Saturday 27 August 2016
MORALITY VS. LEGALITY.
I remember attending a APOC (Adolescent Package of Care) training last year and was surprised to learn that the law allows for teenagers to use contraception no matter the method requested (as long as it's reversible). There seems to be a very thin line between morality and legality. The over-18 limit no longer applies in this current day and age. A 10 year old requesting for Norplant cannot be denied the service as long as informed consent has been given . I didn't think much about it until I saw 15 year olds with Norplant implants , Intrauterine Copper Devices etc, most of which had been forcefully organised by their mothers. Maybe I have been raised up in a rather traditional set-up where 'abstinence' was the only measure talked about and successfully instilled. I still don't get it why a mother would rather protect their daughter from pregnancy and not worry about S.T.Is or infertility. I have seen countless times young girls coming in with irregular menses, total lack of menses or heavy bleeding and on further enquiry learn that they are on hormonal contraceptives. If a teenager is not married and has no boyfriend, I still don't understand why long-term contraception is important.
There are times in the office when I get stuck. I can't have a rather 'adult-talk' with a child and expect them to make a life-changing decision. I also aim at zero-prejudice and let them make the decisions on their own without being judgmental. When I tell them about probable infertility in the future , most of them confidently state that they would tackle it when they grew up and get married. When I tell them about abstinence or Barrier methods of contraception (condoms) , most of them sneer that I'm old-fashioned and don't understand 'these things'. As a young doctor in her twenties,I try hard to come down to their level and reason as one of them , but I just can't seem to get used to this century's shocks.
A teenager can be expected to make some stupid mistakes , but as a mother, why would you make some of these decisions for your child. Have we become so westernized, liberal and 'digital' in a manner that can only be harmful to the upcoming generation ?
Looking at it from the other 'digital' view, I guess that we must face the fact that our teens are sexually active. As much as we are aiming at protecting them from pregnancies, we should also balance the equation and protect them from diseases too. It pains me when I see 14 year olds diagnosed with S.T.Is and H.I.V during their antenatal check-ups. Others are diagnosed during their pre-operative check-ups after illegal abortions gone wrong. Would you rather protect your daughter from pregnancy now and have her suffer from infertility in the future or deadly diseases?
Shouldn't a law be passed regulating contraception use among teenagers? Shouldn't we have parent's consent and some legal framework followed before these kids are allowed to use family planning methods
? Let's ponder about it.
Sunday 10 April 2016
MALE INFERTILITY
MALE INFERTILITY
About 2 weekends ago , I was 'thoroughly' bored in Chaaria on a Saturday evening . I decided to go to Meru Town for company and joined some friends watching football( I know nothing about the game). As they sipped their beer and I continued with my delmonte, they kept making fun of my 'blondness' and total ignorance on matters football; they made it their business to teach me about the game . In the course of conversation, a topic on male infertility somehow arose. They are non-medics so they were very inquisitive about it all. The guys kept on challenging me with questions and giving suggestions on probable treatment . I must say they were very accurate on their suggestions to my amusement . The topic got so intense such that I noted other people in the restaurant starting to pull their chairs towards us and listening keenly to the interesting talk. One of my friends is extremely loud hence the added attention. I was also careful to keep my professionalism and talk only about the theory of the condition without giving any statistics.
I had also written about this topic a while back in my blog about the intense dilemma I go through telling patients about this condition. To most African men it becomes a source of ridicule in society and others even commit suicide. Confidentiality is key in managing this condition , sometimes to the extent of keeping it secret away from the female spouse and letting her continue being branded as the 'problem' by society as we try to find a solution to the husband's condition. This is an extremely chauvinistic way of handling it but hey, this is Africa. A woman can take the ridicule and remain hopeful. That is the general mindset here. Medically it is also easier to treat female infertility compared to male infertility.
Male subfertility or infertility is the inability of a man to make a woman conceive through the natural process. It can be due to a genetic, physiological, pathological or mechanical problem in the production or transport of spermatozoa. About 1 in 20 men are subfertile.
