By E. Dawson. University of Arizona.
If women have a regular cycle and are and might be detrimental to a woman’s position aged <35 years we do not advise starting investi- within the family and the community amoxicillin 500 mg overnight delivery. To over- gations on these couples because it is not cost- come infertility buy amoxicillin 500mg, men and women spend consider- able sums of money in treatment1 cheap amoxicillin american express,2 generic amoxicillin 250 mg. Infertility is a serious reproductive health problem for a society, but has a low priority on We make a distinction between primary and the political and health agenda of low-resource secondary subfertility: countries. International and national policy makers • Primary subfertility: a woman was never pregnant focus on the reduction of maternal and neonatal or a man never made any woman pregnant. At this time, ment of infertility, it is important to study the men- the ovum (the egg which is not visible with the strual cycle again. The cycle starts on the first day of bare eye) will come out of the follicle and can the period (when vaginal blood loss starts) and stops be fertilized. Luteal phase of the cycle: this is the phase in regular if the cycle is between 25 and 35 days: 91– 5 which a fertilized egg (called an embryo at this 97% of those women will have an ovulatory cycle. In this We say that a woman has oligomenorrhea if the phase the endometrium is prepared by the hor- cycle is >35 days and amenorrhea if the cycle is >6 mone progesterone which is produced by the months. On ultrasound in (follicular phase) of the cycle is not the same in all the luteal phase the endometrium is white and women. The length of the second (luteal) phase is always 14 days so ovulation takes place 14 days be- fore the next period starts and you can only deter- mine ovulation retrospectively. Menstruation: discharge of the endometrium (on day 1 to approximately day 4–7). Follicular phase: starts after the blood loss stopped. In this phase the follicle is stimulated, grows and produces estrogen. The growth of the follicle is under the influence of the hor- mone follicle-stimulating hormone (FSH), produced by the pituitary gland. When you make an ultrasound in the follicular phase of the cycle you will see that the endometrium is formed in three layers (Figure 2) and that a Figure 2 An ovary with more follicles. The growth of the follicle which we call the dominant follicle will rupture follicle is (start counting only if the follicle is when it is 2 cm in diameter. Courtesy David van Ham rupture (we call this ovulation) when it is 2 cm. Figure 3 Endometrium in the follicular phase of the Figure 1 Schematic view of the different phases in the cycle: you can clearly see the triple line. Courtesy David female menstrual cycle van Ham 171 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS Table 1 Common causes of subfertility In woman No ovulation PCOS Hyperprolactinemia Early menopause Hypophysis/hormone abnormalities Tubes are not patent Hydrosalpinx Adhesions Proximal tube blockage Endometriosis Figure 4 Endometrium in the luteal phase of the cycle: Cervical hostility you can clearly see that the endometrium does not have triple lines anymore and has become dense. Courtesy In man David van Ham Semen not good enough Azoospermia Oligospermia is no longer triple layered (Figure 4). When the ovum is not fertilized or when the embryo Unexplained is not implanted in the endometrium, the next period will start. For an example of an ultrasound in women with PCOS, see Figure 7. CAUSES OF SUBFERTILITY • Hyperprolactinemia: the pituitary gland in the brain produces too much prolactin (hormone Causes of subfertility could be in the woman, in the that stimulates lactation). Typically these women man, in both, or unexplained (Table 1). In women, will have milk from the breast and a very irregu- the following three problems are the most common lar cycle. Rare causes are large stress: you can ask the patient if she lost a lot of fibroids or Asherman’s syndrome (adhesions of the weight recently. A follicle which ruptures and is fertilized is critical Tubes are not patent for becoming pregnant. Most women (around 91– 97%) with a regular cycle (between 25 and 35 days) This happens often after sexually transmitted infec- will produce a follicle monthly and thus have a tions (STI; see Chapter 17) and often women have chance of becoming pregnant5. The chances for a history of symptoms of STI/pelvic inflammatory women with oligomenorrhea becoming pregnant disease (PID) and sometimes chronic abdominal are less. If you can make an ultrasound you • Polycystic ovary syndrome (PCOS): this is a disease often can see hydrosalpinges (see Figure 6). You in which many small follicles grow (you can see can test the patency of the tubes in several ways (see it on ultrasound, per definition >12 follicles of section on Investigations on subfertility). Women will have oligomenorrhea (cycle of more than During the growth and development of a dominant 35 days) and are often (but not always) obese. An example of this mucus becomes very clear and forms threads. This questionnaire can be seen in the Appendix at the only happens around ovulation. You can also develop your own change in mucus is so that the sperm cells can swim form. The important questions are: up via the cervical mucus inside the uterus. In some • Duration of fertility problem: the longer the women, cervical mucus does not change and stays duration of the subfertility, the less likely it is white and is full of leukocytes: the sperm cells can- that you could help this couple. For example, if not use the mucus to swim up towards the follicle. In older women not mean that if sperm is of lower quality that it is (this does not count