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First Trimester Screening |
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Madam TW was 28 years of age married for 2 years with no children. She complained that her menstruation had stopped for 8 months. She attained menarche at the age of 14 and was having regular menstrual cycle when her menses stopped suddenly. She underwent blood tests and 2 repeated blood tests showed that her follicular stimulating hormone (FSH) and luteinizing hormone (LH) levels were above 40IU (hypergonadotrophic hypogonadism) indicating that she is in menopause. She did not complain of any climacteric symptoms and did not have any family history of similar problems. She was otherwise a healthy lady. Ultrasound showed that her uterus and ovaries were normal. Chromosomal analysis was normal. She was diagnosed as a case of premature ovarian failure. She was started on cyclical hormone replacement therapy and she regained her normal menstrual cycle. After 2 years of regularly taking her HRT, she missed her periods for 2 months. Surprised at this occurrence, she underwent an ultrasound which revealed that she was pregnant. The pregnancy progressed normally, and delivered a healthy child in 2000. Subsequent to the delivery, her serum FSH and LH levels were again very high and she did not regain her menses. She was started back on the HRT. Even though she has been trying to conceive for several years now, she had not achieved a second pregnancy spontaneously.
Premature ovarian failure or premature menopause is defined as cessation of menstruation before 40 years of age. Eventhough these two terms are used interchangeably “Is premature ovarian failure really premature menopause?”
This case above illustrates the difference between natural menopause and premature ovarian failure. When a baby girl is born, her ovaries contain about 2 million oocytes (eggs). When she reaches puberty the number of oocytes dwindles to 300,000 to 500,000. The reason for this is that oocytes are constantly dying, a process called apoptosis. This continues to occur throughout women’s life. For every follicle that ovulates, approximately 1,000 undergo atresia. Women become menopausal when the ovaries are depleted of oocytes. So natural menopause is an irreversible condition resulting from ovarian follicle depletion at an average age of 50. Whereas in young women with premature ovarian failure, there are still many oocytes which will produce oestrogen intermittently despite the presence of high levels of gonadotrophin and so ovulation is still possible. However, the follicles in most cases are not functioning normally. Due to the high levels of LH, inappropriate luteinization of graffian follicles appears to be a major pathophysiologic mechanism impairing follicle function in young women with spontaneous premature ovarian failure
In these patients even though the women cease to menstruate, the ovaries still contain oocytes. Their oocytes although in general are unable to mature and ovulate, on occasion may ovulate and in such instances pregnancy can occur. It is difficult to predict which patients will ovulate and achieve a pregnancy. It is all a matter of chance. There have been many reports of spontaneous pregnancies occurring after premature ovarian failure just like the case illustrated above. As such, some would not like to call premature ovarian failure as premature menopause.
Premature ovarian failure (POF) causing high levels of gonadotrophins (FSH and LH) occurs in 1% of women. In majority of cases the underlying cause is not identified. The known causes include: (a) Genetic aberrations, which could involve the X chromosome or autosomes. (b) Autoimmune diseases causing ovarian damage (c) Iatrogenic following surgical, radiotherapeutic or chemotherapeutic interventions as in malignancies. (d) Environmental factors like viral infections and toxins for which no clear mechanism is known.
Premature ovarian failure may present as either primary (no menses at all) or secondary amenorrhea. The majority of the patients develop ovarian failure after having established regular menses (secondary amenorrhoea). No characteristic menstrual history precedes premature ovarian failure. Approximately 50% of the patients have a history of reduced menstrual flow (oligomenorrhea) or irregular menstruation (dysfunctional uterine bleeding), 25% develop amenorrhea (cessation of menstruation) acutely, some postpartum, and some after stopping oral contraceptives.
Primary amenorrhea is not associated with symptoms of oestrogen deficiency. Symptoms in cases of secondary amenorrhea may include hot flushes, night sweats, fatigue, and mood changes. Incomplete development of secondary sex characteristics may occur in women with primary amenorrhea, whereas these characteristics are usually normal in women with secondary amenorrhea. These young patients generally have normal fertility before developing premature ovarian failure.
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Management of Premature Ovarian Failure |
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Young women find the diagnosis of premature ovarian failure particularly traumatic, and a carefully planned approach is required when informing patients of this diagnosis. It is important to emphasize that premature ovarian failure can be transient and that in most cases we can never be certain that no follicles remain in the ovary. Treatments of such patients are basically two fold. The first is hormone replacement therapy and the second to deal with the issue of infertility.
