352-3. doi: 10.1016/S0140-6736(15)61098-4. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61098-4/fulltext

What is vas deferens

The vas deferens or the ductus deferens is a continuation of the duct of the epididymis (the spermatic cord). The term vasectomy, the surgical method of male contraception, consists of cutting out a short portion of the ductus deferens to interrupt the passage of sperm out of the testicles. Vas deferens is a muscular tube about 45 cm long and 2.5 mm in diameter. From the tail of the epididymis, it passes upward within the spermatic cord and inguinal canal and enters the pelvic cavity. There, it turns medially and approaches the urinary bladder. After passing between the bladder and ureter, the duct turns downward behind the bladder and widens into a terminal ampulla.

The vas deferens ends by uniting with the duct of the seminal vesicle. The duct has a very narrow lumen and a thick wall of smooth muscle well innervated by sympathetic nerve fibers.

The wall of the vas deferens consists of:

• An inner mucosa with the same pseudostratified epithelium as that of the epididymis, plus a lamina propria.
• An extremely thick muscularis. During ejaculation, the smooth muscle in the muscularis creates strong peristaltic waves that rapidly propel sperm through the ductus deferens to the urethra.
• An outer adventitia of connective tissue.

The ejaculatory duct is about 2 cm (1 in.) long and is formed by the union of the duct from the seminal vesicle and the ampulla of the vas deferens (see Figure 2). The short ejaculatory ducts form just superior to the base (superior portion) of the prostate and pass inferiorly and anteriorly through the prostate. They  terminate in the prostatic urethra, where they eject sperm and seminal vesicle secretions just before the release of semen from the urethra to the exterior.

Figure 1. Vas deferens location

Figure 2. Vas deferens

What is the function of the vas deferens

The ductus deferens or vas deferens, stores and transports sperm during ejaculation from the epididymis to the urethra. During ejaculation, vas deferens coordinated muscular contractions propel the spermatozoa toward the urethra. However, the vas deferens does not serve only as a conduit, but also contributes to secretion of fluid for sperm transport and possibly to resorption of spermatozoan remnants from the duct lumen ¹.

Vasectomy or ‘male sterilization’ : In this minor surgery, the physician makes a small incision into both sides of the scrotum, transects both vas deferens, and then closes the cut ends, either by tying them off or by fusing them shut by cauterization. Although sperm continue to be produced, they can no longer exit the body and are phagocytized in the epididymis.

Figure 3. Vasectomy

Vas deferens pain

The cause of the post-vasectomy pain syndrome is unclear ². Some postulated etiologies include epididymal congestion, tender sperm granuloma and/or nerve entrapment at the vasectomy site. Vasectomy reversal is reportedly successful for relieving pain in some patients ².

Chronic scrotal pain

Chronic scrotal pain is defined as pain in the scrotum of more than 3-month duration, appears to be a very common condition and well recognized symptom of young males ³, ⁴. Chronic scrotal pain is historically defined as an intermittent or constant testicular pain, unilateral or bilateral, lasting for over 3 months that interferes significantly with the patients daily activities ⁵.

The probable causes of chronic scrotal pain in young men are:

• Varicocele 54.1%
• Idiopathic (unknown) scrotal pain 34.4%
• Inguinal hernia 4.5%
• Genital infections 4.3%
• Hydrocele 4.2%
• Referred pain 3.3%
• Skin lesion 1.1%
• Torsion–detorsion 0.5%
• Trauma 0.2%
• Kidney stone 0.1%

Varicocele was found in 54.6% of the patients and was more common among patients with longer duration of symptoms (up to 60.6%). The prevalence of varicocele in normal young men estimated at 15–20% ⁶ and the prevalence of pain in individuals with varicocele is estimated between approximately 2 and 10% ⁷, which mean estimated prevalence of painful varicocele of 0.3–2% in normal young men population.

According to Granitsiotis et al. nearly 25% of patients with chronic scrotal pain have no obvious cause for the pain ⁸. In another study, no specific cause could be established in 1062 patients (34.4%) ⁹. The percentage of patients with idiopathic scrotal pain dropped with longer symptom duration. This may suggests that in patients with idiopathic scrotal pain who complain for longer periods of time, further evaluations were done and in most cases, varicocele was found and diagnosed as the presumed cause of the symptoms.

What is varicocele ?

A varicocele is an enlargement of the veins within the loose bag of skin that holds your testicles (scrotum) ¹⁰. A varicocele is similar to a varicose vein that can occur in your leg.

Varicoceles are a common cause of low sperm production and decreased sperm quality, which can cause infertility. However, not all varicoceles affect sperm production. Varicoceles can also cause testicles to fail to develop normally or shrink.

Most varicoceles develop over time. Fortunately, most varicoceles are easy to diagnose and many don’t need treatment. If a varicocele causes symptoms, it often can be repaired surgically.

Causes of varicocele

A varicocele forms when valves inside the veins that run along the spermatic cord prevent blood from flowing properly. Blood backs up, leading to swelling and widening of the veins. (This is similar to varicose veins in the legs).

Most of the time, varicoceles develop slowly. They are more common in men ages 15 to 25 and are most often seen on the left side of the scrotum.

A varicocele in an older man that appears suddenly may be caused by a kidney tumor, which can block blood flow to a vein. The problem is more common on the left side than the right.

Symptoms of varicocele

Symptoms include:

• Enlarged, twisted veins in the scrotum
• Painless testicle lump, scrotal swelling, or bulge in the scrotum
• Possible problems with fertility or decreased sperm count

Some men do not have symptoms.

How is varicocele diagnosed ?

You will have an exam of your groin area, including the scrotum and testicles. The health care provider may feel a twisted growth along the spermatic cord.

Sometimes the growth may not be able to be seen or felt, especially when you are lying down.

The testicle on the side of the varicocele may be smaller than the one on the other side.

Treatment of varicocele

A jock strap or snug underwear may help ease discomfort. You may need other treatment if the pain does not go away or you develop other symptoms.

Surgery to correct a varicocele is called varicocelectomy. For this procedure:

• You will receive some type of numbing medicine (anesthesia).
• The urologist will make a cut, most often in the lower abdomen, and tie off the abnormal veins. This directs blood flow in the area to the normal veins. The operation may also be done as a laparoscopic procedure (through small incisions with a camera).
• You will be able to leave the hospital on the same day as your surgery.
• You will need to keep an ice pack on the area for the first 24 hours after surgery to reduce swelling.

An alternative to surgery is varicocele embolization. For this procedure:

• A small hollow tube called a catheter (tube) is placed into a vein in your groin or neck area.
• The provider moves the tube into the varicocele using x-rays as a guide.
• A tiny coil passes through the tube into the varicocele. The coil blocks blood flow to the bad vein and sends it to normal veins.
• You will need to keep an ice pack on the area to reduce swelling and wear a scrotal support for a little while.

This method is also done without an overnight hospital stay. It uses a much smaller cut than surgery, so you will heal faster.

Outlook (Prognosis) for varicocele

A varicocele is often harmless and often does not need to be treated.

If you have surgery, your sperm count will likely increase. However, it will not improve your fertility. In most cases, testicular wasting (atrophy) does not improve unless surgery is done early in adolescence.

Possible Complications of varicocele

Infertility is a complication of varicocele.

Complications from treatment may include:

• Atrophic testis
• Blood clot formation
• Infection
• Injury to the scrotum or nearby blood vessel

When to Contact a Medical Professional

Call your provider if you discover a testicle lump or need to treat a diagnosed varicocele.

What is hydrocele ?

A hydrocele is a fluid-filled sac in the scrotum ¹¹.

Causes of hydrocele

Hydroceles are common in newborn infants.

During a baby’s development in the womb, the testicles descend from the abdomen through tube into the scrotum. Hydroceles occur when this tube does not close. Fluid drains from the abdomen through the open tube and gets trapped in the scrotum. This causes the scrotum to swell.

Most hydroceles go away a few months after birth. Sometimes, a hydrocele may occur with an inguinal hernia.

