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Gynaecological (medical) History in Fertility

How does a good history help in diagnosing the cause/s of your infertility

Simple questions on menstrual history and medical can give your fertility expert a lot of helpful information.

Menstrual history alone tells us about the most common causes of infertility in women viz. anovulation.

Length of the cycle

It is good to know that a woman has regular cycles. Whilst this is typically understood as cycles of 28-30 days, the range of what is “normal” is quite wide and anything from 22-24 days till around 32-35 days would be regarded as normal. What is important that your period happens at that fixed intervals which is normal to you. So if you had your period every 24 days it would be normal so would it be if your periods happened every 34 days. What would not be normal if they were of 24 days this month and 34 days next. By and large periods vary by a day or two every month.

What does a “regular” cycle tell us ?

If a woman says her periods are regular within the normal range, it tells us that’s he is most likely making an egg on most months. The chance of the cycles being ovulatory is more than 90%- 95%. Irregular cycles typically happen because of anovulation (as in PCOS or Polycystic Ovarian Syndrome).

2. Dysmenorrhoea is good!

Does it hurt during your periods ?  is a common question we ask our women.. Ovulatory cycles are painful so you shouldn’t be offended when you tell the doctor your cycles hurt and doctor says “good”.

If you remember the first few years after the onset of your menses, the cycles were painless. They were irregular as well. This is because the cyclical pattern of your pituitary gland was not established.  It made FSH (Follicle Stimulating hormone) and LH (Luteinizing Hormone) which is important for ovulation. Around 16-17 years of age cycles typically starts becoming regular and that is because the cyclicity of LH secretions is established. Ovulatory cycles secret progesterone in the week following your ovulation. This hormone is linked with release of prostaglandins from the uterus, which in turn makes your periods painful. So regular cycles which give spasmodic pain especially for the first 2-3 days suggests ovulation.

Ovulatory pain is a short sharp pain during mid cycle. This is not felt by all women every month but some women do feel it most months and it is a marker for ovulation.

3. Not all period-pain is good.

If you have problems such as endometriosis or old (chronic) infections of the pelvis, there is a tendency for the periods to be painful. This is not a spasmodic (griping) pain but is dull and starts a few days prior to menses. It gets even worse during the menses. This is unlike the spasmodic pain of an ovulatory cycle which gets better after the first day or two of bleeding.

Such period pain is called congestive type of dysmenorrhea and will often be associated with painful intercourse (any time of the cycle) called dyspareumia.

Women with such history may be benefited by a laparoscopy with suitable remedial corrective surgery at the same time.

4. Heavy periods

Ovulatory cycles will not be too heavy in terms of blood flow. This is because the progesterone limits the extent of growth of the endometrium stimulated by the estrogen hormone in the first half of the cycle. Women with PCOS typically do not have progesterone and the unfettered growth of endometrium leads to heavy bleeding and passage of flakes of endometrium as well as clots.

Heavy periods are judged by how many pads you change but also if you pass clots, especially large ones. Normal menstrual blood does not clot because it is acted upon by enzymes within the uterine cavity which destroy the fibrin protein necessary to hold the clot. If you pass cloths it means the bleeding was so much as to overwhelm the fibrinolytic enzymes. Passing such clots means the uterus has to contract a lot and hence such cycles are not just heavy but also painful.

5. Hirsuitism – unwanted body hair

This is a very subjective question and needs to be understood well. Hirsuitism refers to growth of hair on your body in response to excessive androgens in the blood. This typically happens with PCOS  wherein the secretion of testosterone and other androgens from the ovaries increases. It can also be caused by adrenal tumors, but that is rare.

Hirsuitism is excessive hair growth on your face, side burns, upper lip as well as breasts etc. It should be noted that this “excessive” results to what is normal to you and your family and ethnic types rather than what you think is normal based on popular magazines. Some races like the Far East Asian are remarkably hairless whilst women from Mediterranean areas and North West part of the Indian subcontinent will have more body hair. The familial or ethnic tendency doesn’t reflect on hormonal abnormality.

The solution to this problem is by and large enabling ovulation which then takes care of the main problem which is infertility. For women who are not trying for a baby there are anti androgens that can be used long with local treatment with epilating therapies.

6. Milk like secretions from the breast

The presence of this suggesting increase in Prolactin hormone that comes from the anterior pituitary. Small amounts of elevation of prolactin are known to be associated with PCOS. Acute stress or eating disorders or even fear of needles also give increased prolactin levels in the blood.

The normal role of the hormone is of course to produce milk so if a woman is lactating her prolactin levels will be high. What worries us most is the possibility of having a prolactinoma which is a tumor in the anterior pituitary glands.

Investigations include serum prolactin levels and if elevated, an MRI scans.

Treatments of increased prolactin is mainly medical but surgical options are available.

Other types of history which can be important in diagnosing the cause of infertility

1.  History of abdominal or pelvic surgery

Typically a history of an ectopic pregnancy will indicate that there may be a problem with the Fallopian tubes. A previous history of appendicitis may suggest that the tube/s may be affected. Other surgical conditions such as Chrons’ disease may be associated with tubal pathology

2. History of STI

Sexually transmitted infections even if treated successfully may be associated with abnormal functions of the Fallopian tube. Chlamydia and Gonorrhoea are the usual culprits. The infection may have been long cured but the damage to the sensitive lining of the fallopian tube may have been done already. The tubes may be patent but that does not mean they are working well.

3.  History of medications

Hormone treatments, typically steroids can affect the lining of the womb or the process of ovulation.

In men, anti-hypertensive treatment can affect sexual function and thus contribute to infertility.

We need to know about all medications that you are on. If needed we can discuss and decide if stopping those can help your treatment.