Case – 28

Infertility
Ms. Shobana and Mr. Sathish are software engineers who have been married for the past 6
years. This has been a late marriage and both of them are in their early thirties. They have a happy married
life but the family circle always reminded them that they have to plan for a child as it was already 6 years
after marriage. The couple has taken an appointment to consult a Gynecologist in a Hospital “Good morning
Doctor! I am Shobana and he is my husband Mr. Satish”. “Good morning! I am Dr. Sharadha. Please sit
down” says the doctor, and patiently waits for them to start. Shobana looks at the doctor and slowly begins.
“We are married for the past 6 years and are yet to have a child. We did not worry about it initially but now,
we are concerned. We are worried that there may be some problems with us. So we decided to consult you”.
Dr. Sharadha smiles at them and says, “I will surely help you Shobana! Now……. let me ask you a few
questions. You said that you are married for 6 years, did you adopt any family planning methods?” “Yes
Doctor! For one year I was on oral pills and then I discontinued. For the past 5 years we are not adopting
any methods” says Shobana. “How are your periods Shobana?”, asks the doctor “My periods are regular and
normal ,however around the mid cycle I have been getting excess discharge. Is it abnormal? I also
experience sharp pain for a brief period at the same time. Is it a matter of concern?” The doctor pats her
shoulder and says, “Don’t worry Shobana; I will discuss this with you”. Now the Doctor looks at Sathish and
asks” How is your work pattern, Sathish? Sathish says,” I am a Software Engineer. My work timings are
erratic. However it’s within the city and I don’t need to travel much “. “Do you have any specific
complaints?” asks the doctor “No Doctor not at all”. Dr. Sharadha looks at him thought fully and says “I
need to talk to you in private”. The doctor takes Satish inside the examination room. She requests Dr.
Mohan, her intern to accompany her after 20 minutes of talking and physical examination, they return to the
consulting room. Now the doctor looks at Shobana and says, “I need to examine you as well “. Shobana
accompanies the doctor to the examination room. The doctor does a complete physical examination and asks
a few questions to Shobana in private. She looks at both of them and says “I suggest that Mr Sathish has a
seminal analysis done before I ask for any other tests. She notices a frown on Mr. Sathish’s face as he
hesitantly nods his head in agreement ……………………….

Objectives

1. Physiology of ovulation
2. Physiological basis for causes of male and female infertility.
 Case – 29
Prolapsed uterus

You are a gynecologist at a tertiary care hospital. 54 year old Mrs. Rama has been referred to you by her family
physician. “Good morning doctor, I am Rama, my family doctor has referred me to you”. “Good morning Mrs.
Rama, good to see you, please sit down, and how can I help you?” “Doctor, for the past few months I have a feeling
of heavy sensation in my lower abdomen, lower back pain and also burning sensation while voiding urine. While
coughing or sneezing, I could not control my bladder and there is leakage of urine”. “Do you have any other problems
Mrs. Rama?” you ask. “No doctor otherwise I am fine” replied Mrs. Rama. “How many children do you have?” “I
have five children, doctor”. “Are they normal delivery?” “Yes doctor, all my children were delivered normally”
replied Mrs.Rama. “Mrs. Rama, I need to examine you first, can you kindly go to the examination table?” You
examine her and notice a bulge in her anterior vaginal wall which increases while coughing. “Mrs. Rama, I am going
to advise a voiding cystourethrogram. Kindly take the test and see me tomorrow”. The following day Mrs. Rama
visits you with her report. “Good to see you again Mrs. Rama, have you taken the test?” “Yes doctor and this is the
report”. You see the report which shows the bladder dropping below the symphysis pubis during voiding and loss of
ureterovesical angle. You reassure her and advise surgery………..

Points to be discussed
 Pelvic support structures
 Anatomical basis of back pain, polyuria, burning sensation during micturition
 Stress incontinence
 Anatomical basis of cystocele, prolapse of uterus