Health News. Lots of resources and medical information

An essential quality in any health practitioner is good communication skills. He or she should listen carefully to what you have to say and give you a clear explanation of the possible or likely nature of your illness or disease. Together you should discuss the proposed approach to tests, diagnosis and treatment, including what the proposed approach entails; the expected benefits, common side-effects and risks; whether the intervention is conventional or experimental; and who will undertake it. Your practitioner should raise with you, or you should ask about, other options for investigation, diagnosis and treatment. Another important attribute of a practitioner is the ability to convey information in an effective yet sensitive manner and to recognise what you have gone through already and may yet go through. A practitioner who is unable to put him or herself in your shoes is less likely to understand your preferences or needs. If there are language difficulties between you and your practitioner, encourage the doctor to arrange for an interpreter to be present or, if this is not possible, bring someone with you who can translate.

Once a diagnosis has been arrived at, you should be informed of any uncertainties about that, or about the outcome of any treatment proposed. You need to be sure that the outcome expected from the treatment is compatible with what you want from treatment. For example, if you still desire children and you do not have a life-threatening cancer, a hysterectomy is not a sensible first option for you. The doctor may want to discuss the likely consequences if you do not choose to have a proposed treatment. The expected time to recovery and financial costs are matters that you may also need to discuss. In addition, it is particularly important that you satisfy yourself that the doctor is experienced and skilful in the job to be done, and that any significant risk of long-term physical, emotional, social, sexual or other outcome is known to you.

The issue of what constitutes a ‘significant risk’ received lengthy consideration during a recent Australian High Court decision (Rogers v. Whitaker [1992]). The case concerned a woman who was blinded by the treatment she received, a less than one in 1000 chance in her particular case. The presiding judge defined the risks to be discussed by a doctor with his or her patient as those which, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to if warned of the risk.

In practice, some doctors seem to think they should have control over what is discussed. A 1993 study of over 1000 doctors, conducted for Australian federal health authorities, found that 84% considered there were circumstances in which they would be justified in withholding information.14 Some of the reasons given seem questionable at best. About a third of the doctors said they would consider withholding information if they thought a patient might refuse treatment, while between a third and a half would consider withholding information if they regarded the patient as a poor decisionmaker. Only half of the doctors surveyed said they always discussed the risk of death or serious disability where it occurred at least as often as once in every 100 cases. For lower risks of death or disability (one in 1000 was specified) less than a quarter of the doctors said that they always discussed these with patients. On a more hopeful note, another Australian study of doctors found that the most significant changes to medical practice over a recent five year period were ‘taking more time to explain risks’ and ‘spending more time on patient record keeping’.

Before making decisions about treatment, it is a help if your doctor draws a picture of the suggested treatment approach if this is possible (and it certainly is where surgery is involved), and gives you written materials to take home and think about. If you are unsure, ask more questions. If you are still undecided, ask for time to make up your mind. Don’t be hurried. Except in the case of a diagnosed cancer, time is on your side.

If you need to go to a clinic or a hospital for treatment, the practitioner should provide you with clear information about any pre-treatment requirements (such as stopping the Pill a month before major surgery, stopping smoking at least a week beforehand, and refraining from food and drink from the night before a general anaesthetic). You should also be given details of your continuing health care, for example post-treatment check-ups, once you are discharged from a clinic or hospital.

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It is not easy to get fertility treatment on the NHS and sometimes only drug treatments are available. A study carried out by University College Hospital and Medical School in London showed that 75 per cent of couples end up on long NHS waiting lists and would choose to go privately if medical insurance companies would foot the bill. The best system is in France where the state pays for four IVF cycles. In Germany the couples are allowed four and 30 per cent of the cost is paid for by the state and the rest made up by the insurance companies. The availability of NHS treatment can often depend on where you live. There are no central guidelines. Some couples I see have had a number of IUIs on the NHS, and others who have gone privately for IVF have had their fertility drugs funded by their GP. There are also some non-profit-making clinics where the cost is much lower than private IVF clinics.

