Impotence and sterility

Category: Education

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forensic medicine


Presentation Transcript

Impotence and sterility:

Impotence and sterility

Questions of chapter :

Questions of chapter Sterility Impotence Frigidity Circumstances where this question arises Causes of impotency in males and females Examinations of organs Opinion in the cases

Impotence :

Impotence Person who is not able to perform sexual intercourse Phases of the same in men- erection, mantainence of erection, ejaculation

Phases of sexual performance :

Phases of sexual performance Erection- parasympathetic system controlled by S2- S4 nerves. Leading to release of cyclic GMP for dilatation of the c. cavernosa arterioles. Emission- sympathetic system. Release of secretions from prostrate, seminal vesicles. Ejaculation – sympathetic system controlled by thoracic to lumbar nervesT11-L2. Closure of urethra and contraction of Bulbocavernosus(somatic control dorsal penile/pudendal nerves S2-S4) muscles to further relax ultimately.

Sterility :

Sterility Person is who is not able to beget children Person is not impotent and is able to perform the sexual intercourse.

Semen analysis :

Semen analysis Quantity of semen-3-5ml Sperms- 20- 50 million sperms/ ml. Ph- alkaline becomes liquefied in 20 minutes Progression- 50% in forward progression. Morphology- 30% are of normal shape White blood cells are <10 in high power field. Azoospermia/ oligospermia, asthenospermia, oligoasthenospermia

Base of male reproduction :

Base of male reproduction Hypothalamic pituitary testicular axis: pulsatile gonadotropin releasing hormone from hypothalamus acts on anterior pituitary stimulating release of LH and FSH. LH acts on leydig cells( interstitial) causing testosterone secretion. FSH acts on Sertoli cells causing structural and metabolic support to developing spermatogenic cells FSH and testosterone support germ cells which are responsible for spermatogenesis. Sperm route; epidydymis, vas deferens, ejaculatory ducts, prostatic urethra.

Definitions :

Definitions Frigidity- woman is not able to initiate sexual intercourse and is not able to maintain it Ejaculation precaux- person is not able to maintain erection and ejaculates at early stage before both the partners desire it and can be primary and secondary cause( usually in men 45- 60 years). Causes are psychological and can be a fear of angina. Sexual dysfunction- not able to initiate and not able to maintain the sexual arousal.

Circumstances :

Circumstances Civil – in cases of nullity of marriage, divorce, child contested for paternity of the child, workmen compensation cases Criminal- in cases of rape, adultery, incest

Causes of impotency and sterility :

Causes of impotency and sterility Age of the person Disparity of the organs Acquired and congenital defects generalised diseases Local diseases Psychic

Male genital system :

Male genital system

Age of the indivisual :

Age of the indivisual Young age – non developed genitals. However power of erection present at earlier age than puberty. Precocious puberty is a condition where the child is around 6 years and the secondary sexual characters start to develop. No legal age in which a male has immunity from the said allegations. Old age – spermatozoa present but physically weak

Disparity of organs :

Disparity of organs For coitus there should be- sexual drive( undersexed-satyriasis/ oversexed-nymphomaniac) , sexual arousal, genital union, orgasm ,resolution. Disparity of the penis and vaginal opening for union

Congenital abnormality:

Congenital abnormality Endocrine-kallman syndrome(hypothalmic hypogonadism) Undescended testis- might be present anywhere along the pathway of descent-internal inguinal ring, inguinal canal, external inguinal ring.Klienfelters triad( small firm testis, gynaecomastia and Azoospermia) Epidydymis- absence of organ Vas deferens- absence of vas, cystic fibrosis. Seminal vesicles Prostrate- no secretions Penile – double, hypospadiasis(perineal, scrotal, penoscrotal, proximal penile, midshaft, distal penile, sub coronal, coronal and glandular) Spine problems- spina bifida

Acquired abnormalities :

Acquired abnormalities Endocrine- excess of prolactin, excess androgens and estrogens Testis- varicocele in which dilatation of the pampiniform plexus(35% cases),orchitis, Epidydymis- epidydimitis( gonorrhoea,e.coli),mumps. Vas deferens- bilateral obstruction Seminal vesicles- inflammations Prostrate-BPH, retrograde ejaculation due to surgery Penile- peyronies disease, phimosis ( not able to retract skin over the penis) and paraphymosis( foreskin caught behind glans), tumours Urethra – urethritis, reiter( no pee, see and climb a tree)

General diseases :

General diseases Anemia Diabetes Pulmonary tuberculosis Chronic nephritis Hemiplegic Paranoia Tabes dorsalis General paralysis of insane Medications- anabolic steroids, nitrofurantion Drugs-marijuana, cocaine, tobacco Increased testicular temperatures- sauna, hot baths

Psychic causes :

Psychic causes Anxiety Timidity Quad hance syndrome or bridegroom syndrome Vasculogenic impotence- arteriogenic and venogenic impotence.

