Addressing the Rehabilitation Needs of Women Experiencing Infertility in Ethiopia: Time for Action.

The psychological, social, and financial disabilities caused by infertility are significant for women, particularly those living in low- and middle-income countries such as Ethiopia. Although rehabilitation can be an important form of support for such women, infertility is frequently overlooked as a disability or potential target of rehabilitation interventions. This study aimed to determine what rehabilitation-related services and supports are available for women experiencing infertility in Ethiopia. We used an Interpretive Description design. We purposefully selected fourteen rehabilitation, medical, and policy service providers from diverse institutions across three geographical locations. We used semi-structured questions during our in-person and telephone interviews. The data were analyzed using reflexive thematic analysis with the assistance of NVivo. We identified five main themes, including (a) policies related to infertility, (b) the concept that disabilities are physically visible fails to recognize infertility, (c) the need for rehabilitation services for women with infertility, (d) the importance of wellness services for women experiencing infertility, and (e) the role of religion in rehabilitation services. In conclusion, it is essential to strengthen the policies around infertility, incorporate rehabilitation services in fertility care, and view infertility as a disabling condition for women who experience it in Ethiopia.

Terapia manual para la mejora del flujo sanguíneo de las arterias uterinas en el área vascular endometrial/subendometrial en mujeres infértiles mediante ultrasonografía tridimensional: estudio piloto / Manual therapy for the improvement of blood flow of the uterus arteries in the endometrial/subendometrial vascular area in infertilized women through three-dimensional ultrasonography: Pilot study

Objetivo Evaluar cuantitativamente el efecto de la técnica manual de fisioterapia sobre el volumen endometrial y los valores del histograma en participantes infértiles. Métodos Estudio piloto, analítico, intervencionista, con grupo control, desarrollado en la Clínica Juana Crespo sobre 34 participantes infértiles. Se midió el volumen endometrial y subendometrial del útero, los índices de vascularización (IV%), el índice de flujo de vascularicación (IVF%) y el índice de flujo (IF%) mediante ultrasonografía Doppler 3D, después de aplicar la técnica manual de movilización de tejidos blandos de las fosas ilíacas. Resultados En el grupo experimental la comparación de los volúmenes endometriales totales antes (M=41,09) y después de la aplicación de la técnica fisioterápica (M=47,29) presentó diferencias estadísticamente significativas, z=–3,946 (p<0,001), r=–0,73, al igual que el estudio de los histogramas, alcanzando diferencias significativas en el índice de flujo (IF%) entre los registros pre (M=35,22) y post (M=37,62), z=–2,849 (p<0,005), r=–52. El índice de flujo de vascularización (IFV%) y el índice de vascularización (IV%) no tuvieron diferencias significativas entre el tiempo pre y post. Los histogramas IV%, IF%, IFV% indican p<0,005. Conclusiones La técnica de fisioterapia aumenta los volúmenes endometriales totales y el IF% endometrial después de su aplicación, aunque no varían las variables IV% e IFV% (AU)

Objective To quantitatively assess the effect of physical therapy manual technique on endometrial volume and histogram values in infertile participants. Methods Pilot, analytical, interventional study, with a control group, developed at the Juana Crespo Clinic on 34 infertile participants. The endometrial and subendometrial volume of the uterus, Vascularization Indices (VI%), Vascularization Flow Index (VFI%) and Flow Index (IF%) were measured by 3D Doppler Ultrasonography, after applying the manual mobilization technique in soft tissue of the iliac fossa. Results In the experimental group, the comparison of the total endometrial volumes before (M=41.09) and after the application of the physiotherapy technique (M=47.29) presented statistically significant differences, z=-3.946 (p<0.001), r=-, 73, like the study of histograms, reaching significant differences in the flow index (IF%) between the pre (M=35.22) and post (M=37.62) records, z=-2.849 (p<0.005), r=- 52. The vascularization flow index (IFV%) and the vascularization index (IV%) did not have significant differences between the pre and post time. Histograms IV%, IF%, IFV% indicate p<0.005. Conclusions The physiotherapy technique increases the total endometrial volumes and the endometrial IF% after its application, although the IV% and IFV% variables do not vary (AU)

[Randomized trial of a lifestyle program in obese infertile women]. / Leefstijlinterventie bij obese subfertiele vrouwen.

