FAQ

What is infertility ?
Failure to conceive after one year of regular unprotected intercourse is called infertility.

Is it related to the time period after marriage ?
Yes, during first year after marriage, the frequency of intercourse is more, so there are more chances of pregnancy. More is the time since marriage more are the chances of unexplained infertility.

Is it related to women’s age?
Yes, the women is most fertile between the age of 18 to 25 years. ( 80%). The fertility goes down gradually as the age increases and it reaches as low as 15-20% above the age of 40.

When should a couple see an infertility specialist?
If a couple is unable to conceive even after one year of unprotected regular intercourse, they should see an infertility specialist.

What are the causes of infertility?
In 30-40% of cases the female factors are present like tubal block, PCOs, Endometriosis, ovarian failure, fibroids, septate uterus, bicornuate uterus etc. In 30-40% of cases the male factor is present like low sperm count due to various conditions like varicocele, hydrocele, tobacco and alcohol consumption, undescended testis etc. Patient may have azoospermia ( obstructive / non obstructive ). Some patients have both the male and female factor. Around 15-20% of patients have unexplained infertility.

What are the various treatments available?
If the tubes are open and the sperm count is good, superovulation IUI (Intra uterine Insemination) should be done. If there is a tubal block, PCO and the sperm count is good, IVF ( Invitro fertilization) is the treatment of choice. If there is a male factor infertility, ICSI (Intra cytoplasmic sperm injection) is the treatment.

What is super ovulation?
The female is given medicines like clomiphene citrate, letrozole, Injections like FSH, Urinary FSH, Recominant FSH, HMG etc. This will help to get more than one follicles in both the ovaries. Patient is given hcg injection to rupture the follicles when they reach adequate size. This process increases the chances of pregnancy by 30-40%. This is to be done with caution and should be done with an expert as there are chances of OHSS (Ovarian hyperstimulation syndrome) and multiple pregnancies.

What is IUI?
In this process the patient is stimulated with hormones and when the follicles reach 18 to 20 mm in size they are ruptured using hCG. The semen of husband is processed by either swim up or density gradient method and these processed capacitated sperms are inseminated in to the uterus just below the fundus. It gives 30-40% chance of pregnancy to the patient.

What are the results of IUI at Gynotech Associates(our affiliation) in the last two years ?
Around 960 IUI cycles were done in the last two years and around 332 patients got pregnant through this treatment, with success rate of 34.58%.

What is IVF and ICSI?
IVF is in vitro fertilization. In this technique patient is stimulated with hormones and when they reach size of 18-20mm, they are given Inj. hCG. Around 35 hours after hCG injection, follicles are aspirated transvaginally under USG guidance. The OCCs ( Oocyte cumulus complexes ) are then inseminated with husband’s processed and capacitated sperms for fertilization. The resultant embryos are then transferred back to uterus on day 2 or day-3. In ICSI instead of inseminating OCCs with sperms, each oocyte is cleaned of cumulus cells and is injected with single sperm with the use of micromanipulator. The rest is same as IVF.

What is diagnostic hysteroscopy and laparoscopy?
We don’t take any patient without doing hysteroscopy, because by doing so we can easily find out some treatable causes of infertility and can see the endometrial status. In Diagsnostic hysteroscopy we check the cavity of uterus through hysteroscope to find out any abnormality. Asherman’s syndrome, fibroid, polyp and septum etc can be treated at the same time. In diagnostic laparoscopy we can check ovaries for cysts, dermoids, the fallopian tubes for patency, uterus for adhesions and submucous fibroids. In PCO patient, drilling of cysts, removal of submucous myoma, adhesions etc can be done at the same time doing laparoscopy.

What are the results of IVF ICSI at gynotech associates(our affiliation)?
We expect three to four patients out of ten to get pregnant and usually we do get it.

What is PESA, TESA , MESA ? When is it required?
These are all sperm retrieval techniques. In patients of obstructive azoospermia ejaculate doesn’t contain sperms but we can aspirate sperms from epidydimis. It is called Percutaneous Epidydimal Sperm Aspiration (PESA), MESA is micro epidydimal sperm aspiration. Testicular sperm extraction (TESE) , Testicular sperm aspiration( TESA ) and testicular biopsies are done to get sperms from testis in case we don’t get it through PESA,MESA and in cases of testicular atrophy.

What is Ovum donation ?
The menopausal women, women with ovarian failure, with recurrent abortions, are donated oocytes from a healthy donor who is screened for all infectious diseases like HIV HbsAg and VDRL. The donor takes the hormones to prepare good follicles and so good occytes while the recipient takes estrogen to prepare her endometrium which has to be receptive for the embryos.

What is surrogacy and who requires it?
When embryos developed through infertile couple is implanted in the other fertile women’s uterus for further development, it is called surrogacy and the fertile women who carries the pregnancy and nurtures the child for nine months is called surrogate mother. The woman who has undergone hysterectomy, who has the history of recurrent abortions, who is at very high risk if she gets pregnant, are the potential patients opting for surrogacy.

Who needs sperm donation?
All azoospermic males and those with severe oligoasthenospermia patients with genetically abnormal sperms require sperm donation. Frozen and quarantined sperms which are free of HIV and hepatitis B can be used for insemination. Male factor patients who requires ART and who are not affording can also opt for this treatment.

