ANATOMY AND PHYSIOLOGY OF THE REPRODUCTIVE SYSTEM

The Male Reproduc�ve System

The male internal and external reproduc�ve organs

Male External Structures

Scrotum
The scrotum is a rugated, skin-covered, muscular pouch suspended from the perineum. Its func�ons are to support the testes and help regulate
the temperature of sperm.

Testes
The testes are two ovoid glands, 2 to 3 cm wide, that rest in the scrotum. Each tes�s is encased by a protec�ve white fibrous capsule and is
composed of a number of lob ules. Each lobule contains inters��al cells (Leydig cells) that produce testosterone and a seminiferous tubule that
produces spermatozoa.

Penis
The penis is composed of three cylindrical masses of erec�le �ssue in the penis sha�. The urethra passes through these layers of �ssue, allowing
the penis to serve as both the outlet for the urinary and reproduc�ve tracts in men.

Male Internal Structures

Epididymis
The seminiferous tubule of each tes�s leads to a �ghtly coiled tube, the epididymis, which is responsible for conduc�ng sperm from the tubule to
the vas deferens, the next step in the passage to the outside.

Vas Deferens (Ductus Deferens)

The vas deferens is an addi�onal hollow tube surrounded by arteries and veins and protected by a thick fibrous coa�ng, which, altogether, are
referred to as the sperma�c cord . It carries sperm from the epididymis through the inguinal canal into the abdominal cavity, where it ends at the
seminal vesicles and the ejaculatory ducts below the bladder.

Seminal Vesicles
The seminal vesicles are two convo luted pouches that lie along the lower por�on of the bladder and empty into the urethra by ejaculatory
ducts. These glands secrete a viscous alkaline liquid with a high sugar, protein, and prostaglandin content. Sperm become increasingly mo�le
because this added fluid surrounds them with a more favorable pH environment.

Prostate Gland
The prostate is a chestnut-sized gland that lies just below the bladder and allows the urethra to pass through the center of it, like the hole in a
doughnut. The gland’s purpose is to secrete a thin, alkaline fluid, which, when added to the secre�on from the seminal vesicles, further protects
sperm by increasing the naturally low pH level of the urethra.
Bulbourethral Glands
Two bulbourethral, or Cowper’s, glands lie beside the prostate gland and empty by short ducts into the urethra. They supply one more source of
alkaline fluid to help ensure the safe passage of spermatozoa.

Urethra
The urethra is a hollow tube leading from the base of the bladder, which, a�er passing through the prostate gland, con�nues to the outside
through the sha� and glans of the penis.

The Female Reproduc�ve System

The female external reproduc�ve organs.

Female External Structures

Mons Veneris
The mons veneris is a pad of adipose �s sue located over the symphysis pubis, the pubic bone joint. Covered by a triangle of coarse, curly hairs,
the purpose of the mons veneris is to protect the junc�on of the pubic bone from trauma.

Labia Minora
Just posterior to the mons veneris spread two hairless folds of connec�ve �ssue, the labia minora. Before menarche, these folds are fairly thin;
by childbearing age, they have become fi rm and full; and a�er menopause, they atrophy and again become much smaller.

Labia Majora
The labia majora are two folds of �ssue, fused anteriorly but separated posteriorly, which are posi�oned lateral to the labia minora and
composed of loose connec�ve �ssue covered by epithelium and pubic hair. The labia majora serve as protec�on for the external genitalia; they
shield the outlets to the urethra and vagina.

Ves�bule
The ves�bule is the flatened, smooth surface inside the labia. The openings to the bladder (the urethra) and the uterus (the vagina) both arise
from this space.

Clitoris
The clitoris is a small (approximately 1 to 2 cm), rounded organ of erec�le �ssue at the forward junc�on of the labia minora. It’s covered by a fold
of skin, the prepuce; is sensi�ve to touch and temperature; and is the center of sexual arousal and orgasm in a woman.

Skene and Bartholin Glands

Skene glands (paraurethral glands) are located on each side of the urinary meatus; their ducts open into the urethra.
Bartholin glands (vulvovaginal glands) are located on each side of the vaginal opening with ducts that open into the proximal vagina near the
labia minora and hymen. Secre�ons from both of these glands help to lubricate the external genitalia during coitus.

