What is pelvic inflammatory disease?

PID is an inflammation of the pelvic organs. It is usually caused by an infection spreading from the vagina and cervix to the uterus (womb), fallopian tubes, ovaries and pelvic area. If severe, it can cause an abscess (collection of pus) inside the pelvis.

What is ‘acute’ pelvic inflammatory disease?

Acute PID is the inflammation of the uterus, fallopian tubes, ovaries and pelvic area caused by an infection. If left untreated, it can cause abdominal pain and fertility problems in the future.

Sometimes the inflammation can persist for a long time, and this is known as chronic PID.

What causes Acute PID?

Untreated sexually transmitted infections (STIs) such as chlamydia or gonorrhoea are the most likely causes of PID and account for one-quarter of the cases in the UK. Acute PID is more common in young sexually active women. PID may also be caused by several less common infections that may, or may not, be sexually transmitted. Occasionally, PID can develop after events such as a miscarriage or termination of pregnancy, having a baby or after a procedure such as the insertion of an intrauterine device (IUD) or coil.

What are the symptoms of acute PID?

Sometimes you may not have any obvious symptoms. You may have one or more of the following, which can vary from mild to severe:

• Smelly or unusual vaginal discharge

• Pain in the lower abdomen that is usually on both sides and can feel like period pains

• Pain deep inside during or after sex

• Vaginal bleeding in between periods, bleeding after sex, or heavy periods

• Nausea and vomiting

• Fever

• Low backache.

Many of these symptoms are common and can be caused by other conditions. This means that PID can be difficult to diagnose so, if you have any of these symptoms, it is important to seek medical advice as soon as possible.

How is acute PID diagnosed?

Your doctor will ask you about your symptoms and your medical and sexual history. With your consent, your doctor may also do a vaginal (internal) examination. You should be offered a female chaperone for this. The examination may cause some discomfort, especially if you do have PID.

Swabs may be taken from your vagina and your cervix to test for infection. It usually takes a few days for the results to come back. A positive swab result confirms an infection. A negative swab result means that an infection is unlikely, but, does not mean you are clear of infection.

Further tests

You may be offered blood tests to check for infection. You may be asked for a urine sample. A test for HIV may also be advised.

If there is a chance that you could be pregnant, you will be offered a pregnancy test. This is because other conditions such as ectopic pregnancy (when a pregnancy develops outside the womb) can cause similar symptoms to PID.

If your doctor suspects you have a severe infection, you will be referred to your local hospital for further tests and treatment. You may be offered an ultrasound scan. This is usually a transvaginal scan (where a probe is gently inserted into your vagina) to look more closely at the uterus (womb), fallopian tubes and ovaries. This may help to detect inflamed fallopian tubes or an abscess.

How is acute PID treated

Your doctor or nurse can give you information about the specific treatment you are offered; this should include information about possible side effects. You will usually be given an injection of an antibiotic followed by a 2-week course of antibiotic tablets. Treatment usually does not interfere with contraception or pregnancy. It is very important to complete your course of antibiotics even if you are feeling better. Most women who complete the course have no long-term health or fertility problems.

You may also be offered medication for pain relief. You should rest until your symptoms improve. If they get worse, or do not get better within 48 to 72 hours of treatment, you should see your doctor again.

If you have a severe infection, you may need an operation under a general anaesthetic called a laparoscopy, which is also called keyhole surgery. The doctor uses a small telescope called a laparoscope to look at your pelvis by making tiny cuts, usually into your umbilicus (belly button) and just above the bikini line. Laparoscopy can help diagnose PID and can be used to drain a pelvic abscess.

When should I start treatment?

You should start taking antibiotics as soon as they are prescribed, even if you have not had your test results back. This is because any delay could increase the risk of long-term health problems. (Please see section entitled ‘Are there any long-term effects?’)

Why might I need hospital treatment?

Your doctor may recommend treatment in hospital if:

- Your diagnosis is unclear

- You are very unwell

- They suspect an abscess in your fallopian tube and/or ovary

- You are pregnant

- You are not getting better within a few days of starting oral antibiotics

- You are unable to take antibiotic tablets.

When you are in hospital, antibiotics may be given intravenously (directly into the bloodstream through a drip). This treatment is usually continued until 24 hours after your symptoms have improved. After that, you will also be given a course of antibiotic tablets.

Will I need an operation?

You will usually only need an operation if you have a severe infection or an abscess in the fallopian tube and/or ovary. An abscess may be drained during a laparoscopy or during an ultrasound procedure. The doctor will discuss these treatments with you in greater detail.

What if I’m pregnant?

It is rare to develop PID when you are pregnant. If there is any chance you could be pregnant, you should tell your doctor or nurse as certain antibiotics should be avoided in pregnancy. The risks that are associated with the type of antibiotics prescribed for PID are low for both mother and baby.

What if I have an intrauterine contraceptive device (IUD/coil)?

If your symptoms of PID are not improving within a few days of starting treatment and you have an IUD, your doctor may recommend that you have it removed. If you have had sex in the 7 days before it is removed, you will be at risk of pregnancy.

Should my partner be treated?