What is cryopreservation?
Cryopreservation is the technique to store sperms and embryos for long period of time in liquid Nitrogen. The temperature of liquid nitrogen is -196 degree celcius

What is a Laparoscopy?
Laparoscopy is a procedure where a thin, lighted tube is inserted in your abdomen through a tiny incision. The Surgeon can look through the laparoscope into your abdominal and pelvic cavity and can see whether the Uterus, tubes and ovaries have any pathology.
To the end of the laparoscope is attached a video camera ,which allows us to view and record the image and thus the terminology

Video Laparoscopy:
If incase we find any pathology during diagnostic Laparoscopy, the Doctors at Beams are qualified and have the sophisticated equipment to do operative Laproscopy and take corrective action at the same sitting so that the patient does not have to undergo another surgical procedure.
Laparoscopy and Hysteroscopy at Beams is usually done under General Anesthesia.You may be given a mild sedative to help you relax before the procedure. Once in the operating room, you’ll be given anesthesia. This is so that you don’t feel any discomfort during the procedure.Diagnostic Laparoscopy often lasts just a few minutes and you will be monitored in the recovery area for sometime, you may be sent home the same evening. Once home, it takes 2 to 3 days to recover fully (or longer if you’ve had surgical laparoscopy).

Risks and Complications
Laparoscopy has relatively few risks. Your doctor will discuss these with you before the procedure.

Steps
The surgeon inflates the patient’s abdomen with a harmless gas so that the pelvic organs are easy to see. The laparoscope is inserted through a tiny incision in or near the navel. Other instruments may be inserted through another tiny incision. We attach a video camera to the laparoscope to enlarge and record the view. After the procedure, the gas is released. The incisions are closed with sutures which are self absorbable and do not need to be removed

You’ll see the anesthesiologist before surgery who’ll answer your questions about anesthesia. You’ll need to have a few routine lab tests done before the procedure. These tests tell us if you are well enough to undergo the surgery.
Follow instructions provided by your doctor. You are kept on a liquid diet for 2 days prior to surgery. Do not eat or drink anything after midnight and the morning before the procedure. Do not even drink coffee, tea, or water.
On the Day of the Surgery

• An anesthesiologist or nurse anesthetist may ask questions about the patient’s health, discuss the procedure and explain what to expect from the anesthesia.
• Before the surgery, an intravenous line, which consists of a small flexible plastic tube, may be inserted into a vein in the patient’s arm or hand. It is used to give medications and fluids during the operation. Sometimes intravenous medication is administered before surgery to help the patient relax.

What to Expect after the Surgery?
The effects of general anesthesia make most people feel groggy at first, but they quickly become more alert. Some people experience nausea for a short time after awakening from a general anesthesia. Some Laparscopic procedures require an overnight hospital stay, or a stay of a day or two, if you have had a major operative Laproscopic surgery.

What Problems Can Occur After Surgery?
Complications after laparoscopic surgery are rare. Most people recover quickly and resume their normal activities without problems. However, the risk of infection or other problems exists as with any kind of surgery.

• There may be some soreness near the incisions, especially when twisting or stretching the body.
• If a breathing tube was used for the surgery, patients may have a mild sore throat.
• There may be discomfort in the abdomen, upper chest, shoulders, and neck area due to the carbon dioxide used to inflate the abdomen, but this disappears quickly. You may notice a change in bowel habits for a few days.

You should avoid any heavy Strenuous activity, but are allowed to do all routine activity once you are discharged. You are usually advised to come back for a follow up visit a week after the procedure.

Recovery in Hospital
You may stay in the hospital 1 to 3 days to recover from the surgery and for observation. You are started on liquid diet the next day after surgery and gradually shifted to soft then full diet.

Recovery at Home
You should avoid any heavy Strenuous activity, but are allowed to do all routine activity once you are discharged. You are usually advised to come back for a follow up visit a week after the procedure.

What Self-Care Is Necessary After Returning Home?
Following laparoscopy, it is most likely that you will have to:

• leave the adhesive bandage or dressing on the incision till your next visit. During this period you are allowed to have a shower / bath, the dressing is waterproof.
• Incase the dressing comes out please wash the incision with soap and water, dry it and apply the regular waterproof band-aid.
• You can always comeback to the hospital for a dressing at any time.

How Long Will It Take For Full Recovery?
Recovery time depends on the kind of procedure, the patient’s age, and health before the procedure. The following is a normal timetable for recovery from minimally invasive surgery on the abdomen:

• The groggy feeling from the anesthetic disappears the day after surgery and the individual is fully alert once again.
• Any pain in the shoulders or neck area usually goes away after a few days.
• Soreness in the incisions disappears within a few days and the incisions heal after about five days.
  The bloated feeling after abdominal or pelvic laparoscopy goes away within a few days.

When can I go back to work?
Depending on the procedure most people feel well enough to return to work or normal daily activities three to five days after laparoscopy, although some people may need a week or more of rest.

Looking towards the future
New developments in minimally invasive surgery will result in operations that are even easier on the patient and the treatment of a wider range of diseases. In the future, minimally invasive surgery will:

• Use even smaller incisions that heal faster with even more invisible scars. The standard laparoscope is about one-half inch in diameter. Newer micro-laparoscopes are about one-tenth of an inch in diameter so that some procedures can be performed through small hollow needles.
• Be done for more and more diseases.