The process of sperm formation starts at puberty and continues throughout life. It takes a total of 74 days for sperm formation to be complete and a further ten days for it to be transported to the epididymis for storage for use during ejaculation. The head of the epididymis stores 70% of mature sperm and during ejaculation it exists through the vas-deferens to the urethra.
The real cause of the infertility could be due to total inability to produce mature viable sperms(AZOOSPERMIA), production of abnormal forms of sperm without the ability to move or penetrate an ovum, production of normal sperm but in low quantity (OLIGOSPERMIA), production of normal sperm in quality and quantity but blockage anywhere in the transport system from production to ejaculation , impotence e.t.c. Other factors like getting infected with Mumps in a male child can also cause male sub-fertility later in life due to destruction of the testicular cells.
This condition is first investigated by doing a SPERM-ANALYSIS. This is done after 3-7 days of total abstinence and studying the quantity and quality of the sperms. A normal quantity is more than 20million sperms per one milliliter , with atleast 40 million per ejaculate, atleast 60% normal motility and atleast 30%normal morphology and a pH of above 7.2. Severe acidity can destroy normal sperms.
The next step is doing hormone analysis to rule out production impairment. This can be managed using hormonal treatment.
If hormone analysis is normal, the next step would be doing more intense studies to rule out any mechanical obstruction in sperm transport or even absence of the transport mechanism e.g total lack of vas deferens. Unfortunately this can only be done in very specialized fertility centers and we only have one of such in the country somewhere in Nairobi.
My loud friend kept on giving suggestions on treatment modalities based of above causes and he was absolutely correct and gave all treatment modalities. If a man has normal spermatozoa but in abnormally small quantities, IN-VITRO FERTILIZATION can be done and this involves harvesting the sperm , harvesting ovum , 'fusing' them and doing insemination into the uterus of a fertilized product for implantation.
If the problem is normal production but mechanical blockage in transport, SURGICAL SPERM RETRIEVAL(SSR) can be done. This is a surgical procedure done in theatre in which sperms are extracted directly from the testicles or epidydimis using a fine needle and then used for IVF.
The above treatment modalities are only done in very specialised centres and outcomes vary from individual to individual.
In the case hormonal treatment fails for total lack of sperm production , a DONOR SPERM can be used and injected into the uterus from a chosen donor or from a sperm-bank.
Other couples agree on having the woman conceive naturally and secretly using a selected 'Donor'. This is a cheaper way out but the legal,ethical, religious, cultural,
and emotional implications associated with this method discourages it's use especially in this era of diseases. It was however wildly practised in ancient African Communities mostly using blood relative 'donors'.
They asked me if Miraa (Khat) can cause male subfertility but I don't know about this. The problem could be due to impotence. Research is needed.
We looked at our watches and we were shocked to realise it was well past midnight. The conversation had been so intense. It's a topic that is very extensive but also very sensitive . I hope the post is educative. Any suggestions or questions are welcome.
About 2 weekends ago , I was 'thoroughly' bored in Chaaria on a Saturday evening . I decided to go to Meru Town for company and joined some friends watching football( I know nothing about the game). As they sipped their beer and I continued with my delmonte, they kept making fun of my 'blondness' and total ignorance on matters football; they made it their business to teach me about the game . In the course of conversation, a topic on male infertility somehow arose. They are non-medics so they were very inquisitive about it all. The guys kept on challenging me with questions and giving suggestions on probable treatment . I must say they were very accurate on their suggestions to my amusement . The topic got so intense such that I noted other people in the restaurant starting to pull their chairs towards us and listening keenly to the interesting talk. One of my friends is extremely loud hence the added attention. I was also careful to keep my professionalism and talk only about the theory of the condition without giving any statistics.
