UNDERSTAND MISCARRIAGE : life and death

By Nicole Angemi

 Getting pregnant is usually the most exciting time in a woman’s life. Having a child and being pregnant right now myself,  I know all the emotions associated with the excitement of having a new baby. Most mothers become instantly attached to their new baby the moment they find out they are pregnant. Unfortunately many pregnancies will end up in miscarriage.

A miscarriage is the spontaneous loss of a pregnancy before the 20th week of pregnancy. Pregnancy losses after the 20th week are called preterm deliveries.It is estimated that up to half of all fertilized eggs die and are lost (aborted) spontaneously, usually before the woman knows she is pregnant. Among those women who know they are pregnant, the miscarriage rate is about 15-20%. Most miscarriages occur in the first trimester and the risk decreases the further along the pregnancy is.

The medical term for a miscarriage is abortion. The word abortion simply means a loss of a pregnancy. Abortion can occur in 2 ways, spontaneously and medically/surgically. A spontaneous abortion is one that occurs naturally and is what is commonly called a “miscarriage”. Spontaneous abortions can also be induced with medications such as the “abortion pill” for unwanted pregnancies. Under the category of spontaneous abortion falls a complete abortion, an incomplete abortion, a missed abortion, a blighted ovum, an ectopic pregnancy, and a molar pregnancy. A medical/ surgical abortion is done for 2 reasons: elective and therapeutic purposes. Elective abortions are surgically performed for unwanted pregnancies. Therapeutic abortions are performed for multiple reasons including problems with the pregnancy itself, the fetus and/or the mother.

To understand what to look for in these miscarriages upon arrival to the surgical pathology lab, you must understand the components of a normal pregnancy  in the uterus. In the uterus is the embryo or fetus itself, an amniotic sac and some form of mature or immature placental tissue. A thin layer of membranous tissue is also present between the placental tissue and uterine lining called the decidua. Immature placental tissue or chorionic villi and/ or fetal components must be present in the specimen to prove an intrauterine pregnancy. Decidual tissue alone does not prove an intrauterine pregnancy. This tissue can still grow in the uterus even if the fetus is growing in an ectopic location such as the fallopian tube.

          

Complete/ Incomplete abortion

A completed abortion is when the embryo/fetus and/or products of conception have emptied out of the uterus. A completed miscarriage can be confirmed by an ultrasound. If the patient expels the products at home and saves it, or expels at the hospital, the products will be examined in pathology and decidual tissue, chorionic villi or placenta and/ or embryonic sac will be identified. This may be mixed with blood or mucous material. An incomplete abortion is incomplete expulsion of all products of conception.

This is the most common type of complete abortion we see in the lab. 1st trimester, so the embryo/fetus is small, sometimes too small to see. The photo below shows an intact fetal sac around 7 weeks gestation.

Here is another example of a first trimester complete spontaneous abortion. To the left of the photo is the decidual tissue, the center shows a fetus around 9 weeks gestation and to the right is the spongy chorionic villi tissue. Most spontaneous abortions happen within the first couple of weeks of pregnancy 5-8 weeks. Most products of conception specimens we receive to the lab just contain decidual tissue, chorionic villi and blood. It is not as common to find an embryo/fetus.

This is one type of example of a 2nd trimester complete spontaneous abortion. Before the second trimester, the fetus is usually difficult to identify. Here the fetal sac is intact. The placental tissue is the shaggy tissue surrounding the sac.

Opening the sac reveals a well formed, intact fetus, complete with attached umbilical cord. This fetus is grey and not the normal pink color. This is what we called macerated. This indicates this fetus died several days/weeks before it was spontaneously aborted.

Missed abortion

Women can experience this type of miscarriage without knowing it. A missed abortion is when embryonic death has occurred but there is not any expulsion of the embryo and/or products of conception. It is not known why this occurs. Signs of this would be a loss of pregnancy symptoms such as nausea and tender breasts and the absence of fetal heart tones found on an ultrasound.

Blighted ovum

Also called an anembryonic pregnancy. Basically no baby. A fertilized egg implants into the uterine wall, but fetal development never begins. Often there is a gestational sac with or without a yolk sac, but there is an absence of fetal growth.