If you have developed PID because of an STI, anyone you have had intercourse with in the last 6 months should be tested for infection, even if they are well. You can contact them yourself or, your doctor, or sexual health clinic may help you with this.

When can I have sexual intercourse again?

You should avoid having any sexual contact until after both you and your partner have completed the course of treatment, to avoid reinfection.

What about follow-up?

If you have a moderate to severe infection, you will usually be given an appointment to return to the clinic after 3 days. It is important to attend this appointment so that your doctor can see that your symptoms are responding to the antibiotics. If your symptoms are not improving, you may be advised to attend hospital for further investigations and treatment.

If your symptoms are improving, you will usually be given a further follow-up appointment 2-4 weeks later to check:

• That your treatment has been effective

• Whether a repeat swab test is needed to confirm that the infection has been successfully treated; this is particularly important if you have ongoing symptoms

• That you have all the information you need about the long-term effects of PID

• Whether another pregnancy test is needed

• That you have all the information you need about future contraceptive choices

• That your sexual partner(s) have been treated.

Are there any long-term effects of acute PID

Treatment with antibiotics is usually successful for acute PID. Long-term problems can arise if it is untreated, if treatment is delayed, or if there is a severe infection.

The long-term effects can include:

An increased risk of ectopic pregnancy in the future

Difficulties in becoming pregnant

An abscess in a fallopian tube and/or ovary

Persistent pain in your lower abdomen

Repeated episodes of PID increase the risk of future fertility problems.

Reference- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/acute-pelvic-inflammatory-disease-pid-tests-and-treatment-patient-information-leaflet/

Adenomyosis is a condition where the endometrium (lining of the womb) is found deep in the myometrium (muscle of the uterus).

We do not know exactly why adenomyosis happens, but it is likely that women with adenomyosis have a predisposition due to their genes, immune system and hormones.

Adenomyosis is not an infection, and it is not contagious. It is benign (not cancerous).

How common is Adenomyosis 

Adenomyosis affects as many as one in ten women of reproductive age. It is more common in women aged 40-50 years and who have had children.

What are the symptoms?

The most common symptoms are:

• Heavy, painful or irregular periods

• Pre-menstrual pelvic pain and feelings of heaviness/discomfort in the pelvis

Less common symptoms are:

• Pain during sexual intercourse

• Pain related to bowel movements

About one third of women experience few or no symptoms; other women suffer with many effects. It can also affect other aspects of a woman’s life including her general physical health and emotional well-being. Symptoms generally stop after menopause.

Adenomyosis does not appear to decrease the chance of pregnancy, however it is linked to an increased risk of miscarriage and premature birth.

How is it diagnosed?

Adenomyosis can take a long time, even years, to diagnose because the symptoms and severity can vary between women.

Your doctor may organise and perform a transvaginal ultrasound scan and/or an MRI to investigate your symptoms.

Treatment

The right treatment depends on symptoms but also other factors including age, desire for children and preserving fertility, views on surgery and what treatments have been tried already.

Options include:

• Doing nothing- if symptoms are mild, you are trying for a pregnancy or nearing menopause

• Non hormonal treatments such as tranexamic acid or mefenamic acid to reduce pain and bleeding with your period

• Hormones such as the oral conceptive pill, Depo-Provera ™ injection, Nexplanon™ implant and Mirena™ coil or types that cause a temporary and false menopause state (Zoladex™)

• Hysterectomy (removal of the womb), for women not wishing to preserve fertility

Reference- https://www.nbt.nhs.uk/our-services/a-z-services/gynaecology/adenomyosis

What is AMH?

Anti-Müllerian Hormone (AMH) is produced by small follicles (pouches which contain the eggs) growing in the ovary. It can be measured in a blood test. The level of AMH reflects how many follicles are growing, which gives an indication of how many eggs are present in the ovary. The number of eggs present in the ovary declines as we age, until menopause, when the supply runs out. The more follicles that are growing, the higher the level of AMH in the blood.

The AMH measurement can predict how strongly the ovaries will respond to the hormones used in an IVF cycle. Certain factors may affect AMH levels. If you have polycystic ovaries (PCO), more small follicles are growing in your ovaries, making it likely that you will respond vigorously to the stimulation drugs. In this situation, your levels of AMH may be elevated. This can identify the information needed to modify your hormone doses accordingly. AMH is also increased in certain pathological tumours of the ovary such as a granulosa cell tumours but these occur rarely. Similarly, if you have a low number of growing follicles, for example due to previous illnesses and pelvic operations, chemotherapy or because you are approaching the menopause, it can be identified through low AMH levels and adapt your dosage of gonadotrophins to try to compensate, but this may not always help.

Research has shown that AMH measurement is the most reliable method of predicting the likely response of the ovary, (better than other tests that you might have heard of, such as FSH or inhibin). However, unfortunately, the NHS does not fund AMH measurement, and must be privately funded.

The benefits perceived are that it improves the doctor’s ability to prescribe the best individualised stimulation regime for your personal needs. In this way, treatment can be optimised and give you the best chance of achieving a successful outcome.

It is recommended that you have it done, especially if you are in one of the following situations:

• Previous poor response

• Older women (age>35)

• If you have ever had a high FSH or a high E2 blood test result

• Low antral follicle count on scan examination.