I had also written about this topic a while back in my blog about the intense dilemma I go through telling patients about this condition. To most African men it becomes a source of ridicule in society and others even commit suicide. Confidentiality is key in managing this condition , sometimes to the extent of keeping it secret away from the female spouse and letting her continue being branded as the 'problem' by society as we try to find a solution to the husband's condition. This is an extremely chauvinistic way of handling it but hey, this is Africa. A woman can take the ridicule and remain hopeful. That is the general mindset here. Medically it is also easier to treat female infertility compared to male infertility.
Male subfertility or infertility is the inability of a man to make a woman conceive through the natural process. It can be due to a genetic, physiological, pathological or mechanical problem in the production or transport of spermatozoa. About 1 in 20 men are subfertile.
The process of sperm formation starts at puberty and continues throughout life. It takes a total of 74 days for sperm formation to be complete and a further ten days for it to be transported to the epididymis for storage for use during ejaculation. The head of the epididymis stores 70% of mature sperm and during ejaculation it exists through the vas-deferens to the urethra.
The real cause of the infertility could be due to total inability to produce mature viable sperms(AZOOSPERMIA), production of abnormal forms of sperm without the ability to move or penetrate an ovum, production of normal sperm but in low quantity (OLIGOSPERMIA), production of normal sperm in quality and quantity but blockage anywhere in the transport system from production to ejaculation , impotence e.t.c. Other factors like getting infected with Mumps in a male child can also cause male sub-fertility later in life due to destruction of the testicular cells.
This condition is first investigated by doing a SPERM-ANALYSIS. This is done after 3-7 days of total abstinence and studying the quantity and quality of the sperms. A normal quantity is more than 20million sperms per one milliliter , with atleast 40 million per ejaculate, atleast 60% normal motility and atleast 30%normal morphology and a pH of above 7.2. Severe acidity can destroy normal sperms.
The next step is doing hormone analysis to rule out production impairment. This can be managed using hormonal treatment.
If hormone analysis is normal, the next step would be doing more intense studies to rule out any mechanical obstruction in sperm transport or even absence of the transport mechanism e.g total lack of vas deferens. Unfortunately this can only be done in very specialized fertility centers and we only have one of such in the country somewhere in Nairobi.
My loud friend kept on giving suggestions on treatment modalities based of above causes and he was absolutely correct and gave all treatment modalities. If a man has normal spermatozoa but in abnormally small quantities, IN-VITRO FERTILIZATION can be done and this involves harvesting the sperm , harvesting ovum , 'fusing' them and doing insemination into the uterus of a fertilized product for implantation.
If the problem is normal production but mechanical blockage in transport, SURGICAL SPERM RETRIEVAL(SSR) can be done. This is a surgical procedure done in theatre in which sperms are extracted directly from the testicles or epidydimis using a fine needle and then used for IVF.
The above treatment modalities are only done in very specialised centres and outcomes vary from individual to individual.
In the case hormonal treatment fails for total lack of sperm production , a DONOR SPERM can be used and injected into the uterus from a chosen donor or from a sperm-bank.
Other couples agree on having the woman conceive naturally and secretly using a selected 'Donor'. This is a cheaper way out but the legal,ethical, religious, cultural,
and emotional implications associated with this method discourages it's use especially in this era of diseases. It was however wildly practised in ancient African Communities mostly using blood relative 'donors'.
They asked me if Miraa (Khat) can cause male subfertility but I don't know about this. The problem could be due to impotence. Research is needed.
We looked at our watches and we were shocked to realise it was well past midnight. The conversation had been so intense. It's a topic that is very extensive but also very sensitive . I hope the post is educative. Any suggestions or questions are welcome.