Ectopic pregnancy

Extrauterine pregnancy, located outside the uterus, usually the fallopian tube. To read my post about ectopic pregnancies click here: http://iheartautopsy.com/?p=2042

Molar pregnancies

A  hydatidiform mole or molar pregnancy is caused by a genetic error during the fertilization process that leads to growth of abnormal tissue within the uterus. This can happen if an egg with no genetic information is fertilized or if an egg is fertilized with 2 sperm.  Molar pregnancies rarely involve a developing embryo, but often entail the most common symptoms of pregnancy including a missed period, positive pregnancy test and severe nausea. One clue to key off the physician that a patient has a molar pregnancy is rising hCG levels. hCG is the hormone that is present in all woman when they become pregnant. If the levels rise too fast it may be an indication of a problem.

This is what a molar pregnancy looks like grossly. The chorionic villi are hydropic or show cystic dilations. This specimen is said to look like a cluster of small grapes. These specimens can include fetal parts which would be considered a partial mole and the absence of fetal parts can indicate a complete mole.

Most molar pregnancies result in spontaneous abortion. If it is found by the physician, he may have to perform a D&C to remove the abnormal tissue. hCG levels are followed after the pregnancy has ended to ensure all of the abnormal tissue is removed. There is a small risk in the case of a complete mole that the tissue can become invasive and cancerous. This type of cancer is super rare and is called choriocarcinoma.It is important to avoid pregnancy and to use a reliable contraceptive for 6 – 12 months after treatment for a molar pregnancy. This allows for accurate testing to be sure that the abnormal tissue does not return. Women who get pregnant too soon after a molar pregnancy have a greater risk of having another one.

Risk factors

Most miscarriages are caused by chromosome problems that make it impossible for the baby to develop. Usually, these problems are unrelated to the mother or father’s genes. Other risk factors for miscarriage include drug and alcohol abuse, exposure to environmental toxins, hormone problems, infections obesity, problems with the mothers body including the uterus or immune response, systemic diseases such as diabetes, and smoking. The risk for miscarriage is higher in woman who are older,with increases beginning by 30, becoming greater between 35 and 40, and highest after 40 and woman with a previous history of miscarriage.

Treatment

The main goal of treatment during or after a miscarriage is to prevent hemorrhaging and/or infection. The earlier in the pregnancy, the more likely all the products of conception will expel by itself and will not require further medical procedures. If the body does not expel all the tissue, the most common procedure performed to stop bleeding and prevent infection is a dilation and curettage, known as D&C. A D&C is a procedure when the doctor dilates the cervix and places a tool in the uterus to scoop out the rest of the products of conception. The remainder of the products of conception will be sent to pathology to confirm an intrauterine pregnancy.  The procedure is short and the recovery time is short.

All products of conception are sent to pathology when the products are available. All products get a microscopic evaluation, mainly to look for chorionic villi and confirm an intrauterine pregnancy. A molar pregnancy is also always ruled out. In some cases a portion of the specimen will be sent to cytogenetics for genetic testing. Unfortunately most of the time genetic testing is normal.

WOMEN'S HEALTH: UNDERSTAND LEIOMYOMAS (fibroids)

ByNicole Angemi

 Leiomyomas, otherwise known as fibroids, are tumors of the smooth muscle that can occur in any smooth muscle throughout the body but most frequently occur in the uterus. Fibroids can range in size from an eraser head to the size of a full term infant and larger! These tumors can cause mild to severe problems for woman depending on their size and location within the uterus. They are the most common tumor of the uterus accounting for 30% of hysterectomies in the US.  Many women have them and do not even know it. I see them on a daily basis in uterus specimens taken out for other reasons or incidentally during autopsy.

There are 3 types of muscle located throughout the body. Cardiac muscle, skeletal muscle and smooth muscle. Cardiac muscle is specialized muscle tissue that is seen only in the heart. This muscle moves involuntarily- meaning you can not control its movement. A person can not make their heart beat or stop beating. Skeletal muscle is abundant throughout the skeletal system and diaphragm. This type of muscle is called voluntary- meaning you can control it. If you want to extend your leg you can, and usually this muscle doesn’t move involuntarily. Smooth muscle is found in multiple organs throughout the body and is also involuntary. Fibroids can arise in any smooth muscle throughout the body like the ureters of the kidneys, the esophagus, stomach or bowel wall and the uterus for example. Some muscle tissue can be voluntary and involuntary, for example the diaphragm.  A person can make themselves take breaths, but most of the day the muscle is working on its own to assist with breathing.

