FAMILY PLANNING METHODS AND TREATMENT TO BE FOLLOWED

The term contraception includes all  temporary or permanent measures, to prevent pregnancy .

         
Ideal contraceptive methods should fulfill the following criteria – widely acceptable, inexpensive, simple to use, safe, highly effective and requiring minimal motivation, maintenance and supervision.

      

Fig 1.1 Family Planning Methods and Treatments 

TEMPORARY:    
                                                            

BARRIERMETHODS

IUCD(INTRAUTERINE contraceptive device)

OCP(oral contraceptive pill)

PERMANENT

MALE ---Vasectomy 

FEMALE---Tubectomy

Fig 1.2 Temporary and permanent method  

BARRIER METHODS

·     
        Mechanical:

       1.  Male – Condom
       2. Female – Condom, diaphragm, cervical cap
           Chemical
        (Vaginal contraceptives)
       3. Creams – Delfen (nonoxynol-9, 12.5%)
       4. Jelly – Koromex, Volpar paste
       5. Foam tables – Aerosol foams, Chlorimin T or Contab, Sponge (Today)
           Combination
        

            Combined use of mechanical and chemical

Fig 1.3 Using Condom to Stop pregnant

CONDOM

ADVANTAGES	DISADVANTAGES
	May accidentally break or slip off during coitus.
	Inadequate sexual pleasure.
Easy to carry, simple to use and disposable.	To discard after one coital act.
Useful where the coital act is infrequent and irregular Protection against sexually transmitted diseases, e.g. gonarrhoea, Chlamydia, HPV and HIV
Protection against pelvic inflammatory diseases

Failure rate – 14(HWY); 3(HWY) when used correctly and consistently.

Precautions:

•   To use a fresh condom for every act of coitus.
•   To cover the penis with condom prior to genital contact
•   Create a reservoir at the tip.
•   To withdraw while the penis is still erect.
•   To grasp the base of the condom during withdrawal.

Fig 1.4 Methods to stop Female Pregnancy 

FEMALE CONDOM (FEMIDOM)

It gives protection against sexually transmitted disease and pelvic inflammatory disease. It is expensive. Failure rate is about 3-5/HWY.

VAGINAL CONTRACEPTIVES:

The cream or jelly is introduced high in the vagina . Foam tablets (1-2) are to be introduced high in the vagina at least 5 minutes prior to intercourse.

Fig 1.5 Safety measures to stop pregnancy and anticare

VAGINAL CONTRACEPTIVE SPONGE (Today)

It is made of polyurethane impregnated with 1gm of nonoxynol-9 as a spermicide. Nonoxynol-9 acts as a surfactant which either immobilizes or kills sperm. The sponge should not be removed for 6 hours after intercourse. It’s failure rate is about 10/HWY.

Fig 1.6 Vaginal Contraceptive Sponge  

RHYTHM METHOD:

This method is based on identification of the fertile period of a cycle and to abstain from sexual intercourse during that period.

The first unsafe day is obtained by subtracting 20 days from the length of the shortest cycle and last unsafe day by deducting 10 days from the longest cycle.

Failure rate 20-30 (HWY)

Not applicable during lactational amenorrhoea or when the periods are irregular

Fig 1.7 Rhythm Method to delay conceive

COITUS INTERRUPTUS:

It necessitates withdrawal of penis shortly before ejaculation. Accidental chance of sperm deposition into the vagina. Failure rate – 20(HWY)

Fig 1.9 Coitus Interupptus

BREASTFEEDING, LACTIONAL AMENORRHOEA (LAM)

Thus during breastfeeding, additional contraceptive support should be given by condom, IUCD or injectable steroids where available to provide complete contraception.

When the women is full breastfeeding, a contraceptive method should be used in the 3^rd postpartum month  and with partial or no breastfeeding, she should use it in the 3^rd postpartum week.

full breastfeeding   and amennorhoehic   - risk of pregnancy <2% in first 6 months

 general  ---  risk of pregnancy 1- 10%

                                          

Fig 1.10 Brestfeeding ,lactional amenorrhoea(LAM)

INTRAUTERINE CONTRACEPTIVE DEVICES(IUCD)

Cu T200B  ------ replaced every 3 years

Cu T 380A:- ----Replacement  every 10 years

Multiload Cu 250:- replacement  every 3 years. Multiload Cu375   replaced every 5 years

Levonorgestrel intrauterine system (LNG-IUS):- n replaced every 5 years.

