Dr. Angel Nalbanski d.m., Obsterics and Gynecology

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Сашка Г.
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Виолета Н.

Expert in:

Endoscopic Surgery

In minimally invasive surgery, doctors use a variety of techniques to operate with less damage to the body than with open surgery. In general, minimally invasive surgery is associated with less pain, a shorter hospital stay and fewer complication

Endometriosis

Endometriosis is a condition where tissue similar to the lining of the uterus (the endometrial stroma and glands, which should only be located inside the uterus) is found elsewhere in the body.

Uterine Fibroid

Миомите са доброкачествени новообразувания на матката, произхождащи от мускулния слой. Независимо, че често ще чуете термина “ тумор”, това не е злокачествено заболяване (рак).

Polycystic Ovarian Syndrome

A variable disorder that is marked especially by amenorrhea, hirsutism, obesity, infertility, and ovarian enlargement and is usually initiated by an elevated level of luteinizing hormone, androgen, or estrogen which results in an abnormal cycle of gonadotropin release by the pituitary gland —abbreviation PCOS — called also polycystic ovary disease, polycystic ovary syndrome, polycystic ovary disease, Stein-Leventhal syndrome.

Infertility

Infertility is defined as not being able to get pregnant despite having frequent, unprotected sex for at least a year for most couples. Infertility may result from an issue with either woman or her partner, or a combination of factors that prevent pregnancy.

Useful information

Тук ще намерите полезна информация по различни теми, споделена от д-р Ангел Налбански.

News

Актуална информация за текущи събития и инициативи, в които д-р Ангел Налбански участва.

FAQ

ENDOMETRIOSIS

Endometriosis is a condition where tissue similar to the lining of the uterus (the endometrial stroma and glands, which should only be located inside the uterus) is found elsewhere in the body.

Endometriosis lesions can be found anywhere in the pelvic cavity: • on/in the ovaries

the fallopian tubes
on the pelvic side-wall (peritoneal implants)
the uterosacral ligaments,
the Pouch of Douglas
the rectal-vaginal septum (deep endometriosis)

In addition, it can be found in:

caesarian-section scars
laparoscopy/laparotomy scars
on the bladder
on the bowel
on the intestines, colon, appendix, and rectum.

These locations are not so common. In even more rare cases, endometriosis has been found inside the vagina, inside the bladder, on the skin, in the lung, spine, and brain.

The primary symptom of endometriosis is pelvic pain, often associated with menstrual periods. Although many experience cramping during their menstrual periods, those with endometriosis typically describe menstrual pain that's far worse than usual. Pain also may increase over time.

Common signs and symptoms of endometriosis include:

Painful periods (dysmenorrhea): Pelvic pain and cramping may begin before and extend several days into a menstrual period. You may also have lower back and abdominal pain.
Pain with intercourse: Pain during or after sex is common with endometriosis.
Pain with bowel movements or urination: You’re most likely to experience these symptoms during a menstrual period.
Excessive bleeding: You may experience occasional heavy menstrual periods or bleeding between periods (intermenstrual bleeding).
Infertility: Sometimes, endometriosis is first diagnosed in those seeking treatment for infertility.

Other signs and symptoms: You may experience fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods.

Treatment

Treatment for endometriosis usually involves medication or surgery. The approach you and your doctor choose will depend on how severe your signs and symptoms are and whether you hope to become pregnant. Doctors typically recommend trying conservative treatment approaches first, opting for surgery if initial treatment fails.

Pain medication

Your doctor may recommend that you take an over-the-counter pain reliever, such as the nonsteroidal anti- inflammatory drugs (NSAIDs) ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve) to help ease painful menstrual cramps.
Your doctor may recommend hormone therapy in combination with pain relievers if you're not trying to get pregnant.

Hormone therapy

Supplemental hormones are sometimes effective in reducing or eliminating the pain of endometriosis. The rise and fall of hormones during the menstrual cycle causes endometrial implants to thicken, break down and bleed. Hormone medication may slow endometrial tissue growth and prevent new implants of endometrial tissue.