Hydroceles may also be caused by:

• Buildup of the normal fluid around the testicle. This may occur because the body makes too much of the fluid or it does not drain well. (This type of hydrocele is more common in older men.)
• Inflammation or injury of the testicle or epididymis

Symptoms of hydrocele

The main symptom is a painless, swollen testicle, which feels like a water balloon. A hydrocele may occur on one or both sides.

How is hydrocele diagnosed ?

You will have a physical exam. The health care provider will find that the scrotum is swollen, but not painful to the touch. Often, the testicle cannot be felt because of the fluid around it. The size of the fluid-filled sac can sometimes be increased and decreased by putting pressure on the abdomen or the scrotum.

If the size of the fluid collection changes, it is more likely to be due to an inguinal hernia.

Hydroceles can be easily seen by shining a flashlight through the swollen part of the scrotum. If the scrotum is full of clear fluid, the scrotum will light up.

You may need an ultrasound to confirm the diagnosis.

Treatment for hydrocele

Hydroceles are not harmful most of the time. They are treated only when they cause infection or discomfort.

Hydroceles from an inguinal hernia should be fixed with surgery as soon as possible. Hydroceles that do not go away on their own after a few months may need surgery. A surgical procedure called a hydrocelectomy (removal of sac lining) is often done to correct the problem. Needle drainage does not work well because the fluid will come back.

Outlook (Prognosis) of hydrocele

Simple hydroceles in children often go away without surgery. In adults, hydroceles usually do not go away on their own. If surgery is needed, it is an easy procedure with very good outcomes.

Possible Complications of hydrocele

Risks from hydrocele surgery may include:

• Blood clots
• Infection
• Injury to the scrotum

When to Contact a Medical Professional

Call your provider if you have symptoms of hydrocele. It is important to rule out other causes of a testicular lump.

Pain in the scrotum or testicles is an emergency. If you have pain and your scrotum is enlarged, seek medical help right away to prevent the loss of the testicle.

What is inguinal hernia ?

An inguinal hernia happens when contents of the abdomen—usually fat or part of the small intestine—bulge through a weak area in the lower abdominal wall. The abdomen is the area between the chest and the hips. The area of the lower abdominal wall is also called the inguinal or groin region.

Two types of inguinal hernias are:

• Indirect inguinal hernias, which are caused by a defect in the abdominal wall that is congenital, or present at birth
• Direct inguinal hernias, which usually occur only in male adults and are caused by a weakness in the muscles of the abdominal wall that develops over time

Inguinal hernias occur at the inguinal canal in the groin region.

Figure 4. Inguinal hernia

What causes inguinal hernias ?

The cause of inguinal hernias depends on the type of inguinal hernia.

Indirect inguinal hernias. A defect in the abdominal wall that is present at birth causes an indirect inguinal hernia.

During the development of the fetus in the womb, the lining of the abdominal cavity forms and extends into the inguinal canal. In males, the spermatic cord and testicles descend out from inside the abdomen and through the abdominal lining to the scrotum through the inguinal canal. Next, the abdominal lining usually closes off the entrance to the inguinal canal a few weeks before or after birth. In females, the ovaries do not descend out from inside the abdomen, and the abdominal lining usually closes a couple of months before birth ¹².

Sometimes the lining of the abdomen does not close as it should, leaving an opening in the abdominal wall at the upper part of the inguinal canal. Fat or part of the small intestine may slide into the inguinal canal through this opening, causing a hernia. In females, the ovaries may also slide into the inguinal canal and cause a hernia.

Indirect hernias are the most common type of inguinal hernia ¹³. Indirect inguinal hernias may appear in 2 to 3 percent of male children; however, they are much less common in female children, occurring in less than 1 percent ¹⁴.

Direct inguinal hernias. Direct inguinal hernias usually occur only in male adults as aging and stress or strain weaken the abdominal muscles around the inguinal canal. Previous surgery in the lower abdomen can also weaken the abdominal muscles.

Females rarely form this type of inguinal hernia. In females, the broad ligament of the uterus acts as an additional barrier behind the muscle layer of the lower abdominal wall. The broad ligament of the uterus is a sheet of tissue that supports the uterus and other reproductive organs.

Who is more likely to develop an inguinal hernia ?

Males are much more likely to develop inguinal hernias than females. About 25 percent of males and about 2 percent of females will develop an inguinal hernia in their lifetimes.2 Some people who have an inguinal hernia on one side will have or will develop a hernia on the other side.

People of any age can develop inguinal hernias. Indirect hernias can appear before age 1 and often appear before age 30; however, they may appear later in life. Premature infants have a higher chance of developing an indirect inguinal hernia. Direct hernias, which usually only occur in male adults, are much more common in men older than age 40 because the muscles of the abdominal wall weaken with age ¹⁵.

People with a family history of inguinal hernias are more likely to develop inguinal hernias. Studies also suggest that people who smoke have an increased risk of inguinal hernias ¹⁶.

What are the signs and symptoms of an inguinal hernia ?

The first sign of an inguinal hernia is a small bulge on one or, rarely, on both sides of the groin—the area just above the groin crease between the lower abdomen and the thigh. The bulge may increase in size over time and usually disappears when lying down.

Other signs and symptoms can include:

• discomfort or pain in the groin—especially when straining, lifting, coughing, or exercising—that improves when resting
• feelings such as weakness, heaviness, burning, or aching in the groin
• a swollen or an enlarged scrotum in men or boys

Indirect and direct inguinal hernias may slide in and out of the abdomen into the inguinal canal. A health care provider can often move them back into the abdomen with gentle massage.

What are the complications of inguinal hernias ?

Inguinal hernias can cause the following complications:

• Incarceration. An incarcerated hernia happens when part of the fat or small intestine from inside the abdomen becomes stuck in the groin or scrotum and cannot go back into the abdomen. A health care provider is unable to massage the hernia back into the abdomen.
• Strangulation. When an incarcerated hernia is not treated, the blood supply to the small intestine may become obstructed, causing “strangulation” of the small intestine. This lack of blood supply is an emergency situation and can cause the section of the intestine to die.

How are inguinal hernias treated ?

Repair of an inguinal hernia via surgery is the only treatment for inguinal hernias and can prevent incarceration and strangulation. Health care providers recommend surgery for most people with inguinal hernias and especially for people with hernias that cause symptoms. Research suggests that men with hernias that cause few or no symptoms may be able to safely delay surgery until their symptoms increase.3, 6 Men who delay surgery should watch for symptoms and see a health care provider regularly. Health care providers usually recommend surgery for infants and children to prevent incarceration.1 Emergent, or immediate, surgery is necessary for incarcerated or strangulated hernias.

A general surgeon—a doctor who specializes in abdominal surgery—performs hernia surgery at a hospital or surgery center, usually on an outpatient basis. Recovery time varies depending on the size of the hernia, the technique used, and the age and health of the person.

Hernia surgery is also called herniorrhaphy. The two main types of surgery for hernias are:

• Open hernia repair. During an open hernia repair, a health care provider usually gives a patient local anesthesia in the abdomen with sedation; however, some patients may have
  sedation with a spinal block, in which a health care provider injects anesthetics around the nerves in the spine, making the body numb from the waist down
  general anesthesia

The surgeon makes an incision in the groin, moves the hernia back into the abdomen, and reinforces the abdominal wall with stitches. Usually the surgeon also reinforces the weak area with a synthetic mesh or “screen” to provide additional support.

• Laparoscopic hernia repair. A surgeon performs laparoscopic hernia repair with the patient under general anesthesia. The surgeon makes several small, half-inch incisions in the lower abdomen and inserts a laparoscope—a thin tube with a tiny video camera attached. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the hernia and surrounding tissue. While watching the monitor, the surgeon repairs the hernia using synthetic mesh or “screen.”

People who undergo laparoscopic hernia repair generally experience a shorter recovery time than those who have an open hernia repair. However, the surgeon may determine that laparoscopy is not the best option if the hernia is large or if the person has had previous pelvic surgery.

Most adults experience discomfort and require pain medication after either an open hernia repair or a laparoscopic hernia repair. Intense activity and heavy lifting are restricted for several weeks. The surgeon will discuss when a person may safely return to work. Infants and children also experience some discomfort; however, they usually resume normal activities after several days.