1. Hormone Replacement Therapy
Young women with premature ovarian failure need oestrogen/progestin replacement therapy to relieve symptoms of oestrogen deficiency, to maintain bone density, and to reduce the risk of cardiovascular disease. Patients with karyotypically normal spontaneous premature ovarian failure have a bone mineral density 1 standard deviation (SD) below the mean of similar age women despite taking hormone replacement therapy at least intermittently. Of note, this bone density has been associated with a 2.6-fold increased risk for hip fracture. Young women with premature ovarian failure have a nearly twofold age-specific increase in mortality rate.
All women with premature ovarian failure should fully understand that hormone replacement should be continued at least until the average age of natural menopause (approximately 50 years) and that they should have long-term follow-up by a physician with an interest in this condition. These young women usually require administration of oestrogen at a dose equivalent to 1.25 mg of conjugated estrogen, which is greater than the standard dose given to older women experiencing natural menopause. Androgen replacement should also be considered in women experiencing persistent fatigue, poor well being, and low libido despite adequate oestrogen replacement. Patients with premature ovarian failure should also be informed of the need for adequate calcium intake and physical activity.
2. Infertility-Related Therapy
Women with premature ovarian failure have intermittent ovarian function, and they have a 5-10% chance of spontaneous pregnancy. There is no treatment to restore fertility in young patients with premature ovarian failure that has been proven safe and effective in prospective controlled studies. Theoretically, these unproved therapies might even prevent one of these spontaneous pregnancies from occurring. Hormone replacement therapy does not prevent conception, and indeed these young women may even conceive while taking the oral contraceptive. Attempts at ovulation induction in these patients using clomiphene citrate, human menopausal gonadotropins, and a combination of gonadotropin-releasing hormone analog with purified urinary FSH resulted in no greater ovulation rates than those seen in untreated patients. For women with premature ovarian failure desiring fertility, oocyte donation is an option, and in fact this treatment is as successful in older women as it is in younger women. Anecdotal reports have suggested that glucocorticoid treatment may restore ovarian function in women with premature ovarian failure. However such treatment is currently investigational.
In some cases, it is possible to foresee premature menopause as in patients undergoing anticancer treatment with chemotherapy. Because dividing cells are more sensitive to the cytotoxic effects of these drugs, it has been hypothesized that inhibition of the pituitary–gonadal axis using gonadotrophin releasing hormone analogues (GnRHa) would render the germinal epithelium less susceptible to the cytotoxic effects of chemotherapy. This approach has also been advocated for young women requiring gonadotoxic treatments for SLE, organ transplantation and other autoimmune diseases.
Other fertility options for women diagnosed with cancer include cryopreservation of ovarian tissue, cryopreservation of mature and immature oocytes and IVF followed by cryopreservation of embryos. Pregnancies and life births have been reported after oocyte cryopreservation and subsequent intracytoplasmic sperm injection. Cryopreserved ovarian tissues can be transplanted and follicles can be developed from this transplanted ovary. The first live birth after orthoptic transplantation of cryopreserved ovarian tissue has been reported recently (Donnez et al., 2004).
A woman's age would be a determining factor when considering ovarian cryopreservation. Children are most likely to benefit from it as their ovary contains more primordial follicles than adult women and other alternatives of oocyte or embryo cryopreservation are unavailable for them. It is also expected that by the time these children grow up and need their ovarian tissue, the modalities for its optimal use would become available.
Ovarian tissue cryopreservation and oocyte cryopreservation thus hold promise for fertility preservation in the women likely to undergo ovarian failure following cancer treatments. This treatment may, however, be contraindicated in cases with possible metastasis to the ovaries where oocyte donation and IVF would be safer.
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Follow-up of Patients With Premature Ovarian Failure |
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Young women with premature ovarian failure should be monitored annually regarding their compliance with hormone replacement therapy. Moreover, these patients should be followed up for the presence of signs and symptoms of associated autoimmune endocrine disorders, such as hypothyroidism, adrenal insufficiency, and diabetes mellitus. Additional testing should be performed as clinically indicated. |
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Conclusions |
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Normal menopause occurs at an average age of 50 and results from ovarian follicle depletion. Normal menopause is an irreversible condition, whereas premature ovarian failure is characterized by intermittent ovarian function in half of these young women. As such premature ovarian failure is not synonymous with premature menopause. These young women produce oestrogen intermittently and sometimes even ovulate despite the presence of high gonadotropin levels. Indeed, pregnancy has occurred after a diagnosis of premature ovarian failure. No treatment to restore fertility in young patients with premature ovarian failure has been proven safe and effective in prospective controlled studies. Theoretically, these unproved therapies might even prevent one of these spontaneous pregnancies from occurring.