Use computerized technology developed to run industrial robots. A doctor located hundreds or thousands of miles from the operating room may perform laparoscopic surgery. The doctor may use an image transmitted over the internet, and move surgical instruments by remote control.

Anesthesia is the foundation of much of today’s modern surgical and obstetrical care. Our ability to perform miracles in surgery is based on our ability to safely care for patients. Anesthesiologists are the doctors who, through specialized training, are able to provide this care. In addition to their medical degrees, they have also successfully completed five or more years of speciality training to become experts in their craft. Anesthesiologists play an integral part in your surgical experience. They evaluate and prepare you for surgery and stay with you for the duration of your operation. Once your operation is finished, Anesthesiologists are responsible for your care if you need to be admitted to the intensive care unit. Anesthesiologists are also the driving force behind the ever-improving, specialized techniques that relieve pain after surgery. The Anesthesiologists are an important part of the team who will provide your care throughout your surgical expenses.This is a dynamic,forward-looking group of experts who bring the entire scope of modern anesthesia practice to your community hospital.

General Thought:
Obstetrical anesthesia is different from any other type of anesthesia in that there are two patients involved – you and your baby. It is important that you take both individuals into account when considering your anesthesia choices. Another factor to be considered is that labor is unpredictable. It can range anywhere from relatively quick and easy to painful and exhausting. An important point to remember is that evervone experiences pain differently. Only you will know the level of pain you’re experiencing, so you should never feel guilty about asking for pain relief. When it comes to using anesthesia in childbirth, most women fall into one of three categories: Those who are quite certain they will want pain relief. Those who are unsure of their pain relief options, and how they will affect their labor and delivery.Those who would prefer to give birth without any pain relief. No matter which category you fall into, it is important for you to know how anesthesia and pain relief are used in labor and delivery.No two women experience childbirth in quite the same way, so it is important to keep your options open. Every woman should be prepared for the possibility of needing an anesthetic

The ideal anesthetic should:

• Provide enough pain relief to allow you to deliver your baby with minimal pain and participate in the experience.
• Allow you to push when it is time to do so.

The ideal anesthetic should not:

• Stop contractions
• Make your baby sleepy

Commonly used obstetrical anesthetics:
There are several different forms of anesthesia administered for childbirth. They may be used independentlt or in conjunction with one another. Some of the most commonly administered anesthetics include:

Local anesthesia
Local infiltration – This series of local injections can make you more comfortable for delivery and for the placement of sutures if you need them.

Sedation
Narcotics or tranquilizers – Administered as an injection or intravenously, narcotics or tranquilizers can help reduce the pain of labor but will not eliminate the pain entirely. They are also used to ease the anxiety that sometimes accompanies the delivery process.

Regional anesthesia
Pudendal block – Administered as injections of local anesthetics to numb the vaginal area in preparation for delivery.

Epidural
An epidural is a local anesthetic delivered through a tiny tube called a catheter placed in the small of the back, just outside the spinal canal. An advantage of the epidural is that it allows most women to fully participate in the birth experience continue to feel touch and pressure) while relieving most, if not all, of the pains of labor. In most cases, the anesthetist will start the epidural when cervical dilation is four to five centimeters. Under certain circumstances, it may be desirable to place the epidural earlier.

Spinal (intrathecal)
This anesthetic is similar to an epidural, but because it is administered with a needle into the spinal canal, its effects are felt much faster. You may feel numb and need assistance in moving during the delivery. Spinal anesthetics are sometimes used for delivery by cesarean section or when the use of forceps is indicated. Epidurals or spinals cannot be used if the patient: uses blood thinners or has a bleeding tendency; is hemorrhaging or in shock; has an infection in the back or the blood; has an unusual anatomic condition or spinal abnormality; or if time is of the essence

General anesthesia
General anesthesia is administered by giving anesthetic drugs intravenously and having the patient breathe anesthetic gases. A general anesthetic may be necessary if complications arise during delivery. General anesthetics can be administered quickly, so they’re considered the best choice when time is of the essence. Also, general anesthesia enables the uterus to relax if your obstetrical provider finds it necessary

What your anesthetist should know
In order for your anesthetist to determine which type of anesthesia is best for you and your baby, it is important that you inform your anesthetist about:

• Food and drink intake for the last several hours. • History of difficulty breathing after anesthesia.
  History of lower back problems.
• Family history of high fevers.
• Any respiratory problems such as asthma, bronchitis, pneumonia, or if you have a cold, sore throat or flu.
• Special medical concerns such as cardiac disease, diabetes, asthma, and other medical conditions
  If you are a woman with any of these conditions, it is especially important that you meet with an anesthesiologists.

“Will I remember everything?”
“Will it affect my baby?”
“Will I be able to breast feed?”