Surgery to repair an inguinal hernia is quite safe, and complications are uncommon. People should contact their health care provider if any of the following symptoms appear:

• redness around or drainage from the incision
• fever
• bleeding from the incision
• pain that is not relieved by medication or pain that suddenly worsens

Possible long-term complications include:

• long-lasting pain in the groin
• recurrence of the hernia, requiring a second surgery
• damage to nerves near the hernia

How can inguinal hernias be prevented ?

People cannot prevent the weakness in the abdominal wall that causes indirect inguinal hernias. However, people may be able to prevent direct inguinal hernias by maintaining a healthy weight and not smoking.

People can keep inguinal hernias from getting worse or keep inguinal hernias from recurring after surgery by

• avoiding heavy lifting
• using the legs, not the back, when lifting objects
• preventing constipation and straining during bowel movements
• maintaining a healthy weight
• not smoking.

1. Koslov DS, Andersson K-E. Physiological and pharmacological aspects of the vas deferens—an update. Frontiers in Pharmacology. 2013;4:101. doi:10.3389/fphar.2013.00101. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3749770/
2. Vasectomy reversal for the post-vasectomy pain syndrome: a clinical and histological evaluation. J Urol. 2000 Dec;164(6):1939-42. https://www.ncbi.nlm.nih.gov/pubmed/11061886
3. Aljumaily A, Al-Khazraji H, Gordon A, Lau S, Jarvi KA. Characteristics and Etiologies of Chronic Scrotal Pain: A Common but Poorly Understood Condition. Pain Research & Management. 2017;2017:3829168. doi:10.1155/2017/3829168. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5352901/
4. Rottenstreich M, Glick Y, Gofrit ON. Chronic scrotal pain in young adults. BMC Research Notes. 2017;10:241. doi:10.1186/s13104-017-2590-0. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496592/
5. Analysis and management of chronic testicular pain. Davis BE, Noble MJ, Weigel JW, Foret JD, Mebust WK. J Urol. 1990 May; 143(5):936-9. https://www.ncbi.nlm.nih.gov/pubmed/2329609
6. Evaluation of scrotal masses. Crawford P, Crop JA. Am Fam Physician. 2014 May 1; 89(9):723-7. https://www.ncbi.nlm.nih.gov/pubmed/24784335/
7. Outcomes of varicocele ligation done for pain. Peterson AC, Lance RS, Ruiz HE. J Urol. 1998 May; 159(5):1565-7. https://www.ncbi.nlm.nih.gov/pubmed/9554356/
8. Chronic testicular pain: an overview. Granitsiotis P, Kirk D. Eur Urol. 2004 Apr; 45(4):430-6. https://www.ncbi.nlm.nih.gov/pubmed/15041105/
9. Rottenstreich M, Glick Y, Gofrit ON. Chronic scrotal pain in young adults. BMC Research Notes. 2017;10:241. doi:10.1186/s13104-017-2590-0. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496592
10. Varicocele. Medline Plus. https://medlineplus.gov/ency/article/001284.htm
11. Hydrocele. Medline Plus. https://medlineplus.gov/ency/article/000518.htm
12. Aiken JJ, Oldham KT. Chapter 38: Inguinal hernias. In: Kleigman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia: Elsevier Saunders; 2011: 1362–1368.
13. https://emedicine.medscape.com/article/189563-overview#aw2aab6b2b3
14. Kelly KB, Ponsky TA. Pediatric abdominal wall defects. Surgical Clinics of North America. 2013;93(5):1255–1267.
15. Quintas ML, Rodrigues CJ, Yoo JH, Rodrigues Junior AJ. Age related changes in the elastic fiber system of the interfoveolar ligament. Revista do Hospital das Clínicas. 2000;55(3):83–86.
16. Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13(4):343–403.

What is seminal vesicle

The seminal vesicles (seminal glands) are convoluted pouchlike structures (pair of seminal glands) posterior to the urinary bladder; one is associated with each ductus deferens. A seminal vesicle is about 5 cm long, with approximately the dimensions of one’s little finger. It has a connective tissue capsule and underlying layer of smooth muscle. The secretory portion is a very convoluted duct with numerous branches that form a complex labyrinth. It empties into the ejaculatory duct. Each ejaculatory duct is about 2 cm (1 in.) long and is formed by the union of the duct from the seminal vesicle and the ampulla of the ductus (vas) deferens. The short ejaculatory ducts form just superior to the base (superior portion) of the prostate and pass inferiorly and anteriorly through the prostate. They terminate in the prostatic urethra, where they eject sperm and seminal vesicle secretions just before the release of semen from the urethra to the exterior.

The yellowish secretion of the seminal vesicles constitutes about 60% of the semen.

Figure 1. Seminal vesicle location

Figure 2. Seminal vesicle

What does the seminal vesicle do

The fluid expelled during orgasm is called semen (seminal fluid). A typical ejaculation discharges 2 to 5 mL of semen, composed of about 10% sperm and spermatic duct secretions, 30% prostatic fluid, 60% seminal vesicle fluid, and a trace of bulbourethral fluid. Most of the sperm emerge in the first one or two jets of semen. The semen usually has a sperm count of 50 to 120 million sperm/mL. A sperm count any lower than 20 to 25 million sperm/mL is usually associated with infertility (sterility), the inability to fertilize an egg.

The prostate and seminal vesicles contribute the following constituents to the semen:

1. The prostate produces a thin, milky white fluid containing calcium, citrate, and phosphate ions, which is a nutrient for the sperm,; a clotting enzyme; and a protein-hydrolyzing enzyme called serine protease (prostate-specific antigen, PSA), which is an enzyme that helps liquefy semen. Measuring the levels of PSA  (prostate-specific antigen) in a man’s blood is the most important method of screening for prostate cancer
2. The seminal vesicles contribute an alkaline viscous yellowish fluid, the last component of the semen to emerge. It contains fructose and other carbohydrates, citrate, prostaglandins and clotting proteins called prosemenogelin that are different from those in blood. The alkaline nature of the seminal
   fluid helps to neutralize the acidic environment of the male urethra and female reproductive tract that otherwise would inactivate and kill sperm. The fructose is used for ATP production by sperm. Prostaglandins contribute to sperm motility and viability and may stimulate smooth muscle contractions within the female reproductive tract. The clotting proteins help semen coagulate after ejaculation. It is thought that coagulation occurs in order to keep sperm cells from leaking from the vagina. Fluid secreted by the seminal vesicles normally constitutes about 60% of the volume of semen.

Seminal vesicle cancer

Seminal vesicle cancer (primary malignancy) are extremely rare in clinical practice ¹ and only 100 such cases have been reported in the literature ². However secondary spread is quite common either due to disseminated disease or by contiguous spread from adjacent organ, most commonly from prostate cancer ³. Most common organs from where malignancies spread to seminal vesicle are prostate, bladder and rectum. About 12% of prostate malignancy involves seminal vesicle. Bladder and rectal malignancies involve seminal vesicle only when the primary is locally advanced.

It is important to differentiate between primary and secondary spread as the former is a localized disease with possibility of cure while the later is usually an advanced disease with dismal prognosis. There is paucity of data regarding management protocols and most of the time the treatment is individualized.

Symptoms of seminal vesicle cancer can be hematospermia (blood in semen) and pain during ejaculation ¹.

Types of seminal vesicle cancers

Seminal vesicle malignancies are classified as adenocarcinoma, mesenchymal tumors and mixed epithelial tumors. Adenocarcinoma is the most common primary malignant tumor of the seminal vesicle with the tumour confined to the seminal vesicle without prostatic involvement ¹. Immunohistochemical studies should be negative for both PSA and prostate specific acid phosphatise ⁴. Mixed epithelial tumors ⁵ should have no normal seminal vesicle inside the tumor, without invasion of the prostate and immunohistochemical studies should be negative for both PSA and prostate specific acid phosphatase.

Operable primary seminal vesicle adenocarcinomas are treated with radical surgery – cystoprostosemino-vesiculolectomy with bilateral pelvic lymphadenectomy. Long term survival data are not available. No definite recommendations are available for adjuvant therapy, which must be individualized.

