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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 sexopathologist 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-estrogen 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 husbandrecipient 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.