If you are considering any sort of investigation or treatment, Australia’s National Health and Medical Research Council recommends that you ask your practitioner the following sorts of questions:

• What is the possible or likely nature of my illness or disease?

• What is your proposed approach to investigation, diagnosis and treatment?

— what does this approach entail?

— what are its expected benefits?

— what are the common side-effects and risks of the intervention proposed?

— is the intervention a standard procedure or is it experimental?

— who will carry out the intervention? How much of that particular procedure has that person performed? And with what results, including rates of complications in her/his series of patients. (If he/she doesn’t know, this may indicate a reluctance to self-monitor and may be a bad sign.)

• What are the other options for investigation, diagnosis and treatment?

• How certain is the diagnosis?

• How certain is the treatment outcome?

• What is likely to happen if the proposed investigation or treatment does not occur, or if no procedure or treatment is undertaken?

• What significant long-term effects may be associated with particular investigations or treatments?

• How much time is involved in conducting particular investigations or treatments, and in recovering from them?

• What costs are involved, including costs payable after receiving Medicare and health-insurance rebates?

If you find it difficult to ask these sorts of questions, take someone along with you who can.

*68\198\4*

There are also a number of drug treatments your partner can be offered if problems are found with the quantity or quality of his semen.

hCG and hMG

These two drugs (the same ones as those mentioned above) can be used either separately or together for men who are deficient in LH and FSH, which in turn causes problems with sperm production. Men with a lack of GnRH can benefit from this treatment or the use of pulsing GnRH. It is interesting that many of these men (and women with a lack of GnRH) may have lost their sense of smell, which can also indicate a deficiency of zinc, a vital nutrient for fertility.

Bromocriptine

Men can also have high levels of prolactin which can cause loss of libido and impotence. This drug lowers prolactin, just as it does in women.

Clomiphene or tamoxifen

These are both anti-oestrogens which have been given to men where no hormone imbalances have been found but the sperm count is low. However, these drugs do not have product licenses for male infertility. And the Royal College of Obstetricians and Gynecologists states that the use of these drugs has been shown to be ineffective in treating male infertility.

Testosterone

This is another hormone which is of questionable value in fertility treatment. It is often given where there is no hormone imbalance but there is a problem with the sperm count. Proper development of sperm is dependent on high levels of testosterone and the amount that would need to be taken orally to get the required effect could have a destructive effect on the liver. Also, giving testosterone creates a vicious circle by decreasing levels of FSH and LH, causing further problems with sperm production. The Royal College of Obstetricians and Gynecologists, reviewing the papers on the use of testosterone, felt that there was no evidence for effectiveness and even if it had a placebo effect the dangers of using it were too great.

Corticosteroids

These are sometimes used for men who have anti-sperm antibodies. But there is no real evidence for the effectiveness of this treatment. The side-effects can include weight gain, dyspepsia, facial flushing, bloating, skin rashes, irritability and insomnia.

Case History

Jennifer was 34 and had been trying to conceive for the ten years since she had been married, but her husband had been told that he had a low sperm count. Two varicoceles were diagnosed and operated on but this did not improve his sperm count. Four years previously he had been diagnosed with testicular cancer and one testicle had been removed, followed by radiotherapy and chemotherapy. Some sperm had been frozen before treatment. Jennifer had tried two ICSI treatments but they had been unsuccessful. She contacted me in August 1997 on her own, as the couple lived abroad and she was going back straight away. Her nutritional analysis showed very low levels of magnesium and high levels of copper (common after fertility treatment). I gave her a programme of supplements and suggested changes in her diet which she followed for the four months of the Preconception Plan. At the end of December the same year I received a fax from her telling me she was five weeks pregnant. She now has a lovely baby girl.

*90/73/5*

As a result of the tests carried out your doctor will advise you 3 to the best course for a desired pregnancy.

If all is normal with your partner’s semen analysis it may ¹ suggested that you are failing to ovulate and that a course of fertility drugs such as Clomiphene (Clomid) be taken to induce or increase egg production.

You will be told to start taking Clomid on either day 2 or day 5 (depending on the length of your cycle).