• Polycystic ovaries (PCO/PCOS)

• Uncertainty about response to gonadotrophin injections.

AMH normal ranges

Age Range , AMH (pmol/l)

20-29 years , 13.1 - 53.8

30-34 years , 6.8 - 47.8

35 - 39 years , 5.5 - 37.4

40-44 years , 0.7 - 21.2

45 - 50 years , 0.3 - 14.7

Reference-https://www.uhcw.nhs.uk/clientfiles/files/IVF/CRM%20AMH%20Patient%20Information%20(GEN-PI-000213V11).pdf

Endometriosis is a condition where tissue similar to the lining of the womb starts to grow in other places, such as the ovaries and fallopian tubes. Endometriosis can affect women of any age. It's a long-term condition that can have a significant impact on your life, but there are treatments that can help.

Symptoms of endometriosis

The symptoms of endometriosis can vary. Some women are badly affected, while others might not have any noticeable symptoms.

The main symptoms of endometriosis are:

• Pain in your lower tummy or back (pelvic pain) – usually worse during your period

• Period pain that stops you doing your normal activities

• Pain during or after sexual intercourse

• Pain when using the toilet during your period

• Feeling sick, constipation, diarrhea, or blood in your pee during your period

• Difficulty getting pregnant

You may also have heavy periods. You might use lots of pads or tampons, or you may bleed through your clothes.

For some women, endometriosis can have a big impact on their life and may sometimes lead to feelings of depression.

When to see a GP

See a GP if you have symptoms of endometriosis, especially if they're having a big impact on your life. It may help to write down your symptoms before seeing a doctor.

It can be difficult to diagnose endometriosis because the symptoms can vary considerably, and many other conditions can cause similar symptoms. A GP will ask about your symptoms and may ask to examine your tummy and vagina. They may recommend treatments if they think you have endometriosis.

If these do not help, they might refer you to a specialist called a gynaecologist for some further tests, such as an ultrasound scan or laparoscopy.

A laparoscopy is where a surgeon passes a thin tube through a small cut in your tummy so they can see any patches of endometriosis tissue. This is the only way to be certain you have endometriosis.

Causes of endometriosis

The cause of endometriosis is not known.

Several theories have been suggested, including:

- Genetics – the condition tends to run in families, and affects people of certain ethnic groups more than others

- Retrograde menstruation – when some of the womb lining flows up through the fallopian tubes and embeds itself on the organs of the pelvis, rather than leaving the body as a period

- Problems with the immune system, the body's natural defence against illness and infection

- Endometrium cells spreading through the body in the bloodstream or lymphatic system, a series of tubes and glands that form part of the immune system

None one of these theories fully explain why endometriosis happens. It's likely the condition is caused by a combination of different factors.

There is no cure for endometriosis and it can be difficult to treat. Treatment aims to ease symptoms so the condition does not interfere with your daily life.

Further problems caused by endometriosis

One of the main complications of endometriosis is difficulty getting pregnant or not being able to get pregnant at all (infertility).

Surgery to remove endometriosis tissue can help improve your chances of getting pregnant, although there's no guarantee that you'll be able to get pregnant after treatment.

Surgery for endometriosis can also sometimes cause further problems, such as infections, bleeding or damage to affected organs. If surgery is recommended for you, talk to your surgeon about the possible risks.

Living with endometriosis

Endometriosis can be a difficult condition to deal with, both physically and emotionally.

As well as support from your doctor, Chana offers emotional support for someone going through this diagnosis.

Treatments for endometriosis

There's currently no cure for endometriosis, but there are treatments that can help ease the symptoms.

Treatments include:

Pain relief – such as ibuprofen and paracetamol

Hormone medicines and contraceptives – including the combined pill, the contraceptive patch, an intrauterine system (IUS), and medicines called gonadotrophin-releasing hormone (GnRH) analogues. These slow the growth of endometriosis tissue

Surgery to cut away patches of endometriosis tissue to stop the condition returning, or in severe cases to remove part or all of the organs affected by endometriosis. For example, surgery to remove the womb (hysterectomy), which would also stop the condition returning

Your doctor will discuss the options with you. Sometimes they may suggest not starting treatment immediately to see if your symptoms improve on their own

When deciding which treatment is right for you, there are several things to consider:

- Your age

- What your main symptoms are, such as pain or difficulty getting pregnant

- Whether you want to become pregnant – some treatments may stop you getting pregnant

- How you feel about surgery

- Whether you have tried any of the treatments before

Treatment may not be necessary if your symptoms are mild, you have no fertility problems, or you're nearing the menopause, when symptoms may get better without treatment.

Endometriosis sometimes gets better by itself, but it can get worse if it's not treated. One option is to keep an eye on symptoms and decide to have treatment if they get worse.

Further information on treatments

Pain medication - Anti-inflammatories, such as ibuprofen or paracetamol, may be tried to see if they help reduce your pain. They can be used together for more severe pain. These painkillers are available to buy from pharmacies and do not usually cause many side effects. Tell your doctor if you have been taking painkillers for a few months and you're still in pain.