Choosing a Clinic

In the UK, all clinics offering assisted conception have to be licensed by the HFEA, Human Fertilisation and Embryology Authority. The HFEA produces ‘league tables’ showing how successful the clinics are – essential reading for all couples deciding where to go for treatment. CHILD also produces a helpful booklet called Choosing a Clinic.

If you are going privately, remember that you are a paying customer and you want the service that suits you best. Some couples prefer a small intimate clinic, where they see the same professionals at each visit. Others prefer a large clinic, headed by a well-known name who you may or may not see. This can be more impersonal and it is likely that you will see different doctors each time you go. Some couples say that, in a big clinic, they feel as if they are on a conveyor belt. Others prefer this. It’s best to get brochures from a number of clinics and visit up to three of them to decide whether you would feel comfortable being treated there. Convenience also has to be a factor because you will be going quite a few times and you don’t want to travel too far.

Success Rates

Each clinic releases its own statistics but you can’t really compare them because they are often calculated differently so that you’re not comparing ‘like with like’. The HFEA guide, on the other hand, presents standardized statistics, the most important of which is the ‘take-home baby rate’ per treatment cycle. If the pregnancy rates alone are compared these can look very impressive. But these would tell you nothing about what happened later – the rates of miscarriage, ectopic (tubal) pregnancies, and any other problems that meant the pregnancy did not continue.

The other point to bear in mind is that, since the publication of these HFEA ‘league tables’, some clinics have become more selective in their patients. If they take everybody, including ‘older’ women and other complicated cases, their position in the league tables may be affected.

Some clinics are more honest and upfront than others in telling a couple that, in view of their medical history, they have an extremely small chance of getting pregnant. Others will take anybody who is willing to pay.

Useful Questions to Ask the Clinic

• What tests and treatments are provided?

• Do they specialize in any particular type of infertility?

• Is there a waiting list?

• Are there any restrictions (e.g. due to age or previous treatments)?

• How often will you have to attend the clinic?

• Is counseling provided and is it included in the treatment costs?

• Are there any hidden costs, such as diagnostic tests or anesthetic charges?

• What is the up-to-date take-home baby rate?

• What is their success rate like for a woman the same age as you? (Some clinics have more experience with ‘older’ women.)

Ask each clinic the same questions and compare the answers. You can visit them or some clinics will answer these questions over the phone. The HFEA publishes a patient’s handbook which will help you to compare the different clinics. You really want to get as much information as possible so that you can get the best treatment to suit your individual needs.

Before You Start

Embarking on IVF treatment is a big step, both financially and emotionally, so it- needs to be thought out carefully. Many couples are not aware of the amount of time it is going to take up, the physical effects of the drugs on the woman’s body, and the emotional roller-coaster that it will put them through.

The success rate for IVF is around 20 per cent, which means that 80 per cent of treatment cycles will fail. This success rate is the same for each cycle and is not dependent on how many cycles you have had already. The odds are the same as if you toss a coin. If you have tossed four heads, there is still a 50:50 chance that the next one is going to be another head.

Some couples can feel under pressure to have one IVF cycle after another. Sometimes this pressure comes from the clinics, especially if the woman is ‘older’. However, with the quantities of drugs that are used and the emotional ups and downs that can be experienced, together with the effects of these drugs on your system, it is better to have a break, say two or three months, between attempts and let your body get back to a natural cycle before it is bombarded again.

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Prolactin problems

Prolactin is a hormone that is secreted by the pituitary gland which helps to control ovulation. Research has shown that the levels of prolactin in women with endometriosis are higher than that found in women in general. The high levels of prolactin may contribute to infertility in women with endometriosis but the role that they play is unknown.

Luteinised unruptured follicle syndrome

Luteinised unruptured follicle syndrome, usually known as LUF syndrome, occurs when the ovarian follicle matures and prepares itself for ovulation but at the time of ovulation the follicle fails to rupture and release the ovum.