Inflammation of the seminal vesicle

Seminal vesiculitis is the seminal vesicles inflammation ⁶. It is a common disease of male urogenital tract. Its cause is unclear, but the lack of semenogelin I secretion is believed to be the cause of seminal vesiculitits, as it has antibacterial properties to prevent bacterial inflammation ⁷. Patients with seminal vesiculitis present with hematospermia (blood in semen), discomfort and pain in lumbosacral or perineal region, irritative and obstructive urinary symptoms, decreased semen volume, and/or azoospermia (absence of motile and hence viable sperm in the semen) ⁸. CT and MRI diagnose the complication and transurethral surgery corrected the issue ⁸. Transrectal ultrasonography (TRUS) can diagnosis cases of seminal vesiculitis, as well ⁹. Furuya et. al ¹⁰ determined that patients with urethritis are likely to have seminal vesiculitis, suggesting a close relationship between them. It is also known that epididymitis is possible along with seminal vesiculitis ¹¹.

Seminal vesicle cyst infection

Seminal vesicle cyst infection occurs because of bacterial infection and can result in many complications. Palmer et. al ¹² reported a case of patient presenting symptoms of perineal pain and fever. The patient had come in earlier with methicillin-sensitive staphylococcus aureus bacterium, and was treated with antibiotics. CT revealed an expansion of a seminal vesicle cyst, and MRI was used to confirm the diagnosis as infected cyst. Cyst was drained and it was determined that methicillin-sensitive bacterium was the cause of infection and the patient was discharged on vancomycin ¹². Xu et al ¹³ study revealed hematospermia due to seminal vesicle cyst infection. Transvesical removal of mass was an effective surgical procedure to alleviate the disease.

Seminal vesicle abscess

Seminal vesicles abscess is a rare pathology that is rarely encountered ¹⁴. It is an infection that develops on seminal vesicles due to bacterial or viral microorganisms. Patients suffering from seminal vesicles abscess present with many uro-genital symptoms ¹⁵. Abscesses of the seminal vesicles may develop secondary to a surgical procedure due to infection. Seminal vesicles abscess may be developed secondary to vasectomy, tuberculosis, and prostate biopsy (38-41). There are different diagnostic modalities present to diagnosis seminal vesicles abscess, CT, MRI, but TRUS should be primary means of diagnosis ¹⁶. Cui et al ¹⁷ described another modality, transurethral seminal vesiculoscopy, which is used to diagnosis and treat hematospermia secondary to seminal vesicles. Drainage of abscess is the most common means of treatment ¹⁸.

1. Ramamurthy R, Periasamy S, Mettupalayam V. Primary malignancy of seminal vesicle: A rare entity. Indian Journal of Urology : IJU : Journal of the Urological Society of India. 2011;27(1):137-139. doi:10.4103/0970-1591.78417. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3114576/
2. Bostwick DG. Urologic surgical pathology. In: Bostwick DG, editor. Seminal Vesicles. 2nd ed. China: Mosby Elsevier; 2008. pp. 582–90.
3. Turek PJ. Seminal vesicle and Ejaculatory duct surgery. In: Graham SD, editor. Glenn’s urologic surgery. 6th ed. Philadelphia: Lippincott: Williams and Wilkins; 2004. pp. 439–49.
4. Primary adenocarcinoma of the seminal vesicle. Tarján M, Ottlecz I, Tot T. Indian J Urol. 2009 Jan; 25(1):143-5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684320/
5. Low-grade phyllodes tumor of the seminal vesicle treated with laparoscopic excision. Khan MS, Zaheer LU, Ahmed K, Cahill D, Horsfield C, Rottenberg G, Dasgupta P. Nat Clin Pract Urol. 2007 Jul; 4(7):395-400. https://www.ncbi.nlm.nih.gov/pubmed/17615551/
6. Dagur G, Warren K, Suh Y, Singh N, Khan SA. Detecting diseases of neglected seminal vesicles using imaging modalities: A review of current literature. International Journal of Reproductive Biomedicine. 2016;14(5):293-302. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910035/
7. Liu B, Song Z, Xu A, Su S, Wang Z, Yin C. Is abnormal expression of semenogelin I involved with seminal vesiculitis? Med Hypotheses. 2014;82:338–340. https://www.ncbi.nlm.nih.gov/pubmed/24472869
8. Li YF, Liang PH, Sun ZY, Zhang Y, Bi G, Zhou B, et al. Imaging diagnosis, transurethral endoscopic observation, and management of 43 cases of persistent and refractory hematospermia. J Androl. 2012;33:906–916. https://www.ncbi.nlm.nih.gov/pubmed/22323622
9. Xu B, Li P, Niu X, Zhang X, Wang Z, Qin C, et al. A new method of chronic and recurrent seminal vesiculitis treatment. J Endourol. 2011;25:1815–1818. https://www.ncbi.nlm.nih.gov/pubmed/21870960
10. Furuya R, Takahashi S, Furuya S, Saitoh N, Ogura H, Kurimura Y, et al. Is urethritis accompanied by seminal vesiculitis? Int J Urol. 2009;16:628–631. https://www.ncbi.nlm.nih.gov/pubmed/19456989
11. Furuya R, Takahashi S, Furuya S, Takeyama K, Masumori N, Tsukamoto T. Chlamydial seminal vesiculitis without symptomatic urethritis and epididymitis. Int J Urol. 2006;13:466–467. https://www.ncbi.nlm.nih.gov/pubmed/16734877
12. Palmer WC, Patel NC, Renew JR, Bridges MD, Stancampiano FF. Acute infection of a documented seminal vesicle cyst via hematogenous seeding. Urol J. 2013;10:1157–1159. http://www.urologyjournal.org/index.php/uj/article/view/1181/768
13. Xu LW, Cheng S, Zhang ZG, Li XD. [Transvesical removal of seminal vesicle mass: a report of 5 cases] Zhonghua Nan Ke Xue. 2009;15:357–359. https://www.ncbi.nlm.nih.gov/pubmed/19472913
14. Saha S, Wright G, Arulampalam T, Corr J. An unusual groin mass. Seminal vesicle abscess: a case report. Cases Journal. 2009;2:6531. doi:10.1186/1757-1626-2-6531. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740224/
15. Madrid Garcia FJ, Madronero Cuevas C, Rivas Escudero JA, Parra Muntaner L, Monsalve Rodriguez M, Garcia Alonso J. [Conservative treatment of a seminal vesicle abscess Report of one case] Arch Esp Urol. 2004;57:438–440. https://www.ncbi.nlm.nih.gov/pubmed/15270290
16. Bayne CE, Davis WA, Rothstein CP, Engel JD. Seminal vesicle abscess following prostate biopsy requiring transgluteal percutaneous drainage. Can J Urol. 2013;20:6811–6814. https://www.ncbi.nlm.nih.gov/pubmed/23783054
17. Cui ZQ, Wang YC, Du J, Zhou HJ, Yu ZY, Gao EJ, et al. [Transurethral seminal vesiculoscopy combined with finasteride for recurrent hematospermia] Zhonghua Nan Ke Xue. 2014;20:536–538. https://www.ncbi.nlm.nih.gov/pubmed/25029861
18. Monzo JI, Lledo Garcia E, Cabello Benavente R, Moralejo Garate M, Diez Cordero JM, Hernandez Fernandez C. [Primary seminal vesicle abscess: diagnosis and treatment by transrectal ultrasound] Actas Urol Esp. 2005;29:523–525. https://www.ncbi.nlm.nih.gov/pubmed/16013801

What is prostate gland

The prostate is a gland found only in men, which forms an important part of the male reproductive system. The prostate gland secretes a fluid that keeps sperm alive and healthy and that forms part of semen.

The prostate is a chestnut-shaped structure that surrounds the urethra and ejaculatory ducts. The prostate is found behind the base of the penis and immediately underneath the urinary bladder. It measures about 2 × 4 × 3 cm and is an aggregate of 30 to 50 compound tubuloacinar glands enclosed in a single fibrous capsule. These glands empty through about 20 pores in the urethral wall. The stroma of the prostate consists of connective tissue and smooth muscle, like that of the seminal vesicles. The thin, milky secretion of the prostate constitutes about 30% of the semen.