If a pregnancy still has not occurred after several months you may be advised to try a combination of Clomid with ultrasound scans and injections of HCG (human chorionic gonadotrophin)

The Clomid will encourage the production of an egg(s), the ultrasound scan will determine its maturity and the HCG injection will ensure it is released into the fallopian tube within 36 hours. You will be told to coincide intercourse during that 36 hours.

If these treatments are not successful you will need to consider your options. At this stage the options may include deciding to have no further treatment or to investigate your suitability for IVF (in vitro fertilisation) or GIFT (gamete intra fallopian transfer). However, before embarking on either of these programmes it should be noted that the success rates for full term pregnancies is 10% and 20% for IVF and GIFT respectively.

Maria’s story

As I sat and listened to his words my whole life flashed before me. My only ambitions in life were to get a job, get married and have children. I had achieved the first two ambitions but the third one had caused me great pain. Now as my doctor’s words echoed inside my head it seemed that it would be one goal that I would not reach. His voice came as if in a nightmare.

How could he say that I should have a complete hysterectomy?

My doctor’s words sounded so insensitive and heartless. After being through so much with him it now sounded like he just wanted to wash his hands of me. His face normally was pleasant but now it reminded me of a Dr Jekyil and Mr Hyde’s face. His good looks and charm had disappeared and were replaced by callousness.

As the tears blurred my vision, my body started trembling. Anger, resentment and despair overpowered my thoughts. I wanted to shout at him, abuse him, and scream that it was unfair.

After all that I had been through. The appointments accounted for hours spent waiting, sitting on uncomfortable chairs, reading magazines, looking at the clock and watching its hands move slowly, or staring at the uninspiring paintings on the walls. Then there were the tests, treatments and operations, all of which had been in vain, both mentally and physically.

I kept waiting for my husband to say something. He had always been a great support to me and now when I needed his support the most he was unable to help me.

The doctor was silent. I realized that this would be the last time that I would see him. There would be no more four hour trips travelling to Melbourne to his clinic. No more hours spent huddled with his other patients in the diminutive waiting room.

I was amazed at how quickly his attitude had changed.

He had always been so understanding and hopeful. I guess in retrospect I had intrinsically entrusted him to solve my problem.

Seeing him in a different light I noticed how negative his attitude was. I stared at his masked face and words failed me. It appeared that I had been down all the possible avenues and there would never be any children now.

There was not the usual eye contact or friendly goodbye as we parted. Walking past his receptionist’s desk I remember thinking how I would not be sorry to see the last of her. She had always been so moody and unhelpful. I paused for one moment as the next couple passed by in the corridor on their way to see the doctor. What future lies in store for them? Would they experience the same traumas and ordeals that we had – only to be left with heartbreak at the end?

The lift took longer than usual to reach the ground floor. I walked with my husband out of the building. We still had not spoken a word to each other. When we reached the footpath he put his arm around me and gave me a gentle hug which told me that he too was hurting inside.

Later, after accepting a life without children, we took a good look at our lives and reassessed our priorities; it was a painful process and required courage. We both needed a lot of support and luckily received it from friends and family – and each other.

*79/41/5*

There are specific treatments for most of the faults and, depending on what the problem is, the success rate varies.

In general, the hormonal problems are treated with hormone therapy, for example if a woman is not ovulating it may be possible to induce ovulation with certain hormones. Some of the physical problems can be dealt with by surgery, for example microsurgery on the fallopian tubes may help to open them up again. Other treatment may be recommended, depending on the cause identified.

There are two specific forms of treatment which warrant explanation: artificial insemination and in-vitro fertilization.

Artificial insemination. This technique involve, fertile semen (either fresh or frozen) being deposited through a woman’s cervix. The semen can be from the woman s partner (AIH-artificial insemination using ‘husband’ semen) or, more commonly, from a .perm donor (this used to be called AID, now known as Dl-donor insemination). There are techniques available to make the sperm more potent, if low sperm count, are the problem. The sperm is placed inside the uterus therefore bypassing the cervix, making it a suitable treatment for people with hostile mucus, etc. Donor semen is a treatment for couples m wh.ch the male partner’s semen is unsuitable, the most common problem in male factor infertility.

Ethical problems caused by donor insemination initially caused a big stir. Could the donor be identified? Did the donor have any legal right to the child produced by the technique? The answers at the moment are both no. There are guidelines laid down to protect donors and recipients of donor sperm. (The legislation regarding this protection, like all legislation, may be subject to review at some stage.) It is a very useful treatment for many couples who otherwise would be unable to have children.

