Fabiana Y. Nakano I. Sandro C. Esteves I. Unexplained infertility diagnosis is made in the presence of a normal semen analysis when tubal patency and normal ovulatory function are established.
Vaginal fluid can come in different textures, with different scents, and there may be more of it sometimes and less of it other times. Retrieved Mayo Clinic Marketplace Check out these best-sellers and special offers on books Pandora peaks adult doll newsletters from Mayo Clinic. Clomiphene citrate affects cervical mucus and endometrial morphology independently of the changes in plasma hormonal levels induced by multiple follicular recruitment. Cyclic changes in the physical and chemical properties of cervical mucus. Among the several conditions that may be involved in the pathophysiology of unexplained infertility at the vaginal and cervical levels, What is functional vaginal discharge should pay particular attention What is functional vaginal discharge i inadequate buffering capacity of acid vaginal pH, ii alterations in cervical anatomy caused by surgeries, birth defects and infections, iii alterations in the cervical mucus caused by hormonal dysfunctions, inflammatory disorders, cystic fibrosis, exogenous and immunological factors. Oral agent is fluconazole mg oral tablet once. Vaginal fluids help the vagina clean itself and make sure that the vaginal environment is healthy and working! Quick Hide.
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Oral nystatin works by eliminating the intestinal reservoir of Whaat. The virus funchional remain in the body What is functional vaginal discharge weeks or years without any symptoms. What about resource poor countries? Chlamydia is one of the most common sexually transmitted infections. Br J Gen Pract ; 46 Sex Transm Infect ; 79 Color also can vary with different ethnicities. However, if the discharge is followed by itching and if it has a thick consistency with a cottage cheese texture, it could mean there is a yeast infection. Vaginal discharge may also be a symptom of trichomoniasis. Basically, there is a wide range of what is normal but it is important to know what is normal for your body.
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- The external female genital area is called the vulva.
- Some women that experience vaginal discharge that is not white always feel there is a problem.
- Vaginitis is an inflammation of the vagina that may result in symptoms of itching, burning, and abnormal discharge.
Fabiana Y. Nakano I. Sandro C. Esteves I. Unexplained infertility diagnosis is made in the presence of a normal semen analysis when tubal patency and normal ovulatory function are established. Among several potential causes, unexplained infertility could be attributed to vaginal pH and cervical mucus abnormalities.
Although the vaginal canal and the cervix generally function as effective barriers to sperm, and although the production of mucus is essential to transport them from the vagina to the uterine cavity, these factors receive little attention in the investigation of couples with unexplained infertility. A substantial reduction in sperm number occurs as they transverse the cervix. From an average of to million sperm deposited in the vagina, only a few hundred achieve proximity to the oocyte.
Given this expected high spermatozoa loss, a slight modification in cervical mucus may rapidly transform the cervix into a "hostile" environment, which, together with changes in vaginal environment and cervix structure, may prevent natural conception and be a cause of infertility. In this review, we discuss the physiological role of the vaginal pH and cervical mucus in fertility, and describe several conditions that can render the cervical mucus hostile to sperm and therefore be implicated in the pathophysiology of unexplained infertility.
Infertility is customarily defined as failure of a couple to conceive after 12 months of regular unprotected intercourse. Potential etiologies of unexplained infertility encompass miscomprehensions on the part of the couple regarding the concept of the female fertile window, improper coital techniques, erectile dysfunction, as well as molecular and functional causes of male and female infertility.
Although it is well established that the vaginal pH and cervical mucus play important roles in maintaining sperm function after intercourse, their importance in unexplained infertility is generally underestimated.
The optimal vaginal pH to maintain sperm viability and motility ranges from 7. The cervix generally function as an effective barrier to sperm; an adequate production of cervical mucus is essential to transport sperm from the vagina to the uterine cavity. Altogether, the aforementioned factors highlight the importance of both vaginal pH and cervical mucus as the first barrier to sperm penetration into the uterine cavity.
In this review, we first describe vaginal physiology. Then, we characterize the cervical mucus, including its production, structure and composition. Lastly, we explain how spermatozoa are transported into the cervical mucus and outline several conditions that can interfere with sperm movement through the vagina and cervical mucus and, therefore, be implicated in the pathophysiology of unexplained infertility. Potential of hydrogen, or pH, is the standard measure of hydrogen ion concentration, the quantitative appraisal of the acidity or alkalinity of a solution.
Numerically, it is equal to 7. Levels of pH less than 7. The vaginal pH fluctuates from 3. Substances produced by microorganisms present in the vagina. The vagina is a genital canal that extends from the vulva to the cervix. Its walls consist of non cornified stratified squamous epithelium, a smooth muscle layer and a prominent connective tissue layer, rich in elastic fibers. Vaginal cells are stimulated by estrogen to both synthetize and accumulate increased amounts of glycogen.