Fourchete
The fourchete is the ridge of �ssue formed by the posterior joining of the labia minora and the labia majora. This is the structure that some�mes
tears (lacera�on) or is cut (episiotomy) during childbirth to enlarge the vaginal opening.

Hymen
The hymen is a tough but elas�c semicircle of �ssue that covers the opening to the vagina during childhood. It is o�en torn during the �me of
first sexual intercourse.
 The female internal reproduc�ve organs An anterior view of female reproduc�ve organs showing the
rela�onship of the fallopian tubes and body of the uterus

Female Internal Structures

Ovaries
The ovaries are approximately 3 cm long by 2 cm in diameter and 1.5 cm thick, or the size and shape of almonds. They are grayish-white and
appear pited, with minute indenta�ons on the surface.

Fallopian Tubes
The fallopian tubes arise from each upper corner of the uterine body and extend outward and backward un�l each open at its distal end, next to
an ovary. Fallopian tubes are approximately 10 cm long in a mature woman. Their func�on is to convey the ovum from the ovaries to the uterus
and to provide a place for fer�liza�on of the ovum by sperm.
Uterus
The uterus is a hollow, muscular, pear-shaped organ located in the lower pelvis, posterior to the bladder and anterior to the rectum. The func�on
of the uterus is to receive the ovum from the fallopian tube; provide a place for implanta�on and nourishment; furnish protec�on to a growing
fetus; and, at maturity of the fetus, expel it from a woman’s body. Anatomically, the uterus consists of three divisions: the body or corpus, the
isthmus, and the cervix.
• The body of the uterus is the uppermost part and forms the bulk of the organ. The lining of the cavity is con�nuous with the fallopian
tubes, which enter at its upper aspects (the cornua). The por�on of the uterus between the points of atachment of the fallopian tubes is
termed the fundus. During pregnancy, the body of the uterus is the por�on of the structure that expands to contain the growing fetus.
• The isthmus is a short segment between the body and the cervix. In the nonpregnant uterus, it is only 1 to 2 mm in length. During
pregnancy, this por�on also enlarges greatly to aid in accommoda�ng the growing fetus. It is the por�on where the incision most
commonly is made when a fetus is born by a cesarean birth.
• The cervix is the lowest por�on of the uterus. It represents about one third of the total uterine size and is approximately 2 to 5 cm long.
This is an important rela�onship in es�ma�ng the level of the fetus in the birth canal at the �me of birth.

Vagina
The vagina is a hollow, musculo membranous canal located posterior to the bladder and anterior to the rec tum. It extends from the cervix of the
uterus to the external vulva. Its func�on is to act as the organ of intercourse and to convey sperm to the cervix. With childbirth, it expands to
serve as the birth canal.
MENSTRUATION

A menstrual cycle (the female reproduc�ve cycle) is episodic uterine bleeding in response to cyclic hormonal changes. The purpose of a menstrual
cycle is to bring an ovum to maturity and renew a uterine �ssue bed that will be necessary for the ova’s growth should it be fer�lized. The length
of menstrual cycles differs from woman to woman, but the average length is 28 days (from the begin ning of one menstrual fl ow to the beginning
of the next). It is not unusual for cycles to be as short as 23 days or as long as 35 days.

Characteris�cs of Normal Menstrual Cycles

Menopause
Menopause is the cessa�on of menstrual cycles. Perimeno pausal is a term used to denote the period during which menopausal changes are
occurring. Postmenopausal describes the period following the final menses. Climacteric refers to the total changes that occur at this life stage.
The age range at which menopause occurs is wide, between approximately 40 and 55 years, with a mean age of 51 years.
 Teaching About Menstrual Health

SEXUALITY
Sexuality is a mul�dimensional phenomenon that includes feelings, a�tudes, and ac�ons. It has both biologic and cultural diversity components.
It encompasses and gives direc�on to a person’s physical, emo�onal, social, and intellectual responses throughout life.

Biologic gender is the term used to denote a person’s chromosomal sex: male (XY) or female (XX).

Gender iden�ty or sexual iden�ty is the inner sense a person has of being male or female, which may be the same as or different from biologic
gender.