A leiomyoma or fibroid is a benign tumor arising from the smooth muscle wall of the uterus. These tumors are made up of smooth muscle cells and fibrous connective tissue. These tumors can be found in 3 locations within the uterus; subserosal (beneath the outer surface of the uterus), intramural (within the actual muscle wall of the uterus) or submucosal (beneath the lining of the uterus).

In the pathology lab we see leiomyoma specimens in a variety of ways. Sometimes the surgeon will decide the fibroids are too numerous or large, or they are in locations that are not easily resectable and they will do a complete hysterectomy. Other times they will just remove the fibroids only. This is called a myomectomy and can be done by 4 different surgical procedures; Hysteroscopic– where the fibroids are removed through the cervix without making an incision in the abdomen (done with smaller fibroids), Abdominal– in which the fibroids are removed through an incision in the abdomen, Laparoscopic– in which smaller incisions and a camera are used to remove the tumors; or Robotic assisted in which a “robot” is used as an extension of the surgeons arms for a less invasive procedure.

To the left, this is what a normal uterus looks like from the outside (serosal surface). People are usually shocked to see how small it is (less than 1/2 a pound and about 4″). Especially woman because it causes us so many troubles. Compared to this sharpie marker you can appreciate how small it really is. The photo to the right is an open uterus-split into the anterior and posterior halves (front and back). This is the space where a baby grows (endometrial cavity). Its normal appearance is a triangular cavity as seen below. The lining of this cavity is called the endometrium (mucosa). This is the lining that builds up all month and causes a menstrual period. The period tissue then exits the narrow portion of the uterus (cervix)and then into the vagina. The wall surrounding the cavity is the smooth muscle (myometrium).

In comparison, here is the outer surface of a uterus with fibroids. If you look closely, you can actually see these large tumors have their own blood supply. This particular hysterectomy is about 7 pounds and over 8 inches! The size of a newborn baby!

After opening a uterus of this size, all of the fibroid tumors can be seen.

Upon closer inspection of this uterus, the endometrial cavity can be seen. It is the shiny red strip of tissue towards the bottom left of the photo. Compare this uterus cavity to the one of the “normal” uterus above. The normal shape of the endometrial cavity should be triangular. This uterus has so many fibroid tumors that it is actually distorting the shape of the cavity. This distortion causes a ton of problems in woman including moderate to severe pelvic pain, dysfunctional uterine bleeding, problems getting pregnant, problems keeping a pregnancy and painful intercourse. These tumors can also grow so large that they cause abdominal distention giving a pregnant appearance and can compress on adjacent organs. This particular uterus had multiple subserosal and intramural leiomyomas. This is the “normal” appearance of fibroids. They are fibrous, white-pink and have whorled cut surfaces with no hemorrhage or necrosis. These features are consistent with benign leimoyomas.

This next uterus shows leimoyomas in all 3 locations. The endometrial cavity has submucosal fibroids. Because of their location in the endometrium, these myomas place pressure on the uterine lining that builds with each menstrual cycle. This, in turn, can cause heavy bleeding. Even very small submucosal myomas may cause very heavy bleeding.

This next uterus has a similar appearance upon opening. But the leiomyoma to the left looks a little weird or different. Sometimes these fibroids grow so fast and so big that they begin to outgrow their blood supply. This causes the leiomyomas to have a degenerative, dusky yellow, sometimes pink brown appearance. The fibroids can actually begin to calcify and sort of die or partially die. These changes have a specific appearance and are not to be confused with the appearance of a malignant form of leiomyomas- leiomyosarcoma.

Here is an example of a malignant form of a leiomyoma called a leiomyosarcoma. This appearance is more consistent with malignant features. The tumors have soft pink fleshy cut surfaces with areas of necrosis. If a PA opens a uterus and it looks like this- we automatically know something is up. We would over sample these tumors so the pathologist can have enough slides to determine if it is malignant. The treatment for a leiomyoma vs leiomyosarcoma is VERY different.

Sometimes we receive leiomyoma specimens individually, detached from the uterus if the surgeon decides he can remove the tumors and keep the uterus fairly intact. These procedures are sometimes good for woman of child bearing age who are not ready to lose their entire uterus.

This is a specimen from a classic abdominal myomectomy. This procedure just removes the fibroid tumors and is done through an open incision or laparoscopically depending on the size of the fibroids. The round nodules usually come in a medium to large size specimen container. and can range anywhere from the size of a pea to the size of  watermelon.