Hormone therapy isn't a permanent fix for endometriosis. You could experience a return of your symptoms after stopping treatment.
Therapies used to treat endometriosis include:

Hormonal contraceptives. Birth control pills, patches and vaginal rings help control the hormones responsible for the buildup of endometrial tissue each month. Many have lighter and shorter menstrual flow when they're using a hormonal contraceptive. Using hormonal contraceptives — especially continuous-cycle regimens — may reduce or eliminate pain in some cases.

Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists. These drugs block the production of ovarian-stimulating hormones, lowering estrogen levels and preventing menstruation. This causes endometrial tissue to shrink. Because these drugs create an artificial menopause, taking a low dose of estrogen or progestin along with Gn-RH agonists and antagonists may decrease menopausal side effects, such as hot flashes, vaginal dryness and bone loss. Menstrual periods and the ability to get pregnant return when you stop taking the medication.

Progestin therapy. A variety of progestin therapies, including an intrauterine device with levonorgestrel (Mirena, Skyla), contraceptive implant (Nexplanon), contraceptive injection (Depo-Provera) or progestin pill (Camila), can halt menstrual periods and the growth of endometrial implants, which may relieve endometriosis signs and symptoms.

Aromatase inhibitors. Aromatase inhibitors are a class of medicines that reduce the amount of estrogen in your body. Your doctor may recommend an aromatase inhibitor along with a progestin or combination hormonal contraceptive to treat endometriosis.

Conservative surgery

If you have endometriosis and are trying to become pregnant, surgery to remove the endometriosis implants while preserving your uterus and ovaries (conservative surgery) may increase your chances of success. If you have severe pain from endometriosis, you may also benefit from surgery — however, endometriosis and pain may return.

Your doctor may do this procedure laparoscopically or, less commonly, through traditional abdominal surgery in more-extensive cases. Even in severe cases of endometriosis, most can be treated with laparoscopic surgery.
In laparoscopic surgery, your surgeon inserts a slender viewing instrument (laparoscope) through a small incision near your navel and inserts instruments to remove endometrial tissue through another small incision. After surgery, your doctor may recommend taking hormone medication to help improve pain.

Fertility treatment

Endometriosis can lead to trouble conceiving. If you're having difficulty getting pregnant, your doctor may recommend fertility treatment supervised by a fertility specialist. Fertility treatment ranges from stimulating your ovaries to make more eggs to in vitro fertilization. Which treatment is right for you depends on your personal situation.

Hysterectomy with removal of the ovaries

Surgery to remove the uterus (hysterectomy) and ovaries (oophorectomy) was once considered the most effective treatment for endometriosis. But endometriosis experts are moving away from this approach, instead focusing on the careful and thorough removal of all endometriosis tissue.
Having your ovaries removed results in menopause. The lack of hormones produced by the ovaries may improve endometriosis pain for some, but for others, endometriosis that remains after surgery continues to cause symptoms. Early menopause also carries a risk of heart and blood vessel (cardiovascular) diseases, certain metabolic conditions and early death.

Removal of the uterus (hysterectomy) can sometimes be used to treat signs and symptoms associated with endometriosis, such as heavy menstrual bleeding and painful menses due to uterine cramping, in those who don't want to become pregnant. Even when the ovaries are left in place, a hysterectomy may still have a long- term effect on your health, especially if you have the surgery before age 35.

Finding a doctor with whom you feel comfortable is crucial in managing and treating endometriosis. You may want to get a second opinion before starting any treatment to be sure you know all of your options and the possible outcomes.

What you can do

Your first appointment will likely be with either your primary care physician or a gynecologist. If you're seeking treatment for infertility, you may be referred to a doctor who specializes in reproductive hormones and optimizing fertility (reproductive endocrinologist).