OBJECTIVE: Small intervention studies suggest that modest weight loss increases the chance of conception and may improve perinatal outcome, but large randomized controlled trials (RCT) are lacking. Our objective was to investigate the effects of a lifestyle intervention in obese infertile women in a multicenter RCT. DESIGN: We randomly assigned infertile women with body mass index ≥ 29 k/m² to a six-month lifestyle intervention preceding infertility treatment or to prompt infertility treatment. The primary outcome was the vaginal birth of a healthy singleton at term within 2 years of randomization. RESULTS: Between June 2009-June 2102 we randomly allocated 577 women to one of two treatment strategies: 290 to lifestyle intervention preceding infertility treatment (intervention group) and 287 to prompt infertility treatment (control group). Three women withdrew informed consent, leaving 289 and 285 women for analysis. Discontinuation rate during the lifestyle intervention was 22%. Mean weight loss in the intervention group was 4.4 kg and in the control group 1.1 kg ( p < 0.001); the primary outcome occurred in 76 women (27%) in the intervention group versus 100 (35%) in the control group (RR: 0.77, 95% CI 0.60 to 0.99). The number of natural conceptions leading to ongoing pregnancies was 73 (26%) versus 46 (16%) (RR: 1.6, 95% CI 1.2 to 2.2). Maternal pregnancy-related and labor-related complications and neonatal complications were comparable. CONCLUSION: In obese infertile women lifestyle intervention preceding infertility treatment did not result in better rates of vaginal birth of healthy singletons at term as compared to prompt infertility treatment.

Association of physical activity in the past year and immediately after in vitro fertilization on pregnancy.

OBJECTIVE: To estimate the association of physical activity on in vitro fertilization (IVF). DESIGN: Prospective cohort study. SETTING: Academic infertility clinic. PATIENT(S): Women (n = 121) undergoing nondonor IVF embryo transfer (fresh or frozen). INTERVENTION(S): The women completed a questionnaire on past year physical activity and wore an accelerometer from embryo transfer to serum pregnancy testing. MAIN OUTCOME MEASURE(S): Implantation, intrauterine gestation, and live birth. RESULT(S): Based on self-reported past year physical activity, the adjusted odds of intrauterine gestation was higher among those that had higher continuous active living (odds ratio [OR] 1.96, 95% confidence interval [CI] 1.09-3.50), sports/exercise (OR 1.48, CI 1.02-2.15), and total activity (OR 1.52, 95%CI 1.15-2.01) indices. After embryo transfer, women did almost no vigorous activity (median 0 min/d) as measured by the accelerometer. More of their time was spent in light activity (median 3.0 h/d) and sedentary behaviors (median 9.3 h/d). Accelerometer-measured physical activity and sedentary behavior after embryo transfer were not associated with any IVF outcome. CONCLUSION(S): An active lifestyle in the preceding year favorably impacted the IVF outcome. After embryo transfer, women engaged in mostly light physical activity and sedentary behaviors; therefore, the impact of vigorous physical activity on implantation could not be determined.

[The use of restorative medicine technologies for the rehabilitation of the patients presenting with endometriosis of external genitalia].

This paper reports the results of analysis of the psycho-emotional status and pain syndrome in the women presenting with endometriosis of external genitalia treated with a combination of hormonal preparations and balneotherapy. A total of 216 infertile patients were involved in the study. The duration of the infertility period varied from 1.5 to 19 years. All the patients underwent surgical intervention. The influence of rehabilitative therapy on the quantitative vital indices (psycho-emotional adaptation to the social environment and pain intensity) was estimated before and after the treatment. The patients were divided into 3 groups. Those of group 1 received an oral contraceptive (30 mcg of ethinylestradiol plus 2 mg dienogest) as a continuous three-cycle course (63 tablets) followed by its discontinuation for the 7 day menstrual period and the final three-cycle course (total duration of therapy 6 months). The patients of group 2 were treated with injections of agonists of gonadotropin releasing hormone (GnRH) at a dose of 3.75 mg once every 4 weeks (total duration 6 months). In group 3, the injections of GnRH agonists (3.75 mg once every 4 weeks, total duration 6 months) were combined with a course of balneotherapy using radon. All the three rehabilitative modalities produced a well-apparent positive effect. Chronic pelvic pain before treatment was reported by 90,3% of the patients. After the treatment, the number of such women in groups 1, 2, and 3 decreased to 20,8%, 12,5%, and 30,6% respectively Dyspareunia in the pre-treatment period was diagnosed in 66,7% of the patients. After treatment, this pathology persisted only in 23,6%, 18,1%, and 31,9% of the patients in groups 1, 2, and 3 respectively. Psycho-emotional disorders before treatment were documented in 90,3% of the patients compared with 27,8%, 25%, and 30,6% after therapy. It is concluded that all the three therapeutic modalities markedly improved health conditions of the patients presenting with endometriosis of external genitalia, but the combination of GnRH agonists with radon therapy produced the most pronounced clinical effect.

