INFERTILITY

INFERTILITY

Marriage is considered to be sterile, if during 1 year of regular sexual life without

using of contraceptives, pregnancy does not occur. Infertility happens in 10-12% of all

marriages. It is subdivided into male, female and mixed. About 45% of sterile marriages

are connected with male infertility, 55% of them with female infertility.

Absolute infertility, when there are such changes in organism, at which pregnancy

is absolutely impossible (absence of uterus, ovaries), and relative, infertility when

sterility is caused by some factors, that can be removed are distinguished. Primary

infertility (when a woman has never had pregnancy) and secondary infertility (if there

was pregnancy in the past) are distinguished also.

For finding out infertility cause, couple examination is necessary. Usually

examination begins with husbands because of considerable simplicity.

MALE INFERTILITY

Physiology of male reproductive system

A hypothalamic-pituitary-testicles system in men is a permanently functioning

closed loop system providing biological reliability of reproductive function, producing

few millions of spermatozoa daily. Mature male sexual cells consist of head, neck and

tail portion. A head has an ovoid shape 4,5 micrometers long, 2,5 micrometers in width,

that contains a big nucleus. A tale provides active cell mobility in woman's genital tract.

Spermatozoa receive energy, necessary for motion by endogenous and exogenous

substrates' metabolism. Mechanism of motive spermatozoa function is extraordinarily

complicated, each oscillation is an enzyme-ionic-motive complex. The sperm flagellar

axonema is structurally and chemically complicated organelle, which is capable to

generate undate waves from ATP hydrolysis energy.

Spermatozoa motility changing takes place in-parallel with acquiring of fertilizing

properties — capacitation. This process begins still in epidydymus, where immature

spermatozoa acquire qualitatively new characteristics and turn into mature, mobile

forms, and accomplishes in woman's genital ways, where sperm gets after ejaculation.

Sperm characteristics. The sperm samples agglomerate after 2-3-day up keep

from sexual life. For spermogram it is rvecessary to analyze sperm not later than in 1 -

1,5 hours after ejaculation. It is received either by means of masturbation, or during the

interrupted sexual act. Men agglomerate it into clean dry vessel and supply into

laboratory.

Volume of ejaculate in healthy men is from 2 to 5 ml. General amount of

spermatozoa must compose not less than 50 mm. The lowest norm border is 20x106.

The sperm which contains not less then 50% of spermatozoa and has a good movabitity

is considered to be normal. Spermatozoa motion must be forward, in one direction.

Spermatozoa with oscillatory or circle motions refer to infertile or low-fertile ones.

Pathological changes can be manifested in irregular form and dimensions of head

or tail.

Azoospermy (absence of spermatozoa), necrospermy (dead spermatozoa),

oligospermy (decreasing of spermatozoa amount), theratozoospermy (dominance of

pathologically altered spermatozoa forms), can be found at sperm research.

Causes of male infertility are violation of spermatogenesis as an outcome of

carried inflammatory process, traumas, infectious diseases in childhood (especially

epidemic parotitis), urinary-genital infections in manifestation of orchitis and

epidydymitis (gonorrhea), cryptorchism, varicocele, and also intoxicationwith alcohol

and chemical agents. Frequently infertility is a result of ionizing radiation action,

electromagnetic radiation, high temperature. Herpes simplex virus and Chlamydia

infection are of a great importance in development of infertility. At these infections

sperm can carry infection into female genital organs. Infertility happens also at

exhausting liver, kidneys, lungs diseases, endocrine pathology (diabetes mellitus,

Kushing illness).

Sometimes infertility appears as a result woman's sensibilization to the men's

sperm. In case, when there are changes in spermogram, a man is directed to se-

xopathologist or andrologist. If all spermogram indexes are normal, examination of the

woman should be started.

FEMALE INFERTILITY

Basic causes of infertility in women are:

 disorders of ovogenesis and absence of ovulations — 35-40%

 tubal factors 20-30%

 diseases of genitals — 15-25%

 immunological causes — 2%

Diagnosis of female infertility is based into careful history taking (age, profession,

influence of harmful factors of production, carried diseases, harmful habits). Tactfully

learning of the psycho-sexual life conditions, genital function, meaning that primary

infertility is frequently a result of infantilism, and secondary one is a result of carried

inflammatory processes.