Due to cell shedding and desquamation, glycogen accumulates in the vaginal lumen. Glycogen can be metabolized in a process called glycogenolysis to pyruvic acid, which is converted to lactic acid and water by anaerobic metabolism.
This process is carried out by Doderlein's lactobacillus, the predominant vaginal microorganism, thus decreasing the vaginal pH. As such, the combination of epithelial cells rich in glycogen and the presence of the lactobacillus are essential to maintain vaginal acidity.
Lactobacilli also protect the vagina by competing with other bacteria for adherence to the vaginal epithelium, thus forming a biofilm on the cervical and vaginal mucosae.
Furthermore, lactobacilli produce antimicrobial substances such as hydrogen peroxide, bacteriocins and biosurfactants. As a result of fetal exposure to maternal-placental estrogens in the first month of life, lactobacilli are abundant in the vagina, thus maintaining vaginal pH around 5.
From the first month of life until puberty, the glycogen content of the vaginal epithelial cells decreases in response to decreased estrogen levels. Consequently, the production of lactic acid decreases while vaginal pH rises to about 7.
This modification facilitates the growth of other bacteria, mainly Staphylococcus epidermidis, Streptococcus and E. During the menstrual cycle, the vaginal pH becomes more acidic from the 2 nd to the 14 th day of the cycle, ranging from 6. This decrease in acidity can be maintained for up to two hours after ejaculation.
The vaginal pH also increases during menses, because blood is slightly alkaline, and also in patients with excessive cervical ectropion, which produces alkaline mucus. Increased vaginal pH in the aforesaid conditions predisposes to proliferation of pathogenic bacteria. Variations in the vaginal pH diminish its defense and increase its susceptibility to infections, which can indirectly affect fertility. Lastly, semen disability to neutralize the acidic vaginal pH can also be an infertility factor because spermatozoa are vulnerable to vaginal acidity.
The same is true when semen becomes acidic, which may occur as a result of obstruction in the ejaculatory ducts and due to hypoplasic seminal vesicles.
Under normal conditions, only about out of approximately million spermatozoa deposited in the upper vagina upon ejaculation are capable of successfully traversing the cervical canal. Then, this coagulum is gradually liquefied during the next minutes by seminal-fluid proteolytic enzymes produced by the prostate gland. As a consequence, clustered sperm are trapped within highly viscous semen, which can impair the sperm ability to transverse the cervix.
Most spermatozoa are lost at the vaginal level with the expulsion of semen from the introitus. However, a variable number of spermatozoa are rapidly taken up by the cervical mucus in a process described as "rapid transport", leaving behind the seminal plasma. In fact, spermatozoa are found in the mucus within 90 seconds post-ejaculation.
Sperm movement is predominantly passive, resulting from coordinated vaginal, cervical, and uterine contractions that occur during coitus. Although these contractions are of short duration, they are believed to be the primary force responsible for the rapid progression of sperm to the upper female reproductive tract, as occurs in other mammalian species. Other non-physiological factors may play a role in sperm loss at the vaginal level.
The use of vaginal lubricants during coitus, for instance, has been shown to be toxic to sperm. The cervix, which is the lower narrow portion of the uterus where it joins with the top end of the vagina, generally functions as an effective barrier against sperm.
Protecting sperm from the hostile environment of the vagina; 31 , 46 , Protecting sperm from phagocytosis by vaginal leukocytes; 2 , 7 , 46 , Preventing sperm, microorganisms and particulate matter to access the upper reproductive tract and thus, the peritoneal cavity; 2.
Facilitating sperm transport during the periovulatory period and modulating at other cycle periods; 2 , 7 , 46 , Filtrating morphologically normal sperm; 2 , 7 , 46 , Preserving large numbers of sperm within the cervical crypts, providing a biochemical environment sufficient for sperm storage, capacitation, migration, and release of sperm into the upper genital tract. The anatomical and functional structure of the human cervix facilitates the performance of these aforesaid functions, but the production of mucus is probably the most important one.
Throughout the menstrual cycle, the cervix changes in size and texture. Just prior to ovulation and as a result of the rise in estrogen levels, the cervix swells and softens, while its external os dilates. Also, during this time, the cervix secretes more abundant, slippery, clear and stretchy mucus, which exudes from cervix into the vagina, thus facilitating the entrance of sperm into the uterine cavity. The endocervical canal is lined by single layer of columnar epithelial cells, both ciliated and nonciliated.