Hormone treatment - The aim of hormone treatment is to limit or stop the production of oestrogen in your body, as oestrogen encourages endometriosis tissue to grow and shed. Limiting oestrogen can reduce the amount of tissue in the body. But hormone treatment has no effect on adhesions ("sticky" areas of tissue that can cause organs to fuse together) and cannot improve fertility. Some of the main hormone-based treatments for endometriosis include:

• The combined oral contraceptive pill contains the hormones oestrogen and progestogen. They can help relieve milder symptoms, and can be used over long periods of time. They stop eggs being released (ovulation) and make periods lighter and less painful. These contraceptives can have side effects, but you can try different brands until you find one that suits you. Your doctor may recommend taking 3 packs of the pill in a row without a break to minimise the bleeding and improve any symptoms related to the bleeding.

• Progestogens are synthetic hormones that behave like the natural hormone progesterone. They work by preventing the lining of your womb and any endometriosis tissue growing quickly. But they can have side effects, such as: bloating, mood changes, irregular bleeding, weight gain

Progestogens used to treat endometriosis include:

The Mirena intrauterine system, a small device that's placed in the womb and releases progestogen

The contraceptive injection

The contraceptive implant

The progestogen-only-pill (POP)

Progestogen tablets that are not contraceptives, such as norethisterone

Evidence suggests these hormone treatments are equally effective at treating endometriosis, but they have different side effects. You can discuss the different options and their side effects. Most hormone treatments reduce your chance of pregnancy while using them, but not all of them are licensed as contraceptives. None of the hormone treatments have a permanent effect on your fertility.

Surgery - can be used to remove or destroy areas of endometriosis tissue, which can help improve symptoms and fertility. The kind of surgery you have will depend on where the tissue is.

The main options are:

Laparoscopy – the most commonly used technique

During laparoscopy, also known as keyhole surgery, small cuts (incisions) are made in your tummy so the endometriosis tissue can be destroyed or cut out. Large incisions are avoided because the surgeon uses an instrument called a laparoscope. This is a small tube with a light source and a camera, which sends images of the inside of your tummy or pelvis to a television monitor. During laparoscopy, fine instruments are used to apply heat, a laser, an electric current, or a beam of special gas to the patches of tissue to destroy or remove them.

Ovarian cysts, or endometriomas, which are formed because of endometriosis, can also be removed using this technique.

The procedure is carried out under general anaesthetic, so you'll be asleep and will not feel any pain as it's carried out. Although this kind of surgery can relieve your symptoms and sometimes help improve fertility, problems can recur, especially if some endometriosis tissue is left behind. You may need to take hormone treatment before and after surgery to help avoid this.

Hysterectomy - If keyhole surgery and other treatments have not worked and you have decided not to have any more children, removal of the womb (a hysterectomy) can be an option.

A hysterectomy is a major operation that will have a significant impact on your body. Deciding to have a hysterectomy is a big decision you should discuss with your GP or gynaecologist. Hysterectomies cannot be reversed and, though unlikely, endometriosis symptoms could return after the operation. If the ovaries are left in place, the endometriosis is more likely to return.

If your ovaries are removed during a hysterectomy, the possibility of needing HRT afterwards should be discussed with you. But it's not clear what course of HRT is best for women who have endometriosis. For example, oestrogen-only HRT may cause your symptoms to return if any endometriosis patches remain after the operation.

Talk to your doctor about the best treatment for you.

Any surgical procedure carries risks. It's important to discuss these with your surgeon before undergoing treatment.

Gonadotrophin-releasing hormone (GnRH) analogues

GnRH analogues are synthetic hormones that bring on a temporary menopause by reducing the production of oestrogen. They're sometimes given before surgery to help reduce the amount of endometrial tissue. You would normally take them for 3 months before your surgery. GnRH analogues are not licensed as a form of contraception, so you should still use contraception while using them.

Complementary therapies

There is no evidence that traditional Chinese medicine or other Chinese herbal medicines or supplements can help treat endometriosis.

Women with endometriosis can sometimes experience several complications.

• Fertility problems - Endometriosis can cause fertility problems. This is not fully understood but is thought to be because of damage to the fallopian tubes or ovaries. But not all women with endometriosis will have problems and will eventually be able to get pregnant without treatment. Medication will not improve fertility. Surgery to remove visible patches of endometriosis tissue can sometimes help, but there's no guarantee this will help you get pregnant. If you're having difficulty getting pregnant, infertility treatments, such as in vitro fertilisation (IVF), may be an option. But women with moderate to severe endometriosis tend to have a lower chance of getting pregnant with IVF than usual.

• Adhesions and ovarian cysts. Adhesions – "sticky" areas of endometriosis tissue that can join organs together. Ovarian cysts – fluid-filled cysts in the ovaries that can sometimes become very large and painful These can both occur if the endometriosis tissue is in or near the ovaries. They can be treated with surgery but may come back in the future if the endometriosis returns.