Fertility preservation in women with malignant tumors and gonadotoxic treatments.

BACKGROUND: Because of improved survival rates and recent advances in reproductive medicine, fertility preservation methods in women of reproductive age with malignant or autoimmune diseases have risen in importance. METHODS: Selective literature review based on the authors' clinical and scientific experience. RESULTS: Fertility-preserving techniques are recommended for all girls and women up to age 40 who are at high risk of ovarian failure. As these techniques are complex, special expertise in counseling and treatment is needed; in the German-speaking countries, such expertise is available in centers belonging to the FertiPROTEKT network (www.fertiprotekt.eu). Most of these techniques carry a very low risk and can be performed in two weeks or less. Success rates depend on the patient's age, the experience of the center, and the particular technique used. The highest attainable likelihood of pregnancy after the use of a combination of cryopreservation techniques is estimated at 40% to 50%. Fertility preservation is generally not covered by health insurance; its cost ranges from several hundred to several thousand euros. CONCLUSION: Girls and women up to age 40 who are about to undergo gonadotoxic treatment should be counseled about the availability of fertility-preserving techniques and, if appropriate, should be treated with such techniques in a specialized center.

Effect of patient selection on estimate of reproductive success after surgery for rectovaginal endometriosis: literature review.

The effect of rectovaginal endometriosis on fertility is unclear. Several authors foster radical surgery, including colorectal resection, as a fertility-enhancing procedure. However, interpretation of data is difficult, as the baseline fertility status is often undefined and it is not always possible to discriminate between spontaneous conceptions and those resulting from IVF. A systematic literature review was performed with the aim of defining the pregnancy rate specifically in patients who were infertile before surgery and who sought spontaneous pregnancy. A PubMed search was conducted to identify English language studies published between 2005 and 2011 evaluating reproductive performance after surgery for rectovaginal and rectosigmoid endometriosis. According to the results of the 11 selected studies, the mean post-operative conception rate in all women seeking pregnancy independently of preoperative fertility status and IVF performance was 39% (95% CI 35-43%; 223/571), but dropped to 24% (95% CI 20-28%; 123/510) in infertile patients who sought spontaneous conception (odds ratio 0.50, 95% CI 0.38-0.65%). Patients' selection significantly influences the estimate of the effect of rectovaginal endometriosis excision on infertility. This should be carefully taken into consideration at preoperative counselling. Rectovaginal endometriosis usually is associated with pain symptoms, but the effect of this disease form on fertility is uncertain, as burial of foci beneath rectouterine adhesions with exclusion of the deepest part of the pelvis may limit interference with fertilization processes. Several authors foster radical surgery, including colorectal resection, as a fertility-enhancing procedure. However, interpretation of data is difficult, as the baseline fertility status is often undefined and it is not always possible to discriminate between spontaneous conceptions and those resulting from IVF. A systematic literature review was performed with the aim of defining the pregnancy rate specifically in patients who were infertile before surgery and who sought pregnancy spontaneously. A PubMed search was conducted to identify English language studies published between 2005 and 2011 evaluating reproductive performance after surgery for rectovaginal and rectosigmoid endometriosis. According to the results of the 11 selected studies, the mean post-operative conception rate in all women seeking pregnancy independently of preoperative fertility status and IVF performance was 39% (223/571), but dropped to 24% (123/510) in infertile patients who sought conception spontaneously. The 15% difference is statistically significant. Infertile patients with rectovaginal endometriosis considering surgery, should be carefully informed of the real probability of post-operative conception avoiding generic overestimations.

Fertility after colorectal resection for endometriosis: results of a prospective study comparing laparoscopy with open surgery.

OBJECTIVE: To determine whether the surgical route of colorectal resection for endometriosis is a determinant factor for fertility. DESIGN: Prospective study. SETTING: Tertiary-care university hospital. PATIENT(S): Fifty-two patients with endometriosis were randomly assigned to laparoscopic or open surgery. INTERVENTION(S): Laparoscopically assisted vs. open colorectal resection. MAIN OUTCOME MEASURE(S): Evaluation of fertility outcomes spontaneously and after assisted reproductive therapy. RESULT(S): The mean follow-up was 29 months. Among the 28 patients wishing to conceive, 11 (39.3%) became pregnant. Overall cumulative pregnancy rate at 52 months for these patients was 45.1%. For patients with or without infertility, the cumulative pregnancy rate was 37.6% and 55.6%, respectively, and the cumulative spontaneous pregnancy rate 13.3% and 36.5%, respectively. All the spontaneous pregnancies were observed in the laparoscopy group. CONCLUSION(S): This study demonstrates that spontaneous pregnancy is more frequent after laparoscopy compared with open surgery for colorectal endometriosis.