Fig 1.11 Intrauterine Conceptive Devices

MODE OF ACTION:

Video 1.1 Fertility and Treatments 

•          Biochemical and histological changes in the endometrium
•          Copper devices – Preventing implantation through enzymatic interference.
•          There may be increased tubal motility
•          There may be impaired sperm ascent
•          Levonorgestrel-IUS(Mirena) – It induces strong and uniform suppression of                   endometrium. 
•          Cervical mucous becomes very scantly.
•          I is preferable to insert 2-3 days after the period is over.
• 
  

 CONTRA INDICATION   FOR IUCD INSERTION

1)MENORRHAGEA 

2)PELVIC INFECTION(PID) 

3)DYSMENORRHOEA

factors related to its discontinuation (10%-15%)

Pain, abnormal uterine bleeding and PID

SPONTANEOUS EXPULSION – The expulsion rate is about 5 percent.

FAILURE RATE– 

The pregnancy rate with the device in situ is about 2 per 100 women years of use. Lowest 

pregnancy rates are observed with Cu T 380A (0.8-HWY) and LNG-IUS (0.2 – HWY).

Fig 1.12 Contra indication for insertion 

 Ectopic pregnancy (1-2%).

•     3^rd generation IUCD(Cu T 380A, Multiload Cu375  and Levonorgestrel-IUS(Mirena)
•     Higher efficacy with lowest pregnancy rate (less than one pre 100 women years).
•     Longer duration of action (5-10 years)
•     Low expulsion rate and fewer indications for medical removal.
•     Risk of ectopic pregnancy is significantly reduced (Cu T-380A and LNG-       IUS:0.02HWY)
•     Non-contraceptive benefits specially with LNG-IUD
•     Can be used as an alternative to hysterectomy for menorrhagia, DUB.
•     Apart from the use of Cu T as a contraceptive, it is used following synaecolysis.

OCP(ORAL CONTRACEPTIVE PILLS)   ----- NAMES

COMMERCIAL NAMES	COMPOSITION		No. of tablets
	Progestin’s(mg)	Oestrogen (ug)
1.Mala N( Govt.of India)	Levonorgestreal 0.15	Ethinyl  oestradiaol 30	21+7 Iron tablets
2.Mala- D	Levonorgestreal 0.15	Do	21+7 Iron tablets
3.Femilon (Infar)	Desogestreal 0.15	Ethinyl  oestradiaol 20	21
4.Yasmin(Schering)	Drospirenone 3 mg (p.509)	Ethinyl  oestradiaol 30	21
Depending on the amount of ethinyl oestradiaol (E) and the types of progestin (p) used , pills are defines as: 1ST GENERATION – With E 50 UG or more ; 2nd  GENERATION --  with e 30- 35 ug and p as levonorgestrel or norgestimate ;  3rd GENERATION – WITH e 20- 30 ug and p as desogestrel or gestodene Low dose pills have E less than 50 ug.

HOW TO PRESCRIBE A PILL:

New users should normally start their pill packet on day one of their cycle.

FOLLOW UP:  

After 3months,6 months and yearly check up necessary. The patient above the age 35 should be checked more frequently.

MISSED PILLS:

When she misses two pills in the first week (days 1-7), she should take 2 pills on each of the 

next 2 days and then continue the rest as schedule. Extra precaution has to be taken for next 7 days either by using a condom or by avoiding sex.

If 2 pills are missed in the third week (days 15-21) or if more than two active pills are missed at any time, another form of contraception should be used as back up for nest 7 days as mentioned above. She should start the next pack without a break.

If she misses any of the 7 inactive pills (in a 28day pack only) she should throw away the missed pills. She should take the remaining pills one a day and start the new pack as usual.

Indications for withdrawal : The indication for withdrawal  of the pill are 

                                               
                                                   Fig 1.13 Oral Contraceptive Pills 

1)serve migraine 

2) Visual or Speech disturbance 

3) Sudden chest pain 

4) Unexplained  fainting attack or acute vertigo 

5) Serve cramps and pain sin legs

6) Excessive weight gain 

7) Severe depression

8) Prior to surgery (it should be with held for at least 6 weeks to minimize postoperative           vascular complications). 

9) Patient wanting pregnancy.

pill be continued :

A Woman who does not smoke and has no other risk factor for cardiovascular disease , may continue the pill for 3 to 5 years is considered  enough and safe .

Failure rate:

 1)Protection against unwanted pregnancy (failure rate – 0.1 per 100 women year)

    Non contraceptive benefits  : Improvement of menstrual  abnormalities – 1) Improvement     of menstrual abnormalities

2) Reduction of dysmenorrhea  (40%)

3) Reduction of menorrhagia (50%) 

4) Reduction of premenstrual  tension syndrome (PMS) 

5) Reduction of Mittelschmerz’s  syndrome.

6) Protein against iron deficiency anemia .