Early loss of ovarian function has both significant psychosocial sequelae and major health implications. Young women with premature ovarian failure have a nearly twofold age-specific increase in mortality rate. They need a thorough assessment, sex steroid replacement, and long-term surveillance to monitor their therapy. Also, these young patients should be followed up annually for the presence of associated autoimmune endocrine disorders such as hypothyroidism, adrenal insufficiency, and diabetes mellitus.
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References |
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Kalantaridou, S. N. Premature ovarian failure: not just a premature menopause: 197. European Journal of Clinical Investigation, Supplement. 35 Supplement 2:66, April 2005.
Goswami D, Conway GS, Premature ovarian failure.
Hum Reprod Update. 2005 Jul-Aug;11(4):391-410. Epub 2005 May 26. Review.
D. Nikolaou and A. Templeton, Early ovarian ageing.
Eur J Obstet Gynecol Reprod Biol. 2004 Apr 15;113(2):126-33. Review.
Dr. S. Selva, FRCOG |
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There is universal interest in developing a permanent source of cells which would be capable of generating any cell type and which would avoid the problem of transplant rejection. These human stem cells have the unlimited capacity to divide and the potential ability to develop into most of the specialised cells or tissues of the human body.
Human stem cells can give rise to different types of cells such as muscle cells, nerve cells, heart cells and blood cells. They could be potentially useful in generating replacement cells and tissues to treat many conditions, including Parkinson’s disease, Alzheimer’s disease, leukaemia, stroke and heart attack.
There are two major sources of stem cells: adult stem cells and embryonic stem cells. Cord blood is a relatively rich source of haemopoietic stem cells (HSC). About 100ml can reconstitute the haemopoietic system in small patients, usually children. The first successful related cord blood transplant was undertaken 16 years ago. Since then, over 3,000 transplants have been done worldwide.
In the past, the media has been highlighting such successes. It brings hope to many affected families. The best known staunch supporter of embryonic stem cell research Christopher Reeves (a.k.a Superman) did not live long enough to witness any major breakthroughs in stem cell cures for his spinal paralysis.
It is important that we do not lose perspective of the limitations of this new technology and thus send wrong messages and create false hopes to the general public. Private cord blood banks has hyped on anecdotes and isolated examples of success in stem cell therapy. The issue is clouded further by the sales pitching and often non-evidence based medicine claims of private cord banks. Undoubtedly, parents would be vulnerable to “emotional marketing” at the time of the birth of their child. Professor Nick Fisk, Chairman of the Royal College of Obstetrics & Gynaecology Scientific Advisory Committee said “We are concerned that commercial companies are targeting pregnant women with such emotive literature when the scientific evidence is not yet there to back up their claims”.
There are no accurate estimates on the likelihood of children requiring their own stored cord blood. The best guess of this ever happening range from 1 in 1,000 to 1 in 200,000. There is therefore only a tiny and remote chance of children ever requiring to utilize their own stored cells.
Scientific indications for collection and banking of cord blood are far and few in between. In families where there is a known genetic disease that can be treated by HSC transplantation, cord blood collection and storage are recommended for siblings born into these families. Cord blood collection is also recommended in specific settings, for e.g.
1. A sibling who is suffering from leukemia, just in case he relapses and may require cord blood transplantation
2. A sibling in whom cord blood transplant is indicated but has no match related donor available.
The storing of cord blood privately by private cord banks is based on the premise that the sample is stored specifically for use within the family concerned and more specifically the child's own future use (autologous transplant).
Autologous transplantation itself may be problematic because the use of one’s own stem cells may not cure the underlying pathology. In the case of leukaemia and other congenital disorders, e.g. Thalassaemia and Fanconi’s Anaemia, transplanting one’s own stem cells with the defective genetic and immune structure would only result in returning the disease to oneself.
The 80-100ml of umbilical cord blood collected at birth may not be adequate when the baby grows into an adolescent or adult. The volume of cells is insufficient if he should ever require it later in life. Thus, the concept of a 'biological insurance' which is much hyped by the private cord banks is therefore actuarially unsound given the very low estimates on the likelihood of use, or the need of using one's own cord blood for transplantation. The emotional marketing is however burgeoning the bank balances of private cord banks.
The government has now come out with some guidelines to address the issue of cord blood collection and cord blood banking for future transplantation. The National Blood Bank has been collecting and banking cord blood as part of its non-profitable National Cord Blood Bank. The National Cord Blood Bank would be available to doctors to search the public registry for possible unrelated but matched samples as an alternative source for stem cell transplantation.