Autotransplantation of cryopreserved ovarian tissue in 12 women with chemotherapy-induced premature ovarian failure: the Danish experience.

OBJECTIVE: To describe a cohort of 12 Danish women who received autotransplantation of frozen-thawed cryopreserved ovarian tissue because of premature ovarian failure after cancer treatment. DESIGN: Retrospective study. SETTING: University hospitals. PATIENT(S): Twelve women with autotransplanted frozen-thawed ovarian tissue. INTERVENTION(S): Monitoring of hormonal parameters and results of 56 IVF cycles in 10 women. MAIN OUTCOME MEASURE(S): Levels of gonadotropins and sex steroids, functional life span of the grafts, and results of IVF. RESULT(S): All 12 women regained ovarian function between 8 and 26 weeks (mean 19 weeks) after transplantation. Ten women underwent a total of 56 IVF cycles, 76 follicles developed, 49 oocytes were aspirated, 18 were fertilized, and 16 embryos were transferred resulting in six pregnancies: two biochemical, one clinical that miscarried in week 7, and two ongoing resulting in the delivery of two healthy infants born at term to two women. One of these women subsequently conceived spontaneously and delivered another healthy infant. The life span of the transplanted tissue has been between 6 months and still functioning after 54 months. CONCLUSION(S): Autotransplantation consistently leads to recovery of ovarian function after treatment-induced ovarian failure. Four women became pregnant, after IVF or spontaneously, resulting in the delivery of three healthy infants.

Fertility results and outcomes after pure laparoscopic management of advanced-stage serous borderline tumors of the ovary.

The outcomes of 18 patients treated with pure laparoscopic management (treated conservatively in 14 patients) of serous borderline ovarian tumors with peritoneal implants were reviewed. Eight patients relapsed (three with an invasive recurrence), but none of the patients without residual disease at the end of surgery, or invasive implants or disease with a micropapillary pattern relapsed under the form of invasive carcinoma.

Duration of fertility after fresh and frozen ovary transplantation.

OBJECTIVE: To evaluate the function of human ovarian transplants. DESIGN: Follow a series of fresh ovarian transplants for up to 5 years, and compare fresh and frozen ovarian tissue transplantation. SETTING: Tertiary referral community hospital. PATIENT(S): Nine women with premature ovarian failure who received an ovary donated from a monozygotic twin sibling, and 16 young cancer patients undergoing ovarian cryopreservation. Two of the transplant recipients were cancer survivors rendered sterile by their therapy. INTERVENTION(S): Fresh ovary transplantation between monozygotic twin sisters, as well as transplantation of previously frozen ovarian tissue, and study of cryopreserved tissue in cancer patients. MAIN OUTCOME MEASURE(S): Return of normal menstrual cycling, hormone levels, pregnancy, healthy babies, duration of transplant function, and ovarian tissue evaluation. RESULT(S): Normal serum FSH and regular menstrual cycles returned by 5 months after surgery in all cases, both fresh and frozen. Fourteen spontaneous pregnancies were established leading to eight healthy live births and two healthy ongoing conceptions. All three frozen tissue transplants conceived spontaneously, one delivered, and two were ongoing. Oocyte survival with slow freezing was 42% and after vitrification 89%. CONCLUSION(S): Ovarian transplantation in humans is a robust procedure, even after cryopreservation, and vitrification might prove to be more effective than slow freezing.

[Rehabilitation of the patients with polycystic ovary syndrome during sanatorium-and-spa treatment].

An original method for the combined non-medicamentous balneotherapeutic treatment of the patients with polycystic ovary syndrome and compromised reproductive function has been developed. The method designed to be applied after laparoscopic intervention for the management of infertility includes the use of radon water in combination with acupuncture. It was shown to help to restore regular menstrual cycles in half of the treated women and normalize fertility in some of them.