Make a list of any symptoms you're experiencing. Include all of your symptoms, even if you don't think they're related.
Make a list of any medications, herbs or vitamin supplements you take. Include how often you take them and the doses.
Have a family member or close friend accompany you, if possible. You may get a lot of information at your visit, and it can be difficult to remember everything.
Take a notepad or electronic device with you. Use it to make notes of important information during your visit.
Prepare a list of questions to ask your doctor. List your most important questions first, to be sure you address those points.

If you, or someone you care about, has endometriosis, it is important to research the disease as much as possible. Many myths and misconceptions about endometriosis still persist, even in the medical literature. Endometriosis can be a challenging condition to manage. An early diagnosis, a multidisciplinary medical team and an understanding of your diagnosis may result in better management of your symptoms and improving quality of life.

ENDOSCOPIC SURGERY

In minimally invasive surgery, doctors use a variety of techniques to operate with less damage to the body than with open surgery. In general, minimally invasive surgery is associated with less pain, a shorter hospital stay and fewer complications.

Laparoscopy — surgery done through one or more small incisions, using small tubes and tiny cameras and surgical instruments — was one of the first types of minimally invasivesurgery.

Схема на мини-инвазивна хирургия

Another type of minimally invasive surgery is robotic surgery. It provides a magnified, 3-D view of the surgical site and helps the surgeon operate with precision, flexibility and control.

Хирургически робот Da Vinchi

Continual innovations in minimally invasive surgery make it beneficial for people with a wide range of conditions. If you need surgery and think you may be a candidate for thisapproach, talk with your doctor.

Gynecologists trained in minimally invasive gynecologic surgery specialize in evaluatingand treating women for:

endometrial polyps;

submucose fibroids;

Ashermann syndrome (intrauterine adjesions, synechia);

endometrial hyperplasia;

benign cysts of the ovary - folicular, luteal, dermoid, mucinous;

paraovarian cysts;

endometriosis;

Laparoscopically Assisted Vaginal Hysterectomy (LAVH);

Total Laparoscopic Hysterectomy (TLH);

infertility;

extrauterine pregnancy;

Salpingectomy (removal of the Fallopian tubes, usually before starting an IVF procedure);

endometrial cancer, cervical cancer.

Innovative treatment options

Your doctor will talk with you about a range of innovative treatment options and develop an individualized treatment plan that may involve one of these minimally invasive gynecologic approaches:

HYSTEROSCOPY - This technique does not require any incisions and has minimalrecovery time;
LAPAROSCOPY - This technique has been shown to be an effective treatment that results in shorter hospital stays, less discomfort and a shorter recovery period;
ROBOTIC SURGERY - This approach has the same advantages as advanced laparoscopy, and it allows surgeons to operate with increased precision and accuracy while minimizing trauma to surrounding tissues;
VAGINAL SURGERY - This is the most minimally invasive approach to major gynecologic surgery. It has all of the recovery advantages associated with laparoscopic.

UTERINE FIBROID

Uterine fibroids are noncancerous growths of the uterus that often appear during childbearing years. Also called leiomyomas or myomas, uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer.
Fibroids range in size from seedlings, undetectable by the human eye, to bulky masses that can distort and enlarge the uterus. You can have a single fibroid or multiple ones. In extreme cases, multiple fibroids can expand the uterus so much that it reaches the rib cage and can add weight.

Fibroids are generally classified by their location.

Intramural fibroids grow within the muscular uterine wall.

Submucosal fibroids bulge into the uterine cavity.

Subserosal fibroids project to the outside of the uterus.

SYMPTOMS

Many women who have fibroids don't have any symptoms. In those that do, symptoms can be influenced by the location, size and number of fibroids.
In women who have symptoms, the most common signs and symptoms of uterine fibroids include:

- Heavy menstrual bleeding

- Menstrual periods lasting more than a week - Pelvic pressure or pain

- Frequent urination

- Difficulty emptying the bladder

- Constipation

- Backache or leg pains

- Rarely, a fibroid can cause acute pain when it outgrows its blood supply, and begins to die.

