SEXUALLY TRANSMITTED DISEASE

Protecting your adolescent from STDs:

The surest way to prevent contracting an STD is to advise your adolescent to abstain from
any type of sexual activity. However, if your adolescent becomes sexually active, you can
advise him/her on taking certain precautionary measures for reducing the risk of acquiring an
STD, as recommended by the National Institute of Allergy and Infectious Diseases (NIAID).
These measures include the following:
Have a mutually monogamous sexual relationship with an uninfected partner.
Use (consistently and correctly) a male condom.
Use sterile needles if injecting intravenous (IV) drugs.
Decrease susceptibility to HIV infections by preventing and controlling other STDs.
Delay having sexual relationships as long as possible (the younger a person is when
they begin to have sex for the first time, the more susceptible they become to
developing an STD).
Have regular checkups for STDs.
Learn the symptoms of STDs and seek medical help as soon as possible if any
symptoms develop.
Avoid having sexual intercourse during menstruation.
Avoid anal intercourse, or use a male condom.
Avoid douching.

What should my adolescent do if diagnosed with a STD?
Treatment for STDs should begin as soon as possible. In addition, your adolescent's sexual
partner(s) should be notified so they may seek treatment. Urge your teen to abstain from
sexual activity during his/her treatment and make sure he/she is tested again at a follow-up
checkup.

What are some common types of STDs?
More than 20 STDs have now been identified, and affect more than 13 million people in this
country each year. According to the National Institute for Allergy and Infectious Diseases and
the Centers for Disease Control and Prevention, common types of STDs include the
following:
Acquired Immune Deficiency
Syndrome (AIDS)
AIDS is caused by the human
immunodeficiency virus (HIV), a
virus that destroys the body's ability
to fight off infection.
People who have AIDS are very
susceptible to many life-threatening
diseases and to certain forms of
cancer. Transmission of the virus
occurs during sexual activity or by the
sharing of needles used to inject
intravenous drugs.
Human Papillomaviruses (HPVs)
Human papillomavirus (HPV) is a
common sexually transmitted disease
that can cause genital warts called
condylomas. These condylomas can
occur on the inside or outside areas of
the genitals and may spread to the
surrounding skin or to a sexual
partner. Because HPV infection does
not always cause warts, the infection
may go undetected. Women with
HPV infection have an increased risk
of developing cervical cancer.
Regular Pap smears can detect HPV
infection as well as abnormal cervical
cells.
Although there is treatment for the
condylomas (which sometimes go
away on their own), the virus remains
and warts can reappear. Smoking
appears to increase problems related
to HPV infection. Other types of HPV
can also cause warts on other body
parts such as the hands, called
common warts, however, these do not
generally cause health problems.
Chlamydial Infections
Chlamydial infections, the most
common of all STDs, can affect both
males and females. Infections may
cause an abnormal genital discharge
and burning with urination. In
females, untreated chlamydial
infection may lead to pelvic
inflammatory disease (PID).
However, many people with
chlamydial infection have few or no
symptoms of infection.
Gonorrhea
Gonorrhea causes a discharge from
the vagina or penis and painful or
difficult urination. The most common
and serious complications occur in
females, which include pelvic
inflammatory disease, ectopic (tubal)
pregnancy and infertility.
Genital Herpes
Genital herpes infections are caused
by the herpes simplex virus (HSV).
Symptoms may include painful
blisters or open sores in the genital
area, which may be preceded by a
tingling or burning sensation in the
legs, buttocks, or genital region. The
herpes sores usually disappear within
a few weeks, but the virus remains in
the body and the lesions may recur
from time to time.
Syphilis
The initial symptom of syphilis is a
painless open sore that usually
appears on the penis or around or in
the vagina. If untreated, syphilis may
go on to more advanced stages,
including a transient rash and,
eventually, serious involvement of the
heart and central nervous system.
Genital Warts
Genital warts or venereal warts
Other diseases that may be sexually
transmitted include the following:
(condylomata acuminata) are caused
by a virus related to the virus that
causes common skin warts. Usually,
genital warts first appear as small,
hard, painless bumps in the vaginal
area, on the penis, or around the anus.
Bacterial vaginosis.
Chancroid.
Cytomegalovirus infections.
Granuloma inguinale
(donovanosis).
Lymphogranuloma venereum.
Molluscum contagiosum.
Pubic lice.
Scabies.
Trichomoniasis.
Vaginal yeast infections.
Source: National Institute of Allergy
and Infectious Diseases