Infertilidad de origen tubárico: diagnóstico y manejo / Diagnosis and management of tubal infertility

El objetivo del presente trabajo es revisar algunos aspectos del diagnóstico, manejo y pronóstico de pacientes con infertilidad de origen tubárico, y evaluar el rol de la cirugía tubárica, basados en la evidencia disponible actualmente. Se efectuó una búsqueda bibliográfica en bases de datos electrónicas (Medline, Cochrane) y en libros de texto impresos, seleccionando los artículos considerados de mayor relevancia científica y epidemiológica. Se consultó material publicado entre 1984 y 2008, haciendo énfasis en estudios controlados aleatorizados (ECC). Resultados: El daño de las trompas de Falopio es una causa común en la mujer que tiene dificultad para concebir. La laparoscopia con cromopertubación permanece hoy como la prueba de oro en el diagnóstico de la enfermedad tubárica. Otras modalidades diagnósticas como la histerosalpingografía, sonohisterosalpingografía, salpingoscopia, falloposcopia, y serología para clamidia pueden también evaluar el daño tubárico. Varias opciones de tratamiento están disponibles. Para la obstrucción tubárica proximal, la canulación tubárica transcervical con lavado tubárico es una primera opción razonable. Las técnicas quirúrgicas para reparar las trompas como la salpingostomia o fimbrioplastia para enfermedad tubárica distal pueden dar buenos resultados. Aunque la intervención quirúrgica es efectiva en muchos problemas, el factor tubárico permanece como una de las mayores indicaciones para fertilización in-vitro con transferencia de embriones (FIV-TE). En ciertas situaciones, como embarazo ectópico recurrente o hidrosalpinx, la salpingectomía profiláctica puede ser usada en conjunto con la FIV-TE para mejorar los resultados en embarazos siguientes. Hay limitada evidencia de que haya beneficio o desventaja cuando se compara la microcirugía con técnicas estándar, la laparoscopia con laparotomía, y el uso de láser CO2 en las cirugías para infertilidad tubárica.

The present review is aimed at some aspects of diagnosis, treatment and prognosis of patients with tubal originated infertility, and to assess the role of tubal surgery, based on the available evidence. A reference search was made in electronic databases (Medline, Cochrane) and printed material published from 1984 to 2004, selecting articles considered by the authors to be of an important scientific and epidemiological relevance. Damage to the fallopian tubes is a common cause of infertility in women having difficulty conceiving. The laparoscopic chomopertubation remains as the "gold standard" of the diagnosis of tubal disease. In addition, other diagnostic modalities are available, including hysterosalpingography, sonohysterography, salpingoscopy, falloposcopy, and Chlamydia serology can assess tubal patency. Depending on the nature and degree of tubal dysfunction as well as the age and ovarian reserve of the patient, various approaches to the treatment of tubal infertility are available. For proximal tubal obstruction, transcervical tubal cannulation with tubal "flushing" is a reasonable first approach. Surgical techniques for tubal repair, such as salpingostomy or fimbrioplasty for distal tubal obstruction, can provide good results. While surgical intervention is an effective treatment for most tubal obstructions, tubal factor remains a major indication for in-vitro fertilization and embryo transfer. However, in specific situations, such as recurrent ectopic pregnancy and hidrosalpinx, prophylactic surgery can be used in conjunction with IVF-TE to improve subsequent pregnancy outcomes. There is limited evidence of the benefits or disadvantages of tubal surgery using microsurgery over standard techniques, laparoscopic approach over laparotomy, and the use of CO2 laser.

[Electromagnetic radiation of extra high frequency as a method of rehabilitation after surgical treatment of tubal-peritoneal infertility]. / Elektromagnitnoe izluchenie kraine vysokoi chastoty kak sredstvo vosstanovitel'noi terapii posle khirurgicheskogo lecheniia trubno-peritoneal'nogo besplodiia.

Seventy four patients entered the placebo-controlled study of rehabilitation EHF therapy 1 month after surgical laparoscopy for tubal-peritoneal infertility. It was found that early EHF therapy corrects hemodynamics in small pelvis vasculature characteristic for chronic inflammation of the uterine appendages thus raising the rate of impregnation.

[Recovered reproductive function in female patient with sever genital tuberculosis]. / Vosstanovlenie reproduktivnoi funktsii bol'noi s tiazheloi formoi genital'nogo tuberkuleza.

In severe genitoperitonial tuberculosis, conglomerate forms of the disease, and liquid accumulation between intestinal loop adhesions, laparotomy may verify the diagnosis in the shortest time while other diagnostic methods cannot be used due to contraindications for them. The operation should be maximally saving and only diagnostic. Timely combined antituberculous treatment concurrently with surgical interventions yields good results of recovered reproductive function.