This document discusses prevention of female infertility and contains information on several topics: 1. Age-associated infertility and the decline of fertility with increasing female age. Early childbearing and egg freezing are recommended. 2. Tubal factor infertility caused by infections like pelvic inflammatory disease which can be prevented by screening and treating STDs. Adhesions from surgery can also be prevented using techniques that minimize trauma. 3. Other causes of infertility like endometriosis, ovarian issues, and uterine factors are discussed along with prevention strategies.

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PREVENTION
OF
FEMALE
INFERTILITY
Prof.
Aboubakr
Elnashar
Benha
university
hospital,
Egypt
ABOUBAKR
MOHAMED
ELNASHAR

2. CONTENTS
1.
INTRODUCTION

Prevention
2.
PREVENTION
OF
FEMALE
INFERTILITY
I.
Age
Associated
Infertility
II.
Tubal
Factor
Infertility
III.
Endometriosis
Associated
infertility
IV.Ovarian
Factor
Infertility
V.
Uterine
Factor
Infertility
3.
CONCLUSION
ABOUBAKR
MOHAMED
ELNASHAR
1.
INTRODUCTION

Prevention
Better
than
cure.
An
ounce
of
prevention
is
worth
a
pound
of
cure
Of
infertility:
neglected
Important
in

developing
countries

developed
countries.
{Infertility
tt
including
ARTs
are
expensive
and
their
availability
is
limited}
ABOUBAKR
MOHAMED
ELNASHAR

3. Significant
proportion
of
infertility
could
be
prevented
through
(WHO,
2011)

Standard
public
health
measures

Prevention
of
infections

Prevention
of
iatrogenic
infertility
(Schoysman
and
Segal,
1989)
ABOUBAKR
MOHAMED
ELNASHAR
Iatrogenic
infertility

Infertility
caused
by
a
physician’s
actions:

prescribed
drugs

medical
or
surgical
procedure
(Serour
et
al,
1997)

In
Western
Europe:
5%
(Schoysman
and
Segal,
1989)

In
Egypt:
15.5%
(Serour
et
al,
2002)
1.
High
prevalence
of
folk
methods
of
infertility
2.
High
rates
of
medical
malpractice
3.
Unregulated
private
practices
4.
Lack
of
proper
training
of
doctors
in
new
techniques
ABOUBAKR
MOHAMED
ELNASHAR

4. Level
Definition
Example
Primary
Methods
to
avoid
occurrence
of
disease
by
1.
eliminating
disease
agents
2.
increasing
resistance
to
disease.
1.
Immunization
2.
Healthy
diet
3.
Exercise
4.
Avoiding
smoking
Secondary
Methods
to
detect
and
address
an
existing
disease
prior
to
the
appearance
of
symptoms.
1.
TT
of
hypertension
(risk
factor
for
CVD)
2.
Cancer
screenings
Tertiary
Methods
to
reduce
negative
impact
of
symptomatic
disease:
disability
or
death,
through
rehabilitation
and
tt.
Surgical
procedures
that
halt
the
spread
or
progression
of
disease

Levels
of
prevention
ABOUBAKR
MOHAMED
ELNASHAR
2.
PREVENTION
OF
FEMALE
INFERTILITY
I.
AGE
ASSOCIATED
INFERTILITY
At
birth:
number
of
oocytes/ovary:
one
million
From
puberty
to
menopause:
500
ovulate
and
remainder
degenerate.
ABOUBAKR
MOHAMED
ELNASHAR

5. ABOUBAKR
MOHAMED
ELNASHAR

Number
of
primordial
follicles
and

Poor
quality
of
oocytes
in
relation
to

Female
age
and

Reproductive
events.
ABOUBAKR
MOHAMED
ELNASHAR

6. Parous
women:
significant
decline
in
fertility
after
the
age
of
37
Nulliparous
women:

significant
decrease
in
fertility
from
the
age
of
28
onwards

brings
forward
the
age
of
menopause
Smoking
accelerates
the
age
of
the
menopause
by
up
to
2
y
(Howe
et
al.
Effects
of
age,
cigarette
smoking
and
other
factors
on
fertility:
findings
in
a
large
prospective
study.
BMJ
1985).
ABOUBAKR
MOHAMED
ELNASHAR
Causes
1.
Decrease
quality
of
oocytes
{Increase
in
the
rate
of
oocyte
aneuploidy}
Most
important
2.
Decrease
numbers
of
oocytes:
Decrease
ovarian
reserve
3.
Increase
in
the
miscarriage
rate
ABOUBAKR
MOHAMED
ELNASHAR

7. Indications
of
ORT
≥
35
ys
<
35
ys

Endometriosis

Unexplained
infertility

Single
ovary

Previous
ovarian
surgery

Poor
response
to
FSH

Previous
exposure
to
chemotherapy
or
radiation
(Iii-b)
SOGC,
2011
ABOUBAKR
MOHAMED
ELNASHAR

Married
Women:
Do
not
delay
childbearing

Single
women:
cryopreservation
of
oocytes

Social
egg
freezing

who
are
yet
to
find
a
partner

who
wish
to
pursue
a
career.