In the final analysis, public cord blood banking should be expanded for the benefit of the wider population. Collection of altruistic donations of cord blood and directed donations for families at high risk should be encouraged. The National Cord Blood Bank was set up to achieve these objectives at no cost. Rather than just to keep the cord blood banked for one's own use, it should be made available to others who may need the cord blood in the allogenic (genetically different) setting.
Dato’ Dr Musa Mohd. Nordin, FRCP
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Plastic surgery for the face and body is well accepted by our society and gradually becoming a trend among our young and old women. Our society’s penchant for perfection has finally migrated “below the belt” as well. These latest procedures include tightening and reshaping of the vulva and vagina. What is unique about this area is the patented and secretive nature of some of the most marketed technologies and the large financial gain driving this industry. This leads to a serious concern with regards to its safety and efficacy.
This surgery has brought to public attention two years ago by extensive media coverage especially in developed countries. Articles have appeared in the Wall Street Journal, New York Times, Canadian National Post, and numerous online journals. This publicity has led to an outcry by providers in women’s sexual health especially on an international website. Driving many of the objections are the slick advertisements and supported assertions that their patented methods are superior to conventional techniques without mentioning of its adverse effect. There was a tremendous increase in the request for genitoplasty in the British NHS, twice the number of cases in one year period from 2004-05 (Liao LM 2007).
A similar article regarding cosmetic procedures has also been published in Malaysia, by Health at Large, Sunday 15 April 2007 revealed opinion from a few private gynaecologists. A month later following this article, the Ministry of Health, had come out with a technology review paper regarding their stand pertaining to the procedures titled ‘Laser Vaginal Rejuvenation and Design Laser Vaginoplasty’, which unfortunately completely overlooked the non cosmetic aspect of laser surgery. |
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What is “designer perineum surgery” ?
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It is an aesthetic surgical procedure of the vulva structures, labia minora, labia majora, mons pubis, clitoris, perineum, introitus and hymen. This plastic surgery is to repair or reshape or reduce the vaginal muscles and/or the perineum, and interior/posterior repair, and also reshape the mons pubis. The vaginoplasty surgery tightens the vaginal walls, reinforces the vaginal support (muscles and connective tissue), and tightens the vaginal opening. The latest is Designer Laser Vaginoplasty (DLV). This technique was developed by Dr David Matlock from the United State. It is basically just a modification of traditional perinealrrhaphy, where instead of using a scalpel, laser is used to open up a passage to vagina for a precise surgical incision. The pencil-like tip of laser equipment can take delicate design easily, bloodless, less adhesion, less painful and without scar formation. It has anti-bacterial properties, therefore reduces post operative wound infection and faster recovery. The procedure is done under general, epidural or local anaesthesia which last about 60 to 120 minutes (Matlock 2006) depending on the type of procedure, whether single or combination with Laser Vaginal Rejuvenation (VLR).
Designer Laser Vaginoplasty (DLV) can correct problems ranging from irregularly shaped and sized labia to skin discolouration to restoration of the hymen. Procedures are individually tailored to the patient to address her specific problems and concerns. Laser Reduction Labioplasty can sculpture the elongated or unequal labial minora according to ones specification. Most women they do not want the small inner lips to project beyond the large outer lips. Laser reduction labiaplasty techniques can also reconstruct conditions that are due to the aging process, childbirth trauma, or injury.
- Laser Perineoplasty is to rejuvenate the relaxed or aging perineum. It can also enhance the sagging labia majora and labia minora. Overall, this labia plastic surgery procedure can provide a youthful and aesthetically appealing vulva.
- Augmentation Labioplasty can provide aesthetically enhanced and youthful labia majora by autologous fat transplant (removal of the patient’s fat via liposculpturing and transplanting it into the labia majora).
- Vulvar Lipoplasty can remove unwanted fat of the Mons pubis and upper parts of the labia majora. Liposculpturing can alleviate the unsightly fatty bulges of this area and produce an aesthetically pleasing contour.
- Hymenoplasty (reconstruction of the hymen) can repair the hymen to restore “virginity”.
- Combination of DLV with LVR: LVR and DLV can be performed in combination. They can also be performed with most other cosmetic surgery; the most popular of these are Liposculpturing, breast implants, breast reduction, tummy tuck, nose surgery, and eyelid surgery.
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Laser Vaginal Rejuvenation (LVR) is a modification of a standard gynaecologic surgical procedure for the enhancement of the sexual gratification. According to Masters and Johnson, sexual gratification for female is directly related to the amount of frictional force generated. LVR can help restore optimum friction during intercourse and also provide aesthetic enhancement of external vaginal structures, resulting in a more youthful look. The vaginal muscles and connective tissues are tightened as well as reducing redundant vaginal mucosa. The procedure enhances the vaginal muscle, tone, strength and control, and effectively strenghtens the internal and external introitus. It can also build up the perineal body.