 

Video 1.2 Treatments in Andal Fertility clinic

12) Functional  ovarian cysts 

13) benign breast disease

14) Osteopenia and postmenopausal  osteoporotic  fractures. Prevention of malignancies   Endometrial cancer (50%) 

18) Ovarian cancer (40%)

19) Colorectal cancer (40%)  This protective effects persists for 10 -15 years even after stopping the methods following a use of 6 months to 1 years .

SIIDE EFFECTS : 

NAUSEA, VOMITING ,HEADACHE (OGN) AND LEG CRAMPS (PGN) : These are transient and often subside following continuous use for 2-3 cycles .

WEIGHT GAIN: 

Though progestins have got an anabolic effects due to its chemical relation to testosterone, use of low dose COCs does not cause any increase in weight.

MENSTRUAL ABNORMALITIES -
·      

Breakthrough bleeding  is commonly due to sub threshold blood level of hormones

other causes of break through bleeding in pill takers are

                  1) disturbance of drug absorption – diarrhea , Vomiting
               
                  2)use of enzyme inducing drugs (mentioned earlier) , missing pills, use of low does                              pills
               
                  3) pregnancy complications
               
                  4) Diseases  -- cervical ectopy or carcinoma.
·      

Amenorrhea: 

Post pill amenorrhea of more than 6 months duration occurs in less than 1 percent cases. The association is casual not casual .it is usually more in women with per-existing functional menstrual disorders.

Hypertension: Current low dose COC5 rarely cause significant hypertension. Pre-existing Hypertension  is likely to be aggravated.

Fig 1.14 Oral Natural Abnormalities 

VASCULAR COMPLICATIONS (OGN): 

Venous thromboembolism (vtm)  - the overall risk is to the extent of 4-6 times more than the non –users .pre-existing hypertension, diabetes , obesity and elderly patient (over 35 specially with smoking habits ) are some of the important risk factors ethinyl  oestrodiol in preference to menstranol and the reduction of the dose of the oestrogen compound to 20 ug in the pill markedly reduce the incidence

LIPID (OGN): 

Plasma lipids and lipoproteins are increased .total cholesterol and triglycerides are increased .Preparation with more selective, lipid friendly and third generation progestin’s namely desogestrel, gestodeone or norgestimate, HDL Level is some what elevated .

VITAMINS AND MINERALS: 

Vitamins b6,b12, folic acid ,calcium , manganese, zinc and ascorbic acid levels are decreased  while vit a and vit k levels are increased.

INJECTABLE PROGESTINS: 

NET –EN IN A DOSE OF 200 MG GIVEN AT TWO – MONTHLY INTERVELS.DMPA 150 mg three monthly intervals. 

Mechanism of action :

1) Inhibition of ovulation by suppressing the mid cycle LH Peak 

2) cervical mucous becomes thick and viscid therapy prevents sperm penetration 

3) Endometrium is atrophic preventing blastocyst implantation

Fig 1.14.a. Ingectible Progestins 

Advantages :

 1)it eliminates regular medication as imposed by oral pill

 2) it can be used safely during lactation.

Disadvantages :

There is chance of irregular bleeding and occasional phase of amenorrhea. Loss of bone 

mineral density has been observed with along term use of depot provera.

OTHER EFFECTS : 

Weight gain and Headache

EMERGENCY CONTRACEPTION

·         Hormones

·         IUD

·         ANTIPROGESTRONE

·         OTHERS

                 

 POST COITAL CONTRACEPTIVE

DRUGS	Dose	Pregnancy rate (%)
Levonorgestrel	O.75 MG STAT AND AFTER 12 HOURS	0-1
Ethinyl oestrodiol 30ug + Norgestrel 0.25 mg	2 TAB  STAT AND 2 AFTER 12 HOURS	0-2
Mifepristone	100 MG SINGLE DOSE	0-0.6
Copper IUDs	Insertion within 5 days	0-0.1

Levonorgestrel 0.75 MG ,two doses given at 12 hours intervals , is very successful and without any side effects .

No fetal adverse effects has been observed when there is failure of emergency contraception

Mode of action

·         Ovulation is either prevented or delayed when the drug is taken in the         beginning of the cycle

·         Fertilization is interfered

·         Implantation is prevented as the endometrium is rendered unfavorable.

·         Interferes  with the function of corpus luteum or may causes luteolysis.

Fig 1.4.b PostCoaital Contraceptions

Draw backs: 

Nausea and vomiting are much more intense with oestrogen use

Copper IUD: 

Introduction of copper IUD within a maximum period of 5 days can prevent conception following accidental unprotected exposure .this prevent implantation.

Anti progesterone: 

Anti progesterone binds competitively to progesterone receptors and nullifies the effects of endogenous progesterones.