In objective examination attention is paid to body building, expressiveness of

secondary sexual signs, presence or absence of infantilism. Carefully examination of

internal organs, and in necessity — function of incretion glands should be performed.

During gynecological examination an attention is paid to hairiness on pubis,

external genital organs' abnormalities, state of Bartholin's glands. Examination of

vagina (its width, vaults depth), form and size of uterine cervix, presence of erosive

ectropion is indicated. Uterine size, position, consistence, form, movability and

correlation between cervix and uterus dimensions is examined also.

Endocrine infertility

Most frequently the causes of female infertility are endocrine diseases, which are

associated with ovogenesis and ovulation disorders. Patients with different forms of

hyperprolactinaemia, hyperandrogeny, with polycystic ovarian syndrome, postpuberty

form of adrenogenital syndrome and with other forms of endocrine disorders suffer

from infertility.

Considerable number of infertility cases is a result of endocrine ovarian

dysfunction, and these violations can be both primary and secondary with carried

inflammation. Anovulation or retardation of follicle maturing with defective luteal

phase appear as a result of dysfunction of cyclic processes in ovaries.

Endocrine infertility happens also at dysfunction of hypothalamic-pituitary system.

The irregular menstrual cycle in the form of amenorrhea, hypomenstrual syndrome and

uterine bleeding is attached to infertility of endocrine origin

Examination of patients should include:

 tests of functional diagnostics: measuring of basal temperature (BT)

during3-6 months for estimation of ovulation presence and duration of

luteal phase;

 "pupil" and "fern" symptoms estimation, tension of cervical mucus, taking

smears on «hormonal mirror»

 determination and estimation of hormones level in blood

 biopsy of endometrium with determination of full value of secretion phase

 sonography follicle growth control and endometrial thickness during

menstrual cycle

 laparoscopy

Treatment is in regulation of menstrual cycle, correction of basic disease

manifestations, that caused endocrine infertility, and in stimulating of ovulation.

Ovulation can be stimulated by prescription of Clomiphene citrate in the dose 50 mg

from 5th till 9th cycle day, by Pergonal in combination with Chorionic Gonadotropin.

Tubal and peritoneal infertility

The adhesions process in small pelvis causes the bend of the tube with preserving

of their patency. This is the reason of peritoneal infertility. Tube infertility is

conditioned by anatomic and functional disorders in uterine tubes.

Occlusion of uterine tubes happens as a rule after gonorrheal salpingitis, however it

can be a result of nonspecific inflammatory process. Inflammatory processes can be a

cause of not only uterine tubes' impassability, but also by dystrophic changes in their

walls, violation of peristalsis. Abortions also play a great role in etiology of infertility,

because they bring on inflammatory processes in uterine mucous membrane with the

following dystrophic changes that interfere with implantation.

Finally, salpingoovophoritis can cause ovulation disturbance, and if it takes place,

then the adhesions process doesn't give a possibility for ovum to get into tube. Ordinary

ovarian endocrine dysfunction can usually happen.

Diagnosis of tube infertility is held by means of hysterosalpingography,

hydrotubation or pertubation. It is better to make hysterosalpingography with water

soluble roentgen-contrast solutions (Kardiotrust, Urographyn, Verographyn, Trioblast).

This method gives a possibility to estimate the capacity of uterine tubes.

The state of uterine tubes can also be estimated during the contrasting sonography,

that is made by introduction of a contrasting substance Echovist into uterine cavity

under ultrasonic control.

4 degrees of uterine tubes occlusion are distinguished. They are:

 complete permeability of uterine tubes: a solution from syringe passes

intouterus easily and after removing of a cervical tip it does not return back

 tubes are impassable in isthmic department: one solution portion (up to 2 ml)

passes more or less easily, and then during the introduction a barrier is felt.