Now
acceptable
&
rapidly
increasing
ABOUBAKR
MOHAMED
ELNASHAR

8. 
Advantages:
1.
The
use
of
younger
oocytes:
reduce
the
risk
of
fetal
loss
and
aneuploidies
associated
with
ageing
oocytes
(Goold
and
Savulescu,
2009).
2.
The
use
of
cryopreserved,
autologous
oocytes:
allows
the
mother
to
have
a
genetic
relation
to
her
child
that
not
be
achieved
through
oocyte
donation
(Goold
and
Savulescu,
2009)
3.
Higher
chance
of
pregnancy
than
the
use
of
standard
IVF
at
an
older
age
(Sauer
et
al.,
1990).
PR:
age-dependent
ABOUBAKR
MOHAMED
ELNASHAR

Outcomes

Birth
weight
and
incidence
of
congenital
abnormalities

2.5%

similar
to
those
born
from

spontaneous
conceptions
or

through
regular
IVF
(Chian
et
al.,
2008,
Noyes
et
al.,
2009).

Cobo
et
al.
(2014)

Vitrification
does
not
increase
adverse
obstetric
and
perinatal
outcomes.

No
long-term
follow-up
of
these
children
has
yet
been
published.
ABOUBAKR
MOHAMED
ELNASHAR

9. 
Social
cryopreservatiob
1.
The
most
common
reason
to
delay
childbearing

Lack
of
a
partner

Professional
&
financial
issues.
2.
Oocyte
cryopreservation:
Not
an
experimental
technique.
3.
Efficacy

Optimal
timing
Before
35
y

A
minimum
of
8
10
cryopreserved
oocytes
4.
Safety:
The
procedure
seems
to
be
safe
5.
Usage
rate
is
low
12%
6.
Cost
effectiveness:
There
is
a
limitations
for
assessment
II.
TUBAL
FACTOR
INFERTILITY
Causes:
1.
Infection

PID

Appendicitis
2.
Pelvic
adhesions
3.
Endometriosis
4.
Previous
tubal
surgery
5.
Congenital
anomalies
of
the
tubes
ABOUBAKR
MOHAMED
ELNASHAR

10. 
PID

1
episode:
12%
2
:
23%
3
:
54%
Chlamydial
infections
major
cause
often
silent
severe
adhesions
Ruptured
appendix:
5X
tubal
disease
ABOUBAKR
MOHAMED
ELNASHAR
In
the
developing
world:

the
most
common
and
important
cause
of
acquired
infertility
is
preventable

by
preventing
pelvic
infection
caused
by

STD

Unsafe
abortion
or

Puerperal
infection
(Fathalla,
1999)
ABOUBAKR
MOHAMED
ELNASHAR

11. I.
Prevention
of
PID:
1.
Screening&TT
asymptomatic
females
at
risk
for
CT:

Young

Ectopy

Purulent
cervical
discharge

Multiple
sexual
partners
2.
Doxycyclin
200
mg
or
azithromycin
500
mg
at
insertion
of
IUCD
(Sinei
et
al,
1999).
Little
benefit
(Cochrane
library,2002)
ABOUBAKR
MOHAMED
ELNASHAR
3.
Routine
antibiotic
prophylaxis
before
surgical
evacuation
of
incomplete
abortion

Tetracycline
&
metronidazole
or
amoxicillin/clavulanic
acid
to
nulliparous

Debate

No
difference
in
postabortal
infection
(Cochrane
libarary,2002)
ABOUBAKR
MOHAMED
ELNASHAR

12. 4.Treatment
of
symptomatic
&
asymptomatic
sexual
partners:
No
sexual
intercourse
until
the
husband
is
checked
&
treated
5.
Assessment
of
the
partner
for
CT
&
Gon
6.Women
diagnosed
as
PID
should
be
evaluated
for
other
types
of
STD
ABOUBAKR
MOHAMED
ELNASHAR
7.
Appropriate
methods
of
contraception
for
young
woman.