Tuesday 1 March 2016
SUDDEN DEATH IN YOUNG DIABETICS
On one Monday morning last month, I was doing my usual hospital rounds. I noticed a young man who had just arrived, he was writhing in abdominal pain, breathing so fast and aggressively, he was semi-conscious and his extremities were cold. He also looked severely dehydrated , had a low blood pressure with a rapid heart rate. He also looked like he had a rapid weight loss recently; he was wasted. I quickly stopped all that I was doing and went to him. A nurse, Mr. Ambani, abandoned his 'wound-dressing' duties and quickly followed me. We positioned our patient properly and both of us couldn't help but notice a sweet smell emitting from his mouth (acetone breath due a waste called ketones). He was in a very critical condition. I made a quick working diagnosis of Diabetic Keto-Acidosis (DKA) and asked the nurse to dash and get a glucometer( gadget for measuring blood sugar levels) and resuscitation tray with. I.V branulas and fluids. We were aware that the patient had no history of diabetes but we knew that he could be a new case of the disease . The sugars were unrecordably high ; my diagnosis of Diabetic KetoAcidosis was right . We needed to act in seconds or end up losing the patient . His veins were collapsed so I quickly went for the jugular and was in on the first jab. Meanwhile the nurse had given three shots of insulin and I started giving Fluids intravenously (Normal Saline) as soon as possible. Potassium Chloride and Sodium Bicarbonate was also ready. Another nurse joined us and assisted in putting a urinary catheter and getting a urine sample for the labs. He also helped as we struggled to get another I.V line to keep the fluids running fast. After two hours, the condition was still critical and the sugars were still unrecordably high. We put in a continuous insulin infusion as the fluids ran as we monitored and recorded the sugars every 30 minutes . Still after 4 hours, the sugars were very high but we kept on. His condition was better though not stable. There was a ray of hope soon and the sugars started dropping. The young man's breathing also improved significantly and within hours he was awake and responding to commands. By 10.00pm that evening he was walking around. I ended up not completing my ward rounds because I spent hours on the patient but I was glad that a life had been saved.
This case reminded me of an Autopsy I watched on TV being done by the world renowned pathologist DR.G (Channel 171 Dstv). A Diabetic patient had just collapsed suddenly after a usual day of work. The patient had sensed that she was feeling weak and mistook her situation as a case of low blood sugars so she quickly took a glass of juice, only for her to collapse and die. Her autopsy was unremarkable but he blood analysis confirmed a serious case of Diabetic Keto-Acidosis, a condition caused by high blood sugars. She was strictly adherent to her drugs and diabetic diet so her family could not fathom how the condition could have attacked her. It was later learned that she had travelled a week earlier by bus with her drugs safely carried in her back-pack. The drugs were not stored in the refrigerator as required so their potency was gone. She was injecting herself during the week with insulin that was not working due to high temperatures in the bag and bus hence the high blood sugars .
Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but it is not uncommon in some patients with type 2 diabetes. In layman terms, I tell my patients that Diabetes Type 1 is mainly In those who were diagnosed with Diabetes before the age of ~35years. There usually a total lack or very low production of insulin by the pancreas in this type of Diabetes, hence the need of the patients to be on insulin and not oral drugs.
DKA is a complex disordered metabolic state characterized by high blood sugars, dehydration , ketoacidosis, and ketonuria. ( presence of a metabolic waste called Ketone in the blood and urine).
Signs and symptoms
The most common early symptoms of DKA are the insidious increase in thirst and frequency of urination.
The following are other signs and symptoms of DKA:
Malaise, generalized weakness, and fatigability
Nausea and vomiting; may be associated with diffuse abdominal pain, decreased appetite, and anorexia
Rapid weight loss in patients newly diagnosed with type 1 diabetes.
History of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons.
Decreased perspiration
Altered consciousness (eg, mild disorientation, confusion); frank coma is uncommon but may occur when the condition is neglected or with severe dehydration/acidosis
Signs and symptoms of DKA associated with possible intercurrent infection are as follows:
Fever
Coughing
Chills
Chest pain
Difficulty in breathing
Joint pains
Patients having these symptoms must rush to hospital for check up and proper management. This is for all people irregardless of whether or not they are diabetic. In the case of my patient above, he was not a known diabetic and this was his first time to be diagnosed).
DKA is a condition that is is deadly but at the same time very easy to treat and reverse if diagnosed on time.
It's sad, but I have heard and witnessed stories of diabetic patients found collapsed and dead in their houses. This year alone I have certified deaths of 2 young diabetic patients who collapsed suddenly after a normal working day. We highly suspected DKA.