DIAGNOSIS

Many women have uterine fibroids. You might not even know you have them, since they don’t always cause any symptoms.
You might not know you have them until you see your doctor. Since your doctor will press on your uterus during a pelvic exam, he/she may feel abnormal changes in the shape of your uterus that could be due to fibroids. If so, he/she’ll probably want you go get some tests to find out.

Ultrasound - This is usually the first kind of imaging test your doctor will order. It uses sound waves to take a picture of your uterus, and can show your doctor if you do have fibroids, where they are, and how big they are. During the test, a doctor or technician will take pictures of your uterus by either moving a device over your abdomen, or inserting it into your vagina.

Magnetic Resonance Imaging (MRI)

If the ultrasound didn’t provide enough information, your doctor may want you to get an MRI. It can also help your doctor figure out what kinds of different tumors you may have so they can decide which treatment is best.

TREATMENT
If you have uterine fibroids, you may or may not need treatment. It depends on whether they cause you any problems.
There are several possibilities that you and your doctor can consider.

Fibroid embolization can shrink a fibroid. Your doctor will inject polyvinyl alcohol (PVA) into the arteries that feed the fibroid. The PVA blocks the blood supply to the fibroid, which makes it shrink. It’s not surgery, but you may need to spend several nights in the hospital because you may have nausea, vomiting, and pain in the first few days afterward.

Endometrial ablation is a procedure in which doctors destroy the lining of uterus to cut down on the bleeding linked to small fibroids.

Myomectomy is a surgery to remove fibroids. If you plan to become pregnant, your doctor may recommend this over other procedures. You’ll need to wait 4 to 6 months after surgery before you try to conceive. In most women, symptoms go away following a myomectomy. But in others, the fibroids come back. Whether it works will partly depend on how many fibroids you have and whether the surgeon could remove them all.

A myomectomy may be achieved by abdominal surgery, or your surgeon may use a hysteroscope or laparoscope to remove the fibroids without having to make a large cut on your abdomen.

Hysterectomy is surgery to remove the uterus. Many women don’t need treatment that’s this drastic.

POLYCYSTIC OVARIAN SYNDROME

A variable disorder that is marked especially by amenorrhea, hirsutism, obesity, infertility, and ovarian enlargement and is usually initiated by an elevated level of luteinizing hormone, androgen, or estrogen which results in an abnormal cycle of gonadotropin release by the pituitary gland —abbreviation PCOS — called also polycystic ovary disease, polycystic ovary syndrome, polycystic ovary disease, Stein-Leventhal syndrome.

The exact cause of PCOS is unknown. Early diagnosis and treatment along with weight loss may reduce the risk of long-term complications such as type 2 diabetes and heart disease.

Symptoms:

Symptoms of PCOS may begin shortly after puberty, but can also develop during the later teen years and early adulthood. Because symptoms may be attributed to other causes or go unnoticed, PCOS may go undiagnosed for some time.
People with PCOS typically have irregular or missed periods as a result of not ovulating. Although some people may develop cysts on their ovaries, many people do not.

Other symptoms include:

Weight gain. About half of people with PCOS will have weight gain and obesity that is difficult to
manage.
Fatigue. Many people with PCOS report increased fatigue and low energy. Related issues such as
poor sleep may contribute to the feeling of fatigue.
Unwanted hair growth (also known as hirsutism). Areas affected by excess hair growth may
include the face, arms, back, chest, thumbs, toes, and abdomen. Hirsutism related to PCOS is due to
hormonal changes in androgens.
Thinning hair on the head. Hair loss related to PCOS may increase in middle age.
Infertility. PCOS is a leading cause of female infertility. However, not every woman with PCOS is
the same. Although some people may need the assistance of fertility treatments, others are able to
conceive naturally.
Acne. Hormonal changes related to androgens can lead to acne problems. Other skin changes such as
the development of skin tags and darkened patches of skin are also related to PCOS.
Mood changes. Having PCOS can increase the likelihood of mood swings, depression, and anxiety.
Pelvic pain. Pelvic pain may occur with periods, along with heavy bleeding. It may also occur when
a woman isn’t bleeding.
Headaches. Hormonal changes prompt headaches.
Sleep problems. People with PCOS often report problems such as insomnia or poor sleep. There are
many factors that can affect sleep, but PCOS has been linked to a sleep disorder called sleep apnea. With sleep apnea, a person will stop breathing for short periods of time during sleep.
Diagnosis:
There's no test to definitively diagnose PCOS. Your doctor is likely to start with a discussion of your medical history, including your menstrual periods and weight changes. A physical exam will include checking for signs of excess hair growth, insulin resistance and acne.
Your doctor might then recommend:
A pelvic exam. The doctor visually and manually inspects your reproductive organs for masses,
growths or other abnormalities.
Blood tests. Your blood may be analyzed to measure hormone levels. This testing can exclude
possible causes of menstrual abnormalities or androgen excess that mimics PCOS. You might have
additional blood testing to measure glucose tolerance and fasting cholesterol and triglyceride levels.
An ultrasound. Your doctor checks the appearance of your ovaries and the thickness of the lining of your uterus. A wandlike device (transducer) is placed in your vagina (transvaginal ultrasound). The
transducer emits sound waves that are translated into images on a computer screen.
If you have a diagnosis of PCOS, your doctor might recommend additional tests for complications. Those tests can include:
Periodic checks of blood pressure, glucose tolerance, and cholesterol and triglyceride levels
Screening for depression and anxiety
Screening for obstructive sleep apnea

There is no cure for polycystic ovary syndrome, but there are lifestyle and medical treatments to deal with the symptoms. You and your doctor should talk about what your goals are so you can come up with a treatment plan. For example, if you want to get pregnant and are having trouble, then your treatment would focus on helping you conceive. If you want to tame PCOS-related acne, your treatment would be geared toward skin problems.

Complications:

Complications of PCOS can include:

Infertility
Gestational diabetes or pregnancy-induced high blood pressure
Miscarriage or premature birth
Nonalcoholic steatohepatitis — a severe liver inflammation caused by fat accumulation in the liver
Metabolic syndrome — a cluster of conditions including high blood pressure, high blood sugar, and
abnormal cholesterol or triglyceride levels that significantly increase your risk of cardiovascular
disease
Type 2 diabetes or prediabetes
Sleep apnea
Depression, anxiety and eating disorders
Abnormal uterine bleeding
Cancer of the uterine lining (endometrial cancer)

Obesity is associated with PCOS and can worsen complications of the disorder.

INFERTILITY

Infertility is defined as not being able to get pregnant despite having frequent, unprotected sex for at least a year for most couples. Infertility may result from an issue with either woman or her partner, or a combination of factors that prevent pregnancy.

CAUSES OF MALE INFERTILITY These may include:

Abnormal sperm production or function due to undescended testicles, genetic defects, health
problems such as diabetes, or infections such as chlamydia, gonorrhea, mumps or HIV. Enlarged veins
in the testes (varicocele) also can affect the quality of sperm.
Problems with the delivery of sperm due to sexual problems, such as premature ejaculation; certain
genetic diseases, such as cystic fibrosis; structural problems, such as a blockage in the testicle; or
damage or injury to the reproductive organs.
Overexposure to certain environmental factors, such as pesticides and other chemicals, and
radiation. Cigarette smoking, alcohol, marijuana, anabolic steroids, and taking medications to treat bacterial infections, high blood pressure and depression also can affect fertility. Frequent exposure to heat, such as in saunas or hot tubs, can raise body temperature and may affect sperm production.
Damage related to cancer and its treatment, including radiation or chemotherapy. Treatment for cancer can impair sperm production, sometimes severely.
CAUSES OF FEMALE INFERTILITY Causes of female infertility may include:
Ovulation disorders, which affect the release of eggs from the ovaries. These include hormonal
disorders such as polycystic ovary syndrome. Hyperprolactinemia, a condition in which you have too much prolactin — the hormone that stimulates breast milk production — also may interfere with ovulation. Either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism) can affect the menstrual cycle or cause infertility. Other underlying causes may include too much exercise, eating disorders or tumors.
Uterine or cervical abnormalities, including abnormalities with the cervix, polyps in the uterus or the shape of the uterus. Noncancerous (benign) tumors in the uterine wall (uterine fibroids) may cause infertility by blocking the fallopian tubes or stopping a fertilized egg from implanting in the uterus.
Fallopian tube damage or blockage, often caused by inflammation of the fallopian tube (salpingitis). This can result from pelvic inflammatory disease, which is usually caused by a sexually transmitted infection, endometriosis or adhesions.
Endometriosis, which occurs when endometrial tissue grows outside of the uterus, may affect the function of the ovaries, uterus and fallopian tubes.
Primary ovarian insufficiency (early menopause), when the ovaries stop working and menstruation ends before age 40. Although the cause is often unknown, certain factors are associated with early menopause, including immune system diseases, certain genetic conditions such as Turner syndrome or carriers of Fragile X syndrome, and radiation or chemotherapy treatment.
Pelvic adhesions, bands of scar tissue that bind organs that can form after pelvic infection, appendicitis, endometriosis or abdominal or pelvic surgery.
Cancer and its treatment. Certain cancers — particularly reproductive cancers — often impair female fertility. Both radiation and chemotherapy may affect fertility.

DIAGNOSIS
Before infertility testing, you as a doctor must understand couple’s sexual habits, and you may make recommendations to improve their chances of getting pregnant. In some infertile couples, no specific cause is found (unexplained infertility)

Infertility evaluation can be expensive, and sometimes involves uncomfortable procedures. Some medical plans may not cover the cost of fertility treatment. Finally, there's no guarantee — even after all the testing and counselling — that you'll get pregnant.

Tests for men
Male fertility requires that the testicles produce enough healthy sperm, and that the sperm is ejaculated effectively into the vagina and travels to the egg. Tests for male infertility attempt to determine whether any of these processes are impaired.
Man may have a general physical exam, including examination of their genitals. Specific fertility tests may include:

Semen analysis. The doctor may ask for one or more semen specimens. Semen is generally obtained
by masturbating or by interrupting intercourse and ejaculating your semen into a clean container. A
lab analyzes your semen specimen. In some cases, urine may be tested for the presence of sperm.
Hormone testing. A blood test to determine the level of testosterone and other male hormones.
Genetic testing. Genetic testing may be done to determine whether there's a genetic defect causing
infertility.
Testicular biopsy. In select cases, a testicular biopsy may be performed to identify abnormalities
contributing to infertility or to retrieve sperm for assisted reproductive techniques, such as IVF.
Imaging. In certain situations, imaging studies such as a brain MRI, transrectal or scrotal ultrasound,
or a test of the vas deferens (vasography) may be performed.
Other specialty testing. In rare cases, other tests to evaluate the quality of the sperm may be
performed, such as evaluating a semen specimen for DNA abnormalities.

Tests for women
A general physical exam, including a regular gynecological exam. Specific fertility tests may include:

Ovulation testing. A blood test measures hormone levels to determine whether woman is ovulating.
Hysterosalpingography. Hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee) evaluates the

condition of the uterus and fallopian tubes and looks for blockages or other problems. X-ray contrast is injected into your uterus, and an X-ray is taken to determine if the cavity is normal and to see if the fluid spills out of the fallopian tubes.

Ovarian reserve testing. This testing helps determine the quantity of the eggs available for ovulation. This approach often begins with hormone testing early in the menstrual cycle.
Other hormone testing. Other hormone tests check levels of ovulatory hormones, as well as pituitary hormones that control reproductive processes.
Imaging tests. Pelvic ultrasound looks for uterine or ovarian disease. Sometimes a sonohysterogram, also called a saline infusion sonogram, is used to see details inside the uterus that are not seen on a regular ultrasound.