PERMANENT METHODS    

The operation done on male is vasectomy and that on the female is tubal                    
occlusion, or tubectomy

VASECTOMY

Advantages:

1) The operation can be done as an outdoor procedure

2) Failure rate is minimal – 0.15 percent and there is a fair chance of success of reversal anastomosis operation (50%)

Female : TUBECTOMY

Puerperal:- 24-48 hours after delivery

Interval: 3 months after delivery. It is done after periods

Concurrent: 

done along with termination of pregnancy

Open—pomeroy’s method failure rate .1-.3%

Lap—rings  failure rate-.2--.6% 

        

Fig 1.15 Vasectomy 

Contraceptive prescription should be on individual basis. In an individual , Method may vary according to her phase of reproductive life .Teenage girls, Older women should also be protected.

ROLE OF EMOTIONS IN CONCEPTION

Fertility is s a natural function of the body just like digestion and circulation. It has two aspects physical and functional.  

Video 1.1 Andal Fertility treatments 

         

Conception = Physical    +       Functional

                        Egg            (Immune               +                     Hormone)

                        

                        Tube                ↓

                                            Diet + exercise                                    ↓

                                                                                          Emotions: Family, Society, Self

                        Uterus

                       

                        Hormones

                        

                        Sperm

Fig 1.1 Role of fertility and conception 

Physical factors: 

It comprises egg, tubes, thyroid, Prolactin hormones, haemoglobin in female and semen parameters in male. All physical factors can be assessed through tests and treatment can be monitored.

Functional aspect: 

The factors that are required and used to be follows

1) Immune factor-the quality of egg and sperm.

2) Hormone function-interplay of FSH, LH, estrogen and progesterone.

IMMUNE FUNCTION: 

Earlier (50 years ago) the natural conception rate was high and abortion rate was low. Now it’s the reverse. Egg and sperm quality are affected by the food we consume.

Hormone function:

The process of conception is a natural function. The coordinated functions of ovary, tube and uterus culminate in conception. Hormones function comprises of   perfect balance of hormones FSH and LH, estrogen and progesterone. FSH and LH  are released from the pituitary gland in the brain and The pituitary is controlled by hypothalamus in the brain, which is the  seat of emotions. So hypothalamus is the final remote control; the hormones seem to dance to the tunes of the emotions.

Fig 1.2 Hormonal Functions

Emotions on conception:

Conception----Natural (Not thinking about pregnancy)

                           Stress ----Delay in conception

           Positive mind set---- Quick and easy conception

when we don’t think about pregnancy occurs naturally  at the rate of 10-20% per month that’s how when 100 couples  are married , 80-90 % conceive naturally in one year without treatment.

Fig 1.3 Child in Mothers womb

When we are under stress (anxious, worried, depressed) and negative belief,--stress hormones  are released  that disturb normal hormone balance and delay the conception.

 Stress -----.>acute stress-exam, financial, marital conflict, acute stress hormones—adrenaline and nor adrenaline.

Chronic stress-daily hassles  

Chronic stress hormones—Cortisol.

When we are happy, confident, secure ,positive belief --happy hormones

(b- endorphin and serotonin) are released-they enhance conception. So quick and easy will be the conception. It only has to be seen to be believed.

Thyroid and Prolactin hormonal variations also influence this Reproductive hormonal  balance.

Fig 1.4 Starting Conception Stage 

Let me share my experiences about how I learnt the impact of stress and diversion on conception.

One day   hyma married for 7 years came with +ve pregnancy test. And I was surprised at it. She had been taking treatment from so many doctors for the past 3 to 4 years. She was very desperate about her pregnancy and her physical factors were normal. 

Fig 1.5 Emotional Health and Pregnancy  

She said for the last  2 months she was very busy in the marriage arrangements of her sister-in-law. There were no elders in the family; so she was  totally involved and exhausted  that there was no time to think bout pregnancy. 

She asked me one pertinent question “ when I was taking treatment why I did not conceive, when I stopped treatment  how I could conceive so easily” That question left me perplexed and then I started the search. With in 3 weeks I had three similar cases like hyma .

In  These cases there was common factor of distraction resulting in conception. One lady was actively involved in house construction. Another was busy in the preparation of exam. The third one lost her brother suddenly in an accident and  in bereavement reaction. After seeing all these conceptions.

Fig 1.6 |Fetal Devleopment

 I realized these conception were not accidental or coincidental .there must have been a conducive atmosphere that facilitated conception. It occurred to me that it was the  expectation, anxiety and stress that prevented conception to occur(when physical factors are alright). 

Video 1.2 Excess Oestrogen and pregnancies

Every one conceives only when she is not thinking about it. That means it is the natural function of the body just like digestion and other metabolic activities. 

We interfere with conception by our negative thoughts .when we stop thinking negatively we allow the body function naturally. This gave me lot of relief and immense confidence.