Facts about STDs and adolescents:
Consider the following statistics about STDs and adolescents:
STDs affect males and females of all backgrounds and economic levels. However,
nearly two-thirds of all STDs occur in people younger than age 25.
STDs are on the rise, possibly due to more sexually active people who have multiple
sex partners during their lives.
Almost one in five adolescents (19 percent) of adolescents in grades 9 to 12 has had
four or more sexual partners.
Only half (53 percent) of sexually active adolescents use a condom, and 18 percent
use birth control pills.
Many STDs initially cause no symptoms. In addition, many STD symptoms may be
confused with those of other diseases not transmitted through sexual contact -
especially in females. Even symptom-less STDs can be contagious.
Females suffer more frequent and severe symptoms from STDs. Consider the
following:
o Some STDs can spread into the uterus (womb) and fallopian tubes and
cause pelvic inflammatory disease (PID), which can lead to both infertility
and ectopic (tubal) pregnancy.
o STDs in females also may be associated with cervical cancer.
o STDs can be passed from a mother to her baby before or during birth. Some
infections of the newborn may be successfully treated, but others may cause
a baby to be permanently disabled or even die.
When diagnosed early, many STDs can be successfully treated.

How STDs Spread
One reason STDs spread is because people think they can only be infected if they have sexual intercourse. That's wrong. A
person can get some STDs, like herpes or genital warts, through skin-to-skin contact with an infected area or sore.
Another myth about STDs is that you can't get them if you have oral or anal sex. That's also wrong because the viruses or
bacteria that cause STDs can enter the body through tiny cuts or tears in the mouth and anus, as well as the genitals.
STDs also spread easily because you can't tell whether someone has an infection. In fact, some people with STDs don't even
know that they have them. These people are in danger of passing an infection on to their sex partners without even realizing it.
Some of the things that increase a person's chances of getting an STD are:
Sexual activity at a young age. The younger a person starts having sex, the greater his or her chances of becoming infected
with an STD.
Lots of sex partners. People who have sexual contact not just intercourse, but any form of intimate activity with many
different partners are more at risk than those who stay with the same partner.
Unprotected sex. Latex condoms are the only form of birth control that reduce your risk of getting an STD, and must be
used every time. Spermicides, diaphragms, and other birth control methods may help prevent pregnancy, but they don't
protect a person against STDs.
Symptoms of STDs
Infectious diseases that are transmitted through sexual contact are referred to as sexually transmitted diseases, or STDs. The
symptoms and illnesses caused by STDs vary according to the specific infection, the age of the child/adolescent, and the site of
the infection. Adolescent girls are often asymptomatic. For information on the most common manifestations of STD infections
from sexual abuse, see the table Infections with Very High Likelihood of Sexual Transmission in Evaluation of Sexually
Transmitted Diseases, Appendix E.


Who Should Be Tested
Not all children who have been sexually abused require STD testing. The majority of abuse victims will not have an STD. Only
about 5% do, with sexually active adolescents having the highest rates. As a result, the decision to test for STDs must be made
on an individual basis. However, because many STDs are asymptomatic, tests are often done during the medical evaluation to
exclude a silent infection. While some examiners test all suspected victims for STDs, others limit testing to those whom they
believe are at increased risk for infection, such as those with the findings listed below:
A history of:
A sibling or household contact that was diagnosed with an STD
A previous STD
Prostitution
Prior sexual contact
Abuse by multiple perpetrators or by a perpetrator with high risk behaviors, such as crack or IV drug use, prostitution,
multiple partners, or a history of STDs

A history of or examination findings consistent with:
Vaginal or urethral discharge
Rectal pain or discharge
Genital ulcers, sores, or warts
Physical indications of vaginal or rectal penetration or a genital injury

Findings of:
A diagnosis of another STD
An age of 13 or older (Tanner 3 or greater)
An inability to follow up at a later time if symptoms develop
The child/adolescent may not offer a reliable enough history to adequately determine risk factors. In cases such as this,
individualize the testing based on the information available. If you do not have significant evidence of a recent event, consider a
referral to a Child Advocacy Center or other specialized center for further evaluation.