The cervix does not contain true glandular units; instead, the epithelium is thrown into longitudinal folds and invaginations with blind-ending tubules arising from the clefts forming crypts off the central canal.
The nonciliated cells secrete mucin in granular form through exocytosis. There are several hundred mucus-secreting units in the cervical canal. The daily production varies in relation to the cyclical changes of the menstrual cycle, from mg during midcycle to mg during other periods of the cycle. A few ciliated cells among the secreting cells propel the cervical mucus from the crypt of origin toward the canal. An uncommon cause of cervical infertility is a previous surgery on the cervix such as cryo- or electric cauterization, cone biopsy and loop electrosurgical excision procedure.
These interventions can alter the anatomy of the cervix canal and may lead to constriction or even stenosis. As a result, the production of mucus may be impaired due to the removal of secretory cells. Most of such defects occur in women whose mothers had used diethylstilbestrol, a synthetic nonsteroidal estrogen, which was banned from the marketplace in These abnormalities are often recognized after the onset of puberty, but late presentations may include infertility.
Cervical mucus is a heterogeneous mixture of secretions whose rate of production depends on several factors. These factors include the number of mucus-secretory units in the cervical canal, the percentage of mucus-secreting cells per unit and the secretory activity of the cells in response to circulating hormones.
There are several types of mucus, as characterized by Odeblad. Type G is thick and sticky, and reflects the stimulation of progestogenic hormones. Using nuclear magnetic resonance analysis, Odeblad and others established that the ovulatory mucus E is a mosaic composed of mucus "strings" called Es and "loaves" labeled as El. The strings Es are fluid gels, and the loaves El are more viscid. The Es-El system is very dynamic.
Since Es and El differ in their molecular architecture and their protein content and not all areas of the cervical mucus are equally penetrable by the sperm. While the Es mucus conveys the spermatozoa from the vaginal pool, the El type has a very limited role in this respect. Cervical mucus forms fern-like patterns due to the crystallization of sodium chloride on its fibers, which varies according with the mucus type.
Ultrastructurally, cervical mucus can be seen as a complex biphasic fluid with high and low viscosity components. It is a hydrogel composed of a low-molecular-weight component cervical plasma and a high-molecular-weight component gel phase.
The cervical plasma consists mainly of trace elements zinc, copper, iron, manganese, selenium, sodium and chloride ions , organic components of low molecular weight such as glucose and amino acids, and soluble proteins, such as albumin and globulins. This extremely large macromolecule about 10, KDa is rich in carbohydrate content and is responsible for the high viscosity of the mucus. This peptide connects the mucin molecules through disulphide bridges S-S , thus forming mucin micelles of to glycoprotein chains.
Collectively, mucin molecules form a complex of interconnected micelles, which comprise a lattice whose interstices are capable of supporting the low viscosity phase, which is predominantly water. The protein content is low in the intermicellar spaces of Es mucus. The very low viscosity of Es intermicellar fluid allows very rapid sperm migration.
Therefore, intermicellar spaces play a key role in sperm migration. Abnormalities of cervical mucus can result in infertility. For instance, chronic cervicitis is associated with alterations of cervical mucus. In this case, a different mucus pattern appears, defined as type Q by Odeblad, 51 , 52 in which the mucus composition varies depending on the type, degree and duration of the inflammatory process.
A brown spotting with no vaginal itching or foul smelling is normal in women. Some women have labia that are uneven in size. In threatened miscarriage women may have continuous bleeding and abdominal pain. The vaginal tissue appears to be a target for allergic reactions in susceptible women. Here's what Dr. Vaginal discharge.
What is functional vaginal discharge. Vulvovaginal Health
Vaginal Discharge: Causes, Types and Treatments
Abnormal vaginal discharge in a pregnant woman causes discomfort and increases risk of complications. Management of such patient is difficult as the physician will need to distinguish leucorrhoea of pregnancy from pathological vaginal discharge and also to decide on the drugs to prescribe that are not contraindicated in pregnancy.
Genital Infections and Infertility. Most pregnant women have vaginal discharges that are either physiologic or pathologic. The challenge to the clinician is to separate the vaginal infections with potentially serious input for pregnancy from annoying but not serious secretions, irritation and pruritus [ 1 ].
Infectious vaginitis is usually caused by yeast, such as Trichomonas vaginalis , bacterial vaginosis, gonorrhoea, Chlamydia trachomatis , Mycoplasma , Group B streptococcus or herpes [ 1 ]. Normal vaginal secretions consist of water, electrolytes, epithelial cells, microbial organisms, fatty acid and carbohydrate compounds [ 1 , 2 ]. The concentration of anaerobic bacteria is usually five times than that of aerobic organisms.