COCP
Provides
some
protection
against
PID
does
not
confer
complete
protection
from
STDs,
barrier
methods
of
contraception
should
be
used
in
addition
to
the
COCP
ABOUBAKR
MOHAMED
ELNASHAR

13. Barrier
method

prevents
STD:
reduce
the
incidence
of
CIN:
need
for
cone
biopsy
of
the
cervix
or
LEEP
Surgery
to
the
cervix
±:

disturbance
in
the
production
of
cervical
mucus

cervical
stenosis:
infertility.

cervical
incompetence:
miscarriage.
ABOUBAKR
MOHAMED
ELNASHAR
IUCD:

increase
the
risk
of
PID
by
50%–100%
PID
is
often
severe.
Not
recommend
in
a
nulliparous
woman
unless
the
woman
anticipates
that
she
is
in
a
long-term
relationship
–
an
IUS
could,
however,
be
offered.
Mirena:
minimise
the
risk
of
infection
{its
effect
on
the
cervical
mucus}
ABOUBAKR
MOHAMED
ELNASHAR

14. Termination
of
a
pregnancy.
Increase
PID
risk
Surgical:
Risk
of
infection:
5%
:damage
to
the
cervix,
this
risk
is
reduced
by
cervical
preparation
with
intravaginal
prostaglandins
preoperatively.
If
perforation:
pelvic
infection
ABOUBAKR
MOHAMED
ELNASHAR
Medical
:5%
risk
of
retained
products
of
conception:
pelvic
infection
Risk
slightly
fewer
than
surgical
termination
ABOUBAKR
MOHAMED
ELNASHAR

15. II.
Prevention
of
adhesions
For
general
surgeons
1.
Respect
pelvic
structures:
Pelvic
structures
should
be
left
alone
2.
Surgery
for
appendicitis

should
be
performed
swiftly

preferably
before
peritonitis
3.If
peritonitis:

peritoneal
lavage

antibiotics
for
at
least
2
ws.
ABOUBAKR
MOHAMED
ELNASHAR
4.
If
there
is
doubt
about
the
diagnosis
before
laparotomy

gynaecological
opinion

Laparoscopy
Many
salpingo-oophorectomies
have
been
performed
for
benign
ovarian
cysts
that
may
have
been
managed
conservatively.
ABOUBAKR
MOHAMED
ELNASHAR

16. For
Gynaecologists
Post-operative
adhesions:
50-95%
of
gynecological
surgery
(Diamond
et
al.,
1990;
Haney
and
Doty,
1992)
Preserve
fertility
&
avoid
disrupting
ovarian&
tubal
anatomy.
ABOUBAKR
MOHAMED
ELNASHAR
Surgical
techniques
for
prevention
of
adhesion
formation:
10
Recommendations
1.
Excellent
haemostasis
2.
Use
of
fine
non-reactive
suture
3.
Avoiding
local
ischemia
4.
foreign
bodies
(talc,
starch)
5.
peritoneum
suturing
6.
Reducing
surgical
trauma
7.
tissue
handling
8.
drying
or
overheating
of
tissues
9.
infection
risk
10.
intra-peritoneal
blood
deposits
ABOUBAKR
MOHAMED
ELNASHAR

17. 
Fibrinolytic
agents

Anticoagulants

Anti-inflammatory
agents

Antibiotics

Other
agents
Fibrinolysin
Papain
Streptokinase,
streptodornase
Urokinase
Hyaluronidase
Chymotrypsin,
trypsin,
pepsin
Elastase
Recombinant
tissue
plasminogen
activator
Citrates
Oxalates
Heparin
Corticosteroids
Antihistamines
Non-steroidal
anti-inflammatory
drugs
Tetracycline
Cephalosporin
Progesterone
Oestrogens
Gonadotrophin-releasing
hormone
agonists
Antiproliferative
agents
Aromate
inhibitors
Statins
Melatonin
Pharmacological
anti-adhesive
agents
ABOUBAKR
MOHAMED
ELNASHAR
Gels
and
hydroflotation
agents

effective
adhesion
prevention
agents

no
evidence
that
they
improve

fertility
outcomes
or

pelvic
pain
(Cochrane
SR.
2014)
ABOUBAKR
MOHAMED
ELNASHAR

18. III.
INFERTILITY
ASSOCITED
ENDOMETRIOSIS
Prevention
of
endometriosis

Endometriosis
cannot
be
prevented.
{cause
is
poorly
understood}.