These are some of the questions frequently asked by pregnant women about the use of anesthesia in labor and delivery. Because no two women experience pain or react to drugs in quite the same way, and because different anesthetic techniques have different effects, the answers to these questions will vary. There is no ideal anesthesia for everyone. This makes it very important for you to be informed, and discuss your options with your anesthetist, The purpose of anesthesia is to help you have the most positive birth experience possible. Anesthesia should not hinder you from enjoying your baby as soon as possible after delivery. You should be able to bond with and breast feed your baby, if you so desire. The better prepared you are before labor and delivery, the more rewarding the entire birth experience will be for you

assisted vaginal hysterectomy (LAVH). The technique used to use lasers but now lasers have been mostly replaced by surgical clips, cautery or suturing. It’s really a technique made to replace abdominal hysterectomy. If a vaginal hysterectomy can be performed in the first place, there would be no point in adding the costs and complications of laparoscopy.

I’m not sure what the impression is among women of why a LAVH is desirable. I think many women believe it is safer than an abdominal or even a plain vaginal hysterectomy. Most of the medical literature supports that it has the same complications as an abdominal or vaginal hysterectomy and IN ADDITION it has the complications of laparoscopy. These include injury to major blood vessels, the bowel or the urinary tract by the laparoscope introducer (trocar) or the needle used to infuse carbon dioxide into the abdominal cavity to facilitate visualization of the pelvic structures. Another conception is that the LAVH is faster to recover from. That part is actually true when it is compared to an abdominal hysterectomy. Without a large abdominal incision, there is less pain and recovery to normal activity is faster.

Hysterectomy is the second most commonly performed surgery..
A total or complete hysterectomy is a surgical procedure in which the uterus and cervix are removed. The term oophorectomy (or ovariectomy) refers to the removal of the ovaries, either one (unilateral) or both (bilateral). The fallopian tubes also may be removed in a procedure called salpingectomy. Therefore, when the ovaries and the fallopian tubes are removed along with the uterus, the procedure is called hysterectomy with bilateral salpingo-oophorectomy (BSO).

45.5 percent of all women who undergo a hysterectomy have their ovaries removed at the same time. In some cases, surgery is performed to remove only one ovary; even though the other ovary remains, sudden menopause can occur if the blood flow to the remaining ovary is compromised during surgery.

Commonly cited reasons why hysterectomies are performed include the following:

Pelvic inflammatory disease (PID)–The phrase pelvic inflammatory disease is a generalized term for an infection in the uterus and/or fallopian tubes and ovaries. It is primarily a result of sexually transmitted disease that has spread into the pelvic region. Signs and symptoms of PID may include abdominal pain, mid- to lower back pain, fever, nausea, vomiting, foul-smelling vaginal discharge, pain or bleeding during or after intercourse, and burning upon urination.

Endometriosis–This condition occurs when tissue from the endometrium (the lining of the uterus) attaches itself to other organs, usually in the pelvic area. Organs often affected include the fallopian tubes, ovaries, bladder, and bowel. Since the tissue originated inside of the uterus, it responds to the monthly hormonal cycle in the same way the uterus does. It builds and grows, then breaks down and bleeds. The inflammation and internal bleeding can result in the formation of scar tissue and symptoms such as pelvic pain, painful intercourse, heavy menstrual flow, fatigue, painful bowel movements, constipation, and diarrhea. Endometriosis also is a cause of infertility.

Uterine fibroid tumors–Fibroid tumors, or myomas, are very common and almost always benign (noncancerous). They originate from the muscle tissue of the uterine wall and can grow outward or inward. Small fibroids usually do not create problems, but large ones or clusters of fibroids can cause symptoms, including heavy, prolonged, or irregular menstrual bleeding; abdominal swelling; pelvic or back pain; constipation; and frequent urination.

Uterine prolapse–When the uterus “drops” from its normal position and protrudes through the vagina, it is said to have prolapsed. The normal uterus is anchored in place by ligaments, muscles, and fascia, but over the years, the uterus may change position. It can drop straight down, or tip forward or backward. Childbirth or obesity may entice the uterus to descend. Symptoms of prolapse may include pressure and heaviness in the vaginal region, a feeling of heaviness in the lower abdomen, lower backaches, and urinary frequency and incontinence.

Menorrhagia/metrorrhagia–The term menorrhagia refers to excessive or prolonged menstrual bleeding. Metrorrhagia refers to uterine bleeding between periods. A variety of conditions can result in one or both of these problems. Possible causes include fibroids, polyps, ovarian cysts, hyperplasia, birth control pills, hormonal imbalances, stress, or cancer. Menorrhagia and metrorrhagia need to be carefully evaluated.

Breast cancer–Some forms of breast cancer are estrogen-dependent. This means the hormone estrogen fuels their growth. If this is the case, the ovaries may be removed as part of the cancer treatment. Another breast cancer treatment option is the use of a special medication, such as Tamoxifen, that blocks the estrogen receptors on the cancer cells so they are not responsive to estrogen. Since these medications have become available, oophorectomy is less commonly performed for treatment of breast cancer.
Uterine, ovarian, and advanced cervical cancer–The extent of treatment for these cancers depends upon the type of tumor and how it is staged. Uterine cancer and ovarian cancer normally necessitate a hysterectomy. However, unless cervical cancer is advanced, it usually can be treated more conservatively.

It is important to note that, with the exception of cancer, hysterectomy is not the treatment of choice for the above conditions.

Hysterectomy, with removal of one or both ovaries, is the most common cause of sudden menopause. Because it is surgically induced, hormone levels plummet quickly and menopausal changes follow closely behind. By implementing the appropriate strategies, which are highly individual and span from natural remedies to medication, a high quality of life can be restored.