Another surgical option which is the least invasive option for these tumors  is a robotic procedure. This technique leaves the uterus or fibroid tumors “morcellated”. A robot-assisted myomectomy uses a robotic system such as the da Vinci to help surgeons remove fibroids while preserving the patient’s uterus. The surgeon controls the robotic instruments attached to the surgical system from a remotely positioned console. These instruments act as a computerized extension of the surgeon’s hands, allowing the surgeon to separate the fibroids from the uterus and restore the patient’s anatomy. This procedure can be used with small incisions on larger fibroids, rather than having to make a huge surgical incision to take them out. The robot essentially goes in and chops up the tissue into morcellated strips within the cavity, so it can come out through a smaller incision. This is what it looks like when we get it in the lab. In the close up photo to the right you can appreciate these morcellated fibroids have a “normal” appearance compared to the intact fibroids above.

 

Some patients opt for another procedure as a last resort before surgery. Embolization. Uterine fibroid embolization (also sometimes referred to as uterine artery embolization) is performed by trained interventional radiologists by blocking the arteries feeding blood to the tumors, thus allowing them to shrink and preserving the uterus. The entire procedure takes about an hour and is done under conscious sedation as opposed to general anesthesia.

The fibroid tumors actually have their own blood supply as seen to the left. The interventional radiologist will insert a catheter into an artery located in the groin. Under fluoroscopic (X-ray) guidance, the catheter is advanced into the uterine arteries supplying blood flow to the uterine fibroids. Once the catheter is positioned in the uterine arteries, small particles are injected to block blood flow to the uterine fibroids.

These little particles block off the blood supply causing the fibroid to shrink. This procedure has a high success rate. In those patients that do not have success with embolization, hysterectomy or myomectomy is still necessary. Cutting hysterectomy specimens post a failed embolization attempt are neat. The embolization can be seen grossly. The arteries are dilated with little silicone gel beads. It is super cool looking and can be seen on sections submitted to the pathologist for microscopic exam. Unfortunately I do not have a gross photo, but this illustration shows what the beads look like in the vessels.

Finally, another less invasive procedure is an endometrial ablation. This procedure causes scarring of the endometrium in hopes to control bleeding. This procedure is only to be done after a woman has decided she is done having children. To read more about ablation check out my post “Infrequent Gross Finding: Endometrial Cavity,

In most cases of soft tissue tumors- the general rule for sampling is one section per centimeter- meaning if a fibroid is 15cm we would take 15 different pieces of it to show the pathologist under the microscope. The rules of sampling fibroids vary from lab to lab- mainly because uterine fibroids have such a low malignant potential and some pathologists feel it is not necessary to look at a ton of slides on these specimens. Other pathologists would rather see more slides. The bigger fibroids are usually sampled more because they have a higher chance of being abnormal, but for the most part leiomyosarcoma is very rare- especially compared to the amount of these specimens we see on a daily basis.

understand esophageal diverticulum

What is an esophageal diverticulum?

An esophageal diverticulum is a pouch that protrudes outward in a weak portion of the esophageal lining. This pocket-like structure can appear anywhere in the esophageal lining between the throat and stomach.

Esophageal diverticula (pleural of diverticulum) are classified by their location within the esophagus:

• Zenker’s diverticula (pharyngoesophageal) is the most common type of diverticula of the esophagus. Zenker’s diverticula are usually located in the back of the throat, just above the esophagus
• Midthoracic diverticula, in the mid-chest
• Epiphrenic diverticula, above the diaphragm

Who is affected by esophageal diverticula?

Esophageal diverticula can affect people of all ages, although most cases occur in middle-aged and elderly individuals.

Overall, esophageal diverticula are rare, showing up in less than 1 percent of upper gastrointestinal X-rays and occurring in less than 5 percent of patients who complain of dysphagia (difficulty in swallowing).

Are esophageal diverticula serious?

Typically, esophageal diverticula are nuisances that enlarge slowly over many years, gradually producing increasing symptoms, such as dysphagia, regurgitation and aspiration pneumonia, caused by breathing in regurgitated diverticula content.

When symptoms of esophageal diverticula worsen, a person may be unable to swallow due to an obstruction near the diverticulum; rarely, the esophagus may rupture. An obstruction or rupture caused by an esophageal diverticulum is dangerous, and both complications require immediate attention.