Testing the Suspected Perpetrator
If the sexual abuse victim has been diagnosed with an STD, the suspected perpetrator should be tested, if possible, to
determine if that person also has the infection. Interpret this information cautiously. If the suspected perpetrator has already
received treatment, the test may be negative. If the test is positive, the information will support the allegations of sexual abuse,
although a definitive connection linking the suspected perpetrator to the victim cannot be made. Tests for HIV, syphilis, and
blood borne hepatitis will remain positive even after the suspected perpetrator has received medical treatment.


Techniques for Collecting Specimens
Identification of an STD requires an adequate sample, careful specimen handling, and a qualified laboratory. False negative and
false positive cultures and tests can occur if errors are made.
The supine position is preferred for the collection of vaginal and urethral specimens. Cervical cultures are recommended in the
adolescent while vaginal cultures are sufficient in prepubertal females. In some cases, it may be appropriate to collect vaginal
swabs in an adolescent, particularly if the adolescent was not previously sexually active and the insertion of speculum is
expected to cause unnecessary distress for the patient. The use of relaxation/distraction techniques and labial or perineal
traction maneuvers will assist the medical provider in collecting vaginal specimens without touching the sensitive hymenal
tissue. The vaginal wall can be gently swabbed for cultures.
Rectal specimens are best obtained with the patient in the lateral knee chest position. Introduce the swab(s) as far as the rectal
crypts (approximately 1 to 1 1/2 inches). Collect specimens prior to a digital rectal examination because lubricating agents will
interfere with testing.
Following evidence collection for forensic specimens, STD specimens should be obtained in the following order:
Neisseria gonorrhoeae
Chlamydia trachomatis
Other indicated specimens based on history and examination


Diagnostic Methods
In cases of suspected sexual abuse, it is critical that the tests used to diagnose STDs are recognized as "gold standards." Use
only those tests listed in the tableInfections with Very High Likelihood of Sexual Transmission in Evaluation of Sexually
Transmitted Diseases, Appendix E.
Cultures for N. gonorrhoeae and C. trachomatis are the "gold standard" for sexual abuse evaluations. Prior to making the
diagnosis of an STD in a prepubertal child, the lab must perform additional testing on the culture specimen to be certain of the
pathogen's identity. Non-culture screening tests (i.e., enzyme linked immunoassay, DNA probes) should not be used to
diagnose an STD in a prepubertal child. Most of these tests have only been utilized and approved for the adult population. The
rate of false positive tests can be high when non-culture tests are used in a prepubertal population. Necessary reconfirmation
of the specific subtype and further identification of an organism is only possible with culture techniques.
It may be appropriate to use "non-gold-standard" tests for screening, particularly in primary care settings where patient
compliance can be assured. Such screening tests are site specific and may be used only to test from certain body sites. Early
research utilizing nucleic acid amplification tests (NAATs) looks promising for the future use of these tests for sexually abused
children. Currently, a positive NAAT screening of urine or genital swabs must be confirmed by culture prior to diagnosis and
treatment.


Diagnostic Testing
During the initial examination and follow-up examination, if indicated based on knowledge of last known sexual contact and
incubation period of the STD, perform the following:
Collect cultures for N. gonorrhoeae from the pharynx and anus in both sexes, the vagina in girls, and the urethra in
boys. Cervical specimens are not recommended for prepubertal girls. For boys, a meatal specimen of urethral
discharge is an adequate substitute for an intraurethral swab specimen when discharge is present. In the absence of a
known infected offender or symptoms including discharge or dysuria in the male prepubertal victim, the urethral
swab for gonorrhea may be deferred. Many experts do not obtain urethral specimens unless there are specific
symptoms. If possible, preserve isolates in case additional or repeat testing is required. Some experts recommend
using urine NAATs to screen for urethritis in males and vaginitis in females if the child/adolescent's return for
confirmatory testing can be assured. Use only standard culture systems for the isolation of N. gonorrhoeae. A positive
culture must be confirmed by two additional and unrelated tests. NAATs can be used for screening purposes for
gonorrhea but other non-culture methods (e.g., Genprobe) are unacceptable.
Collect cultures for Chlamydia trachomatis from the anus in both sexes and from the vagina in girls. Limited
information suggests that the likelihood of recovering Chlamydia from the urethra of prepubertal boys is too low to
justify the trauma involved in routinely obtaining an intraurethral specimen. A urethral specimen should only be
obtained if urethral discharge or dysuria is present in the male prepubertal victim. A urine NAAT is an appropriate and
painless test that can be used as an alternative to the urethral/meatal swab. Pharyngeal specimens for Chlamydia
trachomatis are not recommended for either sex because the yield is low and test results can be confused
by Chlamydia pneumonia. Perinatally acquired infection may persist beyond infancy at this site. Use only standard
culture systems for the isolation of Chlamydia trachomatis and make positive identification by the use of specific
antigen testing. Non-culture methods are unacceptable for diagnosis.
If a vaginal discharge is present, obtain cultures, wet mount, and KOH prep of vaginal swab specimens for bacterial
vaginosis, Trichomonas vaginalis, and Candida albicans.
When genital lesions are present, consider diagnostic testing for herpes simplex virus or human papillomavirus.
Decisions about serological testing should be made on a case-by-case basis depending on the child/adolescent's risk
of infection. Collect and preserve serum for subsequent analysis in case follow-up serologic tests are positive. If the
last sexual exposure occurred more than eight weeks prior to the initial examination, sera should be tested
immediately for antibody to STDs such as syphilis, blood borne hepatitis, and HIV (with consent).




