Any major gynaecological surgery, such as an open myomectomy which entails a large incision and a general anaesthetic, will put sex off the agenda for at least six to eight weeks. This does not mean you cannot enjoy each other in intimate ways. The opportunity to give pleasure to each other through massage can help the recovery process. It can also help the sexual relationship in the longer term by allowing partners to communicate their sexual needs to each other and learn about each other’s sexual responses before sexual intercourse resumes.

One type of activity that most couples find enjoyable, starts with partners giving each other a general body massage. Hand cream or body oil, and an atmosphere that is warm and relaxed, will add to the experience. As the massage occurs, the partner who is being stroked and rubbed describes his or her feelings and desires. In this way each partner learns how the other likes to be stimulated and caressed and unexplored areas of communication and fantasy may be unearthed. The activity may continue to climax.

After a hysterectomy, hysteroscopy, laparoscopy, endometrial ablation or endometrial resection, the desire to give and receive love remains. Most people want to continue with intimacy — the challenge is to be flexible enough to manage this when some of the old ways of being intimate are on hold. Giving and gaining pleasure may be achieved by caressing, cuddling and enjoying each other’s company. The use of a hand-held vibrator on many parts of the body can arouse sensations in areas we do not usually think of as pleasure zones, such as the soles of the feet, the face and the lips. Intercourse can be resumed when bleeding or discharge has stopped and the pelvis feels normal. Depending on the type of procedure and the speed with which your body heals this may be anything from a fortnight to several months. A slow start to the resumption of love-making is usually the best approach, with genital touching and gentle penetration later. If you have any concerns, wait until the postoperative check-up to get the all clear.

Drug treatments which induce a temporary menopause may reduce a woman’s interest in sex and may cause intercourse to become less pleasurable because of a decreased output of secretions in the vagina. Fatigue due to hot flushes and sleep disturbances may also reduce sexual responsiveness. Overcoming these adverse effects calls for lateral thinking as outlined above. It will not occur overnight, so a medium- to long-term approach is vital.

Treatments for excessive bleeding, such as the Pill, progestogens, NSAIDs, danazol, and GnRH agonists are a mixed bag as far as sexual function is concerned. Some, notably progestogens and GnRH agonists, can cause a marked reduction in interest in sex; while others, such as the Pill, may produce little change.

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This involves a single sperm being injected directly into the egg to fertilise it. The embryo is then implanted in the womb.

ICSI developed out of a technique called SUZI (Sub-zonal insemination), where five to ten sperm were injected just underneath the layer of cells, the zona pellucida, that surrounds the egg.

Who Should Have It?

ICSI can be used if your partner’s sperm count is so low that IVF is not possible, if he cannot ejaculate, or if he has an obstruction stopping his sperm being released.

What Happens?

You will have to undergo the same preparations with drug treatment and procedures as for IVF.

The human egg is invisible to the naked eye and sperm are minute in comparison to an egg, so ICSI is a very delicate procedure.

For men who can’t ejaculate or whose sperm are obstructed, the sperm samples can be drawn off directly from the testes or epididymis. If this does not work then a biopsy is performed, in which fingernail-size pieces are taken from the testes through a tiny incision. The sperm retrieved in this way are not fully developed and may not move.

Success Rate

The success rate for ICSI, 20-25 per cent, is slightly higher than for IVF. This is probably due to the fact that the sperm is injected directly into the egg so the technique is not dependent on how well fertilisation takes place.

Risks

In IVF a number of sperm are put in with the egg, which seems to be able to favour healthy sperm over those that may be defective. In ICSI the egg has no ‘choice’ because only one sperm is used and inserted directly. Because of this, and the fact that often immature sperm or even sperm cells are used, there have been concerns that ICSI could result in babies being born with chromosome defects or having genetic problems later in life.

Researchers have found that babies born after ICSI are twice as likely to have a major birth defect and 50 per cent more likely to have a minor defect.

