Infertility

Infertility affects one in six couples. As well as medical conditions such as Polycystic Ovaries and Endometriosis, there are numerous lifestyle factors that can affect a couple’s chance of conceiving (e.g. smoking, inadequate diet, excess intake of caffeine). When couples are trying to conceive, 80% will be pregnant after one year and 90% after two. If you are having trouble conceiving we will need to look at your hormones, the patency of your fallopian tubes and your partner’s sperm. These investigations are usually completed in 3-4 weeks and we can then discuss your further management which may include waiting for natural conception, induction of ovulation, surgery for Endometriosis or referral to a specialist fertility unit, Fertility First (see Affiliations)

Back to top.

Endometriosis

Endometriosis is a condition where endometrium, the tissue which normally lines the uterus, is found outside the uterus, usually in the pelvis behind the uterus. This can result in irritation, inflammation and scaring in the pelvis. The abnormal endometrium slowly grows and causes scarring. If it is present on the ovaries it may lead to cyst formation in the ovary.

Endometriosis is a common condition that affects 5-10% of women at some stage during their menstruating years and increases with age. It is one of the leading causes of infertility in women and 25-50% of infertile women will have some degree of Endometriosis. Endometriosis reduces the chance of pregnancy by altering the endometrium in the uterus so that it is less likely for the fertilised egg to implant and continue developing. This effect is due to the release of inflammatory factors by the abnormally sited endometrium. It doesn’t appear to stop fertilisation of the egg or increase the rate of miscarriage although this is an area of some controversy at present.

Classically the symptom associated with Endometriosis is pelvic pain, particularly with periods and intercourse. This is more likely if the pain is a new development, i.e. wasn’t there before. It may also cause changes in the menstrual cycle, particularly heavier periods and pre- and postmenstrual spotting. However, many women with fertility problems will have no symptoms at all – other than the difficulty falling pregnant.

The only way to diagnose Endometriosis with certainty is to have a laparoscopy (see below for more information). A laparoscopy is performed under general anaesthesia and a fine telescope is inserted through a 10mm incision in your navel and another instrument inserted through a 10mm incision just below your pubic hair line. If you have Endometriosis present it will be removed at the time unless it is very extensive. If it is extensive and particularly if it involves the bowel, we would need to operate at a later date after preparing your bowel prior to surgery. This is done because there is an increased risk of injury to the bowel in these circumstances and it is important both to prepare the bowel and to discuss the risks more fully before proceeding with the surgery.

It is a commonly held belief that a normal pelvic ultrasound scan rules out the diagnosis of Endometriosis. Unfortunately this is not true. Ultrasound will only pick up Endometriosis if it has caused a cyst in one or both ovaries. If there is an endometriotic cyst detected in an ovary, research shows that there is a 90% chance of there being Endometriosis present elsewhere in the pelvis. Endometriotic cysts (also called endometriomas) can usually be removed at laparoscopy as well.

A number of hormones have been used to treat Endometriosis and so avoid having surgery (oral contraceptive pill, progesterone, pituitary suppression, Danazole, Mirena IUD). The studies on the different agents clearly show that they are all similar in their effectiveness in controlling the symptoms of Endometriosis so it is best to use the simplest drug with the fewest side effects. There is a lot of debate in the medical literature about whether surgery or drug therapy is better. My view is that the hormonal treatment can sometimes control the symptoms (heavy periods, period pain) but that it will not cure significant Endometriosis. The other problem with hormonal treatment is that it usually prevents pregnancy and is therefore not helpful if the main issue is fertility. If all visible Endometriosis is removed at surgery there is an 80% chance of cure and, if it does recur, in my experience it comes back in 2-3 years at different sites and can be successfully removed again.

Back to top

Colposcopy

While a pap smear samples cells from the cervix it doesn't always show conclusively what is happening on the cervix. Abnormal cells in the pap smear usually mean an underlying abnormality in the skin of the cervix. A small number of women with abnormal pap smears will develop cancer of the cervix if left untreated for a long time (10-15 years). Prompt assessment and treatment will usually mean a simple treatment to remove the abnormal tissue will prevent it developing into cancer.

Women with an abnormal pap smear need to have a colposcopy to determine what is happening to their cervix. The colposcope is a low power microscope which is used to examine the cervix more closely. Colposcopy is performed in the rooms and the cervix is washed with a weak solution of acetic acid (the acid in vinegar) which stains the abnormal cells on the cervix white. This identifies the area(s) from which the abnormal cells on the pap smear are coming and a small biopsy is taken. This is sent off to the pathologist for diagnosis. At most visits I will be able to give you a good idea of what this diagnosis is likely to be and what further treatment will be required. Overall the process takes 5-10 minutes, is uncomfortable (like a pap smear) but more invasive of your personal space. However, it is important to realise that the alternative, avoidance, does put you at risk of later developing cancer of the cervix.