The
condition
may
temporarily
stop
progressing

COC

Pregnancy

Frequent
and
early
pregnancy

Daily
exercise

±all
help
decrease

overall
incidence

severity
of
endometriosis.
ABOUBAKR
MOHAMED
ELNASHAR
Prevention
of
adhesions
during
surgical
TT
of
endometriosis.
Partial
success
with

Interceed

Oxiplex/AP
gel
or

Adept
solution

in
reducing
adhesions
extent
at
second
look
laparoscopy
performed
a
few
weeks
after
initial
surgery
(Somigliana
et
al,
2012)
ABOUBAKR
MOHAMED
ELNASHAR

19. IV.
OVARIAN
FACTOR
INFERTILITY
Viral
oophoritis

uncommon
cause
of
female
infertility

usually
2
nd
ry
to
mumps

prevented
by
MMR
vaccination
in
childhood.
ABOUBAKR
MOHAMED
ELNASHAR
PCOS
cannot
be
prevented.
Early
diagnosis
and
tt
helps
prevent
long-term
complications:

Infertility

Metabolic
syndrome

Obesity

Diabetes

Heart
disease.
Diagnosis
and
tt
of
adolescent
PCOS
ABOUBAKR
MOHAMED
ELNASHAR

20. 
Attention
to
the
history,
physical
examination,
and
laboratory
data
is
important
to
identify
adolescent
girls
at
risk
to
develop
PCOS

DIAGNOSIS:

Early
&
accurate
diagnosis
is
essential

Criteria
for
the
diagnosis
differ
from
those
used
for
adult

Irregular
menstruation
plus
Moderate
to
severe
hyperandrogenism
and/or
hyperandrgemia

Exclusion
of
other
causes
of
hyperandrogenism
with
menstrual
irregularity


EVALUATION:

Metabolic,CV
risks,
psychologic,
dermatologic,
SHT

TREATMENT

Should
be
individualized
depending
on:
age,
symptoms,
risk
factors
&
choices

1st
line:
lifestyle
modifications

1st
line
pharmacological:
COCP

2nd
line
pharmacological:

COCP+
Metformin

COCP+
Antiandrogen

Metformin

21. Diagnosis:
2
years
after
menarche
Hyperandrogenemia
Serum
testosterone
>1
µg/ml:
the
most
reliable
finding
Rotterdam
criteria:
All
3
OR
AE-PCOS
Society
criteria.
ABOUBAKR
MOHAMED
ELNASHAR
Lifestyle
modification
Weight
reduction:
{obesity
worsens
the
endocrine
profile
of
these
women
and
increases
the
risk
of
infertility}
decrease
androgen
effects
increase
ovulation
improve
insulin
sensitivity.
Metformin
COC
ABOUBAKR
MOHAMED
ELNASHAR

22. Before
Chemotherapy
and
Radiotherapy
Oocyte
cryopreservation
To
freeze
oocytes
women
have
to
undergo
the
same
stimulation
as
women
going
through
IVF.
The
survival
rate
is
relatively
low

subsequent
fertilisation
and
pregnancy
are
by
no
means
guaranteed.
Standard
stimulation:
8–12
mature
oocytes/cycle:
LBR:18.3%,
much
lower
than
the
rate
with
conventional
IVF
ABOUBAKR
MOHAMED
ELNASHAR
ABOUBAKR
MOHAMED
ELNASHAR

23. Cryopreservation
of
strips
of
ovarian
cortex

75%
of
oocytes
are
lost,
as
part
of
the
freezing–thawing
and
grafting
process

technique
should
be
reserved
for
those
women
for
whom
there
is
no
other
alternative,
particularly
as
usually
a
whole
ovary
is
required.

preserve
ovarian
tissue
for
later
use,
either
for
ovarian
autografting
or
for
the
in
vitro
culture
of
follicles
from
which
oocytes
can
be
obtained
for
IVF.
ABOUBAKR
MOHAMED
ELNASHAR
Controversy:

effective
(Cochrane
SR;
2011}

Uncertain
(Elgindy
et
al,SR
2013)
ABOUBAKR
MOHAMED
ELNASHAR

24. Environmental
Pollutants
Dioxins
(highly
toxic
compound
produced
as
a
by
product
in
herbicide
production
and
paper
bleaching)
induce
endometriosis
in
Non-human
primate:
unproven
in
humans.
Pesticides
±detrimental
Cigarette
smoke
ABOUBAKR
MOHAMED
ELNASHAR
V.
UTERINE
FACTOR
INFERTILITY
Causes:
1.
Intrauterine
adhesions
2.
Congenital
abnormalities
3.
Leiomyomas
4.
Endometrial
Polyps
5.
Adenomyosis.
ABOUBAKR
MOHAMED
ELNASHAR