Surgery complications

Like all types of surgery, surgery for endometriosis carries a risk of complications. The more common complications are not usually serious, and can include:

A wound infection

Minor bleeding

Bruising around the wound

Less common, but more serious, risks include:

Damage to an organ, such as a hole accidentally being made in the womb, bladder or bowel

Severe bleeding inside the tummy

A blood clot in the leg (deep vein thrombosis) or lungs (pulmonary embolism)

Bladder and bowel problems -Endometriosis affecting the bladder or bowel can be difficult to treat and may require major surgery. You may be referred to a specialist endometriosis service if your bladder or bowel is affected.

Reference- https://www.nhs.uk/conditions/endometriosis/

For further support

https://www.endometriosis-uk.org/

Anti-Müllerian Hormone (AMH): Produced by small follicles (pouches which contain the eggs) growing in the ovary. It can be measured in a blood test. The level of AMH reflects how many follicles are growing, which gives an indication of how many eggs are present in the ovary.

Anovulatory: Absence of ovulation.

Antral Follicles: Smaller follicles which develop as a result of FSH stimulation but are then re-absorbed by the body.

Assisted Hatching: The thinning of the shell or creation of a small hole in the zona of an embryo.

Assisted Reproductive Technology (ART): Procedures that help unite an egg and sperm outside the body in the laboratory.

Asthenozoospermia: Sperm with poor motility

Antisperm Antibodies: Sticky proteins on sperm causing immobilisation.

Azoospermia: Complete absence of sperm in the ejaculate.

Blastocyst: The early stage of an embryo that is 4-5 days old and is a hollow ball of cells whose wall is comprised of a single layer of cells; the blastocyst is the liquid-filled sphere that implants in the wall of the uterus during implantation

Blastocyst Transfer: An embryo that has developed to five days and is transferred into the uterus.

Cervix: The opening to the uterus.

Cervical Mucous: A fluid that enhances the transport of the sperm into the endometrial cavity.

Chromosome: Thread-like structures located inside the nucleus of animal and plant cells. Each chromosome is made of protein and a single molecule of deoxyribonucleic acid (DNA) which is passed from parents to offspring.

Clomifene Citrate: A medication used to treat infertility in women who do not ovulate, including those with polycystic ovary syndrome. (Also known as Clomiphene).

Clomifene Challenge Test: An exam that can determine the egg reserves in the ovaries.

Corpus Luteum: A ruptured follicle. The corpus luteum releases estrogen and progesterone. Progesterone continues to be released if fertilisation has occurred. If pregnancy does not occur, the Corpus Luteum stops producing Progesterone and the female will have a menstrual bleed.

Cryopreservation: The process of freezing commonly used for embryos or sperm. Cryopreservation of oocytes is a relatively recent development and is called vitrification.

Dilation and curettage (D&C): A procedure to remove tissue from inside your uterus. Sometimes used to diagnose and treat certain uterine conditions such as heavy bleeding or to clear the uterine lining after a miscarriage or abortion.

DNA (Deoxyribonucleic acid): The hereditary material in humans and almost all other organisms. Nearly every cell in a person's body has the same DNA

Dysmenorrhea: Pain with menstrual bleeding.

Ectopic Pregnancy: A pregnancy in which a fertilised egg begins to develop outside the uterus normally used in reference to a pregnancy that develops in the fallopian tube.

Egg: The female reproductive cell in animals and plants

Egg Collection: A procedure performed to collect the eggs produced from an IVF/ICSI cycle. This can be performed under sedation or a General Anaesthetic.

Egg Donation: A woman donates eggs through IVF/IVCSI treatment, to another woman (recipient).

Ejaculate: To eject or discharge semen at the moment of sexual climax

Electro-ejaculation: The use of electrical stimulation to aid production of a semen sample in impotent or paralysed men.

Embryo: An unborn offspring in the process of development, during the period from approximately the second to the eighth week after fertilization (after which it is usually termed a foetus).

Embryo transfer: A procedure following IVF/ICSI in which the embryos are replaced back into the uterus.

Endometriosis: A condition in which the lining of the uterus, called the endometrium, grows outside of the uterine cavity. Often, this tissue is found in the pelvic cavity attached to the ovary or fallopian tubes. It can be a cause of infertility in women.

Endometrium: The lining of the uterus which is shed. The lining of the uterus that grows throughout the menstrual cycle and is shed in the monthly menstrual cycle if an embryo does not implant.

Epididymis: Coiled tubing outside the testicles which store sperm.

Estradiol: A hormone secreted by the ovaries.

Estrogen: A female hormone secreted chiefly by the ovaries that stimulates the development of female secondary sex characteristics and promotes the growth and maintenance of the female reproductive system.

Fallopian Tubes: Tubes connected to the uterus and positioned near the ovaries. It is here that fertilisation of the egg and sperm occurs.

Fertilisation: Sperm penetrating the egg which can lead to pregnancy.

Fibroids: non-cancerous growths that develop in or around the womb (uterus).

Foetus: An unborn baby that develops and grows inside the uterus (womb). The foetal period begins 8 weeks after fertilization of an egg by a sperm and ends at the time of birth.

Follicle Stimulating Hormone (FSH): A hormone produced by the pituitary gland that stimulates the growth of the egg-containing follicles in the ovary. In males it contributes to the production of sperm.

Follicles: A fluid filled sac in the ovary in which an egg grows and develops. Although the egg is microscopic, follicles can be visualised by ultrasound.