For detailed information on how to manage menopausal symptoms and reduce risk of osteoporosis, heart disease and cancer, click on Premature Menopause.

Questions Abound Following Hysterectomy

“How long will it take to get back to normal?” “Will I have hot flashes immediately?” These are a sampling of the questions women ask when faced with a hysterectomy.

Each year 600,000 women in this country undergo a hysterectomy. It is the second most commonly performed surgery in the United States.

Hysterectomy is surgery to remove the uterus and often the cervix. Almost fifty percent of the time, the ovaries and fallopian tubes are taken too. Reasons cited for having a hysterectomy include uterine bleeding, fibroids, uterine prolapse, endometriosis, chronic pelvic pain and reproductive cancer. With the exception of cancer, hysterectomy is not the treatment of choice for any of these conditions.

Recovering from a hysterectomy takes at least six to eight weeks. During this time, a woman’s body undergoes a variety of physical and emotional changes. Although every woman’s recovery and healing process is unique, some of her concerns are universal. As a menopause educator and author of Sudden Menopause, I frequently field questions from women across the country regarding hysterectomy. Here are four of the top ones.

Is it normal to be tired? It is normal to feel fatigued following major surgery. Your level of fatigue is influenced by many factors, such as your preoperative state of health and level of fitness. The single most common reason for profound fatigue is anemia. If your blood count was low before surgery or dropped after surgery, you will be more tired than what would be expected. During recovery, you should feel progressively more peppy; but don’t be surprised if it takes up to a year for your energy level to fully return.

When can I exercise my stomach muscles? One of the first observations of women who undergo an abdominal hysterectomy is that their stomach muscles are lax. Since these muscles have been cut and sutured during surgery, they need time to heal. Once you have received medical clearance, typically in six to eight weeks, you can begin toning and strengthening them. Before heading directly to “crunches”, prepare your abdominal muscles by doing isometric exercises. Simply contract your stomach muscles for five to ten seconds and release. Begin by performing 10-20 repetitions, two to three times daily. Strengthening these core muscles will also help alleviate the lower backache that often accompanies a hysterectomy.

Will I become depressed? The debate continues over whether a correlation exists between hysterectomy and emotional health. Many women report no noticeable changes in psychological well-being, in fact, some even state that they feel better. This is particularly true of women who tolerated intense pain or profuse menstrual bleeding. On the other hand, self-reports by countless women, as well as some studies, indicate that the likelihood of experiencing depression is higher after a hysterectomy versus other types of surgery, especially if the ovaries were removed or cease to function post-operatively. Often, changes in mood are attributed to circumstances surrounding the surgery such as coping with infertility, perceived loss of femininity, aging and presence of disease. However, these issues don’t exist for all women having difficulty with their mood. Clearly this experience varies with each individual and is worthy of further research.

Will I go into sudden menopause? If a woman is premenopausal at the time of a hysterectomy with removal of both ovaries, then she will be thrust into sudden menopause. If one ovary remains, it may be able to sustain normal hormonal functioning. Keep in mind though, of the women who have one remaining ovary, fifty percent enter into menopause within five years.

Sudden menopause is more abrupt and generally more severe than natural menopause because the body is thrown into a hormonal tailspin without time to adjust. Menopausal signs such as hot flashes, night sweats, mood swings, memory disturbances and sexuality changes can be managed by implementing dietary strategies, soy, flax, supplements, lifestyle modification and medicine when necessary.

As you can imagine, there isn’t one “right way” of healing from a hysterectomy and no one can predict how you will feel. Each woman’s experience is as unique as the woman herself. Allow yourself the time and support you need, so that your health and well-being will be restored.

How successful is endometrial ablation at stopping uterine bleeding problems?
There are different techniques for performing endometrial ablation. Originally physicians used a cautery “roller ball” technique or a Yag laser to burn the lining of the endometrium so it would not grow and slough each month. Recently a thermal balloon technique is the most popular because it seems to have less complications. In this technique a balloon in introduced into the endometrial cavity after hysteroscopy is performed and water is then injected into the balloon. The water is then heated and the lining of the endometrium is “scalded” so it does not keep growing under hormonal control.

The various techniques used for endometrial ablation may have slightly different outcomes but in general about 1/3 to 1/2 of women are completely without any bleeding afterwards (amenorrheic) while about 15-20% still have bleeding problems severe enough to warrant further surgery . The overall satisfaction rate of endometrial ablation is about 65%.

Is hysterectomy a better treatment than endometrial ablation for bleeding problems?
The two procedures are somewhat difficult to compare. One involves an outpatient surgery with recovery in less than a week and the other involves a 6 week recovery and somewhat higher risk (about 3-4%) of serious complications. One randomized clinical trial has been conducted comparing hysterectomy with endometrial ablation . Further surgical treatment was required during the follow-up period of 4 years by 36% of the women having endometrial ablation and 24% of the women having hysterectomy. Satisfaction rates were high for both groups being 80% in the ablation group and 89% in the hysterectomy group. The difference in satisfaction was due to the different need for retreatment. Premenstrual symptoms improved more in the hysterectomy group. A review or several trials comparing ablation and hysterectomy also came to this same conclusion . Thus you can look at this one of two ways:

Endometrial ablation allows about 75% of women to avoid hysterectomy
Hysterectomy was more successful in the long run in treating the bleeding problems as well as premenstrual symptoms

Another study following women for 6.5 years found that 20% of women undergoing laser endometrial ablation need a hysterectomy at a later time. A study with a shorter follow-up felt endometrial ablation was successful almost 90% of the time . In spite of the success of endometrial ablation, it does not seem to be replacing hysterectomy as a treatment for bleeding on the national or international level . Hysterectomy performance continues at the same per capita rate and ablation is an additional procedure available. The reason for this may perhaps lie in other associated problems for which hysterectomy makes more sense in the long run.