We doctors also over-emphasize to our patients on the dangers of low blood sugar (hypoglycemia) and forget that High Blood sugar is also similarly dangerous. Public education on this matter is needed. Patients should also be advised to own blood sugar measuring machines so that they can properly diagnose themselves for emergency first-aid as they rush to hospital.
I hope this post will help us to prevent sudden deaths in Diabetes .
My patient hopes that his story can help inspire others.
P.S....let us not forget HYPOGLYCEMIA(Low blood sugar) which can also kill in seconds. It is the opposite of this condition I have written about and life can be saved by taking sugar. This requires a whole new post for discussion. I hope to write about it soon. Have a wonderful March 2016.
This case reminded me of an Autopsy I watched on TV being done by the world renowned pathologist DR.G (Channel 171 Dstv). A Diabetic patient had just collapsed suddenly after a usual day of work. The patient had sensed that she was feeling weak and mistook her situation as a case of low blood sugars so she quickly took a glass of juice, only for her to collapse and die. Her autopsy was unremarkable but he blood analysis confirmed a serious case of Diabetic Keto-Acidosis, a condition caused by high blood sugars. She was strictly adherent to her drugs and diabetic diet so her family could not fathom how the condition could have attacked her. It was later learned that she had travelled a week earlier by bus with her drugs safely carried in her back-pack. The drugs were not stored in the refrigerator as required so their potency was gone. She was injecting herself during the week with insulin that was not working due to high temperatures in the bag and bus hence the high blood sugars .
Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but it is not uncommon in some patients with type 2 diabetes. In layman terms, I tell my patients that Diabetes Type 1 is mainly In those who were diagnosed with Diabetes before the age of ~35years. There usually a total lack or very low production of insulin by the pancreas in this type of Diabetes, hence the need of the patients to be on insulin and not oral drugs.
DKA is a complex disordered metabolic state characterized by high blood sugars, dehydration , ketoacidosis, and ketonuria. ( presence of a metabolic waste called Ketone in the blood and urine).
Signs and symptoms
The most common early symptoms of DKA are the insidious increase in thirst and frequency of urination.
The following are other signs and symptoms of DKA:
Malaise, generalized weakness, and fatigability
Nausea and vomiting; may be associated with diffuse abdominal pain, decreased appetite, and anorexia
Rapid weight loss in patients newly diagnosed with type 1 diabetes.
History of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons.
Decreased perspiration
Altered consciousness (eg, mild disorientation, confusion); frank coma is uncommon but may occur when the condition is neglected or with severe dehydration/acidosis
Signs and symptoms of DKA associated with possible intercurrent infection are as follows:
Fever
Coughing
Chills
Chest pain
Difficulty in breathing
Joint pains
Patients having these symptoms must rush to hospital for check up and proper management. This is for all people irregardless of whether or not they are diabetic. In the case of my patient above, he was not a known diabetic and this was his first time to be diagnosed).
DKA is a condition that is is deadly but at the same time very easy to treat and reverse if diagnosed on time.
It's sad, but I have heard and witnessed stories of diabetic patients found collapsed and dead in their houses. This year alone I have certified deaths of 2 young diabetic patients who collapsed suddenly after a normal working day. We highly suspected DKA.
We doctors also over-emphasize to our patients on the dangers of low blood sugar (hypoglycemia) and forget that High Blood sugar is also similarly dangerous. Public education on this matter is needed. Patients should also be advised to own blood sugar measuring machines so that they can properly diagnose themselves for emergency first-aid as they rush to hospital.
I hope this post will help us to prevent sudden deaths in Diabetes .
My patient hopes that his story can help inspire others.
P.S....let us not forget HYPOGLYCEMIA(Low blood sugar) which can also kill in seconds. It is the opposite of this condition I have written about and life can be saved by taking sugar. This requires a whole new post for discussion. I hope to write about it soon. Have a wonderful March 2016.
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