This is the crucial question: Why do implants “take” with some women and not with others? Such is the continuing mystery of endometriosis.

Four basic causes:

• Hereditary factors. You will be more likely to get endometriosis if close female relatives have had the condition, too.

• Immune system stress. Endometrial implants may be more likely to proliferate when this infection-fighting system is weakened.

• Hormone levels. Higher estrogen and prostaglandin levels are associated with more cases of endometriosis and pain from the disease.

• The embryonic theory. One supposition is that you are born with the condition in a dormant state. If the internal environment is right, endometriosis will “take” and grow.

No one knows precisely what combination of factors in what degree will create endometriosis, but I strongly believe that heredity and immune system stress are two major influences. One we cannot change, but the other—immune system stress—can be altered.

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You may focus on your pain by imagining that you are in an open field on a warm sunny day. Just beside you is a helium-filled balloon with a large basket attached. You imagine that you load up the basket with all your pain and discomfort. The balloon now slowly rises up in the air and floats away, taking with it the basket loaded with your pain.

You may focus on your endometriosis by imagining that the endometriosis cells in your body are being invaded by your body’s natural defenders, an array of white blood cells. The white cells destroy the unwanted endometriosis cells and you can visualise your organs healthy once again.

These images may also focus on yourself. You may like to imagine yourself in surroundings that give you enormous pleasure. For example, you may visualise yourself on a tropical island, peacefully lying on the warm golden sands while palm trees gently sway in the breeze and the waves quietly lap onto the shore.

You may like to imagine yourself walking through a field early in the morning, the lush green grass still glistening in the sun from the morning dew. You notice the deep blue sky dotted with wispy white clouds, the golden sun sending forth its warming rays and the spring flowers showing forth a multitude of colours. You then enter a cool dark forest, which feels refreshing after the warm sun. Here you may rest a while, taking in the peace and tranquillity of your surroundings, before returning to reality.

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Back pain-Lower back pain is a far more common symptom of endometriosis than is generally acknowledged. Some 59% of women surveyed reported that they had experienced back pain. The pain may be mild to debilitating and may be felt continuously or more commonly at the time of menstruation or ovulation.

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Nature has designed your reproductive system to work in harmony, each hormone dependent on the other and all working together as a whole system. Any imbalance in any part of this delicate process will affect the production of hormones and with it the chances of conceiving or staying pregnant once fertilisation has occurred. It does not take much to upset the balance; but simple changes in diet and lifestyle can restore it. By getting yourself into optimum health you increase the chances of conceiving because your whole reproductive system will operate more efficiently.

Let’s first look at the hormones step by step, over one cycle, to see how they work:

1.     At the beginning of the menstrual cycle (first day of the period), FSH (follicle stimulating hormone) is released from the pituitary gland.

2.     The FSH stimulates a group of follicles to grow on the surface of the ovary.

3.     Over the next two weeks (the follicular phase of the cycle), the eggs grow and mature and oestrogen produced by the ovary keeps increasing.

4.     As the oestrogen levels increase, the pituitary gland decreases its production of FSH, and LH (luteinising hormone) production is then triggered. Fertile alkaline mucus is produced in the cervix ready to keep the sperm alive and to speed its transport.

5.     As the LH surges, the mature egg (usually only one) is released from the follicle (ovulation) and enters the fallopian tube.

6.     The empty follicle becomes the corpus luteum which produces progesterone. This is the second half of the cycle (the luteal phase).

7.     The fertilised egg stays in the fallopian tube for seven days. On the seventh day after fertilisation (i.e. approximately day 21 of the cycle), the egg (which is now a developing embryo) develops chorionic villi which are special protrusions on its surface to enable it to implant in the womb lining.

8.      The chorionic villi produce a hormone called human chorionic gonadotrophin (hCG) which means that the corpus luteum continues to increase in size and produce more progesterone, thus maintaining the pregnancy. (hCG is the hormone that is picked up by a pregnancy testing kit.)

The timing of all this is crucial. It is vital that the journey through the fallopian tube takes around seven days. If it is shorter then the fertilised egg could arrive in the womb before it is able to embed itself in the lining and die. If the journey takes much longer than seven days then the fertilised egg could embed itself in the fallopian tube instead, causing an ectopic or tubal pregnancy which can be life-threatening for the woman.