Endometrial ablation is a procedure that uses a lighted viewing instrument (hysteroscope) and other instruments to destroy (ablate) the uterine lining, or endometrium. Endometrial ablation can be done by:

• Laser beam (laser thermal ablation).
• Heat (thermal ablation), using:
• Radiofrequency.
• A balloon filled with saline solution that has been heated to 85 C (thermal balloon ablation).
• Electricity, using a resectoscope with a loop or rolling ball electrode.
  Freezing.

The endometrium heals by scarring, which usually reduces or prevents uterine bleeding.

What To Expect After Surgery
Endometrial ablation is usually done in an outpatient facility or hospital. The procedure may be done using a local or spinal anesthesia, although general anesthesia is sometimes used.
Recovery requires from a few days to 2 weeks.

Why It Is Done
Endometrial ablation is used to control heavy, prolonged menstrual bleeding when:

• Bleeding has not responded to other treatments.
• Childbearing is completed.

You prefer not to have a hysterectomy to control bleeding.
Other medical problems prevent a hysterectomy.

How Well It Works
Approximately 90% of women will have reduced menstrual flow following endometrial ablation, and up to half will stop having periods.

Younger women are less likely than older women to respond to endometrial ablation. After an endometrial ablation, younger women are more likely to continue to have periods and need a repeat procedure.

Young women may be treated with either gonadotropin-releasing hormone analogues (GnRH-As) 1 to 3 months before the procedure. This will decrease their production of estrogen and help thin the lining of the uterus (endometrium).

Risks
Complications of endometrial ablation are uncommon but can be quite severe. They can include:

• Accidental puncture (perforation) of the uterus.
• Burns (thermal injury) to the uterus or the surface of the bowel.
• Buildup of fluid in the lungs (pulmonary edema).
• Sudden blockage of arterial blood flow within the lung (pulmonary embolism).
• Tearing of the opening of the uterus (cervical laceration).

What To Think About
Endometrial ablation is not recommended if you have a high risk for endometrial cancer. Regrowth of the endometrium may occur.
Do not consider this procedure if you plan to become pregnant in the future.
Although this surgery usually causes sterility by destroying the lining of the uterus, pregnancy may still be possible if a small part of the endometrium is left in place. Birth control of some form is required if you have not completed menopause and do not wish to become pregnant.

ENDOMETRIAL ABLATION & THE RESECTOSCOPE as the alternative to HYSTERECTOMY

ENDOMETRIAL ABLATION
Endometrial ablation is an out-patient surgical procedure which was designed to destroy the lining of the uterus (endometrium). This procedure has proven an excellent alternative to hysterectomy when the woman suffers from excessive uterine bleeding. It is not effective for large fibroids (leiomyomata) or cancer. More than 85% of women who experience excellent results with endometrial ablation are able to avoid hysterectomy– usually permanently!

OPERATING HYSTEROSCOPE
The procedure of endometrial ablation is performed through an operating scope that looks like a narrow telescope. This is called a hysteroscope because the physician is able to ‘scope’ inside the uterus. The original procedure was performed by Milton Goldrath, M.D. at Sinai Hospital in Detroit in 1979. He taught me his techniques in 1984. However, the original procedure was time consuming using the tip of a Yag laser. Improved techniques were devised in the mid 1980’s using an electrical ball. This is called a ‘roller-ball’ procedure.

ROLLERBALL ENDOMETRIAL ABLATION
The instrument used is called an ‘operating’ hysteroscope. Hysteroscopy is the surgical procedure of looking into the endometrium to determine if an abnormal structure can be seen. The operating hysteroscope allows the gynecologist to remove tissue. He or she may use an electrical ball or bar to ‘burn away’ the surface of the uterus. This is similar to the electric pens used in wood burning. Destroying the endometrium is termed an endometrial ablation as seen in the photograph at right.

THERMAL ABLATION
Hysteroscopy is usually an office procedure. Operative hysteroscopy in usually an out-patient surgical procedure. In office hysteroscopy is relatively easy. Out-patient operative hysteroscopy is much more difficult to perform. Very few individuals reach the level of experience of those of the members of the American Association of Gynecologic Laparoscopists. That is why certain manufacturers have designed in-office and out-patient procedures to assist these surgeons. The most frequently used method is the
Thermachoice(TM) by Ethicon and the Hot Water Method by MEI.

The Thermachoice device uses a special baloon that is placed into the uterus through the cervix by the surgeon. Hot water is circulated in the balloon. After 9 minutes, the procedure is terminated. The limitations of this method is that fibroids or a different shape to the uterus renders this procedure less than ideal.