Further treatment will be organised after the results from the pathologist are received. The treatment involves shaving off the abnormal area of the cervix, either under local anaesthetic or light general anaesthesia as day surgery if preferred. The piece of tissue is sent off to the pathologist to ensure that all the abnormal cells have been removed. Close follow up with Pap smears and colposcopy is required for two years following treatment but the risk of a recurrent abnormality is less than 5% if all the abnormal cells are removed at the first procedure.

Back to top

Vulval Disorders

Problems with the skin on the vulva (the area of skin around the entrance to the vagina) affect some women, usually causing pain or itch which may be severe and disabling. These problems become more common after women pass through their menopause. Some of these problems are simple e.g. thrush or hormone deficiency, while others, such as eczema or psoriasis, are more difficult to diagnose and treat.

I have a particular interest in these conditions and ran a specialised service at St George Hospital for several years. I am regularly referred difficult problems of this nature by other gynaecologists in the St George area. Effective treatment of these problems requires thorough investigation and close monitoring to ensure a successful outcome. Most women will get a marked improvement in symptoms with time but may need long term follow-up and therapy.

Back to top

Bleeding in early pregnancy

Bleeding in early pregnancy is a common problem and there are usually no consequences for the pregnancy. Sometimes, however, it can mean there will be a miscarriage or, less commonly, an ectopic pregnancy (pregnancy outside the womb (uterus), usually in the fallopian tube). The only way to be certain is to have an ultrasound scan which will detect a heart beat in the fetus from between 6 and 7 weeks of pregnancy. However, when we are calculating dates, we count from the first day of your last period, and assume that you conceived two weeks after that date. That may not be so in all pregnancies, particularly if you have an irregular menstrual cycle.

What happens if you bleed before six weeks?

Bleeding at the time of your first missed period is called implantation bleeding and is quite common. Whether it is due to the embryo implanting or not is uncertain, but it happens around the time that implantation is taking place. A blood test for your HCG (pregnancy hormone) and progesterone (pregnancy-maintaining hormone) can be helpful in this situation. If the HCG is at the expected level for your stage in pregnancy (there is a wide range of normal values) and the progesterone is 45 or greater, there is a 90% chance that your pregnancy will continue. If either hormone is less than expected then there is a 50:50 chance that you will lose the pregnancy. The HCG rises very quickly and should double within 48 hours in a healthy pregnancy so a repeat test will confirm this. A smaller rise means that you are more likely to lose the pregnancy or that it is an ectopic pregnancy.

What if the heart beat is present?

Once the fetal heart beat has been seen on an ultrasound scan and is a normal rate (100 beats per minute or greater), there is a 95% chance that the pregnancy will continue, even if you are still bleeding. Once you get to 10-12 weeks of pregnancy with a live fetus the risk of miscarriage is less than 2%. However, because it is stressful when you bleed and continue bleeding in early pregnancy, I suggest you come for weekly scans till 12 weeks to reassure you and make it more bearable.

What are the causes of miscarriage?

Most times the cause is not obvious. The risk of miscarriage increases with maternal age (50% in women over 40) and paternal age. In these instances the miscarriage is most likely to be caused by a genetic problem in the fetus (e.g. Down Syndrome). Other medical conditions in women such as polycystic ovarian syndrome and thyroid disease increase the chance of miscarriage, although the cause is uncertain.

In men, damage to the DNA in sperm also leads to a higher miscarriage rate and the importance of this is that the problem can often be fixed by modifying lifestyle factors alone (for more information see www.fertilityfirst.com.au)

Do you need to have a curette?

If your pregnancy is no longer viable, then as long as the bleeding is not heavy or too painful it is safe to wait, as most studies show that two out of three women will completely miscarry by themselves without needing further treatment. The difficult part is waiting for it to happen, knowing that the fetus has died. This can take two to three weeks and is less likely to happen by itself if your cervix is still closed and the sac is still present (this is called a missed miscarriage). There is a small risk of infection but, in practice, this is very unlikely.