Gender role is the male or female behavior a person exhibits, which, again, may or may not be the same as biologic gender or gender iden�ty.
The Sexual Response Cycle
Excitement occurs with physical and psycho logical s�mula�on (sight, sound, emo�on, or thought) that causes parasympathe�c nerve
s�mula�on. This leads to arterial dila�on and venous constric�on in the genital area. The resul�ng increased blood supply leads to
vasoconges�on and increasing muscular tension. The vagina widens in diameter and increases in length. Breast nipples become erect. In men,
penile erec�on occurs, as well as scrotal thickening and eleva�on of the testes. In both sexes, there is an increase in heart and respiratory rate
and blood pressure.

Plateau stage is reached just before orgasm. In the woman, the clitoris is drawn forward and retracts under the cli toral prepuce; the lower part
of the vagina becomes extremely congested (forma�on of the orgasmic pla�orm), and there is increased breast nipple eleva�on. In men,
vasoconges�on leads to disten�on of the penis. Heart rate increases to 100 to 175 beats/min and respiratory rate to about 40 breaths/min.

Orgasm occurs when s�mula�on proceeds through the plateau stage to a point at which a vigorous contrac�on of muscles in the pelvic area
expels or dissipates blood and fluid from the area of conges�on. In men, muscle contrac�ons surrounding the seminal vessels and prostate
project semen into the proximal urethra. These contrac�ons are followed immediately by three to seven propulsive ejaculatory contrac�ons,
occurring at the same �me interval as in the woman, which force semen from the penis. As the shortest stage in the sexual response cycle,
orgasm is usually experienced as intense pleasure affec�ng the whole body, not just the pelvic area.

Resolu�on is a 30-minute period during which the external and internal genital organs return to an unaroused state. For the male, a refractory
period occurs during which further orgasm is impossible. Women do not go through this refractory period, so it is possible for women who are
interested and properly s�mulated to have addi�onal orgasms immediately a�er the first.

CONTRACEPTION
As many as 93% of women of childbearing age in the United States use some form of contracep�on (CDC, 2012). Major benefi ts of this increase
in contracep�on include decreases in unintended adolescent pregnancies, the need for “morning a�er” or postcoital medica�ons, and elec�ve
termina�ons of pregnancy.

An ideal contracep�ve should be:

• Safe
• Effec�ve
• Compa�ble with religious and cultural beliefs and personal preferences of both the user and sexual partner
• Free of bothersome side effects
• Convenient to use and easily obtainable
• Affordable and needing few instruc�ons for effec�ve use
• Free of effects (a�er discon�nua�on) on future pregnancies

Natural Family Planning

Natural family planning methods, also called periodic abs�nence methods, are, as the name implies, methods that involve no introduc�on of
chemical or foreign material into the body

Abs�nence, or refraining from sexual rela�ons, has a theore�cal 0% failure rate and is also the most effec�ve way to prevent STIs.

Lacta�on Amenorrhea Method As long as a woman is breas�eeding, there is both natural suppression of ovula�on and the return of menses.
Lacta�on amenorrhea method (LAM) is a safe birth control method (a failure rate of about 1% to 5%) if an infant is:
• Under 6 months of age
• Being totally breas�ed at least every 4 hours during the day and every 6 hours at night
• Receives no supplementary feedings, and
• Menses has not returned

Coitus interruptus (withdrawal) is one of the oldest known methods of contracep�on. The couple proceeds with co itus un�l the moment of
ejacula�on. Then the man with draws and spermatozoa are emited outside the vagina.

Fer�lity Awareness Methods

Fer�lity awareness methods rely on detec�ng when a woman will be capable of impregna�on (fer�le) so she can use periods of abs�nence
during that �me. There are a variety of ways to determine a fer�le period, such as using a calendar to calculate the period of �me based on a set
formula, using a visual tool such as “Cyclebeads,” measuring the woman’s body temperature, observing the consistency of cervical mucus, or
employing a combina�on of these methods.

Calendar (Rhythm) Method requires a couple to abstain from coitus on the days of a menstrual cycle when the woman is most likely to conceive.