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Why do cosmetic surgery of the vulva?
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Designer perineal surgeries benefits these groups of patients with the following: pelvic organ prolapse, urinary incontinence, ambiguous genitalia (hermaphrodites), wide, absent or stenosed vagina, painful episiotomy wound or bad perineal scar following vaginal delivery, redundant or stenosed prepuce and enlarge clitoris.
It is increasingly common for gynecological surgery to be performed not just for medical reasons alone but also to enhance sexual pleasure. Other subjective indications include feeling of discomfort when wearing clothing, performing exercises or during sex. Some women claimed that abnormal appearance of their vulva decreases their self-esteem and confidence. Weak perineal muscles reduces vaginal support apparently diminishing sexual gratification. |
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What is the hype all about?
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The aim of cosmetic surgery is to achieve the ideal vulva and vagina! The anatomy of female genitalia is well documented scientifically. Unfortunately, the majority of women do not really know what is normal and what is not. Their knowledge is mainly based on the observation of a child’s genitalia or from the pornographic magazine. The perception of normal perineum is also influenced by cultural taboo (Braun V 2001). Therefore research into socio cultural representations of the vagina may be relevant to consideration of genital appearance.
A wide variation in the genital appearance is to be expected, and as women age there will be changes in the labia minora. Some women are born with a wide vagina. However, a distinction should be made in women who seek labial reduction when there is no suggestion of disease.
High above Sunset Boulevard, in Matlock's plush, 5,000-square-foot office, vaginas are being redesigned, labia modified, vulvae reconfigured. Women are spreading their legs, exposing their personal secrets to the antiseptic trimmings and surgical prunings of a trusty laser, and they are the ad hoc pioneers in a rapidly growing industry. The Laser Vaginal Rejuvenation ad featured a bikini-clad woman writhing in orgasmic delight. The headline read: "You Won't Believe How Good Sex Can Be!" But is LVR truly a way of enhancing sexual gratification or simply a way of selling gynecological surgery while pushing for the perfect vagina? With the reasons for LVR and DLV as diverse as the vagina themselves, the answers are not so cut-and-dried.
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According to Matlock, gynaecology is a super surgical subspecialty as gynaecologists dedicate our entire professional careers to the reproductive tract. But do we ever go back and look at the so called “damage” that result from labor, delivery and childbirth? There can be relaxation of this or that structure and a perceived decrease in sexual gratification.
Sexual gratification is very personal. For women who are “severely damaged”, sex should still be intense and passionate." And herein lays the crux of the problem. No one would disagree that "severely damaged" women are entitled to great sex. While a staggering 30 percent of women will develop some form of pelvic floor disorder resulting in incontinence or compromise of vaginal integrity after birth, about 5 to 10 percent will be so damaged that they are physically and emotionally traumatized. Is this why 40-, 50-, 60-year-old men are courting younger women?
There are over 25 medications for male impotence, and it takes $500 to $600 million to bring one drug into research and development. These are the facts. There is nothing remotely similar for women. There are over 200 prosthetic devices for men in the market but nothing similar for women. If men had babies, and certain body parts are stretched out as a result, they would have been looked at, researched and solved a long time ago.
As cosmetic surgery becomes more widespread, designer vaginas may become as common as the silicon breast -- a sinister prospect that has many women's advocates up in arms. "Women's genitals are fascinating, unique and beautiful," says pioneering sex therapist Betty Dodson, who for decades has helped women discover their genitals, and particularly their clitoris, which she describes as women's "little phallic symbol that terrifies the status quo". She considers LVR and DVR as truly odious procedures except for very extreme cases.
The effectiveness of the procedures is still unclear. Matlock (2006) claimed that he is carrying out numerous studies on the effectiveness of his procedures. The cost for DLV and VLV is estimated to range between USD$3000.00 and USD$20,000 depending on the type of procedure and anaesthesia (Laube 2006).
These procedures are not permanent though, as aging and child birth will destroy the integrity of the vagina. Augmentation labioplasty using autologous fat will only last for few weeks. Like face lift, vaginal cosmetic surgery need to be redone. There is no storng evidence regarding the effectiveness of the procedures and the safety aspect of this technology, only anecdotal claims from customers can be found from the website. To those considering LVR or DLV, these two procedures are not without their risks, among them hemorrhage, infection, loss of sensitivity, lingering pain from nerve damage and sexual dysfunction. To date no related legal action being reported pertaining to these procedures.