HIV
Test a child/adolescent when significant exposure may have occurred. In New York State, the Department of Health protocol for
HIV currently recommends testing and prophylaxis for all victims of sexual assault who are evaluated within 36 hours of the
incident. Provide all patients being tested for HIV antibodies with pre- and post-test counseling in compliance with New York
State HIV Confidentiality Law (Article ~ 27-F) and obtain written, informed consent.
Nonquantitative detection of HIV is the first step in diagnosing infectivity. In adults and older children, enzyme-linked
immunosorbent assay (ELISA) and Western blot assay are used to detect HIV-specific antibodies. These tests are not used for
diagnosis in those younger than two years because maternal antibodies are present in neonatal blood. DNA polymerase chain
reaction (PCR) and/or viral culturing are the standard detection methods in infants and young children. The patient may be
offered rapid HIV testing, using Oraquick or another rapid test. However, initiation of PEP should not be delayed until results
are available and should not be denied if the patient refuses testing. For information about HIV prophylaxis, see TREATMENT
AND FOLLOW-UP: Sexual Abuse, STD Prophylaxis, HIV.




















Infertility primarily refers to the biological inability of a person to contribute to conception. Infertility may also
refer to the state of a woman who is unable to carry a pregnancy to full term. There are many biological causes of
infertility, some which may be bypassed with medical intervention.
[1]

Women who are fertile experience a natural period of fertility before and during ovulation, and they are naturally
infertile during the rest of the menstrual cycle. Fertility awareness methods are used to discern when these
changes occur by tracking changes in cervical mucus or basal body temperature.
Causes in either sex
Factors that can cause male as well as female infertility are:
Genetic factors
A Robertsonian translocation in either partner may cause recurrent spontaneous abortions or complete
infertility.
General factors
Diabetes mellitus, thyroid disorders, adrenal disease
Hypothalamic-pituitary factors
Hyperprolactinemia
Hypopituitarism
The presence of anti-thyroid antibodies is associated with an increased risk of unexplained subfertility
with an odds ratio of 1.5 and 95% confidence interval of 1.12.0.
[12]

Environmental factors
Toxins such as glues, volatile organic solvents or silicones, physical agents, chemical dusts,
and pesticides.
[13][14]
Tobacco smokersare 60% more likely to be infertile than non-smokers.
[11]

German scientists have reported that a virus called Adeno-associated virus might have a role in male
infertility,
[15]
though it is otherwise not harmful.
[16]
Mutation that alters human DNA adversely can cause infertility,
the human body thus preventing the tainted DNA from being passed on
[citation needed]
.
Specific female causes
Further information: Female infertility
The following causes of infertility may only be found in females.
For a woman to conceive, certain things have to happen: intercourse must take place around the time when an egg
is released from her ovary; the systems that produce eggs and sperm have to be working at optimum levels; and
her hormones must be balanced.
[17]