During decreasing of piston's pressure, liquid goes back into syringe. The

liquid outpours from uterus after removing of the tip from the uterus

 tubes are impassable in ampullar region: reflux appears at the end of

insertion (more than 4-5 ml of liquid)

 tubes are partially passable: a liquid slowly goes into uterine cavity, slightly

expressed and quickly passing reflux is observed at lowering of pressure on

piston

Sometimes dye-stuffs are used. For example, Speck's test with 0,06% solution of

Phenolsulfophtalein is common. At permeability of uterine tubes this dye-stuff appears

in urine in 40-60 minutes. After addition to it several drops of 10% NaOH solution it is

coloured into red colour. Aburell's test is performed by analogy (with 0,3 % solution of

Indigocarmine, which tinctures urine into green).

As a rule, diagnosis of permeability is made in the stationary during the first phase

of menstrual cycle, on condition that there are no inflammation signs and the first

degree of vagina purity is present.

Laparoscopy with the use of chromosalpingography with Methyl blue is also of a

great importance. This method allows to estimate the tubal permeability and to find the

occlusion place.

Infertility caused by uterine and cervical factors

Infertility can be caused by the state of uterine mucous membrane, when

endometrium undergoes dystrophic changes that interfere with implantation process and

cause uterine form of amenorrhea in the result of carried inflammatory processes,

repeated curretages of uterine cavity and action of cauterizing chemical substances.

Diagnosis is ought to be made in such directions:

 one should ascertain ovarian function in case of irregular menseses by tests

of functional diagnostics

 to make hormonal tests with progesterone, combined with gestagen-estro-

gen preparations. They are negative due to uterine amenorrhea

 to make hysterography, hysteroscopy for exposure of synechias in uterine

cavity

 to control by sonography the endometrial thickness once or twice during the

menstrual cycle

 to make the biopsy of endometrium

 to hold the sperm contact test with cervical mucus

Infertility can happen as a result of uterine cervix inflammation — endocervicitis.

This is an outcome of cervical canal epithelial structural changes, viscidity and acidity

of cervical mucus, that causes the violation of capacitation processes, interferes with

penetration of spermatozoa into uterine cavity.

In order to exclude influence of vaginal and uterine cervix secrets on sperm

Shuvarsky-Khurner's test is made. This test is made during the day of expec-tative

ovulation. Before this test one should refrain from sexual intercourse for 3-4 days. In

examination day after sexual intercourse the contents of posterior vault is put on object

plate and examined under the microscope; the mobile spermatozoa within eyeshot are

quantifying. The test is considered to be positive at the presence of 5 active spermatozoa

within eyeshot. The test should be repeated 1-2 times more in case negative reaction.

Treatment of infertility

A choice of treatment method depends on infertility cause. Inflammatory process

as the infertility cause must be treated. Physiotherapy methods (diathermy, ozokerite

therapy, mud cure, magnet therapy, laser therapy), biostimulators, contrainflammatory

remedies are widely used.

In case of uterine tubes impassability treatment is made by method ofhydro-

tubation — introduction into uterus and tubes medical mixtures, that include antibiotics,

enzymes, korticosteroids.

It is recommended to take three courses of treatment (6 hydrotubations every other

day), interruption between courses is 1 month. After the third course of hydrotubations a

control of uterine tubes' permeability is recommended. If tubes are passable, it is

recommend to prevent from pregnancy for 5-6 months, making during this time

additional course of hydrotubation and mud care.

In treatment of tube infertility in case of poor efficiency from conservative

therapy surgical methods are used: salpingolysis — release of tubes from adhesions and

renewing of their abdominal parts' passability; salpingostomatoplasty — formation of

the hole at abdominal part of a tube; salpingoanastomosis — suturing the tube together

"end in end", ovarian implantation into the tube or uterus, tubal implantation into uterus.

In case of infertility because of synechias presence in uterus their destruction is

made under hysteroscopy control with the following prescribing of contra-inflammatory

resorption therapy and hormonal preparations during 2-3 menstrual cycles for renewing

of menstrual function.