The alternative is to have a curette (or D & C, dilatation and curette) which is a short surgical procedure performed under a general anaesthetic as a day case. The neck of the womb (cervix) is dilated and a plastic catheter is inserted into the uterus and the contents are removed and may be sent off for further testing or discarded. As with any surgery, there are risks with this procedure, although the risk is low and it is usually straightforward and quick.

What if you've had more than one miscarriage?

Because miscarriages are common (about 20% of pregnancies), most doctors will not recommend further investigations until you have had three or more pregnancy losses. The investigations are mostly blood tests and are expensive. If you are older (35 or more) it may be sensible to think about doing the testing after two pregnancy losses as you have less time to spare. I am happy to discuss this with you.

What treatment is available?

Sadly, very little. Intensive monitoring in early pregnancy (weekly visits with ultrasound scans) has been shown to improve success rates and will help you to cope. One of the uncommon causes of repeated miscarriage is a clotting abnormality (detected by the investigations) and this may be treated by daily doses of low dose aspirin and heparin (a blood thinning agent which can only be injected).

Should you give up?

Only you and your partner can decide this. The statistics are on your side. In young women (25-29) the chance of having a healthy pregnancy is 55% even after four pregnancy losses. The success rate decreases with age but it is also important that you don't stop too soon and later regret not 'giving it your best shot'..

Where can you get help?

If you are bleeding and concerned, please ring me at my rooms or page me after hours (ph. 9214 1015). If you don't have private insurance, there is an Early Pregnancy Assessment Service at St George Hospital which runs daily from 8.30-9.00am in the Women's Health Clinic for women with problems in early pregnancy. If it is more urgent, you will need to go to your local Emergency Department.

If your problem is repeated miscarriage please come and see me prior to getting pregnant where possible, so that we can organise any necessary investigations and discuss how we will manage your next pregnancy.

There is no public clinic in the St George/Sutherland area although we hope to establish one in the next 12-18 months if funding becomes available.

Useful websites:

www.miscarriageassociation.org.uk

www.miscarriage.com.au

Back to top

Vaginal Health

Vaginal infections are one of the most common reasons for women seeking gynaecological advice. Normally the vagina is kept healthy by bacteria (Lactobacilli) that make the vagina more acid and resistant to infection. The Lactobacilli metabolise glycogen in the epithelial cells of the vaginal skin and produce acids, natural antibacterials and hydrogen peroxide which produce a normal vaginal pH 4-4.5.

Vaginal Infections

Most vaginal infections are either due to Thrush (Candidiasis) or Bacterial Vaginosis (BV). Most times the cause is clear from the differing symptoms between the two (see table below)

Thrush

Thrush is a vaginal infection with microscopic fungi or yeast (Candida) and 75% of women will have vaginal thrush at least once in their lives. Hormonal changes such as pregnancy or treatment with antibiotics make infections with thrush more likely. Treatment is often incomplete and 5-8% of women will have 'recurrent candidiasis', which is defined as more than four episodes a year.

Most women know the simple measures to avoid thrush – wear cotton underwear, avoid tight clothing and using soaps or antibacterial washes on the area and reduce sugar and yeast intake in food and drinks.

Probiotics like acidophilus have been around for many years, recommended by naturopaths and other alternative practitioners and used by many women but with very little scientific evidence of their benefit. Because they are a natural product, many women feel more comfortable using them rather than an antifungal. Recently, Blackmores released a new probiotic, Women's Bio Balance™, which contains large numbers of Lactobacilli. This has been tested scientifically and shown to increase numbers of Lactobacilli in the vagina and improve the successful cure rate for women treated for thrush.

In most cases of thrush the infecting organism is Candida albicans but occasionally it can be other species of Candida. The importance of this is that these other species are often more resistant to usual medications for treating thrush like Canesten™ or Nilstat™.



The infecting organisms in women who get repeated infections are also often more resistant and this is one of the main reasons that women get recurrent candidiasis.

Thrush is best treated initially with an antifungal like Canesten or Nilstat together with oral Diflucan™ tablet which will eradicate the Candida from the bowel. I also recommend starting Bio Balance, two tablets daily for two weeks, then one tablet daily for three months. Pessaries (tablets inserted vaginally) are less messy and often more effective than cream. Canesten pessaries come in one, three and six nights. The single dose is usually curative for an initial infection but six nights are more likely to be successful in recurrent candidiasis and particularly in pregnancy.

Your partner doesn't need to be treated unless he has symptoms – redness and/or tenderness on his penis – or you have recurrent candidiasis (see below). You should not have sex (vaginal or oral) until you are completely better.