LUF syndrome is very hard to detect because the usual methods of determining whether or not ovulation has taken place, such as basal body temperature charts and measuring progesterone levels in the second half of the cycle, all indicate that ovulation has occurred. It can only be reliably detected by inspecting the follicle during a laparoscopy or by measuring the size of the follicle during repeated ultrasound scans. In the past many researchers thought that the LUF syndrome was a major cause of infertility in women with endometriosis. However, now many researchers believe that it does not play a significant role and some believe that the LUF syndrome is probably just a random event which occurs in most women from time to time.

Prostaglandins

Prostaglandins are substances that are produced by many tissues throughout the body, including endometrial implants. One of their functions is to control the contraction and relaxation of the muscles in many of the internal organs of the body, including the uterus and fallopian tubes.

It is thought that women with endometriosis have higher concentrations of prostaglandins in their peritoneal fluid and that these higher concentrations may contribute to infertility by hindering or preventing conception and implantation in a number of ways.

It is possible that prostaglandins interfere with the functioning of the ovaries and prevent the release of the ovum thereby preventing fertilization.

Prostaglandins may affect the sperm as they move towards the ovum by slowing down their movement and thus reducing the number of healthy sperm that can reach the ovum in time for fertilization.

Prostaglandins help the ovum move along the fallopian tube.

If the fertilized ovum is propelled too rapidly along the tube the ovum will reach the uterus too quickly. Therefore, when the fertilized ovum reaches the uterus it may not be mature enough to implant itself in the endometrium or the endometrium may not be ready to accept the fertilized ovum. If the fertilized ovum is propelled too slowly down the fallopian tube it may not reach the uterus in time to embed itself in the endometrium.

Prostaglandins may also affect the relaxation and contraction of the uterus. If they produce excessive contractions of the uterus they may prevent implantation of the fertilized ovum or they may cause it to be expelled soon after implantation.

Macrophages

Macrophages, sometimes referred to as scavenger cells, are a special type of white blood cell which are found throughout the body. The function of these cells is to consume or ‘eat up’ and eliminate any unwanted debris or foreign material in the body, including sperm cells.

Women with endometriosis have an increased number of macrophages in their bodies, particularly in their pelvic cavity and fallopian tubes. Consequently, the macrophages are able to consume and destroy larger numbers of sperm than normally occurs, reducing the number of sperm available for fertilization of the ovum.

Auto-immune response

Some women with endometriosis develop an abnormal immune response against their endometrial implants. It is thought that the immune system of these women for some, as yet unknown, reason thinks that the implants are foreign material and therefore begins to produce antibodies against them in an attempt to destroy them. The immune system also perceives the normal endometrium in the uterus as being foreign material and therefore produces antibodies against it as well in an attempt to destroy it. If the immune reaction is strong enough the antibodies produced in the uterine endometrium may prevent implantation of the fertilized ovum.

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Additive effects. In 40 per cent of infertile couples there may be more than one factor affecting fertility. The individual factors may not necessarily make pregnancy absolutely impossible, but having more than one factor will make it less likely. For instance, if a woman has some partial blockage to her tubes, and her partner has a lowish sperm count, they may have quite a bit of difficulty getting pregnant, and present for investigation of their fertility. If the same woman had a different partner, with a normal sperm count, she may have had less trouble becoming pregnant, and might never have had her fertility investigated. The man with the lowish sperm count may have no trouble with a different partner, too; a woman who has perfectly normal tubes may get pregnant despite her partner’s relatively low sperm count.

The psychological. Some people will nor conceive, and will never be able to be given a satisfactory physical, medical explanation, like a blocked tube or something tangible like that. It is the intangible bit that is harder to measure, and to treat. Psychological factors are known to play an important part in fertility. Many people will be able to recount stories of couples who had undergone ‘thousands of tests’, and been seen by ‘hundreds of doctors’, and just when they had put their names down to adopt a baby, they miraculously fell pregnant. Perhaps the added stress of wanting something so much, and trying so hard, can work in the opposite direction and disturb fertility. The hypothalamus and pituitary gland are areas of the brain involved in fertility, and are susceptible to stress.