There is currently no literature addressing the legal aspect of the procedure. It could level DLV as a form of female genital mutilation. According to the WHO definition, all procedures involving partial or total removal of female external genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons is consider genital mutilation (Convoy 2006). In Arabs countries, hymenoplasty is an illegal procedure. Therefore Matlock could become the Salman Rushdie of the Islamic vagina. However, he claimed that "If I can help a woman in this unfair world, then I'm going to go ahead and do it. I have no problems about doing it whatsoever. The man, he gets to do whatever he wants to do. Is he held accountable for anything? Absolutely not.”
Women have to be clear that the procedure would not improve the sexual libido. Sexual gratification is individualized it could be affected by not only physical problems but also psychosocial. Before offering women the procedure, their sexual life has to be explored, preferably by a psychosexual counselor. Unfortunately women who see the problem as physical may resist referral to psychosexual or other psychological services. Furthermore the availability such services are currently rare and there are long waiting lists (R Bramwell 2007). |
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Conclusion |
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To date, there are no robust evidence on the safety, efficacy or cost effectiveness and legality of DLV and VLV. Patient who wish to undergo the procedure need detail counseling regarding the indication, the long term and short term implication especially the safety aspects.
The use of this technology in our society should be made with extreme caution to avoid unethical practicec by gynaecologists as this procedure may be used for the wrong purposes. In the end, the patient should make the final decision regarding their own anatomy. |
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References |
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1. Liao LM, Creighton SM. Requests for cosmetic genitoplasty: how should
health providers respond? BMJ 2007;334:1090-2.
2. Braun V, Kitzinger C. Telling it straight? Dictionary definitions of women’s
genitals. J Socioling 2001;5:214-32.
3. Braun V, Wilkinson S. Socio-cultural representations of the vagina. J
Reprod Infant Psycol 2001;19:17-32.
4. Braun V, Kitzinger C. The perfectible vagina: size matters. Cult health sex
2001;3:263-77.
5. Debra Ollivier.Designer vaginas, Nov.14, 2000
6. Conroy R.M. (2006). Female genital mutilation: whose problem, whose
solution? BMJ,333(7559):106-107.
7. Matlock D(2006). The Laser Vaginal Rejuvenation Institute of Los angeles.
Cited 14” May 2007 and 21st May 2007. Available from
http://www.drmatlock.com
8. Laube D.W. Clinical Obstetrics&Gynaecology,.49(2):335-336
9. Bramwell R, Morland C, Garden AS. Expectations and experience of labial
reduction: a qualitative study. BJOG 2007;114: 1493-1499
10. Kong Howe Leng. Reviving the passage of birth. After birth april 2007.
11. Junainah S, Norzakiah M.T, Rugayah B. Laser Vaginal Rejuvenation,
Designer Laser Vaginoplasty. Health Technology assessment Unit, Medical
Development Division Ministry of Health Malaysia. Mei 2007
Dr Aruku Naidu, MRCOG
Dr Zalina Nusee, MOG |
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Preterm delivery rates vary from 6% to 15% of all deliveries, with the rate increasing in recent years.1 Respiratory distress syndrome (RDS) causes significant mortality and morbidity in these babies.RDS is known to affect 40-50% of babies born before 32 weeks.2 Evidence has been available since 1972 that the antenatal administration of corticosteroids prior to preterm delivery reduces the incidence of RDS.3
Clinicians should offer antenatal corticosteroid treatment to women at risk of preterm delivery because antenatal corticosteroids are associated with a significant reduction in rates of RDS, neonatal death and intraventricular haemorrhage.4This evidence is especially clear for those below 34 weeks but the extent of prematurity will vary according to the pediatric support available in individual units.
Indications for antenatal corticosteroid therapy would be women between 24 and 34
weeks of gestation with any of the following:
- threatened preterm labour
- antepartum haemorrhage
- preterm rupture of membranes
- any condition requiring elective preterm delivery
Between 35 to 36 weeks obstetricians might want to consider antenatal steroid use in any of the above conditions although the numbers needed to treat will increase significantly to reduce the perinatal morbidity for any statistical significance.4
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Healthcare organisations and services should have policies and protocols in place for antenatal steroid treatment because the cost and duration of neonatal intensive care is reduced following corticosteroid therapy.4 It is therefore prudent to initiate antenatal steroid treatment in all high risk cases.
The optimal treatment-delivery interval for administration of antenatal corticosteroids is more than 24 hours but fewer than seven days after the start of treatment.4 Beyond this duration there is insufficient evidence of benefit.