Guide The Medicine of Mother’s breast milk – a miracle elixir

The  TWO real  gifts a mom gives to her baby are

1. Birth

2. Breast milk

In  our tradition mother’s milk is extolled as divine nectar

 A poet says ‘the most miraculous act of GOD is, keeping milk ready for  the un born baby”

It is not only an act of taking food, but a powerful way of improving Emotional bond with the most important person in our lives –“OUR MOTHER”.

                                   
                                           Fig 1.1 Brest Feeding mother to a Baby

We all know breast milk is clean, easily digestible and has anti infective properties (protects from infections); and mom’s milk is the best one for babies.

Let us see other benefits of breast milk:– Both to the babies  and mother.

To the baby:

Short term benefits:

Breast fed babies are less prone for respiratory (cold and cough) infections and diarrhea.

Long term benefits:

Research studies have shown breast feeding enhances brain development and increases IQ ,  because it contains omega-3 fatty acids.

Fig 1.2 Pregnancy Care and Brest Feed 

These babies are less prone to have obesity, diabetes mellitus, eczema, asthma and allergic diseases in later life.

Benefits to the mother:

 Reduces the post delivery bleeding and anemia.

 Helps delay next pregnancy.

 It has protective effect over ovarian and breast cancer

 Decreases the osteoporosis ( softening of bones ).

                   

Fig 1.3 Baby Milk supplied from Mother

The initial milk is thick and yellowish; it is called Colostrum. It is highly nutritive and provides resistance to the baby against various infections. After a few days the milk becomes gradually watery. It contains of 2 parts. Fore milk and hand milk.

Fore milk : It  is first   1st portion of  milk  and is  watery and thin;  it quenches the thirst of the baby.

Hind milk : It is the last portion of milk;    it  is thick and  contains more fat ;it gives energy and appeases hunger of the baby.

                                         

Fig 1.4 Baby Milk Age and Nutrition 

Milk production :

It consists of 2 stages:

1) Milk formation

2) Milk ejection

When baby suckles mother’s nipples, nerves are stimulated, signals are sent tobrain and Prolactin hormone is produced, which helps in milk formation.

So frequent suckling helps in adequate milk production.

Ejection and flow of milk to the baby from the breast, is due to another hormone oxytocin.

Fig 1.5 Milk Production and After Pregnancy 

Oxytocin is released due to :

Sucking of the baby at the nipple

Fig 1.6 Sucking Mother Milk From the Mother 

Mental state of the mother- happy, lovingly thinking of baby, being confident about breast feeding helps in adequate milk supply.

If the mother is anxious and worried that she is not getting sufficient milk, oxytocin reflex is inhibited and milk ejection will be affected.

Good lactation practice: (2 steps)

Proper positioning of baby:

Baby’s neck is straight or slightly bent & whole body is supported

Baby is  turned towards mother

Eye contact between mother and baby established

Proper attachment :

1.Baby’s mouth should catch hold of areola(black part around nipple)

2.Only then when baby suckles, milk flows in to baby’s mouth.

3.When baby is poorly attached breast milk is not effectively transferred and it may seem that milk is not enough.

4.If baby catches only nipple, due to Pressure of sucking - sore nipple ,later cracked nipple occurs. 

5.Factors affecting the breast feeding:

6.When First breast feed is delayed- sometimes it is difficult to establish milk production later.

7.In frequent breast feeding leads to decrease on Prolactin formation, decreased milk production.

8.Improper positioning and attachment

9.Use of bottles and pacifiers  leads to nipple confusion .so baby refuses to suckle the breast

Fig 1.7 Mother Milk Feed Thro cup

Checking About Enough Milk:

1.Adequate weight gain of the baby

2.Passing urine more than six times a day (in 24 hours)     

    

The Baby gets enough breast feed:

1.Be confident.

2.Ensure that the baby sucks enough and frequently.

3.See that the baby sucks effectively in a correct position.

Video 1.1 Mother Feed and pregnancy 

Diets to produce sufficient milk:

Cereals and their products, milk and milk products, eggs, meat, fish, poultry and plant protein , like pulses, legumes, nuts and oilseeds. Green leafy vegetables, carrot, beetroot and Fruits,Spices:  Fenugreek, Fennel, Cumin Seeds, Garlic, Bread, Rice

2) Plenty of water / liquids (90% of milk contains water)

3) Adequate sleep resulting in proper hormone balance.

4) Adequate Hemoglobin status (anemia results in lactation failure, as blood is     converted to milk)

Storage  of milk :

Breast milk can be stored in a refrigerator for 24 hours and at room temperature for 8 hours.

a Refrigerated breast milk should not be heated, as it will destroy protective substances.

b.It should be brought to room temperature before being fed by a cup.