25. Intrauterine
adhesions

Causes
I.
Trauma
1.
Uterine
curettage
of
the
pregnant
or
recently
postpartum
uterus:
After
surgical
tt
for
retained
products
of
conception:
40%
IUA.
2.
Operative
hysteroscopy
3.
Endometrial
ablation
4.
Pelvic
irradiation
5.
Hysterotomy
at
the
time
of
myomectomy
or
CS
II.
Infection
ABOUBAKR
MOHAMED
ELNASHAR
Prevention:
No
Puerperal
curettage
of
the
uterus
Antibiotic
prophylaxis
in
all
cases
following
curettage
Prevention
of
IU
adhesion
after
hysteroscopic
surgery
Estrogen
treatment
was
not
found
to
prevent
intrauterine
adhesions
or
improve
reproductive
outcome
after
hysteroscopic
septal
resection
(Roy
et
al,
2014)
ABOUBAKR
MOHAMED
ELNASHAR

26. 
Conservative
therapy
In
young
women
who
did
not
complete
their
family:
-Postpartum
hge.
-Multiple
fibroid.
-Ovarian
cysts.
-Endometrial
carcinoma.
-Cervical
carcinoma.
-Ovarian
cancer.
ABOUBAKR
MOHAMED
ELNASHAR
3.
CONCLUSION
Prevention
of
female
infertility
I.
Age
1.
Stop
smoking
2.
Do
not
delay
childbearing
II.
Tubal
1.
Prevention
of
PID
2.
Prevention
of
adhesion
III.
Endometriosis
1.
Do
not
delay
child
bearing
2.
Prevention
of
adhesion
of
treatment
ABOUBAKR
MOHAMED
ELNASHAR

27. IV.
Ovarian
1.
MMR
vaccination
in
childhood
2.
Treatment
of
adolescent
PCOS
3.
Oocyte
or
ovarian
tissue
cryopreservation
before
chemotherapy
or
radiotherapy
4.
Avoidance
of
Environmental
Pollutants
V.
Uterine
1.
Prevention
of
IU
adhesions
2.
Conservative
treatment
in
young
women
ABOUBAKR
MOHAMED
ELNASHAR
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28. On
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page
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ABOUBAKR
MOHAMED
ELNASHAR
WHO,
2011
ABOUBAKR
MOHAMED
ELNASHAR

29. HOW
TO
PREVENT
INFERTILITY
1.
Educate
about
reproductive
health
and
age:
There
should
be
access
for
all
to
education
about
fertility
and
infertility
and
the
reduction
of
female
fertility
with
increasing
age.
2.
Educate
about
sex
and
birth
control:
Education
about
sexual
physiology,
sex
practices,
how
pregnancy
occurs
and
methods
of
birth
control
are
important
at
an
early
age.
With
knowledge
women
can
be
empowered
to
increase
their
chances
of
preventing
pregnancy
that
is
at
too
young
an
age
and/or
is
unwanted.
ABOUBAKR
MOHAMED
ELNASHAR
3.
Educate
about
healthy
lifestyle:
Lifestyle
factors
such
as
smoking,
under
nutrition,
chronic
high
stress
and
obesity
can
substantial
reduce
fertility.
Every
educational
approach
to
promote
healthy
living
should
clearly
address
the
effect
of
lifestyle
factors
on
fertility.
4.
Educate
and
practise
ethically:
A
critical
and
essential
aspect
of
providing
healthcare
is
to
know
how
to
and
to
practise
ethically.
This
is
often
challenging,
especially
in
reproductive
medicine,
because
of
different
values
and
forces
that
are
presented
by
society
and
its
customs,
patients
themselves,
and
the
healthcare
provider.
ABOUBAKR
MOHAMED
ELNASHAR

