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Deciding between the different sorts of treatment options described in this book will involve weighing up the positives and negatives as you see them. The simple checklist that follows may be of use to you in this decision-making process. It may help to crystallise your thinking or it may suggest gaps in information that need to be filled before you can make a firm decision.

Step 1. Write the name of the treatment that has been suggested to you in the space provided.

Step 2. Following are two lists of possible outcomes. They have been grouped together as possible reasons in favour of a proposed treatment (pro) and against a proposed treatment (con). Space has been left for any additional pros and cons that you may need to include. Read through the lists and place a tick alongside any pro or con that is relevant to you. Leave a blank if that consideration has no importance one way or the other. If you do not have enough information to tick a line or leave it blank, place a question mark next to it to remind you to seek more information on it.

Step 3. Identify the most important pro and the most important con for you (highlighting or underlining them with a coloured pen may be helpful) and compare their importance.

Step 4. Select the next most important pro and con (using a different coloured pen), and then the next most important pair, and so on.

By continuing this process, it should be possible to decide whether the pros clearly outweigh the cons or vice-versa, or whether they are relatively even. If there is a definite loading one way or the other, you will be more certain of the reasons for accepting or rejecting a particular treatment. On the other hand, you may be alerted to questions that you need to have answered before you can make a decision.

You will notice that identical or similar possible outcomes appear in both the pro and con lists from time to time. This helps make the point that, for example, ‘Pregnancy no longer possible’ is a pro for some women at a particular age and stage of life and a con for other women in different circumstances.

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Looked at simply, these procedures can firstly increase the number of eggs released in any one cycle. (In IUI it can be two to three eggs. In IVF it can be two to eight eggs.) Secondly, these techniques can shorten the distance between your eggs and your partner’s sperm.

Fertilisation can take place inside or outside the body, depending on which procedure is used:

•    In IUI the sperm are put in the womb so fertilisation is inside.

•     In GIFT the sperm and egg are mixed together outside the body but fertilisation takes place inside.

•     In IVF the sperm and egg are put next to each other in the dish so fertilisation is outside.

•     In ICSI the sperm is put inside the egg so fertilisation is outside.

There are a number of different assisted conception treatments available. I will start with the Tow tech’ ones and go on to the more complicated treatments. Unless there is a medical reason not to, I suggest you embark on assisted conception by trying the low tech treatments first. The others are really a last resort. But your choice may be determined by your medical history. For instance, if you have blocked tubes you will need to go straight to IVF, while a partner with an extremely low sperm count will need to go straight to ICSI. Age is another factor. After the age of 35 the success rates for all procedures decline. As IUI has a lower success rate than IVF, a woman over 35 will probably be better advised to go straight for IVF.

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Endometriosis is now being diagnosed more frequently in teenagers than in the past. But very little of the available information has been written with teenagers in mind.

Menstruation is a normal part of a girl’s development. Some girls start having periods at the age of nine while others do not have a period until they are fourteen or older.

At the time of their period some girls develop bad stomach cramps or pains. Because pain is nature’s way of telling us that something is wrong in our body it should not be ignored.

Many teenagers experiencing period pain are told that every woman has period pain and that it is quite normal. In fact, some women never have cramps while others only have mild discomfort. Many girls are told that they will grow out of their menstrual pain. Unfortunately, if there is any underlying problem causing your period pain, you will not grow out of it. In fact, in time it could get worse.

Others are told that everything will be OK once they have a baby — not very helpful advice for a teenager.

You should visit your GP if your menstrual cramps are so severe mat you have to take time off school each month.

Your GP will want to know how you feel throughout your menstrual cycle. Be sure to provide as much accurate information as possible. Write the details down beforehand if necessary. You will be asked how long your period pain lasts, how severe the pain is and whether it stops you from doing your normal activities. You should also be asked if you have any other problems at the time of your period, such as heavy bleeding, backache or pain when you go to the toilet.

If you are not asked these questions and you do have any of these problems then you must say so. If you are sexually active and have found mat intercourse is painful you should tell your GP as intercourse is not normally painful.

After your GP has listened to you and asked questions it may be suggested that you try certain tablets such as Panadol to help ease the pain.