In case, when infertility is associated with underdevelopment of genital organs

replacement therapy, physiotherapy procedures (mainly thermal ones — ozokerite, mud

cure), gynecological massage in combination with hoimonal therapy is prescribed.

Hormonal therapy is obligatory administrated according to the phase of menstrual cycle.

Estrogen-gestagen preparations, ovulation stimulators — Clomiphen citrate, Puregol,

Pregnil are used.

Prophylaxis of infertility is the prevention of diseases, that lead to it: infectious

diseases in childhood and in the period of pubescence, inflammatory processes in adult

women.

An important role in infertility prophylaxis belongs to the doctors of female

dyspencery, which are to propagandize the contemporary methods of contraception, that

will give a possibility to prevent abortions.

While making sanitary-educational work one should pay a special attention to the

question of hygiene of sexual life, to the harm of abortion, especially during the first

pregnancy.

IMMUNOLOGICAL FACTORS OF INFERTILITY

The immunological form of infertility, which is caused by formation of

antispermal antibodies (LsLb) in the man's or woman's organism happens relatively

rarely. Its frequency is 2 % among all infertility forms. In 20-25% of couples with

uncertain infertility ethiology the antibodies to sperm are found at further examination.

Antispermal antibodies are generated in men, than in women more frequently.

Mainly this is a result of barrier break between male reproductive tract and immune

system. The cause of this can be vasectomy, damage of testicles at orchitis, traumas,

infections of reproductive tract.

Antispermal antibodies influence on such reproduction links as: spermatogenesis,

transport of sperm, gamete interaction. Antibodies (IgG) that are connected with

spermatozoon head, disturb the fertilization process. Antibodies (IgA) attached to the

flagellar axonema in the tail part of spermatozoon, influence on cells' mobility.

In women the formation of gumoral tissue antibodies and spermatozoa

phagocytosis are the basic reactions of antisperm immunity. Immunity-competent cells

phagocyte sperm and then use taken information for recognition of antigens. The

formation of antibodies takes place in uterine cervix most actively, more rarely — in

endometrium and tubes. Uterine cervix is the main link of local immunity in female

reproductive system. IgA are generated in uterine cervix. Their concentration change

during menstrual cycle and decrease in the period of ovulation.

Antibodies to antisperm antigens have precipitating, agglutinating, immobilizing

properties. There is a sperm contact test with cervical mucous as a screening-test.

The intrauterine insemination is the most effective method in case of this form of

infertility. A mechanical method of contraception during 6 months using condoms for

removal of sperm contact with female genitals is recommended. It is necessary to

examine a couple for latent infection, because infectious agents contribute to formation

of antisperm antibodies.

PSYCHOLOGICAL ASPECTS OF INFERTILITY

In majority of women with infertility various violations of psychoemotional sphere

such as: feeling of inferiority, loneliness, strained waiting of next menses and hysterical

states connected with its beginning appear. A complex of these symptoms composes the

so-called «pregnancy expecting syndrome».

Indexes of psychological tests, that characterize a degree of personal qualities

instability, fear, confidence in oneself, expressence of psychological reactions on

environment, in families, that do not have children are considerably raised. In sterile

women a high degree of neurotizing is observed. In men there is the tendency to

oppression, violation of behavior reactions. Frequently there happens deviation from

normal scheme of sexual conduct, violations of erection and ejaculation.

A great stress for a couple is examination necessity and later on the execution of

doctor's recommendations concerning the rhythm of sexual life, specifically

determination of ovulation period of wife according to the tests of functional diagnosis

and advice to use for conception exactly a certain time. Sometimes insistent demand of

a wife to have sexual intercourse namely in the certain period can cause functional

impotency in husband and appearing of fear before sexual act and other potency

disorders. Diagnosis of azoospermy or other pathology of sperm can influences

unfavorably on man's potency state. Such news cause impotence in more than in half of

men, and frequency of its beginning depends on wife's reaction. Likely, such disorders

when absence of organic changes are temporal and afterwards potency renews

spontaneously or under the psychotherapy influence.