‘Unexplained infertility’ is the diagnosis doctors give couples in whom no specific cause is found. This can be a difficult concept to come to terms with, especially when there seem to be treatments available for other infertile couples. It does not mean that the couple will never get pregnant. Some do. It means that the factors affecting that couple’s fertility are not among those we can specifically recognize and possibly treat.

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Feeling faint. A classic scene, repeated in many old movies, shows the beautiful young, newly married heroine fainting unexpectedly, often in a crowded place, like a shop or street. The next scene shows her, beaming and neat, holding what is meant to be a newborn baby. This is how a rather coy film-making industry used to handle the announcement and depiction of pregnancy and labour.

As we know, it is not that simple, but it is true that women in early pregnancy may be more inclined to faint than non-pregnant women. Pregnancy changes lots of parts of a woman’s body, including her cardiovascular (heart and blood vessel) system. There is a shift in the distribution of blood in her body, with relatively more going down to the pelvis than previously. There is also a hormonal effect during pregnancy on blood vessels which tends to make them more dilated, getting ready for the next change, which is an increase in the amount of blood circulating around. This increased blood volume is necessary to transfer oxygen and nutrients from the woman to her developing foetus, via the placenta.

Having an expanded space in which to hold your blood, and not yet having made the extra blood may contribute to this fainting business. Your blood pressure (the force of the blood pumping around) will be slightly lowered by these changes. That means that when you stand up quickly, it may take a second longer for the blood to reach your brain, and consequently you might faint.

There are a couple of tricks which can help with this. The first is drink more fluid. Try watery drinks, rather than tea (which has a diuretic effect, making you wee more and perhaps decreasing your fluid load). Pregnant women need extra fluid. It will help to fill up the blood vessel space, and stop the blood pressure from dropping to your boots.

Secondly, it may be worth taking a bit of extra care when you are getting up from sitting and lying. If you do it more slowly (no, you are not an invalid, only pregnant), you may feel more comfortable. Recognize that there may be a bit of adjusting your body needs to do.

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Sometimes the warts will just go away, but it may take a while, and most people seek treatment. There is several different things people use, including grandma’s home remedies.

If people go to a doctor for treatment they may be treated with various methods. (Women should arrange to have a pap smear as well.) There are specific wart paints, like podophyllin, which the doctor can carefully put onto the warts. It is left on for a few hours and then washed off. This process can be repeated two or three times a week until they ate gone. Used properly it is safe, but should not be used for very big areas, or in pregnant women. Another treatment is freezing them, which may sting a bit for a few minutes, but the discomfort is short lived, and it can work well. (It may take a couple of applications.)

If there are heaps, particularly in women, and if they are difficult to get to, or resistant to other treatment, it may be worth considering having them either frozen, surgically burnt (cauterised), or treated with laser, undet a general anaesthetic.

Remember that the treatment is getting rid of the wart, not the virus. The virus remains in the system, and may produce more warts, or more changes in the cervix cells, so continuing to have regular pap smears, even after treatment, is very important.

Prevention. In reality, this is pretty difficult. With so much of the virus in the community, and the fact that it is spread, often without a wart being visible, it is not easy to avoid. Condoms probably offer little protection (because the virus could be transmitted from the uncovered skin near the penis), but regular check ups and pap smears will probably be more useful for women.

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The actual incidence of serious side-effects of the pill is very small. These can be divided into groups: common and pleasant, less common and a nuisance, very rare and nasty, very rare and potentially disastrous.

Very rare and nasty—the pill should not be prescribed to women who have liver problems. This does not mean just people who don’t tike pats; anyone with a past history of liver disease or jaundice (particularly in pregnancy) should discuss this with their doctor when contemplating the pill. Active liver disease is a contraindication to the pill.

If a woman has had breast cancer diagnosed, the decision whether or not she should take the pill should be considered in consultation with her surgeon, GP and gynaecologist. This is still a controversial area, and decisions would be best made by a woman with access to specific individual information. This does not mean that the pill causes breast cancer, but there are some types of breast cancer which are thought to be potentially accelerated by oestrogen. Researchers and clinicians are still trying to sort this one out. Breast self-examination, and regular examination by a doctor are general health measures which should be undertaken by all women, whether taking the pill or not.