Regurgitation caused by a diverticulum often occurs at night when lying down, which can lead to choking, aspiration pneumonia (a lung infection caused by pulmonary aspiration, the entry of secretions or foreign material into the trachea and lungs), and lung abscesses.

Although rare, squamous cell carcinoma can develop in 0.5 percent of those with diverticula. This is thought to be caused by chronic irritation of the diverticula by prolonged food retention. It is important to note that the fear of cancer is not a reason to surgically treat diverticula.

What causes esophageal diverticula?

While the first case of an esophageal diverticulum was reported nearly 250 years ago, little is still known about this condition. It is believed that the internal pressure produced by the esophagus to move food into the stomach can herniate the esophageal lining through a weakened wall, creating a pouch or a diverticulum. There is usually distal end obstruction.

Esophageal diverticula are more common in people who have motility disorders of the esophagus, such as achalasia, that cause difficulty in swallowing, regurgitation of food, and, in some people, a spasm-type pain.

What are the symptoms of esophageal diverticula?

The symptoms of esophageal diverticula include:

• Dysphagia (difficulty swallowing, characterized by a feeling of food caught in the throat)
• Pulmonary aspiration (the entry of secretions or foreign material into the trachea and lungs)
• Aspiration pneumonia (a lung infection caused by pulmonary aspiration)
• Regurgitation of swallowed food and saliva
• Pain when swallowing
• Cough
• Neck pain
• Weight loss
• Bad breath (halitosis)

Some people may experience a gurgling sound as air passes through the diverticulum. This is known as Boyce's sign.

How is esophageal diverticulum diagnosed?

The tests most commonly used to diagnose and evaluate esophageal diverticulum include:

Barium swallow: The patient swallows a barium preparation (liquid or other form) and its movement through the esophagus is evaluated using X-ray technology.

Gastrointestinal endoscopy: A flexible, narrow tube called an endoscope is passed through the gastrointestinal tract and projects images of the inside onto a screen.

Esophageal manometry: This test measures the timing and strength of esophagus contractions and muscular valve relaxations.

24-h pHmetry: A test to check for the presence of gastroesophageal reflux disease (GERD).

How is esophageal diverticulum treated?

Cases of esophageal diverticulum that cause minor symptoms can be treated through lifestyle changes, such as eating a bland diet, chewing food thoroughly, and drinking plenty of water after meals.

If symptoms become severe, several types of surgery are available to remove the diverticula, repair the defects and relieve a patient’s symptoms and improve their quality of life.

Treatment of diverticula require:

1. An examination of the diverticula;
2. Repair of the weakened wall; and
3. Relief of obstruction

The type of surgical treatment recommended depends on the size and location of diverticula, and include:

Cricopharyngeal myotomy: Used in the removal of small diverticula, this surgical treatment can be completed using an open or trans oral approach.

Diverticulopexy with cricopharyngeal myotomy: Used to remove larger diverticula, this procedure involves turning the diverticular sac upside down and suspending it by suturing it to the esophageal wall.

Diverticulectomy and cricopharyngeal myotomy: Diverticulectomy for the treatment of Zenker's diverticula has been performed for almost a century. The procedure involves complete excision of the diverticular sac.

Recently, Cleveland Clinic surgeons have improved the outcome of this procedure by adding the Heller myotomy laparoscopic approach to ensure the movement of food through the lower esophageal sphincter.

Endoscopic diverticulotomy (Dohlman procedure): This procedure divides the septum between the cervical esophagus and the diverticular pouch. By dividing the septum, food can freely drain from the pouch to the esophagus. Cleveland Clinic surgeons complete this division by using a Zenker’s diverticuloscope and a minimally invasive stapling technique to treat Zenker’s diverticulum.

What are the benefits of minimally invasive surgery to treat esophageal diverticulum?

Laparoscopic approaches, such as endoscopic diverticulotomy, offer patients many benefits, including:

• Limited number of small scars instead of one large abdominal scar
• Shorter hospital stay
• Reduced postoperative pain
• Shorter recovery time
• Quicker return to daily activities, including a regular diet

What are the risks of minimally invasive surgery to treat esophageal diverticulum?

The possible complications of minimally invasive surgery include:

• Damage to the lung, spleen, stomach, esophagus or liver
• Postoperative infection or bleeding
• Pneumonia
• Deep vein thrombosis

5 tips to improve your blood glucose levels

Living with diabetes - Tips to better manage diabetes

Frequently, we hear how frustrating it is to manage diabetes.