*175\52\4*

Frequent urination. This is a symptom of early pregnancy, and is probably due to a combination of the effect of hormones, increasing blood flow to the kidneys, and a slight decrease in the capacity of the bladder, as the uterus sits next to it and is getting bigger. If there are no other symptoms (like burning or pain on weeing, or obvious blood in the wee, which may suggest a urine infection), it is usually simply pregnancy related, and will often become less noticeable after twelve weeks or so, and recur later in the pregnancy when the uterus is bigger. It might cause women to wake in the night to wee, interrupting their sleep. It is also a nuisance at other times.

It is important for women to drink plenty of fluid in pregnancy, and the extra weeing this causes is often a disincentive. It is important to drink, however, despite the inconvenience. Perhaps doing more of the drinking during the day, rather than the evening may help prevent the night-time interruptions.

Swelling. Even in early pregnancy, women may notice fluid retention. This is related to the hormonal and blood vessel changes described already. Slightly swollen ankles, or a bloated feeling, or skirts and pants feeling tighter, or putting on a couple of kilograms in a week, are not that uncommon. In very early pregnancy they are usually related to fluid changes, rather than fat deposition. No specific treatment or action is needed for this.

*135\52\4*

What a mouthful. It is pronounced ‘moluskum contay-jee-osum’. They are little bumps in the skin, caused by a virus called the pox virus, and they appear within two to twelve weeks from the time of contact. They are found commonly in children, as well as adults. They may be anywhere on the body, but if they are spread sexually, they are usually on the thighs and abdomen. Sometimes a little bit of waxy stuff can be squeezed out of them. They are not dangerous, a bit annoying, but not dangerous.

Symptoms

Little collections of bumps appear on the skin.

Diagnosis

Usually a doctor will say ‘that looks like molluscum contagiosum’.

Treatment

Some people treat them with liquid nitrogen (freezing), or pop them with a sterile needle. The trend appears to be to leave them alone, if there are not too many of them, because it is likely that within six months they will have disappeared. It depends on how many, and where they are, and how keen you are to get rid of them.

Prevention

This is a common virus in the community, and doesn’t cause any great lasting drama in fit healthy people. It is spread by close contact of many kinds, not only sexual, so it is pretty difficult to avoid it totally if you want to live a normal life.

*96\52\4*

Unfortunately there is a fair amount of confusion regarding this little pill, largely because of its name. Many people believe that the lower-dose combined (oestrogen and progesterone) pills are in fact ‘minipills’. Not so.

The true ‘minipill’, or the ‘progesterone-only pill’ (POP) has been used widely as the pill taken for contraception while breastfeeding (lactating). Together with the natural (but not always reliable) contraceptive effect of lactation the POP gives further protection, without interfering with milk production.

Lactation naturally suppresses ovulation. The World Health Organisation has collated research and has stated that if a baby is under six months old and is fully breast fed (with no additional or formula feeding), and the mother is not having periods, then the chance of the woman becoming pregnant is about 2 per cent. When any of these criteria are not fulfilled, the risk of pregnancy increases significantly. (That is why the minipill is handy.)

However, its usefulness extends further than simply with lactation. It can been used by women who, for a variety of reasons, cannot take oestrogens (and therefore can’t take the combined pill).

It acts by increasing the mucus plug at the cervix, making it much more difficult for sperm to penetrate. It also probably slows down the transport mechanisms in the tubes, so the sperm are less likely to find a comfy place to fertilise and settle. It’s a bit like a picket line, and if a strike breaker does happen to get through, the factory is on a ‘go slow’ campaign.

The failure rate of the POP is about two to three per 100 women years, not bad, but not as good as the combined pill (but with fewer serious side-effects). Because it has narrower safety margin it is even more important to take care not to miss any tablets, or to delay taking them. Problems like vomiting and diarrhoea and antibiotic use can interfere with absorption and effectiveness of the POP, as they can for the combined oral contraceptive pill. You should take added precautions (like condoms or abstain from sex) for the time of increased risk, and for at least two (rather than seven) days after, to avoid getting pregnant.