In a few women blood pressure may be increased by taking the pill, so this too is a condition which requires careful monitoring before starting the pill, and should be checked regularly.

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Certain hormones in the body begin to increase during the early teenage years, usually beginning around 10 or 11. Consequently changes occur which are, in effect, the maturing of the sexual organs in preparation for reproduction. This stage of life is known as puberty. Most of the physical changes follow the same pattern, although there is plenty of room for individual variation. Puberty is said to be ‘precocious’ (early), if it begins before 9 years of age, and ‘delayed’ if absolutely nothing has happened by 14. There will always he people at either end of the developmental spectrum who arc just late or early developers, but the ages are used by doctors as guides. Some children who develop very early or very late may need investigation, hut this is rare.

Breast development usually starts some time before the first period. Girls (and most hoys, much to their horror) will feel what is known as a ‘breast bud’. This is a little button of tissue just under the nipple. At this time it becomes a bit bigger, and is often quite tender. Usually one side starts off before the other one, which sometimes causes alarm, but they generally catch up with one another quite soon. From this little button, the whole breast will develop. The breast goes through stages of development from immature to mature, usually between the ages of 10 and 20. All breasts, like all noses and other bits of our anatomy, have their own shape, growth rate and character. There are as many variations on ‘normal’ as there are breasts. Unless there is a very obvious problem (like completely lacking any breast development by the age of 14 to 15, or having development only on one side), most minor variations sort themselves out by the final stage of maturation.

The development of body hair usually begins around the time of breast growth. There is usually fine, sparse hair in the pubic area, which becomes coarser and thicker with time. Hair also grows in the armpits. Growing all this hair seems like a bit of a waste of time. There appears to be a reason for developing breasts and having periods, if you want to be able to reproduce, but having extra hair in odd parts of the body does not really seem to add to your ability to bear children. At least not now, but when we were slightly more primitive, and cave dwellers, for instance, we did not shower as often. Anthropologists have suggested that the body odours, which were inevitably stronger then, may have been useful, as they are for other species. Dogs, for example, can mark territories, or find out if another dog is on heat. ‘Pheromones’ is the

name given to subtle smells which we probably exude, which tell other people things about us. The messages may not even be registered consciously. It is thought that body odour, which can act as an aphrodisiac (stimulate sexual feelings), is dispersed better through body hair, which is probably why we developed it. Regardless of the reason, it grows.

The average age at which the first menstrual period arrives has changed over the years in Western society. A couple of generations ago it was usually around 14 to 1.5 years of age. Now, largely doe to better nutrition and living conditions, it is earlier, closer to 12 years.

The first periods are likely to be irregular for a while. It is not uncommon to have one, then none for a few months. After a year or two, when the ovaries start working properly, the periods tend to become more regular, and often a bit painful. If a girl has not been told what to expect, the sudden discovery of blood in her underpants or bed can be very frightening. Some parents shy away from talking to their young daughters about menstruation. However, most girls will handle the event better if prepared in some way.

Puberty is a time of rapid growth, not only on the front of the chest, but also vertically. Most teenagers have what is called a ‘growth spurt’, a fairly unglamorous name. Teenagers also change shape. Girls tend towards an ’8′ shape, and boys towards an upside down triangle. Much to the disillusionment of many, no one ends up with a body like a Barbie doll; it is physically impossible.

The hormones floating around the body also affect the skin. Acne is the curse of the teenager, or at least one of the curses. Many teenagers are at a very sensitive and vulnerable time in their lives, particularly where their appearance is concerned. Then along comes an army of pimples waging a battle on their skin.

Despite the fact that so many of their peers are going through the same thing, it does not do wonders for the self-esteem.

Not only is puberty a time of dramatic physical change, but emotional and psychological adjustment as well, as the body and mind start to grapple with new sensations and urges. It coincides with the years during which a child is starting to exert independence, and carving out a distinct personality from the material given to her or him by the family and environment. It can be an immensely traumatic time, for both the child and the parents, as they learn how to cope with changing demands and altered expectations of each other.

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