Follicular Tracking: Scanning a woman during a natural cycle for ovulation.

Gametes: Male sperm and female eggs.

Gonadotropins: Gonadotropin Releasing Hormone (GnRH): Produced by the Hypothalamus, it enables the production of LH and FSH.

Human Chorionic Gonadotropin (HCG): A hormone that is produced by the body in the early stages of pregnancy. It enables the corpus luteum to continue producing Progesterone. In assisted conception HCG is used 36 hours prior to egg retrieval to mature the eggs ready for the egg collection procedure.

Hydrosalpinx: Fluid in the fallopian tube.

Hypothalamus: A specialised gland in the brain that orchestrates the body’s hormonal changes.

Hypospadias: Congenital abnormality, affecting male offspring, in which the opening of the urethra is misplaced or malformed.

Hystero Contrast Sonography (Hycosy): Procedure which checks the patency of the fallopian tubes using ultrasound waves.

Hysteo-Salpingpgram (HSG): Procedure which checks the patency of the fallopian tubes and the uterus under X-ray conditions.

Hysteroscopy: A procedure in which the uterine cavity is visualised by a surgeon. Can help in the diagnosis of fibroids or polyps.

Intracytoplasmic sperm injection (ICSI): An effective treatment for men with infertility. It’s performed as part of IVF and involves the sperm being injected directly into the egg. Some men may need their sperm to be surgically extracted first.

Implantation: For a pregnancy to continue developing the embryo needs to implant into the lining of the womb, the endometrium.

Impotence: the inability in a man to achieve and maintain an erection

In Vitro Fertilisation (IVF): A procedure that involves removing eggs from a woman’s ovaries and fertilising them in the laboratory outside the body. The resulting embryos are then replaced back into the woman’s womb through the cervix.

Infertility: The inability to conceive after a year of unprotected intercourse (six months if the woman is over age 35) or the inability to carry a pregnancy to term.

Intra-Cytoplasmic Sperm Injection (ICSI): A procedure in which a single sperm is injected into a mature egg. Normally offered to couples where the male sperm count is low or there is poor motility. It can also be offered to couples who have experienced failed fertilisation following IVF.

Intrauterine Insemination (IUI): A procedure in which sperm is washed and prepared and then passed directly into the uterus via a fine catheter to enhance the chances of fertilisation.

Klinefelter’s Syndrome: A genetic condition in which men have an extra X chromosome. Menstrual Cycle: Normally a 28-day cycle in which ovulation occurs around day 14 and if fertilisation does not occur, results in a bleed around day 28.

Menorrhagia: Heavy menstrual bleeding.

Miscarriage: Spontaneous loss of a viable embryo or foetus in the womb.

Microsurgical Tubal Reanastomosis: A procedure used to reverse tubal sterilisation.

Motile Forms: Sperm with a heightened ability to swim.

Myomas (fibroids): Benign (non-cancerous), smooth muscle tumours found in the female genital tract.

Laparoscopy: A camera procedure in which the surgeon passes a small, lighted instrument by making a small incision under the belly button to explore the internal structure of the pelvis, in particular the ovaries, fallopian tube and the uterus.

Luteinizing Hormone (LH): A hormone which is produced by the Pituitary gland. In females it is essential for the production of Oestrogen. In males it is necessary for the process of sperm production and testosterone secretion.

Oestrogen: A hormone that aids the thickening of the endometrium lining. It is also produced in small quantities in the male.

Oligozoospermia: Low numbers of sperm in the ejaculate.

Oligo-asthenoteratozoospermia (OATS): Low numbers, reduced motility and abnormality of the sperm shape in the ejaculated sample.

Oocyte: a cell in an ovary which may undergo meiotic division to form an ovum.

Open Approach (Abdominal Myomectomy): A surgical procedure in which only fibroids, but not the uterus, are removed. This preserves childbearing potential. Myomectomy can be performed in different ways depending on the location of fibroids within the uterus. The most common approach is abdominal myomectomy, which allows the surgeon to directly visualise the uterus and fibroids through an abdominal incision.

Ovarian Cysts: Sacs filled with fluid or semisolid material that develops on or within the ovary during the time of ovulation. Most cysts are benign and disappear spontaneously without treatment.

Ovarian Hyperstimulation Syndrome (OHSS): A condition due to excessive response of the ovaries to stimulation drugs, in which the ovaries enlarge and there may be nausea, abdominal swelling and shortness of breath. This develops after the trigger injection and you should always report it to the clinic or an emergency doctor.

Ovary: The female reproductive organs that produce eggs and estrogen on a monthly basis under hormonal influence from pituitary gland.

Ovarian Drilling: Surgical procedure offered to women with PCOS. Small holes are drilled into the ovary to reduce the number of cysts present in an attempt to regulate the menstrual cycle and aid conception.

Ovulation: The release of the egg (ovum) from the ovarian follicle.

Ovulation Induction: Medical treatment performed to initiate ovulation.

Ovum: a mature female reproductive cell, especially of a human which can divide to give rise to an embryo usually only after fertilization by a male cell.

Pelvic Adhesions: Abnormal bands of scar tissue that form in the pelvis and cause organs to stick or bind to one another.