Even though you work hard at managing your blood glucoses, you may be disappointed that your numbers aren't better. I often say you can't possibly do the work of your pancreas all the time. Don't beat yourself up. Doing the best you can is all we ask.

Here are some tips from the American Diabetes Association for improved blood glucose control:

• Meet with your diabetes team. You aren't alone. Choose a healthcare provider who understands diabetes well and ask if you can also meet with a diabetes educator and a dietician. Your team can help you come up with a plan for eating and exercising. If you're on insulin, the diabetes educator can give you guidelines for dose adjustment depending on which insulin program you're on.
• Test your blood sugar on a regular basis per your provider's recommendation. If you're beginning a new exercise program you may need to test more frequently to avoid low blood sugar. Your blood sugars aren't going to always be perfect. If your blood glucoses are frequently too high or too low talk with your diabetes team. Low blood sugar can be dangerous and testing can help you avoid it.
• Write your blood sugars down. Most of you find this a pain. The good news is, you can download most blood glucose meters to your computer and print a copy for your healthcare provider. A blood sugar log can help you to spot patterns much easier. Those who keep the best records usually have better control. Adding food intake and exercise to your record will better help you see correlation between certain foods, or exercise, and your blood glucoses.
• Take your diabetes medication. Missed doses, whether you are on oral diabetes medication or insulin, can lead to high blood glucoses. If missing your insulin dose or oral diabetes medication is a problem for you, set up reminders.
• Diet is important to keeping your blood glucoses under control. Eating regular, healthy meals will give you better blood glucose control. That doesn't mean you can't go out with friends occasionally or have some birthday cake. A dietician can give you guidelines to healthier eating.

I'm sure you can come up with even more tips to share here (please do!). Have a great week.

MEN'S HEALTH: UNDERSTAND MALE INFERTILITY (RISK FACTORS AND CAUSES)

Approximately 15 percent of couples are infertile. This means they aren't able to conceive a child even though they've had frequent, unprotected sexual intercourse for a year or longer. In about half of these couples, male infertility plays a role.

Male infertility is due to low sperm production, abnormal sperm function or blockages that prevent the delivery of sperm. Illnesses, injuries, chronic health problems, lifestyle choices and other factors can play a role in causing male infertility.

Not being able to conceive a child can be stressful and frustrating, but a number of male infertility treatments are available.

SYMPTOMS

The main sign of male infertility is the inability to conceive a child. There may be no other obvious signs or symptoms. In some cases, however, an underlying problem such as an inherited disorder, hormonal imbalance, dilated veins around the testicle, or a condition that blocks the passage of sperm may cause signs and symptoms. Male infertility signs and symptoms may include:

• The inability to conceive a child
• Problems with sexual function — for example, difficulty with ejaculation, reduced sexual desire or difficulty maintaining an erection (erectile dysfunction)
• Pain, swelling or a lump in the testicle area
• Recurrent respiratory infections
• Decreased facial or body hair or other signs of a chromosomal or hormonal abnormality
• Having a lower than normal sperm count (fewer than 15 million sperm per milliliter of semen or a total sperm count of less than 39 million per ejaculate)

When to see a doctor

See a doctor if you:

• Are unable to conceive a child after a year of regular, unprotected sexual intercourse
• Have erection or ejaculation problems, low sex drive, or other problems with sexual function
• Have pain, discomfort, a lump or swelling in the testicle area
• Have a history of testicle, prostate or sexual problems
• Have had groin, testicle, penis or scrotum surgery

CAUSES

Male fertility is a complex process. To get your partner pregnant, the following must occur:

• You must produce healthy sperm. Initially, this involves the growth and formation of the male reproductive organs during puberty. At least one of your testicles must be functioning correctly, and your body must produce testosterone and other hormones to trigger and maintain sperm production.
• Sperm have to be carried into the semen. Once sperm are produced in the testicles, delicate tubes transport them until they mix with semen and are ejaculated out of the penis.
• There needs to be enough sperm in the semen. If the number of sperm in your semen (sperm count) is low, it decreases the odds that one of your sperm will fertilize your partner's egg. A low sperm count is fewer than 15 million sperm per milliliter of semen or fewer than 39 million per ejaculate.
• Sperm must be functional and able to move. If the movement (motility) or function of your sperm is abnormal, the sperm may not be able to reach or penetrate your partner's egg.