It has been suggested that men go for karyotyping (chromosome evaluation) before they embark on ICSI so that any genetic causes of their infertility can be ruled out. If there is a genetic cause for the man’s infertility, the man and his partner should be counseled as to whether it is right for ICSI to proceed because of the possibility of passing on problems to the baby. Boys born following ICSI might, for instance, be infertile and need ICSI themselves in order to conceive.

It is important to know why the man is infertile, especially if he is producing no sperm. If there are chromosome problems in the man then it is also likely that the miscarriage rate could be high after ICSI.

Sometimes we can’t conceive because nature has a fail-safe mechanism to protect the survival of the fittest. Even though we now have the technology to override this, there are some situations where the consequences for the baby should be thought through carefully.

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Guilt

Many women complain about feeling guilty or that they are made to feel guilty about why they developed the disease. Some may even feel that it is a type of punishment that they alone must endure.

For years endometriosis was tagged the ‘career woman’s disease’. This was based on the unfounded idea that women who delay having children are more at risk of developing endometriosis. Women are made to feel guilty that delaying marriage and having children until after they have established a career has been the cause. You ask yourself if you had started your family earlier would you have developed the disease. Would infertility have been a problem?

What must be remembered is that it is not known if delaying childbirth has any connection with the development of endometriosis. Also remember that many women actually get endometriosis after they have had children.

Other women complain that they feel guilty because they may not have been assertive enough in getting a diagnosis. Having been told by one doctor that nothing was wrong they simply suffered in silence and put up with their pain and symptoms.

Sometimes the assumption is made that stress causes the disease. This may make some women think that if they did not have such a stressful job, did not work so hard or didn’t have a difficult family life, they may not have developed the disease.

It does appear that the symptoms of endometriosis may be aggravated when a person is suffering from stress, but it does not mean that it actually develops because of stress.

Women may feel guilty because they cannot cope in certain situations whereas others cope well.

For those who have had an abortion, used contraception such as the Pill or an IUD, used tampons or had sexual intercourse at an early age, there can be the mistaken belief that this has contributed to them getting the disease.

Depression

Most endometriosis sufferers have felt depressed at some stage for one reason or another. Suddenly you have to come to terms with having a chronic illness. There is the constant tiredness and the frustration of feeling lethargic. Sexual relations are put under enormous stress if you suffer pain during intercourse. Pain may also interrupt your lifestyle.

Treatment may not be effective and you worry about what alternatives you may be faced with. So many of your questions seem to go unanswered and at times you really feel as though you are unable to get on with your life.

For those who have fertility problems there is the concern that perhaps you may never have a child. And if you are lucky enough to get pregnant will you miscarry? Will the disease hinder a normal delivery?

Many of us become depressed thinking about the future management of the disease. Will you be faced with more hormone treatment? Will you require more surgery?

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How do you know if you have PID?

PID can cause a variety of symptoms, varying in severity from ‘barely noticeable’ to *in hospital, on a drip, feeling very sick’. For example, chlamydia, being the sneaky little germ that it is, rarely gives significant symptoms initially. Gonorrhoea, however, is more likely to make its presence felt early on. Symptoms can include:

• lower abdominal pain (mild, moderate or severe)

• vaginal discharge

• deep pain with intercourse

• pain on passing poo or wee

• period problems—bleeding between periods, heavy, or painful periods

• fever

• vomiting.

The other tricky thing about this condition is that it can also be ‘acute’ or ‘chronic’. Acute means that the onset is fairly recent. Acute PID may present within a week or two of the infection being transmitted. Chronic means that it has been there a while. Chronic PID may give symptoms intermittently over a period of months or, in some cases, even years.

With so many variables (the fact that it can give rise to any or all of these symptoms, which can be mild, moderate or severe, and acute or chronic), it is not difficult to see why people sometimes have trouble diagnosing PID. We should, however, all be thinking of it whenever something is wrong in the pelvis, and go looking for it.

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Public hospital care. You can book into a public hospital to have your antenatal care, delivery and postnatal care. This option is available to everyone, as you do not require special insurance, and there is no charge to the patient. In Australia, the care of patients in the public hospital system is funded by the government.