PESA-Percutaneous Epidymal Sperm Aspiration: A procedure involving sperm being retrieved directly from the epididymis using a needle.

PGD- Pre-Genetic Implantation Diagnosis: The analysis of a cell, under laboratory conditions, from an embryo to check for genetic disease.

PID-Pelvic Inflammatory Disease: an infection of the female reproductive organs. It most often occurs when sexually transmitted bacteria spread from your vagina to your uterus, fallopian tubes or ovaries

Polycystic Ovarian Syndrome: An endocrine disorder affecting the function of the ovaries.

PMT- Premenstrual Tension: These are symptoms arising from hormonal changes, normally occurring a week before menstrual bleed. They can include irritability, tearfulness and mood swings.

Premature Ovarian Failure: Indicated by an elevated FSH. The ovaries are no longer producing follicles, this can be due to congenital, genetic, chromosomal or damage caused by toxic drugs, such as chemotherapy.

Progesterone: A female hormone secreted by the corpus luteum in the ovaries during the second half of a woman’s cycle. It thickens the lining of the uterus to prepare for the implantation of a fertilised egg.

Pronuculate egg: Fertilised egg.

Scrotum: a pouch of skin containing the testicles.

Semen: The whitish fluid containing sperm (plus other substances) that is released during male ejaculation.

Seminiferous Tubules: Sperm is developed and grows in the tubules.

Shmira: The supervision of reproductive material (sperm, eggs or embryos) while it is either being stored or used in treatment, to ensure that it is the couple’s own material used throughout their fertility journey. While most Halachic authorities in the UK hold that the standard laboratory procedures mandated in this country are sufficient in this regard, some people prefer to also use a Jewish Shomer (supervisor) on top of this, with the agreement of their clinic. This can either be the husband, or another person with specific training in this area.

Sperm: The gamete that contains the genetic material of the male.

Sperm Count: One of the parameter’s that is checked in a semen sample i.e., the number of sperm present in the ejaculate.

Sperm Donation: Donation of sperm, from another person, to help couples conceive.

Spermatogenesis: The production of sperm.

Sperm Morphology: Size and shape of sperm. It is the factor that's examined as part of a semen analysis to evaluate male infertility. Sperm morphology results are reported as the percentage of sperm that appear normal when semen is viewed under a microscope.

Sperm Motility: Another parameter that it checked in the semen sample. It is the ability of the sperm to swim to the egg that enables fertilisation to occur.

STD: Sexually transmitted disease, such as Chlamydia.

Stillbirth: when a baby dies after the 24th week of a pregnancy or during birth. If the baby dies before 24 completed weeks, it's known as a miscarriage or late foetal loss

Surrogacy: A woman carries a pregnancy for a couple.

Teratazoospermia: High numbers of abnormal sperm in ejaculate.

TeSE: Testicular Sperm Extraction, involving sperm being retrieved from a biopsy of testicular tissue.

Testes: The body part where sperm is manufactured.

Testosterone: This hormone aids the production of sperm. It is also found in smaller quantities in women.

Vagina: The birth canal leading to the uterus

Vaginal Ultrasound: Internal scan which enables clear images of the reproductive organs in a female. This will be used to assess follicular development during treatment.

Vas deferens: Tubes which carry sperm from the epididymis to the urethra.

Vasectomy: A surgical procedure which cuts the passages that transport the sperm.

Vitrification: A technology that is used in the embryo and egg freezing process so that they can be stored for later use.

Womb: (Uterus) where the baby grows during pregnancy

Urethra: Tube that drains urine from the bladder outside the body

Uterus: The hollow, pear-shaped organ in a woman's pelvis. The uterus is where a foetus (unborn baby) develops and grows. Also called a womb.

Zona: Shell surrounding the egg/embryo.

Zygote: A fertilized egg cell that results from the union of a female gamete (egg, or ovum) with a male gamete (sperm).

Polycystic ovary syndrome (PCOS) is a common condition that affects how a woman's ovaries work.

The 3 main features of PCOS are:

• Irregular periods – which means your ovaries do not regularly release eggs (ovulation)

• Excess androgens – high levels of "male" hormones in your body, which may cause physical signs such as excess facial or body hair

• Polycystic ovaries – your ovaries become enlarged and contain many fluid-filled sacs (follicles) that surround the eggs (but despite the name, you do not actually have cysts if you have PCOS)

If you have at least 2 of these features, you may be diagnosed with PCOS.

Polycystic ovaries contain many harmless follicles that are up to 8mm (approximately 0.3in) in size. The follicles are underdeveloped sacs in which eggs develop. In PCOS, these sacs are often unable to release an egg, which means ovulation does not take place.

It's difficult to know exactly how many women have PCOS, but it's thought to be very common, affecting about 1 in every 10 women in the UK.

More than half of these women do not have any symptoms.

Symptoms

If you have signs and symptoms of PCOS, they'll usually become apparent during your late teens or early twenties.

They can include:

• Irregular periods or no periods at all

• Difficulty getting pregnant because of irregular ovulation or failure to ovulate

PCOS is one of the most common causes of female infertility. Many women discover they have PCOS when they're trying to get pregnant and are unsuccessful. During each menstrual cycle, the ovaries release an egg (ovum) into the uterus (womb). This process is called ovulation and usually occurs once a month.