Erectile dysfunction :

Erectile dysfunction Consistent more than 3 months duration or recurrent ability to maintain an adequate erection for satisfactory sexual performance. Involves the coordination of psychologic , neurologic, hemodynamic, mechanical and endocrine components.

Diagnosis of erectile dysfunction :

Diagnosis of erectile dysfunction Complete history Questionares- international index of erectile function Physical examination Laboratory examinations- Specialised testing- invasive and non invasive testing. Non invasive is nocturnal penile tumescence monitor and invasive is intercavernous injection of papaverine and Doppler testing( 15 mg or 1 ml along with 0.5 ml of normal saline given intracorporally with 26 gauge needle and response noted as no response, partly and fully).

Treatment :

Treatment Non invasive- alcohol and smoking stoppage and medication change. Minimally invasive- sildenafil( viagra) inhibits phosphodiestrase type 5 to increase intercavernosal cyclic GMP Androgen replacement therapy Vacuum devices. MUSE or male urethral suppositories for erection.

Examination of the male :

Examination of the male History of person Old illness Old surgeries Examination general Local examination –external , per rectal examination Laboratory investigation- semen examination,

Investigations :

Investigations Semen analysis- 2 properly taken sample Complete blood investigations Urine analysis Thyroid analysis Hormonal assay- FSH,TSH,LH Ultrasound examination-varicocele , testicular size Chromosomal studies –kleinefelters syndrome, Y chromosome micro deletion, cystic fibrosis gene mutation Immunologic studies for antisperm antibodies in ejaculate and blood Testicular biopsy Vasography to see patency of vas Papaverine injection

Slide 24:

Testis – surgical repair of pampiniform plexus to improve sperm count Epidydymis-treatment of infection, differentiate from torsion and epidydymitis Vas deferens-treatment of the same Prostrate-surgical correction Urethra- correction of treatment Penile- surgery

Reporting of the case :

Reporting of the case Deviation- may not be able to perform sexual intercourse Normal- nothing to suggest that the person is not able to perform sexual intercourse Other investigations – Vasculogenic- arterio or venogenic, papaverine injections, ultrasonography.

Requirements for conception :

Requirements for conception Ovary Tube Cervix Endometrium sperm

Causes in women:

Causes in women Age – extreme, precocious puberty Disparity of organs Development defects – congenital ( turners, gonadal dsygenisis) acquired Diseases – general and local Psychological- vaginismis

Ovulatory dysfunction :

Ovulatory dysfunction Hypothalmic amenorrhoea Pituitary- prolactinoma, hypopituitarism, cushing syndrome, renal/ hepatic failure. Ovarian- polycystic ovarian syndrome, premature ovarian failure, luteal phase defect Systemic diseases- thyroid, cushing syndrome, renal hepatic failure. Congenital- turners syndrome, gonadal dysgenesis Stress, nutrition deficiency, excess exercise

Outflow tract abnormality :

Outflow tract abnormality Tubal factors- pelvic inflammatory disease, adhesions, ligation or occulusion due to ectopic. Uterine factors- congenital( bicornuate, septate, congenital des exposure), intrauterine adhesions( asherman syndrome), infection( pelvic tuberculosis, endometriosis), fibroid and endometrial ablation. Cervical factors- hostile cervical mucus, anti sperm antibodies, structural( cone biopsies)

Psychic causes:

Psychic causes Impotency is active nature leading to is spasmodic contraction of the vagina due to hyperesthesia. May affect the perineal muscles or only single muscle like levator ani. The vaginal outlet may have involuntary reflex stimulated by imagined, anticipated, real attempts. Aetiological factors- male sexual dysfunction, prior sexual trauma, secondary to dysparunaie

Investigations :

Investigations Hypogonadal hypothalmic disorder- FSH,LH, TSH, prolactin, free testosterone on day 3. on day 21-23 – serum progesterone to confirm ovulation Initiate basal body temperature monitoring Postcoital test- mucus for clarity, ph, spinnbarkeit Tubal factor- hysterosalphigography Peritoneal and uterine factors- hysterosalphigography with a dye. Karyotyping

Treatments :

Treatments Education Medical – ovulation induction with clomiphene citrate which is estrogen antagonist and human menopausal gonadotropin, urofollitropin further followed by HCG for stimulation of ovum release. Bromocriptin, dexamethaxone for hyperandrogenism and luteal phase progesterone supplement.