Basal Body Temperature Method Just before the day of ovula�on, a woman’s basal body temperature (BBT), or the temperature of her body at
rest, falls about 0.5°F. At the �me of ovula�on, her BBT rises a full Fahrenheit degree (0.2°C) because of the rise in progesterone with ovula�on.
Cervical Mucus Method (Billing’s Method) Yet another method to predict ovula�on is to use the changes in cervical mucus that occur naturally
with ovula�on. Before ovula�on each month, the cervical mucus is thick and does not stretch when pulled between the thumb and finger. Just
before ovula�on, mucus secre�on increases. On the day of ovula�on (the peak day), it becomes copious, thin, watery, and transparent. It feels
slippery (like egg white) and stretches at least 1 inch before the strand breaks, a property known as spinnbarkeit.

Two-Day Method To use a two-day method, a woman assesses for vaginal secre�ons daily. If she feels secre�ons for 2 days in a row, she avoids
coitus that day and the day following as the presence of secre�ons suggests fer�lity.

The Symptothermal method of birth control combines the cervical mucus and BBT methods. The woman takes her temperature daily, watching
for the rise in temperature that marks ovula�on. She also analyzes her cervical mucus every day and observes for other signs of ovula�on such as
mitelschmerz (mid cycle abdominal pain) or if her cervix feels so�er than usual.

Standard Days Method: CycleBeads This method is designed for women who have menstrual cycles between 26 and 32 days. A woman
purchases a circle of beads that helps her predict fer�le days.

Barrier Methods of Contracep�on

Barrier methods are forms of birth control that place a chemical or latex barrier between the cervix and advancing sperm so sperm cannot reach
and fer�lize an ovum.

Spermicide is an agent that causes the death of spermatozoa before they can enter the cervix. Such agents are not only ac�vely spermicidal but
also change the vaginal pH to a strong acid level, a condi�on not conducive to sperm survival.

Condom is a latex rubber or synthe�c sheath that is placed over the erect penis before coitus to trap sperm. Male condoms have an ideal failure
rate of 2% and a true failure rate of about 15%, because breakage or spillage occurs in up to 15% of uses.

Diaphragm is a circular rubber disk that is placed over the cervix before intercourse to mechanically halt the passage of sperm. Although use of a
spermicide to coat a diaphragm is not required, using a spermicidal gel with one combines a barrier and a chemical method of contracep�on so
one is usually added.

Cervical cap is made of so� rubber shaped like a thimble, which fits snugly over the uterine cervix. Many women cannot use cervical caps
because their cervix is too short for the cap to fi t properly. Like diaphragms, they must be fited individually by a health care provider.
Hormonal Contracep�on
Hormonal contracep�ves are, as the name implies, hormones that when taken orally, transdermally, intravaginally, or intramuscularly, cause
such fluctua�ons in a normal menstrual cycle that ovula�on or sperm transport does not occur.

Combina�on Oral Contracep�ves Oral contracep�ves, commonly known as the pill, OCs (for oral contracep�ve), or COCs (for combina�on oral
contracep�ves), are composed of varying amounts of natural estrogen (17 -estradiol, estradiol valerate) or synthe�c estrogen (ethinyl estradiol)
combined with a small amount of synthe�c progesterone (proges�n). The estrogen acts to suppress follicle-s�mula�ng hormone (FSH) and LH to
suppress ovula�on. The progesterone ac�on causes a de crease in the permeability of cervical mucus and so limits sperm mo�lity and access to
ova.

Proges�n-Only Pills (Mini-Pills) Oral contracep�ves containing only proges�ns are popularly called mini-pills and, like combina�on types, must
be taken conscien�ously every day. Without estrogen content, ovula�on may occur, but because the proges�ns have not allowed the
endometrium to develop fully or sperm to freely access the cervix, fer�liza�on and implanta�on will not take place.

Estrogen/Progesterone Transdermal Patch refers to patches that slowly but con�nuously release a combina�on of estrogen and progesterone.
Patches are applied each week for 3 weeks. No patch is applied the fourth week. During the week on which the woman is patch free, a menstrual
flow will occur. A�er the patch-free week, a new cycle of 3 weeks on, 1 week off begins again.