Medical causes

Problems with male fertility can be caused by a number of health issues and medical treatments. Some of these include:

• Varicocele. A varicocele is a swelling of the veins that drain the testicle. It's the most common reversible cause of male infertility. This may prevent normal cooling of the testicle, leading to reduced sperm count and fewer moving sperm. Treating the varicocele can improve sperm numbers and function, and may potentially improve outcomes when using assisted reproductive techniques such as in vitro fertilization.
• Infection. Some infections can interfere with sperm production or sperm health, or can cause scarring that blocks the passage of sperm. These include some sexually transmitted infections, including chlamydia and gonorrhea; inflammation of the prostate (prostatitis); and inflamed testicles due to mumps (mumps orchitis). Although some infections can result in permanent testicular damage, most often sperm can still be retrieved.
• Ejaculation issues. Retrograde ejaculation occurs when semen enters the bladder during orgasm instead of emerging out the tip of the penis. Various health conditions can cause retrograde ejaculation, including diabetes, spinal injuries, medications, and surgery of the bladder, prostate or urethra. Some men with spinal cord injuries or certain diseases can't ejaculate semen, even though they still produce sperm. Often in these cases sperm can still be retrieved for use in assisted reproductive techniques.
• Antibodies that attack sperm. Anti-sperm antibodies are immune system cells that mistakenly identify sperm as harmful invaders and attempt to eliminate them.
• Tumors. Cancers and nonmalignant tumors can affect the male reproductive organs directly or can affect the glands that release hormones related to reproduction, such as the pituitary gland. In some cases, surgery, radiation or chemotherapy to treat tumors can affect male fertility.
• Undescended testicles. In some males, during fetal development one or both testicles fail to descend from the abdomen into the sac that normally contains the testicles (scrotum). Decreased fertility is more likely in men who have had this condition.
• Hormone imbalances. Infertility can result from disorders of the testicles themselves or an abnormality affecting other hormonal systems including the hypothalamus, pituitary, thyroid and adrenal glands. Low testosterone (male hypogonadism) and other hormonal problems have a number of possible underlying causes.
• Sperm duct defects. The tubes that carry sperm (sperm ducts) can be damaged by illness or injury. Some men experience blockage in the part of the testicle that stores sperm (epididymis) or a blockage of one or both of the tubes that carry sperm out of the testicles. Men with cystic fibrosis and some other inherited conditions may be born without sperm ducts altogether.
• Chromosome defects. Inherited disorders such as Klinefelter's syndrome — in which a male is born with two X chromosomes and one Y chromosome (instead of one X and one Y) — cause abnormal development of the male reproductive organs. Other genetic syndromes associated with infertility include cystic fibrosis, Kallmann's syndrome and Kartagener syndrome.
• Problems with sexual intercourse. These can include trouble keeping or maintaining an erection sufficient for sex (erectile dysfunction), premature ejaculation, painful intercourse, anatomical abnormalities such as having a urethral opening beneath the penis (hypospadias), or psychological or relationship problems that interfere with sex.
• Celiac disease. A digestive disorder caused by sensitivity to gluten, celiac disease can cause male infertility. Fertility may improve after adopting a gluten-free diet.
• Certain medications. Testosterone replacement therapy, long-term anabolic steroid use, cancer medications (chemotherapy), certain antifungal medications, some ulcer drugs and certain other medications can impair sperm production and decrease male fertility.
• Prior surgeries. Certain surgeries may prevent you from having sperm in your ejaculate, including vasectomy, inguinal hernia repairs, scrotal or testicular surgeries, prostate surgeries, and large abdominal surgeries performed for testicular and rectal cancers, among others. In most cases, surgery can be performed to either reverse these blockage or to retrieve sperm directly from the epididymis and testicles.

Environmental causes

Overexposure to certain environmental elements such as heat, toxins and chemicals can reduce sperm production or sperm function. Specific causes include:

• Industrial chemicals. Extended exposure to benzenes, toluene, xylene, pesticides, herbicides, organic solvents, painting materials and lead may contribute to low sperm counts.
• Heavy metal exposure. Exposure to lead or other heavy metals also may cause infertility.
• Radiation or X-rays. Exposure to radiation can reduce sperm production, though it will often eventually return to normal. With high doses of radiation, sperm production can be permanently reduced.
• Overheating the testicles. Frequent use of saunas or hot tubs may temporarily lower your sperm count. Sitting for long periods, wearing tight clothing or working on a laptop computer for long stretches of time also may increase the temperature in your scrotum and slightly reduce sperm production. The type of underwear you wear is unlikely to make a significant difference in male fertility.

