FUNCTIONAL CLASSIFICATION OF CAUSES

• TIME

Timing of coitus

Frequency of coitus

• SEMEN

Sperm disorders

Disorders of other components

Antisperm antibodies

• OVA

Growth and development of viable ova

Ovulation

Implantation

Adequacy of the corpus luteum 

• TRANSPORT

MALE

Sperm transport

COITAL

Ejaculatory disorders

FEMALE

Cervical transport failure

Uterine transport failure

Tubal transport failure 

• INCUBATOR (UTERINE CAVITY)

Endometrial dysfunction – affecting implantation

• OTHER PROBLEMS

Generalized endocrine disorders

Systemic diseases

Diabetes mellitus

Chronic renal disease

Cardiac disorders

Tuberculosis

Investigations

A thorough evaluation should identify one or more causes in about 90% of couples and appropriate therapy will result in pregnancy in about 40% of couples

There are 3 main reasons for infertility investigations

• To determine the cause of infertility

• To arrive at a prognosis

• To serve as a basis for treatment

 Prevention

1. Life style adjustment – quit smoking, regular exercise, minimize caffeine and alcohol.

2. Practice safe sex to avoid contracting STIs

3. Maintain reasonable ideal body weight

4. Avoid exposure to environmental hazards e.g. pesticides, heavy metals like mercury and lead, proper protection from radiation

5. In the event of STI, seek early medical treatment

6. Maintain good diet

7. Have regular physical examination

3.5 SEXUALLY TRANSMITTED INFECTIONS (STIs)

These are human infections transmitted through sexual intercourse, which may be vaginal, oral or anal. The organisms causing the infections are normally present in the reproductive tract, or introduced from the outside during sexual contact or medical procedures or as a result of an imbalance in vaginal bacterial flora.

There are different and many types of STI, but the commonest are:

Fungal infections

• Candidiasis (Candida Albican)

Protozoan Infection 

• Trichomoniasis (TrichomonasVaginalis)

Bacterial Infection

• Bacterial Vaginosis (GardnerallaVaginalis)

• Chlamydia (Chlamydia trachomatic)

• Gonorrhoea (Neisseria gonorrhoeae)

• Syphilis (Treponemapallidum)

• Chancroid (Haemophilusducreyi)

• Granuloma inguinale (Klebsiellagranulomatis)

• Lymphogranulomavenerum (Chlamydia trachomatis)

Viral Infections

• Herpes simplex or genital herpes

• HIV

• Hepatitis B

• Genital warts (Human Papillomavirus)

• Molluscumcontagiosum (Poxvirus)

STIs have different presentations but similar signs, symptoms and complication expect for HIV/AID.

3.5.1 The Syndromic Approach

In the syndromic approach, health providers diagnose and treat patients on the basis of a group of symptoms, or syndromes rather than for specific STDs, e.g treatment is given for vaginal discharge rather than gonorrhea, Chlamydia, candidaiasis or bacterial vaginosis which all presents with vaginal discharge hence the 4 conditions are treated at once. The approach makes diagnosis more accurate without extensive laboratory tests and allows treatment with a single visit.

Information about the patient’s sexual history can help to distinguish between syndromes that are sexually transmitted and other reproductive tract infections (e.g. candidaiasis and bacterial vaginosis) which are not usually, transmitted sexually.

Benefits of the Syndromic Diagnosis

1. It improves clinical diagnosis by avoiding wrong diagnosis and ineffective treatment.

2. It can be learned by all health providers e.g. CHWs, Nurses etc

3. It allows treatment of symptomatic patients in one visit.

4. It reduce expensive and sometimes unnecessary lab. test 

Disadvantages

1. Failure to provide adequate cure for people with asymptomatic STIs (women with STIs are often asymptomatic).

2. Drug wastage, due to treatment of general symptoms which the patient may not actually have.

Diagnosis

The WHO has developed STD diagnosis and treatment flow chart (step-by-step pathways) using the syndromic approach to help PHC providers manage STD patients. The flow chart classified the four most common syndromes caused by STDs; which are:

1. Genital ulcer in a man or woman

2. Urethral discharge in a man

3. Vaginal discharge

4. Lower abdominal pain in a woman.

Genital Ulcers

1. Syphilis: Produces a single painless ulcer with firm borders that feel like the tip of the nose.

2. Chancroid: Produces a soft, painful ulcer with an irregular shaped border. In women the ulcer may not be painful.

3. Herpes Simplex: Produces blister like lesions in and around vagina, anus or on thigh. Pain may be more severe in women than men.

4. Both syphilis and chancroid may cause enlarge lymph nodes. In syphilis, lymph nodes are enlarged and firm but painless. In contract, choncroid, like LGV can cause enlarged and tender lymph nodes that may burst and leak pus.

5. LGV: Produces ulcers which are small or shallow that looks like herpes blisters and heal without treatment.

6. Donovanosis: Produces ulcers which begin as nodules under the skin that erupt and form usually painless, sharply defined lesions.

7. Human Papillomavirusand Molluscumcontagiosum can cause: non-ulcerative lesions (genital warts) which often looks like a cauli- flower. The lesions of molluscum are white, smooth pimples that contains a while cheese like substance.

Urethral Discharge

1. Identify the origin of the discharge, i.e. either the meatus, or the foreskin of uncircumcised penis. 

2. When discharge is not visible, consider milking the penis from the base to the tip to observe discharge. You may advise the patients to milk the penis by themselves.

3. If the patient urinated shortly before the examination, discharge will have been rinsed and may not reappear for several hours

4. Gonorrhoea, Trichomoniasis and choncroid usually lead to urethral discharge.

Vaginal Discharge

1. Diagnosing an STD on the basis of vaginal discharge is difficult, one have to determine the consistency, the volume of secretion, changes in the colour, foul odour, itching and soreness, painful urination or pain during intercourse.

2. Candidaiasis and bacterial vaginosis cause vaginal discharge although they’re not usually sexually transmitted. They also alter the pH level of the vagina.

3. Check the appearance of vagina and vulva. If they are inflammed, candidaiasis or trichomoniasis may be the cause. Bacterial vaginosis does not cause inflammation.

4. Vulval itching is also a symptom of candidaiasis and trichomoniasis. 

5. The origin of the discharge can help to identify the disease.

1. Discharge from the cervix possibly indicates - Gonorrhoea or Chlamydia.

2. Discharge from the vaginal wall indicates – Trichomoniasis, candidaiasis, or Bacterial vaginosis. Identifying the origin of discharge in the vagina may be difficult; however, wiping off the cervix with a swab can help, where discharge from the cervix may then be observed. Other signs of cervical infection are redness and bleeding when the cervix is touched with a swab.

6. If there is pain when the cervix is touched, use the flow chart for lower abdominal pain.

7. Patients who return often with candidaiasis may have HIV infection or diabetes. Refer them to a hospital for testing.