Some women are infertile because their ovaries do not mature and release eggs. In this case synthetic FSH by
injection or Clomid (Clomiphene citrate) via a pill can be given to stimulate follicles to mature in the ovaries.
Problems affecting women include endometriosis or damage to the fallopian tubes (which may have been caused
by infections such aschlamydia).
Other factors that can affect a woman's chances of conceiving include being over- or underweight, or her age as
female fertility declines sharply after the age of 35. Sometimes it can be a combination of factors, and sometimes a
clear cause is never established.
Common causes of infertility of females include:
ovulation problems
tubal blockage
age-related factors
uterine problems
previous tubal ligation
endometriosis
[edit]Combined infertility
In some cases, both the man and woman may be infertile or sub-fertile, and the couple's infertility arises from the
combination of these conditions. In other cases, the cause is suspected to be immunological or genetic; it may be
that each partner is independently fertile but the couple cannot conceive together without assistance.
[edit]Unexplained infertility
Main article: Unexplained infertility
In the US, up to 20% of infertile couples have unexplained infertility.
[18]
In these cases abnormalities are likely to be
present but not detected by current methods. Possible problems could be that the egg is not released at the
optimum time for fertilization, that it may not enter the fallopian tube, sperm may not be able to reach the egg,
fertilization may fail to occur, transport of the zygote may be disturbed, or implantation fails. It is increasingly
recognized that egg quality is of critical importance and women of advanced maternal age have eggs of reduced
capacity for normal and successful fertilization. Also, polymorphisms in folate pathway genes could be one reason
for fertility complications in some women with unexplained infertility.
[19]

[edit]Assessment
Main article: Fertility testing
If both partners are young and healthy and have been trying to conceive for 12 months to one year without
success, a visit to the family doctor could help to highlight potential medical problems earlier rather than later. The
doctor may also be able to suggest lifestyle changes to increase the chances of conceiving.
[20]