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You don’t catch HIV through touching, hugging, kissing, sharing clothing or eating utensils, sneezing, coughing, insect bites or by using public drinking fountains, toilets or swimming pools. It is especially important to understand this if you are living or working with someone who may be infected, or assisting with the care of someone with AIDS.

If you have any questions, ask someone who knows, or ring the AIDS Information Hotline (in the telephone book) in your State.

So, readers, though this information is only a drop in the ocean, I hope it’s useful to you. Unless the nature of the epidemic changes in Australia, I predict that women’s involvement with AIDS during the next decade will be mainly helping with the support and care of people who are already infected by HIV, or as agents in the prevention of spread (by their behaviour and through the education of their children and others). Knowledge and understanding provide the surest means of preventing further spread of this terrible epidemic.

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Urinary tract infection is more likely if there is anything interfering with the free flow of urine from the kidneys to the outside: for example, congenital abnormal ties of the urinary system; kidney, ureter or bladder stones; tumours or any other obstruction to the bladder outlet; anything that presses on the drainage system from outside, such as the pregnant uterus or a tumour in the abdomen. Foreign bodies (such as a catheter) in the bladder can introduce infection.

The symptoms of acute pyelonephritis are high fever with chills, headache and muscle aching, often vomiting and diarrhoea, pain in the loins, frequency, pain on passing urine, maybe bloodstained, cloudy or foul-smelling urine.

If you suspect pyelonephritis, see your doctor without delay. Prompt treatment is very important to prevent destruction of kidney tissue, which could result in kidney failure or septicaemia. Antibiotics are usually started as soon as a urine specimen has been taken to see which germ is causing the infection and which antibiotics will kill it. When the laboratory results are available (usually after 48 hours), your doctor will tell you whether you’re taking the right antibiotic. Your urine must be checked after treatment to be sure that the infection has completely cleared. If the source of the infection isn’t obvious, your doctor will suggest tests so that the cause can be found and treated to prevent future attacks.

Not all nephritis is caused by infection: the kidneys can become inflamed by some poisons and drugs, and by auto-immune reactions. Non-infectious nephritis is also serious and can lead to kidney failure if it’s not treated. The symptoms and signs of non-infectious nephritis may be much less dramatic, and include reduced urine output, smoky grey urine, puffiness of the face, swelling of the hands and feet, fatigue, and maybe slight fever and mild pain in the loins. Your doctor will always suggest urine and blood tests to check for nephritis if you have any such symptoms with no other obvious cause.

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The cells around the walls of the follicles continue to produce hormones (including some male hormones) in the usual manner, but because there are so many more follicles, much more hormone is released into the blood. At first the excess of oestrogen causes the endometrium to become much thicker, making periods heavier. The lack of progesterone (because no corpus luteum has formed from a ruptured follicle) also contributes to heavier periods, and usually makes bleeding irregular.

Later, as more and more cysts form, ovarian function becomes more disturbed and the production of oestrogen diminishes. There may not be enough to cause any growth of the endometrium, so periods stop. There is now a relative excess of male hormone, and signs of masculinisation begin to appear. These include weight gain, acne, increased growth of facial and body hair and occasionally deepening of the voice.

The cause of the disturbance of ovulation in PCO is not clear. The most popular theory at present is that there is a mix-up of the normal control of ovarian function by the hypothalamus and the pituitary gland.

The ovaries can fail to respond to pituitary hormones. This occasionally happens in women younger than the expected age of menopause, though rarely for women under 30 years of age. Ovaries often fail after treatment of cancer (in any part of the body) with radiation or chemotherapy, but in most other cases the cause of premature menopause is obscure. Treatment by replacement of ovarian hormones is essential to preserve health, and will restore menstruation.

• polycystic ovaries can cause secondary amenorrhoea as can, of course, the destruction of the ovaries by disease or removal by surgery.

Uterine causes

These causes of secondary amenorrhoea are rare. The inner layer of the endometrium may be too deeply removed during curettage, so that there is little left from which a new endometrium can regrow in the next cycle and scar tissue begins to close the uterine cavity. This is called Asherman’s syndrome. It is most likely to happen – though still rare – during curettage for incomplete abortion or after childbirth. It is extremely rare after induced abortion by suction aspiration. For treatment a non-copper IUD is inserted to hold the cavity open enough to prevent scarring and allow the endometrium to regrow from the remaining fragments.

When Rachel saw that she bore Jacob no children, she envied her sister; and she said to Jacob, ‘Give me children, or I shall die’.