The most prevalent organisms in the vagina are lactobacilli, Streptococci , Staphylococcus epidermidis , Gadnerella vaginalis and Escherichia coli. Anaerobic species that are frequently isolated include Peptostreptococci , anaerobic lactobacilli and bacteroides [ 3 ]. Vaginal pH, glycogen content and amount of secretion influence the quantity and type of organisms present in the vagina.
Lactobacilli restrict the growth of other organisms by producing lactic acid, thus maintaining a low pH. These organisms also produce hydrogen peroxide, which is toxic to anaerobes. The normal vaginal bacterial population assists in inhibiting the growth of pathologic vaginal organisms. If the normal vaginal ecosystem is altered, there is a greater chance of proliferation of pathogenic organisms.
The challenge of treating vaginitis in pregnancy is the necessity of making accurate diagnosis and treating correctly [ 2 ]. True infections some of which can have dangerous effect on gestation must be separated and distinguished from the exaggeration of physiologic discharge by pregnancy.
Infection with bacterial vaginosis, Chlamydia trichomonas or Group B Streptococcus has been associated with septic abortion, premature rupture of membranes and premature delivery [ 2 , 4 ]. Vulvovaginal candidiasis VVC is a common cause of vaginal discharge worldwide [ 5 , 6 ]. Candidiasis is caused by the fungus, Candida species.
Candida species include Candida albicans , Candida tropicalis, Candida pseudotropicalis, Candida krusei and Candida stellaloidea. Other strains are torulopsis, glabrata and rhodotromla. Predisposing factors to VVC include pregnancy, diabetes mellitus, immunosuppressive therapy cytotoxic drugs, steroids, etc. Heat and moisture favour the growth of Candida species [ 8 ]. VVC can be sexually transmitted, and several studies reported an association between candidiasis and orogenital sex [ 7 , 9 ].
Most patients with VVC will complain of vaginal discharge [ 5 ]. Dyspareunia, vulval pruritus and burning are the main symptoms [ 17 ]. Patients commonly complain of pruritus and burning after intercourse or upon urination.
Erythema and oedema of the labia majora and minora and rashes on the perineum and thighs may be seen on physical examination, and a whitish, thick and curd-like vaginal discharge is usually present [ 17 ].
Recurrence requiring repeated treatment during pregnancy is likely [ 18 ]. The diagnosis is made on both clinical examination and laboratory identification of Candida by positive wet-mount test or potassium hydroxide KOH preparation [ 17 ]. In the wet-mount test, the spores and Candida are seen when vaginal discharge or scrapings from vulval lesions are mixed with normal saline and viewed under high-power magnifications.
Because vaginal pH usually remains normal in VVC, positive results from these two tests in combination with a normal vaginal pH are helpful in confirming the diagnosis. Most studies demonstrate that most of vaginal isolates are C. Therefore, fungal cultures have not been used by most clinicians as part of the initial evaluation [ 17 ].
Various drug formulations are effective in treating both uncomplicated and complicated infections [ 10 ]. Both intravaginal and oral agents are available [ 10 , 19 ]. Complicated VVC is recurrent candidal infection or severe infection or non-albicans candidiasis C. Women who have four or more candidal infections during a year are classified as having complicated disease [ 9 ]. Oral agent is fluconazole mg oral tablet once.
Prolonged local intravaginal therapy regimens and addition of oral fluconazole may be required to treat non-albicans VVC [ 7 ]. Fluconazole, — mg weekly for 6 months, is also the drug for prevention of recurrent VVC, whereas mg boric acid gelatine capsule intravaginally daily for 2 weeks is useful in the management of non-albicans recurrent VVC [ 7 ]. Vaginal flora of a normal asymptomatic reproductive-aged woman includes multiple aerobic or facultative species as well as obligate anaerobic species [ 9 ].
Of these, anaerobes are predominant and outnumber aerobic species approximately 10—1 [ 20 ]. These anaerobes include gram-negative organisms such as Prevotella , Bacteroides , Fusobacterium species, and Veillonella species and gram-positive bacilli such as Propionibacterium species, Eubacterium species and Bifidobacterium species [ 9 , 20 ]. These anaerobic bacteria cause non-specific vaginitis [ 5 ]. Bacterial vaginosis is characterised by a shift from normal vaginal population of lactobacilli to anaerobes such as G.
It is one of the most frequent conditions encountered in reproductive health clinics throughout the world [ 20 ]. The condition had been previously called Haemophilus vaginalis vaginitis, non-specific vaginitis and G.