Women over the age of 35 should see their family doctor after six months as fertility tests can take some time to
complete, and age may affect the treatment options that are open in that case.
A family doctor will take a medical history and give a physical examination. They can also carry out some basic
tests on both partners to see if there is an identifiable reason for not having achieved a pregnancy yet. If
necessary, they can refer patients to a fertility clinic or a local hospital for more specialized tests. The results of
these tests will help determine which is the best fertility treatment.
[edit]Treatment
Treatment depends on the cause of infertility, but may include counselling, fertility treatments, which include in
vitro fertilization. Treatment methods for infertility may be grouped as medical or complementary and alternative
treatments. Some methods may be used in concert with other methods. Drugs used for women include
Clomiphene citrate, Human menopausal gonadotropin, Follicle-stimulating hormone, Human chorionic
gonadotropin, Gonadotropin-releasing hormone analogs, Aromatase inhibitor, Metformin.
What are the risk factors of infertility?
In medicine, a risk factor is something that raises the risk of developing a condition, disease or symptom. For
example, obese people are more likely to develop diabetes type 2 compared to people of normal weight;
therefore, obesity is a risk factor for diabetes type 2.
Age - a woman's fertility starts to drop after she is about 32 years old, and continues doing so. A 50-year-
old man is usually less fertile than a man in his 20s (male fertility progressively drops after the age of 40).
Smoking - smoking significantly increases the risk of infertility in both men and women. Smoking may also
undermine the effects of fertility treatment. Even when a woman gets pregnant, if she smokes she has a
greater risk of miscarriage.
Alcohol consumption - a woman's pregnancy can be seriously affected by any amount of alcohol
consumption. Alcohol abuse may lower male fertility. Moderate alcohol consumption has not been shown to
lower fertility in most men, but is thought to lower fertility in men who already have a low sperm count.
Being obese or overweight - in industrialized countries overweight/obesity and a sedentary lifestyle are
often found to be the principal causes of female infertility. An overweight man has a higher risk of having
abnormal sperm.
Eating disorders - women who become seriously underweight as a result of an eating disorder may have
fertility problems.
Being vegan - if you are a strict vegan you must make sure your intake of iron, folic acid, zinc and vitamin B-
12 are adequate, otherwise your fertility may become affected.
Over-exercising - a woman who exercises for more than seven hours each week may have ovulation
problems.
Not exercising - leading a sedentary lifestyle is sometimes linked to lower fertility in both men and women.
Sexually transmitted infections (STIs) - chlamydia can damage the fallopian tubes, as well as making the
man's scrotum become inflamed. Some other STIs may also cause infertility.
Exposure to some chemicals - some pesticides, herbicides, metals (lead) and solvents have been linked to
fertility problems in both men and women.
Mental stress - studies indicate that female ovulation and sperm production may be affected by
mental stress. If at least one partner is stressed it is possible that the frequency of sexual intercourse is less,
resulting in a lower chance of conception.
What are the causes of infertility?
There are many possible causes of infertility. Unfortunately, in about one-third of cases no cause is ever
identified.
Medical treatments
Medical treatment of infertility generally involves the use of fertility medication, medical device, surgery, or a
combination of the following. If the sperm are of good quality and the mechanics of the woman's reproductive
structures are good (patent fallopian tubes, no adhesions or scarring), physicians may start by prescribing a course
of ovarian stimulating medication. The physician may also suggest using a conception cap cervical cap, which the
patient uses at home by placing the sperm inside the cap and putting the conception device on the cervix, or
intrauterine insemination (IUI), in which the doctor introduces sperm into the uterus during ovulation, via a
catheter. In these methods, fertilization occurs inside the body.
If conservative medical treatments fail to achieve a full term pregnancy, the physician may suggest the patient
undergo in vitro fertilization(IVF). IVF and related techniques (ICSI, ZIFT, GIFT) are called assisted reproductive
technology (ART) techniques.
ART techniques generally start with stimulating the ovaries to increase egg production. After stimulation, the
physician surgically extracts one or more eggs from the ovary, and unites them with sperm in a laboratory setting,
with the intent of producing one or more embryos. Fertilization takes place outside the body, and the fertilized egg
is reinserted into the woman's reproductive tract, in a procedure calledembryo transfer.
Other medical techniques are e.g. tuboplasty, assisted hatching, and Preimplantation genetic diagnosis.
Pathophysiology
Pathophysiology varies according to aetiology.
Ovulatory dysfunction
o Hypo-gonadotrophic anovulation occurs as a result of hypothalamic or pituitary abnormalities.
o Hyper-gonadotrophic anovulation occurs as a result of ovarian failure.
o Polycystic ovarian syndrome is the most common cause of eugonadotrophic anovulation.
Tubal disease
o Most often caused by gonorrhoea and chlamydia infection. Chlamydia trachomatis is obligate intracellular parasite that invades
the cervix, uterus, and fallopian tubes. This organism is the leading cause for acute salpingitis worldwide. The manifestation of
this disease is varied, ranging from sub-clinical to an acute tubo-ovarian abscess that can include peritonitis and peri-
hepatitis. [19] High anti-chlamydial antibody titres highly correlate to abnormal tubal pathology. [20] The risk of tubal occlusion
has been approximated as 10% for an initial episode of salpingitis, and then doubled with every subsequent infection. [21]
o Any pelvic infection, including appendicitis and diverticulitis, can damage the fallopian tubes.
Endometriosis
o Endometriosis can cause intra-abdominal inflammation and scar tissue. [22]
o This growth of hormonally responsive endometrial tissue outside the uterus may cause anatomical obstruction of the fallopian
tubes. It may also lead to infertility by producing cytokines that may be toxic to sperm or embryos. [2]
Age-related
o Age-related decreases in fecundity are caused by declining oocyte numbers and poorer oocyte quality. Oogenesis begins in
utero. By month 7 of gestation, mitosis completes and the peak number of oocytes (approximately 7 million) is achieved.
Hormone-independent apoptosis begins at this time and continues until menopause, regardless of factors such as
contraceptive use and pregnancy. Although the number of oocytes remaining in the ovary (ovarian reserve) impact on
pregnancy rates, age also leads to a higher rate of oocyte aneuploidy due to decreased chromosomal crossover, [23]meiotic
spindle fragility, [24] and telomeric shortening. [25] This leads to a high likelihood of implantation failure, miscarriage, and
chromosomally abnormal offspring (e.g., trisomy 21). [7]
Unexplained
o Unexplained infertility or subfertility is defined as the failure to conceive after 2 years of regular unprotected sexual intercourse
in the face of normal investigations (namely normal ovulation, normal semen analysis, patent fallopian tubes). [26]
o As couples go through the diagnostic and treatment pathways, an increasing number will acquire some form of diagnosis so
that the proportion of couples with so-called unexplained subfertility will decline.
o The label of unexplained subfertility recognises that there are numerous candidate sites for abnormalities causing reduced
fertility that cannot be recognised by standard diagnostic tests, but that, ultimately, treatment may improve the chance of a
pregnancy.
Uterine abnormalities
o Uterine abnormalities can be congenital or acquired. Failure of Mllerian duct fusion results in uterine malformations including
uterine didelphys, bi-cornuate or uni-cornuate uterus, and uterine septum. [27] Submucosal or large intramural leiomyomata
may have an impact on implantation or cause tubal obstruction. Endometritis, particularly when associated with a dilation and
curettage procedure, can destroy the endometrial lining and cause Asherman's syndrome (intrauterine adhesions).
Cervical abnormalities
o Cervical mucus is critical to facilitate sperm entry into the uterus and to initiate sperm capacitation, the final step in sperm
maturation. During the peri-ovulatory period the mucus becomes abundant, thin, and stretchable. Cervical maladies such as
surgery or infection can disrupt the cervical glands and/or mucus production.