The POP does not have the advantages of cycle control, and in fact spotting, irregular cycles and missed periods can be a problem for some POP-takers. Apart from this, the only other significant side-effect is that some women can experience mood problems (mild depression, PMS-type symptoms) while taking the POP, but this is uncommon as it is such a small dose of progesterone.

However, it is an extremely useful, and probably under-utilised form of contraception. Used alone it provides fairly effective pregnancy prevention (when used properly). It is more effective when combined with another method, like breast feeding or barrier methods.

*56\52\4*

Amenorrhoea is the word used to describe the absence of menstruation for three months or more. At times, like before puberty, during pregnancy and breastfeeding, and after menopause, it is perfectly acceptable not to have periods. At other times it is a little unusual, although fairly common. Amenorrhoea can be ‘primary’ (never had a period), or ‘secondary’ (had them before, but they have stopped).

Oligomenorrhoea is related; it is when you have periods, but not very often. Oligomenorrhoea is defined as having a cycle longer than thirty-eight days, but less than three months (because if it was three months between periods, the doctors would call that amenorrhoea, but it’s all a bit academic, really).

Amenorrhoea and oligomenorrhoea are not diseases. They are symptoms, and may have a variety of causes. Oligomenorrhoea may be a ‘normal’ condition for some women who just have long cycles. More often it is due to an alteration in the pattern of the hormones, as is usually the case in secondary amenorrhoea.

Primary amenorrhoea can simply be due to late puberty. If there arc no periods by the time a girl has reached 16 or 17 years of age it is reasonable to go looking for a cause. There are several rare causes, including failure of development of the reproductive organs, chromosome abnormalities, and ovarian abnormalities.

The commonest reasons for amenorrhoea (primary and secondary) arc stress and low body weight which affect hormone levels. This results in what is called ‘anovulation’ (no egg being produced). Stress, either brief or long term, can affect the hormonal system so that the message to produce eggs, and therefore have a period, does not get through. It is not uncommon for women to have no periods while travelling, or changing jobs or schools, when unwell or in a state of emotional turmoil. Some of the hormones involved with ovulation are made in the brain, close to the areas involved with the production of other hormones, including the ‘stress’ hormones. It is not surprising then, that one can affect the other. Recovery is usually spontaneous, and den ling with the stress, if possible, can help.

Deficiencies of certain vitamins and minerals can have dramatic effects like anaemia (low red blood cell count), problems with the nervous system, and many other systems, resulting in the body not functioning as well as it should. Under a certain weight (different for every woman), a woman’s ovaries will not produce eggs. This shows up as not having periods, like the reaction to

stress, it is possible to see a kind of reason behind this. If the body could talk it may say: i make eggs every month in order to reproduce. If I would not be fit enough (because of stress or lack of nutrition) to have a successful pregnancy, I am not going to make an egg. That means I will not have a period’.

This makes sense in an evolutionary way.

Some girls and women do not just diet; some are suffering from a condition called ‘anorexia nervosa’, one of the class of conditions called ‘eating disorders’. This is a psychiatric condition, which involves compulsive dieting, often excessive exercising and, frequently, intentional vomiting (‘bulimia’). There may be many factors contributing to the development of this condition, which presents in the teenage years most commonly. There are varying degrees of severity of anorexia nervosa. With the correct diagnosis and treatment these conditions can be overcome. However, anorexia nervosa can be serious and, in severe cases, may be fatal. If a person is concerned that she may have an eating disorder, or is worried that a friend or family member may have a problem of this kind, it is a good idea to ask for advice from a doctor.

Young women who have prolonged (like a year or more) amenorrhoea may be at risk of developing the side-effects of lacking oestrogen. It has been shown that bone mass thins when there is not much oestrogen around, like after menopause. We build up our bone mass stores from our teens until our early thirties. Lacking oestrogen during this time may limit the ‘peak bone density’ we achieve. This means that there may be greater risk of osteoporosis and bone damage later in life. For this reason it is not uncommon for doctors to recommend that young women with prolonged amenorrhoea should have hormone supplementation, often in the form of the combined oral contraceptive pill.

There are other hormonal treatments which can be used to stimulate ovulation in women who have problems with amenorrhoea, bur these are usually only given if the woman is actively trying to get pregnant.

*16\52\4*