30. 5.
Prevent
HIV
and
STIs:
HIV
and
other
sexually
transmitted
infections
are
common,
preventable
causes
of
infertility.
Professionals
and
other
providers
in
fertility/infertility
programs
should
identify
and
liaise
with
other
professionals,
providers
and
organizations
that
are
involved
in
HIV
and
STI
education
and
prevention
to
coordinate
activities
that
help
prevent
the
transmission
of
HIV
and
STIs.
6.
Refer
for
safe
abortion:
Unsafe
abortion
can
cause
future
infertility.
Professionals
and
other
providers
in
fertility/infertility
programs
should
identify
and
liaise
with
other
professionals,
providers
and
organizations
provide
safe
abortion
to
coordinate
activities
that
help
all
women
receive
safe
abortion
services
when
needed.
ABOUBAKR
MOHAMED
ELNASHAR
7.
Promote
safe
pregnancy:
Every
wanted,
healthy
baby
born
to
a
healthy
mother
consolidates
a
family
and
reduces
unmet
fertility
desires.
Professionals
and
other
providers
in
fertility/infertility
programs
should
identify
and
collaborate
with
other
professionals,
providers
and
organizations
that
promote
safe
pregnancy.
8.
Promote
healthy
baby
and
mother
care:
Good
neonatal
care
and
healthy
motherhood
are
cornerstones
of
reproductive
health.
They
optimize
current
fertility
and
reduce
the
risk
of
future
infertility
and
childlessness.
Professionals
and
other
providers
in
fertility/infertility
programs
should
identify,
support
and
collaborate
with
other
professionals,
providers,
organisations
and
social
services
that
enable
and
enhance
neonatal
care
and
healthy
motherhood.
ABOUBAKR
MOHAMED
ELNASHAR

31. 9.
Practice
family
planning:
Preventing
unplanned
pregnancies
protects
future
fertility.
It
avoids
the
risk
associated
with
any
pregnancy
and
the
risk
of
unsafe
abortion.
Barrier
contraceptive
methods
protect
against
HIV
infection
and
STIs.
Education
programs
and
social
care
systems
should,
from
a
young
age,
offer
easy
and
accessible
information
on
the
many
benefits
of
preventing,
planning
(and
spacing)
pregnancies.
Education
that
enables
people
to
increase
the
chances
of
pregnancy
when
so
desired
and
to
prevent
pregnancy
when
so
desired
should
be
included
in
health
and
education
programs.
Safe
contraceptive
methods
should
be
available
to
all
sexually
active
men
and
women.
ABOUBAKR
MOHAMED
ELNASHAR
10.
Reduce
infertility
prevalence
by
prevention
and
education:
Infertility
is
largely
preventable.
General
education
and
health
care
prevention
strategies
can
substantially
reduce
the
prevalence
and
burden
of
infertility
which
affects
approximately
80
million
women
worldwide.
ABOUBAKR
MOHAMED
ELNASHAR

32. Prevention
Adopting
a
healthier
life
style
through
simple
lifestyle
changes
may
help
to
reduce
the
chances
of
infertility.
Life
style
changes
include:
(a)Weight
management
is
important
in
preventing
and
treating
infertility.
Women
who
are
overweight
or
underweight
ovulate
less
regularly
compared
to
women
of
a
healthy
weight.
Similarly
overweight
men
are
likely
to
have
reduced
fertility.
Therefore
maintain
a
healthy
weight
with
healthy
diet
and
exercise.
(b)Eat
a
balanced
diet
which
should
include
whole
grains,
pulses,
fresh
fruits
and
vegetables,
low
fat
milk
products.
Limiting
consumption
of
sugar,
alcohol,
caffeine,
no
smoking
including
passive
smoking
can
have
a
beneficial
impact
on
a
couple’s
ability
to
conceive.
(c)Participating
in
moderate
exercise
can
help
improve
menstrual
regularities
and
overall
health,
whereas
sometimes
excessive
exercise
can
disturb
menstrual
cycle
as
seen
in
competitive
athletes
practicing
intense
training
sessions.
(d)Making
time
for
leisure
and
enjoyment
is
a
healthy
step
to
lower
stress
levels
and
improves
physical
and
emotional
health.
(e)
Illegal
drugs
such
as
marijuana
or
cocaine
should
be
avoided
as
can
affect
fertility.
(f)
Practice
safe
sex-Sexually
transmitted
infections
(STIs),
such
as
chlamydia
and
gonorrhea,
are
leading
causes
of
infertility.
STIs
can
lead
to
blockage
of
fallopian
tubes,
prostatitis
and
other
problems
that
reduce
fertility.
(g)Age
and
fertility-
The
decision
to
have
a
baby
and
determining
the
right
time
to
start
a
family
is
a
highly
personal
choice.
However,
women
need
to
understand,
that
the
biological
clock
is
a
real
issue,
older
the
female
partner,
the
more
difficulty
a
couple
can
face
when
trying
to
get
pregnant.
ABOUBAKR
MOHAMED
ELNASHAR