Vaginal Estrogen/Proges�n Rings (NuvaRing) is a flexible silicone vaginal ring that, when placed around the cervix, con�nually releases a
combina�on of estrogen and progesterone (Fig. 6.10). The ring is inserted vaginally by the woman and le� in place for 3 weeks, then removed for
1 week with menstrual bleeding occurring during the ring-free week.

Subdermal Hormone Implants A proges�n-filled miniature rod no bigger than a matchs�ck ( Implanon ) can be embedded just under the skin on
the inside of the upper arm where it will slowly release proges�n over a period of 5 years.

Intramuscular Injec�ons A single intramuscular injec�on of depot medroxyprogesterone acetate (DMPA), a progesterone given every 12 weeks,
inhibits ovula�on, alters the endometrium, and thickens the cervical mucus so sperm progress is difficult. The effec�veness rate of this method is
almost 100%, making it an increasingly popular contracep�ve method.

Intrauterine Devices is a small plas�c device that is inserted into the uterus through the vagina. Although a popular choice worldwide because
they are almost 100% effec�ve and need no memory aide, IUDs are used by only a rela�vely small number of U.S. women.
Vasectomy a small puncture wound (referred to as “no scalpel technique) is made on the scrotum. The vas deferens on each side are then pulled
forward, cut and �ed, cauterized, or plugged, blocking the passage of spermatozoa

Tubal Liga�on Steriliza�on of women could include removal of the uterus or ovaries (hysterectomy), but it usually refers to a minor surgical
procedure, such as tubal liga�on, where the fallopian tubes are occluded by cautery, crushed, clamped, or blocked, thereby preven�ng passage
of both sperm and ova.

PRECONCEPTION CLASSES
Preconcep�on classes are held for couples who plan to get pregnant within a short �me and want to know more about what they can expect
pregnancy to be like and what birth set �ng and procedure choices exist. These classes stress that pre nancy brings with it psychological as well
as physical changes and include recommended preconcep�on nutri�on modifica�ons such as a good intake of folic acid (e.g., green leafy
vegetables) and protein (e.g., meat, tofu, beans) and perhaps a prenatal vitamin during the �me wai�ng to get pregnant to ensure a healthy
fetus.

SIGNS OF PREGNANCY
Weekly Developmental Milestones in Pregnancy

First Trimester

Month 1 (weeks 1-4): As the fer�lized egg grows, a water �ght sac forms around it, crea�ng the amnio�c sac. Placenta develops. A primi�ve face
is formed. The heart tube develops.

Month 2 (weeks 5-8): Facial features con�nue to develop. The neural tube is well formed. At 6 weeks, the heartbeat can be detected via
ultrasound.

Month 3 (weeks 9-12): A�er the 8th week, the developing baby is referred to as the fetus instead of the embryo. Hands, arms, fingers, feet and
toes are fully developed–they will start to explore by opening and closing their fists and mouth. By the end of the third month, the fetus is fully
formed–all organs and limbs are present and will con�nue to develop to become func�onal.

Second Trimester
Month 4 (weeks 13-16): The fetal HR is now audible with a doppler (first heard as early as 10 weeks, but now consistently is heard). Facial
features develop and the nervous system is star�ng to func�on.

Month 5 (weeks 17-20): Fetus is developing muscles and is exercising, hair and lanugo begin to develop, the skin becomes coated with vernix
caseosa.

Month 6 (weeks 21-24): Eyelids begin to open, the fetus responds to movement or increased maternal HR. If born prematurely, the baby may
survive if born a�er 23 weeks (there is o�en a VERY long NICU stay).

Month 7 (weeks 25-28): The fetus begins to develop body fat and hearing is fully developed. The fetus changes posi�on frequently and will
respond to s�muli (sound, pain and light). The fetus is likely to survive if born a�er the seventh month.
Third Trimester
Month 8 (weeks 29-32): Kicking increases and there is rapid brain development. The fetus can see and hear.

Month 9 (weeks 33-36): The lungs complete lung development is this stage. There are coordinated reflexes and the fetus becomes even more
responsive to s�muli.

Month 10 (weeks 37-40): The final month!! Labor can happen any �me during this stage. Movement decreases as space becomes �ghter in the
womb. If not in the right posi�on, the provider will discuss changing the fetal posi�on prior to delivery.