Sterilisation :

Sterilisation Process of making the person sterile and not impotent so that the capacity to beget children is lost. Direct operation of sterility Indirect operation and leads to sterility as of preserving the life of the person

Types of sterilisation :

Types of sterilisation Compulsory- orders of the state. Carried on mental defectives and others from eugenic point of view or as punishments for sexual criminals Voluntary- performed on married persons with consent of both husband and wife.

Voluntary sterilisation :

Voluntary sterilisation Therapeutic –to prevent danger to the health or life of woman due to future pregnancy. Eugenic –performed to prevent the conception of children who are likely to be likely physically or mentally defective. Contraceptive –performed to limit the size of the family

Methods of sterilization :

Methods of sterilization Temporary – pills, jellies, patches Permanent-may be surgical( vasectomy, tubectomy), radiological.

Guiding principles :

Guiding principles Consent- husband and wife for contraceptive sterlisations. Not unlawful if performed on therapeutic and eugenic grounds after obtaining true and valid consent Preferable to have a check up after vasectomy and abstain from sexual intercourse on two successive occasions. Pills containing hormonal substances may be harmful rarely and so necessary precautions have to be taken to avoid any complications.

Artificial insemination :

Artificial insemination Artificial introduction of semen into the vagina, cervix or uterus to produce pregnancy. Types 1.semen of husband or artificial insemination homologous. And 2.semen of some person other than husband or artificial insemination donor .and 3. donor semen to which semen of husband is added or pooled donor.

Biological aspects:

Biological aspects Semen 1 ml is deposited by means of syringe in or near cervix. Timing of insemination is important as spermatozoa is short. Time of maximum fertility coincides with ovulation. Ovum can survive in a fertilized form for 8-12 hours after it leaves ovary. Time taken by sperms to travel from vagina to tube is 6- 24 hours. And power of sperms to fertilize is usually retained for 48 hours.

Frozen semen for AID:

Frozen semen for AID Addition of glycerol, slow cooling, rapid freezing and storage below minus 79 degree C. Cryopreservation are done with liquid nitrogen or any other safe method for a minimum of 3 months in order to exclude the window period and ELISA is done on the donated semen.

Causes :

Causes Husband is impotent but not sterile Husband is having a disease – chromosomal defect Rh incompatibility between partners Local defects – hypospadiasis, epispadiases

Precautions when donor is used :

Precautions when donor is used Consent of donor and wife is essential. Identity of donor must remain a secret. Donor should not know the receiving person and the result of insemination. Donor should be mentally and physically healthy and no chromosomal abnormality should be present. Donor not to be a relative of the either spouse and should be having his own children.

Precautions :

Precautions race and characteristics of donor should resemble the husband of the woman as closely as possible. Couple should be mentally fit and emotionally stable. Woman to be inseminated and her husband must give consent in writing that an unknown donor should be used and a witness to be present when a donor is used.

Precautions :

Precautions It is wise to used a pooled semen as there might be chances that the husband becomes the father of the child Doctor should have discretion while using a donor and the donor to be screened of all chromosomal defects. Physician who has done artificial insemination should avoid delivering the child.

Ways of doing :

Ways of doing AIH AIH Pooled serum

Artificial insemination bill :

Artificial insemination bill Allow issueless couples to have a child through artificial insemination and give it a legal status. To control spread HIV through AI. Regulate donation, sale or supply of human semen/ ovum for artificial insemination. Make obligatory on part of medical practitioners as to not indulge in selective segregation of sex. Prohibit carry on semen bank with out registration.

Side effects :

Side effects Husband might have adjustment problems Mother becomes overpossesive for the child Child suffers mental trauma if he learns his past history.

Legal problems :

Legal problems Adultery- donor and recipient cannot be held guilty of adultery in india as section 497 IPC. Legitimacy- husband is not the actual father of the child so the property cannot to inherited. Nullity of marriage and divorce-artificial insemination is not a ground for divorce as sterility is no ground however if the AI is due to impotency then it is ground for divorce.

Slide 49:

Natural birth- after insemination if the child is born naturally it remains an illegitimate child till it is adopted. Unmarried woman- the child will be an illgitimate Incest- not an offence if the donor child and children of donor born out of AI have a relation .

Assisted reproductive techniques :

Assisted reproductive techniques Indian medical council research has formulated the code of conduct. Accreditation from directorate of health and research Test tubes babies (ovum removed and fertilized, embryo returned to uterus) and surrogate mother.

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