Women may be advised that the use of a single course of antenatal corticosteroids does not appear to be associated with any significant maternal or fetal adverse effects.4 Corticosteroid therapy is contraindicated if a woman suffers from systemic infection including tuberculosis. Caution is advised if suspected chorioamnionitis is diagnosed.4 This is because steroids may mask the signs of chorioamnionitis as well as delay intervention.
Betamethasone is the steroid of choice to enhance lung maturation. Recommended therapy involves two doses of betamethasone 12mg, given intramuscularly 24 hours apart or four doses of dexamthasone 6mg, given intramuscularly 12 hours apart.4 However, newer evidence is to the contrary. Ten trials (1089 women and 1161 infants) were included. Dexamethasone decreased the incidence of intraventricular haemorrhage compared with betamethasone (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.21 to 0.92; four trials, 549 infants). No statistically significant differences were seen for other primary outcomes including respiratory distress syndrome, bronchopulmonary dysplasia, severe intraventricular haemorrhage, periventricular leukomalacia, perinatal death, or mean birthweight.7 Therefore, now dexamethasone has been found to be superior to bethamethasone.
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References |
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1. Slattery MM, Morrison JJ. Preterm delivery. Lancet 2002; 360: 1489-97.
2. Chiswick M.Antenatal TRH. Lancet 1995; 345: 872-3.
3. Liggins GC, Howie RN. A controlled trial of antepartum glucocorticoid treatment for prevention of the respiratory distress syndrome in premature infants. Pediatrics 1972; 50: 515-25.
4. Antenatal corticosteroids to prevent respiratory distress syndrome. RCOG Green Top guideline No 7. February 2004.
5. Crowther CA, Harding JE. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003935. DOI: 10.1002/14651858.CD003935.pub2. Repeat doses of prenatal corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease.
6. Roberts D, Dalziel SR. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004454. DOI: 10.1002/14651858.CD004454.pub2.Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth.
7. Brownfoot FC, Crowther CA, Middleton P. Different corticosteroids and regimens for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane
Database of Systematic Reviews 2008, Issue 4.
Dr. H. Krishna Kumar, MRCOG |
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As the number of Assisted Reproductive Techniques (ART) cycles in Malaysia increases, it is expected that the number of cases of Ovarian Hyperstimulation Syndrome (OHSS) will also increase in tandem. Most assisted conception treatment is conducted in very specialised settings and it is not surprising therefore that many gynaecologists are unfamiliar with the management of this condition, though they may come across it in their practice. This article attempts to provide the general gynaecologists a guide as to how to diagnose and treat this condition.
OHSS is a systemic disease resulting from the release of vasoactive products by hyperstimulated ovaries. It is typically associated with exogenous gonadotrophin administration. The pathophysiology revolves around an increase in capillary permeability resulting in a fluid shift from the intravascular space to third space compartments. Vascular endothelial growth factor (VEGF), a vascular permeability factor which plays an integral role in follicular growth, corpus luteum function and ovarian angiogenesis is implicated in this condition. The levels of VEGF correlate to severity of OHSS.
This is not an uncommon condition, with mild to moderate OHSS occurring in 33% of ART cycles while severe to critical OHSS, 3-8% of ART cycles. There are two typical timing to the onset of OHSS. The early onset OHSS occurs typically within 9 days after Human Chorionic Gonadotrophin (hCG) administration, and is likely to be due to precipitating effect of exogenous hCG. The late onset OHSS (after 9 days), is more likely to be due to endogenous hCG from pregnancy.
It is important to recognise the risk factors for the development of OHSS. This includes young age (<30 yrs), low body weight, Polycystic Ovarian Syndrome (PCOS), the use of GnRH agonists, higher doses of exogenous gonadotrophins, high or rapidly rising serum oestradiol levels, exposure to Luteinizing Hormaone or hCG and previous episodes of OHSS.