At your first appointment, or before, you may have the opportunity to find out about the hospital, what services it offers, and where different parts of the hospital are. It is a good idea to familiarise yourself with the place, and find out who you can contact for more information if you need to.

In larger public hospitals you will usually see a doctor at each or most of the visits. You may see different doctors at the visits, or the same doctor through the pregnancy. The doctors at large teaching hospitals will either be specialist obstetricians, or obstetricians in training (‘registrars’ and ‘resident’ doctors). The specialists will be part of a unit, and have specific registrars and residents working with them. The care of patients in the public hospital system ultimately ism the hands of specialist obstetricians. They will be the ones involved in overseeing any patients who have problems.

In labour you are looked after by the midwives and doctors on duty in the labour ward. After delivery you and your baby can stay in a postnatal ward for a few days, where the midwives are trained in helping mothers with new babies.

Public hospitals also have specialist paediatric care available.

Some hospitals offer variations on the routine antenatal outpatient system.

Midwife clinics. These are becoming more common. In these, women with low-risk pregnancies, identified after the first antenatal visit, may choose to see a midwife, rather than a doctor for the majority of their antenatal visits. If any problems arise during the pregnancy you can be referred back to the care of the doctors if necessary.

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Condom use with many women of different ages and backgrounds, and the same sorts of problems are often mentioned. Many women feel uncomfortable asking a man to use a condom.

A lot of men are happy and willing to use condoms, and see their use as routine in sexual relationships. However, many men give reasons for not wanting to use them, saying that it feels different, or is less satisfying for him, and the old classic, ‘like showering in a raincoat’.

Individuals are constantly making choices based on what is happening to them at the time. Trying to make a decision about the potential risks of catching an STD while in the middle of a steamy, passionate embrace may not be the most sensible thing to do. It is not a good time to think rationally and clearly. A wiser course of action would be to consider that there may be a potential risk, and be prepared. No one likes the idea of breaking up a perfectly satisfactory cuddling session, jumping in the car, or on the bus, and going to the chemist to buy some condoms. It is a sensible precaution to have some available, in case they are ever needed. Having condoms available does not mean you must run out and find someone to have sex with before the use-by date is up. It does not indicate that you intend having sex, or commit you to doing anything you don’t want to do. It simply increases your safety if you do decide to have sex.

People do have a natural shyness about discussing or displaying things relating to sexuality, and that is understandable. However, buying condoms should not feel shameful or embarrassing, because it is a normal, natural, responsible act. It just takes a little getting used to. If it really bothers you, then you could ask someone else to do the actual purchasing for you. Condoms are for sale at supermarkets, pharmacies, convenience stores and vending machines in some pubs and night clubs and some tertiary school campuses. You may feel more comfortable about buying them from a family planning clinic.

Who should bring the condoms? This is up to the couple to decide, but it seems fair that the responsibility be shared, as you are both benefiting from using them. If a woman asks a man to use a condom, and he is not keen on the idea, the woman has a choice to refuse to have sex with that man. Anyone has the right to choose to have sex, or not, at any stage. No one should feel that because they have gone a certain way along the path to having sex that they are under any

obligation to carry on, if it is not what they want to do.

Sometimes pointing out that the condom provides protection for him as well is a good tactic. Until you are both thoroughly checked out there is no guarantee that either of you are free of STDs.

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All bodies contain squillions of micro-organisms, which are tiny, microscopic living things. Most of these are quite happy, and often helpful, like the bacteria in our intestines which help to break down food. Both the host (the body) and the micro-organisms get something out of the relationship, or at least do each other no harm. The body has mechanisms for making sure the bugs don’t get out of hand. The body’s natural defences are its skin, which acts as a mechanical barrier, and its immune system. The immune system includes a range of bug-killing cells (white blood cells, or ‘leucocytes’ ), which float around in the blood stream, like patrolling security guards, making sure the bugs stay in check.

Infections are the conditions or diseases we get when we have a microorganism, either from our own body, or from elsewhere, which is multiplying rapidly, and is causing damage to our body.