For women the necessity of sexual life according to results of functional

diagnostics tests is also a stress situation, upon which not only psyche, but organs of

sexual tract, specifically uterine tubes react. Their spasm (antiperistalsis) can occur. It

disturbs gametes transport even on condition that the tubes are passable. That's why

sometimes woman's fervent desire to become pregnant becomes her enemy. There are

described many cases, in which long-waited pregnancy came after woman has decided

to stop cure, to cancel measuring of basal temperature and waiting attentively for the

time of expectative ovulation.The same thing has happened, when a pair, loosing a hope

for own descendants, adopts a child.

Causes and types of psychological disturbances of persons in sterile marriage are

various, that's why doctor's experience, patience, tact during taking history are

necessary to define personality character, peculiarities of matrimonial relations and

psychosexual reactions. Interpretation of analyses results and also choosing of

examination and treatment methods demand a special caution, specifically, for the

newest reproductive technologies — extracorporal fertilization, insemination with donor

sperm etc.

ADDITIONAL REPRODUCTIVE TECHNOLOGIES

Question about application of additional reproductive technologies is decided by

skilled competent specialist on request of couple after corresponding inspection. It

includes determination of blood type, rhesus-factor, HIV, Wassermann reaction, HBs

antigen, bacterioscopy of vaginal smear, diagnostics of gonorrhea, toxoplasmosis,

trichomoniasis, ureaplasmosis, gardnerelosis, micoplas-mosis, making tests of

functional diagnostics for characteristics of menstrual cycle, ultrasonic examination of

uterus and ovaries, hysterosalpingography, for indications — laparoscopy, double study

of men's (donor) sperm and other necessary examinations. At presence of some

anomalies in reproductive function of couple and at presence of indications for using

additional reproducti /e technology a correspondent treatment is indicated.

Generally, all the contemporary methods of additional reproductive technologies

are based in vitro fertilization biotechnology. Insemination with man's (donor) sperm—

instrumental sperm introduction into internal woman's genitals is widespread.

Female indications for using of this method are:

 anomalies of reproductive organs (old perineum ruptures, which cause

sperm effluence outside just after sexual intercourse, ankylosive damage of

hip joint, different pelvis bone deformations, in the result of which sexual

intercourse can not take place, anatomic vaginal or uterine anomalies in case

of congenital pathology or acquired stenoses)

 severe forms of vaginism

 immunological and cervical factors

 infertility of uncertain etiology

Male indications:

 sexual dysfunctions of different ethiology

 large sizes of hydrocele or inguinal-scrotal hernia, that makes sexual

intercourse impossible

 ejaculation praecox; retrograde ejaculation

 expressed hypospady, some forms of oligoastenospermy, azoospermy,

aspermy

Couple indications:

 unfavorable medical-genetic prognosis for having children

Presence of inflammatory, neoplastic and hyperplastic processes in uterus and its

adnexa, somatic and mental diseases, impassability of uterine tubes, women's age after

40 years are contra-indications for using insemination by donor's sperm.

Insemination is made during one menstrual cycle in periovulatory period. For

women with normal menstrual function and full value ovulation one insemination is

sufficient. However, 2-3 procedures in case when there are some problems connected

with establishment of exact time of ovulation are made. In this case due to the long

functional spermatozoa ability (72 hours) fertilization probability is increased.

Vaginal, cervical, uterine and peritoneal methods of insemination are distinguished

depending on sperm introduction way. Intrauterine insemination is considered to have

the highest effectiveness. It provides introduction of specially processed sperm by

catheter into uterine cavity. Pressing on syringe piston the sperm gradually is introduced

during 2-3 min. An extremely fast sperm hit on uterine mucous membrane can cause its

reflectory contraction, that is followed by pain or expulsion of contents from uterus into

vagina.

Attached to intraperitoneal insemination specially processed sperm is introduced

by means of the posterior vault punction into cul-de-sac. A test on peritoneal

spermatozoa migration is made as a rule, before insemination. This test is considered to

be positive at preserving of spermatozoa motility in peritoneal liquid in vitro.

For sperm indexes improving, before insemination ejaculate is fractionated, motile

forms are separated by filtration, several ejaculates by cryoconserving are accumulated

and some medications (Callicreine, Dextrose, Arginin, Caffeine or prostaglandins) are

added.