Depending on the situation, rarely the testing may include:

Hysteroscopy. Depending on your symptoms, the doctor may request a hysteroscopy to look for
uterine disease. During the procedure, the doctor inserts a thin, lighted device through the cervix into
the uterus to view any potential abnormalities.
Laparoscopy. This minimally invasive surgery involves making a small incision beneath the navel

and inserting a thin viewing device to examine fallopian tubes, ovaries and uterus. A laparoscopy may identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.

Not everyone needs to have all, or even many, of these tests before the cause of infertility is found.

TREATMENT
Infertility treatment depends on:

What's causing the infertility
How long you've been infertile
Your age and your partner's age
Personal preferences
Some causes of infertility can't be corrected.

In cases where spontaneous pregnancy doesn't happen, couples can often still achieve a pregnancy through use of assisted reproductive technology. Infertility treatment may involve significant financial, physical, psychological and time commitments.
MEN
Men's treatment for general sexual problems or lack of healthy sperm may include:

Changing lifestyle factors. Improving lifestyle and certain behaviors can improve chances for pregnancy, including discontinuing select medications, reducing or eliminating harmful substances, improving frequency and timing of intercourse, exercising regularly, and optimizing other factors that may otherwise impair fertility.
Medications. Certain medications may improve sperm count and likelihood for achieving a successful pregnancy. These medicines may increase testicular function, including sperm production and quality.
Surgery. For some conditions, surgery may be able to reverse a sperm blockage and restore fertility. In other cases, surgically repairing a varicocele may improve overall chances for pregnancy.
Sperm retrieval. These techniques obtain sperm when ejaculation is a problem or when no sperm are present in the ejaculated fluid. They may also be used in cases in which assisted reproductive techniques are planned and sperm counts are low or otherwise abnormal.

WOMEN
Some women need only one or two therapies to improve fertility. Other women may need several different types of treatment to achieve pregnancy.

Stimulating ovulation with fertility drugs. Fertility drugs are the main treatment for women who
are infertile due to ovulation disorders. These medications regulate or induce ovulation. Talk about
fertility drug options — including the benefits and risks of each type.
Intrauterine insemination (IUI). During IUI, healthy sperm are placed directly in the uterus around
the time the ovary releases one or more eggs to be fertilized. Depending on the reasons for infertility,
the timing of IUI can be coordinated with a normal cycle or with fertility medications.
Surgery to restore fertility. Uterine problems such as endometrial polyps, a uterine septum, intrauterine scar tissue and some fibroids can be treated with hysteroscopic surgery. Endometriosis, pelvic adhesions, and larger fibroids may require laparoscopic surgery or surgery with a larger
incision of the abdomen.
Assisted reproductive technology
Assisted reproductive technology (ART) is any fertility treatment in which the egg and sperm are handled. There are several types of ART.

In vitro fertilization (IVF) is the most common ART technique. IVF involves stimulating and retrieving multiple mature eggs, fertilizing them with sperm in a dish in a lab, and implanting the embryos in the uterus several days after fertilization.
Other techniques are sometimes used in an IVF cycle, such as:

Intracytoplasmic sperm injection (ICSI). A single healthy sperm is injected directly into a mature
egg. ICSI is often used when there is poor semen quality or quantity, or if fertilization attempts during
prior IVF cycles failed.
Assisted hatching. This technique assists the implantation of the embryo into the lining of the uterus
by opening the outer covering of the embryo (hatching).
Donor eggs or sperm. Most ART is done using a couple's own eggs and sperm. However, if there are
severe problems with either the eggs or the sperm, you may choose to use eggs, sperm or embryos
from a known or anonymous donor.
Gestational carrier. Women who don't have a functional uterus or for whom pregnancy poses a
serious health risk might choose IVF using a gestational carrier. In this case, the couple's embryo is placed in the uterus of the carrier for pregnancy.
COMPLICATIONS OF TREATMENT Complications of infertility treatment may include:
Multiple pregnancy. The most common complication of infertility treatment is a multiple pregnancy

— twins, triplets or more. Generally, the greater the number of fetuses, the higher the risk of premature labor and delivery, as well as problems during pregnancy such as gestational diabetes. Babies born prematurely are at increased risk of health and developmental problems.