Jacob’s anger was kindled against Rachel, and he said, ‘Am I in the place of God, who has
withheld from you the fruit of the womb?

Genesis 30:1-2

The feelings of Rachel and Jacob will be painfully familiar to many subfertile couples. Envy, anger, guilt, blame, denial desperation are still common reactions.

If the cause of subfertility is found, many will search their past for some deed for which they are being punished. Commonly (and most wrongly) blamed are premarital sex, contraception, previous pregnancy or abortion, sexually transmissible infection, extramarital fairs, masturbation, homosexual thou or acts, even sexual pleasure. Feelings of guilt and blame can be very destructive. Needless to say that these thoughts are unproductive, but they’re very hard to suppress. Talking about them with your partner and counsellor helps to put irratational feelings in their place.

You may dread breaking the news to family and friends. Even before a problem is identified, you may have become wary of remarks such as ‘Isn’t it about time we had some grandchildren?’ or ‘When are you thinking of starting a family?’. Couples may keep the secret about their infertility because they don’t want to be objects of pity or receive unsolicited advice. Such advice is often based on myths: ‘Relax and you’ll be OK’; ‘Take a holiday’; if the woman is working ‘Give up your job’; if she’s not working ‘Get a job and stop worrying about it’. Enquiries such as ‘Any luck yet?’ can trigger anger or misery. It only takes one remark perceived as insensitive (though well intended) to make the matter a touchy subject to be avoided.

The problem may be recognized at a time when most of a couple’s friends are starting families. Every pregnancy that’s announced – especially an unwanted one – seems like another turn of the screw. Couples may become so sensitive that they withdraw from any situation that might produce contact with pregnant women or babies. This isolates them even more from what they see as normal, and may deprive them of the comfort and support of friends when they need it.

The inherently sexual nature of subfertility may add to a couple’s difficulties in discussing their worries with anyone, including professional helpers. Most couples would prefer to keep private the intimate details of their sexual relationship, but in the investigation and treatment of subfertility attention is focused on their sexual activity, which is scrutinized, counted, recorded, and directed by influences quite outside their spontaneous feelings for each other. Sex may lose its pleasure and become a perfunctory chore. As one woman said: ‘We don’t make love any more: we only try to make babies’. Another said: We never have sex now except when I’m ovulating. What’s the point’.

So when’s the best time to have sex? Many doctors and women want to use temperature and mucus charts to pinpoint the time of ovulation so that the couple have sex at the ‘right’ time. In my opinion this can be overdone and often leads to sexual tensions and problems. Women may become obsessed with their charts. I have heard of women refusing to go out when they expect to ovulate, or ringing their husbands at work, demanding that they come home at once for sex. Some men have difficulty with erection and ejaculation when they’re required to have sex ‘on demand’ rather than when they feel like it.

In most cases I believe that less anxiety and fewer sexual problems are created if couples trying for pregnancy continue to have sex when the mood takes them, and hope that it happens every couple of days. Of course if you’re on treatment to make you ovulate it’s important not to miss out around the time that ovulation happens. You must take your doctor’s advice on this matter, but let’s hope that sex retains its pleasure and doesn’t become a chore.

Other tensions may develop between the partners, especially if they can’t share their feelings. The woman may despair about her partner’s inability to empathize with her anxiety about procedures, her fixation on her temperature chart, her feelings about menstruation, her anxious hopes when her period is late or her bitter disappointment when it comes. The man may not be able to share his anxiety about having to masturbate to produce a semen specimen to be ’scored and counted’, or to perform sexually as soon as his partner ovulates. Their relationship, especially the sexual side, may suffer badly. Both may fear that they will end up not only childless but divorced.

Of course many couples take subfertility or infertility in their stride and come through with a stronger bond than ever. Those who are well informed and’ communicate well are the most likely to survive the tests, treatments and emotional impact with an intact relationship.

If there’s nothing that can be done for your problem or if treatment fails, you may experience strong feelings of grief and loss. Your counsellor can also help you work through this grief, and can assist if you decide to adopt a child.

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Feeling so good heightens your awareness of what’s happening. You marvel at the miraculous development going on inside you. You have wonderful daydreams and fantasies about life ahead with your child. Your renewed energy starts a burst of enthusiastic preparations for the baby.

You develop a great interest in baby clothes and equipment. You avidly read and learn everything you can about child-bearing and baby-care. This is a very special time, especially during your first pregnancy. Enjoy it!

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