Method of insemination requires the functionally full value uterine tubes and

ovulation in woman. So* before the procedure there must be provided a qualitative

diagnostics of reproductive sphere state, normalization of menstrual cycle, medicinal

stimulation of ovulation and preparation of endometrium for perception of impregnated

ovum. For this reason hormonal, clinical and ultrasonic monitoring are used. The

concentration of gonadotropic hormones, progesterone, estradiol in blood is determined.

Accessible and sufficiently informative are the tests of functional diagnostics and

menocyclogram charts.

Using of ultrasonic diagnostics allows to speak not only about passability of

uterine tubes, growth and development of follicles, but also about quality and full value

of the ovum. Transvaginal sonography enables to get clear image of ovaries and to

realize a follicle growth monitoring even in those patients, which have had operations

on organs of small pelvis, and also in those, which have exessive body weight.

The program of extracorporal fertilization with transferring of embryo into uterus

(in vitro fertilization — IVF) is recommended in those cases, when conservative

methods have failed. Absolute indication to application of this method is tube infertility

due to severe dysfunction or absence of uterine tubes. Relative indications are previous

plastic operations on tubes (woman's age is less than 30 years, time interval after

operation is not more than one year), ineffectual salpingolysis (ovarylysis) in women

aged 35 years, some forms of endometriosis and polycystic ovarian syndrome, infertility

of unknown genesis, immunological infertility in women with constant high titre of

antisperm antibodies during one year, some forms of male infertility.

The method of extracorporal fertilization with transfer of embryo into mother's

uterus includes few stages:

 selection and preparation of patients to program

 stimulating of superovulation

 follicle growth and maturing monitoring with their following punction and

aspiration

 spermatozoa preparation

 fertilization in vitro, cultivation (cryoconserving)

 transplantation of an embryo into uterus

 pregnancy development control

In practice a superovulation stimulating is employed. This is caused by the fact,

that in natural menstrual cycle the chance of simultaneous maturing of several ovums

composes 5-10%, while in stimulated cycles chance of two and more follicles

development can reach 35-60 %. With aim of superovulation stimulating Clomifene

citrate or its analogues in combination with Chorionic gonadotropin is used. Chorionic

gonadotropin-is used in all schemes of superovulation stimulation. It is introduced in

case of enlarging of dominant follicle diameter up to 18-20 mm. In 35-36 hours after

introduction ovocytes are aspirated from the follicle together with follicle liquid. For

this purpose laparoscopy is indicated, during which a mature follicle is punctured with

the needle, creating negative pressure of 120-200 mm Hg. Recently the method of

transvaginal access to follicles during ultrasonic scanning becomes wide-spread.

Received follicular liquid is studied under the microscope for exposure of

follicular-ovocyte complexes in it. At their presence the material is washed by special

environment, that removes a larger half of follicular liquid. Considerable attention is

paid to sperm preparation stage. Its main aim is in spermatozoa capacitating, because

this moment during extracorporal fertilization is absent.

For fertilization a spermatozoa suspension is put into the environment, which

contains 1-3 ovocytes in 1 ml. Incubation duration is 16-20 hours. Received embryos

are cultivated at temperature 37°C in atmosphere containing 5% C02, 5% 02 and 90%

N2 in environment with pH = 7,3.

A fertilization fact is determined to the presence of pronucleus in ovocyte's

ovoplasm and a second polar body in periviteline space.

Transfer of embryo into uterus is made on the 3-4th day from fertilization moment,

that should correspond to the stage of 8 or 16 cells. For this reason a special catheter is

used, with the help of which an embryo with some cultural environment is conducted to

uterine fundus through cervical canal.

For guaranteeing of long adequate function of yellow body in the day of embryo

transfer and in 4 days after this the woman additionally gets 5000 units of Chorionic

gonadotropin. For women with severe pathology of ovaries (for example, early or

physiological menopause), donation of ovocytes is recommended. In that case embryo,

which is developed in the result of fertilization of woman-donor's ovum by husband-

recipient sperm, is put into uterine cavity of his wife, who carries a child.