ROLE OF HUSBAND IN BREAST FEEDING:

Helping the wife with child care, so that she can rest.

Making the wife feel good about herself by praising her job as a mother Avoid :

He  should not doubt on the wife s ability to provide    enough milk  for the baby

In case he smokes, he should not smoke in baby's room.

video 2.1 Pregnancy  Treatments 

Let all Mothers have strong intention to feed the baby with love & positive thoughts, so that all future citizens will bring Health, Joy, Peace & Prosperity to Mother Earth.

Natural Infertility Treatments For Women: Recurrent Abortion and Pregnancies Treatments

Natural Infertility Treatments For Women: Recurrent Abortion and Pregnancies Treatments: Recurrent pregnancy loss (RPL) is one area of reproductive medicine that is filled with controversy and confusion. Ask three doctors a qu...

Recurrent Abortion and Pregnancies Treatments

Recurrent pregnancy loss (RPL) is one area of reproductive medicine that is filled with controversy and confusion. Ask three doctors a question and you are likely to get at least four or five different answers. New research studies enter the medical literature each month, so the answer you receive today may not be the answer you receive next month. Some physicians recommend evaluation after you have lost two pregnancies, and others will not begin a workup until you have lost at least three pregnancies. 

Video PART 1.1 DrAndal baskar Treatments About pregnancy 

So what's a person suffering pregnancy loss to do  Many turn to the internet seeking answers. But often what is found is misinformation and unconfirmed medical theories. So let's start with an overview of this medical condition. I hope that this article will educate you to areas of knowledge and areas of controversy. With this information, you can hold a meaningful discussion with your physician and get the information you need to make informed choices about your own healthcare.

                       

                               

                                              FIG 1.1 Pregnancy Time Treatments 

Traditionally, the diagnosis of recurrent pregnancy loss is not made until a woman has lost at least three pregnancies. Overall about 20% of pregnancies end in miscarriage due to a non-recurrent cause. So, the risk of two consecutive losses is 20% of 20% or 4% of women will experience two losses. The odds of three losses would be 0.16%. This means that if you have lost three pregnancies it is quite unlikely that this is due to three abnormal pregnancies. More likely one specific abnormality or underlying condition resulted in all three losses. And, if undetected or untreated, you may likely be at increased risk for a loss in a subsequent pregnancy.

                      

                                        

                                    FIG 1.2 Pregnancy Treatments During Final Stage 

Some physicians and insurance companies argue that there is no point in initiating an evaluation for recurrent pregnancy loss unless your risk for miscarriage in a subsequent pregnancy is increased. So they refuse to evaluate and treat women who have lost two pregnancies. Unfortunately, at least one in five who have lost two pregnancies will go and miscarry again and the other 4 are likely to worry needlessly that there may be an undetected reason for their miscarriages. So, I recommend that an evaluation be initiated after two prior losses with specific tests individualized based on a person's medical history.

While the most common cause for pregnancy loss is abnormal number of egg chromosomes, the parents usually have normal chromosomes. Recurrent pregnancy loss due to chromosomal abnormalities is a different story. Chromosomal translocations (relocation of a segment of genes from one chromosome to another) may be found in up to 4% of couples. The parents with this condition are normal because they have all the normal chromosomal complement. The sperm and egg each end up with  the original set of chromosomes in a process called meiosis.

                     

                               FIG 1.3 Treatments To be Follow Time of pregnancy

Depending on whether the one, both or none of these switched chromosomes end up in the egg or sperm, you may end up missing a portion of a chromosome or burdened with extra chromosomal material (miscarriage), normal (carrying the same chromosomal anomaly as the parents, or genetically normal. This rare anomaly is seen twice as often in the woman partner. Testing for this condition is by a blood test on both partners and will likely cost between $1000 and $1,800. Insurance coverage is variable. The benefit of genetic testing is that if an abnormality is identified, IVF with genetic testing could prevent another miscarriage.

Uterine anomalies such as fibroid tumors or polyps may result in miscarriage if undiagnosed and untreated. Congenital uterine malformations such as a uterine septum may be associated with recurrent pregnancy loss. Surgical correction by operative hysteroscopy may restore fertility and allow the pregnancy to progress to term. Incompetent cervix is a condition where the cervix dilates prematurely without detectable contractions. The use of cervical cerclage suture placed in the cervix may reduce the risk of this pregnancy complication that can lead to loss.

                                

                                           FIG 1.4 Treatments To be Follow After Abortion 

Infection has been reported to be associated with pregnancy loss. The role of infection is less clear. Chlamydia and gonorrhea culture are an important part of this evaluation. Less clear is the role of the organism ureaplasma urealyticum. This rather prevalent organism is difficult to culture and its role as a causal agent is less clear. As such, while many physicians recommend culturing for this condition, others suggest a brief course of antibiotics as a more cost effective option.