The Hot Water Method devices by Milton Goldrath and marketed by MEI uses no balloon. Based on Goldrath’s studies, the device allows water to fill all the cavities. The procedure is performed with the surgeon observing through the operative hysteroscope. The procedure takes 3 minutes. Both these procedures can be performed in an office with appropriate safe guards.

RESECTOSCOPE
The resectoscope is the most difficult tool to master. For this surgical procedure, the surgeon used a wire loop to cut-out strips of endometrium and the deeper myometrium (muscle). Because there is much more tissue destruction, there is less ability for the uterus to regenerate the endometrial lining. The resectoscope also is able to cut-out polyps and scarring from abnormal development. AT LEFT is the FIBROID! AT RIGHT, the resectoscope has removed the FIBROID entirely! Data from our office confirms that a successful RESECTOSCOPE left women with no menstrual flow more than 85% of the time. In the last two years, in more than 50 cases, only one woman needed a hysterectomy while 6 had very light menstrual flow. Resectoscope is twice as effective as Thermal Ablation for those who perform this procedure routinely.

ADENOMYOSIS
When an endometrial ablation fails, it is often due to Adenomyosis. This is a condition associated with multiple childbirths. After each pregnancy, the endometrial glands grow deeper into the myometrium (muscle wall of the uterus). In some women, these glands grow down more than 1/3 to ever half way through the wall. In these cases, even the deepest resectoscope will not be able to stop the uterine bleeding from these deep glands. The photograph at left shows adenomyosis gland openings and successful resectoscope ablation on the right. In other cases, hysterectomy is best to control the problem of uterine bleeding.

FIBROIDS
Fibroids or leiomyomata are muscle tumors that grow in the uterus. If these growths are within the uterine cavity, it may be possible to cut them out using the resectoscope. If they grow through the walls of the uterus, they cannot be removed. If they are left behind, it is possible that they will grow and cause problems that would necessitate a hysterectomy. Fibroids are surgically removed in women of childbearing age when they become large and obstructive. Small fibroids are usually left alone. It is a myth that menopause will shrink fibroids. Everyone is different. We educate our patients that oral contraceptives and estrogen replacement may enlarge fibroids. Gn-RH agonists, Lupron and Synarel, are used to shrink fibroids. But their use is limited to approximately 9 months.

This operation is called endometrial ablation or endometrial resection.

Does it work?
We’re not sure. Destroying the womb lining can make your periods lighter. But there’s not enough research to say if removing the lining of your womb helps if you have fibroids.

So far, only two kinds of operation to destroy the womb lining (called thermal balloon endometrial ablation and rollerball endometrial ablation) have been tested in women with small fibroids. We need more research in many women, including those with larger fibroids, to know if an operation to remove your womb lining can help symptoms caused by fibroids.

What is it?
The lining of your womb is known as your endometrium. There are lots of different ways of removing the womb lining. It can be cut away in small pieces (known as endometrial resection) using a special instrument, such as a heated wire loop. Or your womb lining can be destroyed (known as endometrial ablation) using heat in a variety of ways. Newer techniques include using heat from microwaves, electrical currents or a heated rollerball (called rollerball ablation). But not all techniques may be suitable if your heavy bleeding is caused by fibroids.

We’ve prepared some extra information for people thinking of having these operations. To read more, see Endometrial ablation (diathermy) and Endometrial ablation (microwave).
Thermal balloon endometrial ablation is a simple treatment that has been tested in women with small fibroids. A surgeon uses a balloon filled with hot water to heat up the lining of your womb and destroy it. You can stay awake during this treatment, and it takes only about 15 minutes to 30 minutes.1
Here’s what you can expect:

• You may be given a sedative or painkiller first
• Your doctor gives injections of local anesthetic in and around the neck of your womb (your cervix) so the treatment won’t hurt
• Your doctor then puts a tube with a balloon on the end into your womb
• Your doctor fills the balloon with water, which is then heated up

Are there any dietary restrictions during pregnancy?
Diet during pregnancy should be focused on eating a variety of nutrient-rich foods that nourish the mother as well as the developing baby. This should include plenty of fresh fruits and vegetables, carbohydrates from grains and breads and protein from fish, meat or nonmeat sources, such as beans and legumes. Women should also take a prenatal vitamin before and throughout pregnancy to ensure that they are getting all of the nutrients their baby requires, including folic acid.

Pregnant women should avoid certain foods and beverages to reduce the risk of sickness, pregnancy complications and birth defects. These include:

• Alcohol – should be completely avoided during pregnancy
• Caffeine – no more than 200 mg/day (about 1-2 cups of caffeinated beverages)
• Raw meat (including sushi that contains raw fish)
• Foods that may carry listeria bacteria including raw eggs, deli meat, hot dogs, soft cheeses, pates and unpasteurized dairy products
• Fish known to contain high mercury concentrations including shark, swordfish, tilefish and king mackerel.

Can I exercise while I’m pregnant?
Regular exercise during pregnancy is safe and can even be beneficial. It can reduce the risk of gestational diabetes and ease constipation and back pain. As a rule, a woman may continue her normal fitness routine while she is pregnant, though some adjustments may be advised. Pregnant women should check with their OB-GYN to make sure their exercise routine is safe.