In recent years a method of gametes' implantation into cavity of uterine tube is

successfully used, which is a variant of additional reproductive technologies. Ovocytes

are received, a suspension of enriched sperm is added to them and inserted during

laparoscopy with special probe into one or two uterine tubes from mature follicles on

background of ovulation stimulating.

In this case both fertilization of ovum taken from the follicle and elementary stages

of embryo dividing take place in uterine tube, that is in natural conditions, not in

incubation ones.

The newest achievement of contemporary reproductology is intracytoplas-matic

injection of one spermatozoon (intracytoplasmatic injection sperm ISO). This program

allows to become pregnant in those cases of male infertility, which were considered to

be hopeless before. A spermatozoon is inserted into the selected ovum. Embryo, being

got by such method is transfered into uterine cavity.

Program of surrogate maternity include the women, which because of pathology of

reproductive sphere can not be pregnant with a child (uterus is absent because of

operative intervention or can't function). Genetically native embryo is transfered into

uterine cavity of a woman, who has given a consent to carry a child.

BASES OF FEMALE SEXOLOGY

Ordinarily sexual disorders, with which women apply to gynaecologists or, for

their direction, to sexopathologist are present.

Sexual function includes: sexual drive (libido), sexual excitement and orgasm.

Sexual drive (libido) is caused by sexual instinct and is manifested by two

components — a desire for mutual intimacy with persons of contrary sex and a desire

for sexual intercourse. One of the most early manifestations of sexual drive is an interest

to the contrary sex having merely platonic character.

Anxiety for close intimacy appears in the process of sexual life and ordinarily only

after development of orgasmic function.

In women libido has an orientation on a specific person, appears in majority of

cases after previous preparation (petting). This drive has physiological cyclicity,

associated with changes in woman's organism during menstrual cycle. That is

considered, that a woman has maximum sexual appetenece just before ovulation, the

least — before menses. There are women, in which the maximum sexual appetence

appears during menses. Mental and emotional overstrain negatively influence on sexual

drive. Concerning the age libido reaches its maximum to 30 years, holds on up to 55,

and then gradually decreases.

Sexual excitement appears under the influence of sexual irritants and is followed

by general changes in organism—speed-up palpitation, blood pressure rise, swelling of

breasts and nipples. In genitals during the sexual excitement some changes also take

place. They are swelling and enlarging of the clitoris, minor and major labia. Vaginal

mucous membrane is also lubricated. Expressed local blood stagnation appears. Due to

it vagina contracts. All these changes contribute to enfolding of the penis by vagina,

enforcing erotic stimulation of both man and woman.

Orgasm as a composing part of sexual function is its basic criterion. Physiological

manifestation of female orgasm are rhythmic contractions of vaginal and uterine

muscles, during which a woman gets physical pleasure. In majority of women from 5 to

12 contractions with 1 second intervals are observed. The organs of orgasmic feelings

mainly are the vagina and clitoris, in some women orgasm type is mixed. Some authors

indicate on presence of urethral, perineal, cervical orgasm.

Such disorders of sexual function are distinguished:

Anorgasmy — absence of orgasm. This form of sexual disorders is most

frequently found. Its cause is disharmony in matrimonial relations.

Absolute and relative anorgasmy is distinguished.

Absolute — when orgasm does not come for none circumstances.

Relative — when orgasm happens in some circumstances.

Also there exists symptomatic anorgasmy as a manifestation of various diseases —

inflammatory processes of female sexual sphere, that are followed by pain during

intimacy, constriction of vagina, underdevelopment of sexual labia, various endocrine

violations. If a patient applies to a doctor by the reason of anorgasmy, first of all it is

necessary to exclude presence of these diseases.

Treatment of anorgasmy is caused by its form. It is necessary to find in patient the

most expressed erogenous zones and to give the suitable recommendations. One should

explain the necessity of emotional background creation and additional stimulation of

erogenous zones. Positions which the partners use during the intimacy are of a great

importance. In case of advantage of vaginal orgasm, traditional European position is

suitable for the pair, at clitoris one — a pose of a "rider" or sideways position. It is

necessary to persuade the pair, that a over pudency in poses choice, neglect of erotic

petting can be a cause of anorgasmy appearing. At symptomatic anorgasmy one should

treat the pathological states, that cause it in time.