for men) fertility becomes a completely impossible to make a woman pregnant. Do not waste time and your patients’ Production of sperm cells takes 3 months and is money tackling infertility problems in women negatively influenced by high temperatures as in over the age of 42 years. If you find a poor sperm sample, you should • Ever pregnant before? Unexplained subfertility N Intrauterine fetal death (IUFD). We diagnose unexplained infertility if all the tests N Abortion (spontaneous, induced or dilatation are normal: the woman is ovulating, the tubes are and curettage, D&C). Any history of infec- patent, the cervical mucus is good, the post-coital tion around that abortion? Then the other tube semen; however, the woman has still not become could be damaged as well. This could be because there are many • Periods and cycle aspects in human fertility which are still not under- N Cycle: from first day of period until first day stood. However, other factors may play a role: of next period infrequent or wrongly timed intercourse, sexual N Regular: women with a cycle between 25 problems, intravaginal application of spermicide and 35 days will have in 91–97% of cases an (washing of the vagina, often with traditional herbs, ovulatory cycle directly after intercourse). The service provider can N Oligomenorrhea: cycle >35 days detect such fertility-hindering factors through N Amenorrhea: cycle >6 months thorough history taking. N The amount of blood loss: heavy bleeding could be a sign of fibroids. Women with galactorrhea often A detailed history will give you directions about have an anovulatory cycle. It is recommended to • Secondary dysmenorrhea (see Chapter 7). After PID (Chapter 17) or endometriosis (Chapter 6). Table 2 WHO criteria for normal semen • Sexual intercourse N Frequency. Pain (deep dys- rapid progressive motile pareunia, see Chapter 6) could be a sign of Morphology ≥30% normal PID (Chapter 17) or endometriosis (Chapter White blood count <1 million per ml 6). Signs of chronic diseases like tuberculosis or AIDS? Ex- cessive weight gain will also give anovulatory cycles and PCOS (see section on causes of subfertility). HIV with chronic infec- tions could lead to anovulation and amenorrhea (read about special considerations for HIV- positive infertility patients in Chapter 18). When women have already changed partners frequently because of sub- Figure 5 An example of a post-coital test under the fertility it will be more likely that the cause of microscope. Use the 40 × ocular and look if progressive infertility is either anovulation or blocked tubes motile sperm cells are present and not poor sperm quality. Production only around period of insertion of cervical mucus is stimulated by hormones (estro- N Depo-Provera: it could take up to 1 year gen produced in growing follicle).
Assessment of metoprolol buy 500 mg amoxicillin mastercard, a cardioselective beta- blocking agent buy amoxicillin cheap online, during chronic therapy in patients with angina pectoris cheapest amoxicillin. Discordance between effects of anti-ischemic therapy on ambulatory ischemia amoxicillin 250 mg with visa, exercise performance and anginal symptoms in patients with stable angina pectoris. Brady AR, Gibbs JSR, Greenhalgh RM, Powell JT, Sydes MR, investigators Pt. Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. Bisoprolol and hypertension: effects on sexual functioning in men. A multicentre study of cardioselective metoprolol (Lopresor) and non-selective propranolol in the management of mild to moderate hypertension. Brunner HR, Waeber B, Ferguson RK, Turini GA, Gavras H. The position of beta- blockers in antihypertensive therapy. 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The risk of encountering such ‘monoglot’ teachers is particularly high in English-speaking countries discount amoxicillin 500 mg mastercard. Spontaneously buy discount amoxicillin 500mg on-line, a series of questions come to mind: Do these teachers know what it means to absorb 5 generic amoxicillin 500 mg line,000 to 15 discount amoxicillin 500mg on line,000 words? Can they imagine how it feels to nail 20 to 50 new words into your brain every day? Do they have the faintest idea of how demanding it is to penetrate the dense thicket of high-speed human speech? Do they simply presage the thrill of discovering a new language? In summary, do they have an appropriate comprehension of the complications and implications of language learning? So if your language classes in Paris, London, Berlin, or Seville, are meant to be more than meeting and mingling opportunities with people from all over the world, make sure that your teachers are polyglots. You wouldn’t want to take sex lessons from nuns and priests. The second group of teachers you should avoid are those who do their job because they didn’t get the job they wanted. Their first choice was perhaps to be a musician, a philosopher, or a writer. But life is unpredictable, dreams don’t always materialise, and in order to make a living, some people accept the role of a language teacher. After a short period of frustration, most of these ‘against-their-will’ teachers will settle into their new life and excel in their profession. However, a minority do not, and will lack the essential skills for teaching a language: energy and enthusiasm. While in other professionals, for example real estate agent, woodcutter, or mortician, a lack of enthusiasm may be irrelevant, in teaching it is not. Don’t be content with anything less than passionate and wholehearted teachers. You have decided to become fluent in another language, you are ready to invest years, and your desire is to achieve the most. Frustrated teachers are infectious individuals who could contaminate what is one of your most valuable resources: motivation. Traditionally, language teachers trained and checked six core competences: vocabulary, understanding of speech, production of speech, reading, writing, and grammar. As we have seen in the Words chapter, vocabulary training is inherently a lonely job because nobody except yourself can transfer thousands of words into your brain. In what is the most important single task of language learning, teachers can do nothing for you. The second most important task is speech recognition. Until relatively recently, language teachers were often the only individuals at hand to produce human speech in another language. In modern times, human speech is ubiquitous, at every corner of your life and in any language you want. As a consequence, audio CDs, audio books, internet news, and TV have supplanted teachers as prime speech sources. The impact of teachers on the third, fourth and fifth tasks – speaking, reading, and writing – is equally limited. Writing comes as a bonus of reading, reading as a bonus of word learning, and as you will see in the Speaking chapter, correct pronunciation comes as a bonus of hundreds of hours of listening. Grammar is therefore the only domain where language teachers will continue to play a certain role in the future. Grammar – the climax of excruciatingly boring language lessons, and a torture for teens? As an adult, please consider grammar rehabilitation. Grammar consists of a fairly limited number of rules that tell you how to modify words and how to arrange them to form correct and beautiful sentences. More importantly, a big chunk of grammar – verbs such as to talk, to love, to play, etc. As these verbs are immensely important in some languages, let’s dedicate a couple of pages to it. Verbs usually denote action (learn, listen, read), occurrence (forget, decompose), or a state of being (love, exist). To English native-speakers, they do not seem impressive because, with the exception of a small number of irregular verbs such as go-went- gone, write-wrote-written, etc. All we can press out of to want are two variations, wants and wanted. Just put a few auxiliaries around them – have, shall, and will – and you will have created all the tenses and moods you need. The Italian equivalent, volere, needs 6 different forms... Dig deeper into volere, and you rapidly discover a whole nest of descendants: volevo, volevi, voleva, volevamo, volevate, volevano, volli, volesti, volle, volemmo, voleste, vollero, vorrò, vorrai, vorra, vorremo, vorrete, vorranno, vorrei, vorresti, vorrebbe, vorremmo, vorreste, vorrebbero, voglia, vogliano, volessi, volesse, volessimo, voleste, volessero. Surprise: verbs are icebergs, and what you see in dictionaries, for example ‘baciare – to kiss’, ‘volere – to want’, ‘fare’ – to do’, ‘andare – to go’, are just the tips. Fortunately, there are strict rules which govern verbs (a discipline which grammarians call ‘conjugation’); and with the exception of some irregular verbs, all variations of a verb can be Web: TheWordBrain. Unfortunately, easily does not mean fast, and lack of speed is disastrous for fluent understanding and fluent speaking. The same repetitive training as in word training: repeated exposure, and heavy nailing. With an additional ‘word load’ of generally below 1,000, this will not demand more than 50 hours of extra training. Free verb training for German, Spanish, Italian, Portuguese, and French is available at http://poliglottus. Now that you have outsourced the study of verb forms to autonomous learning, grammar per se shrinks to a set of about 30 problems to settle. If you followed my prescriptions in the first chapters – 1) Learn 20 or more new words per day; 2) Listen to human speech for at least one hour per day – all I would ask you at this point is to rapidly assemble the knowledge that is needed to recognise the most frequent grammatical structures. Just recognising grammar requires 10 times less training than producing grammar. Even allowing for a few tricky rules, you will be electrified to acquire these passive skills in a few weeks and to discover that grammar is a fairly manageable thing. You will be happy to learn: how to use nouns (boy, girl), adjectives (tall, small, pretty), verb tenses (I go, I went, I have gone, I shall go, etc. Important advice: Make sure that you receive grammar lessons in your native language. Reject all ‘monoglot’ proposals such as being taught Spanish grammar by a Spanish teacher who has never learned another language. Let me narrate an episode that most clearly gives the tone of future grammar teaching. After studying surgery textbooks for five hours per day, he accepted the challenge of adding another three hours of intensive Italian lessons. As I had just developed a small piece of software on the mythical Commodore 64 (see the subsequent Internet release at www. The grammar lessons were focused on simple recognition of the most relevant grammatical structures. The experiment nicely showed the feasibility of a fast introduction to grammar, and also opened the perspective of reading newspapers or magazines, which is clearly more enjoyable and motivating than reading language manuals. Now that grammar teaching will slowly shift away from snail- pace speed to repetitive rounds of ultra-fast overviews, let us try and redefine the part that teachers can play in your language project. In today’s environment, the best role for a language teacher is probably that of a coach. Depending on your previous exposure to your native and subsequent languages, your coach will prepare an individual time schedule for your project; recommend books, podcasts, audio books, and broadcasts; provide the first round of grammar; advise you on how to manage your daily word quota; teach you how to check that new Web: TheWordBrain.