Varicocele (pronounced /vrksil/), also known as varicoscele or varicose seal, is an abnormal enlargement of
the vein that is in the scrotum draining the testicles. The testicularblood vessels originate in the abdomen and
course down through the inguinal canal as part of the spermatic cord on their way to the testis. Upward flow of
blood in the veins is ensured by small one-way valves that prevent backflow. Defective valves, or compression of
the vein by a nearby structure, can cause dilatation of the veins near the testis, leading to the formation of a
varicocele.
Signs and symptoms
Symptoms of a varicocele may include:
Dragging-like or aching pain within scrotum.
Feeling of heaviness in the testicle(s)
Atrophy (shrinking) of the testicle(s)
Visible or palpable (able to be felt) enlarged vein
[1][2]

[edit]Cause
The idiopathic varicocele occurs when the valves within the veins along the spermatic cord do not work properly.
This is essentially the same process as varicose veins, which are common in the legs. This results in backflow of
blood into the pampiniform plexus and causes increased pressures, ultimately leading to permanent damage to
the testicular tissue.
Varicoceles develop slowly and may not have any symptoms. They are most frequently diagnosed when a patient
is 1530 years of age, and rarely develop after the age of 40. They occur in 15-20% of all males, and in 40% of
infertile males.
98% of idiopathic varicoceles occur on the left side, apparently because the left testicular vein connects to
the renal vein (and does so at a 90-degree angle), while the right testicular vein drains at less than 90-degrees
directly into the significantly larger inferior vena cava. Isolated right sided varicoceles are rare.
A secondary varicocele is due to compression of the venous drainage of the testicle. A pelvic or abdominal
malignancy is a definite concern when a right-sided varicocele is newly diagnosed in a patient older than 40 years
of age. One non-malignant cause of a secondary varicocele is the so-called "Nutcracker syndrome", a condition in
which the superior mesenteric artery compresses the left renal vein, causing increased pressures there to be
transmitted retrograde into the left pampiniform plexus.
[3]
The most common cause is renal cell carcinoma(a.k.a.
hypernephroma) followed by retroperitoneal fibrosis or adhesions.
[edit]Pathophysiology
The term varicocele specifically refers to dilatation and tortuosity of the pampiniform plexus, which is the network
of veins that drain the testicle. This plexus travels along the posterior portion of the testicle with the epididymis
and vas deferens, and then into the spermatic cord. This network of veins coalesces into the gonadal, or testicular,
vein. The right gonadal vein drains into the inferior vena cava, while the left gonadal vein drains into the left renal
vein at right angle to the renal vein, which then drains into the inferior vena cava.
The small vessels of the pampiniform plexus normally range from 0.51.5 mm in diameter. Dilatation of these
vessels greater than 2 mm is called a varicocele.
[edit]Diagnosis
Upon palpation of the scrotum, a non-tender, twisted mass along the spermatic cord is felt. Palpating a varicocele
can be likened to feeling a bag of worms.
[2]
When lying down, gravity may allow the drainage of the pampiniform
plexus and thus make the mass not obvious.
[2]
This is especially true in primary varicocele, and absence may be a
sign for clinical concern.
[2]
The testicle on the side of the varicocele may or may not be smaller compared to the
other side.
Varicocele can be reliably diagnosed with ultrasound,
[4][5]
which will show dilatation of the vessels of the
pampiniform plexus to greater than 2 mm. The patient being studied should undergo a provocative maneuver,
such as Valsalva's maneuver (straining, like he is trying to have a bowel movement) or standing up during the
exam, both of which are designed to increase intra-abdominal venous pressure and increase the dilatation of the
veins. Doppler ultrasound is a technique of measuring the speed at which blood is flowing in a vessel. An
ultrasound machine that has a Doppler mode can see blood reverse direction in a varicocele with a Valsalva,
increasing the sensitivity of the examination.
Recent studies have shown that varicocele is a bilateral disease
[6]
and the diagnosis of the right side is missed by
physical examination and even by ultrasonography. The examination should be performed by Ultrasonography
color flow doppler performed by highly experienced radiologist that will diagnose varicocele by demonstrating
back-flow in the right and in the left spermatic veins.
[7]