Bacterial vaginosis has been strongly associated with poor pregnancy outcomes such as preterm delivery and low birth weight infants, and several studies have now established the associations between bacterial vaginosis, human immunodeficiency virus and puerperal sepsis [ 20 , 22 ].
Bacterial vaginosis usually occurs in sexually active patients. Some of the other risk factors include multiple sexual partners, low socioeconomic status, lesbians, presence of intrauterine device and prior STD [ 5 ]. It is still debatable whether it is sexually transmitted; however, supporting this is the recovery of G. Bacterial vaginosis is characterised by a malodorous, profuse, thin, homogenous yellow, white or grey discharge that is adherent to the anterior and lateral vaginal walls.
Typically, the patient may complain of a fishy odour during or shortly after coitus and also during menses. This typical discharge may be found on examination in some patients who in fact have not complained of a vaginal discharge [ 25 ].
The fishy smell of the discharge is the main problem and is often responsible for sexual disharmony between partners. Vulvitis and pruritus are very minimal or totally absent. Nearly half of patients with BV have no symptoms. Obstetric complications include premature rupture of foetal membranes, late miscarriage and postpartum endometritis, whereas pelvic inflammatory disease, post-hysterectomy cuff infection and postabortal sepsis are some of the gynaecological complications [ 25 ].
Culture is the least accurate in making a diagnosis of BV as there is overgrowth of many vaginal organisms in this condition [ 5 ]. Though virtually, all patients with BV have G. In pregnancy, BV should be treated with metronidazole mg three times a day alternatives; metronidazole 2 g single dose, clindamycin mg twice a day; or metronidazole gel [ 5 ].
Trichomoniasis is the commonest sexually transmitted disease worldwide [ 5 ]. It was originally thought to be innocuous but has now been found to be associated with preterm labour, premature rupture of membranes, increased perinatal loss and pelvic inflammatory disease PID [ 5 , 29 ]. The particular trichomonad responsible for vaginitis is T. Other trichomonads, which include Trichomonas buccalis found in the mouth and Trichomonas hominis found in the anal canal and rectum, are known but do not cause vaginal discharge because they cannot survive in the vagina.
The organism may survive for several hours in urine, wet towels and even on toilet seats. The possibility of transmission by these routes had been suggested but not completely proven [ 5 ]. Incubation period is 4—20 days with an average of 7 days. Males are usually asymptomatic, but they can easily infect treated female. The prevalence of trichomoniasis in pregnancy has been found to be 7.
A prevalence of The vaginal discharge of trichomoniasis is malodorous, frothy and profuse, thin creamy or slightly greenish and may cause itching. The patient may also complain of dyspareunia, postcoital bleeding, pruritus vulvae, frequency of micturition and dysuria. Characteristically, vulvitis is minimal or absent compared with candidiasis. The vaginal pH is usually 5—5. Applying litmus to the unlubricated speculum after it has been withdrawn from the vagina easily tests the pH.
A saline wet mount of the swab taken from the vagina or cervix will show motile flagellated protozoa and leucocytes. Monoclonal antibody staining is also used. Metronidazole is effective in eradicating T. Ootrimazole, which is both a fungicide and trichomonacide, can be used intravaginally usually in pregnancy in the same dosage regime as in candidiasis [ 5 ].
In persistent infection, it is best to treat the patient and her male sexual partner simultaneously. Chlamydia and gonorrhoea can both cause vaginal discharge in pregnancy and a major cause of morbidity among women in developing countries [ 31 ]. Both infections have been associated with pregnancy-related complications [ 32 ]. These two conditions are prevalent worldwide particularly in Africa [ 20 ].
They are a major cause of acute pelvic inflammatory disease, infertility and adverse pregnancy outcomes [ 20 ]. According to the WHO, globally new cases of C. In Maiduguri, North-eastern Nigeria, Amin et al. Chlamydia is characteristically asymptomatic [ 39 , 40 ]. About one-third of patients may have symptoms including mucopurulent vaginal discharge [ 5 ]. The role of Chlamydia in infertility is well documented [ 39 — 42 ].
The main cause of tubal pathology is PID. Several different methods to diagnose chlamydial infection are available. Great studies have been performed in the areas of reliable methods of diagnosis [ 40 , 45 ].
Because only viable infectious chlamydial elementary bodies are detected by culture, this is the method of choice for medico-legal issues. The disadvantages of culture include its low sensitivity and is that it depends on the laboratory inter-personal experience [ 46 ].
Non-culture methods include enzyme immunoassay EIA , direct fluorescent staining with monoclonal antibodies DFA , nucleic acid amplification tests NAATs and nucleic acid hybridisation techniques. In the management of chlamydial infection, both the patient and her infected sexual partner must be treated.