It may also be suggested that you try taking anti-prostaglandins such as Ponstan or Naprogesic. Prostaglandins are substances in your body that help control the contraction of your uterus (womb). An imbalance of these prostaglandins may cause your uterus to contract too strongly and therefore cause pain. Anti-prostaglandin tablets may help to dampen down the effect of the prostaglandins and thereby reduce your period pain. Your GP may even prescribe the birth control pill. If you do not ovulate (produce an egg ready for fertilisation) your period pain may not be as severe.

For the majority of teenagers the above treatments will significantly alleviate the pain. However, if none of these treatments help your pain then your GP should refer you to a gynecologist who specializes in treating women with complaints like this.

If your GP does not suggest that you see a specialist then it is OK for you to ask to see a gynecologist.

When you visit the gynecologist you will be asked numerous questions about your menstrual cycle. It will be necessary for you to be examined and the doctor may perform some tests to determine why you are experiencing so much period pain and/or other problems.

One of these tests is called a laparoscopy. This is an operation performed under a general anaesthetic where the gynecologist inserts a telescope-like instrument into a cut just below your navel. The gynecologist can then inspect your organs to see if anything is wrong.

During the operation it may be discovered that you have a disease called endometriosis.

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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.

In-vitro fertilization. Of course, the dramatic breakthrough in the treatment of infertility has been in-vitro fertilization (IVF), also called extra-corporeal (outside the body) fertilization. This is a method by which a blockage in the tubes may be bypassed. The detour is a delicate manoeuvre, and unfortunately not always successful, despite the endless supply of glowing stories and pictures of ‘miracle babies’ in the popular press. The success rate varies from centre to centre, but at the moment it averages about 15 per cent per treatment cycle in most Australian centres.

The procedure is, (very) roughly speaking, like this. Ovulation is usually induced, so there is more than one egg produced per cycle. (There are teams now using the ‘natural’ egg produced, but stimulating ovulation is more common, as it increases the odds of an eventual pregnancy.) The ripe eggs are identified using ultrasound, and removed from the ovary with a fine-needled syringe. The eggs are fertilised outside the woman’s body with semen already collected from the partner or donor. Tiny little embryos are formed. If several eggs are picked up at the initial collecting procedure then several embryos may result. The embryos can then be placed in the uterus. The number of embryos placed in the uterus per treatment cycle may vary, but in some states there are guidelines limiting it to a maximum of three embryos. Any extra embryos can be frozen and stored, and further treatment cycles (placing the embryos in the uterus) can be performed if an ongoing pregnancy does not result from the first treatment cycle. Most couples would undergo several treatment cycles.

There are variations on this procedure, and refinements taking place in the technology all the time in order to improve the success rate, as well as to modify the technology to meet the needs of certain groups. For example, GIFT (gamete intra-fallopian transfer) involves the placing of an egg and some sperm in the fallopian tube, unfertilized, to allow fertilization to take place.

The advances in the field are remarkable for their ingenuity, as well as for the controversy surrounding them. The technology has raced ahead of our comprehension, and only recently have we started to catch up by instituting legislation and guidelines to exert some control over the field.

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Indigestion and heartburn. Although this is classically a later pregnancy symptom (in the second and third trimesters), it is not uncommon for women to suffer from indigestion or heartburn in early pregnancy. It may relate to increased acidity in the stomach and altered eating patterns. Later in pregnancy it is related to the increasing pressure the enlarging uterus is exerting on the stomach, leading to reflux (washing back) of acid into the gullet.

In any stage of pregnancy, stomach problems may be relieved by drinking milk, or taking antacids, most of which are safe to take in pregnancy (check with your pharmacist or doctor).

Vaginal discharge. Many women notice a thin white discharge during pregnancy. This is usually not associated with itching, which distinguishes it from thrush.

Thrush is also more common in pregnancy, and can be treated safely with creams if necessary.

The white discharge associated with pregnancy is called leucorrhoea, and is associated with the change in hormone levels of pregnancy. In fact it becomes heavier in the later stages of pregnancy.

Later pregnancy-related symptoms. These include varicose veins, backache, muscle cramps, itching, and sleep problems, and are covered in books in the recommended reading list.

Well, it sounds like great fun, doesn’t it? Despite the list of unpleasant sensations most women have few problems, and cope well with the ones they do encounter. If you have any questions or concerns about anything that is happening to you, and you want to know if it is ‘normal’, get advice from someone who is likely to know. Usually that means a trained midwife or doctor. They are used to helping women through the uncertainties of early pregnancy. Don’t be afraid to ask.