When micro-organisms start overgrowing, the body usually responds by trying to kill them. It does this by increasing the production of its white blood cells, and may do other things, like raising the temperature, to make it harder for the bugs to survive (which is where fevers come from).

The battle may be localised and brief, or drawn out and deadly. We have developed other methods of fighting bugs, such as antibiotics and antiseptics, and the bugs have often fought back by adapting themselves (for example, developing resistance to our antibiotics).

Not all micro-organisms cause serious infections, but there are an enormous number, and some of them can cause more than one type of infection. The major groups of micro-organisms are: bacteria, viruses, fungi and parasites.

Bacteria. Some of the infections caused by bacteria include:

• abscesses and boils (infections with pus are generally bacterial)

• urinary tract (bladder and kidney) infections

• gonorrhoea

• chlamydia

• blood poisoning (septicaemia)

• tonsillitis

• tuberculosis

• middle ear infections*

• pneumonia*

• meningitis*

(*may also be caused by viruses)

Viruses. Some of the infections caused by viruses include:

• the common cold, and most upper respiratory tract infections, including croup

• mumps

• measles

• chicken pox

• influenza (flu)

• rubella (German measles)

• gastroenteritis

• glandular fever (infectious mononucleosis)

• hepatitis (A, B and C)

• AIDS

• herpes (coldsores)

• warts

• middle ear infections*

• pneumonia*

• meningitis* (*also caused by bacteria)

Fungal infections. These include:

• tinea

• ringworm

• thrush (vaginal candidiasis)

Parasitic infections. These include:

• malaria

• intestinal worms (tapeworm, hookworm, roundworm, pinworm)

• giardia

There are heaps and heaps more, but this is not a textbook on microbiology.

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Sometimes the bleeding will occur after having sex, maybe a day later. This may give the impression of having bleeding fairly often, depending on how often you have sex. Another common story is light bleeding in the week or so before the period is due to arrive, particularly in women on the oral contraceptive pill.

Some women may naturally have a light bleed, more like a Wood-stained discharge, around the time of ovulation. However there are important causes which need exclusion.

Infections may cause intermenstrual bleeding. Women who have never had sex arc unlikely to have a significant infection, but it should be considered in women who are sexually active. There may or may not be other symptoms of infection, such as vaginal discharge or pelvic pain. Infection with chlamydia, in particular, is often associated with intermenstrual bleeding. As some infections can affect fertility it is important to diagnose and treat them.

Endometriosis is another condition which may be associated with light, sometimes painful, intermenstrual bleeding.

Bleeding may be corning from the cervix. Pre-cancerous and cancerous lesions, or even a ‘normal’ variation like a large erosion may lead to bleeding between periods. Smear tests and closer examination of the cervix will help to identify abnormalities.

In older women, particularly, there is a need to exclude a more sinister cause of abnormal bleeding; cancer of the uterus. This is incredibly rare in younger women (under 40 years), and not all that common in older women (about one in a hundred women will develop it), but you would not want to miss it. Most women over 35 who have abnormal bleeding will be offered a curette or hysteroscopy in order to help with the diagnosis, and exclude cancer as a cause.

‘Breakthrough bleeding’ is a fairly common occurrence in women taking the oral contraceptive pill. It may be light bleeding, or more like a period. If the level of hormone floating around the blood stream happens to be lowered bleeding may occur. The level may drop if you miss a pill, or you are late taking it, have gastro, or because other medicines, like antibiotics, interfere with the absorption of the pill. This is usually no cause for alarm. You should continue the pill and, as the hormone level has dropped, you may be at risk of getting pregnant. To avoid this you should take extra precautions, like using condoms, or not having intercourse, for the time of risk (during the course of antibiotics, or gastro), and for at least seven hormone tablets later.

Some people have breakthrough bleeding on some pills, even without missing any. These women will often be offered a slightly different pill preparation (there are several different dosages and types). A different pill may not cause the same problem. However, it is important that other causes for intermenstrual bleeding are ruled out.

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