Ovarian hyperstimulation syndrome (OHSS). Fertility medications to induce ovulation can cause OHSS, particularly with ART, in which the ovaries become swollen and painful. Symptoms may include mild abdominal pain, bloating, and nausea that lasts about a week, or longer if you become pregnant. Rarely, a more severe form causes rapid weight gain and shortness of breath requiring emergency treatment.
Bleeding or infection. As with any invasive procedure, there is a rare risk of bleeding or infection with assisted reproductive technology or reproductive surgery.

PREVENTION
Some types of infertility aren't preventable. But several strategies may increase the chances of pregnancy.

COUPLES
Have regular intercourse several times around the time of ovulation for the highest pregnancy rate. Intercourse beginning at least five days before and until a day after ovulation improves the chances of getting pregnant. Ovulation usually occurs in the middle of the cycle — halfway between menstrual periods — for most women with menstrual cycles about 28 days apart.
MEN
Although most types of infertility aren't preventable in men, these strategies may help:
• Avoid drug and tobacco use and drinking too much alcohol, which may contribute to male infertility. • Avoid high temperatures found in hot tubs and hot baths, as they can temporarily affect sperm

production and motility.
• Avoid exposure to industrial or environmental toxins, which can affect sperm production.
• Limit medications that may impact fertility, both prescription and nonprescription drugs. Talk with

your doctor about any medications you take regularly, but don't stop taking prescription medications

without medical advice.
• Exercise moderately. Regular exercise may improve sperm quality and increase the chances for

achieving a pregnancy. WOMEN

For women, a number of strategies may increase the chances of becoming pregnant:

Quit smoking. Tobacco has many negative effects on fertility, not to mention your general health and
the health of a fetus. If you smoke and are considering pregnancy, quit now.
Avoid alcohol and street drugs. These substances may impair your ability to conceive and have a healthy pregnancy. Don't drink alcohol or use recreational drugs, such as marijuana, if you're trying to
get pregnant.
Limit caffeine. Women trying to get pregnant may want to limit caffeine intake. Ask your doctor for
guidance on the safe use of caffeine.
Exercise moderately. Regular exercise is important, but exercising so intensely that your periods are
infrequent or absent can affect fertility.
Avoid weight extremes. Being overweight or underweight can affect your hormone production and
cause infertility.

Consulting

Д-р Ангел Налбански

Dr. Angel Nalbanski m.d. consults his patients in those areas:

GYNECOLOGY

Gynecological examination
Ultrasound diagnostics
Colposcopy and PAP smear (prevention of cervical cancer)
Microbiological examination of vaginal microflora
Consultations in the field of infertility (sterility, infertility)
Consultations in women with endometriosis, polycystic ovaries and menstrual disorders
Consultation and performance of gynecological operations:
- minimally invasive gynecological surgery (laparoscopy, hysteroscopy);
- conventional gynecological surgery;
- urogynecological surgery (correction of urine leakage);
- oncogynecological surgery (for cancers of the female genital organs).

OBSTETRICS

Consultations and examinations during pregnancy
Normal delivery
Operative delivery (Caesarean section)

ATTENTION: The examinations, consultations and manipulations in "Dr. Gunev" Medical Centre are paid. We do NOT work with referrals to the National Health Insurance Fund. We accept additional health insurance and issue the necessary documents for private health insurance funds. Payment at the medical centre is made in cash due to technical necessity.

Dr. Angel Nalbanski d.m.

Obstetrics and Gynecology

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