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This bug, called trichomonas vaginalis, is a fairly common cause of a vaginal discharge, and is usually sexually transmitted. It could, perhaps, be passed on to other people on towels and toilet seats, etc. but the most effective way to get it (but who wants it), is by having sex with someone who has it. It may take between four days and four weeks from the time of infection for the symptoms to show.

Symptoms

In men there are usually no symptoms, except perhaps a little discomfort passing wee. In women it tends to give a pretty unpleasant discharge, namely greenish-yellow, often smelly, and sometimes frothy. It is sometimes associated with itching. But symptoms may not be present at all in up to 30 per cent of women who have the infection (asymptomatic infection).

Diagnosis

The trychomonad is a little swimming micro-organism, which has a tail. This is how it is identified under the microscope. It is sometimes picked up in asymptomatic women on the routine pap smear, but usually it is diagnosed on a swab test when a woman has investigations for an unusual discharge. When the vagina and cervix are infected they have a typical appearance, and the diagnosis may be made on that alone.

Trichomoniasis does not have any devastating consequences, but it may be travelling with other bugs, like chlamydia, so it is a good idea to be tested for other infections as well.

Treatment

Specific antibiotics will get rid of this infection, but it is essential to treat your sexual partner(s) as well, or you may get it back again. The antibiotics generally used are a seven-day course of metronidazole, or a single dose of tinidazole. In either case, these particular antibiotics do not mix well with alcohol. If you drink alcohol while the drug is in your system you may feel very sick, and vomit a lot. Not nice. The general rules about antibiotics and the oral contraceptive pill apply, too. Other treatments may be used if you are pregnant or breastfeeding.

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The injection is a long acting (twelve- to thirteen-week) hormone preparation (progesterone, no oestrogen). It is a very effective form of contraception, with the chance of an accidental pregnancy being less than with the combined oral pill. The only preparation available in Australia at present is Depo-Provera.

So why isn’t everyone using it? Unfortunately this drug has suffered from some bad press over the years. It has other uses, such as treatment of endometriosis and some cancers. (It is currently being assessed as a contraceptive by the government regulatory bodies in Australia, and it has been recently approved for this purpose in the United States.)

Depo-Provera may have some side-effects which make it less appealing to some women. It may (rarely) cause irregular vaginal bleeding, which may settle spontaneously after a few months. More commonly it causes periods to disappear altogether, and many women find this a welcome bonus, particularly if they suffer from heavy or painful periods. There is usually a delay of six months or more until periods (and therefore ovulation) return after ceasing Depo-Provera. Occasionally the delay may last twelve to eighteen months, but it does not have permanent effects on fertility. Some women do not tolerate progesterone well, and can have mood problems or minor weight gain with Depo-Provera, but this is not common.

Most women who use Depo-Provera have no problems at all with it. It is particularly useful for women who require reliable contraception but have trouble remembering to take a pill every day.

It is a widely used contraceptive in many other countries, including New Zealand, and some developing countries. In Australia it is used by some Family Planning Clinics, GPs and gynaecologists as a contraceptive when other forms are unsuitable. No drug is 100 per cent side-effect free. There is continuing research into this drug and it may one day become be more widely available to women as a contraceptive. We could do with a few more choices.

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Most girls will have irregular periods for the first couple of years after their periods begin. They may have bleeding every few months, or haphazardly at intervals of maybe two to three weeks. This, like most cases of amenorrhoea, is usually due to anovulatory cycles; the hormone levels are not yet sufficient to produce an egg each month. With time this usually changes so that the periods become regular.

Treatment for cycle irregularity is usually unnecessary, as it is a normal phenomenon. If it persists to the time when a woman considers trying to get pregnant it may be investigated and treated. Problems can arise if you have an irregular cycle and are not using contraception. It is difficult to tell if your period is late, or when is your most fertile time if you don’t know how long your cycle is. It is still possible to get pregnant with irregular cycles, as the ovaries may be firing off eggs irregularly, so it is important to remember contraception. The combined oral contraceptive pill has the bonus of regulating the cycle.

It is important to distinguish irregular periods from bleeding between periods (intermenstrual bleeding). Keeping a note of periods on a calendar can help in this. Bleeding between periods should always be investigated, in all women.

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