The urethra, the tube that carries urine from the bladder to the penis, runs through the middle of the prostate.

The prostate slowly increases in size from birth to puberty. It then expands rapidly until about age 30, after which time its size typically remains stable until about age 40-45, when further enlargement may occur, constricting the urethra and interfering with urine flow.

In addition to its susceptibility to prostate cancer and tumors, the prostate is also subject to infection in sexually transmitted diseases (STDs). Prostatitis, inflammation of the prostate, is the single most common reason that men consult a urologist.

Figure 1. Prostate gland

What does the prostate gland do

The fluid expelled during orgasm is called semen (seminal fluid). A typical ejaculation discharges 2 to 5 mL of semen, composed of about 10% sperm and spermatic duct secretions, 30% prostatic fluid, 60% seminal vesicle fluid, and a trace of bulbourethral fluid. Most of the sperm emerge in the first one or two jets of semen. The semen usually has a sperm count of 50 to 120 million sperm/mL. A sperm count any lower than 20 to 25 million sperm/mL is usually associated with infertility (sterility), the inability to fertilize an egg.

The prostate and seminal vesicles contribute the following constituents to the semen:

1. The prostate produces a thin, milky, slightly acidic (pH about 6.5) white fluid containing calcium, citrate, and phosphate ions, which is a nutrient for the sperm, a clotting enzyme; and a protein-hydrolyzing enzyme called serine protease (prostate-specific antigen, PSA), which is an enzyme that helps liquefy semen. Measuring the levels of PSA  (prostate-specific antigen) in a man’s blood is the most important method of screening for prostate cancer. The citric acid in prostatic fluid is used by sperm for ATP production via the Krebs cycle. Several proteolytic enzymes, such as prostate-specific antigen (PSA), pepsinogen, lysozyme, amylase, and hyaluronidase, eventually break down the clotting proteins from the seminal vesicles. The function of the acid phosphatase secreted by the prostate is unknown. Seminalplasmin in prostatic fluid is an antibiotic that can destroy bacteria. Seminalplasmin may help decrease the number of naturally occurring bacteria in semen and in the lower female reproductive tract. Secretions of the prostate enter the prostatic urethra through many prostatic ducts. Prostatic secretions make up about 30% of the volume of semen and contribute to sperm motility and viability.
2. The seminal vesicles contribute a viscous yellowish fluid, the last component of the semen to emerge. It contains fructose and other carbohydrates, citrate, prostaglandins and a clotting protein called prosemenogelin.

What is prostatitis ?

Prostatitis is a frequently painful condition that involves inflammation of the prostate and sometimes the areas around the prostate ¹.

Scientists have identified four types of prostatitis:

• chronic prostatitis/chronic pelvic pain syndrome
• acute bacterial prostatitis
• chronic bacterial prostatitis
• asymptomatic inflammatory prostatitis

Men with asymptomatic inflammatory prostatitis do not have symptoms. A health care provider may diagnose asymptomatic inflammatory prostatitis when testing for other urinary tract or reproductive tract disorders. This type of prostatitis does not cause complications and does not need treatment.

Symptoms of prostatitis

Prostatitis signs and symptoms depend on the cause. They can include:

• Pain or burning sensation when urinating (dysuria)
• Difficulty urinating, such as dribbling or hesitant urination
• Frequent urination, particularly at night (nocturia)
• Urgent need to urinate
• Cloudy urine
• Blood in the urine
• Pain in the abdomen, groin or lower back
• Pain in the area between the scrotum and rectum (perineum)
• Pain or discomfort of the penis or testicles
• Painful ejaculation
• Flu-like signs and symptoms (with bacterial prostatitis)

When to see a doctor

If you have pelvic pain, difficult or painful urination, or painful ejaculation, see your doctor. If left untreated, some types of prostatitis can cause worsening infection or other health problems.

Causes of prostatitis

Acute bacterial prostatitis is often caused by common strains of bacteria. The infection can start when bacteria in urine leak into your prostate. Antibiotics are used to treat the infection. If they don’t eliminate the bacteria prostatitis might recur or be difficult to treat (chronic bacterial prostatitis).

Nerve damage in the lower urinary tract, which can be caused by surgery or trauma to the area, might contribute to prostatitis not caused by a bacterial infection. In many cases of prostatitis, the cause isn’t identified.

Risk factors for prostatitis

Risk factors for prostatitis include:

• Being a young or middle-aged
• Having had prostatitis
• Having an infection in the bladder or the tube that transports semen and urine to the penis (urethra)
• Having pelvic trauma, such as an injury from bicycling or horseback riding
• Using a tube inserted into the urethra to drain the bladder (urinary catheter)
• Having HIV/AIDS
• Having had a prostate biopsy

Complications of prostatitis

Complications of prostatitis can include:

• Bacterial infection of the blood (bacteremia)
• Inflammation of the coiled tube attached to the back of the testicle (epididymitis)
• Pus-filled cavity in the prostate (prostatic abscess)
• Semen abnormalities and infertility, which can occur with chronic prostatitis

There’s no direct evidence that prostatitis can lead to prostate cancer.

Diagnosis of prostatitis

Diagnosing prostatitis involves ruling out other conditions as the cause of your symptoms and determining what kind of prostatitis you have. Your doctor will ask about your medical history and your symptoms. He or she will also do a physical exam, which will likely include a digital rectal examination.

Initial diagnostic tests might include:

• Urine tests. Your doctor might have a sample of your urine analyzed to look for signs of infection in your urine (urinalysis). Your doctor might also send a sample of your urine to a lab to determine if you have an infection.
• Blood tests. Your doctor might examine samples of your blood for signs of infection and other prostate problems.
• Post-prostatic massage. In rare cases, your doctor might massage your prostate and test the secretions.
• Imaging tests. In some cases, your doctor might order a CT scan of your urinary tract and prostate or a sonogram of your prostate. CT scan images provide more detailed information than plain X-rays do. A sonogram is the visual image produced by an ultrasound.

Based on your symptoms and test results, your doctor might conclude that you have one of the following types of prostatitis:

• Acute bacterial prostatitis. Often caused by common strains of bacteria, this type of prostatitis generally starts suddenly and causes flu-like signs and symptoms, such as fever, chills, nausea and vomiting.
• Chronic bacterial prostatitis. When antibiotics don’t eliminate the bacteria causing prostatitis, you can develop recurring or difficult-to-treat infections. Between bouts of chronic bacterial prostatitis, you might have no symptoms or only minor ones.
• Chronic prostatitis/chronic pelvic pain syndrome. This type of prostatitis — the most common —isn’t caused by bacteria. Often an exact cause can’t be identified. For some men, symptoms stay about the same over time. For others, the symptoms go through cycles of being more and less severe.
• Asymptomatic inflammatory prostatitis. This type of prostatitis doesn’t cause symptoms and is usually found only by chance when you’re undergoing tests for other conditions. It doesn’t require treatment.

Treatment for prostatitis

Prostatitis treatments depend on the underlying cause. They can include:

• Antibiotics. This is the most commonly prescribed treatment for prostatitis. Your doctor will choose your medication based on the type of bacteria that might be causing your infection.

If you have severe symptoms, you might need intravenous (IV) antibiotics. You’ll likely need to take oral antibiotics for four to six weeks but might need longer treatment for chronic or recurring prostatitis.

• Alpha blockers. These medications help relax the bladder neck and the muscle fibers where your prostate joins your bladder. This treatment might ease symptoms, such as painful urination.

• Anti-inflammatory agents. Nonsteroidal anti-inflammatory drugs (NSAIDs) might make you more comfortable.

Home remedies for prostatitis

The following might ease some symptoms of prostatitis:

• Soak in a warm bath (sitz bath) or use a heating pad.
• Limit or avoid alcohol, caffeine, and spicy or acidic foods, which can irritate your bladder.
• Avoid activities that can irritate your prostate, such as prolonged sitting or bicycling.
• Drink plenty of caffeine-free beverages. This will cause you to urinate more and help flush bacteria from your bladder.