Recurrent candidiasis can be a tedious, debilitating condition. Often by the time that women come to see me they are so confused by what is happening to them – what makes it worse, what helps, what medications they have tried, etc., that it takes some time to go through the history and work out a plan of treatment. Many find that it recurs after sex or periods, and that they are never without a slight tingling feeling. It is very common in pregnancy where it can be troublesome because most women try and avoid medications when they're pregnant. Most women with this condition have tried many different measures including body washes, Vaseline™, antifungals, steroid creams, probiotics, various diets and the common measures like wearing cotton underwear and loose fitting clothes. Most also feel that they are 'unclean' although my impression is that most of them are more obsessive about vulval cleansing than is normal.

The underlying problem in recurrent candidiasis is most often a failure to completely eradicate the thrush, leading to a long term, low level infection, often with a relatively resistant organism which is reactivated by sex, periods, wet swimming costumes, antibiotics, etc. This is one of the main reasons that vaginal swabs are often negative in this condition – at the time the swab is taken the number of organisms is low and therefore not detected by the swab. I always take a swab and, if it is positive it is helpful, but a negative swab doesn't either prove or disprove that the underlying cause is thrush.

I think you need to be supervised in the treatment because many women have 'lost the plot' by this stage and need guidance. It is also important to ensure that the problem is thrush. Other conditions that can cause vulval itching/soreness are inflammatory skin conditions like eczema and psoriasis, chemical irritation, menopausal changes and viral infections like Herpes.

My usual treatment plan is:

1. Stop using all vaginal/vulval soaps, shower gels, cleansers, perfumes and simply use warm water and gently dry after washing.
2. Take one oral Diflucan tablet
3. Use Boric Acid pessaries 600mg nightly for 14 nights (see below)
4. Take two Bio Balance tablets daily for 14 days then one tablet daily for 6 months or indefinitely
5. Start a low sugar, low yeast diet (see below)
6. Your partner should take an oral Diflucan tablet and use an antifungal cream if he has penile redness or tenderness
7. No sex until you're cured

Boric Acid is used because the organisms are more sensitive to this. Unfortunately it has to be made up at a compounding pharmacy but these are widely available. If you want more information about dietary measures for treating thrush I recommend you contact: www.shepherdworks.com.au and they will do a consultation by phone or Skype.

I find women with recurrent candidiasis need close follow up to reinforce the treatment and deal with any problems. One of the other problems that develops is that the skin of the vulva becomes very sensitive because of recurrent infection and, often, excessive cleansing. This can make the diagnosis tricky and there is often some trial and error to see what is effective.

Bacterial Vaginosis (BV)

This is usually a much simpler condition to treat. The diagnosis is made on the basis of the symptoms (see table above) and vaginal swabs will show 'clue cells' – vaginal skin cells studded with the organisms (see picture below).



Clue cells – vaginal epithelial cells that have bacteria sticking to their surface, obscuring their borders, and giving them a stippled appearance.

The most prominent and distressing symptom is usually the smell which is described as "fishy" (or worse!). The treatment is oral Flagyl™ for 3-5 days or intravaginal clindamycin cream (Dalacin-V™) daily for 7 nights. I tend to use the Flagyl for first infections and the cream if it has been treated before or the infection has been present for a while. Studies have shown that Bio Balance also improves the rate of successful cure of BV so I usually start this at the same time and continue for at least three months.

Vaginal swabs will often come back with various different bacteria – Streptococcus B, Bacteroides, Staphylococcus for example. Unless there are signs of infection – odour or redness - these are not usually significant and are contaminants from the rectum.

Back to top

More Information

The following information sheets are available:

Parents, Obstetricians and Childbirth: Rights and Responsibilities
Vaginal Birth After Caesarean Section – a Guide for Women
Antenatal Care and Routine Tests During Pregnancy – a Guide for Women
Prenatal Screening Tests for Down Syndrome and Other Conditions
Caesarean Section – a Guide for Women
Understanding Endometriosis - a Guide for Women
Laparoscopic Treatment of Endometriosis – a Guide for Women
Hysteroscopy and Laparoscopy – a Guide for Women
Heavy Menstrual Bleeding – a Guide for Women
Abnormal Pap Smear – a Guide for Women
Tubal Occlusion and Vasectomy – a Guide About Female and Male Sterilisation

These (and others) are published by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, are well researched and provide a balanced view.

The full list is available on: the RANZCOG Womens Health page <here>

These are not obtainable directly from the RANZCOG but please contact us on 9588 5155 or 9588 5133 and we will post any that you require out to you free of charge.

Back to top