Frigidity — full absence or abrupt decreasing of sexual drive. It can be primary

and secondary. Primary frigidity is more frequent in young «unaroused» girls and lasts

till the first orgasmic feels. At non-proper (negatively directed) sexual upbringing in

childhood the primary frigidity can remain for the rest of life. It can happen also after

rough or forcible first sexual act.

Secondaty frigidity appears by reason of various causes, however most frequently

it is a result of anorgasmy as an effect of unskillful man's conduct during the sexual act.

Emotions following this phenomenon deepen anorgasmy and bring the libido down. The

basic symptom of frigidity is absence of sexual drive even after previous partner's

petting.

At consulting a woman with the problems of frigidity, first of all it is necessary to

find its possible cause and to give advice for its removal. Psychoerotic training of a

couple gives good result. At first one should find woman's erogenous zones, explain

desirability of their stimulating by a partner, and then in delicate form have a

conversation with a husband, better without his wife.

Hypersexuality (nymphomania) is a raised sexual drive. It is found rather rarely.

There are two its forms — in young women and a climacteric one. Young women rarely

apply for help — only when the need in sexual contacts forces a woman to amoral

conduct. A climacteric nymphomania passes heavily and brings extraordinary sufferings

to women. In majority of cases a nymphomania is a symptom of the CNS disease,

specifically of hypothalamic region, and also of some psychic diseases (autism,

oligophrenia, maniacal states). Treatment of hypersexuality is in radical cure of basic

diseases that cause this pathology.

Onanism (masturbation) is the receipt of sexual enjoyment by means of sexual

organs irritating. Masturbation refers to pathological only then, when it is made

frequently, specially in the background of normal sexual life. In majority of cases

women resort to masturbation on background of long absence of orgasm at presence of

sexual excitement. It is not considered to be a pathology, when sometimes a healthy

woman masturbates because of temporal absence of intimacy. Prolonged surplus

masturbation causes woman's astenization. Excessive masturbation is treated by means

of hypnotherapy, going in for sport, increasing of physical loading is recommended.

Proper psychosexual education in childhood is necessary for prophylaxis of sexual

violations in women. The task consists in giving of necessary information about hygiene

of sexual life, about childbirth. Simultaneously one should remember about delicacy of

such information. One should not wake up girl's sexual appetence early, but one should

not intimidate the girls.

Elucidation should have individual, not public character. Doctors should make the

conversations about sexual education with parents of a growing-up girl, so they could

properly orient their children in this question. Antenuptial consultations on the questions

of sexual life hygiene are very important.

Partners should know, that they have to respect individual peculiarities and the

needs of each other. Sexual intercourse must be realized in civilized conditions, in

conditions of complete secluding. After the first sexual act one should recommend to

avoid coitus for a while, so that the pain could not cause negative reaction on sexual

intercourse. Intimacy is not recommended during inflammatory processes and menses.

In prophylaxis of frigidity and anorgasmy these factors are of a great importance.

Also one should remember that except the body there are other erogenous zones such as

eyesight, hearing, scent.

Very often young people feel a need in everyday intimacy and don't feel tired after

the sexual acts. Such frequency of sexual intercourse is considered to be normal. Sexual

acts are harmful in case when they are repeated in short time intervals. They cause both

general exhaustion and traumatizing of genitals. Coitus interruptus also damages the

health and sexual life of the matrimonial pair. It causes not only blood stagnation in

organs of small pelvis, but influences unfavorable on psychoemotional sphere, that can

lead to sexual violations. One of the important moments of anorgasmy prevention is

reliable contraception. Moral trauma and painful feelings carried by woman during

artificial termination of pregnancy also can cause the appearing of steady anorgasmy.

That's why before making abortions one should prepare the woman psychologically,

and also use a careful anaesthetizing.