Health, lifestyle and other causes

Some other causes of male infertility include:

• Illegal drug use. Anabolic steroids taken to stimulate muscle strength and growth can cause the testicles to shrink and sperm production to decrease. Use of cocaine or marijuana may temporarily reduce the number and quality of your sperm as well.
• Alcohol use. Drinking alcohol can lower testosterone levels, cause erectile dysfunction and decrease sperm production. Liver disease caused by excessive drinking also may lead to fertility problems.
• Occupation. Certain occupations can increase your risk of infertility, including those associated with extended use of computers or video display monitors, shift work, and work-related stress.
• Tobacco smoking. Men who smoke may have a lower sperm count than do those who don't smoke. Secondhand smoke also may affect male fertility.
• Emotional stress. Stress can interfere with certain hormones needed to produce sperm. Severe or prolonged emotional stress, including problems with fertility, can affect your sperm count.
• Weight. Obesity can cause hormone changes that reduce male fertility.
• Prolonged bicycling. Prolonged bicycling is another possible cause of reduced fertility due to overheating the testicles. In some cases, bicycle seat pressure on the area behind the testicles (perineum) can cause numbness in the penis and erectile dysfunction.

RISK FACTORS

A number of risk factors are linked to male infertility. They include:

• Smoking tobacco
• Using alcohol
• Using certain illegal drugs
• Being overweight
• Having certain past or present infections
• Being exposed to toxins
• Overheating the testicles
• Having a prior vasectomy or major abdominal or pelvic surgery
• Being born with a fertility disorder or having a blood relative with a fertility disorder
• Having certain medical conditions, including tumors and chronic illnesses
• Taking certain medications or undergoing medical treatments, such surgery or radiation used for treating cancer
• Performing certain prolonged activities such as bicycling or horseback riding, especially on a hard seat or poorly adjusted bicycle

MEN'S HEALTH : Peyronie’s (Penis) Disease

Definition

This is a disease that affects the male’s genital organ: the penis, as it often causes deformity of the penis and erections are often very painful.

This disease is the development of abnormal scar tissue and /or plaques on the tissues on the penis. The discomfort that is associated with this disease may prevent a man from engaging in sexual intercourse, which can result in stress and anxiety.

Symptoms of Peyronie’s Disease

Deformed Penis

Once the penis becomes erected, its features may come off as being deformed. Its deformed look may fall under these descriptions:

• Penis may bend or curve upwards, which is said to be the most common deformity.
• Penis may curve down to one side
• Penis tends to have an “hourglass” appearance about it.
• Penis might seem as if it is erect but instead it is bent sharply downwards at the base.

Pain

The pain associated with this disease may occur in three situations:

• Once the penis is erected
• Only during an orgasm.
• Once the penis is touched, and there is no erection.

For the first six (6) to eighteen (18) months pain may be experienced during an erection.

Scar tissue under the skin

The scar tissues associated with the identification of this disease, is normally felt on the penis under skin. It should feel like flat lumps or a like a band of hard tissue.

Erectile Dysfunction

Penis Shortening

Causes of Peyronie’s Disease

The cause of Peyronie’s Disease is unknown, but it is “generally considered the result of an unhealed wound. This wound can come about as a result of a sports injury or accident.

How exactly what does a wound healing properly or improperly have to do with this disease? Well with this disease, if the penis is unable to get a normal wound-healing process, then the will be a permanent tissue scar. This permanent scar therefore leaves the elastic tissue (tunica albuginea) inflexible and unable to stretch during the erection. As a result the penis bends or comes off as disfigured.

Treatment of Peyroni’s Disease

Penile Injections

If this is the administered treatment for you, there is a possibility of you receiving multiple injections over several months. Local Anesthesia with also be administered to prevent the discomfort of experiencing pain.

Penile Injections may come in the following form of drugs:

• Verapamil
• Interferon
• Collagenase

Surgery

Depending on the severity of the disease, surgery might be the recommended treatment. In order to go ahead with the surgery, the condition has to be first stabilized.

Types of Surgical Methods used

• Shortening the unaffected side.
• Lengthening the affected side.
• Penile Implants.

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