Nutri�on in Pregnancy
Foods to avoid in pregnancy

● Fish high in mercury.

● Cold deli meats, lox, hot dogs
● Raw meat and eggs
● Unpasteurized dairy products
● Pate or liver
● Unwashed produce
● Caffeine–no more than 200 milligrams per day
● Alcohol

Drugs to Avoid in Pregnancy

● NSAIDs–aspirin, Ibuprofen, Advil, Motrin

● ACE Inhibitors and ARBS
● Sulfonamide and Fluoroquinolone an�bio�cs
● Ciprofloxacin, Levofloxacin, Bactrim (trimethoprim-sulfamethoxazole)
● Chloramphenicol
● Codeine
● Warfarin
● Benzodiazepines
● Clonazepam, Lorazepam, etc.
● Isotre�noin-Bismuth subsalicylate (Pepto-Bismol)
● Castor Oil-Mineral oil
● Cigaretes
● Marijuana
● Illicit drugs (Cocaine, Heroin, Crack, Methamphetamine, Fentanyl, etc.)
Antepartum Tes�ng

Blood type and Rh Factor

● Important to know the mother's blood type and if they is Rh posi�ve or nega�ve.
● If the mother is Rh nega�ve, and the baby is Rh posi�ve, this is considered a ‘set up’ and puts the infant at risk for erythroblastosis fetalis.
● Further tes�ng needed if this is the case - a�er the baby is born.
○ Direct Coombs test
■ Performed on the newborn's blood sample
○ Indirect Coombs test
■ Performed on the mother’s blood sample ● Treatment = Rhogam

Glucose Challenge

Oral Glucose Tolerance Test

● Done at 28 weeks
● Mother drinks 50 grams of glucose in an oral solu�on
● 1 hour later her blood sugar is checked.
● If the BG is greater than 140, the 3 hours glucose test is performed.

3 hour Glucose Tolerance Test

● Done if the 1 hour test is failed or there are other risk factors.
● It is done fas�ng; mothers must not eat or drink for 8 hours prior to the test.
● A fas�ng sugar is checked
● The mother drinks 100 grams of oral glucose.
● Her BG is rechecked a 1 hour, 2 hours, and 3 hours

Nonstress Test (NST)

● This test assesses fetal well-being and oxygena�on of the placenta

● Evaluates if there are changes in the fetal heart rate with movement
○ Increase in fetal heart rate with movement = accelera�on = good
○ Decrease in fetal heart rate with movement = decelera�on = bad
 ■ This is a sign that the fetus will not tolerate labor.
● Results
○ Reac�ve
■ There are at least two accelera�ons of 15 beats per minutes for 15 seconds in a 20 minute period.
○ Non-Reac�ve
■ There are NOT at least two accelera�ons of 15 beats per minutes for 15 seconds in a 20 minute period.
● Further tes�ng required if result is non-reac�ve

Contrac�on Stress Test

● Preformed when the non-stress test is non-reac�ve.

● Oxytocin is administered to induce contrac�ons and the baby is monitored to
evaluate their response to contrac�ons.
● Checking to see if the baby will tolerate labor, or show signs of stress.
● Results
○ Nega�ve
■ Normal
■ The baby did not have decelera�ons in response to contrac�ves
○ Posi�ve
■ Bad
■ The baby had decelera�ons indica�ng distress in response to contrac�ons.

Fetal Heart Rate Monitoring

Variability Fluctua�on in the fetal heart rate

Accelera�on A speeding up of the fetal heart rate

Decelera�on A slowing down of the fetal heart rate

Reassuring The baby looks healthy!

Non-reassuring Something is wrong with the baby

 Fetal Heart Rate Paterns and Causes

Reassuring Non-Reassuring
Baseline heart rate in the normal range: 110-160 Fetal tachycardia - HR >160 ; Fetal bradycardia - HR <110

Moderate variability Decreased variability

Accelera�ons Variable decelera�ons ; Late decelera�ons
Common Complaints of Pregnancy
High Risk Pregnancy Condi�ons

Hyperemesis Gravidarum
Preeclampsia
Gesta�onal Diabetes
Ectopic Pregnancy