Women with PCOS often fail to ovulate or ovulate infrequently, which means they have irregular or absent periods and find it difficult to get pregnant.

• Excessive hair growth (hirsutism) – usually on the face, chest, back or buttocks

• Weight gain

• Thinning hair and hair loss from the head

• Oily skin or acne

PCOS is also associated with an increased risk of developing health problems in later life, such as type 2 diabetes and high cholesterol levels.

What causes polycystic ovary syndrome (PCOS)?

The exact cause of PCOS is unknown, but it often runs in families. It's related to abnormal hormone levels in the body, including high levels of insulin. Insulin is a hormone that controls sugar levels in the body. Many women with PCOS are resistant to the action of insulin in their body and produce higher levels of insulin to overcome this. This contributes to the increased production and activity of hormones like testosterone. Being overweight or obese also increases the amount of insulin your body produces.

Diagnosis criteria

A diagnosis of PCOS can usually be made if other rare causes of the same symptoms have been ruled out and you meet at least 2 of the following 3 criteria:

1- You have irregular periods or infrequent periods – this indicates that your ovaries do not regularly release eggs (ovulate)

2- Blood tests showing you have high levels of "male hormones", such as testosterone (or sometimes just the signs of excess male hormones, even if the blood test is normal)

3- Scans showing you have polycystic ovaries

As only 2 of these need to be present to diagnose PCOS, you will not necessarily need to have an ultrasound scan before the condition can be confirmed.

Treating polycystic ovary syndrome (PCOS)

There's no cure for PCOS, but the symptoms can be treated. Speak to a GP if you think you may have the condition. If you're diagnosed with PCOS, you may be treated by your GP or referred to a specialist, either a gynaecologist (a specialist in treating conditions of the female reproductive system) or an endocrinologist (a specialist in treating hormone problems).

Your GP or specialist will discuss with you the best way to manage your symptoms. They'll recommend lifestyle changes and start you on any necessary medicine.

If you have PCOS and you are overweight then losing weight and eating a healthy, balanced diet can make some symptoms better. You can find out if you are a healthy weight by calculating your body mass index (BMI), which is a measurement of your weight in relation to your height. Your GP may be able to refer you to a dietitian if you need specific dietary advice.

Medicines are also available to treat symptoms such as excessive hair growth, irregular periods (contraceptive pill) and fertility problems (clomiphene, letrozole or metformin). If fertility medicines are not effective, a simple surgical procedure called laparoscopic ovarian drilling (LOD) may be recommended. This involves using heat or a laser to destroy the tissue in the ovaries that's producing androgens, such as testosterone.

With treatment, most women with PCOS can get pregnant.

Follow-up

Depending on factors like your age and weight, you may be offered annual checks of your blood pressure and screening for diabetes if you're diagnosed with PCOS.

Pregnancy risks

If you have PCOS, you may have a higher risk of pregnancy complications, such as high blood pressure (hypertension), pre-eclampsia, gestational diabetes and miscarriage.

These risks are particularly high if you're obese. If you're overweight or obese, you can lower your risk by losing weight before trying for a baby.

Reference- https://www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/

Progesterone levels can contribute to abnormal menstrual periods and menopausal symptoms. Progesterone is also necessary for implantation of the fertilized egg in the uterus and for maintaining pregnancy.

Progesterone is a steroid hormone which is mainly produced by the cells of the Corpus Luteum and, during pregnancy, by the Placenta. Progesterone levels are low during the follicular phase of the menstrual cycle. After ovulation, progesterone production by the corpus luteum increases rapidly, reaching a maximum concentration 4 to 7 days after ovulation. These levels are maintained for 4 to 6 days then fall to baseline levels, inducing menstruation.

Progesterone stimulates the cells of the uterine mucosa in readiness for the implantation of a fertilised ovum. If fertilisation does not occur, the corpus luteum regresses, causing a reduction in progesterone levels, and the cycle begins again.

Progesterone determination is useful in fertility diagnosis for the detection of ovulation and assessment of the luteal phase.

Reference ranges

Follicular: < 5.0nmol/L

Luteal: 3.5 – 67 nmol/L

Post-menopause: < 4.4nmol/L

Progesterone is used as a marker of ovulation in the investigation of infertility. Failure to ovulate is a reason for infertility in about 20% of cases. Failure of progesterone levels to increase in the latter phase of the menstrual cycle indicates an anovulatory cycle or corpus luteum inadequacy.

A progesterone level of greater than 30nmol/L should be seen as a guideline to ovulation rather than an absolute measure. If the progesterone level is above 30nmol/L, further hormone levels are unnecessary and other causes of infertility must be explored.

References- https://www.webmd.com/vitamins/ai/ingredientmono-760/progesterone

https://www.southtees.nhs.uk/services/pathology/tests/progesterone/

https://www.gloshospitals.nhs.uk/our-services/services-we-offer/pathology/tests-and-investigations/progesterone/#:~:text=Progesterone%20is%20used%20as%20a,cycle%20or%20corpus%20luteum%20inadequacy.