Hormonal factors may be a problem. Thyroid disease or pituitary dysfunction can be associated with recurrent pregnancy loss. Studies have shown that women with an elevated LH (those with polycystic ovary syndrome or PCOS) level on cycle day 9 or 10 may be at increased risk of miscarriage. More controversial is the condition called luteal phase defect. It is suggested that an insufficiency of progesterone secretion by the ovary after ovulation can lead to miscarriage. This condition has been traditionally diagnosed by either a blood progesterone level or by performing an endometrial biopsy. 

                     

                                                         FIG 1.5 Recurrent Abortion 

An abnormal result was often treated by supplementing with progesterone. While there may be benefit to progesterone supplementation in some cases I will address this when discussing reproductive immunologic causes for miscarriage.), the evidence suggests that luteal phase defect results from poor follicular development in the first half of the menstrual cycle. So, a follicular phase defect results in low luteal progesterone levels and an egg that is less likely to result in pregnancy and more likely to miscarry if pregnancy occurs. The solution to this problem is not giving progesterone after the ovary has ovulated an "abnormal egg", but rather to enhance egg development with ovulation induction medications.

Age related infertility may result in recurrent loss. An elevation of FSH or decrease in inhibin B on the third day of the menstrual cycle may indicate an age related decline in fertility and an increase in the possibility of miscarriage.

    

                                         

                             

                                               FIG 1.6 Test Done After Check Up 

Abnormal blood clotting in the small placental blood vessels may result in RPL. This may be due to antibodies to phospholipids (antiphospholipid antibodies) important components of blood vessel walls. The result is placental insufficiency and miscarriage. While most physicians test for lupus anticoagulant and anticardiolipin antibodies, about 20-30% of effected individuals will go undetected if more comprehensive antiphospholipid antibody panels are not obtained. Abnormalities in blood clotting function resulting from chromosomal anomalies is also a potential cause of RPL. Factor V Leiden, Prothrombin gene mutation, Antithrombin III and plasminogen activator inhibitor-1 (PAI-1) are genetically determined factors that may increase the risk of miscarriage. Thrombophilia, or a tendency for increased blood clotting may be treated successfully with baby aspirin and heparin anticoagulant injections.

                               

                    

                               FIG 1.7 Pregnancy Check For Treatments After Loss 

The most controversial RPL factor is allogenic immunity. We now that if a husbands kidney is transplanted into his wife, rejection is likely. So we need to ask why the pregnancy is allowed to remain. There are no absolute answers as yet. Many theories and conflicting data exist. Few well-designed, well-controlled studies exist to definitively answer these questions and clarify the role of immune system anomalies in RPL. Suggested explanations include the lack of a protective blocking antibody, increased NK cell numbers (natural killer cells), increased NK cell activity, factors toxic to embryo growth, increased levels of factors that stimulate the immune system to an "attack- response", and absent placental surface HLA-G an important immunosuppressive factor.

Multi-center studies have shown that a negative leukocyte antibody detection (blocking antibody) may indicate a group of patients with three or more consecutive losses who may benefit from paternal white cell immunization. However, a more recent trial conflicts with earlier results. The embryotoxic factor blood test will indicate women who may benefit from high dose progesterone immunosuppressive therapy. Testing for NK cell numbers and activity have lead investigators to consider treatment with IViG (intravenous immunoglobin) infusion or Embrel therapy.

                           

                                   FIG 1.8 Treatments To Be Follows For pregnancies 

Immunotherapy is quite expensive and should be considered experimental. Immunotherapy should be performed under institutional review, using prospective randomization of patients to receive either control or placebo therapy. The cost of such therapy should be covered under research grants; patients should not be expected to pay for as yet unproven, expensive therapies. Hopefully, well designed clinical trials will either support or reject the role of immunotherapy for RPL. Until then, we must be cautious in our approach.

Luckily, for most women this evaluation can be completed in one or two months. While treatment can not guarantee a successful pregnancy, comprehensive evaluation and treatment should result in success rates approaching 85% for most women.

                          

                              FIG 1.9 Miscarriage Research To be Done in a Laboratory 

Recurrent pregnancy loss is defined by the loss of two or more clinical pregnancies. It is distinct from sporadic losses before 10 weeks.

A clinical pregnancy is documented by ultrasound or the pathologic diagnosis of the products of conception.

The incidence of spontaneous miscarriage is about 15-20%. Early losses that occur even before a missed period may be as high as 30-50%. In women who have a history of two or more previous losses the risk increases to about 40%. The risk of miscarriage is increased with advancing maternal age. Evaluation should be instituted after 2 losses especially in the infertility population. About 5% of women will have at least 2 consecutive miscarriages while only 1% experience 3 or more.