Classification of Varicoceles
Subclinical: no evidence of a varicocele with inspection or palpation, but positive scrotal thermography or
Doppler reflux detection.
Grade I: not visible, palpable only with a Valsalva maneuver.
Grade II: not visible, palpable without a Valsalva maneuver.
Grade III: visible through the scrotum without a Valsalva maneuver
Etiology of Varicocele
Primary Varicoceles
The nearly perpendicular configuration of the renal vein with the left internal spermatic vein combined with
incompetent venous valves leads to a long blood column with high pressure. The distal internal spermatic vein and
pampiniform plexus become ectatic and further venous valves decompensate. The different configuration of the
right internal spermatic vein with the vena cava prevents the reflux of blood and varicocele formation.
Two types of varicocele can be differentiated:
Pressure type: retrograde filling of the internal spermatic vein leads to varicocele formation, with no
collaterals to the internal or external iliac vein.
Shunt type: severe retrograde filling leads to the formation of a large varicocele with formation of collaterals
to the internal or external iliac vein,
According to Dubin and Amelar (1970), varicoceles grade I are associated with the pressure type, varicoceles grade
II and III are associated with the shunt type.
Secondary Varicocele
A retroperitoneal mass results in a flow impediment in the internal spermatic vein, which leads to a secondary
varicocele.
Pathophysiology of the Testicular Dysfunction
Reflux of (Adrenal) Blood
Reflux of adrenal blood leads to the increase of norepinephrine in the varicocele and by diffusion in the
testicular artery. This leads to a vasoconstriction in the testes.
Increased Testicular Temperature
Increased venous reflux of warm blood from the core of the body increases the temperature of the testis.
Elevated Venous Pressure
Venous reflux leads to an elevated venous pressure leading to a temperature increase and impairment of the
testicular blood supply.
Dysfunction of the Testis
Reflux of adrenal metabolites, elevated testicular temperature, disturbed testicular perfusion and elevated venous
pressure causes a dysfunction of the germinal epithelium. Signs are a microscopically visible impairment of the
Sertoli cell function, decreased inhibin secretion and increased FSH concentration. The impairment of the testicular
perfusion also affects the Leydig cell function with increased LH and normal to subnormal testosterone in patients
with varicoceles. Abnormal hormone concentrations are often corrected with surgical therapy.
Testicular Pathology due to varicocele
Gross Pathology:
Higher grade varicoceles lead to an atrophy of the testes.
Microscopic Pathology:
Reduction of spermatogenesis. Maturation arrest. In exceptional cases, Sertoli cell-only syndrome
Leydig cell dysfunction
Tubular thickening
Interstitial fibrosis
Signs and Symptoms of a Varicocele
Usually asymptomatic. Often incidental finding in routine examinations for male infertility.
Palpable mass in the spermatic cord, increasing with rising and with Valsalva maneuver.
Scrotal pain, especially with standing
Testicular atrophy: Normally the testes size varies not more than 20% or 2 ml in comparison to the other
side.
The primary varicocele is almost invariably on the left side. The right (and left) varicocele may be a symptom
of a retroperitoneal tumor.
Diagnosis of a Varicocele
Scrotal Ultrasound with Doppler Examination
Dilatated veins of the spermatic cord [Fig varicocele in ultrasound]? In adults, a venous diameter of more
than 3.5 mm is abnormal.
Reflux of blood during Valsalva maneuver [Fig varicocele in ultrasound]?
Testicular size: difference of more than 20% or 2 ml?
Testicular tumor?
Renal and retroperitoneal ultrasound: Tumor?