Generally, low-impact and nonstrenuous activities are best. Contact activities such as football or soccer should be avoided in order to protect the abdomen, as should those which involve repeated jumping or bouncing. Pregnant women should also take extra measures to stay well hydrated and avoid overheating while exercising.

Which over-the-counter medications are safe to take during pregnancy?
Some over-the-counter (OTC) medications are safe to use during pregnancy, but a handful of common medications, including aspirin and ibuprofen, should be completely avoided. All medications should be used sparingly during the first 12 weeks (the first trimester), a particularly important period of fetal organ development.

OTC medications that are safe to use during pregnancy include:

• Tylenol
• Sudafed (avoid during first trimester)
• Robitussin DM
• Imodium
• Benadryl
• Metamucil, Colace, Miralax, Milk of Magnesia – for constipation
• Tums, Rolaids, Pepcid, Gaviscon – for heartburn and indigestion

The above is not a complete list. When in doubt, a woman should be in close contact with her OB-GYN to discuss taking OTC medications and supplements during pregnancy.

What changes will I have to make to my lifestyle during pregnancy?
Some women may need to adopt certain lifestyle changes in order to have the healthiest possible pregnancy and to avoid complications such as gestational diabetes, miscarriage and birth defects. The following adjustments should be made before a woman starts trying to get pregnant, and certainly after she is pregnant:

• Stop use of all tobacco products
• Stop use of all recreational drugs including marijuana
• Stop drinking alcohol
• Lose weight if overweight, or gain weight if underweight
• Start taking a prenatal vitamin
• Eliminate exposure to environmental toxins in the home and workplace, including avoiding scooping cat litter, which can spread a parasite infection called toxoplasmosis.

What are the normal “side effects” of pregnancy?
pregnancy | CU OB-GYN | pregnant woman browsing internetAs the body undergoes significant changes to accommodate and support the developing fetus, certain pregnancy symptoms and side effects are to be expected. Some of the more common ones are listed below.

Morning sickness
Morning sickness is nausea and vomiting that tends to occur in the first trimester of pregnancy. Despite its name, it may occur any time of the day, though many women experience the most severe symptoms upon waking. For most, morning sickness goes away after the first trimester, but for a small number of women it may last throughout the pregnancy.

Medical treatment for morning sickness is usually not needed, as it tends to resolve on its own as pregnancy progresses. Eating small meals throughout the day can help reduce nausea, and in some cases an OB-GYN may advise a patient to take certain anti-nausea medications for relief of symptoms. Natural remedies such as peppermint and ginger can also be helpful.

Constipation
Constipation during pregnancy is common and can be attributed to a variety of factors. Early in pregnancy, constipation is often caused by changing hormones and increased water absorption in the intestines, both of which slow down the digestive system. Prenatal vitamins can also cause constipation in some women. As the pregnancy progresses, decreased physical activity and the enlargement of the uterus can also cause constipation.

Mood changes & fatigue
Mood swings and fatigue are very common aspects of pregnancy. They are attributed to hormonal and physical changes in the body. Changes in mood tend to be particularly severe early in the pregnancy and late in the third trimester as the body prepares for birth.

Some women experience depression during pregnancy, a condition known as antepartum depression. This can be very serious and debilitating. A woman experiencing persistent feelings of hopelessness, guilt, anxiety or lack of interest in things she normally enjoys should contact her doctor right away to discuss treatment options. Our PROMISE Perinatal Mood Disorder Clinic screens our patients from the 20th week of pregnancy and beyond birth for mood problems, offering treatment and support.

Heartburn
As hormone changes brought on by pregnancy cause the digestive system to slow, food stays in the stomach longer. This can lead to acid reflux, in which stomach acid bubbles into the esophagus and throat and causes a painful burning sensation. Additionally, the growing baby can put pressure on the stomach, worsening heartburn symptoms.

Women experiencing heartburn during pregnancy may find relief by eating smaller, more frequent meals, avoiding foods that trigger heartburn, drinking plenty of fluids, and taking antacids such as Tums or Rolaids. If these measures don’t resolve a patient’s heartburn, physicians will often prescribe heartburn medication.

Fetal movement
Sometime during the second trimester, the movement of the baby becomes detectable. This subtle movement is called “quickening.” As the baby develops, the movements will become more pronounced, because the baby is beginning to stretch, hiccup, kick and turn.

During the third trimester pregnant women are advised to take note of how often their baby is moving. As a rule, 12 or more movements should be felt throughout the day during the third trimester. If a woman is observing fewer movements or a sudden decrease in fetal movement, she should contact her OB-GYN.

Contractions
Throughout the third trimester, women will experience an irregular pattern of contractions. These are called Braxton Hicks contractions, and unlike labor contractions, they do not occur in a pattern or increase in severity. However, they are sometimes painful.

True labor contractions tend to last longer than Braxton Hicks contractions (up to a full minute) and will occur at a regular frequency with increasing severity.

How can I plan for labor and delivery?
Developing a birth plan is an important part of pregnancy for most women. A birth plan addresses how the baby will be delivered (vaginally or via cesarean section), how to manage labor pain, desired birthing position, who will be present in the room during delivery, and other important details. Expecting mothers should plan on discussing their birthing plan preferences with their OB-GYN.