Approximately 50% of patients evaluated have a diagnosis. The remainder may never have a definite reason identified for the pregnancy loss.

                           

                                FIG 1.10 Treatments For Pregnancy  Loss and Treatments

Causes of recurrent pregnancy loss

The following factors have been identified as potential causes

Genetics

Chromosomal abnormalities in the fetus account for about 60% of sporadic losses.(Trisomies (an extra chromosome ) is the most frequent and is related to the maternal age. Below the age of 35 the risk of a sporadic miscarriage is between 9-12%. This increases in women at 40 years of age to almost 50%. Parents should undergo chromosomal analysis to rule out any structural rearrangement of chromosomes. Translocations are found in about 2-5% of couples.

                     

                       FIG 1.11 Statistics Shows Of Recurrent Abortion  and Pregnancy 

When women experience multiple miscarriages, genetic counseling may be recommended. Pre-implantation genetic screening (PGS) to diagnose the abnormality in the fetus is an option. The American Society for Reproductive Medicine (ASRM) does not currently recommend routine preimplantation genetic diagnosis for aneuploid (abnormal number of chromosomes) embryos.

Testing the products of conception is also available but there are some issues with maternal contamination of the tissue.  Maternal blood can be analyzed by reflex DNA testing to differentiate between the fetal and maternal source.

                     

                              FIG 1.12 Recurrent Abortion Due To Genetal Factors 

Anatomical Factors

Uterine cavity abnormalities are usually associated with second trimester (after 12 weeks) miscarriages. Congenital abnormalities are present in about 4% of the general fertile population, but in 13% of the recurrent loss patients. The different abnormalities are developmental defects of the uterus. These are an arcuate uterus, a septate uterus, an unicornuate, or bicornuate uterus and a didelphys uterus.

                             

                

             FIG 1.13 Recurrent Abortion And Pregnancies Due To Anatomical cause 

These abnormalities can be detected by performing a hysterosalpingogram and confirming with further tests like a MRI and a 3D sonogram. The highest rate of loss occurs in patients with a septate uterus (44%), followed by 36% in those with a bicornuate uterus, and 26% in patients with an arcuate uterus. Surgical correction of a septate uterus is the treatment of choice since it improves the live birth rate.

Patients with other uterine factors include Asherman’s syndrome, ( intrauterine synechiae), submucous fibroids, and polyps.  Surgical correction of these defects is recommended.

Antiphospholipid Syndrome

This syndrome has been known to be associated with recurrent pregnancy loss. In this group of patients, about 8-42% will test positive for antiphospholipid antibodies.Testing should be performed in these patients, after other causes (anatomic, hormonal and chromosomal) have been excluded. The treatment regimen includes low dose aspirin and low dose heparin.

              

                                 FIG 1.14   Antiphospholipid Syndrome

Routine testing of recurrent pregnancy loss patients for inherited thromobophilias is not currently recommended by the ASRM.

Hormonal and Metabolic factors

Thyroid function should be evaluated and treated if abnormal. TSH levels should, be below 2.5 mIU/L.  Uncontrolled diabetes may be associated with pregnancy loss. Elevated prolactin levels can interfere with adequate follicular development and luteal function. This can result in decreased progesterone levels in the luteal phase of the cycle. Treatment with dopamine agonists can correct this. In patients with recurrent losses, progesterone supplementation can improve pregnancy rates.

                     

                                 FIG 1.15  Hormonal and Metabolic factors

Infections

There is no current consensus in the literature that infections like Ureaplasma, Mycoplasma, Listeria, Toxoplasmosis or rubella cause recurrent pregnancy loss. Routine testing and treatment with antibiotics is not recommended.

Alloimmune Factors

Studies have shown inconsistent results when looking at immunological factors, and treatment results have not been reproducible when analyzed. Several trials have concluded that IVIG (intravenous immunoglobulin) is not effective for primary recurrent pregnancy loss.

                           

                               FIG 1.16 Recurrent Abortion Factors and Issues  

Lifestyle Factors

Cigarette smoking, alcohol and cocaine use and increased caffeine ( more than 3 cups of coffee a day) have been reported to increase the risk of miscarriage.

                     

                                        FIG 1.17 Recurrent Abortion Pain 

                             

                     Video PART 1.2 Treatments For Pregnancies and Counselling 

Unexplained

No cause may be found in 50-75% of patients. In this group of patients the chance of a successful future outcome can be as high as 50-60% depending upon the maternal age. 

Abortion happened due to the pregnancy losses today and some of the food habit also important mainly for the pregnancy loss  and cell phone radiation,food and diet , with out exercise also a main cause that one who suffer in pregnancy.

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