Alternative therapies that show some promise for reducing symptoms of prostatitis include:

• Biofeedback. A biofeedback specialist uses signals from monitoring equipment to teach you to control certain body functions and responses, including relaxing your muscles.
• Acupuncture. This involves inserting very thin needles through your skin to various depths at certain points on your body.
• Herbal remedies and supplements. There’s no evidence that herbs and supplements improve prostatitis, although many men take them. Some herbal treatments for prostatitis include rye grass (cernilton), a chemical found in green tea, onions and other plants (quercetin) and extract of the saw palmetto plant.

Discuss your use of alternative medicine practices and supplements with your doctor.

What is benign prostatic hyperplasia

An enlarged prostate is also called benign prostatic hyperplasia (BPH) ². Most men will have enlarged prostate (benign prostatic hyperplasia) as they get older. Symptoms often start after age 50.

In 2010, as many as 14 million men in the United States had lower urinary tract symptoms suggestive of benign prostatic hyperplasia ³. Although benign prostatic hyperplasia rarely causes symptoms before age 40, the occurrence and symptoms increase with age. Benign prostatic hyperplasia affects about 50 percent of men between the ages of 51 and 60 and up to 90 percent of men older than 80 ⁴.

Benign prostatic hyperplasia (BPH) is not cancer, and it does not seem to increase your chance of getting prostate cancer ². But the early symptoms are the same. Check with your doctor if you have:

• A frequent and urgent need to urinate, especially at night
• Trouble starting a urine stream or making more than a dribble
• A urine stream that is weak, slow, or stops and starts several times
• The feeling that you still have to go, even just after urinating
• Small amounts of blood in your urine

Severe benign prostatic hyperplasia (BPH) can cause serious problems over time. Untreated, prostate gland enlargement can block the flow of urine out of the bladder and cause bladder, urinary tract or kidney problems. If it is found early, you are less likely to develop these problems.

Tests for benign prostatic hyperplasia (BPH) include a digital rectal exam, blood and imaging tests, a urine flow study, and examination with a scope called a cystoscope. Treatments include watchful waiting, medicines, nonsurgical procedures, and surgery.

Symptoms of benign prostatic hyperplasia

The severity of symptoms in people who have prostate gland enlargement varies, but symptoms tend to gradually worsen over time. Common signs and symptoms of benign prostatic hyperplasia include:

• Frequent or urgent need to urinate
• Increased frequency of urination at night (nocturia)
• Difficulty starting urination
• Weak urine stream or a stream that stops and starts
• Dribbling at the end of urination
• Straining while urinating
• Inability to completely empty the bladder

Less common signs and symptoms include:

• Urinary tract infection
• Inability to urinate
• Blood in the urine

The size of your prostate doesn’t necessarily mean your symptoms will be worse. Some men with only slightly enlarged prostates can have significant symptoms, while other men with very enlarged prostates can have only minor urinary symptoms.

In some men, symptoms eventually stabilize and might even improve over time.

Other possible causes of urinary symptoms

Conditions that can lead to symptoms similar to those caused by enlarged prostate include:

• Urinary tract infection
• Inflammation of the prostate (prostatitis)
• Narrowing of the urethra (urethral stricture)
• Scarring in the bladder neck as a result of previous surgery
• Bladder or kidney stones
• Problems with nerves that control the bladder
• Cancer of the prostate or bladder

When to see a doctor

If you’re having urinary problems, discuss them with your doctor. Even if you don’t find urinary symptoms bothersome, it’s important to identify or rule out any underlying causes. Untreated, urinary problems might lead to obstruction of the urinary tract.

If you’re unable to pass any urine, seek immediate medical attention.

Causes of benign prostatic hyperplasia

The prostate gland is located beneath your bladder. The tube that transports urine from the bladder out of your penis (urethra) passes through the center of the prostate. When the prostate enlarges, it begins to block urine flow.

Most men have continued prostate growth throughout life. In many men, this continued growth enlarges the prostate enough to cause urinary symptoms or to significantly block urine flow.

It isn’t entirely clear what causes the prostate to enlarge. However, it might be due to changes in the balance of sex hormones as men grow older.

Risk factors for benign prostatic hyperplasia

Risk factors for prostate gland enlargement include:

• Aging. Prostate gland enlargement rarely causes signs and symptoms in men younger than age 40. About one-third of men experience moderate to severe symptoms by age 60, and about half do so by age 80.
• Family history. Having a blood relative, such as a father or brother, with prostate problems means you’re more likely to have problems.
• Ethnic background. Prostate enlargement is less common in Asian men than in white and black men. Black men might experience symptoms at a younger age than white men.
• Diabetes and heart disease. Studies show that diabetes, as well as heart disease and use of beta blockers, might increase the risk of benign prostatic hyperplasia.
• Lifestyle. Obesity increases the risk of benign prostatic hyperplasia, while exercise can lower your risk.

Complications of benign prostatic hyperplasia

Complications of enlarged prostate can include:

• Sudden inability to urinate (urinary retention). You might need to have a tube (catheter) inserted into your bladder to drain the urine. Some men with an enlarged prostate need surgery to relieve urinary retention.
• Urinary tract infections (UTIs). Inability to fully empty the bladder can increase the risk of infection in your urinary tract. If UTIs occur frequently, you might need surgery to remove part of the prostate.
• Bladder stones. These are generally caused by an inability to completely empty the bladder. Bladder stones can cause infection, bladder irritation, blood in the urine and obstruction of urine flow.
• Bladder damage. A bladder that hasn’t emptied completely can stretch and weaken over time. As a result, the muscular wall of the bladder no longer contracts properly, making it harder to fully empty your bladder.
• Kidney damage. Pressure in the bladder from urinary retention can directly damage the kidneys or allow bladder infections to reach the kidneys.

Most men with an enlarged prostate don’t develop these complications. However, acute urinary retention and kidney damage can be serious health threats.

Having an enlarged prostate doesn’t affect your risk of developing prostate cancer.

How is benign prostatic hyperplasia diagnosed ?

Your doctor will start by asking detailed questions about your symptoms and doing a physical exam. This initial exam is likely to include:

• Digital rectal exam. The doctor inserts a finger into the rectum to check your prostate for enlargement.
• Urine test. Analyzing a sample of your urine can help rule out an infection or other conditions that can cause similar symptoms.
• Blood test. The results can indicate kidney problems.
• Prostate-specific antigen (PSA) blood test. PSA is a substance produced in your prostate. PSA levels increase when you have an enlarged prostate. However, elevated PSA levels can also be due to recent procedures, infection, surgery or prostate cancer.
• Neurological exam. This brief evaluation of your mental functioning and nervous system can help identify causes of urinary problems other than enlarged prostate.

After that, your doctor might recommend additional tests to help confirm an enlarged prostate and to rule out other conditions. These additional tests might include:

• Urinary flow test. You urinate into a receptacle attached to a machine that measures the strength and amount of your urine flow. Test results help determine over time if your condition is getting better or worse.
• Postvoid residual volume test. This test measures whether you can empty your bladder completely. The test can be done using ultrasound or by inserting a catheter into your bladder after you urinate to measure how much urine is left in your bladder.
• 24-hour voiding diary. Recording the frequency and amount of urine might be especially helpful if more than one-third of your daily urinary output occurs at night.

If your condition is more complex, your doctor may recommend:

• Transrectal ultrasound. An ultrasound probe is inserted into your rectum to measure and evaluate your prostate.
• Prostate biopsy. Transrectal ultrasound guides needles used to take tissue samples (biopsies) of the prostate. Examining the tissue can help your doctor diagnose or rule out prostate cancer.
• Urodynamic and pressure flow studies. A catheter is threaded through your urethra into your bladder. Water — or, less commonly, air — is slowly injected into your bladder. Your doctor can then measure bladder pressure and determine how well your bladder muscles are working.
• Cystoscopy. A lighted, flexible cystoscope is inserted into your urethra, allowing your doctor to see inside your urethra and bladder. You will be given a local anesthetic before this test.
• Intravenous pyelogram or CT urogram. A tracer is injected into a vein. X-rays or CT scans are then taken of your kidneys, bladder and the tubes that connect your kidneys to your bladder (ureters). These tests can help detect urinary tract stones, tumors or blockages above the bladder.