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Classification (modified Mathur 2005) |
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Mild |
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Abdominal bloating |
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Mild abdominal pain |
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Ovarian size<8cm |
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Severe |
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Clinical ascites (occasional hydrothorax) |
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Pulse rate≥100 bpm |
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Oliguria |
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Haemoconcentration (Hct>45%) |
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Moderate abdominal pain |
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Nausea± vomiting |
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Pulse rate<100 bpm |
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US evidence of ascites |
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Ovarian size usually 8-12cm |
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Critical |
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Tense ascites or large hydrothorax |
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Pulse rate≥100 bpm |
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Haematocrit>55% |
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Outpatient Management with or without admission to Day Ward |
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Outpatient treatment is suitable for mild, moderate and some of severe OHSS. The mainstay of treatment is supportive with analgesics (opiods-DF118, PCM), antiemetics and antacids. The patient is advised to drink to thirst and concentrate on fluids like isotonic drinks. If possible she is advised to increase protein intake in her diet. The clinician should consider albumin 20% infusion about 50 to 100 mls. The patient’s weight and abdominal girth should be monitored and pelvic ultrasound is carried out to check the ovarian sizes and presence of ascites. Important laboratory tests include haemoglobin, haematocrit, serum electrolytes, creatinine and liver function tests. The patient can be allowed home and is reviewed every two or three days. Her luteal support can be continued provided hCG is avoided. |
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Inpatient Management |
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Most patients with severe OHSS especially those with persistent haemoconcentration and dehydration, and all patients with critical OHSS should be admitted to hospital for further management. The management of this condition requires a multidisciplinary approach. The mainstay of treatment is also supportive care with intravenous fluids (2-3 L/day), albumin 20% infusion 100-150mls two or three times a day, analgesics and antiemetics. As the risk of thrombosis is 0.7-10%, thromboprophlaxis should be considered. The patient’s fluid balance, abdominal girth and weight should be monitored. Consider performing chest ultrasound if hydrothorax is suspected as well as ECG or echocardiography as well if necessary. If the patient is very uncomfortable, consider paracentesis or pleural drainage. |
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Paracentesis: |
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Significant discomfort and respiratory embarassment |
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Persistent oliguria : relief of intraabdominal pressure may promote renal perfusion and improve urine output |
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Drainage of ascitic fluid may resolve hydrothorax |
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Rate of ascitic fluid drainage should be controlled (< 3 L/day) to prevent cardiovascular collapse due to massive fluid shifts |
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Cover with intraveous colloids |
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Prevention |
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As the saying goes, prevention is better than cure. ART practitioners should consider using the lowest dose and duration of stimulatory drug as far as possible. The index of suspicion should be high in patients with risk factors. In women who are likely to be a hyper responder or has polycystic ovaries, consider the GnRH antagonist protocol or ovarian drilling prior to IVF, though this may not be agreeable to all practitioners.
If exaggerated ovarian response occurs, preventive measures can be employed which may help prevent one severe OHSS in every 18 treated. If there are 20-25 follicles above 12mm and the patient is asymptomatic, trigger with a reduced hCG dose of 5000-7500 iu (or Ovidrel 6500iu). Administer IV Albumin 20% 100 mls and 500 mls of Ringer’s lactate at the time of oocyte retrieval.
If there are more than 25 follicles above 12mm or more than 15 follicles above 12mm and the patient is symptomatic, the following should be considered:
- if leading follicle<16mm, reduce the FSH dose by 50-75 iu per day and scan every 2 days
- if leading follicle>16mm, measure serum oestradiol. If the oestradiol level is between 10,000 to 15,000 pmol/l, reduce the FSH dose by 50-75 iu per day and when ready, trigger with hCG 5000iu and give Albumin and fluids during ooyte retrieval. If the oestradiol level is above 15,000 pmol/l, start coasting (i.e. omit FSH but maintain the GnRH Antagonist or GnRH agoinst). Check oestradiol level daily if the level is between 15,000-25,000 pmol/l or every two days if oestradiol level is above 25,000 pmol/l.
Consider triggering once the oestradiol level is below 15,000 pmol/l with hCG 5,000 iu and give albumin and fluids as above. Aspirate and flush all follicles to reduce the number of granulosa cells or increase suction pressure to 110 kP.
Coasting reduces the number of eggs collected but does not adversely affect the outcome of IVF unless prolonged (more than 3 days). We can also consider triggering with GnRH agonist (eg leuprolide 0.5 to 1.0mg SC). However, this is useful only in cycles not involving long down regulation.
Luteal support using hCG should be avoided completely. The clinician should consider elective Single Embryo Transfer (SET) with blastocyst or in the worse case scenario, freeze all embryos if critical OHSS develops. |
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References |
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1. Ovarian Hyperstimulation Syndrome: ASRM Practice Committee. Fertility and Sterility Vol 86, Suppl 4, November 2006
2. The Management of Ovarian Hyperstimulation Syndrome: The RCOG Green-top Guideline No. 5, September 2006
Dr Wong Pak Seng, MOG, MRCOG |
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Disclaimer |
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For Patients:
The health information provided in this website is not intended as a substitute for medical advice, diagnosis, or treatment. Always consult your own physician for your own specific medical condition.
For Health Professionals:
While efforts has been made to get the relevant experts in each topic to contribute, the views and opinions of authors expressed in this section do not necessarily reflect those of the OGSM. |
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