How is benign prostatic hyperplasia treated ?

A wide variety of treatments are available for enlarged prostate, including medication, minimally invasive therapies and surgery. The best treatment choice for you depends on several factors, including:

• The size of your prostate
• Your age
• Your overall health
• The amount of discomfort or bother you are experiencing

If your symptoms are tolerable, you might decide to postpone treatment and simply monitor your symptoms. For some men, symptoms can ease without treatment.

Medication

Medication is the most common treatment for mild to moderate symptoms of prostate enlargement. The options include:

• Alpha blockers. These medications relax bladder neck muscles and muscle fibers in the prostate, making urination easier. Alpha blockers — which include alfuzosin (Uroxatral), doxazosin (Cardura), tamsulosin (Flomax), and silodosin (Rapaflo) — usually work quickly in men with relatively small prostates. Side effects might include dizziness and a harmless condition in which semen goes back into the bladder instead of out the tip of the penis (retrograde ejaculation).
• 5-alpha reductase inhibitors. These medications shrink your prostate by preventing hormonal changes that cause prostate growth. These medications — which include finasteride (Proscar) and dutasteride (Avodart) — might take up to six months to be effective. Side effects include retrograde ejaculation.
• Combination drug therapy. Your doctor might recommend taking an alpha blocker and a 5-alpha reductase inhibitor at the same time if either medication alone isn’t effective.
• Tadalafil (Cialis). Studies suggest this medication, which is often used to treat erectile dysfunction, can also treat prostate enlargement. However, this medication is not routinely used for enlarged prostate and is generally prescribed only to men who also experience erectile dysfunction.

Minimally invasive or surgical therapy

Minimally invasive or surgical therapy might be recommended if:

• Your symptoms are moderate to severe
• Medication hasn’t relieved your symptoms
• You have a urinary tract obstruction, bladder stones, blood in your urine or kidney problems
• You prefer definitive treatment

Minimally invasive or surgical therapy might not be an option if you have:

• An untreated urinary tract infection
• Urethral stricture disease
• A history of prostate radiation therapy or urinary tract surgery
• A neurological disorder, such as Parkinson’s disease or multiple sclerosis

Any type of prostate procedure can cause side effects. Depending on the procedure you choose, complications might include:

• Semen flowing backward into the bladder instead of out through the penis during ejaculation
• Temporary difficulty with urination
• Urinary tract infection
• Bleeding
• Erectile dysfunction
• Very rarely, loss of bladder control (incontinence)

There are several types of minimally invasive or surgical therapy.

Transurethral resection of the prostate (TURP)

A lighted scope is inserted into your urethra, and the surgeon removes all but the outer part of the prostate. TURP generally relieves symptoms quickly, and most men have a stronger urine flow soon after the procedure. After TURP you might temporarily need a catheter to drain your bladder, and you’ll be able to do only light activity until you’ve healed.

Transurethral incision of the prostate (TUIP)

A lighted scope is inserted into your urethra, and the surgeon makes one or two small cuts in the prostate gland — making it easier for urine to pass through the urethra. This surgery might be an option if you have a small or moderately enlarged prostate gland, especially if you have health problems that make other surgeries too risky.

Transurethral microwave thermotherapy (TUMT)

Your doctor inserts a special electrode through your urethra into your prostate area. Microwave energy from the electrode destroys the inner portion of the enlarged prostate gland, shrinking it and easing urine flow. This surgery is generally used only on small prostates in special circumstances because re-treatment might be necessary.

Transurethral needle ablation (TUNA)

In this outpatient procedure, a scope is passed into your urethra, allowing your doctor to place needles into your prostate gland. Radio waves pass through the needles, heating and destroying excess prostate tissue that’s blocking urine flow.

This procedure might be a good choice if you bleed easily or have certain other health problems. However, like TUMT, TUNA might only partially relieve your symptoms and it might take some time before you notice results.

Laser therapy

A high-energy laser destroys or removes overgrown prostate tissue. Laser therapy generally relieves symptoms right away and has a lower risk of side effects than does nonlaser surgery. Laser therapy might be used in men who shouldn’t have other prostate procedures because they take blood-thinning medications.

The options for laser therapy include:

• Ablative procedures. These procedures vaporize obstructive prostate tissue to increase urine flow. Examples include photoselective vaporization of the prostate (PVP) and holmium laser ablation of the prostate (HoLAP). Ablative procedures can cause irritating urinary symptoms after surgery, so in rare situations another resection procedure might be needed at some point.
• Enucleative procedures. Enucleative procedures, such as holmium laser enucleation of the prostate (HoLEP), generally remove all the prostate tissue blocking urine flow and prevent regrowth of tissue. The removed tissue can be examined for prostate cancer and other conditions. These procedures are similar to open prostatectomy.

Prostate lift

In this experimental transurethral procedure, special tags are used to compress the sides of the prostate to increase the flow of urine. Long-term data on the effectiveness of this procedure aren’t available.

Embolization

In this experimental procedure, the blood supply to or from the prostate is selectively blocked, causing the prostate to decrease in size. Long-term data on the effectiveness of this procedure aren’t available.

Open or robot-assisted prostatectomy

The surgeon makes an incision in your lower abdomen to reach the prostate and remove tissue. Open prostatectomy is generally done if you have a very large prostate, bladder damage or other complicating factors. The surgery usually requires a short hospital stay and is associated with a higher risk of needing a blood transfusion.

Follow-up care

Your follow-up care will depend on the specific technique used to treat your enlarged prostate.

Your doctor might recommend limiting heavy lifting and excessive exercise for seven days if you have laser ablation, transurethral needle ablation or transurethral microwave therapy. If you have open or robot-assisted prostatectomy, you might need to restrict activity for six weeks.

Whichever procedure you have, your doctor likely will suggest that you drink plenty of fluids afterward.

Home remedies for enlarged prostate

To help control the symptoms of an enlarged prostate, try to:

• Limit beverages in the evening. Don’t drink anything for an hour or two before bedtime to avoid middle-of-the-night trips to the toilet.
• Limit caffeine and alcohol. They can increase urine production, irritate the bladder and worsen symptoms.
• Limit decongestants or antihistamines. These drugs tighten the band of muscles around the urethra that control urine flow, making it harder to urinate.
• Go when you first feel the urge. Waiting too long might overstretch the bladder muscle and cause damage.
• Schedule bathroom visits. Try to urinate at regular times — such as every four to six hours during the day — to “retrain” the bladder. This can be especially useful if you have severe frequency and urgency.
• Follow a healthy diet. Obesity is associated with enlarged prostate.
• Stay active. Inactivity contributes to urine retention. Even a small amount of exercise can help reduce urinary problems caused by an enlarged prostate.
• Urinate — and then urinate again a few moments later. This practice is known as double voiding.
• Keep warm. Colder temperatures can cause urine retention and increase the urgency to urinate.

The Food and Drug Administration hasn’t approved any herbal medications for treatment of an enlarged prostate.

Studies on herbal therapies as a treatment for enlarged prostate have had mixed results. One study found that saw palmetto extract was as effective as finasteride in relieving symptoms of benign prostatic hyperplasia, although prostate volumes weren’t reduced. But a subsequent placebo-controlled trial found no evidence that saw palmetto is better than a placebo.

Other herbal treatments — including beta-sitosterol extracts, pygeum and rye grass — have been suggested as helpful for reducing enlarged prostate symptoms. But the safety and efficacy of these treatments hasn’t been proved.

If you take any herbal remedies, tell your doctor. Certain herbal products might increase the risk of bleeding or interfere with other medications you’re taking.

1. Prostatitis: Inflammation of the Prostate. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-problems/prostatitis-inflammation-prostate
2. Prostate Enlargement (Benign Prostatic Hyperplasia). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-problems/prostate-enlargement-benign-prostatic-hyperplasia
3. Deters LA. Benign prostatic hypertrophy. https://emedicine.medscape.com/article/437359-overview
4. BPH: surgical management. Urology Care Foundation. http://www.urologyhealth.org/urologic-conditions/benign-prostatic-hyperplasia-(bph)/treatment/surgery?article=31

What are testicles ?

The testicles (also called the testes; a single testicle is called a testis) are ovoid structures about 5 centimeters in length and 3 centimeters in diameter. The testicles are part of the male reproductive system. These 2 organs are each normally a little smaller than a golf ball in adult males and are contained within a sac of skin called the scrotum. The scrotum hangs beneath the base of the penis.

Both testes are within the cavity of the saclike scrotum. A tough, white, fibrous capsule encloses each testis. Along the capsule’s posterior border, the connective tissue thickens and extends into the testis, forming thin septa that divide the testis into about 250 lobules.

A lobule contains one to four highly coiled, convoluted seminiferous tubules, each approximately 70 centimeters long uncoiled. These tubules course posteriorly and unite to form a complex network of channels that give rise to several ducts that join a tube called the epididymis. The epididymis is coiled on the outer surface of the testis and continues to become the ductus deferens. A specialized stratified epithelium with spermatogenic cells (germ cells), which give rise to sperm cells, lines the seminiferous tubules. Other specialized cells, called interstitial cells (cells of Leydig), lie in the spaces between the seminiferous tubules. Interstitial cells produce and secrete male sex hormones.

Scrotum

The scrotum is a pouch of skin and subcutaneous tissue that hangs from the lower abdominal region posterior to the penis. A medial septum divides the scrotum into two chambers, each of which encloses a testis. Each chamber also contains a serous membrane that covers the testis. The serous membrane secretes serous fluid, which reduces friction as the testis moves within the scrotum. The scrotum protects and helps regulate the temperature of the testes. These factors are  important to sex cell production.

Exposure to cold stimulates the smooth muscle cells in the wall of the scrotum to contract, moving the testes closer to the pelvic cavity where they can absorb  heat. Exposure to warmth stimulates the smooth muscle cells to relax and the scrotum to hang loosely, providing an environment 3°C (about 5°F) below body temperature, which is important to sperm production and survival.

Figure 1. Male reproductive system

Figure 2. Testicle anatomy

Testis function

Testicles have 2 main functions:

• They make male hormones (androgens) such as testosterone.
• They make sperm, the male cells needed to fertilize a female egg cell to start a pregnancy.

Sperm cells are made in long, thread-like tubes inside the testicles called seminiferous tubules. They are then stored in a small coiled tube behind each testicle called the epididymis, where they mature.

During ejaculation, sperm cells are carried from the epididymis through the vas deferens to seminal vesicles, where they mix with fluids made by the vesicles, prostate gland, and other glands to form semen. This fluid then enters the urethra, the tube in the center of the penis through which both urine and semen leave the body.

The epithelium of the seminiferous tubules consists of sustentacular cells (Sertoli cells) and spermatogenic cells. Sustentacular cells support, nourish, and regulate the spermatogenic cells.

In the male embryo, the undifferentiated spermatogenic cells are called spermatogonia. Each spermatogonium contains 46 chromosomes (23 pairs) in its nucleus, the usual number for human body cells. Beginning during embryonic development, hormones stimulate spermatogonia to undergo mitosis. Each cell division gives rise to two new cells, one of which (type A) maintains the supply of undifferentiated cells, the other of which (type B) differentiates, becoming a
primary spermatocyte. Sperm cell production, or spermatogenesis, pauses at this stage.

Figure 3. Seminiferous tubule

Figure 4. Spermatogenesis

At puberty mitosis resumes, and new spermatogonia form. Testosterone secretion increases and the primary spermatocytes then reproduce by a special type of cell division called meiosis. Meiosis includes two successive divisions, called the first and second meiotic divisions.

Half of an individual’s 46 chromosomes are inherited from the mother (23), and half from the father (23). The 23 pairs of corresponding chromosomes, called homologous pairs, are the same, gene for gene. They may not be identical, however, because a gene may have variants, and a given chromosome that comes from the mother may carry a different variant of a gene than that chromosome from the father.

Before meiosis I, each homologous chromosome is replicated, so it consists of two identical DNA strands called chromatids. The chromatids of a replicated chromosome attach at regions called centromeres. The first meiotic division (meiosis I) separates homologous chromosome pairs. Thus, each of the secondary spermatocytes that undergoes the second meiotic division (meiosis II) begins with one member of each homologous pair, a condition termed haploid. This second division separates the chromatids, producing cells that are still haploid, but whose chromosomes are no longer in the replicated (two chromatids) form.

After meiosis II, each of the chromatids is an independent chromosome. The halving of chromosome number is accomplished as each primary spermatocyte divides to form two secondary spermatocytes. Each of these cells, in turn, divides to form two spermatids, which mature into sperm cells. Consequently, for the primary spermatocyte that undergoes meiosis, four sperm cells form, with 23 chromosomes each.

Spermatogenesis occurs continually in a male, starting at puberty. The resulting sperm cells collect in the lumen of each seminiferous tubule, and then pass to the epididymis, where they accumulate and mature.

Structure of a Sperm Cell

A mature sperm cell is a tiny, tadpole-shaped structure about 0.06 millimeters long. It consists of a flattened head, a cylindrical midpiece (body), and an elongated tail. The oval head of a sperm cell is primarily composed of a nucleus and contains highly compacted chromatin consisting of 23 chromosomes. A small protrusion of its head, called the acrosome, contains enzymes that aid the sperm cell in penetrating the layers surrounding the oocyte (egg cell from the female ovary) during fertilization. One of the enzymes on the sperm cell membrane contributes to entering the oocyte.

The midpiece of a sperm cell has a central, filamentous core and many mitochondria organized in a spiral. The tail (flagellum) consists of several microtubules enclosed in an extension of the cell membrane. The mitochondria provide ATP for the tail’s lashing movement that propels the sperm cell through fluid.

Figure 5. Sperm Cell

Male Internal Accessory Reproductive Organs

The internal accessory organs of the male reproductive system are specialized to nurture and transport sperm cells. These structures include the two epididymides, two ductus deferentia, two ejaculatory ducts, and the urethra, as well as the two seminal vesicles, the prostate gland, and two bulbourethral glands.

Figure 6. Inside testicles

Epididymides

The epididymides (singular – epididymis) are tightly coiled tubes about 6 meters long. Each epididymis is connected to ducts within a testis. It emerges from the top of the testis, descends along the posterior surface of the testis, and then courses upward to become the ductus deferens.

When sperm cells reach the epididymis, they are nonmotile. As rhythmic peristaltic contractions help move these cells through the epididymis, the cells mature. Following this aging process, the sperm cells can move independently and fertilize oocytes. However, sperm cells usually do not move independently until after ejaculation.

Ductus Deferentia

The ductus deferentia (singular – ductus deferens), also called vasa deferentia, are muscular tubes about 45 centimeters long. Each ductus deferens passes upward along the medial side of a testis and through a passage in the lower abdominal wall (inguinal canal), enters the pelvic cavity, and ends behind the urinary bladder. Just outside the prostate gland, the ductus deferens unites with the duct of a seminal vesicle to form an ejaculatory duct, which passes through the prostate gland and empties into the urethra.

Seminal Vesicles

The seminal vesicles are convoluted, saclike structures about 5 centimeters long. Each attaches to a ductus deferens on the posterior surface and near the base of the urinary bladder. The glandular tissue lining the inner wall of a seminal vesicle secretes a slightly alkaline fluid. This fluid helps regulate the pH of the tubular contents as sperm cells travel to the outside. Additionally, seminal vesicle fluid neutralizes the acidic secretions of the vagina, helping to sustain sperm cells that enter the female reproductive tract. Seminal vesicle secretions also include fructose, a monosaccharide that provides energy to sperm cells, and prostaglandins which stimulate muscular contractions within the female reproductive organs, aiding the movement of sperm cells toward the oocyte.